The Art of Psychotherapy

TRANSFORMATION

THROUGH SUPERVISION

Demetrios Peratsakis, LPCSheronda Farrow, PhD

July 2016

CLINICAL CASE SUPERVISION

INSIGHT

IF YOU CHANGE THE WAY YOU LOOK AT THINGS, THE THINGS YOU LOOK AT CHANGE

-WAYNE DYER

I’ll let you be in my dream, if I can be in yours. -- Bob Dylan

ORIENTATION TO PRACTICEThere are literally several hundred forms of psychotherapy, each with it’s own perspective on human behavior and the origin and treatment of problems. Likewise, there are numerous perspectives on supervision and how best to provide guidance and professional development to counselors.

This Orientation is predicated on the following premises:• Psychological problems originate from unresolved interpersonal conflict or

trauma caused by disaster, illness or abuse. Most often, they lead to sadness (depression) or being afraid (anxiety)

• We interpret, then feel and act accordingly. As social beings we must continually adapt to one another’s change (mutual causality).

• The goal of therapy is adjustment (adaptation) to major life events; it may include the need to heal trauma, reconcile conflict or remedy injustice.

• The therapy session is a primary venue for the practice of new ways of thinking, feeling and behaving, as well as a medium through which to experience intimacy and acceptance.

• Supervision is a transformational process that includes the Supervisor, Counselor and Client. The model of choice herein is one of mentorship, mutual exploration and learning for growth.

SUPERVISION

“No significant learning occurs without a significant relationship”

- Dr. James Comer

THE TRANSFORMATION PROCESS The Client, Counselor, and Supervisor form an intimate relationship

system called the Supervisory Triad. It is a relatively unique arrangement, whose principle purpose is the acquisition of insight as to the process of change. The Triad is a catalyst, providing a fertile medium in which to experience different expressions of one’s own mistaken goals and fictitious beliefs. These emerge in every relationship and are a part, if not the cause, of the inevitable problems and conflicts that arise with others. Just as therapy provides the opportunity to examine one’s own beliefs, and thereby modify their own behaviors, so too supervision is a reflective process of self-examination, insight and growth.

MODELS OF SUPERVISIONThere are several models of counselor Supervision, with most falling into one of several Psychotherapy-based frameworks. These reflect the particular orientation of the patron theory or school of belief; examples, include the Psychodynamic, Adlerian, Cognitive Behavioral, Family Systems, Person-centered, Feminism, and Developmental Models of Supervision. Advantages: ie. uniformity of style, language and perspective; common taxonomy; general

agreement on how to conceptualize treatment and the development of problems; greater predictability and confidence.

Disadvantages: both must adapt the particular theory and employ interventions specific to its model; less flexibility and more limited opportunities for experimentation; may not fit trainee’s beliefs about human nature.

Alternatively, the Integrated Model is a mixture of premises and techniques from various psychotherapy theories and is less strict regarding the therapist's own style or structure of supervision (Haynes, Corey, & Moulton, 2003). Advantages: brings more varied perspectives to supervision; flexibility to work toward

outcome by different paths; increases risk-taking, use of self and experimentation by counselor; broadens opinion on the nature of man

Disadvantages: harder to evaluate and gauge counselor development and progress with clients; supervisors must continually explain the orientation of each strategy or intervention and its purpose; without a more structured framework counselor may become more readily confused or feel inadequate or insecure if beginners.

Ultimately, counselors should be encouraged to be both creative and spontaneous in session while also pushed to learn and practice a broad range of tactics and techniques, irrespective of their model. This will help ensure greater authenticity and caring in their relationship with the client, while building up their overall power and confidence as clinicians.

Client

Supervisor

Counselor

SUPERVISORY TRIAD

The Triad provides the opportunity for continual growth through self-awareness and continuous feedback (mutual causality).

It is also responsible for the creation of “blind spots” (Isomorphism; the Parallel Process), “unconscious” efforts to reconcile power-struggles or conceal potential challenges to one’s world-view that may be deemed

unwelcome or painful.

“….AND THE BLIND SHALL SEE”As with all intimate relationships, the Supervisory Triad is prone to “blind-spots”,

areas around which one avoids, denies, or transfers the true nature of their feelings or beliefs to others. Typically, these are the areas of high sensitivity within

ourselves that are resistant to insight.Closely related, and often used interchangeably, Isomorphism is a construct with philosophical roots in structural and strategic family systems theory that focuses on interrelational aspects of supervision, whereas Parallel Process (PP) is a construct coined by the psychodynamic school of thought and focuses more on unconscious and intrapsychic occurrences in supervision. Parallel ProcessParallel process is an intra-psychic or internal, interpersonal dynamic that occurs in both counseling and supervision (Bradley & Gould, 2001). It is the transference/counter-transference of feelings and attitudes between individuals: it occurs when the emotional resonance expressed between the client and the therapist is reflected in the therapist-supervisor relationship .

IsomorphismEchoing, within inter-relational transactions that “presents itself as replicating structural patterns between counseling and supervision” (White & Russell, 1997). When replicating patterns between counseling and supervision occur, the role of the supervisee and supervisor duplicate the role of client and counselor (White & Russell, 1997): 1) counselors bring the interaction pattern occurring between themselves and the client into supervision and enact the same pattern but in the client's role, or 2) the counselor takes the interaction pattern in supervision back into the therapy session, now enacting the supervisor's role. 

PURPOSE OF SUPERVISION Supervision, is “a distinct intervention that is provided by a senior member of a profession to a junior member or members of that same profession. This relationship is evaluative, extends over time, and has the simultaneous purposes:

a)enhancing the professional functioning of junior members;b)monitoring the quality of professional services offered to the clients; andc) serving as a gatekeeper for those who are to enter the particular profession” (Bernard &

Goodyear, 1992, p. 4)

Binder (2002) defined 4 super-ordinate goals for the student in supervision:

1. to conceptualize clinical material;

2. to select and apply therapeutic interventions;

3. to develop professional beliefs and values; and

4. to behave ethically.

SUPERVISION FORMATS In-supervision formal and informal case presentations Review of session progress note(s) and/or case file Review of video or audio recordings

o Supervisor reviews and provides feedbacko Supervisor and supervisee review in tandem and discuss

Live supervision (supervisor is responsible for treatment outcome; J. Haley, 1996)

Two-way mirror, tele-med link, monitor, or audio link Co-facilitate or supervisor in session as observer Greek Chorus arrangements Consultation; prearranged intervention with counselor and client(s) Group supervision; Peer supervision; Multi-supervisor supervision Post-session interview(s) or treatment review(s) with client(s)

directly

GROUP SUPERVISION“Group supervision is the regular meeting of a group of supervisees (a) with a designated supervisor or supervisors, (b) to monitor the quality of their work, and (c) to further their understanding of themselves as clinicians and the clients with whom they work, and of service delivery in general. These supervisees are aided in achieving these goals by their supervisor(s) and by their feedback from, and interactions with, each other.” Bernard and Goodyear (2009) Types: 1) Case consultation: one member presents for the purpose of feedback, support and

discussion of theory and technique; 2) Peer supervision: a group of similarly trained or skilled individuals (e.g., all addiction counselors, clinicians at a certain developmental level), meeting regularly for mutual supervision and support, which may or may not include a group leader or supervisor; and 3) Team supervision: typically a mixed group with a defined leader or leaders, often with intra-disciplinary or interdisciplinary members at various skill levels (e.g. students to level 3 clinicians).

Size: Groups should not be so large that members are shortchanged nor so small to be unduly impacted by disruptions such as absences or dropouts. The average group should be no less than 4-6 supervisees and no greater than 12.

Benefits: o Economics of time, costs and expertise. o Skill improvement through vicarious learning, as supervisees observe peers conceptualizing and

intervening with clients. o Group supervision enables supervisees to be exposed to a broader range of clients and syndromes than any

one person’s caseloado The normalization of supervisees’ experienceso Supervisee feedback of greater quantity, quality and diversity; other supervisees can offer perspectives

that are broader and more diverse than a single supervisoro Quality increases as novice supervisees are likely to employ language that is more readily understood by

other noviceso The group format enriches the ways a supervisor is able to observe a supervisee o The opportunity for supervisees to learn supervision skills and the manner in which supervisors approach

providing guidance

Limitations to Group Supervision 1) The group format may not permit all individuals to get what they need.2) Less skilled members may monopolize the available time.3) Group dynamics, such as personality conflicts and inter-member competition, can

negatively effect learning. 4) The group may devote too much time to issues of limited relevance to, or interest for

some group members; 5) Group supervision does not have a parallel process to individual supervision. While

group supervision could potentially help one out with their group processes, (depending on the modality) a large portion of discussions in group supervision is regarding individual work with clients.

Group Supervision Supervisory Tasks: 1) Assume an active stance in the group; one that steers a careful course between over-

and under-control. 2) Assert yourself as necessary to redirect the group; impose limits, set Agenda, etc. 3) Listen to and then following the group, challenging direction as necessary. 4) Be able to choose the right fights when inevitable conflicts emerge between

supervisees or within the group itself. 5) Communicate clearly just what you want to happen. Be confident, but not autocratic. 6) As the leader be able to process the groups interaction style and level of development

to understand where members are, rather then where you wish them to be.

THE SUPERVISORA core function of supervision is continual evaluation & feedback to the supervisee(s) on their strengths and their weaknesses and areas that need to be developed, enhanced or improved (Watkins, 1997). To posses advanced knowledge of clinical theory, methods and techniques; have experience with

individual, couple and family systems therapy; and, be knowledgeable in work with a broad variety of client issues and syndromes.

To teach and train on basic counseling technique, the treatment process, the use of self, and the nature of change.

To establish varied clinical experiences, including live supervision, therapy, group supervision and case presentations.

To continually assess the supervisee’s skills and provide them learning experiences appropriate to their level.

To help protect the welfare of clients and ensure that the supervisee is practicing within the guidelines of the profession

To give and receive constructive feedback and openly discuss resonance from isomorphism & the parallel process

To hold the therapist accountable for understanding basic theoretical premises, as well possessing a firm command of the change process, including the development of client rapport, assessment, treatment planning and goal setting

To empower the supervisee to practice new skills in session, develop intimacy, assume risk and go with their instincts.

To move toward licensure, professional writing, community presentations and expertise in select areas of choice.

NOTES TO THE SUPERVISOR In Live Supervision, you are in charge and responsible for the outcome of

therapy/treatment Ensure an agreed upon format and have everyone follow the same model of

treatment Decide, in advance, the extent of disclosure with clients of the team’s strategies

and techniques Be prepared to redirect, block, reframe, or side-line directives by non-lead

counselors Formats may include Supervisor/Counselor(s) alternating, Lead, Tag-team, Good

Cop/Bad Cop Require that all participants must be prepared to practice before the group; they

must practice Require that supervisee is fully prepared to present their case (see next slide) Do not permit mocking, horse-play or ridicule of clients or other counselors (either

side of mirror) Follow 1 or 2 cases from first session to termination, whether the supervisee sees a

concern or not Demonstrate: how to effectively interview (therapy is essentially competent

interviewing; J. Haley) Demonstrate: how to move into the client’s emotional sphere, and then keep

inching forward Demonstrate: how to introduce an in-session task and force work by remaining

undistracted/on-task Demonstrate how to introduce and reach agreement on the need to bring in critical

participants Demonstrate: how to push for the pain, -the worry, the guilt and shame, the anger,

the sorrow Demonstrate: how to button-up after each hard push and then at the end of a

session

THE COUNSELOR“Psychoanalysis is in essence a cure through love” -Sigmund Freud (1906)

Therapy allows for the continuous possibility of a genuine, human-to-human encounter. As the counselor develops greater “therapeutic relational competence” (Watchel, 2008), their power as an agent for change matures and grows. In this manner, both therapist and client grow through authentic encounter with each other (Connell et al.,1999; Napiers & Whitaker, 1978): Be authentic and fully accept and care for the person, not despite their foibles and imperfections, but

because of them. Push for the outpouring of shame, sadness or rage, despite your own primal fear of losing control or

being consumed. Find compassion for the vileness of another’s thoughts, actions or past and discover “What is not so

terrible about them?” Fully embrace that the outcome of therapy is your responsibility and that clients do not fail but are

failed by therapy. Make session a safe haven in which to practice new ways of thinking, feeling and interacting. Do so by

your own willingness to experiment, be in the moment, and experience risk. Whenever possible, pull clients into your own energy, optimism and sense of hope. Self-disclose; it is “an absolutely essential ingredient in psychotherapy – no client profits without

revelation” (Yalom). Don’t push and the client won’t improve; push too hard, and the client will leave. Push, apologize, then

push some more. Freely step into the abject terror of another’s pain, knowing that for at least those few moments they

are no longer alone.

“ …if the therapist doesn’t change, then the patient doesn’t, either”  -Carl Jung

COUNSELOR PREP FOR SUPERVISION1. Counselor-supervisees are students; as such, they should be prepared with all necessary documentation

and client materials, have completed their assignments and forged a bond with their immediate instructor.

2. They should keep an up to date list of Active Clients and a history of session and supervisory meeting dates.

3. Each New Case presented should include, at minimum, the following information:a. Referral source, date and initial reason. If client initiated, their stated purpose for seeking

treatment.b. Genogram, socio-gram or summary of relational issues or snap-shot of the client system, including

individual backgrounds, such as medical conditions; medications; presntation/hygiene; occupation/education level; and living arrangements; as well as more dynamic artifacts, such as life-cycle issues; deaths, births and anniversary dates; family roles, rules, myths and legacies; trauma events and cut-offs and sources of support and distress

c. The Presenting Problem, including the contract for therapy goal(s), participants and expected duration

d. An analysis of who needs to participate and why; what’s the hypothesis on reason from seeking treatment.

e. Number of sessions to date, frequency of treatment and format4. Active Case presentations should include the information above as well as a summary of treatment to

date:a. Overview of treatment goal (s), number of sessions and progress or change to dateb. Relationship with counselorc. Details on how the Presenting Problem, Symptom(s) or Pain has changedd. Plans for Termination date and work

5. Counselors are also expected to a. Follow directives, study assignments, as appropriate to their level demonstrate a working

knowledge of counseling theory, core theoretical constructs, basic counseling techniques and the major elements inherent in specialty issues

b. Join with the client(s), use one’s self in therapy, bond with the client(s)assume risk c. To be receptive to feedback on clinical work, progress and personal growth, including receptivity to

supervisiond. To participate in professional training, conference development, peer supervision, and community-

wide presentations

THE RELATIONSHIPBEGINNING PRACTITIONERSWhile the counselor-supervisor relationship typically begins as a result of fulfilling the explicit requirements for achieving licensure (on average, of 2-3 years), it often becomes a life-long connection that moves to one of professional peers.

Process Overview: Early Phase Establishing the relationship; joining and accommodating to one another’s nuances and personal

learning style Designing a supervision contract, including the rules and terms of the Agreement; housekeeping and

BHP issues Agreement on theoretical approach, how to envision treatment, therapist’s role, case work and

treatment directives Developing competencies: ie. basic counselor skills; assessment, designing treatment plans,

documentation; technique

Common Characteristics of Beginning Practitioners Lack integrated perspective on human nature and socio-cultural elements, including ethical, legal,

occupational, and familial considerations. Tendency to oversimplify the development of self process. Tendency to take in paradigms of therapy and match them against their own personal experiences;

this tends to develop a prejudice for the paradigm of choice that merely fits their own experiences most comfortably.

Tendency to overuse one model, developing an over- simplistic understanding of complex structures. This generalizes behaviors and creates “types” of clients, thereby minimizing individual differences.

Tendency to over-focus on learning new information and performing newly acquired skills, in lieu of understanding the process of therapy the client’s unique perspective and story.

Tendency to over-focus on self, including own anxiety about being a clinician, their lack of skills and knowledge, and the likelihood that they are being regularly evaluated; preoccupations detract from client treatment (cookbook answers, session-to-session planning) and energy for training and study.

Tendency to minimize importance of self-awareness and personal growth. Tendency to: be fearful of more genuine, intimate contact with client; smooth over volatile issues;

avoid inclusion of more volatile members; and, to minimize issues that resonate within own life.

BEGINNING PRACTITIONERS (continued)

Training Issues in Clinician Supervision Practical concerns: BHP requirements; caseload size/mix; treatment space; clinical forms and

documentation; etc. Supervisee anxiety: Provide support and encouragement; promote autonomy and risk-taking;

continuously monitor potential risks to clients; be available to consult or co-facilitate; avoid “rescuing” the supervisee or becoming ghe primary “problem-solver”; encourage and support taking initiative.

Overall development in understanding of human nature, culture, and clinical therapy theory and practical skills: o Train on various theoretical approaches; purpose and process of treatment; symptom

development and management; role of therapist; intervention tactics and techniques; therapy modalities (individual, couple, family, group); etc.

o Train on Practical Skills: authenticity and personal risk; accommodation and joining; assessment; challenging; contracting; assigning tasks and directives; assigning homework; teaching problem-solving and resolving conflict; etc.

o Train on High-risk concerns: threats; trauma; harm to self or others; depression & anxiety; domestic violence; etc.

Observe work using role-plays, case presentation, two-way mirror, videotape, and live supervision

Self-growth: use of self in session; comfort with intensity/intimacy; personal issues that impact client care; cultural competency/sensitivity to difference; the supervisory triad (parallel process); burn out and self-care; etc.

Legal/Ethical issues: mandated reporting,; duty to warn; civil commitment orders; NGRI; subpoenas; confidentiality (42CFR2/HIPAA); separation, divorce and child-custody decrees; Advanced Directives; Human Rights laws; etc.

Professional development, including current events and policies related to the counseling field

MORE EXPERIENCED PRACTITIONERSProcess Overview: Middle Phase Better defining the power structure as the counselor gains confidence and autonomy Personalizing the relationship and allowing behavior to becomes less role bound Supervisees develop skills in case conceptualization, strategy and session by session measures Supervisee demonstrates a greater level of confidence; more risk taking and higher use of self

Common Characteristics Demonstrated continuation of proficiencies in theoretical premises and core skill competencies. Clear growth across various domains, including greater preoccupation with client centered care; a

greater sense of independent functioning and autonomy from the supervisor; broader use of a range of technique; improved use of self; longer-term strategizing in client care; and improved understanding of the therapy and goal setting.

Caution: This period often evidences fluctuating levels of motivation by the counselor, including periods of resistance, ambivalence, and lethargy. This can lead to conflict between the supervisee and supervisor and may also result in a deeper understanding of clinician’s skills and personhood; typically, their confidence is shaken by the increased knowledge of the complexity of the recovery process; frustrations with client progress/satisfaction; treatment failure; etc.

Training Issues in Clinician Supervision Encourage broader experimentation; reduce frequency of supervisor directives; allow counselor to

propose and select interventions. Require supervisee to demonstrate technique, and present to peers clinical issues/peer co-facilitation.

Encourage more cooperative planning between counselor and clients. Require treatment planning in stages.

Increase caseload size and complexity of assigned clients; challenge supervisee’s work by forcing them to articulate their conceptualizations of the client, the interventions they chose, and possible alternatives and their predictable outcomes.

Vary treatment modalities (ie. couple, family therapy); encourage presentations on select topics to various audiences; increase outside training and reading assignments; arrange peer supervision and clinical supervision under guidance.

EXPERIENCED & ADVANCED PRACTITIONERSProcess Overview: Ending Phase Supervisees understand the linkage between theory, technique ansd special issues; practice is Less need for direction from the supervisor Summative evaluation occurs including a discussion of the meaning of termination, feelings, and

thoughts Future and developmental goals are discussed

Common Characteristics Counselor is able to fully empathize with, and understand the client’s perspective on the world, their

goals and desire for change and has a better understanding of human behavior and the therapeutic process.

Counselor motivation has stabilized with an improved appreciation of their own skill ability and limitations. Improvement in skill should have reduced treatment outcome variability, improved dexterity in contracting, and promoted more sophisticated challenging.

Autonomy increases: deeper understanding of treatment methods, accepting of supervisor with different orientation, broad ethical knowledge, is able to switch tracks with clients, and appropriately uses self in therapy.

Is able to lead clinical discussion, supervise Level One counselors, present subject matter expertise, able to present in court and to law enforcement, comfortable ease in individual, group, couple family and multi-family therapy modalities. Able to handle high risk and extremely complex client profiles and syndromes.

Clinician Supervision Issues Role of supervisor is to guide the supervisee toward mastery and integration of all domains, from

assessment to treatment to aftercare. Supervision becomes considerably more collegial, and there becomes a much less differentiation of expertise and power in the supervisory relationship.

Structure in supervision usually comes from the supervisee, rather than the supervisor. Move to life-long peer relationship as professional colleague

ISSUES IN SUPERVISION There are times when problems arise in the supervisory process which could be an indication of

Conflict or boredom with the supervisor; Ambivalence about the field or frustration with one’s own personal abilities; Problems at work or of a personal nature; Conflicting directives from peers and others; or Unidentified resonance or “blind spots” resulting from Parallel Process and Isomorphism

Concerns that may indicate the Counselor is experiencing difficulties: Recent change in supervisee behavior, especially withdrawal, aloofness, or avoidance. Decreased participation in meetings, quality of interaction becoming poor or guarded. Change in overall style of interaction, such as combativeness or sullenness. Over-compliance with supervisor suggestions. Supervisee appearing preoccupied, seeming distant or annoyed, seeming stressed or nervous. Supervisee confusion or passive-aggressive responses to directives and recommendations.

The supervisor should raise their concerns and be open to the need to modify their own style of teaching as well as the need to re-evaluate the growth of the counselor and target their training more appropriately.

COMMON PROBLEMS IN SUPERVISION1. Isomorphism/Parallel process resonance : unresolved personal conflict or trauma activated by the

treatment (counselor-client) or supervisory relationship (supervisee-supervisor) that goes unrecognized or unaddressed, resulting in “blind spots”, transference/counter-transference and the replication of intergenerational patterns, rules, and roles.

2. Skewed power dynamics of the relationship (one-up, one-down as norm, especially for beginning practitioners)

a) Supervisee continually feeling over-powered; high reactivity to limit-setting and rule and role enforcement by the supervisor

b) Misuse of power by the supervisor; fostering feelings of inadequacy, inferiority or shame (abuse)

3. Putting the supervisor on a pedestal: idealization of the supervisor or continual need for acceptance or approval

4. Supervisor having a continual need to be seen as knowledgeable and competent

5. Personal dislike or disdain for the client, supervisee or supervisor

6. Sexual or romantic attraction by to the client, supervisee or supervisor

7. Cultural bias (over-identification or under-sensitivity) between the counselor and client or counselor and supervisee due to age, gender, religion, political viewpoints, sexual orientation or personal beliefs

8. Shame: feeling ashamed or guilty that one is unable to treat or guide successfully9. Using one’s own personal philosophy or our world-view as the default perspective in

treatment

COMMON PROBLEMS (C0NTINUED)

10. Disagreeing with supervisory directives or receiving conflicting feedback from other supervisors, peers or reading materials. While this may broaden insight it may also create confusion or timidity in session Paralysis often occurs because of the fear of doing, the desire to please, or anxiety about being

wrong Supervisees are responsible for following the directive of their assigned primary supervisor Peer observation may have as much (or more) validity and should not be discounted There is rarely only one way of interceding; alternatives provide flexibility & spontaneity in session Counselors, as well as supervisors, should pay attention to the suggestions they like the least Counselors must accommodate feedback to their own language, tempo, and way of working Counselors should avoid selecting a method simply because it “feels safer” or is more

“comfortable” If there are several ways of moving and one is truly “stuck” as to how to proceed, ask the client Learning to “trust one’s gut instincts” is the beginning of independence in counseling While Counseling is only as good as the counselor, Supervision is only as good as the supervisor Counselors should be coached on responsible spontaneity:

o if one is clear on the plan for the session, one is free take whatever step fits best at the moment and fully experience the journey;

o one must always be willing to abandon the plan, in order to go where the client needs to be.

PSYCHOTHERAPY AS TRANSFORMATION

Resolving Conflict and Heartache

Public Secret

Unconscious Blind

Knowledge that is known to one’s Self and others, is called Public. If it is known to one’s Self but not to others, it is called Secret.

If it is not known to one’s Self, yet it is known to others, it is called Blind. If it is not known to one’s Self and also not to others, it is called Unconscious. 

It is the blind Self that therapists target, helping clients see themselves as others see them.

THE JOHARI WINDOW IS A FOUR QUADRANT WINDOW OF SELF-KNOWLEDGE

THE PURPOSE OF PSYCHOTHERAPY

Receive Support, Trust, and Guidance (Acceptance and Love)

Assess Motivation: determine one’s willingness to Change (the “Cost”)

Alleviation of Pain:

o Symptom Management

o Adjustment to Change (Family Life-Cycle)

o Healing of Unresolved Conflict & Trauma, especially Betrayal

Acceptance of Self for Personal Growth

PARTS OF THE THERAPY PROCESS1. Pre-Contact Preparation

a) Basics: meeting space, transportation, forms & releases, Supervisor, etc.b) Appointment setting: connecting, referral purpose, participants, etc.

2. Contractinga) Joiningb) Assessing and Challenging the Identified Problem or Personc) Setting initial goal with time-frame, membership, expected outcomes, etc.

3. Mid-pointinga) Re-assessing progress; evaluating the partnershipb) Re-calibrating toward termination

4. Terminationa) Reaching closureb) Post-therapy supports, predictions and re-connection possibilities

OUR NEEDS ARE UNIVERSAL “And mankind is naught but a single nation” --The Holy Quran

a) Our fears, our pain, our wants: knowing this, helps one join in an authentic and meaningful way

b) Forget the hype on type, emotions are the same. Different triggers, different degrees, same emotion.

c) A global assessment is easy; look to life-cycle as well as what is missing or not working well:

What we all need --courtesy of Mark Tyrrell: feel safe and secure day to day give and receive attention have a sense of some control and influence over events in life feel stretched and stimulated by life to avoid boredom have fun sometimes and feel life is enjoyable feel intimate with at least one other human being feel connected to and part of a wider community be able to have privacy and time to privately reflect have a sense of status, a recognizable and appreciated role in life have a sense of competence and achievement a sense of meaning about life and what we do.

ALL PROBLEMS ARE RELATIONAL As social beings, problems are a product of social interaction, as is their cure. This

includes those syndromes we historically have regarded as intrapsychic, such as depression and anxiety. -D.Peratsakis

Mutual causality: Change occurs in overlapping relationship systems that influence each other through continual feedback loops, the most common being roles, rules, triangles, intergenerational myths and legacies, and habituated structures and patterns such as symptoms and dysfunctional transactions.

This premise, from Family Systems Therapy, adds immeasurable strength to one’s clinical insight o Ask yourself: “Who else is involved (living or dead)?” Trace all that participate in the Presenting

Problem and how. o Ask yourself: “If this was not the problem, what (who) would be?”

Relationships share three common features: Power, Intimacy and Conflicto Cooperation and Conflict are fundamental forces in the drive for Belonging and Independenceo Power: the ability to influence outcome; it shapes Intimacy and Conflicto Intimacy: belonging, acceptance, fusion, cooperation, pair-bonding, closeness, loveo Conflict: differentiation, individualism, independence, innovation

Problems arise due too Difficulties adapting to transition from one developmental stage to the next (Life Tasks; Family

Life Cycle)o Unresolved/Pervasive Conflict, typically due to problems adapting to change: leads to Power-

plays and Betrayalso Trauma due to Disasters, Illness and Betrayal (breaches in the intimacy and trust bonds)

Patterns, structures and worldview realities are relational points of intervention.

PURPOSIVENESSBehavior is purposive. Action is not random; it is goal-directed and consistent with one’s beliefs. This premise, from Alfred Adler, adds immeasurable strength to one’s clinical

insighto "Toward what purpose was the behavior expressed?"o "Toward what goal was the behavior aiming at?"o "What is the 'use' or function of the behavior?”o “What is the outcome that occurs, when the behavior is expressed?”

The primary goal of all human behavior is social belonging, while maintaining significance and a unique sense of self. We each hold beliefs about ourselves and how best to function with others

We interpret all action against these beliefs, interpreting the world and our place in it

Our own behavior shapes the thoughts and feelings of others who behave in a manner that reaffirms our beliefs about the world and social interaction (worldview re-affirmation)

We face the common challenge of maintaining self-esteem as we strive for social belonging

Our actions represent a constant striving from a perceived sense of minus (-), towards a perceived sense of the more positive (+) 

As behaviors, Symptoms also have purpose, they are metaphoric patterns of communication

The responsibility of Free Will lays in the agony of free choice

ANXIETY & DEPRESSIONWe view behavior as having intent (action). So, too, are emotions; they are goal-directed and consistent with one’s beliefs; they are intentional, purposive, conscious and subjectively meaningful activity (Adler). Fear, Anger and Sadness are normative responses to conflict and hurt. Worry, Shame, Guilt, and Rage are recurring conditions (of thought and feeling) that, collectively, comprise Anxiety and Depression in their varied forms. As a set of behaviors, emotion, and interactive patterns, Anxiety and Depression are purposive; their central, underlying element is Power (Control). -Peratsakis

Anxiety: the state of Being Afraid Fear, Dread and Panic: generalized hyper-vigilance against harm or threat Phobia, Obsession and Compulsion: targeted, repetitive actions that relieve stress as well as create it Is Anxiety simply another expression or form of depression, great sadness or sorrow?

Depression: Sorrow, Sadness, Sullenness, Worthlessness, Hopelessness or Despair; reasons and intents

Depression as a normative response to grief and hurt, a closing-in for healing and re-evaluation . -common definition

Depression is a means of protecting one’s self from fear or additional harm. –common definition

Depression may be an act of punishment, revenge, or a win in a power-struggle . –Adler; Family Systems Therapy

Depression may be a means of avoiding responsibility and placing others in one’s service. -Adler

Depression may serve as a means of contrition for shame and wrong-doing (self-blame/shame; guilt). -Adler

Depression as a socially acceptable alternative to expressing rage or the self-blame from “failing to do so”. - Peratsakis

“There's no coming to consciousness without pain.”

-Carl G Jung

THE END