In a Nutshell

In a Nutshell gives a very brief synopsis of various subjects of relevance to student and trained counsellors and psychotherapists. 

Structuring the Therapeutic Process

Integrative models can provide a map to guide us through the territory with work within. My favourite is B. D. Beitman’s in
his book ‘The structure of Individual Psychotherapy’ where he identified four stages: Engagement, Pattern Search, Change 
and Termination. His book is well worth studying. After studying the major models and examing my own approach I found the central focus on the relationship was not emphasised enough and corrected this in my own personal model with the stages of: Building the Relationship, Expressing & Exploring, New Understanding, Developing Options (IACP journal, 1996, 1, 36). It goes without saying perhaps that no model should be taken too literally as the map is not the territory and a model should not be followed mechanically. 

Brief Therapy (Pt I): 

Dermot has been seeing a psychoanalyst for four years for help with his fear of monsters under his bed which has led to chronic insomnia. The psychoanalsis didn’t help so he stops seeing him and decides to try something different. A few years later Dermot bumps into the psychoanalyst who is very surprised to see his former patient looking so rested, full of energy and relaxed. On questioning Dermot says he’s cured and sleeps great. The analyst is amazed and curious. Dermot tells him "I went to see another therapist who called himself a brief therapist who cured me in one session". “ Wow!" the sceptical anaylst replied, “and how did he manage that?". ‘Oh easy, he gave me a saw and told me to cut off the legs of of my bed! 

Brief therapy II. 

There are many forms of brief therapy some use paradoxical approaches which are not encouraged nowadays. See ‘A Brief Guide to Brief Therapy’ by Cade and O’Hanlon for an interesting overview of brief therapy approaches. Solution focused brief therapy focuses the clients sharing on what has worked for them rather than talking about the problem. The therapist looks for exceptions to the rule where the client managed the situation better or when the depressed client had a good day or times when the alcoholic drank less and then encourages more of what did make the difference. (see De Shazers writings: The Keys to Solution in Brief Therapy; Clues: Investigating Solutions in Brief Therapy (1988) and Putting Difference to Work (1991). This approach can be helpful with ‘clients’ that are, as de shazer describes as just ‘visiting’ - a person who doesn't want to talk about their problems/isn’t there to work on them or change but may engage through an affirming approach and acknowledging what is going well - what is working for them. 

Films on Psychotherapy    

General release movies: 'A Dangerous Method' starring Keira Knightley, Michael Fassbender; 'What about Bob' (comedy); '50:50' (comedy & serious); ‘Help' TV comedy series with Paul Whitehouse and Chris Langham. 'The Simpsons' family therapy session. 'The Big Bang theory': Sheldon trains Penny. 'In Therapy' with Susie Orbach (BBC radio): Yalom: 'Yalom’s Cure', 'Understanding group psychotherapy' (out and inpatient), and 'Group supervision'. TA: Emily Rupert. PCT: BrianThorne with client, 'Journey into self' Rogers group therapy. Gestalt: Psychotherapy with the unmotivated patient' (Erving Polster), Perls with Gloria: Christine Padesky - films on bore beliefs, panic, social anxiety etc. using CBT. Three approaches to psychotherapy with Gloria (1965) demos by Perls, Ellis and Rogers. Three approaches to psychotherapy with Kathy 1977 with Rogers, Shostrum and Lazurus ( Many of the above are accessible on youtube. Contact me if you can’t find the one you want after googling it. Most of the demos are with ‘real’ clients not role played roles.


“It has been said that when a co-dependent is in danger of dying, the life experiences of their partner flash before their eyes!” Described as a pattern of painful dependence upon compulsive behaviours and approval of others to find safety, self worth and identity or a family member being unwittingly entwined with, and contributing to, the drinking or drugging habits of the chemically dependent person. The person may go onto fall into similar dysfunctional close relationships, especially with narcissists. Indications: Intense and unstable interpersonal relationships. Inability to tolerate being alone. Chronic feelings of boredom and emptiness. Subordinating one’s own needs to those of the person with whom one is involved. Overwhelming desire for acceptance and affection. External referencing (always checking outside oneself before making choices). Dishonesty and denial. Low self worth. Origins: “…women with an alcoholic parent will be especially attracted to people whom they perceive as having a style of interpersonal relating similar to the substance dependent parent…having become dependent on the esteem of a dysfunctional, dependent person, codependents will continue to seek self-worth from the same type of person.” Lyon and Greenberg (1991). The parent was therefore likely to have been distant, neglectful or had abandoned the child. The parent may not necessarily be a substance abuser. Karen Horney, a german psychoanalyst, was the first to write about co-dependency. She proposed that some people adopt a “Moving Toward” personality style, a defence, to overcome their basic anxiety (from dysfunctional parenting) and to meet their unmet needs through the other person, drove to obtain and preserve affection, even at the expense of engagement in a dependent, exploitive relationship. Reading: Karen Horney (1945) Our Inner Conflicts. Norwood, R. (1985). Women who love too much. Lyon, Deborah and Greenberg, Jeff. Evidence of Codependency in Women With an Alcoholic Parent: Helping Out Mr. Wrong. Journal of Personality and Social Psychology. 1991, Vol. 61, No. 3, 435-439.

Existential Psychotherapy

Existential psychotherapy is a philosophical method that operates on the belief that inner conflict within a person is due to that individual's confrontation with the givens of existence. These ‘givens’ include: the inevitability of death; freedom to choose; isolation; and meaninglessness. Existential psychotherapy emphasises how we apply ourselves to the world. The latin origins of ‘exist’ means to ‘step out’ - capturing the existentialist theme of active engagement with the world and responsibility for one’s destiny. As James Bugental (1992) put it: ”The purpose of the therapeutic process is to increase living awareness of the consciousness of one’s own being, one’s own powers and choices, and one’s own limitations…we must help our clients become aware of how they are constricting their lives and their awareness and of the possibilities that are latent for them.” And Emmy de Deuzen added: “[Existential psychotherapy]...seeks to enable a person to live more deliberately, more authentically and more purposely whilst accepting the limitations and contradictions of human existence”. Texts: Existential Psychotherapy, Irvin Yalom. Existential Psychotherapy, Emmy de Deuzen. Both have wrote many other books of interest that are recommended.Films: Akira and the recent series by Riccky Gervais: After Life. Also Yaloms Cure. Sartres ‘Bad Faith’ can be seen in the film: ‘the Remains of a day’.

Personality Disorders

Personality disorders are long-term patterns of behavior and inner experiences that differs significantly from the ‘norm’. The pattern of experience and behavior often begins in childhood and becomes clear by late adolescence or early adulthood and causes distress or problems in functioning. leads to substantial personal distress and/or social dysfunction, and disruption to others. Not diagnosed until after early adulthood and can be mild to severe in severity.

Borderline (emotionally unstable) personality disorder
Involves a pattern of instability in relationships, self image and affects, coupled with marked impulsivity. Others are regarded as dangerous and bad, and oneself as powerless and vulnerable (victim) as well as inherently bad and unacceptable to oneself and others. DSM Diagnostic Criteria for BPD: BPD is diagnosed on the basis of (1) a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and (2) marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by at least  of the following

  • Frantic efforts to avoid real or imagined abandonment
  • Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
  • Markedly and persistently unstable self-image or sense of self
  • Impulsivity in at least two areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating) 
  • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
  • Affective instability due to marked reactivity of mood (eg, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
  • Chronic feelings of emptiness
  • Inappropriate, intense anger or difficulty controlling anger (eg, frequent displays of temper, constant anger, or recurrent physical fights)
  • Transient, stress-related paranoid ideation or severe dissociative symptoms

Treatment & Prognosis: DBT programmes and General psychiatric and psychotherapy support though the work is most applicable for very experienced psychotherapists and psychologists who have training and experience in this area.  

Remissions can occur but can also be lifetime. With support can learn to manage emotions, behaviour and thoughts better. There is some research showing that borderline personality disorder runs in families and individuals have a higher chance of developing BPD if experienced early sexual abuse or alcoholism in the family.

ME/CFS (Myalgic Encephalomyelitis/Chronic Fatigue Syndrome)
ME/CFS is a serious debilitating chronic multisystem illness that can leave the sufferer house or bed bound. This condition is often misunderstood by many professionals (GP’s, consultants, physio’s, nurses) and lay people as 'all in the mind’ or viewing it as simply fatigue. This is despite having robust evidence showing it to be a biological illness. Affecting many systems of the body, symptoms include profound fatigue, post exertional malaise, sleep disturbance, cognitive impairment, postural orthostatic tachycardia, fibromyalgia type pain, sensitivity to sounds, smells, light, enlarged lymph nodes and IBS. It is diagnosed after having certain conditions ruled out through medical test such as Lyme’s disease, thyroid disease, anemia, Addison disease etc. It is crucial to obtain a early diagnosis from a qualified doctor and a consultant with an understanding of this condition. The hallmark symptom of ME/CFS isn’t fatigue at all: It’s a dramatic worsening of symptoms after exertion (which for some patients can be as little as washing themselves). Cognitive problems can be incapacitating whereby the person can’t talk or read; within half an hour of standing, their blood pressure drops or their heart rate soars; and sleep makes them feel no better. Given all the above many sufferers will, naturally, suffer from depression too. Associations: (frequent events with expert speakers). Reading: Living With M.E.: The Chronic, Post-viral Fatigue Syndrome by Dr. Charles Shepherd. For latest research: ME/CFS/PVFS An exploration of the key clinical issues (2017) from Investinme (research conferences). Article on M.E. (Myalgic Encephalomyelitis) in the Irish Times Tuesday Nov. 28th, 2019 (  Many doctors, psychiatrists, physio's and other professionals lack accurate understanding of ME and it is often misdiagnosed and sufferers given inapproriate and potentially harmful treatment. 
The new NICE guideline 2020 draft for ME/CFS. Informative summary of updated guidelines. Link.

Dialectical Behavior Therapy (DBT) 
Is a modified cognitive behavioral treatment that combines behavioral science with acceptance and mindfulness. It was originally developed by Dr. Marsha Linehan to treat chronically suicidal individuals diagnosed with borderline personality disorder. DBT involves the learning and practicing of particular coping skills such as self monitoring, emotion regulation and tolerance, mindfulness and interpersonal skills. Extended group based programs are available in the HSE which also include individual therapy and phone coaching session. Resources: 

Future topics: Transference, Countertransference, Behavioral Therapy, Cognitive therapy, Gestalt, Transactional Analysis, family sculpt.