May 27, 2015Demetrios Peratsakis, LPC

AGENDA

I. Introductory Comments: The Role of the Therapist,

Contracting and the Presenting Problem

II. How To’s of ordering Directives and Tasks

III. Demonstration (the importance of watching others work)

a) Empty Chair

b) Guided Imagery

c) Early Recollections (time permitting)

1. Autonomy is an IllusionMan is a social being. His problems ---and therefore the solutions to them, are entirely relational.

Look to how others, real or imagined, living or dead, participate in sustaining the problem (s)

2. Behavior is Purposive We behave in such a way as to elicit a particular response in others. That response reaffirms our beliefs about who we are and how we need to behave in order to belong with others .

Look to re-invent the Self through how one thinks about the world and themselves in relation to others (Personhood); reconcile cut-offs; increase social skill competencies and meaningful belonging

3. Symptoms are Remedies that have become Problems Strategies and solutions for adapting to change determine the development or absence of symptoms. Problems

organize behavior and interaction, giving them functional value and power. Look to change the symptom to change the structure to change the system; and vice versa

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Lesson # 1

A good therapist is an Anthropologist, one who studies humankind and the culture within which

individual behavior must be understood

“Man is the only creature who refuses to be what he is”  - Albert Camus

Lesson # 2 A good therapist is willing to immerse themselves in the despair of another person’s suffering, to be one with them in the desolation of their fear, their shame, or their rage .

The great obstacle to this intimacy, is one’s own terror of being swallowed up or blown away.

A therapist must be willing to give up control, in order to acquire power.

Lesson # 3 A good therapist learns how to “See”, not simply to look

“Seeing” is the insight that occurs when one transcends their own belief about a symptom or behavior and apprehends the “purpose” that it serves,

how it reaffirms identity, mediates distress, and controls and organizes behavior

Suicide can be an act of revenge, Depression a means of enslaving others, Anorexia a form of self-sacrifice

Vignette:

As the father’s drinking worsened, he became more combative and abusive while mom grew progressively more listless and depressed.

When the maternal grandmother mother passed, mom became even more depressed and their only child, a 17 ½ year old daughter, began having serious problems in school and displaying risk-taking and self-harm behaviors. This year, she received a DWI and after a final break up with her boyfriend her behavior became more problematic, resulting in frequent hospitalizations and suicide attempts. The parents have rallied to support her, growing more concerned after suspecting her of vomiting after meals in order to keep her weight down. After a recent hospitalization from a failed attempt to over-dose the father took a more active role and become more involved in his daughter’s treatment, even speaking of attending AA.

The hospital diagnosed her with a borderline personality disorder and placed her on medication. Upon discharge, she was brought into treatment by the parents.

Question:

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Lesson # 4 A good therapist takes charge and directs change

1. Therapy is the practice of new ways of thinking and behaving.

2. The therapist is responsible for the outcome of treatment, including if it fails and insight and change do not occur.

3. Change is forced (and fostered) through a continuous string of highly deliberate tasks and directives.

Purpose: To force and foster changeTasks (rituals/scenarios) and Directives (instructions) provide practice in new ways of thinking, feeling and behaving

Mechanics:

1. Define and Assign Task: Scripting and Prescribinga. Assume authority (power) to direct new experienceb. Session as a “safe haven” for changec. Directives are simple commands: keep them behavioral; ie “Talk to her”; “Get up and go sit next to him”; “Get them to behave”d. Tasks are complex commands:

To assign, pretend that you are a Director (therapist) on a movie set: introduce the scene (task) and instruct (directive) the actor’s (client’s) behavior while filming the scene (allowing work to be done):

Simple introductions, include: “Let’s try something”; “Let’s do an experiment”; “Some people find this helpful”; “I’m going to have you try something that may be uncomfortable”; “What if, we do this…”.

e. “Homework” is failure prone: make it highly scripted; make behavior independent of others; predict difficulty or failure

2. Staying on Taska. Once a task has been assigned the therapist's job is to continually redirect any straying or delay back to the task, while working on their own

anxiety, impatience and need to rescue. b. Push-back is to be expected, but not accepted. Two forms of challenge:

- Fear Anxiety or Angst: comfort the fear and encourage them back to task (“This is very hard”; “Let’s slow down and try again”) Morbid Dread: push; if task cannot be completed, focus on the fear: “What is the worse that would happen?”; “What’s happening now?”

- Power-play Aimed at the therapist. Dis-arm, dis-engage and redirect the power-play. Address resentment and anger

3. Button-up and ReviewSimple endings, include: “Was that worse than you thought it would be?”; “How bad was that; what should we do different next time?” “Let’s stop, that’s enough hard work for now”; “I pushed you pretty hard, how pissed-off are you with me?”

Demetrios Peratsakis, LPC8

1. Create a new symptom.

2. Move to a more manageable symptom; ie “chores” versus “attitude”

3. I.P. another family member. (create a new symptom-bearer)

4. I.P. a relationship

5. Reframe or re-label the meaning of the symptom (ie. “It seems that her “school phobia” helps her stay home with mom; should we be worried about mom also?

6. Change the intensity of the symptom/pattern. (Inflate/Deflate)

7. Change the frequency or rate of the symptom/pattern

8. Change the duration of the symptom/pattern

9. Change the time (hour/time of day/week/month/year) of the symptom or pattern.

10. Change the location (in the world or body) of the symptom/pattern

11. Change some quality of the symptom or pattern (ie. use of imagery to impact elements)

12. Perform the symptom without the pattern; short-circuiting.

13. Perform the pattern without the symptom.

14. Change the sequence of the elements in the pattern

15. Interrupt or otherwise prevent the pattern from occurring.

16. Add (at least) one new element to the pattern.

17. Break up any previously whole element into smaller elements

18. Link the symptoms or pattern to another pattern or goal

19. Point to disparities

Demetrios Peratsakis, LPC9

Empty Chair Techniques

 

Use of Chairs: 6 sample Tasks

Chairs are relatively convenient and available props that can be used to illustrate relational issues and dynamics or to heighten and lower tension and confrontation among members within a session.

As such, they make the covert, overt, and allow new forms of alignment and communication to be practiced:

1. “Open Forum”: Set two seats side by side, or facing each other, in the middle of the room and ask “Who wants to work?”

2. Decision Making: Set two chairs facing each, several feet apart; define each chair as representing the opposing or counter-point-of-view in a dilemma.

3. Confronting: Set two chairs back-to-back (not touching). Angry/Volatile clients are encouraged to begin a dialogue.

4. Co-therapist: Set two chairs, side by side, with a third several feet away from both. Have client sit adjacent to you and ask their aide in helping the “client”. ie.

“Chris, tell me what “Chrissy” needs to do to become the new-Chris, “Christina”?

5. Greek Chorus: Set empty chair off to the side of the therapist. Use the “Ghost” therapist as a contrarian “Greek Chorus” meta-message of refusal to change.

Demetrios Peratsakis, LPC11

6. “Ghost”: Advanced technique requiring a relaxation directive

6. A. Make an estranged or cut-off member “visible”Ghosts are family legacies, myths, and legends as well as dead and estranged members whose persona have presence and meaning to the individual or group. They may be “good” ghosts or “bad” ghosts, and may be as simple as a family or personal rule or value or a more complex, over-riding philosophy or vantage point on how to behave, interact and even think.

“Good” ghosts can provide support and nurturance; “bad” ghosts can be inexorable in their demands and ruthless in their punishments.

• “Ghosts” often ‘haunt’ due to guilt, shame, retribution or vengeance. Anger and rage can be elixirs.

• Make covert issues and rules, overt: (ie. “Temper” = adversary that one can battle)

• Work through what makes the ghost more/less restless…what issue needs to be put to rest?

• Write a letter, epitaph or will to the Ghost, emphasize disparities and similarities; develop a new legend or myth; make a “voodoo-doll”; create a ritual for taming the ghost

• Reconnect to estranged partners and members

• Hold a séance or conduct an exorcism

• Prescribe the phantom

6. B. Make a volatile emotion such as Rage or Shame “controllable”This is an excellent technique for acquiring greater mastery of something heretofore experienced as not under one’s control, such as

emotional (ie. rage, sadness) or physical pain.

Picture the “feeling” that you’re having What color is it? What is its shape? It’s size? What texture does it have? What’s its temperature? Can you change its shape….it’s color….it’s temperature…..it’s texture…. Now, make it larger/smaller; hotter/cooler; more

rough/smoother; less red/more red; taller/shorter. For homework, sit and relax and practice changing the one thing we have agreed to (always move to less toxic)

Demetrios Peratsakis, LPC12

How I view the World?

How I view Myself?

How I view the Others?

How I view Men?

How I view Women?

How I view Sex?

How I view Marriage

Simplified Alternative: “I am ______________. Others are ______________. The world is

______________. Therefore, in order to have a place to belong, I must _______________________.

1. Stay comfortable and relaxed….

2. Now think back to a very, very long time ago, a time when you were little, and try to recall the earliest thing that you can recall; the very first thing that you can remember. You may have been a baby or a young child…..the earliest thing that you can remember, the earliest memory that you can recall.

As you are picturing that memory look to see where you are and what you are doing. If there are others there, look to see what they are doing. Picture that memory and recall the feeling that it has, the tone and feeling of that memory.

Hold that memory, remain comfortable and relaxed and when you feel ready to return you may open your eyes.

3. Write your memory down. That memory is like a story. Write down the title that it has. Write down the tone of the memory and the age that you were.

4. Review Is he/she an observer or participant? Is he/she giving or taking? Does he/she go forth or withdraw? What is his/her physical posture or position in relation to what is around him? Is he/she alone or with others? Is his/her concern with people, things, or ideas? What relationship does he/she place him/herself into with others? Inferior? Superior? What emotion does he/she use? What feeling tone is attached to the event or outcome? Are detail and color mentioned? Do stereotypes of authorities, subordinates, men, women, old, young, etc. reveal themselves? Look for interaction with others, what they are doing with each other and with the viewer.

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The New “Selfie”