Tag Archives: existential therapy

Trichotillomania


The diagnosis of Trichotillomania (TM) is synonymous with the act of recurrently pulling one’s own body hair resulting in noticeable thinning or baldness.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 674)  Sites of hair pulling can include any area of the body in which hair is found, but the most common sites are the scalp, eyelashes, eyebrows, and the pubis area.  (Kraemer, 1999, p. 298)  The disorder itself is categorized in the DSM-IV-TR as an “Impulse Control Disorder Not Elsewhere Classified” along with disorders like Pathological Gambling, Pyromania, Kleptomania, and Intermittent Explosive Disorder.  Although TM was previously considered to be a rare disorder, more recent research indicates that prevalence rates of TM may be as high as 2% of the general population.  (Kraemer, 1999, p. 298)  This prevalence rate is significantly higher than the lifetime prevalence rate of .6% that is cited as a potential baseline among college students the DSM-IV-TR.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 676)  The condition appears to be more common among women and the period of onset is typically in childhood or adolescence. (Kraemer, 1999, p. 298)  As is customary with most DSM-IV-TR diagnoses, the act of hair pulling cannot be better accounted for by another mental disorder (like delusions, for example) or a general medical condition.  Like every disorder in the DSM-IV-TR, the disturbance must cause significant distress or impairment in functioning.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 675)

Alopecia is a key concept that must be understood in order to complete the differential diagnosis of TM.  Alopecia is a condition of baldness in the most general sense.  (Shiel, Jr. & Stoppler, 2008, p. 14)  Other medically related causes of alopecia should be considered in the differential diagnosis of TM, especially when working with an individual who deny pulling their hair.  The common suspects include male-pattern baldness, Discoid Lupus Erythematosus (DLE), Lichen Planopilaris (also known as Acuminatus), Folliculitis Decalvans, Pseudopelade of Brocq, and Alopecia Mucinosa (Follicular Mucinosis).  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 676)  Comprehensive coverage of these medical conditions is beyond the scope of this article – all of the aforementioned confounding variables can be eliminated by a general practitioner.

There are a number of idiosyncratic features associated with TM that bear mentioning.  Although the constellation of features covered here is not sufficient to warrant a diagnosis in isolation, they can aid in the differential diagnosis process.  Alopecia, regardless of the cause, has been known to lead sufferers to tremendous feats of avoidance so that the hair loss remains undetected.  Simply avoiding social functions or other events where the individual (and their attendant hair loss) might be uncovered is a common occurrence.  In cases where individual’s focus of attention is on the head or scalp, it is not uncommon for affected individuals to attempt to hide hair loss by adopting complimentary hair styles or wearing other headwear (e.g., hats, wigs, etc).  These avoidance behaviors will be the target of exposure and response prevention later in this article.

In addition to avoidant behavior and elaborate attempts to “cover it up,” individuals with TM frequently present with clinically significant difficulty in areas such as self-esteem and mood.  Comorbidity, or the presence of one or more disorders in the addition to a primary diagnosis, is the rule not the exception in the stereotypical presentation of TM.  Mood disorders (like depression) are the most common (65%) – anxiety (57%), chemical use (22%), and eating disorders (20%) round out the top four mostly likely candidates for comorbidity.  (Kraemer, 1999, p. 298)  These comorbidity rates are not overly surprising since they parallel prevalence rates across the wider population – perhaps with the notable exception of the high rate of comorbid eating disorders.  We can speculate about the source of comorbidity – one possible hypothesis is that a few people who suffer TM also suffer from a persistent cognitive dissonance associated with having happy-go-lucky personality trait which leads them “let the chips fall where they may.”  They are individuals prone to impulsivity, but they are subdued and controlled the shame, guilt, frustration, fear, rage, and helplessness associated with the social limitations placed on them by the disorder.  (Ingram, 2012, p. 269)  On the topic of personality, surprisingly enough, research suggests that personality disorders do not share significant overlap with TM.  This includes Borderline Personality Disorder (BPD) despite the fact that BPD is often associated with self-harming behavior.  (Kraemer, 1999, p. 299)

Differentiating TM from Obsessive-Compulsive Disorder (OCD) can be challenging in some cases.  TM is similar to OCD because there is a “sense of gratification” or “relief” when pulling the hair out.  Unlike individuals with OCD, individuals with TM do not perform their compulsions in direct response to an obsession and/or according to rules that must be rigidly adhered to.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 676)  There are, however, observed similarities between OCD and TM regarding phenomenology, neurological test performance, response to SSRI’s, and contributing elements of familial and/or genetic factors.  (Kraemer, 1999, p. 299)  Due to the large genetic component contributions of both disorders, obtaining a family history (vis-à-vis a detailed genogram) is highly recommended.  The comprehensive genogram covering all mental illness can be helpful in the discovery the comorbid conditions identified above as well.

There is some suggestion that knowledge of events associated with onset is “intriguing, but unnecessary for successful treatment.”  (Kraemer, 1999, p. 299)  I call shenanigans.  There is a significant connection between the onset of TM and the patient enduring loss, perceived loss, and/or trauma.  Time is well spent exploring the specific environmental stressors that precipitated the disorder.  Although ignoring circumstances surrounding onset might be prudent when employing strict behavioral treatment paradigms, it seems like a terrible waste of time to endure suffering without identifying some underlying meaning or purpose that would otherwise be missed if we overlook onset specifics.  “Everything can be taken from a man but one thing: the last of human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way.”  (Frankl, 1997, p. 86)  If we acknowledge that all behavior is purposeful, then we must know and understand the circumstances around onset if we will ever understand the purpose of said behavior.  I liken this to a difference in professional opinion and personal preference because either position can be reasonably justified, but in the end the patient should make the ultimate decision about whether or not to explore onset contributions vis-à-vis “imagery dialogue” or a similar technique.  (Young, Klosko, & Weishaar, 2003, p. 123)  If such imagery techniques are unsuccessful or undesired by the client, a psychodynamic conversation between “internal parts of oneself” can add clarity to the persistent inability of the client to delay gratification.  (Ingram, 2012, p. 292)  Such explorations are likely to be time consuming, comparatively speaking, and should not be explored with patients who are bound by strict EAP requirements or managed care restrictions on the type and length of treatment.  Comorbid developmental disabilities and cognitive deficits may preclude this existential exploration.  I employ the exploration of existential issues of origin in the interest of increasing treatment motivation, promoting adherence, enhancing the therapeutic milieu, and thwarting subsequent lapses by anchoring cognitive dissonance to a concrete event.

TM represents a behavioral manifestation of a fixed action patterns (FAPs) that is rigid, consistent, and predicable.  FAPs are generally thought to have evolved from our most primal instincts as animals – they are believed to contain fundamental behavioral ‘switches’ that enhance the survivability of the human species.    (Lambert & Kinsley, 2011, p. 232)  The nature of FAPs that leads some researchers to draw parallels to TM is that FAPs appear to be qualitatively “ballistic.”  It’s an “all or nothing” reaction that is comparable to an action potential traveling down the axon of a neuron.  Once they are triggered they are very difficult to suppress and may have a tendency to “kindle” other effects.  (Lambert & Kinsley, 2011, p. 233)

There are some unique considerations when it comes to assessing a new patient with TM.  Because chewing on or ingesting the hair is reported in nearly half of TM cases, the attending clinician should always inquire about oral manipulation and associated gastrointestinal pain associated with a connected hair mass in the stomach or bowel (trichobezoar).  Motivation for change should be assessed and measured because behavioral interventions inherently require a great deal of effort.  Family and social systems should not be ignored since family dynamics can exacerbate symptomatlogy vis-à-vis pressure to change (negative reinforcement), excessive attention (positive reinforcement), or both.  (Kraemer, 1999, p. 299)

What remains to be seen is the role of stress in the process of “triggering” a TM episode.  Some individuals experience an “itch like” sensation as a physical antecedent that remits once the hair is pulled.  This “itch like” sensation is far from universal.  Some clinicians and researchers believe that the abnormal grooming behavior found in TM is “elicited in response to stress” with the necessary but not sufficient condition of “limited options for motoric behavior and tension release.”  (Kraemer, 1999, p. 299)  Although this stress hypothesis may materialize as a tenable hypothesis in some cases, it’s by no means typical.  Most people diagnosed with TM report that the act of pulling typically occurs during affective states of relaxation and distraction.  Most individuals whom suffer from TM do not report clinically significant levels of anxiety as the “trigger” of bouts of hair pulling.  We could attribute this to an absence of insight regarding anxiety related triggers or, perhaps anxiety simply does not play a significant role in the onset and maintenance of hair pulling episodes.  Regardless of the factors that trigger episodes, a comprehensive biopsychosocial assessment that includes environmental stressors (past, present and anticipated) should be explored.

The options for treatment of TM are limited at best.  SSRIs have demonstrated some potential in the treatment of TM, but more research is needed before we can consider SSRIs as a legitimate first-line treatment.  SSRIs are worth a shot as an adjunct treatment in cases of chronic, refractory, or treatment resistant TM.  I would consider recommending a referral to a psychiatrist (not a general practitioner) for a medication review due in part to the favorable risk profile of the most recent round of SSRIs.  Given the high rate of comorbidity with mood and anxiety disorders – if either is anxiety or depression are comorbid, SSRIs will likely be recommended regardless.  Killing two birds with one stone is the order of the day, but be mindful that some medication can interfere with certain treatment techniques like imaginal or in vivo exposure.  (Ledley, Marx, & Heimberg, 2010, p. 141)  Additional research is needed before anxiolytic medications can be recommended in the absence of comorbid anxiety disorders (especially with children).  Hypnosis and hypnotic suggestion in combination with other behavioral interventions may be helpful for some individuals, but I don’t know enough about it at this time to recommend it.  Call me skeptical, or ignorant, but I prefer to save the parlor tricks for the circus…

Habit reversal is no parlor trick.  My goal isn’t to heal the patient; that would create a level of dependence I am not comfortable with… my goal is to teach clients how to heal themselves.  Okay, but how?  The combination of Competing Response Training, Awareness/Mindfulness Training, Relaxation Training, Contingency Management, Cognitive Restructuring, and Generalization Training is the best hope for someone who seeks some relief from TM.  Collectively I will refer to this collection of techniques as Habit Reversal.

Competing Response Training is employed in direct response to hair pulling or in situations where hair pulling might be likely.  In the absence of “internal restraints to impulsive behavior,” artificial circumstances are created by identifying substitute behaviors that are totally incompatible with pulling hair.  (Ingram, 2012, p. 292)  Just like a compulsive gambling addict isn’t in any danger if spends all his money on rent, someone with TM is much less likely to pull hair if they are doing something else with their hands.

Antecedents, or triggers, are sometimes referred to as discriminative stimuli.  (Ingram, 2012, p. 230)  “We sense objects in a certain way because of our application of priori intuitions…”  (Pirsig, 1999, p. 133)  Altering the underlying assumptions entrenched in maladaptive priori intuitions is the core purpose of Awareness and Mindfulness Training.  “There is a lack of constructive self-talk mediating between the trigger event and the behavior. The therapist helps the client build intervening self-messages: Slow down and think it over; think about the consequences.”  (Ingram, 2012, p. 221)  The connection to contingency management should be self evident.  Utilizing a customized self-monitoring record, the patient begins to acquire the necessary insight to “spot” maladaptive self talk.  “Spotting” is not a new or novel concept – it is central component of Abraham Low’s revolutionary self help system Recovery International.  (Abraham Low Self-Help Systems, n.d.)  The customized self-monitoring record should invariably include various data elements such as precursors, length of episode, number of hairs pulled, and a subjective unit of distress representing the level of “urge” or desire to pull hair.  (Kraemer, 1999)  The act of recording behavior (even in the absence of other techniques) is likely to produce significant reductions in TM symptomatlogy.  (Persons, 2008, p. 182-201)  Perhaps more importantly, associated activities, thoughts, and emotions that may be contributing to the urge to pull should be codified.  (Kraemer, 1999, p. 300)  In session, this record can be reviewed and subsequently tied to “high risk circumstances” and “priori intuitions” involving constructs such as anger, frustration, depression, and boredom.

Relaxation training is a critical component if we subscribe to the “kindling” hypothesis explained previously.  Relaxation is intended to reduce the urges that inevitably trigger the habit.  Examples abound, but diaphragmatic breathing, progressive relaxation, and visualization are all techniques that can be employed in isolation or in conjunction with each other.

Contingency Management is inexorably tied to the existential anchor of cognitive dissonance described above.  My emphasis on this element is where my approach might differ from some other clinicians.  “You are free to do whatever you want, but you are responsible for the consequences of everything that you do.”  (Ingram, 2012, p. 270)  This might include the client writing down sources of embarrassment, advantages of controlling the symptomatlogy of TM, etc.  (Kraemer, 1999)  The moment someone with pyromania decides that no fire worth being imprisoned, they will stop starting fires.  The same holds true with someone who acknowledges the consequences of pulling their hair.

How do we define success?  Once habit reversal is successfully accomplished in one setting or situation, the client needs to be taught how to generalize that skill to other contexts.  A hierarchical ranking of anxiety provoking situations can be helpful in this process since self-paced graduated exposure is likely to increase tolerability for the anxious client.  (Ingram, 2012, p. 240)  If skills are acquired, and generalization occurs, we can reasonably expect a significant reduction in TM symptomatlogy.  The challenges are significant, cognitive behavioral therapy is much easier said than done.  High levels of treatment motivation are required for the behavioral elements, and moderate to high levels of insight are exceptionally helpful for the cognitive elements.  In addition, this is an impulse control disorder… impulsivity leads to treatment noncompliance and termination.  The combination of all the above, in addition to the fact that TM is generally acknowledged as one of the more persistent and difficult to treat disorders, prevents me from providing any prognosis other than “this treatment will work as well as the client allows it to work.”

References

Abraham Low Self-Help Systems. (n.d.). Recovery international terms and definitions. Retrieved August 2, 2012, from http://www.lowselfhelpsystems.org/system/recovery-international-language.asp

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Frankl, V. E. (1997). Man’s search for meaning (rev. ed.). New York, NY: Pocket Books.

Ingram, B. L. (2012). Clinical case formulations: Matching the integrative treatment plan to the client (2nd ed.). Hoboken, NJ: John Wiley & Sons.

Kraemer, P. A. (1999). The application of habit reversal in treating trichotillomania. Psychotherapy: Theory, Research, Practice, Training, 36(3), 298-304. doi: 10.1037/h0092314

Lambert, K. G., & Kinsley, C. H. (2011). Clinical neuroscience: Psychopathology and the brain (2nd ed.). New York: Oxford University Press.

Ledley, D. R., Marx, B. P., & Heimberg, R. G. (2010). Making cognitive-behavioral therapy work: Clinical process for new practitioners (2nd ed.). New York, NY: Guilford Press.

Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. New York, NY: Guilford Press.

Pirsig, R. M. (1999). Zen and the art of motorcycle maintenance: An inquiry into values (25th Anniversary ed.). New York: Quill.

Shiel, W. C., Jr., & Stoppler, M. C. (Eds.). (2008). Webster’s new world medical dictionary (3rd ed.). Hoboken, NJ: Wiley Publishing.

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. New York: Guilford Press.

Theory and Practice of Existential Group Psychotherapy


Abstract

 

A general description of existential theory and process is provided with specific attention given to the interpersonal dynamics of group facilitation.  Aspects that differentiate this approach from practice guided by Applied Behavior Analysis are presented along with a detailed analysis of the specific group demographics that can be well served by this approach.  Finally, a case example is provided as a concrete example of the application of existential thought to the group environment.

**ALL REFERENCES TO ANY INDIVIDUAL OR PERSONS ARE PURELY COINCIDENTAL

 

 

Theory and Practice of Existential Group Psychotherapy

Death – Freedom – Isolation – Meaninglessness… these words can’t conveniently package a product like existential psychotherapy.  “Existentialism is a philosophy that addresses what it means to be human.”  (Gladding, 2008, p. 352)  We would be hard pressed to find “heavier” content to try to assemble and process against the backdrop of group theory and process.  I choose to start with one word.  Why?  That simple word serves as the underlying premise on which a rewarding existential dialogue can be constructed in a group setting, and the foundation on which this essay is constructed.

Why draw attention to death and death anxiety?  Human beings are unique because they strive to persist in the physical world, yet they are aware of the inevitably of death for the majority of their natural lives.  The terror of death is ever-present and of such enormity that a considerable portion of one’s “oomph” is consumed in the practice of denying death.  (Yalom, 1980, p. 41)  How can we combat death anxiety in the group therapy environment?  “A person cannot bear to face the prospect of inevitable death unless he has had the experience of fully living.”  (Yalom, 1980, p. 208)  Existential group psychotherapy aims to provide that experience.

Patients, given the slightest encouragement, will bring in an extraordinary amount of material related to a concern about death.  They discuss the deaths of parents or friends, they worry about growing old, their dreams are haunted by death, they go to class reunions and are shocked by how much everyone else has aged, they notice with an ache the ascendancy of their children, they occasionally take note, with a start, that they enjoy old people’s sedentary pleasures.  They are aware of many small deaths: senile plaques, liver spots on their skin, gray hairs, stiff joints, stooped posture, and deepening wrinkles.  (Yalom, 1980, p. 57)

Why freedom?  Why responsibility?  “As long as patients persist in believing that their major problems are a result of something outside their control- the actions of other people, bad nerves, social class injustices, genes- then we therapists are limited in what we can offer.”  (Yalom, 1995, p. 139)  Although we almost universally attribute a positive connotation to the word “freedom,” existential psychotherapists recognize and emphasize that freedom comes with a tremendous responsibility.  The burden of structuring our individual lives, and taking responsibility for all our choices- past, present, and future- is not a trivial event.  “One is wholly responsible for one’s life, not only for one’s actions but for one’s failures to act.”  (Yalom, 1980, p. 220)  We yearn for autonomy, but we recoil from its inevitable consequences.  Acknowledgement that we are free to choose comes with an embedded acknowledgment that if we have the power to change our circumstances in the present, we also had the ability to make those same changes in the past.  Where did all that time go?  Existential guilt is created because we come to realize that we have consciously chosen not to free ourselves, to keep ourselves in bondage.  We come to the realization that despite our wish for the future to be different, we must mount sufficient will to traverse the chaotic ocean of uncertainty.

A client drove this concept recent.  This particular client suffered from a traumatic brain injury as a young child.  She was diagnosed with a pervasive developmental disability due to the injury and committed to take up residence in a group home setting for people with developmental disabilities.  It would suffice to say that this individual was very angry with the situation and had an exceptionally difficult time dealing with her persistent desire to live independently.  Although the supporting staff had clearly designated the goal as “a free and autonomous life without need for support” it was clear that the individual served didn’t feel that way.  The individual coveted the luxuries independence, but there was an underlying existential concern that stood opposed to that goal… “if I recover, I will no longer get the support she have become accustomed to.”  The checks from the state will stop.  No more safety-net.  If she fails- she fails and suffers the consequences of failure like everyone else – and that was a scary concept.  Despite repeated encouragement that she was “high functioning enough” to live independently, and reassurances that the agency wasn’t just going to “shove her out the door,” that underlying fear of freedom led to repeated incidents of aggressive behavior that served to insure that the individual would never been removed from the support of the state or the agency entrusted with her care.  The individual “cursed the safety net” while simultaneous embracing it.  She demanded more autonomy and fewer restrictions, yet refused move in that direction for fear that she might appear to be “too competent.”  Real freedom means she had the freedom to fail- and that was unacceptable.  I submit that this cycle of learned helplessness occurs more often than we are willing to admit, especially in the context of supporting individuals with developmental disabilities.

 

Why existential isolation?  There are three types of isolation: interpersonal, intrapersonal, and existential.  Interpersonal isolation is typically experienced as loneliness, and generally refers to the isolation from other individuals.  (Yalom, 1980, p. 353)  Conversely, intrapersonal isolation takes place when we stifle our feelings and subsequently accept “oughts” or “shoulds” (borrowed from Rational Emotive Behavior Therapy and Dr. Albert Ellis) as our own wishes.  (Yalom, 1980, p. 354)  Existential isolation refers to the most fundamental isolation – isolation both from creatures and from the world.  It is the “unbridgeable gulf between oneself and any other being” or thing.  (Yalom, 1980, p. 355)  Our wish to be part of a larger whole hangs in the balance.  No one captures the spirit of existential isolation like Yalom (1980) when he wrote:

We are all lonely ships on a dark sea.  We see the lights of other ships- ships that we cannot reach but whose presence and similar situation affords us much solace.  We are aware of our utter loneliness and helplessness.  But if we can break out of our windowless monad, we become aware of the others who face the same lonely dread.  Our sense of isolation gives way to a compassion for the others, and we are no longer quite so frightened.  (p. 398)

I am wholly in agreement with Yalom (1980) that the best way to combat isolation in all its forms, at least within the context of group therapy, is to foster genuine relationships.  “This requires the therapist to approach the patient without presuppositions, to focus on the project of sharing the patient’s experiences without rushing in to judge or stereotype the patient.”  (Yalom, 1980, p. 409)  In the selfless act of genuine caring the therapist emits “non-conditional” love that transcends “rebelliousness, narcissism, depression, hostility, and mendacity.  In fact, one might say that the therapist cares because of these traits, since they reflect how much the individual needs to be cared for.”  (Yalom, 1980, p. 408)  This concept translates easily into the group therapy environment.  It has been said that “a freely interactive group, with few structural restrictions, will, in time, develop into a social microcosm of the participant members.”  (Yalom, 1995, p. 28)  If an individual group member chooses to stub out anything that resembles an interpersonal supporting structure in their real lives, it should come out in the group.  It is the responsibility of the existential group leader to embolden members to accept personal responsibility for the choices that have led to interpersonal isolation – to provide tools to evade mechanisms of intrapersonal isolation – and to underscore the importance of a “here-and-now focus” through “process illumination.”  (Yalom, 1995, p. 139)

 

Why do we live?  How shall we live?  Making meaning matter.  The existential dynamic conflict of meaninglessness is fueled by meaning seeking human beings who are inescapably thrown into a universe that is devoid of meaning.  Some of the world’s finest minds have approached it from various positions in effort to reveal its raw materials.  Among them, Jung suggests that meaning is merely the recognition of patterns of order.  (Storr, 1983, p. 26)  Gabriel Marcel sits in communion – a valiant effort to protect his subjectivity from annihilation at the hands of materialism.  Jean-Paul Sartre is nauseated by the transcendent cup of consciousness he called – “other.”  Nietzsche’s dead gods yearn for their will to power.  Søren Kierkegaard leaps into a subjective faith while Dostoevsky enlists spiritual values in a timeless war against the hands of evil.  Kafka’s pen drips with characters discovering the depths of alienation and persecution.  Yalom stares at the sun.

 

What we must do is plunge into one of the many possible meanings, particularly one with a self transcendent basis.  It is engagement that counts, and we therapists do most good by identifying and helping to remove the obstacles to engagement.  The question of life is, as the Buddha taught, not edifying.  One must immerse oneself into the river of life and let the question drift away.  (Yalom, 2002, p. 135-136)

 

What populations do existential groups NOT work for?  Existential groups come with some limitations that are inherent in the underlying philosophy, and other limitations that are specific to individual participants in the group.  First among them is a concern that existential groups only benefit members who are verbal, communicative, and unafraid to confront painful issues.  (Gladding, 2008, p. 357)  Tackling concepts like death and the meaning of life aren’t for the faint of heart.  Because of the primacy and intimacy of the content, use is primarily confined to counseling and psychotherapy settings.  Existential concerns are wholly inappropriate for most psycho-educational, task, or work groups.  The approach takes considerable amounts of maturity, life experience, and close supervision and is not recommended which presents a significant obstacle for developing group leaders.  Finally, existentialism and existential groups are characterized as being broadly based because they generally don’t deal with specific behaviors or concerns.  As a result, “group members who need information or immediate answers are not good candidates for these groups.”  (Gladding, 2008, p. 358)

 

“It’s complicated.”  Let us, if we can, bring this conversation back down to earth and use a concrete example – a group activity focused on defining our relationship with our significant other.  It’s complicated is an existential group activity that forces participants to qualitatively explain and justify the relationship status that they pick on Facebook.  It’s based on a very fundamental concept – the relationships we keep are chosen by us, not for us.  The options are many – single, engaged, married, widowed, separated, or divorced.  Perhaps it’s just a relationship, open or otherwise, that defies all of the above.  It could be labeled a civil union, or a domestic partnership.  Last, but certainly not least, there is the most popular choice… “It’s complicated.”  Existential group psychotherapy was tailor-made for “it’s complicated.”  The beauty of the search is that the journey is as important as the destination, and the process of getting there is much more enriching than actually arriving (if that is even possible).

What differentiates existential psychotherapy from other theories?  Yalom defines existential psychotherapy as “a dynamic approach to therapy which focuses on concerns that are rooted in the individual’s existence.”  (Yalom, 1980, p. 5)  Like its Freudian psychodynamic predecessor, existential psychotherapy moves under the tacit assumption that there are “forces” that exist at assorted levels of awareness.  It’s a precious gift of insight surrounded by layer upon layer of repression, denial, displacement, and symbolization.  It’s learning to make choices under the eternal auspice of the future becoming the present.  It’s a royal road that can be traversed in “deep reflection, dreams, nightmares, flashes of profound experience and insight, psychotic utterances, and the study of children.”  (Yalom, 1980, p. 6) 

Comparatively speaking, behavioral psychotherapists rely primarily on what and when questions that focus on the environmental conditions that exist before, during, and after a behavioral episode.  They would much prefer to avoid the question of why.  The question why tends to evoke “mentalistic explanations that are of little value” to a behaviorist who is attempting to understand the behavior of interest.  An existential line of questioning that demands an inquiry into the reason why could be viewed as encouraging “motivational” reasons that are “usually uninformative” to a behaviorist.  (Cooper, Heron, & Heward, 2007, p. 50)  Generally speaking no existential psychotherapist is going to avoid or evade questions about what and when, but I wonder if I am the only one who sees some irony in the dichotomy.  Surely if you ask a behaviorist why someone behaves the way they do they would provide you with an answer, yet they evade motivational questions to which they have no behavioral solutions.  A stalwart behaviorist doesn’t care why because he thinks he knows why.

“A real change occurring in the absence of action (behavior) is a practical and theoretical impossibility.”  (Yalom, 1980, p. 287)  Behaviorists prefer to define behaviors functionally.  “Functional definitions are often simpler and more concise than topographical definitions, leading to easier, more accurate, and more reliable measurement.  (Cooper et al., 2007, p. 66)  Herein lays the problem – “The precision of the result is directly proportional to the triviality of the variable studied.”  (Yalom, 1980, p. 24)  I challenge any behavior oriented therapist to functionally define a concept like love, for example.  “The good therapist fights darkness and seeks illumination, while romantic love is sustained by mystery and crumbles upon inspection.  I hate to be love’s executioner.”  (Yalom, 1989, p. 17)  I’m not suggesting that it’s not worthwhile to document the antecedent, behavior, and consequences of a given behavior- I am suggesting, however, that there are a limited number of conclusions that can be definitively drawn from the discriminated operant and three-term contingency embodied in the antecedent, behavior, and consequence model of behaviorism.  Theory grounded in applied behavior analysis will freely admit that behavior repertoires can appear quickly.  Behavior can spontaneously erupt with little or no direct conditioning.  Behaviorism can offer no real explanations in matters of the heart, and I submit to you that matters of the heart are where the bulk of our work resides.  The opportunity that lurks in the darkness of the unconscious mind cannot reason with our feelings, thoughts, or behavior.

 

References

Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis (2nd ed.). Upper Saddle River, NJ: Pearson Education.

Gladding, S. T. (2008). Groups: A counseling Specialty (6th ed.). Upper Saddle River, NJ: Pearson Education.

Storr, A. (1983). The essential jung. Princeton, NJ: Priceton University Press.

Yalom, I. D. (1980). Existential Psychotherapy. New York: Basic Books.

Yalom, I. D. (1989). Love’s executioner (Harper Perennial ed.). New York: HarperCollins.

Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York, NY: BasicBooks.

Yalom, I. D. (2002). The gift of therapy (Harper Perennial ed.). New York: HarperCollins.

Counseling’s Founding Fathers


There are many people who have influenced the therapy and counseling world but there are a few who have been the most influential. Sigmund Freud is probably the most known and influential in therapy. He developed his own ideas on a variety of topics and taught many people about what he learned. While doing this he sparked several peoples’ interest in the psychoanalyst world. When they began forming their own opinions many of them branched off and began their own school of thought. Unfortunately, because Freud had a low tolerance when people disagreed with him, many of the friendships and collaborations ended. Among these broken friendships came several different points of view. The points of view are from Alfred Adler M.D., Karl Abraham, and Carl Jung. Each of these men studied with Freud for a period of years and then decided on a different point of view and the end result was the breakup of the friendship, with the exception of Karl Abraham, who stayed loyal to Freud and continued to view things as Freud had taught.

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Alfred Adler M.D. was born in Vienna, Austria. He had five siblings and his Father was a corn trader. Growing up he contracted many illnesses and physical ailments, he was quite an unhealthy child. There were two different points in his life where he was run over by a car.

When he was old enough for college, his original goal was to become an ophthalmologist, but later switched to neurology. He had many interests that included philosophy and politics. He was extremely interested in socialism where politics were concerned.

Adler became an associate of Freud’s in Vienna and during that time he researched what he coined Individual Psychology and he developed his theory of human behavior which had a lot of impact on various areas within the counseling field, including education, social sciences, psychology, and psychotherapy. Some of Adler’s techniques have been widely used in many different types of therapy, including Cognitive Behavior Therapy, Solution Focused Therapy, Existential Therapy, and Holistic Therapy. He was among the first therapists to use psychotherapy that was focused and solution oriented but at the same time was much shorter in duration and allowed the patient to be as involved in treatment as the therapist. Typically he would limit a client’s sessions to no more than twenty. He didn’t focus on the patient’s past because he didn’t feel that their past could really define them or that it could dictate the person’s present or future. Because of his beliefs, the Alderian theory makes the assumption that if a person is centered in their own present tense, the way that person looks at the future and expects it to come about can affect the way that person remembers their own past. This belief also helps Alderian therapists create treatment plans that are unique to each client’s situation and needs.

In 1911 Adler separated from Freud because he didn’t believe that sex was the root of neurosis as Freud did. Adler instead thought that when a child experienced feelings of helplessness they would have an inferiority complex later in life. Adler’s theory tried to show how positive social interaction could help treat people with an inferiority complex. This was attributed to his beliefs that humans are goal oriented and need social interaction.

Adler opened Vienna’s first child guidance clinic in 1921 and was able to design tools for parents like educational programs because he was so devout when it came to the prevention of mental health illnesses. He believed if the basic relationships between parents and children and teachers and children were positive, then peoples’ quality of life could be made better for the entire society.

Karl Abraham did not start out studying under Sigmund Freud, he started out instead studying with Carl Jung. When he was chief physician in a psychiatric ward during World War I, war neuroses piqued his interest. He went on to become the founder of the Berlin Psychoanalytic Institute which helped other psychoanalysts work in Germany, Great Britain, and the United States.

Abraham’s interests were geared toward the stages of psychosexual development and their relational patterns. His work helped to pave the way for this type of research both in the United States and in Great Britain. He was one of the very first people to study war neuroses although he mainly concentrated on studying dreams as well as myths and symbols.

Abraham’s contributions to psychoanalysis ranged from sexuality and character development to the psychoanalytical interpretation of dreams and symbolism. He showed how sucking and biting as an infant can affect the development of the libido, saying these two activities give infants their first conflicts. His research in psychosis showed that the disturbances in the libido take more of a toll than other disturbances such as the ego, and he used his theories in the research of schizophrenia.

He separated from Carl Jung because their views became different and Abraham began to see Jung’s practices as a hinder, not a help where psychoanalysis was concerned. When he started collaborating with Freud they studied manic depressive illness.

Carl Jung was a Swiss psychologist who was as influential as Sigmund Freud. He was born in Kesswil in Switzerland. His original intent was to study archeology, but the family finances made it impossible because the schools that taught archeology were too far away and made them too expensive to get to. He settled for studying medicine at the University of Basil, this is where he chose psychiatric medicine as his specialty.

When Jung collaborated with Freud they both studied the unconscious and many of Jung’s findings corroborated a lot of Freud’s ideas. After more than six years of researching together, Jung and Freud’s differing views of the nature of libido and religion finally breaks them apart. Jung felt Freud’s views relied too heavily on pointing toward sexuality when human behavior or psychological complexes was being researched.

Jung’s views were based on the thinking that the unconscious has a creative capacity. He felt that the unconscious serves a positive role in the human culture. Jung had many other interests including flying saucers, he believed they were a sort of psychic projection, he also felt these psychic projections were caused by the global hardships during that time. At one point, Jung went to India where he dreamt of things surrounding King Arthur. These dreams were interpreted by Jung as a message that he should be watchful of Western Spirituality. He did study Western Spirituality which led to interests in mystical traditions, esoteric Christianity and alchemy. When he spoke of what he learned about precognition and parapsychology, the response he received was less than desirable, this also helped lead to the termination of Freud and Jung’s relationship.

Jung developed many opinions of his own including one about the conscious and unconscious being united. He said if this were to happen then the person would actually come to realize their own potential. His work has contributed to the realization of personality tests which are used by many organizations today.

Sigmund Freud has often been called the father of psychoanalysis.  He was an Austrian neurologist as well as a psychiatrist and he co-founded the Psychoanalytic School of Psychology.  He started out planning to study law and was a student at the University of Vienna.  It was at this point that he published his first paper called, “the testicals of eels”.  Some people feel it was because of the research associated with this paper that he seemed to have related his work to signs of hidden sexuality.  In this research he was unsuccessful in finding the male genetalia of eels.

Although he is widely known for his theories related to the unconscious mind, they are controversial and many people not only disagree with them, they call them completely false.  Early on he tried to use hypnosis on patients who were diagnosed as hysterical.  This brought about several confessions of seduction or molestation.  When he was told about a molestation occurring where his friend was the victimizer he classified the confessions as false or made up.

He was among the first to choose talk therapy where the patients had the opportunity to work through their problems by talking through them.  This is now cognitive therapy and Freud’s talk therapy is where it started.

Despite all of his success he still came to suffer from some psychosomatic disorders as well as many phobias.  He used these as a chance to analyze himself as he sorted through his dreams and memories as well as noting what he found about how his personality developed over time.  Once he started looking so closely at this part of himself he discovered that he felt a genuine hostility toward his father as well as realizing that he had sexual feelings toward his mother.

Freud researched the unconscious mind for many years, determining dreams to be the road to the unconscious but after developing and redeveloping the different stages of the unconscious he abandoned it for the concept of the Ego, Super-ego and id.  This theory was about how children go through these stages in order to reach sexual maturity.  Their sexuality would be defined by a strong ego and they would delay gratification.  He also believed that all people have a strong desire for incest and that it must be held back in order to be accepted socially.

Freud, when faced with terminal mouth cancer and after more than 30 surgeries requested to have assisted suicide from his doctor and his friend for which he was obliged, he was given a triple dose of morphine every hour throughout the night after which he passed on.

As stated earlier, Freud’s work has always been and still is considered controversial but just as this is true; it is also true that his impact where psychotherapy is concerned has been seen throughout the years.  His theories and research is referenced by many people throughout the profession.

These men have all been connected at some point in their lives when it comes to their work.  Even though they have researched the same things they have each come up with their own opinions and ideas and eventually broke apart because of them.  The work of each person has sent psychotherapy in a different direction and continues still to influence therapy and research happening today.

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References:

Carl Jung. www.newworldencyclopedia.org;

Karl Abraham. www.newworldencyclopedia.org;

Alfred Adler. www.newworldencyclopedia.org;

Sigmund Freud. www.newworldencyclopedia.org;

Why Should Psychotherapists Be Excited About Adler? Carlson, J., Watts, R., Maniacci, M.

Pick 4 Psychoanalysis Theories! Which do you favor, and why?


My plan is to specialize in Applied Behavior Analysis (ABA).  I like the concept of direct and frequent measurement of variables that can me quantitatively or qualitatively measured.  I like the transparency of the ABA discipline.  “Everything about ABA is visible and public, explicit and straightforward… ABA entails no ephemeral, mystical, or metaphysical explanations; there are no hidden treatments; there is no magic.”  (Cooper, Heron, & Heward, 2007, p. 18-19)  ABA is committed to resolving real world issues not theoretical quandaries.  It’s sensible, it’s practical, and it’s in demand.  ABA focuses on the behavior that needs improvement, not just any behavior. Good results are measurable, conceptually systematic, and able to be replicated.  Finally, a good theory must possess generality of the in the respect that it lasts over time and it appears in environments other than the one in which it was observed.  ABA relies on operant conditioning with the fundamental assumption being that behavior is a function of its consequences.  I intend to make use of positive and negative reinforcement, token economies, extinction, and stimulus control.  I’m not ready to rule out cognitive processed entirely because I want to keep an open stance, but right now, I am “all in” with ABA (more specifically, Dialectical Behavior Therapy (DBT), role-playing, behavioral observation, guided imagery.  If there’s anything I don’t like about ABA, it’s the measure of control that is required to do it right… I would like to soften that requirement a bit and do observation in a more natural setting… the inpatient clinical environment is too artificial to get good measurements or results that can be generalized.

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I really enjoy reading Carl Jung despite the fact that he has fallen out of favor with many of the movers and shakers in psychology.  Conceptually speaking it is a lot different than ABA, but I see some synergy there that is untapped.  Specifically, I really buy the concept of Enantiodromia.  “This word refers to Heraclitus’ law that everything sooner or later turns into its opposite.”  (Corsini & Wedding, 2011, p. 123)  Please forgive the lack of a citation because it comes from memory… but Carl Jung said “the word happiness would lose its meaning if it were not balanced by sadness.”  It’s a concept I will never forget, so, I’d like to learn more about Carl Jung and Analytical Psychotherapy.  The only part I don’t like about Analytical Psychotherapy that is it’s not as practical as “brief therapy” techniques that are more pragmatic.  Realistically, how often am I going to get the opportunity to go 20 sessions + with someone with EAP and managed care looming around the corner?  Not often, I suppose.  It’s more likely to be the croutons on my metaphorical presentation salad, there’s too much meat and too many vegetarians to serve Analytical Psychotherapy as the main course in 22nd Century counseling.  It’s still an intriguing option nonetheless, one that I will definitely continue to read whether it’s assigned or not… it interests me.

I would have put existential therapy at the top of the list if it were a legitimate “stand alone” school of therapy.  I really enjoy the duality and the conflict involved in relativism.  I like shooting for the moon… talking about the BIG PROBLEMS (Death, The Meaning of Life, etc).  I really like that it is more person centered and holistic, as compared to reductionist (like ABA).  I like the idea of creating meaning for people… love, marriage, family, religion, etc.  (Corsini & Wedding, 2011, p. 340)  I would, however, like to bring it back down to earth, if you will… it’s a bit “out there” sometimes.

My last choice would have to be Cognitive Therapy for no other reason that it is so dominant in the field right now.  It seems to be the tool of choice for most people, I don’t suspect we will have any difficulty finding someone to write on this one.  I like the concept of guided discovery, and I am particularly drawn to cognitive restructuring as it relates to phobias, OCD, and eating disorders.  If I had a problem with cognitive therapy at all, it’s that everyone is doing it… and while I can hardly afford to neglect it, CBT just doesn’t “excite me” like the opportunity to measure behavior.  Mostly a personal preference I suppose.

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References

Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis (2nd ed.). Upper Saddle River, NJ: Pearson Education.

Corsini, R. J., & Wedding, D. (2011). Current psychotherapies (9th ed.). Belmont, CA: Brooks/Cole.