Psychotherapy and Culture
Cultural and ideological diversity of clients and professionals
The multi-layered spirit of practice in modern healthcare systems
Engagement and communication: common factors in healing
Collaborative practices
The complexity of change processes
The link between entrenched social disadvantage and physical and mental health
EU Green paper on Mental Health
Bruce Wampold, 2011
“Lest we forget, it is the therapist who makes
psychotherapy, and other helping professions,
effective. Accumulating research demonstrates
that in practice, as well as in clinical trials, much
of the variability in outcomes is attributable to
the therapist, regardless of the treatment being
delivered.”
A SECURE BASE
“For not only young children, it is now clear, but human
beings of all ages are found to be at their happiest
and to be able to deploy their talents to best
advantage when they are confident that, standing
behind them are one or more trusted persons who
will come to their aid should difficulties arise. The
person trusted provides a secure base from which
his (or her) companion can operate.”
Bowlby, 1973
Diana Fosha
“The roots of resilience…….are
to be found in the sense of being
understood by and existing in the
mind and heart of a loving,
attuned, and self-possessed
other.”
What Does the Research Tell Us?
The therapeutic relationship is the key
predictor of client outcome (Elliott et al, 2011)
The therapeutic relationship accounts for
30% of the variance in client outcome
(Lambert and Barley, 2001)
The therapeutic relationship is accepted as
necessary for change in all major
psychotherapies
Empathy is the ‘evidence based component’
of the therapeutic relationship (Norcross and
Wampold, (2011)
What Does the Research Tell Us?
Empathy: A conscious perspective-taking
process (affective and cognitive), whereas
sympathy is an emotional response to
another’s affective state
Rogers ‘accurate empathy’: understanding
the other and communicating this through
reflective listening
Empathy linked to positive engagement: 10%
variance in client outcome
Alcohol use problems: higher empathic
engagement, less drinking…..
What Does the Research Tell Us?
Empathic responding helps clients identify
and modify their own affect
Empathy: acceptance and warmth
Trust: listening, being present, focused,
caring emotional risk taking
If we believe out therapist can help us
stronger commitment to therapy and
therapist’s hope in usefulness of therapy
linked to client engagement
What Does the Research Tell Us?
Therapist empathy and interpersonal skills
highly linked
Empathy trust…
Principal healing components of the
therapeutic relationship (empathy,
genuineness, positive regard and validation)
form the basis of compassion (a higher order
process?)(Kirschenbaum and Jourdan, 2005)
Empathy and curiosity = self-reflexivity
Attributes and/or learned skills??
Active Listening
Focus attention on the child without
interrupting with own thoughts and comments
Acknowledge you are listening, both verbally
and non-verbally – speaker can both see and
sense they are being listened to
Pick up the non-verbal cues – what is not
being said….
Don’t be distracted by thinking of your reply
while child is speaking
Offer an appropriate response
Listening, Speaking and Hearing
Stress responses get in the way of hearing
Anger, fear and panic produce ‘fight or flight’
or dissociation responses cognitive
functioning and memory are impaired
Repeat what has been said and check it has
been understood
Give opportunities to repeat and develop
understanding
Rehearsal helps
Attunement, Empathy & Reflective Function
Empathic and well attuned bonds greater
emotional security
Understand child’s feelings, respond in a way
that effectively communicates that
understanding, and contains distress with
sensitivity
Fonagy: a reflective caregiver increases
likelihood of child’s secure attachment which
in turn, facilitates development of
mentalisation
Attunement: Reading the Rhythms of the Child
“This is why the core of good teaching is attunement. Attunement is
being aware of, and responsive to, another. How does this child
feel? Is she interested, engaged, capable of listening to what I want
to say? What is the best way to communicate this idea, fact,
concept, or principle to her in this moment? What will engage,
encourage and excite her about this subject? What will be heard,
perceived, felt and learned – in short, what the teacher will
communicate – depends upon how receptive the child is. And how
well a teacher reads a child’s receptivity depends upon an
understanding of how humans communicate without words.”
Bruce Perry
Internal Working Models
Beliefs and expectations about
One’s own and other people’s behaviour
Views of the SELF – How loveable, worthy
and acceptable am I?
How available and interested are others in
me, and in caring for and looking after me?
ATTACHMENT STRATEGIES AS A CONTINUUM:
styles of protective & defensive processes
DISMISSING/DE-ACTIVATING PRE-OCCUPIED
Learn that expressing
emotions cannot reliably elicit
comfort or caring, defensive
strategy develops of
distancing or excluding
emotions. Cognition is relied on
and can be employed to help
omit or distort emotional
information: inhibit affect,
falsify, deny physiological
discomfort and pain:
- idealise, care for others
- deny need for others
compulsive reliance on self
Learn that cannot rely on words
and cognition, inability and
failure to predict. Increasingly
rely on affective information. Split
feelings of anger and
vulnerability so display one and
suppress the other. Cognitive
defences involves passive
thinking, reducing complexity by
blaming of others and avoiding
considering own contributions,
rationalising/justifying own
actions:
- anger towards others
- anxiety and vulnerability
ATTACHMENT ALWAYS TWO SIDED
Attachment always has TWO sides. Responses to non-availability of the attachment figures:
PROTEST - anger of hope and of despair
and
VULNERABILITY – sadness/fear/shame
One may be shown more than the other, or shown in rapid alternation. Internal conversation – potential ‘Strange Loops’
Systemic Intervention
Identify unhelpful patterns with the couple – the pattern is the
problem, not the person – unresolved hurt (NB violence needs a
different response – see Cooper & Vetere, 2005)
Validate each person’s experience – deep listening - expand
and process - help to soften a blaming position – intention vs
effect!
Encourage integration of representational systems and
reflection – coherent narrative
Support listening and curiosity about the other’s experience –
compassion, trust, soothing and affect regulation
Support re-bonding enactment in/outside the session
Assisting with other difficulties and worries
Repair, consolidation and new narratives
Implications for Therapy
Naming and regulating emotions
Standing in the emotional shoes of the other
Comforting and self soothing
Information processing
Transformations in representational systems
Secure Attachment
“…what sustains our relationship is, I’m extremely happy with her, and part of it has to do with the fact that she is at once completely familiar to me, so that I can be myself and she knows me very well and I trust her completely, but at the same time she is also a mystery to me in some ways. And there are times when we are lying in bed and I look over and sort of have a start. Because I realise here is this other person who is separate and different and has different memories and backgrounds and thoughts and feelings. It’s that tension between familiarity and mystery that makes for something strong, because, even as you build a life of trust and comfort and mutual support, you retain some sense of surprise or wonder about the other person.”
Barack Obama. The New Yorker, January 19, 2009, P50
“For Better or Worse….”
Physiological and psychological implications
Attachment and Repressive Coping Style
Cancer and the immune system
Hostile conflict and wound healing (Kiecolt-
Glaser and Glaser)
Pain and comfort
Social support networks
London Depression Intervention Trial
John Gottman: ‘divorce prediction’? Criticism,
contempt, stonewalling, defensiveness
Our Wish for Connection: Research
on Bonding
1. Emotional connection: turns on positive emotion (oxytocin) & mediates threat perception
2. Effective dependency and resilience: open systems, curiosity, & the ability to learn and play…..
3. Responsiveness and accessibility: are you there for me?
4. Emotional separation: cues panic and protest
5. Safety and emotional risk-taking: demand – anger of hope (protest); dismiss – anger of despair (shut others out): cues negative cycles, maintains felt insecurity, distorts attachment signals
(John Gottman, Mario Mikulincer, Pat Crittenden, Susan Johnson)
John Gottman: The Science of Trust 2011
Enhance your love map
Nurture fondness and admiration
Turn towards each other
Let your partner influence you
Solve your solvable problems: a) softened ‘start up’;
b) make and receive repair attempts; c) soothe self
and each other as conflict can lead to ‘flooding’; d)
compromise
Overcome gridlock – existential base of unexpressed
dreams
Create shared meanings – stories we tell about our
relationships
“Felt security” in a relationship
Affect regulation (less reactivity, hyper-
arousal & under-arousal)
Support seeking
Information processing (curiosity, open, more
toleration of uncertainty)
Communication (meta-communication,
disclosing, collaborative, assertive, empathic)
‘Sense of self’ (elaborated, articulated,
positive) (Mikulincer and Goodman)
INTERNALISED OTHER INTERVIEWING
Three people : if you can get into pairs (A & B) where you know each other reasonably well.
Person A: Gets into role of becoming Person B Person B: listens Interviewer C: interviews person A as if they were B. “Now B, can you tell me
how you are feeling today, etc..! For about 5 minutes, then Reverse: Interview B as A A, B and interviewer C discuss the conversations: What did this feel like? How accurate were they? What surprised each of them about what the other said?
Couples Therapy & Attachment Theory
Focus on attachment needs & forms of
engagement/disengagement (Minuchin,
1974)
Privileges emotion – “the music of the
attachment dance” (Johnson, 2002)
Therapy as a secure base (Byng-Hall, 1995)
Supports different bonding responses &
events: integration and reflection
Addresses impasses & ‘attachment injuries’
Working with Dynamic Systems
Focus on attachment theory guides interventions
(Dallos & Vetere; Flaskas; Johnson)
The couple relationship can either support or
undermine the sense of emotional safety: for both
partners and their relationship – mutual influences
Couple distress is understood in the context of recent
research (eg John Gottman; Mikulincer and
Goodman; Crittended; Hazan and Shaver)
Attend to key emotional responses that maintain
distress – therapy alliance as secure base
Pursuer-distancer circularities are especially relevant
to an understanding of couples’ attachment
relationships
Working with Dynamic Systems
Support for altering emotional responses and
dispositional representations in ways that enhance
and develop secure connections – reprocessing,
integrating, reflecting and doing
Transition points in families provide a particular
challenge for the couple system, as partners seek
either to re-establish familiar reaction patterns ie
falling back on old solutions, or take the risk to
develop new patterns ie corrective scripts
There is mutual influence between the couple unit
and other subsystems of the family (life cycle theory
and inter-generational family therapy)
Focus on most poignant or vivid aspect of
experience: non-verbal expression of emotions and
non-conscious relational responding
Focus on emotions that are most significant for
attachment needs and fears eg of rejection
Sadness and grief related to a sense of loss and
helplessness
Anger is often a reaction to perceived or actual non-
responsiveness (or threat of abandonment or
rejection) in an attachment figure
Support & help develop differences & interaction
Focusing on Emotions: Johnson, 2008
Shame may indicate a partner’s lack of entitlement
to share their needs and longing for closeness, and
fear that such sharing will lead to rejection
Fear and vulnerability are core aspects of human
attachment and evoke a partner’s longing for
closeness and secure connection
Focus on emotions that play a part in organising
negative cycles of interaction: therapist explores
and expands emotions that are present in couple’s
problematic patterns (Johnson, 2008)
Focusing on Emotions: Johnson, 2008
Expressing and expanding emotional experience is
central to change in interactional patterns
Accessing primary emotions (eg sadness, fear of
loss, shame) enables new meaning to be brought to
understanding family members’ behaviour
Processing the experience and the underlying
emotions that may have been on the edge of
awareness
And to challenge long held perceptions of family
members
Working with Emotions: EFT
Exploring Patterns of Comforting
When you were upset or frightened as a child – what happened?
How did you get to feel better? Who helped you to feel better? How did they do this?
What do you think your parent/s learned from their parents?
What have you learnt from this for your own family?
What do you want to do the same?
What do you want to do differently?
How do people comfort each other in your own family/relationship?
How do you comfort your children?
How do they comfort you?
What do you want your children to learn about comforting, for now, for the future, and for the future of any children they might care for?
Can be held as a family or couple interview or as a one-to-one conversation.
Reaffirming and clarifying clients’ experiences
Modelling acceptance of both partners’ experiences
Slowing down the session, enabling partners to
process their experiences
Helping to organise different aspects of clients’
experiences (action, feeling, thought and intention)
into a more integrated whole – a coherent narrative
Comforting in response to a difficult emotional
experience
Exploring the meaning of important and powerful
human experiences
Empathy & the Therapeutic Alliance
THERAPY AS SCAFFOLDING:
Emotional and cognitive
Developmental perspective: (Vygotsky)
Learning occurs though internalising conversations
‘Zone of Proximal Development’ – staying within the zone of ‘not too familiar and not too different’
What we can do with the assistance of another person/therapist
Therapy and scaffolding:
Emotional base – safety, security – reduce negative arousal
Assisting in identifying and regulating feelings
Encouraging reflexivity – standing in the emotional shoes of the other
Exploring comforting and self-soothing
Assisting integration of feelings and events
Assisting coherence: helping families/couples develop a narrative of how they healed their relationship
Attachment Narrative Therapy with
Families/Couples
Creating a secure base
Mapping the context & talk about talk
Engaging warmly with each member of the family
Reflecting on our relationships in the room – modeling open communication
Use of self – therapist reflecting on his/her own experiences
Adopting a non-blaming approach - working together vs ‘fixing families’, purpose is not to find fault in the past or present
Externalizing Framework
Exploring the ‘problem’ - beliefs, feelings, explanations
A ‘conservative’ (paradoxical) framework - not pushing for change
Access, illuminate, expand, reprocess emotional experience
De-escalating unhelpful patterns
Creating a secure base
Reflection, containment and emotional safety
Supporting, building the therapeutic relationship
Validation and support- acknowledging emotional risks, demands of therapy,
temptation to withdraw
Clarifying, context – how we will communicate
Establishing sense of safety, pacing:
Identifying, exploring and de-escalating unhelpful patterns of interaction
Exploration - Narratives and Attachments within a
Systemic Framework
Identifying attachment dilemmas
Identifying attachment needs and wishes eg for
reassurance, underlying core patterns of feeling,
thinking and behaviour
Discrepancies: thoughts and feelings, head and
heart
Divided loyalties – ambivalences in relationships
Reflections on the therapeutic relationship:
empathy and listening
Exploring problems, emotions and competencies:
Access, illuminate, expand and re-process
emotional experiences
Considering Alternatives – emotional risks
and change
Loosening Attachment Dilemmas
Considering alternatives – unique
outcomes
Acknowledging risks of change,
Threats to perceptions of self and
others
Relational and emotional risk taking, in
therapy and outside – conflict
resolution
Re-bonding – consolidating more
satisfying interactions
The Future:
Maintaining the Therapeutic Base
Shared narratives of healing
Acknowledging possibility of relapse
– temptation to retreat to patterns of
thinking and feeling
Holding each other in mind – how we
will think about each other in the
future
What support will be able to draw on
in future – consolidating change
Creating opportunities for future
reflection
EMOTIONAL SCULPTING
Sculpting with family members themselves, or sculpting with
objects (coins, buttons, stones, figures etc ) …
PROMPTS (can use direct or circular questions…)
Map the current attachment patterns, relationships – who looks
after whom, etc.
How does it feel to be, for example, at the centre, on the edge,
between your parents, and so on?
Now that you and your brother are closer, how does that make
you feel?
If you were to get closer to your mother what would that be like?
How do you think your sister feels being that distant from your
father? And so on.....
Corrective and Replicative Scripts
This utilises ideas from John Byng-Hall that families make comparisons across the
generations in terms of similarities and differences between how our own parents were with each other and us (the children) and how this is repeated or altered in the next generation.
Importantly it allows us to work in a positive frame with the family in that we may construe the intentions of the parents positively, i.e. they have tried to repeat what was good or correct what they felt was bad about their own experiences. This can then lead to a discussion of whether these attempts have been successful or not, and possibly how they might be altered, strengthened, elaborated etc.
What are your thoughts about how similar or different your relationship with each other and your children is to your parent’s (grandparents’) relationships ?
What have you tried to make similar or different to either of these relationships?
What do you value vs feel critical about in either of your parent’s relationships?
Does what you have tried to repeat/change work? Is there anything that you want to alter, strengthen, abandon about what you have been trying to repeat or change?
Suggested Reading:
Dallos R and Vetere A (2009) Systemic therapy and Attachment
Narratives; Applications in a range of clinical settings. London:
Routledge
Dallos, R. and Vetere, A. (2014) Systemic therapy and
attachment narratives: Attachment Narrative Therapy. Clinical
Child Psychology and Psychiatry, 19, 494-502
Johnson S (2002) Emotionally Focused Couple Therapy with
Trauma Survivors. New York: Guilford
Vetere A and Dallos R (2008) Systemic therapy and attachment
narratives. Journal of Family Therapy, 30, 374-385
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