BEREAVEMENT

Grief Counseling
Grief counseling offers individuals who are grieving the loss of a loved one or facing significant
losses in their lives vital support, empathy, and guidance. Through this process, individuals are
encouraged to openly express their emotions, gain insight into the grieving process, and acquire
coping strategies to navigate the emotional difficulties that arise from their loss.
Goals:
To increase the reality of the loss
Help deal with both expressed and latent effect
Help overcome various impediments to readjustment after the loss
Help find a way to remember the deceased while feeling comfortable reinvesting in life
Steps in Grief counseling
Establishing a Therapeutic Relationship: The first step involves building trust and rapport
between the client and counselor. This foundation is crucial for creating a safe space for the
grieving individual to express their emotions and thoughts. (Worden, 2009).
Assessment and Exploration: Counselors assess the individual's unique grief experience,
including the nature of the loss, their emotional reactions, and their coping mechanisms. This
stage helps tailor the counseling approach to the client's specific needs.
Normalizing Grief Reactions: Counselors educate clients about the common emotional and
physical reactions associated with grief. Normalizing these responses helps clients understand
that their reactions are natural and not signs of weakness
Facilitating Expression and Processing: Clients are encouraged to express their feelings,
thoughts, and memories related to the loss. Counselors use active listening and empathy to
support clients in processing their grief.
Coping Skills and Strategies: Counselors teach clients coping skills and strategies to manage
the emotional and practical challenges of grief. This may include relaxation techniques,
cognitive-behavioral strategies, and stress management ( Neimeyer, 2012).
Exploration of Meaning and Integration: Clients are guided in finding meaning in their loss
and integrating it into their lives. This stage often involves exploring the legacy and impact of
the deceased person.
Closure and Transition: The final stage involves helping clients transition from intense grief to
a place of acceptance and adjustment. It focuses on acknowledging the ongoing connection to the
deceased while also moving forward in life (Parkes, 2013).

GRIEF THERAPY
● Used to treat severe or complicated traumatic grief reactions
● Experience the loss of a loved one as a painful, confusing, and disruptive event
● Allow for the expression of feelings and provide bereaved persons with important
opportunities to make sense of their grief experiences
● May be done in either individual or group contexts
Grief therapy is appropriate in situations that fall into three categories
● The complicated grief reaction is manifested as prolonged grief
● The grief reaction manifests itself through some masked somatic or behavioural symptom
● The reaction is manifested by an exaggerated grief response
FOUR TASKS OF MOURNING
● William Worden
● Accept the reality of the loss
● To acknowledge and work through the pain of grief
● To adapt to an environment in which the deceased is missing
● To emotionally relocate the deceased and move on with life
Accept the reality of the loss
● The facts of the loss need to be recognized
● Subtle aspects of the loss—the meaning of the loss and its irreversibility
● To recognize the significance of loss
● First principle- to help the survivor actualize the loss
● To acknowledge and work through the pain of grief
Facilitate the survivor’s talking about his or her experience of the loss
● Difficult task as no one wishes to feel such pain
● Seek to avoid painful feelings and thoughts
● Friends may prefer to avoid the pain of the grieving person’s experiences and leaves the
griever isolated
● Therapists themselves may avoid the griever’s pain in therapy
● Therapist’s role is to both sit with the person’s painful feelings and to help him or her
express these
● Anger is commonly experienced but not always readily expressed
To adapt to an environment in which the deceased is missing
● A deceased person has often played many roles in the survivor’s life
● Self-definition has depended heavily on his or her relationship with the deceased person
● Self perception theory- we come to know ourselves in the same way that we come to
know others: by observing our own behaviors in various situations
● In a bereavement group, members can have many opportunities to engage in altruistic,
supportive, and empathetic behaviors toward other members
● Members can begin to see themselves not as confused and grieving but as active and
engaged with others
To emotionally relocate the deceased and move on with life
● It is often more useful to facilitate the grieving person’s recognition that the lost person is
never really forgotten
● It is possible to go on with other loving relationships
● Such recognitions on the part of the client represent a valid therapeutic goal
Strength and Weakness
● Places a strong explicit emphasis on the feeling experiences of grieving persons
● It is relatively easily understood
● “Tasks” provides a structure for the grieving person as well as for the therapist
● The main criticism of this approach is its implicit stage like quality
● It is very tempting to fit all grieving individuals into a mold of “working through the
stages” (tasks) of grieving
MEANING RECONSTRUCTION
● Robert Neimeyer
● Emphasizes the uniqueness of individuals’ experiences of grieving
● Revision of one’s life story in response to a loss is the central process in grieving
● Opportunity for grieving persons to tell their stories in ways that will help them to make
sense of loss and of life
● Story-telling process
● People “write” and rewrite their stories and thus develop a sense of meaning, purpose,
and identity
● Grief therapy is focused on a retelling or reconstruction of the grieving person’s
narrative.
● This will allow the survivor to once again find meaning in life in the context of a new
reality
● Techniques involve the following
● Writing letters to the deceased
● Keeping a journal
● Putting together a book of memories
● Drawing stories of events in one’s life, including a drawing about the loss.
● Compiling a book of photographs
● Constructing a lifeline consists of drawing a line graph of the experiences of one’s life
along a horizontal axis that can be divided into 10-year increments
CBT strategies to help the bereaved
Identifying and Challenging Negative Thoughts: This strategy involves helping the bereaved
individual identify and challenge unhelpful or distorted thoughts related to their loss. By
questioning and reframing these thoughts, they can develop more adaptive thinking patterns
(Nezu, Nezu & Lombardo, 2001).
Behavioral Activation: Grief can lead to withdrawal and decreased engagement in activities.
Behavioral activation involves helping the bereaved individual resume pleasurable and
meaningful activities, which can improve mood and functioning (Martell, Dimidjian & Herman-
Dunn, 2010).
Grief Journaling: Keeping a grief journal allows individuals to express their feelings, thoughts,
and memories related to the loss. It can promote self-reflection and emotional processing (Lepore
& Smyth, 2002).
Cognitive Restructuring for Guilt and Shame: Some bereaved individuals may experience
guilt or shame related to their loved one's death. Cognitive restructuring helps them address these
feelings and find more compassionate perspectives (Beck, 2011).
Gestalt therapy
The empty chair technique
•Origins in Psychodrama and imported into Fritz Perls’ Gestalt therapy
•One of the most simple but profound techniques
•The empty chair technique involves having clients talk to a loved one with whom they have no
more contact (because of death or lifelong separation) via an empty chair
•Crose (1990) found the empty chair technique to be useful in working with clients who have
unfinished business.
How to implement the technique: 6 steps (Young, 2013)
•Warm up: the client should think about an example in which he felt ambivalent about an issue
(polarities)
•First, arrange the chairs facing each other and explain why the technique is being used
•Second, client picks the side he has strongest feelings for.
•Third, expression in the here and now
•Fourth, counter-expression & switching chairs
•Fifth, the switching continues till both sides of the polarity have been articulated
•Sixth, agree upon an action plan
THERAPY IN TRAUMA
Trauma results from an event or series of events experienced by an individual as physically or
emotionally harmful and has lasting adverse effects on the individual’s neurological, emotional,
physical, spiritual and cognitive function. There are many types of traumatic events, and we
often think of sexual abuse, physical injury, neglect, isolation, trafficking, homelessness, and
disability.
Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is a widely recognized and
evidence-based approach used to treat individuals, especially children and adolescents, who have
experienced trauma. TF-CBT combines cognitive-behavioral techniques with trauma-specific
interventions.It incorporates elements such as psychoeducation, relaxation, affective expression
and regulation, cognitive coping, and gradual exposure to trauma-related material (Cohen,
Mannarino & Deblinger , 2006).
Cognitive Processing Therapy (CPT) focuses mainly on unrealistic and/or unhelpful thoughts a
person has about their traumatic experience and/or how the trauma has impacted their beliefs
about themselves, others, and the world.
Common Elements Treatment Approach (CETA) focuses on specifically targeting the
symptoms of posttraumatic stress, anxiety and/or depression in people affected by their traumatic
experiences. The goal is to choose the treatment components that match the specific symptoms
of the person and then provide the treatment components that work for the specific symptoms
that are most impacting the client. Usually sessions cover one treatment component at a time.
Prolonged Exposure (PE) focuses on reducing the intense negative emotions that are caused by
memories or being reminded of the trauma. The main negative emotions that go with
remembering are fear and shame. The idea is that facing up to the trauma memories or reminders
in a planned way eventually wears down the negative emotions connected to the memories.
Eye Movement Desensitization and Reprocessing (EMDR) aims to help you process and
release traumatic memories through eye movements. Here the therapist will ask the client to hold
a specific aspect of a traumatic event in mind while you focus on their hand moving back and
forth (or, sometimes, rhythmic tapping).
•The aim is to help the brain to “reprocess” the memory, which wasn’t fully processed at the
time due to overwhelming stress by engaging both sides of your brain (known as bilateral
stimulation).
•This reprocessing aims to release the memories, ultimately relieving nightmares, flashbacks and
triggers.
Therapies and techniques in the management of Crisis
Crisis intervention
Crisis intervention refers to the methods used to offer immediate, short-term help to individuals
who experience an event that produces emotional, mental, physical and/or behavioral distress or
problems.
• A crisis can refer to any situation in which the individual perceives a sudden loss of his or her
ability to use effective problem-solving and coping skills (i.e., natural disasters, criminal
victimization, medical illness, mental illness, thoughts of suicide or homicide and loss or drastic
changes in relationships such as death of a loved one or divorce).
Roberts' Seven-Stage Crisis Intervention Model
Stage I: Psychosocial and Lethality Assessment
The crisis worker must conduct a swift but thorough biopsychosocial assessment. At a minimum,
this assessment should cover the client's environmental supports and stressors, medical needs and
medications, current use of drugs and alcohol, and internal and external coping methods and
resources (Eaton & Ertl, 2000). One useful (and rapid) method for assessing the emotional,
cognitive, and behavioral aspects of a crisis reaction is the triage assessment model (Myer, 2001;
Myer, Williams, Ottens, & Schmidt, 1992, Roberts, 2002)
Assessing lethality, first and foremost, involves ascertaining whether the client has actually
initiated a suicide attempt, such as ingesting a poison or overdose of medication. If no suicide
attempt is in progress, the crisis worker should inquire about the client's "potential" for self-harm.
This assessment requires

● asking about suicidal thoughts and feelings (e.g., "When you say you can't take it
anymore, is that an indication you are thinking of hurting yourself?");

● estimating the strength of the client's psychological intent to inflict deadly harm (e.g., a
hotline caller who suffers from a fatal disease or painful condition may have strong
intent);
● gauging the lethality of suicide plan (e.g., does the person in crisis have a plan? how
feasible is the plan? does the person in crisis have a method in mind to carry out the plan?
how lethal is the method? does the person have access to a means of self-harm, such as
drugs or a firearm?);
● inquiring about suicide history;
● taking into consideration certain risk factors (e.g., is the client socially isolated or
depressed, experiencing a significant loss such as divorce or layoff?).

With regard to imminent danger, the crisis worker must establish, for example, if the caller on the
hotline is now a target of domestic violence, a violent stalker, or sexual abuse.
Rather than grilling the client for assessment information, the sensitive clinician or counselor
uses an artful interviewing style that allows this information to emerge as the client's story
unfolds. A good assessment is likely to have occurred if the clinician has a solid understanding of
the client's situation, and the client, in this process, feels as though he or she has been heard and
understood. Thus, it is quite understandable that in the Roberts model, Stage I—Assessment and
Stage II—Rapidly Establish Rapport are very much intertwined.

Stage II: Rapidly Establish Rapport

Rapport is facilitated by the presence of counselor-offered conditions such as genuineness,
respect, and acceptance of the client (Roberts, 2005). This is also the stage in which the traits,
behaviors, or fundamental character strengths of the crisis worker come to fore in order to instill
trust and confidence in the client. Although a host of such strengths have been identified, some
of the most prominent include good eye contact, nonjudgmental attitude, creativity, flexibility,
positive mental attitude, reinforcing small gains, and resiliency.
Stage III: Identify the Major Problems or Crisis Precipitants
Crisis intervention focuses on the client's current problems, which are often the ones that
precipitated the crisis. As Ewing (1978) pointed out, the crisis worker is interested in elucidating
just what in the client's life has led her or him to require help at the present time. Thus, the
question asked from a variety of angles is "Why now?"
Roberts (2005) suggested not only inquiring about the precipitating event (the proverbial "last
straw") but also prioritizing problems in terms of which to work on first, a concept referred to as
"looking for leverage" (Egan, 2002). In the course of understanding how the event escalated into
a crisis, the clinician gains an evolving conceptualization of the client's "modal coping style"—
one that will likely require modification if the present crisis is to be resolved and future crises
prevented. For example, Ottens and Pinson (2005) in their work with caregivers in crisis have
identified a repetitive coping style—argue with care recipient-acquiesce to care recipient's
demands-blame self when giving in fails—that can eventually escalate into a crisis.
Stage IV: Deal With Feelings and Emotions
There are two aspects to Stage IV. The crisis worker strives to allow the client to express
feelings, to vent and heal, and to explain her or his story about the current crisis situation. To do
this, the crisis worker relies on the familiar "active listening" skills like paraphrasing, reflecting
feelings, and probing (Egan, 2002). Very cautiously, the crisis worker must eventually work
challenging responses into the crisis-counseling dialogue. Challenging responses can include
giving information, reframing, interpretations, and playing "devil's advocate." Challenging
responses, if appropriately applied, help to loosen clients' maladaptive beliefs and to consider
other behavioral options. For example, in our earlier example of the young woman who found
boyfriend and roommate locked in a cheating embrace, the counselor at Stage IV allows the
woman to express her feelings of hurt and jealousy and to tell her story of trust betrayed. The
counselor, at a judicious moment, will wonder out loud whether taking an overdose of
acetaminophen will be the most effective way of getting her point across.

Stage V: Generate and Explore Alternatives

This stage can often be the most difficult to accomplish in crisis intervention. Clients in crisis, by
definition, lack the equanimity to study the big picture and tend to doggedly cling to familiar
ways of coping even when they are backfiring. However, if Stage IV has been achieved, the
client in crisis has probably worked through enough feelings to re-establish some emotional
balance. Now, clinician and client can begin to put options on the table, like a no-suicide contract
or brief hospitalization, for ensuring the client's safety; or discuss alternatives for finding
temporary housing; or consider the pros and cons of various programs for treating chemical
dependency. It is important to keep in mind that these alternatives are better when they are
generated collaboratively and when the alternatives selected are "owned" by the client.

The clinician certainly can inquire about what the client has found that works in similar
situations. For example, it frequently happens that relatively recent immigrants or bicultural
clients will experience crises that occur as a result of a cultural clash or "mismatch," as when
values or customs of the traditional culture are ignored or violated in the United States. For
example, in Mexico the custom is to accompany or be an escort when one's daughter starts
dating. The United States has no such custom. It may help to consider how the client has coped
with or negotiated other cultural mismatches. If this crisis precipitant is a unique experience, then
clinician and client can brainstorm alternatives—sometimes the more outlandish, the better—that
can be applied to the current event. Solution-focused therapy techniques, such as "Amplifying
Solution Talk" (DeJong & Berg, 1998) can be integrated into Stage IV.

Stage VI: Implement an Action Plan

Here is where strategies become integrated into an empowering treatment plan or co-ordinated
intervention. Jobes, Berman, and Martin (2005), who described crisis intervention with high-risk,
suicidal youth, noted the shift that occurs at Stage VI from crisis to resolution. For these suicidal
youth, an action plan can involve several elements:

● removing the means—involving parents or significant others in the removal of all lethal
means and safeguarding the environment;

● negotiating safety—time-limited agreements during which the client will agree to

maintain his or her safety;
● future linkage—scheduling phone calls, subsequent clinical contacts, events to look
forward to;
● decreasing anxiety and sleep loss—if acutely anxious, medication may be indicated but
carefully monitored;
● decreasing isolation—friends, family, neighbors need to be mobilized to keep ongoing
contact with the youth in crisis;
● hospitalization—a necessary intervention if risk remains unabated and the patient is
unable to contract for his or her own safety (see Jobes et al., 2005, p. 411).

Obviously, the concrete action plans taken at this stage (e.g., entering a 12-step treatment
program, joining a support group, seeking temporary residence in a women's shelter) are critical
for restoring the client's equilibrium and psychological balance. However, there is another
dimension that is essential to Stage VI, as Roberts (2005) indicated, and that is the cognitive
dimension. Thus, recovering from a divorce or death of a child or drug overdose requires making
some meaning out of the crisis event: why did it happen? What does it mean? What are
alternative constructions that could have been placed on the event? Who was involved? How did
actual events conflict with one's expectations? What responses (cognitive or behavioral) to the
crisis actually made things worse? Working through the meaning of the event is important for
gaining mastery over the situation and for being able to cope with similar situations in the future.

Stage VII: Follow-Up

Crisis workers should plan for a follow-up contact with the client after the initial intervention to
ensure that the crisis is on its way to being resolved and to evaluate the postcrisis status of the
client. This postcrisis evaluation of the client can include

● physical condition of the client (e.g., sleeping, nutrition, hygiene);

● cognitive mastery of the precipitating event (does the client have a better understanding of
what happened and why it happened?);
● an assessment of overall functioning including, social, spiritual, employment, and
academic;
● satisfaction and progress with ongoing treatment (e.g., financial counseling);
● any current stressors and how those are being handled;
● need for possible referrals (e.g., legal, housing, medical).

Follow-up can also include the scheduling of a "booster" session in about a month after the crisis
intervention has been terminated. Treatment gains and potential problems can be discussed at the
booster session. For those counselors working with grieving clients, it is recommended that a
follow-up session be scheduled around the anniversary date of the deceased's death (Worden,
2002). Similarly, for those crisis counselors working with victims of violent crimes, it is
recommended that a follow-up session be scheduled at the 1-month and 1-year anniversary of the
victimization.
Psychological First Aid (PFA)
PFA is a humane, supportive response to a fellow human being who is suffering and who may
need support. It is an acute intervention of choice when responding to the psychosocial needs of
children, adults and families affected by disaster and terrorism. It is designed to reduce the initial
distress caused by traumatic events and to foster immediate and long-term adaptive functioning
and coping.
It involves the following 7 themes:
ACTION PRINCIPLES of PFA
LOOK:
Check for safety, People with obvious urgent basic needs, and people with serious distress
reactions. Crisis situations can change rapidly. You may not have enough time to prepare
adequately or the scene may be different from what you learned before you enter the site. Be
calm, be safe and think before you act.
LISTEN:
Approach people who may need support. Ask about people’s needs and concerns. Listen to
people and help them to feel calm.
1. Help them feel comfortable – eg. offer water
2. Take them to a safer place
3. Protect from exposure to the media for their privacy & dignity.
4. Ask for their specific needs and concerns
5. Help them work out what their priorities are.
6. Stay close to the person
7. Do not force them to talk but listen in case they want to talk about what happened.
8. Be a role model – Stay calm, speak slowly and help them feel Calm
LINK: (Major part of PFA)
Help people address basic needs, access services and cope with their problems. Give them
information of the crisis event, support services available, and how to seek help. Connect people
with loved ones and social support. Make sure vulnerable or marginalized people are not
overlooked. Follow up with people if you promise to do so. Linking people with practical
support is a major part of PFA. PFA is often a short time and one time intervention. So help
people to notice their strengths & help themselves and to regain control of their situation. Being
able to manage a few issues will give the person a greater sense of control in the situation and
strengthen their own ability to cope.

SELF HARM
Self-harm is a behavior, not an illness. Thus, management is highly dependent on the underlying
problems, which could range from psychosis with intense continuing suicidal urges requiring
psychiatric admission, to an impulsive over-reaction to a stressful event that rapidly resolves
with family support.
Cognitive-Behavioral Therapy (CBT)
It offers several techniques to help individuals regulate self-harming behaviors by identifying
and modifying the thoughts, emotions, and behaviors associated with self-harm.
The therapist begins by conducting a thorough assessment to understand the individual's history,
self-harm patterns, triggers, and underlying issues such as depression, anxiety, or borderline
personality disorder.The therapist educates the individual about self-harm, its potential
consequences, and the CBT framework.

The person is encouraged to keep a journal or diary to track their self-harm incidents, including
when, where, why, and how they engage in self-harm. This helps identify patterns and
triggers.Cognitive treatment targets the thoughts, assumptions, rules, attitudes and core beliefs
that support self-harm.Thoughts in their myriad forms play a fundamental role in the onset and
continuation of self-harm.

The cognitive process always precedes the emotion and behaviors associated with cutting,
excoriation, self-burning, and self-hitting and so on.Core beliefs like unlovability, incompetence,
and negative body image would be evaluated with corroborative empiricism.Cognitive needs to
be identified and targeted for a comprehensive and successful treatment.

CBT Technique:
Thought Restructuring: Thought restructuring, also known as cognitive restructuring, involves
identifying and challenging distorted and negative thoughts that may trigger or maintain self-
harming behaviors. Clients learn to replace irrational and harmful thoughts with more rational
and adaptive ones. This technique helps individuals gain better control over their emotions and
behaviors. (Beck, J. S,2011).
Dialectical Behavior Therapy (DBT):
Dialectical Behavior Therapy (DBT) is a widely recognized and evidence-based approach for
individuals who engage in self-harming behaviors. One of the core techniques used in DBT to
address self-harm is "Distress Tolerance." Distress Tolerance skills are designed to help
individuals better tolerate and manage intense emotions without resorting to self-harm.
TIP Skills, which stands for Temperature, Intense Exercise, and Paced Breathing, are a set of
strategies aimed at rapidly reducing emotional distress by altering the body's physiological
response. These techniques help individuals create a physical change in their bodies, which can,
in turn, affect their emotional state and reduce the urge to self-harm (Linehan, M. M, 1993).
Distress Tolerance: The TIP Skills technique is just one component of Distress Tolerance in
DBT. It's important to note that DBT is a comprehensive therapy approach that also includes
other components like emotion regulation, interpersonal effectiveness, and mindfulness, which
are all integrated to help individuals manage their emotions and reduce self-harming behaviors
Mindfulness: Learning to be present in the moment and observe thoughts and emotions non-
judgmentally.
Emotion Regulation: Identifying and managing intense emotions effectively.
Interpersonal Effectiveness: Developing healthy communication and relationship skills.
Acceptance and Commitment Therapy (ACT)
Acceptance and Commitment Therapy (ACT) is a therapeutic approach that aims to help
individuals accept their thoughts and feelings while committing to values-based actions. ACT
can be used to address self-harming behaviors by fostering greater psychological flexibility and
promoting healthier coping strategies.
Defusion techniques in ACT are designed to help individuals distance themselves from their
thoughts and reduce their impact. When applied to self-harm, defusion helps individuals detach
from urges or thoughts related to self-harm, allowing them to view these thoughts as passing
events rather than absolute truths. By doing so, they can choose not to act on these urges (Hayes,
Strosahl & Wilson, 2011).
Metaphor and Personification: Encourage the person to give their self-harming thoughts a name
or visualize them as characters separate from themselves. This can help create distance between
the individual and their thoughts and make it easier to view them objectively.
Thought Labeling: Teach the individual to label their self-harming thoughts as just thoughts, not
necessarily facts or commands. For example, they can say, "I'm having the thought that I should
hurt myself," rather than simply accepting the thought as truth.
Mindfulness and Observing: Encourage mindfulness practices to help individuals observe their
thoughts and emotions without judgment. This can create awareness and detachment from the
urge to self-harm.
Thought Defusion Exercises: Use exercises like "Thanking Your Mind" where individuals thank
their mind for the self-harming thoughts without acting on them. This acknowledges the presence
of the thoughts without engaging in self-destructive behavior.
The Leaves on a Stream Metaphor: Ask the individual to imagine their thoughts as leaves
floating down a stream. They observe each thought without holding onto it or trying to push it
away. This can help detach from distressing thoughts.
Sing It: Encourage individuals to sing their self-harming thoughts or urges to a familiar tune in a
silly or playful manner. This can make the thoughts seem less threatening and easier to defuse.
Thought Experiments: Engage in thought experiments where the individual explores the
consequences of acting on self-harm versus choosing not to. This can help them make more
informed choices based on their values and long-term goals.
Value-Based Commitment: Help the individual identify their core values and connect these
values to actions that promote well-being. This can provide motivation to choose behaviors that
align with their values instead of self-harm.
Mindfulness-Based Cognitive Therapy (MBCT)
It combines principles of mindfulness meditation with cognitive-behavioral techniques. It is
often used to help individuals with recurrent depression and can be adapted to address self-harm
behaviors by increasing awareness and developing healthier responses to difficult emotions.
The Three-Minute Breathing Space is a brief mindfulness exercise designed to help individuals
shift their attention from automatic and potentially self-destructive thoughts or behaviors to the
present moment. It consists of three stages: becoming aware of one's experience, gathering one's
attention, and expanding awareness to the body and surroundings. This technique can be used
when an individual feels the urge to self-harm to help them pause and regain control (Segal.,
Williams & Teasdale, 2002).

PSYCHOTHERAPY FOR SUBSTANCE ABUSE

Psychotherapy, also known as talk therapy or counseling, is an essential component of the
treatment for substance use disorders (SUDs). It is often used in conjunction with other
interventions, such as medication-assisted treatment (MAT) and support groups, to provide a
comprehensive approach to helping individuals recover from SUDs.
Motivation Enhancement Training (MET)
It is an evidence-based approach used to help individuals with substance use disorders increase
their motivation to change their behavior and engage in treatment. MET is typically a short-term
intervention that draws from the principles of motivational interviewing and cognitive-behavioral
therapy. It is designed to help individuals explore and resolve their ambivalence about change,
ultimately moving them towards a commitment to quitting or reducing substance use.
Assessment and Feedback: MET begins with a comprehensive assessment of the individual's
substance use and its impact on their life. This assessment is often accompanied by personalized
feedback, which is a key motivator for change. It helps individuals recognize the discrepancy
between their substance use and their personal goals and values (Miller & Rollnick, 2002).
Expressing Empathy: MET therapists create a nonjudgmental and empathetic environment where
individuals feel understood and respected. Empathy is crucial for building rapport and
facilitating change
Developing Discrepancy: MET helps individuals recognize the inconsistencies between their
current behavior and their desired goals and values. This discrepancy serves as a catalyst for
change (DiClemente & Velasque, 2002).
Avoiding Argumentation: MET therapists avoid confrontation and argumentation, as these can
trigger resistance in individuals with substance use disorders. Instead, they employ strategies to
elicit the person's own arguments for change.
Supporting Self-Efficacy: MET helps individuals build confidence in their ability to change by
identifying their strengths and past successes. This enhances their self-efficacy, which is crucial
for making positive changesm (Bandura, 1977).
Developing a Change Plan: MET assists individuals in developing a concrete plan for change.
This may include setting specific goals, identifying strategies to cope with triggers, and seeking
social support.
Follow-Up and Relapse Prevention: MET often includes follow-up sessions to track progress and
provide ongoing support. Relapse prevention strategies are discussed to help individuals
maintain their gains (Marlatt & Donovan, 2005).
The Motivation Grid
It is a therapeutic tool used in Motivation Enhancement Training (MET) and is based on the
principles of motivational interviewing. It helps individuals with substance use disorders
visualize their ambivalence about change and clarify their feelings and thoughts regarding their
substance use. The grid is typically used during MET sessions to facilitate a productive
conversation about change.

Components of the Motivation Grid:

Change Talk (Pros): This quadrant of the grid represents the positive aspects and reasons for
changing substance use behavior. It includes statements and thoughts that reflect an individual's
desire and motivation to quit or reduce their substance use. These statements may indicate the
benefits of change, such as improved health, relationships, or personal fulfillment.
Sustain Talk (Cons): In this quadrant, individuals express their reasons for maintaining their
current substance use patterns. Sustain talk includes statements that reflect the perceived
advantages or reasons for continuing substance use. It can involve minimizing the negative
consequences or emphasizing the perceived benefits of the substance.
Desire (Importance): The vertical axis of the grid measures an individual's desire or importance
of changing their substance use behavior. It reflects the intensity of their motivation to change,
with high importance indicating a strong desire for change and low importance indicating less
motivation.
Ability (Confidence): The horizontal axis of the grid measures an individual's perceived ability
or confidence in making a change. It reflects their self-efficacy or belief in their capacity to quit
or reduce substance use successfully. High confidence indicates a strong belief in their ability to
change, while low confidence suggests self-doubt or uncertainty
Aversion therapy
Based on classical conditioning principles, aversion therapy is a form of treatment for
substance abuse that pairs the stimulus with some type of negative or aversive stimulus.
Principles of Aversion Therapy: Aversion therapy is based on the principle of classical
conditioning, where a conditioned stimulus (the substance) is paired with an aversive stimulus
(something unpleasant) to create a conditioned response (avoidance of the substance). In the case
of substance use, the goal is to make the act of using the substance physically uncomfortable or
nauseating.
Alcohol Aversion Therapy: For individuals with alcohol use disorder, aversion therapy may
involve the administration of a medication called disulfiram (Antabuse) along with alcohol
consumption. Disulfiram blocks the breakdown of alcohol in the body, leading to the
accumulation of acetaldehyde, a toxic substance. This results in symptoms such as nausea,
vomiting, and headache when alcohol is consumed, effectively deterring the individual from
drinking.
Tobacco Aversion Therapy: In the context of smoking cessation, aversion therapy has been
explored using techniques such as rapid smoking, where individuals are made to smoke rapidly
in a short period, leading to discomfort and aversion to smoking.
Ethical Considerations: It's important to note that aversion therapy can be controversial, as it
involves intentionally inducing discomfort or unpleasant experiences. Ethical guidelines and
informed consent are critical when using aversion therapy techniques, and it should only be
administered by qualified professionals in a controlled and supervised setting (Kranzler &
Liebowitz, 1988).
Rational Emotive Behavior Therapy
REBT helps patients understand their own thoughts and then helps to develop better
habits and thinking in more positive and rational ways and gain healthier emotions.
Relapse prevention training
It involves identifying potentially high-risk situations for relapse and then learning behavioral
skills and cognitive interventions to prevent the occurrence of a relapse
Contingency management
Based on operant conditioning—increasing sobriety/adherence to treatment program
through rewards. In general, patients are “rewarded” with vouchers or prizes in exchange for
abstinence from substance use (Hartzler, Lash, & Roll, 2012). A major benefit of CM is, it
reduces dropping out and relapse (Mignon, 2014).
Alcoholics Anonymous (AA)
It is a well-known international fellowship of individuals who have struggled with alcohol
addiction and who come together to support one another in achieving and maintaining sobriety.
AA is based on a 12-step program that outlines a set of guiding principles and actions to help
individuals recover from alcoholism.
Founding and History: AA was founded in 1935 by Bill Wilson and Dr. Bob Smith, both of
whom were recovering alcoholics. It began as a way for individuals to share their experiences
and provide mutual support to maintain sobriety. Since then, AA has grown into a global
organization with meetings held in many countries.
12-Step Program: The core of AA is its 12-step program, which outlines a series of spiritual
principles and actions to help individuals achieve and sustain sobriety. These steps are based on
self-examination, admitting one's shortcomings, making amends for past wrongs, and offering
support to others.
Meetings: AA meetings are the cornerstone of the program. These meetings are held regularly in
local communities and are open to anyone who has a desire to stop drinking. During meetings,
participants share their experiences, discuss their progress in recovery, and offer support to one
another. Meetings can vary in format, including speaker meetings, discussion meetings, and
more.
Sponsorship: AA encourages the concept of sponsorship, where more experienced members
(sponsors) provide guidance and support to newcomers (sponsees) as they work through the 12
steps and navigate the challenges of recovery.
Anonymity: Anonymity is a fundamental principle of AA. Members are encouraged to maintain
confidentiality and not disclose the identities or personal stories of fellow members outside of
meetings. This helps create a safe and non-judgmental environment for individuals seeking help.
Residential treatment centers
The individuals are completely removed from their environment and live, work, and
socialize within a drug-free environment while also attending daily individual, group, and family
therapy.
Community reinforcement
The goal is to abstain from substance use by replacing the positive reinforcements of the
substance with that of sobriety, through several different techniques such as motivational
interviewing, learning adaptive coping strategies, and encouraging family support (Mignon,
2014).
Multi-Systemic Therapy (MST)
An intensive family- and community-based treatment program designed to make positive
changes in the various social systems (home, school, peer relations) that contribute to the serious
antisocial behaviors of children and adolescents. It seeks to empower parents with the skills and
resources needed to independently address the difficulties that arise in raising teenagers.
Matrix Model: It is a combination of various therapeutic techniques that is originally developed
for the treatment of individuals with stimulant addictions. The therapists focus on rewarding
good behaviors and teaching patients to believe in themselves; self-esteem, dignity, and self-
worth.
Community Reinforcement Approach (CRA)
Generally, utilizes social, recreational, familial, vocational and other community
reinforcers to aid patients in the recovery process. Typical components include vocational
counseling; job finding agencies; recreational counseling and activities; social skills training;
social clubs; etc.
PSYCHOTHERAPY FOR PERSONALITY DISORDERS
A group of disorders characterized by long-standing patterns of intra- and interpersonal
difficulties – tends to be highly structured, integrative, and often long-term, with special attention
made to the relationship between therapist and patient.
Personality disorders stress the chronic, long-standing nature of characteristics and patterns of
responding to distress that often are limited in variability and rigidly applied regardless of
appropriateness to context (Levy and Johnson 2016). PDs are highly prevalent in the general
population (likely around 10%, with some estimates of up to 18%).
Cognitive therapies
Cognitive analytical therapy: It combines cognitive and analytical approaches and has been
applied to the treatment of personality disorders, particularly the borderline group.The clinical
manifestations of this condition are postulated to be a set of partially dissociated ‘self-states’
which account for the clinical features of this disorder. Such patients typically describe rapid
switching from one state of mind to another, experiencing intense uncontrollable emotions or
alternatively feeling muddled, or emotionally cut-off. Such ‘dissociative states’ (different from
the conditions of similar name formerly linked to hysteria) are said to be activated by severe
external threats and to be maintained by repetitions of threat and reinforcement by memories or
situations which are similar to the original source of threat.
Cognitive analytical therapy is concerned with the identification of these different self-states and
helping patients to identify ‘reciprocal role procedures’, or patterns of relationships which are
learned in early childhood and are relatively resistant to change. The patient is taught to observe
and try to change damaging patterns of thinking and behaviour which relate to these self-states
and to become more self-aware. The therapist’s role is to gather information about the patient’s
experience of relationships and the different states he or she experiences, including interpretation
where necessary. Although the standard measure of evidence of effectiveness, the randomized
controlled trial, has still not yet been reported for this treatment it has gathered an impressive
group of adherents and has become widely used and now has a good theoretical and pragmatic
base.
b) Cognitive behaviour therapy: The cognitive model of personality disorder does emphasize
cognitive, emotional, and behavioural factors but the origins of personality problems are
regarded as originating in the temperament of the child, childhood development, and
experiences. Early infant attachment patterns, the child’s internal working model of
relationships, self-identity, self-worth, and the emotional availability of the infant’s caregivers
are central to how the child develops and these shape the adult self-identity, interpersonal
relationships in adulthood, and behavioural and emotional coping responses.
One of the first tasks of cognitive therapy in personality disorders is to gain an historical account
of the patient’s childhood development and background from which the therapist can derive
a cognitive formulation linking past difficulties and presenting problems. Through the
formulation, and understanding of the patient’s view of self and others, unique core beliefs are
identified that are linked to affect and to overdeveloped behavioural patterns that prevent the
individual from functioning in an adaptive manner, particularly in interpersonal contexts.
Therapy focuses on beliefs that concern core concepts about the self and others that have
developed from childhood onwards and associated behaviours that have developed as coping
strategies. Once a clear understanding of the content of patient’s core beliefs and associated
overdeveloped or compensatory behavioural patterns has been established, patients are
encouraged to test out their beliefs and assumptions about others by learning new, more adaptive
strategies for relating to others and to themselves.
In borderline personality disorder, typically patients hold beliefs such as ‘I am a bad and
inadequate person’ and ‘others will abandon or reject me’. Having formed these beliefs through
experiences in childhood, borderline patients, for example, may have learnt to avoid close
relationships, are highly sensitized to signs of disapproval in others and have developed a
punitive, self-critical style of thinking and behaviour, including self-harm. The emphasis in
cognitive therapy is in developing new ways of thinking about self and others and in testing out
new ways of behaving that are less self-defeating and more likely to improve the patient’s
interpersonal skills.
In comparison with the treatment of Axis I disorders, cognitive therapy with personality-
disordered individuals takes more sessions and spans a longer time because the underlying
problems are more pervasive and ingrained.
(c) Other related psychological therapies
Schema-focused therapy
Schema-focused therapy is now becoming increasingly used in the treatment of borderline and
antisocial personality disorders. It is a compendium of cognitive behaviour therapy, object
relations theory, and gestalt therapy, and also involving what Young calls ‘limited reparenting’.
It is given in a relatively intensive form—two to three sessions a week for 1–2 years—but has
been shown to be both more effective and cost-effective than transference-focused
psychotherapy in a trial of treatments for borderline personality disorder
Dialectical behaviour therapy
The era of evidence-based therapy in personality disorder began with a formal trial of dialectical
behaviour therapy, a form of cognitive behaviour therapy linked to skills training and detached
acceptance (or mindfulness), was compared with treatment as usual in a group of repeatedly self-
harming female patients with borderline personality disorder. The hypothesis that dialectical
behaviour therapy was effective in reducing self-harm was supported. Now several other
randomized trials have taken place that show that DBT is particularly effective in reducing self-
harm though in another study, DBT improved hopelessness, depression, anger, and suicidal
ideation but showed no difference in suicide attempts.This treatment has also been used
systematically in the treatment of borderline personality disorder and those with comorbid
substance abuse
Cluster A PD Treatments
Cluster A comprises paranoid personality disorder (PPD), schizoid personality disorder (SPD),
and schizotypal personality disorder (StPD). These disorders affect 2%, slightly less than 1%,
and 4% of the Western population, respectively, and can be highly disabling. Their incidence is
higher in men than in women and the conditions are characterized by odd, eccentric, or cold
behavior (particularly SDP and StPD). It is thought that a biological relationship may exist
between the disorders and the schizophrenias, although of the three, StPD is more demonstrably
linked to schizophrenia phenomenologically and genetically (McGlashan, 1983). SPD and StPD
are sometimes grouped as part of a continuum, given the similarity of certain symptoms. No
distinctive set of psychoanalytic, cognitive-behavioral therapy (CBT) or group theories is
applicable to these conditions. More research is needed before specific psychological theories
can be established. Conceptualization of Cluster A disorders tends to utilize theories developed
from the study of psychosis
Psychodynamic approaches pay special attention to transference counter transference
phenomena in order to grasp what is taking place in the therapeutic relationship. Without careful
attention to the therapeutic alliance and interpretation of the transference particularly the
negative transference treatment can founder, above all with PPD where levels of suspicion are
high. In practice, this means that the therapist must try to understand how he or she is being
experienced by the patient, not least in object relations terms (Who am I currently representing
for the patient, and in what way? and to how the patient is making the therapist feel [e.g. I am
now experiencing strong feelings (these may be boredom, sexual, aggressive feelings, etc.): to
what extent do these feelings originate in me or is the patient inducing me to feel these?). The
effects of splitting of the patient’s ego and of the object (cf. the paranoid-schizoid position,
Klein, 1946) underlie these transference/ countertransference issues and can make treatment
confusing and erratic. At one moment the therapist may be experienced positively, even as an
idealized figure; this can change dramatically into the therapist being seen as a persecuting critic
or tyrant. This can take place without the therapist saying anything controversial and signifies a
radical disjuncture in the patient's affective experience of others.
The more a patient can express true feelings in the transference, the more therapeutic the
treatment is likely to be. Avoiding malignant regression is important. Regression is a defensive
reversion, under stress, to earlier forms of thinking and object-relating and is often inevitable in
therapy. Benign regression signifies a healthy satisfying of certain infantile needs by working
these through collaboratively in the therapy. Malignant regression denotes a situation is which
the patient tries but fails to have these needs met and the situation yields a vicious cycle of
demanding, addiction-like states. The analyst's technique, counter transference responses and
capacity for maintaining boundaries are important in avoiding malignant regression (Balint,
1968). To achieve the trust of a Cluster A patient the therapist must tolerate difficult, even
extreme counter transference feelings. These feelings are commonplace because the patient will
try to rid him or herself of unacceptable feelings by projecting them on to the therapist. This
activity needs to be attended to for its communications value and for its potential to derail an
understanding of the patient's emotional state if the therapist reacts in an overemotional way
(Heimann, 1950; Carpy, 1989; Gabbard and Wilkinson, 1994).
Negative therapeutic reactions (stubborn resistances to improvement usually following some
improvement; cf. Freud, 1923; Riviere, 1936; Steiner, 1994) are to be expected and the
separation anxieties, narcissistic rages, and envious impulses associated with these require
interpretation. For SPD patients’ transference interpretation of claustro-agoraphobic anxieties is
necessary (Rey, 1994). Actings-out by patients and crises over money, timings, holidays, etc. can
arise and these may need to be responded to by reality-based, supportive interventions, together
with interpretation of the anxieties being defended against. Therapeutic goals require realistic
assessment and regular monitoring: progress may be slow and erratic with setbacks and perhaps
limited eventual gains. Interpretation and explication together may be required to support
movement from disorganized thinking towards integration of severe anxieties, especially in StPD
where fragmentation of the ego may prevail.
Cognitive approaches tend be technically similar for all Cluster A disorders in that they target
the pathological belief or system (schema) and this helps particularly in the amelioration of
maladaptive habits and in limit setting. Associated problems of depression and self-image are
tackled as secondary phenomena. Establishing initial trust in the therapeutic relationship requires
a flexible approach that is sensitive to changes in the patient’s mental state. A neutral standpoint
is maintained in relation to the patient's perspective of their problems alongside validation of the
affective experience. The therapist teases out particular life circumstances and events that
provide a context for the formation and maintenance of the patient's beliefs. One important
difference between a psychodynamic and CBT perspective is that paranoid responses (these are
common in Cluster A disorders) are not necessarily regarded as transference issues but instead as
reactions to perceived threat. In CBT the patient is invited to test out their beliefs and to review
evidence and alternative hypotheses. A new, more realistic model of events is constructed with
the patient. The therapist and patient collaborate to examine and assess evidence for and against
certain beliefs using behavioral experiments.
Negative self-evaluations may be isolated and reviewed according to a more realistic appraisal of
the person’s circumstances.
Group approaches are based upon the conscious and unconscious network of relationships
within groups, sometimes referred to as the matrix (Blackwell, 1998). The emphasis lies on
social functioning rather than individual unconscious drives (the whole is more elementary than
the parts). The matrix” or the way the group functions as a social unit”is a powerful agency. It is
an object of attachment and a source of safety and containment, and these harbor therapeutic
potential. Group analytic theory was developed by Foulkes, a psychoanalyst, who paved the way
for understanding group relations processes (Foulkes, 1964, 1986). He identified processes in
groups such as resonance, condenser phenomenon, and mirroring through which unconscious
activity can be described: (1) resonance involves shared experience of supportive identifications
between group members; (2) condenser phenomena describe articulation of unconscious feelings
through shared forms of symbolization; and (3) mirroring is where group members can observe
and integrate split-off parts of themselves by seeing them in others and coming to understand
them through engagement with the group. Nonverbal therapeutic techniques such as acceptance
of silence without striving to explore or interpret (particularly for schizoid members), tolerance
of oddness (for the schizotypal) and use of sympathetic eye contact can be therapeutically
effective in addition to verbal interventions. Foulkes ideas have been applied to work in TCs
(therapeutic community) where the activities of daily living offer a benefit to Cluster A patients
as they can be engaged in therapeutic relationship building without needing to talk. TC
approaches embody two main precepts: the community as the agent of change and the TC culture
of self-help. Typically, TCs are residential facilities and the resident is expected to adhere to
certain behavioral norms. The resident may progress through a hierarchy of increasingly more
important roles, with greater privileges and responsibilities. Individual and group therapy, group
sessions with peers, community-based learning, confrontation, games, and role-playing may all
be utilized as part of an extensive therapeutic experience. TC treatment varies but can be
broadly divided into three major stages: (1) induction during the first month or so in order to
assimilate the individual into policies and procedures; (2) systematic involvement at multiple
levels of engagement individual, group and social using the methods described above (a typical
day might start at 7 a.m. and end at 11 p.m. and comprise morning and evening community
groups/meetings, groups, seminars, work tasks, individual therapy, and recreation); and (3) a
phased transition into the outside world in which the values and practices of TC are carried into
normal living.
Challenges
Cluster A individuals are the least likely of the personality disorder groups to undertake
psychotherapy of any kind due to their reduced capacity to engage in relationships. However, it
does not follow that psychotherapy is automatically contraindicated: many patients do benefit
from therapy. All forms of therapy face significant challenges with Cluster A patients, although
their strategies for dealing with these differ. PPD patients threaten the therapeutic relationship
through their suspiciousness and distorted conviction that hostility and danger are omnipresent.
Alertness to signs of mounting suspiciousness is therefore essential: this needs to be responded
to by transference interpretation (psychodynamic therapists), empathic discussion, and review of
evidence for beliefs (CBT) and open acknowledgement within the matrix (group therapists).
Directly confronting PPD beliefs by argument can have the effect of reinforcing the belief as
PPD patients use projective identification extensively to externalize hostile impulses for fear of
destroying the therapeutic relationship. The following is an extract from a psychoanalytic
psychotherapy session with a 40-year-old patient with PPD symptoms. She suffered an internal,
superego voice that advised her against relationships.
Research on psychotherapy for the treatment of Cluster A (paranoid, schizotypal, and schizoid)
PDs has been fairly limited, perhaps because such patients may be less likely to present for
treatment.Research from naturalistic follow-up studies of hospitalized patients suggests that
patients with Cluster A PDs do not show much improvement over time. A few trials have found
that patients with mixed Cluster A PDs improved significantly following psychotherapy.One
study found that patients in day hospital and inpatient conditions experienced greater
improvement than patients in an outpatient treatment condition (Bartak et al. 2011) suggesting
that more intensive approaches may be helpful for patients with Cluster A PDs.
Cluster B PD Treatments
The majority of psychotherapy outcome research for Cluster B PDs has focused on BPD. There
is evidence of varying degrees of support for at least nine therapies for this disorder, derived
from a range of psychotherapy orientations. These treatments include the following individual
psychotherapies (some with additional group-based components) from a cognitive behavioral
tradition:
Dialectical behavior therapy (DBT), schema-focused therapy (SFT), and standard CBT, and the
following from a psychodynamic tradition, mentalization-based treatment (MBT), transference-
focused psychotherapy (TFP), dynamic deconstructive psychotherapy (DDP), and cognitive
analytic therapy (CAT).
Mentalization based treatment (MBT) based on the developmental theory of mentalizing,
which integrates philosophy (theory of mind), ego psychology, Kleinian theory, and attachment
theory.Mentalizing involves both (1) implicit or unconscious mental processes that are activated
along with the attachment system in affectively charged interpersonal situations and (2) coherent
integrated representations of mental states of self and others.
Transference-Focused Psychotherapy (TFP) focus on the development of integrated
representations of self and others, the modification of primitive defensive operations, and the
resolution of identity diffusion that perpetuates the fragmentation of the patient’s internal
representational world (Yeomans et al. 2013).
In this treatment, a triad of clarifications, confrontations, and interpretations are used to both help
the therapist understand the internal world of the patient and then to help the patient understand
and come to terms with the conflicts involved in this world.
Dynamic Deconstructive Psychotherapy. DDP is a 1-year psychodynamic treatment package
that addresses three neurocognitive functions distorted in individuals with BPD: attribution
(thoughts of value or motive assigned to people and behaviors), association (linking symbols or
language to experiences or physical characteristics), and alterity (ability to realistically and
objectively view the world and others).
Cluster C PD Treatments
Although highly prevalent in both the general population and clinical settings, there are relatively
few psychotherapy efficacy studies specific to Cluster C personality disorders.
Svartberg et al. (2004) report findings from study in which they compared a short-term
psychodynamic treatment with CBT for Cluster C PDs and found significant reduction in
symptomatology for the psychodynamic group but not the CBT group (although there were no
statistical differences between the two groups).
The literature suggests that compared to other Cluster C personality disorders, individuals with
OCPD tend to show greater improvement in treatment.
Winston et al. (1994) found that short-term psychodynamic interventions were especially
effective for individuals with OCPD features.In Avoidant Personality Disorder, improvements
can be found with treatments that employ social skills training alone or in combination with
exposure and cognitive techniques and that CBT may outperform dynamic treatments for AVPD.
Common Challenges for Therapists Treating PDs
The chronic nature of PDs and the tendency for PD symptoms to be severe and pervasive
impacting the way patients perceive, think about, and relate to themselves and others – can be
challenging for clinicians to treat.
The therapists may have strong, intense, and uncomfortable reactions to patients with PDs,
sometimes referred to as countertransference. Feelings evoked in therapists may lead them to
enactments of problematic behaviors or roles or to engage in iatrogenic behaviors (Levy and
Johnson 2016).
In ASPD, there may be a higher risk for criminal acting out or manipulation of the
therapist.Patients with BPD may engage in suicidality or self-injury and experience frequent,
sometimes “unrelenting” crises (Linehan 1993). They may tend to split providers into idealized
and devalued groups, which, if not well-managed, can impact the treatment team’s ability to
collaborate effectively.
The potential for such risks, the possibility for intense emotional reactions on the part of both
patient and therapist, the importance of maintaining the treatment frame, and the length of
treatment required combine to make the treatment of PDs challenging
Therapists may be at risk for experiencing burnout as a result of the challenges associated with
treating personality pathology. Burnout results from prolonged stress related to work, causing
physical, cognitive, and emotional dysfunction in professionals who were previously motivated
and high-functioning. In the context of psychotherapy for PDs, providing treatment can result in
emotional exhaustion, a reduced sense of personal efficacy, and a tendency to feel distant or
disconnected or view patients in a cynical manner (Clarkin et al. 2006).

CHRONIC MENTAL ILLNESS

Chronic mental illness refers to conditions with persistently debilitating psychiatric symptoms
and severely impaired function. Individuals with chronic mental illness suffer from symptoms
that may interfere with their ability to perform activities of daily living (ADLs) and to participate
in work, school, and interpersonal relationships. At times in their lives, these individuals often
require significant care from family and from mental health care providers.
The limitations caused by schizophrenia, severe mood disorders, and some personality disorders
(such as schizotypal, schizoid, or borderline) may lead to chronically disabling symptoms.
Severe substance abuse is commonly co-morbid among individuals with chronic mental illness,
and may, by itself, lead to chronic impairment.
Medication Management
Medication management is a critical component of the treatment of various chronic mental
illnesses, including schizophrenia, bipolar disorder, major depressive disorder, and anxiety
disorders. This approach involves the careful and systematic use of psychiatric medications to
alleviate symptoms, stabilize mood, and improve overall functioning.
Psychotherapy: Different forms of psychotherapy can be effective in managing chronic mental
illnesses. These include:
Cognitive-Behavioral Therapy (CBT): Helps individuals identify and change negative thought
patterns and behaviors, often used for depression, anxiety, and bipolar disorder.
Dialectical Behavior Therapy (DBT): Focuses on emotional regulation and interpersonal skills,
beneficial for borderline personality disorder and other conditions.
Acceptance and Commitment Therapy (ACT): Promotes psychological flexibility and
acceptance of distressing thoughts and emotions, useful for various conditions.
Psychosocial Rehabilitation: This approach focuses on helping individuals with chronic mental
illnesses develop skills and strategies to improve their daily functioning, social relationships, and
vocational skills. It often includes programs such as supported employment, housing, and
education.
Family Therapy: Involves working with the family to address communication issues and
improve support systems. It can be particularly beneficial for conditions like schizophrenia and
bipolar disorder.
Group Therapy: Provides a supportive and therapeutic environment where individuals with
similar conditions can share their experiences, learn coping strategies, and reduce feelings of
isolation.
Peer Support: Peer support programs involve individuals with lived experience of mental illness
providing guidance and support to others facing similar challenges.
Mindfulness and Meditation: These practices can help individuals manage stress, reduce
symptoms, and improve overall well-being. Mindfulness-based interventions are increasingly
used in the treatment of chronic mental illnesses.
Rehabilitation Programs: These programs focus on restoring functional abilities, such as
vocational training, social skills training, and cognitive remediation, to enhance the
independence and quality of life for individuals with chronic mental illnesses.

Case Management: Case managers assist individuals in accessing necessary services,

coordinating care, and addressing practical life issues like housing and financial stability.
Teletherapy: In recent years, the availability of online and teletherapy services has expanded,
making mental health support more accessible for individuals with chronic mental illnesses,
especially in remote or underserved areas.
Integrated Care Coordinated care that combines psychological interventions with medication
management and other medical services can provide comprehensive treatment for individuals
with chronic mental health conditions.
It's essential to tailor psychological interventions to the specific needs and preferences of the
individual with a chronic mental illness. Effective treatment often involves a multidisciplinary
approach, with collaboration between mental health professionals, primary care providers, and
support networks. Additionally, ongoing evaluation and adjustment of the treatment plan are
crucial to address the evolving needs of individuals with chronic mental illnesses.

References

Bateman, A., & Fonagy, P. (2006). Mentalization-based treatment for borderline personality
disorder: A practical guide. Oxford: Oxford University Press.
Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. (2006). Psychotherapy for borderline
personality: Focusing on object relations (1st ed.). Arlington: American Psychiatric
Publishing.
Farrell, J. M., Shaw, I. A., & Webber, M. A. (2009). A schema-focused approach to group
psychotherapy for outpatients with borderline personality disorder: A randomized
controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 40(2), 317–328.
Gerstley, L., McLellan, A. T., Alterman, A. I., Woody, G. E., Luborsky, L., & Prout, M.
(1989). Ability to form an alliance with the therapist: A possible marker of
prognosis for patients with antisocial personality disorder. The American Journal
of Psychiatry; Washington, 146(4), 508–512.
Leichsenring, F., & Leibing, E. (2003). The effectiveness of psychodynamic therapy and
cognitive behavior therapy in the treatment of personality disorders: A meta-analysis. American
Journal of Psychiatry, 160(7), 1223–1232
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality
disorder. New York: Guilford Press.
Muran, J. C., Safran, J. D., Samstag, L. W., & Winston, A. (2005). Evaluating an alliance
focused treatment for personality disorders. Psychotherapy: Theory, Research, Practice,
Training, 42(4), 532
Weinberg, I., Gunderson, J. G., Hennen, J., & Cutter, C. J., Jr. (2006). Manual assisted
cognitive treatment for deliberate self-harm in borderline personality disorder
patients. Journal of Personality Disorders, 20(5), 482.
Yeomans, F. E., Levy, K. N., & Caligor, E. (2013). Transference-focused psychotherapy.
Psychotherapy, 50(3), 449–453
Hawton, K., et al. (2016). Cognitive-behavioral therapy for self-harm: Systematic review and
meta-analysis. JAMA Psychiatry, 73(8), 1-9.
Turner, B. J., et al. (2019). Cognitive-behavioral therapy for adolescents who self-harm: A
systematic review and meta-analysis of randomized controlled trials. Journal of the American
Academy of Child & Adolescent Psychiatry, 58(1), 40-51.
Ougrin, D., et al. (2015). Randomized controlled trial of therapeutic assessment versus usual
assessment in adolescents with self-harm: 2-year follow-up. Archives of Suicide Research, 19(3),
337-353