Strategic SelfTherapy

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Strategic Self-Therapy

• John O. Beahrs, M.D.
• Professor Emeritus of Psychiatry, Oregon Health
  Science Univ.
• for 10th Ericksonian Congress
• December 6, 2007

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Target Personality Disorders and Posttraumatic
Conditions

• 1. Disordered Experience Behavior
• 2. Repetitive Traumatic Sx Re-Enactment
• (a) behavioral risk to self or others
• (b) perceived as outside of voluntary control
• 3. Confused Personal Identity
• (a) confusion of who is responsible for what
• (b) high risk of in-tx regressive dependency

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Need for Strategic Treatment

• 1. Limited Resources
• (a) few clients can afford long term intensive
  tx
• (b) can be supplemented by self-therapeutic
  activity
• 2. Avoidant Personalities
• (a) shun treatment settings
• (b) welcome utilizing their autonomous
  strengths
• 3. Regressive Clients
• (a) no treatment as recommendation of choice
• (b) alternative replace dependency with self-tx

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Problematic Mis-Presumptions

• 1. Psychological Structure is Relatively Fixed
• 2. Change ? Comprehensive Working-Through
• 3. Tx. Occurs Only in Therapist Consulting Room
• 4. Therapists Indispensable Change Agents
• 5. Clients are Too Impaired for Self-Therapy

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Alternative Presumptions

• 1. Psychol. Structure Context-Dependent
• (a) social causation ? clinically manipulable
• 2. Change ? Focal Points
• 3. Clients Self-Therapy Locus of Control
• (a) interdict problem-maintaining behaviors
• (b) access utilize autonomous strengths
• 4. Therapist Stimulus gtgtgt Change Agent
• (a) the paradox of helping by not helping
• 5. Intrinsic Skills Present, Hidden, Accessable

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Ambivalence Games

• 1. Ambivalence Gain Rapport at Both Levels
• (a) utilization (Erickson, 1959)
• (b) resonance (Watkins, 1976)
• 2. Games e.g., Yes, But (Berne, 1964)
• (a) overt request versus covert opposition
• (b) payoff as traumatic re-enactment
• (c) antithesis deflect back onto client
• 3. Common Theme Helping by Not Helping

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Regressive Clients Likely to Worsen in Therapy

• 1. Incongruity
• (a) dependency needs
• (b) demand for autonomy
• 2. Blurred Interpersonal Boundaries
• (a) project self-responsibility onto therapist
• (b) rebel against resulting perceived threat
• 3. Probable Effect of Psychological Trauma
• (a) traumatic affect ? dependency
• (b) helplessness ? demand for autonomy

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Regressive Factors in Tx

• 1. Failure to Resonate
• (a) therapist on wrong track
• (b) failing to speak clients language
• 2. Covert Reinforcement of Symptomatology
• (a) cathartic therapies ? get rid of
• (b) re-living traumas ? more helplessness
• 3. Attempted Rescue of Regressive Clients
• (a) covertly threatens clients autonomy
• (b) specialness denial of basic being

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Regressive Dependency

• 1. Conflicted Relationship of Client Therapist
• (a) sx ? rescue ? threat of acting out
• 2. Vicious Circle Model
• (a) dependency vs. demand for autonomy
• (b) dependency ? anxiety ? worse sx.
• 3. Antithesis Challenge Clients Hidden
  Strength
• (a) frustrating and likely to be tested
• vehicle for tx. change in regressive clients

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Definition of Strategic Self-Therapy

• 1. Limited Intensity
• (a) real tx. outside consulting room
• (b) orig. monthly 1 prn or SST group
• 2. Rigorous Differentiation of Responsibility
  (a) between clients, therapists, system
• 3. Contextual Reframing Change Vehicle
• (a) esp. redefining personal identity

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Differential Responsibilities

• 1. Client Own Therapist
• (a) goals, pace, plan
• (b) behavioral safety
• 2. Therapist Consultant, (a) 2nd opinion,
• dx/rx, channel attention, reframe, info
• (b) NOT doer-to nor 1o crisis resource
• 3. Independent System Crisis Resource
• separation of treatment and protection

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Engagement Phase I.

• 1. Consensual Diagnosis and Contracting
• (a) dx. per DSM, framed in clients language
• (b) framed as context-dependent, voluntary
• (c) informed consent, client locus of control
• 2. Attitude Optimum Balance
• (a) validation distress perceived nonvolition
• (b) challenge client duties self-evident
• shift from nurturance ? challenge

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Engagement Phase II.

• 3. Parameters of Behavioral Safety
• (a) client guarantee of safety
• precondition for treatment
• (b) separation of treatment protection
• (c) contingencies consequences
• 4. Client Must Earn Therapists Trust

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Engagement Phase III.

• 5. Contracting
• (a) roles, limits of availability, crisis
  resources
• (b) goals, alternatives, informed consent
• 6. Therapeutic Leverage
• (a) what therapist cant, wont, will do
• (b) standing firm vs. symptomatic coercion
• I wont change you ? ? Who Are You???

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The Judgmental Continuum

• 1. Basic Being Reframing
• 2. Feeling States
• 3. Thoughts, Impulses
• 4. Actions, Behaviors Confrontation
• Reframing/Paradox for Unconscious Rapport
• Respect, Confrontation, Face-Saving for Cs

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Criteria for Positive Reframing

• 1. Literally True
• -paradoxical only if unconventional
• 2. Feels Better
• -re-aligns motivational dynamics
• 3. Implies Desirable Change
• -encourage concurrent movement
• -desirable inherently value-driven

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Criteria for Confrontation

• 1. Behavior is Unacceptable
• 2. Persisting or Escalating
• 3. Volition is Close Enough to the Surface
• -reframing often needed
• -policeman at elbow test
• -I trust that you can find some way
• -traditional risk assessment, protectors

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Defining Personal Identity

• 1. Self-Description (character in a novel)
• 2. Value Priorities (manifesto)
• 3. Sense of Direction
• (a) goals
• (b) perceived roadblocks
• (c) plan for overcoming these
• SST Ongoing Revision of Personal Identity
• General ? Specific, Toward Focal Points

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Define Discordant Aspects

• 1. Re-Do from Alternative Perspectives
• (a) missing elements, faulty cognitions
• 2. DIS-Advantages of Therapeutic Change
• (a) responsibility ? shame, guilt
• (b) rejection (relationship issues)
• (c) uncertainty ? vulnerability
• 3. Paradoxes of Personal Identity
• (a) liberation ? optimum constraint
• (c) defining it ? changes it

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Strategic Behavior Control

• 1. Health Maintenance
• (a) medical diet, exercise, social, leisure
• (b) meditative approaches
• 2. Affect Containment
• (a) affect ? identify signal functions
• (b) options (include doing nothing)
• 3. Self-Programming
• (a) planned dreams, self-reparenting
• 4. Identify Interdict Traumatic Re-Enactment

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Cognitive Reframing Projects

• 1. Structured Narratives
• (a) time lines, diaries, journals
• 2. Mapping Relationships
• (a) part-selves, affects, motivations
• 3. Identify Cognitive Errors Omissions
• (a) judgmental factual errors
• (b) volition/nonvolition, words of abuse
• 4. Informational Adjuncts, Presentations

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Relational Patterns

• 1. Boundaries
• (a) define pre-existing transferences
• (b) patterns of projective identification
• (c) identified patient locus of control
• 2. Use of Family and Independent Socialization
• (a) independent narratives
• (b) extra-therapeutic social supports
• (c) identify role confusions re-enactments
• 3. Educational Occupational Advancement
• (a) sheltered workshops, volunteer work

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Coping with Healthy Change

• 1. Dysphoria Support
• (a) unresolved grief
• (b) traumatic affect
• 2. Social Naivete Learn Rules of the Game
• (a) adaptive deception, face-saving
• (b) maintaining ones edge
• (b) politics of everyday living
• 3. Consider Rituals
• (a) integration, differentiation
• (b) specific role transitions

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Assessment Theory in SST

• 1. Hypnosis and Social Influence Research
• (a) paradigm for all waking experience
• (b) consciousness volition are complex
• (c) context dependence
• 2. Consciousness Not Causal (Wegner, 2002)
• (a) serves accountability and face
• 3. Evolutionary Biology
• (a) kin selection ? family values
• (b) reciprocity ? deceit, social emotions
• (c) human mind as shared self-deception?

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Problems Assessing Strategic Tx

• 1. Flexibility to Unique Client
• versus operationalized algorithms
• 2. Multivariate
• (a) utilization of whatevers there
• 3. Diffusion of Care
• (a) participation of multiple parties
• 4. Effectiveness as Practiced in the Field

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Presumptive Data

• 1. Anecdotal ? Possibility In-Principle
• Palo Alto Group rule of thirds
• 2. Masters Johnsons Paradoxical Tx.
• (a) 80 effective in non-organic sexual
  dysfunction
• 3. 3rd Party Leverage
• (a) Al-Anon in EtOH dep, MHCs for families of
  CMI
• 4. Meta-Analysis Paradoxical gt Direct Txs
• (a) at 1-month followup, in more seriously
  disturbed,
• (b) if accompanied by positive reframing

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Strategic Self-Therapy (SST) vs.Exploratory
Psychodyn. Tx (EPT)

• 1. Measures (clinician estimates, 0-4)
• (a) Regressive Dependency (RDL,
  operationalized, r 0.89)
• (b) Regressive Potential (RPRS, composite
  estimates, r 0.80)
• (c) Pt. Self-Therapeutic Activity (STAL,
  composite, r 0.71)
• (d) Therapeutic Progress (TPRS, composite, r
  0.77, 0.82 )

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2. Comparative Effectiveness

• 1. Definitions EPT Differs from SST
• (a) doubly time-intensive
• (b) therapists accept role of change agent
• (c) therapists accept role of crisis resource
• 2. Effectiveness Equal in Both Modalities
• (a) SST was doubly cost efficient
• (b) but suffered 27 dropouts vs. nil in EPT
• 3. Tradeoff Between Efficiency and Adherence

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3. Regressive vs. Tx. Effects

• 1. Regressive Dependency
• Correlated with Regressive Potential
• (a) more in EPT (r 0.74),
• validating the vicious circle model
• (b) less in SST (r 0.45), corroborating
  value of shifting attention to patient autonomy
• 2. Regressive and Therapeutic Effects
• Did not Correlate at all
• (SST 0.02, EPT 0.17),
• (a) regressive tx effects are separable issues

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4. Therapeutic Progress Varies with Clients
Helping Themselves

• 1. TPRS correlated with STAL
• (a) almost linearly
• (b) equally in both modalities
• -Implic Tx Optimally Stimulates Pt Self-Tx
• 2. Relevance of a Pseudocorrelation
• (a) STAL and TPRS share common elements
• (b) STAL gtgt TPRS is experienced as voluntary
• Implic effec. tx reframes TPRS as STAL

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Selected References I.

• Beahrs JO A social brain interpretation of
  psychotherapy. Psychiatric Annals 2005
  35(10)816-822
• Beahrs JO Assessing attributive causation
  therapeutic results
• correlate with self-therapeutic activity.
  Clinical Neuropsychiatry 2006 3(2)154-161
• Beahrs JO, Butler JL, Sturges SG, Drummond DJ,
  Beahrs CH Strategic self-therapy for
  personality disorders. J Strategic Systemic
  Therapies 1992 11(2)33-52
• Berne E Games People Play. New York Grove
  Press, 1964
• Erickson MH Further clinical techniques of
  hypnosis utilization techniques. Am J Clin
  Hypn 1959 23-21
• Fisch R, Weakland J, Segal L The Tactics of
  Change Doing Therapy Briefly. San Francisco,
  CA Jossey-Bass, 1982
• Haley J Uncommon Therapy The Psychiatric
  Techniques of Milton H. Erickson, M.D. New
  York Norton, 1973.

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Selected References II.

• Masters WH, Johnson VE Human Sexual Inadequacy.
  Boston, MA Little, Brown, 1970.
• Shoham-Salomon V, Rosenthal R Paradoxical
  interventions a meta-analysis. J Clin Consult
  Psychol 1987 5522-28
• Wampold BE The Great Psychotherapy Debate
  Models, Methods and Findings. Mahwah NJ
  Lawrence Erlbaum, 2001
• Watkins JG The Therapeutic Self. New York
  Human Sciences Press, 1978
• Watzlawick P, Beavin JH, Jackson DD Pragmatics
  of Human Communication A Study of Interactional
  Patterns, Pathologies, and Paradoxes. New York
  Norton, 1967
• Watzlawick P, Weakland J, Fisch R Change
  Principles of Problem Formation and Problem
  Resolution. New York Norton, 1974
• Wegner DM The Illusion of Conscious Will. MIT
  Press, 2002