Appendix A: Agencies and Organizations That Can Help
(United States and Canada) 289
Appendix B: Suggestions for Further Reading 298
Index 307
ABOUT THE AUTHOR 313
{xi}
BEFORE WE BEGIN ...
* A recent study by the National Institute of Mental Health shows that
one American in five suffers from some type of psychiatric disorder:
50.5 million Americans have one or another of eight serious psychiatric
disorders, ranging from anxiety disorders and phobias to depression and
schizophrenia.
* Of these, only one person in five seeks professional help. More than
40,400,000 severely troubled people do not receive any treatment.
* An unknown number of healthy, emotionally untroubled Americans enter
therapy for reasons of self-development.
* More than 130 distinguishable therapies now exist.
* These therapies are offered by a variety of health care
professionals, including social work counselors, clinical and
counseling psychologists, psychiatrists, biofeedback therapists, and
others. Their backgrounds, training, fees, and durations of treatment
vary considerably.
* These professionals practice in a number of different settings: in
private practice, group sessions, public and private agencies,
hospitals, newly established nonhospital {xii} inpatient facilities,
and in the context of educational programs.
* Most people who enter therapy do not know what alternative approaches
to therapy exist or how to choose among them. They usually locate a
therapist in a more or less random way.
* Most people fear the idea of entering counseling or psychotherapy.
They do not have a clear conception of what to expect: they do not know
in advance what the _experience_ of therapy is like.
* For a variety of reasons, many people who think of going to a
therapist are concerned about whether their relationship with the
therapist will really be confidential. If you are especially concerned
about privacy, you should be aware of several ways that confidentiality
may be broken, what the laws concerning confidentiality are, and, in
particular (what few people realize), how insurance claims for
psychological care can invade an individual's privacy.
* Counselors and therapists tend to specialize in one or a small number
of alternative approaches to therapy. Some approaches to therapy are
most appropriate for treating certain problems or responding to certain
personal interests; others are better suited to providing help with
other problems and concerns. Choosing a therapist with an orientation
that is right for _you_ can be extremely helpful and can help you save
much time, money, and energy.
These facts highlight the situation in counseling and psychotherapy
that anyone faces who enters therapy today.
From them, you can see that there is a bewildering array of counseling
professions, of distinct approaches to therapy, and of settings in
which help is offered. This guide's intention and hope is to help you
understand the alternatives, and to help you form your own judgment how
it may be best to proceed.
The book hopes to give you real assistance so you may make a good
choice--thereby saving you emotional investment, time, money, and the
potential discouragement of avoidable false starts with therapies that
may not help because they are not relevant to your goals, values, and
personality.
{xiii}
Be patient. Take the time to think about yourself, your life, and your
hopes for a better life. This book was written for you, to help you to
improve your life, your self-esteem, and your relationships with
others. They are worthy goals.
Nothing in this world can mean as much.
May you have the energy, courage, and perseverance to achieve them!
{xv}
ACKNOWLEDGMENTS
I would like to express my gratitude to Dr. William Altus, then
Professor of Psychology at the University of California, Santa Barbara,
who went out of his way to encourage my first interests in
psychotherapy when I was a graduate student there twenty years ago. To
Professor Paul Ricoeur, I would like to express my admiration for his
original contributions to Freud scholarship and my enduring gratitude
for his willingness to direct my doctoral research at the Université de
Paris.
I am indebted to Dr. Raphael Becvar, Professor, Marriage and Family
Therapy, Saint Louis University, both for making it possible for a
faculty colleague to learn from him in several of his excellent
seminars and for his later comradeship. To my good friend, Dr. Thomas
Maloney, clinical psychologist in Clayton, Missouri, I want to extend
my warmest appreciation for his personal guidance and voluntary
supervision of my first efforts in counseling. If ever the qualities
of compassion, depth of understanding, humor, and genuine care are to
be found in one person, they are in him. I would also like to thank
Professor Lillian Weger, George Warren Brown School of Social Work,
Washington University, St. Louis, for generously welcoming me into her
fine seminar in psychodynamic models.
{xvi}
I especially thank Dr. Renate Tesch and Professor Hallock Hoffman, of
the Psychology Faculty of the Fielding Institute in Santa Barbara, for
making possible a writer's retreat in the California desert: the loan
of their home in Sky Valley made writing the last group of chapters a
special and memorable pleasure. One is fortunate to have such friends.
If this book became more readable after its first draft, it was due in
great part to the conscientious energy of my wife, Karen, in spotting
the weeds of obfuscation that seem to grow effortlessly in an
academic's garden. I want to thank her for her patience, with both me
and the book.
I would also like to take this opportunity to thank Miss Libby
McGreevy, Assistant Editor, Contemporary Books, Inc., for her helpful
suggestions and for her regular doses of encouragement that made
writing this book a happy experience.
{1}
_When You
Don't Know
Where
To Turn_
THE PURPOSE OF THIS BOOK
I would like to introduce this book by telling you what happened to a
real and likable person who ran into some very difficult times and as a
result entered therapy.
Frank is a large man, a former college football player, powerfully
built. He has always prided himself on his strength and determination.
He used to be friendly and outgoing. He had a pleasant smile,
complemented by his clear blue eyes.
Frank had worked for eleven years for a manufacturer of tools. Not
long ago, he was promoted to the position of managing the company's
sales division in a large midwestern city. Soon after Frank and his
wife moved, his wife became pregnant with their third child. Frank had
a well-paying job, excellent benefits, a pleasant home they had just
bought, and a contented relationship with his wife. But in spite of
these things, he became severely depressed. And he began to feel
terribly frightened: he had to leave his desk several times each
morning and again in the afternoon. He would go to the men's room,
lock the door, turn on the water faucets, and cry.
Frank lost fifteen pounds in three months. He had a poor appetite,
slept badly, and was very anxious around his {2} co-workers. He
couldn't understand what had happened to him, and he was unwilling to
let others know how unhappy he felt. He was ashamed of what he took to
be a weakness in himself: like many men, he was raised to believe that
men shouldn't cry, and his crying bouts shook his sense of identity and
stability. His marriage began to suffer. Frank and his wife seldom
made love. Frank was irritable and impatient with his wife and his
children. Frank's wife knew he was very troubled, but he refused to
talk to her about it.
For several months, Frank fought against his depression. (If only he
had been aware of the _strength_ that he mustered to do this!) Then he
reached a crisis and could not force himself to go to work. He stayed
home with a bad cold, slept as much as he could, and was very
short-tempered. He was crying a good deal. Frank's wife persuaded him
to see a doctor. The doctor referred him to a psychiatrist. The
psychiatrist saw Frank twice a week for two-and-a-half months, but
Frank was troubled by side effects from the antidepressant medication
he took under the psychiatrist's supervision. He resisted the idea of
"taking drugs," so he decided to see a psychotherapist who, in
cooperation with the psychiatrist, monitored Frank's condition as he
gradually went off the antidepressants.
However, after five months, Frank did not feel he was making any real
progress. He changed to another therapist who, his wife had heard,
specialized in the treatment of depression.
Together, Frank and his new therapist came, over a period of months, to
recognize that Frank's depression had resulted from two conflicts:
Frank had hated his job but had refused to admit this to himself, and
now his wife was pregnant again, and because of this added financial
responsibility he felt forced to stay with his present job, where he
had seniority, good salary, and benefits.
Once the basis for his depression was made clear, it was possible to
begin to treat Frank's problem. His wife was very willing to encourage
him to plan for a change of jobs, even though this would mean a
temporary reduction in his income. Frank saw a vocational therapist
and received guidance that led him to take some evening classes and
then to become a computer programmer for a rapidly growing local
company. His {3} depression faded away, and he now seems genuinely to
be content.
WHAT YOU CAN EXPECT FROM THIS BOOK
I knew Frank personally, as his therapist in a group. (His name, like
all others in this book, has been changed, along with certain details
about his situation.) With professional help, Frank was able to
improve his life--his sense of self-esteem, his marriage, and his
family life. It was a long and painful process, as much self-change
can be. But perhaps Frank's experience might have been _less_ painful,
perhaps Frank might have felt less devastating isolation, and perhaps
his path to a resolution of his difficulties could have been shortened
if a practical guide to counseling and therapy had been available to
him when he first decided to find help.
MAKING INTELLIGENT CHOICES
This book is about how you can get the most appropriate kind of help
for your problems, goals, and personality. Specifically, _When You
Don't Know Where to Turn_ sets out to help you become adequately
informed about the range of therapists and therapies--_as these relate
to your own assessment of your goals and interests_--so that you will
be able to make intelligent decisions about these issues:
* the _kind of professional_ to seek out
* the _type of therapy_ most likely to help you with a certain
complaint or set of interests and values
* how to locate the form of therapy that seems most promising to you at
_a price you can afford_ and with _an expected duration_ you can live
with
* what _setting_ to look for in which the help you would like is offered
This book uses two approaches, both presented here for the first time
and both based on common sense and intelligent advance planning.
{4}
First, you will be able, through a series of carefully organized
questions and easily followed instructions in Part I, to pinpoint one
or more approaches to therapy that may be most promising given your
initial objectives, problems, or interests. For the first time, a
_self-diagnosing map_ to the major approaches to therapy is made
available.
Second, you will have the opportunity to glimpse what typically happens
during the sessions of counselors, psychologists, and psychiatrists as
they treat clients or patients using the different main approaches to
therapy. You will come to see what the _experience_ of therapy is like
in these different approaches.
In other words, the self-diagnosing map will point you in the direction
of one, and sometimes more than one, approach to therapy that may be
most promising for you to begin the process of self-change, and you
will then be able to gain an insider's perspective on that approach so
that you can judge how well suited to you the approach is and how it
compares to the other main approaches to therapy.
If this guide helps you choose a path to the kind of therapy that will
be appropriate and useful to you, it will have done something
worthwhile. A guide to counseling and psychotherapy should, however, do
more than this.
OVERCOMING ISOLATION AND GETTING STARTED
People who are troubled tend to try to hide it. They frequently isolate
themselves when they are distressed, so overcoming the desire to
withdraw is the first order of business if they are to improve their
lives and feelings.
One of the things this book sets out to do is to help you see that very
likely the problems you are facing are not one of a kind. You have a
lot of company; the difficulties you are having are probably very
familiar to counselors and therapists. Realize that there are ways of
resolving most problems and that doing so often is easier with the
sympathy, empathy, moral support, friendship, or direction of a
counselor or therapist than by yourself.
CAN YOU HELP YOURSELF?
However, sometimes it _is_ possible to help yourself a great deal {5}
through your own initiative. This book will describe ways that you can
be your own source of help and will pay particular attention to _when_
it may be appropriate and safe to rely upon inner resources.
CLEARING THE CONFUSING JUNGLE
Most people are not familiar with the differences among the main kinds
of "psychosocial" helping professionals--the various types of
counselors, clinical psychologists, psychiatrists, psychotherapists,
psychoanalysts, social workers, etc. Another purpose of this book is
to clarify these labels, to describe how the approaches used by their
practitioners are distinct and how they are similar, and to give an
idea of how their fees and durations of treatment vary.
Individual chapters in Part II are devoted to describing the main
varieties of therapy available today: psychoanalysis; psychotherapies;
behavior-changing therapies; marriage and family therapy; group
therapies; exercise, biofeedback, relaxation, hypnosis, and meditation;
and drug therapy. Each approach will be described in the context of
experiencing professional help _and_ in terms of how and when it may be
possible to apply the approach on your own. These chapters will help
you understand what in general to expect if you choose a particular
kind of treatment, how the course of treatment may go, and what point
of view is shared by professionals who use it.
FINDING SOMEONE TO HELP
Part III of this book will describe how you can go about locating good
professional care, whether from a family therapist, an analyst, a
social worker, a psychiatrist, a clinical psychologist, or another kind
of therapist. You will learn how you can find a reputable professional
with a particular specialization, and you will be encouraged to ask him
or her some useful questions before beginning treatment.
As we will see in detail later on, there are numerous settings in which
counselors and therapists work. Many are in private practice, but many
also work for a variety of agencies, both public and private, for
hospitals and newly established nonhospital residential facilities, and
even for educational institutions. We {6} will discuss each of these
settings in Part III so that you will have a clear idea both of the
alternatives that exist and of important factors to consider when
deciding among them.
SHOULD YOU BE HOSPITALIZED?
"Should I consent to hospitalization?" "What will I encounter if I
accept hospitalization?" "Is it necessary, is it desirable?" Another
chapter in Part III is devoted to answering these and related questions.
IS YOUR PRIVACY PROTECTED?
In many ways it will be, and in other ways it may not be.
Confidentiality as it relates to the treatment of emotional or
psychological difficulties is a thorny issue, one that worries many
people. In Part III, a chapter is devoted to a discussion of this
potentially important area of personal concern.
DOES THERAPY WORK?
You may, of course, feel a certain amount of skepticism about the real
utility and effectiveness of any one of the many therapies that now
exist. This is, in my judgment, a healthy skepticism. A chapter in
Part III will review what you may be able to expect, and perhaps should
not expect, in the light of recent evaluations of the effectiveness of
the main therapies. To complement these as yet incomplete scientific
findings, I will emphasize a measure of ordinary common sense as we go
along.
LIFE AFTER THERAPY
The last chapter in this book deals with what to expect _after_
therapy. Recurrences, future crises--they often come with the package:
life! Relapses--re-experiencing feelings of distress--have received
too little attention. Often, old habits and feelings remain with us
and reappear during times of stress. Too, we know that as life goes
on, we need to be able to tackle new problems and new situations and
sometimes must handle unexpected crises. Chapter 21 tells you how the
experience of therapy will help you cope with possible setbacks and the
uncertainties of the future.
{7}
PARTI
GETTING STARTED
{9}
1
PRISONS WE MAKE FOR OURSELVES
Which of us is not forever a stranger and alone?
Thomas Wolfe, _Look Homeward, Angel_
What other dungeon is so dark as one's own heart! What jailer so
inexorable as one's self!
Nathaniel Hawthorne, _The House of the Seven Gables_
When you have shut your doors, and darkened your room, remember
never to say you are alone, for you are not alone, but God is
within, and your genius is within.
Epictetus, _Discourses_
When people are in pain and most need others, many wall themselves in.
This very human tendency is illustrated by a famous story.
In 1934, Admiral Richard Byrd led an expedition to Antarctica, where he
established a base on the edge of the Ross Ice Barrier, 700 miles north
of the South Pole. Byrd then decided to set up a small weather
observation post closer to the pole, which he chose to man alone. He
would stay in a one-room cabin, a box {10} that measured nine feet by
thirteen feet, lowered into a rectangular hole cut into the ice to
protect the cabin from gale-force winds during the coming winter months.
Byrd was committing himself to a degree of personal isolation few men
have ever taken on. What happened to him in the months ahead reveals
something important to psychologists that all of us should bear in mind.
Byrd's men left him in his tiny station and returned across the ice to
the main base 123 miles to the north. Winter blizzard conditions soon
surrounded Byrd. He knew he was in for a long period of solitary
confinement, with no hope of returning to the base, even if a medical
emergency demanded this. He could never make the return trip to the
base on his own, and it would be too dangerous for a team of men to try
to get to him in the winter darkness across the miles of ice.
After several months of isolation, Byrd became very ill. He was
distressed and confused about his condition--nausea, vomiting, terrible
headaches, blurred vision, great weakness. Days would go by, and he
would cling to life by a thread, his mind wandering, drifting in and
out of the dizzying incoherence of frequent comas. He would, by sheer
force of will, gather his reserve of fading energy and stagger across
the tiny room to light the stove and open a can of food, which he soon
lost from his stomach. Gradually, he came to realize that the fumes
from his kerosene stove and from the gasoline-powered generator for the
telegraph were poisoning him. But if he turned off the stove, he would
freeze to death, and the telegraph was his only contact with others.
He knew his life was in real danger, yet he refused to let his men know
of his desperate situation. Nor could he _admit_ to _himself_ that he
was in trouble.
Listen to his own words, written half a century ago, in his snow-buried
room with the air heavy with fumes and the inside walls encrusted with
glistening ice:
It is painful for me to dwell on the details of my collapse....
The subject is one that does not easily bear discussion, if only
because a man's hurt, like his love, is most seemly when concealed.
From my youth I have believed that sickness was somehow
humiliating, something to be kept hidden....
To some men sickness brings a desire to be left alone; animal-like,
their instinct is to crawl into a hole and lick the hurt.
{11}
There were aspects of this situation which I would rather not
mention at all, since they involve that queer business called
self-respect....
For a reason I can't wholly explain, except in terms of pride, I
concealed from [my] men, as best I could, the true extent of my
weakness. I never mentioned and, therefore, never acknowledged
it.... I wanted no one to be able to look over the wall....[1]
[1] Richard E. Byrd, _Alone_ (New York: G. P. Putnam's Sons, 1938), pp.
166, viii, 294-295.
In spite of his efforts to keep his condition to himself, Byrd's radio
operator at the main base seems to have intuited that Byrd was in
danger. A rescue party was sent as the winter weather became less
harsh, and Byrd was brought back to the base, probably just in time,
before the fumes killed or permanently injured him.
In many ways, Byrd's Antarctic experience parallels that of many of us
who, because of our own pain and hardship, isolate ourselves from
others. Our lives become cold, desolate, despairing. Our suffering is
real, but for one reason or another we cannot or will not reach out to
others.
WALLING YOURSELF OFF FROM OTHERS
Most of us are aware of a need for human company and companionship.
But when we are in pain or are severely troubled, we often forget what
has been recognized for a long time:
Frederick II, the thirteenth-century ruler of Sicily, believed that all
children were born with a knowledge of an ancient language. When they
were taught the language of their parents, however, he theorized, their
knowledge of the older language was overridden and blotted out. King
Frederick hypothesized that if children were raised without being
taught a language, they would, in time, spontaneously begin to speak in
some ancient tongue.
He therefore appointed a group of foster mothers, had new-born infants
taken from their natural mothers, and ordered the foster mothers to
raise the children in silence.
The upshot of this early experiment--as the legend goes--was {12} that
Frederick never found out whether his theory was true. All of the
babies died. They could not live without affection, touching, and
loving words. Apparently, the foster mothers withdrew all human warmth
when they sought to obey the king's order.
Today, we are aware of a baby's vital need for affection, for human
contact--and even so, in our adult lives, when human contact is equally
essential, we sometimes cut ourselves off from others.
THE MYTH OF SELF-SUFFICIENCY
As adults, we tend to emphasize self-control. We think of ourselves as
_responsible_--to ourselves, our parents, our employers, our children.
All this responsibility can sometimes be a heavy load! During periods
of illness or emotional crisis, the emphasis on _control_ can be
excessive. It can create the bars of a prison, a grillwork of defenses
that stands between us and others who are able to offer encouragement,
warmth, understanding, and direction.
There is no lonelier person than someone who has decided to take his or
her own life. The decision is the ultimate form of self-isolation. It
is the ultimate admission that one's imprisonment is final and that
there is no escape.
Fortunately, the decision to take one's life is reversible, if the
person is helped in time. The help may come from within or from
without, but it always involves the _recognition of hope_ that the
self-imprisonment may not be final, that there are others who would
help, that, even for someone who is terminally ill, there may be
periods of satisfaction and joy that make living worthwhile.
Western European, American, and Japanese societies are very
control-oriented. There is much evidence that when members of these
societies are emotionally troubled they often perceive a fault within
themselves. They see their troubles as springing from a loss of
self-control: "Just pull yourself together!" "It's just a matter of
self-discipline, of _will_!"
The greater our sense of responsibility--the more we emphasize personal
control over our inner and outer affairs, the more we see ourselves as
individualists whose individualism is based on strength of will,
discipline, guts--the more we are _trapped by the myth of
self-sufficiency_.
{13}
People who as children were forced to become independent too early, who
lacked a long enough period of closeness to their mothers, whose
parents were immature and self-absorbed frequently develop what is
called _pseudo-self-sufficiency_ or _premature ego development_. Such
a person is the neurotically extreme form of the "do-it-yourselfer."
He or she refuses to relinquish control, whether to the car mechanic,
the sewer cleaner, or a lover. There is an urgent and obsessive need
to maintain control, never to be "out of control."
For such people, anxiety, depression, and loneliness can be especially
devastating because they have walled themselves in to such an extent
that emotional growth and change are blocked.
Yet most of us share, to some extent, this belief in self-sufficiency.
It is one of the most tenacious forms of self-imprisonment that we have
available to us, literally at our own disposal. It is a prison we
often take great pride in. Pride, control, and self-sufficiency are
usually close friends. They keep us from having _real_ friends and
stand in the way of our being good friends to ourselves.
THE FEAR OF BEING LABELED EMOTIONALLY DISTURBED
It is woven into the fabric of our society that we should conform. A
young teenager from Australia now in a California high school tries as
quickly as possible to lose the accent that differentiates her, that
makes her the object of laughter. The same pressures motivate the
stutterer to keep quiet, speaking only when absolutely necessary. The
National Merit Scholar says "ain't" among his school friends to be one
of them.
Children are especially sensitive to covert expectations, the implicit
_shoulds_ that are handed down from the adult world and are frequently
refashioned to fit the stages children move through.
At each stage, the implicit maxims are _dress alike, talk alike, think
alike_. Be "in." Especially, have the same feelings, values, and
hopes. Most of us are raised to fear being different because we might
come to be a lonely minority of one.
But when we become ill, especially if we are emotionally troubled, the
rules change radically. Animals, from the aquarium angelfish to the
household dog or cat, seem to have an instinct to {14} seek isolation
when ill. This tendency probably has evolved because it contributes to
survival: the sick animal can more easily rally its energy for
self-healing in quiet, undisturbed by others of its kind. And going
off to be alone reduces the chance that the animal will spread any
disease it has.
Added to an animal's self-isolating tendency is the tendency to hide
the very _signs_ of illness or injury. An animal that shows signs of
injury or illness is immediately a target for predators who look for
the weaker members of the species.
We human beings also tend to choose solitude and to hide the revealing
symptoms of sickness or injury. Admiral Byrd admitted to these
defenses only in his loneliness. But it is important to realize that
hiding our feelings and isolating ourselves frequently are not in our
best interests.
Animals do not practice medicine, though many species are capable of
offering moral support and even a certain amount of physical
assistance, as in the case of a sick whale who may be supported by its
fellows in the water in order to breathe. But only we have developed
medicine, and we have more recently begun to develop ways to treat
problems that affect our emotions, attitudes, and behavior. When
individuals, perhaps instinctively, distance themselves from others and
bottle up their malaise, they turn their backs on the educated
assistance and goodwill that are available.
Sometimes we do so out of fear of treatment coupled with fear of
admitting that we are not as self-sufficient as we want to believe.
But more often in the case of problems that directly affect our
moods--i.e., "psychological problems"--we feel ashamed and afraid of
the stigma, the disgrace, that our society attaches to those who admit
they have unhappy or confused feelings.
There can be little doubt that society is unbalanced in legitimating
physical sickness while reacting with alarm and repugnance to problems
of a psychological nature. Think of the discrimination _against_
psychological disorders, in favor of physical complaints, practiced
openly by nearly all health insurance companies, offering reduced
benefits for mental health. Psychological pain does not hurt any less
because it is emotionally based. Even so, emotional distress is held
suspect, and insurance coverage for it, if not ruled out completely, is
frequently only partial. It was, after all, not more than a century
ago that our mental hospitals were run with an inhumanity that {15}
still can send shivers down one's spine. Unhappily, it is clear that
we have not entirely left this phase of our development: the film _One
Flew over the Cuckoo's Nest_, for example, points to continuing
inhumanity in some psychiatric hospitals. And there is the alleged
case of a Ukrainian woman who was involuntarily committed and held for
some thirty years in a mental hospital. She was thought to be insane
because, unfortunately, no one involved in her case recognized her
"gibberish" as Ukrainian!
Emotional and mental problems are still not accepted by many. There is
a fear of the unknown and a skepticism that psychological problems are
nothing more than signs that a person is malingering, simply does not
want to try to get better. And there is a gut-level anxiety when
confronted by someone who, we worry, "may be close to going over the
edge."
TEARING DOWN PRISON WALLS
What undue hardship this causes! As wonderful as the body is, we
accept its imperfections, its susceptibility to disease and injury.
But our brains, our minds, our spiritual dimension--how less well we
understand these in their greater complexity! Is it so strange and
unacceptable that they should be prone to their own problems, that
they, too, may bring suffering?
Because society does not legitimate emotional pain, many people are not
able to see their own pain as legitimate. So they deny it, to
themselves and to others. But pain is usually a healthy signal; it
tells you that something is wrong: Withdraw your hand from the fire!
Move your cramping legs! Do something about your abusive, alcoholic
husband! Get help for your depression!
Every one of these pains is a warning. To ignore all except those that
are physical would be like saying that we are only bodies, without
feelings, without humanity.
When you are in pain, whatever its source and kind, pay attention to
it! Pain is often what points to a better life.
It is surely better to cope with a label applied in ignorance by some
members of society, if this must be, than to live an unsatisfying and
painful life. You must not manage your life just to avoid the
potentially critical judgment of people who are ignorant of, or who
refuse to acknowledge, the realities of human psychology. You can feel
sure that among well-informed people, if you have had to deal with
alcoholism, drug abuse, a difficult {16} marriage, job depression, or
any other "psychological" problem, you will be thought to be just as
"respectable" as if you had coped with major surgery after an
automobile accident. In fact, since overcoming a psychological
difficulty demands a great deal more of your own voluntary effort,
coming up a winner will increase your own self-respect and the respect,
and even admiration, of those whose judgment is meaningful.
The first step to freedom from pain is to become aware of the walls of
the prison that shut you in. Only then can you begin to tear them down.
{17}
2
PATHS TO HELP
To wrench anything out of its accustomed course takes energy,
effort and pain. It does great violence to the existing pattern.
Many people want change, both in the external world and in their
own internal world, but they are unwilling to undergo the severe
pain that must precede it.
Rivers in extremely cold climates freeze over in winter. In the
spring, when they thaw, the sound of ice cracking is an incredibly
violent sound. The more extensive and severe the freeze, the more
thunderous the thaw. Yet, at the end of the cracking, breaking,
violent period, the river is open, life-giving, life-carrying. No
one says, "Let's not suffer the thaw; let's keep the freeze;
everything is quiet now."
Mary E. Mebane, _Mary, Wayfarer_
If you decide to enter therapy, your therapist will probably ask you to
think about two interrelated questions (they may be expressed in a
variety of ways): "Where are you now?" and "Where do you want to go?"
Your therapist or counselor will, as he comes to know you, often be
able to help you to answer these by sharing his perceptions of you.
One of the main tasks of the counseling process is to help a person
gain improved self-understanding that embraces both present problems
and future goals.
{18}
Yet if you can gain a certain measure of self-understanding and
self-direction _before_ entering counseling or therapy, it will be
easier for you to choose an approach to counseling or therapy that more
closely fits your problems, values, objectives, available time, and
even your financial needs. You should find in this book a basis for
preliminary _self_-counseling that will give you a sense of how and
where best to begin therapy.
It is important to recognize that none of us ever reaches a final state
of self-knowledge: as long as we live, our self-understanding is
capable of growing. What we really understand about ourselves and what
we believe ourselves to need and want are never more than provisional,
tentative. Additional experience, just the fact of living longer, very
likely will lead you to perceive yourself differently and motivate you
to modify your priorities and change your goals.
WHERE ARE YOU NOW?
Late in 1984, the National Institute of Mental Health released the
first published results of the largest mental health survey ever
conducted. The results are startling and are an unhappy commentary on
our society and world.
The report shows that 20 percent of Americans suffer from psychiatric
disorders. Yet only one in five of these seeks help. The others live
with their suffering.
The most common problems are these:
_Millions of Americans_
_Psychiatric Name of Condition_ _with This Disorder_
Anxiety disorders 13.1
Phobias 11.1
Substance abuse (alcohol, drugs, etc.) 10.0
Affective disorders (including
depression and manic depression) 9.4
Obsessive-compulsive disorders 2.4
Cognitive impairment 1.6
Schizophrenia 1.5
Antisocial personality 1.4
The NIMH study also shows that women are twice as likely to seek help
as men. Two interrelated inferences are commonly made from this
previously known fact: women are often more accepting of their
emotional state (men in our society are taught to disregard their
feelings, part of _machismo_), and women are less willing to allow
pride to stand in their way of getting help (women are less affected by
the myth of self-sufficiency).
{19}
The NIMH report indicates, too, that the incidence of psychological
problems drops by approximately half after the age of forty-five. The
below-forty-five years are usually those of highest stress. Above
forty-five, individuals tend to become psychologically better
integrated. This probably reflects increased maturity and a more
accepting, calmer attitude toward life. The lowest rate of emotional
disturbance appears to be in people over sixty-five. Yet there are
many thousands of individuals over forty-five, and indeed over
sixty-five, for whom life remains a difficult inner struggle.
The statistics from the NIMH study reveal how very wide-spread personal
psychological difficulties are. Given the degree of complexity of our
mental, emotional, and spiritual makeup, this should be understandable,
especially when we take into account twentieth-century stresses that
wear us down. Caught up as most of us are in our jobs, families, and
daily worries, we are unaware that, in a very real sense, mental and
emotional health problems have assumed epidemic proportions. If you
bear in mind how fearful our society encourages us to be of admitting
such difficulties, you can perhaps imagine how substantial the
"iceberg" of psychological suffering is: most of it lies below the
waterline of public consciousness.
The NIMH study results should encourage you, if you suffer from
personal emotional difficulties, to realize that you are not alone in
the problems you face. Knowing that there are many good and fine
individuals with very likely similar problems may urge you to take an
honest look at where you are now and then to try to decide what changes
may be helpful to you: where you want to go from here.
If you are fortunate, you may already be aware of the main things in
you and in your life that bring you distress. If so, you are one step
closer to being able to do something about them. Many of us, however,
have become so clever and effective in denying what we really feel that
we have lost touch with our true selves. {20} Desires to repair an
unhappy marriage are shelved while the children are growing up; the
unrewarding nature of a job is ignored because priority is given to
financial security; you may be unable or unwilling to face the pain you
bring to yourself and others as a result of a drug- or alcohol-abuse
habit.
In most cases, it is not possible to gain the motivation and means to
solve a problem until you are willing to accept that there is a problem
that needs to be solved.
Because of the blinding nature of the habits you may have established,
and because of your defensive desires to disregard what disturbs the
equilibrium of habit, it may be hard to acquire a clear picture of
where you stand right now. Sometimes it can be useful to check with
others: how do they see you?
A close friend of mine, after years in her profession, began rather
suddenly to feel how unrewarding her job was, and she began to suspect
that she may have hidden these feelings for a long time. She had
maintained a regular, almost once-a-week exchange of letters with her
mother for twelve years. She knew that her mother kept her letters, so
she went to visit her and asked if she might skim through them, paying
attention to comments she had made over the years about her work. It
quickly became clear to her that, consistently, she had had only very
negative things to say about her job. After skimming through dozens of
letters written over a period of years, she became convinced of her
real and enduring feelings and changed her line of work.
Such self-knowledge does not usually come this easily. We may pride
ourselves on honesty, but there are few of us who permit ourselves
self-honesty to any real degree. Existential-humanistic psychologists
have paid much attention to these ways that we live "in bad
faith"--each of us trying to be a person he or she really is not and
denying the person he or she really is.
We live in a society that emphasizes conformity, "being somebody,"
gaining status and wealth and a good position--yet these values may not
coincide with being true to ourselves. Parental influences can be
strong, as can expectations from our spouses. We internalize many of
these values so that it becomes difficult to see who we really are and
what we really want from life and from our efforts.
There are no easy routes to self-realization. We must all do a certain
amount of hunting in the dark--or, as a colleague of mine {21} likes to
say, "scrabbling about"--for a sense of real identity.
Recognizing that your self-understanding is probably always imperfect
does not mean that it is of little value. It is, in the end, all any
of us has to go on.
It may be useful to ask people close to you what they perceive about
you. Reading through a group of old letters, keeping a journal, or
simply setting aside a few minutes for self-appraisal at the end of
each day or week may also be enlightening. If you do this
self-examination, gradually where you are and what you feel will become
clearer, and then it will be natural and appropriate to ask what the
next step is.
WHERE DO YOU WANT TO GO? WHAT KIND OF
PERSON DO YOU WANT TO BECOME?
Influences from society, your parents, your spouse, or your close
friends make it difficult for you to know yourself. Defensive habits
and fear of change also stand in the way. These are significant blocks
to self-understanding.
When you turn your attention to the future, to what kind of person you
want to become, you will encounter more blocks to overcome. Life is
like that! It seems that few things come without effort and
perseverance.
There are two major obstacles to designing the model of the person you
would like to become. Because they can be so important, I want to
introduce them early in this book. They are blame and guilt, and they
are like the two ends of a seesaw.
When we appraise what we have done in our lives, we usually find
reasons to blame others, or perhaps to blame limited educational
opportunities, or social pressures, or discrimination--in short, our
past environment: all the factors that limited our lives, interfered
with the attainment of our hopes, and were not under our control.
On the other end of the seesaw sits guilt. And guilt is really blame
turned inward.
If we try to pinpoint the factors that have been responsible for our
lives not having turned out better, we tend to blame environmental
limitations, or else we feel guilt for what we see as our own failings.
Usually, we locate responsibility in both areas.
Most of us, however, have unbalanced seesaws. We usually {22} blame
things _outside ourselves_ for our disappointments. Doing so is a
habit that allows us to avoid responsibility for ourselves and, in
turn, limits our future development.
On the other hand, some of us blame ourselves much too readily: we
carry an exaggerated burden of responsibility, which weighs us down and
also limits our growth as individuals.
Ideally, psychotherapy would like us to let go of so-called "past
negative conditioning"--blame as well as guilt--so that we are free to
choose who we are and will become. Even though this is certainly a
desirable attitude, most of us cannot really forget and let go. We are
all inheritors of a tenacious past: the influences of past events have
a certain power over us, and we must either resign ourselves to being
controlled by the past or fight its influence. The _attitude_ we take
toward the past will usually affect how we meet the future, often
diminishing our freedom to change old habits and undermining our hope
and faith in ourselves.
For example, if Jeff blames his limitations today on his parents, on
the ways they influenced him, he may set goals for himself that are far
from being freely chosen. Jeff may choose them _in reaction to_
domination by his parents years ago. His parents may have tried to
influence him to be a gentle, courteous person with artistic interests.
But as a result of other past influences--for example, because of
frequent moves of the family and repeatedly being bullied as the "new
kid" at different schools--Jeff may feel hostile toward others, so (in
reaction to his parents' influence and because of pent-up hostility) he
decides to go into science (rather than art, for which he perhaps has a
talent) and rejects gentle, courteous qualities in himself.
It is difficult to choose freely. Some psychologists do not believe it
actually is possible. And yet, whether we are ever truly free or not,
we still try to plan our lives, and we believe our plans (and
frequently the lack of them) have something to do with what we make of
living.
Most people who enter counseling or psychotherapy want to improve some
aspect of their living. Individuals whose seesaw is weighted on the
side of blaming outside influences too often come to feel it is too
much work and quit therapy because they cannot accept the need to make
choices and decisions _in spite of_ past influences. On the other
hand, people who blame {23} themselves may be so guilt-ridden that they
are impaired in their openness to the future and feel unable to
initiate fundamental changes in their lives.
When you ask yourself, "What kind of person do I want to become?," try
to be aware of the extent that your answer may be weighed down by
feelings of blame and guilt. All too often we continue to perpetuate,
unknowingly, the same old unsatisfying patterns because we are trapped
by our habits of blaming others or ourselves.
If you feel bogged down by feelings of guilt or burdened by the
limitations of an unfair past, it may be difficult for you to develop a
freely chosen sense of direction. But perhaps you will be able to
acknowledge that the guilt or blame you feel is an obstacle to be
overcome. If so, you have defined an objective that you may use to
decide what type of counseling or therapy may be a most promising first
step.
What I am suggesting is that an obstacle that makes it hard for you to
gain a sense of direction can _itself_ point you in a direction. If
there are blocks, it can be helpful to meet them head-on. In therapy,
the phrase _working through a problem_ often means exactly this.
Choosing what kind of person you wish to be is a _process_, not an
event. It is not something that happens and then is over. Choice is
something implicit in each day of your life; sometimes it is quite
conscious, but it is often dulled by the unconsciousness of habit.
Your personal goals may undergo gradual or abrupt change.
Psychological growth is your response to these changes in outlook.
WHAT DOES THERAPY TRY TO DO?
Individual therapy or counseling (therapy for groups and families will
be discussed in detail later) is really an attempt to build a bridge
between answers to these two now familiar questions: "Where are you
now, or what kind of person are you now?" and "Where do you want to go,
or what kind of person do you want to become?" Think of therapy as an
attempt to build a bridge so that you can pass from a present situation
to a desired way of being.
Carl Rogers defines therapy as "a relationship in which at least {24}
one of the parties has the intent of promoting the growth, development,
maturity, improved functioning, improved coping with life of the
other."[1]
[1] Carl Rogers, _On Becoming a Person: A Therapist's View of
Psychotherapy_ (New York: Houghton Mifflin, 1961), pp. 39-40.
Psychiatrist Allen Wheelis takes this definition further:
Therapy may offer insights into bewildering experience, help with
the making of connections, give comfort and encouragement, assist
in the always slippery decision of whether to hang on and try
harder or to look for a different way to try....
The place of insight is to illumine: to ascertain where one is, how
one got there, how now to proceed, and to what end. It is a
blueprint, as in building a house, and may be essential, but no one
achieves a house by blueprints alone, no matter how accurate or
detailed. A time comes when one must take up hammer and
nails....[2]
[2] Allen Wheelis, _How People Change_ (New York: Harper and Row,
1973), pp. 101, 107.
Therapy involves a three-fold relationship among a helping
professional, the approach to therapy used by him or her, and, what is
most important, the outlook of the individual client. In this book we
will examine each of these three dimensions of therapy in some detail,
but here we will concentrate on the one therapists generally agree is
the most important: you--the kind of person you are, what your
attitudes and outlook are, and, of course, how much you really want to
develop or change. Your attitudes will determine, probably more than
anything else, what variety of therapy you will most benefit from.
Therapists, like teachers (which they really are), find that their
clients or patients can be divided into two groups: active and passive
learners. When you go to a doctor with a broken arm, your relationship
to your doctor is a _passive_ one: you need only to cooperate as he
examines your arm, perhaps administers an anesthetic, and sets the
break. You may take medication for pain, and then you simply _wait_
until, thanks to the body's automatic healing processes, the break is
fused. The public's conception of medicine is predominately a passive
one. To be a "patient" is for the most part to be a passive bystander:
the physician is the active agent who brings about healing. There are
occasional {25} exceptions--for example, physical therapy and
rehabilitation therapy after a serious injury or illness, when the
patient must become more active and accept more responsibility.
As we will see, a few approaches to counseling and psychotherapy
preserve, to some extent, the traditionally passive role of the
patient. Most of them, however, require a good deal of initiative and
just plain hard work on the part of the patient or client.
In building the house of one's life or in its remodeling, one may
delegate nothing; for the task can be done, if at all, only in the
workshop of one's own mind and heart, in the most intimate rooms of
thinking and feeling where none but one's self has freedom of
movement or competence or authority. The responsibility lies with
him who suffers, originates with him, remains with him to the end.
It will be no less his if he enlists the aid of a therapist; we are
no more the product of our therapist than of our genes; we create
ourselves. The sequence is suffering, insight, will, action,
change. The one who suffers, who wants to change, must bear
responsibility all the way. "Must" because so soon as
responsibility is ascribed [outside oneself] the forces resisting
change occupy the whole of one's being, and the process of change
comes to a halt. A psychiatrist may help, perhaps crucially, but
his best help will be of no avail if he is required to provide a
degree of insight which will of itself achieve change.[3]
[3] Wheelis, _How People Change_, pp. 101-102.
WHY IS IT SO COMPLICATED?
For better or for worse, human nature is a many-splendored thing. It
doesn't take an advanced degree in psychotherapy to know that people
can have many different kinds of personal problems. This fact, if we
appreciate it fully, makes more understandable why there are so many
alternative approaches to helping people with their difficulties.
In the world of theory, a _model_ is a simplified representation of
reality. Your checking account record is a model, in just this sense,
of how many real dollars and cents you have in the bank.
Here is a much simplified model that represents five main
psychological, emotion-laden dimensions of a person:
{26}
[Illustration: Five main psychological dimensions of a person:
feelings, hopes, abilities, relationships with others, and behavior]
We see right away that, for the same reasons that there are specialties
in medicine--e.g., orthopedy for bones, neurology for nerves, dentistry
for teeth--there should be special approaches that focus on different
psychological dimensions of the person.
Something else you may see is that the five dimensions in the model are
not isolated from one another. They interrelate and overlap a good
deal. Just as a dentist must know about the orthopedy of the jaw and
skull and the neurology of the teeth a neurologist and an orthopedist
are expected to know something, though not in great detail, about
dentition. Each of us is a unity of what all the medical and
psychological specialties study in different ways, plus a good deal
more, as artists, writers, theologians, and musicians make evident.
That more than 130 distinguishable therapies have now been developed
may perhaps strike us, even so, as excessive. But efforts are being
made to unify many of these approaches, and this book is one of them.
Rather than talking about 130 different approaches, we will center our
attention on the main categories into which the many approaches can be
sorted.
One of the interesting and hopeful things that can be said {27} about
the multiplicity of approaches to therapy and counseling is that
treatment by any one of them can often be of some help. For example,
Helen may wish to stop drinking (a habit in the behavior category), and
she may be helped by means of behavior modification. She may then find
that, as a direct result, her self-concept (feeling category) has grown
stronger, while her marriage (relationship category) has also improved.
Or, Ralph may go to a vocational counselor who helps him define a
direction (hope category) in keeping with his interests and aptitudes.
Ralph goes back to school and develops a background (abilities
category) that reflects these aptitudes and interests. The sense of
direction he has gained helps Ralph stop using drugs (behavior),
reduces his hostility and anxiety (feelings), and improves his
relationships with others. In other words, a helpful change in one
direction can often lead to noticeable changes in others.
However, there also are risks that we should not ignore: Sue goes to an
analyst and learns over a period of months that her marriage to Fred
was based on a sense of inadequacy Sue learned during her childhood.
Her father was so highly controlling and critical of her that she was
never able to develop a sense of her own value. Her husband, Fred, is
also domineering and authoritarian, and he abuses Sue frequently,
usually mistreating her through criticism, but he has sometimes also
beaten her physically. Sue has accepted this without question for a
long time, but due to the emotional support received from her analyst,
she is beginning to develop a sense of self-esteem. As her self-esteem
grows, she comes to realize that her marriage is a self-destructive
relationship and decides to divorce Fred. Her therapy has been helpful
to Sue, but it has, indirectly, resulted in a breakdown of her
admittedly unhappy marriage. A change in one dimension can sometimes
lead to an initially unintended change in another area.
IF IT HURTS, DON'T PROCRASTINATE!
One of the marvelous things about human nature is the ability to feel
pain. This may seem like an odd thing to say, but reflect for a
moment. Pain is frequently what spurs us on from an unsatisfying and
even destructive situation to a better future. Pain tells you to jerk
your hand away from a hot stove. A different kind of pain tells you it
is time to get on with living, time to {28} initiate some positive
changes. Anxiety, sleeplessness, irritability, resentment,
depression--they all can be painful inner feelings that tell us that
all is not well in our inner selves.
It is well-known to counselors and therapists that, in general, the
longer these signs of need are ignored, the longer it may take to help
a person resolve the difficulties that have been pressing for
attention. Distress is not easily buried. When suppressed, it tends
to pop up again later, sometimes with increased severity.
We can, ironically, choose to be "strong" and ignore these messages
from within, or we can listen to our feelings, pay attention to our
hopes, develop needed abilities, seek to improve our relationships with
others, and work to change some ways we behave that block our happiness.
Problems that concern your inner well-being and the health of your
relationships with others who are important to you are better resolved
than buried, and the earlier they are given the attention they deserve,
the easier your path through change to a better life will be.
{29}
3
BRIDGES FROM HERE TO THERE
AN OVERVIEW OF THE FIELD OF THERAPY
THE HELPING PROFESSIONAL
Professionals in the fields of counseling and psychotherapy have a wide
range of different backgrounds and perspectives. They can be broken
down into these categories:
_Social work counselors_: counselors for individuals; marriage and
family counselors; group counselors; and vocational guidance counselors
_Psychologists_: clinical psychologists; counseling psychologists; and
psychometrists
_Psychiatrists_
_Other therapists_: religious counselors; biofeedback therapists;
hypnotherapists; relaxation and meditation instructors; holistic
therapists such as bioenergetics therapists, yoga instructors, and
exercise therapists; etc.
The education, supervised training, and outlooks of these professionals
vary greatly, as do their fees and the average length of time therapy
can be expected to last. We will look more closely at these
differences later on.
{30}
THE RANGE OF APPROACHES TO THERAPY
Because of their differences in training and personal or theoretical
preferences, the distinct classes of therapists represent a diversity
of approaches to therapy. There are numerous schools of
psychoanalysis, psychotherapy, behavioral therapy, group therapy, and
marriage and family therapy, and a range of approaches to personal
adjustment, including exercise therapies, relaxation techniques, forms
of meditation, and drug and nutrition therapies.
From any one of these, a multitude of schools of thought branches out.
For example, psychoanalysis has, since Freud, developed along a number
of different lines: each major psychoanalyst has formulated his or her
own approach to analysis that distinguishes itself from Freud's.
Psychotherapy, to take another example, is not a single approach to
therapy, but rather makes up an entire field. It is the largest and
most rapidly growing area relating to mental health. In it are
included distinct approaches, such as client-centered therapy, Gestalt
therapy, transactional analysis, rational-emotive therapy,
existential-humanistic therapy, reality therapy, logotherapy, Adlerian
therapy, emotional flooding therapies, and direct decision therapy.
In later chapters, we will look at these approaches to psychotherapy
more closely. The goal throughout this book will be to enable you to
understand enough about each of the major therapies to make an informed
decision in choosing an approach (and there may be more than one) that
will be most useful in relation to your own understanding of your
objectives, whether they are long-range or focused on the need to
eliminate immediate obstacles to growth.
THE DIFFERENCE BETWEEN COUNSELING AND PSYCHOTHERAPY
Counseling and psychotherapy have developed a great deal in recent
years--so much so that their boundaries have often overlapped.
Clear-cut distinctions between the two fields are increasingly hard to
draw. Nevertheless, some professionals prefer to call themselves by
one name and some by the other.
In general terms, _counseling_ tends to be a short-term process the
purpose of which is to help the client, couple, or family {31} overcome
specific problems and eliminate blocks to growth. Counseling gives
individuals a chance to resolve personal problems and concerns. Most
counselors attempt to help their clients become aware of a widened
range of possibilities of choice; from this perspective, counseling
tries to free clients from rigid patterns of habit.
Habits can be useful, but they can also interfere with life. The
technical habits of a pianist, for example, are essential in
performance. Similarly, only when language skills become habitual does
a speaker of a foreign language achieve command of it. On the other
hand, fears can also become habitual, and they may come to interfere
with everyday activities. Anxiety over public speaking may become
habitual. There are many personally destructive habits--alcoholism,
smoking, over- or under-eating, abusive behavior, shyness and social
withdrawal--and all can become self-perpetuating patterns. Counseling
can help people break out of these habits, often in part by helping
clients become aware of unrecognized alternatives.
_Psychotherapy_ tends to be more concerned than counseling with
fundamental personality-structure changes. Frequently, psychotherapy
is a longer-term process. Frequently, too, the problems treated in
psychotherapy are hard to pin down and are less specific. They include
chronic depression, pervasive ("free-floating") anxiety, generalized
lack of self-esteem, and so on. Such difficulties are not well
defined; their causes may be vague or uncertain, and often much time
must be spent to get at their basis. Psychotherapy seeks to bring
about an intensive self-awareness of the _inner dynamics_--the internal
forces and the principles that govern them--that are involved in
chronic forms of personal distress. Sometimes, as in analytical
psychotherapy or psychoanalysis, attention is focused on the role of
unconscious processes in inner conflicts; treatment attempts to resolve
these conflicts by understanding the unconscious forces involved.
The term _psychotherapy_ is often used to imply more advanced
professional training, whereas counseling is something individuals with
more modest academic credentials may practice. Whether a professional
is called a counselor or a therapist has to do with his or her level of
training, with the setting in which services are offered, and, to a
certain degree, with that person's theoretical orientation.
{32}
In practice, these differences in outlook frequently amount to
differences in _emphasis_ rather than approach. In this book, I will
speak of counseling and psychotherapy interchangeably unless there is a
need to be especially restrictive.
THERAPY: THE ART OF CHANGE
HOW WE ARE ABLE TO CHANGE
We are what we do ... and may do what we choose.
Allen Wheelis, _How People Change_
Freud identified five causes of personality development:
* growth and maturation
* frustration
* conflict
* inadequacy
* anxiety
By the time we become adults, most of us have developed sets of
defenses to enable us to cope with everyday problems _in spite of_
feelings of frustration, conflict, inadequacy, and anxiety. But as
these feelings become more pronounced, when we encounter situations
that intensify these feelings, we must put more and more energy into
our defenses. They allow us to continue living and acting in habitual
ways, usually by hiding, by denying, and sometimes by distorting our
perceptions of reality.
Facing the inadequacies of a marriage, the unrewarding nature of a job,
the extent of conflicts with a child, or difficulties relating to
friends can cause intense anxiety. So, to avoid this anxiety, we
frequently "defend against" these realizations: we try to uphold the
belief that our marriages are just fine, that things are OK between us
and our children, that our jobs are at least tolerable--that, in spite
of some problems "here and there," we can get along all right. We do,
in short, try to see our lives through rose-tinted glasses.
We continue to do this until our negative feelings become too strong,
until we have expended so much energy to maintain our defenses that we
are _emotionally exhausted_. If we reach such a state of real
depletion, and our defenses can no longer hold against the building
pressure of our feelings, the result is {33} _nervous breakdown_. This
is the layman's name for a variety of psychological conditions that
develop due to _a burned-out emotional fuse_.
A fuse is a protective device that prevents an overload of electricity.
Our defense mechanisms are analogous devices that protect us against
emotional overload. When an emotional fuse burns out, it is often
because we have maintained defenses too long in the face of increasing
inner frustration and pain. The result may involve severe depression,
incapacitating anxiety, or serious withdrawal.
Now, when you decide to change in some psychologically fundamental way,
you must push against the rigid framework of certain of these
protective defenses. When you do this, you will feel anxiety. You are
forcing your emotional fuses to adjust to a different pattern of
behavior and feelings.
Your sense of personal identity is made up of a network of ways you
have come to perceive yourself, your loved ones, your work, and your
world. Any attempt--even if it is your own, entered into through your
own choosing--to change patterns that are psychologically basic to your
sense of identity will threaten that established identity and produce a
measure of anxiety.
The longer these habitual patterns of behavior and feeling have been in
force, the more deeply rooted they become in your sense of identity,
and the more unsettling and anxiety-producing an attempt to change them
will be.
Although your defenses protect against emotional overload, they also
stand in your way of change. They are fundamentally _conservative_
mechanisms: established habits of thought, feeling, and behavior are
_familiar_, and familiarity reduces the anxiety brought about by
uncertainty. If you are considering making significant changes in your
life, your defenses will rally to protect the equilibrium of habits you
have formed in the past. If you push yourself to change, you will face
a predictable degree of anxiety. Fortunately, there are, as we shall
see, many ways of coping with the anxiety brought about by change;
therapy offers some of these, and some are available to us all if we
draw on inner resources.
As long as you are alive it is possible to change. Ultimately, the
decision to change is an expression of your choice and will. When
change _is_ achieved, it usually comes after long and arduous trying.
We are all aware of the heroic efforts some {34} people can and do make
to overcome a physical handicap. Overcoming deeply entrenched
emotional habits can require similar tenacity and commitment. If you
want to bring about some basic changes in yourself or in your
relationships with others, your inner strength and resolve will be
essential.
Frequently, individuals expect a therapist to accomplish change _for_
them: they are willing to come for an hour's consultation once or twice
a week, and they will be very cooperative during each visit, but they
seem unwilling or unable to develop the initiative to carry on efforts
begun in the therapist's office.
Some clients, in spite of what they say, do not really _want_ to
change. Their habits are deeply ingrained, serving purposes they may
be only dimly aware of at the beginning of therapy. Sometimes it
becomes necessary in therapy to reappraise the goals that have been
set. The decision to pursue a certain course of change may result in
so much anxiety and upset that both therapist and client must pause to
reconsider. Some changes may turn out to be too difficult, too taxing;
some clients may be unwilling to put in the work required to bring
about a certain change.
Most changes of the kind I am referring to--fundamental changes in
outlook, in daily thoughts and feelings, in behavior--can be made only
gradually. Since any move in the direction of change will threaten
your existing defenses, resistance and protest are likely to well up
from within you. New ways of _being_ will feel intimidating,
unpleasant, or just plain _unnatural_. And this is understandable, is
it not? You must confront and do battle against habits that may have
been with you for a long time. _The longer that undesirable patterns
have been in force, the more control they acquire over you, and the
more your defenses become committed to preserving them_. Change is
made steadily more difficult.
Always remember, however, that change can be brought about. You need
to be patient with yourself; it will not come overnight. Long-standing
habits take time to be replaced, You must have patience, and you must
feel hope and encouragement. If you are depressed now, if maintaining
your defenses has exhausted you, then it will be difficult to feel the
measure of hope that you need to begin the process of therapy.
This, perhaps more than anything else, is the most immediate and
perceptible benefit of therapy: a good therapist is a source {35} for
hope and encouragement when you cannot sustain these yourself.
Therapists are trained to help people who want to change, to bring it
about.
THE RESULTS OF THERAPY
In the past twenty to thirty years, there has been a gradual shift away
from a medical, illness-based orientation in therapy to one that
focuses on personal growth. By no means everyone enters therapy
because of emotional pain. Increasingly, therapists are seeing clients
who enjoy psychological and emotional good health but believe that
therapy can help them lead fuller, richer, more satisfying lives. As a
consequence, the objectives of many current approaches to therapy
involve more than only the resolution of personal difficulties and
crises.
There are many potential benefits of therapy. To varying degrees, all
the therapies we will discuss in this book claim to assist you in
achieving the following goals.
_Resilience and Tolerance to Stress_
As a consequence of therapy, you come to be less frustrated by stress,
able to recover from stressful experiences more quickly. You become
less defensive and more accepting of others and yourself, able to
adjust more easily to unexpected demands in living. You have a
decreased tendency to hold rigid expectations of the world, so you feel
less disappointment and frustration.
_Congruence_
You come to be more unified in the present moment, aware of your
feelings, and less disposed to ignore, deny, or distort your
perceptions out of defensive needs. Congruence means a close match
between what you feel and how you think and act. Congruent people are
well integrated, no longer in need of "masks." When we admire a
person's sense of "integrity," we often feel that the person not only
behaves in ways that show self-respect, but that he or she is
self-accepting, is genuine, and appears to be comparatively free of
inner conflict. Such individuals are, in short, able to be themselves.
People who no longer are engaged in a battle against themselves and
against others will tend to show congruence.
{36}
_Self-Esteem_
People with high self-esteem can allow themselves to feel modest and to
behave with modesty. High self-esteem does not imply pride or
arrogance. Self-esteem and self-acceptance (and hence congruence) are
interrelated. Individuals with strong self-esteem no longer need to
prove themselves. They value the kind of people they are and are not
inclined to be self-undermining through perfectionistic self-criticism.
_Openness and Love_
Ideally, if you undergo therapy, you become less defensive and less
uptight about yourself; you will therefore have less need for
self-absorption, so you will be able to develop an increased capacity
to feel warmth for others. You may become more giving, and less hooked
on the need to recover for what you do give, tit for tat. There are
fewer "shoulds" to stand in your way, to use to blame yourself, or to
use to criticize others. You can let go of these requirements and
accept others for what they are, for what they can do, and for what
they may feel. You feel less disappointment and resentment about your
relationships and more of a sense of ease and peace.
_Freedom_
Since you are less hooked by the expectations and values of others, and
you have reduced the list of requirements that others must fulfill in
order to be acceptable, you gain a great measure of personal freedom.
The habitual process of sizing others up and comparing them with
yourself, which many of us expend so much time and energy doing, is no
longer needed. You can more freely set your life goals. You will
probably feel more real, meaningful satisfaction with your life, since
you are no longer imprisoned by uptight standards of judgment. You are
able to be much more relaxed because you are able to feel more
accepting toward others and toward yourself.
_Displacing the Negative with the Positive_
These are among the major potential positive benefits of therapy. They
make up one way of describing the _ideal outcomes_ of therapy. They
are one side of the coin; the other side consists of the many negative
feelings and ways of behaving that are {37} eliminated when they are
_displaced_ by these positive personality qualities. The negatives
that make up such a familiar part of "normal" life include these:
* fears that stand in the way of desired goals
* anxiety and depression that cripple normal living
* low self-esteem, resentment, and hostility that poison the formation
and development of satisfying relationships
* incapacity to deal with stress, and dependence on alcohol, drugs, or
other means to reduce anxiety
* inability to accept yourself, your family, or your present place in
the world--which often leads to bitterness, withdrawal, and even the
cultivation of fantasies that further isolate
* confusion, disorientation, and perhaps even physical signs of poor
health, as a result of emotions that have assumed a magnitude that can
no longer be held in check by tired defenses
We tend to think of these as the usual reasons for entering therapy.
But, again, the positive qualities we have described are attracting
clients increasingly to therapy. Whether you need to eliminate
emotional pain or are fortunate to be comparatively untroubled but are
searching for certain positive qualities of perspective and character
that you believe will bring increased satisfaction to your living,
therapy may offer what you are seeking.
WHAT MAKES A GOOD THERAPIST?
According to several studies, certain qualities in therapists are
associated with effective therapy. The kind of person who is able to
help others bring about important life changes has these qualities:
* the ability to understand the client's feelings and life world
* heightened sensitivity to the client's feelings and attitudes so that
the therapist frequently is able to uncover significant aspects of the
client's outlook and personality of which the client would probably
remain unaware
{38}
* warmth of interest in the client's well-being, without emotional
overinvolvement
* psychological maturity, characterized by self-acceptance,
genuineness, and congruence
* a sense of acceptance toward the client: a nonjudgmental,
noncritical, positive regard for the client, his separateness, and
individuality
* an attitude, conveyed by the therapist's behavior and approach, that
encourages positive change, independence, and freely made choices and
decisions, and implicitly discourages the formation of long-term
dependence of the client on the therapist
These studies also identified several attitudes that clients,
regardless of the orientation of their therapists, felt were especially
_counterproductive_ in some therapists:
* lack of interest
* remoteness or distance
* excessive sympathy
In general, clients whose evaluations of therapy have been studied
appear to be in agreement that the personal character, attitudes, and
feelings of therapists are more important than a therapist's technique,
procedures, and theoretical orientation. Therapy is an intrinsically
human process, one that is especially sensitive to the human dimensions
of therapists. Later we will look at objective evaluations of the
effectiveness of various approaches to therapy and weigh them against
the emphasis that clients place on the personal qualities of therapists.
{39}
4
THE THERAPEUTIC JUNGLE,
PART I
Social Workers, Psychologists, and Psychiatrists
I have reluctantly come to concede the possibility that the
process, direction, and end points of therapy may differ in
different therapeutic orientations.
Carl Rogers, _On Becoming a Person_
Fifty years ago, people with personal or marital problems had a choice
between two main kinds of assistance: psychoanalysis and religion.
Freud's approach to psychiatry had gained popularity among physicians,
psychoanalytic training was being made available to clinical
psychologists, and the ideas of Freudian analysis had come to dominate
the public's conception of therapy. And, sometimes overlooked in this
context, the church--the world's faithful and oldest
psychiatrist--continued to offer spiritual and personal guidance.
These two basic choices have expanded into an impressive--and
confusing--array of different therapies. The more than one hundred
varieties of counseling, even when they are grouped together, cannot be
reduced to fewer than perhaps twenty families of therapies.
Different counseling professions have evolved that now range from
social work to psychotherapy to psychiatry; religious counseling is
still offered; and there are the newer therapies of {40} relaxation
training, biofeedback, bioenergetics, etc., as well as a renaissance of
older approaches such as meditation, yoga, and holistic practice. The
choices of fifty years ago seem modest, limited, and certainly less
perplexing. However, the recent proliferation of therapies has brought
with it increased sensitivity, sophistication, and effectiveness.
In spite of this growth of therapeutic options, most people who decide
to enter therapy are unaware of the choices open to them and so cannot
intelligently weigh their alternatives. This and the next chapter will
help you to see clearly what alternatives exist. As the book helps you
to clarify your personal objectives, you will be able to home in on one
or more approaches to therapy that may be especially promising for you,
your temperament, interests, and goals. You will be encouraged to
follow a "map" that will guide you to several approaches to therapy, to
help you find the shortest and most effective route to where you want
to go.
SOCIAL WORK COUNSELORS
As we have seen, the four main categories of social work counselors are
counselors for individuals, marriage and family counselors, group
counselors, and vocational guidance counselors.
ORIENTATION AND TRAINING
The main purpose of social work is to help people cope with stress from
interpersonal or social problems. The focus of the social worker may
therefore be on individuals, families, or groups or on their social and
work environments, their organizations, and their communities.
Social workers are trained to deal with developmental problems, life
crises, and emotional problems that arise in a variety of social
situations.
Graduate schools of social work require varying periods of supervised
internship; they usually offer specializations within the field--e.g.,
drug and alcohol abuse, developmental disabilities, child welfare,
correctional approaches, family services, care of the aged, and others.
It is now possible to find social workers whose training is quite
specialized.
{41}
In some states, social workers may practice with a bachelor's degree;
in many states, a master's degree is required. In addition, counselors
are usually required to put in a substantial number of hours of
counseling under the supervision of a licensed counselor.
FEES
Social workers in private practice normally charge on an hourly basis
for their services, with sessions lasting thirty to fifty minutes.
Rates vary considerably, in direct relation to other health care costs.
Rates are higher in larger metropolitan areas and also higher in New
England and California than in the South and Midwest. An approximate
range of $35 to $65 per counseling session is normal at the time of
this writing.
Costs for marriage and family counseling and for vocational guidance
counseling are similar to rates for individual counseling.
The charge for group therapy is frequently made for a block of
sessions. The group therapist may, for example, recommend that a group
meet for ten sessions. The resulting per-session cost is normally
significantly lower than is individual counseling. (However, the goals
of individual and group therapy are in general different, as we will
see; neither can automatically be substituted for the other.)
Many social workers offer their services through a counseling agency.
Some of these are privately run; others are funded by the county or
state. Frequently, agencies charge for counseling services based on a
sliding scale, which takes into account the financial situation of
clients. Sliding scale rates can be very economical for lower-income
individuals. Bills for services in some county and state agencies are
made on a monthly basis; individual counseling may cost only a few
dollars per session for individuals with restricted budgets.
There are many opportunities for clients to obtain economical care,
especially in metropolitan areas where counseling services are
widespread.
DURATION OF TREATMENT
It is impossible to give any hard and fast rules as to how long {42}
counseling will take. Obviously, much has to do with an individual's
objectives, the severity of the problem, and, frequently, how long the
problem has been neglected or ignored. On the other hand, much also
has to do with the counselor's own orientation.
Today, many counselors receive training that emphasizes "brief"
therapy. Specific goals of therapy are set, and it is frequently
possible to reach those goals within a matter of a few months. On the
other hand, some counselors prefer, or have been trained, to offer
long-term individual psychotherapy. Some counselors have been
influenced by the psychoanalytic approach, which is usually of long
duration, frequently requiring one to several years.
There is no reason you, as a prospective client, should not ask a
counselor what kind of approach he or she uses and approximately how
long therapy can be expected to last. You should not hesitate to ask a
counselor questions that reflect your concerns. As you read further,
this book will provide you with a frame of reference so that you may
evaluate more fully the answers a counselor gives you.
PSYCHOLOGISTS
As mentioned in the last chapter, there are three kinds of
psychologists who are involved in different aspects of therapy:
clinical psychologists, counseling psychologists, and psychometrists.
ORIENTATION AND TRAINING
_Clinical psychology_ emphasizes the understanding, diagnosis, and
treatment of individuals in psychological distress. Clinical
psychology is historically based on laboratory work that stressed
psychological assessment tests, and experimental and statistical
analysis.
Clinical psychologists generally have a Ph.D. and complete a lengthy
internship in a clinical setting. Most clinical psychologists develop
competence in both diagnostics and intervention. The area of
diagnostics includes individual interviews, psychological testing, and
personality assessment (psychological evaluation to determine what a
client's difficulties are). Intervention (the actual approach used to
help a person) includes individual psychotherapy, group therapy, and
marriage and family therapy.
{43}
The objective of _counseling psychology_ is to encourage growth in the
three major life areas of family, work, and education and to prevent
excessive psychological stress in them. Like clinical psychologists,
counseling psychologists receive training in individual, group, and
marriage and family counseling as well as in vocational counseling,
assessment, and rehabilitation.
Often, you will find clinical psychologists in private practice, while
many counseling psychologists hold positions in organizations, schools,
and social service agencies. Counseling psychologists generally have a
master's degree or Ph.D. and also are required to complete internships
in supervised counseling.
_Psychometrists_ are specifically trained to give and to evaluate
psychological tests. They are, so to speak, the "radiologists" of the
fields of counseling and psychotherapy. Clients may be referred to a
psychometrist in order to take one or more psychological tests; the
psychometrist's interpretation of the results is then forwarded to the
client's therapist or counselor. Increasingly, psychologists are being
trained to do much of this work themselves, so it has become less
common to refer clients to psychometrists unless an extensive amount of
testing is desired.
If you are advised to take one or more psychological tests, you may be
interested in knowing what to expect. Many psychological tests are
multiple-choice. You are given a printed list of questions and an
answer sheet. There are no "right" answers. You answer such questions
as "Would you rather go to a party or stay home and read a good book?"
Tests like this attempt to provide insight into a client's outlook,
personality, concerns, values, and interests. Some tests help to
assess concentration, coordination, and problem-solving ability.
Results of psychological tests can be helpful to a counselor in
deciding how best to treat a client's problems. Testing can be a great
time- and money-saver in therapy: the results of a twenty-minute test
can give a counselor information about a client that might otherwise be
gained only through a number of sessions.
FEES
Because of their more advanced training, clinical psychologists can be
expected to charge fees that are somewhat higher than what social
workers in private practice receive. Charges for {44} the services of
a clinical psychologist are made on an hourly basis; counseling
sessions usually last forty-five to fifty minutes, although some
psychologists will see clients for shorter periods.
Rates vary considerably according to geographical area. An approximate
range of $50 to $80 per private session is normal at this time. Group
session rates tend to be significantly lower.
If you consult a clinical or counseling psychologist who works through
an agency, you will often find that a sliding scale is used to
determine charges, as in social work. If you have limited or no health
insurance, and financial concerns are a problem, you can telephone
counseling agencies in your area to ask whether a sliding scale is used
and, if so, what charges correspond to your monthly income. Later, we
will look at how to locate counseling agencies, as well as
professionals in private practice.
Fees for psychological testing, whether through a psychologist or a
psychometrist, are usually billed on the basis of the tests
administered. To give some idea, many tests cost $15 to $20 for a
psychologist to administer. This charge is passed on to the client.
The test results can sometimes be reviewed during a counseling session
so that no additional charge may be made for the evaluation of the
results.
DURATION OF TREATMENT
Duration of treatment under a clinical or counseling psychologist is
similar to that of a social work counselor. The best way to proceed is
to ask prospective therapists how long they believe it will be
necessary to see them. Most professionals will be open and candid; if
the client's goals are specific and lend themselves to "brief" therapy,
a psychologist will make this clear. And, as we have already observed,
much depends on the type of therapy practiced by the psychologist.
Behavioral therapies tend to be of shorter duration; psychoanalysis is
longer-term. In between these there are, as we will see, many
therapies that have different emphases, methods, and goals.
PSYCHIATRISTS
ORIENTATION AND TRAINING
Before they specialize in psychiatry, psychiatrists receive the {45}
training required of any physician. After this, there is specialized
course work followed by a period of psychiatric internship. The
educational background of psychiatrists enables them sometimes to
identify physical bases for emotional difficulties. A later chapter
discusses this growing area of awareness.
Until fairly recently, the therapeutic training of psychiatrists
emphasized almost exclusively the approach of psychoanalysis.
Psychoanalysis developed within a medical context: Freud was a
physician, and his outlook was influenced by his medical orientation.
His approach was therefore felt to be the special province of
psychiatric medicine. Eventually, as we have already noticed, the
methods of psychoanalysis came to be used by psychologists and some
social workers. But for a long period, analysis was the primary and
exclusive focus of medical psychiatry.
The psychoanalytical orientation still dominates much psychiatry, and
many psychiatrists in private practice use psychoanalysis as their
therapy of choice. However, there has been a general broadening of the
perspective of psychiatrists. Other approaches to psychotherapy are
increasingly being used by psychiatrists. Cognitive therapy is
important among these; we will discuss its purpose and methods later.
Psychiatrists are the only therapists who may prescribe medication, and
some of the most important recent advances in psychiatry have come in
this area. Many emotional problems appear to have a biochemical basis.
Many forms of anxiety, panic disorders, and depression respond well to
the growing family of psychopharmaceutical drugs. Other emotional
difficulties, including alcohol and drug abuse, can be moderated by
pharmaceutical therapy.
Psychiatrists, then, can be especially helpful in these ways:
* to provide a medical evaluation for complaints that sometimes have a
physical basis
* to give assistance especially by means of psychoanalysis and by means
of an increasing number of alternative therapies
* to help patients with medication to acquire a degree of emotional
equilibrium that will allow them to begin to solve personal problems so
that, in time, they may no longer require medication
{46}
Although an M.D. may call herself or himself a psychiatrist, most
psychiatrists have had specialized advanced training in psychiatry.
Full qualifications involve completion of a residency in psychiatry,
full membership in the American Psychiatric Association, completion of
a program of study at an institute of psychotherapy, and board
certification. Many psychiatrists who practice are eligible for board
certification but simply have not yet taken the national examinations
that are required in order to be certified by a national examining
board. Although apparently many of us need to be reassured of this,
you need not feel that there is anything wrong or embarrassing about
asking a prospective psychiatrist, or his or her secretary, to describe
the doctor's background and training.
FEES
At the time of this writing, the fees of psychiatrists in private
practice range approximately from $75 up to $100 and occasionally more
per session. Private psychiatric assistance is therefore largely
reserved for the fairly well-to-do or for those who have health
insurance with substantial psychiatric benefits.
Fortunately, psychiatric care is available through many agencies; those
that are run by counties and states normally have sliding scales (some
private agencies will also take an individual's finances into account
when setting fees). Rates for consultation with a psychiatrist at a
public agency can be very reasonable (as little as a few dollars per
visit, depending on the patient's income). This makes the services of
psychiatrists available to those with modest or low incomes.
DURATION OF TREATMENT
If a psychiatrist finds that an emotional problem has a physical basis,
or that it is due to biochemical depletion or imbalance in the body,
successful treatment may be relatively short, sometimes a matter of a
few months.
If you choose to enter psychoanalysis, then the duration of treatment
generally will be longer, often lasting a year and more; during this
time, psychoanalysts may expect you to come for two or three sessions
each week.
Shorter-term therapies, such as cognitive therapy, are--in part because
of the normal long duration required by psychoanalysis--increasingly
advocated by psychiatrists. Biofeedback and relaxation training (see
Chapter 5) are also among these shorter-term approaches. They may be
effective within a period of several months.
In this chapter, we have discussed the professions that make up the
mainstream of professional practice in counseling and psychotherapy.
However, beyond the established and more closely regulated professions
of social worker, psychologist, and psychiatrist, there are a number of
other kinds of therapists who offer services that are sufficiently
different in nature that they deserve to be treated in a separate
chapter. The next chapter describes their contributions to therapy.
{48}
5
THE THERAPEUTIC JUNGLE,
PART II
Outside the Mainstream
Outside of any profession's frame of reference that defines what
problems it will handle and how, we usually find a group of approaches
that do not completely fit the established mold. They often can
contribute creative and innovative ideas, and yet they often lead to
abuses in the name of novelty and experimentation. And sometimes an
older approach that fails to fit the newer frame of reference is left
behind, to keep company with more radical approaches.
Just these things have happened in the practice of counseling and
psychotherapy, as we will see.
RELIGIOUS COUNSELORS
The world's first professional counselors were religious. Guidance
from priests, rabbis, and pastors has a long tradition. The tradition
is such an old one, in fact, that going to talk to a religious
counselor has a respectability that the public has generally not yet
extended to other forms of counseling.
Many people with problems, even people with a religious attitude or
upbringing, tend to ignore the kind of help religious counselors may be
able to give. This probably stems from the {49} belief that social
workers, psychologists, psychiatrists, and some other certified
therapists whom we will discuss in a moment have received special
training in helping people with personal, emotional problems, whereas
religious advisors have not.
However, this is not universally true. Many professional religious
representatives now _do_ receive training in contemporary therapies.
Increasingly, Catholic, Protestant, and Jewish educational institutions
are incorporating course work and workshops in modern counseling
methods into programs of study for priests, pastors, and rabbis.
Individuals who have been trained in this way are easily located within
a religious organization; a telephone call to the organization should
give you leads to follow.
In spite of the widespread attempt many religious institutions are
making to remain up to date on contemporary approaches to counseling,
there is probably something also to be said for traditional guidance.
All religious views seek to fulfill the needs of men and women to find
meaning in everyday life and to cope effectively with life's hardships.
Contemporary approaches to psychotherapy and counseling can offer much;
their history, however, is comparatively brief, extending over just the
last century. For many people--depending on their inclinations,
values, and sympathies--traditional religious guidance may provide much
that is as yet not to be found in the more scientific and systematic
schools of contemporary therapy.
If you decide to go to a religious professional for counseling, you
will probably find the process relatively informal and friendly. Also,
religious professionals generally expect that their private counseling
services will not be remunerated; contributions to the supporting
religious organization are of course hoped for but are often not
required in exchange for guidance.
In contrast to the authorized community of social workers,
psychologists, and psychiatrists, it can be more difficult to locate a
religious professional who _specializes_ in a particular approach to
counseling. The background in modern approaches to counseling that
religious professionals tend to receive is "eclectic." They normally
receive training in a variety of approaches; their programs of study
are based on the belief that flexibility in counseling is essential,
that nothing works well for everyone. This openness can be of value to
many people. But, as you read this book, you may decide to locate a
therapist who has a certain {50} specific orientation. He or she may
be a religious counselor, a psychologist, or another qualified
professional. In general, if you have a specific form of therapy in
mind, you will have to ask a prospective therapist whether he or she
has the training to give you the kind of help you are looking for.
This is especially true of religious counselors.
BIOFEEDBACK THERAPISTS
Biofeedback is a newcomer to the therapeutic world that has grown
tremendously in popularity in the last ten years or so. Biofeedback
therapy gradually enables individuals to become aware of certain
physical changes in their bodies. These physical changes are detected
by means of sensitive measuring instruments that give information back
to clients so they can learn to control a particular physical response.
Biofeedback is used by therapists who have been specially trained in
its use, as well as by some licensed psychologists, psychiatrists,
social workers, physical therapists, speech pathologists, and even some
dentists. Some psychiatrists now work jointly with a biofeedback
therapist: the psychiatrist can prescribe medication and provide
psychotherapy or analysis, while the associated biofeedback therapist
can teach patients how to lessen their responses to pain and
stress-related problems.
The Biofeedback Society of America is an interdisciplinary group of
healthcare professionals; it is presently developing training standards
and guidelines for certification of biofeedback practitioners.
RELAXATION, HYPNOSIS, AND MEDITATION THERAPISTS
Relaxation training, hypnosis, and meditation all seek to bring about a
deep sense of relaxation in a person. We will examine each in greater
detail later; a short overview of these approaches is given here.
RELAXATION TRAINING
Relaxation training involves exercises that enable a person to learn to
induce _at will_ a state of physical and mental calm. Relaxation
training is a practical skill--it can be very effective {51} and useful
in coping with stressful situations. Like any learned skill, control
comes only with practice, usually over a period of several months.
Many social workers and psychologists teach clients relaxation
techniques. Certification standards specifically for relaxation
training have not been established.
HYPNOSIS
Hypnosis involves two stages: (1) progressive, deep relaxation to a
point at which an individual is in a peaceful, trancelike state, still
self-aware but profoundly relaxed; and (2) suggestion, which persuades
the person to adopt certain future attitudes, thoughts, or behavior.
Hypnosis, like relaxation training, can be learned. Most people
treated by means of hypnosis steadily improve in their ability to be
hypnotized so that they can more effectively allow themselves to be
influenced by means of carefully planned suggestions. Many
psychologists and psychiatrists make use of hypnosis in the context of
therapy; some practitioners treat patients exclusively by means of
hypnosis.
The certification of therapists trained in hypnosis is still unsettled
in many states, where anyone can hang out a shingle. Since many
licensed psychologists and psychiatrists and some certified social
workers _do_ receive professional training in hypnosis, these are the
professions to which it is most reliable to go for hypnotherapy.
MEDITATION
Meditation is still a "fringe" therapy. Techniques of meditation tend
seldom to be taught to clients in psychotherapy, although there is a
growing body of evidence that meditation is able to bring about great
resistance to stress, an increased sense of inner calm, and even actual
changes in brain-wave patterns associated with deep relaxation. These
effects of meditation are now being studied, with encouraging results.
The practice of meditation is, in the author's view, at present best
learned on one's own, although some commercial organizations provide
instruction. A later chapter discusses approaches to meditation and
suggests some of the ways meditation can be of value.
{52}
HOLISTIC THERAPIES:
BIOENERGETICS, YOGA, AND EXERCISE
Holism views man as a unity of body and mind. The established
approaches to therapy and counseling, represented by social workers,
psychologists, psychiatrists, and to a certain extent by some religious
professionals, all focus attention on our mental-psychological
dimension. Similarly, biofeedback, hypnosis, and meditation emphasize
the central role of _mental_ control.
Holistic approaches, on the other hand, attempt to bring about positive
change by means of emphasis on physical factors that are believed to
have a close connection to mental processes. Although holism sees
human beings as integral organisms, holistic approaches are inclined to
have this physical focus.
Holistic therapies, like meditation, are "fringe" therapies. They are
not generally employed by members of the "authorized" community of
health practitioners, for two reasons: First, a kind of professional
respectability and elitism have come to be associated with the
psychological approach; social work, psychology, and psychiatry have an
established place in institutions of higher learning, whereas fringe
therapies do not. Second, since physicians treat the body, there is an
institutionalized prejudice against nonmedical treatment that has the
same focus.
Chiropractic has encountered this problem, as have other forms of
holism, such as bioenergetics, yoga, diet therapy, and rolfing.
Although much of value may be offered by these fringe therapies, they
have also resulted in abuse to consumers. Because of a general absence
of licensing standards and of scientific credibility, people frequently
are drawn in by the sometimes extravagant promises of unscrupulous or
overly enthusiastic fringe therapists. In this area, as in all others
that affect the consumer, the proper attitude is one of healthy
skepticism and restraint.
BIOENERGETICS
Of these holistic therapies, bioenergetics is perhaps considered the
most respectable because it _is_ used by some psychologists.
Bioenergetics attempts to diminish an individual's psychological
defenses by means of sequences of specially designed {53} physical
exercises that, in a controlled and deliberate way, stress the person
physically. Practitioners of bioenergetics believe that physical
exercises of this kind rapidly put a person in touch with buried
(repressed) feelings and speed up the process of inner integration that
all holistic practices, as well as traditional therapy, wish to achieve.
YOGA
Yoga exists in various forms. The two main varieties are hatha yoga
and raja yoga. Hatha yoga emphasizes physical flexibility; raja yoga
teaches breathing techniques and meditation. Hatha yoga, because of
its focus on the body, belongs to the family of approaches we are
considering here.
Hatha yoga practitioners believe that the physical flexibility and
control that are acquired through an extended period of physical
training in yoga exercise tend to influence your mental orientation.
You become, in this view, more flexible, less rigid, less defensive,
less subject to stress, more open, responsive, alert, and capable of
warmth in human relationships.
EXERCISE THERAPY
Counselors and therapists are starting to take very seriously the idea
that exercise brings emotional benefits. Exercise therapy, more so
than other physically based approaches discussed in this chapter, has
been tested in various ways. Many emotional conditions--for example,
anxiety and depression--seem to be significantly reduced thanks to
periods of sustained vigorous exercise. Tolerance to stress and to
pain appears to be increased. Physical exercise can be an outlet for
pent-up hostility and aggression that, according to many theorists, may
be turned inward, then fester, and eventually take the form of a
variety of psychological disorders. Furthermore, vigorous, sustained
aerobic exercise--like running or swimming--appears to have a calming
effect as a result of certain chemical compounds that are released into
the bloodstream. We will look at some of the interesting recent
studies of the therapeutic value of exercise later on.
{54}
6
WHERE YOU CAN FIND HELP
PRIVATE PRACTICE
As we have seen, social work counselors, psychologists, psychiatrists,
biofeedback therapists, hypnotherapists, and other therapists may all
offer their services through private practice. In general, there can
be definite advantages to counseling in the setting of a therapist's
private practice. You are given a degree of personal care that, as an
individual paying customer, you are less likely to receive in
counseling provided by agencies. You become part of a therapist's own
practice, so it is natural for him or her to devote special attention
to you. Therapists are likely to be more personally involved in their
private practice and in the quality of care they try to give their
private clients than it is possible or even personally desirable for
them to be when they work by the hour for an agency.
On the other hand, private sessions with a therapist tend to be
considerably more expensive than counseling can be through many
agencies. You ought not to take too seriously general comparisons
between therapy as you may encounter it privately and therapy in the
setting of an agency. You can often find a counselor who is congenial,
interested, attentive, and skilled; whose services will be easier for
you to bear financially; and who {55} offers his or her services
through an agency. If finances are restrictive for you, you should
look into agency-sponsored counseling.
Many social work counselors, psychologists, and some psychiatrists who
maintain private practices intended mainly for individual therapy also
offer group therapy. Often, a therapist will observe that a number of
individual clients share certain problems and experiences, and he or
she will suggest that these people meet together as a group. The
per-session price can be expected to be a good deal lower than for
individual sessions; the rate usually reflects the number of people who
meet in the group and the length of time the group is expected to
continue.
Some social workers and some psychologists _specialize_ in group
therapy. Groups are formed periodically, run a set number of weeks,
and may or may not bring together individuals with common problems.
Some group therapists believe that diversity in a counseling group is
valuable: in such a group, you might find one person combating
alcoholism, another trying to cope with loneliness and grief after the
death of a spouse, someone trying to break out of the confines of
shyness, a person suffering from public speaking anxiety, someone
wanting to change careers but who is blocked by fear, and others. An
exchange of views among participants with diverse backgrounds can
frequently encourage growth in the group members.
Most counseling agencies also offer group therapy, as do many hospitals
and schools. We will take a look at each of these settings in turn.
COUNTY, STATE, AND PRIVATE AGENCIES
Individual, marriage and family, and group counseling are all offered
by many counseling agencies.
County and state agencies receive public funding and usually have
sliding scales for the rates they charge. Often, one or more
psychiatrists work in association with counselors, who may be social
workers or psychologists. If you go to a county or state agency, you
will probably be interviewed initially by a receptionist or nurse. You
will be asked questions about your financial situation and health
insurance coverage, if you have any, and you will be asked to agree to
a proposed rate for the services of the agency. Some county and state
agencies make a monthly charge {56} for their services; you may consult
regularly with members of the staff, counselors and/or psychiatrists,
in accordance with your individual needs.
Private counseling agencies function in a similar way. Their services
tend to be more expensive because they do not receive public financial
support, as do county and state agencies.
Many health insurance plans that provide psychological benefits can be
used to pay for the services of a private or a public counseling agency.
HOSPITALS AND OTHER INPATIENT SERVICES
Individuals with severe problems who need complete care can enter
private, county, or state hospitals that offer psychiatric services. A
separate chapter discusses pros and cons of the sometimes frightening
alternative of hospitalization.
Again, publicly funded hospitals tend to charge on the basis of a
sliding scale, which takes a person's financial situation into account.
Where financial concerns are not pressing, private hospitals in general
tend to offer a greater degree of individual attention and higher
quality of care and physical facilities.
In addition to hospital facilities, many metropolitan areas have
established organizations to provide counseling services on an
inpatient basis. Some are private; some are public. They offer an
alternative to hospitalization. They tend to be more informal and open
and are managed by their own staffs of professional counselors and
psychiatrists. These residential care facilities usually are intended
for stays of from one to several weeks. They have a variety of
counseling programs, ranging from individual therapy to group
counseling and vocational guidance.
One way to locate such an inpatient organization is to telephone a
crisis intervention (sometimes called _suicide prevention_) number
likely to be listed at the beginning of your telephone directory. A
volunteer probably will answer your call and should be able to direct
you to inpatient facilities available in your area.
ACADEMIC SOURCES OF COUNSELING
Counseling is one of the services available to full- and part-time {57}
students who are enrolled in junior or four-year colleges and graduate
schools. Many educational institutions offer individual counseling,
normally by counseling psychologists, and all colleges offer academic
advising in the context of a certain amount of vocational guidance.
Colleges with programs in counseling and psychology usually also offer
certain classes with a practical, problem-solving focus. Although they
may not be specifically intended to help individual students with life
problems, this is in fact what they frequently end up doing. It is
inevitable for students in a practically oriented counseling class to
apply much that they learn to their own problems. Many class meetings
of this kind tend to be almost indistinguishable from group therapy
sessions: students receive guidance from a professionally trained
instructor, exchange views, and express personal concerns. You might
think of college classes with a practical, psychological emphasis
especially if you are drawn to therapy as an opportunity for general
personal growth.
Classes of this kind may be offered in a college's regular programs,
which are sometimes open only to students working toward a degree.
Other similar opportunities, however, are available through many
continuing education, or adult education, programs. Many secondary
school districts offer practical, psychologically-focused classes for
adults who do not choose to enter a degree program. This is also true
of community, state, and many private colleges.
Colleges and private professionals offer intensive workshops with a
variety of counseling emphases. Two-day weekend workshops have become
especially popular. Topics range from alcoholism, drug abuse,
child-rearing problems, and separation and divorce to illness and
chronic pain, marital concerns, depression, stress control, and so on.
Newspapers announce counseling workshops; you will often find notices
about them posted in public and college libraries.
SOME REFLECTIONS ON WHERE YOU GO FOR COUNSELING
You should bear in mind that where you go for counseling or therapy is
nothing more than an address. What is important is what happens in
your relationship with your counselor or {58} therapist. If you have
found a therapist whom you respect and feel motivated to work with, it
makes little difference, as far as the benefits you obtain from therapy
are concerned, whether your therapist works in private practice or
offers his or her services through an agency, school, hospital, or
residential facility.
On the other hand, where you go for counseling _will_ greatly determine
the price you will pay for services and frequently whether health
insurance will cover your expenses. To some extent, where you go can
sometimes, as we have noted, influence the quality of care and
individual attention you receive. But this is a generalization; you
frequently will be able to locate excellent care through less expensive
facilities. This will depend to some extent on luck, but more on the
amount of effort you put into locating the kind of help you may need.
Since you are reading this book, you already have initiative like this:
you have the ability to influence what kind and quality of therapy you
will receive. For you, it will be less a matter of pure luck than it
is for people who choose a therapy and therapist arbitrarily.
{59}
7
SELF-DIAGNOSIS
Mapping Your Way to a Therapy
This chapter is central to your use of this book as a guide. There are
two main ways to use this book to help you to choose a therapy:
1. You can familiarize yourself with all of the major approaches to
therapy, weigh their advantages and disadvantages in relation to your
needs, and then make a choice. Twenty-six approaches to therapy are
discussed and evaluated in this book, so keeping your judgments of
their pros and cons clearly in mind can be challenging. Although
comprehensive understanding has a value of its own, it may not be
essential to you.
2. You may prefer to go through three simple steps to narrow the
alternatives down to a small number of therapies that have been most
successful for specific goals, problems, and personal attributes that
most closely approximate your own. This is a less time-consuming
process, and it will take into account professional evaluations of the
different therapies.
In either case, your informed judgment will be the basis for your
eventual choice. This chapter is intended to help you if you prefer
the second route--to narrow down the alternatives in a clear and
logical way. If you prefer, however, to become acquainted with all of
the major therapies discussed in this book, {60} you might skim through
sections of this chapter to give you a framework for more efficient
understanding.
The information in this chapter relates to many different sets of
goals, problems, and kinds of people. Not all of this information will
be relevant to you, so you will find instructions to direct you to
specific recommendations that take into account your own needs and
interests.
This chapter is where practical and prudent planning can begin. In
fact, this book represents the first attempt to match you, your
personal qualities, and your goals with the most effective therapy or
therapies available to you.
Even though nearly all of the main approaches to counseling and therapy
are creations of the past century, it may seem surprising that no
unified effort has been made to identify what specific kinds of
problems each approach is especially useful for treating and for what
types of clients. In this respect, the field of medicine is much
better developed. The discipline of medical diagnostics is now on the
verge of becoming scientific, and it is now possible to identify for
many conditions and in individual cases very concrete and well-defined
treatment procedures that are likely to be effective. This has not
been true in the field of psychology: most research efforts have so far
gone into formulating definitions of the various mental and emotional
disorders. But the important work, from the prospective client's point
of view, had yet to be done: to make it possible for him to know--in
relation to his individual problems, goals, interests, abilities, and
temperament--which approaches to therapy are likely to help him the
most.
If you are in serious emotional pain, waiting until all of the research
results are in is just not possible; you need help _now_. In spite of
incomplete knowledge in psychotherapy, a large body of information has
come from studies of the effectiveness of therapies for different
problems and for different kinds of people. But until now this
information existed only in fragmented form and was familiar only to
professional psychologists. Enough data are in to begin to draw
reasonable guidelines for individuals who seek psychological help.
The mapping process described in this chapter is the result of
assembling and then organizing large quantities of data from many
sources. It was then necessary to design an easily followed {61}
step-by-step approach to enable you to narrow down the many therapeutic
alternatives to a small number that, through your efforts and the
assistance of a therapist, can be of help to you. Guidelines of this
kind are never static; they will change to some extent as time and
knowledge advance.
OBSTACLES TO FINDING A THERAPY THAT FITS YOU
There are real obstacles to efficient treatment in psychotherapy. They
cost people much time, energy, hope, and money as they try to find
appropriate help. Psychotherapy is not yet a systematic field.
There are three main reasons why it is so difficult to find approaches
to therapy that will fit individual clients and their needs:
* Emotional and mental difficulties vary tremendously. Psychologists
and psychiatrists are still in the process of classifying the kinds of
emotional and mental problems people have.
* People are individuals. Their personalities, likes and dislikes, and
motivations for entering therapy differ greatly.
* Therapists, too, are individuals. Their personalities, interests,
values, and motivations for _offering_ therapy differ greatly. Their
professional training and preferences in favor of one or several
approaches to therapy also vary significantly.
As a result, what works for one patient will not necessarily work for
another. _What_ helps and _who_ helps in one person's situation may
not help in another's. Yet all three of the factors on which effective
treatment depends--a patient's goals and problems, his or her
personality traits, and the approach of the therapist--in many cases
_can_ be matched intelligently. You, as a prospective client, know a
great deal about yourself; it doesn't make sense to choose arbitrarily
among the many therapies. It takes very little time to map your way:
in the process, you will learn more about yourself, what to anticipate
in therapy, and in what direction to start.
{62}
REALISM: A GOOD BEGINNING
In order to identify one or more therapies that may be most promising
in relation to _your_ goals, _your_ problems, and _the kind of person
you understand yourself to be_, you must begin your search with a good
measure of realism.
SETTING GOALS
It can be very difficult for anyone who is seriously troubled to think
clearly and use good judgment. You may find it hard, perhaps
impossible, at this time to identify your goals. You may feel
confused, anxious, depressed, and not know why you feel that way. Even
so, you will find as you read on that you can set important goals for
yourself.
If you are at a loss and have no sense of purpose, _that_ fact gives
you a goal to work toward in therapy: to develop clearly thought-out
goals. Though you may not know what precipitated your feelings of
confusion, anxiety, or depression, you at least _know_ that you feel
confused, anxious, or depressed, and you will find recommendations in
this chapter on how to find appropriate help for your suffering. Do
not judge yourself harshly if you lack a sense of direction or if you
are troubled but do not know why. Just keep reading.
OPENING YOURSELF TO CHANGE
There is a second thing you should be realistic about when you do know
what you want and what your problems are. Our experiences and what we
learn about ourselves _change_ us. If you enter therapy based on your
present perceptions of yourself, it is likely that these are going to
change to some extent as a result of your experiences in therapy. Does
that mean that you cannot plan or select a therapy intelligently?
Clearly, it doesn't. _Everyone has to start where he or she is_.
There is no other choice. But you should try to persuade yourself to
be open to changes in your views and feelings. If you feel rigid about
your own perceptions of yourself, it is just possible that your
rigidity may be contributing to the problems you want to resolve. As
in any attempt to learn or to change, it is important periodically to
reevaluate your needs, values, and the results you may have achieved so
far. If you select a therapy using the structured {63} approach in
this chapter, you may decide to retrace your footsteps a few months in
the future. You may find that you would take a different path in the
light of what you then see.
BEING HONEST ABOUT YOURSELF
There is a third piece of realism that I would like you to consider,
and this is _very_ hard for anyone to take to heart. If you can, you
are a very unusual person. Answering the following questions honestly
takes some real courage. But you must ask yourself: "To what extent do
I _need_ my present symptoms? Is it useful to me _not_ to have a sense
of direction? Am I somehow _benefiting_ from feeling depressed? Is my
anxiety _helpful_ to me in some way?"
You may think these suggestions are no more than contrived and unkind
psychologizing. After all, who _chooses_ to suffer? Does anyone
_want_ to wake up at 4:00 A.M. shaking and crying? Yet, again and
again, therapists who care very much about their patients find that
many of them "cling to their symptoms with the desperation of a
drowning man hanging onto a raft."[1]
[1] Lewis R. Wolberg, _Hypnosis_ (New York: Harcourt Brace Jovanovich,
1972), p. 238. (In this guide, see Chapter 15, on hypnosis.)
For diverse reasons, many people--even people who are suffering
greatly--do not _want_ to change. Their unhappiness, pain, and
confusion can serve numerous functions. You may not believe this right
now, but from time to time as you read this book, and later in your
life, this question may occur to you, if only for a moment: "How may
this unresolved problem benefit me?"
The plain truth is that even suffering can confer benefits on us. This
is at the root of much of the tragedy of emotional problems that prove
to be resistant to treatment. The distressed, despondent, overwrought,
and trembling person seated before the therapist may have found a way
to gain the attention he was unable to get otherwise. Or perhaps his
suffering is a way to lighten a burden of guilt that eventually caused
an inner collapse. There are many "benefits," many very good reasons
to want _not_ to change but to try _anyway_.
So, before you begin to seek a specific type of therapy, try to be
realistic and keep these thoughts in mind:
{64}
1. Specifying clear-cut goals and understanding why you feel troubled
are not essential now. Certainly it will be helpful if you can
translate vague complaints into concrete problems, to help both your
own understanding and eventually your therapist's. The more specific
you can be about what is troubling you, what situations especially
distress you, and what has motivated you to come to therapy, the easier
it will be for you to find help and for the therapist you choose to
help you. But in times of crisis, clarity can be very hard to gain, so
be patient.
2. If you do have clear-cut goals and a good understanding of yourself
now, use these to plan how to proceed, remembering that openness to
change will profit you and that, in all likelihood, your initial
perceptions of yourself will change as you become involved in therapy.
3. You may, at least now, need your symptoms, however painful they may
be. How successful therapy will be for you may have a great deal to do
with your willingness to let go of the possible benefits of being
troubled, in pain, or disabled.
4. Resist digging ruts for yourself. Try to refrain from locking into
a particular course of action until you have given yourself time to
consider alternatives. Once you have chosen a direction, if after a
reasonable time the therapy and the therapist you have selected do not
seem to be helping you, it is essential to try another approach. This
is especially difficult once you have invested your time, energy, and
money and perhaps have developed a good relationship with your
therapist. You may like him or her, feel comfortable and comforted,
but if you are not gaining what you want, you have to stop and try
again.
5. Finally, have a thorough physical examination before entering
therapy, if you have not had one recently. Be truthful and open with
your physician. Some emotional and mental problems are produced by
underlying physical conditions, many of which can be treated
effectively (see Chapter 8).
HOW TO MAP YOUR WAY TO A THERAPY
The remainder of this chapter presents a three-step process {65} for
choosing an approach to therapy that is potentially best-suited to your
personal needs and personality.
In the first step, you become familiar with the main kinds of goals and
problems that motivate people to enter therapy. You check those that
seem to be most relevant to you and then try to confirm the accuracy of
your choices. This will point you in the direction of one or more
promising therapies.