Formularea Clinica a Cazului Conspect

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AFRAMEWORK FOR CASE FORMULATIONS

Un cadru pentru pentru formularea clinica

O formulare clinica a cazului este o schema conceptuala careorganizeaza explica sau furnizeaza o semnificatie clinica unei maricantitati de date si influenteaza deciziile terapeutice ( Lazare, 1976)

Jerome Frank (Frank & Frank, 1991) defineste doua componente aleformularii clinice:

1. o explicatie plauzibila a simptomelor pacientului sub forma unei

scheme conceptuale sau chiar a unui mit care furnizeazaargumente pentru2. prescrierea unui tip de ritual sau a altui tip de procedura pentru

pentru a le rezolvaIn baza acestei definitii putem identifica urmatoarele elemente ale uneformulari clinice a cazului:

Simptomele sau problemele care trebuie schimbate O mare cantitate de date care trebuie sa fie organizate

O schema conceptuala care furnizeaza o explicatie Decizii terapeutice care conduc la proceduri specifice

In afara unei bune comunicari cu supervizorii si cu alti profesionisti o bunaformulare clinica are , de asemnea, urmatoarele avantaje:

Incredere crescuta si anxietate scazuta in fata unor cazuri noi Furnizeza instrumente si modele de actiune pentru evaluarea

nevoilor clientului si intelegerea clientilor din multiple

perspective Furnizeaza o strategie coerenta pentru aplicarea cunostintelor

in munca cu clientii Asigura o structura ce permite utilizarea creativitatii in procesul

de ajutorare a pacientilor

Cum procedam ?

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Pentru a crea o formulare clinica putem fie sa alegem o orientare si sa-iurmam regulile, fie dezvoltam o formulare unca, integrativa pentru fiecareclient.

Alegerea unei anume teoriipentru a dezvolta o formulare clinica areurmatoarele:

avantaje: - ofera o anume structura, garanteaza o anume consistenta sicoerenta a ideilor - latura ambiguitatea si stresul determinat de obicei de de deciziileclinice

dezavantaje:- introduce clientul n modelul preferat de clinician chiar daca alte

ipoteze clinice pot conduce la interventii terapeutice mai eficiente.

Dezvoltarea unor formulari unice , integrative

Terapeutul integreaza idei, abilitati si tehnici din diferite abordari teoreticepentru a crea o formulare unica pentru fiecare problema a clientuli, pentrufiecare personalitate si context sociocultural. Acasta abordare recunoasteca fiecare teorie poate oferi ceva valoros dar nu este suficienta ca singurghid pentru terapie.

Un plan terapeutic integrativ combina concepte si tehnici din diferite

abordari terapeutice intr-o modalitate sistematica si coerenta pentru a

ntalni nevoile unui client unic.

Doua caracteristici ale formularii cazului

Integrarea ideilor din 28 ipoteze clinice principale

Aceste ipoteze :

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Extrag ideile explicative esentiale din toate teoriile si abordarileterapeutice

Permit combinarea si integrarea componentelor diferitelor teorii Conduc intr-o maniera logica la planul terapeutic

Un cadru structurat numit metoda orientarii pe prolema

Metoda orientarii pe problema (MOP) necesita: Identificarea problemeicare este tinta interventiei terapeutice Specificarea rezultatului obiectiv, schimbarea dorita n functionarea

clientului Un sumar bine organizat al informatiei colectate despre client (baza

de date)

O explicatie coerenta pentru fiecare problema care sa integrezeipotezele clinice (evaluarea) Planul tratamentului recomandat in acord cu explicatia si focalizat

direct pe realizarea rezultatului obiectiv

Ipotezele clinice nucleu

O ipoteza clinica nucleu este o singura idee explicativa care ne ajuta sa

structuram datele despre un anume pacient astfel incat sa ajungem la omai buna ntelegere , la luarea unei decizii si la o alternativa terapeutica.

(Lazare, 1976)

28 ipoteze clinice nucleu

1. Ipoteze biologice

a. Cauza biologica

b. Interventii medicale

c. Interactiuni minte corp

2. Crize, situatii stresante, tranzitiia. Urgenta

b. Stresori situationali

c. Tranzitie developmentala

d. Doliu si pierderi

3. Modele comportamentale si de invatare

a. Antecedente si consecinte

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b. Raspuns emotional conditionat

c. Deficit al abilitatilor sau lipsa competentei

4. Modele cognitive

a. Asteptari utopice

b. Harta cognitiva eronatac. Procesare eronata a informatiei

d. Monolog interior disfunctional

5. Modele existentiale si spirituale

a. Probleme existentiale

b. Evitarea responsabilitatii si libertatii

c. Dimensiune spirituala

6. Modele psihodinamice

a. Parti interne si subpersonalitati

b. Reactivarea unor experiente primare infantilec. Un simt imatur al sineluisi a conceptiei despre ceilalti

d. Dinamici inconstiente

7. Factori sociali, culturali si de mediu

a. Sistemul familial

b. Contextul cultural

c. Suportul social

d. Performanta rolului social

e. Problema sociala este o cauza

f. Rolulsocial al pacientului cu tulburari mentaleg. Factori de mediu

h.

Formularea clinica a cazului - 28 ipoteze clinice nucleu

Ipoteze biologice:

B1 Cauza biologica - problema are o cauza biologica: clientul arenevoie de o interventie medicala pentru a-"i proteja via#a "i a

preveni deteriorarea, sau are nevoie de asistenta psihosocial$pentru a se adapta cu boala, dizabilitatea sau cu alte limit$ri biologice.

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(Ac. ipotez$ se aplica , de ex. n accidente vasculare, tumori cerebrale,sindromul Alzeimer, st"ri toxice tranzitorii, intoxica#ii etilice sau cu droguri,SIDA, deficit de vitamine, tulburari endocrine etc)

B2 Interventii medicale - exist$ interven#ii medicale( ex. medica#ie,interven#ii chirurgicale sau protezari) care trebuie luate in consideratie.Aceast$ ipotez$ este recomandat$ cnd utilizarea unei medica#iipsihotrope este indicat$pentru o tulburare psihiatric$.

Cunostin#ele de psihofarmacologie sunt importante pentru oricepsihoterapeut. Competentele care trebuie dezvoltate sunt: a) abilitatea de arecunoa"te simptoamele "i sindroamele care justific$ trimiterea la unpsihiatru pentru o evaluare a medica#iei, b) o in#elegere a efectelor

terapeutice "i a efectelor adverse a celor mai utilizate tipuri demedicamente psihotrope, "i c) abilitatea de a discuta medica#ia cu clien#iicu in#elegerea factorilor care promoveaz$si mpiedica complian#a.

Indica#ii pentru referirea pacientului catre un psihiatru pentru evaluareamedica#iei:1. Clientul este activ suicidal sau are deficite func!ionale severe2. Simptomele au persistat in ciuda interven!iilor psihoterapeutice3. Clientul utilizeaz#automedic!ia

4. Medica!ia psihotrop#i-a fost util#clientului n trecut5. Medica!ia psihotrop# a fost util# n trecut membrilor familiei cusimptome similare.

B3 Conexiuni minte - corp - o n#elegere holist$a conexiunilor minte

corp conduce la tratamente pentru problemele psihologice care sefocalizeaz$ pe corp si la tratamente pentru probleme fizice care secentreaz$pe minte.

Aceasta ipotez$se potrive"te pacien#ilor care somatizeaz$, pacien#ilor careacuz$diverse tipuri de stres si tensiuni, celor cu tulbur$ri sexuale. Clien#iiau deseori nevoia de creste con"tientizarea si controlul corpului lor si sadezvolte o constientizare somatic$a emo#iilor. Multe din terapiile corporalesunt utile pentru problemele psihologice. St$rile psihologice pot afectacreierul, sistemul nervos autonom si sistemul imun. Problemele de

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s$n$tate, precum cancerul "i SIDA, beneficiaz$ de pe urma st$rilormentale pozitive.

Crize, situa!ii stresante, "i tranzi!ii

Exist$dou$erori care trebuie evitate:- ratarea prevenirii unor consecin#e serioase, inclusiv moarte, ac#iuni

distructivesi patologie pe termen lung prin ner$spunderea cupromptitudine la situa#ia de criz$;

- patologizarea unei condi#ii care, desi dureroas$ si debilitant$, este maibine n#eleas$ca normal$, ca raspuns asteptat la stresori, traume, situa#ii

de tranzi#ie.

CS1 Urgen!# - simptomele clientului constituie o urgen#$: se impune oac#iune imediat$. Aceasta ipotez$ trebuie avut$ n vedere n prima"edin#$ datorit$ severelor consecin#e negative ale unei noninterven#ii. Ea se aplic$situa#iilor n care pacientul trebuie spitalizat "in care exist$reglement$ri legale pentru raportarea abuzului sau aviolen#ei inten#ionate. Ea se potrive"te si situa#iei n care clientul sepoate angaja ntr-o ac#iune irevocabil$.

Managementul clientului violent

1.Men#inerea unei atmosfere de calm "i ncredere; nu gr$bi#i situa#ia2.Dac$clientul se simte amenin#at de ceva, nl$tura#i amenin#area din scen$3.Defini#i-v$ rolul: doresc sa v$ajut s$v$controla#i aceste sentimente; doresc s$v$ajut s$g$si#i celemai bune modalit$#i s$controla#i situa#ia.4.Nu blocati accesul clientului c$tre u"$5.Asigura#i-v$ca ave#i suportul persoanelor disponibile - l$sa#i u"a deschis$, asigura#i prezen#a unei altepersoane sau accesul la un sistem de alarm$.6.Scade#i emo#ionalitatea clientului: vorbi#i ntr-un limbaj direct simplu, ajuta#i exprimarea sentimentelorprin cuvinte, si puneti ntreb$ri factuale.7.Furniza#i o structur$si limite: exprima#i clar c$violen#a nu va fi tolerat$8.Recompensa#i orice semn ca clientul "i controleaza comportamentul9.Chema#i poli#ia sau echipa de urgen#e psihiatrice dac$este nevoie10.Nu ezita#i sa face#i orice va securizeaz$, chiar dac$gndi#i c$pacientul s-ar sim#i ofensat

Evaluarea poten#ialului de suicid

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1.Fi#i directi n abordarea temei suicidului, ar$tnd confort n abordarea acesteia: V-a#i gndit sa va pune#icap$t vie#ii?2.Pune#i ntrebari specifice referitoare la durata "i intensitatea gndurilor suicidale: Ct de des v$gndi#is$va mpu"ca#i?3.Interesa#i-va de existen#a unui plan.4.Evalua#i letalitatea metodei alese; cu ct mai specific este planul cu att letalitatea este mai mare.

5.Explora#i comportamentul suicidar ca modalitate de comunicare. Ce mesaj dore"te persoana s$comunice? La ce raspuns se a"teapt$?Exist$ o anume persoan$ din partea c$reia se a"teapt$ unr$spuns? A ntrerupt persoana comunicarea cu ceilal#i "i "i-a pierdut speran#a n orice ajutor?6.Culegeti detalii referitoare la tentative anterioare.7.Evalua#i resursele suportului social: Ct de izolat este clientul? Cine l-ar putea ajuta? Persoanasemnificativ$pentru pacient este o resurs$sau parte a problemei?8.Evalua#i nivelul curent al abuzului de substan#e - un factor care diminueaza controlul impulsului.9.Evalua#i nivelul depresiei "i posibilitatea unei psihoze - factori care cresc riscul.10.Explora#i factorii precipitan#i. Exist$vreun stresor acut n viata unei persoane stabile sau avem de-aface cu un patern al unui comportament suicidar cronic?11.Evalua#i nivelul de ambivalen#$: Ct de puternic$este partea moarte versus partea rami n via#$12.Exist$altcineva n familie care a ncercat s$se sinucid$sau s-a sinucis?13.Au fost realizate pregatiri finale pentru moarte, precum scrierea unui testament, ncredin#area altei

persoane a unor valori sau a animalelor de cas$?

Interven#ii terapeutice pentru pacien#ii cu idea#ie suicidar$

1.Informa#i familia si persoanele semnificative despre idea#ia suicidar$. Cere#i-le sa supraveghezepacientul 24 ore din 24 pn$cnd criza trece.2.Asista#i clientul n dezvoltarea con"tientiz$rii propriilor mesaje cognitive care nt$resc disperarea "ineajutorarea.3.Realiza#i un cotract cu clientul n care men#iona#i ce va trebui sa fac$de fiecare dat$cand va reapareidea#ia suicidar$.4.Asista#i clientul n g$sirea lucrurilor pozitve "i d$t$toare de speran#$din via#a sa n prrezent.

5.Aista#i clientul n dezvoltarea strategiilor de coping cu idea #ia suicidar$ ( de pild$mai multe exerci#iifizice, diminuarea concentrarii asupra universului interior, cre"terea implic$rii sociale, exprimareasentimentelor.)6.Cnd idea#ia suicidar$este nso#it$de vinov$#ia supravie#uitorului, implementa#i un ritual de peniten#$7.Asista#i clientul s$con"tientizeze factorii care au determinat debutul idea#iei suicidare.

CS2 Stresori situa!ionali - simptomele pacientului rezult$ din stresorisitua!ionali recen#i sau din experien#e traumatizante trecute. Este

important sa evalu$m dac$ simptomele clientului sunt propor#ionale cunivelul stresului. Trebuie s$ men#ionam stresorii externi, care pot s$mearg

$ de la traume care pun via

#a n pericol pn

$ la acumularea unor

neajunsuri zilnice "i s$ avem o modalitate obiectiv$ de m$surare aseverit$#ii acestora. Tehnicile de interven#ie n criz$ pot mpiedicatransformarea reac#iilor de criz$n tulburari cronice

Cele patru faze de dezvoltare a crizei (Caplan 1964)

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Cre"terea tensiunii Eforturi de coping far$succes Mobilizarea resurselor de urgen#$

Dezorganizarea

Principalii pa"i n interven!ia n stare de criz# (cuprinde idei din Hipple&Hipple-1983, Aguilera - 1998, Greenstone&Levitone 1993)

Scop Actiunile terapeutului

mbun!t!"ireastarii emo"ionale

Inspirati speran"!#i securiza"i clientul. Demonstra"i c!sunte"icalm #i ncrez!tor n atingerea unor rezultate pozitve. Normalizatiexperien"a pentru a contracara teama c!simptomul nsamn!

slabiciune sau nceputul nebuniei

Stabili"i direc"ia Conducce"i interviul, furniza"i o structur!, prezenta"i-va ca expertn problem solving. Implica"i membrii familiei sau al"i membri aire"elei sociale. Ajuta"i clientul sa pun!ordine n mintea sa.

Evaluarea crizei Utilizati tehnicile focusarii active pentru a obtine o evaluareadecvata a factorilor precipitanti.Evaluati factori precumperceptia evenimentului, suportul social, mecanisme de copingfolosite, sau daca nu au fost folosite, care sunt disponibile.Interesati-va de experientele pozitive de coping pentru a

identifica resurse. Evaluati deopotriva ntelesurile reale sisimbolice ale evenimentului criz!.

Evaluareagradului deurgent!

Evaluati daca clientul este un pericol pentru el sau pentru ceilaltisi apreciati nevoia de spitalizare. Daca persoana are ideatiesuicidara, utilisati un contract non-suicid si cresteti frecventasedintelor.

Ajutarea clientuluisa inteleaga criza

Explicati relatia dintre stresori sau trauma si intensitatea reactiiloremotionale. Furnizati educatie despre posibilele faze alereactiilor emotionale care urmeaza trauma.Explicati teoria crizei,utilizand conceptele echilibrului si dezechiibrului. Ajutati clientulsa realizeze ca starea de criza ste temporara

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Facilitateaexprimariiemotionale

Incurajati clientul sa-si exprime emotiile. Aratati intelegere inlegatura cu reactiile emotionale, utilizand cuvinte referitoare laemotii in raspunsurile dvs( ex. soc, confuzie, spaima, vinovatie,

afi depasit). Ajutati clientul sa acceseze emotiile care pot fireprimate, precum teama fata de persoane iubite - un catharssisemotional cu un ascultator suportiv poate reduce tensiunea.Opotunitatea de a verbaliza experientele poate ajuta prevenireaevitarii care caracterizeaza PTSD.

Utilizarearestructurariicognitive

Tehnicile restructur!rii cognitive pot schimba evaluareastresorilor casi capacitatatea de coping a clientului. Clien"ii potavea credin"e gre#ite referitoare la faptil c!anumite evenimentetraumatice ar fi putut fi anticipate #i prevenite dac!ei ar fireactionat diferit, #i de aceea ei se pot blama nejustificat.

Dezvoltarea unuiplan de ac"iune

Deprinderile modelului problem-solving. Lista"i alternativele #isjuta"i clientul s!le evalueze pro #i contra. Asigura"iv!c!planuleste n acord cu valorile personale si culturale alepacientului.Diviza"i planul n pa#i simpli, concre"i, reali#ti #iadecva"i nivelului de func"ionare a clientului. Obiectiveleintermediare trebuie stabilite n termeni temporali - ore, zile.Dac!sunt implic"i si al"i agen"i asigura"i-va ca exist!ocoordonare adecvat!.

Delimitareasuportului social

Suportul social poate veni fie din re"eaua social!individual!, fiedin partea altor persoane care sufer

!de aceea

#i problem

!, fie

din partea organiza"iilor comunitare. Dac!este posibil, include"imemebrii familiei n procesul terapeutic.. Interveni"i daca aparsemne ca se dezvolt!o criz!familial!din cauza crizei personalea clientului. ncuraja"i partticiparea la activit!"i de grup carefurnizeaz!suport #i canalizeaz!energia c!tre obiectiveadecvate.

Monitorizareaprogresului

Pe m!sur!ce schimbb!rile pozitve se manifest!, sumariza"iprogresul #i ajuta"i clientul s!n"eleag!care strategii de copingau fost cele mai eficiente.. Furniza"i recompense #i ncuraj!ri.Utiliza"i deprinderi de problem solving pentru dep!#ireaobstacolelor neprev!zute.

Planificareaanticipat!

Dup!ce criza curent!este menegeriat!, ajuta"i clientul s!dezvolte insight-uri si deprinderi de a preveni viitoarele situa"ii decriz!#i sa se adapteze mai bine la ele daca apar.

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Terminarea Terminati interventia cnd clientul revine la echilibrul anterior #icontroleaz!problemele sale n mod eficient. Dac!este nevoiede un ajutor ulterior discuta"i un contract terapeutic pentru

problemele identificate.

CS3 Tranzi!ie developmental# - clientul este ntr-o tranzi #iedevelopmental$confruntndu-se cu probleme legate de trecerea de la unstadiu al vie#ii la altul.

La fiecare 5-10 ani o tranzi#ie developmental$ este inevitabil$ datorit$interac#iunii dintre maturarea biologic$, dezvoltarea personalit$# ii,expecta#iile sociale de rol pentru persoanele de vrste diferite. Aceast$ipotez$ normalizeaz$ disrup#iile dramatice "i conduce la interven#ii carempiedica o criza de maturizare s$devina o tulburare cronic$. Oamenii aunevoie de suport pentru a face alegeri personale "i pentru a realizasarcinile developmentale n propriul lor ritm

Cele sase stadii ale rolului de p#rinte (Galinsky, 1987)

Stadiulp#rintelui Stadiul copilului Sarcini developmentale

Stadiul form!riiimaginii

Prenatal Acceptarea sarciniiPregatirea pentru rolul de p!rintePregatirea pentru na#tere

Stadiul dezvolt!rii De la na#tere labebelu#

Reconcilierea imaginii na#terii cu realitateaConfruntarea cu sentimenteleata#amentuluiRedefinirea rela"iilor

Stadiul autorit!"ii Dela bebe la vrstascolar! Dezvoltarea autorit!"iiC#tigarea distan"ei

Controlul rolurilor de sex #i identit!"ii

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Stadiulp#rintelui

Stadiul copilului Sarcini developmentale

Stadiulinterpret!rii

Debutul #colii -#coala medie

Interpretarea propriei persoane ca p!rinteSeparare #i conectare

Interpretarea lumii c!tre copilDecizia cu privire la nivelul de implicareAnticiparea vrstei adolescentine

Stadiulinterdependen"ei

Scoala superioar! Adaptarea la o nou!autoritate rela"ional!Controlul sexualit!"iiAcceptarea identit!"ii adolescentineFormarea unei noi rela"ii cu copilul aproapematur

Stadiul plec!rii Scoala superioar!

-colegiu #i maideparte

Pregatirea pentru plecare

Adaptarea la plecareSchimbarea imaginilorRelaxarea controluluiAsumarea succeslor #i insucceselor

CS4 Pierderi si doliu

Clientul a suferit o pierdere "i are nevoie de ajutor pe durata doliului saupentru rezolvarea unor probleme legate de pierdere.

Pirederile pot fi externe(ex. moarte, divor#, dezastre naturale), interne(pierderea unor capacit$#i datorit$ bolii sau vrstei), sau combinate(pierderea serviciului determina pierderea identit$#ii ca "i cap al familiei)Cunoa"terea stadiilor tipice ale suferin#ei (grief) este util$, atta timp ctdiferen#ele culturale si individuale sunt acceptate. Uneori pierderea este ocauz$precipitant$ a unor simptoame emo#ionale; alteori, clientul nu estecon"tient de aceast$conexiune.

Stroebe "i Schut (2001) au dezvoltat o teorie a proceselor duale cu privirela suferin#$.

Procese orientate c#tre pierdere: Att confruntarea ct si evitareapierderiipe m$sur$ce persoana traverseaz$procesul suferin#ei.

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Procese orientate catre ns#n#to$ire: Copingul cu problemele "iresponsabilit$#ile determinate de pierdere "i descoperirea propriului loc nlume f$r$persoana decedat$.

Stadiile suferin!ei (doliului) (Lindemann, 1994)

1. %oc, neacceptare, letargie, amor#eal$2. Confruntarea cu pierderea "i tr$irea durerii "i dorului3. Rezolvarea pierderii "i realizarea accept$rii

Prescrip!ii terapeutice pentru Suferin!#(doliu) (Worden, 1991)

1. Acceptarea realit$#ii pierderii

2. Travaliul durerii3. Adaptarea la un mediu f$r$persoana sau lucrul pierdut4. Relocarea emo#ional$"i continuarea vie#ii.

Tipuri de doliu complicat (W.Stroebe, Schut, and Stroebe (2005)

1. Tipul cronic: focalizare excesiv$asupra pierderii; experient$prelungit$asimptomelor fazei acute precum furie, sup$rare, triste#e, am$r$ciune,depresie" men#inerea unei rela#ii fantasmatice cu decedatul cu

sentimentul ca el/ea este mereu prezent($) "i prive"te; dor intens "ic$utarea persoanei decedate,; lipsa progresului n sarcinile derestaurare

2. Tipul amnat, inhibat sau absent: focalizare sc$zut$asupra pierderii cuconcentrare exclusiv$asupra sarcinilor de restaurare

3. Tipul traumatic: Confruntare foarte intens$ "i persistent$ cu pierdereacombinat$ cu evitarea; tr$irea simptoamelor caracteristice PTSDprecum flashback - uri, co"maruri, amintiri intruzive.

Factorii de risc pentru apari#ia complica#iilor:

1. Tipul de rela#ie cu decedatul2. Circumstan#ele decesului ( nea"teptat, violent, suicid etc )3. Procesul de doliu: ncerc$ri de evitare a tr$irii durerii, credin#a ca un

doliu limitat este o tr$dare a celui decedat )4. Personalitatea "i istoria individului

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5. Al#i factori de stres concuren#i6. Lipsa unui suport social adecvat

n DSM-IV-TR, se considera ca o persoana care a trait doliul poate fi

considerata ca avand un episod depresiv major, doar daca simptomelesunt prezente dupa doua luni de la pierderea fiintei dragi.

Interven!ii terapeutice

Utiliznd teoria procesului dual a doliului Stroebe & Schut, 2001),interven!iile se vor centra fie pe procesel orientate c!tre pierdere fieprocesele orientate c!tre restaurare, func!ie de nevoile individuale aleclientului.

Interven!ii terapeutice focalizate pe procesele centrate pe pierdere:

Tehnica gestaltist!a scaunului gol: clientul poate vorbi direct cu decedatul"i s!-"i exprime sentimentele, poate lucruri pe care nu a avut ocazia sa lespuna nainte de decesul persoanei, s!ierte sau s!cear! iertare. Formulala revedere, r!mas bun este de evitat de"i este important ca pacientuls!accepte pierderea.

Tehnica imageriei ghidate:terapeutul poate ghida clientul printr-un set de

experien!e care pot culmina cu experien!a de a vorbi cu persoanadecedat!. Procesul este intern "i silen!ios; terapeutul poate s!cear! saunu clientului s!povesteasc!experien!a sa.

Scrierea unei scrisori, a unui jurnal etc.

Realizarea unor lucr!ri artistice -catharsis, con"tientizarea unor sentimente,se form!unor unor emo!ii incoerente

Comemorare: clientul poate crea uncolaj cu scrisori, fotografii, "i alteobiecte ale persoanei decedate.

Ritualuri vindec!toare : ritualuri de r!mas bun, de adio( nu numai n raportcu persoana decedat!ci "i cu durerea "i suferin!a.

Interven!ii terapeutice centrate pe procesele de ns!n!to"ire:

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Terapia narativ!: Terapeutul ajut! clientul sa creeze o poveste coerent!despre propriul viitor f!ra prezen!a persoanei decedate dar avndamuntirea acesteia "i libertatatea de a se angaja n noi activit!ti "i rela!ii.

Terapie cognitiv comportamental!: Terapeutul provoac!limitele credin!elor"i schemelor "i ajut!clientul s!creeze altele care pot sprijini competen!a

n noile roluri "i sarcini "i asigur! permisiunea de a merge mai departe.Terapeutul poate utiliza un model structurat de problem-solving "i ajut!clientul sa dezvolte "i s!implementeze un plan de ac!iune.

Dezvoltarea de deprinderi: de pild!, deprinderi de management financiar,deprinderea de comportament autosuportiv, formarea de noi rela!ii deprietenie. Terapeutul poate ajuta clientul s! identifice punctele tari

"i pe

cele slabe, furnizeaza ocazia de a exersa unele situa!ii interpersonale preinjocuri de rol.

BL1 Antecedente "i consecin!e: analiza comportamental! att acomportamentului problem! ct "i a comportamenului dorit trebuie s! sebazeze pe informa!ii referitoare la Antecedente "i consecin!e care vor fiutile n construirea unei interven!ii.

In constructia interventiei terapeutice se utilizeaza principiile condi!ion!riiclasice "i condi!tionarii operante.

Modelul behaviorist initial Antecedente - Comportament - Consecinte adevenit Antecedente - Mediere cognitiva - Emo!ii - Comportament -Consecinte

BL2 Un r!spuns emo!ional condi!ionat - ( anxietate, team!, furie,depresie ) este la originea unor emo!ii excesive, comportemente deevitare, a unor mecanisme maladaptative de evitare a unor emo!ii

dureroase.

R!spunsul emo!ional intens nu este justificat de stimulii din mediul curent,prin urmare infer!m nv!!!ri anterioare care implic!"i care explic!reac!ii!eexcesive. Tratamentul va necesita noi nv!!!ri: extinc!ia emo!iilor

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problematice "i contracondi!ionarea unor raspunsuri emo!ionale maiadaptative.

BL3 Deficit de deprinderi sau lipsa competen!ei- problema are la baz!un deficit de deprinderi - absenta deprinderilor necesare - sau lipsacompeten!ei n utilizarea deprinderilor, abilit!!ilor "i cuno"tin!elor pentruatingerea unui obiectiv

Problem - solving/ Luarea deciziilor

Aceste deprinderi necesit!o abordare metodica, sistematic!:

1. Identificarea "i clarificarea problemei2. Culegerea de informa!ii "i c!utarea de explica!ii3. Brainstorming pentru solu!ii alternative4. Evaluarea costurilor si beneficiilor fiec!rei solu!ii "i alegera celei mai

bune

5. Implementarea unui plan de ac!iune si monitorizarea rezultatelor

Modele cognitive

C1 Expecta!ii utopiceC2 Harta cognitiv!eronat!

C3 Procesare eronat!a informa!ieiC4 Monolog interior disfunc!ional

C1 Expecta!ii utopice -clientul sufer!de obi"nuita mizerie a vie!ii de zicu zi "i are a"tept!ri utopice, nerealiste n leg!tur!cu ceea ce ar trebui s!fie via!a; clientul dore"te s!elimine dezam!girile , problemele,"i emo!iilenepl!cute care sunt p!r!i inevitabile ale vie!ii. Confundnd dificult!!ilenormale ale vie!ii cu problemele care necesit! terapie, clientul vizeaz!

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obiective de neatins. Terapeu!ii trebuie s!evite s!ncheie contracte careurm!resc atingerea unei vieti perfecte f!r!probleme.

Scurt ghid pentru convorbirea terapeutic!:

-centra!i-v!

pe discrepan!a ntre ceea ce este via!a clentului acum "iceea ce dore"te s!fie.- fi!i foarte empatici "i suportivi- discuta!i despre viitor n termeni de probabilitate- utiliza!i umorul n situa!ii adecvate

C2 Harta cognitiv!eronat!- problemele sau imposibilitatea rezolv!rii lorsunt determinate de elemente limitative sau dep!"ite ale unei h!r!icognitive eronate; terapeu!ii trebui s!ajute clien!ii s!modifice aspecte alegndirii lor , nu doar din cauza standardelor arbitrare cu privire la ceea ceeste bine sau r!u ci "i pentru ca harta eronat!limiteaz!alegerile, creeaz!suferin!!, "i interfereaz! cu satisfacerea nevoilor lor. cu atingereaobiectivelor "i cu capacitatea de a se bucura de via!!. Sunt schememaladaptative, postulate, reguli, credin!e, predic!ii ce se automplinesc,povesti personalecare trebuie identificate, evaluate, schimbate "i revizuite.

Erori fundamentale ( Alfred Adler)

Erori fundamentale ExempleSuprageneralizarea Oamneii sunt ostili

Via"a este periculoas!

Obiective de securitate falsesau imposibile

Un pas gre#it #i e#ti mortTrebuie s!plac tuturor

Percep"ii gre#ite n leg!tur!cu via"a #i cerin"ele vie"ii

Vi"a nu mi-a dat niciodat!vreun moment de r!gaz.Via"a este grea.

Minimizarea meritelor

(Complex de inferioritate)

Nu merit nimic.

Nu sunt capabil sa-mi rezolv problemele.Exagerarea meritelor( complex de superioritate)

Sun superior celorlal"i.Nevoile mele sunt mai importante dect ale celorlal"i.

Valori gre#ite Fii primul chiar dac!va trebui sa calci peste al"ii.E mai bine daca i fac pe ceilal"i sa ndeplineasc!responsabilit!"ile mele.

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C3 Procesare eronat!a informa!iei -clientul demonstreaz! o procesare

eronat!

a informa!iei (ex. suprageneraalizare, stil dihotomic, lecturagndurilor etc.).Via!a de zi cu zi necesit!abilitatea de a percepe adecvatdatele experien!ei"i de a schimba schemele pentru a se adapta noilorexperien!e. Prelucrarea adecvat! a informa!iei implic!aplicarea regulilorlogice, practicarea metodei "tiin!ifice, voin!a de a urmari validitateagndurilor, fie prin experimentare fie ntr-o modalitate consensual! curealitatea celorlalte persoane.Problemele pot fi formulate n termenii lipseideprinderilor cognitive "i a stilurilor cognitive care sunt inadecvate pentrucontext "i obiective.

C4 Monolog interior disfunc!ional - problema este declan"at! "i/saumen!inut!de un monolog interior disfunc!ional; Exist!mul!i termeni pentrumonolog interior: auto-mesaje, vorbire intern!, voce intern!, film interior,gnduri automate etc. Monologul interior disfunc!ionaldetermin!sentimente dureroase,si comportamente neadaptative. Uneori clientul estecon"tient de acest monolog interior: alteori este nevoie ca pacientul sa fieajutat sa descopere aceasta voce intern!.

IPOTEZE EXISTEN#IALE $I SPIRITUALE

ES1 Probleme existen!ialeES2 Evitarea libert!!ii "i responsabilit!!iiES3 Dimensiune spiritual!

Probleme existen!iale - Clientul se confrunt! cu Probleme existen!iale,care includ cautari filosofice fundamentale cu privire la scopul "i sensulvie!ii; Exemple de probleme existen!iale includ scopul "i sensul vie!ii,

mortalitatea "i moartea, "i izolarea fundamental!a fiin!ei umane. Utilizndipoteza ES1 recunoa"tem c! fiecare persoan! trebuie s!-"i descoperepropriile sale r!spunsuri. Anxietatea este parte normal!a vie!ii "i durereadeterminat! de confruntarea cu acceste probleme nu poate fi eliminat!.Terapeutul trebuie s!se ab!in!de la asumarea unui rol de gurusau expert;

n locul acestei atitudini, trebuie sa recunoasc! faptul ca face parte dinaceeasi categorie a pelerinului care s-a confruntat "i continu! sa se

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confrunte cu probleme similare. ( Luarea deciziilor care implic!libertatea,responsabilitatea,alegerea, curajul "i implicarea se adreseaza ipotezeiES2)Ex. DE problemeFulfillment of Potential

People often come to therapy wanting more than relief from symptoms or restora- tion of how they werebefore the current crisis. There is a yearning for a higher quality of living or the need to wrestle with deepquestions and find a new orien- tation to life. These clients want to be responsible adults withoutsacrificing the vitality and sense of play of childhood. They want challenge and excitement intheir dailylives, instead of stagnation and boredom. Typical goals might include meaning and purpose in their lives;fulfillment of their highest potential; a sense of control over their future paths; becoming morespontaneous and creative; feeling more alive, real, and whole; and achieving authentic contact with theirinner being as well as with other humans. Mere conformity to societys definition of normal is not enough:Therapists will have an inadequate grasp of their clients needs if they restrict themselves to goalsendorsed by health care case managers.

Emotional Suffering

Suffering cannot be eliminated from life. Although we cannot always control or prevent events that causesuffering, existential theorists believe that we have the freedom to choose how we react to those events.

Meaning and Purpose in Life

Existential philosophers describe the human condition as the dilemma of meaning- seeking creaturesthrown into a universe that has no intrinsic meaning. When we are young, we derive meaning from therules and examples of our parents, which derived from the customs and traditions of their cultures. Manypeople live con- tented lives continuing to accept that meaning. However, other people experience a crisisof meaning, perhaps following a major loss or when they reach the pinnacle of the road they were toldwould bring fulfillment.When the meaning systems that people have taken for granted are no longer viable, there are manydistressing emotional responses. The existential litera- ture describes the experience of the absurd andthe response of nausea to the realization that there is no intrinsic meaning in the external world or thecourse of our lives. Clients may describe feeling emptinessa void.

Authenticity and Honesty

Authenticity in human relations is a standard that many people have trouble living up to, and therapistswho are not capable of it in their own personal relationships will not be able to provide this neededingredient of the therapeutic relationship. When you are engaged in an authentic encounter, you wouldbe (a) present in the moment rather than adrift on a mental side trip; (b) genuine and not hiding behindmasks; (c) honest and truthful about what you choose to express, reserving the right to decline to revealwhat you hold private; (d) open and vulnerable, allowing yourself to be impacted and changed by theother; and (e) willing to take the risk of being spontaneous. Spontaneity does not mean saying whatever

comes into your head because you experience the vulnerability of the other person and want to behelpful. A precondition for authenticity with others is that you are vigilant against self-deception andhave learned to hold yourself accountable for your own dishonesties.

The Question of Suicide

When therapists face people who are contemplating suicide, they frequently panic. They focus onassessing risk, taking emergency measures, getting med- ication evaluation, and doing whatever possibleto get rid of the suicidal thoughts. Although all of these actions are essential, they are insufficient: Theclient needs someone to listen calmly and patiently and help her explore the crisis of meaning and the

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issues that have made life unbearable. When people has terminal illnesses, we consider it reasonable forthem to contemplate how suicide will allow them to die with dignity and relieve their loved ones ofburdens. However, when someone, by our standards, has sufficient reasons to find satis- faction in life, weare apt to label his or her wishes as abnormal, irrational, selfish, or transient symptoms of depression.

Philosophical Discussion

When the focus of therapy is the clients search for meaning, the dialogue between therapist and clientcan take the form of philosophical discussionabout both abstract theory and the clients specificphilosophy of life. Sheldon Kopp (1976) challenged clients to examine some of the assumptions aboutlife that they developed in childhood and proposed a set of his own philosophical truths, which includethe following: Nothing lasts. There is no way of getting all you want. The world is not necessarily just. You dont really control anything. You cant make anyone love you.

Viktor FranklsLogotherapy offers to the client three ways of satisfying the search for meaning:1. Creating a work or doing a deed (e.g., achievement and accomplishment)2. Experiencing a value such as goodness, truth, beauty, or love3. Finding meaning in unavoidable suffering

ES2 Evitarea libert!!ii "i responsabilit!!ii - Clientul evit! Libertatea "iautonomia care vin odat! cu intrarea n vrsta adult!"i/sau nu accept!responsabilitatea pentru pre zent "i alegerile trecute; clientul are nevoie deajutor pentru a face alegeeri bune care sa-l puna n mi"care c!tre obiectivepozitive

"i sa se angajeze. Ei au nevoie s!disting!ntre limit!rile care sunt

reale "i cele care sunt autoimpuse. Unii oameni "i neag!responsabilitateapentruac!iunile trecute "i al!ii se blameaz!pentru evenimente pentru carenu au fost responsabili. Evitarea libert!!ii poate lua multe forme:men!inerea iluziilor copil!riei, blamarea altora, dependen!a de al!ii crefurnizeaz! salvare.Cnd clien!ii sunt gata s! se angajeze n ac!iuniresponsabile, ei pot avea navoie de ajutor n clarificarea valorilor, luareadeciziilor, planificarea "i implementarea planurilor.

Precondi!ii pentru exersarea efectiv!a libert!!iiAlternative disponibile Capacitatea de a anticipa consecin!ele Capacitatea de a amna ac!iuneaAlegerile "i au originea n dorin!ele noastre reale Organizare "i autodisciplin! Deprinderi "i resurse

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maturitate

Evitarea responsabilit!!ii

Am nevoie de garan!ii

A"a sunt eu (autoetichetare) Nu pot sau nu am putut Nu vreau Trebuie / a trebuit Po!i s!faci asta pentru mine Obiceiuri Conformism "i obedien!!

Responsabilitate

Identificarea cauzei sau a creatorului ac!iunilor "i a consecin!elor Conceptele legale ale responsabilit!!ii ( capacitate diminuat!, boala

psihic!, constrngere etc.) Clarificarea ndatoririrlor "i obliga!iilor ntr-o anumit!situa!ie Cai de evitare a responsabilit!!ii ( am urmat un ordin, El m-a facut s!...,) Evaluarea caracterului adecvat al sentimentelor de vinov!!ieAutoblamarea Conceptul de victim!Angajare (clien!ii conduc problemele c!tre dou!extreme: 1)incapacitatea

de a realiza "i men!ine un angajament - deseori numit!iresponsabilitate

de c!tre al!ii "i 2) incapacitatea de a finaliza un angajament mai vechifundamentat pe o analiz!cost-beneficiu actualizat!.

Stages of Autonomous Decision Making

The process of autonomous decision making can be conceptualized into these stages:Identify Wants!Evaluate Behavior!Choose!Will!Plan!Act!EvaluateTable 7.2 Applying the ES2

Avoiding Freedom and Responsibility HypothesisPROBLEM TITLES

Struggling with making a choice:Indecision about a job offer Ambivalence over whether to make a marital commitment Dilemma over choice of educational paths

Uncertainty over choosing timing of retirement

Stuck in an unhappy situation:

Victim of spousal abuse Dissatisfaction with boring job Feels incapable of living as an independent adult separate from parents

Difficulty setting realistic goals and developing constructive plans for future

Frustration with inability to behave in accordance with intentions (lack of self-control):

Difficulty adhering to weight loss plan Excessive angry outbursts at children Starts new sexual relationship despite intention to

experience a period of celibacy Inability to maintain sobriety

Engaging in behavior that brings negative consequences for self or others:

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Engages in unprotected sex with multiple partners Difficulty maintaining employment At risk for flunking out of college because

of poor grades Exercises poor judgment in choice of partners

Emotional distress related to guilt, anxiety, or lack of confidence:

Anxiety over making major decisions Inability to overcome guilt for past mistake Excessive fear over taking risks and trying new

experiences

ILLUSTRATIONS OF CLIENTS THINKING AND BEHAVIOR

Self-imposed limitations (avoidance of freedom):

Client believes that past misfortunes, such as inadequate parenting, permanently limit her possibilities for a happy future. Client is overly conforming and rule-ridden, talking in terms of shoulds and cants and doing exactly what her parentsexpected, despite being unhappy with some of these choices.Failure to recognize real-world limits:

Client describes grandiose fantasies for future projects without any realistic sense of the skills, resources, and self-disciplinerequired to achieve these goals. Client persists in pursuing a career for which he lacks talent. Client copes poorly with the natural changes of aging and pursues surgeries in an attempt to pass for someone 20 years younger.(continued)

Table 7.2 (Continued)Avoidance of responsibility:

Clients interpretation of painful experiences involves blaming others and taking the role of victim or martyr. Client reports guilt and shame over past behavior but does not take any action to make amends or to refrain from similar actionin the present and future.

Client refuses to accept obligations in life, insisting on doing whatever she wants, regard- less of the consequences.Lack of self-control and self-discipline:

Client uses many words that show feelings of passivity and difficulty taking action toward goals: Im trying. Im working onit. Its hopeless. Client states values and moral code, but then claims I cant help it for engaging in morally wrong behavior (e.g., having anaffair). Client expects good things to come to him without needing to expend effort.

Relinquishing Childhood IllusionsHere are examples of childhood illusions that need to be uncoveredand challenged: A prince will come along and find me and, without any effort on my part, we will live happily ever

after. If I am good and do what I am told, then bad things wont happen to me. I am responsible for my mommys happiness; if she isnt happy, then I have done something wrong. If I show that I am weak and helpless, someone will take care of me. IfIshowthatIamvulnerable,peoplewilltakeadvantageofmeandhurtme.

Paradox and Reframing: The Dont Change Position

There are certain therapeutic approaches that are called paradoxical because instead of pushing forchange, they urge the client to accept the status quo and toExistential and Spiritual Models 261262 Twenty-Eight Core Clinical Hypothesesagree that change is not necessary. The therapist can take one of three paradoxical positions:1. Where you are is exactly where you want to be; If you wanted things to be different, you would have

changed already.2. There is absolutely nothing wrong with staying exactly as you are now, so convince me why you shouldtry to be any different.

3.Dont try to change, do more of the same. (This tactic was called paradoxical intention by Frankl andis also referred to asprescribing the symptom.)These approaches can lead to one of the following outcomes, all of which are positive: The client wants to prove you wrong and therefore needs to intensify her determination to change. Thismobilizes the will to change and stimu- lates action.

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The client gets permission to stay the same and experiences your accep- tance. You are not like all theother people who tried to change her, so she can relax and stop resisting you. This creates a space whereshe can experience her deepest feelings about the status quo. If the feelings turn out to be intenselynegative, this pain can fuel some steps toward change. The client may discover that the status quo really is what she wants, and all the pressure to change wasreally coming from external sources, or from the messages she internalized from others. This means that

now the client isnt stuck in a bad place, which she feels helpless to leave; instead, she is freely choosingthis place. When a client stops trying to decrease a problem behavior, but instead in- creases it, he develops a sense

of control over something that seemed out of control.

ES3 Dimensiune spiritual! - Nucleul problemei "i/sau resursele de careeste nevoie pentru rezolvarea problemei sunt fundamentate pedimensiunea spiritual! a vie

!ii, care poate sau nu s! includ religia; o

importanta aplicare a acestei ipoteze este situa!ia n care clientul secon f run t! cu prob leme re l ig ioase, inc lus iv re la! ia sa cuDumnezeu.Termenul spiritual se aplic! unei mari variet!!i de experien!e,credin!e "i activit!!i. Clien!ii care trebuie sa se adapteze la ideea mor!ii, cudileme morale "i blocarea creativit!!ii beneficiaz! deseor!de focalizareaasupra spiritualit!!ii. Tehnici preluate din religiile estice ( ex.medita!ia,con"tientizare) si din religiile occidentale ( rug!ciunea si citireaBibliei) pot fi integrate n terapie. Trimiterea la/sau colaborarea cu clericisau al!i practicieni spirituali se poate dovedi adecvat!.

There are two risks when therapy enters the spiritual domain: (1) The therapist will impose values andsteer clients in a direction that is counter to the clients pref- erences, and (2) the therapist will be tootimid to probe and challenge, as if the clients spirituality is too fragile to withstand a thoroughexploration.

Table 7.3 Concepts of SpiritualityConnection with the Sacred or Divine

Search for the sacred or divine Transcending the self and connecting to a higher power Feelings of harmony and oneness withtruth, humanity, or God Feeling uplifted and recharged by connection to a nonhuman source of energy and enlightenmentExperiencing ones own inner goodness and value as stemming from a higher power Contacting an Inner GuideGoals to Be a Better Person and Have a More Meaningful Life

Development of a personal moral code and the desire to live a virtuous, ethical lifeStriving to be the best possible human being one can beSeeking personal transformation, wholeness, or integrationSeeking to replace negative emotions such as anger, envy, and fear with positive emotions such as love, compassion, andforgivenessThe desire to be less selfish and self-oriented and become more altruistic, generous, and engaged in service to othersThe search for meaning and purpose in life that is higher than ones usual material, superficial concernsOn a quest for some higher goal, such as ones true (or higher, deeper) self or a path with heartPsychological Experiences

The capacity to enter into heightened states of consciousness that erase the boundary of the self

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Having a specific mystical experience that cannot adequately be described in words, which involves contact with the divine andintense emotions such as awe, wonder, and blissExperiencing a sense of creativity and flow, which includes intense concentration, self- forgetfulness, and clarityExperiencing a sense of unity, wholeness, and timelessness Achieving a sense of inner peace and detachmentBeliefs

Believing in a divine purpose that permeates the universeBelieving that there is an alternate reality that is invisible but more real than the reality we experience with our senses

Believing that overinvestment in ones separate ego is a source of suffering instead of strength Believing in the continuation ofspiritual existence after the physical body has diedBelieving that the spirits of our ancestors make demands on us that we are obligated to obey Believing that ones work is aspiritual vocation to which one was called and chosenActivities and Behaviors

Prayer; meditation; communing with natureReading tarot cards, using crystals for their healing energy, or communicating with spirits who have passed to the other sideEngagement in efforts to make the world a better place and stamp out problems such as hunger, social injustice, and racismSinging or playing sacred musicNourishing the soul through activities such as reading, viewing great art, listening to classical music, enjoying aromas, andcreating artThe Therapist as Moral Consultant

Doherty (1996) created a framework of moral consultation, offering a list of eight therapist actions, in

order of increasing intensity:1. Validate the language of moral concern when clients use it spontaneously.2. Introduce language to make more explicit the moral horizon of the clients concerns.3. Ask questions about the clients perceptions of the consequences of actions on others, and explore thepersonal, familial, religious, and cultural sources of these moral sensibilities.4. Articulatethemoraldilemmawithoutgivingyourposition.5. Bring research knowledge and clinical insight to bear on the consequences of certain actions,particularly for vulnerable individuals.6. Describe how you generally see the issue and how you tend to weigh the moral options, emphasizingthat every situation is unique and that the client will, of course, make his or her own decision.7. Say directly how concerned you are about the moral consequences of the clients actions.8. Clearly state when you cannot support a clients decision or behavior, explaining your decision on

moral grounds and, if necessary, withdraw from the case.

Modele psihodinamice

P1 Par"i interne #i subpersonalit$"iP2 Reactualizarea unor Experien"e Infantile PrimareP3 Sens imatur al sinelui #i al concep"iei despre al"iiP4 Dinamici incon#tiente

P1 Par"i interne #i subpersonalit$"i - Problema este explicat" n termenii unorpar#i inerne $i subpersonalit"#i care au nevoie s"fie auzite, n#elese $i coordonate;este natural, nu patologic, s" fii con$tient de diverse par#i interne $isubpersonalit"#i. Problema rezid"n lipsa con$tientiz"rii $i comunic"rii ntre p"r#ileinterne, conflictul ntre diferite p"r#i, suprimarea unei p"r#i $i dominarea de c"tre o

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anumit"parte.Problemele pot fi rezolvate prin cre$terea con$tientiz"rii p"r#ilor$i adinamicii lor, ncurajarea unor procese interne de grup s"n"toase $i stabilirea unorobiective specifice pentru fiecare parte specific".

Table 8.2 Criteria for Healthy Internal Dynamics

Harmony, Cohesiveness, and Impulse Control

All parts, even unpleasant ones, are accepted and owned. They are not attacked, suppressed, or distorted but are allowed to beheard. The dynamics of the internal group are harmonious and free from coercion and abuse. As in a functional family, ahierarchy is maintained and the leadership comes from mature, responsible parts rather than from impulsive, Child parts. When adecision is made and an action agreed on, the inner selves cooperate and function as a cohesive, unified entity, without thepresence of secret saboteurs. Child parts who usually want instant pleasure are able to tolerate frustration and delay gratification.Good Morale and Optimism

There are internal sources of esteem: Parent parts are supportive, nurturing, and encouraging and when they evaluate and criticize,they are constructive, rational, and fair. Inner parts all feel and believe that the person has a right to happiness, pleasure, andsuccess. There are sources of higher ideals and a sense of purpose. The internal parts can maintain morale in face of frustration anddisappointments.Ability to Set Goals and Engage in Goal-Directed Behavior

An executive (Adult) part is able to mediate among conflicting parts, create compromises, and assure unified cooperation towarda goal. Goals are based on values (Parent), reality test- ing (Adult), and respect for the rights of the Child to have pleasure,creativity, and a rich emotional life.

Summary of Goals

The various approaches to working with inner parts and subpersonalities share these goals:Embracing (acceparea) all the selves: Helping the client to achieve awareness of each part, reclaiming disowned parts, andpermitting verbal expression from each part without fearing it will take over the personality. Strengthening the awareness and executive parts of the personality: A strong, competent Adult needs to be behind the steeringwheel, assuring that no single subpersonality dominates or acts out independently. The executive part examines the messagesfrom different parts, describes and analyzes internal and interpersonal process, and communicates to others to resolve conflict.The client experiences increased choice, self-control, and autonomy.Modifyingparts:Goalswillincludetoningdownapartthatistoodominant, supporting and strengthening weak parts that need to beheard, updating the rules and methods of powerful Parent parts, creating new parts to serve important functions such as boostingself-esteem and soothing painful affects, and developing a strategy to deal with self-destructive parts.Learningtotoleratevulnerabilityintheselfandinothers:Thisopensupthe opportunity for intimacy and the development of mature

ways of taking care of ones need for safety and trusting relationships.

Table 8.3 Problems Explained by P1 Internal Parts and Subpersonalities Hypothesis

Difficulty Making a Decision and Selecting a Course of Action Inner conflict: Any problem title that contains words likeindecision, ambivalence, confusion,

dilemma, which could be expressed as torn between two lovers, or to stay or to break up.Problems of fear and avoidance: A part of the client wants to do something, another part holds back, is afraid, thinks I cant,or feels fear. Indecision, with immobilization and inner torment: As an example, Hamlets famous solilo- quy, to be or not to

be, deals with the conflict between a passive part and a part that wants to take arms against a sea of troubles and by opposingend them.

Difficulties Sticking to a Chosen Course of Action

Internal opposition:

Difficulty breaking bad habits: A part of me says I should stop smoking, another part just loves cigarettes. Procrastination: Ishould do something, but I just cant get myself to start it. Lack of persistence: Its not worth it. Its too much trouble. Ididnt want it anyway.Impulsivity: Restraining parts (e.g., voice of reason, reminders about consequences, self- control, or responsibility to others) areeither silent or too weak to exert any influence on the impulsive parts.

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Poor frustration tolerance: An impatient Child part wants exactly what it wants, immediately. There is a lack of a good plannerpart who knows how to break the task into small bits and reward small accomplishments.Suppression of Feelings and Spontaneity

Rigidity: Goals are based entirely on shoulds, obligation, duty, or concern for the reaction of others. The parts that representpassion, play, pleasure, and spontaneity are completely ignored and may act as saboteurs.Blocks to creativity: Overly perfectionistic and critical parts interfere with immersion in creative process; there is suppression ofa creative, grandiose part.Problems Related to DepressionSuicidal risk: There are parts that want to die versus parts that want to live. It is crucial for therapists to search for, find, andstrengthen the parts that want to live. Self-hatred: The hypothesis of anger turned inward can be explored by identifying a self-criticalperhaps self-loathing and self-destructiveinner part.Excessive guilt: There is the presence of a punitive, internal voice, combined with the lack of a part that is nurturing, tolerant, andforgiving.Low self-esteem: An inner part that attacks the self, combined with the lack of inner parts that soothe and offer self-praise.Problems of Stress, Exhaustion, and Overwork

Excessive commitments and obligations: Multiple parts make commitments without regard to reasonable limits set by time andhealth. A pleaser part that cant say no to the demands and requests of others. Lack of relaxation and pleasure: There is a lackof a strong advocate for the inner parts that demand relaxation and pleasure; There is a moralistic, demanding Parent part (cantplay until all the work is done) and a worthless part, which only feels good when it is busy and productive and thus comes outwhen there are no obligations to fulfill.Perfectionism: There is a perfectionist part or a relentless pusher with unrealistic demands and standards. An Adapted Child part

feels like a failure unless he gets straight As.Instability in Emotions and Relationships

Dramatic alternation of moods: Alternation between grandiose self and weak, empty self, and a lack of inner parts thatmaintain self-esteem and soothe moods. If the Vulnerable Self makes appearances and gets hurt, the powerful parts rush in toprotect it. Unstable relationships: The person switches among different roles in relationships, such as Victim, Persecutor, orRescuer, or shifts from a part that idealizes another to a part that devalues the other person.

Table 8.4 Voice Dialogue Instructions

Physically Separate the Subpersonalities

Either the therapist or the client can pick a subpersonality to hear from first. An easy method is to have a wheeled chair and let theclient choose whether to roll the chair right or left.Talk to the Subpersonality

Talk to the subpersonality as you would talk to a real person. Begin the conversation by asking Who are you? or Which part ofAlice am I speaking to? Ask open-ended questions and para- phrase back what you hear, being empathic and nonjudgmental: Tellme about yourself. What about that bothers you? Sounds like you get very frustrated when she ignores you. What do you want for

yourself ? How do you feel about her? The therapist must not take sides or reject any parts. Your goal is to facilitate the self-expression of the subpersonality, not to try to change it in any way.Coach the Subpersonality to Stay in Character

Guide the subpersonality to speak of the whole person as a separate entity. You might para- phrase what the subpersonality says,changing pronouns, You mean she (referring to the position where the client sits during the session) wants to finish thedissertation but you want to quit and just stay home with your children. If it sounds like a separate subpersonality is beginning tospeak, you can say, I hear that the part who feels guilty is coming in. We can hear from him later, but now lets stay with whatyou have to say.Learn about the History of the Subpersonality

Often the subpersonality is focused on the current issue. It is important to move from talking to a part in a specific conflict to asubpersonality who has been around for a long time. Ask the subpersonality: When did you first join her personality? Can you

think of a time in childhood when you had a big part to play in her life?Invite the Client to Return to the Center

Before ending the conversation with the subpersonality, askDo you have anything further to say before you return to the centerposition? Then when the client is back in the original position, allow her to settle in and return to her normal state ofconsciousness. Ask for reactions to the subpersonality: What is your reaction to what she said?Consider Hearing from Another Subpersonality

If it seems appropriate to hear from a different subpersonality, ask the client to move to a different position. Again, the choice ofwhich part to hear from can come from the client or the therapist.Assure Closure to the Exercise

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The exercise ends with the client back in the center position, given time to reflect on the activity. Never end the activity with theclient in a subpersonality. Be sure to allow time for the client to get back to normal consciousness before leaving the session. Atthe very end of the exercise, if you want, you can ask the client to stand behind you and look at the chair as you summarize thedifferent phases of the activity. This gives the higher, aware self, a chance to process the experience and possibly have newinsights.

Creative Activities

Either directly or indirectly, you want to engage the clients Creative Part in the therapeutic work, both during the session andin homework assignments.Writing

Use one of these assignments or create your own. Imagine a bus that contains all of your subpersonalities. Watch it come toward you down the road, draw up, and stop. Describethese personalities, one by one, as they get off the bus. Give each one a nickname (Snow, 1992). Write a dialogue between two different parts that are involved in a specific conflict. Write a scene in a drama that includes several of your subpersonalities. First, list the cast of characters, describing each onebriefly.

Art

Write a letter from a subpersonality to the whole personality, describing its feelings and needs.Have a specific subpersonality answer a list of questions such as the following, taken from Rowan (1990): What do you looklike? How old are you? What situations bring you out? What is your approach to the world? What do you want? What do youneed? What do you have to offer? Where did you come from? Where did you first meet (name of person)? What would happen ifyou took over permanently?These activities are useful for exploring emotional aspects of internal dynamics. They also help strengthen creative and nonverbalsubpersonalities. Using different colored markers, draw all the different inner personalities that you are aware of now, showing their relationshipsto each other, and giving them names. Draw bubbles over their heads to show what they think and feel. Havetheclientcreatedrawingsorpaintingsfromseparatesubpersonalities.

P2 Reactualizarea unor Experien"e Infantile Primare - problema este oreactualizare a unor experien#e infantile primare: sentimente $i nevoi din primacopil"rie sunt reactivate $i pattern-uri din familia de origine sunt repetate;

experien#ele din prima copil"rie pot avea influen#e profunde asupra func#ion"riiadulte. Multe din problemele adul#ilor pot fi n#elese ca eforturi de a rezolvaconflicte $i a satisface nevoi nesatisf"cute ale copil"riei. Rela#iile cu p"rin#ii $i al#imemebri semnificativi ai familiei func#ioneaz" ca $i cadru pentru rela#iieladultului.. Con$tientizarea pattern-urilor recurente nu este suficient"; pacientul arenevoie sa tr"iasc"$i s"nve#e s"tolereze emo#ii dureroase $i s"-si schimbe stlurileautoprotective de rela#ionare.

Attachment Theory

The attachment of the child to the original caregiver functions as a template for adult intimate relationships (Ainsworth, 1982;Bowlby, 1988; Bretherton, 1992). Children build important belief systems ( internal working models) re- garding the reliability ofattachment figures, and their own lovability, worthi- ness, and competence. Three types of attachment styles were originallyidentified, but a fourth one has been added in recent years (Cassidy & Shaver, 1999).1. Secure: The child develops faith in herself and her attachment figures, and feels free to explore the environment because shecan count on the other tobe available for comfort and reassurance. This is the most adaptive style in adulthood.2.Anxious-ambivalent insecure (also called anxious-resistant): The attachment figure is inconsistent and unreliable, and thechild grows up to have low self-esteem, and is often clingy and insecure in adult relationships.

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3.Anxious-avoidant insecure: The child was rebuffed, rejected, and ignored, and so develops a cold, distant attitude; inadulthood, a person with this style rejects others and treats relationships as if they do not matter.4. Disorganized: In contrast to the prior two styles, which have coherent patterns and are sometimes effective, this style refers

to the lack of a coherent template for interacting.

Table 8.6 Problems Explained by the P2 Reenactment of Early Childhood Experiences Hypothesis

Problems with Authority Figures

Authority figures in the clients life are targets for feelings toward parents. The clients responses reflect negative feelings ofbeing dominated, controlled, and disrespected, as well as inappropriate positive expectations to be indulged and rescued. Theseemotional responses are excessive to the real stimulus: The client will interpret behavior from the boss as outra- geous andintolerable, whereas the therapist will think that it is, at worst, typical insensitivity of someone with poor managerial skills. Someof the problematic reactions are helpless dependence, blind defiance, misperceptions of favoritism, and irrational fears ofexpressing independent thought.Difficulty Establishing and Maintaining Satisfying Intimate Relationships

Perhaps the most common reasons people seek therapy include (a) difficulty finding an appropriate partner; (b) maintenance offrustrating and painful relationships; (c) repetitious patterns (e.g., falling in love with the perfect person and then discardingher; pursuing relationships with unavailable or rejecting people); (d) marital problems (e.g., excessive conflict, inability totolerate separateness in their partner, and withdrawing and distancing behaviors).Inappropriate Emotional Reactions

When the presenting problem is excessive anxiety or anger, the roots of these reactions often lie in early childhood experiences.For instance, overreactions to separations can reflect an insecure attachment. When the client becomes enraged at the therapistsminor lapses in empathy, the client may be reacting as she did when she was a child with a self-absorbed mother.Difficulty Maintaining Equal and Cooperative Peer Relationships

The client may relate from either a position of superiority or inferiority, may be unable to quell competitive feelings, could take arole of self-sacrifice and put others needs ahead of her own, have inappropriate expectations of being spoiled and catered to, andexperience jeal- ousy and hostility over the achievements of others.Difficulties with Parenting

Parenting styles can either replicate or completely reverse what one experienced in childhood. As children reach successivebirthdays, new childhood issues are reactivated for parents.Problems in Relationships between Adult Children and Their Parents

Problems can include excessive emotional reactivity when relating to parents, difficulties deal- ing with parents in grandparentrole, and continuing to respond to the mother-of-today as if she were the mother-of-childhood. Another problem that is becomingmore common as the life span gets longer is the difficulty of coping with aging parents. When adult children are put in caregiver

roles for their elderly parents, the roles are reversed from childhood and the child has the power while the parent is helpless anddependent. This can provide healing opportunities, as the child sees the parent in a new light, or it could be the recipe for elderabuse.

P3 Sens imatur al sinelui #i al concep"iei despre al"ii - Dificult"#ile rezid" nincapacitatea clientului de a progresa dincolo de un sim# imatur al sinelui $i alconcep#iei despre ceilal#i care este normal pentru copii foarte tineri; Ceilal#i oameninu sunt aprecia#i ca indivizi unici cu nevoi, sentimente $i perspective distincte cisunt experien#ia#i ca extensii ale eului $i valoriza#i pentru func#iile pe care le

ndeplinesc. Clientul are nevoie de ceilal#i pentru a-i proteja stima de sine $i de a-i

alina durerile emo#ionale, lipsindu-i capacitatea de a-$i asigura singur acestefunc#ii. n baza evalu"rii capacit"#ilor $i deficitelor adultului, putem fixa stadiulcopil"riei primare n care maturarea s"n"toasa a fost perturbat".

Table 8.8 Examples of Capacities of a Healthy Self

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Spontaneity and aliveness of affect You can experience emotion deeply and have a capacity for aliveness, joy, vitality,excitement, and spontaneity.

Self-entitlement You feel entitled to appropriate experiences of mastery and pleasure and to theenvironmental input necessary to achieve these objectives. This sense is neitherdeficient nor inflated

Self-activation, self-assertion, and self-support

.You are able to identify your unique wishes and to use autonomous initiative andassertion to express them in reality and to support and defend them when underattack. Direction comes from internal ideals, values, and ambitions.

Maintenance of self-esteem You can fuel adequate self-esteem, on your own, by giving positiveacknowledgment to yourself.

Soothing of painful affects You are able, on your own, to devise means to limit, mini- mize, and soothe

painful affects.

Continuity of self You recognize and acknowledge that the I of one experience is continuousover time and related to the I of another experience.

Commitment You can commit to an objective or a relationship and perse- vere, despiteobstacles, to attain that goal or maintain that relationship.

Object Relations

Object relations is the psychoanalytic jargon for relationships with other human beings and the name of a complex theory thathas been explained with clarity by various authors (e.g., Scharff & Scharff, 1995; St. Clair, 1996). Table 8.9 lists thecharacteristics of mature object relations.

Table 8.9 Mature Object Relations

Other People Are Real and Separate and Do Not Revolve around You

You experience others as free, separate selves with their own feelings and experiences. The other person has his or her own centerof initiative, exists without you, is not an extension of you, does not revolve around you and your needs, nor can be controlled byyou. You deal with the reality of the other person, not your fantasy of who the other person is.Other People Are Unique and Different from You

Others are not just interchangeable, replaceable things who serve functions for the self, but you appreciate them as separate,unique persons with their own needs, feelings, and talents. Another human will never be your perfect clone. Although we mayoften have similar feelings and opinions, it is impossible to always feel the same or to agree on everything. Because this isunderstood, disagreements are expected and are not experienced as threats to your sense of self or the relationship.There Are Multiple Valid Perspectives

Because you can shift perspectives, you realize that you are not the center of every event and interaction. You can think in termsof multiple perspectives, instead of one absolute truth. You can observe yourself from the perspective of another person andaccept negative feed- back without viewing it as an attack on yourself. You can imagine how you appear to others and the impactthat your behavior has on them.You Can Tolerate Ambivalent Feelings toward Someone You Love

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People are not all good or all bad. Only in fantasy is someone perfect, so you know that idealization of another person cant last.When flaws appear, you do not flip into devaluation of the person. You can express anger and receive anger in the relationshipwithout it destroying the bond.You Can Experience Interdependence in Relationships

It is normal in times of stress to turn to others to have them serve functions such as shoring up self-esteem and soothing painfulemotions. However, the roles can be reversed: You can do the same for another person in need. When you set goals, you canconsider the impact on the other person. You can put anothers needs ahead of yours.You Are Capable of Committed Intimate RelationshipsYou are able to sustain trust, develop secure attachments, and tolerate separation, believing in the constancy of another even whenthat person is not physically present. Because you love a real person, you do not fluctuate between idealization and devaluation,but rather can tolerate periods when needs are not met.

Childhood Adulthood Parallels

MOST IMMATURE STAG : SYMBIOTIC MERGER

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Formularea Clinica a Cazului Conspect

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