PSYC3082 Psychotherapies & Counselling Lectures PDF

PSYC3082 Psychotherapies & Counselling Person Centred Psychotherapy Dr Cassandra Tellegen (She/Her) School of Psychology University of Queensland 1 Acknowledgement of Country The University of Queensland (UQ) acknowledges the Traditional Own...

PSYC3082 Psychotherapies & Counselling Person Centred Psychotherapy Dr Cassandra Tellegen (She/Her) School of Psychology University of Queensland 1 Acknowledgement of Country The University of Queensland (UQ) acknowledges the Traditional Owners and their custodianship of the lands on which we meet. We pay our respects to their Ancestors and their descendants, who continue cultural and spiritual connections to Country. We recognise their valuable contributions to Australian and global society. 2 Quiz next week Tues 10 Sept 1pm to Wed 11th Sept 5pm Questions on weeks 1-6 (6 lectures + readings) Does not include questions on today’s lecture Via Blackboard 60 minutes to complete it once you start (can only attempt once) 50 multiple choice questions (worth 0.5% each 25% total) Quiz items randomly selected from a pool Practice questions on Blackboard Lecture Outline 1. Carl Rogers and the context 2. Theoretical foundations 3. Core conditions of therapy 4. Empirical research on PCT 5. Contributions and limitations 6. Motivational interviewing 7. Emotion Focused Therapy Carl Rogers & the Context 1902-1987 Farming background – Illinois Studied agriculture then theology before psychology. 1930-40s: Psychoanalysis & directive approaches were used in hospitals. Deeply ambivalent about the exercise of power in therapy. He challenged the validity of commonly accepted procedures such as: - Advice - Suggestion - Direction - Persuasion - Teaching - Interpretation - Diagnosis Four periods of development 1. Nondirective counselling 3. Becoming one’s experience 1940s Late 1950s-70s reaction against directive Testing hypotheses Process and outcomes of therapy 2. Client-centered therapy Client-therapist relationship 1950s Extended to education Emphasis on client Move from feelings to world of client 4. Person-centered approach Actualising tendency Expanded to other groups – industry, groups, conflict, peace Leadership, international relations, politics Nobel Peace Prize Humanistic Therapy Movement Developed humanistic movement (includes PCT, existential therapy and gestalt therapy). One of three major schools of psychotherapy, alongside behavioural and psychodynamic traditions. PCT emphasises people's capacity to make rational choices and develop to their maximum potential. Important themes: Concern & respect for others. Deep trust in the individual’s wisdom and resourcefulness. Therapist must take care not to undermine this by assuming an expert / directive role. First to use term “client” (rather than “patient” or “analysand” used by Freud and the psychoanalysts). Theoretical Foundations View of human nature: Positive Essentially trustworthy Resources for self, understanding and growth. Basic drive to fulfilment and self- actualisation (cf. sexual and aggressive drives in Freud’s drive theory). Angry or destructive actions seen as product of environment. View of the World In contrast with the “expert” view of psychoanalytic therapist. In PCT “no other individual can determine what is correct or incorrect behaviour for anyone else”. Roger’s influence went beyond individual therapy context into social groups and international relations....if humans are truly present and practice empathic understanding etc they will be able to resolve disputes and differences. Implications of View Primary responsibility with client. Active client, therapist not authority. Therapist’s focus: Constructive side of human nature. What is right with the person. Assets clients bring to therapy. Central Constructs of PCT Experiencing: Everything that is going on in the individual at that point in time e.g., emotions and sensory and physiological events. In order to grow, individuals must experience accurately and discriminate between events that contribute to wellbeing and those that are harmful. Therapist should stay present with the clients’ experience in therapy from moment to moment, without judging or offering advice or interpretation. Actualising tendency: Innate drive for growth & autonomy. Motivational construct. Movement towards realization of full potential. Self-Concept (+, -, ideal): A portion of experience that becomes labelled as the self e.g., if I discover I am good at maths, and I value maths, then this ability becomes part of a positive self concept. Markers of Increased Actualisation Openness to experience. Trust in self. Internal source of evaluation. Willingness to continue growing. Impact of External Factors Potential influence by interactions with others. Unconditional positive regard “I’ll love you no matter what you do” growth. Conditional regard “I’ll only love you if you do what I say” reliance on external sources of validation. Self Actualisation Based on work of Maslow (1970) Studied what he called ‘self-actualising people’ Different from ‘normal people’ Characteristics – self-awareness, freedom, honesty, caring, trust, autonomy Hierarchy of needs – physiological, safety, belonging and love, esteem (basic needs met then self-actualising) Movement from control by external forces autonomy. Individual drawn to that which enhances full potential (through desire to self-actualise). All behaviour energised by drive to self- actualise. For You to Consider Think about who you really are – your true, authentic self. Is this the “you” that others know or are there aspects / potentials in you that are buried? Do you feel hindered by your current circumstances / habits in being your true self? These are often life long questions. Therapeutic Process & Goals In person centred therapy the emphasis is on world of the client. Therapist’s role is to be present and accessible to client and to focus on the here-and-now experience. Therapist does not offer interpretation or guidance. Goals: Focus is on person not on problems. Increase independence and integration. Assist with growth process to cope better with future problems. Becoming a fully functioning person (self- actualised). Three Core Conditions of PCT Therapeutic relationship based on: Accurate empathic understanding Congruence (genuineness) Unconditional positive regard for the client These are the “core conditions” of therapeutic change Carl Rogers’ on how he will be working with Gloria (1965) (from 3 mins) Carl Rogers’ on how he will be working with Gloria https://www.youtube.com/watch?v=ee1bU4XuUyg 9mins 26 sec Explore feelings and attitudes more deeply Feeling valued and approved of by the therapist – value and approve of herself more Listen to some meanings in her own words Senses a realness in the therapist which fosters a realness in herself Move from being remote to her experience to more immediate experience in the moment Move to internal sense of evaluation Empathetic Understanding Rogers on empathy: The therapist resonates in a bodily felt response to a client’s functioning and conveys aspects of this interaction to the individual. Empathy involves adopting an overall attitude and should not be equated to a single technique such as reflection. Therapist tries to sense the client’s subjective experience. By careful and perceptive attention to what the client is saying. Using attending & micro-counselling skills (Lecture 1) Empathy cannot just be felt – it must be communicated. Congruence A congruent therapist is open and genuine with the client rather than presenting a “professional front”. Therapists who function this way have all their feelings available to them in therapy sessions. Shares his/her experience of the client when therapeutically helpful. Does NOT mean the focus of therapy shifts to the therapist or disclosure of therapists’ personal problems. Unconditional Positive Regard Deep and genuine caring for client. Caring is not judgmental or evaluating. Non-possessive. Acceptance but not necessarily approval. E.g. withholding direct responses to requests for advice. 23 Roger’s View of Conditions & Counselling Process Conditions: Apply to all clients. Necessary and sufficient for change. Apply to all relationships. Therapist need not have specialised knowledge. Diagnosis is not necessary Counselling Process: Explore beliefs and feelings. Express feelings too negative to accept. Increasing integration. Feel safe become more open to experience, and become more realistic. Empirical Research Rogers was the first to study the counselling process in depth by analysing the transcripts of actual therapy Expectancy effect sessions. 15% He was the first clinician to conduct major studies on psychotherapy using quantitative methods. Extra-therapeutic change He was the first to formulate a comprehensive theory of 40% personality and psychotherapy grounded in empirical Therapeutic research. Alliance Earlier studies indicated that the three conditions correlated 30% with outcome. Studies on individual components e.g. empathy - correlation with outcome mixed. Techniques 15% More recent literature – focus on core components as facilitative (i.e. necessary but not sufficient for client change). Therapeutic relationship Contributions & Limitations Contributions: Important shift in status of the client in therapy – client becomes equal. Shift in focus from techniques to therapeutic relationship. Focus on empathy. Emphasis on research and evaluation. Limitations: Limited scope for techniques in PCT. Little place for educative function/skills training. Therapists can be supportive and not challenging Are the core conditions sufficient for change for all? Motivational Interviewing From early 1980s Miller & Rollnick (2002) “Motivational Interviewing: Preparing people for change” Theory that motivation is a dynamic construct, a product of the interaction between client and therapist. Motivation used to be viewed as a stable construct, like a personality trait: “the client didn’t improve because he lacks motivation”. Started with addictive behaviours, then mental illness, health behaviours, etc. We know that telling a person to stop a harmful behaviour does not work. Aim is for the client to tell you why they should change their behaviour. Motivational Interviewing Miller & Rollnick (1993): Define behaviour. Identify and emphasise with positives. Identify and emphasise with negatives. Integrate with summary. Invite possibility of change. Principles: Empathic approach toward client. Develop discrepancy. Avoid argumentation. Roll with resistance. Support client’s self efficacy for change. Example: Developing discrepancy Let’s say you have a client who is binge eating and wants to stop but doesn’t know how Ask the client to list the good things about that behaviour Beside that list, ask the client to list the less good things about that behaviour On balance of the two lists, ask how ready the client is to change the behaviour Could ask client to visualise their life in 5 years, goals, values, and then ask how their continued behaviour would influence this imagined future. Motivation vs Confrontation Confrontation involves direct feedback to client on the negative consequences of their behaviour. Evokes shame as a way of pushing the client into change (negative emotion). Motivational interviewing focuses on building positive emotions (interest, hope, inspiration) and the client sees how change can meet his/her own needs. Bem’s (1972) self-perception theory that people tend to become more committed to that which they hear themselves state. Listen for and emphasise “change talk” from the client. Bad example https://www.youtube.com/watch?v=_VlvanBFkvI What did the interviewer do here? What were the client’s reactions? Good example https://www.youtube.com/watch?v=67I6g1I7Zao What was different in this video? What techniques did you see here? How did the client react? Stages of Change People progress through stages Not always linear Match intervention to stage of change Meta-analysis of MI Hettema et al. (2005): Meta-analysis of 72 studies found that MI generally shows small to medium effects in improving health outcomes. As a stand-alone brief intervention, MI is supported for addictive behaviours, except smoking. MI is showing some promise in chronic health management and treatment adherence. Effect sizes tend to decrease over time. Emotion Focused Therapy takes part of its theoretical foundation from PCT First called Process Experiential Therapy, focus on the client’s experiencing and making sense of his/her emotions: PCT relationship Gestalt experiential techniques Biological theories of emotion (Greenberg, 2008) https://www.youtube.com/watch?v=4AHJkOF6eR8 Emotion Focusing and Regulation Safe, validating and empathic environment “How do you feel in your body as you’re saying that?” “I imagine that must have hurt your feelings...” “Can you stay with that feeling and tell me what it might mean?” Emotional reflection and transformation Primary (first) and secondary (second) emotions - E.g. getting angry (secondary emotion) when shame/fear (primary emotion) is behind this Once the client makes sense out of his/her emotions, they can work out what they need One emotion can be transformed into another - E.g. Sadness into anger (which will energise the client into more assertive behaviour) EFT Example in Couples Therapy https://www.youtube.com/watch?v=xaHms5z-yuM Dr Sue Johnson EFT Interventions Gestalt/Mindfulness Focus Repeat, exaggerate Emotional awareness coaching Empty chair and split chair techniques to resolve unfinished business with significant others EFT vs PCT for Treatment of Depression Person Centred Therapy EFT M = 18 sessions M = 18 sessions Rogerian/ Client centred CC approach PLUS Empathy Emotion focussed interventions Acceptance Empty chair dialogue for unresolved interpersonal emotion Genuineness Two chair dialogue for addressing critical inner self 30 BDI Depression 20 PCT 10 EFT 0 Pre Post 6 mo Time (Ellison, Greenberg, Goldman, & Angus, 2009) Next week Quiz Lecture: Compassion Focused Therapy with Assoc Prof James Kirby Reading: Gilbert (2014) The Origins and Nature of compassion focused therapy COMPASSIONATE MIND RESEARCH GROUP What is Compassion Focused Therapy? PSYC3082 Acknowledgement of Country We acknowledge the Traditional Owners and their custodianship of the lands on which we meet. We pay our respects to their Ancestors and their descendants, who continue cultural and spiritual connections to Country. We recognise their valuable contributions to Australian and global society. 2 Hello! I AM JAMES KIRBY A/Prof & Clinical Psychologist at the School of Psychology, The University of Queensland Co-Director of the Compassionate Mind Research Group at UQ 3 Compassionate Mind Research Group The University of Queensland What is compassion? 8  Donation Weakness Hurt Relating Listening Motivation Friendship Human Capacity Fears Giving Faith Hope Intelligence Closeness Support Emotion Costs Sensitivity Ability Social Kindness Heart Charity RecognitionTrust Family Love Empathy State Assistance Values COMPASSION Cognitive Insight Feeling Skill Aid Sympathy Awareness Problem Help Care Distress Trait Sharing Understanding Trouble Concern Together Shame Religion Behaviour Prosocial Feeling Suffering Positivity Action Experience Worried Patience Warmth Vulnerability Communication Soft Healthcare 9  ENGAGEMENT STIMULUS DETECTION does buttlying you ↑ red land now meait ? A sensitivity to suffering in self and others, with a commitment to try to alleviate and prevent it ↓ ↳ minine Leth toreas wir ACTION STIMULUS RESPONSE 10  COMPASSION IN THREE FORMS you noeasily ? lev depende ou ↳ Self- context Compassion Culture Family Compassion School Compassion to Others Organisation from Others 12 1. Do you find one of these directions of compassion easier than the other? 2. Do you find one of these directions of compassion harder than the other? 13  COMPASSION IS A MOTIVATION Compassion Callousness Sensitivity to suffering Insensitivity to the in self and others with suffering of self and a commitment to try to others and carelessly or alleviate and prevent it purposefully causing it Examples of Facilitators and Inhibitors: Liking Similarity Competence Anxiety/Fear Empathy Time Cost Time Cost Likeability 15  COMPASSION IS A MOTIVATION Compassion Callousness Sensitivity to suffering Insensitivity to the in self and others with suffering of self and a commitment to try to others and carelessly or alleviate and prevent it purposefully causing it Role Examples that Facilitate or Inhibit: Parent Friend Partner Therapist Client Competitor Group 17 Compassion: A Royal Road to a Range of Benefits Mental Health Compassion Parenting Physiology (Heart rate variability) Social Connection Prosocial Emotion Attachments Behaviour Regulation Emotional Tone the Origins of CFT Gilbert, in his early days, really noticed the emotional textures of thoughts not just the content He particularly focused on the hostility and attacking nature the tone would take Prof Paul Gilbert O.B.E. Focus on head-heartlay Affiliative Knowinga ↳ Emotions not & Self-Critical Client "Your husband loves you, your kids love you. You know this!" Paul asked the client: IS THIS SOM “Would you consider saying that KIND OF SIC again to yourself, but use a kind and friendly inner voice-tone?” JOKE? CFT is… An approach to psychotherapy based on Social Mentality Theory Originally developed for those suffering from high levels of self-criticism and shame, underpin many of the mood and anxiety disorders Growing meta-analytic evidence base supporting it (Kirby et al, 2017; Millard, et al., 2023; Petrocchi et al., 2024)) Unique Features? having prevetitive Definition of compassion e Psychoeducation of evolved Tricky Brain & Not Your Fault Model of affect regulation with special focus on affiliation and the parasympathetic system Specifically building a compassion focused motive: The Compassionate-Self Work with fears, blocks and resistances to compassion and positive affiliative emotion  Understanding our Motives and Emotions Motives evolved because they help animals to survive, seek out things that are important (e.g., food, shelter, relationships, status, reproduction, etc), and to help leave genes behind Emotions guide us to our motivations/goals and respond if we are succeeding (e.g., happy, excited) or threatened (e.g., anxiety, anger) There are three types of emotion regulation systems 1. Those that focus on threat and self-protection 2. Those that focus on doing and achieving 3. Those that focus on contentment and feeling of safeness  Three Circles Model Hese systems can coregulate each other Drive and Soothing and achievement Incentive focused, connection wanting, pursuing, Content, safeness, calm, achieving, status not-wanting Threat and self-protect Protection and safety seeking, fight/flight  Three Circle Check-In How would you draw your ‘circles’ in proportion? How would you draw your ‘circles’ in proportion? Soothing and Drive and connection achievement Threat and self- protection Heart Rate Variability Successive Inter-beat Standard Deviation of Intervals Inter-beat (ms) Intervals over 60 second period 945 897 858 799 821 Lower HRV is associated 846 with a range of mental, 851 social, and physical health 858 problems 879 879  Heart rate variability is an increasingly used physiological A/Prof James Kirby marker to measure emotion regulation Lower HRV associated with with depression, anxiety, rumination, Dr James Doty insecure attachment, and self- criticism Higher HRV found to be associated with well-being, empathy, secure Dr Nicola Petrocchi attachment and compassion Compassion interventions can increase HRV Prof Paul Gilbert Compassion, HRV, and Dosage Figure 1. HRV change over time Figure 2. Dosage impact on 37HRV 37 38  Three Circles Model Drive and achievement Incentive focused, wanting, pursuing, achieving, status Threat and self-protect Protection and safety seeking, fight/flight Systems out of balance: how would you draw your ‘circles’ in proportion? Soothing and Drive and connection achievement Failure Threat and self- protection Self- Criticism When something goes wrong for you, what do you usually say to yourself? How do you feel towards yourself? A personal example: “You f*cking idiot”  SELF-CRITICISM SELF-COMPASSION Emotional Statement: 'I fail to keep up with my commitments in life’ Neutral Statement: “I keep up with my commitments in life’  RED: Salient, Negative, Painful Stimuli YELLOW: Threat 1 Anterior Insula Signal Amygdala Signal Change Anterior Cingulate 1 Signal Change 0.8 Change ** * 0.8 *** 1.1 ** 0.9 0.6 0.6 0.7 * 0.4 0.4 0.5 0.2 0.2 0.3 0 0.1 0 -0.1 -0.2 -0.2 Criticism -0.3 Criticism Criticism -0.4 Compassion -0.4 -0.5 Compassion -0.7 -0.9 Compassio *** p your answer is different for people anxiety is part of life  life is accidental Lorna’s Story The Human Being is Three Dimensional you are treating the whole person Human Dimensions PSYCHIC mind essence SOMATIC body The Purpose of Logotherpy Enhance other approaches engage the “defiant power of the Human Spirit” towards meaning Driven by “needs” vs Pulled by Values John’s Story If I don’t do it, who will do it? If I don’t do it now, when will I do it? If I do it only for myself, then who am I? Rabbi Hillel. John’s Story  Lesson 2 – Philosophy Life always has meaning, in all circumstances, even the most miserable. Lesson 3 – “Techniques” Socratic Dialogue Within a philosophy of life Self-distancing Freedom and Responsibility The greater our awareness, the greater our possibilities for Inauthenticity: freedom. Lacking awareness of our personal responsibility for our lives. Defining ourselves as a fixed or static entity – we can then avoid choosing. Capacity to live fully increases as we expand our awareness of: Not acting in line with what is important causes inauthenticity.  our finiteness,  our potential to act or not act, Existential guilt:  the meaning in our life circumstances, Being aware we have evaded a commitment.  our responsibility for choices, Making a choice or allowing others to define us or make choices for us.  our aloneness. Authenticity: Dovetails with Gestalt, third wave CBTs, Mindfulness The courage to be who we are The Illusion of Happiness Brian’s Story WHAT IS MEANT (INTENDED?) WHAT IS THE BEST LOGOS POSSBILE (MEANING) FOR ALL INVOLVED IN A SITUATION? WHAT OUGHT TO BE? WHAT DOES THE VOICE OF TRANSCENDENCE SAY? what makes you a better person? Elisabeth Lukas, PhD Self-awareness vs Self-Transcendence Anxiety: A Condition of Living Yalom’s 4 givens of existence create anxiety: death is important Death: We will all die, there is no escape. Freedom: Each person is ultimately responsible for and the author of his/her own world, own life design, and own choices and actions. doesn’t mean you can do what u want Meaninglessness: If we all die … If we all create our own world … and if each of us is ultimately alone … then what possible meaning can life have? Isolation: Interpersonal isolation (gulf between self & others), intrapersonal isolation (isolated from parts of ourselves), existential isolation (no matter how closely we relate to others, there remains an unbridgeable gap). We enter existence alone – we must die alone. People may be present when we die, but we alone experience death.  Lesson 2 – Philosophy Life always has meaning, in all circumstances, even the most miserable. Our greatest desire – to Find meaning in life We have capacity to choose Lesson 2 – Philosophy Meanings are unique The meaning of the decision I make now is unique It cannot be undone you can’t go back in time Anxiety: A Condition of Living you need anxiety —> its part of life Existential anxiety is normal - life cannot be lived, nor can death be faced, without anxiety. Neurotic anxiety, of which we typically are unaware, is anxiety about concrete things that is out of proportion to the situation. Facing existential anxiety = viewing life as an adventure rather than hiding behind imagined securities. Opening up to life means opening up to anxiety. A healthy view of anxiety: Anxiety can be a stimulus for growth as we become aware of and accept our freedom; it can be a catalyst for living authentically and fully. We can blunt our anxiety by creating the illusion that there is security in life. If we have the courage to face ourselves and life we may be frightened, but we will be able to change. Frankl on Choice David’s Story what you can’t avoid Guilt guy with ptsd Lizzie’s Story Lizzie’s Story Lesson 4 The Tragic Triad the answer is the attitude you take Lesson 3 – “Techniques” Socratic Dialogue Within a philosophy of life Self-distancing to look at yourself objectively Dereflection Modification of Attitudes Research in Logotherapy Existential Therapy Contributions Limitations Existentialists have contributed a new dimension to the The individualistic focus may not fit within the world views of understanding of death, anxiety, guilt, frustration, loneliness, and clients from a collectivistic culture. alienation. The focus on self-determination may not fully account for real- life limitations of those who are oppressed and have limited choices. Its emphasis on the human quality of the therapeutic relationship Some practitioners may lack the level of maturity, life is a strength. experience, and intensive training required to be effective. The approach does not focus on specific techniques, making The key concepts of the existential approach can be integrated treatments difficult to standardize and study empirically. into most therapeutic schools. Social injustices may lead clients to feel patronized or It does not dictate a particular way of viewing or misunderstood if the therapist too quickly conveys that they have choice in improving their lives. relating to reality. Questions or Comments? Contact [email protected] Or go to www.lifechange.net.au Week 10: PSYC3082 Psychotherapies & Counselling Process Issues, Ethics & Culturally Sensitive Psychotherapy Dr Cassie Tellegen (She/Her) School of Psychology University of Queensland 1 Acknowledgement of Country The University of Queensland (UQ) acknowledges the Traditional Owners and their custodianship of the lands on which we meet. We pay our respects to their Ancestors and their descendants, who continue cultural and spiritual connections to Country. We recognise their valuable contributions to Australian and global society. 2 Lecture Overview Process issues in therapy Ethics Diversity What are Process Issues? Process issues mostly concern what transpires in the relationship between therapist and client. CONTENT of therapy = WHAT PROCESS of therapy = HOW Some therapies are ALL about the process (e.g., psychodynamic group therapy). Others make less use of process (e.g., CBT). these issues cut across all therapies they can affect outcomes Process Issues Can significantly impact the outcome of therapy. Example: person challenges group therapist on the first morning of a substance abuse treatment group: “How old are you? What are your qualifications? Have you ever used drugs before?” If therapist simply responds to the content, could miss the important process issues. What could the process issues be here? Process issues example https://www.youtube.com/watch?v=5StMSuuQe9w The Importance of the Therapeutic Relationship The consistent failure to find differences in the efficacy of different forms of psychotherapy supports the important of the therapeutic relationship. The finding that therapy nonspecific factors account for a large proportion of the variance in outcome. Effectiveness of the client-therapist relationship is a function of at least 5 factors: Client’s personal characteristics (e.g., personality, values, expectations, previous therapy, symptoms). Personal characteristics of the therapist. Competence and expertise of therapist. Match between client and therapist. Factors outside of therapy (e.g., client’s personal social system, culture, and society). The Importance of the Therapeutic Relationship Misunderstandings and dashed client expectations can be minimized if the therapist: - Listens carefully to the client. - Invites feedback about the therapist’s actions. - Asks for feedback at every session. - Sets consensual therapy goals at the beginning. - Remains flexible and non-defensive throughout therapy. Negative process is indicative of a “rupture” in the therapeutic alliance (Safran, 1993). Alliance ruptures are the product of: - Client’s pattern of maladaptive cognitions and behaviours. - Therapist’s complementary reactions to these patterns. “Alliance rupture” overlaps with client resistance and transference/countertransference from psychoanalysis. Alliance Ruptures Breaches in the therapeutic alliance are: Inevitable A serious barrier to therapeutic progress. Provide the therapist with indispensable information. Important for the therapist to clarify the contributions that BOTH parties are making to the interaction. From an interpersonal perspective, any strain in the therapeutic alliance reflects both client & therapist contributions. Become aware of & make use of negative feelings & responses rather than attempting to deny or overcome them. Directly confront problems that arise within the client-therapist relationship. Identify evidence for influence of client’s maladaptive interpersonal patterns in various important relationships throughout his/her life. Alliance Ruptures Explore ruptures by directing client’s attention to the here-and-now of the therapeutic relationship or to his/her immediate experience. Collaborate & Compromise Therapist can create an atmosphere of cooperation by being flexible. Empathy for the Resistance Show you understand the function of the client’s behaviour/resistance, and that you have compassion for related fears. Speak the Client’s Language Maximise the Use of Client Self-Direction: Make maximum use of “flashes” of client cooperation Resistance Definition: Any client behaviour that is unhelpful to the progress in therapy. Common forms of resistance: Lack of engagement in the therapeutic dialogue. Being late for sessions. Not attending sessions. Resisting addressing particular areas of concern. Failure to do between session assignments. High levels of expressed emotion towards the therapist (from hostility to over flirtation). Subtle avoidances in session. Homework non-completion Reasons: Resistance Lack of understanding of task Lack of understanding of importance of task Lack of reinforcement for completion Barriers Additional stressors Homework completion Address resistance Explain homework clearly and check for understanding Complete example of homework Explain importance of doing homework Check homework at the beginning of next session Reinforce client for completing homework Address barriers and stressors Clients Who Over Talk or Don’t Talk Enough Over Talking Why? What could be done? Under Talking Why? What could be done? 14 Process Issues for Therapist Leakage via non-verbal behaviour. Setting limits while still conveying empathy. Self-awareness – knowledge of limitations. Expectations of self/client. Anxiety and insecurity over competence. Having enough experience with other similar clients. Concern about whether a therapeutic relationship will be established. Difficult questions from clients Personal questions. Questions about the future. Seeking advice. Black and white type questions. Questions you don’t know the answer to, but feel you should. Client developing feelings for therapist. Group Therapy Selecting group participants Setting context Expectations Roles and responsibilities of therapist and group members Rules for working in a group What if one person dominates? What if group member(s) don’t contribute? What if a group member is clearly not appropriate for the group? Ethics APS has a code of ethics that psychologists must abide by. As you build your skills in counselling, this involves: Becoming familiar with ethical standards of your profession. Understanding the ethical issues that you may encounter. Learning to apply your knowledge in everyday practice. Morals vs Ethics Morals and ethics are both concerned with “right” and “wrong” conduct. Morals are the individual’s own ideals and principles. Ethics: ‘Standards of conduct or actions in relation to others’. ‘Moral principles adopted by a group to provide rules for right conduct’. Mandatory vs Aspirational Ethics Mandatory ethics: minimum level of professional practice. Aspirational ethics: highest standards of conduct to which a professional can aspire. Code of Ethics Purposes: Educate about responsibilities. Provide basis for accountability. Provide basis for reflecting on and improving one’s professional practice. Available from: Australian Psychological Society Australian Counselling Association Psychotherapy & Counselling Federation of Australia Ethical issues What types of ethical issues are therapists likely to come across? What should a code of ethics cover? APS Code of Ethics The Code is built on 3 general ethical principles: A: Respect for the rights and dignity of people and peoples (ie how the psychologist treats others) B: Propriety (i.e. fitness to practice psychology) C: Integrity (i.e. broader conduct) The Code expresses psychologists’ responsibilities to: Their clients The community and society at large The profession Colleagues General Principle A: Respect Definition: Respect for the rights and dignity of people and peoples Justice Respect Informed Consent Privacy Confidentiality Release of information to clients Collection of client information from associated parties 22 General Principle B: Propriety Definition: conforming to conventionally accepted standards of behaviours or morals. Competence Record keeping Professional responsibility Provision of psychological services at the request of a third party Provision of psychological services to multiple clients Delegation of professional tasks Use of interpreters Collaborating with others for the benefit of clients Accepting clients of other professionals Suspension of psychological services Termination of psychological services Conflicting demands Psychological assessments 23 Research General Principle C: Integrity Definition: the quality of being honest and having strong moral principles. Reputable behaviour Communication Conflict of interest Non-exploitation Authorship Financial arrangements Ethics investigations and concerns 24 An Ethical Scenario Your client is a 15-year-old girl. One day the parents request a session to discuss their daughter’s progress and to see what they can do to help. a. What parts of the code of ethics does this involve? b. What information can you share with the parents and what can you not disclose? c. What might you discuss with the girl before you see her parents? d. What will you do if she makes it clear that she does not want you to see her parents or tell them anything? Code of Ethics – Limitations & Steps to Ethical Decisions Code of Ethics: Does not make decisions for you. Is often challenging to interpret and apply to specific situations. Not static. Impossible to be comprehensive. Steps in making ethical decisions: Identify the problem Identify the potential issues Examine relevant ethical codes Know applicable laws and regulations Seek consultation Brainstorm possible courses of action List consequences of actions Decide on best course of action Right of Informed Consent Education about rights and responsibilities  empowerment and a trusting relationship. Informed choices  greater client autonomy and active participation in own treatment. Aspects of Informed Consent: Explaining the nature and purposes of procedures. Clarifying risks, adverse effects and possible disadvantages. Explaining how information will be collected, recorded, stored, and who will have access. Advising clients that they can decline to participate/withdraw and also of the consequences of this. Clarifying fees, services, length of therapy. Discussing termination. Explaining confidentiality and limits to confidentiality. Confidentiality Central to developing a trusting and productive relationship. Limits: Client confidentiality may be broken in cases where there is: Clear and imminent risk of harm to the self or others. Child abuse or neglect. Court action – your notes and files can be subpoenaed at any time. Client request – clients can request access to their files through informal or formal (FOI) channels. Guidelines: Discuss these limits with your clients! Keep records secure. Always seek client permission for accessing or releasing information (unless required by law). Duty to Warn & The Tarasoff Case Duty to warn or protect intended victims of client harm: Poddar (student at UC Berkeley) murdered Tatiana Tarasoff in 1969 – had told therapist of intentions. Therapist and supervisor had told police but Poddar denied intent and was released. Tarasoff vs Regents of the University of California, 1969. Supreme Court of California held that mental health professionals have a ‘duty to protect’ individuals who are being threatened with bodily harm. Original 1974 decision mandated warning the individual. 1976 rehearing called for increased ‘duty to protect’ including notifying police, warning the intended victim, and taking other reasonable steps to protect the threatened individual. Colorado Cinema Shooting 2012 Mass shooting in Aurora, Colorado during a midnight screening of The Dark Knight Rises. A gunman in casual clothes set off tear gas grenades and shot into the audience. 12 were killed and 70 injured. A widow filed a lawsuit against the University of Colorado in Federal Court alleging that a school psychiatrist could have had Holmes detained after he admitted he “fantasised about killing a lot of people”. http://edition.cnn.com/2013/01/15/justice/colorado-theater-shooting-lawsuit/ Multiple Relationships These occur when a therapist providing a service to a client also is or has been: In a non-professional relationship with the same client or an associated party. In a different professional relationship with the same client. A recipient of a service provided by the same client. Possible examples: Teacher/supervisor and therapist Bartering Borrowing money Providing therapy for relative, friend, or employee Engaging in a social relationship with the client Accepting an expensive gift Becoming emotionally or sexually involved Going into business with a client Multiple Relationships – Why not? Can impair objectivity Exploitative Potentially harmful On the other hand, multiple relationships are: Sometimes difficult to avoid Not always clear cut Interpersonal boundaries are not static Ethical Breaches listed on AHPRA Ways of Minimising Risk Set healthy boundaries Consultation Work under supervision Self monitor Client vs Therapist Needs Professional relationships exist to benefit clients. Question yourself: whose needs are being met in this relationship? Issues to consider: Satisfying own needs Promoting own agenda Imposing values APS has Guidelines around: Working with people who pose a high risk of harm to others. On the teaching and use of hypnosis, and related practices. Providing psychological services and products on the internet. Psychological practice with lesbian, gay and bisexual clients. Psychological services for and the conduct of psychological research with, older adults. Managing professional boundaries and multiple relationships. And many other specific issues and populations – see information on working with Culturally and Linguistically Diverse (CALD) clients. Psychotherapy and Diversity/Cultural considerations Ethnicity or culture Gender Sexual preference Differences in ability Connecting with people with diversity: The therapist must provide non-discriminatory practices, free of bias, stereotyping, racism, and prejudice. Connecting with People with Diversity Use a consultative approach. Never make assumptions. Respect differences. Use appropriate communication skills. Obtain assistance from interpreters as required. Use appropriate language and non verbals. Be honest when difficulties arise. Seek supervision. Refer on as necessary. Become informed on the particular presenting diversity. Culturally Competent Therapist - Characteristics Cultural Awareness: Therapist is sensitive to their own personal values and biases and how these may influence perceptions of the client, the client’s problem, and the therapy relationship. Cultural knowledge: Therapist has knowledge of the client’s culture, worldview, and expectations for the counselling relationship. Cultural skills: Therapist has the ability to intervene in a manner that is culturally sensitive and relevant. Culturally Competent Interventions Cover a range of activities: Language match Discussions of cultural issues Delivery of treatment in a culturally consistent manner CBT research shows that cultural competency interventions are effective: Several studies show that cultural competency adaptations to CBT were superior to non-adapted CBT (Kohn et al, 2002; Miranda et al, 2003). Up Next and Reading No tutorials next week (Monday public holiday) Week 11: Schema Therapy Guest lecture by Dr Julieta Castellini Fassbinder & Arntz (2021) Chapter 17 on Schema Therapy Week 12: Working with Aboriginal and Torres Strait Islander people - Guest lecture by Dr Kate Thompson Schema Therapy Dr Julieta Castellini DPsych (Clin), BPsych (Hons), MAPS, FCCLP, ISST Member Clinical Psychologist Advanced Schema Therapist, Supervisor and Trainer 1 Acknowledgement of Country The University of Queensland (UQ) acknowledges the Traditional Owners and their custodianship of the lands on which we meet. We pay our respects to their Ancestors and their descendants, who continue cultural and spiritual connections to Country. We recognise their valuable contributions to Australian and global society. 2 Schema Therapy: Background Developed 1990 by Jeffrey Young. Expansion on CBT. Initially developed as a treatment for clients with entrenched, chronic psychological disorder (e.g., personality disorders, particularly Borderline Personality Disorder [BPD]). Blends: - CBT - Attachment theory - Object relations - Gestalt - Constructivist - Psychoanalytic Why was an Addition to CBT Needed? CBT was a relatively short treatment (~12 sessions) with focus on problems in current life Treatment outcome studies usually report high success rates (Barlow, 2001) that is not reflective of clients in treatment A depression study could note a success rate of 60% immediately after treatment (post), but the relapse rate is about 30% after 1 year (follow up) More complex clients, e.g. those with fail to respond to traditional CBT treatments (Beck, Freeman et al., 1990) some ppl dk their troubles Schema Therapy Compared to Standard CBT not rly session by session Systematic and dynamic approach that expands on CBT by drawing on multiple modalities Can be brief, intermediate, or longer term (i.e. ~12 sessions to 30 sessions+) Much greater emphasis on the therapeutic relationship and dynamic within the session More in-depth exploration and discussion of childhood origins of psychological problems and developmental processes Greater emphasis on affect, emotion and mood states Treatment focuses on the chronic, characterological aspects of disorders, rather than necessarily on symptom reduction Not indicated for clients experiencing psychosis, acute Axis I disorder, major crisis or presenting problem is situational or when there is very short-term funding or timeframe available for Pling" challenges Young’s Definition of Early Maladaptive Schemas (EMS) Y is A broad, pervasive theme or pattern behavior (1 elres response ud Comprised of memories, emotions, cognitions, and bodily , prems scheud sensations Regarding oneself and one’s relationships with others Developed during childhood or adolescence Elaborated and perpetuated throughout one’s lifetime, feel “right” and familiar Dysfunctional to a significant degree Impacted by innate emotional temperament Influenced by culture, ethnicity, religion, social and economic factors ↑ narrative pa Some are preverbal a Development of Early Adaptive Schemas beat he https://youtu.be/0Zcf4HV7NzY there are positive 200 schemas  was earlier schema The Origins of Schemas carpenea EMS are developed when specific, core childhood needs are not met Core childhood needs are universal The interaction of innate temperament (e.g., biological sensitivity) and the environment result in these needs needs not being met & pareching + temperament e sont met Some develop from childhood trauma or mistreatment; others from being overprotected or sheltered  we're all Emotional Temperament born differently Temperament is an important factor in schema development Each child has a unique and distinct personality. Research backs the biological underpinnings of personality (e.g., Kagan, Reznick, & Snidman, 1988). Inborn dimensions of temperament considered relatively unchangeable through therapy alone (Young, Klosko, Weishaar, 2003): Labile ↔ Non-Reactive Dysthymic ↔ Optimistic Anxious ↔ Calm Obsessive ↔ Distractable Passive ↔ Aggressive Irritable ↔ Cheerful Shy ↔ Sociable Core Childhood Needs Secure Attachments to Freedom to others Realistic limits express valid (includes safety, and self control needs and stability, emotions nurturance, and acceptance) Autonomy, competence, Spontaneity and and sense of play identity Core Childhood Needs “I was never told I “Children Secure was loved must be Attachments to by my seen and Freedom to others parents” not heard” Realistic limits express valid (includes safety, and self control needs and stability, emotions nurturance, and acceptance) “I was allowed to “I was kind Autonomy, just do of just competence, “Mondays I had Spontaneity and whatever I piano, Tuesdays expected to and sense of and Thursdays play wanted” play identity swimming, Wednesdays basketball” jujitsu…” Schema Domains Five broad categories for 18 schemas for unmet emotional needs. 1. Disconnection and Rejection 3. Impaired Limits 1. Abandonment 10. Entitlement/Grandiosity 2. Mistrust/abuse 11. Insufficient self-control 3. Emotional Deprivation 4. Other-Directedness 4. Defectiveness/Shame 12. Approval Seeking 5. Social Isolation 13. Subjugation 2. Impaired Autonomy & Performance 14. Self Sacrifice 6. Dependence/Incompetence 5. Overvigilance & Inhibition 7. Vulnerability to harm 15. Negativity/Pessimism 8. Enmeshment/Underdeveloped self 16. Emotional Inhibition 9. Failure 17. Punitiveness 18. Unrelenting Standards Disconnection & Rejection “The expectation that one’s needs for security, safety, stability, nurturance, empathy, sharing of feelings, acceptance, and respect will not be met in a predictable manner.” (Young et al., 2008). Clients with this domain of schemas: Are unable to form secure, satisfying attachment to others They believe their needs of stability, feeling safe, nurtured, loved, that they belong - will not be met. Tend to rush into one self destructive relationship after another or avoid close relationships First 4 schemas prominent in individuals with BPD Therapy relationship is central to these clients and for effective treatment Disconnection & Rejection Typical family of origin will be: Unstable (Abandonment/Instability) Abusive (Mistrust/Abuse) Cold (Emotional Deprivation) Rejecting (Defectiveness/Shame) Isolated from the outside world (Social Isolation/Alienation). These are clients who report childhoods full of neglect and disappointment Disconnection & Rejection - Schemas Abandonment: the perceived instability or unreliability of those available for support and connection. Mistrust/Abuse: the expectation that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage. Harm is seen as intentional or the result of negligence. Emotional Deprivation: the expectation that one’s desire for emotional support will not be met. Three types: Deprivation of nurturance, empathy, and protection. Defectiveness/Shame: the feeling that one is defective, bad, unwanted, inferior, or invalid or that one would be unlovable to significant others if exposed. Social Isolation: the feeling that one is isolated from the world, different from other people, and/or not part of any group or community. Impaired Autonomy & Performance “Expectations about oneself and the environment that interfere with one’s perceived ability to separate, survive, function independently, or perform successfully.” (Young et al., 2008). Clients with this domain of schemas: Have expectations about themselves and the world that interfere with their ability to differentiate themselves from parent figures and function independently Are not able to forge their own identities/create their own lives Not able to set personal goals and master requisite skills Catastrophise that disaster will strike at any moment and they will not be able to cope Compare themselves excessively to others and always end up on the bottom They remain children well into their adult lives Impaired Autonomy & Performance Typical family of origin will be: Overprotective with parents doing everything Enmeshed family unit Hardly ever cared for or watched over them (more rare) Parents undermined confidence & failed to reinforce competent performing outside the home https://youtu.be/X-Wqu-awI7g?si=LioiNlvb2ITJYe4G Impaired Autonomy & Performance - Schemas Dependence/Incompetence: Belief that one is unable to handle one’s everyday responsibilities in a competent manner, without considerable help from others. Often presents as helplessness. Vulnerability to Harm or Illness: Exaggerated fear that imminent catastrophe will strike at any time and no one will be able to prevent it. Internal/external crises. Enmeshment/Underdeveloped Self: Excessive emotional involvement and closeness with one or more significant others at the expense of full individuation or normal social development. Failure: the belief that one has failed, will inevitably fail, or is fundamentally inadequate relative to one’s peers in areas of achievement. Often involves beliefs that one is stupid, inept, untalented, lower in status, less successful than others etc. Impaired Limits “Deficiency in internal limits, responsibility to others, or long-term goal orientation. Leads to difficulty respecting the rights of others, cooperating with others, making commitments, or setting and meeting realistic personal goals.” (Young et al., 2008). Clients with this domain of schemas: Lack the capacity to restrain their impulses (I). Cannot delay gratification for the sake of future benefits (I). Low frustration tolerance (I). No regulation of expression or impulses (I). Feel superior to other people and have special rights and privileges (E). Do not feel bound by rules of reciprocity (E). Insist they should be able to do whatever they want regardless of cost to others (E). Impaired Limits Typical family of origin will be: Overly permissive and indulgent Children not required to follow the rules that apply to everyone else, to consider others, or to develop self-control Setting limits in relation to taking responsibility Cooperating in a reciprocal manner Lack of direction and/or goal setting Confrontation dealt with using superiority Distress tolerance not fostered Inadequate supervision, direction, or guidance Avoidant Impaired Limits - Schemas Entitlement/Grandiosity: the assumption that one is superior to other people and therefore entitled to special rights and privileges. Rules of reciprocity do not apply. Demanding, dominating, and lack empathy. Insufficient Self Control/Self Discipline: cannot or will not exercise sufficient self-control and frustration tolerance to achieve personal goals. Do not regulate emotion and impulses. Other-Directedness “The patients in this domain place an excessive emphasis on meeting the needs of others rather than their own needs. They do this in order to gain approval, maintain emotional connection, or avoid retaliation. When interacting with others, they tend to focus almost exclusively on the responses of the other person rather than on their own needs, and often lack awareness of their own anger and preferences.” (Young et al., 2008). Clients with this domain of schemas: As adults, rather than being directed internally, they are directed externally and follow the desires of others. Excessive focus on needs of others at the expense of their own needs. Motive is to gain approval, maintain emotional connection, or avoid retaliation. Lack of awareness of their own anger in life and day to day preferences. Other-Directedness Typical family of origin: Not free to follow their natural inclinations The typical family origin is based on conditional acceptance: Children must restrain important aspects of themselves in order to obtain love or approval The parents value their own emotional needs or social “appearances” more than they value the unique needs of the child Other-Directedness - Schemas Subjugation: excessive surrendering of control to others because one feels coerced. Function is to avoid anger, retaliation, or abandonment. Two forms: subjugation of needs; and subjugation of emotions (especially anger). Self-Sacrifice: meets the needs of others voluntarily at the expense of their own. Motives are to spare others pain, avoid guilt, gain self esteem, or maintain an emotional connection. Approval Seeking/Recognition Seeking: values gaining approval or recognition from other people at the expense of developing a secure and genuine sense of self. Self esteem is dependent on the reactions of others. Excessive preoccupation with social status, appearance, money, or success. Overvigilance & Inhibition “Suppression of spontaneous feelings and impulses. They often strive to meet rigid, internalized rules about their own performance at the expense of happiness, self-expression, relaxation, close relationships, or good health.” (Young et al., 2008). Clients with this domain of schemas: Lifelong focus on negative aspects of life – minimisation of positive aspects (N) Fear that their lives could fall apart if they fail to be alert and careful at all times (N) Hold back spontaneous actions, feelings, and communication (EI) Strive to meet very high internalised standards to avoid disapproval or shame (US) Punish others and self for making mistakes (P) Overvigilance & Inhibition Typical family of origin will be: Grim, repressed and strict childhood Self-control and self-denial dominated over spontaneity and pleasure Not encouraged to play and pursue happiness They learned to be hypervigilant to negative life events and regard life as bleak Overvigilance & Inhibition - Schemas Negativity/Pessimism: a pervasive, lifelong focus on the negative aspects of life (e.g., pain, death, loss, disappointment, conflict, betrayal) while minimising the positive aspects. Exaggerated expectation that things will go seriously wrong in a range of work, financial, or interpersonal situations. Emotional Inhibition: a constraining of spontaneous actions, feelings, and communication in order to prevent criticism or losing control of their impulses (e.g., anger, joy, affection, sexual excitement), difficulty expressing vulnerability, and emphasis on rationality while disregarding emotions. Overvigilance & Inhibition - Schemas Unrelenting Standards/Hypercriticalness: a sense that one must strive to meet very high internalised standards, usually in order to avoid disapproval or shame. Results in feelings of constant pressure and hypercriticalness towards self and others. Presents as perfectionism, rigid rules, and a preoccupation with time and efficiency. Punitiveness: the conviction that people should be harshly punished for making mistakes. Tendency to be angry and intolerant with those people (including oneself) who do not meet one’s standards. Usually includes difficulty forgiving mistakes because one is reluctant to consider circumstances, to allow for human imperfection, or take to intentions into account. Unconditional vs Conditional Schemas Abandonment/Instability Vulnerability to Harm or Illness Subjugation Mistrust/Abuse Enmeshment/Undeveloped Self Emotional Deprivation Self-Sacrifice Failure Defectiveness Negativity/Pessimism Approval/Recognition Seeking Social Isolation Punitiveness Emotional Inhibition Dependence/Incompetence Entitlement/Grandiosity Insufficient Self-Control/Self-Discipline Unrelenting Standards/Hypercriticalness Unconditional Schemas Conditional Schemas Developed early in life Developed later in life Most at the core of self Hold out possibility of hope – a person might change Hold no hope – no matter what the person the outcome does, the outcome will be the same By acting out the schemas, the person can subjugate, 28 Schema encapsulates what happened to self-sacrifice, seek approval, inhibit emotions, or strive them as a child to meet high standards and perhaps avert the negative outcome, even temporarily Unconditional vs Conditional Schemas Unrelenting Standards in response to Defectiveness The individual believes, “If I can be perfect, then I will be worthy of love.” Subjugation in response to Abandonment The individual believes, “If I do whatever the other person wants and never get angry about it, then the person will stay with me.” Emotional Inhibition in response to Social Isolation “If I suppress my emotions, I won’t feel the pain of being different and others won’t see it either.” Schema Modes Moment to moment emotional states and coping responses we all experience Adaptive and maladaptive Triggered by life situations Originated from work with BPD individuals Four types: Healthy adult Child modes Dysfunctional coping modes Dysfunctional parent modes We all have modes we ‘flip’ into Dysfunctional coping modes are cut off from experiencing to various degrees Goal is to increase healthy adult mode, reduce “banish” dysfunctional parent modes and nurture child modes Schema Modes Child Modes (innate & universal) Vulnerable Child: experiences most of the core schemas. It is the abandoned child, the abused child, the deprived child or rejected child. Angry Child: part that is enraged about unmet emotional needs and acts with disregard to consequences. Impulsive/Undisciplined Child: expresses emotions, acts on desires and follows natural inclinations in a reckless manner. Happy Child: part whose needs are currently met. Coping Styles Based on fight, flight, freeze Operate outside of conscious awareness Developed as a way of coping with not getting needs met or fear of the intense emotions that come from the schema These coping styles keep people stuck in their schemas Overcompensation: fight the schema as though the opposite were true; pressured; get locked into counterattacking e.g. perfectionism, over control, excessive self-reliance, demanding Avoidance: arrange their life so the schema is not activated; attempt to live in denial; use distraction and suppression e.g. detachment, substance abuse, social withdrawal, dietary restriction Surrender: yield to the schema and accept it as true; pain is felt directly, enacts a pattern of reliving the childhood experience; behaviourally they choose partners who are most likely to treat them as the offending parent did 32 e.g. compliance, self-blame/punishment Coping Styles 33 Schema Modes Dysfunctional Coping Modes (correspond to 3 coping styles) Complaint Surrenderer: submits to the schema, becomes helpless and passive, must give in to others Detached Protector: withdraws psychologically from the pain by emotionally detaching, abusing substances, self-stimulating, avoiding people etc Overcompensator: fights back by mistreating others or behaving in extreme ways in an attempt to disprove the schema in a dysfunctional manner Schema Modes Parent Modes (internalised parent) Punitive Parent: punishes the child for being “bad” Demanding Parent: continually pushes and pressures the child to meet excessively high standards Healthy Adult Can moderate and heal dysfunctional modes https://youtu.be/DcWXr6LVYMI?si=OLugGRRg FM8wYENA Balanced and compassionate Modes in Action American Beauty https://youtu.be/Vt0rz5iPuaA?si=HvU-Jdp6PbkG82SM Bernardo’s Ad https://youtu.be/DAYLh09JxJE?si=TmTofNYY-X3boedo Stages of Schema Therapy Schema Therapy can be provided in individual or group therapy, to adults, children/adolescents and couples Assessment and Education - Young Schema Questionnaire and Schema Mode Inventory to assist in identifying schemas and modes; limitations to these - Clinical interview including life history, can use imagery exercises - Self monitoring (e.g. automatic thoughts) and downward arrow technique - Process and catch in session information; how are they relating within the session and what does this say - Psychoeducation on schemas and coping styles used, clients asked to monitor schemas and modes between sessions Goals of Schema Therapy Goals: Psychological awareness. Link schemas with childhood memories, emotions, bodily sensations, cognitions, and coping styles. Increase conscious control over schemas via weakening associations between schemas and: - Memories - Emotions - Bodily sensations - Cognitions - Behaviours Schema Operations: - Re-parent VC - Heal - Bottom up approach (core issues dealt with first) Stages of Schema Therapy Change - Blend of cognitive, experiential, behavioural, and interpersonal strategies flexibly week to week. - Cognitive: CBT strategies challenging distorted thinking. Highlights evidence against the schema but instead an ingrained message from childhood. Flash cards. - Experiential Techniques Imagery, imagery rescripting and chairwork. Allows expression of anger and sadness about what happened to them. Learn to stand up to the parent and protect vulnerable child. Get to talk about what they needed but did not get. Breaks power at an emotional level. - Behavioural: allows maladaptive responses to be changed with adaptive ones. Stops reinforcement of the schemas. Experiments planned as homework collaboratively then discussed afterwards. Over time maladaptive strategies are replaced. Experiential strategies Imagery - Diagnostic eg child on a path, pick up crying baby - Rescripting - Safe place Chairwork -Scott Kellogg Transformational Chairwork (2014) https://youtu.be/ef7rQniaz5c?si=dP8RUBme16hZXm5B Client Therapist Relationship – Limited Reparenting Therapist assesses and treats the schemas, modes, and coping styles as they come up in therapy Relationship serves as a partial antidote, offers what denied during childhood Client internalises the therapist as a “Healthy Adult” that fights against schemas and develops an emotionally fulfilling life 1. Care: Support and validates clients, on their side 2. Give Guidance: Encourage to open up, provide feedback 3. Empathic Confrontation: Showing empathy and also showing their reactions are distorted or dysfunctional in ways that reflect EMS/modes 4. Setting Limits: Setting limits with clients, what “good parents” would do Empirical Research Young Schema Questionnaire – Long Form (Young & Brown, 1990): Translated in many languages. Primary subscales evidenced high test retest reliability and internal consistency. Good convergent and discriminant validity on measures of psychological distress, self esteem, cognitive vulnerability to depression, and personality disorder symptomology. Empirical Research Schemas: Freeman (1999). Results indicated weaker endorsement of EMS were predictive of greater interpersonal adjustment. Consistent with Young’s tenet that EMS’s are by definition negative and dysfunctional. Personality Disorders Schmidt et al. (1995) Paranoid – Mistrust/Abuse Dependent – Dependence BPD - Insufficient Self-Control Obsessive-Compulsive – Unrelenting Standards Empirical Research Meta Analyses Taylor, Bee, & Haddock (2017) 12 studies (N = 316) BPD (7), eating disorders (2), agoraphobia and personality disorders (1), PTSD in veterans (1) and depression (1). Low quality design: case series, open trials, one RCT. Demonstrated ability to reduce early maladaptive schema scores across mental health disorders. Small to large effect sizes. Koruk & Ozabaci (2018) ST for depression 7 studies (N = 133) High efficacy in the treatment of depressive disorders Empirical Research Evidence for Link Between Adverse Childhood Events & EMS Pilkington, Bishop, & Younan (2020) 33 studies (N = 8,340) 124 meta analyses conducted! Small to large correlations with Emotional neglect and Emotional Deprivation. Small to moderate correlations with emotional abuse to Vulnerability to Harm and Emotional Deprivation. Small correlations with physical neglect, physical abuse, sexual abuse to Vulnerability to Harm, Emotional Deprivation and Social Isolation. Only one study was longitudinal – rest were cross sectional.  not standardized Limitations Hard to research and produce good quality trials Therapy is often long, especially for complex clients (avg for BPD 4 years) Clients need to be willing to face their discomfort, which is difficult for some clients Some people find the concept difficult to grasp Questions or Comments?  Week 12: Working with Aboriginal and Torres Strait Islander peoples, families, and communities Kate Thompson  Acknowledgement of Country I begin by acknowledging the Traditional Custodians of the lands on which we are today, the Turrbal and Yuggera peoples and acknowledge their ongoing connections to land, sea and community. I pay my respects to Elders past, present and future. I acknowledge the various Aboriginal and Torres Strait Islander language groups as distinct and diverse sovereign nations with their own distinct and rich cultures. I acknowledge that sovereignty was never ceded. I acknowledge the strength and resilience of Aboriginal and Torres Strait Islander peoples and communities and their ongoing efforts to ensure Aboriginal and Torres Strait Islander children and young people can develop strong cultural connections and identity. I acknowledge the devastating impacts and ongoing nature of colonisation and past government policies and practices, and the profound suffering, grief and loss inflicted on Aboriginal and Torres Strait Islander peoples, families, and communities. INDH2017/7107  Acknowledgement of Artwork The artwork used throughout this PowerPoint were created by Maureen Nampijinpa Hudson, and also Isaiah Nagurrgurrba, and is part of The Balarinji Collection available on Canva Pro Disclaimer: Please be advised that this presentation contains images of Aboriginal and Torres Strait Islander peoples and Māori peoples who have passed away. Please note that the term Indigenous peoples will be used throughout this lecture to refer to Indigenous peoples internationally. The term Aboriginal and Torres Strait Islander peoples will be used to refer to the Traditional Custodians of this country now called Australia.  Overview of Lecture 1. Introductions - Who am I? 2.Check In 3.Learning Objectives 4.Lecture Learning Goals 5.Cultural Safety 6.Social and Cultural Determinants of Health 7.Social and Emotional Wellbeing 8.Check Out INDH2107/7107 About Me  Check In How are you feeling today?  Lecture Learning Goals By the end of this lecture, you will be able to: Define and understand the importance of cultural safety for Aboriginal and Torres Strait Islander peoples’ health and wellbeing at individual, family and community levels. Define and understand the importance of culturally respectful communication Continue your journey to transform your practice knowledge and skills through critical reflection to work with Aboriginal and Torres Strait Islander peoples, families, and communities in a culturally safe and responsive way. If you have come here to help me, you are wasting your time. But if you have come because your liberation is bound up with mine, then let us work together. - Aunty Lilla Watson Reflect. Unlearn. (Re)Learn. Critically reflect on what you have been taught previously, paying attention to the perspectives from which this guest lecture is taught from – Aboriginal and Torres Strait Islander perspectives; Unlearn the entrenched colonised perspectives that have been forced upon you from the systems that were created for and by the colonisers, and not necessarily for Aboriginal and Torres Strait Islander peoples, families and communities; Re-Learn from decolonised, Aboriginal and Torres Strait Islander perspectives  Have a question throughout the lecture? Scan QR Code and keep tab open to post your questions Cultural Safety  Question What are the key theoretical frameworks or concepts that underpin your understanding of cultural safety?  Theory, Historical Background, Significance Concept of cultural safety developed by Māori nurse, Irihapeti Ramsden, in collaboration with Māori nurse educators and Maori student nurses Ramsden and students developed a set of culturally safe standards that were known as “Kawa Whakaruruhau”, which translates to cultural safety (Papps & Ramsden, Dr Irihapeti Ramsden was an 1996) anthropologist, nurse and Developed in response to colonial context and poor nursing educator who brought about a revolution in health status of Māori peoples, tangata whenua the way the health system (Indigenous peoples), of Aotearoa (New Zealand) considers the cultural context of the patients it serves. Cultural Safety in Nurse Training, Irihapeti Ramsden with Kim Hill https://www.ngataonga.org.nz/search-use- (Nga Toanga, n.d.) collection/search/242833/ Journey to Culturally Safe Practice Culturally safe practice is “an outcome of nursing and midwifery education that enables safe service to be defined by those that receive the service” (Ramsden, 2002, p.117) Culturally unsafe practice - any omission or action that disempowers, demeans or diminishes the cultural identity and wellbeing of a patient/individual (Papps & Ramsden, 1996). Culturally Respectful Communication  What is Culturally Respectful Communication? Culturally respectful communication with Aboriginal and Torres Strait Islander peoples involves acknowledging and understanding the unique ways in which we communicate. Some key aspects of culturally respectful communication include, but not limited to: Respectful language Understanding communication styles Building Rapport and Trust Openness to learning (Eckermann et al., 2010, p.128)  Respectful Language What language do you use when referring to Aboriginal and Torres Strait Islander peoples, families, and communities? Share your thoughts on Slido!  Terminology Guides Let’s take a look at what terminology guides around Australia say about respectful language. https://staff.uq.edu.au/files/242/using-inclusive- language-guide.pdf https://www.uq.edu.au/about/files/1685/RAP_ter minology%20guide.pdf https://www.health.qld.gov.au/__data/assets/pd f_file/0031/147919/terminology.pdf  Respectful Language - Do’s and Don’ts Do use: Don’t use: Aboriginal and Torres Strait ATSI Islander peoples A&TSI Aboriginal peoples^ indigenous** Torres Strait Islander aboriginal** peoples^ torres strait islander** First Nations people* Islanders Indigenous peoples* Aboriginals^^ ^Use these terms when you are only referring to **Use of lowercase letters is not a demonstration that broader cultural group of respectful language *Important to use a disclaimer when using these ^^Aboriginal peoples would be a demonstration terms to clearly show who you are referring to of culturally respectful communication Including Torres Strait Islander peoples (Australian Bureau of Statistics, 2021) Understanding Communication Styles  Importance of Understanding Communication Styles This is crucial for culturally respectful communication for several reasons, including: Avoiding misunderstandings Building trust and rapport Effective communication Preventing stereotypes Fostering inclusivity (Eckermann et al., 2010) Cultural Differences in Communication (Eckermann et al., 2010, p.128) Building Trust and Rapport  Trust Trust is about relationships and trusting another is important to our social and emotional wellbeing. Johns (1996, p.80 cited in Eckermann et al., 2010, p.130) defined trust as a ‘willingness to assume vulnerability and rely upon someone or something to perform as expected’. What does distrust and mistrust look like?  Building Rapport Building rapport refers to establishing a connection or a sense of mutual trust and understanding with another person. It’s about creating a positive and comfortable atmosphere where you can communicate effectively. Some key aspects of building rapport include: Respect Active listening Empathy Friendliness Common ground Positive communication (avoid being critical or judgemental) (Eckermann et al., 2010) Oppeness to Learning Break  Deficit Discourse What is it? Why is it important to understand and address? Importance of Understanding Deficit Discourse Understanding deficit discourse is important because: It reveals hidden biases: It helps us recognise when language or policies are framed in a way that blames the disadvantaged group. It promotes better solutions: By focusing on the root causes of disadvantage, we can develop fairer and more effective strategies for improvement. It fosters respect: Using respectful language and acknowledging the strengths of all groups is crucial for building a more equitable society. Examples of Deficit Discourse in Policy and Practice Northern Territory Emergency Response https://www.youtube.com/watch?v=1ZmEgQCqBbo&t=1s  Examples of Deficit Discourse Share your thoughts on examples of deficit discourse from the video Examples of Deficit Discourse in Policy and Practice Culturally Safe Practice  Five Principles of Cultural Safety In 2005, the Nursing Council of New Zealand shared five principles of cultural safety. This discussion applies these principles to the Australian context. 1. Reflect on your own practice 2.Seek to minimise power differentials 3.Engage in discourse with the client 4.Undertake a process of decolonisation 5.Ensure that you do not diminish, demean, and/or disempower others through your actions (Best, 2017)  Examples of Culturally Safe and Unsafe Practice Give Nothing to Racism https://youtu.be/g9n_UPyVR5s?si=ZwswCt7NMhG2-p7O What were the most valuable takeaways from today's guest lecture?  References Australian Bureau of Statistics. (2021, June 30). Estimates of Aboriginal and Torres Strait Islander Australians. ABS. https://www.abs.gov.au/statistics/people/aboriginal-and-torres-strait-islander-peoples/estimates-aboriginal-and-torres-strait-islander-australians/latest- release Adams, M., Adams, Y., Drew, N.. (2019). Indigenous psychology in Australia. In Wen Li, W. Hodgetts, D. Hean Foo, K. (Ed.), Asia-Pacific Perspectives on Intercultural Psychology (pp. 175-197). Abingdon, United Kingdom: Routledge. Arvin, M., Tuck, E., & Morrill, A. (2013). Decolonizing feminism: Challenging connections between settler colonialism and heteropatriarchy. Women’s Studies: Gender and Sexuality, 25(1), 8–34. doi:10.1353/ff.2013.0006 Best, O. (2017). The cultural safety journey: An Aboriginal Australian nursing and midwifery context. In O. Best & B. Fredericks (Eds.), Yatdjuligin: Aboriginal and Torres Strait Islander Nursing and Midwifery Care (pp. 46-66). Cambridge: Cambridge University Press. doi:10.1017/9781108123754.005 Eckermann, A.-K., Dowd, T., Chong, E., Nixon, L., G