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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 ca preconditie a psihoterapiei avuta in vedere.(C.Rogers, 1957) L. Cancrini: Elementele importante pentru stabilirea diagnosticului apar oricum, foarte firesc, in cadrul unui inteviu centrat de la inceput pe finalitatile de ordin therapeutic. O 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 APA - Evaluare psihologica, diagnostic: Procedurile pot include, dar nu sunt limitate la, 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 experientei si comportamentului uman care poate contribui la intelegerea si ajutarea utilizatorului. Diagnosticul este un process. Este mai mult decat determinarea unei etichete sau a unei categorii dintr-o clasificare psihopatologica. El este o analiza a functionarii clientului in vedera prescrierii celei mai utile interventii terapeutice. (Woody, Hansen, Roossberg, 1989) Utilizarea computerului in evaluarea psihologica si in psihoterapie P.M.G.Emmelkamp: Studii 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. In terapia orientata de computer, computerul insusi determina si furnizeaza feed-back-ul pacientului. Rezultatele terapiei ghidate de computer cu pacienti avand tulburari anxioase si tulburari depressive moderate intr-o clinica din Londra sunt comparabile cu cele obtinute intr-o terapie cognitive-comportamentala fata in fata dar terapia ghidata de computer este mul mai eficienta din punct de vedere al costului. Evaluarea multiaxiala DSM
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Axa I Tulburarile clinice.Alte conditii care se pot afla in centrul atentiei clinice Axa II Tulburarile de personalitate. Retardarea mentala Axa III - Conditiile medicale generale Axa IV Problemele psihosociala si de mediu Axa V - Evaluarea globala a functionarii Formularea (conceptualizarea) cazului: Bergner, 1998: organizeaza toate faptele iportante ale cazului in jurul unei surse cauzal explicative (linchpin) defineste aceasta sursa in termenii factorilor care pot fi supusi interventiei directe impartaseste clientului aceasta formulare in vederea obtinerii beneficiilor asteptate J.C. Norcross: prezentarea problemei factori biopsihosociali cheie obiectivele si planul terapiei DSM/Formularea cazului DSM nu stimuleaza clinicianul sa identifice factorul central de mentinere a problemei DSM nu sprijina ideea ca formularea clinica a cazului sa fie realizata in termenii unor variabile care sa poata fi supusi unei interventii directe DSM 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 (Woody, Hansen, Rossberg) daca un comportament are consecinte personale negative, atunci el poate deveni obiectiv al schimbarii terapeutice un model centrat pe descrierea problemelor manifeste si simptomatologiei este potential mai benefic pentru pacient decat sunt rezultatele unei baterii de teste (Sweeney, Clarkin, Fitzgibbon, 1987) Cum facem distinctia dintre tulburare mentala si normalitate? Jahoda (1958) 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- ingrijire o perceptia realitatii si sensibilitatea sociala o controlul mediului si comportamentul adecvat in fata cerintelor vietii.

abordarea lui Millon (1981) privind definirea personalitatilor normale si patologice necesita diferentierea dintre pattern-urile personalitatii, tulburarile simptom si reactiile comportamentale o pattern-urile personalitatii rezista la actiunile de modificare o simptomele se modifica greu o reactiile comportamentale se modifica usor Sarcinile terapeutului sunt urmatoarele: o sa identifice structurile de personalitate care dau pacientului stabilitate si autonomie si care se exprima 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 Halleck 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 yoga, relaxare miscare, masaj) o experiente 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

Teste utilizate frecvent in evaluarea clinica: Wade &Baker (1977): -Rorschach, TAT, WAIS, MMPI, Bender VisualMotor Gestalt Test, WISC Lubin, Larsen, Matarazzo(1984) - WAIS, MMPI, Bender VisualMotor Gestalt Test, Rorschach, TAT, WISC Piotrowski(1985 ) ancheta printre membrii Society of Personality Assessment: -Teste obiective: MMPI ( 87%), CPI (30%),Edwards Personal Preference Schedule (11%) -metode proiective: Rorschach (94%), TAT (91%), Sentence Completition method (47%) Oportunitatea prescrierii unei interventii terapeutice

1)Capacitatea pacientului de a stabili 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. - Calitatea aliantei terpeutice - Istoria relationala -Conditii de viata supportive ( timp pentru psihoterapie, venituri financiare adecvate, support la locul de munca, support familial. 2)Factori ai modelului de functionare a pacientului - capacitatea de introspectie - orientare catre analiza psihologica, capacitatea de a lucra cu conceptele unei anume psihoterapii - existenta unei acuze principale, formulare timpurie -recunoastera patternurilor neadaptative 3) Caracteristici specifice pacientului individual - gradul de integrare a superego-ului( capacitatea de a se abtine de la exploatarea si manipularea celorlalti, mentinerea onestitatii si integritatii morale in absenta unui control extern) -capacitatea de testare a realitatii -puterea eului ( slabiciunea eului: slaba toleranta la frustrare, slab control al impulsurilor, lipsa tolerantei anxietatii, lipsa capacitatii de sublimare) - bune rezultate scolare sau profesionale -lipsa tendintelor spre somatizare 4) Interventiile cu scop evaluativ - raspunsuri adecvate la intrebarile exploratorii - 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 formularea clinica

O formulare clinica a cazului este o schema conceptuala care organizeaza explica sau furnizeaza o semnificatie clinica unei mari cantitati de date si influenteaza deciziile terapeutice ( Lazare, 1976) Jerome Frank (Frank & Frank, 1991) defineste doua componente ale formularii clinice: 1. o explicatie plauzibila a simptomelor pacientului sub forma unei scheme conceptuale sau chiar a unui mit care furnizeaza argumente pentru 2. prescrierea unui tip de ritual sau a altui tip de procedura pentru pentru a le rezolva In baza acestei definitii putem identifica urmatoarele elemente ale une formulari clinice a cazului: Simptomele sau problemele care trebuie schimbate O mare cantitate de date care trebuie sa fie organizate O schema conceptuala care furnizeaza o explicatie Decizii terapeutice care conduc la proceduri specifice

In afara unei bune comunicari cu supervizorii si cu alti profesionisti o buna formulare clinica are , de asemnea, urmatoarele avantaje: Incredere crescuta si anxietate scazuta in fata unor cazuri noi Furnizeza instrumente si modele de actiune pentru evaluarea nevoilor clientului si intelegerea clientilor din multiple perspective Furnizeaza o strategie coerenta pentru aplicarea cunostintelor in munca cu clientii Asigura o structura ce permite utilizarea creativitatii in procesul de ajutorare a pacientilor

Cum procedam ? Pentru 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. Alegerea unei anume teorii pentru a dezvolta o formulare clinica are urmatoarele: avantaje: - ofera o anume structura, garanteaza o anume consistenta si coerenta a ideilor - ilatura ambiguitatea si stresul determinat de obicei de de deciziile clinice

dezavantaje: - introduce clientul in modelul preferat de clinician chiar daca alte ipoteze clinice pot conduce la interventii terapeutice mai eficiente. Dezvoltarea unor formulari unice , integrative

Terapeutul integreaza idei, abilitati si tehnici din diferite abordari teoretice pentru a crea o formulare unica pentru fiecare problema a clientuli, pentru fiecare personalitate si context sociocultural. Acasta abordare recunoaste ca fiecare teorie poate oferi ceva valoros dar nu este suficienta ca singur ghid pentru terapie. Un plan terapeutic integrativ combina concepte si tehnici din diferite abordari terapeutice intr-o modalitate sistematica si coerenta pentru a intalni nevoile unui client unic. Doua caracteristici ale formularii cazului Integrarea ideilor din 28 ipoteze clinice principale Aceste ipoteze : Extrag ideile explicative esentiale din toate teoriile si abordarile terapeutice Permit combinarea si integrarea componentelor diferitelor teorii Conduc intr-o maniera logica la planul terapeutic Un cadru structurat numit metoda orientarii pe prolema Metoda orientarii pe problema (MOP) necesita: Identificarea problemei care este tinta interventiei terapeutice Specificarea rezultatului obiectiv, schimbarea dorita in functionarea clientului Un sumar bine organizat al informatiei colectate despre client (baza de date) O explicatie coerenta pentru fiecare problema care sa integreze ipotezele clinice (evaluarea) Planul tratamentului recomandat in acord cu explicatia si focalizat direct pe realizarea rezultatului obiectiv Ipotezele clinice nucleu O ipoteza clinica nucleu este o singura idee explicativa care ne ajuta sa structuram datele despre un anume pacient astfel incat sa ajungem la o mai buna intelegere , la luarea unei decizii si la o alternativa terapeutica. (Lazare, 1976) 28 ipoteze clinice nucleu 1. Ipoteze biologice a. Cauza biologica b. Interventii medicale c. Interactiuni minte corp 2. Crize, situatii stresante, tranzitii a. Urgenta b. Stresori situationali c. Tranzitie developmentala d. Doliu si pierderi
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3. Modele comportamentale si de invatare a. Antecedente si consecinte b. Raspuns emotional conditionat c. Deficit al abilitatilor sau lipsa competentei 4. Modele cognitive a. Asteptari utopice b. Harta cognitiva eronata c. Procesare eronata a informatiei d. Monolog interior disfunctional 5. Modele existentiale si spirituale a. Probleme existentiale b. Evitarea responsabilitatii si libertatii c. Dimensiune spirituala 6. Modele psihodinamice a. Parti interne si subpersonalitati b. Reactivarea unor experiente primare infantile c. Un simt imatur al sineluisi a conceptiei despre ceilalti d. Dinamici inconstiente 7. Factori sociali, culturali si de mediu a. Sistemul familial b. Contextul cultural c. Suportul social d. Performanta rolului social e. Problema sociala este o cauza f. Rolulsocial al pacientului cu tulburari mentale g. Factori de mediu Formularea clinica a cazului - 28 ipoteze clinice nucleu Ipoteze biologice: B1 Cauza biologica - problema are o cauza biologica: clientul are nevoie de o interventie medicala pentru a-si proteja viata si a preveni deteriorarea, sau are nevoie de asistenta psihosociala pentru a se adapta cu boala, dizabilitatea sau cu alte limitari biologice. (Ac. ipoteza se aplica , de ex. in accidente vasculare, tumori cerebrale, sindromul Alzeimer, stsri toxice tranzitorii, intoxicatii etilice sau cu droguri, SIDA, deficit de vitamine, tulburari endocrine etc) B2 Interventii medicale - exista interventii medicale( ex. medicatie, interventii chirurgicale sau protezari) care trebuie luate in consideratie. Aceasta ipoteza este recomandata cand 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 justifica 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) abilitatea de a discuta medicatia cu clientii cu intelegerea factorilor care promoveaza si impiedica complianta.

Indicatii pentru referirea pacientului catre un psihiatru pentru evaluarea medicatiei: 1. Clientul este activ suicidal sau are deficite functionale severe 2. Simptomele au persistat in ciuda interventiilor psihoterapeutice 3. Clientul utilizeaza automedictia 4. Medicatia psihotropa i-a fost utila clientului in trecut 5. Medicatia psihotropa a fost utila in trecut membrilor familiei cu simptome similare. B3 Conexiuni minte - corp - o intelegere holista a conexiunilor minte corp conduce la tratamente pentru problemele psihologice care se focalizeaza pe corp si la tratamente pentru probleme fizice care se centreaza pe minte. Aceasta ipoteza se potriveste pacientilor care somatizeaza, pacientilor care acuza diverse tipuri de stres si tensiuni, celor cu tulburari sexuale. Clientii au deseori nevoia de creste constientizarea si controlul corpului lor si sa dezvolte o constientizare somatica a emotiilor. Multe din terapiile corporale sunt utile pentru problemele psihologice. Starile psihologice pot afecta creierul, sistemul nervos autonom si sistemul imun. Problemele de sanatate, precum cancerul si SIDA, beneficiaza de pe urma starilor mentale pozitive Crize, situatii stresante, si tranzitii Exista 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 criza; - patologizarea unei conditii care, desi dureroasa si debilitanta, este mai bine inteleasa ca normala, ca raspuns asteptat la stresori, traume, situatii de tranzitie. CS1 Urgenta - simptomele clientului constituie o urgenta: se impune o actiune imediata. Aceasta 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 exista reglementari legale pentru raportarea abuzului sau a violentei intentionate. Ea se potriveste si situatiei in care clientul se poate angaja intr-o actiune irevocabila. Managementul clientului violent 1.Mentinerea unei atmosfere de calm si incredere; nu grabiti situatia 2.Daca clientul se simte amenintat de ceva, inlaturati amenintarea din scena 3.Definiti-va rolul: doresc sa va ajut sa va controlati aceste sentimente; doresc sa va ajut sa gasiti cele mai bune modalitati sa controlati situatia. 4.Nu blocati accesul clientului catre usa 5.Asigurati-va ca aveti suportul persoanelor disponibile - lasati usa deschisa, asigurati prezenta unei alte persoane sau accesul la un sistem de alarma. 6.Scadeti emotionalitatea clientului: vorbiti intr-un limbaj direct simplu, ajutati exprimarea sentimentelor prin cuvinte, si puneti intrebari factuale. 7.Furnizati o structura si limite: exprimati clar ca violenta nu va fi tolerata 8.Recompensati orice semn ca clientul isi controleaza comportamentul
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9.Chemati politia sau echipa de urgente psihiatrice daca este nevoie 10.Nu ezitati sa faceti orice va securizeaza, chiar daca ganditi ca pacientul s-ar simti ofensat Evaluarea potentialului de suicid 1.Fiti directi in abordarea temei suicidului, aratand confort in abordarea acesteia: V-ati gandit sa va puneti capat vietii? 2.Puneti intrebari specifice referitoare la durata si intensitatea gandurilor suicidale: Cat de des va ganditi sa va impuscati? 3.Interesati-va de existenta unui plan. 4.Evaluati letalitatea metodei alese; cu cat mai specific este planul cu atat letalitatea este mai mare. 5.Explorati comportamentul suicidar ca modalitate de comunicare. Ce mesaj doreste persoana sa comunice? La ce raspuns se asteapta?Exista o anume persoana din partea careia se asteapta un raspuns? A intrerupt persoana comunicarea cu ceilalti si si-a pierdut speranta in orice ajutor? 6.Culegeti detalii referitoare la tentative anterioare. 7.Evaluati resursele suportului social: Cat de izolat este clientul? Cine l-ar putea ajuta? Persoana semnificativa pentru pacient este o resursa sau parte a problemei? 8.Evaluati nivelul curent al abuzului de substante - un factor care diminueaza controlul impulsului. 9.Evaluati nivelul depresiei si posibilitatea unei psihoze - factori care cresc riscul. 10.Explorati factorii precipitanti. Exista vreun stresor acut in viata unei persoane stabile sau avem de-a face cu un patern al unui comportament suicidar cronic? 11.Evaluati nivelul de ambivalenta: Cat de puternica este partea moarte versus partea ramai in viata 12.Exista altcineva in familie care a incercat sa se sinucida sau s-a sinucis? 13.Au fost realizate pregatiri finale pentru moarte, precum scrierea unui testament, incredintarea altei persoane a unor valori sau a animalelor de casa? Interventii terapeutice pentru pacientii cu ideatie suicidara 1.Informati familia si persoanele semnificative despre ideatia suicidara. Cereti-le sa supravegheze pacientul 24 ore din 24 pana cand criza trece. 2.Asistati clientul in dezvoltarea constientizarii propriilor mesaje cognitive care intaresc disperarea si neajutorarea. 3.Realizati un cotract cu clientul in care mentionati ce va trebui sa faca de fiecare data cand va reapare ideatia suicidara. 4.Asistati clientul an gasirea lucrurilor pozitve si datatoare de speranta din viata sa an prrezent. 5.Aistati clientul in dezvoltarea strategiilor de coping cu ideatia suicidara ( de pilda mai multe exercitii fizice, diminuarea concentrarii asupra universului interior, cresterea implicarii sociale, exprimarea sentimentelor.) 6.Cand ideatia suicidara este insotita de vinovatia supravietuitorului, implementati un ritual de penitenta 7.Asistati clientul sa constientizeze factorii care au determinat debutul ideatiei suicidare.

CS2 Stresori situationali - simptomele pacientului rezulta din stresori situationali recenti sau din experiente traumatizante trecute. Este important sa evaluam daca simptomele clientului sunt proportionale cu nivelul stresului. Trebuie sa mentionam stresorii externi, care pot sa mearga de la traume care pun viata in pericol pana la acumularea unor neajunsuri zilnice si sa avem o modalitate obiectiva de masurare a severitatii acestora. Tehnicile de interventie in criza pot impiedica transformarea reactiilor de criza in tulburari cronice Cele patru faze de dezvoltare a crizei (Caplan 1964) Cresterea tensiunii Eforturi de coping fara succes Mobilizarea resurselor de urgenta Dezorganizarea

Principalii pasi in interventia in stare de criza (cuprinde idei din Hipple &Hipple1983, Aguilera - 1998, Greenstone&Levitone 1993) Scop Actiunile terapeutului

imbunatatirea starii Inspirati speranta si securizati clientul. Demonstrati ca sunteti calm emotionale 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. 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 si simbolice ale evenimentului criza.

Evaluarea crizei

Evaluarea gradului Evaluati daca clientul este un pericol pentru el sau pentru ceilalti si de urgenta apreciati nevoia de spitalizare. Daca persoana are ideatie suicidara, utilisati un contract non-suicid si cresteti frecventa sedintelor.

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Scop Ajutarea clientului sa inteleaga criza

Actiunile terapeutului 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 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. 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. 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 ale pacientului.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 asigurativa ca exista o coordonare adecvata.

Facilitatea exprimarii emotionale

Utilizarea restructurarii cognitive

Dezvoltarea unui plan de actiune

Delimitarea supor- Suportul social poate veni fie din reteaua sociala individuala, fie tului social 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 apar semne 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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Scop

Actiunile terapeutului

Monitorizarea pro- Pe masura ce schimbbarile pozitve se manifesta, sumarizati progresului gresul 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 antici- Dupa ce criza curenta este menegeriata, ajutati clientul sa dezvolte pata 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.

CS3 Tranzitie developmentala - clientul este intr-o tranzitie developmentala confruntanduse cu probleme legate de trecerea de la un stadiu al vietii la altul. La fiecare 5-10 ani o tranzitie developmentala este inevitabila datorita interactiunii dintre maturarea biologica, dezvoltarea personalitatii, expectatiile sociale de rol pentru persoanele de virste diferite. Aceasta ipoteza normalizeaza disruptiile dramatice si conduce la interventii care impiedica o criza de maturizare sa devina o tulburare cronica. Oamenii au nevoie de suport pentru a face alegeri personale si pentru a realiza sarcinile developmentale in propriul lor ritm Cele sase stadii ale rolului de parinte (Galinsky, 1987) Stadiul parintelui Stadiul formarii imaginii Stadiul dezvoltarii Stadiul copilului Prenatal Sarcini developmentale Acceptarea sarcinii Pregatirea pentru rolul de parinte Pregatirea pentru nastere

De la nastere la be- Reconcilierea imaginii nasterii cu realitatea belus Confruntarea cu sentimentele atasamentului Redefinirea relatiilor

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Stadiul parintelui Stadiul autoritatii

Stadiul copilului

Sarcini developmentale

Dela bebe la varsta Dezvoltarea autoritatii scolara Castigarea distantei Controlul rolurilor de sex si identitatii Interpretarea propriei persoane ca parinte Separare si conectare Interpretarea lumii catre copil Decizia cu privire la nivelul de implicare Anticiparea varstei adolescentine Adaptarea la o noua autoritate relationala Controlul sexualitatii Acceptarea identitatii adolescentine Formarea unei noi relatii cu copilul aproape matur Pregatirea pentru plecare Adaptarea la plecare Schimbarea imaginilor Relaxarea controlului Asumarea succeslor si insucceselor

Stadiul interpretarii Debutul scolii scoala medie

Stadiul interdepen- Scoala superioara dentei

Stadiul plecarii

Scoala superioara -colegiu si mai departe

CS4 Pierderi si doliu Clientul a suferit o pierdere si are nevoie de ajutor pe durata doliului sau pentru rezolvarea unor probleme legate de pierdere. Pierderile pot fi externe(ex. 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. Uneori pierderea este o cauza precipitanta a unor simptoame emotionale; alteori, clientul nu este constient de aceasta conexiune. Stroebe si Schut (2001) au dezvoltat o teorie a proceselor duale cu privire la suferinta. Procese orientate catre pierdere: Atat confruntarea cat si evitarea pierderiipe masura ce persoana traverseaza procesul suferintei. Procese orientate catre insanatosire: Copingul cu problemele si responsabilitatile determinate de pierdere si descoperirea propriului loc in lume fara persoana decedata.

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Stadiile suferintei (doliului) (Lindemann, 1994) 1. 2. 3. soc, neacceptare, letargie, amorteala Confruntarea cu pierderea si trairea durerii si dorului Rezolvarea pierderii si realizarea acceptarii Prescriptii terapeutice pentru Suferinta (doliu) (Worden, 1991) 4. 5. 6. 7. Acceptarea realitatii pierderii Travaliul durerii Adaptarea la un mediu fara persoana sau lucrul pierdut Relocarea emotionala si continuarea vietii. Tipuri de doliu complicat (W.Stroebe, Schut, and Stroebe (2005) 8. Tipul cronic: focalizare excesiva asupra pierderii; experienta prelungita a simptomelor fazei acute precum furie, suparare, tristete, amaraciune, depresies mentinerea unei relatii fantasmatice cu decedatul cu sentimentul ca el/ea este mereu prezent(a) si priveste; dor intens si cautarea persoanei decedate,; lipsa progresului in sarcinile de restaurare 9. Tipul amanat, inhibat sau absent: focalizare scazuta asupra pierderii cu concentrare exclusiva asupra sarcinilor de restaurare 10. Tipul traumatic: Confruntare foarte intensa si persistenta cu pierderea combinata cu evitarea; trairea simptoamelor caracteristice PTSD precum flashback - uri, cosmaruri, amintiri intruzive. Factorii de risc pentru aparitia complicatiilor: 11. 12. 13. Tipul de relatie cu decedatul Circumstantele decesului ( neasteptat, violent, suicid etc ) Procesul de doliu: incercari de evitare a trairii durerii, credinta ca un doliu limitat este o tradare a celui decedat ) 14. Personalitatea si istoria individului 15. Alti factori de stres concurenti 16. Lipsa unui suport social adecvat in DSM-IV-TR, se considera ca o persoana care a trait doliul poate fi considerata ca avand un episod depresiv major, doar daca simptomele sunt prezente dupa doua luni de la pierderea fiintei dragi. Interventii terapeutice Utilizand teoria procesului dual a doliului Stroebe & Schut, 2001), interventiile se vor centra fie pe procesel orientate catre pierdere fie procesele orientate catre restaurare, functie de nevoile individuale ale clientului. Interventii terapeutice focalizate pe procesele centrate pe pierdere:

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Tehnica gestaltista a scaunului gol: clientul poate vorbi direct cu decedatul si sa-si exprime sentimentele, poate lucruri pe care nu a avut ocazia sa le spuna inainte de decesul persoanei, sa ierte sau sa ceara iertare. Formula la revedere, ramas bun este de evitat desi este important ca pacientul sa accepte pierderea. Tehnica imageriei ghidate: terapeutul poate ghida clientul printr-un set de experiente care pot culmina cu experienta de a vorbi cu persoana decedata. Procesul este intern si silentios; terapeutul poate sa ceara sau nu clientului sa povesteasca experienta sa. Scrierea unei scrisori, a unui jurnal etc. Realizarea unor lucrari artistice -catharsis, constientizarea unor sentimente, se forma unor unor emotii incoerente Comemorare: clientul poate crea uncolaj cu scrisori, fotografii, si alte obiecte ale persoanei decedate. Ritualuri vindecatoare : ritualuri de ramas bun, de adio( nu numai in raport cu persoana decedata ci si cu durerea si suferinta. Interventii terapeutice centrate pe procesele de insanatosire: Terapia narativa: Terapeutul ajuta clientul sa creeze o poveste coerenta despre propriul viitor fara prezenta persoanei decedate dar avand amuntirea acesteia si libertatatea de a se angaja in noi activitati si relatii. Terapie cognitiv comportamentala: Terapeutul provoaca limitele credintelor si schemelor si ajuta clientul sa creeze altele care pot sprijini competenta in noile roluri si sarcini si asigura permisiunea de a merge mai departe. Terapeutul poate utiliza un model structurat de problem-solving si ajuta clientul sa dezvolte si sa implementeze un plan de actiune. Dezvoltarea de deprinderi: de pilda, deprinderi de management financiar, deprinderea de comportament autosuportiv, formarea de noi relatii de prietenie. Terapeutul poate ajuta clientul sa identifice punctele tari si pe cele slabe, furnizeaza ocazia de a exersa unele situatii interpersonale prein jocuri de rol. BL1 Antecedente si consecinte: analiza comportamentala atat a comportamentului problema cat si a comportamenului dorit trebuie sa se bazeze pe informatii referitoare la Antecedente si consecinte care vor fi utile in construirea unei interventii. In constructia interventiei terapeutice se utilizeaza principiile conditionarii clasice si condittionarii operante. Modelul behaviorist initial Antecedente - Comportament - Consecinte a devenit Antecedente - Mediere cognitiva - Emotii - Comportament - Consecinte

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BL2 Un raspuns emotional conditionat - ( anxietate, teama, furie, depresie ) este la originea unor emotii excesive, comportemente de evitare, a unor mecanisme maladaptative de evitare a unor emotii dureroase. Raspunsul emotional intens nu este justificat de stimulii din mediul curent, prin urmare inferam invatari anterioare care implica si care explica reactiite excesive. Tratamentul va necesita noi invatari: extinctia emotiilor problematice si contraconditionarea unor raspunsuri emotionale mai adaptative.

BL3 Deficit de deprinderi sau lipsa competentei - problema are la baza un deficit de deprinderi - absenta deprinderilor necesare - sau lipsa competentei in utilizarea deprinderilor, abilitatilor si cunostintelor pentru atingerea unui obiectiv Problem - solving/ Luarea deciziilor Aceste deprinderi necesita o abordare metodica, sistematica: 17. 18. 19. 20. 21. Identificarea si clarificarea problemei Culegerea de informatii si cautarea de explicatii Brainstorming pentru solutii alternative Evaluarea costurilor si beneficiilor fiecarei solutii si alegera celei mai bune Implementarea unui plan de actiune si monitorizarea rezultatelor Modele cognitive C1 C2 C3 C4 Expectatii utopice Harta cognitiva eronata Procesare eronata a informatiei Monolog interior disfunctional

C1 Expectatii utopice - clientul sufera de obisnuita mizerie a vietii de zi cu zi si are asteptari utopice, nerealiste in legatura cu ceea ce ar trebui sa fie viata; clientul doreste sa elimine dezamagirile , 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. Terapeutii trebuie sa evite sa incheie contracte care urmaresc atingerea unei vieti perfecte fara probleme. Scurt ghid pentru convorbirea 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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C2 Harta cognitiva eronata - problemele sau imposibilitatea rezolvarii lor sunt determinate de elemente limitative sau depasite ale unei harti cognitive eronate; terapeutii trebui sa ajute 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 capacitatea de a se bucura de viata. Sunt scheme maladaptative, postulate, reguli, credinte, predictii ce se autoimplinesc, povesti personalecare trebuie identificate, evaluate, schimbate si revizuite. Erori fundamentale ( Alfred Adler) Erori fundamentale Suprageneralizarea Obiective de securitate false sau imposibile Oamneii sunt ostili Viata este periculoasa Un pas gresit si esti mort Trebuie sa plac tuturor Exemple

Perceptii gresite in legatura cu Vita nu mi-a dat niciodata vreun moment de ragaz. viata si cerintele vietii Viata este grea. Minimizarea meritelor (Complex de inferioritate) Exagerarea meritelor ( complex de superioritate) Valori gresite Nu merit nimic. Nu sunt capabil sa-mi rezolv problemele. Sun superior celorlalti. Nevoile mele sunt mai importante decat ale celorlalti. Fii primul chiar daca va trebui sa calci peste altii. E mai bine daca ii fac pe ceilalti sa indeplineasca responsabilitatile mele.

C3 Procesare eronata a informatiei -clientul demonstreaza o procesare eronata a informatiei (ex. suprageneraalizare, stil dihotomic, lectura gandurilor etc.).Viata de zi cu zi necesita abilitatea de a percepe adecvat datele experienteisi de a schimba schemele pentru a se adapta noilor experiente. Prelucrarea adecvata a informatiei implica aplicarea regulilor logice, practicarea metodei stiintifice, vointa de a urmari validitatea gandurilor, fie prin experimentare fie intro modalitate consensuala cu realitatea celorlalte persoane.Problemele pot fi formulate in termenii lipsei deprinderilor cognitive si a stilurilor cognitive care sunt inadecvate pentru context si obiective. C4 Monolog interior disfunctional - problema este declansata si/sau mentinuta de un monolog interior disfunctional; Exista multi termeni pentru monolog interior: auto-mesaje, vor17

bire interna, voce interna, film interior, ganduri automate etc. Monologul interior disfunctionaldetermina sentimente dureroase,si comportamente neadaptative. Uneori clientul este constient de acest monolog interior: alteori este nevoie ca pacientul sa fie ajutat sa descopere aceasta voce interna. IPOTEZE EXISTENtIALE sI SPIRITUALE ES1 Probleme existentiale ES2 Evitarea libertatii si responsabilitatii ES3 Dimensiune spirituala Probleme existentiale - Clientul se confrunta cu Probleme existentiale, care includ cautari filosofice fundamentale cu privire la scopul si sensul vietii; Exemple de probleme existentiale includ scopul si sensul vietii, mortalitatea si moartea, si izolarea fundamentala a fiintei umane. Utilizand ipoteza ES1 recunoastem ca fiecare persoana trebuie sa-si descopere propriile sale raspunsuri. Anxietatea este parte normala a vietii si durerea determinata de confruntarea cu acceste probleme nu poate fi eliminata. Terapeutul trebuie sa se abtina de la asumarea unui rol de gurusau expert; in locul acestei atitudini, trebuie sa recunoasca faptul ca face parte din aceeasi categorie a pelerinului care s-a confruntat si continua sa se confrunte cu probleme similare. ( Luarea deciziilor care implica libertatea, responsabilitatea,alegerea, curajul si implicarea se adreseaza ipotezei ES2) Ex. DE probleme Fulfillment of Potential People often come to therapy wanting more than relief from symptoms or restora- tion of how they were before the current crisis. There is a yearning for a higher quality of living or the need to wrestle with deep questions and find a new orien- tation to life. These clients want to be responsible adults without sacrificing the vitality and sense of play of childhood. They want challenge and excitement intheir daily lives, instead of stagnation and boredom. Typical goals might include meaning and purpose in their lives; fulfillment of their highest potential; a sense of control over their future paths; becoming more spontaneous and creative; feel- ing more alive, real, and whole; and achieving authentic contact with their inner being as well as with other humans. Mere conformity to societys definition of normal is not enough: Therapists will have an inadequate grasp of their clients needs if they restrict themselves to goals endorsed by health care case managers. Emotional Suffering Suffering cannot be eliminated from life. Although we cannot always control or prevent events that cause suffering, existential theorists believe that we have the freedom to choose how we react to those events. Meaning and Purpose in Life Existential philosophers describe the human condition as the dilemma of meaning- seeking creatures thrown into a universe that has no intrinsic meaning. When we are young, we derive meaning from the rules and examples of our parents, which derived from the customs and traditions of their cultures. Many people live con- tented lives continuing to accept that meaning. However,
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other people experience a crisis of meaning, perhaps following a major loss or when they reach the pinnacle of the road they were told would bring fulfillment. When the meaning systems that people have taken for granted are no longer viable, there are many distressing emotional responses. The existential litera- ture describes the experience of the absurd and the response of nausea to the realization that there is no intrinsic meaning in the external world or the course of our lives. Clients may describe feeling emptinessa void. Authenticity and Honesty Authenticity in human relations is a standard that many people have trou- ble living up to, and therapists who are not capable of it in their own personal relationships will not be able to provide this needed ingredient of the thera- peutic relationship. When you are engaged in an authentic encounter, you would be (a) present in the moment rather than adrift on a mental side trip; (b) genuine and not hiding behind masks; (c) honest and truthful about what you choose to express, reserving the right to decline to reveal what you hold private; (d) open and vulnerable, allowing yourself to be impacted and changed by the other; and (e) willing to take the risk of being spontaneous. Spontaneity does not mean saying whatever comes into your head because you experience the vulnerability of the other person and want to be helpful. A precondition for authenticity with others is that you are vigilant against self-deception and have learned to hold yourself accountable for your own dishonesties. The Question of Suicide When therapists face people who are contemplating suicide, they frequently panic. They focus on assessing risk, taking emergency measures, getting med- ication evaluation, and doing whatever possible to get rid of the suicidal thoughts. Although all of these actions are essential, they are insufficient: The client needs someone to listen calmly and patiently and help her explore the crisis of meaning and the issues that have made life unbearable. When people has terminal illnesses, we consider it reasonable for them to contemplate how sui- cide will allow them to die with dignity and relieve their loved ones of burdens. However, when someone, by our standards, has sufficient reasons to find satis- faction in life, we are apt to label his or her wishes as abnormal, irrational, self- ish, or transient symptoms of depression. Philosophical Discussion When the focus of therapy is the clients search for meaning, the dialogue be- tween therapist and client can take the form of philosophical discussionabout both abstract theory and the clients specific philosophy of life. Sheldon Kopp (1976) challenged clients to examine some of the assumptions about life that they developed in childhood and proposed a set of his own philosophical truths, which include the following: Nothing lasts. There is no way of getting all you want. The world is not necessarily just. You dont really control anything. You cant make anyone love you. Viktor Frankls Logotherapy offers to the client three ways of satisfying the search for meaning: 1. Creating a work or doing a deed (e.g., achievement and accomplishment)

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2. 3.

Experiencing a value such as goodness, truth, beauty, or love Finding meaning in unavoidable suffering ES2 Evitarea libertatii si responsabilitatii - Clientul evita Libertatea si autonomia care vin odata cu intrarea in varsta adulta si/sau nu accepta responsabilitatea pentru pre zent si alegerile trecute; clientul are nevoie de ajutor pentru a face alegeeri bune care sa-l puna in miscare catre obiective pozitive si sa se angajeze. Ei au nevoie sa distinga intre limitarile care sunt reale si cele care sunt autoimpuse. Unii oameni isi neaga responsabilitatea pentruactiunile trecute 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 angajeze in actiuni responsabile, ei pot avea navoie de ajutor in clarificarea valorilor, luarea deciziilor, planificarea si implementarea planurilor. Preconditii pentru exersarea efectiva a libertatii Alternative disponibile Capacitatea de a anticipa consecintele Capacitatea de a amana actiunea Alegerile isi au originea in dorintele noastre reale Organizare si autodisciplina Deprinderi si resurse maturitate Evitarea responsabilitatii Am nevoie de garantii Asa sunt eu (autoetichetare) Nu pot sau nu am putut Nu vreau Trebuie / a trebuit Poti sa faci asta pentru mine Obiceiuri Conformism si obedienta Responsabilitate Identificarea 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 Autoblamarea Conceptul de victima Angajare (clientii conduc problemele catre doua extreme: 1)incapacitatea de a realiza si mentine un angajament - deseori numita iresponsabilitate de catre altii si 2) incapacitatea de a finaliza un angajament mai vechi fundamentat pe o analiza cost-beneficiu actualizata.

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Stages of Autonomous Decision Making The process of autonomous decision making can be conceptualized into these stages: Identify Wants Evaluate Behavior Choose Will Plan Act EvaluateTable 7.2 Applying the ES2 Avoiding Freedom and Responsibility Hypothesis PROBLEM TITLES Struggling with making a choice: Indecision about a job offer Ambivalence over whether to make a marital commitment Dilemma over choice of educational paths Uncertainty over choosing timing of retirement Stuck in an unhappy situation: Victim of spousal abuse Dissatisfaction with boring job Feels incapable of living as an independent adult separate from parents Difficulty setting realistic goals and developing constructive plans for future Frustration with inability to behave in accordance with intentions (lack of selfcontrol): Difficulty adhering to weight loss plan Excessive angry outbursts at children Starts new sexual relationship despite intention to experience a period of celibacy Inability to maintain sobriety Engaging in behavior that brings negative consequences for self or others: Engages in unprotected sex with multiple partners Difficulty maintaining employment At risk for flunking out of college because of poor grades Exercises poor judgment in choice of partners Emotional distress related to guilt, anxiety, or lack of confidence: Anxiety over making major decisions Inability to overcome guilt for past mistake Excessive fear over taking risks and trying new experiences ILLUSTRATIONS OF CLIENTS THINKING AND BEHAVIOR Self-imposed limitations (avoidance of freedom): Client believes that past misfortunes, such as inadequate parenting, permanently limit her possibilities for a happy future. Client is overly conforming and rule-ridden, talking in terms of shoulds and cants and doing exactly what her parents expected, despite being unhappy with some of these choices. Failure to recognize real-world limits: Client describes grandiose fantasies for future projects without any realistic sense of the skills, resources, and self-discipline required to achieve these goals. Client persists in pursuing a career for which he lacks talent. Client copes poorly with the natural changes of aging and pursues surgeries in an attempt to pass for someone 20 years younger. (continued) Table 7.2 (Continued) Avoidance of responsibility: Clients interpretation of painful experiences involves blaming others and taking the role of victim or martyr.
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Client reports guilt and shame over past behavior but does not take any action to make amends or to refrain from similar action in the present and future. Client refuses to accept obligations in life, insisting on doing whatever she wants, regard- less of the consequences. Lack of self-control and self-discipline: Client uses many words that show feelings of passivity and difficulty taking action toward goals: Im trying. Im working on it. Its hopeless. Client states values and moral code, but then claims I cant help it for engaging in morally wrong behavior (e.g., having an affair). Client expects good things to come to him without needing to expend effort. Relinquishing Childhood Illusions Here are examples of childhood illusions that need to be uncovered and challenged: A prince will come along and find me and, without any effort on my part, we will live happily ever after. If I am good and do what I am told, then bad things wont happen to me. I am responsible for my mommys happiness; if she isnt happy, then I have done something wrong. If I show that I am weak and helpless, someone will take care of me. IfIshowthatIamvulnerable,peoplewilltakeadvantageofmeandhurtme. Paradox and Reframing: The Dont Change Position There are certain therapeutic approaches that are called paradoxical because in- stead of pushing for change, they urge the client to accept the status quo and to agree that change is not necessary. The therapist can take one of three paradoxi- cal posions: 1. Where you are is exactly where you want to be; If you wanted things to be different, you would have changed already. 2. There is absolutely nothing wrong with staying exactly as you are now, so convince me why you should try to be any different. 3. Dont try to change, do more of the same. (This tactic was called para- doxical intention by Frankl and is also referred to as prescribing the symptom.) These approaches can lead to one of the following outcomes, all of which are positive: The client wants to prove you wrong and therefore needs to intensify her determination to change. This mobilizes the will to change and stimu- lates action. The client gets permission to stay the same and experiences your accep- tance. You are not like all the other people who tried to change her, so she can relax and stop resisting you. This creates a space where she can experi- ence her deepest feelings about the status quo. If the feelings turn out to be intensely negative, this pain can fuel some steps toward change. The client may discover that the status quo really is what she wants, and all the pressure to change was really coming from external sources, or from the messages she internalized from others. This means that now the client isnt stuck in a bad place, which she feels helpless to leave; instead, she is freely choosing this place. When a client stops trying to decrease a problem behavior, but instead in- creases it, he develops a sense of control over something that seemed out of control.

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ES3 Dimensiune spirituala - Nucleul problemei si/sau resursele de care este nevoie pentru rezolvarea problemei sunt fundamentate pe dimensiunea spirituala a vietii, care poate sau nu sa includ religia; o importanta aplicare a acestei ipoteze este situatia in care clientul se confrunta cu probleme religioase, inclusiv relatia sa cu Dumnezeu.Termenul spiritual se aplica unei mari varietati de experiente, credinte si activitati. Clientii care trebuie sa se adapteze la ideea mortii, cu dileme morale si blocarea creativitatii beneficiaza deseora de focalizarea asupra spiritualitatii. Tehnici preluate din religiile estice ( ex. meditatia,constientizare) si din religiile occidentale ( rugaciunea si citirea Bibliei) pot fi integrate in terapie. Trimiterea la/sau colaborarea cu clerici sau alti practicieni spirituali se poate dovedi adecvata. There are two risks when therapy enters the spiritual domain: (1) The therapist will impose values and steer clients in a direction that is counter to the clients pref- erences, and (2) the therapist will be too timid to probe and challenge, as if the clients spirituality is too fragile to withstand a thorough exploration. Table 7.3 Concepts of Spirituality Connection with the Sacred or Divine Search for the sacred or divine Transcending the self and connecting to a higher power Feelings of harmony and oneness with truth, humanity, or God Feeling uplifted and recharged by connection to a nonhuman source of energy and enlightenment Experiencing ones own inner goodness and value as stemming from a higher power Contacting an Inner Guide Goals to Be a Better Person and Have a More Meaningful Life Development of a personal moral code and the desire to live a virtuous, ethical life Striving to be the best possible human being one can be Seeking personal transformation, wholeness, or integration Seeking to replace negative emotions such as anger, envy, and fear with positive emotions such as love, compassion, and forgiveness The desire to be less selfish and self-oriented and become more altruistic, generous, and engaged in service to others The search for meaning and purpose in life that is higher than ones usual material, superficial concerns On a quest for some higher goal, such as ones true (or higher, deeper) self or a path with heart Psychological Experiences The capacity to enter into heightened states of consciousness that erase the boundary of the self Having a specific mystical experience that cannot adequately be described in words, which involves contact with the divine and intense emotions such as awe, wonder, and bliss Experiencing a sense of creativity and flow, which includes intense concentration, self- forgetfulness, and clarity Experiencing a sense of unity, wholeness, and timelessness Achieving a sense of inner peace and detachment Beliefs Believing in a divine purpose that permeates the universe Believing that there is an alternate reality that is invisible but more real than the reality we experience with our senses

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Believing that overinvestment in ones separate ego is a source of suffering instead of strength Believing in the continuation of spiritual existence after the physical body has died Believing that the spirits of our ancestors make demands on us that we are obligated to obey Believing that ones work is a spiritual vocation to which one was called and chosen Activities and Behaviors Prayer; meditation; communing with nature Reading tarot cards, using crystals for their healing energy, or communicating with spirits who have passed to the other side Engagement in efforts to make the world a better place and stamp out problems such as hunger, social injustice, and racism Singing or playing sacred music Nourishing the soul through activities such as reading, viewing great art, listening to classical music, enjoying aromas, and creating art The Therapist as Moral Consultant Doherty (1996) created a framework of moral consultation, offering a list of eight therapist actions, in order of increasing intensity: 1. Validate the language of moral concern when clients use it spontaneously. 2. Introduce language to make more explicit the moral horizon of the clients concerns. 3. Ask questions about the clients perceptions of the consequences of ac- tions on others, and explore the personal, familial, religious, and cultural sources of these moral sensibilities. 4. Articulatethemoraldilemmawithoutgivingyourposition. 5. Bring research knowledge and clinical insight to bear on the consequences of certain actions, particularly for vulnerable individuals. 6. Describe how you generally see the issue and how you tend to weigh the moral options, emphasizing that every situation is unique and that the client will, of course, make his or her own decision. 7. Say directly how concerned you are about the moral consequences of the clients actions. 8. Clearly state when you cannot support a clients decision or behavior, explaining your decision on moral grounds and, if necessary, withdraw from the case. Modele psihodinamice P1 P2 P3 P4 Parti interne si subpersonalitati Reactualizarea unor Experiente Infantile Primare Sens imatur al sinelui si al conceptiei despre altii Dinamici inconstiente

P1 Parti interne si subpersonalitati - Problema este explicata in termenii unor parti inerne si subpersonalitati care au nevoie sa fie auzite, intelese si coordonate; este natural, nu patologic, sa fii constient de diverse parti interne si subpersonalitati. Problema rezida in lipsa constientizarii si comunicarii intre partile interne, conflictul intre diferite parti, suprimarea unei parti si dominarea de catre o anumita parte.Problemele pot fi rezolvate prin cresterea constientizarii partilorsi a dinamicii lor, incurajarea unor procese interne de grup sanatoase si stabilirea unor obiective specifice pentru fiecare parte specifica.

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Table 8.2

Criteria for Healthy Internal Dynamics

Harmony, Cohesiveness, and Impulse Control All parts, even unpleasant ones, are accepted and owned. They are not attacked, suppressed, or distorted but are allowed to be heard. The dynamics of the internal group are harmonious and free from coercion and abuse. As in a functional family, a hierarchy is maintained and the leadership comes from mature, responsible parts rather than from impulsive, Child parts. When a decision is made and an action agreed on, the inner selves cooperate and function as a cohesive, unified entity, without the presence of secret saboteurs. Child parts who usually want instant pleasure are able to tolerate frustration and delay gratification. Good Morale and Optimism There are internal sources of esteem: Parent parts are supportive, nurturing, and encouraging and when they evaluate and criticize, they are constructive, rational, and fair. Inner parts all feel and believe that the person has a right to happiness, pleasure, and success. There are sources of higher ideals and a sense of purpose. The internal parts can maintain morale in face of frustration and disappointments. Ability to Set Goals and Engage in Goal-Directed Behavior An executive (Adult) part is able to mediate among conflicting parts, create compromises, and assure unified cooperation toward a goal. Goals are based on values (Parent), reality test- ing (Adult), and respect for the rights of the Child to have pleasure, creativity, and a rich emotional life. Summary of Goals The various approaches to working with inner parts and subpersonalities share these goals: Embracing (acceparea) all the selves: Helping the client to achieve awareness of each part, reclaiming disowned parts, and permitting verbal expression from each part without fearing it will take over the personality. Strengthening the awareness and executive parts of the personality: A strong, competent Adult needs to be behind the steering wheel, assuring that no single subpersonality dominates or acts out independently. The executive part examines the messages from different parts, describes and analyzes in- ternal and interpersonal process, and communicates to others to resolve con- flict. The client experiences increased choice, self-control, and autonomy. Modifyingparts:Goalswillincludetoningdownapartthatistoodominant, supporting and strengthening weak parts that need to be heard, updating the rules and methods of powerful Parent parts, creating new parts to serve im- portant functions such as boosting self-esteem and soothing painful affects, and developing a strategy to deal with self-destructive parts. Learningtotoleratevulnerabilityintheselfandinothers:Thisopensupthe opportunity for intimacy and the development of mature ways of taking care of ones need for safety and trusting relationships. Table 8.3 pothesis Problems Explained by P1 Internal Parts and Subpersonalities Hy-

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Difficulty Making a Decision and Selecting a Course of Action Inner conflict: Any problem title that contains words like indecision, ambivalence, confusion, dilemma, which could be expressed as torn between two lovers, or to stay or to break up. Problems of fear and avoidance: A part of the client wants to do something, another part holds back, is afraid, thinks I cant, or feels fear. Indecision, with immobilization and inner torment: As an example, Hamlets famous solilo- quy, to be or not to be, deals with the conflict between a passive part and a part that wants to take arms against a sea of troubles and by opposing end them. Difficulties Sticking to a Chosen Course of Action Internal opposition: Difficulty breaking bad habits: A part of me says I should stop smoking, another part just loves cigarettes. Procrastination: I should do something, but I just cant get myself to start it. Lack of persistence: Its not worth it. Its too much trouble. I didnt want it anyway. Impulsivity: Restraining parts (e.g., voice of reason, reminders about consequences, self- control, or responsibility to others) are either silent or too weak to exert any influence on the impulsive parts. Poor frustration tolerance: An impatient Child part wants exactly what it wants, immediately. There is a lack of a good planner part who knows how to break the task into small bits and reward small accomplishments. Suppression of Feelings and Spontaneity Rigidity: Goals are based entirely on shoulds, obligation, duty, or concern for the reaction of others. The parts that represent passion, play, pleasure, and spontaneity are completely ignored and may act as saboteurs. Blocks to creativity: Overly perfectionistic and critical parts interfere with immersion in creative process; there is suppression of a creative, grandiose part. Problems Related to Depression Suicidal risk: There are parts that want to die versus parts that want to live. It is crucial for therapists to search for, find, and strengthen the parts that want to live. Self-hatred: The hypothesis of anger turned inward can be explored by identifying a self- criticalperhaps selfloathing and self-destructiveinner part. Excessive guilt: There is the presence of a punitive, internal voice, combined with the lack of a part that is nurturing, tolerant, and forgiving. Low self-esteem: An inner part that attacks the self, combined with the lack of inner parts that soothe and offer self-praise. Problems of Stress, Exhaustion, and Overwork Excessive commitments and obligations: Multiple parts make commitments without regard to reasonable limits set by time and health. A pleaser part that cant say no to the demands and requests of others. Lack of relaxation and pleasure: There is a lack of a strong advocate for the inner parts that demand relaxation and pleasure; There is a moralistic, demanding Parent part (cant play until all the work is done) and a worthless part, which only feels good when it is busy and productive and thus comes out when there are no obligations to fulfill. Perfectionism: There is a perfectionist part or a relentless pusher with unrealistic demands and standards. An Adapted Child part feels like a failure unless he gets straight As. Instability in Emotions and Relationships Dramatic alternation of moods: Alternation between grandiose self and weak, empty self, and a lack of inner parts that maintain self-esteem and soothe moods. If the Vulnerable Self
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makes appearances and gets hurt, the powerful parts rush in to protect it. Unstable relationships: The person switches among different roles in relationships, such as Victim, Persecutor, or Rescuer, or shifts from a part that idealizes another to a part that devalues the other person. Table 8.4 Voice Dialogue Instructions

Physically Separate the Subpersonalities Either the therapist or the client can pick a subpersonality to hear from first. An easy method is to have a wheeled chair and let the client choose whether to roll the chair right or left. Talk to the Subpersonality Talk to the subpersonality as you would talk to a real person. Begin the conversation by asking Who are you? or Which part of Alice am I speaking to? Ask open-ended questions and para- phrase back what you hear, being empathic and nonjudgmental: Tell me about yourself. What about that bothers you? Sounds like you get very frustrated when she ignores you. What do you want for yourself ? How do you feel about her? The therapist must not take sides or reject any parts. Your goal is to facilitate the self-expression of the subpersonality, not to try to change it in any way. Coach the Subpersonality to Stay in Character Guide the subpersonality to speak of the whole person as a separate entity. You might paraphrase what the subpersonality says, changing pronouns, You mean she (referring to the position where the client sits during the session) wants to finish the dissertation but you want to quit and just stay home with your children. If it sounds like a separate subpersonality is beginning to speak, you can say, I hear that the part who feels guilty is coming in. We can hear from him later, but now lets stay with what you have to say. Learn about the History of the Subpersonality Often the subpersonality is focused on the current issue. It is important to move from talking to a part in a specific conflict to a subpersonality who has been around for a long time. Ask the subpersonality: When did you first join her personality? Can you think of a time in child- hood when you had a big part to play in her life? Invite the Client to Return to the Center Before ending the conversation with the subpersonality, ask Do you have anything further to say before you return to the center position? Then when the client is back in the original posi- tion, allow her to settle in and return to her normal state of consciousness. Ask for reactions to the subpersonality: What is your reaction to what she said? Consider Hearing from Another Subpersonality If it seems appropriate to hear from a different subpersonality, ask the client to move to a dif- ferent position. Again, the choice of which part to hear from can come from the client or the therapist. Assure Closure to the Exercise The exercise ends with the client back in the center position, given time to reflect on the activity. Never end the activity with the client in a subpersonality. Be sure to allow time for the client to get back to normal consciousness before leaving the session. At the very end of the exercise, if you want, you can ask the client to stand behind you and look at the chair as you summarize the different phases of the activity. This gives the higher, aware self, a chance to process the experience and possibly have new insights.
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Creative Activities Either directly or indirectly, you want to engage the clients Creative Part in the therapeutic work, both during the session and in homework assignments. Writing Use one of these assignments or create your own. Imagine a bus that contains all of your subpersonalities. Watch it come to- ward you down the road, draw up, and stop. Describe these personalities, one by one, as they get off the bus. Give each one a nickname (Snow, 1992). Write a dialogue between two different parts that are involved in a spe- cific conflict. Write a scene in a drama that includes several of your subpersonalities. First, list the cast of characters, describing each one briefly. Art Write a letter from a subpersonality to the whole personality, describing its feelings and needs. Have a specific subpersonality answer a list of questions such as the fol- lowing, taken from Rowan (1990): What do you look like? How old are you? What situations bring you out? What is your approach to the world? What do you want? What do you need? What do you have to offer? Where did you come from? Where did you first meet (name of person)? What would happen if you took over permanently? These activities are useful for exploring emotional aspects of internal dynamics. They also help strengthen creative and nonverbal subpersonalities. Using different colored markers, draw all the different inner personalities that you are aware of now, showing their relationships to each other, and giving them names. Draw bubbles over their heads to show what they think and feel. Havetheclientcreatedrawingsorpaintingsfromseparatesubpersonalities. P2 Reactualizarea unor Experiente Infantile Primare - problema este o reactualizare a unor experiente infantile primare: sentimente si nevoi din prima copilarie sunt reactivate si pattern-uri din familia de origine sunt repetate; experientele din prima copilarie pot avea influente profunde asupra functionarii adulte. Multe 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 suficienta; pacientul are nevoie sa traiasca si sa invete sa tolereze emotii dureroase si sa-si schimbe stlurile autoprotective de relationare. Attachment Theory The attachment of the child to the original caregiver functions as a template for adult intimate relationships (Ainsworth, 1982; Bowlby, 1988; Bretherton, 1992). Children build important belief systems (internal working models) re- garding the reliability of attachment figures, and their own lovability, worthi- ness, and competence. Three types of attachment styles were originally identified, but a fourth one has been added in recent years (Cassidy & Shaver, 1999). 1. Secure: The child develops faith in herself and her attachment figures, and feels free to explore the environment because she can count on the other tobe available for comfort and reassurance. This is the most adaptive style in adulthood.
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2. Anxious-ambivalent insecure (also called anxious-resistant): The attach- ment figure is inconsistent and unreliable, and the child grows up to have low self-esteem, and is often clingy and insecure in adult relationships. 3. Anxious-avoidant insecure: The child was rebuffed, rejected, and ignored, and so develops a cold, distant attitude; in adulthood, a person with this style rejects others and treats relationships as if they do not matter. 4. Disorganized: In contrast to the prior two styles, which have coherent pat- terns and are sometimes effective, this style refers to the lack of a coher- ent template for interacting. Table 8.6 Problems Explained by the P2 Reenactment of Early Childhood Experiences Hypothesis Problems with Authority Figures Authority figures in the clients life are targets for feelings toward parents. The clients responses reflect negative feelings of being dominated, controlled, and disrespected, as well as inappropriate positive expectations to be indulged and rescued. These emotional responses are excessive to the real stimulus: The client will interpret behavior from the boss as outra- geous and intolerable, whereas the therapist will think that it is, at worst, typical insensitivity of someone with poor managerial skills. Some of the problematic reactions are helpless dependence, blind defiance, misperceptions of favoritism, and irrational fears of expressing independent thought. Difficulty Establishing and Maintaining Satisfying Intimate Relationships Perhaps the most common reasons people seek therapy include (a) difficulty finding an appropriate partner; (b) maintenance of frustrating and painful relationships; (c) repetitious patterns (e.g., falling in love with the perfect person and then discarding her; pursuing relationships with unavailable or rejecting people); (d) marital problems (e.g., excessive con- flict, inability to tolerate separateness in their partner, and withdrawing and distancing behaviors). Inappropriate Emotional Reactions When the presenting problem is excessive anxiety or anger, the roots of these reactions often lie in early childhood experiences. For instance, overreactions to separations can reflect an insecure attachment. When the client becomes enraged at the therapists minor lapses in empathy, the client may be reacting as she did when she was a child with a self-absorbed mother. Difficulty Maintaining Equal and Cooperative Peer Relationships The client may relate from either a position of superiority or inferiority, may be unable to quell competitive feelings, could take a role of self-sacrifice and put others needs ahead of her own, have inappropriate expectations of being spoiled and catered to, and experience jeal- ousy and hostility over the achievements of others. Difficulties with Parenting Parenting styles can either replicate or completely reverse what one experienced in childhood. As children reach successive birthdays, new childhood issues are reactivated for parents. Problems in Relationships between Adult Children and Their Parents Problems can include excessive emotional reactivity when relating to parents, difficulties dealing with parents in grandparent role, and continuing to respond to the mother-of-today as if she were the mother-of-childhood. Another problem that is becoming more common as the life span gets longer is the difficulty of coping with aging parents. When adult children are put in caregiver roles for their elderly parents, the roles are reversed from childhood and the child has the

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power while the parent is helpless and dependent. This can provide healing opportunities, as the child sees the parent in a new light, or it could be the recipe for elder abuse. P3 Sens imatur al sinelui si al conceptiei despre altii - Dificultatile rezida in incapacitatea clientului de a progresa dincolo de un simt imatur al sinelui si al conceptiei despre ceilalti care este normal pentru copii foarte tineri; Ceilalti oameni nu sunt apreciati ca indivizi unici cu nevoi, sentimente si perspective distincte ci sunt experientiati ca extensii ale eului si valorizati pentru functiile pe care le indeplinesc. Clientul are nevoie de ceilalti pentru a-i proteja 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 fixa stadiul copilariei primare in care maturarea sanatoasa a fost perturbata. Table 8.8 Examples of Capacities of a Healthy Self

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 neither deficient nor inflated . 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. You can fuel adequate self-esteem, on your own, by giving positive acknowledgment to yourself.

Self-activation, self-assertion, and selfsupport

Maintenance of self-esteem

Soothing of painful affects

You are able, on your own, to devise means to limit, mini- mize, and soothe painful affects. You recognize and acknowledge that the I of one experi- ence is continuous over time and related to the I of another experience.

Continuity of self

Commitment

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

Object Relations

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

Other People Are Real and Separate and Do Not Revolve around You You experience others as free, separate selves with their own feelings and experiences. The other person has his or her own center of initiative, exists without you, is not an extension of you, does not revolve around you and your needs, nor can be controlled by you. You deal with the reality of the other person, not your fantasy of who the other person is. Other People Are Unique and Different from You Others are not just interchangeable, replaceable things who serve functions for the self, but you appreciate them as separate, unique persons with their own needs, feelings, and talents. Another human will never be your perfect clone. Although we may often have similar feelings and opinions, it is impossible to always feel the same or to agree on everything. Because this is understood, disagreements are expected and are not experienced as threats to your sense of self or the relationship. There Are Multiple Valid Perspectives Because you can shift perspectives, you realize that you are not the center of every event and interaction. You can think in terms of multiple perspectives, instead of one absolute truth. You can observe yourself from the perspective of another person and accept negative feed- back without viewing it as an attack on yourself. You can imagine how you appear to others and the impact that your behavior has on them. You Can Tolerate Ambivalent Feelings toward Someone You Love People are not all good or all bad. Only in fantasy is someone perfect, so you know that idealization of another person cant last. When flaws appear, you do not flip into devaluation of the person. You can express anger and receive anger in the relationship without it destroying the bond. You Can Experience Interdependence in Relationships It is normal in times of stress to turn to others to have them serve functions such as shoring up self-esteem and soothing painful emotions. However, the roles can be reversed: You can do the same for another person in need. When you set goals, you can consider the impact on the other person. You can put anothers needs ahead of yours. You Are Capable of Committed Intimate Relationships You are able to sustain trust, develop secure attachments, and tolerate separation, believing in the constancy of another even when that person is not physically present. Because you love a real person, you do not fluctuate between idealization and devaluation, but rather can tolerate periods when needs are not met.

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Childhood

Adulthood Parallels MOST IMMATURE STAGE: SYMBIOTIC MERGER

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