Posts Tagged ‘therapy’
Edgar, a child of five, is the oldest son of a marriage that has lived with great economic and family pressures. The mother began going to therapy two years ago for her distress because of her pregnancy. She left treatment. A short while later, she asked for an emergency appointment. She told me by phone that she had just gotten Edgar out of the hospital, and he did not want to return home because she was afraid of his father who, in an attack of fury and impatience, had hit him against the wall, fracturing his cranium.
I met with the whole family in therapy because that permitted me to under- stand the family situation, to perceive their emotions and to explore their resources. Once I have an idea of the family structure and the context in which the problem occurred, I can tell a story (or build a story together with the children) that represents the problem and different solutions. In an abuse situation, it is necessary to censure actions, not the persons implicated, trying to see them as parents who make mistakes. In this case I constructed the story because the child was immobile in a chair, not wanting to look at anyone, much less participate.
I told them a story about a lion cub and its family. Mommy lion went out to work and to look for food, while Daddy lion stayed to guard his territory and did- n’t like to be disturbed. The lion cub really wanted to go hunting. He wanted to go out to explore. He saw the older lions roar and fight and he was dying to do it too. He wanted someone to play with him, but when Mommy arrived, she wanted to do anything but play. She was tired and wanted him to eat. The little cub began to think he was not interesting or important enough for his mother to play with him.
One day the little cub decided to do as the older lions did. He ran close by his father growling like the older lions, but Daddy lion did not move. The cub growled louder and louder without success. Finally he decided to bite the Daddy lion’s paws and ears to get his attention. He didn’t know that Daddy’s paws had been hurt many years ago. How surprised he was when he bit his daddy and his daddy gave him a shove, throwing him against a rock.
The poor little lion was hurt very badly. At this precise moment, Mommy came back from hunting. Scared, she ran to her cub and started to lick him. She growled very loudly at Daddy lion, more loudly than in other times. Daddy lion also ran to see what had happened to his little son. He hadn’t wanted to hurt his son and he didn’t know why he had let out such a strong blow and why his claws had come out when normally they only came out for attack and defense.
The story continues telling how the little cub had been healed at a special cave, but his little heart still felt very sad and something still hurt inside. All the family went to consult a Leopard therapist that helped the parents and cub to cure their wounds. Leopard told them, “Now is time to heal your wounds, before they become infected.”
While listening to the story, Edgard had drawn a picture of himself that showed the open wound in his head. He drew merthiolate and band aids over the wound and at the end of the session he felt calm about going home. His father talked about his own past psychiatric diagnoses and agreed to visit the psychiatrist again.
They came to three more sessions. Although the problems of the family environment continued, the father’s aggression disappeared and they became closer and more communicative.
The Ericksonian techniques utilized were: story telling, metaphors and reframing through the story.Reference:
Robles, Teresa (1990) A concert for four brain hemispheres in psychotherapy, Alom Editores, México y (1991) Terapia cortada a la medida. Un seminario con Jeffrrey K. Zeig, Alom Editores, México.
Christine Padesky is a clinical psychologist and cofounder of the Center for Cognitive Therapy in Huntington Beach, California. Along with Kathleen Mooney, she is now developing “strength-based cognitive therapy.” Padesky is the coauthor of five books, including the bestseller, Mind Over Mood. She is recipient of the Aaron T. Beck Award from the Academy of Cognitive Therapy for significant and enduring contributions to the field of cognitive therapy and she also received the Distinguished Contribution to Psychology Award from the California Psychological Association.
The following is an edited version of a 50-minute interview. To watch the full interview visit: https://www.erickson-foundation.org/yapko-padesky-interview-january-2018/.
Michael Yapko: Let me start by asking you about some of the work that you do that is more experiential. You bring another element to cognitive therapy that a lot of people don’t. Could you please talk about the role experiential learning has played in the therapy that you do.
Christine Padesky: I’m glad you asked about that. Therapy is a learning process. I think of myself as an educator when I’m doing therapy and I want to help people learn in the best ways possible. I’m not an educator in the sense of didactically telling people things, but in the sense of trying to use our relationship and the experiences that we share to maximize client learning and discovery. We know from research that one of the best ways we learn is through experience.
Talk alone can often lead to insight…but that insight can be short-lived if it’s not backed up with experience. In therapy, I try to use methods that are experiential including interactive writing and behavioral experiments. I also use a lot of imagery and sometimes role-playing and psychodrama. I put a high value on experiences because it’s through those interactive experiences that you get activation of thoughts, emotions, and behavior in ways that are going to be memorable, and that the client will likely put into practice in their life.
MY: That parallels with Erickson’s work. He was a big fan of experiential learning. I think you’re doing what a good therapist does, which is getting people moving.
CP: We might have somewhat different theoretical frames and ways of understanding what we’re doing, but I have observed throughout my career that therapists from different modalities do many of the same things in the therapy hour.
MY: Can you give some insight into how you decide what kinds of action-oriented approaches you’re going to use?
CP: Some of it depends on the current therapy alliance and relationship. For example, I’m much more likely early on in a therapy relationship to do interactive writing or some behavioral experiments that are short and in-the-moment. I think to do psychodrama or a two-chair technique, I need to have a much better therapy relationship; a lot more trust. So that would be one thing, the level of the relationship. The second thing would be the client’s issues. People might have beliefs like, “If I don’t feel motivated, I can’t do something.” or “If I don’t have much energy, then it’s not possible for me to do something.”
You could talk to death about those beliefs, but usually you can break through them within a matter of minutes just by doing an experiment. So, if someone has a belief that is testable in that moment, rather than talk about it, I would just test it out right then and there. For example, with someone who is depressed who says, “I don’t have energy. I can’t do things.” I might ask them, “What’s your energy level right now?” And, if they say, “It’s quite low,” I’ll be quite happy, because then I’ll say, “Well, let’s stand up for a moment and walk over here and look at this picture and talk about it for a minute.” Then I will do some kind of interaction with them for a few minutes and say, “I’m curious, what’s your energy level now?” And from that kind of experiment, it’s not just the doing of the action, but it’s the debriefing of it. I’ve tried to hone over the years a skill of using dialogue about experience to guide client discovery. If they say their energy is higher, I’ll say, “Well, that’s interesting…we started out with you telling me if you didn’t have much energy, that you couldn’t do things. You didn’t have a lot of energy and yet you were able to do this. What do you think explains that?” I’ll ask them a series of questions and we write down a summary of what they learned and their observations. Then, I’ll ask them to reflect on that and I’ll say, “I wonder, is there a way you could use these ideas to help yourself this week?” If there’s anxiety, or if I’m wanting people to envision something positive that doesn’t yet exist in their life, then I’m more likely to use imagery because imagery is powerful in terms of helping people imagine new things they aren’t quite confident can exist. I might also use imagery if I want people to go out in the world and practice something. We know from research that imagery practice increases the likelihood that people will go out and follow through and do something. It turns out that people think in imagery almost all of the time. I think in the decades ahead, an important part of examining cognition will be looking at imagery. Now, if we’re looking at imagery in terms of crafting some kind of change, for example, a new behavior, then I’m going to ask the person, “How would you like to be? What would you like to do? Let’s take a few minutes and have you imagine what that might look like.” Then I’ll have them imagine what they might be doing, and I’ll try to direct their awareness to different parts of that experience. “What does that feel like in your body? What emotions are you feeling?” I get people to make more careful observations, and to draw into their attention, multiple aspects of their experience.
Sometimes if I’m working with personality disorders and more chronic conditions, I’ll have people develop an image of what they wish their life was like, or what they wish they were like. And then I’ll have them do similar things, where they can imagine scenarios. I ask them, “How does that feel physically?” Where do you feel that in your body? What emotions are you experiencing? What metaphors and additional images come to mind as you begin to enact this?” I think imagery is so wonderful and rich because it includes every aspect of experience within it.
MY: You and Kathleen Mooney have recently focused on strength-based CBT. What sparked this interest?
CP: Kathleen and I have always been interested in strengths. She did some strengths-based work in her first career, which she carried into her second career as a psychologist. When I started graduate school back in 1974, I was interested in strengths, but the zeitgeist at the time didn’t support it. I couldn’t find a single faculty member who would work with me on questions. In the late 1990s and the early part of this century, we started talking more in our trainings about strengths. What cemented this and got us intensively working in that area was the 9/11 attack. When that occurred, the next morning we had a meeting set up to plan the next year’s training program and we said, “Wow, this changes a lot of things in our country. So, what are people going to want to learn about in six months?” We decided they might be interested in resilience. When tough things happen, resilience is usually the story that follows. So we put our minds together and devised a four-step model to build resilience for people who struggled with resilience. We recognized that all of us are resilient in some areas of our lives and we all lose resilience at other points in our lives. We began to articulate a model of CBT that is strengths-based. When you work with people on depression, anxiety or relationship difficulties, it’s worthwhile early in the first session to learn about their strengths. This is good for the therapy alliance, but it’s also good because when you hit roadblocks in therapy. I find if you lean on the client’s strengths, you can go through those roadblocks quickly.
The second thing would be using CBT to build strengths, and this is what we did with our four-step model to build resilience. We came up with a simple way of helping people identify the strengths they already had, and then helped them figure out within just a couple of sessions how they could put these together to become more resilient. The third thing we developed involved developing what we call the new paradigm,” which we started out applying with personality disorders. This was meant to help people build a completely new sense of themselves and how they operate in the world, which is more strengths-based and more resilience-based and a much more transformative kind of application of strengths-based CBT. We were quite heartened that when we met with Aaron Beck, he told us that he’s taken the strengths-based idea and is now applying it to recovery-oriented work for psychosis. It’s exciting! I hope this is the future of CBT.
MY: Let’s talk about the book you co-wrote with Dennis Greenberger, Mind Over Mood, now in its second edition. That book sold unbelievably well. I read it, and it’s wonderfully practical and supportive. How were you able to put all this together, and what has the reaction been?
CP: Well, there’s always a certain amount of luck in why a book becomes successful. But, I think there are a couple things Dennis and I did that hadn’t been done at the time we wrote the first edition and because of that, we substantially improved upon those things in the second edition. Therapists have been embracing this book and using it with a lot of clients. I think the appeal is that many therapists want to use methods with clients that have an evidence-based proof of working. One of the things we’ve done in the second edition is we’ve made reading guidelines clear, so that if you’re working with a client’s depression, then read the chapters in this order. If you’re working with them on anxiety, then read the chapters in this order. We made it a bit easier for therapists to do an evidence-based CBT practice. We tried to write a book that people will want to read that’s interesting, and at the same time, skills-based. We know from current research that lots of different therapies can be helpful for depression, but what seems to predict relapse, or the likelihood of relapse is whether or not people acquire skills that they can apply on a daily basis in their lives. We focused our book around teaching core skills that have been shown in research to make a difference in people’s happiness and reduce their depression, anxiety, anger, guilt, shame, etc. The second edition has 60 worksheets, 25 more than in the first. These worksheets are quite motivating for readers. The other thing we did right is include measures of each of the moods, for example, a measure for happiness, so that people can measure their mood and see if their efforts are paying off or not. That kind of feedback is important to keep people going with the program. The book’s success has been very moving for us. It’s already in eight or nine different languages, and I think by the end of this year, there will be 15 or 20 different translations available. The cross-cultural appeal of this book surprises me. I think Mind Over Mood fulfills a need for people to have a self-help book that’s interesting to read, but at the same time, teaches skills that make a difference.
MY: So, what’s next for you?
CP: Right now I’m finishing up a book on how to foster guided discovery in therapy and what types of therapist-client interactions foster client discovery. I’m also currently writing the Clinicians Guide to the second edition of Mind over Mood, which will be out in 2019. When those books are done, I am going to give myself a little creative time to think about what I want to teach therapists. I love teaching and training and consulting. I do a lot of consulting with therapists, and I’m interested in things we can do to engage clients, foster transformation, and be more creative in our therapy methods.
MY: Can people who are interested in your workshops go to your website to see your teaching schedule?
CP: Yes. It’s padesky.com. On our website there are lots free downloads of papers that we’ve written over the years. We also have a store with training audio CDs and DVDs.
MY: Thank you so much for being so generous with your ideas and perspectives.
CP: Thank you Michael, it’s a pleasure to talk to you.
Michael D. Yapko, Ph.D., is a clinical psychologist residing in Southern California. He is internationally recognized for his work in clinical hypnosis, brief psychotherapy, and the strategic treatment of depression, routinely teaching to professional audiences all over the world. He is the author of 15 books, including his most recent book, Taking Hypnosis to the Next Level. He is a Fellow of the American Psychological Association and the American Society of Clinical Hypnosis. He is the recipient of numerous major awards, including the Milton H. Erickson Lifetime Achievement Award for Outstanding Contributions to the field of Psychotherapy. Learn more about Dr. Yapko at www.yapko.com.
By Angela Z. Wu, MFTBackground:
Lisa is a 32-year-old single Chinese woman living in Shanghai who has been seeing me for six months via Zoom (online chat like Skype). Two years ago, she discovered that both of her parents were having affairs. Soon after, her periods ceased and she began to get headaches.
Lisa’s parents treated her like a boy, and this angered her, as the little girl inside her yearned to be loved and treated like a girl. In therapy, we did a lot of active imagination so that Lisa could take care of that little girl; love and mother her. She also met a trustworthy man — her acupuncturist – who played a role in her recovery.
Lisa plays the guzheng (classical Chinese string instrument) well, and wants to study violin. During therapy, she cut off contact with her parents. She also ended an uncomfortable romantic relationship, quit her data analyst job, and made plans to study violin in Europe.
Lisa reported that although she was not menstruating, she felt more “woman juice” flowing out of her, and felt her body get warm. However, the headaches remained.Sessions:
Using The Pain Map, (Drs. Eric and Lori Greenleaf, 1997), she drew all of her pain (physical, emotional and spiritual) on one map, and all of her resources on another. Then, in her imagination, she applied a particular resource to a specific pain.
Lisa: My headache became closer, heavier. I see an angry face: a child, but it is my father. Father’s angry face is replacing the headache. [pauses] Now the angry face is getting closer and clearer. I don’t feel much headache.
Angela Wu: What does the child want — to be angry, or not? [pauses],
L: He doesn’t know what to do; he only knows anger.
AW: Suppose the child gets comfort from someone?
L: I feel my acupuncturist is touching the child’s head to calm him. The child is getting quiet and calm. [After a long pause, Lisa begins to cry.] AW: I see the tears; they are real, and my heart gets tender when I see tears. [pauses] Often tears are sacred; they remind us to grieve or to know joy. It is a strong, real emotion. It shows us real life, with all kinds of feelings. When I see your tears, I feel you are so real.
L: I’m crying as I see the angry boy calm down. He said, “I am sorry” to me.
AW: Very nice hearing, “I am sorry.”
L: I see a little girl come out. That was me at 12.
AW: Welcome. How is she?
L: Finally, she can come out. She was so scared by that angry boy.
AW: What does she want? [long pause]
L: She wants to have her period.
AW: That is right. She wants to have her period. Suppose you help her to prepare for her period: read her books, get her sanitary pads, cute underwear, nail polish, or a promise of her favorite ice-cream when the period is over. [Lisa smiles and nods.]
L: The little girl wants to perform music. Her parents always told her that she was not good enough; now she wants to perform. But she is shy, not sure if she can.
AW: Suppose the girl gets dressed in a beautiful Chinese qipao [form-fitting dress]; sets up her guzheng in her room; prepares two seats for her parents. Then she can play and record the saddest melody, and mail it to her parents, as if you are mailing your bad headache to your parents.
L: That is a good idea. I will do that. I am more comfortable playing in my own apartment. And I will mail them my sadness and my bad headache.
AW: One more thing. I do not know about you, but for me, two or three days before my period I often have bad headaches. When I feel that headache, I know I will prepare myself.Two weeks later:
Lisa felt overwhelmed when she played the guzheng, and she stopped. She didn’t record or send the music to her parents. Before our next session, she sent me a link to a classical Chinese violin piece called, “So Long.” She said, “When I hear it, I feel gentleness, unconditional love, separation, and sadness. I may want to hear it during the session. Let’s be prepared.”Session:
L: I don’t feel the headache. I started to feel a mother’s unconditional love, but it is not my mom.
AW: If now you use your body as the map, where do you feel the love?
L: In my feet, and my hands.
AW: What is the sensation when your feet and hands feel love?
L: It is freedom to move around.
AW: Good. Focus on that freedom — your feet and hands. Does that feeling stay still or move around?
L: It is moving up, coming to my hands. I feel very gentle and warm, like a baby’s skin. Now it’s moving to my belly button. [pauses] AW: What is happening there?
L: The little belly button wants to say something.
AW: Before a baby’s born, she is connected with mother through the cord. The baby gets food; feels mother’s heartbeat. In this way baby communicates with mom, so of course the belly button wants to say something. [pauses]
L: The belly button feels mom’s love. She was held in big hands; warm and gentle. The little belly button feels mom’s gentle touch, gentle kisses. [Lisa nods, and begins to cry; long pause.] Then, the little belly button grew up. Mom starts to say she is not good enough, and is very harsh to her. She didn’t want to talk. She is so scared all the time; scared, sad, and hurt. She is afraid of talking; felt something stuck in her throat.
AW: Let’s start with a long, deep breath; breathing out first. Really clear out all the fear, all the worries and sadness inside of her. Then breathe in all the fresh air and oxygen that she needs. That’s right; just breathe, breath by breath. She is growing up, she is still good. The little belly is still good.
Now she is an adult, and she can open a new file for her life. She is going to put the people she likes and loves; the loving memories, in her new file. She knows she has unconditional love with her; right on her feet, right on her hands. She just needs to feel it. [pauses]
L: The little belly walked to a door. It is oval; a glass door. She is nervous, scared.
AW: Where does the door take her to? [pauses]
L: The other side of the door is the womb.
AW: Does little belly want to go there?
L: She is nervous and scared…even with unconditional love. It is dark over there.
AW: Can little belly put a flashlight in her pocket?
L: Yes, a flashlight will be useful.
AW: If you like, you can take me with you. You can hold my hand.
L: Yes, let’s do that. I am shining the flashlight and holding your hand. I’m walking in. [tears; long pause] I saw an old friend.
AW: What does the old friend look and feel like?
L: It is round, soft, sticky. It is red.
AW: Very good. Say, “Hi” to this old friend. Tell her, “I missed you, and I’m so happy to see you. I know you’re here, so today I came. We are old friends. I know I’ll always see you.”
L: I started to feel warm. I started to feel the blood running through my body. Now it’s time to play the music.
AW: [I push the button and music plays.] Yes, you are saying good-bye to the fear, to the worries. Now feel the blood and the freedom. Feel and enjoy the love. [pauses]
Ten days later, Lisa sent me a message saying that her periods resumed.The session after her period:
Before the session, Lisa sent me another violin solo called, “Raise Me Up,” to play as background music for the session. She still gets a headache from time to time, but isn’t bothered by it. She remembered that she often had a headache around her period. She began to remember her grandfather, who loved her very much.
L: I feel that I need to walk home and become a mature woman. I feel lonely. I am scared to be with the old friend; to be a normal woman.
AW: Now you’re telling me, so you’re not lonely anymore. You’re walking towards your home; not a little girl going to her parents’ home.
L: I feel the love was buried by hate for so long. Now I have to go through the pain to find it. [crying] I haven’t been crying like this.
AW: This is good. When the love is opening up and meeting the pain, two strong energies meet, and it can be overwhelming.
L: I see so many things: I see grandfather; I see me on the stage as a grown, beautiful woman playing violin; I see a man that I want to love — only his back, not his face yet.
AW: These are beautiful things. They are somewhere — awaiting. And now I know you can go there. You have met your old friend, and you will meet many new friends.
L: [still crying] I know. I am walking home. My home.
We decided to do a monthly checkup, and eventually terminate the therapy. Lisa is now looking into studying music in Europe and has started to date men.Commentary
Eric Greenleaf, PhD
Relationships shape therapy, and the language used represents human experience. The patient often speaks in symptom language: a headache, amenorrhea, or anxiety. Ericksonian therapists speak in image, metaphor, and a common language: “the little girl,” “an oval door,” “the old friend.” Angela Wu’s gentle, healing touch and patient inquiry formed a relationship that drew healing from the patient’s inner life resources. And, hand-in-hand, both therapist and client shone a light together into the frightening darkness — and they created beautiful music.