Rafael Rabenstein

rafael@rabenstein.net

Probably the best known and most common model of the therapeutic process is by Kanfer et al 1996, “7-phase” model. This model is similar to D’Zurilla and Goldfried’s problem-solving process or Bartling’s process model (Bartling et al., 2004).

Figure 24: Process models of problem solving (Kanfer et al., 1996; Bartling et al., 2004).

Phase 1 Initial phase: creating favorable starting conditions

The goal of the first phase is to establish a sustainable and cooperative therapeutic relationship/alliance. In addition to these relationship aspects, this phase also serves to gather information and clarify the framework conditions.

The reason for the contact, questions about the current problem situation, the referral context and initial anamnestic data must be clarified. The patient’s goals should also find room here, also to clarify whether a working alliance makes sense and is possible. Whether the formulated goals are achievable for the patient and whether they meet the patient’s own needs can only be seen in the further course of the treatment.

Likewise, it is important to discuss expectations, concerns, and any fears about psychotherapy at the outset to reduce barriers.

Another aspect that should not be underestimated is the current psychopathology. Acute suicidality, disorganized thinking, intoxication are just a few crisis-like conditions that require immediate intervention.

Key points in Phase I/first interview:

• Assignment context
• Framework
• Current problems
• Targets
• Expectations of the therapy
• Psychopathology
• Medical history

Phase 2 Building motivation for change and selection of therapeutic starting points

The aim of this phase is to motivate the patient to change. The reduction of worries fears and anxieties. Motivational strategies are the focus here. Motivational and motivational relationship building can be used for this purpose. The choice of starting points must be made in consultation with the patient. As soon as this is done, we move on to the next phase. However, building motivation for change is an important task at all stages.

Phase 3 Problem analysis, behavior analysis and condition model

This phase includes horizontal and vertical behavioral analysis. So the micro and macro analysis. The condition model should be created individually depending on the patient and disorder-specific elements should be adapted and integrated. The condition model is completed when the genesis of the problem situation and a possible solution become recognizable and comprehensible for patient and therapist. Similarly, it is important to acknowledge and consider resources and functional coping strategies.

Phase 4 Goal clarification and analysis

Based on the condition model and previously stated goals for therapy, this phase focuses on the concretization of goals. It is important to consider conflicts between plans and rules, and to capture any conflicting goals in terms of approach and avoidance goals. Also the functionality of the existing behavior is to be reflected critically at the latest here and a cost/benefit analysis which changes a treatment of goals can bring along.

Phase 5 Intervention phase

In Phase 5, the planning, selection, and implementation of specific interventions are developed. The selection is made after considerations with the patients. Initially, “targets” should be worked on that will allow the patient to succeed. It is always important to consider individual goals and problems and not to offer disorder-specific interventions alone. Behavioral therapy is always a personalized and evidence-based treatment.

Phase 6 Evaluation

The review of the set interventions may lead to a conclusion, adjustment or adaptation of the approach. This can be done by means of a goal achievement scale, by summarizing what has been achieved or by means of diagnostics accompanying therapy. Once one goal is achieved, another goal can come into focus, or the achievement of the goal is coherent for the patient.

Phase 7 Final phase

This phase may be longer or shorter depending on the length of therapy and individual patient characteristics. It is important to ensure that clear contingency plans have been developed as part of relapse prevention. In addition to these more technical aspects, however, the end of the therapeutic relationship is the biggest hurdle, especially for people with insecure attachment styles. Here it is necessary to plan the farewell in a reasonable time and to deal with difficulties. Booster sessions can help stabilize successes but also to make it easier to say goodbye. It also makes sense to collect catamneses on the one hand to check the stability of what has been achieved, but also to offer patients a relationship for new crises.

Summary

The phases listed rarely, if ever, run in a linear fashion. A dynamic and flexible approach is necessary to take into account difficulties, fears, but also changes in the patient’s living environment.

Literature:

Bartling, G., Echelmeyer, L., Engberding, M. & Krause, R (2004). Problem Analysis in the Therapeutic Process, 5th ed. Stuttgart: Kohlhammer.

D’Zurilla TJ, Nezu AM (2010). Problem-solving therapy. In Dobson KS (ed.). Handbook of Cognitive-behavioral Therapies. Pp. 197-225, New York: Guilford.

Kanfer FH, Reinecker H, Schmelzer D (1996). Self-management therapy. Berlin: Springer.