that are relevant to your choice of therapy. Again, you check those
that seem most to apply to you and then confirm your
self-understanding. Step 2 will also direct you to one or more
therapies.
In the third step, you use your results from Step 1 and Step 2 to
select an approach to therapy that most closely matches your needs,
interests, and personality.
Let's begin.
STEP 1. DIAGNOSING YOUR PROBLEMS AND SETTING YOUR
GOALS: IDENTIFYING APPROPRIATE THERAPIES
a. Read through Table 1 (pages 67-69).
b. Check the goals or problems most applicable to you. If you are in
doubt, refer to the numbered short descriptions in the section
"Matching Your Goals and Problems with Most Promising Therapies"
following Table 1.
c. Choose one or two goals or problems that are the most important to
you.
d. Confirm your choices: Refer to the section "Matching Your Goals and
Problems with Most Promising Therapies" that follows Table 1. In that
section, read the corresponding short descriptions of the one or two
goals or problems you checked in Table 1 and ask yourself whether, in
fact, these accurately apply to you. For example, if you checked §7 in
Table 1, then read the corresponding §7 in "Matching Your Goals and
Problems with Most Promising Therapies."
e. If, after doing this, you continue to believe that the goals or
problems you checked relate to you, make a record of the therapy letter
codes given at the end of each description. You will find that
occasionally letter codes are divided into two groups: those judged to
be generally more effective (called "primary"), and a set of
alternatives ("secondary"). Now go directly to Step 2. On the other
hand, if you come to feel that the goals or problems you checked really
do _not_ apply to you, go back to Table 1 and consider other
alternatives.
{66}
STEP 2. SELF-UNDERSTANDING:
IDENTIFYING APPROPRIATE THERAPIES
a. Read through Table 2 (page 79).
b. Check the personal qualities that seem best to describe you.
c. Choose one or two of these that are the most significant to you.
d. Confirm your self-understanding: Refer to the section "Matching Your
Personality with the Most Promising Therapies" following Table 2. Read
the short descriptions of the one or two personal qualities you checked
and respond to the questions you will find there.
e. If, after doing this, you believe that the personal qualities you
checked in Table 2 do, in fact, describe you accurately, make a record
of the therapy letter codes given at the end of the questions. Now go
directly to Step 3. If, on the other hand, judging from your responses
to the questions you answered, you do _not_ feel that the personal
qualities you checked are true of you, return to Table 2 and consider
other alternatives.
STEP 3. CHOOSING A THERAPY
a. Compare the two sets of letter codes you recorded as a result of
Steps 1 and 2. If one or more letter codes are common to both sets,
make a special note of the common code(s); otherwise, group the letter
codes together.
b. Refer to Table 3 (pages 86-87), which summarizes the letter codes of
all the therapies discussed in this guide. Check the code(s) you just
listed.
c. If you feel that you have taken your time, have been thoughtful
about yourself, and now feel reasonably confident about the tentative
conclusions you have reached, turn to the chapter(s) in this book that
discuss the approaches to therapy you checked. As you read these, try
to imagine yourself as a client in each of the therapy situations
described. Which approach seems most appropriate given your goals or
problems? Do you feel that _you_ have the personal traits that the
therapy is most suited for? If so, give that approach to therapy a
reasonable trial period. If not, consider other alternatives you
checked.
{67}
AN EXAMPLE OF FOLLOWING STEPS 1, 2, AND 3
Suppose you check §3.1, shyness passivity, in Table 1. You refer to
the section following Table 1, relating to personality trait problems.
You feel that shyness _is_ something that interferes significantly with
your life, interests, and desires, and you want to do something to
overcome it. Therapies Q, C, N, and D are recommended to you as
potentially useful. Then, in Table 2, you check §7. You refer to §7
following Table 2, and you decide that you especially need to work on
pent-up feelings in need of release. Therapies C and J are suggested
there as potentially appropriate for you.
You now have two sets of therapy letter codes to consider: Q, C, N, and
D; and C and J.
Therapy C is common to both recommended groups of therapies, but you
are interested in comparing the other therapies with C. In addition to
reading about C, you decide to read the discussions of therapies D, J,
N, and Q. From Table 3, the five letter codes C, D, J, N, and Q denote
Gestalt therapy, transactional analysis, bioenergetics,
counter-conditioning, and group therapy, respectively. After reading
about these therapies, you come to feel that Gestalt therapy probably
would challenge you in especially needed ways, so you decide to locate
a therapist with training in Gestalt therapy. (For information on
locating a therapist, see Chapter 17.)
STEP 1
_TABLE 1:_
_AN OVERVIEW OF PRINCIPAL GOALS AND
MAIN EMOTIONAL AND MENTAL DISORDERS
THAT LEAD PEOPLE TO ENTER THERAPY_
§1 Personal development goals
[ ] §1.1 developing new skills and personal traits: education leading
to growth
[ ] §1.2 eliminating self-destructive habits or undesirable personality
traits: re-education leading to change (see §3 below)
{68}
§2 Disorders usually first noticed in childhood or adolescence
[ ] §2.1 mental retardation
[ ] §2.2 autism
[ ] §2.3 emotional disturbances: separation anxiety, sleep terror and
sleepwalking disorders, etc.
[ ] §2.4 suffering from childhood pain, neglect, or abuse; traumatic
experiences from childhood, unmet childhood needs
[ ] §2.5 behavior problems: hyperactivity, antisocial behavior,
movement disorders (see §10 below)
[ ] §2.6 delinquency and criminal behavior
[ ] §2.7 eating disorders: obesity, bulimia, anorexia nervosa
§3 Personality trait problems
[ ] §3.1 shyness/passivity
[ ] §3.2 loneliness/emptiness
[ ] §3.3 hostility/overbearing personality
[ ] §3.4 fear of withdrawal of affection and of abandonment
[ ] §3.5 general interpersonal problems
[ ] §3.6 need to improve effectiveness of communication skills
[ ] §3.7 difficulties in coping with persons in authority
[ ] §3.8 loss of faith in oneself or in others, or in life's purpose
or end
[ ] §3.9 low self-worth, desire for a success-identity (self-esteem
resulting from a sense of achievement)
[ ] §3.10 deep discouragement with life (see §5 below)
§4 Neuroses
[ ] §4.1 anxiety disorders, panic disorders, post-traumatic stress
disorders, etc.
[ ] §4.2 phobias
[ ] §4.3 compulsions
[ ] §4.4 noögenic neuroses (resulting from serious conflicts between
opposing values)
[ ] §4.5 psychosomatic disorders, hypochondria
[ ] §4.6 sexual disorders
[ ] §4.7 impulse control disorders: e.g., pathological gambling,
kleptomania, pyromania
{69}
§5 Mood disturbances (affective disorders)
[ ] §5.1 depression
[ ] §5.2 mania
[ ] §5.3 manic depression
§6 Adjustment problems
[ ] §6.1 in relation to a new environment or an already familiar one;
work inhibitions
[ ] §6.2 in persons with counterculture attitudes and values
[ ] §6.3 emotional difficulties arising from poverty and from the
deprivations suffered by minority groups
[ ] §6.4 inability to accept realities that limit life: e.g.,
financial limitations, restricted opportunities, aging and death (see
§9 below), jobs with "no future," responsibilities that stand in the
way of personal development
[ ] §7 Marital problems
[ ] §8 Family problems
§9 Problems related to aging
[ ] §9.1 emotional problems in facing old age
[ ] §9.2 problems facing the recently widowed
[ ] §9.3 coping with physical pain and disability
§10 Involuntary behaviors
[ ] §10.1 stuttering
[ ] §10.2 shaking or motor tic disorders
[ ] §10.3 insomnia
§11 Crisis intervention: a need for _prompt_ relief from severe
symptoms
§12 Psychoses: schizophrenia, manic and paranoid psychoses, hysterical
psychoses, etc.
§13 Organic disorders
[ ] §13.1 senescence, Alzheimer's disease
[ ] §13.2 Parkinsonism/Huntington's chorea
[ ] §13.3 substance-induced: alcoholism, drug addiction, smoking
[ ] §13.4 organic brain dysfunctions: epilepsy, narcolepsy, amnesia,
dementia, delirium
{70}
MATCHING YOUR GOALS AND PROBLEMS WITH MOST
PROMISING THERAPIES
§_1 Personal Development Goals_
These may involve either (§1.1) _adding_ new skills or qualities or
(§1.2) _subtracting_ habits or undesirable traits.
§1.1. There are basically two different approaches to achieving the
first goal:
* You identify a specific skill or personality trait you would like to
develop--see Table 1, §3. For example, you may want to develop a
stronger success-identity (§3.9), improve your communication skills
(§3.6), gain a stronger sense of life's purpose (§3.8), or become more
assertive (i.e., overcome a degree of shyness, §3.1). For references
to recommended therapies for these goals, see §3 below. For vocational
counseling and therapy: H, I, M
* Alternatively, you decide to approach self-development with a desire
for _broad-spectrum_ improvements. Therapies with this orientation are
not especially concerned with highly specific behaviors or problems but
attempt to treat the whole person so that self-esteem is gradually
increased, as are a sense of satisfaction in daily living, enjoyment of
others, and a feeling of being at ease with them.
Primary therapy (judged to be generally more effective): A, B
Secondary therapy (somewhat less effective): J
§1.2. Refer to §3 below.
§_2 Disorders Usually First Noticed in
Childhood or Adolescence_
§2.1. Mental retardation: O
§2.2. Autism: self-injuring behavior, withdrawal from reality: O, Y
§2.3. Emotional disturbances in children: S, W
§2.4. Suffering from childhood pain, neglect, or abuse: traumatic
experiences from childhood, unmet childhood needs (see §3.4): A, K
{71}
§2.5. Behavior problems in children: O, C
Hyperkinetic behavior:
Primary: Y, O
Secondary: Z
§2.6. Delinquency and criminal behavior: O, E, H, I
§2.7. Eating disorders: obesity, bulimia, anorexia nervosa: O, W
§_3 Personality Trait Problems_
§3.1. Shyness/passivity: Q, C, N, D
§3.2. Loneliness/emptiness: F, Q, D
Sense of estrangement, alienation from others: G
§3.3. Hostility/overbearing personality: E, D, N, Q
§3.4. Fear of withdrawal of affection and of abandonment (also see
§3.2 above): R or S, D, A
§3.5. General interpersonal problems:
If you are willing to work on these within a wider focus: A
Involved in relating to others on an individual basis: E, P, W
§3.6. Need to improve effectiveness of communication skills: D
In groups of people: Q
§3.7. Difficulties in coping with persons in authority: C, D
§3.8. Loss of faith in yourself or in others or in life's purpose or
end: F, G, X
§3.9. Low self-worth: B
Desire for a success-identity: H, M
§3.10. Deep discouragement with life (see §5 below): I
§_4 Neuroses_
A person is said to suffer from a neurosis if he or she has exaggerated
emotional responses or ideas of reality that blow things out of
proportion. Individuals with neuroses are able to communicate normally
or with mild emotional interference. Their emotional problems
interfere with normal living but do not impair them so that their lives
are clearly out of control (as in psychoses, alcoholism, drug
addiction, etc.).
§4.1. Anxiety disorders, panic disorders, post-traumatic stress
disorders, etc.:
{72}
_Anxiety and panic attacks_ are characterized by feelings of fear,
dread, and tension. You may have a sense of imminent disaster or
death, a feeling of helplessness often followed by depression. (These
are also symptoms of _chronic anxiety_.) Other symptoms of anxiety and
panic attacks include dizziness, dry mouth, sweating, headaches, heart
palpitations, increased blood pressure, rapid breathing, weakness,
insomnia, increased urination, a feeling of unreality, diminished
concentration, memory difficulties, indecision, obsessive thinking
about anxiety symptoms, second-order anxiety (anxiety that you are or
will be anxious), and desperation to obtain relief.
Primary: Y, H, F, V, T, W, X Secondary: H, K, U
_Post-traumatic stress disorders_ are frequently misdiagnosed as
anxiety disorders. Patients suffering from post-traumatic stress have
been exposed to situations of great stress--e.g., battlefront
conditions, rape, imprisonment in a concentration camp. These
situations are perceived as inescapable, and they leave long-lasting
emotional scars. Symptoms include reactions delayed until days or
months have passed since the trauma situation, emotional numbing,
chronic anxiety, restlessness, irritability, recurrent nightmares,
increased startle responses, impulsive behavior, and depression.
Primary: Y, in conjunction with therapies recommended for anxiety
and panic attacks.
§4.2. Phobias: Phobias are fears that are disproportionate to the
threat of a situation. They are involuntary and cannot be reasoned
away. They lead to avoidance of the feared situation.
Primary: N, L, Y, W, V Secondary: U, A, K, D
For fears of public speaking, especially: E
§4.3. Compulsions: People with neurotic compulsions engage in
repetitive rituals that give them temporary relief from anxiety.
Compulsive behaviors are often motivated by a desire for exactness and
perfection--for example, compulsive hygiene, washing, counting,
praying, reflecting about yourself, repetitive isolated thoughts,
preoccupation with trifling details, etc.
Primary: E, M, O, A Secondary: Y, T, K
Compulsions that arise, or may be resolved, in relation to your family:
S
{73}
§4.4. Noögenic neuroses: A person can be emotionally disabled by
serious conflicts between opposing personal, ethical, or religious
values. This problem has not gained widespread recognition among
psychiatrists and therapists. It is a focus of logotherapy (see
Chapter 11): G
§4.5. Psychosomatic disorders, hypochondria: Physical disorders caused
by emotional problems are psychosomatic. Examples include some cases
of colitis, stomach cramps, diarrhea, constipation, ulcers, cardiac
arrhythmias, impotence, back and neck spasms, and migraines.
Hypochondria involves an exaggerated concern over potential and
imagined symptoms of disease.
Physical examination followed by: P, C, N, W, X
§4.6. Sexual disorders: These include impotence, frigidity, vaginismus
(vaginal muscle spasm), premature ejaculation, and sexual role
disturbances when accompanied by emotional disorders or poor social
functioning (some cases of homosexuality, transsexualism): P, E, O, N,
W; sometimes with Y
If you are willing to work on this within a wider focus: A
§4.7. Impulse control disorders: e.g., pathological gambling,
kleptomania, pyromania: O, M, E, Q
§_5 Mood Disturbances (Affective Disorders)_
There are three primary mood disorders: depression, mania, and manic
depression. They may be neurotic, or they may be psychotic, in which
you experience hallucinations, delusions, and withdrawal from reality.
Each disorder may be situational or nonsituational, depending on the
role of precipitating events, such as the death of a loved one, loss of
a job, diagnosis of terminal illness, etc. Situational mood disorders
usually disappear with time. All three disorders may appear as
isolated episodes, or they may be recurrent.
§5.1. Depression: Clinical depression is not simple sadness or grief.
Severely depressed people speak slowly, laboriously. It is difficult
for you to maintain attention and concentration. You may have feelings
of hopelessness, despair, heaviness, self-blame, heightened
self-criticism, great pessimism about the future, inability to make
decisions, tendencies to think of suicide and sometimes to commit it.
Dependence on loved ones increases as you feel helpless. Interests
diminish in work, hobbies, and friends. You may cry frequently; you
may be irritable and {74} inclined to have angry outbursts. You
probably sleep poorly and awaken frequently, particularly in early
morning. Anxiety is common in about 50 percent of patients. There is
frequently little appetite for food or for sex: Y, E, P, U, T, W, X
As a sense of deep discouragement with life: H
Depressed as a result of a conflict in personal values: G
If you are willing to work on your problems within a wider focus (also
see §1.1): A
§5.2. Mania: You tend to have exaggerated beliefs in your
capabilities; you tend to be euphoric and may fall in love easily and
repeatedly. You suffer from impulsiveness, poor judgment, racing
thoughts, sometimes explosive anger. Milder degrees of mania are often
welcomed by you, family, and friends, who admire your enormous energy
and your many "irons in the fire." Only when family and friends become
aware of your poor judgment in buying sprees, delusions of grandeur, or
sexual excesses do they try to encourage you to seek treatment, usually
against your own wishes: Y (especially lithium therapy), E, P, T, W, X
§5.3. Manic depression: You are trapped on an emotional roller coaster:
at times you are depressed (see §5.1), and at other times you
experience the highs of mania (see §5.2): Y (especially lithium
therapy), and therapies listed under §5.1.
§_6 Adjustment Problems_
Some critics of psychotherapy have argued that its main purpose is to
serve the interests and values of society: a person is judged to be
"abnormal" if he does not want, or refuses, for example, to work from
nine to five all but two weeks of the year; if he does not accept the
responsibilities society claims he should respond to as an adult, a
citizen, a husband, or a father. These social demands--so critics of
therapy have argued--have been internalized by most therapists so that
therapies often do not really serve the individual's needs but rather
the prevailing belief-system of society. Whatever validity the
critics' argument may have, it relates particularly to this area of
emotional suffering that falls under the heading of adjustment
disorders.
Some adjustment disorders clearly lie outside the boundaries of this
criticism. For example, a woman faces the loss of her husband and
resulting poverty. She becomes anxious and depressed, {75} and these
feelings do not go away with time. Or, a man agrees to a job transfer,
wants to succeed at his new position, but is overwhelmed by anxiety in
his new environment. His anxiety doesn't go away.
§6.1. In relation to a new environment or an already familiar one;
work inhibitions: H, M, E, P, N
§6.2. In persons with counterculture attitudes and values: H, D
§6.3. Emotional difficulties arising from poverty and from the
deprivations suffered by minority groups: C
§6.4. Inability to accept realities that limit life: e.g., financial
limitations, restricted opportunities, aging and death (see §9 below),
jobs with "no future," responsibilities that stand in the way of
personal development: F, H
§_7 Marital Problems_
It may be worth mentioning that after a period of therapy some problems
turn out to be marital in nature even though both husband and wife
believed them to be an individual's emotional problem--the man's
problem, not the wife's, or vice-versa, and certainly not a "marital
problem." Sometimes it is only after many individual sessions of
therapy that the marital basis of a problem becomes clear. When
appropriate, the expressed willingness of a spouse to become involved
in his or her partner's individual therapy can be a real help,
providing emotional and treatment support and also saving time when in
fact the marital relationship itself contributes to the individual's
problems.
General marriage therapy: Primary: R, D, E, H, I
Secondary: P, N, I
For communication problems: R, D
§_8 Family Problems_
There is a growing realization among therapists that many individual
problems are produced by families torn by conflict. Often, family
therapy can provide more effective help to a troubled individual than
therapy that treats the individual alone. This seems to be especially
true in many cases of schizophrenia (see §12 below) and in fears of
withdrawal of affection and of abandonment (see §3.4 above).
General family therapy: S, D, C, I, N
{76}
§_9 Problems Related to Aging_
§9.1. Emotional problems in facing old age: E, G
§9.2. Problems facing the recently widowed: H, G
§9.3. Coping with physical pain and disability: U, V, W, Y, X
§_10 Involuntary Behaviors_ (see §13 below)
§10.1. Stuttering: U, G, I, O, W
§10.2. Shaking or motor tic disorders: U, G, I, Y, W
§10.3. Insomnia: V, U, W, Y
§_11. Crisis Intervention:_ _A Need for_ Prompt _Relief from Severe
Symptoms_
Crisis telephone hotlines are available in most metropolitan areas for
immediate counseling and referrals. If such services do not exist in
your area, your family physician, minister, local clinic, hospital, and
even police can be of assistance.
Primary: usually Y followed by B, C, F, or G
Secondary: W, N, O, or P
§_12 Psychoses_
If you have a psychosis, you behave in response to delusions or
hallucinations. Your behavior is seen by others as strange and
inappropriate; you are inclined to withdraw from social groups. You
are severely impaired, out of touch with reality, often unable to
communicate, illogical, rambling, incoherent. Your emotional responses
are greatly out of proportion, even inconsistent, with external events.
There are numerous forms of psychosis, including types of
schizophrenia, manic and paranoid psychoses, hysterical psychoses, and
others. Since self-diagnosis for these conditions is neither
appropriate nor likely to be accurate, no detailed discussion of the
distinct forms of psychosis will be given here. Any diagnosis of
psychosis requires a careful evaluation by a psychiatrist, clinical
psychologist, or psychotherapist.
Primary: Y (antipsychotic drugs) in conjunction with M, O, or H
Secondary: Y with S or A; Y with T
{77}
§_13 Organic Disorders_
§13.1. Senescence, Alzheimer's disease: Senescence is associated with
aging. Three-quarters of persons sixty-five years old and older have a
chronic, disabling condition such as emphysema, heart disease, or
hypertension. Most elderly individuals are able to cope with these
disabilities for the rest of their lives. Some, however, begin to have
psychological problems associated with senescence--e.g., confusion,
depression, paranoia, and sometimes delirious states: supportive
therapies: (e.g., B) and sometimes Y
In Alzheimer's disease, which is a distinct disease and not simply a
sign of aging, you may have numerous physical complaints that cannot be
traced to a physical illness. You may be irritable, lack energy, be
apprehensive, show increasing forgetfulness and changes of personality.
Family members may complain that you "are not yourself." Presenile and
senile dementia are two forms of Alzheimer's disease; both are
progressively degenerative: Y, care by family or by nursing home to
provide supportive environment, planning of daily activities, etc.
§13.2. Parkinsonism/Huntington's chorea: Both are movement disorders
that can produce psychiatric problems, including depression and
schizophrenic disturbances.
§13.3. Substance-induced: alcoholism, drug addiction, smoking.
Alcoholism: Y, O, Alcoholics Anonymous
Drug abuse: Primary: Y, Synanon, O
Secondary: M, D, K
Smoking: O, W
Potentially useful for all of the above as adjunctive treatments: T, X
§13.4. Organic brain dysfunctions: epilepsy, narcolepsy, amnesia,
dementia, delirium. There are numerous conditions caused by
abnormalities in brain function. They do not lend themselves to
self-diagnosis or treatment. The main treatment is: Y
{78}
STEP 2
TAKING YOUR PERSONALITY INTO ACCOUNT
What is challenging for a therapist is discerning the form of
learning that each patient can best utilize and then working to
adopt techniques that are best suited for the patient.... An
important area of research is a way of detecting in a patient his
optimal modes of learning. If we can pinpoint these, we can then
more precisely determine the best means of therapeutic operation.[2]
[2] Lewis R. Wolberg, _The Technique of Psychotherapy_, 2 vols. (New
York: Grune & Stratton, 1977), vol. I, p. 271.
Some people are more amenable to certain approaches to therapy than
others; for example, some people like and benefit from group therapy,
while others hate it. Sometimes what a person likes or would prefer
needs to be overlooked in favor of treatment that is believed to be
effective. But the vast majority of people who enter therapy do this
of their own volition. If the therapy they enter is unsatisfying or
downright distasteful to them, they will soon give it up. We simply
tend not to learn and profit from experiences we dislike or that don't
fit the kinds of people we are.
For some time now therapists have recognized that a client's
personality often tends to incline him or her toward certain approaches
and away from others. In the second step in identifying a potentially
promising approach to therapy, you are encouraged to take traits of
your own personality into consideration. It is not merely the goal or
problem that suggests a particular approach to therapy, but--what is
often more important--the nature of the person. Too little attention
is given to the appropriateness of an individual for a given kind of
therapy.
{79}
_TABLE 2:_
_AN OVERVIEW OF MAIN PERSONALITY TRAITS
RELEVANT TO THE CHOICE OF A THERAPY_
Choose no more than three of the following that you believe influence
most strongly the way you approach day-to-day living:
[ ] §1 Self-discipline
[ ] §2 Commitment to tasks you set for yourself
[ ] §3 Patience
[ ] §4 Initiative
[ ] §5 Tolerance to frustration
[ ] §6 Rigidity
[ ] §7 Inhibition
[ ] §8 Introversion or extroversion
[ ] §9 Motivation and capacity for physical exercise
[ ] §10 Need for acceptance, human warmth, and gentle encouragement
[ ] §11 Articulateness and analytical attitude
[ ] §12 Reflectiveness--thinking about your own feelings, thoughts, and
behavior
[ ] §13 Imagination
[ ] §14 Sensitivity to values
[ ] §15 Comfort in a group setting
[ ] §16 Severe impairments--learning, communication, or emotional
disabilities, including addictions that seriously disrupt your daily
life
{80}
In the following section, you will find questions relating to the
sixteen personal qualities listed in Table 2. For those qualities you
check, answer the questions as realistically as you can. If, for the
most part, you answer "yes" to a given group of questions, then the
approach(es) to therapy identified there may be especially appropriate
for the kind of person you are. If you answer "no" to most of the
questions in a group, then the listed therapy or therapies may not be
especially well suited to you.
MATCHING YOUR PERSONALITY WITH
THE MOST PROMISING THERAPIES
§_1 Self-Discipline_
Therapies rely on self-discipline in clients in several ways:
Are you able to _stick_ to a prescribed routine and do practical
assignments on your own outside of therapy sessions to practice
attitudes, communication skills, or behaviors?
Will you take _personal responsibility_ for coming to regular
appointments on time?
Can you _give up_ any real payoffs of being emotionally troubled?
When _any_ approach to therapy is successful, it is in large measure
because a client has strong personal motivation, a strong will.
However, some approaches to therapy depend more heavily than others on
a client's strength of determination. They include: M, O, E, P, I, N,
H, A, X, T
§2 Commitment to the Process of Therapy
Do you believe you can commit yourself to therapy that spans many
months and sometimes several years? If you hope to gain long-lasting
benefits from your experience in therapy, you will need to commit
yourself to certain practices and ways of thinking _after_ formal
therapy has ended. Do you feel that you have this kind of _tenacity_
and _ability to follow through_?
These are both qualities related to self-discipline, but they have more
to do with sustaining a process over a long period of time: in a word,
_commitment_.
Do you feel you can develop a strong sense of commitment to long-term
therapy? A
To a long-range plan for life improvement? H, M
{81}
§_3 Patience_
If you are suffering from incapacitating anxiety or depression, being
patient about the process of therapy can be very demanding. Long-term
therapies require more patience, endurance, and tolerance than do
short-term therapies.
Are you able to put your trust in a process where results are noticed
only very gradually? (If not, you may feel that what is most urgent
now is to obtain prompt relief from symptoms--see the "Summary of Main
Approaches to Psychotherapy," at the end of this chapter, to get some
idea of the average durations of the different therapies.)
Therapies especially requiring patience--with yourself, with the
challenge, or with the duration of therapy--include: A, H, M, X
§4 Initiative
Some approaches to therapy offer very little direction or specific
advice from the therapist.
Do you feel that you have the initiative to proceed without explicit
direction from the therapist? If so, what you probably need in a
therapist is primarily the capacity to understand you well, to accept
you as a person, and to encourage you in a warm and positive way to do
what you think is best: B
§_5 Tolerance to Frustration_
Do you have a fairly high threshold of frustration when your beliefs
and ideas are challenged? When you do not immediately get what you
want, can you tolerate fairly well what may seem like a long route to
get where you want to go? (Do you cope well with the frustration of
getting lost in your car, for example?) Can you tolerate, without
serious irritation, anger, or hurt, being pushed to confront some of
the pretenses or distortions or illusions you may have lived by?
Can you accept, with some calmness of mind, having someone point out to
you that you have not been as clear about things as you thought, and
that sometimes your attitudes are not consistent, that you are, to some
extent, confused? A, C, E, P
§_6 Rigidity_
Do you often find yourself trying to be, or wishing you were someone
you're not? C
{82}
Are you perfectionistic? Upset when you make even fairly minor
mistakes? Concerned that "things be in their proper place"? Are you
frequently intense and uptight? C, J
Are you "overcontrolling"--anxious when you do not feel you have things
clearly under control?
Are you depressed (see §5, Table 1) or phobic (see §4.2, Table 1)?
Do you suspect that other people think that you magnify evils, blowing
negative things out of proportion? Are you inclined to be moralistic,
dogmatic, critical, or judgmental?
Are you an uncompromising person?
Do you feel, deep down, that perhaps your expectations and demands
(concerning others, yourself, and the world) may be unrealistic?
Do you think you are often inclined to confuse what you would like with
what you need? E, P, H
§_7 Inhibition_
Do you feel blocked, inhibited, or held in check by an overly critical
self? B
Do you feel that you have pent-up feelings that are in need of release?
Do you feel stultified or oppressed by your relationships with your
spouse, friends, or family? Does your life lack emotional intensity?
Do you obtain little joy or satisfaction from living? C, J
Do you feel that somehow there are blocks _in you_ that are standing in
the way of your self-realization, of fulfilling your potential? H
§_8 Introversion or Extroversion_
Are you inner-directed? Would you rather be alone or with one or two
friends than attend a party? Are you impatient, or do you even resent
receiving unsolicited suggestions? A, F
On the other hand, are you at ease with groups of people? Is it
important to your self-image what other people think of you? (Are you
perhaps status-oriented?) Do you often find it useful or helpful to
receive advice? Q
§_9 Motivation and Capacity for Physical Exercise_
Are you free of physical handicaps?
Do you _like_ to be physically active, to exercise?
{83}
Do you begin to feel restless when a week or more goes by and you have
been sedentary?
If you are not physically fit now but are healthy, does it appeal to
you to work regularly and hard to become physically stronger and to
improve your endurance? T, J, yoga (see U)
§_10 Need for Acceptance, Human Warmth,
and Gentle Encouragement_
Do you feel that perhaps no one has ever taken the time to listen to
you, to take a genuine interest in you and in your problems as a person?
Do you feel, perhaps because of circumstances or problems over which
you've had no control, that you have received rather little human
warmth from others?
Would you prefer encouragement that is patient and warm rather than a
forceful push to change your life? B
§_11 Articulateness and Analytical Attitude_
Can you talk openly and clearly about your feelings, about what is
troubling you? Can you fairly readily describe examples of situations
that may bother you?
If you were asked to describe the _personality_ (not his or her
physical features and behavior) of someone you talked with last night
for half an hour at a party, could you do this without a lot of
hesitation and brow-furrowing?
Do you _like_ to talk about personal problem solving, about your
feelings, past events, and why you have come to feel as you do? Do you
feel a _need_ to acquire an overall sense of understanding of yourself,
your family, and how they have influenced you? A
§_12 Reflectiveness_
Do you often find yourself thinking about your feelings, about the
purpose of life, and about whether yours has a meaningful direction?
Do you tend to come home from a visit with friends or family and go
over in your mind what went on and wonder why people said and did
certain things?
Do you have a mental habit of standing apart from what you're doing and
judging yourself and your work?
Do you spend much time just "thinking about things," even dwelling on
problems that concern you? A, G
{84}
§_13 Imagination_
As a child, did you have an imaginary friend?
When you sit on a rock by a brook in the woods, do you quickly begin to
feel a special sense of relaxation? Or, watching the waves breaking on
the beach, do you find yourself lulled into a sense of absorption in
nature?
Do you enjoy reading? As you read a descriptive novel, do you tend to
"see" many of the places and people? Do the events come alive for you?
Do you find yourself thinking about the events in the book as though
they make up a real world of their own? W
§_14 Sensitivity to Values_
Are personal values very important to you? For example, do you
sometimes find yourself thinking that so much of television programming
is mediocre, trash, a waste of time? Do you _feel_ that there are
human values that are more important than how much money you make, what
model car you drive, and the luxuriousness of your home?
Are you a religious or spiritual person, whether you attend church or
not?
Do you like art, music, or literature?
Do you feel, really feel, a sense of compassion or empathy for people
who face poverty and misfortune? Do you sometimes feel guilty because
of your own situation, that there always seem to be others who are
worse off?
Have you ever faced the opportunity to take advantage of someone or of
a situation and simply decided not to (even though you _knew_ you could
do this without risk) because you simply wanted to feel honest or
retain a sense of your own integrity?
Are you in search of a richer meaning in life? Do you wonder whether
what you are doing with your life is really right for you? G
§_15 Comfort in a Group Setting_
Do you feel comfortable and safe in groups?
Do you feel friendly when you pass a house where a party is going on?
Do you enjoy parties or social gatherings?
Did you come from a family with several children? Q, C
{85}
§_16 Severe Impairments_
Do you have any learning or communication disabilities?
Are you so troubled because of emotional upheaval that you cannot work
or maintain your family responsibilities?
Do you have any addictions that are causing grief for you or others
close to you?
Do you sometimes have to "let off steam," even though you know you are
hurting others, damaging their property, or injuring yourself?
{86}
STEP 3
_TABLE 3:_
_THE APPROACHES TO THERAPY
DISCUSSED IN THIS BOOK_
In the left column are the letters used in this chapter to identify
each approach to therapy:
_Letter
Code_ _Approach to Therapy_ _Chapter_
[ ] A Psychoanalysis 9
[ ] B Client-centered therapy 10
[ ] C Gestalt therapy 10
[ ] D Transactional analysis 10
[ ] E Rational-emotive therapy 10
[ ] F Existential-humanistic therapy 10
[ ] G Logotherapy 11
[ ] H Reality therapy 11
[ ] I Adlerian therapy 11
[ ] J Bioenergetics } 11
} Emotional
[ ] K Primal therapy } flooding 11
} therapies
[ ] L Implosive therapy } 11
[ ] M Direct decision therapy 11
[ ] N Counter-conditioning } 12
}
[ ] O Behavior modification } Behavioral 12
} psychotherapies
[ ] P Cognitive approaches }
to behavior change } 12
[ ] Q Group therapy 13
[ ] R Marriage therapy 14
[ ] S Family therapy 14
[ ] T Therapeutic exercise 15
[ ] U Biofeedback 15
{87}
[ ] V Relaxation training 15
[ ] W Hypnosis 15
[ ] X Meditation 15
[ ] Y Drug therapy 16
[ ] Z Nutrition therapy 15
HOW TO USE THE INFORMATION YOU NOW HAVE
If you have followed the instructions for Steps 1, 2, and 3, you should
have identified a potentially promising therapy, or group of therapies,
in relation both to your goals or problems and to your own estimation
of certain important traits of your personality or character.
The therapy or approaches to therapy you have identified now need to be
tested, first, in your imagination as you read the chapters of this
book, which will give you an idea of what each major approach to
therapy is like, and then, if you decide to proceed, in reality, when
you have located a suitable therapist (see Chapter 17).
The need for this testing is a matter of simple realism: you now have a
sense of direction, or perhaps several alternative directions, to
consider. The approach to self-diagnosis described in this chapter is
intended to be useful, but it is not infallible; much depends on the
accuracy of your problem diagnosis, the appropriateness of the goals
you have set, and your self-understanding. Much also will depend on
the therapist you locate and how well you are able to work together.
The recommended therapies listed by letter codes for Steps 1 and 2
reflect evaluations from several sources: (1) Therapists themselves
claim that certain approaches favored by them have been shown to be
useful for treating certain problems, for realizing certain goals, and
for clients with certain personal qualities. (2) Various studies also
have attempted to demonstrate for what and sometimes for whom many of
the major therapies are most successful (see Chapter 20). (3)
Primarily in the _ordering_ of letter codes in connection with the
specific {88} goals, problems, and personal qualities listed in Steps 1
and 2, I have relied on my own experience and judgment. Letter codes
_listed first_ designate therapies that, in general, are commonly
regarded by therapists and psychologists as most useful. At times,
when general consensus appeared to be lacking, I have used my own
evaluation.
The intention in this chapter is to make explicit a simple and
reasonable process of choosing a therapy. Many therapies are not
mentioned in connection with specific goals, problems, or personality
traits. To be sure, some of the therapies that are not mentioned _can_
be useful to certain individuals who have a given goal, problem, or
trait. But the objective of this book is to improve the _general
reliability_ of a person's self-diagnosis and self-understanding. The
book is a _guide_, not a bible.
COMBINING APPROACHES
There is evidence that combining two therapies for certain problems can
frequently be more effective than using either in isolation. Treatment
for individuals suffering from severe anxiety or depression often will
combine drug therapy, for example, with one of the fourteen approaches
to therapy described in Chapters 9-12 and 14 (and listed below, under
"A"). Or, individuals who have problems due to excessive stress may,
for example, be advised to combine biofeedback, relaxation training,
hypnosis, meditation, or exercise therapy with a form of psychotherapy.
Usually, when therapies are combined, one is a formal psychotherapy and
the other is an _adjunctive_ therapy--that is, a therapy that most
often is not relied on exclusively. Some adjunctive therapies lend
themselves very well to use by individuals on their own. Combined
treatments tend, then, to employ one approach taken from list A and one
from list B:
_A (Main Therapies)_
Psychoanalysis
Client-centered therapy
Gestalt therapy
Transactional analysis
Rational-emotive therapy
Existential-humanistic therapy
{89}
Logotherapy
Reality therapy
Adlerian therapy
Direct decision therapy
Behavior modification
Cognitive approaches to behavior change
Marriage and family therapy
_B (Adjunctive Therapies)_
Drug therapy
Meditation
Hypnosis
Relaxation training
Biofeedback
Therapeutic exercise
_Approaches That May Appear Under Either A or B_
Bioenergetics
Primal therapy
Implosive therapy
Counter-conditioning
Group therapy
{90}
_A SUMMARY OF THE MAIN APPROACHES TO PSYCHOTHERAPY_
_Average_
_Therapy_ _Best Suited For:_ _Duration_[*] _Cost_[**]
--------------------------------------------------------------
_Client's Personality (not_
_all traits may apply to a_
_Problems or Goals_ _single person)_
-------------------------------------------------------------------------------------------------------------
[*] 1 = Brief therapies, frequently 12 weekly sessions or less; 2 = 3-6
months; 3 = long-term therapies, 6 months to several years
[**] = initially expensive, then $10-25/hr.; ++ = expensive
$50-100+/hr.; + = moderate, $25-50/hr.; 0 = inexpensive, $10-25/hr.; #
= often available on a sliding scale basis (see Chapter 4) through
county clinics, agencies etc
A. Psychoanalysis self-development: broad-spectrum self-disciplined 3 ++ #
improvements committed
suffering from childhood traumas patient
fear of withdrawal of affection tolerant to frustration
and of abandonment introverted
interpersonal problems articulate
phobias analytical
compulsions reflective
sexual disorders
depression
mania
manic depression
psychoses
B. Client-centered self-development: broad-spectrum inhibited 2 + #
improvements possessing initiative
low self-worth needing acceptance,
crisis intervention human warmth, and
gentle encouragement
C. Gestalt behavior problems in children tolerant to frustration 1-2 + to 0
shyness/passivity rigid
coping with persons in authority inhibited
psychosomatic disorders able to work in a group
adjustment problems: minorities setting
and the poor
family conflicts
crisis intervention
{91}
D. Transactional shyness/passivity interested in effective 1-2 0 #
analysis loneliness/emptiness communication
hostility/overbearing personality
fear of withdrawal of affection
and of abandonment
improving effectiveness of
communication
coping with persons in authority
phobias
adjustment problems
marital problems, especially
those involving communication
difficulties
family conflicts
drug abuse
E. Rational- hostility/overbearing self-disciplined 2 +
emotive personality rigid
interpersonal problems
anxiety disorders
post-traumatic stress
phobias
compulsions
sexual disorders
impulse control disorders
depression
mania and manic depression
adjustment problems
marital problems
delinquency and criminal behavior
{92}
F. Existential- loneliness/emptiness introverted 2 +
humanistic loss of faith in yourself, sensitive to existential
in others, or in life's purpose issues
inability to accept life's
limitations
crisis intervention
G. Logotherapy estrangement/alienation from reflective 2 +
others sensitive to values
loss of faith in yourself, in
others, or in life's purpose
noögenic neuroses
depression due to value conflicts
inability to accept life's
limitations
emotional problems in facing
old age
problems of the recently widowed
stuttering
shaking and motor tic disorders
crisis intervention
H. Reality desire for a success-identity self-disciplined 1-2 +
anxiety disorders committed
post-traumatic stress patient
adjustment problems rigid
marital problems
problems of the recently widowed
vocational problems
delinquency and criminal behavior
psychoses
{93}
I. Adlerian deep discouragement with life self-disciplined 1-2 + #
marital problems inhibited
family conflicts
stuttering
shaking and motor tic disorders
vocational problems
delinquency and criminal behavior
J. Bioenergetics self-development: broad-spectrum inhibited 1-2 +
improvements motivated and able to
suffering from childhood pain undertake physical
exercise
K. Primal anxiety disorders pent-up feelings 1-2 =
post-traumatic stress
phobias
compulsions
drug abuse
L. Implosive phobias (nonspecific) 1 +
M. Direct decision desire for a success-identity self-disciplined 1 +
compulsions committed
impulse control disorders patient
vocational problems
adjustment problems
psychoses
drug abuse
{94}
N. Counter- shyness/passivity self-disciplined 1-2 + #
conditioning hostility/overbearing personality
phobias
psychosomatic disorders
sexual disorders
adjustment problems
marital problems
family conflicts
crisis intervention
O. Behavior mental retardation self-disciplined 1-2 + #
modification autism possibly impaired
behavior problems in children
hyperkinetic behavior
delinquency and criminal behavior
eating disorders
compulsions
sexual disorders
impulse control disorders
stuttering
crisis intervention
psychoses
{95}
P. Cognitive interpersonal problems self-disciplined 1-2 + #
approaches anxiety disorders rigid
to behavior post-traumatic stress
change psychosomatic disorders
sexual disorders
depression
mania and manic depression
adjustment problems
marital problems
crisis intervention
Q. Group shyness/passivity extroverted 1 0 #
loneliness/emptiness tolerant to group
hostility/overbearing involvement
personality
improving communication
effectiveness
impulse control disorders
R. Marriage marital problems
supportive therapy for individual (nonspecific) 1-2 + #
problems
fear of withdrawal of affection
and of abandonment
S. Family family conflicts (nonspecific) 1-2 + #
supportive therapy for individual
problems
emotional disturbances in children
fear of withdrawal of affection
and of abandonment
family-based compulsions
psychoses
{96}
T. Therapeutic depression self-disciplined 2-3 0 or
exercise anxiety disorders motivated and able to no
post-traumatic stress undertake physical cost
marital problems exercise
alcoholism
drug abuse
smoking
psychoses
U. Biofeedback physical pain and disability (nonspecific) 1-2 + #
shaking and motor tic disorders
stuttering
insomnia
anxiety disorders
post-traumatic stress
phobias
depression
V. Relaxation anxiety disorders (nonspecific) 1-2 + #
training post-traumatic stress
phobias
physical pain and disability
insomnia
{97}
W. Hypnosis emotional disturbances in imaginative 1-2 +
children trusting
eating disorders
interpersonal problems
anxiety disorders
post-traumatic stress
phobias
psychosomatic disorders
sexual disorders
depression
mania and manic depression
physical pain and disability
stuttering
shaking and motor tic disorders
X. Meditation loss of faith in yourself, in self-disciplined 3 0 or
others, or in life's purpose patient no
anxiety disorders cost
post-traumatic stress
depression
mania and manic depression
physical pain and disability
alcoholism
drug abuse
smoking
{96}
Y. Drug autism possibly impaired 1-3 + + #
hyperkinetic disturbances
anxiety disorders
post-traumatic stress
phobias
compulsions
sexual disorders
depression
mania and manic depression
physical pain and disability
shaking and motor tic disorders
insomnia
crisis intervention
Z. Nutrition possibly hyperkinetic behavior no data available -- --
as well as other
problems (see Chapter 14)
[*] 1 = Brief therapies, frequently 12 weekly sessions or less; 2 = 3-6
months; 3--long-term therapies, 6 months to several years
[**] = initially expensive, then $10-25/hr.; ++ = expensive
$50-100-f/hr.; + = moderate, $25-50/hr.; 0 = inexpensive, $10-25/hr.; #
= often available on a sliding scale basis (see Chapter 4) through
county clinics, agencies, etc.
{99}
8
EMOTIONAL PROBLEMS
THAT MAY HAVE
PHYSICAL CAUSES
This chapter has a single important purpose: to persuade you, if you
are in serious emotional distress, to have a comprehensive physical
examination _before_ beginning psychotherapy. Imagine how disheartened
and frustrated you might feel after a period of unsuccessful therapy,
only to find out afterward that your problems could be traced to a
physical cause. It is essential that you eliminate the possibility of
a physical basis for your problems before seeking therapy. In fact,
most therapists routinely recommend that you have a complete physical
before entering therapy.
Rest assured that doing so will _not_ be a waste of time. Richard
Rada, Director of College Hospital in Cerritos, California, estimates
that between five and ten percent of clients with depression, anxiety,
or unusual thoughts and behavior may have underlying physical
conditions that are responsible, including gland {100} dysfunction, an
epileptic abnormality, heart disease, cancer, and so on. The following
facts, too, should convince you that having a comprehensive physical is
paramount:
* As many as one patient in every ten who suffer from serious
depression has a thyroid disorder.
* One person in every four who are diagnosed as having psychiatric
disorders and who are over sixty-five has an underlying physical
illness that is responsible.
* An equal number of individuals over sixty-five have emotional
problems that are made worse by underlying physical disorders.
* Three percent of people who regularly take prescription medication
develop mental symptoms.
Dr. Leonard Small, a specialist in the field of neuropsychodiagnosis,
has found that the more severe emotional or mental symptoms are, the
more likely it is that therapists (and patients) will overlook the
possibility of underlying physical disorders.[1]
[1] Leonard Small, _Neuropsychodiagnosis in Psychotherapy_ (New York
Brunner/Mazel, 1980), p. vii.
It isn't necessary or possible to give a detailed or comprehensive
catalog of physical causes of emotional and mental disturbances here,
but it may be helpful to many people to see some of the principal ways
in which psychological symptoms can be produced by physical problems.
Hopefully, these illustrations will persuade you, if you are
emotionally or mentally troubled, of the wisdom of a thorough physical.
It is a small price to pay if emotional symptoms can be traced to a
physical cause.
It is well known that virtually any serious organic illness or injury
can produce emotional suffering, either in the form of physical pain or
in the form of anxiety and depression. Chronic pain is a chronic
stress and can lead to the same emotional problems as prolonged stress
of any variety: anxiety or depression. Similarly, prolonged severe
anxiety or depression can cause physical deterioration and make the
body more susceptible to disease.
{101}
There are, then, two "vicious circles," or feedback loops, that can
play a role in causing or aggravating emotional disturbance:
[Illustration: The two "vicious circle" or feedback loops that may
exist between physical disorders and emotional disturbances]
In the first loop, an underlying physical disorder, which may be a
disease or a physical injury, leads to emotional symptoms (and very
likely to physical symptoms as well, although these may not be as
pronounced). However, the emotional reactions that are produced can
themselves make the physical disorder worse, and certainly emotional
disturbance makes living with and treating the underlying physical
disorder more difficult.
In the second loop, emotional disturbances cause certain physical
disorders: a peptic ulcer, heart palpitations, ulcerative colitis,
backache, hypertension, or high blood pressure, etc., and may
predispose certain individuals to arthritis, cancer, or diseases of the
immune system. Once a psychosomatic link has been established between
a troubled mind and the body, and an organic disorder has come about,
the physical disorder, in turn, can produce stronger or more
exaggerated emotional reactions. Anxiety or depression may increase
because the person is now both physically ill and emotionally troubled.
These two so-called positive feedback loops can obviously {102} lead to
a runaway process that becomes worse and worse. Psychosomatic medicine
focuses on the second of these; our focus here is on the first:
physical origins of emotional disturbance.
Underlying physical disorders of this kind include metabolic diseases,
disorders and diseases affecting the brain and nervous system, head
injuries, other physical disorders and conditions, infectious diseases,
reactions to medication, and drug addiction and alcoholism. Each is
discussed in the remainder of this chapter.
METABOLIC DISEASES
Several well-known metabolic diseases can lead to emotional
disturbances:
HYPERTHYROIDISM
An overactive thyroid, known as _hyperthyroidism_, is usually caused by
the pituitary gland's overproduction of a hormone called _TSH_, or
_thyroid-stimulating hormone_. This causes the thyroid, a
butterfly-shaped gland in the lower part of the neck, to produce an
excess of the thyroid hormone thyroxine. Hyperthyroidism is eight
times more common in women than in men.
The emotional symptoms of hyperthyroidism include a more intense and
chronic nervousness than in hypothyroidism (discussed below),
overreactions to minor crises, moodiness, frequent fear without knowing
why, a sense of agitation, dread, and occasionally trembling or
shaking. Some patients with serious hyperthyroidism may have symptoms
resembling those of schizophrenia, in which there is little or no
contact with reality.
Physical symptoms include rapid loss of weight, unusual appetite, rapid
pulse, diarrhea, and muscle weakness (especially in the legs, as when
climbing stairs). The classical symptoms of hyperthyroidism are
staring eyes and enlargement of the neck, but these need not be present.
It is interesting to note that certain factors in upbringing and
personality seem to predispose people to hyperthyroidism (this would
mean that a feedback loop of the second type may precipitate the
disease in some people). Individuals who later develop hyperthyroidism
often have these characteristics:
{103}
* They were forced prematurely to become self-sufficient and
responsible.
* They felt rejected by one or both parents and feared a loss of
emotional support.
* Their early dependence needs (their needs for affection, mothering,
warmth, etc.) were frustrated, and this led to feelings of insecurity
and low self-esteem and to the belief that the world is a threatening
place.
* They often had dominant, tight-lipped, overcontrolling mothers.
HYPOTHYROIDISM
An underactive thyroid, known as _hypothyroidism_, is caused by an
inadequate production of thyroid hormone. It is most common in
middle-aged women.
The emotional symptoms of hypothyroidism include mental sluggishness,
nervousness, depression, irritability, impatience, and frequently
dislike of everyday activities.
Physical symptoms include a sense of heaviness and lethargy, dry skin,
sensitivity to cold, constipation, and thinning hair.
HYPER- AND HYPOPARATHYROIDISM
The parathyroid glands, which are four bean-size glands located on top
of the thyroid gland, manufacture hormones that regulate phosphorus and
calcium levels in the body. Excess hormone raises the calcium level
too high, and psychotic-like behavior can result. Too little hormone
lowers the calcium level to the point that a person may behave like an
alcoholic. These conditions are comparatively rare.
DIABETES
Diabetes, or hypoinsulism, which at the time of this writing affects as
many as 2.5 million Americans, results from underproduction of insulin,
which in turn causes an excess of sugar in the blood and urine.
Diabetes takes two forms: juvenile onset (or insulin-dependent) and
adult onset (or noninsulin-dependent) diabetes. The first type starts
in childhood or young adulthood, and is caused by the body's failure to
produce enough insulin. Juvenile onset diabetes is {104} usually
controlled by means of regular injections of insulin.
Adult onset diabetes is less serious than juvenile diabetes; it occurs
more often in the elderly and especially in people who are overweight.
Diabetes can appear in a person after a traumatic event: great stress,
a physical accident, surgery, infection, or a severe emotional
disturbance. It may also appear after a person has gone through a long
period of fatigue, depression, indecision, or sense of hopelessness.
Those who become diabetic may be individuals who felt strong resentment
toward their parents while growing up or who were "spoiled children."
Diabetic men often were dominated by their mothers while being
excessively dependent on them. Adult onset diabetes is usually
controlled without insulin injections, particularly during the early
stages of the disease. Treatment in about one-third of
noninsulin-dependent diabetics is possible by diet alone; in others, it
is necessary to take oral hypoglycemic drugs that stimulate the release
of insulin.
The emotional symptoms of both forms of diabetes may include apathy,
depression, personality disorders, or even psychosis as a result of
undersecretion of insulin.
Physical symptoms include the need to urinate frequently, day and
night, unusual fatigue and weakness, tingling in hands and feet,
reduced resistance to infections (especially of the urinary tract),
blurred vision, impotence in men, and lack of menstrual periods in
women.
HYPOGLYCEMIA
Hypoglycemia, or hyperinsulism, which affects perhaps as many as five
million Americans, is caused by overproduction of insulin. Excess
insulin leads to low blood sugar (literally, _hypoglycemia_).
Sometimes this overproduction of insulin is caused by a tumor of the
pancreas; the growth can often be removed surgically to correct the
condition.
The emotional symptoms of hypoglycemia include depression and anxiety.
Physical symptoms include fast pulse, palpitations, dizziness, general
weakness, faintness, stomach pain, blurred vision, and sweating. These
symptoms often occur a few hours after eating and disappear after
eating again.
{105}
Hypoglycemia has become almost a fad disease among
"psychonutritionists." The condition is believed by most physicians,
however, to be confined mainly to diabetics who have not kept to a
prescribed routine and have allowed their levels of insulin to become
too high. Sometimes stomach surgery, liver disease, pregnancy, and
periods of high fever can cause attacks of hypoglycemia.
DISORDERS AND DISEASES AFFECTING
THE BRAIN AND NERVOUS SYSTEM
EPILEPSY
The second most common physical cause of emotionally distressing
symptoms, after the metabolic disorders we have just discussed, is
epilepsy. Approximately 7 percent of mentally disturbed patients have
some form of epilepsy.
Epilepsy affects between 1 and 2 percent of the U.S. population. Of
people who have epilepsy, two-thirds appear to have no structural
abnormality of the brain; in the remaining third, the disease can be
traced to brain damage at birth, a severe head injury, an infection
that caused brain damage, or a brain tumor.
The emotional symptoms of epilepsy can involve either anxiety or
depression or both. Once a person has had a convulsive seizure, he or
she may live in constant apprehension that another seizure will occur.
There may be occasional, transient feelings of unreality.
Physical symptoms include peculiar stomach sensations, distorted
vision, occasional bizarre behavior such as laughing for no apparent
reason or sudden and unprovoked anger, loss of consciousness, and
convulsions.
PARKINSONISM
Parkinson's disease often causes anxiety or depression. Physical
symptoms early in the course of the disease include slowing of movement
and inability to write one's name without the handwriting becoming
smaller and smaller. Later symptoms include tremors, muscle stiffness
or rigidity, nervousness, and tension.
{106}
MULTIPLE SCLEROSIS
Multiple sclerosis usually begins in people between the ages of twenty
and forty, affecting slightly more women than men. Symptoms may
disappear after one or a number of attacks, or they may get
progressively worse and cause severe disability.
Emotional symptoms include anxiety, panic attacks, and depression.
Physical symptoms may involve a feeling of numbness or tingling
affecting one limb or one side of the body, temporary blurring of
vision, slurred speech, and difficulty or lack of control in urinating.
BRAIN TUMORS
Brain tumors may cause severe headaches, blurred or double vision,
vomiting without the warning of nausea, general weakness, and, in some
cases, epileptic seizures.
Emotional symptoms may involve nervousness, irritability, memory
problems, and personality changes.
HEAD INJURIES
Head injuries that damage the brain generally cause headaches and
dizziness.
Emotional symptoms usually involve nervousness and sometimes confusion.
In more serious injuries, there may be loss of memory, depression, and
decreased alertness. Severe damage to the brain can cause
unconsciousness that may persist for days or weeks.
OTHER PHYSICAL DISORDERS AND CONDITIONS
PANCREATIC CANCER
Cancer of the pancreas can cause severe depression and insomnia. These
emotional symptoms can occur early in the course of the disease. This
kind of cancer kills nine out of ten of its victims within a year of
being diagnosed. One reason for this tragedy is that pancreatic cancer
frequently reaches an advanced stage before the appearance of its
physical symptoms: loss of appetite and loss of weight, nausea,
vomiting, and upper abdominal {107} pain that may spread to the back.
It is believed that alert psychiatrists can save many lives that
otherwise would be lost as a result of pancreatic cancer by detecting
the disease in its early stages.
ANEMIA
Anemia is caused by an abnormal drop in either red blood cells or
hemoglobin (the main constituent of red blood cells). Iron deficiency
can cause anemia, as can vitamin B12 or folic acid deficiency.
Inherited blood disorders such as sickle-cell anemia can also lead to
anemia.
The main emotional symptom of anemia is depression.
Physical symptoms include weakness, breathlessness, and heart
palpitations, which may occur as the heart attempts to compensate for
anemia by circulating blood faster than normal.
HEART CONDITIONS
Mitral incompetence is a heart condition in which the flaps of the
mitral valve, separating the upper and lower chambers of the heart, do
not close properly. The heart of a person with this disorder must
therefore work harder than normal. Physical symptoms may involve
shortness of breath and fatigue.
Paroxysmal tachycardia is another heart condition, in which the
heartbeat suddenly speeds up to 160 beats per minute or more. An
attack may last for from several minutes to several days. Physical
symptoms include breathlessness, fainting, chest pain, and awareness of
the rapid heartbeats.
The emotional symptoms of both mitral incompetence and paroxysmal
tachycardia may involve anxiety and panic attacks.
MENOPAUSE
Menopause is not a disorder but a natural condition of aging that
involves changes in hormone levels in the body. Menopause in women can
cause intermittent periods of strong anxiety, chronic nervousness,
depression, irritability, lack of confidence, and headaches. Physical
symptoms include hot flashes, sweating, and palpitations. Male
menopause is increasingly being recognized by doctors; symptoms most
frequently appear when a man {108} is in his fifties. Emotional
symptoms may involve anxiety and depression; physical symptoms include
hot flashes, sweating, fatigue, and insomnia.
INFECTIOUS DISEASES
Frequently, emotional symptoms are the first warnings of infectious
disease. For example, fatigue and nervousness maybe the only early
complaints of patients who have hepatitis, infectious mononucleosis,
tuberculosis, and many other diseases. Anxiety and tiredness are
symptoms that deserve careful diagnostic judgment; they are not always
innocuous.
REACTIONS TO MEDICATION
Both over-the-counter and prescription medications can sometimes
produce emotional or mental side effects. Too, as the number of
manufactured drugs increases, the potential for interactions among
different medications increases greatly. Certain drug interactions
produce symptoms of marked agitation, restlessness, and anxiety.
Furthermore, patients who have regularly taken a particular medication
may sometimes find that it begins to cause unexpected side effects.
"False senility" in elderly patients, for example, is often induced by
medication; when the medication is stopped, the undesirable symptoms
disappear.
DRUG ADDICTION AND ALCOHOLISM
Both are runaway habits that can cause nervousness and overreactions to
small crises. Ironically, individuals are usually first attracted to
narcotics or alcohol in order to obtain _relief_ from anxiety. But
once the addictions have become firmly established, emotional symptoms
of depression, irritability, sudden changes of mood, nervousness, and
paranoia are common, as are memory loss and difficulty in concentrating.
Caffeine is an emotionally habit-forming drug. Real addiction--i.e.,
physical dependence with withdrawal symptoms--appears to be rare.
Nevertheless, coffee, tea, and cola drinkers can become emotionally
dependent on caffeine. The drug is a {109} frequent cause of chronic
nervousness in habitual caffeine users. Smoking is a habit that causes
a person to lose approximately 5½ minutes of life expectancy for each
cigarette smoked. Beyond this, smoking is also a common but
unrecognized cause of chronic nervousness, in spite of the fact that
many smokers believe smoking will help steady their nerves.
By now it should be evident that the two main signs of emotional
distress--anxiety and depression--can sometimes be the symptoms of
undetected physical disorders. Especially in cases of severe anxiety
or depression _without_ physical complaints, both therapists and
clients tend to overlook the possibility of physical illness.
It is true that, at present, the majority of such cases cannot be
traced to underlying physical causes; they are therefore treated by
means of psychotherapy or psychiatric drug therapy. As medicine and
biochemistry develop, however, mental and emotional complaints are
increasingly being understood in more physical terms.
Emotional distress clearly does sometimes mask or camouflage the
presence of physical disorders. If you are suffering from serious
anxiety or depression, it is important to have a comprehensive physical
before _beginning_ psychiatric treatment. This is true especially when
the onset of emotional symptoms was sudden--within a period of days or
one to two weeks. It may be most useful to see a diagnostic
specialist--for example, a doctor of internal medicine. But bear in
mind that physicians, even those who are familiar with psychiatric
problems, vary considerably in their diagnostic skills, and sometimes a
second opinion can be worthwhile before you decide that the most
appropriate treatment is psychotherapy.
{111}
PART II
EXPERIENCING THERAPY
In Part II you will be able to develop an overall understanding of the
main approaches to therapy available today. We will look at
psychoanalysis, the first of the psychotherapies, developed by Freud at
the beginning of the twentieth century; and then, in the next two
chapters, discuss ten major psychotherapies. Because of their
widespread use and value, individual chapters will then focus on
approaches to behavioral psychotherapy, group therapy, and marriage and
family counseling. The two final chapters in this section deal with
the therapeutic value of exercise, biofeedback, relaxation methods,
hypnosis, meditation, psychopharmacology or the use of drugs in
therapy, and dietary approaches.
In the discussion of each approach to therapy you will find:
* _a concise description_ of its special perspective
* information on _the kinds of problems_ it is thought to be most
useful in treating--and closely connected with this, but seldom taken
into account--
* a description of _the kinds of individuals_ who tend to profit most
from that approach; and
* an account of _a successful experience in therapy_, reconstructed
from the reports of clients as they look back on their treatment
{112}
HOW TO USE PART II
There are two ways you may find it profitable to use this section of
the book. Perhaps you may decide to combine both of them.
First, you can use the "map" in Chapter 7 to define your goals and to
suggest specific approaches to therapy that, based on your own
self-diagnosis, you might find most beneficial.
On the other hand, you may not feel that mapping out your problem or
goals in the way that Chapter 7 suggests is for you. Perhaps you are
simply curious about the field and would like to learn more about it,
or perhaps you are considering counseling or psychotherapy as an
opportunity for personal growth and do not have particular difficulties
or issues that you want to focus on. For you, it may be more relevant
to read about a wide range of approaches and by so doing gain a clearer
understanding of what the alternatives are, how they work, and what
they may offer you. This "window-shopping" can then form the basis for
a more informed decision later on if you want to enter counseling or
psychotherapy.
THE EXPERIENCES OF CLIENTS IN THERAPY
The reports in this book that describe the personal lives and
experience of real individuals in therapy have all been deliberately
recast to mask all traces of their identities. Their names, life
situations, ages, and other characteristics have been changed.
Descriptions of the experiences of clients in therapy have been greatly
abbreviated and sometimes simplified. As we have already seen,
counseling and psychotherapy last varying lengths of time. Even a very
short period of therapy, over a period of weeks, will bring to light
much more detail than it would be useful for us to discuss here. The
personal lives of the real persons that are portrayed here are
immeasurably more complex and multifaceted than short reports can bring
out.
Sometimes we will use a time-lapse strategy, describing the evolution
of a person's therapy over a period of many months by skipping over
weeks at a time. Always the intent will be to try to convey to you how
real people with real problems have come to deal with their
difficulties more effectively and often, in the process, have been able
to reach a richer understanding of themselves and of others.
{113}
9
PSYCHOANALYSIS
_For wide-range improvements in individuals
who are not severely impaired and who are
articulate, reflective, patient, self-disciplined,
and able to make a potentially long-term
commitment to therapy._
The past hides but is present....
Bernard Malamud, _A New Life_
Psychoanalysis is the root from which the large family of different
theories of psychotherapy and counseling has grown. Sigmund Freud's
first efforts to develop psychoanalysis began in the 1880s. He lived a
long life and was active into his eighties; he died in 1939. Freud
left behind one of the most important contributions to the field of
mental and emotional health. It formed the historical basis for the
diversity of approaches that would follow. Even when later thinkers
took issue with Freud, their work in different ways relied on the
foundation of his pioneering work.
Many of Freud's ideas have worked their way into our everyday
vocabulary: the unconscious, the ego, repression, the Oedipus {114}
complex, and so forth. His work has influenced the study of
anthropology, sociology, history, philosophy, and literature.
FREUD'S THEORY
During Freud's early medical training, he went to Paris to study with a
well-known neurologist, J. M. Charcot. Charcot had begun to use
hypnosis to treat patients with certain physical disorders--paralysis,
for example--for which there was no apparent physical cause (so-called
hysterical symptoms). Working with Charcot, and later with a
physician, Joseph Breuer, Freud began to suspect that these symptoms
were _motivated_ by earlier traumatic experiences that so distressed
the patients that they were forgotten (repressed).
Freud's theory of emotional and mental illness began then to take shape
around this central idea that neurotic behavior has a _purpose_: there
is an underlying _motive_, the motive itself is very upsetting to the
person, and so it is repressed from awareness. But it continues to
gnaw away below the level of conscious awareness and eventually leads
to the disturbance that brings the patient to the point at which he or
she is in need of professional help. Freud believed that recovery
would occur if a patient could be helped to gain insight into these
painful events and feelings that had been forgotten or suppressed. In
a moment, we will look at two real examples.
Freud's theory has several dimensions. First, his theory offers an
explanation of how the mind operates through its defense mechanisms: as
we have noted, excessively painful feelings and memories are repressed.
Second, his theory tries to identify the different psychologically
critical stages children go through on their way to adulthood: the
oral, anal, and genital stages. And third, his theory seeks to
distinguish the parts of the psyche, which together underlie an
individual's personality: the _ego_ (the rational portion of the mind
that deals with reality), the _id_ (made up of basic instincts that
press for gratification), and the _superego_ (formed from parental
influences that have been internalized).
HOW PSYCHOANALYSIS IS DONE
Together, these three so-called dynamic, developmental, and {115}
intrapsychic dimensions of Freud's theory make up the general framework
of psychoanalysis. The central technique of psychoanalysis is to help
the patient become aware of motives that are unconscious.
Psychoanalysis, or analysis for short, is basically an attempt to
extend self-control, bringing disturbing feelings and behavior under a
person's conscious management.
One of the principal techniques is free association. The patient is
made to feel relaxed and comfortable--one reason a couch is sometimes
used. He is encouraged to talk in an uninhibited way about his
concerns and feelings. During this process, the analyst usually
remains detached and restrained so as not to interfere with the
patient's free expression. From time to time, the analyst shares with
the patient certain of the interpretations he has developed on the
basis of the patient's reports and behavior. The analyst's objective
is to help the patient recover lost and painful memories that are
responsible for the conflicts, weaknesses, or inabilities that cause
the patient to suffer.
This process can be very hard on the patient: he or she must revisit
experiences that may be very painful. Analysis requires perseverance,
endurance, and courage. It is not, as we will see, for everyone or
every problem.
One of the most important developments in psychoanalysis has to do with
the increasing popularity of psychoanalytic psychotherapy (also called
_dynamic psychotherapy_), meaning psychoanalysis that is extremely
brief (12 to 20 sessions, for example). Considerably more patients are
now treated with psychoanalytic psychotherapy than with traditional,
intensive psychoanalysis.
TWO EXAMPLES OF PSYCHOANALYSIS
Other than the length and intensity of treatment, the main difference
between Freudian psychoanalysis and brief analysis has to do with the
amount of emphasis that is placed on sexual matters. Freud believed
that an infant's relationship to his environment and parents is
predominantly _sensual_: a baby seeks oral gratification; his attention
is absorbed by what he puts into his mouth. Later, attention is
focused on excretory processes; toilet-training requires the child to
exercise self-regulation for the first time. Later, genital sexuality
becomes the dominant {116} interest. These sexual phases of
development identify the dominant areas of attention that influence the
infant, the child, and then the adult in their behavior toward others.
Brief psychoanalysis generally does not affirm Freud's sexually based
(libido) theory of motivation. The second example that follows
illustrates this shift of emphasis. The first example was described by
Freud himself[1]; the second illustrates brief psychoanalysis.
[1] Sigmund Freud, "Lecture 17," _General Introduction to
Psychoanalysis_ (New York: Garden City Pub. Co., 1943).
A CASE FROM FREUD
Freud describes the analysis of a girl who has repressed a strong
desire for sexual intercourse with her father and has, as a result,
developed a bizarre pattern of behavior.
Unconsciously, the dread of actually making love with him has
generalized to a dread of sexual activity of any kind. Without any
conscious intent on her part, an association is formed between sexual
intercourse and breaking a vase. She is not aware of the unconscious
symbolic connection she has established between these acts. Similarly,
she begins to associate the bolster at the head of her bed with her
father and identifies her mother with the headboard.
The pressure of this repressed material impels her to go through an
elaborate ritual each night before she can get to sleep. First she
arranges the several vases in her room so that she feels they are well
protected against being broken (thereby guarding against sexual
intercourse). Then she makes sure that the bolster does not come into
contact with the headboard (in this way she gains the substitute
satisfaction of keeping her mother and father apart).
As her analysis proceeds, and the analyst is able--and here, timing is
important--to encourage her to become conscious of her repressed
feelings and generalized dread of sex, her need for the nightly ritual
is gradually eliminated.
It is not difficult to think of other problems, sometimes of a
handicapping kind, that, because of their obsessive or compulsive
nature, interfere with normal living. Compulsive handwashing is a
classical example; compulsive overeating, bulimia, {117} and its
opposite, anorexia nervosa, as well as nymphomania, a need for sexual
promiscuity, are a few others.
AN EXAMPLE OF BRIEF PSYCHOANALYSIS
Dr. Richard Chase is a psychiatrist who specializes in emotional
problems of children. John and Rachel Edmonton have come to see him
about their twelve-year-old son, Bobby, their only child. John is an
evangelical minister in his early forties who travels a great deal,
taking his family with him.
When Bobby was eight years old, he began to have strange and violent
nightmares. He would go to sleep and then apparently awaken about an
hour later, asking for a drink of water or expressing a need to go to
the bathroom. A few minutes later, Bobby would seem to lose his
balance and stumble over furniture, sometimes running into walls,
crying aloud that he was "turning inside out" and was dying. Often his
parents would have to restrain him to keep him from hurting himself.
After a few minutes, the nightmare would end and Bobby would come out
of it, a terrified, confused little boy in tears.
So far, John and Rachel, with their frequent moves, had not been able
to get professional help that had made a difference. Bobby had been
examined by a neurologist, and an electroencephalograph test was done
to determine if some kind of epileptic disorder might be involved. The
test was negative. They had also taken Bobby to a child psychologist,
who said that Bobby was bright, sensitive, and precocious, that this
kind of nightmare was called a _night terror_ (_pavor nocturnis_), and
that the problem would eventually subside.
Four years passed, and the night terrors did not. The family of three
was becoming battle-scarred. Bobby hated to go to bed at night,
fearing the inevitable. His parents, sometimes patient, sometimes not,
used whatever ways they could, even a prescribed sedative for Bobby, so
he could relax and get to sleep, to no avail.
Could Dr. Chase help?
Dr. Chase decided to meet with Bobby by himself. He found that Bobby
was very willing to talk about his "bad dreams." Dr. Chase asked him
to describe what happened each night.
"Oh, Doctor," Bobby began, "it's really awful. I know it's going to
happen, but I can't do anything to stop it. I stay up as late as {118}
I can, and I will do anything not to go to sleep. But when I do, I'll
_kind of_ wake up a little later, and I'll see Mother and Dad looking
very worried. At the same time, I'll see a box, with white walls,
glowing brightly, but not in the room where Mother and Dad are. It's
in some space, I guess it's in my mind, a black space, with that
white-colored cube just floating there. And then it begins to turn
inside out. My stomach feels like it's turning inside out, and it
hurts and scares me. It feels awful. I really think if the cube
turned all the way inside out, I'd die. But it never does; I always
wake up first."
Dr. Chase began to meet with Bobby three times a week. He gradually
gained his trust. At a session during the third week of treatment, he
asked Bobby if he would play a word association game with him.
DR. CHASE: Tell me what you think of when I say, "dog."
BOBBY: Cat.
DR. CHASE: Black.
BOBBY: White.
DR. CHASE: Chair.
BOBBY: Cushion.
DR. CHASE: Box.
BOBBY: House.
DR. CHASE: Angry
BOBBY: Mad.
Dr. Chase spent about fifteen minutes writing down some of Bobby's
associations. Bobby gave back associations in the rapid-fire way Dr.
Chase asked, doing this almost automatically, leaving no time to
deliberate. Gradually, Dr. Chase felt he saw a pattern emerging, and
he was able to confirm this from Bobby's associations in later sessions.
Toward the end of the sixth week, Dr. Chase sketched for Bobby's
parents the interpretation he had developed during Bobby's short-term
experience in psychoanalysis: "I believe Bobby has unconsciously been
trying to tell you something in a highly symbolic form: often the mind
expresses deep-seated fears in the imagery of dreams.
"I've tested Bobby in a variety of ways. Always, he appears to
associate the box in his dream with home or with a house. I'm fairly
certain that 'being turned inside out' symbolizes for him the process
of moving out of all the houses you have moved away {119} from. A
house really is turned inside out when you move: all of its contents
are taken out, usually in boxes.
"I believe Bobby is hurting because of your frequent moves. I think if
you will stay in one place, even though I realize that you, John, would
probably have to give up evangelical work, you will gradually see a
real improvement in Bobby."
Dr. Chase's advice was received with a good deal of disbelief by John
and Rachel, but they did, eventually, decide to try it. John became
assistant minister at a local church.
Two years later, Dr. Chase received the following letter:
Dear Dr. Chase:
Maybe you'll remember treating our son, Bobby, for what you called
his "recurrent night terrors." My wife and I followed your advice:
We told him we had decided to stay in Atlanta, so that he could go
to the same high school for all four years.
In about two months, Bobby's night terrors were down to about one a
week. After three months had passed, the suffering our family has
endured for more than five years came to an end. Bobby hasn't had
another episode since then. He's doing well in school, has
friends, and seems quite happy. We all are.
It's sure a pleasure to be freed from the experience that
terrorized us all.
Bless you,
John and Rachel Edmonton
AN ANALYST LOOKS BACK AT HIS OWN PSYCHOANALYSIS
Psychoanalysis is unique among approaches to counseling and
psychotherapy in that it requires analysts, as a part of their training
leading to certification, to undergo psychoanalysis themselves. Not
only is this intended to be an educational experience, but it is
considered essential to their competence in later professional
practice: it is important that they be completely aware of what are
called _countertransference_ feelings toward patients. Just as
patients develop toward their therapists feelings they had toward
significant persons in the past--called _transference_--the analysts,
no less human, do the same. Their relationships with their patients
can revive some of the analysts' own conflicts. They will be unable to
understand the patient clearly, free from distortions created by their
own {120} countertransference tendencies, unless they have come to
understand themselves as thoroughly as it is possible to do so by means
of their own psychoanalysis.
After undergoing a long and intensive period of personal analysis while
in psychoanalytic training, Dr. Tilmann Moser referred to his analysis
as "a successful life-saving operation for my soul." He sought relief
from depression, caused, he now believes, by a troubled relationship
with his parents. He describes his experience in these terms:
Psychoanalysis is a piece of the work of conciliation with one's
own origins. The important ability to be implacable, attached to
the wrong place in the neurotic unforgivingness toward ... [my]
parents, has been freed for aspects of life where it can be used
for efforts directed toward social change, the changing of
conditions that cause avoidable suffering to countless human
beings. The longtime impassable road of affection toward my
parents, based on humor, has been re-opened.[2]
[2] Tilmann Moser, _Years of Apprenticeship on the Couch: Fragments of
My Psychoanalysis_, trans. by Anselm Hollo (New York: Urizen Books,
1977), p. 18.
APPLICATIONS OF PSYCHOANALYSIS
In general, psychoanalysis is successful in bringing about what are
called _broad-spectrum improvements_. It is less intended for
abatement of specific symptoms. In other words, those with highly
_specific_ goals they wish to achieve through therapy tend not to be
good candidates for analysis. For example, a person seeking specific
and prompt relief from depression, public-speaking anxiety, or shyness
may not be appropriate for psychoanalysis. Long-term, intensive
psychoanalysis, because it is long-lasting and very detailed, can lead
to very broad improvements: a sense of increased satisfaction in daily
living; a stronger, more positive sense of self-esteem; a greater
capacity to enjoy and be at ease with others. In the process, specific
symptoms often do subside or disappear, but the focus is general, and
the patient must be willing to embrace a commitment to general
improvement.
On the other hand, _brief_ psychoanalysis may begin by focusing on
specific problems experienced by a patient, but treatment quickly
widens in scope to touch on matters that affect the {121} patient's
life in a general way. We saw this in Bobby's case, where recurrent
night terrors revealed his general need for the greater emotional
stability that comes from feeling settled, having friends, etc.
Psychoanalysis is best suited to problems that fall into two categories:
* Problems that are clearly "neurotic" in nature: they interfere with
living to some degree but do not totally impair you so that your life
is clearly out of control, as in cases involving psychoses (where you
are no longer able to distinguish reality from fantasies and
hallucinations), alcoholism, or drug addiction
* Problems that involve sexual difficulties, mood disturbances, and
impairment of personal relations, assuming that you are willing to work
on these problems within the wider focus that analysis usually requires
Psychoanalysis is _not_ generally considered to be the treatment of
choice for severe impairments, such as alcoholism, drug abuse, and
psychotic disturbances, when your life is clearly out of control.
Analysis is also _not_ generally an appropriate form of treatment for
immediate problems arising from sudden environmental changes, such as
the loss of a job, or loneliness after a transfer to a new job
location, or after a divorce or separation. In some instances, if
problems of this kind are not resolved after a reasonable adjustment
period, analysis might then be considered. Other approaches to therapy
lend themselves better to specific and immediate adjustment problems,
as we will see.
We have been describing the appropriateness of psychoanalysis for the
treatment of certain kinds of problems, but there is an equally
important, and frequently overlooked, question: whether psychoanalysis
is appropriate _for the kind of person you are_. Psychoanalysis is
best suited to individuals with these characteristics:
* They are verbally articulate.
* They have a sense of curiosity about themselves.
* They have a good reflective capacity and an interest in achieving
insight through a careful analysis of their thoughts, feelings,
behavior, and past history.
{122}
* They are comparatively unimpaired in their abilities to form
relationships.
* They are able to tolerate the frustration, and endure the pain, of
re-experiencing disturbing feelings and memories.
* They are willing to be patient through a potentially long period in
treatment and can sustain a commitment to that process.
{123}
10
PSYCHOTHERAPY, PART I
Client-Centered Therapy, Gestalt
Therapy, Transactional Analysis,
Rational-Emotive Therapy, and
Existential-Humanistic Therapy
The approaches to therapy we will look at in this chapter are called
_humanistic therapies_. They include client-centered therapy, Gestalt
therapy, transactional analysis (or TA), cognitive therapy, and
existential (or existential-humanistic) psychotherapy. These
approaches share the view that an effective therapist must be able to
become conscious of the world as it is for the client. Doing this
requires the therapist to have a heightened sensitivity to others, feel
a fundamental measure of respect for them, and ideally be able to
adjust to their very individual needs and concerns. All of the
therapies we will examine in this chapter place priority on the
client's subjective feelings and experiences.
{124}
CLIENT-CENTERED THERAPY
_For people who have not developed a sense of
personal worth; who are in need of
acceptance, human warmth, and gentle
encouragement; and who have the
initiative to proceed both in therapy
and outside of therapy without
explicit direction from the therapist._
The development of client-centered, or nondirective, therapy has
largely been the work of Carl Rogers (1902-1987). His clinical
experience as a child psychologist and his later work in training
students in therapy led him to believe that people frequently come to
have personal problems as a result of the _conditional_ love of their
parents. To receive love and approval from their parents, children
must satisfy certain _conditions of worth_ the parents lay down. If
the children do not live up to the parents' demands, they are punished
by the withdrawal of the parents' affection--a far more serious and
emotionally scarring punishment than a physical spanking. Raised in
this way, people later in life will tend to link their self-worth to
internalized parental standards. Rogers observed that the more the
love expressed by parents is conditional in this sense, the more it is
likely that a person will experience emotional difficulties later on.
As a result, Rogers gradually developed an approach to therapy that
emphasizes "unconditional positive regard." Ideally, a client-centered
therapist is able to express a sense of complete acceptance and respect
toward the client. The therapist does not associate positive regard
with implicit conditions of worth that the client must satisfy. In
other words, client-centered therapy attempts gradually to reverse a
habit that has come to undermine the client's sense of self-worth. It
is a habit that we all, to differing degrees, develop as parents and
society teach us to relinquish self-acceptance in favor of the
conditional love or appreciation of others. Eventually, the habit
becomes so ingrained that it can jeopardize our own feelings of
self-esteem.
Client-centered therapy encourages a client to grow in several ways:
{125}
1. by feeling comfortable enough in the company of the therapist to
express feelings freely and openly
2. by coming to recognize his own feelings of incongruence, of being
divided against himself, often due to experiences that have encouraged
a negative or insecure sense of self-worth
3. by perceiving that the therapist is an integrated, accepting person,
able to convey acceptance and warmth toward the client
4. by reintegrating a sense of self, freeing himself from the
distortions of self-worth brought about by love that has strings
attached
AN EXAMPLE
Melissa Adams is twenty-eight years old, the district manager of a
large pharmaceuticals marketing division in the Midwest. She is
slender, immaculately dressed, and--as Dr. Feldman could see
immediately--rigid and very uptight about herself.
Melissa came to see Dr. Feldman, a clinical psychologist, because of a
growing sense of estrangement toward her husband and tension and
anxiety at work. She described her upbringing in an extremely rigid,
judgmental atmosphere in which her self-worth was implicitly tied to
her parents' conditions of achievement. She was apparently encouraged
by her parents, who realized Melissa was a bright child, to skip a
grade and then to complete her undergraduate work in three years by
attending summer school each summer. Her parents were very proud of
her.
She admitted to having had little fun and would turn a vacation into an
opportunity for achievement. She frequently could not enjoy television
or the movies "because it felt frivolous." She was free from
self-doubts only when hard at work, so she worked virtually all the
time. Her husband wanted a family, but Melissa believed that children
would be an undesirable interruption and distraction.
Melissa quickly lost her fear of the weekly meetings with Dr. Feldman.
She was able to relax in his company. She felt that he cared about her
as a person, whether she achieved or did not. He would not make
active, directive suggestions, but rather listened {126} to her in a
genuine, positive way. During one session, Melissa asked him if he
would give her some "straight advice" about her relationship with her
husband. Dr. Feldman declined. He felt that telling another person
what to do did not show respect for that person's individuality. He
could see that Melissa was intelligent. He believed that she could
trust her own decision-making abilities, and he would encourage her to
believe in herself.
Over a period of a little more than a year, with weekly visits,
Melissa's personality began to soften. She dressed more casually. She
was more relaxed. She was beginning to enjoy herself more, although
occasionally the old self-doubts would come back to assail her. But
she usually was able to fend them off. Her marriage was improving, she
looked forward to "a real vacation" in the near future, and she was not
closed to discussing the possibility of children with her husband,
although they had not yet made a decision on that issue.
APPLICATIONS OF CLIENT-CENTERED THERAPY
Client-centered therapy focuses especially on difficulties that stem
from a client's negative feelings of self-worth. Client-centered
therapy may be the therapy of choice especially for individuals who
feel anxiety, uncertainty, and pain because of a low sense of
self-esteem. A client-centered therapist can be expected to value
personal genuineness, integrity, and honesty. The approach can be
helpful to persons who suffer from loneliness and isolation.
Client-centered therapy is most effective for individuals with these
characteristics:
* They are able to exercise initiative, both in expressing their
difficulties to the therapist and in attempting to make desired
changes. Most client-centered therapists will refrain from giving
direction.
* They are interested primarily in personal growth rather than the
removal of specific symptoms.
* They are blocked, inhibited, or rigid because they are too
self-critical.
* They are not severely impaired in their abilities to relate to others.
{127}
GESTALT THERAPY
_For very rigid people who are always trying to
be someone they are not, who will commit
themselves to a challenging and usually
frustrating process of growth leading to
personal integration and genuineness._
GESTALT PSYCHOLOGY
Gestalt therapy has its roots in Gestalt psychology, which was
established early in this century by the German psychologists Wolfgang
Köhler (1887-1967), Kurt Koffka (1886-1941), and Max Wertheimer
(1880-1943). The main contribution of Gestalt psychology consisted of
studies of human perception. Gestalt psychologists demonstrated that
perception reveals the existence of organized wholes that cannot be
reduced to the sum of their parts. They called such an organized
totality a _Gestalt_. (Outside of psychology, _Gestalt_ in German
means "form.")
A famous example, shown below, demonstrates how an object that you see
can be closely linked to its background. Here, the figure and the
ground can oscillate, depending on whether you concentrate on the faces
or the vase. The figure depends on its background for its identity,
and vice versa.
[Illustration: A famous illustration of a white vase set between the
black silhouettes of two faces in profile; at one moment you perceive
the vase, at another you see the two faces]
{128}
GESTALT THERAPY
Frederick (Fritz) Perls (1893-1970) brought together certain of the
basic concepts of Gestalt psychology, psychoanalysis, and psychodrama,
an approach to therapy developed by J. L. Moreno (1889-1974) that
emphasizes role-playing, acting out of fantasies, and group interaction.
Perls transformed the Gestalt psychologists' central idea so it would
serve as a basis for his approach to psychotherapy. Let's look at an
example.
A man has been stranded in the desert and has become severely
dehydrated. He has wandered for several days in search of water. He
stumbles along, nearly blinded by the sun, seeing only vaguely defined
shapes of rocks and cacti. Suddenly, out of this hazy world, something
becomes clearly defined: he sees a watering hole, surrounded by low
bushes. It is clearly etched in his eyes, set against the indistinct
background of the hot desert. Once he has plunged his head into the
water and quenched his thirst, his Gestalt is _closed_: the need that
caused him to struggle for days has performed its purpose.
In this derivative sense, _Gestalt_ means "a problem (figure) that
arises out of a situation (background) which motivates an individual to
action." If his action is successful, his Gestalt is closed: the
problem is resolved, and the motivation is fulfilled. Like the Gestalt
of the psychologists, the closed Gestalt of therapy signifies an
organized whole. In the example, the man suffering from thirst in the
desert has a Gestalt that impels him to find water. When he does, his
thirst is satisfied, and the Gestalt is resolved into a whole that no
longer stands in need of completion.
Perls saw life as a succession of unfinished situations, incomplete
Gestalts. No sooner is one closed than another takes its place. To
cope effectively with living, we must be able to deal with life's
problems and challenges, yet not all of us can.
Perls used the term _growth disorders_ to refer to what other
therapists might call _personality disorders_ or _neuroses_. He
believed that emotional problems result from "getting stuck" in the
natural process of growth. People get stuck in childish patterns of
dependency because of a variety of childhood experiences. For example,
a mother and father may withdraw the support of a stable environment,
while a child relies on this for a sense of security. (The example of
Bobby in the chapter on {129} psychoanalysis may come to mind.) Or,
parents may force a child to accept adult responsibilities prematurely.
It is as if a child were asked to walk before his sense of balance and
leg strength had developed sufficiently. The child will _learn_
uncertainty; his natural early fear of falling becomes pronounced and
will leave a mark that can stand in his way later. Perls called such
experiences _impasses_, and they form _blocks_ to a person's growth.