EMOTIONAL HEANING.doc

Emotional Healing and Self Renewal : Addressing Psychic and Spiritual
Disturbances Using Transpersonal, Clinical and Counseling Techniques (page 3-10)
Beth Hedva Ph.D., R.psych., RMFT, DABPS
Canada

“…If the individual’s spirit is awakened, he or she could access a renewed
courage, righteousness, and self-respect…”
“Dr. Ramses Saleem, The Illustrated Egyptian Book of the Dead : A new
translation with commentary.” Page 64
Sometimes stress reactions not only initiate increases in psychological disturbances, but
they may also initiate increases in paranormal psychic and spiritual disturbances. Western
parapsychologists call these 'psi disturbances', and include such phenomena as apparitions
or communications with spirit, unexplained smells; chahges in temperature (cold spots, or
hot spots); psychic dreams, contact with 'shadow' figures or 'angelic,' figures.; deceased
loved ones, poltergiest, hauntings, spirits of trauma, spirits who feed on human suffering,
spirit possession to name a few. (Modi, 1997; Fiore, 1987, Auerbach,1993). It is
important to note that possession trance is included as part of the diagnostic criteria in the
American Psychological Association's DSM-IV. In possession trance states, a person may
seem to have a sudden personality change, act in highly uncharacteristic ways, or
describe him or herself as 'not myself.' The DSM describes it as a
"Dissociative trance disorder: single or episodic disturbances in the state of
consciousness, identity, or memory that are indigenous to particular locations and
cultures. Dissociative trance involves narrowing of awareness of immediate
surroundings or stereotyped behaviors or movements that are experienced as
being beyond one's control. Possession trance involves replacement of the
customary sense of personal identity by a new identity, attributed to the influence
of a spirit, power, deity, or other person, and associated with stereotyped
"involuntary" movements or amnesia." (page 232).
The American Psychological Association suggests that spirit possession is "not a
normal part of a broadly accepted collective cultural or religious practice."' I have found
that psychic and spiritual disturbances, including spirit possession, is actually not
uncommon among two thirds of the worlds populations; particularly for those living in
Asia and Africa, as well as indigenous cultures with shamanic healing traditions in the
Americas and Europe.
From my own clinical experience, I have observed that a person who is feeling
'empty' as a result of any number of psycho-social conditions, may be more vulnerable to
the experience of spirit possession and other psychic or spiritual disturbances, especially
if these phenomena are part of one's cultural tradition. The unexpected loss of a loved
one, an emotional shock or disappointment, an unforeseen separation, unplanned career
transition, or lack of employment, the sudden feeling of abandonment (emotionally,
mentally or physically), a sudden death, life-threatening diagnosis or prognosis for which
one is not prepared, an act of injustice, a betrayal, panic, unexpected anger or worry,
unresolved fear or sudden threat may all activate a natural stress response. (Arnett, and

Ekman, 2005). All these circumstances may leave someone vulnerable to feeling
existential loneliness,, or feeling isolated and alienated.
Psycho-spiritual injury may occur anytime from 'connection' through adulthood,
and the degree of reaction may vary depending on the scale of the event, and one's
personal history, background or pre-existing conditions, such as:
1. Biological conditions congenital birth defect, birth trauma, or physical accident,
illness or disability
2. Interpersonal /social / relationship conditions including inter-personal violations
and / or neglect
3. Collective or archetypal conditions due to external factors, forces beyond ones
control: e.g. systemic violations to human rights; political or socioeconomic social
conditions, social injustice and conflict, war, terrorism, man-made and environmental
disaster.
4. Spiritual conditions "Acts of God," catastrophic events, Spirit Communication, Near
Death Experiences other unexplainable Spiritually Transforming Experiences,
Psychic and Spiritual Disturbances
Psychic or spiritual distress may arise in vulnerable individuals, especially during
times of emotional shock, trauma or transition, and leave them more susceptible to
psychic intrusion. The nature of the intrusion, and 'why` it is showing up may be
culturally specific. (Auerbach, 1993). For example, I understand that in Indonesia, there
are many different kinds of trance states, and spirit beliefs, including traditions about
guardian spirits, place spirits, familiar spirits, frightening spirits and possessing spirits.
(Geertz, 1960) All this is worthy of scientific research and the psychological study of
those individuals who report the phenomena.
Now that we have looked at the problems lets appreciate that there are many
methods available to assist individuals in the growth and .development they require to get
through and beyond their psychic trauma. Conventionally, the current treatments of
choice coming out of North America are medication management and cognitivebehavioral models, including relaxation techniques, breath retraining, and exposure
therapy (which is a form of classical desensitization); combined with psycho social
interventions and play-therapy for children. Added to this are recent trends in positive
psychology which emphasis building resilience by focusing on character strengths.
(Seligman and Csikszentrnihalyi, 2000).
Research indicates that religious belief and spiritual practices promote resilience
in part because religious beliefs and spiritual practices help provide meaning in times of
adversity. (Chen, and Koenig, 2006) Spirituality 'and’ religious beliefs also tend to
promote stability and help to create an environment that fosters community cohesion and
a sense of connectedness. It is easy to understand how cross-cultural healing traditions
from ancient and indigenous practices including: prayer, ceremony, meditation, dream
work, breathing practices, energy techniques and intuition anything that connects a
person with his or her true spirit or inner spiritual strength fosters resilience. All these
practices are valued as transpersonally significant psychological interventions.

Transpersonal psychotherapies integrate a holistic body-mind-spirit approach to
growth and change. The field Is largely known for its research into cross cultural spiritual
traditions, including, meditative or psychic experiences and transcendental process. When
psychologists or helping professionals address psychic and spiritual disturbances, for
example, it is important to be sensitive to the cultural context of the person having the
experience (Tedlock, 2005). I have noticed that, in general, these phenomena have three
components, and each needs to be distinguished from the other two before it is addressed.
Specifically we must identify and address:
1. The psychic or spiritual phenomena that is creating the disturbance, on a
phenomenological level, within the context of the cultural, spiritual or folk
traditions that support it
2. The condition of psychological vulnerability of the person experiencing the
phenomena, and
3. The necessity to utilize spiritual resources, which may also awaken an innate,
greater spiritual potential within those who are suffering, and thereby bring great
healing or resolution to all parties involved (including both the physical and nonphysical participants; or human 'and 'non-human’ agents).
Spiritual resources and healing practices may be blended with conventional
clinical and counseling practices, including cognitive behavioral therapy techniques, with
great success. For example: finding spiritual meaning through self-transcendent values
has been shown to reduce relapses and improve well-being in an Australian randomized
control trial of patients with depression, schizophrenia and terminal diseases. Seventy
nine percent (79%) of the patients surveyed rated their spirituality or religious beliefs as
either important or very important, and more than half (60%) said that rituals and
practices helped them cope with psychological pain. (D' Souza , 2004).
The key to making use of transpersonal therapies may be to blend together
indigenous and Eastern spiritual practices with Western psychological theory and more
clinical practices to offer a contemporary approach toward a greater healing practice. For
example: ancient and indigenous approaches to community health and wellness, like
initiatory rites of passage, simultaneously address healing in several dimensions of being,
spiritually, emotionally, cognitively/mentally and behaviorally/physically.
Initiation, as a model for responding to change - including unexpected traumatic
events - may show us how to integrate even the most radical of changes by facing them as
a spiritual test, and I have integrated this approach into my training programs. (Hedva,
2006). There are five stages of initiation: 1) separation, 2) responding to emotional,
psychic and physical ordeals during purification rites, 3) confronting symbolic death, 4)
gaining new knowledge or awareness, 5) experience of a symbolic renewal or spiritual
rebirth, (Hedva, 1992, 2001). Each of these correlates to one of five distinct stages of
recovery from trauma:
1) the shock of trauma correlates to the `shock' of separation that is associated with
all initiatory rites of passage, during which time one is literally or symbolically
cut off from one's previous way of life or expectation-set
2) crisis and triage (during delivery of emergency services) reflects feeling
emotionally overwhelmed by physical and psychological ordeals, tests and' trials

3) loss and mourning requires consciously confronting death, symbolically or
actually, and may include consciously responding to survivor's guilt
4) intuitive quest for meaning, fosters new awareness by creating personal value
and meaning out of the traumatic experience within the greater context of one's
Insight into or intuitive understanding of one's greater 'life-purpose'
5) personal and community renewal empowers symbolic rebirth through
integration of the one's sense of purpose, as he or she takes on a new and
meaningful role in his or her community, and begins to make valuable
contributions that bring forth both personal fulfillment and benefit to the
community simultaneously.
Training clients to intuitively perceive life's challenges as a spiritual test, or as
part of an initiatory ordeal can re-awaken the sense of spiritual wholeness instead of
psychological broken-ness. A Native American teacher from the Seneca Tradition, Jamie
Sams, says, "The ultimate goals of all rites of passage or initiations in human life are
learning to heal the past and all regret; having no fear of the future; and focusing on being
aware and fully present at all times." (Sams, 1999) .We can use spiritual resources to help
us regain a sense of being whole.
Ancient Egyptians suggested that there are three primary spiritual resources that
can help us awaken spiritually, the use of:
1.
Subtle spiritual energy - also known as 'chi' 'ki' or prana' in parts of Asia, and by a
host of other names throughout the world. Across cultures, it is taught that we may
mobilize vital life forces and subtle spiritual energies through the physical action of
breathing
2.
Intentional thought - a cognitive function that may direct subtle energies toward
organismic healing, health and wholeness
3.
Expanded intuitive awareness - a perceptual function which identifies subtle
signals that we may use to guide our healing. (Wisner, 2000)
- I explore the use of healing energies, intentional thought and intuitive awareness in
greater depth in the workshop entitled Transpersonal Psychology- Bringing the
Psycho-Spiritual into Clinical Practice that is also part of this conference.
For now, let me introduce a 5-Step Spiritually Directed Therapy Protocol that
blends transpersonal, clinical and counselling skills together in support of a cross-cultural
approach to emotional healing and self-renewal. (Hedva, 2006).

5-step Spiritually Directed Therapy Protocol
for Emotional Healing, Self-Renewal and Community Wellness
1. Connect, Ground and Be 'Present spiritually, physically, emotionally and
mentally.
--Use breath / energy work, intentional thought and intuitive awareness
2. Assess and evaluate needs
--1) physical safety; and 2) emotional safety: a) degree of shock, b) crises,
c) grief/mourning, d) intuitive insight, e) resilience and / or f) psychopathology
3. Listen empathetically
--build or rebuild interpersonal connection and psychosocial support systems,
acknowledge, appreciate and allow for memories and emotional expression encourage expression and normalize traumatic stress reactions as is appropriate
relative to the degree of shock, mourning / expression of loss, or insight and
resilience
4. Train clients to connect with inner transpersonal Self and use intuitive
resources
-- provide tools, including breath / energy work and intuition training— including
symbolic process, expressive arts therapies, psychodrama or play therapy for
children to gain insight, "greater meaning' or 'meaningful inner guidance' for
personal healing
5. Empower individuals to support community renewal
-- Train clients to use both inner and outer resources to develop individualized
cognitive-behavioral action plans (including emergency disaster plans in times of
disaster trauma ) that integrates inner guidance and spiritual resources with
concrete strategies for self-care and meaningful community involvement

Transpersonal and transcendent dimensions of being--those distinct elements
which are 'beyond' our personality, beyond the standard identity of who and what we are
—are available for us to use, to help us 'through' life. Waiting to be discovered in the core
of who and what we are as human beings, is an expanded consciousness -- not outside of
us, but rather running 'through' each person. In fact, it is frequently the process of going
through very human experiences, including a crisis or challenge, that we awaken to
unknown strengths and come to experience greater resources within our being.
We start by acknowledging that trauma impacts our world in ways that change us.
Just like a prism breaks up sunlight into different colors along the spectrum of a rainbow,
disaster trauma breaks up human consciousness into a spectrum of different reactions and
patterns. And, just like light is the source of the full spectrum of colors (and all colors,
regardless of their frequency, are still light), all the varied pathologies, and reactions to
trauma are still a reflection of one single unifying consciousness. (Wilber, 1980).

Ultimate Consciousness
Spectrum of Psychological Reaction to
Human Consciousness
Traumatic Conditions
Autism,
psychosis,
schizophrenia,
Personal
personality disorders, bipolar, OOD etc,
Ego-Identity forming human being
morbid depressan neurotic disabling
Bio-psycho-social safety & security needs
anxiety phobia
Inter-personal
Depression, anxiety, addictions, coBuild strong, healthy, flexible ago identity
dependence,
relational
and
sexual
Need to belong feel worth, esteem,
dysfunctions, ATS, PTSD, Grief Suicide
competence achievement.
Trans-personal
Ego-Identity is transformed beyond ego
human being
Psychic-Spritual Disturbances ESP PK.
Need for meaning, purpose, beauty,
acsthetics, altruism.
Non-personal Transcedent Identity
Self-actualized. Self realized: Embodiment
of Fell Human Potential
The same way that light changes into different colors when seen through a prism,
we as individuals will see the world differently (and exhibit different behaviors), as well
as need different therapeutic interventions, depending on where we are on the spectrum of
consciousness.
With severely disturbed populations who suffer from disabling psychopathologies
(only about 2% of the world population according to the World Health Organization,
2005), therapists need to help clients develop and rebuild a personal sense of self. Deficit
needs, as defined by Abraham Maslow in his hierarchy of needs, are primary. Physical
safety and emotional security are most important. Use structure building techniques,
concrete actions or activities, including ayes-open grounding exercises that support
‘containment’.
The Personal-Material Self needs ego-building interventions
Under stress expect ego de-compensation and regression
This is 2% of population at any give time and can increase to 4% after a traumatic disaster
Spectrum of Human Conditions Spectrum of Reactions to Trauma
Personal ego identity is under-developed
Psychosis; Autism; Schizophrenia etc.
There is no self-awareness or differentiation
between self and other

Personal ego identity differentiates
Obsessive – Compulsive, Hysteria,
Ego takes form ‘persona’ and ‘shadow’ as Phobias, control; Morbid Depression,
Impulse socially acceptable vs. unacceptable Neurotic Anxiety
identity etc.
Treatment Modalities : At these three stages of the spectrum we develop
physically/materially as a human being. Medications; Concrete structure building
interventions; cognitive-behavioral therapies with spiritually meaningful practices, ritual
or ceremony; soothing healing touch/laying on of hands, energy work; eyes-open breath
work; concrete intuition development.
After injury Help clients to meet physical/material safety needs and primary emotional
security needs to feel safe and loved. Support them to build or rebuild their personal
identity. The personal-material self has concrete physiological needs. The basic human
need to feel safe physically and secure emotionally is dominant.
According to the World Health Organization people with either moderate or
severe psychological distress or with mild distress that tends to be labeled with DSMIV
psychiatric diagnoses is approximately 20% of the world population, (and may increase
to up 50% after a mass disaster like the Boxing Day tsunami disaster). Therefore, most of
the people you see will need ego-strengthening to in order to build a strong, healthy
flexible ego structure. Because interpersonal relationships and psychosocial development
are often key to emotional healing for this population, group work, family therapy, and
psycho-social interventions, like community involvement, occupational therapy, and play
therapy are very effective.
The Interpersonal-Social Self needs ego-strengthening interventions
Under stress expect Increases in Ego-Inflation/Ego-Deflation
This is 20% of the general world population. After mass disaster trauma may increase to
30%-50%
Spectrum of Human Conditions
Spectrum of Reactions to Trauma
Building Social-Self
Anxiety; Depression; Alcohol/drug use/abuse;
Adjustment disorders
Acute and Post Traumatic Stress; Childhood:
Build self-worth/self-esteem
Bedwetting;
Stuttering;
Attention Deficit and Learning Disorders; Conduct
“you are valuable”
and Eating Disorders
Building Authentic – Self

Relationship and Sexual Problems; Religious or
Spiritual Problems;
Bereavement; Academic and Occupational
Problems;

Engage with others
Identify Problems
“it’s OK to be you”
Building Sense of Meaning
Existential Anxiety; Loss of Faith; Intensification
“Your presence makes a difference” of Religious belief

Treatment modalities : Cognitive-Behavioral Therapy (CBT), Client Centered, Brief
therapies, Eye movement desensitization re-programming (EMDR; hypnosis;
occupational therapy; psycho-social/psycho-educational therapy; family, group, and
child therapy; play therapy; creative and expressive arts therapies; guided imagery;
imaginal exposure therapy; breathing and energy work practices, prayer, ceremony
ritual; peer counseling; group facilitation/leadership skills
After injury help clients to engage interpersonally: 1) it is good to be with us, 2) it is
good to do things with us, 3) it is good to do things for others. We all have a need to
belong, feel worthy/self-esteem, need to feel valued, feel competent and make a
meaningful contribution.
Build or rebuild social relationships and acceptance of self and others. At these
three stages of the spectrum we learn that ‘being human’ means corning to accept
differences, including personal gifts and vulnerabilities in ourselves and others, and our
(and others) positive and negative traits as part of the human condition.

With regards to transpersonal dimensions of being, WHO has no specific
statistics for the percentage of the population that has Spiritually Transformative
Experiences. However there are some European and American surveys that suggest that
the population may vary culture to culture. The 1984 University of Chicago’s National
Opinion Research Council survey, by sociologist Andrew Greeley, reported the following
percentages for Americans: Psychic Dreams, ESP/Telepathy/Clairvoyance, (67%),
Visions (21%), Spirit Communication (67%), Near Death Experiences (4-5% of
population). Changes in the percentage of the population after disaster trauma is
unknown.
The trans-personal spiritual self needs spiritual connection to awaken and
transform the ego identity. Growth needs, as defined by Maslow in his herarchy of needs,
emerge as a need for purpose, beauty, harmony, altruism and self-actualization. (Maslow,
1998) There are a variety of transpersonal and spiritually transformative experiences,
including experiences of visions, ESP, psychic dreams, near death experiences (NDE’s),
and inspired or new sense of meaning or purpose in life, communications with spirits, or
other 'unexplainable' spiritual phenomena. Spirit communication and transpersonal
experience may be comfortable or challenging to different individuals. For example, in
the case of spirit communication, a client may feel that spirits offer help, comfort or
support. In other cases, the person may feel frightened, intimidated or manipulated.
Dr. Barbara Tedlock, who is the granddaughter of a Native Ojibway healer and
midwife, is trained in and initiated into the shamanic practices of the Maya in Guatemala,
as well as being an academic at State University of New York, (SUNY) in Buffalo, New
York. She says that in Peru there are two approaches to working with spirits, a male
approach and a female approach, and gave the example how "mate shamans (and females
trained and Initiated by male relatives) will transcend illness by fighting unseen enemies
and ordering them away a more feminine tradition focus(es) on healing inner emotional
and physical imbalances; they insist on a patient's self-awareness, purification, acceptance

and surrender."9 This later style of de-possession and spiritual healing may be consistent
with psychotherapeutic process if the therapist has the skill or training to work intuitively
with clients.
In my work with the Office of Paranormal Investigation (OPI), among others, I
also use a female approach, though I have worked with others on OPI research teams who
use the more directive approach. Both approaches will work, and which to use will
depend on the needs of the client. The female approach focuses on the psychic, the
psychological and the spiritual dimensions of paranormal phenomena as three distinct
elements that may become braided together. In my experience, spirits show up in a
person's life for one of two reasons; either to give something or to get something (for
example: to give help or get help). We recognize the phenomena, notice the psychological
and emotional vulnerabilities, and ask for help from a supreme spiritual healing source-one that can bring the healing we need, help us purify of fears, accept ourselves and our
true spiritual path. The healing is complete as we surrender to living that spiritual life tha
is intended for us by the Creator, as it has been revealed to us during this de-possession or
spiritual healing process. Each aspect must be addressed, especially in the case of
disturbing psychic phenomena.
If you are comfortable with spiritual work, or trained to work with these kinds of
phenomena, then confirm the presence of psychic phenomena when it is present. Next,
use expanded spiritual healing resources (including training the client to use his or her
own spiritual healing resources) to help. the client strengthen and resolve psychological
vulnerabilities. Also consider working with someone who is trained in the local wisdom
and knows local practices, a trained healer, or local practitioner. This may be especially
important because every culture has developed methods, including rituals, ceremonies,
scriptures or the use of local medicines or herbs for example--an array of tools and
techniques to address these kinds of concerns.

Transpersonal Self transforms the ego-identity
Under stress expect increases in acts of altruism and spiritually transformative experiences
% Population may vary culture to culture. Change in % of population after disaster trauma
is unknown.
Psychic Dreams, ESP/Telepathy/Clairvoyance, (67%), Visions (21%), Spirit
Communication (67%), Near Death Experiences (4-5% of population), Spritual
Awakening, (% unknown)
Spectrum of Human Conditions

Spectrum of Reactions to Trauma

Building Sense of Purpose

Building Spiritual Connection
Communication ; Mystical
Building Sense of Altruism

Exception Human Experiences; ESP; Psychic
Dreams; Spontanecus
Healing ‘Peak’ Experiences; ‘Dark Night of the
Soul’; Compassion Fatigue;
Psychic Openings; Near Death Experiences;
Possession; Trance;
Over-identification with the archetype; Spirit
Experiences, spiritual discrimination
Heart-Opening; Kundalni Awakening; Failure to
integrate; Glimpses of Self-actualization/ spiritual
realization.

Treatment Modalities: Full range of transpersonal therapies, including crosscultural spiritual healing practices: prayer, meditation, ceremony and ritual,
dream incubation, mind-body practices, yoga, martial arts etc, chanting, music,
(like drumming in Africa and Aboriginal cultures, gamalin in Indonesia, or
Tibetan Bells etc) dancing, sacred drama (like Shadow Puppets in Indonesia; or
Noh Theater in Japan), story-telling, creative expressive art therapies,
calligraphy, inner guidance, breath and energy work, study of sacred writings
and philosophy, spiritual teachings; holy texts, spiritual discipline; study of life
as a spiritual practice; spiritual leadership development; lead by example.

Because consciousness is pervasive instead of hierarchical, therapists may need
to address the full spectrum of human experiences - personal, interpersonal, transpersonal
and transcendent dimensions -- simultaneously. To integrate the transcendent dimensions,
it is helpful to draw on the example of those transcendent souls, spiritual teachers,
spiritual leaders or saints who offer us inspiration as we walk through life.
Regardless of the phenomena, whether it is physical, psychic, psychological or
spiritual, or due to a blend of bio-psycho-social and spiritual conditions, the job of the
helping professional is to help the client progress instead of fixate. To help clients'
progress instead of regress, therapists meet clients where they are. This may be at a
personal level of need, an interpersonal level, or a transpersonal and transcendent level.
And sometimes there is a blending of all these levels in one person at different moments.
This is often the case with a psi disturbance, in which the psychic phenomena correlates
to a psychological vulnerability and can often be resolved by calling upon or connecting
with the healing power of greater spiritual resources.
Dr. Jean-Charles Crombez, professor at the University of Montreal and Director

of Research on Healing at Notre Dame Hospital suggests that loneliness, 'helplessness or
hopelessness' and 'doubt or worry' are the primary impediments to healing. He has been
focusing on the study of healing for the last 30 years, and distinguishes 'curing' from
'healing'. Curing is primarily physical, and addresses the elimination of disease, and
symptoms of disease, by addressing the cause of the disease at its physical or
physiological origin. Healing, on the other hand, is concerned with re-establishing overall health, a sense of wholeness and well being.
While researching the impact of unexpected wrenching events, like living with a
terminal illness that does not respond to treatment, Crombez has found that we can still
heal, if we address feelings of loneliness, helplessness or hopelessness, worry or doubt i.e. the impediments to healing. (Crombez, 2003). Because we can not turn back the clock
and eliminate the cause of traumatic injury, healing is more important than curing. We
heal by establishing a state of well-being, instead of focusing solely on eliminating the
psychological symptoms of trauma through medication management.
Humans appear to have the capacity to tap an infinitely creative consciousness
within their being, (Mitchell, 1974) and it is from this ultimate creative source within
consciousness, that new life is born out of the ashes of trauma or tragedy. Tragedy acts as
a 'spiritual teacher;'(Seleem, 2005), in which we learn about not only our vuinerabilities
but perhaps also have an opportunity to discover unexplored strengths and capacities. In
this way we discover our 'true spirit.'
During every phase of healing we may use standard counseling skills together'
with spiritual resources, including .energy work, breathing techniques, intentional thought
and intuitive resources -both to help you stay present and to train the client to do the
same.
1. Be client-centered, and create emotional safety and security.
2. Acknowledge and recognize the client's world view .
3. Normalize the experience, and validate psi experiences if present (if you are trained
or naturally able to do so).
4. Offer concrete tools to help the individual work with fear and stress.
5. Train the individual in energy work and breath work for self-healing--unless
contraindicated (as in the case of decompensation and psychosis.)
6. Train the individual to use spiritual resources and subtle healing energies to respond
to intruding, disturbing negative thoughts, emotional flooding, and or body memory.
7. Use intervention techniques that build self-worth and competence, to restore
emotional safety, security needs and alleviate or reduce fear
8. Offer concrete strategies that include building or utilizing psycho-social support
systems to address loneliness, helplessness/hopelessness, and worry.
9. Give, and follow-up on homework that offers a blend of spiritually directed
interventions with strategic cognitive-behavioral action-plans that specifically address
impediments to healing including: fear, loneliness, hopelessness, and doubts or worry.
10. Keep doing your own emotional healing and self-renewal work (using your personal
inner and outer resources), to remain clear, present and spiritually connected.

Both you and your client are learning to cultivate your own full potential as
human beings, while simultaneously being 'works in progress.' We are training each other
to honor the paradox of being spirits, sparks of a greater intelligence, living and working
in human bodies - with distinct bio-psycho-social limitations or conditioning - embodying
a human consciousness which may progress, evolve or change as we grow, develop or
actualize the full potential of that consciousness.
LECTURE 2
The Significance of the Therapeutic Alliance in Psychopharmacological Treatment
(page 11-15)
Jan Prasetyo
Department of Psychiatry Faculty of Medicine University of Indonesia - Cipto
Mangunkusumo Hospital
Jakarta, Indonesia
Psychopharmacological medication has been quite beneficial for many patients to
relief their suffering. However it can also have, for some, significant economic
consequences, and sometimes crucial adverse side effects, such as metabolic,
neurological, and psychological.
The ultimate goal of any kind of treatment including psychopharmacological
treatment - is to ensure an effective outcome. To achieve this outcome is, in a large part, a
function of "treatment compliance" or "treatment adherence" which evolves from a good
doctor patient relationship.
What is "compliance" or "adherence" to treatment?
In clinical terms, "compliance" refers to how faithfully a patient follows the
advice and direction of the clinician (Sperry, 1985). But recently, from the humanisticempathic perspective, this meaning has acquired a negative connotation implying a
passive patient subservient to an active, authoritarian clinician - a patient's submission to
the authority of the physician. The doctor is supposed to know best and the patient just
has to submit to his instructions. The problem comes up when the patient does not obey;
the issue of incompliance comes up, disturbing the doctor-patient relationship, which then
will affect the treatment outcome. However, a poor doctor-patient relationship can also
cause the patient's disobedience / incompliance.
The word "compliance" should then be used in a more broader meaning, which
include an agreement, a mutual process of feeling, illustrating an empathic connection,
that occurs between two parties. Unfortunately this empathic connection, and shared
responsibility in the treatment process are very often disregarded.
The term "adherence" (which has a connotation of "faithfulness, commitment, closeness,
involvement") has then become the description preferred in most treatment programs,
although most clinicians continue to use "medication compliance" in relation to drug
usage.
Compliance can thus contribute to a poor outcome if used in its narrow meaning ,
and if it places psychopharmcology at the center of the therapeutic endeavor, giving

supremacy to medication as the essential, curative force in treatment, and put other
factors (such as the patient, the doctorpatient relation, and family) in a secondary or even
more minor role.
Gonzales de Rivera stated "Human beings are complex creatures and, …….pure
"medication management" is not enough to restore their holistic equilibrium. Impairments
in optimal autoregulation requires a complex intervention at all levels of functioning,
from the molecular to the meaningful. However, attempts to reduce one or both
therapeutic approaches - biologic and psychologic - to mere "techniques", that can be
applied by any independent "expert", is one of the biggest mistakes of modern
psychiatry'.
How can good "compliance or "adherence"be achieved?
The key variable known to affect compliance as designated above, is the doctor-patient
relationship in the therapeutic setting - "the therapeutic alliance". This important
variable is influenced by three factors : the patient, the doctor and the family.
The following part of this paper will highlight some of the important aspects of these
variables:
1. The patient factor - belief and explanatory model regarding illness and
medication.
2. The doctor factor - belief and explanatory model regarding illness and
medication
3. The family factor - family's role in the patient's life and socio-cultural values
4. The therapeutic alliance -which is build upon the above factors 1. to 3.
The patient factor.
Patients as consumers and doctors as prescribers, very often have different
perceptions about the usefulness and safety of psychopharmacological medication.
The various meanings that medication have for everyone in our society, whether
in the role as patient, doctor, and member of a community, is important to be uncovered
and understood, because the patient's attitude toward medication will be much influenced
by these meanings. For some, medication is like a life saver, for others medication is
poison (ranging from "cure" to "poison"); for some others medication is like magic with
an expected instant cure. Medication can also be perceived as both "means" and "agent"
of control. It may be viewed as a chemical means by which the doctor exerts control over
the patient's thoughts or actions, particularly with psychotropic medication which affect
the patient's cognitive, affective and behavioral functions, and the stigma in society about
these drugs' potentials to cause habituation and adiction.
How the patient explains his/her illness and related beliefs, is essential to
establishing a collaborative relationship. The patients explanatory formulation of why he
or she is ill and about the formation of symptoms, can be full with misinformations or
reds-attribution. Those "explanations" can, and very often has to be used as the basis for
further psychoeducation and negotiation.

A recent study by Day et al.( 200S), points that the attitude of patients to
medicaticn was closely related with the level of insight, involvement of the patient in
treatment decisions, the patient's admission experience (how the patient was referred or
admitted for treatment), and the relationship with the doctor. If a patient is able develop
trust through being treated with respect, being included in treatment decisions and not
being coerced unreasonably, he was more likely to view medication more positively.
Rosenfield suggested four types of patients' perceptions of doctors and to clarify
the various meanings that patients ascribe to medication:
1. There are patients who view the doctor as a coercive persecutor forcing poison
into them.These patients typically refuse treatment and can end up being
involuntarily medicated. This attitude appears to be mediated through paranoid
delusions and hallucinations primarily, but is also clearly affected by poor insight,
agitation, poor alliance (the doctor may not be able to establish a trusting
relationship for venous reasons), medication adverse effects, and cultural factors.
2. A second common perception of the doctor is as a misguided manipulator. The
patient may believe strongly in his delusions, but see a need to appease the
doctor. The patient may pretend to take medications but spit them out in private
("ciieeking") or take them reluctantly as a way to get out of the hospital faster.
Both doctor and patient can get engaged in a dance of deception and
manipulation, mediated by a poor therapeutic alliance, the doctor's actual use of
manipulation, or the patient's past experience of manipulation.
3. Some other patients do not develop a significant relationship with the doctor and
he is merely an insignificant distant figure. These patients may forget to take
medications or avoid taking them. These are often patients with negative
symptoms, cognitive deficits, disorganisation, and/or internal preoccupation.
4. There are many patients who actually do experience the doctor as a helpful ally.
These patients tend to take medication willingly and independently. They have
good insight, a positive attitude towards and experience of treatment, an ability to
tolerate or speak up about adverse effects of medication, and better cognition and
functioning. Their doctors are able to be empathic and collaborate in treatment.
These, according to Rosenfield, could help us empathize better with patients,
understand better the cause of discontent or rejection of treatment, recognize the interplay
of culture and personal experience in the formation of attitudes, and establish more
effective modes of communication.
To develop a therapeutic alliance requires that the doctor be sensitive to these
meanings and roles as well as to the cultural context in which the therapeutic relationship
is set up.
Since personality style reflects persistent and predictable patterns of perceiving,
thinking, feeling, and acting, a knowledge of the patient's personality style or dominant
traits can be useful in the understanding and interpretation of patterns of compliance and
noncompliance, and in building a therapeutic alliance.
Helping patients understand their illness is best done in a biopsychosocial context
(Ward, 1991). Negotiated explanations that are adjusted and suited to the patient's
experience are particularly valuable. Such explanations should be simple, integrate

biological and psychosocial mechanisms, and incorporate some elements of the patient's
explanatory model.
For example, bipolar patients who believe that their illness was caused by
insomnia and can be cured by a good night's sleep, need to have their
"explanations" corrected by educating them about the psychosocial aspects of
bipolar disorder.
A- patient who explains her generalized anxiety in terms of a single early life
trauma, should hear the clinician describe a more complete model / formulation
of the illness, that other factors also contribute besides her particular concerns
about the early trauma. The misbelief that the medication prescribed is a poison,
is one other obvious example that should be corrected by biomolecular
explanations and medical research evidence.
How are the patient's irrational beliefs and explanatory models assessed?
The clinician should inquire about the patient's meaning and explanation of illness,
symptoms, and susceptibility to illness. Furthermore the clinician need to know the
patient's fantasies about medication and its effects, beliefs about the benefits of treatment,
and how the financial, social and psychological costs of the reatment will influence the
patient's compliance and adherence (Doherty, 1988).
Doctor's facto:.
The psychiatrist may be convinced for good reason that his prescribed medication
will help reduce the patient's suffering , but the patient however, may not be so quick to
agree that it is the medication that works. This lack of congruity between doctors and
patients perceptions can lead to a disturbance in the doctor - patient relationship. The
doctor's as well as the patient's perception, expectation, and attitudes, can lead to
resentments in both parties. The doctor should focus primarily on the understanding of
the patient's perception first, and not coerce his perception to the patient. Thus it is
important that the doctor be aware of his own personality traits.
Personality factors of the doctor, his pattern of perceiving. thinking, feelings and
action needs to be self evaluated in order to be aware of the countertransference that may
occur in the doctorpatient relationship.
For example; a patient's need for a sense of autonomy and control, may threaten b
doctor's self-image as a "caring and helpful" professional. The dtoctor does not
feel properly appreciated; and he may, for example, be involved in debates and
arguments, a power struggle of "who knows best", or act out his feelings by
giving some form of "punishment" - such as withholding or limiting refills; or
giving many refills so he can avoid contact with the patient. The scheduling of
frequency of follow-up visits may also be another way for enacting
countertransference and transference issues.
As treating physicians we have to recognize at least two different cultures in
which we live: that of the patient and that of the doctor. Historical, cultural and scientific
as well as individual factors, has to be recognized that will influence both the prescribing
and taking of psychopharmacological medications.
When we are part of the patient culture, we experience ourselves as ill: we are

preoccupied with our symptoms, and we arc greatly influenced by the very personal and
often idiosyncratic meanings of illness, meanings of the associated treatments, and
meanings of health care personnel have about us, as patients. We may have the
opportunity to see ourselves, acting just like patients - difficult and incompliant, with our
own historical, cultural and individual perceptions. Physicians are notorious for treating
themselves - often incorrectly and recklessly (Davidson & Schatter, 2003; Hem et at.,
2005; Rosvoid & Bjeitness, 2002).
When we are part of the doctor culture, we then think in terms of disease. We
tend to focus on the scientific perceptions phenomenology, pathophysiology,
psychodynamics, and psychopharmocology of diseases or disorders.
Clinicians have the responsibility to examine and inquire their own assumptions
and attitudes about medication - as they are also part of society's collective, historical
memory of psychiatric treatment - thus influencing the meanings that they attribute to
medications (e.g. the stigma, doubt and fears regarding the safety and utility of
psychopharmacological treatment, etc). Hopefully we as doctors could also tune in to our
own perceptions, biases, and psychodynamics - because there is no such thing as pure
objectivity.
Medication may improve the disturbance and suffering of the patient, but it may
also replace or add it with another - adverse effects, as already mentioned at the
beginning of this paper. The doctor should not base his/her explanation only on his
statistical/scientific model of medication, and neglecting the patient's personal
perceptions. Statistical / scientific dates may often be of little value for the patient, and
doctors who are doing this, may even be experienced as unempathic, rejecting, and
intrusive, thus encouraging incompliance.
Modification of the treatment regimen then becomes necessary when
inconvenience about it is expressed. Clarification, simplification, and tailoring
(negotiated and adjusted) to the patients response, can greatly enhance treatment
collaboration and compliance.
There is much evidence that complex treatment regimens - e.g multiple
medications prescribed or given in complicated divided doses - adversely affect
medication compliance (Blackwell, 1976). Doctors have to be aware about this when
prescribing medication.
Another important issue is that the doctor must be aware of the dynamic forces
acting upon the doctor-patient relationhip, especially in writing a prescribtion. Those are
from: the drug companies, family, peer pressures, other therapists and health care
professionals, internal and unconscious fantasies - or dissociated aspects self. (Benjamin,
2006).
The doctor has to be aware that health management organizations (insurance
companies) procedures and commercial interest of drug companies have influenced the
doctor-patient relationship turning it into a dialectic of providers and consumers, with a
tendency to reduce treatment to merely pure "medical management", "techniques", that
can be applied by any independent "experts" (doctors, psychiatrists) to a patient.

According to Jeffrey Rubin, MD., this may have, to an extent, constructive motives, but it
may also backfire into and exaggerated focus on the transactional, financial, or business
aspects of mental health care (and health care in general).
Doctors know best because they are very much informed both by marketing and
by cost containment, where it make sense to dispense even more expensive drugs at the
fastest possible pace. The pharmaceutical complex has used its strong influence to
convinced the doctor that drugs represent biological knowledge of disease, that they are
critical to treatment, and that nothing more is needed from the doctor patient interaction
than the diagnosis of the patient's condition and provision of the correct drug to treat it.
And of course only the newest and most expensive drugs are promoted. They have-even
mounted their own compliance campaigns directly encouraging patients to take their pills
to boost sales (Pollack,2006).
The art of individual therapy at present tends to work against the flow and the
spirit of modern times, which is in favor of the business and mass approach.
Psychiatrists should be extra aware of this mistake, and persue to maintain and enhance
the importance of individuality, of collaboration between clinician and patient to optimize
compliance and adherence to treatment in its holistic meaning.
Family factor.
The patient's spouse or family can greatly influence medication compliance and
treatment adherence. Supportive spousal / familial behaviors that enhanced compliance
are "reminders" and "encouragement", while nonsupportive behaviors are 'nagging" and
"lack of concern". (Sackett & Haynes, 1976). The family may become more important
and potentially problematic when the patient has an extended family system, where other
members of the Family besides the spouse has strong influence on decission making.
Especially when the patient's life is to an extend dependent on the family (e.g financially).
Psychiatric patients are more prone to have some disturbance in their marital or
family life (Beavers, 1985). This disturbance can take many forms. Among these are
beliefs antithetical to the conduct of treatment, overt or covert efforts to undermine
treatment, and lack of external monitoring of the patient's behavior regarding adherence
to the treatment regimen (Doherty, 1988).
The doctor must be sensitive and aware of this potential problem, and include the
family in building up the therapeutic alliance.
A family system's view of medication compliance and treatment compliance has
been described by Doherty and Baird (1984). It involves a therapeutic triangle consisting
of the clinician, the patient, arid the patient's family. Compliance of the tripartite involves
the cooperative effort from which the patient derives the resources, support, and
information necessary to adhere to the agreed upon treatment regimen.
Four factors are necessary for the triangle relationship to strengthen the
therapeutic relationship and thus enhance compliance (Sperry, 1995) :
1. There must be congruence in expectations and belief related to the psychiatric
disorder and treatment. The patient and the family must acknowledge and accept

the diagnosis and need for treatment.
2. The clinician and the family must know how to support the patient's attempts to
comply with the regimen.
3. The clinician and family must be sufficiently motivated to provide such support.
4. The clinician and family must provide sufficient support.
These four factors must be worked through during the process of developing a therapeutic
alliance.
The therapeutic alliance (the clinician - patient relationship)
Based on the above factors the patient, the doctor, the family -the development of
a good therapeutic alliance could be build upon.
The complex approach to a complex being can not be achieved by fragmentation,
but by the construction of a therapeutic dyad / triad. Very close communication and
understanding the holistic therapeutic approach – biological and psychological - both
professional and personal (doctor-patientfamily), is needed.
The concept of alliance in therapy between patient and therapist has expanded
into the development of a therapeutic dyad. As already mentioned above, the semantic
use of "compliance" or "adherence", should not be limitted to obedience, but of mutual
cooperation with co-responsibility on results (Eve Leeman, 2006). Empathy as the
important affective-cognitive component has to work both ways. Patients are not passive
recipients, and the doctor is best medicine only when his service and advocacy make
sense in the patient's world. The patient has to understand the doctor's reasoning and take
part in his,or her therapeutic hypothesis. The therapist has to be good and sensitive
enough to mediate, as the doctor sees in the patient a disease process which can be
influenced by medication, but the patient on the ther hand, experience an illness which is
a highly personal and unique experience.
An interesting recent study (Day et al. 2005) points to the importance of the
relationship between doctor end patient in determining adherence and attitude towards
treatment.
Inevitably all treatments are grounded in the relationship between caregiver and
carereceiver. As already mentioned above, this relationship may consist of a "dyad" but it
is often a "triad" or more (the patient, the doctor, the family). The doctor has to be aware
and to include them in the triangle relationship when necessary.
Several studies have examined the various risk factors including poor insight, a
negative attitude towards medications, a negative subjective response to medication, lack
of efficacy, intolerability, poor planning of stopping medication, lack of family and social
support, and a poor therapeutic alliance.
Not only compliance but also the therapeutic effects of medication are enhanced
when patients have a working, collaborating relationship with the clinician who is
concerned and positive.(8lackwell, 1976; Ward, 1991).
Collaboration can be enhanced by tailoring the nature of the doctor-patient relationship.
How the clinician relates to the patient depends on the patient's diagnosis, degree of
impairment, and personality style.
For example: the clinician must decide how much dependence to allow the

patient, as well as how much authority io exert. With more impaired patients, the
collaboration between clinician and patient will be more dependent trap with less
impaired patients who are capable of more autonomy and are willing to use it
Similarly, the clinician must also decide the extent of warmth and affection the
patient can tolerate. As the patient improves, the clinician must be prepared to
shift the relationship. So, as the patient gains more autonomy, the clinician must
allow the patient a wider range of choices and decisions.
It has been documented repeatedly that the more attention that is paid to the
person who has the illness and his perception of his illness, the better the treatment
collaboration will be. However, the doctor must also be constantly aware of the
occurrence of the transference countertransference phenomena it, the relationship.
Psychodynamic understanding of the meanings of illness and treatment to our particular
patient and ourselves as doctors, is an important tool in this endeavor. Mere compliance is
a very poor substitute for a truly therapeutic relationship/ collaborative endeavor.
The relationship between doctors and patients in a therapeutic setting – tile
therapeutic alliance - plays a central role in the creation of the meanings of medications,
in enhancing compliance and adherence to medication, and in optimizing the therapeutic
outcome. An understanding and enhancing the building of this relationship is of primary
importance in any treatment endeavor, and in psychopharmacological treatment in
particular.