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Compare and contrast the theories

Part I

1. Compare and contrast the theories and basic treatment models of Albert Ellis and Aaron T. Beck. Include a discussion of the structure, theoretical/philosophical positions, therapist activity, demands on the client, and empirical support.

Albert Ellis's basic treatment model is rational emotive behavior therapy (REBT). The theoretical basis of Ellis's model is that individuals routinely cope with life issues by reconstructing their beliefs, affect, and behaviors in adaptation to the problem (Ellis, 2000). While this psychological process seems like a positive way to adapt in regards to an issue, many individuals inevitably construct poor beliefs and behave in a repetitive and maladaptive manner. Meaning, that not only does the problem still exist in one way or another, but that the behavior, or more specifically the schematic agenda, created by this poor cognitive process only adds to a schema that is poorly built. In this regard, the future result of the next problem will be dealt with poorly all over again due to a lack of introspection of the past consequences or possibly simply due to a lack of individual skills.

Additionally, REBT considers that most individuals bring about problems for themselves by creating personal imperatives (Ellis, 2000). These personal imperatives involve internal statements that include: I will perform well to gain others' approval, my life should be trouble-free and enjoyable, and everyone should treat me well (Ellis, 2005). In this manner, when these expectations (demands) are not met, individuals create their own affective misery. In response to this, therapists using REBT are expected to use a more directive manner than when using a psychodynamic approach, for example. Clients are shown how to acknowledge and then dispute within themselves their irrational beliefs. In addition, therapists not only give the clients unconditional acceptance, but the therapist must gives themself Unconditional Self-Acceptance (aka USA) (Ellis, 2005).

Beck's Cognitive therapy rests on the principle of collaborative empiricism (Hollon & Beck, 2000). Cognitive therapy theorizes that clients have automatic thoughts and that these thoughts are incorrect beliefs, therefore, they create maladaptive behaviors (Wenzel, Brown, & Beck, 2009). A cognitive therapist would teach their clients how to think more like a scientist by showing them that their beliefs are not necessarily facts. Meaning, client would collect data from their issues, their behaviors, and their consequences, and pseudo-empirically test their possibly irrational beliefs. Within this process, the hope is that the automatic thoughts will be addressed and corrected.

Though, Beck's Cog­nitive therapy is somewhat different than Ellis's Rational Emotive-Behavior Ther­apy (REBT). While they both have their basis in the processes of cognition and how those thoughts motivate behavior, one could argue that REBT uses the influence of logic reasoning to change the client's schema (Hollon & Beck, 2000). Also, Beck's Cog­nitive therapy differs from REBT because there is an emphasis in the testing of beliefs in-vivo from an empirical point of view. In either type of cognitive-based therapy, there are a large degree of empirical data that supports how effective CBT is. In fact, there are studies that suggest CBT is more effective than medication for depression (McGinn, 2000).

2. The "First Wave" was behavior therapy. The "Second Wave" was Cognitive and cognitive-behavioral therapy. The "Third Wave" includes the works of Hayes and Linehan. Is the "Third Wave" a wave, a tsunami, or just a gentle lapping at the shore? How are these "waves" different?

The first wave, Behavior therapy, is based upon the theories of classical conditioning and operant conditioning developed by B.F. Skinner and Ivan Pavlov. Behavior-based therapy considers the behavior's antecedent and reaction, then viewing how the consequence is processed to influence the occurrence and the repetition of the same behavior (Skinner, 1969). The second wave involves the addition of the cognitive model. This model is based on how interpretations or misinterpretations are created and how they eventually relate to the individual's affective experiences and the behavior that is manifested. (Wenzel, Brown, & Beck, 2009). The combination of behavioral and cognitive aspects in this wave is the use of reinforcers that are directly related to personal experiences. Meaning, that the exposure of thoughts, reinforcers, and behaviors to the client will help in the realization of negative thought patterns in relation to their situation. Thus, in the true essence of CBT, they will be able to scrutinize themselves, the world, and the future. The hope is that the client will work, with the therapist, towards beneficial life changes.

The third wave is its own wave. This wave of Cognitive therapy was developed as a consequence of the restructuring process of the second wave of Cognitive Therapy. As described by Linehan & Dimeff (2001), Dialectic Behavioral Therapy (DBT) was created due to the "failures" of standard Cognitive and/or Behavioral therapy. It is suggested that too much emphasis was put on change the of individual which resulted in an invalidation of the client; an invalidation of the ability of the client to succeed when they have, in their perception, failed so much already. Therefore, a large conceptual part of DBT is skills training of "emotion regulation, interpersonal effectiveness, mindfulness, and distress tolerance" (Linehan & Dimeff, 2001, p. 1). DBT purposefully takes into account not only the change that needs to occur cognitively, but also the in the moment affect of the client.

Concurrently with DBT, Acceptance and Commitment Therapy (ACT) was created by Steven Hayes as a psychological intervention that also uses mindfulness but has a spotlight on personal acceptance (Hayes, 2009). Hayes coins a term called psychological flexibility, in where an individual is able to fully connect to themselves in spite of the changing situations and personal mood. With this flexibility in mind, the third wave CBT and the mindfulness concept differs from traditional second wave CBT due to highly dynamic approach that is expected from the therapist towards the client. Maybe too simply put, 2nd wave CBT focuses highly on cognition while DBT focuses more on behavior and skills (or lack of). Therefore, the central aspect of the new third wave CBT is helping clients review and accept their thoughts in order to alter the maladaptive automatic reactions they have been using to cope. CBT is not just 'how your cognitions effect your behavior', but an attempt to understand the complex interconnection of schemas that produce reactions in all areas of functioning including: affect, physiology, and behavior (Claessens, 2010).

3. From your reading and research what would be the main points of agreement and difference between: 1) CBT, 2) psychodynamic therapy, and 3) family systems therapy.

While psychodynamic therapy and family systems therapy agree that human development is largely determined by significant interpersonal relationships, and that this understanding is crucial to treatment, CBT places greater emphasis on the individual. The main focus of CBT is placed only on the person in therapy, their schemas, automatic thoughts, and cognitive distortions (Freeman & Eig, n.d.). Conversely, psychodynamic theory revolves around feelings and behavior being determined by interactions with others. Transference plays a key role in understanding present patterns of behavior which originated in previous attachment-based relationships (Leichsenring, Hiller, Weissberg, & Leibing, 2006). Psychodynamic psychotherapy aims to identify problematic relationships from the past and to provide the client with a safe, therapeutic relationship, as well as helping them build additional positive relationships. While family systems therapy also works within the context of attachment-based relationships, the focus is on the relational dynamics taking place in the moment. Family and couples therapists work with all affected people, together and separately, in order to address intrapersonal and interpersonal dysfunction (Liddle, 2010).

CBT and psychodynamic therapy both address the client's core beliefs, though how these beliefs were formed is not necessarily crucial to CBT based treatment. Family systems puts the focus on developing positive interactions between family members. Meanwhile, relationships in family systems therapy are already established and occurring in the present (Liddle, 2010). Psychodynamic therapy focuses on harmful relationships of the past and understanding them, but not always focusing on building positive relationships in the future.

While both the CBT and Psychodynamic approach attempt to diminish psychopathological symptoms and grief, a very central difference between CBT and psychodynamic therapy is that psychodynamic therapy attempts to determine at why you feel or behave the way you do. Specifically, psychodynamic therapy concentrates on trying to uncover the deep and often unconscious motivations for feelings and behavior whereas CBT does not necessarily consider this a priority - you can't see what's ahead of you when you're looking over your shoulder (Freeman, 1993, 2011). In practice, CBT attempts to lessen the client's suffering as quickly as possible training their mind to replace maladaptive thought patterns, perceptions, and conduct with helpful ones in order to modify behavior and affect.

Part II

1. How is structure used in CBT? What is the purpose of structuring the sessions? What techniques would be used to achieve the structure for the therapy and for the sessions?

Structure in therapy can have several meanings. Structure could mean the format of the therapy as a whole, whether it would be very brief, short-term, or long-term. Structure could mean the environment of where therapy takes place, such as in a hospital or in a private office. However, the most relevant and crucial meaning of structure within CBT is the structure of the session. 45-50 minutes a week is not a great length of time, so the structure of CBT in practice should be designed to be as efficient as possible. Each session should be a meaningful exchange between therapist and client. The therapist's and client's collaborative goals should always be center stage, but the set agenda needs to take precedence. As Freeman, Pretzer, Fleming, & Simon (1990) notes, spending a few minutes each session is an asset to the therapeutic milieu and is possibly the most valuable technique in creating a environment of progression instead of digression.

A typical structure of a session as described by Freeman, Pretzer, Fleming, & Simon (1990) involves: agenda setting, a review of client's current status, consideration of events of the past week, requesting feedback regarding previous session, review any homework from the previous session, a focus on main agenda issues, develop any new homework, and once again looking for feedback regarding current session (p.17). Taking into consideration how the client and therapist envision the sessions while creating a agenda allows redirection of the client when the discussion goes off the expect path, but also reduces the likelihood that the client will feel pushed around or invalidated (Freeman, Pretzer, Fleming, & Simon, 1990). Additionally, a client who is defensive, aggressive, or always in crisis may make the progression of the weekly session unstable when a joint program is not set (Persons, Davidson, & Tompkins 2001).

Therefore, the collaboration between client and therapist when setting the main agenda is essential. If this teamwork does not occur, in where the therapist decides completely the topic of the session, the client may not effectively grasp the meaningfulness of the session due to a lack of motivation because they do not feel involved. Additionally, a lack of review of the agenda with the client may also put the inexperienced therapist unsure of where to go next in the session (Persons, Davidson, & Tompkins 2001). The termination of a session should not be an unexpected and sudden event for the client. A therapist must bring some sort of closure in relation to goals of the session while allowing sufficient time to address the ending of therapy and any issues the client still has. (Joyce, Piper, Ogrodniczuk, & Klein (2007). Therefore, even with an opportunity for feedback about the previous session toward the beginning of a session, there should be a set time for feedback about the current session at the end of the therapy. In both instances, this time allows for a discussion of problems that may have occurred, such as errors in communication, misunderstandings, or general feedback from the client (Freeman, Pretzer, Fleming, & Simon, 1990).

4. How is Narcissistic Personality Disorder defined, assessed, conceptualized, and treated? How does a therapist deal with this resistant patient?

Narcissistic Personality Disorder is defined by cognitive processes that involve selective attention of the meaning of events and dichotomous thinking (Freeman, n.d.). This dysfunctional internal thought arrangement is due to the postulation that the individual considers themselves as special, or just better than others. However, from a psychodynamic perspective, the definition of the disorder changes a bit. Ledermann (1982), describes the disorder as something of an opposite of an individual who considers themselves as special or has a proclivity to engage in self-worship, "it is the inability to love oneself and hence the inability to love another person...They are fixated on an early defense structure which springs into being in infancy—when, for whatever reasons, there is a catastrophically bad fit between the baby and the mother, frequently compounded by the lack of an adequate father and by other inimical experiences in childhood. Babies, thus deprived, grow into persons who lack trust in other people...They experience their lives as futile and empty, and their feelings as being frozen or split off" (p.303). This psychodynamic perspective is a bit extremist and obviously over-analyzed. To say that the narcissistic individual is unable to love is akin to calling an individual with low self esteem a sociopath. On second thought, it has been noted that a narcissistic individuals is very similar to a sociopath due to a lack of empathy for others and no desire to do what is right (Freeman, Pretzer, Fleming, & Simon, 1990). Regardless, one could argue that the narcissistic individual really does suffer from low esteem. That maybe they are grasping at the straws of the world looking for someone to approve of them. The more likely reality is that on a day by day, second to second process, the narcissistic individual is looking for aspects of their lives and environment that feed or fit into their own schema of how great they are. This could also entail an ignoring of any evidence that goes contrary to their belief structure.

Therefore, the treatment and the goal of therapy for the narcissistic individual is not to necessarily expose the cognitive flaws and the interpersonal manipulations that have occurred. Doing so would go against the foundation of the narcissistic individual's schematic structure and probably prematurely end therapy (Freeman, Pretzer, Fleming, & Simon, 1990). First, a realization of the difficulty that lies ahead must occur for the client and the therapist. There must be a observed equalization of power between the therapeutic alliance because preventing a power struggle is generally the first step that must be taken. Freeman, Pretzer, Fleming, & Simon, (1990) allude to the idea that homework assignments may not be the best approach with these individuals due to the likelihood of noncompliance because of the patient's belief that they are special. Instead the therapist must present the therapy to the client as something of great value to them instead of a type of humiliation (Freeman, n.d.). A resistant patient such as this is not only opposing to feedback or questioning, they see it as a fundamental aggressive criticism that attacks their very existence. Due to their innate response to invalidate a therapist's statement or view, a therapist must be dynamic and hold an "absolute positive regard" towards the individual and appear to appreciate deeply what is stated by the client.

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