Formularea Clinica a Cazului Conspect4

8/16/2019 Formularea Clinica a Cazului Conspect4

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Evaluare psihologica/Diagnostic/Formularea cazului

“Nu avem intentia de a afirma ca evaluarea diagnostica este inutila. Noi insine am utilizat intens

astfel de metode in cercetarile noastre asupra schimbarii personalitatii. Ea este inutila capreconditie a psihoterapiei avuta in vedere.“(C.Rogers, 19!"

#. Cancrini$

“Elementele importante pentru stabilirea diagnosticului apar oricum, foarte firesc, in

cadrul unui inteviu centrat de la inceput pe finalitatile de ordin therapeutic.% faza formala dedicata evaluarii diagnostice se traduce deseori , mai ales pentru

pacientii mai gravi, intr&o procedura de invalidare care poate face ulterior travaliul

terapeutic foarte dificil'

) & Evaluare psihologica, diagnostic$ “)rocedurile pot include, dar nu sunt limitatela, observatia comportamentului, interviul, si administrarea si interpretarea instrumentelor de

evaluare a performantelor educationale , a deprinderilor academice, aptitudinilor, intereselor ,

abilitatilor cognitive, emotiilor, motivatiilor , statusului psihoneurologic, caracteristicilor personalitatii, ori a oricarui alt aspect al e*perientei si comportamentului uman care poate

contribui la intelegerea si a+utarea utilizatorului.'

“Diagnosticul este un process. Este mai mult decat determinarea unei etichete sau a uneicategorii dintr&o clasificare psihopatologica. El este o analiza a functionarii clientului in vedera

prescrierii celei mai utile interventii terapeutice.' (ood-, ansen, Roossberg, 19/9"

Utilizarea computerului in evaluarea psihologica si in psihoterapie

P.M.G.Emmelkamp:

“0tudii care au comparat versiuni on&line si creion hartie ale unor teste de personalitate au demonstratca testele on&line au proprietati psihometrice comparabile cu cele

traditionale'

Recent computerele au fost utilizate pentru tratamente psihologice. 2n terapiaorientata de computer, computerul insusi determina si furnizeaza feed&bac3&ul pacientului.

Rezultatele terapiei ghidate de computer cu pacienti avand tulburari an*ioase si tulburari

depressive moderate intr&o clinica din #ondra sunt comparabile cu cele obtinute intr&o terapiecognitive&comportamentala fata in fata dar terapia ghidata de computer este mul mai eficienta

din punct de vedere al costului.

Evaluarea multiaiala D!M

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*a 2 4ulburarile clinice.lte conditii care se pot afla in centrul atentiei clinice

*a 22 4ulburarile de personalitate. Retardarea mentala

*a 222 & Conditiile medicale generale*a 25 )roblemele psihosociala si de mediu

*a 5 & Evaluarea globala a functionarii

Formularea "conceptualizarea# cazului$6ergner, 199/$

· organizeaza toate faptele iportante ale cazului in +urul unei surse cauzal

e*plicative (linchpin"

· defineste aceasta sursa in termenii factorilor care pot fi supusi interventiei

directe

· impartaseste clientului aceasta formulare in vederea obtinerii beneficiilorasteptate

7.C. Norcross$

·

prezentarea problemei· factori biopsihosociali cheie

· obiectivele si planul terapiei

D!M/Formularea cazului80 nu stimuleaza clinicianul sa identifice factorul central de mentinere a

problemei

80 nu spri+ina ideea ca formularea clinica a cazului sa fie realizata in termenii

unor variabile care sa poata fi supusi unei interventii directe80 nu contine recomandarea ca formularea diagnostica sa fie impartasita

clientului

Utilizarea diagnosticului pentru orientarea tratamentului

- prima aplicare a diagnosticului la terapie incepe cu recunoasterea faptului ca

patologia si normalitatea sunt creatii statistice (ood-, ansen,Rossberg"

- daca un comportament are consecinte personale negative, atunci el poatedeveni obiectiv al schimbarii terapeutice

- “un model centrat pe descrierea pro$lemelor mani%este sisimptomatologiei este potential mai benefic pentru pacient decat sunt rezultateleunei baterii de teste' (0:eene-, Clar3in, ;itzgibbon, 19/!"

-

Cum facem distinctia dintre tul$urare mentala si normalitate< 7ahoda (19/"considera ca tulburarea mentala implica deficiente clar definite in$o constientizarea, acceptarea si corectitudinea imaginii de sine

o dezvoltarea continua si auto actualizare

o integrarea si unitatea personalitatii

o autonomia si capacitatea de auto& ingri+ire

o perceptia realitatii si sensibilitatea sociala

o controlul mediului si comportamentul adecvat in fata cerintelor vietii.

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- abordarea lui illon (19/1" privind definirea personalitatilor normale si patologice

necesita diferentierea dintre pattern&urile personalitatii, tul$urarilesimptom si reactiile comportamentale

o pattern&urile personalitatii rezista la actiunile de modificare

o simptomele se modifica greu

o reactiile comportamentale se modifica usor - 0arcinile terapeutului sunt urmatoarele$

o sa identifice structurile de personalitate care dau pacientului stabilitate si

autonomie si care se e*prima indiferent de situatiile stimul specifice

o sa identifice reactile comportamentale, cele care conduc deopotriva la

echilibrare sanatoasa si destructurare

o sa decida cum sa utilizeze factorii sintonici, cei care confera pacientului

sentimentul confortului si acceptarii

o sa focalizeze schimbarea terapeutica asupra tulburarilor simptom ego

distonice care determina discomfort,si comportamente irationale sau specifice

- allec3 distinge patru sectoare care pot genera problemele pacientului si pentru

fiecare din ele recomanda un anume demers terapeutic$o disfunctii biologice chimioterapie, interventii fiziologice (medicatie,

psihochirurgie, terapie electroconvulsive, terapii fizice -oga, rela*are

miscare, masa+"

o e*periente trecute invatate interventii comportamentale ( tehnici bazate pe

conditionarea clasica sau operanta"

o ipoteze informationale ( deficit in constientizarea sau insight&ul referitor la

aspecte relevante ale sinelui sau mediului" psihoterapii orientate pe insight

o ipoteze enviromentale spitalizare, mediu terapeutic

'este utilizate %recvent in evaluarea clinica:(ade )*aker "+--#:&Rorschach, 44, 20, )2, 6ender 5isualotor =estalt 4est, 20C

u$in, arsen, Matarazzo"+0#- 20, )2, 6ender 5isualotor =estalt 4est, Rorschach, 44, 20C

Piotro1ski"+2 # 3 ancheta printre mem$rii !ociet4 o% Personalit45ssessment:

&'este o$iective: )2 ( /!>", C)2 (?@>",Ed:ards )ersonal )reference0chedule (11>"

&metode proiective: Rorschach (9A>", 44 (91>", 0entence Completitionmethod (A!>"

%portunitatea prescrierii unei interventii terapeutice

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+#6apacitatea pacientului de a sta$ili o relatie de lucru productiva& Motivatia (construct multidimensional care include motivatia de schimbare,

capacitstea de insight, auto intelegere, participare active, nivelul initial al distresului, dorinta de a

inlatura suferinta, beneficiile secundare ale bolii, asumarea responsabilitatii, obiective

realiste,asteptri realiste cu privire la eficienta terapiei., dechidere psihologica

, comunicare onesta.& 6alitatea aliantei terpeutice& 7storia relationala&6onditii de viata supportive ( timp pentru psihoterapie, venituri financiareadecvate, support la locul de munca, support familial.

8#Factori ai modelului de %unctionare a pacientului& capacitatea de introspectie

& orientare catre analiza psihologica, capacitatea de a lucra cu conceptele unei anume psihoterapii

& e*istenta unei acuze principale, formulare timpurie

&recunoastera patternurilor neadaptative9# 6aracteristici specice pacientului individual& gradul de “integrare a superego&ului'( capacitatea de a se abtine de la e*ploatarea si

manipularea celorlalti, mentinerea onestitatii si integritatii morale in absenta unui control e*tern"

&capacitatea de testare a realitatii

&puterea eului ( slabiciunea eului$ slaba toleranta la frustrare, slab control al impulsurilor,lipsa tolerantei an*ietatii, lipsa capacitatii de sublimare"

& bune rezultate scolare sau profesionale

&lipsa tendintelor spre somatizare0# 7nterventiile cu scop evaluativ

& raspunsuri adecvate la intrebarile e*ploratorii

& defense modificabile&raspuns pozitiv la interventiile transferentiale ( capacitaea de a lucra “aici si acum'"

&monitorizarea si utilizarea contratransferului

Utilizarea clinica a criteriilor de oportunitate- coreletia dintre acesti factori si rezultatele terapiei sunt slabe

- ei trebuie avuti in vedere impreuna si nu separat

- pacientii care satisfac in mare masura aceste criterii beneficiaza bine de terapiile

scurte

Un cadru pentru pentru %ormularea clinica

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% formulare clinica a cazului este “ o schema conceptuala care organizeaza e*plica sau

furnizeaza o semnificatie clinica unei mari cantitati de date si influenteaza deciziile terapeutice' (

#azare, 19!B"

7erome ;ran3 (;ran3 ;ran3, 1991" defineste doua componente ale formularii clinice$

1. o e*plicatie plauzibila a simptomelor pacientului sub forma unei schemeconceptuale sau chiar a unui mit care furnizeaza argumente pentru

D. prescrierea unui tip de ritual sau a altui tip de procedura pentru pentru a le rezolva

2n baza acestei definitii putem identifica urmatoarele elemente ale une formulari clinice acazului$

· 0imptomele sau problemele care trebuie schimbate

· % mare cantitate de date care trebuie sa fie organizate

· % schema conceptuala care furnizeaza o e*plicatie

· 8ecizii terapeutice care conduc la proceduri specifice

2n afara unei bune comunicari cu supervizorii si cu alti profesionisti o buna formulare clinicaare , de asemnea, urmatoarele avanta+e$

· 2ncredere crescuta si an*ietate scazuta in fata unor cazuri noi

· ;urnizeza instrumente si modele de actiune pentru evaluarea nevoilor clientului si

intelegerea clientilor din multiple perspective

· ;urnizeaza o strategie coerenta pentru aplicarea cunostintelor in munca cu clientii

· sigura o structura ce permite utilizarea creativitatii in procesul de a+utorare a

pacientilor

6um procedam ;

)entru a crea o formulare clinica putem fie sa alegem o orientare si sa&i urmam regulile, fie

dezvoltam o formulare unca, integrativa pentru fiecare client.

5legerea unei anume teorii pentru a dezvolta o formulare clinica are urmatoarele$

avanta


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4erapeutul integreaza idei, abilitati si tehnici din diferite abordari teoretice pentru a crea o

formulare unica pentru fiecare problema a clientuli, pentru fiecare personalitate si conte*t

sociocultural. casta abordare recunoaste ca fiecare teorie poate oferi ceva valoros dar nu estesuficienta ca singur ghid pentru terapie.

Un plan terapeutic integrativ com$ina concepte si tehnici din di%eritea$ordari terapeutice intr&o modalitate sistematica si coerenta pentru a intalninevoile unui client unic.

Doua caracteristici ale %ormularii cazului

7ntegrarea ideilor din 8 ipoteze clinice principale

ceste ipoteze $

· E*trag ideile e*plicative esentiale din toate teoriile si abordarile terapeutice

· )ermit combinarea si integrarea componentelor diferitelor teorii

·

Conduc intr&o maniera logica la planul terapeutic

Un cadru structurat numit metoda orientarii pe prolema

etoda orientarii pe problema (%)" necesita$

· 2dentificarea pro$lemei care este tinta interventiei terapeutice· 0pecificarea rezultatului o$iectiv, schimbarea dorita in functionarea clientului· n sumar bine organizat al informatiei colectate despre client "$aza de date"· % e*plicatie coerenta pentru fiecare problema care sa integreze ipotezele clinice

"evaluarea#· )lanul tratamentului recomandat in acord cu e*plicatia si focalizat direct pe realizarea

rezultatului obiectiv

7potezele clinice nucleu

= ipoteza clinica nucleu este o singura idee eplicativa care ne a


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9. Modele comportamentale si de invatarea. 5ntecedente si consecinte$. >aspuns emotional conditionatc. Decit al a$ilitatilor sau lipsa competentei

0. Modele cognitive

a. 5steptari utopice$. ?arta cognitiva eronatac. Procesare eronata a in%ormatieid. Monolog interior dis%unctional

2. Modele eistentiale si spiritualea. Pro$leme eistentiale$. Evitarea responsa$ilitatii si li$ertatiic. Dimensiune spirituala

@. Modele psihodinamicea. Parti interne si su$personalitati$. >eactivarea unor eperiente primare in%antile

c. Un simt imatur al sineluisi a conceptiei despre ceilaltid. Dinamici inconstiente

-. Factori sociali, culturali si de mediua. !istemul %amilial$. 6ontetul culturalc. !uportul sociald. Per%ormanta rolului sociale. Pro$lema sociala este o cauza%. >olulsocial al pacientului cu tul$urari mentaleg. Factori de mediu

Formularea clinica a cazului & 8 ipoteze clinice nucleu7poteze $iologice$

61 6auza $iologica & problema are o cauza biologica$ clientul are nevoie de ointerventie medicala pentru a&si prote+a viata si a preveni deteriorarea, sau are nevoie deasistenta psihosociala pentru a se adapta cu boala, dizabilitatea sau cu alte limitari biologice.

(c. ipoteza se aplica , de e*. in accidente vasculare, tumori cerebrale, sindromul lzeimer,

stsri to*ice tranzitorii, into*icatii etilice sau cu droguri, 028, deficit de vitamine, tulburariendocrine etc"

6D 7nterventii medicale & e*ista interventii medicale( e*. medicatie, interventii

chirurgicale sau protezari" care trebuie luate in consideratie. ceasta ipoteza este recomandatacand utilizarea unei medicatii psihotrope este indicata pentru o tulburare psihiatrica.

Cunostintele de psihofarmacologie sunt importante pentru orice psihoterapeut. Competentele

care trebuie dezvoltate sunt$ a" abilitatea de a recunoaste simptoamele si sindroamele care +ustifica trimiterea la un psihiatru pentru o evaluare a medicatiei, b" o intelegere a efectelor

terapeutice si a efectelor adverse a celor mai utilizate tipuri de medicamente psihotrope, si c"

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abilitatea de a discuta medicatia cu clientii cu intelegerea factorilor care promoveaza si

impiedica complianta.

2ndicatii pentru referirea pacientului catre un psihiatru pentru evaluarea medicatiei$+. 6lientul este activ suicidal sau are decite %unctionale severe

8. !imptomele au persistat in ciuda interventiilor psihoterapeutice9. 6lientul utilizeaza automedictia0. Medicatia psihotropa i&a %ost utila clientului in trecut2. Medicatia psihotropa a %ost utila in trecut mem$rilor %amiliei cu

simptome similare.

6? 6oneiuni minte & corp & o intelegere holista a cone*iunilor minte corp conduce latratamente pentru problemele psihologice care se focalizeaza pe corp si la tratamente pentru probleme fizice care se centreaza pe minte.

ceasta ipoteza se potriveste pacientilor care somatizeaza, pacientilor care acuza diverse tipuri

de stres si tensiuni, celor cu tulburari se*uale. Clientii au deseori nevoia de creste constientizareasi controlul corpului lor si sa dezvolte o constientizare somatica a emotiilor. ulte din terapiile

corporale sunt utile pentru problemele psihologice. 0tarile psihologice pot afecta creierul,sistemul nervos autonom si sistemul imun. )roblemele de sanatate, precum cancerul si 028,

beneficiaza de pe urma starilor mentale pozitive

6rize, situatii stresante, si tranzitii

E*ista doua erori care trebuie evitate$

- ratarea prevenirii unor consecinte serioase, inclusiv moarte, actiuni distructivesi patologie pe termen lung prin neraspunderea cu promptitudine la situatia de crizaF

-

patologizarea unei conditii care, desi dureroasa si debilitanta, este mai bine inteleasa canormala, ca raspuns asteptat la stresori, traume, situatii de tranzitie.

C01 Urgenta & simptomele clientului constituie o urgenta$ se impune o actiune imediata.ceasta ipoteza trebuie avuta in vedere in prima sedinta datorita severelor consecinte

negative ale unei non interventii. Ea se aplica situatiilor in care pacientul trebuie spitalizat si in

care e*ista reglementari legale pentru raportarea abuzului sau a violentei intentionate. Ea se potriveste si situatiei in care clientul se poate anga+a intr&o actiune irevocabila.

anagementul clientului violent

1.entinerea unei atmosfere de calm si incredereF nu grabiti situatiaD.8aca clientul se simte amenintat de ceva, inlaturati amenintarea din scena

?.8efiniti&va rolul$ doresc sa va a+ut sa va controlati aceste sentimenteF doresc sa va a+ut sa gasiticele mai bune modalitati sa controlati situatia.

A.Nu blocati accesul clientului catre usa

.sigurati&va ca aveti suportul persoanelor disponibile & lasati usa deschisa, asigurati prezentaunei alte persoane sau accesul la un sistem de alarma.

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B.0cadeti emotionalitatea clientului$ vorbiti intr&un limba+ direct simplu, a+utati e*primarea

sentimentelor prin cuvinte, si puneti intrebari factuale.

!.;urnizati o structura si limite$ e*primati clar ca violenta nu va fi tolerata/.Recompensati orice semn ca clientul isi controleaza comportamentul

9.Chemati politia sau echipa de urgente psihiatrice daca este nevoie

[email protected] ezitati sa faceti orice va securizeaza, chiar daca ganditi ca pacientul s&ar simti ofensat

Evaluarea potentialului de suicid

1.;iti directi in abordarea temei suicidului, aratand confort in abordarea acesteia$ 5&ati gandit sa

va puneti capat vietii<D.)uneti intrebari specifice referitoare la durata si intensitatea gandurilor suicidale$ Cat de des va

ganditi sa va impuscati<

?.2nteresati&va de e*istenta unui plan.A.Evaluati letalitatea metodei aleseF cu cat mai specific este planul cu atat letalitatea este mai

mare.

.E*plorati comportamentul suicidar ca modalitate de comunicare. Ce mesa+ doreste persoana sacomunice< #a ce raspuns se asteapta


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B.Cand ideatia suicidara este insotita de vinovatia supravietuitorului, implementati un “ritual de

penitenta'

!.sistati clientul sa constientizeze factorii care au determinat debutul ideatiei suicidare.

6!8 !tresori situationali & simptomele pacientului rezulta din stresori situationali

recenti sau din e*periente traumatizante trecute. Este important sa evaluam daca simptomeleclientului sunt proportionale cu nivelul stresului. 4rebuie sa mentionam stresorii e*terni, care potsa mearga de la traume care pun viata in pericol pana la acumularea unor nea+unsuri zilnice si sa

avem o modalitate obiectiva de masurare a severitatii acestora. 4ehnicile de interventie in criza

pot impiedica transformarea reactiilor de criza in tulburari cronice

6ele patru %aze de dezvoltare a crizei "Caplan 19BA"

• Cresterea tensiunii

• Eforturi de coping fara succes• obilizarea resurselor de urgenta

• 8ezorganizarea

Principalii pasi in interventia in stare de criza "cuprinde idei din ipple ipple&19/?, guilera & 199/, =reenstone#evitone 199?"

Scop Actiunile terapeutului

imbunatatirea starii

emotionale

Inspirati speranta si securizati clientul. Demonstrati ca sunteti

calm si increzator in atingerea unor rezultate pozitve. Normalizati

experienta pentru a contracara teama ca simptomul insamna

slabiciune sau “ inceputul nebuniei”Stabiliti directia Conducceti interviul, furnizati o structura, prezentati-va ca expert

in problem solving. Implicati membrii familiei sau alti membri ai

retelei sociale. Ajutati clientul sa puna ordine in mintea sa.

Evaluarea crizei Utilizati tehnicile focusarii active pentru a obtine o evaluare

adecvata a factorilor precipitanti.Evaluati factori precum

perceptia evenimentului, suportul social, mecanisme de coping

folosite, sau daca nu au fost folosite, care sunt disponibile.

Interesati-va de experientele pozitive de coping pentru a

identifica resurse. Evaluati deopotriva intelesurile reale sisimbolice ale evenimentului criza.

Evaluarea gradului

de urgenta

Evaluati daca clientul este un pericol pentru el sau pentru ceilalti

si apreciati nevoia de spitalizare. Daca persoana are ideatie

suicidara, utilisati un contract non-suicid si cresteti frecventa

sedintelor.

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Ajutarea clientului

sa inteleaga criza

Explicati relatia dintre stresori sau trauma si intensitatea reactiilor

emotionale. Furnizati educatie despre posibilele faze ale

reactiilor emotionale care urmeaza trauma.Explicati teoria crizei,

utilizand conceptele echilibrului si dezechiibrului. Ajutati clientul

sa realizeze ca starea de criza ste temporara

Facilitatea

exprimarii

emotionale

Incurajati clientul sa-si exprime emotiile. Aratati intelegere in

legatura cu reactiile emotionale, utilizand cuvinte referitoare la

emotii in raspunsurile dvs( ex. soc, confuzie, spaima, vinovatie,

afi depasit). Ajutati clientul sa acceseze emotiile care pot fi

reprimate, precum teama fata de persoane iubite - un catharssis

emotional cu un ascultator suportiv poate reduce tensiunea.

Opotunitatea de a verbaliza experientele poate ajuta prevenirea

evitarii care caracterizeaza PTSD.

Utilizarea

restructurarii

cognitive

Tehnicile restructurarii cognitive pot schimba evaluarea

stresorilor casi capacitatatea de coping a clientului. Clientii pot

avea credinte gresite referitoare la faptil ca anumite evenimente

traumatice ar fi putut fi anticipate si prevenite daca ei ar fi

reactionat diferit, si de aceea ei se pot blama nejustificat.

Dezvoltarea unui

plan de actiune

Deprinderile modelului problem-solving. Listati alternativele si

sjutati clientul sa le evalueze pro si contra. Asigurativa ca planul

este in acord cu valorile personale si culturale alepacientului.Divizati planul in pasi simpli, concreti, realisti si

adecvati nivelului de functionare a clientului. Obiectivele

intermediare trebuie stabilite in termeni temporali - ore, zile.

Daca sunt implicti si alti agenti asigurati-va ca exista o

coordonare adecvata.

Delimitarea

suportului social

Suportul social poate veni fie din reteaua sociala individuala, fie

din partea altor persoane care sufera de aceeasi problema, fie

din partea organizatiilor comunitare. Daca este posibil, includeti

memebrii familiei in procesul terapeutic.. Interveniti daca aparsemne ca se dezvolta o criza familiala din cauza crizei personale

a clientului. incurajati partticiparea la activitati de grup care

furnizeaza suport si canalizeaza energia catre obiective

adecvate.

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Monitorizarea

progresului

Pe masura ce schimbbarile pozitve se manifesta, sumarizati

progresul si ajutati clientul sa inteleaga care strategii de coping

au fost cele mai eficiente.. Furnizati recompense si incurajari.

Utilizati deprinderi de problem solving pentru depasirea

obstacolelor neprevazute.

Planificarea

anticipata

Dupa ce criza curenta este menegeriata, ajutati clientul sa

dezvolte insight-uri si deprinderi de a preveni viitoarele situatii de

criza si sa se adapteze mai bine la ele daca apar.

Terminarea Terminati interventia cand clientul revine la echilibrul anterior si

controleaza problemele sale in mod eficient. Daca este nevoie

de un ajutor ulterior discutati un contract terapeutic pentru

problemele identificate.

C0? 'ranzitie developmentala & clientul este intr&o tranzitie developmentala confruntandu&se cu probleme legate de trecerea de la un stadiu al vietii la altul.

#a fiecare &1@ ani o tranzitie developmentala este inevitabila datorita interactiunii dintrematurarea biologica, dezvoltarea personalitatii, e*pectatiile sociale de rol pentru persoanele de

virste diferite. ceasta ipoteza normalizeaza disruptiile dramatice si conduce la interventii care

impiedica o criza de maturizare sa devina o tulburare cronica. %amenii au nevoie de suport pentru a face alegeri personale si pentru a realiza sarcinile developmentale in propriul lor ritm

6ele sase stadii ale rolului de parinte "=alins3-, 19/!"

Stadiul parintelui Stadiul copilului Sarcini developmentale

Stadiul formarii

imaginii

Prenatal Acceptarea sarcinii

Pregatirea pentru rolul de parinte

Pregatirea pentru nastere

Stadiul dezvoltarii De la nastere la

bebelus

Reconcilierea imaginii nasterii cu realitatea

Confruntarea cu sentimentele

atasamentului

Redefinirea relatiilor

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Stadiul parintelui Stadiul copilului Sarcini developmentale

Stadiul autoritatii Dela bebe la

varsta scolara

Dezvoltarea autoritatii

Castigarea distantei

Controlul rolurilor de sex si identitatii

Stadiul interpretariiDebutul scolii -

scoala medie

Interpretarea propriei persoane ca parinte

Separare si conectare

Interpretarea lumii catre copil

Decizia cu privire la nivelul de implicare

Anticiparea varstei adolescentine

Stadiul

interdependentei

Scoala superioara Adaptarea la o noua autoritate relationala

Controlul sexualitatii

Acceptarea identitatii adolescentine

Formarea unei noi relatii cu copilul aproape

matur

Stadiul plecarii Scoala superioara

-colegiu si mai

departe

Pregatirea pentru plecare

Adaptarea la plecare

Schimbarea imaginilor

Relaxarea controlului

Asumarea succeslor si insucceselor

6!0 Pierderi si doliu

Clientul a suferit o pierdere si are nevoie de a+utor pe durata doliului sau pentru rezolvarea unor

probleme legate de pierdere. )ierderile pot fi e*terne(e*. moarte, divort, dezastre naturale",interne (pierderea unor capacitati datorita bolii sau varstei", sau combinate (pierderea serviciului

determina pierderea identitatii ca si cap al familiei". Cunoasterea stadiilor tipice ale suferintei

(grief" este utila, atata timp cat diferentele culturale si individuale sunt acceptate. neori pierderea este o cauza precipitanta a unor simptoame emotionaleF alteori, clientul nu este

constient de aceasta cone*iune.

0troebe si 0chut (D@@1" au dezvoltat o teorie a proceselor duale cu privire la suferinta.

• Procese orientate catre pierdere: tat confruntarea cat si evitarea pierderiipemasura ce persoana traverseaza procesul suferintei.

• Procese orientate catre insanatosire: Copingul cu problemele siresponsabilitatile determinate de pierdere si descoperirea propriului loc in lume fara persoanadecedata.

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!tadiile su%erintei "doliului# (#indemann, 199A"

1. soc, neacceptare, letargie, amortealaD. Confruntarea cu pierderea si trairea durerii si dorului

?. Rezolvarea pierderii si realizarea acceptarii

Prescriptii terapeutice pentru !u%erinta "doliu# (orden, 1991"

A. cceptarea realitatii pierderii

. 4ravaliul durerii

B. daptarea la un mediu fara persoana sau lucrul pierdut

!. Relocarea emotionala si continuarea vietii.

4ipuri de doliu complicat (.0troebe, 0chut, and 0troebe (D@@"

/. 4ipul cronic$ focalizare e*cesiva asupra pierderiiF e*perienta prelungita a simptomelor

fazei acute precum furie, suparare, tristete, amaraciune, depresies mentinerea unei relatiifantasmatice cu decedatul cu sentimentul ca elGea este mereu prezent(a" si privesteF dor intenssi cautarea persoanei decedate,F lipsa progresului in sarcinile de restaurare

9. 4ipul amanat, inhibat sau absent$ focalizare scazuta asupra pierderii cu concentrare

e*clusiva asupra sarcinilor de restaurare1@. 4ipul traumatic$ Confruntare foarte intensa si persistenta cu pierderea combinata cu

evitareaF trairea simptoamelor caracteristice )408 precum flashbac3 & uri, cosmaruri,

amintiri intruzive.

;actorii de risc pentru aparitia complicatiilor$

11. 4ipul de relatie cu decedatul1D. Circumstantele decesului ( neasteptat, violent, suicid etc "

1?. )rocesul de doliu$ incercari de evitare a trairii durerii, credinta ca un doliu limitat este o

tradare a celui decedat "1A. )ersonalitatea si istoria individului

1. lti factori de stres concurenti

1B. #ipsa unui suport social adecvat

in 80&25&4R, se considera ca o persoana care a trait doliul poate considerata caavand un episod depresiv ma


15/32

4ehnica gestaltista a scaunului gol: clientul poate vorbi direct cu decedatul si sa&sie*prime sentimentele, poate lucruri pe care nu a avut ocazia sa le spuna inainte de decesul persoanei, sa ierte sau sa ceara iertare. ;ormula “la revedere', “ramas bun' este de evitat desi

este important ca pacientul sa accepte pierderea.

4ehnica imageriei ghidate: terapeutul poate ghida clientul printr&un set de e*periente care pot culmina cu e*perienta de a vorbi cu persoana decedata. )rocesul este intern si silentiosFterapeutul poate sa ceara sau nu clientului sa povesteasca e*perienta sa.

!crierea unei scrisori, a unui ealizarea unor lucrari artistice &catharsis, constientizarea unor sentimente, se formaunor unor emotii incoerente

6omemorare: clientul poate crea uncola+ cu scrisori, fotografii, si alte obiecte ale persoanei

decedate.

>itualuri vindecatoare $ ritualuri de ramas bun, de adio( nu numai in raport cu persoanadecedata ci si cu durerea si suferinta.

2nterventii terapeutice centrate pe procesele de insanatosire$

'erapia narativa: 4erapeutul a+uta clientul sa creeze o poveste coerenta despre propriul viitor fara prezenta persoanei decedate dar avand amuntirea acesteia si libertatatea de a se anga+a in noi

activitati si relatii.

'erapie cognitiv comportamentala: 4erapeutul provoaca limitele credintelor sischemelor si a+uta clientul sa creeze altele care pot spri+ini competenta in noile roluri si sarcini siasigura permisiunea de a merge mai departe. 4erapeutul poate utiliza un model structurat de problem&solving si a+uta clientul sa dezvolte si sa implementeze un plan de actiune.

Dezvoltarea de deprinderi$ de pilda, deprinderi de management financiar, deprinderea decomportament autosuportiv, formarea de noi relatii de prietenie. 4erapeutul poate a+uta clientul sa

identifice punctele tari si pe cele slabe, furnizeaza ocazia de a e*ersa unele situatii interpersonale prein +ocuri de rol.

*+ 5ntecedente si consecinte$ analiza comportamentala atat a comportamentului

problema cat si a comportamenului dorit trebuie sa se bazeze pe informatii referitoare lantecedente si consecinte care vor fi utile in construirea unei interventii.

2n constructia interventiei terapeutice se utilizeaza principiile conditionarii clasice sicondittionarii operante.

odelul behaviorist initial “ntecedente & Comportament & Consecinte' a devenit “ ntecedente& ediere cognitiva & Emotii & Comportament & Consecinte'

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*8 Un raspuns emotional conditionat & ( an*ietate, teama, furie, depresie " este laoriginea unor emotii e*cesive, comportemente de evitare, a unor mecanisme maladaptative deevitare a unor emotii dureroase.

Raspunsul emotional intens nu este +ustificat de stimulii din mediul curent, prin urmare inferaminvatari anterioare care implica si care e*plica reactiite e*cesive. 4ratamentul va necesita noiinvatari$ e*tinctia emotiilor problematice si contraconditionarea unor raspunsuri emotionale mai

adaptative.

*9 Decit de deprinderi sau lipsa competentei & problema are la baza un deficit dedeprinderi & absenta deprinderilor necesare & sau lipsa competentei in utilizarea deprinderilor,

abilitatilor si cunostintelor pentru atingerea unui obiectiv

Pro$lem & solving/ uarea deciziilor

ceste deprinderi necesita o abordare metodica, sistematica$

1!. 2dentificarea si clarificarea problemei

1/. Culegerea de informatii si cautarea de e*plicatii

19. 6rainstorming pentru solutii alternativeD@. Evaluarea costurilor si beneficiilor fiecarei solutii si alegera celei mai bune

D1. 2mplementarea unui plan de actiune si monitorizarea rezultatelor

Modele cognitive

6+ Epectatii utopice68 ?arta cognitiva eronata69 Procesare eronata a in%ormatiei60 Monolog interior dis%unctional

6+ Epectatii utopice & clientul sufera de obisnuita “mizerie a vietii de zi cu zi' si areasteptari utopice, nerealiste in legatura cu ceea ce ar trebui sa fie viataF clientul doreste sa eliminedezamagirile , problemele,si emotiile neplacute care sunt parti inevitabile ale vietii. Confundand

dificultatile normale ale vietii cu problemele care necesita terapie, clientul vizeaza obiective de

neatins. 4erapeutii trebuie sa evite sa incheie contracte care urmaresc atingerea unei vieti perfectefara probleme.

!curt ghid pentru convor$irea terapeutica$&centrati&va pe discrepanta intre ceea ce este viata clentului acum si ceea ce doreste sa fie.

- fiti foarte empatici si suportivi

- discutati despre viitor in termeni de probabilitate

- utilizati umorul in situatii adecvate

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←

68 ?arta cognitiva eronata & problemele sau imposibilitatea rezolvarii lor suntdeterminate de elemente limitative sau depasite ale unei harti cognitive eronateF terapeutii trebuisa a+ute clientii sa modifice aspecte ale gandirii lor , nu doar din cauza standardelor arbitrare cu

privire la ceea ce este bine sau rau ci si pentru ca harta eronata limiteaza alegerile, creeaza

suferinta, si interfereaza cu satisfacerea nevoilor lor. cu atingerea obiectivelor si cu capacitateade a se bucura de viata. 0unt scheme maladaptative, postulate, reguli, credinte, predictii ce seautoimplinesc, povesti personalecare trebuie identificate, evaluate, schimbate si revizuite.

Erori %undamentale ( lfred dler"

←

Erori fundamentale Exemple

Suprageneralizarea Oamneii sunt ostili

Viata este periculoasa

Obiective de securitate falsesau imposibile

Un pas gresit si esti mortTrebuie sa plac tuturor

Perceptii gresite in legatura cu

viata si cerintele vietii

Vita nu mi-a dat niciodata vreun moment de ragaz.

Viata este grea.

Minimizarea meritelor

(Complex de inferioritate)

Nu merit nimic.

Nu sunt capabil sa-mi rezolv problemele.

Exagerarea meritelor

( complex de superioritate)

Sun superior celorlalti.

Nevoile mele sunt mai importante decat ale celorlalti.

Valori gresite Fii primul chiar daca va trebui sa calci peste altii.E mai bine daca ii fac pe ceilalti sa indeplineasca

responsabilitatile mele.

←

←

←

69 Procesare eronata a in%ormatiei &clientul demonstreaza o procesare eronata ainformatiei (e*. suprageneraalizare, stil dihotomic, lectura gandurilor etc.".5iata de zi cu zi

necesita abilitatea de a percepe adecvat datele e*perienteisi de a schimba schemele pentru a seadapta noilor e*periente. )relucrarea adecvata a informatiei implica aplicarea regulilor logice,

practicarea metodei stiintifice, vointa de a urmari validitatea gandurilor, fie prin e*perimentarefie intr&o modalitate consensuala cu realitatea celorlalte persoane.)roblemele pot fi formulate in

termenii lipsei deprinderilor cognitive si a stilurilor cognitive care sunt inadecvate pentru conte*t

si obiective.

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60 Monolog interior dis%unctional & problema este declansata siGsau mentinuta de unmonolog interior disfunctionalF E*ista multi termeni pentru monolog interior$ auto&mesa+e,

vorbire interna, voce interna, film interior, ganduri automate etc. onologul interior disfunctionaldetermina sentimente dureroase,si comportamente neadaptative. neori clientul este

constient de acest monolog interior$ alteori este nevoie ca pacientul sa fie a+utat sa descopere

aceasta voce interna.

7P='EAE EB7!'ECt75E s7 !P7>7'U5E

E!+ Pro$leme eistentialeE!8 Evitarea li$ertatii si responsa$ilitatiiE!9 Dimensiune spirituala

Pro$leme eistentiale & Clientul se confrunta cu )robleme e*istentiale, care includ cautarifilosofice fundamentale cu privire la scopul si sensul vietiiF E*emple de probleme e*istentiale

includ scopul si sensul vietii, mortalitatea si moartea, si izolarea fundamentala a fiintei umane.tilizand ipoteza E01 recunoastem ca fiecare persoana trebuie sa&si descopere propriile sale

raspunsuri. n*ietatea este parte normala a vietii si durerea determinata de confruntarea cu

acceste probleme nu poate fi eliminata. 4erapeutul trebuie sa se abtina de la asumarea unui rol de

gurusau e*pertF in locul acestei atitudini, trebuie sa recunoasca faptul ca face parte din aceeasicategorie a pelerinului care s&a confruntat si continua sa se confrunte cu probleme similare.

( #uarea deciziilor care implica libertatea, responsabilitatea,alegerea, cura+ul si implicarea se

adreseaza ipotezei E0D"E*. 8E problemeFulllment o% Potential)eople often come to therap- :anting more than relief from s-mptoms or restora& tion of ho:

the- :ere before the current crisis. 4here is a -earning for a higher Hualit- of living or the needto :restle :ith deep Huestions and find a ne: orien& tation to life. 4hese clients :ant to beresponsible adults :ithout sacrificing the vitalit- and sense of pla- of childhood. 4he- :ant

challenge and e*citement intheir dail- lives, instead of stagnation and boredom. 4-pical goals

might include meaning and purpose in their livesF fulfillment of their highest potentialF a sense of control over their future pathsF becoming more spontaneous and creativeF feel& ing more alive,

real, and :holeF and achieving authentic contact :ith their inner being as :ell as :ith other

humans. ere conformit- to societ-Is definition of normal is not enough$ 4herapists :ill havean inadeHuate grasp of their clientsI needs if the- restrict themselves to goals endorsed b- healthcare case managers.

Emotional !uering0uffering cannot be eliminated from life. lthough :e cannot al:a-s control or prevent eventsthat cause suffering, e*istential theorists believe that :e have the freedom to choose ho: :ereact to those events.

Meaning and Purpose in i%eE*istential philosophers describe the human condition as the dilemma of meaning& see3ing

creatures thro:n into a universe that has no intrinsic meaning. hen :e are -oung, :e derive

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meaning from the rules and e*amples of our parents, :hich derived from the customs and

traditions of their cultures. an- people live con& tented lives continuing to accept that meaning.

o:ever, other people e*perience a crisis of meaning, perhaps follo:ing a ma+or loss or :henthe- reach the pinnacle of the road the- :ere told :ould bring fulfillment.

hen the meaning s-stems that people have ta3en for granted are no longer viable, there are

man- distressing emotional responses. 4he e*istential litera& ture describes the e*perience of“the absurd' and the response of nausea to the realization that there is no intrinsic meaning in the

e*ternal :orld or the course of our lives. Clients ma- describe feeling emptinessJa void.

5uthenticit4 and ?onest4uthenticit- in human relations is a standard that man- people have trou& ble living up to, andtherapists :ho are not capable of it in their o:n personal relationships :ill not be able to provide

this needed ingredient of the thera& peutic relationship. hen -ou are engaged in an authentic

encounter, -ou :ould be (a" present in the moment rather than adrift on a mental side tripF (b"genuine and not hiding behind mas3sF (c" honest and truthful about :hat -ou choose to e*press,

reserving the right to decline to reveal :hat -ou hold privateF (d" open and vulnerable, allo:ing

-ourself to be impacted and changed b- the otherF and (e" :illing to ta3e the ris3 of beingspontaneous. 0pontaneit- does not mean sa-ing :hatever comes into -our head because -ou

e*perience the vulnerabilit- of the other person and :ant to be helpful. precondition for

authenticit- :ith others is that -ou are vigilant against self&deception and have learned to hold

-ourself accountable for -our o:n dishonesties.

'he uestion o% !uicidehen therapists face people :ho are contemplating suicide, the- freHuentl- panic. 4he- focus on

assessing ris3, ta3ing emergenc- measures, getting med& ication evaluation, and doing :hatever

possible to get rid of the suicidal thoughts. lthough all of these actions are essential, the- areinsufficient$ 4he client needs someone to listen calml- and patientl- and help her e*plore the cri&

sis of meaning and the issues that have made life unbearable. hen people has terminalillnesses, :e consider it reasonable for them to contemplate ho: sui& cide :ill allo: them to die:ith dignit- and relieve their loved ones of burdens. o:ever, :hen someone, b- our standards,

has sufficient reasons to find satis& faction in life, :e are apt to label his or her :ishes as

abnormal, irrational, self& ish, or transient s-mptoms of depression.

Philosophical Discussionhen the focus of therap- is the clientIs search for meaning, the dialogue be& t:een therapist

and client can ta3e the form of philosophical discussionJabout both abstract theor- and the

clientIs specific philosoph- of life. 0heldon Kopp (19!B" challenged clients to e*amine some ofthe assumptions about life that the- developed in childhood and proposed a set of his o:n

philosophical truths, :hich include the follo:ing$

• Nothing lasts.

• 4here is no :a- of getting all -ou :ant.

• 4he :orld is not necessaril- +ust.

• Lou donIt reall- control an-thing.

M Lou canIt ma3e an-one love -ou.

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5i3tor ;ran3lIs ogotherap4 offers to the client three :a-s of satisf-ing the search formeaning$

1. Creating a :or3 or doing a deed (e.g., achievement and accomplishment"D. E*periencing a value such as goodness, truth, beaut-, or love

?. ;inding meaning in unavoidable suffering

E!8 Evitarea li$ertatii si responsa$ilitatii & Clientul evita #ibertatea si autonomia carevin odata cu intrarea in varsta adulta siGsau nu accepta responsabilitatea pentru pre zent si

alegerile trecuteF clientul are nevoie de a+utor pentru a face alegeeri bune care sa&l puna in

miscare catre obiective pozitive si sa se anga+eze. Ei au nevoie sa distinga intre limitarile care

sunt reale si cele care sunt autoimpuse. nii oameni isi neaga responsabilitatea pentruactiuniletrecute si altii se blameaza pentru evenimente pentru care nu au fost responsabili. Evitarea

libertatii poate lua multe forme$ mentinerea iluziilor copilariei, blamarea altora, dependenta de

altii cre furnizeaza salvare.Cand clientii sunt gata sa se anga+eze in actiuni responsabile, ei potavea navoie de a+utor in clarificarea valorilor, luarea deciziilor, planificarea si implementarea

planurilor.

Preconditii pentru eersarea e%ectiva a li$ertatii • lternative disponibile

• Capacitatea de a anticipa consecintele

• Capacitatea de a amana actiunea

• legerile isi au originea in dorintele noastre reale

• %rganizare si autodisciplina

• 8eprinderi si resurse

• maturitate

Evitarea responsa$ilitatii• m nevoie de garantii

• sa sunt eu (autoetichetare"

• Nu pot sau nu am putut

• Nu vreau

• 4rebuie G a trebuit

• )oti sa faci asta pentru mine

• %biceiuri

• Conformism si obedienta

>esponsa$ilitate•

2dentificarea cauzei sau a creatorului actiunilor si a consecintelor • Conceptele legale ale responsabilitatii ( capacitate diminuata, boala psihica, constrangere etc."

• Clarificarea indatoririrlor si obligatiilor intr&o anumita situatie

• Cai de evitare a responsabilitatii ( am urmat un ordin, El m&a facut sa...,"

• Evaluarea caracterului adecvat al sentimentelor de vinovatie

• utoblamarea

• Conceptul de victima

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• nga+are (clientii conduc problemele catre doua e*treme$ 1"incapacitatea de a realiza si

mentine un anga+ament & deseori numita “iresponsabilitate' de catre altii si D" incapacitatea de

a finaliza un anga+ament mai vechi fundamentat pe o analiza cost&beneficiu actualizata.

!tages o% 5utonomous Decision Making4he process of autonomous decision ma3ing can be conceptualized into these stages$2dentif- ants Evaluate 6ehavior Choose ill )lan ct Evaluate 'a$le -.8

5ppl4ing the E!8

5voiding Freedom and >esponsi$ilit4 ?4pothesisP>=*EM '7'E!!truggling 1ith making a choice:7ndecision a$out a


22/32

'a$le -.8 "6ontinued#5voidance o% responsi$ilit4:M ClientIs interpretation of painful e*periences involves blaming others and ta3ing the role ofvictim or mart-r.

M Client reports guilt and shame over past behavior but does not ta3e an- action to ma3e amends

or to refrain from similar action in the present and future.M Client refuses to accept obligations in life, insisting on doing :hatever she :ants, regard& less

of the conseHuences.ack o% sel%&control and sel%&discipline:M Client uses man- :ords that sho: feelings of passivit- and difficult- ta3ing action to:ard

goals$ “2Im tr-ing.' “2Im :or3ing on it.' “2tIs hopeless.'M Client states values and moral code, but then claims “2 canIt help it' for engaging in morall-

:rong behavior (e.g., having an affair".

•Client e*pects good things to come to him :ithout needing to e*pend effort.

>elinHuishing 6hildhood 7llusions ere are e*amples of childhood illusions that need to

be uncovered and challenged$• prince :ill come along and find me and, :ithout an- effort on m- part, :e :ill live happil-

ever after.

M 2f 2 am good and do :hat 2 am told, then bad things :onIt happen to me.

M 2 am responsible for m- momm-Is happinessF if she isnIt happ-, then 2 have done something:rong.

• 2f 2 sho: that 2 am :ea3 and helpless, someone :ill ta3e care of me.

• 2f2sho:that2amvulnerable,people:illta3eadvantageofmeandhurtme.

Parado and >e%raming: 'he LDonJt 6hange Position

4here are certain therapeutic approaches that are called parado*ical because in& stead of pushingfor change, the- urge the client to accept the status Huo and to agree that change is not necessar-.4he therapist can ta3e one of three parado*i& cal posions$

1. (here 4ou are is eactl4 1here 4ou 1ant to $eN 7% 4ou 1anted things to $edierent, 4ou 1ould have changed alread4.D. 'here is a$solutel4 nothing 1rong 1ith sta4ing eactl4 as 4ou are no1, soconvince me 1h4 4ou should tr4 to $e an4 dierent.?. DonJt tr4 to change, do more o% the same. (4his tactic :as called para& do*icalintention b- ;ran3l and is also referred to as prescri$ing the s4mptom."

4hese approaches can lead to one of the follo:ing outcomes, all of :hich are positive$

M 4he client :ants to prove -ou :rong and therefore needs to intensif- her determination tochange. 4his mobilizes the :ill to change and stimu& lates action.M 4he client gets permission to sta- the same and e*periences -our accep& tance. Lou are not li3e

all the other people :ho tried to change her, so she can rela* and stop resisting -ou. 4his creates

a space :here she can e*peri& ence her deepest feelings about the status Huo. 2f the feelings turn

out to be intensel- negative, this pain can fuel some steps to:ard change.M 4he client ma- discover that the status Huo reall- is :hat she :ants, and all the pressure to

change :as reall- coming from e*ternal sources, or from the messages she internalized from

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others. 4his means that no: the client isnIt stuc3 in a bad place, :hich she feels helpless to

leaveF instead, she is freel- choosing this place.

• hen a client stops tr-ing to decrease a problem behavior, but instead in& creases it, hedevelops a sense of control over something that seemed out of control.

E!9 Dimensiune spirituala & Nucleul problemei siGsau resursele de care este nevoie pentrurezolvarea problemei sunt fundamentate pe dimensiunea spirituala a vietii, care poate sau nu sainclud religiaF o importanta aplicare a acestei ipoteze este situatia in care clientul se confrunta cu

probleme religioase, inclusiv relatia sa cu 8umnezeu.4ermenul spiritual se aplica unei mari

varietati de e*periente, credinte si activitati. Clientii care trebuie sa se adapteze la ideea mortii,cu dileme morale si blocarea creativitatii beneficiaza deseora de focalizarea asupra spiritualitatii.

4ehnici preluate din religiile estice ( e*. meditatia,constientizare" si din religiile occidentale

( rugaciunea si citirea 6ibliei" pot fi integrate in terapie. 4rimiterea laGsau colaborarea cu clericisau alti practicieni spirituali se poate dovedi adecvata.

4here are t:o ris3s :hen therap- enters the spiritual domain$ (1" 4he therapist :ill impose

values and steer clients in a direction that is counter to the clientIs pref& erences, and (D" thetherapist :ill be too timid to probe and challenge, as if the clientIs spiritualit- is too fragile to

:ithstand a thorough e*ploration.

'a$le -.9 6oncepts o% !piritualit46onnection 1ith the !acred or Divine0earch for the sacred or divine 4ranscending the self and connecting to a higher po:er ;eelingsof harmon- and oneness :ith truth, humanit-, or =od ;eeling uplifted and recharged b-

connection to a nonhuman source of energ- and enlightenment E*periencing oneIs o:n inner

goodness and value as stemming from a higher po:er Contacting an 2nner =uideGoals to *e a *etter Person and ?ave a More Meaning%ul i%e

8evelopment of a personal moral code and the desire to live a virtuous, ethical life0triving to be the best possible human being one can be

0ee3ing personal transformation, :holeness, or integration

0ee3ing to replace negative emotions such as anger, env-, and fear :ith positive emotions suchas love, compassion, and forgiveness

4he desire to be less selfish and self&oriented and become more altruistic, generous, and engaged

in service to others4he search for meaning and purpose in life that is higher than oneIs usual material, superficial

concerns

%n a Huest for some higher goal, such as oneIs “true (or higher, deeper" self' or a “path :ith

heart'Ps4chological Eperiences4he capacit- to enter into heightened states of consciousness that erase the boundar- of the self

aving a specific m-stical e*perience that cannot adeHuatel- be described in :ords, :hich

involves contact :ith the divine and intense emotions such as a:e, :onder, and bliss

E*periencing a sense of creativit- and flo:, :hich includes intense concentration, self&forgetfulness, and clarit-

E*periencing a sense of unit-, :holeness, and timelessness chieving a sense of inner peace and

detachment

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*elie%s6elieving in a divine purpose that permeates the universe

6elieving that there is an alternate realit- that is invisible but more real than the realit- :e

e*perience :ith our senses6elieving that overinvestment in oneIs separate ego is a source of suffering instead of strength

6elieving in the continuation of spiritual e*istence after the ph-sical bod- has died6elieving that the spirits of our ancestors ma3e demands on us that :e are obligated to obe-

6elieving that oneIs :or3 is a spiritual vocation to :hich one :as called and chosen5ctivities and *ehaviors)ra-erF meditationF communing :ith nature

Reading tarot cards, using cr-stals for their healing energ-, or communicating :ith spirits :ho

have passed to the other sideEngagement in efforts to ma3e the :orld a better place and stamp out problems such as hunger,

social in+ustice, and racism

0inging or pla-ing sacred music

Nourishing the soul through activities such as reading, vie:ing great art, listening to classical

music, en+o-ing aromas, and creating art 'he 'herapist as Moral 6onsultant8ohert- (199B" created a frame:or3 of moral consultation, offering a list of eight therapist

actions, in order of increasing intensit-$

1. 5alidate the language of moral concern :hen clients use it spontaneousl-.D. 2ntroduce language to ma3e more e*plicit the moral horizon of the clientIs concerns.

?. s3 Huestions about the clientIs perceptions of the conseHuences of ac& tions on others, and

e*plore the personal, familial, religious, and cultural sources of these moral sensibilities.A. rticulatethemoraldilemma:ithoutgiving-ourposition.

. 6ring research 3no:ledge and clinical insight to bear on the conseHuences of certain actions,

particularl- for vulnerable individuals.

B. 8escribe ho: -ou generall- see the issue and ho: -ou tend to :eigh the moral options,emphasizing that ever- situation is uniHue and that the client :ill, of course, ma3e his or her o:n

decision.!. 0a- directl- ho: concerned -ou are about the moral conseHuences of the clientIs actions.

/. Clearl- state :hen -ou cannot support a clientIs decision or behavior, e*plaining -our decision

on moral grounds and, if necessar-, :ithdra: from the case.

Modele psihodinamice

P+ Parti interne si su$personalitati

P8 >eactualizarea unor Eperiente 7n%antile PrimareP9 !ens imatur al sinelui si al conceptiei despre altiiP0 Dinamici inconstiente

P+ Parti interne si su$personalitati & )roblema este e*plicata in termenii unor partiinerne si subpersonalitati care au nevoie sa fie auzite, intelese si coordonateF este natural, nu

patologic, sa fii constient de diverse parti interne si subpersonalitati. )roblema rezida in lipsaconstientizarii si comunicarii intre partile interne, conflictul intre diferite parti, suprimarea unei

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parti si dominarea de catre o anumita parte.)roblemele pot fi rezolvate prin cresterea

constientizarii partilorsi a dinamicii lor, incura+area unor procese interne de grup sanatoase si

stabilirea unor obiective specifice pentru fiecare parte specifica.

'a$le .8 6riteria %or ?ealth4 7nternal D4namics

?armon4, 6ohesiveness, and 7mpulse 6ontrolll parts, even unpleasant ones, are accepted and o:ned. 4he- are not attac3ed, suppressed, or

distorted but are allo:ed to be heard. 4he d-namics of the internal group are harmonious andfree from coercion and abuse. s in a functional famil-, a hierarch- is maintained and the

leadership comes from mature, responsible parts rather than from impulsive, Child parts. hen adecision is made and an action agreed on, the inner selves cooperate and function as a cohesive,

unified entit-, :ithout the presence of secret saboteurs. Child parts :ho usuall- :ant instant

pleasure are able to tolerate frustration and dela- gratification.Good Morale and =ptimism4here are internal sources of esteem$ )arent parts are supportive, nurturing, and encouraging and

:hen the- evaluate and criticize, the- are constructive, rational, and fair. 2nner parts all feel and believe that the person has a right to happiness, pleasure, and success. 4here are sources of

higher ideals and a sense of purpose. 4he internal parts can maintain morale in face of frustration

and disappointments.5$ilit4 to !et Goals and Engage in Goal&Directed *ehaviorn e*ecutive (dult" part is able to mediate among conflicting parts, create compromises, and

assure unified cooperation to:ard a goal. =oals are based on values ()arent", realit- test& ing

(dult", and respect for the rights of the Child to have pleasure, creativit-, and a rich emotionallife.

!ummar4 o% Goals

4he various approaches to :or3ing :ith inner parts and subpersonalities share these goals$

M Em$racing "acceparea# all the selves: elping the client to achieve a:areness of each part, reclaiming “diso:ned parts,' and permitting verbal e*pression from each part :ithout

fearing it :ill ta3e over the personalit-.M !trengthening the a1areness and eecutive parts o% the personalit4: strong,competent dult needs to be behind the steering :heel, assuring that no single subpersonalit-

dominates or acts out independentl-. 4he e*ecutive part e*amines the messages from different

parts, describes and anal-zes in& ternal and interpersonal process, and communicates to others toresolve con& flict. 4he client e*periences increased choice, self&control, and autonom-.

M Modi%4ingparts:=oals:illincludetoningdo:napartthatistoodominant, supporting and

strengthening :ea3 parts that need to be heard, updating the rules and methods of po:erful)arent parts, creating ne: parts to serve im& portant functions such as boosting self&esteem and

soothing painful affects, and developing a strateg- to deal :ith self&destructive parts.

•earningtotoleratevulnera$ilit4inthesel%andinothers:4hisopensupthe opportunit-for intimac- and the development of mature :a-s of ta3ing care of oneIs need for safet- and

trusting relationships.

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'a$le .9 Pro$lems Eplained $4 P+ 7nternal Parts and !u$personalities?4pothesis

Dicult4 Making a Decision and !electing a 6ourse o% 5ction 7nner conIict:n- problem title that contains :ords li3e indecision, am$ivalence, con%usion,

dilemma, :hich could be e*pressed as “torn bet:een t:o lovers,' or “to sta- or to brea3 up.'Pro$lems o% %ear and avoidance: part of the client :ants to do something, another partholds bac3, is afraid, thin3s “2 canIt,' or feels fear. 7ndecision, 1ith immo$ilization andinner torment: s an e*ample, amletIs famous solilo& Hu-, “to be or not to be,' deals :iththe conflict bet:een a passive part and a part that :ants to Ltake arms against a sea o%trou$les and $4 opposing end them.Diculties !ticking to a 6hosen 6ourse o% 5ction7nternal opposition:8ifficult- brea3ing bad habits$ “ part of me sa-s 2 should stop smo3ing, another part +ust lovescigarettes.' )rocrastination$ “2 should do something, but 2 +ust canIt get m-self to start it.' #ac3

of persistence$ “2tIs not :orth it.' “2tIs too much trouble.' “2 didnIt :ant it an-:a-.'

7mpulsivit4: Restraining parts (e.g., voice of reason, reminders about conseHuences, self&control, or responsibilit- to others" are either silent or too :ea3 to e*ert an- influence on theimpulsive parts.Poor %rustration tolerance: n impatient Child part :ants e*actl- :hat it :ants,immediatel-. 4here is a lac3 of a good planner part :ho 3no:s ho: to brea3 the tas3 into small

bits and re:ard small accomplishments.!uppression o% Feelings and !pontaneit4>igidit4: =oals are based entirel- on “shoulds,' obligation, dut-, or concern for the reaction ofothers. 4he parts that represent passion, pla-, pleasure, and spontaneit- are completel- ignoredand ma- act as saboteurs.*locks to creativit4: %verl- perfectionistic and critical parts interfere :ith immersion in

creative processF there is suppression of a creative, grandiose part.Pro$lems >elated to Depression!uicidal risk: 4here are parts that :ant to die versus parts that :ant to live. 2t is crucial fortherapists to search for, find, and strengthen the parts that :ant to live. !el%&hatred: 4heh-pothesis of anger turned in:ard can be e*plored b- identif-ing a self& criticalJperhaps self&

loathing and self&destructiveJinner part.Ecessive guilt: 4here is the presence of a punitive, internal voice, combined :ith the lac3 of a part that is nurturing, tolerant, and forgiving.o1 sel%&esteem: n inner part that attac3s the self, combined :ith the lac3 of inner partsthat soothe and offer self&praise.Pro$lems o% !tress, Ehaustion, and =ver1ork

Ecessive commitments and o$ligations: ultiple parts ma3e commitments :ithoutregard to reasonable limits set b- time and health. pleaser part that canIt sa- no to the demands

and reHuests of others. ack o% relaation and pleasure: 4here is a lac3 of a strongadvocate for the inner parts that demand rela*ation and pleasureF 4here is a moralistic,

demanding )arent part (“canIt pla- until all the :or3 is done'" and a :orthless part, :hich onl-feels good :hen it is bus- and productive and thus comes out :hen there are no obligations to

fulfill.

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Per%ectionism: 4here is a perfectionist part or a relentless pusher :ith unrealistic demandsand standards. n dapted Child part feels li3e a failure unless he gets straight s.7nsta$ilit4 in Emotions and >elationshipsDramatic alternation o% moods: lternation bet:een grandiose self and :ea3, empt- self,and a lac3 of inner parts that maintain self&esteem and soothe moods. 2f the 5ulnerable 0elf

ma3es appearances and gets hurt, the po:erful parts rush in to protect it. Unsta$lerelationships: 4he person s:itches among different roles in relationships, such as 5ictim,)ersecutor, or Rescuer, or shifts from a part that idealizes another to a part that devalues the other

person.

'a$le .0 oice Dialogue 7nstructions

Ph4sicall4 !eparate the !u$personalitiesEither the therapist or the client can pic3 a subpersonalit- to hear from first. n eas- method is to

have a :heeled chair and let the client choose :hether to roll the chair right or left. 'alk to the !u$personalit4

4al3 to the subpersonalit- as -ou :ould tal3 to a real person. 6egin the conversation b- as3ing(ho are 4ou; or (hich part o% 5lice am 7 speaking to; s3 open&ended Huestionsand para& phrase bac3 :hat -ou hear, being empathic and non+udgmental$ 'ell me a$out4oursel%. (hat a$out that $others 4ou; !ounds like 4ou get ver4 %rustrated1hen she ignores 4ou. (hat do 4ou 1ant %or 4oursel% ; ?o1 do 4ou %eela$out her; 4he therapist must not ta3e sides or re+ect an- parts. Lour goal is to facilitate theself&e*pression of the subpersonalit-, not to tr- to change it in an- :a-.6oach the !u$personalit4 to !ta4 in 6haracter=uide the subpersonalit- to spea3 of the :hole person as a separate entit-. Lou might para&

phrase :hat the subpersonalit- sa-s, changing pronouns, LOou mean she (referring to the posi&tion :here the client sits during the session" 1ants to nish the dissertation $ut -ou

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4he e*ercise ends :ith the client bac3 in the center position, given time to reflect on the activ&

it-. Never end the activit- :ith the client in a subpersonalit-. 6e sure to allo: time for the client

to get bac3 to normal consciousness before leaving the session. t the ver- end of the e*ercise, if -ou :ant, -ou can as3 the client to stand behind -ou and loo3 at the chair as -ou summarize the

different phases of the activit-. 4his gives the higher, “a:are self,' a chance to process the

e*perience and possibl- have ne: insights.

6reative 5ctivitiesEither directl- or indirectl-, -ou :ant to engage the clientIs “Creative )art' in the therapeutic

:or3, both during the session and in home:or3 assignments.(ritingse one of these assignments or create -our o:n.M 2magine a bus that contains all of -our subpersonalities. atch it come to& :ard -ou do:n the

road, dra: up, and stop. 8escribe these personalities, one b- one, as the- get off the bus. =ive

each one a nic3name (0no:, 199D".

M rite a dialogue bet:een t:o different parts that are involved in a spe& cific conflict.

M rite a scene in a drama that includes several of -our subpersonalities. ;irst, list the cast ofcharacters, describing each one briefl-.

5rtrite a letter from a subpersonalit- to the :hole personalit-, describing its feelings and needs.

ave a specific subpersonalit- ans:er a list of Huestions such as the fol& lo:ing, ta3en fromRo:an (199@"$ hat do -ou loo3 li3e< o: old are -ou< hat situations bring -ou out< hat is

-our approach to the :orld< hat do -ou :ant< hat do -ou need< hat do -ou have to offer<

here did -ou come from< here did -ou first meet (name of person"< hat :ould happen if-ou too3 over permanentl-<

4hese activities are useful for e*ploring emotional aspects of internal d-namics. 4he- also help

strengthen creative and nonverbal subpersonalities.M sing different colored mar3ers, dra: all the different inner personalities that -ou are a:are ofno:, sho:ing their relationships to each other, and giving them names. 8ra: bubbles over their

heads to sho: :hat the- thin3 and feel.

•avetheclientcreatedra:ingsorpaintingsfromseparatesubpersonalities.

P8 >eactualizarea unor Eperiente 7n%antile Primare & problema este o reactualizarea unor e*periente infantile primare$ sentimente si nevoi din prima copilarie sunt reactivate si

pattern&uri din familia de origine sunt repetateF e*perientele din prima copilarie pot aveainfluente profunde asupra functionarii adulte. ulte din problemele adultilor pot fi intelese ca

eforturi de a rezolva conflicte si a satisface nevoi nesatisfacute ale copilariei. Relatiile cu parintii

si alti memebri semnificativi ai familiei functioneaza ca si cadru pentru relatiiel adultului..Constientizarea pattern&urilor recurente nu este suficientaF pacientul are nevoie sa traiasca si sa

invete sa tolereze emotii dureroase si sa&si schimbe stlurile autoprotective de relationare.

5ttachment 'heor4

4he attachment of the child to the original caregiver functions as a template for adult intimate

relationships (ins:orth, 19/DF 6o:lb-, 19//F 6retherton, 199D". Children build important

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belief s-stems (internal 1orking models" re& garding the reliabilit- of attachment figures,and their o:n lovabilit-, :orthi& ness, and competence. 4hree t-pes of attachment st-les :ere

originall- identified, but a fourth one has been added in recent -ears (Cassid- 0haver, 1999".1. !ecure: 4he child develops faith in herself and her attachment figures, and feels free toe*plore the environment because she can count on the other to be available for comfort and

reassurance. 4his is the most adaptive st-le in adulthood.D. 5nious&am$ivalent insecure "also called anious&resistant#: 4he attach& mentfigure is inconsistent and unreliable, and the child gro:s up to have lo: self&esteem, and is often

cling- and insecure in adult relationships.?. 5nious&avoidant insecure: 4he child :as rebuffed, re+ected, and ignored, and sodevelops a cold, distant attitudeF in adulthood, a person :ith this st-le re+ects others and treatsrelationships as if the- do not matter.

A. Disorganized: 2n contrast to the prior t:o st-les, :hich have coherent pat& terns and aresometimes effective, this st-le refers to the lac3 of a coher& ent template for interacting.

'a$le .@ Pro$lems Eplained $4 the P8 >eenactment o% Earl4 6hildhood

E*periences -pothesis

Pro$lems 1ith 5uthorit4 Figuresuthorit- figures in the clientIs life are targets for feelings to:ard parents. 4he clientIs responses

reflect negative feelings of being dominated, controlled, and disrespected, as :ell as

inappropriate positive e*pectations to be indulged and rescued. 4hese emotional responses aree*cessive to the real stimulus$ 4he client :ill interpret behavior from the boss as outra& geous

and intolerable, :hereas the therapist :ill thin3 that it is, at :orst, t-pical insensitivit- of

someone :ith poor managerial s3ills. 0ome of the problematic reactions are helpless

dependence, blind defiance, misperceptions of favoritism, and irrational fears of e*pressingindependent thought.

Dicult4 Esta$lishing and Maintaining !atis%4ing 7ntimate >elationships)erhaps the most common reasons people see3 therap- include (a" difficult- finding anappropriate partnerF (b" maintenance of frustrating and painful relationshipsF (c" repetitious

patterns (e.g., falling in love :ith the “perfect person' and then discarding herF pursuingrelationships :ith unavailable or re+ecting people"F (d" marital problems (e.g., e*cessive con&

flict, inabilit- to tolerate separateness in their partner, and :ithdra:ing and distancing

behaviors".7nappropriate Emotional >eactionshen the presenting problem is e*cessive an*iet- or anger, the roots of these reactions often lie

in earl- childhood e*periences. ;or instance, overreactions to separations can reflect an inse&

cure attachment. hen the client becomes enraged at the therapistIs minor lapses in empath-, the

client ma- be reacting as she did :hen she :as a child :ith a self&absorbed mother.Dicult4 Maintaining EHual and 6ooperative Peer >elationships4he client ma- relate from either a position of superiorit- or inferiorit-, ma- be unable to Huell

competitive feelings, could ta3e a role of self&sacrifice and put othersI needs ahead of her o:n,

have inappropriate e*pectations of being spoiled and catered to, and e*perience +eal& ous- and

hostilit- over the achievements of others.Diculties 1ith Parenting

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)arenting st-les can either replicate or completel- reverse :hat one e*perienced in childhood. s

children reach successive birthda-s, ne: childhood issues are reactivated for parents.Pro$lems in >elationships $et1een 5dult 6hildren and 'heir Parents)roblems can include e*cessive emotional reactivit- :hen relating to parents, difficulties deal&ing :ith parents in grandparent role, and continuing to respond to the mother&of&toda- as if she

:ere the mother&of&childhood. nother problem that is becoming more common as the life spangets longer is the difficult- of coping :ith aging parents. hen adult children are put in care&

giver roles for their elderl- parents, the roles are reversed from childhood and the child has the po:er :hile the parent is helpless and dependent. 4his can provide healing opportunities, as the

child sees the parent in a ne: light, or it could be the recipe for elder abuse.

P9 !ens imatur al sinelui si al conceptiei despre altii & 8ificultatile rezida inincapacitatea clientului de a progresa dincolo de un simt imatur al sinelui si al conceptiei despre

ceilalti care este normal pentru copii foarte tineriF Ceilalti oameni nu sunt apreciati ca indivizi

unici cu nevoi, sentimente si perspective distincte ci sunt e*perientiati ca e*tensii ale eului sivalorizati pentru functiile pe care le indeplinesc. Clientul are nevoie de ceilalti pentru a&i prote+a

stima de sine si de a&i alina durerile emotionale, lipsindu&i capacitatea de a&si asigura singur aceste functii. in baza evaluarii capacitatilor si deficitelor adultului, putem fi*a stadiul copilariei primare in care maturarea sanatoasa a fost perturbata.

'a$le . Eamples o% 6apacities o% a ?ealth4 !el%

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 the

environmental 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 and

assertion to express them in real- ity and to support and defend them when under

attack. Direction comes from internal ideals, values, and ambitions.

Maintenance of self-esteem You can fuel adequate self-esteem, on your own, by giving positive

acknowledgment 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 continuous

over time and related to the “I” of another experience.

Commitment You can commit to an objective or a relationship and perse- vere, despite

obstacles, to attain that goal or maintain that relationship.

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=$elations

=$eal and !eparate and Do Cot >evolve around OouLou e*perience others as free, separate selves :ith their o:n feelings and e*periences. 4he other

person has his or her o:n center of initiative, e*ists :ithout -ou, is not an e*tension of -ou, doesnot revolve around -ou and -our needs, nor can be controlled b- -ou. Lou deal :ith the realit- of

the other person, not -our fantas- of :ho the other person is.=ther People 5re UniHue and Dierent %rom Oou%thers are not +ust interchangeable, replaceable “things' :ho serve functions for the self, but -ouappreciate them as separate, uniHue persons :ith their o:n needs, feelings, and talents. nother

human :ill never be -our perfect clone. lthough :e ma- often have similar feelings and

opinions, it is impossible to al:a-s feel the same or to agree on ever-thing. 6ecause this isunderstood, disagreements are e*pected and are not e*perienced as threats to -our sense of self

or the relationship. 'here 5re Multiple alid Perspectives

6ecause -ou can shift perspectives, -ou realize that -ou are not the center of ever- event andinteraction. Lou can thin3 in terms of multiple perspectives, instead of one absolute truth. Loucan observe -ourself from the perspective of another person and accept negative feed& bac3

:ithout vie:ing it as an attac3 on -ourself. Lou can imagine ho: -ou appear to others and the

impact that -our behavior has on them. Oou 6an 'olerate 5m$ivalent Feelings to1ard !omeone Oou ove)eople are not all good or all bad. %nl- in fantas- is someone perfect, so -ou 3no: that ideal&ization of another person canIt last. hen fla:s appear, -ou do not flip into devaluation of the

person. Lou can e*press anger and receive anger in the relationship :ithout it destro-ing the

bond. Oou 6an Eperience 7nterdependence in >elationships

2t is normal in times of stress to turn to others to have them serve functions such as shoring upself&esteem and soothing painful emotions. o:ever, the roles can be reversed$ Lou can do the

same for another person in need. hen -ou set goals, -ou can consider the impact on the other

person. Lou can put anotherIs needs ahead of -ours. Oou 5re 6apa$le o% 6ommitted 7ntimate >elationshipsLou are able to sustain trust, develop secure attachments, and tolerate separation, believing in the

constanc- of another even :hen that person is not ph-sicall- present. 6ecause -ou love a real

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person, -ou do not fluctuate bet:een idealization and devaluation, but rather can tolerate periods

:hen needs are not met.

Childhood Adulthood Parallels

MOST IMMATURE STAGE: SYMBIOTIC MERGER

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