Psychotherapy: A Practical Guide

274 Pages·2016·26.349 MB·English

by  Jeffery Smith

Jeff ery Smith
Psychotherapy
A Practical Guide
123
Psychotherapy
Jeffery Smith
Psychotherapy
A Practical Guide
Jeffery Smith
New York Medical College
Valhalla
New York
USA
www.howtherapyworks.com
[email protected]
ISBN 978-3-319-49459-3 ISBN 978-3-319-49460-9 (eBook)
DOI 10.1007/978-3-319-49460-9
Library of Congress Control Number: 2016961346
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Foreword
The practice of psychotherapy has evolved over more than 100 years through various
theoretical explanatory models and, correspondingly, many varieties of therapeutic
techniques. Some approaches focus on the centrality of emotion, while others focus on
cognition and manifest behavior. Simultaneously, some techniques call for psychothera-
pist “neutrality” as others call for “active engagement.” Competing volumes on this
subject often seem devoted to the demonstration of the “specificity”—implicitly,
“superiority”—of a particular psychotherapy model, and hence technique, over others.
To his great credit, Jeffery Smith, MD, takes a stance that can be considered
“atheoretical,” or respectful of many different psychotherapy traditions. A well-
trained and long-experienced psychotherapist, Dr. Smith focuses on the centrality of
the patient-therapist relationship, which remains the central dyadic force in all mod-
els of individual psychotherapy. This applies to the rest of medicine too, a fact often
neglected in the current era of the “industrialization” of the practice of medicine. It
is in the establishment of the psychotherapeutic dyad, with a psychotherapist stance
of safety provision, that the patient is able to most fully explore both the emotional
and cognitive experiences that underlie so much of psychiatric illness.
Unique to this book, Dr. Smith introduces the concept of the entrenched dysfunc-
tional pattern (EDP) and the affect avoidance model, newly proposed terms that
represent a series of explanatory schemas and the resultant avoidance of associated
painful affects to describe deficits in the intrapsychic space expressed in clinical
symptoms. He uses elements of recent advancements in the neurosciences, includ-
ing discussion of learning, long-term potentiation, and neuroplasticity, to propose
neural network underpinnings of clinical phenomena seen in patients. Pertinent to
actual psychotherapeutic technique, he uses the metaphor of the patient’s “inner
child” to advise psychotherapists in the exact approaches to patients who have
experienced long-term suffering (often the residua of abuse experiences) and to thus
assist in targeted psychotherapeutic techniques, particularly as relates to strongly
held emotional material. By psychotherapists understanding EDPs and the affect
avoidance model, patients can then be effectively guided to examine, break down,
analyze, and thus modify dysfunctional emotions and behaviors, ultimately adapt-
ing to a higher degree of psychiatric function.
Why a new instruction book on psychotherapy now? The rising degree of eco-
nomic prosperity and growth in a modernizing and socially interconnected world
v
vi Foreword
surely represents great progress. However, as more people function at a higher
social level, the adverse experience of neurotic and social conflict becomes much
more manifest at a population level. Such empowered, yet symptomatic, patients
will seek out psychotherapy to address these concerns. Simultaneously, diffusion of
information technology gives people everywhere prompt access to the latest
advancements in the clinical literature. Given the need for more access to, and
expectations of success in, psychotherapy, instructional books on the techniques of
psychotherapy necessarily need to be accessible to clinicians from various profes-
sional disciplines and backgrounds. Dr. Smith’s book, describing in a pragmatic
way the elements of various psychotherapy models, provides a synthesis that is as
timely as it is concisely written. It will be of value in training programs for begin-
ning psychotherapists and is a helpful resource for more experienced psychothera-
pists as well. This book should be of particular use in master of social work and
psychiatric nurse practitioner training programs, and a valuable addition for clinical
psychology doctorate programs and psychiatry residency programs.
Anyone interested in the “how and why” of psychotherapy will find this volume to
be an engaging read. For beginning students, the extensive discussion of the momen-
tary experiences within psychotherapy sessions will serve to ground them in basic
psychotherapeutic techniques and prepare them for more productive use of psycho-
therapy supervision of their cases. For the established clinician, the thoughtful organi-
zation of this book will serve to buttress the psychotherapist’s existing strengths while
inspiring still greater mastery. Finally, teachers of psychotherapy now have a volume
that will prove versatile in the areas of basic instruction, technique, and supervision.
With the contemporary pressures to expect all clinical interventions to be patient-
centered, cost-effective, and justified in terms of outcomes, Dr. Smith helps to refine
the powerful role that psychotherapy will continue to play in the management of
psychiatric illness, which is finally being recognized as a major source of disability
worldwide. He advances the field of psychotherapy scholarship at a time when we
in academic psychiatry need to more fully understand and appreciate the role of this
most central of psychiatric interventions.
Dr. Smith has capitalized on his own long experience, seasoned by thoughtful
reflection, to develop a remarkably unifying theoretical framework of understanding
of disorders of emotions, thoughts, and behaviors, which translates into a cogent and
patient-centered approach to psychotherapy. Readers have the opportunity to learn
from his experience in this concise yet thoughtfully thorough book, masterfully and
lovingly provided for the field to share. We are all enriched by this contribution to the
psychiatric literature.
James A. Bourgeois, OD, MD
University of California
San Francisco, USA
Acknowledgments
Since this book is, in a way, the culmination of a career, I owe gratitude to all those
who have inspired and supported me on my journey. First, and most of all, thanks to
Claude, my wife, who stuck with me all the way.
Dr. P., my therapist in college, gave me a taste of what it is to have someone to
talk to. Dr. Stilwell took me seriously when I said I wanted to go to medical school.
J.C.B. Grant, my anatomy professor, showed us how to discern the natural divisions
between structures. Dr. Obeid, “The Ear,” taught how to listen to the heart. Milt
Rosenbaum demonstrated how to connect with patients, and Joel Kovel told me to
go ahead and “mix it up” with them. Leon Balter not only insisted on rigor when it
came to theory but shared his private knowledge of identification with the aggressor.
With Eleanor Galenson, I learned to see the world through the eyes of children. John
Moneypenny was the recovering alcoholism counselor who introduced me to the
wisdom of AA. Dr. H., my therapist, helped me untangle my past.
To my patients I owe enormous gratitude. They taught me, lesson by lesson, a
large part of all I know about healing and growth.
I am grateful to Cindy for urging me to write long before anyone else and to
Robert Oxnam, my second DID patient, who asked me to write an epilogue to his
book, A Fractured Mind: My Life with Multiple Personality Disorder. In doing so,
he gave me my first taste of writing for the reading public.
Thanks to Maj-Britt Rosenbaum for giving me the break that started my private
practice and to Dr. Jim Walkup, who picked up the baton from there. Since the early
1980s, Dr. Michael Blumenfield has quietly encouraged me on every turn of my
pathway, starting with the American Psychiatric Association. He also urged me to
join the American Academy of Dynamic Psychotherapy and Psychoanalysis, where
I met Jim Bourgeois, my writing mentor. Thanks to John Norcross and SEPI, the
Society for the Exploration of Psychotherapy Integration, for providing a supportive
and welcoming intellectual home.
I am grateful to Shelley and Margot, my two development editor sisters who sup-
ported and encouraged my writing, and especially to my daughter, Anne, who has
been a constant source of warm encouragement.
Finally, Rachel Trusheim, my editor, has been a super cheerleader and subtle
helper in shaping and refining this book.
vii
Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Part I How Therapy Works
2 Layers of Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.1 Jack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.2 Dividing the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.3 Jack’s Personality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.4 Dealing with Jack’s Reluctance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.5 Jack’s Panic Attack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.6 Asking Why . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.7 A Third Module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.8 A More Complete Picture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.9 The Basic Unit of Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.10 A dvantages of the EDP Concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.11 Resisting Positive Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.12 A Fresh Approach to Jack’s Treatment . . . . . . . . . . . . . . . . . . . . . . . 16
2.13 Integrated, Modular Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3 The Affect Avoidance Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.1 Affect Avoidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.2 Use of the Word Affect. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.3 The Mind as a Control Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.4 A Silver Lining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.5 Affect Avoidance Is Not a New Concept . . . . . . . . . . . . . . . . . . . . . . 22
3.6 What Is the Role of Pleasure? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.7 What About Biology? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3.8 Relating the Affect Avoidance Model to Other Therapies . . . . . . . . . 25
3.9 Compatibility with Other Models . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.10 The Detailed Structure of EDPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
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3.11 The Nonconscious Problem Solver . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.11.1 Potential Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.11.2 Helpers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.11.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3.12 H ow Protections Become Problems . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3.13 T he Gifts of Consciousness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.14 T he Affect Avoidance Model Applied to Psychotherapy . . . . . . . . . . 34
3.15 A Unifying View of Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.16 Making Use of Different Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.17 Putting It All Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.18 Modular Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.19 Cyclical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.20 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
4 Avoidance Patterns and Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.1 What Shapes Avoidance Patterns? . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.2 The New Science of Memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
4.3 Practical Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4.4 Procedural Memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.5 A Catalog of EDPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.5.1 Dysfunctional Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.5.2 Helpers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
4.5.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
4.5.4 Anxiety-Based Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
4.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
5 How Affects Are Healed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.1 Breaking the Chain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.2 How Healing Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
5.3 Extinction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.4 Reconsolidation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
5.5 Anna O.: A Case of Reconsolidation . . . . . . . . . . . . . . . . . . . . . . . . . 55
5.6 Healing in the Real World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
5.7 Repetition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
5.8 From Words to Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
5.9 Healing Beyond Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
5.9.1 Pride, Guilt, and Shame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
5.9.2 Attachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
5.9.3 Ideas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
5.9.4 Psychological Development . . . . . . . . . . . . . . . . . . . . . . . . . . 58
5.10 C onclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Contents xi
6 A Context of Connection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
6.1 A Prototype . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
6.2 The Ubiquity of Emotional Healing . . . . . . . . . . . . . . . . . . . . . . . . . 62
6.3 Are There Exceptions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
6.4 Mindfulness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
6.5 A Proposed Explanation of Mindfulness . . . . . . . . . . . . . . . . . . . . . . 64
6.6 W hen a Witness Is Necessary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
6.7 What if the Therapist Is Overwhelmed . . . . . . . . . . . . . . . . . . . . . . . 65
6.8 What About Involuntary EDPs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
6.9 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
7 Motivation, Internal and External . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
7.1 The Special Situation of the Trainee . . . . . . . . . . . . . . . . . . . . . . . . . 67
7.2 What Makes Patients Seek Therapy? . . . . . . . . . . . . . . . . . . . . . . . . . 67
7.2.1 The Chief Complaint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
7.2.2 Location of the Problem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
7.2.3 Hopes and Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
7.2.4 Eliciting Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
7.2.5 The Inner Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
7.3 Hope and the SEEKING System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
7.4 Outside Motivation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
7.4.1 Leverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
7.4.2 When There Is No Leverage . . . . . . . . . . . . . . . . . . . . . . . . . 71
7.5 W hy Do Patients Stay? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
7.6 W hy Do Patients Quit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
7.6.1 Missing Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
7.6.2 Deciding to Quit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
7.7 Internal Resistance to Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
7.8 Biological Motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
7.9 Timing and Motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
7.10 T he Therapist as Motivator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
7.11 “Cat and Mouse” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
7.12 The Patient Is Part of a System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
7.13 E nabling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
7.14 P atients Don’t Tell Us Unless We Ask . . . . . . . . . . . . . . . . . . . . . . . . 76
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
8 A Developmental Primer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
8.1 Developmental Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
8.2 Knowledge Brings Compassion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
8.3 An EDP Most of Us Have . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
8.4 Young and Adult Thinking Mixed . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
8.5 Working with Rationalizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81