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ESSENTIAL PSYCHOTHERAPIES
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Models of Brief Psychodynamic Therapy:

A Comparative Approach
Stanley B. Messer and C. Seth Warren
 ESSENTIAL
PSYCHOTHERAPIES
THEORY AND PRACTICE

F OUR T H EDI T ION

edited by
STANLE Y B. MESSER
NADINE J. K ASLOW

The Guilford Press

New York   London
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 In memory of
Alan S. Gurman, PhD, ABPP (1945–2013)
Brilliant colleague and collaborator
on three editions of Essential Psychotherapies

Jeremy D. Safran, PhD (1952–2018)

Dear friend, valued colleague,
and outstanding scholar
            —S. B. M.

In memory of
Alan S. Gurman, PhD, ABPP (1945–2013)
Beloved family and couple therapy teacher,
mentor, and sponsor par excellence

Edward F. Foulks, MD, PhD (1937–2018)

Who showed me in our therapeutic relationship
all that is essential about psychotherapy
            —N. J. K.
 About the Editors

Stanley B. Messer, PhD, is Distinguished Professor Emeritus and former Dean of the Gradu-
ate School of Applied and Professional Psychology at Rutgers, The State University of New
Jersey. Past president of the Society for the Exploration of Psychotherapy Integration, he is
a Fellow in several American Psychological Association (APA) societies and was awarded
an honorary doctorate by the Chicago School of Professional Psychology. Dr. Messer has
published extensively on the application of psychodynamic theory and research to brief and
integrative therapies, as well as on evidence-based practice. He has also conducted empirical
research on the process of psychotherapy. Dr. Messer is associate editor of the online jour-
nal Pragmatic Case Studies in Psychotherapy and maintains a clinical practice in Highland
Park, New Jersey.

Nadine J. Kaslow, PhD, ABPP, is Professor and Vice Chair of the Department of Psychia-
try and Behavioral Sciences at Emory University School of Medicine. Past president of the
APA, the American Board of Professional Psychology, and the Association of Psychology
Postdoctoral and Internship Centers, she was awarded an honorary doctorate by Pepperdine
University. Dr. Kaslow is former editor of the Journal of Family Psychology. She is a recipi-
ent of the Distinguished Contributions to Education and Training Award and a Presidential
Citation from the APA, as well as the Elizabeth Hurlock Beckman Award, and is a Distin-
guished Member of Psi Chi, the International Honor Society in Psychology. With over 300
publications, Dr. Kaslow has expertise in couple and family psychology, psychology educa-
tion/training, family violence, and suicide.

vii
 Contributors

Jonathan S. Abramowitz, PhD, Department of Psychology and Neuroscience, University of North

Carolina at Chapel Hill, Chapel Hill, North Carolina
Martin M. Antony, PhD, ABPP, Department of Psychology, Ryerson University, Toronto,
Ontario, Canada
Arthur C. Bohart, PhD, Department of Psychology, California State University Dominguez Hills,
Dominguez Hills, California, and Saybrook University, Pasadena, California
Virginia Brabender, PhD, ABPP, Institute for Graduate Clinical Psychology, Widener University,
Chester, Pennsylvania
Jennifer L. Buchholz, MD, Department of Psychology and Neuroscience, University of North
Carolina at Chapel Hill, Chapel Hill, North Carolina
Jordan E. Cattie, PhD, Department of Psychiatry and Behavioral Sciences, Emory University
School of Medicine, Atlanta, Georgia
Marianne P. Celano, PhD, ABPP, Department of Psychiatry and Behavioral Sciences,
Emory University School of Medicine, Atlanta, Georgia
Rebecca Coleman Curtis, PhD, Department of Psychology, Adelphi University, Garden City,
New York, and William Alanson White Institute, New York, New York
Eugene W. Farber, PhD, Department of Psychiatry and Behavioral Sciences, Emory University
School of Medicine, Atlanta, Georgia
Jerry Gold, PhD, ABPP, Department of Psychology, Adelphi University, Garden City, New York
Nadine J. Kaslow, PhD, ABPP, Department of Psychiatry and Behavioral Sciences, Emory University
School of Medicine, Atlanta, Georgia
Shalonda Kelly, PhD, Graduate School of Applied and Professional Psychology, Rutgers, The State
University of New Jersey, Piscataway, New Jersey
Orah T. Krug, PhD, Department of Humanistic and Clinical Psychology, Saybrook University,
Pasadena, California
Jay L. Lebow, PhD, ABPP, The Family Institute at Northwestern, Northwestern University,
Evanston, Illinois
Ariella P. Lenton-Brym, MA, Department of Psychology, Ryerson University, Toronto,
Ontario, Canada

ix
x Contributors

Akihiko Masuda, PhD, Department of Psychology, University of Hawai’i at Manoa,

Honolulu, Hawaii
Stanley B. Messer, PhD, Graduate School of Applied and Professional Psychology, Rutgers,
The State University of New Jersey, Piscataway, New Jersey
Hamid Mirsalimi, PhD, ABPP, Department of Psychiatry and Behavioral Sciences,
Emory University School of Medicine, Atlanta, Georgia
Shireen L. Rizvi, PhD, ABPP, Graduate School of Applied and Professional Psychology,
Rutgers, The State University of New Jersey, Piscataway, New Jersey
Lizabeth Roemer, PhD, Department of Psychology, University of Massachusetts Boston,
Boston, Massachusetts
Kirk J. Schneider, PhD, Existential–Humanistic Institute, Saybrook University, Pasadena,
California, and Teachers College, Columbia University, New York, New York
George Stricker, PhD, Department of Psychology, Adelphi University, Garden City, New York
Jeanne C. Watson, PhD, Ontario Institute for Studies in Education, University of Toronto,
Toronto, Ontario, Canada
David L. Wolitzky PhD, Postdoctoral Program in Psychotherapy and Psychoanalysis,
New York University, New York, New York
 Contents

PART I. INTRODUCTION

CHAPTER 1 Current Issues in Psychotherapy Theory, Practice, and Research: 3

A Framework for Comparative Study
Stanley B. Messer and Nadine J. Kaslow

PART II. PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

CHAPTER 2 Contemporary Freudian Psychoanalytic Psychotherapy 35

David L. Wolitzky

CHAPTER 3 Relational Psychoanalytic/Psychodynamic Psychotherapy 71

Rebecca Coleman Curtis

PART III. BEHAVIORAL AND COGNITIVE APPROACHES

CHAPTER 4 Behavior Therapy: Traditional Approaches 111

Martin M. Antony, Lizabeth Roemer,
and Ariella P. Lenton-Brym

CHAPTER 5 Cognitive Therapy and Cognitive-Behavioral Therapy 142

Jordan E. Cattie, Jennifer L. Buchholz,
and Jonathan S. Abramowitz

CHAPTER 6 Third-Wave Cognitive-Behaviorally Based Therapies 183

Akihiko Masuda and Shireen L. Rizvi

xi
xii Contents

PART IV. EXPERIENTIAL AND HUMANISTIC APPROACHES

CHAPTER 7 Person-Centered and Emotion-Focused Psychotherapies 221

Arthur C. Bohart and Jeanne C. Watson

CHAPTER 8 Existential–Humanistic Psychotherapies 257

Kirk J. Schneider and Orah T. Krug

PART V. SYSTEMS-ORIENTED APPROACHES

CHAPTER 9 Family Therapies 297

Nadine J. Kaslow, Hamid Mirsalimi,
and Marianne P. Celano

CHAPTER 10 Couple Therapies 333

Jay L. Lebow and Shalonda Kelly

CHAPTER 11 Group Psychotherapies 369

Virginia Brabender

PART VI. OTHER INFLUENTIAL MODELS OF THERAPEUTIC PRACTICE

CHAPTER 12 Interpersonal Psychotherapy and Brief Psychodynamic Therapies 407

Eugene W. Farber

CHAPTER 13 Integrative Approaches to Psychotherapy 443

Jerry Gold and George Stricker

Author Index 481

Subject Index 490

 PART I

INTRODUCTION
 CHAP TER 1

Current Issues in Psychotherapy

Theory, Practice, and Research
A Framework for Comparative Study

Stanley B. Messer
Nadine J. Kaslow

T his book presents the core theoretical and applied aspects of essential psychotherapies in
contemporary clinical practice. In our view, essential psychotherapies are those that form
the conceptual and clinical bedrock of psychotherapeutic training, practice, and research
rather than those that may generate momentary enthusiasm but are soon likely to fade
from the therapeutic scene. We believe there are two fairly distinct categories of essential
psychotherapies. There are those approaches whose origins are found early in the history of
psychotherapy, although all of these have been revised and refined considerably over time.
Examples of such foundational and time-honored approaches are Freudian-derived psycho-
analytic psychotherapy; existential–humanistic and person-centered models; traditional
behavior therapy; and group therapy. Then there are the more recently developed psycho-
therapies that have had a strong influence on practice, training, and research, and are likely
to have staying power. Examples are the relational/psychodynamic, cognitive and cognitive-
behavioral, third-wave cognitive-behavioral, family, couple, brief, and integrative therapies.
The first three editions of Essential Psychotherapies have become a primary source for
comprehensive presentations of the most prominent contemporary influences in the field of
psychotherapy. Although there are literally hundreds of differently labeled “psychothera-
pies,” the great majority are only partial methods, single techniques, or minor variations on
existing approaches. We believe they can be subsumed by about a dozen quite distinguish-
able types.
As editors, we have challenged our contributing authors to convey not only what is basic
and core to their ways of thinking and working but also what is new and forward-looking
3
4 INTRODUCTION

in theory, practice, and research. Our demographically and professionally diverse group of
contributors, all eminent scholars, practicing clinicians, and clinical educators, have helped
to forge a volume that is well suited to exposing advanced undergraduates, graduate stu-
dents, and advanced trainees in all the mental and behavioral health professions to the
major schools and methods of modern psychotherapy. Because the chapters were written by
cutting-edge representatives of their therapeutic approaches, there is something genuinely
new in these presentations that will be of value to more experienced therapists as well.
As in the first three editions, each chapter offers a clear sense of the history, current
status, assessment approach, techniques, and research on the therapy being discussed, along
with its foundational ideas about personality and psychological health and dysfunction.
However, each of these sections now pays greater attention to cultural factors. Further-
more, in keeping with current trends, attention is paid to the ways in which each approach
is consistent with the evidence-based practice (EBP) movement, and applicable to not only
mental/behavioral health concerns but also general physical health care. As academicians,
psychotherapy trainers, and practicing psychotherapists ourselves, we endorse the adage
that “there is nothing so practical as a good theory” (Lewin, 1951, p. 169). Each chapter bal-
ances the discussion of theory and practice, and emphasizes the interaction between them.
Before detailing our organizing framework for the chapters in this book, three com-
ments about its contents are in order. First, while Essential Psychotherapies provides sub-
stantive presentations of the major schools of psychotherapeutic thought and general guide-
lines for practice, it does not emphasize, per se, treatment prescriptions for specific disorders
or “special populations.” Included, however, are examples of such applications. Whereas
forces in the contemporary world of psychotherapy support a rather broad movement to
specify particular techniques for particular problems and types of persons (although see
below for some recent changes in this regard), we continue to believe that the majority
of practitioners approach their work from the standpoint of theory as it informs general
strategies and techniques of practice. Optimally, such techniques and interpersonal stances
have survived in the crucible of systematic research and can be considered supported or
validated. In other words, we believe that there is an interplay among theory, practice, and
research that encompasses what we know about evidence-based treatments and techniques
(e.g., American Psychological Association Presidential Task Force on Evidence-Based Prac-
tice, 2006), as well as those aspects of the psychotherapy relationship that have a marked
effect on the success of therapy (e.g., Messer & Fishman, 2018; Norcross, 2011; Norcross
& Wampold, 2018).
Second, there is considerable energy being devoted to the development and refinement
of integrative approaches to psychotherapy (see Gold & Stricker, Chapter 13, this volume).
While valuing the search for integrative principles and common factors that transcend par-
ticular therapies (e.g., Goldfried, 2019; Laska, Gurman, & Wampold, 2014), we support the
continuing practice of teaching relatively distinct schools or systems of psychotherapy. We
agree with Feldman and Feldman (2005) that “for therapists to offer a truly balanced and
systematic integration, they need to be well versed in the core concepts and techniques of a
variety of orientations and conscious of the strengths and limitations of each perspective”
(pp. 398–399).
Third, we believe that therapists’ personalities increase their attraction to certain
approaches and diminish their interest in others. Fortunately, the field of psychotherapy
provides enough variety of concepts and modes of practice to match the personal predilec-
tions of any aspiring clinician.
 Current Issues in Psychotherapy 5

THE EVOLUTION OF PSYCHOTHERAPY AND OF “ESSENTIAL PSYCHOTHERAPIES”

Although the essential approaches are largely the same as when this volume first appeared
in 1995, there have been some important changes in the landscape of psychotherapy. Gestalt
therapy and transactional analysis have left their imprint on current models, and were popu-
lar and prominent therapies in earlier times, but they are less so today. As a result, there
are no separate chapters devoted to them. Gestalt therapy, however, is addressed (Bohart
& Watson, Chapter 7, this volume) in a discussion of person-centered and emotion-focused
approaches. Due to the growth of various offshoots of behavior and cognitive therapy, such
as dialectical behavior therapy, acceptance and commitment therapy, and mindfulness-
based cognitive therapy—known as the “third wave” of behavior therapy—we now have a
chapter on these and other related innovations (Masuda & Rizvi, Chapter 6, this volume).
The chapter on brief psychotherapy from previous editions has been reconfigured to focus
on its two most prominent forms, namely, interpersonal psychotherapy and brief psychody-
namic therapies.
The various models of psychotherapy appearing here stem from different views of
human nature, about which there is no universal agreement. Working from alternative epis-
temological outlooks (e.g., introspective [from within] vs. extraspective [from the outside]),
these schools of therapy embrace quite different ways of getting to know clients/patients.
In addition, these therapies encompass distinct visions of reality or combinations thereof,
such as tragic, comic, romantic, and ironic views of life (Messer & Winokur, 1984), which
influence what change consists of and how much is considered possible. We believe it is
important for the field to appreciate and highlight the different perspectives and visions
exemplified by each model or school of therapy, while simultaneously respecting both the
search for common principles in theory and practice and the emphasis on integration across
approaches.

A FRAMEWORK FOR COMPARING THE PSYCHOTHERAPIES

Our theories are our inventions; but they may be merely ill-reasoned guesses, bold
conjectures, hypotheses. Out of these we create a world, not the real world, but our own
nets in which we try to catch the real world.
—K arl Popper

I think psychotherapy saves lives and is hugely meaningful and I think that one of the
unfortunate aspects of prescription drugs working well is that people tend to think that’s
enough.
—K ay R edfield Jamison

As in the earlier editions of Essential Psychotherapies, we have provided the authors with a
comprehensive set of guidelines (presented below). These have proven useful in facilitating
readers’ comparative study of the major models of contemporary psychotherapy and also
may be used by the student as a template for studying therapeutic approaches not included
here. These guidelines include the basic and requisite elements of an adequate description of
any type of psychotherapy.
In offering these guidelines to our authors, we aimed to steer a midcourse between pro-
viding the reader with sufficient anchor points for comparative study, while not constraining
authors’ expository creativity. We are pleased that our contributors succeeded in following
6 INTRODUCTION

the guidelines, while describing their respective approaches in an engaging fashion. Authors
were encouraged to sequence their material within chapter sections according to their own
preferences. They were also advised that they did not need to limit their presentations to the
matters raised in the guidelines or address every point identified therein, but to address these
matters if they were relevant to their treatment approach. Authors were also free to merge
sections of the guidelines if doing so helped them communicate their perspectives more
meaningfully. We highlighted those features we considered essential to include. (See italics
below for required content.) We believe the authors’ flexible adherence to the guidelines
helped to make clear how theory organizes clinical work and facilitates case conceptualiza-
tion. The inclusion of clinical case material in each chapter serves in a concrete and engaging
way to illustrate the constructs and methods described previously.
Although most of our author guidelines remained unchanged from those in the third
edition, we have made a few additions and modifications. We asked the authors to be sure
to address cultural factors such as ethnicity, race, religion/spirituality, social class, gender,
and sexual orientation. We also asked them to consider health-related issues, applications
to serious mental illness, ethical considerations, and psychotherapy integration. We again
requested suggestions of videos that illustrate their approach. We now present these author
guidelines, along with our rationale for, and commentary on, each area. In this fashion, we
hope to bring the reader up to date on continuing issues and controversies in the field.

HISTORICAL BACKGROUND
History is the version of past events that people have decided to agree on.
—Napoleon Bonaparte

The work of today is the history of tomorrow, and we are its makers.
—Juliette G ordon Low

PURPOSE: To place the approach in historical perspective within the field of

psychotherapy.

Points to consider:
1. The major influences that contributed to the development of the approach
(e.g., people, books, research, theories, conferences). What were the sociohis-
torical forces or Zeitgeist that shaped the emergence and development of this
approach (e.g., Victorian era, American pragmatism, modernism, postmod-
ernism)?
2. The therapeutic forms, if any, that were forerunners of the approach (e.g., psy-
choanalysis, learning theory, client-centered theory).
3. Types of patients with whom the approach was developed, and speculations as
to why.
4. Early theory and/or therapy techniques.
5. Ways that cultural factors (e.g., gender, ethnicity, race, sexual orientation,
religion/spirituality, social class) were considered, if at all, in the develop-
ment of this form of psychotherapy.
 Current Issues in Psychotherapy 7

People’s lives can be significantly influenced for the better in a wide range of ways—for
example, a parent adopts a new approach toward a defiant adolescent, a member of the
clergy facilitates a congregant’s self-forgiveness, an athletic coach or teacher serves as a life-
altering role model for a student, and so on. Yet none of these, or other commonly occurring
healing or behavior-changing experiences, qualifies as psychotherapy. Psychotherapy refers
to a particular process rather than just to any experience that leads to desirable psycho-
logical outcomes. Written five decades ago, Meltzoff and Kornreich’s (1970) definition of
psychotherapy is still quite apt, although their term techniques has to be seen as including
relationship factors, and the phrase “judged by the therapist” must be broadened to include
the client’s/patient’s perspective:

Psychotherapy is . . . the informed and planful application of techniques derived from

established psychological principles, by persons qualified through training and experience
to understand these principles and to apply these techniques with the intention of assisting
individuals to modify such personal characteristics as feelings, values, attitudes and behav-
iors which are judged by the therapist to be maladaptive or maladjustive. (p. 4)

Given such a definition of psychotherapy, we believe that developing an understanding

and appreciation of the professional roots and historical context of psychotherapeutic mod-
els is an essential aspect of one’s education as a therapist. (Norcross, VandenBos, & Freed-
heim [2010] provide the most comprehensive accounts of the histories of all the major psy-
chotherapy approaches to date.) Lacking such awareness, a particular therapy might seem to
have evolved from nowhere and for no known reason. A key factor in a therapist’s ability to
help people change lies not only in the therapist’s belief in the more technical aspects of the
chosen orientation, as in the aforementioned definition, but also in the worldview implicit in
it. Having some exposure to the historical origins of a therapeutic approach helps clinicians
comprehend its worldview.
In addition to attending to the professional roots of therapeutic methods, it is enlighten-
ing to understand why particular methods, or sometimes clusters of related methods, appear
on the scene in particular historical periods. The intellectual, economic, and sociopolitical
contexts in which therapeutic approaches arise often provide meaningful clues about the
emerging social, scientific, and philosophical values that frame clinical encounters. Such
values may have a subtle but salient impact on whether newer treatment approaches endure.
For example, until quite recently, virtually all the influential and dominant models of psy-
chotherapy were derived from three broad outlooks: psychoanalysis, humanism, and behav-
iorism.
In the last few decades in particular, however, two newer conceptual forces have
shaped the landscape of psychotherapy in visible ways. The systems-oriented methods
of couple, family, and group therapy have grown out of an increasing emphasis on the
contextual embeddedness of all human behavior (Gurman & Snyder, 2010). Indeed, even
the more traditional therapeutic approaches, such as those grounded in psychoanalytic
thinking or behavioral therapy, have become more relationally focused. Likewise, emerg-
ing integrative and brief psychotherapeutic approaches have gained recognition and stat-
ure in the last three decades, in part as a response to increased societal and professional
expectations that psychotherapy demonstrate both its efficacy and its efficiency (see, in
this volume, Farber, Chapter 12, and Gold & Stricker, Chapter 13; Messer, Sanderson, &
Gurman, 2013).
8 INTRODUCTION

THE CONCEPT OF PERSONALITY

Children are natural mimics—they act like their parents in spite of every attempt to teach
them good manners.
—A nonymous

PURPOSE: To describe within the therapeutic framework the conceptualization

of personality, such as the patterns of behaviors, thoughts, feelings,
emotions, and social adjustments that are consistently exhibited over
time and that influence one’s expectations, self-perceptions, values,
and attitudes.

Points to consider:
1. What is the theory of personality development (or related constructs) in this
approach?
2. What are the basic psychological concepts used to describe and understand
people (e.g., schemas, traits, character types, behaviors, emotions, motiva-
tions)?

Although there are different definitions of what constitutes personality, three elements
are usually included:

1. Personality is not merely a collection of individual traits or disconnected behaviors,

but is structured, organized, and integrated.
2. This structural criterion implies a degree of consistency and stability in personality
functioning. Behavioral manifestations of that structure may vary, however, accord-
ing to the situational context. This is due to behavior being a function of the interac-
tion of personality and situational factors.
3. There is a developmental aspect to personality that takes into account childhood
and adolescent experience; that is, personality emerges over time out of a matrix of
biological and social influences.

There exists an intimate connection between personality theory and the factors posited
to bring about change by any theory of psychotherapy. Psychoanalysis, for example, empha-
sizes unconscious aspects of human functioning, including disguised motives, ambivalence
in all human relations, and intricate interactions among the structures of mind, namely, id,
ego, and superego. Thus, it is not surprising that an essential curative factor in this theory is
interpretation of motives, defenses, conflicts, and other relatively hidden features of person-
ality. A cognitive theory of personality, by contrast, is based on the assumption that mental
structures determine how an individual comes to evaluate and interpret information related
to the self and others. In particular, this theory posits that “schemas” (Neisser, 1967) orga-
nize and determine individuals’ behavior, affect and experience. Psychotherapy, within this
approach, involves cognitive reeducation, in the course of which old, irrational, or maladap-
tive cognitions are unlearned and replaced by new, more adaptive ones. As well, areas of
deficiency are remedied by the learning of new cognitive skills. On the flip side of the coin,
some theories of therapy are not linked to a specific theory of personality. A good example
 Current Issues in Psychotherapy 9

is behavior therapy, which accounts for consistency in people’s behavior with concepts such
as conditioned and operant learning, stimulus generalization, and modeling.
In a meta-analysis, Roberts et al. (2017) investigated the extent to which personality
traits changed as a result of interventions, especially clinical interventions. These interven-
tions were found to be associated with fairly large changes in personality trait measures,
regardless of the therapy employed in a particular study (e.g., supportive therapy, cognitive-
behavioral therapy (CBT), and psychodynamic therapy). Such changes took place over an
average of 24 weeks, which were maintained in longitudinal follow-ups.

PSYCHOLOGICAL HEALTH AND PSYCHOPATHOLOGY

All my writing is about the recognition that there is no single reality. But the beauty of it
is that you nevertheless go on, walking towards utopia, which may not exist, on a bridge,
which might end before you reach the other side.
—M arguerite Young

PURPOSE: To describe the way in which psychological health and pathology are
conceptualized within the approach.

Points to consider:
1. Describe any formal or informal system for diagnosing or categorizing indi-
viduals.
2. How do symptoms or problems develop? How are they maintained?
3. To what extent does the approach diagnose and treat individuals with seri-
ous mental illness?
4. Is there a concept of the ideal or healthy personality or optimal functioning
within this approach?

Much can go awry in the developing personality due to biological or psychosocial

factors. Symptoms can result from contemporaneous stresses and strains or, more typi-
cally, from the interaction of a personality disposition with a current event that triggers
emotional disturbance or maladaptive interpersonal behavior (the diathesis–stress model;
Ingram & Luxton, 2005). Although some theories avoid the use of language and labels that
pathologize human experience, they still speak clearly about what constitutes maladaptive
behavior. Thus, even schools of therapy that do not formally judge the health of a person
based on external criteria, such as symptoms or interpersonal difficulties, do attend to the
consequences of behavior in terms of that person’s welfare and interest. In addition, there is
mounting appreciation of the need to conceptualize personality not just in terms of diathesis
and stress, but in a broader social–ecological framework, in which human development is
understood as a bidirectional interaction between individuals and the multiple systems in
which they are embedded (Bronfenbrenner, 1979).
It should be noted that psychological disorders possess no natural boundaries, only
loose categorical coherence. This is not an instance in which nature is carved at its joints.
In fact, there is a recent proposal to conceptualize psychopathology along a single dimen-
sion, called p, parallel to the g factor of general intelligence. It is an effort to unite all mental
10 INTRODUCTION

disorders. “Studies show that the higher a person scores on p, the worse that person fares on
measures of family history of psychiatric illness, brain function, childhood developmental
history, and adult life impairment” (Caspi & Moffitt, 2018, p. 831).
All efforts to date have failed to identify objective features that underlie the various
mental disorders as characterized by DSM-5 (American Psychiatric Association, 2013) and
ICD-11 (World Health Organization, 2018). What people seem to agree on is their undesir-
ability, which is more a moral than a scientific valuation (Woolfolk, 1998). In fact, a therapy
may reveal its esthetic and moral values by how it conceptualizes mental health and psy-
chological well-being. For example, “Psychoanalysis puts forth the ideal of the genital per-
sonality, humanistic psychology the self-actualized person, and cognitive-behavior therapy,
the objective problem-solving human being” (Messer & Woolfolk, 1998, p. 257).
In other words, the terms of personality theory, psychopathology, and the goals of psy-
chotherapy are not neutral. They are embedded in a value structure that determines what
is most important to know about and change in an individual, couple, family, or group
(Woolfolk, 2015). Even schools of psychotherapy that attempt to be neutral with regard to
what constitutes healthy (and, therefore, desirable) behavior, and unhealthy (and, therefore,
undesirable) behavior inevitably, if unwittingly, reinforce the acceptability of some kinds of
client strivings more so than others.
Ways of assessing personality and pathology are closely linked to the underlying theory.
If the latter focuses on unconscious factors, for example, asking about dreams and early
memories may be considered a more fertile mode of assessment than self-report question-
naires (Messer & Wolitzky, 2007). In the following chapters, the reader is encouraged to
look for the links among personality theory, the description of psychopathology, the manner
of assessing these dimensions, and the kinds of changes that are sought.

THE PROCESS OF CLINICAL ASSESSMENT

If you are sure you understand everything that is going on, you are hopelessly confused.
—Walter Mondale

I was a keen observer and listener. I picked up on clues. I figured things out logically, and
I enjoyed puzzles. I loved the clear, focused, feeling that came when I concentrated on
solving a problem and everything else faded out.
—Sonia Sotomayor

PURPOSE: To describe the methods used to gain understanding of an individual’s

(or couple’s or family’s) style or pattern of interaction, symptoms, and
adaptive resources.

Points to consider:
1. What, if any, is the role of standard psychiatric diagnosis in your assessment?
Does it influence treatment planning, or is it used primarily for administrative
purposes?
2. At what unit level(s) is assessment made (e.g., individual, dyadic, system)? At
what psychological levels is assessment made (e.g., intrapsychic, behavioral,
interpersonal, systemic)?
 Current Issues in Psychotherapy 11

3. To what extent and in what ways are cultural factors (e.g., gender, ethnicity,
race, sexual orientation, religion/spirituality, social class) considered in your
assessment?
4. Are any tests, devices, questionnaires, or structured observations typically
used?
5. Is assessment separate from treatment or integrated with it (e.g., what is the
temporal relationship between assessment and treatment)?
6. Are the patient’s strengths/resources a focus of your assessment? If so, in what
way?
7. What other dimensions or factors are typically involved in assessing dysfunc-
tion?

The practicality of a good theory of psychotherapy, including ideas about personality

development and psychological dysfunction, becomes evident as the therapist tries to make
sense of both problem stability (how problems persist) and problem change (how problems
can be modified). As indicated earlier in Meltzoff and Kornreich’s (1970) classic definition
of psychotherapy, the therapist is obligated to take some purposeful action in regard to an
understanding of the nature and parameters of whatever problems, symptoms, complaints,
or dilemmas are presented. Therapists typically are interested in ascertaining what previous
steps clients/patients have taken to resolve or improve their difficulties, and what adaptive
resources they, and possibly other people in their world, have for doing so.
Moreover, the therapist pays attention to the cultural (ethnic, racial, religious, social
class, gender) context in which clinically relevant concerns arise. Such contextualizing fac-
tors can play a critical role in how the therapist collaboratively defines the problem at hand
and selects a general strategy for addressing the problem therapeutically. The 2017 Multi-
cultural Guidelines set forth by the American Psychological Association (2017) highlight
the necessity of incorporating an ecological framework when conducting interviews and
assessments with culturally diverse clients/patients. Similarly, mounting attention has been
paid to cultural variations in assessing various forms of psychopathology and culture-bound
syndromes in forms of evaluation ranging from neuropsychological to personality assess-
ment (Paniagua & Yamada, 2013; Smith & Krishnamurthy, 2018).
How therapists actually engage in clinical assessment varies from one approach to
another (Eells, 2007), but all include face-to-face clinical interviews. The majority of thera-
pists emphasize the immediate therapist–client/patient conversation as the source of such
understanding. A smaller number of therapists also opt to complement such conversations
with direct observations of the problem as it occurs as in family and couple conflict situa-
tions, or in cases involving anxiety-based avoidance of specific stimuli. In addition, some
therapists regularly include in the assessment process a variety of patient self-report ques-
tionnaires or inventories, and may also use structured interview guides, which are usually
research-based instruments. Generally, therapists who use such devices have specialized
clinical practices (e.g., focusing on a particular set of clinical disorders for which such mea-
sures have been specifically designed) or come from specific theoretical traditions.
The place of standard psychiatric diagnosis in the clinical assessment phase of psycho-
therapy likewise varies widely. The overwhelming majority of psychotherapists of differ-
ent theoretical orientations routinely consider the traditional diagnostic, psychiatric status
of patients according to the criteria of the current edition of DSM (American Psychiatric
12 INTRODUCTION

Association, 2013) and/or the ICD-11 (World Health Organization, 2018), at least to meet
requirements for financial reimbursement, maintenance of legally mandated treatment
records, and other such institutional necessities. Although engaging in such formal diagnos-
tic procedures may provide a useful orientation to the general area of a patient’s/client’s con-
cerns, every method of psychotherapy has developed and refined its own, more fine-grained,
idiosyncratic ways of understanding each individual patient’s/client’s problem. Moreover,
some approaches to psychotherapy argue that “diagnoses” do not exist “out there” in nature
but merely represent the consensual labels attached to certain patterns of behavior in par-
ticular cultural and historical contexts. Such therapy approaches see the use of diagnostic
labeling as an unfortunate and unwarranted assumption of the role of “expert” by therapists,
which may inhibit genuine collaborative exploration between therapists and “patients” or
“clients” (e.g., see Bohart & Watson, Chapter 7, this volume). For such therapists, what mat-
ters more are the fluid issues with which people struggle, not the diagnoses they are given
(e.g., see Schneider & Krug, Chapter 8, this volume).
All things considered, one primary dimension along which clinical assessments vary
is the intrapersonal–interpersonal one. Some therapy models emphasize intrapsychic pro-
cesses, whereas others emphasize social interaction. In fact, there is a constant interplay
between people’s inner and outer lives. Emphasis on one domain versus another reflects an
arbitrary punctuation of human experience that probably says as much about the perceiver’s
theory as it does about the client/patient who is perceived. Another dimension on which
such assessments vary relates to the extent to which attention is paid to affects, behaviors,
or cognitions.

THE PRACTICE OF THERAPY

In theory, there is no difference between theory and practice. In practice, however, there
is.
—A nonymous

We delight in the beauty of the butterfly, but rarely admit the changes it has gone through
to achieve that beauty.
—M aya A ngelou

PURPOSE: To describe the typical structure, goals, techniques, strategies,

and process of a particular approach to therapy and their tactical
purposes.

Points to consider:
A . Basic Structure of Therapy
1. How often are sessions typically held?
2. Is therapy time-limited or unlimited? Why? How long does therapy typi-
cally last? How long are typical sessions?
3. Who is typically included in therapy? Are combined formats (e.g., indi-
vidual plus family or group sessions) ever used?
4. How structured are therapy sessions?
5. Are individuals with more serious disorders (e.g., schizophrenia, bipolar
 Current Issues in Psychotherapy 13

disorder, personality disorders such as borderline personality disorder)

treated within this approach? What, if anything, is different in treating
them? (See also the section on “Treatment Applicability.”)

B. Goal Setting
1. Are there treatment goals that apply to all or most cases for which the
treatment is appropriate (see the sections “Treatment Applicability” and
“Ethical Considerations”) regardless of presenting problem or symptom?
2. Of the number of possible goals for a given client/patient group, how are
the central goals selected? How are they prioritized? Who determines the
goals of therapy? Are therapist values involved in goal setting?
3. Do cultural factors (e.g., gender, ethnicity, race, sexual orientation, reli-
gion/spirituality, social class) typically influence the setting of treatment
goals and, if so, how?
4. Do you distinguish between intermediate or mediating goals and ultimate
goals?
5. Is it important that treatment goals be discussed with clients/patients
explicitly? If yes, why? If not, why not?
6. At what level of psychological experience are goals established (are they
described in overt behavioral terms, in affective–cognitive terms, etc.)?

C. Process Aspects of Treatment

1. Describe and illustrate with brief case vignettes major commonly used
techniques and strategies.
2. How is the decision made to use a particular technique or strategy at a
particular time? Typically, are different techniques used in different phases
of therapy?
3. Are homework or other out-of-session tasks used? If so, give examples.
4. How are cultural considerations addressed in the therapeutic/intervention
process?
5. What are the most commonly encountered forms of resistance to change?
How are these dealt with?
6. What are both the most common and the most serious technical errors a
therapist can make operating within your therapeutic approach?
7. Are psychotropic medications ever used (either by the primary psychother-
apist or in collaboration with a medical colleague) within your approach?
What are the indications–contraindications for their use?
8. On what basis is termination decided, and how is termination effected?
9. Have recent findings in neuroscience influenced important process aspects
of your therapeutic approach?
10. Is there a trend toward integrating features of other therapies? If so, are
there particular approaches that are most often integrated and how does
this integration occur?
14 INTRODUCTION

Psychotherapy is not only a scientific and value-laden enterprise but also part and par-
cel of its surrounding culture. It is a significant source of our current customs and world-
views and thus possesses significance well beyond the interactions between clients/patients
and therapists. For example, when laypeople refer to Freudian slips, defenses, guilt com-
plexes, conditioned responses, existential angst, identity crises, codependency, an enabling
partner, or discovering their true self, they are demonstrating the impact of psychological
and psychotherapeutic categories on their vocabulary and cultural conversations. Similarly,
when they explain their problems in terms of childhood occurrences such as parental neglect,
repressed memories, conditioned emotional reactions, family dysfunction, lack of uncondi-
tional positive regard, or maladaptive behavior or thoughts, they are affirming that the
institution of psychotherapy is much more than a technical, medical, or scientific endeavor.
It helps to shape the very terms in which people think, and even constitutes the belief system
they use to explain and make sense out of their lives (Messer & Woolfolk, 1998).
Recent years have witnessed growing support for cultural competency in psychothera-
peutic interventions. Although some have argued for the cultural universality of psycho-
therapies, others have underscored the importance of cultural modifications or adaptations
to ensure effective treatment of individuals from diverse backgrounds (Bernal & Domenech
Rodriguez, 2012). A meta-analysis that included 14,000 participants, 95% of whom were
non-European Americans, revealed that culturally adapted interventions are more effec-
tive than other interventions or no intervention (Hall, Ibaraki, Huang, Marti, & Stice,
2016). Similarly, in another meta-analysis that compared culturally adapted with unadapted
psychotherapy, the former was more effective on measures of psychological functioning
(Benish, Quintana, & Wampold, 2011). It has been argued that the therapist’s cultural
competence is relevant to effective psychotherapeutic practice because it leads to a better
relationship, enabling the client/patient to feel empathically understood and empowered
(Chu, Leino, Pflum, & Sue, 2016a).
Not surprisingly, psychotherapy is a sensitive barometer of cultural customs and out-
looks to which the different modes of practice are responsive and incorporate within their
purview. The relation between psychotherapy and culture, then, is one of reciprocal influ-
ence (Messer & Wachtel, 1997). For example, two currently important cultural phenomena
affecting the practice of psychotherapy are the medicalization of how psychological disorder
is treated and the technology revolution.
Regarding the medicalization of mental health treatment, the language of medicine has
long been prominent in the field of psychotherapy. We talk of “symptoms,” “diseases,” “dis-
orders,” “psychopathology,” and “treatment.” Many medications have been at least mod-
erately successful in treating the full array of psychological disorders. These medications
are actively promoted on television and via social media directly to the consumer, with the
promise of the pill removing a person’s worries and blues. Thus, the pharmaceutical com-
panies have played their part in promoting a biological approach to mental disorder. This
is despite the fact that psychological treatments are often at least as effective as pharmaco-
therapy. For example, a recent review of hundreds of randomized controlled trials (RCTs) of
the effects of psychological treatment of adult depression concluded that such interventions
are evidence-based and have comparable benefits to those found with antidepressant medi-
cations (Cuijpers & Gentili, 2017). The authors went on to note that the positive outcomes
for psychotherapy may be of longer duration than those for pharmacological interventions.
What about the combination of medication and psychotherapy in the treatment of
depression? In a meta-analysis of 23 RCTs in which combined treatment was compared to
 Current Issues in Psychotherapy 15

either psychotherapy or antidepressant medication alone, Karyotaki et al. (2016) reported

that in the acute phase of major depressive disorder, the combination of medication and
psychotherapy outperformed antidepressants alone. In the maintenance phase, combined
psychotherapy with antidepressants resulted in better sustained treatment response com-
pared to antidepressants alone. Psychotherapy alone was as effective as both treatments
combined at 6 months posttreatment or longer. Furthermore, Dunlop (2016) concluded that
the sequential addition of psychotherapy for individuals whose depression does not remit
following a trial of antidepressant medication shows the most support in terms of improving
remission rates and reducing relapse and recurrence rates over time. There is also evidence
from a recent meta-analysis that the combination of the two interventions is most likely to
be associated with improvements in functioning and quality of life (Kamenov, Towmey,
Cabello, Prina, & Ayuso-Mateos, 2017). In our view, these results argue for the importance
of psychotherapy in the treatment of depression either alone or often in combination with
medication.
The growing appreciation of a biopsychosocial–cultural framework has had an impact
on the practice of psychotherapy. Individuals who present for psychotherapy and their ther-
apists are more likely to consider having medication prescribed. Psychologists and other
nonmedical therapists collaborate more frequently with physicians in treating their patients.
Courses in psychopharmacology are now routinely offered or even required in training
programs for various behavioral health professionals. Relatedly, recent advances in neu-
roscience, especially in the realm of “affective neuroscience” (e.g., Panksepp, 2013) and
“interpersonal neurobiology” (e.g., Solomon & Siegel, 2017), have demonstrated the brain’s
capacity for plasticity and change, providing a basis for some broad principles to guide psy-
chotherapy with individuals (Cozolino, 2017), couples (Fishbane, 2013), and groups (Kinley
& Reyno, 2016). Levenson (2017), however, advises caution about prematurely concluding
“that we can identify specific neurological processes and brain structures to explain pre-
cisely why and how our therapeutic interventions work” (p. 121). From our standpoint, it
would be unfortunate if the range of essential therapies described herein were not taught and
practiced, if the psychological outlook these essential therapies convey were not respected,
and if the important kind of psychological help these therapies offer were made less avail-
able because of excessive biologizing of our understanding of psychological suffering and
change.
It should be noted that controlled comparisons among therapies typically result in a
finding of “no difference” (Lambert, 2013). For instance, when CBT was compared to psy-
chodynamic therapy for adult outpatient depression on measures of psychopathology, inter-
personal functioning, pain, and quality of life, no significant differences were found (Dries-
sen et al., 2017). About 45–60% of the individuals who completed posttreatment assessment
showed clinically meaningful change for most outcome measures regardless of intervention
condition. Much more study is needed before we can conclude which psychotherapies are
best for which individuals with which diagnoses or problems. Such investigations must take
into account not only the different psychotherapeutic approaches being compared but also
the clients’/patients’ preference for a particular modality, given that such preferences are
associated with lower levels of dropout and more positive treatment outcomes (Swift, Cal-
lahan, Cooper, & Parkin, 2018).
In terms of the technology revolution, technology has increasingly become integrated
into psychotherapy delivery in the past 15 years. Technology-based psychotherapy has sur-
faced as an alternative approach to in-person psychotherapy services when these are not
16 INTRODUCTION

accessible. Initially, the focus was on the use of telephone technology in psychotherapy,
which has been found to be effective for a range of psychological disorders, as well as for
individuals with medical problems (Alvandi, Van Doorn, & Symmons, 2017). Building on
the use of the telephone has been videoconferencing for psychotherapy. Recently, guide-
lines have been developed to address the provision of such telepsychology services including
psychotherapeutic interventions (Joint Task Force for the Development of Telepsychology
Guidelines for Psychologists, 2013).
Concomitant with the recent dramatic proliferation of a range of Internet technologies
(e.g., Internet digital gaming, virtual reality, robotics) for health promotion and intervention
(i.e., eHealth) has been the proliferation of mobile device use (e.g., smartphones, tablets, per-
sonal digital assistants, wearable devices) within the health care context to support the pro-
motion, maintenance, and intervention of health-related concerns (i.e., “mHealth”; Luxton,
McCann, Bush, Mishkind, & Reger, 2011). mHealth includes mobile phone applications
(apps), text messaging systems, personal digital assistants, social media usage, ecological
momentary assessment (EMA) and ecological momentary intervention (EMI), and sensory
technology (Borrelli & Ritterband, 2015). Apps are the most common form of mHealth,
and a plethora of them have been developed to increase the accessibility, convenience, and
effectiveness of mental health treatment (Crooks, Mack, Nguyen, & Kaslow, in press; Lux-
ton et al., 2011). mHealth technologies are convenient, portable, and readily accessible, and
thus have the potential to bypass stigmatizing attitudes toward the seeking of behavioral
health. Such resources also help reduce disparities in mental health care (Crooks et al., in
press). Despite preliminary evidence that mobile apps and other forms of mhealth technol-
ogy are acceptable to patients/clients and effective in treating behavioral health symptoms
(Lindhiem, Bennett, Rosen, & Silk, 2015), the limited research investigating their efficacy
means that it is premature to conclude that they are effective for behavioral health treatment
(Clough & Casey, 2015).
In keeping with the advancement of technology usage in psychotherapy, there has been
an explosion in the number and variety of technologies in psychotherapy supervision and
training (e.g., videoconference supervision, cloud-based file sharing software, clinical out-
come tracking software; Rousmaniere, 2014; Wolf, 2011). Research on technology-assisted
supervision and training (TAST) demonstrates that it enhances the education and training
process (Rousmaniere, Abbass, & Frederickson, 2014).

THE THERAPEUTIC RELATIONSHIP AND THE STANCE OF THE THERAPIST

Remember that the best relationship is one in which your love for each other exceeds your
need for each other.
—The Dalai Lama

Walking with a friend in the dark is better than walking alone in the light.
—Helen Keller

PURPOSE: To describe the stance the therapist takes with clients/patients.

Points to consider:
1. To what extent is the therapeutic alliance prioritized in this approach?
2. How does the therapeutic relationship influence the outcome of therapy?
 Current Issues in Psychotherapy 17

3. What techniques or strategies are used to create a treatment alliance (e.g.,

warmth, empathy, acceptance, coaching, accurate interpretations especially
of the therapist–patient interaction). Describe and illustrate the nature of the
therapeutic alliance.
4. How are cultural factors taken into account, if at all, in the formation and/or
maintenance of the alliance?
5. To what degree does the therapist overtly control sessions? How active/
directive is the therapist?
6. Does the therapist assume responsibility for bringing about the changes
desired? Is responsibility left to the client/patient? Is responsibility shared?
7. Does the therapist use self-disclosure? What limits are imposed on therapist
self-disclosure? In general, what role does the “person” of the therapist play
in this approach? Describe and illustrate.
8. Does the therapist’s role change as therapy progresses? Does it change as ter-
mination approaches?
9. Is countertransference or the therapist’s experience of the client/patient rec-
ognized or employed in any fashion?
10. How are ruptures in the alliance handled and repaired?
11. What clinical skills or other therapist attributes are most essential to success-
ful therapy in your approach?

In recent years, a great deal of effort has been expended to identify EBPs among the
many existing forms of psychotherapy (e.g., Nathan & Gorman, 2015). Although such
efforts can be useful for important public policymaking decisions, they tend to focus heav-
ily on one particular domain of the therapy experience—the role and impact of thera-
peutic techniques. Increasingly, evidence-based therapy-oriented efforts have been counter-
balanced by efforts to investigate and understand the essential characteristics and effects
of evidence-based therapy relationships (Norcross, 2011; Norcross & Wampold, 2018;
Wampold & Imel, 2015). Regarding the latter, as far back as 1913, Freud understood that
collaboration and cooperation between therapist and patient required a certain degree of
rapport between them. For a patient to be receptive to their interventions, Freud posited,
therapists had to show a serious interest in the patient, be sympathetic, avoid moralizing
and not take the part of a third, contending party (Messer & Wolitzky, 2010). Since that
time, hundreds of studies have confirmed that there is a moderate correlation between the
strength of the therapeutic alliance and therapy outcome (e.g., Crits-Christoph, Connelly
Gibbons, & Mukherjee, 2013) regardless of the specific type of psychotherapy. The ele-
ments of the relationship that have garnered the most empirical support include the alliance
(in individual, couple, and family therapy), collaboration, agreement about goals, cohe-
sion (group therapy), empathy, positive regard and affirmation, and client/patient feedback
(Norcross & Wampold, 2018).
Different therapies, however, make use of the therapeutic relationship (TR) (or thera-
peutic alliance) in different ways. Messer and Fishman (2018) present a two-by-two model
to map these differences: One dimension is the establishment of a relationship in order to
have more leverage when using techniques to bring about therapeutic change versus the TR
itself as the hub of the treatment. The second dimension pertains to how directly the thera-
pist’s actions address the TR: Are the therapist’s interventions designed to address it directly
18 INTRODUCTION

or are they not, even if the interventions nevertheless impact the TR. For example, in CBT,
the TR is considered necessary but insufficient to bring about change, but how the thera-
pist’s actions are implemented has an indirect impact on the TR. By contrast, in psychody-
namic therapy, the TR is part and parcel of the treatment itself, and the therapist’s actions
are designed to address the TR directly. In family systems therapy, the TR is necessary but
insufficient, as in CBT, but different from CBT, in that the therapist’s actions are designed
to address the TR directly. As Messer and Fishman demonstrate, other therapies in a similar
fashion can be placed in one of the four cells created by this matrix.
Another way of understanding the role of the alliance has been proposed recently
by Zilcha-Mano (2017). She differentiates between the alliance as trait-like—that is, the
person’s ability to form satisfactory relationships with others, including the therapist—
and the alliance as state-like, which changes during treatment and is an active ingredient
in bringing about change. She posits that in some treatment models the alliance may be
“predominantly a precondition for therapeutic change whereas in other orientations it
may also be curative in itself” (p. 320). Although they were developed independently,
there is clearly overlap between the Messer and Fishman (2018) and Zilcha-Mano (2017)
models.
Work on the alliance or relationship provides a solid empirical basis for arguing that
the therapist as a person exerts at least moderate effects on the outcome of psychotherapy,
and that these effects often outweigh those that are attributable to treatment techniques
per se (Wampold & Imel, 2015). Even symptom-focused therapy encounters, which rely sub-
stantially on the use of clearly defined change-inducing techniques, occur in the context of
human relationships characterized by support and reassurance, persuasion, identification,
and the modeling of active coping.
The kind of TR required by each approach to psychotherapy affects the overall “stance”
the therapist takes to the experience (how the working alliance is fostered, how active and
self-disclosing the therapist is, etc.). Thus, different therapeutic orientations appear to call
forth (and call for) somewhat different therapist attributes and interpersonal inclinations.
For example, therapists with a more “take charge” personal style may be better suited to
practicing therapy approaches that require a good deal of therapist activity and structuring
than to those therapies requiring a more reflective style.
Given the presumed outcome equivalence of the major modes of psychotherapy (Lam-
bert 2013), it is not surprising that idiosyncratic personal factors influence therapists’ pre-
ferred ways of practicing. Thus, it has been found that therapists generally do not advocate
different approaches on the basis of their relative scientific status but are more influenced
by their own direct clinical experience, personal values and philosophy, and life experiences
(Norcross & Prochaska, 1983; Stewart & Chambless, 2007).

CURATIVE FACTORS OR MECHANISMS OF CHANGE

The road is not the road, the road is how you walk it.
—Juan R amón Jiménez

Here are the values that I stand for: honesty, equality, kindness, compassion, treating
people the way you want to be treated and helping those in need. To me, those are
traditional values.
—E llen DeGeneres
 Current Issues in Psychotherapy 19

PURPOSE: To describe the factors (i.e., mechanisms of change that lead to change)
and to assess their relative importance. Include key research findings if
possible.

Points to consider:
1. What are the proposed curative factors or mechanisms of change in this
approach?
2. Do patients need insight or understanding in order to change and, if so,
describe. Are interpretations of any sort important and, if so, do they take
history into account? If interpretations of any kind are used, are they seen as
reflecting a psychological “truth,” or are they viewed rather as a pragmatic
tool for effecting change?
3. How important is the learning of new interpersonal skills as a curative ele-
ment of change? When important, are these skills taught in didactic fashion,
or are they shaped as approximations that occur naturalistically in treat-
ment?
4. Does the therapist’s personality or psychological health play an important
part in bringing about change?
5. How important are techniques as opposed to relational factors, such as the
therapeutic alliance, for the outcome of therapy?
6. Are corrective emotional or cognitive experiences considered curative?
7. To what extent does the management of termination of therapy determine
outcome?
8. What aspects of your therapy are not unique to your approach (i.e., are com-
mon to all or most psychotherapies)?

A current controversy in the psychotherapy research literature is whether change is

brought about largely by specific ingredients of therapy or factors common to all thera-
pies. The former usually refers to specific technical interventions, such as biofeedback, sys-
tematic desensitization, in vivo exposure, cognitive reframing, interpretation, or empathic
responding, which are said to be the ingredient(s) responsible for client/patient change. In
some therapies, these techniques are set out in detail in manuals to which the practitioner is
expected to adhere in order to achieve the desired result. The specific ingredient approach
has some similarities to the medical model insofar as it treats a particular disorder with a
psychological technique (akin to administering a pill or employing a surgical technique),
producing the psychological equivalent of a biological or physical effect. Its proponents tend
to fall in the behavioral, cognitive, and cognitive-behavioral camps, but at least in theory
could hail from any of the psychotherapy schools. Followers of the EBP movement are typi-
cally adherents of this approach, advocating specific modes of intervention for different
forms of psychopathology.
Common factors are relevant to all therapeutic approaches and are not anchored in
any specific model of treatment. Because outcome studies comparing different individual
therapies have found few between-group differences (Lambert, 2013), it has been argued
that common factors are key change elements and the curative elements responsible for
20 INTRODUCTION

therapeutic success in individual therapy, as well as in couple and family therapy (e.g.,
Sprenkle, Davis, & Lebow, 2009). The following are the key categories of variables that
have been shown to be common factors:

•• Client/patient factors that have been deemed to be common to positive outcomes

across psychotherapies include a genuine motivation to and readiness for change, active par-
ticipation in the therapeutic process, requisite skills and confidence to change, and a belief
that change will be beneficial (Bohart & Tallman, 2010).
•• Therapist factors include the capacity to create a healing setting; listening and
conveying presence, empathy, and warmth; affirming the client’s/patient’s feelings and
experiences; treating the client/patient as an individual and a human being; highlight-
ing the client’s/patient’s strengths, abilities, and resources; and instilling hope and posi-
tive expectations for change (Blow, Sprenkle, & Davis, 2007; Moix & Carmona, 2018;
Wampold, 2012).
•• Therapeutic relationship/alliance factors include collaboration, mutuality, cohesions,
a trusting bond, cultural respect, a consensus about therapeutic goals and tasks, and devel-
opment of an explanatory framework and belief shared by both parties (Moix & Carmona,
2018; Wampold, 2012).
•• Therapeutic interventions that have been subsumed within the common-factors
approach include reflective listening, use of “I” statements, varied use of questions, pro-
vision of feedback, and efforts to help the client/patient acquire mastery (Weinberger &
Rasco, 2007). Recently, it has been purported that the common-factors perspective offers
an additional evidence-based approach for understanding the mechanisms of change in psy-
chotherapy (Laska et al., 2014).

Drawing on the common-factors approach, Wampold (2001) developed what he refers

to as a contextual model. In it, “the purpose of specific ingredients is to construct a coher-
ent treatment that therapists believe in, and this provides a convincing rationale to clients.
Furthermore, these ingredients cannot be studied independently of the healing context
and atmosphere in which they occur” (Messer & Wampold, 2002, p. 22). In a sense, this
is a common factors model that also takes account of the context in which those factors
occur, namely, a healing atmosphere and the employment of a specific theoretical model.
Wampold (2001) has made a case for the centrality of common factors such as the therapy
alliance, the therapist’s allegiance to his or her theory or rationale for treatment, and the
personality qualities and skills of the therapist. He reviews the evidence for the specific
ingredients model and finds it wanting (see also Wampold & Imel, 2015). Nevertheless,
proponents have also presented convincing evidence in favor of the specific ingredients
model (e.g., Baker, McFall, & Shoham, 2009; Chambless & Ollendick, 2001; Yulish et
al., 2017).
A third approach has been to challenge the dichotomy of relationship and technique, to
show that they are partly overlapping categories (Lundh, 2017) and that neither approach
can exist without the other (McAleavey & Castonguay, 2015). In a similar vein, Lin (2016)
presents a framework for integrating common and specific factors in therapy. Consistent
with this outlook, there have been mounting calls for the benefits of teaching and practicing
therapy-specific models alongside common factors approaches with individuals, as well as
with couples and families (Karam, Blow, Sprenkle, & Davis, 2015).
 Current Issues in Psychotherapy 21

TREATMENT APPLICABILITY AND ETHICAL CONSIDERATIONS

All who drink this remedy recover in a short time, except those whom it does not help,
who all die and have no relief from any other medicine. Therefore, it is obvious that it
fails only in incurable cases.
—Galen

Our motto, E Pluribus Unum, of many one, signals our appreciation that we are the
richer for the religious, ethnic, and racial diversity of our citizens.
—Ruth Bader Ginsburg

PURPOSE: To describe those patients for whom your approach is especially

relevant and any health-related applications.

Points to consider:
1. For what kinds of clients/patients is your approach particularly relevant?
2. For whom is your approach either not appropriate or of uncertain relevance?
3. Are there either inherent or likely advantages and/or limitations in the appli-
cability of your approach to people of diverse cultural backgrounds (e.g., as
a function of gender, ethnicity, race, sexual orientation, religion/spirituality,
social class)?
4. When, if ever, would a referral be made for another (i.e., different) type of
therapy?
5. Are there applications of your approach to general health care (e.g., smoking,
pain, weight loss, psychosomatic symptoms, exercise)? Give examples.

PURPOSE: To describe ethical issues that are particular to your approach.

Points to consider:
1. Are there features of your approach that can lead to specific ethical issues? If
so, describe them.
2. Provide a vignette of an ethical issue that has arisen and how it was resolved.

Questions about the applicability, relevance, and helpfulness of particular psychother-

apy approaches to particular kinds of symptoms, problems, psychopathology, and issues are
best answered through careful research on treatment efficacy (as determined via random-
ized clinical trials) and effectiveness (studies in practice or other real-world settings). Testi-
monials, appeals to established authority and tradition, and similar unsystematic methods
are insufficient to the task. Psychotherapy is too complex to track the interaction among,
and impact of, the most relevant factors in therapeutic outcomes on the basis of only indi-
vidual participants’ perceptions. Moreover, the contributions to therapeutic outcomes of
therapist, client/patient, the relationship, and technique factors probably vary from one
therapeutic method to another.
When Galen’s observations (in the opening epigraph) about presumptively curative
medicines are applied to psychotherapy nowadays, they are likely to be met with a knowing
22 INTRODUCTION

chuckle and implicit recognition of the inherent limits of all our treatment approaches. Still,
new therapy approaches rarely make only modest and restrained claims of effectiveness,
issue “warning labels” for “customers” for whom their ways of working are either not
likely to be helpful or may possibly be harmful, or suggest that alternative approaches may
be more appropriate under certain conditions. In fact, Meichenbaum and Lilienfeld (2018)
have developed a “Psychotherapy Hype Checklist” that comprises 19 warning signs that
point to exaggerated claims of a therapy’s effectiveness.
If therapy methods continue to grow in number (and we see no reason to predict other-
wise), the ethical complexities of the psychotherapy field may grow commensurately. There
are generic kinds of ethical matters with which therapists of all orientations must deal: for
example, confidentiality, adequacy of recordkeeping, duty to warn, respect for personal
boundaries regarding sexual contact and dual relationships, and so forth. Yet more recent
influential approaches, especially those involving multiperson clientele (e.g., couple, family
and group therapy), raise practical ethical matters that do not emerge in more traditional
modes of practice—for example, balancing the interests and needs of one person against the
interests and needs of another, while also trying to help maintain the very viability of the
client/patient system (e.g., couple or family; Gottlieb, Lasser, & Simpson, 2008).
Such potential influences of new perspectives on ethical concerns in psychotherapy
are perhaps nowhere more readily and saliently seen than when matters involving cultural
diversity are considered. Certainly, all psychotherapists must be sensitive in their work to
matters of race, ethnicity, social class, gender, sexual orientation, and religion, adapting
and modifying both their assessment and treatment-planning activities, and perspectives
and active intervention styles as is deemed functionally appropriate to the situation at hand.
To do otherwise risks the witting or unwitting imposition of the therapist’s values onto the
patient, such as in the important area of setting goals for their work together.
To begin with, the American Psychological Association has offered a series of guidelines
for working with specific client/patient populations based on age, gender, sexual orientation,
gender identity, etc. The initial Guidelines on Multicultural Education, Training, Research,
Practice, and Organizational Change for Psychologists crafted by the American Psychologi-
cal Association (American Psychological Association, 2003) recently were updated with an
eye toward the transformation that has occurred with regard to diversity and multicultural-
ism since the publication of the original guidelines, combined with a greater appreciation
of the intersectionality, that is, the overlapping and interconnected nature, of various social
identities and categories (American Psychological Association, 2017). These updated guide-
lines, entitled Multicultural Guidelines: An Ecological Approach to Context, Identity, and
Intersectionality, which became the policy of the organization in 2017, encourage psycholo-
gists and other psychotherapists to attend to developmental and contextual antecedents
of identity and to adopt a richer and more complete appreciation of diversity and human
differences and their impacts across individuals and communities (American Psychological
Association, 2017).
A rapidly growing number of books and articles on culture and diverse topics such
as race, feminism, immigration, religion and spirituality, sexual orientation, and gender
identity, as they pertain to psychotherapy and counseling, have appeared, putting multi-
culturalism closer to the center than the periphery of practice (Chu, Leino, Pflum, & Sue,
2016b; Hook, Davis, Owen, & DeBlaere, 2017). Research has followed suit, producing
results such as a positive association between clients’/patients’ perceptions of their thera-
pists’ multicultural competence and their ratings of the therapeutic alliance, satisfaction
 Current Issues in Psychotherapy 23

with the psychotherapy, and view of the therapist’s overall competence as well as with their
treatment outcomes (Tao, Owen, Pace, & Imel, 2015). That psychotherapy is at least as
much a socially and culturally situated activity as a biologically driven one is elaborated in
a series of papers on psychotherapy as practiced internationally (Wachtel, 2008).

RESEARCH SUPPORT AND EBP

If all the evidence as you receive it leads to but one conclusion, don’t believe it.
—Molière

The process of being scientific does not consist of finding objective truths. It consists of
negotiating a shared perception of truths in respectful dialogue.
—Robert Beavers

PURPOSE: To summarize existing research that supports the efficacy and/or

effectiveness of your approach and generally to describe the role of
research in the typical practice of your approach.

Points to consider:
1. Describe the nature and extent of empirical research that supports the effi-
cacy and/or effectiveness of your approach.
2. If supportive research is not abundant, on what other bases can the effective-
ness of your approach be argued?
3. Do research findings on your approach typically get incorporated into clinical
practice? If so, how?
4. How does your approach regard the movement toward EBP?

Psychotherapy Process and Outcome Research

Each chapter in this volume provides a snapshot of the outcome research backing its par-
ticular model of therapy. The many hundreds, if not thousands, of studies on the outcome
of psychotherapy are testament to investigators’ efforts to place the field on a firm scientific
footing. In recent times, a statistical process known as meta-analysis, which statistically
compiles the results across a number of studies, has become very prominent. This procedure
compares the efficacy of a particular therapy to a waiting-list control group, to another
therapy, or to other treatment modalities, such as medication. Two major findings have
emerged from these meta-analyses. The first is that being treated in psychotherapy is helpful
to roughly 40–60% of clients (Lambert, 2013), which is higher than many evidence-based
medical practices that are much costlier and come with side effects. The second is that there
is little comparative difference in the effectiveness of the therapies that have been exten-
sively practiced and researched, such as the ones discussed in this volume. Time and again,
the results of comparative studies have shown that when pitted against one another, each
therapy is more effective than being on a waiting list, but not better than any other standard
therapy (e.g., Lambert, 2013; Wampold & Imel, 2015).
The other major kind of psychotherapy research is known as process research. Rather
than focusing on the question of whether therapy works, it studies what takes place during
24 INTRODUCTION

the therapy, such as the nature of the techniques employed, and frequently their impact. A
subset of process research is process-to-outcome research, which attempts to answer the
question of how therapy works; that is, it relates process variables to change within a ses-
sion or to therapy outcome. For example, the effects of client/patient factors (e.g., race, age,
defensiveness, motivation), therapist factors (e.g., warmth, attunement, experience), types
of interventions (reflection, cognitive reframing, interpretations), and the interaction among
these and other variables and their relation to outcomes are all part of process research.
Thousands of such studies cannot be as neatly summarized as the field’s outcome results.
However, after their extensive review of process-to-outcome research, Crits-Christoph et
al. (2013) concluded that the strongest association between process and outcome is the
therapeutic alliance. Lambert (2013) concurs that a positive affective relationship and posi-
tive interpersonal encounters that characterize most forms of psychotherapy “loom large as
stimulators of patient improvement” (p. 206). The reader will find further examples in the
research sections or elsewhere in the body of the individual chapters.

EBP: The Science and Practice of Psychotherapy

There is a long history of disconnection between psychotherapy practitioners and psycho-
therapy researchers (e.g., Norcross, Klonsky, & Tropiano, 2008). The latter typically criti-
cize clinicians for engaging in practices that lack empirical justification (e.g., Baker et al.,
2009), and clinicians characterize researchers as being out of touch with the complex reali-
ties of conducting psychotherapy (e.g., Zeldow, 2009). Unfortunately, such criticisms are
not entirely unwarranted.
As already noted, the world of psychotherapy has seen increased pressure placed on
the advocates of particular therapeutic methods to document both the efficacy of their
approaches through carefully controlled clinical research trials and the effectiveness of these
methods via evaluations in uncontrolled, naturalistic clinical practice contexts (Nathan &
Gorman, 2015). This movement to favor empirically supported treatments (ESTs) has been
challenged by a complementary movement of psychotherapy researchers who assert the
often overlooked importance of evidence-based relationships in therapy (Norcross, 2011;
Wampold & Imel, 2015). Messer (2016), in an article on EBP, of which ESTs are a com-
ponent, spelled out the advantages and disadvantages of ESTs. Among the advantages are
a shared language regarding psychopathology via use of the DSM; ability to draw causal
conclusions about the efficacy of a therapy; possibility of replication of the procedures in
a standardized way by use of a manual; and the measurement of outcomes (e.g., symptom
change, psychosocial improvements) to ensure that we are not fooling ourselves when we
say that a therapy works.
Among the disadvantages of ESTs are that diagnosis is excessively narrow and mecha-
nistic, encompassing a limited view of the person, and does not apply to couples and fami-
lies; RCTs are subject to researcher allegiance effects in which researchers’ theoretical per-
suasion affects outcomes; exclusion of many people from RCTs or high dropout rates that
lead to overestimates of the value of the therapy for everyday practice; and deemphasis of
individual characteristics of clients/patients (e.g., cultural background) and of therapists
who are known to differ markedly in the outcomes they achieve. ESTs also tend to minimize
the crucial role of the therapist–patient relationship.
Whereas the term EST refers to the results of research affirming the positive outcomes
of a specific therapy, the prestigious Institute of Medicine (2001) defined the broader con-
struct of EBP as the integration of research (the emphasis in ESTs) with clinical expertise
 Current Issues in Psychotherapy 25

and patient values. Following suit, a report of an American Psychological Association Presi-
dential Task Force on Evidence-Based Practice (2006) defined EBP as “the integration of the
best available research with clinical expertise in the context of patient characteristics, cul-
ture and preferences” (p. 273). As the document explains, ESTs focus on each specific psy-
chotherapy and its efficacy for specific disorders or problems under specified circumstances,
whereas evidence-based psychological practice (EBPP) has as its starting point the client/
patient and addresses the empirical evidence (including data from RCTs) that will enable the
mental health professional to attain the optimal outcome. This definition is far friendlier
to the essential roles of therapists and clients/patients, and to the kinds of therapy that put
more emphasis on relationship factors than techniques (e.g., psychodynamic, experiential
and other humanistic therapies).
At the risk of oversimplification, those who advocate an EST perspective tend to be
associated with certain theoretical orientations (e.g., behavioral, cognitive, and cognitive-
behavioral), whereas those who adopt an evidence-based relationships perspective tend to
be associated with other theoretical orientations (contemporary Freudian psychoanalytic,
relational psychoanalytic/psychodynamic, person-centered and emotion-focused, existen-
tial–humanistic). Other dominant approaches (e.g., couple, family, group, integrative) stand
somewhere in the middle, akin to an EBP perspective.
In recent years, the American Psychological Association has begun to promulgate clini-
cal practice guidelines. For example, there are now guidelines for posttraumatic stress dis-
order, and obesity and overweight in children and adolescents, and many more are in the
pipeline (e.g., for depression). These guidelines offer information about strongly but condi-
tionally recommended ESTs and medications for these various psychological disorders and
are designed to serve as resources for practitioners as well as clients/patients and their fami-
lies. While these guidelines can be useful in informing psychotherapeutic practice and other
clinical interventions, and are in keeping with the emphasis in health care on EBP, many
practitioners have expressed concerns about the constraining nature of the clinical practice
guidelines and their overemphasis on ESTs as opposed to evidence-based relationships or
culturally informed psychotherapeutic practice.
Regarding their role in daily practice, Zeldow (2009) points out that clinicians will
always have to deal with uncertainty and uniqueness as they respond during therapy ses-
sions in a moment-to-moment way, and will have to rely on not only empirical research
but also their clinical judgment and values. Wolf (2009) sums it up well, stating that “both
a scientific knowledge base and a model of clinical practice that value the judgment of
the expert are necessary for psychology to be a learned profession” (p. 11). Can the field
of psychotherapy foster more EBP without unduly constraining the kinds of evidence and
expertise that are needed to inform it? That is, can we create a truly scientific practice that
is truly practice-friendly?

CASE ILLUSTRATION
A good example is the best sermon.
—Yankee P roverb

PURPOSE: To illustrate the clinical application of this model by detailing the

major assessment, structural, technical, and relational elements of
the process of treating a person–couple–group viewed as typical, or
26 INTRODUCTION

representative, of the kinds of clients/patients for whom this approach

is appropriate.

Points to consider:
1. Relevant case background (e.g., presenting problem, referral source, previous
treatment history, sociodemographic factors).
2. Description of relevant aspects of your clinical assessment: functioning,
structure, dysfunctional interaction, resources, and individual dynamics/
characteristics, including how you arrived at this description.
3. Description of the process and content of goal setting.
4. Highlight the major themes, patterns, and so forth, of the therapy over the
whole course of treatment. Describe the structure of therapy, the techniques
used, the role and activity of the therapist, and so forth.

NOTE: Do not describe the treatment of a “star case,” in which therapy

progresses perfectly. Select a case that, while successful, also illustrates the
typical course of events in your therapy.

The first psychotherapist to use case illustrations was none other than the founder
of modern psychotherapy, Sigmund Freud. Here is what he wrote about the case history
approach:

It still strikes me as strange that the case histories I write read like short stories and that, as
one might say, they lack the serious stamp of science. I must console myself with the reflec-
tion that the nature of the subject is evidently responsible for this, rather than any prefer-
ence of my own. . . . A detailed description of mental processes such as we are accustomed
to find in the works of imaginative writers enables me, with the use of a few psychological
formulas, to obtain at least some kind of insight into the course of that affliction [i.e., hys-
teria]. [The case histories provide] an intimate connection between the story of the patient’s
suffering and the symptoms of his illness. (Breuer & Freud, 1895/1955, p. 160)

There are several advantages to the case report as a method for presenting the process
of therapy. The therapist is in a privileged position to know what has happened over the
course of therapy. A case study summarizes large quantities of case material in a richly
textured, narrative fashion. Well-written cases bring material alive in a compelling way and
bring us in on the unfolding sequence of events, major emergent themes, and results of the
therapy. The treating therapist permits readers to participate in the discovery process and
share in the excitement in elaborating new ideas and techniques (Messer & McCann, 2005).
Case reports offer a more in-depth understanding of a particular approach to psychotherapy
and, as such, have unique educational value (Nissen & Wynn, 2014).
There are disadvantages to the case report as well, particularly from a scientific stand-
point. First, it is one person’s view only, albeit that of a trained observer. What is not
recorded may be technical mistakes that are not remembered or are simply omitted to avoid
guilt or shame (Spence, 1998). We cannot assume that accounts prepared for publication
are veridical, because we know memory is affected by wishes and confirmatory bias. The
summary report is therefore not a substitute for the recording of actual dialogue between
client/patient and therapist, because the data are selected in terms of both what is reported
and the inferences that are drawn by the reporting therapist. Furthermore, it may be more
 Current Issues in Psychotherapy 27

challenging to generalize from case reports than from RCT data; it is difficult to determine
a cause-and-effect relationship; and there may be a danger in overinterpreting findings (Nis-
sen & Wynn, 2014).
Nevertheless, there have been several creative endeavors to employ case studies in such a
way as to partially overcome these obstacles. One such effort employs a “hermeneutic single-
case efficacy design” (Elliott et al., 2009; Elliott & Widdowson, 2017), which incorporates a
combination of quantitative and qualitative data to create a rich report that offers evidence in
support of and counter to the hypothesized causal influence of psychotherapy on client/patient
outcomes (Elliott et al., 2009); that is, it searches for negative evidence to rule out compet-
ing explanations as to how events external to therapy might have resulted in client/patient
improvement. It has been argued that this approach offers researchers a viable alternative to
between- and within-group experimental designs (Benelli, De Carlo, Biffi, & McLeod, 2015).
A second approach, called the “pragmatic case study method” (Fishman, 2013), refers
to systematic, qualitative case studies that capture the process and outcome of psychother-
apy as practiced, and that are written up under standardized headings. Such cases also
include, where possible, a comparison of the individual with others via intake and outcome
data on standardized quantitative measures. (See the volume by Fishman, Messer, Edwards,
& Dattilio, 2017, for case examples derived from RCTs that combine qualitative and quan-
titative methods). The overall aim is to maintain the clinical richness and creativity of the
case study, while generating a database that permits cross-case comparisons and more gen-
eralized rules of psychotherapeutic practice. The pragmatic case study has been developed
in an Internet-based journal called Pragmatic Case Studies in Psychotherapy (pcsp.librar-
ies.rutgers.edu/index.php/pcsp/about/pcspabout), allowing open access and sufficient space
for a rich narrative case exposition and expert commentary on the cases.
In a review of the Fishman et al. (2017) volume, Bohart (2017) summarized the advan-
tages of case studies as follows:

• Identifying therapist and client/patient factors that may help determine success or
failure.
• Ascertaining extratherapeutic factors, such as the role of parents.
• Examining how mismatches between client/patient and therapy can affect outcome.
• Determining the role of culture.
• Examining how the process of a specific therapy works.

For other rigorous and systematic methods that enhance the scientific value of case
studies, see McLeod (2010) and Yin (2014). It remains to be seen to what extent such clini-
cal, single-case research efforts will be generative and supplement more typical group-based
empirical approaches in the future.

SUGGESTIONS FOR FURTHER STUDY

PURPOSE: To aid the instructor in assigning relevant readings and/or videos as

supplements to the text.

Points to include (plus one- or two-sentence annotation for each reference):

1. Two articles or accessible book chapters that provide detailed, extensive
clinical case studies.
28 INTRODUCTION

2. Two research-oriented articles or chapters, preferably one of which includes

an overview of research findings or issues pertinent to your approach.
3. Two videos that demonstrate your therapeutic approach.

ACKNOWLEDGMENT

We authors thank Don Cohen, a student in the Graduate School of Applied and Professional Psychol-
ogy at Rutgers University, for his assistance with this chapter. We also thank Jim Nageotte, Senior
Editor at The Guilford Press, for teaming us up to coedit this volume and for his helpful guidance
along the way.

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 PART II

PSYCHOANALYTIC/
PSYCHODYNAMIC APPROACHES
 CHAP TER 2

Contemporary Freudian
Psychoanalytic Psychotherapy
David L. Wolitzky

T he purpose of this chapter is to introduce the theory and practice of contemporary Freud-
ian psychoanalysis and the psychoanalytic psychotherapy that derived from it. The term
psychoanalysis refers to (1) a theory of personality and psychopathology, (2) a method of
investigating the mind, and (3) a theory of and approach to treatment. Here, I am concerned
primarily with the theory of treatment, but I need to present some of the basic theoretical
concepts as the context for understanding the rationale for therapeutic intervention.

HISTORICAL BACKGROUND

Sigmund Freud (1856–1939) was the founder of psychoanalysis and the father of modern
psychotherapy. Although he was confronted with the exigencies of the clinical situation,
Freud’s primary aspiration was to develop psychoanalysis as a theory of the human mind
and secondarily as a therapeutic modality. Accordingly, his theoretical writings consume the
bulk of the 23 volumes of his collected works, published as the definitive Standard Edition
of the Complete Psychological Works of Sigmund Freud (Freud, Volume 1, 1891–Volume
23, 1940).
As a comprehensive theory of personality and psychopathology, psychoanalysis had
a profound impact on 20th-century thought and culture. Psychoanalytic theorizing has
not only aimed at understanding and explaining the nature of psychopathology but it has
also addressed the broader domain of the development of normal personality functioning.
Attempts to understand art, literature, music, religion, and virtually all other significant
aspects of human experience according to psychoanalytic principles (so-called applied psy-
choanalysis) have filled innumerable journals and books for more than a century.

35
36 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

The origins of psychoanalysis can be traced back to the last two decades of the 19th
century, to the cultural context of turn-of-the-century Vienna. In the past century, we saw
many post-Freudian developments in psychoanalytic theory and practice. All of them took
their point of departure from Freud by either extending or modifying a line of thought
implicit or undeveloped in his work, or by rejecting essential Freudian assumptions.
There is by now significant diversity within what has been termed “the common ground
of psychoanalysis” (Wallerstein, 1990), meaning primary attention to the clinical phenom-
ena of transference and resistance. However, even these phenomena are conceptualized dif-
ferently by different psychoanalytic theorists. Thus, it is no longer accurate to refer to the
psychoanalytic theory of personality or of treatment. Rather, we need to specify the par-
ticular theoretical perspective from which we derive our clinical approach. In this chapter,
I focus primarily on the contemporary Freudian approach to treatment. This approach is
heavily influenced by traditional Freudian theory, its ego psychological extensions and the
development of object relations theories and self psychology.
For our present purposes, leaving aside Freud’s earliest theoretical formulations, we
can divide theoretical changes in psychoanalytic thinking into four main eras: (1) Freud’s
postulation of libidinal and aggressive instinctual drives as the prime movers of mental life;
(2) the development of ego psychology, which focused on the defensive and coping devices
used to deal with conflicted, often unconscious wishes; (3) the evolution of various versions
of object relations theories, with their focus on needs for relatedness rather than gratifica-
tion of sexual and aggressive wishes, and on the internalized representation of interpersonal
relationships; and (4) the advent of self psychology (Kohut, 1971), in which the cohesion
and fulfillment of the self came to be regarded as the individual’s primary aim (Pine, 1990).
According to Kohut (1971), the healthy personality is characterized by a firm, integrated,
positively toned sense of self with a strong center of initiative and personal agency. Essential
to this kind of personality development is consistent parental empathy, especially in the
form of “mirroring” the child’s experience (i.e., reflecting it back) and allowing oneself to
be idealized.
In the last two decades, we have witnessed the widespread influence of what broadly
may be termed American relational theory. Developed mainly by Mitchell (1988), relational
theories are an amalgam of Sullivan’s (1953) interpersonal theory and British object rela-
tions theories, primarily Fairbairn (1952) and Winnicott (1965). Relational theorists’ point
of departure from Freudian theory is captured in Fairbairn’s (1952, p. 82) dictum that
“libido is object seeking, not pleasure seeking,” in other words, that we are more hardwired
to seek relationships than to satisfy instinctual drives.
This chapter focuses primarily on the first and second eras of psychoanalytic theoriz-
ing and on the contemporary understandings of those views. (See Curtis, Chapter 3, this
volume, for more on the third and fourth eras.) This contemporary Freudian approach con-
tinues to adhere to most of the core propositions of Freud’s clinical theories in the context
of subsequent modifications and extensions of those theories. Current conceptualizations
dispense with Freud’s metapsychological concepts such as “cathexis” and “psychic ener-
gies,” because such concepts have little scientific basis and are far removed from the clini-
cal situation. Having provided this brief, orienting context, I can now proceed to trace the
evolution of the Freudian theory of treatment.
Prior to the development of any form of psychoanalytic therapy, the main methods of
treating emotional and mental disturbances were rest, massage, hydrotherapy (warm baths),
faradic therapy (the application of low-voltage electrical stimulation to areas of the body
 Freudian Psychoanalytic Psychotherapy 37

that were symptomatic), and hypnosis. The psychoanalytic method evolved from attempts
to treat symptoms via hypnosis (e.g., Charcot, 1882; Janet, 1907).
Freud, impressed by Charcot’s demonstrations of hypnotic effects, became particularly
interested in the potential of hypnotic suggestion as a therapeutic tool. The kinds of patients
first treated by Freud were usually late adolescent women who presented with hysterical
symptoms, that is, disturbances in the senses and/or the musculature, such as “blindness,”
paralyses, mutism, convulsive-like motor actions (e.g., trembling), and anesthesia (i.e., loss
of or diminished sensation in one or more parts of the body). These symptoms came to be
regarded as psychological when no organic basis for them could be found, although it is
quite likely that some organic conditions were mistaken for neurotic ones and vice versa.
At first, Freud tried the direct hypnotic suggestion that the symptom(s) disappear, an
approach that generally met with limited success. Some patients could not readily be hyp-
notized; in other patients, symptoms would dissipate but return. These early clinical expe-
riences led Freud to become more curious about the causes and mechanisms of symptom
formation and to search for more effective therapeutic methods. With regard to the latter,
Freud sometimes used the so-called “pressure technique,” in which he placed his hand on
the patient’s forehead and gave the strong suggestion that the patient would remember the
original experience associated with the onset of the symptoms. These early variations in
technique evolved into the method of free association, in which the patient is asked to say
whatever comes to mind, without the usual editing and inhibition characteristic of typical
social interactions.
The patient known as Anna O provided a critical turning point for Freud and for the
development of psychoanalysis. Anna O was suffering from a variety of hysterical symp-
toms. She wanted the opportunity to talk and have a “catharsis”; this marked the birth of
psychoanalysis as the “talking cure.” Breuer and Freud (1895/1955) published their ideas
about Anna O and other patients in Studies on Hysteria, the key idea contained in this
work being that “hysterics suffer from reminiscences”; that is, a painful memory is dissoci-
ated from the mass of conscious experience, and the “quota of affect” associated with that
memory is converted to a bodily symptom. The release of the dammed-up affect via retriev-
ing and talking about the memory allows for the “associative reabsorption” of the blocked
idea and feelings, and causes the symptom to disappear.
In this early phase of his work, Freud’s focus was on eliminating the symptom. How-
ever, Freud soon realized that patients’ symptoms were meaningful expressions of their
character and overall personality functioning. Over the next several decades, Freud evolved
his theory of personality development and psychopathology, which took into account the
interaction of biological and experiential factors, to explain both symptom formation and
the development of character traits and defenses. Little explicit attention was given to cul-
tural factors such as race, ethnicity, religion, or social class.
As he developed his psychodynamic point of view, Freud saw patients as being moti-
vated by a desire not only to seek gratification of wishes but also to keep wishes and their
associated affects out of awareness if they were regarded as apt to arouse anxiety, were
considered dangerous (i.e., could lead to punishment), and/or were regarded as unacceptable
according to the person’s moral standards. In Freud’s eventual theory, aggressive and sexual
wishes were the main sources of threat to the person.
This view was referred to as the “drive-defense” model, in which a key defense was
repression (i.e., the motivated expulsion of the conflicted wish from consciousness). Repres-
sion and other defensive maneuvers (e.g., projection, denial, reaction formation) appear to
38 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

banish threatening wishes, but although they drive them underground, they do not destroy
them, and they always weaken the personality by impairing its integrated functioning.
Below is a list of some major defenses used to ward off anxiety and other negative
affects:

1. Repression. Freud regarded repression as “the cornerstone of psychoanalysis,” the

major defense. Repression is motivated forgetting; one fails to remember something that
expresses or reminds one of wishes and feelings that are threatening. It refers to the preven-
tion of entry into consciousness of unacceptable impulses or their rapid banishment from
consciousness. For example, a husband forgets his wife’s birthday. Although historically,
repression was thought of as motivated forgetting, its broader essence is the avoidance of the
meanings associated with the forgotten material. Self-deception (i.e., avoidance of the true
meaning of a thought, feeling, or action) is the essence of all defenses.
2. Denial. This refers to the failure to acknowledge a piece of external reality that is
threatening. Up to a point, denial is adaptive. For example, not seeing the flaws in one’s
spouse enables a person to maintain an idealization that favors romantic feelings toward a
“special” person. On the other hand, if one ignores obviously ominous medical symptoms,
the denial is not adaptive. Denial can also take the form of what is called denial in fantasy.
Examples include a little girl who is convinced that she has a penis in her body that will
eventually emerge, or a boy who thinks his parents are not really his parents.
3. Projection. This refers to the tendency to disown and disavow an unacceptable feel-
ing toward someone else and, instead, attribute it to another person. For example, instead
of “I hate him,” the person harbors the belief “He hates me.” Another example would be
a man trying to avoid awareness of his homosexual interests toward his friend by claiming
that his friend is the one with homosexual interests toward him. In such a case a friendly,
innocent hug might be seen as evidence of sexual interest.
4. Displacement. In projection, the source of the impulse is externalized. In displace-
ment, it is the object of the impulse that shifts. The prototypical example is the man who is
furious at his boss who kept him waiting but, without realizing it, is hypercritical of his wife
because she was 5 minutes late to their dinner appointment.
5. Intellectualization. This defense is characterized by an attempt to distance one-
self from feeling. For example, a patient says, “I had a satisfactory marital experience last
night,” instead of talking directly about having sex with his wife.
6. Isolation of affect. Here, the attempt is to separate ideas from feelings. The person
might talk about very disturbing things, but there is no accompanying, appropriate affect.
To use the previous example, the person might talk directly about sex and not be evasive in
verbalizing the details but not show the affects linked to what is being said.
7. Reaction formation. In this defense, the person expresses the exact opposite of the
underlying, unconscious reaction in order to gain as much distance as possible from the
unacceptable reaction. A typical example is to present a saccharin-sweet façade to conceal
underlying hostility.
8. Undoing. As in reaction formation, the person tries to cancel or nullify a previous
action or thought by doing or thinking the opposite. This defense often takes on a compul-
sive quality. For example, a woman who is plagued by disturbing sexual thoughts that make
her feel dirty becomes preoccupied with the idea of cleaning her house.
 Freudian Psychoanalytic Psychotherapy 39

9. Regression. In this defense, one partially reverts to an earlier mode of functioning as

a way of avoiding certain feelings or anxieties. For example, a 4-year-old starts to suck his
thumb again soon after the birth of a younger sibling, rather than express anger at feeling
displaced.
10. Splitting (sometimes called “primitive splitting”). This term refers to the motivated
tendency to see things in black and white, that is, as “all good” or “all bad,” rather than
tolerate the ambivalence of a more balanced appraisal. An example, would be to idealize
one’s romantic partner to the point that obvious flaws or faults are ignored, denied, or
rationalized.
11. Rationalization. This means fooling oneself by giving an apparently socially rea-
sonable explanation that conceals one’s underlying, unacceptable motive or painful feeling
(known in common parlance as “sour grapes”). An example is telling your friend that you
were actually glad you were not invited to a party because you had too much homework,
when below the surface you felt hurt that you were not on the invitation list.
12. Sublimation. This is considered the healthiest defense, in that it involves the rechan-
neling of unacceptable sexual, aggressive, or other wishes into socially useful, acceptable,
adaptive ends. For example, becoming a surgeon, in part, to be able to indirectly express
aggressive impulses or becoming a photographer of nudes as a way of gratifying voyeuris-
tic impulses. From a broader perspective, we can view sublimation as the redirecting of
impulses of any kind to socially useful, adaptive endeavors.

THE CONCEPT OF PERSONALITY

For Freud, the basic focus of study was the intrapsychic life of the individual, that is, the
basic motives, wishes, anxieties, defenses, and regulatory capacities of the developing child,
as seen primarily from the perspective of psychic conflicts within the person.
What are the basic tensions one must reduce to avoid unpleasure and achieve instinc-
tual gratification? Freud always postulated two major classes of instinctual drives. At first,
the two drives were the sexual, or libidinal, and the self-preservative, or ego instincts. Later,
Freud theorized that the two major drives were the libidinal (or sexual) drive and the aggres-
sive drive, both broadly conceptualized. According to the theory, a drive is the psychical
representative of the instinct. It is a demand made on the mind for work. It impels the
organism to mental and physical activity, the aim of which is to discharge the nervous sys-
tem excitation produced by the drive. According to Freud’s final theory, sexuality (broadly
conceived as sensual) and aggression, also broadly conceived (e.g., competition) were the
two basic human motivational wellsprings of behavior.
Freud believed that there were two basic tendencies governing mental life, the plea-
sure principle and the reality principle. According to the pleasure principle, the basic
tendency of the organism is to maximize pleasure and to minimize pain, and to do so
in as rapid and automatic a way as possible. Increases in endogenous excitation were
regarded as unpleasant, whereas decreases were associated with pleasure. Reality forces
the organism to give up sole reliance on the pleasure principle (Freud, 1911/1958). For
example, the hungry infant needs eventually to discriminate between a fantasy of being
fed and actually eating, in other words, to operate according to the reality principle.
Freud also put forward the abstract philosophical idea that we are governed by “eros”
40 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

and “thanatos,” a life drive and a death drive, but these notions have been abandoned in
current thinking.
Freud’s theory has a strong developmental emphasis, as seen in his formulation of stages
of psychosexual development. These stages are the oral, anal, phallic, and genital. Each
stage is influenced by the preceding ones and in turn influences subsequent stages. As the
name implies, the oral stage centers on concerns with hunger, with the mouth as the chief
bodily zone involved, but is conceived of more broadly as including maternal care and com-
fort. At this stage, the primary fear is loss of the object—that is, of the mother as the sup-
plier and regulator of the infant’s needs. In the anal phase, the focus is on toilet training,
and the major anxiety is loss of the parent’s love. In the phallic phase, the boy is subject to
castration anxiety (and the girl to penis envy), and in the genital stage, guilt is the major
danger (Freud, 1891–1940, 1901/1960, 1911/1958, 1913, 1938).
Erikson (1950) presented a psychosocial elaboration of Freud’s psychosexual stages
in which he emphasized the psychological experiences central to each psychosexual stage
(e.g., describing the oral stage as a “zone” of significant psychological experience in which
the individual responds in a particular “mode” (i.e., the oral zone is the context in which
the infant first establishes a “basic trust” or “mistrust” as a mode of relating to the social
world).
The anticipation of the dangers in each psychosexual stage gives rise to signal anxiety
and triggers a defense against a potentially full-blown, traumatic anxiety. For example, sup-
pose a young boy has incestuous wishes toward his mother but believes and fears that such
wishes are dangerous and wrong, and will lead to his castration by the father. The boy, who
both loves his father and fears and resents him as an unwanted rival, now needs to defend
against his sexual wishes toward his mother. This, of course, is the classic Oedipal conflict
so central to traditional Freudian theory.
Two other key Freudian concepts deserve at least brief mention: fixation and regres-
sion. According to Freud, excessive frustration or satisfaction at each psychosexual stage
could lead to a fixation, or rigid clinging to a particular mode of satisfaction characteristic
of that stage. For example, excessive oral satisfaction (or frustration) could lead to the per-
sistence of thumb-sucking long after it is age appropriate. Regression refers to the reinstate-
ment of a mode of seeking satisfaction that is no longer age appropriate. If, for example, the
birth of a sibling leaves the older sibling feeling terribly unloved, he or she might revert to
thumb-sucking. Freud believed that the major modes of adaptation to the environment and
to the regulation of tension states are well developed by the time a child is about 6 years old
and change relatively little after that.
The core, interrelated propositions of traditional Freudian theory that contemporary
Freudians still embrace include the following:

1. The principle of psychic determinism states that there is a lawful regularity to men-
tal life; that is, even seemingly random or “accidental” mental phenomena (e.g., “Freudian
slips”) have causes.
2. A substantial part of mental life takes place outside conscious awareness. Uncon-
scious wishes and motives exert a powerful influence on conscious thought and behavior.
3. All behavior is motivated, either directly or indirectly, by a desire (a) to avoid being
rendered helpless by excessive stimulation, and (b) to maximize pleasure and minimize pain
(the pleasure principle).
 Freudian Psychoanalytic Psychotherapy 41

4. Inner conflict is inevitable and ubiquitous; all behavior reflects efforts at effecting
a compromise among the various components of the personality, principally one’s desires
for instinctual drive gratification (sexual and aggressive) and the constraints against such
gratification (physical reality, social constraints, and superego prohibitions).
5. In his “structural theory,” Freud (1923, 1926) grouped psychological forces into
three main agencies of the mind—the id, the ego, and the superego. The id refers to our
sexual and aggressive instinctual strivings. The ego is described in terms of a variety of
functions (e.g., judgment, planning, reality testing, coping, and defensive strategies) that
work together to determine the cost–benefit of expressing particular id urges. The superego
has two aspects, our internalized values (i.e., our conscience) and our ego ideals (our criteria
for feeling good about ourselves). In a healthy, functioning person, these three aspects of
personality blend relatively harmoniously with one another (Freud, 1923).
Although textbooks continue to present the standard Freudian view of id, ego, and
superego, among many contemporary Freudians, this conceptualization has given way
in recent years to one in which all mental activity is viewed as a compromise formation
(Brenner, 1994). This concept, part of Brenner’s (1982, 1994) modern conflict theory,
describes the mind as functioning to give expression to the person’s wishes, while taking
into account the potential anxiety, fear, and guilt the free expression of wishes might engen-
der. For example, a married man wishes to have an affair with his best friend’s wife. Instead
of acting on this wish, he fantasizes having sex with the woman.
Freud and Brenner agree on the centrality of inner conflict in human behavior. How-
ever, Brenner took issue with the positing of three functionally separate, independent “struc-
tures” in the mind (i.e., id, ego, and superego), though for many analysts this tripartite view
served as a convenient metaphor for talking about conflict. One of several problems with the
structural theory is that the id is considered to be the reservoir of primitive, raw instinctual
urges, lacking ideational content, and assumed to be the source of all motivation. For one
thing, this formulation neglects the motivational properties of affects. Another difficulty
with the structural theory is the fact that most wishes or impulses have an ideational com-
ponent (e.g., notions about the desired impact on the person to whom the urge is directed).
In addition, Brenner’s “experience-near” descriptive conceptualization avoids several unten-
able assumptions (e.g., the nature and distribution of so-called “psychic energies”) and the
reification involved in the structural theory.
6. Anxiety in small doses (i.e., signal anxiety) is a danger signal that triggers defensive
measures designed to avoid awareness of and/or behavior geared toward gratification of
unconscious wishes, in order to avoid an anticipated full-blown traumatic experience of
anxiety that would totally overwhelm the ego and flood the organism with an unmanage-
able amount of excitation.

Psychoanalytic ego psychology was developed, in part, as a corrective to an excessive

emphasis on sexual and aggressive motives. Aspects of ego psychology were implied by
Freud but fully developed by Anna Freud (1937), Hartmann (1939), and others. As seen
by these theorists, ego capacities (e.g., cognition, delay of gratification, reality testing, and
judgment) can be involved in conflict but later function as “conflict-free spheres of the ego.”
This theoretical thrust was an attempt to flesh out the ego’s role in adaptation and to make
theoretical room for behaviors, interests, and motives that are not always embedded in con-
flict and are not simply indirect expressions or sublimations of sexual or aggressive wishes.
42 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

Thus, the ego has a certain “primary autonomy” (i.e., inborn capacities that mature in an
“average expectable environment”; Hartmann, 1939) independent of the drives.
Mahler’s (1968) studies of separation–individuation and Jacobson’s (1964) work on the
self have contributed significantly to our understanding of the development of the selfhood,
a topic largely ignored in early psychoanalytic writings. In more recent years, issues of self-
esteem and disturbances in the sense of self (Jacobson, 1964) have been a prominent focus of
psychoanalytic theorizing, particularly in borderline and narcissistic conditions (Kernberg,
Selzer, Koenigsberg, Carr, & Appelbaum, 1989; Kohut, 1971).

PSYCHOLOGICAL HEALTH AND PSYCHOPATHOLOGY

Behavior is considered dysfunctional or pathological to the extent that the compromise

formations among the constituents of the personality (wishes, moral standards, preferred
modes of defense, judgments about reality, etc.) are maladaptive; that is, they create more
pain than pleasure, bring the person into significant interpersonal conflict, create undue
anxiety and/or guilt and depressive affects, lead to significant inhibitions in personal func-
tioning, and thereby impair the person’s capacity to love and/or work. In this view, there
is no sharp demarcation between “normal” and “abnormal” functioning (Brenner, 1994).
For example, there is a continuum of social anxiety, from minimal to severe. It is considered
normal to approach the task of public speaking with a certain amount of apprehension.
However, it would be considered abnormal if one’s social anxiety led to the strenuous avoid-
ance of any kind of social contact.
The Freudian drive-defense model also is used as part of the explanation for develop-
ment of personality or character styles. By personality or character (Reich, 1933), I mean
the unique psychological organization (of traits, conflicts, defensive and coping strategies,
attitudes, values, cognitive style, etc.) that characterizes the individual’s stable, enduring
modes of adaptation across a wide range of conditions encountered in his or her “average
expectable environment” (Hartmann, 1939).
If a person is able to approximate Brenner’s (1994) main criterion of mental health—
adaptive compromise formations—how might this be reflected in the person’s thoughts,
feelings, and actions? Based on clinicians’ input, Shedler and Westen (2007) presented a
long list of characteristics indicative of mental health from a psychodynamic perspective.
These criteria are not rated as only present or absent but on a continuum:

• Is able to use talents, abilities, and energy effectively and productively.

• Enjoys challenges: takes pleasure in accomplishing things.
• Is capable of sustaining a meaningful love relationship characterized by genuine inti-
macy and caring.
• Finds meaning in belonging and contributing to a larger community (e.g., church).
• Is able to find meaning and fulfillment in guiding, mentoring, or nurturing others.
• Is empathic; is sensitive and responsive to other people’s needs and feelings.
• Is able to assert him- or herself effectively and appropriately when necessary.
• Appreciates and responds to humor.
• Is capable of hearing information that is emotionally threatening (i.e., that chal-
lenges cherished beliefs, perceptions, and self-perceptions) and can use and benefit
from it.
 Freudian Psychoanalytic Psychotherapy 43

• Appears to have come to terms with painful experiences from the past; has found
meaning in and grown from such experiences.
• Is articulate; can express him- or herself well in words.
• Has an active and satisfying sex life.
• Appears comfortable and at ease in social situations.
• Generally finds contentment and happiness in life’s activities.
• Tends to express affect appropriate in quality and intensity to the situation at hand.
• Has the capacity to recognize alternative viewpoints, even in matters that stir up
strong feelings.
• Has moral and ethical standards and strives to live up to them.
• Is creative; is able to see things or approach problems in novel ways.
• Tends to be conscientious and responsible.
• Is psychologically insightful; is able to understand self and others in subtle and
sophisticated ways.
• Is able to find meaning and satisfaction in the pursuit of long-term goals and ambi-
tions.
• Is able to form close and lasting friendships characterized by mutual support and
sharing of experiences.

THE PROCESS OF CLINICAL ASSESSMENT

The unit of study is the individual or, more specifically, the problematic aspects of his or her
personality functioning as seen in the person’s behavior and intrapsychic life.
The primary means of assessing the individual’s personality and psychopathology is
through a series of unstructured and semistructured clinical interviews, on the basis of
which the clinician assesses the prospective patient’s suitability for psychoanalytic treatment
(Messer & Wolitzky, 2007). In the course of the clinical interviews, the therapist attempts
to form an initial picture of the patient’s current and past level of functioning, including the
nature, onset, duration, intensity, and fluctuation of symptoms and of maladaptive behav-
ior patterns. The clinician also is interested in the psychodynamic significance of current
stresses faced by the prospective patient and factors influencing the patient’s decision to seek
treatment. Part of this broad assessment of functioning includes an appraisal of the person’s
ego interests, areas of and capacity for pleasure, personality strengths, achievements, and
the current reality situation.
In the course of eliciting this information, the clinician also appraises the prospective
patient’s suitability for psychoanalytic treatment. Among the main qualities evaluated are
the person’s motivation for change; ego resources, including capacity to regress in the service
of the ego (e.g., to engage in fantasy); access to and tolerance of affects; capacity to form
a good therapeutic alliance; and degree of psychological mindedness. The latter refers to
the patient’s capacity for self-reflective awareness, an introspective tuning in on one’s inner
experiences.
Referrals for routine psychological testing are relatively rare, both at the stage of the
initial assessment and later on. Such a referral is more likely when there is little treatment
progress or marked unclarity regarding diagnosis (e.g., if organicity or a learning disability
is suspected).
Psychoanalysts today generally have little use for the official psychiatric diagnostic
44 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

system, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psy-
chiatric Association, 2013). To address the limitations of DSM-5 (e.g., as a merely descrip-
tive, atheoretical classification scheme), psychoanalytic clinicians devised the Psychody-
namic Diagnostic Manual, version 2 (PDM-2; Lingiardi & McWilliams, 2017). The PDM-2
provides a more comprehensive assessment of personality, including more of a focus on the
patient’s inner life and defensive patterns (see also Kernberg et al., 1989).

THE PRACTICE OF THERAPY

Basic Structure of Therapy
In what follows, I confine myself to an account of the practice of psychoanalytic treat-
ment as it is usually thought of in relation to neurotic and some relatively high-functioning
patients with borderline personality disorder. I do not discuss the modifications that are
made for patients with serious borderline and narcissistic disorders, nor do I consider spe-
cific treatment approaches to particular syndromes (e.g., panic disorder, schizophrenia).
Some introductory comments are in order prior to a discussion of the basic structure of
therapy. First, it is inaccurate to refer to the contemporary Freudian approach to treatment,
because even among those who identify themselves as contemporary Freudians, one can
delineate a range of positions (Ellman, 1998). This range can include traditional Freudian
theory, with its focus on sexual and aggressive conflicts; an emphasis on the interpretation
of unconscious fantasy; special attention to the transference; a focus on the ego’s defensive
maneuvers; and an emphasis on the therapeutic alliance and the therapeutic benefits of a
good patient–therapist relationship.
Second, psychoanalytic approaches to treatment can be arrayed on a continuum from
what has been called “expressive,” “exploratory,” “insight-oriented,” or “interpretive” at
one end to an explicitly “supportive” approach that features reassurance, praise, advice, and
encouragement instead of interpretations of transference and defense at the other. It should
be noted that even in expressive therapy there are inherently supportive elements (e.g., listen-
ing with interest, being nonjudgmental) that not only help build a treatment alliance that
makes patients more receptive to interpretations but also may be therapeutic in their own
right. For example, Schachter and Kächele (2007) advocate what they call “psychoanalysis-
plus,” that is, the deliberate, albeit judicious, use of explicitly supportive interventions in the
context of an overall psychoanalytic treatment.
Third, there has been a lot written about the distinction between psychoanalysis and
psychoanalytically oriented psychotherapy. There are some who make a sharp, qualitative
distinction between these two forms of treatment and others who stress their similarities and
overlap. In the past, the distinction has rested mainly on external criteria, such as frequency
of sessions and the use of the couch. Since then (Gill, 1982, 1994), the distinction is based
on the main intrinsic criterion—the degree of sustained transference-focused interpretations
is emphasized more in psychoanalysis (Høglend & Gabbard, 2012; Levy et al., 2017).
For those who favor the distinction, the implication is that whenever it is applicable,
psychoanalysis, rather than psychoanalytic therapy, is the treatment of choice. It is regarded
as a deeper, more thorough approach to the patient’s problems. Other forms of treatment
(e.g., dynamically based supportive psychotherapy) are said to mix the “pure gold of psycho-
analysis” with the “copper of suggestion” (Freud, 1913). Thus, the common clinical maxim
that has guided psychoanalytically oriented clinicians is to be as supportive as necessary
 Freudian Psychoanalytic Psychotherapy 45

and as exploratory as possible, that is, to minimize suggestion, advice, and reassurance and
to focus on interpretations leading to insight, whether one is conducting psychoanalysis or
psychoanalytic therapy.
In psychoanalysis today, sessions typically are held three or four times per week, for 45
or 50 minutes, over a period of many years. Psychoanalytic psychotherapy and supportive
therapy usually take place at a frequency of once or twice a week in the face-to-face position.
Psychoanalytic psychotherapy can last as long as psychoanalysis or may be as short as 12
sessions (e.g., Messer & Warren, 1995).
In what follows, I focus primarily on psychoanalysis, with the understanding that most
of what I say is more or less applicable to psychoanalytic psychotherapy.

Goal Setting
After the initial consultation sessions and arrangements for the therapy (e.g., frequency of
sessions, fee), the sessions are deliberately unstructured. The analyst invites the patient to
free-associate, that is, to say whatever comes to mind. Thus, the patient determines the
content of the session. The more freely and openly the patient talks, and the more he or she
is able and willing to suspend the normal inhibitions and editing processes that are part
and parcel of our usual dialogue with others, the more self-disclosing the person becomes,
and the easier it will be for previously repressed or suppressed feelings and thoughts to
come to the surface for analytic scrutiny and understanding. The rationale for use of the
couch is that being in a supine position and not seeing the analyst will facilitate the turning
of attention inward rather than responding to visual cues emitted by analyst (e.g., facial
expressions).
The goal of encouraging the patient to free-associate is a mediating or process goal. It
allows both patient and analyst to observe when and how the patient engages in defensive
maneuvers in the face of actual or anticipated anxiety, or other dysphoric affect. In this
manner, the patient gets an increasingly clear sense of how his or her mind works, and how
these workings are shaped by unconscious factors, and by anxiety and defenses.
Rarely is a time limit imposed on the therapy. The main exception is brief, psychoana-
lytically oriented treatment, in which the initial treatment contract makes clear that the
therapy comprises a fixed number of sessions or a fixed time period (for an account of the
variety of short-term psychoanalytically oriented psychotherapies, see Messer & Warren,
1995; also see Farber, Chapter 12, this volume, for a discussion of brief psychodynamic
therapies). There also are a variety of psychoanalytically informed therapies that I do not
discuss in this chapter, including child, couple, family, and group therapies.
Stated in general terms, the ultimate goal of treatment is to increase adaptive function-
ing by ameliorating the disabling symptoms, crippling inhibitions, and maladaptive defenses
and conflict solutions that have plagued the patient. As the patient gradually reduces the
neurotic vicious cycles that characterized prior adaptive efforts, he or she experiences this
change as involving an expanded sense of personal agency and freedom. Usually, this goal is
assumed to be so basic and obvious as not to require explicit verbalization.
At first, Freud thought that the path to cure involved “making the unconscious con-
scious.” His later epigrammatic statement of the goal of psychoanalysis was consistent with
the replacement of the topographic theory of mind as being constituted of conscious, pre-
conscious, and unconscious elements by the structural theory (id, ego, superego) (Freud,
1923). In other words, awareness was still considered a necessary but now a no longer
46 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

sufficient condition for change. The patient must also be able to accept and to integrate
previously disavowed, split off aspects of his or her personality.

Process Aspects of Treatment

The main strategy in the conduct of psychoanalytic treatment is the analysis of transference
reactions and resistances that emerge from the patient’s “free associations.” Compared with
psychoanalysis proper, in psychoanalytic psychotherapy there is relatively less focus on the
transference.

Transference
As a useful, working definition of transference, one can cite Greenson (1967): Transference
is the “experience of feelings, drives, attitudes, fantasies, and defenses toward a person in
the present which do not befit that person but are a repetition of reactions originating in
regard to significant persons of early childhood, unconsciously displaced onto figures in the
present” (p. 155). In describing transference as a new edition of an old object relationship,
Freud (1912/1953) noted that the repetition need not be literal, just that it express the origi-
nal, childhood conflicts.
Freud first mentioned transference in Studies on Hysteria (Breuer & Freud, 1895/1955),
calling it a “false connection,” because the patient’s reaction could not be adequately
accounted for by the present situation. Freud assumed that it derived from unresolved child-
hood conflicts related to the parents. He saw transference as both a powerful obstacle to
and an essential factor in the treatment. The value of transference reactions is that they
can bring to light, with strong emotion, the patient’s hidden and forgotten unacceptable
impulses, conflicts, and fantasies. At the same time, patients naturally resist awareness of
these kinds of mental contents, particularly when they are directed toward the person of the
therapist. However, the emotional reliving of childhood conflicts with the analyst can bring
the patient’s problems into bold relief.
Transference reactions to emotionally significant persons in the present are fairly ubiq-
uitous and are not restricted to experiences in analysis. In fact, in everyday life, they often
are a source of considerable difficulty in interpersonal relationships. What is distinctive
about psychoanalytic treatment is that they are facilitated by the structure of the treatment
situation (e.g., the patient’s supine position on the couch in psychoanalysis but not in psy-
choanalytic therapy) and they are analyzed.
Freud originally classified transference reactions into three kinds: the positive (erotic)
transference, the negative (hostile), and the unobjectionable (i.e., aim-inhibited or nonerotic)
positive transference necessary for cooperating and collaborating in the analytic work (an
attitude that is part of the “working alliance”; Greenson, 1965). The other characteristics
of transference reactions, which essentially follow from Greenson’s definition, are that they
show evidence of inappropriateness, tenacity, and capriciousness. However, it is important
to realize that so-called “transference” reactions are not created out of “whole cloth” but
are triggered by real qualities of the analyst. Therefore, Gill (1994) argues that transference
reactions should not be considered “distortions” but be viewed as the patient’s experience
of the analyst.
Contemporary analysts focus at least as much on the “here-and-now” transference as
 Freudian Psychoanalytic Psychotherapy 47

on the past. One way to think about the “new” and the “old” in the therapeutic relationship
is that the patient needs to experience the analyst as an “old” object in order for the trans-
ference to form and take hold, and as a “new” object in order for the patient to collaborate
with the analyst, and to understand and to resolve the transference. Finally, I should note
that not all analysts define transference in the same way. Eagle’s (2018b) review of the litera-
ture shows at least nine different meanings given to the term transference.

Resistance
As the patient attempts to free-associate, there inevitably will be indications of resistance to
both the awareness of warded-off mental contents and the behavioral and attitudinal changes
that might be attempted, based on such awareness. Resistance, following Gill (1982), can
be defined as defense expressed in the transference, though Freud initially defined it more
broadly as anything that interferes with the analysis.
Because the patient fears the anxiety and/or depressive affect (e.g., humiliation, shame,
and guilt) that is anticipated as an accompaniment to the awareness of certain wishes and
fantasies, particularly those that involve the analyst, the natural tendency is to defend
against and to avoid becoming aware of those mental contents. At the same time, the ana-
lytic situation has been deliberately designed to maximize the possibility of such awareness.
Resistance can and does take many forms, both blatant (e.g., a deliberate refusal to say
what is on one’s mind) and subtle (e.g., filling every silence quickly out of fear that the ana-
lyst may be critical of “resistance”). The last example highlights the fact that the patient’s
resistance is usually connected to the analyst, and these transference resistances are the
major focus of analytic attention. As Freud (1912/1953) said, “The resistance accompanies
the treatment step by step. Every single association, every act of the person under treatment
must reckon with the resistance and represents a compromise between the forces that are
striving towards recovery and the opposing ones” (p. 103). In other words, the patient is
simultaneously motivated to express and to conceal wishes, fantasies, and conflicts associ-
ated with dysphoric affects.
Patients (and, unfortunately, also many therapists) think of resistance as something
“bad,” as something to be overcome. This pejorative connotation doubtless derives from the
early days of psychoanalysis, in which Freud used hypnosis and pressure techniques, and
insisted on complete candor (“You must pledge to tell me everything that comes to mind”)
in the initial formulation of the “fundamental rule” of free association. Thus, resistance
naturally and inevitably includes “opposition to free association, to the procedures of analy-
sis, to recall, to insight, and to change” (Eagle & Wolitzky, 1992, p. 124). Resistances are
designed to protect the patient against anxiety and the fear of change, that is, to maintain
the familiar, apparent safety of status quo, however painful. Finally, it should be noted that
the affirmative, as well as the obstructive, aspects of resistance need to be recognized. For
instance, resistance can be used in the service of forestalling a feared regression, asserting
the patient’s autonomy, or protecting the therapist from one’s destructive impulses.
The underlying sources of the clinical manifestations of resistance include the constitu-
tional strength of the instinctual drives, rigid defenses, and powerful, repetitive attempts to
seek particular, familiar forms of drive gratification (what Freud called the “adhesiveness
of the libido”). A major focus of psychoanalysis and psychoanalytic psychotherapy is the
interpretation of transference and resistance, which is the next topic.
48 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

Interpretation (and Insight)

Interpretation (particularly, though not exclusively, of the transference) leading to insight
has long been regarded as the major curative factor in the Freudian approach to treatment.
In recent years, however, many analysts have given considerable weight to the curative prop-
erties of the noninterpretive elements in the therapeutic relationship (e.g., therapist empathy
and implicit support), particularly with more disturbed patients.
Interpretation, broadly conceived, refers both to meanings attributed to discrete
aspects of the patient’s behavior and experience, particularly its unconscious aspects, and to
constructions that attempt to offer a more comprehensive account of larger portions of the
patient’s history and behavioral patterns (Wolitzky, 2007).
Schematically stated, the optimal interpretation, though not necessarily presented com-
prehensively at one time, would take the form “What you are doing (feeling, thinking, fan-
tasizing, etc.) with me now is what you also are doing with your current significant other
(spouse, child, boss, etc.), and what you did with your father (and/or mother) for such and
such reasons and motives and with such and such consequences.” In the convergence of the
past and the present (both in the treatment relationship and in other current relationships),
the recognition of repetitive, pervasive, and entrenched patterns of relating and of personal
functioning can have significant emotional impact. This process is facilitated by the patient’s
identification with the analyst and the analytic attitude of self-reflection.
Although interpretation of transference resistances is considered to be “the single most
important instrument of psychoanalytic technique” (Greenson, 1967, p. 97), other interven-
tions usually are necessary prerequisites to interpretation. For example, confrontation and
clarification are preparatory to interpretation. Confrontation points to the fact of resistance
(e.g., “I notice that when you are reminded of your mother, you quickly change the subject”).
Clarification refers to exploration of why the patient is resisting (e.g., “Talking about your
mother that way seems to have made you uncomfortable”). This line of inquiry blends into
interpretations of the unconscious fantasies and motives for the resistance (e.g., “You think
that wishing to be alone with your mother was wrong and that I will chastise you for feel-
ing that way”). A detailed exposition of these techniques can be found in Greenson (1967).
The overarching therapeutic strategy is to foster and flexibly maintain the conditions
necessary for interpreting the transference. It is believed that a good working alliance
(defined later) and an “optimal” degree of transference gratification–frustration will facili-
tate the desired oscillation between the patient’s self-observation and expression of feeling,
and the analysis of defense and transference. However, there will be occasions, particularly
with the so-called “nonclassical” analytic patient, when the therapist knowingly and advis-
edly employs nonanalytic interventions, including advice, active support, suggestions, and
so on.
Among some contemporary Freudians (e.g., Levenson, 2007), the emphasis has not
been on directly interpreting the unconscious wishes underlying the transference but on
interpreting defenses against awareness of warded-off mental contents. So-called defense
analysis focuses on the ways in which the patient attempts to ward off anxieties and fears.
Most analysts today agree that defense analysis should start at the “surface” and proceed
gradually to “deeper” levels, like peeling the layers of an onion. Some theorists stress that
feeling safe as a result of the analyst passing tests posed by the patient (e.g., Weiss & Samp-
son, 1986) enables the patient to access his or her own previously warded-off mental con-
tents, with little or no interpretation from the analyst.
 Freudian Psychoanalytic Psychotherapy 49

Despite the increased flexibility of analytic technique and open acknowledgment of the
inevitably interactive, two-person nature of the analytic relationship, contemporary Freud-
ians, like their more traditional predecessors, cannot seem to shake the image of being aloof,
authoritarian, and technique driven. However, contemporary Freudians readily agree that
any analyst who is wooden in style and lacking in spontaneity, while slavishly and inflexibly
adhering to a set of preselected clinical techniques and theories, or to a treatment manual,
is not likely to be effective.
Clearly, everything that transpires between the patient and therapist, including interpre-
tations, is part of an ongoing interaction. The distinction is really between interactions that
emphasize interpretations and interactions that do not. Thus, interpretations are particular
kinds of interactions. It is safe to say that virtually all contemporary Freudian psychoana-
lysts have discarded the original model of the analyst as a “blank screen” in favor of the view
of the therapeutic relationship as an ongoing, two-person transference–countertransference
matrix in which patient and analyst mutually influence one another. Analysts appreciate the
recursive nature of the transference (i.e., that often the patient and the analyst are enacting
the very theme about which they are talking).
The shifting cultural attitude away from a positivistic, objective, knowable reality
toward a more relativistic, pluralistic, constructivist view has had a significant impact on
psychoanalysis, particularly with regard to views of interpretation. This change has been
referred to as the “hermeneutic turn” in psychoanalysis. From this perspective, interpreta-
tions are regarded much more as co-constructions by analyst and patient than as discoveries
of an underlying psychic reality discerned by the analyst. Lines of interpretation are consid-
ered to be as much a reflection of the analyst’s preferred story lines and narratives as they
are veridical readings of the patient’s psychic reality (Schafer, 1992). In part, this view is
an antidote to an analytic stance in which the analyst thinks he or she possesses something
akin to interpretive infallibility, a countertransference danger that can plague any analyst,
regardless of theoretical persuasion (Eagle, Wolitzky, & Wakefield, 2001).

Process of Therapy
In psychoanalytic treatment, clinicians distinguish between an opening phase, the extended
middle phase of “working through,” and the termination phase. According to Freud, psy-
choanalysis can be likened to chess; the opening moves and the end game are fairly stan-
dard, but the long middle phase is not predictable and is open to many variations. Actually,
these variations also can be found in the opening phase and in the termination phase.

The Opening Phase: Attention to the Working or Therapeutic Alliance

The primary emphasis in the opening phase of treatment is on the establishment of rap-
port and a good working relationship, the importance of which was recognized early on
in Freud’s notion of the “unobjectionable positive transference.” Subsequently, this aspect
of the therapeutic relationship has been called the “working alliance” (Greenson, 1965;
Messer & Wolitzky, 2010).
According to Greenson (1967), the working alliance is the “relatively non-neurotic,
rational relationship between patient and analyst which makes it possible for the patient
to work purposefully in the analytic situation” (p. 45). The patient achieves this attitude
when feeling safe and accepted in the analyst’s presence. Being in a stable, nonjudgmental,
50 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

predictable relationship focused mainly on the patient’s needs contributes to the “back-
ground of safety” (Sandler, 1960) that enables the patient to communicate his or her
thoughts and feelings more openly. It also fosters an identification with, or at least an adop-
tion of, the clinician’s analytic stance. This collaborative spirit of inquiry and understand-
ing, which is part of the alliance between the analyst’s analytic attitude and the patient’s
reasonable, self-observing ego, is not a once-and-for-all achievement but one that is inevi-
tably disrupted by the patient’s transference reactions, as well as the therapist’s counter-
transference reactions.
Analytic interventions, as well as silence, can be experienced as narcissistic injuries
caused by the patient’s sense of the analyst’s failure of empathy. Ruptures in the alliance are
not only inevitable but are also seen as important and necessary spurs to the therapeutic
process, because, when recognized, they create the opportunity for repair and the reestab-
lishment of the alliance, which usually strengthens it. Thus, although the ruptures might
arouse negative feelings and shake the patient’s trust in the analyst, the repairs can restore
and solidify it. The patient learns that a relationship can survive some pain and misunder-
standing when the analyst is a fair and decent person (Messer & Wolitzky, 2010; Safran &
Muran, 2000; Safran, Muran, & Shaker, 2014).
An unwitting transference–countertransference enactment in which the patient and
therapist are drawn into and engage in neurotically based interactions, without awareness,
is the most common cause of a disruption in the alliance. The rupture can take the form of
subtle avoidance and withdrawal or it may be overtly confrontational (e.g., questioning the
analyst’s competence). In recent years, we have seen an extensive theoretical and research
literature on the alliance, its rupture, and its resolution (e.g., Safran et al., 2014).
How does one foster the treatment alliance? The primary answer is that one listens
empathically and nonjudgmentally; is alert to detecting and managing countertransference
reactions; explains, to the extent necessary, the rationale for the rules and the framework
of the treatment (e.g., why one does not routinely answer questions); and offers interpreta-
tions with proper timing, tact, and dosage. By the latter, I mean that the therapist develops
a sense of the patient’s optimal level of anxiety and his or her vulnerabilities to narcissistic
injury (blows to self-esteem). The therapist functions in a way that is aimed at not trau-
matically exceeding these levels. These considerations take precedence over any technical
rules for handling the opening phase of treatment (or any phase, for that matter). Thus, the
usual technical precepts of analyzing defenses before impulses, beginning with the surface,
allowing the patient to determine the subject of the session, and so on, are all liable to be
suspended if clinical judgment so dictates.
Given this perspective, the most common and serious technical errors a therapist can
make are really not technical per se but stem from countertransferential attitudes and inter-
ventions that reflect rigid, arbitrary, unempathic responsiveness to the patient and thereby
fail to respect the patient’s individuality, integrity, autonomy, and anxiety tolerance. Any
specific, discrete technical error (e.g., intervening too rapidly) is considered problematic
but relatively minor when compared to the danger of retraumatization that can occur if the
therapist acts in the manner previously described. Thus, common technical errors, such as
failing to leave the initiative with the patient; frequent interruptions and questions (espe-
cially those that call for a simple “yes” or “no” rather than encouraging exploration); offer-
ing farfetched, intellectualized, or jargon-filled interpretations; an excess of therapeutic
zeal; attitudes of omniscience and grandiosity; dogmatism; the need to be seen as clever;
 Freudian Psychoanalytic Psychotherapy 51

persistent failure to begin or end the session on time; and being punitive or overly apologetic
all derive their potentially adverse effects from the extent to which they express undetected
and therefore unmanaged countertransference.

The Middle Phase: Working Through

In the extended middle phase of treatment, the focus is on the analysis of transference and
resistance, with the aim of having patients “work through” their long-standing conflicts.
Working through refers to “the repetitive, progressive and elaborate explorations of the
resistances which prevent insight from leading to change” (Greenson, 1967, p. 42).
Resistance to change often can be slow to dissolve. Maintaining the status quo com-
monly is seen as the safest course. Fear and guilt concerning the consequences of change
(e.g., feeling that one does not deserve to be happy, feeling that changing means abandoning
or being disloyal to a parent, and the reluctance to relinquish long-cherished fantasies and
beliefs) continue to be analyzed in their various, often subtle forms, so that the secondary,
as well as the primary, gain of the symptoms or neurotic patterns may be understood and
lessened.
Thus, repeated exploration and elaboration of the patient’s key unconscious conflicts
and the defenses against them as they become expressed in the context of the therapeutic
relationship, and in other aspects of the patient’s life, are the core of the analytic process.

The End Phase: Termination

It is generally agreed that termination usually should not be forced (as in setting a specific
time limit), unilateral, premature, or overdue. As the work proceeds, therapist and patient
periodically assess the degree of progress made toward achieving the therapeutic goals. Ide-
ally, the idea of termination emerges naturally in the minds of both participants as they
recognize that the therapeutic goals (both those articulated at the start and others that
developed in the course of treatment) have been essentially met, and that the treatment has
therefore reached the point of diminishing returns.
The rationale for a planned termination phase rather than an abrupt ending includes
the idea that separation from the analyst is a significant psychological event that will evoke
feelings, fantasies, and conflicts that resonate with earlier separations from or losses of sig-
nificant others. It is not unusual that once a target date for termination is set, feelings along
these lines emerge, feelings that previously had been latent or not dealt with before termina-
tion became a looming reality. The temporary return of symptoms in the termination phase
is not uncommon, often as an expression of separation fears (“See, I’m not ready to stop
treatment”). Treatment does not fully resolve all conflicts, nor is it expected to permanently
immunize the patient from future psychological difficulties.

THE THERAPEUTIC RELATIONSHIP AND THE STANCE OF THE THERAPIST

The analyst’s stance is best described as one in which the primary aim is to maintain an
analytic attitude (Schafer, 1983) that facilitates and maintains a positive working alliance
and make analytic work possible. A major component of the analytic attitude is the analyst’s
52 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

genuine interest in helping the patient, expressed, in large part, through the creation of a
safe, caring, nonjudgmental therapeutic atmosphere.

Analytic Neutrality
Analytic neutrality is considered an essential feature of the proper analytic attitude. Neu-
trality is here understood not in the sense of indifference to the patient but in the sense of not
taking sides in the patient’s conflicts. In other words, the analyst attempts to be objective in
the context of offering an empathic understanding of the patient. This stance has also been
called benevolent neutrality or technical neutrality.
In addition, the analyst respects the uniqueness and individuality of the patient and
does not attempt to remake the patient to fit any particular image or set of values. The
analyst does not exploit the patient to meet his or her own needs. The analyst does not try
to rescue the patient, to play guru, to become engaged in power struggles with the patient,
or to seek the patient’s adulation. The analyst appreciates that patients both seek and are
frightened by the prospect of change, and that ambivalence is a ubiquitous feature of human
experience.
Therapeutic neutrality does not prohibit the therapist from some ordinary human inter-
actions, such as saying “hello” and “good-bye” to a patient or wishing the patient well on
the eve of an important experience (childbirth, graduation, marriage, surgery, etc.).
It should be noted that several silent factors inherent in the treatment situation can be
powerful sources of satisfaction and security. Foremost among these elements is the sense
of steady support that comes from the sustained, genuine interest of a benign listener over a
long course of regular and frequent contacts. This sense of support has been referred to as a
holding environment (Winnicott, 1965). This term is a metaphor derived from Winnicott’s
view that the analytic setting bears a similarity to features of the mother–child interaction,
in which the child is not only literally held as a means of soothing but is also cared for and
loved more generally, and comes to rely on the provision of this protection.

Empathy
Based on the amalgam of past clinical experience, knowledge of human development,
general models of human behavior, and particular psychoanalytic theories, the analyst
tries to listen, as Freud recommended, with “evenly hovering attention” (i.e., not with
a preset bias toward certain kinds of material) and will later organize the material in
particular ways to develop a working mental model of the patient. This crucial, nonjudg-
mental listening process is guided by the analyst’s empathy. Empathy involves a partial,
transient identification with the patient, in which the analyst attempts to apprehend in a
cognitive–affective manner what it is like for the patient to experience his or her outer and
inner world in a particular manner. In other words, the analyst tries to enter the patient’s
experiential world by imagining, both cognitively and affectively, what the patient’s sub-
jective experience is like. The analyst oscillates between relating to patients in this way
and stepping back periodically as an observer and reflecting on why patients seem to be
experiencing their inner world in a particular manner. These reflections serve as the basis
for the private clinical inferences made by the analyst that then lead to the actual interpre-
tations made to the patient. Offered with proper timing, tact, and dosage, interpretations
attempt to convey both empathic understanding and explanation of patients’ difficulties.
 Freudian Psychoanalytic Psychotherapy 53

(For a detailed examination of the nature of empathy and its role in therapy, see Eagle &
Wolitzky, 1997).

Countertransference
At first, countertransference was thought of as the direct counterpart to the patient’s trans-
ference (i.e., as the analyst’s transference to the patient’s transference, or to the patient
more generally). By this definition, countertransference was regarded as an unconscious,
undesirable, potentially serious obstacle to effective treatment. Freud (1910/1957) held that
the therapist’s countertransference limited the degree to which the patient could progress in
treatment.
In more recent years, influenced in large part by work with more disturbed patients, the
concept of countertransference has been broadened to a view that includes all the analyst’s
emotional reactions to the patient, whether conscious or unconscious, and the analyst’s
transference reactions to not only the patient’s transference but also the patient’s overall
personality, as well as the analyst’s reactions to being in the role of analyst with a particular
patient and with patients in general. Some authors (e.g., Weiner & Bornstein, 2009), make
a distinction between specific and generalized countertransference. The former refers to an
analyst’s reactions that are unique to a particular patient and triggered when some aspect
of the patient or what the patient says triggers unresolved issues in the analyst that lead to
positive (e.g., overly nurturing) or negative (e.g., hostile) reactions to the patient; the latter
refers to reactions that tend to be present in all, or most, cases treated by a particular analyst
(e.g., a strong need to be idealized).
The broader definition of countertransference has been called “totalistic,” in contrast
to the earlier “classical” definition (Schlesinger & Wolitzky, 2002). The therapist’s emo-
tional reactions, whether based primarily on his or her own conflicts or due mainly to the
fact that the patient’s behavior would likely evoke the same reaction in virtually all analysts,
are inevitable. Being aware of one’s emotional reactions to the patient is potentially quite
useful, indeed vital to understanding the patient. For example, the therapist’s reactions,
when subjected to self-reflection, can point to feelings that the patient might be “pulling
for” from the therapist. However, an analyst needs to be careful not to assume automatically
that just because he or she is feeling a certain way, the patient must be trying to evoke that
particular reaction. To make such an automatic assumption, as one unfortunately encoun-
ters not infrequently in some recent psychoanalytic literature, is to ignore the possibility that
it is primarily one’s own conflict-based countertransference that is responsible for what one
thinks the patient is trying to make one feel.
Transference–countertransference enactments are episodic and/or chronic patient–
therapist interactions (e.g., victim–perpetrator) that express unresolved conflicts or unsatis-
fied needs of both participants. To the extent that the asymmetrical structure of the analytic
situation allows the therapist to be somewhat less emotionally vulnerable than the patient,
the therapist can afford to hold in relative abeyance during the sessions his or her unre-
solved issues while at the same time being aware of when he or she is being drawn into an
enactment. The prescription for dealing with countertransference reactions is self-analysis,
informed by the analyst’s own prior training analysis and clinical supervision, and, if neces-
sary, supplemented by consultations with colleagues and/or the analyst’s resumption of his
or her own therapy. The presumption is that undetected (and therefore unmanaged) coun-
tertransference reactions always have a detrimental impact on the treatment.
54 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

Unclear, and rather controversial, is the issue of countertransference disclosure. In

other words, to what extent and under what circumstances should the analyst disclose to the
patient the fact of his or her countertransference and perhaps include the presumed basis for
it? Some analysts, more typically those with a relational orientation, regard self-disclosure
as essential to fostering the egalitarian spirit of the analytic process and for affirming the
patient’s sense of reality, whereas other analysts feel that it could unnecessarily burden the
patient and should be employed quite sparingly. In any event, self-disclosures can be of vari-
ous kinds (e.g., personal facts about one’s history, favorite vacation spots, or feelings toward
one’s patient). Which kinds of self-disclosures can facilitate the treatment and which kinds
can interfere or even jeopardize it is an issue that requires investigation.

CURATIVE FACTORS OR MECHANISMS OF CHANGE

Since the inception of psychoanalysis, there has been ongoing discussion and debate con-
cerning its curative ingredients. For many years, Freudians believed that insight generated
by interpretation of the transference was the key therapeutic ingredient. By now, it is clear
that no single factor can be said to be the major element in therapeutic change for all
patients.
There is a general consensus that the conditions conducive to positive treatment out-
comes include the following: (1) a person who (a) is suffering emotionally, (b) is motivated to
change, (c) shows some degree of psychological mindedness, (d) has sufficient ego strength
and frustration tolerance to endure the rigors of the treatment, and (e) has a decent enough
history of gratifying, trusting interpersonal relationships to form and maintain a reasonable
working alliance in the face of the inevitable difficulties involved in the treatment; and (2) a
therapist who (a) can provide a safe, nonjudgmental atmosphere, (b) can be an effective cata-
lyst for the patient’s self-exploration, (c) can facilitate and maintain the therapeutic alliance
in the face of its inevitable strains and ruptures (Messer & Wolitzky, 2010), (d) is relatively
free of unmanaged countertransference reactions, and (e) provides accurate, empathically
based interpretations of transference and extratransference behaviors with the timing, tact,
and dosage necessary to facilitate insight into the unconscious conflicts that influence the
patient’s symptoms and maladaptive patterns of behavior.
Broadly speaking, the curative factors in the conditions just listed have been divided
into two main categories—insight and the relationship. This is potentially a false distinc-
tion, because insight based on interpretation takes place in the context of the patient–
therapist relationship. Thus, an interpretation leading to an emotionally meaningful insight
can be, and often is, simultaneously experienced as a profound feeling of being under-
stood. Nonetheless, the distinction between insight and relationship factors is retained in
an attempt to assign relative influence to the element of enhanced self-understanding ver-
sus the therapeutic benefits of the relationship per se. Among the benefits of the latter,
one can include the support inherent in the therapeutic relationship; the experience of a
new, benign relationship with a significant person (i.e., one who does not re-create the
traumatic experiences the patient suffered in relation to the parents); and identification
with the analyst and the analytic attitude, which includes a softening of superego self-
punitiveness and feeling understood, supported, and a sense that one’s emotional upheavals
can be safely “contained” by the analyst, even when the analyst’s interpretive efforts arouse
some degree of anxiety. Alexander (1950) and Alexander and French (1946) have had a
 Freudian Psychoanalytic Psychotherapy 55

significant influence with their view of psychoanalytic treatment as a “corrective emotional

experience.”
Among most contemporary Freudian analysts, especially those who maintain a more
or less traditional view, these relationship elements are mainly regarded as necessary but
secondary background factors that give interpretations their mutative power. Echoing the
views of Kohut’s (1971) self psychology, as well as those of object relations theorists, other
contemporary Freudian therapists regard the relationship as directly healing in its own right.
From this perspective, the main impact and virtue of interpretations is that they strengthen
the empathic bond between patient and therapist.
A comprehensive theory of curative factors would have to consider that the relative
therapeutic efficacy of insight and relationship factors might depend on the type of patient
being treated (“anaclitic” [dependent] vs. “introjective” [self-critical]; Blatt, 2008), and
the stage of treatment. A generalization found in the literature is that, relatively speaking,
patients whose early history was marked by serious disturbances in the mother–child rela-
tionship would benefit more, relatively speaking, from the healing aspects of the relation-
ship, whereas patients who have more mature object relationships would find insight a more
potent factor.
A major example of the emphasis on insight rather than on the therapeutic relationship
is seen, for example, in the work of Gray (1994), who advocates “close process monitor-
ing.” In this approach, the analyst is particularly alert to moments in the session when the
patient’s associations and behavior suggest that anxiety signals have become active and
defenses have been instigated to ward off the anxiety. The patient is encouraged to become
an observer of this process and (implicitly) to refrain from instituting defensive operations
in order to uncover the warded-off, anxiety-laden mental contents.

Variations in Psychoanalytic Technique and in Patients’ Experiences

Although there is a fairly good consensus among analysts regarding the value of certain clin-
ical concepts and technical precepts, there is only a loose coupling of theory and practice. As
Fonagy and Target (2003, p. 282) noted, “psychoanalytic practice is not logically deducible
from available theory.” Contemporary analysts take seriously the desirability of adapting
their techniques to the unique personality characteristics of their different patients and to
the particular circumstances of each treatment rather than automatically forcing a standard
technique on each patient. We see this, for example, in variations in what analysts consider
the optimal balance of supportive and exploratory interventions, in how much attention
they devote to dealing with ruptures and attempted repairs of the therapeutic alliance, in
the degree of self-disclosure they deem appropriate and useful, and so on. Rather than cling-
ing to a preset group of techniques, such as might be found in a treatment manual, analysts
are also increasingly mindful of the potential usefulness of psychotherapy integration. For
example, there are times when analysts might decide to use some cognitive-behavioral tech-
niques (e.g., Frank, 1993).
There is reason, therefore, to believe that patients’ experiences can be very different as
a function of who the clinician is. It used to be assumed that competent, well-trained ana-
lysts were interchangeable in the sense that the same transference patterns unfold regardless
of who is sitting behind the couch. With the abandonment of the “blank screen” model
of the analytic situation in favor of the recognition of the analytic situation as involving a
two-person psychology, we have come to see that the patient’s transference patterns can be
56 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

dramatically different depending on who the analyst is (see Hurwitz [1986] for a compelling
account in which he had a vastly different experience that seemed to stem from the different
personalities of his two analysts and their preferred interpretive emphases).

TREATMENT APPLICABILITY

Patients typically seek psychoanalysis or psychoanalytic psychotherapy for reasons they seek
other forms of therapy (e.g., actual or anticipated changes in or loss of important personal
relationships, setbacks in one’s career or life transitions, disturbing anxiety and depressive
symptoms, the unavailability of usual social or emotional supports). When stressful life
changes occur in a context of chronic, unresolved conflicts, the resulting state of disequilib-
rium can result in symptoms that prompt the person to seek treatment.

Types of Patients and Patient Pathology

Patient Populations
Freud never intended that classical psychoanalysis would have a broad range of application;
he realized that to be employed more widely, it would require significant modification. Over
the years, psychoanalytically oriented approaches have been developed for the treatment of
children, adolescents, couples, groups, and families. A separate chapter would be required
to begin to do justice to the range and complexity of the factors involved in these treatment
applications.

Range of Pathology
Although originally geared to neurotics, psychoanalytic treatment, in one variation or
another, has been applied to patients with serious psychiatric disturbances, such as those
with severe narcissistic and borderline personality disorder (Kernberg et al., 1989) and
schizophrenia (Karon, 1992; Searles, 1965). In general, it has been recognized that patients
with significant pathology require the use of “parameters” (Eissler, 1953; i.e., adaptation
of the usual guidelines to meet the particulars of a given case). In more recent years, how-
ever, the practice of psychoanalytic therapy with patients with schizophrenia seems to have
diminished substantially in favor of drug therapy and other forms of intervention (e.g.,
supportive therapy, social skills training, behavior therapy, family therapy, and community
treatment programs). Nevertheless, there still are a few residential treatment centers and
outpatient clinics in which psychodynamic psychotherapy is practiced with seriously dis-
turbed patients, some of whom are schizophrenic but most of whom have severe borderline
personalities.

Social and Cultural Factors

In the past two decades, there has been a marked increase in the emphasis on cultural com-
petence in psychotherapy. Factors such as race, ethnicity, gender, social class, immigration
and cultural dislocation, sexual orientation and identity, religion, social oppression, dis-
crimination, and stereotyping clearly influence the psychotherapy process, often in subtle
ways. Clinicians are urged to be knowledgeable about and sensitive to the various ways
 Freudian Psychoanalytic Psychotherapy 57

in which individual differences in the cultural background and identities of their patients
influence their inner dynamics, sense of identity, motivation, and interpersonal relationships
(Altman, 1995). The therapist’s ongoing commitment to self-reflection is essential to under-
standing transference–countertransference enactments related to these cultural factors. (For
an excellent explication of these issues, see Tummala-Narra, 2016).
Psychoanalytic psychotherapy has certain inherent features and values that set bound-
aries on its range of application. For instance, psychoanalytic treatment encourages the free
expression of emotions, so cultures that value restraint of emotional expression and strong
family loyalty would find this central feature incompatible with their cultural traditions.
In addition, collectivist cultures might find group, family, or community approaches more
compatible. People from some cultures are less inclined to take the initiative and expect the
therapist to be more active and to provide more structure than is typical in psychoanalytic
treatment. Obviously, a therapist who is not sensitive to cultural differences will have a more
difficult time understanding and helping a patient from a different culture. For accounts of
modified psychoanalytic treatment with disadvantaged populations, see Altman (1995) and
Tummala-Nara (2016).
Psychotherapy in general, and psychoanalysis in particular, has long been criticized
as limited to the very small segment of the population at high socioeconomic status (SES)
levels. The so-called YAVIS syndrome refers to the typical psychotherapy patient as young,
affluent, verbal, intelligent, and successful. Psychoanalytic patients have been depicted as
those who meet the criteria of the YAVIS syndrome, sometimes referred to as the “worried
well” (Kaley, Eagle, & Wolitzky, 1999). According to this view, psychoanalysis could be
seen as a personal journey of self-exploration for the narcissistically self-indulgent rather
than an experience in which individuals encounter painful truths about their dysfunctional
relationships and difficulties in their work. However, the former is not an accurate view, as
one finds significant emotional suffering even among those at higher SES levels.
Efforts were made early in the psychoanalytic movement to make treatment available
to underprivileged and disadvantaged populations, with whatever modifications deemed
necessary (Altman, 1995). Unfortunately these efforts have been fairly limited. It remains
an important challenge to tailor psychodynamic approaches to treatment to the diverse cul-
tural backgrounds and SES levels one encounters in clinical practice (Tummala-Narra, 2014,
2016). It appears that those at higher SES levels are more likely to be in psychoanalysis proper
or intensive psychotherapy rather than in a once-a-week psychodynamic psychotherapy.

ETHICAL CONSIDERATIONS

Although practitioners have a natural inclination to recommend to patients the kind of

treatment they have been trained to conduct, ethical considerations require caution. For
example, standard psychoanalysis is not the treatment of choice for patients whose real-
ity situation is so dire and overwhelming as to preclude prolonged, leisurely introspection,
nor should it be recommended to someone whose sole aim is to overcome a specific habit
(e.g., smoking). In general, the ethical issues relevant to psychoanalysis are those relevant to
psychotherapy in general. Perhaps the most important ethical precept is not to exploit the
patient’s emotional vulnerability (e.g., engaging in sex with the patient). Needless to say, the
therapist should adhere to the highest professional and ethical standards in all aspects of
work with the patient as well as after the treatment is terminated.
58 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

RESEARCH SUPPORT AND EVIDENCE-BASED PRACTICE

For most of its history, psychoanalysis has based its theories and assessments of treatment
outcome almost exclusively on the case study method. Few analysts were trained in research
methodology, yet they claimed (incorrectly) that in conducting an analysis they were simul-
taneously engaged in research, and that their clinical data had probative value at least equal
to that from systematic empirical studies. With the popularity of psychiatric drugs, the
ascent of rival therapies, and the influence of managed care, analysts began to heed the
call for accountability and to supplement clinical insights and claims with more systematic,
empirical, methodologically sophisticated inquiries focused on the process and outcome of
treatment.
The first consideration in addressing this body of research is to be clear about what
differentiates psychoanalytic therapy and psychoanalysis from rival therapies (e.g., CBT).
In this regard, Blagys and Hilsenroth (2000) noted that certain kinds of interventions
are specific to psychoanalytic approaches to treatment: (1) a focus on the expression of
affects; (2) exploration and interpretation of the tendency to avoid certain topics and other
forms of resistance; (3) exploration of past experiences, particularly interpersonal rela-
tions; (4) a focus on the dynamics of the therapeutic relationship; and (5) an examination
and understanding of the patient’s wishes, fantasies, and core conflicts. A Q-sort method
for establishing a prototype of an ideal psychoanalytic session closely follows Blagys and
Hilsenroth’s (2000) criteria and adds the features of technical neutrality, being nonjudg-
mental and empathic, and promoting new insights (Ablon & Jones, 2005). The correlations
between successful treatment outcomes and approximating the prototype for psychoanaly-
sis, analytic therapy, and brief therapy were, respectively, .58, .47, and .37 (Ablon & Jones,
2005).
It has been about four decades since clinicians got good news and bad news about psy-
chotherapy outcomes. Meta-analytic studies showed that (1) psychotherapy is effective (the
good news), but (2) there are no consistent differences in the effectiveness of different brands
of psychotherapy—the bad news for clinicians who want to think their preferred therapy
method is superior. The implication of this latter finding is that it is the factors common to
diverse forms of therapy (e.g., the quality of the therapeutic alliance) that account for com-
parable positive outcomes (Wampold, 2015).
Shedler’s (2010) review of research in therapy concluded that such treatment now has
substantial empirical support. He noted that “effect sizes for psychodynamic therapy are as
large as those reported for other therapies that have been actively promoted as ‘empirically
supported’ and ‘evidence based.’ In addition, patients who receive psychodynamic therapy
maintain therapeutic gains and appear to continue to improve after treatment ends” (p. 98).
Doidge (1999) reviewed the major pre–post studies of psychoanalysis proper in the United
States. He claims that the outcome for those patients deemed suitable for psychoanalysis
ranges from 60 to 90%. Some studies showed a correlation between outcomes and length of
treatment and frequency of sessions.
Sandell et al. (2000) defined psychoanalysis as including the use of the couch, more
than two sessions a week, and more than 2 years of treatment. Given these criteria, meta-
analyses of retrospective studies using self-report showed effect sizes that were “moderate to
large, larger for psychoanalysis than for psychotherapy, and larger at follow-up than at ter-
mination” (Sandel, 2012, p. 398). This last finding is intriguing and potentially quite impor-
tant, as it suggests a posttreatment consolidation of treatment gains. However, it remains to
 Freudian Psychoanalytic Psychotherapy 59

be seen whether, across many studies, psychoanalytic approaches consistently show superior
posttreatment gains compared with rival treatments.
Other relevant findings regarding psychoanalytically oriented psychotherapy (Eagle,
2018b, pp. 47–55) include the following:

1. There is a modest positive correlation between the quality of the therapeutic alliance
and outcome.
2. There is a positive correlation between attention to the patient’s core conflictual
relationship theme (CCRT) and outcome.
3. The quality of interpretations is related to what we think of as a “good” analytic
hour (e.g., more access to affect, recovery of memories; Waldron, Scharf, Hurst, Firestein,
& Burton, 2004).
4. When analysts “pass” patients’ tests, the patients show more access to previously
warded off mental contents (Weiss & Sampson, 1986).
5. Successful sequences of ruptures and repairs of the therapeutic alliance are related
to outcome (Safran et al., 2014).
6. “Mentalization”-based therapy in which the focus is on borderline patients explor-
ing and understanding their own motives and feelings and the motives and feelings of others
is effective. At termination, 57% of the patients no longer met the criteria for borderline
personality disorder; assessed again at an 8-year follow-up, 87% no longer met the criteria
for borderline personality disorder. The percentages for the control group, which received
standard care, were 13% at termination and 13% at the 8-year follow-up (Bateman &
Fonagy, 2008).
7. Transference-focused therapy is effective with borderline patients (Høglend & Gab-
bard, 2012; Levy et al., 2017).
8. The results of RCTs, considered by many to be the “gold standard” in psychotherapy
research, have been summarized in a lengthy, comprehensive, worldwide review of process
and outcome studies of psychoanalytic treatment (Leichsenring, Leweke, Klein, & Stein-
ert, 2015). These authors reported that positive treatment outcomes with psychodynamic
therapy (PDT) have been obtained across a wide range of disorders: depressive disorders,
complicated grief disorders, anxiety disorders, posttraumatic stress disorder (PTSD), eating
disorders, somatoform disorders, and personality disorders (including borderline personal-
ity disorders). Only rarely was a rival form of treatment superior to PDT. The authors con-
clude that PDT does have solid empirical support. See also Leuzinger-Bohleber and Kächele
(2015) for a similar review.
Leichensring and Rabung (2008) selected studies that had a duration of at least 1 year,
or at least 50 sessions. They included a total of 23 studies (11 of which were based on RCTs)
that involved a total of 1,053 patients with complex mental disorders. At the end of treat-
ment, these patients were better off than 96% of patients in the comparison groups—quite
an impressive result.
de Maat, de Jonghe, Schoevers, and Dekker (2009) reviewed 27 studies with a total of
5,063 patients in long-term psychotherapy. They concluded that long-term psychotherapy
is an effective treatment, with moderate to large effects for a large range of psychopathol-
ogy. Their findings included some indications of larger effect sizes at follow-up than at
60 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

termination, suggesting a posttreatment consolidation of therapeutic gains. Finding this

kind of result consistently in future studies would be a strong argument in support of long-
term treatment.
The cited studies give encouragement to the idea that long-term treatment of depressive
disorders (which tend to be chronic) and other complex mental disorders (i.e., comorbid
disorders) benefit from long-term treatment.
Obviously, it is difficult to compare treatment outcome studies when the criteria of
outcome are different. Most outcome studies use change in the level of self-reported and/
or observer-reported anxiety and depression as outcome criteria. Yet psychoanalysts also
are interested in personality change (sometimes called “structural” change.) One major
effort to assess personality change is Wallerstein’s (1991) Scales of Psychological Capaci-
ties. Using this method (Huber, Henrich, & Klug, 2005), clinicians rate the patient on 17
different dimensions that together describe a broad range of optimal psychological func-
tioning. Raters judge deviations from an optimal level of each capacity. For example, “self-
esteem” is rated on a continuum from “humility to grandiosity” and from “self-respect to
self-depreciation.”
Huber, Henrich, Gastner, and Klug (2012) studied depressed patients in psychoanalytic
psychotherapy, psychodynamic psychotherapy, and CBT. They found that at 1 year follow-
up, the psychoanalytic psychotherapy group functioned better than the other two groups.
However, the range of sessions for the psychoanalytic psychotherapy group was from 17 to
370, while in the CBT group the range of sessions was from 7 to 100. Thus, it is not clear
whether the superior results in the psychoanalytic psychotherapy group of patients was
due to the much greater number of sessions or to differences in the techniques employed.
A study of these patients by Zimmerman et al. (2015) concluded that both the application
of psychoanalytic techniques and a high number of sessions facilitated positive therapeutic
change (e.g., decrease in interpersonal problems) in patients with major depression at the
termination of treatment and at 1-, 2-, and 3-year follow-up.
In a meta-analytic review of treatment outcome studies, comparisons of short-term
and long-term (50 sessions or more) psychodynamic psychotherapy, Leichensring and
Rabung (2008, p. 1563), found that long-term psychodynamic psychotherapy was “sig-
nificantly superior to shorter-term methods of psychotherapy with regard to overall out-
come, target problems, and personality functioning.” These findings included “patients
with personality disorders, multiple mental disorders, and chronic mental disorders”
(p. 1563). They also reported that overall effect sizes increased between the end of therapy
and follow-up.
9. There are mixed findings concerning the conditions under which the frequency of
transference interpretations is helpful (see Eagle, 2018a). In some studies, contrary to clini-
cal expectations, patients showing a weak therapeutic alliance and poor object relations
benefited more from transference interpretations. However, further studies are needed in
which measures of the quality of the interpretations are included in the study design.
10. There is an increasing interest in tracking changes in particular regions of brain
activity in relation to changes in psychotherapy. For example, investigators are finding nor-
malization of functional abnormalities in brain circuits related to improvement in depressive
symptoms (e.g., Buchheim et al., 2012).
11. Wampold (2015) has made a strong case for the importance of a variety of “com-
mon factors” (e.g., a good therapeutic alliance, provision of empathy, arousing positive
 Freudian Psychoanalytic Psychotherapy 61

expectations) as accounting for the success of all forms of psychotherapy, including psycho-
analytic therapy.

Overall, the research on treatment supports the claim that psychoanalytically oriented
therapy for depressive and comorbid disorders is evidence-based, and that there is merit in
longer term treatments for these and other disorders.

CASE ILLUSTRATION

As a framework for reading the case illustration that follows, it will be helpful to provide a
condensed statement regarding the transition from traditional to contemporary Freudian
theory and practice as applied to both psychoanalysis and psychoanalytic psychotherapy:

1. In Freud’s view, the central function of the mental apparatus is the discharge of
excitation (assumed to be pleasurable) associated with an instinctual drive (sex or
aggression). In the more current view, “the essence of contemporary psychoanalytic
theories of mind is to establish, maintain, and preserve ties to others” (Eagle, 2011,
p. 107).
2. A decreased focus on Oedipal themes, sexuality, and conflict.
3. A greater reliance on Brenner’s (1994) experience-near “modern conflict theory” in
place of the abstract, metapsychologically based, structural theory of id, ego, and
superego.
4. An increased emphasis on the adverse impact of early trauma and of ego deficits.
5. An emphasis on the value of concepts from attachment theory, object relations
theories, and self psychology (e.g., narcissism and the development of the self) as
relevant to contemporary Freudian practice (Eagle, 2011).
6. A much weaker distinction between psychoanalysis and psychoanalytic psycho-
therapy.
7. A view of the analytic relationship from the perspective of a “two-person,” interac-
tive psychology rather than the one-person view of the analyst as a “blank screen”
and objective observer of the patient’s mental functioning.
8. An increased emphasis on “here-and-now” transference interpretations as com-
pared with the past stress on so-called “genetic” transference interpretations (i.e.,
interpretations of the meanings of early childhood experiences).
9. A decline in emphasis on the curative role of transference interpretations leading to
insight as the key therapeutic ingredient in favor of a greater emphasis on the direct
therapeutic value of a positive therapeutic alliance and other healing aspects of the
patient–therapist relationship (e.g., empathy).
10. A decreased concern about the patient experiencing transference gratification as an
obstacle to analytic exploration and the achievement of insight.
11. An emphasis on analysts’ countertransference reactions (broadly conceptualized),
their judicious disclosure, and their help in understanding the patient from the per-
spective of the mutual influences of two personalities on one another.
12. The espousal of a more egalitarian therapist–patient relationship.
13. An increased appreciation of multiple theoretical perspectives.
14. A more complex view of gender and female sexuality.
62 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

15. Greater attention to the burgeoning empirical research literature on analytic theory
and the process and outcome of treatment.

These, and other, shifts in emphasis from classical to contemporary psychoanalysis are
summarized in Table 2.1.
Mr. T started treatment at the age of 24, having been referred by his university counsel-
ing service. He was on the verge of being dropped from the university for an increasingly
long string of incompletes that began in his freshman year (age 18). He showed marked
procrastination in not only his academic work but also in every realm of his life (paying bills
late, missing trains because he arrived late, etc.).
The patient grew up in an upper-middle-class family in a Midwestern suburb. He felt
clearly favored over his brother, 2 years his senior. His father was a successful attorney
who also was actively involved in the life of his community. The boy was awed by and
envious of the respect and esteem accorded his father. He experienced his mother as con-
trolling, manipulative, opinionated, unempathic, and stern. She led him to believe he was
special, and that he had not only the ability and the potential but also the obligation to
achieve greatness as an adult. These frequent messages contributed to the patient’s sense
of having a special destiny that he ought to fulfill. Together with the model of mastery
provided by his father, the patient’s sense of a duty to perform, combined with his per-
fectionistic strivings, motivated him to overextend himself and contributed to his severe
procrastinating behavior. His procrastination also expressed his underlying resentment of
and rebellion against the external and internalized pressure to succeed, as well as his fear
that he would fail. Mr. T never completed any project until faced with a truly unavoidable
and serious deadline. Not surprisingly, Mr. T felt himself to be the passive victim of an
unremitting barrage of environmental impingements and hassles (e.g., bills and taxes that
he was expected to pay on a timely basis) and interpersonal expectations that he experi-
enced as onerous obligations (e.g., being on time for therapy sessions and for dates with
friends or women).
Given the entrenched nature of Mr. T’s problems, his characterological difficulties, and
his vulnerability to feelings of depression and frustration, in a context of adequate psycho-
logical mindedness, intact reality testing, capacity for relatedness, and generally good ego
resources, I recommended, after three or four initial interviews, that we embark on psy-
choanalysis at a frequency of four sessions per week. I reviewed with him the material and
the themes of the initial interviews and summarized the main presenting issues he seemed
to want to explore, e.g., his severe procrastination, his feelings of anxiety, depression, and
low self-esteem; his turbulent, sticky relationship with his mother; and his difficulties with
women (e.g., frequent power struggles), his problems in concentration, and his need to take
on more than he could handle.
Time was a bitter enemy of Mr. T’s life in every aspect. He would resist doing things
until he inevitably was coerced into action, even though he consciously hated being coerced.
Transitions from one activity to another were extremely difficult for Mr. T. He recalled that,
as a child, he had a strong resistance to going to sleep, exceeded by his even more powerful
resistance to getting up on time to go to school. For Mr. T, simply to be awake and con-
scious was to feel automatically a profound sense of the impingement of reality demands. He
complained of an aversive sense of burden and responsibility in relation to all his unfinished
daily tasks, to say nothing of the grand accomplishments on his future agenda. So profound
were his yearnings to be free of these pressures that it was a burden to stand up straight and
 Freudian Psychoanalytic Psychotherapy 63

TABLE 2.1. Changes in Theoretical and Clinical Emphasis from Classical to Contemporary
Freudian Psychoanalysis
Traditional Freudian views
Traditional Freudian theory
Traditional Freudian theory
Oedipal themes
Inner conflict
Psychoanalysis
Neuroses
Insight as curative
Analyst’s interpretations
Singular theories
Transference as “distortion”
One-person psychology
Intrapsychic focus
Genetic transference interpretations
Transference interpretations key
Focus on intrapsychic conflict that is expressed
to a “blank-screen” analyst
Search for early pathogenic memories
Analytic anonymity
Technical neutrality, maintain analytic
restraint
Countertransference as hindrance and as flaw
in the analyst and hindrance to treatment
Therapeutic alliance important as precursor
to effective interpretation
Analyst as “blank-screen” observer
Unitary self
Main defense: Repression
Empathy as source of information
Intrapsychic conflict
Contemporary views
Relational theory and self psychology
Modern conflict theory
Pre-Oedipal experiences; attachment
Ego deficits
Psychoanalytic psychotherapy
Borderline and narcissistic disorders
Relationship (e.g., therapeutic alliance) as curative
Co-constructed narratives
Theoretical pluralism
Transference as “plausible” view
Two-person psychology
Intrapsychic and interpersonal focus
“Here-and-now” transference interpretations
Transference and extratransference
interpretations
Focus on mutual transference–
countertransference enactments
Implicit relational knowing in the present
Judicious analyst self-disclosure
Less worry about neutrality and transference
gratification
Countertransference–transference enactments as
source of vital information
Analyst attunement to “rupture and repair” of
the alliance is therapeutic
Intersubjectivity of the analytic pair
Multiple selves and self states
Main defense: Dissociation
Empathy as curative (Kohut)
Focus on self and interpersonal relationships

carry himself erect, as opposed to his strongly preferred position of being supine or at least
slouched.
The patient’s problems with time were intimately intertwined with his problems in con-
centration. To pay attention and to concentrate felt painfully coercive to him. The patient
did not have a basic deficit in attention, because he could concentrate well, but only when
he was doing what he wanted to do.
I turn now to some of the technical precepts and interventions in my overall approach
to this patient. By my listening, by my periodic requests for associations (e.g., “What comes
64 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

to mind?”), and by occasional specific but open-ended questions designed to elicit further
associations (“Any other thoughts or feelings about what you just said?”), I attempted to
understand and to collaborate with him in the interpretation of the probable meanings of
his behavior and experiences. We came to understand his chronic lateness and his difficul-
ties in concentration as expressions of unconscious, core conflicts originating in childhood
power struggles with his mother and reenacted in his relationship with me and with others.
For example, some months into the analysis, I pointed out to the patient that he had
been late a lot, something that, of course, he knew. He replied that it was difficult for him to
get anywhere on time, that I should therefore not take it personally, and that he did not keep
track of time enough to focus on when he would have to leave to show up on time for the
session. The tone of his remarks suggested to me that he took my observation as a criticism.
Rather than respond directly to the content of what he said, I focused first on the affect
implied in his reply. The technical precept guiding this choice was the idea of focusing on an
affective aspect of the “here-and-now” transference.
From the perspective of technique, my reference to his lateness is what one would call a
confrontation. It conveys the message, schematically stated, “Both the fact of your repeated
lateness and your response to my calling attention to it are matters of psychological import
that we might profitably examine together.”
By inquiring whether he might have experienced my observation as a criticism, I was
engaging in the technical intervention that Greenson (1967) calls clarification. As indicated
earlier, confrontation and clarification are preparatory to interpretation, which searches
for the probable meanings of behavior and experience. My confrontation and clarification
already hint at the possibility of a transference reaction. At the same time, I wanted to
maintain a positive therapeutic alliance by suggesting that we collaborate in examining our
interchange. As the therapist, I also needed to be aware of why and how I chose to intervene
at that time with my particular choice of words and their tone. Not surprisingly, the patient
replied that he did feel somewhat chastised by my comment and that it reminded him of a
similar reaction to the female therapist he saw initially who referred him to me and actually
chided him for lateness to his sessions with her.
At this point, I had to consider whether I, too, was silently annoyed at him, although
I did not chide him overtly (having taken his story about his prior therapist as a warning).
Were we on the threshold of a rupture in the therapeutic alliance, which would need to
be addressed and repaired? As best as I could tell, I had mixed feelings about his frequent
lateness. On the one hand, there were times I was mildly annoyed and imagined how his
habitual lateness could be irritating to others, which stimulated me to think that he might
have wanted to give me a taste of how he felt when his mother was late in picking him up
from school. He had previously complained bitterly about his mother’s lateness and readily
accepted my interpretation that his lateness to his sessions (as well as to virtually every other
appointment) was intended as “payback.”
Mr. T’s thoughts next turned to his mother and her almost invariable lateness in pick-
ing him up from elementary school in the afternoon. He felt angered at what he felt was the
power differential and double standard in their relationship; she constantly chided him for
being late in getting ready for school, yet she apparently had no compunction about keeping
him waiting in all sorts of situations (e.g., she would drag him to stores and take her time
shopping, while he waited impatiently and with much frustration). After listening to him
elaborate these memories and feelings, I returned to my earlier interpretation and asked him
 Freudian Psychoanalytic Psychotherapy 65

to consider the possibility that one meaning of his lateness with me might be a desire to keep
me waiting as his mother had kept him waiting, to right the humiliating, infuriating wrong
that he felt she had imposed upon him. I suggested that his understandable desire for revenge
was expressed by reversing roles and being late with others (myself included) as she was with
him. The patient agreed; the idea had a strong, immediate emotional resonance for him.
Variations and elaborations of this line of interpretation were offered repeatedly in
contexts in which issues of control, autonomy, and a sense of obligation were prominent
in the patient’s associations and in a host of childhood memories, as well as in his current
behavior.
As indicated earlier, the patient’s problems with time were closely linked to his dif-
ficulties in concentration. For example, it was evident that Mr. T had a great deal of dif-
ficulty listening to my comments and interpretations. Not infrequently, he would remark,
“Could you say that again? I completely lost track of what you said.” Rather than simply
repeat what I had said, which I did at the beginning of treatment, I asked him what came to
mind about his not retaining it in the first place. He replied, “As you know, I’ve always had
trouble paying attention to what I’m doing. I can’t concentrate and often don’t realize that
I’m not concentrating until some time later. If I’m reading an assigned chapter in a textbook,
I find that after a few pages I turn to some unassigned portion of the text and start to read
with much less problem in concentration or in remembering what I read.”
I then said, “It seems that you often experience what I say in here as carrying the
demand that you pay attention and do your ‘homework’ here immediately. Perhaps that
resonates with your feelings about submitting to your mother’s demands.” The patient,
struggling to retain my comment, replied that he did feel that expecting him to pay attention
to what I had to say felt coercive.
It should be emphasized that what I am describing here is a tiny fragment of a long, often
arduous process. It is not that patient and analyst suddenly arrive at one all-encompassing,
blinding insight in which everything heretofore cloudy and obscure gels, such that long-
standing conflicts suddenly become fully and forever resolved. This image, still a common
fantasy, is a holdover from the rapid, usually short-lived dramatic “cures” in the early days
of psychoanalysis that followed immediately upon the retrieval of an unconscious, traumatic
memory. In fact, the analytic process is one in which insights are gained, lost, and regained.
There are strong resistances against translating insight into action. This is why analysts talk
about the importance of working through.
Mr. T, as is the case with virtually all of my patients, did not fit neatly into a single
DSM diagnostic category; instead, he had features of several categories. Dynamically, his
core conflicts centered on (1) his autonomous strivings to free himself from enmeshment
with his mother; (2) his rage at, and desire to defy, maternal authority on the one hand, and
his feeling that he should obediently yield to it in order to be a “good boy.” The reenact-
ment, eventual understanding, and working through of the conflicts in the transference in
a context of empathy, support, and a basically sound therapeutic alliance contributed to the
patient’s increased sense of personal agency and self-esteem, and a diminution of the super-
ego pressures that he fulfill his alleged potential for greatness. One could say that he had to
perceive me as an “old object” (i.e., as similar to his mother) for the transference to develop,
and as a “new object” (different than his mother) for the transference to be analyzed. Even-
tually, Mr. T’s battles with time diminished and his ability to concentrate improved. His
mother became less of a persecutory internal presence.
66 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

SUGGESTIONS FOR FURTHER STUDY

Recommended Reading
There are several complex concepts and issues regarding theories and techniques of psychoanalytic
psychotherapy that I could not cover in this chapter. Therefore, the interested student is encouraged
to read further and would do well to start with the references cited in the next section, and the next
chapter in this book on relational psychoanalytic/psychodynamic therapy.

Eagle, M. N. (2011). From classical to contemporary psychoanalysis: A critique and integration.

New York: Routledge.—Traces the development of psychoanalytic theory from Freud to the
present.
Gabbard, G. (2004). Long-term psychodynamic psychotherapy—a basic text. Washington, DC:
American Psychiatric Press.—An exposition of key concepts and principles of psychodynamic
psychotherapy, with clinical vignettes.
Thoma, H., & Kächele, H. (1992). Psychoanalytic practice: Vol. 2. Clinical studies. Berlin: Springer-
Verlag.—A series of highly detailed psychoanalytic case studies.
Wolitzky, D. L. (2011). Psychoanalytic theories of psychotherapy. In J. Norcross, G. R. VandenBos,
& D. K. Freedheim (Eds.), History of psychotherapy (2nd ed., pp. 65–100). Washington DC:
American Psychological Association.—An account of the development of psychoanalytic theory
and practice.
Wolitzky, D. L. (2016). Psychoanalytic theories. In J. Norcross (Ed.), APA handbook of clinical
psychology. (Vol. 2, pp. 19–52). Washington, DC: American Psychological Association.—An
account of the variety of psychoanalytic theories.
Wolitzky, D. L., & Eagle, M. (1997). Psychoanalytic theories of psychotherapy. In P. L. Wachtel & S.
B. Messer (Eds.), Theories of psychotherapy: Origins and evolution (pp. 39–96). Washington,
DC: American Psychological Association.—An account of the theory and technical aspects of
the main psychoanalytic approaches to treatment.

DVDs
McWilliams, N. (2007). Psychoanalytic therapy (DVD Systems of Psychotherapy Video Series).
Washington, DC: American Psychological Association.—Dr. McWilliams conducts an initial
therapy session with a woman who has a young daughter and remains in an abusive relationship
with a man.
Safran, J. (2012). Psychoanalysis and psychoanalytic therapies (DVD Systems of Psychotherapy
Video Series). Washington, DC: American Psychological Association.—Dr. Safran presents six
sessions that illustrate the early stages of psychotherapy with special emphasis on the therapeutic
alliance.

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 CHAP TER 3

Relational Psychoanalytic/
Psychodynamic Psychotherapy
Rebecca Coleman Curtis

HISTORICAL BACKGROUND

Relational approaches to psychoanalytic psychotherapy represent a paradigm shift consis-

tent with other developments in science and the humanities in the 20th and 21st centuries.
The number of relational analysts in the world has been steadily increasing, with members
from 40 countries in the International Association of Relational Psychoanalysis and Psycho-
therapy. The relational approach breaks with much, but certainly not all, of the Freudian
tradition and encompasses what has been known as interpersonal psychoanalysis, object
relations theory, and self psychology. These orientations all consider relations with others
to be people’s major motivation, not the satisfaction of sexual and aggressive drives as in
Freudian thinking. Another major change is that the analyst is no longer considered to be a
blank screen or an objective observer as in the 19th-century model of natural science, but
rather a participant observer. Heisenberg had demonstrated that physical phenomena were
always affected by being measured, and this thinking has permeated relational psychoanaly-
sis.
The idea of the therapist influencing the individual’s participation in the therapy as a
participant-observer was taken up in the United States by Sullivan (1953) in his develop-
ment of what was first called interpersonal psychiatry. Unlike many psychoanalysts who
worked with rather well-functioning patients, Sullivan developed many of his ideas working
with schizophrenic males. Sullivan joined forces with several prominent psychoanalysts who
were also interested in social and cultural influences on personality development—Horney
(1926), Fromm 1964), Fromm-Reichmann (1959), and Clara Thompson. He formed, with
the latter three therapists, what became known as the interpersonal school of psychoanaly-
sis, also called the cultural school. In this connection, Horney is credited with being the
founder of feminist psychology. Horney and Thompson published papers on femininity and
71
72 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

the fear of women’s power, and this tradition is maintained by relational psychoanalysts
currently in the journal, Studies in Gender and Sexuality, with essays on not only a feminist
point of view but also on masculinity and queer theory. Culture was discussed extensively
by Horney and Fromm (e.g., the competitive nature of American society), with Fromm
describing what he called the marketing personality of some Americans.
Ferenczi in Budapest was known as an analyst’s analyst and was often sent difficult
patients other analysts could not help. Clara Thompson and Melanie Klein were analyzed
by him. He was known for his focus on nonverbal interactions between mother and child,
prioritizing such engagement over Freud’s emphasis on innate drive states as the building
blocks of human personality and the Oedipus complex. Ferenczi (1926) also experimented
with various new techniques, including conceptualizing the psychoanalytic relationship
between therapist and patient as mutually constructed. Both Ferenczi and Rank experi-
mented with more active and brief approaches to therapy (Messer & Warren, 1995).
Ferenczi and Sullivan had considerable influence on the development of relational psy-
choanalysis, the former more indirectly, through his impact on analysands such as Thomp-
son, Klein, and Balint. Klein and Balint were key to the development of different aspects
of object relations theory in Europe. Although there are important differences among these
traditions, all basically share the view that relationships with caretakers are the most cen-
tral features in any effort to understand development of personality. All three traditions
highlight various ways, beyond objective observation, that therapists both unwittingly and
purposefully interact with their patients. Perhaps partly because some of these analysts were
working with more disturbed patients than those of their classical counterparts, they devi-
ated early on from the standard Freudian technique of the time, which was largely interpre-
tation and analysis of transference.
Around the same time that Sullivan was developing interpersonal psychiatry in the
United States, W. R. D. Fairbairn in Great Britain was arguing that people are primarily
motivated to seek other people rather than reduce drives. He developed simultaneously with,
but independent of Klein and Balint, an “object relations theory of psychoanalysis,” drawing
from the philosophical tradition of “subjects” (people) and the “objects” they observed. For
Fairbairn, the term objects referred to the internalization of experiences with other people.
In 1983, Greenberg and Mitchell published a volume titled Object Relations in Psy-
choanalytic Theory. They argued that a paradigm shift had taken place in psychoanalysis,
such that relations with others “constitute the fundamental building blocks of mental life”
(p. 3), in contrast to Freud’s emphasis on the unfolding of biologically based drives. All
of the approaches Greenberg and Mitchell included under the “relational” umbrella have
in common the focus on relationships, external and internalized, as the primary way of
understanding human development and personality organization. Greenberg and Mitchell
combined the emphasis on interpersonal relations of interpersonal psychoanalysis with the
ideas of internalized representations of others from the object relations tradition. Other key
psychoanalytic theorists, such as Winnicott, are viewed as moving psychoanalysis toward
this emphasis, some without breaking completely with a Freudian framework. Edgar Leven-
son (1972), a major contributor to the interpersonal tradition, had already described para-
digm shifts from Freud’s work-machine model, to the organismic model found in biology, in
which every element has connections with many other elements, so that influence can flow
in several directions. Levenson emphasized the interpersonal entanglements into which the
analyst could be drawn by the patient. The therapist in the interpersonal/relational approach
was a subjectivity of his or her own, interacting with the other subjectivity—the patient.
 Relational Psychoanalytic/Psychodynamic Psychotherapy 73

In the United States, Kohut (1971) also developed many ideas that were in considerable
harmony with Ferenczi’s original view of the analyst as an empathic observer. Stolorow and
others (Orange, Atwood, & Stolorow, 2001) have tried to extend Kohut’s self psychology by
integrating it into the interpersonal and relational perspectives.
Although the journal Contemporary Psychoanalysis represents the interpersonal per-
spective to a large extent, in 1991, a new journal, Psychoanalytic Dialogues: A Journal of
Relational Perspectives, became a forum for comparing and contrasting the numerous tradi-
tions that lie within the large relational umbrella: interpersonal, varieties of object relational
(Fairbairn, Winnicott, and Klein), self psychological, intersubjective (i.e., the approach of
Orange et al., 2001), and postmodern feminist thinking. A relational orientation was estab-
lished within the New York University Postdoctoral Program in Psychotherapy and Psycho-
analysis in 1988, the Stephen A. Mitchell Center for Relational Studies in 2007, and via a
relational perspectives book series in 1990. The relational approach continues to inspire
interest and involvement, with the International Association for Relational Psychoanalysis
and Psychotherapy, founded by Stephen Mitchell, holding its first meeting in 2002, with
subsequent meetings taking place in various parts of the world.
Relational approaches have been influenced by other intellectual trends in the 20th cen-
tury, particularly postmodernism, relativism, perspectivism, and constructivism. In regard
to constructivism, an orientation of critical constructivism is taken, meaning that it recog-
nizes that realities exist but human beings are constantly constructing their own view of
these realities. Relational configurations are considered to be formed on the basis of actual
experiences, but not identical to what was experienced. Recently, views of self-organizing
processes have been derived from theories about how order can emerge out of chaos; that
is, living systems change to fit in with the environment. Psychological change involves fluc-
tuations in response to differing external realities to the extent that a “tipping point” is
reached, resulting in a new psychological organization; that is, the self is a dynamic system
that is constantly changing.

THE CONCEPT OF PERSONALITY

Because relational approaches draw from some very disparate theoretical frameworks, there
is not a unified concept of personality. Generally, it is thought that individuals develop rela-
tively stable patterns of being in the world. Many relational therapists believe that people
tend to construct unconsciously their contemporary world to conform to the familiarity of
past experience (cf. Hoffman, 1998). The formation of the personality is based on relation-
ships with real and imagined others, as well as temperament and individual inclinations.
For Sullivan, the personality referred to the entire functioning of a person. He referred
to the self as a self-system, a composite of experiences. Anxiety-free experiences as an infant
with the caretaker, usually the mother, lead to the experience of the good me, whereas
anxiety-filled experiences lead to the bad me. Some experiences, however, are so traumatic
that they cannot be integrated at all. These experiences Sullivan refers to as the not me. They
are experiences felt as dread or as horror, such as in a nightmare. Concerns with the lack of
integration of positive and negative experiences in persons suffering from disorders of the
self are a central theme in many relational writings.
Most relational analysts view people as having different self-states, feeling and behav-
ing differently with different people and when alone. Although Winnicott had differentiated
74 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

a static true self from a false self, most relational analysts reject this view. All multiple
self-states are viewed as real, including one or more that may be oriented toward pleas-
ing others, instead of being considered “false.” In relational thought, the person is never
conceived of as an isolated being: Winnicott stated that there is no such thing as a baby,
only a nursing couple. He was trying to convey the idea that there are properties of a dyad
that transcend the attributes of each individual person. Similarly, relational analysts refer
to their approach as a two-person psychology, because these properties of the relation-
ship between two people must always be taken into account in efforts to understand the
individual. Thomas Ogden, a contemporary Kleinian analyst, for example, has referred to
the space between the analyst and the patient as the “analytic third”; in other words, the
reflective space of psychoanalysis is another presence in the room. Consistent with Kurt
Lewin’s field theory, in which individuals are affected by the current forces in their environ-
ment (cf. D. B. Stern, 2015), the ultimate creation is greater than the sum of its parts. I have
also heard of the surrounding culture, always present, as a third party in the relationship
between two people.
Sullivan’s theory of personality was very influenced by developments in the cognitive
science of his time. Instead of repression, he posits a lack of connection, or dissociation,
of experiences that would be so conflictual as to be overwhelming if held in conscious-
ness simultaneously. Such awareness may be disorganizing because it is incongruous with
the current and stable organization of experience. For relational analysts, the boundary
between conscious and unconscious is fluid. Unconscious processes are not so much hidden
as generative and creative, the therapeutic work creating new meanings and understandings.
Many relational analysts have expanded their ways of thinking about unconscious pro-
cesses to include those such as physiological processes and experiences that have never been
integrated. These processes are similar in some ways to what cognitive psychologists refer to
as procedural memory, and implicit perceptual and memory processes. Donnel B. Stern has
also referred to “unformulated experiences” that a person has never consciously articulated.
For Sullivan, anxiety may lead to selective inattention regarding experiences that are
inconsistent with a person’s dominant views or ways of being. To the extent that the person
is anxious, his or her flexibility in attending to incongruous information and responding
becomes more rigidified. The focus on selective inattention and selective memory, rather
than repression, allows for a reconciliation with mainstream psychology. “Repression” was
never accepted in much of psychology because it could not be demonstrated conclusively in
the laboratory (understandably). Motivated forgetting, on the other hand, is a term used in
general psychology. Motivated forgetting may occur in order to avoid upsetting experiences
that may conflict with the dominant views of self, others, and the world.
A dissociative view of the mind prevails in relational thinking (cf. Bromberg, 2011;
Davies, 1999). Fairbairn, in his medical thesis, had argued that repression is a specific type
of dissociation. People suffering from posttraumatic stress disorder can burst into a dissoci-
ated state that is frightening. For example, veterans of wars can enter into a state in which
they attack others, feeling and thinking they are in a battle situation. It is believed that the
affects from traumas are too intense to be reflected on and integrated into the whole self.
Trauma may also lead to a dissociation of experiences, such that a person may seem numb
or intellectualized when discussing a traumatic event, all the while experiencing signs at
other times that something is amiss. Dissociated experiences may be conscious but not expe-
rienced simultaneously. Whereas in classical psychoanalysis, the therapist was to make the
unconscious conscious, the task of the relational analyst is to bring these different self-states
 Relational Psychoanalytic/Psychodynamic Psychotherapy 75

into consciousness simultaneously, so that the person experiences the conflict. Internal con-
flict, nevertheless, is an ever-present aspect of the human condition.
Fairbairn thought that the needs to love and be loved were people’s central motives.
Overall, in relational theories, aggression is not seen as instinctual. It is viewed as stemming
from frustration or pain, or learned through identification with a familiar aggressor. To the
extent that the parent is empathic and able to take the baby’s perspective or to reflect on the
baby’s functioning (D. N. Stern, 2008), the child is likely to feel soothed when anxious, and
be more likely eventually to satisfy his or her desires. Infant researchers, such as Beebe and
Lachmann (2013), have observed that caretakers who can match the rhythm of their infants
in a sort of dance-like interaction are able to help the baby regulate his or her emotions.
Sexuality, though instinctually based, is viewed as an important medium in which rela-
tional struggles are played out. The form of one’s sexuality is developed through relational
interaction. Sexuality provides the imaginative elaboration of bodily functions. It is a “pow-
erful medium in which emotional connection and intimacy is sought, established, lost, and
regained” (Mitchell, 1988, p. 107).
Relational analysts have been among the strongest critics of Freudian theories regard-
ing the development of sexuality since Freud expressed them. Clara Thompson and Karen
Horney (1926) both criticized his notions of female sexuality, arguing that penis envy was
related not to biological differences but to the cultural advantages given to men. Freud’s
“castration” fears, in the sense of feelings of threat and/or helplessness, are seen as univer-
sal. “Masochistic” tendencies in women have been viewed by Jessica Benjamin as a conse-
quence of a lack of recognition of a girl’s subjectivity by the father, not as a consequence of
an adjustment to a sense of having been “castrated.”
Relational analysts think that the development of heterosexuality needs as much expla-
nation as the development of homosexuality or bisexuality; there are no universal causalities
for either. In addition, homosexuality and bisexuality are viewed as normal variants, not
as pathological. This is also true for much of other sexual behavior, which historically had
been referred to as “perversions” (Dimen, 2001). Because of the importance of attachment
in the ideas about development, relational analysts have explored the connections between
attachment needs and sexuality. Their overlap and disconnections still remain a subject of
controversy.
Aggression comes from being aggressed upon, from frustration, and from threat,
although the capability is innate. If empathy is learned through the experience with a loving
caretaker, the impulse to hurt another can be contained. Although all people have aggressive
feelings, when loving feelings outweigh aggressive ones, relationships are easier to maintain.
The desire to hurt others by people who have been neglected or harmed is not to be under-
estimated (Harris, 1998).
Relational theory has sometimes been criticized for reducing human motivation to a
single drive—that for relationships. However, relational theorists have posited other needs
(see the section on psychological health below). Relational analysts are more likely to think
about desires than about drives, and these are “experienced always in the context of related-
ness” (Mitchell, 1988, p. 3).
Personality formation begins in the early stages of infancy, or even in the uterus. Rela-
tional analysts have embraced the work of attachment theorists and researchers, such as the
pediatrician/psychoanalyst John Bowlby (1980), who posited that infants develop expecta-
tions that others will be available to them emotionally to the same extent as the early care-
taker. The infant develops expectancies of characteristic interaction sequences that become
76 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

generalized in the first year of life, at the time when the ability to abstract information devel-
ops. Bowlby referred to the baby developing internal working models, whereas, similarly,
D. N. Stern (1985) referred to interactions that have been generalized. The unconscious
organizing structures early in life are believed to play a major role in the way other people
are integrated into one’s life. An “attachment-based psychotherapy” has been developed by
Costello (2013), and Slochower (2013) has recently elaborated on ideas of attachment in her
writing on “holding.”
Aggressive fantasies on the part of the child may produce guilt when parents are benign.
Although Oedipal dynamics are examined, problems in living arise from a larger variety of
reasons than spelled out in Freudian theory. For example, personality continues to develop
during the elementary school years, when the formation of a close friendship may mitigate
or modify earlier troubled engagements with caretakers. Relational theory agrees with Freud
that conflicts within the personality are inevitable. Detailed descriptions of the dynamics of
various personality disorders, such as obsessiveness, narcissism, paranoia, and borderline
personality, as viewed from an interpersonal–relational perspective, can be found in the
Handbook of Interpersonal Psychoanalysis (Lionells, Fiscalini, Mann, & Stern, 1995).
Relational psychoanalysis from its inception, but especially in the last decade, has looked
at how life-threatening and out-of-the-ordinary experiences affect personality (Davies &
Frawley, 1993). Sexual abuse is found in the history of many people and it is not a fantasy
of a desired wish, as posited by Freud. Relational psychoanalysis has dedicated considerable
attention in the last decade to the body and mind–body connections (or the lack thereof)
(e.g., Damasio, 2000). For example, in response to the prevalence of eating disorders, there
has been an increased focus on factors leading people to turn to food and substances as
opposed to others for comfort (Petrucelli, 2019). Similarly, issues of addiction, heretofore
neglected by psychoanalysts, have become a subject of attention. Those with severe depen-
dence are usually referred for treatment outside the therapy. Eating disorders have become
a prominent focus of a number of analysts, as have problems related to infertility, adoption,
and multiracial individuals and families.
Newirth (2003) suggested that unconscious processes remain important, but they are
often considered generative and create meaning, rather than the “seething cauldron” of
repressed impulses that Freud imagined. In fact, many other analysts now see psychoanaly-
sis as creating meaning. Eagle (2018) went so far as to say, “Until recently it would have
been difficult to imagine psychoanalytic theory without the concept of unconscious pro-
cesses at its center. (I say ‘until recently’ because the concept of unconscious processes does
not appear to be central to the contemporary theories of self psychology and relational psy-
choanalysis” (p. 5). Unconscious processes have become important again, however, with the
focus on nonverbal communication, especially in infancy. It should also be pointed out that
relational psychoanalysis has moved away from thinking in terms of traditional personality
styles to consideration of forms of relational organization, such as the ways people act and
feel in the presence of particular other people and in particular situations (e.g., Beebe &
Lachmann, 2013; D. N. Stern, 2008).

PSYCHOLOGICAL HEALTH AND PSYCHOPATHOLOGY

The relational therapist will note the level of functioning, including work, social relations,
and reflective functioning, in getting a history and hearing the current experience of the
 Relational Psychoanalytic/Psychodynamic Psychotherapy 77

patient. Sullivan (1953) preferred the term problems in living over other nomenclatures for
psychiatric disorders, such as the diagnostic categories present in textbooks of abnormal
psychology and psychopathology. Fromm criticized the conformist personality he saw in
American culture and was scathing in his attack on the “marketing personality.” Joyce
McDougall coined the term normopath, and Christopher Bollas referred to the normatic
personality; both terms refer to people who conform to the values of a society to the extent
that their individual vitality is stifled. Thus, the problems in living for relational psychoana-
lysts do not correspond neatly with the criteria in the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders. Nonetheless, relational analysts do make assess-
ments, often thinking in terms on a dimensional scale of various problems, not categories.
They may prescribe medication or refer patients for medication evaluations if they believe
that such medicine will be helpful. They are, however, quite critical of the “disease” model
inherited from medicine. They do not expect to uncover a pathogen—a single repressed
wish, for example. Instead, they view personality patterns as having been largely learned in
social situations, and as having been reasonable, adaptive ways of coping in those situations.
(Obviously, the temperaments with which infants are born also play a role.) If troubled ways
of being are learned, new ways of relating also can be learned.
Relational analysts make note of patients’ strengths and help them become more aware
of these and how to appreciate them. At the same time, relational analysts look at the gaps
in patients’ resources and help them become aware of these deficits. Flexible ways of relating
are signs of health, whereas rigid ways of being are signs of inhibition and anxiety.
A number of relational analysts have made important contributions to the understand-
ing of severe disturbances. In particular, Sullivan, Fromm-Reichmann, and Harold Searles
worked successfully with patients with schizophrenia before the advances of psychotropic
medications. For Sullivan, the self in the schizophrenic patient has lost control of awareness
and the sense of a consensually validated self. Sullivan, Fromm-Reichmann, and Searles
all subscribed to an ethos characterized by Sullivan’s attitude that we are all more simply
human than otherwise. They argue that although patients with schizophrenia are more dif-
ficult to work with, they are not essentially different from others. Many have found useful
Melanie Klein’s distinctions between a paranoid–schizoid position and a depressive position
in understanding disturbed people. The idea that people feel guilt for hurting others, seeking
to repair it and seeing others as both good and bad (the “depressive” position) is viewed as a
healthy way of being, and is more widely accepted than the concept of the paranoid–schiz-
oid position. Mitchell (1993, p. 222) also referred to pathology as a “failure of the imagina-
tion,” presumably not referring to psychotic states.
The relational tradition has paid more attention to what has actually happened to the
person, namely, the social and cultural contributions to problems in living, and fantasy
based on those experiences, than does classical psychoanalysis; that is, the interpersonal and
relational analysts believe that patients’ stories of abuse can be based on events that really
occurred rather than on their fantasies. Traumas, especially those stemming from betrayal
by parents, relatives, and other people in positions of authority, affect feelings and expecta-
tions in current situations in ways that fantasies not founded upon experiences do not. Pat-
terns of interaction from the past are seen as being maintained in the present.
Health is seen, as in other psychotherapies, as the ability to meet basic physical and psy-
chological needs. Health, however, does not simply represent having better feelings about
oneself and others. By allowing more experiences into awareness, a person may also notice
more threatening experiences when they exist. Health means a greater tolerance for such
78 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

anxiety-provoking experiences, in addition to tolerance for desired, exciting experiences.

Psychic health, as much as anything, refers to the ability to assimilate new experience, to
transcend the identifications and the constraints of the past.
Relational theory has sometimes been criticized for reducing human motivation to a
single drive—that for relationships. Yet Jay Greenberg, for example, has posited two broad
categories of basic relational needs—one for security or safety, and the other for effectance.
A theory of seven systems in the work of Lichtenberg, Lachmann, and Fosshage (1996,
2011) has been incorporated into much of relational thinking. These seven systems are (1)
physiological requirements, (2) attachment and affiliation, (3) exploration and assertion,
(4) responding aversively through withdrawal and antagonism, (5) sensual enjoyment and
sexual excitement and, added in the 2011 volume, (6) affiliation with groups and (7) care-
taking. Relational analysts are more likely to think about desires than about drives. The
satisfaction of these needs and desires is considered in the assessment of health. Curtis
(2009) has suggested two broad categories of desire—physical and psychological—or physi-
cal survival and survival of the meaning-making system. Satisfaction of these basic needs is
necessary for health.

THE PROCESS OF CLINICAL ASSESSMENT

Relational therapists make informal assessments of patients in all interactions, even as they
are gathering a history of the patient. Assessments are made at both interpersonal and
intrapsychic levels, consistent with the origins of the approach. Of particular note are the
interactional styles, styles of coping and defense, the range of emotions, cognitive abilities,
feelings about oneself and others, and conflicts and inhibitions that may block the patient
from achieving his or her goals. Diagnostic categories are known to the therapist, but cat-
egories eliminate the unique qualities of the individual that are of interest to the relational
therapist. Such categories are used to the extent that they are required for records and
are useful in summarizing characteristics of the patient, but they are generally viewed as
too restrictive and stereotyping, especially in regard to personality disorders. Assessment is
rarely a topic for relational therapists except for assessing whether someone is appropriate
for psychoanalysis (Coltart, 1986). Relational therapists do speak of the extent to which
people are obsessive and/or narcissistic, for example, but these characteristics are perceived
as lying along various points on scales, not as distinct categories. Assessments are usually
made at the individual level, consistent with requirements from institutions and insurance
companies, but they are also made at dyadic and systemic levels, with the phrase “relational
diagnosis” being used. As these are not psychiatric diagnoses and are hard to understand,
they have not caught on. Although the individual is the primary focus of attention, the
therapist is monitoring continually what transpires in the therapeutic dyad, and is cognizant
of the cultural context as well. If the therapist thinks that couple or family therapy would
be of benefit, such treatment (usually with a different therapist) is recommended, often in
addition to individual treatment.
The events and feelings preceding a problem, the overall context in which it occurs,
and any secondary gains (e.g., extra attention from others) that the problem may provide
are given serious consideration. A detailed inquiry is made into any problems that require
specialized treatment, such as substance abuse. It is generally considered that a patient will
not benefit from therapy while still addicted. In the case of potential danger to self and
 Relational Psychoanalytic/Psychodynamic Psychotherapy 79

others, inquiry into matters related to the likelihood of such events is conducted, and a judg-
ment is made as to optimal treatment. Relational therapists working in a hospital or clinic
setting utilize any formal assessments (e.g., psychological tests) usually conducted in that
setting. Therapists in private practice refer patients for psychological, neuropsychological,
or medical assessments when appropriate. Some relational analysts may still use the Ror-
schach Inkblot Test, the Thematic Apperception Test, and other psychological instruments
to understand patients better, although these measures do not seem to be used frequently
outside clinics or for diagnoses. They appear to be used by relational analysts largely for
research purposes. Generally, providing a diagnostic assessment is considered to be judg-
mental and not beneficial to a therapeutic process except in the case of serious problems that
would definitely benefit from medication. Patterns of interactions are described. Instead of
assessing defenses, relational therapists may note that certain responses that worked in a
previous setting are now overused or used when and where they may not be effective.

THE PRACTICE OF THERAPY

In the practice of psychotherapy, relational therapists draw from the rich literature of case
studies and theory in psychoanalysis, although their practice may differ somewhat from that
of their classical forebears. The relational emphasis is distinct from that of some other con-
temporary approaches, particularly psychotherapies that focus largely on symptom reduc-
tion. The therapist is not likely to tell the patient what to do, as in cognitive-behavioral
therapy (CBT), although with more disturbed patients, the therapist may suggest strategies
that might work better. For relational therapists, the unique experiences and meanings of
people’s existence are of very special interest. This contrasts with an interest in the general
characteristics of all patients with a particular psychiatric diagnosis, and with the applica-
tion of a standard technique that is relevant to everyone with that diagnosis. Every therapist,
every patient, and every dyad is unique. Indeed, most relational therapies prefer the term
approach to the more technical word technique. Still, a short-term psychotherapy derived
from Sullivan’s interpersonal psychotherapy (Klerman, Weissman, Rounsaville, & Chevron,
1984) has the general goal of increasing and improving interpersonal relations. This therapy,
originally designed for depression, while not psychoanalytic in its approach, is being used
very widely for a number of disorders, including bingeing, overeating, and borderline per-
sonality disorder (see Farber, Chapter 12, this volume). As Safran and Muran (2000) noted
in their version of a short form of relational therapy, there is, overall, a focus on awareness
and the present moment (vs. the past), on metacommunication, that is, looking at what
the communications mean and their consequences, and on optimal disillusionment (which
means finding out that the therapist also has weaknesses). The role of failures in attunement
and resolving such ruptures in the alliance is considered a natural part of the therapy pro-
cess.

Basic Structure of Therapy

Relational therapists usually prefer to meet with patients more than once a week, although
often this is not possible. Rarely would a relational therapist set a time limit for the therapy
unless the therapist’s work is consistent with one of the models of brief therapy (see Farber,
Chapter 12, this volume). Most relational therapists would prefer frequent sessions over an
80 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

extended time period in order that the interpersonal interactions with others that the patient
finds problematic emerge in the interaction with the therapist (transference). These prob-
lematic interactions may take some time to occur, or a meaningful level of intimacy may be
slow to develop. Although the treatment is most likely to be individual therapy, family or
group therapy may be used, often in conjunction with individual treatment. Despite sessions
generally being unstructured, the relational therapist becomes more active if life-threaten-
ing or treatment-threatening issues occur, and when treating seriously disturbed patients.
Although some use is being made of face-to-face Internet therapies (e.g., Skype), and tele-
phone sessions, use of these media does not remain without controversy (Bayles, 2012).

Goal Setting
Obviously, in relational psychoanalytic therapy, the relationship between the patient and
others is of primary importance and the relationship between the patient and the therapist
is often of central importance in the change process. The latter relationship is believed to
be the means through which all other interventions work or not (cf. Curtis, Field, Knaan-
Kostman, & Mannix, 2004) and often itself to be the major curative factor. For relational
psychoanalytic psychotherapy, awareness of what goes on between people is the primary
goal, with what goes on inside people also of great importance. Traditionally, the goal of
psychoanalytic treatment has been to increase awareness and through this process to effect a
broadening of the organization of experience, so that a person is more flexible and less rigid.
Increased awareness of interpersonal interactions is a major focus. Enrichment of experi-
ence often takes priority over symptom reduction, and optimal functioning in the areas of
love, work, and play are of interest to relational therapists, as they are to all psychoanalytic
therapists. The creation of new meanings, rather than the lifting of repression, is an empha-
sis in the therapy.
Another patient walked in and asked for help with his premature ejaculation (ejacu-
lating too quickly). I told him about the “stop and squeeze” method, in which the penis is
squeezed to stop ejaculation, but as we talked, it turned out he was often impulsive, as he
was during sex—doing things too quickly. Symptoms often have larger meanings. Many
times the precise goals of the therapy are not known in advance, because the hope is that
the patient will open up to new experiences and, in this process, formulate new goals. Ulti-
mately, however, the patient sets the goals, and the patient is certainly free to choose less
ambitious aims than what most analytic therapists prefer. If the therapist has reservations
about a goal the patient expresses, he or she has an obligation to express a dissenting opin-
ion or attempt to arrive at a mutually compatible goal. The relationally oriented therapist
has a responsibility to explain in the first set of meetings something about the way he or she
works if the patient comes from a background that is likely devoid of such knowledge. For
example, if the patient comes to the therapist saying that he or she would like to work more
hours each week and is already working an 80-hour week, the therapist might question this
goal and suggest an alternative, such as exploring what makes working that many hours so
important.
Despite the ambitious aims of most analytic therapies, patients often want help, first
and foremost, with symptom reduction. Addressing life-threatening and treatment-threat-
ening behaviors takes priority over other goals. Certain other behavioral problems may also
take priority, such as a substance abuse problem that will neutralize any benefit that psycho-
analytic therapy may offer. Financial problems of low-income patients must be addressed.
 Relational Psychoanalytic/Psychodynamic Psychotherapy 81

Relational analysts vary in the extent to which they refer a patient for behavioral and other
auxiliary treatments, or integrate such treatments into their own approach. Most rela-
tional analysts include cognitive techniques, which are seen as common sense. For example,
patients were asked, “What is the worst that can happen?” long before cognitive therapy
came on the scene. Catastrophizing, minimization, black-and-white thinking, and other
cognitive distortions (see Cattie, Buchholz, & Abramowitz, Chapter 5, this volume) are fre-
quently pointed out. Integrating other therapy approaches has increasingly been a subject of
interest. In books such as Relational Theory and Psychotherapy Integration: An Emerging
Synergy (Bressler & Starr, 2015), various techniques incorporated into a relational therapy,
including eye movement desensitization and reprocessing, Gestalt therapy, and many oth-
ers, are demonstrated and discussed. Similarly, Wachtel (2010) highlights the integration of
relational theory with family and CBT.
Relational therapists consider the different situations that the symptoms may commu-
nicate, how they have been adaptive, what they may symbolize, and with what they may
coincide. For example, a man who has retarded ejaculation may procrastinate elsewhere.
The sexual partner may be anxious and/or undermine the patient’s confidence. The man
may prefer not to be involved with this partner, or he may prefer a partner of another sex.
To the extent that therapists conceive of the presenting problem as embedded in a larger
picture, they will listen to the patient’s communications with an open mind, or inquire in a
more structured manner, so as to have a more nuanced picture of the whole person and his
or her difficulties.
In helping the patient achieve whatever goals he or she has articulated, the therapist
also has ideas about how best to achieve these goals. As already noted, the therapist will
likely have in mind the traditional psychoanalytic goal of helping the patient work, love, and
play more freely. Relational analysts will have in mind a variety of desired outcomes, such
as tolerance of uncertainty and emotions, arousal of curiosity, greater awareness of one’s
impact on others, increased capacity for self-reflection, mourning of losses and lost possi-
bilities, separation from being stuck in the past, and finding richer meaning in life.
In many cases, the patient will prioritize the treatment goals. The therapist, however,
may think it likely that the patient’s goals are linked with other goals that the patient has
not considered important. For example, a woman who is obese may state that she wishes
to lose weight. However, the weight may serve a purpose that is not fully conscious. For
example, the weight may keep people away or help the woman avoid sexuality. The therapist
is wondering how the patient can stop turning to food for comfort without an alternative
and might suggest that food is her most comfortable “relationship.” The relational therapist
is likely thinking about the possible adaptive purposes a symptom may be serving, and that
an attempt to remove the symptom without the patient developing an available alternative
way of fulfilling a longing or desire may not be effective. In this way, the relational therapist
is not simply trying to remove the symptom without first understanding its meaning.

Process Aspects of Treatment

Blagys and Hilsenroth (2000) have found the following to characterize psychodynamic ther-
apy versus CBT: (1) a focus on affect; (2) attempts to avoid disturbing thoughts and feelings;
(3) identification of recurring themes and patterns; (4) discussion of past experiences; (5) a
focus on interpersonal relations; (6) a focus on the therapeutic relationship; and (7) explora-
tion of wishes and fantasy life. However, relational therapists likely will be more active with
82 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

more disturbed patients and, therefore, more CBT-like. Traditionally, psychoanalytic thera-
pists have tried to facilitate a patient’s coming up with his or her own solutions to problems
through increased awareness, and less rigid and defensive ways of being. But psychotherapy
is inherently interactional. Psychoanalysts have attempted to avoid “transference cures,”
that is, having the patient simply adopt the therapist’s ways of being or belief system out of
liking, identification with, and/or respect for the therapist. Traditionally, techniques such as
reassurance, and particularly suggestion, were to be avoided largely because of the danger
of influencing patients to conform to the values of the therapist. Because relational thera-
pists are very aware of the interactive nature of the therapeutic relationship, however, they
recognize that some of these processes may inevitably seep into the interaction. Indeed, even
therapist questions may contain an element of suggestion. For example, the question “How
is it that you didn’t go to the party?” may suggest to the patient that the analyst thinks it
would have been a good idea to go to the party. Reassurance is often given nonverbally and
inadvertently with an “uh-huh.” Among the more insidious aspects of therapy is the pos-
sibility that the patients changes in accordance with the therapist’s desires alone. Further-
more, the therapist takes a more empathic stance in place of the traditional “neutral” stance
that can be perceived as negative, cold, and aloof. Analysts are often cautioned, however,
that being too empathic (too nice) can make it hard for patients to express angry feelings.
Patients may then be reluctant to develop or express the negative feelings that are central to
a crucial problem.

History Taking and Inquiry

Some relational analysts begin therapy by gathering a thorough developmental history,
including the background of the parents and grandparents, such as their place of birth,
ethnicity, race, and religion. Also noted are the way the parents met, birth order of siblings,
childbirth, preschool years, and relationships through childhood and adolescence. This sort
of history taking was recommended by Sullivan, who suggested that therapists conduct a
“detailed inquiry” into all of the areas of the patient’s life, though this need not occur in
the beginning of treatment and may, indeed, be quite gradual. Therapists can explain that
they will not be asking so many questions in future sessions. It is important, for example,
for the therapist to know whether the patient has ever attempted suicide or been hospital-
ized. Taking a history can be therapeutic. After one patient described his mother and his
problems with his wife, he exclaimed in surprise, “Wow! She’s just like my mother!” For
most relational therapists, it is important to strike a balance between therapeutic reserve
and impassioned interest. Curiosity is a vital therapist quality. The relational therapist may
ask questions to examine not only what the patient says but also what he or she omits.
The therapist’s inferences about what may be taking place are also posed as questions. The
therapist may ask, “Could it be that . . . ?” or say, “I wonder if. . . . ” The therapist may also
express a feeling of being in a bind by saying something to the effect, “I’m afraid that if I
say . . . , you’ll be hurt, but I’m afraid that if I don’t address this, you’ll. . . . What do you
think I should do?”

Exploration of Desires, Fears, Feelings, and Affect Regulation

Any therapy must start off with understanding what the patient wants and the obstacles
encountered. Relational analysts are often told, “Go for the affect.” There is concern about
 Relational Psychoanalytic/Psychodynamic Psychotherapy 83

affect regulation, because often the patient has not learned how to reduce anxiety or control
anger. The process of discussing anxiety in a safe place is one way of increasing the toler-
ance.

Attention to Defense and Resistance

Resistance to change, and therefore to the therapeutic process, is universal. Every patient
who comes to treatment wishes both to change and to remain embedded in her or his old
world. Remaining stationary requires limiting awareness of dissociated and unconscious
internal experience. Anxiety is likely whenever what was disconnected in the first place is
reactivated in the therapeutic process. Like classical analysts, relational analysts try to help
patients understand what is fearful about going further. As one patient said, “If I were to
feel my anger, my mind would split into a million different pieces.” The therapist’s task is
to help the patient feel safe enough to experience these dissociated and unconscious aspects
of self in a way that begins their integration into self-experience. Bromberg (1998) has sug-
gested that the analyst’s job is to “stand between the spaces” of different self-states.
As I mentioned earlier, major defenses employed by patients are dissociation, discon-
nection of any kind, or selective inattention. For example, a patient had been told as a child
that he was puny, and he was pitied by his father. When he ran into business difficulties, he
felt panicky and dysfunctional. He did not have a repressed memory or become aware of
an unconscious desire. Rather, in making the connections between past and present expe-
riences, he was able to acquire a new perspective regarding his current situation (Eagle,
2018).
The extent to which relational therapists point out how the patient is avoiding experi-
ence varies. Curtis and colleagues found, however, that when interpersonal analysts rated
which of 68 analyst behaviors they had found most helpful in their own analysis, the item
“helped me experience feelings I was avoiding” was rated the most helpful (Curtis, Field,
Knaan-Kostman, & Mannix, 2004). Some therapists, in acknowledgment of the patient’s
sense of vulnerability, simply wait for the defenses to wither away.
Another form of resistance is called “resistance to the awareness of transference” (Gill,
1982). Some patients resist the idea that patterns that have occurred with other people out-
side the treatment are occurring with the therapist. For therapists hoping to use the impor-
tant leverage of the session’s here-and-now situation, this form of resistance necessitates
that they persistently point out interactional phenomena, until patients are able to see how
a pattern is occurring in their relationships.

Empathy
Perhaps largely due to the influence of Kohut (who is believed to have known of the work
of Carl Rogers, also from Chicago), empathy is a major technique among relational thera-
pists. But Kohut (1971) knew that empathy would inevitably fail and that the repair of the
relationship would make a significant difference. Kohut thought that problems ensued from
the failure of parents to give the child what he or she needed. Although Mitchell objected to
this model, he did not disagree with the notion of Franz Alexander and Thomas French of
a corrective emotional experience—meaning that the therapist helps the patient feel some-
thing in the relationship that was not felt before, so that the therapy is a new experience
for the patient. He is reputed to have said, “If we are not doing that, what are we doing?”
84 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

Increasingly, relational therapists are asking, “Where in your body are you feeling that?”
This has been shown to be useful in getting at a feeling (Fosha, Siegel, & Solomon, 2009).
Fosshage (1997) has differentiated what he calls “empathic-centered” and “other-
centered” listening. Therapists vacillate between these two perspectives at times—either
reflecting empathic immersion in the patient’s point of view (e.g., Kohut, 1971) or taking the
position of the other (being the observer of the patient). By empathizing with patients’ expe-
riences and reflecting these experiences, the therapist actually may be joining the patient’s
defenses or resistance to make the intervention more acceptable. For example, the therapist,
in the “empathic-centered” mode, might reflect the patient’s experience with parents and
say: “Yes, you feel you should take care of your parents at your own expense.”

Focus on the Relationship with the Therapist and Other Patterns of Interaction
Although it is assumed that patients arrive in treatment with some expectations based on
previous relationships, it is not thought that patients are necessarily distorting reality in
their view of the therapist. Instead it is thought that patients are selectively attending to
aspects of the therapist. The therapist is another subjectivity, not a “blank screen.” The
therapist will inquire of the patient, “What did I do?” or “What about me led you to feel
that way?” The relationship between the therapist and patient often becomes the focus of
much attention in the therapeutic interaction. As patterns of interaction and selective atten-
tion emerge that have worked to reduce anxiety for the patient in the past, the patient may
not only see the therapist in ways that he or she has viewed an important person in the past
but also elicit responses from the therapist that have been elicited from others. In this way,
patients’ transferences often become actualized, reflected in the core relational concept that
people tend to construct their contemporary world to conform to the past.
When the therapist indeed acts in a way that the patient elicited, this process is referred
to as an enactment (see the section below on enactment). In the interpersonal tradition, if
the therapist is accused of being cold and uncaring, the therapist needs to inquire with true
curiosity how he or she might be cold. Lichtenberg et al. (1996) have referred to this process
as “wearing” the attribute, implying that it is plausible that the therapist may indeed be
acting icily, thereby repeating jointly with the patient interactions from the latter’s past. As
treatment progresses, the patient may become attuned not only to aspects of the therapist
that repeat the patient’s old relational processes but also interactions that include something
new. Repetitive patterns can occur in relationships outside therapy but not be repeated with
the therapist. These also need to be pointed out by the therapist. As well, repetitive patterns
can certainly occur that did not happen with early caretakers. For example, a man was hav-
ing difficulty arranging with his former wife custody hours with his children. On the phone
he told me he could only come Tuesdays and Thursdays at 8:00 a.m. After the first week,
he told me he could only come on Tuesdays and Thursdays at 5:00 p.m. Then he told me he
could only come on Mondays and Wednesdays at 5:00 p.m. His wish to have control over
the time in both situations was obvious.
Kohut’s (1971) ideas have contributed considerably to recent ideas about transference.
He noted that many people, especially narcissists, need to maintain an idealizing transfer-
ence (in which the patient idealizes the therapist) for quite a while, and that the analyst
should not interfere with it. For children who did not have sufficient experience with an
understanding and available caretaker who expressed admiration of their characteristics
and allowed for appropriate childhood feelings of specialness (or grandiosity), this experi-
ence is considered valuable.
 Relational Psychoanalytic/Psychodynamic Psychotherapy 85

Otto Kernberg (Kernberg, Yeomans, Clarkin, & Levy, 2008), coming largely out of
an object relations orientation, recently developed “transference-focused psychotherapy,”
although much of psychoanalytic therapy can be considered transference-focused. This ther-
apy was developed for persons with personality disorders and is used frequently with those
diagnosed as borderline personality disorder.

Intersubjectivity and Mutual Recognition

Intersubjectivity refers to the capacity to enter the subjective experience of another. Although
the roots of intersubjectivity can be considered to go as far back as Ferenczi’s “mutual
analysis,” in which the patient analyzed the therapist, as well as the therapist analyzing the
patient (and which did not turn out well), Stolorow and his colleagues began to use the term
in the late 1970s. Orange et al. (2001) emphasized the bidirectionality of conscious and
unconscious processes. Implicit relational knowing can occur in ways that are not based in
language but in nonverbal cues and experiences.
A number of relational practitioners, such as Jessica Benjamin, refer to their therapy as
intersubjective, meaning that what occurs between the individuals in the therapeutic dyad
is seen as what is most important. When this does not happen, mutual recognition may col-
lapse into a sadomasochistic solution of “doer–done to” relatedness (Benjamin, 2017). Con-
sistent with the antiauthoritarian stance of this therapy, morality is seen as arising from the
identification with the cares of others. Such intersubjectivity is seen as necessary to group
formation, group cohesion, coordination in collective action, and cooperation. Relational
therapists may ask patients to interpret their therapists’ own experience—their thoughts
and feelings. Such interventions can be helpful in understanding from the patient’s point of
view what is going on. Thinking about what is happening in someone else’s mind has been
referred to as “mentalization,” “theory of mind,” or “reflective functioning.” Such mutual-
ity is an important concept in relational psychodynamic therapy. It means that each person
is affected by and is affecting the other person; it is not just the patient projecting trans-
ferences onto the therapist. It should be noted, however, that the therapeutic relationship
does not involve equal self-disclosure. That would be more like friendship. The relationship
remains asymmetrical in this regard. It has been hypothesized that structures in the brain
called mirror neurons help most people (although maybe not those on the autism spectrum)
to understand what someone else is experiencing.
Thinking about what is going on in someone else’s mind is considered to be crucial to
empathy and interpersonal relations. In order to increase reflective functioning, the thera-
pist may inquire of the patient what was going on during a rupture in the alliance or the
appearance of a surprising emotion or comment. Or, some therapists will ask patients, “Do
you think I think about you when you’re not here?” If patients did not have a parent who
did this, the patient may say “no.” Then the therapist may inquire, “Do you think about
me when you are not here?” Most likely the patient will answer “yes.” Then the therapist
may ask, “If you think about me when you are not here, how could it be that I don’t think
about you?”

Mutual Enactment
Many contemporary analytic therapists no longer believe that therapists are able to be neu-
tral, as they were advised to be in classical psychoanalysis. Just like patients, therapists also
unconsciously enact their subjectivity in the context of an intersubjective relationship; that
86 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

is, countertransferential enactments are seen as inevitable, much as are transferential enact-
ments. The concept of participant-observer liberated many therapists from the unrealistic
expectancy of achieving therapeutic neutrality and objectivity. From this newer point of
view, analytic therapists should attempt to be both neutral and objective, and to refrain
from purposefully influencing patients, while simultaneously recognizing that revealing
aspects of their own personalities is inevitable. The word enactment, first used by Theodore
Jacobs, came to be used frequently by relational therapists and now also by those from other
analytic schools.
Countertransference, subjectivity, unwitting participation, and enactment all can refer
to more or less the same phenomenon—unconsciously based interaction that is unintended
yet unavoidable. Once viewed as feelings that patients are unlikely to notice, therapist coun-
tertransference, or co-transference, as many like to call it, is now considered to be expressed
in the form of subtle nonverbal, tonal, and attitudinal actions that inevitably have impact
on patients. The enactment occurs when the therapist’s functioning as a witness has col-
lapsed (e.g., the therapist is not remaining objective, but is reacting largely from his or own
countertransference and cannot get back into a more objective way of listening; an example
is given below). D. B. Stern (2004) has observed that people may play out a state of self that
they cannot tolerate or experience directly. The state cannot be experienced by one mind but
is experienced in two minds.
The concept of mutual enactment follows logically from the intersubjective way of
thinking about analytic therapeutic process. One of the ways that therapists express the
unconscious aspects of their countertransference is in the context of what some have
referred to as actualization of patients’ transferences. This is not as complicated as it may
sound initially. For example, D. B. Stern (2004) reported a treatment with a talented young
man who had ruined every academic and professional opportunity. For a year and a half or
so the work seemed to be productive. Then the treatment began to feel less alive, and Stern
became uneasy. He found out later that the young man had acted in a similar way with
his parents. On the face of it, he was a dutiful and loving son, but their expectations had
little to do with what their son wanted out of life. He failed to accomplish anything that
would really please them. Due to his parents’ narcissistic vulnerability, he never protested
for fear of hurting them. As Stern had begun to enjoy the collaboration, the patient had
begun to resent his pleasure and treated Stern as if Stern needed this narcissistic pleasure.
The relationship evolved into a pseudoalliance and ingratiation. On reflection, Stern had
noticed the patient’s appreciative responses to his interpretations, so he made more of them.
Stern was enjoying it enough that the patient had reason to believe that he needed to keep
this up if they were going to continue getting along. They had become securely locked into
an unconscious set of interpersonal patterns, and they did not know who was responsible
for provoking the interaction in the first place. In some fundamental ways, the patient’s life
history was relived in therapy—relived through not only transference enactment but also
an unconscious enactment with his therapist, meaning that the therapist participated in
the enactment, reacting largely according to his or her own countertransferences. At some
point, it is expected that either the patient or the therapist becomes aware of such unwitting
mutual interactions and addresses them in the therapy. This example captures the essential
aspects of what many relational therapists believe is an ongoing aspect of any therapeutic
relationship.
Every patient who enters psychotherapy is expressing a wish to change, although there
exists a part of the patient that wishes to repeat the past (i.e., stay loyal to the “internalized
 Relational Psychoanalytic/Psychodynamic Psychotherapy 87

family”). Therapists get drawn into reliving old and maladaptive interactions, that is, mutual
enactments, and this seemingly unfortunate occurrence may be turned into therapeutic gold
when it is recognized and examined. As Edgar Levenson (2003) has said, therapists must
become part of the problem before they can help patients avoid repeating their internalized
pasts.

Interpretation
Although a relational therapist may suggest a possible meaning to feelings, thoughts, or
events, such a communication is viewed as only a hypothesis rather than a truth about the
patient’s mental life. Interpretations are frequently offered as questions: “Could it be that
. . . ?” Interpretations may be provided in order to deconstruct or to reframe the patient’s
usual understanding. In general, the therapist’s observations are offered in a spirit of mutual
discovery, not as objective pronouncements. They are provided in a collaborative manner
to help patients make more sense of their lives and to expand consciousness. Interpreta-
tions explain current life by examining historical antecedents. They reflect the fundamental
psychoanalytic value that self-awareness is preferable to mystification. Still, relational psy-
choanalytic therapy has moved from a focus on interpretation to one of engagement, that is,
interacting and commenting on the interaction patterns (Eagle, 2018).
An example of a technical error in therapy is the therapist suggesting that a patient’s
perception of the therapist is replicating an earlier, similar one with a parent. Such an inter-
pretation ignores the role of the therapist. The suggested approach, instead, is to inquire
what about the therapist has aroused this perception. In this fashion, patients get to talk
about their perceptions and feelings in a way not done previously and that can help work
through the transference.

Silence, Free Association, and Reverie

Giving the patient space is important to most relational therapists so that they do not con-
trol what the patient wishes to talk about, allowing the patient’s own ways of interacting to
emerge. This is accomplished through silence and free association. Too much anxiety may
occur, however, and this anxiety must be prevented. The analyst’s reserve can help that
patient’s idiosyncratic ways of seeing the world emerge. By remaining in the background,
the therapist allows the patient to emerge into the foreground. Still, there is not the empha-
sis on free association and interpretation that there was in classical analysis. One relational
therapist (Grossmark, 2012, p. 287) even suggested that the fulcrum of contemporary psy-
choanalysis is the enactive engagement (that is, playing out the interpersonal patterns with
the therapist), “just as free association was once to classical analysis.”
The therapist tries to create an environment in which the patient can feel held or con-
tained, to use Winnicott’s terms. In this tradition, the therapist attempts to be neither
neglectful nor impinging. An atmosphere of safety is aimed at, with regularly scheduled
appointments and definite session starting and stopping times. A moderate degree of anxi-
ety is considered optimal. Regarding patient learning, too little arousal leads to little new
learning, and too much leads to repetition of the already dominant response, or, in this
case, likely mental paralysis. In other words, the patient should feel “safe but not ‘perfectly’
safe” (Bromberg, 2011, p. 17). In this relatively nonstructured situation, the patient’s own
unique experiences are most likely to come into high relief. The therapist notes the sequence
88 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

of topics discussed, attempting to help the patient provide concrete, vivid examples if he or
she tends toward generalities and abstractions.
Relational analysts posit that they are often providing a corrective emotional expe-
rience. Since the time of Frieda Fromm-Reichmann (cf. Kavanaugh, 1995), it is believed
that many types of experiences can lead to change, and elements of the relationship may
be curative in and of themselves. Those who speak of the relationship as mutative usually
refer to a sequence of unwittingly living through old and “bad” experience with the patient,
examining this experience, and evolving something new. At its best, this new experience and
new relational configuration becomes internalized by the patient. One relational therapist
stated that despite not seeing anything that she did as helpful in the treatment and, fur-
thermore, that she found the patient quite boring, the patient nevertheless improved, which
she thought was simply due to their relationship. Fromm-Reichmann (1952/1959) was very
clear, however, that childhood deprivations cannot be remedied in treatment simply by giv-
ing the adult what the child lacked. Mitchell (1988) also cautioned against what he called
the “developmental tilt” in psychoanalysis—the idea that simply providing an experience
with the good type of parental figure the patient did not have as a child will repair the early
deficiencies. Unfortunately, meaningful change does not come that easily. Lawrence Epstein
once stated (personal communication, 2000; cf. 1999, March 1st) that therapists often wish
to be the good parent the patient did not have, but it is, unwittingly, in being the “bad par-
ent” that the patient is most helped. This is what allows the patient to work through bad
feelings and come to feel understood. Salubrious new experience can only develop in a con-
text in which old experience is first repeated, mourned, and let go.
Some relational therapists find considerable value in tuning in to their thoughts that
are not directly about the patient during the analytic session. They find that thinking about
these daydreams or reveries may provide information about the patient, especially uncon-
scious communications. As the emphasis on the value of the analyst’s feelings about the
patient has increased, more attention is being given to these reveries. D. B. Stern (1990) has
noted that the unbidden thoughts and experiences of the analyst can be very useful, and that
unbidden thoughts of the patient may be surprising to patient and analyst. Interpersonal
novelty, ideas not anticipated by either party, are valued. The freedom of thought that is
encouraged in the treatment allows for the imagination to articulate or construct what one
has refused to think or talk about.

Exploration of Dreams
Dreams hold special significance for relational analysts (Blechner, 2018), just as they have
for psychoanalysts from Freud forward. The interpersonalist Fromm (1951) traced the
importance of dreams through history and described the lack of value given to them in
Western industrialized cultures. Fromm’s tradition of discussing dreams in groups has been
revived in a process called “social dreaming.” The dream is viewed as a message to oneself
to examine something that might lead to trouble if unexamined. In the context of psycho-
analytic therapy, often transferential implications of the dream may reveal feelings that have
arisen or may arise in the therapeutic interaction that have yet to be addressed. Relational
analysts may also investigate the different experiences of the self represented in the dream
using the Gestalt technique of asking the patient to “become” each object and person in
the dream. Dreams are also viewed as a way of consolidating or reconsolidating memories
(Wamsley & Stickgold, 2011).
 Relational Psychoanalytic/Psychodynamic Psychotherapy 89

Experiences in the Moment

Relational therapists might ask patients to imagine being in a situation in the moment to
help them experience it fully. Comments such as “Imagine being there right now” are used.
Such interventions are especially likely when the patient is describing an event but having
difficulty recalling parts of it, or when the patient is avoiding the affect associated with the
event. Similarly, relational therapists may emphasize experiences going on in the moment
with the therapist, referred to as “now moments.” When patient and therapist are in the
same place, Aron (1996) refers to the experience as “a meeting of minds.” D. B. Stern
(2015), using Gadamer’s term, has considered moments of understanding as a “fusion of
horizons.” He notes, citing Foehl, that whereas earlier analysts attempted to find the causes
of experience, “contemporary thinking focuses on the nature of experience itself” (p. 166).
Stern focuses on the patient’s freedom to experience unbidden and novel conscious experi-
ences.

Technical Errors
Since relational approaches can vary so much from one tradition to another, within each
tradition, and from one practitioner to another, it is often difficult to agree on what is and
is not a technical error. The term error suggests that there are right and wrong ways of con-
ducting therapy. Although this relational flexibility is quite liberating for therapists, there is
always the risk that such an attitude can lead to an “anything goes” approach. Nonetheless,
psychoanalytic therapists of most persuasions agree about basic boundary issues, such as a
set amount of time for each session; stability of fee among patients; no social contact out-
side of therapy hours; and avoidance of advice giving or imposition of the therapist’s values.
The dilemma of following rules or not has been referred to by Irwin Hoffman (1998) as a
conflict between ritual and spontaneity.
Aside from issues related to basic boundaries, some common possibilities for thera-
pist error are as follows: imposition of a preferred theory on the patient’s verbalizations,
thereby failing to understand the unique individuality of each patient; a rush to interpreta-
tion, before the patient has the chance to express him- or herself fully; failure to inquire
about patient statements; withholding observations that may be illuminating; imposing so
many observations that the patient becomes the secondary party in the interaction; assum-
ing or insisting that a particular interaction is transferential despite the patient’s insistence
that it is not; and failing to address transferential material when it may be vividly present in
the interaction.
Another common error is the provision of an intellectual explanation or understanding
without an experience-near or emotional insight. In most instances, such activity avoids the
necessary emotional encounter required for meaningful change to occur. Still another error
is frequently pointing out problematic behaviors or defenses, to the extent that the patient
feels unduly criticized. It is important for all therapists to acknowledge how particular inter-
actional patterns that have developed were adaptive—the only ones possible in a past situa-
tion—or how they were indeed rewarded in previous situations.
Wachtel (2010) has described a number of “errors” in the therapist’s wording of com-
munications, and ways for therapists to express themselves in a more helpful fashion. It is
less blaming, for example, to point out how a defense was useful in the past than to say
simply that a patient is being defensive in a particular way. Wachtel and others have also
90 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

described some ways to avoid what they consider “errors” from a relational perspective by
integrating techniques from nonpsychoanalytic approaches. Wachtel notes that modeling,
a concept from learning theory, for example, is very important from his perspective. The
therapist models a tone of voice—not disdainful or dismissive—that can help the patient
adjust his or her own tone of voice.

Integration of Neuroscience Findings

The importance of nonverbal activities of the brain, largely localized in the right side of
the brain, have been crucial to the development of an emphasis on nonverbal aspects of
change in relational psychoanalysis. Emotions and behaviors may change without conscious
awareness. The effects on the brain’s functions of memory from trauma have given analysts
a better understanding of the long-lasting effects of disconnections of verbal processing at
the time of impactful experiences. Schore (2015) has noted that affect regulation is internal-
ized as nonverbal and unconscious activity by the right hemisphere. Empathy is seen as also
being affected by mirror neurons, another recent connection made between an important
psychological concept and its possible neural basis. Mind–body connections are believed to
be crucial as the result of increasing knowledge about their interplay. For example, aerobic
exercise has positive effects on working memory (Wei, Si, & Tang, 2017); attention-based
meditative practices affect areas of the brain involved in reward processing, sensory atten-
tion, awareness, and integration; and self-referential processes and emotional control and
deactivation of the amygdala are involved in emotional processing (Acevedo, Pospos, &
Lavretsky, 2016). All of these developments have led to an increased emphasis on the impor-
tance of nonverbal factors in therapeutic change, with the therapist communicating in ways
that are not necessarily consciously processed.

Integration of Other Approaches

Psychoanalysis predated other forms of psychotherapy and already included elements of
therapies that were developed later. In this sense, it was already an integrated therapy. In
regard to other schools of psychotherapy, relational therapists were encouraged to focus on
affect long before the advent of emotion-focused therapies. As psychoanalysts have always
incorporated narrative construction, narrative therapy has always been a part of it. Mind-
fulness approaches have permeated relational psychoanalysis from its inception (Fromm,
1957), and are even more prominent now (Safran, 2003). As can be gleaned from the earlier
discussion of internalized relational models and interpersonal patterns of interaction, there
is an overlap with cognitive therapy, with its emphasis on cognitive schemas (see Cattie et
al., Chapter 5, this volume), and with IPT (see Farber, Chapter 12, this volume), although
relational psychoanalysis includes more emphasis on emotional, nonverbal, and unconscious
interactions.
The integration of relational psychoanalysis with other therapies, such as CBT, is
described by Bressler and Starr (2015), Frank (1999), Curtis (2009), and Wachtel (1997,
2010). Because relational psychoanalysis is consistent with recent developments in cognitive
science, this integration happens seamlessly. For example, analysts frequently make com-
ments such as “That seems like black-and-white thinking,” or “You are catastrophizing.”
Psychoanalysts have always paid attention to ways of thinking that are distortions or det-
rimental.
 Relational Psychoanalytic/Psychodynamic Psychotherapy 91

Termination
Termination depends upon achieving the patient’s goals, although the particular style of
termination is reflective of and coordinates with the interaction up to that point. Therapeu-
tic goals often change; at times, the goals initially set are achieved but new goals emerge.
Although a particular patient may still have goals to pursue with the help of a therapist,
patient and therapist at some point may realize that the patient is able to pursue these goals
largely on his or her own. In regard to psychoanalysis, Earl Witenberg (1976) commented,
“Analysis never terminates: It is visits-to-the-analyst that terminate” (p. 336). In other words,
a goal of any analytic therapy is to help the patient become his or her own therapist. Certainly
the therapist can provide an opinion about the advisability of termination, but the decision
ultimately rests with the patient. The therapist may see the therapy as having endless pos-
sibilities. Optimism can be helpful, but illusions do have to confront the clinical realities.
Termination brings up feelings of attachment, separation, and loss. Sometimes symp-
toms reappear when a termination date is set. Because intense feelings may arise, a termina-
tion date is set well in advance. Some relational therapists taper off sessions, in order for
patients to see how they manage on their own. Others may schedule a final appointment a
month or so after the second-to-last meeting. Therapists help patients focus on what they
have done themselves in order to bring about change. Some therapists inquire as to what was
helpful and hurtful in the treatment.

THE THERAPEUTIC RELATIONSHIP AND THE STANCE OF THE THERAPIST

An intense therapeutic relationship is considered essential to change. Otherwise, the thera-

pist would not be able to help a patient face fears and wishes that have been too frightening
to face during a whole lifetime. By trial and error, the relational therapist must find a bal-
ance between the safety of the old and the danger of the new. An alliance is created between
patient and therapist through rapport, empathy, support, reflection, and the patient’s sense
of being known. A good example of a supportive comment is that of Fromm-Reichmann
(1952/1959, p. 181) who, when working with a very disturbed woman, steeped in her own
feces in her room as an inpatient. The patient, apparently envious of Fromm-Reichmann,
saw the label inside Fromm-Reichmann’s coat from the Best department store in Wash-
ington, DC. The patient commented, “Best, best, best—you have the best of everything.”
Fromm-Reichmann supportively answered, “I hope you’ll be shopping again soon at Gar-
finkel’s” (referring to a fancier store than Best in Washington).
Different relational approaches have different basic stances; most conceive of the rela-
tionship as mutual but asymmetrical (Aron, 1996). Mutuality does not imply equality. The
relationship is considered mutual because there is inevitably mutual influence, recognition,
and empathy. The relationship remains asymmetrical, however, because the therapist does
not purposefully disclose personal information to anywhere near the extent that the patient
does. If the therapist were to take on a role similar to that of the patient, the relationship
would blur into one similar to a friendship.

Countertransference
Conscious countertransferential feelings are often a therapist’s strongest source of data in
efforts to understand patients. As subjective as such data are, a therapist is in a prime
92 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

position to speculate about the way patients are with others, by experiencing the feeling of
otherness in the context of the therapeutic dyad. To give an example, one lonely man entered
therapy with the complaint that women seemed unresponsive to him. It quickly became
apparent that everything about this man’s demeanor smacked of coldness, aloofness, and
self-absorption. Although of the same gender as he, the analyst assumed that the women he
pursued found him equally off-putting. Using his own feelings of boredom, disinterest, and
reciprocal withdrawal, the analyst pointed out to him how he perceived him, suggesting that
prospective girlfriends might be feeling something similar. Had he not been aware of his
feelings and their import, he might have acted out his countertransferential disinterest, and
essentially abandoned the patient emotionally. Countertransferential awareness provided
the dual reward of controlling the possibility of abandoning his patient and making him
aware of the way he related to others. Some relational therapists are more cautious than oth-
ers about sharing their countertransferential observations, believing that such input might
be experienced as too imposing.
Another type of countertransference is discussed by those therapists who are referred to
as “Kleinians” or Kleinian object relationists. They emphasize a type of countertransference
termed projective identification by Wilfred Bion (1967), in which the therapist has feelings
“projected” onto him or her by the patient, because they are too frightening for the patient
to tolerate. Once the therapist becomes aware of the projected feeling with which the patient
identifies, he or she can both reduce the patient’s anxiety by experiencing the feeling with
less anxiety and better know the patient firsthand by experiencing the same feeling. When
people simply “project,” the targeted person does not change. Projective identification is
differentiated from projection in that the targeted person, in this case the therapist, actu-
ally feels what is “projected” onto him or her. The Italian analyst Antonio Ferro (2008) has
stressed that the analyst must be open to experiences that the patient needs to have him or
her feel.
Here is an illustration of this process. For a number of years, an analyst worked with
a highly articulate and intelligent college professor, who spent a portion of his session time
berating the analyst for his inadequacies in not helping him, and attempting to humiliate
him for the many weaknesses he perceived him to have. His presenting complaint was
an inability to feel happy, regardless of his achievements and his sexual conquests. The
patient’s way of relating to the analyst closely resembled the way his father had interacted
with him. Throughout his childhood, he was the butt of his father’s sadistic teasing and
put-downs. This persecution was unceasing, lasting until the day his father died. The ana-
lyst feared that the patient would remain this way until one of them died. The patient could
not be happy, because he internalized his father’s sadistic and competitive assaults, and
no one could tolerate a close relationship with him because he identified with his hateful
father. The analyst’s primary feeling state when with this man resembled the way the man
felt with his father. The patient demonstrated firsthand what it was like to be him, and to
live with his hidden sense of abject humiliation. This gave the analyst a very clear sense of
what it was like inside the patient’s skin, beneath his most defensive attacking ways. The
analyst was then able to convey to the patient what he imagined he felt and what it was
like to live with his father. His ability to conceptualize this enabled him to refrain some-
what from retaliation and to withstand the patient’s assaults. As one might imagine, this
interactional pattern did not cease with a single interpretation, although it helped give them
both a framework to make more sense of the patient’s life, and it aided the analyst in not
drowning in his patient’s attempted humiliations. While many relational analysts find the
 Relational Psychoanalytic/Psychodynamic Psychotherapy 93

concept of projective identification useful, others from a more interpersonal perspective

find the concept mystifying.
Countertransference tends to be less central in the tradition that represents the Win-
nicottian stream under the relational umbrella (vs. the interpersonal and Kleinian object
relations theories just discussed), since the basic therapeutic model is conceived of as a
mother–child dyad, or a “holding environment.” With regard to countertransferential
feelings, therapists are normally advised to serve as “containers” for their patients’ dif-
ficult affects, until the patients prove ready to experience consciously and regulate such
feelings.
The newer tradition of self psychology (Kohut, 1971) bears great similarity to Win-
nicott’s object relational theory in its basic view of the patient–therapist interaction. From
this perspective, the primary therapeutic intention is toward empathic immersion in the
patient’s experiences. Empathy is the food that the patient lacks, and by providing enough
consistency, the attuned therapist allows the patient to come closer to her or his potential.
Self psychologists are well aware that perfect empathic attunement is impossible, and lapses
in attunement are both inevitable and potentially beneficial in that they can be examined
therapeutically. As in the holding environment, patients are expected to be hurt and/or
angry when the therapist fails.
Every relational perspective holds that therapists are always “countertransferring,” and
that affective neutrality is impossible. Given this assumption, awareness of countertransfer-
ence is always preferable to absence of awareness, even when such feelings are not revealed
by the analyst directly.

Self-Disclosure
Relational analysts may disclose their feelings to a patient or provide other information,
usually after asking the patient the reasons behind a question they may have posed to their
therapist. Tauber and Green (1959) made the controversial suggestion that an analyst might
decide to tell a patient a dream the analyst had about the patient. For example, one morning
before a patient came to his session, the therapist woke up dreaming that the patient brought
a bag of golf clubs to the session. The therapist did not mention the dream to the patient in
that session, but continued to think about it. Not getting anywhere that seemed to make any
sense in that session, the therapist decided to mention it to the patient at the following ses-
sion. The patient responded immediately, “I think of golf as what people do when they have
nothing else to do. I’ve been taking it easy in here, lately. That is what your dream is about.”
Davies (2004), who has addressed the potential value of judicious affective counter-
transference disclosures, gave the following example of such a disclosure. A patient had been
pushing to schedule a session earlier during the coming week. Davies was getting annoyed.
The patient stated, “You’re cold and unfeeling and ungiving. You’ve never been there for
me, not ever. I mean, sometimes you pretend, but it’s just skin-deep. Down deep inside you,
where I can see, it’s just ice. The least you could do is admit it” (p. 715). Davies responded,
“Sometimes we hate each other, I think. Not always. Not even usually. But sometimes we
can get to this place together. I guess we’re gonna have to see where we can get from here.
Neither of us likes it much. It just is” (p. 716). Among relational therapists, self-disclosure
exists as one option, with some therapists self-disclosing fairly liberally, whereas others
rarely, if ever, do so. It has been noted that self-disclosures have greater effect when they
are rare.
94 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

CURATIVE FACTORS OR MECHANISMS OF CHANGE

New experiences and the development of new meanings of experiences are the major factors
leading to change according to the relational approach (Curtis, 2009). Although new experi-
ences include an increase in awareness of that which was previously unconscious, they often
include a new relational configuration with the therapist as well. Some relational theorists
think that the relationship, in and of itself, is curative. The therapist must not, however, act
in a way that is so kind and gratifying that it deprives the patient of the freedom to feel anger
that will likely arise in the context of a more ambiguous and reserved therapeutic situation.
Gill (1982) criticized his contemporaries for spending too much time on the past, when
the real leverage in psychoanalysis, he believed, came from discussions of the relationship
between the two therapy co-participants. Since that time, there has been an increasing focus
on the analysis of transference, with most relational analysts noting that the analyst has
transferences as well and can therefore never be simply an objective observer of patients’
transferences.
Some relational therapists emphasize the analysis of other, outside relationships over
analysis of the transference. Sullivan had noted that it was too anxiety provoking, especially
for disturbed patients, to discuss the relationship in the “here and now.” Therefore, thera-
pists could help patients deal with experiences in other relationships in their lives and by
so doing, at least in some cases, patient and therapist might communicate implicitly about
their own relationship. In contrast, Searles (2018) worked with patients with schizophrenia
in a way that brought explanation of the transference–countertransference matrix into the
very center of the work. That said, relational therapists can be quite different from one
another and may have very different emphases in their work. For instance, strengthening the
“healthier components” of a patient’s personality by being supportive of adaptive qualities
is considered a major curative factor.
Analytic therapists have always relied on insight to bring about change. Insight may be
about the relationship with the therapist, about matters outside the relationship, and espe-
cially about the impact of life history on current functioning. Such insights at best are not
simply cognitive realizations—they are profoundly emotional, especially when focused on
the here-and-now relationship between the two therapeutic participants. In the relational
paradigm, change results not from a focus on insight into “the truth” but from the expan-
sion of awareness of a wider set of interactional patterns and experiences. The patient has
new experiences of self and others as hidden or disavowed aspects are noticed and reclaimed.
Incorporation of these experiences into the person’s self-representation is also considered an
expansion of awareness. Increased tolerance of uncertainty and anxiety allows conflictual
ways of being to be held in awareness simultaneously. Living with paradox may be seen as
one sign of “health.” Consistent with dynamic systems theory, new self-organizing pro-
cesses and meanings emerge from previously unformulated experiences. Nonverbal factors,
such as some of those in acquiring new interactional patterns, are also considered beneficial.
Mourning lost possibilities is considered to be another curative factor by relational
psychotherapists. Many patients must grieve the loss of good relationships with parents,
or aspects of family relationships on which they missed out. Patients may also have missed
opportunities that must be mourned, or they may benefit from coming to grips with the real-
ity that all choices foreclose other possibilities. When impossible goals are fully mourned,
more energy is available for the possible ones.
Expansion of awareness, openness to new experiences, new meanings of experiences,
 Relational Psychoanalytic/Psychodynamic Psychotherapy 95

and new self-organization are curative factors that occur in a situation of safety. Some ana-
lysts have called such a state “regression.” The word regression is misleading, however, in
that a person does not “regress” to an earlier level of development but instead feels such a
sense of safety with the therapist that he or she feels held or contained. In this relaxed state,
all may be experienced—rational and irrational. Worst fears are experienced in a state of
relative safety. Unfulfilled desires are tolerated. Those in the patient’s life who never will
be satisfied are mourned. The anxiety regarding the uncertainty of whether desires will be
fulfilled is also better tolerated.

TREATMENT APPLICABILITY

Relational psychoanalytic therapy is applicable to a wide variety of patients, including those

who are very disturbed. As with any verbal therapeutic endeavor, it is most likely to be effec-
tive with patients who are self-reflective, verbal, and willing to examine their own contribu-
tions to their problems in living. Psychoanalytic therapists, however, adjust their interven-
tions with patients who are not ideal candidates for analytic therapy, and engage in a form
of treatment that may lead up to it. For example, with patients who externalize their prob-
lems or are narcissistic, the therapist may need to emphasize reflective and empathic modes
of intervention. With children or patients who are less verbal, modifications in the tech-
nique are required (e.g., the therapist might decide to talk more with a seriously disturbed
patient who is mute). Play therapy is usually conducted with children. Sign language has
been used with the deaf. For patients who may come from a cultural background in which
it is inconceivable that a professional will not provide professional direction or advice, the
therapist may want to grant the patient’s wishes to some extent, and attempt to examine the
consequences of these interventions later. Therapists adjust their approach with inner-city
patients (Altman, 2010), bilingual patients, immigrants, and those with addictions. Patients
with psychosomatic concerns have also been treated (e.g., Lord, 2018). The concepts of dis-
sociation and multiple self-states have been found to be useful in applying a psychoanalyti-
cally informed approach to patients suffering from trauma. Boulanger (2004), in working
with an immigrant, argued that different self-states holding different passports can coexist
peacefully and that moving back and forth between self-states is a more desirable goal than
allowing one self-state to dominate over another.
If a patient comes for treatment exclusively for a specific behavioral problem, such as
substance abuse, a phobia, sexual misconduct, or smoking, the patient might be referred
for a behavioral treatment dealing specifically with this problem (see Antony, Roemer, &
Lenton-Brym, Chapter 4, this volume). A therapist might decline to treat a child alone if
the child would benefit more by being seen with the whole family. Home and hospital visits
are made to critically ill and dying patients. A systems approach has led to an adaptation to
families, as relational therapists emphasize interactions that are happening in the real world
and that may be disturbing people.
Much attention has been paid in relational psychoanalysis to the treatment of gay, les-
bian, bisexual, and transgender patients. These varieties of sexual choice are not considered
to be pathological, as they were among early psychoanalysts. Issues of multiracial patients
and the role of “whiteness” as distinguished from other racial and multiracial backgrounds
in Western culture (Altman, 2006) have also been considered.
Relational approaches have been used extensively with patients who have experienced
96 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

trauma. Although transference and enactments may often occur with sexually abused
patients and those who have experienced torture, the therapist may serve simply as a sym-
pathetic listener. It is also helpful, as with other experiences that have not been symbolized,
if the patient can move away from the concrete images of what happened and verbalize the
feelings in the situation. Such has always been the idea of the “talking cure.”

ETHICAL CONSIDERATIONS

Relational therapists must be clear with patients seeking symptom reduction about the man-
ner in which they work and the length of time treatment may take. Problems ensue if the
therapist overvalues patient fantasies and fails to inquire or be sufficiently concerned about
external realities (e.g., losing a job or physical health). Relational therapists face ethical con-
siderations similar to other types of therapists, namely, the lack of knowledge of techniques
from other theoretical orientations that may be more effective for particular problems, or
the overuse of an approach they prefer compared to other approaches that have been shown
to be more effective. A body of research suggests that symptoms dominated by substance
abuse may be best alleviated through treatments established by groups such as Alcoholics
Anonymous (Arkowitz & Lilienfeld, 2011) or by a period of residential treatment. System-
atic exposure and applied relaxation (progressive muscle relaxation) have been found to
be the most efficacious treatments for patients with agoraphobia, social phobia, and post-
traumatic stress disorder (Lambert & Vemeersch, 2002). Exposure-based treatment out-
performed alternative active therapies (eye movement desensitization and reprocessing and
cognitive therapy) for specific phobias (Wolitzky-Taylor, Horowitz, Powers, & Teich, 2008),
and behavior therapy was better than control groups for seven kinds of specific phobias
(Ost, 1996). Even Freud recommended behavioral exposure for the treatment of phobias
(1918/1953). In additional areas of dysfunction, where many research findings have sug-
gested that a biological component plays a large role (e.g., bipolar I disorder, schizophrenia),
almost all believe that medications must be employed in addition to “talk therapy.” Some
relational therapists, indeed, are disinclined to employ psychoanalytic therapy in situations
in which the research literature indicates that other approaches have been more effective.
Relational therapists view symptoms in the context of overall personality functioning
and culture, so they are often not comfortable focusing on the presenting problem only,
without taking into account the larger context. For example, a Muslim patient who was
hospitalized for depression due largely to guilt over an affair she had while waiting for her
fiancé to come to this country, told me, before a family meeting, that her father would have
to kill her if he found out about the affair. I certainly did not mention the affair! It was
central, however, to her depression. The importance of taking culture into account is seen
in the use of the term ethical non-neutrality. For those working with survivors of torture
or families with members who have been made to “disappear,” therapists often have to
make clear where they stand in regard to the politics of the country of origin in order to
gain patients’ trust. This also occurs when patients are involved, or have been involved, in
politics that are not acceptable in their home country. Some patients from the former Soviet
Union have to be assured that the progress notes will not be turned over to the government.
Patients from Latino or Hispanic cultures must not be considered psychotic if they practice
santería or espiritismo, both of which involve trance and communicating with spirits. For
a fuller discussion of race and working in the inner city from a relational psychodynamic
 Relational Psychoanalytic/Psychodynamic Psychotherapy 97

perspective, see Altman (2010). In summary, it is unethical for a therapist to neglect or

ignore cultural factors.
Ethical quandaries can occur when the clinician suddenly becomes ill or is dying. If the
therapist has to suspend therapy for a time, disclosing the illness can make some patients
overly concerned about the therapist’s health, which would be a detriment to the therapy.
Fonagy (2009) has considered the ethics regarding responsible action when a practitioner
is known to be losing mental capacities. Another ethical concern is whether to continue
treatment when it is not helpful, which then raises the ethical issue of abandonment of the
patient. Ethics regarding use of telephone sessions or Skype when the therapist has not met
the patient in person remain controversial.
Regarding preservation of the confidentiality of the therapeutic relationship, there are
difficulties in small communities in which one might encounter a patient in a social situa-
tion, where, say, parents are introducing themselves and their children. Another potential
ethical issue is that although most analysts believe that patients should pay by check rather
than by cash, in a small town, this would reveal the patient’s name to bank tellers, thus
breaching confidentiality (Mellinger, 2009).

RESEARCH SUPPORT AND EVIDENCE-BASED PRACTICE

In relational psychodynamic therapy, the relationship with the therapist is considered to be

crucial and likely the most important factor in treatment. In fact, the therapeutic alliance is
the most frequently researched aspect of psychotherapy and has been found to be correlated
consistently with outcome at a moderate level (Horvath, Del Re, Fluckiger, & Symonds,
2011). The relationship accounts for more of the variability in outcome than any other spe-
cific ingredient (e.g., Messer & Wampold, 2002). Brief relational therapy has been shown to
have fewer dropouts than CBT or other psychodynamic therapy (Muran, Safran, Samstag,
Wallner, & Winston, 2005)
A meta-analysis of 23 randomized control trials (Abbass et al., 2014) has supported
the efficacy (in controlled experiments) and effectiveness (in actual practice) of psychody-
namic therapy. In another meta-analysis of 17 randomized control trials (Leichsenring,
Rabung, & Leibing, 2004), large effect sizes were found at termination and even larger ones
at long-term follow-up. Although there is considerable recent support for the effectiveness
of psychoanalytic treatments (Leichsenring & Rabung, 2008; Levy & Ablon, 2009), these
studies tend not to include “relational” psychoanalytic psychotherapy as a particular sub-
type. Regarding individual diagnoses, randomized controlled trials have supported efficacy
for psychoanalytic treatments for depression, anxiety, panic, somatoform disorders, eating
disorders, substance-related disorders, and personality disorders (Leichsenring, 2009). Fur-
thermore, long-term psychoanalytic psychotherapy of at least 50 sessions was found to be
superior to short-term treatments in 23 studies with comparison groups for patients who
met criteria for DSM Axis I or Axis II disorders, for overall outcome, target problems, and
personality functioning (Leichsenring & Rabung, 2008).
In a later study, Sandell (2012) and colleagues followed over 400 patients in analytically
based psychotherapy over 3 years. Some of the analysts in this study likely held an object
relations orientation. This study showed progressive improvement in measures of symptoms
and morale the longer the patients were in treatment. It is interesting to note that the use
of a classical analytic stance, that is, the nongratifying style Freud advocated, was found to
98 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

be counterproductive. In another review of the efficacy of psychodynamic treatments (Gib-

bons, Crits-Christoph, & Hearson, 2008) it was concluded that psychodynamic treatments
were efficacious for major depressive disorder and opiate dependence with patients who
were also on medication, and likely efficacious with psychotherapy alone.
In the United States, most of the research on psychoanalytic therapy has been con-
ducted on brief treatments, a number of which are relational approaches. Interpretation of
the patient’s core conflictual relationship theme in Luborsky’s (Crits-Christoph, Cooper,
& Luborsky, 1998) supportive–expressive therapy has been found to be related to better
outcomes, including improvement in symptoms. A study of a brief interpersonally oriented
psychodynamic therapy derived from this approach (Safran, Muran, Samstag, & Winston,
2005) indicated symptom remission in patients with general anxiety disorder. Brief rela-
tional therapy focuses on resolving ruptures in the therapeutic relationship; training/super-
vision in this approach led to improvements compared with therapists who did not have
such training (Safran, Muran, & Eubanks-Carter, 2011). Brief relational therapy was also
found to be as effective as cognitive-behavioral and ego-psychological (supportive) treat-
ment for patients with whom therapists find it difficult to establish a therapeutic alliance
(Muran et al., 2005). And, of course, considerable research demonstrates the importance of
the alliance and the relationship itself (Norcross, 2011). Relational analysts are critical of
randomized control trials that often exclude many patients who fit more than one diagnostic
category and sometimes do not hold up in long-term follow-ups. Relational analysts prefer
“relationships that work.”
Although not specific only to relational psychoanalytic approaches, there is also research
evidence for the existence of transferential processes. Whereas the evidence regarding the
effectiveness of transference interpretations is mixed, positive therapy outcome has been
found to be related to accurate transference interpretations in low dosages for high-func-
tioning patients (Messer, 2001). Progress in therapy was also found to be related to therapist
adherence to a psychodynamic focus formulated in object relations terms (Messer, Tishby,
& Spillman, 1992). Transference-focused psychotherapy (TFP), although not derived from
a relational perspective but central to it, has been found to be effective for borderline per-
sonality disorder (BPD). In this therapy, behavioral symptoms are explained by internal,
emotional factors that become clear in the mutual interactions in the therapy. In a study
comparing TFP, dialectical behavior therapy, and supportive therapy, with 30 patients with
borderline personality disorder assigned to each treatment for 40 sessions, only transfer-
ence-focused and supportive therapies showed reductions in patient impulsivity, and only
TFP showed reductions in irritability and verbal and direct assaults (Levy, Wasserman,
Scott, & Yeomans, 2009). TFP also resulted in positive changes in attachment styles and
reflective functioning (Levy et al., 2006).
Attachment research has been very influential in relational theories of development.
Both attachment style and representations of self and other have been found to change
during psychotherapy, which is consistent with the relational psychoanalytic approach.
Mentalization-based therapy, a psychodynamic therapy rooted in attachment and cognitive
theories, and described earlier, helps patients become more aware of their own and others’
mental states in order to address their difficulties (Bateman & Fonagy, 2012). In a ran-
domized controlled trial (Bateman & Fonagy, 2009), mentalization-based therapy showed
a steeper decline in all significant problems in an 18-month treatment, including suicide
attempts and hospitalizations for patients with BPD, than did structured clinical manage-
ment.
 Relational Psychoanalytic/Psychodynamic Psychotherapy 99

CASE ILLUSTRATION*

Eve, a single woman in her early 30s, was a PhD candidate in the humanities and also taught
courses. She had a boyfriend whom she had been dating for many years. The patient was
quite attractive, appealing, and always well-dressed, in spite of buying her clothing at thrift
shops. She told me that she had difficulty in relationships, especially with her family and
with women. Eve was also depressed from time to time and had taken Prozac, but it did not
help. She had never attempted suicide, nor did she abuse alcohol or use drugs.
In the first session, Eve reported a dream from the previous night in which her sister-in-
law, trained in CBT but not practicing, had rearranged the dishes in her dishwasher. I asked
if she might be concerned that I would rearrange her ideas about things and she responded
“yes.” We discussed what would go on in therapy, and she was pleased with the discussion.
In relational therapy, it is important to consider the transference implications of dreams. I
noticed on a form I give out to new patients that her birthday was the same day as mine,
but I never mentioned this. Still, I know that I identified with her and had an empathic reac-
tion each time she spoke of birthday plans. I think that this coincidence led to more positive
feelings toward her. In the first two sessions I took a thorough history, in the interpersonal
tradition.
For many sessions Eve discussed the problems in her family. When she was around
them, she believed that she became the “bad one” and that the family drew out this side
of her. She was sort of a different person when with them, but I never saw her in this
state of being. Her father was bipolar and the parents had gotten divorced when she was
an adolescent. When Eve was age 20, her parents would not pay for her to finish college,
because they found out that she was having an affair, but she managed to finish college
anyway. Her mother was very religious. Eve’s relationship to religion was often a subject
of discussion in therapy, as was spirituality. She wanted to figure out how to have mean-
ing in life.
The parents did support the other siblings throughout college. Her mother said that she
did not get to pursue a PhD because she got pregnant with Eve. Subsequently, two brothers
and a sister were born. These siblings appeared to be preferred by the mother and Eve was
preferred by the father. In fact, she appeared to be an “Oedipal winner,” meaning that she
succeeded in getting the father to love her more than he did her mother. She believed that
her relationship with her father was another source of the envy her mother seemed to feel
toward her. One time she told me that she was with another man and woman and believed
she deliberately tried to make the other woman jealous of her. This seemed a bit odd, as
I would have thought that she might have tried to get the man to be attracted to her. She
believed she tried to get the other woman jealous of her so that she could feel superior to her.
Eve recognized that she probably had done this as well with her siblings, sister-in-law, and
others. In retrospect, having heard of her relationships with women, I wondered if she was
trying to get this woman to be attracted to her, but she did not mention this, and I did not
think of it at the time. Sexual attraction to women had not come up. Due to the anger Eve
apparently showed to others from time to time, I thought she must have had a different way
of being, or different self-state, with others than with me, but I rarely got her to tell me what
she had said or done that led to her difficulties. I felt envious in regard to her attractiveness,
but not in any other way.

*This case is a compilation of two cases.

100 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

At one point, her sister-in-law asked Eve if she loved her other brother more than she
loved her (the sister-in-law’s) husband. She said that she supposed she did, as she felt closer
to him. Eve’s sister believed that she had likely been sexually abused by their father, but the
patient did not think so, as they had shared a room and she never saw anything that led her
to think this. The sister and the brothers did not speak much with the father, who was quite
difficult and often explosive.
In her graduate program, Eve felt that men were given more opportunities, even if they
were neither as smart nor worked as well as she did. The incidents that occurred in school
were frequently a subject of her sessions. She also often complained that she was not in a
more prestigious doctoral program and would have difficulty getting a job in her field, in
which there were very few jobs available. She was correct about this, but she loved engaging
in scholarship and, knowing that I taught at a university, asked me what I thought would
help her to gain employment. I said that I was sure she knew—namely, presenting at confer-
ences and publishing articles and books. In fact, she attended conferences and presented and
published a paper. She received two teaching awards during the period in which she was
in therapy. Her relationships with her fellow students were close; Eve often had coffee and
sometimes dinner with these students. We also discussed her envy of me, as I had a teaching
job and was apparently married. Because of her awareness of this envy, she did not act in a
hostile manner or try to act superior.
The sister-in-law was also quite religious and called Eve a whore for having lived with
her boyfriend. She told her that she did not want her to be around her children. The brother
did not help to repair the situation. I knew that Eve could be provocative, but it seemed to
me that her sister-in-law was neither as smart nor as attractive as Eve. The brother had been
given money for a house by the mother, although the patient did not have much money.
Generally he and his wife were treated better than the patient, as was the other brother who
lived across the country. The mother now had a good, well-paying job but would not give
Eve any money. Her sister-in-law and brother lived near the mother; the other siblings did
not live nearby. Her sister was married and lived out of the country. At Christmas time, the
sister-in-law and brother said they would not come over to her mother’s house as long as
Eve was there (she was living with her mother at this point). Her mother suggested that she
not be there when her sister-in-law wanted to visit. Eve got angry and told me she would not
give any Christmas presents. I told her that in her family, this would be very provocative.
She asked if her parents could call me and I agreed, as I had conducted family sessions with
a few patients. The parents got together at the mother’s house on two different telephone
lines and called at the appointed time. I had agreed with the patient to tell them that Eve
felt the sister-in-law was treated better than she was. The mother seemed to agree with this,
and I said that it was not right to treat the sister-in-law better than her own daughter. The
mother then worked out a way for everyone to come over on Christmas, and the patient gave
everyone presents.
It happened that we both read poetry at the same venue (poetry was not her field, so I
had not expected to see her). I said “hello” and smiled, but we did not speak further. When
I asked in session how she felt about it, she said she was pleased that I, too, wrote poetry
and was happy to see me there. Furthermore, she said she liked my poems. Sometime after
this, a film was being made in my neighborhood and she saw a famous, good-looking, male
movie star on the way to my office. After her appointment, she gave this man a poem. (I am
not sure whether she had it with her or wrote it after our appointment). It was a testament
to her attractiveness that he allowed her to approach him.
 Relational Psychoanalytic/Psychodynamic Psychotherapy 101

She frequently talked to me about papers she was presenting or turning in for her
courses. When she was writing her dissertation, she asked me for some psychoanalytic ref-
erences. I knew a number of references that would be useful to her, and she said she would
acknowledge me in her work. I was quite interested in the topic, which she spoke about fre-
quently. I found her comments on various works quite interesting. She would also mention
various writings, saying I might like them, too, which I did. One was A Dangerous Beauty.
During this period she also spoke frequently about her financial difficulties, and that her
boyfriend and father gave her some money.
Eve was working on a journal with a professor who made sexual advances toward her
on a number of occasions. He then propositioned her, which she told me about. I asked her
how she would feel afterward, and she then declined his invitation. When it came time for
Eve to get a job, the professor would not write a letter of recommendation for her. She asked
another professor, who told her to meet him at his home. He made it clear that he would
only write one for her if she had sex with him, which she was not willing to do. She later
learned that this was not the first time he had propositioned one of the students. As he was
chair of the department, she did not feel comfortable reporting this. (All of this occurred
before the current firing of men who sexually harass or abuse women.) Her dissertation
sponsor did write a letter for her, as did two other professors, and Eve got a teaching job,
although she had also applied to teach in prep schools in case she did not.
The relationship with the boyfriend had always been problematic. He would not discuss
intellectual matters, she had erratic sexual attraction to him, and he drank a lot. With no
siblings, his parents lived in another country and he rarely saw them. He spoke frequently
of a rich friend who lived in another state, of whom she was envious. Eve’s mother, though,
liked him a lot. Eve reported a dream that he had an affair with another woman, which
turned out to be true, so she moved back to her mother’s house. Her mother complained
both to her and her siblings that Eve had cats she would not give up and that she left her
room messy. The siblings told Eve that she should move out. She then got involved with
a younger man and lived with him and his mother. She frequently discussed with me her
romantic relationships and what she should do. She decided that the new lover was too
involved with his mother, among other problems, and broke off the relationship.
One day Eve brought in a paper from Scientology on “psychiatric rape” (a pamphlet
reporting therapy did not work), saying she thought I might find it interesting. The paper
was about the misuse of psychiatry, but the word rape was provocative. I had seen the leaflet
before, but gave some thought to it and asked why she thought I might find it interesting.
She responded that it was the way some people considered psychotherapy. I did not think she
thought I was aggressive in the therapy, nor was I aware of any sexual feelings toward her.
My feelings were more those of a mother and a professor. Now I had to give sex some reflec-
tion, as well as our aggression. I knew, and she knew, that I felt annoyed when she cancelled
sessions or called to say she would be late. This had gone on with friends and relatives, and
we had discussed how this affected her relationships. Given the title “psychiatric rape,” I
had to wonder how much might I wish to hurt her? In the relational tradition of noticing
one’s countertransference, I knew I had lived vicariously through her many relationships
with men, the way her flirtations with men turned into having a cup of coffee with them
and then something more.
It seemed that her sense of entitlement and envy of others was often having a negative
effect, in that she made comments that would not lead others to like her. Then she men-
tioned toward the end of the session that she had dreamed that I lay down on top of her
102 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

on the couch. I was a bit startled and felt anxious. I asked her if she thought I was sexually
attracted to her, and she demurred. I did not ask her if she was sexually attracted to me,
probably out of anxiety, but it also seemed presumptive. The next session she came in and
said, “Remember in the last session when you asked me if I was sexually attracted to you?”
Now this was not what I had asked, although I certainly had thought it. She went on to say,
“I think of you as a Farrah Fawcett-Majors (a sexy woman in films) type for your genera-
tion.” I suggested that she might be sexualizing relationships and asked if this might make
others uncomfortable at times. She thought it was possible. This exchange was bringing up
for me all sorts of thoughts and feelings. Had I been resistant to the thought of her having
sexual feelings toward me? I had been aware of such feelings before from patients, but they
were from men or lesbians. Had I been resistant to the awareness of Eve’s feelings toward
me? Was there a possibility of resistance to the awareness of countertransference? Had she
also had sexual feelings toward her mother, or did the mother have them toward her? The
mother was attractive, elegant, had a well-paying job, a lovely house, and had been married
with children. Was the mother unconsciously attracted to Eve? Was this part of the reason
she treating Eve badly? That is, did her mother wish to remain distant from her daughter?
These are the kinds of feelings and thoughts a reflective relational analyst might pose to
him- or herself in order to understand what is transpiring in the patient–therapist relation-
ship. Resistance to the awareness of transference is a concept that Gill (1982) noted, and
resistance to the awareness of countertransference is a concept that follows from it.
The following week, Eve was offered a 1-year research fellowship in a nearby city and
had to pack and find a place to live. She developed a brief relationship with a woman there,
during which time I saw her occasionally. I have found that when patients get sexually
attracted to me and I show no reaction, or point out, to make clear where I stand, that thera-
pists do not have physical relationships with patients, they often develop a relationship with
someone else. This happened in Eve’s case, but she quickly moved on to a relationship with
a man. The two had serious differences regarding politics and religion, and did not continue
to see each other. My guess is that she was also envious and could be hostile at times.
As Eve also had no further income in that city, she returned home, where she lived with
her mother and continued to apply for jobs but did not get an interview. She then applied
for jobs in other countries and asked me to write a recommendation. She had given me her
dissertation some time previously, which I had read and thought excellent. Knowing what
had happened with the two male professors who had sexually harassed her in her previous
job search, I agreed to write a letter based on the dissertation. Was this an enactment suc-
cumbing to her seductiveness? At the graduate program where I teach, we have had some
recommendations from applicants’ therapists, although that did not seem proper to me. In
the case of Eve, I only commented on her intellectual abilities as an academic consultant. I
doubt that I will do this again or even have such an occasion to do so. Still, I feel uncomfort-
able writing about it, even though I am not an orthodox analyst. I imagine I also wanted her
to be able to pay for her sessions, but I do not recall thinking about it at the time.
Eve did get a job at a university in another country where English is spoken. However,
there were no therapists who spoke English in the city where she lived and she asked to
continue therapy with me via Skype, to which I agreed. There were no laws in that country
prohibiting such treatment. Eve had problems at work, where there appeared to be consider-
able discrimination against women. She spoke a lot about difficulties getting the university
to pay for her airfare to get there and again to come home at Christmas and to present at a
conference. She had an affair with another American man teaching at the same university,
 Relational Psychoanalytic/Psychodynamic Psychotherapy 103

about which she could not let anyone at the university know. It did not work out. I also
heard a lot about her housing difficulties and problems in the department. The political
situation and discrimination became worse. Her former boyfriend in the United States was
asking her to come back, so she decided to return to this country. Eve and her boyfriend got
married and rented an apartment far from New York City. She also got a part-time teaching
job near where she lived. Both parents then became ill, and Eve was very good about taking
care of them, which greatly improved her relationship with her mother.
The sister-in-law became an administrator at the university (her husband worked there)
where Eve was teaching part-time. The sister-in-law was actually in charge of the part-time
teaching assignments in the unit where Eve worked. When the father was dying, the sister-
in-law claimed that Eve had said that her sister-in-law wanted the father to die when she
advised against having another medical procedure. Eve said she did not say this and, in fact,
did not remember it, but her brother stuck up for his wife. I thought Eve had likely said this
in another self-state that led to problems, a part of her that she did not let me see. It seemed
as if she dissociated these states, and this was likely why she could not remember what she
said or did. Eve wrote a letter apologizing if she had said something like this when she pan-
icked the day her father died. She got no response and was not rehired. The sister-in-law was
also likely angry because, although the father’s will divided his assets equally, Eve got some
money from another source, as she had helped him everyday, whereas the others did not see
him except once a year.
This was the point at which Eve returned for two sessions, having continued part-time
work out of her field, and to live with her husband, which was working out satisfactorily.
She also had various teaching jobs, such as at libraries and with reading groups, without
much pay, but which were very rewarding to her. Because getting into New York City from
her home was very difficult, we did a few Skype sessions and then terminated.
Elements of the therapy that made it relational were the focus on interpersonal rela-
tionships, consideration of the relationship between the two of us—that is, the transference
and countertransference—the enactment of her problems with me, and the considerations
of her various self-states. In the interpersonal tradition, I focused on what she said and did
with other people, and the consequences and potential consequences. The support I gave her
was likely in the tradition of self psychology. Many analysts would object to my supporting
Eve in her career, thinking that it would have been better for me to disappoint her, so that
she would reexperience the lack of support from her parents at a crucial time. I cannot say
which would have been better, as a case can be made for either approach.
I believe that the question I asked Eve about her dream in the first session set the stage
for our not getting into the kind of competitive relationship she had with her sister-in-law
and mother. Although her relationship with her sister-in-law did not improve (I think that
not much of this problem was due to Eve), her relationships with other women, including her
mother, definitely improved during the therapy. She seemed to be in a satisfactory marriage
relationship and returning to school in an area in which there were more jobs available.

SUGGESTIONS FOR FURTHER STUDY

Recommended Readings
Gerson, M. J. (2014). Clinical implications for the expressions of self and identity in adolescent
psychotherapy: Case studies of a vampiress and a gangster. Psychoanalytic Dialogues, 24(6),
719–732.—Blanca was a 16-year-old female, desperate for intimacy who claimed allegiance
104 PSYCHOANALYTIC/PSYCHODYNAMIC APPROACHES

to death if she could be a vampire. This identity apparently represented a wish to join her dead
father until the analyst began to interpret and confront her with facts such as vampires not cast-
ing reflections.
Leichsenring, F., Klein, S., & Salzer, S. (2014). The efficacy of psychodynamic psychotherapy in
treating specific mental illness. Contemporary Psychoanalysis, 50(1–2), 89–130.—Focusing
on, but not limited to, randomized control trials, the article reports results showing psychody-
namic therapy is efficacious for depression, anxiety, somatic disorders, eating disorders, post-
traumatic stress, substance abuse, and uncomplicated grief. These results contradict assertions
made repeatedly claiming psychodynamic psychotherapy is not empirically supported, noting
that research on long-term therapy for specific mental disorders is required.
Lingiarti, V., Holmqvist, R., & Safran, J. D. (2016). The relational turn and psychotherapy research.
Contemporary Psychoanalysis, 52(2), 275–312.—This article also demonstrates how the study
of clinical variables important to relational psychoanalysis such as countertransference, empa-
thy, self-disclosure, and rupture and resolution in the patient–therapist relationship, have influ-
enced the work of psychotherapy researchers, noting that psychoanalysts have traditionally been
skeptical of studies reporting group averages that may obscure the uniqueness of individual
cases.
Samstag, N. (2017). Change in sex or a case of pseudo-relatedness. In R. C. Curtis (Ed.), Psycho-
analytic case studies from an interpersonal-relational perspective (pp. 35–56). New York:
Routledge.—A 30-year-old, heterosexual, socially isolated, Jewish male who appeared to view
his analyst as his most recent employee with a collection of professional functions rather than
a person, was often fired in spite of his talent, could not go out of his way for people, showed
contempt for his colleagues, and had primary relationships with ideas and abstract principles.
Over the course of the analysis, he changed his dominant sexual orientation, first developing
first a close, loving relationship with a dog and then with a man. He went from “a life apart to
a life among.”

DVDs
Safran, J. (2012). Relational psychotherapy with a male client. Washington, DC: American Psycho-
logical Association.—Jeremy Safran meets for one session with a male client who would like to
understand more about the way he relates to his wife, children they both have from previous
marriages, and others. The client wishes to avoid repeating relational patterns and Safran also
looks at their own therapeutic relationship
Wachtel, P. (2008). Integrative relational psychotherapy (Systems of Psychotherapy Video Series).
Washington, DC: American Psychological Association.—Paul L. Wachtel demonstrated his
therapeutic work, which centers on disrupting the vicious circles in which a client’s interactions
with other people perpetuate the distressing affect states and internal conflicts that generated
their actions in the first place.

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 PART III

BEHAVIORAL AND
COGNITIVE APPROACHES
 CHAP TER 4

Behavior Therapy
Traditional Approaches

Martin M. Antony
Lizabeth Roemer
Ariella P. Lenton-Brym

B ehavior therapy is not a unified approach to psychotherapy. It includes a range of techniques,

including exposure-based therapies, relaxation training, biofeedback, reinforcement-based
treatments, assertiveness training, and many others. Modern behavioral treatments have
expanded to include cognitive strategies, mindfulness- and acceptance-based approaches,
and motivational interviewing. In addition, the theoretical assumptions of modern behav-
ior therapy are diverse. Behavior therapists differ with respect to the importance placed on
environmental contingencies; the role of cognitions in understanding behavior; and the need
to develop a unique, individualized, evidence-informed treatment plan for each client versus
relying only on standardized, session-by-session treatment protocols that have been sub-
jected to randomized controlled trials (RCTs). A 2013 survey in the United States showed
that fewer than 10% of practicing therapists routinely use manuals in their practice, though
most incorporated them in some way (Becker, Smith, & Jensen-Doss, 2013).
Despite the differences among behavioral treatments, there are shared characteristics
that distinguish behavioral treatments from other forms of psychotherapy. First, rather than
emphasizing childhood factors that may have contributed to a problem, behavior therapists
focus on immediate factors thought to predispose, trigger, strengthen, or maintain prob-
lematic behaviors. Behavior therapists work directly on problematic patterns of behavior
by helping clients make changes, such as decreasing avoidance of feared situations (e.g., in
phobias) or improving social skills (e.g., in schizophrenia).
Second, whereas therapists in other approaches tend to be nondirective, behavior thera-
pists tend to be directive, modeling alternative behaviors and teaching new skills to the cli-
ent. Behavior therapy is didactic, and typically involves instruction, education, and weekly

111
112 BEHAVIORAL AND COGNITIVE APPROACHES

homework. Third, behavior therapy is often brief (e.g., one to 16 sessions), particularly
when standard evidence-based protocols are followed. The length of treatment may be lon-
ger when presenting problems are complex or when the client wants to work on multiple
problems. Whereas most psychotherapies take place in the therapist’s office during a 45- to
50-minute hour, behavior therapy sessions may last longer and may occur outside the thera-
pist’s office. Finally, behavioral treatments are more strongly rooted in empirical research
relative to some other psychotherapies.
This chapter provides the reader with an understanding of the theory and practice
of behavior therapy. Although modern behavior therapy is usually delivered as part of a
comprehensive treatment package that also includes cognitive strategies, this chapter does
not describe in detail the cognitive aspects of treatment, which can be learned from Cattie,
Buchholz, and Abramowitz, (Chapter 5, this volume), or the mindfulness and acceptance-
based strategies that are often integrated, which are detailed by Masuda and Rizvi (Chapter
6, this volume).

HISTORICAL BACKGROUND

Interest in behavior therapy blossomed in the 1950s and 1960s, thanks to researchers (e.g.,
Eysenck, Franks, Lazarus, Marks, Rachman, Wolpe) in South Africa, England, and the
United States. Two conditions set the stage for the early popularity of behavior therapy: (1)
In the 1950s, basic research on learning theory-based explanations for clinical phenomena
was becoming popular, and (2) a number of clinical researchers (e.g., Eysenck, 1952) were
becoming disenchanted with psychoanalysis, the dominant form of psychotherapy at the
time, because it lacked research support and was ineffective in many cases.
In the first publication to include behavior therapy (Lindsley, Skinner, & Solomon,
1953), the term described the application of an operant conditioning model to change prob-
lem behaviors in psychotic patients. Lazarus (1958) subsequently used the term to refer to
Wolpe’s procedures for treating neurotic clients by reciprocal inhibition (Wolpe, 1958), and
shortly thereafter, other influential writers (e.g., Eysenck, 1960) used the term to refer to
treatments based on learning theory, including the principles of classical and operant condi-
tioning. Beginning in the 1960s, the term behavior modification was used as well, particu-
larly in the United States (e.g., Bandura, 1969; Ullmann & Krasner, 1965). Although these
terms are used interchangeably, behavior modification has often been called on to describe
treatment procedures based on operant conditioning (e.g., token economy and aversive con-
ditioning; O’Donohue & Krasner, 1995) and behavior therapy is used with regard to out-
patient, clinic-based practice of behavioral approaches. By the 1960s, behavior therapy was
being established as a bona fide approach to treating psychopathology.
The domain of behavior therapy is no longer limited to treatments based on traditional
learning theory and, increasingly, it is difficult to articulate the boundaries of this approach,
because it is defined by those who practice it. Many behaviorally oriented clinicians now
include a wide range of evidence-based techniques in their practices. However, the impor-
tance of using treatments supported by rigorous scientific study remains a hallmark.

Cultural Considerations in the Development of Behavior Therapy

Early principles of behavior therapy emerged largely from research conducted with animal
models (Pavlov, Skinner). Eysenck’s (1959) conceptualization of mental disorder (“neurosis”)
 Behavior Therapy 113

was rooted in modern learning theory. He argued that neurosis reflects a set of “unadap-
tive” learned behaviors that emerge from the formation of inappropriately strong condi-
tioned responses (e.g., an individual who develops a severe flying phobia after experiencing
turbulence on a plane), or from a failure to form stimulus–response connections necessary
for proper socialization. Treatment, then, is a process of extinguishing or forming such
connections. Though Eysenck recognized that there is individual variability in the ease and
speed with which people learn conditioned behaviors, it was assumed that fundamental
principles of learning occurred universally across humans and animals. Given this presumed
universality, cultural factors were not viewed as an important consideration in the develop-
ment of behavior therapy.
However, the importance of culturally sensitive behavioral treatment is increasingly
recognized in the literature (e.g., Iwamasa & Hays, 2019; Rosmarin, 2018). Research has
been criticized for being conducted in Western countries and primarily with clients in domi-
nant groups (e.g., white, middle class) from these countries. It has rarely compared treat-
ment efficacy across groups from different countries, or across different socioeconomic,
racial, ethnic, and religious backgrounds within these countries. Moreover, studies that
include individuals who identify with marginalized racial or ethnic groups within Western
countries have demonstrated lower levels of mental health service utilization (Chu & Sue,
2011), higher dropout rates, and poorer outcomes (Rathod, Kingdon, Smith, & Turkington,
2005). These findings may be due to a range of factors: The values that underlie behavior
therapy (e.g., individualism, scientific empiricism, verbal expression, self-disclosure; Sue &
Sue, 2016) may be incongruent with the worldviews of individuals from marginalized or
non-Western backgrounds (Rathod, Kingdon, Phiri, & Gobbi, 2010); behavior therapists
may not routinely attend to cultural and systemic stressors (e.g., acculturation, discrimina-
tion) and contextual barriers (e.g., limited time and resources), and may overlook cultural
strengths (Hays, 2016).
There has been a push toward culturally adapted psychotherapy, with empirical suc-
cess. Research has demonstrated the efficacy of adapting behavior therapy for marginalized
groups, integrating cognitive-behavioral and multicultural perspectives in treating individu-
als from marginalized backgrounds (e.g., Graham-LoPresti, Gautier, Sorenson, & Hayes-
Skelton, 2017), and establishing guidelines for culturally adapting behavioral interventions
(Barrera, Castro, Strucker, & Toobert, 2013). Meta-analyses have demonstrated that cul-
turally adapted psychotherapy is more effective than unadapted psychotherapy for improv-
ing psychological functioning (Hall, Ibaraki, Huang, Marti, & Stice, 2016). Progress has
also been made in determining the perceived compatibility of cognitive-behavioral therapy
(CBT) with personal values among individuals from non-Western countries. For example,
Naeem, Gobbi, Ayub, and Kingdon (2009) reported that among Pakistani students, CBT
was generally viewed as compatible with their personal values but not necessarily their reli-
gious values. Finally, research has also shown that behavior therapy can be used successfully
in non-Western countries (e.g., Bella-Awusah et al., 2015).

THE CONCEPT OF PERSONALITY

The notion of personality is based on the idea that individuals have characteristic patterns
of feeling, thinking, and acting. Trait theories suggest that individuals respond differently to
situations based on the unique combination of personality traits they possess. In contrast,
behavioral theorists emphasize the role of context or situational factors in determining an
114 BEHAVIORAL AND COGNITIVE APPROACHES

individual’s behavior. Mischel (1984) is known for demonstrating that people do not act
consistently across situations, and that it is difficult to predict behavior based on measures
of personality. For example, people who report high levels of trait anger on personality
measures are not angry in all situations. A person may be angry in one situation (e.g., being
cut off while driving) and calm in other challenging situations (e.g., when a child spills his
or her soup). From a behavioral perspective, the situation, rather than personality traits,
determines behavior.
On the surface, behavioral theory may appear at odds with a trait-based approach
to understanding personality. However, the two approaches are actually compatible. Trait
theorists acknowledge the role of context and situational factors in determining behavior.
However, all factors being equal, a trait approach would predict that different individu-
als would behave in characteristically different ways given the same situation. Similarly,
most behaviorists would acknowledge that predisposing factors affect how an individual
responds to situations, and that in some cases individuals respond similarly to a broad
range of situations. However, behaviorists differ from other theorists in the way they define
and explain these stable tendencies to respond to a diverse situations in similar ways (i.e.,
personality). From a behavioral perspective, personality reflects an individual’s behaviors,
and behaviors are assumed to occur primarily as a result of an individual’s learning history.
Most behaviorists acknowledge the role of biological constraints on learning; genetic
composition, temperament, and other biologically determined factors influence the ways
in which one learns, thereby influencing personality. When behavior therapists refer to an
individual’s learning history, they include a range of experiences. For example, a number of
repeated assaults in various public places could lead a person to fear being alone in public
through classical conditioning (i.e., the pairing of a neutral stimulus, such as being outside,
with an event that naturally triggers a characteristic response, such as an assault). Through
stimulus generalization (i.e., the spreading of the conditioned association to new situations
that are similar to the situation where the trauma occurred), the individual might begin to
feel unsafe in a wider range of situations, developing what one might consider an “anxious
personality.”
Although classical conditioning may contribute to the development of personality,
operant conditioning is thought to play an even larger role. Skinner (1974) suggested that
behaviors are determined by patterns of reinforcement and punishment from the environ-
ment (radical behaviorism). Thus, an individual who is dishonest and antisocial may have
been reinforced for these behaviors in the past (e.g., spending time with friends who engaged
in these behaviors and reinforced the individual for engaging in these behaviors with praise,
attention, and social connection).
Other forms of learning also contribute to personality. Social learning theorists (e.g.,
Bandura) discuss the influence of modeling (observing others who exhibit a particular
behavior) on behavior. Cognitive-behavioral theorists emphasize the causative role of an
individual’s beliefs and assumptions in determining behavior. Our beliefs are thought to
arise from these various types of learning experiences.

PSYCHOLOGICAL HEALTH AND PSYCHOPATHOLOGY

A behavioral approach to psychopathology does not judge behaviors as “healthy” or

“unhealthy,” separate from their context and consequences. Instead, behaviors are discussed
 Behavior Therapy 115

with respect to whether they are adaptive or maladaptive in a particular context. Whether
a pattern of behavior is considered pathological depends on the consequences and sociocul-
tural context of the behavior and not on the content or form of the behavior. This definition
allows for appreciating differences between cultures and other groups.
Also, according to behavioral theory, adaptive and maladaptive behaviors are caused
by the same basic learning processes. Differences between nonclinical manifestations of a
problem and clinically relevant symptoms are thought to be quantitative, not qualitative,
differences. In other words, the key differences between an individual with clinical depres-
sion and a healthy individual who occasionally experiences sad mood are in the frequency,
intensity, and consequences of the depression, not in the quality of the mood state.

THE PROCESS OF CLINICAL ASSESSMENT

Conceptual Issues in Behavioral Assessment
There are three general purposes of assessment: to understand an individual’s problem, plan
treatment, and measure change. In traditional behavior therapy, understanding a problem
includes a comprehensive functional analysis, which involves considering four areas that
can be summarized by the acronym SORC (stimulus–organism–response–consequence;
Nelson & Hayes, 1986). The term stimulus refers to the antecedents of a problem behavior,
including the controlling variables that trigger the behavior. Variables having to do with
the organism are those that are unique to the individual (e.g., physiological factors, tem-
perament, learning history, cultural beliefs and experiences, expectancies, other cognitive
factors). Describing the person’s responses involves conducting a detailed analysis of the
individual’s behavior. For example, in the case of the individual who drinks excessively,
the therapist would want to know how frequently the person drinks, how much the person
drinks, and what the person drinks. The assessment should identify problem target behav-
iors (e.g., behavioral excesses and deficits that will be the focus of change) and alterna-
tive behaviors (i.e., behaviors that can replace the problem behaviors). Finally, functional
analysis involves examining the consequences of the behavior to understand the patterns
of reinforcement and punishment from the environment that may be influence the problem.
The functional analysis results may be used to develop an individualized treatment plan
that involves changing the triggers and reinforcing consequences for the problem behavior.
In recent years, many behavior therapists have shifted away from traditional functional
analysis toward a symptom-focused assessment, with the goal of measuring the presence,
absence, and severity of symptoms; understanding the triggers for these symptoms; and
establishing a diagnosis based on criteria from the fifth edition of the Diagnostic and Sta-
tistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013).
Behavioral treatments have been developed and empirically validated in the context of par-
ticular DSM-5 diagnoses. Thus, for example, knowing if a person suffers from panic dis-
order versus social anxiety disorder can inform decisions regarding the best treatment. In
addition, insurance companies in some countries (including the United States) may require a
diagnosis to reimburse clients for psychological treatments. Ideally, a comprehensive behav-
ioral assessment should include aspects of both approaches.
One way behavior therapy differs from most other therapies is its value on measur-
ing outcome. Before treatment, measures are taken at a baseline period to establish the
pretreatment level of symptoms. Measurement of problem behaviors continues throughout
116 BEHAVIORAL AND COGNITIVE APPROACHES

treatment, followed by a posttreatment assessment and occasional repeated follow-up

assessments.

Assessment Strategies Used in Behavior Therapy

Behavior therapists recognize that information obtained during an assessment is often
inconsistent, depending on the way it is collected. Therefore, a multimodal approach to
assessment is recommended, in which different sources of information (e.g., clients, family
members, and teachers) and methods of collecting information are used in combination.
Assessment tools may include behavioral observation, diaries, clinical interviews, self-report
scales, and psychophysiological measures. Each of these approaches is discussed in this sec-
tion.

Direct Behavioral Observation

Behavior therapists often use observation to assess their clients’ symptoms directly. Ther-
apists who treat phobias behaviorally often use behavioral approach tests (BATs), which
involve instructing a client to enter a feared situation and measuring his or her responses,
including subjective fear ratings (e.g., using a scale ranging from 0 to 100, called a subjec-
tive units of distress scale, or SUDS), physical symptoms, overt behaviors, and anxious
thoughts. Video recording can be useful in assessing behavior.
Unobtrusive observation in which the client is unaware of being observed is most likely
to provide a more typical sample of behavior. Often, however, unobtrusive observation
is impractical or unethical. The effect on behavior of knowing that one is being observed
can be minimized by observing the client for long periods (allowing time for habituation
to the presence of the observer), or by ensuring that the client is unaware of which specific
behaviors are being measured. In session, the therapist can observe a sample of the client’s
interpersonal behavior, although behavior observed during therapy may not generalize to
other situations.

Monitoring Forms and Behavioral Diaries

Almost all behavioral treatments involve monitoring of symptoms. For example, diaries can
be used to measure food intake in clients with eating disorders. The diary is a helpful tool
for facilitating compliance with homework. The diary can provide information about the
location and duration of the practice, SUDS ratings, anxiety-related behaviors, thoughts
that were experienced, and the outcome of the practice.
Perhaps the biggest advantage of behavioral diaries is that they circumvent the problem
of clients not recalling the details of their symptoms and experiences from the previous
week. Having individuals record their experiences as they occur increases the likelihood
that the information will be accurate. However, from a measurement standpoint, one disad-
vantage of behavioral diaries is reactivity, the tendency for behavior to change as a result of
being assessed or monitored. Literature demonstrates that monitoring one’s own behavior
can lead to changes in behavior, particularly when the client first starts completing diaries.
Therefore, therapists should be aware that baseline symptoms and behaviors measured by
diaries may not reflect the true baseline levels of these symptoms and behaviors.
Though reactivity limits the accuracy of baseline assessments of self-monitoring, it
 Behavior Therapy 117

illustrates the utility of monitoring as part of an intervention. When clients begin to notice
their symptoms and associated circumstances, it helps them change problematic patterns of
responding. This likely happens because monitoring (1) increases and expands awareness,
so clients are able to recognize patterns early on and initiate behavior change; and (2) leads
clients to approach their symptoms with curiosity and distance rather than judgment and
criticism.

Clinical Interviews
Behavior therapists use clinical interviews to collect information about their clients, includ-
ing the types of problems individuals experience, relevant symptoms, behavioral manifesta-
tions of the problem, cognitive manifestations of the problem (e.g., dysfunctional beliefs),
contributing factors and triggers, consequences of the problem, and treatment history. These
interviews can also gather information about clients’ cultural context (see Hays, 2016, for
guidance on this type of assessment). For much of the information collected, therapists must
rely on unstructured interviews, in which the clinician determines what questions to ask and
how information will be used. The questions asked are determined by the types of informa-
tion the client provides.
Though they provide maximum flexibility, unstructured interviews can be unreliable,
leading different interviewers to obtain different information. Therefore, behavior thera-
pists prefer structured or semistructured interviews to supplement the information obtained
via unstructured interviews. These interviews standardize the content, format, and order of
questions and often have solid psychometric properties. Generally, to establish a diagnosis
in a clinical setting, semistructured interviews are preferable to structured ones, because
they permit the interviewer to ask follow-up clarification questions (Summerfeldt, Klooster-
man, & Antony, 2010).

Self-Report Measures
Thousands of self-report questionnaires exist for measuring a range of problems. Ideally,
a comprehensive behavioral assessment includes client-administered measures to balance
information obtained from clinician-administered scales, which can be influenced by inter-
viewer biases. Self-report scales have the advantage of being relatively cost-effective in that
they often are easy to score and do not require clinician time to administer.

THE PRACTICE OF THERAPY

Traditional behavior therapy emphasizes an idiographic approach to changing behavior;

each client receives an individually tailored treatment, depending on the symptoms reported
and the variables that maintain those symptoms. Over time, there has been a move toward
developing standardized protocols for particular diagnostic categories that contain behav-
ioral and cognitive techniques validated in controlled clinical trials. In addition, there is
increased interest in transdiagnostic treatment manuals (e.g., Barlow et al., 2018), which are
parsimonious, as they provide broad interventions that can be applied to an array of clinical
presentations. They facilitate the training of empirically supported treatments and enable
clinicians to tackle comorbid conditions.
118 BEHAVIORAL AND COGNITIVE APPROACHES

Although the movement toward using standardized treatments in clinical practice

has been controversial (Addis, Cardemil, Duncan, & Miller, 2006), this development has
arisen for several reasons. The emphasis placed on identifying and validating empirically
based treatments has helped distinguish behavioral treatments from other psychotherapies.
The development of treatment manuals has also facilitated the dissemination of effective
psychological treatments. Finally, managed care in the United States has demanded that
clinicians deliver short-term treatments that work; evidence-based psychological treat-
ments have met those demands well. There are a number of sources for empirically sup-
ported treatment manuals and relevant research (e.g., Barlow, 2014; Nathan & Gorman,
2014).

Common Strategies
In this section, we describe strategies commonly used in behavior therapy: goal setting,
psychoeducation, exposure-based strategies, response prevention, operant strategies, behav-
ioral activation, social and communication skills training, modeling, problem-solving train-
ing, relaxation-based strategies, and emotion regulation skills training.

Goal Setting
Setting goals is a critical component of behavior therapy. Once the client’s main problems
have been identified, client and therapist collaborate to generate initial treatment goals.
Though clients decide which goals to prioritize, therapists help ensure that their goals are
safe, specific, measurable, and attainable. A recent meta-analysis showed a small but sig-
nificant, unique effect of goal setting on behavior change across a range of domains (Epton,
Currie, & Armitage, 2017).

Psychoeducation
Most behavioral treatments include psychoeducation, particularly during early sessions.
Initial psychoeducation sessions include discussion of a behavioral model for the problem,
describe the treatment process, and overview ways that treatment procedures are likely to
impact the problem. Psychoeducation should involve a two-way discussion in which the cli-
ent is presented with new information and invited to provide feedback about the ways his
or her symptoms are consistent (or inconsistent) with the model. It may involve correcting
misinformation that the client has gathered and suggesting readings about the target prob-
lem or its treatment. Psychoeducation makes the process of therapy transparent; the client is
informed as to reasons for each intervention.

Exposure-Based Strategies
Some of the earliest behavioral treatments were based on the notion that exposure to feared
objects and situations leads to a reduction in fear. Today, exposure is considered a necessary
component of treatment for phobias, obsessive–compulsive disorder (OCD), and other fear-
based problems. In the case of certain specific phobias (e.g., spiders, needles), a single session
of in vivo exposure is enough for most sufferers to overcome their fear (Hood & Antony,
2012). For other anxiety disorders (panic disorder, social anxiety disorder), exposure is a
 Behavior Therapy 119

key component of a treatment protocol that typically includes different strategies and occurs
over a period of months.
Exposure can be delivered in a number of different ways. In most cases, the method of
choice is in vivo exposure, which involves exposure to the feared object or situation in real
life. For example, an individual with OCD who fears contamination is encouraged to touch
things perceived as contaminated. A second manner is imaginal exposure, which involves
having a client imagine being in a feared situation. Imaginal exposure is not as power-
ful as in vivo exposure, but there are two contexts in which it is advised: (1) if clients are
afraid of their own thoughts, images, or memories; and (2) if clients are unable or unwilling
to do in vivo exposure. A third form of exposure, interoceptive exposure, involves expo-
sure to feared sensations. It is used particularly when treating panic disorder, a problem
in which individuals are frightened of the sensations associated with physical arousal and
panic attacks. It involves repeatedly exposing oneself to feared sensations using a series of
exercises, such as hyperventilation (to induce lightheadedness and other symptoms; Antony,
Ledley, Liss, & Swinson, 2006). Over time, exposure to these and other exercises decreases
the fear of panic symptoms that contributes to the occurrence of panic attacks and related
symptoms through the process of extinction (Forsyth, Fusé, & Acheson, 2009) or inhibi-
tory learning (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). A fourth modal-
ity is virtual reality exposure, which involves using three-dimensional, computer-generated
images projected on the inside of a head-mounted display worn in front of the eyes. Several
controlled studies have used virtual reality exposure to treat specific phobias, public speak-
ing fears, and posttraumatic stress disorder (PTSD). Meta-analyses (e.g., OpriŞ et al., 2012)
support the use of virtual reality exposure for anxiety disorders, and effect sizes appear to
be comparable to those for in vivo exposure. Head-to-head comparisons (e.g., Rothbaum et
al., 2006) indicate that virtual reality is as effective as in vivo exposure for certain phobias.
How exposure is conducted significantly impacts outcome (Abramowitz, Deacon, &
Whiteside, 2011; Moscovitch, Antony, & Swinson, 2009). The following general principles
should be considered: (1) the focus, intensity, and duration of exposures should be under
the client’s control and conducted in a predictable manner, yet be enhanced by introducing
unpredictability over time (with the client’s permission); (2) exposure practices should be of
sufficient duration to learn that one’s feared consequences do not come true (in some cases,
a reduction in fear may be a sign the cognitive change has occurred); (3) exposure should be
intense enough to trigger a fear response, though it is not necessary for the fear to be over-
whelming; (4) exposure practices should be spaced close together (daily, if possible), which
requires completion between sessions; (5) the stimulus should be varied across exposure
practices; (6) exposure practices should be conducted in multiple contexts to protect clients
against experiencing a return of fear; (7) clients should focus on the feared stimulus during
exposure practices rather than engaging in safety behaviors or subtle avoidance, such as
distraction (although the judicious use of safety behaviors may reduce attrition).
To facilitate exposure, therapists and clients often generate an exposure hierarchy, a list
of situations that an individual fears and avoids, rank-ordered from most to least difficult.
The hierarchy can be used to guide the content of future exposure practices. Traditionally,
exposure starts with items near the bottom of the hierarchy and progresses to more difficult
items, until the client is able to address the items near the top of the hierarchy with little fear.
However, the hierarchy can be used more flexibly. Antony and Swinson (2000) recommend
that exposure begin with moderately difficult practices (as challenging as the client is willing
to try) and that clients move to more difficult items as quickly as they are willing. Craske
120 BEHAVIORAL AND COGNITIVE APPROACHES

and colleagues have recommended that clients complete exposures from their hierarchy in a
random order; variable exposure is associated with reductions in subjective fear at follow-up
(Kircanski et al., 2012). Exposure hierarchies can be used as an outcome measure by having
the client rate levels of fear and avoidance for each item and repeating the ratings at each
session.

Response Prevention
Response prevention involves preventing behaviors designed to decrease anxiety, fear, or
tension (e.g., compulsive hand washing), until the urge to perform these overprotective
behaviors subsides. Conceptually, it is a means of providing exposure experiences, and in
practice, these two strategies are often used together. Although response prevention is used
for a variety of problems, the most common use is for OCD, in which this method is some-
times referred to as ritual prevention (Franklin & Foa, 2007). The best supported psycho-
logical treatment for OCD is the combination of exposure to triggers (e.g., contamination)
and prevention of rituals (e.g., washing). If a person feels unable to prevent a ritual, he or
she might be asked to delay the ritual for progressively longer periods. Over the course of
treatment, the urge to perform rituals usually decreases and may be eliminated completely.
Exposure and response prevention are supported by numerous studies for the treatment of
OCD, and response prevention contributes to successful treatment outcome over and above
the effects of exposure alone (Franklin & Foa, 2007).

Operant Strategies
A basic tenet of behavioral theory is that consequences for behaviors increase (reinforce) or
decrease (punish) the likelihood that behaviors will recur. Reinforcement can be positive
(i.e., receiving a reward in response to a particular behavior) or negative (i.e., removing an
aversive consequence in response to a behavior). Similarly, positive punishment involves
receiving an aversive consequence (e.g., electrical shock) after a particular behavior, whereas
negative punishment involves removing something desirable (e.g., permission to borrow the
family car) following a particular behavior.
Behavior is thus determined by environmental cues (signals known as discriminative
stimuli) that indicate whether a behavior is likely to be rewarded or punished, and by previ-
ous history of reward or punishment for a given behavior in a given context. This model
helps clients and therapists understand seemingly incomprehensible behavior (e.g., a heroin
addict responding to the strong negatively reinforcing contingency of removal of distress
that follows heroin use) and provides clear targets for intervention through contingency
management (i.e., arranging for different consequences to follow a given response). Applied
behavior analysis incorporates these principles into comprehensive, individually focused
treatment plans that emphasize reinforcing desired alternative behaviors and reducing rein-
forcement of problematic behaviors (see Spiegler & Guevremont, 2016, for a review). These
interventions have demonstrated efficacy across a wide range of presenting problems and
settings (see Byrne & Petry, 2014, for a review).
Space permits only a brief overview of operant interventions. An essential first step
is a detailed assessment of the stimuli and consequences associated with target behaviors
(behaviors for which either reduced frequency or increased frequency is desired). Attention
is paid to identifying the contingencies maintaining problematic behaviors. Efforts can then
 Behavior Therapy 121

be made to eliminate reinforcement of problematic behavior and introduce reinforcement

of less frequent, desired behavior. For instance, a parent might be encouraged to ignore a
child’s screaming and to pay attention when the child speaks quietly. When a desired behav-
ior does not occur at all, shaping can reinforce successive approximations of the desired
behavior. Reinforcers should be identified for the individual, because not all consequences
have the same effect for all individuals. A consequence is “reinforcing” (positively or nega-
tively) only if it increases the likelihood of an individual’s previous response.
Extinction (withdrawal of reinforcers) helps reduce the frequency of problematic behav-
iors, but in some cases, negative punishment (or response cost procedures) may be used.
These procedures involve removing available rewards contingent on an undesired behavior
(e.g., time-out procedures). In extreme cases (e.g., self-injurious behavior), positive punish-
ment or response-contingent aversive stimulation (e.g., applying an unpleasant consequence
after a behavior is performed) may be used. However, numerous problems associated with
these procedures (e.g., the lack of long-term efficacy) have led them to be used infrequently.
Pairing strategies for reducing behaviors, with procedures aimed at increasing desirable
behaviors, provides clients with a sense of how to get what they want out of life and other
people, rather than just teaching them how to avoid what they do not want (Nemeroff &
Karoly, 1991).
In addition to altering consequences for clinically relevant behaviors, cues (i.e., dis-
criminative stimuli) for behaviors can be the targets of intervention. Individuals learn that
responses in a specific context, with a specific stimulus present, yield certain consequences.
These procedures involve bringing a target behavior under stimulus control. For instance, a
client trying to lose weight (target) might be encouraged to eat only in the kitchen (discrimi-
native stimulus) or in response to hunger cues, thus reducing stimuli that signal a response
of eating.
Although contingency management procedures often are applied in controlled settings
(e.g., institutions, schools), these same principles can be applied flexibly in many contexts.
Natural reinforcers (that occur in everyday environment), rather than artificial reinforcers,
are more likely to lead to maintenance and generalization of behavior change. For example,
responding empathically when a client shares a painful emotion is more effective than say-
ing, “Thank you for sharing that feeling with me.” Clients can use self-management or self-
control procedures to provide contingencies themselves (e.g., put aside money not spent on
cigarettes each day and use it to buy a reward).

Behavioral Activation
Behavioral activation (BA) therapy for depression (aimed at helping depressed individu-
als increase their contact with positive reinforcers and decrease patterns of avoidance and
inactivity) was developed by Jacobson and colleagues (e.g., Martell, Addis, & Jacobson,
2001; Martell, Dimidjian, Herman-Dunn, & Lewinsohn, 2010). An early dismantling study
revealed that BA alone had comparable efficacy to CBT, which included BA techniques
and cognitive restructuring (Jacobson et al., 1996). Building on these findings, Jacobson
and colleagues developed BA as a treatment in its own right. An RCT revealed that BA is
comparable to medication and cognitive therapy in the treatment of all levels of depression,
with evidence for enhanced efficacy compared to cognitive therapy for severe depression
(Dimidjian et al., 2006).
BA focuses on external factors as potential causal and maintaining factors for depression.
122 BEHAVIORAL AND COGNITIVE APPROACHES

Its emphasis is on the inactivity characteristic of depressed individuals, leading to decreased

contact with potential positive reinforcers, thus reducing opportunities for action to be
reinforced. The inertia and withdrawal typical of depressed individuals serve a negatively
reinforcing function, similar to the avoidance behaviors characteristic of anxiety disorders.
Despite the short-term relief that results from inactivity (by reducing experiences with non-
reinforcing environments), these avoidance behaviors can lead to secondary problems (e.g.,
occupational or relational difficulties), limit opportunities for positive reinforcement, and
disrupt routines, which can play an etiological and maintaining role in depression (Ehlers,
Frank, & Kupfer, 1988). BA therapists emphasize the goal of changing behavior rather than
altering mood. Clients’ tendencies to believe they cannot engage in an action until they feel
better is gently challenged by therapists requesting that clients engage in planned behaviors
regardless of how they feel.
A critical element of BA is its focus on functional analysis. Clients are taught to con-
duct their own functional analyses and are encouraged to do so particularly after therapy
ends to prevent relapse. Rather than encouraging activity generally, as many behavioral
approaches do, BA focuses on idiographic identification of activities that the client believes
will be beneficial. Avoidance behaviors are modified by helping clients identify the function
of these behaviors (immediate relief and longer-term problems) and choose alternative cop-
ing responses.

Social and Communication Skills Training

Social skills and communication training involves teaching individuals or groups to com-
municate more effectively. This may include learning basic skills (e.g., making eye contact)
or more complex skills (e.g., being more assertive). Typically, social skills training involves
psychoeducation, modeling, behavioral rehearsal or role plays, and feedback. Clients may
be video-recorded while role playing so that they can later observe their performance. Social
skills training is a standard treatment for schizophrenia (e.g., Granholm, McQuaid, &
Holden, 2016) and is often included in the treatment of social anxiety (e.g., Beidel, Alfano,
Kofler, & Rao, 2014) and emotional and behavioral problems in children (e.g., Antshel &
Remer, 2003).

Modeling
Modeling was first described early in the history of behavior therapy by social learning
theorists (e.g., Bandura, 1969). This procedure involves demonstrating a particular behavior
in the presence of a client, usually before asking the client to perform the behavior. It may
be combined with reinforcing an appropriate response by the client. Modeling is often used
in the treatment of fear-based problems.

Problem-Solving Training
The aim in problem-solving training is to teach clients to solve problems effectively, with the
goal of reducing psychopathology and enhancing psychological and behavioral functioning
(Nezu, Nezu, & D’Zurilla, 2013). Problem solving involves (1) modifying problem orienta-
tion and (2) teaching problem-solving skills (also referred to as “problem-solving proper”).
Problem orientation refers to an individual’s appraisal of both his or her awareness of prob-
lems that arise and his or her ability to solve problems. This component of treatment includes
 Behavior Therapy 123

strategies for overcoming obstacles in problem solving, fostering self-efficacy, recognizing

problems when they arise, viewing problems as challenges, understanding the role of emo-
tions, and learning to “stop and think” rather than react impulsively (D’Zurilla & Nezu,
2010). Problem-solving skills are the specific steps needed to solve problems effectively.
This component of treatment teaches clients to solve problems using five steps: (1) problem
definition and formulation, (2) generation of possible solutions, (3) selection of the best solu-
tions, and (4) implementation of selected solutions and evaluation outcome. Problem-solving
training has been used alone or as part of a multicomponent treatment package for depres-
sion, stress, social anxiety, schizophrenia, and physical complaints (Nezu, 2004).

Relaxation-Based Strategies
Relaxation training is often used as a stand-alone intervention or it is integrated into a
multicomponent treatment package. The most extensively studied form of this intervention
is progressive muscle relaxation (PMR; Bernstein, Borkovec, & Hazlett-Stevens, 2000; E.
Jacobson, 1938), which is taught in the context of applied relaxation (Bernstein et al., 2000).
PMR involves instructing clients to tense and then “let go” of various muscle groups. The
tension cycles are provided to increase awareness of tense sensations in each muscle group
and to provide momentum that enables a deeper level of relaxation. The process of relax-
ation is gradually shortened once a client has developed the ability to relax using a given
strategy, until relaxation can be achieved rapidly through recalling the experience. Applied
relaxation for anxiety (its most common use) involves three necessary components: (1) early
detection of anxiety cues, (2) PMR, and (3) learning to apply relaxation skills when anxiety
cues are first detected. Applied relaxation has demonstrated efficacy for various diagnoses,
and is used primarily in the treatment of generalized anxiety disorder (GAD).

Emotion Regulation Skills Training

Many behavioral therapies implicitly or explicitly help clients develop skills to recognize,
understand, and respond to their own emotions (Mennin & Farach, 2007). CBT protocols
developed within an emotion regulation framework have been incorporated into behavioral
treatments for deliberate self-harm (Gratz & Gunderson, 2006), symptoms associated with
child sexual assault (Cloitre, Koenen, Cohen, & Han, 2002), and anxiety and depressive
disorders (Barlow et al., 2018; Ehrenreich-May et al., 2018; Mennin, Fresco, O’Toole, &
Heimberg, 2018), and these approaches have demonstrated efficacy in RCTs.
Interventions intended to enhance emotion regulation skills typically emphasize helping
clients identify and clarify their emotional responses as they occur. Clients learn to differ-
entiate among emotional responses and distinguish between primary emotional responses
(direct responses to environmental events that provide important information) and second-
ary emotional responses (results from reactions to initial responses or efforts to avoid emo-
tions). They learn strategies that can help them respond adaptively in response to intense
emotional experiences.

Cultural Considerations in Behavior Therapy

As with all modalities of therapy, it is important to approach behavioral treatments with
cultural sensitivity. Hinton and Jalal (2014) provide helpful suggestions for implementing
culturally sensitive CBT that include consulting local religious or spiritual leaders to better
124 BEHAVIORAL AND COGNITIVE APPROACHES

understand types of distress typically seen within their clients’ cultural group, identifying
cultural stressors and types of trauma, and considering psychopathological dimensions that
may deviate from the diagnostic categories outlined by the DSM (e.g., somatic symptoms
are recognized as a core feature of posttraumatic stress among Cambodians; Hinton, Hin-
ton, Eng, & Choung, 2012). Research suggests that cultural adaptation of psychotherapeu-
tic interventions results in improved outcomes in individuals from diverse cultural back-
grounds. Methods of adapting interventions include incorporating specific cultural values
into therapy, working with resources within one’s community (e.g., spiritual leaders, family
members), and making therapy accessible within the local context (Griner & Smith, 2006).
As with all approaches to therapy, culturally responsive treatment requires that therapists
develop their own cultural awareness, knowledge, and skills (Sue & Sue, 2016). Another
recommendation has been to match clients with therapists who share their culture and
speak their native language. Although racial or ethnic matching does not improve therapy
outcomes directly, it affects how positively patients view their therapists (Cabral & Smith,
2011). Conversely, conducting interventions in the patient’s first language may improve the
effectiveness of the interventions (Griner & Smith, 2006).
Cultural considerations are also pertinent to the nature of behavioral interventions
selected. Take, for example, a 45-year-old man who presents to treatment with social
anxiety disorder, reporting that his anxiety has prevented him from establishing a desired
romantic relationship. One could imagine the utility of having this person practice increas-
ingly challenging exposures from his hierarchy, perhaps first striking up a casual conversa-
tion with a female acquaintance, and eventually asking a woman on a date. Now consider
two alternatives. First, imagine that he is an Orthodox Jew. Casual dating before marriage is
not permitted, and rabbinic laws limit the nature of interactions he can have with an unmar-
ried woman. In this context, though exposures should be designed to challenge his beliefs
that others will reject him, the exposure requiring him to converse casually with a woman
may be culturally inappropriate. Conversely, imagine that the patient is Japanese and suffers
from the cultural syndrome of taijin kyofusho. Rather than fearing negative evaluation by
others, his symptoms focus on the fear of offending others. Like the man in the first exam-
ple, his fears keep him from initiating a desired romantic relationship. Here, the initially
proposed exposure may work well. However, in this case, differences abound in the nature
of the beliefs being challenged by the behavioral intervention. These examples demonstrate
how the nature of exposure practices themselves, as well as the beliefs that exposures are
designed to test, may require adaptation for certain cultural groups.

THE THERAPEUTIC RELATIONSHIP AND THE STANCE OF THE THERAPIST

Recent evidence suggests that self-help treatments (e.g., bibliotherapy, online therapies)
based on behavioral principles may lead to improvement at posttreatment (e.g., Andersson,
Cuijpers, Carlbring, Riper, & Hedman, 2014). Do these findings mean that the therapeutic
relationship is unimportant in behavior therapy? Probably not. In most studies of self-help
treatments, there is a confound: Clients are required to have regular contact with a clini-
cian for the study assessments. Along these lines, some research groups have found that
increased therapist engagement improves computerized CBT outcomes in certain popula-
tions (e.g., Spek et al., 2007). In contrast, in a systematic review, Richardson, Stallard, and
Velleman (2010) found that extent of therapist involvement was unrelated to youth CBT
 Behavior Therapy 125

outcomes. The relative efficacy of face-to-face versus online treatment is also unclear, with
discrepant results (e.g., Andrews, Davies, & Titov, 2011; Haug, Nordgreen, Öst, & Havik,
2012).
For a long time, researchers have focused more on the efficacy of particular behavioral
techniques, with little discussion of the context in which behavior therapy occurs. However,
in recent years, therapists working within a behavioral framework have become interested
in the role of the therapeutic relationship and in the effects of therapist behavior on treat-
ment outcomes (e.g., Kazantzis, Dattilio, & Dobson, 2017). The therapist is potentially
a powerful source of social reinforcement; thus, from a behavioral perspective, it follows
that the therapeutic relationship and therapist behavior play a role in the process and out-
come of treatment. Functional analytic psychotherapy (FAP) is an approach that was devel-
oped around the premise that in-session reinforcement and contingent responding to client
behavior can yield therapeutic benefit. FAP therapists help clients identify clinically relevant
behaviors—those that occur in session and are relevant to the client’s real-life problems
(e.g., a perfectionistic client avoids coming to therapy for fear that her homework was not
done perfectly). They also reinforce change in these behaviors that can also be observed in
session (Kohlenberg & Tsai, 1991).
Although behavior therapists are relatively directive during sessions, there is increasing
recognition of the benefits of taking a more client-centered approach with individuals who
are ambivalent about enacting change in their lives, particularly early in treatment. To this
end, some behavior therapists have begun to incorporate motivational interviewing (MI;
Miller & Rollnick, 2013) into their practice. MI is a collaborative conversation style used
to help clients explore and resolve ambivalence about making change. In a study in which
patients received pure CBT (i.e., no formal MI), clinicians’ use of MI-like behavior (e.g.,
using reflection rather than advocating for change) during moments of client resistance was
associated with improved outcomes and reduced subsequent resistance (Aviram, Westra,
Constantino, & Antony, 2016). Moreover, a trial of individuals with GAD showed that
those treated with integrated MI and CBT had five times better odds of no longer meet-
ing diagnostic criteria at 1-year follow-up as compared to those receiving CBT alone. This
finding was especially true for those who were most ambivalent about treatment (Button,
Westra, Constantino, & Antony, 2016; Westra, Contantino, & Antony, 2016). Moreover, a
recent meta-analysis indicated that across 12 trials, conjunctive MI and CBT outperformed
CBT alone in overall reduction of anxiety symptoms (Marker & Norton, 2018).
However, the role of the therapeutic relationship in outcomes has been fraught with con-
troversy, as some research groups have argued that the alliance has demonstrated reduced
importance in certain contexts, particularly in treatments that have been supported by
RCTs (Siev, Huppert, & Chambless, 2009; Strunk, Brotman, DeRubeis, & Hollon, 2010).
Additionally, the alliance–outcome relationship has demonstrated heterogeneity, leading
researchers to explore potential moderators, with mixed results. One research group found
that several hypothesized moderators (e.g., use of manuals, type of treatment) did not dem-
onstrate predictive capacity over the alliance–outcome relationship (e.g., Del Re, Flückiger,
Horvath, Symonds, & Wampold, 2012). Conversely, others have shown that clients with
severe symptoms and those who are in treatment for longer benefit more from a strong ther-
apeutic alliance (Zilcha-Mano & Errázuriz, 2015). The importance of the therapeutic alli-
ance may vary based on the disorder being treated. For example, in a recent study, Strauss,
Huppert, Simpson, and Foa (2018) found that common factors were relatively unimportant
in the treatment of OCD.
126 BEHAVIORAL AND COGNITIVE APPROACHES

Attending to Ruptures in the Therapeutic Alliance

Ruptures to the alliance can occur for a variety of reasons, including disagreement in the
goals or course of therapy, perceived lack of empathy or understanding, or schedule con-
flicts. General guidelines for responding to therapeutic ruptures include having the therapist
take the initiative in exploring the rupture, responding empathically and nondefensively,
and accepting responsibility for the rupture (Safran, Muran, & Eubanks-Carter, 2011).
If a similar issue occurs repeatedly, it may be important to consider the function that the
behavior holds for the client. If a client repeatedly cancels sessions prior to beginning expo-
sure exercises, this behavior may be functioning as an avoidance strategy. In this case, a
therapist’s willingness to reschedule sessions without penalty may inadvertently reinforce
the client’s avoidance. From an operant perspective, the therapist may wish to intentionally
reinforce the client’s efforts to show up and participate in treatment. In addition, though
behavior therapists who use MI typically do so at therapy onset, there is increasing recog-
nition that MI can be usefully applied at any stage of treatment (e.g., Westra et al., 2016);
that is, even once active behavioral treatment has begun, clinicians may return to the MI
framework when their clients express ambivalence or resistance to change.

CURATIVE FACTORS OR MECHANISMS OF CHANGE

Changes in Environmental Contingencies
Given that behavior is thought to be functional (i.e., maintained by contingencies in the
environment), behavior change is assumed to result from alterations in environmental con-
tingencies. This may take several forms. The individual’s context may be altered to reduce
reinforcement for problematic behavior and increase reinforcement for desired behavior.
This may be the case, for example, in parent training interventions in which the child’s
environment is directly altered. Often the environment is not directly altered, but the cli-
ent learns to engage in new behaviors that in turn are reinforced by existing environmen-
tal contingencies. For instance, in social skills training, it is expected that the individual
will receive meaningful, natural social reinforcement for new skills. To maximize adaptive
responding to new environments, behavior therapy helps clients develop flexible behavioral
repertoires (Goldiamond, 1974) rather than rigid behavioral patterns based on past learn-
ing, which promotes continued adaptation after therapy has ended.

Emotional Processing and Inhibitory Learning

Exposure-based interventions were developed to extinguish fearful responses to classically
conditioned stimuli. However, research has demonstrated that fearful associations are never
fully unlearned. Based on these findings, newer models suggest that exposure results in
learning new, nonfearful associations to previously feared stimuli. According to Foa and
Kozak’s (1986) classic emotional processing model, fearful responses are altered when an
individual fully accesses the associative fear network (including stimulus, response, and
meaning elements of the fear) and incorporates new, nonthreatening information. However,
in an update of the theory, Foa, Huppert, and Cahill (2006) noted that reductions in fearful
responding within sessions may not be necessary for new information to be incorporated.
 Behavior Therapy 127

Craske and colleagues (2008) reviewed inconsistencies in the data supporting these pro-
posed indicators of successful exposure and suggested that exposure-based treatments are
instead effective because they provide an opportunity for inhibitory learning (through the
development of competing, non-threat-related associations) and the development of toler-
ance for fear and anxiety.
In light of this research, recent empirical work has sought to maximize the impact of
exposure therapy using an inhibitory learning approach. Based on the knowledge that dis-
crepancy between expectations and outcomes is critical for associative learning, Craske et
al. (2014) suggested designing exposures that maximize clients’ expectancy violation. In line
with this model, Deacon et al. (2013) have shown that the benefit of interoceptive exposures
for panic disorder is heightened when patients continue with the exposure until their expec-
tation of an aversive outcome (but not necessarily their fear level) is substantially decreased.
Additional suggestions for maximizing inhibitory learning include “deepened extinction”
(e.g., extinguishing fear responses to multiple conditioned stimuli), removal of safety behav-
iors, and increasing stimulus variability (Craske et al., 2014; Craske, 2015).

Cognitive Changes
Many researchers have noted that exposure-based treatments may lead to cognitive change
for individuals, and this may be the mechanism of change. For instance, Mineka and
Thomas (1999) suggested that exposure disconfirms clients’ beliefs that they do not have
control over anxiety-provoking situations. Similarly, Zinbarg (1993) and Rachman (1996)
noted that exposure techniques may alter emotionally relevant cognitive representations.
In other words, clients’ experiences when engaging in previously avoided activities may
challenge their beliefs that such behaviors are dangerous or impossible, leading them to be
more likely to continue engaging in such behaviors. Behavioral experiments have been an
integral part of cognitive therapy, suggesting that a client’s own experiences may provide
particularly salient disconfirming data for clinically relevant cognitions. To date, there is
a lack of research addressing whether behavioral techniques are efficacious due to their
facilitation of cognitive change. Although some data suggest that cognitive techniques
do not add to the efficacy of behavioral techniques for depression (e.g., Jacobson et al.,
1996), this does not mean that the behavioral techniques do not have their effect due to
cognitive change.

Changes in Clients’ Relationship with Internal Experiences

Many aspects of behavior therapy, such as self-monitoring, early cue detection, and ima-
ginal, interoceptive, and in vivo exposure, may be effective because they reduce the degree
to which thoughts, emotions, sensations, and memories are associated with threat, judg-
ments, reactivity, and criticism. Behavioral therapies may help clients to decenter (recognize
thoughts as mental events rather than indicators of truth or the nature of the self) from their
thoughts, and this may be a common mechanism of change across disparate strategies (e.g.,
Teasdale et al., 2002; Hayes-Skelton, Calloway, Roemer, & Orsillo, 2015). This reduction
in reactivity and avoidance may be understood as an increase in tolerance of internal experi-
ences (e.g., Craske et al., 2008) and is likely to be associated with enhanced emotion regula-
tion skills (Mennin & Farach, 2007).
128 BEHAVIORAL AND COGNITIVE APPROACHES

Biological Changes
Although it is commonly assumed that psychosocial interventions are efficacious through
psychological mechanisms, recent research has indicated that these interventions can lead to
biological changes (for a review, see Barsaglini, Sartori, Benetti, Pettersson-Yeo, & Mechelli,
2014). Most striking have been findings in the OCD literature, in which successful behavior
therapy has been associated with changes in glucose metabolic rates in the brain, compa-
rable to changes found following pharmacotherapy (e.g., Saxena et al., 2009). Although this
may mean that such biological changes are the mechanisms of change for behavior therapy,
they may instead be correlates rather than causes of change.

TREATMENT APPLICABILITY

Behavioral interventions have been applied to a range of presenting problems, including

anxiety, obsessive–compulsive, trauma and stressor-related, depressive, substance use, eat-
ing, personality, and childhood disorders, as well as to serious mental illness in combination
with pharmacotherapy. Research has provided support for the application of behavioral
interventions to general health care, including smoking cessation, weight loss and manage-
ment, chronic headache, and stuttering. For example, a patient who wants to stop smok-
ing cigarettes might be advised to avoid smoking-relevant cues. If the client’s daily routine
begins with waking up and having a cigarette outdoors, the balcony may become a “forbid-
den” zone first thing in the morning.
Behavioral interventions tend to be effective when clients present with focal target
problems (and these types of presentations have been the most commonly studied); however,
functional analysis and behavioral principles can be adapted to address a range of more
complex clinical presentations. Recently researchers have begun to investigate the impact
of behavioral interventions targeting a single disorder or comorbid disorders that are not
necessarily the focus of treatment. In a number of cases, comorbid disorders improve when
a target problem (e.g., panic disorder) is treated, suggesting that learning that takes place in
these interventions may generalize to other, related problems (Craske et al., 2007).
In addition, because many disorders have similar core symptoms, several transdiag-
nostic therapy protocols have been developed with considerable success in recent years. Of
note, use of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders
(Barlow et al., 2017, 2018) was associated with improved symptoms across diagnoses in
individuals with DSM-5 anxiety disorders in a recent study (Laposa, Mancuso, Abraham,
& Loli-Dano, 2017). Similarly, Pearl and Norton (2017) demonstrated that the difference in
efficacy between transdiagnostic and diagnosis-specific CBT was not clinically significant
(though it was statistically significant).

ETHICAL CONSIDERATIONS
Ethical Issues
In addition to the ethical considerations associated with any psychotherapy, behavioral
approaches raise specific challenges that should be kept in mind. Given the focus on behav-
ioral change, and the use of strategies that have an intentional impact on the likelihood of
 Behavior Therapy 129

certain behaviors, people often express concern that behavior therapy can be coercive and
impose change chosen by the therapist rather than the client. In fact, this is a consideration
in all forms of therapy; contingencies are always present that affect clients’ behavior. In
behavior therapy, the goal of behavioral change is made explicit, and therapists collaborate
with clients to ensure consensus on treatment goals. Progress and goals are continually
assessed to provide repeated opportunities for clients to influence the course and direction
of their therapy. Nonetheless, as in all therapies, therapists should attend to the power dif-
ferential inherent in therapy and be sure that mutually agreed upon goals are in place.

Case Example for Ethical Challenge

Mateo, a 20-year-old Latino man from a working-class background, was seeking treatment
for claustrophobia. As a result of his phobia, Mateo avoided numerous situations, such as
entering an elevator, which was becoming increasingly problematic since several of his col-
lege classes were held in tall buildings. At Session 2, Mateo’s therapist introduced the con-
cept of exposure therapy. As an initial exposure, they agreed to ride the elevator together.
Mateo’s fears were maximized in crowds, so his therapist recommended that they go to an
elevator in the back of the building, which was likely to be empty.
As Mateo and his therapist walked to the elevator, they discussed what to expect when
they arrived. However, the elevator was further than the therapist had remembered, and
the conversation began to shift to other topics. Mateo began making small talk by asking
his therapist if he had any children, if they were in college, and what school they attended.
When they arrived at the elevator, Mateo was suddenly reminded about what they were
about to do. He had not been on an elevator in over 3 years, and he began to have a panic
attack. Noticing his distress, a security guard walked over and asked if everything was OK.
Initially, the therapist responded with a quick “yes,” but the security guard persisted and
asked what was happening. Unsure of how to handle the situation, Mateo looked to his
therapist. The therapist calmly assured the guard that everything was OK and thanked him
for his concern. Eventually the security guard left and they were able to get on the elevator
and complete Mateo’s first exposure, which went well. On the way out, Mateo noticed a
security camera in the corner of the elevator. He asked his therapist if others would be able
to see his panic attack on camera.
Three ethical considerations are raised in this vignette. First, simply walking to the set-
ting of the exposure involves unstructured time, and since it occurs outside of the therapy
room, it may be unclear to a patient what the expectations are for the nature of this inter-
action. Do the same rules for therapist self-disclosure apply outside the therapy room? The
second issue involves explaining the activity to the questioning security guard. The therapist
is obligated to protect Mateo’s privacy, and so must respond without violating that privacy.
Finally, the third issue surrounds the uncertainty over whether Mateo was recorded on a
security camera, as well as who would have access to this footage. These ethical dilemmas
relate to self-disclosure, boundary setting, and confidentiality—issues that are relevant to
all types of therapy. However, these issues may require special consideration in the case
of behavior therapy, which often involves activities that take place outside the therapist’s
office. Changes in context challenge traditional conceptualizations of the boundaries that
surround therapy. It is important to be aware of the potential for these activities to be mis-
construed by clients as evidence of a different sort of relationship. The clear rationale for the
therapeutic utility of these activities assists in clarifying how they fall within a therapeutic
130 BEHAVIORAL AND COGNITIVE APPROACHES

domain rather than a social domain. Moreover, therapists should prepare carefully for
exposures taking place outside the clinic, ideally selecting nearby settings. The introduc-
tion of exposure-based interventions is also an excellent time to review consent procedures
with the client. Issues such as public surveillance cameras should be addressed at this time,
and the client and therapist should discuss in advance how they might handle a situation in
which they are approached or questioned by a third party. Of course, therapists must also
be sensitive to any potential danger to clients during exposures, being sure at all times to
protect their safety. Therapists should acknowledge that unexpected events may occur dur-
ing exposures and make sure there is time available postexposure, back in the therapy room,
to talk about anything unplanned that happened.
Cultural considerations are important in addressing these ethical issues as well. Depend-
ing on how centrally Mateo holds, and how he expresses, the value of personalismo, some
amount of personal exchange may be part of the therapeutic relationship and may enhance
the alliance, while still maintaining an appropriate focus on meeting his treatment goals.
This might affect how the conversation on the way to the elevator proceeds and should be
considered in preparing for exposures. Depending on Mateo’s previous experiences with
security guards, that exchange may be an understandable trigger for additional anxiety,
which should be noted and explored by the therapist, along with any lingering concerns
about the camera when they return to the therapy room.

RESEARCH SUPPORT AND EVIDENCE-BASED PRACTICE

Without question, behavioral and cognitive-behavioral interventions are the most studied
and therefore the best supported psychological treatments for most disorders. The Society
of Clinical Psychology (Division 12 of the American Psychological Association) maintains
a website (www.div12.org/psychological-treatments) describing evidence-based treatments
for a wide range of problems, and indicates whether each treatment is strongly supported
by research, modestly supported by research, or controversial. At the time that this chapter
was written, the site described 80 treatments for specific psychological disorders. At least 46
of the 49 treatments listed as having strong support were behavioral (broadly defined) and
included strategies such as exposure-based approaches, cognitive interventions, behavioral
family therapies, skills training, and other strategies for changing behavior (Society of Clini-
cal Psychology, 2018).
Since behavior therapy was first developed in the 1950s, hundreds (if not thousands) of
studies have evaluated its effectiveness and efficacy. For example, a meta-analysis of RCTs
of BA for depression reviewed 34 studies, concluding that BA is a well-established treat-
ment for depression that works as well as other established approaches, such as cognitive
therapy (Mazzuchelli, Kane, & Rees, 2009). Another article identified 269 meta-analyses of
CBT studies, reviewing a representative sample of 106 (Hofmann, Asnaani, Vonk, Sawyer,
& Fang, 2012). This article reviewed only studies that included cognitive and cognitive-
behavioral interventions, and did not include studies based only on traditional behavioral
treatments. As noted earlier, behavioral strategies are typically combined with cognitive
approaches for most problems. These studies included comparisons covering 16 disorder
or problem categories, including depression, anxiety disorders, schizophrenia, anger and
aggression, eating disorders, criminal behaviors, and chronic pain. The review provided
strong support for CBT across a wide range of problems.
 Behavior Therapy 131

To assess the cost-effectiveness of CBT, Myhr and Payne (2006) reviewed 22 health
economics studies on CBT for mood, anxiety, psychotic, and somatoform disorders. Evi-
dence from studies conducted in the United States, the United Kingdom, Australia, Canada,
and Germany have generally found that CBT, provided alone or in combination with phar-
macotherapy, leads to improved outcomes and cost savings by reducing health care use.
Another study from the United Kingdom reported that the addition of CBT to usual care
had a 92% probability of being cost-effective as compared to usual care alone in individuals
with treatment-resistant depression (Wiles et al., 2016). With so many studies demonstrat-
ing the positive effects of behavioral treatments, a full review is beyond the scope of this
chapter. A more thorough review is available elsewhere (e.g., Nathan & Gorman, 2014).

CASE ILLUSTRATION
Background Information and Pretreatment Assessment
Charlie was a white 43-year-old. Though the sex assigned at birth was female, Charlie
identified as genderqueer or nonbinary. Charlie had come out to their family as genderqueer
5 years earlier, at the age of 38. Charlie was married to a cisgender woman, and together
they had two children. Charlie reported difficulties with social anxiety for as long as they
could recall. The problem became particularly difficult in college, when Charlie lived in a
residence in which floors were separated by gender. Though Charlie publicly identified as
a woman at that time, they felt different from, and judged by, the other students on their
floor. To avoid interactions with others, Charlie would often stand by their residence door,
waiting until the hall was cleared to exit their room. Charlie had to drop several courses due
to anxiety over giving presentations. Although they could not recall how the problem began,
they remembered a number of life events that seemed to lead to exacerbation of their anxi-
ety. For example, during one difficult year in high school, they remembered being teased on
a regular basis and pretending to be ill on several occasions so they could stay home from
school to avoid being around their classmates. They described their home life while growing
up as relatively happy, although they also reported that their parents were critical at times,
and that they often felt pressure from their parents to meet high standards in school and in
other areas of their life. Moreover, their parents placed pressure on them to act in line with
stereotypically “female” behaviors (wear dresses, take dance lessons).
As part of their initial assessment, Charlie received the Structured Clinical Interview
for DSM-5 (SCID-5; First et al., 2015). DSM-5 criteria were met for a principal diagnosis of
social anxiety disorder, and a past diagnosis of major depressive disorder, triggered by the
loss of a job 10 years earlier. Charlie reported significant fear and avoidance of a wide range
of social situations, including parties, public speaking (except when teaching their students),
writing in public, speaking to people in authority, meeting new people, being assertive, and
having conversations with others. They reported that their social anxiety had prevented
them from making friends and returning to school to complete their master’s degree. Charlie
finally decided to seek treatment after beginning a new job. Charlie’s symptoms were being
exacerbated as a result of being surrounded by new coworkers, who Charlie felt did not
understand their gender identity.
Charlie reported several characteristic thoughts that seemed to contribute to their social
anxiety. Their primary concerns in social situations were that others did not understand
their gender nonconformity, and that others would criticize their behavior and judge Charlie
132 BEHAVIORAL AND COGNITIVE APPROACHES

as incompetent or unintelligent for other reasons. Charlie’s anxiety-provoking thoughts

were particularly problematic at work and around people whom they did not know well.
For example, during their first week at work, Charlie disclosed to their coworkers that
they preferred gender neutral pronouns (i.e., they, rather than he or she). Though most of
their coworkers respected this request, some continued to use she and her when referring to
Charlie. Charlie wanted to correct them, but felt nervous about being judged and criticized.
As a result, Charlie would often stay silent instead. Moreover, Charlie recognized that there
were opportunities to get involved with planning inclusion-based workshops in their school
and was passionate about repeated training and education about respect for diverse gender
identities. However, Charlie’s concern about negative evaluation kept them from getting
involved, which in turn made Charlie feel disappointed in themselves. Charlie reported
feeling self-conscious when writing or speaking in public and meeting new people, with
repeated thoughts that people were judging them negatively.
At their initial assessment, Charlie completed a series of self-report scales to measure
symptoms of social anxiety and depression. They rated their fear and avoidance for each of
12 items from their exposure hierarchy, using scales ranging from 0 (no fear; no avoidance)
to 100 (maximum fear; complete avoidance), and completed a BAT that involved trying to
correct a coworker who used gendered pronouns to refer to them. Charlie was able to cor-
rect the coworker but did so while looking down and speaking quietly. Immediately after-
ward, Charlie was very concerned about whether the coworker was criticizing them and
regretted having corrected the coworker’s language.

Behavioral Conceptualization
Charlie’s social anxiety seemed related to a series of events early in their life, in which they
were teased by their peers for nonconformity and criticized by their parents more generally.
More recently, the anxiety appeared to be maintained by their avoidance of social situations
and their exaggerated beliefs about the potential dangers of being around other people, as
well as ongoing messages they received about binary gender conformity. A number of situa-
tions appeared to trigger Charlie’s anxiety.

Treatment
Charlie received cognitive-behavioral group treatment, similar to that described by Heim-
berg and Becker (2002). Their group, which included six other clients, all with a principal
diagnosis of social anxiety disorder, met for 12 weekly 2-hour sessions. At treatment outset,
the group leader asked each member to disclose their preferred pronouns. They collabora-
tively devised a list of group rules that included treating other group members with respect
and inclusivity, and refraining from any discriminatory actions.
The first two sessions included psychoeducation about the nature of social anxiety and
its treatment. These sessions began with a discussion of the notion that anxiety and fear
are normal emotions, and that attempts to avoid experiencing them can actually increase
their frequency and intensity. In addition, the survival value of social anxiety and its asso-
ciated symptoms was reviewed. Clients were encouraged to recognize that not all social
anxiety is problematic. At times, social anxiety can protect us from making mistakes that
might otherwise be associated with severe negative social consequences. Sociocultural and
environmental factors in social anxiety were acknowledged, including that experiences of
 Behavior Therapy 133

discrimination and exclusion can naturally lead to heightened social anxiety. Clients were
encouraged to conceptualize their social anxiety in terms of physical (e.g., blushing, shak-
ing, and sweating), cognitive (e.g., unrealistic assumptions about social situations), and
behavioral (e.g., avoidance and safety behaviors) components. The treatment strategies (see
below) were reviewed, with an emphasis on how each technique can be used to target par-
ticular components of anxiety. Assignments during these initial sessions involved monitor-
ing anxiety symptoms in diaries and completing assigned readings, including introductory
chapters from the Shyness and Social Anxiety Workbook (Antony & Swinson, 2017). Rel-
evant readings from this book were assigned throughout the remaining sessions of treatment
as well.
Subsequent sessions included primarily instruction in cognitive restructuring and expo-
sure to feared situations (both during in-session simulated exposures and between-session in
vivo exposures practiced for homework). Typically, cognitive restructuring involves teach-
ing the group to identify anxiety-provoking beliefs (e.g., “It is important for everyone to like
me” and “If my hands shake during a presentation, people will think I am incompetent”)
and to consider more balanced or realistic interpretations regarding social situations, after
evaluating the evidence for them. However, clients who experience discrimination often
have automatic negative thoughts that are not fundamentally erroneous (Graham-LoPresti,
Gautier, Sorenson, & Hayes-Skelton, 2017). For example, in this context, Charlie’s con-
cerns about being judged by coworkers was not irrational—a small subset of their cowork-
ers indeed made frequent disparaging remarks about their nonbinary status. Consequently,
cognitive restructuring in this case focused on restructuring the internalization of discrimi-
natory experiences (e.g., challenging the belief that “There must be something wrong with
me because others are judging me for being nonbinary”) rather than the occurrence of the
experiences themselves (e.g., challenging the belief that “People will judge me for being non-
binary”; Graham-LoPresti et al., 2017).
For their exposure practices, Charlie was encouraged to engage in previously avoided
behaviors, such as correcting an acquaintance who forgot to use gender-neutral pronouns,
attending a social event with coworkers, and volunteering to help with inclusion-based ini-
tiatives at work. Each client in the group, including Charlie, developed an individualized
hierarchy used to guide their exposure practices. In addition to cognitive- and exposure-
based strategies, one session of the group was spent discussing strategies for improving com-
munication skills. Charlie learned techniques for assertive communication, which they then
put into action when confronting a coworker about a derogatory remark.

Outcome
Relative to the other members of the group, Charlie’s progress was more gradual. However,
they were particularly motivated and completed almost all of their between-session assign-
ments. By the end of treatment, Charlie continued to acknowledge the unfortunate reality
of workplace discrimination. However, they were now able to challenge their assumptions
about the meaning of the discrimination. The extent to which Charlie’s anxiety was con-
trolling their behavior had also been mitigated: They were standing up for themselves in a
respectful and assertive manner and engaging in volunteer initiatives in the workplace. At
the end of treatment, Charlie repeated the BAT. This time, Charlie was able to confidently
correct their coworker after he referred to them as “she.” Charlie received positive feedback
from the coworker, who apologized and appreciated the reminder.
134 BEHAVIORAL AND COGNITIVE APPROACHES

CURRENT AND FUTURE TRENDS

Because behavior therapy is grounded in a commitment to scientific inquiry, its practice is

constantly evolving and changing. An integration of behavioral and cognitive techniques is
more common than a separation of these two elements, so this is certainly a current (as well
as a past) trend. In addition, researchers are investigating the potential utility of integrating
other intervention strategies (both psychological and pharmacological) to maximize efficacy
of interventions. For certain conditions, such as depression (Khan, Faucett, Lichtenberg,
Kirsch, & Brown, 2012), bipolar disorder (Miklowitz, 2014), and schizophrenia (Guo et al.,
2010), combining psychological and pharmacological treatments appears to lead to more
improved outcomes than either approach alone. Recently, in a meta-analysis, Cuijpers et al.
(2014) found that combined treatment was more effective than either treatment alone for
major depressive disorder and some anxiety-related disorders (e.g., panic disorder, OCD),
but not other disorders (GAD, dysthymic disorder, PTSD; Cuijpers et al., 2014).
Another current trend in behavior therapy involves investigating ways to improve its
accessibility to broader populations. Internet-based CBT has been an important develop-
ment in this endeavor, as computerized treatments can be accessed from any location and
are relatively cost-effective. Similarly, fundamentals of behavior therapy can be learned
and implemented with the assistance of newly developed smartphone apps, such as Joy-
able, AnxietyCoach, Headspace, and MoodKit. The Anxiety and Depression Association
of America (2018) provides an overview of available mental health apps with correspond-
ing ratings based on variables such as ease of use, effectiveness, and research evidence (see
http://adaa.org/finding-help/mobile-apps). Finally, CBT is increasingly being used in inte-
grated primary care settings, which are typically easily accessible and often the first point
of contact for individuals with mental health complaints. Research has shown that brief
CBT delivered in primary care settings may be more efficacious as compared to treatment
as usual (e.g., Serfaty et al., 2009; Wiles et al., 2016).
A potentially promising new area of pharmacological study involves the use of d -cyclo-
serine (DCS), an antibiotic medication that also has effects on the brain. Specifically, DCS
has been found to enhance extinction learning in animals, and to increase the rate of
improvement during exposure therapy for certain anxiety disorders. Preliminary investi-
gations in clinical samples appear promising (Rodrigues et al., 2014). In addition, studies
have begun to explore the utility of methylenedioxymethamphetamine (MDMA)-assisted
psychotherapy in the treatment of PTSD, with initial promising results (e.g., Chabrol &
Oehen, 2013). Researchers are also examining the efficacy of integrating mindfulness- and
acceptance-based techniques into behavioral treatments for a range of disorders (Roemer &
Orsillo, 2009), as well as whether the addition of interpersonal or experiential elements to
CBT increases efficacy (e.g., Mennin & Fresco, 2010; Mennin et al., 2018; Newman et al.,
2011). We expect to learn more about the utility of psychotherapy integration in the coming
years.
A recent trend concerns studying the use of behavioral interventions in frontline clini-
cal settings (known as effectiveness research) as opposed to highly controlled research set-
tings (known as efficacy research). Compared to efficacy studies, effectiveness studies typi-
cally have fewer exclusion criteria, include more representative samples, and are designed
to investigate the utility of treatments in the contexts in which they will be applied. Initial
findings on effectiveness are promising; a meta-analysis of effectiveness studies of CBT for
 Behavior Therapy 135

anxiety disorders found large effect sizes that were generally comparable to those from rep-
resentative efficacy studies (Stewart & Chambless, 2009).
Finally, behaviorists are developing interventions that target disorders not previously
treated effectively, comorbid clinical presentations, and clients from diverse backgrounds.
Researchers and clinicians are exploring how behavioral interventions can be delivered in a
culturally sensitive manner. In addition, several protocols have been developed specifically
to target comorbid and more complex clinical cases. These efforts, combined with the focus
on effectiveness, will help behavior therapists to continue developing interventions that can
optimally treat the clients presenting for services.
An important area for future study will be continued development of cultural adapta-
tions of behavioral approaches. It is important to determine how to effectively use these
evidence-based strategies to help individuals manage chronic stress (e.g., war), and experi-
ences of discrimination and marginalization. Behavior therapy, with its emphasis on help-
ing people adapt effectively to their environments, potentially has a great deal to offer in
these contexts. However, it is necessary to learn more about what an adaptive response to
maladaptive contexts looks like and how to help clients more effectively address systems
and contexts themselves, in order to reduce the suffering these systems cause in individu-
als.

SUGGESTIONS FOR FURTHER STUDY

Recommended Reading
Antony, M. M., & Roemer, L. (2011). Behavior therapy. Washington, DC: American Psychological
Association.—Provides an up-to-date overview of behavior therapy.
Barlow, D. H. (Ed.). (2014). Clinical handbook of psychological disorders (5th ed.). New York: Guil-
ford Press.—This edited volume provides detailed, session-by-session, evidence-based protocols
for treating a wide range of psychological problems.
Haynes, S. N., Kaholokula, J. K., & O’Brien, W. H. (2015). Behavioral assessment. In R. L. Cautin
& S. O. Lilienfeld (Eds.), Encyclopedia of clinical psychology. Hoboken, NJ: Wiley.—Provides
an excellent overview of behavioral assessment.
Hofmann, S. G., & Asmundson, G. J. G. (2017). The science of cognitive-behavioral therapy. San
Diego, CA: Academic Press.—An excellent overview of the evidence regarding behavioral and
cognitive-behavioral treatments.
O’Donohue, W. T., & Fisher, J. E. (2012). Cognitive behavior therapy: Core principles for practice.
Hoboken, NJ: Wiley.—Reviews the use of 14 core behavioral and cognitive treatments.
Spiegler, M. D., & Guevremont, D. C. (2016). Contemporary behavior therapy (6th ed.). Boston:
Cengage Learning.—Covers all major behavioral approaches, including historical perspectives,
assessment, theory, strategies, and outcome.
Tolin, D. F. (2016). Doing CBT: A comprehensive guide to working with behaviors, thoughts and
emotions. New York: Guilford Press.—This text provides practical advice on how to administer
a wide range of behavioral and cognitive interventions.

DVDs
Antony, M. M. (2009). Behavioral therapy over time. Washington, DC: American Psychological
Association.—Includes six sessions of treatment with a client who has problem hoarding.
Wilson, R. (2012). Exposure therapy for phobias. Mill Valley, CA: Psychotherapy.Net.—Demon-
strates exposure therapy for a client with claustrophobia.
136 BEHAVIORAL AND COGNITIVE APPROACHES

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 CHAP TER 5

Cognitive Therapy and

Cognitive-Behavioral Therapy
Jordan E. Cattie
Jennifer L. Buchholz
Jonathan S. Abramowitz

C ognitive-behavior therapy (CBT) helps clients by addressing their maladaptive thoughts

and unhelpful coping practices to reduce distress and impairment; this enables clients to
optimally navigate their environments. Craske (2017) defines CBT in its contemporary form
as an amalgam of cognitive and behavioral interventions, derived from theories of learn-
ing and cognition, and guided by principles of empirical science. In contrast to some other
therapies, CBT is problem-focused, present-focused, time-limited, and readily summarized
in manuals. However, its effective implementation relies on the therapist’s understanding
of underlying theories and methods (Abramowitz, 2013) and ability to forge a collabora-
tive relationship with the client (Leahy, 2008). Depending on the client’s presenting con-
cerns and functional assessment of symptoms, specific cognitive and/or behavioral skills are
selected and emphasized.
Although cognitive therapy was developed to conceptualize depression and early
behavioral interventions targeted fear and phobias, today CBT is used to treat a range of
psychological concerns and disorders (e.g., anxiety, mood, eating, obsessive–compulsive,
schizophrenia spectrum). Its wealth of health-related applications include pain manage-
ment, smoking cessation, and medical treatment adherence. With individuals throughout
the life cycle, CBT’s efficacy has been demonstrated in randomized controlled trials (RCTs),
and effectiveness has been shown in naturalistic settings (e.g., Carpenter et al., 2018). Many
brief manualized treatments that have been developed facilitate the dissemination of treat-
ments tested in RCTs (Kazdin, 2008), congruent with a broader movement by the American
142
 Cognitive Therapy and Cognitive-Behavioral Therapy 143

Psychological Association to highlight evidence-based practices (EBPs) that integrate the

best available research findings; therapist expertise; and the client’s characteristics, culture,
and preferences (American Psychological Association Task Force on Evidence-Based Prac-
tice, 2006).
CBT is an umbrella term encompassing a range of approaches. Cognitive and behavioral
methods may be more often used together than separately, but they have distinct processes/
goals. Behavioral therapy focuses on learned behavior, typically examined in response to
one’s environment. Broadly, behavioral interventions aim to decrease maladaptive behav-
iors and increase adaptive behaviors through a process of modifying their antecedents and
consequences and via guided practice of new behaviors that result in learning and reinforce-
ment. Treatment targets are the behaviors themselves. Cognitive therapy focuses on an indi-
vidual’s thoughts, often examining and attempting to modify specific beliefs and expecta-
tions about the self, the world, and the future. According to cognitive theory, these thoughts
are associated with a range of responses (emotional, physiological, and behavioral) that
may contribute to distress and difficulty functioning. The targets of therapy, and sources of
pathology, are believed to be various maladaptive thoughts that have been learned, adopted,
and ingrained; individuals respond to these thoughts as if they are true, without necessarily
examining whether this is the case. Cognitive therapy targets thoughts ranging from fleeting
automatic thoughts that may not be consciously detected to more deeply ingrained schemas
(i.e., beliefs about the self and the world developed over the course of an individual’s early
life experiences), to the most ingrained and deeply held ideas (i.e., core beliefs). Behavioral
techniques may be used in cognitive therapy; however, the goal in this context extends
beyond behavior change to the development of new ways of thinking and learning about
the situation.
This chapter focuses on second-wave CBT models that combine basic principles from
behavioral and cognitive psychology. Facilitated by advances in social psychology (e.g.,
attribution theory) and enhancements to scientific methods (e.g., development of computer
science and programming), second-wave CBT interventions are popular due to their demon-
strated efficacy and appeal to clients and therapists alike.

HISTORICAL BACKGROUND

The origins of CBT can be traced to the separate development of behavioral and cognitive
therapies, which shared a commitment to empiricism and gradually converged to become
integrated with one another.

Behavior Therapy
Behavior therapy was developed in the 1950s and 1960s by applying the principles of behav-
iorism to psychological symptoms. Behaviorism emphasized observable behavior and using
replicable experimental methods to test hypotheses about how learning and information
processing may guide voluntary behaviors. By operationalizing concepts into experimental
terms, psychology was viewed as an empirical science for the first time. This approach con-
trasted with Freudian psychoanalysis (the prevailing model of psychotherapy at the time),
which focused on unobservable phenomena, including the unconscious mind. Behaviorists
viewed these phenomena as difficult to verify.
144 BEHAVIORAL AND COGNITIVE APPROACHES

Psychologists including Joseph Wolpe, Hans Eysenck, B. F. Skinner, and O. Hobart

Mowrer turned to learning theory to explain the development and maintenance of specific
maladaptive behaviors. They developed treatment approaches based on how associations
can develop between experiences (i.e., classical conditioning) and between experiences and
behaviors (i.e., operant conditioning), with the goal of helping clients modify behaviors
and interrupt cycles of unhelpful behaviors. Mowrer’s two-factor model was particularly
influential; he posited that fear develops as a result of classical conditioning (e.g., getting
bitten by a dog) and operant conditioning (e.g., experiencing relief by avoiding dogs). These
principles were used to help clients modify behaviors to interrupt cycles of avoidance that
maintained fear. Similarly, Wolpe (previously one of Freud’s followers) observed that the
Freudian approach appeared less effective when treating soldiers presenting with what is
now described as posttraumatic stress disorder (PTSD). He began researching alternative
methods for understanding and treating PTSD based on the premise that learning (and an
individual’s environment) can shape emotional experiences and behaviors in either adaptive
or maladaptive ways. Efficacy studies of these novel behavioral treatments were featured
in new journals such as Behaviour Research and Therapy by the 1970s and 1980s, but by
this time, significant concerns were being expressed about whether learning theory could
fully explain psychopathology. For example, it was considered problematic that the classical
conditioning model of fears and phobias could not explain why all individuals who had an
aversive learning experience would not go on to develop a phobia.

Cognitive Therapy
Contemporaries of the behaviorists, such as Aaron T. Beck and Albert Ellis, were trained
in psychoanalysis but deviated from this orientation after years of working with patients
to develop an alternative model for psychopathology. They posited that strict behavior-
ism neglected key aspects of a person’s experience—specifically, cognitive appraisals and
early learning experiences—that could be powerful determinants of emotions and behav-
iors. Beck is credited with developing cognitive therapy in the late 1950s. Influenced by
Stoic philosopher Epictetus, who said, “What upsets people is not things themselves but
their judgments about the things,” Beck noted that many of his depressed clients shared
negative thoughts about themselves, the world, and the future. Beck and Ellis developed
cognitive interventions they named “cognitive therapy” and “rational therapy,” respectively.
Both approaches identified negative interpretations and attributions as primary features
of psychological problems, and highlighted the relationships among antecedents, beliefs,
behaviors, and consequences (see the ABC model below). They borrowed from treatments
that emphasize insight into past experiences and proposed that maladaptive cognitions may
originate from negative early life events (e.g., childhood trauma) and can be continually
reinforced by later experiences. They hypothesized that such beliefs result in biased infor-
mation processing and faulty problem solving (manifesting in behaviors counterproductive
to the individual). They linked distorted thinking to distressing emotions and maladaptive
behaviors, and focused treatment on shifting clients’ unhelpful thought processes. Whereas
rational emotive therapy challenged clients about their irrational beliefs, cognitive therapy
sought to join clients and their therapists in a collaborative process of discovery and invited
them to become scientific observers of their own experiences. Socratic dialogues were used
to guide clients toward more functional outlooks, to notice and respond more rationally to
 Cognitive Therapy and Cognitive-Behavioral Therapy 145

automatic thoughts, to label cognitive distortions, and to engage in cognitive restructuring

(described in more detail later).
Since cognitive therapy first rose to prominence, numerous additional behavioral and
cognitively based therapies have been developed. The list is too extensive to summarize
here, but we refer the reader to recommended readings at the conclusion of this chapter.
Therapists of a wide range of theoretical orientations have utilized cognitive approaches to
varying degrees. Psychodynamic therapists may focus on uncovering and examining sub-
consciously held beliefs and interpersonal schemas, whereas more behavioral therapists may
utilize briefer models of treatment that emphasize active and psychoeducational models
with an explicit goal of behavior change. The proliferation and success of cognitive and
CBT methods today can be attributed in large part to Beck’s development of the science
alongside the practice of therapy, including assessment tools (e.g., Beck Depression Inven-
tory; BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) and testing treatments using
RCTs. Today, there are hundreds of RCTs focusing on cognitive and cognitive-behavioral
therapies (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). Beck focused on developing
protocols to address specific psychological disorders and symptom profiles, which enabled
therapists to pursue targeted symptom relief using these training aids. He also willingly inte-
grated features of other therapies that demonstrated efficacy (e.g., behavioral therapy meth-
ods, including behavioral activation, exposure exercises, behavioral experiments, relaxation
training, and social skills training).

Integration of Behavioral and Cognitive Frameworks

Behavioral and cognitive frameworks became more fully integrated beginning in the 1980s.
By this time, the two approaches had been recognized to overlap significantly and provide
complementary sets of skills and approaches. This integration, sparked by the cognitive
revolution, marked a challenge to the traditional behavior therapy approaches (i.e., the first
wave; see Antony, Roemer, & Lenton-Brym, Chapter 4, this volume) and became known
as the second wave, in which attention was paid to how thinking impacted emotions and
behavior. The third wave of therapies, which have become increasingly commonplace over
the past 20 years, were developed by a subset of CBT therapists to incorporate theoreti-
cal and clinical developments related to the impacts of mindfulness and present-moment
awareness on psychological well-being. These third-wave approaches place less emphasis on
cognitive restructuring and controlling thoughts and emotions, and use mindfulness as an
alternative approach to changing the way attention is allocated to the environment. Third-
wave approaches, which build on an Eastern approach, emphasize responding to thoughts
in new ways and placing them in context. These interventions are summarized separately
within this volume.
Whereas some CBT manuals aim to treat psychological distress transdiagnostically
(e.g., the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders [UP]; Bar-
low et al., 2017), numerous specific CBT protocols have been developed to address cogni-
tive and behavioral factors relevant for a unique diagnosis, syndrome, or set of problems.
Although disorder-specific manuals differ with regard to treatment techniques, they share
the same conceptualization of psychological distress and general treatment approach.
Early research on CBT was not conducted in diverse samples, and despite its widespread
use, the practice-oriented research on CBT has historically focused almost exclusively on
146 BEHAVIORAL AND COGNITIVE APPROACHES

people of European American identities and cultural majority groups. CBT’s reliance on
conscious processes and overt behaviors has been conceptualized by some authors as rela-
tively “value-neutral.” However, efforts have been made in recent years to conduct research
and adapt CBT interventions across populations and contexts. A recent meta-analysis (Hall,
Ibaraki, Huang, Marti, & Stice, 2016) of cultural adaptations of psychological interven-
tions included 24 studies of CBT adapted for various ethnic-minority groups, and found
that these interventions produced better outcomes than comparison conditions. In addition,
an increasing recognition of the influence of multicultural factors has led to the develop-
ment of work incorporating principles of multiculturalism into every aspect of CBT (Hays
& Iwamasa, 2006; Hays, 2009). The decisive impact of multiculturalism on psychology
has resulted in its characterization as the “fourth force” in the development of psychol-
ogy, building on psychoanalysis, behaviorism, and humanism (Pedersen, Draguns, Lonner,
& Trimble, 2002). CBT and multicultural therapy share several assumptions that readily
allow their integration. For example, both emphasize the need to tailor interventions to the
unique needs and strengths of the individual, both emphasize conscious processes that can
be easily observed or stated (which can be useful outside of a client’s first language), and
both empower the client (in CBT, through teaching specific skills that can be utilized as they
wish). The emphasis of ongoing assessment in CBT is consistent with culturally responsive
practice, in that it communicates respect for the client’s viewpoints regarding their own
progress, and CBT’s behavioral focus on environment can be inclusive of cultural influ-
ences.*

THE CONCEPT OF PERSONALITY

Beck conceptualized clinically significant psychological symptoms as representing the

extreme end of a continuum of normal emotional and behavioral functioning, rather than as
indicative of stable personality traits. In keeping with this, CBT’s model of distress describes
the influence of maladaptive cognitions (how individuals perceive situations and events)
on emotions, behaviors, and physiology—and in turn, the maintenance of emotional and
behavioral problems. This model hypothesizes that a situation or event (in isolation) does
not determine how people feel or behave; instead, the resulting cognitions explain why
several individuals experiencing the same event may feel or respond in very different ways.
For example, based on the resulting interpretations, an ambiguous situation such as being
asked to meet with a supervisor at work might result in anxiety (“Oh no! I must have made
a mistake. Am I going to get fired?”), frustration (“Of course she’s pulling me aside. It’s
always my fault”), or more a more neutral emotional response (“Hmm. I wonder if there’s
an update about our project”). According to this model, cognitive-behavioral patterns are
learned and practiced over time, defining the ways in which individuals interact with their
environment. Whereas trait theories of personality suggest that dispositional factors explain
behavior across situations based on a set of attributes or dimensions, cognitive-behavioral
theories are more aligned with social-cognitive theories of personality that emphasize the

*Because there are members of the LGBT community who do not identify with either of the traditional
gender distinctions, we have chosen to try to avoid, as much as possible, the use of pronouns such as “he or
she,” “his or her,” or their variants. This means that there are occasions when we will use pronouns such
as “they” or “them” to refer to singular persons.
 Cognitive Therapy and Cognitive-Behavioral Therapy 147

interaction among the roles of the environment (different stimulus conditions), mood states,
and an individual’s beliefs about the environment. As a result, cognitive-behavioral theory
posits that human functioning is a product of ongoing interactions between characteristics
of the person (thoughts/beliefs, emotions, behaviors) and the environment.
Early experiences are thought to inform an individual’s views about the world around
them. These beliefs, or schemas, influence how people attend to and understand the world,
and organize incoming information within the context of past experiences. Individuals
are more likely to fit new experiences within the framework of preexisting schemas than
to than change schemas to accommodate discrepant information (Kovacs & Beck, 1986).
Because schemas serve as a lens through which individuals experience and respond to the
world around them, they can be conceptualized as influencing personality. Beck proposed
that cognitive vulnerabilities influence the development and manifestation of psychopathol-
ogy, and specifically contrasted the beliefs of individuals with autonomous versus socio-
tropic personality types. He noted that autonomous individuals are more likely to become
depressed after negative events that happen to only them, whereas sociotropic individu-
als are more likely to become depressed after an interpersonal stressor. Building on this
theoretical frame, cognitive-behavioral models of therapy attend to thoughts (ranging from
negative automatic thoughts to enduring core beliefs, memories, expectations, attributions,
and others), behaviors (learned, action urges), and emotions, as well as factors related to the
environment.

PSYCHOLOGICAL HEALTH AND PSYCHOPATHOLOGY

Beck (1979) observed that many disorders are characterized by extreme and persistent forms
of normal emotional responses, and conceptualized a continuum ranging from adaptive to
inappropriate responses associated with psychopathology. This model of psychopathology
posits that dysfunctional cognitions, behaviors, and emotions found across psychological
disorders are extensions of normal, adaptive processes. Beck focused on cognitive explana-
tions that are rapidly generated, which he labeled negative automatic thoughts, particularly
those that produce unnecessary discomfort or suffering, or lead to self-defeating behaviors.
According to him, individuals may not be aware of the automatic thoughts that power-
fully influence how they act and feel, and how enjoyable their experiences are. Maladaptive
thoughts may interfere with their ability to cope with life experiences, disrupt feelings of
well-being, or result in strong emotional reactions that are more painful than needed. The
characterization of thoughts as maladaptive is not defined by the therapist’s values; instead,
they are defined collaboratively by the client and therapist, including the client’s identi-
fication of thoughts that interfere with well-being or fulfillment of important objectives.
Frequently, among these are thoughts referred to as “self-statements” or “self-talk” (Ellis,
1962).
The conceptual basis of CBT is the cognitive specificity model of emotion, derived from
the work of Ellis and Beck. This model stipulates that emotions are not directly caused by
situations or stimuli per se, but rather by how the person ascribes meaning to situations or
stimuli. This conceptualization, often referred to as the “ABC model” (as shown in Figure
5.1), includes three components: “A” (the activating event) symbolizes some event or situa-
tion that happens to the person, such as receiving a failing grade on an exam; “B” (beliefs)
represents the individual’s thoughts, perceptions, and assumptions about the event in “A,”
148 BEHAVIORAL AND COGNITIVE APPROACHES

such as I am stupid; and “C” (consequences) denotes the person’s emotional and behavioral
responses, such as feeling depressed, worthless, and seeking social isolation. To reiterate,
it is “B” (beliefs) rather than “A” (activating event), that primarily give rise to “C” (conse-
quences); that is, our thinking, in large part, determines our distress.
The “cognitive specificity model” is labeled as such because it posits that particular
emotions (as well as corresponding behaviors and so-called “psychological disorders”)
result largely from specific types of irrational or otherwise maladaptive “B’s” (beliefs and
interpretations). Overly general beliefs concerned with failure and loss, for example, lead to
depression and depressive behavior, as in the previous example. Rigid beliefs concerned with
rules or demands for how others should or must behave (e.g., “People must always be polite
and respectful of me”) lead to feelings of anger and hostile behavior when others inevitably
break such rules; and those concerned with intolerance (e.g., “I can’t stand discussing poli-
tics with my uncle”) lead to frustration. Beliefs characterized by global self-blame (e.g., “I
should have been a better daughter”) lead to guilt, and exaggerated and catastrophic over-
estimates of danger (e.g., “Air travel is very dangerous”) lead to anxiety, fear, and taking
action to reduce the perceived threat (e.g., avoidance).
The ABC model has implications for understanding and treating emotional and behav-
ioral problems. First, people tend to assume that such disturbances arise from the situations,
people, and things in their environment. They do not usually recognize the role that their
thoughts and beliefs play in their emotions and behaviors. Accordingly, when they experi-
ence difficulties at “C,” they are apt to try to change “A.” Yet while this approach might
sometimes work, it is unreliable, because many things (e.g., other people’s behavior) are not
under our control. This fact places the individual in the unfortunate position of having his
or her emotional and behavioral well-being be dependent on people (and situations) behav-
ing just so and working out “just right.” A more elegant solution is to learn how to be the
master of one’s own emotions and behavior given any circumstance by learning to modify
one’s thinking—a much more straightforward and productive (yet still not easy) task than
trying to control situations and people. CBT involves learning skills to be able to think more
adaptively and rationally, in order to conquer distress and lead a happier and more produc-
tive life.

A = Activating Event

Relevant aspects of the situation

B = Beliefs C = Consequences

Thoughts and perceptions about “A” Emotional and behavioral responses

FIGURE 5.1. The ABC model illustrating the cognitive specificity model of emotions, which
forms the conceptual basis of CBT. This model states that emotions are not directly caused by
events; they are determined by how a person ascribes meaning to the situation.
 Cognitive Therapy and Cognitive-Behavioral Therapy 149

A related implication of the ABC model, and a basic assumption of CBT, is that if peo-
ple think more rationally, they will experience more appropriate or manageable emotions,
be more well-adjusted, and increase their satisfaction with life. To this end, CBT draws an
important distinction between rational and positive thinking. Healthy emotions and behav-
ior are thought to stem from the former, whereas the latter is considered a way of rational-
izing and ignoring the problem. Indeed, experiencing appropriate emotions does not mean
being happy all the time. In fact, in CBT, it is considered healthy to experience appropriate
negative emotions such as sadness, frustration, displeasure, fear, concern, and a sense of
conscience (less frequently the more intense anger, anxiety, self-loathing, depression, guilt).
Appropriate emotions are viewed as stemming from rational beliefs about inherently nega-
tive “A’s,” such as those that involve loss or threat. Such emotions also may be motivational,
in that they can lead to healthy coping and problem solving in challenging situations, as
opposed to the ineffective and destructive actions that often arise from more intense and
long-lasting negative emotions.
According to the CBT model, when a client experiencing symptoms of schizophrenia
or another serious mental illness has delusional beliefs (e.g., “That person is looking at
me—they must be out to get me”), these are viewed as falling on a continuum with nor-
mal and other unhelpful beliefs—they are just particularly strongly believed. A belief such
as “The government has me under surveillance” is viewed simply as a distorted belief,
similar to those that arise with clients who endorse depression, anxiety, or other mental
health concerns. There is evidence that delusional beliefs can be modified to become less
life-interfering, and that CBT can be effective for clients with psychotic disorders (Hazell,
Hayward, Cavanagh, & Strauss, 2016). CBT also has been shown to improve adherence
to pharmacotherapy and support relapse prevention, two components of treatment that
are important for severe mental illness. Additional treatment targets in serious mental ill-
ness may include suicidality, mania, substance abuse, and sleep difficulties. See the section
“Research Support and Evidence-Based Practice” for a summary of how CBT incorporates
these themes.

THE PROCESS OF CLINICAL ASSESSMENT

Assessment in CBT is an ongoing and conceptually driven pursuit in which the cognitive
model of emotion determines what is most important to evaluate. Assessment begins with
a discussion of the purpose for seeking treatment and a history of the chief complaint(s).
The individual’s level of functioning, support network, personal and medical history,
co-occurring or previous mental health diagnoses (including potential for violence), and
experiences with treatment also are considered important to assess, in order to help iden-
tify factors that might warrant immediate attention, exacerbate or ameliorate current
symptoms, or impact adherence to CBT. Finally, it is deemed essential to understand the
client’s expectations of therapy and to work collaboratively to establish goals and targets
for treatment.
It would be convenient if clients routinely provided reliable and valid answers to que-
ries about the frequency, intensity, and duration of their problematic emotions and behav-
iors; yet since this is not always the case, psychometrically validated self-report instruments
should be used to supplement the clinical interview and functional assessment. Self-report
measures have the advantage of using carefully worded questions that are consistent over
150 BEHAVIORAL AND COGNITIVE APPROACHES

time. They also allow the therapist to compare the client’s responses to well-established
norms for other people with similar complaints. Accordingly, questionnaires are valuable
for screening purposes, to corroborate information obtained in a clinical interview, and to
monitor symptom severity over the course of treatment; they are not, however, a substitute
for careful clinical interviewing. A wealth of self-report questionnaires to measure the wide
array of psychological symptoms is available, and we suggest the use of resources such as
A Guide to Assessments that Work (Hunsley & Mash, 2018) when choosing an appropri-
ate instrument for this purpose. Although CBT-focused assessments of adults are primarily
conducted at the individual level, with child or adolescent clients or families in which fam-
ily members are directly involved in or impacting the client’s symptoms, it is useful for the
assessment phase to include these individuals (e.g., in order to assess family accommodation
or conflict, both of which have been associated with adverse treatment outcome or treat-
ment discontinuation).

Functional Assessment
The most critical information necessary for implementing CBT comes from functional
(a.k.a. cognitive-behavioral) assessment, which refers to the gathering of the client’s spe-
cific information about the proximal factors that control his or her emotional distress.
These factors include situations and stimuli associated with distress (“A’s” or “activating
events”), cognitions about the activating events (“B’s” or “beliefs”), and the emotional and
behavioral responses in the context of activating events (“C’s” or “consequences”). Func-
tional assessment is typically begun during the first session and may not appear (to the
client) to be distinct from therapy itself, since psychoeducation about the relation between
cognitions and emotional responses into the assessment process can be easily woven into
this type of assessment. Notably, functional assessment is an idiographic (profile of psy-
chopathology specific to the individual) and conceptually driven approach to understand-
ing the individual’s triggers, thoughts, behaviors, and emotional experiences, as well as
the relations among them. Diagnostic assessment, on the other hand, is a nomothetic
(group-based, referring to shared characteristics) approach in which the person’s experi-
ences are compared to established descriptive criteria (usually the DSM). Accordingly,
establishing a psychiatric diagnosis is neither necessary nor sufficient for implementing
CBT. In part, this is because two people who have been diagnosed with the same mental
health concern may have completely different symptom presentations, so a diagnosis in
isolation would not be a very effective guide for treatment. For example, depression may
manifest with symptoms of profoundly depressed mood with binge-eating episodes and
sleep in excess of 18 hours per day, or with mildly depressed mood with profound anhe-
donic loss of interest in daily activities, almost no appetite, and insomnia. The treatment
of individuals with these two different presentations would be expected to differ signifi-
cantly, despite addressing symptoms consistent with the same disorder. In addition, many
individuals may not have a clear diagnosis or may have more than one diagnosis, and it
would be difficult to establish a strong scientific basis for each diagnosis, much less for the
various combination of problems/diagnoses. Understanding syndromes of psychological
problems (ranging from mild to severe, occurring alone or in combination, and impact-
ing quality of life and daily functioning in observable ways) is considered informative for
treatment planning in CBT.
 Cognitive Therapy and Cognitive-Behavioral Therapy 151

Components of Functional (Cognitive-Behavioral) Assessment

The Problem List
The therapist can begin by working with the client to identify the most salient (target) com-
plaints. Clients often come to therapists seeking help with solving practical problems, such
as how to win more friends or make sure Aunt Edna does not ruin the next family gather-
ing. In CBT, however, the emphasis is (at least initially) on addressing maladaptive cognitive
and emotional responses to such negative activating events. Thus, suitable target problems
include negative emotions such as depression, anger, anxiety, and guilt, that occur with a
frequency, intensity, or duration that is inappropriate or maladaptive (indeed, such emotions
may be perfectly appropriate or adaptive in some situations) and that lead to psychological
suffering, violence/aggression, interference in functioning or relationships, and punishing
behavior from others. The more specifically such problems can be defined, the more tar-
geted the application of CBT is possible. Thus, clients might initially be asked to complete a
“homework” task of self-monitoring between sessions in which they use a log to record dis-
crete episodes of mood fluctuations or problem behavior, the situations associated with such
episodes, as well as the thoughts and images associated with them. The log can be reviewed
at the subsequent session to determine predominating patterns of emotional distress and the
contexts in which they occur.

Assessing “C” (Consequences)

Given the emphasis on targeting emotional consequences of situations in CBT, it is usually
helpful to begin with assessing the client’s emotional and behavioral responses to particular
activating events. Emotions can be assessed using open-ended questions (e.g., “What did
you feel when that happened?”), as well as by picking up on descriptions of client behavior
associated with certain emotions. For example, avoidance usually indicates anxiety, aggres-
sive behavior indicates anger, and self-injurious behavior might indicate guilt or depression.
Emotions can also be inferred through nonverbal behavior, the client’s life circumstances,
as well as the client’s belief systems. It is important to distinguish emotions from thoughts
or beliefs. Whereas the former are feeling states (and often denoted by a single word, e.g.,
“worried”), the latter are usually statements or predictions about oneself or the world (and
usually denoted by a string of words, e.g., “I just know I won’t be able to handle the stress
of college”).

Assessing “A” (Activating Events)

Assessing the activating event entails determining the objective facts of a situation that
triggered emotional distress (e.g., “She threw a party and I wasn’t invited”). The more spe-
cifically a situation can be defined, the better. It is essential to separate the facts from the
client’s perception or idiographic explanation of what happened (e.g., “She forgot about
me” or “She didn’t want me there”). This can be accomplished via detailed questioning
or journaling (record keeping between sessions). Sometimes clients have difficulty with
specificity and report they feel depressed about everything, or that there is no trigger. In
such instances, one can ask about recent life changes (e.g., relationship breakup) and ongo-
ing stressors (e.g., work/school, finances) likely to serve as activating events. When clients
152 BEHAVIORAL AND COGNITIVE APPROACHES

report constant experiences of negative emotions, it may be helpful to ask them to record
the relative strength of this emotion in relation to activating events (“My depression was 80
when I felt rejected by my friend . . . probably 60 when I was by myself in my room feeling
guilty for not doing something”).

Assessing “B” (Beliefs)

Clients’ beliefs, assumptions, and perceptions about their activating events can be func-
tional (adaptive, logical) or dysfunctional (maladaptive, illogical), and it is important to dis-
criminate between the two. Functional beliefs, which might be positive, neutral, or negative
in valence, are internally consistent, supported by facts, flexible, and congruent with attain-
ing goals. Dysfunctional beliefs, on the other hand, are logically or empirically inconsistent
(overgeneralizing, inaccurate), exaggerated and extreme, inflexible, and incongruent with
goal attainment. In other words, “buying into” dysfunctional beliefs and acting on them as
though they are true typically takes the client further away from achieving his or her goals.
Moreover, dysfunctional beliefs lead to strong negative emotions and often exacerbate the
client’s problems. Dysfunctional beliefs and assumptions about activating events can be
assessed in various ways, such as asking questions about the situation; for example, “What
does that mean to you? How does this pose a problem for you?” and “What did you tell
yourself about that?” The therapist also can ask the client to complete a sentence about the
situation, such as “When your classmates laughed at you, you told yourself       .”
The downward arrow technique is another strategy for assessing deeply held beliefs that
influence emotions and behaviors. It involves (1) identifying a particular activating event;
(2) asking the client what this situation means about themselves, others, or the world; and
(3) continuing to ask the same question until a dysfunctional belief is revealed. Finally, the
therapist also might review a list of dysfunctional cognitions (e.g., the one in Table 5.1) with
the client to identify particular thinking patterns that the client may observe.
Again, in CBT, assessment is ongoing, as the patient continues to test hypotheses,
develop more adaptive beliefs and approaches, incorporate new skills, and develop a more
nuanced sense of the relationships between events, thoughts, emotions, and behavioral
responses.

Culture and Assessment

As the diversity among individuals living in the United States increases, it has been recog-
nized that developing cultural competence is critical for achieving the most favorable out-
comes in therapy, and that utilizing multicultural competencies to tailor CBT practices to a
given individual may best serve the mental health needs of marginalized populations (e.g.,
Chu, Leino, Pflum, & Sue, 2016). Many excellent sources (e.g., Hall et al., 2016; Huey, Til-
ley, Jones, & Smith, 2014) summarize the need for including cultural considerations into
evidence-based interventions such as CBT, provide a framework for incorporating multi-
cultural principles into assessment and treatment, and offer recommendations for work-
ing with marginalized populations. Hays (2008) developed an acronym, the ADDRESS-
ING framework, to help therapists attend to key aspects of the diverse backgrounds and
lived experience of clients that merit consideration in the context of therapy including: Age
and generational influences, Developmental disabilities, acquired Disabilities, Religion and
spiritual orientation, Ethnicity (and race), Socioeconomic status (which includes education),
 Cognitive Therapy and Cognitive-Behavioral Therapy 153

TABLE 5.1. Common Cognitive Distortions or “Unhelpful Thinking Styles”

Cognitive distortion Description Example
All-or-nothing Seeing things in absolute, black- “If I can’t do it perfectly, I’m a
thinking and-white terms failure.”

Catastrophizing Exaggerating the significance of an “He’s late for dinner; he’s probably
event, or taking a “shortcut” to the lying dead in a ditch somewhere.”
worst possible outcome

Probability Predicting a low-probability event “My plane will crash.”

overestimation as likely, without evidence (or in
the context of evidence that the
event is not likely)

Overgeneralization Seeing isolated events as a global “I missed a deadline; therefore,

or never-ending pattern I can’t do anything right and I’ll
never succeed in life.”

Personalizing Blaming yourself for external “My boss has an angry look on her
events, or believing that all events face. I must have done something to
are in some way related to you make her upset.”

“Should” statements Making (often arbitrary) “rules” “People should always treat me
about how you or others must how I treat them. If I put others
behave; becoming distressed when first, they should put me first.”
these rules are broken. These rules
are often not recognized/followed
by the rest of the world.

Emotional reasoning Assuming that your emotions “I felt embarrassed after the
reflect the way things really are; conversation, so I must have made
using emotions as evidence some awful mistake.”

Mind reading Guessing what someone else “I’m sure he didn’t like me; no, he
is thinking or feeling, without didn’t say anything—I just know!”
sufficient evidence (or in the
context of contradictory evidence)

Discounting Downplaying the significance of “So what if I graduated from

the positive positive or neutral events; fixating college—it barely counts because I
on negative events got a B average! I’m hopeless.”

Sexual orientation, Indigenous heritage, National origin (and generational status), and Gen-
der. Infusing a CBT-focused assessment with a multicultural perspective involves attending
to these facets of identity, as well as issues of power (the ability to decide who has access
to resources), privilege (advantages and benefits of dominant group members), and margin-
alization, to understand the impacts of these constructs on the experiences of clients from
diverse backgrounds.
Completing an initial assessment in a culturally responsive manner typically involves
increasing the therapist’s cultural knowledge, which includes understanding the client’s cul-
ture, values, beliefs, behaviors and their meaning/significance, worldview, and expectations.
It is expected that the therapist will continue to learn throughout treatment, but during the
assessment phase, it is incumbent on the therapist to proactively create opportunities for the
154 BEHAVIORAL AND COGNITIVE APPROACHES

client to share their cultural perspective in a way that is consistent with clinical assessment.
Specific questions may aim to elicit information about cultural beliefs and attitudes. Explor-
ing these topics is likely to elicit strengths and resources, challenges, and ways in which the
individual’s cultural background may interact with their presenting concerns in a nuanced
manner. It may be helpful to ask about and understand factors such parenting practices,
gender roles, acculturation or immigration history, the role/importance/structure of family
or community, discrimination experiences, religious/spiritual beliefs and practices, views of
mental health symptoms and treatment, language, gender identity, sexual orientation, and
beliefs about adversity and healing/recovery. The therapist also must attend to their own
cultural awareness and beliefs (ways these may impact perception of the client or problem),
and cultural skills (ability to intervene in a culturally sensitive and relevant manner; Sue,
Zane, Nagayama Hall, & Berger, 2009).
In addition to understanding a client’s concerns and sources of distress, CBT values
understanding all relevant strengths to capitalize and build on cognitive or behavioral
approaches that serve the client well or can be applied in other contexts. CBT and positive
psychology have been formally integrated into strengths-based CBT (Padesky & Mooney,
2012), which identifies client strengths in a more structured manner, utilizes these strengths
to form a personal model of resilience, and practices fostering resilience/persistence in the
context of obstacles (rather than seeking problem resolution).

THE PRACTICE OF THERAPY

CBT always involves helping clients to examine ways in which they understand themselves
and their world (cognitions) and to experiment with new ways of responding (behaviors).
Clients can learn new approaches (cognitive and behavioral) that help them to reduce and
more effectively cope with negative emotions, and to behave more adaptively and effectively.
CBT is structured, both within and between sessions, in that an agenda is set each session,
and treatment proceeds in alignment with a conceptualization and corresponding treatment
plan. However, it is also quite flexible, in that the working conceptualization and treatment
plans are expected to change based on client learning and progress. Certain key practices
are used with all clients (ongoing psychoeducation, assessment, creating a problem list, goal
setting, conceptualization, agenda setting, homework, updating of conceptualization based
on subsequent learning). However, CBT involves flexibly applying different cognitive and
behavioral techniques as needed, depending on the presenting problems and conceptualiza-
tion for each specific client. In CBT, treatment involves both the therapist and the client
taking an informed and active role. For example, clients are expected to know exactly what
they are working on (are able to describe the technique) and why (the clinical rationale and
how this would be expected to help). This collaborative partnership is often summarized as
the client serving as the expert on their life and experience, while the therapist is the expert
on the specific therapy techniques.

Basic Structure of Therapy

CBT sessions on an outpatient basis are often held weekly and last 50–60 minutes. When
therapists adhere to standard, evidence-based protocols, the course of treatment is typically
no longer than 15 sessions. However, the length of treatment may be more variable in routine
 Cognitive Therapy and Cognitive-Behavioral Therapy 155

clinical practice, or when a client has complex or multiple presenting problems. Depend-
ing on the specific concerns and types of interventions that are being used, the frequency
and duration may increase (e.g., exposure therapy for OCD often involves twice-weekly
90-minute sessions). CBT is also commonly available in higher doses in condensed formats
such as in intensive outpatient programs, involving several hours weekly for several weeks
(Öst & Ollendick, 2017) or in residential programs that involve additional opportunities
for guided practice and wraparound supports (case management, family therapy, coaching
outside of scheduled sessions, and other resources that align with the goals of CBT).
Most types of CBT involve working directly with the client for at least part of the ther-
apy, although when it is determined that they may be helpful, family members may be asked
to participate. This is particularly likely when working with pediatric clients or addressing
patterns of interaction in the home that may have perpetuated the client’s difficulties. For
example, a family system that has accommodated a patient’s anxiety by completing daily
tasks for them so that the patient avoids discomfort (e.g., making phone calls or running
errands so that the client does not need to do so) may be included in sessions to learn why
certain practices are unhelpful over the long term. Actually, this prevents the client from
learning that avoidance is counterproductive and not necessary (“It didn’t go as badly as I
expected; the clerk approached me asking if she could help find something, so it wasn’t that
hard to ask for what I needed”). They also may be involved to support their family member
in skillbuilding and practice. In pediatric samples, some cognitive-behavioral treatments
involve working primarily or exclusively with the parent(s) or caregiver(s), depending on the
client’s capacity and/or willingness to engage. CBT-oriented group therapy models also have
demonstrated effectiveness in treating a wide range of concerns (depression, social anxiety,
OCD, insomnia, chronic pain, medication adherence; e.g., Selles et al., 2018).
Each therapy session is typically structured using an agenda that is collaboratively set
between the therapist and client. The rationale for using an agenda is explained to the cli-
ent at the outset: The agenda allows the session to focus on the most important and time-
sensitive issues, and enables the client and therapist to examine new issues in the context
of the overall problems and goals that have been identified. This process keeps therapy on
track and helps prompt client and therapist to continually review homework and connect
individual examples to larger themes, instead of “bouncing around” in a manner that is less
likely to result in the generalization of skills. When a client adds items to the agenda, this
reinforces the client’s active role in therapy and conveys the value of their opinions, needs,
and priorities. Mood checks also are routine in CBT and help to promptly identify the most
salient issues (e.g., if sadness or anxiety is rated on a particular day as 10/10, exploring and
addressing this would become an agenda item).
In CBT, client feedback is routinely elicited during each session and incorporated into
the therapy. Feedback may include any questions or concerns about therapy, responses to
difficult moments in therapy, and aspects or elements of therapy that the client finds either
more or less helpful. The purpose is to regularly assess and identify problem areas that
may interfere with the therapeutic process, and promptly attend to and address these con-
cerns. Obtaining and utilizing client feedback is considered to be a critical part of effective
CBT (Janse, De Jong, Van Dijk, Hutschemaekers, & Verbraak, 2017; Spielmans, Pasek, &
McFall, 2007). Normalizing the experience of talking about discomfort and disagreement,
and providing opportunities in which to constructively change course based on these experi-
ences, are viewed as a valuable aspect of the work. These processes help to keep the alliance
strong and communication clear and effective during CBT.
156 BEHAVIORAL AND COGNITIVE APPROACHES

Homework is considered critical for treatment success in CBT, as this is the process by
which skills developed in therapy become implemented and generalized to a client’s every-
day environments. High levels of homework completion are predictive of favorable out-
comes (e.g., Callan et al., 2019), and including homework early in treatment increases the
likelihood of ongoing practice. Devoting time in session to reviewing homework and associ-
ated learning, troubleshooting obstacles to homework completion or discussing reactions
to homework, providing a clear rationale for practicing in everyday life, and brainstorming
potentially helpful homework assignments collaboratively can all be helpful in enhancing
adherence to (and full engagement in) CBT. Common homework assignments might include
activity monitoring, refining the problem/goal list, reading about new skills or topics, think-
ing of potential agenda items for the next session, observing and tracking changes in mood
and accompanying thoughts and experiences, and/or practicing new behaviors in specific
environments.

Goal Setting
Regardless of the client’s presenting problem or clinical diagnosis, the overarching goal
of CBT is to reduce emotional distress by helping the person modify maladaptive beliefs
(B’s) that give rise to distress (C’s) and behaviors that are not useful for helping the person
pursue long-term values and goals. This is consistent with the cognitive-behavioral model
of emotion discussed previously, which emphasizes that it is one’s beliefs about situations,
not the situations or circumstances themselves, that cause our negative emotions. Many
clients approach therapy with the idea that their therapist will provide them with “advice”
on how to change situations and circumstances; thus, among the first procedures in CBT
is socializing the client to the idea that instead of trying to change situations (e.g., other
people’s behavior), the aim of therapy is to change how the person thinks about and
responds to such situations. It should be conveyed that this will entail the client attend-
ing to emotions, thoughts, and behaviors; learning to break experiences into component
parts in order to understand them in cognitive-behavioral terms; and constructing col-
laboratively a working conceptualization (or model) for understanding what predisposes,
triggers, and maintains the presenting concerns, and what is protective and facilitates
resilience.
Within the overall goal of changing beliefs about circumstances, each person presents
with a unique and specific set of maladaptive and dysfunctional thinking patterns (and asso-
ciated behaviors) that become targeted for therapeutic change. These specific beliefs and
associated responses are identified, then prioritized on the basis of functional assessment.
For example, if high levels of distress accompanying self-critical thoughts in interpersonal
situations are identified as the most important problem, cognitive skills may be prioritized.
If avoidance of interpersonal situations is identified as the problem, behavioral (exposure)
skills may be prioritized. Cognitions or behaviors causing the most distress interference in
functioning might become focus, although decisions about which areas to emphasize are
identified jointly between client and therapist. Often, smaller or more attainable goals are
targeted early in therapy (perhaps using behavioral strategies) in order to provide “small
wins” and reinforce experiences that help the client to gain confidence in the treatment and
their own ability to utilize these tools successfully.
Individual and cultural considerations may impact every aspect of the intervention pro-
cess, including what is considered an important goal, what is acceptable to think or talk
 Cognitive Therapy and Cognitive-Behavioral Therapy 157

about, and what acceptable methods of facilitating change may look like. An individual’s
stance toward their thoughts and behaviors may be particularly important to understand.
For example, does the client believe that thoughts reflect one’s self or values, that individuals
are “responsible” for their thoughts, or that behaviors are determined by the environment
and interpersonal context versus the individual? Individual/cultural factors influence goal
setting as well, in that the client must determine which goals and methods are palatable. In
recent years, incorporating cultural variables (e.g., spirituality) into CBT has been a major
area of development in research and clinical practice (Rosmarin, 2018). To do so compe-
tently, CBT therapists should seek out opportunities to increase multicultural awareness
(e.g., workshops, literature) and ask culture-related questions rather than make assump-
tions. As noted previously, cognitive and behavioral strategies can be modified to address a
person’s specific personal and cultural experiences (Graham, Sorenson, & Hayes-Skelton,
2013). For example, cognitive techniques that ask someone to consider the validity of their
negative thoughts may be especially challenging when thoughts are based in reality (e.g.,
experiencing bias and discrimination from others). Behavioral techniques (exposure exer-
cises for anxiety) must be determined in partnership with the client to identify relevant,
albeit challenging, exercises that are culturally appropriate and consistent with the client’s
values. Psychoeducation and treatment rationales can also be presented within a cultural
context.
Values enter into the goals of CBT, with this approach emphasizing enjoyment in life.
It is assumed that thinking logically leads to appropriate emotions that minimize emotional
struggles and maximize satisfaction with life. Importantly, appropriate emotions are not
the same thing as positive emotions, and the goal of CBT is not to feel happy all the time.
Indeed, negative emotions such as sadness, regret, disappointment, concern, and frustra-
tion are appropriate responses to certain circumstances (e.g., the death of a loved one or
the aftermath of a trauma). In CBT, appropriate and adaptive emotions are differentiated
from more intense and long-lasting negative emotions (e.g., depression, anxiety, rage) that
stifle healthy coping and can lead to impulsive or self-destructive behavior. Another value
in CBT is self-acceptance. This entails learning to be comfortable viewing oneself as fallible
and seeing one’s self-worth as separate from one’s behaviors and circumstances. One might
fail an exam, act unethically, or spend money unwisely, but this does not make him or her a
bad or poor person, merely a person who (like everyone else) has strengths and limitations,
and makes both good and poor decisions. To this end, however, it is important to note that
rather than being a tool for rationalizing undesirable behavior, CBT is a tool for thinking
rationally about it. Moreover, natural consequences of behavior are viewed as important in
guiding future thoughts and behaviors.

Process Aspects of Treatment

A summary of commonly used techniques and strategies is presented below, focusing on (1)
providing psychoeducation; (2) conceptualizing the case; (3) conducting behavioral experi-
ments; (4) identifying, evaluating, and modifying automatic thoughts; and (5) addressing
core beliefs. The items below summarize various cognitive techniques but by no means
comprise an exhaustive list. Although technically classified under the umbrella of CBT,
approaches including exposure-based strategies, operant strategies, behavioral activation,
skills training (social/communication and problem solving), and relaxation strategies are
summarized in a discussion of behavior therapy by Antony et al. (Chapter 4, this volume),
158 BEHAVIORAL AND COGNITIVE APPROACHES

and mindfulness and acceptance strategies are summarized by Masuda and Rizvi in a dis-
cussion of third-wave cognitive-behaviorally based therapies (Chapter 6, this volume).

Providing Psychoeducation
Psychoeducation is an important ingredient both in initial sessions and throughout treat-
ment to ensure that individuals develop a “map” or sense of how symptoms and treatment
works (and can progress). During the psychoeducation-focused initial sessions, it is typical
to focus on the following:

• What symptoms are called; what is known about how they are caused and main-
tained.
• How CBT promotes change; how this approach may be similar or different from
other forms of therapy the individual has used or heard about in the past.
• Developing realistic expectations about treatment progression and response.

Developing a deeper understanding of the symptoms and intervention approaches tends to

increase the client’s sense of self-efficacy, which is useful in this type of therapy, in that it
requires considerable initiative, hypothesis testing, and observation on the part of the client.
Psychoeducation is provided with regard to specific cognitive and behavioral strategies, and
how and when they may be used. CBT often involves helping the client practice new skills
in a high-fidelity manner that is likely to produce therapeutic effects (adaptive thoughts and
behaviors). Common adaptive thoughts developed through CBT might include “I can take
one step at a time, and use my tools to help myself cope with life stressors.” Finally, the
development of a collaborative relationship is a central focus during the psychoeducation
phase. It is during this initial phase that the client comes to understand that the therapist
will be the expert on a range of effective techniques and will serve as a “coach,” whereas
the client will act as the expert on their own life and experience and what works and does
not work for them.

Conceptualizing the Case

Case conceptualization, an active process that occurs explicitly and in partnership with
the client, is considered a tool for building curiosity and interest, and engaging the client.
This case conceptualization process, which suggests pathways for reaching intermediate
and ultimate goals, can lead to greater understanding of difficulties and a sense of mas-
tery. Although struggles may persist, a client may feel empowered when patterns unfold in
expected ways, or become more understandable when they “hang with” other experiences.
This can help make complex or multiple problems feel more manageable. A client may iden-
tify patterns or functions of behavior (e.g., avoidance of negative mood states) that may con-
tribute to multiple problems in many areas of life (e.g., substance use, problematic Internet
use, procrastination, and passive interpersonal approaches that prevent formation of close
relationships), which help all of the puzzle pieces to fit together. Core cognitive or behav-
ioral mechanisms may therefore serve as linchpins that connect a client’s primary concerns,
inform potentially efficient ways of working toward therapy goals, and guide the selection
of intermediate goals. Impasses or problems in therapy can lead to testing the “fit” of the
 Cognitive Therapy and Cognitive-Behavioral Therapy 159

conceptualization, then move forward accordingly. This fluid process of constant learning,
hypothesis testing, confirming, disconfirming, or modifying hypotheses, and revision of the
chosen strategy, is a hallmark of the cognitive-behavioral model.
Case conceptualization guides the selection, focus, and sequence of interventions, which
is helpful given that the number of CBT interventions is large and continuously expanding.
It also fosters clients’ understanding of what they are doing, clarifies the need for change to
produce a different outcome, and provides a clearer therapy focus and rationale for making
particular choices at particular times. Creating shared conceptualizations in a clear and
explicit way helps the client fully participate in making decisions about prioritizing the goals
and tasks of therapy. It also can be used to anticipate challenges, obstacles, or upcoming
targets for which it would be helpful to be prepared. For example, a client may state: “It’s
going to feel helpful for my mood to become more active again and go back to working a
regular schedule . . . but it’s likely that as soon as I start, I’ll start experiencing more anxiety
triggers as I start to get new assignments.”

Conducting Behavioral Experiments

It is useful to distinguish between several types of thoughts that are recognized as meaning-
ful within CBT. Immediate thoughts (or automatic thoughts) can influence the conclusions
that individuals draw from situations and inform behavior. Automatic thoughts may be
informed by underlying assumptions, which can take the form of operating principles or
generalized rules about how things work (“If I make the wrong decision, the results will be
awful”). Underlying assumptions and core beliefs form part of the schema system. Schemas
are “deeper” cognitive structures (e.g., the “world-as-dangerous-place” schema, the “per-
fectionist” schema) that include emotional, physiological, sensory, and behavioral compo-
nents. Schemas may systematically bias the types of information that individuals attend to,
store, and retrieve from memory (e.g., selectively attending only to mistakes, or focusing
on past successes). Underlying these may be core beliefs, which are understood as lasting
and global beliefs about oneself, others, and the world or how it operates. Another class of
beliefs that may maintain emotional disorders is metacognitive beliefs (Wells, 2000), beliefs
that individuals have about their own thoughts (e.g., “Worrying is dangerous and uncon-
trollable”). Understanding the difference between these types of cognitions is necessary,
because although a core belief may maintain distress, psychotherapists search for specific
beliefs and ideas for the client to test empirically using behavioral experiments.
Behavioral experiments are planned experiential exercises that are completed for the
purpose of directly testing a specific cognitive formulation of a problem (e.g., “I won’t know
what to say and it will be terribly awkward”). Their primary purpose is to test a specific cog-
nition directly through observation. The approach used in behavioral experiments follows
the scientific method in that “if this theory is true, then I would expect X to happen.” If the
theory’s predicted outcome does happen, the client may conclude that the theory is some-
times or often true. If the theory’s predicted outcome does not happen, the client is invited
to consider new information and test a new theory that may be more accurate or helpful.
This process may help to test the validity of the client’s existing beliefs about themselves,
others, and the world, then to subsequently construct new adaptive beliefs and/or behavioral
responses. By participating in behavioral experiments either in session or between sessions,
the client learns to test and verify their cognitive formulations, as well as to undertake
160 BEHAVIORAL AND COGNITIVE APPROACHES

new behaviors likely to be effective. As observed by Bennett-Levy et al. (2004), behavioral

experiments are a direct result of behavioral therapy’s findings that doing something differ-
ently can be a powerful tool in changing cognitions and emotions.

For example, Everett may use a behavioral experiment to answer the question: “If I
prepare for a test imperfectly, and do not answer every practice problem, will I fail (as
my existing belief would predict) or will I just feel anxious (an alternative theory)?” To
test his theory, Everett may choose to skip every fourth practice problem or violate the
conditions of the thought in some tolerable way. This will involve completing his study-
ing rather differently than he ordinarily would; typically, he would feel anxious and
“not ready” for the test if he could not answer even a single practice problem. The belief
that he will not perform well on a test unless he can “ace” every problem has been prob-
lematic for Everett; it has caused him anxiety and motivated him to stay up very late
during the week before exams, meticulously completing practice problems even when
professors specifically recommended studying using other materials and in other ways.

On the surface, behavioral experiments may sound similar to the technique of exposure
in behavior therapy. There are similarities between these approaches; however, exposure
therapy aims to change behavior consistently in a manner that changes the response to the
experience (e.g., reduction in pathological fear or change in reinforcement value of a behav-
ior). Behavioral experiments are used specifically to check the validity of thoughts, expecta-
tions, and beliefs, and potentially develop new operating principles and beliefs (“This situa-
tion is not actually dangerous”; Bennett-Levy et al., 2004).

Identifying, Evaluating, and Modifying Thoughts

Cognitive-level interventions are used when therapists aim to directly address cognitive pro-
cesses rather than target these indirectly via behavioral-level or emotion-level interventions.
Targets in cognitive-level interventions may include biases in attention and memory, mal-
adaptive interpretations of events, or core beliefs that may be maintaining distress and inef-
fective behavioral responses. Cognitive-level interventions may include increasing the client’s
awareness and identification of thoughts, beliefs, or interpretations (using self-monitoring
tools such as thought records). When bringing awareness to specific thoughts that may not
be helpful, the distinction is sometimes made between “cold” thoughts and “hot” thoughts
(Greenberger & Padesky, 2016). Cold thoughts (“My friends aren’t here yet”) are relatively
neutral and do not elicit a strong emotional response. Hot thoughts (“No one likes me; I’m
all alone”) elicit strong emotions. Identifying hot thoughts can help to uncover aspects of
the pathological patterns of thoughts, emotions, and behaviors that are troubling the client.
Another cognitive-level intervention involves challenging negative automatic thoughts or
core beliefs by reevaluating thoughts and developing more adaptive alternative explanations
(labeled cognitive restructuring). An additional type of cognitive-level intervention entails
using mindfulness and acceptance (third-wave) strategies to increase tolerance of unwanted
thoughts and painful emotions. Table 5.2 summarizes common techniques for identifying,
evaluating, and modifying thoughts.

Addressing Core Beliefs

Once unhelpful thoughts and interpretations have been identified, clients can learn to prac-
tice alternative ways of thinking, which may be more useful (and certainly less distressing).
  Cognitive Therapy and Cognitive-Behavioral Therapy
TABLE 5.2. Techniques for Identifying, Evaluating, and Modifying Automatic Thoughts
Technique Description
Socratic •• Therapist uses open-ended and
questioning brief questions in a nonjudgmental
fashion (rather than statements)
to help the client discover his or
her own idiosyncratic thoughts,
feelings, and behaviors associated
with a particular situation.
Dysfunctional beliefs are
ultimately exposed and can then be
challenged.
Role playing •• Therapist and client reenact
or enact an anxiety-producing
situation in the office so the client
can practice, better understand the
situation and his or her reaction
to it, reflect on his or her actions,
and consider how to respond to
situations more effectively in the
future.
Monitoring •• Client records (1) relevant
thoughts aspects of the situation in which
a shift in emotions occurred,
(2) the interpretations/thoughts
themselves, (3) emotional and
physical responses (often rated
0–100 to estimate intensity).
Identifying •• Client observes and documents in a
cognitive systematic manner certain common
distortions types of unhelpful or maladaptive
thoughts, to become more aware
of the link between thoughts and
emotions.
Examining •• Client begins to observe that
evidence for and thoughts may not be 100%
against automatic accurate and are subject to biases,
thoughts practices treating thoughts as
testable hypotheses, and attends
to evidence for or against the
thought (or the consequences of
the thought). Client distinguishes
between irrational thoughts and
rational perspectives so they can
begin to cultivate a more rational
and balanced perspective about the
self and the world.
161
Example
Client: Then he left! He just left!
Therapist: What part about leaving felt so
upsetting? What did it mean?
Client: It felt like everyone always leaves
eventually, and that this will never
change.
Therapist: Let’s begin the interview. Tell
us about your previous experience in
information technology.
Client: I’ve been working in this field for the
past five years. For the past two years I’ve
managed three employees.
Client (breaking character): I’m noticing
fears that he’ll be able to tell I’m anxious.
I need to practice focusing on listening
to the question and giving an answer,
instead of trying so hard to seem calm.
Client: So the part that felt scary to me
wasn’t where we were—it was the
much bigger size of the group that day.
I thought: “Any second now I will fall
apart in front of everyone.” I was at a
95/100 for anxiety at first.
Client: So the thought “if I make a mistake,
the whole thing is ruined” is pretty black
and white . . .
Therapist: Wow. It sounds like it’s either
perfect or terrible, with nothing in
between.
Client: That’s exactly what my thought said.
I don’t believe that 100%—that’s pretty
intense.
Client: Evidence that she hates me . . . well,
she was very distant at the event.”
Therapist: OK . . . anything else?
Client: So, it seems there is evidence she
was preoccupied or upset (and wasn’t
acting like her usual self). But I guess
I didn’t notice how she was with other
people after I had that thought, so I can’t
compare. I have evidence she was upset,
but not that it was definitely about me.
             (continued)
 162 BEHAVIORAL AND COGNITIVE APPROACHES

TABLE 5.2. (continued)

Technique Description Example

Generating •• Client is challenged to question Therapist: What other possibilities are

alternative the evidence for and against
thoughts supported an automatic thought based
by evidence on available information, use
that evident to generate a more
balanced thought that can serve
as an alternative explanation and
consider its believability, and
consider the change in the level of
their emotion in response to the
alternative thought as compared to
the automatic thought.
there?
Client: That something happened before she
got there, that something else happened at
the event (we didn’t have a confrontation),
that she was having an “off” day . . .
Therapist: Which may be more or less
likely?

Examining locus •• Client observes automatic thoughts
of control or related to whether they are fully,
responsibility partially, or not responsible at
all for a given event or outcome.
Client learns to take appropriate
levels of responsibility for own
successes as well as difficulties (i.e.,
take credit for successes and not
inappropriately blame oneself for
problems).
Therapist: You’re really feeling guilty. At
what point did you decide to try to make
her upset?
Client: OK, so I guess I couldn’t have known
how it would go in advance. . . . I didn’t
know her relationship had just ended.
Therapist: So what happened was not your
intention, and you were missing some
critical info?
Client: Yeah. Definitely not my intention. It
was terrible but not really preventable.

Examining pros •• Client lists pros and cons for each
and cons of potential solution for a problem,
solutions examines these in the context
of how practical/desirable each
solution is, determines and then
enacts a plan based on the balance
of pros and cons, and ascertains
how well the solution worked.
Therapist: Which works best?
Client: Well, first I thought I’d go straight to
my boss, but that is more risky depending
on whether he agrees. Starting with
gathering more information would have a
slower but safer result.

Importantly, the goal of identifying alternative thoughts is not to find happy, positive inter-
pretations—just thoughts that are more realistic or more likely to be helpful in deciding on
an effective next action. At times, the thought itself (e.g., “I’m going to get in trouble”) is
true, but the consequences of the thought (“I’ll be fired on the spot!”) are distorted. When
learning about a client’s interpretations, patterns often emerge—the client can then learn
what these individual events have in common. The therapist may notice an unhelpful core
belief, often identified using Socratic questioning. Another way to uncover core beliefs is to
use the Downward Arrow technique, which involves asking a series of “if–then” questions,
each assuming that the client’s previous statement is true. For example, the therapist might
ask versions of the questions “If that were true, what would that mean?” to help a client
travel from the specific prediction “They’ll judge me for being nervous” to the more general
and deeply held core belief “I won’t ever be accepted.” There are different schools of thought
within CBT about the importance of modifying core beliefs for a given client, and when/
how this might occur. As seen in Table 5.3, clients are often able to identify general themes
or core beliefs such as “The world is dangerous” or “Making mistakes is unacceptable.”
 Cognitive Therapy and Cognitive-Behavioral Therapy 163

TABLE 5.3. Linking Negative Automatic Thoughts to Core Beliefs

Client’s negative automatic thoughts Core beliefs
“My daughter isn’t picking up her phone; she must have
been in an accident.” “The world is dangerous.”

“If I’m late for the meeting, there will be an awful “Disaster could strike at any moment.”
consequence.”

“We’ll lose all of our money in the stock market.”

The client may also be able to provide evidence for these thoughts, or identify when in
the course of their experiences these lessons were learned (“No matter what we did, my dad
kept hitting us”). These reactions can be validated as part of the client’s experience, even
while recognizing that their interpretation may not fit every situation in which it is elicited,
or that responding as though it is factually true may not always be helpful. Helping a client
to observe that these general thoughts (core beliefs) may not always fit the specific contexts
in which they occur can be a useful step; individuals can then learn to observe relevant fac-
tors about their present-moment context that can inform their approach to thinking about
or responding to a situation.

Resistance to Change
Common forms of resistance to change that are commonly noted in CBT include refusal to
participate in in-session activities, ambivalence about treatment, poor homework comple-
tion, and premature dropout. These are sometimes called treatment-interfering behaviors.
In a related vein, “stuck points” may also occur in therapy when patients have learned new
approaches but may be having a hard time letting go of old ways of responding to thoughts
(“I know it’s not rationally true but it’s still freaking me out, so it feels true”). The client may
directly or indirectly resist the idea of interpreting or responding to a situation differently,
which may indicate that the client’s readiness or willingness for change is lower than the
therapist thought (or there could be a problematic core belief impacting therapy). Some core
beliefs (e.g., “No one cares about me” or “My needs will never be met”) may be activated or
impact the therapeutic relationship itself (Prasko et al., 2010); the client may appear skepti-
cal or guarded, oppositional, or fearful of abandonment by the therapist. The client may be
able to use similar cognitive-behavioral practices to give voice to the thoughts and action
urges associated with their resistance, such as “I feel nervous; I have the thought that if I’m
successful, everyone will expect too much of me. It makes me want to stop trying.” Moti-
vational interviewing (MI) (collaboratively exploring intrinsic readiness for change to build
motivation) and principles of mindfulness and acceptance (including shifting focus from
working toward a “goal” to moving toward one’s values) are both described below, and may
be useful when exploring why and how a client might choose to continue despite feelings of
ambivalence, stuck-ness, or discomfort.

Technical Errors
Because CBT approaches have been manualized thoroughly, one common and serious tech-
nical error that therapists can make is being guided by a manual instead of the working
164 BEHAVIORAL AND COGNITIVE APPROACHES

conceptualization for a specific client. For example, breathing exercises may be presented in
a manual for panic disorder before the client learns to recognize exaggerated, catastrophic
thoughts, but if your client discontinues therapy after Session 3 due to overwhelming fears
that “I’ll never be able to do this; the panic is too strong,” learning breathing approaches
first may not have been helpful (particularly if cognitions were not attended to thoroughly).
Inadequate attention to the model or to the mechanisms underlying the treatment is another
common error that can result in clients feeling less trust in and efficacy about the process.
Poorly designed interventions can reinforce the connection between the antecedent and
the consequence. In addition, clients may sometimes expect results without practice. For
example, because the CBT model makes sense and clients see how a new approach could
help, they may expect to automatically think differently without having to sort through a
situation, address specific thoughts that get in the way, and respond with effective behaviors
(e.g., breaking the problem into small steps instead of avoiding it). Homework is essen-
tial for providing this practice and is associated with symptom improvement, so neglecting
or ineffectively integrating homework into therapy is considered a serious technical error
(Haarhoff & Kazantzis, 2007). Finally, it is critical to indicate to a client when their cur-
rent behaviors and engagement in CBT are not consistent with existing data on symptom
remission, and when improvement would not be expected (e.g., for a depressed client who
is participating in cognitive exercises in session but not increasing scheduled activities and
continuing to isolate in their room). Failing to do so is another common error.
Medications are commonly used in combination with CBT interventions. Generally,
studies find more favorable long-term results for combined treatment than for medications
alone. It is hypothesized that learning developed during CBT may reduce risk of symptoms
returning in the future, whereas a medication may lose its effect when it is discontinued. It
is helpful for the therapist, psychiatrist, and client to collaborate and ensure that the use of
medications does not become a “safety behavior,” and that the client’s beliefs about medi-
cations are accurate and not likely to adversely impact aspects of treatment adherence. For
example, the thought, “This is just a reminder that something is wrong with me,” may be
associated with lower medication adherence relative to “I can’t control it 100%, but this is
an extra support for my mood.” Cognitive therapy techniques are commonly employed in a
range of populations to increase medication adherence.
CBTs increasingly have become more integrated with other EBTs, particularly MI tech-
niques and third-wave approaches emphasizing mindfulness and acceptance (Hayes & Hof-
mann, 2018). Due to the emphasis on change (both cognitive and behavioral), it is common
to encounter ambivalence, and to employ MI techniques in the course of CBT interventions
(Arkowitz, Miller, & Rollnick, 2015). MI, a collaborative conversation focused on build-
ing rapport and addressing ambivalence about changing behavior, draws out clients’ own
ideas about change and strengthens their motivation for and commitment to change. MI
“rolls” with resistance rather than confronts clients and emphasizes clients’ autonomy and
self-efficacy by noting they have the capacity to define the problem, develop solutions, and
change current behavior to lead them toward values and future goals. As another example
of integration, Twohig and colleagues (2015) provide a model for integrating acceptance and
commitment therapy (ACT) with exposure and response prevention (ERP). In this approach,
the integration between the two approaches takes place at all stages—preparing, selecting,
setting up, and concluding exposure exercises.
CBTs have been integrated with one another as well. For example, the UP, developed to
be applied to a broad range of emotional disorders, combines elements of behavioral therapy,
 Cognitive Therapy and Cognitive-Behavioral Therapy 165

cognitive therapy, and mindfulness. It is a transdiagnostic adaptation of CBT developed for

individuals diagnosed with anxiety disorders, depression, and related disorders (referred to
as emotional disorders) created by Barlow and colleagues (2017) at Boston University. This
transdiagnostic treatment targets the core features that maintain multiple disorders, thereby
simultaneously reducing symptoms across comorbid conditions instead of sequentially tar-
geting symptoms of different disorders. The overarching goal of the UP is to help clients
learn new ways of responding to uncomfortable emotions, which in turn reduce symptoms
across a range of problems. Goal-directed, relatively brief, and present-focused, the UP has
been used to treat many disorders (e.g., panic, social anxiety, obsessive–compulsive, gen-
eralized anxiety, posttraumatic stress, anxiety not otherwise specified, major depressive,
persistent depressive, bipolar, borderline personality, eating) and problems (e.g., suicidal
self-injury, primary insomnia). Barlow and colleagues propose that the UP has three cen-
tral components: modifying antecedent cognitive appraisals; preventing emotional avoid-
ance; and facilitating opposing action tendencies when the dysregulated emotion arises (i.e.,
encouraging dysregulated clients to behave in a manner congruent with effective behavior
rather than their current emotion). The treatment includes standard emotional exposure and
mood-induction exercises, tailored to the specifics of a given patient’s presentation.

THE THERAPEUTIC RELATIONSHIP AND THE STANCE OF THE THERAPIST

One common misconception about CBT is that the focus on techniques indicates a lack
of attention to, or underemphasis on, the therapeutic relationship. Increasingly, empirical
attention has been paid to the therapeutic alliance in CBT. CBT therapists argue that a
strong alliance is essential if they hope to bring about problem identification, change behav-
ior, and approach rather than avoid/escape their clients’ discomfort. For clients to learn,
practice, and utilize CBT tools independently, they must develop trust in the therapist, expe-
rience safety and the potential value in the therapy and the techniques employed, be hon-
est about successful and less successful moments, and perceive the therapist as authentic
and empathic. Because a primary goal is learning, the therapist must strive to cultivate a
curious, engaged, and nonjudgmental stance in their clients, in part by modeling empathic
acceptance and encouraging authentic engagement with the therapist as an imperfect per-
son. As noted earlier, a collaborative therapeutic relationship that frames both the therapist
and the client as learners is emphasized, with the therapist being a credible “coach” who
is knowledgeable about CBT techniques, and the client possessing knowledge about their
life and experience. The therapist becomes known to the client as a person, with a distinct
perspective on and predictable approaches to problems, which can become internalized by
the client. A typical exchange may sound like the following:

Client: You’ll never believe what happened at the party—you would have loved it.
Therapist: I do appreciate learning moments and approaching discomfort . . .
Client: Oh, I know. When I got there, David opened the door—you know he makes
me incredibly anxious. I had to say hello to him right away and make conversation,
or it would have been completely awkward. So instead of the big goal for the night
being to have a miniconversation with him, I had to do it instantly! I could hear us
practicing in my head, so I just jumped in and did it.
166 BEHAVIORAL AND COGNITIVE APPROACHES

Self-disclosure is often employed (although with variable frequency by therapist); it is

not problematic in CBT for the client to know their collaborator as a person. Self-disclosure
may help to build trust; normalize and validate the client’s experience; or indicate that dis-
tress and discomfort are normal, make sense in context, and are experienced differentially
by people. It is essential that CBT therapists are their authentic selves in session, as the ther-
apy employs such a collaborative and engaged style. This role leaves little room for attempts
to “do CBT correctly” in a single specific manner; this would be perceived as disingenuous.
As a result, cognitive-behavioral therapists exhibit a range of personal styles depending on
their individual personalities. Whereas all should be engaged with their clients, they may use
humor, sarcasm or irreverence, gentleness, warmth, and other characteristics to different
degrees. The regular provision of feedback relies on the therapist’s honesty and the client’s
perception of the therapist’s genuine connection to and investment in the client’s well-being.
Clinical skills and therapist characteristics considered essential for advanced CBT practi-
tioners to develop include flexibility and willingness to learn and adapt interventions in
response to client needs and feedback, ability to build and maintain strong alliances along
with hope and motivation for change, familiarity with cognitive and behavioral skills and
specific knowledge pertaining to certain presentations, and the ability to negotiate obstacles
and setbacks in treatment.
Several approaches are employed to assist with the creation of a therapeutic alliance
and the degree of partnership that is desirable in CBT. Collaborative empiricism describes
learning from and working jointly with a client to understand the presentation of symptoms
and problems, along with designing approaches to test potentially problematic or unhelpful
interpretations (negative automatic thoughts, schemas, core beliefs). Guided discovery, a
key component of collaborative empiricism, involves the therapist adopting a genuine, non-
judgmental, and curious stance, and asking a series of strategic questions to guide patients
through their own thoughts and experiences (Beck & Dozois, 2011). Importantly, guided
discovery involves the therapist not knowing the “correct” answer in advance or intending
to change the client’s mind in a particular way. The goal is for the therapist to understand
the client’s view of things (their experience and cognitive processes) more fully and bring
attention to potentially relevant aspects of the situation that may not have garnered much
of the client’s attention previously. This stance leads to a very active, engaged client. This
process of gathering data, looking at the data in different ways with the client, and inviting
the client to devise their own plan for what to do with the information that arises, ensures
that the client’s conclusions and gains are owned by the client and not the therapist. This
approach aims to help the client foster their own curiosity about the process of CBT and
increase intrinsic motivation to actively pursue therapeutic goals, and conceptualize and
devise action plans to address the problem using the skills he or she is developing.
Cognitive-behavioral therapists often state as an explicit goal of treatment that clients
will be able to “be their own therapist” after treatment and will not need to meet with
the therapist indefinitely; successful terminations after symptom remission and increases
in quality of life are common practice in CBT. As a result, the client is both responsible for
bringing about the change and empowered to maintain these changes after the termination
of therapy. The therapist gradually becomes less directive over time and relies on the client
to lead and practice selecting and using skills and tools, which enables termination of treat-
ment to feel like a natural progression of the client’s independence. Relapse prevention skills
become an explicit focus later in treatment, in order to anticipate potential challenges and
prepare the client to cope effectively. Following termination, the use of “booster sessions”
 Cognitive Therapy and Cognitive-Behavioral Therapy 167

is common to ensure maintenance of progress and address any challenges that may occur
in effectively utilizing skills. Also, it is clearly conveyed that a client is welcome to return to
therapy at a later point to address a new challenge or maintain accountability.
Countertransference, or the therapist’s emotional response to the client, is a funda-
mental component of CBT, although the term is not part of the common language (Prasko
et al., 2010). For example, it may be observed in the course of CBT in the form of feed-
back or Socratic questioning to explore underlying processes. The therapist and client are
both invited to acknowledge difficult moments, comment on the process in the therapy
room, observe shifts in affect or tone, or name emotions or thoughts. Examples may include
“What just changed? I noticed a shift in your expression” or “I notice myself feeling very sad
after hearing your interpretation of what happened.” Countertransference is also evident
when the relationship with the client activates automatic thoughts and schemas in the thera-
pist that in turn influence the therapeutic relationship and process (Vyskocilova, Prasko,
Slepecky, & Kotianova, 2015). The therapist is expected to use CBT techniques to modify
such countertransference responses and in the process also assist the client. Countertransfer-
ence reactions can be used as valuable information about the client’s interpersonal relations.
As in any therapy, ruptures in the therapeutic relationship may occur. In CBT, this may
happen when a therapist inadvertently misunderstands a client, a conceptualization misses
the mark, a therapist forgets key information, or a carefully devised plan goes poorly. At
times, strain in the relationship may occur if a therapist over- or underestimates a client’s
current abilities. The treatment’s overall objective of learning and adaptation to one’s envi-
ronment, with mistakes and “bumps in the road” considered normal, can be useful in these
moments. These instances become opportunities for the therapist to acknowledge making
a mistake or their role in inadvertently causing pain for the client, striving to understand
miscommunications or sources of the rupture in the alliance, and empathizing with the cli-
ent. The focus may then shift to repairing the alliance by using listening skills to address
the client’s engagement/disengagement in therapy and empathically relating to the client’s
response in a way that is validating. The rupture may be used as a collaborative oppor-
tunity to reconsider the case conceptualization and treatment plan, and to realign shared
goals if it is determined that the rupture reflects the client’s difficulties. In this manner,
the therapist can directly address the problem, recognizing and acknowledging their own
contribution to the problem and encouraging the client to do the same (Castonguay, Con-
stantino, McAleavey, & Goldfried, 2011).

CURATIVE FACTORS OR MECHANISMS OF CHANGE

In CBT, the mechanism of change involves systematically and strategically targeting dys-
functional interrelations among thoughts, emotions, and behaviors. The “cognitive appraisal
model” of CBT assumes that the mechanism of action is a change in dysfunctional assump-
tions and core beliefs toward a more rational and evidence-based orientation, which in turn
reduce distress and enable learning and practice of helpful behavioral responses (Arch &
Craske, 2009). This is the precise nature of insight that is developed and hypothesized to
be required for symptom remission. These observations and insights are employed directly
as tools for creating change, by applying this new information to infer what more effective
responses (cognitive or behavioral) may look like. Clients learn about how negative cogni-
tions and information processing biases shape emotional experiences, specifically, thoughts
168 BEHAVIORAL AND COGNITIVE APPROACHES

about the self, the world, and the future. Clients learn to (1) identify patterns of distorted
or biased thoughts, (2) develop new skills to challenge or evaluate these cognitions (nor-
malize the experience of having negative thoughts and associated emotions, interpreting
thoughts as testable hypotheses instead of as facts) as a means of reducing emotional dis-
tress, and (3) reduce maladaptive behaviors and increase adaptive behaviors. For example, a
depressed individual may learn skills to notice the negative thoughts (e.g., “I won’t have any
fun anyway”) that result in avoidance of previously enjoyed activities such as spending time
with friends. Gradually reengaging with key sources of reinforcement and reward provides
conflicting information and more adaptive thinking (e.g., “I almost always have negative
thoughts and predictions before I leave the house; but in my experience it doesn’t mean I’ll
hate it when I get there. The most stressful part is before I leave home”).
To facilitate changes in behaviors and related cognitions, behavioral experiments are
often used to utilize a client’s own direct experiences to challenge and disconfirm cognitions
(often, behavioral experiments are challenging predictions and expectations about what will
happen if the client completes a new or frequently avoided behavior). Generally, this process
involves planning (what specific belief or prediction is being tested?), experiencing (typically
completing a new behavior, or completing a behavior in a new way), observing (what hap-
pened?), and reflecting (making sense of what happened, reflecting on implications about
the original belief). Given evidence that individuals selectively attend to specific stimuli or
aspects of the situation, these attentional biases may need explicit attention by cuing the
patient to attend to other aspects of the experience. Mindfulness skills (see detailed coverage
in Masuda & Rizvi, Chapter 6, this volume) may be particularly useful in noticing what/
how one observes and what may be helpful or unhelpful about these patterns. By increasing
the client’s completion of new or target behaviors, it becomes possible to modify environ-
mental contingencies or change the relation between the environment and behavior. Specifi-
cally, there may be increased reinforcement for helpful behaviors, and (we hope) decreased
reinforcement for unhelpful behaviors. In this way, clients are able to learn to engage in new
behaviors, which are then reinforced and maintained by the environment.
Cognitively, clients who engage in behavioral experiments are observing and apprais-
ing these new experiences, which ostensibly results in changes in their relation with internal
experiences previously evaluated to be problematic or dangerous. With time and practice,
clients develop more accurate appraisals of triggers, emotions, and thoughts, as well as
increase their acceptance of bodily sensations. Regardless of the strategy used, CBT prac-
tices deemphasize initial cognitions/body experiences and reduce behavioral avoidance and
reactivity. At times, the conceptualization may reveal a skills deficit; clients may engage
in a maladaptive behavior because they do not yet know how to engage in a more effec-
tive response. Examples include “blowing up” at a friend or family member due to lack of
practice asserting one’s needs calmly, avoiding parties due to lack of practice/skill making
small talk and fears of being judged as “weird,” continuing to use substances due to dif-
ficulty saying “no,” or having difficulty reading social cues and using nonverbal cues that
signal interest and engagement to others. Common skills deficits explicitly addressed in
CBT relate to emotion regulation (aiming to downregulate or tolerate emotions), social
interactions (including assertive communication), and problem solving. Therapists may help
clients examine behaviors that are not functioning well, identify opportunities to respond
differently, and suggest which approaches may be most helpful. Behavioral skills training
typically proceeds from assessment (via observation, tracking, or role plays) to instruction
of the skill (including breaking it down into smaller steps, discussing it in a more didactic
 Cognitive Therapy and Cognitive-Behavioral Therapy 169

fashion, modeling or role playing, practicing in artificial settings, providing feedback, and
“road testing” in real-life situations). Continuing to practice in everyday situations is consid-
ered essential to promote generalization of skills and willingness to use them.
As summarized earlier, a good therapeutic relationship is necessary but not sufficient
for achieving changes in a client’s behavioral or cognitive response. Techniques are valu-
able in and of themselves. For example, CBT delivered via Internet courses with minimal
therapist contact (called iCBT) has demonstrated medium to large effect sizes in reducing
depressive symptoms across meta-analyses (Andrews & Williams, 2015). Effective symptom
change, however, is associated with a positive therapeutic relationship (Marker, Comer,
Abramova, & Kendall, 2013). Such an alliance emerges when the therapist is viewed as a
trusted and credible source who must be viewed as helpful initially, but as treatment pro-
gresses, such a perception is not essential. The desired relationship in CBT may be somewhat
unique given that interventions tend to be time-limited, and clients must quickly implement
change, while learning and trusting that they will not always (or as frequently) need their
therapist’s participation to maintain progress or continue these practices.

TREATMENT APPLICABILITY

CBT approaches have been developed, tested, and validated for most presenting concerns,
including anxiety and major depression (Cujipers, Cristea, Karyotaki, Reijnders, & Huibers,
2016), psychosis (Hazell et al., 2016), health-related applications (e.g., chronic pain; Ehde,
Dillworth, & Turner, 2014), and others. Transdiagnostic approaches have been validated
using RCTs (Barlow et al., 2017). CBT has demonstrated effectiveness from pediatric to
geriatric samples (Wang et al., 2017; Dear et al., 2015). Therefore, a specific diagnosis or
set of symptoms is not necessarily indicative of whether a patient’s goals may be effectively
addressed. Instead, assessing relevance for CBT or ability for a given individual to benefit
has more to do with the congruence with the client’s worldview regarding well-being and
what maintains it, and the client’s willingness to participate in manner that emphasizes data
and learning (e.g., symptom and behavior tracking), breaking situations down into com-
ponent parts to understand them, and employing and testing new cognitive and behavioral
responses in challenging situations.
Behavioral therapy methods may be helpful starting points in instances that require a
different set of behaviors to improve functioning or alleviate distress (e.g., depressive symp-
toms, including isolation to one’s room), whereas cognitive methods may be optimal when
the rationale for current effective behaviors is described as related to one’s interpretations of
the self, world, or future. CBT may be a natural fit for clients who value “rational” respond-
ing and are amenable to collecting data, as well as actively testing new skills. Consistent
with the literature summarizing common factors associated with positive outcome in all
types of therapy (Wampold, 2015), clients who are amenable to the goals and tasks of CBT,
and are willing to participate in these behaviors consistently within and outside of session,
are most likely to benefit from this type of therapy. In addition, this active and collaborative
approach may be a good fit for individuals who value proactive and shared approaches to
solving problems. Critically, clients also must be interested in learning and testing struc-
tured, concrete skills that they can readily utilize in their everyday lives, so it may be use-
ful to equate CBT to another set of skills that the patient has learned and mastered in the
past (e.g., learning to play an instrument, or training for an athletic event). Interpersonally,
170 BEHAVIORAL AND COGNITIVE APPROACHES

a client who is willing to collaborate actively, flexibly, and honestly with the therapist is
often well served by CBT. Although CBT involves structured techniques that have been
summarized in numerous manuals, rote or rigid approaches to treatment (vs. developing a
personalized conceptualization with the client that guides flexible selection of targets and
intervention strategies) may result in reduced treatment benefit.
Although CBT is transdiagnostic by nature and has been adapted for many presenting
problems, some presentations pose challenges for this approach. For example, individuals
who engage in harmful behaviors may require additional support outside the framework of
CBT (e.g., substance use, eating disorders, and active self-harm). Sometimes stabilization
is required before initiating CBT, and CBT can be used in conjunction with other inter-
ventions (e.g., detoxification, refeeding, crisis management, pharmacotherapy). Given the
active and verbal nature of CBT, individuals with difficulty summarizing their experiences
verbally or abstractly may find participating in CBT exercises to be challenging.
For clients from diverse cultural backgrounds, CBT employs some underlying assump-
tions likely to be beneficial, as well as some potential limitations (further described in several
excellent sources; e.g., Hall & Ibaraki, 2016; Hays, 2009). For example, CBT emphasizes
assertiveness, personal independence, behavior change, attention to thoughts, and rational-
ity, which may clash with cultural beliefs that prioritize subtle communication, interdepen-
dence, acceptance, nonlinear types of cognitive processing, and a spiritually oriented world-
view (Jackson, Schmutzer, Wenzel, & Tyler, 2006). In addition, emphasis on one’s personal
history may neglect collective experiences of individuals who share a cultural background
that informs their experiences and behaviors. Efforts to define culturally responsive CBT
have resulted in practices that take into account both the individual and important family
or community systems, emphasize culturally respectful behavior (perhaps connected by one
of the ADDRESSING influences) to inform agentic change, and attend to culturally related
as well as personal strengths and supports. Modifications to the assessment phase that take
a slower and less directive stance may be considered, as well as enabling the client to have
control over whether or how they share information that may reflect negatively on their
family or culture. In addition, culturally responsive CBT emphasizes attending to internal
(to the client) versus external (pertaining to the situation) influences, informed by cultural
factors, which define the client’s situation (potentially including experiences of oppression
and minority stress) as well as options for responding (Bedoya, Dale, & Ehlinger, 2017;
Hays & Iwamasa, 2006).
CBT approaches have been empirically supported and utilized in numerous applica-
tions for general health care, including insomnia, smoking cessation, medication adherence,
management of chronic pain, weight loss, change in health behaviors (modifying diet and
activity level), and others (e.g., Sperry, 2009). Behaviors and cognitive appraisals pertaining
to specific health conditions and experiences become the focus of such interventions. For
example, CBT is now the first-line approach for insomnia (labeled CBT-I; Trauer, Qian,
Doyle, Rajaratnam, & Cunnington, 2015). Interventions modify unhelpful cognitions per-
tinent to sleep, such as “I’m never going to be able to function tomorrow.” More realistic
appraisals, such as “This isn’t ideal, but I’ve functioned at work with little sleep many times
before” or “This may be uncomfortable, but one night of poor sleep won’t hurt me long
term,” may reduce distress and facilitate sleep. Ineffective behaviors (inconsistent sleep and
wake times, napping to “catch up”) are identified and modified. CBT also has become a
common psychological treatment for low back pain, headaches, arthritis, orofacial pain,
fibromyalgia, and pain associated with cancer and its treatment. The goals of CBT for
 Cognitive Therapy and Cognitive-Behavioral Therapy 171

pain are to reduce psychological distress and improve physical and role function by helping
individuals decrease maladaptive behaviors (avoidance of activities due to fears of increased
pain or bodily harm), increase adaptive behaviors (effective activity pacing), identify and
correct maladaptive thoughts and beliefs (“I can control or eliminate my pain if I do the
‘right’ behaviors; my pain may become unbearable unless I am constantly vigilant”), and
bolster self-efficacy for pain management (Ehde et al., 2014).

ETHICAL CONSIDERATIONS

The fact that CBT has been demonstrated to be effective for numerous populations and
presenting concerns is accompanied by some specific ethical issues surrounding (1) prac-
tice within the boundaries of one’s areas of competence and (2) attending appropriately
to aspects of identity in diverse populations. One major consideration that arises from the
broad application of CBT is the question of when to obtain consultation or additional train-
ing. CBT is employed across such a wide array of populations and encompasses so many
diverse techniques that it would be next to impossible to remain within one’s areas of com-
petence without obtaining additional training or consultation in new areas of CBT practice.
It is recommended that individuals obtain consultation when utilizing techniques with new
populations or addressing new target areas, or when employing new techniques that fall
under the CBT umbrella. In addition, the large and continuously growing literature fre-
quently refines or further contextualizes therapy approaches, so even without changes in
population or techniques, it is imperative for therapists to stay abreast of new developments
in order to practice ethically in this quickly developing area.
Due to the extensive empirical support for CBT in majority white populations, practi-
tioners may neglect to consider what is known about its effectiveness in nonmajority popu-
lations or how aspects of an individual’s identity may impact what it known about or may
be beneficial as part of a CBT treatment. For example, Stewart and Chambless (2009)
conducted a meta-analysis of 57 effectiveness studies of CBT for adult anxiety disorders
and found CBT to be beneficial across studies; however, in only six (10.5%) studies did
African Americans or Caribbean Americans of African descent make up at least 20% of
the sample, and in only two (3.5%) did Latinos make up at least 20% of the sample. A few
studies explicitly explored the efficacy of CBT in marginalized groups and tested culturally
sensitive adaptations for gay, lesbian, and bisexual clients, recent immigrants to the United
States, and others (e.g., Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015). A
new trainee, after arriving at a diagnosis of social anxiety for a new client who is an interna-
tional student at a university and identifies as gender fluid, would be ethically remiss if they
chose to administer a “standard” intervention without attending to the aspects of identity
and multicultural perspectives likely to impact the evidence base and the ethical provision
of mental health services.

RESEARCH SUPPORT AND EBP

CBT was developed and refined using empirical methods and principles, and was the first
form of psychotherapy tested using the most rigorous criteria (RCTs including active compar-
ators). CBT has consistently demonstrated efficacy in RCTs and effectiveness in community
172 BEHAVIORAL AND COGNITIVE APPROACHES

settings (David, Cristea, & Hofmann, 2018). CBT practices have changed over time in
response to refinements in the scientific literature; for example, a more nuanced understand-
ing of mechanisms underlying exposure therapy has resulted in the development of practices
that deemphasize habituation and optimize inhibitory learning (Craske, Treanor, Conway,
Zbozinek, & Vervliet, 2014). More recently, CBT has included a more transdiagnostic and
process-based approach, which links therapeutic technique to the therapeutic process and
particular client to test moderators and mediators based on testable theories (Hayes &
Hofmann, 2018). Empirical support is so comprehensive that most recent studies combine
separate trials in meta-analyses to evaluate overall outcomes of CBT. Taken together, these
studies provide a strong evidence base for cognitive-behavioral interventions. In a review of
269 meta-analyses for a wide range of psychological problems and populations published
since 2000, Hofmann et al. (2012) found that CBT was associated with higher response
rates than comparison treatments or control conditions in the majority of studies across
psychological diagnoses. In a more recent meta-analysis of 48 studies comparing CBT to
treatment as usual for anxiety and depression, CBT consistently demonstrated superiority,
with effect sizes depending on the type of comparison treatment (Watts, Turnell, Kladnitski,
Newby, & Andrews, 2015).
Meta-analysis results vary in their strength of support for CBT relative to other treat-
ments across presentations, although evidence suggests that CBT may be preferable for
depressive and anxiety disorders (Tolin, 2010). An early review of meta-analyses found
the largest effect sizes for CBT for depression, generalized anxiety, panic, social phobia,
posttraumatic stress, and childhood depression and anxiety (Butler, Chapman, Forman, &
Beck, 2006). A more recent review concluded that CBT has demonstrated efficacy as a reli-
able first-line approach for social anxiety, panic, specific phobia, generalized anxiety, post-
traumatic stress, and obsessive–compulsive disorders (Hofmann et al., 2012). With regard
to depression, although CBT appears more effective than control conditions (e.g., wait-
ing list), studies comparing CBT to other active treatments (e.g., problem-solving therapy,
interpersonal psychotherapy) have found mixed results; authors have highlighted the lack
of statistical power in many comparative outcome studies that complicate the detection of
differences (Cuijpers, 2016). CBT and medication treatments have similar effects on chronic
depressive symptoms, and several studies suggest that pharmacotherapy is a useful addition
to CBT (e.g., Hollon et al., 2014). The efficacy of CBT for alcohol and drug use disorders
has been demonstrated consistently, although there is some evidence of greater effect sizes
for contingency management approaches (McHugh, Hearon, & Otto, 2010). Meta-analyses
revealed a small beneficial effect of CBT on positive symptoms of schizophrenia (i.e., delu-
sions and/or hallucinations) as well as general functioning, mood, and anxiety, particularly
as an adjunct to pharmacotherapy (Jauhar et al., 2014). In terms of eating issues, CBT was
associated with reduced body dysmorphic disorder symptoms and body image disturbances,
and medium effect sizes were found in meta-analyses comparing CBT to control treatments
for bulimia nervosa and to pharmacotherapy for binge-eating disorder (Hofmann et al.,
2012). CBT for insomnia has consistently been shown to be more efficacious than control
treatments (Trauer et al., 2015). Results of meta-analyses of CBT for personality disorders,
however, are mixed (e.g., Cristea et al., 2017).
The efficacy of CBT has been demonstrated for both negative and positive symptoms of
psychosis. CBT is typically used in combination with pharmacotherapy, although effective-
ness has been demonstrated in medication-resistant psychosis (Burns, Erickson, & Brenner,
2014). The focus of CBT when treating positive symptoms is not to eliminate hallucinations
 Cognitive Therapy and Cognitive-Behavioral Therapy 173

or delusions; instead, the work aims to normalize symptoms and reduce the distress asso-
ciated with them, addressing problems that are caused by the emotional and behavioral
responses to them (Beck, Rector, Stolar, & Grant, 2009). When using CBT with individuals
who manifest symptoms of psychosis, the meanings associated with hallucinations and delu-
sions are typically explored using a gentle, curious, Socratic approach (Marcus & Cather,
2016). Using this method, the patient’s thoughts/hypotheses (e.g., “I am being followed
by the FBI”) can be tested rather than disputed once the patient’s own explanations of
what is happening is elicited. There has been some evidence that negative symptoms can be
impacted by under 20 sessions of CBT emphasizing beliefs and behavioral experiments, and
that changes in specific cognitions may mediate changes in negative symptoms (Staring, ter
Huurne, & van der Gaag, 2013).
The abundance of evidence-based treatment manuals for a wide range of presenting
concerns facilitates the integration of CBT research and practice. Evidence suggests that
mental health providers with relatively little experience can be trained to deliver effective
manualized CBT treatments (Wilson, 2007). Nevertheless, therapist expertise in the prin-
ciples (and underlying theories) of CBT is a relevant component of EBP, particularly because
manual-based CBT requires that the therapist individualize therapy by formulating a treat-
ment plan, actively engaging patients within the collaborative framework of CBT, and iden-
tifying and targeting specific maladaptive cognitions and behaviors (Flynn & Warren, 2014).
The American Psychological Association defines EBP as “the integration of the best available
research with clinical expertise in the context of patient characteristics, culture and pref-
erences” (American Psychological Association Presidential Task Force on Evidence-Based
Practice, 2006, p. 271). Empiricism is a defining feature of CBT, as both cognitive and behav-
ioral approaches emerged as part of a trend toward the development of scientifically driven
psychological interventions. Today, CBT is the most commonly implemented evidence-based
approach, and governmental and professional guidelines across the globe include CBT as a
recommended first-line intervention for many psychological conditions. The move toward
EBP in CBT has resulted in an effort to define and effectively teach the core competencies
(measurable knowledge base, skills, and attitudes) that lead to successful implementation
of CBT, as well as effective CBT clinical supervision. The British Department of Health has
provided a map of competencies required to deliver effective CBT for depression and anxi-
ety disorders, available at www.ucl.ac.uk/clinical-psychology/competency-maps/cbt-map.
html, and several authors have operationalized clear competencies and skill sets in CBT
(Newman, 2013; Roth & Pilling, 2008).

CASE ILLUSTRATION
Background: Presenting Problems, Treatment History,
Sociodemographic Factors
JR, a 26 year-old male, was living alone in an on-campus studio apartment and had
recently started his first year of medical school at the time of his self-referral for CBT. He
reported that he had seen a flyer for a free depression screening at the medical school, and
although he stated, “I would never ever go to that,” seeing the symptoms listed on the flyer
had helped him realize he was experiencing symptoms, including low mood and loss of
interest in activities, reduced appetite, unusual fatigue, and difficulty making decisions. JR
reported he would like to address these symptoms so that they did not interfere with his
174 BEHAVIORAL AND COGNITIVE APPROACHES

academic performance during his first semester, and so he could “get on track.” JR denied
feelings of hopelessness or thoughts of death but reported that his mind was “full at all
times” due to intense worry about being judged in social situations, making social mis-
takes, or having others notice that he is anxious (due to physical symptoms.) He reported
having anticipatory anxiety for hours before class, avoiding “optional” interpersonal situ-
ations such as going to the gym or socializing, and effortfully “forcing myself to breathe
normally so other people can’t tell I’m anxious” while spending time with others. He
reported then retreating to his apartment and spending excessive amounts of time replay-
ing and critiquing every interaction. JR reported that relatively mild interpersonal situa-
tions (e.g., choosing a place to sit in the library) had become very challenging and aversive.
JR reported feeling less anxious in the session, because it was taking place in a large office
building across town from his dorm room; thus, peers who saw him leaving campus would
not know where he was going and suspect he felt anxious or depressed. Furthermore, he
reported a reduction in his anxiety, because he felt that the session “is like problem solv-
ing, so it feels better that I’m doing something.” In the room, JR appeared appropriately
engaged with somewhat restricted affect (smiled slightly throughout the interview, which
was at times incongruent with the topic being discussed), was well groomed, with a short
haircut and neatly trimmed beard, was appropriately dressed in a polo shirt and jeans, and
was sitting with upright posture. His eye contact was intermittent; he looked down at the
floor at times while answering questions, then appeared to notice this, smile brightly, and
resume eye contact before continuing. During the interview, his speech was somewhat soft
and monotone, but his responses were logical and analytical. He reported that he had never
participated in therapy or taken medications for any mental health concerns in the past,
and had decided to seek treatment with a clinical psychologist because he did not want to
take medications that might impact his functioning at school or make him feel less alert or
“fuzzy.” Although he acknowledged that symptoms of depression were getting in his way,
his “most interfering problem” was identified as social anxiety and fear of being judged or
evaluated negatively by his peers.

Initial Assessment
A complete developmental, social, and medical history were obtained during the clinical
interview. This revealed that JR was an only child, who grew up living with both parents in
a small town. Medically, he has been healthy, and until starting medical school, he worked
out regularly at a local gym to stay fit. He described his upbringing as “comfortable but not
fancy,” and both parents had maintained regular employment within the local public school
system (his mom as a fifth-grade teacher, his dad as a coach). He had been very interested
and successful academically, but participated in few social activities in PreK and elementary
school. He attributed this in part to the fact that his family lived farther outside of town,
so it was more difficult for him to participate in playdates or extracurricular activities.
He eventually joined an afterschool soccer league and made a few lasting friendships that
became his core group of friends throughout high school. He reported struggling socially
in middle school after being bullied and teased. In retrospect, he reported that the bullying
was from one kid “who was a jerk to everyone” and that the teasing was not severe, but he
reported that this “hit me really hard” and “taught me to just play it safe to make it through
the day.” He reported that his friends were more “default friends” rather than people with
whom he shared important commonalities. His family never moved, and the schools he
 Cognitive Therapy and Cognitive-Behavioral Therapy 175

attended were relatively small, so he did not need to make new friends to adapt as he transi-
tioned to high school. He reported feeling that his peers had more friends or appeared to feel
more comfortable than he did, “but I had enough to get by.” He reported that his identity
became “the smart guy who was driven; people knew I wanted to go to med school, so I got
a pass” for things like limited social contact and attending a small commuter college near
his home “to save money for med school.” His parents were proud of his academic accom-
plishments and encouraged him to participate in more social activities, but JR declined, say-
ing he was not interested. Throughout high school and college, he only did things in which
he felt sure he could be successful.
In addition to gathering the aforementioned history via clinical interview, during the
initial assessment, a battery of objective rating scales was administered to gain a clearer
understanding of JR’s presenting concerns. His scores on the Beck Depression Inventory
(BDI) and Liebowitz Social Anxiety Scale were 23 and 64, respectively, indicating moder-
ate depressive symptoms and significant social anxiety and avoidance. Upon interview, it
became clear that his panic symptoms only occurred predictably in interpersonal situations.
Due to multiple statements that JR made describing extremely high standards for himself,
the Multidimensional Perfectionism Scale was also administered. His scores were elevated
for both self-oriented perfectionism and other-oriented perfectionism.

Cognitive Formulation
It was hypothesized that JR’s depression and social anxiety are superimposed on (and are
likely maintained by) a perfectionistic and self-critical style of thinking and behaviors
geared to keep him “safe” and to avoid making mistakes. This cautious, passive interper-
sonal approach has resulted in a lack of social practice that would provide more realistic
information about the costs of a social misstep, and help JR to feel more comfortable and
confident talking to new people. For the past several years, he has only socialized with a
peer group that he has known since childhood, so he has a lack of practice meeting and
interacting with new people. He also has a long-standing pattern of passive responding;
once others indicate social interest, he invests in the relationship (but not before). Even in
his long-standing friendships, he notices that he holds extremely high standards for others
and feels frustrated when others do not behave in the way he expects or would behave if the
situation were reversed. When this occurs, he does not “rock the boat” by bringing up dif-
ficult topics or emotions, and he avoids conflict. He tended to respond to feelings of depres-
sion and anxiety through ruminating and social withdrawal (berating himself for “failing”
by feeling this way) rather than adaptive coping or seeking a sense of accomplishment or
mastery in nonacademic settings.
JR’s current difficulties were as follows:

Current Thought Content

• “I must be no good because no one likes me.”
• “If someone likes me, they will invite me to be part of a friend group.”
• “Discomfort is bad; it means something is wrong or I’ve made a mistake. I should feel
confident and happy after starting medical school.”
• “People should treat me the way I treat them [just world].”
• “They’re going to figure out any minute that I shouldn’t be here [impostor syn-
drome].”
176 BEHAVIORAL AND COGNITIVE APPROACHES

Behavioral Coping Strategies

• Does not express own needs or desires for connection; excessively monitors and
attends to needs of others; avoids uncertainty by verifying that everyone else is happy.
• Lacks initiation/risk taking socially (very passive style). In middle school, this resulted
in only making friends with the few kids who initiated contact with him. His friend
network did not grow in high school or college due to lack of new activities.
• Fantasizes about quitting; ruminates about consequences of quitting.

Cognitive Distortions
• Black-and-white thinking
• Catastrophizing
• Emotional reasoning
• Self-worth contingent on performance
• Excessively high standards for self and others

Automatic Thoughts
• “If I make a mistake or don’t know what to do, I shouldn’t be included anyway.”
• “They must be jerks. I’m a pretty nice guy.”
• “I should never make a mistake.”
• “People will find out I’m an imposter.”

Assumptions
• “If I can ‘pass’ for being social, and no one knows I’m isolated, I won’t need to worry.
• “People should want to socialize with me and initiate friendships (because I’m a nice
person).”
• “People should know I’m a nice person without me demonstrating this to them.”
• “Discomfort is bad and means there’s a problem.”
• “If I feel uncomfortable, I must have made a mistake.”

Schemas
• “There must be something wrong with me [self].”
• “The world is stressful [world].”
• “People are not interested in me, but they should be [social relations].”

Course of Therapy
The initial aim of therapy with JR was to build rapport and develop a shared understand-
ing of current problems, and goals and the way the therapy will address these. This entailed
sharing information about depression and social anxiety, and introducing the CBT frame-
work, including the process of CBT (what will take place during sessions, what types of
homework exercises will be recommended to practice between sessions). It was reflected to
JR that his report about his anxiety in the present moment feeling lower than usual (and
attribution to thoughts that an anxiety specialist was a “safe” person) served as evidence
that his current anxiety level may be related to his thoughts about the situation.
During initial sessions, JR said it made sense that his thinking and mood were related,
but he repeatedly expressed skepticism about the idea that changing his behaviors might be
 Cognitive Therapy and Cognitive-Behavioral Therapy 177

useful “because it’s really what they’re doing that doesn’t make sense.” JR labeled the prob-
lem (his peers’ lack of meaningful interactions with him) as outside his control and driven
by factors he could not possibly determine. He expressed frustration with members of his
cohort who appeared to be forming social connections, and even after acknowledging that
a classmate who initiated study groups was more likely to have opportunities for friend-
ship, he stated, “I shouldn’t have to do anything but be myself.” Although he was willing
to monitor his thoughts, mood, and behavioral responses, he was reluctant to brainstorm
about pros and cons of potential solutions and noted he was not interested in considering
alternative perspectives.
As the semester continued, JR reported that his mood continued to worsen and his
social anxiety increased as he began monitoring who appeared to have grown friendlier
with whom. He continued to be unwilling to respond differently in his own behavior;
specifically, he refused to proactively (verbally or nonverbally) engage with his classmates,
even though waiting for others to initiate contact was proving ineffective over and over
again in various interpersonal situations. One step forward in treatment occurred when JR
acknowledged that his fears of making mistakes had been helpful in academic contexts but
that “playing it safe” was not working well in the context of his current challenges (having
to make new friends for the first time since childhood). During cognitive exercises, JR had
difficulty taking the perspectives of his peers (“I don’t know why they’re not reaching out
to me; maybe it is because I’m not talking to them, but maybe not”) or generating plausible
alternative solutions that may be useful. His attendance in therapy was intermittent when
his coursework became more demanding. JR stated, “I will always do my work first, no
matter what” and was unresponsive to the idea that prioritizing his well-being might be
valuable as well.
Ultimately, despite his conceptualization that his main problem was social anxiety,
JR was unwilling to engage in exposure therapy and unsuccessful in engaging in cognitive
exercises geared toward increasing cognitive flexibility or considering alternative thoughts
to inform his behaviors when in the vicinity of his classmates. He insisted that although
perfectionism created stress at times, “I don’t want to give it up, just in case it all goes
away.” This impasse necessitated a shift in the treatment plan. The therapist began to use
MI to elicit change talk when she noticed an opportunity to change tactics (informed by the
evidence) when JR stated, “I don’t actually need friends. The only time I need to be social
or assertive is once I’m actually a doctor.” The therapist furthered altered her approach by
incorporating some values work that helped JR observe that even if it was not important
to him if he had a social life during medical school, he believed it was necessary to present
confidently and introduce himself and his treatment plans to patients, hospital staff, and
colleagues (after graduation). JR was willing to acknowledge that this new interpersonal
approach would take practice in real-life settings to master. For several weeks, JR commit-
ted to starting his treatment plan but did not complete the homework (introduce himself to
someone while making eye contact). One week, JR reported that someone had proactively
introduced herself to him and had shaken his hand forcefully but appropriately. This left
a highly positive impression when he “saw her doing what a competent doctor would do.”
He was so impressed that for the rest of that afternoon, he had emulated this individual in
different settings around the hospital, introducing himself to people he had not yet met by
name. He reported that despite his initial discomfort, he felt highly motivated to practice
this behavior because it was in line with what he considered critical to becoming a compe-
tent and effective physician.
178 BEHAVIORAL AND COGNITIVE APPROACHES

Ultimately, this realization in treatment did not result in JR developing lasting willing-
ness to engage with others socially. JR continued to maintain rigid beliefs about the role
of his own and others’ behaviors in maintaining the current dynamic (which he continues
to dislike). However, he reported that a significant moment had involved “deciding that
this matters even aside from right now” and beginning to practice approaching others (not
because it is easy or because he believes he “should” need to, but because his job will dictate
that he do so). He went on to join two extracurricular clubs within the medical school that
provided additional opportunities to assist with patient care and practice “the demeanor
part.” In these contexts, he felt competent, which slightly reduced his avoidant behavior
with his peers. Once he was involved in regularly occurring activities outside of the class-
room, he reported feeling slightly less lonely, although he admitted that the other students
involved in the clubs did not know him well. He discontinued therapy after feeling better
“enough,” citing that he really should get back to focusing on his studies.

SUGGESTIONS FOR FURTHER STUDY

Recommended Reading
Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond. New York: Guilford Press.—
Chapter 3 covers cognitive conceptualization, including a clear and practical overview of theory
and practice with case examples.
Craske, M. G. (2010). Cognitive-behavioral therapy. Washington, DC: American Psychological
Association.—A review of relevant research and comprehensive attention to aspects of theory
(vs. practice) of CBT.
Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cogni-
tive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5),
427–440.—Summarizes research in CBT.
Tolin, D. F. (2016). Doing CBT: A comprehensive guide to working with behaviors, thoughts, and
emotions. New York: Guilford Press.—Extensive and varied case examples are included for each
topic.

Videos
The American Psychological Association (www.apa.org) maintains a series of videos on CBT skills
by Jacqueline Persons, Michael Tomkins, and Joan Davidson. Topics include activity schedul-
ing, structure of therapy, using thought records, individual case formulation and planning, and
schema change methods.
The Beck Institute for Cognitive Behavior Therapy provides videos summarizing cognitive therapy for
depression (www.beckinstitute.org).

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 CHAP TER 6

Third-Wave Cognitive-Behaviorally
Based Therapies
Akihiko Masuda
Shireen L. Rizvi

HISTORICAL BACKGROUND

Cognitive-behavioral therapy (CBT) is a family of psychosocial interventions that is widely

recognized as having the most extensive empirical support (e.g., Herbert & Forman, 2013;
Mennin, Ellard, Fresco, & Gross, 2013). CBT, when viewed in this way, is often said to have
three historical waves (Dimidjian et al., 2016; Hayes, 2004). The first wave of this tradition
came about with the dawn of behavior therapy, which emerged in the late 1950s and early
1960s as an alternative to the psychodynamic approach, the major paradigm of psychother-
apy at that time. This first wave of CBT is characterized by the application of basic learn-
ing principles (e.g., operant conditioning, respondent conditioning, and stimulus–response
[S-R] learning) to well-evaluated applied methods of behavioral change. Examples of first-
wave CBT methods include contingency management, shaping, and systematic desensitiza-
tion applied to inpatient adults with severe mental illness, outpatient children and adults
with anxiety concerns, and children with skills deficits or behavioral issues. By the late
1970s, behavior therapy had moved into the era of cognitive therapy (CT). This second wave
of CBT was marked by a new generation of methods and concepts that emphasized the role
of cognitive processes (e.g., schemas, automatic thoughts) in human conditions. Follow-
ing the philosophical worldview of elemental realism, second-wave CBT used therapeutic
methods, such as cognitive reappraisal and questioning the evidence, to identify and modify
dysfunctional cognitions that are theorized to be at the core of human psychopathology
(Beck, 1993; Hofmann, Asmundson, & Beck, 2013).
The origin of third-wave CBT as a collective movement can be traced back to the vol-
ume Acceptance and change: Content and context in psychotherapy (Hayes, Jacobson, Fol-
lette, & Dougher, 1994). At that time, the term third-wave CBT was not formally used to
183
184 BEHAVIORAL AND COGNITIVE APPROACHES

describe this movement. Nevertheless, the proponents of this movement already had expli-
cated the key themes of what would later be called third-wave CBT, such as functional,
contextual, and dialectical philosophical assumptions (Jacobson, 1997) and the synthesis
between acceptance and change in applied theory and practice (Linehan, 1994).
The arrival of third-wave CBT was officially declared by a series of writings published
in 2004. These included the volume Mindfulness and Acceptance: Expanding the Cogni-
tive-Behavioral Tradition (Hayes, Follette, & Linehan, 2004) and a seminal paper by Steven
C. Hayes (2004), “Acceptance and Commitment Therapy, Relational Frame Theory, and
the Third Wave of Behavioral and Cognitive Therapies.” These writings introduced accep-
tance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2012), dialectical behav-
ior therapy (DBT; Linehan, 1993), mindfulness-based cognitive therapy (MBCT; Segal, Wil-
liams, & Teasdale, 2013), behavioral activation (BA; Martell, Dimidjian, & Herman-Dunn,
2013), and several others (e.g., Kohlenberg & Tsai, 2007; Wells, 2009), as the members of
third-wave CBT. Of those, ACT, DBT, and MBCT are described as third wave CBTs the
most in literature (see Dimidjian et al., 2016), and will be the focus of the present chapter.
As with the case of CBT tradition, third-wave CBT methods (e.g., ACT, DBT, and
MBCT) come from different philosophical and theoretical lineages within CBT. Such philo-
sophical differences are noted even in the fact that Linehan, the developer of DBT, has never
embraced the “third wave” label, frequently stating that “DBT is behavior therapy.” Nev-
ertheless, these newer treatments do appear to share certain philosophical, theoretical, and
methodological features, as summarized by Hayes (2004):

Grounded in an empirical, principle-focused approach, the third wave of behavioral and

cognitive therapy is particularly sensitive to the context and functions of psychological
phenomena, not just their form, and thus tends to emphasize contextual and experien-
tial change strategies in addition to more direct and didactic one. These treatments tend
to seek the construction of broad, flexible and effective repertoires over an eliminative
approach to narrowly defined problems, and to emphasize the relevance of the issues
they examine for clinicians as well as clients. The third wave reformulates and synthesizes
previous generations of behavioral and cognitive therapy and carries them forward into
questions, issues, and domains previously addressed primarily by other traditions, in hope
of improving both understanding and outcomes. (p. 658; emphasis in original)

As illustrated in this definition, a distinct feature of third-wave CBT is the holistic,

contextual, and functional nature of its underlying philosophical assumptions (e.g., scien-
tific worldviews), especially when compared to those of traditional CBTs (Hayes, Villatte,
Levin, & Hildebrandt, 2011). In other words, the client’s overall functioning and presenting
concerns are understood using the framework of “behavior of a whole person in a context”
(e.g., behavior–environment interaction). Similarly, cultural factors that are relevant to cli-
ent concerns (e.g., gender, ethnicity, sexual orientation, religion/spirituality, social class) are
translated into the framework of a contextually situated act of a whole person (Masuda,
2014a, 2016). In theory, as with the case of the second generation of CBTs, third-wave
CBTs place greater emphasis on cognitive process in human conditions, such as psycho-
logical health, pathology, and behavioral change. However, their focus is on the contextu-
ally shaped function of cognition and other private events, such as feelings, memories, and
bodily sensations (e.g., the way a person relates or responds to them), as compared to the
content and frequency of these private events. For example, Segal, Williams, and Teasdale
(2013) summarize this shift in focus as follows:
 Third-Wave Cognitive-Behaviorally Based Therapies 185

Our analysis of how cognitive therapy has its lasting effects . . . suggests that this patient
would be less likely to relapse if, during the course of her therapy, she changed the rela-
tionship to her thoughts; this is, although the explicit emphasis of cognitive therapy would
be on changing the content of her thoughts through challenging them, answering them
back, seeking evidence for and against their truth value, we suggest that changes need to
take place at another level. This level had always been present in cognitive therapy but left
implicit. Our analysis suggests that unless, through the cognitive and behavioral techniques
within cognitive therapy, the patient had begun to shift her relationship to thoughts, to
recognize her thoughts as thoughts, she would remain vulnerable to relapse and recurrence.
(p. 301)

Contributions of Third-Wave CBTs

Nearly 15 years have passed since the official declaration of third-wave CBT, and we are
now in a position to begin to evaluate the impact that third-wave CBT has brought to
the field. There is no question that many third-wave applied concepts and methods (e.g.,
emotion dysregulation, experiential avoidance, distress tolerance, mindfulness, acceptance,
decentering, values) have become central parts of CBT in theory and practice (Mennin et al.,
2013); these newer concepts and methods coexist with previously established ones (e.g., con-
tingency management, exposure, and cognitive reappraisal). Given this ongoing synthesis,
using the term waves of CBT to differentiate them may not be a useful heuristic any more. In
fact, experts, including the proponents of third-wave CBT, imply that the field of CBT may
have already moved into the next phase in history (Hayes & Hofmann, 2017).
From this historical point of view, one of the most notable contributions of third-wave
CBT is the recognition of CBT as the reticular system of basic scientific theory, applied
theory (e.g., middle-level theory), and practice, which is guided by an underlying philo-
sophical worldview (Hayes, Long, Levin, & Follette, 2013). In fact, the field of CBT now,
more so than before, recognizes the importance of being clear about one’s own underlying
philosophical assumptions (Herbert, Gaudiano, & Forman, 2013; Klepac et al., 2012). As
we describe in detail below, each philosophical worldview has its own unique preanalyti-
cally chosen assumptions of (1) the fundamental unit of analysis (e.g., what the subject of
interest is and how it is understood), (2) principal goal of analysis (e.g., description, predic-
tion, influence), and (3) truth criteria to be followed to evaluate one’s own work (e.g., cor-
respondence, successful working; Klepac et al., 2012). The contribution of third-wave CBT
in this domain is significant (Hayes & Hofmann, 2017), as every CBT researcher, clinician,
and theorist follows a particular philosophical worldview but often without knowing it.
Clarification of one’s own philosophical worldview not only promotes the development and
refinement of clinical knowledge and technology within that worldview, but it also alleviates
unnecessary tensions among CBT clinicians, researchers, and theorists who happen to fol-
low different worldviews (Klepac et al., 2012). The set of assumptions derived from a given
worldview is simply chosen and assumed prior to one’s scientific and clinical work, and it
is not subject to direct empirical verification.
Scrutiny and clarification of underlying philosophical worldviews have naturally led to
a great focus on developing and refining basic and applied models of psychological health
and behavior change (Hayes, Barnes-Holmes, & Wilson, 2012). Third-wave CBTs, such
as ACT, DBT, and MBCT, have focused far less on tightly crafted treatment protocols for
specific mental disorders. Rather, more emphases are placed on broadly applicable evi-
dence-based processes (e.g., emotion regulation, decentering, behavioral flexibility) linked
186 BEHAVIORAL AND COGNITIVE APPROACHES

to evidence-based procedures (Hayes & Hofmann, 2017, 2018). This is another major con-
tribution of third-wave CBT, as CBT as a whole now emphasizes functionally important
pathways of change that cut across various diagnostic categories (Klepac et al., 2012; Men-
nin et al., 2013).
Finally, given the rapid permeation of third-wave CBT throughout the field of behav-
ioral health in recent years, its clinical effectiveness across diverse client populations and its
cultural adaptation have been central topics of discussion (Cheng & Sue, 2014; Hall, Hong,
Zane, & Meyer, 2011; Masuda, 2016). For example, individuals with expertise in multicul-
tural and diversity psychology have pointed to potential biases within third-wave CBTs, and
advocated for their cultural adaptation when applied to groups of clients with particular
sociocultural backgrounds (e.g., Asian American clients; Hall et al., 2011). In this context,
some third-wave cognitive-behavioral psychologists have argued for the importance of care-
ful and thorough examination of third-wave CBTs and the cultural adaptation of third-wave
CBT methods that goes beyond mere stylistic modification (Hayes, Muto, & Masuda, 2011;
Masuda, 2014b). More specifically, they have advocated for the cultural adaptation of third-
wave CBT that is functional and contextual to maximize its clinical effectiveness (Masuda,
2014a, 2016). This functional, contextual, and process-informed adaptation is consistent
with the notion of effective cultural competency proposed by experts of diversity psychol-
ogy (Sue, Zane, Hall, & Berger, 2009; Whaley & Davis, 2007).

THE CONCEPT OF PERSONALITY

In the field of psychological science, personality is a major concept used to describe and
understand the fundamental characteristics of human functioning (e.g., who we are, and
what we do as individual beings). Although personality is not necessarily a central topic in
third-wave CBT or the CBT tradition in general, it is possible to understand it using a third-
wave CBT theoretical framework. To do so, it is first important to clarify its philosophical
underpinnings.

Philosophical Underpinnings of Third-Wave CBTs

CBT researchers, clinicians, and theorists across all generations generally follow one of the
following philosophical worldviews: elemental realism or functional contextualism (Her-
bert et al., 2013; Klepac et al., 2012). Whereas the two philosophical perspectives share
many features (e.g., commitment to empiricism), they also differ from each other in impor-
tant ways.
Elemental realism, which is also known as mechanism or methodological behavior-
ism, is probably the most widely followed philosophical worldview in behavioral science
communities. It assumes that the behavioral phenomenon of interest consists of critical ele-
ments interacting with one another. As a philosophy of science, elemental realism stresses
operationalism in defining components that together form the reality of interest, and aims to
create an accurate model of that reality (Hayes, Hayes, & Reese, 1988; Klepac et al., 2012).
More specifically, it adopts prediction as the fundamental analytic goal of science and tends
to embrace soft determinism in casual accounts (e.g., one step in the mechanism, such as a
mental state, that put in motion the next step, such as the activation of another cognitive ele-
ment). Furthermore, elemental realism emphasizes nomothetic research methods in theory
 Third-Wave Cognitive-Behaviorally Based Therapies 187

building over idiographic research methods. Among third-wave CBTs, MBCT clinicians and
researchers tend to follow elemental realism more often than do DBT and ACT research-
ers and clinicians, although applied methods of MBCT (e.g., meditation exercise) reflect a
functional and contextual worldview, which we describe in the next section.
Functional contextualism views the phenomenon of interest as the manifestation
of behavior–environment interactions as a whole (i.e., act of a whole person in context).
Unlike elemental realism, functional contextualism is holistic, not elemental, emphasizing
the ongoing change in the act of a whole person in context. As a philosophy of science, the
principal analytic goal of functional contextualism is the prediction and influence of this
ongoing change of act in context with precision and scope (see our discussion of precision
and scope in theory below). As such, theories and practices that are based on functional con-
textualism tend to “insist on a stronger version of determinism as reflected in the emphasis
on idiographic research methods” (Klepac et al., 2012, p. 691). Furthermore, unlike elemen-
tal realism, functional contextualism deemphasizes ontology and assumes that knowledge
is constructed and justified for a preanalytically stated purpose and aim (e.g., what is true
is what is working).
Basic theories, applied theories, and applied practice that are guided by the philo-
sophical position of functional contextualism are organized and refined based on its philo-
sophical assumptions described earlier. Exemplars of basic theories guided by functional
contextualism are principles of operant conditioning, verbal behavior, and rule-governed
behavior systematized by B. F. Skinner (1957, 1974), as well as relational frame theory
(Hayes, Barnes-Holmes, & Roche, 2001), a contemporary behavior analytic theory of com-
plex human behavior. Among the three most cited third-wave CBT methods, ACT clinicians
and researchers tend to follow the functional and contextual worldview, whereas DBT clini-
cians and researchers appears to fall somewhere between MBCT and ACT (Hughes, 2018):
Whereas DBT is extremely pragmatic, functional, and contextual in scientific worldview
and practice, hence dialectical, its applied middle level theories of psychopathology and
health (e.g., biosocial theory of emotion dysregulation) reflects the features of elemental
realism (e.g., ontological account of emotion dysregulation). Below is an exemplar of the
third-wave CBT account of personality using the framework of functional contextualism, a
major philosophical assumption followed by many third-wave CBTs. Elemental realism and
its account of personality have been discussed in previous chapters in this volume. As such,
the following section focuses on a functional contextualist account of personality.

Functional Contextualism and Its Core Philosophical Assumptions

In functional contextualism, the core unit of analysis is the “ongoing act of a whole person
in context” (Hayes, Barnes-Holmes, et al., 2012). This means that a phenomenon of inter-
est, whatever it is (e.g., psychopathology, personality, happiness, mindfulness), is understood
using this fundamental framework. Ongoing actions of a whole person refer to anything
that a person does, including thinking, feeling, and perceiving. Contextual factors here can
be roughly viewed as a person’s learning history unfolding in the current environment that
occasions the behavior of interest. This basic unit resists any attempts to reduce or expand
whole actions into component parts as an explanatory strategy, whether those elements are
material (e.g., component parts of the organism) or contextual (e.g., “stimuli” considered as
physical things). This is because the focus is the function, purpose, or meaning of the behav-
ioral phenomenon of interest, and they are found only in the behavior–context relation.
188 BEHAVIORAL AND COGNITIVE APPROACHES

Personality, from a functional contextual perspective, is a set of contextually shaped

behaviors of a whole person that are relatively stable in time and situation. The functional
unit of personality can be set flexibly based on the analysis of interest, and it can range
from a single strand of a stable behavioral pattern (e.g., negative affect) in a given circum-
stance (e.g., when the person is alone) to a whole behavioral repertoire of an individual
throughout the life cycle (Hayes, Barnes-Holmes, et al., 2012). Regardless of the size of the
unit, the primary analytic goal of functional contextualism is the prediction and influence
of the behavior of interest (Hayes, Barnes-Holmes, et al., 2012). It is important to note
that “prediction and influence” is a unified goal: Analyses should help accomplish both
simultaneously. As such, for a functional contextualist, it is not enough to know that Aki
is neurotic: It is critical to understand what functions his “neurotic” responses serve (e.g.,
regulating emotions), which contextual factors currently maintain this behavioral tendency
(e.g., fatigue, demands from work), and which contextual factors influence this tendency
(e.g., treatment intervention, improvement in sleep hygiene). This functional and contextual
account of personality is particularly salient in Linehan’s account of emotion dysregulation
and borderline personality disorder (see Linehan, 1993).

PSYCHOLOGICAL HEALTH AND PSYCHOPATHOLOGY

Most behaviors in normally developed adolescents and adults (i.e., language-able adoles-
cent and adult) are cognitively and socially regulated (Hayes, Strosahl, et al., 2012). Simi-
larly, most presenting concerns brought by them are cognitive and interpersonal, and their
cognitive and behavioral efforts to resolve these concerns are also verbally and cognitively
regulated. From a third-wave CBT perspective, the problems of cognitions and other private
events (e.g., thoughts, feelings, perceptions) are not so much their occurrence or content, but
the way a person has learned to respond to them (Segal et al., 2013).
Cognitively regulated behavior is often very useful, such as problem-solving behaviors
for completing everyday tasks, but human cognitive process can also create many problems
unique to humans (Hayes, Strosahl, et al., 2012). More specifically, cognition (e.g., verbal
antecedents/rules) restricts behaviors available in a given context, and as a result, direct con-
tingencies in that context have limited opportunity to shape alternative and more adaptive
behaviors. Cognitive appraisals that clients have related to their presenting concern (e.g., “I
can’t fix my depression”) tend to be rigid: Once they are formed, they are likely to remain
in their behavioral repertoires, and are reactivated under certain circumstances (Segal et
al., 2013). This rigid and contingency-insensitive nature of cognitive processes can lead an
individual to continue to engage in futile problem-solving and avoidance efforts, called emo-
tion dysregulation and experiential avoidance, which are theorized to be the core process of
psychopathology (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996).

A Third-Wave Cognitive-Behavioral Account of Psychological Health

Taking this cognitively and socially regulated nature of human behavior, applied theories
used in third-wave CBTs point to three generalized behavioral repertoires that account for
a wide range of human conditions (Hayes, Villatte, et al., 2011). Exemplars of third-wave
applied models include the psychological flexibility model in ACT (Hayes, Luoma, Bond,
Masuda, & Lillis, 2006) and emotion dysregulation model, along with the “hierarchy of
treatment goal and target” in DBT (Koerner, 2012). In this chapter, we tentatively call them
 Third-Wave Cognitive-Behaviorally Based Therapies 189

centered, open, and engaged response styles. As discussed elsewhere (e.g., Kashdan & Rot-
tenberg, 2010), the synthesis of these three behavioral dimensions serves as a unified model
for psychological health and behavior change. Below, we discuss each of these response
styles in the context of psychological health.

Aware and Centered Response Style

For third-wave CBTs, the centered response style is a cluster of behavioral skills, including
the repertoires of (1) intentionally becoming aware of whatever one is experiencing moment
by moment; (2) shifting, focusing, and expanding one’s intentional awareness and focus;
and (3) experiencing the self as the context in which all perceptual experience unfolds. In
practice, applied concepts, such as present-moment awareness, self-as-context, and being
mode of mind, are used to describe and teach this skills set. For third-wave CBTs, this cen-
tered awareness or sense of self is “a hinge of conscious and flexible contact with ‘the now’ ”
(Hayes, Strosahl, et al., 2012, p. 78), and it serves as a behavioral prerequisite for establish-
ing effective open and engaged response styles. Furthermore, this behavioral stance is theo-
rized to undermine the behavioral regulatory function of private experiences for impulsive
behavior, experiential avoidance, emotion dysregulation, and rumination (Hayes, Strosahl,
et al., 2012; Segal et al., 2013).

Open Response Style

The open response style points to a particular functional quality of responding to the pres-
ent-moment experience. It refers to the extent to which one is experiencing the present
moment fully and openly as it is, without reacting to it or acting on it (Hayes, Villatte, et al.,
2011). In third-wave CBTs, the terms acceptance, detachment, metacognitive awareness,
decentering, defusion (i.e., looking at a thought as a mental event), emotion regulation, and
the like, often are used to capture the aspects of this behavioral process. For many clinicians
and researchers outside third-wave CBTs, this open response style, together with a centered
response style, are the defining features of third-wave CBT (Note that third-wave CBTs are
often called “mindfulness- and acceptance-based CBTs,” as mindfulness involves both cen-
tered and open response styles.)

Engaged Response Style

For third-wave CBTs, what makes life meaningful are the connections with closely held val-
ues through engaging in daily activities. Values in this context can be understood as freely
chosen, verbally constructed consequences of ongoing, dynamic, and evolving patterns of
activities. For example, wholeheartedness is a value for many adult clients; this personally
chosen value can serve as a behavioral compass, and makes any activities that reflect it (e.g.,
listening to a loved one, cooking, working, and socializing with colleagues) intrinsically
reinforcing. The term engaged response style represents a set of behavioral repertoires with
this functional quality (Hayes, Villatte, et al., 2011).

A Third-Wave Cognitive-Behavioral Account of Psychopathology in a Nutshell

At a more applied level across various third-wave CBTs, psychopathology is often character-
ized by the narrowness, rigidity, and imbalance in behavioral repertoires, characterized by
190 BEHAVIORAL AND COGNITIVE APPROACHES

behavioral deficits in centered, open, or engaged response styles, along with the behavioral
excesses of repertoires referred to as experiential avoidance, emotion dysregulation, and
rumination. Once again, in this applied account, a specific focus is placed on a contextually
situated act of a whole person, with a strong emphasis on identifying controlling variables
and systematically manipulatable contextual variables for behavior change. As such, the
third-wave CBT account of psychological health and pathology is qualitatively different
from that in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American
Psychiatric Association, 2013) and the International Statistical Classification of Diseases
and Related Health Problems (ICD; World Health Organization, 1992, 2018), which are
categorical and descriptive. In practice, third-wave CBTs may use a DSM or ICD diagnosis
as an entry point of clinical work, but assessment, case conceptualization, and treatment
are not bound to them. Below are three major behavioral dimensions of psychopathology
addressed by the third-wave CBTs that are incompatible to centered, open, and engaged
response styles.

Mindlessness, Impulsivity, Rumination, and Lack of Awareness

According to third-wave CBTs, behavioral patterns referred to as (1) autopilot mode of
mind, (2) impulsivity, (3) attachment to self-narrative and conceptualized past or future,
(4) inflexible attention to the present moment experiences, and the like, are exemplars of
behavioral repertoires that are incompatible to the centered response style (Koerner, 2012;
Segal et al., 2013). These behavioral patterns are indicative of insensitivity to changes in
one’s environment and, in some sense, entanglement with cognitive contents (e.g., cognitive
fusion). It is important to highlight that these repertoires themselves are not pathological
nor problematic. However, when they serve as a contextual factor that maintains inflex-
ible and limited behavioral repertoires (e.g., excesses of emotion dysregulation, experiential
avoidance), they are considered major pathological processes.

Experiential Avoidance, Emotion Dysregulation, and Low Distress Tolerance

Second, emotion dysregulation, experiential avoidance, and lack of distress tolerance, are
terms often used to describe a set of behavioral repertories that are antithetical to the open
response style (Hayes, Villatte, et al., 2011). Experiential avoidance and emotion dysregula-
tion are characterized as excessive and rigid behavioral and cognitive efforts to downregu-
late or avoid unwanted emotional experiences and associated private events. These verbally
and cognitively regulated cognitive and behavioral efforts can be manifested in various
forms, such as problematic drinking, self-harm, social withdraw, safety behavior, and rumi-
nation (Hayes et al., 1996; Koerner, 2012). For many third-wave CBTs, these avoidance and
regulation efforts, not the private events to which these regulation efforts are directed, are
viewed as the self-perpetuating core process of psychopathology (Hayes, Strosahl, et al.,
2012; Koerner, 2012).

Narrowness or Deficits in Constructive Behavioral Repertoire

Finally, for third-wave CBT, psychopathology is also characterized in part as the deficits
in constructive and adaptive behavioral repertoires that link to an adequate level of daily
functioning. The ultimate aim of many third-wave CBTs is to expand these repertoires,
 Third-Wave Cognitive-Behaviorally Based Therapies 191

especially under the circumstance in which futile experiential avoidance and emotion dys-
regulation are dominant.

Summary
In summary, greater behavioral adaptation or psychological flexibility characterized by the
combination of centered, open, and engaged response styles may be viewed as an ideal state
of well-being or healthy personality. These behavioral skills do not eliminate psychological
struggles, but they help individuals navigate themselves through the joy and sorrow their
lives bring. In a review of third-wave CBT methods, Hayes, Villatte, et al. (2011) summarize
the unification of centered, open, and engaged response styles as follows:

Like the legs of a stool, when a person is open, aware, and active, a steady foundation is
created for more flexible thinking, feeling, and behaving. Metaphorically, it is as if there
is greater life space in which the person can experiment and grow and can be moved by
experiences. Although not all of the approaches target all of the processes, it seems as
though contextual forms of CBT are designed to increase the psychological flexibility of
the participants by fostering a more open, aware, and active approach to living. (p. 160)

THE PROCESS OF CLINICAL ASSESSMENT

Clinical assessment is fundamental to effective treatment. As with the case of CBT tradition
as a whole, assessment in third-wave CBT is an ongoing process throughout the course of
treatment. For this reason, assessment and treatment in third- wave CBT should be viewed
as two sides of the same coin. In this section, we present functional assessment, a particular
type of clinical assessment used in DBT and ACT individual therapies (Hayes, Strosahl,
et al., 2012; Koerner, 2012; Linehan, 1993). Simply put, functional assessment, which is
typically done at the psychological level of analysis, is a process of gathering information
relevant to the client’s presenting concerns, current functioning, and the goal of treatment
using the framework of behavior–environment interaction (e.g., act in historical and situ-
ational context).
As with the case of the CBT tradition, the focus of functional assessment is to have
a better understanding of how the target behavior is currently maintained. In ACT and
DBT individual therapies, this individually focused assessment is guided by their nomo-
thetic and general models of psychological health and behavioral change (Hayes, Strosahl,
et al., 2012; Koerner, 2012). Once again, in this context, the psychological flexibility model
(Hayes et al., 2006) and emotion dysregulation model, along with the hierarchy of treat-
ment goal and target (Koerner, 2012), serve as guiding models for ACT and DBT, respec-
tively. These applied models point to client information that clinicians should attend to and
gives them a framework for organizing information gathered. For example, it is crucial for
ACT therapists to assess whether a client’s presenting concern (e.g., depression, relationship
with a partner) reflects experiential avoidance, as well as proximal contextual factors that
maintain it. Exemplars of contextual factors are verbally evaluated intense negative affect,
immediate relief from that negative affect following the regulation effort, and any relevant
cognitive appraisals. Similarly, in ACT, certain culturally and socially supported beliefs
are theorized to be manifested in a client’s belief system (e.g., “Anxiety is bad”), which
serve as a maintaining factor (Hayes, Strosahl, et al., 2012, pp. 3–10). As such, when done
192 BEHAVIORAL AND COGNITIVE APPROACHES

successfully, a case conceptualization drawn from functional assessment reflects the func-
tional and contextual formulation of idiographically defined, culturally and contextually
situated acts of a given client (Masuda, 2016, 2014b).
In DBT, the use of a behavioral chain analysis, a form of functional assessment, is a key
clinical tool (see Rizvi & Ritschel, 2014). More specifically, chain analysis is the in-depth
analysis of one particular instance or set of instances of a problem or a target behavior.
Linehan (1993) described chain analysis as a self-conscious and focused effort on the part
of both the client and clinician to identify the factors leading up to and following the target
behavior, which allows them to begin to make testable hypotheses about controlling vari-
ables across problems and behaviors.

Hierarchy of Treatment Goal and Target

Some clinical cases are very complicated, with multiple behaviors and disorders requiring
attention. When done effectively, functional assessment informs clinicians of initial targets
and priorities of treatment. Whereas many third-wave CBT methods use functional assess-
ment for this purpose, DBT explicitly emphasizes a hierarchy of treatment priorities and
targets, using functional assessment to establish that hierarchy (Koerner, 2012; Linehan,
1993). This target hierarchy (described below) is critical, because DBT tends to be used as a
treatment for severe and complicated cases that other therapies, including other third-wave
CBT methods, often refer out.

Psychiatric Diagnosis within Third-Wave CBTs

As the field of behavioral health in the United States is still very much in the era of the DSM
and ICD, a formal psychiatric diagnosis may be sought within the context of third-wave
CBT. However, for many sites, psychiatric diagnosis is pursued primarily for administrative
purposes. Given their transdiagnostic, functional, and contextual orientation, third-wave
CBTs consider the process of a formal psychiatric diagnosis (i.e., assessing the constellation
of symptoms—or behavioral manifestations) itself as incomplete. For DBT and ACT, the
most vital outcome of assessment is developing a tentative hypothesis of how behaviors are
maintained and how they can be changed (Koerner, 2012; Rizvi & Sayrs, 2017). In other
words, if the symptoms included in the assigned psychiatric diagnosis are considered the
target of treatment, it is crucial to identify potential contextual factors that may maintain
them, as well as evidence-based treatment procedures that are likely to influence them.

Psychological Level of Analysis and Cultural Considerations

Generally, assessment in DBT and ACT individual therapies are done at a psychological
level, using the functional framework of the act of a whole person in context (e.g., behav-
ior–environment interaction). Once again, “the act of a whole person” is the target behavior
of interest in treatment, and anything an individual does as a whole person, including think-
ing, feelings, and perceiving, fits this domain. The context here refers to the interaction of
the client’s learning history and current internal and external environment that contributes
to the occurrence of that target behavior. For example, from the standpoint of a given target
behavior (e.g., ruminating of past failure), other behaviors surrounding that target behavior,
such as the experience of intense negative affect, can be viewed its contextual factors. As
 Third-Wave Cognitive-Behaviorally Based Therapies 193

such, this “act of a whole person in context” represents a contextually situated pattern of
target behavior from the perspective of the target behavior.
In the process of this functional assessment, cultural factors (e.g., gender, ethnicity,
race, sexual orientation, religion, spirituality, social class), if relevant, are translated into
the unit of “act of a whole person in context” (Masuda, 2014a, 2016). Suppose a 40-year-
old Native Hawaiian American male client has reported modern racism in his workplace.
Through a functional assessment, a certain physiological reaction (e.g., tension in the neck),
emotional reactions (e.g., irritation, shame), thoughts (e.g., “Here it is again”), and behavior
(e.g., smiling and choosing not to say anything) may be identified along with the anteced-
ent (e.g., a coworker saying something) and immediate consequence (e.g., thinking about it
more) of this behavioral sequence. Additionally, it is crucial to assess his cognitive appraisal
of this incident and other, similar incidents relative to how these experiences collectively
influence his overall health and functioning.
Another feature of functional analysis is that the size of the functional unit (e.g., act-
in-context) can be flexibly adjusted to the target behavior of interest; that is, the functional
assessment can be done for a very specific behavior in a particular situation (e.g., a client’s
compensatory behavior of hand washing occurring at home) or expanded as a large set of
certain behaviors across different life contexts (e.g., self-care and health-promoting behav-
iors).
Finally, many presenting concerns brought to therapy by a client have historical origins,
such as the recurrent reexperiencing of trauma. However, as with the case of the CBT tradi-
tion as a whole, the focus of functional analysis is to have a better understanding of how the
target behavior is currently maintained. Furthermore, the goal of functional assessment also
is to identify contextual factors that can be added to the context of the target behavior (e.g.,
learning history and situational arrangement) to influence the target behavior.

THE PRACTICE OF THERAPY

Most clients seen by third-wave CBT therapists have a wide range of behavioral and psy-
chological concerns, including depression, anxiety, substance and alcohol use problems,
chronic pain, and self-directed violence (e.g., cutting). As with the case of first and second
generations of CBT, when delivered in a group format, third-wave CBTs tend to organize
a group of clients based on a specific concern, such as binge eating, self-harm, and relapse
prevention for those with a past history of depression. For clients with more severe concerns
(e.g., psychotic experience, severe self-harm and parasuicidal actions), third-wave CBTs can
be delivered as part of interdisciplinary treatment, including pharmacotherapy, in either
inpatient or outpatient settings. Among third-wave CBTs, DBT is known as a treatment for
clients with serious concerns regarding their safety and treatment-interfering behavior.

Basic Structure and Goal Settings of MBCT, DBT, and ACT

The basic structure of most third-wave CBTs is similar to that in most traditional therapies.
In research, treatment protocols generally range from 8 weeks (e.g., MBCT) to 1 year (e.g.,
DBT). In natural settings, the length of third-wave CBT treatment varies depending on the
nature of treatment settings, client characteristics, and progress in therapy.
Regardless of presenting concerns, the ultimate goal of many third-wave CBTs is the
194 BEHAVIORAL AND COGNITIVE APPROACHES

promotion of greater psychological health and behavioral adaptation (Hayes, Villatte, et

al., 2011; Koerner, 2012). As described earlier, psychological health can be characterized as
the extent to which an individual is flexibly and openly centered and oriented to whatever
he or she is experiencing in a given moment, and chooses behaviors in service of his or her
values when a situation affords doing so. For many third-wave CBTs, psychological struggle
is viewed an inevitable aspect of life, and the goal of therapy is not the complete elimination
of psychological struggle. Rather, it is to help clients foster the centered, open, and engaged
response styles to sufficient degrees so that they may navigate themselves through their lives
more flexibly. As such, third-wave CBTs are often terminated when this goal is achieved.
Below are brief summaries of MBCT, DBT, and ACT in basic structure and goal setting
throughout the course of therapy.

Mindfulness-Based Cognitive Therapy

MBCT (Segal et al., 2013) is an 8-week, 2-hour per week, group program that incorporates
mindfulness meditation with cognitive therapy to target relapse vulnerability among for-
merly depressed individuals. The mindfulness training of MBCT was drawn from mindful-
ness-based stress reduction (MBSR; Kabat-Zinn, 1990), which was originally developed for
clients with psychosomatic and medical conditions. The central theory underlying MBCT
is that individuals with a history of depression are vulnerable to relapse to depression, espe-
cially during dysphoric mood states that were present during previous episodes of depres-
sion.
MBCT is a closed course: This means that new members cannot join the course once it
starts. Importantly, the therapist must have gone through an MBCT course as a participant,
along with the experience of personal daily mediation practice for at least 1 year prior to
treating clients. Class size depends on the facilities available, but typically includes about 12
individuals, according to the developers of MBCT (Segal et al., 2013). Each group session
usually starts with a guided mindfulness exercise, which lasts for 30–40 minutes. Following
the initial mindfulness mediation, each session typically includes a brief mediation exercise
or two in addition to CT-informed didactics and experiential discussions that cover (1) the
process of depressive rumination and (2) awareness and decentering as ways to alter the
trajectory of ruminating process. In addition to in-session mindfulness mediations, daily
mindfulness practices (e.g., 10-minute audio-instructed sitting mediation, 40-minute audio-
guided body scanning mediation) and activities (e.g., choosing one activity that is pleasant
and engaging it daily) are independently explored by clients.
Unlike individual ACT and DBT, the contents and sequence of each MBCT session
are fairly standardized, and MBCT is offered more commonly as a course rather than a
group psychotherapy. Furthermore, according to Segal et al. (2013), the structure of MBCT
is divided into two phases (Sessions 1–4 and Sessions 5–8). The goal of Sessions 1–4 is to
learn the basis of mindfulness. More specifically, first, participants learn experientially how
little attention is usually directed toward daily life. They are then taught to notice mental
processes (e.g., automatically shifting from one topic to another) and how these mental
processes keep them from becoming aware of the present-moment experience. Second, par-
ticipants learn to bring their awareness to a single focus, when the mind is wondering. This
is taught first with the focus exercise that guides participants to become aware of parts of
the body one at a time (e.g., body scan mediation; Segal et al., 2013, pp. 120–128) or of
breathing (e.g., sitting with the breath; Segal et al., 2013, pp. 166–168). Paying attention to
 Third-Wave Cognitive-Behaviorally Based Therapies 195

a single focus, such as breathing, is a prerequisite skill to become aware of habitual mental
process of depressive rumination when it occurs. Third, participants learn how this habitual
mental process can lead to an escalation of negative thoughts and feelings. Recognizing
this rumination process when it occurs, especially in the nascent phase of its initiation, is a
crucial skill to recognize the critical juncture at which an alternative response to negative
thoughts and feelings (e.g., decentering) can be initiated.
Once participants acquire the skills of looking at present-moment experience, includ-
ing mind wandering, and of shifting awareness back to an anchor object such as breath or a
body part, they are then able to learn how to manage mood shifts. Learning to handle mood
shifts is the central goal in Sessions 5–8. During these sessions, participants learn to allow
a negative thought and feeling to be in the present moment whenever it arises, explore it as
it is, then respond to it skillfully. More specifically, this skillful response involves becoming
aware of these thoughts or feelings (e.g., decentering), then acknowledging and experiencing
them openly and fully without trying to change, and moving their attention to their breath-
ing for a minute or two before expanding attention to the body as a whole (e.g., breathing
space; Segal et al., 2013, pp. 196–198). This new skill is theorized to disrupt the habitual
pattern of rumination and create a context in which alternative and nourishing behaviors
are more likely to occur.
Finally, in Sessions 7 and 8, participants are encouraged to become more aware of their
own unique warning signs of impeding depression and to develop specific action plans for
when this might occur. In this context, participants are also encouraged to mindfully engage
in activities that give pleasure and sense of mastery. Consistent with the unified model of
centered, open, and engaged response styles, expanding behavioral repertories in Sessions
7 and 8 is theorized to promote greater behavioral adaptation and flexibility across various
life domains.

Dialectical Behavior Therapy

DBT (Linehan, 1993, 2014) is a comprehensive outpatient treatment conducted by a team
of DBT therapists. It was originally developed for treating chronic suicidal behavior, then
subsequently for individuals diagnosed with borderline personality disorder (BPD). To date,
DBT also has been expanded as a treatment approach for individuals with chronic emo-
tion dysregulation, a common transdiagnostic process of psychopathology, more broadly.
In traditional outpatient settings, DBT structures the treatment environment into weekly
individual therapy, weekly group skills training, and phone coaching for the clients and peer
consultation team of the therapists.
DBT is based on a biosocial view that emphasizes an interaction between an indi-
vidual’s biological predisposition toward dysregulating emotions and an environment that
chronically and pervasively invalidates his or her private experience. DBT is dialectical in
theory and practice in that it focuses on an ongoing synthesis between alternative and even
contradictory positions. The primary dialectical principle within DBT is the one between
acceptance and change (Linehan, 1993; Robins, Schmidt, & Linehan, 2004). Acceptance
and validation strategies reflect a similarity to unconditional positive regard emphasized in
client-centered therapy, while change strategies are very similar to those of traditional cogni-
tive or behavioral therapies (Koerner, 2012). According to DBT, neither strategy is viewed as
superior; each alone can be problematic, depending on the context. DBT, in this sense is an
ever finer balance of acceptance and change themes. A goal of DBT is to increase dialectical
196 BEHAVIORAL AND COGNITIVE APPROACHES

thinking in clients, such that clients become aware of the constant tensions in their own lives
and thinking, and look for the middle path and synthesis.
Although the length of treatment varies, depending on the client’s presenting concerns,
the initial length of treatment to which clients are asked to commit is typically 6 or 12
months (Linehan, 1993). DBT defines four broad stages of therapy that are based on the
level of disorder with which the client presents. In Stage 1, the objective for the client is
to build a life worth living by decreasing life-threatening behavior (suicidal, homicidal,
and self-injurious behaviors), decreasing therapy-interfering behavior, decreasing signifi-
cant quality-of-life-interfering behaviors (e.g., substance abuse, eating disorder behaviors,
homelessness) and increasing behavioral skills (i.e., mindfulness, interpersonal effective-
ness, emotional regulation, distress tolerance, and self-management). These categories (life-
threatening behavior, therapy-interfering behavior, and quality of life interfering behavior)
form the target hierarchy from which the therapist works and plans the foci of each session.
Stage 2 focuses on decreasing misery and increasing capacity to experience the full range of
emotional experiences, and frequently emphasizes exposure and acceptance. In Stage 3, the
therapeutic focus moves to attaining “ordinary” happiness by acquiring life skills in key life
domains (e.g., employment, education, and interpersonal relationships). Finally, the goal in
Stage 4 is to increase capacity for joy, generally through mindfulness. The clear majority of
research has been conducted on Stage 1 DBT, with no empirical studies of Stages 3 and 4
to date.

Acceptance and Commitment Therapy

ACT (Hayes, Strosahl, et al., 2012) is an applied extension that derives from the philosophy
of functional contextualism and a basic behavior analytic theory of language and cogni-
tion, called relational frame theory (Hayes et al., 2001). A core insight of relational frame
theory is that cognitions and verbally labeled or evaluated emotions, memories, bodily sen-
sations, and other private events achieve their potency (i.e., behavior regulatory function)
not by their form but by the historical and situational context in which they occur. In other
words, these functions of private events are learned phenomena. For ACT (Hayes, 2004),
many forms of psychopathology can be conceptualized as (1) unhealthy efforts to control
these private events, and (2) a lack of clarity about or construction of core values and the
ability to behave in accordance with them. Again, the whole idea is that undermining the
literal impact of verbal events helps to alter clients’ contexts (e.g., learning history), so that
value-oriented actions are more likely to occur, and patterns of experiential avoidance are
less unlikely to occur.
ACT has been delivered in both individual and group psychotherapy formats. In
research, the length of the intervention varied greatly across studies, ranging from three
45-minute sessions over 2 weeks to 48 sessions over 16 weeks (Hayes et al., 2006), depend-
ing on the treatment settings and the nature of the client’s presenting concern. Stylistically,
ACT is experiential, and uses less confrontational and less directive forms of verbal interac-
tion, such as metaphor, paradoxes, and experiential exercises, to loosen the entanglement
of thoughts and self-narrative (Hayes, Strosahl, et al., 2012). ACT does not reject direct
change efforts; rather it refocuses them toward more readily changeable domains, such as
overt behavior or life situations, rather than personal history or private events. ACT shares
common ground with experiential therapies in that experiencing and feeling are accepted
and valued.
 Third-Wave Cognitive-Behaviorally Based Therapies 197

Guided by the unified model of centered, open, and engaged response style (Hayes,
Strosahl, et al., 2012; Hayes, Villatte, et al., 2011), the immediate goal of ACT is to estab-
lish a therapeutic context as a form of therapeutic relationship in which client and therapist
pursue a mutually agreed upon treatment goal (e.g., finding another way to handle dif-
ficult thoughts and feelings, and pursuing the life that is meaningful and fulfilling) with
shared expectation in therapy (e.g., experiential nature of therapy, expected challenges). In
practice, depending on the client’s concerns, some ACT cases start with the promotion of
engaged response repertoire, whereas others begin with targeting the promotion of open
and centered response styles. This being said, many ACT cases typically start with an ACT-
informed assessment (e.g., chain analysis) to build client awareness of their presenting con-
cerns and how their presenting concerns are maintained. More specifically, through the
ACT-informed chain analysis, therapist and client experientially examine whether the cli-
ent’s presenting concerns reflect futile cognitive and behavioral efforts to downregulate or
avoid unwanted private events (i.e., experiential avoidance), and if so, whether the client
has the insight of these cognitive and behavioral efforts, as well as the costs of these efforts,
brought out to his or her important life domains. Strategically, the ACT-informed chain
analysis points to which life domains or circumstances the open response style (e.g., psy-
chological acceptance, openness, decentering, self as a point of view, mindfulness) are to be
promoted, and which activities may promote a life that is fulfilling.
Once a client experientially develops insight into his or her presenting concerns in terms
of the experiential avoidance and deficits in values-consistent behavioral engagement, ACT
moves into the next step: the promotion of (1) centered and open response styles or (2) cen-
tered and engaged response styles. The promotion of centered response style is chosen in
either path, as it is the foundation skill for both open and engaged response styles.
Similar to MCBT, to build a skill of psychological openness and acceptance of difficult
thoughts and feelings, the client first learns to be centered and become aware of present-
moment experience (e.g., noticing what is noticed in the present moment one at a time,
learning to shift a focus from one thing to the next one at a time). Once the client learns
this stance of decentering and awareness, he or she is then encouraged to “lean into or be
with thoughts openly and fully.” For promoting the engaged response style, ACT therapists
and clients use many traditional behavioral strategies (Martell et al., 2013) to identify and
activate target behaviors. One strategy in this domain that was originally unique to ACT
was the construction and elucidation of personal values that transform activities that are
identified as being value-consistent into becoming intrinsically reinforcing and meaningful
(Wilson & Dufrene, 2008).

Process Aspects of Treatment

As mentioned earlier, third-wave CBTs collectively aim to promote centered, open, and
engaged response styles, and these behavioral domains are often theorized to be key pro-
cesses of change in third-wave CBTs (Hayes, Villatte, et al., 2011). As these three processes
are theorized to be different aspects of the same overall behavioral adaptation, targeting
one process will have ramifications for the other processes (Hayes, Strosahl, et al., 2012).
In addition to directly promoting these processes in therapy, it is also important to develop
the therapeutic relationship to promote behavioral changes in these three processes. As such,
we illustrate common strategies used for building and maintaining (1) third-wave CBT rela-
tionship, (2) centered response style, (3) open response style, and (4) engaged response style.
198 BEHAVIORAL AND COGNITIVE APPROACHES

Orientation to Third Wave CBT and Establishment of Mutually Agreed-Upon

Treatment Goals
As we describe below in detail, the establishment and maintenance of an effective therapeu-
tic relationship in which client and therapist pursue mutually agreed-upon goals is perhaps
one of the most critical processes for treatment success. For third-wave CBT, this may mean
that a client is encouraged to consider the possibility of letting go of his or her culturally
supported problem-solving strategies for difficult private events and a willingness to pursue
psychological openness and acceptance as an alternative. Then the client is also asked to
consider the promotion of overall functioning as a treatment goal. For many clients who are
struggling with difficult thoughts and feelings, suggesting the pursuit of psychological open-
ness and a meaningful fulfilling life may appear to be counterintuitive, and even invalidat-
ing. For this reason, it is essential that the third-wave CBT therapist gradually and regularly
orient the client to these treatment goals, while minimizing the resistance to change. In DBT,
this process is often referred to as “micro-orienting” (see Koerner, 2012, pp. 78–80).
The following vignette highlights how this therapeutic orientation can be done. This
vignette is drawn from the first session of outpatient individual ACT with a 21-year-old
woman, pseudo-named Sophia, who endorses problematic purging, body dissatisfaction,
and negative self-image (see Masuda, Ng, Moore, Felix, & Drake, 2016, for the complete
case report of Sophia). The first author (Masuda) served as the ACT therapist.
Unsurprisingly, Sophia originally endorsed control-oriented beliefs (e.g., “I wish I could
get rid of them all”) and viewed her disordered eating concerns to be unacceptable and
shameful. She also reported that learning to control them would be the only way to be
normal. Rather than dismissing her control-oriented agenda, the therapist gently suggested
the promotion of a fulfilling life as an additional treatment goal. He did so by directing her
awareness to the costs of her disordered eating concerns on everyday activities, especially
those that were fulfilling to Sophia, such as emotional closeness with her friends.

Therapist: (pauses, with a gentle tone of voice) So it seems that throwing up was a
solution that made you feel relieved after eating or after feeling bad about your
body and yourself. (pause)
Sophia: (Nods quietly.)
Therapist: Then, it has become itself a problem as if you don’t want to do it, but you
can’t stop it. It was used to help you to feel a sense of peace at least for a little while,
but now, a sense of relief is followed by a strong feeling of shame.
Sophia: (Nods quietly with tears.)
Therapist: (pause) And it seems that it costs you a lot, taking up a lot of your energy,
sort of taking over your life. (pause)
Sophia: True.
Therapist: So you came to see me for your throwing up and negative body image and
shame, and really for getting your life back.
Sophia: Yes.
Therapist: How about our work is also about that, reclaiming your life, the life you
feel fulfilling and “happy.”
Sophia: Yes.
 Third-Wave Cognitive-Behaviorally Based Therapies 199

Therapist: Could I share one thing with you, if it’s OK?

Sophia: Yes.
Therapist: Many of us think this, so it may be the case with you. (showing one hand
with a holding shape to Sophia) Here are the emotional issues or problems, your
case is shame, negative body image, and throwing up . . .
Sophia: (Nods quietly, but orients well to the therapist.)
Therapist: (showing the other hand with a holding shape) Here is the life you want
. . . OK.
Sophia: (Nods quietly.)
Therapist: Many people think in order to achieve this (moving the hand represent-
ing the life that Sophia wants slightly and gently), they have to get rid of this first
(moving the hand representing the problems).
Sophia: Yes.
Therapist: Here is what I wanna share with you. And you don’t have believe what I am
about to say. But, I was wondering if it is OK with you to consider it as a possibil-
ity, even a very tiny possibility is OK.
Sophia: (Smiles quietly.)
Therapist: What if I say you don’t have to wait to get rid of this (moving the hand rep-
resenting the problem), for starting to pursue this (moving the hand representing
the life the client wants). What if I say I think you really deserve it?

Awareness and Centered Response Style

For third-wave CBTs, the centered awareness of present-moment experience or the sense
of self as a space or locus at which this present-moment experience unfolds is the basis for
open and engaged response patterns. It is this centered and gentle awareness that allows
the person to see difficult thoughts and feelings as mental events distinguished from the
self. Similarly, it is this centered and gentle awareness of the present moment that makes
behavioral engagement intrinsically reinforcing, especially the ones framed as being “value-
consistent.” Below is a brief mindfulness exercise used in MBCT, called “breathing space”
(Segal et al., 2013). The breathing space is introduced to group members in Session 3, and
they are encouraged to practice it daily for several times throughout the rest of MBCT.

“We are going to do a brief meditation now—it is called the 3-minute breathing space.
The first thing we do with this practice, because it’s brief and we want to come into a
moment quietly, is to take a very definite posture [pause] relaxed, dignified, back erect
but not still, letting our bodies express a sense of being present and awake.
“Now close your eyes, if that feels comfortable for you, the first step is being
aware, really aware, of what is going on with you right now. Becoming aware of what
is going through your mind; what thoughts are around? Here, again, as best you can,
just noting the thoughts as mental events. [pause] So we note them, and then we note
the feelings that are around at that moment [pause] in particular, turning toward any
sense of discomfort or unpleasant feelings. So rather than try to push them away or
shut them out, just acknowledge them, perhaps saying, ‘Ah, here you are, that’s how it
200 BEHAVIORAL AND COGNITIVE APPROACHES

is right now.’ And similarly with sensations in the body. [pause] Are there sensations of
tension, of holding, or whatever? And again, awareness of them, simply noting them.
OK, that’s how it is right now.
“So, we’ve got a sense of what is going on right now. We’ve stepped out of auto-
matic pilot. The second step is to collect our awareness by focusing on a single object—
the movements of the breath. So now we really gather ourselves, focusing attention in
the movements of the abdomen, the rise and fall of the breath [pause] spending a min-
ute or so to focus on the movement of the abdominal wall [pause] moment by moment,
breath by breath, as best you can. So that you know when the breath is moving in, and
you know when the breath is moving out. Just binding your awareness to the pattern
of movement down there [pause] gathering yourself, using the anchor of the breath to
really be present.
“And now as a third step, having gathered ourselves to some extent, we allow our
awareness to expand. As well as being aware of the breath, we also include a sense of
the body as a whole. So that we get this more spacious awareness. [pause] A sense of the
body as a whole, including any tightness or sensations related to holding in the shoul-
ders, neck, back, or face [pause] following the breath as if your whole body is breath-
ing. Holding it all in this slightly softer [pause] more specious awareness.
“And then, when you are ready, just allowing your eyes to open.” (p. 197)

When sharing a mindfulness mediation practice, such as the breathing space mindfulness
mediation, with a client, it is important to micro-orient the client so that mindfulness medi-
ation is not about clearing the mind or achieving a particular state of mind, but about begin-
ning over and over again. As such, when the client reports frustration and mind wandering
before and after the exercise, the therapist can gently suggest the client notice and acknowl-
edge that experience, and gently return attention to the breath or body, whichever one he or
she is being instructed to draw one’s own attention to.

Open Response Style

Once the aware and centered response style is relatively strengthened, the session moves
to the generalization of this skill to the context of emotion dysregulation and experiential
avoidance. Experiential exercises used for building open response style encourage the client
to notice and even lean into the difficult thoughts and feelings evoked by these exercises,
then encourage the client to experience his or her bodily sensation, breathing, feelings,
and thoughts that emerge as they are, without trying to change them. One of the most
commonly used experiential exercises that ACT therapists use to teach an open response
style is the observer exercise (Hayes, Strosahl, et al., 2012, pp. 233–237), a variant of
self-identification exercise developed by Assagioli (1974). This exercise is used to vitiate
self-identification by creating a brief—but powerful—psychological state in which there is
a sense of transcendence and continuity, a self that is aware of content but is not defined by
that content. From this experiential standpoint, the client is encouraged to experience some
of his or her difficult self-narrative and feelings. Below is a shorter version of the observer
exercise.

“Close your eyes if you feel comfortable to do so, get settled into your chair, and fol-
low my voice. If you find yourself wandering, just gently come back to the sound of
my voice. For a moment, now, turn your attention to yourself in this room. Picture
 Third-Wave Cognitive-Behaviorally Based Therapies 201

the room. Picture yourself in this room and exactly where you are. Now begin to go
inside your skin and get in touch with your body. Now notice how you’re sitting in
the chair. See if you can notice exactly the shape that is made and the parts of your
skin that touch the chair. Notice any bodily sensations that are there. As you see each
one, just acknowledge that feeling, and allow your consciousness to move on. [pause]
Now, notice any emotions you are having, and if you have any, just acknowledge them.
[pause] Now, get in touch with your thoughts, and just quietly watch them for a few
moments. [pause] Now I want you to notice that, as you noticed these things, a part of
you noticed them. You noticed these sensations . . . those emotions . . . those thoughts.
And that part of you we will call the ‘observer you.’ There is a person in here, behind
those eyes, who is aware of what I am saying right now. And it is the same person you’ve
been your whole life. In some deep sense, this observer you is the you that you call ‘you.’
“Now let’s move on to the most difficult area—your own thoughts. Thoughts are
difficult because they tend to hook us and pull us into them. If that happens, just come
back to the sound of my voice. Notice how your thoughts are constantly changing. You
used to be ignorant—then you went to school and learned new ways of thinking. You
have gained new ideas and new knowledge. Sometimes you think about things one
way and sometimes another. Sometimes your thoughts may make little sense some-
times they seemingly come up automatically, from out of nowhere. They are constantly
changing. Look at your thoughts even since you came in today, and notice how many
different thoughts you have had. And yet in some deep way the you that is aware of
what you think is not changing. So, that must mean that while you have thoughts, you
do not experience yourself to be just your thoughts. Do not believe this. Just notice it.
And even as you realize this, notice that your stream of thoughts continues. And you
may get caught up with them. And yet, in the instant that you realize that, you also
realize that a part of you is standing back, watching it all. So, now watch your thoughts
for a few moments—and, as you do, notice also that you are noticing them. [Observes
a brief period of silence.]
“So, as a matter of experience and not of belief, you are not just your thoughts.
These things are the contents of your life, while you are the arena . . . the context . . . the
space in which they unfold. Notice that the things you’ve been struggling with and try-
ing to change are not you. No matter how this war goes, you will be there, unchanged.
See if you can take advantage of this connection to let go just a little bit, secure in the
knowledge that you have been you through it all and that you need not have such an
investment in all this psychological content as a measure of your life. Just notice the
experiences in all the domains that show up, and, as you do, notice that you are still
here, being aware of what you are aware of. [Observes a brief period of silence.]
“Now again picture yourself in this room. And now picture the room. Picture
[describes the room]. And when you are ready to come back into the room, open your
eyes.”

See Hayes, Strosahl, et al. (2012, pp. 233–236) for the complete version of observer exercise.

Engaged Response Style

Finally, the third major process of change is the promotion of the engaged response style
characterized by a behavioral commitment to values-consistent activities. Like the entire
CBT tradition, third-wave CBT emphasizes the promotion of adaptive behaviors in major
202 BEHAVIORAL AND COGNITIVE APPROACHES

life domains (e.g., interpersonal communication skills, self-care, parenting). To promote the
sustainability of response, as well as access to intrinsic joy and happiness, many third-wave
CBTs provide experiential exercises that extract or construct values that are intrinsically
important to the client, and frame these values (e.g., caring) to behaviors that reflect these
values (playing with a daughter, watching her grow). To do so, engagement in these behav-
iors themselves becomes intrinsically reinforcing regardless of their consequences. Below
is part of the Sitting Inside Significant Questions exercise that is designed to explicate and
construct a client’s personal values in major life domains (see Wilson & Dufrene, 2008,
pp. 172–178, for a complete description of this exercise).

“We’re working to get a sense of how different life domains are more or less important
to you. We’ve both come in here kind of busy with the activities from the weeks, days,
hours, and minutes before pushing us along, and I want to make sure that we treat these
topics with the respect and attention that they deserve. So I’d like to take just a minute
briefly for us to settle here in the room and to call to mind these different domains.
First, I’ll help you to settle in, and then I’ll ask you a series of questions. When I begin
to ask questions, you don’t need to come up with answers. Instead, I’ll ask you to just
linger with the questions. I’ll pause with you, and together we’ll just see how each group
of questions moves us.
“First, let your eyes close and see if you can just breathe in the experience of being
here in this room right now. See if you can allow your eyes to gently close. Sit up straight
in your chair with your head balanced at the top of your spine, allowing your shoulders
to drop and the muscles in your face to relax. I want you to just take a moment, and I
want you to just let your attention come gently to rest right now on the inflow and out-
flow of breath. And if you find yourself thinking forward to what we’re doing, gently
let go of that and notice again that in the midst of all that mental activity, your breath
continues . . . each time you drift, gently returning back to your own breath.
“I’m going to ask you a series of questions about areas of life that some people
value. Some of these areas may be very important to you. Others may not. Even if the
area isn’t one that’s important to you, just let yourself be curious about the question.
Notice any thoughts, feelings, sensations, or memories that come up for you and then
gently release them. These are important areas of living, and we don’t always pause and
give ourselves time to appreciate them. I don’t want you to necessarily answer these
questions. Just imagine that these questions flow over you like water. If you find your-
self drawing anything conclusions, just gently let go of those conclusions and return to
the question.
“And as you notice these reactions, let go of the urge to understand them, to judge
them, to grip onto them, or to push them away. When you notice your reactions, just
breath that experience in, and on the next exhale, slowly set it aside and see what shows
up next.
“Let’s look at the area of family generally—outside of marriage and parenting. As
yourself, if something were to happen in your life in the area of family, what would that
mean to you? What does it mean for you to be a son/daughter, a brother/sister? What
does family mean to you? Listen to these words and just let yourself settle into each
of them, noticing whatever shows up. [Allows pauses between each word.] Brother,
sister, grandmother, grandfather, granddaughter, grandson, cousin, aunt, uncle, niece,
nephew, mother, father, family. Once again, just allow yourself to settle into those
 Third-Wave Cognitive-Behaviorally Based Therapies 203

questions. Let yourself settle into the meaning of these things for you and allow your
awareness to stretch out into the questions.
“And, gently breath. Just settle and allow your attention to come gently to rest on
your own breath. [Pauses briefly.]
“And now we’ll begin with intimate relations. Please allow yourself to sit within
these questions. Ask yourself, if something were to happen in your life in the area of
intimacy, what would that mean to you? What does it mean for you to be a lover, a
partner, a husband/wife? Just allow yourself to settle into those questions, allowing
your awareness to stretch out into the question.
“And gently breath. Just settle and allow your attention to come gently to rest on
your own breath. [Pauses briefly.]
[Continues this for the areas of parenting, friend and social life, work, education
and training, recreation and fun, spirituality, community life, physical self-care, the
environment, and aesthetics.]
“And gently breath. Just settle and allow your attention to come gently to rest
on your own breath. [Pauses briefly.] Let your awareness touch gently each of these
areas—family, intimate relations, parenting, friendship, work, education, recreation,
spirituality, community, and self-care. And now, I’d like to call your attention gently
back to your own body here in this room right now. In just a minute, I’m going to ask
you to open your eyes and take 10 minutes to write about what shows up for you as the
most important thing or things in your life, and why this is important and meaningful
to you. Write your deepest thoughts and feelings about this area of living. What you
write doesn’t have to be grammatically correct. Don’t worry about spelling or even
necessarily writing in complete sentences. Please write for the entire 10 minutes. If you
can’t think of what else you might say, just write the last thing over and over until some-
thing new comes up. When you’re ready, open your eyes and begin writing.”

Cultural Considerations
As described throughout this chapter, the functional–contextual perspective that many
third-wave CBTs follow emphasizes the way a client’s life experience, together with the cur-
rent environment, shapes and maintains behavioral patterns (Masuda, 2014a, 2016). More
specifically, whether a given behavior is effective and adaptive is determined contextually
by taking sociocultural norms operating in the client’s life context and his or her person-
ally held values into consideration. Throughout the therapeutic process, client and therapist
identify behaviors that are considered adaptive and meaningful to the client in his or her
psychosocial environment. For this reason, the case conceptualization, treatment plan, and
treatment delivery guided by this perspective is fundamentally idiographic and culturally
sensitive if done effectively.

The Most Common and Most Serious Technical Errors

Third-wave therapies, most notably ACT and DBT, are principle-based rather than proto-
col-based treatments; that is, there is frequently not a session-by-session manual or script.
Thus, therapeutic errors can arise when clinicians veer away from the core principles or
guidelines. A common error is doing therapy without having a clear direction (treatment
goals), an understanding of where the client is currently in terms of the treatment goals, and
204 BEHAVIORAL AND COGNITIVE APPROACHES

not being sensitive to the progress of therapy, or identifying and adjusting the therapeutic
steps to get there (e.g., a series of skills acquisitions). For example, given the popularity of
acceptance and mindfulness, many clinicians include mindfulness exercises in their practice
without having a clear sense of their purpose or function. Another common therapeutic
error is failing to assess sufficiently before jumping to solutions (Rizvi & Sayrs, 2017).
When this happens, the generated solutions are less likely to be effective, because they are
not based on the idiographic assessment.

THE THERAPEUTIC RELATIONSHIP AND THE STANCE OF THE THERAPIST

The therapeutic relationship is considered central in successful therapy for many third-
wave CBTs, including MBCT, DBT, and ACT (Hayes, Villatte, et al., 2011; Rizvi, 2011).
This may sound surprising for some as the CBT tradition is often criticized for its focus on
treatment techniques (e.g., “specific” factors), over therapeutic relationship. Approaching
this issue as a dichotomy is an error (Hofmann & Hayes, 2018). In fact, third-wave CBTs
do assume that the therapeutic relationship influences the outcome of therapy, and that
both client and therapist share the responsibility for bringing about the changes desired.
Third-wave CBTs emphasize the importance of therapeutic relationship from the stand-
point of a conceptual and applied framework that is different from those of common-factor
approaches, however.

Successful Working as the Truth Criteria for a Good Therapeutic Relationship

From a functional–contextual perspective, psychotherapy from the perspective of a client is
a context in which to learn a new set of behaviors or insights through interacting with a cli-
nician (Robins et al., 2004); therefore, the therapist serves as a crucial contextual factor for
the client’s behavior change. For a clinician, psychotherapy is also an interpersonal context
that requires the clinician to be flexible in response to changes in each therapeutic moment
with the client (Kohlenberg & Tsai, 2007). This therapeutic context is therefore character-
ized as the contextually situated interplay between the client and the therapist as historical
and situational beings (Hayes, Strosahl, et al., 2012, see pp. 141–149).
From a third-wave CBT perspective, one cannot assume that a given form of interper-
sonal style (e.g., the therapist being warm, empathic, validating, directive) is universally
effective. For a third-wave CBT, the therapeutic relationship is purposeful, and whether
a given client–therapist relationship is therapeutic is determined by the extent to which it
meets a stated therapeutic goal (e.g., closest approximation of the ultimate treatment goal) in
each moment in session. For example, in ACT, a positive therapeutic relationship is defined
as the extent to which it serves as a context that promotes the client’s greater behavioral
flexibility and adaptation (Hayes, Strosahl, et al., 2012, see pp. 141–161). For DBT (Line-
han, 1993; Robins et al., 2004), the therapeutic relationship is the context in which a more
adaptive worldview and a resulting set of behaviors are fostered. The style of effective thera-
peutic relationship varies in each client–therapist interplay, and it also changes throughout
the course of therapy: A therapist may play an active and directive role in an early phase of
therapy, then gradually shares an active role with the client as the therapy progresses. As
such, it is imperative that the therapist has the ability to fine-tune the relationship in each
moment for achieving the stated therapeutic goals.
 Third-Wave Cognitive-Behaviorally Based Therapies 205

Therapist Self-Disclosure, Countertransference, and Rupture in Alliance

Compared to more traditional CBTs, third-wave CBTs, such as DBT and ACT, encourage
the therapist to attend behavioral processes referred to as self-disclosure, countertransfer-
ence, and rupture in alliance. For third-wave CBTs, the topics of self-disclosure, counter-
transference, and rupture in alliance should be viewed throughout the framework of behav-
ior–environment interaction, with a specific focus on clinical effectiveness.
Regarding the therapist’s self-disclosure, a consensus is to do so if it is therapeutic to the
client. For example, the therapist’s self-disclosure of his or her emotional reaction during the
session, as well as his or her own previous or current psychological struggle, may promote a
client’s centered and open response styles (e.g., openly experiencing difficult affect, normal-
izing and validating the client’s struggle). The therapist’s sensitivity and awareness of his
or her own reactions toward a client and their impact on their therapeutic work with that
client allow the therapist to stay cognizant of his or her therapeutic effectiveness. Finally,
recognizing and responding to rupture in alliance is also critical for the therapist to regain
his or her clinical effectiveness as the client’s major contextual factor of behavior change. As
with other psychotherapies, ruptures should be attended to as soon as they are recognized
as interfering with therapy.

CURATIVE FACTORS OR MECHANISMS OF CHANGE

Technically speaking, the primary goal of third-wave CBTs is to bring and develop the cli-
ent’s behavioral repertoires under adaptive verbal and cognitive contingencies (Hayes &
Hofmann, 2017, 2018). From a functional–contextual perspective, this change is produced
by adding new learning history to a client’s extant contextually situated set of behavioral
repertoires. For many third-wave CBTs (Hayes, Villatte, et al., 2011), the curative factors
and processes of change are the centered, open, and engaged response styles delineated in
the unified model of psychological health and behavioral change. These behavioral pro-
cesses are promoted by a new verbal and cognitive context shaped in part through the inter-
play between client and therapist.

Insight and Understanding

One behavioral domain that is often viewed as a curative factor is insight, the way we per-
ceive, think, and feel about the world, ourselves, and our problems. Insight and understand-
ing are crucial for sustainable behavioral change, and many third-wave CBTs employ thera-
peutic procedures to develop particular forms of insight in clients. For example, in DBT,
MBCT, and ACT, clients learn to view and understand their presenting concerns (i.e., what
the problem is, and how it is maintained) functionally and contextually in the context of
learning the centered response style. Such insights then serve as verbal antecedents for pro-
moting constructive behaviors and preventing maladaptive behaviors from being escalated.
For example, through chain analysis, clients in DBT and ACT learn that their problematic
behaviors (e.g., self-injurious behaviors) are contextually situated ongoing acts and see how
their behavior flows and changes from one form of behavior to another, along with associ-
ated antecedent and consequence (Hayes, Strosahl, et al., 2012; Koerner, 2012; Linehan,
206 BEHAVIORAL AND COGNITIVE APPROACHES

1993). Similarly, mindfulness meditation exercises used in MBCT help clients have a meta-
awareness of (i.e., insight into) how the mind operates (Segal et al., 2013).

Interpersonal Skills
Another curative factor that is often discussed in the field of psychotherapy is interpersonal
skills. As discussed extensively elsewhere (Hayes, Strosahl, et al., 2012; Wilson & Dufrene,
2008), humans are social beings, and our core personal values, such as being honest, kind,
and caring, often reside in the context of interpersonal relationship (e.g., family, couples,
community, friendship). Similarly, many of our personal struggles emerge from interper-
sonal contexts (e.g., issues related to intimacy, conflicts with loved ones) or the absence of
interpersonal relationship (e.g., loneliness).
From the perspective of the unified model of behavioral change, interpersonal skills
are viewed as part of open, centered, and engaged response styles that a client chooses to
nurture. In fact, a number of third-wave CBTs target the promotion of skillful interpersonal
behaviors in this behavioral domain. For example, functional analytic psychotherapy (FAP;
Kohlenberg & Tsai, 2007), a relationship-focused third-wave CBT, centralizes interper-
sonal effectiveness as the essential vehicle of greater behavioral adaptation and shapes cli-
ents’ effective interpersonal skills through the in-session therapeutic relationship. Similarly,
DBT explicitly states that interpersonal effectiveness is one of the core DBT skills (Koerner,
2012), and teaches clients these skills in both didactic and in vivo fashion when necessary.
DBT clients are taught these skills so that they approach conversations in a more thoughtful
and deliberate manner rather than acting and reacting impulsively with intense emotions.
Finally, in ACT, clients often identify their personal values in the areas of intimacy, family,
parenting, and social relationships, and pursue the embodiment of these values through
committing to interpersonal behaviors (e.g., spending times with family, listening to the
partner).

TREATMENT APPLICABILITY AND ETHICAL CONSIDERATIONS

Given the transdiagnostic and process-based nature of third-wave CBTs, particularly

MBCT, DBT, and ACT, it is possible to speculate about their broader applicability to a
wide range of behavioral and medical concerns. In fact, a larger body of evidence collected
in North America and Europe show that third-wave CBT methods have been applied to
adolescents and adults with a plethora of behavioral and medical conditions, including
depression, anxiety, self-directed violence, substance use problems, and chronic pain, in
diverse behavioral health settings (Dimidjian et al., 2016; Hayes, Villatte, et al., 2011).
Regarding specific third-wave CBTs, extant evidence (e.g., Dimidjian et al., 2016) suggests
that MBCT is particularly suitable for formerly depressed individuals with cognitive vul-
nerability (e.g., repertoires of depressive thinking and rumination); DBT is suitable for cli-
ents with a pervasive behavioral pattern of emotion dysregulation to the degree of services
that the DBT treatment team can offer; ACT may be a good treatment option for those
with chronic pain, substance use problems, and a range of anxiety-related issues. Evidence
also suggests that MBCT, DBT, and ACT achieve their clinical outcomes through the tar-
geted processes of change, such as psychological openness, mindfulness, adaptive emotion
 Third-Wave Cognitive-Behaviorally Based Therapies 207

regulation, decentering, and engagement in values-guided actions (Atkins et al., 2017; Gu,
Strauss, Bond, & Cavanagh, 2015). As is the case with other behavioral health treatments,
evidence is still limited regarding the effectiveness of third-wave CBTs in understudied
populations, such as ethnic minorities and sexual minorities in the United States (Cheng &
Sue, 2014).
Many ethical considerations that can arise from third-wave CBTs are not unique:
Clients must be informed about the nature and expected course of therapy (e.g., weekly
50-minute individual therapy for 2 months), confidentiality, and rules related to payment
and cancellation of a session, for example. In addition to the standard ethical principles
and codes of conduct that cut across behavioral health practices, some third-wave CBTs
have their own set of rules for participants to stay in therapy, and clients should be clearly
informed of these specific rules as well.
Given the growing body of empirical support and increasing popularity (Dimidjian et
al., 2016; Hayes, Villatte, et al., 2011; Norcross, Pfund, & Prochaska, 2013), one ethical
consideration that may be particularly relevant to, but not limited to, third-wave CBTs is
the boundaries of competence. The bottom line is that third-wave CBTs are not effective
for every client. It is crucial for clinicians to become cognizant of the literature regarding
the level and nuance of empirical support of the specific third-wave CBT in question and
to make clinical decisions on when to use and adapt the treatment based on the present-
ing issues of each unique client. Furthermore, as discussed extensively elsewhere (Hayes,
Strosahl, et al., 2012; Linehan, 1993; Segal et al., 2013), third-wave CBT models and inter-
vention methods can be easily misunderstood and misused. As such, clinicians must have
adequate training, supervision, and consultation on an ongoing basis, while recognizing
limits of their own clinical competency and multicultural humility in conducting a third-
wave CBT.

RESEARCH SUPPORT AND EVIDENCE-BASED PRACTICE

Despite concerns raised by the critics of third-wave CBT for its weaker commitment to
empiricism (Öst, 2008, 2014), the extant literature shows that third-wave CBTs, especially
ACT, DBT, MBCT, and BA, have continued to commit to the empirical roots of CBT in
theory and treatment development (Dimidjian et al., 2016; Hayes, Villatte, et al., 2011).
For example, in their systematic review of 26 meta-analyses of third-wave CBT (ACT = 8,
DBT = 5, MBCT = 6, and BA = 7), Dimidjian and colleagues (2016) concluded the following
about the empirical status of third-wave CBT as a whole:

There is little doubt based on the meta-analyses reviewed that there exists a strong and
growing evidence base supporting the efficacy of individual therapies commonly identified
as “third wave.” . . . Each is supported by numerous efficacy studies, which overall attest
to at least moderate to large effect sizes for between-group comparisons, using primarily
WL [waiting list] or TAU [treatment as usual] conditions, or within group comparisons,
although concerns have been raised about the use of such contrasts. . . . It is clear that
the existing evidence base supports the efficacy of the specified therapies in the treatment
of problems and populations that are of high public health relevance, including anxiety,
depression, borderline personality disorder and suicidal behaviors, and eating disorders.
(p. 898)
208 BEHAVIORAL AND COGNITIVE APPROACHES

Below are very brief summaries of research support for MBCT, DBT, and ACT.

Mindfulness-Based Cognitive Therapy

As MBCT was originally developed to target relapse vulnerability in formerly depressed
individuals, most empirical evidence of MBCT is in this clinical area. One of the earlier
meta-analyses of MBCT (Piet & Hougaard, 2011) shows that MBCT reduces relapse risk
by 34%. A systematic review of meta-analyses of MBCT also indicates a reliable reduc-
tion of relapse risk in the range of 35–50% across studies (Dimidjian et al., 2016) and this
reduction rate is comparable to traditional CT for depression across 24 months of follow-up
(Farb et al., 2018). More recently, research shows preliminary empirical support of modi-
fied versions of MBCT as a treatment for individuals with a wide range of behavioral and
medical conditions (Segal et al., 2013, pp. 406–407). These conditions include but are not
limited to overeating and obesity, acute depression, substance use, and chronic pain. In
particular, MBCT has been shown to promote effective coping skills and life satisfaction in
these individuals.

Dialectical Behavior Therapy

Although DBT can be considered a transdiagnostic treatment of generalized emotion dys-
regulation, empirical evidence of its efficacy has been found primarily with clients present-
ing with self-directed violence, BPD, comorbid substance use, and binge eating and purging
(Dimidjian et al., 2016). There is a particularly significant evidence base supporting the
efficacy of DBT in decreasing suicide attempts and nonsuicidal self-injury, as well as use
of crisis services, depression, and anger. For example, one of the most recent meta-analytic
reviews shows the efficacy of DBT, relative to TAU for self-injury and in reducing the fre-
quency of accessing psychiatric crisis intervention service among clients with suicide-related
outcomes, such as suicidal ideation (DeCou, Comtois, & Landes, 2018). Similar to MBCT,
a modified version of DBT has been applied to clients with other behavioral and medical
conditions. For example, a recent meta-analytic review indicates that DBT is probably effi-
cacious as a treatment for individuals with binge eating, with or without purging (Linardon,
Fairburn, Fitzsimmons-Craft, Wilfley, & Brennan, 2017).

Acceptance and Commitment Therapy

In one of the most recent meta-analytic reviews of ACT, Atkins and colleagues (2017)
reported that there are at least 170 randomized controlled trials (RCTs) of ACT examin-
ing its efficacy as a treatment for a wide range of clinical and applied issues, including (1)
chronic pain; (2) substance use; and (3) a range of anxiety-related concerns, including obses-
sive–compulsive disorder. A series of systematic reviews and meta-analyses of ACT suggest
that (1) ACT is a transdiagnostic procedure that attains better outcomes than WL and TAU,
especially for the three clinical areas identified earlier; (2) overall, ACT is at least as good as
traditional CBT and other evidence-based methods; and (3) the efficacy of ACT is at times
moderated by factors distinct from traditional CBT or other evidence-based methods, and
vice versa. Finally, Atkins and colleagues also report that theoretically coherent ACT pro-
cesses commonly mediate ACT outcomes.
 Third-Wave Cognitive-Behaviorally Based Therapies 209

CASE ILLUSTRATION

Once again, we present the case of “Sophia,” a 21-year-old college student seen in an out-
patient individual ACT therapy with the first author (Masuda). In this section, we present
an abbreviated version of the case to illustrate a typical course of individual third-wave CBT
(see Masuda et al., 2016, for a detailed description of this clinical case report).

Background Information
Sophia, a 21-year-old, U.S. permanent resident, had moved approximately 10 years earlier
from Costa Rica with her biological mother and an older sister; her biological father had
stayed in Costa Rica. Sophia contacted the therapist because of daily self-induced vomiting
and fear of gaining weight, which she considered “extremely shameful” and “getting out
of control.” Self-induced vomiting started 2 years earlier, with the onset triggered by the
unexpected end of a long-term romantic relationship. According to Sophia, the frequency of
self-induced vomiting gradually increased from once every 2 months to almost daily within
a year. Sophia kept her self-induced vomiting and negative body image to herself. Using the
Structured Clinical Interview for DSM-IV-TR Axis I Disorders (First, Spitzer, Gibbon, &
Williams, 2002), Sophia met DSM-5 criteria for other specified feeding and eating disor-
ders (OSFED), subcategory purging disorder (PD). She self-identified as being heterosexual
and was single. Sophia lived with her mother and sister. Throughout the course of therapy,
Sophia completed daily self-monitoring of self-induced vomiting, weekly self-report ques-
tionnaires of psychological inflexibility and psychological flexibility specific to body image
and disordered eating concerns, and monthly self-report questionnaires of general function-
ing and disordered eating concerns (see Masuda et al., 2016).

Case Conceptualization
Based on the information gathered during the intake session, Sophia’s primary concern of
self-induced vomiting was hypothesized to serve as a behavioral effort to downregulate or
avoid negative affect (e.g., intense anxiety) triggered by her negative views toward herself
and her body. Her self-induced vomiting appeared to be immediately followed by a tem-
porary relief from negative affect, but it was subsequently followed by a strong sense of
shame, which seemed to perpetuate the vicious cycle of self-induced vomiting. Self-created
rules about herself and control-based problem solving (e.g., “I’m disgusting,” “It’s not right
(to have them), I have to keep them under control”) also appeared to maintain the cyclical
pattern of self-induced vomiting, feelings of shame, and negative self-judgment. Sophia also
appeared to use other strategies, such as distracting herself, keeping herself busy, or con-
fronting herself, to regulate her urge to purge and negative effect, but without the success
(e.g., “I’m going to throw up anyway”). At times, Sophia appeared to be preoccupied with
her self-induced vomiting and shames surrounding this ineffective coping, and her apprais-
als of her disordered eating concerns and efforts to resist and downregulate them appeared
to cause her distress and interfere in some key interpersonal domains (e.g., Sophia kept her
self-induced vomiting from her family members and close friends). Despite these concerns,
Sophia continued to be fairly high-functioning, doing extremely well at school and having a
few close friends providing strong emotional support (although they did not know about her
210 BEHAVIORAL AND COGNITIVE APPROACHES

body dissatisfaction and self-induced vomiting). There were no medical concerns or immedi-
ate risks of her being danger to herself or others. Sophia was also forthcoming for her future.

Sociocultural Considerations Relevant to the Client

Sophia’s presenting concerns of self-induced vomiting are understood as the behavioral
manifestation of historical and situational sociocultural contingencies that have operated in
her life context (e.g., dissonance between mainstream U.S. culture and her Latino culture
around ideal body aesthetic and pressures to fulfill these expectations). Similarly, her strong
feelings of shame associated with having behavioral health concerns and seeking profes-
sional behavioral services for these concerns are also viewed as culturally and contextually
shaped behavior.
In session, as Sophia and the therapist came from different sociocultural backgrounds
(e.g., gender, age, culture, and ethnic background), conscious efforts were made to build a
strong therapeutic rapport at the outset of therapy. For example, the therapist often shared
his experiences as an immigrant (e.g., challenge of acculturation, adjustment to the U.S.
academic system) in sessions when doing so was likely to be therapeutic (e.g., Sophia trust-
ing and relating well with the therapist, establishing shared treatment goal). Additionally,
Sophia and the therapist often discussed topics and issues that emerged in sessions through
various sociocultural lenses. For example, during an early phase of the ACT delivery, Sophia
noted that she felt shame when talking about herself to others because she perceived doing
so as a sign of being a burden to others. In response, the therapist disclosed that he had simi-
lar experiences given his cultural background. The therapist then suggested to Sophia that
whether self-disclosure was appropriate depended on the context, and that psychotherapy
was a place where she could openly share about herself.

Course of Treatment
Given this tentative case formulation, the ultimate goal of therapy was for Sophia to pro-
mote her quality of life by engaging in activities she found meaningful and fulfilling and by
learning to be open to negative affect without choosing to engage in self-induced vomiting.
More specifically, an initial plan involved teaching and encouraging Sophia to experience
negative feelings and thoughts openly. It was hypothesized that normalization of disor-
dered eating experiences and learning to experience thoughts and emotions simply as mental
events would undermine the intensity and regulatory functions of Sophia’s control-based
self-rules and negative affect. It was also hypothesized that self-induced vomiting would
decline as Sophia learned the behavioral repertoire of psychological openness.

Sessions 1–3: Undermining the Impact of Control-Oriented Rules

and Normalizing Suffering
Continuing from the intake assessment, Session 1 focused on establishing a relationship in
which Sophia and the therapist mutually agreed on their expectations of therapy and estab-
lished treatment goals (see the clinical vignette presented earlier). Subsequently, Sessions
2 and 3 aimed to shift Sophia’s focus from controlling her difficult thoughts and feelings
(e.g., fear of gaining weight, body dissatisfaction, shame) to becoming psychologically open
to them. More specifically, the treatment goals for these sessions were (1) to promote her
 Third-Wave Cognitive-Behaviorally Based Therapies 211

centered and aware response style in the areas of her self-induced vomiting, especially its
long-term costs as a maladaptive emotion regulation effort, and (2) to normalize and vali-
date her struggles with these difficult thoughts and feelings in order to lessen the perceived
need to “fix them.”

Sessions 4 and 5: Promotion of Psychological Openness through Decentering

and Self-Compassion
From Session 4, Sophia began to report a change in her perception of negative body image.
More specifically, Sophia still had negative perceptions of herself and her body, but she
found them less disturbing. She also intentionally let her negative body image and distress
come and go without trying to control them. As such, therapist and client decided to con-
tinue to foster the open response style in Session 4, more specifically, negative self-judgment
and shame relevant to body dissatisfaction and disordered eating concerns. As described
earlier, several key ACT exercises were used in Sessions 4 and 5, including experiential
exercises similar to the observer exercise described earlier (Hayes, Strosahl, et al., 2012,
pp. 233–237).

Sessions 6–8: Psychological Acceptance in the Context of Behavioral Activation

and Self-Validation and Compassion
As negative body image and self-induced vomiting became a less dominant part of her life,
Sophia and the therapist began to focus on daily activities in various domains, including
friendship, dating, career, and academic achievement. For example, in Session 6, Sophia
and the therapist identified being present with feelings of discomfort while on a date as an
immediate goal of treatment. Sophia also decided to pursue her career in the Army, despite
discomfort and negative self-judgment associated with it (e.g., “I’m not strong enough”).
Furthermore, when progress in the area of centered and open response styles was made,
Sophia shared her history of negative body image concerns with the therapist in depth. In
Session 7, Sophia disclosed to the therapist she still avoided looking at a photo on her phone,
taken when she was 15 years old, when she was heaviest. According to her, the image of
“15-year-old” Sophia showed up whenever she gained weight and triggered greater fear
of gaining weight and body dissatisfaction or vice versa. The therapist judged that this
therapeutic moment would be an ideal opportunity to further promote her psychological
openness and self-compassion, and asked her to stay on this topic a little while. Then, he
invited her to imagine what she was like back when she was 15—the things she saw, the
things she heard, the feelings she had, and how she had felt about herself. Upon her agree-
ment, the therapist then asked her to imagine that 15-year-old Sophia was right in front of
her, opening up to her about her body image concerns with tears, providing her with an
opportunity to dialogue with her younger self. The therapist then asked what she would say
to the 15-year-old Sophia:

Therapist: If the 15-year old you were here, what would you say to her?
Sophia: (Nods and begins to tear up.)
Therapist: Knowing what she has gone through, and what she will go through . . . I
was wondering what you would say to her. Would you say to her to go away? . . .
Would you say to her that she is disgusting . . . ?
212 BEHAVIORAL AND COGNITIVE APPROACHES

Sophia: No, I would tell her that she will be OK.

Therapist: . . . Would you let her know that she deserves self-compassion and kind-
ness?
Sophia: Yes. I would give her a hug. (Smiles.)
Therapist: Wonderful. She’s you, you know.
Sophia: (Nods with tears.) I know . . . I know . . .

Sessions 9 and 10: Continued Commitment to Body Image Flexibility

The plan for Sessions 9 and 10 originally was to continue to cover the domain of engaged
response style. However, at the beginning of Session 9, Sophia appeared discouraged and
disclosed that she had vomited twice in the previous week, partially in response to the
breakup of a romantic relationship. According to Sophia, the boyfriend broke up with her
after she disclosed to him her body image concerns and self-induced vomiting. In ACT ther-
apy, the lapse of the presenting concern is not uncommon, especially when the client begins
to expand activities. When this happens, the ACT therapist gently brings the client’s focus
back to the importance of personal values and values-directed activities. This was the case
with Sophia and her therapist. After the therapist validated her feelings of discouragement
and distress, he gently micro-oriented Sophia back to her personal values and encouraged
her to continue to choose value-directed action:

Therapist: I’m so sorry . . . and now I can see why you looked so discouraged. Wish I
could take your pain away from you.
Sophia: (Nods with tears.)
Therapist: (with a gentle voice) I am not sure if this is a right time to ask you this. . . .
I was wondering if I could ask you this question . . .
Sophia: (Looks the therapist in the eyes and nods.)
Therapist: Would honesty and intimacy still be important to you, despite the fact that
moving toward them could be very painful sometimes, like the one you’re experi-
encing now.
Sophia: (Nods.)
Therapist: Would they still be worth it?
Sophia: (slowly) Yes, I feel really sad, but it’s still worth it. If I didn’t, nothing changed.
It was fun to be back in a relationship, and I am thankful to him. . . . It didn’t work
out this time, but it’s nice to show up . . . being true to myself . . .
Therapist: (Nods quietly, looking at her gently and kindly.)
Sophia: I also shared that [i.e., her eating concerns] to my sister and my best friend. My
sister was very supportive of me, and my friend was too. She also shared her body
image issue with me.
Therapist: . . . Beautiful . . . because you opened up . . . and people you care about,
your sister and your best friend, opened up.

At the end of Session 9, the therapist offered Sophia a few more sessions if she wanted
to continue therapy. She then told the therapist that she would be OK with the next session
 Third-Wave Cognitive-Behaviorally Based Therapies 213

being the last. In Session 10, Sophia disclosed that she had been kinder to herself than before
and shared a list of wisdoms that she learned from the psychotherapy experience, including
being open to her emotional experiences, even when she made mistakes, and engaging in the
activities that make her genuinely happy.

Results and Summary

Prior to the individual ACT sessions, Sophia had engaged in self-induced vomiting almost
daily (five times per week on average). The rate of purging decreased to once a week on aver-
age during treatment, with no self-induced vomiting at 3-month and 12-month follow-up
periods. Similarly, Sophia shared with the therapist at the 12-month follow-up that she had
been more active and was grateful to her life, despite occasional “ups and downs.”

REFLECTION AND CONCLUSION

Over a decade has passed since the official declaration of third-wave CBT. Despite some
heated debates, many third-wave applied concepts and methods, such as psychological
acceptance, mindfulness, and decentering, are now considered defining features of CBT
(Hofmann & Hayes, 2018; Mennin et al., 2013). As discussed in this chapter, perhaps
a major historical contribution of third-wave CBT has been to revitalize the ultimate
questions to be answered in CBT: “What treatment, by whom, is most effective for this
individual with that specific problem, under which set of circumstances, and how does it
come about” (Paul, 1969, p. 44). More specifically, today, CBT, as a reticular system of
knowledge and technology development, has placed greater emphases on broadly appli-
cable evidence-based processes of change linked to evidence-based procedures (Hayes &
Hofmann, 2017, 2018) than on tightly crafted treatment protocol for a specific mental
disorder.

SUGGESTIONS FOR FURTHER STUDY

Recommended Readings
Hayes, S. C., Follette, V. M., & Linehan, M. M. (Eds.). (2004). Mindfulness and acceptance: Expand-
ing the cognitive-behavioral tradition. New York: Guilford Press.—An excellent overview of
third wave CBTs.
Hayes, S. C., & Hofmann, S. G. (Eds.). (2018). Process-based CBT: The science and core clinical
competencies of cognitive behavioral therapy. Oakland, CA: New Harbinger.—An excellent
overview of process-based and principle-based understanding and practice of CBT.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The
process and practice of mindful change (2nd ed.). New York: Guilford Press.—The original
volume of ACT.
Koerner, K. (2012). Doing dialectical behavior therapy: A practical guide. New York: Guilford
Press.—An excellent volume for learning DBT in practice.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New
York: Guilford Press.—The original volume of DBT.
Masuda, A. (Ed.). (2014). Mindfulness and acceptance in multicultural competency: A contextual
approach to sociocultural diversity in theory and practice. Oakland, CA: Context Press/New
Harbinger.—An excellent overview of cultural considerations in third-wave CBTs.
Rizvi, S. L., & Sayrs, J. H. R. (in press). Assessment-driven case formulation and treatment planning
214 BEHAVIORAL AND COGNITIVE APPROACHES

in dialectical behavior therapy: Using principles to guide effective treatment. Cognitive and
Behavioral Practice.—The title says it all.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for
depression (2nd ed.). New York: Guilford Press.—The original volume of MBCT.
Wilson, K. G., & Dufrene, T. (2008). Mindfulness for two: An acceptance and commitment therapy
approach to mindfulness in psychotherapy. Oakland, CA: New Harbinger.—An excellent vol-
ume for learning therapeutic relationship in third wave CBTs.

DVDs
American Psychological Association. (Producer). (2005). Mindfulness-based cognitive therapy
[DVD]. Available from www.apa.org/videos.—A wonderful introductory video for learning
MBCT.
American Psychological Association. (Producer). (2008). Acceptance and commitment therapy
[DVD]. Available from www.apa.org/videos.—A wonderful introductory video for learning
ACT.
American Psychological Association. (Producer). (2018). Dialectical behavior therapy [DVD]. Avail-
able from www.apa.org/videos.—A wonderful introductory video for learning DBT.

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 PART IV

EXPERIENTIAL AND
HUMANISTIC APPROACHES
 CHAP TER 7

Person-Centered and
Emotion-Focused Psychotherapies
Arthur C. Bohart
Jeanne C. Watson

O ur focus in this chapter is person-centered psychotherapy and emotion-focused psycho-

therapy. We also briefly cover focusing-oriented psychotherapy. All three share the idea
that psychotherapy is a process that is based in humans’ potential for growth and creative
actualization of their potential, and that the main impetus for therapeutic change arises
from clients themselves, mobilized in a warm, accepting, empathic relationship with a thera-
pist, and supported by liberating therapeutic activities.
The term person-centered refers to a theoretical view of the nature of human beings
and their interactions, originally developed by Carl Rogers in the 1940s and 1950s, and to
a philosophy of how to relate to human beings in growth-producing ways, both inside and
outside psychotherapy. Rogers first developed his ideas in the form of client-centered ther-
apy and later changed the name to “person-centered” when he expanded the practice of his
ideas to other realms of human interaction, such as education and international conflict res-
olution. Both focusing-oriented psychotherapy and process–experiential/emotion-focused
therapy (PE-EFT, often abbreviated to EFT) evolved out of the person-centered approach.
They are part of a larger “family” of person-centered experiential psychotherapies (PCEP).

HISTORICAL BACKGROUND
Carl Rogers
As a youth, Carl Rogers spent much of his time on a farm, where he was particularly inter-
ested in the processes of facilitating growth. He also studied scientific experimentation with

221
222 EXPERIENTIAL AND HUMANISTIC APPROACHES

respect to agriculture. Facilitating growth and testing hypotheses characterized Rogers’s

experimental attitude toward both life and understanding human interaction. This attitude
guided the development of his theoretical constructs, as well as his interest in research,
which led to his being recognized as the “father of psychotherapy research.”
Rogers originally set out to be a minister. However, over the course of his college years,
his interests shifted toward psychology. A trip to China at the end of his senior year of col-
lege had a particularly significant impact on him. Congruent with his subsequent interest in
supporting each individual in their uniqueness, he became aware that there were many dif-
ferent ways to look at the world. He also witnessed extensive human suffering, and his goal
became to help people. This, and other experiences contributed to Rogers’s emphasis on the
importance of accepting people and on looking to bring out the best in them.
Later, when Rogers was working as a child guidance counselor, he was exposed to the
ideas of Otto Rank, especially as they were espoused and developed by Jessie Taft. Rankian
ideas that influenced Rogers included an emphasis on individuals’ creativity and potential,
with the aim of therapy being acceptance of the self as unique, and on individuals’ capacity
to grow and develop to overcome adversity. Rogers saw the client as the central figure in
the therapeutic process, emphasizing that clients have an innate sense of what they need to
develop, with the therapists’ role being to support this by focusing on clients’ present experi-
ence in therapy.
For Rogers, the most formative influences came from his experience with clients. This
is how he recalled their impact:

I had been working with a highly intelligent mother whose boy was something of a hellion.
The problem was clearly her early rejection of the boy, but over many interviews I could not
help her to this insight. . . . Finally I gave up. I told her that it seemed we had both tried,
but we had failed, and that we might as well give up our contacts. She agreed . . . and she
walked to the door of the office. Then she turned and asked, “Do you ever take adults for
counseling here?” When I replied in the affirmative, she said, “Well then, I would like some
help.” She came to the chair she had left, and began to pour out her despair about her mar-
riage, her troubled relationship with her husband, her sense of failure and confusion. . . .
Real therapy began then, and ultimately it was very successful. This incident was one of
a number which helped me to experience the fact . . . that it is the client who knows what
hurts, what directions to go in, what problems are crucial. (1961a, pp. 11–12)

In the 1940s Rogers formulated an early version of person-centered therapy, known

as “nondirective therapy.” This stage was characterized by a fundamental emphasis on the
therapist’s nondirectiveness: The goal was to create a permissive, open atmosphere that was
not driven by therapists’ techniques or agendas but rather was designed to facilitate clients’
self-disclosure and openness to their own experience. The major therapeutic “interventions”
were acceptance of the client and clarification of what the client was saying. By the 1950s,
empathic understanding of the client was increasingly emphasized, along with the thera-
pist’s receptivity to the client’s feelings. Later, in the 1960s, this shifted to an emphasis on
the congruence or genuineness of the therapist.
Subsequently, Rogers’s interests expanded beyond the field of psychotherapy. He began
to work increasingly in group settings to facilitate growth in nonpatient populations and,
in his last years, focused his energy on using the group format to foster world peace. The
person-centered perspective was also extended to education and medicine. There have been
 Person-Centered and Emotion-Focused Psychotherapies 223

many other innovations and derivations that have flowed from the person-centered phi-
losophy, including communication skills training, as well as programs for training parents,
leaders, and teachers, and for enhancing relationships (see Larson, 1984).
Carl Rogers’s impact on the field of psychotherapy has been profound. Smith (1982)
conducted a poll of members of the Clinical and Counseling Psychology divisions of the
American Psychological Association, as well as of members of the American Counseling
Association. Rogers was rated the most influential of all therapists, even more so than
Freud. A more recent survey (Cook & Biyanova, 2009) also found that Rogers is rated by
psychotherapists as the person who most influenced their work.

Eugene Gendlin
Another important figure in the PCEP approach was Eugene Gendlin, born in Vienna, Aus-
tria, in 1926. As Jews forced to flee the rise of the Nazis, his family emigrated to the United
States in 1939. In getting his family out of Austria safely, Gendlin’s father had to meet with
various sources and leads. In one case, after meeting with a man who supposedly was going
to help them, he decided he could not trust the man to ensure his family’s safe passage out
of Germany. His father explained his decision by saying that his gut feeling was “No.” It
subsequently turned out that his father had been correct about the man. Gendlin was quoted
as saying, “I was surprised then and often asked myself later what kind of feeling it is which
tells you something. Sometimes I tried to find such a feeling within myself, but I could not.
But that I started to look for it had its effect in the end. Forty years later when I was asked
how I could discover focusing, I remembered these circumstances” (Korbei, 1994, page
number unavailable). Later, when his father ran into someone else whom he felt he could
trust, they followed that person’s guidance and escaped successfully.
Gendlin (personal communication, April 2, 2007) also said that his parents did not get
along well, and from this he learned to see things from different points of view. He could
understand each of their points of view, but they could not understand each other’s. He
found that he became bored with that with which he agreed, so would read other points of
view. As a college undergraduate he developed a method whereby he could communicate
with people on both sides of various issues (e.g., religious people and atheists, Marxists and
McCarthyites, behaviorists and Freudians). The method was to accept their entire system,
then try to formulate whatever point was being made in terms of the ideas and symbols from
within that system. This became one of Gendlin’s primary interests: the symbolization of
experience.

Laura Rice and Leslie Greenberg

Another important figure in the PCEP approach was Laura Rice, who worked to under-
stand and promote clients’ experiencing in the session. Rice had studied with Rogers at the
University of Chicago in the 1950s (Rice, 1992). Born in 1920 in New England to parents
of Puritan descent, Rice was home schooled; she was in her early teens before she went to
a public school with peers, an experience that had a lasting impact on her as she struggled
to fit in (Watson & Wiseman, 2010). After graduating with her PhD, Rice worked in the
Counseling Center at the University of Chicago before moving to a faculty position in the
newly formed Department of Psychology at York University in Toronto, Canada. There she
224 EXPERIENTIAL AND HUMANISTIC APPROACHES

established a strong research tradition in psychotherapy process, while mentoring a number

of students who later became prominent, including Leslie Greenberg, Jeanne Watson, Wil-
liam Pinsof, Hadas Wiseman, and Robert Elliott, all of whom continue her work today.
Leslie Greenberg was one of Rice’s graduate students and later a colleague; together
they established a research paradigm called “task analysis” to help illuminate different client
processes in therapy. Out of this work they developed the process–experiential approach to
psychotherapy (Greenberg, Rice, & Elliott, 1993). While Rice was a firm adherent of Rog-
ers’s client-centered therapy, Greenberg was integrating her influence with that of Gestalt
therapists (see below). They each developed models of specific in-session change processes,
including systematic evocative unfolding for problematic reactions, two-chair dialogues at
conflict splits, and empty chair dialogues for unfinished business, which they subjected to
empirical testing and verification. These models would later become the basis for PE-EFT
(Greenberg et al., 1993).

Types of Clients with Whom the Approach Was Originally Developed

Person-centered therapy was developed from work with a wide range of clients in a number
of different settings. In terms of issues of cultural diversity, according to Howard Kirschen-
baum, Carl Rogers’s biographer,

Many of Carl’s clients in Rochester, Ohio and Chicago were lower class, many were
women, some were of color, and other minorities would likely have been represented. So
in that sense, Carl and his colleagues’ theories and methods would have grown out of their
experience with a somewhat diverse clientele. But Carl was intent on identifying universal
principles about growth, development and helping relationships, rather than on thinking
about treating different types of people and treating them differentially. (personal commu-
nication, May 18, 2018)

In terms of the diversity of problems Rogers treated, he worked first at child guid-
ance clinics in New York City and Rochester, New York. According to Kirschenbaum,
the children at the Rochester clinic “represented every behavior and personality problem
imaginable: enuresis, stealing, lying, extreme sex curiosity, sex perversions, sadism toward
animals or younger children, extreme withdrawal or aggressiveness, incest, stammering,
eating dirt and worms, and numerous other comparable problems” (Kirschenbaum, 2009,
pp. 62–63). Later, at the University of Chicago Counseling Center, Rogers and his col-
leagues saw clients from both the community and the college campus. In these settings, per-
son-centered therapists worked with problems of all types, including depression, anxiety,
personality disorders, and psychosis. During the late 1950s, a major research project with
people with schizophrenia resulted in elaborations to the theory and practice of person-
centered psychotherapy.

THE CONCEPT OF PERSONALITY

Personality as Process
The core of the person-centered concept of personality is that humans are growing, chang-
ing organisms, that is, living systems. While they may be comprised of personality traits
or cognitive schemas, as other theories propose, what is more important is that they are
 Person-Centered and Emotion-Focused Psychotherapies 225

dynamic organizations that are constantly configuring and reconfiguring themselves as

they interact with their environments. They are biological organisms more similar to trees
than to fixed structures. The organism is always changing and its processes elaborated in
relationship to events going on within them and around them. Personality structures, such
as traits or cognitive schemas, are not necessarily fixed in early childhood—they evolve.
Personality characteristics are “structures in process.” Even when a personality trait such
as dependency continues throughout a lifetime, it can evolve such that the way a person is
dependent as an adult may be different from, and more adaptive than, the way the person
was dependent as a child. Support for this idea is provided by a study that found immature
dependency evolved into a mature form of maintaining dependent relationships, with such
people becoming effective and caring partners with significant others (Caspi, Elder, & Her-
bener, 1990).
The person-centered view of personality therefore focuses on how the organism orga-
nizes itself, navigates through the world, and confronts problems. We consider the follow-
ing aspects: the focus on growth, the nature of the self, the idea of multiple realities, open
internal and external communication, the process of experiencing, emotion, and dialectical
constructivism.
According to the person-centered view, persons have a capacity for continual growth.
This capacity manifests itself in moment-by-moment adaptation. Behavior in any given situ-
ation is an integration of a person’s personality dispositions, or their preexisting knowledge
with the specific circumstances of a particular situation. The blend of preexisting knowl-
edge and current circumstances always results in slightly new and different behavior than
before. As behaviorist Robert Epstein (1991) has said, “The behavior of organisms has
many firsts, so many, in fact, that it’s not clear that there are any seconds. We continually
do new things, some profound, some trivial. . . . When you look closely enough, behavior
that appears to have been repeated proves to be novel in some fashion. . . . You never brush
your teeth exactly the same way twice” (p. 362). This implies that the most important
characteristics of the human being are the capacity for learning and creativity. Learning
results in constantly fleshing out and modifying beliefs, concepts, schemas, constructs, and
personality traits. On occasion, it leads to major, significant shifts in personality or belief.
The growth principle therefore operates most effectively if persons are able to be present
in the moment. This means they have to be open to information within themselves and to
information in their environment.
Rogers originally discussed this capacity for growth in terms of an actualizing ten-
dency in all living things. He later expanded this idea by suggesting that it was an individual
form of a broader, formative tendency found in the universe. This formative tendency is for
things (e.g., crystals, as well as living creatures) to move toward greater order, complexity,
and interrelatedness. On the level of the individual person, the actualizing tendency is the
inherent tendency of individuals to develop by maintaining and enhancing their function-
ing through forming more differentiated and integrated personal life structures. Although
the view of people’s capacity for growth was challenged for many years, recent advances
in medical science support the concept of neuroplasticity as just one of the many ways that
individuals grow and develop over the lifespan (Doidge, 2007).
It is because of this tendency that persons have a built-in potential for resilience. Based
on their research on children who grow up and survive in adverse circumstances, Masten,
Best, and Garmezy (1990) suggested that “studies of psychosocial resilience support the
view that human psychological development is highly buffered and self-righting” (p. 438).
226 EXPERIENTIAL AND HUMANISTIC APPROACHES

Following Rogers, Bohart and Tallman (1999) have argued that it is people’s capacity for
self-righting that is the primary force that makes psychotherapy work.
The view of persons as ongoing, evolving processes implies that they are inherently
interactional. They are in continual dialogue with themselves and their environments. Their
behavior arises both from their personalities and from relationships in their “ecological
niches.” It is meaningless to talk about individuals as if they are completely free of con-
texts. In this respect, person-centered theory has been called a “field” theory, meaning that
behavior arises from people’s perceptions and interactions with the field of relationships or
environment within which they are embedded.
The concept of self is key for person-centered theory. However, the self is not an entity
inside the person. It is a concept, or a “map,” that the person develops to help navigate the
world. This map should be held tentatively, because no map is the territory. Maps, as with
any other concept or belief, must be able to be revised and evolve with new input. The sense
of self, therefore, can evolve and become more richly differentiated over time. One may
continually discover new aspects of the self. However, holding the map of the self rigidly
can lead to psychological dysfunction. Self-actualization is the tendency of the organism to
enhance its own self-development. It can go in either positive or negative directions, depend-
ing on whether the person holds their self-concept tentatively, which promotes productive
learning; or rigidly, which promotes defensive and maladaptive development.* This in turn
depends on the kind of positive, supportive, or negative, invalidating life experiences the
person has had.
In spite of the emphasis on context, person-centered theory has been accused of plac-
ing excessive emphasis on individualism. Rogers postulated a move from other-directedness
to autonomy as a major goal of human development, similar to most theories of personal-
ity developed in the West. Rogers saw the fully functioning person as having an internal
locus of control and operating on the basis of personally chosen values rather than by rig-
idly conforming to the dictates of society. However, the emphasis on a separate, bounded,
autonomous self has been criticized by both feminists and multiculturalists as reflecting
largely Western, white male values. In cultures that hold a “sociocentric” view of the self,
the boundary of the self does not stop at the skin of the person but is extended to the family
or the group. Within these other cultures the determinants of behavior are seen as located in
a field of forces, which includes the self, in contrast to Western psychology, in which causes
are located inside the individual (Holdstock, 1990).
Although Rogers emphasized self-direction, he rejected our culture’s overemphasis on
self-sufficiency and believed in human interconnectedness (Holdstock, 1990). We believe
person-centered theory is compatible with an interconnected, sociocentric view of the self.
We interpret autonomy in terms of a sense of agency, a sense that one can take action, make
decisions, and confront challenge. It also refers to the sense that one can operate out of
motives that reflect one’s sense of self, even if the self is an interconnected sociocentric one.
There is research that shows that operating out of personally congruent motives is associ-
ated with positive outcomes in life (Ryan & Deci, 2017). Furthermore, a sense of ableness or
effectance may be more important than a sense of self-sufficiency. Because challenge is an

*Because there are members of the LGBTQ community who do not identify with either of the traditional
gender distinctions, we have chosen to try to avoid, as much as possible, the use of pronouns such as “he or
she,” “his or her,” or their variants. This means that there are occasions when we will use pronouns such
as “they” or “them” to refer to singular persons.
 Person-Centered and Emotion-Focused Psychotherapies 227

inherent part of doing most things that are worthwhile in life (careers, relationships, child
rearing), having a sense of ableness that one can confront and cope with challenges is funda-
mental to effective functioning (Dweck & Leggett, 1988). This sense of agency encompasses
a sense of responsibility for self, including one’s actions and feelings, as well as awareness
and consideration of other people and the environment.
The recognition that different cultures have different concepts of self is part of a larger
recognition that personal and social realities are fundamentally multiple. Individuals and
cultures find different viable but workable ways of constructing personal realities. There-
fore, PCEP therapists respect the potential for growth toward more effective ways of being
and the possibility for change within each person’s personal reality rather than try to impose
a so-called objectively “correct” way of being on them. This belief makes PCEP theory par-
ticularly compatible with the belief in the importance of respecting cultural diversity.
Because person-centered therapists assume that each individual’s subjective, perceptual
universe makes sense, facilitating communication among different people’s personal reali-
ties, including those between therapist and client, is more important than judging who has
the correct view. PCEP therapists believe that open sharing of feelings and perspectives in
a mutually respecting and accepting atmosphere will facilitate movement toward mutual
understanding, and mobilize both individual wisdom and the “wisdom of the group”
(O’Hara & Wood, 1983).
An open internal process of communication in which all aspects of the self are respected
and listened to is equally important. Open, “friendly” listening to thoughts, feelings, and
experiences, including internalized “voices” from parents and society, allows one’s “internal
community” to move toward creative synthesis. All internal voices may have something to
contribute. The capacity to listen to and integrate the information from multiple sources to
enhance well-being is what person-centered therapists call congruence.

Experiencing and Feelings

Person-centered and experiential therapists value both intellectual, rational thinking and
feelings and experience as important sources of information about how to deal with the
world creatively. However, being open to internal experience is particularly important for
effective functioning. Rogers originally talked about an “organismic valuing process.” He
argued that the organism “knows” what it needs for survival and growth. Persons function
most effectively when they are aware of and take into account the “wisdom of their organ-
isms.”
Later, Gendlin developed his theory of experiencing, which Rogers adopted. Experi-
encing is a different, more fundamental way of knowing self and world than can be acquired
from rational, conceptual thinking alone. Experiencing is also different from emotion; it is
the immediate, nonverbal sensing of patterns and relationships in the world and within the
self. It includes what is often called “intuitive knowing.” However, there is nothing mysteri-
ous about it. We can sense or perceive relationships that we cannot easily describe in words.
People can, for instance, sense or “feel” when a human face is drawn out of proportion,
before they can cognitively and intellectually identify what is wrong with it. Porges (2009)
highlighted the role of neuroception in emotional responding and social interactions. Simi-
lar to Gendlin, he defined neuroception as an inner, bodily felt sense that provides informa-
tion to the organism about what is happening in the environment to assess safety and threat.
The meanings that are acquired through direct experiencing are more powerful than
228 EXPERIENTIAL AND HUMANISTIC APPROACHES

meanings acquired through conceptual thought. The experience of feeling loved in a rela-
tionship is a complex, whole-bodied sense of interaction that has more to it than any intel-
lectual or conceptual description can convey. Infants can tell from their interactions with
their mothers whether the latter are empathically attuned to them, before they can put that
knowing into words. We experience the world long before we develop the capacity for lan-
guage. Gendlin (1970) believed that experiencing is more complex than conscious verbal–
conceptual thought and is the source of creativity. Einstein, for instance, had a nonverbal
“felt sense” of relativity theory before he had spelled it out in concepts. Internally we have a
“felt sense” of how our lives are going and how each specific situation presents itself to us.
According to Gendlin, it is at the level of felt sense that therapeutic change must take place.
Therapy must lead to a directly felt shift in how we relate to the world, rather than merely to
intellectual change. Gendlin’s (1996) focusing-oriented psychotherapy is based on this idea.
Person-centered therapists are well-known for advocating “getting in touch with” and
“trusting” feelings. This is not a blind trust but rather one that suggests we need to be open
and allow ourselves to be informed by our feelings. Feelings, from a person-centered view,
are not synonymous with emotions; instead they can refer to the immediate, nonverbal
sensing of patterns and relationships in the world and within the self that we mentioned
previously. Although we can feel anger and sadness, we also feel or sense complex meaning
patterns. To be aware of feelings, therefore, is to be aware of both emotions and of sensed
patterns of relationships between self and world. One can “feel that something is wrong in
a relationship” and “feel that one’s life is out of balance.” To “trust one’s feelings” means to
listen to them as a source of information and to be in dialogue with them. It does not mean
to do what they say.
For example, a client came to one of us (Bohart) after seeing another therapist. His
problem was that he was feeling that his wife did not love him. Yet intellectually, when he
thought about it, he could identify no logical reason for that feeling. His wife claimed she
loved him, and the other therapist had concluded that he was misperceiving the situation
based on childhood problems with his mother. A month or two after he had started to see
Bohart, the client’s wife suddenly announced that she was leaving him. She admitted that
she had been having an affair for months and was in love with someone else. Clearly, the
client’s feeling had been based on his apprehension of a set of subtle changes in his wife’s
manner of relating that were so subtle that his intellectual, rational side could not identify
them. If he had been able to trust his feelings, he would have explored his experience more
carefully and might have been able to identify the subtle cues involved.
Person-centered theorists believe that fully functioning people use all their faculties.
They use their ability both to think rationally and to problem-solve, and to sense experien-
tially what is personally meaningful to them.

Emotion
Theorists of PE-EFT, while viewing experiencing as important, have particularly empha-
sized the role of emotion in both human functioning and psychotherapy, and have incor-
porated emotion theory and dialectical constructivism (explained below) into their view of
human functioning and change. These theorists see emotion as fundamentally adaptive and
as providing information quickly and efficiently to individuals about the impact of their
environments, so that they can respond to meet their needs and goals. For example, to seek
solace when sad, or to set limits when violated. According to recent developments in PE-EFT
theory, emotion alerts individuals to what is important and significant in their environment
 Person-Centered and Emotion-Focused Psychotherapies 229

and provides a sense of the personal meaning of events. It is regarded as coordinating experi-
ence and providing a sense of unifying wholeness (Elliott, Watson, Goldman, & Greenberg,
2004). Process–experiential theorists suggest that emotion schemes organize experience.
Emotion schemes consist of four elements: perceptual–situational, bodily–expressive, moti-
vational–behavioral, and symbolic–conceptual.
The perceptual–situational aspect refers to the person’s awareness of the external situ-
ation, as perceived and often accessed through episodic memories. The bodily–expressive
aspect refers to the bodily reaction and felt sense (e.g., experiencing a sense of helplessness
when ridiculed). The symbolic–conceptual aspect refers to the verbal and visual representa-
tions of experience or the labels we apply to differentiate states (e.g., irritation, anger, rage).
These may be metaphorical articulations or imagistic representations of the felt sense of
being in the world. The motivational–behavioral aspect refers to the needs, actions, and
behaviors that accompany different emotional states (e.g., crying when sad or running away
when scared; Greenberg et al., 1993).
Another aspect of emotion theory that informs recent variants of PE-EFT is the role
of affect regulation. These theorists (Elliott et al., 2004; Greenberg et al., 1993; Kennedy-
Moore & Watson, 1999) identify a number of processes and activities that facilitate affect
regulation, including awareness, acceptance, labeling, reflection, and modulation of distress
and expression. They see these activities as key to the therapeutic process and to person-
centered and experiential psychotherapies in particular (Watson, 2007). An important com-
ponent of person-centered theory is the focus on clients’ inner experience. Rogers observed
that one of the processes in person-centered therapy is that clients become more aware of
their experience and work to symbolize or represent that experience in words. This process
is akin to becoming aware of feelings and labeling them in conscious awareness (Wexler &
Rice, 1974). In addition, process–experiential theorists are concerned with helping clients to
accept and tolerate their emotional experience and internalize and develop ways of soothing
themselves when it is intolerable, as well as to develop ways of expressing it so that they can
realize their goals and meet their needs in ways that are appropriate to their current context
(Greenberg et al., 1993).

Dialectical Constructivism
The other important influence incorporated into PE-EFT theorists’ accounts of personality
is dialectical constructivism (Greenberg & Pascual-Leone, 2001). According to this view,
the self is a constantly evolving but organized multiplicity of selves (Elliott, Watson, et al.,
2004; Greenberg et al., 1993). Thus, people are seen as consisting of different voices, or
aspects of the self. Other experiential theorists describe them as experiencing potentials
(Mahrer, 1983). These experiencing potentials or voices emanate from different emotion
schemes that are triggered by interactions with the environment. According to this view,
no single way of construing the world is dominant; rather, there are an infinite number of
ways a person can construe and interact with the world given the multiple ways of perceiv-
ing experience.

Theory of Development
Person-centered theory has implied but not emphasized a view of development. First, the
infant at birth is an active, curious, exploratory organism, interested in learning about the
world and intrinsically interested in developing its own capacities. The child listens to and
230 EXPERIENTIAL AND HUMANISTIC APPROACHES

learns from interacting with others. The child is particularly interested in learning what
results from their own efforts and exploratory activity.
The child is seen as a growing organism whose development continues across the lifes-
pan. In contrast to classical psychoanalytic theory, in which early experience is seen as
“foundational,” and as the primary shaping influence on all later constructions of personal
reality, PCEP approaches hold that all developmental periods are important. As people
develop, they are capable of incorporating what was learned earlier into broader and more
inclusive frameworks for understanding themselves and their world. Only if early experi-
ence is continuously invalidating or particularly traumatic may development be significantly
constrained by it. Otherwise, earlier ideas and experience are retained but are integrated
into newer, more sophisticated constructions of reality. This view of development is similar
to the ideas on cognitive development of the psychologist Jean Piaget (Cowan, 1978).
Humans are oriented more toward exploring and confronting challenge than toward
avoiding pain and frustration. Psychodynamic theorists assume that humans have a “ubiq-
uitous tendency to avoid pain” (Strupp & Binder, 1984, p. 32), and that children (and adults)
commonly avoid, deny, and repress painful experiences or emotions. While not denying that
people want to avoid pain, we are frequently amazed by our clients’ courage and persistence
in confronting painful and challenging situations in an attempt to master them and find
alternative means of coping. Children repeatedly face up to painful events and frustrating
experiences in attempts to master and cope with their experience. Consider, for instance,
a child as she learns to walk. She repeatedly falls, yet gets up and keeps trying. Pain is a
response that alerts organisms to harmful experiences. In the absence of other coping strat-
egies, humans may attempt to avert painful experiences especially if they feel incompetent
to deal with them, as might occur with overwhelming experiences such as early childhood
abuse. However, painful experiences also pose problems for people to solve, with the result
that they may continue to revisit painful experiences to find more effective ways of handling
them than merely avoiding them.

PSYCHOLOGICAL HEALTH AND PSYCHOPATHOLOGY

From a PCEP perspective, abnormal behavior is an attempt to cope that goes wrong. It
is likely to arise if a person is unable to utilize their potential to operate in an evolving,
growing way. Psychological problems are not faulty beliefs or perceptions, dysfunctional
emotional reactions, nor are they inadequate or inappropriate behaviors per se. As humans
confront challenges in life, they periodically misperceive, operate on mistaken beliefs, expe-
rience anxiety or depression, and behave inadequately. Dysfunctionality occurs if we are
unable to be open to information so that we can learn from feedback. As a result, we remain
stuck in misperceptions, dysfunctional emotions, or inadequate behavior. Dysfunctionality
is the result of blocks to learning.
According to Rogers, a primary cause of dysfunction is incongruence between aspects
of the self-concept and experience. For example, Janet was a premed student one of us
(Bohart) knew in college. Part of her self-image was that she was going be a doctor, yet she
experienced classes in biology and chemistry as alien and unfulfilling. The incongruence
between her self-concept and experience troubled her.
However, it is not incongruence per se that creates dysfunctionality but how the per-
son responds to and tries to resolve the incongruence. All people experience incongruence
 Person-Centered and Emotion-Focused Psychotherapies 231

periodically. If constructs are held tentatively, one will be able to work toward integrating
disparate aspects of the self, and information from without. It is from such integration that
creativity arises. However, if aspects of the self-concept are held rigidly, integration and
synthesis are blocked.
People learn to hold parts of their self-concept rigidly when parents, teachers, or culture
impose conditions of worth on them. They are made to feel that they are of value only when
they conform to others’ standards and values. This leads to the adoption of rigid “shoulds”
about how they are supposed to be. When incongruence between rigid “shoulds” and expe-
rience occurs, people are unable to challenge their “shoulds” and so may respond by trying
to ignore their experience or by misinterpreting it. Being unable to listen to their own experi-
ence, they disempower themselves. They then rely exclusively on the rigid “shoulds” to guide
their choices. When that does not resolve anxiety and incongruence, they feel helpless and
may develop dysfunctional behavior. Janet had been “programmed” for years by parents
and teachers to become a doctor. To follow this she had to ignore inconsistent feelings, such
as those toward her chemistry and biology classes. This appeared to affect her personality as
well. She came across as a distant and guarded person. One day, however, she came to class
and was open, warm, and friendly. She told Bohart that she had made a major decision and
had changed her major to literature. She disclosed that she had finally begun to listen to her
experience and had realized that she did not want to be a doctor. Trusting that part of her
experience allowed her to “open up” in other ways.
In general, it is when individuals are not open to experience, particularly internal expe-
rience, that problems arise. Gendlin held that psychological problems result from a failure to
listen empathically to the flow of internal experience (to “focus”) in a manner that promotes
creatively working on problems. In cases of major disruptions in personal functioning, such
as schizophrenia (Gendlin, 1967), individuals come to feel that their own inner life is so
chaotic and “sick” that they turn away from it altogether, assuming that there is nothing
there to be trusted.
PE-EFT theorists have a related but slightly different view. They particularly emphasize
the importance of emotional reactions in human functioning. Emotions reflect action ten-
dencies, which inform people as to what they need in a given moment. Therefore, the failure
to be aware of or to access emotional information interferes particularly with adaptive capa-
bilities. This failure may lead to a persistence in dysfunctional reactions and an inability to
choose new behaviors flexibly to meet the demands of a situation.
Recent variants of PE-EFT theory distinguish between primary adaptive emotion and
three types of dysfunctional emotional responses (Elliott, Watson, Goldman, & Greenberg,
2004; Greenberg et al., 1993). Primary adaptive emotion is regarded as a direct emotional
response that is consistent with the situation and enables the person to take appropriate
action in response to it. Examples include expressing happiness at seeing a significant other
or taking a rest when tired. These types of automatic responses are essential for survival.
In contrast, dysfunctional responses include maladaptive emotional responses, secondary
reactive emotions, and instrumental emotions. These theorists see maladaptive emotions
as emanating from overlearned responses to difficult and traumatic experiences. They are
viewed as not adaptive to the current life situation and as interfering with current function-
ing. Secondary emotions are those that occur in response to adaptive emotions so as to
transform them (e.g., becoming angry when hurt in order to hide vulnerability; or being
disgusted by fear when forcing oneself to be brave in the face of danger). Instrumental
emotions are deliberate attempts to use emotional reactions as a way of manipulating or
232 EXPERIENTIAL AND HUMANISTIC APPROACHES

controlling others. When using instrumental emotions, a person is being deliberately and
consciously incongruent in order to try to influence another’s behavior (e.g., appearing sad
to receive a reward, or acting hostile in an attempt to intimidate the other). Emotion schemes
enable a person to synthesize experience, and they provide both a holistic sense of the person
in a given situation and specific emotional reactions, which organize the person for action.
Psychological problems occur because individuals either fail to attend to and symbolize their
own internal reactions or because of rigid “emotion schemes.”

When One Is Functioning Fully

Rogers and his colleagues (e.g., Rogers, 1961b) developed a Process Scale to measure change
in therapy from “dysfunctional” to more “fully functional” ways of being. He described the
scale thus: “It commences at one end with a rigid, static, undifferentiated, unfeeling, imper-
sonal type of psychologic functioning. It evolves through various stages to, at the other end,
a level of functioning marked by changingness, fluidity, richly differentiated reactions, by
immediate experiencing of personal feelings, which are felt as deeply owned and accepted”
(p. 33). When people are functioning fully, they are therefore fluid and flexible: holding
constructs tentatively, testing them against experience, open to and accepting of feelings,
listening to and learning from feedback, dialoguing with themselves and their surroundings,
and experiencing themselves as able to direct their own lives.
Full functioning refers to a mode of being, namely, that of operating as an evolving
process. This does not mean the person necessarily feels fulfilled, content, or even happy
(Rogers, 1961a). Nor is there such a thing as a “fully functioning person” who is always
operating optimally. Even when functioning fully, people may periodically feel blocked,
incompetent, inadequate, or frustrated. However, by being in touch with the inner flow
of experience and processing it, they are able to struggle with problems, try to learn, and
continue to develop.

THE PROCESS OF CLINICAL ASSESSMENT

Person-centered and experiential therapists generally do not find traditional diagnostic or

assessment procedures useful. Such procedures encourage an “outside” expert perspective
on the client, as if the client were being put under a microscope and dissected. This is anti-
thetical to the person-centered, empathic stance in which the therapist’s focus is on the
unique experience of this client. Categorizing people tends to bias the therapist toward treat-
ing the individual as a member of a class rather than as a unique being. Person-centered and
experiential therapists would be interested in understanding and relating to Jack or Carolyn,
not Jack-the-person-with-borderline-personality-disorder or Carolyn-the-narcissist. More-
over, the nature of the PCEP relationship encourages greater sharing of power, because
clients are seen as the experts on their own experience and the therapist, as a companion
or guide. However, because the mental health field uses diagnostic labels, person-centered
therapists employ them for communication purposes.
In contrast to other PCEP therapists, process–experiential therapists (Greenberg et al.,
1993) make process diagnoses in therapy, which are assessments of how clients are relating
to their emotional experience at any given moment in the session. For example, whether a cli-
ent is experiencing a conflict between alternative ways of acting or repeatedly experiencing
 Person-Centered and Emotion-Focused Psychotherapies 233

negative feelings in the presence of a significant other, indicates that the client’s experiencing
with the other is stuck. These ways of processing emotion are thought to indicate dysfunc-
tional emotion schemes that clients are struggling to change. These moments are seen as
indications that the client may be ready to work on these issues at that point in therapy. It
is important to note that the therapist does not identify the emotion scheme or its content
(e.g., perceiving a raised voice that triggers feelings of shame and anger toward another
because one’s father had been critical and angry). Rather, the therapist notes that the client
is experiencing some block in the process of resolving a personal problem. These blocks
are identified by markers, which are specific verbal, behavioral, or emotional signs that a
client is struggling with a particular kind of emotional processing problem. For instance, a
marker for a problematic reaction point (PRP) is that clients are puzzled by their reaction to
a situation or person, which may consist of feeling that their reactions were unreasonable,
dysfunctional, exaggerated, or unexpected.
The identification of specific markers suggests to the therapist what type of interven-
tion to suggest to the client in the moment to foster the client’s exploration to understand or
resolve what the client experiences as problematic. Process diagnoses and the corresponding
interventions are informed by therapists’ implicit knowledge of what happens in therapy, as
well as from intensive study of clients’ successful performances and resolution of specific
blocks such as problematic reactions. Thus, at a marker for a PRP, PE-EFT therapists might
suggest that, together with the client, they engage in systematic evocative unfolding to access
the client’s episodic memory of a situation and the accompanying feeling or emotion to
identify the trigger for the reaction and to help clients gain a better understanding of it. If
a client agrees that focusing on the PRP would be useful, the PE-EFT therapist will gently
ask the client to describe the memory vividly using concrete, specific, and detailed language,
while they track when the reaction was triggered to isolate what was salient in the moment.
This way of representing experience can help clients gain a better sense of their experiencing
in the moment, including their feelings, perceptions, environmental stimuli and bodily reac-
tions, when the reaction occurred.

THE PRACTICE OF THERAPY

The core of PCEP practice is for therapists to focus on what is happening between themselves
and the client in the moment. This includes focusing on both the client’s moment-by-moment
experience and the therapist’s own moment-by-moment experience with the client. Working
with what is most “alive,” present, or central for the client is thought to be the best way to
promote the client’s processes for change. Therapists focus on connecting and dialoguing as
clients’ ongoing attempts to change, stabilize, understand, or reorganize themselves emerge
in the moment. Although most PCEP therapists would agree with this, there are differences
in how they work with the moment-by-moment process. Traditional person-centered thera-
pists operate in a “nondirective” way. The therapist’s goal is to be a companion on the client’s
journey of self-discovery. By being warm, empathic, accepting, and genuine, the therapist
provides an atmosphere in which the client’s own thrust toward growth can operate. Thera-
pists largely stay within the client’s frame of reference, focusing their efforts on understand-
ing and reflecting the client’s communication and experience. Rarely would a traditional
person-centered therapist suggest a technique or engage in self-disclosure.
However, a trend in the 1960s among some person-centered therapists was to treat
234 EXPERIENTIAL AND HUMANISTIC APPROACHES

person-centered therapy more as a philosophy of therapy than as a specific way of doing

it. It was argued that if therapists were warm, accepting, empathic, and genuine, while
respecting clients’ growth processes, they could go beyond the traditional nondirective
mode, share their own thoughts and reactions, and even suggest techniques. For many
therapists, person-centered therapy became a philosophy in whose context they could prac-
tice in eclectic ways. Natalie Rogers (1997), Carl Rogers’s daughter, included art and dance
in her “person-centered expressive therapy.” Similarly, Gendlin’s (1996) focusing-oriented
therapy and Greenberg et al.’s (1993) PE-EFT hold that therapists can systematically facili-
tate clients’ experiencing in the moment (e.g., by use of the Gestalt two-chair technique) to
help them resolve problematic issues and grow while remaining essentially person-centered.

Philosophy of Therapy
Person-centered and experiential therapies are based on the belief that it is clients who
ultimately “heal” themselves and create their own self-growth (Bohart & Tallman, 1999).
People are “built” to evolve and grow, although external processes can facilitate or retard
that process.
Person-centered and experiential therapies are unique in comparison to most other ther-
apeutic approaches in how much they emphasize the self-righting, self-healing tendencies of
the person. The focus of person-centered and experiential therapists is to provide optimal
conditions under which the intrinsic self-organizing and growth tendencies of the person
can operate. Under supportive conditions, the client’s thrust toward growth overrides any
tendencies toward avoidance of pain. Given proper conditions, clients move toward whole-
ness, psychological health, and interpersonal effectiveness and responsibility. Therapists do
not have to make clients face up to even extremely repressed, painful experiences, such as
those of early childhood abuse. If conditions are provided under which clients can begin to
develop a sense of self-efficacy in their own capacity for self-righting and growth, they will
come to face up to such experiences when necessary for their continued development. At that
point, such experiences begin to emerge naturally as a part of the process of self-healing.
Person-centered and experiential psychotherapists accept where clients are in their devel-
opment and growth when they come into therapy. If the client’s problem is feeling chronically
tense, the PCEP therapist works on what the client chooses to focus on and does not assess
whether there are “deeper issues” to confront. This is due to the belief that clients’ develop-
ment of their capacities for self-direction and self-regulation are the most important aspect of
therapy, and that clients delve deeper when necessary, and when they are ready. This is also
true for PE-EFT psychotherapists who may try to facilitate and augment clients’ experiencing
by suggesting different ways of working in therapy. However, they remain respectful of their
clients’ sense of self-direction and what is important to them at different times.

Basic Structure of Person-Centered and Experiential Therapies

PCEP therapists are flexible in how they, in dialogue with the client, structure the therapy
interaction. A client might be seen more or less than once a week, sessions might be longer
or shorter than 1 hour, and meetings might or might not be held in the therapist’s office. For
example, Gendlin (1967) worked with hospitalized patients by taking them for a walk to the
hospital cafeteria. One of us (Bohart) worked with a young hospitalized client with para-
noid schizophrenia by meeting with him on the hospital lawn. The other (Watson) worked
 Person-Centered and Emotion-Focused Psychotherapies 235

with a severely developmentally challenged and autistic young man by accompanying him
in an exploration of a garden reflecting his interests and actions, in a manner that is known
and formulated as pretherapy (Prouty, 1990). Person-centered and experiential therapists
do not dictate the number of sessions that may be required for each person. Although usu-
ally several sessions are necessary, person-centered and experiential therapists believe that
it is possible for important change to occur in a single session. At the other end of the con-
tinuum, some people may need to be in therapy for a number of years to address adequately
the issues they seek to resolve. Thus, no meaningful “average length” can be prescribed for
person-centered therapy. Person-centered and experiential therapists might use any or all of
individual, couple, family, or group therapy formats.

Goal Setting
Person-centered and experiential therapists believe that it is the client who, at some level,
knows what hurts and what needs to be changed, although it may take the therapy process
to access this knowledge. Therefore, therapists do not set goals for what changes clients need
to undergo in order to improve. In PCEP, it is the client who sets the goals. However, there
is a difference in whether the therapist explicitly starts therapy with a discussion over goals.
Traditionally, person-centered therapists start right out in dialogue with the client. They
might ask, “How can I help?” But beyond that, they would not focus on setting explicit
goals unless the client wanted to do so. If the client starts the session by launching into their
problems, the therapist goes with that. Goals may never be discussed if the therapeutic pro-
cess is moving along. However, in process–experiential work when specific techniques such
as chair-dialogues are introduced, it is essential to get clients’ agreement about engaging in
the task and to ensure that they agree with the therapist’s framing of how the task might be
helpful to facilitate their goals.
Although all person-centered and experiential therapists agree on not setting goals for
what clients need to change, they differ on whether to have goals regarding how best to help
clients find their own answers. Traditional person-centered therapists set no goals for their
clients or for the therapy process at all. Although traditional person-centered therapists
believe that therapy leads to outcomes such as people being more open to experience, more
fluid, and more differentiated, they believe that these changes are most likely to occur if they
do not try to make them happen but focus instead on how they can best be present with their
clients. Traditional person-centered therapists’ goals are ones they set for themselves: to be
empathic, accepting, respectful, and congruent.
In contrast, while focusing-oriented and process–experiential therapists, like their per-
son-centered counterparts, agree that there are no clearly defined outcomes other than the
ones set by their clients, they nonetheless may suggest specific process goals to clients. This
is an attempt to help clients who feel stuck to resolve certain cognitive–affective problems,
such as feeling more confident and empowered in their interpersonal relationships or resolv-
ing a conflict about two different courses of action or better understanding their reactions.

Techniques and Strategies

Person-Centered Psychotherapy
For person-centered therapy, the establishment of a facilitative therapeutic relationship is
itself the therapeutic technique and strategy. The process of “being with” the client in the
236 EXPERIENTIAL AND HUMANISTIC APPROACHES

sense of accepting the client as they are, respecting the client’s agency and supporting their
capacity for decision making, entering imaginatively into the client’s world of perception
and feelings, and being authentic, together with the client being able to receive what the
therapist offers, is sufficient for the facilitation of a process of change.
What the therapist primarily does is express their attempt to understand the client’s
experience. This often comes out in the form of reflection, which is a way of responding in
which the therapist tries to communicate understanding of what the client is experiencing
and trying to say, and implicitly asking the client to check whether it is accurate and fits.
Implicitly this acknowledges clients as experts on their feelings and perceptions, and encour-
ages them to reflect on them. Therapists reflect feelings, meanings, experiences, emotions,
or any combination thereof. They often go beyond what the client has explicitly said to try
to grasp the meanings and feelings the client is struggling to articulate and has left unsaid.
However, the therapist tries to grasp only what is within the client’s current range of aware-
ness of experiencing. The therapist does not try to grasp potentially unconscious aspects of
the client’s experience, which is the main theoretical difference between a reflection and a
psychodynamic interpretation. The following example compares a reflection and an inter-
pretation:

Client: “I’m feeling so lost in my career. Every time I seem to be getting close to doing
something creative, which would lead to a promotion, I manage to screw it up. I
never feel like I am using my potential. Something is blocking me.”
Reflection: “You’d really like to find out what’s blocking you from fulfilling your
potential.”
Psychodynamic interpretation: “It sounds like every time you get close to success you
unconsciously sabotage yourself. Perhaps success means something to you that is
troubling or uncomfortable, and you are not aware of what that is.”

Notice that this interpretation may, in fact, be accurate, but it is an attempt to make the
client think about their behavior as opposed to mirroring and adequately representing their
experiencing and facilitating further internal exploration and symbolization. Thus, it works
to bring to the client’s attention to something that is not currently in the client’s awareness.
This is the key difference between reflections and interpretations.
Although reflection has been the traditional form for expressing empathy, spontaneous
expressions of empathy may take many other forms (Bozarth, 1997), such as self-disclosure
of the therapist’s own experience in “resonance” with that of the client. At a given moment,
the sense of sharing between therapist and client might also lead the therapist spontaneously
to suggest a technique. Person-centered therapists are not banned from suggesting tech-
niques. It is how they suggest techniques that is important. A technique is only suggested
when to do so furthers the process of client and therapist working together in a mutual, col-
laborative relationship. It is not an attempt to “do anything” to the client or “make anything
happen.” The client is always free to reject the technique. However, techniques are suggested
infrequently by person-centered therapists. Although experiential therapists also emphasize
the client-centered nature of the relationship and prize the therapeutic conditions empha-
sized by Rogers, they, more frequently than their person-centered colleagues, tentatively
introduce other techniques or ways of working to facilitate clients’ process in the session.
While focused on working to provide therapeutic climates for clients to initiate change,
person-centered and experiential therapists are not opposed to the use of medication. They
 Person-Centered and Emotion-Focused Psychotherapies 237

would not decide for the client whether medication is indicated. They might discuss the
possibility of medication with the client, but it would be up to the client to decide whether
to pursue its use. If the client decided they were interested, the therapist would make the
appropriate referral.

Focusing-Oriented Psychotherapy
Gendlin’s (1996) focusing-oriented psychotherapy is based on the idea that change arises
from tuning into and working with a “bodily felt sense.” Research has shown that clients
grow when they actively refer inwardly to their experience and feelings, and articulate that
experience (Hendricks, 2002). They are less likely to grow if they talk about their problems
in distanced, intellectual ways or focus externally on the situations in their lives. Based on
this premise, focusing-oriented psychotherapists try to facilitate this experiencing process
in psychotherapy in three basic ways. First, they use a variant of empathic responding—
“experiential” responding. Experiential responses specifically focus on the felt aspects of
the client’s present experience and often rely on metaphors. An experiential response to our
aforementioned client might be as follows: “It sounds like you’re feeling really up against it,
like up against a big wall, which you’re trying to push aside, and you don’t know how to.”
A second technique used by experiential therapists is the sharing of their own immedi-
ate experience in the therapy relationship with their clients (Gendlin, 1967). This helps ther-
apist and client clarify the nature of what is going on between them, and provides a model
of how to relate inwardly to their own experience. For instance, the therapist might say to
a silent, sad client who has just suffered a loss: “Part of me wants to reach out and contact
you and talk about the loss, and part of me feels like I just want to sit in silence with you
and keep you company in your pain. I’m not sure what you want, but I want you to know
that I’m here if you want to talk, and I’m here even if I just stay silent with you for a while.”
The third technique is focusing (Gendlin, 1996). Clients are asked to focus inwardly
and to “clear a space” by imagining that they have set all problems aside for the moment.
Then the client reaches for the problem that seems most salient or that is “calling for atten-
tion” and tries to focus on how the problem feels inside. Although a person can think about
only parts of a problem at any given moment, they can feel all those parts together. The
client waits and listens to see whether some words or images or concepts come from the feel-
ing. This process often leads to a felt shift in which the sense of the problem reorganizes, so
that the person can get a better “handle” on the crux of it.

Process–Experiential/Emotion-Focused Psychotherapy
PE-EFT (Greenberg et al., 1993), an integrative psychotherapy based in a person-centered
view of the nature of the human being, also draws on ideas from cognitive theory, Gestalt
psychotherapy, and affective neuroscience. It is a member of a larger class of integrative,
emotion-focused psychotherapies that also includes “emotion-focused therapy for couples”
(Greenberg & Johnson, 1988; Johnson & Boisvert, 2002).
Carrying forward work by Wexler and Rice (1974) and others, process–experiential
therapists (Greenberg et al., 1993) view clients’ problems as resulting from inadequately
processing certain aspects of their experiencing, including cognitive–affective information.
The goal of the PE-EFT therapist is to facilitate different types of cognitive–affective opera-
tions in the client at different times to enhance deeper exploration. The job of the therapist
238 EXPERIENTIAL AND HUMANISTIC APPROACHES

is (1) to listen for statements that clients make that indicate that they might be struggling
with a specific issue and suggest ways of working that might be useful, and (2) if the client
agrees, the therapist then offers suggestions and guides the client systematically through
specific steps—for example, more concrete description, as in the case of problematic reac-
tions points or imagining a significant other, as in empty chair dialogues. The specific steps
are all different ways to promote clients’ access to their inner experiencing and emotions.
It is close attention to clients’ behaviors, which serve as therapeutic markers, that guide the
therapist in choosing which intervention to suggest.
Greenberg and colleagues (1993) have modeled five basic therapeutic tasks, two of
which we briefly describe. The first client task is two-chair dialogues, one marker for which
is a conflict split, with the client torn between two different courses of action. Often one
side is governed by a value or “should” that says “do this,” while the other side may be gov-
erned by a “want” saying “I don’t want to.” With this marker, the Gestalt two-chair exer-
cise is suggested. In this task, the client role-plays both sides, speaking from the “should”
side, then switching chairs to speak from the “want” side. The objective is for the client to
become more aware of different aspects of the conflict to be able integrate the two sides in a
manner that allows the client to move forward. Clients are encouraged to clearly articulate
each side of the conflict, with its concomitant needs, wishes, hopes, and fears. In the pro-
cess, clients often access organismic needs and feelings that may not have been represented.
This can lead to a shift in the power balance between the two sides as the client’s “should”
side sees the suffering or negative impact of its behavior and moves from talking in oppres-
sive, controlling language to expressing concerns, hopes, and fears. Instead of “You should
study harder,” it says, “I’m worried that if you don’t study harder, you won’t achieve your
goals, and that makes me scared, because how will we support ourselves?” This softening
or expression of vulnerability allows the “want” side to offer reassurance and negotiate a
better balance, such that the needs of both sides get met.
Another task that has been modeled is empty chair dialogues. The marker for this is
when clients express chronic negative feelings toward a significant other, often referred to as
“unfinished business” with another person. For this problem, a version of the Gestalt empty
chair exercise is used. In this dialogue, the client imagines the significant other and usually
gets in contact with their felt sense of the other and the relationship. They are encouraged to
express feelings and emotions to the other, along with what they wish for and need from the
other. After the client has expressed their feelings and needs, they may be asked to take on
the role of the other and respond to what the client has expressed. This role play allows the
client to symbolize the other’s response, which, if it is caring and concerned, can lead to a
resolution of the emotional pain experienced in the relationship with the other person, or, if
it is dismissive and uncaring, to greater self-protection and boundary setting. For instance,
a sexually abused daughter might role-play a dialogue between herself and her father. She is
supported by her therapist to express her rage, guilt, and sadness over what her father has
done to her. Once she has expressed her feelings fully and has the opportunity to respond as
her father. She may express deep remorse and sorrow that he harmed her, if this is how she
experiences her father. Alternatively, she may respond to him as an “unrepentant bastard.”
If the latter, the client may need to grieve the father’s inability to protect and care for her,
and to let go of her wish for him to do so as she assumes full responsibility for protecting
herself and ensuring she is not harmed again. Ideally, in either case, she will be able to let
go of her guilt and pain and instead reclaim a sense of her own worth and potency (Elliott,
Watson, Goldman, & Greenberg, 2004; Greenberg & Paivio, 1997).
 Person-Centered and Emotion-Focused Psychotherapies 239

Process of Therapy
For each of the previously described therapies, the therapeutic process is one of staying
closely with the “flow” of what is happening in the session. Therapists focus on what clients
bring up to talk about and do not try to guide the conversation toward topics they think are
important. What is talked about is not as important as the moment-by-moment process: For
example, are clients relating to themselves in a productive, growth-producing way no matter
what the content?
From person-centered and experiential perspectives, “resistance” is not a useful con-
cept. What other therapists call resistance may be defined as occurring when the therapist
thinks the client should be talking about something, feeling something, or doing something
other than what the client is doing. When clients are “resisting,” they are trying to follow
what they feel will best help them maintain or grow at that time. Person-centered and expe-
riential therapists respect the resistance and try to empathize with where the client is com-
ing from at that moment. Moreover, if there is resistance, then PCEP therapists use this as
an indicator that they may not be fully in tune with a client’s experience and need to work
harder at being more empathic and congruent in the session. Were an experiential therapist
to use a technique at that point, it would be used in an experimental way to see whether it
helps them coordinate better with their client and move the process forward. Clients grow
out of resistance if the therapist remains in empathic and genuine contact, but they may get
stuck in resistance if the therapist (or anyone else) relates to them in a “superior” manner—
correcting them or imparting “truth” to them. Virtually all the errors a person-centered or
an experiential therapist may commit arise from failing to be warm, empathic, and genuine;
imposing an agenda upon the client; or failing to be in touch with the unfolding moment-
by-moment process.
Because person-centered and experiential therapists invest so much trust in clients’ abil-
ity to direct their process of growth, termination of therapy is rarely a problem. In our expe-
rience, clients are motivated to move away from being dependent on the therapist to “trying
their wings” when they are ready. They do not need to be “fully healed,” with all problems
resolved, to try to live on their own. Problems are a part of life, and clients sometimes leave
because they now feel they can manage the problems on their own. Sometimes clients ease
themselves into termination by deciding to come every other week for a time instead of every
week, before they decide to stop altogether. In other instances, clients may just decide they
are ready to stop.

THE THERAPEUTIC RELATIONSHIP AND THE STANCE OF THE THERAPIST

The therapeutic relationship is the most important factor in both person-centered and expe-
riential approaches. According to Rogers (1957), the three primary conditions of a good
therapeutic relationship are unconditional positive regard or warmth, empathic under-
standing, and genuineness or congruence. Rogers postulated that these basic relationship
conditions are “necessary and sufficient” for therapeutic growth to occur.
The implications of Rogers’s (1957) statement were (and are) radical: It is the relation-
ship that is the “healing” element in therapy. Techniques, theoretical points of view, and
even professional training have little to do with making therapy work. Strupp and Hadley
(1979), for instance, found that untrained college professors, chosen for their sensitivity,
240 EXPERIENTIAL AND HUMANISTIC APPROACHES

were on average as therapeutic as professional therapists. Similarly, Anderson, Crowley,

Himawan, Holmberg, and Uhlin (2016) found that a pretherapy measure of therapists’
interpersonal skills predicted client outcome better than how much clinical training they
had.
Although experiential therapists would agree that the relationship is healing, they
believe that the use of additional techniques and strategies can facilitate the growth process
in therapy. In a sense, while they might agree that the relationship conditions are necessary
and sufficient for most clients much of the time, sometimes they are insufficient for clients
who may be blocked; that is, the use of exercises, such as the empty chair and focusing, can
enhance the effectiveness of the process.
Warmth or unconditional positive regard has also been called “acceptance,” “respect,”
“liking,” “prizing,” or even “nonpossessive love.” The quality is a basic attitude of lik-
ing, respecting, or prizing directed at the client as a whole person. It rests on a distinction
between the client as a person and the client’s behavior. Just as good parents continue to like
and prize their children even while disliking specific behaviors (e.g., writing on the walls
with crayons), the person-centered therapist continues to prize the client as a person even
when the client’s behavior is dysfunctional. Unconditional regard does not mean the person-
centered therapist conveys support or approval for dysfunctional behavior.
Feeling liked and prized as people, clients begin to feel safe to explore their experience
and to take a more objective look at their behavior. Clients are able to distinguish between
their intrinsic worth as persons and the dysfunctionality of current ways of experiencing
and behaving. Bozarth (1997) has held that unconditional positive regard is the core healing
element in therapy.
Empathic understanding is based on the ability to intuit oneself inside the client’s per-
sonal reality, to come as close as one can to seeing and feeling as the client sees and feels.
Studies that have investigated the role of mirror neurons, social understanding, and empa-
thy support Rogers’s view of empathy as an “as if” condition distinct from sympathy and
compassion (Watson & Greenberg, 2010). Currently, empathy is conceived as a complex
process, with three subprocesses located in different cortical areas, including the process of
simulating or imitating the emotion of others, perspective taking, and emotion regulation
(Elliott, Bohart, Watson, & Murphy, 2018).
From an “outside” perspective, client behavior often seems irrational, self-destructive,
manipulative, narcissistic, rigid, infantile, or egocentric. However, from an empathic, “inside”
perspective, behaviors that seemed dysfunctional and irrational from the outside usually
make “sense.” This does not mitigate the behavior’s dysfunctionality. Rather, it suggests
that from within the client’s skin, there is some understandable reason underlying it.
One client was arrested for exposing himself to his neighbor’s 12-year-old daughter.
As the therapist struggled to understand this behavior from the viewpoint of the client’s
personal reality, it became clear that the client felt totally helpless and impotent in his deal-
ings with this girl, whom he experienced as consistently making fun of him and treating
him with disrespect. Exposing himself was an extreme (albeit dysfunctional) reaction to one
particularly hurtful show of disrespect, and his way of expressing helplessness, anger, and
rage. We later describe what happened in this case.
There are a number of different positive therapeutic effects of empathic understanding.
First, the experience of being known seems to be intrinsically therapeutic. When a person
feels fully known and understood by another, it is as if the person comes into focus to them-
selves. The person feels better able to sort things out and to make choices. Second, finding
that there is some sense in their experience, even when they have acted dysfunctionally,
 Person-Centered and Emotion-Focused Psychotherapies 241

makes the person feel generally less “crazy” or dysfunctional. The person begins to have
some confidence in their own inner experience, which allows them to look at things more
carefully, to confront painful experience, and to change dysfunctional behavior.
Third, therapists’ empathic understanding provides a model of a “friendly” way for
clients to listen to their own experience. This friendly listening lets clients accept and hear
meanings that they previously feared because they seemed “unfriendly” to the self, thus
allowing them to begin to find more productive ways of dealing with those feelings and
meanings. As the aforementioned client began to listen to his own experience in a friendly
manner, he began to realize there was some “sense” in his impulsive act of exposing himself
to his neighbor’s daughter. He was trying to assert himself. He then decided that he wanted
to develop more proactive and less harmful ways of asserting himself and dealing with his
anger, which is what he and the therapist worked on.
Fourth, therapist empathic understanding helps to soothe the client and modulate emo-
tions. As clients begins to put experience into words and feel heard and understood, they feel
calmer and less anxious, and more able to confront difficult and painful experiences. Fifth,
therapist empathic understanding facilitates clients’ deconstruction of their experiencing
and worldview (Watson, 2002).
Genuineness or congruence refers to the degree to which therapists are in touch with
and aware of themselves in therapy. This does not mean that therapists act out feelings or
say whatever is on their minds. Rather, genuineness and congruence are matters of inner
connection. They have to do with the degree to which therapists are in touch with the flow
of their inner experience, and the extent to which their outward behavior reflects some truly
felt aspect of their inner experience.
Lietaer (1991) has distinguished between congruence and transparency. Congruence is
attending inwardly to one’s experience and working to sort out its meanings. Transparency
is the open self-disclosure of what the therapist is experiencing in the relationship. Although
person-centered therapists value self-disclosure in therapy, it should be “sensitively relevant”
to what promotes the therapeutic process. Rogers has argued that therapists should only
disclose their reactions when (1) they are persistent and (2) are getting in the way of the
therapeutic relationship itself.
Gendlin (1967) cautioned that therapists must self-disclose in more effective and pro-
ductive ways than the person in the street. The way people in the street are “honest” is often
to label, criticize, and judge (e.g., “You’re boring”). If the therapist has a reaction to a client
(e.g., anger), which the therapist concludes should be shared, the therapist first must work
with it themselves before self-disclosing. The therapist turns inward and tries to differentiate
between the degree to which the therapist’s reaction reflects their own issues and the degree
to which it reflects something useful in the relationship to be shared. The therapist then
shares it as their own reaction, not as “the truth.”
Recently, the emphasis on genuineness has contributed to the idea of the therapist work-
ing at relational depth with the client (Mearns & Cooper, 2005), which has to do with
the sense of closeness and connectedness that develops between therapist and client. These
experiences of “deep meeting” are not only highly meaningful but also therapeutic for cli-
ents and therapists alike.

Transference and Countertransference

Many person-centered therapists, including the authors, do not find the concepts of trans-
ference and countertransference to be therapeutically useful. These terms originate in
242 EXPERIENTIAL AND HUMANISTIC APPROACHES

traditional Freudian psychoanalytic theory. Transference refers to the tendency of the client
to read things into the therapist’s behavior based on the client’s past experience, primarily
those with caretakers. The traditional psychoanalytic meaning of countertransference refers
to the tendency of the therapist to read things into the client’s behavior based on the thera-
pist’s past experience and unresolved problems.
These concepts are problematic because they do not make meaningful distinctions
between different kinds of experiences. To understand the present, we always “transfer”
past experience onto it. Whenever we use past experience to interpret the present, there is
the possibility of error. For instance, in some other cultures, people stand much closer to one
another when they talk than they do in Northern European American culture. Based on our
past experience, we might misinterpret the behavior of people from such a culture as being
intrusive or overly familiar. We might continue to feel uneasy around them, even when we
know intellectually that we are just dealing with a cultural difference. We might also make
dysfunctional decisions about the person based on our erroneous interpretation.
The key is not whether we use our past experience to understand the present. It is
whether we are open to exploring our experience of self and the world in order to correct
possible misperceptions. Therapy is about learning how to be open in this respect. It is
important to attend to the discrepancies between what is new and different in the present
and our past experience, and use that to learn and to adjust our perceptions. Clients often
appear to persist in their “misreadings” of the therapist, but, from a PCEP point of view,
that is not because they are “transferring.” Rather, their ability to listen openly to correc-
tive information, both from others and from their own inner experiencing, is compromised
because they are feeling threatened, self-critical, or defensive. As they come to trust them-
selves and the therapist, and as they learn how to listen to their feelings, they become better
and better at being open to exploring and correcting possible misreadings of situations,
including misreadings of the therapist.
It is interesting to note that person-centered and experiential psychotherapists do not
often speak of transference issues with their clients. One reason for this might be that it
does not manifest as readily, if at all, in relationships where the objective is to remain within
clients’ frame of reference. While it is possible that PCEP therapists, like all therapists, might
inadvertently trigger a response from their clients by their behavior (e.g., a misunderstand-
ing of what a client is trying to communicate might make a client feel invisible, which might
resonate with extremely painful feelings of not being seen and cared for as a child), as long
as therapists are able to respond with empathy, acceptance, and understanding of those
feelings, as well as to validate how the client might have experienced the interaction, it is
likely that the feelings will be modulated and the relationship repaired. It is as if by trying
to remain within their clients’ frame of reference and being accepting of their reactions and
perceptions, PCEP therapists fly under the radar and seldom activate painful feelings from
the past within the therapeutic relationship.
With respect to countertransference, it once referred to the psychodynamic idea that
therapists “transfer” onto clients their own unconscious conflicts from childhood. More
recently, psychodynamic therapists take it to refer to the kinds of reactions that clients
“pull” from their therapists. Whereas traditional psychoanalytic therapists tried to elimi-
nate countertransference, modern psychodynamic therapists try to use it to understand their
relationship to the client. This is similar to how person-centered and experiential therapists
utilize their personal reactions to the client. For client-centered therapists, their reactions to
clients are always interactional—partly a result of how they experience the world, and partly
 Person-Centered and Emotion-Focused Psychotherapies 243

a result of how clients are impacting on them in the moment. As we have already noted,
therapists’ personal reactions can be productively used in therapy if they are expressed ther-
apeutically and owned as therapists’ own reactions rather than presented as objective truth
about the client. What is important is that both therapists and clients engage in a process of
coming to know what is unique and different about this person and this situation compared
to the past.

Relationship Problems and Disconnections (“Ruptures”)

For person-centered and experiential psychotherapists, misunderstandings, disconnections,
and temporary lapses in relationship trust are a normal part of human dialogue and rela-
tionships. They are an opportunity for therapist and client to learn how to better stay in
touch with one another, thereby furthering the therapeutic process. Since the main goal of
both person-centered and the experiential therapies is to stay in dialogue, such therapists
are particularly sensitive to a disruption in dialogue. This may be explicit—the client may
explicitly challenge the therapist, such as by telling the therapist that they are angry or hurt.
It may be implicit—the dialogue may lapse into an uncomfortable silence, or become life-
less. The nonverbal expression of the client may suggest that something is wrong.
At such times, the therapist will broach the issue, such as by self-disclosing: “My sense
is that something has gone wrong between us. I wonder if that is just my imagination or
if there really is something going on.” Hopefully, therapist and client then can dialogue
about what went wrong and learn from that experience. Gendlin (1968) has emphasized
that therapists and clients can learn as much from mistakes that happen in therapy as from
things that go smoothly.

CURATIVE FACTORS OR MECHANISMS OF CHANGE

From a person-centered point of view, the major “mechanism” of change is the client’s
capacity for productive and creative self-organization and growth, or what Bohart (2016)
has called an increase in the capacity for “self-organizing wisdom.” Therapists foster this
capacity through how they relate to clients. Provision by person-centered and experiential
therapists of an engaged, experientially supportive, empathic relationship, including the use
of empathically attuned techniques and procedures, provides a “conflict-free zone” that
mobilizes clients’ consciousness raising. As clients feel understood, supported, and “met”
by the therapist, their creative intelligence begins to overcome self-criticism, defense, and
emotional blocks. Clients become curious about their own experience and perceptions, and
begin to explore and trust them more. This exploratory process leads to the creative syn-
thesis of incongruities between different thoughts and perspectives, or thoughts and experi-
ences. It leads clients to learn to incorporate and include all their experience. Clients feel
free to try out new proactive behaviors, and allow themselves to fail with them before they
refine them, so that they become more effective. They also experiment with developing more
effective, satisfying, and responsible relationships with others.
As part of that process, clients relate to old traumatic experiences in new ways, allow-
ing them to be worked through and more productively incorporated into personal function-
ing. A person who was abused as a child may come to appreciate and value the processes
whereby they managed to preserve themselves and survive. The person may mine that for
244 EXPERIENTIAL AND HUMANISTIC APPROACHES

a sense of strength rather than one of weakness, and may find ways of using experience to
develop their own sensitivity and capacity for caring.
Because the therapy process is creative, therapists often do not know how new but
adaptive solutions will emerge. Mahoney (1991) and others have talked about the research
of Ilya Prigogine in chemistry and physics, who found that systems confronted with disor-
ganization can spontaneously jump to entirely new, more sophisticated levels of organiza-
tion. Person-centered therapists believe this is what often happens in therapy. Therefore, the
therapist does not have to be the expert who knows the answer. Rather, the therapist must
be a “process expert” who can facilitate the creative process.
Through clients’ own self-experimentation, they begin to build a sense of efficacy:
“I can learn and change and move my life forward.” Clients learn that they can struggle
with something they are up against and make some productive accommodation with it, no
matter how awful the problem. For instance, a client may learn to live productively even if
paralyzed. One learns that life is a process of continual confrontation of problems and chal-
lenges, and of moving forward.
In addition to raising clients’ consciousness of issues so that they can begin to solve
their problems in living, another active ingredient is internalization of the therapeutic rela-
tionship. Barrett-Lennard (1997) speaks of the self-empathy that develops out of the thera-
peutic relationship. With the development of self-empathy, clients come to accept and view
as legitimate their experience, and to represent it accurately, so that they can modify harsh
conditions of worth and develop other guidelines for living that are less annihilating or
neglectful of self. In addition, as clients come to attend to, accept, and try to represent accu-
rately their inner experiences, they learn to regulate their affect. In the process of exploring
their experience with their therapists, clients learn to become aware of their feelings and to
label them, more able to tolerate negative affect and to modulate both levels of arousal and
expression of feelings and emotions (Watson & Greenberg, 2017).
Focusing-oriented and process–experiential psychotherapists particularly emphasize
the role of feelings and emotions in the change process. However, unlike their more client-
centered counterparts, experiential and process–experiential therapists believe that it can
be helpful to provide clients with active guidance in processing different kinds of emo-
tional experiences that may be getting in the way of their capacity for productive self-
reorganization. Focusing-oriented therapy stresses the importance of clients tuning into the
bodily felt sense of their problems and turning that felt sense into words. This leads to a
creative unfolding process that produces a bodily shift in how the problem is experienced,
accompanied by a bodily felt reorganization of the problem in a new, more productive
way. Similarly, process–experiential therapy stresses a process of accessing emotions so as
to facilitate the restructuring of emotion schemes in terms of seeing a situation differently,
accessing different feelings in response to a situation, identifying new needs and goals, or
symbolizing experience in new ways.
Person-centered therapists do not explicitly teach life skills, as do some behavioral
therapists. Nevertheless, the process is one in which skills such as learning to explore and
to listen to one’s experience, as well as good communication skills, are modeled and experi-
enced. The client learns that there is something valuable in everyone’s experience, and that
it is better to listen to others than to impose one’s will and values upon them. Dialoguing
in an open, cooperative way about mutual problems is the best way to find a solution and
mobilizes the “wisdom of the group.” Respecting different ways not only is interperson-
ally important, but it also fosters the creativity that comes from openness to difference.
 Person-Centered and Emotion-Focused Psychotherapies 245

Experiential therapists, however, may include some teaching of life skills. The focusing exer-
cise, for instance, can be taught, then utilized as a self-help skill outside of psychotherapy.

Insight and Corrective Experience

Acquiring insight is not a primary change mechanism in person-centered or experiential
therapy, although clients often may attain it. Change often occurs without insight. It is
the direct experience of the therapy relationship itself that has the most impact. What one
learns about oneself is less important than the changes that come about in how one relates
to oneself, to others, and to problematic experience. These are complex, lived, whole-bodied
changes that occur in an experiential manner rather than being guided “from above” by
insight.
Corrective experience is a change mechanism in person-centered and experiential psy-
chotherapies, as well as in many other forms of therapy. Clients, who may have been dam-
aged by invalidating relationships either in childhood or in their current life, may learn
through the relationship with the therapist that they are valuable, that they make sense,
that they have a voice, that they can think and perceive in effective ways, and that they can
handle their own emotions (Watson & Greenberg, 2017). However, the therapeutic relation-
ship does not just provide a corrective experience. It also facilitates a creative experience, in
that clients not only learn that they have the generative capacity to creatively move their lives
forward in a positive way, but they also actively begin to do so.

The Role of the Therapist’s Personality

We have previously described how the therapist’s ability to be congruent and to be a real
person in therapy, as well as the ability to be warm and empathic, is crucial to the change
process. Good therapists seek out their own therapy whenever it appears that their problems
or personalities are getting in the way of providing a therapeutic environment for the client.

Factors That Limit the Success of Person-Centered and Experiential Therapies

Practically all the factors that limit the success of person-centered and experiential thera-
pists have to do with whether client and therapist create a good enough working relation-
ship so that the client engages actively in the tasks of therapy. Although person-centered
and experiential therapists have developed ways of working with unmotivated clients (e.g.,
Gendlin, 1967), effectiveness can be limited by low client motivation. To work with clients
who are in therapy against their will, such as court-referred clients or adolescents brought
by their parents, is challenging. The establishment of a good relationship becomes even
more central with such populations.
Clients with whom it is difficult to establish a relationship can likewise limit the effec-
tiveness of PCET. Working with clients with difficult emotional regulation problems (some-
times called “personality disorders”) can be challenging, not because their personality
structure is primitive, as some would say, but because some of them have difficulty staying
with the frustrations that are a normal part of the working environment of therapy. Based
on both our experience as well as on evidence, if a strong therapeutic alliance can be formed,
then these clients can be worked with effectively in a PCEP format.
It has been asserted at times that person-centered therapy is not useful with “nonverbal”
246 EXPERIENTIAL AND HUMANISTIC APPROACHES

clients. However, person-centered therapists have had success with nonverbal clients with
schizophrenia (Gendlin, 1967). Prouty (1990) developed pretherapy for working with people
with severely regressed schizophrenia, as well as those who are developmentally challenged.

Curative and Common Factors Shared with Other Approaches

There are features that PCETs share with other approaches. One example is the emphasis
on the relationship and on empathy (e.g., Bohart & Greenberg, 1997), now seen as impor-
tant in modern relational psychodynamic and self psychology approaches. The importance
of accessing emotion and experiencing is becoming more and more emphasized in both
cognitive therapy (see Cattie, Buchholz, & Abramowitz, Chapter 5, this volume) and recent
approaches to psychodynamic therapy (see Farber, Chapter 12, this volume). Additionally,
the person-centered therapist’s willingness to personally share and self-disclose is also being
used in both modern relational psychodynamic approaches (see Curtis, Chapter 3, this vol-
ume), and certain cognitive-behavioral approaches.
Motivational interviewing (Miller & Rollnick, 2012), an approach developed for the
treatment of alcoholism and other addiction problems, is based on the same fundamental
premise as PCEPs: that humans have considerable potential for self-righting and self-healing.
The core therapeutic strategy is the use of empathic listening. Miller (2000) reports research
that indicates empathic listening works better than confrontation with people who have
alcohol problems. In addition to empathic listening, motivational interviewing adds other
strategies that encourage clients to think out for themselves why it is to their benefit to
modify their drinking.
PCEPs place a heavy emphasis on acceptance of the client by the therapist. The
empathic, accepting therapeutic environment allows clients to access and to accept their
experience and themselves. Rogers often noted that clients need to accept themselves and
their experience in order to change. This idea of acceptance is now a key part of many mod-
ern cognitive-behavioral therapies (CBTs), such as Linehan’s dialectical behavior therapy
(Linehan, 1993), and acceptance and commitment therapy (Hayes, Strosahl, & Wilson,
1999; see Masuda & Rizvi, Chapter 6, this volume).
Finally, the importance of focusing on learning through experiencing has been hypoth-
esized to be a common factor by a variety of writers, and is now stressed in many different
approaches (Castonguay & Hill, 2012). For both person-centered therapy and the experi-
ential therapies, learning through experiential processes instead of through primarily intel-
lectual processes is the major way of facilitating change.

TREATMENT APPLICABILITY AND ETHICAL CONSIDERATIONS

PCETs have been used with a wide range of client problems, including alcoholism, schizo-
phrenia, depression, anxiety disorders, and personality disorders. There is empirical evi-
dence that PCETs are helpful with a variety of medical and health issues (Elliott et al.,
2013). They have also been used with individuals with mental handicaps and older adults
(cf. Lietaer, Rombauts, & Van Balen, 1990). Process–experiential therapy has been success-
fully applied to the treatment of depression (Greenberg & Watson, 2006; Watson, Gordon,
Stermac, Steckley, & Kalogerakos, 2003), trauma, and social and generalized anxiety (Sha-
har, Bar-Kalifa, & Alon, 2017; Watson & Greenberg, 2017). Focusing-oriented therapy
has been used with a variety of problems, including borderline personality disorders and
 Person-Centered and Emotion-Focused Psychotherapies 247

cancer (Greenberg, E1liott, & Lietaer, 1994). A number of person-centered therapists have
developed models for working with families and couples (Levant & Shlien, 1984; Lietaer et
al., 1990; O’Leary, 2012). Emotionally focused therapy (Johnson & Boisvert, 2002), a vari-
ant of process–experiential therapy, is an empirically supported approach for couples (see
Lebow & Kelly, Chapter 10, this volume). Person-centered therapy was originally developed
in a child guidance clinic, and person-centered play therapy has been employed successfully
with children (Bratton & Ray, 2002).
Their philosophy makes person-centered and experiential therapies particularly appro-
priate for work with people who have been marginalized in various ways, such as women,
minorities, people of different cultural backgrounds, or people of alternative sexual orien-
tations. This is because the therapist is not an “expert” who is going to impose the “right
way of being” on the client; rather, the therapist is a “fellow explorer” who tries to enter the
life world of the client in a curious, interested, accepting, and open way. The therapist tries
to work from the frame of reference that the client thinks is important. Paradoxically, this
might lead the therapist to become somewhat more directive with clients who might want
directiveness based on their cultural background, at least until they become comfortable
taking the “reins” into their own hands.
Working with people who come from different experiential backgrounds than the ther-
apist, however, imposes a particular responsibility on therapists to check continually to
make sure their perceptions of clients’ experience are not being colored by their own back-
ground and preconceptions. While this is expected when working with any client, it is all the
more salient when working with clients whose experience may reflect diverse intersections
in terms of culture, sex, gender, race, socioeconomic status (SES), and so forth. Despite
the fact that PCEP theory dictates openness to different ways of experiencing and constru-
ing reality, PCEP therapists, like all therapists, must be careful that their implicit cultural
assumptions do not color what they do. This requires therapists to draw heavily on the
relational attitudes of empathy, prizing, acceptance, and genuineness that see every human
being as unique, facing their own distinct set of challenges. However, Fuertes et al. (2006)
emphasized that when working with diverse populations, therapists need to be empathic
with their clients’ specific circumstances, as well as the complexities inherent in their social
and political locations. Diverse clients’ perceptions of their therapists as empathic are highly
correlated with reports of greater satisfaction with treatment and an intention to follow up
on treatment recommendations (Fuertes et al., 2006, 2007; Gillispie, Williams, & Gillispie,
2005). These findings suggest that clients from diverse groups may have a greater need for
therapists to be understanding, nonjudgmental, and emotionally supportive during treat-
ment to ensure they continue to participate.
An in-depth understanding of clients’ specific location within society includes sensitiv-
ity to issues of race, oppression, SES, gender, sex, and religion, as well as other sociopolitical
forces. It has been suggested that person-centered and experiential therapists working with
diverse populations need to display high levels of personal empathy, as well as relational and
moment-to-moment empathy in the session for their clients’ experiences. Sensitivity to the
power and oppression implicit in intersectional identities may require therapists to reflect
on and analyze their theories and to better understand privilege and oppression impact
their work and the lives of their clients (Grzanka, Santos, & Morada, 2017). Some person-
centered theorists have questioned the potentially implicit cultural assumptions in person-
centered theory that emphasize individualism and autonomy (Hett, 2016). The emphasis on
responsibility for self may not be congruent with the values of persons from some cultures
that emphasize responsibility to the community over self. Balancing the demands of self and
248 EXPERIENTIAL AND HUMANISTIC APPROACHES

other is a delicate process that requires adjustment for each individual person. The other
aspect of person-centered and experiential theory and practice that has been challenged is
the principle to try to balance the power dynamic by having a more egalitarian relationship
with the client. This objective may ignore the fact that the therapist–client relationship is
culturally structured to put the therapist on top in terms of power insofar as the therapist
often sets many of the terms of the relationship, including time, location, intervention, and
so forth, and the fact that clients from some cultures expect the therapist to take a direc-
tive role. For example, O’Hara (1996), after analyzing a film of Carl Rogers working with
a woman, pointed out how his implicit cultural assumptions, particularly about autonomy,
interfered with his hearing her concerns.
There are no particular ethical issues unique to person-centered or experiential therapy.
However, the egalitarian, democratic stance of the therapist, along with the belief in cli-
ents’ self-healing potential, can sometimes create a disparity with the perspectives of other
professionals. The issue is that person-centered and experiential therapists do not adopt an
“expert” stance vis-à-vis the client. Although they may have expertise, they share it with
their clients in a collaborative, nonauthoritarian way and do not prescribe treatment for
the client. The field of psychotherapy is currently increasingly adopting a “medical” view
in which the therapist is the “expert/professional” who decides on the course of treatment.
For instance, for a client who has been sexually abused as a child, some therapists hold that
the number-one priority of therapy must be working with the abuse. Because a crucial part
of PCEP is to trust the client’s judgment (within limits imposed by legal and ethical consid-
erations), if a client chose not to explore their childhood abuse, then the therapist would go
along with that decision. This might bother therapists who believe it is largely the expert/
professional’s role to decide what focus is best.
Generally a person-centered or experiential therapist might look for a number of differ-
ent indicators as signs that therapy is effective, including clients’ greater access to and accep-
tance of feelings and experiencing; a greater sense of self-acceptance and self-trust; signs of
more initiative in making personal choices; signs that the client is beginning to relate more
as an equal to the therapist; more client comfort with personal self-disclosure; and signs that
the client can better tolerate, face up to, and continue to try to master adversity. Ultimately,
because client-centered and experiential therapists place their trust in clients’ increasing
capacities to know their own experience, the single most important criterion of effectiveness
is the client’s own reflective judgment that they are making progress.

RESEARCH SUPPORT AND EVIDENCE-BASED PRACTICE

The PCEP approach has had a long and distinguished history of exploring its effectiveness
through empirical research. Rogers, often called the “father of psychotherapy research,” was
the first to record psychotherapy interviews for research study. Other person-centered and
experiential researchers, such Greenberg, Rice, Gendlin, Elliott, and Stiles, have become
internationally known for their work. Below we consider findings on PCEP.

Research on Therapy Outcome

Elliott et al. (2013) conducted a meta-analysis of 186 studies in which changes were mea-
sured in 14,206 clients before and after therapy. In 59 of these studies, person-centered
 Person-Centered and Emotion-Focused Psychotherapies 249

or experiential therapy was compared to a control group, and in 100 studies, person-
centered or experiential therapy was compared to another form of therapy. Effect sizes
(ESs; a measure of impact; 0.8 is considered a large ES; 0.2 or less is a small ES) were
as follows: On pre–post treatment studies; that is, comparing changes within the client
group, the ES at the end of treatment was 0.96, and at 12-month follow-up was 1.11. The
ES compared to untreated controls was 0.81. The ES versus other forms of therapy was
–0.02 (a small, nonsignificant difference suggesting equivalence between these and other
forms of therapy).
In particular, the two most researched therapies from this group, person-centered
therapy and PE-EFT, both appear to be as effective as cognitive-behavioral therapy (CBT).
Person-centered therapy is virtually equivalent in effectiveness to CBT (ES = –0.06), with
even this small difference disappearing when the authors statistically control for the theo-
retical allegiance of the studies’ researchers. PE-EFT appears to be somewhat superior in
effectiveness to CBT (ES = 0.53), although that difference may in part be due to researcher
allegiance.
As concrete examples of these findings, Stiles, Barkham, Mellor-Clark, and Connell
(2008) studied 5,613 clients in the United Kingdom who received either person-centered
therapy, CBT, or psychodynamic therapy for various disorders. They found that the average
client showed significant improvement, but there was no difference in effectiveness among
the three approaches. Watson et al. (2003) compared PE-EFT with CBT in the treatment of
major depression in a researcher-allegiance-balanced randomized clinical trial. Client levels
of depression, self-esteem, general symptom distress, and dysfunctional attitudes signifi-
cantly improved in both therapy groups. Although the outcomes for clients in both treat-
ment groups were generally equivalent, there was a significantly greater decrease in clients’
self-reports of their interpersonal problems in PE-EFT than in CBT. Additional support for
the effectiveness of client-centered therapy and PE-EFT in the treatment of depression was
provided in a study by Goldman, Greenberg, and Angus (2007).
The conclusion is that there is substantial evidence for the effectiveness of these expe-
riential psychotherapies. Although there is less evidence supporting focusing-oriented psy-
chotherapy, it can be effective in coping with cancer, in dealing with weight problems, and
in helping with public speaking anxiety (Greenberg et al., 1994). Studies also indicate that
focusing is effective with prison inmates, older adults, health-related concerns, and stress
management (Hendricks, 2002).
Other evidence (Elliott et al., 2013) indicates that person-centered and experiential
therapies are ameliorative for problems of depression, anxiety, “mixed neurotic” problems,
schizophrenia and personality disorders, health-related problems, problems of minor adjust-
ment, and relationship problems. Bratton and Ray (2002) have concluded that humanistic
play therapy, particularly person-centered therapy, is empirically supported. In most of these
areas, the evidence is strong enough to meet formal criteria for what is considered “empiri-
cally supported therapy” in the field.

Research on Therapy Process

Rogers emphasized two qualities of importance to successful therapy: the active self-healing
agency of the client—the person’s actualizing tendency—and the therapeutic relationship.
Rogers hypothesized that clients have the capacity to heal themselves if they have a warm,
empathic, accepting, and genuine relationship within which they can engage in the kind of
250 EXPERIENTIAL AND HUMANISTIC APPROACHES

self-exploration/self-examination process that leads to personal evolution. What is the evi-

dence for this proposition?
After reviewing the literature, Bohart and Tallman (1999, 2010) concluded that therapy
is primarily a process of mobilizing clients’ capacities for change. First, there is now consid-
erable evidence for humans’ capacities for resilience and self-righting. Second, client involve-
ment is one of the best predictors of change in therapy. Third, there is evidence that clients
creatively utilize and transform what they gain from therapy and actively work outside ther-
apy to facilitate change. Finally, Rennie (2002) has found that clients are active and agentic
in how they pursue their aims in therapy, picking and choosing what they want to use from
therapists’ communications, subtly trying to influence the therapist if they feel the therapist
is off track, and so on. In summary, Rogers’s faith that clients have considerable capacities
for self-healing, and that it is they who make therapy work, has received research support.
Research has generally shown that the most important factor that therapists provide
is the therapeutic relationship (e.g., Norcross & Lambert, 2019). In keeping with Rogers’s
hypothesis, the quality of the relationship seems to be a stronger predictor of outcome than
the use of therapeutic techniques. Rogers (1957) hypothesized that the necessary and suf-
ficient conditions for psychotherapy to work are the therapist’s levels of warmth, empathy,
and genuineness. While, it has not been shown that these conditions are necessary and suf-
ficient, there is evidence linking them to psychotherapy outcome. A meta-analysis of studies
relating empathy to therapy outcome, found an ES equivalent to 0.58, suggesting a moderate
relationship between therapist empathy and outcome (Elliott et al., 2018). Similarly, after a
review of the research on positive regard, Farber, Suzuki, and Lynch (2018) concluded that it
also bore a small positive (ES of 0.28) relationship to therapeutic outcome. The research on
congruence/genuineness found a moderately positive relationship (ES of 0.46) between thera-
pist genuineness and therapeutic outcome (Kolden, Wang, Austin, Chang, & Klein, 2018).
Hill and Knox (2002) found a weak but positive link between self-disclosure and outcome.
Another hypothesis about therapy process concerns the role of experiencing and emo-
tion in facilitating change. Hendricks (2002) concluded that 50 studies indicate that clients’
level of “focusing” (the degree to which clients are tuning into their experience) is correlated
with therapy outcome. With regard to emotion, there is evidence that emotional activation
is also important in facilitating change in many therapeutic conditions (Elliott et al., 2013).
Ratings of clients’ depth of experiencing have been related to good outcome consistently
in person-centered/experiential psychotherapy (Elliott, Greenberg, et al., 2004; Hendricks,
2002; Pos, Greenberg, Goldman, & Korman, 2003; Watson & Bedard, 2006). Moreover,
clients’ emotional processing in the session has been found to be beneficial across a range
of therapeutic approaches other than person-centered and experiential therapy, including
CBT and psychodynamic therapy (Giyaur, Sharf, & Hilsenroth, 2005; Godfrey, Chaider,
Risdale, Seed, & Ogden, 2007). In conclusion, Rogers’s two major hypotheses concerning
the importance of the client’s self-healing capacities and the relationship have both received
research support. In addition there is growing support for the proposition that focusing and
emotional activation are also important factors in the change process.

CASE ILLUSTRATION

Kevin came to therapy suffering from severe depression. He felt trapped in his marriage and
had thoughts of suicide. He was not sure that psychotherapy would help but was desperate
 Person-Centered and Emotion-Focused Psychotherapies 251

to overcome the pain he felt. Kevin, who was 35 and married with three children, was
exhausted. His wife was an invalid who required care. Her moods were unpredictable; she
was irritable and given to angry outbursts. To care for her and the children, Kevin gave
up many of his activities, including playing the piano, swimming, and tennis. Initially in
therapy, he focused on the demands of his domestic situation. As he examined it, he realized
how much his wife’s moods affected him and recalled his experiences growing up.
Kevin’s mother had become severely ill and was hospitalized for a number of months
when he was 3, and he had been sent to live with his paternal grandmother. Kevin suspected
his mother had been hospitalized for depression when he was 3; she was later hospitalized
for depression when he was 12 and 16, as she became catatonic at times. He grew up fearing
she would disappear without notice. He suppressed his own needs and tried to care for his
mother to ensure that she would stay around. In addition, his other sibling required special
care, as he had a learning disability and would throw tantrums when he became frustrated.
His mother catered to his tantrums, leaving Kevin feeling forgotten and invisible.
Kevin went to university when he was 18 to become a social worker. There he met his
future wife. After their marriage, they both worked until they had children, at which time
his wife stayed home to raise their three sons. When Kevin’s sons were teenagers, his wife
contracted Lyme disease, and Kevin began cutting back on his own activities to care for his
family, gradually becoming more and more depressed.
His therapist worked to establish a person-centered relationship, in which Kevin felt
prized, accepted, safe, and respected. The focus was on understanding his experience of
himself and his world. Kevin was aware that he had never had the opportunity to put his
experience into words; doing so was difficult but comforting for him in therapy. He appreci-
ated his therapist’s attentive listening as they worked to understand the source of his depres-
sion. He realized that it was rooted partly in conditions of worth that he had internalized as
a boy—to be good and not cause trouble to ensure that his mother did not become depressed
and forsake the family again. In discussing these matters, Kevin was very rational, intellec-
tual, and out of touch with his feelings, which increased his general frustration.
To address this, his therapist suggested focusing. In the process, he realized how scared
he was of attending to his feelings and being overwhelmed and unable to cope. As they
continued to explore his fears, his therapist proposed two-chair dialogues to address his
ambivalence. Hesitantly, Kevin agreed. Two-chair work proved helpful. Kevin realized
that he feared that, like his mother, he might be hospitalized if he got in touch with his
pain. However, a stronger, more resilient part wanted to change. Once the ambivalence was
resolved, Keven began trying to access and represent his inner experience using focusing. As
he began to listen to his inner experience and represent it symbolically, Kevin gained a better
understanding of his feelings and needs.
Exploring his inner experience, Kevin became aware of how scared he had been as
a child that his mother would leave. He also recalled how sad he had felt when he left his
grandmother to return home. His grandmother had died when he was 11, and Kevin missed
her greatly. To address his grief, his therapist suggested an empty chair dialogue. Imagin-
ing his grandmother, he described an older woman with kind blue eyes, smiling at him in
encouragement. He then expressed his sadness at leaving her and recalled how happy he
had been with her. He had memories of working in the garden with her, being cuddled and
feeling safe with her. After she died, he felt lost and alone. In the empty-chair exercise in the
role of his grandmother, Kevin said what a special child he had been and that he was dearly
loved. His grandmother affirmed the fun they had had and said that she had missed him,
252 EXPERIENTIAL AND HUMANISTIC APPROACHES

too, when he returned home. She asked him to hold on to the happy memories and to know
that she loved him very much.
After this work, Kevin’s depression lifted somewhat, and he began to focus on how he
could best cope with his wife’s illness. He realized that her moodiness triggered an intense
reaction that he did not understand. They explored this as a problematic reaction using
systematic evocative unfolding. As Kevin vividly described an interaction with his wife, he
realized that her tantrums reminded him of his sibling’s behavior. He recalled how awful it
had been at home when his sibling was upset and his mother had to cater to him, worried
that it would send her back to the hospital. Subsequently, Kevin explored the impact of his
mother’s repeated hospitalizations more fully. He processed how scary they were for him
and how much he had suppressed his own feelings. He had carried this style of being into
his adult relationships, continually monitoring and accommodating himself to the wishes
of his wife and colleagues, so that by the time he entered therapy, Kevin felt almost obliter-
ated. Kevin continued in therapy for the next 2 years, reprocessing his experiences as a child
and seeing how they affected him in the present. He engaged in empty chair work with his
mother to address the pain he had experienced as a result of her treatment of him and her ill-
ness. He did this chair exercise as well with his sibling to free himself of the resentment and
grief he felt over his sibling’s needs. He grieved the loss of adequate nurturing, allowing his
childhood wounds to heal, and gradually assumed greater care for himself, trying to meet
his needs in ways that were balanced with those of his wife and children.

SUGGESTIONS FOR FURTHER STUDY

Recommended Reading
Cain, D. J., Keenan, K., & Rubin, S. (Eds.). (2016). Humanistic psychotherapies: Handbook of
research and practice (2nd ed.). Washington, DC: American Psychological Association.—This
volume summarizes research on each of the approaches covered in this chapter, as well as on
therapy with children, group therapy, relationship variables, the self, and emotion.
Farber, B. A., Brink, D. C., & Raskin, P. M. (Eds.). (1996). The psychotherapy of Carl Rogers: Cases
and commentary. New York: Guilford Press.—Cases of Carl Rogers with commentaries by
eminent psychotherapists of various points of view.
Gendlin, E. T. (1996). Focusing-oriented psychotherapy: A manual of the experiential method. New
York: Guilford Press.—This book gives details on practicing focusing-oriented psychotherapy
and gives extensive case history material.
Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating emotional change: The moment-by-
moment process. New York: Guilford Press.—This book on process–experiential psychotherapy
has detailed case histories at the end.

DVDs
Greenberg, L. S. (2006). Emotion-focused therapy over time (Psychotherapy in Six Sessions Video
Series). Washington, DC: American Psychological Association.—Demonstration of emotion-
focused therapy over six sessions with a client with anxiety, depression, and marital problems.
Shostrom, E. L. (Producer). (1965). Three approaches to psychotherapy: Carl Rogers. Orange, CA:
Psychological Films.—The most famous film of Carl Rogers working with Gloria.
Watson, J. C. (2013). Emotion-focused therapy in practice: Working with grief and abandonment
(Specific Treatments for Specific Populations Video Series). Washington, DC: American Psy-
chological Association.—Demonstration of emotion-focused therapy with a client with grief,
trauma, and abandonment issues.
 Person-Centered and Emotion-Focused Psychotherapies 253

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 CHAP TER 8

Existential–Humanistic
Psychotherapies
Kirk J. Schneider
Orah T. Krug

HISTORICAL BACKGROUND

Existential–humanistic (E-H) therapy is distinguished by two ongoing questions—“How is

one presently living?” and “How is one willing to live?”—in this inimitable moment, with
this exceptionally attuned human being? While most often posed tacitly and sometimes
explicitly, these questions run through every major aspect of the work and form the bedrock
for the E-H approach to healing. Accompany us now, as we plumb this inquiry—and the
treasures it can yield. We believe you will find, as many have, that today’s E-H therapy is at
the vanguard of a paradigmatic shift in the field of psychotherapy, a shift that stresses the
intimate and evolving relationship over preset and technical factors in the optimization of
effectiveness.
Existential humanism is rooted in the deepest recesses of recorded time. All who have
addressed the question “What does it mean to be fully and subjectively alive?” have par-
taken in the E-H quest. Existentialism derives from the Latin root ex-sistere, which literally
means to “stand forth” or to “become” (May, 1958, p. 12), whereas humanism originates in
the ancient Greek tradition of “knowing thyself” (Grondin, 1995, p. 112). Together, existen-
tial humanism embraces the following three values: (1) freedom (e.g., to know oneself), (2)
experiential reflection (e.g., to discover what one is becoming), and (3) responsibility (e.g.,
to act on or respond to what one is becoming).
Although existential humanism has its roots in Socratic, Renaissance, Romantic, and
even Asiatic sources (Moss, 1999; Schneider, 1998; Taylor, 1999), not until the mid-19th cen-
tury was existential philosophy, as such, formalized. With the advent of Søren Kierkegaard’s
(1844/1944) The Concept of Dread, a new era had dawned in which freedom, experiential
reflection, and responsibility played an increasingly pivotal philosophical and therapeutic
257
258 EXPERIENTIAL AND HUMANISTIC APPROACHES

role. In Kierkegaard’s thesis, freedom emerges from crisis, and crisis from intellectual, emo-
tional, or physical imprisonment. In Kierkegaard’s time, this imprisonment often took the
form of acquiescence to the Catholic Church or to objectifying trends in science. In one of
the most damning oppositions to social objectification (and doctrinaire living) ever waged,
Kierkegaard called for a complete transformation of values. We must move, Kierkegaard
exclaimed, from a mechanized or externalized life to one that is centered in the subject, and
that struggles for the truth of the subject. It is only through facing and grappling with our
selves, Kierkegaard elaborated, that consciousness can expand, deepen, and seek its vibrant
potential.
Writing at about the same period, but with an even feistier style, Friedrich Nietzsche
(1844–1900) traced the devitalization of conventional culture to the dominance of Apol-
lonian (or rationalist–linear living) over Dionysian (or nonrationalist–spontaneous) living.
Although these strains were in tension—in Nietzsche’s time, as in the time of the ancient
Greeks who formulated them—Nietzsche foresaw the era when Apollonian technocracy
would overshadow and level all in its path. To remedy this situation, and to restore the
Dionysian spirit, Nietzsche (1889/1982) called for a Dionysian–Apollonian rapprochement.
This rapprochement would “afford” people not only “the whole range and wealth of being
natural” but also, and in concert with the latter, the capacity for being “strong, highly edu-
cated,” and “self-controlled” (p. 554).
The next major revolution in E-H psychology occurred in the early 20th century, with
the advent of behaviorism and psychoanalysis. Behaviorism, championed by advocates such
as John Watson, stressed the mechanistic and overt aspects of human functioning, whereas
psychoanalysis, spearheaded by Freud and his followers, promoted a covert intrapsychic
determinism. In neither case, existential humanists contended, was the human psyche illu-
minated in its radiant and enigmatic fullness—its liberating and yet vulnerable starkness—
and so they rebelled. Among these rebellions were the rich and far-ranging meditations of
William James, Otto Rank, C. G. Jung, and Henry Murray (Moss, 1999; Taylor, 1999). But
while this group drew tangentially from E-H philosophy, another group of mainly former
Freudians drew directly on the E-H lineage. Ludwig Binswanger (1958) and Medard Boss
(1963), for example, based their psychiatric practices on the existential and phenomenologi-
cal philosophies of Martin Heidegger (1962) and Edmund Husserl (1913/1962). Expanding
on Kierkegaard’s emphasis on the subjective, Heidegger developed a philosophy of being. By
being, Heidegger meant neither self-enclosed individualism nor deterministic realism, but a
“lived” amalgam of the two that he termed “being-in-the-world.” “Being-in-the-world” is
Heidegger’s attempt to illustrate that our Western tradition of separating inner from outer,
or subjective from objective, is misleading and that, from the standpoint of experience, there
is no clear way to separate them. In a phrase, we are both separate subjective selves and
related to the external world, according to Heidegger. To develop his thesis, Heidegger drew
on the method and practices of phenomenology, originated by his mentor, Edmund Husserl.
According to Husserl (1913/1962), the chief task of phenomenology is to apprehend human
experience in its living reality, that is, in its full subjective and intersubjective context (see
also Churchill & Wertz, 2015; Giorgi, 1970).
By the 1960s, E-H psychotherapy had evolved into a mature and recognized movement,
but it was also a diverse movement. Whereas most E-H practitioners stressed freedom, expe-
riential reflection, and responsibility, they did so with varying degrees of intensity. There
were times, for example, such as in the aftermath of World War II and during the flowering
of the human potential movement of the 1960s, when existential freedom may have been
 Existential–Humanistic Psychotherapies 259

stressed to the neglect of responsibility (e.g., see May, 1981; Merleau-Ponty, 1962; Yalom,
1980), or other times when responsibility was accented to the detriment of freedom (Rowan,
2001) or experiential reflection to the neglect of responsibility (Spinelli, 2001), and so on.
These controversies persist today (see Cooper, 2017, on differences between European and
U.S. approaches).
However, today’s E-H practitioners have an advantage over those of their predecessors—
hindsight. With such hindsight, many contemporary E-H therapists are wary of one-sided
formulations, be they of the E-H variety or those with which E-H practitioners traditionally
differ. Contemporary E-H practitioners, moreover, tend to value holism, integration, and
complementarity. They tend to see the intrapsychic aspects of therapy on a par with those
of intersubjectivity (Schneider & Krug, 2017); the social and cultural implications of their
work on a level with individual transformation; and the intellectual and philosophical bases
of practice on a plane with those of emotion and spirit. Finally, the contemporary E-H prac-
titioner does not shy away from behavioral or even biological interventions, as those may be
appropriate (i.e., Schneider, 1995, 2008; Shahar & Schiller, 2016; Yalom, 1980).
This breadth of outlook has widened the E-H client base. Less and less is E-H practice
confined to the rarified environs of its psychoanalytic forebears, or to upper-class elites;
rather, it is opening out to the world within which most of us dwell (O’Hara, 2001, 2015;
Schneider, 2008; Schneider & Krug, 2017). Put another way, the E-H attitude can be seen in
a variety of practice settings, from drug counseling to therapy with war veterans, to therapy
with minorities to gay and lesbian counseling, to therapy with psychotic clients, to eman-
cipatory practices with groups, and from cognitive-behavioral interventions with anxious
and phobic clients to psychodynamic mediations with spiritually and religiously distressed
clients, to neurobiological and experiential interventions with sufferers of attachment disor-
der (Cooper, 2017; Decker, 2007; Schneider & May, 1995; Schneider, 2008) .
Yet in spite of their expanded vision, contemporary E-H practitioners still share a core
value with their predecessors: the personal or intimate search process that is at the crux of
depth practice. As we shall see, this process entails four basic stances or conditions—the
cultivation of therapeutic presence, the activation of presence through struggle, the working
through of resistance or “protections,” and the rediscovery of meaning and awe.
In the next section we describe the theory of personality that underlies this core value
and the practical consequences that follow.

THE CONCEPT OF PERSONALITY, PSYCHOLOGICAL HEALTH,

AND PSYCHOPATHOLOGY

The concept of personality is useful but, for our purposes, limited. From the standpoint
of E-H psychology, one does not experience a personality; one lives an experience. More-
over, lived experience is the basis on which one creates a sense of self or personal identity
(May, 1975). Orah Krug (Krug, 2016; Krug & Schneider, 2016; Schneider & Krug, 2017)
has described how identity formation refers to the foundational structure of human expe-
rience—namely, we make meaning from experiences in the external, objective world to
create our internal, subjective worlds. Meaning making is the act of “making sense” of an
experience. This existential structure of human experience challenges the Cartesian notion
of a world made up of objects—and subjects who simply perceive those objects. We are not
simply aware, we are conscious—aware of being the ones who construct meanings from
260 EXPERIENTIAL AND HUMANISTIC APPROACHES

experiences. May (1975) asserts that this dialectical process of meaning making, which he
calls “passion for form,” is the essence of genuine creativity.
Krug argues that if we construct our personal worlds, then within the definition of
existence lies (1) agency (i.e., we are centered in our being and create meanings about our
world and our selves), (2) freedom (i.e., we choose how we perceive and experience our
world), (3) responsibility (i.e., we are responsible for the choices we make), and (4) change
(i.e., we have agency to create new meanings about our world and our selves). Understand-
ing the structure of existence through this meaning-making lens underscores the need for
therapists to sensitively attune to the personal meanings and associated feelings of cli-
ents over and above dispensing a particular treatment or technique (Krug, 2016; Krug &
Schneider, 2016).
The meanings we make from lived experiences create self and world construct systems
(essentially beliefs regarding oneself, others, and the world), and patterned ways of being to
protect core traumas and wounds. These constructs and protective patterns constitute our
subjective worlds or personal contexts that vary, continually influenced by the cultural, his-
torical, and cosmological experiences of each individual. Quite often these constructs and
protective patterns are outside of personal awareness. Moreover, they are not constituted
as dry abstractions but as embodied meanings, richly laden with personal feelings thoughts
and opinions. All incoming and outgoing information flows through the lens of our per-
sonal contexts. Personal contexts are always “in process” being shaped and reshaped (see
Krug, 2016; Krug & Schneider, 2016).
Similar to the limiting notion of personality as a static construct, the notions of psy-
chological health and pathology can have static, culturally normative qualities that may not
reflect the lived experience of distinctive individuals (see Becker, 1973). Nevertheless, there
are patterns within these lived experiences—characterological structures—that existential
humanists have carefully described phenomenologically. Let us consider a sampling of these.
As suggested earlier, the E-H understanding of functionality (i.e., psychological health)
rests on three interdependent dimensions—freedom, experiential reflection, and responsi-
bility. Although E-H theorists almost invariably highlight all three of these dimensions, they
do so in diverse ways. For example, Rollo May (1981) gives primary attention to freedom
and that which he terms “destiny.” By freedom, May means the capacity to choose within
the natural and self-imposed (e.g., cultural) limits of living. Freedom also implies responsi-
bility, for, as he suggests, if we are conferred the power to choose, is it not incumbent upon
us to exercise that power?
May defines destiny in terms of the consciousness of our limits. He then goes on to
define four basic limits or forms of destiny—the cosmic, the genetic, the cultural, and the
circumstantial. Cosmic destiny embraces the limitations of nature (e.g., earthquakes and
storms), genetic destiny addresses the limits of physiology (e.g., lifespan and temperament),
cultural destiny entails preset social patterns (e.g., language and class), and circumstantial
destiny pertains to sudden situational developments (e.g., war and recession).
How, then, do we deal with these contending forces according to May, and what hap-
pens when we do not? Let us consider the latter first. The failure to acknowledge our free-
dom, according to May (1981) leads to a dysfunctional identification with destiny or lim-
its (e.g., depression, obsessive–compulsiveness, and hyperanxiety), whereas the failure to
acknowledge our limits leads to a dysfunctional identification with our possibilities (e.g.,
narcissism, impulsivity, and psychopathy). Hence, the failure to acknowledge freedom can
be seen in the forfeit of the capacity for wonder, experimentation, and boldness. Among
 Existential–Humanistic Psychotherapies 261

those who embody those imbalances are the shy and retiring wallflower, the rigid bureau-
crat, and the robotic conformist. The failure to acknowledge limits, on the other hand,
can be detected in the sacrifice of the ability to discern, discipline, and prioritize one’s life.
Among those who illustrate this polarity are the aimless dabbler, the impulsive philanderer,
and the arrogant abuser.
The great question, of course, is how to help people redress these imprisoning disposi-
tions—how to help them broaden and thereby mobilize their range of behavioral, cogni-
tive, and affective resources. Although there is no simple answer to this query, May finds
that intra- and interpersonal struggles (or encounters) are key ameliorative dimensions. It
is only through struggle, according to May (1981), that freedom and destiny—capabilities
and limits—can be illuminated in their fullness, substantively explored, and meaningfully
transformed.
The polarities of freedom and destiny or limitation, and the challenge to respond to
these polarities, are central to leading E-H conceptions of psychological health. James
Bugental (Bugental & Sterling, 1995), for example, draws on a similar dialectic with his
emphasis on the self as embodied yet changing; choiceful yet finite; isolated yet related. We
are ever in the process of change according to Bugental, no matter how we choose to con-
ceive it. Our challenge, Bugental elaborates, is to face that change, sort through its manifold
features, and etch out of it a meaningful and action-oriented response.
Irvin Yalom (1980) conceives of four “givens” of human existence—death, freedom,
isolation, and meaninglessness. Depending on how we confront these givens, Yalom elabo-
rates, we confront the design and quality of our lives. To the extent that we confront death,
for example, we also encounter the urgency, intensity, and seriousness that death arouses.
To the extent that we confront isolation, we also contact and become aware of our need for
relation, or its opposite, solitude. For Yalom, the composition of a life is directly propor-
tional to the composition and array of one’s relationship to givens, and the priorities one sets
to integrate, explore, or coexist with those givens.
Kirk Schneider (1995, 1999, 2008) has elaborated a constrictive–expansive continuum
of conscious and subconscious personality functioning. This continuum is identified as a
capacity that is freeing yet limited. We have a vast capacity to “draw back” and constrict
thoughts, feelings, and sensations, as well as an equivalent capacity to “burst forth” and
expand thoughts, feelings, and sensations. At the same time, each of these capacities is
delimited. We can only constrict (e.g., focus and accommodate) and expand (e.g., enlarge
and assimilate) so far, before the givens of existence (e.g., death, genes, and culture) deter
and curtail us. For Schneider, it is the interplay among constrictive and expansive capacities,
the ability to respond to those capacities, and the ability to integrate those responses into a
meaningful whole that constitute optimal personal and interpersonal dynamics.
In more recent years, Krug (2016; Krug & Schneider, 2016) has described healthy func-
tioning as the extent to which we can make sense of experiences and people (i.e., “take in the
world” without excessive distortions), allowing for expanded presence with self and others.
The capacity for expanded presence reflects a fluid and flexible self and world construct
system. Contrast that with perceiving the world largely through a “lens of the past,” where
protective patterns distort events and constrict presence. Individuals with such lenses are
likely to have static and inflexible self and world construct systems. These individuals are
“caught in their context” unable to perceive what’s really “out there” and projecting onto
others and the world their static personal beliefs. For example, if I believe I’m unworthy and,
for that reason, you won’t like me, then I’ll most likely hold onto that belief in an exchange
262 EXPERIENTIAL AND HUMANISTIC APPROACHES

with you; meaning that I’m unable to perceive how you really feel about me, because you
can only be who I imagine you to be.
To summarize, healthy functioning individuals, with fluid and flexible construct sys-
tems, often experience joyful living and close relationships, whereas unhealthy functioning
individuals, with static and inflexible construct systems, often experience emotional dis-
tress, deadened living, and superficial relationships.
Schneider (2008) and Schneider and Krug (2017) have also elaborated an “existential–
integrative” (E-I) approach to therapy. This approach holds that levels of “liberation” (e.g., the
physiological, the environmental, and the interpersonal) are interwoven into the constrictive–
expansive continuum noted earlier. E-I therapy is now at the forefront of a broadened—and
steadily growing—E-H practice philosophy (Schneider & Krug, 2017; Shahar & Schiller,
2016; Wampold, 2008). This practice philosophy draws from conventional E-H principles,
but it also differs in one major respect—scope of practice. While the conventional E-H
model emphasizes only the experiential (e.g., intensive, in-depth) level of client contact,
and thus restricts its practice base, the E-I model explicitly embraces diverse levels of client
contact and thus expands its capacity to serve. Put another way, the E-I approach arose
out of the need to address today’s ethnically and diagnostically diverse clinical popula-
tions, whereas the older E-H modality arose out of a narrower set of priorities (May,
1958; Schneider, 2008; Schneider & Krug, 2017). Within that context, E-I interventions
are viewed as “liberation conditions,” and client dysfunctions as (often restricted) “levels
of freedom” or choice (Schneider, 2008, p. 35). Liberation conditions can represent a wide
range of interventions (e.g., from the relatively “nonexperiential” medical and behavioral
strategies to the “semiexperiential” psychoanalytic and intersubjective modalities, to the
relatively “experiential” existential and transpersonal approaches). Depending on the cli-
ent’s desire and capacity for therapeutic change, E-I therapy proceeds holistically toward
an experiential level of contact. By holistically, we mean that even when E-I therapy is
engaged non- or semi-experientially, it is still engaged within an ever-varying, ever-available
experiential context.
Maurice Friedman (1995, 2001) echoes the philosophy of Martin Buber with his “dia-
logical” approach to psychological functioning. The dialogical approach, based on Buber’s
philosophy of “I–thou” relationships, emphasizes the interpersonal and interdependent
dimension of personality. For Friedman, psychological growth and development proceed
not merely or mainly through the encounter with self but through the encounter with
another. This “healing through meeting,” as Friedman puts it, is characterized by the ability
to be present to and confirming of oneself, at the same time being open to and confirming
of another. The freedom and limits of such a relationship then become transferred to the
freedom and limits experienced within oneself, and the trust developed to risk affirmation
of the self.

THE PROCESS OF CLINICAL ASSESSMENT

The question of assessment is essentially the question of understanding: On what basis

do E-H therapists understand an individual’s pattern of interaction, symptomatology, and
adaptive resources? E-H therapists employ a variety of means to understand lives. Among
these means can be paper-and-pencil tests, ratings of symptomatology, and history tak-
ing. However, these modalities tend to be implemented sparingly rather than as a staple of
 Existential–Humanistic Psychotherapies 263

practice. The reason for this caveat is that, as a rule, assessment—like therapy—is an ongo-
ing process for E-H practitioners and not a linear or mechanistic procedure (Krug, 2016;
Krug & Schneider, 2016). Appraisal is holistic, in other words, and should not be mistaken
for a global or rigid declaration (Bugental & Sterling, 1995). For example, client “X” may
be a “depressive” for an E-H practitioner, but he is also a living, dynamic human being,
and this is pivotal information—both for client and therapist. Symptoms are understood
as methods to maintain selfhood that shut out disavowed feelings and experiences. Conse-
quently an E-H practitioner might wonder, “How is my client understanding his depressive
symptoms and relating to them?” “What are the meanings of these symptoms at this point
in my client’s life? What do they want to ‘tell’ my client?” (Krug, 2016; Krug & Schneider,
2016).
E-H practitioners are concerned as much or more with depth and breadth of the indi-
vidual’s personal context as with specific overt behaviors. It is assumed that the client’s
past—all of the meanings constructed about self and others—flow into the present moment
manifesting concretely as vocal tones, affect, body postures, language, dreams, and rela-
tional behavior patterns. These “ways of being and relating” are understood as the client’s
process, an amalgam of feelings, thoughts, and behaviors, which are present in the living
moment but are often out of awareness. Consequently, there is no need to go on an “archeo-
logical dig” to find the “actuality of a client’s life—it is, in fact, concretely manifesting in the
here and now, potentially visible and kinesthetically felt. E-H practitioners recognize that
the lives of their clients are before them, as well as the clients themselves. The challenge for
E-H practitioners is to deeply attune to what is most alive in the moment and appropriately
reflect it back. This mirroring process will likely expand clients’ awareness of themselves
and others (Krug, 2016; Krug & Schneider, 2016; Schneider & Krug, 2017).
Ideally, to summarize, nothing is spared in E-H therapeutic assessment. The unfolding
moment, the client’s explicit and implicit intentions in the moment, the horizons of the past,
and the full person-to-person field that is evoked each moment are of equal and abiding
import.
Generally speaking, contemporary E-H practice is an integrative practice (Schneider
& Krug, 2017; Yalom, 1980). E-H practitioners value the whole human being—conscious
and nonconscious, past, present, and evolving—in the therapeutic encounter. Cultural back-
ground, too, is integral for E-H practitioners. Although E-H therapy does not proclaim to
be a one-size-fits-all model, increasingly it urges practitioners to learn as much as possible
about cultural—as well as political—influences on practice, and it draws on therapeutic
presence to deepen and refine those sensibilities. As such, E-H practitioners are concerned
with how best to understand clients in their moment-to-moment unfolding, and their given
level of relation and experience. Presence is the chief tool of E-H assessment. Through pres-
ence, the holding and illuminating of clients’ moment-to-moment experience, E-H thera-
pists are able to attune to the subtler nuances of clients’ concerns, from the cognitive and
behavioral to the affective and spiritual. Physiological (e.g., nutritional) and even medical
support are not ruled out by the contemporary E-H practitioner; the question is, are these
approaches understood within an overarching context of how a person is willing to live his
or her life?
As mentioned earlier, although E-H therapists value the content (or explicit features) of
clients’ experiences, they are acutely and simultaneously sensitized to the process or implicit
aspects of those experiences. For example, whereas the content of a client’s report (e.g.,
binge eating) may be physiological in nature, the process or implicit aspects may be intensely
264 EXPERIENTIAL AND HUMANISTIC APPROACHES

spiritual, ontological (i.e., pertaining to being), or interpersonal in nature. E-H assessment,

therefore, is predicated on not only a client’s presenting problem (or complaint) but also the
entire atmosphere of a client’s predicament. Everything and anything is open to investiga-
tion within the E-H framework, from the initial manner in which the client greets the thera-
pist to the position of the client’s hands while elaborating his or her concern. Put another
way, every E-H assessment is holographic (i.e., interconnected). Every moment is believed
to be a microcosm and in some sense dovetails with every other moment, and no moment
stands in isolation.
For example, one of the first areas of focus within E-H therapy—even before any words
are exchanged—is “What is my client expressing in his body?” The E-H therapist is particu-
larly attuned to the manner in which these expressions resonate within him- or herself—
their associations to feelings, sensations, and images. In effect, the E-H therapist uses his or
her body as a barometer or register of clients’ tacit and overt struggles. Here is a sample of
Schneider’s own thoughts upon greeting a given client:

What kind of world is this man trying to hold together? What kind of life-design do his
muscles, gestures, and breathing betray? Is he stiff and waxy or limber and fluid? Is he
caved in and hunched over or stout and thrust forward? Does he curl up in a remote corner
of the room or does he “plant himself in my face”? What does he bring up in my body? Does
he make me feel light and buoyant or heavy and stuck? Do my stomach muscles tighten, or
do my legs become jumpy? Do my eyes relax, or do they become “hard,” or guarded? What
can I sense from what he wears? Is he frumpy and inconspicuous or loud and outrageous?
What can be gleaned from his face? Is it tense and weather-beaten or soft and innocent?
(Schneider, 1995, p. 154)

Each of these observations begins to coalesce with others, cumulatively, to disclose a world.
Each oscillates with others to form a shape, sense, and overarching Gestalt of this particular
man’s strife.
Presence, then, is the sine qua non of E-H assessment (Krug & Schneider, 2016).
Through the illumination of presence, E-H therapists open to and begin to discover the
client’s self and world construct systems, protective patterns, overt and covert scripts, osten-
sible and tacit agendas, and unfolding rivalries within the battleground of self. Furthermore,
they begin to sense the shape of their own responses to these revelations and how best to
“meet” or facilitate them. For example, an E-H therapist might ask (silently to him- or her-
self), what are the resources, difficulties, and potential tools necessary to address an acutely
fragile client? What about a combative client, or a client who resists exploration? These
issues challenge any serious-minded therapist but are especially trying to E-H practitioners,
who prize depth of connection over symptom relief. The question for the E-H therapist is,
How can I best meet this client “where he or she lives,” within the abilities and constraints
of where he or she lives, yet hold out the possibility for a fuller and deeper connection? This
holding out of the possibility for an enlarged and deepened contact is one of the primary dis-
tinctions between prevailing and E-H visions of healing. Whereas conventional practitioners
may tend to calibrate their actions to given parts of the therapeutic concern (e.g., those that
pertain to behavior or cognition or childhood), E-H practitioners endeavor to be available
to clients across the range of their difficulties, from the measurable and overt to the felt and
unformed. It is in this sense that diagnosis is a part of the ongoing contact in E-H therapy,
and that formulations must fit people and not the other way around (Fischer, 1985/1994;
May, 1983). This latter point is particularly relevant to clients who are readily stereotyped
 Existential–Humanistic Psychotherapies 265

or labeled. Although E-H practitioners are encouraged to learn as much as possible about
conventional approaches to given diagnostic or cultural populations, they apply these data
with great care. Such approaches are considered valid only to the extent that they resonate
with the living, evolving individuals to whom they are applied.
Given its evolving and holistic approach, then, E-H assessment must be artfully and
mindfully engaged. While psychiatric diagnoses may be useful to E-H practitioners at given
stages of therapy, the assessment overall is based on therapist attunement, experience, and
clinical judgment. As a rule, the client’s desire and capacity for change and the therapist’s
mindful and sensitive alertness to these criteria guide the ensuing work.

THE PRACTICE OF THERAPY AND THE STANCE OF THE THERAPIST

The aim of E-H therapy is to “set clients free” (May, 1981, p. 19). By freedom, E-H thera-
pists do not at all mean caprice or licentiousness, or even truth in the unqualified sense.
What they do mean, however, is the cultivation of the capacity for choice; and choice, as
is well established in the existential literature, implies limits, ambiguities, and risk (May,
1981; Tillich, 1952).
Freedom is limited because it arises in a sociobiological–spiritual context, only degrees
of which are accessible, changeable, and clear. It is ambiguous, because for every choice
there is a choice not taken, and for every gain there is a commensurate relinquishment. If I
devote myself to sports, for example, my ability to perform intellectually is likely to suffer.
If I affirm social visibility, I relinquish my capacity to withdraw, and so on. Finally, freedom
is risk because it is ever set against uncertainty and the potential for collapse. But freedom
is also vibrant, poignant, and energizing; and for many, it is the point of being alive, in spite
of and perhaps even in light of its many challenges.
As suggested earlier, contemporary E-H therapy is both integrative and incremental in
its approach to freedom. The client’s desire and capacity for change (Schneider, 2008), the
alliance and context of the therapy (Bugental, 1987), and practical elements (Yalom, 1989)
all figure in. Hence, for some E-H clients, at some stages of therapy, choice can mean drug-
induced stability or nutrition-based evenness of mood or reasoned-based empowerment,
and so on. However, that which distinguishes E-H facilitation is its ability to address not
only programmatic (i.e., externally based) adjustments but also internally sparked com-
mitments. Commitment, for E-H therapists, refers to a sense “I-ness,” agency, or profound
caring about a given direction. It implies a sense that the life one chooses really matters to
oneself and is worth one’s whole (embodied) investment. This ontological or experiential
level of commitment manifests clinically as a sense of immediacy (aliveness), affectivity (pas-
sion), and kinesthesia (embodiment), and is typified in the deepest and most pivotal stages of
therapy. In short, E-H therapists endeavor not only to meet clients “where they are at” but
also to be available to the fullest potential of those clients to “own” or claim the life that is
presented to them.
In light of this background, E-H therapy can vary in both length and intensity. It can
proceed, on rare occasions, within one or two sessions (e.g., see Galvin, 2008) or it can
occur in a limited way within a short-term, focused format (e.g., Bugental, 2008; Schneider
& Krug, 2017). Typically, however, E-H engagements are intimate (e.g., trust building),
long term (e.g., 2–5 years), and intensive (e.g., weekly to twice weekly). Furthermore, E-H
therapy can be of benefit to a more diverse range of clientele than is generally presumed (e.g.,
266 EXPERIENTIAL AND HUMANISTIC APPROACHES

see Rice, 2008; Vontress & Epp, 2015), although those who tend to be introspective, emo-
tionally tolerant, and exploratory are likely to derive maximal benefits. Put another way,
E-H therapists try not to preconceive the contexts within which clients operate. Although
they are mindful of the general influence of those contexts, be it religious, cultural, or politi-
cal, it is still the living, breathing human being who takes primacy.
To summarize then, the chief question for the E-H therapist is how does one help this
person (client) find choice—direction, meaning, and depth—in his or her life, in spite of
(and sometimes in light of) all the threats to these possibilities? Clearly, there are no easy
answers to this question, yet it is precisely its difficulty, its struggle, that for E-H therapists
is key to its unfolding. In other words, E-H therapists challenge clients to grapple with their
concerns, and not just intellectually, behaviorally, or programmatically, but experientially,
in order to maximize their capacities to transform themselves.

Existential Stances or Conditions

To achieve the aforementioned aims, E-H therapists use a variety of means. These means,
however, are not techniques in the classical sense; they are stances or conditions through
which experiential liberation, or profound experiential transformation, can take root.
Among the core (intertwining and overlapping) E-H stances are the following: the cultiva-
tion of therapeutic presence (presence as ground); the activation of therapeutic presence
through struggle (presence as method and goal); the encounter with the resistance to (or
protections from) therapeutic struggle; and the coalescence of the meaning, intentionality,
and awe that can result from the struggle. We now proceed to elaborate on these dimen-
sions.

Basic Structure
The Cultivation of Therapeutic Presence (Presence as Ground)
The gravity of presence is illustrated by Rollo May’s (2007) incisive declaration that in dedi-
cated E-H therapy, it is “the client’s life that is at stake,” and that is how the therapist should
view it. There is a vivid distinction, in our view, between a therapist who approaches a client
as a problem-solving “doctor” and a healer who is available for inter- and intrapersonal con-
nection. The former offers a specific set of remedies for an isolated and definable malady;
the latter offers a relationship, an invitation, and an accompaniment on a journey. And
although the former is likely to appeal to a client’s immediate needs for relief (and sometimes
ultimate goals), the latter is likely to appeal to a client’s underlying urges for discovery, self-
sustainment, and vitality. To be sure, both modalities are often relevant over the course of a
given therapy, and both are useful. But in today’s market-driven, standardizing atmosphere,
rarely are both made available.
Through the dimension of presence, however (including a willingness to negotiate
fees!), both the problem-solving and journey-accompanying modalities can be made avail-
able to clients. And clients, in turn, can substantively benefit from these resources. Without
the latter (journey-accompanying) mode, however, clients are likely to feel shortchanged,
and, arguably, short-circuited.
Presence is the “soup,” the seedbed of substantive E-H work (e.g., see also the grow-
ing mainstream support for this conception by investigators such as Geller & Greenberg,
2012; Shahar & Schiller, 2016; and Wampold, 2008). In this light, Yalom (1980) draws an
 Existential–Humanistic Psychotherapies 267

intriguing parallel between the masterful preparation of a meal and E-H therapy. Whereas
the average cook prepares a meal in accordance with a standardized menu, the masterful
cook, while not ignoring the latter guidelines, also prizes the “add-ons” that make for an
enticing whole. The masterful cook, in other words, has a good sense of how to prepare
a basic meal but can also sprinkle in spices, seasonings, and flavorful mixtures that can
radically enhance and transform it. For Yalom (1980), it is precisely these nonprescriptions,
these “throw-ins” (p. 3), as he puts it, that matter most.
Analogously, it is precisely the present and attuned therapist who is prepared to help
his or her client most, according to E-H practice philosophy. Such a therapist is optimally
prepared to provide the atmosphere, personality, and moment-to-moment adjustments that
can mobilize client change (Bugental, 1987). Interestingly, even standardized psychotherapy
research upholds the latter postulate: Wampold (2001), for example, found that “common
factors,” such as therapist–client alliance and personality variables, account for about nine
times the variance in outcomes over specific therapeutic techniques. This general finding has
been upheld in the latest outcome literature (Laska, Gurman, & Wampold, 2014). Yalom
(1989) states it this way:

The capacity to tolerate uncertainty is a prerequisite for the profession. Though the public
may believe that therapists guide patients systematically and sure-handedly through pre-
dictable stages of therapy to a foreknown goal, such is rarely the case. . . . The powerful
temptation to achieve certainty through embracing an ideological school . . . is treacherous:
such belief may block the uncertain and spontaneous encounter necessary for effective
therapy. (p. 13)

“This encounter,” Yalom concludes, is “the heart of psychotherapy, . . . a caring, deeply

human meeting between two people, one (generally, but not always, the patient) more trou-
bled than the other” (p. 13).
Finally, the value of being present as a vulnerable yet distinctive person is illustrated by
Friedman (1995) in the following client-authored vignette. Following a 4-year therapy with
Friedman, his client, Dawn, reports the following:

“When I think about our therapeutic relationship, it is the process that stands out in my
memory, not the content.
“Up until the time I met Maurice, I had always “picked out” a male authority figure
(usually a teacher or psychologist), put him on a pedestal, and obsessed about him a lot—
not usually in a romantic or sexual way, although there was an erotic element. I just wanted
him to like me and approve of me and to think I was smart and interesting. A real relation-
ship, though, was terrifying to me—I kept my distance and rarely ever talked to them. The
greater the attraction, the greater the fear.
“When I first met Maurice, I could feel myself wanting to fall into this same pattern
with him. However, I could never quite feel intimidated by him—although I think I really
wanted to. He was too human for that. I never felt that I had to be interesting or smart,
good, bad, happy, or sad—it just wasn’t something I had to be concerned with. If the thera-
pist can be human and fallible, that gives me permission to be human and fallible, too.”
(p. 313)

For Friedman, as with most E-H therapists, then, presence is the foundation that both
holds and illuminates. It holds by supporting, embracing, and opening to clients’ travails,
and it illuminates by witnessing, disclosing, and engaging with those travails. In short,
268 EXPERIENTIAL AND HUMANISTIC APPROACHES

presence holds and illuminates that which is palpably (immediately, affectively, and kin-
esthetically) significant within the client and between the client and therapist, and it is the
ground and goal of substantive E-H transformation.

Goal Setting and Process of Treatment

The Activation of Therapeutic Presence through Inner Struggle (Presence as Therapeutic
Method and Goal)
As suggested earlier, presence not only forms the ground for E-H encounter, but it is also the
therapeutic method and culminates in its goal. To the extent that clients can attune, at the
most embodied levels, to their severest conflicts, healing in the E-H framework is likely to
ensue. This healing is a kind of reoccupation of oneself—an immersion in the parts of one-
self that one has designed a lifetime to avoid, and it is an integration thereby of the potential
or openings that become manifest through that reoccupation. The question for this particu-
lar phase of the therapeutic process is: What are the ways and means to activate presence in
the client? Or, how can therapists help to mobilize clients’ presence? (Bugental, 1987).
As we shall see, the activation of client presence within E-H therapy is characterized by
two basic modes or access points—the intrapsychic and the interpersonal. Although these
modalities overlap, and indeed intertwine (Merleau-Ponty, 1962), they nevertheless reflect
two basic E-H practice styles that are gradually, and for many, refreshingly, beginning to
merge (Fosha, 2008; Krug, 2009, 2016).
Bugental (1987), for example, is more representative of the intrapsychic or individualist
tradition, although this characterization is far from discrete, and much about his approach
can be considered interpersonal as well (Krug, 2009). Within the former tradition, then,
Bugental (1987) outlines four basic practice strategies, or what he terms “octaves” for acti-
vating clients’ presence. These are listening, guiding, instructing, and requiring.
The first octave, listening, draws clients out, encourages them to keep talking, and
obtains their story without “contamination” by the therapist. It allows the therapist to enter
the client’s subjective world, to make contact with the client’s lived experiences. Examples of
listening include “getting the details” of clients’ experiences, “listening to emotional cathar-
sis, learning [clients’ views of their] own life or . . . projected objectives” (Bugental, 1987,
p. 71). The second octave, guiding, gives direction and support to clients’ speech, keeps it
on track, and brings out other aspects, such as the implicit process underlying the story’s
content. Examples of guiding include exploration of clients’ “understanding of a situation,
relation, or problem; developing readiness to learn new aspects or get feedback” (p. 71).
The third octave, instructing, transmits information or directions having rational and/
or objective support. Examples include “assignments, advising, coaching, describing a sce-
nario of changed living,” or reframing (Bugental, 1987, p. 71). Finally, the fourth octave,
requiring, brings a “therapist’s personal and emotional resources to bear” to cause clients
to change in some way. Examples of requiring include “subjective feedback, praising, pun-
ishing [e.g., admonishing], rewarding,” and “strong selling of [a] therapist’s views” (p. 71).
Listening and guiding comprise the lion’s share of E-H activation of presence. Whereas
instructing and requiring can certainly be useful from the E-H point of view, they are imple-
mented in highly selective circumstances. For example, instructing may be helpful to clients
at early stages of therapy, or for those who have fragile emotional constitutions, such as vic-
tims of chronic abuse, or for clients from authority-dependent cultures. Requiring, similarly,
 Existential–Humanistic Psychotherapies 269

may be useful not only in the foregoing situations but also in the case of therapeutic impasses
or entrenched client patterns, as we shall see. For the majority of E-H practice situations,
however, listening and guiding are pivotal to the deepening, expanding, and consolidating
of substantive client transformation.
May (1981) illustrates the value of listening with his notion of the pause:

It is in the pause that people learn to listen to silence. We can hear the infinite number of
sounds that we normally never hear at all—the unending hum and buzz of insects in a quiet
summer field, a breeze blowing lightly through the golden hay. . . . And suddenly we realize
that this is something—the world of “silence” is populated by a myriad of creatures and a
myriad of sounds. (p. 165)

The client, similarly, is almost invariably enlivened in the pause. As Bugental (1987,
p. 70) suggests, it is in the therapist’s silence at given junctures that abiding change can take
root.
The provision of a working “space,” a therapeutic pause (and, where appropriate, a
therapeutic response) not only helps the therapist to understand, but most importantly, also
assists the client to vivify him- or herself. Vivification or illumination of a client’s subjec-
tive and interpersonal worlds is one of the cardinal tasks of E-H therapy. To the extent that
clients can “see” the worlds in which they live, the obstacles they have created, and the
strengths or resources they possess to overcome those obstacles, they can proceed to a foun-
dational healing. Listening and appropriate responsiveness promotes one of the most crucial
realizations of that vivification—the contours of a client’s battle.
The client’s battle—and virtually every client has one—becomes evident at the earliest
stages of therapy. For some this battle takes the form of an interpersonal conflict, for others
it is an intrapsychic split; for some it may encompass the compulsion for and rejection of
binge eating; for others it may relate to a desire for closeness but a fear of rejection (interper-
sonal conflict); for still others it may be a struggle between squelched vocational potential
and evolving aspirations (intrapsychic split), and so on. Regardless of the content of clients’
battles, however, their form can be understood in terms of two basic valences—the part of
themselves that endeavors to emerge, and the part of themselves that endeavors to resist,
protect, oppose, or block themselves from emerging (Krug, 2016; Schneider & Krug, 2017).
Whereas therapeutic listening acquaints and sometimes immerses clients in their battle,
therapeutic guiding intensifies that contact. Therapeutic guiding can be further illustrated
by encouragements to clients to personalize their dialogue (e.g., to give concrete examples of
their difficulties, to speak in the first person, and to “own” or take responsibility for their
remarks about others, such as “What part might you be contributing to this problem?”).
Guiding is also illustrated by invitations to expand or embellish on given topics, such as
in the suggestion “Can you say more?” or “How does it feel to make that statement?” or
“What really matters about what you’ve conveyed?” Finally, guiding is exemplified by the
notation of content–process discrepancies, such as “You smile as you vent your anger at
him,” or “Notice how shallow your breathing is right now” (Bugental, 1987; Schneider,
1995).
Schneider (1998, 2008) has formulated a mode of guiding that he calls embodied medi-
tation, which in essence is client-guided and begins with a simple grounding exercise, such
as breathing awareness or progressive relaxation (usually assisted by the closing of the eyes).
From there, it proceeds to an invitation to the client to become aware of his or her body.
270 EXPERIENTIAL AND HUMANISTIC APPROACHES

The therapist may then ask what, if any, tension areas are evident in the client’s body. If the
client identifies such an area, which often occurs, the therapist asks the client to describe,
as richly and fully as possible, where the tension area is and what it feels like. Following
this, and assuming the client is able to proceed with the immersion, he or she is invited to
place his or her hand on the affected area (Schneider finds that this somatic element can
often, although not necessarily, be experientially critical). Next, the client is encouraged to
associate experientially to this contact. Prompts such as “What, if any, feelings, sensations,
or images emerge as you make contact with this area?” can be of notable therapeutic value.
Schneider has seen clients open emotional “floodgates” through this work, but he also has
observed clients who feel overpowered by it. To recap, it is of utmost importance for the
therapist to be acutely attuned while practicing this and other awareness-intensive modes.
Guidance is also illustrated by a variety of experimental formats that can be offered
in E-H therapy. These experiments, including role play, rehearsal, visualization, and expe-
riential enactment (e.g., pillow hitting and kinesthetic exercises), serve to liven emergent
material and vivify or deepen the understanding of that material (Mahrer, 1996; Schneider,
2008; Serlin, 1996). Krug (2016) has developed a “guiding” experiment whereby a client
first identifies a “part” in the body that is somatically present, such as “the protector part”
or the “fear part,” then says, “Let’s imagine if the part could speak. What might it say, and
what might we ask it?” She and her client then proceed to dialogue with the part, inviting
it to speak and asking it questions that she and her client think are relevant to her client’s
battle: “Who are you?”; “How long have you been with [client’s name]?”; “What are your
duties?”; “What do you want [client’s name] to understand about you?” When the “parts”
“speak” clients invariably discover something unknown; for example, the protector believes
its services are still needed. Moreover, this “parts” work invariably creates a friendlier inter-
nal atmosphere, softening antagonistic attitudes and making room for disowned parts to
integrate. (Krug’s “parts of self” work is illustrated in the Diana vignette later in this chap-
ter). The phrase “Truth exists only as it is produced in action” (Kierkegaard, cited in May,
1958, p. 12) has much cachet in this context. When clients can enact (as appropriate) their
anxieties, engage their aspirations, and simulate their encounters, they bring their battles
“out on the table,” so to speak—in “living color”—for close and personal inspection.
While experimentation within the therapeutic setting is invaluable, experimentation
outside the setting can be of equivalent or even superior benefit. After all, it is the life outside
therapy that counts most for clients, and it is in the service of this life that therapy proceeds.
Experimentation outside therapy, then, has two basic aims: (1) It reinforces intratherapy
work, and (2) it implements that work in the most relevant setting possible—the lived expe-
rience. Accordingly, E-H therapists encourage clients to practice being aware and present in
their outside lives. They may gently challenge clients to reflect on or write about problematic
events, or they may propose an activity or therapeutic commitment (e.g., Alcoholics Anony-
mous or assigned readings). They may also challenge clients to do without a given activity
or pattern. For example, Yalom (1980) challenged his promiscuous client Bruce to try living
without a sexual partner for an extended period. This was a highly demanding exercise for
Bruce, whose sexual compulsions were formidable and afforded no pause. Yet after the exer-
cise, Bruce reported rich therapeutic realizations, such as the degree to which he felt empty
in his life, and the blind and compulsive measures he took to fill that emptiness. Emptiness,
Yalom reported, subsequently became the next productive focus.
Prompts to clients to “slow down,” or “stay with” charged or disturbing experience
can also facilitate intensified self-awareness. We have known many a supervisee (and even
 Existential–Humanistic Psychotherapies 271

seasoned colleague) who has had difficulties with this latter facilitation. Such practitioners
are superb at helping clients to reconnect with the parts of themselves they have shunted
away, and they inspire deep somatic immersion in expressiveness, but they are left with
one gaping question: “What do I do after the client is immersed?” The exasperation in this
puzzlement is understandable. E-H work can seem tormenting. It can instigate profound
moments of unalloyed pain. The last thing a therapist wishes to do in such a situation is
to enable increased suffering, or to hover in continued despair. Yet given the client’s desire
and capacity for change, these are precisely the allowances that E-H therapists must pro-
vide; precisely the groundwork they must pursue. They must develop trust, and a sense
that the work will unfold (Welwood, 2001). Hence, what do we advise our supervisees and
colleagues? We suggest that it is in their interest to trust; in particular, to trust that gentle
prompts to the client to “stay with” or “allow” intensive feelings or thoughts will almost
invariably lead to changes in that material. Although these changes may not be immediately
welcome or gratifying—indeed, they may even feel regressive for a time—they do represent
evolution, the “more” that every person is capable of experiencing.
Much of the therapist’s task within E-H therapy is to facilitate this “more.” In time, and
as clients become aware of their wounds, they also tend to feel less daunted by them, less
imprisoned; they begin to realize, in other words, that they are more than their wounds, and
through this process, that they are more than their “disorder.” For example, “Steven”—a
composite of several of our clients—felt sure that he was despicable, defective, and demonic.
His parents had convinced him so over a period of 18 years, and not through the usual route
of abuse and punishment but exactly the opposite, through indulgence. Steven was led to
believe he was a king, a seer, and a god. He was given “everything,” and praised for virtually
every routine move. The result: As soon as Steven hit adulthood, the trials and pressures of
college, dating, and vocation, his bubble burst. No longer able to live under his former illu-
sions, he now had to face his foibles, inabilities to compete, and his far from developed will.
The convergence of these factors sent Steven into a tailspin. His view of himself completely
reversed—such that he now (in his 30s) repudiated himself, whereas he had earlier glorified
himself; and where he once saw a titan for whom every whim was fulfilled, he now saw an
outcast for whom every desire was unreachable.
The work with Steven is highly illustrative of the trust dimension in the activation of
presence. Although his self-hatred was formidable, it was not irrevocable. We spent many
sessions on his anguish, self-pity, and searing guilt. There were many times when he could
go only so far with these feelings, and had to warp back into the semblance of self and self-
image that he had constructed as a defense. But there were times, increasingly productive
times, when he could glimpse a counterpart. For example, in the midst of his self-devaluing,
he might suddenly become frustrated and realize moments of self-affirmation, that is, times
when he actually liked himself and liked being alive, regardless of the strokes he would
receive from doting associates. At first this realization was fleeting, but eventually, as he
stayed with it, it became the major counterpoint to his despairing self-reproach. Back and
forth he would swing, between burning self-debasement and gleaming self-validation—
including compassion, appreciation, and even exultation at being alive. This latter quality
was also connected to his growing sense of outrage at not only his outdated sense of self but
also his upbringing and well-intentioned but clueless parents. He began to realize that his
lowliness, far from being an inherent defect, was a product of environment, circumstance,
and, in part, choice.
To summarize, despite Steven’s repeated resistance and readiness to give up, the
272 EXPERIENTIAL AND HUMANISTIC APPROACHES

therapist’s empathic invitations to “give his hurt a few moments” or to “see what unfolds”
were crucial to his reengagement with his larger self. And through this reengagement he
began to discover that he was so much vaster than his stuck sense of unworthiness; he began
to see that he was sensitive, alive, and resiliently mortal—and that these were enough.

The Interpersonal Activation of Presence

The cultivation of presence can also occur through the interpersonal route, or that which
E-H therapists term the encounter (Phillips, 1980–1981; see also Krug, 2009, 2016), which
is illustrated by E-H therapists in myriad and diverse forms. For example, the calling of
attention to disturbances or undercurrents in the immediate relationship exemplifies the
E-H concern with encounter, as does the recognition of transference and countertransfer-
ence projections, as does the encouragement to explore the status of the therapeutic bond at
given junctures. As a whole, E-H encounter is characterized by the following three criteria:
(1) the real or present relationship between therapist and client (which can include past
projections, but chiefly as they are experienced now rather than in the remoteness of remi-
niscences; e.g., the difference between reporting about and “living” transferential material);
(2) the future and what the potential is in the relationship (vs. strictly the past and what
has already been scripted); and (3) the enactment or experiencing, to the degree possible, of
relational material (see especially Krug & Schneider, 2016, on “therapeutic enactments”).
Attention to the encounter or intersubjective, as an emerging cadre of psychoanalysts
have termed it (Stolorow, Brandchaft, & Atwood, 1987), is a vital part of E-H facilita-
tion. The reason for this is that interpersonal contact has a uniquely intensive quality that
both accentuates and mobilizes clients’ presence. The encounter accentuates presence by
awakening it to what is real, immediate, and directly personal, and it mobilizes presence by
demanding of it a response, engagement, and address. There is something profoundly naked
about the turn to an immediate interaction. It takes the parties out of their inward routine
(assuming that is there) and focuses the spotlight on a new and utterly alternative reality—
themselves. In short, there is something undeniably “living” about face-to-face interactions;
they peel away the layers of pretense and expose the inflamed truth of embattled humanity
(Krug, 2009). There are no easy exits from such interactions, and there are fewer “patch-up
jobs” as a result.
Most E-H practitioners assume that the therapeutic relationship (i.e., the way a client
relates to the therapist) is a reflection of how he or she relates with others outside the therapy
room (Krug & Schneider, 2016; Schneider & Krug, 2017; Yalom, 1980). Consequently the
encounter becomes a “living laboratory” whereby the client’s interactions can be under-
stood not only in the immediate therapeutic context but also in a broader context of the
client’s relational world.
The following vignette describes how one of us (Orah Krug) helped her client Diana
(a composite of several 30-something women) experience this reality and vivify disowned
parts of her self.
The session began with Diana describing, with evident pride and satisfaction, how she
had successfully completed a challenging task given to her by her supervisor.

Orah: You seem very pleased with your accomplishment.

Diana (exclaiming strongly): Following through on a commitment is very important
to me.
 Existential–Humanistic Psychotherapies 273

Orah: You put a lot of energy in those words. Keeping your commitments seems like
something you really value.
Diana: Yes, it is. I can feel it in my body.
Orah: Can you go inside and explore its meaning a little more? Just let your mind relax
and say whatever is there. [I intentionally slow the process down because Diana’s
energized statement indicates “aliveness,” on which I want her to focus. I typically
highlight implicit aliveness with clients who tend to tamp it down, as is Diana’s
proclivity. I sensed a constructive part of Diana was attempting to emerge, and by
slowing down the process, she could make “space” for it.]
Diana: It’s about being responsible, showing up in life, growing as a person. (Suddenly
she stops, laughs, and says:) I don’t know where I’m going.
Orah: You’re doing just fine. [I immediately realize my mistake. My comment was an
attempt to rescue her from her discomfort instead of allowing her to explore and
understand the meaning behind her “stopping.” I backtrack, inviting her to get
curious about her process.]
Orah: Did you notice when you said: “I don’t know where I’m going” it stopped you
dead in your tracks? Can you go inside and explore what’s happening?
Diana: I thought I was saying something stupid, blah, blah, blah, and I thought you
thought so, too.
Orah: Do you recognize that when you did that, you stopped “showing up” for your-
self?
Diana: No I didn’t, until now, but that’s true, I shut myself down.
Orah: Perhaps “showing up” triggers something scary?
Diana: (pauses, reflecting on what I’d said and then with tears in her eyes) Yes, a fear
of being out there and not knowing what’s coming—I squish myself.
Orah: You squish yourself if you’re “out there” and I see you. Can you go slow and
explore what’s scary about that?
Diana: I feel exposed, vulnerable, ashamed. I imagine I’m sounding stupid and you
think so too.
Orah: Would you like to ask me something about that?
Diana: (shyly asks) Did you think I was sounding stupid?
Orah: I did not. On the contrary, I was struck by how strong and confident you seemed
as you told me that you liked yourself showing up and being responsible. Your
spontaneous honesty moved me, I felt closer to you. How is it for you to hear me
say that?
Diana: I’m surprised but it feels good and true because I felt that inside—that I was
speaking my truth and I felt closer to you—and then I got scared. I didn’t know I
shut myself down when I think I’m sounding stupid. I don’t want to keep shutting
myself down when I speak my truth.
Orah: Shall we work on that right now?
Diana: Sure. How do we do that?
274 EXPERIENTIAL AND HUMANISTIC APPROACHES

Orah: We could work with the part of you that shuts you down. It seems that part
believes it needs to protect you from feeling stupid and ashamed. We all have pro-
tectors constructed to protect us. We could invite yours to be here, and imagining
it could speak, we could ask it a few questions, OK?

Diana’s protector spoke of being created long ago, so she would not feel stupid in front
of others. When Diana was a child and teenager, her father would constantly compare
Diana to her brothers, reminding her she wasn’t as smart or as competent as they were,
comparisons that wounded Diana. Her wound expressed itself as a belief about herself:
“I’m stupid” and a belief that others “will judge me.” Her protector was constructed to shut
her down, shaming her when she was “out there expressing herself.” This session marked a
turning point in our work. Since Diana and I were now both aware of her protector and its
duties, Diana was able to recognize when it tried to shut her down and in a friendly way she
let it know that she wanted to “show up,” and did not want it to shut her down. Our inter-
personal encounter organically focused us on how she related to herself and to me, helping
to vivify her protective pattern and bring us closer. The intimate interaction (and those that
followed) made our therapeutic relationship a safe space for her to face and work through
her shameful and scary feelings of being “out there” and “stupid.” Slowly, Diana developed
not only a friendlier relationship with her “protector” but also a sense of responsibility and
agency for it, along with agency for the more vulnerable, shameful feelings it was shielding.
Eventually, she was able to acknowledge, accept, and ultimately dissolve those shameful
feelings, becoming comfortable with “being out there” and being competent. As that hap-
pened, Diana grew into herself, feeling no longer like a little girl but more like a woman.
This vignette illuminates how E-H therapists cultivate presence to intra- and interper-
sonal process and work with resistance to self-expansion. Diana’s “resistance” was under-
stood as a functional protective mechanism, and as an expression of her self and world
construct system. Because the therapeutic relationship is a microcosm of their world, clients
invariably bring their protective, patterned ways of being into the relationship and transfer
onto the therapist particular attitudes and beliefs that express their sense of self in relation
to the other, evidenced when Diana “stopped herself.” However, my reassuring comments
almost caused us to miss and not vivify the “transference enactment.” Diana’s shame-based
feelings were so palpable that I reactively tried to protect her from them. I was caught in
my context of “the good caretaker,” which, thankfully, I recognized and from which I
recovered. My misstep emphasizes how quickly unconscious reactivity can take the place
of conscious presence. E-H therapists understand transference and countertransference as a
patterned way of being in the world that involves a significant other and that is reactivated
within the relationship. In Diana’s case she experienced herself as “stupid” and me as the
“judgmental other.” I experienced her as “someone in pain” and myself as “the one to take
it away.” It is crucial to address transferences and countertransferences when they arise,
allowing clients (and therapists) corrective emotional experiences, as illustrated in the previ-
ous example.
Several key E-H theoretical and clinical principles are expressed and demonstrated in
this vignette: (1) the client’s (and the therapist’s) past is alive in the present moment, (2) the
therapeutic relationship is a microcosm of the client’s (and the therapist’s) personal and rela-
tional worlds, and (3) it is within a safe and intimate therapeutic relationship that constric-
tive patterns, enactments, and underlying core wounds (of both the client and the therapist)
can be illuminated, dissolved and/or healed, and (4) for this to happen, the therapist must
 Existential–Humanistic Psychotherapies 275

be keenly attuned to the client’s implicit processes, as well as his or her own processes and
personal contexts.
To summarize, the E-H encounter is a complex and dynamic process whereby the entire
therapeutic context is taken into consideration; among the salient factors within this con-
text are the client’s desire and capacity for change, the therapeutic alliance, and practical
considerations. The guiding therapeutic question is: To what extent does encounter further
the cause of immersion in, engagement with, and integration of clients’ intensive struggles;
or, on the other hand, to what extent does encounter do the opposite and defeat or stifle
facilitative processes?

The Struggle with Resistance (or “Protection”)

When the invitation to explore, immerse, and interrelate is abruptly or repeatedly declined
by clients, then the perplexing problem of resistance, or ”self-protection,” as more E-H ther-
apists are terming it, must be considered. Resistance is the blockage to that which is palpably
(immediately, affectively, kinesthetically) significant within the client, and between client
and therapist. Several caveats must be borne in mind when considering client resistance.
First, therapists can be mistaken about resistance. What Therapist A, for example, labels an
internal resistance may in fact be a refusal on the part of Client B to accept Therapist A’s
agenda for him or her. Resistance may also be a safety issue for a given client, or an issue of
cultural or psychological misunderstanding. From an E-H perspective, then, it is of utmost
importance that therapists suspend their attributions of resistance and discern their relevant
contexts.
Second, it is crucial to respect resistance from an E-H point of view. Resistance is a
lifeline to many clients, and as miserable as their patterns may be, this lifeline represents
the ground or scaffolding of an assured or familiar path. Although this path may seem
crude or even suicidal to clients who experience it, it is starkly preferable to the alternatives
(May, 1983, p. 28). Accordingly, it is important for E-H therapists to tread mindfully when
it comes to resistance, acknowledging both its life-giving and life-taking qualities. It is also
important to be wary of challenging clients’ resistance prematurely, lest such challenges
exacerbate rather than alleviate defensive needs.
From an E-H point of view, resistance work is mirroring work. By mirroring work, we
mean the feeding back and elucidation of the client’s monumental experiential battle. As
suggested earlier, this battle consists of two basic factions: the side of the client that strug-
gles to emerge (e.g., to liberate from, transcend, or enlarge his or her impoverished world),
and the side that vies to suppress that emergence and revert. Whereas the activation of pres-
ence (e.g., the calling of attention to what is alive) mirrors the client’s struggles to emerge,
resistance work, as previously noted, elucidates the client’s barriers to that emergence, and
the ways and means they immobilize.
In summary, resistance work must be artfully engaged. The more that the therapist
invests in changing the client, the less he or she enables the client to struggle with change.
By contrast, the more that the therapist enables the client to clarify how he or she is willing
to live, the more the therapist fuels the impetus (and often frustration!) required for lasting
change (Schneider, 2008).
There are two basic forms of resistance work: vivification and confrontation. Vivifi-
cation of resistance is the intensification of clients’ awareness of how they block or limit
themselves. Specifically, vivification serves three basic functions: (1) It alerts clients to their
276 EXPERIENTIAL AND HUMANISTIC APPROACHES

defensive worlds, (2) it apprises them of the consequences of those worlds, and (3) it reflects
back the counterforces (or “counter-will,” as Otto Rank, 1936, put it) aimed at overcoming
those worlds. There are two basic approaches linked to vivifying resistance—noting and
tagging. Noting apprises clients of initial experiences of resistance. Here is an illustration:
“You suddenly get quiet when the subject of your brother arises” or “You laugh when speak-
ing of your pain” or “We were just speaking about your anxieties working with me and you
suddenly switched topics” or “I sense that you’re holding down your anger right now.”
In a distinctly dramatic illustration of noting resistance, Bugental (1976) reported a
highly stilted, initial interview with a client, in which decorum rather than genuine feel-
ing permeated. Laurence (Bugental’s client) took extensive pains to show how competent
he was, how many accolades he had won, and how important his life was. But after some
period of this self-puffery, Bugental “took a calculated risk” (p. 16). Instead of placating his
new client or emulating the standard intake role of detached observer, Bugental turned to
Laurence, faced him directly and averred: “You’re scared shitless”—and at that, Laurence
shed his mask of bravado and began a genuine interchange with Bugental.
Sometimes noting resistance takes the form of nonverbal feedback. For example, just
sitting with clients in their uncertainty at a given moment can feed back to them the realiza-
tion that a change or mobilization of some sort is necessary in their lives. Or through the
therapist’s mirroring of clients’ crossed arms or furrowed brow, clients may begin to become
clearer about how closed they have been, or how tensely they hold themselves.
Tagging alerts clients to the repetition of their resistance. Examples of tagging include
“So here we are again; at that same bitter place” or “Every time you note a victory, you go
on and beat yourself up” or “You repeatedly insist on the culpability of others” or “What
is it like to feel helpless again?” Like noting, tagging implies a subtle challenge, a subtle
invitation to reassess one’s stance. Implicitly, it enjoins clients to take responsibility for their
self-constructions and to revisit their capacities to transform.
Revisitation is a key therapeutic dimension. Every time clients become aware of how
they stop (or deter) themselves from fuller personal and interpersonal access, they learn
more about their willingness to approach such situations in the future. Frequently, many
revisitations are required before “stuck” experiences can be accessed; clients must revisit
many frustrations and wounds before they are ready substantively to reapproach those con-
ditions. Yet, as entrenched as their miseries may be, each time clients face them, they face
remarkable opportunities for change; and each incremental change can become monumen-
tal—a momentum shift of life-changing proportions.
Another form of vivifying resistance, tracing out, entails encouraging clients to explore
the fantasized consequences of their resistance. For example, Schneider has encouraged
obese clients who fear weight loss to review and grapple with the expectations of that
weight loss, and not just intellectually but experientially, through dramatizing an antici-
pated scene; identifying the feelings, body sensations, and images associated with the scene;
and encountering the fears, fantasies, and anticipated consequences of following the scene
to its ultimate conclusion. Although clients often find such tracing out disconcerting, they
also often find it illuminating, as it animates their overinflated fears, unexpected resources,
and resolve, in addition to their harrowing frailties. The tracing out of capitulation to a
behavior or experience is also highly illuminating. Such tracing out, for example, might
take the form of foregoing weight loss and the anticipated fears, fantasies, and implications
of maintaining the status quo. The question “Where does this (reluctance to lose weight)
 Existential–Humanistic Psychotherapies 277

leave you?” or “How are you willing to respond (to such intransigence)?” can help elabo-
rate these exercises.
When clients’ stuckness becomes intractable, but with a potential for substantive
change, a confrontation may be called for. Confrontation with resistance is a direct and
amplified form of vivification. However, instead of alerting clients to their self-destructive
refuges, confrontation alarms them, and in lieu of nurturing transformation, confronta-
tion presses for and demands (or requires, to use Bugental’s [1987] term) such transforma-
tion (Schneider, 2008). There are several caveats, however, about confrontation that bear
consideration. First, confrontation may risk an argument or power struggle between client
and therapist, versus a deepening or facilitative grappling. Second, confrontation risks the
surrender of clients’ decision-making power to therapists, with the resultant withdrawal of
that decision-making power from clients’ own lives. Third, confrontation risks alienating
clients—not merely from an individual therapist but from therapy as a whole.
As unfortunate as these potentially calamitous outcomes may be, they are not by any
means foreordained. Engaged optimally, confrontation requires not only careful and artful
encouragements to clients to change but also, and equally important, a full appreciation for
the consequences of such encouragements. Prior to decisions to confront, therefore, thera-
pists must carefully weigh the stakes—such as their intervention’s timeliness, their degree of
alliance with clients, and their own personal and professional preparedness.
Bugental (1976) provides a keen illustration of confrontation with his case of Frank,
who was an obstinate and reproachful young man. He repeatedly scorned life, yet refused
to entertain its possibilities for betterment as well. At one peculiarly frustrating juncture,
Frank chastises Bugental: “Whenever you guys want to make a point but can’t do it directly,
you tell the sucker he’s got some unconscious motivation. That way. . . . ”

[Bugental responds:] “Oh shee-it, Frank. You’re doing it right now. I answer one question
for you and get sandbagged from another direction. You just want to fight about everything
that comes along.”
[Frank:] “It’s always something I’m doing. Well, if you had to eat as much crap every-
day as I do, you’d . . . ”
[Bugental:] “Frank, you’d rather bellyache about life than do something about it.”
[Frank’s “pouting tone” changes.]
[Bugental continues:] “Frank, I don’t want all this to get dismissed as just my tired-
ness or your sad, repetitive life. I am tired, and maybe that makes me bitch at you more. I’ll
take responsibility for that. But it is also true that somehow you have become so invested
in telling your story of how badly life treats you that you do it routinely and with a griping
manner that turns people off or makes them angry. You don’t like to look at that, but it’s
so, and I think some part of you knows it.” (p. 109)

This vignette illustrates several important points. First, by intensifying his description
of Frank’s behavior, Bugental stuns or gently shocks Frank into a potentially new view of
himself—that of responsible agent rather than passive victim. By accenting Frank’s “invest-
ment” in complaining, he tacitly asks Frank to reassess that investment, and his entire
stance, in fact, of treating himself as a victim. Second, the vignette illustrates how a thera-
peutic interaction can reflect a more general reality in a client’s day-to-day world. As Bugen-
tal’s comment makes plain, Frank’s “griping” must turn off a lot of people, and, as in the
case with Bugental, this reaction can only complicate, if not exacerbate, Frank’s intransigent
278 EXPERIENTIAL AND HUMANISTIC APPROACHES

bitterness. Third, and by way of summary, Bugental’s remarks challenge Frank to reassess
his whole stance, the issues leading up to that stance, and the necessity of maintaining that
stance. In effect, Bugental beseeches, “What is the payoff of staying bitter, and is it worth
the price?”
On the other hand, there are notable times when such imploring (or even gentle inquir-
ing) with clients is futile, if not outright hazardous. At such times, clients may feel sapped,
“spent,” or defiantly entrenched, and instead of confronting or challenging those states
(which may have the unintended effect of threatening and thereby hardening intractable
defenses), the best strategy from the E-H view may simply be to enable or allow those
devitalizing realities (e.g., see Schneider, 1999). Frequently, for example, Schneider has
found that clients’ investments in their resistance directly parallel his own investment in
their overcoming that resistance. Furthermore, when Schneider pulled back some from his
own intransigence, clients, too, have seemingly loosened up and pulled back. This dynamic
makes sense; for what is being asked of clients, in effect, is to leap headlong into the doom
that they have designed a lifetime to avoid. However, to the extent that such clients feel that
they have room, can take their own pace, and can shift in their own time-tested fashion,
they are often more pliable, flexible, and inclined toward change.
To summarize, resistance work is mirror work and must be skillfully facilitated. Vivifi-
cation (noting and tagging) of resistance alerts, whereas confrontation alarms clients about
their self-constructed plights. Presumptuousness, however, must be minimized in this work.
Whereas some clients are amenable to the accentuation and vivification of their life patterns,
others are more reticent, and such reticence should not be undervalued. It, too, can be infor-
mative and eventually facilitate a fuller and deeper stance.

The Coalescence of Meaning, Intentionality, and Awe

As clients are able to face and overcome the blocks to their aliveness, as they begin to choose
rather than succumb to the paths that beckon them, they develop a sense of life meaning.
This meaning is wrought out of struggle, deep presence to the rivaling sides of oneself, and
embodied choice about the aspect of oneself that one intends to live out. The overcoming of
resistance, in other words, is preparatory to the unfolding of meaning, and the unfolding of
meaning is preparatory to revitalization.
Such revitalization, or what Rollo May (1969) terms “intentionality,” is the full-bodied
orientation to a given goal or direction. It is different from intellectual or behavioral change,
because its impetus derives from one’s entire being, one’s entire sense of import, and one’s
entire sense of priority (see also the “I am” experience in May, 1983).
The coalescence of meaning and intentionality takes many forms. Sometimes clients
find it on the job site, in the home, with friends, or with community. At times it takes the
form of a sport or a class or a trip, and sometimes it is without form (e.g., the freedom to
be). The pivotal issue here is attitude. To what extent does a client’s life meaning align with
his or her inmost aspirations, sensibilities, and values, and how much is the client willing to
risk (take responsibility for) the consequences of those alignments?
The task of the therapist at this stage is to assist clients in their quest to actualize their
life meanings. This assistance may take the form of a Socratic dialogue about possible ways
to change one’s lifestyle or relate to a partner, or begin a new project. It may be manifest as
an invitation to visualize or role-play new scenarios, inner resources, or concerted actions.
It may develop as a reflection on one’s dream life and the symbols, patterns, and affects
 Existential–Humanistic Psychotherapies 279

associated with the dream’s message. It may take the shape of a challenge to try out new-
found capacities in real-life circumstances—a desired encounter, a wished for avocation, a
contemplated journey. Following each of these explorations, meaning is further cultivated
by encouraging clients to sort through their experiential discoveries. For example, by attun-
ing to the feelings, sensations, and general life impact of risking a new relationship, clients
are in an enhanced position to evaluate the significance of that relationship.
While the coalescence of meaning and intentionality addresses a client’s life priorities,
it may sometimes lead beyond discernable priorities. Schneider (2008, 2009) has come to
call this “beyond,” awe, which is the humility and wonder, thrill and anxiety, of simply life
itself. It is the capacity to experience the adventure of life, regardless of a particular mode
or path. E-H therapy, in other words, forms a staging ground for not only attainment of
particular goals but also the inner freedom to experience more fully and deeply the context
within which goals operate, and this colors all of one’s life experience. One result of E-H
therapy, then, is that clients can experience the fuller ranges of life—both its vulnerable lows
and its transcendent peaks. They become more “whole,” but whole in the sense of being able
to experience the great paradoxes of life—vulnerability and unsettlement, as well as resil-
iency and pluck—and they become less susceptible to polarizing identifications.
At the same time, one does not necessarily have to come through a formal therapeu-
tic process to arrive at these awe-based realizations—Viktor Frankl (1963), for example,
discovered them in a concentration camp. However, what one does need is the capacity for
the cultivation of presence. Ultimately, E-H therapy is about “access and expressibility”
(Bugental, 1987, p. 27)—the capacity to access and express the maximal range of ourselves,
including ranges of spiritual depth.

A Note about the Social and Spiritual Dimensions of E-H Transformation

E-H therapy takes very seriously the question: On whose behalf does a therapist function—
the culture, the organization within which he or she works, the demands of the health care
industry, or the client him- or herself? Although none of these can be neglected from an E-H
point of view, it is emphatically the client, and the profound subjective and intersubjective
realizations of depth-experiential inquiry, that reflect E-H therapy’s primary commitment.
This person-centered priority, moreover, is not just for the revitalization of individuals; it
is for the revitalization of their (our) community, culture, and indeed, world (e.g., Bugental
& Bracke, 1992; May, 1981). To put it another way, E-H therapy promotes depth inquiry,
and depth inquiry promotes a sense of what deeply matters. Although such a sense does not
always lead to social engagement, in our experience—and that of many E-H practitioners—
this is predominantly what results (Schneider, 2013, 2017; Schneider & Krug, 2017).
One point, therefore, must be underscored: One cannot simply heal individuals to the
neglect of the social context within which they are thrust. To be a responsible practitioner,
one must develop a vision of responsible social change alongside and in coordination with
one’s vision of individual transformation—and increasingly, E-H practitioners are becoming
conscious of this interdependence (Hoffman, Cleare-Hoffman, & Jackson, 2015; Hoffman,
Stewart, Warren, & Meek, 2015; Mendelowitz, 2008; O’Hara, 2001, 2015; Schneider,
2009, 2013). Another area where such interdependence is key is that of spirituality (or one’s
relationship to existence as a whole). Although it is not often well publicized, spirituality
has a long and venerated lineage within E-H therapy. This lineage dates back to the roman-
tic philosophers of 18th- and 19th-century Europe, such as Johann von Goethe and Søren
280 EXPERIENTIAL AND HUMANISTIC APPROACHES

Kierkegaard, and wends its way into the 20th century through luminaries such as William
James, Paul Tillich, Rollo May, and Ernest Becker (Elkins, 1998; Moss, 1999; Schneider,
1998). The essence of this lineage is an appreciation of life’s paradoxes: among them, our
separateness from yet relatedness to others; our limitedness yet remarkable capacity to tran-
scend.
In E-H therapy, life’s paradoxes, such as isolation and fusion, humility and boldness,
are central. Over and over again, clients revisit these paradoxes, and persistently they emerge
from them anew. The result is that, over time, clients learn to be more present with them-
selves, more able to respond to rather than react against their paradoxical natures—and
more able to be present to, or stand in awe of, the paradoxes of life (Mendelowitz, 2008;
Schneider, 2008, 2009, 2013). This capacity to stand in awe, to experience the humility and
wonder—or adventure—of life is perhaps the apex of E-H therapy; it is perhaps the apex of
spiritual renewal.

CURATIVE FACTORS OR MECHANISMS OF CHANGE

As previously indicated, the core of E-H change processes is presence. Without presence,
there may well be intellectual or behavioral or physiological change but not necessarily the
sense of agency or personal involvement that core change requires. To put it another way,
E-H therapy stresses presence to what really matters, both within the self and between the
self and the therapist. This presence has two basic functions: (1) It reconnects people to
their pain (e.g., blocks, fears, and anxieties), and (2) it attunes people to the opportunities
to transform or transcend that pain.
Presence, then, is both the ground (condition, atmosphere) and the goal for E-H facilita-
tion. As ground, presence holds and illuminates that which is palpably (immediately, affec-
tively, and kinesthetically) significant within the client and between client and therapist.
Presence in this sense provides the holding environment whereby deeper and more intensi-
fied presence can take root. As goal, presence mobilizes clients. It accompanies them during
their deepest struggles, their search to redress those struggles, and their day-to-day integra-
tion of those struggles (Bugental, 1987; May, 1981).
In addition to facilitating experiential forms of change, such as those previously men-
tioned, presence also guides and provides a container, where appropriate, for more behav-
ioral or mechanistic levels of change. The question that presence illuminates is “What is
really going on with this client, and how can I optimize my assistance to her?”—or to put
it another way, “What is this client’s desire and capacity for change?” (Schneider, 1995).
Insight in E-H therapy is more like “inner vision,” as Bugental (1978) frames the
term. Inner vision facilitates an experience of past, present, or future issues rather than
an explanation or formulation about them. The end goal of inner vision is not so much to
“figure issues out” as to stay with them, attend to their affective and kinesthetic features,
and sort out how or whether one is willing to respond to them. To the degree that one can
follow this process through, one can not only become more intentional (i.e., concerted,
purposeful) in one’s life, but also, and paradoxically, more flexible, tolerant, and capable
of change.
Interpretations are provided in E-H therapy more to facilitate a deepening of experi-
ence than to strengthen analytical skills. Although a strengthening of analytical skills can
 Existential–Humanistic Psychotherapies 281

certainly be of benefit over the course of an E-H regimen, the thrust of the work is toward
empowering clients to find their logical or adaptive paths. In this sense, interpretations tend
to take the form of mirroring responses in E-H therapy, reflecting and amplifying clients’
rival impulses.
E-H change processes comprise both an intra- and interpersonal dimension. The
intrapersonal aspect is facilitated through concerted efforts to survey the self, whereas the
interpersonal dimension is facilitated through the naturally evolving “I–thou” dynamic of
relationship. Although E-H practitioners tend to emphasize different aspects of intra- and
interpersonal exploration, there is essential unanimity when it comes to the core of these
emphases—immediacy and presence.
To summarize, E-H therapy has two essential aims, which also constitute the “mecha-
nisms” of cure or change: (1) to cultivate presence (i.e., attention, choice, and freedom),
and (2) to cultivate responsibility (i.e., ability to respond) to that presence. These aims are
fulfilled by therapists through their capacity to attune to, tolerate struggle with, and vivify
emergent patterns, and by clients through their commitment to and capacity for change.
Although E-H therapy parallels, and indeed grounds, many other intensive therapies (see
the section “Research Support and Evidence-Based Practice”), its emphasis on presence,
struggle, and whole-bodied responsiveness renders it unique.

TREATMENT APPLICABILITY AND ETHICAL CONSIDERATIONS

As suggested earlier, E-H therapy applies to a diverse population of clients. Despite its high-
brow image, E-H practice has been applied to substance abusers, ethnic and racial minori-
ties, gay and lesbian clientele, psychiatric inpatients, and business personnel (Schneider,
2008; Schneider & Krug, 2017). Furthermore, E-H principles of presence, I–thou rela-
tionship, and courage have now been adopted by a plethora of practice orientations (see,
e.g., Bunting & Hayes, 2008; Fosha, 2008; Shahar & Schiller, 2016). That said, however,
the expansion and diversification of E-H therapy is a relatively recent phenomenon; most
E-H practice still tends to take place in white, middle-to-upper-class neighborhoods with a
white, middle-to-upper-class clientele. Yet there is no necessary link between such clientele
and successful E-H therapy; as E-H practitioners are discovering, the benefits of presence,
I–thou encounter, and responsibility are cross-cultural, as well as cross-disciplinary (Rice,
2008; Vontress & Epp, 2015).
While E-H therapists realize that they cannot be “all things to all people,” and that
certain problems (e.g., circumscribed phobias and brain pathology) are best handled by
specialists, a definite ecumenicism impacts contemporary E-H practice. This ecumenicism
emphasizes cross-disciplinary openness, adaptations for diverse populations, and sliding-fee
scales.
Therefore, the key ethical considerations of E-H practice are (1) the engagement of
presence, along with clinical and cultural competency, to assess clients’ personal, culturally
situated circumstances; (2) the capacity of the E-H practitioner to address these personal
and culturally situated circumstances; (3) the consideration of alternative modes of practice
or professional referrals in the case of limitations in the capacity of E-H practitioners to
address clients’ circumstances; and (4) the flexibility to meet diverse cultural and financial
needs.
282 EXPERIENTIAL AND HUMANISTIC APPROACHES

RESEARCH SUPPORT AND EVIDENCE-BASED PRACTICE

Inasmuch as E-H therapy places a premium on factors that are held in common across
the different therapies (e.g., the therapeutic alliance, empathy, and expressed emotion),
it is increasingly being recognized as an evidence-based approach (e.g., Angus, Watson,
Elliott, Schneider, & Timulak, 2015; Elkins, 2016; Shahar & Schiller, 2016; Wampold,
2008; Wolfe, 2016). Not to be discounted, moreover, is E-H therapy’s enduring lineage
of eloquent case studies (e.g., Binswanger, 1958; Boss, 1963; Bugental, 1976; May, 1983;
Schneider, 2008; Schneider & May, 1995; Spinelli, 1997; van Duerzen, 2015; Yalom, 1980).
That said, however, the systematic, corroborative evidence for E-H therapy is still compara-
tively limited (Craig, Vos, Cooper, & Correia, 2016) for two major reasons. First, the E-H
theoretical outlook has tended to attract philosophically and artistically oriented clinicians
who are more at home with clinical practice or case study narratives than with labora-
tory procedures or controlled investigations (Wertz, 2015). Second, when E-H therapists or
theorists have attempted to conduct research, they have found themselves facing an array
of theoretical, practical, and political barriers. Among these barriers are the difficulties
of translating long-term, exploratory therapeutic processes and outcomes into controlled
experimental designs and requirements (Schneider, 1998; Seligman, 1996); the problems
of quantifying complex life issues (Miller, 1996a); and the hardships of obtaining research
funds for “alternative” therapeutic practices (Miller, 1996b). Furthermore, the obstacles are
even more daunting for those in the E-H therapy community who have called for qualita-
tive (e.g., phenomenological) assessment of their practices. Although many consider such
assessments more appropriate than their conventional counterparts to evaluate E-H subject
matter, there are substantial barriers associated with their implementation (Wertz, 2015).
Among them are not only perplexing theoretical and practical challenges but also, and
no less confounding, disparagement from a quantifying, medicalizing research community
(Elkins, 2016; Wertz, 2015).
These difficulties, however, appear to be lessening. In recent years, mainstream concep-
tions of therapeutic process and outcome research have undergone notable reevaluations,
and models once considered invulnerable are now being revised. For example, the random-
ized controlled trial (RCT) once considered the “gold standard” of therapeutic evaluation
research, has been criticized as falling short especially in providing guidance for practice
(Elkins, 2016; Messer, 2016). Conversely, qualitative research, once considered practically
and scientifically untenable, has attained professional legitimacy (Elliott, 2015; Wertz,
2015). So, too, is the structured and systematic case study enjoying renewed interest as
a form of legitimate research, as are methods that combine qualitative and quantitative
approaches (Fishman, Messer, Edwards, & Dattilio, 2017).
In light of these changes, E-H therapy has been accumulating a considerable base of
empirical support. Although still comparatively circumscribed, this base is both rigorous
and integral to the psychotherapy field as a whole (Angus et al., 2015; Elkins, 2016; Walsh
& McElwain, 2002); it also dovetails consistently with the latest findings about so-called
“common factors” research, which shows convincingly the value of E-H practice principles
for effective psychotherapy (Elkins, 2016; Wampold, 2008, 2012). In the domain of system-
atic quantitative inquiry, for example, there is growing support for key E-H principles of
therapeutic rapport, attunement to clients’ needs, facilitation of emotional expression, and
personal accessibility (or genuineness). This support is reflected in both the “common fac-
tors” and “contextual factors” research that consistently upholds relationship as opposed
 Existential–Humanistic Psychotherapies 283

to technical factors as the core facilitative condition (Elkins, 2016; Messer & Wampold,
2002; Wampold, 2008, 2012). It is echoed in the research on therapeutic alliance (Horvath,
1995), empathy (Bohart & Greenberg, 1997), genuineness and positive regard (Orlinsky,
Grawe, & Parks, 1994), and clients’ capacity for self-healing (Bohart & Tallman, 1999),
and it is mirrored in the existing research on expressed emotion (e.g., Angus et al., 2015;
Gendlin, 1996; Elliott, 2015). Greenberg (2007) and colleagues, for example, demonstrated
that E-H compatible facilitations such as evocative unfolding (or vivifying a problematic
scene), empty-chair technique (role play with an imagined other), and experiential process-
ing (which includes evoking awareness of experience, attendance to unclear or emergent
experience, ownership of emotional reactions, interpersonal contact, development of a
meaning perspective, and translation of emerging awareness into daily life) all correlated
with positive outcome.
Finally, in a little known but provocative study of E-H therapy with patients diag-
nosed with schizophrenia and treated in the alternative, minimally medicating psychiatric
facility Soteria House, Mosher (2015) reported that at 2-year follow-up, the experimental
(E-H treated, minimally medicated) population had significantly better outcomes regarding
rehospitalization, psychopathology, independent living, and social and occupational func-
tioning than their conventionally treated (intensively medicated) counterparts over the same
investigative period. The findings of this study (which was conducted in the 1970s and
1980s) were subsequently confirmed and accompanied by an “urgent” recommendation to
evaluate Mosher’s approach further (Calton, Ferriter, Huband, & Spandler, 2008, p. 181).
On the qualitative side of the equation, Bohart and Tallman (1999), Rennie (1994), and
Watson and Rennie (1994) have demonstrated the value of such E-H stalwarts as presence
and expanding the capacity for choice in effective facilitation. Specifically, they showed
that successful therapy, as understood by clients, necessitates “a process of self-reflection,”
consideration of “alternative courses of action, and making choices” (Walsh & McElwain,
2002, p. 261). In a related qualitative study, Hanna, Giordana, Dupuy, and Puhakka (1995)
investigated what they termed “second order” or deep and sweeping change processes in
therapy. Compatible with existential emphases on liberation, they found that “transcen-
dence,” or moving beyond limitations, was the essential structure of change. Furthermore,
they found that transcendence comprises “a new perspective on the self, world, or problem”
(p. 148).
There have also been a series of qualitative studies upholding the value of existen-
tial–integrative (E-I) therapy—an offspring of E-H therapy, supporting its value in treating
conduct disorders, addiction, obsessive–compulsive disorder, depression, generalized anxi-
ety, psychosis, multicultural and gender issues, and even dissociative disorder (Schneider &
May, 1995; Schneider, 2008; Schneider & Krug, 2017; Wolfe, 2016).
Finally, in a study of clients’ perceptions of their E-H–oriented therapists, Schneider
(1985) reported that although techniques were important to the success of long-term (i.e.,
2-year-plus) therapeutic outcomes, the “personal involvement” of the therapist—which
comprised his or her genuineness, support, acceptance, and deep understanding—was
by far the most critical factor identified. Such involvement, moreover, inspired clients to
become more self-involved and to experience themselves as more capable, responsible, and
self-accepting. (For a comprehensive review of E-H therapeutic investigations, see Craig et
al., 2016; Elkins, 2016; Elliott, 2002; Geller & Greenberg, 2012; Schneider & Krug, 2017).
To summarize, empirical investigation of E-H therapy is in a nascent but flowering stage.
Many conceptual dimensions of E-H practice have been confirmed by both quantitative and
284 EXPERIENTIAL AND HUMANISTIC APPROACHES

qualitative investigation, and many remain to be more fully illuminated. Yet if the trends in
therapy research continue, E-H practice may become a model, evidence-based modality that
stresses three critical variables: (1) the therapeutic relationship, (2) the therapist’s presence
or personality, and (3) the active self-healing of clients. By implication, on the other hand,
statistically driven manuals, programs, and techniques may become increasingly adjunctive,
if not peripheral, in their facilitative role (Bohart & Tallman, 1999; Elkins, 2016; Messer &
Wampold, 2002; Wampold, 2012).

CASE ILLUSTRATION

The following is Kirk Schneider’s case report to help elucidate the aforementioned principles.
This case report is based on the E-I approach to therapy, which, again, is one way to under-
stand and coordinate a variety of bona fide approaches within an overarching existential
or E-H context (Schneider, 2008). Mary was a self-referred, 240-pound, single, European
American sales clerk. She had a minimal 3-month history of “mental health” counseling (as
a young adolescent) and no history of psychotropic medication. From the moment Mary
stepped into my office, I could sense a deep connection with her, yet, at the same time, a
curious reluctance on her part to engage.
Seduced and teased as a child, Mary had minimal trust in men, little trust in herself in
the presence of men, and minute trust in the culture that tacitly assented to these conditions.
Yet here she was, at 30 years old, declaring her commitment to reenvision and reassemble
her life. Here she was—partly with my encouragement—dashing off reams of journal pages
about the pain, injustice, and outrages of her life, but at the same time, about the dreams,
desires, and possibilities that could be her life. She would read from, and we would share
reflections about, her entries and she would scrap tirelessly with them. Back and forth, she
would swing—between searing self-abasement and rising self-attunement, between deplet-
ing worry and replenishing confidence. Her struggle displayed all the earmarks of the depth
excursion, the depth entanglement, that precedes restoration. She, like so many therapy
clients, had to straddle contending life paths, to sift out the implications of those life paths,
and to consolidate a plan, direction, and vision based on those implications. Following
3 years of such wrangling and deep experiential immersions, she gradually and doggedly
reemerged. She found that capitulating to her father, the culture, and the taboo of asserting
herself was no longer tolerable and that changes had to occur.
Her first step, which I encouraged, was to allow herself to be angry and indignant
enough to halt her automatic bingeing and to peer into the void it replaced. Instead of
instantly seeking food as a refuge, therefore, and based on my recommendation, she insti-
tuted a pause in her experience; she allowed the fears and hurts to percolate. Yet in this
percolation were much more than fears and hurts. She realized, for example, that she did
not have to be so readily panicked over being seen by others, that she would not inexorably
be attacked by the person she feared, and that, greatest of all, she had a value and truth that
she could not squander. Regardless of her obesity, Mary realized, she had worth; a tender,
loving essence inside her, yearning to be felt, heard, and held.
Her second step, which we coordinated with a local weight loss clinic, was the long and
arduous process of losing her excess girth and of confronting the barriers to this toilsome
process. It is not that she felt an obligation to lose pounds or even that this ordeal was man-
datory for her physical health (which was notably compromised). All these “supposed to’s”
 Existential–Humanistic Psychotherapies 285

were increasingly peripheral to her. By contrast, that which was mandatory for her was an
internal rightness about losing her weight. She did not want to go into a program until she
felt clearly that health, attractiveness, and integrity were necessary for her—not for some
imagined other.
Following this clarification, Mary embarked on an 8-month trial with a powder diet as
a replacement for meals. This course had its own thorny challenges, but she met them well.
On the one hand, the powder was “easy” because it was readily available, habit forming, and
required little forethought. On the other hand, precisely because it was not food, the powder
presented Mary with opportunities to reassess her associations to food. Among these asso-
ciations were the comfort value of food, the special linkages to sweets, and the pleasure of
cooking. But chief among Mary’s discoveries was that behind all these compelling features
of food was the daunting capacity of food to protect. From the standpoint of protection,
Mary realized, food was not simply a distraction or a pleasurable obsession; it was a refuge
from perceived annihilation. By eating the powder, and particularly, by attending to the
feelings, sensations, and images conjured up by her abstinence from food, Mary began to
confront death, the “death” (or brutality) she associated with her nakedness, beauty, and
rawness, removed from her culinary refuge. As a result, she began to cope better with that
death anxiety. She became less anxious and acquired new patterns of self-support—such as
speaking up for herself, or associating with caring company. She also found freedom in her
newfound visibility, particularly the freedom to play. She indulged in play like a kid on her
first visit to a beach. She ran, worked out, hiked, and simply reveled in her newfound (130
pound) mobility. She also reveled in her newfound attractiveness to men.
Despite these Herculean developments, however, and like so many who embark on
the dieting path (see, e.g., Sifferlin, 2017), Mary emphatically relapsed. After 8 energiz-
ing months, and upon transitioning to real food, Mary discovered yet another layer to her
ordeal: She had yet to confront her rage. Oh, Mary could get angry. She could rail at the
indignities of life, the injustices of culture, the cruelty of her narrow-minded peers, and so
on. Yet what she could not do earlier, in the ease and comfort of her powdered diet, was to
rail at the chief source for her oppression—her incest-mongering father.
The reexposure to food then brought back a torrent of memories, hurts, and defenses
for Mary. She conveyed a dream—early on in this transition—that coupled a hovering,
heavily breathing face, with a tiny, prenatal body. I asked her to focus on the feeling tone
of this dream and to explore its affective and kinesthetic associations. Although reluctant
at first, she soon was able to “live out” the sequences of the dream and to “speak” from its
urgent depths. The voice that stood out consequently was the prenatal voice, which was her
voice, of course, struggling for its survival. But suddenly a shift occurred: The ostensibly
fragile, prenatal cry, became a blood-curdling scream, and the scream became an attacking
fist. But this sequence only lasted a few seconds. In moments, she would revert again to a
cry. Mary spent many subsequent months unpacking the above sequence, delving ever closer
to her core battle. Repeatedly, we would call attention to her swings between abject timidity,
helplessness, and vulnerability, and flagrant rebellion, vengefulness, and fury; then her fear
and guilt would set in, and the whole cycle would be repeated.
The instantiation of this pattern was evident in Mary’s daily life. Consistently she
would oscillate between holing herself up in her house with bags of candy, to bulldozing
her coworkers, to bloating and flagellating herself again with food. After 6 months of
her transition back to food, Mary regained 60% of her postdietary weight loss (about 65
pounds).
286 EXPERIENTIAL AND HUMANISTIC APPROACHES

There were, of course, livelier times for Mary, but at this juncture, they were mercilessly
under siege. The encrusted layers of pain, dormant just 6 months earlier (in association with
her powder diet), now broke open into raw, exposed gashes; and although Mary empathized
with these gashes, their intensity sometimes overwhelmed her. Binge eating, as noted pre-
viously, was one avenue of defense against this intensity, but so were vain efforts to gain
control, such as bulimic purging and even mild cutting.
At one point I mirrored these patterns back to Mary. I echoed back to her what I expe-
rienced as her slow “suicide,” her pull to “give up,” and her readiness to defer her power.
In turn, Mary bristled at my characterizations, denied that she was in crisis, and simmered
in defiance. Yet, at the same time, Mary and I both knew that I had touched a chord at
some level, that death was at her doorstep, and that time was slipping fast. It is during just
such periods that clients stand before a crossroad in E-H therapy—the crossroad of life or
death, possibility or foreclosure—and it is precisely the handling of that crossroad (by both
therapist and client) that has an indelible impact on recovery. In light of these contexts, I
concertedly invited Mary to stay present to herself, to reverberate to her agonizing dilemma,
and to open to the possibilities, the “more” that her dilemma foretold. A part of this “more”
encompassed Mary’s relationship with me. To the degree that Mary and I could tussle with
one another—could face one another’s ire and awkwardness and discomfort—to that extent
we could also begin to appreciate one another and the “truth” we separately offered to one
another. Mary’s truth, as I grew to appreciate it, was the stark terror of confronting and
overcoming her father’s wrath. It was the dread of change, and of becoming the “new”
person who has to embody that change. The truth that I held for Mary, on the other hand,
which she grew to appreciate, was the anguish, self-deprecation, and disability she counte-
nanced by remaining in her father’s thrall, and, conversely, the freedom, mobility, and life
that awaited her on the other side of that thrall.
This I–thou meeting afforded Mary a chance to reappraise her relationship to herself,
her father, and me. It helped her see—in vivid and experiential immediacy—that she was
more than her paralyzing fragility, more than a rape victim, and even more than a victim of
women-hating men but a person who could struggle and be vulnerable with another person,
yet emerge with renewed vigor.
Gradually then, and with mounting force, the side of Mary that aspired to feel, deepen,
and live began to predominate, whereas the regressive side, the side that pulled to hide,
waned. (Although this was not a permanent state of affairs, it definitely set the tone for the
future.) These changes afforded Mary and me a chance to revisit the question of her trans-
formation. The first step in our reassessment was to institute a stopgap measure; in order
for Mary to reemerge, the “blood letting” had to be stanched. Accordingly, Mary limited
her bingeing, stopped her cutting, and ceased her purging. With my encouragement, further-
more, she enrolled in an intensive, yearlong rehabilitation program. This program—which
comprised nutritional counseling, group therapy, and behavioral modification training—
was aimed at curtailing her bingeing, bolstering her life-management skills, and strength-
ening her capacity to communicate. From the E-I standpoint, these are precisely the “foot-
holds” or bases on which a fuller and deeper self-exploration can be built (Schneider, 2008).
Accordingly, once Mary began stabilizing—which was about 8 months after her transi-
tion to food—she gained some control over her external patterns, and was able to intensify
her encounter with self. Her behavioral skills building, in other words, paved the way for
the next and more pivotal phase of internal skills building, which, for those who are ready
and capable, is the core of the E-H/E-I approach.
 Existential–Humanistic Psychotherapies 287

In the final phase of our work, Mary focused on living while dieting rather than diet-
ing to live. Over the course of her many ordeals, Mary had learned to grab the life that
awaits her now rather than postponing it for some unreachable ideal. In accord with this
philosophy, and in the midst of her ongoing weight management, she began dating again,
went on trips that she had deferred, and resumed her “working through” with her father.
For example, to facilitate Mary’s rising self-confidence in relation to her father, we worked
with a variety of exploratory outlets—from role plays to cathartic drawings, to rituals with
effigies wherein her father could be symbolically overcome.
Yet, whereas these initial encounters with her father were imaginary, Mary soon began
to shift her tack and contemplate an actual confrontation. She spent many weeks exploring
the necessity of such a confrontation, but by closely attending to her experience—imme-
diately, affectively, and kinesthetically—she emphatically arrived at a decision: She would
write him a letter, spelling out her entire experience of him—decimating, as well as ambiva-
lent and loving—and offer personally to discuss that letter at a location of her choosing.
This decision on Mary’s part was a turning point of therapy. Regardless of how her
father responded, in my view, Mary had turned the tide with this decision, from floundering
panic to concerted choice, and from impotence to agency. As it turned out, Mary fulfilled
her plan and met with her father. Although he was reportedly “shaken” by the ordeal, it did
bring a renewed life to their relationship, and most important, it helped to restore Mary’s
life, the “life” that she could give to herself.
By the end of our work together—about 3½ years of therapy—Mary acquired a revivi-
fied sense of self. Although she continued to contend with weight issues (e.g., she was now
about 30% overweight) and harbored residual anxieties, these no longer stifled her or pre-
vented her from concertedly living. First and foremost she ate more healthfully, significantly
lowered her risk for severe physical disorders, such as heart disease and Type II diabetes, and
began a promising romantic relationship. She also experienced a great deal more freedom in
her life, and that sensibility paid off in her deepened friendships, expanded physical activi-
ties, and enhanced service to the community.
Finally, although Mary was “liberated,” she did not completely eradicate her symp-
toms. What she did eradicate, on the other hand, was a corrosive view of life, which was a
partial view that stressed helplessness over possibility and anxiety over courage. Like many
E-H therapy clients, Mary formed a new relationship with her symptoms; she learned that
she could expand beyond them and through that expansion discover new relationships to
food, to her father, and even to existence itself, to a sense of the awesomeness of existence
itself (see also Roth, 1991).
Mary was a deeply troubled but extraordinarily dedicated E-H therapy client. She grap-
pled with some of the most trying personal and social barriers with which humans must con-
tend—incest, obesity, depersonalization—yet she comparatively and realistically triumphed.
Beginning with her furious journal writing; our introductory struggles; and her fitful align-
ment with fears, desires, and outrages, Mary gradually reconstructed her life. Through my
presence and our presence to each other, Mary was able to experience the safety to do more
than merely report about her life but to “work out” that life amid torments of the past,
promptings of the present, and callings of the future. Through invitations to stay present to
herself—particularly the feelings, sensations, and images evoked within herself—she began
to illuminate not only what she profoundly desired in her life (e.g., freedom, mobility, and
intimacy) but also, and equally important, what separated her from those profound desires
(e.g., terror of annihilation—her father, men—suppressed rage, and entrenched habits).
288 EXPERIENTIAL AND HUMANISTIC APPROACHES

In the meantime, adjunctive therapies were employed at key stages throughout the E-H
therapy process. These therapies, such as nutritional counseling and behavioral skills train-
ing, provided a key confidence-building component to the E-H work. At the same time that
they helped Mary to stabilize, they also helped to empower her, and this empowerment
translated into her willingness to take risks in depth therapy.
In short, E-H therapy provided a forum whereby presence and its activation through
inner struggle, resistance work, and coalescence of meaning and awe, along with an adjunc-
tive program of rehabilitation, could converge to reassemble a life. To the extent that such
opportunities for meaningful convergence are being hampered by cost-control measures
today, there are dwindling opportunities to reassemble lives, and this, lamentably, may be
the direst legacy of market-driven mental health care.

CURRENT AND FUTURE TRENDS

The outlook for E-H therapy is both guarded and promising. It is guarded to the extent
that all depth therapies are guarded and under threat today—by an encroaching medical-
ized ethos. Moreover, on the one hand, as students, instructors, and professional organiza-
tions acquiesce to and, in some cases, encourage the foregoing ethos, there is a decreasing
incentive to teach, let alone apply E-H alternatives. On the other hand, the outlook for the
future is not so one-sided as it may seem. As previously suggested, there are trends, such as
the embrace of experientially informed practice, that run directly counter to the aforemen-
tioned scenario. These trends suggest that a backlash is building, and that E-H therapy is
on its cutting edge. The special issues on “The Renewal of Humanism in Psychotherapy”
and “Existential-Humanist Integrations of Psychotherapy” in the 2012 and 2016 journals
Psychotherapy and Journal of Psychotherapy Integration are indications of this aforemen-
tioned trend; and so are the best-selling second edition of Existential–Humanistic Therapy
as well as its companion volume Supervision Essentials of Existential–Humanistic Therapy
both published by the American Psychological Association (Schneider & Krug, 2017; Krug
& Schneider, 2016). “It could be,” as Wampold (2008) observes, “that an understanding of
existential therapy is needed by all therapists, as it adds a perspective that . . . might form
the basis of all effective treatments” (p. 6).
On the other hand, we do not want to sound glib about the challenges that lie ahead.
Medicalization and expedience are here to stay, and there are sound bases for their existence
(e.g., Schneider, 2008). But what we do wish to emphasize is that with discernment, focus,
and passion, a major transformation can be staged in psychology. This change will not be
exclusivist—it will not reject conventional modalities—but it will widen, deepen, and inte-
grate these modalities, and it will weave them into a liberating whole.

SUGGESTIONS FOR FURTHER STUDY

Recommended Reading
Bugental, J. F. T. (1976). The search for existential identity: Patient–therapist dialogues in humanis-
tic psychotherapy. San Francisco: Jossey-Bass.—This book is a classic of the E-H case literature.
Krug, O. T., & Schneider, K. J. (2016). Supervision essentials for existential–humanistic therapy.
Washington, DC: American Psychological Association.—This is one of the first formal texts on
E-H principles of supervision.
 Existential–Humanistic Psychotherapies 289

Schneider, K. J. (Ed.). (2008). Existential–integrative psychotherapy: Guideposts to the core of prac-

tice. New York: Routledge.—This edited volume extends E-H therapy to a new, more diverse
generation of practitioners.
Schneider, K. J., & Krug, O. T. (2017). Existential–humanistic therapy (2nd ed.). Washington, DC:
American Psychological Association.—This book covers the very latest in E-H theory, practice,
and research.

DVDs
Bugental, J. F. T. (1995). Existential–humanistic psychotherapy in action. San Francisco: Psychother-
apy.Net. Available at www.psychotherapy.net.—This is a classic presentation of James Bugen-
tal’s enlivening approach to therapy, along with commentary.
May, R. (2007). Rollo May on existential psychotherapy. San Francisco: Psychotherapy.Net. Avail-
able at www.psychotherapy.net.—Conducted by two of his former graduate students, Kirk
Schneider and John Galvin, accompanied by colleague Ilene Serlin, this is one of the rare, dis-
tinctly candid and personal elucidations of Rollo May’s practice philosophy.
Schneider, K. J. (2006, 2009). Existential–humanistic therapy (Systems of Psychotherapy Video Series).
Washington, DC: American Psychological Association. Available at www.apa.org/videos.—These
are two of the first video demonstrations of existential–humanistic (E-H) therapy for the Ameri-
can Psychological Association. The 2009 video, E-H Therapy Over Time, is especially in depth
and noteworthy.

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 PART V

SYSTEMS-ORIENTED
APPROACHES
 CHAP TER 9

Family Therapies
Nadine J. Kaslow
Hamid Mirsalimi
Marianne P. Celano

HISTORICAL BACKGROUND

Family therapy’s roots are in social work, marriage and family life education, marriage
counseling, and psychiatry. Many early theorists were psychoanalytically trained and began
including family members in the treatment of individuals because they believed patients’
symptoms were maintained by dysfunctional family patterns that individual therapy was
insufficient to change. Early family therapists turned to general systems and communication
theories to enhance their understanding of complex human interactions. This early phase
in the evolution of family therapy was based on the observation that expanding one’s lens
beyond the individual to the entire family offered new understandings of the impact of fam-
ily relationships and opportunities for more far-reaching approaches to treatment (Sexton
& Lebow, 2016).
The first wave of research was conducted with adults with schizophrenia and their fami-
lies. Bateson, Jackson, Haley, and Weakland (1956) argued that the key family determinant
in the development of schizophrenia was double-bind communication (i.e., two or more
contradictory messages from the same person require a response guaranteed to meet with
disapproval). This concept is now considered more pertinent to the maintenance than the
etiology of schizophrenia, which is understood as a biologically based disorder that may be
exacerbated by stress. In addition to Bateson and colleagues and Satir at the Mental Research
Institute, other founders studied persons with schizophrenia and their families: (1) T. Lidz
and coworkers Fleck, Cornelison, and R. Lidz; (2) Bowen; (3) Wynne; (4) Boszormenyi-
Nagy; and (5) Whitaker, Malone, and Warkentin. Other early leaders were Bell, one of the
first to conduct sessions with all family members, and Midelfort, who authored the first book
solely devoted to family therapy.

297
298 SYSTEMS-ORIENTED APPROACHES

During the same period, family theories and interventions were applied when the index
patient was the child, as Ackerman viewed the family as the proper unit of diagnosis and
treatment (Ackerman & Sobel, 1950). Clinicians who felt thwarted in their work with chil-
dren turned their focus to the family as the unit for change. This paradigm shift emphasized
family processes and the interactional context in which child behavior occurs. Related to
this, Minuchin (1974) and colleagues at the Philadelphia Child Guidance Center studied
family therapy with delinquents, low-socioeconomic-status families, and psychosomatic
families.
The second wave (1962–1977) began with the publication of Family Process, the first
family therapy journal. National training centers were established and certification and
licensure were emphasized. The American Association for Marriage and Family Therapy
(AAMFT) began accrediting graduate training programs. This decade witnessed the devel-
opment of competing models and a clamor for outcome and process research (Gurman &
Kniskern, 1981/2013, 1991). This wave ended with the establishment of the American Fam-
ily Therapy Academy (AFTA).
The following are major changes in recent decades that deserve attention. First, there
has been growing awareness of the common factors intrinsic to all family therapies and how
these factors are mechanisms of change in all models (Sprenkle, Davis, & Lebow, 2009).
This movement builds on the classic common-factors approach to individual therapy and
highlights common factors unique to couple and family therapy: maintaining a relational
frame and a multisystemic focus; mixing individual, couple, and family sessions; managing
sessions with more than one person present; using homework to promote change within the
family; engaging positive family processes; enhancing the durability of change; adapting
to the family’s culture; and engaging in a shared metalevel process (Lebow, 2014). Sec-
ond, over the past 20–25 years, the field has become increasingly integrative. Integrative
models either borrow from various family and other schools of therapy or are created as
integrative approaches (Fraser, Grove, Lee, Greene, & Solovey, 2014; Lebow, 2014; Pinsof,
Breunlin, Russell, & Lebow, 2011). These models, which often build on factors relevant
to change across family interventions, require therapists to be open to diverse perspectives
yet disciplined in their application (Imber-Black, 2015). Even theorists historically aligned
with a specific model have expanded their horizons and incorporated other frameworks
(Minuchin, Reiter, & Borda, 2014).
Third, there has been an appreciation of a biopsychosocial perspective (Doherty,
McDaniel, & Hepworth, 2014). Research on genotype–environment interplay, functional
brain activity associated with emotion and behavior, and neuroplasticity now inform family
case conceptualization and intervention (Celano, 2013). Research in pediatric and family
psychology (Wood, Miller, & Lehman, 2015) supports conceptualizing and treating ill-
ness in a biopsychosocial context. Collaboratively practiced medical family therapy is an
illustrative example of the application of the biopsychosocial model (McDaniel, Doherty,
& Hepworth, 2014). With awareness of the integral nature of culture, the field is embrac-
ing a biopsychosocial–cultural framework for formulating family processes and intervening
effectively.
Fourth, the field’s long-standing focus on context laid the groundwork for intentional
incorporation of diversity and multiculturalism, with emphasis on heterogeneity within and
across families regarding ethnicity/race, culture, immigration status, gender, sexual orienta-
tion, gender identity, socioeconomics, and spirituality (Kelly, 2017; McGoldrick & Hardy,
2008). Family therapists recognize that cultural values influence behavior and beliefs and
 Family Therapies 299

clinical encounters reflect an engagement between the therapist’s and the family’s cultural
constructions about family life and healthy–abnormal behavior. They attend to intersecting
cultural characteristics and factors associated with worldviews and values, experiences and
contexts, power dynamics, and beliefs about intimacy (Kelly, 2017). They use assessment
tools (cultural genogram) to raise cultural awareness and strive to offer culturally acceptable
interventions.
Fifth, the role of gender and power in the context of families is recognized. Pioneering
feminist therapists pointed to the lack of attention to power dynamics in family relation-
ships and argued that observed differences between women and men reflect socially sanc-
tioned power differences in the family rather than true differences between the two sexes
(Goldner, 1985; Hare-Mustin, 1987). There is a growing appreciation that although many
couples strive for equality, gender and power have an insidious impact on family dynamics
related to issues as diverse as communication patterns, roles and responsibilities, and career
choices (Knudson-Martin & Mahoney, 2009). Guidelines have been offered for address-
ing power dynamics in families and transforming them from gender- to equality-based
(Knudson-Martin et al., 2015).
Sixth, there have been efforts to highlight relational diagnoses buttressed by research
showing that relational processes are key to the development and maintenance of psycho-
logical problems and that reliable, standard, and internationally agreed upon criteria for
relational problems can facilitate diagnosis and treatment. As a result, there have been
systematic interorganizational and interdisciplinary efforts to incorporate relational pro-
cesses into standard diagnostic efforts. While only limited advancements were made in
the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5;
American Psychiatric Association, 2013), more progress is evident in the World Health
Organization’s International Classification of Diseases (ICD-11; Wamboldt, Kaslow, &
Reiss, 2015).
Seventh, practice increasingly combines scientific evidence with clinical judgment and
consideration of the family’s values and preferences, and research is more informed by prac-
tice (Sexton & Datchi, 2014). Empirical strides have been made possible by assessment mea-
sures and interactional coding schemas, and the ability to track families and their therapists
over the course of treatment. They has been facilitated by an appreciation of the need to
combine qualitative and quantitative methods to gather comprehensive and systemic con-
ceptualizations (Rohrbaugh, 2014). Outcome research has become more sophisticated as it
identifies change mechanisms that underlie clinical outcomes. Eighth, there has been prog-
ress toward establishing evidence-based intervention and prevention programs, ascertain-
ing the effectiveness of such efforts (Carr, 2018; Kaslow, Broth, Smith, & Collins, 2012),
and identifying evidence-based principles that guide the application of these programs (e.g.,
stages of change).
Ninth, competency-based training in couple and family psychology (CFP), marital and
family therapy, and family psychiatry has become the norm (Celano, 2018b; Kaslow, Plat-
ner, & Domingue, 2019). In addition to specialty-specific competencies, these efforts have
attended to ensuring familiarity with a systemic epistemology, application of systems theory
to all professional endeavors, appreciation of the broad and evolving definition of fami-
lies, and a developmental perspective for understanding the health–dysfunction continuum.
Recent calls for competency-based models to be integrated with a capability framework
highlight the need for those working with families to develop specialty expertise (Kaslow
et al., 2019).
300 SYSTEMS-ORIENTED APPROACHES

Tenth, recent years have witnessed the internationalization of the field, with the emer-
gence of the International Family Therapy Association and the publication of materials on
international family therapy (Kaslow, 2009). There are many family therapy innovations
across the world as systemic ideas have become powerful in diverse contexts around the
globe, and these have increasingly influenced family therapy in the United States (Roberts
et al., 2014).
Finally, family practitioners and scholars are now utilizing a systemic framework in
their work beyond traditional mental health and medical settings, such as in the legal sys-
tem, child protective services, and foster care (Imber-Black, 2015). They are using this frame
to address social justice concerns (e.g., immigration), enabling them to have greater impact
across systems.

THE CONCEPT OF THE FAMILY

We focus in this section on the concept of the family rather than personality; family the-
ory views the family as the primary unit and interactions between individuals as key. The
definition of family is a cultural and political phenomenon. Although cultures have simi-
lar definitions of a family, who is included in the family, relative importance of members,
and expectations of family conduct differ across cultures. In Western industrial nations,
nuclear family members tend to have the most influence, whereas Middle Eastern families
are influenced by traditional rules, morals, and extended family expectations. Since most
theories have been proposed by Western scholars, the focus has been on the nuclear fam-
ily, traditionally defined as a group of people connected by blood or legal bonds that share
a residence. This definition has evolved to include groups perceived to be a family, united
by marriage/partnership, blood, or residence sharing. Step, cohabitating, LGBTQ (lesbian,
gay, bisexual, transsexual, queer), foster, and adoptive families, and commuter relationships
represent variations of the modern family. Despite changes in the structure, the family’s
primary function remains mutual exchange among members to meet each person’s physical
and emotional needs.
General systems theory (von Bertalanffy, 1950) undergirds family therapy. A system is
a group of elements that interact with one another. Families are ongoing, living systems that
comprise networks of interrelated parts and are organized around these consistent relation-
ships (organization) and are part of the larger ecological context. Family units change and
advance toward greater levels of organization and functioning (anamorphosis), while also
self-regulating to maintain equilibrium (homeostasis). When families experience disruption,
members strive to regain homeostasis. The balance between change and stability enables the
family to function adaptively throughout the life cycle. Families exchange information via
feedback loops, circular patterns of responses in which there is a return flow of information
within the system. When these exchanges indicate that the family is experiencing disequi-
librium, corrective actions are required to restore relationships to the prior balanced state.
Positive feedback increases deviation from the steady state, enabling the family to evolve to
a new state and a greater level of change. Negative feedback counteracts or attenuates devia-
tions in the system to restore homeostasis.
Family interactions reflect circular causality; single events are viewed as cause-and-
effect and reciprocally related, with no beginning or end to the sequence of events. Families
may be viewed in terms of structure and function. Structure refers to the organization: how
 Family Therapies 301

subsystems are arranged, power hierarchy or chain of command, and the invisible set of
demands that influence member members’ interactions. The key structural property of the
family is wholeness (i.e., the whole is greater than the sum of its parts). The family comprises
interdependent, coexisting subsystems that carry out distinctive functions and processes to
maintain themselves and sustain the system. Each member belongs to several subsystems,
providing the basis for differential relationships with other members. Subsystems can be
formed by generation, gender, interest, and/or function. The family unit is a subsystem; it
interacts with the extended family, community, and outside world.
Subsystems are delineated by boundaries, invisible lines that separate them from their
surroundings and protect the subsystem’s integrity, while allowing interaction between sub-
systems. Boundaries can be more or less permeable and adapt to the changing needs of
the family. Impairments in functioning arise if boundaries are too rigid (overly restrictive,
do not allow for adequate communication between subsystems, result in disengagement in
which members are isolated) or too diffuse (overly blurred, allowing too much communica-
tion with other subsystems, are associated with enmeshment in which family members are
overinvolved in one another’s lives). Family systems’ boundaries regulate transactions with
the outside world and fall on a continuum from open to closed. An open system has flex-
ible and permeable boundaries, permitting interaction with the outside community without
compromising the integrity of the family, and allows the family to be receptive to new
experiences and eliminate maladaptive interactional patterns. Conversely, a closed system
has rigid and relatively impermeable boundaries, minimizing contact with the outside world
and keeping members from benefiting from what is important in the environment and from
trusting the outside world.
To maintain their structure, family systems have rules, operating principles that enable
them to perform the tasks of daily living. Some rules are negotiated openly and are overt,
whereas others are unspoken and covert. Healthy families have rules that are consistent,
clearly stated, and fairly enforced over time yet can be adapted to the developmental needs
of the family. Each member plays roles (e.g., partner, parent, child, sibling, victim, hero,
caregiver, scapegoat) influenced by family of origin, gender, and generation within the
nuclear family. Optimally, roles are negotiated to accommodate the needs of the unit and the
developmental stages of the members, as well as to eliminate dysfunctional roles. Changes
in gender roles as a result of societal changes have impacted family functioning as men and
women negotiate new interactive patterns and at-home responsibilities.
Family routines are observable practices, whereas family rituals demark transitions
(e.g., beginnings, endings, separations, unions) and provide a context within which to notice
and honor these changes. They signify the family’s identity and reflect the family’s life cycle
stage and cultural environment.
Family development refers to the growth of individual members and changes in the
structure, tasks, and interactional process of the unit over time. Family relationships shift
during common family life cycle stages: (1) leaving home: single young adults; (2) joining
of families through marriage: the new couple; (3) families with young children; (4) families
with adolescents; (5) launching children and moving on; and (6) families in later life (Carter
& McGoldrick, 1998). These stages do not fit every family, and there are different devel-
opmental sequences in other families (e.g., single-parent led, divorcing, remarried, LGBT)
and in different sociocultural contexts (e.g., immigration). Passage through family life cycle
stages, which differ qualitatively from one another, includes continuous and discontinu-
ous change. Successful passage depends on the developmentally appropriate negotiations of
302 SYSTEMS-ORIENTED APPROACHES

tasks and stressors. Interactions at any stage are influenced by interactions at earlier stages;
thus, dysfunctional resolution at one stage increases the likelihood of further impairments.

FAMILY HEALTH AND PATHOLOGY

Family Health
With the growing diversity of families, there has been recognition that beliefs about family
health are socially constructed, influenced by cultural ideals, change across the family life
cycle, and depend on the sociocultural context (Walsh, 2012). Healthy families comprise
individuals who are healthy in physical, spiritual, contextual, nutritional, interactional, sen-
sual, emotional, and intellectual domains. These families work together to meet each mem-
ber’s basic needs, are cohesive and bonded, and have clear yet flexible structures. Genera-
tional and individual boundaries are understood, allowing closeness to coexist with respect
for privacy. Healthy families encourage age-appropriate autonomy, express well-modulated
emotions, are empathic toward family members, maintain a sense of humor, and are open
to feedback. They share beliefs that are transmitted across generations, enabling them to
address existential concerns.
Healthy families adapt their power structure, roles, and rules in response to demands
and new information. Relatively equal power is the norm for the marital/partnership dyad.
A clear hierarchy exists between the parents and children, and control and authority dynam-
ics are clear to all members. The power dynamics change throughout the family life cycle.
Standards for controlling behavior are reasonable and modified using negotiation and prob-
lem solving. These families manage stress and crises effectively and recognize when they
need assistance. These families have positive and clear communication related to feelings
and practical matters. There is congruence between the content and process of the commu-
nications (contextual clarity). Members communicate appreciation, respect, and affection
toward one another. Healthy families are resilient and cope successfully with adversity or
trauma. As a result, individual members flourish with warmth and cohesion. The unit has
a positive outlook, accord, flexibility, and adaptive communication. Members effectively
handle finances, enjoy time together (shared recreation, routines and rituals) and support
one another through individual or family crises.

Pathological Family Functioning

Psychiatric nomenclature is less relevant to understanding family pathology than are inter-
action patterns. Dysfunctional families struggle to change in response to environmental
or situational demands or developmental changes, tend to have poor boundaries, and fail
to provide an environment conducive to healthy individual development and trusting rela-
tionships. They have a poorly defined power structure, impaired communication, difficul-
ties with problem solving and negotiation, and a pervasively negative affective quality with
minimal caring and warmth. They lack an appropriate level of cohesion, but rather are
disengaged or enmeshed. Heterogeneity in the expression of the pathology depends on the
family’s characterization on dimensions such as cohesion, adaptability, and communication
style. Dysfunctional family patterns are associated with low rates of and long time to recov-
ery, risk for relapse, problems with treatment adherence, and poor quality of life (Staccini,
Tomba, Grandi, & Keitner, 2015).
 Family Therapies 303

Historically, theorists highlighted the etiological role of family patterns in individual

pathology. As more has become known about the interactive contributions of genes and
environment, attention has been paid to family patterns associated with disorders through-
out the lifespan, without causal implications and with appreciation of the reciprocal influ-
ence between an individual’s symptoms and the family’s interactions. This shift has led to
an emphasis on family strengths to empower families to cope with a loved one’s concerning
behavior.
One extensively studied family characteristic associated with dysfunction is expressed
emotion, which refers to high levels of criticism, hostility, and/or emotional involvement in
the caregivers of a person with a psychiatric disorder. Youth and adults with various psy-
chiatric and medical disorders have more problematic courses if they reside in families with
high levels of expressed emotion (Hooley, 2007; Rosland, Heisler, & Piette, 2012). Models
of “toxic family stress” (frequent, sustained, uncontrollable stress without protective influ-
ences) have informed our understanding of the ways expressed emotion in the family inter-
acts with an individual’s biological vulnerabilities to promote illness onset and recurrence
(Peris & Miklowitz, 2015).

THE PROCESS OF CLINICAL ASSESSMENT

Assessment is key to many family therapies, although not all view diagnosis, particularly of
an individual, as important or appropriate. For example, structural family therapies view
the family as the unit in need of change and challenged the importance of individual diag-
nosis (Haley, 1976; Minuchin, 1974). Experiential (Whitaker & Keith, 1981), postmodern
(de Shazer, 1988), and poststructuralist (White, 2011) family therapies reject the notion of
diagnosis altogether. Regardless, most family therapies take the position that good assess-
ment, even if not diagnosis, is necessary and yields an overview of family dynamics that lead
to appropriate problem and case formulation, which in turn provides information that can
inform intervention selection. Integrated into the therapeutic process, assessment guides the
revision of systemic conceptualizations, and leads to treatment modifications and determi-
nation of progress. Many family therapists agree that while a formal assessment is valuable,
it is the process of interacting with the family over time that yields the richest data.
The family therapist’s orientation guides the assessment (e.g., intrapsychic variables,
behavioral functioning, systemic patterns) and extent to which it is structured. Structured,
formal assessments incorporate a multisystem, multimethod approach that includes clini-
cal interviews, observational techniques, and self-report measures. Clinical interviews may
involve meetings with the entire family and/or with individuals, dyads, and subsystems.
They focus on family history, structure, and interactive patterns, including feedback loops
among family members; ways individual symptoms impact family functioning and vice
versa; and members’ worldviews. Attention to cultural factors (e.g., gender, ethnicity, race,
sexual orientation, religion/spirituality, social class, acculturation level) within the family
system and in individual members is focal in the clinical interview process. Observational
techniques may focus on the parental subsystem, parent–child interactions, or the entire
family system. Direct observations provide information about the complexities of interac-
tional processes about which family members may or may not be conscious and offer an
outsider’s perspective on the family’s functioning.
Self-report measures are easy and inexpensive to administer and score, useful in
304 SYSTEMS-ORIENTED APPROACHES

assessing family relations and processes, and can measure change and intervention effec-
tiveness. However, they do not assess key variables (e.g., family power), and they assess only
individual member’s perspectives about the system and its interrelationships. The most often
used and psychometrically sound self-report measures include the McMaster measures, cir-
cumplex measures, Beavers systems measures, the Family Environment Scale, the Systemic
Therapy Inventory of Change, the Global Assessment of Family Relational Functioning
Scale, and the Systemic Clinical Outcome and Routine Evaluation, or SCORE (Lebow,
2014).

THE PRACTICE OF THERAPY

There is not one brand of family therapy; we would do a disservice to depict the practice
of family therapy as homogenous. Distinct schools characterized family therapy in its early
years, and many of these models remain popular. However, current practice is dominated by
integrated approaches that meld two or more schools into a unifying framework. Given the
array of models, there is debate about how best to categorize the approaches. A variety of
categorization models have emerged to simplify the landscape. Our presentation reflects one
division, models that (1) focus on history and the past; (2) focus on the present and have a
systemic emphasis, (3) focus on the present and are not dominated by systemic thinking, and
(4) are integrative. Rather than detail all the approaches that fall within a specific rubric, we
highlight a few illustrative examples.

Models with a Historical Focus

A number of models have a dominant focus on the past, notably psychodynamically informed
family therapy, intergenerational–contextual family therapy, family systems theory, family-
of-origin therapy (not covered here as it is more of a couple therapy approach), object rela-
tions family therapy, and attachment-based family therapy (ABFT). After briefly summa-
rizing these approaches, in-depth attention will be paid to object relational family therapy.
Despite the rebellion of family therapy pioneers against the historically individual focus asso-
ciated with the psychoanalytic tradition view, psychodynamic concepts have been integral to
several family therapy models. Psychodynamically informed family therapy, which acknowl-
edges its ties to psychoanalytic thinking, values the role of the unconscious and past history
in determining behavior and motivations, the necessity of insight for behavior change, and
the importance of transference and countertransference dynamics. Ackerman, the “grandfa-
ther” of family therapy, is the most noted early, psychoanalytically oriented family therapist.
Other early key figures include Framo, Boszormenyi-Nagy, Skynner, Paul, and Bell.
Intergenerational–contextual family therapy, associated with Boszormenyi-Nagy and
colleagues (Boszormenyi-Nagy, Grunebaum, & Ulrich, 1991) emphasizes intrapsychic and
interpersonal dynamics; past and present; legacy, loyalty, indebtedness to one’s family of
origin; and biological roots. Loyalties are structured expectations to which family mem-
bers are committed (e.g., maintenance of the family rather than self-differentiation). Family
members maintain a ledger of merits (investments in relationships) and debts (obligations)
for each relationship that changes according to family members’ investments (e.g., sup-
porting others) and withdrawals (e.g., exploiting others). When perceived injustices occur,
repayment of psychological debts is expected.
 Family Therapies 305

Family systems theory of Bowen (1993) emphasizes differentiation of self, triangles,

the nuclear family emotional process, the family projection process, the multigenerational
transmission process, the importance and impact of sibling positions, family emotional cut-
offs, societal emotional processes, what constitutes a normal family development, and fam-
ily disorders. This long-term, depth-oriented approach, which works well with individuals,
couples, and families, aims to alleviate anxiety in the family system by raising the level
of differentiation among family members. Bowenian family therapists developed the geno-
gram, a graphic tool for visually illustrating family patterns across at least three generations,
which is widely considered to be useful in understanding multigenerationally transmitted
family dynamics (McGoldrick, Gerson, & Petry, 2008).
Increasingly, writers have integrated psychoanalytic theory with family systems mod-
els, such as is the case with object relations family therapy (Scharff, 1989). Family-of-origin
attachment experiences (e.g., secure attachments, childhood trauma) provide the foundation
for sense of self, personality formation, internalized images of significant others (introjects),
expectations for close relationships, and psychopathology. Symptomatic behavior represents
unresolved conflicts that stem from one’s family of origin and are reenacted with one’s fam-
ily of creation. Reenactment occurs when people project introjected “bad objects” (negative
internalized image of one’s parent[s]) onto others in their adult life. Interpersonal interac-
tions are viewed as being consistent with one’s inner object world of positive and negative
introjects. People unconsciously seek a mate who is a willing recipient of their lost and
split-off introjects, which means that the partner experiences as his or her own, the feel-
ings and impulses that the mate is unable to tolerate. This results in a collusive partnership
that protects each partner and the couple as a unit from their fears of intimacy. Symptoms
are part of a recurring, predictable, interactional pattern that ensures equilibrium for the
individual but impairs the family’s ability to adapt to change due to rigid, stereotypical,
or rapidly shifting family roles. Unresolved conflicts often result in unconsciously placing
a family member in a role in which he or she is criticized and blamed for family tension
(scapegoating). Scapegoating validates negative introjects, thus exacerbating individual and
family dysfunction.
ABFT is a developmentally informed, culturally sensitive, integrative evidence-based
approach that incorporates models with a historical focus (attachment theory, contex-
tual therapy, emotion-focused therapy) with present-oriented systemic and nonsystemic
approaches (structural, multidimensional). It is based on the view that poor attachment
bonds in the face of high levels of conflict and criticism and low levels of affective attun-
ement interfere with the development of the internal and interpersonal skills to cope with
family, social, and community stress. ABFT seeks to repair ruptures in the attachment rela-
tionship and build trust between adolescents and parents. This semistructured manualized
treatment uses five treatment tasks: relational reframing, alliance building with both parent
and adolescent, reattachment (i.e., rebuilding a family attachment bond), and promotion
of competency (G. S. Diamond, Reis, Diamond, Siqueland, & Isaacs, 2002). Most clinical
trials conducted with ABFT have included primarily low-income minority families (G. S.
Diamond, Russon, & Levy, 2016).

Basic Structure of Therapy

Object relations family therapy is conducted weekly and is long term to address unre-
solved intrapsychic conflicts reenacted in one’s current life and causing interpersonal and
306 SYSTEMS-ORIENTED APPROACHES

intrapsychic difficulties. Session membership depends on the presenting problem and goals
of each phase of the work. Membership may include family of origin, family of creation,
intimate partner dyad, and/or the individual. Concurrent treatments (e.g., individual and
group therapy, medication management) may be conducted. Although the therapist provides
the external structure, the family’s interactions and comments provide the internal struc-
ture.

Goal Setting
The goals, which are not differentiated into intermediate and long term, are relatively similar
across families with a variety of problems and are implicit rather than overtly discussed and
negotiated. Therapists help family members achieve increased insight; strengthen ego func-
tioning; acknowledge and rework defensive projective identifications; attain more mature
self and object representations; develop more satisfying relationships supporting their needs
for attachment, individuation, and psychological growth; and reduce interlocking patholo-
gies among family members. The desired outcome is for members to have more access to
their true selves, become more intimate with the true selves of significant others, and view
others realistically rather than as projected parts of themselves. This enables the family to
achieve a developmental level consistent with the needs of its members and the tasks to be
addressed.

Process Aspects of Treatment

In the initial phase, the therapist provides a frame, a holding environment that includes a
specified time, space, and structure for the therapy. The therapist observes family interac-
tions during an open-ended interview to ascertain members’ level of object relations, defense
mechanisms, and the relation between current interactional patterns and family-of-origin
dynamics. A comprehensive history is conducted with all members present, with attention to
family-of-origin dynamics and early experiences and resultant attachment patterns, present-
ing problems, and treatment history. Object relations family therapists view the examina-
tion of family history as essential to the conceptualization of current family functioning.
Establishing a therapeutic alliance is key. Once such an alliance is established, the
therapist interprets conflicts, defenses, and patterns of interaction by addressing dynamics
of individual members and/or various family subsystems and linking an individual or fam-
ily’s history with current feelings, thoughts, behaviors, and interactions, permitting more
adaptive family interactional patterns and intrapsychic changes. In making empathic inter-
pretations, the therapist relies on theoretical knowledge and affective responses to each
person and the unit.
The primary techniques are interpretations of resistance, defenses, negative transfer-
ence, and interaction patterns indicative of unresolved family-of-origin and intrapsychic
conflicts. To facilitate change, therapists address external and internal resistances, and
transference and countertransference dynamics (see Wolitsky, Chapter 2, and Curtis, Chap-
ter 3, this volume). They use their own reactions to family members’ behavior and inter-
action patterns (objective countertransference) to understand empathically the shared yet
unspoken experiences of each member related to family patterns (unconscious family system
of object relations). Therapists employ their objective countertransference reactions to inter-
pret interpersonal patterns in which one member is induced to behave in a circumscribed
 Family Therapies 307

and maladaptive fashion (projective identification). Operating within this approach, failure
to effectively use countertransference responses is likely the most serious error a family
therapist can make. Homework or other out-of-session tasks are rarely used as techniques
in this approach.
The therapist attends to termination each session and toward the end of the therapy.
Time boundaries for ending sessions and the therapy course are respected, communicating
the therapist’s commitment as a consultant to the change process. Discussions and interpre-
tations regarding conflicts and feelings of separation and mourning precipitated by the finite
nature of each session and of the therapy help the family prepare for termination. During
the termination phase, salient conflicts are reviewed and unresolved family transferences
are reworked. The family mourns the loss of the therapist, who has become a significant
attachment figure.
Although little direct attention has been given to cultural considerations, object relations
family therapy is steeped within the broader object relations approach, which acknowledges
the interaction between sociocultural variations in family patterns, child-rearing practices,
and attachment patterns on the one hand, and object relations on the other. As a result,
object relational family therapists tend to be mindful about the internal and interpersonal
worlds of object relations in interaction with the external world of diversity and multicul-
turalism.

Present-Oriented Systemic Approaches

A number of models can be classified as present-oriented systemic approaches. After review-
ing a number of these models, we discuss the exemplar of structural family therapy in
detail. Strategic approaches (Haley, 1976) understand problems as maintained by maladap-
tive family interaction sequences, including faulty and incongruent hierarchies and malfunc-
tioning triangles. Systemic family therapy, pioneered in Italy by the Milan group (Boscolo,
Cecchin, Hoffman, & Penn, 1987; Selvini-Palazzoli, Boscolo, Cecchin, & Prata, 1978),
views the family as a nonlinear and complex cybernetic system with interlocking feedback
mechanisms and repetitive patterns of behavior sequences; problems emerge when the fam-
ily’s epistemology (rules and conceptual framework for understanding reality) is no longer
adaptive. Postmodern approaches (e.g., narrative, solution-focused), which are social con-
structivist in nature, offer a paradigm shift within systemic thinking: Problems are contex-
tualized as context-bound constructions co-created by family members’ interpretations and
linguistic accounts of their social, cultural, and historic experiences (de Paula-Ravagnani,
Guanaes-Lorenzi, & Rasera, 2017). Family therapy in this tradition is collaborative, empha-
sizes therapeutic dialogue and reflection, and helps family members change their story of
the problem by focusing on positive elements and unseen resources. One popular, evidence-
based social constructivist approach to family work with individuals with a psychotic illness
is the dialogic practice associated with open dialogue (Aaltonen, Seikkula, & Lehtinen,
2011). All these present-oriented systemic models share the goal of second-order change,
fundamental changes in the system’s structure and functioning, rather than first-order
change, superficial modifications that do not affect the structure. In a family with an oppo-
sitional adolescent son, first-order change occurs when the parents become more lenient and
the son more willingly complies with parental requests, and second-order change is evident
when the son’s behavior is responsible in the context of age-appropriate separation and the
parents no longer triangulate their son in their marital relationship.
308 SYSTEMS-ORIENTED APPROACHES

An illustrative example of a present-oriented, systemic approach is structural family

therapy (Minuchin, 1974). Founded by Minuchin and colleagues (e.g., Auerswald, Mon-
talvo, Aponte, Haley, Hoffman, Rosman), this model serves as a guiding framework for
family therapy today (McAdams et al., 2016). Its central tenet is that health–pathology stems
from the family’s organization (e.g., boundaries, alignments, power hierarchy) (Minuchin et
al., 2014). Boundaries demarcate subsystems and are the rules that define who participates
and how in various activities. Families are hierarchically organized, with caregivers posi-
tioned in the executive subsystem above their children. Alignment refers to the joining or
opposition of one member to another in carrying out an operation and may be a coalition
(covert alliance between two members against a third) or an alliance (two individuals share
a common interest not held by a third person). Power refers to the relative influence of each
member on the outcome of an activity. The structural dimensions of boundaries and align-
ments depend on power for action and outcome.

Basic Structure of Therapy

The structure is flexible in terms of location, length, and frequency of interviews. Typically,
it is brief (5–7 months) and participants are family members who interact daily. However,
who attends is based on the case formulation and treatment goals. A single therapist usu-
ally conducts this therapy, which focuses on ensuring effective working of the family unit
through making modifications to the family’s structure. The therapist implements interven-
tions in response to family interactions, guided by the treatment goals and case formulation.

Goal Setting
The main goal negotiated between the therapist and the family is resolving the presenting
problem. Although the family members may prefer to accomplish this by focusing on the
index person, the therapist makes clear the problem can be solved only by restructuring the
family unit so that healthier patterns prevail. A second aim is changing the family’s con-
struction of reality; the therapist helps members develop an alternative explanatory model
for the problem so that more adaptive transactions can take place. Goals applicable to most
families include (1) restoring adaptive boundaries within the family or between the family
and community; (2) disentangling the child from triangulation in the tension between the
parents; or (3) strengthening the caregiver’s developmentally appropriate parenting author-
ity over the children. Goals are influenced by the therapist’s understanding of the family’s
interpersonal, social, and cultural context.

Process Aspects of Treatment

This approach has three cyclical, overlapping stages: joining, assessing, and restructuring.
Joining involves forming an alliance with each family member, so that the members feel
less anxious and more engaged in the change process and the therapist can understand
how the family interacts. The therapist joins the family rapidly and in a position of leader-
ship by using maintenance (supports family’s existing structure), tracking (follows content
of the family’s communication with minimal intervention), and mimesis (adopts the fam-
ily’s style and affect). The therapist initially accepts the family’s view of the problem and
 Family Therapies 309

designs interventions to ameliorate the problem by changing the family structure. As symp-
tom reduction proceeds, the family gains confidence in the therapist’s expertise and may be
more inclined to address underlying structural issues. Assessing focuses on (1) structure,
boundary quality, and resonance (sensitivity to the actions of members and tolerance for
deviation); (2) flexibility and capacity for change; (3) interaction patterns of the spousal/
intimate partnership, parental, and sibling subsystems; (4) the role of index person and how
the symptoms maintain family homeostasis; (5) the ecological context within which the
problem develops and is maintained; and (6) the developmental stage of the family and its
members. Assessment often entails asking the members to demonstrate a conflict situation
during a therapy session so that the therapist gains insight into the family’s structure and
transactions. This assessment enables the therapist to conceptualize how structural prob-
lems and current symptoms are interrelated (i.e., case formulation). Restructuring redresses
the structural difficulties and altering boundaries. As symptoms indicate dysfunctional pat-
terns for managing stress, stress is escalated to help the system develop more effective inter-
actions. Strategies for escalating stress include prolonging an enactment (promote the family
members acting out of habitual patterns in the session), introducing new variables (e.g., new
family members), blocking typical patterns of relating, challenging the family’s communica-
tion rules and structure, or suggesting alternative transactions in session that may facilitate
change outside the session. Spatial interventions (e.g., rearranging the seating, removing
members from the room temporarily to observe interactions from behind a one-way mirror)
are used to alter the perspectives of family members and improve interpersonal boundaries.
Tasks may be assigned to yield information about the family’s openness to alter maladaptive
patterns and structure.
In recent years, structural family therapists have integrated other theoretical perspec-
tives to respond to unique family needs. For example, ecosystemic family therapy integrates
the structural approach with attachment theory to address the effects of trauma on family
relationships (Lindblat-Goldberg & Northey, 2013).

Present-Oriented, Nonsystemic Approaches

A number of models are classified as present-oriented, nonsystematic family therapies,
such as experiential and humanistic, psychoeducational, and behavioral and cognitive-
behavioral. After reviewing these, we attend to behavioral and cognitive-behavioral family
therapies (CBFTs). Although these therapies are primarily nonsystemic, there are key points
of overlap between present-oriented systemic and nonsystemic approaches related to their
focus on structure and organization, context, communication, and homeostasis (Patterson,
2014).
Theories identified with the experiential–humanistic school include symbolic–experiential
family therapy (SEFT; Whitaker & Keith, 1981), Gestalt family therapy (Kempler, 1982), the
human validation process model (Satir, 1988), and psychodrama (Moreno, 1987). Experi-
ential and humanistic family therapies emphasize present experiences and affects and their
meanings, and conceptualize dysfunctional behavior as a failure to fulfill one’s potential for
personal growth. Although experiential and humanistic theorists work with families dif-
ferently, they (1) believe change results not from catharsis or insight, but from the relation-
ship and process co-created by the family and therapist; (2) strive to behave authentically
in their interactions with families, a stance that promotes spontaneity and idiosyncratic
310 SYSTEMS-ORIENTED APPROACHES

interventions; and (3) emphasize choice, free will, human capacity for self-determination,
and self-fulfillment.
Psychoeducational family therapy was first used with individuals with schizophrenia
and their families and was based on the diathesis–stress model (Anderson, Reiss, & Hog-
arty, 1986). Family psychoeducational models, designed to remediate individual and fam-
ily difficulties and enhance functioning, train family members to be helpers to their loved
ones; teach communication, problem-solving, and conflict resolution skills; and prevent the
emergence of problems to enhance the quality of family life. Psychoeducational programs
have been developed for diverse areas of focus, such as parent training, marriage and fam-
ily enrichment, substance abuse recovery, and working with medically ill individuals (i.e.,
medical family therapy; McDaniel et al., 2014). Psychoeducation has been expanded to
include alternative modes of delivery (e.g., mobile crisis teams), online interventions, and
recovery and peer support.
Most CBFTs focus on couples rather than families (Patterson, 2014). However, there
are family-focused CBFTs, such as the McMaster problem-solving model (Epstein, Bishop,
& Levin, 1978), CFBTs for various problems in youth (Asarnow, Berk, Hughes, & Ander-
son, 2015; West et al., 2014), and parenting-focused interventions such as the Parent Man-
agement Training—Oregon Model (PMTO; Forgatch & Patterson, 2010) and parent–child
interaction therapy (PCIT; McNeil & Hembree-Kigin, 2010). While, in general, these inter-
ventions have not been culturally adapted, nor have they attended adequately to cultural
values (Forehand & Kotchick, 2016), increasingly the field has witnessed the emergence
of culturally adapted family-oriented CBFTs (Parra-Cardona et al., 2017; Whealin et al.,
2017). Behavioral family therapies are predicated on social learning theory and behavior
exchange principles, whereas cognitively oriented approaches view family difficulties as
influenced by an interaction of cognitive, behavioral, and affective factors. Despite differ-
ences in techniques associated with various CBFTs, all approaches are built on research
findings. Current advances incorporate theoretical constructs and data from social and
cognitive psychology, sociology, and pathophysiology. Therefore, unlike other models that
are tied in part to charismatic leaders and their contributions, the progress of CBFTs has
depended on collaborations between researchers and clinicians.
The behavioral approach to family assessment and treatment expands on the individ-
ual approach to behavioral treatment and views maladaptive behavior as generated and
maintained by environmental contingencies, including learning history. Interactions reflect
reciprocal patterns of behavior in which one person’s behavior reinforces the other’s behav-
ior, and circular and potentially escalating patterns emerge. Behavioral family therapists
attend to environmental events that precede and follow problem behaviors to determine how
the behaviors have been learned and reinforced. Although, historically, these approaches
have been nonsystemic, recently they have attended to the reciprocal influences of behavior
on various members and the impact of the community on family and individual behav-
ior. Cognitive approaches to family therapy, outgrowths of individual cognitive therapy
and rational-emotive behavior therapy, assume that one family member’s cognitive process-
ing influences others’ behaviors, transactions, and emotional and behavioral reactions. As
family members cognitively appraise external events (e.g., other family members’ behaviors
directed to them, observations of family interactions) they develop cognitions regarding self,
relationship between self and family members, and interrelationships among subsystems. In
healthy families, perceptions are positive, realistic, and open to change via direct communi-
cation, whereas in dysfunctional families, perceptions tend to be distorted.
 Family Therapies 311

Basic Structure of Therapy

CBFTs are brief, time-limited, structured, and conducted by a single therapist. Membership
varies from attendance by caregivers (e.g., parent training) to the whole family, depending
on the model and reason for referral. Extended family members are not likely to be included.
There is an emphasis on gathering assessment data at baseline to determine family inter-
action patterns, providing assessment feedback to the family to collaboratively determine
intervention targets, and engaging in ongoing assessment to ascertain changes in the tar-
get behaviors (Dattilio & Epstein, 2016; Patterson, 2014). Out-of-session assignments are
designed to support practice and generalization of newly learned behaviors and cognitions.

Goal Setting
A hallmark of CBFTs is development of specific, measurable goals. Goal setting follows a
functional analysis of maladaptive behaviors and cognitions, and the environmental con-
tingencies supporting these, and the ways family members’ reciprocal interactions affect
their relational satisfaction. Based on this analysis, the therapist and family delineate goals.
The intervention is discussed, and the therapist obtains a commitment from the parties to
participate in a plan that may be formalized in a treatment contract or behavioral change
agreement.

Process Aspects of Treatment

CBFT interventions are designed to reduce negative behaviors and increase positive behav-
iors within the family, and to help family members recognize the impact of their thoughts
on their behaviors and affective responses, so they can interact more effectively and improve
family satisfaction. Interventions often include communication and problem-solving train-
ing (Dattilio & Epstein, 2016) and focus on changing maladaptive behaviors by modifying
environmental contingencies, facilitating flexible behavior control, increasing positive inter-
actions, teaching adaptive behaviors, and fostering the maintenance and generalization of
newly acquired behaviors. They alter maladaptive cognitions by teaching family members
to identify automatic thoughts and associated emotional reactions and behavior, be aware
of and label cognitive distortions, test and reinterpret their automatic thoughts, test predic-
tions with behavioral experiments, and use imagery and role playing.
In parent training, CBFT therapists educate parents about operant learning principles,
develop their capacity to observe their children’s behavior, and impart skills to better equip
parents to address their children’s problematic behaviors (e.g., reinforce positive behavior,
ignore negative behavior, set constructive limits, implement time-out). Therapists coach par-
ents in new skills and ways of interacting with their child, and supervise their implementa-
tion of these skills at home. Parents are recognized as offering unique insights into the day-
to-day routines, behaviors, and emotions of their child. Parents and therapist work together
and share their expertise to help the parents better help the child. Parent training results
in improved parenting behavior and positive changes in the parents’ relationship with the
child. This short-term intervention is accessible, understandable, maintainable, generaliz-
able, ecologically valid, and time- and cost-efficient. As a result, adults seek out this treat-
ment, adhere to the protocol, and apply skills learned over time. Parent training has been
advocated for parent–child relationship disorders and for parents whose children manifest
312 SYSTEMS-ORIENTED APPROACHES

externalizing behavior disorders (e.g., attention deficit, disruptive behavior, developmental,

habit). It has been integrated with attachment-based approaches, such as PCIT (McNeil &
Hembree-Kigin, 2010).

Integrative Models
Although integrative models vary in theoretical constructs and strategies for intervention,
they (1) offer a theory of change or an algorithm for when to use specific techniques; (2)
attend to multiple levels of human experience; (3) consider common factors across schools;
(4) understand the presenting problem in systemic terms and view the family system as a
vehicle for change; (5) incorporate psychoeducation and skills development; (6) describe the
intervention and change process in a manner that transcends theoretical orientation; (7) tai-
lor interventions to specific populations; (8) utilize data to organize, build, and evaluate the
model; (9) use a practical approach of achieving change through the simplest strategy avail-
able; and (10) focus on family strengths (Lebow, 2014). Integration also applies to session
formats; who is seen in a given session is dictated by pragmatic considerations and phase-
specific goals. Integrative models are either broadly targeted, describing theories and prac-
tice that apply to all problems and populations, or specific to a given problem or population.
Despite compelling arguments for integrative approaches, no single model is the stan-
dard of practice. For some clinical problems, there are several evidence-based integrative
approaches from which to choose. For example, adolescent substance abuse can be treated
with multisystemic therapy (MST; Henggeler, Clingempeel, Brondino, & Pickrel, 2002),
multidimensional family therapy (MDFT; Liddle, 2016), functional family therapy (FFT)
(Sexton, Alexander, & Gilman, 2004), or brief strategic family therapy® (BSFT®; Szapoc-
znik, Hervis, & Schwartz, 2003). Although these differ in content and format, they share
a contextual framework and incorporate behavioral and cognitive-behavioral strategies,
communication skills and problem-solving training, and techniques from structural and
strategic models.
Some integrative models can be applied to any problem for which people seek therapy,
such as integrative problem-centered therapy (IPCT; Pinsof, 1995), the metaframeworks
model (Breunlin, Schwartz, & Mac Kune-Karrer, 1997), integrative problem-centered
metaframeworks therapy (IPCM; Pinsof et al., 2011), and integrative systemic therapy
(IST; Pinsof et al., 2017). These metamodels are distinguished by the following features: (1)
Assessment and intervention are inseparable and co-occurring; (2) problems are conceptual-
ized on multiple levels of human experience; and (3) algorithms decide which level of human
experience to target with an intervention, and when to move from intervention at one level
to the next. For example, IPCT identifies the most parsimonious way to resolve presenting
problems by providing principles for sequenced intervention strategies and a system for
organizing integration across methods. The metaframeworks model proposes five levels of
depth; if intervention at the first level—the level of action—does not solve the problem, it is
assumed that meaning or the family’s narrative about the problem and/or emotion are con-
straining the solution, and intervention at the second level, experiential, is needed. Deeper
levels address historical and intrapsychic constraints to problem solving. The IPCM model
integrates IPCT with metaframeworks and an emphasis on common factors. Intervention
strategies are sequenced as in IPCT, and family feedback is linked with hypothesis gen-
eration and treatment planning. Finally, IST offers the means to continually assess the full
 Family Therapies 313

complement of factors (psychological, biological, interactional, cultural) that contribute to

family problems, and a blueprint for decision making that draws on the strategies of various
theoretical models and evidence-based treatments.
Common factors offers an integrative paradigm for understanding therapeutic change,
with the view that efficacy is due to mechanisms that cut across all models (Sprenkle et al.,
2009). Adherents assert that different models conceptualize the same systemic processes
underlying dysfunction and recommend similar interventions to help families solve prob-
lems. These common processes include (1) conceptualizing problems in relational terms;
(2) disrupting dysfunctional patterns; (3) expanding the direct treatment system to include
family members of the index patient; and (4) expanding the therapeutic alliance to include
each individual, various subsystems, the whole family, and the indirect treatment system.
Although this paradigm has sparked debate, with some theorists and therapists having
concerns that it dismisses the need for specific therapeutic techniques or procedures and
is not adequately scientific, to a growing number of proponents this the common-factors
approach offers a framework to guide change in family therapy, particularly when targeted
evidence-based models are not available. In this vein, integrative family and systems treat-
ment (I-FAST), an evidence-informed, metamodel is organized around these common fac-
tors: (1) creating a positive therapeutic alliance; (2) intervening to bring about second-order
change in problematic patterns by having the parents be the ones to solve the presenting
problem; and (3) working with various systems involved with the family so they collabora-
tively support the parents as the ones solving the presenting problem (Fraser et al., 2014).
Lebow (2014) has advocated for an accessible and pragmatic integrative model that
promotes an individualized approach to each family based on a systemic case formulation.
Like other integrative frameworks, it draws from a multilayered, contextual view of fam-
ily functioning and problems, and attends to multiple levels of human experience. It moves
beyond common factors to encompass a shared base of concepts and intervention strategies
anchored in relationship science, which includes research on family therapy efficacy and
process, family interaction and development, and relationship satisfaction and distress. In
other words, this expanded model not only accentuates the common factors that undergird
family therapy today but also highlights the core evidence-based family therapy intervention
strategies and techniques. Lebow recommends that therapists shape their own personal-
ized, intentional approach to family therapy integration, based on a set of guidelines that
highlight a consistent method of case formulation and of practice consonant with that for-
mulation, reliance on systems theory and common factors, and familiarity with a core set of
concepts and strategies. This integrative approach, which is detailed below, is evolving and
changes with the development of the therapist and the field.

Basic Structure of Therapy

In most integrative approaches, session format depends on treatment goals and case formu-
lation. Most models combine individual, couple/parent, and family therapy. Evidence-based,
adjunctive psychopharmacology has a place in this integrative model, though there is no
consensus about when or under what circumstances medication is most helpful, except in
cases of severe psychiatric disorders (Lebow, 2014).
314 SYSTEMS-ORIENTED APPROACHES

Goal Setting
There is recognition of the complexity of setting goals within a family system, as members
often have different objectives. Skillful therapists strive to guide family members in creat-
ing a shared working agenda that takes into account the multiple perspectives. When these
differences reflect variances in worldviews or priorities, the therapist must strive to have a
balanced view toward each family member. However, when one or more family members
engage in harmful behaviors (e.g., substance abuse), the family therapist may side with other
members in the goal-setting process.

Process Aspects of Therapy

Assessment of the family unit considers multiple levels of relational assessment using inter-
view, observational, and paper-and-pencil measures. The approach to intervention is col-
laborative, but it includes some structuring as well. Intervention strategies include (1) moni-
toring family and therapist interactions in session (such tracking can produce change); (2)
offering psychoeducation; (3) applying a neurobiological understanding (e.g., the amygdala
gets activated when a person feels emotionally flooded; thus, a reaction may be due to brain
functioning rather than negative intention); (4) using social learning and related behav-
ior change efforts (e.g., parent training, communication training); (5) working with cogni-
tion and emotion (e.g., changing cognitions, mindful practice, promoting acceptance); (6)
changing family organization; (7) promoting family members’ understanding about family
patterns; (8) employing experiential activities to stimulate emotion or insight (e.g., fam-
ily sculptures and rituals); (9) promoting dialogue between family members to construct a
narrative; and (10) applying evidence-based principles of practice (e.g., fostering productive
communication among family members). Therapists select from these strategies according
to their case formulation, personal preferences, perceived acceptability of the strategy to the
family, and research-informed estimate of how useful the strategy is likely to be in a specific
case. Attention also is paid to termination and the key tasks associated with this process.

THE THERAPEUTIC RELATIONSHIP AND THE STANCE OF THE THERAPIST

Models with a Historical Focus
There are marked differences with regard to the therapeutic relationship and stance of the
therapist across the models with a historical focus, so we focus in this section focuses on
these topics in object relations family therapy and in ABFT. Of utmost importance in object
relations family therapy is the provision of a “good-enough” holding environment, which
is a therapeutic environment in which the therapist enables family members to feel safe
and secure, so that they can express their feelings and beliefs and feel intimate with one
another, while maintaining a sense of self. The therapist functions as a “good-enough”
parent, reparenting the family by providing nurturance, a secure attachment, and structure
(e.g., limit setting) to enhance the development of individual members and the family unit.
The therapist tends to be nondirective, and the family is responsible for change. The self of
the therapist is relevant in terms of the focus on the therapist’s attention to countertrans-
ference and the use of these responses to inform the work. Attention is paid to ruptures in
the alliance with the family and their repair; this focus is deemed to be informative about
 Family Therapies 315

earlier attachment relationships pertinent to the family’s current attachment patterns and
dynamics. Virtually no attention has been paid to the role of culture in the formation and
sustenance of the therapeutic alliance within this approach to family therapy.
Within ABFT, the therapist creates a safe environment by empathizing with each person,
validating each person’s experience of the family, and conveying a commitment to support-
ing and protecting each individual. As safety takes hold, the therapist facilitates difficult,
direct, and honest conversations among family members. AFBT therapists have focused on
the impact of culture on the therapeutic relationship. In applying ABFT to sexual minority
young adults and their nonaccepting parents, the value of the therapist being gay-affirming
has been highlighted (G. M. Diamond & Shpigel, 2014). Within this evidence-based model,
little attention has been paid to transference and countertransference, self-of-the-therapist,
or rupture–repair processes.

Present-Oriented, Systemic Approaches

Although these approaches prioritize the therapeutic alliance, the stance of the therapist is
conceptualized differently depending on the model. Strategic and structural therapists typi-
cally take an active and authoritative stance, whereas therapists in the systemic and post-
modern traditions are less hierarchical and more collaborative. However, in all these mod-
els, the therapist strives to remain neutral and objective, develops a relationship with each
member, and generally avoids alignment with any faction. This neutrality allows maximum
leverage for achieving change, as the therapist is free to attend to the system in its entirety,
without being pulled into the family’s repetitive patterns of interaction.
Minuchin (1974) considers the therapist as a distant and friendly relative who takes an
active and authoritative stance by asking probing questions and giving homework assign-
ments. The structural family therapist directs the process of therapy, communicating exper-
tise in helping the family mobilize adaptive resources to facilitate change. The cultural
aspects of the therapeutic process are key, and family therapists steeped in this tradition
examine cultural influences on their perceptions and actions. They also disclose their beliefs
about problems and therapy. The referring source and therapy team are integral to the
coevolving ecosystem.

Present-Oriented, Nonsystemic Approaches

The therapeutic relationship and stance of the therapist in present-oriented, nonsystemic
approaches differ depending on the model. On the one hand, SEFT is typically conducted
by a cotherapy team, enabling each therapist to perform unique functions and interchange
these functions when indicated. The cotherapy dyad models adaptive relationships and pro-
vides experiential alternatives for family interactions. SEFT therapists engage actively in the
family’s interactional process, yet they do not direct the therapy. They listen, observe, attend
to their own affective reactions, and intervene to change the family’s functioning, without
focusing on etiology. They express warmth and caring for the family and use their person-
alities (true self) in sharing their internal processes, without losing their differentiated sense
of self. They are like “coaches” or surrogate grandparents, roles that require structure and
discipline, as well as compassion and availability. The emphasis on participant observation
underscores the family’s responsibility for change, even though the therapists are responsible
316 SYSTEMS-ORIENTED APPROACHES

for the interventions. Resistances are considered inevitable in the change process and are not
interpreted. Rather, they are managed with a combination of challenge, support, and humor.
Conversely, those who practice CBFTs function as scientists, collaborators, educators,
role models, and teachers in the Socratic tradition. They are active, present-focused, and
teach the family about processes associated with maladaptive behavior. They direct the treat-
ment process, taking responsibility for setting the agenda, reviewing homework, and enforc-
ing the contract. They can serve as consultants as family members test their perceptions,
and generate and rationally assess alternative hypotheses regarding individual and relational
functioning. Because the approach is geared toward building adaptive skills, the therapist
serves as a teacher who supervises the family’s rehearsal of new behaviors. Although a col-
laborative alliance is essential for behavior change, transference is not addressed specifically
or considered important. Limited attention has been paid to cultural aspects of the thera-
peutic relationship in this approach.

Integrative Models
Integrative approaches prioritize a therapeutic alliance, in which therapists are engaged,
hopeful, empathic, assertive, and appropriately challenging when necessary. According to
Lebow’s model, therapists are mindful of how the therapy appears from the family’s per-
spective. Treatment goals are set collaboratively, and the therapist actively seeks feedback
from the family members on their perceptions of intervention strategies and treatment prog-
ress. In addition, integrative therapists are aware of their own preferences for (or comfort
with) various interventions and their personal values as related to clinical decisions and
ethical issues. For example, a therapist may favor exploration of family-of-origin issues
with more educated families and development of behavioral or social skills competencies
with less educated families. In this case, the impact of therapist values on practice should
be distinguished from knowledge about best practices, with the goal of optimizing therapy
outcomes for the family.

CURATIVE FACTORS OR MECHANISMS OF CHANGE

Models with a Historical Focus
Family therapy focuses on individuals’ early family experiences, feelings about one another,
and relationships. Primary mechanisms of change are interpretations of interpersonal pat-
terns, including transference and countertransference dynamics, offered in the context of a
positive working alliance and a safe holding environment. Interpretations help family mem-
bers gain historic–genetic and interactional insights into their psychological realities. Such
insight combined with the corrective emotional experiences that occur within the holding
environment are key to therapeutic change. Although the therapy does not directly teach
adaptive interpersonal skills, the development of these skills is an outgrowth of increased
insight. Effective management of affects elicited during termination is crucial to a successful
outcome, as it provides the individual an opportunity to rework unresolved separation issues
related to the family of origin. There are specific techniques associated with object relations
family therapy, yet these are secondary to the therapist–family relationship in defining this
approach. Rather, the defining characteristic is the therapist’s joining with the family and
creating a holding environment in which family members rediscover each other and the lost
 Family Therapies 317

parts of the self that are projected onto one another. Object relations family therapists focus
on the relationship as a curative factor and use transference interpretations as a cornerstone
of the treatment. Thus, successful resolution of transference–countertransference dynam-
ics in the termination process is seen as relevant to the family’s emotional growth and the
sustainability of the progress made. Given the importance of addressing countertransference
dynamics, the therapist’s psychological health and family-of-origin dynamics influence the
treatment process. These therapists therefore need to address unresolved intrapsychic and
interpersonal conflicts in supervision and personal treatment.
Within ABFT, change mechanisms have been delineated (G. S. Diamond, Siqueland, &
Diamond, 2003). The improvement of attachment security is considered the primary mecha-
nism of change. This is accomplished in part through the reattachment process, which dif-
fuses tension in the family system, reestablishes the family as a secure base, and empowers
the adolescent to function more autonomously and without concern about family conflicts.
This reattachment process is the focus of the early phases, when the adolescent is helped
to share about historical and current family situations that have ruptured the attachment
bonds and damaged trust. The parents are supported in listening to and acknowledging
these disclosures and apologizing for their contributions to these ruptures. These acknowl-
edgments lay the groundwork for greater understanding, acceptance, and a shared invest-
ment in repairing the attachment bonds. A second change mechanism is promotion of the
adolescent’s age-appropriate autonomy within the context of a secure family base that is
nurturing, supportive, and encouraging, and that has realistic expectations. This enables
the adolescents to develop better self-esteem, connect more to peers, and have a restored
capacity to navigate developmental challenges and transitions.

Present-Oriented, Systemic Approaches

Techniques are of paramount importance in effecting change. Present-oriented systemic
approaches emphasize behavior change as opposed to development of insight. Although
models vary in how much focus is on symptom reduction, all aim to achieve change within
the family. Curative factors for the structural and strategic models include correcting the
hierarchy by encouraging the parental subsystem to use its power appropriately, helping
members negotiate agreements, and establishing adaptive boundaries. The effective use of
structural family therapy techniques requires clarity of purpose and a balance between com-
mitment to change and sensitivity to corrective feedback from the family. In the postmodern
approach, the primary curative factor is deconstruction of (challenging) the problem story
and its supporting assumptions, so individuals reenvision their past and future, create “pre-
ferred” stories, and discover adaptive solutions and identities through dialogue with the
therapist and family members.
Family members are not educated directly in interpersonal or parenting skills in pres-
ent-oriented systemic models, yet the directives often require the development of a more
adaptive parenting or communication. In the structural tradition, resistance is circumvented
through the use of enactments or challenged by escalating the stress within the family.
However, resistance to change is not typically interpreted by the therapist. The therapist’s
personality is important insofar as it enables him or her to relate attentively, while entertain-
ing systemic hypotheses. Transference and countertransference dynamics are not integral to
the curative process.
318 SYSTEMS-ORIENTED APPROACHES

Present-Oriented, Nonsystemic Approaches

Two different models that fall under this rubric reflect the continuum of curative factors and
mechanisms of change associated with these approaches. The basic assumption of SEFT is
that families change as a result of experiences, not education or interpretation. Chief mecha-
nisms for change are experiencing new relational stances with family members, expressing
strong emotions, and challenging current interactional patterns, all of which lead to interac-
tional insights. Interactional insights are considered more prominent and effective than are
historical ones. The therapists’ roles within their families of origin and creation affect their
interactions with the family and cotherapist. Therefore, family therapy for the therapist is
encouraged.
The mechanisms of change in CBFTs are related to techniques used to attain goals. For
most families, learning new interpersonal skills is curative. Reality testing is viewed as essen-
tial for behavior change. The focus is on the present, and the relationship between the thera-
pist and family members is not viewed as key to bringing about change. However, a therapist
who has difficulty structuring sessions or helping family members challenge their distorted
cognitions is unlikely to affect behavior change or improve relationship satisfaction.

Integrative Models
Curative factors in integrative treatment are common to many models. Integrative family
therapists argue that all evidence-based treatments are a combination of common-factor
ingredients and a shared set of interventions, organized into a coherent framework. What
remains unresolved is the extent to which the organization and ingredients matter (Lebow,
2017). Advocates of targeted integrated treatment models (e.g., FFT) claim that fidelity
and adherence to the organization and content of treatment are critical to success (Rob-
bins, Alexander, Turner, & Hollimon, 2016), whereas advocates of common-factors and
integrative treatment (Lebow, 2014) value therapist flexibility and adaptation to the specific
clinical situation. Curative factors are those pathways that can be achieved only on the basis
of considering the specific individuals within the family and the family as a system, the
therapist, the presenting problem, the cultural context, the intervention strategy, and how
the family responds to what is occurring in therapy.

TREATMENT APPLICABILITY
Models with a Historical Focus
There are theoretical writings about the application of object relations family therapy to
high functioning families and families in which one or more members has a personality
disorder or a serious mental illness (Scharff, 1989). In general, AFBT has been applied to
families with an adolescent with an internalizing disorder. Developed for depressed youth
(G. S. Diamond et al., 2002), it has been extended to families of suicidal youth (G. S. Dia-
mond et al., 2010). AFBT has been used alone or in combination with cognitive-behavioral
therapy for adolescents who are anxious (Siqueland, Rynn, & Diamond, 2005) and families
in which the youth has an externalizing problem (G. M. Diamond, Shahar, Sabo, & Tsvieli,
2016). Modifications for sexual minority young adults have been proposed, with a focus on
enhancing the parent–child relationship and promoting connection and acceptance (G. M.
 Family Therapies 319

Diamond & Shpigel, 2014). This approach has been applied to youth in various countries
outside the United States (G. S. Diamond et al., 2016).

Present-Oriented, Systemic Approaches

Present-oriented systemic models have been applied to families with various disorders (e.g.,
externalizing behavior disorders, eating disorders, and substance abuse) and families expe-
riencing violence or trauma or in the process of divorce; or building a remarried, blended,
or stepfamily. Developed for low-income African American families, applications of the
structural therapy model have been responsive to diverse cultures and family configurations
(McAdams et al., 2016) and the approach has a more evolved conceptualization of gender.

Present-Oriented, Nonsystemic Approaches

SEFT has been used with families in which the index person presents with a range of prob-
lems, including severe psychopathology. However, it is difficult to use this approach with
families with a member who has a severe personality disorder. For families coping with a
trauma, this treatment may be emotionally overwhelming and thus contraindicated. CBFTs
have been applied to a broad range of problems (e.g., affective disorders, internalizing and
externalizing child behavior problems, and substance abuse) and have been adapted to form
culturally sensitive family interventions (Parra-Cardona et al., 2017; Whealin et al., 2017).
They have been implemented in multiple countries, and though developed primarily for
young children with disruptive behavior disorders, they have been tailored and adapted to
physically abusive parents, foster parents, and children with internalizing and autism spec-
trum disorders.

Integrative Models
Integrative family therapy models have been applied to culturally diverse adolescents with
conduct disorder, substance abuse, delinquency, and serious mental health problems, with
high rates of engagement (Coatsworth, Santisteban, McBride, & Szapocznik, 2001). The
meta-models and the common-factors approaches have been applied to various presenting
problems and clinical populations (Celano, 2018a). Given the flexibility of Lebow’s integra-
tive approach, it may be ideal for culturally diverse populations, as it allows for integration
of cultural understanding into case conceptualization, treatment planning, and interven-
tion.

ETHICAL CONSIDERATIONS

Ethical principles that apply to all mental health services are relevant to family therapy. This
section focuses on common ethical challenges in family therapy.
The therapist has an ethical responsibility to each family member and at times, one
person’s needs conflict with the best interests of another person or the system as a whole
(Glick, Rait, Heru, & Ascher, 2016). The therapist must help the family members navigate
conflicting interests and engage them in determining the optimal course of action. In rare
instances, the therapist must respond to ethical tensions by taking action on behalf of one or
320 SYSTEMS-ORIENTED APPROACHES

more members (e.g., child or elder abuse reporting). When this occurs, the systemic alliance
may be threatened, and some parties may withdraw from the therapy, but safety concerns
must take precedence. A systemic alliance is most likely preserved in such cases if the family
therapist makes the report in the presence of all relevant parties, discloses only information
needed by the statutory protection agency for the investigation, and informs them of the
family’s participation in treatment and their strengths, and explores members’ reactions to
the report.
The following are examples of issues related to confidentiality. Questions often arise
when the therapist interacts with family members separately, and as a result, during the
informed consent process, guidelines should be established for the appropriate use of indi-
vidual sessions or phone calls and how information obtained will be handled. This may
be salient when minors are involved. Youth, especially adolescents, may hesitate to share
information for fear it will be disclosed to their parents, and this concern can interfere with
family therapists’ ability to establish rapport with them. Yet parents have a legal right to be
informed about their children’s medical (including mental health) treatment; not providing
such information may be illegal and may undermine the alliance with the parents. One way
of resolving this dilemma is to address it with the family and gain agreement that parents
will be informed about safety concerns, but otherwise information obtained from the youth
will remain private.
A second confidentiality issue occurs when a parent or adult child requests the release
of information related to family therapy that has taken place, such as in cases of divorce
and child custody. Family therapists should be aware that a consent to release information is
needed from all adult members who have participated in therapy before any such informa-
tion is shared. A related dilemma arises when one parent asks for the therapist’s support in
a custody proceeding. The family therapist may feel torn because he or she has an opinion
about the optimal plan yet is bound by confidentiality. Two factors highlight the signifi-
cance of confidentiality in such instances: (1) Family therapists cannot provide a document
or opinion, or attend court proceedings to support one parent without consent from both
parents to release information, and (2) courts can order independent custody evaluations by
someone who has not had a preestablished role (as a family therapist) or gather information
about each parents’ fitness through a guardian ad litem (i.e., person appointed by the court
to represent the child).
A third dilemma pertains to family secrets. In general, keeping secrets reflects the thera-
pist’s collusions with one member against another, which jeopardizes the systemic alliance
and therapy effectiveness. The therapist should help the member examine why he or she dis-
closed the secret and develop a plan to share the information with relevant family members.
A mother who discloses an extramarital affair should be encouraged to share this with her
husband when they are alone or in the next session without the children present. Children
who witness their parents’ fights should be supported in sharing their reactions in family
therapy. The family therapist may need to both prepare the child to share a secret (e.g., “I
might be gay”) or question (“Am I adopted?”) and coach the parents to respond optimally
before a family session is held (Celano, 2018a).
A fourth ethical issue involves informed consent. One example of this pertains to con-
sent to treatment in families in which parents have been divorced. Although parents might
have joint custody, only one parent may have medical custody, including the ability to decide
whether a minor child can receive therapy. Family therapists should not assume that the
parent who brought the child to therapy has medical custody. Asking for the divorce decree
protects the therapist from providing therapy to a minor without appropriate consent.
 Family Therapies 321

Professional competence is another ethical issue. The conduct of family therapy requires
attaining the competencies associated with this intervention. Finally, additional dilemmas
may arise while conducting family therapy. Family therapists are advised to refer to their
professional codes of ethical conduct and consult with colleagues, attorneys, and state pro-
fessional organizations when challenging ethical dilemmas that arise in the provision of
family therapy.

RESEARCH SUPPORT AND EVIDENCE-BASED PRACTICE

Models with a Historical Focus
ABFT has been shown to be a promising treatment for depressed adolescents (G. S. Dia-
mond, Diamond, & Levy, 2015). Compared to a minimal contact control group, it is
more successful in decreasing depression, anxiety, hopelessness, and suicidal ideation,
and improving mother–adolescent attachments (G. S. Diamond et al., 2002). Similarly,
compared to enhanced usual care, ABFT is associated with greater improvements in sui-
cidality and depression (G. S. Diamond et al., 2010). Data also support ABFT for anx-
ious adolescents (Siqueland et al., 2005). It is associated with reductions in anxiety and
depression, and appears as effective as cognitive-behavioral therapy for this population.
ABFT has been modified for specific cultural groups (e.g., lesbian, gay, and bisexual ado-
lescents) and preliminary data on these modified interventions is compelling (G. M. Dia-
mond et al., 2012). There is initial evidence that improvements in adolescents’ symptoms
in response to ABFT are due in part to reductions in maternal psychological controls
and increases in maternal psychological autonomy granting in response to intervention
(Shpigel, Diamond, & Diamond, 2012). Together, these findings suggest that ABFT is
an evidence-based intervention aimed at repairing attachment ruptures and is associated
with improvements in adolescent function and family interactional dynamics (G. S. Dia-
mond et al., 2016).

Present-Oriented, Systemic Approaches

Structural family therapy in its pure form is studied less frequently today, but its theory
and strategies have informed several integrative, evidence-based family treatments, such as
BSFT (Szapocznik, Muir, Duff, Schwartz, & Brown, 2015), MDFT (Liddle, 2016), MST
(Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 2009), and structural ecosys-
tems therapy (SET; Mitrani, Robinson, & Szapocznik, 2009). For example, BSFT, based on
an integration of structural and strategic approaches, reduces behavior problems and drug
abuse among Hispanic youth (Santisteban et al., 2003). According to a multisite effective-
ness study (Robbins et al., 2011), BSFT is superior to usual treatment in reducing drug abuse
in a culturally diverse sample of youth. As another example, dozens of randomized clinical
trials (RCTs) demonstrate positive benefits of MST in reducing criminal activity in serious
and violent juvenile offenders (Henggeler et al., 2009). Longitudinal follow-up data show
that MST results in more positive outcomes in caregivers and siblings of serious juvenile
offenders (Johnides, Borduin, Wagner, & Dopp, 2017; Wagner, Borduin, Sawyer, & Dopp,
2014). SET yields higher levels of HIV medication adherence for African American women
than does person-centered therapy (Feaster et al., 2010) and reduces children’s problems
and mothers’ psychological distress and drug relapse (Mitrani, McCabe, Robinson, Weiss-
Lazer, & Feaster, 2010).
322 SYSTEMS-ORIENTED APPROACHES

Present-Oriented, Nonsystemic Approaches

Empirical studies of SEFT have not yet appeared. The conduct of such research largely runs
counter to the experiential and humanistic nature of the approach.
A review and meta-analysis of psychoeducational interventions for family caregivers
of individuals diagnosed with psychotic disorders reveals that such interventions reduce
caregivers’ global morbidity, level of burden, and expressed emotion but are not associated
with improvements in their overall well-being (Sin et al., 2017). There is evidence that fami-
lies with a loved one with schizophrenia respond to family psychoeducational approaches
that are culturally informed (de Mamani, Weintraub, Gurak, & Maura, 2014). There is
mounting support for the effectiveness of family psychoeducation for improving patient and
family outcomes in individuals across the lifespan with a range of psychological disorders,
including major depressive disorder (Brady, Kangas, & McGill, 2017) and bipolar disorder
(Soo et al., 2018).
In addition, there is considerable support for CBFTs such as parent training. This
approach shows positive outcomes for the families and parents of youth with a range of
disorders and for the youth themselves. For example, behavioral parent training is benefi-
cial for families with youth with disruptive behavior, attention deficit, and autism spec-
trum disorders (Bearss et al., 2015; Colallillo & Johnston, 2016). Reviews indicate that
with younger children, including interactive programs associated with digital-based parent
training (DBPT) is more effective in improving disruptive behavior than is behavioral par-
ent training alone (Baumel, Pawar, Kane, & Correll, 2016). Similarly, there is tremendous
support of PCIT for young children with diverse problems (disruptive behavior, attention-
deficit/hyperactivity, anxiety, language impairment, and intellectual and developmental dis-
orders) and for abusive parents and children in foster care (Funderburk & Eyberg, 2011).
There are promising results for PCIT delivered via the Internet (I-PCIT; Comer et al., 2017),
underscoring the promising role of technology for expanding the delivery of this CBFT.
PCIT has been adapted for Mexican American, African American, and Puerto Rican fami-
lies, and families throughout the world (e.g., Europe, Asia, and Africa).

Integrative Models
Integrative family therapy approaches have accumulated empirical support for adolescents
with externalizing behavior problems. Four models meet the criteria for evidence-based
family treatments (Sexton et al., 2011): BFST, MST, FFT, and MDFT. The success of these
models has been demonstrated in community dissemination (i.e., effectiveness) and in RCTs
demonstrating that these integrative interventions improve family functioning and reduce
presenting problems (Robbins et al., 2016). However, the comparative efficacy of these
models has not been tested.
Research on specific common factors in family therapy is in its infancy. Data indicate
that therapeutic alliance, the most studied factor in family therapy, is essential to success-
ful outcomes for all effective models. Split alliances, in which one member feels positively
about therapy and another does not, jeopardize engagement and treatment efficacy (Fried-
lander, Escudero, Heatherington, & Diamond, 2011). Balanced alliances appear to be more
important to treatment outcome than the strength of the alliance (Robbins et al., 2008).
 Family Therapies 323

These data support the importance of monitoring family and therapist interactions in ses-
sion, as well as seeking feedback from each family member about the developing systemic
alliance.
Data supporting the remaining common factors comes from their shared origin in evi-
dence-based therapy models. For example, psychoeducation and social learning strategies
are key ingredients of systemic and nonsystemic evidence-based approaches. Application of
neurobiological understanding in family therapy is a relatively new common factor made
possible by advances in neuroscience identifying complex, recursive relationships between
neurobiological systems and social/relational context (Celano, 2013). Neurobiology can be
used to explain family members’ experiences when they become emotionally flooded and
to justify use of calming strategies (e.g., mindfulness). Support for the concepts and strate-
gies used in integrative family therapy also comes from the field of relationship science.
For example, the concepts of family enmeshment, disengagement, cohesion, and adaptabil-
ity have been validated in research. Process research documents how therapist reframing
reduces expressed negativity in early sessions, which decreases the family’s risk for dropout
and optimizes positive outcomes.

CASE ILLUSTRATION

Maryam, an Iranian woman residing in the United States, contacts Dr. Robert Brown, seek-
ing help for her daughter, Mitra, who has experienced a drop in school performance, has
shown interest in boys, has been asking to get a tattoo, and has been disrespectful toward
her parents. Maryam states that Mitra saw an individual therapist briefly, but since Mitra
was reluctant to continue and her behavior had worsened, Maryam and her husband, Hos-
sein, are now seeking Dr. Brown’s help. Dr. Brown asks to meet with the entire family for
an initial appointment. Maryam replies that she and her husband do not have issues with
their two older daughters, who are engaged in their own activities, and that her husband
may not have time. However, she is open to asking her husband. Maryam calls back and
makes the appointment for herself, her husband, and Mitra. Prior to this appointment, Dr.
Brown consults with a colleague from Iran whose practice largely includes individuals from
his homeland, as he wanted to begin the family therapy with a cultural lens.
During the first appointment, Dr. Brown learns that Hossein, age 50, is a software
engineer and Maryam, 48, is a registered nurse who works at a local hospital. The couple,
who immigrated to the United States years ago, has three daughters: Azita, a 25-year-old
accountant engaged to an Iranian man who lives in a neighboring state; Mehry, a 21-year-
old college student who devotes all her time to studying; and Mitra, the 15-year-old, a
freshman in high school. Dr. Brown observes Maryam and Mitra together on a couch, while
Hossein sits alone in an armchair. Maryam appears careful in what she says, often looking
at Hossein and Mitra in what seems to be an attempt to read them and minimize conflict.
Mitra appears defiant, often looks away, and quietly wipes off tears. She complains that
her parents are controlling and backward thinking, do not understand American culture,
and want to make her life miserable. Hossein appears frustrated, concerned for and unsure
of what to do with Mitra, and in disbelief about what is happening to his family. When
he states that he and his wife have not had any difficulties with their two older daughters,
Mitra yells, “Stop comparing me to them!” Hossein becomes angry and is quiet for the
rest of the session. Recognizing the tension, Dr. Brown asks to have one meeting with each
324 SYSTEMS-ORIENTED APPROACHES

member alone. He promises the parents, in front of Mitra, that if he learns that Mitra is
engaging in dangerous behavior he would inform them, but asks their permission to keep
the rest of what Mitra shares with him confidential; everyone agrees to that arrangement.
During the meeting with Mitra, Dr. Brown learns that she is sad and frustrated and
sees her parents as controlling and not wanting to allow her to have fun. She reiterates that
her parents do not understand American culture, that they get upset if she wants to hang
out with friends until late at night, and that they do not allow her to stay at friends’ houses
overnight, and are uptight about grades. Dr. Brown learns that Mitra talks to her mother
more than her father, but longs for a deeper connection with her father. She shares that she
is tired of listening to her mother talk about her homesickness, marital difficulties, and wor-
ries about her parents back home.
During the meeting with Hossein, Dr. Brown learns that he was 12 when the Iran–Iraq
war started. His father, an officer in the Iranian military, was killed in the war. Hossein
recalls the fear he felt every time an Iraqi plane flew over where he was living and explains
that his father’s death was painful, as were the financial struggles that ensued. His mater-
nal grandfather had died by then and his paternal grandfather, who had been addicted to
opium, was unable to help; hence, culturally sanctioned social structures were not available.
Dr. Brown explains trauma symptoms and encourages Hossein to seek individual therapy.
Hossein states he is doing well enough not to need therapy, but reluctantly consents to fam-
ily therapy.
During the session with Maryam, she reports feeling depressed and alone; no member
of her family of origin lives in the United States. She reports being worried about her elderly
parents. She does not want to burden anyone back home with her feelings, as they have
problems of their own. Maryam asserts that she does not receive support from her husband,
who has been withdrawn for years. At the end of this session, Dr. Brown suggests a meeting
with the couple.
Dr. Brown, who takes an integrative and culturally informed approach, shares his con-
ceptualization of the family’s struggles with them at the fourth session. He suggests that
Hossein, having experienced the trauma of war, his father’s death, and addiction in his
grandfather, has been emotionally guarded and closed off. He remarks that as a result,
Maryam is lonely in her marriage, similar to how her parents felt in their relationship. He
suggests that Mitra has been emotionally parentified by Maryam, who has tried to find
comfort in talking to her daughter about her sadness, and that Mitra has been uncon-
sciously and unwillingly recruited to save their marriage. He notes that Maryam’s loneliness
has become more profound as the older daughters have left home, leaving Mitra to carry the
burden as an emotional caregiver. The family was asked to ponder this formulation prior
to the next session and give feedback. At the next session, the members each indicate that
Dr. Brown’s framing of the family is consistent with their experience. However, the mother
adds that since their two older daughters were 15 and 11 when they arrived in the United
States but Mitra was only 5, Mitra is the most acculturated; thus, she and her husband are
having the most difficulties with Mitra’s adolescence. Dr. Brown agrees that this cultural
dynamic is a key addition to the conceptualization and encourages them to examine their
shared beliefs, such as the view that the family is the basis of the social structure and that
family loyalty is very important. He supports their exploration of how different levels of
acculturation might be associated with different views on the family and on adolescence.
To help the family stabilize, Dr. Brown uses boundary making and unbalancing (struc-
tural); he asks Maryam and Hossein to sit on the couch and Mitra to sit on the single chair.
 Family Therapies 325

This creates a boundary between the two subsystems and begins to weaken the unhealthy
mother–daughter alliance and strengthen the couple’s bond. Recognizing that the family
has a hard time communicating, Dr. Brown uses skills building, teaching them to engage
in reflective listening (behavioral). He encourages an enactment of one of their arguments
(they select one about Mitra wanting to spend time with boys) and guides them in reflec-
tive listening in the session. Hossein has difficulty with the exercise but does not verbalize
his distress. Mitra enjoys the exercise, as she feels heard. Given the topic they selected, Dr.
Brown follows up on a conversation from the second session about cultural beliefs and
supports them in discussing how their different cultural upbringings may relate to the par-
ent–child conflicts. He helps them begin to negotiate differences due partially to differences
in acculturation.
During the next few sessions, Dr. Brown encourages the family to create a genogram
to gain an intergenerational and contextual framework for the current family dynamics.
During these sessions, Hossein recognizes that his tendency to be emotionally guarded is
a multigenerational coping technique that is destructive. He begins to wonder aloud if his
grandfather’s addiction to opium had resulted in his father being unavailable when Hossein
was a child, and if his father’s death led him to use the same strategy of emotionally cut-
ting off because it was the only one modeled for him by a man. Hossein realizes that being
emotionally cut off is not healthy for him or his family, yet he states that he does not know
what other strategies he can use. With that awareness, Hossein agrees to couple therapy
with Maryam, as they recognize that if they improve their relationship, Mitra may func-
tion better. They both acknowledge that they need help working through the traumas they
experienced leaving their home country because of persecution, coming to the United States
and having cultural shock, and becoming acculturated. They appreciate Dr. Brown’s focus
on their strengths and resilience during these conversations.
As a result, the next phase includes alternating sessions with the couple and the fam-
ily, during which Dr. Brown uses emotion-focused couple therapy and ABFT to strengthen
the attachment bonds. In the couple work, Maryam reveals how lonely she has felt in the
marriage and how, when Hossein does not respond to her desires for closeness, she becomes
depressed and less connected to him. As a result, she becomes more focused on her children
and work, which Hossein experiences as her lack of responsiveness to his requests for sup-
port and connection. Over approximately 6 months, Dr. Brown helps the couple identify
this negative interaction cycle associated with each person’s emotional pain and sense of
disconnect in the relationship. He encourages them to engage in different ways, so that they
become more emotionally open, experience and exhibit greater emotional attunement with
each other, and gradually become closer and rekindle the love that was present in the early
stages of their relationships. They begin to forgive one another for the hurts they each have
experienced. As the couple feels more bonded, they engage in individual trauma work in
the presence of their partner, which they prefer over individual therapy, so they can receive
comfort and support. As a result of the couple work, they are more able to effectively cope
with their daughter’s adolescent struggles.
In the family work, the parents recognize that they both were raised in homes in which
mother-led parenting was the norm and father–child interactions were limited and often
critical in nature, and that they had repeated this family pattern. They came to appreciate
that Mitra is exposed to many families in which fathers are more engaged in their children’s
lives and praise their children, and that this is what she craves. Hossein and Mitra begin to
steadily interact with each other, becoming more comfortable with each other, and the bond
326 SYSTEMS-ORIENTED APPROACHES

between them deepens. As they talk more about the ways in which Mitra has felt rejected
and hurt by her father, and Hossein is able to emotionally engage in the conversation, their
interactions become better regulated and more authentic. Simultaneously, the parents sup-
port Mitra in processing her emotions about the family, such as her fears about the disso-
lution of the family if she becomes more independent. They help Mitra see that they want
what is best for her and are profoundly worried for her, but that they are committed to
supporting her increasing emotional independence while simultaneously strengthening their
positive and age-appropriate connections.
Not surprisingly, at the end of 9 months of family therapy, Mitra’s acting-out behaviors
resolve, her grades are good, and she is active with her peers. Her parents are interested in
and curious about her life and generally interact with her in a warm and supportive manner,
but do not set limits unless indicated and only do so as a team. Furthermore, Maryam and
Hossein report that they are enjoying a more emotionally engaged and fulfilling marriage.

CONCLUSION

The evolution of family therapy has been the product of several historical trends involving a
focus on family and interpersonal process, structure, and interaction. Sociocultural, philo-
sophical, economic, and scientific influences have contributed to the development of more
divergent practices, which has resulted in greater diversity among models. This growth has
broadened the concept of family intervention, which has enhanced the utility, flexibility,
and adaptability of family-based treatment. Many models that have originated from the
unified theories of charismatic leaders have been integrated with other theories, adapted to
account for sociocultural differences, evaluated using family-oriented assessment devices,
held accountable for producing meaningful outcomes, applied to prevention, and focused on
contemporary societal problems. Although family therapy models have grown more diver-
gent in some cases, there has been a greater move toward integrative approaches in practice
and research. Family therapists have articulated philosophies and standards of practice,
supervision, and training.
The central unifying concept remains general systems theory. A family therapist not only
takes into account systemic forces in accounting for problem behavior but also engages these
forces to create change. Differences in models not only involve therapist conceptualization of
problem behavior but also focus on distinct methods of interacting that will lead to therapeu-
tic change. As these models are applied to contemporary problems and settings, and evaluated
for their efficacy, they will continue to evolve. The integration of various perspectives offered
through these distinct approaches will continue to advance the work of family therapists.

SUGGESTIONS FOR FURTHER STUDY

Recommended Reading
Kaslow, N. J., Broth, M. R., Smith, C. O., & Collins, M. H. (2012). Family-based interventions
for child and adolescent disorders. Journal of Marital and Family Therapy, 38, 82–100.—This
article shows promising results from RCTs of family-based interventions for children and adoles-
cents with mood, anxiety, attention-deficit/hyperactivity, disruptive behavior, pervasive devel-
opmental (particularly autism spectrum), and eating disorders. It presents data that support
specific family-based interventions for young people and offers a practitioner perspective with
regard to recommendations for future practice and training.
 Family Therapies 327

Pinquart, M., Oslejsek, B., & Teubert, D. (2016). Efficacy of systemic therapy on adults with mental
disorders: A meta-analysis. Psychotherapy Research, 26, 241–247.—This meta-analysis, which
reviews RCTs of family therapy for adults with psychiatric disorders, reveals short-term posi-
tive effects for such interventions for eating, mood, obsessive–compulsive, schizophrenia spec-
trum, and somatoform disorders but positive long-term effects only found for eating, mood, and
schizophrenia spectrum disorders.

DVDs
Psychotherapy.net has an array of DVDs that focus on assessment and engagement, various approaches
to family intervention, family interventions that target topics salient in work with families (e.g.,
loss, family secrets), and family interventions with diverse families.
Psychotherapy Videos and DVDS: Online Training Resource for Psychotherapy also has DVDs that
highlight various forms of psychotherapy—www.psychotherapydvds.com.
The American Psychological Association has DVDs related to family therapy, covering family therapy
over time and with individuals who have physical and behavioral health problems, models of
family therapy, and interventions that address key topics (e.g., divorce, stepfamilies).

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 CHAP TER 10

Couple Therapies
Jay L. Lebow
Shalonda Kelly

C ouple therapy is primarily a mode of intervention in which partners meet together with
a therapist to improve their relationships. However, the boundaries of couple therapy
are not as clear as might be indicated by this common expectation. Couple therapy may be
used for couples to determine whether they will continue or end their relationship or it may
serve as a venue in which couples work together to ameliorate one partner’s difficulties (e.g.,
depression, substance misuse). Some couple therapies are done with one individual in the
room at a time, whereas others employ a combination of couple and individual sessions, and
still others see multiple couples together in a group therapy setting.
Couple therapy focuses more on the relational bond between two people than the per-
sonality or well-being of an individual (Gurman & Fraenkel, 2002). First and foremost,
the success of relationships matters to almost all of those who participate in them. Second,
problems within an adult couple relationship can adversely affect the individual well-being
of the partners, and the well-being of their children (e.g., Lebow, Chambers, Christensen,
& Johnson, 2012). Third, the degree of stress and conflict related to couple distress is severe
enough to be considered a public health problem (Markman, Stanley, Jenkins, Petrella, &
Wadsworth, 2006). Fourth, while data show that those with personality disorders and cer-
tain other difficulties tend to have poorer relationship quality, differences in personality and
other individual characteristics between partners are normative, and couple distress stems
from how those differences are addressed within the couple.

HISTORICAL BACKGROUND

Couple therapy has had a long history. Early in the 20th century, some practitioners began
what was called “marriage counseling” to address couples’ relationship complaints. These

333
334 SYSTEMS-ORIENTED APPROACHES

early methods mostly comprised advice giving about matters such as sexuality and parent-
ing (Gurman & Fraenkel, 2002). Such interventions became common, although they were
rarely referred to as “therapy.” Indeed, those with relational difficulties seeking psychother-
apy were then referred for individual therapy to resolve the relationship problem (a practice
that subsequent research indicates is rarely effective for improving relationship satisfaction
(Gurman & Burton, 2014). This was followed by a period in which some therapists (primar-
ily psychoanalytic in theoretical orientation) began to extend their individual therapies to
couples’ problems in relating.
The breakthrough for couple therapy came with the emergence of the family systems
movement in the 1950s and 1960s, in parallel with the sweeping changes that were occur-
ring about the nature of relationships and the importance of relationship satisfaction. The
family systems movement questioned the traditional focus on individual functioning of
almost all psychotherapies and replaced it with one centered on the processes occurring
within and the functioning of relationship systems. Drawing on origins in general systems
theory (von Bertalanffy, 1975) and cybernetics (Wiener, 1948), couples (and families) were
seen through the lens of various basic properties of social systems. These included a focus on
circular sequences and recursive feedback loops (one person’s behavior leads to the other’s
behavior, whose behavior in turn leads back to the first person’s behavior in an endless
chain), so that no one person was viewed as the “cause” for the patterns of the relationship.
In tandem with the emergence of this systemic view, the word therapy began to emerge as
the principal way to describe intervention with couples, though many continue to use couple
counseling as a synonym for couple therapy. The family system movement also prompted
the first formally described methods of couple therapy, with these methods having their base
in systems theory.
From these early origins emerged several distinct first-generation approaches to cou-
ple therapy. Jackson created a systemic focused therapy that centered on creating positive
reciprocal exchanges between couples, improving communication, and strategic interven-
tion (Lederer & Jackson, 1968), which has led to strategic couple therapy (Rohrbaugh &
Shoham, 2015). Bowen (1978) created a different approach that emphasized individual dif-
ferentiation, which is still encountered in practice. Sager (1976), Ackerman (1968), and
Framo (1992) created other forms that integrated psychoanalytic concepts related to uncov-
ering and working with the presence of patterns out of awareness, which often had their
origins in partners’ family-of-origin experiences. These methods have in turn evolved into
present object relations and psychoanalytic approaches (Siegel, 2015). And in a distinct
thread evolving out of behavior therapy, Weiss (1978) and Jacobson and Margolin (1979)
formulated approaches focused on social exchange that have led to present-day cognitive-
behavioral couple therapy (Baucom, Epstein, Kirby, & LaTaillade, 2015).
Other powerful social changes in couple life that emerged in the 1960s and 1970s fur-
ther impacted couple therapy. One such change is indicated by the replacement of the term
marital therapy with couple therapy, pointing to the emerging greater diversity of couple
relationships. Feminists brought a postmodern consciousness to couple therapy, questioning
the highly gendered expectations of couple life that had dominated coupledom and couple
therapy (Goldner, 1985; Hare-Mustin & Marecek, 1988). Such a postmodern consciousness
led to the emergence of therapies that eschewed therapist directiveness, such as narrative
therapy (Freedman & Combs, 2015) and collaborative therapy (Anderson, 2016). Lesbian,
gay, bisexual, transexual, and queer (LGBTQ) couples came to be more often represented
in couple therapy, with attention to special considerations in therapy with these couples
 Couple Therapies 335

(Green & Mitchell, 2015). With the increased frequency of divorce, one subtype of couple
therapy came to focus on helping troubled marriages to survive and/or divorce well (Lebow,
2015). And couple therapy, once almost exclusively the province of middle- and upper-
class well-educated white people, was extended to diverse individuals. This brought into
focus the value of dealing with culture in therapy and a deepening understanding of how to
work in specific cultural contexts (Boyd-Franklin, Kelly, & Durham, 2008; McGoldrick &
Hardy, 2008). Other therapies have focused on other, now more widely represented subsets
of couples, such as couples in stepfamily situations (Papernow, 2013) or those with health
issues (Ruddy & McDaniel, 2015). Furthermore, as an offshoot of couple therapy, widely
circulated programs developed for premarital preparation and relationship education pre-
sented not as therapy but as psychoeducation (Ragan, Einhorn, Rhoades, Markman, &
Stanley, 2009).
Finally, the 21st century has witnessed an evolution toward couple therapies anchored in
relationship science about couple process (Gottman & Gottman, 2015) and therapies tested
for their efficacy. Here, emotionally focused (Johnson, 2015), cognitive-behavioral (Epstein,
Dattilio, & Baucom, 2016), and integrative behavioral (Christensen, Doss, & Jacobson,
2014) couple therapies have emerged as well validated, widely practiced psychotherapies,
and Gottman therapy has emerged as a prominent approach anchored in relationship sci-
ence. Also, recently emerging have been evidence-based couple therapies primarily intended
as the agent of individual change in problems such as mood, substance use, posttraumatic
stress, and eating disorders (Baucom, Belus, Adelman, Fischer, & Paprocki, 2014; McCrady
& Epstein, 2015). Here couple therapy is used not so much to advance the relationship but
to use the relationship to help intervene with the specific problem in focus.
Paradoxically, for all the specific forms of therapy, most couple therapists practice
in an integrative way rather than adhering to one specific approach. That is, there is an
integrative mix of elements common across most couple therapy (Lebow, 2014), perhaps
due to the pragmatic problem-solving focus of much of couple therapy. Several prominent
integrative couple therapies have been described (Fraenkel, 2009; Gurman, 2015; Kelly,
Bhagwat, Maynigo, & Moses, 2014; Pinsof et al., 2018), though none of these approaches
is as widely practiced as the narrower methods of couple therapy. Also, in contrast to the
carefully researched couple therapies, it remains relatively easy to create a couple therapy,
and popular relationship experts (some are therapists; others are not) put forth their own
views on couple process every day. Notably, other than Gottman’s and Johnson’s methods,
many of the best-selling books about couple relationships have little to do with the wisdom
of relational science.
This chapter overviews the field of couple therapy as a whole. Given the commonalities
and differences across couple therapies, responding to the broad questions framed by the edi-
tors of this book to elicit core concepts and methods for the specific therapies described in the
suggested outline for chapters might be answered differently across different couple therapies
(e.g., What is health in relationships?). To present the breadth and common ground in the
field, we present four responses within each section describing couple therapy. The first three
represent the most widely practiced methods of couple therapy: cognitive-behavioral therapy
(CBT), emotionally focused therapy, and psychoanalytic therapy. Within CBT we include tra-
ditional CBT, the third-wave treatment, integrative behavioral couple therapy (IBCT; Chris-
tensen, Dimidjian, & Martell, 2015; Christensen et al., 2014), and (stretching the boundary
of CBT a bit) Gottman therapy (Gottman, 1999), which is like third-wave behavioral treat-
ments. For emotion-focused therapy we emphasize Johnson’s emotionally focused therapy
336 SYSTEMS-ORIENTED APPROACHES

(EFT; Johnson, 2015), though we also refer to Greenberg and Goldman’s emotion-focused
couple therapy (Greenberg & Goldman, 2008). Object relations theory is the psychodynamic
theory most applied to marital interaction, although other current approaches are considered
(Scharff & Scharff, 1997; Siegel, 2015). The fourth point of view is an integrative one, while
also providing space for other salient ideas that lie outside the bounds of the three approaches
on which we primarily focus in this chapter. Given that even each of these four groupings of
therapies includes what actually are several specific approaches, what is presented is the most
prominent view from within each category of treatment, with attention to important varia-
tions. The integrative viewpoint intrinsically must be an amalgamation given that the only
common ground is that the approach integrates (and almost any treatment approaches can be
integrated). Here, we primarily focus on the best-known approaches, which include elements
of each of the three more specific therapies emphasized (Fraenkel, 2009; Pinsof et al., 2018).

THE CONCEPT OF THE COUPLE

Couple therapies agree that the focus of therapy is on improving couple relationships. How-
ever, there are differences in what is seen as essential to couples’ relating.

Cognitive-Behavioral Therapy
From the perspective of CBT, participating in a successful relationship is about the things
partners do with one another and how they think about one another. Couples are viewed as
engaging in an endless series of small and large exchanges with one another. To the extent
that these exchanges are positive and satisfying, couples are likely to be happy, whereas if
these exchanges focus on unresolved differenced or become coercive, relationship difficulty
can be expected.
Weiss (1978) and Gottman (Gottman, Swanson, & Murray, 1999) conducted research
pointing to the imbalance in positive and negative exchanges in happy versus dissatisfied
couples. For those satisfied with their relationships, the ratio of positive to negative behav-
iors in small and large exchanges throughout the day runs at least 5 to 1, whereas in less
satisfying relationships, there are as many, if not more, negative behaviors relative to posi-
tive ones. Early on in the practice of CBT, these findings led to an explicit focus on creat-
ing a “marital quid pro quo” of structured positive exchange. However, because CBT is a
science-based therapy, the field remained open to new data as findings emerged. Further
study showed that while the 5 to 1 ratio of positive to negative behaviors remains true,
simply prescribing positive exchanges reduces the positive impact of those exchanges. Rela-
tional happiness depends on the sense that a partner is freely choosing to be positive to his
or her partner rather than simply calculating that one positive behavior will produce good
personal results.
This development speaks to the wrestling among cognitive-behavioral therapists with
what others refer to as love and attachment. The mechanistic aspects of CBT must be
adapted to speak to how partners experience relating. CBT emphasizes partners’ devel-
opment of relational competencies; couples cannot engage in adaptive behaviors without
the requisite skills. CBT therapists have done pioneering work in cataloguing and find-
ing optimal ways to learn and practice such competencies, for example, by developing and
 Couple Therapies 337

enhancing communication, problem solving, and sexual skills, and recognizing and work-
ing with gendered behavioral patterns.
The growing emphasis on cognitions made the adaptation of CBT to the couple con-
text much easier. Relationships could be seen as more than exchanges of behavior. What
partners think of one another came into major focus. Gottman offered the useful notion
of positive and negative sentiment override. Sentiment override suggests that how partners
view behavior is as important as the behavior itself. In positive sentiment override, a filter
reshapes behavior to be seen as positive rather than negative, while in negative sentiment
override, the opposite occurs. This conceptualization led to efforts to directly increase posi-
tive sentiment override and decrease negative sentiment override.
In IBCT, Christensen and Jacobson took the focus on the Gestalt of each partner’s view
of the other further. Attention shifted to helping partners recognize the difference between
those behaviors that can be changed and those that are relatively unchangeable (e.g., fixed
aspects of one’s partner’s personality). For behaviors that can be changed, the focus remains
on behavior change, as in traditional CBT, but with behaviors that cannot be changed,
attention shifts to acceptance.
There remains some difference in the vision of the ideal couple across CBT therapists.
Some, especially those who practice traditional CBT, look to minimize conflict and create
as smooth a relationship as possible. Others, such those who practice Gottman therapy,
emphasize conflict as a normal part of relationship life; thus, while they look to lessen con-
flict, they see value in occasions in which couples express and work with strong emotions. A
parallel difference in CBT therapists is between those who work toward an optimal relation-
ship and others, like Gottman, who see some problems as simply recurring in evolving form
throughout the life cycle, never to be fully resolved, but lived with.

Emotionally Focused Therapy

Johnson describes partners in a couple relationship as being normatively interdependent;
this thought is anchored in the attachment theory upon which EFT is based (Johnson,
2015). Attachment theory states that human beings are biologically designed to develop
secure attachment bonds characterized by mutual accessibility, responsiveness, and engage-
ment as part of an innate survival mechanism throughout the lifespan. Infants first develop
secure attachment bonds to their caregivers through safe attunement and engagement, and
this secure base enables infants to attune to and actively engage with the world, modulate
stress, and maintain emotional balance as they grow older. When there is a secure attach-
ment, the mutual “effective dependency” of each partner within a couple empowers the indi-
vidual efficacy and autonomy of each partner. EFT describes a repeating cycle of behaviors
around couple interactions that characterize secure and insecure attachment bonds. Any
given issue can lead to attachment yearnings for a secure relational bond and associated
core, vulnerable, primary emotions, such as sadness within partner A. If the attachment
is insecure, partner A will protect him- or herself with a focus on secondary or hard emo-
tions (e.g., anger) and engage in associated thoughts, feelings, and behaviors to cope with
attachment yearnings and vulnerable primary emotions. Thus, partner A’s behavior leads
to attachment yearnings in partner B, who goes through a parallel process. Couples come
to engage in repetitive cycles around attachment that deepen bonds in securely attached
couples because partners are mutually accessible, engaged, and responsive, but are highly
unsatisfying among insecurely attached couples.
338 SYSTEMS-ORIENTED APPROACHES

Psychodynamic Therapy
Psychodynamic therapists believe that childhood relationships and later intimate relation-
ships shape the structure of each individual’s personality, including his or her expectations,
motives, and coping, which lead to negative couple interactions and relationship distress
(Siegel, 2015). Infants are envisioned as being born with a self that seeks attachment. From
the infant’s interaction with the mother, the infant becomes aware of differing self-states
and its psychic structure evolves. As the child develops, when its needs are not met by the
mother and it gets frustrated, underlying issues may evolve that include unmet or unclearly
articulated needs, fears, and traumas, which often are below conscious awareness. The
infant’s personality develops with a core self, but it has repressed cravings that are accompa-
nied by unrequited longing or anxious neediness, and a rejecting self that is characterized by
anger and sadness. Each of these aspects of the personality interacts inside of the individual.
Each person develops defense mechanisms to cope with the pain of underlying unconscious
issues. These aspects of individual psychology are viewed from a psychodynamic perspective
as crucial in couple relationships, where most of the important interactions and exchanges
are seen as occurring outside of conscious awareness. It is unconscious wants and desires
that have the greatest importance in determining couple relationship satisfaction. And pro-
cesses for being in the world that make for coping early in life readily can have negative
carryover to couple relationships.
Defense mechanisms that form to protect the individual are seen as having a crucial
role in relationship problems. Partners are seen as bringing transferences from their earlier
lives to their interactions with their partners. Here, partners’ experiences of each other are a
function of their own needs and fears rather than of objective reality. For example, partners
may view each other in all-or-nothing terms such as all good or all bad, a process referred
to as splitting. A related process, introjection, occurs when early interactions foster images
and belief systems that are unconsciously internalized, and negative or painful images and
beliefs become “enduring pathogenic introjects.” Or partners may draw on the primitive
defense mechanism of projective identification, in which the partners project or push onto
each other some aspect of painful unresolved themes. For example, Nielsen (2017) writes
that a husband may want to buy a new car but also want to save money, so he projects one
side of his dilemma onto his wife in saying that he wants a new car, only to experience his
wife as frustrating in terms of wanting to save money. Projective identification involves part-
ners unconsciously trying to make others, including their romantic partners, fit into known
roles in their lives that get reenacted based on their early life experiences and unmet needs.
This repetition of the past in the present is an unconscious attempt to resolve unfinished
business. In this way, psychodynamic therapists describe why, despite the best hopes and
conscious intentions, relationships fail.

Integrative/Other Approaches
An integrative view incorporates the aspects we discussed earlier into an overall formula-
tion. Thus, being in a couple is envisioned as a combination of behavior exchanges, cogni-
tions, emotional connection, attachment, and out-of-awareness forces that lead to a sense
of relationships being satisfying or not. Each level of experience (e.g., attachment) can be
viewed as developing and manifested through and under the influence of the other factors
(e.g., behaviors, cognitions); that is, from an integrative perspective, couples depend on
 Couple Therapies 339

having a strong level of attachment, but that develops and is maintained through behav-
ioral exchanges, emotional experiences, and moments of continuing to build or question
one’s relationship, with all of these factors informed and shaped by earlier experiences that
affect not only how one acts and feels but also how various aspects of the relationship are
experienced.
There are a variety of conceptual considerations about couple processes that are less
driven by theoretical orientation and more by broader trends in society. One question is
what constitutes a couple. In simpler times, this demarcation was clear: Married partners
were couples; unmarried ones were not. Changes in the nature of relationships have broad-
ened this definition to include a range of partnerships. In general, those who think they are
in a committed relationship are understood to be in one.
In a different vein, some suggest that couples can only be understood in their cultural
context. For those anchored in such a vision, much of understanding of couple process
resides in helping clients understand, appreciate, and build on their specific cultural heri-
tages. Methods that flow from such a framework look to articulate, honor, and work in the
context of the specific cultural heritages of each partner.

PSYCHOLOGICAL HEALTH AND PSYCHOPATHOLOGY

There is a broad consensus among couple therapists about some aspects of relationship in
distinguishing health and pathology. Well-functioning couples are seen as having high levels
of relationship satisfaction, although there is expected to be a natural course of satisfaction
that varies within normal limits over the life of a couple (Cherlin, 2009). Better functioning
couples have been traditionally seen as finding ways to work and grow together through
difficult times; thus, divorce is typically seen as a negative outcome for couples. Yet here a
growing minority view has come to regard collaborative decisions to divorce as one option
for relational success in a world in which marriage for a lifetime now represents a minority
among couples. There also is a broadly shared view among couple therapists that relation-
ship satisfaction is a continuum ranging from most to least satisfied, but with a clear thresh-
old that separates satisfied couples from other couples (Whisman, Beach, & Snyder, 2008).
It is also broadly understood that if either partner experiences relational distress, the couple
is relationally distressed; that is, a couple is only as happy as its most distressed partner.
For most, monogamy is presumed to be an intrinsic aspect of a successful partnership, as is
having children, though, again, today there are more childless couples by choice and more
polyamorous couples than in earlier eras.
Another agreed-upon distinction between couple health and pathology relates to mal-
adaptive constellations of couple behavior (e.g., Epstein & Baucom, 2002; Johnson, 2019;
Nielsen, 2017). The most common pattern that both indicates and maintains relationship
distress involves one partner pursuing the other, and the other withdrawing, and this pat-
tern is referred to with a range of labels, such as demand–withdraw and pursuer–distancer
(Eldridge, Christensen, Noller, & Feeney, 2002). Other common distressed patterns involve
both partners attacking each other in a hostile manner, and both partners withdrawing
and becoming disengaged from each other over time. While various approaches to couple
therapy label or diagnoses problems differently and focus on different etiological and main-
tenance factors, across all approaches, these are considered to be dysfunctional patterns of
couple interactions. Conversely, partners in healthy couple relationships primarily approach
340 SYSTEMS-ORIENTED APPROACHES

each other in ways that are vulnerable, soft, and positive, and experience positive thoughts
and emotions about one another.

Cognitive-Behavioral Therapy
Cognitive-behavioral therapists relate health to reports of high levels of satisfaction in cou-
ples; if people believe they are satisfied, this is regarded as sufficient. Yet, for the cognitive-
behavioral therapist, other aspects of relationship matter and are essential to building and
maintaining relationship satisfaction. One is the presence of certain basic relational skills
sets in each partner. Being in a couple requires the ability and willingness to manifest a wide
range of relationship skills. Successful couples can communicate and engage in mutual prob-
lem solving, at least when they need to, regarding areas such as sexuality, finances, family
relationships, and a wide range of specific relationship issues. To successfully so engage,
individual problems should not interfere with such processes. For example, one partner may
be highly anxious, but this should not interfere with the process of finding relational con-
nection.
From a CBT perspective, healthy relationships are characterized by a preponderance
of positive exchanges and feature a high level of positive sentiment override. In contrast,
distressed relationships are characterized by fewer positive than negative exchanges, high
levels of acrimony and coercion, and poor communication and problem solving. The first
hypothesis is that partners in distressed relationships do not have or manifest the needed
skills to successfully engage in relationships, leading to a significant part of the treatment
centered on teaching and practicing the skills of those who are successful in relationships.
Cognitive-behavioral couple therapy has highly egalitarian roots. Therefore, exchanges
in which one partner dominates and the other is submissive are not only seen as pathological
because such couples often tend to be unhappy, but because part of the ethos of CBT is to
promote more egalitarian relationships.
Traditionally, CBT has included a set of approaches that has emphasized smooth, rela-
tively conflict-free rational problem solving. In this tradition, better functioning couples
are able to verbalize and to problem-solve, and arguments are kept to a minimum. This
viewpoint has been a point of contention both within CBT and as it interfaces with other,
related forms of couple therapy. There is, even within traditional CBT, an awareness that
some amount of conflict is intrinsic and perhaps even helpful for most relationships. Some
CBT therapists look to promote “fair fighting” as the antidote to the deleterious effects of
high conflict, that is, staying within a rule-governed framework in which certain behaviors
are avoided, such as name calling, and space is provided for affect to stay within limits
(Stanley, Blumberg, & Markman, 1999). Others (e.g., Gottman, Christensen & Jacobson)
have embraced the value of finding methods of accepting and working with the normality
of conflict in a couple’s life.

Emotionally Focused Therapy

According to attachment theory, upon which EFT is based, a happy, healthy, functional
couple relationship comprises two partners who are securely attached to one another. Con-
versely, an unhappy, dysfunctional, unhealthy couple relationship comprises partners who
are not securely attached to one another. In adulthood, each person in successful relation-
ships is seen as similarly developing a securely attached bond with a mate, though the adult
 Couple Therapies 341

attachment bond is more mutual, less concrete, and also incorporates sexual behavior as
another important form of touch that regulates and holds the person securely.
Persons who experience secure attachment see themselves as lovable and entitled to
care, and see others as dependable and trustworthy. Thus, they can flexibly interact with
others, and reflect on themselves and their relationships, and they report high levels of
dyadic intimacy, trust, and satisfaction. Conversely, those who experience attachment inse-
curity have experienced attachment injuries over the course of their development, or key
moments of vulnerability and a need for comfort during which attachment figures were not
accessible, responsive, or engaged with them. These attachment injuries result in insecurely
attached adults who have developed chronic, rigid, and unhelpful strategies to obtain and
maintain the attention of their romantic partners. They may pursue their romantic part-
ners, perhaps in a critical or emotionally heightened manner, to deal with anxiety gener-
ated by the lack of responsiveness of their early attachment figures, or they may avoid
and distance themselves from perceived criticism or relationship failure. Both sets of rigid
strategies prevent healthy, safe emotional engagement and maintain each couple’s problems
(Johnson, 2015).
Greenberg and Goldman (2008), in their emotion-focused couple therapy, add a focus
of identity to Johnson’s focus on attachment. Both Johnson’s and Greenberg and Goldman’s
approaches emphasize the ways in which secondary emotions, such as rage at one’s partner,
can mask primary emotions at work, such as feeling insecure.

Psychodynamic Therapy
From a psychodynamic perspective, the essence of successful relationship is anchored in
individual and mutually satisfying exchanges about basic needs and expectations, many of
which are out of awareness and driven by early experience. Negative, dysfunctional couple
interactions are viewed as being fueled by underlying individual issues that flow from the
poorly described or unmet hopes, needs, and desires of each partner. Distressed relationships
evoke basic fears about underlying issues. Frequently encountered are fears of abandonment
or rejection, shame and humiliation, jealousy, guilt, being controlled, being overwhelmed or
overburdened by the partner’s needs, and revisiting past traumas (Nielsen, 2017).
The couple relationship is viewed as evoking each partner’s hopes and desires for joint
activity and shared experiences, such as sharing thoughts, building lives together, having
children together, having sex with each other, and having the partner involved and invested
in joint efforts that engender co-constructed meaning. For some couples, the relationship
can evoke such a holding environment for each partner. However, such fears and dreams can
also lead to emotional distress, and relationship distress may develop when partners employ
defense mechanisms (e.g., transferences, introjection, projection) to cover or minimize con-
cerns evoked within the relationship. Defense mechanisms such as projective identification
are present not only in those with serious mental illness but also in healthier people and
often play out in distressed relationships. In distressed couples, the partners lack insight into
their defense mechanisms, and their transferences to one another tend to be interlocking.
Moreover, to the extent that partners are not able to soothe or empathize with each other,
their dysfunctional defensive reactions to each other confirm their fears. Conversely, happy
and functional couples have fewer underlying individual issues and greater insight, such
that they can own, contain, and thereby accept their own transference reactions enough
to prevent harm to the relationship. Moreover, the interpersonal connection within happy
342 SYSTEMS-ORIENTED APPROACHES

couples, a form of self–object bonding, helps them mourn any desires that may never be met
by the partner.

Integrative/Other Approaches
Integrative couple therapists view each of the factors from the specific approaches work-
ing in tandem to differentiate healthy and distressed relationships. Healthy couples are
seen as manifesting good relational skills, working together in what primarily are posi-
tive exchanges, being securely attached in the relationship with one another, and bringing
insight and some useful process to various parts of the self in relationship that touch on
family-of-origin issues. Each module of relating is seen as helping to build and maintain
each of the other modules in a positive relationship. In contrast, those in distressed relation-
ships are viewed as having each component add to the problems in the other components.
Some integrative approaches emphasize a level of case formulation for locating which area
of relationship difficulty is most essential to the manifestations of problems on other levels.
Those integrative approaches, such as integrative systemic therapy (Pinsof et al., 2018), use
case formulation to suggest the target for initial intervention that is seen as most salient.
Other approaches have much to add about what is key in distinguishing couple health
and pathology. Feminist family therapists (Goldner, 1985) emphasize directly and unequiv-
ocally challenging the patriarchal and highly gendered nature of much of couple relating.
From this vantage point, traditional patriarchal relationships are intrinsically pathologi-
cal. Those who emphasize culture similarly suggest the need to explore the role of cultural
beliefs in ideas of normality. For most with this emphasis, cultural heritage opens the pos-
sibility of digesting the impact of heritage and anchoring notions of health and pathology
in older traditions or in the conflict that results in having to work at the interface between
two cultures, with distinct ways of experiencing. In this way, culturally informed traditions
(much like feminist ones) at times find different answers to distinguishing health and pathol-
ogy than do traditional models that have psychological and systemic foundations.
Psychological health and psychopathology also are evaluated in the shifting expecta-
tions for relational life. As noted, there has been a softening of the view that marriages that
result in divorce are intrinsically pathological, with an alternative view that successful mar-
riage for a time that accomplishes positive tasks may be better than one that lasts but with-
out much relationship satisfaction. In such times of shifting expectations, what is normative
in terms of fidelity also is changing, although a more traditional view of monogamous
relationships remains dominant.

THE PROCESS OF CLINICAL ASSESSMENT

How do we assess couple processes? One broad point of agreement is that couples ultimately
decide on the success or failure of their relationships. One index of this is whether they
choose to remain in a relationship or not, which is a binary choice. Perhaps more salient
in delineating success is the degree of relational satisfaction reported by each partner. The
simplest method for assessing this is to ask. Beyond this, there are well validated instru-
ments for assessing self-reported relationship satisfaction overall and in specific areas (e.g.,
communication, sexuality) including the Marital Satisfaction Inventory—Revised (Snyder
& Aikman, 1999) and the Dyadic Adjustment Scale (Spanier, 1976). Instruments such as the
 Couple Therapies 343

Conflict Tactics Scales–2 (Straus & Douglas, 2004) assess more focused aspects of being a
couple, such as relational violence.
Clinical assessment is focused on the dyad in whole or major part, although most
approaches explore individual psychopathology and diagnose partners when relevant. All
couple therapies attend to the interactions between the partners and thus involve an inter-
personal level of assessment. Most foci of couple therapy use the clinical interview as the
instrument for assessment that guides the case formulation. Such assessment may occur in a
clearly labeled assessment phase (Chambers, 2012) or a less clear combination of assessment
and intervention early in therapy. Either way, therapists assess the relationship through-
out treatment, exploring problems and strengths. With more than one person in the room,
couple therapists of all approaches tend to have a systemic view, in which the couple is seen
as a unit embedded in influential contexts. The systemic tenet that the whole of the couple
relationship is greater than the sum of its parts is widely accepted. This means that each
partner’s contributions to relationship distress are viewed as transactional, and one part-
ner’s behavior cannot be understood without understanding the context presented by the
other partner’s behavior.

Cognitive-Behavioral Therapy
Beyond the obvious indices of satisfaction with relationships, CBT couple therapists focus
on the patterns of exchange that are occurring. What is the ratio of positive to negative
exchanges? What is the frequency of highly problematic relationship behaviors such as partner
violence, psychological abuse, contempt, or stonewalling? There is also attention to sequences
of behavior. Which behavior precedes and leads to other behavior? For example, in a pur-
suer–distancer cycle, pursuit cannot be understood without being related to the distancing
employed by the other partner. Cognitions are very much in focus, particularly global cogni-
tions such as negative sentiment override. Strengths in relationships are identified by observ-
ing behavior, reports about behavior, or examining cognitions as they appear. Assessment in
part lies in observing behaviors; one part in hearing about the history of the relationship and
the other in using self-report instruments to better pinpoint points of strength and difficulty.
CBT couple therapists consider individual and couple factors. There is literature about
using CBT couple therapy to treat individual diagnostic problems (e.g., depression, posttrau-
matic stress disorder). Yet CBT couple therapists differentiate between these two targets in a
relationally distressed couple that includes a partner with an individual diagnosis, and in most
cases tailor together two different evidence-based strategies for treating each problem in one
therapy.
Traditional CBT is optimistic in terms of diagnosis. Problems are assessed, solutions are
constructed, and there is a core belief that through skills building and practice, problems
can be alleviated (Messer & Winokur, 1984). Third-wave CBT, such as IBCT, has aug-
mented these assumptions by making a strong distinction between what can and cannot be
changed. Assessment helps ascertain this difference and suggests aiming to change what can
be changed and accepting what cannot be changed.

Emotionally Focused Therapy

The EFT assessment occurs as part of the clinical interview after the therapist has joined
with the couple. It involves listening to the couple’s presenting problems to identify relational
344 SYSTEMS-ORIENTED APPROACHES

problems and the partners’ negative cycle around their problems, as well as the strengths in
the relationship. The therapist obtains information about how the partners met and became
attracted to each other, and how and when their problems became manifest (including those
associated with life transitions such as birth and death). In individual sessions, the therapist
obtains an additional perspective on the couple relationship, particularly around sensitive
topics such as past and present abuse and relevant attachment history. Assessment also
involves observing couple processes, most especially around attachment, in sessions. While
questionnaires have been used to study the efficacy of EFT, none are deemed essential for
EFT assessment. Moreover, assessment continues throughout treatment to determine where
the couple is along the process of establishing a secure bond and which tasks need to be used
to help the couple.

Psychodynamic Therapy
Psychodynamic assessment occurs as part of the clinical interview and throughout treat-
ment. Early in the initial interview, the therapist asks the partners why they are seeking
treatment; the qualities that attracted them to each other; what led to their commitment,
their shared life (e.g., careers, children), and life stressors; each partner’s family and past
romantic relationships; life cycle stage and challenges; and boundaries between each part-
ner and work, extended family, and other systems. These questions help create a historical
context of meaning for the partners to gain insight. Throughout, the therapist attends to
the relational dynamics that ensue, such as blaming, rejecting, and significant nonverbal
behavior. The therapist notices nonverbal processes of closeness and distance and how these
relate to each partner’s individual personality and early experiences. Assessment emphasizes
shared and interlocking transferences; therapy is a place in which transferences between the
partners and toward the therapist emerge and inform the understanding of the couple and
each partner. The therapist can assess family dynamics by seeing the living history of inner
objects that emerges during affectively charged moments.
The therapist diagnoses at the intrapsychic level, identifying what type of transfer-
ences and countertransferences exist in treatment with a couple. Countertransferences are
as important as transferences, because the emotions aroused in the therapist are seen as a
type of emotional communication that alerts the therapist to unresolved dynamics being
enacted within the couple’s relationship. These countertransferences are considered to be
closer to the heart of the problem than what might be gathered from deductive reasoning.

Integrative/Other Approaches
Integrative therapists view problems as occurring across the specific levels identified by
CBT, EFT, and psychoanalytic therapists. Their assessment and case formulation work to
incorporate the kinds of information described earlier to a particular case. For some, com-
prehensive assessment across levels points to one set of factors being most central in the
couple problem, and that set of factors (e.g., attachment) is then primarily addressed. For
others, multiple foci are maintained across levels. And for yet others, models are sequen-
tially invoked as each seems most relevant. Depending on the formulation used by the thera-
pist, this may lead to a core sense that all problems can change with the right formulation
and focus, or some balance between deciphering what is changeable and what is not, and
how that which cannot be changed can be mitigated as relational problems.
 Couple Therapies 345

There are minority views within couple therapists that are important to add here.
There remain couple therapists who eschew individual diagnosis and feel that even rela-
tional assessment is not useful. These therapists, who primarily identify as poststructural,
narrative, strategic or solution focused, believe diagnosis (and, most especially, individual
diagnosis) unnecessarily pathologizes, encompasses a nonsystemic position, and does not
promote problem resolution. Still other therapists pay primary attention to arcs in larger
systems such as multigenerational processes that repeat certain patterns (e.g., Bowen ther-
apy), family loyalties (e.g., contextual therapy), cultural patterns (couple therapies targeted
to specific ethnic groups), or structural factors (e.g., the presence of children from earlier
marriages).

THE PRACTICE OF THERAPY

Several aspects of the practice of couple therapy extend across theoretical orientation. For
example, frequency of meetings, typically are once per week for an hour, may vary with
longer or more or less frequent sessions. Here, there are key differences across therapists, but
they are rarely related to theoretical orientation. Similarly, most couple therapists do most
of their treatment in conjoint sessions with both partners, though here theoretical orienta-
tion does impact somewhat. Couple therapists share the tendency to phase out of successful
treatment, diminishing the frequency of sessions as termination approaches.

Cognitive-Behavioral Therapy
Cognitive-behavioral couple therapy is by design a short-term focused therapy. Meetings are
typically weekly, with homework being essential. Meetings are a mix of sessions with the
partners together and separately. Conjoint meetings identify and work on shared patterns,
and individual meetings address skills building around deficits viewed as essential to treat-
ment progress (e.g., work on an individual’s primitive communication skills). More recent
third-wave CBT approaches (i.e., IBCT) tend to use individual sessions more than tradi-
tional CBT and typically involve longer courses of therapy to accomplish the broad goals to
achieve mutual acceptance that are at the center of those therapies.
Contracting about goals is central; what is to be worked on is almost always explic-
itly named, and goals are set in relation to the problem formulation in collaboration with
the clients. Clients select their own goals, though this selection is informed by therapists’
assessment of strengths and deficits in the relationship. Beyond the global goal of increas-
ing relationship satisfaction, treatment goals are presented in behavioral terms. As already
noted, IBCT is a bit different than other CBT therapies in that part of the assessment is
about which goals may be achievable and which may not, with an explicit shaping of goals
in relation to what is achievable.
Intervention in traditional CBT therapy takes several forms. First, there is activation:
efforts to find or reinvigorate lost parts of the relationship. Therapists may contract with the
partners to put a date night in place in their schedule, as couples often lose this piece of rela-
tional life. Second, there is the specific teaching and practicing of relationship skills, particu-
larly where there are difficulties manifesting the behavioral patterns of successful couples
because individual skill is lacking or other aspects of the relationship have blocked these
patterns. For example, in communication training, couples learn to use the speaker–listener
346 SYSTEMS-ORIENTED APPROACHES

technique to speak and then repeat what the partner has said, promoting clear speaking
and accurate hearing (Stanley, Markman, Blumberg, & Eckstein, 1997). In problem-solving
exercises, couples learn and practice how to solve problems, particularly when there are dif-
ferences in viewpoint. Where sexuality is an issue, couples explore their sexuality with one
another and practice to achieve satisfying sex. Third, CBT therapists focus on identifying
distorted cognitions partners have about one another that contribute to relationship dys-
function, especially those that lead to and accompany negative sentiment override, and the
“four horsemen” that point to a high probability of severe relationship problems identified
by Gottman: criticism, contempt, defensiveness, and stonewalling. As in individual CBT,
distorted cognitions are examined for their factual basis, and these now more grounded
cognitions are used to temper negative affect and arousal. Again, here there are variations in
the context of IBCT, where one focus lies in explicitly recognizing the limitations of partners
and helping partners to accept those limitations in each other.
When couples become stuck, CBT therapists work with the specific intervention in
focus to make it more effective. For example, if a plan is made for partners to pursue an
evening out and they do not do so, the assignment is reshaped to make it more viable (e.g.,
to plan a couple of hours out for coffee). Other ways of dealing with noncompliance come
in the form of examining cognitions that block positive engagement using standard cogni-
tive therapy methods for challenging dysfunctional cognitions. In IBCT, there is a stronger
recognition that some assignments will not be carried out, and when this occurs, it brings
into focus which assignments are unproductive. Then, the focus moves to accepting the
foundation of what cannot be changed in this relationship and finding effective ways to live
in that context.
In CBT, termination occurs when couples reach their behavioral goals. Typically, this
also involves reaching some acceptable level of relationship satisfaction.
The most frequent problems with CBT lie in finding the mix of interventions for those
who are demoralized or for other reasons are not ready to engage in the active skills build-
ing and practice that is at the center of CBT. With those clients, therapists often incorporate
motivational interviewing, a method designed to find motivation by helping couples exam-
ine the reasons they might or might not want to change, before engaging with more direct
intervention strategies.

Emotionally Focused Therapy

The EFT therapist meets with the partners in one or two conjoint sessions to join with
them and assess their relationship. Then the therapist has an individual session with each
partner to deepen the alliance and assess the attachment history of each as well as sensi-
tive topics. The therapist develops a therapeutic contract with both partners, and lets them
know that he or she will be their process consultant, and that the purpose of therapy is
to shift their negative cycle of interaction into a new one that fosters safety and support.
The remaining sessions tend to involve both partners. The therapist encourages feedback
and correction from the partners to learn their unique experiences in their attachment
relationship. While EFT has been shown to work in as few as 12 sessions, the treatment
is not time limited.
EFT is fluid. Across sessions, the therapist engages in three core tasks: “(1) to create a
safe, collaborative alliance; (2) to access, reformulate, and expand the emotional responses
that guide the couple’s interactions; and (3) to restructure those interactions in the direction
 Couple Therapies 347

of the accessibility and responsiveness that build secure, lasting bonds” (Johnson, 2015,
p. 105). Within each session, the therapist cycles through five moves that build in intensity:
(1) reflect the process of interaction in the couple’s negative cycle, (2) deepens one partner’s
experience and exploration of emotion, (3) has that partner do an enactment in which the
expanded experience is communicated to the other partner, (4) helps the partners process
the enactment (asks each what it is like to share and receive the new message and the accom-
panying feelings) and contains and explores negative responses, and (5) provide a coherent
overview of the new interactions and their attachment relevance to help the partners inte-
grate the expanded experience.
In all cases, EFT’s goal is to develop secure attachment bonds, identifying the couple’s
negative cycle of interaction and subsequently changing it to help the partners reach for
each other and express their vulnerable, attachment-related emotions, toward developing a
secure bond. EFT has three intermediate goals that correspond with stages of treatment: (1)
ally with the partners, assess their cycle, and deescalate their interactions; (2) restructure
the couple’s bond to include more engagement and responsiveness; and (3) help the partners
identify new solutions to their differences and problems and consolidate new partner posi-
tions within positive cycles of secure attachment.
When hearing the couple’s problems, EFT therapists seeks to weave in the partners’
complaints into a common goal that encompasses the concerns of both. They privilege emo-
tion as a source of information about the couple’s goals, and discuss them at the behav-
ioral, cognitive, affective, somatic and attachment levels of psychological experience. EFT
addresses cultural factors in identifying and addressing universal emotions and needs, yet
it is based on Westernized conceptions of attachment and emotion, and there are cross-
cultural variations in how emotions are experienced, expressed or displayed, and appraised,
what constitutes sensitivity, and the experience of security. As therapists must be able to deal
with their own anxieties around strong emotions, it is likely that treatment is impacted by
their values around these aspects of emotion. Therapists are transparent about the process
of change, and open to explaining the EFT process when appropriate. Johnson (2015) high-
lights that it is crucial for therapists to collaborate with the partners in a way that helps them
see the link between the tasks of EFT and their goals.
Many interventions facilitate the tasks and basic moves of the EFT therapist (Johnson,
2015, 2019). They include reflecting the process around the emotional experience, using
evocative questions, heightening the experience such as with what is labeled RISSSC (repeat,
imagery, slow, soft, simple language in the client’s words), using a proxy voice to share the
partner’s vulnerable emotions, validating, asking evocative questions, and providing tenta-
tive empathic interpretations that are close to the leading edge of the partners’ experience
to expand and transform their experience of emotion. To restructure the partners’ interac-
tions, the therapist tracks, reflects, and replays their interactions to slow down and clarify
their steps in the cycle. The therapist reframes those interactions in the context of the cycle
and attachment processes, and restructures them using enactments and choreographing of
attachment-relevant change events. The therapist works with all types of couples, includ-
ing those on medication and in various settings, and those of different cultures (Johnson,
2015). The culturally responsive therapist validates cultural influences on behaviors and
emotional expression and simultaneously reflects the impact of cultural influences on the
couple’s negative cycle (Greenman, Young, & Johnson, 2009). The EFT therapist rarely
gives homework, which may reflect an emphasis on the present moment and the therapists’
role in choreographing interactions.
348 SYSTEMS-ORIENTED APPROACHES

There are EFT interventions designed to assist with resistance and blockages to the
couple’s development of secure bonds (Johnson, 2015, 2019). The therapist might contain
(called “catch the bullet”), validate, reframe, and further explore negative responses as the
partners go through the basic moves of EFT. When there are impasses, the therapist remains
hopeful and engaged, and validates the difficulties the partners experience. The therapist
can reflect the impasse with the partners and invite them to articulate their stuck posi-
tions, thereby heightening those positions and facilitating new small steps to remove the
constraints of those positions. The therapist can provide disquisitions, or archetypal stories
that capture the partners’ dilemmas but do not require their responses. Sometimes an indi-
vidual session may help to explore an impasse and soothe a partner’s fears around emotional
engagement with the other partner. Sometimes there is an attachment injury; EFT has devel-
oped specific treatment steps to address this more serious impasse (Makinen & Johnson,
2006; Zuccarini, Johnson, Dalgleish, & Makinen, 2013).
For example, consider the real-life case wherein the therapist assists a husband in pro-
viding an enactment to his wife about how he feels angst (primary emotion) when his wife
dismisses his complaints about work, and how he longs to be heard and seen by her (attach-
ment yearnings). When asked by the therapist what that was like for her to hear, rather than
coming closer, the wife pulls away and angrily replies that what he is saying is not valid,
because she always is trying to lift him up. The therapist decides to catch the bullet of her
negative emotional response because it is poignant, because it is salient in regard to his
attachment fears, and because it is the fourth of the five basic therapist moves throughout
EFT. Thus, the therapist acknowledges that it makes sense that it is hard for the wife to
believe her husband feels dismissed, because she works hard to support him (validation), and
how they can see on her face how painful (primary emotion) it must feel to hear that mes-
sage when she longs to be there for him and works so hard to show it (attachment).
As partners progress through the third stage of treatment, they become ready for ter-
mination. The therapist becomes less directive and emphasizes each partner’s shifts in posi-
tion, supports constructive interaction patterns, and helps the partners articulate a narrative
that captures how they changed and the nature of their new relationship. EFT therapists
highlight ways the partners have found to get off of the negative cycle and create closeness
and safety within the relationship. Couples are encouraged to discuss future relationship
goals, and booster sessions are given as options when environmental factors may impact the
relationship.
EFT primarily focuses on emotion; thus, therapists success depends on how they work
with emotion. EFT therapists have three general guides in making decisions about emotion
on which to focus: (1) the most poignant and vivid aspects of either partners’ emotional
experiencing, (2) salient emotion in regard to attachment needs and fears, or (3) emotion
that appears to influence how negative interactions are organized within the couple. The
most common errors that EFT therapists make involve failure to work appropriately with
the partners’ emotions. For example, Bradley and Furrow (2004) indicate that therapists are
unsuccessful if they do not use evocative interventions focused on the partners’ attachment-
related fears of reaching while holding negative view of the self and the partner.

Psychodynamic Therapy
Psychodynamic couple therapy, like other couple therapies, tends to occur with both part-
ners, yet specific issues and situations may exist for either or both partners that alter this.
Concurrent individual therapists for one or both partners are common, so that each might
 Couple Therapies 349

work on his or her individual issues (Siegel, 2015). The structure of psychodynamic therapy
is fairly fluid and it can range from months’ to several years’ duration. Therapists maintain
a posture of curiosity and awareness, and try to explore emotions that may lead to associa-
tions, memories, and unconscious material that had not been previously known or under-
stood, particularly involving transferences and countertransferences. They seek to recog-
nize and validate the emotional and factual aspects of partners’ memories and experiences,
and to guide the partners in recognizing and empathizing with each other. This includes
acknowledging themes presented as being located in one partner but that represent mutual
themes.
In the process of psychodynamic goal setting, therapists construct goals collaboratively
with the partners, and the partners establish priorities, often around emotionally charged
issues and current problematic events, which can relate to cultural contexts. Psychodynamic
goals are not very specific and often change over time. Goals tend to include understanding
the presenting problem, but in a broader way that recognizes underlying issues. Therapists’
goals never focus on symptom removal, given that partners’ symptoms are seen as beacons
to lead therapists through partners’ defenses and underlying issues.
Psychodynamic therapists’ proximate goals include fostering insight while repairing
and strengthening the couple bond. As part of fostering insight, the first intermediate goal is
to make transference wishes and fears more explicit. Therapists seek to uncover important
and often unconscious defenses and the motives, desires, and fears and underlying issues of
each partner that lead to negative couple interactions. These negative couple interactions
act to confirm the interlocking, simultaneous negative transferences of each partner, and
frustrate or invalidate the basic human needs of each. Insights generated about their dynam-
ics help with attunement and empathy, fostering another common goal of having the part-
ners understand each other and feel understood. This in turn strengthens the couple bond.
Partners are assisted in recognizing their own and each other’s hidden fears, in addition to
articulating what they need from each other. Therapists improve the partners’ contextual
holding capacity so that each can provide for the other’s attachment and autonomy needs.
In the early stages of treatment, therapists help the partners shift from blame to a
complex understanding of each of their emotional and behavioral responses, in which they
recognize their transferences and underlying dynamics that need to be further explored and
addressed. They seek to recognize and rework mutual projective and introjective identifica-
tions of the partners; help them provide for each other’s attachment and autonomy needs;
build their capacity for empathy, intimacy, and sexuality; individuate and differentiate their
needs; and return to basic life cycle stage tasks.
After creating safety, psychodynamically oriented therapists utilize many interventions
designed to foster insight and strengthen the couple bond. It is crucial for therapists to main-
tain safety in the session, which necessitates creating not only a balance between acknowl-
edging the emotions and validating each partner’s key points that need to be understood,
but also interrupting and stopping the toxic ways that their points at times are communi-
cated. The methods used to foster insight are the same as those in individual treatment,
employed in the presence of the partner. These interventions include empathic immersion,
reducing resistance, interpreting behaviors, and exploring the past, as well as the therapist’s
exploration of his or her own countertransference. Other important interventions include
nondirective listening for unconscious themes; following the affect; analyzing indirect mate-
rial such as dreams, fantasies and associations; and exploring family histories as they relate
to the couple relationship. The methods that psychodynamically oriented couple therapists
use to strengthen the couple bond include helping partners to express their hopes and fears
350 SYSTEMS-ORIENTED APPROACHES

to each other in an effective manner, exploring and countering partners’ reluctance to alter
their responses, and helping partners work to prevent and rein in future negative interac-
tions via using their new insights and their bond.
As an example, Nielsen (2017) presented the case of Fred and Beth. Nielsen helped Fred
to identify his transference reaction to Beth, based in his tendency to see her as his depressed
and negative mother whenever she voiced a complaint, and to feel hopeless and respond
with angry frustration, which he tried to quiet with distancing. He also helped Beth to see
that when Fred distanced himself, it would trigger her transference reaction of thinking that
nobody cared about her and that she did not deserve help or consideration. A turning point
in treatment occurred when Fred spoke of his needs and their origins, such as when a recent
professional honor he received reminded him of how his mother forced herself to attend
his school graduation when she was deeply depressed, and how he would try to cheer up
his mom, who was unresponsive. This brought out Beth’s kindness and helped her take his
distancing behavior less personally.
Psychodynamic couple therapy has multiple criteria for judging when couples are ready
for termination. Success can be indicated by improvement in a couple’s ability to function
or the resolution of presenting problems, and this is when termination is raised (Siegel,
2015). Successful outcome and termination follows when the partners have internalized
the therapeutic space; they can provide themselves and their family a reasonable holding
environment; and they recognize, own, and take back their own unconscious projective
identifications. The partners should be able to work together as mates, be intimate with
each other and achieve mutual sexual gratification, envision their future, and separate their
needs and address them. An alternative criterion for termination is when the partners under-
stands their unconscious object relationship incompatibility and separate after having done
grief work to mourn the loss of their relationship. However, partners themselves are seen as
the ultimate judges of when termination is best. Moreover, psychodynamic therapists use
termination as an opportunity to resolve more of their ambivalent attachment to their own
internal couple to best be prepared to help the next couple.
Psychodynamic therapists note common errors in this form of therapy. The first is the
tendency to do too much. In wanting to be worthwhile, they may take unnecessary action to
address their own unease, such as talking too much. Such actions are seen as normal devia-
tions from which therapists can recover, and they can be seen as enactments that give clues
to understanding the couple’s repeating difficulties. A second common error is failing to stay
neutral. Psychodynamic therapists agree that partiality to either spouse is an error, and that
fairness is the intention of the therapist. A third common error is the failure to recognize
that one or both partners is in emotional overload and is shutting down, sometimes through
intellectualization that dissociates them from their emotions, which can be corrected by
questioning if the pace of treatment is too fast. A fourth common error occurs when thera-
pists experience emotional overload by not understanding and managing uncomfortable
countertransference states, not cleansing themselves of the identification that can ensue, and
not restoring their prior state of well-being.

Integrative/Other Approaches
Integrative therapists parsimoniously draw from the range of interventions across the vari-
ous forms of couple therapy to create an individualized plan with a specific couple that best
fits the partners’ case formulation. Goals are arrived at in a collaborative way with couples,
 Couple Therapies 351

and may range from resolving one issue in couple life (e.g., in-law issue) to fully rebuilding
what has become a highly unsatisfying relationship. Given such a range of goals and meth-
ods, integrative couple therapy varies in frequency, length, and number of sessions. Some
therapies require one or two sessions, whereas others work on relationships over years.
Nonetheless, the one session per week format dominates.
Most therapists have all sessions be conjoint, though many intersperse individual ses-
sions to focus on individual constraints to achieving the therapy goals. As in all the formats
in which individual sessions are employed, ground rules for what is shared and what is con-
fidential in individual sessions are key. Certain secrets challenge the therapeutic relationship
when these are shared in individual meetings. For this reason, most therapists who include
individual sessions specify that this is a private space where thoughts can be freely shared,
but that there are limits to what can be shared without the therapist feeling obligated to
insist that the content be shared with the partner. Active infidelity and active efforts to
divorce are the most obvious secrets therapists mostly choose not to hold. Having said that,
a minority of therapists will hold such secrets, believing it is better for the therapist to know
what is occurring than operate in the dark.
Integrative therapists draw from their own idiosyncratic toolkits of interventions; that
is, the shared base of interventions on which to draw include CBT, EFT, psychoanalytic,
and other major schools of therapy, but therapists have their own preferred intervention
strategies and ways of delivering those strategies. Integrative therapists select among poten-
tial interventions in some algorithm about the order for exploring them. For example, Pin-
sof and colleagues (2018) choose direct problem-focused interventions first, leaving those
methods that involve greater self-examination for situations not resolved by direct methods.
Nielsen (2017) reverses the Pinsof et al. sequence, preferring to create a psychoanalytic
framing first, before moving to CBT interventions to solve specific problems. Clients play
an important role in the selection of intervention as well. Interventions are selected in part
to the extent they are perceived as likely to be acceptable to clients. Also, different couples
require different methods. The young couple with little relationship experience is often best
served by having skills building CBT interventions dominate, whereas the couple whose
relationship has atrophied in the context of painful emotion that have made for profound
effects on attachment is better suited to methods that focus on emotion. Some therapist
choice is also centered on the therapist toolkit, which may include integration of as few as
two approaches (e.g., CBT and EFT) or numerous approaches and strategies for change.
Integrative therapists expect clients to work actively toward therapeutic goals, then
reach points of being blocked in that pursuit. When such blocks are encountered, the focus
moves to being sure the therapeutic alliance is sufficient or to changing the intervention
strategy in relation to the block that is occurring. In this way, “resistance” is seen more as
the therapist needing to find alternative successful pathways.
Termination occurs in integrative therapies when therapy goals are accomplished. As
noted, integrative therapy may seek change at multiple levels beyond simple behavior change,
so termination may occur after only a few sessions or many years of therapy.
The principal difficulty in integrative therapy lies in therapists and couples becoming
lost in the presence of multiple therapeutic perspectives or interventions targeted at very dif-
ferent aspects of being a couple. Maintaining coherence is essential to the success of integra-
tive therapy, and clients can only be expected to digest a limited range of their experience
in any therapy. Skillful integrative therapists combine multiple perspectives and methods,
while presenting a coherent narrative about the change process.
352 SYSTEMS-ORIENTED APPROACHES

We should add that there are other prominent methods of practice in couple therapy
that follow much different pathways than in the models described in this chapter. Most
prominently, narrative and postmodern couple therapies envision therapy more as a conver-
sation of equals than as a top-down presentation of how to improve relationships. Much of
the process of therapy in these methods lies simply in witnessing clients’ experience (Wein-
garten, 2013). From a different perspective, Bowen therapists emphasize explicit work of
each partner in the presence of the other to find new ways of differentiating from their fami-
lies of origin. In this therapy, there is almost no partner work in the therapy, even though
both partners are present. And from yet another perspective, feminist therapists actively
intervene when patriarchal legacies are encountered, viewing such patterns as antithetical
to optimal couple and individual functioning.
All couple therapies acknowledge cultural variations among couples’ struggles and
appear able to incorporate cultural factors. Therapists from all orientations have found
viable ways to tailor use of theoretical models to diverse populations. Kelly et al. (2014)
review how each couple therapy orientation addresses diversity. CBT considers culture as
the therapist collaborates with the partners to address their unique concerns, forms an ideo-
graphic assessment, and considers socioeconomic status and extended families. The Gott-
man method focuses on addressing emotional mismatches and building partners’ shared
meanings across cultures. EFT notes that every culture prioritizes some emotions over oth-
ers, such as how men in the United States are encouraged to suppress vulnerable emotions
and women are encouraged to express them. Thus, EFT encourages all couples to break out
of culture-bound constraints that restrain the expression of universal vulnerable, attach-
ment-related emotions. Psychodynamic approaches highlight how culture determines how
partners respond unconsciously to each other.
Therapists can encounter major problems in using theoretical orientations without tai-
loring them to diverse populations when needed. Kelly et al. (2014) note that despite claims
of universal applicability, approaches to couple therapy “typically are developed by, for, and
on White American, heterosexual, upper or middle-class, suburban, able-bodied Christian
participants, the dominant group in the United States” (p. 484), thereby favoring internal
validity over external validity. They all espouse a Eurocentric orientation that inherently
fails to explicitly teach therapists how to consider and bridge cultural differences; thus, they
can be used to stereotype and marginalize other ways of being, sometimes to the extent
of practicing outside of the bounds of their competence. Kelly and colleagues compiled
examples of these issues from the view of proponents of each couple therapy orientation. For
example, U.S. culture values rational thinking, individualism, and independence as norma-
tive (e.g., Smith, 2010), and considers values that differ from those ideals as deviant. In line
with those values, CBT assumes that direct focus on problems and open discussion of emo-
tions are superior ways to improve relationships, although some cultures may instead favor
communication that depends on context and nonverbal information (Sevier & Yi, 2009).

THE THERAPEUTIC RELATIONSHIP AND THE STANCE OF THE THERAPIST

As noted by Sprenkle, Davis, and Lebow (2009), in couple therapy, the therapeutic relation-
ship has been less emphasized than techniques. Yet evidence has accrued that the success
of couple therapy is related to its success in creating and maintaining a therapeutic alliance
(Friedlander, Heatherington, & Escudero, 2016). The alliance is more complex in couple
 Couple Therapies 353

therapy than in individual therapy, including components of the relationship of each client
to the therapist, both clients together to the therapist, and each client with each other during
the therapy (Pinsof et al., 2018). A special problem arises when there is a split alliance, that
is, when one partner has a strong alliance with the therapist and therapy, and the other does
not. That circumstance is related to negative outcomes. A challenge lies in maintaining the
positive side of spilt alliances while improving the alliance with the other partner.

Cognitive-Behavioral Therapy
As did individual CBT therapists, CBT couple therapists came late to attending to the thera-
peutic alliance. However, present practice recognizes the importance of collaborating to
establish an effective alliance. Alliance is primarily established through action. Clients see
therapists doing useful things and in so doing ally with the therapist. Thus, the effective
therapist is the one most able to skillfully follow and employ the procedures of CBT. Thera-
pists are active and directive, and take responsibility for the direction of the therapy, albeit
incorporating client feedback. More recent CBT couple therapies also prescribe attention to
cultural factors that are relevant.
CBTs are the couple therapies that have been most often transmuted into educational
programs and online modules with or without the presence of an actual person serving as
therapist; that is, there is movement to free the educational skills building aspects of this
therapy from the presence of the person of a therapist. Early outcomes from such programs
have been positive (Doss, Benson, Georgia, & Christensen, 2013). CBT couple therapists
only rarely attend to countertransference, viewing therapy as more the teaching and practic-
ing of skills.

Emotionally Focused Therapy

EFT therapists present as process consultants for the couple and are active and collab-
orative partners with the couple in piecing together and processing experience (Johnson,
2015). They strive for genuineness, being emotionally present and available, attuning to and
accepting both partners in a nondefensive manner. EFT therapists accept members of each
couple as they are, respecting each partner’s emotional experience, and work to place that
experience within the context of the couple’s relationship cycle. This allows these therapists
to ally with the couple in framing both as victims of dysfunctional cycles rather than as
being the problem themselves. The therapeutic relationship is a high priority; thus, EFT
therapists monitor it throughout treatment, attending to and repairing strains or ruptures
to the alliance. This is especially important, as the therapeutic alliance serves as the secure
base in treatment that enables partners to explore and reprocess their emotional experiences
and engage in potentially threatening interactions. The therapist’s stance is to assume that
although clients make the best choices that they can in their life situations, those choices
may restrict their responses in other contexts, thereby creating problems. The focus is on the
patterns of processing and interacting rather than on either partner as the problem, which
helps strengthen the therapeutic alliance. When the therapist experiences an impasse, he or
she accepts the partners’ rights to dictate the goals, pace, and form of change, and tries to
“slice it thinner” by lowering the level of vulnerability and risk to an acceptable level for
the partners. Self-disclosure and use of countertransference are not typically a major part
of EFT.
354 SYSTEMS-ORIENTED APPROACHES

Psychodynamic Therapy
Psychodynamic therapists believe that their first vital task is to create and preserve a safe
holding environment. The foundation for this lies in the therapeutic relationship with each
partner, which can enable self-discovery and transformation. The therapist’s capacity for
tolerating anxiety is what primarily fosters the working alliance with the couple. In creating
a holding environment, psychodynamic therapists bear the anxiety stemming from the emer-
gence of unconscious material and affect, containing and modifying it via internal process-
ing of projective identifications. They work from the psychodynamic principle of remaining
fundamentally nondirective at the level of the unconscious, where the therapist follows,
rather than leads. This stance remains steady as therapy progresses. Therapists let themes
emerge, interact, share the experience, and interpret it, so that the partners feel understood
and held. Therapists use their own presence, and may use their countertransference to share
a fantasy or a feeling in association to what material is manifest for the couple, but they do
not share personal information or let their reactions dominate the session. Therapists’ use of
self is best accomplished after having gained an understanding of their own family histories
and object relations in their own therapy to be able to calibrate the self as a therapeutic and
diagnostic tool Once therapists become skillful in understanding defenses, they can sense
when partners are overwhelmed, and intervene by labeling and exploring affect to prevent
partners from attacking each other.

Integrative/Other Approaches
Integrative therapists almost invariably emphasize the therapeutic alliance. A first phase
of therapy is often about establishing a working alliance with each partner. Alliances are
formed by combining all the ways alliances are cemented in other therapies: the therapist
being empathic and warm, witnessing client struggles, forming agreed-upon goals, creating
a holding environment, and being competent in action in terms of intervention. Ruptures
in alliance are important moments of pause in integrative therapies; healing the rupture is
seen as essential to successful outcome. Integrative therapists attend to countertransference
in their work, so that they do not contaminate the therapy with what are personal reactions,
and use these reactions (and the projections likely involved in that countertransference) in
the ongoing assessment, case formulation, and treatment planning that are essential to the
integrative treatment process.
Other couple therapies range in their emphasis on the alliance. Bowen therapy, with
its highly structured format for exploring each client’s family of origin, barely attends to it.
Now rarely practiced, early strategic therapies warned against the risks of the couple becom-
ing too bonded to the therapist instead of more appropriately emphasizing their bond with
one another. Narrative and other constructivist and social-constructivist therapies empha-
size the therapeutic relationship as by far the most important aspect of therapy, seeking to
create a coequal relationship in which clients fully experience their expertise as the best
experts in their own lives.

CURATIVE FACTORS OR MECHANISMS OF CHANGE

Each model presents a distinct set of curative factors and primary mechanisms of change.
 Couple Therapies 355

Cognitive-Behavioral Therapy
CBT couple therapists see treatment as being about skills building and practice of the behav-
ioral and cognitive skills involved. One key set of underlying principles is learning theory
and, more specifically, social learning theory. Here, classical and operant conditioning are
viewed as key mechanisms in how behaviors are shaped over time. Behaviors that are rein-
forced are learned and those that are not diminished. The positive and negative experience
of a partner is similarly viewed as being subject to classical conditioning. Learning also can
occur through the vicarious experience of seeing the positive effects of effective behaviors
in others.
A second thread of curative factors in CBT focuses on social exchange. Here, people
are viewed as engaging in exchanges that can help build or challenge relational life. CBT
therapists focus on creating and maintaining positive exchanges. A third set of curative fac-
tors centers on how partners think about one another. Here, focus centers on challenging
thoughts that promote negative sentiment override or constrain positive sentiment override.
In CBT, thoughts and behavior are seen as related. If behavior improves, then thoughts
about that behavior and the general sense of positive sentiment are also likely to improve,
and vice versa.

Emotionally Focused Therapy

With EFT, corrective emotional experiences are the keys to change in the couple relation-
ship. Emotion is envisioned as transforming partners’ inner experiences, thoughts, and
behavior compellingly and rapidly, and building the attachment security that maintains
couple bonds. For example, reactive, negative emotions are expanded to include previously
unacknowledged and marginalized emotional experiences, such as fear and helplessness.
These reformulated emotional experiences lead one partner to engage with more emotional
depth and affiliation with the other partner (Greenman & Johnson, 2013). In turn, this
leads to expanded emotional experiences, new ways to think about the relationship, and
positive reaching from the other partner. Thus, new cycles of securely attached bonding are
created in which partners can seek reassurance and comfort from each other, and soothe
and respond effectively to each other. Like most approaches, EFT considers the therapeutic
alliance as a high priority. Yet unlike other approaches, EFT emphasizes developing the
alliance to provide safety for the partners to access and acknowledge vulnerable emotions,
rather than skills, insight, or other factors deemed important within other theories.

Psychodynamic Therapy
Psychodynamic therapists believe that insight, emotional intelligence, and mutual empathy
and attunement of partners are curative. Therapists’ personality and psychological health
play a role; therapists must understand and contain their own countertransferences to create
a validating and safe therapeutic environment. Insight is seen as a key ingredient of change.
Partners learn to observe themselves in a new way, thus developing an observing ego that
reflects on and makes sense of their emotions. Their pattern of defenses become seen and
understood such that the partners name, experience, and work through their underlying
issues together. Any “skills” would be manifest as the partners’ improved capacity to con-
tain their projections, as partners learn to modify each other’s projections, to distinguish
356 SYSTEMS-ORIENTED APPROACHES

them from aspects of the self, then take back their projections. This process involves correc-
tive emotional experiences. Mutual empathy, attunement, and emotional intelligence grow
in relation to the therapist’s empathy with and attunement to both partners. Couples grow
in their abilities to perceive each other as separate and love each other for who they are
rather than being governed by unconscious repressed parts of themselves. Thus, couples
develop a mature love, in which the partners become more lovable and more loving.

Integrative/Other Approaches
Integrative models see change in all the ways specific models envision change as occurring.
One integrative view emphasizes common factors and common pathways. Benson, McGinn,
and Christensen (2012) propose such a model of psychotherapy integration that highlight
five shared empirically supported principles (ESPs): (1) altering the way the partners view
the presenting problem to be more objective, contextualized, and dyadic; (2) decreasing
emotion-driven, dysfunctional behavior; (3) eliciting emotion-based, avoided, private behav-
ior; (4) increasing constructive communication patterns; and (5) promoting strengths and
reinforcing gains. According to this model, the five ESPs are the curative factors that all
couple therapy approaches have in common.
A second view of curative factors in integrative approaches emphasizes drawing on the
most effective intervention strategies from various orientations applicable to a specific case
(Snyder & Mitchell, 2008). For example, assimilative integrative models add specific aspects
of a second model as useful to a host model. A third thread of transtheoretical integra-
tion models combines the various orientations and their curative factors into a metatheory,
which provides an overarching perspective on what helps couples. Kelly et al.’s (in press)
principle-based approach suggests that what is curative for couples lies in the integration of
the core principles of the treatment models. For example, attachment and social learning
principles would comprise the curative factors for a principle-based approach to integration
that blends EFT and CBT, respectively.

TREATMENT APPLICABILITY

Couple therapy is applicable in two major places. First and foremost are couple relationship
problems and, most prominently, couple distress related to a range of relationship problems
and seriousness of difficulties. Here, couple therapy is the only treatment with an evidence
base showing its effectiveness. Specific problems addressed may include diverse topics such
as communication challenges; problems dealing with money, parenting, extended family,
and health concerns; and sexual difficulties or infidelity. Couple therapy is most effective
when problems are less severe, but several studies point to its considerable impact in the
most distressed couples (Lebow et al., 2012).
The second place is as either a primary or adjunctive therapy for various individual
problems (e.g., mood, anxiety, eating, and substance use disorders). In this context the cou-
ple relationship is used as a mechanism to help the person with the disorder to work with his
or her problem. For example, in depression, the partner can be instrumental in supporting
activation and helping put into place effective habits that help to counter depressed patterns.
There are two widely identified problems in which couple therapy is contraindicated.
The first is a certain kind of relational violence, sometimes termed domestic terrorism, in
 Couple Therapies 357

which it is dangerous to be in a particular relationship. The danger here is that improving

the surface of the relationship without sufficiently addressing the violence places the abused
partner (almost always a woman in this circumstance) at risk. The second is when one
partner wants to preserve the relationship and the other partner has made a final decision
to actively exit the relationship. In this latter case, Doherty and Harris’s (2017) discernment
counseling is recommended before the couple can move into couple therapy to see whether
the relationship can be salvaged or whether it might better focus on how to divorce well in
divorce therapy.
Couple therapy is equally applicable and effective across cultural groups, kinds of
relationships, and socioeconomic circumstances. Good couple therapy is always culturally
informed. Cultural traditions matter. Even if those involved have assimilated into a domi-
nant culture, there remain intergenerational legacies of cultural beliefs and experiences.
When treatment is with those deeply engrained in a culture, it requires adaptation to the
context of the culture. Sometimes such adaptations are simple, requiring only knowledge
about the traditions within a culture or factors that are relevant for a particular socioeco-
nomic group (e.g., availability of child care) such that therapy can be consistent with those
traditions. Others are more complex, when, for example, a culture has a tradition of female
subservience, a circumstance that is implicitly in conflict with the gestalt of all couple thera-
pies and explicitly in some therapies.

ETHICAL CONSIDERATIONS

Ethical considerations in therapy are governed by principles such as the American Psycho-
logical Association’s (2017) Ethical Principles and Code of Conduct. With couple therapy,
as with other approaches, ethically it is important for therapists to have a clear set of policies
that preferably is written and consistent across cases (Gottlieb, Lasser, & Simpson, 2008).
It is best practice to discuss these policies at the onset of treatment. It helps to discuss risks
and benefits of each policy, then review the therapy contract and relevant agreements with
the couple at relevant shifts in treatment and shifts in the couple’s circumstances.
One ethical dilemma in couple therapy that brings much complexity is the question of
who is the client (Gottlieb et al., 2008). The American Psychological Association’s (2017)
Ethical Principles and Code of Conduct warns that couple therapists must clarify at the
outset of treatment if their client is the referring partner, other partner, or the couple, and
the role the therapist will take with each person, and how the information obtained and
services provided may be used. Most couple therapists see the couple as the client, and
consider the needs of both partners and of the relationship. However, there can arise many
circumstances in which this useful abstract idea is challenged (e.g., when one partner acts in
some destructive way toward the other).
Related to the issue of who is the client are several ethical questions to be addressed
early in couple therapy and beyond. First, with a distressed couple, there often is one partner
who seeks treatment and one who does not want it. Here, the therapist’s dilemma is whether
or not to deny one partner treatment or coerce the other partner into treatment. There are
multiple ways to navigate this dilemma (Gottlieb et al., 2008). For example, couple thera-
pists typically reach out to the reluctant partner to engage that person in treatment, often
around something the reluctant partner wants changed, so that both partners become will-
ing to engage in psychotherapy (e.g., Kelly & Iwamasa, 2005). Second, once couples enter
358 SYSTEMS-ORIENTED APPROACHES

treatment, partners often have different and conflicting agendas about issues (e.g., separat-
ing vs. staying together) or about the problem on which the therapy should focus. When
the question is about whether to separate or work on the relationship, one alternative is to
contract to meet over the short term to see whether the partners might come to agree about
the nature of the therapy. Partners may have very different notions of the goals of therapy
and/or what they are prepared to explore and work on in therapy. Therapy must be a shared
collaborative process between two coequal clients and the therapist.
Third, there are issues about who has rights to what information. Here, early in ther-
apy, therapists must provide couples with their policy on the uses and limits of information
about the therapy. This includes confidentiality of the therapy content in the outside world
and confidentiality of information between partners. Confidentiality to the outside world is
usually guaranteed except in exceptional circumstances (e.g., when both partners agree to
the sharing of that information in child custody evaluation in divorce). Matters about confi-
dentiality between partners are more complex. As long as the policy is provided at the start
of treatment, it is ethically defensible to keep all confidences with the information that each
individual partner discloses from the other partner, keep no confidences, or for therapists
to employ limited confidentiality, bringing their own discretion to bear about what needs to
be shared between partners (Gottlieb et al., 2008). As noted earlier, most therapists choose
the safer path of not holding major secrets between partners, but many therapists do allow
for such possibilities.
Later in treatment, at times, couple therapy involves a change in format from individual
or family therapy to couple therapy, and vice versa (Gottlieb et al., 2008). Situations like
these provide one reason that it is crucial for therapists to provide their policies at the outset
and revisit and discuss them as changes arise. Consider the case of Henry and Charlotte.
Within the first four sessions of treatment, Charlotte decided to leave Henry. At first, both
contacted lawyers, whose litigious foci made each raise the possibility of a custody evalua-
tion with their therapist. The therapist informed them that her therapist role differs from the
role of an evaluator, and how therapists are ethically bound to avoid dual roles. Thus, she
created a boundary in informing them that she would not be the right person to do an evalu-
ation, but also offered her continued therapeutic services to help them to separate amicably
and effectively coparent their young son Declan. After some discussion and troubleshooting
about how they would handle their separation, they agreed to continue with the therapist
staying in a therapeutic role, but the focus changed to building an amical postseparation and
coparenting relationship.
Sometimes the issue of to whom the therapist is responsible carries a legal mandate. For
example, irrespective of who is chosen as the client, Snyder and Doss (2005) note that thera-
pists have an ethical responsibility to be familiar with legal mandates regarding the duty to
warn partners in the cases where one partner tests positive for HIV or sexually transmitted
infections or diseases. They note that therapists also have a duty to notify their clients at the
outset of confidentiality policies regarding such issues.

RESEARCH SUPPORT AND EVIDENCE-BASED PRACTICE

Couple therapy, when evaluated in a meta-analysis of all couple therapy studies, is effective,
with an effect size comparable to that of other therapies (Lebow et al., 2012). Typically,
three of four couples are helped by couple therapy (Shadish, Baldwin, & Sprenkle, 2002).
 Couple Therapies 359

Yet the research also points to challenges. While most therapy improves couple distress,
maintaining those changes is difficult over time, with only a few studies showing similar
continuing levels of couple satisfaction. Also, moving couples from the distressed range into
the normal range is difficult, and many couples do not achieve that criterion of success.
Several couple therapies that have been assessed as having strong empirical support
for their success: CBT, EFT, and IBCT. Paradoxically, studies have yet to show that these
treatments exceed the outcomes of more generic couple therapy. A meta-analysis found no
difference in impact between the best validated therapy, CBT, and other therapies (Shadish
& Baldwin, 2005). However, there are few or no studies that demonstrate the efficacy or
effectiveness of several widely practiced couple therapies, including psychoanalytic therapy,
narrative therapy, collaborative therapy, Bowen therapy, and solution-focused therapy; that
is, there is no research evidence that these treatments are effective. Also of note is that couple
distress is a special problem; without intervention, those who are clinically distressed are
highly likely to stay as distressed or become even more distressed (Baucom, Shoham, Mue-
ser, Daiuto, & Stickle, 1998). This has several clinical implications. First, control groups are
not much needed in research on couple therapies, because couples do not improve without
therapy. Second, when a certain threshold of relationship dysfunction is reached, some inter-
vention is needed. Third, measures taken to improve relationships before relationships reach
such levels of distress are clearly indicated (Halford, Markman, Stanley, & Kline, 2002).
CBT couple therapies have been shown to have considerable impact on individual dif-
ficulties such as depressive, bipolar, eating, and obsessive–compulsive disorder. (Fischer,
Baucom, & Cohen, 2016). Couple therapies are also are among the most effective psycho-
logical means for helping those with health concerns, ranging from heart disease to quitting
smoking (Ruddy & McDaniel, 2015).

CASE ILLUSTRATION

Byron and Bedelia were a couple in their late 30s with a seven-year-old son, Max. Byron was
a welder, and Bedelia was a first-year graduate student in social work. They had been mar-
ried 5 years, and Bedelia had had Max with her ex-husband. They presented with problems
related to Byron’s infidelity and the impact of Bedelia’s depression on the marriage.
In the first session held with both, the spouses gave their perspectives on the marriage.
Bedelia reported that the incident leading to treatment was a combination of her recurring
feelings of being overwhelmed at the end of the term with papers due, and Byron telling her
that he saw a prostitute when he took a temporary job at an out of town site for more money.
Byron reported total commitment to the relationship, and that his guilt and shame led him
to confess to Bedelia a month earlier. Bedelia, too, reported that she really wants to save
their marriage, but since Byron told her about his infidelity, Bedelia’s depression worsened,
and both reported that their communication/intimacy “was null.” Bedelia reported wanting
to manage how her depression affects the relationship, to function as an equal partner, and
not overlook Byron’s needs. Bryon discussed how he had been holding things in so as to not
hurt Bedelia, but that the pressure to move their family forward kept building, and some-
times he was too tired to deal with it. The therapist ended with exploring their strengths by
asking how they met, what drew them together and made them commit. They had met at
an adult game night, had mutual friends, and their relationship steadily progressed until he
proposed to her a year later, and they soon married. Byron was attracted to her looks, and
360 SYSTEMS-ORIENTED APPROACHES

soon learned of her loving spirit, while Bedelia stated that Byron was handsome, emotion-
ally secure, safe, and he got along well with Max. On this positive note, the therapist sent
them home with questionnaires and scheduled individual sessions with each. Their inter-
views and questionnaires revealed that both were significantly stressed and diagnosed as
depressed, though Bedelia’s depression was moderate and recurring, while Byron’s was mild.
In each individual interview the therapist used a genogram to assess their family histo-
ries, relationship histories, and cultural aspects of their lives. Bedelia’s genogram revealed
that she came from a proud African American family; her father had very high standards
that she could not meet, including having had to withdraw from her undergraduate educa-
tion for years due to multiple episodes of depression. Also, her middle-class family had
beliefs that each member is to accomplish certain achievement milestones in a certain order,
then have a family. In addition, her father had been unfaithful to her mother, and they
showed little affection, although she had good but distant role models of couple relation-
ships in her extended family. In addition, her ex-husband, a devout Christian, was verbally
and physically abusive, which led her to question God after her divorce. Byron’s genogram
revealed that his family was hardworking but had fewer role models of couple relationships,
with lots of instability and poor communication. He reported that many in his family would
act content on the surface, but their negative reactions would come out in multiple ways,
such as through alcoholism, depression, and infidelity. Both were strongly pro-black and
reported wanting a strong family life.
The couple had a well-entrenched negative pattern that operated across each of their
problem areas. For example, when Bedelia would have a depressed mood, Byron would see
her on the couch and think, “We’re not moving ahead, we’re just surviving.” He would feel
sad, angry, and doubtful that things would change, but he would try to hold those feelings
in to support Bedelia. After a while, he would try to get Bedelia to do less schoolwork or
take fewer classes, or get her off of the couch to spend time with him and with Max. Bede-
lia would sense that she was not meeting Byron’s expectations; she would feel sad, guilty,
and overwhelmed, regret taking so long to finish school, and think about how she did not
want to disappoint him. So she would try to prove that she could get on top of everything,
and try to get a clear minimum set of expectations from him. Byron would then complain
about Bedelia not listening to him regarding setting school boundaries, disbelieving her
claims that they would move forward, as his feelings of being overwhelmed with all of the
responsibility and feeling distant from Bedelia would grow. Then Bedelia would either get
more depressed or try to get more clarity on exactly how she needed to please Byron, feeling
that she was failing him, and feeling afraid to discuss just how hard it was to come out of
her depression, and they would feel less and less connected. At times, Max would get trian-
gulated or brought in as a way to address their problems, as Byron would point out to Max
that Mommy was often tired. While Byron really enjoyed fathering Max, in the individual
session he reported how Max always called him Mr. Hubert rather than Dad, and how he
wanted to move the family forward and have a second child.
The therapist saw the couple using principle-based integrative therapy (PBIT; Kelly et
al., 2019), which enabled her to apply CBT, EFT, multicultural theory (MC), and systems
theory (ST) to help this couple. A principle-based perspective involves four key tenets that
ensure that the theories combined each have (1) a unique and necessary principle or mecha-
nism of change not automatically addressed by the other orientations, (2) techniques that
the therapist can choose to engender the proposed change mechanisms of any of the orien-
tations espoused, (3) a level of complementariness with the change principles of the other
 Couple Therapies 361

approaches, and (4) some degree of empirical support that is not limited to randomized
controlled trials.
In the fourth session, the therapist elicited the couple’s negative cycle in the room and
validated their stances around it, gave the couple feedback according to the IBCT model,
and gave positive behavioral exchange homework in the form of a date. Their cycle imme-
diately began when Bedelia asked Byron if he was OK and Bryon said that she’d asked him
multiple times, and Bedelia exclaimed that she just wanted to connect and Byron com-
plained that he was not allowed to have his own needs. Then Bedelia sat farther away from
Byron, after which he apologized, saying that he just needed a pause, and that he just did
not want to go down the road of depression, which Bedelia took to another level with the
nervous energy that she brought in, or sat in a fog like at home. So the therapist intervened,
saying that she wanted to make space for the feelings of both, empathizing with Bedelia’s
high emotion when she sees Byron not responding, and Byron’s openness about his needing
time to process it all before expressing himself, and how it gets a bit tough to say that he just
needs a moment to process it all. Both appeared soothed, and Bedelia reported feeling better
that Byron was processing the relationship, given that despite coming to therapy together,
she feared that he really did not want treatment.
In the same feedback session, the therapist listed their presenting problems, let them
know that they were distressed but highly committed, and had a back-and-forth discussion
with them about the contribution of their recent stressors and lost resources (e.g., class and
job issues), their own depression, their family and relationship histories relative to how they
became distressed. She discussed their strengths of their commitment, how each saw the
other as warm and loving, attractive, and desirous of having a strong and positive family
life. The partners reported that the formulation made sense to them. The therapist stated
that throughout treatment, she would work with them to increase their bond, but also she
would work to build their skills, help them to turn to each other rather than bring in others,
and incorporate their cultural values in treatment. The therapist provided psychoeducation
around the importance of positive behavioral exchanges to create a positive atmosphere and
the motivation to do the work of therapy, and gave them homework to make it a priority to
do something together that they both enjoyed once per week.
From a CBT perspective, the therapist sought to involve social learning principles
around creating positive behavioral exchanges, alleviate their depression, and conduct cog-
nitive restructuring of Bedelia’s negative self-talk about herself and the relationship. After
the homework of their first date, the positive behavioral exchanges involved purposeful
extension of positives across sessions, such that they asked each other to do things that each
liked, adding new activities to their repertoire. Late in treatment, she helped them build
more of what they liked into their sexual relationship after they were more bonded. Draw-
ing from data on couple therapy for depression, they were given psychoeducation about the
biological basis of depression and how it can burden the (formerly) nondepressed spouse due
to its impact on couple communication, diminished sexual libido, and social interaction.
She had them decide together how Byron could help during situations when Bedelia sat on
the couch overwhelmed, and determine their mutual standards for their relationship, help-
ing them to increase empathy and support versus criticism and blame. She also helped them
to accept that the depression was there but not identify with it. In the same vein, she taught
them to challenge and replace their negative thoughts. For example, Bedelia learned to chal-
lenge thoughts about what she had not done, which sometimes led her to spiral down into
depression, and replace them with more realistic and compassionate thoughts, and she had
362 SYSTEMS-ORIENTED APPROACHES

Byron encourage Bedelia to use that skill and behavioral activation to alleviate both of their
depressed moods. Also, at the end of treatment, they identified and prepared themselves to
address their individual and couple risk factors for relationship distress and cheating that
might arise in the future.
These behavioral interventions complemented the therapist’s systems approach to the
couple’s problems. From a systems perspective, the therapist sought to decrease polarization
processes with the both–and intervention, in framing one of their issues as both Bedelia
wanting to be strong for the relationship and Byron wanting to be there for her. The thera-
pist’s system’s approach also included drawing a permeable boundary around the couple
relationship, so that family members’ needs would be kept outside of their relationship and
not get between them. For example, the therapist helped them to identify a united way to
approach Max without making Bedelia seem like the sick partner, and Bedelia clarified
for Byron that attending to Max was a motivator for her, and not a stressor from which he
needed to shield her. She added that it helped to have him join her in helping Max, for exam-
ple, around dinner, homework, and bedtime, which in turn increased his positive experience
of fatherhood. The CBT psychoeducation around depression, Bedelia’s acceptance of her
depression but nonidentification with herself as sick or unworthy, and their learning that
Byron also was not immune to depression helped to balance their roles with each other.
These CBT and systems interventions also were complementary to the multicultural
interventions. She informed them about data showing that African American couple rela-
tionships benefited from both help with addressing racism and not letting it come between
them, and from their praying for each other. While experiences of discrimination were not
particularly salient for this couple, the therapist recognized Bedelia’s family coping styles as
related to their status as African Americans, as well as their pride. So the therapist identified
how many African Americans coped with discrimination and stigma by being perfect or
tough, which are two ways of being strong. She gave Bedelia’s family as an example of being
the best, with their strong teachings about educational achievement and the proper steps to
advancing career and family, and Byron’s family stress leading him to feel like he had to be
strong for both his current family and his siblings, which at times overwhelmed him. Both
appreciated her focus on strengths and values of their culture, and though Bedelia had come
to question God, she agreed to try praying for Byron and he for her, which led both to report
feeling spiritually closer to each other.
Consistent with the PBIT second tenet, the other interventions also helped to engender
EFT’s corrective emotional experiences and a secure attachment bond, and vice versa. For
example, the behavioral interventions facilitated bonding and decreased some of the triggers
to their cycle, which provided early deescalation of their cycle. Also, EFT discussions of how
each found aspects of the other’s emotional experience hard to believe were used to facilitate
cognitive restructuring of both partners’ negative relationship beliefs. Consistent with both
CBT and EFT, the couple developed ways that Bedelia could check in with Byron regarding
his feelings about the relationship and any desire for other women, yet would not trigger a
negative cycle. They also explored ways that Byron could talk to Bedelia about his stressors,
so that they might be processed between them.
In one powerful EFT bonding moment, Bedelia enacted how she was desperate to move
forward with Byron toward their family goals of getting through school to get a job to
enable them to afford a house, to have a baby before getting too old, and how she wanted
to get off of that couch. She also shared how she felt depressed about her failures to fin-
ish school more quickly, and how she tried to prove that she could function and hide how
 Couple Therapies 363

overwhelmed she was and persevere to make Byron happy. To her surprise, Byron told her
that she did not have to hide her feelings, as he wanted to be there for her and support her.
After his family history of people staying silent about their pain, Byron let her know that
he really wanted her to be able to share it, as that was what he was there for as a husband.
Over time, the therapist got Byron to enact how he would criticize and withdraw because
he was afraid that she would sit and not do anything, which overwhelmed and made him
doubtful about them reaching their mutual goals. More importantly, he enacted how even
though he would tell her to do less, such as take fewer classes or lower her standards, it
was because he missed her, and felt distant and lost when she was not by his side. He stated
that he wanted to enjoy life with her, and that their goals were only special because they
involved her. Bedelia reported that this was new and that it felt really good to hear that
his complaints and criticisms were about him missing her, rather than her failing him and
not being good enough. As the couple got more comfortable with sharing their needs, the
therapist tended to end sessions with behavioral homework that incorporated those needs.
For example, Bedelia was asked to share her fears, and Byron was asked to verbalize his
emotional support, while simultaneously Bedelia committed to taking a small step forward,
to assure Byron that they were moving forward together.
Overall, the therapist used elements of multiculturalism and three couple therapy
approaches to improve Byron and Bedelia’s relationship at multiple levels. This included
the interpersonal-level focus of CBT, the inner attachment and emotional levels of EFT, the
family level of ST, and the spiritual and community levels of MC. Her integration of these
approaches was coherent in its focus on the principles of change of each orientation, and the
freedom that PBIT gave her to use any of their techniques to engender any of those change
principles, to the extent that she experienced them as congruent or complimentary. Not all
of their problems were dealt with 100%. For example, Bedelia had seen herself as the “sick”
partner for so long that she at times was resistant to hearing about Byron’s stress in thinking
that it was because she was not a good enough partner, rather than him being vulnerable
and in need of her strength. But Byron became quite open to sharing his own vulnerabilities,
and after seeing his positive responses to her listening and encouragement, Bedelia began to
experience herself more often as an equal partner who was needed by her husband.

SUGGESTIONS FOR FURTHER STUDY

Recommended Reading
Baucom, D. H., Epstein, N. B., Kirby, J. S., & LaTaillade, J. J. (2015). Cognitive-behavioral couple
therapy. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple
therapy (5th ed., pp. 24–60). New York: Guilford Press.—A summary of theory and interven-
tion in cognitive-behavioral couple therapy.
Christensen, A., Doss, B. D., & Jacobson, N. S. (2014). Reconcilable differences: Rebuild your rela-
tionship by rediscovering the partner you love—without losing yourself (2nd ed.). New York:
Guilford Press.—The definitive text about integrative behavioral couple therapy.
Gottman, J. M. (1999). The marriage clinic: A scientifically based marital therapy. New York: Nor-
ton.—The most complete description of Gottman’s approach and its basis in couple research.
Johnson, S. M. (2015). Emotionally focused couple therapy. In A. S. Gurman, J. L. Lebow, & D.
K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 97–128). New York: Guil-
ford Press.—A concise summary of theory and methods of intervention in emotionally focused
couple therapy.
Siegel, J. P. (2015). Object relations couple therapy. In A. S. Gurman, J. L. Lebow, & D. K. Snyder
364 SYSTEMS-ORIENTED APPROACHES

(Eds.), Clinical handbook of couple therapy (5th ed., pp. 224–245). New York: Guilford Press.—
A concise summary chapter describing theory and intervention in object relations couple therapy.

DVDs
Baucom, D. H. (2009). Enhanced cognitive-behavioral couple therapy (Relationship Video Series).
Washington, DC: American Psychological Association.—A demonstration of enhanced CBCT
by its developer Donald Baucom, with commentary.
Christensen, A. (2012). Integrative behavioral couple therapy (Relationship Video Series). Washing-
ton, DC: American Psychological Association.—A demonstration of IBCT by one of its develop-
ers, Andrew Christensen.
Johnson, S. M. (2009). Emotionally focused couple therapy (Relationship Video Series). Washing-
ton, DC: American Psychological Association.—A couple session of emotionally focused couple
therapy conducted by Susan Johnson, with commentary.
The Love Lab: Putting Marriages Back Together. (2009). Princeton, NJ: Films for the Humanities
and Sciences.—A look inside John Gottman’s love lab that explicates many of its findings about
couple process.
Wachtel, E. F., & Wachtel, P. (2018). Integrative couple therapy (Relationship Video Series). Wash-
ington, DC: American Psychological Association.—A demonstration of integrative couple ther-
apy that includes psychodynamic strategies by Ellen and Paul Wachtel, with commentary.

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 CHAP TER 11

Group Psychotherapies
Virginia Brabender

G roup psychotherapy is a highly efficient and effective modality for the treatment of a
wide range of psychological problems. To address the great array of difficulties that
people present, contemporary therapy groups include a tremendous variety of formats. Yet
all of them that have potential for fostering substantial positive change have critical attri-
butes that capitalize on the unique features of this modality. I describe in this chapter the
rich differences among groups, as well as the underlying commonalities.

HISTORICAL BACKGROUND

In the early 1900s, both the events and intellectual currents of the time favored the emer-
gence of group psychotherapy as a distinct modality. During the first three decades of the
century, large-scale events affecting vast segments of society inspired health care profes-
sionals to recognize the potential usefulness of bringing people together for the purpose of
therapy.

The Beginnings
The first documented group occurred in response to the epidemic of tuberculosis. Joseph
Pratt (1905), a Boston internist, after seeing one tubercular patient after another, began
to suspect that his patients might be a source of mutual comfort. He also reasoned that
meeting as a group would provide his patients with respite from the loneliness that accom-
panies tubercular patients’ long periods of convalescence. To explore this possibility, Pratt
convened thought-control classes, which he and “a friendly visitor” led (1992/1907, p. 29).
Although Pratt provided minilectures on the characteristics of the disease and techniques

369
370 SYSTEMS-ORIENTED APPROACHES

for coping with them (very much within the tradition of today’s psychoeducational groups),
he felt that much of the benefit of attendance entailed bolstering morale and positive emo-
tions. Pratt wrote, “One [member] confided to the friendly visitor that the meeting was her
weekly picnic. Made up as our membership is of widely different races and different sects,
they have a common bond in a common disease. A fine spirit of camaraderie has been devel-
oped” (p. 29).

The Concept of the Group and Its Application to Group Psychotherapy

As the century progressed, the simmering tensions in Europe, culminating in World War I,
drew attention to the large-scale destruction that could be wrought by large groups. Late
19th-century thinker Gustav LeBon (1895/1985) wrote about the potential of large groups
to regress to a primitive level of functioning, in which emotions and impulses gain domi-
nance over rational thought. He noted that within the group, the phenomenon of contagion
can occur, wherein group individuals adopt the emotional states exhibited by others, so that
feelings travel through a group with great rapidity. William McDougall (1923), who served
in World War I, also emphasized the destructive potential of groups but, at the same time,
saw groups as having the capability for constructive action. McDougall posited the contro-
versial notion of a group mind, revealed by the distinctive patterns of behavior individuals
manifest when part of a collective.
In Group Psychology and the Analysis of the Ego (1921/1955), Sigmund Freud cata-
pulted the study of groups by raising the question “What is a group?,” a query that requires
grappling with the fundamental issue of how a group becomes a group. He answered it by
highlighting the important role of identification as a process distinguishing a true group
from a mere collection of individuals. Freud saw members of a group identifying with one
another through their shared attachment to the leader. He saw members’ yearning for an
exclusive relationship with the leader as a process akin to falling in love, in which members
substituted their own values and principles (ego ideal) with those of the leader. The notion
of the leader’s centrality to the forging of member connections and the very existence of
the group itself proved to be a key tenet of most developmental models of group life, and a
resource employed by group psychotherapists in assisting members in achieving therapeutic
goals.
In Burrow’s (1928/1992) work, we see in a particularly clear way the influence of a
major intellectual current on group theory—American pragmatism. For Burrow, the group
situation is one that addresses problems in living within society. In consonance with the
pragmatic supposition that the value of knowledge is in its ability to enhance adaptation,
Burrow believed that groups offer an individual the ability to correct conceptualizations of
self and other in a way that improves communication and ultimately strengthens the indi-
vidual’s capacity to forge constructive relationships within society. Burrow emphasized the
importance of attending to process, recognizing the latent content of communications, and
understanding that phenomena exist at the level of the “group as a whole,” a term Burrow
coined that was destined to have great importance in group theory.
The interest in groups shifted in a very practical direction both during and following
World War II, which created the need to treat a large number of military personnel effi-
ciently. Group psychotherapy was a natural choice as a means to accommodate this demand.
The workings of these military-based groups were understood against their sociopolitical
backdrop of war. Group thinkers continued to work on the problem of the characteristics
 Group Psychotherapies 371

of the group as a whole and what distinguished group behavior from actions of individuals
operating in isolation. Bion (1959), a military psychiatrist who both conducted psycho-
therapy groups and administered a group program in a London military hospital, detailed
further the regressive aspects of group life identified by LeBon and the group as a whole
phenomenon recognized by McDougall.
Bion (1959) differed from Freud (1921/1955) in that he believed group dynamics tran-
scend the cumulative identifications members experience in their common relation to the
leader (Schermer, 2000). Influenced by object relationist Klein, Bion (1959) described the
“group as a whole” phenomenon through his distinction between basic assumption groups,
representing primitive modes of cognition and affect, and the work group, representing a
more mature, adult mode of functioning. Bion held that the anxieties stimulated by group
membership invite the emergence of basic assumption states, in which the group is in the
thrall of some fantasy that temporarily inoculates it against the anxieties stimulated by
group membership. He identified three basic assumption states, each of which was associ-
ated with a belief about the group. In the dependent state, the group behaves as though it
believes an all-capable, all-knowing leader will eradicate members’ difficulties. In the fight–
flight state, the group acts as if its survival is in jeopardy and it needs a leader who will either
lead group members away from the danger or mobilize the group to obliterate the threat. In
the basic pairing state, the group behaves as though a messiah will emerge from the union
between two members. When a basic assumption has taken hold of the group, members
exhibit minimal appreciation of reality, while emotions and urges dominate behavior. Con-
trasting with these configurations is the work group, in which members’ behavior is goal-
directed and reality-oriented. Bion’s delineation of these psychological states furthered the
notion that the “group as a whole” phenomenon exists beyond the psychology of individual
members.
During the war and postwar periods, other important theorists articulated processes
whereby alterations in the group can change individuals. Lewin (1951) wrote about the
group and the individual as moving toward a state of mutual adaptation—a notion that
explains how the group can be used to change the individual. Foulkes (1975/1986) proposed
the notion of the group matrix, the unique web of communications built by a group. Foul-
kes posited that the group process provides members with an invaluable resource to achieve
communications that are more direct, and broader and richer in expression.

The Popularization of the Psychotherapy Group

Beginning in the 1960s, group psychotherapy transitioned from a modality used in specialty
contexts to one that pervaded most segments of society. In the United States, the burgeon-
ing of community mental health centers, due to the Community Mental Health Center
Act of 1963, saw the availability of affordable group psychotherapy virtually everywhere
(National Council for Behavioral Health, 2018). Some of these groups had a more struc-
tured character than past groups, with methods of intervention tailored to help members
meet highly specific goals. The Vietnam War bred mistrust of authority, the consequence
for group psychotherapy being the establishment of groups without clear authority figures
(Brabender, Fallon, & Smolar, 2004). Groups came to be used for purposes of personal
growth rather than the amelioration of psychological difficulties, a development in keeping
with the current positive psychology movement (Seligman & Csikszentmihalyi, 2000). This
expansion in purpose led to an enormous increase in the number of individuals participating
372 SYSTEMS-ORIENTED APPROACHES

in group psychotherapy, either as group leaders or as members. Many individuals who took
on leadership roles were not adequately trained to assume this responsibility. Moreover,
some individuals who were accepted into the group lacked the personality strengths to cope
with reactions stimulated by the group, a problem intensified when the leader was mini-
mally trained. The upshot of these circumstances was that many widely publicized casual-
ties occurred and bred skepticism in the public about group psychotherapy.
This skepticism was an impetus to research the effectiveness of group psychotherapy.
Although research programs were initiated in the 1960s, it was in the next decade that stud-
ies possessed sufficient rigor to permit drawing conclusions about the value of this modal-
ity (Fuhriman & Burlingame, 1994). Most studies yielded findings supportive of group
psychotherapy relative to no treatment, alternative types of groups, and individual therapy
(Fuhriman & Burlingame, 1994).
A related event during the 1970s was the publication of Yalom’s (1970) seminal text The
Theory and Practice of Group Psychotherapy, which described an interpersonal approach
to group psychotherapy and built on others’ efforts (especially Corsini & Rosenberg’s
review, 1955) to identify change-fostering mechanisms present in an effective group. This
work was the impetus for many studies on therapeutic factors and continued the emphasis
on the careful examination of group process that has characterized the history of research
on group treatment.

Group Psychotherapy in Context

In the last several decades, a sociocultural and economic environment emphasizing effi-
ciency and effectiveness of treatment has shaped group psychotherapy. This modality is
inherently efficient, because it involves the treatment of multiple individuals simultaneously
by one or two professionals. The efficiency of group psychotherapy has been enhanced fur-
ther by the development of brief and short-term frameworks for various types of settings,
such as the interpersonal psychotherapy group (ITP-G; Wilfley, MacKenzie, Welch, Ayes,
& Weissman, 2000), Yalom’s (1983) interactional agenda model for ongoing groups, or Bra-
bender’s (1985; Brabender & Fallon, 2009) model for closed-ended groups (those in which
all members begin and end group participation during the same sessions). Short-term mod-
els for the treatment of homogenous populations (e.g., individuals with depression, anxiety,
or eating disorders) are increasingly available (Brabender & Fallon, 2009). Effectiveness
continues to be assessed by meta-analytic reviews that examine trends across studies and
have the potential of revealing patterns that might not be evident otherwise. This meta-
analytic work is considered later in the chapter.
A second trend is the use of psychotherapy groups outside of the traditional mental
health context. In particular, psychotherapy groups are becoming increasingly common in
primary care settings. Specialized group formats have been developed to address an array
of health problems, including adherence in pediatric insulin-dependent diabetes (Carpen-
ter, Price, Cohen, Shoe, & Pendley, 2014), anger management following acquired brain
injury (Aboulafia-Brakha & Ptak, 2016), prevention of depression in individuals with epi-
lepsy (Thompson et al., 2015), and enhancement of well-being in individuals with advanced
cancer (Breitbart et al., 2015). These groups tend to incorporate a strong psychoeducation
component, as well as the use of universality wherein members can derive relief from the
awareness of shared suffering.
A third trend addresses the long-term problem in the delivery of effective group
 Group Psychotherapies 373

psychotherapy services that therapists conducting the groups have frequently been inad-
equately trained. Increasingly, the group psychotherapy community recognizes that formal
academic programs in colleges and universities do not emphasize training in the theories and
techniques of group psychotherapy (Brabender, 2010), leading professional organizations to
take on this responsibility by providing organized curricula. For example, the American
Group Psychotherapy Association has developed a core curriculum (Bernard et al., 2008)
that trainees can pursue using diverse resources, some of which may be accessed within their
academic programs or at conferences and regional workshops. Finally, much greater atten-
tion has been given in the last decade to the topic of diversity and multiculturalism, that is,
how the practice of group psychotherapy must consider the culture and identity of the thera-
pist and the members, and recognize how disparities among cultures and identities within
the group can function both as impediments to relating and opportunities for growth. As
Nitsun (2012) notes, “Of all the psychotherapies, group therapy is the closest in spirit to
a diverse society since the group approach is usually based on plural membership and the
appreciation of difference (Thyssen, 1992)” (p. 398). However, it is only recently that group
psychotherapy scholars have begun to contemplate how the group can be a workplace for
members to constructively approach differences rather than resorting to stereotyping and
discrimination.

THE CONCEPT OF PERSONALITY, PSYCHOLOGICAL HEALTH,

AND PSYCHOPATHOLOGY

Marsh (1931), one of the first group psychotherapists, said, “By the crowd have they been
broken; by the crowd shall they be healed” (p. 330). This famous quote reveals the thread
running through theoretical perspectives on group psychotherapy and its relationship to
the individual’s personality. Personality, it suggests, is forged through interaction with oth-
ers, and is, in large part, defined by an individual’s relational patterns. When we say a
person is “outgoing,” “shy,” “stubborn,” “rebellious,” “domineering,” or “passive,” we are
talking about attributes of both personality and interpersonal relations. Those theoretical
approaches informing the practice of group psychotherapy subscribe to the notion that per-
sonality is rooted in, and defined by, interpersonal relations. Four theoretical strains have
had a large influence on group psychotherapy practice—interpersonal theory, psychody-
namic theory, cognitive theory, and action-oriented approaches. Each of these theories has
a distinctive view of health and psychopathology.

Interpersonal Orientation
Harry Stack Sullivan (1940, 1953), the founder of the interpersonal school, held that per-
sonality has its foundation in the longing of the child to establish a secure attachment with
others. The child both perceives the interpersonal world and acts in that world in such a
way as to enable him or her to feel a strong sense of connection to and acceptance by others,
especially the parents. Whatever perceptual and behavioral patterns the child establishes
during the early years become formative—that is, basic features of personality.
Suppose a child, Peter, must contend with the difficulty of establishing an emotional
bond with a parent whose affect toward him ranges between indifference and hostility.
Peter may respond to this challenge by reinterpreting the parent’s hostility as concern (a
374 SYSTEMS-ORIENTED APPROACHES

phenomenon Sullivan labeled a parataxic distortion) and engage in behavior to evoke con-
cern (hostility) and avoid indifference. While Peter is a child, his reinterpretation has adap-
tive value in that it enables him to gratify his longings for attachment. Yet when Peter reaches
adulthood, the selective perception of feelings and behaviors attached to this misperception
is no longer adaptive. They might, for example, lead Peter to strive to evoke hostility in
others, thereby preventing him from enjoying authentically positive emotional interactions.
The interpersonal view of personality is highly compatible with group psychotherapy,
because this modality provides a venue wherein parataxic distortions (representations of
self and others which are incongruent with most people’s perceptions) can be corrected by
the individual’s access to the observations of group members. Members in the group have
the opportunity to obtain feedback on others’ perceptions of their behaviors, and the reac-
tions members have to those behaviors. In an interpersonally oriented group, Peter would
achieve greater acuity in reading others’ feelings toward him, because the group culture
would promote members’ speaking about their feelings with greater openness than that
which Peter would encounter in his life outside the group. This information would allow
him to disentangle anger, indifference, and affection. He would also come to identify what
relational patterns elicit these different feelings in the other members and, by extension,
those outside of the group. This idea that the learning a member achieves with the group is
transferable outside involves another concept critical to interpersonal theory: the group as a
microcosm (or “little world”). The notion that individuals manifest their interpersonal style
wherever they go has received some support in the empirical literature (e.g., Goldberg &
Hoyt, 2015). Particularly conducive to the manifestation of different aspects of this style is
a circumstance in which the individual must interact with a great range of personalities. The
psychotherapy group is just such a situation: Inevitably within the group, those behaviors
that create difficulties for members in their everyday lives will appear and evoke responses
characteristic of others’ reactions outside of the group.

Psychodynamic Orientation
Highly compatible with an interpersonal perspective of personality is a psychodynamic ori-
entation from which has emerged many more specific theoretical approaches, such as self-
psychology, ego psychology, and object relations theory. All of them place emphasis on the
formative role of early experience in shaping personality. From a psychodynamic perspec-
tive, personality development takes place across a sequence of stages. Within each stage are
conflicts and tasks, and how the child addresses them will affect the individual’s adult per-
sonality. Impediments to resolving conflicts and completing tasks make persons vulnerable
to particular types of psychopathology.
For the psychodynamic therapist, the group provides a useful medium, because the
group proceeds through group as a whole stages of development (Brabender & Fallon, 2009,
2018). Although the development of the group has its own unique character, it nonetheless
evokes the conflicts that may have been insufficiently addressed and resolved in individual
development. Group psychotherapy provides the opportunity to redress those conflicts more
satisfactorily, in part by modifying those mechanisms of defenses on which members rely
to keep out of awareness psychological contents that are felt to be intolerable to the person.
As part of this process, some defense modification can occur: Those members who enter
the group with primitive defenses that distort reality are enabled to develop more mature
defenses that do not run roughshod over reality as most people know it, and that can be
 Group Psychotherapies 375

used flexibly in concert with other defenses. Group work also entails strengthening those
basic intrapsychic processes that are key to the individual’s capacity to adapt to the social
world such as the process of mentalization discussed in this section.
Psychodynamic group psychotherapy is a general term covering a variety of more spe-
cific theories, such as drive theory, ego psychology, object relations theory, self psychology,
relational theory, intersubjectivist, and mentalization approaches. Each provides a unique
view of both personality and psychopathology, and how the latter should be addressed in
group psychotherapy. Mentalization theory serves here as an example.
Mentalization theory holds that infants come into the world to form an attachment
to other human beings. In the context of a secure attachment, a child learns to understand
that the caregiver and, ultimately, others have intentions that govern behavior. Through the
caregiver’s careful attunement to the child’s reactions, the child also learns that he or she has
intentions and other internal elements. For example, the caregiver engages in marked mir-
roring, whereby the caregiver imitates the infant’s reactions but in such an exaggerated way
that the infant comes to realize that the reactions belong to the infant and not the caregiver
(Fonagy, Gergely, Jurist, & Target, 2002). From this and other, related processes, the aware-
ness of having a self emerges. The developmental task of acquiring mentalization can be
subverted by difficulties within the caregiver–infant relationship. When the caregiver fails
to provide adequate mirroring, the child fails to develop theory of mind, which means that
the child is unable to understand his or her own intentions and those of others. Instead, the
child shows a proneness to persist in immature forms of cognition characterized by psychic
equivalence, in which representations are thought to be an exact representation of reality,
and manifests itself in thinking that is “schematic, concrete, black–white, and insisting”
(Karterud, 2015, p. 7).
Mentalization theory has implications for the group treatment of individuals with per-
sonality disorders, who have weak abilities to mentalize. When placed in relational circum-
stances that evoke affect, they have limited wherewithal to make sense out of the emotions
they or others are experiencing (Karterud, 2015). As a consequence, they exhibit marked
difficulties in affect modulation and impulse control in a way that makes the maintenance
of stable, satisfying relationships extremely challenging. Moreover, they adhere to psychic
equivalence, the tendency to regard their perceptions and cognitions as being literally true
rather than mere perspectives on interpersonal events. Their attitude toward themselves
and others is incurious, so that whatever original notions exist about an interpersonal event
persist no matter how off base they might be.
Group psychotherapy can serve as a mentalization laboratory. The group therapist
works to establish a positive emotional climate in which members’ attachment systems are
stimulated. As members continue to relate to one another, negative affects emerge both
because they are part of most human interactions and because the propensities of indi-
viduals with personality disorders will beget them. In the group, members are supported in
responding to their own impulses, affects, and behaviors with questions about what wishes
and intentions might have given rise to these experiences. For example, suppose that Mei Lin
interrupts Gerald, who instantly responds with fury. The therapist would encourage Gerald
to pause and consider why Mei Lin might have experienced an urgency to interrupt him. He
might speculate that she might wish to retaliate against him for some misdeed toward her in
the prior session. The therapist might then turn to Mei Lin and ask her why she thought she
had interrupted Gerald’s flow of communications. She might offer a distinctly different per-
spective, such as being excited by her ability to relate to what he was saying. What would be
376 SYSTEMS-ORIENTED APPROACHES

important in this exchange is helping each member to see that the other has an inner life (i.e.,
a set of intentions that give rise to behaviors) and that each member has a distinct perspec-
tive on what these intentions are. Along similar lines, Gerald’s attention might have been
directed to what about the current situation led him to respond so intensely. Through this
process, members gradually develop an awareness of their own and others’ minds and as
they do, cognition based on psychic equivalence diminishes. This awareness supports affect
regulation in that members increasingly have the means to contextualize their reactions.
The mentalization approach has spawned a good deal of research including studies on
individuals in inpatient and day hospital groups (e.g., Bateman & Fonagy, 2008; Bo et al.,
2017; Brand, Hecke, Rietz, & Schultz-Venrath, 2016). Overall, favorable changes have been
demonstrated in terms of improvements in interpersonal functioning, global functioning,
and in variables specifically developed to reflect mentalization in response to mentalization-
focused group therapies.

Cognitive-Behavioral Approaches
Over the last 20 years, the use of cognitive-behavioral group psychotherapy to treat a variety
of psychological problems has increased greatly. These applications are based on a funda-
mental tenet of cognitive-behavioral therapy that an individual’s cognition is a prime driver
of how the person feels and behaves (Beck, 1995); that is, as individuals face everyday
situations, they develop interpretations of those situations (“Sally rushed by me and must
not want to walk with me”). These interpretations or automatic thoughts are generally
unconscious and affect how an individual responds emotionally and what the individual
does within the situation. Shaping the interpretations an individual makes of any situation
are early life experiences with significant figures that develop into core beliefs. For example,
individuals who experience rejection have a readiness to see a current situation as another
example of rejection, whether it is or not. The core belief might be “Others will inevitably
find me to be unacceptable to them.” Schemas are clusters of core beliefs that develop along
certain thematic lines and capture an individual’s broad views of self (“I am incompetent”),
others (“People are unsupportive”), and the world (“Life only brings misery”). The auto-
matic thoughts that emanate from the application of a core belief to an immediate situation
typically entail the commission of one or more thinking errors. For example, an individual
might engage in all-or-none thinking, wherein an individual fails to see various points along
a continuum and recognizes only the extremes (e.g., “I am either stupid or brilliant”). When
this cognitive bias is combined with another, that of discounting the positive, the individual
creates a foundation for developing self-devaluing automatic thoughts in a variety of situa-
tions.
Cognitive-behavioral therapy involves teaching individuals to modify their cognitions
in a direction to promote their well-being and adaptation to the environment. Cognitive-
behaviorally oriented group psychotherapy provides a workplace for the examination and
modification of cognitions, and the thinking patterns that give rise to them. Within this
approach, the therapist fosters a relationship of collaborative empiricism with the group
members, relating to members as nonhierarchically as possible, conveying that members
must be active in working toward their own therapeutic goals. The therapist employs a struc-
tured session designed to ensure that the group’s progress is efficient and that each member
receives his or her share of the group’s attention. Typically, in the initial session, members’
symptoms are assessed with tools such as the Beck Depression Inventory—Second Edition
(Beck, Steer, & Brown, 1996) and the Beck Anxiety Inventory (Beck, Epstein, Brown, &
 Group Psychotherapies 377

Steer, 1988) or their counterparts for a child or adolescent population. Members also moni-
tor their moods and other symptoms, typically using a scale from 1 to 100 (with 100 = the
highest level of intensity), a practice that will be a staple in the group as a means of assessing
change.
Following the evaluation phase, members are offered instruction in cognitive-behavioral
theory, most especially the notion that cognitions lead to actions and behavior. The therapist
then sequentially focuses on each individual, applying these concepts to that person’s problem
areas. The therapist employs Socratic questioning (Norton, 2012), systematically inviting
group members to identify the dysfunctional automatic thoughts and cognitive areas giving
rise to feelings and behaviors. The goal of Socratic questioning is not to convince members
that their ideas are incorrect but rather to instigate their critical analysis of the evidence at
hand. Sometimes, the therapist encourages members to expand the pool of evidence by con-
ducting mini-behavioral experiments inside or outside of the group. The assignments out-
side of the group constitute homework, and the early part of subsequent sessions is devoted
to reviewing the homework, typically prior to members’ developing agendas for the session
and working on fulfilling them (Brabender, 2002).
After members have proceeded through a sufficient number of sessions to work produc-
tively with their cognitions, various specialized elements might be introduced. For example,
in groups designed for heterogeneous anxiety disorders, the therapist might conduct expo-
sure sessions in which members address their fears in a hierarchical way (i.e., from least
to greatest) (Norton, 2012). In a group designed for individuals with a substance abuse
disorder, sessions are devoted to acquiring strategies to deal with triggers and urges (Wen-
zel & Liese, 2012). Final sessions are devoted to wrap-up, wherein members anticipate the
difficulties that are likely to emerge after termination and are encouraged to craft their own
programs to cope with those problems. In many group applications, booster sessions are
incorporated to solidify skills.
One particular type of cognitive-behavioral therapy that developed out of the failure of
cognitive treatment to adequately meet the needs of chronically suicidal therapy is dialecti-
cal behavior therapy (DBT), a treatment first developed for borderline personality disorder
but subsequently adapted to serve the needs of other populations with severe difficulties
(Linehan, 1993; Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006). DBT addresses the
vulnerability of borderline individuals to extreme emotional reactivity, a degree of dys-
regulation that evokes negative responses in caregivers and others, which evokes still more
intense responses in the individual. DBT group psychotherapy, which typically is an element
of a larger treatment package including individual psychotherapy, helps members acquire
the basic skills by which they can learn to respond more adaptively to a state of emotional
dysregulation. Rather than engaging in a range of self-injurious behaviors, the treatment
fosters in members acceptance of feelings within the here and now, and offers members
validation within the context of their relationships with the therapist and one another. At
the same time, the group member is taught various skills such as contingency management,
exposure-based strategies, and interpersonal problem solving, all of which contribute to
members’ more effective emotional regulation, reduced daily problems in living, and greater
capacity for joy in living.

Action-Oriented Theory
This family of approaches rests on the notion that to effect internal change, individuals
must behave differently. A variety of group models employ components of action. One type
378 SYSTEMS-ORIENTED APPROACHES

of action-oriented theory that is prominent in today’s group psychotherapy landscape is

social skills training, because it is particularly suited to the treatment of individuals with
persistent and severe mental illness. Social skills training, which is rooted in behaviorism,
uses the group setting to train members in the very basic social skills that members need to
have productive relationships with others (Granholm & Harvey, 2018; Mueser & Bellack,
2007). As in any skills training approach, the activities of providing instruction, modeling,
practice, and feedback are of paramount importance. For example, if an individual needed
to acquire the skill of terminating a social interaction, that individual would be provided
with instruction on the steps of the termination process, modeling by the therapist to see
how it is done, practice opportunities of ending the interaction, feedback on the practice,
then further practice implementing the feedback. Also characteristic of social skills training
is the division of any complex skill into sequentially mastered microskills. For example, a
client working on the skill of greeting another person might learn to gauge the appropriate
distance to maintain from the other person.
The group psychotherapy situation is especially compatible with the needs of social
skills training. The fact that multiple individuals can simultaneously receive instruction in a
skill creates efficiency. Having multiple members in the session is advantageous for conduct-
ing role plays. In repeating role plays with different members, participants have an oppor-
tunity to strengthen their skills and increase their transferability to the environment outside
of the group. Those who are not at any moment involved in a role play can offer feedback to
the others who are. In doing so, they strengthen their capacities to discern what constitutes
more effective behaviors in the social world. As part of the action in social skills therapy,
therapists assign participants homework on the skills practiced in a session and solicit mem-
bers’ feedback on their success–challenges in completing it in the subsequent session.
Consistent with its behavioral roots, social skills training places emphasis on the mea-
surement of outcomes. When individuals enter the group, they are assessed with such tools
as the Social Skills Checklist (Bellack, Mueser, Gingerich, & Agresta, 2004). Then, indi-
viduals are evaluated at regular intervals to ensure that progress toward the goals occurs
and to enable fine-tuning of the treatment.

THE PROCESS OF CLINICAL ASSESSMENT

Group psychotherapists carry the responsibility of ensuring that those individuals selected
to participate in a psychotherapy group are likely to benefit from it. In recent years, tools
have been developed and tested for this purpose. Two particularly promising instruments
are the Group Therapy Questionnaire (GTQ; Burlingame et al., 2006) and the Group Selec-
tion Questionnaire (GSQ; Davies, Seamam, Burlingame, & Layne, 2002). Both instruments
primarily identify individuals who are likely to do poorly in group psychotherapy—not
those who will do relatively well. Another approach is the use of personality assessment
tools, which can identify personality characteristics that auger well for group participation
such as extraversion, openness, and conscientiousness (Ogrodnikzuk, Piper, Joyce, McCal-
lum, & Rosie, 2003).
In determining whether a candidate is appropriate for a given group, the therapist
should consider the composition of the group. If the potential member will increase the het-
erogeneity of the group on some important dimension such as level of ego functioning, the
therapist must anticipate how the group is likely to respond to that member’s outlier status.
 Group Psychotherapies 379

For example, if a member functions more poorly than others in the group, the therapist must
assess the risk that a candidate’s qualities would create a vulnerability to the candidate being
scapegoated, a process in which group members project unwanted impulses and affects.
What is the likelihood that the member will drop out of group prematurely? Simply because
the therapist anticipates that a new member might challenge a group’s smooth functioning
does not mean that the individual should be excluded from group participation. Indeed,
individuals with different worldviews, identities, and experiences can enrich a group greatly
by helping members to see that they can form warm connections despite differences.
To enhance the likelihood that the processing of differences in group will play a con-
structive role in member’s growth, acceptance of members into a group should be preceded
by a multicultural assessment—an appraisal of the person’s status on key identity and cul-
tural dimensions. This assessment serves four functions. First, members experience groups
through the lenses of their identities and their cultural backgrounds. For example, the same
aggressive exchange could seem deeply disturbing to one member and be par for the course
to another based on how their cultures regard the communication of hostility. Some group
members are likely to experience much greater discomfort with self-disclosure than others,
based on culture (Chen, Kakkad, & Balzano, 2008). Second, identity and cultural variables
affect how both parties experience the therapeutic relationship and the expectations the
member might have for the therapist. For example, within some cultures, the quality of
humility is important (Comas-Diaz, 2006) and a prospective member might misinterpret
the therapist’s confident manner as arrogant. Third, some members might have undergone
various types of oppression and discrimination. Acknowledging these difficult events builds
the therapist–patient bond. Also, it alerts the therapist to the work that might be important
for that member. Increasingly, protocols are being developed to assist members in address-
ing the psychological aftermath of discrimination (e.g., Heilman’s [2018] protocol for treat-
ment of internalized homophobia). Fourth, the differing identities of members in the group
can create group tensions that must be addressed in the treatment. The therapist is aided
by being able to anticipate what tensions are likely to arise. A multicultural assessment
performed by the therapist before the member enters the group entails the exploration of
all-important aspects of a group member’s identity, such as race, ethnicity, socioeconomic
status, religion and spirituality, sexual orientation, identity status, and disability status.
As the therapist explores these facets of each client’s identity, he or she also can prepare
each member that others in the group are likely to have other identities, and at times, the
discussion of these differences can be helpful to members’ movement toward their goals.
The therapist might, for example, ask a Veteran, “What would it be like for you to talk
about your military experiences with someone who had never served in the military?” For
therapists who have never performed a multicultural assessment, the DSM-5 Culture For-
mulation Interview (CFI) provides useful questions to pose (Lewis-Fernandez, Aggarwal,
Hinton, Hinton, & Kirmayer, 2016).
Once members are accepted into the group, the therapist has an obligation to track
each member’s progress to ensure that he or she is meeting goals established at the outset of
treatment. Increasingly, clinicians are being called upon to find evidence that their methods
are producing favorable outcomes (Burlingame & Beecher, 2008). Accordingly, group psy-
chotherapists need the means to assess what their group members derive from participation
in the group. Moreover, in order for the therapist to respond with maximum sensitivity and
helpfulness, the therapist must link progress to processes in the group. Both outcome and
process measures are provided by the Clinical Outcomes REsults Standardized Measures
380 SYSTEMS-ORIENTED APPROACHES

(CORE) battery (Burlingame et al., 2006). In some cases, therapists might wish to incor-
porate process measures into the group experience, sharing the members’ feedback as it is
being garnered (Schwartz, Waldo, & Moravec, 2010). In this way, members, too, are given
the information they need to make adjustments in their participation in the service of their
growth. For example, suppose members take the Group Climate Questionnaire—Short
Form (MacKenzie, 1983; McClendon & Burlingame, 2010) and learn that strong avoid-
ance is present in the session. They then could engage in a discussion of what deterrents
exist to process issues openly with one another, a discussion that potentially lowers avoid-
ance.

THE PRACTICE OF THERAPY

Basic Structure of the Therapy
In designing a psychotherapy group, the therapist must think carefully about each structural
element, because every variable has an influence on the process and progress of the group.
A typical group psychotherapy session lasts between 45 minutes and 2 hours. Sessions in
which each member is accorded a segment of time (as in most cognitive-behavioral applica-
tions) tend to run longer. Hence, one consideration in establishing the length of the session
is to determine the requirements of the model. A second factor is the level of functioning of
the group members. Lower-functioning members generally use the group optimally when
sessions are relatively brief (Brabender & Fallon, 2019).
Another temporal variable is the anticipated length of member participation, whether
therapy is brief (1–11 sessions), short term (12–24 sessions), or long term (beyond 24 ses-
sions)? The relationship between member goals and length of participation is bidirectional.
When the length of group participation is prescribed by some entity external to the thera-
pist–client relationship, the length determines the goals. For example, in an inpatient group,
members may remain for only two to three sessions, not because they cannot benefit from
further group work but because the third-party payer will not provide coverage for a longer
duration of hospitalization. However, when an external factor does not create a limit, the
clients’ goals and motivation play a role in determining the length of group involvement.
Short-term group therapy has been demonstrated to produce a reduction in symptoms over
a short period of group participation. In fact, most of the outcome data on group psycho-
therapy—research that has been resoundingly favorable—has been carried out on short-
term groups.
Nevertheless, when individuals are seeking interpersonal change that is far-reaching,
a longer course of group participation might be necessary. What the long-term situation
affords people is the opportunity to proceed with the other group members through the
stages of group development, each one of which offers people an opportunity to do sig-
nificant interpersonal work (Bernard et al., 2008). Stage 1 provides members the chance
to explore basic conflicts about being involved with others. In Stage 2, members examine
conflicts related to authority figures—the wish to depend on authority and the longing for
self-sufficiency. This stage is likely to emerge most clearly in relatively unstructured groups
in which members’ frustration with the leader becomes palpable. In action-oriented group
psychotherapy, the therapist’s directive stance does not create the latitude for members’
feelings toward authority to emerge in as salient a way as in the other approaches. In Stage
3, members begin to explore issues related to intimacy, and in Stage 4, they approach the
 Group Psychotherapies 381

conflict of how to maintain individuality within the context of an intimate relationship.

Stage 5 allows members to address issues that pertain to loss and approaching the future.
Each of these stages requires time, and individual groups vary in the length of time they
spend within each stage.
The size of the typical psychotherapy group ranges from seven to 10 members. The
number of group members is an important factor in a group’s functioning. Too few mem-
bers deprive the group of the needed multiplicity of perspective and interactional styles, and
might even instigate members’ fear of the dissolution of the group (Rutan, Stone, & Shay,
2007). Having too many members hinders each member from being active in the group, and
the therapist from adequately monitoring each member’s progress.
Sessions vary greatly in terms of level of structure. Generally, the psychodynamic and
interpersonal models require relatively unstructured sessions in which members can interact
spontaneously with one another. Cognitive and action-oriented approaches tend to demand
a much more structured session composed of different segments, with each directed by the
therapist.

Combined Therapy
Group psychotherapy is frequently used in concert with other modalities. Group members
also may be in individual therapy, family therapy, pharmacotherapy, or an alternative inter-
vention. The person may be in individual therapy and group psychotherapy, either with
the group therapist (an arrangement referred to as combined therapy) or another profes-
sional. The presence of both modalities has innumerable advantages. Raps (2009) provided
a case illustration of Gary, a hospitalized Vietnam War Veteran who had sexually abused
his daughter. Within the individual treatment, the client approached difficult topics, such
as his experiences in combat, and eventually his shame and guilt in relation to his daughter,
which at that juncture he would not have considered sharing in the group. After a year, how-
ever, the client himself noted that something was missing. The therapist accepted the client
into his psychotherapy group, in which his difficult self-disclosures led to acceptance. Raps
writes, “Regarding guilt, the group had come to function as an external, kinder superego
for Gary” (p. 81). This experience in turn led him to deepen his explorations in individual
therapy. In this example, each modality intensified the other (see Special Series on Com-
bined Psychotherapy [Billow, 2009] for further discussion).
Reciprocally, the group members were provided an opportunity to understand how
identity status (military identity) and life experiences (work-induced trauma) led to Gary’s
current life difficulties. When these members are unable to achieve such empathy because of
early-life issues (e.g., problems in attachments to caregivers), these blocks can be explored
and diminished in individual therapy.

Goal Setting
The task of the group psychotherapist during the evaluation phase is different from that of
the individual therapist, in that the group design involves the establishment of certain goals.
Whereas the individual therapist has great flexibility to set goals for a given client, the group
psychotherapist must ascertain whether each individual’s goals broadly fit into the goals
that have been established for the group. However, very often, the goal that group therapy
candidates state initially may not be what is most important to them.
382 SYSTEMS-ORIENTED APPROACHES

Sylvia was a young Costa Rican woman who had recently arrived in the United States
to pursue her graduate education. She contacted the therapist because of an overwhelm-
ing weariness, which appeared to have no medical roots. She said she wanted to get
more zest for living. The therapist attempted to help her develop a more specific goal;
Sylvia seemed preoccupied with describing her physical symptoms.
Shortly after Sylvia joined the therapist’s psychotherapy group, she related to sev-
eral other young members of the group who spoke of feeling loneliness and a sense
of alienation in transitioning from college to the work world. With much feeling, she
talked about her own similar feelings, precipitated by ensconcing herself in a country
where she had few close friends. The therapist realized that Sylvia wanted assistance
with her sense of isolation and the identification and removal of any obstacles to estab-
lishing close ties in her new situation.

As the example of Sylvia suggests, in accepting a member into group, the therapist is
enlisting an individual with more than a diagnosis or a set of psychological problems. Each
member has an identity that is informed by a host of factors, such as cultural background,
gender, race, sexual preference, religious beliefs, and socioeconomic status. The therapist,
by virtue of identity and range of experiences, may have a limited grasp of the worldview
of an incoming member. In such instances, the therapist has a professional obligation to
become educated on how these factors affect the experiences and behaviors of the group
member. For example, Sylvia’s therapist would have been aided by knowing that in Costa
Rican and other Latino cultures, it is not uncommon for psychological problems to have
a strong somatic component. A full consideration of Sylvia’s immigration status would be
critical to both identifying appropriate goals and working with her effectively. Furthermore,
the therapist must have an understanding of how culture impacts his or her own social
behaviors, as well as the interpersonal behaviors of group members. For example, if a female
group member comes from a culture in which women are expected to be passive, she may
have a longer, more challenging course of pursuing the goal of becoming more assertive than
a woman from a different culture. Likewise, an entering group member who has been bul-
lied because of his identity as a trans woman is likely to be apprehensive about what shape
her interactions with a new group of individuals will take. With this knowledge, the thera-
pist can help the members to take microsteps en route to their group goals.
In contemplating members’ goals, the therapist might usefully distinguish between the
ultimate goals of treatment and intermediate goals. The therapist in the previous exam-
ple who identifies microsteps is recognizing the intermediate steps between the member’s
psychological status upon entering the group and the desired change upon departure and
posttreatment. However, sometimes the intermediate steps are achieved not merely by the
individual but by the group as a whole. Earlier, I described the stages of group development.
Each stage requires the accomplishment of a goal, the resolution of a conflict, or the accom-
plishment of a task for the group to progress to the subsequent stage of development. From
this perspective, the completion of each stage is an intermediate goal.

THE THERAPEUTIC RELATIONSHIP AND THE STANCE OF THE THERAPIST

In addressing the role of the therapist, the focus in this section is on the common qualities of
effective group psychotherapists regardless of their theoretical orientation, the implications
of the leadership structure, and the role of countertransference in the therapist’s work.
 Group Psychotherapies 383

Essential Qualities
Lieberman, Yalom, and Miles (1973) carried out a large-scale research study that remains
one of the primary investigations of group leadership in groups devoted to personal explora-
tion. So influential was this study that it was featured in the recently promulgated practice
guidelines of the American Group Psychotherapy Association (Bernard et al., 2008). Lieber-
man et al.’s (1973) study was extraordinary in the range of groups studied, process variables
tracked, and outcome variables measured. Individuals participated in one of 18 encounter
groups, with group membership being part of matriculation in a “Race and Prejudice”
course. Experienced clinicians observed the groups as they took place, and a factor analysis
of the observations yielded four leadership functions: executive, caring, meaning attribu-
tion, and emotional stimulation. The investigators linked these functions to outcome, yield-
ing information that is relevant across theoretical models.

•• The executive function comprehends those structural activities that enable the group
to run. A partial list of executive activities includes recruiting members, goal setting, direct-
ing members’ actions, and enforcing rules. The investigators found that a moderate level
of executive function is optimal. A group with a low level of executive function lacks clear
direction. A high level can induce passivity and deprive members of the necessary leeway to
show their typical social behaviors. Even models that require the therapist to take a highly
directive role, such as cognitive-behavioral therapy and psychodrama, to be optimally effec-
tive, must accord members the freedom for members to reveal their social selves.
•• The caring function entails the leader’s demonstration of affection toward and pro-
tection of the group member. Lieberman et al. (1973) noted, “Stylistically, such leaders
express considerable warmth, acceptance, genuineness, and a real concern for other human
beings in the group. The style is characterized by the establishment of specific, definable,
personal relationships to particular group members who [sic] the leader works with in a
caring manner” (p. 238). These investigators found leader caring directly associated with
favorable outcomes.
•• Meaning attribution is the provision of structures that enable members to make
sense of their experiences. Many of the theoretical models make a contribution in offering
the therapist a vocabulary and awareness of a set of relationships by which members can
organize their reactions to group events. The relationship between meaning attribution and
outcome is positive and direct: the more, the better. In a study by Lieberman and Golant
(2002), professional leadership of support groups composed of cancer patients resulted in
lower depression, fewer physical problems, more favorable well-being, and better function-
ing. Management–executive behaviors also contributed to positive outcomes.
•• Emotional stimulation is an activity of the therapist that enhances members’ engage-
ment in the group and is often accompanied by emotional expression. For example, when
the therapist calls attention to the group process, the function of emotional stimulation is
being served. The therapist’s self-disclosure can be highly provocative and stimulating to
the group. The relationship between emotional stimulation and outcome is curvilinear. A
moderate level is optimal and far preferable to high and low levels of emotional stimulation.
At low levels, group members are insufficiently activated, and at high levels, they are insuf-
ficiently secure. An example of a low level of emotional stimulation is a circumstance in
which the therapist avoids calling attention to group process; such a circumstance reduces
384 SYSTEMS-ORIENTED APPROACHES

the group to little more than an indifferent conversation about issues, much like members
would have in their lives outside the group. An example of a high level is the situation in
which the therapist engages in risky self-disclosure—for example, talking about his or her
own unresolved problems. Disclosure revealing the therapist’s active psychopathology is
associated with poorer outcome and less activity on the part of the group members (Dies,
1977).

The popularity of Lieberman et al.’s (1973) four-dimension system exceeds its empirical
support (Kivlighan, 2008). In one of the few empirical tests of this system, Tinsley, Roth,
and Lease (1989) failed to replicate the four-dimensional structure, but they identified eight
dimensions that were consistent with their data. Kivlighan (2008) pointed out that in other
domains of group study (e.g., organizational psychology), much more progress has been
made in isolating those leadership dimensions that bear on outcome and developing mea-
sures to render the dimensions operational. He noted that group psychotherapists might
take advantage of work in other areas of group scholarship to advance understanding of the
effective leadership of psychotherapy groups.
Additionally, research is needed to determine the optimal target of the leader’s interven-
tions. Should interventions be targeted at the individual, dyadic, subgroup, or group-as-a-
whole level? Investigating a youth support group, Kivlighan and Tarrant (2001) found that
leader behavior influences group climate, which affects member outcome. Ogrodniczuk and
Piper (2003) demonstrated the importance of group atmosphere through their study of two
12-week psychotherapy groups, one supportive and the other interpretive, for participants
with at least moderate symptoms of grief and social role dysfunction. The investigators
found that the atmosphere dimension of group engagement significantly affected outcome
for both types of groups. Members’ perception of a high level of engagement among mem-
bers was associated with greater diminution of grief and other symptoms. When conflict
was perceived to be higher, however, a lower level of engagement was associated with more
favorable outcomes. This latter finding suggests that members benefit from feeling that if
they need to maintain some distance from the conflict in the session, they can. However, the
broader finding is that group psychotherapists must concern themselves with how members
experience the group’s climate.

The Significance of Countertransference

Countertransference has played a critical role in group psychotherapy, but how it is under-
stood has changed drastically over the years (Bernard, 2005). Freud contributed the notion
of countertransference as the influence of the therapist’s unresolved conflicts, which needed
to be recognized to prevent it from limiting the therapist’s understanding of the patient. The
contribution of object relations theory fostered awareness that because countertransference
has an interactive component, it provides a window into the dynamics of the group. By turn-
ing inward and reflecting on his or her reactions to the group, the group psychotherapist
can learn something about the group. In recent years, a postmodern perspective has allowed
an understanding of the co-constructed character of both transference and countertransfer-
ence. To elucidate the group psychotherapist’s reactions, it is necessary to examine not only
the members’ reactions to the therapist, but also the therapist’s reactions to the members
(Brabender & Fallon, 2009). Additionally, the therapist has a set of cultural identities, which
individually and intersectionally (or the unique space corresponding to the overlap between
two identities in a given person or subgroup; see Brabender & Mihura, 2016) affects how
 Group Psychotherapies 385

each member is experienced. With the therapist’s acknowledgment of responsibility for the
role that he or she plays in the experiences both participants have, each member receives a
validation that encourages the member to take reciprocal responsibility and to make him- or
herself vulnerable within the group.

Leadership Structure
Groups vary in terms of leadership structure—that is, whether a solo therapist or a co-
therapy team conducts the group. Advantages and disadvantages accrue to each approach
(Luke & Hackney, 2007). Solo leadership bypasses many of the complexities introduced by
cotherapy, such as the need to attend to the dynamics of the cotherapy relationship itself on
a personal and professional level and the management of compensation for each therapist.
Cotherapy provides opportunities for each therapist to receive feedback on group leader-
ship and enables greater continuity in the sessions (i.e., one therapist can be absent from
the group and the group can continue to meet). Sometimes cotherapy is needed to manage
the number of tasks that a particular model requires such as in social skills training groups
(Brabender & Fallon, 2019).

CURATIVE FACTORS OR MECHANISMS OF CHANGE

Among the theoretical approaches to group psychotherapy, both overlap and variability exist
with respect to understanding how change proceeds and how positive outcomes are effected
in the psychotherapy group. All the approaches use the interpersonal aspect of the group,
so those factors that have been identified by the interpersonal model largely pertain to the
others as well. Hence, in this section, the mechanisms of change are outlined, followed by a
description of the contributions of the other approaches. In the everyday practice of group
psychotherapy, group psychotherapists, even if they have a primary theoretical allegiance,
typically employ and integrate the change concepts of the other major approaches.

Interpersonal Approach
In 1955, Corsini and Rosenberg published what they considered to be a comprehensive
list of mechanisms whose operation was believed to have a curative effect. These inves-
tigators reviewed 300 group psychotherapy articles, extracting 10 factors highlighted by
different authors as being important to their group members’ progress: acceptance, altru-
ism, universalization, intellectualization, reality testing, transference, interaction, spectator
therapy, ventilation, and miscellaneous. Although some of the factors specified by Corsini
and Rosenberg have received little attention and others have been combined, their effort
was extremely important in that it catalyzed research on the factors that effect change. For
example, only 8 years later, Berzon, Pious, and Farson (1963) proposed an alternative but
similar system of nine factors based on their analysis of group members’ responses to the
question of what event in a given session was most critical or important to them.
Probably the most significant scheme to influence the work of both group psychothera-
pists and researchers was Yalom’s work, which rested heavily on prior efforts and advanced
those efforts. Yalom (1970) and collaborators conducted their own empirical research
and came up with a similar list, which appeared in the seminal volume The Theory and
Practice of Group Psychotherapy. The therapeutic factors included in Yalom’s most recent
386 SYSTEMS-ORIENTED APPROACHES

text (Yalom & Leszcz, 2005) are the following: universality, altruism, instillation of hope,
imparting information, corrective recapitulation of primary family experience, development
of socializing techniques, imitative behavior, cohesiveness, existential factors, catharsis,
interpersonal learning–input, interpersonal learning–output, and self-understanding.
Several points should be considered about the therapeutic factors, the first of which is
that none of these factors is inherently therapeutic, but all are potentially so, depending on
the context. Second, not all groups access all types of factors. Part of developing a design
for a group is identifying those factors that are expected to have the most significant role in
affecting outcomes. Third, therapeutic factors have different types of relationships to one
another and to outcome, with some factors, such as cohesion, creating the conditions for
other factors to more directly mediate outcome.
The linchpin of the interpersonal model is the process of interpersonal learning (Yalom
& Leszcz, 2005). Critical to interpersonal learning is the notion that members’ interpersonal
behaviors are stable, such that the behaviors members demonstrate within the group are
representative of those they exhibit in their relationships outside. However, the group situa-
tion differs from their engagements outside the group because, in the latter situations, mem-
bers rarely obtain information about how their interpersonal behaviors affect others. The
group psychotherapy situation provides exactly this opportunity but requires that members
be immersed in the here and now—in their immediate experience with one another—rather
than in the more remote events outside the group. When members share their reactions to one
another’s behaviors, it almost invariably stimulates affect. For example, Harry’s communica-
tion to Carlotta that her constant interrupting annoys him is likely to evoke feelings in her,
such as shame, anger, or indignation. If their engagement in this interaction progresses no
further, little benefit is to be had for either of them. Members’ achievement of understanding
of their affective responses and interpersonal behaviors is crucial. For example, rather than
berating herself for interrupting behavior, Carlotta could benefit from Harry’s feedback by
learning to recognize the features within a social context that elicit her interrupting behavior.
As a mechanism of change, then, interpersonal learning engages various systems of the
group member. For example, cognition plays an important role in at least two respects. The
individual gains information and, ultimately, he or she constructs a cognitive frame for the
information. Affect is also critical, both in terms of the member’s recognition of another’s
affect and the activation of his or her own. Affect arousal fosters a high level of interest in
the present situation, which enables continued engagement and processing until significant
learning has been achieved. The perceptual system is also involved, in that interpersonal
learning leads to a change in how people see others and themselves. For example, Carlotta
may interrupt Harry because she sees him as a threat, a perception that may be rooted in
early experiences. Through their mutual exchanges, she may come to see him differently,
which will in turn lessen her need to interrupt him. Sullivan (1940) would describe this
development as involving the correction of parataxic distortions, perceptions that may have
been accurate or useful at an earlier point in life but are no longer functional.

Psychodynamic Approaches
Within psychodynamic group psychotherapy are many specific approaches, and each pro-
vides its own descriptions of the mechanisms of change, which vary from one to another.
Yet the authors of a leading text on psychodynamic group psychotherapy, Rutan et al.
(2007), identified three processes that are germane to most forms of psychodynamic group
 Group Psychotherapies 387

psychotherapy: imitation (an emulation of another’s behavior), identification (taking in a

quality or attribution of another and making it part of the self), and internalization. This
discussion focuses on the third process, internalization, which leads to the deepest and
most far-reaching change and has the most significant ramifications for the member’s life
outside of group.
Internalization entails an alteration in basic psychological structures, functions, or
both. For example, the defense of projective identification involves a group member’s pro-
jection of some unwanted internal content, perhaps a feeling or an urge, onto an external
figure. A member might project anger, for instance, onto the therapist, and even succeed
in evoking anger in the therapist. However, the therapist will contain those feelings rather
than be stimulated to retaliate or to manifest some extreme negative reaction toward the
member. Over time, the group member’s emotional connection to the therapist allows him
or her to incorporate the therapist’s capacity for control to help with his or her own emotion
regulation. This in turn makes the anger less toxic, and the group member’s felt pressure to
project this feeling increasingly diminishes. In the group member’s life outside of group, a
lessened tendency toward projection reduces the negative emotionality that imbues his or
her interactions. Note that from a psychodynamic perspective, interactions in the group are
critical to instigating intrapsychic change. Yet the processes that effect change are them-
selves intrapsychic.
Earlier in this chapter, I described mentalization groups. In these groups, the therapist
promotes acquisition of the skill of mentalizing, which entails recognition that the self and
others have minds from which intentions arise. The group provides continuous opportu-
nities for members to practice mentalizing in the context of an attachment relationship
and the emergence of affect within that relationship. For example, Greta’s therapist might
encourage her to be curious about why Alonzo interrupted an intimate exchange she was
having with Gladys. Alonzo responded that he was trying to address his tendency to back
off when he saw others connecting, leading to his frequent isolation. In that moment, what
had seemed to Greta a mere act of rudeness was a multilayered behavior, enabling her to
recognize a mentalizing presence (a mind) behind the behavior. Seeing that her own prelimi-
nary interpretation differed from Alonzo’s, she could discern her own mind as well. This
example illustrates that, for some applications, skills acquisition is central to how individu-
als benefit from participation in a psychodynamic group.

Cognitive Approaches
Cognitive approaches emphasize the meditational effects of cognition on experience and
behavior. The effort in cognitive-behavioral therapy is not merely to alter cognitions or
even schemas exclusively but rather to cultivate in the group member the skills to modify
cognitions in a healthy direction (Brabender, 2002). Therefore, cognitive-behavioral group
psychotherapy constitutes training for members in learning to identify cognitions that are
dysfunctional and the biases that give rise to these cognitions. Members gain practice in
these skills by attending to others’ cognitions as well as their own during the sessions. They
also strengthen their skills through homework assignments that entail identifying dysfunc-
tional thoughts. Obstacles to completing the homework are fodder for the group and help
members to cope with stumbling blocks they are likely to encounter following termination.
Some thoughts might require validation or dismissal through behavioral experiments that
can be performed inside the group or for homework. Often, through such experiments,
388 SYSTEMS-ORIENTED APPROACHES

members acquire evidence that their dysfunctional notions about themselves, others, or the
world are either incorrect or too extreme.
Increasingly, cognitive-behavioral therapists have recognized the importance of mar-
shaling group process in supporting group members’ movement toward their therapeutic
goals. For example, cognitive-behavioral therapists capitalize on the therapeutic factor of
universality, assisting members in deriving benefit from recognizing the presence of shared
difficulties and striving to promote group cohesion in order to increase members’ motivation
to work in the group (Bieling, McCabe, & Antony, 2009; Wenzel & Liese, 2012). Cognitive-
behavioral therapists also use members’ interactions as a way of capturing dysfunctional
thoughts that can then be targeted in the treatment for modification:

In a partial hospital group, three members were bickering when the session began.
Another member urged them to refocus on the group. The therapist indicated that
whatever was bothering them might be useful to explore. Once each member reported
on his or her successes and challenges in completing the homework assignment, the
therapist said that the group might look at the difficulty that had arisen between the
three members in terms of the work the group had been doing. The members shared
with hesitation that two members were engrossed in conversation at the lunch table
when a third member, Alaina, sat down. The members who were already seated at the
table nodded at Alaina but continued with their conversation. Alaina felt hurt by their
failure to include her in their discussion. The group worked with Alaina to identify
her automatic thought stimulated by the others’ behavior. Eventually, she was able to
articulate the thought, “If they didn’t immediately greet me, it means they have no
interest in me.” This identification led the other two members to challenge her cogni-
tion. They indicated that had she waited, they would have finished their topic and
turned to her. Other members indicated that they did not share Alaina’s expectation
that others would drop their conversation simply because of the arrival of another per-
son. With the group’s help, Alaina identified alternative thoughts that actually fit the
social reality. Alaina’s exchanges with the other members and the therapist formed the
basis for Alaina’s homework assignment, which involved allowing situations to unfold
more fully before forming a judgment about others’ feelings toward her.

In this illustration, the mechanism of change was the identification of Alaina’s auto-
matic thought and its modification based on experiential data, as well as the identification
of alternative thoughts. A means of challenging her automatic thought was Alaina’s applica-
tion of feedback from the other group members.

Action-Oriented Approaches
The action-oriented approaches emphasize the transformative role that action can have in
fostering a change in relationships and internal experiences. Action-oriented approaches are
variable in terms of the mechanism of change identified. For example, in social skills train-
ing, members’ opportunities to role-play new, more effective behavior, particularly after
witnessing a model performing the desired behavior, leads to more effective relationships,
which in turn builds members’ self esteem. Conditioning principles account for members’
acquisition of more adaptive social behaviors. For example, if Harry consistently receives
the group’s approbation for standing an appropriate distance from the person to whom he is
speaking, gradually his distance monitoring will become a regular component of his social
behavior. On the other hand, if Tom’s tendency to laugh inappropriately as other members
 Group Psychotherapies 389

are speaking is ignored, while other behaviors are positively reinforced, gradually, the inap-
propriate behaviors will extinguish.
By way of contrast, psychodrama (Moreno, 1969) is an approach in which members
create role plays dramatizing challenging situations in their lives. Action serves a very dif-
ferent purpose for psychodrama than for social skills training. For the former, action in
therapy is necessary, because when a group member merely verbalizes the way one does in
the traditional psychotherapy group, he or she leads with the adult self, a self in which many
aspects of the person have been submerged in the process of becoming an adult. In contrast,
bodily activity within the session provides the participant with access to more child-like
parts of the person that enrich the self (Blatner, 2000). Calling these less mature elements to
the fore enables the client’s integration of not only accessible facets of the self but also those
that are ordinarily inaccessible, thereby liberating the full range of the client’s resources.

TREATMENT APPLICABILITY

Given the variety of group formats, an appropriate group structure exists for individuals
with a great range of personal characteristics and psychological problems. However, three
characteristics of the potential group member would suggest that group therapy, regardless
of format, is not likely to be useful and could even produce harm (Roback, 2000). The first
is degree of cognitive intactness. Individuals with severe neurological impairment, such as
Alzheimer’s disease, are not able to track the interactions among members sufficiently to
derive benefit from group psychotherapy. The second contraindication is an extreme level of
suspiciousness of others. Most group formats require that the individual develop in the early
stage of group psychotherapy some identification with, and attachment to, the other mem-
bers. A new member who sees the other group members as posing a great threat to personal
security will have difficulty constructively engaging with them. If the suspicion is reactive
rather than long-standing, the person may be able to adjust to the group. In the former
instance, an extended preparation for group psychotherapy may enhance the individual’s
receptivity to forging relationships with the other member. The third characteristic is an
inability to control aggressive impulses. The concern here is the safety of other members. In
some settings (e.g., forensic), special resources exist to ensure the safety of members despite
members’ control difficulties.
As Roback (2000) points out, the therapist must always be alert to qualities that may
lead a group member to assume deviant roles within the group. Such role assignments,
particularly on a prolonged basis, lead that individual to be cast as a scapegoat, a process
whereby members project their own negative feelings on to the person, then attack him or
her for possessing these psychological contents. Especially in vulnerable populations, this
process can lead to negative treatment outcomes.

UNIQUE ETHICAL AND LEGAL CONSIDERATIONS THAT CHARACTERIZE

THE PRACTICE OF GROUP PSYCHOTHERAPY

These issues generally pertain to the fact that this modality involves the simultaneous, inter-
active treatment of individuals who generally are strangers to one another before entering
the group.
390 SYSTEMS-ORIENTED APPROACHES

Confidentiality, Privilege, and Privacy

Confidentiality is a condition of successful treatment. A client in any modality will not have
the necessary trust to engage in treatment if he or she worries that material shared in ses-
sions will be shared with others. What distinguishes group therapy from individual therapy
is that the individual therapist can strictly control the flow of information. The individual
therapist can absolutely guarantee that material from the sessions will not be shared in any
circumstances except those required by law (e.g., suicidality on the part of the patient). In
the group situation, the therapist can offer no such assurance (Brabender, 2002, 2006). The
group members are free agents; the therapist can influence their behavior but cannot com-
pletely control it. This problem confers special responsibilities on the group psychotherapist.
The first is that the therapist must establish confidentiality as a rule and do all that he or
she can to elicit members’ compliance. Therapists can foster observance of confidentiality
by cultivating members’ understanding of the rationale for this rule during the preparation
phase. Group members can be helped to see that violations in confidentiality lead to other
negative consequences for members, such as loss of relationships or employment. Another
way is to provide regular reminders of this member obligation throughout the course of the
group, and still another is to establish consequences for violations in confidentiality, which
may include dismissal from the group, particularly if the violation is intentional. The follow-
ing vignette highlights the complexities that can arise in relation to confidentiality.

Dot, a 72-year-old woman, had been in a long-term outpatient therapy group for 6
months when it was discovered that her son had gone to school with Dirk, another
member of the group, who had entered in the past month. The therapist reminded all of
the members that they were bound by confidentiality not to share anything they learned
about another member of the group. Both Dot and Dirk pledged to abide by this group
rule. Several weeks later, Dot responded to Dirk’s ongoing discussion about a work-
related problem by saying, “When I told my son about it, he was astounded that you
didn’t get fired for speaking to your boss that way.” Dirk looked at the therapist and
said, “Isn’t that a violation of confidentiality?” The therapist indicated that it was. Dot
became extremely upset and said that she had never told her son which member had the
work-related problem. She said she thought it was only a violation if the member were
identified. The therapist asked the group members what they thought. Some members
indicated that they had construed the confidentiality rule to mean that absolutely noth-
ing could be shared, but others indicated that they were unsure. The therapist clarified
that any disclosure of what another member communicated in the group was a viola-
tion, with the exception that they could speak to the therapist about their own experi-
ences in the group.
Upon hearing that she had, indeed, violated confidentiality, Dot became tearful
and contrite, and indicated that she would never make the mistake again. She then gave
a heartfelt apology to Dirk. The therapist felt some unease, because she felt that she
had reviewed these points with Dot during the informed consent process. However, she
sensed a sincere resolve in Dot to abide by the rule. Hence the therapist took no further
action.
For 6 months, no further difficulty arose in relation to confidentiality. However,
one evening, Dot blandly shared her son’s opinion of another member’s situation,
revealing that she had talked about it. The member became visibly upset and asserted
that Dot had violated her confidentiality. Dot, speaking in a puzzled tone, provided an
almost verbatim response of what she had said previously. Again, the therapist provided
clarification and again, Dot insisted that now that she understood the rule, she would
honor it.
 Group Psychotherapies 391

This vignette is instructive in that it captures the fact that not all inappropriate dis-
closures outside the group are intentional. In Dot’s case, question exists as to whether she
is capable of maintaining confidentiality. The therapist is likely to be assisted in decision
making by considering the foundational ethical principles that should guide practice in the
human service professions: nonmaleficence (do no harm) and beneficence (do good), respect
for autonomy, and justice (Beauchamp & Childress, 2012). The usefulness of such principles
lies in the fact that rules and laws are never sufficiently specific to cover all situations. The
therapist needs additional resources to fortify decision making. In this instance, a conflict
exists between beneficence, the benefit Dot could obtain from participation in the group,
and respect for autonomy, the right members have to maintain control over their personal
information. Most Western societies regard respect for autonomy as having precedence
over beneficence. Therefore, the right of the group members to have their privacy protected
would supersede Dot’s right to receive group treatment. Of course, a decision in the direc-
tion of removing Dot from the group would need to be based on a fair and full determina-
tion that she was unable to maintain confidentiality. For example, the group psychotherapist
might want to have a cognitive evaluation performed on Dot. Were the therapist to decide
that Dot’s continuing participation in the therapy group was not tenable, the therapist’s
obligations would not be over. The therapist must attempt to harmonize ethical principles
in a manner that each principle is being honored to the fullest extent possible by a given
course of action even as a particular principle is given precedence. Even though Dot might
be unable to continue to participate in the group, her therapy needs remain. The therapist
adheres to beneficence by finding other therapeutic opportunities for Dot to work toward
treatment goals. Also, a cognitive evaluation could serve beneficence by enabling Dot and
her treating professionals to respond in constructive ways to any arising cognitive difficul-
ties. The therapist would also have an obligation to assist remaining group members with
any residual feelings arising from a decision to remove a member.
Yet another responsibility that falls on the therapist due to his or her inability to guar-
antee confidentiality is to make this fact clear in the informed consent. Members must
understand that while the therapist will do everything he or she can to ensure that members
do not discuss material shared by other members with individuals outside the group, the
therapist cannot strictly guarantee it (Lasky & Riva, 2006).
A related obligation concerns the legal concept of privilege, the guarantee that what is
said within a session will not be used in a court of law without the expressed permission of
the client (Slovenko, 1998). However, the court has generally interpreted privilege to mean
a communication made exclusively to the therapist. In the group psychotherapy situation,
a communication is made to a therapist and multiple nontherapists, thereby raising a ques-
tion as to whether the condition for privilege is fulfilled. Because the group therapist cannot
answer this question definitively, the burden is placed on that therapist to reveal the possible
lack of privilege during the informed consent process (Lasky & Riva, 2006). Members also
may be told, however, that the therapist is willing to take steps to have privilege granted
by the court to the client’s communications during the session. The outcome of such steps
depends on multiple factors, such as the jurisdiction in which the material in question is
being considered and the value of the information to the case.
With particular types of groups, special issues present themselves with respect to con-
fidentiality and the individual’s right to the privacy of his or her information. For exam-
ple, groups for children and adolescents often take place in school settings. In attempting
to recruit participants for theme-based groups (e.g., coping with parents’ divorce), school
392 SYSTEMS-ORIENTED APPROACHES

counselors must recruit participants and conduct the group in such a way that group mem-
bers and their families are not identified to the broader community as having a psychologi-
cal problem (Knauss, 2007).

Multiple Relationships
As noted previously, the benefits of group psychotherapy may be enhanced through the
concomitant introduction of one or more other modalities. However, combining modalities
requires the group psychotherapist to negotiate certain ethical challenges, one of which con-
cerns the sharing of information the member discloses in a particular modality. If the thera-
pist is the same for group and individual psychotherapies, the question is whether the thera-
pist should ever disclose information obtained in individual therapy in the group. Group
psychotherapists have taken different stances on this issue. Some group psychotherapists
argue that the therapist may need to disclose material from individual therapy to preclude
the group member’s use of the individual treatment as a resistance to group work. What is
critical, whatever policy the therapist establishes, is that it be made explicit in the informed
consent process (Brabender & Fallon, 2009), because in this way, the client is free to enter
the group or not, based on knowledge of this feature. Likewise, the client must agree to the
intended plan for communication that occurs between the group psychotherapist and other
professionals, an agreement that may be obtained at the beginning of group participation.
In the area of multiple relationships, another problem is the possible presence of coer-
cion. For example, when the individual therapist makes a recommendation for the client to
join his or her psychotherapy group, the client may feel more compelled to do so than if he or
she were referred to another practitioner’s group. If the therapist practices in both modali-
ties, the client may perceive him- or herself as highly dependent on the therapist, and this
sense could influence the client’s decision making about one of the modalities (Brabender &
Fallon, 2009). For example, the client may wish to terminate group psychotherapy but fear
the loss of the therapist in individual therapy. The therapist must be ever-alert to ensure that
the multiple relationships do not place inappropriate limits on the client’s autonomy.
The relationships between and among members outside of the group also must be
addressed in the informed consent. Outpatient group therapists differ from one another
on whether members are permitted to interact outside the sessions. Whereas some thera-
pists feel that extragroup interactions can easily dilute the group, providing a valve for the
release of useful tension, others feel that such contact could provide members with addi-
tional opportunities to practice skills acquired in the group (Brabender, 2002). However, in
groups that take place in a broader treatment context, such as an inpatient group or residen-
tial treatment center, members necessarily interact with one another outside of group. Even
in such groups the therapist could establish rules for what members can and cannot discuss
outside of the group. Whatever decisions a therapist makes about extragroup contact, it is
important that they be carefully crafted and clearly communicated to members.

Qualifications of the Group Psychotherapist

Another ethical issue concerns the group psychotherapist’s achievement of competence in
the types of psychotherapy groups he or she runs. All practitioners have an ethical responsi-
bility to acquire the knowledge bases and skills for their domain of practice. Group psycho-
therapy is a modality that, historically, has received relatively little attention during graduate
 Group Psychotherapies 393

training in the mental health professions (Brabender et al., 2004). For example, Weinstein
and Rossini (1998) found that those PhD programs that offer group psychotherapy training
are in the minority, and although most PsyD programs offer a group psychotherapy course,
generally these offerings are elective. Moreover, based on their survey research, Marcus
and King (2003) found that although group psychotherapy experiences are common dur-
ing predoctoral psychology internship, they are also narrow in terms of the types of groups
interns conduct, the time frame of the groups, and the theoretical orientation used. More-
over, they found that doctoral programs do not sufficiently prepare interns for conducting
psychotherapy groups on internship. Brown (2010) points to the need across disciplines for
programs to develop training strategies that are rooted in evidence on what is effective in
promoting acquisition of an agreed-upon set of competencies.
This training deficit places greater responsibility in crafting an individual training pro-
gram on the individual who wishes to become a competent group psychotherapist than on
individuals pursuing other modalities (Brabender, 2010). A useful strategy for the individual
who seeks to complete his or her training is to affiliate with a national organization associ-
ated with the advancement of group psychotherapy, such as the American Group Psycho-
therapy Association or the Association for Specialists in Group Work. These organizations
offer an array of educational resources that enable the trainee to remedy gaps in his or her
training.

RESEARCH SUPPORT AND EVIDENCE-BASED PRACTICE

Evidence of the efficacy of group psychotherapy with a range of populations and problems
is overwhelming. Burlingame, MacKenzie, and Strauss (2004) undertook a review of 14
meta-analyses and 107 individual studies involving the use of a range of treatment models.
In 50 of the studies, group psychotherapy was compared to individual therapy. They found
that the effectiveness of group and individual therapy did not differ. Overall, group ther-
apy produced a reliably favorable effect, regardless of whether it was used as a primary or
adjunctive intervention. More recently, Burlingame and colleagues (2016) examined studies
that directly compared group and individual psychotherapies. Overall, they found, across
diagnoses, no differences in acceptance of treatment, dropout, improvement, and remission.
Beyond knowing that group psychotherapy is effective, we need to know with whom it
is effective. Burlingame, Fuhriman, and Mosier (2003), based on their review of 111 stud-
ies, found that the average recipient of group psychotherapy exhibits at termination a more
favorable psychological profile than 72% of untreated controls. Among the dimensions
accounting for variability in outcome, three have been identified: diagnosis, group com-
position, and setting. They found that group members with depression or eating disorders
exhibited greater positive change than members with other diagnoses, such as anxiety dis-
orders, stress reactions, and medical conditions. Members in diagnostically homogeneous
groups had more favorable outcomes than members in heterogeneous groups, and inpatient
group members showed more favorable changes than those in outpatient groups. However,
as Kivlighan (2008) pointed out, this is merely one type of homogeneity, and others (e.g.,
interpersonal style) need exploration. The meta-analysis by Kosters, Burlingame, and Nich-
tigall (2006) also demonstrated the usefulness of inpatient group psychotherapy.
Burlingame et al. (2004) pointed out that prior empirical efforts suffer from many limi-
tations, two of which are especially significant. First, researchers should be careful to assess
394 SYSTEMS-ORIENTED APPROACHES

durability of change by at least having follow-up assessments at the 6-month and 1-year
points. Additionally, they should study retention of group members given that retention
rates are highly variable. The generally positive empirical effects of group treatment can be
lost if a group is subject to the disorganizing effect of high membership loss, particularly is
members’ participation is less than the anticipated length of their tenures. Hence, identify-
ing those factors that mediate retention rates would be essential to get a full picture of the
effectiveness of group psychotherapy.
Most studies have focused on short-term groups; more information is needed on the
effectiveness of long-term group psychotherapy. Lorentzen’s (2005) study suggests that long-
term treatment may benefit a different population than does short-term treatment. In his
study, the factors that are typically predictive of outcome, such as the presence of a person-
ality disorder, negative expectations, and intensity of symptoms, had no predictive power
on outcome following participation in a group in which members remained an average of
32.5 months. Instead, age was a predictive factor, with older members faring more poorly.
Overall, 86% of members demonstrated recovery or significant improvement 1 year after
treatment (Lorentzen, Bogwald, & Hoglend, 2002).

CASE ILLUSTRATION

The group featured in this vignette was a private outpatient group. In all cases, the individ-
ual therapists referred the members for group treatment. Members had proceeded through
multiple interviews with the group psychotherapist, first to ensure their suitability for the
group, then to prepare them for group participation. By the time members entered the group,
they had clearly identified their personal goals and recognized the group processes they
could use to pursue them.
The group comprised eight group members. For the reader’s tracking ease, only six of
them are described. The group had been meeting for 9 months and had lost one member
during the first few weeks of the group’s life. The therapist’s approach combines elements of
interpersonal and psychodynamic theory.

Members
•• Marion—A white woman in her early 60s and a successful business woman whose
children had children and were very busy. She struggled with a sense of emptiness and worry
about whether her children would resent her efforts to secure their time and attention.
•• Alberto—A Latino man in his early 50s whose parents had emigrated from Nicara-
gua to the United States when he was a child. He was a contractor who frequently defaulted
on his work responsibilities because of symptoms associated with bipolar disorder.
•• Aurora—A black, bisexual woman in her mid-30s whose distress was connected to
her failure to achieve a committed, long-term relationship. Aurora had a waning modeling
career. She felt self-recrimination for having valued career over relationships. Her bisexual-
ity had been a focus several months earlier but more recently, she and the group focused on
other issues.
•• Russell—A 32-year-old white man who entered the group after the dissolution of a
2-year relationship that he had initiated but later regretted.
•• Genevieve—A 40-year-old white woman who had recently left her husband due to
 Group Psychotherapies 395

discovery of his 3-year affair. Feelings of inadequacy prevented her from engaging in activi-
ties to form new relationships.
•• Betty—A 34-year-old white woman with three young children, who experienced
severe depression following the birth of her third child. In connection with this depression,
she developed the conviction that she was no longer attractive to her husband, the expres-
sion of which evoked consternation in him.

Group Session
The session featured in this vignette is a composite of multiple sessions. This condensation
allows readers to see how change occurs in a group. Typically, however, progress would be
slower.
The members were all present when the therapist entered the room. Genevieve told Rus-
sell she had been thinking about him since the last session. She asked whether he had been
brooding over his lost relationship this past week, and he confessed that he had been rumi-
nating continuously. Aurora responded that, over the week, she had worried about Russell,
and Betty revealed that she attempted to think what she could say to help him. Marion
asked Russell if he had made any attempt to go out, and with a slight note of impatience, he
stated that he had not.
She firmly stated, “Of course, you will never feel better unless you try to help yourself.”
“OK, I’ll do that just as soon as this session is over,” he quipped. Betty laughed ner-
vously. Alberto, ignoring the sarcasm, expressed agreement with Marion and asked Russell
if he had thought about reestablishing ties with his parents. Russell answered in a more tem-
perate tone that engaging with his parents at the present time would work to his detriment.
Aurora agreed with Russell that in times of stress and loss, family members are the least
helpful individuals. The therapist wondered aloud if Russell doubted whether some other
members were particularly helpful members of the group.
Russell muttered, “Well, maybe some are more helpful than others.” Genevieve noted
that everyone tried to be helpful, but not everyone had the same experiences, so sometimes
relating to one another was difficult. Marion remarked that she was sure the younger mem-
bers saw her as being one of the unhelpful members. Alberto said he thought he was prob-
ably in her club. Genevieve said that it depended on the topic—sometimes a member could
understand and make helpful comments, and other times he or she could not. The therapist
noted that members were trying very hard to protect others’ feelings.
Marion insisted that she did not want anyone protecting her feelings. She had been in
the group 9 months, she noted, and felt that some members treated her like a piece of “Meis-
sen china,” and in other ways like someone who “just wasn’t part of the team.” She won-
dered whether she was too old to be in the group. Alberto said, “Then where do we draw
the line? Am I too old?” Genevieve said she felt very uncomfortable with that idea—that
someone should not be the right age to be in the group. The therapist wondered whether
a focus on this difference might obscure other differences that might be causing tension.
She noted that disharmony seemed to begin with the interaction between Marion and Rus-
sell, and suggested that their interaction, and others’ reactions to it, might warrant further
exploration.
Genevieve said she felt that Russell had spoken to Marion impatiently, almost rudely,
and had she been Marion, she would have felt hurt. Yet she also recognized immediately
that Russell would not appreciate Marion asking him whether he went out. When asked
396 SYSTEMS-ORIENTED APPROACHES

why, she said, “When I’m at my lowest ebb, it doesn’t help for people to tell me that I should
be doing something, no matter how right they may be. In fact, it’s because they’re right that
it’s so irritating, but, Russell, I must say, you get irritated very easily.”
Aurora said, “But I thought Russell wouldn’t have gotten irritated so quickly had Mar-
ion just waited a little before she said what she said. In fact, I was getting ready to say
something similar, but I was biding my time and choosing my words.” A member asked
her to elaborate and she responded, “I had just asked him how he was doing, and he hardly
finished before Marion started pressuring him. It was just too early to do that.”
Russell responded, “I don’t know—I just feel that if she had said what she did a few
minutes later, I would have responded exactly the same way.”
Alberto added, “Because she’s a mom. She’s going to make those kinds of comments
and you’re going to have the reaction you did.”
Russell agreed, “You know, now that you mention it, I think that’s why I get so annoyed.
[to Marion] You do remind me of my mother, because she needs to fix things. If I tell her
something in my life that’s bothering me, she can’t just let me complain. She has to come up
with something I could do to take it away, and I know why she does it—because she can’t
stand to see me unhappy. But I would feel better if she would just let me feel unhappy.”
Marion remarked, “I probably do that with my kids. I can’t stand it when they’re miser-
able. I want something to take it away.”
Aurora commented, “But they need you just to listen. I bet that’s what they want from
you. Anyway, that’s what we want.”
The therapist asked Marion what feelings members’ comments evoked from her. Mar-
ion responded, “It makes things easier for me. If I could just accept the fact that everyone I
care about is going to have troubles, I would feel freer, although I suspect I still might annoy
Russell. Honestly, I’d like to know why I irritate him so much.”
“Why do you say that you irritate him so much?” asked Genevieve.
“Well, I think I’ve been the way I have with other people in the group and they don’t
bite my head off like he does,” Marion explained.
Alberto noted, “She has a point, man.”
“I won’t deny it, but I can’t put my finger on it, either,” Russell responded.
Aurora said, “Well, I can’t say for sure what it is with you and Marion, but for me,
Marion does seem more like a parent. When she told you that you had to do something for
yourself, it just seemed like a reprimand.”
Russell said, “Yes, Marion, I thought you were judging me, and I realize I don’t know
if you were. I react to you as a kind of parent, and I don’t give you a chance.”
The therapist asked, “What do you mean by not giving Marion a chance?”
Russell answered, “I assume she is evaluating me, without asking her what she meant
or if she’s feeling negatively toward me.”
Alberto turned to Marion and asked, “Were you evaluating him?”
She hesitatingly responded, “Well, I don’t think so—not this time. But I can’t say that I
never do that. I really judge everyone.”
Betty said, “Including in here, including everyone?”
Marion responded, “Yes, I suppose I do.”
[Long silence.]
Genevieve reflected, “I know what you mean—I find myself judging people, and I don’t
like that about myself but I do it anyway.”
Russell protested, “I don’t see you that way at all. I never hear a judgmental tone in your
voice.” Marion and Aurora agreed with him.
 Group Psychotherapies 397

Alberto laughed and commented, “It’s obvious: She was trying to lift Marion up. She
thought Marion might get in trouble for telling us that she judges. So she said that she does,
too. And because she’s nice, well, she knew we would be OK with Marion doing it if she
does it too.” Members were amused but acknowledged that this account might have some
accuracy.
With an expression of bemusement, Genevieve shook her head. The therapist said, “Is
that head shake a disagreement? Or something else?”
“It’s disagreement and something else,” Genevieve responded.
“Say, what?” Russell demanded.
“When Marion said she judges others, I did think the group was going to jump on her.
But here’s the thing: What I said is true. I see myself as a judgmental person. I have high
standards for others, and it’s easy to get in trouble with me. Only one thing: I’m really good
at covering it up [speaking softly, almost to herself]. I am so critical that I’ve had to hide it
to survive.”
“That is so hard to believe. You seem so accepting of everyone,” said Aurora.
Russell said, “Yeah, if you think about it, no one could possibly be as accepting as
Genevieve seems.”
Betty remarked, “What you’re saying is making me very shaky. It bothers me to think
I know someone only to find out another side is lurking around.”
Aurora reasoned, “I know that everyone has multiple sides, so I’m not surprised to find
a new one. But somehow, with Genevieve, I find it really disturbing. I guess I count on her to
be a safe harbor. If all the group is against me, she will be for me, kind of protect me. Now
I’m worried that it’s all been fake, and that makes me feel very alone and exposed.”
Genevieve exclaimed, “Why would you think I am fake?”
Aurora responded, “If you’ve been having negative thoughts and expressing other
thoughts—positive ones, then, that is pretty fake.”
Russell said, “I don’t think that means what Genevieve says is disingenuous.”
Aurora injected, “Can you say that in English?” (The group members laugh.)
Russell answered, “OK—sorry, I don’t feel that Genevieve is insincere and, obviously
you can talk for yourself, Genevieve, but I think it’s not that what you say is insincere but
you hold back on reactions you have that are critical.”
Genevieve responded, “That’s exactly right. [to Aurora] It upsets me to think that you
would think that of me.”
Aurora said, “I don’t know if I do really think that. I’m confused.”
Betty added, “Me, too. When I think about it, I know that Genevieve is not a liar. And
I have to acknowledge that I have had thoughts I haven’t shared.”
The therapist said, “Perhaps others can identify with holding back.”
Russell responded, “Are you kidding? I don’t know if I hold back per se, but I con-
stantly water down my comments. For example, if I think something a member does in
here is revolting, I might say that it is disturbing, annoying, irritating, or something mild
like that.”
Marion lamented, “I try to be diplomatic and try not to give advice because my children
hate it, but you see how I fail.”
The therapist commented, “Different people have different ways of holding back. But
then the question becomes: What are the fears that lead you to present only the positive or
to keep certain reactions to yourself?
Alberto said, “I just don’t want to stick out too much. That’s how you get in trouble.”
Genevieve added, “Well, I worry always about hurting other people, so I do that in
398 SYSTEMS-ORIENTED APPROACHES

here. I worry about hurting Marion and Betty and Russell and, really, everyone. In fact,
even with all of my inhibiting myself, I still leave here and feel guilt about different things I
said, and better ways I might have said them.”
“Have you said anything in the current session that might have caused you to worry?”
the therapist asked.
“Yes!” Genevieve responded. “I told Russell that he was acting rudely toward Marion.”
“But it was true,” noted Betty.
“Even so, I would have worried later, because I suspect it would bother Russell.”
Russell commented, “Yes, you’re right, But I also felt relieved when you said it. Being
called out on the carpet that way helps me to shift gears, so I can respond in a more con-
structive way. I’m telling you, I’m better if other people check me.”
The session continued, with some members sharing their fears of what would occur if
they were more candid with one another and other members identifying those fears, or as
Russell did, offering their appraisal of the extent to which the fears were warranted. Typi-
cally, this process leads members to realize that while their fears are not altogether unwar-
ranted, they are exaggerated, and their dominion hinders members from accomplishing
their therapeutic goals.

Comment
In this vignette, we see a relatively mature group in operation. One manifestation of matu-
rity is that Aurora leaves the group thinking about Russell, and Genevieve wonders how he
is faring during the week. Members’ maintaining an intrapsychic connection to one another
outside of the session is a manifestation of a cohesive group. In addition, the group members
demonstrate awareness of how group psychotherapy works. They exhibit some appreciation
of the process of feedback but do not yet show a facility in identifying how to use feedback
to reduce interpersonal tensions.
Aware that the group had stepped away from the session’s hot points, the therapist
performed the function of translating members’ discussion of external figures into here-
and-now terms. Genevieve exerted a leadership of another sort in reminding members of
their good intentions toward one another. It is more than a Band-Aid: It bolsters members’
efforts to be honest with one another. However, members avoid dealing with one another
in their particularity by taking refuge in a resource that is always available to groups—
stereotypic subgrouping (Agazarian, 1997), which occurs when members see one another
in terms of demographic categories, and unite and divide based on demographic variables.
The therapist’s gentle challenge of the stereotypic subgrouping paves the way for members
to see one another as individuals and to engage in observation and reflection—observation
of others’ behaviors and reflection on how those behaviors affects oneself. Members’ effort
to understand their experiences led them to foster Marion’s awareness of her discomfort
and difficulty in sitting with others’ affective reactions. Behaviorally, Marion learned that
her uneasiness with others’ feelings leads her to interrupt their expression.
Yet, in this example, both Marion and Russell made a contribution to the disconnec-
tion between them. Had Marion not taken the initiative to explore further Russell’s reac-
tions to her, it would have been important for the therapist to encourage this investigation.
In Russell, we see a member who is willing to take responsibility for his behavior, so all that
was required of the therapist was to help him to be more explicit about his self-observations,
so that they would be more useful to him. Had he been unable to take this responsibility,
 Group Psychotherapies 399

the therapist might have invited other members to reflect on whether Marion had actually
expressed judgment of Russell.
Marion has an ability to be quite forthright in her appraisal of herself and others, a
quality that is helpful to the progress of the group, but one that also leads her to earn the
disapprobation of the other group members. In this instance, Marion is candid about the
fact that she judges other members. During this period in the life of the group, members tend
to deny negative affects and judgments except when some provocation overrides their efforts
at control. Although Marion is functioning in a leadership role, Genevieve’s modulation of
negative reactions performs another. Her admission is threatening to the group: The person
who functions as a protector is someone, they learn, who could also challenge rather than
bolster self-esteem. Yet this shift in Genevieve provides a potent stimulus for members to
begin to integrate all aspects of their perceptions of one another—positive and negative. It
frees them up to share their reactions to others more openly—a step that is critical for each
member to obtain the highly specific, individual feedback he or she requires to make sub-
stantive interpersonal change. Her admission is also threatening to herself, and the therapist
works to help her pinpoint this threat, using her immediate group experience. All members
appear to identify with Genevieve’s self-exploration.
Although we cannot follow the trajectory of all members over the course of treatment,
we can see the work Genevieve has cut out for her. Essentially, the therapeutic goal would be
to diversify her repertoire of ways of relating to others, and to expand her range of aware-
ness of her full psychic contents and to accept all of them. The therapist will assist Genevieve
to reach this goal based on the group’s stage of development. Stage 1 will require very little
intervention on the part of the therapist. Genevieve’s self-esteem will be bolstered, because
members will show appreciation of the aid she provides them in relating to one another.
The therapist will merely support her in engaging in this activity. Stage 2 will be much more
challenging. Genevieve’s discomfort with negative affect will require that the therapist assist
her in exploring her fears of expressing negative feelings toward the therapist. In part, the
therapist encouraging Genevieve and others who share this reticence to form a subgroup
will make this task easier for her. The safety of a subgroup will bolster her confidence in
making the difficult investigation of her feelings toward authority. In Stage 3, Genevieve is
likely to be a leader of the movement toward the eradication of group boundaries, and the
therapist plays an important role in helping her and others to recognize the consequences
of the loss of those boundaries. In Stage 4, in which the vignette takes place, the therapist
supports members in giving Genevieve the crucial feedback she needs to modify her inter-
personal style. For example, Genevieve learns in this session how vital it is to members that
she remain within a particular role. In Stage 5, the greatest challenge for Genevieve is to
acknowledge any disappointment in the group or particular members. The therapist’s assis-
tance in helping her to achieve an integrated experience of loss—one that takes into account
the positive and negative aspects—will be crucial.
A final note concerns Alberto’s presence in the group. Upon reflecting, the therapist
might note that Alberto’s contributions consistently were of a sort to join with other mem-
bers. His worry about “sticking out” was not pursued by anyone in the group. In thinking
about Alberto’s therapeutic needs, the therapist should be cognizant of his identity statuses.
Alberto is a second-generation Hispanic man. To what extent might his group behavior be
predicated on a need to assimilate with the other members of the group? If such an assimi-
lation pressure drives his interactions, to what extent does it exclude other needs and ways
of relating to others? Although keeping in mind various members’ multifaceted identities
400 SYSTEMS-ORIENTED APPROACHES

is a formidable task, it also provides valuable insights into the roles members embrace and
the forces that lead them to limit themselves. Conversely, group members lack of pursuit of
Alberto’s anxiety about sticking out might in itself constitute a communication to him that
he should stay in his place. Attention to this possible dynamic also would be important for
members’ increased awareness of their own racial biases (Schmidt, 2018).

SUGGESTIONS FOR FURTHER STUDY

Recommended Reading
Barlow, S. H. (2007). Evidence bases for group practice. In R. K. Conyne (Ed.), The Oxford hand-
book of group counseling (pp. 207–230). New York: Oxford University Press.—Barlow sum-
marizes the major findings of studies on the effectiveness of group psychotherapy, outlines the
major methodological issues in, and controversies over, such research, and possible compromises
for resolving these controversies.
Bernard, H., Burlingame, G., Flores, P., Greene, L., Joyce, A., Kobos, J. C., . . . Feirman, D. (2008).
Clinical practice guidelines for group psychotherapy. International Journal of Group Psycho-
therapy, 58(4), 455–542.—This article offers a road map for conducting psychotherapy groups
with attention to all core elements of group treatment, such as selection and preparation of
members.
Brabender, V., & Fallon, A. (2019). Group psychotherapy in inpatient, partial hospital, and resi-
dential care settings. Washington, DC: American Psychological Association Books.—This text
offers six models for working with individuals in brief or short-term time frames, with groups
being conducted in a larger treatment context. Extended case examples are offered.
Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy. New York: Basic
Books.—Chapter 1 provides an extensive coverage of group therapeutic factors.

DVDs
Godby, D. C. (Producer). (2016). Demonstration of a mature psychotherapy group: A new member
joins; Jerome Gans, MD, as therapist [Video file]. Retrieved from www.gapdallas.com/new-
member.—This free-access video provides a demonstration of an exploratory group in which a
new member enters. A discussion of group members (psychiatric resident actors) and the thera-
pist (Dr. Gans) follows.
Yalom, I. (1990). Understanding group psychotherapy: Process and practice. Pacific Grove, CA:
Brooks/Cole.—Vol. I presents segments of sessions with outpatients. Vol. 2, focusing on inpa-
tient group psychotherapy, features an entire group session led by Yalom.

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 PART VI

OTHER INFLUENTIAL MODELS

OF THERAPEUTIC PRACTICE
 CHAP TER 12

Interpersonal Psychotherapy
and Brief Psychodynamic Therapies
Eugene W. Farber

A cross the theoretical and practice spectrum of brief psychotherapy frameworks, an atti-
tude prevails that making the most of time in the immediacy of each session yields the
potential for here-and-now change (Budman & Gurman, 1988; Hoyt, 2017; Levenson,
1995). This chapter highlights the contributions of interpersonal psychotherapy and brief
dynamic psychotherapy to the development of methods and strategies for time-efficient
intervention. These frameworks are major contributors within a rich and varied landscape
of brief psychotherapy approaches that, although spanning a wide range of conceptual and
practical perspectives, share commonalities that characterize the overarching brief psycho-
therapy genre. Five key components help to define brief psychotherapy (Bloom, 1992): swift
initiation of intervention, active psychotherapist stance, formulation of a psychotherapy
focus, delineation of specific and circumscribed goals, and establishment of limits on psy-
chotherapy duration. More broadly, all forms of brief psychotherapy are guided by an inten-
tional use of time limits. As Budman and Gurman (1988) observe, although the number of
sessions may vary across models, brief psychotherapy is perhaps most succinctly character-
ized as “therapy in which the time allotted to treatment is rationed” (pp. 5–6; emphasis in
original).

THE LANDSCAPE OF BRIEF PSYCHOTHERAPY

The Rationale for Brief Psychotherapy
Psychotherapy length historically was influenced heavily by psychoanalytic conceptions
of clinical symptoms as manifestations of multiply determined and complex psychological

407
408 OTHER INFLUENTIAL MODELS

conflicts requiring lengthy and intensive intervention to resolve. The proliferation of brief
psychotherapy in the latter decades of the 20th century was propelled by its relative effi-
ciency and cost-effectiveness, psychotherapy conceptualizations and frameworks that elu-
cidated shorter pathways to change, and the psychotherapy evidence base (Bloom, 1992).

Efficiency and Cost-Effectiveness

Imbalances between demand and availability of psychotherapy services, along with afford-
ability considerations and limitations in insurance rate reimbursement, make brief psycho-
therapy attractive and accessible. A recent study comparing cost-effectiveness of brief and
long-term psychotherapy in a cohort followed over a 5-year period showed that brief inter-
vention is more cost-effective than long-term psychotherapy, largely because of the signifi-
cantly lower direct costs for the psychotherapy itself (Maljanen et al., 2016). While many
study participants who completed brief psychotherapy required subsequent ancillary mental
health intervention that added to costs over time, overall costs remained below that of long-
term psychotherapy. Additional studies also have shown reductions in overall health care
costs among individuals who have received brief psychotherapy (Abbass, Bernier, Kisely,
Town, & Johansson, 2015; Abbass, Kisely, Rasic, Town, & Johansson, 2015).

Evolving Theories and Methods

Theoretical and clinical innovations have informed the development of brief interventions.
Cognitive-behavioral, humanistic–existential, narrative, and systemic frameworks, along
with evolutions in psychoanalytically informed psychotherapy highlighting adaptive and
relational functions, have yielded a plurality of concepts and methods that inform efforts to
facilitate rapid clinical change. Emphasizing psychological strengths and adaptive function-
ing, solution-focused approaches also have contributed to the development of brief psycho-
therapy. Rapid symptom resolution and growth promotion are key goals, while character-
ological change is deemphasized in these models.

Evidence Base
The rationale for brief psychotherapy is further compelled by the psychotherapy evidence
base. Randomized controlled trials and meta-analytic studies demonstrate the efficacy of
brief psychotherapy (e.g., Driessen et al., 2015; Maljanen et al., 2016; Town, Abbass, Stride,
& Bernier, 2017). Also, the psychotherapy utilization literature and research on psychother-
apy dose–response (i.e., the relationship between number of sessions and extent of progress)
have particular relevance for brief psychotherapy.

Psychotherapy Utilization
Nationally representative studies of U.S. psychotherapy utilization patterns indicate that
most psychotherapy is of short duration (Olfson & Pincus, 1994; Olfson & Marcus, 2010).
For example, findings based on the 2007 Medical Expenditure Panel Survey showed that
the mean number of visits for psychotherapy utilizers was 7.92, representing a significant
decline from a mean of 9.67 visits in 1998 (Olfson & Marcus, 2010). Of these utilizers,
38.4% received one to two psychotherapy visits, 41.5% received three to ten visits, 11.2%
 Interpersonal and Brief Psychodynamic Therapies 409

received eleven to twenty visits, and only 9% received more than twenty visits. A similar
utilization pattern was seen across a spectrum of outpatient clinical settings, with the aver-
age number of sessions received ranging from 3.3 to 9.5 sessions (Hansen, Lambert, &
Forman, 2002).
Discontinuation of psychotherapy prior to completion of the intervention course or
before clinical problems are resolved also is a common phenomenon. For example, a meta-
analysis of premature psychotherapy discontinuation in 125 psychotherapy studies showed
a mean discontinuation rate of nearly 47% (Wierzbicki & Pekarik, 1993). More recently,
a dropout rate of almost 20% was reported in a meta-analysis that included 669 studies
(Swift & Greenberg, 2012). These findings show that, whether intended or not, a signifi-
cant proportion of brief psychotherapy is “naturally occurring” (Stern, 1993, p. 169). They
also underscore the importance of exerting deliberative effort to maximize the potential for
change in each session, that is, brief psychotherapy by design rather than default (Bloom,
1992; Budman & Gurman, 1988).

Psychotherapy Dose–Response. Dose–response research has yielded insight into rela-

tionships between number of psychotherapy sessions (dose) and measurable clinical effects
(response), demonstrating a negatively accelerating curve, such that the percentage of patients
showing clinical improvement increases most rapidly in earlier sessions, with percentage of
improvement increasing more gradually in later sessions (Hansen & Lambert, 2003; How-
ard, Kopta, Krause, & Orlinsky, 1986). Higher session frequency (once a week vs. once
every 2 weeks) may accelerate rates of clinically significant change (Erekson, Lambert, &
Eggett, 2015). Dose–response findings estimate that roughly 13–18 sessions are needed
for 50% of patients to reach clinical recovery, although this varies by type of problem or
severity of diagnosis (Hansen et al., 2002). Psychotherapy also can be substantially under-
dosed, with one study showing that among patients receiving psychotherapy across a spec-
trum of outpatient clinical settings, the median number of psychotherapy sessions received
ranged from three to eight, the percentage showing clinical improvement ranged from 14.3
to 24.4%, and the percentage achieving clinical recovery ranged from 5.7 to 9.1% (Hansen
et al., 2002). Therefore, while a relatively small number of sessions can confer significant
clinical benefit, it is important to optimize psychotherapy amount and frequency to achieve
clinically meaningful change; if psychotherapy is too brief, its benefits may be attenuated.
More generally, research showing the underdosing of psychotherapy underscores the need
for social and public policy efforts to increase psychotherapy service access.

Varieties of Brief Psychotherapy

Numerous brief psychotherapies have been developed, representing a range of theoretical
frameworks and intervention models (for an overview, see Messer, Sanderson, & Gurman,
2013). Setting aside for a moment interpersonal and brief psychodynamic psychotherapies,
Table 12.1 provides a sampling of some of the most influential of these approaches. Each is
derived from one or more of the broad psychotherapy orientations or schools, as reflected
by clear differences represented across the models with respect to clinical emphasis, focus,
and intervention. Accordingly, each approach offers a unique point of view that adds to the
repertoire of possibilities for brief psychotherapy application.
Although distinct, these models are all time-efficient and share a similar practice
410 OTHER INFLUENTIAL MODELS

TABLE 12.1. Key Varieties of Brief Psychotherapy Frameworks

Approach
Brief strategic therapy (e.g.,
Nardone & Watzlawick, 2005)
Theoretical influences Focus and change mechanisms
Systemic Ascertaining and disrupting positive
feedback loops in which well-
intentioned efforts sustain rather than
address the problems they are meant to
resolve

Solution-focused brief therapy Brief family therapy; Highlighting strengths and defining
(e.g., Franklin, Trepper, systemic and/or reframing problems as solvable
Gingerich, & McCullum, 2012) in order to illuminate a solution-
oriented perspective

Cognitive-behavioral therapy Cognitive theory; Identifying and changing problem-

(e.g., McGinn & Sanderson, learning theory sustaining thought patterns and
2001) expanding adaptive behavioral skills
repertoires

Experiential brief therapy (e.g., Humanistic Facilitating emotion processing as a

Elliott, 2001) vehicle for heightened self-awareness,
self-understanding, and integrated
experience of self

I-D-E brief therapy (e.g., Integrative Illuminating and resolving clinical

Budman & Gurman, 1988) problems at the intersection of
interpersonal, developmental, and
existential (I-D-E) dimensions

architecture. Each specifies clinical suitability criteria and methods for evaluating them.
Each also organizes the intervention framework into phases, including (1) early-phase work
to establish the psychotherapy alliance, intervention focus, and expectations and goals; (2)
midphase intensive work on the central psychotherapy focus; and (3) end-phase work to
process psychotherapy termination, review accomplishments, anticipate future challenges,
and plan postintervention follow-up where clinically indicated (Hoyt, 2017).

A Note on Ethics in Brief Psychotherapy

Consistent with the general ethical principles of beneficence and nonmaleficence, as in all
psychotherapies, brief psychotherapists must ensure that practice promotes benefit and does
not pose harm to recipients of psychotherapy services. To the degree that brief psychother-
apy entails the rationing of psychotherapeutic time (e.g., Budman & Gurman, 1988), the
implementation of time limits in brief psychotherapy has clinical implications and ethical
ones as well. For example, the clinician must be thoughtful in managing time limits in order
to optimize potential benefit and mitigate against potential harm (e.g., underdosing). The
parameters and protocols of a given brief psychotherapy approach must be flexibly applied,
with individual patient needs and circumstances in mind.
In their framework for conducting brief psychodynamic therapy, Binder and Betan
(2013) describe a relational–contextual approach to the ethics of brief clinical intervention.
They suggest that modes of clinical engagement and use of relational power must be guided
by values and moral sensibilities that support the patient’s welfare and autonomy. Mindful
of the practicality that full self-awareness is more aspirational than realistically attainable,
 Interpersonal and Brief Psychodynamic Therapies 411

Binder and Betan underscore the importance of consultation as well as self-care activities
(including personal psychotherapy to promote self-awareness) as facilitators of sound, ethi-
cally informed brief psychotherapy practice.

OVERVIEW OF INTERPERSONAL AND BRIEF PSYCHODYNAMIC THERAPIES

Having rendered a synopsis of the rich diversity of brief psychotherapy models and the
rationale for brief intervention, in the remainder of the chapter I explore interpersonal psy-
chotherapy (IPT) and brief psychodynamic therapy (BPT) as brief psychotherapy exemplars.
Although distinct frameworks, the two brief psychotherapy models share broad similarities,
examples of which include the use of time limits and the adoption of a defined intervention
focus. Each advocates a collaborative relational stance, and both explore affective responses
along with relational experience, albeit with different emphases and aims (Markowitz, Svar-
tberg, & Swartz, 1998). Additionally, some of the theoretical constructs that inform IPT
(e.g., interpersonal theory, attachment theory) have similarly influenced some of the more
relational BPT variants.
However, IPT and BPT have separate lineages and overarching conceptual and techni-
cal differences that distinguish them as discrete, time-limited psychotherapy models (Blei-
berg & Markowitz, 2007; Markowitz et al., 1998). IPT was explicitly developed for use
in clinical research trials and is grounded in a uniform set of principles and techniques
(Markowitz et al., 1998). BPT is not a unitary approach; rather, it comprises a family of
psychotherapies that share a common anchoring in the psychoanalytic tradition. Differing
theoretical strands within psychoanalysis inform specific BPT variants, with corresponding
differences in clinical focus.
Contrasts between IPT and BPT also can be seen in their respective goals and clinical
emphases. Key IPT strategies include psychoeducation about linkages between interper-
sonal problem areas and clinical symptoms, active problem solving, evaluation of options,
and social skills enhancement. BPT intervention uses interpretive and experiential strategies
to promote self-awareness and insight regarding intrapsychic conflicts, patterns of psycho-
logical adaptation (i.e., defense mechanisms), relational processes, and connections between
current problems and formative developmental experience. Linkages between patient expe-
riences of the psychotherapy relationship (including transference patterns), current relation-
ships outside of the psychotherapy dyad, and key past relationships in the patient’s life also
are explored.
Both IPT and BPT have made important contributions to the brief psychotherapy genre.
Beginning with IPT, these are highlighted presently, including the historical lineage and
theoretical foundations of each approach, along with their respective methods and applica-
tions.

INTERPERSONAL PSYCHOTHERAPY
Historical Background
IPT was originally formulated in the 1970s by Klerman, Weissman, and colleagues as a
manualized psychotherapy intervention for use in clinical trials, particularly as a treat-
ment arm in studies testing pharmacotherapy for depression (Bleiberg & Markowitz, 2007;
Weissman, Markowitz, & Klerman, 2018). The inclusion of a standardized psychotherapy
412 OTHER INFLUENTIAL MODELS

approach in trials of psychopharmacological agents was aimed at replicating real-world

clinical conditions for depression treatment. Given its extensive use in research trials, IPT
has substantial empirical support (Weissman et al., 2018). More recently, IPT has enjoyed
increasingly widespread use in clinical settings.

Conceptual Foundations
IPT is not grounded by a theory of personality per se, though its social–interpersonal focus
is influenced by a combination of research on the overarching impact of the social environ-
ment on health and well-being (e.g., Holt-Lunstad, 2018), as well as the respective contribu-
tions of interpersonal and attachment theory. Specifically, IPT drew from the contextual
framework for understanding psychopathology articulated by Adolf Meyer, along with the
interpersonal theory developed by Harry Stack Sullivan (1953), who eschewed the strictly
intrapsychic emphases of classical psychoanalytic drive theory in favor of a theoretical posi-
tion that emphasized the centrality of the interpersonal field in shaping personality and
psychopathology. John Bowlby’s (1988) theory of social attachment also was influential in
the development of IPT, particularly its articulation of the potential for deleterious psycho-
logical consequences of threats to and/or disruptions of attachment bonds.
Conceptually, IPT follows a diathesis–stress model in which the onset of psychological
dysfunction is viewed as a phenotypic behavioral change associated with multidetermined
environmental conditions and genetically based susceptibilities to psychopathology (Weiss-
man et al., 2018). The primary environmental conditions of interest are social–interpersonal
events (e.g., loss, social role changes, life transitions). While not specifying a causal theory
of psychopathology, IPT focuses on interrelationships between clinical symptoms and inter-
personal events. Elucidating these linkages provides a plausible narrative framework within
which patients can understand and address the psychological challenges for which they seek
psychotherapy (Markowitz & Swartz, 2007; Weissman et al., 2018). The approach is firmly
grounded in the medical model of psychopathology; it therefore does not concern itself with
elaborating explicit characterizations of healthy or optimal psychological functioning.

Framework, Structure, and Process of IPT

As a time-limited intervention, IPT typically encompasses 12–16 weekly sessions that are
45–50 minutes in length. Intervention targets conscious and preconscious psychological
processes and addresses here-and-now interpersonal problems linked to psychological
symptoms. Consistent with a medical model, IPT frames diagnosed psychological problems
(e.g., major depression) as treatable illnesses, with patients correspondingly placed tempo-
rarily in a “sick role.” The aim is to mitigate attributions by patients of self-blame for their
psychological condition and simultaneously enlisting them to engage actively in a collab-
orative process of recovering the healthy role (Bleiberg & Markowitz, 2007; Weissman et
al., 2018). Change is brought about by addressing interpersonal problem areas. In what is
referred to as acute treatment, IPT comprises initial, intermediate, and termination phases.

Initial Phase
The initial phase of IPT lasts between one and three sessions, and focuses on clinical
assessment and diagnosis, including identification of interpersonal problem areas. The
 Interpersonal and Brief Psychodynamic Therapies 413

frame, expectations, and focus of psychotherapy are set, and the patient is assigned the
sick role. Assessment is made at the level of the individual, although it also focuses on the
social–interpersonal context in relation to individual-level psychological distress, particu-
larly events in the interpersonal field that are proximal to the onset of clinical symptoms.
Objectives of the assessment process are to elucidate the chief complaint; evaluate the
presence, duration, and severity of clinical symptoms; and obtain the patient’s psychiatric
history in order to assign a clinical diagnosis. An “interpersonal inventory” is conducted to
obtain a history of the patient’s interpersonal functioning and assess current social relation-
ships (e.g., levels of intimacy and relational satisfaction, degree of reciprocity or symmetry
in relational expectations, shifts in social role functioning; Markowitz & Swartz, 2007;
Weissman et al., 2018). This allows interpersonal problem areas across one or more of four
domains to be identified: grief, role dispute, role transition, and interpersonal deficits (see
Table 12.2).
Assessment findings are used to develop a case formulation that links clinical symp-
toms to interpersonal problem area domains. Where more than one interpersonal problem
area is identified, the formulation typically centers on only one or two of the most salient of

TABLE 12.2. Characteristics of IPT Interpersonal Problem Domains and Intervention Goals
Problem area Characteristics Intervention goals
Grief Complicated bereavement •• Activate a grieving process.
associated with a past or recent •• Cultivate new interests and
loss due to death. Includes relationships.
instances where grief is deferred/
not adequately processed or is
sufficiently prolonged/severe that
it impedes return to functional
capacity.

Interpersonal role Asymmetries or imbalances in role •• Explore the relationship and

disputes expectations representing points of
relational conflict.
pinpoint areas of dispute.
•• Consider options/pathways to
dispute resolution.
•• Adapt relational expectations
and/or address ineffective
communication strategies.

Role transitions Shifts in social roles associated
with changes in life circumstances.
May include a sense of loss
associated with changing
relationship status (e.g., ending a
romantic involvement) or specific
life events (e.g., employment
changes, illness, life cycle
vicissitudes).
•• Support grieving of loss of old role
and acceptance of role change.
•• Facilitate consideration of
potentials and opportunities
associated with the new role.
•• Promote self-esteem and efficacy
relative to the new role.

Interpersonal deficits Patterns of limited or impoverished •• Lessen social isolation.

social relationship resources, •• Promote opportunities for social
challenges in sustaining substantive connection.
interpersonal ties, ongoing social
isolation.
414 OTHER INFLUENTIAL MODELS

them to ensure parsimony and clarity of clinical focus (Bleiberg & Markowitz, 2007). The
psychotherapist works collaboratively with the patient to establish mutual agreement on the
interpersonal problem areas to work on, along with a willingness to address them.
By way of illustration, Carl is a 52-year-old man with new onset of depression after
receiving a cancer diagnosis. The psychotherapist seeks to understand the impact of this
life event on Carl’s relationships, including his current relational network and social sup-
port resources. Through this line of inquiry, Carl reveals a pressing concern that his cancer
treatment will compromise his capacity to perform in his work as a prominent attorney. He
also worries about burdening his family with having to take care of him, which is contrary
to his accustomed role as family guardian. Within an IPT perspective, this clinical finding
suggests that Carl’s depression is linked to a social role transition. To encapsulate the prob-
lem, suggest a plan of intervention, and invite collaboration, the psychotherapist shares the
following with Carl:

“Based on what you’ve told me your symptoms suggest you have a major depression,
which is a treatable illness that is not at all something you brought on or is your fault
in any way. Your depression seems to be related to the fact that while you’re undergo-
ing cancer treatment you won’t be able to put as much into your work or be there for
your family in ways that you’re used to and this is a big adjustment for you. I think if
we can focus on addressing this big role transition in your life it will help resolve your
depression. How does all of this sound? Does this seem like a worthwhile focus to you
or would you like to talk it over a little bit more?”

This illustration conveys how, based on the clinical assessment, the psychotherapist
concludes the initial psychotherapy phase by sharing diagnostic impressions and a formula-
tion that links the clinical diagnosis to an interpersonal problem area. The psychotherapist
also elicits the patient’s input and seeks agreement on the overarching focus of intervention.
Once this agreement is established, IPT moves into the next phase of the work.

Intermediate Phase
The bulk of the intensive work on the identified interpersonal problem areas and their links
to clinical symptoms occurs in the intermediate phase of IPT. Each session begins with the
psychotherapist asking the patient how things have been since their last appointment. The
psychotherapist listens, explores affective expressions, offers encouragement in response to
positive change, and provides psychoeducational input regarding symptoms and their links
to behavior as a way of helping the patient to gain perspective and/or disentangle from self-
blame (e.g., framing low motivation as a manifestation of depression rather than as a sign
of patient weakness). When a setback occurs, the psychotherapist offers empathy, helps to
clarify the patient’s wishes, and explores options for handling similar circumstances in the
future. Additionally, the psychotherapist facilitates a detailed examination of interpersonal
events and patient responses, while linking states of mind to interpersonal outcomes. At
the conclusion of each visit, the psychotherapist offers a recap and summary of what has
occurred in the session (Bleiberg & Markowitz, 2007; Weissman et al., 2018).
As depicted in Table 12.2, the specific goals in an IPT course vary depending on which
of the interpersonal problem areas are selected as the focus of the work. These goals inform
which psychotherapy strategies are used. For example, strategies enacted to address grief
 Interpersonal and Brief Psychodynamic Therapies 415

encourage the recounting of experiences with the deceased person as a means of supporting
emotional expression and productive mourning. For role disputes, a comprehensive inven-
tory is taken, focusing on the qualities of the relationship at hand, the dimensions of the
dispute and possible avenues for its resolution, and options for managing impasses. Where
resolution of an impasse may not be achievable, the patient is asked to systematically weigh
the pros and cons of accepting the relational status quo or consider the step of ending the
relationship, including identifying options and anticipating consequences associated with
each of these respective possibilities. Strategies to address role transition problems center on
facilitating emotional processing of the loss of the previous role, reflection on anticipated
possibilities and limitations associated with the new role, and mastery in enacting the new
role (e.g., skill sets, social support resources). Finally, strategies for addressing role defi-
cits include taking an inventory of the positive and negative qualities of the patient’s past
important relationships, encouraging pursuit of activities that increase social contact and
engagement, and cultivating social skills efficacy (Bleiberg & Markowitz, 2007; Markowitz
& Swartz, 2007; Weissman et al., 2018).
IPT explicitly assumes the importance of evidence-based common factors for psycho-
therapy change, such as psychotherapist warmth, genuineness, adoption of a nonjudgmental
stance, empathy, and creating a safe and confidential space within which the psychothera-
peutic dialogue can unfold (Weissman et al., 2018). Additionally, IPT employs a constella-
tion of techniques to facilitate achievement of its intervention goals (see Table 12.3). These
techniques are not unique to IPT per se and may be recognizable for their applications across
a range of psychotherapy approaches, including many that may be used in psychodynamic
psychotherapy. What is distinctive is their applications within IPT to advance its overarch-
ing goals of ameliorating clinical symptoms and the interpersonal problems linked to them.
For Carl, the intermediate phase of IPT focuses on helping him to navigate role tran-
sition challenges precipitated by his cancer diagnosis. Carl describes placing a premium
on “always being strong and in charge,” insisting that “there’s no room for cancer in this
scenario.” The psychotherapist empathizes with Carl, while also applying a combination of
nondirective and direct elicitation interventions to assist Carl in giving voice to apprehen-
sions that his cancer battle will “weaken” him and leave him in a “diminished” state. Carl
is encouraged to express these feelings and associated concerns that he might no longer be
able to perform in ways that he previously had expected of himself at work or in his family.
He notes feeling some emotional relief from talking about these issues but also expresses
feeling “lost” and unsure of the way forward. Tying these role transition themes to Carl’s
depression, the psychotherapist suggests that perhaps his depression-induced pessimism is
adversely affecting Carl’s ability to identify workable options and possibilities. Upon reflec-
tion on this clarifying point, Carl realizes that his cancer battle and role transition chal-
lenges offer an opportunity for him to utilize his highly valued strength and adaptability
in new ways. Energized by this shift in perspective, in subsequent sessions Carl engages in
a process of decision analysis that yields meaningful dialogues with his family members,
through which they communicate a wish for a mutually supportive relationship with him.
This discovery prompts Carl to ease up on his self-imposed expectations regarding his “fam-
ily guardian” role. As an additional step, Carl makes arrangements to establish a flexible
schedule at his law firm, providing the leeway needed to optimize his work contributions
within the constraints of his cancer treatment. The psychotherapist supports Carl in mak-
ing these role transitions, while also addressing his lingering apprehension and uncertainty
about embracing them. On balance, Carl reports improved mood and enhanced self-esteem.
416 OTHER INFLUENTIAL MODELS

TABLE 12.3. A Catalogue of Techniques to Advance IPT Goals

Technique Description Exemplars
Nondirective Eliciting spontaneous •• Employing open-ended queries
exploration expression of issues and •• Inviting elaboration on significant
concerns themes

Direct elicitation Structuring the psychotherapy •• Soliciting specific facts about the
dialogue to elicit specific clinical history
content, experience, or behavior •• Inquiring about interpersonal
communication sequences

Encouragement Facilitating opportunities •• Promoting awareness and acceptance of

of affect for emotional expression, painful feelings
comprehension, and regulation •• Cultivating affect modulation in
relationships
•• Eliciting expression of overmodulated
emotions

Clarification Amplifying awareness of •• Rephrasing statements to illuminate an

clinically relevant experiences important theme
and concerns •• Pointing out thematic contradictions
•• Linking unhelpful beliefs to symptoms
(e.g., depression)

Communication Identifying and working with •• Appraising perceptions of how

analysis ineffective communication communications are heard
patterns •• Identifying indirect/ambiguous
communication and encouraging direct
communication

Decision analysis Considering the range of •• Identifying goals for solving

problem-solving options and interpersonal problems
anticipated effects •• Sequencing options for achieving goals

Role play Enacting a simulation of •• Examining feelings and communication

a salient interpersonal style
circumstance •• Practicing new modes of interpersonal
interaction

As this case description shows, in the intermediate phase of IPT psychotherapy, tech-
niques are used to enhance psychological functioning relative to one or more of the interper-
sonal problem areas. In this example, the aim is to facilitate a systematic process of navigat-
ing the patient through a role transition in his family and professional workplace.

Termination Phase
Comprising roughly three to four sessions, termination is conceptualized as a type of role
transition in which accomplishments are highlighted and the potential for sadness as a nor-
mative part of ending psychotherapy is acknowledged. The psychotherapist recaps the steps
taken by the patient to achieve IPT goals, credits the patient for making positive changes,
and communicates confidence in the patient’s independent capacity to carry the changes
forward once psychotherapy ends. The patient also is invited to reflect on how perspectives
 Interpersonal and Brief Psychodynamic Therapies 417

and skills gleaned from IPT might be applied in future instances of psychological challenge.
When psychotherapy falls short of desired outcomes, next steps in the treatment process are
explored, including options such as maintenance IPT (reviewed below) or referral for inter-
vention using a different psychotherapy modality. The cause of unsatisfactory outcomes is
attributed to IPT and not to the patient so as to minimize the likelihood of patient self-blame
and/or discouragement regarding the prospects for change (Bleiberg & Markowitz, 2007;
Weissman et al., 2018).
Returning to Carl, in the termination phase, the psychotherapist highlights his signifi-
cantly improved mood and successful negotiation of his role transition with both family
members and coworkers as clear evidence of his capacity to advance his own growth and
anticipate future stressors. When Carl expresses sadness about ending, the psychotherapist
frames this as a natural part of saying good-bye, acknowledging that they indeed made a
good team, having shared a meaningful journey together on behalf of Carl’s emotional heal-
ing.

The Therapeutic Relationship and the Stance of the Therapist

The IPT psychotherapist engages actively, is an advocate, adopts an openly supportive
stance, and cultivates a collaborative alliance with the patient on behalf of the change pro-
cess (Markowitz et al., 1998; Weissman et al., 2018). The establishment of a positive patient
experience of the psychotherapy relationship and a collaborative working alliance begins
in the initial phase of intervention through the clinician’s efforts to develop mutual agree-
ment with the patient on understanding the problem and identifying psychotherapy goals.
The active stance of the psychotherapist guides the patient’s efforts to initiate behavior
change. Direct advice giving or suggestions about how to approach a given problem are only
sparingly used, as IPT emphasizes facilitating processes and activities that support patient
autonomy in finding workable solutions to the challenges brought to psychotherapy.
Exploring the patient’s behavior vis-à-vis the psychotherapy relationship, including
transference and countertransference phenomena, is not a focus of IPT. However, given
the importance of the psychotherapy alliance, the psychotherapist monitors the patient’s
experience of the relationship and encourages the patient to share any concerns or negative
responses to the process or the psychotherapist. This allows potential alliance breaches to
be identified and quickly managed. Interpersonal patterns enacted within the psychotherapy
relationship may occasionally be tapped as teachable moments that enhance patient under-
standing of and responses to interpersonal problem areas (e.g., role disputes, interpersonal
deficits) in outside relationships (Markowitz et al., 1998; Weissman et al., 2018). For exam-
ple, the psychotherapist may connect an instance in which a patient expresses frustration
about feeling unheard in the session to a role dispute in an outside relationship that centers
on this problem and explore solutions that can be enacted to enhance the patient’s sense of
feeling heard in that relationship.

Diversity Considerations
Although diversity factors were not explicitly considered in the development of IPT, its core
focus on the ubiquity of connections between interpersonal relationships and psychological
functioning has made it readily adaptable for use with persons from diverse backgrounds
and cultures. Adherents to IPT suggest that interpersonal bonds and the emotional impact
of imagined or actual threats to social connections are universally relevant. What is critical
418 OTHER INFLUENTIAL MODELS

is to understand the cultural influences on individual experiences, attitudes, expectancies,

and behavior as they pertain to interpersonal relationships and associated clinical problems.
When conducting IPT assessment, case formulation, goal setting, and intervention planning
with a given patient, cultural norms and customs for interpersonal expectancies and func-
tioning must be considered (Markowitz & Swartz, 2007; Weissman et al., 2018).
The extant evidence base suggests that IPT strategies and methods are responsive to
individuals from diverse backgrounds. Specifically, research trials have demonstrated both
the acceptability and clinical benefits of IPT for individuals of various racial and ethnic
backgrounds, persons from different income levels, and of different nationalities (Markow-
itz & Swartz, 2007). Additionally, IPT has been incorporated into mental health treatment
guidelines both nationally and internationally, including wide dissemination as part of the
World Health Organization’s mental health initiatives, reflecting the remarkable scope of
its reach across cultures globally as a clinical intervention modality (Weissman et al., 2018).

Adaptations of IPT
Several adaptations of IPT have been developed that warrant mention. One of these is an
empirically tested eight-session version called brief interpersonal psychotherapy (ITP-B),
which is designed for use in instances in which a longer psychotherapy course is not feasible
because of internally or externally driven resource constraints (Swartz, Grote, & Graham,
2014). Additionally, IPT has been adapted as a maintenance intervention (IPT-M) that per-
mits longer term intervention with lower frequency of sessions (e.g., monthly; Miller, Frank,
& Levenson, 2012). Where clinically indicated, IPT-M provides an intervention option for
patients who remain symptomatic or continue to experience unresolved interpersonal chal-
lenges after a course of acute IPT. IPT-M also can be helpful in reinforcing and/or consoli-
dating gains obtained in acute IPT, and in preventing or increasing the time span between
episodes of acute psychological dysfunction. Additionally, ITP adaptations for group and
couple therapy have been developed, as well as telephone and Internet IPT formats (Weiss-
man et al., 2018).

Suitability for IPT

While originally developed for the treatment of depression, IPT has been adapted for use
with a range of psychological problems and disorders (Weissman et al., 2018). Examples
include bipolar disorder, eating disorders, anxiety disorders, trauma-related disorders, and
personality disorders. The efficacy of IPT for primary psychotic disorders (e.g., schizophre-
nia or schizoaffective disorder) is unknown; therefore, the approach may not be appropri-
ate for patients presenting with these disorders. IPT has been adapted to target themes
and concerns that correspond to different developmental epochs (e.g., adolescence, older
adulthood). Additionally, it has been applied with medical populations, examples of which
include patients in primary care and persons living with HIV disease (Bleiberg & Markow-
itz, 2007; Weissman et al., 2018).

Conclusions
IPT is a pragmatic, time-limited intervention that links clinical problems to interpersonal
complications within a medical model framework. It has widespread applications and has
 Interpersonal and Brief Psychodynamic Therapies 419

enjoyed broad dissemination worldwide. Developed specifically as a psychotherapy inter-

vention framework for use in clinical research trials, IPT is well researched and anchored
by a vast empirical evidence base (Bleiberg & Markowitz, 2007; Weissman et al., 2018).
Having characterized the key tenets and methods of IPT, I now examine the principles and
interventions that typify the BPT family of psychotherapies.

BRIEF PSYCHODYNAMIC THERAPY

Historical Background
Dating to the 1890s, Freud’s earliest psychotherapeutic endeavors were time-limited and
centered on catharsis of repressed emotion associated with traumatic memories. His stance
was active, supportive, and psychoeducative, and the typical length of treatment was several
weeks to several months (Messer, 2001; Messer & Warren, 1995). The years-long proposi-
tion for which psychoanalysis is currently known was a later evolution that developed as
Freud elevated free association and cultivated transference as cornerstone methods for psy-
choanalytic work; as a result treatment became increasingly lengthy (Budman & Gurman,
1988; Messer & Warren, 1995).
In the 1920s, key psychoanalytic figures advocated modifications of traditional psycho-
analytic practice, including Ferenczi, who proposed that the analyst actively direct the focus
of the patient’s associations and catalyze affective experience in the analytic process. Rank
highlighted the value of attending to the patient’s current experience of the relationship and
proposed designating an endpoint for the analytic treatment course. In a mid-1920s col-
laborative work, Ferenczi and Rank endorsed an active analytic stance, the setting of time
limits, and a focal approach for psychoanalytic work (Levenson, 2017).
Following on these ideas, Alexander and French in the mid-1940s highlighted the
importance of conducting psychotherapy as briefly as is feasible, aided by the development
of a psychodynamic case formulation within the first few sessions to inform goal setting
and treatment planning (Messer, 2001). They articulated the provision of a “corrective emo-
tional experience” as a core change factor in psychoanalytic work. This entailed facilitation
of reexperiencing emotionally laden past conflicts via a relational psychotherapeutic stance
calculated to differ constructively from that of important early relationships in which these
conflicts were presumed to originate. For example, the psychotherapist might frequently
praise the psychotherapeutic accomplishments of a patient whose key childhood parental
figure was unduly harsh and critical. This strategy was met with significant criticism from
psychoanalytic traditionalists, who viewed it as an abandonment of analytic neutrality.
Despite this controversy, the work of Alexander and French presaged innovations in
psychoanalytic practice that resulted in the emergence in the 1960s and 1970s of psycho-
dynamic psychotherapies explicitly designed to be focal and time-limited. These include
Malan’s (1963) brief intensive psychotherapy, Sifneos’s (1972) short-term anxiety-provoking
psychotherapy, Davanloo’s (1978) intensive short-term dynamic psychotherapy, and Mann’s
(1973) time-limited psychotherapy. Although their clinical methods veered from those of tra-
ditional psychoanalytic practice, the work of Malan, Sifneos, and Davanloo was anchored
conceptually by classical psychoanalytic views regarding intrapsychic conflicts surrounding
the expression of unconscious impulses. Mann’s approach drew conceptually from the inte-
gration of a broad range of psychoanalytic tenets, including developmental precepts regard-
ing the processes of separation and individuation (Messer & Warren, 1995).
420 OTHER INFLUENTIAL MODELS

The 1980s witnessed further development of BPT frameworks, key examples of which
include supportive–expressive psychotherapy (Luborsky, 1984) and time-limited dynamic
psychotherapy (Strupp & Binder, 1984). These models took a decidedly more interpersonal–
relational conceptual turn relative to first-generation BPT approaches (Messer & War-
ren, 1995). They also were derived from treatment manuals developed for psychotherapy
research programs. The evolution and refinement of BPT models continued through the
1990s and into the present era (e.g., Binder, 2004; Binder & Betan, 2013; Gibbons et al.,
2012; Levenson, 1995, 2017). As Levenson (2017) observed, recent BPT developments have
trended toward increased emphasis on experiential psychotherapeutic processes, practical-
ity, and theoretical and technical integration of concepts and methods originating outside of
the psychoanalytic domain.

Conceptual Foundations
The psychoanalytic tradition within which BPT variants are rooted itself comprises mul-
tiple theoretical strands that vary in how they inform psychotherapy practice (Lemma,
2016; Wolitzky, 2011). While differing in important respects, these strands share a common
emphasis on articulating the influence of unconscious processes on conscious functioning,
the human disposition to symbolize psychological experience, the role of development in
shaping personality functioning, and the manifestations of psychological conflict.
The strands of psychoanalytic theory that have most influenced BPT models include the
drive/structure, object relations, and relational frameworks. While a comprehensive review
of the rich theoretical depth and nuance of these respective approaches is beyond the scope of
this chapter (and is covered by Wolitzsky in Chapter 2 and Curtis in Chapter 3, this volume),
their conceptualizations of motivation, psychological structure, development, and conflict
are encapsulated in Table 12.4. Broadly speaking, these strands differ in the extent to which
they highlight intrapsychic versus relational processes as the units of focus for understand-
ing psychological functioning (Messer & Warren, 1995; Lemma, 2016; Wolitzky, 2011).
The drive/structure framework concerns itself primarily with the internal psychological
world; therefore, it is sometimes referred to as a “one-person” psychology. Object relations
theory, while still largely focused on intrapsychic life, introduces a more dyadic slant by elu-
cidating the shaping of personality through the internalization of interpersonal experience.
This so-called “two-person” psychology framework is most fully elaborated in the context
of relational theory, which postulates that self-organization emerges from an intersubjec-
tive relational matrix. Whereas object relations theory posits that the inner object world
maintains an organizing influence on psychological life, relational theory suggests that at
any given moment psychological functioning reflects the ongoing bidirectional influences of
internal structure shaped by the past and present interpersonal experiences (Wachtel, 2017).
Adoption of a one-person framework in BPT tends to guide an intervention focus cen-
tering on conflictual intrapsychic affective experiences, while a two-person framework
lends itself to a more dyadic treatment focus, based on the assumption that the psycho-
therapy relationship is a key facilitator of change. With the ascendancy in recent years of
relational dynamic theory, contemporary BPT models have increasingly been influenced by
the two-person psychology perspective, even when the clinical focus is primarily on intrap-
ersonal experience.
Consistent with this trend, many BPT models also are informed by attachment the-
ory, which describes interactional behavioral mechanisms that underlie human attachment
  Interpersonal and Brief Psychodynamic Therapies 421

TABLE 12.4. Psychoanalytic Theories Informing BPT Approaches

Motivation Structure Development Conflict
Drive/structure theory
Personality is Id: Repository of drives. Id and conflict-free Incongruities between
propelled by aspects of ego present at wishes associated with
Ego: Reality-oriented structure
dual biologically birth. Superego develops id impulses pressing
that comprises conflict-free
innate sexual and from introjection for expression and the
executive adaptive functions
aggressive drives of social beliefs and moral sensibilities of
(perception, planning,
seeking gratification norms. Patterns of drive the superego and/or
judgment, environmental
and expressed in regulation and defense the reality-based
adaptation) and intrapsychic
derivative form as established through apprehensions of the
conflict management/drive
wishes or impulses. experiences with ego.
regulation functions, including
consequences of drive
mechanisms of defense.
expression.
Superego: Internalized societal
moral and values-based
standards.

Object relations theory

Personality is Object relations units:
propelled by a need Internalized cognitive–affective
for connection to representations of self in
objects. relation to key persons (objects)
that provide the foundation
for self-structure and influence
relational experience.
Representations of self Real or imagined
in relation to objects discrepancies between
are internalized based wishes of the self and
on both subjective those of objects that
impressions and pose a threat to object
actual interpersonal ties.
experience.

Relational theory
Personality is Relational matrix: The Individuality emerges Misalignment
propelled by intersubjective relational world contextually and of expressions
intersubjective within which human beings bidirectionally through of interpersonal
engagement. are fundamentally embedded, experiences of and connection and
and in the context of which within the relational individual agency.
subjectivity/self is elaborated matrix.
and internalized.

(Bowlby, 1988). Drawing on ethological principles, attachment theory posits a biologically

rooted attachment behavioral system that keeps the young in proximity to parental figures
to ensure survival. Experiences with attachment figures are schematized over time as inter-
nal working models of relationships that influence relational expectancies, including attach-
ment quality (i.e., secure vs. insecure attachment).

Framework, Structure, and Process of BPT

The spectrum of BPT approaches share in common a practice framework that is informed
by psychodynamic conceptual principles, incorporates the formulation of a discrete psycho-
therapy focus, and is oriented to time limits. Although a few adhere to strict a priori time
limits (e.g., 12 sessions in Mann’s time-limited psychotherapy), most adopt a relatively flex-
ible stance on psychotherapy length, which ranges from roughly 20 to 40 sessions, though
422 OTHER INFLUENTIAL MODELS

sometimes may be conducted in 10–15 or fewer sessions as determined by clinical need.

Within these time parameters, some BPT models formally establish the number of sessions
or a termination date early on in the psychotherapy course, while others make decisions
about the timing of psychotherapy termination in accordance with the clinical progress of
a given patient over time. Determining a categorical diagnosis is of clinical interest in order
to obtain a general grasp of the extent and severity of psychopathology, particularly as
this pertains to determining suitability for or exclusion from a given BPT model. However,
BPT models emphasize the need to understand the patient’s problems and symptoms ideo-
graphically. Thus, considerable attention is placed on understanding the key intrapsychic
and/or relational psychological themes, modes of adaptation, conflicts, and meanings that
comprise the clinical presentation. While most BPT models privilege the characterization of
psychopathology over well-being, some of the newer integrated models incorporate concepts
of positive states of mind. Like the psychoanalytic enterprise from which it descended, BPT
is generally practiced as an individual psychotherapy modality. The unit of focus is on the
individual, though dynamic processes expressed in the psychotherapy dyad also are exam-
ined as opportunities to promote insight and provide new experiences of relationship.
A proliferation of BPT models has followed in the wake of the pioneering work of
Malan, Sifneos, Davanloo, and Mann, whose respective contributions and innovations
are summarized in Table 12.5. A sampling of the most well-known and widely practiced
approaches is described presently. For the purposes of discussion, these models are orga-
nized in accordance with their theoretical roots in BPT models tied to the drive/structure or
relational perspectives, though object relations and relational perspectives have increasingly
influenced the range of BPT frameworks. Also, many have taken an integrative turn by
incorporating concepts and methods from nonpsychodynamic traditions.

Drive/Structure Approaches and Their Variants

BPT models anchored by drive/structure theory take the intrapsychic world of the indi-
vidual as the unit of psychotherapeutic focus. The primary psychotherapy goal is to promote
conscious insight into intrapsychic conflicts involving consciously objectionable impulses
or feelings, the direct expression of which is avoided due to guilt, shame, and anticipated
negative consequences for attachment to key persons (both past and present). Consistent
with drive/structure theory, the clinical symptom is seen as a symbolic manifestation of
an intrapsychic compromise that reflects both partial expression and partial inhibition of
consciously unacceptable impulses or feelings. For example, depressive feelings of worth-
lessness might represent a disguised expression of unacceptable outwardly directed angry
impulses experienced consciously in the form of self-devaluation. Insight is regarded as a
cognitive–affective phenomenon, with emotional expression serving an important function
in the process. Interpretive techniques are the primary means through which intrapsychic
conflicts are consciously illuminated. This includes interpretation of conflict as expressed in
the individual’s experience of the psychotherapy relationship (i.e., transference). Because of
the intensity of the interpretive process in brief work, supportive techniques (e.g., empathic
validation, praise, buoying perseverance) also reinforce the working alliance.

Intensive Short-Term Dynamic Psychotherapy. Of the pioneering BPT models rep-

resented in Table 12.5, Davanloo’s (1978) intensive short-term dynamic psychotherapy
 Interpersonal and Brief Psychodynamic Therapies 423

TABLE 12.5. Key Innovations of First-Generation BPT Approaches

Framework Clinical objectives
Brief intensive psychotherapy Highlight and promote
(Malan) resolution of a focal problem
and a corresponding
intrapsychic conflict
Innovations
Use of the triangle of conflict
(relationship between
impulses/feelings, anxiety,
and defenses) and triangle
of person (experiences of
the psychotherapist, current
relationships, and past
relationships relative to key
impulses/feelings and defensive
operations) to guide clinical
formulation and interpretation
around a specific treatment focus

Short-term anxiety-provoking Link symptoms to conflicts Use of direct interpretation of

psychotherapy (Sifneos)
involving Oedipal themes (i.e., impulses/feelings and adoption
interpersonal triangulation of a didactic role regarding
relative to intrapsychic psychodynamic processes
impulses/wishes), facilitate
their resolution, and enhance
interpersonal relationships

Intensive short-term dynamic Reduce defensive avoidance Use of trial therapy as an

psychotherapy (Davanloo)
to allow direct experience
of feared emotion and
promote insight regarding
interrelationships between
impulses/feelings, anxiety, and
defenses
evaluative clinical tool, and
application of persistent
clarification and confrontation to
challenge defenses and illuminate
unconscious impulses/emotions

Time-limited psychotherapy
(Mann)
Ameliorate negative self-
image tied to a central issue
involving chronic emotional
pain perceived to continuously
pervade experience over time
Use of firm time limits to elicit
the working through of conflicts
pertaining to time, separation–
individuation, loss, and the limits
of relationships, including their
finiteness

(ISTDP) has garnered the most attention. The broad strategy of ISTDP centers on the sys-
tematic challenge of psychological defenses. The aim is to overcome resistances to awareness
and work through unresolved, conflictual unconscious feelings with presumed origins in
attachment trauma. Guided by a series of intervention strategies comprising what is called
the central dynamic sequence, ISTDP uncovers and facilitates the exploration of affective
experience while managing anxiety and thwarting defenses that support affect avoidance.
This work is highly emotionally activating and leads to what is referred to as an unlock-
ing of the unconscious, in which a mixture of deeply meaningful and conflictual emotions
previously outside awareness becomes available for conscious processing, thereby advancing
change (Abbass, 2015; Abbass & Town, 2013; Coughlin, 2017).
The ISTDP focus is formulated using Malan’s (1976) templates for the triangles of con-
flict and person. The triangle of conflict portrays clinical problems in terms of dynamic con-
figurations involving impulses/feelings (I/F) deemed unacceptable to consciousness, anxiety
(A) aroused by the prospect of their breaking through to conscious awareness, and defense
424 OTHER INFLUENTIAL MODELS

mechanisms (D) mobilized to reduce anxiety by keeping the I/F unconscious. The triangle
of person depicts the enactment of these dynamic configurations in the individual’s relation-
ship with the therapist (T), current outside relationships (C), and significant persons from
the past (P) with whom patterns of intrapsychic conflict are presumed to have originated.
For example, an individual who as a child was told by parental figures (P) to “always stay
strong” may as an adult demonstrate a pattern in which feelings of sadness (I/F) lead to
emotional numbing (D) as a means of avoiding anxiety tied to shame for feeling “weak”
emotions (A).
Building on Davanloo’s original contributions, the principles of ISTDP continue to be
elaborated, and the model remains well represented in the present-day BPT scholarly litera-
ture, including research trials demonstrating its efficacy (Abbass, 2015; Abbass, Sheldon,
Gyra, & Kalpin, 2008; Coughlin, 2017; Frederickson, 2013; Town et al., 2017). Though
not explicitly intended as such, some of Davanloo’s time-efficient methods, along with those
of colleagues Malan and Sifneos, bore resemblance to those practiced by cognitive and/or
humanistic psychotherapists (McCullough & Andrews, 2001). This unwitting integrative
turn influenced a generation of contemporary BPT clinicians and models (e.g., Fosha, 2000;
Magnavita & Carlson, 2003; McCullough et al., 2003).
Two such approaches with roots in the drive/structure BPT tradition that have emerged
as integrative intervention models in their own right are affect phobia therapy (McCullough
& Andrews, 2001; McCullough et al., 2003; Osborn, Ulyenes, Wampold, & McCullough,
2015) and accelerated experiential dynamic psychotherapy (Fosha, 2000). Broadly speak-
ing, each emphasizes the motivational role of affect and highlights emotional activation in
the context of a strong psychotherapy alliance as a key mechanism of change, a perspective
that is descended from ISTDP’s focus on uncovering unconscious affect and providing a
corrective emotional experience. In contrast to the relentless interpretation of defense and
resistance that is a hallmark of ISTDP, these newer frameworks favor empathic validation
as a key facilitator of the emotional uncovering process.

Affect Phobia Therapy. As suggested in its name, affect phobia therapy (APT) ties
psychopathology to fears about feelings deemed consciously objectionable, called affect
phobias. Combining inspiration from Davanloo’s methods for exposing conflictual affec-
tive experience and Malan’s triangle of conflict/person templates with behavioral concepts
of exposure and response prevention, APT represents an assimilative integration paradigm
(Messer, 2015). Intervention centers on systematic activation of the feared affect (exposure)
while inhibiting habitual defenses against it (response prevention) and providing support in
regulating the associated anxiety until its intensity lessens (habituation). In essence, APT
involves use of systematic desensitization to address feared internal feeling states in a fash-
ion that parallels applications of traditional behavioral intervention for ameliorating phobic
responses to external environmental stimuli (McCullough & Andrews, 2001; McCullough
et al., 2003).
The APT focus is developed by using the triangle of conflict template to identify the
feared affect states (I/F), the inhibitory anxiety/affect states that they activate (A), and
behaviors enacted to avoid conflictual feelings (D). Once this dynamic configuration is iden-
tified, the triangle of person template is used to understand patterns of enactment of this
dynamic configuration in key relationships. In addition to interpretive psychodynamic and
 Interpersonal and Brief Psychodynamic Therapies 425

self psychological empathic validation techniques, APT incorporates cognitive, behavioral,

and experiential intervention strategies (McCullough & Andrews, 2001).
By way of illustration, Mia is a 22-year-old woman presenting with generalized anxiety
that has grown increasingly intense over the few months since starting her first job upon
graduating from college. Although excited by the opportunities afforded by her job, Mia
feels pressure to “make my mark” while also perceiving a pattern in which coworkers get
credit for her suggestions and ideas. Her response is to feel “a little discouraged.” She adds,
“Some people might get angry, but that just seems petty to me. It’s the collaboration that’s
the important thing and not who gets credit for the idea. As my parents always reminded
me, it’s important to always remain humble no matter what.” In this scenario, Mia’s affect
phobia associated with her generalized anxiety symptoms might be formulated in terms of
competitive strivings (I/F) that generate guilt-driven anxiety (A) and propel her to inhibit
competitive feelings by intellectualizing and minimizing the importance of being individu-
ally recognized for her work (D). Mia’s developmental history suggests that her competitive
strivings conflict with an internalized parental proscription to “always remain humble” (P)
that is now being enacted in her relationships with coworkers (C).
This formulation guides the specific aims of APT, which include the restructuring of
defenses, affect, and images of self and others. In working with Mia on defense restructur-
ing, the psychotherapist assists her in becoming aware of maladaptive intellectualization
defenses (e.g., “I noticed that when I asked you how you felt about the fact that a coworker
was recognized by your boss for an idea you’d originally expressed, you said something
about the importance of teamwork instead of saying how you feel”). The psychotherapist
also seeks to motivate Mia to consider letting go of maladaptive defenses (e.g., “Unfor-
tunately, making sure you’re always humble comes at the cost of never getting the credit
you deserve for your contributions at work. I wonder if there’s a happy medium you can
find between accommodating the needs of others and getting your needs met too?”). When
focusing on affect restructuring, the psychotherapist facilitates Mia’s experiencing of the
avoided feeling (e.g., “I’m hearing how frustrating it was for you to watch someone else in
your workgroup get praised for an idea that you came up with. Can you feel the frustration
in your body right now?”) and helps her to learn adaptive ways of expressing it (e.g., “What
if when you and a coworker accomplish something together you say something like ‘Hey, I
think we make a great team.’ What would that be like for you?”).
In self- and other-restructuring, the focus is on increasing positive views of both self
and others. Here the psychotherapist intervenes to explore Mia’s negative self-appraisal of
her wish to be appropriately recognized at work (e.g., “Help me understand how occa-
sionally wanting your accomplishments to be acknowledged reflects poorly on you?”). The
psychotherapist might also challenge Mia’s anticipatory concerns about how others’ might
respond to her need for recognition (e.g., “Sounds like you automatically assume people will
be critical or resentful. Is it possible some of your coworkers might enjoy celebrating you for
your contributions?”).
In APT, the restructuring process is repeated through the psychotherapy course, with
movement between exposure to the feared emotion, blocking maladaptive responding
(defenses), and soothing inhibitory affects (e.g., anxiety, guilt, shame) activated by the expo-
sure process (McCullough & Andrews, 2001; McCullough et al., 2003). Empirical testing
of APT is limited, though extant research trials support its efficacy (Julien & O’Connor,
2017).
426 OTHER INFLUENTIAL MODELS

Accelerated Experiential Dynamic Psychotherapy. Integrating psychodynamic, emo-

tion-processing, and relational attachment concepts, accelerated experiential–dynamic psy-
chotherapy (AEDP) highlights access to emotional experience as a change catalyst (Fosha,
2000; Markin, McCarthy, Fuhrmann, Yeung, & Gleiser, 2018; Russell & Fosha, 2008).
The model assumes the presence of an innate disposition toward healing that is activated
through the uncovering and processing of affects. By cultivating a safe and affirming psy-
chotherapy relationship and regulating the management of emotional experience in the psy-
chotherapy dyad, core affective experiences that previously have been avoided as a means
of self-protection can be encountered openly and processed fully. These core affects encom-
pass categorical emotional experiences (e.g., sadness, joy, surprise, anger, disgust, fear),
experiences of self (e.g., vulnerability, empowerment), and experiences of relationships (e.g.,
emotional closeness, distance). Because of the presumed adaptive potential of core affects,
their activation is seen as providing a central pathway for rapid and discontinuous change.
AEDP also makes use of psychotherapist disclosure of feelings and reactions to the patient
in the change process (e.g., sharing a sense of being deeply moved by a patient’s willingness
to engage painful feelings).
AEDP privileges formulation of the psychological conditions that facilitate healing over
those that sustain psychopathology (Fosha, 2000; Russell & Fosha, 2008). As depicted in a
schematic called the triangle of experience (an AEDP adaptation of the triangle of conflict
template), resilience and healing are facilitated when emotionally activating experiences
trigger so-called green-signal affects (e.g., hope, curiosity) that have the effect of temper-
ing anxiety levels and moderating defenses, thereby giving the go-ahead to explore inner
affective experience. This configuration is sustained by affect-affirming environments that
support the processing of core affective experience and enable the emergence of transforma-
tional affects. Transformational affects are positive emotions that result from a favorable
experience in the psychotherapy process (e.g., feelings of mastery, joy, gratitude). These
affects, in turn, offer a pathway to core state experience, itself a positive state of mind char-
acterized by openness to and deep contact with authentic feelings.
Conversely, as schematized in the AEDP triangle of experience, psychopathology results
when emotionally activating experiences trigger red-signal affects (e.g., anxiety, guilt,
shame) that mobilize defenses, thereby creating barriers to emotional processing of painful
emotions and/or relational experience. This configuration is sustained by affect-aversive
environments that thwart expression of core affects, elicit pathogenic affects (e.g., shame,
anxiety, distress), and generate excruciating experiences of aloneness. Thus, psychopathol-
ogy in AEDP is seen as largely rooted in aloneness in confronting overwhelming affect.
The work of AEDP centers on moderating the effects of defenses and pathogenic affects,
facilitating the accessibility and adaptive transformation of core affects (including painful
affects), and ultimately cultivating core state experiencing. To accomplish these tasks AEDP
employs three categories of technique, including (1) relational techniques aimed at softening
defenses by creating safety in the psychotherapy dyad; (2) restructuring techniques aimed at
promoting awareness and understanding of affective and interpersonal experience; and (3)
experiential–affective techniques aimed at circumventing defenses to illuminate core affects
and enhance the core state. These techniques are applied differentially in accordance with
the moment-to-moment focus of AEDP intervention, which encompasses three states and
two state transformations in the experiential processing of emotion (Fosha, 2000; Russell
& Fosha, 2008).
State 1 is defense, with intervention aimed at neutralizing defenses and pathogenic
 Interpersonal and Brief Psychodynamic Therapies 427

affects. Key to this work are relational interventions that promote a safe and affect-affirming
dyadic context. These conditions shepherd the first transformation from defensive respond-
ing to openness to core affect (State 2). For example, Mia, whose case was introduced ear-
lier, presents to psychotherapy with a low affective receptivity posture (State 1). Her triangle
of experience configuration reflects profound shame and guilt (red-signal affects) that trig-
ger minimization and intellectualization (defenses), effectively burying Mia’s availability to
experiencing her wish to be celebrated for her work contributions (core affects). The psycho-
therapist cultivates a safe relational space, while also amplifying hints of core affect expres-
sion to increase Mia’s openness to self-exploration and temper her defenses. This results in
a significantly heightened receptivity to core affect experiencing (first state transformation
to State 2 functioning).
Intervention in State 2 centers on core affect deepening, along with the regulation and
working through of newly accessed intense emotional experience, such that what previ-
ously felt overwhelming or painful now feels enlivening. This second state transformation is
facilitated by metatherapeutic processing, which refers to the systematic exploration of the
patient’s experience of positive change in the immediacy of the moment. Metatherapeutic
processing itself helps to consolidate change by eliciting a combination of so-called “adap-
tive action tendencies” (e.g., productive grieving of a loss), postbreakthrough affects (e.g.,
relief, hope, strength), and transformational affects (e.g., mastery feelings, gratitude, curios-
ity). What follows from this work is the core state (State 3), which is characterized by high
degrees of awareness, vitality, and emotional congruence/authenticity.
Returning to Mia, State 2 work requires her to confront a painful conflict between
her wish for recognition and her deeply held internalized parental proscription to “always
remain humble.” Restructuring techniques are applied to help Mia reconcile this conflict,
such that she feels increasingly comfortable expressing a wish for recognition without also
feeling that this automatically equates with self-absorption. This realization is accompanied
by tears that simultaneously reflect a sense of relief in letting go of inhibitory internalized
emotional proscriptions (postbreakthrough affects), along with pride and gratitude for hav-
ing achieved this hard-fought emotional change (transformational affects). Experiential–
affective processing of these emotions facilitate Mia’s emerging core state experience in
which she gains a sense of emotional clarity and confidence (second state transformation to
State 3 functioning).
Although AEDP itself has not been directly tested in research trials, many of the inte-
grative concepts and intervention strategies from which it draws are themselves grounded in
an empirical evidence base (Markin et al., 2018). While AEDP has partial roots in Davan-
loo’s ISTDP, its attachment framework and emphasis on providing the relational conditions
that soften defenses rather than directly challenging them bear striking similarity to the
relational BPT focus on using the psychotherapy relationship as a vehicle for change.

Relational Dynamic Approaches and Their Variants

Relational BPT models focus the work of psychotherapy on exploring internal experiences
and representations of self in relation to objects and corresponding interpersonal relational
modes. The clinical symptom is understood in terms of internal representations of self and
others that are polarized to varying degrees into extremes of good and bad. Symptoms
may also arise from overly rigid and narrowly construed expressions of self-in-relation. For
example, depression might reflect a worthless child (bad self) self-representation in relation
428 OTHER INFLUENTIAL MODELS

to an object-representation of a disparaging parental figure (bad object). It could also sig-

nify a disempowerment-themed relational narrative that limits the breadth and quality of
relating and experience of self in the relational context. The primary psychotherapy goal
is to moderate rigidly organized internalized representations of self-in-relation that restrict
the flexibility of relational experiencing and/or ameliorate repetitive and maladaptive inter-
personal patterns. Conflicts arising from actual or perceived mismatches between personal
wishes and the requirements of the relational situation also are addressed. Additionally, psy-
chotherapy illuminates how patterns of maladaptive interpersonal behavior based on faulty
relational expectancies elicit unwanted reciprocal interpersonal responses, thereby creating
unwelcome self-fulfilling prophecies. The relational models described here are descendants
of psychotherapy research lines. Though grounded in dynamic theories, these models are
conceptually integrative and flexibly apply technique.

Supportive–Expressive Psychotherapy. Introduced as a broadly manualized approach,

supportive–expressive psychotherapy (SEP) employs interventions along the supportive–
expressive continuum of dynamic psychotherapy (Luborsky, 1984; Vinnars, Dixon, & Bar-
ber, 2013). Examples of supportive work include communication of empathy, acceptance,
collaboration, and realistic hope for change, along with intervention to augment defenses
and coping resources that sustain positive adaptation. Expressive techniques comprise inter-
pretations aimed at facilitating new ways of experiencing and understanding psychological
life and relational patterns. A secure and trusting psychotherapy relationship is essential to
abide the expressive aspects of the work, which can involve significant emotional intensity.
Therefore, the psychotherapist regularly balances the use of supportive and expressive meth-
ods based on the clinical needs a given patient. Severity of psychopathology is also consid-
ered, with persons whose symptoms trend toward the severe end of the clinical spectrum
requiring more supportive intervention.
SEP begins with a focus on establishing psychotherapy goals and parameters (e.g., ses-
sion frequency, length of sessions, estimated length of psychotherapy course, education on
how the intervention process works). Establishing a supportive psychotherapy relationship
and working alliance is also prioritized. Additionally, the psychotherapist elicits a relational
narrative for formulating an understanding of presenting problems that establishes the psy-
chotherapy focus and guides intervention. In this formulation, symptoms are seen as efforts
to solve interpersonal problems, albeit in maladaptive ways.
The organizing formulation template, called the core conflictual relationship theme
(CCRT), encapsulates narratives of a patient’s predominant interpersonal interaction pat-
terns called relationship episodes. Relationship episodes comprise three principal compo-
nents: (1) a wish, need, or intention (W); (2) an imagined or real response of others to the
wish (RO); and (3) the emotional, cognitive, and/or behavior response of self (RS). The
RO and RS also are assigned either positive or negative valence designations. To illustrate,
Michael, a 38-year-old man, is seeking psychotherapy for depression following a relation-
ship breakup. He describes a recurrent pattern of feeling alone and unsupported by family
and friends, exclaiming bitterly, “Everyone comes and cries on my shoulder but no one ever
has my back when I need it. . . . No one really cares about me.” Using the CCRT template,
it appears that Michael wants to feel cared about (W) but instead he perceives abandonment
(negative RO), to which he responds with intense resentment (negative RS). His resentment
may unwittingly contribute to depriving Michael of his wish by alienating the very people
from whom he seeks caring and support.
 Interpersonal and Brief Psychodynamic Therapies 429

Expressive interpretive work unfolds in four steps: listening, understanding, respond-

ing, and returning to listening (Luborsky, 1984). Active listening, including attention to ver-
bal and nonverbal communications, is a prerequisite for formulating a clinical understanding
of the patient and formulating the CCRT. Once clinical understanding is sufficiently crystal-
lized, the psychotherapist offers a response. Responding typically involves an interpretation
centering on links among relationship episode components and/or links to symptoms identi-
fied in the CCRT formulation. For example, Michael’s psychotherapist might say, “When
your friends don’t return your phone calls (RO), you get angry (RO) and your depression
gets worse (symptom). I’m wondering if maybe in those moments you assume they don’t care
about you (W)?” This question encourages Michael to reflect on his assumptions about oth-
ers’ intentions and how this affects both his wish to feel cared for and his angry responses to
others. Parallels in recurring interpersonal themes captured in the CCRT formulation also
are interpreted across the so-called triad of relationship spheres: current, past, and psycho-
therapist relationships (e.g., Michael’s feeling ignored by friends as reminiscent of childhood
memories of emotional neglect). The final step in the SEP interpretive process is returning
to listening. Guided by the CCRT formulation, the psychotherapist both anticipates and
observes the patient’s responses to the interpretive process, while at the same time remaining
open to new clinical evidence that may suggest the need to refine the CCRT focus.
The extant evidence base supports the efficacy of SEP (Vinnars et al., 2013). The CCRT
method provides a relatively simple means to formulate both intrapsychic representations
and interpersonal patterns involving relational conflict and identify their expression in the
moment-to-moment psychotherapy process. This method bears similarity to case formula-
tion modalities used by other relational BPT models, and points to an integrative pathway
for incorporating a cognitive schema perspective into BPT work.

Dynamic Interpersonal Therapy. Influenced theoretically by attachment, object

relations, and interpersonal theory, dynamic interpersonal therapy (DIT) was originally
developed as an intervention for depression, and has recently been included in the United
Kingdom’s Improving Access to Psychological Therapies program aimed at increasing the
accessibility of evidence-based psychotherapies (Lemma, Target, & Fonagy, 2010, 2013).
The model was designed to be accessible and easily learned by experienced clinicians inter-
ested in gaining the requisite skills to practice the approach. Psychotherapy is structured
as a 16-session intervention that comprises an engagement and assessment phase (Sessions
1–4), a middle phase (Sessions 5–12), and an ending phase (Sessions 13–16), though these
time frames are broad and flexibly applied. The principal aims are to promote awareness of
an unconscious core relational pattern that is linked to clinical symptoms and to enhance
interpersonal competency by promoting self-reflective capacity. In part because of United
Kingdom’s Improving Access to Psychological Therapies program requirements, DIT is
somewhat unique among BPT models in its incorporation of session-to-session outcome
monitoring. DIT recipients complete a self-report questionnaire at the beginning of each
session, yielding feedback that informs the psychotherapy discourse.
The initial phase takes up the task of identifying a central and repetitive unconscious
interpersonal pattern that can be tied to depressive symptoms (Lemma et al., 2013). This pat-
tern, called the interpersonal–affective focus (IPAF), corresponds to an internal self–other
representation that includes relational expectancies that, in turn, complicate interpersonal
behavior. The IPAF is discerned in part from the patient’s descriptions of key relationships,
salient expectations therein, and links to current problems and concerns. The emerging
430 OTHER INFLUENTIAL MODELS

transference relationship also can provide experiential clues relevant to IPAF formulation,
particularly “cautionary tales” that point to unconscious fears and corresponding self–other
expectancies (e.g., relationships as unreliable, disappointing, hurtful) expressed in the devel-
oping psychotherapy relationship (Lemma et al., 2013). In the case of Michael, introduced
earlier, the IPAF might center on a pattern in which a basic expectancy that people will
disappoint and hurt him disposes Michael to a heightened sensitivity to perceived neglect
from others. His corresponding interpersonal behavior may therefore be typified by insecu-
rity, high demand, and hostility that, in turn, may prompt others to distance from him over
time, thereby confirming his expectancy of interpersonal disappointment and reinforcing
his depressive symptoms. Once developed, the psychotherapist directly shares the IPAF for-
mulation with the patient as a means of providing a collaborative focus and reference point
for the psychotherapy work.
The working through of the IPAF is the principal task of the middle phase of DIT (Lemma
et al., 2013). Grounded by a spirit of collaboration and mutual curiosity, intervention centers
on methodical scrutiny of internal states of mind (thoughts, affects, wishes, beliefs) and their
concomitant interpersonal behaviors. The development of this self-reflective capacity rela-
tive to IPAF configurations is a critical aim of DIT. For example, transference interpretation
focuses on developing the patient’s ability to consider how here-and-now thoughts and feel-
ings pertain to the experience of the psychotherapist and reflect the IPAF; the aim is to illu-
minate the patient’s mental operations in the immediacy of the psychotherapy relationship.
Returning to Michael, if he perceives that a brief lapse in attention by the psychotherapist
is a sign of indifference, he is asked to share his perceptions and feelings about the psycho-
therapist, as well as his ideas about how the psychotherapist thinks and feels about him. The
purpose is to familiarize Michael with the mental operations that inform his conclusion that
the attentional lapse is a signal that the psychotherapist lacks concern about him. Michael’s
behavioral responses (e.g., an impulse to withdraw) also are linked to these mental states.
This focus on illuminating mental states also helps to identify previously unconscious moti-
vation to maintain patterns of relating that the patient consciously wants to change. One
component of this work is to identify defenses, including their adaptive functions and poten-
tial costs to overall well-being.
Along with exploring thoughts and feelings about ending psychotherapy, consolidating
gains, and troubleshooting anticipated future challenges and concerns, the psychotherapist
writes a good-bye letter to the patient in the end phase of DIT. This letter, which describes
the formulation, summarizes the work achieved, and acknowledges that which remains to
be achieved, is discussed and worked on collaboratively with the patient. It provides a tan-
gible synopsis of the psychotherapy work on which the patient can reflect and refer back to
once psychotherapy ends. It also provides a powerful vehicle for marking the end of the psy-
chotherapy relationship, and where needed, working through feelings of separation and loss.
The techniques and strategies of DIT are based on a collection of competencies and
methods derived from empirically tested manualized dynamic psychotherapy models. How-
ever, empirical tests of the model are so far limited though promising (Lemma et al., 2010,
2013). DIT’s systematized outcome monitoring component is consistent with recent calls for
routine clinical outcome evaluation as a standard element of BPT practice (e.g., Binder &
Betan, 2013).

Time-Limited Dynamic Psychotherapy. Time-limited dynamic psychotherapy (TLDP)

is descended from a psychotherapy research line and in its original form was influenced
 Interpersonal and Brief Psychodynamic Therapies 431

theoretically by interpersonal and object relations concepts (Strupp & Binder, 1984). Build-
ing on the conceptual and technical pluralism of the original model, contemporary TLDP
is highly integrative, incorporating relational dynamic and attachment concepts with expe-
riential learning principles (Levenson, 1995, 2017) and cognitive science, and skills-based
learning concepts (Binder, 2004; Binder & Betan, 2013). TLDP does not articulate a set of
model-specific clinical techniques. Rather, it provides a highly adaptable framework that
permits the flexible application of a broad range of intervention strategies in accordance
with the psychotherapy focus and goals. The essence of this framework is relational, in that
all applications of technique are interpersonally contextualized; each intervention is viewed
as a relational act (Levenson, 2017).
Consistent with its conceptual pluralism, the clinical focus of TLDP is on interrelated
experiences of self, interpersonal relationships, and emotion (Binder & Betan, 2013; Leven-
son, 2017). The psychotherapy focus is guided by the formulation of the cyclical maladaptive
pattern (CMP), which characterizes the patient’s basic relational suppositions and expec-
tations, along with corresponding patterns of relating and concomitant emotions. Bear-
ing similarity to the CCRT and IPAF frameworks in SEP and DIT, respectively, the CMP
template in TLDP incorporates intrapsychic and interpersonal elements, and illuminates
repetitive interaction configurations that sustain problems in the experience of relationships
and self. Rather than taking a deficit view of the CMP, TLDP frames it as a maladaptive
self-protective effort from which the patient needs to become unstuck (Levenson, 2017). The
categories from which the CMP is formulated include acts of self (relational wishes/needs),
expectations of others’ reactions (internalized schemas that reflect imagined interpersonal
reactions to wishes/needs), perceived acts of others toward self (observations and interpreta-
tion of others’ responses to wishes/needs), and acts of self toward self (consequences for self-
functioning). To these categories that comprise the original TLDP case formulation model,
Binder and Betan (2013) add a fifth category called acts of self-protection, which refers to
patients’ efforts to protect themselves from anticipated negative interpersonal responses or
associated emotional states. These protective actions often have the unfortunate effect of
eliciting the very reactions the patient fears. Alternatively, Levenson (1995, 2017) adds ther-
apist’s interactive countertransference as a CMP category to capture the clinician’s experi-
ence of the patient in the psychotherapy dyad.
Returning again by way of illustration to the case of Michael, a plausible CMP for-
mulation might begin with his strong wishes for support and caring (acts of self), and his
anticipation that others will at best be indifferent and at worst abandon him in times of
greatest need (expectations of others). These beliefs elicit preemptive demands for atten-
tion from Michael (acts of self-protection). This insistence, rather than eliciting the support
Michael seeks, prompts others to take distance in reciprocal fashion (perceived acts of oth-
ers). This reinforces Michael’s belief that others abandon him in moments of need, along
with an experience of self as unworthy of the caring he craves (acts of self toward self). The
psychotherapist also notes feeling pressure to validate Michael, along with uncharacteristic
apprehension about disappointing him (therapist’s interactive countertransference).
Once developed, the CMP formulation is discussed collaboratively with the patient,
who is invited to share reactions and provide input. The CMP also becomes an ongoing
reference point for the psychotherapy work. This includes goal setting, two broad catego-
ries of which Levenson (2017) identifies as new experiences (i.e., experiential learning) and
new understandings (i.e., cognitive processing and meaning making) of self and relation-
ships. Binder and colleagues (Binder, 2004; Binder & Betan, 2013) highlight a third broad
goal, which is to cultivate new relationship skills that enhance behavioral repertoires (i.e.,
432 OTHER INFLUENTIAL MODELS

interpersonal skills building and practice). Thus, consistent with its theoretical and practical
pluralism, TLDP targets change along interconnected experiential, cognitive, and skills-
based pathways.
For Michael, key goals might be to gain a new experience of containment of his support
needs without abandonment, a new understanding of the self-defeating quality of his sup-
port-seeking actions (i.e., demanding behavior), and new interpersonal assertiveness skills.
TLDP strategies in the service of these goals include engagement in activities to cultivate and
maintain the working alliance; illuminate and process emotions; empathically understand
facts, experiences, and meanings through a process of inquiry informed by the CMP focus;
explore thoughts, feelings, and transactional processes in relationships (including the psy-
chotherapy relationship); encourage new experiences and/or reflection on experiences that
disconfirm maladaptive narratives; and develop new, more flexible narratives (Levenson,
2017). While the patient’s experiences of the psychotherapy relationship are important in
TLDP, transference interpretations are not emphasized and are used only sparingly (Binder,
2004; Binder & Betan, 2013). When resistances arise, the psychotherapist invites collabora-
tive exploration of their possible adaptive significance.
Research using a pretest–posttest design supports the effectiveness of TLDP (e.g.,
Poduba, Crothers, Goldblum, Dilley, & Koopman, 2008). However, the model has not been
tested in randomized trials using a control condition. While anchored by psychodynamic
principles, TLDP has evolved into a highly flexible and integrative approach, making it
accessible to practitioners from a range of psychotherapy orientations.

The Therapeutic Relationship and the Stance of the Therapist

The BPT psychotherapist adopts an active stance in order to direct the psychotherapy pro-
cess in a time-efficient manner. As aptly characterized by Binder (2004), this activity is
directed toward encouraging authentic patient communication, facilitating joint exploration
of key clinical concerns, optimizing the balance between listening and intervening, and for-
mulating assessments and strategies to address clinical problems. Directive interventions are
used in some cases, examples of which include coaching (e.g., facilitating self-monitoring,
self-reflection, behavior change), encouraging practice of new skills, and homework assign-
ments (Binder, 2004; Levenson, 2017). In uncovering-focused BPT models (e.g., ISTDP), the
psychotherapist actively focuses directly on avoided affective experience.
The psychotherapist’s activity in directing the BPT process presupposes a strong psy-
chotherapy alliance. Activities conducted to cultivate the alliance vary to some degree across
BPT models. For instance, in ISTDP, activating painful emotions is presumed to elicit an
unconscious psychotherapy alliance driven by a wish for healing that, in turn, propels a
collaborative encounter with inner emotional truths (Abbass & Town, 2013). Alternatively,
AEDP articulates deliberate relational intervention strategies that facilitate the alliance, key
examples of which include the provision of affirmation, validation, empathy, and encourage-
ment (Fosha, 2000). Maintaining the psychotherapy alliance requires ongoing attunement,
flexibility, and responsiveness to the relationship and patient needs over the psychotherapy
course. Providing a systematic means for regular patient feedback also is critical for moni-
toring the patient’s experience of psychotherapy and the alliance (Binder & Betan, 2013).
Alliance ruptures are addressed rapidly, including collaborative exploration of contribut-
ing psychotherapist–patient transactional patterns along with transference–countertrans-
ference phenomena, as applicable. Willingness of the psychotherapist to be open, flexible,
 Interpersonal and Brief Psychodynamic Therapies 433

nondefensive, and tolerant of negative affect from the patient is critical to resolving alliance
ruptures (Binder & Betan, 2013).
The person of the psychotherapist is salient in BPT approaches, especially the rela-
tional variants in which intersubjective process is focal and countertransference is regarded
as a key source of clinical understanding. Selective self-disclosure of countertransference
experience is offered in the service of illuminating key patterns that contribute to clinical
problems, including those expressed in the psychotherapy relationship. Careful and well-
reasoned psychotherapist self-disclosure of personal experience as a means of translating
new insights into real-world behavior change also may serve an educative function (Binder,
2004; Levenson, 2017). For example, the psychotherapist may share a specific personal
experience to illustrate a problem-solving strategy that may be helpful for a given patient.

Diversity Considerations
Reflecting the historical neglect of social context in the psychoanalytic tradition (Tummala-
Nara, 2015), BPT approaches have tended not to include substantive discussion of diversity
factors in the explication of their models. However, increasing attention to diversity in BPT
practice has occurred with the ascendancy of contextual–relational approaches and recent
evolutions toward more pluralistic and integrative BPT frameworks. For example, Leven-
son (2017) highlights the importance of sociocultural context for developing a BPT clinical
formulation, responding to the patient’s experiences of psychotherapy and the psychother-
apy relationship, and attending to dynamic interrelationships between the worldviews of
the patient and the psychotherapist in the psychotherapy process. Binder and Betan (2013)
assert that in light of the increasing diversity of those seeking psychotherapy services, “there
is an ethical obligation to understand diverse meanings of experience in different settings, as
well as to reconceptualize treatment and the views of patients and ourselves in this context
of diversity” (p. 177). They suggest that a cultural sensibility in clinical practice is an essen-
tial BPT competency, in which the psychotherapist understands the fundamental cultural
embeddedness of assumptions regarding psychological health and psychotherapy practice,
ensures that ideas and values about mental health and well-being are relevant to patients
from diverse backgrounds, and incorporates diversity factors and cultural context into the
full range of psychotherapy case formulation and intervention practices.
A broad cultural competence framework for psychoanalytic theory and psychotherapy
practice proposed by Tummala-Nara (2015) includes strategies to (1) recognize historical
trauma and cultural context in an expanded self-examination approach; (2) illuminate the
influence and meanings of both the patient’s and the psychotherapist’s conscious and uncon-
scious cultural narratives; (3) understand language use and emotional expression through a
contextual lens; (4) consider how the psychotherapy dyad, process, and outcome are influenced
by both the patient’s and the psychotherapist’s experiences of oppression and stereotypes of
the other; and (5) appreciate the dynamic qualities of the cultural context, including patterns
of psychological adaptation, in navigating multifaceted and intersecting cultural identifica-
tions. These strategies can inform a comprehensive diversity framework for BPT models.

Adaptations of BPT
By definition, the range of BPT models represents time-limited adaptations of traditional
psychoanalytic psychotherapy and psychoanalysis. The approaches described herein by and
434 OTHER INFLUENTIAL MODELS

large are conducted as individual psychotherapy modalities. Additional BPT adaptations,

including developmentally tailored lifespan frameworks for children, adolescents, and older
adults have been articulated (e.g., Messer & Warren, 1995) as have group therapy variants
(Piper, Ogrodniczuk, & Duncan, 2002).

Suitability for BPT

The BPT pioneers assumed that their methods were best suited for so-called “high function-
ing” patients who could adhere to a circumscribed intervention focus and tolerate the con-
frontation of defenses required to uncover intense affective experience. In the current era,
BPT is seen as applicable to a broad range of patient functioning levels and clinical problems
(Abbass, Kisely, et al., 2015; Binder, 2004). For example, ISTDP has been utilized to treat
depressive and anxiety disorders, personality disorders, and somatic disorders (Coughlin,
2017). By and large, contemporary thinking suggests that patients who are motivated to
participate, willing to invest in the process, and disposed to accept responsibility for col-
laborative psychotherapeutic engagement could potentially benefit from brief psychother-
apy, presuming psychotherapy is clinically indicated for their presenting concerns (Binder,
2004). Quality of relating also may be a prognostic indicator of psychotherapy responsive-
ness, with those evidencing a capacity for a positive and flexible relational style more likely
to substantively engage in the BPT process (Binder & Betan, 2013). Contraindications may
include acute impulsivity, psychotic states, suicidality, severe personality disorders, or neu-
rocognitive compromise. For ways of dealing with the “difficult” patient, see Messer and
Warren (1995).

Conclusions
BPT approaches have contributed significantly to the evolution and growth of brief psycho-
therapy. Although anchored by psychoanalytic theories and concepts, contemporary BPT
frameworks are increasingly integrative, allowing their flexible application for a range of
clinical symptoms and problems. While there is a growing evidence base for the BPT genre,
it is unevenly distributed across the specific approaches. Therefore, additional research is
needed to achieve a critical mass of empirical support.

A CASE ILLUSTRATION USING TLDP

Assessment Phase
Eva, a 32-year-old woman, presents for psychotherapy feeling “distraught” after initiating
the breakup of a 6-month romantic relationship. Her chief complaint is that she is unable to
sustain her romantic involvements beyond a few months. In the initial session she describes
a pattern in which she easily meets potential romantic partners and becomes quickly
immersed, expressing that she “can’t get enough” of feeling wanted and loved. Once the
initial intensity of being in a new relationship wanes, however, she quickly becomes restless
and bored. Imagining there’s someone else out there yet to be discovered, with whom “the
spark would be there all the time and never go away,” she ends the relationship she is in and
begins a quest for someone new. As this pattern repeats itself, Eva is increasingly worried
about ending up alone.
 Interpersonal and Brief Psychodynamic Therapies 435

In characterizing her childhood history, Eva describes her mother as an emotionally

neglectful alcoholic who frequently moved in and out of chaotic romantic involvements.
Eva’s father became her primary caretaker once her parents divorced when she was 3 years
old. However, he was frequently absent and emotionally unavailable, often passing Eva
off to her mother or other relatives while he moved around the country for various jobs or
romantic relationships. Food was scarce at times, and parental or other nurturing attention
was completely absent. Eva’s father would repeatedly bring her back home with promises
of attention, but this would last only briefly, as he would leave again in pursuit of his next
venture.
Based on Eva’s description of her current life patterns and developmental history, the
psychotherapist surmises that Eva’s pattern of rapid and intense attachment followed by
emotional disengagement may reflect her best effort to fulfill a core wish for security and
love in a social world she experiences as patently disappointing and unreliable. This clinical
hypothesis is the anchor point for the CMP formulation shown in Figure 12.1, which the
psychotherapist shares with Eva while inviting collaborative input:

Therapist: It sounds like maybe you need a lot of convincing that the person you’re
with really cares about you, so when a relationship settles into a routine, you start
to doubt if that person can provide the love and affirmation you’re looking for.
Your uncertainty leads you to pull back and even start looking for someone new.
In the short term this provides some relief, but after a while you worry that you
may never find someone who you can count on to love you in a sustained way. You
also may wind up questioning if you’re worthy of the love you’re looking for. How
does this sound to you?
Eva: Well, it sounds about right. I’m not sure about the not being worthy of love part,
though. I actually think I’m pretty lovable. (Laughs awkwardly.)
Therapist: OK, so the part about you being uncertain about the person you’re with
causing you to distance feels right, but you’re not aware of feeling like you’re not
worthy of love.
Eva: Truthfully I’ve never really thought about it before, so I’m not really sure.
Therapist: OK, so maybe that’s something we can explore more as we go along.

While much of the initial CMP formulation resonates with Eva, she at first discounts
but then expresses uncertainty about the idea that she may not feel worthy of the love she
seeks. She and the psychotherapist agree to explore this theme further and psychotherapy
goals are set based on the CMP formulation (see Figure 12.1). Psychotherapy is structured
as weekly 50-minute sessions for 20 weeks. A termination date is established at the outset
of the psychotherapy course.

Working Phase
Considerable attention is given in the early part of this phase to ensuring that Eva under-
stands the CMP and can begin to recognize it in her daily life. Key tasks are to illuminate
self-protective acts, their potential to contribute to unwanted outcomes, and challenges in
regulating her feelings in both the attraction and withdrawal phases of her CMP enactments.
Several sessions in, Eva gleefully reports having met someone new, whom she describes as
436 OTHER INFLUENTIAL MODELS

Wish for Acts of

affirma�on Self
and love

Security - People will

Acts of Self I'm not withdraw Expecta�ons
lovable. Seeking Self and
toward Self of Others
abandon me.

Disappoin�ng
Social World
Internal
Intern
rn
r all Work
Working
in
i g
Model

Passions Preemp�ve Acts of Self-

Perceived Acts emo�onal
cool Protec�on
of Others withdrawal

Experiential Goal: To provide relational constancy in response to Eva’s efforts to regulate interpersonal
closeness and distance.
Cognitive Goal: To link Eva’s fear of abandonment and pre-emptive withdrawal in romantic relationships.
Skills Goal: To enhance Eva’s self-reflective capacity in interpersonal transactions while slowing
impulsive decision-making.

FIGURE 12.1. Eva’s CMP formulation and psychotherapy goals.

“just the person I’ve been looking for.” The psychotherapist acknowledges her enthusiasm
while also gently inviting Eva to reflect on her apparent conclusion that, based on a brief
initial encounter, this new person is an ideal match for her. In exploring this pattern, Eva
describes her challenge in regulating her excitement about the prospect of finding the love
and security she seeks.

eva: I’m just so afraid I’m always going to be alone.

theraPist: Of course, that’s a natural feeling. I’m wondering, though, does going
down this same path get you any closer to that?
eva: No, I guess not. I always end up getting restless and leaving anyway.
theraPist: Well I wonder if feeling restless and leaving is a way to protect yourself—
your past experience suggests maybe you can’t count on people to be there for you,
and so you make sure to leave them before they can leave you.
eva: So you’re saying I rush in because I don’t want to be alone, and then I break up
because I don’t want to be left? Now that’s depressing. (Becomes tearful.) I think
I’ve had enough for today. (Abruptly leaves the session before time is up.)
 Interpersonal and Brief Psychodynamic Therapies 437

As the psychotherapist encourages Eva to reflect on her emotional impulses, she becomes
increasingly aware of the sadness and abandonment anxiety that propels her to maintain a
cycle that keeps her stuck. Feeling emotionally vulnerable, she takes distance by leaving the
session early. Eva arrives late to the next session and is unusually quiet:

Therapist: How are you feeling right now?

Eva: This is getting to be a drag. I just feel like nothing’s happening and wondering if
I need a change from this.
Therapist: Hmmm. Last week you shared some pretty tough feelings in here. What
was that like?
Eva: Well, not fun, that’s for sure. What’s your point?
Therapist: People have disappointed you a lot, and I can see where after sharing such
important feelings you might start to wonder if you can count on me.
Eva: (Silent and averting her gaze . . . becomes tearful.) It’s just that I’m not usually this
real with anyone and it scares me.
Therapist: That makes total sense. It’s scary to be real when you don’t know if you
can count on someone to stick around. I can imagine how risky it feels to really
trust someone to be there for you when you need them, even me as your therapist.
Eva: (Speaks softly.) Yeah . . . it feels like a huge risk.

This exchange illustrates a deepening of Eva’s experiential comprehension of the CMP,

particularly the depth of her sense of vulnerability about potential relational abandonment. In
subsequent sessions, Eva further works through these feelings, gaining appreciation for how
the pattern affects not only her romantic pursuits but also her friendships. Though the process
is primarily focused on her present relationships, linkages also are drawn to formative child-
hood experiences to expand Eva’s appreciation of the CMP as a self-protective pattern.

End Phase
In the end phase, Eva’s gains are reviewed, unfinished areas requiring additional work are
identified, and applications of new insights and skills to address potential future challenges/
setbacks are explored. This work is aimed at promoting Eva’s sense of empowerment and
efficacy in continuing the change process on her own. As the psychotherapy course nears
its end, Eva expresses worry about lapsing into “old patterns” without the weekly structure
and support of her sessions. The psychotherapist empathizes, while also highlighting Eva’s
increased capacity to recognize the CMP, her enhanced emotion regulation capacity, and
her expanded behavioral repertoire to respond adaptively rather than reflexively. Even with
these gains, the pull of the CMP remains a work in progress for her.

Eva: As we get close to saying good-bye, I can feel myself pulling in, like I want to run
away. It worries me about what will happen when I’m not seeing you anymore.
Therapist: I’m very encouraged by your sharing this with me, because it shows how far
you’ve come in being able to recognize your feelings and your patterns rather than
just acting on them without thinking. Change is an ongoing process, so it’s natural
you’d still feel these things even with therapy ending.
438 OTHER INFLUENTIAL MODELS

While Eva’s impulse to flee remains, she is now able to observe her pattern with aware-
ness rather than acting on it. The psychotherapist also emphasizes that change continues
over time. The fact that Eva is able to tolerate the ending of the psychotherapy relationship
without preemptively fleeing is a favorable indicator of her growth.

BRIEF INTERVENTION AND THE FUTURE OF PSYCHOTHERAPY

The forward movement of psychotherapy innovation is arguably in the direction of articu-

lating routes to theoretical and technical integration (e.g., Wachtel, 2018). Current BPT
frameworks reflect cohesive psychotherapy models that draw on a range of perspectives
falling outside of the psychodynamic sphere (Levenson, 2017). Similarly, IPT is grounded
in a plurality of theoretical and empirically informed frameworks (Weissman et al., 2018).
The pluralism that typifies these brief psychotherapy approaches, along with their emphasis
on the pragmatics of time-efficient intervention, positions them well to contribute substan-
tively to advancing psychotherapy integration into the future. In exploring integrative brief
psychotherapy methods, Fosha (2004) observes that “brief therapy is therapy, only more so:
It is human nature to try make [sic] every moment count when confronted with finiteness”
(p. 66). It is perhaps this existential dynamic that unifies the varieties of brief psychotherapy
and compels those who develop and utilize them to search, via integrative pathways, for
optimal methods to engender change in each moment of the clinical encounter.

SUGGESTIONS FOR FURTHER STUDY

Recommended Readings: Clinical
Levenson, H. (2003). Time-limited dynamic psychotherapy: An integrationist perspective. Journal of
Psychotherapy Integration, 13, 300–333.—This article provides an accessible synopsis of TLDP
from an integrative perspective, including a lengthy case illustration.
Markowitz, J. C., & Swartz, H. A. (2007). Case formulation in interpersonal psychotherapy of
depression. In T. D. Eells (Ed.), Handbook of psychotherapy case formulation (2nd ed., pp.
221–250). New York: Guilford Press.—This chapter provides an overview of interpersonal psy-
chotherapy, including case formulation and practice methods using clinical case examples.

Recommended Readings: Research

Cuijpers, P., Geraedts, A. S., van Oppen, P., Andersson, G., Markowitz, J. C., & van Straten, A.
(2011). Interpersonal psychotherapy for depression: A meta-analysis. American Journal of Psy-
chiatry, 168, 581–592.—This article reports on meta-analytic findings demonstrating the effi-
cacy of interpersonal psychotherapy for depression.
Lilliengren, P., Johansson, R., Lindqvist, K., Mechler, J., & Andersson, G. (2016). Efficacy of expe-
riential dynamic therapy for psychiatric conditions: A meta-analysis of randomized controlled
trials. Psychotherapy, 53, 90–104.—This article provides meta-analytic findings for the efficacy
of brief dynamic psychotherapy, particularly affect-focused variants.

DVDs and Videos

Levenson, H. (2010). Brief dynamic therapy over time (running time 300 minutes). Washington, DC:
American Psychological Association.—This training video demonstrates basic principles of brief
dynamic psychotherapy from a relational perspective as illustrated in clinical work over six ses-
sions with a young woman.
 Interpersonal and Brief Psychodynamic Therapies 439

Ravitz, P., Watson, P., & Grogoriadis, S. (2015). Interpersonal psychotherapy for depression (stream-
ing video; running time 58 minutes). Available at www.psychotherapy.net/video/interpersonal-
psychotherapy-depression.—This training video provides a didactic overview of interpersonal
psychotherapy, along with clinical vignettes that illustrate its principles.

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 CHAP TER 13

Integrative Approaches
to Psychotherapy
Jerry Gold
George Stricker

T he term psychotherapy integration encompasses a philosophical, conceptual, and clini-

cal orientation to the study and practice of psychotherapy. This perspective is defined
by openness to understanding the convergences and commonalities among the vast array
of sectarian psychotherapies, and by an interest in promoting dialogue among therapists
of all orientations. Psychotherapy integration is defined also by a willingness to learn from
all therapies and therapists rather than to declare exclusive loyalty to one school or model
of psychotherapy. Our preference is for a process of integration that guides psychotherapy
rather than any single product or integrative psychotherapy that might become yet another
sectarian approach, with all the limitations attendant upon that status (Stricker, 2010). It is
impossible to discuss any single integrative psychotherapy as the definitive version, as these
approaches are highly varied and, optimally, are in a continuous state of evolution. In this
chapter we discuss those contemporary integrative approaches that generally are considered
most influential, and we attempt to describe the commonalities and consistencies among
these models when possible.

HISTORICAL BACKGROUND

As with many developments in psychotherapy, perhaps the first inklings of what became
psychotherapy integration appeared in Freud’s (1914) early writings. The founder of psy-
choanalysis saw that understanding and insight often were insufficient to produce change,
as he advised other analysts to take an active stance with phobic and obsessive patients.

443
444 OTHER INFLUENTIAL MODELS

For the former group, he mentioned the need for the analyst to “compel” the patient to face
the object of his or her fears, while for the latter group he noted the need for the patient to
actively interrupt his or her obsessional thinking. It seems that he was aware of the role of
techniques such as in vivo exposure and thought-stopping long before these interventions
were described by behavior therapists.
French (1933) was perhaps the first analyst to advocate for integration at a theoretical
level, as he alerted psychoanalysts to the need for psychoanalytic theory and practice to
account for the findings of Pavlov in the area of classical conditioning. A second seminal
contribution was Rosenzweig’s (1936) introduction of the hypothesis that the many varieties
of psychotherapy shared a limited number of essential effective ingredients, or common fac-
tors. His article is the forerunner of contemporary versions of common-factors integration.
During the 1940s and 1950s, several efforts at integrating then-current versions of psy-
choanalytic theory and learning theory were proposed. The most extensive, influential, and
long-lasting contribution was made by Dollard and Miller (1950), who integrated central
psychoanalytic ideas about unconscious motivation and conflict with concepts drawn from
the learning theories of Hull, Spence, Tolman, and Mowrer (Klein, 2009). Although both
orthodox psychoanalysts and learning theorists often were scornful and dismissive of this
model, thinkers who were open to contributions from other theories and from empirical
research found inspiration in Dollard and Miller’s unique synthesis.
Another highly important influence on many integrative clinicians, although not spe-
cifically integrative, was Psychoanalytic Therapy (Alexander & French, 1946). This volume
introduced the concept of the corrective emotional experience, referring to an event that
takes place between therapist and patient. During the course of the therapeutic interaction,
certain attitudes, emotions, and behaviors of the therapist were found to modify, powerfully
and immediately, unconscious assumptions and perceptions derived from the patient’s early
development and interpersonal history. For example, the concept of the corrective emotional
experience, and its prescriptive perspective on interventions, expanded the psychoanalyst’s
role from the provision of insight via interpretation to the provision of new experiences lead-
ing to change within the therapeutic interaction.
The seminal contribution of J. Frank (1961) was influenced by several disciplines, such
as psychology, anthropology, and sociology. It sought commonalities in the change process
initiated by a variety of interventions, ranging from psychotherapy to faith healing. As such,
it provided the foundation for works investigating the common factors in psychotherapy.
In the 1960s, the first explicit attempts at integrating two or more psychotherapeutic
systems were published. Most of these focused on combining concepts and methods drawn
from behavioral and psychoanalytic models. An early and neglected classic of this type was
the marriage of Freud and Skinner proposed by Beier (1966), who described the role that
reinforcement and operant conditioning processes played in the shaping, maintenance, and
extinction of unconscious conflict and motivation.
In the next decade there were several efforts that crossed the boundaries of the tradi-
tional psychotherapies and created integrative, or eclectic (as they were more often known
at that time), psychotherapies. Examples of these explorations were the papers published
by Marmor (1971) and by Feather and Rhodes (1973), who found that unconscious issues
could be treated through the use of behavioral methods, such as being desensitized to one’s
core conflict. Lazarus’s (1976) multimodal therapy laid the foundation for the technical
integration approach to psychotherapy integration, which combines techniques from several
different theoretical approaches without allegiance to any of them.
 Integrative Approaches to Psychotherapy 445

This trend culminated in the publication of Psychoanalysis and Behavior Therapy:

Toward an Integration (Wachtel, 1977), which has been perhaps the single most important
and influential work on the theoretical integration of various psychotherapies. This book,
and the positive response it generated, opened the floodgates in the field of psychother-
apy integration. During the 1980s, many prominent psychotherapy scholars and clinicians
explored the technical, theoretical, and philosophical possibilities of integrating therapies in
a newly invigorated and enthusiastic way (Arkowitz & Messer, 1984). The Society for the
Exploration of Psychotherapy Integration (SEPI; www.sepiweb.org), founded in the early
1980s, began to publish the Journal of Psychotherapy Integration in 1991. Two thorough
handbooks on psychotherapy integration, which included many of the most important inte-
grative therapies then available, were published in the early 1990s (Norcross & Goldfried,
1992; Stricker & Gold, 1993). They demonstrated that integrative thinking had progressed
beyond an exclusive focus on the synthesis of psychoanalytic and behavioral models.
In his discussion of the evolution and development of scientific theories, Kuhn (1962)
noted that maturing theories move from innovation to a state of “paradigm elaboration,” in
which the now-established model is advanced in small increments that reflect the assump-
tion that it is “true” or correct. It is possible that psychotherapy integration has reached
this stage of paradigm elaboration, as it has become widely endorsed as a preferred perspec-
tive within the field of psychotherapy. Evidence of this acceptance is widespread. Reports
of integrative training in university graduate programs, and models of integrative supervi-
sion have become commonplace. Holt et al. (2015) described an educational and research
program in which graduate students in psychology are trained and evaluated in learning
the integrative model of prescriptive psychotherapy. Other approaches to teaching integra-
tive therapies have been described by Boswell (2017); Trub and Levy (2017); and Watkins
(2018). A third edition of the most widely read handbook on psychotherapy integration was
published (Norcross & Goldfried, 2003). A perusal of the tables of contents of mainstream
psychotherapy journals yields the awareness of the frequent publication of articles with an
integrative content.
Two surveys of psychotherapists also attest to the widespread acceptance of an integra-
tive perspective amongst psychotherapists. Norcross, Karpiak, and Santoro (2005) surveyed
the members of the Division of Clinical Psychology of the American Psychological Associa-
tion, asking those clinicians to identify their primary therapeutic orientation. Twenty-nine
percent of the respondents indicated that they identified with an eclectic orientation, the
most frequently endorsed orientation in the study. When two of these authors repeated the
study (Norcross & Karpiak, 2012), 22% indicated allegiance to an eclectic orientation,
second only to a cognitive framework.
Why is it that psychotherapy integration as a perspective, and integrative psychothera-
pies as therapeutic models, have become so widely accepted in the last 20 to 30 years? Most
students of the history of psychotherapy integration (Gold & Stricker, 2006) suggest that
the failure of any traditional model of psychotherapy to “win all the prizes” and to establish
itself as clearly superior to the others had much to do with this change. Another important
group of factors was external to psychotherapeutic practice but affected psychotherapists
most profoundly. These factors included the rise of biological models of psychopathology;
the introduction of new generations of increasingly effective psychiatric drugs; and new
requirements by the public, the government, and insurance companies for therapists to dem-
onstrate the effectiveness of their methods. Suddenly, the “enemy” was no longer the psy-
choanalyst, the cognitive-behaviorist, or the Gestalt therapist across the road. As people
446 OTHER INFLUENTIAL MODELS

have always done when under siege, therapists put aside their differences and began to work
together and to learn from each other.
Other, more positive events may be responsible for the rapid rise of interest in integra-
tive therapies. Most of the founding schools of psychotherapy had their origins 50–100
years ago. The founders and founding generations are gone, and the succeeding generations
may be more confident in crossing boundaries and assimilating new, “foreign,” ideas than
were those early therapists struggling to establish a new therapeutic position. As the world
has become smaller and more integrated, dissemination of ideas and communication among
contributors occurs more rapidly. The decades of the 1960s, 1970s, and 1980s saw a ques-
tioning of traditional authority in academics and in politics, integration in the social realm,
as well as the cross-fertilization of many aspects of Western culture, including music, visual
arts, literature, sports, and science.
A recent trend that has emerged in psychotherapy integration may in fact mark the end
of psychotherapy integration as we know it. Magnavita and Anchin (2013) proposed that
the larger field of psychotherapy is undergoing a paradigmatic shift in theorizing, one that
may have been brought about in large part by the movement toward integration. This shift
in thinking, they argued, is characterized by an interest in the unification of many forms
of psychotherapy rather than the integration of elements of single-school therapies. These
authors, and others, have begun the task of describing and fleshing out the theoretical scaf-
folding and clinical methods that might be contained within a unified psychotherapy. Mag-
navita and Anchin have provided one such framework for this unification, termed unified
psychotherapy, which has received positive attention in the general psychotherapy literature.
It is too early to tell whether they will be proved correct. Their argument has been countered
by Messer (2008), for example, who pointed out that in the social sciences there are always
alternative ways to conceptualize any phenomenon, thus making a single, unified psycho-
therapy highly improbable.

MODELS OF PSYCHOTHERAPY INTEGRATION

Currently there are four commonly accepted modes or forms of psychotherapy integration
(Gold & Stricker, 2006). These modes, which define general ways in which theory and
technique have been integrated, are known as technical eclecticism, the common-factors
approach, theoretical integration, and assimilative integration. The ongoing process of psy-
chotherapy integration relies on these modes, and each established integrative approach to
psychotherapy can be considered an example of one of these modes, although the boundar-
ies between them occasionally are fuzzy.

Technical Eclecticism
Technical eclecticism is the most clinical and technically oriented form of psychotherapy
integration, but it involves the least amount of conceptual or theoretical integration. Clini-
cal strategies and techniques from two or more therapies are applied sequentially or in
combination, usually following a broad and comprehensive assessment of the patient. This
assessment describes the interconnections between the problems to be addressed and the
cognitive, behavioral, emotional, and interpersonal characteristics of the patient. Tech-
niques are chosen on the basis of the best clinical match to the needs of the patient, as
 Integrative Approaches to Psychotherapy 447

guided by clinical knowledge and research findings, regardless of their theoretical origin.
It is important to note that this may not actually be a form of integration, as techniques
often are merely combined rather than integrated, and have a synergistic rather than an
integrative impact.
The most important examples of this type of integrative psychotherapy are (1) multi-
modal therapy (Lazarus, 2006), (2) transtheoretical psychotherapy (Prochaska & DiClemente,
2002), and (3) prescriptive psychotherapy and systematic treatment selection (Beutler, For-
rester, Gallagher-Thompson, Thompson, & Tomlins, 2012).

Multimodal Therapy
Multimodal therapy grew out of Lazarus’s dissatisfaction with traditional behavior therapy
and relies on supplementing behavioral interventions with cognitive, imagery-based, and
experiential techniques. Lazarus (2006) assesses seven areas of each patient’s biopsychoso-
cial functioning (BASIC ID, which is an acronym for Behavior, Affect, Sensation, Imagery,
Cognition, Interpersonal relations, and Drugs/biology), and develops a treatment plan that
targets any of those areas for intervention, selecting the particular techniques on the basis
of the empirical literature, clinical guidelines, and clinical experience. Lazarus argued that
this eclectic therapy produced the broadest and most specific assessment of the patient and
his or her immediate adjustment, and allowed the therapist to tailor treatment to the unique
excesses, deficits, and eccentricities of functioning presented by each individual.

Transtheoretical Psychotherapy
Transtheoretical psychotherapy (Prochaska & DiClemente, 2002) is a broadly studied, empir-
ically validated, and widely applied framework for identifying the best match of the patient’s
characteristics and specific therapeutic models and techniques. In particular, patients are
assessed for their readiness for change, and for the unique processes of change that will
work best for them. These authors have identified 10 change processes that predominate
in the majority of therapies: consciousness raising, dramatic relief, self-reevaluation, envi-
ronmental reevaluation, self-liberation, social liberation, counterconditioning, stimulus con-
trol, reinforcement management, and the helping relationship. They also have been able to
demonstrate that every patient arrives in therapy at one of six stages of readiness to change,
which include precontemplation, contemplation, preparation, action, maintenance, and ter-
mination. Someone who begins therapy at the stage of precontemplation is not even ready to
think about change, while at the stage of contemplation he or she can imagine changing but
is not yet ready to do anything to change. In the next stage (preparation) he or she is gather-
ing energy and resources to alter his or her life, while in the action stage the patient makes
overt use of therapy. The last two stages focus on making sure that new ways of living are
permanent (maintenance), then on ending therapy (termination). This system also includes
an assessment of the levels of change that are necessary for each patient. This idea refers to
the particular domains of psychological problems from which the patient suffers. Assessment
of the necessary levels of change in this model includes the areas of symptoms and situational
problems, maladaptive cognitions, current interpersonal conflicts, family and system con-
flicts, and intrapersonal conflicts. Once the patient is assessed in these three domains—pro-
cesses of change, stages of change, and levels of change—via specifically designed self-report
448 OTHER INFLUENTIAL MODELS

scales, an individualized treatment plan drawn from all potential psychotherapeutic tech-
niques can be developed (Prochaska & DiClemente, 2002).
Norcross, Krebs, and Prochaska (2011), who conducted a meta-analysis of the research
on this model that included 39 high-quality studies, concluded that the stages of change
model is useful in predicting progress in psychotherapy, as degree of change by the patient
was correlated with stage of change. Patients who entered therapy in the stages of pre-
contemplation and contemplation improved least, while patients who began therapy at the
preparation and action stages improved to a greater degree. Stage of change also was found
to predict the status and quality of the therapeutic alliance, and of dropout rate, again with
the earlier stages being correlated with poor alliance and higher rates of premature termina-
tion. The authors offered guidelines for integrative practice based on the theory and their
research findings, which included early, careful assessment of each patient’s stage of change,
matching of relationship qualities to stage of change, and matching of techniques to stage
of change.

Prescriptive Psychotherapy
Prescriptive psychotherapy does not limit the schools of therapy from which it draws its
techniques, aiming similarly at the best match of therapist, strategies, and techniques to
the patient’s problems and characteristics. Variations on four dimensions of the wide range
of psychotherapies are considered in relation to each patient’s attributes. These therapeutic
dimensions include (1) the necessary intensity of the therapy, (2) a focus in the therapy on
insight or on skill and behavior change, (3) the degree to which the therapist is directive,
and (4) changes in the ways in which the patient’s emotions are managed within sessions.
The patient is assessed on several dimensions. The patient’s degree of functional impairment
determines the type and intensity of the therapy, for example, whether pharmacotherapy
or psychotherapy is the intervention of first choice. The patient’s level of distress is under-
stood to lead to choices between interventions aimed at affect regulation (for high levels
of distress), or techniques that increase awareness of and access to emotion (for patients
with lower levels of pain). The patient’s coping style (internalizer vs. externalizer) points
to the type of psychotherapy that is offered: Internalizing styles are better matched with a
more insight-oriented approach, while impulsive or externalizing styles have been found to
respond more positively to more behavioral methods. A relative absence of resistance on the
patient’s part encourages the use of a more directive stance by the therapist, while greater
indications of reactance are matched with relatively more nondirective interactions. Finally,
positive motivation for participation in therapy and for change is encouraged by the selec-
tion of techniques that modulate and maintain the patient at an optimal (moderate) level
of emotional arousal and distress (Beutler et al., 2012). Beutler, Forrester, Holt, and Stein
(2013) have continued to refine and test this integrative approach, and have accumulated
impressive data that support its clinical applications and predictive value.

Common-Factors Approaches to Integration

Common-factors approaches start with the identification of effective ingredients that
are practiced in common across many therapies. This way of thinking has its origins in
Rosenzweig’s (1936) seminal discovery that all therapies share certain change processes,
despite their idiosyncratic theories and techniques. J. Frank’s (1961) observation, central to
 Integrative Approaches to Psychotherapy 449

common-factors thinking, was that all systems of psychological healing share certain com-
mon, effective ingredients, such as socially sanctioned rituals, the provision of hope, and the
shaping of an outlook on life that offers encouragement to the patient.
Integrative therapists who use a common-factors approach try to identify which of the
several known common factors will be most important in the treatment of a particular indi-
vidual. Once the most salient common factors are selected, the therapist reviews the array of
interventions and psychotherapeutic interactions to find those that have been found to pro-
mote and contain those ingredients. The integrative therapies that result from this process
are structured around the goal of maximizing the patient’s exposure to the unique combina-
tion of therapeutic factors that will best ameliorate his or her problems. Garfield’s (2000)
common-factors integrative therapy, which relies on the combination of insight, exposure,
and the provision of new experience and hope through the therapeutic relationship, is one
well-known form of common-factors integration.
Wampold (2015) presented a contextual model for psychotherapy extracted from the
research literature that investigated the relative contributions of common factors and treat-
ment-specific factors to therapeutic outcome. He concluded that there is a far more con-
vincing argument for common factors as being critical to therapeutic change than for the
treatment effects of any specific ingredient of individual therapies. Furthermore, Wampold
identified a number of common factors that have been found to have medium to large treat-
ment effects. These included goal collaboration between patient and therapist; therapist
empathy; the therapeutic alliance; therapist provision of affirmation and positive regard;
and therapist characteristics such as congruence, that is, freedom from active personal con-
flict while engaging in psychotherapy.
Another somewhat radical approach to common-factors integration has been contrib-
uted by Duncan, Miller, Wampold, and Hubble (2010), who argue that the therapeutic
alliance and client engagement are the crucial change factors across all psychotherapies.
Having studied the work of “supershrinks,” that is, expert therapists who have been found
to be most highly effective, these authors suggested that the impact of psychotherapy is
determined by the therapist’s willingness and ability to monitor the alliance and the client’s
experience of engagement, by soliciting and using feedback from the client with regard to
the state of the therapeutic relationship and what could be done to improve it.

Theoretical Integration
Theoretical integration is the most complex, sophisticated, and difficult mode of psycho-
therapy integration. Psychotherapies that are theoretically integrated rely on a process of
synthesizing aspects of varied personality theories, combining models of psychopathology,
and integrating various mechanisms of psychological change from two or more traditional
systems. These novel integrative theories may indicate the mutual influence of environmen-
tal, motivational, cognitive, and affective variables.
Theoretically integrated systems of psychotherapy use interventions from each of the
component theories, as well as propose original techniques that may be added to the techni-
cal selection of the traditional therapeutic schools that are the basis of this new approach.
Wachtel’s (1977) cyclical psychodynamic theory and its integrative therapy was the first
fully developed form of theoretical integration. He developed a psychodynamically based
model of personality, psychopathology, and change that acknowledged and used reinforce-
ment and social learning principles, along with traditional psychoanalytic exploration. The
450 OTHER INFLUENTIAL MODELS

usual model of exploration leading to understanding and then change was supplemented
by the idea that behavioral change, produced by behavioral interventions, might lead to
increased understanding. For example, changing impulsive behavior may not require prior
understanding, but understanding might follow from impulsive behavior change. Wachtel
(2014) has continued to expand and enhance this model through several iterations, incor-
porating concepts and methods from experiential therapies, family systems approaches, and
attachment theory. He also has expanded his understanding of the role of such cultural and
social issues as racism, poverty, and sexism in determining the psychological state of the
individual and the role of these factors in his integrative psychotherapy,
Process–experiential therapy (Greenberg, Rice, & Elliott, 1993) is an example of a
theoretically integrative approach that can be placed within the humanistic psychotherapy
tradition. This therapy builds on the relationship factors of warmth, empathy, and priz-
ing by adding active interventions and concepts from Gestalt and cognitive therapies, and
attachment theory, all of which are utilized with the aim of changing the patient’s experi-
ence of self and his or her relationships with an internalized other.
Emotionally focused therapy (Brubacher, 2017; Johnson, 2004) originated as an off-
shoot of process–experiential therapy as applied to the treatment of couples. It has devel-
oped into a unique, integrative approach to psychotherapy for couples and individuals that
synthesizes attachment theory with experiential concepts.

Assimilative Integration
Assimilative integration has been the focus of much recent interest (Messer, 2001, 2015;
Stricker & Gold, 2019) and can be seen as a derivative of both theoretical integration and
technical eclecticism. Messer (1992) introduced this concept into the field of psychotherapy
integration when he noted that all actions are defined and contained by the interpersonal,
historical, and physical context in which those acts occur. As any therapeutic intervention
is a highly complex interpersonal action, therapeutic interventions are defined, and per-
haps even re-created, by the larger context of the therapy. Certain theoretically integrative
approaches may be understood to be assimilative as they incorporate new techniques into
an existing conceptual model of therapy. When techniques are applied clinically within a
theoretical context that differs from the context in which they were developed, the mean-
ing, impact, and use of those interventions may be modified in powerful ways. For example,
when interventions such as the use of systematic desensitization are assimilated into client-
centered therapy, the meaning, impact, and purpose of this intervention will be altered by
this new context and by the alternative goals and outlook of the therapist. Thus, a behav-
ioral method such as systematic desensitization may mean something entirely different to a
patient whose ongoing therapeutic experience has been defined by experientially oriented
exploration than that same intervention would mean to a patient in traditional behavior
therapy. And the intervention may produce results entirely different than when used in its
usual setting: In this example, the introduction of this behavioral technique may be a dem-
onstration of the therapist’s empathy and prizing of the patient.
The psychodynamically based integrative therapy proposed by Stricker and Gold
(2019) is an example of this form of integrative therapy. In this approach, therapy proceeds
according to standard psychodynamic guidelines, but methods from other therapies, such as
the two-chair technique from Gestalt or process–experiential therapy, are used when called
for, and they may advance certain psychodynamic goals indirectly at the same time as being
 Integrative Approaches to Psychotherapy 451

effective in treating the target problem. As this model has evolved, ideas and interventions
drawn from new and innovative therapies such as acceptance and commitment therapy
(Hayes, Strosahl, & Wilson, 1999) have become increasingly important integrative compo-
nents as well (Gold, 2014). In addition, Stricker and Gold (2019) have discussed the need to
locate and understand the patient’s psychology and psychopathology within an individual-
ized social and cultural framework, in order to make accessible to intervention any difficul-
ties connected to issues of diversity and discrimination
Newman, Castonguay, Borkovec, Fisher, and Nordberg (2008) have described an
ambitious and highly successful research program that has aimed at testing and validat-
ing an assimilative integrative treatment for generalized anxiety disorders. Their integra-
tive model is based on cognitive-behavioral therapy (CBT) and integrates experiential and
interpersonal concepts and methods. These authors suggested that the outcome of standard
cognitive-behavioral protocols can be surpassed when the patient’s emotional process is
addressed directly through experiential techniques. Furthermore, they pointed out that the
painful work of addressing anxiety symptoms, and the cognitive precursors of those symp-
toms, often provoke ruptures and strains in the therapeutic relationship, which are most
effectively addressed through interpersonal exploration. When this therapy was compared
to a standard cognitive-behavioral approach, it was found to have a greater positive impact
on patients’ symptoms, and a longer lasting and more noticeable effect on both symptoms
and interpersonal problems.

BRINGING THE BODY INTO PSYCHOTHERAPY INTEGRATION

Certain recent developments in psychotherapy integration do not fit neatly within the frame-
work of the models we described earlier. These new models share a concern with and a focus
on integrating various forms of psychotherapy with interventions that have direct impact
on the body. The developers of these integrative approaches (Levine & van der Kolk, 2015)
share certain assumptions about the relationship of the brain, the body, and central psy-
chological processes such as cognition and emotion. Most importantly, all of these models
are built on the hypothesis that psychological variables can be changed, and psychological
suffering can be alleviated, by directly utilizing or intervening in physiological processes.
Some, but not all, of these integrationists also believe that most, if not all, forms of psycho-
pathology have concurrent bodily manifestations, and that if these correlates are addressed
directly and simultaneously, the effectiveness of psychological interventions is increased.
Eye movement desensitization and reprocessing (EMDR; Shapiro, 2017) has emerged
as an important and somewhat controversial method for the treatment of trauma and of
posttraumatic stress disorder. Shapiro (2017) serendipitously discovered that the deliberate,
simultaneous linkage of rapid eye movements with the emergence of disturbing thoughts
and images led to a dramatic reduction in the emotional impact of those cognitions, as well
as lessening the time during which those ideas and images remained in the patient’s mind.
EMDR therefore can be understood to be an integrative therapy that is based on the behav-
ioral change principle of exposure, but that incorporates other active physical interventions
and both psychodynamic and cognitive concepts and methods. Among the chief modifica-
tions that EMDR utilizes is the therapist’s active elicitation of the patient’s eye movements
during the exposure phase of the therapy. This is accomplished by instructing the patient
to follow the therapist’s hand, a wand, or some other stimulus as it is moved laterally and
452 OTHER INFLUENTIAL MODELS

rapidly in front of the patient’s face. At the same time, the patient is instructed to recall a
traumatic memory and to describe all of the associated memories, thoughts, feelings, and
bodily sensations that are connected to and stimulated by the memory. After this phase is
completed, the clinician attempts to link or to install new and positive ways of thinking
about traumatic experiences. The EMDR therapist operates from the assumption that suc-
cessful exposure and desensitization now allow the patient to consider and to adopt more
useful and adaptive ways of thinking about past events. The installation is conducted as
was the exposure: The patient is instructed to think about the traumatic event in a new way
while following the therapists’ finger or wand in rapid, side-to-side eye movements.
EMDR has been evaluated in a very large number of studies and found to be as effective
as other cognitive and behavioral therapies for the treatment of trauma (Seidler & Wagner,
2006). However, other writers (Prochaska & Norcross, 2009) have suggested that what is
effective in EMDR is its imagery-based exposure component, and that there is no evidence
that the eye movements add any benefit to the therapy. In a recent meta-analysis of outcome
studies of EMDR, Chen et al. (2014) found that it is effective in reducing the symptoms of
posttraumatic stress disorder (PTSD), anxiety disorders, depression, and subjective distress.
As EMDR has become more widely known and accepted within the general psychothera-
peutic community, a trend toward assimilating its techniques into longer, more traditional
therapies, including client-centered, psychodynamic, and systems approaches, has emerged
(Shapiro, 2017).
Other new versions of integrative psychotherapy use direct bodily interventions to
influence psychological states and their physical manifestations. Somatic experiencing psy-
chotherapy (Levine & van der Kolk, 2015) is another integrative therapy of this type, in
which techniques meant to increase awareness of and comfort with bodily experiences are
introduced into exploratory verbal psychotherapy. Rappaport (2015) has suggested that
aspects of somatic experiencing therapy can be integrated into a relational psychoanalytic
model. A recent controlled trial of the effectiveness of this treatment for patients with PTSD
suggested that it is highly effective at reducing symptoms and enhancing psychological func-
tioning (Brom et al., 2017).

THE CONCEPT OF PERSONALITY

Personality as an explanatory or organizing construct (i.e., as an implicit or inferred set of

psychological constructs and behaviors) is very much a part of certain integrative psycho-
therapies. Other systems of psychotherapy integration barely acknowledge the notion of
personality or exclude it completely. Attention to personality is omitted from most inte-
grative models that are based on common-factors integration or on technical eclecticism.
The prescriptive focus of these psychotherapies, in which symptoms and targeted problems
are matched with therapeutic ingredients (common factors) or with assumed effective tech-
niques (technical eclecticism), results in the therapist using a narrower lens to understand
the patient and his or her behavior and experience. An inferred conceptual system or model
of personality presumably would add little to the effectiveness of the prescriptive power of
these psychotherapies and might, in fact, serve as an intellectual distraction for the therapist.
Personality is a much more important concept in those integrative psychotherapies that
are based on theoretical or assimilative integration. Assimilative integration has a single
personality theory and theory of therapy as its organizing feature. Theoretical integration
 Integrative Approaches to Psychotherapy 453

involves the synthesis of two or more independent personality theories into a novel model
of personality. A critical assumption behind this theoretical amalgamation is that this new,
integrative personality theory is an improvement over the component theories in its abil-
ity to inform the therapist’s understanding of psychological development, psychopathology,
and, most importantly, the best and most efficacious choice of interventions.
Integrative theories of personality are employed in two ways, the first of which is simi-
lar to the manner in which traditional theories of personality are used in pure forms of
psychotherapy: as a guide in the identification of psychological structures (e.g., schemas
and defense mechanisms) and other features (e.g., anxiety, unconscious motivation, and
affect) that need to be influenced and changed by therapy. Second, and uniquely, these theo-
ries posit and explain the relationship between psychological phenomena that are ignored
or considered irrelevant by traditional theories. Such explanations illustrate an extremely
important and singular characteristic of integrative models of personality: Integrative theo-
ries substitute circular conceptualizations of causation for the linear views of causation
that are typical of traditional personality theories. Circular views of causation suggest that
there are no levels or areas of psychological life that are unimportant, or that should be
understood merely as superficial, as may result from the more narrow views inherent in
older models of personality.
Gold (1996) has pointed out that the personality theories supporting contemporary
integrative approaches share a number of common assumptions and emphases, regardless
of deviations in the specific terminology used in each contribution. Integrative personality
theories share a deep concern for the way the individual comes to understand his or her
experience, and for those core meaning structures that compose the person’s sense of self
and representation of significant relationships. Attachment theory (Bowlby, 1980) seems to
have become a meeting ground for integrative thinkers who employ a model of personal-
ity. Its foundational principle of internal working models of attachment relationships can
be seen as theoretically neutral and can therefore be integrated into cognitive-behavioral,
humanistic, and psychodynamic models, all of which are concerned with the ways in which
patients construe the facts of their lives and relationships.
The most comprehensive and influential integrative theory of personality is cyclical
psychodynamics (Wachtel, 1977, 2014). Cyclical psychodynamic theory presented a model
of personality that emphasizes the mutually and reciprocally determining nature of behav-
ior, interpersonal relationships, and unconscious motivation and conflict, demonstrating
that a clinically viable and conceptually elegant synthesis of psychoanalytic and learning
theories may be achieved. The theory assisted therapists in understanding how changes in
psychodynamics could both lead to and follow from changes in behavior and in interactions
with others. The latest iteration of cyclical psychodynamics has expanded the theory to
include concepts drawn from family systems theory, relational psychoanalysis, experien-
tial theories, and cognitive theory. As noted earlier, Wachtel (2014) also has addressed the
meaning and impact of systemic, contextual and sociocultural issues such as discrimination
and poverty, and has described the impact of these environmental variables on the develop-
ment of individual personality
The procedural sequence object relations model (Ryle & McCutcheon, 2006) is another
integrative approach to personality. This model informs cognitive analytic therapy (CAT)
and is a synthesis of concepts drawn from cognitive psychology, cognitive therapy, and
psychoanalytic object relations theory. The theory describes the complex interrelationships
between the way that the individual consciously processes information about the self and
454 OTHER INFLUENTIAL MODELS

others and the unconscious developmental antecedents of the person’s cognitive structures,
beliefs, assumptions, and role definitions. The therapist presents this understanding of func-
tioning and motivation to the patient, and they then work together to modify it using both
cognitive-behavioral and psychodynamic techniques.
Another example of this type of integrative personality theory, proposed by Johnson
(2004), integrates attachment theory with ideas from client-centered, cognitive, and experi-
ential therapies, as the foundation of emotionally focused therapy. Johnson sees personality
as the collection of schemas and models of relatedness that derive from early interactions
with significant others and that serve as the driving forces of adult relationships. Meanings
concerned with and reflective of early relationships are understood to unwittingly shape
and bias current experiences in one’s relationship with oneself and with others. This theory
serves as a foundation for therapeutic interventions drawn from the three aforementioned
source therapies, all of which can address the modification of pathological meanings.

PSYCHOLOGICAL HEALTH AND PSYCHOPATHOLOGY

Few integrative approaches specifically offer a comprehensive psychological model of health,

and the “disease orientation” is true of the majority of psychotherapies (Bohart & Tallman,
1999). Most integrative therapies contain within them the definition and conceptualization
of health and pathology that derive from the specific component therapies that are amal-
gamated. However, many integrationists share certain critical assumptions about the nature
and appearance of psychological health.
Psychological health seems to consist of freedom from psychological constraints on
the perception and construction of meaning and experience (Bohart, 1992; Greenberg et
al., 1993); repetitive, dysfunctional patterns of thought and of the organization of cogni-
tive data (Guidano & Liotti, 1983); redundant and maladaptive ways of engaging and
relating to others (K. Frank, 1999); and the unwitting repetition and maintenance of
developmental traumas, conflict, and attachments (Gold & Stricker, 2015). Thus, inte-
grationists seem to characterize psychological health as the ability to define one’s goals;
successfully jettison, modify, or retain goals depending on their (individual and social)
adaptive benefit; develop plans to obtain and actively seek out these goals; learn from
self-generated and other-generated feedback; and attain them without intrapersonal or
interpersonal interference.
It stands to reason, then, that an integrative perspective on the development and main-
tenance of psychopathology would focus on those psychological and environmental factors
that inhibit the individual’s freedom of experience and responsiveness, and eventuate in psy-
chological and behavioral redundancy. Most integrative theorists work from a developmen-
tal framework in that they emphasize the role of childhood and adolescent events in laying
down the foundations of perception, thinking, and motivation that lead to psychopathol-
ogy (Wachtel, 2014). Essentially, these theorists posit that negative, painful, anxious, and
defeated familial and social interactions are internalized and become part of the patient’s
cognitive and emotional representational systems. This negatively toned representational
system, which consciously and unconsciously leads to ongoing predictions and construal of
danger (shame, guilt, humiliation, abandonment, etc.) in many, if not most, important inter-
personal situations, cannot help but lead the patient into avoidant, defensive, and ultimately
self-defeating and self-replicating patterns of construing reality and of social relatedness
 Integrative Approaches to Psychotherapy 455

(Wachtel, 1977). These “vicious circles” (Wachtel, 2014) are central variables in most inte-
grative accounts of psychopathology.
Most integrative theories of psychopathology operate within what Messer (1992) has
identified as the “ironic vision”; that is, things come out badly and redundantly despite the
person’s best efforts to achieve a new result or experience (Wachtel, 2014). Few persons
are aware of the restricting power of their representational systems or of the ways in which
they unwittingly reproduce past hurts and disappointments in the present. They are aware,
however, of the cognitive, emotional, and interpersonal sequelae of those hurts, and it is this
distress that often eventuates in the decision to enter therapy.
The various models of integrative psychotherapy rely on several diagnostic systems,
some of which are generic (i.e., the fifth edition of Diagnostic and Statistical Manual of
Mental Disorders [DSM-5]; American Psychiatric Association, 2013) and others of which
are uniquely associated with the particular psychotherapy that is used. We have already
described the diagnostic model (BASIC-ID) that is at the heart of multimodal therapy (Laza-
rus, 2006). In transtheoretical psychotherapy (Prochaska & DiClemente, 2002) the patient
is evaluated on a three-dimensional matrix. Ryle’s (1997; Ryle & McCutcheon, 2006) CAT
is built around a detailed and formal assessment of the patient’s cognitive functioning or
procedural sequences, with particular attention paid to “traps” (dysfunctional assump-
tions and beliefs), “dilemmas” (polarized alternative conceptualizations of experience), and
“snags” (aims that are abandoned due to the anticipation of negative consequences).

THE PROCESS OF CLINICAL ASSESSMENT

Assessment in most integrative approaches is based on the methods that are typical of the
component therapies that make up each integrative method. This is most often the case for
those integrative therapies that are exemplars of either theoretical or assimilative integra-
tion, as these therapies tend to be more long term and more concerned with “deeper” or
more complex changes (e.g., in personality structure and representational systems). Thus,
an integrative therapy that leans heavily on a psychodynamic foundation, such as cyclical
psychodynamics (Wachtel, 2014) or assimilative psychodynamic psychotherapy (Stricker &
Gold, 2019), for example, assesses patients initially and primarily with regard to psycho-
dynamic issues such as conflict, character, resistance, and object representations. These
therapies also include ongoing, process-oriented assessments, as do traditional psychody-
namic treatments: The patient is evaluated, and the therapist’s understanding is revised and
reformulated on an ongoing basis throughout therapy, based on the patient’s responses and
form of participation.
The integrative assessment is expanded to include evaluation of the person’s function-
ing at the cognitive, experiential, and behavioral levels, and the mutual influence of those
levels on each other and with psychodynamic issues and structures. Similarly, a theoretically
integrated therapy that primarily is behaviorally based, such as Fensterheim’s (1993) behav-
ioral psychotherapy, would assess the usual behavioral variables in a context that includes
an ongoing evaluation of the variables that are considered critical from the additional and
integrated therapeutic orientation. Where integrative assessment differs from a traditional
assessment is in the therapist’s awareness of, and attention to, the possibility and advantage
of using an intervention from another therapeutic system (e.g., a psychodynamic therapist
may use techniques from CBT or experiential therapy, among others). The parameters of
456 OTHER INFLUENTIAL MODELS

assessment are expanded to include an ongoing evaluation of the benefits and limitations of
the “home” or foundation therapy, and of the patient’s individualized needs, goals, strengths,
and weaknesses, all of which may best be met by an integrative shift. Certain integration-
ists (Bohart, 2000; Gold, 2000) advocate the ongoing assessment of the patient’s conscious
assessment of the therapy, and his or her ideas about which techniques and strategies would
be most helpful. As mentioned earlier, Duncan (2010) has built his common-factors-based
approach on the technique of immediate feedback by the client about the state of the thera-
peutic alliance and about therapeutic progress.
Integrative therapies are oriented to the individual; the “unit” of assessment is the
individual person, with awareness that this person cannot be understood separately from
the interpersonal context in which he or she is located. There exists, however, an increas-
ing number of exceptions to this individual focus, as an impressive number of therapists
have made important contributions to integrated versions of couple, family, and group psy-
chotherapies (Johnson, 2004; Lebow, 2006; Pitta, 2015). In these therapies, assessment is
guided by the specific theoretical approach to the functioning of the particular unit, be it
two or more members.
The focus of integrative assessment usually is broader and deeper than assessment in
any single, pure-form therapy, and includes interest in intrapsychic, cognitive, behavioral,
experiential, and interpersonal variables. Perhaps the chief benefit of assessment within an
integrative model is that there are no aspects of the patient’s psychological life and envi-
ronmental situation that cannot be included in a therapeutic formulation. The emphasis on
specific psychological processes, experiences, or relationships is a reflection of the specific
component therapies that are integrated. Interest in assessing the individual within a contex-
tual framework is an intrinsic part of many integrative approaches. Assessment of context
includes an evaluation of past and current interpersonal relationships and the ways in which
others in the patient’s life become neurotic accomplices (Wachtel, 1977). This term refers to
the way that significant persons contribute to the maintenance and exacerbation of patients’
problems by confirming their fears and their problematic representational processes. Assess-
ment of context has been extended by some to include much broader issues as well. Wachtel
(2014), and Stricker and Gold (2019) have discussed the need to account for the effect of
racial discrimination, poverty, and social disenfranchisement on individual psychology and
psychopathology, and have included evaluation of the effects of gender discrimination and
political disempowerment on psychological suffering and psychotherapy.
Most integrative therapists explicitly describe an assessment of patients’ strengths as
an integral part of their work. These strengths often become the basis of interventions, as
patients are helped to take on challenges and areas of weakness by using and extending
skills in which they are already proficient. As noted earlier, certain theorists (e.g., Bohart,
2000; Duncan, 2010) have suggested that patients often know best what they need, and may
even have the skills to change, but are unaware of the ways in which those skills could be
best applied or in which situations these efforts would be most productive.
Certain integrative approaches that are examples of technical eclecticism or of com-
mon-factors integration are based on an immediate, comprehensive assessment of the
patient and of the best match with particular therapists and therapies that lead directly into
the selection of therapeutic interventions. These therapies are almost entirely driven by this
assessment. We have already discussed several examples of this type of integrative therapy:
multimodal therapy (Lazarus, 2006); transtheoretical therapy (Prochaska & DiClemente,
2002); and systematic treatment selection (STS; Beutler et al., 2013). These approaches
 Integrative Approaches to Psychotherapy 457

frequently use standardized psychological tests to conduct assessments. For example, Beu-
tler and colleagues mention specific instruments, such as the STS Clinician Rating Form,
the Patient Compliance Scale, and the STS Therapy Process Rating Scale, as essential and
regular sources of data that inform the process through which prescriptive treatment plans
evolve. Variables such as the stages of change and processes of change are assessed in trans-
theoretical therapy through the use of self-report measures (the University of Rhode Island
Change Assessment [URICA] and the Processes of Change [POC] measure; Prochaska &
DiClemente, 2002). Few integrative systems based on theoretical integration include such
heavy reliance on standardized tests, though individual therapists may use some at their
discretion. We discussed earlier the predictive validity of these assessments with regard to
the status of the therapeutic alliance and treatment outcome.
Few integrative therapies rely heavily on formalized psychiatric typologies such as
DSM-5 or ICD-10. Those that do typically use psychiatric diagnosis as a starting point for
a more intensive and psychologically oriented assessment. An example of this approach is
the cognitive-behavioral analytic system of psychotherapy (CBASP), an integrative therapy
developed for the treatment of dysthymic disorder (depression) by McCullough (2001). In
this model, the psychiatric diagnosis is the entry point, which indicates that this therapy is
appropriate for this patient. However, the assessment that is crucial to the progress of the
treatment goes beyond diagnosis and into the spheres of cognition, behavior, and interper-
sonal skills.

THE PRACTICE OF THERAPY

There is considerable variation in the basic structure of therapy across the many varieties of
integrative psychotherapies. As we have stressed in this chapter, the characteristics of each
approach are determined largely by its component therapies. Thus, as a general rule, though
one with more than enough exceptions, those integrative therapies that are more heavily
psychodynamic are longer term (2 or more years) and tend to meet at least on a weekly basis,
with two or even three sessions per week being far from unknown. Integrative approaches
that give more emphasis to cognitive-behavioral and experiential schools tend to be shorter
in length and meet once a week or even less frequently. Typically, sessions last from 45 min-
utes to 1 hour.
Several integrative therapies that have been described are specifically identified as short
term. These include accelerated experiential–dynamic psychotherapy (Fosha, 2000), short-
term restructuring psychotherapy (Magnavita & Carlson, 2003), and CAT (Ryle, 1997),
among others. These integrative therapies are designed to be completed in 20–30 weekly ses-
sions. In the earlier stages of the development of psychotherapy integration, most integrative
efforts were focused on individual therapy, and the majority of current integrative models
remain individually focused; therefore, attendance in sessions is limited to patient and thera-
pist. However, as we noted earlier, an increasing number of well-received integrative systems
have emerged in the areas of couples and family therapy (Johnson, 2004, 2019; Pitta, 2015).
Therapists working within these models schedule sessions with individuals, couples, fami-
lies, subsystems within families, and groups, as dictated by clinical necessity. The degree to
which any session is structured or governed by a predetermined agenda is a function of the
theoretical slant of the specific integrative model. Therapies that lean heavily on humanis-
tic, experiential, or psychoanalytic foundations are less likely to be highly structured than
458 OTHER INFLUENTIAL MODELS

those that are more cognitive-behavioral in orientation. For example, CBASP (McCullough,
2001) resembles standard cognitive-behavioral approaches much more than other integra-
tive therapies in its extensive use of homework assignments and goal setting for each session,
and in the therapist’s active direction of the content and process of each session.
The various integrative therapies differ significantly with regard to the nature and spe-
cifics of the goals determined for each patient. Those approaches that are based on a psy-
choanalytic or humanistic–experiential foundation posit that most patients can benefit from
certain broadly defined changes, regardless of the particular presenting problems. These
universal goals include changes in underlying meaning or representational structures, char-
acter structure, getting in touch with one’s feelings, feeling freer to act, and the patient’s
ability to be open to the symbolization and integration of new experiences. Those therapies
(typically those within the mode of technical eclecticism, which are more prescriptive or
shorter term due to their reliance on a structured assessment), tend to avoid such general,
shared goals. Instead, they focus more specifically on the patient’s immediate subjective
distress and those symptoms and functional deficits that accompany or eventuate in that
distress.
Most integrative models stress that goal setting is best accomplished through a process
of collaboration in which the therapist may take the lead through the assessment process
but is open and respectful of the patient’s needs, wishes, and ideas, particularly as these may
reflect the patient’s efforts to revise or reject the therapist’s formulation and treatment plan.
Most integrative therapists emphasize overt discussion of some, if not all, therapeutic goals.
This is an essential part of establishing trust, respect, and a therapeutic alliance. Goals that
are more likely to be discussed are those that are connected to the patient’s overt behavior,
conscious thoughts and feelings, and relationships. For example, discussion of the wish to
deal with uncomfortable affect or the problem caused by repetitive difficulty in relationships
may provide clear goals for the patient and the therapist. Goals that may guide the therapist,
but which refer to psychic processes and structures, probably are discussed less frequently
with patients. It is possible to place the many integrative therapies on a continuum of goals
that, at one end, would be described as therapist-driven, and at the other, patient-driven.
Those therapies that are found at the patient-driven end are typically concerned with resolu-
tion of the presenting problem and give less emphasis to inferred intrapsychic issues. This
patient-specific approach to goals is most evident in the model of client-directed therapy
developed by Duncan (2010), in which patient and therapist collaborate in developing thera-
peutic strategies and selecting interventions based on the patient’s theory of change, and his
or her plan for achieving those changes.
Advocates of psychotherapy integration argue emphatically that one of the main advan-
tages of this attitude is that integrative models allow goals to be established at any level, or
in any realm of psychological experience: relational, behavioral, cognitive, affective, moti-
vational, and characterological. Goals do not have to be excluded, overlooked, or character-
ized as “shallow” or inconsequential due to a preordained theoretical position. Of course,
integrative therapies have their limits, broad as they may be. For example, Lazarus (2006)
has made it clear that patients who understand their problems as reflecting unconscious
psychosexual conflicts, and who wish to work on such issues, would be best referred to a
therapist who could concur with those goals.
Almost any form of conventionally accepted therapeutic intervention may be used
when deemed clinically appropriate. The choice of intervention may combine the theoreti-
cal perspective of the therapist and the needs of the patient (in theoretical or assimilative
 Integrative Approaches to Psychotherapy 459

integration) or may reflect the therapist’s clinical assessment of the patient’s needs and the
process of matching (as in technical eclecticism and common-factors integration). Inter-
pretation of unconscious processes is used in those therapies that integrate psychodynamic
principles, when the therapist hypothesizes that insight into unwitting motives, conflicts,
resistances, and self and object representations would be helpful to the patient.
Integrative therapists also use cognitive restructuring, skills-building interventions, and
exposure techniques from cognitive-behavioral approaches; experiential techniques, such as
the empty chair and two-chair dialogue methods from Gestalt therapy; and empathy, priz-
ing, and reflection of feeling from client-centered therapy, to name just a few of the more
prominent types of interventions. At one point in a session, the patient may work on tol-
erating anxiety generated by a feared confrontation with a boss (imaginal desensitization),
practice a conversation with someone he or she would like to date (assertiveness training),
or work on resolving a long-standing grief reaction by conversing with a deceased parent
who has been “placed” in the empty chair across the room. At other times during a session,
or in later sessions, the focus might be on alleviating the patient’s overly harsh self-criticism
by pointing out the “shoulds” and “musts” that dominate his or her thinking, and by help-
ing the patient to keep track of these thoughts and to substitute more soothing and realistic
ideas. Had these interventions been selected in the context of a therapy defined as techni-
cally eclectic or as a common-factors approach, the selection would have been guided by the
central, pressing clinical need and by identification of the technique that would best meet
that need. Selection of that technique in a theoretically or assimilatively integrated theory
would be based also on the effect of that technique on recognition of the meaning of the
psychological experience, as well as on the problem.
Homework is a central feature of most integrative therapies, especially those that are
based on a cognitive-behavioral foundation, since that school of therapy has always incor-
porated homework as an essential treatment component. The extension of therapeutic work
to homework assignments has become a more frequent and commonplace part of other inte-
grative methods. The regularity of incorporating homework into integrative therapies was
demonstrated by the publication of a special issue of the Journal of Psychotherapy Integra-
tion (2006) that was devoted to this topic.
Sometimes the homework assignments, which usually are developed collaboratively,
are traditional applications of cognitive, behavioral, or experiential exercises in the context
of another theoretical orientation: Patients whose in-session work leads to psychodynamic
insights about their avoidant behavior challenge themselves to face new social situations
or to modify the thoughts that drive the anxiety. Other instances of homework are more
assimilative and integrative in nature: Homework exercises are used to provoke changes
in areas of psychological life other than those with which they usually are associated. For
example, patients may be taught relaxation techniques not only because these methods lead
to the expected reduction in anxiety but also because successfully lessening those symptoms
lead to changes in their self-image and perception of the therapist as willing to be helpful
(Gold & Stricker, 2015). Patients might be asked to evaluate the effects of the relaxation
when entering situations in which they are ordinarily fearful (e.g., going through a tunnel in
a train) and to see whether lessened anxiety might lead to increased awareness about feel-
ings, thoughts, memories, and conflicts associated with that event.
Brodley (2006) studied the naturally occurring instances of homework in client-cen-
tered therapy and found that it typically was initiated by the patient without input from the
therapist. Nelson and Castonguay (2017) conducted an investigation of the use of homework
460 OTHER INFLUENTIAL MODELS

within the context of an assimilatively integrative psychotherapy and found that regular use
of such assignments was related to significant patient improvement.
Perhaps the most critical strategic and technical questions in any integrative psycho-
therapy are when to move from one technique to the next and, correspondingly, when to
shift orientations and strategies from the behavioral to the experiential to the psychody-
namic, and so on. The answers are easier and more straightforward in those technically
eclectic and common-factors-based integrative models that feature a comprehensive and
specific assessment geared to prescriptive matching. In these therapies, a shift in technique
occurs when the clinical focus changes. For example, as the patient gains certain skills with
a behavioral intervention, other issues of a cognitive or emotional nature may emerge. After
patient and therapist agree on the next issue to be addressed, the process of prescriptive
matching is reapplied and may occur many times until the completion of therapy.
Knowing when to make an integrative shift in a theoretically or assimilatively inte-
grated therapy is more difficult and usually is guided by immediate process observations
made by the therapist, often as a reflection of his or her subjective experience of the thera-
peutic relationship and alliance. K. Frank (1999), and Gold and Stricker (2015) have sug-
gested some guidelines for such integrative shifts. Essentially, these writers agree that move-
ment from one orientation and set of therapeutic techniques to another (perhaps from the
psychodynamic to cognitive-behavioral) is indicated when the initial way of working has
become uncongenial to the patient, overtaxes the patient’s ability to cope or cooperate with
therapy, requires skills that the patient has not yet developed, or unwittingly is damaging
to the patient.
Gold and Stricker (2015), among others, have suggested that certain patients, especially
those who are more fragile, less trusting, and less psychologically sophisticated, often make
more rapid progress in therapy when the first techniques used are more concrete and prag-
matic (i.e., more cognitive-behavioral). These patients seem to make better use of psychody-
namic exploration when it is introduced after presenting problems have been ameliorated to
some degree, and after the therapist has been established as helpful and trustworthy. A shift
away from a psychodynamic toward a more immediately pragmatic form of therapy often
may help patients avoid or alleviate feelings of being confused, mystified, and frustrated by
the more subtle goals and methods of psychodynamic therapy and can give these individuals
a critically important boost in self-esteem when they have used a cognitive, behavioral, or
other technique to solve a problem.
Resistance to change in integrative therapies is conceptualized as resulting from a single
factor or a combination of psychological and social factors. In prescriptive psychotherapy,
resistance is seen as deriving from the personality trait of reactance, defined as the degree to
which the person accepts or chafes and rebels against structure and direction. The psycho-
dynamic component of many models suggests that resistance occurs when the patient feels
frightened of some internal state that is about to emerge into awareness, or is pained, guilty,
or ashamed about some past experience, or about the prospect of leaving old ways of living
and former attachments behind. The cognitive and behavioral contributions to understand-
ing resistance allow therapist and patient to look at the contribution of each member of
the dyad. Has the therapist asked too much of the patient, or has he or she underestimated
the impact of a suggestion or intervention? On the patient’s side, resistance may arise from
a lack of understanding of the tasks that are posed, an unwillingness to be open to the
therapist’s interventions, or a lack of investment in actively changing. Resistance shows itself
in myriad forms, from the subtle characterological patterns with which psychodynamic
 Integrative Approaches to Psychotherapy 461

therapists are familiar to the more overt types of reactance or noncompliance described by
cognitive-behavioral therapists (Dowd, 1999). Examples of the former include the patient
consistently missing a few minutes of the session; engaging the therapist in an overcompli-
ant, hostile, or idealizing manner; or avoiding certain key subjects by substituting others.
On the more obvious side is a failure to keep appointments, a disregard for agreed-upon
homework assignments, and an unwillingness to participate fully in active interventions of
whatever type.
Resistance is resolved clinically by exploration of the meaning of the problem at
any level that is necessary (interpersonal, psychodynamic, systemic, cognitive, affective,
or behavioral), shifting an interpretation, altering the tone and stance of the therapeutic
relationship, or rethinking the choice and intensity of the interventions that are suggested.
Resistance may be a sign of a therapeutic rupture, in which case it is important to identify it
and resolve it as quickly as possible.
Integrative therapists who understand individual functioning in a contextual, interper-
sonal context are acutely aware of “accomplices in neurosis,” that is, significant individuals
who unwittingly or knowingly interfere with the patient’s progress in therapy (Wachtel,
2014). Integrative therapists may work directly with these significant others on occasion,
while at other times the therapeutic focus is on helping the patient to develop the necessary
interpersonal skills to overcome the influence of an accomplice, or to end the relationship,
if all else fails.
The most common therapist errors that are unique to integrative models are the failure
to make an integrative shift when it is called for and the too rapid use of an integrative shift
when ongoing work within one theoretical and technical framework is a better fit. The first
type of error seems to occur frequently because of the somewhat vague guidelines for timing
shifts, and sometimes when the therapist is still bound up by loyalties and anxieties about
his or her allegiance to one therapy school. Overly rapid shifting, or the overuse of integra-
tion, may also occur due to (countertransferential) anxiety on the part of the therapist. For
example, the therapist may feel too uncomfortable to continue working with a particular
issue and may therefore suggest a shift in strategy or technique.
Psychotropic medications are often a part of integrative therapy (Beitman & Saveanu,
2005). The therapist who is a psychiatrist or psychopharmacologist may integrate biologi-
cal and psychological components of the therapy, or may refer the patient to a colleague
for a medication consult. Otherwise, medication is handled much as it is in any traditional
therapy.
Termination of therapy usually results from a mutual decision by patient and therapist
that the treatment has reached its end. Some of the specifically short-term integrative mod-
els mentioned earlier specify a number of sessions at the start. Other integrative therapies
do not, particularly those that have a significant psychodynamic component. In this latter
group of therapies, termination often is considered a significant event that is explored for
several weeks or months, with particular concern for evoked developmental issues around
separation and loss.

THE THERAPEUTIC RELATIONSHIP AND THE STANCE OF THE THERAPIST

The therapeutic relationship is one of the central common factors that produces changes in
virtually all forms of psychotherapy (Rosenzweig, 1936; Wampold, 2015). On this point,
462 OTHER INFLUENTIAL MODELS

most therapists of most orientations agree. Where and how the various therapies deviate
from each other is in their relative emphasis on the many effective ingredients of the thera-
peutic relationship that make it so potentially potent, and on how to maximize the impact
of the relationship.
In our earlier discussion of the common-factors approach to integration, we noted how
central relationship factors and the therapeutic alliance are related to progress and outcome
in psychotherapy. It is doubtful that any integrative thinker or practitioner would contradict
this point. The central theme of this chapter is highly applicable here: Integrative therapies
aim to expand the therapeutic relationship as fully as possible to make that relationship as
effective as possible.
Again, the particular conceptualization of the relationship in each specific integrative
therapy is guided by the way the relationship is construed and used in the major compo-
nent therapies. Thus, an integrative therapy that is heavily interpersonal (Safran & Segal,
1990), psychodynamic (K. Frank, 1999; Wachtel, 2014), or experiential and person-centered
(Elliott, 2017) will emphasize, respectively, identifying and resolving enactments of the cli-
ent’s problems with the therapist; the interpretation of transference; or prizing, empathy,
and warmth. These are considered the most important variables in producing change. Inte-
grative therapies that are more cognitive-behavioral or systemic in orientation do not ignore
the therapeutic relationship and its effectiveness but see it as one factor among several that
can lead to change, and as a platform for the active learning that takes place in the more
technical parts of the therapy. A major difference is that the latter approach uses the rela-
tionship as the foundation of care, whereas the former approach uses it as the vehicle of
change.
Many integrative forms of therapy converge around the concept of the therapeutic alli-
ance, as most integrative approaches are founded on the view that effective change occurs
best when patient and therapist are bonded in a mutually agreed-upon set of goals, within
the context of a positively toned and perceived interaction. The process of integration, and
the notion of the integrative shift in particular, seems to some integrative writers (Gold &
Stricker, 2015) to be particularly effective in establishing an alliance firmly and quickly,
and is a way to reestablish or repair the alliance when it has been strained or ruptured. K.
Frank (1999) noted that the inclusion of cognitive and behavioral techniques in a psycho-
analytic therapy constitutes not only a technical shift but also an interpersonal communica-
tion to the patient, one that in effect says, “I’m aware of your suffering with these thoughts,
actions, and feelings, and I will try actively to help. I won’t let you sit there alone.” Along
these same lines, Gold and Stricker (2015) point out that skills-building techniques, such as
assertiveness training, and self-soothing cognitive techniques may enhance self-esteem and
can assist the patient in overcoming negatively toned perceptions of his or her experience in
therapy, thus enhancing the therapeutic alliance.
Some of the strengths of integrative therapy also carry the seeds of potential short-
comings. For example, the flexibility and creativity that can be exercised by the integrative
therapist also may open the door to more undisciplined approaches, particularly when
there is no theoretical rationale for the intervention. Messer (2006) has also presented a
significant challenge to integration. He has spelled out what he refers to as visions of real-
ity, taking the terminology from literary criticism. Different visions characterize different
therapeutic orientations, and sometimes different versions of the same orientation. For
example, an extended psychodynamic treatment can be described as “tragic” because of its
recognition of human limitations, whereas briefer psychodynamic therapy and behavioral
 Integrative Approaches to Psychotherapy 463

approaches are more readily described as “comic” because of the focus on a happy ending.
An integrative therapist often shifts from one approach to another, but with the shift in
technique there also is a shift between what may be incompatible visions of the nature of
reality.
Integrative therapists sometimes take active control of the sessions. This is the case
when the therapist suggests an integrative shift, or a homework assignment. The therapist
shifts from an exploratory, facilitative role when he or she introduces an active interven-
tion into psychodynamic or experientially oriented psychotherapy. Certainly, therapists who
identify themselves as multimodal or prescriptive, and those who work from a common-
factors perspective, often are active and directive in sessions. However, active and directive
does not mean dictatorial and authoritarian. The key phrase a few sentences ago was “the
therapist suggests.” Most integrative therapists view their patient or client as a collabora-
tor and partner. (In fact, we think all good therapists share this perspective, regardless of
orientation.) Thus, the patient’s sense of what will work for him or for her, the patient’s
own theory of change (Duncan, 2010), and the patient’s right to refuse a suggestion must be
respected. It is the therapist’s task to provide the conditions in which change is most likely
to occur. It is the therapist’s responsibility to know and to offer the patient a variety of
ideas, experiences, tasks, and resources that may lead to change. It is the patient’s task and
opportunity to attempt to make use of these conditions and experiences to see whether he
or she can and will change. The therapist may work with those issues (anxiety, resistance,
neurotic accomplices, or lack of skill) that interfere with the patient’s ability to change, but,
ultimately, progress comes from the patient’s efforts (Bohart, 2000).
The therapist’s own history as a person and professional and his or her experience of
the patient obviously enter into any therapy to some degree. As well versed as any clinician
may be in theory and technique, ultimately, he or she will understand the patient and his or
her situation and needs from a personal point of view. Once again, we must reiterate that
how an integrative therapy makes use of issues such as therapeutic self-disclosure, counter-
transference, and the “person” of the therapist varies from system to system. These issues
are most evident in models that are concerned with interpersonal issues such as enactment:
an event within the therapeutic relationship in which the therapist is “hooked” into replay-
ing with the patient the kinds of interactions that affected the patient negatively in the past,
or that currently are dysfunctional (K. Frank, 1999; Safran & Segal, 1990). There is no way
to know that an enactment is occurring without examining one’s feelings, thoughts, and
experiences, and often these must be shared with the patient before the enactment can be
resolved.
As therapy progresses, and especially as termination of therapy nears, most integrative
models suggest that the therapist turn responsibility for decision making about the ses-
sions, homework, and integrative shifts over to the patient. This reinforces autonomy and a
sense of self-efficacy, minimizes the patient’s anxiety about life after therapy, and allows the
patient to practice the “self-therapy” he or she will need in the future.
It is daunting to work as a therapist in any form of therapy. It may be more daunting
and personally demanding to work as an integrative therapist. The integrationist must be
able intellectually to master the concepts and methods of two or more systems. He or she
also must be able to stay free of the common human desire to align with one school of
thought, and to tolerate the ambiguity that lurks in all psychotherapies. The therapist must
be able to straddle the roles of authority, participant, collaborator, and follower, and must
neither idealize nor devalue his or her technical, interpersonal, and experiential expertise.
464 OTHER INFLUENTIAL MODELS

CURATIVE FACTORS OR MECHANISMS OF CHANGE

Integrative psychotherapies explicitly are designed to include as many relevant change fac-
tors as possible, and therefore to broaden the likelihood that patients are exposed to those
factors that best meet their needs. Any change mechanism that has been described consis-
tently in the psychotherapy literature may be found to play a prominent role in one version
or another of integrative psychotherapy. Most integrative models stress some combination
of the following: insight into, or increased awareness of, conscious and unconscious psycho-
logical processes; exposure to anxiety-generating stimuli; learning of new behavioral skills
and correction of behavioral dysfunctions, cognitive restructuring, and modification of deep
meaning structures (schemas, object representations, models of attachment, etc.); enhancing
one’s capacity to put experience into words and to experience emotion by directing the focus
of inquiry in this direction; provision of an explanation for the troublesome behavior or
relational pattern; and bringing about change in repetitive and destructive patterns of inter-
personal relatedness. This last mechanism includes the provision of new experiences within
the therapeutic relationship through the “corrective emotional experience” (Alexander &
French, 1946) or through those relationship conditions, emphasized in humanistic psycho-
therapies, such as prizing, warmth, and genuineness on the part of the therapist. Gold and
Stricker (2015) and Wachtel (2015) have pointed out that a change factor that seems to cut
across many, if not most, forms of psychotherapy and psychotherapy integration is accep-
tance of distressing emotions and experiences, and the subsequent expansion of awareness.
The particular emphasis given to each of the several mechanisms of change is deter-
mined by the specific nature of the integrative model, and by the theories and methods com-
bined in that model. For example, as we have discussed previously, therapies based on tech-
nical eclecticism or on common-factors integration attempt to match the patient’s problems
with those curative factors that have been demonstrated to be most effective. Theoretical
integration and assimilative integration add to this prescriptive focus a certain number of a
priori assumptions about which of the many change factors are likely to be most important,
stemming from the home theory.
For example, psychodynamically influenced integrative therapies proceed from the
assumption that insight is an important change factor but expand the therapy to include
other change factors, such as direct exposure, learning new interpersonal skills, and direct
intervention in the patient’s family system. Wachtel’s (1977) cyclical psychodynamic therapy
and Gold and Stricker’s (2015) assimilative psychodynamic therapy are examples of this
way of thinking. In addition, virtually all integrative therapists agree that there are “many
roads to Rome”: that several types of interventions can lead to the same change factor
becoming operative, and that change factors can be linked. Wachtel (1977) has discussed
the important observation that insight often follows behavioral change rather than always
preceding it. Similarly, Safran and Segal (1990) base their cognitive interpersonal therapy
on the premise that important cognitive structures can and will change only after the ongo-
ing interpersonal patterns that maintain them have changed. The notion of a cyclical rather
than a linear direction of change is an important one.
Because change in interpersonal skills is considered crucial to change at every level of
psychological life, any legitimate technique may be applied. Certain integrative approaches
emphasize change within the therapeutic relationship, asserting that the most problematic
interpersonal patterns and skills deficits will appear in the therapeutic interaction. Not sur-
prisingly, these therapies tend toward the interpersonal, humanistic, and psychodynamic.
 Integrative Approaches to Psychotherapy 465

Didactic instruction in interpersonal functioning tends to be more typical of models that

slant toward the cognitive-behavioral, though these boundaries frequently are crossed, as is
the wont in integrative therapies. It often is the case that changes will be experienced first in
the therapeutic relationship but then be generalized, with the active assistance of the thera-
pist, to relationships outside therapy.
Most integrative therapies include as significant change factors the impact of the thera-
pist’s personality and of the therapeutic relationship. The many lists of common factors that
are available (Wampold, 2015) always prominently include these variables. Integrative ther-
apies that are based heavily on person-centered therapy (e.g., Bohart’s [1992] experiential
approach to integration) stress the classical Rogerian conditions of unconditional positive
regard, accurate empathy, and warmth as critical change factors, though not to the exclusive
degree that Rogers did. In many ways, a unifying goal of psychotherapy integration is the
attempt to go beyond the therapeutic relationship and the impact of the therapist as a person
by noting and including technical interventions that have positive influence as well.
In this regard, integrative therapists have stressed client factors as a central element
in change more clearly and frequently than has any single school of psychotherapy. Bohart
and Tallman (1999) suggested that client involvement is the most important factor in any
form of psychotherapy, reporting that research indicates that up to 30% of change may be
accounted for by the client’s active participation. Bohart (2000), Gold (2000), and Duncan
(2010) have discussed this curative factor in the context of several different forms of integra-
tive therapy, ranging from therapies based on strategic models to experientially and human-
istically oriented approaches, to a model that is psychodynamically informed.
To summarize, there is little that is unique about curative factors in psychotherapy inte-
gration, almost by definition, because the integrative process draws on other approaches to
treatment. Some approaches to integration, such as the common-factors approach, are com-
posed entirely of general change factors rather than unique factors. Technical eclecticism
is made up entirely of interventions drawn from different approaches. Both theoretical and
assimilative integration are based on a home theory and at least one other major approach.
They not only share a view of change with the home approach but also show a willingness
to incorporate constructs or interventions from other approaches, indicating an expanded
view of change. The uniqueness of psychotherapy integration rests in the breadth of the
process rather than in any theoretical or technical aspect of the treatment.

TREATMENT APPLICABILITY AND ETHICAL CONSIDERATIONS

Goldfried (1999) illustrated both conceptually and visually the dilemma of the psychother-
apy patient in a cartoon that he included with an article concerned with the advantages
of psychotherapy integration. This cartoon depicts the first meeting of a therapist and a
patient. While this duo is shaking hands in greeting, the thoughts of both are revealed in a
bubble above the head of each person. The patient privately frets, “I wonder if he can treat
what I have?” The therapist, equally troubled, ponders the question, “I hope he has what I
treat!”
In large part, interest in psychotherapy integration, and in specifically integrative
therapies, evolved in order to solve this problem. Integrative psychotherapies, at least in
theory, seem to be uniquely suited to the needs of patients with diverse backgrounds and
problems, those whose lives, personalities, and psychopathology deviate from the “ideal
466 OTHER INFLUENTIAL MODELS

types” most easily treated by one of the sectarian therapies. Among the most obvious and
important characteristics of successful integration are the flexibility of the therapist and of
the therapeutic approach, and the overarching concern for the uniqueness of the patient.
Several integrative systems, such as the transtheoretical model and STS, are geared toward
developing the most efficacious patient–technique match possible. Common-factors inte-
gration, theoretical integration, and assimilative integration, although not based on explicit
prescriptive matching, still guide the therapist toward interventions that are broader and
more individualized than is possible in any traditional psychotherapeutic system. There is
a broad spectrum of patient populations, psychological problems, and psychopathological
disorders to which these methods have been successfully applied. As the basic premise of
integrative psychotherapy is using the best of what works, any therapeutic approach to any
problem, at least in theory, may be improved by the addition of active ingredients from
other models.
Integrative therapists are bound by and must follow the same set of ethical principles as
do their colleagues who work within traditional models of therapy. Integrative psychothera-
pies do carry with them at least two unique ethical challenges. First, the integrative therapist
must be fully trained and competent to use techniques from each and any of the therapies
that are integrated. Failure to reach this level of competence would mean that the therapist
might be engaging in malpractice. Second, the therapist might have good clinical reasons to
make an integrative shift. Patients are not to be experimented on, especially without their
knowledge and consent. Perhaps to work fully within good ethical boundaries, the therapist
must explain and obtain consent whenever a change of method is considered. These points
have not been addressed to any great extent in the integrative literature.
Integrative approaches have been applied to obsessive–compulsive disorder (McCarter,
1997) and to panic and anxiety disorders (Gold, 1996). Newman et al. (2008) described
an assimilative integration approach to the treatment of generalized anxiety disorder that
utilizes CBT as its foundation and selectively incorporates interpersonal and experiential
techniques. The authors found that this approach led to a significant improvement in anxi-
ety symptoms that was maintained for at least a year, and that this improvement appeared
to be greater than that found with other trials of standard CBT for this disorder.
Though these contributions differ, they share a concern with the provision of behav-
iorally oriented exposure techniques, and psychodynamically and experientially oriented
interventions. In this way, these integrative therapies go further than traditional therapies
in ensuring that “all the bases are covered” with regard to the level of psychological activity
implicated in this group of disorders.
Depression in its acute and chronic forms has been the focus of much effort on the part
of integrationists. For example, Klerman (Klerman, Weissman, Rounsaville, & Chevron,
1984) has an integrative, interpersonal psychotherapy for depression. Hayes and Newman’s
(1993) integrative treatment for depression combined techniques from cognitive therapy,
behavior therapy, interpersonal therapy, psychodynamic therapy, experiential therapy, and
biological psychiatry. McCullough’s (McCullough, Schramm, & Pemberthy, 2015) inte-
grative CBASP model is the most effective therapy for chronic depression that has been
introduced to date. The CBASP model integrates concepts and methods from cognitive,
behavioral, analytic, and systems approaches and it leads to a therapy that is tailored to the
specific psychological deficits and problems that cause the ongoing depressive symptoms.
An integrative therapy for depression that incorporates interpersonal techniques
aimed at resolving alliance ruptures within a standard cognitive-behavioral framework
 Integrative Approaches to Psychotherapy 467

was developed by Castonguay (2011), who also reported that he had obtained preliminary
research support for this approach. Likewise, McCarthy, Keefe, and Barber (2016) found
that moderate levels of the assimilative use of process–experiential techniques in a psy-
chodynamically based therapy led to an enhanced outcome in the treatment of depressed
patients.
More severe forms of psychopathology that often are refractory to traditional psy-
chotherapies also have been treated with integrative therapies. Linehan’s (1987) dialectical
behavior therapy (DBT) for borderline personality disorder is a prominent example. Gold
and Stricker (1993) explored the integration of cognitive-behavioral and psychodynamic
therapies for the treatment of personality disorders, a therapeutic approach that strongly
resembled Ryle’s (1997) application of CAT to borderline and narcissistic disorders. Kel-
lett (2005) found that CAT also was effective in the treatment of patients with dissociative
identity disorder. More recently, Clarke, Thomas, and James (2013) followed up on Ryle’s
(1997) work and found that patients with a range of personality disorders responded posi-
tively when treated with CAT. Hilsenroth and Slavin (2008) reported on an approach to
the treatment of comorbid depression and borderline personality disorder that combined
psychodynamic, behavioral, and cognitive methods, and was supported by research findings
as well.
There are several effective integrative methods for the treatment of substance abuse and
dependence. Knack (2009) described an approach that integrated psychodynamic psycho-
therapy and 12-step work in the treatment of alcoholism. Gottdeiner (2013) has successfully
applied a psychodynamically oriented method of assimilative integration to the treatment of
substance abuse and dependence, while Rothchild (2015) has described an integrative treat-
ment for substance abuse that combines psychoanalytic methods with techniques drawn
from traditional substance abuse treatment.
A new and promising area of study is the use of integrative methods with patients suf-
fering from physical distress and illness. For example, Dornelas (2008) created an integrative
psychotherapy that improved the psychological and physical well-being of cardiac patients.
Luyten and Van Houdenhove (2013) found that an integrative psychotherapy based on men-
talization and attachment was effective in treating patients with chronic fatigue syndrome.
Malberg (2013) described the effective use of a mentalization-based, assimilative integration
approach to group psychotherapy with chronically ill adolescents.
A number of investigators have expanded on earlier efforts to treat severe forms of
psychopathology, including bipolar disorder, psychosis, and schizophrenia, with integra-
tive therapies (e.g., Hellkamp, 1993; Zapparoli & Gislon, 1999). Harder and Folke (2012)
introduced a psychotherapy for schizophrenia that integrates standard CBT with the psy-
choanalytically influenced intersubjective approach. This work includes the effective use
of CAT in the treatment of psychosis (Taylor, Jones, Huntley, & Seddon, 2017), and with
patients diagnosed with bipolar disorder (Evans, Kellett, Heyland, Hall, & Majid, 2017).
Jenner (2015) introduced hallucination-focused integrative therapy (HFIT), an approach
that specifically targets the auditory and visual symptoms of psychosis. This therapy incor-
porates aspects of CBT, family systems approaches, psychoeducation, crisis intervention,
and motivational interviewing. Jenner reported that the effectiveness of this therapy, and its
superiority to standard cognitive-behavioral approaches, has been demonstrated through a
series of clinic trials.
This description of wide applicability may make the integrative therapies seem to be
the treatment of choice for all patients. Although integrative therapy may be more widely
468 OTHER INFLUENTIAL MODELS

applicable than any other single approach, because it can go beyond that single approach, no
treatment can be all things to all people. The type of integration that is practiced, and the
presenting problem and goals of the patient establish the limits of the integrative therapies.
On the one hand, a patient who is interested solely in self-exploration and has no focal symp-
tom would be best treated by a person with a psychodynamic or a humanistic orientation.
On the other hand, a patient who has a focal symptom and no interest in self-exploration or
change beyond the presenting problem would be best treated by a person with a behavioral
or cognitive-behavioral orientation. Of course, the patient who presents with one and only
one interest, be it self-exploration or symptom alleviation, is unusual. Comorbidity is more
likely than unidimensional problems, and the integrative therapies, because of their breadth
and flexibility, have much to recommend them.
Several integrative therapists also have developed models of therapy that account spe-
cifically for the unique goals, experiences, needs, and perspectives of particular patient pop-
ulations. Integrative models have been developed for persons of color who live in the United
States (Franklin, Carter, & Grace, 1993) and for patients who are members of traditional
African societies. Madu (1991) introduced an integrative model that combined traditional
African modes of healing with Western psychotherapies. Other integrative approaches are
aimed at patients for whom spirituality and religion are important (Sollod, 1993). Butollo
(2000) and Wachtel (2014) have demonstrated how an understanding of the economic,
political, and ethnic situations in which patients live can be incorporated in therapies that
also integrate psychodynamic, cognitive-behavioral, and systems components. Van Dyk and
Nefale (2005) also have described an integrative therapy that is sensitive to, and incorpo-
rates, indigenous ideas and methods of healing into the framework of standard psychody-
namic psychotherapy. Their model, based on their experiences working in rural areas of
South Africa, addressed the needs of patients who live within the complex, multicultural
environment of that nation and of much of Africa.
Integrative models have been developed for virtually all age groups and for individuals,
couples, and families. Coonerty (1993) described an integrative therapy for children that
synthesizes behavioral, family systems, and psychodynamic elements. Several integrative
approaches focus on adolescents and their families (e.g., adolescents with anxiety disorders
and depression [Fitzpatrick, 1993] and high-risk adolescents [Alexander & Sexton, 2002]).
Papouchis and Passman (1993) described an integrative model of psychotherapy designed
to meet the needs of geriatric patients, involving a judicious integration of cognitive-behav-
ioral techniques into a psychodynamically oriented psychotherapy. The specialties of couple
therapy and family therapy have, as noted earlier, been the focus of an increasing number of
important integrative contributions in recent years. As examples of these developments we
can mention the following. Earlier, we described Johnson’s (2004) emotionally focused ther-
apy for couples. Gerson (2015) has developed an approach to couple therapy that integrates
psychoanalytic work with systems theories and interventions. Pitta (2015) has described an
assimilative integration model for work with families that synthesizes a Bowenian model
with psychoanalytic and cognitive-behavioral methods.

RESEARCH SUPPORT AND EVIDENCE-BASED PRACTICE

Research supporting integrative approaches to psychotherapy has been reviewed in detail

in several summary articles (Castonguay, Eubanks, Goldfried, Muran, & Lutz, 2015;
 Integrative Approaches to Psychotherapy 469

Schottenbauer, Glass, & Arnkoff, 2005; Zarbo, Tasca, Cattafi, & Compare, 2015). In each
of these reviews, the authors concluded that there was a solid and ever-expanding empirical
base for the effectiveness of a variety of integrative approaches.
Cromer (2013) surveyed the empirical literature that reported on the utility of integra-
tive techniques and their relationship to positive processes and outcomes in psychotherapy:
improved therapeutic alliance, patient satisfaction and engagement, and improvement of
symptoms. Four classes of integrative interventions were found to be related to these pro-
cess and outcome variables: affect-focused techniques, supportive techniques, exploratory
techniques (including cognitive and psychodynamic interventions), and interactional inter-
ventions.
Chambless, Goldstein, Gallagher, and Bright (1986) described an integrative approach
to treating agoraphobia that combined behavioral, systemic, and psychodynamic theories
and techniques, without the use of drugs. They found that their integrated model led to
marked or great improvement for almost all agoraphobic symptoms and enhanced asser-
tiveness for their patients. This integrative therapy had a much lower dropout rate than
traditional approaches to agoraphobia, but there was no direct comparison of effectiveness
with any other treatments.
Linehan’s (1987) integrative therapy, DBT, is aimed at alleviating the symptoms of
borderline personality disorder. DBT is an amalgam of skills training, cognitive restructur-
ing, and collaborative problem solving from CBT with relationship elements (e.g., warmth,
empathy, and unconditional positive regard) from client-centered therapy, and with Bud-
dhist meditative practices, especially mindfulness. DBT has gained wide acceptance among
clinicians in recent years due in great part to the research support for its effectiveness
(Pistorello, Fruzzetti, MacLane, Gallop, & Iverson, 2012). Patients who received DBT dem-
onstrated better treatment retention, had fewer suicide attempts and episodes of self-injury,
fewer hospitalizations, decreased anger, greater social adjustment, and more improved gen-
eral adjustment compared with those who received standard therapies as practiced in the
community (Linehan, 1987). A series of studies conducted since 1987 has confirmed and
expanded these findings, yielding a solid foundation of empirical support for the efficacy of
DBT (Pistorello et al., 2012) as one of several effective approaches to borderline personality
disorder.
Empirical evaluations of integrative psychotherapies that combine psychodynamic
components with behavioral, cognitive, or experiential interventions have yielded positive
results. Klerman et al. (1984) found that an integrative interpersonal psychotherapy for
depression repeatedly outperformed medication and other psychological interventions. Sha-
piro and Firth-Cozens (1990) studied the impact of two sequences of combined CBT and
psychodynamic therapy for depression: psychodynamic work followed by active interven-
tion, or vice versa. Patients in the psychodynamic–behavioral sequence obtained the greatest
improvement and reported the most comfortable experiences of treatment. Patients in the
behavioral–dynamic sequence more frequently deteriorated in the second part of the ther-
apy and did not maintain their gains over time as often as did patients in the other group.
This finding seemingly contradicts other observations mentioned earlier, which suggested
that a sequence of behavioral work followed by dynamic work might be the most effective
approach. However, this specific sequencing effect may depend on the presenting problem
and be different with patients who present with nonfocal problems (i.e., those who are more
disturbed or personality disordered), and who therefore might be more disrupted by an inte-
grative therapy that begins with psychodynamic exploration.
470 OTHER INFLUENTIAL MODELS

Similarly, Ryle (1997) found that CAT was more effective than purely psychodynamic or
behaviorally oriented approaches, although random assignment was not part of the research
design. This approach has been widely investigated and there has developed considerable
empirical support for its utility. In a meta-analysis of studies of CAT, Calvert and Kellett
(2014) found 25 high-quality studies of this approach and limited but positive support for
its efficacy across a wide range of populations.
Another theoretically integrated approach that has been tested empirically is pro-
cess–experiential therapy which, as described earlier, is an integration of principles and
methods derived from client-centered, Gestalt, and cognitive therapies. This therapy has
been found to be more efficacious than behavior therapy (Greenberg et al., 1993). This
integrative model has been demonstrated to be more effective for individuals with prob-
lems such as anxiety and depression than client-centered therapy or CBT alone (Greenberg
et al., 1993). Emotionally focused therapy, which is derived from and is an expansion
on this model for the treatment of couples, also has been the subject of several empirical
studies. In a recent review of this research, Wiebe and Johnson (2016) reported that at
least 10 studies have demonstrated the efficacy of emotionally focused therapy, and that
it has been demonstrated to be effective with a number of specific populations of couples,
including couples in which one or both partners suffer from depression, medical illnesses,
or PTSD.
CBASP (McCullough et al., 2015) is the first psychotherapy that has been demonstrated
empirically to be effective for treating dysthymic disorder. It has been found to be as effec-
tive as antidepressant medication and traditional forms of psychotherapy in alleviating the
symptoms and interpersonal problems involved in chronic depression. The results from this
integrative therapy are more enduring and more resistant to relapse than are other treat-
ments.
The effectiveness of acceptance and commitment therapy (Hayes et al., 1999), an
approach that combines cognitive, behavioral, and experiential techniques, has been dem-
onstrated to be effective in eight controlled studies in which this model was tested with
several patient populations (Schottenbauer et al., 2005), including those with depression,
substance abuse, anxiety, and psychosis.
Another integrative couple therapy that has been tested empirically is integrative behav-
ioral couple therapy (Roddy, Nowlan, Doss, & Christensen, 2016), which combines stan-
dard behavioral methods with techniques aimed at enhancing emotional detachment and
acceptance. Roddy et al. reviewed the existing research literature and found three studies
that demonstrated this approach is efficacious. These authors also pointed out that there are
research findings that identify specific gains for couples treated with this method, including
improvement in communication, relationship stability, and relationship satisfaction.

CASE ILLUSTRATION

In our assimilative psychodynamic model of integrative psychotherapy (Gold & Stricker,

2015) we base our assessment and interventions on an expanded psychoanalytically ori-
ented framework that we call the three-tier model. We consider detailed evaluations of
behavior and social interactions (Tier 1) and of cognitive activity and emotional experience
(Tier 2), and we share the traditional psychoanalytic concern with unconscious processes,
mental representations, and character traits (Tier 3). We also assess interactions among
 Integrative Approaches to Psychotherapy 471

issues at these three levels of experience in an attempt to understand the vicious circles
(Wachtel, 1977) and relationship patterns that maintain problems at any of the tiers. In
addition, we attend to interactions between the patient and significant people in his or her
life, and the larger cultural surround (Stricker, 2010). This three-tier approach guides our
understanding during assimilative psychodynamic psychotherapy integration. We conduct
psychotherapy according to psychodynamic principles of exploration, clarification, con-
frontation, and interpretation, and are especially concerned with observing the interaction
between patient and therapist, and identifying transference phenomena. However, we often
intervene directly at the levels of Tier 1 and Tier 2, when it is clinically advantageous to do
so. We use interventions from many therapies, including cognitive-behavioral, humanistic,
and systems approaches, within an assimilative perspective: We include these interventions
for their direct utility in changing behavior, thinking, and emotion; for their possible effects
on unconscious sources of resistance, transference, conflict; and their effects on uncon-
scious representational systems. We also believe that it is critical to help the patient extricate
him- or herself from those relationships and situations that exert a reinforcing influence on
the patient’s psychopathology.
Integrative interventions are assimilated carefully into the therapy. We always suggest
an integrative shift in a tentative way, as an experiment for the patient to try out, evaluate,
retain, or toss away, as he or she deems best. We also attend to cognitive, emotional, and
dynamic reactions to an integrative shift, and to the success or failure of the technique after
the fact. As Wachtel (1977) and other integrative therapists have noted, the impact of the
technique on the therapeutic relationship and on the transference–countertransference situ-
ation must be continuously monitored.
Ms. F, a 36-year-old woman, was referred to psychotherapy by her internist because
of chronic anxiety punctuated by periodic panic attacks and episodes of depression. Her
DSM-5 diagnoses were generalized anxiety disorder (300.02), panic disorder without ago-
raphobia (300.01), and major depressive disorder (296.30). She also described ongoing dis-
comfort in social situations and a pattern of managing that discomfort by maintaining
superficial and distant relationships, especially with men, that met the criteria for a diagno-
sis of avoidant personality disorder (301.82).
Ms. F reported that she had experienced depression and anxiety since early childhood,
and that these symptoms had worsened during the last year, with the addition of panic
attacks. During this period, she had changed careers and had experienced the death of
her mother after a lingering illness. Ms. F worked in a professional field that had required
graduate education, and she enjoyed her work, though it was demanding of her time and
energy and did not pay well. She was forced to share an apartment with a roommate due to
financial considerations and experienced this relationship as a constant source of irritation
and tension. Ms. F had not had any previous experience in psychotherapy. Her internist had
recommended that she consider making use of psychiatric medication in addition to psycho-
therapy, but she had not followed up on this recommendation.
Ms. F was the youngest of several children and had been academically talented. Her
mother was described as passive, depressed, and demanding of much of Ms. F’s time and
attention. Ms. F reported that her mother seemed concerned only about Ms. F’s professional
successes and had little interest in her social life, hobbies, or other interests. She stated that
she had been involved in her mother’s care during her illness, and that she herself had not
“felt much” about her mother’s death at the time or during the ensuing period. Her father
was described as a distant man who “never had much to say to or about his children.” He
472 OTHER INFLUENTIAL MODELS

had been a shadowy figure during his wife’s illness and after her death, had offered little in
the way of support to Ms. F, and rarely called or visited her.
In the initial assessment of this patient at Tier 1 (behavior and social interactions), the
most prominent issues were her avoidant behaviors and interpersonal anxiety that led to
the lack of supportive and satisfying friendships, and of the intimate heterosexual relation-
ship that she desired. Tier 2 phenomena (cognitive and social spheres) included preoccupa-
tion and overconcern with the minutiae of her work, which provoked intrusive thoughts of
being unable to cope with her responsibilities and of losing her job. This pattern of thinking
evoked considerable conscious anxiety and periodic experiences of panic. At a more uncon-
scious level (Tier 3, which includes unconscious phenomena, mental representations, and
character traits), Ms. F seemed to be afflicted with an image of herself as unlovable and as
unworthy of love. She had a wish to please an implacable mother and unattainable father,
resulting in mental representations of others as demanding, impossible to please, and self-
ishly unconcerned. Deeply felt but disavowed pools of anger, resentment, loss, grief, and
deprivation were evoked by these representations of self and others.
Ms. F’s familial and professional relationships also were involved in the evocation and
reinforcement of these problems. Her coworkers, siblings, and father relied on her “to fill in
all of the gaps,” which she always did, fearing a loss of their already unreliable esteem and
interest were she not to do so. Her overt anxiety, rigidly avoidant interpersonal style, and
disavowed anger and resentment kept other people at a distance and limited their ability to
sympathize with her plight. These reactions fed into Ms. F’s unconscious sense of vulner-
ability and her perceptions of others as unavailable, hateful, and incapable of responding to
her needs. They also added to her image of herself as unloved, and to the smoldering anger
and resentment that seemed to be at the foundation of her depression. These vicious circles
had also kept alive her unhappy and anxiety-fraught relationships with her parents.
Ms. F’s therapy began, as do most psychodynamic therapies, with an exploration of
the patient’s present and past life and of the unconscious motivations, conflicts, fears, and
residues of past relationships that contribute to current problems. Ms. F was encouraged to
talk as freely as she could; to report dreams, fantasies, and idle thoughts; and to examine her
interaction with the therapist as well. The therapist listened closely, asked Ms. F questions,
and occasionally offered interpretations of the unconscious processes to which Ms. F’s com-
munications might be alluding.
These standard psychodynamic methods, however, were supplemented by integrative
work at Tiers 1 and 2. The therapist targeted those behavioral, cognitive, experiential, and
interpersonal variables that might benefit from integrative intervention. These integrative
efforts always were considered with at least a dual purpose: to assist Ms. F to change an
ineffective, problematic issue in Tiers 1 and 2, and potentially to resolve unconscious con-
flict and to change her ways of experiencing herself and other people at Tier 3.
Two central types of integrative work in Tiers 1 and 2 were used during Ms. F’s therapy.
The first was employed during the early weeks of the therapy, when it became obvious how
weighted down Ms. F was by her insistence on “filling in the gaps” left by those people in
her life who shirked important responsibilities, knowing that Ms. F would take over. These
internal demands, which manifested themselves in the form of thoughts such as “I should be
able to do more without complaining” or “If I don’t take over here, they’ll be angry” (Tier
2), were modified by standard cognitive techniques of recording one’s thoughts, evaluating
the evidence for them, and refuting or modifying that way of thinking based on this exami-
nation. Changing these thoughts was seen as advantageous and important by the therapist
 Integrative Approaches to Psychotherapy 473

for several reasons. First, change in this way of thinking obviously would reduce Ms. F’s
experience of being overwhelmed, of always being behind in things, and would lessen her
anxiety and make her less prone to panic. Second, this reduction in suffering might stabilize
a rather shaky therapeutic relationship in which Ms. F had been having some difficulty let-
ting go of her transferential reactions to the therapist, whom she experienced as a parent
who expected her to meet everyone else’s needs. Third, it had become clear that the pain
and preoccupation caused by these deeply familiar and ingrained thoughts and behavioral
patterns had become defenses against the anger, resentment, and neediness they continued
to evoke. In the sessions, these issues had become resistances that precluded any exploration
of such psychodynamic meanings and origins.
This integrative intervention accomplished much. Ms. F became less anxious and less
prone to panic as she learned to “stop filling in.” At the same time, she achieved important
insight into her history and its transference manifestation in the therapy. This technique
helped her to experience her therapist as someone who wanted her to take on less and to
get more out of life, therefore enabling Ms. F to make a crucial discrimination between her
transference and her real experience of the therapist. As she saw in a deeply felt way how she
had come to perceive the therapist as someone from her past, she began to explore the ways
in which these transference perceptions influenced her relationships outside therapy, specifi-
cally with regard to the frequency with which she cast potential friends and lovers in the role
of her hurtful siblings and parents. Finally, as her need “to fill in” became less pressing and
less frequent, Ms. F was able to relax her resistance against exploring these issues. Her new
understanding of her unconscious fear of being unlovable, and of the resulting self-hatred
that this self-perception had generated, allowed Ms. F the chance to reevaluate those mental
representations. In addition, as she more frequently took the chance of saying “no,” she
learned that her worst fears of abandonment sometimes were not confirmed. It is impossible
to determine how much of Ms. F’s transference was based solely on her expectations as a
function of historical factors and how much on the experience of the active therapist in the
relationship. Had the therapist been more silent, the same issue probably would have arisen
but would likely have been construed in a traditional way: as reflecting a past relationship
brought into the present, rather than an active and current way of experiencing long wished
for and previously absent nurturance by the therapist. The therapist’s level of activity pro-
vided an immediate contrast to Ms. F’s images of her parents as disinterested and unhelpful
when she was in distress.
These new experiences helped Ms. F free herself from many of the interpersonal vicious
circles that had fueled her anger and resentment, and allowed her to find a few new friends
and begin to go out on dates. These new experiences had an impact on her at all three tiers.
New and more assertive behavior was accepted and therefore tacitly reinforced by new
friends. Her progress in modulating her conscious fears and concerns about “filling in” also
were supported. And, at the psychodynamic level, these new relationships gradually helped
Ms. F to integrate the anger, sadness, and resentment that she had disavowed through most
of her life. As a result, her anxiety, panic, and depression gradually abated.
As Ms. F’s therapy continued, her dreams and the contents of her conversation in ses-
sions began to coalesce around the death of her mother and the unresolved grief connected
with that loss. Psychodynamic work did not seem helpful. Ms. F noted that although she
had attained a much greater intellectual appreciation of the effects of her unresolved grief,
she could not feel much about this event or its aftermath. Attempts to analyze her defenses
against her grief led to nothing but frustration and dejection.
474 OTHER INFLUENTIAL MODELS

This impasse indicated that an integrative shift might be helpful. The therapist sug-
gested an experiential, Gestalt-therapy-influenced exercise in which Ms. F imagined herself
in conversation with her mother as they sat together in the therapist’s office. Ms. F began
hesitantly, and with considerable embarrassment, but soon fell into the dialogue more natu-
rally. After a couple of sessions, she found herself experiencing and expressing the sadness,
fear, anger, and guilt that she had disavowed since her mother’s death.
In addition to these important changes, some other gains accrued from this integrative
intervention. These changes were of immediate conscious benefit to the patient, and they
also aided the psychodynamic work of the therapy. Ms. F found that her painful dialogue
with her mother had led to a new sense of confidence and more acceptance of her own
needs, wishes, and anger. She decided that she would give more weight to relationships
with people who were open to knowing about her feelings, positive and negative, and Ms.
F began to describe herself as “throwing her weight around a little” with her siblings, and
with her father on his rare visits. She also reported that the therapist’s active interest in help-
ing her to grieve, and his ability to tolerate and to empathize with the feelings that she had
contacted during the Gestalt exercise, had been helpful in allowing her to test, challenge,
and modify the negative view of emotional intimacy that she long had held.
Ms. F’s therapy lasted about 20 months and was conducted on a once-weekly basis.
Approximately 65–75% of the sessions might be identified as psychodynamically oriented
exploration, whereas the remaining time was spent working in the active, integrative way
described previously. Ms. F decided to end therapy after this period, because she felt she had
come as far as she could and needed a break to consolidate her gains and all that she had
learned. She had been free from any major depressive episodes and from panic attacks for
over 6 months. Her ongoing level of anxiety had improved, though she noted that it was
her hope to have more anxiety-free hours and days in the future. Her relationship with her
roommate had improved to the point that they had developed a casual friendship, occasion-
ally sharing a meal or going to a movie together, and Ms. F’s level of irritation and tension
about sharing her home had diminished. She had made a couple of other female friends and
was hopeful that her relationship with one of these women could become a closer and more
enduring friendship. She continued to date and to feel guardedly optimistic about marrying,
though she had not yet established the serious intimate relationship with a man that she
wanted.

SUGGESTIONS FOR FURTHER STUDY

Recommended Reading
Beutler, L. E., Forrester, B., Holt, H., & Stein, M. (2013). Common, specific, and cross-cutting
psychotherapy interventions. Psychotherapy, 50, 298–301.—A summary of a research-based
approach to technical integration.
Castonguay, L. G., Eubanks, C. F., Goldfried, M. R., Muran, J. C., & Lutz, W. (2015). Research on
psychotherapy integration: Building on the past, looking to the future. Psychotherapy Research,
25(3), 365–382.—A review of the empirical support for many of the approaches described in
this chapter.
Gold, J. (2005). Anxiety, conflict, and resistance in learning an integrative perspective on psycho-
therapy. Journal of Psychotherapy Integration, 15, 374–383.—A description of some problems
involved in learning an integrative approach.
Messer, S. B. (2000). Applying the visions of reality to a case of brief therapy. Journal of Psychotherapy
 Integrative Approaches to Psychotherapy 475

Integration, 10, 55–70.—An application of the perspectives of a number of therapeutic outlooks

to a case example.
Stricker, G. (2010). Psychotherapy integration. Washington, DC: American Psychological
Association.—A brief summary of the major components of psychotherapy integration.
Wachtel, P. L. (1997). Psychoanalysis, behavior therapy, and the representational world. Washing-
ton, DC: American Psychological Association.—An expanded edition of a classic in psychother-
apy integration that remains the most complete and influential version of theoretical integration.
Wampold, B. E. (2015). How important are the common factors in psychotherapy?: An update. World
Psychiatry, 14, 270–277.—A summary of the current state of common factors work.

DVDs
Stricker, G. (2009). Psychotherapy integration over time (Psychotherapy in Six Sessions Video Series).
Washington, DC: American Psychological Association.—A DVD illustrating the practice of
assimilative integration.

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 Author Index

Aaltonen, J., 307 Appelbaum, A. H., 42 Becker, R. E., 132

Abbass, A. A., 16, 97, 408, 423, 424, Arch, J. J., 167 Bedard, D., 250
432, 434 Arkowitz, H., 96, 164, 445 Bedoya, C. A., 170
Ablon, J. S., 58, 97 Armitage, C. J., 118 Beebe, B., 75, 76
Aboulafia-Brakha, T., 372 Arnkoff, D. B., 469 Beecher, M. E., 379
Abraham, G., 128 Aron, L., 89, 91 Beidel, D. C., 122
Abramova, V., 169 Asarnow, J. R., 310 Beier, E. G., 444
Abramowitz, J. S., 81, 112, 119, 142, Ascher, M. S., 319 Beitman, B. D., 461
246 Asmundson, G. J. G., 183 Bella-Awusah, T., 113
Acevedo, B. P., 90 Asnaani, A., 130, 145 Bellack, A. S., 378
Acheson, D. T., 119 Assagioli, R., 200 Belus, J. M., 335
Ackerman, N. W., 298, 304, 334 Atkins, P. W., 207, 208 Benelli, E., 27
Addis, M. E., 118, 121 Atwood, G. E., 73, 272 Benetti, S., 128
Adelman, C. B., 335 Austin, S. B., 250 Benish, S. G., 14
Agazarian, A., 398 Aviram, A., 125 Benjamin, J., 75, 85
Aggarwal, N. K., 379 Ayes, V. E., 372 Bennett, C. B., 16
Agresta, J., 378 Ayub, M., 113 Bennett-Levy, J., 160
Aikman, G. G., 342 Ayuso-Mateos, J. L., 15 Benson, L. A., 353, 356
Alexander, F., 54, 83, 419, 444, 464 Berger, L. K., 154, 186
Alexander, J. F., 312, 318, 468 B Berk, M., 310
Alfano, C. A., 122 Bader Ginsburg, R., 21 Bernal, G., 14
Alon, E., 246 Baker, T. B., 20, 24 Bernard, H. S., 373, 380, 383, 384
Altman, N., 57, 95, 97 Baldwin, S. A., 358, 359 Bernier, D., 408
Alvandi, E. O., 16 Balzano, J., 379 Bernstein, D. A., 123
American Psychiatric Association, 10, Bandura, A., 112, 122 Berzon, B., 385
11–12, 44, 115, 190, 299, 455 Barber, J. P., 428, 467 Best, K. M., 225
American Psychological Association, Bar-Kalifa, E., 246 Betan, E. J., 410, 411, 420, 430, 431,
11, 22, 357 Barkham, M., 249 432, 433, 434
American Psychological Association Barlow, D. H., 117, 118, 123, 128, Beutler, L. E., 447, 448, 456
Presidential Task Force on 145, 165, 169 Bhagwat, R., 335
Evidence-Based Practice, 4, 25, Barnes-Holmes, D., 185, 187, 188 Bieling, P. J., 388
143, 173 Barrera, M., Jr., 113 Biffi, D., 27
Anchin, J. C., 446 Barrett-Lennard, G. T., 244 Billow, R. M., 381
Anderson, C. M., 310 Barsaglini, A., 128 Binder, J. L., 230, 410, 411, 420, 430,
Anderson, H., 334 Bateman, A., 59, 98, 376 431, 432, 433, 434
Anderson, N. L., 310 Bateson, G., 297 Binswanger, L., 258, 282
Anderson, T., 240 Baucom, D. H., 334, 335, 339, 359 Bion, W. R., 92, 371
Andersson, G., 124 Baumel, A., 322 Bishop, D. S., 310
Andrews, G., 125, 169, 172 Bayles, M., 80 Biyanova, T., 223
Andrews, S., 424, 425 Beach, S. R. H., 339 Blagys, M. D., 58, 81
Angelou, M., 12 Bearss, K., 322 Blatner, A., 389
Angus, L., 249, 282, 283 Beauchamp, T. L., 391 Blatt, S. J., 55
Antony, M. M., 95, 111, 117, 118, Beavers, R., 23 Blechner, M. J., 88
119, 125, 133, 145, 157, 388 Beck, A. T., 144, 145, 146, 147, 166, Bleiberg, K. L., 411, 412, 414, 415,
Antshel, K. M., 122 172, 173, 183, 376 417, 418, 419
Anxiety and Depression Association Beck, J. S., 376 Bloom, B. L., 407, 408, 409
of America, 134 Becker, E. M., 111, 260, 280 Blow, A. J., 20

481
482 Author Index

Blumberg, S. L., 340, 346 Burton, M., 334 Combs, G., 334
Bo, S., 376 Bush, N. E., 16 Comer, J. S., 169, 322
Bogwald, K. P., 394 Butler, A. C., 172 Compare, A., 469
Bohart, A. C., 5, 12, 20, 27, 221, Butollo, W., 468 Comtois, K. A., 208
226, 229, 230, 231, 234, 240, Byrne, S. A., 120 Connell, J., 249
243, 246, 250, 283, 284, 454, Connelly Gibbons, M. B., 17
456, 463, 465 C Constantino, M. J., 125, 167
Boisvert, C., 237, 247 Cabello, M., 15 Conway, C. C., 119, 172
Bollas, C., 77 Cabral, R. R., 124 Cook, J. M., 223
Bonaparte, N., 6 Cahill, S. P, 126 Coonerty, S., 468
Bond, F. W., 188 Callahan, J. L., 15 Cooper, A., 98
Bond, R., 207 Callan, J. A., 156 Cooper, M., 15, 241, 259, 282
Borda, C., 298 Calloway, A., 127 Correia, E., 282
Borduin, C. M., 321 Calton, T., 283 Correll, C. U., 322
Borkovec, T. D., 123, 451 Calvert, R., 470 Corsini, R., 372, 385
Bornstein, R. F., 53 Cardemil, E. V., 118 Costello, P., 76
Borrelli, B., 16 Carlbring, P., 124 Coughlin, P., 423, 424, 434
Boscolo, L., 307 Carlson, T. M., 424, 457 Cowan, P. A., 230
Boss, M., 258, 282 Carmona, J., 20 Cozolino, L., 15
Boswell, J. F., 445 Carpenter, J. K., 142 Craig, M., 282, 283
Boszormenyi-Nagy, I., 304 Carpenter, J. L., 372 Craske, M. G., 119, 127, 128, 142,
Boulanger, G., 95 Carr, A. C., 42, 299 167, 172
Bowen, M., 305, 334, 345 Carter, B., 301 Cristea, I. A., 169, 172
Bowlby, J. A., 75, 76, 412, 421, 453 Carter, R. T., 468 Crits-Christoph, P., 17, 24, 98
Boyd-Franklin, N., 335 Casey, L. M., 16 Cromer, T. D., 469
Bozarth, J., 236, 240 Caspi, A., 10, 225 Crooks, C., 16
Brabender, V., 369, 371, 372, 373, Castonguay, L. G., 20, 167, 246, 451, Crothers, L., 432
374, 377, 380, 384, 385, 387, 459, 467, 468 Crowley, M. E. J., 240
390, 392, 393 Castro, F. G., 113 Csikszentmihalyi, M., 371
Bracke, P., 279 Cather, C., 173 Cuijpers, P., 14, 124, 134, 169,
Bradley, B., 348 Cattafi, F., 469 172
Brady, P., 322 Cattie, J. E., 81, 90, 112, 142, 246 Cunningham, P. B., 321
Brand, T., 376 Cavanagh, K., 149, 207 Cunnington, D., 170
Brandschaft, B., 272 Cecchin, G., 307 Currie, S., 118
Bratton, S. C., 247, 249 Celano, M. P., 297, 298, 299, 319, Curtis, R. C., 36, 71, 78, 80, 83, 90,
Breitbart, W., 372 320, 323 94, 246, 306, 420
Brennan, L., 208 Chabrol, H., 134
Brenner, C., 41, 61 Chaider, T., 250 D
Brenner, C. A., 172 Chambers, A. L., 333, 343 Daiuto, A. D., 359
Bressler, J., 81, 90 Chambless, D. L., 18, 20, 125, 135, Dale, S. K., 170
Breuer, J., 26, 37, 46 171, 469 Dalgleish, T. L., 348
Breunlin, D. C., 298, 312 Chang, Y., 250 Damasio, A., 76
Bright, P., 469 Chapman, A. L., 377 Datchi, C., 299
Brodley, B. T., 459 Chapman, J. E., 172 Dattilio, F. M., 27, 125, 282, 311,
Brom, D., 452 Charcot, J. M., 37 335
Bromberg, P., 74, 83, 87 Chen, E. C., 379 Davanloo, H., 419, 422, 423, 424,
Brondino, M., 312 Chen, Y. R., 452 427
Bronfenbrenner, U., 9 Cheng, J. K. Y., 186, 207 David, D., 172
Broth, M. R., 299 Cherlin, A. J., 339 Davies, J. M., 74, 76, 93
Brotman, M. A., 125 Chevron, E. S., 79, 466 Davies, M., 125
Brown, B. K., 376 Childress, J. F., 391 Davies, R., 378
Brown, C. H., 321 Choung, S., 124 Davis, K. E., 186
Brown, G., 376 Christensen, A., 333, 335, 337, 339, Davis, S. D., 20, 298, 352
Brown, N., 393 340, 353, 356, 470 De Carlo, A., 27
Brown, W. A., 134 Chu, J. P., 14, 22, 113, 152 De Jong, K., 155
Brubacher, L., 450 Churchill, S., 258 de Jonghe, F., 59
Buber, M., 262 Clarke, S., 467 de Maat, S., 59
Buchheim, A., 60 Clarkin, J. F., 85 de Mamani, A. W., 322
Buchholz, J. L., 81, 112, 142, 246 Cleare-Hoffman, H., 279 de Paula-Ravagnani, G. S., 307
Budman, S. H., 407, 409, 410, 419 Clingempeel, W., 312 de Shazer, S., 303
Bugental, J. F. T., 261, 263, 265, 267, Cloitre, M., 123 Deacon, B. J., 119, 127
268, 269, 276, 277, 278, 279, Clough, B. A., 16 Dear, B. F., 169
280, 282 Coatsworth, J. D., 319 Deci, E. L., 226
Bunting, K., 281 Cohen, L. R., 123 Decker, L., 259
Burlingame, G. M., 372, 378, 379, Cohen, M. J., 359, 372 DeCou, C. R., 208
380, 393 Colallillo, S., 322 DeGeneres, E., 18
Burns, A. M., 172 Collins, M. H., 299 Dekker, J., 59
Burrow, T., 370 Coltart, N. E., 78 Del Re, A. C., 97, 125
Burton, A., 59 Comas-Díaz, L., 379 DeRubeis, R. J., 125
 Author Index 483

Diamond, G. M., 305, 315, 317, 318, Epstein, R., 225 Frank, K. A., 55, 90, 454, 460, 462,
319, 321, 322 Epton, T., 118 463
Diamond, G. S., 305, 317, 318, 319, Erbaugh, J., 145 Frankl, V., 279
321 Erekson, D. M., 409 Franklin, A. J., 468
DiClemente, C. C., 447, 448, 455, Erickson, D. H., 172 Franklin, C., 410
456, 457 Erikson, E. H., 40 Franklin, M. E., 120
Dies, R. R., 384 Errázuriz, P., 125 Fraser, J. S., 298, 313
Dilley, J. W., 432 Escudero, V., 322, 352 Frawley, M. G., 76
Dillworth, T. M., 169 Eubanks, C. F., 468 Frederickson, J., 16, 424
Dimen, M., 75 Eubanks-Carter, C., 98, 126 Freedheim, D., 7
Dimidjian, S., 121, 183, 184, 206, Evans, M., 467 Freedman, J., 334
207, 208, 335 Eyberg, S. M., 322 French, T. M., 54, 83, 419, 444, 464
Dixon, S. F., 428 Eysenck, H. J., 112, 113, 144 Fresco, D. M., 123, 134, 183
Dobson, K. S., 125 Freud, A., 41
Doherty, W. J., 298, 357 F Freud, S., 17, 26, 35, 36, 37, 38, 39,
Doidge, N., 58, 225 Fairbairn, W. R. D., 36, 73, 74 40, 41, 44, 45, 46, 47, 49, 52,
Dollard, J., 444 Fairburn, C. G., 208 53, 61, 72, 76, 88, 96, 97, 258,
Domenech Rodriguez, M. M., 14 Fallon, A., 371, 372, 374, 380, 384, 370, 371, 419, 443, 444
Domingue, H. K., 299 385, 392 Friedlander, M. L., 322, 352
Dopp, A. R., 321 Fang, A., 130, 145 Friedman, M., 262, 267
Dornelas, E. A., 467 Farach, F., 123, 127 Fromm, E., 71, 72, 88, 90
Doss, B. D., 335, 353, 358, 470 Farb, N., 208 Fromm-Reichmann, F., 71, 77, 88, 91
Dougher, M. J., 183 Farber, B. A., 250 Fruzzetti, A. E., 469
Douglas, E. M., 343 Farber, E. W., 7, 45, 79, 90, 246, 407 Fuertes, J. N., 247
Dowd, E. T., 461 Farson, R., 385 Fuhriman, A., 372, 393
Doyle, J. S., 170 Faucett, J., 134 Fuhrmann, A., 426
Dozois, D. J., 166 Feaster, D. J., 321 Funderburk, B. W., 322
Draguns, J. G., 146 Feather, B. W., 444 Furrow, J. L., 348
Drake, C. E., 198 Feeney, J. A., 339 Fusé, T., 119
Driessen, E., 15, 408 Feldman, L. B., 4
Duff, J. H., 321 Feldman, S. L., 4 G
Dufrene, T., 197, 202, 206 Felix, I., 198 Gabbard, G. O., 44, 59
Duncan, B. L., 118, 449, 456, 458, Fensterheim, H., 455 Galen, 21
463, 465 Ferenczi, S., 72, 73, 85, 419 Gallagher, R., 469
Duncan, S. C., 434 Ferriter, M., 283 Gallagher-Thompson, D., 447
Dunlop, B. W., 15 Ferro, A., 92 Gallop, R., 469
Dupuy, P., 283 Field, C., 80, 83 Galvin, J., 265
Durham, J., 335 Firestein, S. K., 59 Garfield, S., 449
Dweck, C. S., 227 First, M. B., 131, 209 Garmezy, N., 225
D’Zurilla, T. J., 122, 123 Firth-Cozens, J., 469 Gastner, J., 60
Fiscalini, J., 76 Gaudiano, B. A., 185
E Fischer, C. T., 264 Gautier, S. W., 113, 133
Eagle, M. N., 47, 49, 53, 57, 59, 60, Fischer, M. S., 335, 359 Geller, S. M., 266, 283
61, 76, 83, 87 Fishbane, M. D., 15 Gendlin, E. T., 223, 227, 228, 231,
Eckstein, D., 346 Fisher, A., 451 234, 237, 241, 243, 245, 246,
Edwards, D. J. A., 27, 282 Fishman, D. B., 4, 17, 18, 27, 282 248, 283
Eells, T. D., 11 Fitzpatrick M., 468 Gentili, C., 14
Eggett, D. L., 409 Fitzsimmons-Craft, E. E., 208 Georgia, E. J., 353
Ehde, D. M., 169, 171 Flückiger, C., 97, 125 Gergely, G., 375
Ehlers, C. L., 122 Flynn, H. A., 173 Gerson, M. J., 468
Ehlinger, P. P., 170 Foa, E. B., 120, 125, 126 Gerson, R., 305
Ehrenreich-May, J. T., 123 Folke, S., 467 Gibbon, M., 209
Einhorn, L. A., 335 Follette, V. M., 183, 184, 188 Gibbons, M. B. C., 98, 420
Eissler, K. R., 56 Follette, W. C., 185 Gifford, E. V., 188
Elder, G. H., 225 Fonagy, P., 55, 59, 97, 98, 375, 376, Gill, M. M., 44, 46, 47, 83, 94, 102
Eldridge, K. A., 339 429 Gillispie, C., 247
Elkins, D. N., 280, 282, 283, 284 Forehand, R., 310 Gillispie, R., 247
Ellard, K. K., 183 Forgatch, M. S., 310 Gilman, L., 312
Elliott, R., 27, 224, 229, 231, 238, Forman, E. M., 172, 183, 185, 409 Gingerich, S., 378
240, 246, 247, 248, 249, 250, Forrester, B., 447, 448 Gingerich, W. J., 410
282, 283, 410, 450 Forsyth, J. P., 119 Giordana, F., 283
Ellis, A., 144, 147 Fosha, D., 84, 268, 281, 424, 426, Giorgi, A., 258
Ellman, S., 44 432, 438, 457 Gislon, M., 467
Eng, K. T., 124 Fosshage, J., 78, 84 Giyaur, K., 250
Epp, L., 266, 281 Foulkes, S. H., 371 Glass, C. R., 469
Epstein, E. E., 335 Fraenkel, P., 333, 334, 335, 336 Gleiser, K. A., 426
Epstein, L., 88 Framo, J. L., 334 Glick, I. D., 319
Epstein, N. B., 310, 311, 334, 335, Frank, E., 122, 418 Gobbi, M., 113
339, 376 Frank, J., 444, 448 Godfrey, E., 250
484 Author Index

Golant, M., 383 Hall, J., 467 Hong, J. J., 186

Gold, J. R., 4, 7, 443, 445, 446, 450, Han, H., 123 Hood, H. K., 118
451, 453, 454, 455, 456, 459, Hanna, F. J., 283 Hooley, J. M., 303
460, 462, 464, 465, 466, 467, Hansen, N. B., 409 Horney, K., 71, 72, 75
470 Harder, S., 467 Horowitz, J. D., 96
Goldberg, S. B., 374 Hardy, K. V., 298, 335 Horvath, A. O., 97, 125, 283
Goldblum, P., 432 Hare-Mustin, R. T., 299, 334 Howard, K. I., 409
Goldfried, M. R., 4, 167, 445, 465, Harris, A., 75 Hoyt, M. F., 407, 410
468 Harris, S. M., 357 Hoyt, W. T., 374
Goldiamond, I., 126 Hartmann, H., 41, 42 Huang, E. R., 14, 113, 146
Goldman, R. N., 229, 231, 238, 249, Harvey, P. D., 378 Huband, N., 283
250, 336, 341 Hatzenbuehler, M. L., 171 Hubble, M. A., 449
Goldner, V., 299, 334, 342 Haug, T., 125 Huber, D., 60
Goldstein, A., 469 Havik, O. E., 125 Huey, S. J., Jr., 152
Gordon, L. B., 246 Hayes, A., 466 Hughes, J. L., 310
Gorman, J. M., 17, 24, 118, 131 Hayes, L. J., 186 Hughes, S., 187
Gottdeiner, W., 467 Hayes, S. C., 115, 164, 172, 183, Huibers, M. J., 169
Gottlieb, M. C., 22, 357, 358 184, 185, 186, 187, 188, 189, Hunsley, J., 150
Gottman, J. M., 335, 336, 337, 340 190, 191, 194, 196, 197, 200, Huntley, C., 467
Gottman, J. S., 335 201, 204, 205, 206, 207, 211, Huppert, J. D., 125, 126
Grace, C., 468 213, 246, 281, 451, 470 Hurst, D., 59
Graham, J. R., 157 Hayes-Skelton, S. A., 113, 127, 133, Hurwitz, M. R., 56
Graham, P., 418 157 Husserl, E., 258
Graham-LoPresti, J. R., 113, 133 Hays, P. A., 113, 115, 146, 152, 170 Hutschemaekers, G. J., 155
Grandi, S., 302 Hayward, M., 149
Granholm, E. L., 122, 378 Hazell, C. M., 149, 169 I
Grant, P., 173 Hazlett-Stevens, H., 123 Ibaraki, A. Y., 14, 113, 146, 170
Gratz, K. L., 123 Hearon, B. A., 172 Imber-Black, E., 298, 300
Grawe, K., 283 Hearson, B., 98 Imel, Z. E., 17, 18, 20, 23, 24
Gray, P., 55 Heatherington, L., 322, 352 Ingram, R. E., 9
Green, M., 93 Hecke, D., 376 Institute of Medicine, 24
Green, R.-J., 335 Hedman, E., 124 Isaacs, L., 305
Greenberg, J. R., 72, 78 Heidegger, M., 258 Iverson, K. M., 469
Greenberg, L. S., 224, 229, 231, 232, Heilman, D., 379 Iwamasa, G. Y., 113, 146, 170, 357
234, 237, 238, 240, 244, 245, Heimberg, R. G., 123, 132
246, 247, 248, 249, 250, 266, Heisler, M., 303 J
283, 336, 341, 450, 454, 470 Hellkamp, D., 467 Jackson, D. D., 297, 334
Greenberg, R. P., 409 Hembree-Kigin, T. L., 310, 312 Jackson, L. C., 170
Greenberger, D., 160 Hendricks, M. N., 237, 249, 250 Jackson, T., 279
Greene, G. J., 298 Henggeler, S. W., 312, 321 Jacobs, T., 86
Greenman, P. S., 347, 355 Henrich, G., 60 Jacobson, E., 42, 123
Greenson, R. R., 46, 48, 49, 51, 64 Hepworth, J., 298 Jacobson, N. S., 121, 127, 183, 184,
Griner, D., 124 Herbener, E. S., 225 334, 335, 337, 340
Grondin, J., 257 Herbert, J. D., 183, 185, 186 Jalal, B., 123
Gross, J. J., 183 Herman-Dunn, R., 121, 184 James, K., 467
Grossmark, R., 87 Heru, A. M., 319 James, W., 258, 280
Grote, N. K., 418 Hervis, O. E., 312 Jamison, K. R., 5
Grove, D., 298 Hett, J., 247 Janet, P., 37
Grunebaum, J., 304 Heyland, S., 467 Janse, P. D., 155
Grzanka, P. R., 247 Hildebrandt, M., 184 Jauhar, S., 172
Gu, J., 207 Hill, C. E., 250 Jenkins, N. H., 333
Guanaes-Lorenzi, C., 307 Hilsenroth, M. J., 58, 81, 250, 467 Jenner, J. A., 467
Guevremont, D. C., 120 Himawan, L., 240 Jensen-Doss, A., 111
Guidano, V. F., 454 Hinton, A. L., 124 Jiménez, J. R., 18
Gunderson, J. G., 123 Hinton, D. E., 123, 124, 379 Johansson, R., 408
Guo, X., 134 Hinton, L., 379 Johnides, B. D., 321
Gurak, K., 322 Hoffman, I. Z., 73, 89 Johnson, S. M., 237, 247, 333, 335,
Gurman, A. S., 4, 7, 267, 298, 333, Hoffman, L., 279, 307 336, 337, 339, 341, 347, 348,
334, 335, 407, 409, 410, 419 Hofmann, S. G., 130, 145, 164, 172, 353, 355, 450, 454, 456, 457,
Gyra, J., 424 183, 185, 186, 204, 205, 213 468, 470
Hogarty, G. E., 310 Johnston, C., 322
H Høglend, P., 44, 59, 394 Joint Task Force for the Development
Haarhoff, B. A., 164 Holden, J. L., 122 of Telepsychology Guidelines for
Hackney, H., 385 Holdstock, L., 226 Psychologists, 16
Hadley, S. W., 239 Hollimon, A., 318 Jones, E. E., 58
Haley, J., 297, 303, 307 Hollon, S. D., 125, 172 Jones, E. O., 152
Halford, W. K., 359 Holmberg, J. K., 240 Jones, S., 467
Hall, G. C. N., 14, 113, 146, 152, Holt, H., 445, 448 Joyce, A. S., 378
170, 186 Holt-Lunstad, J., 412 Julien, D., 425
 Author Index 485

Jung, C. G., 258 Koerner, K., 188, 190, 191, 192, 194, Levine, P. A., 451, 452
Jurist, E. L., 375 195, 198, 205 Levy, D., 445
Kofler, M. J., 122 Levy, K. N., 44, 59, 85, 98
K Kohlenberg, R. J., 125, 184, 204, 206 Levy, R. A., 97
Kabat-Zinn, J., 194 Kohut, H., 36, 42, 55, 73, 83, 84, 93 Levy, S. A., 305, 321
Kächele, H., 44, 59 Kolden, G. G., 250 Leweke, F., 59
Kakkad, D., 379 Koopman, C., 432 Lewin, K., 4, 74, 371
Kaley, H., 57 Kopta, S. M., 409 Lewinsohn, P. M., 121
Kalogerakos, F., 246 Korbei, L., 223 Lewis-Fernandez, R., 379
Kalpin, A., 424 Korman, L. M., 250 Lichtenberg, J. D., 78, 84
Kamenov, K., 15 Kornreich, M., 7, 11 Lichtenberg, P., 134
Kane, J. M., 322 Kosters, M., 393 Liddle, H. A., 312, 321
Kane, R., 130 Kotchick, B. A., 310 Lieberman, M. A., 383, 384
Kangas, M., 322 Kotianova, A., 167 Liese, B. S., 377, 388
Karam, E. A., 20 Kovacs, M., 147 Lietaer, G., 241, 246, 247
Karoly, P., 121 Kozak, M. J., 126 Lilienfeld, S. O., 22, 96
Karon, B. P., 56 Krasner, L., 112 Lillis, J., 188
Karpiak, C. P., 445 Krause, M. S., 409 Lin, Y. N., 20
Karterud, S., 375 Krebs, P. M., 448 Linardon, J., 208
Karyotaki, E., 15, 169 Krishnamurthy, R., 11 Lindblat-Goldberg, M., 309
Kashdan, T. B., 189 Krug, O. T., 12, 257, 259, 260, 261, Lindhiem, O., 16
Kaslow, F. W., 300 262, 263, 264, 265, 268, 269, Lindsley, O. R., 112
Kaslow, N. J., 3, 16, 297, 299 270, 272, 279, 281, 283, 288 Linehan, H., 467, 469
Kavanaugh, G., 88 Kuhn, T. S., 445 Linehan, M. M., 184, 188, 191, 192,
Kazantzis, N., 125, 164 Kuo, J. R., 377 195, 196, 204, 205, 207, 246,
Kazdin, A. E., 142 Kupfer, D. J., 122 377
Keefe, J. R., 467 Lingiardi, V., 44
Keith, D. V., 303, 309 L Lionells, M., 76
Keitner, G. I., 302 Lachmann, F. M., 75, 76, 78 Liotti, G., 454
Keller, H., 16 Lambert, M. J., 15, 18, 19, 23, 24, Liss, A., 119
Kellett, S., 467, 470 96, 250, 409 Loli-Dano, L., 128
Kelly, S., 247, 298, 299, 333, 335, Landes, S. J., 208 Long, D. M., 185
352, 356, 357 Laposa, J. M., 128 Lonner, W. J., 146
Kempler, W., 309 Larson, D., 223 Lord, S., 95
Kendall, P. C., 169 Laska, K. M., 4, 20, 267 Lorentzen, S., 394
Kennedy-Moore, E., 229 Lasky, G. B., 391 Low, J. G., 6
Kernberg, O. F., 42, 44, 56, 85 Lasser, J., 22, 357 Luborsky, L., 98, 420, 428, 429
Khan, A., 134 LaTaillade, J. J., 334 Luke, M., 385
Kierkegaard, S., 257, 258, 270, Lavretsky, H., 90 Lundh, L.-G., 20
280 Layne, C. M., 378 Luoma, J. B., 188
King, D. A., 393 Lazarus, A. A., 112, 444, 447, 455, Lutz, W., 468
Kingdon, D., 113 456, 458 Luxton, D. D., 9, 16
Kinley, J. L., 15 Leahy, R. L., 142 Luyten, P., 467
Kirby, J. S., 334 Lease, S. H., 384 Lynch, D. A., 250
Kircanski, K., 120 LeBon, G., 370 Lynch, T. R., 377
Kirmayer, L. J., 379 Lebow, J. L., 20, 247, 297, 298, 304,
Kirsch, I., 134 312, 313, 316, 318, 319, 333, M
Kirschenbaum, H., 224 335, 352, 356, 358, 456 Mac Kune-Karrer, B. M., 312
Kisely, S., 408, 434 Lederer, W. J., 334 Mack, S., 16
Kivlighan, D. M., Jr., 384, 393 Ledley, D. R., 119 MacKenzie, K. R., 372, 380, 393
Kladnitski, N., 172 Lee, M., 298 MacLane, C., 469
Klein, M., 72, 73, 77 Leggett, E. L., 227 Madu, S., 468
Klein, M. H., 250 Lehman, H. K., 298 Magnavita, J. J., 424, 446, 457
Klein, S., 59 Lehtinen, K., 307 Mahler, M., 42
Klein, S. B., 444 Leibing, E., 97 Mahoney, A. R., 299
Klepac, R. K., 185, 186, 187 Leichsenring, F., 59, 60, 97 Mahoney, M., 244
Klerman, G. L., 79, 411, 466, 469 Leino, A., 14, 22, 152 Mahrer, A. R., 229, 270
Kline, G. H., 359 Lemma, A., 420, 429, 430 Majid, S., 467
Klonsky, E. D., 24 Lenton-Brym, A. P., 95, 111, 145 Makinen, J. A., 348
Kloosterman, P., 117 Leszcz, M., 386 Malan, D. H., 419, 422, 423, 424
Klug, G., 60 Leuzinger-Bohleber, M., 59 Malberg, N. T., 467
Knaan-Kostman, I., 80, 83 Levant, R. F., 247 Maljanen, T., 408
Knack, W., 467 Levenson, E. A., 72, 87 Mancuso, E., 128
Knauss, L., 392 Levenson, H., 15, 407, 419, 420, Mann, C. H., 76
Kniskern, D. P., 298 431, 432, 433, 438 Mann, J., 419, 421, 422, 423
Knox, S., 250 Levenson, J. C., 418 Mannix, K., 80, 83
Knudson-Martin, C., 299 Levenson, L. N., 48 Marcus, H. E., 393
Koenen, K. C., 123 Levin, M. E., 184, 185 Marcus, P. H., 173
Koenigsberg, H. W., 42 Levin, S., 310 Marcus, S. C., 408
486 Author Index

Marecek, J., 334 Messer, S. B., 3, 4, 5, 7, 10, 14, 17, Newman, M. G., 134
Margolin, G., 334 18, 20, 24, 26, 27, 43, 45, 49, Nezu, A. M., 122, 123
Marker, C. D., 169 50, 54, 72, 97, 98, 282, 283, Nezu, C. M., 122
Marker, I., 125 284, 343, 409, 419, 420, 424, Ng, S. Y., 198
Markin, R. D., 426, 427 434, 445, 446, 450, 455, 462 Nguyen, J., 16
Markman, H. F., 335 Meyer, A., 412 Nichtigall, C. S., 393
Markman, H. J., 333, 340, 346, 359 Meyer, O. L., 186 Nielsen, A. C., 338, 339, 341, 350,
Markowitz, J. C., 411, 412, 413, 414, Mihura, J., 384 351
415, 417, 418, 419 Miklowitz, D. J., 134, 303 Nietzsche, F., 258
Marmor, J., 444 Miles, M. B., 383 Nissen, T., 26, 27
Marsh, L. C., 373 Miller, B. D., 298 Nitsun, M., 373
Martell, C. R., 121, 184, 197, 335 Miller, I. J., 282 Noller, P., 339
Marti, C. N., 14, 113, 146 Miller, M. D., 418 Norcross, J. C., 4, 7, 17, 18, 24, 98,
Mash, E. J., 150 Miller, N. E., 444 207, 250, 445, 448, 452
Masten, A. S., 225 Miller, S. D., 449 Nordberg, S., 451
Masuda, A., 5, 112, 158, 168, 183, Miller, W. R., 125, 164, 246 Nordgreen, T., 125
184, 186, 188, 192, 193, 198, Mineka, S., 127 Northey, W. F., 309
203, 209, 246 Minuchin, S., 298, 303, 308, 315 Norton, P. J., 125, 128, 377
Maura, J., 322 Mirsalimi, H., 297 Nowlan, K. M., 470
May, R., 257, 259, 260, 261, 262, Mischel, W., 114
264, 265, 266, 269, 270, 275, Mishkind, M. C., 16 O
278, 279, 280, 282, 283 Mitchell, A. E., 356 O’Connor, K. P., 425
Maynigo, P., 335 Mitchell, S. A., 36, 72, 73, 75, 77, O’Donohue, W., 112
Mazzuchelli, T., 130 83, 88 Oehen, P., 134
McAdams, C. R., 308, 319 Mitchell, V., 335 Ogden, J., 250
McAleavey, A. A., 20, 167 Mitrani, V. B., 321 Ogden, T., 74
McBride, C. K., 319 Mock, J., 145 Ogrodniczuk, J. S., 378, 384, 434
McCabe, B. E., 321 Moffitt, T. E., 10 O’Hara, M. M., 227, 248, 259, 279
McCabe, R. E., 388 Moix, J., 20 O’Leary, C., 247
McCallum, M., 378 Molière, 23 Olfson, M., 408
McCann, L., 26 Mondale, W., 10 Ollendick, T. H., 20, 155
McCann, R. A., 16 Mooney, K. A., 154 Opris, D., 119
McCarter, R., 466 Moore, M., 198 Orange, D. M., 73, 85
McCarthy, K. S., 426, 467 Moradi, B., 247 Orlinsky, D. E., 283, 409
McClendon, D. T., 380 Moravec, M. S., 380 Orsillo, S. M., 127, 134
McCollum, E. E., 410 Moreno, J. L., 309 Osborn, K. A. R., 424
McCrady, B. S., 335 Moreno, J. S., 389 Öst, L.-G., 96, 125, 155, 207
McCullough, J. P., Jr., 457, 458, 466, Moses, E., 335 O’Toole, M. S., 123
470 Mosher, L., 283 Otto, M. W., 172
McCullough, L., 424, 425 Mosier, J., 393 Owen, J., 23
McCutcheon, L., 453, 455 Moss, D., 257, 258, 280
McDaniel, S. H., 298, 310, 335, 359 Mowrer, O. H., 144 P
McDougall, J., 77 Mueser, K. T., 359, 378 Pace, B. T., 23
McDougall, W., 370, 371 Muir, J. A., 321 Pachankis, J. E., 171
McElwain, B., 282, 283 Mukherjee, D., 17 Padesky, C. A., 154
McFall, J. P., 155 Muran, J. C., 50, 79, 97, 98, 126, Padesky, J., 160
McFall, R. M., 20 468 Paivio, S. C., 238
McGill, K., 322 Murphy, D., 240 Paniagua, F. A., 11
McGinn, L. K., 410 Murray, H., 258 Panksepp, J., 15
McGinn, M. M., 356 Murray, J., 336 Papernow, P. L., 335
McGoldrick, M., 298, 301, 305, Muto, T., 186 Papouchis, N., 468
335 Myhr, G., 131 Paprocki, C., 335
McHugh, R. K., 172 Parkin, S. R., 15
McLeod, J., 27 N Parks, B. K., 283
McNeil, C. B., 310, 312 Naeem, F., 113 Parra-Cardona, J. R., 310, 319
McQuaid, J. R., 122 Nagayama Hall, G. C., 154 Parsons, J. T., 171
McWilliams, N., 44 Nardone, G., 410 Pascual-Leone, J., 229
Mearns, D., 241 Nathan, P. E., 17, 24, 118, 131 Pasek, L. F., 155
Mechelli, A., 128 National Council for Behavioral Passman, V., 468
Meek, L., 279 Health, 371 Patterson, G. R., 310
Meichenbaum, D., 22 Nefale, M., 468 Patterson, T., 309, 310, 311
Mellinger, M. V., 97 Neisser, U., 8 Paul, G. L., 213, 304
Mellor-Clark, J., 249 Nelson, D. L., 459 Pawar, A., 322
Meltzoff, J., 7, 11 Nelson, R. O., 115 Payne, K., 131
Mendelowitz, E., 279, 280 Nemeroff, C. J., 121 Pearl, S. B., 128
Mendelson, M., 145 Newby, J. M., 172 Pedersen, P. B., 146
Mennin, D. S., 123, 127, 134, 183, Newirth, J., 76 Pekarik, G., 409
185, 186, 213 Newman, C. F., 173, 466 Penberthy, K., 466
Merleau-Ponty, M., 259, 268 Newman, M., 451, 466 Pendley, J. S., 372
 Author Index 487

Penn, P., 307 Reiter, M. D., 298 Sager, C. J., 334

Peris, T. S., 303 Remer, R., 122 Sampson, H., 48, 59
Petrella, J. N., 333 Rendina, H. J., 171 Samstag, L. W., 97, 98
Petrucelli, J., 76 Rennie, D. L., 250, 283 Sandell, R., 58, 97
Petry, N. M., 120 Reyno, S. M., 15 Sanderson, W. C., 7, 409, 410
Petry, S., 305 Rhoades, G. K., 335 Sandler, J., 50
Pettersson-Yeo, W., 128 Rhodes, J. W., 444 Santisteban, D. A., 319, 321
Pflum, S., 14, 22, 152 Rice, D., 266, 281 Santoro, S. O., 445
Pfund, R. A., 207 Rice, L. N., 223, 224, 229, 237, 248, Santos, C. E., 247
Phillips, J., 272 450 Sartori, G., 128
Phiri, P., 113 Richardson, T., 124 Satir, V., 309
Piaget, J., 230 Ridsdale, L., 250 Saveanu, R. V., 461
Pickrel, S., 312 Rietz, C., 376 Sawyer, A. M., 321
Piette, J. D., 303 Riper, H., 124 Sawyer, A. T., 130, 145
Pilling, S., 173 Ritschel, L. A., 192 Saxena, S., 128
Pincus, H. A., 408 Ritterband, L. M., 16 Sayrs, J. H. R., 192, 204
Pine, F., 36 Riva, M. T., 391 Schachter, J., 44
Pinsof, W. M., 224, 298, 312, 335, Rizvi, S. L., 5, 112, 158, 168, 183, Schafer, R., 49, 51
336, 342, 351, 353 192, 204, 246 Scharf, R., 59
Pious, C., 385 Roback, H. B., 389 Scharff, D. E., 336
Piper, W. E., 378, 384, 434 Robbins, M. S., 318, 321, 322 Scharff, J. S., 305, 318, 336
Pistorello, J., 469 Roberts, B. W., 9 Schermer, V. L., 371
Pitta, P., 456, 457, 468 Roberts, J., 300 Schiller, M., 259, 262, 266, 281, 282
Platner, A. K., 299 Robins, C. J., 195, 204 Schlesinger, G., 53
Poduba, T., 432 Robinson, C., 321 Schmidt, C., 400
Popper, K., 5 Roche, B., 187 Schmidt, H., III, 195
Porges, S. W., 227 Roddy, M. K., 470 Schmutzer, P. A., 170
Pos, A. E., 250 Rodrigues, H., 134 Schneider, K. J., 12, 257, 259, 260,
Pospos, S., 90 Roemer, L., 95, 111, 127, 134, 145 261, 262, 263, 264, 265, 269,
Powers, M. B., 96 Rogers, C. R., 83, 221, 222, 223, 270, 272, 275, 276, 277, 278,
Prasko, J., 163, 167 224, 225, 226, 227, 230, 232, 279, 280, 281, 282, 283, 284,
Prata, G., 307 234, 239, 240, 241, 248, 250 288
Pratt, J. H., 369, 370 Rogers, N., 234 Schoenwald, S. K., 321
Price, J. E. W., 372 Rohrbaugh, M. J., 299, 334 Schoevers, R., 59
Prigogine, I., 244 Rollnick, S., 125, 164, 246 Schore, A., 90
Prina, A. M., 15 Rombauts, J., 246 Schottenbauer, M. A., 469, 470
Prochaska, J. O., 18, 207, 447, 448, Rosen, D., 16 Schram, E., 466
452, 455, 456, 457 Rosenberg, B., 372, 385 Schultz-Venrath, U., 376
Prouty, G. F., 235, 246 Rosenthal, M. Z., 377 Schwartz, J., 380
Ptak, R., 372 Rosenzweig, S., 444, 461 Schwartz, R. C., 312
Puhakka, K., 283 Rosie, J. S., 378 Schwartz, S. J., 312, 321
Rosland, A. M., 303 Scott, L. N., 98
Q Rosmarin, D. H., 113, 157 Seamam, S., 378
Qian, M. Y., 170 Rossini, E. D., 393 Searles, H. F., 56, 77, 94
Quintana, S., 14 Roth, A. D., 173 Seddon, C., 467
Roth, G., 287 Seed, P., 250
R Roth, J. A., 384 Segal, Z. V., 184, 188, 189, 190, 194,
Rabung, S., 59, 60, 97 Rothbaum, B. O., 119 195, 199, 206, 207, 208, 462,
Rachman, S. J., 127 Rothchild, D., 467 463, 464
Ragan, E. P., 335 Rottenberg, J., 189 Seidler, G. H., 452
Rait, D. S., 319 Rounsaville, B., 466 Seikkula, J., 307
Rajaratnam, S. M., 170 Rounsaville, B. J., 79 Seligman, M. E. P., 282, 371
Rank, O., 222, 258, 276, 419 Rousmaniere, T., 16 Selles, R. R., 155
Rao, P. A., 122 Rowan, J., 259 Selvini-Palazzoli, M., 307
Rappaport, E., 452 Rowland, M. D., 321 Selzer, M. A., 42
Raps, C. S., 381 Ruddy, N. B., 335, 359 Serfaty, M. A., 134
Rasco, C., 20 Russell, E., 426 Serlin, I. A., 270
Rasera, E. F., 307 Russell, W. P., 298 Sevier, M., 352
Rasic, D., 408 Russon, J., 305 Sexton, T. L., 297, 299, 312, 322,
Rathod, S., 113 Rutan, J. S., 381, 386 468
Ray, D., 247, 249 Ryan, R. M., 226 Shadish, W. R., 358, 359
Rector, N. A., 173 Ryle, A., 453, 455, 457, 467, 470 Shahar, B., 246, 318
Rees, C., 130 Rynn, M., 318 Shahar, G., 259, 262, 266, 281, 282
Reese, H. W., 186 Shaker, A., 50
Reger, G. M., 16
S Shapiro, D., 469
Reich, W., 42 Sabo, D., 318 Shapiro, F., 451, 452
Reijnders, M., 169 Safran, J. D., 50, 59, 79, 90, 97, 98, Sharf, J., 250
Reis, B. F., 305 126, 462, 463, 464 Shay, J., 381
Reiss, D. J., 299, 310 Safren, S. A., 171 Shedler, J., 42, 58
488 Author Index

Sheldon, A., 424 Stickgold, R., 88 Town, J. M., 408, 423, 424, 432
Shlien, J. M., 247 Stickle, T. R., 359 Trauer, J. M., 170, 172
Shoe, K. M., 372 Stiles, W. B., 248, 249 Treanor, M., 119, 172
Shoham, V., 20, 334, 359 Stolar, N., 173 Trepper, T. S., 410
Shpigel, M. S., 315, 319, 321 Stolorow, R. D., 73, 85, 272 Trimble, J. E., 146
Si, G., 90 Stone, W. N., 381 Tropiano, H. L., 24
Siegel, D. J., 15, 84 Straus, M. A., 343 Trub, L., 445
Siegel, J. P., 334, 336, 338, 349, 350 Strauss, A. Y., 125 Tsai, M., 125, 184, 204, 206
Siev, J., 125 Strauss, B., 393 Tsvieli, N., 318
Sifferlin, A., 285 Strauss, C., 149, 207 Tummala-Narra, P., 57, 433
Sifneos, P. E., 419, 422, 423, 424 Stricker, G., 4, 7, 443, 445, 446, 450, Turkington, D., 113
Silk, J., 16 451, 454, 455, 456, 459, 460, Turnell, A., 172
Simpson, G. L., 22, 357 462, 464, 467, 470, 471 Turner, C. S., 318
Simpson, H. B., 125 Stride, C., 408 Turner, J. A., 169
Sin, J., 322 Strosahl, K. D., 184, 188, 189, 190, Twohig, M. P., 164
Siqueland, L., 305, 317, 318, 321 191, 196, 197, 200, 201, 204, Tyler, J. D., 170
Skinner, B. F., 112, 114, 144, 187, 205, 206, 207, 211, 246, 451
444 Strunk, D. R., 125 U
Slavin, J., 467 Strupp, H. H., 230, 239, 420, 431 Uhlin, B. D., 240
Slepecky, M., 167 Strycker, L. A., 113 Ullmann, L. P., 112
Slochower, J. A., 76 Sue, D. W., 113, 124 Ulrich, D., 304
Smith, A. M., 111 Sue, S., 14, 22, 113, 152, 154, 186, Ulvenes, P. G., 424
Smith, C. A., 152 207
Smith, C. O., 299 Sullivan, H. S., 36, 71, 72, 73, 74, 77, V
Smith, D., 223 79, 82, 373, 374, 386, 412 Van Balen, R., 246
Smith, P., 113 Summerfeldt, L. J., 117 van der Gaag, M., 173
Smith, S. R., 11 Suzuki, J. Y., 250 van der Kolk, B. A., 451, 452
Smith, T. B., 124, 352 Svartberg, M., 411 van Deurzen, E., 282
Smolar, A., 371 Swanson, C., 336 Van Dijk, M. K., 155
Snyder, D. K., 7, 339, 342, 356, 358 Swartz, H. A., 411, 412, 413, 415, Van Doorn, G., 16
Sobel, R., 298 418 Van Dyk, G., 468
Society of Clinical Psychology, 130 Swift, J. K., 15, 409 Van Houdenhove, B., 467
Sollod, R. N., 468 Swinson, R. P., 119, 133 VandenBos, G., 7
Solomon, H. C., 112 Symmons, M., 16 Velleman, S., 124
Solomon, M. F., 15, 84 Symonds, D., 97, 125 Verbraak, M. J., 155
Solovey, A., 298 Szapocznik, J., 312, 319, 321 Vermeersch, D. A., 96
Soo, S. A., 322 Vervliet, B., 119, 172
Sorenson, S., 113, 133, 157 T Villatte, M., 184, 188, 189, 190, 191,
Sotomayor, S., 10 Taft, J., 222 194, 197, 204, 205, 206, 207
Spandler, H., 283 Tallman, K., 20, 226, 234, 250, 283, Vinnars, B., 428, 429
Spanier, G. B., 342 284, 454, 465 von Bertalanffy, L., 300, 334
Spek, V., 124 Tang, Y. Y., 90 von Goethe, J., 279
Spence, D. P., 26 Tao, K. W., 23 Vonk, I. J., 130, 145
Sperry, L., 170 Target, M., 55, 375, 429 Vontress, C., 266, 281
Spiegler, M. D., 120 Tarrant, J. M., 384 Vos, J., 282
Spielmans, G. I., 155 Tasca, G. A., 469 Vyskocilova, J., 167
Spillman, A., 98 Tauber, E. S., 93
Spinelli, E., 259, 282 Taylor, E. T., 257, 258 W
Spitzer, R. L., 209 Taylor, P., 467 Wachtel, P. L., 14, 23, 81, 89, 90,
Sprenkle, D. H., 20, 298, 313, 352, Teasdale, J. D., 127, 184 420, 438, 445, 449, 450, 453,
358 Teich, M. J., 96 454, 455, 456, 461, 462, 464,
Staccini, L., 302 ter Huurne, M. A. B., 173 468, 471
Stallard, P., 124 Thomas, C., 127 Wadsworth, M. E., 333
Stanley, S. M., 333, 335, 340, 346, Thomas, P., 467 Wagner, D. V., 321
359 Thompson, C., 71, 72, 75 Wagner, F. E., 452
Staring, A. B., 173 Thompson, L., 447 Wakefield, J., 49
Starr, K. E., 81, 90 Thompson, N. J., 372 Waldo, M., 380
Steckley, P., 246 Tilley, J. L., 152 Waldron, S., 59
Steer, R. A., 376, 377 Tillich, P., 265, 280 Wallerstein, R. S., 36, 60
Stein, M., 448 Timulak, L., 282 Wallner, L., 97
Steinert, S., 59 Tinsely, H. E., 384 Walsh, F., 302
Sterling, M., 261, 263 Tishby, O., 98 Walsh, R. A., 282, 283
Stermac, L., 246 Titov, N., 125 Wamboldt, M. Z., 299
Stern, D. B., 74, 76, 86, 88, 89 Tolin, D. F., 172 Wampold, B. E., 4, 14, 17, 18, 20, 23,
Stern, D. N., 75, 76 Tomba, E., 302 24, 58, 60, 97, 125, 169, 262,
Stern, S., 409 Tomlins, J., 447 266, 267, 282, 283, 284, 288,
Stewart, R. E., 18, 135, 171 Toobert, D. J., 113 424, 449, 461, 465
Stewart, S., 279 Towmey, C., 15 Wamsley, E. J., 88
Stice, E., 14, 113, 146 Town, J., 408 Wang, C., 250
 Author Index 489

Wang, Z., 169 Westen, D., 42 Wolitzky-Taylor, K. B., 96

Ward, C. H., 145 Westra, H. A., 125, 126 Wolpe, J., 112, 144
Warren, C. S., 45, 72, 419, 420, 434 Wexler, D. A., 229, 237 Wood, B. L., 298
Warren, R., 173 Whaley, A. L., 186 Wood, J. K., 227
Warren, W., 279 Whealin, J. M., 310, 319 Woolfolk, R. L., 10, 14
Wasserman, R. H., 98 Whisman, M. A., 339 World Health Organization, 10, 12,
Watkins, C. E., 445 Whitaker, C. A., 303, 309 190
Watson, J. C., 5, 12, 221, 223, 224, White, M., 303 Wynn, R., 26, 27
229, 231, 234, 238, 240, 241, Whiteside, S. P, 119
244, 245, 246, 249, 250, 258, Widdowson, M., 27 Y
282, 283 Wiebe, S. A., 470 Yalom, I. D., 259, 261, 263, 265,
Watts, S. E., 172 Wiener, N., 334 266, 267, 270, 272, 282, 383,
Watzlawick, P., 410 Wierzbicki, M., 409 372, 385, 386
Weakland, J., 297 Wiles, N. J., 134 Yamada, A.-M., 11
Wei, G. X., 90 Wilfley, D. E., 208, 372 Yeomans, F. E., 85, 98
Weinberger, J. L., 20 Williams, A. D., 169 Yeung, D., 426
Weiner, I. B., 53 Williams, E., 247 Yi, J. C., 352
Weingarten, K., 352 Williams, J. B. W., 209 Yin, R. K., 27
Weinstein, M., 393 Williams, J. M. G., 184 Young, M., 9
Weintraub, M. J., 322 Wilson, G. T., 173 Young, M. Y., 347
Weiss, J., 48, 59 Wilson, K. G., 184, 185, 188, 197, Yulish, N. E., 20
Weiss, R. L., 334, 336 202, 206, 246, 451
Weiss-Lazer, N. S., 321 Winnicott, D. W., 36, 52, 72, 73, Z
Weissman, M. M., 79, 372, 411, 412, 74, 87 Zane, N. W. S., 154, 186
413, 414, 415, 417, 418, 419, Winokur, M., 5, 343 Zapparoli, G., 467
438, 466 Winston, A., 97, 98 Zarbo, C., 469
Welch, R. R., 372 Wiseman, H., 223, 224 Zbozinek, T., 119, 172
Wells, A., 159, 184 Witenberg, E. G., 91 Zeldow, P. B., 24, 25
Welwood, J., 271 Wolf, A. W., 16, 25 Zilcha-Mano, S., 18, 125
Wenzel, A., 170, 377, 388 Wolfe, B. E., 282, 283 Zimmerman, J., 60
Wertz, F. J., 258, 282 Wolitzky, D. L., 10, 17, 35, 43, 47, Zinbarg, R. E., 127
West, A. E., 310 48, 49, 50, 53, 54, 57, 306, 420 Zuccarini, D., 348

Note. f or t following a page number indicates a figure or a table.
ABC model, 144, 147–149, 148f,
151–152, 156–157. See also
Activating event; Beliefs;
Cognitive-behavioral therapy
(CBT); Consequences
Accelerated experiential–dynamic
psychotherapy (AEDP),
426–427
Acceptance, 183–184, 189,
195–196, 240, 246. See also
Unconditional positive regard/
warmth
Acceptance and commitment therapy
(ACT)
case illustration, 209–213
clinical assessment and, 191–193
contributions of, 185–186
curative factors or mechanisms of
change, 205–206
integrative approaches to
psychotherapy and, 470
overview, 184, 196–197
personality and, 187
person-centered and experiential
therapies and, 246
process aspects of, 197–203
psychological health and
psychopathology, 188–189
research support and EBP, 207,
208
technical errors and, 203–204
therapeutic relationship and the
stance of the therapist, 204–205
treatment applicability and ethical
considerations and, 206–207
Action-oriented theory, 377–378,
380–381, 388–389
Activating event, 144, 147–149, 148f,
151–152. See also ABC model
Activation, 345–346
Actualization, 86, 225–226, 278–279
Adaptation, 115, 190, 371
ADDRESSING framework, 152–153,
170
Affect phobia therapy (APT),
424–427
Subject Index
Affect regulation, 81, 82–83, 229,
386
Agency, 226–227, 265
Aggression, 75, 76
Agoraphobia, 96
Anal stage of psychosexual
development, 40
Antecedents. See ABC model;
Activating event
Anxiety. See also Anxiety disorders
behavior therapy and, 128, 134
cognitive-behavioral therapy (CBT)
and, 169, 172
contemporary Freudian
psychoanalytic psychotherapy
and, 41
exposure techniques and, 118–119
person-centered and experiential
therapies and, 246–247
psychosexual development and, 40
relational psychoanalytic/
psychodynamic psychotherapy,
77
Anxiety disorders, 118–119, 125,
134, 172, 246–247. See also
Anxiety
Applicability of treatment. See also
Client/patient factors; Treatment
behavior therapy and, 128
brief psychodynamic therapies
and, 434
cognitive-behavioral therapy (CBT)
and, 169–171
contemporary Freudian
psychoanalytic psychotherapy
and, 56–57
couple therapies and, 356–357
existential–humanistic
psychotherapies and, 281
family therapies and, 318–319
group psychotherapies and,
378–379, 389
integrative approaches to
psychotherapy and, 465–468
interpersonal psychotherapy (IPT)
and, 418
490
overview of author guidelines
regarding, 21–23
person-centered and experiential
therapies and, 246–248
relational psychoanalytic/
psychodynamic psychotherapy,
95–96
third-wave cognitive-behaviorally
based therapies, 206–207
Assessment tools, 145, 378, 457. See
also Clinical assessment
Assimilative integration model,
446, 450–451, 452–453, 455,
470–474. See also Integrative
approaches to psychotherapy
Attachment, 91, 98, 337, 340–341,
347
Attachment theories, 75–76, 337,
420–421
Attachment-based family therapy
(ABFT), 304–305, 314, 317,
321
Attachment-based psychotherapy,
76, 312
Author guidelines
case illustration, 25–27
clinical assessment, 10–12
curative factors or mechanisms of
change, 18–20
historical background, 6–7
personality, 8–9
practice of therapy, 12–16
psychological health and
psychopathology, 9–10
research support and EBP, 23–25
suggestions for further study,
27–28
therapeutic relationship and the
stance of the therapist, 16–18
treatment applicability and ethical
considerations, 21–23
Automatic thoughts, 157, 159–160,
161t–162t. See also Thoughts
Avoidance, 121–122, 127, 189, 190
Awareness, 190, 199–200
Awe, 278–279
 Subject Index
B Brief psychodynamic therapies
BASIC ID acronym, 447, 455
Behavior modification, 112
Behavioral activation (BA), 121–122,
157, 184, 207
Behavioral assessment, 115–116. See
also Clinical assessment
Behavioral regulation, 189
Behavioral therapy
behavioral adaptation, 191
behavioral experiments and, 157,
159–160
case illustration, 129–130,
131–133
chain analysis, 192
clinical assessment and, 115–117
cognitive-behavioral therapy (CBT)
and, 143, 145–146, 169
curative factors or mechanisms of
change, 126–128
diaries/self-monitoring, 116–117
family therapies and, 310
historical background, 112–113
origins of CBT and, 143–144
overview, 111–112
personality and, 113–114
practice of therapy and, 117–124
psychological health and
psychopathology, 114–115
relational psychoanalytic/
psychodynamic psychotherapy,
81
research support and EBP,
130–131
skills training and, 168–169
suggestions for further study,
134–135, 135
therapeutic relationship and the
stance of the therapist, 124–126
treatment applicability and ethical
considerations and, 128–130
Behaviorism, 143–144, 258
Behaviors, 42, 90, 144, 187–188,
454–455
Beliefs. See also ABC model
assessment of, 152
behavioral experiments and,
159–160
cognitive-behavioral therapy
(CBT) and, 160, 162–165, 163t,
167–168
goal setting in CBT and, 156–157
origins of CBT and, 144
overview, 147–149, 148f
personality and, 147
therapeutic techniques and,
161t–162t
Biological factors, 114, 128, 195–196
Biopsychosocial perspective, 15, 298
Bipolar disorder, 134
Bisexuality, 75. See also LGBTQ
clients; Sexuality
Body, 451–452
Borderline patients, 59
Borderline personality disorder (BPD),
98, 195, 246–247, 377
Boundaries, 301, 308
Brief intensive psychotherapy, 423t
(BPT)
adaptations of, 433–434
applicability of, 434
case illustration, 436f
conceptual foundations of,
420–421, 421t
diversity considerations in, 433
ethical considerations and,
410–411
future of, 438
historical background, 419–420
integrative approaches to
psychotherapy and, 457–458
overview, 407–411, 410t, 434
practice of therapy and, 421–432,
423t
suggestions for further study,
438–439
therapeutic relationship and the
stance of the therapist, 432–433
Brief strategic family therapy®
(BSFT®), 312, 321, 322–323.
See also Family therapies
Brief strategic therapy, 410t
C cognitive-behavioral therapy (CBT)
Caring function, 383
Case conceptualization. See
Conceptualizing the case
Case formulation, 342, 343,
344–345, 413–414
Castration anxiety, 40
Centered response style, 189,
199–200
Chain analysis, 192, 205–206
Change mechanisms. See also
Curative factors
behavior therapy and, 126–128
cognitive-behavioral therapy (CBT)
and, 156–157, 167–169
contemporary Freudian
psychoanalytic psychotherapy
and, 54–56, 60–61
couple therapies and, 354–356
dialectical behavior therapy (DBT)
and, 195–196
existential–humanistic
psychotherapies and, 280–281
family therapies and, 316–318
group psychotherapies and,
385–389
integrative approaches to
psychotherapy and, 460–461,
464–465
overview of author guidelines
regarding, 18–20
person-centered and experiential
therapies and, 243–246
relational psychoanalytic/
psychodynamic psychotherapy,
94–95
therapeutic relationship and, 91
third-wave cognitive-behaviorally
based therapies, 205–206
transtheoretical psychotherapy
and, 447–448
treatment applicability and ethical
considerations and, 21–22
491
Childhood disorders, 128, 172,
246–247
Circular causality, 300–301
Circumstantial destiny, 260
Clarification, 48, 64, 416t
Classical conditioning, 114
Client feedback, 155
Client-centered therapy, 221, 459–
460. See also Person-centered
psychotherapy
Client/patient factors. See also
Applicability of treatment
contemporary Freudian
psychoanalytic psychotherapy
and, 55–57
integrative approaches to
psychotherapy and, 459–
461
overview, 20
person-centered and experiential
therapies and, 224, 234
relational psychoanalytic/
psychodynamic psychotherapy,
95–96
Clinical assessment
behavior therapy and, 115–117
and, 149–154, 153t
contemporary Freudian
psychoanalytic psychotherapy
and, 43–44
couple therapies and, 342–345
culture and, 152–154
existential–humanistic
psychotherapies and, 262–
265
family therapies and, 303–304
group psychotherapies and,
376–377, 378–380
integrative approaches to
psychotherapy and, 447–448,
455–457
interpersonal psychotherapy (IPT)
and, 413–414
overview of author guidelines
regarding, 10–12
person-centered and experiential
therapies and, 232–233
relational psychoanalytic/
psychodynamic psychotherapy,
78–79
third-wave cognitive-behaviorally
based therapies, 190, 191–193
Clinical interviews, 11, 117,
149–150, 303. See also Clinical
assessment
Cognitive analytic therapy (CAT),
453–454, 467, 470
Cognitive approaches, 387–388
Cognitive changes, 127
Cognitive distortions, 153t, 161t,
161t–162t, 346. See also
Thoughts
Cognitive restructuring, 145, 160,
459
Cognitive therapy (CT), 142–143,
144–146, 310. See also
Cognitive-behavioral therapy
(CBT)
492
Cognitive-behavioral analytic system
of psychotherapy (CBASP)
model, 457, 458, 466, 470
Cognitive-behavioral family therapies
(CBFTs), 309–312, 316, 318,
322. See also Family therapies
Cognitive-behavioral therapy (CBT).
See also ABC model; Behavioral
therapy; Third-wave cognitive-
behaviorally based therapies
case illustration, 173–178
clinical assessment and, 149–154,
153t
couple therapies and, 335–337, 340,
343, 345–346, 353, 355, 362
cultural factors and, 113
curative factors or mechanisms of
change, 167–169
emotion regulation skills training
and, 123
existential–humanistic
psychotherapies and, 259
group psychotherapies and,
376–377, 387–388
historical background, 143–146
integrative approaches to
psychotherapy and, 451, 469
list of cognitive distortions, 153t
overview, 142–143, 410t
personality and, 146–147
person-centered and experiential
therapies and, 246, 249
practice of therapy and, 154–165,
161t–162t, 163t
psychological health and
psychopathology, 147–149, 148f
relational psychoanalytic/
psychodynamic psychotherapy,
79, 81–82, 90
research support and EBP,
130–131, 171–173
suggestions for further study,
134–135, 178
therapeutic relationship and the
stance of the therapist, 18,
124–126, 165–167
treatment applicability and ethical
considerations and, 169–171
Collaboration, 17, 20, 307, 334,
350–352. See also Therapeutic
relationship
Common-factors approach. See
also Integrative approaches to
psychotherapy
clinical assessment and, 456–457
contemporary Freudian
psychoanalytic psychotherapy
and, 60–61
curative factors or mechanisms of
change, 19–20
existential–humanistic
psychotherapies and, 282–283
family therapies and, 313,
322–323
models of psychotherapy
integration, 446
overview, 448–449
therapeutic relationship and the
stance of the therapist, 461–462
Subject Index
Communication skills, 122, 302, 314,
337, 416t
Compromise formation, 41, 42–43
Conceptualizing the case, 157,
158–159, 190
Confidentiality, 97, 320, 358,
390–392
Congruence, 239, 241, 250
Connection, 341–342
Consciousness, 45–46, 90, 244,
259–260, 261
Consequences. See also ABC model
assessment of, 151
goal setting in CBT and, 156–157
origins of CBT and, 144
overview, 115, 120–121, 148–149,
148f
Constrictive–expansive continuum,
261
Constructive behavioral repertoire,
190
Contemporary Freudian
psychoanalytic psychotherapy
case illustration, 61–65, 63t
clinical assessment and, 43–44
curative factors or mechanisms of
change, 54–56
historical background, 35–39
overview, 35
personality and, 39–42
practice of therapy and, 44–51
psychological health and
psychopathology, 42–43
research support and EBP, 58–61
suggestions for further study, 66
therapeutic relationship and the
stance of the therapist, 51–54
treatment applicability and ethical
considerations and, 56–57
Contextual factors
common-factors approaches and,
449
curative factors or mechanisms of
change, 20
existential–humanistic
psychotherapies and, 282–283
group psychotherapies and,
372–373
integrative approaches to
psychotherapy and, 461
personality and, 187–188
Contingency management, 120, 121,
377
Core beliefs, 160, 161t–162t,
162–165, 163t. See also Beliefs
Core conflictual relationship theme
(CCRT), 59, 428–429
Corrective emotional experiences, 88,
245, 444
Countertransference. See also
Projective identification
brief psychodynamic therapies
and, 433
cognitive-behavioral therapy (CBT)
and, 167
contemporary Freudian
psychoanalytic psychotherapy
and, 50–51, 53–54, 57, 61
couple therapies and, 344, 353
family therapies and, 306–307
group psychotherapies and, 382,
384–385
person-centered and experiential
therapies and, 241–243
relational psychoanalytic/
psychodynamic psychotherapy,
86, 91–93, 94
therapeutic stance and, 17
third-wave cognitive-behaviorally
based therapies, 205
time-limited dynamic
psychotherapy (TLDP) and, 431
Couple therapies
case illustration, 359–363
clinical assessment and, 342–345
concept of the couple, 336–339
curative factors or mechanisms of
change, 354–356
historical background, 333–336
integrative approaches to
psychotherapy and, 457, 468
overview, 333
practice of therapy and, 345–
352
psychological health and
psychopathology, 339–342
research support and EBP,
358–359
suggestions for further study,
363–364
treatment applicability and ethical
considerations and, 356–358
Cultural factors. See also
Multiculturalism
behavior therapy and, 112–113,
123–124, 135
brief psychodynamic therapies
and, 433
clinical assessment and, 11
cognitive-behavioral therapy (CBT)
and, 146, 152–154, 156–157,
170, 171
competency and, 56–57, 152–154,
171
contemporary Freudian
psychoanalytic psychotherapy
and, 56–57
couple therapies and, 352, 357,
363
cultural destiny, 260
diversity considerations in, 433
family therapies and, 298–299,
303
group psychotherapies and,
384–385
practice of therapy and, 14–15
therapeutic relationship and, 17
third-wave cognitive-behaviorally
based therapies, 203
treatment applicability and ethical
considerations and, 22–23
Curative factors. See Change
mechanisms
D
Decentering from thoughts, 127,
189
Decision analysis technique, 416t
 Subject Index
Defenses. See also Drives; Projective
identification
brief psychodynamic therapies and,
425, 426–427
contemporary Freudian
psychoanalytic psychotherapy
and, 37–39
couple therapies and, 338,
341–342
defense analysis, 48
family therapies and, 306–307
group psychotherapies and,
374–375, 387
integrative approaches to
psychotherapy and, 454–455
psychosexual development and,
40
relational psychoanalytic/
psychodynamic psychotherapy,
83, 89–90
Defusion, 189
Denial, 38
Dependent state, 371
Depression
behavior therapy and, 128, 134
cognitive-behavioral therapy (CBT)
and, 142, 169, 172
couple therapies and, 356,
361–362
group psychotherapies and,
376–377
integrative approaches to
psychotherapy and, 466–467,
470
interpersonal psychotherapy (IPT)
and, 411–412
person-centered and experiential
therapies and, 246–247
Desires, 82–83
Destiny, 260–261
Detachment, 189
Developmental factors
couple therapies and, 338
family development, 301–302
personality and, 74, 75–76
person-centered therapy and,
229–230
relational psychoanalytic/
psychodynamic psychotherapy,
82
Diagnosis. See also Psychological
health and psychopathology
behavior therapy and, 117
clinical assessment and, 10, 11–12,
43–44
cognitive-behavioral therapy (CBT)
and, 150
contemporary Freudian
psychoanalytic psychotherapy
and, 65
couple therapies and, 343, 344
empirically supported treatments
(ESTs) and, 24–25
family therapies and, 303
functional analysis and, 115
integrative approaches to
psychotherapy and, 455, 457
interpersonal psychotherapy (IPT)
and, 412–413
person-centered and experiential
therapies and, 232–233
relational psychoanalytic/
psychodynamic psychotherapy,
77
third-wave cognitive-behaviorally
based therapies, 190, 192
Diagnostic and Statistical Manual of
Mental Disorders (DSM-5)
contemporary Freudian
psychoanalytic psychotherapy
and, 44
family therapies and, 299
functional analysis and, 115
integrative approaches to
psychotherapy and, 455, 457
relational psychoanalytic/
psychodynamic psychotherapy,
77
third-wave cognitive-behaviorally
based therapies, 190, 192
Dialectical behavior therapy (DBT)
borderline personality disorder
(BPD) and, 98
clinical assessment and, 191–193
contributions of, 185–186
curative factors or mechanisms of
change, 205–206
group psychotherapies and, 377
overview, 184, 195–196, 467
psychological health and
psychopathology, 188–189
research support and EBP, 207,
208, 469
technical errors and, 203–204
therapeutic relationship and the
stance of the therapist, 204–205
treatment applicability and ethical
considerations and, 206–207
Dialectical constructivism, 229
Diathesis–stress model, 412
Digital-based parent training (DBPT),
322
Direct behavioral observation,
116, 303. See also Clinical
assessment; Observation
Direct elicitation technique, 416t
Dissociative view, 74–75
Distorted thoughts. See Cognitive
distortions
Distress tolerance, 190
Diversity
brief psychodynamic therapies
and, 433
cognitive-behavioral therapy (CBT)
and, 152–154
contemporary Freudian
psychoanalytic psychotherapy
and, 57
existential–humanistic
psychotherapies and, 259, 281
family therapies and, 298–299
interpersonal psychotherapy (IPT)
and, 417–418
treatment applicability and ethical
considerations and, 22–23
Domestic terrorism, 356–357
Dose–response, 409
Dream exploration, 88, 278–279
493
Drives, 37–38, 39–40, 420,
421t, 422–427. See also
Contemporary Freudian
psychoanalytic psychotherapy;
Defenses
Dropping out of treatment, 97–98
Dynamic interpersonal therapy (DIT),
429–430
E
Early termination, 409
Eating disorders, 128
Economic contexts, 7, 372–373
Effectiveness, 21, 134–135, 408
Efficacy, 21, 55, 125, 134–135,
172–173
Ego, 36, 41
Emotion regulation
behavior therapy and, 127
cognitive-behavioral therapy (CBT)
and, 168–169
dialectical behavior therapy (DBT)
and, 195
skills training and, 123
third-wave cognitive-behaviorally
based therapies, 188, 189, 190
Emotional processing, 126–127
Emotional stimulation function,
383–384
Emotionally focused therapy (EFT).
See also Emotion-focused
psychotherapies
couple therapies and, 335–336,
337, 340–341, 343–344,
346–348, 351, 352, 353, 355,
362–363
integrative approaches to
psychotherapy and, 450
overview, 221
Emotion-focused couple therapy,
336. See also Couple therapies;
Emotionally focused therapy
(EFT)
Emotion-focused psychotherapies.
See also Emotionally focused
therapy (EFT); Person-centered
psychotherapy
case illustration, 250–252
clinical assessment and, 232–233
couple therapies and, 335–336
curative factors or mechanisms of
change, 243–246
historical background, 221–224
overview, 221
practice of therapy and, 233–239
research support and EBP,
248–250
suggestions for further study, 252
therapeutic relationship and the
stance of the therapist, 239–243
treatment applicability and ethical
considerations and, 246–248
Emotions
ABC model and, 148–149, 148f
behavior therapy and, 127
existential–humanistic
psychotherapies and, 283
family health and pathology, 303
goal setting in CBT and, 156–157
494
person-centered and experiential
therapies and, 231–232
process–experiential/emotion-
focused therapy (PE-EFT) and,
228–229
relational psychoanalytic/
psychodynamic psychotherapy,
90
Empathic understanding, 239–241
Empathy
contemporary Freudian
psychoanalytic psychotherapy
and, 52–53
couple therapies and, 341–342
person-centered and experiential
therapies and, 236, 246, 250
relational psychoanalytic/
psychodynamic psychotherapy,
83–84, 90, 91
Empirically supported principles
(ESPs), 356
Empirically supported treatments
(ESTs), 24–25
Empty chair dialogues, 238, 251–252
Enactments, 83, 85–87, 347–348, 463
Encouragement of affect technique,
416t
Engaged response style, 189, 201–203
Environmental factors, 126, 298,
372–373, 454–455
Errors in therapy. See Technical errors
in therapy
Ethical considerations
behavior therapy and, 128–130
brief psychotherapies and,
410–411
cognitive-behavioral therapy (CBT)
and, 171
contemporary Freudian
psychoanalytic psychotherapy
and, 57
couple therapies and, 357–358
existential–humanistic
psychotherapies and, 281
family therapies and, 319–321
group psychotherapies and,
389–393
integrative approaches to
psychotherapy and, 465–468
overview of author guidelines
regarding, 21–23
person-centered and experiential
therapies and, 246–248
relational psychoanalytic/
psychodynamic psychotherapy,
96–97
third-wave cognitive-behaviorally
based therapies, 206–207
Ethical non-neutrality, 96–97
Ethnicity, 124, 146. See also Cultural
factors
Evidence-based practice (EBP)
behavior therapy and, 130–131
cognitive-behavioral therapy (CBT)
and, 171–173
contemporary Freudian
psychoanalytic psychotherapy
and, 58–61
couple therapies and, 358–359
Subject Index
existential–humanistic
psychotherapies and, 282–
284
family therapies and, 321–323
group psychotherapies and,
393–394
integrative approaches to
psychotherapy and, 468–470
overview of author guidelines
regarding, 23–25
person-centered and experiential
therapies and, 248–250
relational psychoanalytic/
psychodynamic psychotherapy,
97–98
therapeutic relationship and the
stance of the therapist, 17
third-wave cognitive-behaviorally
based therapies, 207–208
Evidence-based psychological practice
(EBPP), 25
Existential–humanistic (E-H)
psychotherapies, 257–259,
262–265
Existential–humanistic
psychotherapies
case illustration, 284–288
curative factors or mechanisms of
change, 280–281
overview, 288
personality and, 259–262
practice of therapy and, 265–280
psychological health and
psychopathology, 259–262
research support and EBP,
282–284
suggestions for further study,
288–289
Existential–integrative (E-I) approach,
262
Experiencing, 89, 227–228, 229,
263, 280
Experiential avoidance, 188, 189,
190. See also Avoidance
Experiential brief therapy, 410t
Experimentation, 270–271
Exposure and response prevention
(ERP), 164
Exposure hierarchy, 119–120. See
also Exposure techniques
Exposure techniques
behavior therapy and, 118–120
brief psychodynamic therapies
and, 424
cognitive-behavioral therapy (CBT)
and, 157
cultural factors and, 124
curative factors or mechanisms of
change, 126–128
ethical considerations and,
129–130
group psychotherapies and, 377
integrative approaches to
psychotherapy and, 444
relational psychoanalytic/
psychodynamic psychotherapy,
96
treatment applicability and ethical
considerations and, 281
Exposure-based therapies, 111,
118–120, 130–131. See also
Behavioral therapy
Expressed emotion, 283, 303. See
also Emotions
Expressive work, 428–429
Extinction, 119, 121, 126–127. See
also Exposure techniques
Eye movement desensitization and
reprocessing (EMDR), 451–
452
F
False self, 74. See also Self-system
Family, 300–303
Family systems theory, 305, 334
Family therapies
case illustration, 323–326
clinical assessment and, 303–304
concept of the family, 300–302
curative factors or mechanisms of
change, 316–318
family health and pathology,
302–303
historical background, 297–300
integrative approaches to
psychotherapy and, 457, 468
overview, 326
practice of therapy and, 304–314
research support and EBP,
321–323
suggestions for further study,
326–327
therapeutic relationship and the
stance of the therapist, 314–
316
treatment applicability and ethical
considerations and, 318–321
Fantasies, 76, 81
Fears, 82–83, 96, 118–119, 444
Feedback, client, 155
Feelings, 81, 82–83, 227–228, 264
Feminist psychology, 71–72, 342
Fight–flight state, 371
Focusing-oriented psychotherapy,
237, 246–247
Formative tendency, 225–226
Free association, 37, 46, 87–88
Freedom, 260–261, 265
Freudian psychoanalytic
psychotherapy. See
Contemporary Freudian
psychoanalytic psychotherapy
Functional analytic psychotherapy
(FAP), 206
Functional assessment. See also
Clinical assessment
cognitive-behavioral therapy (CBT)
and, 149–150, 151–152
functional analysis, 115–116, 122,
206. See also Clinical assessment
integrative approaches to
psychotherapy and, 455–456
third-wave cognitive-behaviorally
based therapies, 191–193
Functional beliefs, 152. See also
Beliefs
Functional contextualism, 186–188,
196
 Subject Index
Functional family therapy (FFT),
312, 322–323. See also Family
therapies
Functional–contextual perspective,
204
Functionality, 232, 260, 261–262
G Health-related applications, 169,
Gender, 299, 337
Generalized anxiety disorder (GAD),
125, 246–247
Genetic factors, 260, 298
Genital stage of psychosexual
development, 40
Genotype–environment interplay, 298
Genuineness, 239, 241, 283
Gestalt family therapy, 309–310. See
also Family therapies
Goal setting. See also Treatment goals
behavior therapy and, 115–116,
118, 128–129
cognitive-behavioral therapy (CBT)
and, 156–157, 166–167
contemporary Freudian
psychoanalytic psychotherapy
and, 45–46
couple therapies and, 349
existential–humanistic
psychotherapies and, 268–279
family therapies and, 306, 308,
310, 314
group psychotherapies and,
381–382
integrative approaches to
psychotherapy and, 458
overview, 13
person-centered and experiential
therapies and, 235
relational psychoanalytic/
psychodynamic psychotherapy,
80–81
third-wave cognitive-behaviorally
based therapies, 192, 193–197,
198–199
Gottman therapy, 335–337, 352. See
also Couple therapies
Green-signal affects, 426
Grief, 413t, 414–415
Grounding, 269–270
Group processes, 85
Group psychotherapies
case illustration, 394–400
clinical assessment and, 378–380
curative factors or mechanisms of
change, 385–389
historical background, 369–373
overview, 369
personality and, 373–378
practice of therapy and, 380–382
psychological health and
psychopathology, 373–378
research support and EBP,
393–394
suggestions for further study, 400
therapeutic relationship and the
stance of the therapist, 382–385
treatment applicability and ethical
considerations and, 389–393
Guilt, 40, 76
H existential–humanistic
Habituation, 424
Hallucination-focused integrative
therapy (HFIT), 467
Health, psychological. See
Psychological health and
psychopathology
246–247
Heterosexuality, 75. See also LGBTQ
clients; Sexuality
Holding environment, 52, 87–88,
306–307, 316–317
Holistic approaches, 184, 262, 263
Homeostasis, 300
Homework between sessions, 156,
159–160, 387–388, 458,
459–460
Homosexuality, 75. See also LGBTQ
clients; Sexuality
Human validation process model,
309–310. See also Family
therapies
Hypnosis, 36–37
I Couple therapies
Id, 41
I-D-E (interpersonal, developmental,
and existential) brief therapy,
410t
Identification, 387. See also Projective
identification
Imaginal exposure, 119. See also
Exposure techniques
Impulsivity, 189, 190, 450
In vivo exposure, 119, 444. See also
Exposure techniques
Incongruence, 230–231
Informed consent, 320
Inhibition, 77
Inhibitory learning, 119, 126–127.
See also Exposure techniques
Insight
cognitive-behavioral therapy (CBT)
and, 167–168
contemporary Freudian
psychoanalytic psychotherapy
and, 48–49, 55
couple therapies and, 341–342
curative factors or mechanisms of
change, 205–206
person-centered and experiential
therapies and, 245
Insomnia, 170–171
Instructing octave, 268–269
Instrumental emotions, 231–232
Integrative approaches to
psychotherapy. See also
Common-factors approach
bringing the body into, 451–452
case illustration, 470–474
clinical assessment and, 455–457
cognitive-behavioral therapy (CBT)
and, 164–165
couple therapies and, 334, 336,
338–339, 342, 344–345,
350–352, 354, 356
curative factors or mechanisms of
change, 464–465
495
psychotherapies and, 263
family therapies and, 312–314,
316, 318, 319
historical background, 443–446
models of psychotherapy
integration, 446–451
overview, 4, 322–323, 443
personality and, 452–454
practice of therapy and, 457–461
psychological health and
psychopathology, 454–455
relational psychoanalytic/
psychodynamic psychotherapy,
81, 90
research support and EBP,
468–470
suggestions for further study,
474–475
therapeutic relationship and the
stance of the therapist, 461–463
treatment applicability and ethical
considerations and, 465–468
Integrative behavioral couple therapy
(IBCT), 335–336, 337. See also
Integrative family and systems
treatment (I-FAST), 313. See
also Family therapies
Integrative problem-centered therapy
(IPCT), 312–314
Integrative systemic therapy (IST),
312–314
Intensity of treatment, 265–266
Intensive short-term dynamic
psychotherapy (ISTDP),
422–424, 423t, 427, 432–433
Intentionality, 278–279
Interaction patterns, 306–307, 347.
See also Patterns
Interconnectedness, 226–227
Interdependence, 279–280
Intergenerational–contextual family
therapy, 304. See also Family
therapies
Internalization, 127, 300, 387
International Statistical Classification
of Diseases and Related Health
Problems (ICD), 190, 192, 299,
457
Internet-based CBT, 134, 169, 345
Internet-based parent–child
interaction therapy (I-PCIT),
322
Interoceptive exposure, 119. See also
Exposure techniques
Interpersonal factors, 71–72, 81,
272–275, 373–374, 385–386.
See also Interpersonal skills
Interpersonal psychotherapy group
(ITP-G), 372. See also Group
psychotherapies
Interpersonal psychotherapy (IPT)
applicability of, 418
historical background, 411–412
interpersonal psychotherapy (IPT)
and, 413–414
overview, 407, 411–419, 413t,
416t
496
practice of therapy and, 412–417,
413t, 416t
suggestions for further study,
438–439
therapeutic relationship and the
stance of the therapist, 417
Interpersonal role disputes, 413t, 415
Interpersonal skills. See also
Interpersonal factors
couple therapies and, 341–342,
345–346
family therapies and, 299
group psychotherapies and,
380–381
interpersonal psychotherapy (IPT)
and, 413t
third-wave cognitive-behaviorally
based therapies, 206
Interpersonal–affective focus (IPAF),
429–430
Interpretation
contemporary Freudian
psychoanalytic psychotherapy
and, 48–49, 64–65
existential–humanistic
psychotherapies and, 280–281
family therapies and, 306–307,
316
relational psychoanalytic/
psychodynamic psychotherapy,
87
Intersubjectivity, 85, 272
Interventions, 20, 161t–162t,
458–459, 460
Interviews, 11, 117, 149–150, 303.
See also Clinical assessment
L overview, 163
Language factors, 124, 228. See also
Cultural factors
Learning, 87–88, 112–113, 314
Length of treatment, 154–155,
265–266, 380
LGBTQ clients, 75, 334–335. See also
Sexuality
M Multicultural Guidelines (APA,
Maintenance, 308–309
Maladaptive behavior, 42, 115
Maladaptive emotions, 231–232
Maladaptive thoughts, 147, 153t. See
also Thoughts
Manipulation, 231–232
Marital therapy. See Couple therapies
MDMA(methylenedioxymeth-
amphetamine)-assisted
psychotherapy, 134
Meaning attribution function, 383
Meaning making, 259–260, 278–279
Meaninglessness, 261
Measurable outcomes, 115–116, 124
Mechanisms of change. See Change
mechanisms
Medications
behavior therapy and, 128, 134
cognitive-behavioral therapy (CBT)
and, 164, 172
integrative approaches to
psychotherapy and, 461
Subject Index
interpersonal psychotherapy (IPT)
and, 411–412
overview, 13
person-centered and experiential
therapies and, 236–237
practice of therapy and, 14–15
relational psychoanalytic/psycho-
dynamic psychotherapy, 96
Memories, 127
Mental health. See Psychological
health and psychopathology
Mentalization theory, 59, 375–376,
387
Merits, 304
Metacognitive awareness, 189
Mimesis, 308–309
Mindfulness, 145, 168, 269–270, 323
Mindfulness-based cognitive therapy
(MBCT)
contributions of, 185–186
curative factors or mechanisms of
change, 205–206
overview, 184, 194–195
personality and, 187
process aspects of, 197–203
research support and EBP, 207, 208
therapeutic relationship and the
stance of the therapist, 204–205
treatment applicability and ethical
considerations and, 206–207
Mirror neurons, 85, 90
Modeling, 114, 122
Monitoring, self. See Self-monitoring
Motivation, 40–41, 75
Motivational interviewing (MI)
cognitive-behavioral therapy (CBT)
and, 164
person-centered and experiential
therapies and, 246
therapeutic relationship and the
stance of the therapist, 125
Motivational–behavioral aspects, 229
Multicultural assessment, 379.
See also Clinical assessment;
Multiculturalism
2017), 11
Multiculturalism. See also Cultural
factors
cognitive-behavioral therapy (CBT)
and, 146, 171
couple therapies and, 363
family therapies and, 298–299
treatment applicability and ethical
considerations and, 22–23
Multidimensional family therapy
(MDFT), 312, 321, 322–323.
See also Family therapies
Multimodal therapy, 447, 455,
456–457
Multisystemic therapy (MST), 312,
321, 322–323
Mutuality, 85, 85–87, 91, 371
N Parent Management Training—
Narrative therapy, 334
Negative (hostile) transference, 46,
306–307. See also Transference
Negative automatic thoughts, 147,
167–168. See also Thoughts
Negative feedback, 300
Neuroception, 227–228
Neuroscience
family therapies and, 314
intersubjectivity and, 85
practice of therapy and, 13, 15
relational psychoanalytic/psycho-
dynamic psychotherapy, 90
Neurotic accomplices, 456
Neutrality, 52, 96–97
Nondirective exploration technique,
416t
O
Object relations family therapy,
305–307, 316–317. See also
Family therapies
Object relations theories
brief psychodynamic therapies and,
420, 421t
contemporary Freudian
psychoanalytic psychotherapy
and, 36
countertransference and, 92
couple therapies and, 334
group psychotherapies and,
384–385
integrative approaches to
psychotherapy and, 453–454
relational psychoanalytic/
psychodynamic psychotherapy,
72–73, 92–93
Objective countertransference,
306–307. See also
Countertransference
Observation, 11, 116, 303. See also
Clinical assessment
Obsessional thinking, 444
Obsessive–compulsive disorder
(OCD), 118–119, 120, 125,
128, 466
Open response style, 189, 200–201
Operant strategies, 114, 120–121,
157
Oral stage of psychosexual
development, 40
Outcome research
behavior therapy and, 134–135
contemporary Freudian
psychoanalytic psychotherapy
and, 59–61
group psychotherapies and,
393–394
overview of author guidelines
regarding, 23–24
person-centered and experiential
therapies and, 248–249
relational psychoanalytic/
psychodynamic psychotherapy,
97–98
Outcomes, measurable, 115–116, 124
P
Oregon Model (PMTO), 310
Parent training, 311–312, 322. See
also Family therapies
 Subject Index
Parent–child interaction therapy
(PCIT), 310, 312, 322. See also
Family therapies
Patient factors. See Client/patient
factors
Patterns
cognitive-behavioral therapy (CBT)
and, 168
couple therapies and, 339–340,
345–346, 353
existential–humanistic
psychotherapies and, 260,
278–279
family health and pathology, 303
family therapies and, 306–307, 314
integrative approaches to
psychotherapy and, 454–455
relational psychoanalytic/psycho-
dynamic psychotherapy, 81
time-limited dynamic
psychotherapy (TLDP) and, 431
Personality
behavior therapy and, 113–114
brief psychodynamic therapies and,
420–421, 421t
clinical assessment and, 43
cognitive-behavioral therapy (CBT)
and, 146–147
contemporary Freudian
psychoanalytic psychotherapy
and, 39–42, 60
existential–humanistic
psychotherapies and, 259–262
family therapies and, 300–302
group psychotherapies and,
373–378
integrative approaches to
psychotherapy and, 449–450,
452–454
interpersonal and brief
psychodynamic therapies, 412
overview of author guidelines
regarding, 8–9
person-centered therapy and,
224–230
relational psychoanalytic/
psychodynamic psychotherapy,
73–76
third-wave cognitive-behaviorally
based therapies, 186–188
Person-centered experiential
psychotherapies (PCEP).
See also Person-centered
psychotherapy
clinical assessment and, 232–233
curative factors or mechanisms of
change, 243–246
development and, 229–230
historical background, 221–224
overview, 221
practice of therapy and, 233–239
psychological health and
psychopathology, 230–232
research support and EBP,
248–250
therapeutic relationship and the
stance of the therapist, 239–243
treatment applicability and ethical
considerations and, 246–248
Person-centered psychotherapy.
See also Emotion-focused
psychotherapies; Person-
centered experiential
psychotherapies (PCEP)
case illustration, 250–252
clinical assessment and, 232–233
curative factors or mechanisms of
change, 243–246
historical background, 221–224
overview, 221
personality and, 224–230
practice of therapy and, 233–239
psychological health and
psychopathology, 230–232
research support and EBP,
248–250
suggestions for further study, 252
therapeutic relationship and the
stance of the therapist, 239–243
treatment applicability and ethical
considerations and, 246–248
Pharmacotherapy. See Medications
Phobias, 96, 118–119
Posttraumatic stress disorder (PTSD)
cognitive-behavioral therapy (CBT)
and, 144, 172
exposure techniques and, 119
eye movement desensitization and
reprocessing (EMDR) and, 452
integrative approaches to
psychotherapy and, 470
MDMA (methylenedioxymeth-
amphetamine)-assisted
psychotherapy and, 134
relational psychoanalytic/
psychodynamic psychotherapy,
96
Power, 299, 302
Practice of therapy. See Therapy,
practice of
Presence, 263–264, 266–268,
272–275, 280, 281
Present-moment awareness, 145, 189
Present-oriented, nonsystemic
approaches, 309–312, 315–316,
318, 319, 322
Present-oriented systemic approaches,
307–309, 315, 317, 319, 321.
See also Systems-oriented
approaches
Primary adaptive emotion, 231–232
Primary care settings, 134, 372
Principle-based integrative therapy
(PBIT), 360–363
Privacy, 391–392
Problematic reaction point (PRP),
233
Problem-solving skills, 122–123, 123,
188, 337
Process aspects of treatment. See also
Therapy, practice of
brief psychodynamic therapies and,
421–432, 423t
cognitive-behavioral therapy (CBT)
and, 157–160
contemporary Freudian
psychoanalytic psychotherapy
and, 46–49, 49–51
497
existential–humanistic
psychotherapies and, 268–279
family therapies and, 306–307,
308–309, 310–312, 314
interpersonal psychotherapy (IPT)
and, 412–417, 413t, 416t
overview, 13–16
person-centered and experiential
therapies and, 239, 249–250
relational psychoanalytic/psycho-
dynamic psychotherapy, 81–91
third-wave cognitive-behaviorally
based therapies, 197–203
Process measures, 379–380. See also
Clinical assessment
Process–experiential therapy, 450
Process–experiential/emotion-
focused therapy (PE-EFT), 221,
228–229, 232–233, 237–238,
249. See also Emotion-focused
psychotherapies
Progress monitoring, 379–380
Progressive muscle relaxation, 96,
123. See also Relaxation
training
Projective identification, 92–93, 307,
338, 341–342, 387. See also
Countertransference; Defenses
Psychic equivalence, 375–376
Psychoanalysis, 44–45, 258
Psychoanalytic ego psychology,
41–42. See also Contemporary
Freudian psychoanalytic
psychotherapy
Psychoanalytically oriented
psychotherapy, 44–45, 58–61.
See also Contemporary Freudian
psychoanalytic psychotherapy;
Relational psychoanalytic/
psychodynamic psychotherapy
Psychodrama, 309–310. See also
Family therapies
Psychodynamic Diagnostic Manual,
version 2 (PDM-2), 44
Psychodynamic orientation. See
also Contemporary Freudian
psychoanalytic psychotherapy
couple therapies and, 338,
341–342, 344, 348–350, 354,
355–356
group psychotherapies and,
374–376, 386–387
integrative approaches to
psychotherapy and, 469
overview, 37
Psychoeducation
behavior therapy and, 118
cognitive-behavioral therapy (CBT)
and, 157, 158
couple therapies and, 362
family therapies and, 310, 314,
322
group psychotherapies and, 377
Psychological flexibility, 188–189,
191
Psychological health and psychopa-
thology. See also Diagnosis
behavior therapy and, 114–115
clinical assessment and, 43
498
cognitive-behavioral therapy (CBT)
and, 145, 147–149, 148f
contemporary Freudian
psychoanalytic psychotherapy
and, 42–43, 56, 60
couple therapies and, 339–342
existential–humanistic
psychotherapies and, 259–262
family health and pathology,
302–303
group psychotherapies and,
373–378
integrative approaches to
psychotherapy and, 454–455
overview of author guidelines
regarding, 9–10
person-centered and experiential
therapies and, 230–232
relational psychoanalytic/
psychodynamic psychotherapy,
76–78
third-wave cognitive-behaviorally
based therapies, 188–191
Psychopathology. See Psychological
health and psychopathology
Psychosexual development, 40
Psychosocial stages of development,
40
Psychotherapy integration. See
Integrative approaches to
psychotherapy
Psychotherapy utilization patterns,
408–409
R couple therapies and, 358
Race, 124, 146. See also Cultural
factors
Rapport, 17. See also Therapeutic
relationship
Rationalization, 39, 149, 227–228.
See also Thoughts
Reactivity, 38, 116–117, 127,
460–461
Red-signal affects, 426
Regression, 39, 40, 95
Reinforcement-based treatments, 111,
120–122. See also Behavioral
therapy
Relational frameworks, 196, 420,
421t, 427–432
Relational functioning, 241, 243,
299, 345–346, 356, 356–357.
See also Couple therapies
Relational psychoanalytic/
psychodynamic psychotherapy
case illustration, 99–103
clinical assessment and, 78–79
curative factors or mechanisms of
change, 94–95
historical background, 71–73
personality and, 73–76
practice of therapy and, 79–91
psychological health and
psychopathology, 76–78
research support and EBP, 97–98
therapeutic relationship and the
stance of the therapist, 91–93
treatment applicability and ethical
considerations and, 95–97
Subject Index
Relational violence, 356–357
Relational–contextual approach,
410–411
Relationship-focused CBT, 206. See
also Third-wave cognitive-
behaviorally based therapies
Relationships, 392
Relaxation training, 96, 111, 123,
157, 323. See also Behavioral
therapy
Repression, 37–38
Resistance
to change, 163
contemporary Freudian
psychoanalytic psychotherapy
and, 47
couple therapies and, 348
existential–humanistic
psychotherapies and, 275–278
family therapies and, 306–307
integrative approaches to
psychotherapy and, 460–461
person-centered and experiential
therapies and, 239
relational psychoanalytic/
psychodynamic psychotherapy,
83
Response prevention, 120, 424
Response-contingent aversive
stimulation, 121
Responses, 115, 189
Rituals, 120, 301
Role playing, 161t, 416t
Roles
family health and pathology, 302
family therapies and, 301
group psychotherapies and, 389
interpersonal psychotherapy (IPT)
and, 413t, 415
role transitions, 413t, 415–416
Rules, 301, 302
Rumination, 189, 190
Ruptures in the therapeutic alliance,
126, 205, 243, 353. See also
Therapeutic relationship
S group psychotherapies and,
Schemas, 147, 159–160
Schizophrenia, 134, 283
Self psychology, 36, 93
Self-disclosure. See also Therapeutic
relationship
behavior therapy and, 129–130
cognitive-behavioral therapy (CBT)
and, 166
couple therapies and, 353
group psychotherapies and, 379
person-centered and experiential
therapies and, 236, 241
relational psychoanalytic/
psychodynamic psychotherapy,
93
therapeutic stance and, 17
third-wave cognitive-behaviorally
based therapies, 205
Self-help treatments, 124–125
Self-monitoring, 116–117, 121, 151,
161t, 377
Self-report measures, 117, 149–150,
303–304, 342–343
Self-system, 73–75, 226–227, 231
Sensations, 127, 264
Sexual abuse, 76
Sexuality, 75, 259, 337, 346. See also
LGBTQ clients
Short-term anxiety-provoking
psychotherapy, 423t
Signal anxiety, 40, 41
Silence, 87–88
Skills training, 157, 168–169, 355,
377–378. See also Social skills
training
Social factors, 56–57, 279–280, 314,
355
Social phobia, 96, 172, 246–247
Social skills training, 122, 378, 415.
See also Skills training
Sociocultural factors, 372–373
Socioeconomic status (SES), 57, 357
Socratic dialogues, 144–145, 161t,
162–163, 278–279
Solution-focused brief therapy, 410t
Spiritual context, 279–280
Splitting, 39, 338
Stance of the therapist. See Therapist,
stance of
Stimulus, 114, 115, 121
Strategies, treatment, 13, 235–238.
See also Treatment
Strengths, 77, 154
Structural ecosystems therapy (SET),
321
Structural family therapy, 308–309.
See also Family therapies
Structural theory, 41, 45–46
Structure of therapy
cognitive-behavioral therapy (CBT)
and, 154–156
contemporary Freudian
psychoanalytic psychotherapy
and, 44–45
existential–humanistic
psychotherapies and, 266–268
family therapies and, 305–306,
308–309, 310, 313
380–381
interpersonal psychotherapy (IPT)
and, 412–417, 413t, 416t
overview, 12–13
person-centered and experiential
therapies and, 234–235
relational psychoanalytic/
psychodynamic psychotherapy,
79–80
third-wave cognitive-behaviorally
based therapies, 193–197
Subconsciousness, 261. See also
Consciousness
Substance use/abuse, 96, 128, 467
Suicidal behavior, 195, 377
Superego, 41
Supportive–expressive psychotherapy
(SEP), 428–429
Symbolic–experiential family therapy
(SFT), 309–310, 318. See also
Family therapies
 Subject Index
Systematic treatment selection (STS),
456–457
Systems, 300–302
Systems-oriented approaches. See also
Family therapies
couple therapies and, 334, 362
historical background, 7
overview, 300–302, 305, 307–309,
334
T and, 417
Target behaviors, 115, 151, 192
Technical eclecticism model,
446–448, 465
Technical errors in therapy, 87,
89–90, 163–165, 203–204, 350.
See also Therapist factors
Techniques in treatment, 13, 79,
235–238. See also Treatment
Technology-based psychotherapy
couple therapies and, 345
digital-based parent training
(DBPT), 322
Internet-based cognitive-behavioral
therapy, 134, 169, 345
Internet-based parent–child
interaction therapy (I-PCIT),
322
overview, 15–16
virtual reality exposure, 119
Termination
brief psychotherapies and, 409
cognitive-behavioral therapy (CBT)
and, 166–167
contemporary Freudian
psychoanalytic psychotherapy
and, 51
couple therapies and, 348, 350,
352
family therapies and, 316
integrative approaches to
psychotherapy and, 461, 463
interpersonal psychotherapy (IPT)
and, 416–417
practice of therapy and, 13
relational psychoanalytic/
psychodynamic psychotherapy,
91
Theoretical integration model, 446,
449–450, 452–453. See also
Integrative approaches to
psychotherapy
Therapeutic presence, 263–264,
266–268
Therapeutic relationship. See also
Self-disclosure; Therapist, stance
of; Therapist factors
behavior therapy and, 124–126
brief psychodynamic therapies and,
432–433
cognitive-behavioral therapy (CBT)
and, 155, 165–167
confidentiality and, 97
contemporary Freudian
psychoanalytic psychotherapy
and, 49–54, 55, 61
couple therapies and, 353, 354
curative factors or mechanisms of
change, 20
existential–humanistic
psychotherapies and, 267–268,
272, 283
family therapies and, 306–307,
308–309, 314–316
group psychotherapies and,
382–385, 383–384, 392
integrative approaches to psycho-
therapy and, 461–463, 465
interpersonal psychotherapy (IPT)
overview of author guidelines
regarding, 16–18
person-centered and experiential
therapies and, 236, 239–243,
244, 249–250
relational psychoanalytic/
psychodynamic psychotherapy,
81, 91–93, 97
third-wave cognitive-behaviorally
based therapies, 204–205
Therapist, stance of. See also
Therapeutic relationship;
Therapist factors
behavior therapy and, 124–126
brief psychodynamic therapies and,
432–433
cognitive-behavioral therapy (CBT)
and, 165–167
contemporary Freudian
psychoanalytic psychotherapy
and, 51–54
existential–humanistic
psychotherapies and, 265–280
family therapies and, 314–316
group psychotherapies and,
382–385
integrative approaches to
psychotherapy and, 461–463
interpersonal psychotherapy (IPT)
and, 417
overview of author guidelines
regarding, 16–18
person-centered and experiential
therapies and, 239–243
relational psychoanalytic/
psychodynamic psychotherapy,
91–93
third-wave cognitive-behaviorally
based therapies, 204–205
Therapist factors. See also Technical
errors in therapy; Therapeutic
relationship; Therapist, stance
of
contemporary Freudian
psychoanalytic psychotherapy
and, 51–54
couple therapies and, 358
curative factors or mechanisms of
change, 20
existential–humanistic
psychotherapies and, 270–271,
272
family therapies and, 299, 303,
308–309, 321
group psychotherapies and,
372–373, 383–384, 392–393
integrative approaches to
psychotherapy and, 463
499
interpersonal psychotherapy (IPT)
and, 417
overview, 4
person-centered and experiential
therapies and, 234, 239–243,
245, 248
relational psychoanalytic/
psychodynamic psychotherapy,
89–90
Therapy, practice of. See also Process
aspects of treatment
behavior therapy and, 117–124
brief psychodynamic therapies and,
421–432, 423t
cognitive-behavioral therapy (CBT)
and, 154–165, 161t–162t, 163t
contemporary Freudian
psychoanalytic psychotherapy
and, 44–51
couple therapies and, 345–352
existential–humanistic
psychotherapies and, 265–280
family therapies and, 304–314
group psychotherapies and,
380–382
integrative approaches to
psychotherapy and, 457–461
overview of author guidelines
regarding, 12–16
person-centered and experiential
therapies and, 233–239
relational psychoanalytic/
psychodynamic psychotherapy,
79–91
third-wave cognitive-behaviorally
based therapies, 193–204
Third-wave cognitive-behaviorally
based therapies. See also
Acceptance and commitment
therapy (ACT); Behavioral
activation (BA); Cognitive-
behavioral therapy (CBT);
Dialectical behavior therapy
(DBT); Mindfulness-based
cognitive therapy (MBCT)
case illustration, 209–213
clinical assessment and, 191–193
curative factors or mechanisms of
change, 205–206
historical background, 183–186
overview, 213
personality and, 186–188
practice of therapy and, 193–
204
psychological health and
psychopathology, 188–191
research support and EBP,
207–208
suggestions for further study,
213–214
therapeutic relationship and the
stance of the therapist, 204–205
treatment applicability and ethical
considerations and, 206–207
Thoughts. See also Automatic
thoughts; Cognitive distortions
behavior therapy and, 127
behavioral experiments and,
159–160
500
cognitive-behavioral therapy (CBT)
and, 142, 147–149, 148f, 160,
167–168
couple therapies and, 346
group psychotherapies and,
376–377
integrative approaches to
psychotherapy and, 444
list of cognitive distortions, 153t
person-centered and experiential
therapies and, 227–228
relational psychoanalytic/
psychodynamic psychotherapy,
81
therapeutic techniques and,
161t–162t
thought monitoring, 161t
Time-limited dynamic psychotherapy
(TLDP), 430–432, 434–438,
436f
Training, 299, 372–373
Transference
contemporary Freudian
psychoanalytic psychotherapy
and, 46–47, 50–51, 57, 61
couple therapies and, 338, 344,
350
family therapies and, 306–307
Subject Index
person-centered and experiential
therapies and, 241–243
relational psychoanalytic/
psychodynamic psychotherapy,
82, 83, 86, 94
time-limited dynamic
psychotherapy (TLDP) and,
431
Transference–countertransference
enactments, 50, 53–54, 57, 94
Transference-focused psychotherapy
(TFP), 59, 98
Transtheoretical psychotherapy,
447–448
Trauma
behavior therapy and, 128
eye movement desensitization and
reprocessing (EMDR) and, 452
integrative approaches to
psychotherapy and, 470
person-centered and experiential
therapies and, 246–247
relational psychoanalytic/
psychodynamic psychotherapy,
74–75, 77
Treatment, 11, 13–16, 21–23, 54,
150. See also Therapy, practice
of
Treatment goals. See also Goal setting
interpersonal psychotherapy (IPT)
and, 412–417, 413t, 416t
termination and, 91
third-wave cognitive-behaviorally
based therapies, 192, 198–
199
Two-chair dialogues, 238, 251–252
U
Unconditional positive regard/
warmth, 239–241, 250, 283.
See also Acceptance
Unconscious family system of object
relations, 306–307
Unconsciousness, 40, 45–46, 90,
306–307
V
Validation strategies, 195–196, 348
Virtual reality exposure, 119. See also
Exposure techniques
W
Warmth, 239–241, 250, 283
Working alliance, 49–51. See also
Therapeutic relationship
Working through, 51, 65