Three Approaches to Psychotherapy With a Female Client: The Next Generation
In Three Approaches to Psychotherapy With a Female Client — The Next Generation, three leading therapists demonstrate three different therapeutic orientations with a single client.
Inspired by the original "Three Approaches to Psychotherapy" video, which featured three pioneering therapists working with client "Gloria," this DVD revisits the original program concept with presentations of cognitive therapy with Judith S. Beck, emotion-focused therapy with Leslie S. Greenberg, and psychodynamic therapy with Nancy McWilliams. Beck, Greenberg, and McWilliams define and illustrate their individual approaches, engage in a roundtable discussion about their work, and provide voiceover commentary for their respective sessions.
This spirited presentation demonstrates the shared features and key differences of contemporary therapeutic approaches, allowing the viewer a chance to compare and contrast the techniques and qualities of three master psychotherapists.
Judith S. Beck: Cognitive Therapy
Cognitive therapy is a comprehensive system of psychotherapy, and treatment is based on an elaborated and empirically supported theory of psychopathology and personality. It has been found to be effective in more than 400 outcome studies for a myriad of psychiatric disorders, including depression, anxiety disorders, eating disorders, and substance abuse, among others, and it is currently being tested for personality disorders. It has also been demonstrated to be effective as an adjunctive treatment to medication for serious mental disorders such as bipolar disorder and schizophrenia.
Cognitive therapy has been extended to and studied for adolescents and children, couples, and families. Its efficacy has also been established in the treatment of certain medical disorders, such as irritable bowel syndrome, chronic fatigue syndrome, hypertension, fibromyalgia, post-myocardial infarction depression, noncardiac chest pain, cancer, diabetes, migraine, and other chronic pain disorders.
Developed by Aaron T. Beck, MD, in the mid-1960s, cognitive therapy is a time-sensitive, structured therapy that uses an information-processing model to understand and treat psychopathological conditions. The theory is based, in part, on a phenomenological approach to psychology, as proposed by Epictetus and other Greek Stoic philosophers and more contemporary theorists such as Adler, Alexander, Horney, and Sullivan. The approach emphasizes the role of individuals' views of themselves and their personal worlds as being central to their behavioral reactions, as espoused by Kelly, Arnold, and Lazarus. Cognitive therapy was also influenced by theorists such as Ellis, Bandura, Lewinsohn, Mahoney, and Meichenbaum.
Cognitive therapy is based on a cognitive theory of psychopathology. The cognitive model describes how people's perceptions of, or spontaneous thoughts about, situations influence their emotional, behavioral (and often physiological) reactions. Individuals' perceptions are often distorted and dysfunctional when they are distressed. They can learn to identify and evaluate their "automatic thoughts" (spontaneously occurring verbal or imaginal cognitions), and to correct their thinking so that it more closely resembles reality. When they do so, their distress usually decreases, they are able to behave more functionally, and (especially in anxiety cases), their physiological arousal abates.
Individuals also learn to identify and modify their distorted beliefs: their basic understanding of themselves, their worlds, and other people. These distorted beliefs influence their processing of information, and give rise to their distorted thoughts. Thus, the cognitive model explains individuals' emotional, physiological, and behavioral responses as mediated by their perceptions of experience, which are influenced by their beliefs and by their characteristic ways of interacting with the world, as well as by the experiences themselves.
Therapists use a gentle Socratic questioning process to help patients evaluate and respond to their automatic thoughts and beliefs — and they also teach them to engage in this evaluation process themselves. Therapists may also help patients design behavioral experiments to carry out between sessions to test cognitions that are in the form of predictions. When patients' thoughts are valid, therapists do problem solving, evaluate patients' conclusions, and work with them to accept their difficulties.
The goals of cognitive therapy are to help individuals achieve a remission of their disorder and to prevent relapse. Much of the work in sessions involves aiding individuals in solving their real-life problems and teaching them to modify their distorted thinking, dysfunctional behavior, and distressing affect.
Therapists plan treatment on the basis of a cognitive formulation of patients' disorders and an ongoing individualized cognitive conceptualization of patients and their difficulties. A developmental framework is used to understand how life events and experiences led to the development of core beliefs, underlying assumptions, and coping strategies, particularly in patients with personality disorders.
A strong therapeutic alliance is a key feature of cognitive therapy. Therapists are collaborative and function as a team with patients. They provide rationales and seek patients' agreement when undertaking interventions. They make mutual decisions about how time will be spent in a session, which problems will be discussed, and which homework assignments patients believe will be helpful. They engage patients in a process of collaborative empiricism to investigate the validity of the patient's thoughts and beliefs.
Cognitive therapy is educative, and patients are taught cognitive, behavioral, and emotional-regulation skills so they can, in essence, become their own therapists. This allows cognitive therapy to be time-limited for many patients; those with straightforward cases of anxiety or unipolar depression often need only 6 to 12 sessions. Patients with personality disorders, comorbidity, or chronic or severe mental illness usually need longer courses of treatment (6 months to 1 year or more) with additional periodic booster sessions.
Cognitive therapists elicit patients' goals at the beginning of treatment. They explain their treatment plan and interventions to help patients understand how they will be able to reach their goals and feel better. At every session, they elicit and help patients solve problems that are of greatest distress. They do so through a structure that seeks to maximize efficiency, learning, and therapeutic change. Important parts of each session include a mood check, a bridge between sessions, prioritizing an agenda, discussing specific problems and teaching skills in the context of solving these problems, setting of self-help assignments, summary, and feedback.
Therapists use a wide variety of techniques to help patients change their cognitions, behavior, mood, and physiology. Techniques may be cognitive, behavioral, environmental, biological, supportive, interpersonal, or experiential. Therapists select techniques based on their ongoing conceptualization of the patient and his or her problems and their specific goals for the session. They continually ask themselves, "How can I help this patient feel better by the end of the session and how can I help the patient have a better week?" These questions also guide clinicians in planning strategy.
There is no one typical client for this approach, as cognitive therapy has been demonstrated in numerous research studies to be effective for depression, anxiety disorders, substance abuse, eating disorders; for bipolar disorder and schizophrenia (as an adjunct to medication); and for a variety of medical problems with psychological components. Of course, treatment has to be varied for each disorder and therapists must not only understand the cognitive formulation of a specific disorder but also be able to conceptualize individual clients accurately and devise a treatment plan based on this formulation and conceptualization.
Cognitive therapy interventions must also be adapted for older adults, children, and adolescents and for group, couples, and family treatment.
Leslie S. Greenberg: Emotion-Focused Therapy
Emotion-focused therapy is an exciting approach to helping clients live in harmony with their emotions. Rather than desiring to control or avoid emotions, clients learn that emotions tell us what is important in a situation and act as guides to what we need or want. Clients experience emotions as they arise in the safety of the therapy session and discover the value of greater awareness and more flexible management of emotions, with the goal of attaining emotional health.
Emotion-focused therapy focuses on helping clients gain access to and process previously avoided feelings and thoughts. This versatile and useful approach offers a complete theory of human functioning based on the adaptive role of emotion and on a therapy practice founded on the idea that emotional change is central to enduring change. Distinctions are made between different types of emotion, those that are more primary and those that are secondary reactions to and often obscure the more primary emotions. In addition primary emotions can be either adaptive or maladaptive.
Therapy involves the awareness, acceptance, regulation, understanding, and transformation of emotion, and proposes that primary adaptive emotions have a transformational potential that, if activated, can help clients to change. Emotion-focused therapists help clients to experience their emotions in the safe setting of therapy so that, rather than avoiding or controlling their feelings, clients learn to use their primary feelings as a guide to what is important or necessary in their lives.
Emotion-focused therapy centers on helping the client to experience and express emotions more easily and to symbolize unprocessed feelings and thoughts in awareness so that they may be dealt with openly. In the case of depression, having "feelings turned outward" can undo the disorder by giving access to previously untapped resilience in the client. A central issue for this treatment is achieving a balance between relational responsiveness and process directiveness, between leading and following. The aim is for the therapist and client to work collaboratively to explore the client's experience and to construct new meaning.
In this approach, the therapist is viewed as an expert in how and when to facilitate particular kinds of exploration of experience but not as an expert on the content of the client's experience. Rather, clients are viewed as experts on their own experience, and therapy is a discovery-oriented process. The therapist, therefore, works to guide the client's experiential processing in different ways at different times to promote the type of cognitive and emotional processing that is likely to be most productive at that point and likely to lead to the resolution of relevant tasks.
Emotion plays a central role in this approach. Emotions are seen as organizing processes that enhance adaptation and problem solving. Accessing emotion in therapy, making sense of it by symbolizing it in awareness leads to the promotion of further emotional processing and to narrative change. It is this combination of emotional arousal and narrative meaning that is seen as leading to enduring change. Emotions are therefore evoked in therapy to help people make sense of what they feel and to promote emotional reorganization through the synthesis of previously unavailable internal resources.
Nancy McWilliams: Psychodynamic Therapy
Dr. McWilliams's fascination with individuality has been the engine behind her journey as a therapist. In the therapeutic role — whether she is appreciating individual differences in psychopathology, personality, ethnicity, sexual orientation, life experience, religious belief, or any other phenomena that shape a person's sense of self and create his or her psychological vulnerabilities — Dr. McWilliams tries to attune herself to what it is like for each unique person to engage with the world.
Dr. McWilliams was trained as a psychoanalyst in the tradition of Theodor Reik and was also influenced by the personology of Henry Murray, the affect theory of Silvan Tomkins, the British object relations movement, the American interpersonal movement, and the humanistic, "third-force" psychologists.
In recent years, Dr. McWilliams has been attracted to the writings of relational psychoanalysts and control-mastery theorists. She is temperamentally integrative and resonates to the work of synthesizing theorists like Fred Pine and Martha Stark. Dr. McWilliams appreciates the findings of researchers such as Sidney Blatt, whose studies have revealed a dimension of individual difference with significant implications for how to foster healing, especially from depressive conditions. She pays attention to the empirical literature in areas such as attachment, affect, development, defense, and brain function, as well as research on psychotherapy process and outcome.
What Dr. McWilliams values most about the psychoanalytic tradition is its emphasis on individual subjectivity. Despite the widespread belief that analysts treat all their clients with one inflexible technique, Dr. McWilliams has seen scant evidence for that stereotype. The proverbial fly on the wall watching her with various clients would see continuity in who Dr. McWilliams is, but considerable discontinuity in whether she talks a lot or a little, whether she asks the patient to talk about the past or not, whether she answers questions or explores the motives for asking them, whether she jokes with the client or wonders aloud why the person needs to keep her laughing. Analysts derive their style with any patient from their evolving knowledge of that person in the context of the relationship that develops in the therapy process.
Psychoanalytic therapy does not fit well into the paradigm of an expert applying a technique. It is more like a laboratory in relationship. In this peculiar and safe arrangement, one person is encouraged to say as much as possible about his or her thoughts, feelings, fantasies, wishes, hopes, conflicts, and impulses — especially as they arise within the treatment and are felt toward the therapist — while the other tries to make sense out of these expressions. Repetitive patterns are observed by both parties, and meanings are inferred that cast light on the patient's life outside the consulting room. Beyond those generalities, it is hard to characterize a "typical" psychoanalytic treatment.
When working with anyone, Dr. McWilliams attends constantly to transference phenomena (the ways in which a patient's past experiences shape their responses to the therapist and the therapy), but whether she brings transference issues into their conversation depends on her sense of the person's particular needs. Dr. McWilliams trusts her own subjectivity to register subtle and critical data; she keeps a close eye on her emotional reactions, imagery, and associations to understand what the person is communicating through tone, facial affect, body language, and other nonverbal modes. Whenever possible, she prefers that the client come up with the insights, while she simply facilitates the process of exploration. How one listens is ultimately more important than what one says.
Dr. McWilliams sees herself as in a long line of analysts who have stressed that patients need a new experience, not just new knowledge. At the same time, she is struck with the variability of what patients experience as helping. She does not think there is one therapeutic mechanism: What is helpful varies greatly from person to person. Some people benefit from insight into themselves, others from experiencing a new kind of relationship. Some feel helped by emotional catharsis, while others need to put a cognitive frame around unwieldy feelings. Some need sensitive reflection, and others need blunt confrontation. Clinical and empirical psychoanalytic studies of individual differences help clinicians to make informed choices about what to do with whom, and when.
Dr. McWilliams expects to make mistakes and to disappoint her patients frequently during their struggle together to grasp complicated and difficult issues, and she has learned that her patients profit from opportunities to confront and correct her when she has misunderstood them. These inevitable ruptures in the therapeutic relationship allow clients to learn how damaged relationships may be repaired and strengthened, something many people have not previously experienced. She hopes that her willingness to admit to, and explore the consequences of, her errors also models a capacity for self-acceptance despite imperfection. In her experience, realistic self-acceptance can be more valuable than behavior change per se, though behavior typically changes as self-acceptance increases.
While she is passionate about psychoanalytic therapy, a calling that suits her personality, she believes there are many ways to help people. The temperament of some individuals is not a good fit for the introspective, affectively dense nature of analytic work. Some people need medication, a twelve-step program, cognitive–behavioral treatment, or family systems work more than they need what Dr. McWilliams offers. Other people need different approaches as prerequisites or accompaniments to psychoanalytic collaboration.
Like most people who become therapists out of a wish to help, Dr. McWilliams is grateful for anything that reduces a patient's suffering. But what she most enjoys doing — and what she sees as offering short-term, long-term, and preventive outcomes that go far beyond symptom relief — is intensive psychoanalytic therapy and analysis.
Judith S. Beck, PhD, is the president of the Beck Institute for Cognitive Behavior Therapy in suburban Philadelphia and clinical associate professor of psychology in psychiatry at the University of Pennsylvania. She received her doctoral degree from the University of Pennsylvania in 1982 and currently divides her time among administration, supervision and teaching, clinical work, program development, research, and writing.
Dr. Beck has presented hundreds of workshops nationally and internationally on cognitive therapy for a variety of disorders. She is the author nearly 100 articles and chapters and of the widely adopted textbooks, Cognitive Behavior Therapy: Basics and Beyond, translated into 20 languages, and Cognitive Therapy for Challenging Problems: What to Do When the Basics Don't Work. Her other books include Cognitive Therapy of Personality Disorders, The Oxford Textbook of Psychotherapy, and several books for consumers on the topic of weight loss and maintenance.
Dr. Beck is a founding fellow and past president of the Academy of Cognitive Therapy, a nonprofit organization that certifies mental health professionals in cognitive therapy, and has been a consultant for several National Institute of Mental Health research studies.
Leslie Greenberg, PhD, is distinguished research professor of psychology at York University in Toronto, Canada, and director of the York University Psychotherapy Research Clinic. He has authored the major texts on emotion-focused approaches to treatment, and his next book with Lynne Angus is Working With Narrative in Emotion-Focused Therapy (2011).
Dr. Greenberg is a past president of the Society for Psychotherapy Research (SPR), and he is a recipient of the SPR Distinguished Research Career Award and APA's Carl Rogers Award. He conducts a private practice for individuals and couples and offers training in emotion-focused approaches.
Nancy McWilliams, PhD, is the author of Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (1994; rev. ed. 2011), Psychoanalytic Case Formulation (1999), and Psychoanalytic Psychotherapy: A Practitioner's Guide (2004), and is associate editor of the Psychodynamic Diagnostic Manual.
She teaches at the Graduate School of Applied and Professional Psychology at Rutgers, the State University of New Jersey. She served as president of APA's Division 39 (Psychoanalysis), and she is on the editorial boards of the Psychoanalytic Review and Psychoanalytic Psychology.
Dr. McWilliams has written widely on personality structure and personality disorders, psychodiagnosis, sex and gender, trauma, intensive psychotherapy, and contemporary challenges to the humanistic tradition in psychotherapy. Her books have been translated into 14 languages, and she has lectured widely both nationally and internationally. Her book on case formulation was given the Gradiva Award for best psychoanalytic clinical book of 1999, and in 2004 she was given the Rosalee Weiss Award for contributions to practice by the APA's Division 42 (Psychologists in Independent Practice).
A graduate of the National Psychological Association for Psychoanalysis, she is also affiliated with the Center for Psychoanalysis and Psychotherapy of New Jersey and the National Training Program of the National Institute for the Psychotherapies in New York City. She has a private practice in Flemington, New Jersey.
- Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York, NY: Guilford Press.
- Beck, J. S. (2005). Cognitive therapy for challenging problems: What to do when the basics don't work. New York, NY: Guilford Press.
- Goldman, R. N., Greenberg, L. S., & Angus, L. (2006). The effects of adding emotion-focused interventions to the client-centered relationship conditions in the treatment of depression. Psychotherapy Research, 16, 536–546.
- Greenberg L. (2011). Emotion-focused therapy. Washington, DC: American Psychological Association.
- Greenberg, L., & Goldman, R. (2008). Emotion-focused couples therapy: The dynamics of emotion, love and power. Washington, DC: American Psychological Association.
- Greenberg, L. S., & Watson, J. C. (2006). Emotion-focused therapy for depression. Washington, DC: American Psychological Association.
- McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York, NY: Guilford Press.
- McWilliams, N. (2009). Psychoanalysis. In I. Marini & M. A. Stebnicki (Eds.), Professional Counselor Desk Reference (pp. 289–300). New York, NY: Springer.
- McWilliams, N. (2005). Preserving our humanity as therapists (with critique from and response to John Norcross). Psychotherapy: Theory, Research, Practice, Training, 42, 139–159.
- McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner's guide. New York, NY: Guilford Press.
- McWilliams, N., & Weinberger, J. (2003). Psychodynamic psychotherapy. In G. Stricker & T. A. Widiger (Eds.), Comprehensive Handbook of Psychology, Vol. 8: Clinical Psychology (pp. 253–277). New York, NY: Wiley.
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