most superficial, outside layer, moving inward, there is the usually
insincere _cliché_ layer ("How are you?," asked without real interest),
the _role-playing_ layer (the habitual masks of father, mother,
businessperson, homemaker, therapist, client), the _impasse_ layer (the
person stripped of clichés and masks, often very frightening), the
_implosive_ layer (where emotions are either vented or explode inward),
and the innermost layer, which makes up the _genuine_ personality as it
is, freed from learned pretensions. The goal of Gestalt therapy is to
reach this last layer. In a word, Gestalt therapy seeks to encourage
the growth of _authenticity_--a combination of a balanced sense of
reality, of inner integration complemented by its outward expression,
personal integrity, and of independence from the need for the approval
of others.
In Gestalt therapy, self-change seems paradoxical. As long as inner
conflicts continue, you try _not to be_ the person you are; you cannot
be genuine and are divided against yourself. Change, the Gestalt
therapist claims, is possible only when you give up, at least for a
time, trying not to be the person you are. There must be a firm place
to stand from which to initiate change, and that place can only be the
person you are right now.
WHAT GESTALT THERAPY IS LIKE
Gestalt therapy as it was developed by Perls is individual therapy done
in a group setting. Gestalt therapists since Perls most commonly
continue to practice therapy this way: individual members of a group
are asked to volunteer to take the "hot seat"; the volunteer then
becomes the focus of attention. This is not group therapy where
relationships among members of the group are most important (see
Chapter 13). In Gestalt therapy, emphasis is on the individual, who is
pushed to drop his or her masks and pretensions. Other members of the
group form an {130} audience and try to learn by example until it is
time to occupy the hot seat themselves.
Perls would ask for someone in the group to sit in a chair, facing him
and the audience. Then Perls would launch an attack on the client's
defenses. At times, he could be almost merciless. He did not believe
in mothering clients; this served only to keep their defenses intact.
Perls would notice nonverbal clues to the client's feelings. If the
client was an inhibited woman, he would comment about her thighs, which
were pressed firmly together. If the client was shy, he would remark
about how the client held one hand in the other: Did he feel a need to
have his hand held by Mother?
If the client burst into tears, Perls would make no attempt to stop the
tears with reassurance but would try to make the client aware of his
motivation in crying: Was it to elicit pity? Were the tears a way of
hiding from self-responsibility? Were the tears another mask, standing
in the way of self-acceptance, authenticity, and growth?
The objective of Gestalt therapists is to tear away clients' defensive
masks and roles that usually keep them from real, sometimes painful or
frightening, feelings. In this, the therapists' main technique is to
_frustrate_ the clients' attempts to hide behind their masks and roles
and to _block_ their attempts to control their therapist. Clients
often do this by trying to make the therapist feel sorry for them, give
them parental warmth, respond to their inadequacies, and so on.
Instead, Gestalt therapy is comparatively _tough_. Perls used these
instructions in beginning a workshop:
So if you want to go crazy, commit suicide, improve, get
"turned-on," or get an experience that will change your life, it's
up to you. I do my thing and you do your thing. Anybody who does
not want to take responsibility for this, please do not attend this
session. You come here out of your own free will. I don't know
how grown up you are, but the essence of a grown-up person is to be
able to take responsibility for himself--his thoughts, feelings,
and so on. Any objections? ... O.K.[1]
[1] Frederick Perls, _Gestalt Therapy Verbatim_ (Lafayette CA: Real
People Press, 1969), p. 79.
{131}
By refusing to give unnecessary emotional support even when clients cry
for it, Gestalt therapists convey through their behavior that clients
do have what it takes to stand on their own two feet. Ideally, Gestalt
therapists are genuine, mature people; they refrain from interfering in
the lives of others and expect them to be self-supporting. They try to
impress on their clients that they do not exist to live up to the
expectations of others, nor do others exist to live up to theirs.
APPLICATIONS OF GESTALT THERAPY
Gestalt therapy is most effective in treating persons with these
characteristics:
* They tend to be very rigid--restrained, overcontrolled,
perfectionist--or depressed, or phobic. That is, they have certain
well-defined fears; for example, fear of public speaking, of insects,
of sexual intercourse.
* They have become stultified in their relations with others and have
pent-up feelings in need of release.
* They obtain little joy or satisfaction from living; their lives lack
emotional intensity.
* They are not excessively frightened by group activity.
Specific conditions Gestalt therapy often treats include these:
* psychosomatic disorders, such as stomach pain, colitis, back and neck
spasms, and migraines
* behavior problems in children
* difficulties in coping with persons in authority
* shyness and passivity
* emotional difficulties arising from poverty and from the deprivations
suffered by minority groups
* rigid, conflict-torn family situations
* crisis intervention: treating individuals in despair who have lost
the will to live or are suicidal
Gestalt therapy is _not_ generally the treatment of choice for people
whose lives are out of control or who show signs of psychosis. Gestalt
therapy relies on your capacity to make your {132} own practical life
decisions, to tolerate the stress and frustration of being in the hot
seat, and to benefit from being challenged by the therapist to confront
your own pretenses, distortions, and confusions. People who have lost
these capacities for the time being due to problems such as alcoholism,
drugs, and loss of touch with reality tend not to benefit from Gestalt
techniques.
TRANSACTIONAL ANALYSIS
_For less troubled people who want to improve
the effectiveness of their communication skills
and break free from frustrating, self-destructive
patterns._
Transactional analysis has perhaps done more than any of the other main
approaches to therapy to increase the sensitivity of the public to the
psychological dimensions of human relationships. It has achieved
widespread popularity in a short time largely because of its simple,
commonsense vocabulary that is easy to apply to personal, family, and
group situations.
Eric Berne (1910-1970) completed his medical training in 1935, then
finished his psychiatric residency at Yale in 1941. He soon separated
himself from psychoanalysis and began to formulate his theory of
transactional analysis (TA).
By the mid-sixties, TA was gaining in popularity: Berne wrote his book,
_Games People Play_, primarily for professionals, but it became a
best-seller filling a need for an easy-to-understand and easy-to-apply
approach to therapy.
TA is based on the premise that human personality has three parts:
Berne called them the _Parent_, _Adult_, and _Child_. Although similar
in meaning to Freud's _superego_, _ego_, and _id_, Berne's terms were
intended to name dimensions of personality that could be observed
directly; his three "ego states" are not theoretical constructs.
The Child ego state is the source of fun, humor, creativity, wishful
thinking, and irresponsibility. It is impulsive and resists control.
The Parent ego state is the repository of values, attitudes, and
expectations inherited from one's parents. _Shoulds_, _oughts_, {133}
hands-on-hips, and finger-wagging gestures are common expressions of
the Parent.
The Adult ego state is the source of reason, logic, and unemotional
evaluation. It forms the basis for decision making and predicting
outcomes.
Only one ego state can be in control of our emotions or behavior at a
time.
Berne observed that many emotional difficulties in individual clients
result from problems involving their ego states. Some personality
problems come about because a person cannot separate his or her ego
states and switches from one to another erratically and uncontrollably.
For example, a young mother begins--in a calm rational way--to describe
the behavior of her nine-year-old son. She talks about his impertinent
and disrespectful behavior, and, as she does, she becomes enraged, her
face turns beet-red, and she yells at her therapist that someday she is
going to give her boy a beating he'll never forget! Transactional
analysis would try to show her that she tends to slip from her
reasonable Adult state to the state of an angry Parent who demands
complete respect and subservience. Berne called this structural
problem of the personality _confusion_.
[Illustration: PERSONALITIES: Normal Personality, Confused, Excluded,
Contaminated]
_Exclusion_ is another structural problem. An individual rigidly
adheres to one ego state, locking out the other two. A Don Juan gives
free expression to his Child, while his Adult and Parent states are
suppressed. A workaholic, on the other hand, permits {134} his Parent
to block the expression of his Adult and Child ego states.
_Contamination_ is a third personality problem. One ego state subverts
another. A woman cannot commit herself fully to her chosen profession
because her Child has undermined her sense of determination by
persuading her that a wealthy knight in white armor will soon appear to
relieve her of the need to exert herself.
WHAT TRANSACTIONAL ANALYSIS IS LIKE
Transactional analysis normally begins with "structural analysis" in
which clients are taught how to distinguish ego states that may be
confused, excluded, or contaminated. This phase of therapy is
sometimes done on an individual basis and sometimes in a group workshop
or classroom environment. Therapy then proceeds to transactional
analysis proper, in which frustrating or painful forms of communication
and unsatisfying life directions are discussed. Most commonly this is
done in a group setting, since a group encourages a variety of
different styles of communication.
TA teaches clients to determine which ego state is active at a given
moment--in themselves and in others with whom they are trying to
communicate. _Transactions_ or communication patterns between people
are the focus of TA. Some typical transactions are diagrammed on the
facing page.
In (a) on the facing page, person 1 communicates in an Adult mode and
receives an Adult response from person 2: "Where are you going?" "To
the cleaner's."
In (b), a Parental boss receives a petulant response from the Child ego
state of an employee: "What took you so long?" "My little boy is sick,
and there's just too much work for one secretary."
In (c), an Adult-to-Adult message receives a Child-to-Parent reply;
this is an example of _crossed transaction_. It is one of the most
common sources of frustration and conflict in family and professional
life. For example, a therapist says, "You seem to be late for your
appointment today." (Adult-to-Adult, or A-A.) The client replies,
"You're just like my father, always picking on me." (C-P.)
{135}
[Illustration: DIAGRAMS OF TYPICAL TRANSACTIONS]
{136}
Diagram (d) illustrates communication that involves an ulterior
message. For example, a psychologically clever salesman is showing
hair driers to a woman. She tells him how much she is prepared to
spend and then asks, "How much is that one?" The salesman (arrow 1 in
the diagram) replies: "You wouldn't be able to afford that model." His
response is based on his customer's stated budget limitations and
appears to be Adult-to-Adult. However, the hidden message (dotted
arrow [1]) is directed to his customer's Child state, which, as he
predicts, causes her to reply rebelliously (arrow 2), "That's the one I
want."
In (e), another example of this class of communications that are not
what they appear to be, there are two ulterior transactions. A
secretary returns a few minutes late from lunch. Her boss asks,
apparently Adult-to-Adult (arrow 1), "What time is it?" They both know
what the hidden message is. The secretary answers sharply (arrow 2):
"It's 1:15." The ulterior message from the boss is "Are you late
again?" (P-C: arrow [1].) The secretary's covert or hidden reply is
"Get off my back: you're always criticizing." (C-P: arrow [2].)
The central objective of TA, then, is to make clients aware of these
and other patterns or games that their habitual ways of communicating
reveal. By doing this, clients find that communication becomes less
problematic and more effective as they learn to control their responses.
AN EXAMPLE
Joyce was forty-one when she decided to take her seventeen-year-old
only son, Joe, to see Dr. Goldstein, a transactional analyst. For
about five years, ever since his father died, Joe and his mother had
quarreled a great deal.
Dr. Goldstein met with Joyce, then with her son, and then with them
both. After he listened to their complaints about one another, he
agreed to try to help.
For six weeks, Joe and his mother met once a week with Dr. Goldstein as
"TA students." They were to put family problems on a back burner;
their energy was devoted to learning to apply the concepts of
transactional analysis. Dr. Goldstein had them {137} analyze many
examples of communication.
During a second six-week period, Joyce and her son were coached to
learn to talk to one another more effectively. Here are some samples
of their automatic patterns of response _before_ they began to use TA:
SON: The soup's too salty. (A-A or C-P)
MOTHER: I don't know why I work so hard! All you do is
complain! I'm just not appreciated! (C-P)
SON: Mom, here's the sports jacket I bought for graduation. (A-A)
MOTHER: You can't go in _that_! We're taking that jacket back. I
can't trust you to buy clothes for yourself. Let's go! (P-C)
MOTHER: We're going to dinner tonight at Esther and Gary's. Get
out of those jeans; we have to leave in fifteen
minutes. (P-C)
SON: But Mom, I told you last Wednesday that Fred and I are
going camping this weekend. We're leaving in Fred's
car in just an hour. (A-A or C-P)
MOTHER: I don't remember anything like that. Esther and Gary
are _expecting_ us. You're always wrecking our plans! (C-P)
MOTHER: Mmm, isn't this the most delicious soufflé you've ever
tasted? (C-P)
SON: That's it, compliment yourself! (C-P)
MOTHER: Well, if I don't, no one else will! You don't know how
lucky you are, having a mother who really knows
how to cook. (C-P)
SON: I sure hope I don't learn how to be modest from you! (C-P)
The problems weren't hard for Dr. Goldstein to spot: Joyce had low
self-esteem, was easily hurt, and, when she was, put her son down (the
salty soup). She wanted to be indispensable to him and was unwilling
to let him grow up (the sports jacket). She had little respect for
Joe's plans, especially if they interfered with her desires (Joe's
camping trip). She felt unappreciated and had grown to be resentful of
her role as mother (the soufflé).
Joe, on the other hand, was feeling the natural rebelliousness {138} of
a seventeen-year-old. He needed some free rein, even if he made some
mistakes. His mother was always "getting in his hair" or "getting
under his skin."
The sample transactions above led each of them to anger and hurt.
Seldom did Dr. Goldstein see Joe and his mother communicate
Adult-to-Adult. Instead, their transactions crossed and re-crossed,
and resentments piled up.
Joyce saw Dr. Goldstein without Joe present for several weeks. She
learned from Dr. Goldstein that her expectations toward her son were
inappropriate; she needed to strengthen her sense of self-worth outside
of her family role. She was excessively dependent on her son for
recognition and appreciation. Especially since her husband died, she
was easily hurt when her desires for appreciation were not satisfied by
Joe, so she put him down. What she needed to do was to strengthen her
Adult and weaken the domination of her self-pitying Child and
overcritical Parent ego states.
Dr. Goldstein then met with Joe for several sessions. Joe began to see
his mother in a different light. Dr. Goldstein made him aware of his
mother's sadness in being left alone and of her needs to feel
worthwhile.
During the joint sessions that followed, Dr. Goldstein typically would
ask them to recall recent conversations or exchanges that had been
unpleasant. He would ask them to analyze these in TA terms and then
would push mother and son to imagine more appropriate and less uptight
ways of responding.
After several months of joint therapy, their former pattern of
transactions began to look very different:
SON: Mom, there's too much mustard on the ham. (A-A or C-P)
MOTHER: Well, then it's OK with me if you want to scrape some
off. (A-A or P-C)
SON: How do you like my new tie? (A-A)
MOTHER: I'd need a lot of courage to wear it myself, but I'm not
you! (A-A or C-C)
SON: Mom, your roast is delicious. It's great to have a
mother who's a good cook! (A-A)
MOTHER: Thanks, Joe. I guess now I've learned that you really
hate soufflé! (A-A)
{139}
APPLICATIONS OF TRANSACTIONAL ANALYSIS
TA has been used in individual and group therapy, in nonclinical
settings to help business executives improve communication skills, and
also in prisons. It has been used to treat a wide range of problems,
including these:
* personality trait problems: e.g., shy, lonely, depressed,
overbearing, or hostile individuals
* troubled relationships in couples and families
* fears of withdrawal of affection and of abandonment
* drug abuse
* phobias
* difficulties in relating to authority figures, such as a boss, a
teacher, a parent
* adaptation problems in individuals with counterculture attitudes and
values
Few controlled evaluative studies have been done to determine how
effective TA really is. At this time, and in this author's judgment,
TA is most useful as an _educational therapy_ to assist less severely
troubled individuals with communication problems by helping them
sharpen their perceptions of their own ego states and the ego states of
others. TA is most effective for clients who are able to exercise
responsibility for themselves. TA appears to be especially useful in
helping individuals who are caught in frustrating relationships to
break free from self-destructive patterns or games.
COGNITIVE THERAPY:
RATIONAL-EMOTIVE THERAPY
_For people who tend to think and judge in
very rigid ways, who are frequently intense
and uptight, and who tend to magnify and
exaggerate evils._
Man is not disturbed by events, but by the view he takes of them.
Epictetus, _Enchiridion_
{140}
"It is absolutely essential to you to be loved by members of your
family and to be appreciated by your friends and employer."
"You must be consistently competent and nearly perfect in all your
endeavors."
"Some people are really bad, their actions should be restricted, and
they should be punished when they do wrong."
"It is terrible when things are not the way you would like them to be."
"Events outside your control are largely responsible for how you feel."
"You should be anxious in relation to what is uncertain, unknown, or
potentially dangerous."
"It is much easier to avoid problems than to face life's difficulties
and responsibilities."
"It is necessary to have something greater or stronger than yourself to
rely on."
"The present is largely determined by past events."
"Happiness comes when one has complete leisure."
"If you don't work hard to please others, they will abandon you."
"If people don't approve of you, you ought to question your self-worth."
By telling ourselves things like these, we create our own unhappiness,
frustration, and anger; that is the point of view of cognitive therapy.
During the 1950s, Albert Ellis (1913-2007) developed a theory of
personality that claims that people are largely responsible for their
emotional reactions. They tell themselves that things _ought_ to be
different, that people _should_ do certain things, and that what they
desire they _must_ have. Life, for people whose thoughts are filled
with _shoulds_, _oughts_, and _musts_, is full of disappointment,
annoyance, and hurt.
Ellis observed that, as time goes by, we tend to reinforce an emotional
pattern that amplifies our sensitivities more and more. The emotional
reactions we create in ourselves become more exaggerated, distorted,
and self-destructive.
{141}
But, like any habits, these mental (or cognitive) habits can be broken.
Cognitive therapy attempts to do this.
Ellis called his own approach _rational-emotive therapy_. By this, he
acknowledged that people have both rational and emotional dimensions.
Their emotions and thoughts (cognitions) are so thoroughly intertwined
that they cannot be clearly separated. Yet mental evaluations and
ideas are given so much power that cognitive habits are responsible for
emotional responses. It is thinking that makes it so.
Rational-emotive therapy is the most widespread approach to cognitive
therapy, so we will examine Ellis's approach in some detail.
The main technique of rational-emotive therapy, and of cognitive
therapy in general, is to focus clients' attention on their belief
systems, their views about what "should" and "ought" to be, their
cognitive "filters" through which they interpret, in a semiautomatic
way, the world around them. If the "activating event" is a failure or
a rejection, for example, a client's _rational_ belief system will lead
to feelings of regret, sorrow, disappointment, or annoyance; if an
individual's beliefs are _irrational_, on the other hand, he or she may
instead feel depression, worthlessness, futility, and severe anxiety.
For rational-emotive therapy, emotional good health depends on the
rationality of the way a person receives and interprets events.
WHAT RATIONAL-EMOTIVE THERAPY IS LIKE
Therapy usually begins with individual sessions. Once clients have
learned how to identify mental habits that create disturbing emotions,
therapy is sometimes continued in groups, where new attitudes and forms
of behavior can be practiced in a kind of microcosm of the larger
world. Rational-emotive therapy that is done in a group context is
not, however, "group therapy," since the therapist's focus is on
individual styles of thinking, not on relationships among members of
the group.
During therapy, clients are very quickly challenged to give evidence
for their irrational beliefs. The rational-emotive therapist will
openly and ruthlessly oppose the foolish absolutes that clients express
and make it clear how they are upsetting themselves emotionally by
insisting on such nonsense. It is not considered essential that the
therapist be a kind, warm, {142} supportive person. In fact,
rational-emotive therapy encourages therapists to show their impatience
with irrational beliefs that cannot be defended empirically or
logically. Once clients are shown that many of their beliefs cause
them misery and disappointment, they are asked to _dispute_--silently,
in their own minds--their irrational beliefs whenever they find the old
habits taking over. It takes time to extinguish old habits; it doesn't
happen overnight. Clients need patience and tenacity to oppose their
old reflexes and replace them with rational, realistic beliefs.
An hour a week in rational-emotive therapy is really, then, like a
tutorial session with a teacher. The client-students talk about their
feelings; the therapist criticizes underlying irrational beliefs and
makes it clear to the clients what a rational response would be. Then
the clients are asked to practice applying rational beliefs on their
own, outside of therapy. Gradually, a more rational way of looking at
things takes the place of the old habits.
AN EXAMPLE
Joan Hendley is single, twenty-nine years old, and assistant manager of
a bank. She has come to Dr. Kovac because of chronic depression, a
sense of low self-worth, and feelings of insecurity and anxiety.
Lately, she has begun to drink heavily and regularly feels the need to
use sleeping tablets.
The following is a sample of their dialogue during their first session
of rational-emotive therapy:
DR. K.: Well, what would you like to start on?
JOAN: It's hard to put it into words. I guess it's that I've been
depressed a lot, about _everything_. I feel like there's no
purpose to my life. I don't know where to go or how to decide.
DR. K.: So, right now you don't know where you're headed. What's
so terrible about that? It would be _nice_ if you knew, but you
don't. Is that _awful_?
JOAN: Yes, it is! Everybody should have a purpose!
DR. K.: Why _should_ they? Most people go through life without
much of a sense of purpose.
JOAN: Well, that's what I believe in.
DR. K.: Look, Joan, you appear to me to be an intelligent person.
You and I can agree that it would be more satisfying for you to
have a sense of direction, but you take this {143} one more step,
and it's a _very_ big step! You think it's _terrible_ that you
don't feel there's a purpose to your life right now. You think you
_should_ have a purpose, and I suspect you're punishing yourself
because you don't live up to that _should_.
JOAN: But most people believe in things like that.
DR. K.: And a lot of them end up feeling miserable! I know: I've
seen dozens of people sitting where you are, and their thinking is
chock-full of _oughts_, _shoulds_, and _musts_. And that's what
makes them feel upset. They feel much better when they can come to
say to themselves, "It would be nicer, or more pleasant, or better
if things were different."
JOAN: You mean, if I can get rid of _shoulds_ and _musts_ in my
_thinking_, I'd feel better?
DR. K.: That's exactly what I'm saying. If you were to follow
what I've told you, you'd seldom be upset again, and probably never
enough to get yourself really depressed.
JOAN: Uh-huh. I'm not sure I really see how that can be. I feel
pretty stupid.
DR. K.: So here you go again! You think of yourself as a pretty
bright person, and so you say to yourself, "I ought to be able to
catch on to anything pretty fast." And now here you are, and
you're not all that sure you've followed everything already, and so
you tell yourself, "Oh my, I must be stupid."
JOAN: [Nods appreciatively, laughs.]
DR. K.: You don't _have_ to upset yourself. You can _choose_ what
you tell yourself, and then you'll have control over what you
_feel_. Tell me about your job. You're in the role of a leader,
aren't you?
JOAN: Yes.
DR. K.: But you don't think you're doing a great job?
JOAN: No, I don't.
DR. K.: But _they_ think you're doing OK, isn't that correct?
JOAN: Yes, but my job seems to be taking more and more out of me.
[Begins to cry.]
DR. K.: Well, it seems like you're doing your job OK; it's just
that you, from _your_ point of view, aren't perfect! So
_therefore_ it's all just empty pretense: you're just faking it!
But, if you'll give up your nutty perfectionism, you'd be in the
clear, because you're obviously satisfying people at work; you're
satisfying _their_ expectations. But since you feel bad about
yourself, you say to yourself, "Well, they just haven't found me
out! When {144} they do, I'm in for it." And so you live in a
state of fear.
JOAN: That's it.
DR. K.: It's all because of your unreasonable _expectations_. Can
you see that?
JOAN: [At least temporarily convinced.] Yes, I think I can!
DR. K.: This is what I'd like to work on with you. It's going to
take some self-discipline on your part, but together we can help
you get rid of some mental habits that bring you unhappiness. They
don't serve a useful purpose, and they drag you down. Why don't
you tell me more specifically what upsets you at work?
APPLICATIONS OF RATIONAL-EMOTIVE THERAPY
Although rational-emotive therapy has been used to treat many different
kinds of problems, Ellis admits that his approach is most effective for
the treatment of clients with a single major symptom or clients who are
only moderately disturbed. In addition, Ellis does advocate
rational-emotive therapy for individuals whose patterns of irrational
thought are severe, but for such individuals--when they can be
helped--therapy is a long-term process.
From evaluative studies completed so far, it appears that
rational-emotive therapy is especially effective in reducing anxieties
resulting from such things as public speaking, relating to others on an
individual basis, and facing old age. Other specific applications of
rational-emotive therapy include these:
* problems of maladjustment, where you have increasing difficulty
coping with either an already familiar environment or a situation new
to you
* marital problems and sexual difficulties
* psychosomatic problems
* anxiety
* depression
* problems of criminals and delinquents
Individuals who are most effectively treated with forms of cognitive
therapy tend to have one or more of these personal characteristics:
{145}
* They tend to think in very rigid ways.
* They are inclined to think in all-black, or all-white terms. They
are absolutists who think in terms of _what is right_ and _what is
wrong_. Life, for them, is an uncompromising affair.
* They are often perfectionists about themselves, so they tend to have
unrealistic expectations of others as well. They are idealistic.
* Their behavior is frequently uptight, intense, judgmental, and
intolerant _or_ shy, self-effacing, and inclined to self-condemnation.
* They tend to think that if there is one bad apple, the whole bushel
must be rotten. They tend to magnify and exaggerate evils.
* They confuse what they would like to have with what they believe they
absolutely _need_. They are demanding and exacting.
EXISTENTIAL-HUMANISTIC PSYCHOTHERAPY
_For individuals who suffer from feelings of
acute loneliness and emptiness, who have lost
faith in themselves or others, and who tend to
be analytical and introverted._
There is no single, well-defined theory accepted by most existential
therapists. Instead, existential psychotherapy is a point of view, a
general philosophy that attempts to describe what it means to be human
and to live meaningfully in the world.
There is, nevertheless, a consensus among existential therapists
concerning the objectives of the approach. Existential therapy seeks
to help clients achieve these goals:
* to accept and make constructive use of their own personal _freedom_
* to become _authentic_ individuals, shedding the conventions and
conformities that obscure the real persons they are
* to establish human relationships based on _honesty_ and _personal
integrity_
* to be _fully present_ in the immediacy of the moment
{146}
* to learn to _accept_ the natural limits of life
Existential therapy cannot be described in terms of a group of
techniques commonly used by therapists. In fact, existential
therapists are inclined to resist the formulation and application of
specific techniques of therapy, believing that psychotherapy is
essentially a human endeavor and that the drive to formulate techniques
is basically a dehumanizing, objectifying interest.
To understand existential therapy, then, we ought not to expect to
encounter a set of specific techniques. What really characterizes
existential therapy are its self-consciously endorsed attitudes about
life. They include these realizations:
* Anxiety frequently motivates individuals to change their lives.
Anxiety often is present to tell you that you need to change; it is not
necessarily a bad feeling from which no good will come.
* Eventually each of us will die, and clutching life anxiously will
stand in the way of finding real meaning in living.
* Past events need not control what you feel and do now; you are free
to change old, unsatisfying patterns.
* Guilt is often a sign that you have missed opportunities for personal
growth: you have not been true to yourself and have "sinned against
yourself" in some important way.
* If you are to become a mature and genuine person, you must discard
the _lies_ you have cultivated. Among these is living the lie of
trying _not to be_ the person you really are; another is the lie of
trying to be a person you are _not_, and there are many others.
* To be content within the limitations of life, it is vital that you
have a sense of your own value. You become inauthentic if you base
your sense of self-esteem on what others think of you.
It is obvious that _individual responsibility_ is central to
existential therapy. You are responsible for the person you choose to
become. You may choose to be genuine, or you may choose to lie to
yourself and others. It is when you abdicate responsibility for
becoming authentic that you will often come to feel anxiety and a sense
of guilt. Anxiety and guilt are often present, in other {147} words,
when there is a fundamental lack of congruence, of being whole, of
being in accord with yourself.
The main contributors to existential psychotherapy have been the Swiss
analysts Ludwig Binswanger (1881-1966) and Medard Boss (1903-1990),
along with Rollo May (1909-1994), who was the founder of existential
psychotherapy in America. Today, existential psychotherapy is
practiced under a variety of names: _humanistic psychology_,
_experiential psychotherapy_, and also in the context of the related
approaches, logotherapy and reality therapy (see Chapter 11).
WHAT EXISTENTIAL THERAPY IS LIKE
Existential psychotherapy is usually individual therapy, with sessions
commonly scheduled a few times a week, as in psychoanalysis.
Existential therapy often shows its psychoanalytic origins: as in
analysis, existential psychotherapy focuses largely on anxiety and the
suppressed issues that anxiety veils. Existential therapists will push
clients to confront anxiety directly; they will try to understand the
clients' anxiety in relation to the lies that clients tell themselves
in order to protect themselves from more anxiety.
As we have already seen, existential therapists very commonly regard
anxiety and depression as _promising_ symptoms because they can shake
clients out of unfulfilling patterns of living. Anxiety and
depression, instead of being viewed as undesirable symptoms to be
eliminated, can motivate people to change and grow. Consequently,
existential therapists tend to disapprove of the use of drugs in
therapy. If clients take pills to reduce anxiety, for example, they
will reduce the awareness of motivating pain that, if faced squarely,
may bring about a more meaningful, satisfying life.
Here is an example of the way an existential therapist forces a client
to face issues head-on. What the therapist is thinking is in brackets.
CLIENT: I don't know why I stay with my job. It just makes me
depressed. All I do is tell you the same things over and over.
I'm not getting anywhere.
THERAPIST: [She is complaining because I'm not curing her. She has
to do this herself.] To be frank, I'm impatient, {148} too. We
talk, but you're not able to act. [She has to see that I can't
take responsibility for her procrastinating].
CLIENT: What do you think I ought to do? I can't keep living like
this.
THERAPIST: [I can't make her decisions for her.] I can't tell you
which way to go. I do know that you've been avoiding a decision.
I believe you're going to take charge of your life but, until then,
we may both feel impatient....
What _do_ you want to do? [She has to be pushed to make up her
mind. She's ready now to decide but is understandably scared.]
CLIENT: I want to stop worrying, stop feeling so anxious and upset.
THERAPIST: [She'd like me to mother her.] Look, Diane, you've been
coming to see me for three months now. You know what I think about
feeling upset: if you're upset, there's something bothering you
that you need to pay attention to. We both know you dislike your
job and that you stay on mainly because you're afraid of a change.
We can talk a long time about your unhappiness at work and about
your fear of change, but eventually it will be time to stop talking
and to try some alternatives. Do you think you're ready? I think
you are.
CLIENT: (Sighs.) I guess you're right. I seem to be dragging my
feet. If I want a satisfying job, I'm just going to have to try
something else. Can we talk about some of my alternatives, then,
and I'll try to stop complaining!
THERAPIST: [Now she's starting to face up to the challenge.]
APPLICATIONS OF EXISTENTIAL PSYCHOTHERAPY
These are some of the difficulties existential psychotherapy is
designed to treat:
* feelings of _real estrangement or alienation_ from others--from your
immediate family and friends or from neighbors or colleagues at work
* a sense of _acute loneliness_, of being cut off from humanity and
from normal everyday activities and interactions
* an awareness that your life has become an _empty pattern_ {149} of
habit, that your activities or work no longer feel meaningful or
valuable
* an inability to _accept_ the realities that limit life; for example,
anxiety experienced by older persons as they become more aware of the
need to face the reality that life will end or anger and frustration
experienced by individuals who must cope with real limitations--persons
with physical impairments and chronic pain, individuals whose
opportunities are limited by poverty, by their ties of responsibility
to others, or by social disadvantage
Individuals who benefit most from existential psychotherapy tend to
have these characteristics:
* They are reflective and analytical.
* They tend to be introverted.
* They have _lost faith_--in their sense of social commitment, in their
identity and role within their families, in their belief that their
work is of value, or in their religion.
{150}
11
PSYCHOTHERAPY, PART II
Logotherapy, Reality Therapy
Adlerian Therapy,
Emotional Flooding Therapies,
Direct Decision Therapy
In this second chapter devoted to major approaches to psychotherapy, we
will look at logotherapy, reality therapy, Adlerian therapy, the family
of emotional flooding therapies, and direct decision therapy. Like the
five psychotherapies described in Chapter 10, these focus special
attention on a client's personal style of relating to the world and
others. They all seek to help a person to free himself or herself from
troubling feelings and negative attitudes and to replace these with a
stronger and more confident self-concept. Each therapy is a different
path to that goal.
LOGOTHERAPY
_For reflective individuals who are sensitive to
values and who are in search of a richer sense
of meaning in life._
He who has a _why_ to live for can bear with almost any _how_.
Friedrich Nietzsche
{151}
Viktor Frankl (1905-1997) is worthy of much respect and admiration.
Out of three terrible years of suffering in a concentration camp,
during which his mother, father, brother, and wife were taken from him,
Dr. Frankl developed logotherapy (from the Greek _logos_, roughly
equivalent to "meaning"). Logotherapy is an approach to therapy that
addresses our inherent need for meaning and value in living. The
belief that sustained Dr. Frankl during this period of intense
suffering was the conviction that people, in spite of great adversity,
anguish, and the loss of all they hold dear, can remain free within
themselves and are able to maintain, and even to strengthen, their
sense of self-respect and integrity. To communicate how it is possible
to do this became Dr. Frankl's lifework.
Logotherapy is a therapy of meaning for those who are unable to find a
reason for living. It is a form of therapy related to existential
analysis (see Chapter 10), but it is specific in its concern for
helping clients find what it is that really matters to them, that makes
hardships and pain worthwhile.
If Freudian psychoanalysis looks to the past for insight, logotherapy
focuses instead on the future, on a person's _life task_. In this,
there is no abstract and general answer to the question "What is the
meaning of life?"
For the meaning of life differs from man to man, from day to day
and from hour to hour. What matters, therefore, is not the meaning
of life in general but rather the specific meaning of a person's
life at a given moment. To put the question in general terms would
be comparable to the question posed to a chess master, "Tell me,
Master, what is the best move in the world?" There simply is no
such thing as the best or even a good move apart from a particular
situation in a game and the particular personality of one's
opponent. The same holds for human existence.... Everyone has his
own specific vocation or mission in life; everyone must carry out a
concrete assignment that demands fulfillment.... Ultimately, a man
should not ask what the meaning of life is, but rather must
recognize that it is he who is asked. In a word, each man is
questioned by life; and he can only answer to life by _answering
for_ his own life; to life he can only respond by being
responsible.[1]
[1] Viktor E. Frankl, _Man's Search for Meaning: An Introduction to
Logotherapy_ (New York: Washington Square Press, 1963), pp. 170-171.
{152}
Dr. Frankl liked to compare logotherapy to the role of the eye
specialist: the logotherapist's role is to help the patient see more
clearly the range of lived values and meaning available to him.
WHAT LOGOTHERAPY IS LIKE
An elderly physician came to Viktor Frankl to ask for help with severe
depression. His wife, whom he loved above all else, had died two years
before. His sense of loss would not heal. Could Dr. Frankl help him?
Dr. Frankl responded with a question: "What would have happened,
Doctor, if you had died first, and your wife had had to survive you?"
"Oh," he said, "for her this would have been terrible; how she would
have suffered!"
"You see, Doctor, such a suffering has been spared her, and it is you
who have spared her this suffering; but now, you have to pay for it by
surviving and mourning her."
The physician said nothing, but rose to his feet, shook Dr. Frankl's
hand, and calmly left his office. "Suffering ceases to be suffering in
some way at the moment it finds a meaning, such as the meaning of
sacrifice."[2] It is the basic concern of logotherapy to help patients
see the meaning in their lives.
[2] Frankl, _Man's Search for Meaning_, pp. 178-179.
Logotherapy is known for two techniques endorsed by Viktor Frankl. He
called them _dereflection_ and _paradoxical intention_.
Many emotional problems have their roots in what psychotherapists call
_anticipatory anxiety_: a woman who is afraid of blushing when she
enters a room filled with people will tend to blush. A man who fears
impotence and who tries to achieve an erection will often fail. A
woman who willfully tries to achieve orgasm also will frequently fail.
These are examples of excessive, or hyper-, reflection. Excessive,
anxious attention is paid to what we fear or wish, bringing about the
very thing we are trying to avoid.
Frankl developed specific ways of refocusing or rechanneling this
excessive attention. _Dereflection_ could take the form, for example,
of persuading the blushing woman to concentrate on particular things
when she enters a crowded room: to look for acquaintances, to admire
what someone may be wearing, or to {153} look for objects in the room
to appreciate, for example. In the case of impotence or frigidity,
often a shift of attention from yourself to your partner's pleasure
will eliminate anticipatory anxiety.
Frankl describes an attempt to help a bookkeeper who was in real
despair and close to suicide. For several years he had suffered from
writer's cramp: very real muscular cramps that reduced his legible
script to an illegible scrawl. He was in danger of losing his job.
He was treated with _paradoxical intention_. He was asked to write in
an intentionally illegible scrawl. But he found that when he
deliberately tried to scrawl, he could not. Within two days, his
writer's cramp had vanished. Similar approaches have been very
effective--and long-lasting--in certain cases of severe stuttering,
uncontrolled shaking, washing compulsions, insomnia, sexual
difficulties, and other problems.
Logotherapists tend to be warm, accepting individuals. They will often
use humor. Yet they are trained to confront individuals: to push their
clients to face their inner feelings of futility and despair, and then,
out of their often overlooked and underestimated inner resources and
moral strength, to _will_ that their lives become meaningful.
Logotherapists try to encourage clients to see more clearly what it is
that gives them a sense of value in living and to use what they see to
direct themselves toward more satisfying and personally fulfilling
lives.
APPLICATIONS OF LOGOTHERAPY
As we have already observed, logotherapy has been used to treat a wide
range of individual problems involving a loss of faith in the value of
living, behavior that no longer is under voluntary control, or behavior
that frustrates your desires.
Logotherapy is especially well-suited to helping individuals with
_noögenic neuroses_, Frankl's term for personal problems that have
their basis in conflicts between opposing values. Noögenic (from the
Greek _nous_, meaning "spirit" or "mind") neuroses have their origin in
personal moral or spiritual, but not necessarily religious, conflicts.
They lead to a feeling of existential frustration: a person's will to
find meaning is blocked. When sufficient pressure is built up, anxiety
and depression can follow. You can imagine how pressure might build up
in the inner lives {154} of a business executive who wishes she had a
family instead of a career identity, a university professor who yearns
to be an independent artist, or a financially successful businessman
who despises his own pretenses and opportunism.
I asked the poor creatures who listened to me attentively in the
darkness of the hut to face up to the seriousness of our position.
They must not lose hope but should keep their courage in the
certainty that the hopelessness of our struggle did not detract
from its dignity and meaning. I said that someone looks down on
each of us in difficult hours--a friend, a wife, somebody alive or
dead, or a God--and he would not expect us to disappoint him. He
would hope to find us suffering proudly--not miserably.[3]
[3] Frankl, _Man's Search for Meaning_, p. 132.
REALITY THERAPY
_For persons able to make a commitment to a
plan for life improvement, whether they have
emotional or behavioral problems or simply
want to develop a success-identity._
... [U]nhappiness is the result and not the cause of irresponsibility.
William Glasser, _Reality Therapy_
Reality therapy was developed in the 1950s by psychiatrist William
Glasser (1925-2013). His approach to therapy evolved as a result of
his work with delinquent teenage girls, with clients in private
practice, and with severely troubled patients in a VA hospital.
Reality therapy, as the name implies, attempts to help by strengthening
a person's practical understanding of reality and by encouraging
concrete planning that will bring about an improved sense of personal
adjustment to reality. It emphasizes a very practical,
feet-on-the-ground focus on the present: a person's past experience
cannot be rewritten. Reality therapists do not believe in the
essential value of psychoanalytic interpretation, dream analysis,
nondirective counseling, or intellectual {155} insight. A reality
therapist focuses on the present, specifically on attempts patients may
now be making to become more successful _from their own points of
view_. If a patient is not able to make definite plans of this kind
and cannot sustain a commitment to them, the focus of reality therapy
will be to encourage the patient to begin to do this. It is an
approach that believes that a strong sense of personal identity can
come only from _doing_: if an individual is able to develop a degree of
self-responsibility that is solid and enterprising, a feeling of
personal success and effectiveness will follow.
Reality therapists are opposed to making diagnoses. A diagnostic label
frequently adds a burden to individuals who are already burdened by
emotional, family, or adjustment problems. Glasser notes, for example,
that being labeled a schizophrenic "can be worse than the disease as
far as incapacitating one in the course of life's activities."[4]
[4] William Glasser and Leonard M. Zunin, "Reality Therapy," in Raymond
J. Corsini, ed., _Current Psychotherapies_ (Itasca, IL: F. E. Peacock
Publishers, 1979), p. 329.
Reality therapists can resist diagnosing and labeling their clients
because their approach claims that personal psychological difficulties,
except those due to physical illness (see Chapter 8), result from a
lack of personal discipline and responsibility. People are often
caught in the habit of blaming their failures on their families, their
lack of opportunity, their race, poverty, and other outside forces. It
is a habit with a dead end: it ignores the potential success that can
come from initiative motivated by responsibility and moral courage. As
Ernest Hemingway said when asked if he ever anticipated failure, "If
you anticipate failure, you'll have it."
THE EXPERIENCE OF REALITY THERAPY
It isn't hard to gain a feeling for what reality therapy is like.
These are the basic principles of the approach:
The relationship between therapist and client must be personal. The
therapist tries to make clear that he is a genuine person who has, in
some areas of his life, been able to plan effectively and to develop a
sense of personal success.
The focus of individual sessions is on what the client _does_, not on
what he or she may _feel_. Behavior can be changed much more {156}
directly than feelings, and feelings soon fall into place once behavior
is more satisfying. What is important is for the client to develop
intelligent plans and then to work to carry them through. If certain
goals are not realized, the therapist's concern is to encourage the
client to take the next practical step, rather than to spend time and
energy analyzing what went wrong.
The reality therapist accepts that the first steps are often halting
ones. It is important not to be disconcerted by occasional stumbling
and a few falls. What is essential is a commitment to self-discipline
and progress, refusing to punish yourself when a plan may not succeed,
but going beyond it with a positive attitude that eventually can become
a habit.
Glasser gives this illustration of the persistent refocusing on
practical issues that characterizes reality therapy: a teenage girl
expresses to her therapist that she would like to look for a job. The
therapist does not respond, "Good, let me know how it works out," but
instead begins the following exchange.[5]
THERAPIST: What day next week?
GIRL: I don't know. I thought Monday or Tuesday.
THERAPIST: Which day? Monday or Tuesday?
GIRL: Well, I guess Tuesday.
THERAPIST: You guess, or will it be Tuesday?
GIRL: Tuesday.
THERAPIST: What time Tuesday?
GIRL: Well, sometime in the morning.
THERAPIST: What time in the morning?
GIRL: Oh, well, 9:30.
THERAPIST: Fine, that is a good time to begin looking for a job.
What do you plan to wear?
[5] Glasser and Zunin, "Reality Therapy," _Current Psychotherapies_, p.
324.
In another example of reality therapy, a patient says, "I feel
depressed and miserable." Instead of responding, "How long have you
felt this way?" or "What have you been feeling depressed about?," a
reality therapist might ask, "What have you been doing that continues
to make you depressed?" or "Why aren't you even _more_ depressed?"
With both of these responses, the therapist makes it clear that he
believes the client can influence his or her feelings.
Often therapists, no matter what their approach, will say to {157}
clients who are going through a difficult time that they may phone
after hours if there is an emergency. A reality therapist may, in
addition, also say, "I hope you'll call me if you have had a special
success."
APPLICATIONS OF REALITY THERAPY
Reality therapy has been used in connection with these types of
problems:
* individual problems involving anxiety, marital conflicts,
maladjustment, and some psychoses where a person is comparatively out
of touch with reality and may have hallucinations or delusions
* teenage delinquency
* difficulties faced by women who have recently been widowed
* designing school programs that stress the development of individual
identity based on a sense of personal success
Reality therapists believe that their approach is of value to people
who want to develop a more successful pattern of living, of managing
their own affairs, and of coping effectively with challenges at work
and with problems of everyday living. Reality therapy has also been
used in industry with organizational problems and with difficulties
experienced by individual employees.
Reality therapy is not useful in treating problems in which there is
severe withdrawal (as in autism) or cases involving serious mental
retardation. To be effective, reality therapy presupposes that clients
are able to communicate and are both willing and able to cultivate
habits of self-discipline and personal responsibility.
ADLERIAN PSYCHOTHERAPY
_For individuals interested in personal growth,
especially in social directions, and for persons
with low self-esteem who feel blocked and
discouraged about life._
{158}
The greatest principle of living is to love one's neighbor as oneself.
Rabbi Akiva, writing 2,000 years ago
Alfred Adler (1870-1937) was a contemporary of Freud. Early in his
career, Adler was invited by Freud to participate in his special circle
of professionals interested in the development of psychoanalysis.
Adler's already formulated views were not in accord with Freud's, their
differences became more pronounced, and Adler eventually separated
himself from psychoanalysis. Freud was embittered and became a
lifelong enemy of Adler.
In contrast to Freud's technical and abstract theory, Adler's is
humanistic, open, and concrete. Where Freudian analysis believes that
emotional disturbances have a sexual basis, Adlerian therapy claims
that neurosis comes about through distorted perceptions and from habits
and attitudes that are _learned_. In Adler's system of _individual
psychology_, there is no concern for unconscious processes or for
internal divisions of the self into id, superego, and ego. Adlerians
stress that a person forms a unity and must be treated as a whole.
Adler's approach to psychotherapy is based on the view that feelings of
inferiority are normal. They exist in children, and they continue to
be present in adults who may feel weak psychologically, socially, or
because of physical limitations. To compensate for feelings of
inferiority, adults strive for superiority by dealing effectively with
the world, or they become deeply discouraged (however, they are not
considered to be "sick") and lose contact with positive, constructive
activities.
Adler also postulated that emotional difficulties come about when you
are convinced that you simply cannot solve the problems of life in a
way that is compatible with a need to be superior in some way. Certain
attempts to compensate for feelings of inferiority can lead to
emotional problems later. They include seeking a feeling of
superiority by requiring attention from others, striving for power over
others, taking revenge, and giving up--declaring that you cannot cope
because of personal deficiencies and weakness. Children from families
where there is distrust, domination, abuse, or neglect tend to choose
these paths.
Another facet of Adler's approach is that individuals who {159} cannot
compensate for feelings of inferiority are inclined to make a number of
"basic mistakes" in perceiving the world. They will overgeneralize
("Nobody cares about me."), depreciate their worth ("I'm just a
housewife."), set unrealistic goals ("I should please everyone."),
distort ("You have to lie to get ahead."), and hold faulty values
("Win, even if you have to climb over others.").
Finally, Adler felt that, over the course of their lives, many people
strengthen these basic mistakes while in pursuit of the ultimately
unsatisfying desires for attention, power, revenge, or escape. Their
styles of living may lead to depression, chronic anxiety, crime,
alcoholism, drug abuse, and other problems.
WHAT ADLERIAN THERAPY IS LIKE
Adlerian therapists try to help people change unfulfilling patterns of
living in several ways.
First, and perhaps most important, is the belief that therapy should do
more than help clients with immediate problems. It should help them
develop an adequate philosophy of life, encourage them to cultivate an
approach to living that is self-sustaining, positive, and inherently
_social_ in focus. The paradox of inferiority and low self-esteem is
that the suffering they cause disappears once people can forget
themselves and begin living to some extent for others. Adler would
remind his clients to "consider from time to time how you can give
another person pleasure."[6] Adlerian therapy stresses the importance
of social goals. For Adler, we are foremost social creatures; our
individual identities can be developed and our problems resolved only
in a social context.
[6] Alfred Adler, _Problems of Neurosis_ (New York: Harper and Row,
1964), p. 101.
Since Adler believed that most emotional difficulties we experience
result from feelings of inferiority that have led to discouragement,
the second goal of Adlerian therapists is to offer _encouragement_.
They are as much concerned with mirroring clients' strengths as they
are with analyzing their problems. Adlerian therapists will devote a
good deal of attention to identifying and encouraging the personal
assets of each client.
Adler suggested several techniques that have also come to be used by
other schools of psychotherapy:
{160}
_Acting "As If"_
Frequently, clients express a wish to begin acting in new ways--to be
more assertive, to make an effort to break out of confining patterns of
living, to conquer certain fears. However, they usually feel that the
new behaviors are phony, so they are reluctant to try. Adler suggested
that clients try a new behavior for the next week only as they would
try on new clothing: they need only act _as if_. Adler found that, as
clients began to act differently, they would begin to feel differently.
When their feelings were positive, they tended to make new ways of
behaving part of themselves. (Behavior modification, described in the
next chapter, builds on this idea.)
_Paradoxical Intention_
We encountered this technique, also called _negative practice_, in the
preceding section on logotherapy. It can be a very effective technique
when certain habits can no longer be controlled. If you suffered from
insomnia, you would be asked to focus your attention on staying awake:
to put an end to the habit, you would be asked to amplify it. Oddly
enough, in many cases, this judo-like dropping of resistance and
redirection of attention can bring involuntary behavior back under
control.
_The Push-Button Technique_
Many of us have unpleasant thoughts and emotions that refuse to leave
us. We find ourselves on familiar tracks that we know lead to sadness,
regret, anger, panic, or frustration. But we can't seem to subdue what
Zen calls "these chattering monkeys of the mind." Adler taught clients
that they _could_ create whatever feelings in themselves they wished,
simply by deciding what to think. It is possible, with some practice,
to imagine a happy or peaceful memory or scene and to direct your
attention to it when negative thoughts try to dominate. We all have
this push button available. Like all exercises in self-discipline, it
strengthens us the more we use it. (Cognitive therapy, discussed in
Chapter 10, is especially concerned with this influence of thoughts on
emotions.)
SETTINGS FOR THERAPY
Adlerians use a variety of settings for therapy. Individual {161}
therapy is common, but sometimes two therapists may work together with
one client, an approach that gives clients an experience of cooperation
between professionals who may perceive them differently. Adlerian
workshops are popular with parents concerned with problems in rearing
children. Other workshops exist for married couples. Adlerians have
often been innovative: Rudolf Dreikurs, a well-known student of Adler,
was, for example, one of the first therapists to use group therapy in
private practice.
APPLICATIONS OF ADLERIAN PSYCHOTHERAPY
Because Adler did not view human problems as forms of sickness,
Adlerians see emotional and behavioral difficulties as blocks that
people encounter in their attempts to realize themselves. Many of the
problems Adlerian therapists treat are therefore considered to be
_normal_ problems of living faced by _normal_ people. Many clients
enter therapy to learn about themselves and to grow.
Adlerians have worked with a wide range of clients with a wide range of
human problems:
* clients interested in personal development
* individuals who have become deeply discouraged about their lives
* couples and families
* delinquents and criminals
EMOTIONAL FLOODING THERAPIES
Today there are three main varieties of emotional flooding therapies:
bioenergetics, primal therapy, and implosive therapy. They share the
central belief that, by taxing you, pushing you to experience
frustration, anger, or anxiety, the therapist may help you achieve a
lasting sense of emotional relief and well-being.
These three therapies do, however, vary a good deal in the techniques
they use to encourage clients to experience strong emotions.
Bioenergetics makes use of an unusual approach to physical exercise.
Primal therapy encourages clients to relive early painful memories.
Implosive therapy asks clients to use imagery to increase, in a
controlled manner, feelings that cause emotional distress. These
approaches share the assumption that {162} emotional difficulties can
be helped by a direct release of feelings that have come to be blocked.
BIOENERGETICS
_For rigid, inhibited people who have pent-up
feelings in need of release._
Alexander Lowen (1910-2008) was trained as a physician and then as a
psychoanalyst under the direction of Austrian psychoanalyst Wilhelm
Reich (1897-1957). Reich believed that emotional problems resulted
from sexual repression. He was a social revolutionary in his attempts
to bring about sexual freedom. He became a controversial figure and
was not able to put his ideas on a serious and professionally
respectable footing.
Lowen was interested in the therapeutic implications of Reich's work.
He developed an approach to therapy that emphasizes not sexual
liberation and pleasure as Reich did, but a sense of freedom that he
felt could result only from an approach to the body that allows you to
drop tense muscular armor and to feel integrated and fully alive.
Lowen found that emotionally troubled people were physically knotted
and rigid and tended to breathe in a shallow and constricted way.
Lowen devised a variety of physical exercises, such as holding your
body in an arched position until exhaustion sets in, making contact
with the floor only with hands, head, and feet. These exercises can
cause enough stress to arouse intense emotions: crying out, collapsing,
feeling rage or tenderness. As these pent-up feelings are released,
many clients often discover an increase in positive emotional strength.
Bioenergetic therapists offer individual therapy as well as workshops.
They tend to act as teachers, pointing out very bluntly how a client's
physical rigidities reflect rigid qualities of personality: "Your chest
muscles are this tense because you have been defending yourself so
long, like a boxer," or "Your jaw muscles ache because you've been
biting back angry impulses."
Because of its physical approach to human emotions, bioenergetics is
sometimes regarded as the West's therapeutic version of yoga. (For a
discussion of yoga, see Chapter 15.)
{163}
_Applications of Bioenergetics_
Bioenergetics appears to be most useful for people with any of these
characteristics:
* Their feelings are markedly inhibited, or they feel deadened
emotionally.
* They feel impaired sexually or do not experience orgasm for
nonphysical reasons.
* They are rigid, uptight, and inclined to be obsessive perfectionists.
* They have pent-up feelings of anger, hostility, or grief that are in
need of an outlet.
Bioenergetics is not the treatment of choice when deeper insight and
self-knowledge are important. Bioenergetic therapists are not in
general especially concerned with a client's personal history, family
and work environment, or specific adaptation problems.
PRIMAL THERAPY
_For individuals who continue to suffer from
childhood pain._
Arthur Janov (1924- ) was psychoanalytically trained as a clinical
psychologist and psychiatric social worker. He had been practicing for
seventeen years when a shy and withdrawn client in a group therapy
session let out a piercing, primitive scream. The inhibited client
experienced a sense of release and insight. This event fascinated
Janov and eventually transformed his professional perspective.
He developed an approach to therapy that encourages patients to
re-experience repressed painful memories from childhood. Janov calls
these _primal_ pains: they come about when a child's emotional needs
repeatedly are not met. The inner suffering that results is
suppressed; the pain cannot be dissipated. It takes energy to continue
to block out painful feelings. The constant expenditure of energy then
shows up in conscious tension. Janov came to believe that emotional
problems in adults stem from {164} their unwillingness to experience
feelings that a child would find crushing but--though painful--can now
be faced. When primal pain is faced, Janov claims, individuals gain a
degree of freedom and maturity they could not otherwise achieve.
Janov's primal therapy is best known for the "primal scream" we
mentioned above that some patients let out when they confront the pain
they have suppressed for so long. Primal therapy encourages a repeated
cathartic release of pent-up feelings. During the first three critical
weeks of therapy (which normally cost in excess of $2,000), the primal
therapist is on call twenty-four hours a day for a single patient. The
patient is isolated for the first week in a hotel room, without TV,
cigarettes, alcohol, sex, or companionship, and has daily therapy
sessions with the therapist that last from two to three-and-a-half
hours. Patients then spend six to twelve months in a primal therapy
group.
Janov has been criticized for his apparent desire for public charisma
and for capitalizing on advertising hype. He tends not to reveal in
writing details of his procedures in therapy and will share his
professional secrets only with initiates at his primal therapy
institute. Comparatively few therapists have had this special
training. However, many therapists offer what they claim is the
equivalent of primal therapy, which they call _intensive feeling
therapy_. They have the same format for therapy: isolation in a hotel
room, three weeks' exclusive attention to each client, and the
resulting high fees.
_Applications of Primal Therapy_
Primal therapy has been used to treat these problems:
* chronic depression and anxiety
* compulsions
* phobias
* drug addiction
* problems of homosexuals
* marital problems
Like bioenergetics, primal therapy is best suited for individuals who
have repressed or pent-up feelings they have not found ways to release.
{165}
It is important to bear in mind that primal therapy is initially one of
the most expensive therapies, since it devotes exclusive attention to
each client at the beginning of therapy. It may not be the therapy of
choice for more verbal, intellectual clients who want to develop an
understanding of themselves beyond an experience of catharsis.
IMPLOSIVE THERAPY
_For people with phobias._
This emotional flooding therapy was developed by Thomas Stampfl (1923-
). Stampfl was trained as a clinical psychologist at Loyola of Chicago
and was influenced by both psychoanalysis and the psychology of
learning. Early in his career, he became convinced that clients with
phobias tend to reinforce their fears by automatically avoiding what
they fear. He developed an approach to help people face the
situations, feelings, or memories they most fear.
Stampfl's approach is most easily understood in the light of recent
experimental work on animal avoidance behavior. A dog, for example, is
confined in a cage that is divided in two. A low wall separates the
two halves of the cage, over which the dog can jump. On one side there
is a bell that rings just before the dog receives an electric shock.
The dog promptly learns that he can avoid the shock by jumping to the
other side of the cage. Soon he will learn to do this automatically,
whenever the bell rings. What is significant from a psychologist's
point of view is that the dog will continue for a long time to jump to
the opposite side of the cage, even once no further shocks are given.
The dog's fear is maintained in force only by his own memory.
Animal psychologists have found a quick way to end the dog's fear: ring
the bell, but _prevent_ the dog from jumping to the other side of the
cage. Once the anxiety-stricken animal realizes that he is no longer
going to be shocked, the old habit based on fear simply disappears.
Implosive therapists make use of an equivalent technique with human
beings. Patients are asked to imagine, as vividly as {166} possible,
that they are facing the very thing they chronically have tried to
avoid. For example, an individual may have suffered from a terrifying
fear of elevators for years. The therapist tries to use exaggerated
imagery to produce maximum anxiety. He might ask the patient to
imagine being stuck in an elevator fifty floors up, having the elevator
shake and abruptly fall a foot, then have the lights go out, and so on.
By _maintaining_ this contrived elevator nightmare long enough,
implosive therapists claim that, frequently, the level of anxiety of
patients quickly and dramatically falls, and they lose their
exaggerated fears.
Implosive therapists are therefore not primarily concerned with being
genuine, sympathetic, or mothering. They focus their energy and
attention on pushing clients to confront the worst fears and
catastrophes they can imagine. All the while, clients are aware both
that the intense anxiety they experience is an _intended_ goal of
therapy and that the therapist is convinced they are much stronger than
they have thought.
Implosive therapy is usually done on an individual basis and is
comparatively brief, usually lasting less than a dozen sessions. It
should be mentioned that, when not successful, implosive therapy may
occasionally _sensitize_ clients to feel even more anxiety than they
did at the outset. It therefore tends to be a higher-risk treatment,
but it can be remarkably effective. Visualizing anxiety-producing
events also has successfully been used by individuals on their own.
(For more information, see "Appendix B: Suggestions for Further
Reading.")
_Applications of Implosive Therapy_
Implosive therapy is especially appropriate for the treatment of phobic
individuals who characteristically tend to avoid certain kinds of
behavior, situations, or objects because of the severe anxiety and
agitation these produce in them. Implosive therapy, when effective,
can be dramatically effective in a comparatively short time. However,
less arduous approaches to therapy can often be as effective and may
involve less risk of increasing a client's existing anxiety.
Alternative short-term therapies especially well-suited to the
treatment of phobias include behavior modification (Chapter 12),
Gestalt therapy (Chapter 10), reality therapy (earlier in this
chapter), primal {167} therapy (earlier in this chapter), and
biofeedback, relaxation training, and hypnosis (Chapter 15).
DIRECT DECISION THERAPY
_For individuals capable of exercising
determination and self-discipline who
earnestly desire to change._
[I]f there's one thing my experience as a psychotherapist has
taught me, it is that no one has to be a victim. However important
external factors like health, physical appearance, and upbringing
may be, they don't have to determine the happiness quotient in
anyone's life story. The way we experience our lives is, quite
simply, up to us.
Harold Greenwald, _The Happy Person_
At the time of this writing, the majority of academic and research
psychologists regard themselves basically as Freudians. Yet most
psychiatrists, psychotherapists, social workers, and counselors have
moved beyond Freud's formal categories and made use of their own common
sense and interpretive abilities. Harold Greenwald's emphasis on the
central role of _choice_ in making fundamental life decisions
implicitly represents the approach of a great many therapists and
counselors today. His conception of therapy is casual, simple, and
often good-humored.
Greenwald (1910-2011) was originally trained as a psychoanalyst. As
Greenwald gained professional experience, however, his perspective
began to change. He gradually came to believe that many patients had,
at some critical moment, made a _decision_ to "go crazy." There was a
point when they could exercise control, and at that moment, they chose
to be depressed or anxious, to withdraw completely into catatonia, to
become schizophrenic, alcoholic, or whatever their decision might be.
I discovered in working with people who have had psychotic breaks
... that most of them described a particular moment when there was
a choice of whether to stay in control or let go.... You will
find, again and again, if you speak to patients who have broken
down, and if you search for it, that there is always {168} a point
at which they had a choice, and it is at that point that they still
have the possibility of controlling themselves. If they have
confidence in their ability to control themselves they can exercise
it.[7]
[7] Harold Greenwald, "Treatment of the Psychopath," in Raymond J.
Corsini, ed., _Readings in Current Personality Theory_ (Itasca, IL:
F. E. Peacock Publishers, 1978), p. 355.
This _choice point_ that people experience became the focus of Dr.
Greenwald's direct decision therapy.
AN EXAMPLE
Here is one of the most dramatic examples of his approach: Dr.
Greenwald had been invited to give a demonstration of direct
decision therapy at a mental hospital in Norway. He asked for a
volunteer from the inmates, someone who could speak English. A
twenty-year-old patient named Marie came forward. She had the
appearance of a back ward schizophrenic. She was haggard,
wild-eyed, and unkempt. Here is Dr. Greenwald's description of
their opening conversation:[8]
[8] Harold Greenwald and Elizabeth Rich, The Happy Person (New
York: Stein and Day, 1984), pp. 180-181.
I gestured toward a chair. "Won't you sit down, please?"
"When I'm ready. I'll sit when I'm ready."
"Would you tell me your name?"
She waved an arm toward the staff member seated behind me. "You
heard him. Marie, my name is MARIE!"
"I'm sorry, Marie, I didn't catch it at first. Now I wonder if
there is anything I can do for you. Would you like me to help you?"
"You can't help me, none of you can help me. Why don't you _leave
me alone_? WHY ARE YOU ALWAYS AT ME?..."
She rushed on, shouting at the top of her voice and using a mixture
of expletives and obscenities that showed an admirable command of
English as well as Norwegian.
Nothing I could do could make the situation worse, so I decided to
try something drastic. I outshouted her.
"CUT IT OUT, MARIE! YOU KNOW YOU DON'T HAVE TO TALK LIKE THAT."
She stopped suddenly and focused on me for the first time. The
muscles in her face relaxed ever so slightly, and her eyes {169}
showed awareness and intelligence.
"How'd you know?"
I stared at her for a minute, giving her my best foxy-grandpa look.
"It takes one to know one," I said finally--at which point Marie's
face broke into a grin.
"You mean _you're_ crazy? You too?"
"Perhaps. And perhaps the only difference between you and me is
that I know how to act sane."
Marie seemed to like the sound of that. She tightened the sash of
her bathrobe and sat down.
As Marie calmed down, she agreed that she would like Dr. Greenwald to
help her. She wanted badly to leave the institution.
DR. G.: If you really want to get out, Marie, you'll have to make a
very simple decision.
MARIE: What's that?
DR. G: Decide to act sane.
Dr. Greenwald asked her to think of the benefits, the payoffs, that
came to her as a result of her crazy behavior. There were a number of
major payoffs: she didn't have to look after herself, didn't have to
look for a job, didn't have to listen to her mother.
The upshot was that Marie decided to give up being crazy and to return
to everyday living. It would have been easy for Dr. Greenwald to
conclude that she had been faking all the years she was in the mental
institution. But she had not been play-acting. Yet her illness began
through a _choice_ she had made, and it ended the same way.
Leaving the hospital world was not easy for her. In fact, it was often
very difficult. But she stayed with her decision and often had to
reaffirm it. She married and had a child. She wrote to Dr. Greenwald:
I found myself beginning to drift off, drift out of my life, the
way I used to. And--I didn't! I decided to be the kind of person,
the kind of wife and mother, that I want to be. Not perfect, just
what's possible. And if I drift off, I won't be able to hear my
daughter, I'll be just like my mother was with me.
Marie went back to school and earned a degree in psychology. After her
experience, she was, she felt (as did Dr. Greenwald), in {170} a
special position to be helpful to other people in suffering.
WHAT DIRECT DECISION THERAPY IS LIKE
On your own or with professional help, the truth about you--whoever
you are--is that you carry within yourself the resources to heal
your most grievous pains, overcome your most paralyzing fears,
devise ingenious solutions to your most burdensome problems.
Harold Greenwald, _The Happy Person_
During the first session with a client, Dr. Greenwald often says
something like, "Do you want me to concentrate on your problems, or
would you like us to work together in making you happy?" Immediately,
he suggests to clients that in fact they are able to change and become
happier.
Dr. Greenwald describes seven phases that direct decision therapy
involves:
1. Decide what you want in order to be happy (or happier).
2. Find the decision behind the problem: what has your implicit
decision been in your life that has established an unhappy, or less
happy, pattern? Greenwald calls these _life decisions_: they form the
center around which you organize your life. They are responsible for
your attitudes, perceptions, what you value most, and your behavior.
If your life decision is to suffer, you will interpret everything that
happens to you as more suffering-to-be-endured. If you are praised,
you may question whether the praise has an ulterior motive. "Sufferers
... have the ability to snatch disaster from every victory."[9]
3. When was the original decision made? Did your life decision come
from your upbringing? Did you inherit it from your parents?
4. Identify the payoffs for the decision. Even extreme
unhappiness--chronic clinical depression--can have real payoffs:
release you from responsibilities, gain you attention from others,
allow you to return to the comfort of childhood dependency, etc.
Anxiety can give you good reasons for {171} disqualifying yourself from
stressful situations and reinforce your belief that you cannot cope.
5. What are your alternatives to the behavior that is causing a
problem? It is often hard to see that you are _not_ really trapped in
a state of unhappiness. There are always alternatives.
6. Choose your alternative and put it into practice. Trust yourself.
"[H]appy people have a sense that whatever happens, things will
eventually work out. In short, they trust themselves to react in their
own best interest."[10]
7. Support yourself in carrying out your decision. Habits die slowly.
You must be patient. Your decision has to be made over and over again,
just as an overweight person who loves food must decide again and again
to say "No" to this dessert today, the baked potato tomorrow.
Gradually, the strength of your decision builds as _you_ build strength
into it.
[9] Greenwald and Rich, _The Happy Person_, p. 29.
[10] Greenwald and Rich, _The Happy Person_, p. 29.
APPLICATIONS OF DIRECT DECISION THERAPY
As we have seen, direct decision therapy is based on the assumption
that you are _able_ to begin to exercise self-discipline and that you
are _willing_ to give up the real payoffs that being emotionally
troubled frequently does achieve.
These interrelated things--ability and willingness to change--simply
are not present in many people who enter therapy. They come to therapy
for a variety of other, often unconscious, reasons: for temporary
comforting, for escape from an upsetting situation or environment, or
for a chance to release painful feelings and to express painful
thoughts. Clients come in order to procrastinate; they come to prove
to themselves that they simply _can't_ change and that the therapist
just isn't good enough. They come out of anger, frustration, despair.
But comparatively few enter therapy because they really are persuaded
they _can_ change and are committed to bringing change about.
These people are unquestionably the most promising candidates for _any_
approach to psychotherapy. Clients who come to therapy for other
reasons make up the daily challenge and the daily frustration, concern,
worry, and hope of the therapist. The therapist believes that, in
time, and with proper treatment, {172} people who are imprisoned within
walls of their own habits can rally the determination and faith to tear
them down and to gain a measure of personal freedom.
In this author's judgment, direct decision therapy, perhaps more than
any other approach, relies on a client's determination and
perseverance. If these personality qualities are there, or if they can
successfully be encouraged by a good therapist, the approach can be
effective with a very wide range of problems.
[W]hat ... many ... patients proved to me is that, given the choice
to be happy, many unhappy people are able to decide that happiness
is what they want. Then ... they develop the ability to experience
their problems in a different way.[11]
[11] Greenwald and Rich, _The Happy Person_, p. 53.
{173}
12
BEHAVIORAL
PSYCHOTHERAPY
_For people who want prompt relief
from specific symptoms and who have
the incentive and discipline to practice
new patterns of behavior._
[M]uch of our suffering is just so obscure ... frigidity, social
anxiety, isolation, boredom, dissatisfaction with life--in all such
states we may see no correlation between the inner feeling and the
way we live, yet no such feeling can be independent of behavior;
and if only we find connections we may begin to see how a change in
the way we live will make for a change in the way we feel.
Alan Wheelis, _The Desert_
Many of us today feel forced to adapt to ways of living that will lead
to unhappiness, loneliness, fear, and illness. Is unlocking all five
bolts on one's apartment door in the morning, checking that the can of
Mace is in your purse, joining the sidewalk crowd to the subway, hoping
you are not mugged (or worse), and then spending the daylight hours in
a windowless office, in an atmosphere of tension, pressure,
competitiveness, and cigarette {174} smoke, with time out for caffeine
(or, again, worse) and then a lunch soaked in alcohol a desirable and
healthy way to live?
Behavioral psychotherapy seems to have been developed to respond
especially to present needs.
Clients usually respond ... with a great sense of relief on finding
they are not seen as sick or weak; they appreciate the positive
orientation toward changing the problematic situation rather than
dwelling on it.[1]
[1] Dianne L. Chambless and Alan J. Goldstein, "Behavioral
Psychotherapy," in Raymond J. Corsini, ed., _Current Psychotherapies_
(Itasca, Il.: F. E. Peacock Publishers, 1979), p. 234.
Behavioral psychotherapy is best known for focusing on symptoms as its
main target, rather than viewing symptoms as signs of underlying
problems. Like most generalities, this one has its exceptions; some
behavioral psychotherapists are very much concerned with understanding
the underlying causes of an individual's difficulties. Nevertheless,
behavioral therapies do tend to aim for concrete, specific, and prompt
relief of symptoms. They frequently are effective, and they are based
on techniques that have been tested extensively.
THE THREE SCHOOLS
Today there are three main schools of behavioral psychotherapy:
COUNTER-CONDITIONING
Also called _reciprocal inhibition_, this approach was developed by
Joseph Wolpe (1915-1997), a Jewish psychiatrist trained in South
Africa. Anxiety is offset by means of desensitization, assertiveness
training, and sex therapy. As the basis for desensitization, deep
relaxation is used to inhibit anxiety. Assertiveness training is used
to counteract anxiety due to excessive shyness or aggressiveness by
helping individuals form balanced habits of assertiveness that are
neither submissive nor hostile. Sex therapy makes use of techniques of
relaxation and desensitization to permit clients to feel sexual arousal
and, in this way, to overcome sexual anxiety.
{175}
BEHAVIOR MODIFICATION
This approach was derived from the work of American behaviorist B. F.
Skinner (1904-1990) and others, who attempted to show that a great many
emotional problems result from situations in which a person has been
punished. He or she comes to fear these situations and develops
emotional symptoms in an effort to escape from them. In behavior
modification, attempts are made to change behavior through the use of
rewards or punishments.
COGNITIVE APPROACHES TO BEHAVIOR CHANGE
These approaches make use of techniques developed outside of behavioral
psychotherapy, especially those of Albert Ellis's rational-emotive
therapy (see Chapter 10). These cognitive approaches are based on the
belief that a person can gain control over undesirable behavior and
psychosomatic problems by learning new habits of thinking.
These three schools of behavioral psychotherapy claim that the problems
leading people to enter therapy are _learned_ and can be unlearned
through systematic training. In particular, anxiety--the primary
source of emotional discomfort--can become a learned habit. When this
happens, anxiety is linked to stimuli that in themselves are usually
harmless. A person may come to feel extremely anxious, for example,
when in the presence of people in authority, when in bed with a sex
partner, when near dogs or insects, when criticized by others, when in
a confined space, or in any number of other situations. Anxiety in
these situations is learned, and it gradually becomes an involuntary
habit. But the habit frequently can be broken and eliminated.
WHAT BEHAVIORAL PSYCHOTHERAPY IS LIKE
COUNTER-CONDITIONING
When you are exposed to a situation that you believe is threatening,
your blood pressure and pulse rate go up, your muscle tension
increases, the blood supply to your large muscle groups increases,
circulation to your stomach and genitals is {176} reduced, your pupils
may dilate, your mouth may get dry. A startling noise or a physical
shock can produce these symptoms. They are the physical manifestations
of anxiety, and they are the focus of counter-conditioning techniques.
Anxiety _generalizes_ very easily. If you were repeatedly punished for
playing with dirt as a child, dirt can evoke strong anxiety in you as
an adult. If you were bitten by a dog, the sight of a dog years later
may make you feel anxious. Anxiety can come to be associated with
almost any experience. What is particularly destructive about this is
that you soon find yourself caught in a vicious circle: a certain
situation makes you anxious, you try to avoid the situation and the
anxiety it produces in you, and as you do this, you build up
_secondary_ anxiety--you get anxious that you'll get anxious. So
anxiety compounds, feeding on itself, fueling itself.
Counter-conditioning therapists have found that, to varying degrees, we
are all capable of inhibiting anxiety. A behavior therapist tries to
teach you how to do this, eventually so that you can use relaxation
techniques on your own.
The following are the main phases of desensitization
therapy--assertiveness training and sex therapy are similar, gradual,
and reassuring processes:
1. You are taught how to achieve a state of relatively complete
physical relaxation. Many therapists will tape relaxation instructions
so that you can practice daily at home for twenty to thirty minutes.
Some therapists will instruct you to _tense_ your arms, hold the
tension for ten seconds or so, then relax and feel the resulting sense
of relaxation, the sense of relief from tension and strain. Or, some
therapists use _suggestion_, asking you to imagine that your arms are
becoming heavier and heavier, encouraging you to relax deeply. Each of
your major muscle groups is relaxed in turn until you feel fully
relaxed. This first phase of therapy usually takes from two to six
sessions.
2. Next a hierarchy is constructed by the therapist for each individual
client, ranking situations or stimuli from most to least
anxiety-producing. A person who fears to leave the sense of security
of home already is aware of such a hierarchy: low anxiety may be felt
on the front steps, greater anxiety when going out to the mailbox, more
{177} anxiety in walking around the block, and extreme anxiety when
facing a trip or a move to another residence.
3. The last phase is the actual process of desensitization. You are
asked to relax deeply with eyes closed, usually in a recliner in the
therapist's office. You are asked to imagine a scene taken from the
low-anxiety end of your hierarchy. The therapist tries to describe the
scene as realistically and vividly as possible. If you begin to feel
anxious, you can raise an index finger, and then the therapist will
shift away from the imagined scene and will turn back to relaxation
instructions. When you are again relaxed, the process continues until,
in time, you are able to imagine a scene high on the hierarchy, but
still sustain deep relaxation.
Once this process of desensitization can be accomplished in the office,
you begin anew, but now with actual situations--first with those low on
your hierarchy and then working your way toward situations that used to
cause you high anxiety. Frequently, behavior therapists will accompany
their clients outside the office, helping them to remain relaxed--e.g.,
while riding elevators, in crowds, even sometimes on airline flights if
fear of flying is the problem.
BEHAVIOR MODIFICATION
The central idea behind behavior modification is that undesirable
habits of behavior will gradually be eliminated if, consistently, they
are not rewarded or even are punished. Conversely, desirable habits
are encouraged when they consistently are reinforced or rewarded.
Therapists who use behavior modification techniques may recommend both
punishments and rewards to clients. If you are a chronic smoker or
overeater, for example, you may be given a small device with which to
shock yourself moderately each time you reach for a cigarette or a
second helping. Or, you may be asked to deposit $100 with the
therapist, and a certain amount will be donated to your most disliked
political group each time you go astray.
Rewards, on the other hand, include material rewards that clients may
promise themselves once a habit is successfully under control for a
certain length of time. Most therapists {178} encourage you eventually
to substitute inner satisfactions: pride in your slim appearance or
improved health, strengthened self-confidence, growth of sexual
satisfaction, and, most importantly, a developing sense of self-respect
as you learn to gain control over anxiety, frustration, or
dissatisfaction.
Behavior therapists also use _distraction_ techniques. They encourage
you to do things that are incompatible with the problem you wish to
resolve. Bicycling or lovemaking may prove to be good antidotes for
some individuals who overeat. Hiking or jogging, or physical
reassurance, massage, or relaxing baths may lessen anxiety. Laughter
releases tensions and offers its own special kind of encouragement and
healthier perspective.
Behavior modification requires strong initiative and discipline on the
part of the client. More than these, it requires that you be willing
to let go of old habits that have been unsatisfying or destructive and
work to form new, more rewarding habits. In the beginning, forcing
yourself to behave in new ways may feel like pretense or dishonesty.
This is a common experience and should not be allowed to block your
desire to change. Unfamiliar and even uncomfortable ways of behaving
do become familiar and more comfortable the more they are practiced.
If these new ways of behaving come to offer satisfactions or
compensations that old habits did not, they will gradually be absorbed
into your own sense of personal identity. What at first may feel to
you like an act slowly is made a part of your personality until a habit
is established that feels entirely natural. This takes time, patience,
practice, and more practice.
COGNITIVE APPROACHES TO BEHAVIOR CHANGE
Behavioral psychotherapists use a variety of techniques designed to
help clients control their own behavior and individual physical
responses more effectively.
_Biofeedback_
Biofeedback can help many people gain control over habitual, automatic
processes. Biofeedback equipment can be used to teach you how to
reduce tension, develop skills to bring about relaxation, or cope more
successfully with chronic pain. (For a detailed discussion of
biofeedback, see Chapter 15.)
{179}
_Thought Stopping_
Thought stopping can help you break chains of negative and
self-undermining thoughts. Thought stopping is a technique that begins
by having you think out loud during therapy sessions. If you
repeatedly express negative, troubling thoughts, the therapist shouts,
"Stop!" In this way, you are made acutely aware of self-destructive
thinking habits. You gradually learn to stop yourself from trapping
yourself in upsetting thoughts by silently commanding your mind to
"stop!" It is a simple but often effective technique, related to two
techniques we have already discussed: the push-button technique of
Adlerian psychotherapy (see Chapter 11) and the technique of disputing
your own irrational beliefs in rational-emotive therapy (see Chapter
10).
_Problem Solving and Decision Making_
These techniques have been developed to help clients solve personal
problems and make life decisions more effectively. Behavioral
therapists who offer assistance of this kind emphasize the importance
in problem solving and decision making of several factors.
One is refraining from implementing solutions or decisions until you
have clearly defined and understood your problem or situation. Another
is becoming aware of emotional blocks to solving problems and making
decisions. For example, procrastinating serves to protect people from
facing risks. Individuals are frequently also deterred from solving
practical problems because they are emotionally distracted by other
difficulties that demand attention first. And people are inclined to
jump at one possible solution that then acts as a blinder to seeing
other potentially more promising alternatives.
Behavioral therapists also believe you must realize that, often,
difficulties you experience when trying to solve problems or make
decisions are due to conflicts between incompatible goals or values.
Sometimes one objective cannot be achieved without compromising
another. They also believe you must develop abilities to imagine a
wider range of alternatives. And finally, they believe you must become
better able both to foresee likely personal consequences of
implementing a particular solution or decision and to evaluate these in
relation to what is personally most important.
{180}
AN EXAMPLE OF BEHAVIORAL PSYCHOTHERAPY
Anne Holt was thirty-two when she came to see Dr. Cantwell. She was
noticeably anxious, wringing her hands, tense, and easily startled, as
when a car's exhaust backfired in the street below. She complained of
feeling unloved by her husband and was always in dread of his
criticisms. She also felt her mother-in-law was very critical of her.
Anne wanted to get away from the house but had quit two jobs in
succession, in each instance when her boss's criticism of her work
upset her.
Dr. Cantwell explained the rationale behind desensitization to her and
taught Anne how to practice systematic muscle relaxation, beginning by
tensing her hands, then relaxing them, tensing them, then relaxing them
again, and doing this with her arms, shoulders, calf muscles, thighs,
abdomen, jaw, neck muscles, cheek, and mouth muscles. He recorded his
instructions on a tape for her to use at home.
After five weeks of daily practice, Anne was usually able to relax
deeply in less than a minute. Dr. Cantwell, in the meantime, had
gained a clearer idea of what troubled Anne, and he had made up the
following hierarchy:
_Criticism directed at Anne from:_
High anxiety Her husband
| His mother
| A boss
| Anne's mother
Low anxiety Anne's neighbor
Dr. Cantwell decided to use a combination of desensitization and
assertiveness training with Anne. During half of each weekly session
with Dr. Cantwell, Anne was asked to relax in a recliner with her eyes
closed, and Dr. Cantwell would then describe situations low on her
hierarchy. Anne was to try to maintain her sense of relaxation _in
spite of_ Dr. Cantwell's description of an imagined situation involving
Anne's neighbor. She was to imagine that her neighbor, who was very
fastidious about her own yard, knocked at Anne's door to complain about
Anne's habit of setting the trash out the night before pickup.
Gradually, in a similarly concrete way, Dr. Cantwell had Anne imagine
her mother criticizing Anne for using the same sponge for wiping up
{181} in the kitchen as for washing the dishes; a boss asking Anne to
retype a business letter using another format that he preferred; Anne's
mother-in-law "dropping the hint" that her son liked to have his
T-shirts ironed; Anne's husband complaining because Anne always
overcooked the soft-boiled eggs.
During the second half of each session with Anne, Dr. Cantwell played
roles with Anne in which he taught her how to assert herself more in
situations involving criticism. In one session, for example, he took
the part of Anne's mother and chose a typical remark she might make:
"Annie, dear, don't you think it would be smarter to use a different
sponge for wiping the kitchen counter? You should use a separate one
for the dishes." Dr. Cantwell then asked Anne to think of a way she
could reply to her mother's "nice" criticism, without feeling bad about
herself, without "getting hooked."
ANNE: Well, one way you've taught me would be to use humor: I could
say to her, "Mom, anytime you'd like to come over to do the dishes,
it would be fine with me." And then laugh.
DR. C.: That's a good approach. But you don't want to be
offensive; you don't want to laugh _mockingly_. _How_ you do this
is important. You want to set a good-natured feeling. Humor can
be very useful to offset the sting of criticism. Can you think of
a different way to reply to your mother, in addition to humor?
ANNE: Well, let's see.... Yes, well, I could go with her
suggestion and not interpret what she says to me as criticism at
all. I could say, "Mom, thanks for the idea. Maybe I'll do that."
DR. C.: Sounds very good. That's another way. The more
alternatives you can prepare yourself with ahead of time, the less
likely she will hook you, leaving you with nothing to say and
simply feeling bad. Would you try to think of one more
alternative? What other tack could you take?
ANNE: (After a moment of silence.) I can't think of another.
DR. C.: How about telling your mother how you actually feel when
she criticizes you? How _do_ you feel?
ANNE: Well, I wish she'd say some positive things instead, at least
sometimes. That would be nice.
DR. C.: Great. How could you tell her that?
ANNE: Well, I could say, "Mom, you know, you give me a lot of
suggestions. Some are OK, now and then, but, to be {182} honest,
I'd really like to hear some praise sometimes. Do you think you
could find some things to compliment me on? I don't want any false
praise, but I need to hear some encouraging things from people I
love."
DR. C.: Anne, you're doing very well: ... Humor, reinterpreting so
you don't feel criticized, and talking about criticism from a more
detached point of view. You're definitely learning how to cope
with criticism much better.
APPLICATIONS OF BEHAVIORAL PSYCHOTHERAPY
Desensitization is normally used in the context of individual therapy.
Behavior modification and cognitive approaches to behavior change are
frequently used in groups. People with problems in common--smoking,
obesity, phobias, etc.--are sometimes grouped together. Often,
however, a mixture in groups is desirable. For example, it is
frequently helpful for shy people to be part of a group in which they
may watch others who can model more assertive ways of acting. (For
more about group therapy, see Chapter 13.)
Behavioral approaches to therapy must be tailored to the individuality
of each client; whatever goals are established have to be in accord
with the client's own desires. Behavioral psychotherapy presupposes
that clients will practice instructions and new behaviors between
sessions and that they can maintain an adequate level of motivation,
both while in treatment and after treatment ends, so that new habits of
behaving or thinking can become effective and reliable parts of their
own personalities.
In general, behavioral approaches to therapy have been less effective
in treating panic attacks, chronic depression, substance abuse
(smoking, for example, is one of the habits most resistant to formal
therapy), and psychosis.
COUNTER-CONDITIONING
This approach, which includes desensitization, assertiveness training,
and sex therapy, has been used effectively in treating these problems:
* phobias
* psychosomatic complaints
{183}
* sex, marriage, and family problems
* passivity and shyness
* personality trait problems: lonely, anxious, hostile, or overbearing
individuals
BEHAVIOR MODIFICATION
This approach has been used successfully in connection with these
problems:
* sexually deviant behavior
* children's problems, school discipline, academic performance, and
juvenile delinquency
* problems of the mentally retarded and of psychotically regressed
individuals
* some instances of obesity, alcoholism, and smoking
* schizophrenia
* stuttering
COGNITIVE APPROACHES TO BEHAVIOR CHANGE
These approaches have, for example, been used to treat such problems as:
* anxiety and depression
* adjustment problems
* marital and sexual difficulties
* psychosomatic problems
The popular conception of behavioral therapists is that they tend to be
coldly scientific and mechanical. Yet a number of studies show that
they are inclined to be warm individuals who show positive regard for
their clients. In general they tend to be empathetic and
self-congruent. These qualities are very much needed if we as clients
are to feel encouraged to face one of the most difficult challenges
life can pose for us: to change ourselves.
{184}
13
GROUP THERAPY
_Especially well-suited to people who are
outer-directed but lonely, who want to
develop their interpersonal skills,
and who would like to learn about
themselves from the perceptions of others._
Group therapy is ancient. For as long as men have gathered together to
share their experiences, thoughts, and feelings and to give one another
comfort, group therapy has existed. As an approach to modern
psychotherapy, however, it was in its infancy fifty years ago. No
single great mind stands behind group therapy; it has been and
continues to be innovative, flexible, and free from ties to any
particular orthodox school of thought.
Clients who are attracted to group therapy and who often benefit from
group experience tend to have these characteristics:
* They are passive in their interactions with others. They are more
comfortable being told what to do than facing the need to decide for
themselves.
* They are often lonely or socially isolated. Individual {185}
therapy, with its one-to-one relationship between therapist and client,
does not encourage some clients enough for them to feel like members of
humanity. They tend to feel sorry for themselves while in individual
therapy or to judge themselves harshly for their need for help. Being
with other clients in a group situation answers their needs better.
* They are outer-directed people: what others think of them is crucial
to how they think about themselves. Inner-directed individuals are
likely to feel more interested in and comfortable with individual
therapy.
For people who are relatively passive, lonely, yet outer-directed,
group therapy has some distinct advantages:
* It gives them a place within a group of people--they are no longer
alone.
* It gives them opportunities to express themselves freely, confront
other people, and say things that they otherwise might not be able to
express, thanks to the close and confidential environment of the group.
* They can hear how a variety of other people perceive them. They are
not limited to the observations, ideas, and recommendations of a single
therapist.
* They often feel more at ease in a group. They feel less fear or
intimidation in the presence of the authority figure the therapist
represents.
* They may benefit from the experiences of other group members who have
similar problems or who have very different kinds of difficulties.
Knowing that they are not troubled minorities of one can be a comfort;
knowing that other people have problems in areas where they don't can
be reassuring.
In general, group therapy can give you insight provided by the thoughts
and perceptions of others; it can help you develop social ties if you
feel isolated; and it can offer group support if you need emotional
bolstering in order to cope with difficult situations, undertake
decisions that may frighten you, and face more calmly and confidently
the many challenges life can present. But it can also help you deal
with more specific problems, such as facing an especially stressful
situation--the death of {186} someone very close to you, divorce or
separation, serious illness, unemployment, drug addiction, or
alcoholism. Or perhaps you have problems relating to others, such as
having a history of being fired from job after job despite your efforts
to hold them. For that matter, group therapy can even offer
information about job opportunities, how to develop occupational
skills, how to apply for a job, and how to keep a position you hold.
Some psychologists have commented that the popularity and the need for
the kind of experience that group therapy offers are due to the decline
of community life and to the virtual disappearance of extended families
living physically and emotionally close to one another.
Group therapy is offered in private practice, in hospitals, and in
halfway houses; in psychiatric and counseling centers, in clinics and
hospital wards for patients with diabetes, AIDS, epilepsy, arthritis,
heart conditions, paralysis, blindness; in prisons and juvenile
detention centers; and in schools, for students with behavior problems
and truancy. Group therapy is often used for marriage, family, and
child-guidance counseling and to help families in which a member is
physically or emotionally disabled. Group therapy is used by churches
for family guidance and for spiritual counseling. It is used in
virtually any area where people share problems: victims of crime and
physical abuse, former patients, the aged, children of the aged, those
who are discriminated against--the list goes on.
So, group therapy cuts across virtually the whole range of human
problems. Because it is used in so many areas, it is impossible to
define it as a single approach--many distinct approaches actually may
be involved.
Many of the approaches to psychotherapy we have already looked at are
used in groups. There are psychoanalytically oriented groups, Adlerian
groups, Gestalt groups, groups that use behavior modification, and
others. Perhaps the most useful way to understand group therapy is to
liken it to education. Many sorts of things can be taught, and many
can be learned. Group therapy may be understood most clearly in
relation to what kinds of learning and teaching really go on in it.
Since group approaches to problem solving include many applications
beyond our scope here--in industry, religion, schools, etc.--we will
look more closely at the following forms of group therapy that are used
in the context of psychotherapy: brief group psychotherapy, T-groups,
{187} human potential groups, self-help groups, and the use of
specialized approaches to psychotherapy in a group setting. (Marriage
and family therapy, which are special forms of group therapy, are of
interest to a large number of people, so they are discussed separately,
in Chapter 14.)
BRIEF GROUP PSYCHOTHERAPY
Also known as _short-term encounter groups_, brief group psychotherapy
is intended for people who face life crises, who are motivated to
change, and who are comparatively free of individual emotional
disorders. Normally, there are about ten sessions. People who find
short-term group therapy useful generally have well-defined problems to
solve. Their experience in group therapy encourages them to become
involved in new activities, join clubs, perhaps do volunteer work after
being recently widowed, divorced, or separated; to take specific steps
to find employment; or to practice new ways of behaving--to become more
assertive, to implement a weight-loss plan, to return to school after
raising a family, or to change careers.
T-GROUPS
Training groups were an outgrowth of the National Training
Laboratories, an organization formed in 1947 by social psychologists
who were interested in improving education. T-groups were made up of
"normally adjusted people" who were interested in improving their
communication skills so they could become more competent in difficult
interpersonal situations.
T-groups gradually widened their focus and became the basis for the
practical orientation of many therapy groups today. Clients who feel
isolated or alienated, find it hard to relate to others, lack a sense
of meaning and direction, and do not have strong self-discipline often
are attracted to T-groups.
HUMAN POTENTIAL GROUPS
These groups have probably done the most to give group therapy its
popular image. "Growth centers" are usually rural retreats where
psychological growth of participants is encouraged. Visits last from a
weekend to several weeks. The first {188} center was called Lifewynn,
organized in the 1920s at a summer camp in New York's Adirondack
Mountains. The best-known growth center is the Esalen Institute in Big
Sur, California, formed in 1962 by Michael Murphy. Its program
combines Gestalt therapy with Eastern meditation (see Chapter 15).
Other similar growth centers have sprung up across the country. In
addition to these, the est (Erhard Seminars Training) organization has
attracted a good deal of public attention and controversy. The est
approach is eclectic, combining Eastern thought, Gestalt therapy,
transactional analysis, psychoanalysis, Jungian philosophy, positive
thinking, meditation, and other approaches. Some est leaders have been
described as charismatic, proselytizing personalities who claim to be
able to lead participants to salvation.
SELF-HELP GROUPS
There are self-help groups to aid you with many different kinds of
problems. They provide group moral support for members with shared
problems. They are not intended to bring about deep-seated personality
change. Alcoholics Anonymous (AA), founded in 1934, probably is the
most well-known self-help organization. Recovery, Inc., also known as
the Association of Nervous and Former Mental Patients, was formed in
1936 by psychiatrist Abraham A. Low. Meetings focus on members'
conscious control of symptoms; Recovery, Inc., frequently encourages
members to become involved in volunteer social work.
There are many other self-help organizations--for the handicapped,
widows, battered wives, diabetics, victims of AIDS, hemophiliacs,
homosexuals, drug addicts, and others. (For further information see
"Appendix A: Agencies and Organizations That Can Help.")
PSYCHOTHERAPY IN A GROUP SETTING
Most of the approaches to psychotherapy that we have discussed provide
treatment in the form of group therapy in addition to individual
therapy. Group therapy is frequently offered, for example, by
psychoanalysts, client-centered therapists, Gestalt therapists,
transactional analysts, rational-emotive therapists and general
cognitive therapists, existential-humanistic {189} therapists, reality
therapists, Adlerian psychotherapists, emotional flooding therapists,
and behavior modification therapists. In the remainder of this
chapter, we will discuss how group therapy is handled by the main
psychotherapies.
WHAT GROUP THERAPY IS LIKE
Although your experience with group therapy will vary depending on
which school of therapy you have chosen, you will find some common
elements regardless of the approach.
Initially, there is likely to be a period of group confusion, awkward
periods of silence, some polite superficial conversation, and often a
frustrating lack of overall organization and continuity. Different
group members will speak up, and what they say may have absolutely
nothing to do with what the previous speaker has said; people are
waiting for the chance to talk about themselves and tend to concentrate
so much on what they are preparing to say that they don't pay attention
to what others have been saying.
Gradually, a more organized style of interacting comes into being
through the directive efforts of the therapist or as a result of
general group frustration over the lack of coherence. At the same
time, group members will begin to feel more at ease with one another
and will in time begin to lift their public masks and reveal more of
their private selves--their often hard-to-admit feelings of loneliness,
pain, anxiety, depression, etc.--and to express their personal needs.
Frequently, the first steps in the direction of expressing private
feelings will involve attacks on the therapist for not structuring the
group's interactions more or attacks on one member for monopolizing
group sessions. Experienced group therapists realize that these common
negative attacks are understandable tests of the trustworthiness and
the safety of the group as a place to express personal feelings. If an
atmosphere of acceptance is established, and these initial complaints
are allowed to occur without catastrophe, some group members will
usually then begin to open up, to reveal some deeper feelings. One
member may begin to talk about her unhappy marriage, a man about his
gambling obsession, another about his loneliness since his wife died.
At about this time it is common for group members to begin to {190}
tell one another how they feel about each other, how they see one
another. Some of these comments will be positive, some negative. Here
are some examples:
"You have a really nice smile."
"You remind me of my father, all these _shoulds_, _oughts_, and
rules!"
"You never say much, so I feel you're just sitting there judging
us."
"You make me nervous, biting your nails all the time."
"Every time you say something, you put yourself or somebody else
down."
As this process continues, one or two group members will begin to take
an interest in the personal problems of some of the others and express
a desire to help. They will ask questions for more information,
express sympathy or empathy, and begin to offer suggestions. It is at
this point that the process of group interaction begins to acquire a
focus on healing and problem solving. Frequently, these expressions of
desire to help one member will encourage him or her for the first time
to begin to accept the kind of person he or she has been, to realize
that "I _have_ been too hard on myself because I'm so damned
perfectionistic," "I _am_ a controller; I want other people to do
things _my_ way," or "I live in a suit of armor; I'm just afraid of
other people."
As members of the group come to know one another as real personalities,
they tend to become impatient whenever anyone tries to put on his
public mask again. The group demands and expects members to be honest
about themselves. Feelings can run hot whenever Fred tries to make
Alice accept his suggestions because he _knows_ what she really needs.
Group members can show quick impatience with Judy whenever she tries to
persuade herself, even though her husband has severely beaten her
several times, that her marriage is _really_ OK.
Group members quickly gain a good deal of information about how others
see them and feel about them. As a result of an implicit commitment to
honesty, some members' ways of behaving gradually change: a rough tone
of voice becomes less abrasive and calmer; offensive gestures and
judging looks {191} disappear; self-centeredness gives way to a certain
amount of sympathy and interest in other people.