Handbook of Contemporary Psychotherapy: Toward an Improved Understanding of Effective Psychotherapy

Handbooks

Edited by: William O'Donohue & Steven R. Graybar

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  • Dedication

    With love to our families: Jane, Katie, and Anna; Gretchen, Alex, and Oliver

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    Preface

    This book is a product of a long-term friendly dialogue between the two editors. We both felt that there was a gap in the literature regarding psychotherapy; on the one hand, there were many speculative books that sometimes were not clear about the evidential status of their claims; and on the other hand, there were many books that were tied to the data but seemed too constrained when compared to the kinds of problems clients presented with. After much discussion we thought we would try to bridge this gap: Cover important clinical material in ways that were unique and potentially helpful but were honest regarding the evidential status of these claims. We hope the reader will agree that we have achieved at least some of this aim.

    We would like to thank Linda Goddard for all her expert help in the preparation of this manuscript. We would like to thank the following reviewers for their helpful comments to earlier drafts: James T. Hansen, Oakland University; Louis Hoffman, Vanguard University of Southern California; Leslie W. O'Ryan, Western Illinois University-QC; and A.J. Whitmore, Forrest Institute of Professional Psychology. We would also like to thank the folks at Sage for their professionalism and helpfulness, especially Kassie Graves, Veronica Novak, and Karen Wiley. Without these folks, this book would not have been possible.

    Introduction: Where Science Meets Practice

    WilliamO'Donohue, StevenGraybar

    Psychotherapy is a complex process. People present with complicated problems, related to intricate personality dimensions, nested in both complex interpersonal relations and detailed personal histories. This picture is further complicated because this is experienced through similar complexities brought by the therapist (see chap. 8, this volume) … When one looks at therapy in this way, it is a wonder that much progress is ever achieved.

    Part of the reason therapy can be useful is that simplifying assumptions and processes are invoked. One set of these is that there is no radical idiography, but rather there are some commonalities across dimensions. Bob James is seen as both unique but also as an exemplar of abstract types. These abstract types may come from our prescientific folk notions (e.g., “middle aged,” “divorced male”), but also from our scientific research efforts. Thus, Bob also is seen as an individual with a Narcissistic Personality Disorder who is currently experiencing a Major Depression. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is an attempt to reduce the radical uniqueness of the world to a manageable set of constructs that simplify complexity while performing a set of pragmatic functions. One important pragmatic function is to provide a link between the idiographic experience in the therapy room and knowledge, particularly knowledge of the future (i.e., prognosis, outcomes given certain treatments). The extent to which the DSM “carves nature at its joints,” provides the best constructs, and provides diagnostic categories that have such predicitive validity is, of course, quite controversial. But there are clearly gaps between the constructs that therapist and clients use and the ones that the DSM uses. This fact is important to realize because the DSM also has tremendous influence on what researchers will investigate because it is often the case that funders such as the National Institute of Mental Health (NIMH) will couch their funding questions with DSM terminology (e.g., efficacy studies of Panic Disorder with Agoraphobia). Thus, one concern about this gap is that certain key constructs can be orphaned. If a woman comes in distraught because she feels she can no longer trust her husband because of his recent infidelity, through the DSM, we can access knowledge about marital problems and perhaps depression (if this is her problem), but because the DSM does not talk about trust, her therapist is in a bit of a pickle. There are many of these key constructs about which the DSM and science are relatively silent. A partial list would include: guilt, shame, ambivalence, trust, boredom, loss, fear of death, inferiority, mindfulness, pain, happiness, joy, appreciation, satisfaction, fulfillment, love, and so on.

    Some constructs can be thought to be meaningless, poorly formed, or rejected for various reasons. Constructs such as Virgo, inner child, aura, psychic, and past life seem to involve assumptions that are so problematic that we as liberally educated individuals need not concern ourselves with them. Although there are interesting debates concerning these constructs (the marketplace of ideas does not seem to be superlative in getting rid of its garbage), sometimes we, as therapists, are confronted with these kinds of constructs. The first author once had a clinical case in which grandparents brought in their 10-year-old granddaughter because she had “ESP spells,” in which she would accurately predict the future (the predictions were of the order that they should not turn on the evening news because bad things would be reported). So these constructs can play a role in therapy, and it is an interesting meta-problem (and underresearched) on clinical strategies on how to deal with these cases.

    Before we continue, we want to clear up one possible misunderstanding. We are not saying that these constructs should be included in the DSM. We do not want a further proliferation of mental disorders. We think that people can have problems with, for example, trust without the necessity of a Trust Disorder occurring in the DSM. We have sympathy for Thomas Szasz's (1984) view that there are problems in living, and these problems do not have to been seen as mental disorders in order for people to legitimately want help dealing with them. However, because everything is controversial in our field, we know that there would be those who would argue that these kinds of problems should be placed in the DSM. At times they might be right and may prevail (and they may be wrong and still prevail, given the trend to increase the number of mental disorders in the DSM). Sometimes it is unfortunate, but the most telling arguments can be pragmatic: If it is not in, it cannot be reimbursed, thus depriving many due to their financial circumstances from receiving help for this problem. Again, these debates are ongoing, but we side step them here.

    To recap, we believe that there are key constructs that are excluded in the more formal, systematic aspects of our field. Thus, there are gaps between what we may be concerned about clinically and what the “information web” of our field contains. We designed this book to examine some of these gaps and to see both what information exists and what research agendas are needed.

    In addition, there is a need to think productively about the therapy process. Therapists need to rise to the meta-level and ask questions such as: What information do I need in this case and how do I best gather it? Is my case formulation reasonable? How is the therapeutic relationship and if it has problems how do I understand these problems? Is the client ready for termination? Interestingly, these questions involve unique constructs such as countertransference, but they also at times may invoke the same constructs (e.g., trust, loss, mindfulness, pain, happiness).

    We see that because science has largely ignored these constructs, therapists have turned to other sources for this information. Some of this information has come from therapist scholars who have written, often theoretically and clinically, about these constructs. We have tapped some of the more prominent and perspicacious of these to be authors of chapters in this book. Some of this information also has come from psychodynamic writers, often writing many decades ago. These writers were not as constrained by the DSM (if only in many cases their writings predate even the DSM-I), and thus they were more influenced by the kind of issues with which their clients presented. The good psychotherapist needs a more complex repertoire of conceptual categories to constructively engage these problems. The successful psychotherapist needs an armamentarium of practical ways to detect and assess what else may be occurring. The good psychotherapist needs a tool bag of practical techniques to try to help these difficult cases. This book is designed to provide these tools. It also is designed to be a “practitioner's companion.”

    We see some of the chapter authors' writings as presenting interesting possibilities. We use the philosopher of science Hans Reichenbach's distinction between the contexts of discovery and justification. The context of justification is when research attempts to systematically gather information regarding corroboration or falsification of a claim (when intervention x is compared to no treatment and comparisons are made between changes in trust levels, this is the context of justification). However, Reichenbach emphasized that the grist for the scientific mill needs to come from somewhere. He called systematic creative efforts to come up with the best grist—the context of discovery. We believe that the astute, clinically oriented writers are excellent sources in the context of discovery. They have a lot of experience dealing with these complex clinical problems, and the most astute ones can be shaped by their trial-and-error experience (Skinner even recognized what he called “the skill of the craftsman” as being derived from learning due to the direct experience with the operative contingencies). We want to see what these craftsmen have learned and to make educated guesses regarding what is best likely to survive and dominate in the context of justification. Thus, we have asked each of our authors to provide a section on the research agenda related to his or her domain of interest. In an important sense, we wanted this book to capture interesting clinical beliefs that may pertain to these issues not captured in the DSM or traditional research, but may be shown in future research to be important and effective.

    We asked each author to include the following:

    • Definition
    • Theory
    • Possible role in pathology
    • Possible role in treatment
    • Measurement
    • Intervention strategies
    • Case illustration
    • Future research
    Chapter Summaries

    In our lead chapter, Michael Lavin (chap. 1) differentiates supportive from expressive therapies, and provides a solid overview of psychoanalytic theory and practice. His explication of psychoanalytic psychotherapy allows the nonanalytic practioner to pick and choose from a buffet of therapeutic options, interventions, and stances.

    Jeffrey K. Zeig (chap. 2) considers the process of change in psychotherapy. He uses a case study of Milton Erickson to compare the process of change in psychotherapy to the unfolding of a drama. Zeig's sense that art and therapy must both be staged in sequences to promote a dramatic effect and facilitate change that will appeal to therapists across theoretical orientations.

    William C. Follette and Deborah Davis (chap. 3) review and elucidate the questions and controversies within the repressed and recovered memory debate. In their thoughtful chapter, the authors consider relevant research and the epistemological divide that has separated clinicians from researchers in this area.

    As a foundation for much of what follows in the remainder of this text, Deborah Davis and Aaron McVean (chap. 4) review two theories (attachment and terror management) and a substantial body of research that not only supports the existence of the unconscious, but highlights the role of unconscious processes in promoting healthy and unhealthy, as well as functional and dysfunctional thoughts, feelings, and behaviors.

    Kenneth Cloke (chap. 5) draws from contemporary mediation theory, Zen Buddhism, ego psychology, and poetry to examine the origins and resolution of human conflict. His chapter is a step-by-step guide through conflict for each of us.

    In their chapter, James W. Maddock, John C. Friel, and Linda D. Friel (chap. 6) consider the crucial role that context plays in understanding and intervening with individual and family functioning and psychopathology. Their ecological approach to treatment focuses on the interactions between systems, rather than one characteristic or flaw apparent in a single system.

    In his chapter, Robert Waska (chap. 7) literally brings to life the death instinct. A Freudian concept largely dismissed by contemporary psychotherapists, the death instinct takes on a renewed significance through Waska's ability to write so clearly about it and provide relevant clinical vignettes.

    In his chapter on countertransference, Jeffrey H. Corpuel (chap. 8) examines the therapist's reactions to the client and therapeutic exchange. He highlights where the therapist's reactions originate and how they influence therapy, for better and for worse.

    In her chapter on projective identification, Patricia M. Chatham (chap. 9) tackles a complex phenomenon. Projective identification, although grounded in psychoanalytic and object relations theory, describes a common and unsettling experience for all therapists who have been the target of intense and confusing client affect.

    In their chapter on mindfulness, Akihiko Masuda and Kelly Wilson (chap. 10) discuss the popularity of Eastern concepts among Western psychotherapists. They go beyond the popularity of mindfulness to describe the paradigm shift it represents away from the medical model and exclusively symptom-focused psychotherapy.

    David Antonuccio and Robert Jackson (chap. 11) review the literature on forgiveness and underscore the practical implications forgiveness can have on one's own health and relationships.

    In her chapter about dreams, Lois Parker (chap. 12) not only defends dream work in psychotherapy, but offers it as an enriching endeavor for both client and clinician alike. Although her chapter highlights her approach to dreams, she offers “loose guidelines” for clinicians interested in engaging their clients through their dreams.

    Through a number of rich case examples, William K. Hahn (chap. 13) considers shame and its many ramifications for our clients and their emotional well-being. Hahn views shame as a ubiquitous human experience with evolutionary origins and one that is at the heart of much suffering and psychopathology.

    James C. Overholser and Nicole J. Peak (chap. 14) consider the “common cold” of mental health—clinical depression. In their chapter, the authors provide a thorough review of their empirically supported approach to depression and their depressed clients.

    No subject is referred to more often and with less precision than the subject of boundaries in psychotherapy. In his chapter, Ofer Zur (chap. 15) discusses therapeutic boundaries and their role in defining and delimiting psychotherapy, as well as their potential to enhance or diminish treatment.

    Steven Graybar and Leah Leonard (chap. 16) consider the topic of termination. In the chapter, termination is seen as a neglected area of research and practice. Despite this professional neglect, the research that does exist on termination suggests that the end of therapy plays a significant role in how clients view the totality of their treatment experience.

    Reference
    Szasz, T. (1984). The myth of mental illness. New York: Harper.
  • Author Index

    About the Editors

    William T. O'Donohue, PhD, received a doctorate in psychology from the State University of New York at Stony Brook and a master's degree in philosophy from Indiana University. He is a licensed clinical psychologist in Nevada. He is a full professor of clinical psychology at the University of Nevada, Reno, and has been since 1999. He has been a member of the Association for the Advancement for Behavior Therapy and has served on the Board of Directors of this organization. Since 1996, he has received more than $1,500,000 in federal grant monies from sources including the National Institute of Mental Health (NIMH) and the National Institute of Justice (NIJ). He has edited more than 40 books, coauthored 5 books, and published more than 100 articles in scholarly journals.

    Steven R. Graybar, PhD, divides his time between his private practice and his work as a clinical professor in the Department of Pediatrics at the University of Nevada School of Medicine. He has presented and published on topics ranging from the role of addictive processes underlying war and peace to exploring nontraumatic pathways to borderline personality disorder. His professional interests have been and continue to be the teaching and practice of self-psychology and the psychodynamic understanding of chronic illness and patient adherence to medical regimens.

    About the Contributors

    David Antonuccio, PhD, is a professor in the Department of Psychiatry at the University of Nevada School of Medicine. A fellow of the American Psychological Association (APA) and an American Board of Professional Psychology (ABPP) diplomate in clinical psychology, Dr. Antonuccio is internationally known for his work in depression and smoking cessation. His articles on the comparative effects of psychotherapy and pharmacotherapy have received extensive coverage by the national media and are models of careful scholarship. He was named Outstanding Psychologist by the Nevada Psychological Association (NSPA) in 1993, received an award of achievement in 1999 from NSPA for his work on depression, was awarded the 2000 McReynolds Foundation Psychological Services Award for “outstanding contributions to clinical science,” and received the Association for Psychologists in Academic Health Centers (APAHC) Bud Ogel Award for Distinguished Achievement in Research in 2006.

    Patricia M. Chatham, PhD, received her doctorate from the Wright Institute, Berkeley, California. For 30 years, she was a staff psychologist and a former director of APA internship training at the V.A. Sierra Nevada Health Care System of Clinics, Reno, Nevada. She published a textbook, Treatment of the Borderline Personality Disorder, which is still available. For the last 2 years, she has been the supervisor for the psychodynamic therapy team on an NIMH grant at the University of Nevada studying suicidal and depressed college students. She continues to lecture on personality disorders.

    Kenneth Cloke, JD, LLM, PhD, is Director of the Center of Dispute Resolution in Santa Monica and a mediator, arbitrator, consultant, and trainer. He is the author of Mediating Dangerously: The Frontiers of Conflict Resolution; Resolving Conflicts at Work: Eight Strategies for Everyone on the Job; Resolving Personal and Organizational Conflicts: Stories of Transformation and Forgiveness; The Crossroads of Conflict: A Journey Toward the Heart of Conflict; and Conflict Revolution: Mediating Evil, War, Injustice, and Terrorism. He is an adjunct professor at Pepperdine Law School; Harvard Law School's Program on Negotiation, Insight, Initiative; and is president of Mediators Beyond Borders.

    Jeffrey H. Corpuel, PhD, received his doctorate in 1981 from the California School of Professional Psychology, Berkeley. He is an adjunct faculty member at the University of Nevada, Reno, in the Department of Psychiatry and Behavioral Sciences. Dr. Corpuel is currently in private practice in Reno, Nevada, specializing in intensive psychodynamic psychotherapy with adults and older adolescents. His professional interests include psychotherapy supervision, transference/countertransference, and the process of psychological change. Dr. Corpuel is a former president of the Nevada State Psychological Association.

    Deborah Davis is Professor of Psychology at the University of Nevada, Reno. She received her degree in Social Psychology and has since published extensively in the areas of psychology and law, attachment theory, and romantic relationships across the lifespan. She testifies as an expert witness in the areas of eyewitness memory and coerced confessions, and she offers continuing legal education seminars on these and other law-related topics across the United States and Canada.

    William C. Follette, PhD, is an associate professor of clinical psychology at the University of Nevada, Reno. He received his doctorate from the University of Washington. His research interests include psychotherapy outcome research design, treatment development, and heuristic errors in research and clinical assessment. He has interests in understanding and disseminating therapeutic principles that underlie clinically significant change in the therapy process. Along with Drs. Elizabeth Loftus and Deborah Davis, Dr. Follette has written on the difficulties surrounding informed consent in repressed memory therapy.

    John C. Friel, PhD, is a licensed psychologist in private practice in Minneapolis—St. Paul and Reno, Nevada; as well as an adjunct assistant clinical professor in the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Nevada, Reno. He does concentrated couples' therapy, helps adults resolve and rewrite unhealthy family-of-origin templates, and has conducted ongoing men's therapy groups since 1985. With his wife, Linda Friel, he is the best-selling coauthor of eight books, including Adult Children: The Secrets of Dysfunctional Families and The 7 Best Things (Happy) Couples Do. Their web address is http://www.clearlife.com.

    Linda D. Friel, MA, is a licensed psychologist in private practice in Minneapolis—St. Paul, Minnesota, and a mentor/coach in Reno, Nevada. She specializes in women's issues; helps clients rewrite painful family-of-origin templates so they can move out of victim-perpetrator cycles into competent, healthy adulthood; and has conducted ongoing women's therapy groups since 1988. She designed and implemented the first hospital-based treatment program for codependency. With her husband, John Friel, she is the best-selling coauthor of eight books, including An Adult Child's Guide to What's “Normal” and The 7 Worst Things (Good) Parents Do.

    William K. Hahn, PhD, earned his doctorate in clinical psychology from Purdue University, where he was the recipient of the prestigious James D. Linden award for excellence. He completed an internship in the Department of Psychiatry at Indiana University School of Medicine. He has been with the University of Tennessee since 1987, where he has taught graduate and undergraduate courses, supervised interns and graduate students in counseling and clinical psychology, and provided short- and long-term psychotherapy from a psychodynamic perspective. He has published numerous articles on shame and other topics in both individual and group psychotherapy.

    Robert Jackson, PhD, completed his doctorate in clinical psychology from Fuller Theological Seminary in 1999 where he was active in research on the psychology of shame and the psychology of forgiveness. He also completed a master's degree in theology from Fuller. This emphasis laid the groundwork for his doctoral dissertation in the area of shame reduction through the promotion of empathy and forgiveness. Dr. Jackson spent eight years on active duty in the U.S. Army where his main area of service involved the integration of behavioral health services within primary care. He now works in Hawaii in private practice with his wife, Dr. Shawna Ledward, with a focus on the treatment of anxiety disorders as well as interpersonal trauma.

    Michael Lavin, PhD, is a psychologist in private practice in the Washington, DC area. Before training as a psychologist, he was an Associate Professor of Philosophy at the University of Tennessee. He earned a doctorate in psychology from the University of Arizona. He also earned a doctorate in Philosophy and Humanities from Stanford. He has published papers, chapters, and reviews on a variety of topics in medical ethics and conceptual issues in mental health.

    Leah Leonard, PhD, is the Clinical Director of The Center for Hope of the Sierras, a residential treatment program for women with eating disorders. She received her doctorate in clinical psychology from the University of Nevada, Reno, and served as a clinical fellow in psychology at Harvard Medical School. Her clinical and research focus includes eating disorders, the treatment of women diagnosed with borderline personality disorder, issues that can arise from a history of sexual abuse, and the importance of the therapeutic relationship.

    James W. Maddock, PhD, is a Licensed Psychologist and a Licensed Marriage and Family Therapist at Meta Resources in St. Paul, Minnesota. He also is Emeritus Professor in Family Social Science at the University of Minnesota, where he taught marriage and family therapy courses and conducted research on families and sexuality. Dr. Maddock currently consults on marriage and family issues with therapists throughout the United States and in Europe.

    Akihiko (Aki) Masuda, PhD, is an assistant professor at the Georgia State University. His interests are broad, ranging from experimental analysis of psychopathology to acceptance and mindfulness practice of living. Dr. Masuda received a doctorate in psychology (clinical psychology) from the University of Nevada, Reno, in 2006.

    Aaron McVean is currently a graduate student in the interdisciplinary social psychology PhD program at the University of Nevada, Reno. He received his MA in academic research from Humboldt State University. His primary research interests are in the field of social cognition. In particular, Aaron is currently conducting original research examining the cognitive structure of existential meaning systems using a Terror Management Theory (TMT) paradigm to examine the concept of existential certainty. Aaron plans to graduate with his PhD in 2010.

    James C. Overholser, PhD, received his doctorate in clinical psychology from the Ohio State University in 1986. He completed his predoctoral internship and postdoctoral fellowship in clinical psychology through the Department of Psychiatry at Brown University in Providence, Rhode Island. Dr. Overholser is licensed as a psychologist in the state of Ohio and Board certified in Clinical Psychology. In 1988, Dr. Overholser joined the faculty of Case Western Reserve University in Cleveland, Ohio. He is currently a Professor of Psychology and Director of Clinical Training in the APA-approved graduate training program in clinical psychology. Dr. Overholser has coauthored 20 books on the evaluation of suicide risk, 13 book chapters, and more than 140 peer-reviewed journal articles. Dr. Overholser is actively involved in research on the assessment of depression and the evaluation of suicide risk. His research has examined depression in adult psychiatric inpatients with a Major Depressive Disorder, adult suicide attempters, adult medical inpatients struggling with depression, adolescent psychiatric inpatients, adolescent suicide attempters, and individuals who had died by suicide.

    Lois Parker, Director Emerita of Counseling Services, University of Nevada, Reno, is a licensed psychologist who for more than 35 years has specialized in a narrative approach to psychotherapy. She is the author of Mythopoesis and the Crisis of Postmodernism: Toward Integrating Image and Story and is now the founder of the Parker Institute, an entity dedicated to orchestrating scholarly symposia, wherein barriers of time, disciplines, and cultures are crossed in an effort to find the right questions to make tomorrow's story better than the one we have to tell today.

    Nicole J. Peak is currently a doctoral student in the APA-approved graduate training program in clinical psychology at Case Western Reserve University. She is actively involved in research pertaining to depression and suicide in adult individuals.

    Robert Waska, MFT, PhD, is the author of five textbooks and more than 60 articles on various contemporary Kleinian topics, including projective identification, loss, borderline and psychotic states, the practical realities of psychoanalytic practice in the modern world, and the establishment of analytic contact with difficult, hard-to-reach patients. He emphasizes the moment-to-moment understanding of transference and fantasy as the vehicle for the gradual integration and mastery of unconscious conflict and paranoid or depressive states. Dr. Waska maintains a private psychoanalytic practice for individuals and couples in San Francisco.

    Kelly Wilson, PhD, is an Associate Professor of Psychology at the University at Mississippi. He is Representative-at-Large for the Society for a Science of Clinical Psychology and past president of the Association for Contextual Behavioral Science. Dr. Wilson received his PhD from the University of Nevada, Reno, in 1998. He joined the faculty at the University of Mississippi in 2000, where he founded the Mississippi Center for Contextual Psychology. His interests include the application of behavioral principles to understanding topics such as purpose, meaning and values, therapeutic relationships, and present moment processes.

    Jeffrey K. Zeig, PhD, is the founder and director of the Milton H. Erickson Foundation. Dr. Zeig is the architect of the Evolution of Psychotherapy Conferences, the most important conferences in the history of psychotherapy. He organizes the Brief Therapy Conference, the Couples Conference, and the International Congresses on Ericksonian Approaches to Hypnosis and Psychotherapy. A psychologist and marriage and family therapist, Dr. Zeig has a private practice and conducts workshops internationally (40 countries). He has been an invited speaker at major universities and teaching hospitals, including The Mayo Clinic, Menningers, and MD Anderson. Dr. Zeig is president of Zeig, Tucker, & Theisen behavioral sciences publishers. He is founder of the Erickson Foundation Press. Dr. Zeig has edited, coedited, authored, or coauthored more than 20 books on psychotherapy that appear in 11 foreign languages.

    Ofer Zur, PhD, is a psychologist practicing in Sonoma, CA, an author, and a forensic consultant. He is director of the Zur Institute, LLC, which offers more than 90 online courses for continuing education credits for psychotherapists at http://www.zurinstitute.com/homeonline.html. He is the author of dozens of articles and four books focusing on ethics, therapeutic boundaries, fee-for-service private practice outside managed care, and much more. His books include Dual Relationships in Psychotherapy (2002, with A. Lazarus), HIPAA Compliance Kit (2005), Private Practice Handbook (2007), and Boundaries in Psychotherapy published by APA in 2007. His website is http://www.zurinstitute.com.


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