Treating Diverse Populations

diversityby Jen L’Insalata

When working with a diverse client population it is important to acknowledge varying ideological concepts between demographic groups. In other words, a diverse population of clients requires a therapist to utilize a diverse repertoire of treatment approaches. Elements such as race, gender, age, religion, and sexual orientation impact the client’s response to particular therapeutic approaches. A therapist must recognize and utilize the best fit and appropriate approach for each individual client. Often when working with diverse population, it becomes necessary to integrate elements from varying psychotherapeutic approaches. Such integration allows for the necessary flexibility in clinical treatment that yields evidence based best practice results.

Methods of Integrating Psychotherapies

The integration of psychotherapeutic treatments can be as diverse as the theories themselves. However integration often takes the form of one of four main pathways. Each pathway allows a therapist to customize and blend psychotherapeutic treatments and modalities to best fit a particular client’s receptiveness and needs (Wedding, & Corsini, 2014).

Technical eclecticism is a research specific approach to integrating psychotherapeutic theories.  This integration style allows unrelated concepts of varying therapeutic theories to be integrates and combined. Technical eclecticism draws on research which compares effective treatments to particular problems and client characteristics and utilizes concepts and techniques from varying theories (Wedding, & Corsini, 2014).

Theoretical integration includes multiple therapies which are combined to achieve the best result. The overarching concept blends together multiple theoretical approaches in order to create a more effective conceptual framework for treatment. Integration of psychodynamic and interpersonal, cognitive and behavioral, or systems, and humanistic are most widely used in combination (Wedding, & Corsini, 2014).

Combining treatments based on common factors is an integrative approach that identifies core similarities of varying treatment modalities. Treatment techniques are then developed based on key combinations of commonalities. Combining common factors focuses on the effective commonalities in theoretical concepts of treatment processes rather than the individual theoretical differences (Wedding, & Corsini, 2014).

Assimilative integration is an integrative technique that utilizes one primary therapeutic theory as a foundation. It then selects specific elements of other theoretical approaches to assimilate into a single treatment modality. This combinations allows a foundation in one coherent system of treatment with the ability to interject a broader range of treatment techniques (Wedding, & Corsini, 2014).


Empirical and evidence based research shows that the integration of theoretical approaches provides advantages from a variety of therapeutic modalities. Integrative therapies tend to focus on the clients individual circumstance and experiences rather than an overarching or abstruse theory (Ponterotto, 2013). Studies show that by integrating psychotherapeutic modalities for individual clients, the client attains the best possible outcome.

It is possible to conduct quantitative research without understanding epistemology however qualitative research relies on awareness of philosophical perspectives among client sub cultures. Qualitative research recognizes the sociocultural compounds of expression and experiences within a various populations and accounts for their voice or cultural input in the effectiveness. Qualitative research accounts for social, cultural, and economic realities for clients that impacts the structure and relationship of the therapeutic process (Ponterotto, 2013).

Mahrer’s 1989 Study

The Mahrer’1989 study investigated the integration of various psychotherapeutic techniques with concrete operating procedures. Mahrer utilized videotapes and transcripts to identify therapist’s behaviors that promoted client change. He believed that particular behaviors could be utilized and integrated into a range of options to achieve therapeutic goals. (Richert, 2007).

Concrete operations is describes as a set of ordered behaviors that a therapist would perform in sequence in order to elicit particular behaviors from a client. A therapist would utilize activities such as s Socratic questioning, teaching disputation, and the recording of automatic thoughts to implement a broader range of cognitive problem solving. Four specific theoretical orientations were selected for the integration into concrete operations procedures; humanistic and existential, cognitive and constructivist, analytic and dynamic, and interpersonal. (Richert, 2007).

According to Mahrer’s study, a constructivist therapeutic approach integrated most effectively with concrete operational procedures. Constructivist approach integrates unconditional positive regard, transference-counter transference while utilizing empathic reflections, two-chair dialog exercises, metacommunication or therapist self-disclosure, and dream work. Mahrer believed that a constructivist approaches proved favorable for integration due to emphasizing meaning-based practice, disputing irrational beliefs and self-monitoring procedure adapted from REBT and CBT (Richert, 2007).


Changing demographics in the United States calls for the continued development and integration of psychotherapy approaches. The ethnic and cultural diversity in which a clinician sees in their clients is increasing. More people from ethnicities who previously did not seek treatment are turning to therapist and clinicians with traumatic histories. Often these immigrant populations are underserved, under insureds, and receive treatment that is ineffective (Cook, & Tedeschi, 2007).

It is important to remember that when working with culturally diverse clients a therapist enters and experiences a foreign world and mindset. Empathy, respect and understanding of differences is imperative. A therapist must be able to suspend any preconceived concepts or stereotypes surrounding a particular population. (Ponterotto, 2013).

Blended elements from varying psychotherapeutic theories are effective when working with diverse populations. It is important for the therapist to keep an open mind about integrating treatments in the same manner as the must to toward each individual client. An effective integrative therapist recognizes the individual needs and limitations to therapy and creates a personalized therapeutic plan for each individual.



Wedding, D., & Corsini, R. J. (Eds.). (2014). Current psychotherapies (10th ed.). Belmont, CA: Brooks/Cole. ISBN: 9781285083711.

Ponterotto, J. G. (2013). Qualitative research in multicultural psychology: Philosophical underpinnings, popular approaches, and ethical considerations. Qualitative Psychology, 1(S), 19-32. doi:10.1037/2326-3598.1.S.19

Richert, A. J. (2007). Concepts, processes and procedures: An introduction to the special issue on integration of concrete operating procedures. Journal Of Psychotherapy Integration, 17(1), 1-9. doi:10.1037/1053-0479.17.1.1

Cook, J. R., & Tedeschi, R. G. (2007). Systems of care and the integrative clinician: A look into the future of psychotherapy.Journal Of Psychotherapy Integration, 17(2), 139-158. doi:10.1037/1053-0479.17.2.139

A Historical Perspective of Schizophrenia

schizophrenia1by Jen L’Insalata

Schizophrenia cannot be explained in its entirety by one particular theoretical model and the underlying neurobiological foundation for the disease is still relatively unknown.  Rather it is the descriptions and observations of the primary psychotic symptoms that have allowed several theories surrounding schizophrenia to evolve (Mishara, & Schwartz, 2013). Historically, schizophrenia was considered to be constructive in which anomalous experiences provide the construct of one self. Early clinical observations emphasized subjective self-experiences and altered self-awareness. The concept of self-experience is still referenced in modern work with schizophrenia. (Parnas, & Henriksen, 2014).

The earliest depictions of schizophrenia were recorded in France during the 12th century but were not linked to any particular disorder. Writing described individuals who deviated from what was considered to be normal self-perception; anomalous self-experiences. In many cases writing illustrate a disunity of consciousness in which a person’s thinking, perception, movement, and vision were disjointed and incongruent with presented stimuli (Parnas, & Henriksen, 2014).

The modern understanding of schizophrenia rose form the work of Emil Krapelin, an influential German psychiatrist working in the late 19th and early 20th century. Krapelin research surrounding the combination of symptoms and psychiatric illness from a biological origin highlighted two forms of psychosis; manic depression and dementia praecox (Ebert, & Bär, 2010). The disturbance known as Krapelin’s dementia praecox consisted of the phenomenon currently recognized as schizophrenia. During his research, Krapelin described the deterioration of what he believed to be perception and attention in combination with muscular tension (Mishara, & Schwartz, 2013).

Throughout the late 1800’s and early 1900’s core symptoms were studied by individuals from a psychodynamic perspective such as Carl Jung, Josef Berze, and Hans Walter Gruhle. Many of these theorists called attention to various cognitive and affective characteristics of the disorder. Jung in particular was fascinated by patients displaying confused speech which he described as a state of sleep-drunken-ness and confusion. Their theories critiqued by many other early psychotheorists and the phenomenon later was renamed schizophrenia in 1908 by Eugen Bleuler (Mishara, & Schwartz, 2013).

Bleuler theorized individuals with schizophrenia experienced a general loose association with a fissure personality which was highly influenced by Jung’s work. Bleuler believed that such loose associations allowed aspects of the unconscious to invade the consciousness and lead to an ego disorder. The unconscious invasion would erode the functioning of the ego to the level in which it exists in dreams. Gruhle added to Bleuler’s work and theorized that the primary symptoms of schizophrenia operated independently and observed a dysfunction between the cognitive and the affective components of the disorder (Mishara, & Schwartz, 2013).

Josef Berze criticized Jung’s work and theories believing that the symptoms were due to a reduction in mental activity rather than attention. He theorized that mental activity is more closely related to consciousness than affect and highlighted the concept of a disruption in self as the essences of schizophrenia. Berze also noted diminished mental activity in goal setting, linguistic coherence, and the ability to access the autobiographical self. Much of his work was inspired by emerging neurobiological research. He theorized that schizophrenia symptoms originated at a subcortical area, specifically the thalamus which gave rise primitive drives and motivations (Mishara, & Schwartz, 2013).

Jaspers integrated and critiqued his predecessors work in his book General Psychopathology published in 1913. (Mishara, & Schwartz, 2013). Highly influenced by the philosopher Descartes, he solidified the concept of self-experience pertaining to schizophrenia. Jaspers recognized that an individual may have and recognize experiences that are invalid and referred to positive symptoms as first person symptoms (Parnas, & Henriksen, 2014).

During the 1940s Freud’s psychoanalytic work continued to influence much of the theories surrounding schizophrenia and emphasized an etiological root stemming from early relationships. Psychoanalytic writers produces detailed descriptions of the schizophrenic experience including disruptions in interpersonal relationships and the self-experience due to the psychosis (Hamm, & Lysaker, 2016).

Writers such a Freud and Searles illustrate individuals that were detached from the world and redirected psychic energies inward during psychosis. Such writings provide the concept of an altered self-experience from which the schizophrenic individual is unable to integrate life experiences. Psychodynamic approaches took a pessimistic view of schizophrenia treatment which failed to produce empirically supported and measurable treatment modalities. Eventually, such treatment modalities fell out of favor and were replaced by psychosocial and cognitive behavioral perspectives (Hamm, & Lysaker, 2016).

With the publication of the ICD 8 and 9, Schizophrenia was recognized as a disturbance of personality and involved disorder concepts of individual uniqueness and self-direction. During that time the term personality referred to a subjective self rather than the personality descriptions used in contemporary psychology. Research surrounding a subjective self could be measured using systematic approached however lacked reliability in its methods. This notion soon fell out of favor and was replaced with an operational model following the publication of the DSM-III in 1980 (Parnas, & Henriksen, 2014).

The DSM-III emphasized behavioristic components of schizophrenia which stress observable features over the subjectivity and inference of previous theories. Biological concepts such as genetics in the etiology of schizophrenia were highlighted and lead to the emergence of a spectrum of observable features and predictors. Among the most noted were deficits in emotion, eccentricity, and thought disorder which caused interpersonal difficulties in social and occupational function. The inclusion of the diathesis stress model illustrated how core vulnerability combined with environmental stressors and produce cognitive changes observed in schizophrenia (Parnas, & Henriksen, 2014).



Asenjo Lobos, C., Komossa, K., Rummel-Kluge, C., Hunger, H., Schmid, F., Schwarz, S., & Leucht, S. (2010). Clozapine versus other atypical antipsychotics for schizophrenia. The Cochrane Database of Systematic Reviews, (11), CD006633. Advance online publication.

Ebert, A., & Bär, K.-J. (2010). Emil Kraepelin: A pioneer of scientific understanding of psychiatry and psychopharmacology. Indian Journal of Psychiatry, 52(2), 191–192.

Hamm, J. A., & Lysaker, P. H. (2016). Psychoanalytic phenomenology of schizophrenia: Synthetic metacognition as a construct for guiding investigation. Psychoanalytic Psychology, 33(1), 147-160. doi:10.1037/a0038949

Mishara, A. L., & Schwartz, M. A. (2013). Jaspers’ critique of essentialist theories of schizophrenia and the phenomenological response. Psychopathology, 46(5), 309-19. doi:

Parnas, J., & Henriksen, M. G. (2014). Disordered Self in the Schizophrenia Spectrum: A Clinical and Research Perspective. Harvard Review of Psychiatry, 22(5), 251–265.

Spencer, E. K., & Campbell, M. (1994). Children with schizophrenia: Diagnosis, phenomenology, and pharmacotherapy. Schizophrenia Bulletin, 20(4), 713-725.

CBT: Cognitive Behavioral Therapy

woodbrainby Jen L’Insalata

In most psychotherapeutic environments the term CBT is tossed around all the time. CBT in research; my insurance providers prefer CBT; CBT; CBT; CBT. So what is this CBT stuff? CBT is short for cognitive behavioral therapy and essentially addresses both thoughts and the underlying emotions that influence behavior. This is achieved by bringing together components of both cognitive therapy and behavioral therapy is a direct and effective manner.

Behavior Therapy

Behavior therapy is centered on the concept that human behavior serves a function and results from stimuli within the individual’s environment. Behaviors result in response to environmental stimuli and behavioral patterns result from the reinforcement or punishment received from the interaction between the individual and their particular environment. The psychosociocultural viewpoint encompasses a wide range of therapeutic strategies that aim to change the environmental factors that stimulate maladaptive behaviors (Wedding, & Corsini, 2014).

Cognitive Therapy

Cognitive theory is a theory of personality in which individuals respond to life events cognitively, motivationally, and behaviorally. An individual perceives, interoperates, and assigns meaning to particular life events. Maladaptive behaviors and affects are caused due to the misinterpretation of stimuli, situations, and events. Cognitive therapy aims to adjust the way the individual processes incoming information by examining the individual’s belief about their self, the world, and others (Wedding, & Corsini, 2014).

Five Concepts That Add Dimension

Both behavior and cognitive therapy recognize that personality is consistent and an individual’s response to environmental stimuli can be predicted. Behavior therapy acknowledges five core domains from which personality can be assessed. Behavior therapy teaches flexibility within an individual’s personality domains and introduces healthy coping mechanisms and responses for environmental stimuli (Wedding, & Corsini, 2014).

Cognitive therapy recognizes schemas to explain and predict responses to environmental stimuli and situational cues.  A network of affective, motivational, and behavioral schemas known as modes asses and interoperate situations. Some modes are rooted in instinct and are referred to as primal modes. Primal modes are often ridged, automatic, and absolute. Primal thinking leads to maladaptive behavior. Cognitive therapy teaches a client to consciously override primal modes through means of deliberate thinking and problem solving (Wedding, & Corsini, 2014).

Behavior therapy focuses on the behaviors and actions that are conditioned responses to external stimuli. Cognitive therapy focuses on the affect and mental interpretation of a particular stimuli (Zaretsky, Segal, & Fefergrad, 2007). Due to similarities, behavior therapy and cognitive therapy are often combined in a treatment known as cognitive behavioral therapy. CBT targets the bias mental interpretations acknowledged in cognitive therapy and teaches the client to regulate emotions causing maladaptive behaviors (Harvey, Bélanger, Talbot, Eidelman, Beaulieu-Bonneau, Fortier-Brochu, & … Morin, 2014).

CBT is often used as a primary treatment for depression and mood disorders.  By leveraging a client’s awareness of the changes in their cognition, (Zaretsky, Segal, & Fefergrad, 2007) treatment techniques encompassing mindfulness, relaxation, meditation, exposure, (Wedding, & Corsini, 2014) and modeling teach the client ways to regulate their affect and reduce symptoms (Zaretsky, Segal, & Fefergrad, 2007).

When addressing depression, cognitive therapy addresses the client’s negative views of one’s self, their experiences, and future. A client’s interpretation of their environment is often bleak and the client maintains a pessimistic bias toward themselves and their future. Motivational symptoms appear such as a lack of energy and sometimes paralysis that inhibits the completion of everyday life tasks. Increasing activity and social exposure combined with combating negative interpretations of situations are used to alleviate the cognitive components of depression (Wedding, & Corsini, 2014).

Behavior therapy addresses the conditioned response to stimuli. Behaviors increase due to reinforcement (Wedding, & Corsini, 2014). Maladaptive coping strategies and behaviors continue to reinforce depressive behaviors. Treatments focused on positive social exposure and activity work to reinforce positive experiences for the depressed individual and reduce exposure to negative experiences such as isolation. Exposure to positive stimuli aids in reinforcing non-depressive behaviors (Ryba, Lejuez, & Hopko, 2014).

Modeling behaviors occurs when an individual observers others in a sociocultural environment. Anxiety or phobias are maladaptive behaviors that can be learned through modeling abuse (Wedding, & Corsini, 2014). If an individual observes a social fear or anxiety about a particular situation, it is likely to be interoperated as a truth. An individual may model the anxious or phobic behavior learned from observation.

Behavior therapy addresses the hyperarousal brought on by anxiety and phobia by combining exposure and relaxation training. Practicing relaxation techniques while exposed to environmental stimuli helps alleviate the physical stress and tension associated with phobia and anxiety. Cognitive therapy teaches an individual to reevaluate the particular stimuli and interoperate it as less threatening (Wedding, & Corsini, 2014).

Substance abuse is often coupled with depression and anxiety. The recognition of psychosocial factors maintain the maladaptive belief and subsequent behaviors are addressed by combining cognitive and behavioral therapies (Harvey, Bélanger, Talbot, Eidelman, Beaulieu-Bonneau, Fortier-Brochu, & … Morin, 2014). Substance abuse may begin as a molded socioenvironmental behavior and become reinforced through positive social experiences. Reinforcement of addictive behaviors may be reinforced when a client engages in self-medication to alleviate depression and anxiety symptoms.

Stimulus control is a behavioral technique that can be used to help individuals with substance abuse issues and addiction. Principles of classical conditioning state that conditioned cues illicit behavioral responses.  Stimulus control aims to correct the problems associated with a particular stimuli (Wedding, & Corsini, 2014). For example, a client may associate a place or event with the acquisition and consumption of substances. Clients are encouraged to avoid places and situations which are cues for their addiction.



Wedding, D., & Corsini, R. J. (Eds.). (2014). Current psychotherapies (10th ed.). Belmont, CA: Brooks/Cole. ISBN: 9781285083711.

Zaretsky, A., Segal, Z., & Fefergrad, M. (2007). New developments in cognitive-behavioural therapy for mood disorders.Canadian Journal of Psychiatry, 52(1), 3-4. Retrieved from

Harvey, A. G., Bélanger, L., Talbot, L., Eidelman, P., Beaulieu-Bonneau, S., Fortier-Brochu, É., & … Morin, C. M. (2014). Comparative efficacy of behavior therapy, cognitive therapy, and cognitive behavior therapy for chronic insomnia: A randomized controlled trial. Journal Of Consulting And Clinical Psychology, 82(4), 670-683. doi:10.1037/a0036606

Ryba, M. M., Lejuez, C. W., & Hopko, D. R. (2014). Behavioral activation for depressed breast cancer patients: The impact of therapeutic compliance and quantity of activities completed on symptom reduction. Journal Of Consulting And Clinical Psychology, 82(2), 325-335. doi:10.1037/a0035363

Theories of Moral Development

Jen L’Insalata

Morality is often defined as an individual’s ability to judge and understand what is right and wrong and then to act in accordance to what they judge to be right. An individual’s moral and belief system influence their behaviors. Behaviors aligned with personal beliefs and morals help to build self-concept and self-esteem (Broderick, & Blewitt, 2010).

A child’s early sense of morals are influenced by a system of rewards and punishment established by the caregiver. Young children will act in accordance of with the egocentric self to meet the standards of their primary caregiver and avoid punishment. Perspective-taking improves and parental established morals give way to a conscience that intertwines emotions, cognition, and behavior (Broderick, & Blewitt, 2010).

Despite cultural and religious influences on morality, there are several universal component that establish good morals. Generally speaking, morality take into account the concern for others, a sense of justice and fairness, honesty and trustworthiness, and self-control (Broderick, & Blewitt, 2010). Feelings of morality and actions are often at a conflict and moral conduct appears to be determined more by situational assessment then by moral reasoning (Broderick, & Blewitt, 2010).

Several theories surrounding moral development exist. Freud discussed in his Psychoanalytic Theory that infants and young children are driven by the impulses of the self-serving id. The superego emerges and establishes a source of morals around preschool age (Broderick, & Blewitt, 2010). Freud believed these morals stemmed from an internalized system of rewards and punishments driven by parental conflict. Around the age of three, vague sexual desires toward the parent of the opposite sex and leads to an internal conflict and competition with the parent of the same sex. The solution to this conflict is to identify with the dominant same sex parent in order to be like them and satisfy this sexual longing (Broderick, & Blewitt, 2010). Morals are established by imitating the same sex parent’s actions.

Later research has failed to support Freud’s Psychoanalytic predictions. Finding show that children as young as eighteen to twenty-four months are capable of understanding empathy. This is inconsistent with Freud’s timeline for the emergence of the id ego and superego (Broderick, & Blewitt, 2010). Toddlers do however preform pro-social actions as a willingness to comply with the authority of their parents. The Psychoanalytic Theory associates this compliance with a fear of the same sex parental conflict. This concept contradicts research establishing that secure attachment and warm affectionate parental styles forester pro-social behavior and moral development (Broderick, & Blewitt, 2010).

Cognitive Theories of moral development center on the works of Piaget, Kohlberg, and Gilligan and emphasize changes in logical thinking at the core of moral development. Piaget theorized that there are three stages to moral development, premoral, heteronomous, and autonomous (Broderick, & Blewitt, 2010). In studies, Piaget presented children with moral dilemmas and asked them to assess the behavior of the protagonist or the rules of a game. During the premoral stage, infants have no concern for rules and often make up their own rules to serve an egocentric purpose. Around age five, children enter the heteronomous stage and view morals and rules through a realist perspective. They view rules at concrete and never to be broken. Violation of rules requires immediate justice and punishment. During middle childhood socialization and perspective-taking abilities become more refined. The child transitions into the autonomous stage and views morals as a social agreement to promote fairness. Rules can be modified and amended to serve a higher social purpose (Broderick, & Blewitt, 2010).

Kohlberg expanded on Piaget’s theory and assessed moral development beyond childhood into adulthood. Kohlberg based much of his work off philosophical concepts of morality referenced in Plato’s The Republic (Jorgensen, 2006) which morality is centered on justice. Utilizing unconventional philosophical scenarios, Kohlberg established three levels of moral reasoning each broken into stages. The preconventional level corresponds with Piaget’s heteronomous stage and established that children follow rules to avoid punishment and judgment from a superior authority during stage one. During stage two, children follow rules to serve their own interest, however may include the interests of others (Broderick, & Blewitt, 2010).  The conventional level is reached during adolescence and young adulthood. In stage three, social relationships become moral motivators and shared interests trump personal interest. Stage four focuses on social and societal order. Morals and behaviors at this stage are motivated by contributions to society, responsibility, and laws (Broderick, & Blewitt, 2010).  The postconvetional levels focus on universal standards of justice, democratic principles, and individual rights. Stage five establishes a moral social contract and is reached around adulthood. Stage six takes a more theoretical approach and addresses abstract concepts of social justice (Broderick, & Blewitt, 2010).

Research supports both Piaget and Kohlberg and shows that children indeed pay attention to the consequences and punishments surrounding moral violations and older children pay more attention to the intent of the protagonist to establish moral basis (Broderick, & Blewitt, 2010).  However finding show that children have a greater capacity for focusing on intentions and moral reasoning then given credit in the theories of Piaget and Kohlberg. Studies also show that preschoolers are able to differentiate between an intentional lie and a mistake and judge the liar more harshly (Broderick, & Blewitt, 2010).  Piaget believed that children believed all rules to be handed down from a superior authority. Children do however show a philosophical understanding of the difference between moral rules, conventional rules, and cultural rules. Children have the capacity to view cultural rules as arbitrary, but adhere more strictly to personal self-governed rules (Broderick, & Blewitt, 2010). Thus demonstrating that children have the understanding moral context.

Gilligan often criticized Kohlberg stating that his description of moral reasoning focused primarily on cerebral components of justice, ignoring the care and concern involved in moral reasoning (Jorgensen, 2006). Gilligan argued that morals developed on different trajectories for males and female. Women are more inclined to introduce sympathy, empathy and compassion into moral reasoning, whereas males utilize justice as an emphasis for moral reasoning (Broderick, & Blewitt, 2010).  This feminine viewpoint has earned Gilligan criticism question her bias in her approach to moral reasoning (Jorgensen, 2006).



Jorgensen, G. (2006). Kohlberg and Gilligan: duet or duel?. Journal Of Moral Education, 35(2), 179-196. doi:10.1080/03057240600681710

Broderick, P. C., & Blewitt, P. (2010). The life span: Human development for helping professionals (3rd ed.). Boston, MA: Allyn & Bacon. ISBN: 9780137152476