How to Treat Trauma April 2019

ADVANCED METHODS IN COUNSELING AND PSYCHOTHERAPY
The Philosophy and Practice of Clinical Outpatient Therapy
Western Tidewater Community Services Board

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DISCLAIMER
The purpose of training in Advanced Clinical Methods
is to improve one’s practice of therapy through a deeper understanding of methods.
It is intended to augment, not replace, the instruction and practice expectations
of one’s home Community Services Board or Agency.
The material is consistent with Adlerian, Cognitive, and Family System Theory
perspectives on human motivation and pathology.
It is applicable to short-term, solution-focused therapy, as well as to mid-
and long-term trauma related care.
____________________ . ____________________

Presenter’s Orientation
Disclaimer: Given the number of counseling approaches there is no shortage of opinion on how best to view the basic constructs within our field.
The ideas presented herein are simply those that assist me in my work and in my understanding of human motivation and pathology.
I entered the field in the mid-1970s amid widespread turmoil in community-based care. Few were adequately prepared for the scope of
New York City’s problems with addiction, de-institutionalization and wartime PTSD. Facing similar crises nation-wide practice turned
toward more intensive methods for treating psychological injury, comorbidity and the intergenerational transmission of trauma.
I began training with Dr. Robert Sherman in 1980 and continued until his retirement and relocation from New York in 1992. Robert was
an AAMFT Clinical Supervisor, Author, co-founder of Adlerian Family Therapy, a long-time Fellow at the North American Society of
Adlerian Psychology and Chair of the Department of Marriage and Family Therapy Programs at Queens College which he founded and
where I served on faculty in 1986 and 1987. This remarkable 12-year mentorship included small-group instruction with noted Adlerians
Kurt Adler (1980), Bernard H. Shulman (1980), Harold Mosak (1980-1981) and Larry Zuckerman (1982-1983), as well as a unique
series of live-practice seminars with Maurizio Andolfi (1981), Carlos Sluski (1983), Murray Bowen (1984), James Framo (1985),
Bunny Duhl (1986), Monica McGoldrick (1987), Carl Whitaker (1988), Jay Haley (1989), Salvador Minuchin (1990 and 1991) and
Peggy Papp (1992). In March 1991, we completed a two-day intensive with Patricia and Salvador Minuchin.
In 1990, I also began a 2-year apprenticeship with Dr. Richard Belson, Director of the (Strategic) Family Therapy Institute of Long
Island. This included an innovative 30-session live-supervision practicum for treating highly intractable problems through a team co-
therapy model. At the time, Richard was collaborating with Jay Haley and Cloe Madanes at the Family Therapy Institute of Washington,
D.C. (1980 to 1990) and serving on the editorial board of the Journal of Strategic and Systemic Therapies (1981 to 1993). Richard was
also on faculty at the Adelphi School of Social Work and Graduate Programs in Marriage and Family Therapy.
The following notes stem from these varied, yet interconnected, perspectives.
_______________________ . ________________________
Demetrios Peratsakis, M.Ed, DSDA, LPC, ACS, Western Tidewater Community Services Board
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ADVANCED METHODS IN CLINICAL PRACTICE
“There's no coming to consciousness without pain.”
- Carl G Jung

On the Art of Seeing in Psychotherapy
“For a sorcerer, reality, or the world we all know, is only a description
that has been pounded into you from the moment you were born.
The reality of our day-to-day life, then, consists of an endless flow of perceptual
interpretations which we have learned to make in common.
I am teaching you how to see as opposed to merely looking,
and stopping the world is the first step to seeing.”
- Carlos Castaneda, The Teachings of Don Juan
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A Good Therapist Learns How To See, Not Merely To Look
This training will help you to see behavior in a very different way!
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Why Clinical Orientation Matters
Perspective drives
1) Assessment
2) Treatment Planning
3) Method of Intervention

Major Approaches and Methodologies
Despite several hundred distinct form of therapy there is little agreement on fundamentals: How is personality
structured? What constitutes change? How do symptoms originate? How does the therapeutic alliance foster
growth? How should the therapy process be organized? and What method provides the best clinical outcomes?
Most models fall into one of two broad categories:
1. Psychosocial Models of Counseling (Talk-therapy)
a) Psychodynamic: Disordered behavior is controlled by unconscious forces shaped by childhood experiences
b) Behavioral: Disordered behavior is caused by identifiable factors in the person’s environment and results from learning
c) Cognitive: ineffective or inaccurate thinking is the root cause of mental illness
d) Sociocultural/Evolutionary: Mental illness is the product of broad social and cultural forces
2. Biological/Neuro-genomic Models (Psychiatry) Disordered behavior is caused by biological
conditions, such as genetics, hormone levels, or changes in structural or neurotransmitter activity
Note: Hybrid Models, growing in popularity, combine predisposition factors with environmental
stressors to trigger a psychological disorder (ie. Diathesis-stress model; Bio-psycho-social model)
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Psychiatry Counseling/Psychotherapy
1. Disorders are caused by psychosocial
factors
a) Psychosocial factors seem a necessary precondition
b) Twin concordance rates are NOT 100%
2. Relationships are the locus of treatment
3. Primary intervention is ‘talk therapy’
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Neurobiomedical vs Psychosocial Talk-therapy
1. Disorders are caused by neuro-biomedical factors
a) Common markers for Autism, Bipolar, MDD, ADHD,
Schizophrenia
b) Twin concordance rates of up to 40%
2. Individual is the locus of treatment
3. Primary intervention is psychopharmacology

NOTE: While NOT mutually exclusive, Meds and Talk-therapy can be at cross-purposes:
1. Root Cause of Dysfunction: Biology versus Belief system
2. Use of Psychopharmacology in mood stabilization and pain management
3. Volition: the degree one can exert control over the symptom; “Can’t” versus “Won’t”

Psych
Only
Meds
Only
Psych
+ Meds
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Drawing on data from the nationally representative Medical Expenditure Panel Surveys conducted by the federal Agency for Healthcare Research and Quality, the
authors found that the percentage of the general population who used psychotherapy stayed the same between 1998 and 2007. But over the same period, outpatient
mental health care has changed. Over that decade, the use of psychotherapy on its own and in conjunction with medication has dropped, while medication-only visits
have increased. More than 57 percent of patients now receive medication without psychotherapy, up from 44 percent. The percentage who receive
psychotherapy only has dropped from almost 16 percent to 10.5 percent, while the percentage who receive a combination has dropped from 40 to 32 percent.
Psych
Only
Psych
+ Meds
Meds
Only

“The brain…contains more than 100 billion neurons…each firing dozens to hundreds of times a second, and connected to each other by 240 trillion synapses. There is no
way that our 20,000 genes could in any simple top-/down fashion instruct the intricate wiring and firing of so many connections…The Bottom Line: The rush to apply
each new genetic finding to the clinic before it can be examined critically in studies that take into account the complexity of human neurobiology and experience is an
example of the aphorism that the faster you go, the longer it takes to get where you are going. Right now, genetic studies give us an early insight into interacting
dimensions of illness that are influenced not just by genes, but by interactions of genes with regulatory components, experience, and the actual illness and its treatment.”
-Allen Frances, M.D., was the chair of the DSM-IV Task Force and is currently a professor emeritus at Duke
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Less relapse after cognitive therapy compared with antidepressant medication. The second phase of the parent antidepressant medication (ADM) versus cognitive therapy (CT)
study35 followed patients who had responded to ADM or to CT38. Patients who had responded to ADM were randomly assigned to either continue ADM treatment for one year (beige
and red lines) or to change to placebo treatment for 1 year (green line). Patients who responded to CT were allowed three sessions of CT during the 1-year continuation period. In the
follow-up period, none of the patients received any treatment. The figure shows that prior treatment with CT protected against relapse of depression at least as well as the continued
provision of ADM, and better than ADM treatment that was subsequently discontinued. Note that the patient group that was given ADM in the continuation year contained a number of
patients who did not adhere to the medication regimen. The red line indicates the response of the ADM-continuation group including these non-compliant patients, whereas the beige
line shows the response of the patients in this group after the non-compliant patients had been removed from the analysis. Figure modified, with permission, from Ref. 38 © (2005)
American Medical Association.
NOTE: DEPRESSION, which underlies most conditions,
has many causes and is best thought of as a “Spectrum Disorder”
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Small, but representative
sample study

1. Rule Out Medical or Neurological Conditions
2. Use Talk Therapy Augmented with Medication, if indicated.
As a (very) General Rule:
1. SMI Mood Disorder; SA OP; MH OP; SED = Consider Talk Therapy augmented by
Medication, if indicated
2. TCM SMI; DD; Acute Care = Consider Medication augmented by Talk Therapy
3. Change the Belief System to Treat the Underlying Purpose that the
Psychological Symptom Serves
Symptoms most often occur at stress points of change -“frozen” junctures between the
imperative to change and the desire to remain the same.
4. Accept Responsibility for Change and the Success or Failure of Treatment
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Once you accept full responsibility for change
-- including blame for when therapy fails,
your work becomes exceedingly precise and deliberate.
Once you forego the safe haven of ambiguity
and regard each of your interventions
-as either therapeutic or counter-therapeutic,
your work becomes nothing short of remarkable.

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“Reality is Merely an Illusion, Albeit a Very Persistent One”
-Albert Einstein
Social Constructivism and Human Pathology

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“Other animals fight for territory or food; but, uniquely in the
animal kingdom, human beings fight for their 'beliefs.' The reason is
that beliefs guide behavior which has evolutionary importance
among human beings”.
― Dr. Ian Malcom, Jurassic Park (aka Michael Crichton, The Lost World )

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“Chaos is not just random and unpredictable.
We actually find hidden regularities within the complex variety of a system's behavior.” –Ian Malcom

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1. We behave and feel in a manner consistent with our beliefs
“Believing is Seeing!” (Constructivism)
2. Others react to our actions which, in turn, reaffirms our beliefs about
how to act
3. In part, we drive the behavior and emotions of others in order to
obtain the very reactions that reaffirm our own beliefs
4. Together, we create constructs and shared imaginings called social
patterns and structures.
5. These patterns and structures acquire purpose, meaning and power
Interpretation Drives Behavior

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1. Behaviors, feelings and thoughts surrounding the Presenting Problem (PP),
Identified Patient (IP) or symptom harden over time becoming interactional
patterns that acquire history with well-defined roles and rules and expectations.
2. In essence, a pattern or “structure” around which communication and
membership is organized, boundaries defined, and power expressed and
reconciled.
3. In particular, the emerging pattern fulfills the mutual purposes of its
participants, providing a vehicle for communication and attachment and the
open expression of love, anger, trust, and responsibility.
4. Underlying this, we often find a prolonged and deeply embedded power-
struggle, fueled by concomitant feelings of hopelessness, resentment and rage.
It is often passive-aggressive, often cloaked even from the symptom-bearer.
How Psychological Symptoms Form

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 Symptoms are examples of extremely rigid patterns of behavior and belief
structures. Most, originate as a consequence of
a) Bioneuromedical illnesses and conditions;
b) Discord, severe duress or chronic interpersonal conflict that results
in power-plays or attempts to control others;
c) Unresolved psychological injury from trauma; namely, suffering a
significant loss, becoming the victim of betrayal by a trusted or
loved one, or experiencing a significant disaster.
 By their nature, symptoms are shared constructs that acquire purpose,
meaning and power.
 Their power must be disengaged in order to challenge their meaning and
alter their purpose.

Family Systems/
Relational Perspective on Symptoms
Origination and formation of enduring patterns of
behavior, structures or syndromes that organize social
interaction, mediate stress and provide adaptive
response to change
1. Symptoms are hardened patterns of
interaction around which individuals
express power and control.
2. Symptoms acquire history as they
organize social behavior including how
roles and rules of behavior become
defined and how love, hate, need and
want are communicated and shared.
3. Symptoms acquire Purpose, Meaning
and Power
Trauma -from disaster, loss, or betrayal, as well as
from conflict that results in misbehavior and
victimization, results in psychological injury.
Unresolved, this invariably leads to depression and
anxiety which are fueled by Guilt, Anger, and Shame
(GASh). The “injury” is to self-worth, to trust and
intimacy; to one’s willingness to be vulnerable.
Symptoms
1. Biomedical Condition
(CBD, ABI, TBI)
2. Chronic Discord or Duress
(Control and Power-struggles)
3. Trauma
(Loss; Trust Betrayal; Disaster)
Source or Cause
Demetrios Peratsakis, LPC, ACS © 2018
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Bowen on Symptom Origination
“When anxiety increases and remains chronic for a certain period, the
organism develops tension, either within itself or in the relationship system,
and the tension results in symptoms or dysfunction or sickness.
The tension may result in physiological symptoms or physical illness, in
emotional dysfunction, in social illness characterized by impulsiveness or
withdrawal, or by social misbehavior.” -Family Therapy in Clinical Practice, 1978; p. 361.
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1. Partner Discord
2. Dysfunction in One of the Partners
3. Dysfunction in One or More of the Children
4. Emotional Cut-off , including expulsion, escape, or becoming
the “black sheep”, “scape-goat” or “lightening rod”

1. Attention Seeking behavior
2. Power displays and Power-plays
3. Revenge (acts of punishment and vengeance)
4. Failure or Displays of Inadequacy
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1. Symptoms “safe-guard” the individual, family or social system through triangulation, a
process of (dis-) stress reduction and protection whereby the symptom or Identified Patient
(IP) serves as the “lightning rod” or “scapegoat” for blame
2. Symptoms organize roles, rules and terms for social interaction, acquiring history and
embedding in identity, forming a part of the individual’s belief system on how to be with
others. In time, they become part of the system’s imaginings, a shared identity that “creates”
future behaviors through expectations reaffirmed through rigid, transactional patterns
3. While symptoms are natural, social mechanisms that “safe-guard” mechanisms against further
hurt or injury, complex symptoms or syndromes are “stalemates”, power struggles that
are often passive-aggressive power-plays to retain or obtain control
4. Symptoms contain inherent traits of “nobility” creating “worth” and rendering the struggle
as morally good. Complimentary and reciprocal roles provide bonding and shared imaginings
5. Symptoms control, often punish, others and are a passive-aggressive expression of rage
6. Symptoms avoid individual and family responsibility for blame
7. Symptoms avoid individual and family responsibility for change
8. Symptoms avoid intimacy and the risk of getting hurt again
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“Anxiety and Depression --including such varied forms of expression as dread, worry, hesitation, remorse,
grief, and despair, are affective conditions fueled by guilt and shame -highly corrosive negative estimations
of the self. Because guilt and shame are rooted in the opinion of others, a corresponding sense of anger or
resentment occurs –and worsens, whenever there is a perception of injustice or critique.
The ensuing Guilt, Anger and Shame (GASh) corkscrew into repetitive cycles called rumination. This may
deepen into feelings of worthlessness, hopelessness, and suppressed rage expressed as depression and
anxiety.
The root of emotional pain is the hurt caused by any of the many kinds of trauma, most simply categorized
as either a loss, betrayal or disaster. Unresolved, the ensuing damage, or psychological injury, is a degree of
harm to one’s perceived sense of self in relation to others --their self-esteem or sense of self-worth. This
mars their desire to trust and to be intimate and causes them to feel dis-empowered and less capable.
Symptoms may develop as a means to gain or re-gain control and to stabilize and reorganize the individual
and their relationship system. As such, they accumulate meaning and power -the ability to influence
outcome. Over time, the behaviors may concretize into established transactional patterns or habits that we
call symptoms. These become rigid and resistant to change.
As counselors, our main concern is when these conditions fulfill some important function or method of
coping. In particular, we are concerned when they serve as a means of controlling -perhaps even punishing,
others or as a method of excusing or avoiding responsibility for change.” – Demetrios Peratsakis, LPC, ACS
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Symptoms
1. Biomedical Condition
(CBD, ABI, TBI)
3. Trauma
(Disaster; Loss; Trust Betrayal)
2. Chronic Discord or Distress
(Control and Power-struggles)
Source or Cause
1.Rule-Outs
• Examine need for testing and
medication
• Demarcate physiogenic from
psychogenic
• Examine purposiveness of
symptoms/behavior (Can’t
versus Won’t)
2. Resolve
Conflict
• Establish truce
• Disengage and redirect
power-plays
• Mediate and problem-
solve
3. Heal Trauma
• Redefine guilt and shame
• Tap into anger and drive
for revenge
• Find paths to forgiveness
and redemption
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STEP 1: Global Assessment
STEP 2: Rule Out Medical or Neurological Conditions
STEP 3: Challenge the Meaning and Purpose of the Symptom
1) Track the Beliefs Surrounding the Presenting Problem (PP), Identified Patient (IP) or
Symptom(s)
2) Test the Rigidity of the Belief System
3) Unbalance the Beliefs and Introduce New Possibilities
4) Return to PP with expanded perspective
STEP 4: Contract for Talk Therapy -augmented with medication, if necessary *
As a (very) General Rule:
 SMI Mood Disorder; SA OP; MH OP; SED = Talk Therapy augmented by Medication
 TCM SMI; DD; Acute Care = Medication augmented by Talk Therapy
* Medication may greatly curtail interest in attending psychotherapy
Goals of Talk Therapy
1) Problem-solve and Resolve Conflict;
2) Heal Unresolved Trauma; and
3) Treat the Underlying Purpose that the Psychological Symptom Serves
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1) Meet and Greet/Initial Impression
a) What impression is the client striving to make; how do they join and control?
b) Reason for Referral; Who set up the meeting
c) Who arrives at session; who did not. Who lives at home or nearby; who is involved with the
client(s); Seating/Who sits where; Who speaks first; then who speaks
2) Examine Level of Functioning/Adaptation to the Developmental Tasks of Life
General adjustment and adaptation to major life changes. General strengths, abilities and resiliency of
each member.
a) Adler’s Tasks of Life
1. Work: contributing to the welfare of others
2. Friendship: social relationships with others
3. Partnership/Marriage: love and sex with others (see Family Life-cycle)
b) Family Life Cycle (Bowen) Expounded on by McGoldrick & Carter/Bowen
Stage 1: Launching the Young Adult/Differentiation of Self in Relation to the Family of Origin
Stage 2: Developing the Couple Relationship Vulnerability, Trust and Intimacy
Stage 3: Parenting/Families with Children: Establishing the Executive Subsystem
Stage 4: Families with Teens: Transition of Power
Stage 5: Launching Children and Moving On
Stage 6: Families in Later Life
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 Draw a Genogram (examines relational component of the individual Family Organization)
1. Family Organization aides adaptation to change
2. Family Organization helps meet basic needs, social responsibilities and child-rearing functions
3. Family Organization occurs through patterns and structures. These are purposive, defined
interactional transactions that acquire meaning, concreteness and history:
 roles: tasks, responsibilities, and power associated with certain functions (identities)
 rules: beliefs governing transactions and behaviors toward others (who does what and how)
 sub-systems: association by common role or function; ie. the “parents”, “siblings”, or “men”
 hierarchies: distribution of power (the ability to influence outcome) and responsibility, typically by age, experience,
role or function
 boundaries: two, related meanings, both regarding the degree of emotional fusion within a relationship:
o a marker of the degree of flexibility within a relationship system. Flexibility, is a necessary condition for adaptation to change;
it is measured as “rigid” (too inflexible), “clear” (appropriate) or “diffuse” (too vague) and illustrated by family mapping.
o the term “boundary” also refers to the degree of emotional proximity or reactivity within a relationship, sometimes understood
as the degree of separateness or independence of thought, feeling and action (fusion). This is best illustrated by use of the
genogram.
 These patterns of interaction -or “structures”
1. become habituated over time; they acquire history, function and purpose
2. comprise a major part of that which we define as our “identity”
3. are transmitted intergenerationally
4. rigidify under stress, restricting problem-solving and creative adaptation to change
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4) Examine Intimacy and Love Supports
 A critical task of life; those not actively seeking affection and love are fearful of injury
 Consider a) How I view Men; b) How I view Women; c) How I view “Marriage”; d) How I view Sex
5) Examine Issues of Power and How Power is Expressed?
 Power underlies all social interaction; it defines the rules, roles and styles of interaction
 Examine Overt and Covert Conflict, Power Struggles and Power-Plays
a) Cutoffs; b) Alliances and Coalitions that are supportive; c) Collusions and Triangulations that are
corrosive
6) Examine Unresolved Trauma (How I view Myself; How I view the World/Others)
7) Create and Continuously Strengthen the Therapeutic Alliance: client’s attitude and
responsiveness to the therapist and the treatment process. The therapeutic alliance is the single most proponent
of change.
8) Challenge Mistaken Beliefs, Irrational Beliefs and Cognitive Distortions
The first and most rigid distortion to challenge is the belief system
surrounding the Presenting Problem

 Mistaken beliefs or cognitive distortions were first described by Adler as the schema by
which we make judgements as to how one
a) belongs with family and community;
b) feels worthwhile and significant; and
c) feels safe and secure.
 These develop early in childhood and surround such core conceptualizations as self-concept,
self-ideal and the manner in which one must operate with others and in the world at-large.
 In great part, these core concepts can become fundamental impediments to change.

 Bernard Shulman, MD (1973) categorized “mistaken” beliefs into 6 categories:
1. Distorted attitudes about Self (“I am less capable than others”)
2. Distorted attitudes about the World and People (“People are hurtful”; “men will
always let you down”)
3. Distorted Goals (“I must be perfect”; “I must win at all cost”)
4. Distorted Methods of Operation (ie. excessive competition; procrastination;
avoidance)
5. Distorted Ideals (“ a real man…..”)
6. Distorted Conclusions (“Life is…”; “I am a Failure/Victim…”)
 Harold H. Mosak (1988) described 5 Basic Mistakes:
1. Overgeneralizations
2. False or Impossible Goals
3. Misperceptions of Life and Life's Demands
4. Denial of One's Basic Worth
5. Faulty Values

Beck’s/Burns’ Cognitive Distortions
(Common Distortions listed by Neo-Freudians Aaron Beck and David Burns)
David Burns, 1-11; Feeling Good Handbook, 1989)
1. All-or-Nothing Thinking / Polarized Thinking “Black-and-White” thinking; inability or unwillingness to see
shades of gray; tendency to view toward the extreme
2. Overgeneralization: taking one instance or example and generalizing it to an overall pattern. Mental Filter: Similar
to overgeneralization, focus is on a single negative and excludes all the positive
3. Disqualifying the Positive: acknowledging positive experiences but rejecting them instead of embracing them
4. Jumping to Conclusions – Mind Reading: inaccurate belief, typically a negative interpretation, that we know
what another person is thinking
5. Jumping to Conclusions – Fortune Telling: the tendency to make conclusions and predictions based on little to
no evidence and holding them as gospel truth
7. Magnification (Catastrophizing) or Minimization: either greatly exaggerating or minimizing the
importance or meaning of things
8. Emotional Reasoning: the acceptance of one’s emotions as fact. It can be described as “I feel it, therefore it must be true.”

9. Should Statements
Statements that you make to yourself about what you “should” do, what you “ought” to do, or what you “must” do. They are applied
to others also, imposing a set of expectations that will likely not be met. We are generally disappointed by the failure resulting in
guilt, perhaps even shame; others not meeting our expectations leads to our disappointment, anger and resentment
10. Labeling and Mislabeling
Extreme forms of overgeneralization, in which we assign judgments of value to ourselves or to others based on one instance or
experience. Mislabeling refers to the application of highly emotional, loaded language when labeling.
11. Personalization
Taking everything personally or assigning blame to yourself for no logical reason to believe you are to blame. This distortion covers a
wide range of situations, from assuming you are the reason a friend did not enjoy the girl’s night out because of you, to the more
severe examples of believing that you are the cause for every instance of moodiness or irritation in those around you.
Additional distortions identified by Beck and Burns (Beck, 1976; Burns, 1980):
12. Control Fallacies
A control fallacy manifests as one of two beliefs: (1) that we have no control over our lives and are helpless victims of fate, or (2) that
we are in complete control of ourselves and our surroundings, giving us responsibility for the feelings of those around us. Both
beliefs are damaging, and both are equally inaccurate.
13. Fallacy of Fairness: contrary to popular belief (or hope) life is inherently unfair
14. Fallacy of Change: expecting others to change and tying our happiness to it
15. Always Being Right: that we must always be right, correct, or accurate.
16. Heaven’s Reward Fallacy: the belief that one’s struggles/suffering or hard work will result in a just reward

Common Cognitive Distortions or Irrational Beliefs listed by Neo-Adlerian, Albert Ellis (REBT):
1. I must do well and get the approval of everybody who matters to me or I will be a worthless person.
2. Other people must treat me kindly and fairly or else they are bad.
3. I must have an easy, enjoyable life or I cannot enjoy living at all.
4. All the people who matter to me must love me and approve of me or it will be awful.
5. I must be a high achiever or I will be worthless.
6. Nobody should ever behave badly and if they do I should condemn them.
7. I mustn’t be frustrated in getting what I want and if I am it will be terrible.
8. When things are tough and I am under pressure I must be miserable and there is nothing I can do about this.
9. When faced with the possibility of something frightening or dangerous happening to me I must obsess
about it and make frantic efforts to avoid it.
10. I can avoid my responsibilities and dealing with life’s difficulties and still be fulfilled.
11. My past is the most important part of my life and it will keep on dictating how I feel and what I do.
12. Everybody and everything should be better than they are and, if they’re not, it’s awful.
13. I can be as happy as is possible by doing as little as I can and by just enjoying myself.
Ellis’ Irrational Beliefs

While there are numerous ways and countless workbooks specific to identifying and
categorizing distorted beliefs, many find benefit in assessing the overall “theme” of such
schema and their relationship to one another.
The Self-concept, comprised of the Self-image, Self-esteem and Ideal Self (Rogers), is best
understood as an amalgam of personal and social identities along with their past histories and
future imaginings. The self-concept is inextricably tied to the opinion of others whereby
worth -or one’s sense of value, in great part arises.
The great value of Projective Techniques -psychodrama, artwork, writing, dance, dream-work,
and early recollections to name a few, assist the client and the clinician to better understand
the fundamental themes or colorations that permeate once belief system.
These mediums, along with Guided Imagery and Fantasy work, provide viable means for
assessing, as well as treating cognitive distortions and, more importantly, for understanding
their purpose.

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Life-Style or Style of Life: The individual's unique, unconscious, and repetitive
way of responding to (or avoiding) the main tasks of living: friendship, love, and work.
Simple methods for discovering one’s mistaken beliefs, include
1) Examining choice of activities, art, fashion, and relationships
2) Discoveries from Projective Technique, especially psychodrama, dream-work,
fantasies, artwork, writing, dance, dream-work, and Early Recollections
3) Responses to select questions about the self, others and the world at-large:
1. How I View Myself?
2. How I View the World?
3. How I View Men?
4. How I View Women?
5. How I View Sex?
6. How I View Marriage/Partnership?

Is a medical condition expressing in symptoms termed psychological? Includes all disorders
associated with injury or irregularities of the body and brain due to medical, hormonal,
neurological/neurochemical, structural, congenital or brain injury conditions, including CAT
1) Congenital Brain Damage (CBD): genetic (pre-birth) or birth trauma (at–birth
2) Acquired Brain Injury (ABI)/Neurological and Medical Illnesses
ie. stroke, tumors, aneurysms, thyroid disease, cancer, vitamin D deficiency, poisoning/exposure to
toxic substances, infection, choking, effects of drugs or alcohol
3) Traumatic Brain Injury (TBI): head injury (accidents, sports injuries, falls, physical
violence). Look for symptoms, which make medical illness more likely:
- a change in headache pattern
- visual disturbances, either double vision or partial visual loss
- speech deficits, either dysarthrias (problems with the mechanical production of
speech sounds) or aphasias (difficulty with word comprehension or word usage).
- abnormal autonomic signs (blood pressure, pulse, temperature)
- disorientation and/or memory impairment
- fluctuating or impaired level of consciousness
- abnormal body movements
- frequent urination, increased thirst (possible symptoms of diabetes)
- significant weight change, gain or loss
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How to Rule-Out It Out?
1) Evidence of Progressive Decline in Cognitive Performance from a previous level,
namely complex attention, executive function, learning and memory, language, perceptual-
motor, or social cognition, as documented by self-report; the expressed concern of a
knowledgeable clinician, informant or observer and supported by
a) Mental Status Exam (MSE) or standardized neuropsychological testing for detecting
cognitive impairment, ie. https://www.alz.org/documents_custom/141209-CognitiveAssessmentToo-kit-final.pdf
b) Medical examination (ie. blood test, cat scan, MRI, MRSI, MEG or diffuse tensor imaging)
c) Serial 7 Series: 100 – 7, all the way down.
2) Selectivity of the Impairment: Is performance relatively consistent across similar tasks or
activities or does it appear to vary depending on interest, surroundings or participants?
3) Attitude toward Impairment by Caregivers: Does the behavior elicit compassion or
anger? “Can’t” versus “Won’t”
4) “Miracle Question”: “If I waived magic a wand and it got rid of this symptom forever, what
would be different?”; variation: “…what negative consequences would arise?”
(Adler/M.Erickson) = 1) what does it mask? 2) somatic or psychogenic?
47

49
 Challenge the beliefs, patterns or sequences of interaction surrounding the
Presenting Problem and introduce new possibilities.
 This will modify the rigidity of the symptom and alter its inevitability.
Unbalancing the World View

50
Part 3
Button Up / Return
to original PP
Part 1
Explore PP and track
the sequences that
uphold the beliefs
Part 2
1) Test the rigidity of the beliefs
2) Unbalance the perspective
3) Introduce new possibilities
Home Base =
Safe Territory

Tracking the Belief System Surrounding
the Symptom, PP or IP
1) History of Presenting Problem (PP): major nodal events surrounding the problem onset
(this clues you in on the possible purpose the symptom or problem serves)
2) Pattern of Interaction (sequence of behavior surrounding the PP): who does what, when and
where = who maintains the presenting problem and how. This pattern maintains the dysfunction.
 Therapist Questions to Self
o Why now?  Why not six months ago, or six months from now? What has changed?
o Why this symptom?  Why this particular problem
o Why this person?  Why this Identified Patient (IP) and not somebody else?
o Who participates?  Who else is affected by the problem and how?
o If this was NOT the problem, what -or who, would be?
 What does it mask? What is at risk if things change?
 Tracking and Sequencing: who does what, when?
o Denote the dysfunctional transactional pattern that maintains and repeats the symptom
o 3 ways to sequence: Self-report (good); Family Report (better); and Enactment or Simulation (best)
51

1. Create a new symptom (ie. “I am also concerned about
________; when did you first start noticing it?”)
2. Move to a more manageable symptom (one that is
behavioral and can be scaled; ie. chores vs attitude)
3. I.P. another family member (create a new symptom-
bearer or sub-group; ie. “the kids”, “the boys”)
4. I.P. a relationship (“the relationship makes her
depressed”)
5. Push for recoil through paradoxical intention (caution!)
6. “Spitting in the Soup” –make the covert intent, overt
7. Add, remove or reverse the order of the steps (having the
symptom come first)
8. Remove or add a new member to the loop
9. Inflate/deflate the intensity of the symptom or pattern
10.Change the frequency or rate of the symptom or pattern
11. Change the duration of the symptom or pattern
12. Change the time (hour/time of day/week/month/year)
of the symptom or pattern
13. Change the location (in the world or body) of the
symptom/pattern
14. Change some quality of the symptom or pattern
15. Perform the symptom without the pattern; short-
circuiting
16. Perform the pattern without the symptom
17. Change the sequence of the elements in the pattern
18. Interrupt or otherwise prevent the pattern from
occurring
19. Add (at least) one new element to the pattern
20. Break up any previously whole elements into smaller
elements
21. Link the symptoms or pattern to another pattern or
goal
22. Reframe or re-label the meaning of the symptom
23. Point to disparities and create cognitive dissonance
Note: 1-4, Minuchin/Fishman; 5-6, 22, 23, Adler; 7-21, O’Hanlon.
Pattern or element may represent a concrete behavior, emotion, or family member
Testing the Rigidity and Introducing New Possibilities
Rule # 2: Broaden narrow perspectives
53
Rule # 1: Narrow broad perspectives

Step 3: Buttoning-Up & Contracting
Button-UP
 Return to the Presenting Problem and reaffirm it as the purpose for meeting
 Be clear that other things can be explored once the PP has been solved
 Lay out what might be involved, who should ideally participate and what part
of the PP should be step-1. Be clear on how limitations will impact work
Contract for Work
 Contracting is the most sophisticated part of the therapy process.
 Contracting is Not a prequel to therapy, but therapy itself.
 Contracting requires continuous and ongoing refinement of the agreement to work
o How often should we meet and how long will this take?
o How will we understand success and measure progress toward it?
o Who needs to be in attendance?
o What are the consequences of the desired change?
o What is the motivation for change? Is it truly worth it?
54

 Good work is predicated on a solid therapeutic alliance
If clients are to experiment with new ways of thinking and feeling, they
must experience a sense of encouragement, trust and mutual respect. They
require a safe place in which to practice new ways of interacting and being.
Note:
 Poor contracting is the #1 reason for therapist burnout
 Anger at therapist is the #1 reason for client leaving therapy
 Predictions:
1. Predict that no change will occur as yet
2. Predict that the desire to come back or continue treatment may wane
3. Predict residual anger at therapist for being “pushy”
 Recommend at least 1 more meeting!
55

There is no greater privilege, then to share in the suffering of another!

Accidents, Natural Disaster, Illness, Injury
1. Accidental Physical Injury
2. Fire
3. Industrial Accident
4. Work Accident
5. Invasive Medical Procedures
6. Injury or Illness
7. Motor Vehicle Accident
8. Natural Disaster
9. Property Loss
Threat or Harm to Others
1. Death of a Loved One
2. Injury or Illness of a Loved One
3. Threat to a Loved One
4. Witness to Violence
5. Suicide of a loved one
Threat or Harm to Self
1. Adult Sexual Assault
2. Captivity
3. Childhood Sexual Abuse
4. Combat & Military Sexual Trauma
5. Communal Rejection (Scapegoating, Shunning)
6. Cults and Entrapment
7. Domestic Violence
8. Physical Assault
9. Rape
10. Robbery
11. Sexual Harassment
12. Threat of Physical Violence
13. Torture
14. Victim of Crime
15. Victim of Violence
16. Witnessing Traumatic Event
A broad spectrum of events can lead to trauma and complications in mood,
thought and one’s sense of self and beingness in the world
57

Common Signs and Symptoms of Psychological Trauma
Cognitive/Behavioral:
 Intrusive thoughts, images, smells and sounds of the event
 Nightmares
 Disorientation, confusion, loss of memory or ability to concentrate
 Mood swings, especially fear, sadness and anger
 Avoidance or lack of interest in activities or places that trigger memories
 Social isolation and withdrawal
Physical:
 Fatigue and exhaustion
 Tachycardia; irritable or edgy, nervous or easily startled
 Insomnia or difficulty sleeping; loss of appetite of eating problems
 Sexual dysfunction
 Hypervigilance; preoccupation with safety, danger or risk
Psychological:
 Feeling overwhelmed or fearful; feeling anxious, vulnerable and unsafe; panic attacks
 Ritualized behavior, obsessive and compulsive behaviors; rumination
 Depression or detachment from others
 Failure or self-defeating behavior
 Blaming, shaming or feelings of guilt
 Anger
Untreated Psychological Trauma, may include
 Addiction, Alcoholism or Substance abuse
 Sexual problems or dysfunctions
 Distrust/Issues with intimacy, closeness or trust
 Hostility or rage
 Combativeness, pervasive irritability or social withdrawal
 Self-destructive behaviors including self-injury and suicide
58

A Simpler Model for Understanding Psychological Injury

“Anxiety and Depression --including such varied forms of expression as dread, worry, hesitation, remorse,
grief, and despair, are affective conditions fueled by guilt and shame -highly corrosive negative estimations
of the self. Because guilt and shame are rooted in the opinion of others, a corresponding sense of anger or
resentment occurs –and worsens, whenever there is a perception of injustice or critique.
The ensuing Guilt, Anger and Shame (GASh) corkscrew into repetitive cycles called rumination. This may
deepen into feelings of worthlessness, hopelessness, and suppressed rage expressed as depression and
anxiety.
The root of emotional pain is the hurt caused by any of the many kinds of trauma, most simply categorized
as either a loss, betrayal or disaster. Unresolved, the ensuing damage, or psychological injury, is a degree of
harm to one’s perceived sense of self in relation to others --their self-esteem or sense of self-worth. This
mars their desire to trust and to be intimate and causes them to feel dis-empowered and less capable.
Symptoms may develop as a means to gain or re-gain control and to stabilize and reorganize the individual
and their relationship system. As such, they accumulate meaning and power -the ability to influence
outcome. Over time, the behaviors may concretize into established transactional patterns or habits that we
call symptoms. These become rigid and resistant to change.
As counselors, our main concern is when these conditions fulfill some important function or method of
coping. In particular, we are concerned when they serve as a means of controlling -perhaps even punishing,
others or as a method of excusing or avoiding responsibility for change.” – Demetrios Peratsakis, LPC, ACS
60

 Hurt or harm from suffering a loss, becoming the victim of the breach of a sacred trust
(betrayal) or experiencing a disaster. Each creates a psychological injury that we call trauma.
 The injury, or trauma, is damage to one’s sense of self-worth, one’s self-esteem or estimation of
self in regard to the cumulative opinion of others, one’s past, and one’s idealized self.
 Anger arises at the perceived injustice of others, Life, God or the World.
 Symptoms emerge as protective, safe-guarding behavior that help reassert control and safe-
guard or shield the individual and their relationship system from further injury or harm. This is
very different way of understanding symptom development. Instead of thinking of symptoms as
the expression of conditions that befall the individual this viewpoint regards them as purposive,
constructive belief structures
 The most common symptoms are depression and anxiety, which generate psychological as well
as somatic changes and carry strong evolutionary advantage. Depression and anxiety are
identical; their temporal frame differs. Depression (bad/sad) is past-oriented, whereas anxiety
(fear/dread) is a foreboding of events as yet to come.
 Depression and Anxiety are fueled by Guilt, Anger and Shame (GASh).
 Left unresolved, Anxiety and Depression may become a means of avoiding or risk of further
injury. In some instances, it may be used to deflect blame, control others, punish others, or
avoid the responsibility to change.
61

Loss
Including ambiguous loss, loss of a loved one,
prestige, prized possession, familiar way of
being, health, or goal
Betrayal (breach of trust)
Interpersonal injury; the breach of the trust
agreement in friendship and love, including
abuse, neglect, incest and sexual affairs
Disaster
An event causing great suffering, destruction,
and distress, such as a serious accident, crime, or
natural catastrophe.
• Feeling/Tone: Emptiness
• Distinguishing Feature: Grief
• Preoccupation: Replacement
• Feeling/Tone: Power Struggle
(Conflict)
• Distinguishing Feature: Anger; Rage
• Preoccupation: Revenge
• Feeling/Tone: Vulnerability
• Distinguishing Feature: Fear (Dread)
• Preoccupation: Avoidance (Safety-
Needs
OftenOverlap
62

Loss, Betrayal,
Disaster
Guilt, Anger, Shame (GASh)
Depression, Anxiety
Secondary
Symptoms
Emotional Pain is expressed as Depression and Anxiety,
fueled by continual thoughts and feelings –or rumination, of Guilt, Anger and Shame (GASh).
Secondary Symptoms evolve as protective mechanisms, which in turn
can create unresolved problems and stifle adaptive growth.
63

The Development of Depression and Rage
Trauma, including Losses, Disasters and Betrayals from abuse, neglect, incest and affairs
Anger
Guilt
Shame Anxiety/Dread
Sadness
DepressionRage
Primary Emotion/Initial Reaction:
Complex Emotion/Over Time:
Sense of Discouragement and Worthlessness
Fear
Demetrios Peratsakis, LPC, ACS © March 2016
Anger, sadness and fear are natural responses to psychological injury. They result in feelings of depression and anxiety, which are fueled by thoughts of guilt and
shame. Anger, which can provide a faulty sense of power, is an attempt to counter-act the feelings of guilt and shame; to retain the anger, the harm or emotional
pain must be continually reactivated (rumination), often, in the form of self-pity or blame. This can result in feelings of helplessness and worthlessness or the desire
to over-power, punish or seek revenge. Unresolved, the effects of trauma are cumulative and typically erode confidence in self and trust and intimacy with others.
Treatment considerations for Depression and Anxiety:
1. Resolve conflict and disengage and redirect the power-play; practice enacting new ways of behaving and interacting. Challenge the meaning and the power of
the depression and its symptoms; examine how it avoids responsibility and how it controls others.
2. Tap underlying feelings of anger; seek acknowledgement and de-escalation; examine betrayal and work on revenge, forgiveness and redemption.
3. Bridge emotional cut-offs; fill loss; connect to meaningful activity and relationships; develop a sense of purpose and rekindle spiritual being-ness.
4. Consider medication and safety/suicide planning, as needed. Look to self-care and general health.
OverlappingandCyclicEmotionalStrands
64

Depression
Feeling sad, bad, hopeless or worthless. Experiencing guilt
or shame over conduct or actions.
Common depression signs and symptoms include:
 Persistent sad, anxious, or "empty" mood
 Feelings of hopelessness, pessimism
 Feelings of guilt, worthlessness, helplessness
 Loss of interest or pleasure in hobbies and activities that
were once enjoyed, including sex
 Decreased energy, fatigue, being "slowed down“
 Difficulty remembering, making decisions
 Insomnia, early-morning awakening, or oversleeping
 Appetite and/or weight loss, or overeating and weight
gain
 Thoughts of death or suicide; suicide attempts
 Restlessness, irritability
 Persistent physical symptoms that do not respond to
treatment, such as headaches, digestive disorders, and
chronic pain
Anxiety
Fear, dread or foreboding; a state of uneasiness,
apprehension, uncertainty, and fear resulting from
anticipation of a realistic or fantasized threatening event
future uncertainties or situation, often impairing physical
and psychological functioning
Common anxiety signs and symptoms include:
 Feeling nervous, restless or
 Having a sense of impending danger, panic or doom
 Increased heart rate/Breathing rapidly (hyperventilation)
 Sweating, trembling, feeling weak or tired
 Trouble concentrating/thinking anything other than the
present worry
 Having trouble sleeping
 Experiencing gastrointestinal (GI) problems
 Having difficulty controlling worry
 Having the urge to avoid things that trigger anxiety
Past Events Future Events
66

Self-worth: An amalgam of one’s estimation of self as compared to others, one’s past, one’s potential or
idealized self, and one’s beliefs about the opinions of others.
Guilt: I did wrong (“Somehow, I am less than”): I did not do something I should have done; I did not do
something wrong but wanted to; I did not do enough; I did better than someone else; etc. “I should
know/do better!”
Shame: I am wrong (“Somehow, I am less than”): I am less able, less capable, not up to snuff. “Others are
better than me!” “I should be “better!”
 Guilt and Shame diminish one’s sense of self-worth, their self esteem
 Despite their corrosive nature Guilt and Shame have self-protective as well social corrective value, reaffirming
morays, idealized icons, and guiding socially acceptable behavior and thought (evolutionary advantage)
 Guilt and Shame breed resentment (Anger) at the perceived injustice of others, fate, the world or God. Anger
always accompanies Guilt, always accompanies Shame (Guilt, Anger, Shame or GASh). It is often kept hidden as
one feels even more devalued being angry at other when they have acted or thought wrongly. For this reason, one
must tap into the underlying anger in order to move beyond guilt and shame.
 Guilt and Shame have great “nobility” and may serve as a means to reassert control (self-deprecating behavior
means one controls their own punishment or “should-ing”); punish others (“look at how you make me feel”); avoid
responsibility (“if I show contrition I need not actually change”) and express remorse, garnering sympathy
(expressing good intentions) instead of actual change. The best remedy for guilt is restitution and change.
 Guilt/Shame = I am less worthy. Anger = you hurt me, you are less worthy.
67

70
Anger
Sadness
Fear
Guilt
Shame

 Anxiety = fear and foreboding (tension; distress) due to a perceived sense of vulnerability,
especially with preoccupation and concern over the potential reoccurrence of harm (dread).
 Depression = feelings of sadness and hurt from experiencing a disaster, suffering a
significant loss or becoming the victim of betrayal by a trusted or loved one.
 Both include feelings of Anger that is fueled by Guilt and Shame.
 Anxiety is future-oriented; Depression, past tense
- Demetrios Peratsakis, LPC, ACS

1. Examine the Injury. Identify the source of the injury (loss, betrayal, betrayal).
Personal injury and the betrayal of a trust agreement by a friend or loved one cut
the deepest.
2. Challenge the Manner in Which the Pain is Distracted or Suppressed
- the anger and blame will come forward and replace guilt and shame (GASh)
a) Tell the Story; the hurt and anger must be voiced
b) The thirst for revenge must be (symbolically) quenched
c) The passivity and victimhood of Depression and Anxiety must be mobilized to action
d) Promote Self-worth
4. Reconcile power-struggles and betrayals (real or imagine; present or past) in
the intimate relationships.
5. Work through victimhood; identity and replace with self-actualization
72

- Demetrios Peratsakis, LPC, ACS
Sadness
Fear
Anger
Guilt
Shame
1
2
3
Depression and
Anxiety will lift
Work through
Guilt and
Shame
Tap into
underlying Anger
Self-worth
Improves

Personal Injury, the Leading Cause of Psychological Injury
74

75
“It is that we are never so defenseless against suffering as when we love, never so helplessly
unhappy as when we have lost our loved object or its love.” Sigmund Freud

76
At Issue, Is Why We Hold Onto Them?!

Intimacy Requires an Equal Sharing of Power

 Power is the expression of will and intent; the ability to influence outcome
 Power is at the core of every social interaction; power is influence and control within the
relationship system
 Conflict is always about power; it occurs around issues of money, work, sex, children,
chores, and “in-laws”
 Determines style of communication and how love, caring, anger, and other emotions are
expressed and understood
 Determines style of decision-making and problem-solving
 Defines level of trust for meeting or not meeting needs
 Establishes rules for interdependence, independence and for distance and closeness between
members (attachment/mutual accommodation; affection/expressing and experiencing love)
 Defines rules around positions and roles; these are usually reciprocal, interactive patterns of
behavior found primarily in the Family of Origin. The rules are taken or assigned to
individual in the family unit and are expected to be maintained; they are relatively enduring
(permanent) and acquire “moral character” and “status” which results in one’s placement in
the family's power hierarchy, often replicated outside the family at work and with others.
78

Intimacy: a Psychotherapist’s Definition
An agreement (Trust) to risk hurt and pain (Vulnerability) in order to
experience acceptance (Love) and belonging in a meaningful way (Worth).
1. Belonging in a Meaningful Way = Self-Worth = Mental Health
2. Intimacy increases belonging in a meaningful way
3. Trauma reduces our capacity for love; it makes us self-protecting, reducing
our willingness to risk pain.
4. Psychological Injury is damage to our sense of self-worth
79

Inequality of power reduces one
partner’s ability to openly share,
succeed in conflict and feel
fairly valued
1. The potential for personal
growth is reduced
2. Stress is increased
Intimacy Requires an Equal Sharing of Power
80

Power and Intimacy
Mutuality of influence allows each partner to feel important and supported
in the relationship -affirming identity and worth. Partners can then open
themselves to being changed by the other, to accept influence.
They also feel safe enough to reveal their innermost thoughts, express
concerns, even admit weakness, uncertainty, or mistakes in a partner’s
presence. Mutual vulnerability becomes a high-water mark of bringing one’s
whole self into a relationship (Carmen Knudson-Martin; Family Process)
81

How to Treat Trauma April 2019

1. Power is the natural expression of will and intent to influence outcome
2. When two or more express desires and interests that conflict, tension arises
(discord)
3. These are reconciled and mediated in a variety of mutually productive and less
productive ways
4. Anger, a natural response to disappointment and not getting one’s way is used
effectively to overpower and control; to increase one’s power through threat
and domination
83

Problem-solving Remedies
1. Collaboration/Alliance (win/win)
2. Compromise (I bend/you bend)
3. Accommodation (I lose/you win)
4. Competition (I win/you lose)
5. Avoidance (no win/no lose)
6. Triangulation (win/win/lose)
84

Anxiety Builds
Problem-solving
Remedies
•Collaboration/Alliance
(win/win)
•Compromise (I bend/you
bend)
•Accommodation (I lose/you
win)
•Competition (I win/you
lose)
•Avoidance (no win/no lose)
•Triangulation
(win/win/lose)
Conflict
Natural to
human
interaction
Chronic Tension
Results in*
•Open Discord
•Stable, unsatisfying
•Unstable
•Impairment in a Child
•Attention Seeking
•Power Seeking
•Revenge Seeking
•Displays of Inadequacy
•Impairment in a Partner
•Failure
•Depression
•Illness
•Detouring to an Identified
Patient (IP)/Scapegoating
* Bowen; Adler
Power
Struggle
Intense unresolved
discord
Neutralizes or
Breaks the Impasse
(often results in
trauma or betrayal)
Examples:
•Treachery/Betrayal
•theft, disloyalty, sabotage,
incest, abandonment, infidelity
•Revenge
•punishment, suicide, crime,
depression, addiction, eating
disorders, failure or acts of
inadequacy
•Violence
•warfare, bullying, threats, rage,
domestic violence, abuse
•Escape/Emotional Cut-off
•Expulsion/Rejection
Power Play
Frustration and
hurt lead to
desperate and
unhealthy
solutions
85

• Drive; natural force of Life
• Expression of one’s Will,
interests & wants
• Ability to Influence Outcome
Power
• Natural product of interaction;
collision of Wills
• Routinely mediated and
reconciled
• Tension ensues offset by
Triangulation
Conflict
• 2 “Wills” Become 1 “Won’t”
• Stale-mate/Power Balances
• Power may be passive-aggressive
or issues may be “avoided”.
Chronic tension may lead to illness,
dysfunction or misbehavior
• Members may hurt one another
Power-Play
• Action to break the Stalemate
• Negative Triangulation: scape-
goat others/issues; collusions
• Misbehaviors
• Betrayal, Failure, Violence,
Revenge, etc.
Misbehavior
Power….where there’s a “Will” -there’s a “Won’t!”
-Demetrios Peratsakis, LPC, ACS
Power and Conflict Sequence
86

Unresolved CONFLICT  Power-Struggles 
 Misuse of Power/Acts of Revenge to Punish or Break the Stalemate
1. Combat: fighting, bickering, forcing, hurting, bullying, shaming, withholding, stealing, et
al. often triangulating outside parties, for added power, such as friends, family,
counseling, the police, the courts, threats of separation or divorce, seeking legal counsel
2. Sabotage: undermining the partner, their sources of support, their resources or their
attempts to remedy the situation, kids, work, etc.
3. Inadequacy/Failure: One partner becomes dysfunctional, ill, fails or becomes the
Identified Patient (I.P.) to frustrate their partner
4. Isolating/Witholding/Cutting-off: escape to solo activities, such as hobbies or individual
interests; solo acts of defiance and selfishness
5. Triangulating Others: patterns of adding power through the inclusion of a third-party,
such as friend, family member or child(ren); ie. Collusions and Alliances
6. Betrayal: violence, rape, incest, extra-marital affairs or sexual relationships
 Caution on Violence: fear of being together or separate creates swings between fear
of abandonment and fear of engulfment  equated with loss of self/identity
87

The Power of Controlling Others, Avoiding Responsibility and Blame and Obtaining Revenge
1. Becoming the Identified Patient (IP) or Presenting Problem (PP)
2. Failure/Inadequacy: “Can’t Versus Won’t”
3. Hesitation, procrastination, stalling,
4. Guilt Feelings (Should-on-you)
5. Depression
6. Victimhood/Self-punishment; rejection; abandonment
88

Anger/Aggression, a natural, protective reaction to fear and injury, is one of the four primary emotions:
Anger/Disgust, Fear/Surprise, Sadness, and Joy
1. Anger is a way to control/to get one’s way
 It may be overt (bullying/violence, persuasion) or covert (passive aggressive)
 It can provide a faulty sense of power
 To retain the anger, the harm or emotional pain must continually be reactivated
(rumination), often in the form of self-pity or blame
2. Anger can mobilize and counter-act feelings of Sadness, Guilt and Shame
 It can counter-act feelings of depression and anxiety
 This is why we often feel sad, when we are, in fact, angry. In some families it is so
toxic that it is more acceptable to become ill, depressed or “insane”
 Guilt and shame result in feelings of worthlessness and hopelessness (aka
powerlessness)
 Individuals prone to feelings of worthlessness often develop a great sense of
‘nobility’, stemming from beliefs associated with the desire to change, make
amends or seek revenge. The ensuing struggle justifies one’s good intentions
despite the unwillingness to change or relinquish its control of others.
3. Anger may establish distance or stave off intimacy
The (Mis-) Use of Anger
According to Adler (1913) there are two, unconstructive methods by
which one safeguards their self-esteem, depression and aggression.
89

Retaliation and Abuse in the Relationship System
(see section on Domestic Violence)

We punish, steal, cheat and lie to the ones we love.
We beat them, degrade them and abuse them.
We even maim, rape and kill them.
Why?!
91

Adler posited that the central part of individual behavior
is to compensate for normal feelings of inadequacy
(Peluso & Kern, 2002; Ansbacher & Ansbacher, 1964).
 Individuals usually conquer feelings of inadequacy by forming
cooperative relationships, which are the underpinnings of social
interest, socialization and social belongingness, critical advantages
to evolutionary adaptation to change.
 Some, attempt to overcome their inferiority feelings by striving for
superiority. Overpowering and the control and taking advantage of
others provides a false sense of importance and security.
93

1) Revenge
a) Vengeance and Retribution: You hurt, betray or fail to protect
b) Displacement: redirection of fear, anger or aggression feelings stemming from an insoluble
conflict or injury onto another, typically less powerful substitute target (A. Freud, 1936). The
target can be a person or an object that can serve as a symbolic substitute. Someone who is
frustrated by their boss or partner may kick the dog, beat up a family member, or engage in
social or criminal mischief. Someone who feels uncomfortable with their sexual desires for a
real person may substitute a fetish.
2) Domination
a) Greed and envy
b) Fear and need to feel in control
1. Both make us feel in control, provide a false sense of superiority
2. Both are fueled by excitement, some of which may be highly sexualized
3. Men -as well as certain roles, are enculturated to be “superior” and are, therefore, more
prone to domination -depending on the individual’s level of perceived inferiority.
94

1) Victimhood
a) Feelings of Worthlessness: I only matter when I am hurt or exploited by others
b) Nobility: there is a “nobility” to the suffering and pain that mitigates the sense of worthlessness and
inferiority. Hurt attracts the sympathy of others and has prestige.
2) Revenge/Retaliation
a) Passive-aggressive: My anger makes me feel more powerful, more in control; I punish you with my
victimhood, the guilt and shame
b) Fear and need to feel in control
1. Both make us feel in control, provide a false sense of superiority
2. Both are fueled by excitement, some of which may be highly sexualized
3. Women -as well as certain roles, are enculturated to be “inferior” and are, therefore, more
prone to victimhood -depending on the individual’s level of perceived inferiority.
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I feel less powerful and
significant than others.
I feel hurt but cannot
reconcile this with its
cause
I redirect my anger to
others (displacement).
Controlling others makes
me feel more important
and in control
I rationalize blame to
avoid further feelings of
guilt and shame
Cycle of Rationalization

Activation of Childhood
Trauma
Guilt and Shame
Powerlessness; feelings of
Inadequacy, Helplessness and
Insignificance
I must over-power others to
be significant; False sense of
empowerment through abuse
and control of others
Guilt and shame
Sharpened feelings of
inadequacy

Eris, the Goddess of Strife and Discord and mother to painful Ponos ("Hardship"), Lethe, ("Forgetfulness") and Limos ("Starvation") and the
tearful Algea ("Pains"), Hysminai ("Battles"), Makhai ("Wars"), Phonoi ("Murders"), and Androktasiai ("Manslaughters"), Neikean ("Quarrels"),
Pseudo-Logoi ("Lying Stories"), Amphillogiani ("Disputes"), Dysnomia ("Anarchy") and Ate ("Ruin") . -Hesiod's Theogony (circa 650-750 BC)
Given the scope and breadth of Depression it should be considered a spectrum disorder,
ranging from a normative response to disappointment and hurt to pervasive melancholia
that negatively effects thinking and functioning,
driving neuro-biomedical changes as well as being driven by them.
Therapy must include treatment of its symptoms and the psychological
injury and functional value associated with it.
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The Center for Disease Control (CDC) and the National Institute of Mental Health (NIMH)
estimate that in any given year almost 25% of the adult public suffers from a serious,
debilitating mental health condition, 26% of whom suffer from chronic depression.
Annual World Health Organization estimates:
350 million suffer from depression, 800,000 of who commit suicide.
US: 15 million depressed, 30,000 suicides, at an annual cost of $210 Billion (MDD)
 Depressed Mood (Irritability and anger in adolescents)
 Anger
 Markedly diminished interest or pleasure
 Significant change in appetite and/or weight
 Insomnia or hypersomnia
 Psychomotor agitation or retardation
 Fatigue or loss of energy; diminished concentration
 Becoming withdrawn or isolated
 Feelings of worthlessness or excessive guilt
 Recurrent thoughts of death or suicide
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Depression is a biochemical, social and psychological syndrome
1. Major depression - severe symptoms that interfere with the ability to work, sleep, study, eat, and enjoy life. An episode
can occur only once in a person’s lifetime, but more often, a person has several episodes.
2. Persistent depressive disorder - depressed mood that lasts for at least 2 years, often with episodes of major
depression along with periods of less severe symptoms; symptoms must last for 2 years.
3. Psychotic depression, which occurs when a person has severe depression plus some form of psychosis, such as having
disturbing false beliefs (delusions) or hearing or seeing upsetting things that others cannot hear or see (hallucinations).
4. Postpartum depression, many women experience after giving birth, when hormonal and physical changes and the
new responsibility of caring for a newborn can be overwhelming.
5. Seasonal affective disorder (SAD), which is characterized by the onset of depression during the winter months,
when there is less natural sunlight. The depression generally lifts during spring and summer.
6. Premenstrual Dysphoric Disorder, or PMDD, is a depression that may affect women during the second half of
their menstrual cycles.
7. Complicated Bereavement, prolonged Situational Depression/Adjustment disorder initially triggered by a stressful
or life-changing event, such as job loss, the death of a loved one or trauma.
8. Bipolar disorder or manic-depressive illness, less common than major depression or persistent depressive disorder. It
is characterized by cycling mood changes, such as extreme highs (e.g., mania) and extreme lows (e.g., depression).
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Depression may accompany, precede or cause several problem syndromes, each of which must be
regarded within their own right:
 Suicide and Self-Injurious Behavior
 Eating Disorders
 Major illnesses, including HIV/AIDS, heart disease, stroke, cancer, diabetes, and Parkinson's
 Post-partum depression
 Depression in Childhood due to parent’s depression, illness, divorce, or parental abuse
 Alcohol or Drug Dependence
 Depressive Style of Life (“Victims”)
 Anxiety Disorders, including PTSD, OCD, Phobias and Panic Attacks
 Trauma
 Life-long Depressives: adult victims of prolonged childhood trauma, including neglect,
abuse or severe discouragement
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Anxiety Disorders
Separation Anxiety Disorder
Selective Mutism
Specific Phobia
Social Anxiety Disorder (Social Phobia)
Panic Disorder
Panic Attack (Specifier)
Agoraphobia
Generalized Anxiety Disorder
Substance/Medication-Induced Anxiety Disorder
Anxiety Disorder Due to Another Medical Condition
Other Specified Anxiety Disorder
Unspecified Anxiety Disorder
Obsessive-Compulsive and Related Disorders
Obsessive-Compulsive Disorder
Body Dysmorphic Disorder
Hoarding Disorder
Trichotillomania (Hair-Pulling Disorder)
Excoriation (Skin-Picking) Disorder
Substance/Medication-Induced Obsessive-Compulsive and
Related Disorder
Obsessive-Compulsive and Related Disorder Due to Another
Medical Condition
Other Specified Obsessive-Compulsive and Related Disorder
Unspecified Obsessive-Compulsive and Related Disorder
Trauma- and Stressor-Related Disorders
Reactive Attachment Disorder Disinhibited
Social Engagement Disorder Posttraumatic
Stress Disorder Acute Stress Disorder
Adjustment Disorders Other Specified Trauma-
and Stressor-Related Disorder Unspecified
Trauma- and Stressor-Related Disorder
Depressive Disorders
Disruptive Mood Dysregulation Disorder
Major Depressive Disorder, Single and
Recurrent Episodes Persistent Depressive
Disorder (Dysthymia) Premenstrual Dysphoric
Disorder Substance/Medication-Induced
Depressive Disorder Depressive Disorder Due
to Another Medical Condition Other Specified
Depressive Disorder Unspecified Depressive
Disorder
Somatic Symptom and Related Disorders
Illness Anxiety Disorder
(additional disorders not listed)
Strong correlation between symptoms of Depression and Anxiety
85% with major depression diagnosed with generalized anxiety disorder; 35% had symptoms of panic disorder.
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1. Kessler et al. Arch Gen Psychiatry, 1995 2. DSM-IV 3. Rasmussen. Psychopharmacol Bull, 1988 4. Van Ameringen et al. J
Affect Disord, 1991 5. Brawman-Mintzer, Lydiard RB. J Clin Psychiatry, 1996 6. Stein et al, Am J Psychiatry, 2000
Major
Depression
Posttraumatic
Stress Disorder
Social Phobia
(Social Anxiety Disorder)
OCD
Panic Disorder
GAD
8%-39% of
Patients with GAD5
67% of Patients
with OCD3
34-70% of Patients with
Social Phobia4,6
48% of Patients with PTSD1
50% to 65% of Patients
with Panic Disorder2
Lifetime Comorbidity
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 At some point in their lives, about one in four Americans will experience depression. In market economies (ie. US) depression is the leading form of mental illness (g)
 Risk factors: past abuse (physical, sexual, emotional), certain medications, conflict with family or friends, death or loss, chronic/ major illness, family history of depression (a)
 Depressed individuals have two times greater overall mortality risk than the general population due to direct (e.g., suicide) and indirect (medical illness) causes (g)
 Almost 20 million people in the United States suffer from depression in a given year (a)
 Positive events, such as graduating, getting married, or a new job can lead to depression (b)
 Nearly 30% of people with substance abuse problems also suffer from depression (e)
 Depression may occur in 1 in 33 children and 1 in 8 teenagers (USA); he or she has a greater than 50% chance of experiencing another episode in the next five years (b)
 Total cost of depression in US estimated at $44 billion: $12 billion in direct treatment, $8 billion in premature death and $24 billion in absenteeism and reduced productivity at
work. This excludes out-of-pocket family expenses, costs of minor and untreated depression, excessive hospitalization, general medical services, and diagnostic tests (g)
 Women are twice as likely to suffer from depression than men. Women may be at a higher risk due in part to estrogen, which may alter neurotransmitter activity (b)
 Increased risk of depression in mid-life men due to the decrease of testosterone (b)
 Men experience depression differently from women; women feel hopeless, men feel irritable. Women prefer a listening ear, men may became withdrawn, violent or abusive (b)
 Depressed women are especially at risk for developing osteoporosis (c)
 As many as 15% of those who suffer from some form of depression take their lives each year (g)
 According to the National Institute of Health (NIH), more than 6% of children suffer from depression and 4.9% of them have major depression (g)
 Self-mutilation (cutting or burning) is one way in which individuals show they are depressed (b
 Because the brains of older people are more vulnerable to chemical abnormalities, they are more likely than young people to suffer depression (b)
 Sufferers of depression are more likely to have a heart attack and people who have had heart attacks or heart surgery are more at risk for depression (g)
 Approximately 80% sufferers of depression are not receiving treatment (a)
 Recent research suggests that depression can shorten the lives of people with cancer by years (g)
 Mental Health America reports that over 5.5 million adults in the United States suffer from bipolar disorder in a given year. This illness tends to run in families (b)
 Postpartum depression affects about 10% of new mothers, according to the National Women’s Health Information (a)
 Fifty-eight percent of caregivers for an elderly relative experience symptoms of depression (b)
 Perimenopause (menopause transition) and the resulting reduced and fluctuating hormone levels can trigger depression (c)
 Long-term use of marijuana leads to changes in dopamine production and has been implicated in the onset of depressive symptoms (b)
 People with depression are five times more likely to have a breathing-related sleep disorder than non-depressed people (f)
 On a worldwide basis, depression ranks fourth as a cause of disability and early death according to the Global Burden of Disease Study (g) The World Health Organization
estimates that depression will be the second highest medical cause of disability by the year 2030, second only to HIV/AIDS (g).
 Age of depression onset is becoming increasingly younger (b). Today the average age for the onset of depression varies between 24-35 years of age, with a mean age of 27 (g)
 Depression often presents itself in four ways: mood changes, cognitive (memory and thought process) changes, physical changes, and behavioral changes.e
 Long-term use of some prescription medications may cause depressive symptoms, such as corticosteroids (Deltasone, Orasone), the anti-inflammatory Interferon (Avonex,
Rebetron), bronchodilators (Slo-phyllin, Theo-Dur), stimulants (e.g., diet pills), sleeping and anti-anxiety pills (Valium, Librium), acne medications (Accutane), some blood
pressure and heart medications, oral contraceptives, and anticancer drugs (tamoxifen) (b)
 Some diseases interconnected with depression, such as thyroid problems, heart disease, stroke, cancer, Alzheimer’s, Parkinson’s, obstructive sleep apnea and chronic pain (g)
 Depression is common among those with eating disorders such as anorexia nervosa, bulimia nervosa, and binge eating disorder (a)
References
a Berne, Emma Carlson. 2007. Depression. Farmington Hills, MI: The Gale Group
b Brees, Karen K, PhD. 2008. Everything Guide to Depression. Avon, MA: F+W Publications, Inc.
c “Depression Hard on the Bones.” Reuters Health. September 17, 2009. September 27, 2009
d “Eating Seafood While Pregnant May Boost Mood.” Reuters Health. July 30, 2009 Sept 26, 2009
e Edwards, Virginia, M.D. 2002. Depression and Bipolar Disorders: Everything You Need to Know. Buffalo, NY: Firefly Books Inc.
f Hendrick, Bill. “Adults Playing Video Games: Health Risks?” WebMD.com. August 20, 2009
g Lam, Raymond W. and Hiram Wok. 2008. Depression. New York, NY: Oxford University Press.
h Preidt, Robert. “Foreclosures Plunge People into Depression.” University of Pennsylvania School of Medicine, News Release August 18, 2009
i “Suicide Risk with Antidepressants Falls with Age.” HealthDay. August 12, 2009
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.
Prevailing thoughts and models that add to our understanding of Depression
Six (6) different Viewpoints:
1. Depression is a medical disease caused by neurochemical or hormonal
imbalances (Neurobiology Model)
2. Depression is the result of unfortunate experiences (Psychosocial Model)
3. Depression is caused by certain styles of thinking (Cognitive-Behavioral
Model)
4. Depression as evolutionary advantage (Evolutionary Psychology)
5. Depression as existential dread (Existentialism)
6. Depression as power/unexpressed rage: purposive emotion and behavior
(Adler/Peratsakis)
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Depression is a medical disease caused by neurochemical, structural or hormonal imbalances
1. Chemical Imbalance/Faulty Brain Wiring
Electro-chemical disruption to monoamine neurotransmitters (serotonin, dopamine, norepinephrine, neuropeptides) or neural communication receptors of
the limbic system, a part of the brain associated with the regulation of sleep, appetite, memory and emotional processes; low levels, particularly of
norepinephrine and serotonin, appear to result in depression, whereas excess or imbalanced levels, particularly of dopamine, appear associated with mania.
Neuro-imagery shows lower activity levels in the frontal lobes during depression, the part of the brain associated with higher cognitive processes, and high
levels of activity in the amygdala, the part of the brain associated with fear, a possible correlation. Research suggests that with each subsequent period of
mood disturbance 1) the period of time between each episode decreases, 2) the episodes occur more readily, and that 3) the experience is more debilitating.
3. Brain Atrophy
CT and MRI scans have found atrophy or deterioration in the cerebral cortex and cerebellum in severe cases of unipolar depression and bipolar depression.
Patients with left frontal stroke often manifest depressive symptomatology, whereas, patients with right frontal stroke often manifest manic
symptomatology. Loss of brain volume (atrophy) in the frontal lobe, prefrontal cortex, and hippocampus, areas associated with emotions and important in
the consolidation of information from short-term memory to long-term memory, has been implicated in the development of depression through suppression
of the the BDNF (brain-derived neurotrophic factor) protein essential to neurogenesis and cell survival. BDNF modification of synaptic transmission,
especially in the hippocampus and neo-cortex, may contribute to conditions such as epilepsy, chronic pain sensitization, and all mood related
neuropsychiatric disorders.
4. Hormonal Imbalances
Chronic activation (endocrinal default) in the hypothalamic-pituitary-adrenal (HPA) axis, the region that manages the body’s response to stress, has been
associated with depression. When stressed, the hypothalamus produces corticotropin-releasing factor (CRF) and other substances that stimulate the pituitary
gland to release stress hormones that send a flight-or-fight response. PET scans have also shown decreased metabolic activity in the frontal area of the
cortex of people with severe depression.
5. Genetics
Genetics are believed to predispose individuals toward or away (vulnerabilities/resiliencies) the development of depression or other mood disorders. Twin
studies suggest 46 percent matching for identical twins, compared with 20 percent of fraternal twins.
6. Brain Inflammation
Activation or inflammation of Microglia, endogenous immune cells of the brain, by pathogens such as peripheral immune cells or toxins, leeched through
the blood vessel walls, has been implicated in depression. Major stimulators of inflammation in our diet are gluten and sugar; depression is found in as
many as 52 percent of gluten-sensitive individuals.
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Depression is the Result of Unfortunate Experiences
 Genetic and biomedical factors predispose individuals to vulnerabilities that may trigger anxiety and
depression when major changes and life events result in psychosocial distress.
 Trauma, loss and other extremely disruptive events overwhelm an individual and override their resiliency.
 Anxiety, phobia and compulsions are different manifestations of depression, caused by harm
 Loss of loved one, treasured possession, body part, status or prestige, goal, or familiar way of being
 Natural catastrophe, war or disaster
 Betrayal
 Incest
 Rejection, isolation, ostracism or shunning
 Domestic violence; physical and emotional abuse and neglect
 Rape or sexual violence
 Bullying
 Chronic childhood discouragement
 Sadness complicated by event(s) that further reduce resiliency or increase vulnerability resulting in downward spiral
characterized by excessive rumination and self-deprecation (Blame/Shame)
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Depression is caused by certain styles of thinking
 Events do not trigger depression; how we respond to the things that happen to us in life does
 Depression relies on how we explain things to ourselves; how we interpret reality
 Depressive thinking-styles form a pattern of thinking (a cycle of depression); the patterns create a
downward spiral that fuels the depression
Behavioral Theories
Depression results from negative life events that represent a reduction in positive reinforcement; sympathetic responses
to depressive behavior then serve as positive reinforcement for the depression itself.
Learned Helplessness Theory
Uncontrollable negative event(s) lead to stress and belief that one is helpless to control important outcomes. In turn,
hopelessness leads to loss of motivation, to reduced actions that might control the environment, and to an inability to
learn how to control situations that are controllable.
Cognitive Distortion Theory (A. Beck)
Depression results from errors in thinking leading to a gloomy view of one’s self, the world, and the future: All or
nothing thinking (seeing things in black or white); Overgeneralization (seeing a single negative event as part of a large
pattern of negative events); Disqualifying the positive (rejecting positive experiences by discounting them), Jumping to
conclusions (concluding that something negative will happen or is happening with no evidence), Emotional reasoning
(assuming that negative emotions necessarily reflect reality), “Should” statements (putting constant demands on
oneself), and Labeling (overgeneralizing by attaching a negative, global label to a person or situation)
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Analytical (or adaptive) rumination hypothesis (ARH) by Andrews PW, and Thomson JA Jr.
Depression as a suite of body responses designed to promote rumination, reportedly a form of intensive problem-
solving. Specifically, “… that depression is a stress response mechanism (a) that is triggered by analytically
difficult problems that influence important fitness-related goals; (b) that coordinates changes in body systems to
promote sustained analysis of the triggering problem, otherwise known as depressive rumination; (c) that helps
people generate and evaluate potential solutions to the triggering problem; and (d) that makes trade-offs with other
goals to promote analysis of the triggering problem, including reduced accuracy on laboratory tasks. Collectively,
we refer to this suite of claims as the analytical rumination hypothesis.” Psychological Review, 2009
1. Depression as a form of healing and self-compassion
 Body language and emotional tone are universal communications
 One withdraws in self-protection to reconsider and recharge, potentially to improve
 Others form a protective ring of support, reaffirming pairing, familial and social bonds
 Anxiety acts as a fear response furthering self-protection and healing
2. Rumination: an intense, analytic thinking process examining problems and concerns
 Persistent analysis and contemplation provides solution-oriented action
 Rumination can continue uninterrupted with minimal neuronal damage due to 5HT1A receptor activity
Depression as an adaptive response to hurt and stress
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Depression as Existential Dread, the Fear of Dying and Non-beingness
Depression and anxiety are the result of one’s recognition of the meaninglessness of
life, our intrinsic isolation, the agonizing responsibility of being free to choose and
become, and the utter finality of our death and non-beingness (Yalom)
Death Anxiety: Conflict between awareness of death and desire to live
a) What comes after death? b) the act of Dying; c) Ceasing to be
o To cope we erect defenses against death awareness.
o Psychopathology in part is due to failure to deal with the inevitability of death
Freedom: Conflict is between groundlessness and desire for ground/structure
 we are responsible for our own choices
 Implications for therapy: Responsibility, Willing, Impulsivity, Compulsivity, Decision
Isolation: Angst that each of us enters and departs the world alone
Meaninglessness: Conflict stems from “How does a being who requires meaning
find meaning in a universe that has no meaning?”
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Alfred Adler considered all behavior and emotion to be purposive; that action was a means by which we
communicate intent within social interactions that is meaningful and consistent with our world-view. In this
regard, depression that results from tragedy, loss or betrayal could be viewed as more than a condition or
syndrome that merely happens, but rather as a dynamic expression of the individual’s beliefs about how to
reconcile power struggles in their relationship with others. Irrespective of its cause, depression often acquires
functional value within relationship systems around which interaction becomes ritualized. The ensuing
dysfunctional interactional pattern becomes a stylized method of interacting and belonging with others or
negotiating issues of power.
This perspective can provide unique insight into the purpose of anxiety and depression and its treatment
through psychotherapy:
 Depression as a means of cutting off and avoiding conflict with others
 Depression as a means of blaming and “guilting” others
 Depression as a means of winning or mitigating loss in a power-struggle
 Depression as an act of punishment or revenge
 Depression as a means of avoiding responsibility and placing others in one’s service (Adler)
 Depression as a means of contrition for shame and wrong-doing (self-blame/shame; guilt)
 Depression as a means of protecting one’s self from fear or additional harm
 Depression as a socially acceptable alternative to expressing rage or the shame from failing to do so
Depression is a form of physical and psychological fatigue that results from psychological pain
and the expenditure of energy required to contain unexpressed rage.
It acquires functional value in relationships, becoming purposive for healing as well as for retaliation
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As with its predecessors, DSM 5 neatly categorizes disorders of mood by type and
severity of symptom. While ideal for assessment purposes, many clinicians prefer a
working format that views the anxieties, depressions and compulsive disorders as
related, if different, manifestations of the same underlying processes associated with
unresolved trauma or conflict.
One such consideration is to view all disorders related to mood (including affective
disorders, anxiety neurosis, compulsive disorders, hysteria and phobic disorders) as by-
products of depression, falling into one of three categories:
1. “Simple” Depression: Normative response to harm, loss, disappointment or rejection.
2. “Complicated” Depression: Function in major life spheres is compromised
3. “Depressive Life-style”: A cognitive-style of social interaction characterized by the use of
helplessness and depression to control and over-power others. It has features of the so-called
Borderline and Dependent personality disorders.
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7

Sadness Mixed with Anger
Normative response to harm, loss, disappointment or rejection.
Mood and thoughts draw others near and foster nurturing and opportunity to self-heal;. Guilt and
rumination may benefit self-activation. Social pairing and intimacy bonds are often re-affirmed.
 Degree of worthlessness (sense of helplessness and despair) and discouragement is low or non-
existent
 The depression or sadness is used for healing of the self; a pulling into one’s self for self–
reflection and perspective. Often accompanied by some anger, which is activating
 Improvement and healing occur with or without the help and support of others
 May occur at any time or age. The cause of the depression may or may not be associated with
others and revenge may or may not be needed or beneficial
 Others feel sympathetic and find joy in helping
 The number one reason for depression is disappointment or loss, which may take several forms
o Loss of a loved one; Loss of a valued possession; Loss of familiar way of being
o Loss of prestige, job, status or lifestyle; Loss of a body part, function or ability; Loss of a goal, even
through its attainment
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8

Depression and anxiety as a consequence of trauma or unresolved conflict; mixed with anger,
shame, guilt and blame. Rage often develops as a consequence of unresolved power-struggles.
Depending on how pervasive or prolonged the trauma, one’s thoughts of themselves and the
world can be changed creating complication in identity and function. Unresolved, guilt, shame,
and anger result in despair and a sense of helplessness; damage occurs to one’s sense of worth.
 The depression is used to protect the self from additional or further harm (safe-guarding) and typically
develops in concert with sustained anxiety or tension. Improvement and healing occur better and faster
when supported by others, especially when empathy by other survivors is present
 May occur at any time or age, as a single trauma or prolonged episode of harm. It often occurs in a social
context or with close social implications. Revenge can be an important and needed method of healing
 Others feel empathetic, although may also experience anger, disgust or rejection
 The number one reason for complicated depression is unresolved trauma or conflict that results in a sense of
extreme powerlessness and loss of hope. Rumination recycles feelings of shame, guilt, anger and blame
resulting in anger and rage.
 Depression may acquire functional value and become a means of organizing family functions, avoiding
responsibility, dominating a power-play or seeking revenge
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9

Common Techniques for the
Treatment of Depression
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0

Kinds of Treatment
1. Prolonged-exposure therapy, developed for use in PTSD, a therapist guides the client to recall traumatic
memories in a controlled fashion, eventually regaining mastery of thoughts and feelings around the incident.
2. Cognitive-processing therapy, a form of cognitive behavioral therapy, or CBT, developed to treat rape
victims and later applied to PTSD. This treatment includes an exposure component but places greater
emphasis on cognitive strategies to help people alter erroneous thinking that has emerged because of the event.
Other forms of cognitive therapy, including cognitive restructuring and cognitive therapy.
3. Stress-inoculation training, another form of CBT, where practitioners teach clients techniques to manage and
reduce anxiety, such as breathing, muscle relaxation and positive self-talk.
4. Brain stimulation therapies including electroconvulsive therapy (ECT) or repetitive transcranial magnetic
stimulation (rTMS). Induction of a brain seizure by electrical current (ECT) relieves depression in 50-60
percent of patients. Increases permeability of the blood-brain barrier, allowing antidepressant medications
more fully into the brain, stimulates the hypothalamus and increases the number and sensitivity of the
serotonin receptors. Relapse rate can be as high as 85%.
5. Light therapy Treatment for seasonal affective disorder that involves exposure to bright lights during the
winter months. May impact circadian rhythms (natural cycles of biological activities that occur every 24hrs.),
regulate the hormone melatonin and increase serotonin levels.
6. Self-Management Exercise, Nutrition, Sleep, Stress Reduction, Social Support
7. Mind/Body/Spirit approaches including acupuncture, nutrition, meditation, faith and prayer
8. Eye-movement desensitization and reprocessing, or EMDR, where the therapist guides clients to make eye
movements or follow hand taps, for instance, at the same time they are recounting traumatic events.
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9. Medications, including antidepressants, mood stabilizers and antipsychotic medications;
specifically selective serotonin reuptake inhibitors. Two in particular-paroxetine (Paxil) and
sertaline (Zoloft)-have been approved by the FDA for use in PTSD.
 Tricyclic Antidepressants ie. (imipramine (Tofranil), amitriptylene (Elavil), desipramine (Norpramin).
Prevent reuptake of monoamines in the synapse while changing the sensitivity and number of monoamine
receptors; 60-85% response rate; can take 4-8 weeks to show an effect.
 Selective Serotonin Reuptake Inhibitors
ie. fluoxetine (Prozac), paroxetine (Paxil). Inhibit reuptake of serotonin increasing the amount in the
synapse; quick acting (first couple of weeks), less severe side effects.
 Monamine Oxidase Inhibitors (MAOIs) ie. phenelzine (Nardil), tranyclpromine (Parnate). Inhibit
monoamine oxidase, an enzyme that breaks down monoamines in the synapse, resulting in more
monoamines; studies show MAOIs as less effective than the tricyclic antidepressants
 Lithium Reduces levels of certain neurotransmitters and decreases the strength of neuronal firing; 30-
50% response rate. More effective in reducing the symptoms of mania than of depression. Used as a
prophylactic to avoid relapse.
 Anticonvulsants, Antipsychotics, and Calcium Channel Blockers
Alternatives to lithium and its side effects: anticonvulsant drugs reduce mania with less volatile side effects;
antipsychotic drugs reduce levels of dopamine but neurological side effects or tics
 Ketamine IM/Nasal (Esketamine) Anesthetic; popular nightclub club drug of the 1980s and 1990s
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2

Treatment of choice: psychotherapy, augmented with medication
for the management of more disturbing symptoms.
Double-blind, controlled trials for outpatient treatment with mild-to-moderate depression have reported
remission rates of 46% for medication alone, 46% for psychotherapy and 24% for control conditions
(Casacalenda et al., 2002), leaving up to 50% of patients with some degree of persistent symptoms.
General Purpose of Therapy
1. Identify the source of the depression and the impact to self-worth
2. Understand the behaviors, emotions, and ideas that contribute to one’s depression
3. Reconcile and problem-solve power-struggles, conflict and areas of duress
4. Express and work through underlying feelings of shame, blame, guilt and anger
5. Regain a sense of control and power
6. Seek meaning and purpose to transcend trauma injury
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3

Choose a Model of Therapy, Then Follow These Guidelines
1. Rule Out Medical or Neurological Conditions (“When in doubt, check it out!” )
a) Congenital Brain Damage (CBD): genetic (pre-birth) or birth trauma (at–birth)
b) Acquired Brain Injury (ABI)/Neurological and Medical Illnesses: ie. stroke, tumors, aneurysms,
thyroid disease, cancer, vitamin D deficiency, poisoning/exposure to toxic substances, infection,
strangulation/choking, effects of drugs or alcohol
c) Traumatic Brain Injury (TBI): head/skull injury to brain (accidents, sports injuries, falls,
physical violence)
2. Rule Out Addiction
3. Monitor Risk of Harm (Continuously monitor suicide ideation and risk of self-harm
and harm to others)
4. Review Need for Medication Management (Use of medication to stabilize mood; close
coordination with psychiatry)
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5. Coordination and Reporting (Treatment often includes coordination and reporting,
especially for youngsters, with key stakeholders, including medical, family, courts,
CPMTs/FAPTs, employers, law enforcement, schools and hospitals)
6. Review Companion Issues (Review for addiction, domestic violence, eating disorders,
and phobias, as well as the need to work with ancillary problems such as criminal justice
involvement and work-place or school-related failure)
7. Monitor for AMA (Need to monitor premature (AMA) exiting from therapy once
depressions begins to lift)
8. Monitor Self for Burn-out (Continually monitor self for burn-out and possible
resentment of client’s demands)
9. Tap into Anger (Many depressions are tied to feelings of anger and resentment in
addition to helplessness and worthlessness); Resolve open conflict and disengage and
redirect existing power-plays. Bridge emotional cut-offs; fill loss; connect to meaningful
activity and relationships; develop a sense of purpose and rekindle spiritual being-ness.
10. Make a Genogram Think in relational/systemic terms. “Who makes you angry?”
“How are others affected by your sadness, your hurt?”
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10. Challenge the meaning and the power of the depression and its symptoms; examine
how it avoids responsibility and how it controls others. In particular, challenge
Mistaken Beliefs that serve to justify failure to accept responsibility for change, seek
revenge or work toward increased intimacy and belongingness with meaningful activity
a) Distorted attitudes about Self (“I am less capable than others”)
b) Distorted attitudes about the World and People (“People are hurtful”; “men will always let you down”)
c) Distorted Goals (“I must be perfect”; “I must win at all cost”)
d) Distorted Methods of Operation (ie. excessive competition; procrastination; avoidance)
e) Distorted Ideals (“ a real man…..”)
f) Distorted Conclusions (“Life is…”; “I am a Failure/Victim…”)
11. Address underlying feelings of Guilt, Anger and Shame (GASh)
a) Tragedy: address fears and apprehensions; secure safety and attend to proper health measures (exercise, rest,
nutrition, etc). Obtain support and protection from others
b) Loss: “Fill the hole” that loss has left through letters, foundation, new relationships and meaningful activity;
reconnect to others; address long-standing cut-offs;
c) Betrayal: use of revenge techniques; negotiate amends and routes to redemption, an enormously powerful remedy for
wrongful acts and thoughts
d) General:
a) Give voice to anger
b) Challenge the nobility of the suffering (“spit in the soup”)
c) Disengage and redirect the power-play
12. Enhance Feelings of Self-worth (next several slides)
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How to Treat Trauma April 2019

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Editor's Notes