International Journal of Psychotherapy, Counseling & Psychiatry: Theories, Researches & Clinical Practices

Effective and Efficient Psychotherapy

Which psychotherapy is effective and efficient to help individuals get cured of the vast arrays of psychopathologies such as depression, anxiety and schizophrenia? There are many forms of psychotherapy that are able to do so. But they are not necessarily efficient. And most are not effective.

Limitations of Cognitive Behaviour Therapy

Cognitive Behaviour Therapy (CBT) Beck, (1967); Clarke (1996); Barlow (2002), has shown that it is able to help patients with ~~the~~ [JY1] many pathologies but there is no evidence that this outcome last. There isis no longitude studies of the effect of CBT. This is because CBT is not based on attachment science. Human being is a social and relational being as Siegel (2010) has shown. It is because when this relational and social context were not properly provided during childhood that psychopathologies develop. CBT did not help patients to re-establish their dysfunctional attachments and therefore their psychopathologies did not get cured.

Limitations of Imago Therapy

Imago Therapy was founded by Hendrix & Hunt (1998). It was based on the Freudian idea of individuals growing up with unmet needs during childhood. Hendrix and Hunt never specified these unmet needs but rather kept them fluid and loosely undefined. However, they postulated that individuals with unmet needs due to the specific sets of negative personality traits of their parents would subconsciously find partners with similar sets of negative personality traits (ie: the imago) to trigger the wanting of these unmet needs with the subconscious intention to get them met.

Hendrix and Hunt (1998) has the insight that humans are relational and social beings with Imago attractions, but they fail to provide a therapeutic process to capitalise on this insight.

The Imago therapists were not able to help couples resolve their conflicts and cure them of their dysfunctional schemas (Young, Weishaar & Klosko, 2003). Various imago techniques such as the Couple Dialogues (Hendrix & Hunt, 2015) were used with couples in the therapy room. However, when these techniques were prescribed as homework for couples to do on their own outside the therapy room, they often fail to do so successfully and were not able to resolve their chronic conflicts and psychopathologies. On their own, the couple's dysfunctional Imago coping modes arising from their dysfunctional schemas (Young et al., 2003) are just too strong to change. The couples in their own vulnerable and dysfunctional schemas do not feel safe enough to reconnect with each other. There is no outcome study on Imago Therapy.

Schema Therapy and Schema Couple Therapy

Young, Rafaeli & Bernstein (2010) formulated and specified a number of dysfunctional schemas based on these childhood unmet needs that trigger various dysfunctional coping modes.

They did not formulate the imago concept of individuals finding partners with Imago dysfunctional coping modes which is postulated in Imago Therapy (Hendrix and Hunt, 2015).

As Young said: the ultimate objective of schema therapy is to help adults get their own needs met, even though these needs may have not met in the past. (Young et al., 2010, p. 52)

However as Young himself admitted: the nurturance of the Vulnerable Child mode, and the access to the mode that it requires, are often quite difficult to achieve. (ibid). It is therefore difficult for the schema therapist to get patient into this state of vulnerability.

And as pointed out by Young: If the vulnerability is kept hidden or obscured, no such process can take place: the schemas cannot heal unless the patient is in the Vulnerable Child mode. (ibid).

The patient in relationship however as Hendrix and Hunt (1998) has observed and all of us who are and have been relationships can also attest to, have access to our Vulnerable Child modes regularly with chronic conflict outcomes leading to the high separation and divorce rates that we see today.

And yet couples get back together, albeit with different partners because as Hendrix and Hunt (2015) and Muro, Holliman and Luquet (2016) had observed, the (subconscious) desire to get healed is just too strong. We need relationship to survive as Siegel (2010) has observed.

Schema therapy needs couples to be in the therapy room to be effective. Schema Couple Therapy (Simeone-Difrancesco, Roediger & Stevens, 2015) attempts to do so but did not utilise a therapeutic process that enable them to do so effectively. There is no outcome study on Schema couple therapy.

A new breed of therapists is therefore needed: to set up the couples safely and be there with the couples to facilitate and help the patients feel safe to do the therapy not only effectively but also efficiently with the shortest possible number of sessions. The Couple Drama Therapist is able to so with the Couple Drama Therapy (CDT).

Couple Drama Therapy

CDT is an integration of both Imago Therapy and Schema Therapy to enable therapy to be practiced in a specific way with patients as couples to trigger their dysfunctional schemas, dysfunctional coping modes, unmet childhood attachment needs safely - in the therapy room.

The therapy of CDT involves the dramatization and retraumatisation of childhood painful emotional events of individuals with their caregivers and using their partner as auxiliaries similar to that that used in psychodrama (although in psychodrama partners were often not involved as auxiliaries for fear of projections and counter projections which CDT intentionally encourages) to role play and dramatize those painful emotional events (Moreno, 2011). This therapy is grounded in neuroscience which informs us that the amygdala learned the schema of danger during childhood needs to relearn a different schema: of safety. In order to do this, it needs to re-experience the previous danger and re-experience it again to be different - that it is safe this time. Pare, Quirk and Ledoux (2004) shown that the amygdala was able to rewire itself based on such context.

This amygdala learning and rewiring is done without signalling from the prefrontal cortex which other therapy such as Emotion Focused Therapy (Johnson, 1996) requires and thus take much longer and many more sessions to achieve.

During the dramas provided in CDT, the patients would verbalise and re-experience their emotional pain of unmet needs with their partners as their caregivers who “facilitated” the development of these unmet needs, dysfunctional schemas, vulnerable/angry child and the other dysfunctional coping modes.

The partners in role playing the parents' roles of their partners would subconsciously respond to their partner's emotional pain and cry of their unmet needs with their dysfunctional Imago modes which attracted their partners in the beginning of their relationship. As Hendrix and Hunt (2015) has observed partners are drawn to each other with dysfunctional modes similar to that of their parents.

The subconscious response would typically be in the form of a dysfunctional coping modes that would be similar as those of the parents of their partner, hence perpetuating their partners' unmet needs and dysfunctional developmental schemas and coping modes eg abandoned child schema and vulnerable child/angry child modes, and thereby reinforcing the vulnerable child mode of the vulnerable partner. This process triggers an amygdala response.

The CDT therapist would point out these dysfunctional modes of the responding partner and the developmental modes of the vulnerable partner to the couples. CDT is therapeutic because it brings to awareness in real time with actual clinical material safely the dysfunctional and developmental modes that couples are normally using without awareness which would – without CDT - perpetuate their chronic conflicts.

CDT is effective because it is based on the fact that humans are relational and social beings with brains that need to be developed optimally and healthily with a nurturing environment as Siegel (2010) and Bowlby (1969) have shown.

CDT enables patients as couples to break free from the dysfunctional schemas and connect to each using their modes in ways which schema therapy and imago therapy were not able to do and EFCT was not able to do very efficiently (see below).

The CDT therapist facilitates the unfolding dramatization of dysfunctional couple Imago dynamics for both the couples to experience safely without judgement and criticism of each other.

In doing so, the responding partner acquires the insight that his response was not attuned to the emotional need of his partner’s vulnerable child mode. This insight enables him to change his response and gives him the motivation to do so because of the promise of reconnection with his significant other that was ruptured in childhood. This is the attachment needs observed by Bowlby (1969) and Siegel (2010) which motivated to do therapeutic reconnection with his partner. This is where the CDT therapist is able to help couples change their dysfunctional coping modes into healthy adults coping modes which are therapeutic for both couples because it allows them to connect emotionally with each other. This enables the transformation of the ~~couples~~couple’s dysfunctional schemas into healthy adults schema. The partner with the vulnerable child mode at the same time in CDT is able to experience his/her developmental needs met as he/she has subconsciously intended in the first place by falling in love with their partners with the similar dysfunctional coping modes as that of their parents and in doing so would eventually have their dysfunctional developmental schemas necessarily surfaced as Young et al. (2010) has wanted, to be transformed, finally, into the happy child schemas that the patients have been longing for since childhood but did not get.

Limitations of Emotionally Focused Couple Therapy

Emotionally Focused Couple Therapy (EFCT) (Johnson, 1996) found that couples can indeed relearn their dysfunctional attachment schema and reconnect with their partners but it takes about 20 sessions to do so. This is because the learning needs signalling from the prefrontal cortex signalling to the amygdala (Sapolsky, 2017). EFCT requires couples to deescalate their conflicting stressful emotional amygdala communication and change it to safe amygdala soothing communication. The de-escalation is a PFC task that couples need to learn through the ECFT (ibid) process that requires 20 sessions of therapy.

CDT short-circuit this process. Couples are able to gain insight of the task they need to provide for each other’s amygdalas to rewire and learn without the signalling from their PFCs as Pare et. al. (2004) has shown possible.

CDT therefore is able to help distressed couples to reconnect in one or two sessions whereas EFCT may do the same in 20 sessions. CDT is able to do so because the therapy is based on a more efficient human brain process of amygdala direct rewiring and learning (Pare et. al. Ibid) rather than signalling via the PFC (Sapolsky 2017) which requires a much longer time for couples to learn to deescalate their stressful communication with each other and communicate with the safety signals that their amygdalas require.

CDT explains why couples are able to find each other from the thousands of individuals around them and fall in love in the way that Imago therapy (Hendrix & Hunt, 1996) did which Emotion-Focused Therapy (Greenberg & Johnson, 1988) and Emotion-Focused Couple Therapy (Greenberg & Goldman, 2013) were not able to do. Emotionally Focused Therapy (Johnson, 1996) is an effective form of therapy because it is based on attachment science (Bowlby, 1969) and utilise a therapy process that helps couples to attain their attachment needs that they did not get which Emotion-Focused Therapy (Greenberg & Johnson, 1988), Emotion Focus Couple Therapy (Greenberg and Goldman 2013) and Schema Couple Therapy (Simeone-Difrancesco et al., 2015) were not able to do because their process did not involve couples communicating directly with each other. Imago Therapy involves couple communicating with each other but is not able to get their amygdalas learn because the necessary therapeutic environment is not provided (Hendrix & Hunt, 1996).

Couple Drama Therapy as Efficient and Effective Couple & Individual Psychotherapy

Couple Drama Therapy is the most efficient and effective form of couple and individual psychotherapy. Patients with all psychopathologies can now get their pathologies effectively and efficiently cured.

In order to do so efficiently they need to find an Imago partner and a CDT therapist to help them do so. By Imago partner we mean a partner that they have experienced “falling in love” with (as opposed to partnership from arranged marriage). This is not to say partners from arranged marriages or other non-Imago partnership will not find benefit from CDT as transference and countertransference will still occur with the partnership especially if stable attachment develops.

The single patients can also benefit from CDT but the therapist will have to occupy the role of the partner to dramatize the transference and countertransference materials from developmental dysfunctional schemas

CDT enables couples and individuals to be cured from all of their psychopathologies effectively and efficiently by having their developmental attachment needs met. Their brains and amygdalas are able to learn and rewire to the healthy and optimal state free from all psychopathologies provided by the required relational environment from the CDT therapeutic process.

The patient with their dysfunctional and vulnerable child modes are able to get their dysfunctional schemas transformed to the healthy adult schema and attain the happy child schemas that they have been longing for throughout their lives. They get the attachment needs with their partners that they did not get with their caregivers. They get reconnected and fall in love again with their partners.

References

Ardalani, L., Refahi, Z., & Honarparvaran, N. (2016). Evaluate the effectiveness of training imago-therapy on willingness to forgive in betrayed couples. Indian Journal of Positive Psychology, 7(1), 88-92. Retrieved from http://www.iahrw.com/index.php/home/journal_detial/19#list

Barlow, D. (2002). Anxiety and its disorders. New York: NY: Guilford Press

Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York: Harper and Row.

Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York, NY: Basic Books.

Clarke, D. M. (1996). Science and practice of cognitive behaviour therapy. Oxford, UK: Oxford University Press

Denton, W. H., Johnson, S. M., & Burleson, B. R. (2009). Emotion-focused therapy-therapist fidelity scale: conceptual development and content validity.

Dessaulles, A., Johnson, S. M., & Denton, W. H. (2003). Emotion-focused therapy for couples in the treatment of depression: A pilot study, The American Journal of Family Therapy, 31(5), 345-353. doi: 10.1080/01926180390232266

Greenberg, R. N., & Goldman, L. (2013). Working with identity and self-soothing in emotion-focused therapy for couples, 52(1), 62-82. doi:10.1111/famp.12021

Hendrix, H. (1996). The evolution of imago relationship therapy: A personal and professional journey. Journal of Imago Relationship Therapy. Retrieved from http://imagorelationships.org/pro/wp-content/uploads/sites/3/2016/02/The_Evolution_of_Imago_Relationship_Therapy-published_version.pdf

Hendrix, H., & Hunt, H. (1988). Getting the Love You Want: A Guide for Couples. New York: Henry Holt and Company.

Hendrix, H., Hunt, H., Luquet, W., & Carlson, J. (2015). Using the Imago dialogue to deepen couples therapy. Journal of Individual Psychology, 71(3), 253-272. doi10.1353/jip.2015.0029

Johnson, S. M. (1996). The practice of emotionally focused couple therapy: creating connection. London, UK: Taylor and Francis Ltd

Johnson SM, Talitman E (1997) Predictors of success in emotionally focused marital therapy. Journal of marital and family therapy 23, 135–152. doi:10.1111/j.1752-0606.1997.tb00239.x.

Johnson SM, Williams-Keeler L (1998) Creating healing relationships for couples dealing with trauma: The use of emotionally focused marital therapy. Journal of Marital and Family Therapy 24, 25–40. doi:10.1111/j.1752-0606.1998.tb01061.x.

Johnson SM, Hunsley J, Greenberg L, Schindler D (1999) Emotionally focused couples therapy: Status and challenges. Clinical Psychology: Science and Practice 6, 67–79. doi:10.1093/clipsy/6.1.67.

Johnson SM, Whiffen VE (1999) Made to Measure: Adapting Emotionally Focused Couple Therapy to Partners’ Attachment Styles. Clinical Psychology: Science and Practice 6, 366–381. doi:10.1093/clipsy.6.4.366.

Johnson SM, Bradley B, Furrow JL, Lee A, Palmer G, Tilley D, Woolley S (2005) ‘Becoming an emotionally focused couple therapist: The workbook.’ doi:10.4324/9780203955161.

Johnson SM (2005) Broken Bonds : An Emotionally Focused Approach to Infidelity. Handbook of the Clinical Treatment of Infidelity 17–29. doi:10.1300/J398v04n02.

Johnson SM, Lee AC (2005) Emotionally Focused Family Therapy: Restructuring Attachment. ‘Child. Ther. Using Fam. as a Resour.’ pp. 112–133

Johnson SM, Greenman PS (2006) The path to a secure bond: Emotionally focused couple therapy. Journal of Clinical Psychology 62, 597–609. doi:10.1002/jclp.20251.

Johnson SM (2007) The contribution of emotionally focused couples therapy. Journal of Contemporary Psychotherapy 37, 47–52. doi:10.1007/s10879-006-9034-9.

Johnson SM (2009) Attachment theory and emotionally focused therapy for individuals and couples. Attachment theory and research in clinicak with adults 410–433.

Johnson S, Zuccarini D (2010) Integrating Sex and Attachment in Emotionally Focused Couple Therapy. Journal of Marital and Family Therapy 36, 431–445. doi:10.1111/j.1752-0606.2009.00155.x.

Johnson SM, Wittenborn AK (2012) New research findings on emotionally focused therapy: Introduction to special section. Journal of Marital and Family Therapy 38, 18–22. doi:10.1111/j.1752-0606.2012.00292.x.

Kriston, L., Schäfer, J., von Wolff, A., Härter, M., Hölzel, L. P. (2012). The latent factor structure of young’s early maladaptive schemas: are schemas organized into domains. Journal of clinical psychology, 68(6), 684-698. doi:10.1002/jclp.21846

Muro, L., Holliman, R., & Luquet, W. (2016). Imago relationship therapy and accurate empathy development. Journal of Couple and Relationship Therapy, 15(3), 232-246. doihttp://dx.doi.org/10.1080/15332691.2015.1024373

Monero, J. L. (2011). Psychodrama; action therapy and principles of practice, North-West Psychodrama Association.

Sapolsky, R. M. (2017). Behave : The biology of humans at our best and worst. London, UK: Vintage Publishing

Siegel, D. J. (2010). Mindsight: The new science of personal transformation. New York, NY: Bantam Books

Simeone-Difrancesco, C., Roediger, E., & Stevens, B. A. (2015). Schema therapy with couples. Chiscester, UK: John Wiley and Sons Ltd

Pare, D., Quirk, G.J. & Ledoux, J.E. (2004) New vistas on amygdala networks in conditioned fear. J. Neurophysiol., 92, 1–9

Greenberg, L. S., & Johnson, S. M. (1988). Emotionally Focused Therapy for Couples. New York: Guilford Press.

Wiebe, S. A., Johnson, S. M., Lafontaine, M., Burgess Mosser, M., Dagleish, T. L., & Tasca, G. A. (2017). Two-year follow-up outcomes in emotionally focused couple therapy: an investigation of relationship satisfaction and attachment trajectories. Journal of Marital & Family Therapy, 43(2), 227-244. doi:10.1111/jmft.12206

Young, J., Rafaeli, E. & Bernstein, D. P. (2010). Schema Therapy. London, UK: Taylor & Francis Ltd

Young, J., Weishaar, M. E., & Klosko, J. S. (2003). Schema Therapy: A practitioners guide. New York, NY: Guilford Press

Zuccarini, D., Johnson, S. M., Dalgleish, T. L., & Makinen, J. A. (2013). Forgiveness and reconciliation in emotionally focused therapy for couples: the client change process and therapist interventions. Journal of Marital & Family Therapy, 39(2), 148-162. doi: 10.1111/j.1752-0606.2012.00287.x