Practice in Clinical & Health Psychology
Psychotherapies

 

 

  

What is Psychotherapy?

 

 

 

 

 Psychotherapy is...

  • Therapy dealing with emotional or psychological aspects of a problem.
  • Treatment of behavioral or emotional disorders using psychological methods, such as counselling, instead of physical methods and is designed to produce a response by mental rather than by physical effects.
  • A process in which a patient talks with a psychiatrist, psychologist, social worker or licensed counsellor about a mental health condition. The treatment of mental and emotional disorders using psychological methods, such as counselling.
  • “A treatment by psychological means, of problems of an emotional nature in which a trained person establishes a professional relationship with the patient with the object of (1) removing, modifying, or retarding existing symptoms, (2) mediating disturbed patterns of behavior, and (3) promoting positive personality growth and development.” (Wolber, The Technique of Psychotherapy, 1977).
  • Therapy involving psychological instead of medical treatment of mental disorders. It can include supportive dialogue, counselling, and cognitive behavioral approaches to achieve a thinking-feeling reorganization.
  • Involves regular sessions with a psychotherapist trained to connect with people in emotional need and to help them grow, learn, and heal. Many things may lead you to psychotherapy including feelings of sorrow or unhappiness, stress or sleeplessness, or a conviction that it's time to make changes in your life and you're not sure where to begin.
  • Psychotherapy is a set of techniques intended to cure or improve psychological and behavioural problems in humans. The commonest form of psychotherapy is direct personal contact between therapist and patient, mainly in the form of talking. Because sensitive topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect patient privacy and client confidentiality.

There are many different forms or “schools” of psychotherapy each based in its own theory or “model” of how the mind works and psychological problems develop in people. While most practitioners today use more than one specific form of psychotherapy with their clients, the majority are only trained in a relatively limited number of approaches which are usually related to each other through a common theoretical viewpoint. Dr. Mueller is trained in behavioural, cognitive, and schema-based cognitive psychotherapies asw well as applied psychophysiology and applies a broad number of specific techniques available within each of these psychotherapy schools to the treatment of his clients as may be necessary to obtain effective resolution of each client’s problems. 

 

 COGNITIVE BEHAVIORAL THERAPY

What is Cognitive Behavioral Therapy?

Cognitive Behavioral Therapy (CBT) is currently the most popular type of psychotherapy in Canada and the United States and has largely developed out of the work of Albert Ellis in the latter half of the 1950s and Aaron Beck in the late 1970s and early 1980s. CBT is a merger of cognitive therapy techniques (e.g., Rational Emotive Therapy, Cognitive Restructuring, Cognitive Therapy, etc.) with earlier behavioral experimentation and therapy methods (e.g., instrumental and operant learning techniques, A-B-C research designs, single-case study methods, behavior charting, etc.).

CBT is not just a set of therapy techniques-- it also includes comprehensive theories of human behavior.

CBT proposes a "biopsychosocial" explanation of how people come to feel and act as they do-- that is, that a combination of biological, psychological, and social factors are involved.

The most basic premise in CBT is that almost all human emotions and behaviors are the result of what people think, assume, or believe about themselves, other people, and the world in general. It is what people believe about situations they face-- not the situations themselves-- that primarily determines how they feel and behave. However, CBT also acknowledges that a person's biology also affects their feelings and behaviors and places some limits on how much an individual can change. As well, an individual's social environment and culture will also have significant influence on their feelings and behavior-- most often through setting out what beliefs are socially acceptable.

Within this basic biopsychosocial framework, CBT is the first psychotherapy to concentrate on thought processes and their connection with emotional, behavioral and physiological states. CBT is centered on the notion that cognition (i.e., thinking/thoughts) is a key determining factor in how people feel and behave, and that modifying cognition through the use of various cognitive and behavioral techniques can lead to productive change in dysfunctional emotions and behaviors and improvements in how individuals cope with and manage problems of day-to-day living.

As a mental health therapeutic approach, CBT is deeply rooted in the belief that people are capable of making choices about how they interpret events in their lives and that each of us can choose to change our cognitions and the effects of our thinking on our emotional well-being.

"Men are disturbed not by things,
but by the view which they take of them."
 
...Epictetus, philosopher, AD 50-120

 

"There is nothing good nor bad
but thinking makes it so." 
                ...From Hamlet, Act II, Scene ii, William Shakespeare 

CBT is based on the concept that changing negative thinking patterns and behaviors can have a powerful effect on a person's emotions. CBT helps identify, analyze and change counter-productive thoughts and behaviors, which helps to alleviate feelings of depression and anxiety.

How is Cognitive Behavioral Therapy different
from other therapies?

Years of clinical research and experience have shown that Cognitive Behavioral Therapy (CBT) is an extremely effective form of therapy. It relies on simple yet powerful interventions, not "trendy," unproven techniques. CBT is based on logic and the scientific method, as well as a belief in the power of the individual to make choices; to "take charge" and change negative thoughts, feelings,and actions. It is strongly structured and action-oriented and usually of relatively short duration.

CBT has been demonstrated to be effective on its own or alongside other therapeutic interventions such as biofeedback or medications.

"We are what we think.
All that we are arises with our thoughts.
With our thoughts we make the world."
  
 ...the Budda

How does one develop a psychological disorder?

Early in life we develop cognitive "mindsets" or schemas which determine our patterns of behavior. These cognitions become habitual and automatic and often consist of underlying "rules" about how we, the world, and life should be. These cognitive schemas often include dysfunctional, irrational beliefs-- often outside our conscious awareness-- that cause us to think and behave in negative or self-defeating ways. Negative thinking and behavior can lead to serious psychological problems such as clinical depression and anxiety disorders. It is important to remember that negative feelings such as deep sadness, fear and inappropriate guilt are actually created by dysfunctional thinking and behavior.

"Happiness cannot come from without.
It must come from within.
It is not what we see and touch, but that
which we think and do."  
...Helen Keller, 1880-1968.

How does Cognitive-Behavioral Therapy work?

Extensive scientific research has shown that changing the way a person thinks and behaves can have a profound effect on their emotional state. CBT utilizes a very directive, action-oriented approach which teaches a person to explore, identify and analyze dysfunctional patterns of thinking and acting. Once these counterproductive patterns are identified, the therapist instructs the patient in how to effectively challenge and restructure his or her beliefs, assumptions, thoughts, and  behavior. Behavior becomes based on rational, reality-based and life enhancing thinking. Negative emotional states such as depression and anxiety are soon alleviated. Self-defeating behavior patterns are identified and eliminated. The therapist provides the patient with coaching in the skills and techniques needed to successfully address problems; which can then be practiced independently, reducing the need for ongoing treatment which may be lengthy  and expensive.

A recent study at the Rotman Research Institute at Baycrest Centre in Toronto used fMRI brain imaging technology to compare ex-depressed patients who had responded to CBT to those who responded to antidepressant medications. The study authors concluded that patients who recover from depression with CBT show changes in brain functioning (increased activation) in the frontal cortex— areas associated with thinking— whereas, those who recovered with drugs showed changes (decreased activity) in the deeper brain structures associated with basic emotions.

Who can be helped by Cognitive-Behavioral Therapy?

CBT is based on a collaborative relationship between doctor and patient. It is most effective with highly motivated people who are determined to help themselves feel better. CBT has helped many people who are suffering from depression, anxiety, obsessive compulsive disorder, and other disorders, such as chronic pain.

CBT has also been shown to be an effective adjunct to medically-supervised weight-loss programs.

How well does CBT work?           

Numerous research studies over the last 40 years have concluded that CBT alone is at least as effective in the treatment of depression as medications— generally about 60% effective.

A 2005 meta-analysis of the literature on treatment outcomes of CBT for a wide range of psychiatric disorders by Andrew Butler and colleagues  found large effect sizes for CBT treatment of unipolar depression, generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders. Effect sizes for CBT of marital distress, anger problems, childhood somatic disorders and chronic pain were in the moderate range.

When combined with medications, CBT reduces the drop-out rate and reduces the likelihood of a return of depression after treatment ends.

But CBT requires a well-trained therapist, more commitment and time on the part of the patient, and is more expensive than medications.

A recent large scale treatment study at Brown University, Rhode Island, studied 681 patients diagnosed with chronic depression. A third of the patients were randomly assigned to receive an antidepressant drug— nefazodone (Serzone)— twice daily. Another third, received an hour-long session of CBT each week, and the final third received both treatments.

Among the patients who completed the 12 weeks of treatment, 85% of the combined treatment group obtained a significant reduction in their depression symptoms, compared with 52% in the CBT only group and 55% in the medications only group.

 

To see a brief YouTube video on cognitive-behavioral therapy, GOTO: http://www.youtube.com/watch?v=c7jTzbJm7iY&feature=related   

 

Schema-Focused Cognitive Therapy
A Treatment for Life-Long Patterns
Schema-Focused Cognitive Therapy is a therapy approach developed by Dr. Jeffrey Young, who originally worked closely with Dr. Aaron Beck, the founder of Cognitive Therapy. While treating clients at the Center for Cognitive Therapy at the University of Pennsylvania, Dr. Young and his colleagues found a segment of people who had difficulty in benefiting from the standard Cognitive-Behavioral approach. He discovered that these people typically had long-standing patterns or themes in thinking and feeling— and consequently in behaving or coping— that required a different means of intervention. Dr. Young’s attention turned to ways of helping patients to address and modify these core themes or deeper patterns that patients keep repeating throughout their lives, also known as “schemas” or “lifetraps.”
This cognitive-development model is based on the assumption that many negative cognitions have their roots in past experiences.
Schema-Focused Cognitive Therapy proposes an integrative systematic model of treatment for a wide spectrum of chronic, difficult and characterological problems. Dr. Young developed the schema-focused approach to deliberately address lifelong, self-defeating patterns that typically begin early in life, called early maladaptive schemas (EMS). Through clinical observation over more than 17 years, Dr. Young and his associates have identified 18 early maladaptive schemas that correspond to specific emotional needs and are common sources of problems seen in therapy.
The basic premise of Dr. Young's approach is that individuals with more complex problems have one or more early maladaptive schemas that must be identified and targeted in treatment.
Early maladaptive schemas are defined as 'broad pervasive themes or patterns regarding oneself and one's relationship with others, developed during childhood and early adolescence and elaborated throughout one's lifetime, that are dysfunctional to a significant degree'. These patterns consist of negative or dysfunctional thoughts and feelings that have been repeated and elaborated upon, and pose obstacles for accomplishing one’s goals and getting one’s emotional needs met. Some examples of schema beliefs are: “I’m unlovable,” “I’m a failure,” “People don’t care about me,” “I’m not important,” “Something bad is going to happen,” “People will leave me,” “I will never get my needs met,” “I will never be good enough,” and so on. Early maladaptive schema lead to unhealthy life patterns.
Although schemas are usually developed early in life (during childhood or adolescence), they can also form later, in adulthood. These schemas are perpetuated behaviorally through the coping styles of schema maintenance, schema avoidance, and schema compensation. In some cases, the person will surrender to their emotionally painful schemas; some find ways to block out or escape from their pain; while others fight back or overcompensate. The Schema-Focused model of treatment is designed to help the person to break these negative patterns of thinking, feeling and behaving, which are often very tenacious, and to develop healthier alternatives to replace them and get their emotional needs met.
The Schema-Focused approach combines the best aspects of cognitive-behavioral, experiential, interpersonal and psychoanalytic therapies into one unified model of treatment. Schema-Focused Therapy has shown remarkable results in helping people to change patterns which they have lived with for a long time, even when other methods and efforts they have tried before have been unsuccessful.
What type of early childhood experiences lead to the acquisition of maladaptive schemas?
  • The child who does not get his or her core needs met-- e.g., needs for nurturance, protection, affection, empathy, and guidance, etc.
  • The child who is traumatized or victimized by a very domineering, abusive, or critical parent or peers.
  • The child who learns primarily by internalizing the parent's voice. Every child internalizes or identifies with both parents and absorbs certain characteristics of both parents, so when the child internalizes the punitive punishing voice of the parent and absorbs these characteristics they become schemas.
  • The child who receives too much of a good thing. The child is overprotected, overindulged, or given an excessive degree of freedom and autonomy without limits being set. 
Therefore early maladaptive schemas begin with something that was done to us by our families or by other children, which damaged us in some way. We might have been abandoned, ignored or deprived, overly criticized, overprotected or entitled, emotionally or physically abused or bullied, socially excluded or emotionally deprived and, consequently, the schema becomes part of us. Schema are essentially valid representations of early childhood and adolescence experiences, and serve as templates for processing and defining later behaviors, thoughts, feelings, and relationships with others. Early maladaptive schema include entrenched patterns of distorted thinking, disruptive emotions and dysfunctional behaviors. These schemas become fixed when they are reinforced and/or modeled by parents and important others in our early years.
Common Maladaptive Schema
Some of the more common schemas that have been identified by Dr. Young and his colleagues are…
Emotional Deprivation:
The belief and expectation that your primary needs will never be met. The sense that no one will nurture, care for, guide, protect or empathize with you.
Abandonment:
The belief and expectation that others will leave, that others are unreliable, that relationships are fragile, that loss is inevitable, and that you will ultimately wind up alone.
Mistrust/Abuse:
The belief that others are abusive, manipulative, selfish, or looking to hurt or use you. Others are not to be trusted.
Defectiveness:
The belief that you are flawed, damaged or unlovable, and you will thereby be rejected.
Social Isolation:
The pervasive sense of aloneness, coupled with a feeling of alienation.
Vulnerability:
The sense that the world is a dangerous place, that disaster can happen at any time, and that you will be overwhelmed by the challenges that lie ahead.
Dependence/Incompetence:
The belief that you are unable to effectively make your own decisions, that your judgment is questionable, and that you need to rely on others to help get you through day-to-day responsibilities.
Enmeshment/Undeveloped Self:
The sense that you do not have an identity or “individuated self” that is separate from one or more significant others.
Failure:
The expectation that you will fail, or belief that you cannot perform well enough.
Subjugation:
The belief that you must submit to the control of others, or else punishment or rejection will be forthcoming.
Self-Sacrifice:
The belief that you should voluntarily give up of your own needs for the sake of others, usually to a point which is excessive.
Approval-Seeking/Recognition-Seeking:
The sense that approval, attention and recognition are far more important than genuine self-expression and being true to oneself.
Emotional Inhibition:
The belief that you must control your self-expression or others will reject or criticize you.
Negativity/Pessimism:
The pervasive belief that the negative aspects of life outweigh the positive, along with negative expectations for the future.
Unrelenting Standards:
The belief that you need to be the best, always striving for perfection or to avoid mistakes.
Punitiveness:
The belief that people should be harshly punished for their mistakes or shortcomings.
Entitlement/Grandiosity:
The sense that you are special or more important than others, and that you do not have to follow the rules like other people even though it may have a negative effect on others. Also can manifest in an exaggerated focus on superiority for the purpose of having power or control.
Insufficient Self-Control/Self-Discipline:
The sense that you cannot accomplish your goals, especially if the process contains boring, repetitive, or frustrating aspects. Also, that you cannot resist acting upon impulses that lead to detrimental results.
Common Identified Schema Modes
Long after we leave the home and environment we grew up in, we continue to create situations in which we are mistreated, ignored, put down, or controlled and in which we fail to reach our desired goals.
Schemas are perpetuated throughout our lifetime and become activated under conditions relevant to that particular schema. Our maladaptive schema modes of coping are triggered by life situations that we are overly sensitive to (our "emotional buttons") and may lead us to over or under react to situations and end up acting in ways that may be self-defeating-- hurting ourselves or others. 
Some of the common Schema Modes identified by Dr. Young and his colleagues are...
Angry Child. This mode is primarily fueled by feelings of victimization or bitterness, leading towards negativity, pessimism, jealousy, rage, etc. While experiencing this schema mode, person may feel urges to yell, scream, throw/break things, or possibly injure themselves or others. The "angry child" is enraged, anxious, frustrated, self-doubting, feels unsupported in ideas, and vulnerable.
Impulsive Child. This is the mode where anything goes. If a person is having an "identity crisis" or moments of depersonalization this mode might come into play. Behaviors of the "impulsive child" may include: reckless driving, substance abuse, cutting oneself with lack of suicidal thoughts and intent, gambling, fits of rage or tantrums, unsafe sex, rash decisions, etc. The "impulsive child" is the rebellious and careless schema mode and can lead to conscious suicidal thoughts if not stopped.
Detached Protector. This schema mode is based in escape. Individuals in "detached protector" withdraw, dissociate, alienate, or hide in some way. This mode may be triggered by numerous stress factors or feelings of being overwhelmed. The lack of coping skills when a person is in a life situation involving high-demand or a chain of thoughts/emotions revolving obsessively often can trigger "detached protector". Stated simply, the person becomes numb in order to protect him/herself from the harm or stress of that which they fear is yet to come or fear of the unknown in general. Feelings of mistrust often trigger such fears.
Abandoned Child. The "abandoned child" is a schema mode in which the person may feel defective in some way, thrown aside, unloved, obviously alone, or may be in a "me against the world" mindset. Feeling as though peers, friends, family, and even the entire world have abandoned you are the things which live within this schema mode. Behaviors of individuals stuck in "abandoned child" include, but are not limited to: falling into major depression, pessimism, feeling unwanted, inferiority complexes arising, feeling unworthy of love, and personality traits perceived as unchangeable flaws are the ways of the "abandoned child". In this mode suicidal ideation, hypersensitivity to criticism, stubborness, avoidance behavior, and the "why bother?" attitude all make up the "abandoned child".
Punitive Parent. The "punitive parent" schema mode is characterized by a belief that you should be harshly punished perhaps due to a feeling of being somehow defective or a failure, or after making a mistake. When the "punitive parent" takes over the psyche, the individual may feel that they deserve to be punished for even existing. Sadness, anger, impatience, and judgmental natures come out in "punitive parent" mode and are directed to the self and onto others. The person in "punitive parent" mode has great difficulty in forgiving him/herself. Thinking is often very "black and white".
Healthy Adult. The "healthy adult" schema mode is what Schema Therapy strives to help patients achieve. The "healthy adult" is good with decision-making and problem-solving, rational, flexible, nurturing, comforting, appropriately assertive, ambitious, sets limits and boundaries, aware of their self-worth, enjoys/partakes in healthy adult activities, takes care of his/her physical and mental health. The "healthy adult" forgives the past, is able to life in the moment and remain focused on the present day, views the future with hope and strives towards the best tomorrow possible, does not view the self as a helpless victim but rather as a survivor, and views difficulties in terms of challenge.    
 
Is Schema-Focused Cognitive Therapy right for you?
The basic philosophy of Schema-Focused Therapy is that if basic safety, care, guidance, and affection are not met in childhood, we develop maladaptive schemas that trigger powerful emotions and specific coping modes that will in later life lead to unhealthy/unstable relationships, poor social skills, unhealthy lifestyle choices, self-destructiveness, and generally poor functionality. As adults, these maladaptive schemas and their associated strong emotions may be triggered by various life events (e.g., beginning or ending a relationship, loss of a job, failure to achieve a personal goal, etc.) and result in our repeating our maladaptive coping pattern. Schema-focused therapy deals with life-long patterns rather than current situations, which have arisen. Because schemas are dimensional it is not whether you have it or don't have it that's relevant but how much you have it. In other words, how intense is the schema when it is activated and how pervasive and broadly does it affect your life.
Some of the problems or signs that could indicate that you have an early maladaptive schema influencing your life include...
  • being stuck in some area of your life which you don't seem to be able to change,
  • feelings of inadequacy, loneliness, chronic anxiety, or relapsing depression,
  • over-dependency on others,
  • problems choosing appropriate partners in life--e.g., getting into relationships where you always feel criticized, deprived or ignored, controlled, always fighting and feeling angry, etc. 
  • being out of touch with your feelings.
Presenting problems which are chronic or long-term such as eating disorders, substance abuse, relapsing depression or general anxiety, rigid and inflexible thinking and behavior patterns, and repeating relationship problems.
Cognitive therapy is often combined with schema therapy and focuses on exactly what many other forms of psychotherapy tend to leave out-- i.e., how to achieve beneficial change, as opposed to mere explanation or "insight". Because understanding the past is rarely curative without change, both traditional cognitive therapy and schema-focused cognitive therapy are structured and systematic, helping patients to identify, challenge and change core cognitive schemas.
The main goals of schema-focused therapy are...
  • Identifying early maladaptive schemas that are maintaining the presenting problem behaviors and seeing how these schemas are played out in everyday situations.
  • Changing dysfunctional beliefs and building alternative beliefs, which can be used to fight the schemas.
  • Breaking down maladaptive life patterns into manageable steps and changing the coping styles, which maintain the schemas, one step at a time.
  • Providing patients with the skills and experiences that will create adaptive thinking and healthy emotions.
  • Empowering patients and validating their emotional needs that were not met, so that their needs will be met in everyday life.
Reference: "A Client's Guide to Schema-Focused Cognitive Therapy" by David C. Bricker, Ph.D. and Jeffrey E. Young, Ph.D., Cognitive Therapy Center of New York. 1993.
 
Where can I get Cognitive-Behavioral and
Schema-Based Therapy?
Dr. Horst Mueller, a registered psychologist with a private practice in Edmonton, is trained in a number of cognitive and behavioral approaches to psychotherapy and has years of experience treating individuals with depression and anxiety disorders using CBT interventions, often combined with applied psychophysiological therapies such as biofeedback or neurofeedback. He is also well-versed in the application of schema-based cognitive therapy in the treatment of more long-standing personal and interpersonal problems.
CBT can be an especially effective form of therapy for persons suffering from depression, anxiety disorders, and chronic pain. The addition of certain biofeedback and/or neurofeedback therapies can greatly enhance CBT's efficacy in these disorders.