Skill promotion

We shall continue expounding technique sequences in change promoting. A patient differentiates and accesses healthy self-parts. His negative schemas are known and in his consciousness alternative, benevolent self- and other-representations have emerged. He has also tried, with some success, to counteract maladaptive coping and continues to apply himself.

However there is the problem of how to act! This is common in patients with chronic agency problems, coming from social withdrawal histories and isolated for years. At this stage in therapy patients have goals and desires, validate them and only marginally fear the consequences of exposure, but their world map is limited. They lack relational procedures for action. A component of experiential work directed at acquiring skills and expertise is now needed.

A typical sequence starts from imagery with rescripting work or a drama technique. Patients know how to reply to a critical, invalidating, suffering and constrictive other. For example, the wish to court a partner, undertake a training programme or start a recreational activity has got reignited after, thanks to experiential exercises, they overcame their feelings of fear, embarrassment or guilt. They know that replying differently in imagery to their father, mother, boss, spouse, colleague or friend is modifying their way of being and is not aimed at generating different replies to that specific person in reality.

If patients see this aspect very clearly, we now use rescripting for affecting reality and building different relationship forms too. This can still be done in-session with various forms of rescripting, or between sessions. We therefore plan behavioural experiments to inclusively enrich patients’ cognition and behaviour repertoire; to learn how to do what they wish to achieve.

Thinking in technique sequence terms, patients and therapists may have completed guided imagery with rescripting or a drama technique where the replies to the other are different. There is now an anchoring to the positive feelings emerging during rescripting and a planning of activity directed at acquiring skills. Patients can, for example, repeat a drama technique, to try again and again a new way of acting or responding with a view to training new sensorimotor and behaviourpatterns that seem effective. The drama, or imagery, technique will not be tied necessarily to past narrative episodes. Imaginary scenes, where patients act in new ways or contexts, can be enacted.

This time therapists can offer feedback on the reality level, still naturally respecting patients’ ideas and especially knowing they are not adopting a prescriptive stance. For example, patient and therapist might enact a university exam, a call to a girlfriend whom the former wishes to date, or advances to a girl or man who attracts him/her. After this simulation patients are asked if the scene is plausible and the actions staged seem sufficiently meaningful to them. The next step is behavioural exposure, with therapists offering their opinion about the functionality of the behaviour.

A specific case of technique sequence is MIT-G (Chapter 10). Patients first perform role-play aimed at improving metacognition. In the next session they perform new role-play, again within a specific motive, but with the goal of mastering their problematic situation differently and more effectively. It is thus a rescripting aimed both at changing schemas and stimulating more developed metacognitive and relational skills. In individual sessions, as in MIT-G, therapists do not indicate the right, prescriptive solution. They suggest adopting an exploratory and flexible approach, attempting new actions and empirically assessing what will make it possible to move towards satisfying wishes, by triggering benevolent responses in others.

With patients not following the MIT-G protocol, one can also therefore use the sequence: 1) guided imagery or drama technique exercise; 2) rescripting directed at schema change; 3) rescripting aimed at building new metacognitive and relational skills. Naturally not all the steps need to be performed in the same session. When we talk of technique sequences, we refer to operations covering periods of therapy from a few weeks to months. What is important is always observing the decision-making procedure.

Therapists can propose behavioural exposure even without simulating the new behaviour in sessions and by limiting themselves to imagining with the patient what might happen, what the latter could do and how he could feel. They now plan the new behaviour and review it in the following session (Chapter 8).

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