Analytical Psychotherapy, Person-Centered Therapy: How an individual progresses through the four stages of Analytic therapy.  
	Confession covers the client provided history of his/her personal life, feelings, and conscious and unconscious secrets.  This is the first stage of Analytic therapy and includes the client’s initial descriptions of his/her personal life, the presenting problem, and discussions of underlying problems, secrets, concerns, or other issues, either conscious or unconscious.  This intense sharing allows the client to benefit from confessing to hidden feelings, relieving the client from feelings of guilt or feelings of being the only person to have ever felt this way.  Transference occurs during this time. The client projects his/her own feelings onto the therapist.  A client may have strong feelings of anger and resentment toward his father. In therapy the client may view the therapist as being angry toward the client.
	Elucidation is a clarification of what has happened during the therapeutic relationship, specifically describing the transference that has occurred and its likely origins in infancy. This is stage describes the therapist’s assistance in helping the client see and understand the source of the transference and bringing a level of insight to the client of his/her personal short comings. The client is encouraged to accept him/herself along with these shortcomings.  The client mentioned above, may be told in therapy that his/her anger is due to his/her anger that was directed toward an absent father who left the family when the client was an infant.  The anger was intensified by the client’s mother’s overtly angry descriptions of the father and any other father figure in the client’s life. The client might be told that this anger affects others who experience similar childhood events and that the client is not tied to this anger forever.
	Education describes the activities with the client that helps him/her become more adaptive socially. This stage covers the conscious aspects of the personality that the client can use to develop a healthier lifestyle. A plan may be developed with the client that could assist the client in achieving a more responsible life.  The client’s anger is discussed and a schema for resolving the anger is developed with the client that will help the client deal more effectively with future male figures.
	Transformation describes the desire in some clients to continue on in therapy toward greater self-actualization. Not all clients enter this stage. It is often prevalent in adults during mid-life who are searching for greater meaning to their lives.  The client has progressed through the three previous stages, but is now interested in exploring additional development toward a life that is more whole or complete.  The client expresses interest in developing other aspects of his/her life.

The Client-Centered therapist must make sure three facilitative conditions are met in his/her relationship with the client (also called the Therapeutic Triad).  The three therapist-offered facilitative conditions are congruence, empathy, and unconditional positive regard.  Carl Rogers believes that these three conditions are necessary in the establishment of a therapeutic relationship. Without them change is less likely to occur. 
	Congruence refers to the genuineness between the thoughts and behaviors of the therapist. The therapist reflects his/her real and true self to the client during therapy, not a professional image that is not in keeping with the true feelings or thoughts of the therapist. 
	Empathy describes a profound interest in the feelings and meanings of the client and the client’s statements.  It is a sharing of feeling with the client.
	Unconditional positive regard describes an ultimate level of acceptance on the part of the therapists. The therapist presents to the client that there is nothing that can be said that will shake the therapist’s acceptance of that person.
	This triad works by providing the opportunity for a supportive relationship to develop between the client and the therapist. The combination of genuinely sharing values with the client, Congruence; exhibiting warm interest in and sharing emotions with the client, Empathy; and doing each of these while showing a genuine level of acceptance, unconditional positive regard; meets the majority of the universal needs all clients face.  Meeting these needs is a large part of the therapeutic process.  Limitations from the therapist’s point of view may be an inability to express one or all three of these with a specific client due to either the client’s background or behaviors or the background of the therapist.  Limitations from the client’s point of view may surround an inability to communicate well, a severe cognitive limitation, or being so heavily guarded in sharing personal information that little or no information is provided to the therapist.  This provides an opportunity for the client to return to the mother-child relationship, hopefully one that is positive, warm, caring and safe.  It fosters a calm place from which to discuss and examine problems.

Rational Emotive Behavior Therapy (REBT): How REBT is used for brief psychotherapy and in marriage and family therapy and the use of the A-B-C model for psychotherapy. 

	Ellis’s ABC model is based on the assumption that though an emotional consequence (C) may appear to be related to a significant event (A), it is more likely related to a specific value or belief system (B).  By recognizing that it is not “A” that causes “C”, but rather the person’s belief system or “B” that is the primary cause of “C”, helps the person clarify his/her own part in the contribution of “C”.  The client who presents as emotionally distraught and is citing distress regarding a particular event or issue, can benefit from the use of Rational Emotive Behavior Therapy (REBT) in determining how the source of the emotional conflict or concern is related to the client’s belief system.   
	In a marriage, REBT can help both partners realize a more honest appraisal of what is causing their concerns.  For example: The wife presents that she is angry because the husband is lazy and shiftless. She says this is because he does not take out the garbage as he should. In taking a history, this sequence is discovered. The wife asks her husband to carry out the garbage in the morning and he says he will. Later in the day she discovers he has left for work for the week and did not take out the garbage as promised. She describes intense anger at what she describes as his lack of responsiveness, lack of caring, lack of concern, his lack of desire toward her, and her feelings of undesirability.  Using REBT the wife is led to an understanding that her husband’s failure to comply with her wishes is not a reflection of her lack of desirability or a reflection of his true worth. It is just a mistake by someone who forgot. She recognizes that her belief system has led her to this way of thinking and that by examining her belief system from a rational point of view, she is able to release or defuse her emotions over this issue. The therapist disputes her irrational beliefs and helps her gain more rational ones. For individual therapy the session is often taped for the client to listen to the session repeatedly and a form is provided for the client to use in doing self-therapy using the REBT method following or in between sessions.	
	The concept is similar for work with family therapy as well as in marriage therapy. In both instances, REBT can assist the members of the family in examining how their irrational belief systems can cause faulty logical conclusions in interpreting the behaviors of others and lead to needless emotional turmoil.  In marriage therapy the members are often seen together. Work is toward helping each see, that though they may disagree with one another, their level of being upset is not justified by the events or relationships.  
	In family therapy the adults are sometimes seen separately from the children, though they may be all viewed at once to get a sense of the types of group behaviors.  Children are led to see that parents are not perfect and that to expect such is irrational. The same process is done with the parents, encouraging acceptance.  Tolerance for self and others is taught.
	REBT is designed to help the client face the irrational and illogical beliefs that are at the heart of the individual’s distress. The therapist provides unconditional positive regard, but in a no nonsense way disputes irrationally held theories or beliefs held by the client. The therapist spends a good deal of time educating the client and leads from information provided by the client into new areas where the client may be holding other illogical beliefs. Homework is assigned and the therapist approaches the client from a ‘tough love’ standpoint, insisting that therapy is hard work and should be approached as a significant task to be accomplished. It focuses on removing the “should’s”, “must’s”, and “ought’s” that many people collect in their lives, replacing these with “… it would be better if..”. This shift in thinking assists in the removal of blame, guilt, shame, anger, disappointment, and disillusionment, which are at the source of much of the angst clients bring to therapy.

Core concepts of Behavioral therapy:  classical conditioning, operant conditioning, extinction, discrimination learning, social-cognitive learning

Classical conditioning: This behavioral phenomenon was first described by Ivan Pavlov in his work with dogs.  This is the pairing of a neutral stimulus with an unconditioned stimulus enough times until it becomes conditioned. He paired the ringing of a bell (neutral stimulus) with the offer of food (unconditioned response of the dogs salivating in the presence of food). He noticed that over time the dogs would become conditioned to the sound of the bell, which would serve as a trigger (conditioned stimulus) to salivating (conditioned response). The stimulus of offering of food, resulting initially in increased salivation, with the pairing of the bell with the offering of food, led to the salivation eventually becoming a conditioned response to the sound of the bell. Using a human example, during church, a preacher states, “Let us pray” each Sunday, precisely four minutes prior to ending the service. Children and adults become increasingly restless when a new pastor extends this time between the closing prayer and dismissal.  The anticipation of leaving has been paired with these words in the Order of Worship and now the anticipatory behaviors continue even when the service has not ended, resulting in a confused and inattentive audience.
Operant conditioning: This behavioral approach is referred to as shaped or shaping behaviors.  As behaviors approximate desired outcomes, they are reinforced through the use of rewards or positive re-enforcers.  Uses of stimulus control, extinction, or punishment can shape behavior to a desired outcome. An example might be dimming the light slightly each time a prisoner moved closer to completion of a desired task in a situation where the light has been on 24 hours a day.  Or perhaps a better example, intermittent reinforcing of a child’s on-task behaviors in class, by occasionally rewarding his behaviors by acknowledging on-task behaviors with a word of praise, an piece of candy, or a star or sticker.
Extinction: When the connections between the previously conditioned stimulus and the unconditional stimulus is removed and the person learns that the conditioned stimulus no longer is associated with an unconditional stimulus
Discrimination learning: This describes a term in behavior response theory when a response is rewarded in one situation but not in another.  Mike Tyson, the boxer, could be one example of this. His aggressive, violent behaviors, including language use, and physical attacks toward others, are highly rewarded at times, while at other times are highly criticized, such as when he is accused of bullying, personal lashing out at news media, or sexual assault. 
Social-cognitive learning: This theory highlights the importance of being aware in the learning process. It is important that the person be able to think critically of events in the person’s environment. Learning occurs best when the person is fully aware of the rules regarding consequences of behaviors. It is much more educational in focus.  An example would include having a client watch a film on ethics that raises questions about how someone should respond given specific situations. The client could then discuss personal responses to the situations presented and reflect on variations in approaches. 
Brief review of Classical Conditioning:  Pavlov - was an Russian physiologist doing research at the St. Petersburg University School of Medicine. He was awarded a Nobel Prize for science, for his research on digestion and ulcers. Believe it or not, this is what led Pavlov to study learning in dogs.......which led to the basic components of classical conditioning theory:
a) There are stimulus --> response relationships that occur in nature. Pavlov called these naturally occurring events unconditioned stimuli (UCS) and unconditioned responses (UCR). Here are some examples:
Unconditioned Stimuli --->	Unconditioned Responses	
1. meat for dinner	the dog salivates	
2. a balloon pop	a startle response	
3. an air puff to your eye	blinking your eye	
b) When a neutral stimulus and unconditioned stimulus are presented together often enough, they becomes associated - thus the neutral stimulus is like a signal or clue that the unconditioned stimulus is coming next. After several pairings, the neutral stimulus becomes a conditioned stimulus (CS) because it elicits behavior that is a mild form of the UCR - this mild behavior is called the conditioned response (CR).
c) Important terms
•	acquisition - the initial phase of classical conditioning where an organism is learning to associate a neutral stimulus with an unconditional stimulus
•	extinction - a phase in classical conditioning where an organism learns that a previously conditioned stimulus no longer is associated with an unconditional stimulus
•	spontaneous recovery - the reappearance of a conditioned behavior following an extinction phase
•	response generalization - the tendency to respond to stimuli that are similar to a previously conditioned stimulus (CR)
•	stimulus discrimination - the tendency to distinguish between similar stimuli, responding to one but not the other
John B. Watson - was one of the first people to earn a Ph.D. in psychology in the United States in 1902. Only a few universities had a psychology department in 1902 and even fewer has animal research laboratories.  So, in graduate school Watson collected city rats and set up experiments in his apartment; later he set up research labs at Johns Hopkins University.  Watson also conducted his experiments with Little Albert, a one-year old boy, and other children to show how classical conditioning can create phobias and other mental health problems. 
Little Albert's mother stopped Watson's experiment with her son once she found out the details of the study and complained to the University.  Watson was warned about his questionable lab procedures and later was fired for studying human sexual responses with this lab assistant, Rosalie Rayner.  No one knows what happened to Little Albert.  
Operant Conditioning Theory - based on the work of E.L. Thorndike and B.F. Skinner.
E. L. Thorndike – was studying mind reading in children for his Ph.D. dissertation.  He asked children to guess what he was thinking and if they guessed right, he rewarded them with a piece of candy.  What he observed was that children made the same guesses again when it led to a piece of candy. Well, the research with children was a failure – so he switched to studying learning with animals.  And this led to the Law of Effect (1898).  The simple version is: 
Learning = behavior + consequences
Thorndike built a puzzle box for cats.  The cat was placed inside; it thrashed about randomly until it happened to press a latch that opened a door so the cat could escape.  This is an acquisition trial.  Thorndike put the cat back in the box repeatedly.  Eventually, the cat learned exactly what to do –press the latch to escape from the box.  Pressing the latch was the behavior that led to a satisfying event – the escape. 
B.F. Skinner – started with Thorndike’s theory and made some important changes:
1. He changed the learning environment.  In Thorndike’s box, the cat only had an opportunity to learn when the experimenter put it in the learning environment.  In other words, the experimenter controlled the cat's opportunities for learning.  Skinner created an operant conditioning chamber (everyone else called this kind of apparatus a Skinner Box).  The animal could remain in the chamber and have unlimited opportunities to learn.  An example was a rat cage with food, water, an exercise wheel, etc., but it also contained a lever that the rat could press to get more food.  The rat is free to press the lever repeatedly.  (How should this change in environment affect the rate of learning?)
2. Skinner's boxes (operant conditioning apparatuses) helped him discover shaping.  Obviously, the rat doesn’t know that pressing the lever will get more food – so it has to be rewarded for successively closer approximations of the desired response.  In other words, the experimenter gives a food pellet to the rat only if it is close to the lever, then only if it stands on its’ hind legs next to the lever, then only if it touches the lever......until the rat presses the lever by itself. 
(Do you think shaping could lead to strange behavior?  What is an example?  Why would this happen?)
3. Skinner also discovered schedules of reinforcement. Rather than giving a reinforcement (i.e. a food pellet) after every response (i.e. a lever press), Skinner fixed the operant conditioning chamber to give a reinforcement only after 2 or 3 responses.  This is a partial reinforcement schedule.  Learning with a partial reinforcement schedule is more resistant to extinction.

4. Ratio & Interval reinforcement schedules.  Ratio schedules give reinforcement after    x    number of responses.  The ratio of responses to reinforcement can be either fixed or variable.  A fixed ratio schedule gives reinforcement after every (5) responses, for example.  A variable ratio schedule gives reinforcement ‘on the average’ every (5) trials – sometimes the reinforcement comes after 2 responses, then after 7 responses, then 6 responses, etc. , so that reinforcement occurs on the average after every 5 responses.
Interval schedules give reinforcement after a time interval.  A fixed interval schedule gives reinforcement every (5) minutes.  A variable interval schedule gives reinforcement ‘on the average’ every five minutes - sometimes the reinforcement comes after 2 minutes, then after 7 minutes, then 6 minutes, etc. 
(Which type of reinforcement should lead to faster responding –ratio or interval schedules? Why?) (Can you think of examples of ratio or interval schedules that occur in daily life?)
5. Types of reinforcement are positive reinforcement, negative reinforcement, and punishment.  
•	Positive reinforcement - the organism performs the desired behavior and gets a desirable reward.  For example, a rat presses a level and is rewarded with a food pellet. 
•	Negative reinforcement - an undesirable event occurs until the organism performs the desired behavior.  For example, the floor of the rat cage is electrified until the rat presses a lever to turn off the electricity.  Positive and negative reinforcement both increase the frequency of behavior. 
•	Punishment  - is the opposite of reinforcement.  It decreases the frequency of the behavior.  The organism performs an undesirable behavior and an aversive or negative consequence is administered. 

6. Secondary reinforcement – some reinforcers are only signals that a positive reinforcement is on the way.  For example, Skinner fixed an operant conditioning chamber to give food pellets when the rat pressed a lever but only if a signal light was on.  When the light was off, the rat could not get food by pressing the lever.  Next, Skinner trained the rat to do something else to turn on the light.  For example, running in the exercise wheel will turn on the light.....so the rat learned to run in the wheel, then press the lever whenever it wanted to eat. 
 
Cognitive therapeutic relationship and 5 of the cognitive and behavioral techniques/strategies a Cognitive therapist might use.  

	The Cognitive therapeutic relationship is a partnership or collaboration between the client and the therapist in the examination of the thoughts and thought processes of the client.  It is present centered, directive, active, and problem-oriented.  The therapist’s role is one of a guide, encouraging the client through the therapeutic process.  The therapist presents unconditional positive regard toward the client, expressing warm and acceptance. Goals are jointly developed and are initiated from the client’s point of view. A dialogue consisting of questions designed to clarify problems, to assist in the identification of thoughts and assumptions, and to examine the meaning of events for the client. Negative automatic thoughts are uncovered and monitored in terms of their effectiveness for the client.  The connections between behaviors, feelings, and thoughts are discussed and examined in light of distortions in thinking. The client is educated about more reality-oriented ways to interpret events and to learn ways to avoid future biases that interfere with their effectiveness.

	Hypothesis testing is the framing of a supposition the client asserts so that the client can accurately test or gauge the assumptions the client is making in the client’s cognitive process. The therapist might add to information the client provides that fills out the hypothesis. The client is then encouraged to test this hypothesis to see if it has validity.  A client might say that he is a terrible father. The therapist would suggest the client develop a list of the traits of the perfect father and help the client list things such as: Provides for the family, listens to his children and wife, reads to his children, models behavior, sets rules, keeps the car running, mows the yard, etc..  The therapist then goes over this list with the client and asks him to test the hypothesis he has earlier made about his being a poor father, against this list.  By showing the client that he is meeting most if not all of these attributes, his initial hypothesis is debunked.
	Homework is therapist directed structure to apply the cognitive principles covered during therapy sessions, outside of the sessions.  This includes keeping record of behaviors and thoughts in given situations and reporting these back during the next session.  The client may be asked to count the number of times he is thinking about losing his job and what he is doing at the time of these thoughts. 
	Behavioral rehearsal and role-playing are used to act out techniques and newly acquired skills in the safety of the therapy session. The opportunity for feedback and direct modeling of suggested behaviors assist the client in developing a more objective view of the client’s behaviors.  The client and therapist might do a reverse role play of the client’s experience with a business associate with whom he had an earlier argument. The client would play the arrogant boss and the therapist would play the part of the client as weak willed and convinced he is going to be fired.
	Diversion techniques include the assignment of specific activities that might get in the way of negative thoughts. Swimming, diving, running, dancing, playing card games, or other activities that require some refocusing of the client’s thinking may help diminish the power of a specific negative thought.  The client may be assigned to jog for fifteen minutes every time the client has a negative thought about his appearance.
	Activity Scheduling is having the client structure the client’s day and having the client rate the various aspects of the day as to the level of satisfaction gleaned from the activity. This allows the client to see that activities are both controllable and that the client can subjectively assess a variety of levels of enjoyment to a variety of tasks.  This returns some sense of self-control and self mastery to the client.  The client might be encouraged to divide his day into blocks of time associated with distinct activities and to evaluate his satisfaction following each activity. At the next session these results would be discussed in terms of the client’s differentiation between the activities.
	Verbal techniques are used to elicit information about the client’s automatic thoughts. This information is used to analyze the logic and identify unworkable assumptions the thoughts reflect.  A history is taken from the client and used to gather data on how the client approaches problems in thinking and behavior. This information is used to help the client see the validity of logical thinking vs. the negative effects thinking that does not work as well for the client.  The client would be asked to share details of his thinking processes.  These would be discussed in terms of how they worked for the client and if, on closer examination, if they tended to support the client in all areas or did they contribute to deficits for the client.
	Decatastrophizing is an exercise of playing ‘what if’ with the client. By suggesting that the client consider some of the client’s worst fears by having them think through how they may respond if their fears came true, allows them to consider, in a safe environment, the viability of surviving these dire consequences. More often once these undifferentiated fears are given some substance, they become easier to manage.  The client who expressed fear on public speaking might be asked to elaborate on why he was fearful. He might state that he feared he would mess up and be humiliated. By having him consider and reflect on what he would do and feel if that happened, may help the client cope better with the fear by being able to consider, discuss, and develop ways of better dealing with the feared event. This activity may do much to reduce the client’s fear of public speaking.
	Reattribution is a method of suggesting that other possible causes be viewed in considering events.  It is a form of reality testing that helps the client better focus on appropriate assignment of responsibility for causal factors.  A client who blames his headaches on his wife on his headaches, might be encouraged to consider his drinking, staying up late, or his unexpressed anger as possible causes for his headaches. 
	Decentering is used to help anxious clients move from feeling as if they are the center of everyone’s attention.  Helping see the illogical nature of assuming that everyone is interested in them and their activities, removes some of their fears and concerns.  A person may be fearful of driving because he states that his fear is related to thoughts that everyone will be making fun of him when he makes a mistake. By suggesting that in traffic, most people do not make fun of others and most do not look or observe others, and asking the client to observe traffic for awhile to see if this is true, is one way of exhibiting to the client that he is not the center of undue attention in the area of his fear.  

The 4 ultimate concerns identified by Yalom and describe how a therapist addresses each of these concerns with the patient, and the Existential concepts of guilt, anxiety and being in the world. 

Death is man’s ultimate concern and the conflict between the desire to live and the awareness of impending death is at the core of the individual’s ultimate fear.  Man develops maladaptive defenses against the awareness of death, which appear in forms of denial of its existence, various degrees of symptomatic behaviors, or character disturbances. A client might be asked to imagine the scene at the client’s funeral, considering who might speak about their life, and what might be said to help them begin to address the concept of their death and their related fears.  Also, discussions of significant life events in terms of passages through life, may help the client learn to better deal with or gain some relief from death anxiety.
Freedom in this context is a terrible or awe filled concept. The fact that man has the freedom to make choices places his destiny entirely in his own hands. This realization is frightening in that suddenly the person realizes that he is working without a net or a safeguard and that the person is solely responsible for his success, safety, and whatever meaning his life has. The person is responsible for the will to act and make choices.  In therapy work would focus on helping the client recognize that the client is responsible for his/her life’s design.  The client would be refocused toward viewing behaviors as acts of personal will instead of out-of-control reactions to external events.  Complaints would be examined as creations of the client, and questions would direct the client to examine their part in the creation of the situation that has lead to the current complaint.
Isolation in the context of existential isolation describes the conflict between man’s fundamental isolation or separateness and his wish to be merged with or be a part of a larger whole.  This sense of isolation is what defines us or sets us apart from the universe. Facing death is the ultimate sense of being totally alone as one’s death is uniquely one’s own experience. Whether or not there is something called the collective consciousness as described by Jung or others, existential isolation and the related anxiety it may create in the individual may be one of the motivators for taking positive stand on the existence of a collective universal conscious as it would provide some relief from this profound sense of isolation. A client might be asked to spend incremental times in a park or quiet place alone, either writing, drawing, painting, or journaling, with the responsibility of reporting back feelings and thoughts in therapy.  These increasing times of personal isolation would be discussed in therapy and would be reinforced as the client became more comfortable with isolation.
Meaninglessness in this context refers to a universal expectation of man that life has meaning or purpose.  Man has a natural tendency to see patterns and extrapolate from partial information to the whole, whether or not such a complete pattern exists. Meaning allows for the possibility of prediction of future events from current observations, which provides comfort in an uncertain environment. With out this opportunity, man is often depressed or anxious. Meaning in life establishes the framework for the development of values and a hierarchical ordering of behaviors and desires. Man wants the universe to have meaning in order that personal life can also reflect meaning. A client might be given the assignment to spend time each week reading to a shut in or to a group of patients at a nursing home.  This engagement in the lives of others may help to provide a higher level of meaning for the client.  This particular task also provides a sense of unconditional positive regard for the client by those to whom he/she is reading.  This provides a level of meaning for the client and is self-reinforcing, often creating or strengthening a wish to help others. 

The  Existential concepts of guilt, anxiety and being in the world. 
Guilt in this context describes neurotic guilt feelings that emanate from one’s failure to live up to personal standards or our sense of one’s own being. Not living up to one’s potential is the underpinning of this form of guilt.  It is a debt that is self-owed that creates this feeling of guilt.
Anxiety in this context refers to a broader notion than usually associated with simple distress or apprehension over an event or series of thoughts. It includes a general sense of concern over survival, self-image preservation, and need to assert one’s self. Some level of anxiety is normal, but it is commensurate with the event and it is generally controllable. Neurotic anxiety is not commensurate with the precipitating event. The feelings generated by this level of anxiety are overwhelming, destructive, and causes paralysis. The therapist’s goal is to help the client cope with normal anxiety and to move neurotic anxieties to a more manageable place in the client’s life.
Being-in-the-world in this context refers to the person in the situation. The life of the client is not simply the environment, even if the micro, mezzo, and macro aspects are all considered along with the biological, psychological, and sociological issues surrounding the client.  Each person has unique relationships and points of view with respect to the person’s environment. These are referred to as the Umwelt (This term describes the person’s relationship with the biological and environmental world around the client.), the Mitwelt (This term describes the relationships the person has with his fellow human beings.), and the Eigenwelt (This term describes the relationship the person has with self.).  A person’s being-in-the-world is viewing the totality of the person, reviewing all aspects of the client’s life, health, well-being, loves, thoughts, relationships, and self-perceptions.

Reality Therapy, Multimodal Therapy: An example of an individual seeking therapy from a Reality Therapist and outline the treatment strategy specifically for this individual.

	Joan contacted the therapist for what she described as depression following her recent divorce and subsequent custody fight over her 2 yr old daughter. Following the initial discussions about ethical issues related to treatment and a summary of what she can expect from reality therapy she gave the following history with little prompting. She married her high school sweetheart following graduation from high school. John was the first person she dated and she was two months pregnant when they married. She expressed some embarrassment over this and described her father as being furious with them at the time.  John worked nights and on weekends, spending up to two weeks away from home at least every other month. Following the birth of their child, she described feeling more and more lonely and cut off from her husband and others. She loved caring for her child, but her sex life with her husband diminished even more following the birth. At times they would go a month or more without having sex.  She said he would initiate sex more often than she, but she would say she wasn’t feeling well. She explained that she told him that she did not feel as if she knew him any more. 
	She described feeling overwhelmed, lonely, and detached from others.  She said she began to focus more and more on staying at home with her child, even putting shopping for groceries off until the very last minute, and then only to get milk for the baby. She has lost a good deal of weight and her personal appearance has suffered.  Her arguments with John were often over her lack of attention to anything except the care of the baby. The overall appearance of the inside of the home deteriorated from general neglect. Only the child’s room has remained neat and clean.  She has almost stopped seeing her parents, who live out of state and whose health condition has prohibited their visiting more than twice since the birth of the baby.  His parents are deceased.  Her only sibling also lives out of state. They talk on the phone occasionally, but her sister’s demanding job has limited much contact with her.  Joan’s circle of friends from school enrolled in college in another town and she only occasionally hears from them. She states that when she got married, everyone knew she ‘had to get married’ and that she is ashamed when she sees her friends in town. When she does see them at a store, she states she puts her shades on and tries to avoid them. If they call her when they are in town, she makes excuses not to see them and has not let them come over to see the baby, citing the baby being ill at the time.
	Most of Joan’s needs of belonging, power, fun, and freedom are clearly not being met.  She has little or no sense of belonging to others. Her feelings of shame and guilt prevent her contacting old school mates. She describes feelings and behaviors that evidence powerlessness over her environment. She rarely goes outside even to shop for groceries and essentials. The only activities she expresses any interest or animation about are those involved in caring or playing with her child.  She seems tied solely to her relationship with her child and lacks the freedom to engage in outside supportive relationships with other adults.  Her choices seem limited to her.
	Therapy will include discussing with Joan what she wants out of her life now and trying to help her focus on the present and near future. Her presenting problem, depression, will be discussed in terms of how she feels it affects her. She will be asked to consider how things might be if she was not depressed and to imagine what her life would be like if she was happy and had all her wants and needs met. The following discussion would use this information to develop a current list of specific wants for Joan.  These would be reflected back to her and revised until she was satisfied that these wants were what she felt accurately described her longings and would meet her needs. This would lead to a discussion on how her current behaviors were meeting or not meeting these wants and how she would like to see her behaviors changed.  A discussion would be developed that would elicit her affirmative commitment to changing behaviors.  Her actual behaviors, such as getting up late, going to bed early, spending too much time in bed, crying for hours at a time, watching television too much during the day, and other behaviors she connects to depression, would be explored in terms of how they relate to meeting her wants or not meeting her wants. Also, the therapist will elicit and suggest other possible depression related behaviors to add to this list.  
	What she is currently doing will be addressed. She will be asked to evaluate each of her behaviors in terms of how effective they are. Agreed upon assignments for specific behavior changes will be reached during therapy. These behaviors would be discussed to clarify how they would support or meet the wants Joan describes and how her life would benefit from them.  As she adds or alters behaviors she will be asked to evaluate the changed behaviors and her subsequent altered feelings in light of how her wants are being met and where she feels her behaviors are taking her.  A routine examination or reflection process will be mutually agreed upon where Joan is to regularly consider how her behaviors relate to the overall goals she has set for herself and if these goals are still viable for meeting her wants.  The therapist will reflect Joan’s wants back to her on a regular basis to determine shifts in perception on Joan’s part, assisting her in viewing her behaviors from a distance and from a critical perspective in determining if they are helpful or harmful. She will be asked if she were to review her behaviors objectively, what would she imagine the behavior’s goal to be. The therapist would help Joan look more closely at the goals she wants versus the goals that her current behaviors seem to be defining for herself.
	With assistance from the therapist she would develop a plan for incorporating behaviors into her life that would better meet her needs and to develop a pattern of personal feedback that would continually remind her of how well her behaviors are achieving this goal.  The plan would be clarified with Joan to ensure that new and current behavior goals contain the elements of being simple, attainable, measurable, immediate, and committed to.

An example of an individual seeking treatment from Arnold Lazarus and use of the 7 modalities summarized by the acronym BASIC I.D.

	Mary presented the following concern for treatment of what she described as depression over her inability to relate well to men while dating.  Though she dates men frequently and states that she generally seems to have an enjoyable time, she describes feelings of panic that occur during her dates, specifically when her date holds her closely, even during dancing.  
	Her modality profile reflects the following:
Behavior: Generally outgoing in most relationships, but markedly stand-offish if confronted with being held physically.
Affect: False levity or humor at these times.
Sensation: Feelings of cold with sweating and flushing.
Imagery: Of being smothered or trapped in a small space.
Cognition: Thinking, “I must be in control to protect self.”
Interpersonal: Avoidance of relationships that may deepen into more physical encounters.
Drugs/Biologicals: None
	In therapy she describes breaking out in a cold sweat, trembling, having a tremulous voice, heightened breathing rate, a rapid pulse, and flushing as occurring at the same time or shortly after even the most innocent embrace.  During therapy Mary is asked to detail what happens. She describes that this has become a repetitive ordeal for her and explains that she seems to follow a consistent pattern. She is usually having a good time with her date, enjoying either conversation, jogging, shopping, swimming, or even dancing (only apart, not close dancing), and each time she feels he might put his arms around her in a closed embrace, she gets this mental image (I - Image) of being smothered with a pillow or being pushed under a bed or into a closed space.  When she tries to put this out of her mind, she immediately begins to think (C - Cognition) about losing control. Sometimes this is a sense that he might force himself on her and at other times it is that she may not be able to stop herself from engaging in heavy petting or encouraging sexual intercourse.  At times she feels she would enjoy this escalation to further physical activity, but even when she thinks she would, she cannot deal with the fear of loss of control that she has during these moments.  She says that it seems the more she tries to gain control of her thinking the less control she has. 
	Her concern about control continues to escalate and she begins to feel flushed (S - Sensation) and she begins to sweat copiously.  She then feels herself stiffen (B - Behavior) and starts to pull away.  When she tries to retain some sense of normalcy or at least avoid offending her date, she begins to tremble. To cover this she laughs loudly or tries to make a joke of it (A - Affect). Her dates often get mad and call her a tease.  She says that most of the time she and her date continue to have a good time, especially if her date has a good sense of humor, as he often laughs with her. Her dates often express or exhibit obvious confusion over her affect and behaviors.  This often leads to the ending of the relationship as a close one (I. - Interpersonal), producing for her a string of acquaintances with no relationship progressing to physical intimacy. She finds this distressing as she has been really attracted to several of her dates, but she cannot seem to tolerate letting the relationship progress physically.  She does not take any drugs other than aspirin or medication for seasonal allergies. (D - Drugs/Biologicals).
	In therapy, her sequence is defined as I C S B A I., (Image, Cognition, Sensation, Behavior, Affect, and Interpersonal), reflecting the order in which she processes information. Imagery comes first for her, with a mental picture of her being smothered, and followed by her thoughts of becoming out of control, Cognition. This leads to the sensations of cold sweats and flushing, followed by distancing behaviors. These she tries to minimize by laughing and appearing funny or happy, altering her affect. This sequence is repeated and leads to behaviors that often stall a desired relationship and they become ‘just friends’.  
	Treatment would include a plan that gives Mary a sequence of activities and thinking processes that would mirror the same order, I C S B A I.  This sequence would deal first with her imagery.  She would be given other possible coping images to accompany and eventually replace the one of being smothered with a pillow. An alternative vision may be introduced that breaks the power of the pillow or diffuses the pillow’s negative image, or Mary may be encouraged to modify the pillow image to one that she is better able to deal with, such as a smaller pillow or one with few feathers. At the same time she would practice behaviors that would initially maximize her sense of control during embracing activities, perhaps with a friend or a doll. The therapist could use guided imagery to help Mary practice surviving embracing with incrementally less control issues until the act of embracing lost some of it’s power over her thinking, and reduced its tie to her vision and association with control.  These two sequences would be practiced in therapy, her new imagery followed by her new thinking about the control issue related to physical embraces.  Then using guided imagery, the therapist would work on better defining the sensations she is experiencing and encourage her to try experiencing these same feelings in other ways.  Through therapist or self guided imagery she would be asked to practice increasing and decreasing these sensations until she gains some sense of control of them by manipulating her thoughts in other areas. 
	She would practice suggested new behaviors to supplant her stiffness and pulling away, possibly engaging her date in the process.  Initially she may be given a specific time and method by which to ‘test’ her ability to withstand an embrace and limit embraces only to that specific situation in order for her to feel safer. By explaining her feelings and encouraging her date to provide feedback on her new behaviors, she may be better able to incrementally increase her time in an embrace.  Also, by engaging her date in her therapeutic trials, she would avoid some of her perceived need for her false affect in the relationship that she was using to cover her nervousness and embarrassment for pulling away from her date. Hopefully this will reduce her apprehension in deepening relationships and consequently help her decrease her avoidance behaviors that have prevented her from deepening her relationships with her dates.  
	The therapist would cover this sequence with Mary and help her practice the application of these new behaviors through guided imagery. During subsequent sessions, information on how she is doing in her attempts on refocusing, rethinking, and altering behaviors would be discussed.  Her images, behavior, and cognitive processes would be regularly revisited for changes that would benefit Mary.