>> Welcome to the final lecture, we are going to be going through Chapter 14 Psychotherapy and Counseling Integration. So we're going to focus on eclectic, meaning pulling from various ideas and theories. Or integrational approaches to counseling and psychotherapy. It's going to help us put things together and hopefully see the possibilities of integrating what you've learned in your own practice, meaning that it doesn't -- like we don't have to stick to just one approach. Each of these approaches are systems in multi-theoretical practice and empirically based. So there's a few approaches that we're going to talk about today, just briefly, that are current and integrate multiple theories. Together, they represent the future of counseling and psychotherapy. So as stated, we -- you know, no matter what modality or, you know, theory that you're going off of, culture is going to always be applicable. Every individual is unique. There's no one size fits all, as we've talked about before. Because everyone is so unique. Think of humans like a snowflake, no two are identical. Really, it makes sense to ask the question, how can we expect uniformity in counseling and psychotherapy theory and practice? Our different cultural and subcultural values and perspectives will always influence how therapists and clients view contemporary therapy. Contemporary again, meaning current, and how we practice today. Integrating many theoretical perspectives gives us a better chance to addressing the real needs of real people in the real world. So instead of only remaining just like straight from the textbook, or from the manual, we are looking at people as individuals, and humans, and unique. So it's great to know, you know, the theory really well. But we also have to allow ourselves to be flexible in how we treat our clients. So five options are available for practicing ethical theory based counseling and psychotherapy. The first is ideological purity. The second is theoretical integration. The third is focus on common factors. The fourth is technical eclecticism. And the fifth is assimilative integration. We're going to break down each of these, starting with Ideological Purity. Really, when someone is referring like an ideological purist therapist, it's really just when someone -- a therapist is practicing from a single therapy model and striving to apply it ethically and competently. So basically, knowing a lot about one theory, and not so much about more theories. They place more value in depth over breadth. Meaning I want to know as much as I can about this one theory and I'm not going -- I'm going to master this one approach, rather than be a jack-of-all-trades. I'd rather know a lot about a little versus a little then, you know, about a lot. So taken to an extreme, ideological purity can lead to dogmatism. Meaning, kind of, really approaching it as one size fits all. But on the positive side, it can allow the practitioner to have specialties. So, you know, I'm going to purely be a trauma-focused cognitive behavioral therapist and specialize in treating trauma. Or I'm going to have a specialty in treating eating disorders. And that's great in that, you know, you could really do some great work, especially having so much knowledge about like one approach and one diagnoses. But the problem is that, you know, we could have 10 people who have an eating disorder, and they all respond different to -- you know, my approach might work really well with a few of them. But for the others, they have different backgrounds, different histories. It might require me to be a little more flexible in my approach. So we still surprisingly see ideological purists in the clinical world. But we're, kind of, have broken away from this, to try to integrate approaches more to better meet the needs of our unique clients. Theoretical Integration basically is just theory smushing. Combining two or more theoretical approaches to maximize therapy effectiveness. So it's more flexible, and it's not just specific theories that have been integrated or smushed together. It's multiple. But what I really just want you to know here is that theoretical integration involves combining two or more theoretical approaches to maximize therapeutic effectiveness. I won't go through these. These are just really popular publications about, kind of, the first individuals who integrated two or more approaches. A lot of it was psychoanalysis and behaviorism. The Common Factors approach -- values overlapping, or -- you know, overlapping or involving key ingredients that different theories or theoretical orientations share. So taking common factors within each theory, such as the therapy relationship or alliance, right? We talked about how basically, in every approach, there has to be somewhat of a strong rapport between the client and the therapist, or else, you know, how can we expect our clients to trust us? The second is positive expectations or hope. We see that when someone comes in with, like, a belief, a strong belief, and they're not willing to kind of look in a different direction or willing to reconsider, that therapy isn't going to work, or it's just going to get worse or stay the same. It's hard to make change because they're not all in. Hope is another big thing. Usually, there is some hope, some level of hope. If they're coming into your office, they believe that things might be able to get better. But even if they don't have hope, we can hold the hope for them. But there has to be some level of willingness, and desire, and expectations that things could shift for them for the more positive. And then extra therapeutic client resources, meaning that we can't only expect their life to get better as a whole, just by coming and talking with us for 50 minutes, or an hour per week. We also have to, you know, talk about what they're going to do outside of sessions, provide them with different clinical resources, maybe encouraging them to go to group therapy or providing them resources on things such as, like a crisis hotline, if they're a high risk client, and so forth. Rosenzweig, who was a famous psychologist, marked three contributing factors, which includes hope, as we talked about. The second is interpretation that makes client's problems more understandable. So really normalizing what they're coming in with. They're probably not the first person who's come in with a similar or -- you know, a similar difficulty. And then the synergistic nature of change. Another is -- with the Common Factors is that we often talk about -- across approaches, the Corrective Emotional Experience. Meaning offering a different experience. So it's noted in your book, "In all forms of psychotherapy, the basic therapeutic principle is the same; to reexpose the patient under more favorable circumstances to emotional situations, which he could not handle in the past. The patient in order to be helped must undergo a corrective emotional experience, suitable to repair the traumatic influence of previous experiences." Okay, so basically responding to them in a healthy way that they probably haven't gotten before. So if they were abused or neglected, or just weren't responded to well, emotionally, with the majority of their relationships, instead of saying -- being dismissive about what they bring to the room, or, you know, kind of responding to them that gives the message of you're too much, you're too sensitive, we normalize, we validate. And that is really, really healing. So and that is common across the board. That is something that makes therapy so unique, that makes it so different than just a conversation that you have with anyone in your life. Is that the therapist is so attuned to the client, and validating, and unconditional, that the corrective emotional experience is really powerful because they're getting a response from us that they've never gotten before. So people who come for therapy are also experiencing common forms of distress, which is known as the demoralization hypothesis. And that occurs because of lack of certain skills or confusion of goals and the individual becomes persistently unable to master situations, which both the individual and others expect them to handle. Or when the individual experiences continued distress, which they cannot adequately explain or alleviate. Demoralization can be summed up as a feeling of subjective incompetence, coupled with distress. So, you know, we see this kind of, like I talked about commonalities. We see, you know, across our clients is that, you know, we see similar issues, and that can include low self-esteem. You know, not believing in oneself, anxiety, sadness, or depression and hopelessness. And are often the initial targets of therapy. So again, it's -- we see there's -- even though everyone is unique, as far as their stories, what they respond to, who they are as people, how their issues or experience manifest, and, you know, kind of what brings them to our office are things such as these common factors that we see. Low self-esteem, so not feeling good about oneself, not believing about themselves, having a low level of self-worth, you know, feeling really anxious, anticipating the future, feeling sad and hopeless. And those often are targets in therapy. Shared Therapeutic Components. So an emotionally charged confiding relationship. Contemporary practitioners usually refer to this component as the therapeutic relationship or working alliance. So what's going on between me as the therapist and the client. The second is a healing setting. The setting elevates the therapist's prestige and provides a sense of safety. So if I -- we've talked about this in a previous lecture about making our offices like a safe place or making them well known without having to actually say it out loud that they're accepted. So maybe having like an LBGTQI poster that, you know, you're an advocate, or this is a safe place for everyone. And also knowing -- like, if I have someone come into my office, and I keep the door open and there's traffic -- as in, like people walking back and forth, that's not a safe environment, right? Or if my office smells really funky, or the furniture is just really, really worn and there's stains on it. Or you know, there's no wall art, it's just a room. It's those things that also play a role in their experience. So we want to keep our offices warm, we want to just have our -- offices have an energy of calmness, tranquility, and safety. The third rationale, conceptual scheme, or myth, clients need a plausible explanation for their symptoms and for the treatment approach to be used. So explaining therapy and the rationale behind it to clients is crucial. And usually, that's done in the informed consent process, but it could also be done throughout the therapy, you know? So we need to -- if I'm -- I see a lot of kids and do a lot of play therapy. It's so important for -- some parents understand the idea behind play therapy, but a lot don't. So if I'm not explaining the logic behind play therapy, it really just come -- it could come off very easily like they're bringing their -- they're paying me to play a game with their kid, you know? But it's really -- it's so much more than that and so it's so important for me to explain to parents, kind of, what the process involves, what the expectations are and what the logic behind it is. And then a ritual. Clients and therapists need to process a ritual they both believe in that will bring a cure to improved functioning. So if a client's just sitting there and saying, I don't believe in this crap, you know? Okay, well, it's going to be really difficult we could explore that but there has to be some -- again, some level of hope. All therapeutic myths and rituals, irrespective of differences and specific content, have in common function that combat demoralization by strengthening the therapeutic relationship, inspiring expectations of help, providing new learning experiences, maybe arousing the client emotionally, enhancing the sense of mastery or self-efficacy, and affording opportunities for rehearsal and practice. Technical Eclecticism involves using logic and empirical data to choose the best treatment for a specific person, with a specific problem. Practitioners who use technical eclecticism, may or may not subscribe to the underlying theories. The multimodal approach discussed below is a good technical prototype. So the multimodal approach was developed by Arnold Lazarus. And he selected a particular therapy technique that is based on three factors: empirical research, what's practical for the situation, as well as clinical intuition. So I might have an empirically validated approach. And something that is -- it's very obvious that this form of treatment has been shown over and over to be effective for this type of diagnosis. But my intuition is telling me that the client might respond to something -- you know, something different in a more positive way. Because my intuition is ringing because I -- maybe I'm considering their culture as well. Some professionals avoid singular theoretical commitments. Instead, these therapists choose one techniques for one client, but use a different technique with the next. They might consider using two theoretically diverse techniques for a single client without concern for theoretical compatibility. Their selection of particular therapy technique is usually based on one of these three things. So what the empirical data shows, what's practical for the situation, and what's, you know, the presenting concerns, as well as just my clinical intuition and that comes from experience. So more on technical eclecticism. There's a distinction between bad and good eclecticism. So bad would be seat-of-the-pants and good empirical and planful. Choosing techniques in a whimsical or impulsive manner is syncretism. As one of -- you know, as people have said, in this field, sometimes counselors mix up the words eclectic, or electric. They think that they can just do whatever they feel like. What treatment by whom is most effective for the individual with a specific problem, under which set of circumstances, and how does it come about, is really the question to be asked. Behaviorists are naturally collective. Movement towards technical eclecticism came from the behavioral camp. So the question that we ask ourselves is the who, how, whom question. And that is, what treatment by whom is most effective for this individual with that specific problem? And under which set of circumstances and how does it come about? Okay? So we could have treated a thousand different -- you know, a thousand patients with eating disorders, but I still have to remember that this person is not them. Okay? So the Practice of Integrative Therapies. There's Multimodal Therapy, and again, that was developed by Lazarus. And it's an early model that is technically eclectic, so one of the first. It uses pan theoretical model for assessment and intervention. Lazarus has been a prolific and controversial clinician and writer for more than 50 years, but he was the one who coined the term technical eclecticism. Noting that to attempt a theoretical reproachment is as futile as trying to picture the edge of the universe. But to read through the vast amount of literature and psychotherapy in search of techniques, can be clinically enriching and therapeutically rewarding. So he was a self-identified behaviorist, and was interested in practical application of approaches that help his clients. His assessment system used psychological difficulties as multifaceted. So it's not just like A plus B equals C, there's so much more to it. And his "BASIC I.D." quote unquote, looks at seven parameters of human functioning, which include what I have here: behavior, affect, sensation, imagery, cognition interpersonal and drugs or biological. We'll break those down. So B for behavior. So it's kind of self-explanatory that someone's actions, reactions, habits, A, affective responses. This is like their emotions or moods. Sensations for S, that's, you know, our sensory system. So taste, touch, smell, vision, auditory, which is hearing. Imagery, mental pictures or visualization, cognition, non-visual thoughts, verbalizations. So again how we -- what we think. I interpersonal relationships. So any human interaction and then D is biological or drugs. So physiological areas including substance use. So treatment focuses on alleviating problems occurring within these seven domains. So some might be applicable and others may not be. We just go based off what's presenting in the room. So multimodal therapy requires skill in numerous therapy interventions. In his book, he lists 39 principal techniques. He wrote, "a flexible therapist has no fixed pattern of approaching new patients. He usually perceives what the patient needs and then tries to fit the role." So that makes so much sense to us now, and I hope you see why that's important. Back then, this was a very new idea and it stirred up a lot of controversy. He refers to becoming an authentic chameleon. Meaning that you adapt with whatever the client brings to the world. Interestingly, the research base for multimodal therapy is small. And another thing is that he refers to shifting the therapeutic style as becoming an authentic chameleon. Let me just say more of that. So some interpersonal variables; therapists should consider varying their styles depending on the client's needs, preferences, or expectations, including level formality or informality. So if they come from a culture where they value actual authority, we might be a little bit more direct and formal. But if they are already having a hard time being there, knowing that you're technically the professional, we might be more informal. The second would be -- you know, another consideration would be the amount of personal disclosure. So for one client, it might be really helpful to share more about myself, again, within boundaries. It always has to be clinically appropriate and it -- the only reason why I'd be sharing about, like maybe a personal experience, or something that I've been through is because it would be a value of the client. So that like an example would be, I work with a lot of teenagers. And to be more relatable is to be -- maybe share something that I went through in high school, that they would have never guessed. But if I'm working with an adult male, that might feel a little bit more inappropriate and unnecessary. Another would be how much or how often; a new topic of conversation is initiated. The level of directness. So like I said, it might be better to be more indirect versus direct with certain clients. The level of supportiveness and the level of reflectiveness. So the Practice of Integrative Therapies: Third Wave Models. Well, we're -- so in your book, they review six contemporary models with integrative qualities, known as third world therapies, or Third-Wave therapy, excuse me. We're not going to go -- I'm going to just go over the ones I want you to really focus on. There's a few more in your book that I want you to read. But as far as like, testing purposes, I'm not going to include them all, just because we've gone through so many theories already. Third Wave behavioral approaches have a common central principle. And that is the approaches generally focus on acceptance. So no matter what the client brings, we accept them, you know. Helping clients process their disturbing cognitive and emotional symptoms. So you might have heard of EMDR or maybe you haven't. If you watched the Apple TV series, "The Me You Can't See" with Oprah and Prince Harry. Prince Harry talks about how EMDR was -- has been monumental in his journey of healing his personal trauma. EMDR is something that I'm trained in, specialize in, and it's an evidence-based treatment for trauma in adults and children and it's developed by Francine Shapiro. So EMDR, Eye Movement Desensitization and Reprocessing. It integrates the following perspectives, which you are all at this point familiar with. The first is psychodynamic or psychoanalytic. And that is where we focus on past traumatic events, a car accident, a rape, emotional neglect. The second is behaviors. So we focus on how that has manifested. So our present fear and specific stimuli, so our behaviors. Maybe we are binge eating, maybe we are using substances heavily, maybe we avoid contact with people. The third is cognitive, so that more thought piece. And usually they're not coming in with positive thoughts about themselves, they're coming in with negative thoughts or beliefs about themselves. And of course, the idea is to shift that into a positive perspective. Fourth is person-centered. And that's that acceptance piece. Following the client's lead, not pushing them too hard, not doing anything they're uncomfortable with, not saying, hey, I think we should focus on that, instead of this. If they need to focus on something else, even though we'd rather focus on another thing, we go with them. And then, of course, that unconditional positive regard. And then the other thing that's a little bit different is it's a very body-based technique. So there's a lot of physiological components. And we look at physical sensations because trauma lives in the body. And if you think about it, we feel our feelings. That's why they're called feelings. They're going on in our body. We usually can feel them in our body unless we're really disconnected. But what we're focusing on is the physiological symptoms that have been manifested, and that are connected with the traumatic experiences. So like, maybe the panic attacks or things like this. There's eight phases in EMDR. The first is assessment, and history. So we are talking about the client's past and also their readiness. And for, you know, the process and initial treatment. Sometimes there's -- believe it or not, you know, someone's gone through a traumatic experience, and really are living miserably, but sometimes there's apprehension in change. So for example, I had a client who had lost a parent traumatically. And their fear about -- you know, they wanted to feel better and wanted relief, but the fear of going through the treatment, you know, because we -- you know, I explained to her kind of how this worked. Her fear was that she was going to lose her memories of her father. Okay? So kind of debunking those maladaptive, or faulty beliefs, or exploring the more. And then the second phase is preparation. Making sure clients have skills for coping with stress that might be generated from the treatment process. Because we're going into things that they were, frankly, trying to avoid all this time. So sometimes it feels worse before it feels better. But we want to make sure that they have the appropriate skill set to stay healthy during those hard moments. The third is assessment. And this is where a target memory is identified. So maybe a memory of being in the car accident or being in the store. Or it doesn't have to be the actual trauma, but just a memory that stands out to them. And it's usually occurrent negative beliefs about the self, linked to the target memory. And it's identified and rated along with a hoped for positive belief. So the current belief related to this memory is that I'm helpless. And the hope, we pick a more positive belief, we don't do it for them, they pick it. So maybe instead of thinking I'm helpless, they think, I have the tools to survive this. Associated emotional and physical characteristics are also articulated. And then we go through the desensitization process. And this is bilateral stimulation. So if you're not familiar with what bilateral stimulation is -- and that's perfectly okay, most people are not. And now you will be after today. But it's the use of alternating right and left stimulation such as eye movement, or tapping of the knees, tapping of the shoulders, tapping toes or feet on the floor. And it's used to activate and integrate information from the brains two hemisphere. So the right and left -- we won't get too much into that piece, and like -- kind of like how it works. But just that's where like the eye movement comes in. But you don't necessarily have to do eye movement. And that's a big misconception. So like with me, when I work with kids, we do something called butterfly tapping, and that's like tapping on shoulders. And you know, you will read more about this but therapists will explain process and follows the clients experiences during the desensitization component. And then there's installation, which comes next. And that's when our bilateral stimulation -- so the eye movement or the tapping is repeated linking to the positive belief to the memory. And then -- so that's kind of where we're replacing the negative belief with the new one. And then we body scan. And so there is a review of the client's physical body sensations. So what comes up for you? Where do you feel this in your body? And sometimes it's really intense. We've had clients throw up in session, or maybe they get a headache, or maybe they feel a huge sense of relief. Negative sensations are processed through the bilateral stimulation, which is why you get these physical responses. And again, there's a lot of training that goes involved in this. So the therapist is competent in how to deal with this. And then it's the closure phase. So the client is asked to keep a journal of experiences during the upcoming week and is reminded of the self-calming strategies used in Stage 2. And then we come back and reevaluate things. So when the client returns for the next session, a reevaluation of status and progress is conducted. So this is a really interesting technique, and it's shown to be very effective specifically with trauma, complex PTSD, eating disorders, substance abuse. Detailed information regarding EMDR practice, if you're interested in learning a little extra, you could go to EMDR.com, but I think I'll show a video at the end of this presentation. We also -- another one, third wave therapy is DBT, Dialectical Behavioral Therapy. This one's a little more well known. It blends cognitive, behavioral, and Eastern meditation practices. So that's the acceptance piece with elements of psychodynamic, person-centered, Gestalt, strategic and paradoxical approaches. This DBT is an excellent example of psychotherapy integration. And it was developed by a practitioner who is still popular today named Marsha Linehan. And it's most known for treating a difficult personality disorder called borderline personality disorder. Which, if you've taken abnormal psychology, you know the symptoms. Borderline personality disorder really is just a -- it gets a bad rap, unfortunately. And to me that feels really sad because they come off as really challenging clients. But really, it's a result of complex trauma abuse. Borderline personality disorder is known -- you know, kind of if you aren't familiar, the symptoms really involved emotional instability, feelings of worthlessness, insecurity, a lot of impulsivity and impaired social relationships, very black and white. And really, the roots are just this fear of abandonment. So they either see people as all good or all bad. Marsha Linehan had actually had a diagnosis of borderline personality disorder. And she's one of the most popular third-generation behavioral therapies. BPD borderline personality disorder are very much so -- it's -- you know, they will threaten suicide if they're not getting their way. And so they're very emotionally charged clients. And again, it's all a source of pain. But DBT has been shown to be one of the few therapies that is so effective with borderline personality disorder, but it doesn't stop there. It's been used for eating disorders, depression, anxiety. Just a few characteristics. DBT is based on a biosocial theoretical model of BPD. Like I said, it focuses on emotion dysregulation. Therapists view emotional dysregulation as the primary deficit associated with whatever diagnosis is coming in. It's said that individuals with BPD have emotional responses to environmental stimuli that occur more quickly, are much more intense, and have a slower return to baseline than the responses of, you know, your average person. People with borderline personality disorder are often told their emotional behavioral responses are faulty or inappropriate. Very parallel to what gaslighting is. And over time, the social environment becomes emotionally invalidating because it's really hard because these people are viewed as just being very dramatic, too extreme and no one basically has like, the bandwidth to deal with them. So their core fear of being abandoned often becomes true because they drive people away. So it's a really sad diagnoses but, you know, there's so much help and hope available. And their symptoms are only a source of their pain. Okay? On the social side, borderline personality clients often come from living in environments that are really poor fit for their emotional sensitivity. And over time, the social environment can become chronically and pervasively, emotionally invalidating. Meaning that it becomes like a self-fulfilling prophecy. Everyone leaves, no one can be trusted. So this is the theories class, not a diagnosing class. But, you know, whenever you hear anything about DBT, dialectical behavioral therapy, half the time, you're going to see that it's involving borderline personality disorder, because it's been such an instrumental tool in this population, but it -- like I said, it doesn't stop there. It's been shown to be really effective with eating disorders and depression, as well. A big intervention that's used that's helpful is radical acceptance. So in working with clients, DBT therapists communicate the attitude, I accept you as you are, and I'm helping you to change. This statement is a therapy stance of radical acceptance. Because, again, I'm sorry, I forgot to change the slide. Because just like we talked about in the previous slide, because of their environment, because people are, like -- really just don't know the roots of what is at the crux of borderline personality, most people don't accept them in their lives. They're told that they're too much. They're too extreme. They're crazy. But there's that emotional, corrective, emotional experience, right? I accept you as you are, and I'm helping you to change. Okay? So DBT practices include five functions: enhancing skills. So skills to regulate, to be successful during their days. Improving motivation, generalizing skills from our office to the real-world setting. So in their work setting, at home. Improving therapist's skills, and motivations, structuring the client's environment to support and validate the clients and therapists capabilities. So we need to -- it would be very important to educate their family as well, or whoever their support systems are, because knowledge is power. So instead of them just saying that she is crazy -- that's a bad word in therapy, but this is a term that they've often heard. Understanding what's behind that behavior. So DBT, as you could probably tell, is not a brief therapy. Okay? It could be years. There's a lot of research that shows positive outcomes after two years. And DBT really gives therapists and clients hope for success with challenging treatment populations that display a range of disturbing behaviors. Okay? Okay, the other one approach we're going to go over is Acceptance and Commitment Therapy, ACT. Another third wave behavioral therapy that combines committed action with Buddhists. So like Rogers' Person Centered Therapy. So unconditional positive regard congruence, authenticity, and the idea of acceptance. ACT -- so that's acronym for acceptance and commitment therapy, rejects existing diagnostic and medical models. Believing that the assumptions of healthy normality and abnormality as disease are flawed and unhelpful. So basically saying labels are unhelpful. This approach offers an alternative referred to as destructive normality. The idea that a normal person can use normal psychological processes and end up feeling quite disturbed. Okay? ACT is listed as having strong research supports for treating pain and modest research support for treating depression, mixed anxiety, obsessive compulsive disorder, so OCD and even psychosis. A few characteristics and protocols in ACT. One big one is that thoughts do not represents reality. They're only thoughts. So thoughts aren't facts, right? We have thousands of thoughts per day. It's not possible for all of them to be realistic or valid. ACT avoids judging negative cognitions as unhealthy or deviant. So instead of saying like. being hard on ourselves, why are we having this thought? Like why can't -- why am I thinking that? Not judging them. Oh, just another thought. There it goes. There my brain goes again. Relational frames theory is the theory underlying ACT. It's basically the theories -- aims to better understand the link between human language and behavior. So how our thoughts and language affect how we behave. Another big one is cognitive fusion, and that occurs when individuals operate as if I am my thoughts. Pulling thoughts too closely into the self contributes to psychological suffering. So if I'm having the thought that I'm going to screw up in this presentation, I feel way less secure, way less confident, and therefore I act that way. And then experiential avoidance is defined as the tendency for individuals to engage in a struggle to escape, and/or avoid unpleasant or unwanted private experiences. So I'm really scared to feel uncomfortable during my presentation. So I'm just going to avoid it altogether, which really gives me a short-term relief but, in the end, there are consequences. Maybe I feel disappointed in myself, maybe I get it -- maybe it's for a presentation at work, and I get in trouble, or written up, or maybe I get a zero, if it's something for school. Oops, sorry about that. There are six additional components to act and the first is, be here now. So making contact with the present moment and say, okay, I'm going somewhere else in my head. I'm having these thoughts about messing up in this presentation, but you know what, I'm not there right now. Which you know, those thoughts lead to anxiety, uncomfortable physical sensations. Instead, I'm right here, I'm safe. I'm at my house. So I am in the present, I'm not in the future. And I'm not in the past. Diffusion is separating and detaching from private thoughts, holding on to thoughts lightly not tightly. So hey, I'm recognizing that I'm having a thought that I'm going to do really poorly on this presentation. But I am not that thought. That's literally just a thought, it's not real. Acceptance is opening up and making room for all experiences, including so called unpleasant ones. So hey, you know what, even if I do mess up, it's not the end of the world, okay? Or I'm having this thought and it's not fun, but that's okay. It's just another thought, and I've had thousands of them. Self-as-context. The observing self determines context and is the entity through which awareness happens. The other is values, the goal you desire and activities, beliefs that matter to you. So this takes into consideration values. And so, you know what's important to me. So if I value a strong work ethic, then I'm definitely not going to avoid that presentation. If I value friendships, and I have social anxiety, I'm definitely going to place more of my energy on maintaining relationships than I am my anxiety. And then committed action; doing what you need to do to move towards and live by your values. So even though I have this anxiety, one of my values is my relationships. So I'm going to feel the fear and do it anyways. Okay? ACT is a relatively new approach, but its research base is extensive. It shows promise in substance abuse treatments, as well as disorders such as anxiety. So there needs to be more research supporting this, but it has shown to be effective. The last we will talk about his MBCT, Mindfulness-Based Cognitive Therapy. So it's another third wave therapy in which combines mindful acceptance and psychoeducation as a means of treating various mental health problems in life changes. The most notable application of MBCT is in the treatment of clinical depression. Particularly the prevention of depressive relapse. Because we know that once someone has one depressive episode, it's likely that there will be another time in their life where they have another. It has also been shown to be effective with insomnia, substance abuse, relapse prevention, eating problems. And the characteristics include, it's a shorter timeline, so -- and group is highly popular in this approach. And themes include awareness and automatic pilot. So just basically, having awareness on, kind of, what we do automatically without thinking about it. Living in our heads, so again, getting too consumed with our thoughts, when knowing that we are not our thoughts. Gathering the scattered mind. So that monkey mind, you know, like my thoughts, basically are my reasons for having so much anxiety. So kind of focus on being more present and grounded. Recognizing aversion, so what makes us want to avoid things? Allowing and letting it be. So okay, I'm having a moment where I feel uncomfortable. I'm going to allow that; I'm not going to try to do anything to avoid it or fight it. Such as use drugs or -- which easier said than done, there's more to it than that. But I'm not going to be -- I'm just going to allow this discomfort and I'm going to let it pass. Again, easier said than done. More tools are involved. We learn skills to be able to do that. Maintaining the idea that thoughts are not facts, like I keep saying. How can I best take care of myself? So I'm feeling uncomfortable, what can I do to feel better? I could go out and exercise, I could meditate, I could practice mindfulness, and maintaining and extending new learning. MBCT has also shown promise in the treatment of many other mental health problems. Like I said, a big one is relapse prevention for both depression and substances and eating disorder. Just to note on Higher Order Integration, you might -- as you move forward in the field of clinical psychology, Transtheoretical Change Model is created by James Prochaska. And he looked at theories in psychotherapy in a new way. Most theories orient therapies towards why people don't change rather than why people do change. And so this model seeks to respect the diversity and unit of therapy systems, emphasize empiricism, account for how people change in and out of therapy, address physical and mental health problems, encourage therapists to be innovators. The Transtheoretical Model: Common Change Process includes consciousness raising, dramatic relief, self-reevaluation, environmental reevaluation, feeling liberated, myself and in a social setting, counter conditioning, stimulus control, reinforcement management and helping relationships. So he's really known for the Stages of Change, which you probably have heard of. Some clients come to therapy ready to change for the better, and other clients end up in therapy with little or no motivation for change. Recognizing these basic differences, as well as more subtle change levels, Prochaska identified six changes -- six stages of changes. The first is precontemplation. So during this stage, the individual has little or no interest in changing their behavior. I'm only here because my wife tells me to be, or because my mom tells me to be. I don't -- I'm not the problem, other people are the problem. And then, you know, after that might come the contemplation stage. During this stage, the individual's aware that a problem does exist, but they have yet to make a clear commitment to make a personal change. So okay, I recognize that maybe my drinking is a problem, but you know, I'm not sure I want to do anything about it. The third is preparation. And during this stage, there may be some intention and effort made towards change. So for example, maybe someone who wants to get in better shape physically, and they don't move their body a lot through their day, might go out to buy just running shoes or join a fitness club. Not do anything with it, but kind of start to look into it. Or someone with a substance use problem might start to do research on groups they could attend. There may be occasional attempts for action, but mostly the individual are so -- are still so deep into contemplation that they're only beginning some minimal action towards change, but are not yet in the next phase, which is the action phase. And during this people are plunging into the change process. So they're actually going out for a run, they're actually attending an AA meeting. These are the clients whom therapists love to see because their motivation is so high that they quickly engage in the therapy process, and often make considerable amount of progress really actually quickly. Prochaska defines the stage as a successful alteration of a problem behavior for a period from one day to six months. And then we have the maintenance phase. Okay, like I'm sober, or I've gotten into better physical shape. I feel better, my lab results are coming back better. And during maintenance people continue with their actions and deepen their commitment towards permanent change. So instead of saying that was temporary, this is more of a lifestyle change. There is continual work or action towards relapse prevention. The stage continues from six months to infinity, but relapse often occurs at some point during maintenance, which is, you know, part of the process. And there's a lot of shame in that, but that's where our unconditional positive regard comes in, is that we are still here. So for example, many alcoholic or drugged -- addicted individuals reached the maintenance stage. So sobriety, and then relapse. Maybe something stressful came up and they went to the bar or used. And then they generally cycle back through the stages of change in an effort to obtain mastery over their problem. The recycling tendency is apparent in many non-clients, as many individuals repeatedly make the same goals. Like New Year's resolutions, right? Until finally maintaining their goal for six months or longer. And then something that's not included here another stage that's been added and not so common, it's termination. And during termination, people have 100% confidence that they will not engage in problem behaviors again. So I don't need AA anymore, which -- that's controversial in itself. Some people say it's lifelong. Or I don't need to, you know, be in therapy anymore because I have all the skills that I need to. And I know that if something does come up that I don't feel confident in, you know, just tackling on my own, I know when to get help. They also report having no urges to engage in the problematic behavior. So like the cravings have gone away. Prochaska uses a five-year criterion of symptom liberation, plus 100% confidence for classification into the stage. Okay? So sometimes people get it and sometimes people aren't ever confident or comfortable, you know, stopping what helps them maintain that and that's okay, too. It's kind of an individual thing and choice. You also identify five levels of change, and that's one, symptoms, situational problems. Two, maladaptive cognition, so problematic thoughts. Three, current interpersonal conflicts, so problems within relationships. Four, family system conflicts, and five, interpersonal conflicts, okay? And that could be with past relationships. Most clients initially come to therapy seeking relief from particularly distressing symptom or situation. But as clients participate in therapy for longer periods, they delve deeper into cognition, interpersonal, familial, and intrapsychic issues. So kind of like the deep rooted stuff. Okay? Just to say one more thing. One more advantage of a transtheoretical model is that it emphasizes on the interactive and integrative nature of therapeutic processes, stages, and levels. So for example, when clients are in a pre-contemplative stage. So they are not even contemplating change, it's likely they will resist action oriented therapy interventions. Alternatively, when clients are in contemplative or preparation stages, they may be ready for experience, sudden dramatic relief, followed by regression and relapse. It's best to focus on symptoms and situational issues with clients in these early stages of change. Because they're unlikely to be motivated to explore deeper, more personal issues such as like past traumas. So finally, one thing on -- like just a final couple of notes on choosing your theory and concluding comments. Obviously, none of you are going to go and you know, see clients, but you -- some of you may go to pursue a career in therapy, may go to graduate school. So the final advice here is to, you know, choose a theory but don't grip onto it too tightly, and get ready to integrate. So you could have, kind of, like a baseline theory. Like, hey, I really resonated with cognitive behavioral therapy. And no, I'm going to make sure I know enough about the other theories, so I can use them when I feel like it's appropriate. At first, it might feel random, but you'll begin to sense your growing ability to discern when to bring in another theoretical approach or technical strategy. The practice of counseling and psychotherapy makes for a fabulous lifelong learning process. Wisdom consists of knowing both what to know and how to use what you know. So my people, my wonderful students. In the end, I challenge you to look beyond the face of these theories. Treat them as more than narrow historical artifacts. If you can view these theories as a product of time, place, deep contemplation, and a sincere desire to understand and alleviate human suffering, you'll be better served. Just be you. You don't want to be -- like the goal is not to sound so clinical, and use the language only used within that theoretical model. Clients want to authenticity. Just be you. You're enough. Of course, we need to have the school that education and the knowledge about, you know, what theoretical models entail what. But you always want to put your own personal spin on it, within, of course, ethical boundaries. Okay, so I hope this class was a good starter point to jump into what it is like to be a therapist. You know, kind of getting familiar with the idea that it goes beyond just talking. There's really a lot of guidelines and factors that we have to take into consideration, but the goal is always the same, connecting with our clients and supporting them through symptom relief. Okay? I added a video on EMDR therapy. You're free to watch it. I will be honest, there's not going to be -- it's like a 9-minute video. I'm not going to test specifically on this video. But if you're interested, you can watch it just to gain a better understanding. It's really interesting. It might be, you know, for professional reasons, but it also might be for personal reasons. EMDR is getting really big in the clinical field. If you haven't heard of it yet, you definitely will. I mean, you have in this class at this point, but you will very likely hear more about it. It's becoming more and more popular in graduate programs. So enjoy it. Enjoy, you know, the break ups coming up. And I'm wishing you the best of luck on the final. It'll look exactly like the two midterms. No tricking you, just straight forward and just remember I believe in all of you, not only as students but as in people as well. Okay? You've gotten here for a reason. You've survived whatever you've gone through in your life, up until this point. Meaning that you're resilient, you're strong and don't lose sight of yourself. You are more than your grades. You are more than your theoretical orientation. You are more than your diagnoses if you have one. You're a whole human being and just don't ever lose sight of your self-worth. Okay? I'm proud of you and just keep being you. Take care.