Clinical Models

Week Thirteen

Transtheoretical Model(Stages of Change)

• James Prochaska and Carlo DiClemente

Stages of Change

This model has been applied to a variety of problems including:

•smoking cessation•exercise•low fat diet•radon testing•alcohol abuse•weight control

•condom use•organizational change•use of sunscreens•drug abuse•medical compliance•mammography screening

Stages of Change:The Temporal Dimension

1. Pre-contemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance

How Change Occurs

• Experiential Processes• Consciousness raising

• Dramatic relief

• Social liberation

• Self re-evaluation

• Environmental re-evaluation

How Change Occurs

• Behavioral Processes• Self-liberation

• Counter-conditioning

• Stimulus control

• Reinforcement management

• Helping relationships

Stages of Change

Pre-contemplation

• The stage in which people are not intending to take action in the foreseeable future– Reluctant: Uninformed or under-

informed– Rebellious: Resistant to change– Resigned:Demoralized– Rationalizing:In denial

Stages of Change

Contemplation

• The stage in which people are:– intending to change in the next 6 months– more aware of the pros of changing– acutely aware of the cons

Stages of Change

Preparation

• The stage in which people:– are intending to take action in the

immediate future– have taken some significant action– have a plan of action– should be recruited for action-

oriented programs

Stages of Change

Action

• The stage in which people:– have made overt modifications– are facing triggers– are gaining confidence– are in more danger of relapsing

Stages of Change

Maintenance

• The stage in which people are:

– working to prevent relapse

– more confident

Constructive Living Overview

• Created by David Reynolds• Combines teaching from Morita

Therapy and Naikan Practice• Focus is to develop a relationship

with reality– What is controllable?– Accepting my feelings, yet finding the

action that is implied– Correcting my view of reality with

gratitude

Constructive Living Basics

• Constructive Living aims at helping a person see the world realistically and act on that knowledge in practical and constructive ways. – what is controllable and what is not? – Control indicates that something is possible. . .all

the time. – Having control does not necessarily mean that it is

easy, only that it is possible. • We use the words "can" and "can't" to reflect this

meaning and urge our students to be clear in their speech. "I just can't seem to exercise lately," says Mary. I point out that she is not speaking accurately. She actually can exercise; she simply hasn't recently, I remind her.

Constructive Living Basics

• Lets look at the list of what is not controllable: – the weather,

– other people's actions,

– other people's opinions,

– the outcome of events,

• What is controllable, then? My own behavior is always controllable. I do it because it needs to be done.

• Realistically we know that life can't be perpetually easy, comfortable, "exciting" all the time.

• The "good news" is that my behavior is in my control at all times. I can act now. My behavior is always controllable.

Constructive Living Basics

The five principles of feeling.  1. Feelings are uncontrollable directly by

the will.

2. Feelings must be recognized and accepted as they are.

3. Every feeling, however unpleasant, has its uses.

4. Feelings fade in time unless they are restimulated.

5. Feelings can be indirectly influenced by behavior.

Constructive Living Basics

• If we accept that feelings are not controllable, it follows that the best thing to do with them is to accept them -- as they are.

• This does not mean that one need be passive. If I am angry over some injustice I might work to change conditions.

• But not every feeling requires action. • Some feelings do point to something that

needs doing.

Constructive Living Basics

• Constructive Living's perspective derives from a Japanese practice called Naikan.

• This form asks the participant to use three powerful questions to correct their view.

• These questions may be asked concerning individuals- family, friends, mentors, enemies, even strangers.

• The questions may also be asked with reference to a day or an event in ones life.

Constructive Living Basics

• These are the questions for reflection: – 1. What have I received from ____?– 2. What have I given to _______?– 3. What troubles and bothers have I

caused________?

• Called "Daily Naikan" practice, these three questions provide a frame for assessing the day

• Answering Naikan's questions and the simple exercise of saying "thank you" starts a new habit of mind.

Cognitive Behavioral Therapy (CBT)

• Modern adaptation by Arnold Lazarus

Cognitive Behavioral Therapy

• Draws from – cognitive therapies (Albert Ellis’ Rational Emotive Therapy, Aaron

Beck’s Cognitive Therapy) and

– behavioral therapies (Pavlov, Wolpe, Skinner, Eysenk)

• Here-and-now orientation• Briefer and time-limited (efficacy within <16 sessions)• highly instructive nature and the fact that it makes use of

homework assignments.• the goal of therapy is to help clients unlearn their unwanted

reactions and to learn a new way of reacting. • Cognitive-behavioral therapy is based on the idea that our

thoughts cause our feelings and behaviors, not external things, like people, situations, and events. 

• The benefit of this fact is that we can change the way we think to feel / act better even if the situation does not change.

CBT Techniques

• Techniques include:– Validity testing– Cognitive rehearsal– Guided discovery– Writing in a journal– Homework– Modeling– Systematic positive reinforcement– Aversive conditioning

CBT Techniques (cont’d)

• Slow-talk/slow walk/slowing down• Stopping automatic negative

thinking (ANTs)• The acceptance paradox: how

we keep the fires burning and how to put them out

• Rational and helpful self-statements that can become permanent and "automatic”

CBT Techniques (cont’d)

• Continuing to move our self-statements up

• Whose voice are you listening to, anyhow? Do we have to listen and believe all those old lies?

• The determination factor: becoming more focused and gently determined

• Focusing: What are you paying attention to?

• Later, it’s important we address:– perfectionism, anger, frustration,

setbacks, and our view of the world

Transactional Analysis

• People are OK; thus each person has validity, importance, equality of respect

• Most everyone has the capacity to think• People decide their story and destiny,

and these decisions can be changed• Freedom from historical maladaptations

embedded in the childhood script is required

• The aim of change under TA is to move toward autonomy (freedom from childhood script), spontaneity, intimacy, problem solving

Transactional Analysis

Client Centered Therapy

• Carl Rogers

• This technique uses a non-directive approach.

• This aids patients in finding their own solutions to their problems.

Client Centered Therapy

• Rogers stated that there are six necessary and sufficient conditions required for therapeutic change:– Therapist-Client Psychological

Contact– Client incongruence, or Vulnerability– Therapist Congruence, or

Genuineness– Therapist Unconditional Positive

Regard– Therapist Empathic understanding– Client Perception

Narrative Therapy

• Michael White

• From the post-modern branch of counseling

• Narrative therapy holds that our identities are shaped by the accounts of our lives found in our stories or narratives

Concepts ofNarrative Therapy

• The narrative therapist is a collaborator with the client in the process of discovering richer ("thicker" or "richer") narratives

• “The person is not the problem, the problem is the problem.”

• Operationally, narrative therapy involves a process of deconstruction and "meaning making”

Common Elements in Narrative Therapy

• The assumption that narratives or stories shape a person's identity

• An appreciation for the creation and use of documents

• An "externalizing" emphasis• A focus on "unique outcomes" or

exceptions to the problem• A strong awareness of the impact of power

relations in therapeutic conversations, with a commitment to checking back with the client about the effects of therapeutic styles

• Responding to personal failure conversations