Reality, Gestalt & Existential Therapy

• Psychotherapy Orientations explores the various approaches to psychotherapy.
• Focuses on psychoanalysis, psychodynamic, adlerian, humanistic, existential, and gestalt therapies.

Theoretical Orientations

• Table 1.1 details the theoretical orientations of psychotherapists in the United States.
• Clinical Psychologists: Cognitive (31%) and Eclectic/Integrative (22%) are the most used orientations.
• Counseling Psychologists: Eclectic/Integrative (34%) and Cognitive (19%) appear to be the most common.
• Social Worker: Eclectic Integrative (26%) and Cognitive (19%) are favored by Social workers.
• Counselors Cognitive (29%) and Eclectic/Integrative (23%) seem to be typical.

Definition of Psychotherapy

• Psychotherapy helps assist people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that participants deem desirable.
• Psychotherapy involves the informed and intentional application of clinical methods and interpersonal stances.
• Therapeutic techniques also involve the use of established psychological principles.

Common Elements of Psychotherapy

• Psychotherapy relies on positive patient expectations and a strong therapeutic alliance between the therapist and client.
• Positive expectations involve belief or expectation that influences behaviors in a way that makes the belief come true through three states:
• Expectation: A person holds a belief about themselves, others, or a situation.
• Behavioral Response: This belief influences how they act.
• Outcome Confirmation: Their behavior causes the belief to come true, reinforcing the original expectation.

Psychoanalysis/Psychodynamic Theory

• Sigmund Freud (1856-1939) developed the idea that the basis of neurosis arises from the conflict between the id, superego, and ego.
• Defense mechanisms arise in the ego and unconscious conflicts originate in childhood.
• Defense mechanisms are the ego's protective method of reducing anxiety by unconsciously distorting reality, where one may exhibit:
• Repression: Banishing distressing thoughts and feelings from consciousness.
• Projection: Disguising threatening impulses by attributing them to others.
• Rationalization: Offering self-justifying explanations in place of the real, more threatening, unconscious reasons for one's actions.
• Reaction Formation: The ego unconsciously makes unacceptable impulses look like their opposites.
• Displacement: Diverting sexual or aggressive impulses toward an object or person that is psychologically more acceptable than the one that aroused feelings.
• Sublimation: Expressing a socially unacceptable impulse in a socially acceptable way.
• Freud's Psychosexual Stages:
• Oral (0-18 months): Pleasure centers on the mouth – sucking, biting, chewing.
• Anal (18-36 months): Pleasure focuses on bowel and bladder elimination, coping with the demand for control.
• Phallic (3-6 years): Pleasure zone is the genitals; coping with incestuous sexual feelings.
• Latency (6 to puberty): Dormant sexual feelings.
• Genital (puberty on): Maturation of sexual interests.
• If there is a conflict that is unresolved during one of these stages, then that conflict may manifest itself at a later age.
• In therapy, the goal is for the patient to gain insight into unconscious conflicts.
• Psychoanalysis involves using free association or saying whatever comes to mind.
• Projective testing involves ambiguous picture being presented to the client to ascertain what their perception is.
• Transference projects feelings, attitudes, and thoughts from the past onto a psychoanalyst.
• Resistance is a tendency for an individual to resist change in a way that undermines the therapeutic process.
• Interpretation is the therapist's attempt to sense the patient's experience, articulate a hypothesis about the patient's unconscious experience, or draw the patient's attention toward unconscious self-defeating patterns.
• A criticism involves a lack of research supporting the effectiveness of long-term psychoanalytic therapy.
• Some research suggests that psychoanalysis is better than no treatment but it could be better than other therapy.
• Psychodynamic therapy evolved from psychoanalytic therapy and is concerned with interpersonal conflicts.
• Brief Psychodynamic Therapy is also used and relies on many of Freud's beliefs.
• Experiences in childhood lead us to develop an inner model for adult relationships.
• How the patient acts in session and relates to the therapist may reflect how they operate with other people and their other relationships.
• Sessions are unstructured, where a patient decides what to talk about. Focusing on interpersonal conflicts as opposed to inner conflicts.
• Brief Psychodynamic Therapy includes:
• Targets a main interpersonal problem.
• Time limited (e.g., 12-40 sessions).
• More structure/planning.
• More active/directive therapist.
• Therapeutic alliance is emphasized.
• Limited research support.

Adlerian Theory

• "Striving for Superiority" is the core motivation.
• Explores both conscious and unconscious thought.
• States one grows up feeling a sense of inferiority and envisioning idealized image of their life in the future.
• Mistakes and cognitive distortions happen when striving for superiority.
• People think in incorrect ways because of striving for superiority.
• Basic mistakes consist of exaggerated, absolute, unwarranted conclusions.
• Psychopathology is caused by striving for superiority in an unhealthy way.
• Birth order influences personality and chosen lifestyle. Believes that birth order/experience influences our personality.
• Also called Individual Psychotherapy.
• Therapeutic relationship is egalitarian where patients and therapist insights are equally important.
• Focuses on family life and relationships, roles between everyone, and focuses on the whole individual.
• Lifestyle assessments involve family constellation interviews and address how well life would be if one were well.
• Motivations and behaviors are identified.
• Basic mistakes are identified by highlighting unhealthy ways of thinking.
• Techniques include:
• Constructing a future autobiography
• Catching oneself
• Creating new images and perspectives
• Acting "As If"
• Using push-button techniques
• Limited research support has been found
• Many of its ideas have been incorporated into other therapies like CBT.

Person-Centered Therapy

• Carl Rogers (1902 – 1987) stated people strive to be better and everyone is inherently good.
• Trained in psychoanalysis, but found that listening and letting the client lead worked better.
• Human connection is key in therapy and should maintain egalitarianism.
• Features of Rogers' personality theory:
• Conditions of worth - conditional positive regard
• Conditions of worth are the conditions we think are needed to get love and approval from others.
• Psychopathology arises from a discrepancy between ideal and real self.
• The goal of therapy is to become more aware and accepting of the real self, and to reduce discrepancy between ideal self and real self. Encourages a nurturing environment.
• Necessary and sufficient conditions for therapy:
• Unconditional positive regard
• Acceptance of who the patient is
• Accurate empathy
• Genuineness
• The therapist takes on a nondirective role; patient says whatever they want to say.
• Reflection is used to repeat back what the patient says to help them learn to be more aware and understood.
• Encourages that there need to be less questions asked in order to help the patient continue to open up.
• Contemporary Approaches:
• Classic person-centered therapy is more heavily affected than all other therapies except for CBT for specific problems like anxiety disorders.
• Typically blended with other approaches. Therapists are more active/directive compared to the classical approach.
• First made to help with addiction but what ultimately works well is empathetic therapists.
• Therapist empathy is the strongest predictor of positive outcomes for behavioral self-control techniques.

Motivational Interviewing

• Collaborative, person-centered approach for addressing ambivalence about behavior change.
• Allows the patient to decide if they want to change. Primarily aimed at addiction, but now used for a variety of problems.
• Addresses the questions:
• Do you think it's important to make a change?
• How confident are you that you can actually make the change?
• How committed are you to make the change?
• General Principles include:
• Express empathy.
• Develop discrepancy.
• Roll with resistance.
• Support self-efficacy to instill autonomy in the patient. Core MI techniques use the OARS acronym:
• Open-ended questions
• Affirmations: Statements that recognize the clients strengths.
• Reflections
• Summaries
• Silence provides the space to think and reflect.
• The therapist listens for change talk, then reflects and asks open-ended questions
• Research supports MI, especially for substance-related problems (Hettema, Steele, & Miller, 2005).

Existential Therapy

• Developed in the context of post WWI & WWII.
• Focuses on the immediate human experience, involving self awareness.
• Anxiety is a normal part of human existence and we should embrace it and not run from it.
• Neurotic anxiety is extra anxiety that comes from not facing the normal anxiety.
• Existential anxiety stems from: Awareness of looming death Threat of meaninglessness Isolation Necessity of making decisions (personal responsibility)
• stems from emotional avoidance, isolation
• Psychopathology stems from low self-awareness, emotional avoidance, and struggling with existential anxiety
• Finds a way to develop Meaning
• About facing death/isolation Coming to terms how how we fell alone and how we can learn to live with it.
• Self-awareness; Discover/explore authentic self
• Recognize and accept the control we do have, Live life to the fullest
• Recognize the things we cant control
• Acceptance of the things we can't control, recognizing Life is full of uncertainty that
• Experience our emotions authentically - the good and bad
• Accept Personal freedom & take Personal responsibility for our choices
• Therapeutic relationship is authentic and the therapist is available, present, and warm.
• Feedback is given and confrontation, use of encouragement and
• Does not necessarily make use of prescribed techniques/procedures or the rigid methods
• Paradoxical intention
• Changing cognitive meaning/change perspective meaning, try to gain more meaning from our experiences.
• Lack of RCTs investigating existential therapy because it is not intended to reduce symptoms but is more for living a better life
• Studies show that some existential group therapy is helpful for facing the impact of life-threatening illnesses

Gestalt Therapy

• Fritz Perls (1893-1970) helped develop therapy in WWII & growing Apartheid in South Africa.
• Founded the New Institute for Gestalt Therapy, showing existential & humanistic influences that emphasize self-awareness & present moment.
• Involves taking responsibility for your own decisions.
• Personality involves a holistic shape of context & interpretations, where one grows to becomes whole by being self-aware in the present moment.
• Develops self awareness and uses your senses to live in the present moment.
• Psychopathology stems from:
• Living in the past
• Worrying about the future
• Clinging to illusions about self
• Failing to learn from experience
• Gestalt therapy emphasizes increasing self-awareness and current awareness of the present moment. Focuses on attention to body language (especially signs of suppressing emotion).
• Addresses unfinished business and experiments with Gestalt therapy.
• Uses Empty-Chair technique or Reversal technique.
• Act opposite of how they usually act to recapture their whole selves and take responsibility. Gestalt therapy is better than placebo, but is less effective than CBT

Reality Therapy

• William Glasser (1925-2013) published "Reality Therapy: A New Approach to Psychiatry" (1965).
• Has existential & humanistic roots.
• Emphasizes personal freedom & responsibility and a therapeutic relationship.
• Choice theory states that humans are internally motivated and can choose their own behaviors. Human behavior driven by:
• Survival
• Love and belonging
• Power (or achievement or inner control)
• Freedom (or independence)
• Fun (or enjoyment)
• The "Quality World" is one's world of wants including:
• People. Things/experiences/activities. Ideas or system of beliefs.
• Total Behavior consists of: acting, thinking, feeling, physiology.
• The automobile analogy is used to describe the idea of one being responsible for their behavior so there is no mental illness.
• Has direct control on front 2 wheels and indirect control on back 2 wheels. Unhappiness happens often because one person controls another.
• Clients should choose their lives and take responsibility for their choices through the WDEP questions:
• Wants: What do you want?
• Doing: What are you doing?
• Evaluation: Is it working?
• Planning: Should you make a new plan?
• Also focuses present reality and strengths

Questions cover choice theory, Reality Therapy's WDEP system, and the 'Quality World'. Also includes Gestalt therapy's techniques and views on psychopathology, as well as the goals of existential therapy, and transference.