Psychological Society of Northern Greece

HELLENIC JOURNAL OF PSYCHOLOGY
ΙSSN 1790-1391

Edited three times a year by the Psychological Society of Northern Greece (PSNG)
Volume 6, Issue 3, 2009

Legally responsible:
George Grouios, President of the Psychological Society of Northern Greece
Department of Physical Education and Sport Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece. Phone: +30-2310-992177; E-mail: ggrouios@phed.auth.gr

Editors

*Editor-in-Chief:*	Anastasia Efklides	Aristotle University of Thessaloniki, Greece
*Associate Editors:*	Maria Dikaiou Angeliki Leondari Georgios D. Sideridis	Aristotle University of Thessaloniki, Greece University of Thessaly, Volos, Greece University of Crete, Rethymno, Greece
*Assistant Editors:*	Irini Dermitzaki Mary H. Kosmidis Filippos Vlachos Plousia Misailidi Pagona Roussi	University of Thessaly, Volos, Greece Aristotle University of Thessaloniki, Greece University of Thessaly, Volos, Greece University of Ioannina, Greece Aristotle University of Thessaloniki, Greece
*Guest Editors of the Special Section*	Evrinomy Avdi and Pagona Roussi	Aristotle University of Thessaloniki, Greece

Anastasia Efklides
George Grouios
Shulamith Kreitler
Diomedes Markoulis
Robert Neimeyer
Markku Niemivirta
Jose M. Prieto
Wolfgang Schnotz
Yannis Theodorakis
Maria Tzouriadou
Marja Vauras
Marcel Veenman

Aristotle University of Thessaloniki, Greece
Aristotle University of Thessaloniki, Greece
Tel-Aviv University, Israel
Aristotle University of Thessaloniki, Greece
University of Memphis, USA
University of Helsinki, Finland
Complutense University, Madrid, Spain
University of Koblenz-Landau, Landau, Germany
University of Thessaly, Volos, Greece
Aristotle University of Thessaloniki, Greece
University of Turku, Finland
University of Leiden, The Netherlands

Publisher:
ELLINIKA GRAMMATA: Emm. Benaki 59, 106 81 Athens, Greece
Τel: ++30-210-3891800 - Fax: ++30-210-3836658
Bookstore: Zood. Pigis 21 & Tzavela 1, 106 81 Athens, Greece

© Copyright 2009: Psychological Society of Northern Greece (PSNG)
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) for commercial purposes without the written permission of the copyright owners. Manuscripts submitted to the journal in no case are returned back

SPECIAL ISSUE:

CURRENT ISSUES IN PSYCHOTHERAPY

Guest Editors: Evrinomy Avdi and Pagona Roussi

Prologue
Evrinomy Avdi & Pagona Roussi .................................................................................VII

Values in acceptance and commitment therapy:
A comparison with four other approaches
           James E. Yadavaia & Steven C. Hayes........................................................................244

The nature and basis for compassion focused therapy
          Paul Gilbert……….………...............................................................................................273

Affect regulation, metacommunication and mindfulness in action
         Jeremy D. Safran & Julia N. Belotserkovsky..…....………......................................................292

Some implications of attachment research for psychotherapeutic
practice
         Jeremy Holmesy .………..…………………....……………….……….....................................................310

Seeking a balance between knowing and not knowing in the
consulting room
Patrick Casement..………..…………………....……….............……....................................….…........334

This special issue, entitled “Current Issues in Psychotherapy”, considers contemporary discussions in psychotherapy theory and practice. The contributors are all well-known authors and/ or researchers in their respective areas of expertise in the field of psychotherapy, as well as practicing therapists. On a theoretical level, their orientations include modern behavioural, cognitive-behavioural, relational and psychoanalytic approaches to therapy. Despite the diversity in the authors’ theoretical orientations, these contributions converge on several points which we will briefly discuss, as they reflect issues central to contemporary discussions and developments in psychotherapy theory and practice.
      First, all contributions in this special issue exhibit an interdisciplinary tendency, with significant links being made between the specific approaches to psychotherapy and other fields, such as research on attachment and affective neuroscience, as well as disciplines outside psychology and psychotherapy, such as philosophy and Buddhism. Jeremy Holmes, for example, discusses the implications of attachment theory for conceptualising and studying the process of psychoanalytic psychotherapy. In his discussion, he draws from research on affective communication between parents and infants, on changes in narrative coherence and on mentalisation, and explores the implications these findings have for describing the interaction between therapist and client. In this way, he cogently demonstrates how research findings from attachment theory and affect regulation lend support to contemporary psychoanalytic work with borderline clients.
      Paul Gilbert, on the other hand, draws heavily from evolutionary models of human functioning and recent findings from affective neuroscience research to discuss Compassion Focused Therapy, an approach which is consistent with the recent emphasis on experiential strategies within the cognitive-behavioural tradition (Hayes, Follette, & Linehan, 2004). He developed this approach while working with clients who experience complex emotional difficulties and that, as a result, find it difficult to engage in psychotherapy on an emotional level. He also draws from attachment theory and suggests that the attachment system is important not only for physiological maturation but also for affect regulation, the development of the capacity for empathy and mentalisation. He discusses the processes involved in helping clients develop compassion, in the context of research on the neuroscience of feeling soothed, safe and content, whilst acknowledging the links with Buddhist approaches to compassion.
      Jeremy Safran and Julia Belotserkovsky also draw from contemporary emotion theory and research, as well as from evolutionary approaches, with a particular focus on affective communication and mutual affective regulation, and explore the implications of these findings for understanding the process of change in psychotherapy. More specifically, they suggest that the client is helped to learn to better regulate his or her affect intersubjectively, that is, through the therapist regulating his/her affective experiences that arise in the clinical encounter. Moreover, they suggest that therapeutic metacommunication and the practice of mindfulness, a notion and practice originating in Buddhist mediation, can help both therapists and clients to better recognise, tolerate and constructively utilise their affective states.
      Finally, James Yadavaia and Steven Hayes present Acceptance and Commitment Therapy, a modern approach to behavioural psychotherapy based on functional contextualism. They explore the similarities and differences in the ways in which personal values have been conceptualised in this model as well as in client-centred therapy, Motivational Interviewing, positive psychology and radical behaviourism. Their discussion shows the traditional boundaries between therapy schools of widely different orientations to be less clear-cut than often assumed. They too draw from Buddhist approaches, by highlighting the importance of mindfulness processes in psychotherapy, but the emphasis here is on committed action rather than on symptom reduction or changing negative thinking.
      A second focus shared by the contributions in this special issue is that on psychotherapy as relationship. Patrick Casement discusses the issue of certainty (and non-certainty) in therapy and the pitfalls involved in the therapist assuming that he or she knows about the clients’ inner experience based on theory and/ or his or her (the therapist’s) own perspective. He suggests that for therapy to become truly helpful, rather than a form of brain washing or compliance, the analytic process needs to be protected from anything that may distort it, including the therapist’s theoretical knowledge and preconceptions. He describes therapy as a process of mutual exploration and meaning-making, a relationship dynamic that unfolds in the analytic space; he cautions against the therapist ‘putting things in the analytic space’ and proposes processes (such as internal supervision and trial identification with the client) that can help maintain an open and exploratory attitude in both therapist and client. In addition, he also discusses several situations where certainty and firmness on the part of the therapist are required.
      The focus on the interpersonal nature of therapy is shared by Safran and Belotserkovsky, who draw upon relational perspectives on therapy, when discussing the mutual affective regulation that takes place in the clinical encounter. They, similarly, propose that the therapist is a central and active participant in the co-creation of the clinical situation, which is seen to be the product of both conscious interventions and the (unconscious) relational schemas of both participants.
      In a similar vein, in his presentation of attachment theory as a meta-perspective for approaching interactions in therapy, Holmes also assumes an interpersonal stance when discussing emotional connectedness, attunement and mirroring; he also suggests that the therapist’s attachment style interacts with that of the client and contributes both to the development of transference and to enactments.
      Gilbert, from a different perspective, also suggests that the formulation regarding the client’s difficulties is co-constructed between therapist and client and points out the importance of a compassionate therapeutic relationship. However, in his paper, the focus of therapy is on psycho-education (Compassionate Mind Training), in contrast to Holmes, Casement, and Safran and Belotserkovsky, who emphasise the importance of the therapeutic relationship as a vehicle for change.
      Finally, Yadavaia and Hayes also emphasise the therapeutic relationship, albeit less than Safran and Belotserkovsky, Holmes, and Casement. However, their lack of commitment to a specific set of values “as the right ones” and their position that the therapist guides the client to discover his or her own set of values through action, so that he or she can lead a meaningful life, basically assume that the therapist will be willing to know himself or herself, be able to tolerate uncertainty and support the client through this discovery process. Indeed, this is something that Hayes discusses more explicitly in other writings (Hayes, Strosahl, & Wilson, 1999).
      Lastly, the regulation of affect is considered, in these papers, to play an important role both in psychopathology and in the changes effected through therapy. The importance of affect regulation and ways of facilitating its development are discussed explicitly and at length by Safran and Belotserkovsky. More specifically, they argue that emotions play a central part in human functioning, have an important evolutionary role and provide a form of embodied knowledge about the self and the social world. In this context, an important goal of therapy is to help the client develop his or her capacity to modulate and integrate emotional responses, to accurately process affective information from others and to gradually own his or her respective role in unconscious enactments. This capacity for affect regulation is suggested to help individuals act in a way that is responsive to their needs but not impulsive. In this way, the regulation of affect is seen to involve higher level cognitive functioning and meaning is assumed to be based on emotional experience. In addition, they suggest that mindfulness in the therapist is facilitated by a self-accepting stance, which leads to surrender and ultimately to the fuller acceptance of the other.
      The importance of affect regulation is also discussed by Holmes, from an attachment theory perspective, in his utilisation of the concept of mentalisation, a reflexive capacity which is considered to be central to psychological well-being. It has been suggested that mentalisation may potentially provide a unifying concept in psychotherapy theory.
      Being aware of one’s emotions and developing an accepting and compassionate attitude towards them forms an important aspect of Compassion Focused Therapy and particularly as it applies to clients who are highly self-critical, self-attacking and prone to feeling shame. However, here the emphasis is on the individual rather than the therapeutic relationship. Gilbert suggests that compassion is an important component of the emotion system associated with feelings of safeness, soothing and reassurance, and that for compassion to develop one needs to be in touch with one’s needs, wants, pain and distress, and to be able to self-monitor one’s emotions.
      In a similar vein, although from a behavioural perspective, contacting and accepting one’s mental events, as contrasted with experiential avoidance, while realising that these are “just things that the mind does” form important aspects of the mindfulness process of Acceptance and Commitment Therapy, as described by Yadavaia and Hayes. The processes are considered crucial in removing barriers and providing a context for action and behaviour change.
      Finally, Casement, in his discussion of the need for therapists to develop a balance between knowing and not-knowing in therapy, suggests that therapists can sometimes use theory defensively against the feelings and anxieties evoked by not-knowing. This, he suggests, can significantly limit the scope of therapeutic work by distorting and contaminating the analytic space and imposing preconceived meanings on clients, rather than allowing the understanding of a particular client’s individual experiences to remain open, fluid and provisional for a while. This skill relies on the therapist being able to tolerate non-certainty and the feelings associated with it.
      In our opinion, an important aspect of these papers is that they propose general psychological principles in order to conceptualise the development of problems and the way psychotherapy works; in this way, they focus on the individual and his or her difficulties rather than on psychopathology and diagnostic categories. With regards to their application, the principles proposed appear to be particularly relevant to dealing with clients with complex and chronic difficulties, conceptualised in some of these papers as involving difficulties with mentalisation or affect regulation.
      As evidenced by the breadth and diversity of approaches presented in this special issue, psychotherapy is a lively field that continues to develop new ideas and techniques, in conjunction with recent developments in other disciplines, such as neuroscience and attachment, and long-standing traditions, such as Buddhism.

Hayes, S. C., Follette, V. M., & Linehan, M. M. (2004). Mindfulness and acceptance. Expanding the cognitive-behavioral tradition. New York: Guilford.

Address: Evrinomy Avdi, School of Psychology, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece. E-mail: avdie@psy.auth.gr
Address: Pagona Roussi, School of Psychology, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece. E-mail: roussi@psy.auth.gr