Cognitive-Behavioral Treatment of Depression, Part IX: Confronting Predisposing Factors

Cognitive-behavioral therapy can help many depressed clients learn more effective ways of coping with problems in their lives. However, for many clients with chronic or recurrent depression, it can be helpful to examine the biological, psychological, and social/cultural factors that may predispose a person toward depressive episodes. In order to address possible biological predispositions, it is important to assess for a positive family history of depression, evaluate family members' response to previous treatments, and refer for medications when needed. In order to address possible psychological predispositions, it is useful to evaluate long-standing personality styles, identify negative events from childhood, examine the client's relationship with his or her parents, evaluate the history of abuse, and identify early loss experiences. Cultural factors may play an influential role in the etiology of depression, and can be useful to incorporate into a broad treatment plan. However, cultural factors are difficult to modify through individual psychotherapy. Hence, they are unlikely to play a central role in cognitive-behavioral therapy for depression. Overall, therapists working with depressed clients should be prepared to confront a broad range of biological, psychological, and environmental factors that can create or perpetuate a client's risk for depression.     

An experimental inquiry into transference roles and age

In this psychotherapy analogue investigation, the effects of client age and therapist age on transference-like projections onto therapists were examined. Young (25-35) and older (60-70) pseudoclients compared paraprofessional therapists to significant figures in their own lives after a dyadic "helping" interview. The results provide empirical support for the phenomenon of reverse transference in therapy with older patients. Older clients were more inclined than young clients to view therapists, particularly younger therapists, as similar to their children. Young clients more willingly attributed parental qualities to older therapists. Both old and young clients may see therapists more as peers or friends than as family members.     

Managing Anxiety: A Therapist Common Factor

In this paper, we propose that therapist anxiety in the therapy room, especially anxiety stirred up by difficult or triggering clients, represents a challenge to effective therapy, and that effective management of this anxiety be considered as a necessary therapist skill for conducting quality couple and family therapy (CFT). We propose that effective therapists need to be able to manage their emotions, especially their anxiety, in order to truly help their clients. The failure to do this can lead to break downs in the alliance and the flow of therapy, and these deleterious effects can be prevented when therapists actively navigate their internal states through self-awareness and ongoing introspection. Bridging psychotherapy literature, we discuss specific strategies to this end, and make clinical recommendations for CFTs and CFT training programs.     

Language and meaning in RET

The same verbal labels can have different semantic meaning. RET often assigns idiosyncratic meaning to commonplace words and misunderstandings between therapists and clients may result. In this article the issue of language and meaning in RET is discussed with special reference to feeling words, rational and irrational concepts, and the language of change. Some therapeutic strategies are suggested to help therapists develop shared meaning frameworks with their clients.     

Changes in meaning in life across the course of psychodynamic psychotherapy

Using the Meaning in Life Questionnaire (MLQ), we studied Presence and Search for meaning for 34 adult clients in psychodynamic psychotherapy. Clients completed the MLQ and Outcome Questionnaire (OQ) before intake and after every eight sessions. Variance in Presence scores was mostly attributable to clients; variance in Search scores was mostly attributable to clients and therapists. Clients initially high in Presence decreased and then increased back to initial levels; clients initially low in Presence increased and then decreased back to initial levels. Clients initially low in Search increased and then leveled off; clients initially high in Search decreased and then leveled off. In lagged cross panel analyses, when clients decreased in psychological distress during one eight-week time period, they increased in Presence during the next eight-week time period; when they increased in psychological distress during one eight-week time period, they increased in search in the next time period. Excerpts from post-therapy interviews illustrate the process of working with meaning in life in psychotherapy. Implications for practice and training are discussed.     

Interventions in everyday lives: How clients use psychotherapy outside their sessions

The purpose of psychotherapy is to help clients address and overcome problems troubling them in their everyday lives. Therapy can therefore only work if clients include it in their ongoing lives to deal with their problems. Detailed, systematic research is needed on how clients do so in their everyday lives outside their sessions. A design of exploratory case studies on this topic is presented in this article. The main outcomes of such a case study on family therapy are then laid out in general terms. They highlight how treatment practices and clients’ ordinary everyday practices interact when clients change their everyday lives to overcome their troubles. They also highlight what it involves for clients to accomplish this. It is concluded that we need more research on how to understand intervention; on the interaction between interventions and clients’ conduct of their everyday life; on sessions as a particular, secluded part of clients’ ongoing everyday lives, and on how to consider therapists’ procedures and conduct of sessions accordingly.     

Treating Depression During a Recession: Psychotherapy with Indigent Clients

During the last few years, the global economy has struggled and many clients have experienced significant financial hardship. It can be difficult to confront emotional problems when there are multiple life stressors impinging on clients and disrupting their daily functioning. Several recommendations are provided for helping clients to oppose their depressive tendencies when financial problems are real, significant, and lasting. First, therapists can provide a stable and supportive relationship that helps to ease the client’s emotional distress and lays the foundation for other aspects of treatment. Second, therapy can help to protect an optimistic attitude and instill hope for a better future. Third, behavioral activities can be used to encourage productive activity each day. Fourth, problem-solving skills can help many clients deal with stressors in a direct, constructive, and proactive manner. Fifth, therapy can examine ways to expand and improve the client’s social relationships. Finally, psychotherapists should collaborate with other health care professionals in order to ensure the optimal, integrated care for the client. It is hoped that these recommendations will be helpful for therapists who work with financially impoverished clients.     

Effective Psychotherapy With Low-income Clients: The Importance of Attending to Social Class

The purpose of this article is to explore some of the issues associated with conducting psychotherapy with low-income clients. Throughout the article, we draw from our specific clinical experiences working with low-income Latina mothers in a depression prevention program. The themes that we address regarding class and psychotherapy are in the areas of assessment of social class, integration of class issues into the therapy process, and managing differences in social class between therapists and clients. As we discuss these themes, we provide concrete recommendations in order to advance awareness and effectiveness in working with economically disadvantaged populations.     

Technology-Assisted Psychotherapy (TAP): Adapting Computerized Treatments into Traditional Psychotherapy for Depression

Technology may be changing the process of psychotherapy. Unfortunately, some therapists lack the computer skills or financial resources needed for the newest technology. The literature is reviewed for journal articles on the treatment of depression published during the past 7 years in which treatments have been guided by technology. Six findings are summarized that may be helpful when therapists lack skills or resources for advanced technology. (1) The assessment of depression can be facilitated by technology, whether using standardized questionnaires or simple ratings of mood submitted each day. (2) Technology tools can be used to send daily reminders to help clients develop more adaptive habits in thoughts or actions. (3) Clients can confront their problems through therapeutic dialogue, whether conducted in person, over the telephone, or via videoconference. (4) Depressed clients can confront their negative attitudes, often triggered by some form of loss, failure, or rejection, whether real, imagined, or anticipated. (5) Clients can use writing assignments to identify, label, explore and express their thoughts and feelings. These writing assignments can be conducted via email, or internet forms. (6) Clients value rapport with a therapist, and this bond seems important to ensure participation and adherence with treatment. Therapists can strengthen the treatment of depression using basic technology tools to extend, or supplement traditional sessions. However, it is important to protect the rapport needed for sustained participation in psychotherapy sessions.     

An Infertility Primer for Family Therapists: II. Working with Couples Who Struggle with Infertility

The distress of infertility and its medical treatments are profound, and the effects reverberate in each partner, the couple dyad, and the couple's relationships with family, friends, and medical systems. Yet family therapists, like others in our society, are often uninformed or misinformed about the experience of infertility. While the legacies of infertility may be painful and enduring, they often remain unspoken, and hence may be overlooked in standard interviews. This article describes the experiences of couples struggling with infertility, most of whom have sought medical intervention, and it provides treatment interventions for guiding couples through this difficult and often uncharted terrain. Case vignettes derived from 2 years of this clinical research study are included.     

Transparency and self-disclosure in family therapy: dangers and possibilities

Therapy is a paid intimate relationship that thrusts clients and therapists into navigating personal and professional boundaries. When, where, why, and how is it appropriate and ethical for family therapists to be transparent, and when is it damaging? Theorists take varied stances from Haley's position of tight boundaries around therapist disclosure—whether in treatment or training—to the narrative viewpoint that therapists should be transparent about models of therapy, personal values, and life experiences that inform their practice and beliefs. However, these positions are not research based, and theorists who support disclosure offer few guidelines other than general statements. This article examines the history of ideas about disclosure in six major family therapy models, and the dangers and possibilities of transparency. It looks at the research on self‐disclosure in individual therapy and whether and how it could apply to family therapy. Guidelines are proposed that take into account the multiple social identities of therapists and clients, and issues of safety and transparency.     

Just for Women? Feminist Multicultural Therapy with Male Clients

Feminist multicultural therapy is an integrative approach to psychotherapy that emphasizes a systems-level understanding of psychological distress and the process of therapeutic change. In the present exploratory study, the experiences of feminist multicultural therapists working with male clients were studied using Consensual Qualitative Research (CQR) (Hill et al. 1997). Phone interviews were conducted with eight female practicing licensed or license-eligible therapists who had worked with at least one male client in the past 6 months. Consistent with the theoretical approach, all of the therapists interviewed expressed their belief that psychological symptoms can be seen as a reaction to a loss of power or related to the effects of an oppressive system. Additionally, the therapists believed that this theoretical model is broad enough to be used with varying types of intersecting social identities. The findings illustrate the ways in which the counseling approach may work similarly across genders, as well as ways in which one’s therapeutic approach may be altered when working specifically with men. Implications for therapists who work with male clients (both the rewards and the challenges) as well as for researchers who wish to study the application of therapeutic interventions with men are discussed.     

Bulletin Board

Abstract

When psychotherapy is viewed as shared reconstruction, there are implications for both clients and therapists. My clients become sources of expectations, myths, thought, and feelings about themselves and their therapists. I, as therapist, become a source of intentions and reflections, with capacities for self-awareness and abilities to construe my clients and their constructs, languages, and metaphors. Both participants in psychotherapy can then be seen as involved in reconstruction through the sharing and rebuilding of narratives. It is the life stories of clients that are likely to be more changed in therapy, but my life stories and my stories about the therapeutic process are also open to change     

Honoring Protective Responses: Reframing Resistance in Therapy Using Polyvagal Theory

Therapists often conceptualize resistance as client behaviors that impede progress; this perspective threatens the therapeutic alliance, especially in couple and family therapy where increased resistance and multiple alliances are present. Polyvagal theory reframes and normalizes resistant behaviors as preconscious, protective responses emerging from our autonomic nervous system. The theory also explains how humans reciprocate safety cues to connect with each other; therapists can use concepts of polyvagal theory to manage their own emotional regulation and foster safety and connection in therapy. Polyvagal concepts deepen our understanding of protective behaviors presenting in couple and family therapy; therapists can help couple and family clients to recognize protective behaviors in their own relationships and facilitate safer connection and engagement. Clinical implications are presented: psychoeducation can help clients normalize and understand their protective processes; therapist presence and immediacy acknowledges and normalizes protective behaviors as they arise; therapist and client self-regulation skills support connection; therapist genuineness is a precondition to client safety; and understanding of polyvagal theory enhances assessment of conflict and enactments in couple and family therapy.

     

The family therapist as a system interventionist

Family therapists need to develop therapeutic strategies which can be effective in helping members of dysfunctional and crisis oriented families reconnect with additional sources of support and strength.The extended family and social system can serve as this source of support when it is convened, mobilized and reactivated to become involved with the concerns of the ailing members of the family. This paper describes the unfolding six network phases, and the roles undertaken by the team of therapists serving as system convenors, mobilizers, choreographers and resource consultants. The task of the therapists working with a dysfunctional family and its larger extended support system is seen as that of an effective clinical stategist mobilizing the resourcefulness and energies of himself and his team to reactivate a dysfunctional system to change.A modified version of this paper appears in the author's book Networking Families in Crisis, Human Sciences Press: New York, 1978.     

Characteristics of Therapist Self-Disclosure in the Counseling Process

A survey was sent to practicing therapists to investigate their uses of self-disclosure in counseling and psychotherapy. A total of 46% returned surveys, and most indicated that they used at least some self-disclosure in their work with clients. Overall, respondents reported disclosing about professional qualifications and experience most often and indicated that they disclosed mainly to increase similarity between themselves and clients.     

Transitional Faith: A Developmental Step Toward Religious Maturity

Nonjudgmental exploration of religious concerns may be a vital component of psychotherapy with religiously oriented clients. This article summarizes a recent stage model of psycho-religious functioning that was developed to help psychotherapists work with religious material in clinical practice. Following this introduction a case study is presented that illustrates my clinical work with a young woman in the transitional stage of development. The presentation depicts the entanglement of her spiritual struggles with her emotional and interpersonal conflicts. Because transitional faith is a pivotal point in the developmental spectrum, counselors and therapists working with clients in this stage can play a key role in promoting clients' spiritual development.