Integrative problem-centered metaframeworks therapy I: core concepts and hypothesizing

Over the last 20 years psychotherapy and family therapy have been inundated with a plethora of empirically validated treatments for particular disorders. That trend will increase. Psychotherapists will increasingly be exhorted and ultimately required to integrate empirical data and multicultural competence into their practice. Additionally, individual psychotherapy's default dominance of psychotherapeutic discourse needs to integrate and come to theoretical and clinical terms with the implications of the growing body of research demonstrating the validity and value of a multisystemic perspective. This article (and its companion article) presents a comprehensive, integrative, multisystemic, and empirically informed psychotherapeutic perspective to help therapists and psychotherapy trainers successfully address these challenges-Integrative Problem Centered Metaframeworks (IPCM) Therapy. This first article presents and illustrates IPCM's theoretical foundation, core concepts, and "case formulating" components. It delineates a Blueprint for the practice and teaching of 21st century psychotherapists who can meld science and art into best practice.     

Treatment for Deliberate Self-Harm: Integrating Emotion-Focused Therapy

This article proposes that Emotion-Focused Therapy (EFT) can be effectively utilized as a treatment modality for deliberate self-harm or integrated with existing treatment approaches. A brief literature review examines evidence suggesting that attachment and emotion regulation are important etiological variables associated with deliberate self-harm. EFT addresses these variables by emphasizing the importance of the therapeutic relationship and assisting clients in the regulation and transformation of negative, maladaptive emotions. The article describes the basic tenets of EFT, comparing and contrasting this approach with therapeutic models most commonly used in the treatment of deliberate self-harm. Finally, it is recommended that future outcome research utilize randomized clinical trials to evaluate the effectiveness of EFT and compare it with other treatment modalities.     

Cognitive-Behavioral Therapy: The Truth Behind the Allegations

In response to several pejorative statements about Cognitive Behavioral Therapy in a recent issue of Psychotherapy (Silverman, 1999), a point by point counter argument to these criticisms are presented. Among other contentions, Silverman (1999) disparaged empirically validated methods as being simplistic and scientifically impoverished. The validity of these statements are challenged and empirical evidence is presented to support each counter argument. The efficacy of Cognitive Behavioral Therapy for a broad range of disturbances and presenting problems is presented. The future of Cognitive Behavioral Therapy and other empirically validated protocols are discussed, as well as recommendations for their use.     

Promoting Clinical Knowledge,Skills, and Empathy via a Creative Self-Suicide Assignment

Abstract

Suicide is a leading cause of American deaths. Given suicide's overall frequency and negative effects, specialized suicide training is warranted. This article describes a creative self-suicide assignment designed to enhance doctoral students? suicide assessment and intervention knowledge and clinical skills, and promote greater counselor empathy for clients presenting with suicidal ideation. Doctoral students who participated in the assignment reported increased suicide assessment and intervention knowledge and skills, and enhanced empathy toward clients presenting with suicide-related issues. Student summarizations related to their assignment experiences are included.     

Infant mental health programs: Experimenting with innovative models—One center's experience with new program funding

This article describes one child and family treatment center's process of creating a long‐awaited, new infant/child early intervention program. An experimental service model is discussed in the context of the need for empirically validated assessment and intervention for very young clients in high‐risk families. Case examples and illustrations of service flow are provided. Some features of this program, such as the fact that it was set up for a seamless transition to a treatment research project, are highlighted.     

Who Benefits From Computerized Career Counseling?

The Adaptive Counseling and Therapy (ACT: Howard, Nance, & Myers, 1986) model was used to predict who would benefit from computerized career counseling. Specifically, clients who had more stable goals and aspirations and more defensive independence were expected to derive more benefit from computerized career counseling, an intervention that provides low levels of direction and support. A total of 54 clients who came to the Career Planning and Placement Center seeking career assistance were referred to the System for Interactive Guidance and Information PLUS (SIGI-PLUS). As hypothesized, clients with more stable goals had the greatest gains in vocational identity. Additionally, clients who showed more defensive independence were more satisfied with the SIGI-PLUS treatment. Implications, limitations, and suggestions for future research are discussed.     

Clinical Approaches to Conflicts Between Religious Values and Same‐Sex Attractions: Contrasting Gay‐Affirmative,Sexual Identity,and Change‐Oriented Models of Therapy

The literature germane to the care of clients presenting for psychotherapy with conflicts between their sexual orientation and religious values typically addresses the topic from within a particular therapeutic approach. This article addresses the issue from a broader perspective that takes into account 3 different paradigms: gay‐affirmative therapy, sexual identity therapy, and change‐oriented therapy. The authors describe the 3 approaches, compare and contrast them across several different key dimensions of theory and practice, and identify some strengths and potential limitations of each approach for assisting clients who are attempting to navigate the resolution of their conflict.     

Written Exposure Therapy for Suicide in a Psychiatric Inpatient Unit: A Case Series

Patients with posttraumatic stress disorder (PTSD) are at an elevated risk of suicide. For patients hospitalized for suicide risk, psychosocial treatment and stabilization are routinely offered; however, the availability of evidence-based, manualized therapeutic interventions for PTSD is sparse. Typically, the short duration of hospitalization makes it difficult to accommodate evidence-based, trauma-focused treatments. This article presents the clinical course of four active-duty service members with PTSD who were hospitalized in a psychiatric inpatient unit for acute suicide risk and treated with Written Exposure Therapy for Suicide (WET-S). WET-S is a brief, five-session therapy based upon Written Exposure Therapy and augmented with Crisis Response Planning for Suicide Prevention. Both posttraumatic stress symptoms and suicidal ideation were reduced from pre- to posttreatment for three of the four patients treated. WET-S shows promise as a manualized therapeutic intervention that can be delivered on an inpatient psychiatric unit.     

The Effectiveness of Collaborative/Therapeutic Assessment for Psychotherapy Consultation: A Pragmatic Replicated Single-Case Study

This pragmatic study evaluated the effectiveness of a collaborative assessment intervention as an approach to midtherapy consultation, which has yet to be empirically tested. Ten adult participants in ongoing psychotherapy with a variety of presenting concerns, primarily consisting of general mood and adjustment issues, received a brief assessment-based intervention based on Finn's (2007) Therapeutic Assessment model. Following the collection of assessment questions and the administration of a multimethod assessment battery, clients and therapists participated in a joint feedback session with the assessor. Clients were then followed as their psychotherapy continued. The results of idiographic and aggregate analytic approaches revealed significant reductions in client-reported symptomatic distress, as evidenced by a medium effect size (d = –.50) and a significant change in the trajectory of distress. Client reports of the process of psychotherapy revealed a significant increase in the clients’ ratings of the working alliance. The findings suggest that a midtherapy consultation using collaborative/therapeutic assessment methods is beneficial but that further rigorous investigation is needed.     

Confirming,Validating, and Norming the Factor Structure of Systemic Therapy Inventory of Change Initial and Intersession

Progress or feedback research tracks and feeds back client progress data throughout the course of psychotherapy. In the effort to empirically ground psychotherapeutic practice, feedback research is both a complement and alternative to empirically supported manualized treatments. Evidence suggests that tracking and feeding back progress data with individual or nonsystemic feedback systems improves outcomes in individual and couple therapy. The research reported in this article pertains to the STIC^® (Systemic Therapy Inventory of Change)—the first client‐report feedback system designed to empirically assess and track change within client systems from multisystemic and multidimensional perspectives in individual, couple, and family therapy. Clients complete the STIC Initial before the first session and the shorter STIC Intersession before every subsequent session. This study tested and its results supported the hypothesized factor structure of the six scales that comprise both STIC forms in a clinical outpatient sample and in a normal, random representative sample of the U.S. population. This study also tested the STIC's concurrent validity and found that its 6 scales and 40 of its 41 subscales differentiated the clinical and normal samples. Lastly, the study derived clinical cut‐offs for each scale and subscale to determine whether and how much a client's score falls in the normal or clinical range. Beyond supporting the factorial and concurrent validity of both STIC forms, this research supported the reliabilities of the six scales (Omega_hierarchical) as well as the reliabilities of most subscales (alpha and rate–rerate). This article delineates clinical implications and directions for future research.     

The effect of Multi Convergent Therapy on the psychopathology,mood and performance of Chronic Fatigue Syndrome patients: A preliminary study

Objectives: Multi Convergent Therapy combines approaches such as Cognitive Behaviour Therapy and Graded Exercise Therapy in an holistic treatment of Chronic Fatigue Syndrome. Initial follow‐up data showed that patients were benefiting from this individualised form of therapy. The objective of the present study was to evaluate this Multi Convergent approach, developed at a specialised Chronic Fatigue Syndrome Outpatient clinic in Cardiff, and compare it to Relaxation Therapy and control groups using multiple outcome measures. Design: Thirty‐five participants fitting the Centre for Disease Control criteria for Chronic Fatigue Syndrome were recruited from two outpatient clinics and members of our existing patient panel. Patients were assigned to Multi Convergent Therapy (N=12), Relaxation Therapy (N=14) or recruited as controls (N=9). Methods: Each patient completed a battery of mood and performance tasks along with comprehensive set of questionnaires at baseline, post‐treatment and at six‐month follow‐up. These measures had been validated in previous studies on untreated patients and matched healthy controls. Results: Patients attending the Multi Convergent Therapy clinic showed statistically significant improvements in many of our measures. Most importantly we have produced data indicating that Multi Convergent Therapy provides improvements in objective measures of psychomotor performance and cognition. Discussion: The outcomes of this small study are encouraging. Multi Convergent Therapy has not only produced results indicating significant improvements in standardised questionnaire based measures but also in objective cognitive performance tasks. The next step would be to assess Multi Convergent Therapy at the primary medical care level, with a greater number of patients to further evaluate its efficacy as a treatment for Chronic Fatigue Syndrome.     

How individuals with self‐reported anxiety and depression experienced a combination of individual counselling with an adventurous outdoor experience: A qualitative evaluation

Background: Adventure therapy is a short‐term experiential psychotherapeutic approach that utilises adventurous activities and being in natural environments in order to facilitate therapeutic change in clients. The present paper examines how students with self‐reported anxiety and depression experienced participating in an innovative intervention that combined individual therapy with an adventurous outdoor experience. Clients participating in the Adventure Therapy Project received between 10–15 one‐to‐one counselling sessions prior to the outdoor experience, as well as ongoing counselling following it. Method: Interpretative Phenomenological Analysis was used in order to record and analyse the experiences of three male and three female students who presented at a major UK university student counselling service with self‐reported depression and anxiety. Findings: Twelve themes emerged which were categorised into four major domains: enhancing intrapersonal relationships; improving interpersonal relationships; providing an experiential outdoor venue for achieving therapeutic change; offering a secure, personal place for achieving inner healing. The intervention was perceived to improve the ways in which interviewees related towards themselves and other people. Interviewees perceived the counselling sessions as offering a safe therapeutic space within which they could unveil their anxieties and achieve inner healing. Conclusions: Outdoor experiences offer an experiential venue for achieving personal change and, it appears enhance the therapeutic process. Prior and subsequent individual therapy increases the benefits of such experiences.     

Emotionally Focused Couple Therapy

Abstract

Working with couples who are both survivors of emotional abuse and are currently in an emotionally abusive relationship can be particularly challenging for the clinician. This article focuses on Emotionally Focused Couple Therapy as a recommended practice approach for clients who are caught in emotionally abusive patterns with one another. The article reviews relevant literature on this approach and illustrates the specific interventions applied lo an emotionally abusive couple.     

A Therapeutic Model of Self‐Forgiveness With Intervention Strategies for Counselors

Self‐forgiveness is associated with psychological and relational well‐being and may be a worthwhile treatment goal for clients who have hurt others. The authors utilized theoretical and empirical literature to describe a 4‐component therapeutic model of self‐forgiveness—responsibility, remorse, restoration, and renewal—and offer suggestions for promoting each component with clients. Finally, the authors explore potential contraindications and the applicability of self‐forgiveness for military veterans, clients in substance abuse treatment, and clients convicted of a crime.     

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.     

Toward the re‐enchantment of psychotherapy: Stories as container

Abstract

Storytelling by a therapist to clients may serve to increase clients’ ability to bear pain, to increase self‐complexity, and expand clients’ senses of the allowable. A model delineating the therapeutic impact of therapist storytelling in psychotherapy is proposed. Stories may change clients’ selves so that they may accommodate traumatic experiences and internal complexity. Stories increase clients’ capacity to tolerate painful experience and therefore serve as a container of tragic life experiences. The artistry of therapeutic story selection is defined as choosing stories consonant with clients’ strengths, rather than with the nature of the trauma. The power of story‐listening to alter consciousness in pleasant ways (storystoned) increases its usefulness as an intervention that is neither anxiety provoking nor re‐traumatizing.     

Meaning Therapy: An Integrative and Positive Existential Psychotherapy

Meaning Therapy, also known as meaning-centered counseling and therapy, is an integrative, positive existential approach to counseling and psychotherapy. Originated from logotherapy, Meaning Therapy employs personal meaning as its central organizing construct and assimilates various schools of psychotherapy to achieve its therapeutic goal. Meaning Therapy focuses on the positive psychology of making life worth living in spite of sufferings and limitations. It advocates a psycho-educational approach to equip clients with the tools to navigate the inevitable negatives in human existence and create a preferred future. The paper first introduces the defining characteristics and assumptions of Meaning Therapy. It then briefly describes the conceptual frameworks and the major intervention strategies. In view of Meaning Therapy’s open, flexible and integrative approach, it can be adopted either as a comprehensive method in its own right or as an adjunct to any system of psychotherapy.     

Hypothesis testing in patients with chronic progressive multiple sclerosis

Patients with chronic progressive MS (N = 38) were compared with an age and education matched medical control group (N = 19) on a visual discrimination task designed to evaluate hypothesis testing and focusing behavior. Thirty-three MS patients (85%) and all control patients were able to formulate and use hypotheses, but MS patients were less likely to employ strategies leading to a correct solution. Furthermore, MS patients were more likely to perseverate with one strategy despite negative verbal feedback. Five MS patients were unable to formulate hypotheses. These findings suggest that MS patients have impaired cognitive functioning in addition to previously reported problems with memory.     

Brief strategic family therapy: lessons learned in efficacy research and challenges to blending research and practice

In this article, we present key lessons that we have learned from (1) a long program of research on an empirically supported treatment, brief strategic family therapy (BSFT), and (2) our ongoing research and training efforts related to transporting BSFT to the front lines of practice. After briefly presenting the rationale for working with the family when addressing behavior problems and substance abuse in adolescent populations, particularly among Hispanic adolescents, we summarize key findings from our 30-year program of research. The article closes by identifying barriers to the widespread adoption of empirically supported treatments and by presenting current work within the National Institute on Drug Abuse's Clinical Trials Network that attempts to address these barriers and obstacles.