Some of the values of group therapy are sensitively expressed in this

passage from a letter written by a client to his group:

"I have come to the conclusion that my experiences with you have

profoundly affected me. I am truly grateful. This is different

from personal therapy. None of you _had_ to care about me. None

of you had to seek me out and let me know of things you thought

would help me. Yet you did, and as a result it has far more

meaning than anything I have so far experienced. When I feel the

need to hold back and not live spontaneously for whatever reasons,

I remember that twelve persons ... said to let go and ... be myself

and of all the unbelievable things they even loved me.... This has

given me the _courage_ to come out of myself many times since

then...."[1]

[1] Quoted in Carl R. Rogers, _Carl Rogers on Encounter Groups_ (New

York: Harper and Row, 1970), p. 33.

THE RISKS

Unfortunately, like many healing processes, group therapy is not for

everyone. There are recognized _risks_ of entering group therapy.

When members leave the intimacy of their group and return to the "real

world," they may feel disappointed and discouraged. Their experience

has given them the opportunity to dispense with social masks, to become

more authentic, to see the lies and pretenses of others more clearly.

But the vast majority of people outside the group have not learned

these things and _do_ live behind masks they are not even conscious of.

When you gain from a learning experience a perspective you can share

with comparatively few people, you're likely to feel discontented and

alienated.

You should also be aware that some of the changes that occur in group

therapy simply may not last very long after the group stops meeting

because the emotional and moral support offered by the group are no

longer there. Or, group therapy may make you aware for the first time

of personal problems you had ignored or evaded, leaving you hanging

when the group terminates. So group therapy may bring about a need to

solve problems that, before the group experience, you didn't even {192}

know you had. These problems may then motivate you to enter individual

therapy.

Finally, if you enter group therapy but your spouse does not, your

experience could bring marital tensions into the open, leaving your

spouse at a disadvantage. Your spouse, who is unfamiliar with what

transpired during your group sessions, may react defensively and

without empathy to your desire to talk about your feelings.

GROUP TECHNIQUES

The techniques discussed below are commonly used in group therapy.

_Content Analysis_

A member of the group describes a problem he or she is having, and the

therapist and other members make problem-solving suggestions. Their

focus may be on why the person does not want to solve the problem or on

how the person brought the problem on and maintains it.

_Group Process_

After a series of interactions, comments, suggestions and personal

observations by group members, the therapist will ask the group to

stand back and look at the pattern of their communication. The group

may become aware of the way one member is consistently overlooked and

is not given a fair share of attention because of shyness or because

another more forceful member dominates the group's attention.

_Models_

One member can work on personal problems in group therapy by noting how

another member goes about handling a similar problem and then trying to

learn from that example.

_Analysis of Nonverbals_

The group therapist and members of the group can often help make an

individual better aware of how his or her behavior has contributed to

personal problems. For example, Jim tends to be shy, makes poor eye

contact with people, has bad posture, and speaks indistinctly because

he has a habit of covering his mouth {193} with his fingers. The

impression he makes on people is weak. By helping him pay attention to

these nonverbal habits, group members can encourage Jim to change so he

will be more successful, for example, at job interviews and generally

feel more confident.

APPLICATIONS OF GROUP THERAPY

As we have seen, group therapy is most helpful to people with these

characteristics:

* They are lonely, socially isolated, or passive.

* Their sense of worth depends greatly on what others think of them.

* They would like to improve their interpersonal skills.

* They may be drawn to group therapy for the practical reason that it

tends to be less expensive than individual therapy.

Group therapy has the distinct advantage of providing clients with

multiple points of view; they receive feedback from the therapist as

well as from other members of the group.

Group therapy is potentially useful for a very wide range of problems.

This is evident from the fact that most approaches to psychotherapy

offer therapy in a group setting. Group therapy is generally _not_ the

treatment of choice for these individuals:

* persons lacking communication skills

* those who lack the motivation to attend group sessions regularly or

who refuse to keep information about other group members confidential

outside of the group

* people who are severely disturbed

* individuals who are intellectually impaired

* those suffering from chronic depression

* psychopathic or sociopathic adolescents (who do not have a sense of

social conscience)

Group therapy, as we have noted, also appeals _less_ to inner-directed

individuals and is therefore less likely to be helpful to them.

{194}

14

MARRIAGE AND FAMILY THERAPY

_For couples and families with problems of

communication, strain, and conflict,

and for individuals whose difficulties

are best resolved with the participation

of other family members._

The family is the basic source of health or sickness.

Vincent D. Foley, _Current Psychotherapies_

During the last forty years there has been a gradual shift away from an

emphasis on individual therapy to a belief that many emotional

difficulties people experience have their roots--and often, also their

solutions--in their marriages or families. As this shift in emphasis

grew, many therapists saw that marriage and family relationships make

up units, or systems, each with a personality of its own. Members of a

family gain their identities from their roles in the family system.

This systems view made it possible for therapists to understand

families and marriages more clearly as interdependent, interlocking,

functioning wholes.

{195}

Marriage and family therapy treats emotional disorders in terms of the

interdependent relationships among members. The marriage or family

system is thought of as a unit with properties that reach beyond the

sum of the personal qualities of the individuals who make it up.

Usually, one person in a family or marriage is more troubled; his or

her symptoms are more pronounced. The husband tends to feel his wife

has "the problem," or vice versa. Mother and father feel that little

Richard is "the problem." However, therapists believe that the

problems experienced and expressed by the "sick" person are really

signs that something is wrong with the whole system. A "heart problem"

is frequently part of a larger problem, such as poor diet or excessive

stress, and the same is true for couples or families. One person's

distress tells the therapist that, often, something is troubling both

husband and wife or all the members of a family.

This interdependence between partners of a marriage or members of a

family system frequently leads to a complex situation in which

emotional difficulties are contagious, one person's improvement is

connected with another's getting worse, or treating one person

separately draws the members of a relationship apart.

One of the very difficult problems troubled couples or families face is

that emotional disturbance can often "spread." Repeatedly, therapists

observe that there is a kind of subtle transmission from one generation

to the next of inner conflicts and difficulties in coping with life.

And beyond this, there are intimate connections between the emotional

makeup and emotional balance of married partners or family members.

For example, it is all too common for the partner of a chronically

depressed person also to fall into a serious depression. Marriage and

family therapists are therefore inclined to see the emotional

disturbance of one member in terms of a troubled, ineffective pattern

of interaction.

Because of their close ties, sometimes one person's behavior,

attitudes, or feelings get better while another family member develops

new symptoms or problems. We will look at a real example of this in a

moment.

Marriage and family therapists have noticed that, when one person in a

marriage or family is treated separately, the family members frequently

are drawn apart instead of brought closer {196} together. Therefore,

therapists generally feel it is essential to see husband and wife

together or to involve both parents and children in therapy.

The purpose of marriage or family therapy is not only to resolve

existing problems but also to help clients cultivate a new way of

communicating and interacting together. Marriage therapy and family

therapy of course seek to relieve emotional distress by helping to

reduce or end conflicts and to lessen anxiety, frustration, anger, or

resentments. But beyond these, marriage and family therapists try to

show clients how to complement one another's personal needs. They also

attempt to strengthen bonds between them so that they are able to face

crises and emotional upsets with greater strength, balance, and

courage. And they try to redirect clients' values in a way that will

support the personal growth of each person.

How long marriage or family therapy will take depends primarily on the

goals of the couple or family. Here are some estimates:

* to reduce tensions: perhaps six sessions

* to reduce symptoms such as emotional distress or behavioral problems:

ten to fifteen sessions

* to improve communication habits: twenty-five to thirty sessions over

six to eight months

* to restructure relationships so that members of the family system

will have more independence and will cultivate an awareness that they

do have separate identities: forty sessions or more

WHAT MARRIAGE AND

FAMILY THERAPIES ARE LIKE

Marriage therapy and family therapy are distinct from group therapy in

two important ways. First, unlike in group therapy the clients in

marriage or family therapy have a shared history and, if therapy is

successful, will often be able to enjoy a shared future. Second, in

marriage and family therapy, the therapist is more active and directive

than in group therapy. Any changes made by members of a group come

about because of interactions among the group members; a group

therapist acts as a moderator or facilitator, while the role of a

marriage or family therapist resembles that of a teacher.

{197}

Marriage and family therapy focuses on _present_ interactions between

husband and wife or among family members. It is not that the past is

judged to be unimportant, but it is not generally useful to pay a great

deal of attention to what has already happened. What causes problems

_now_ are the current patterns and habits of interaction in the family

or marriage. A wife may have been drinking for fifteen years because

her mother undermined her sense of self-confidence, but the fact is

that she no longer lives with her mother. However, she _did_ choose to

live with a man who continued her mother's pattern of undermining

abuse. A marriage therapist will focus on present difficulties and, by

doing this, may be able to help her resolve her drinking problem by

improving a troubled relationship with her husband.

Jay Haley (1923-2007), a leading marriage and family therapist, has

expressed the belief that concentrating on feelings and thinking will

not lead to change, that empathy on the part of the therapist does not

correct problems, and that insight often just provides an excuse for

intellectual rationalization and game-playing.[1]

[1] Jay Haley, "Marriage Therapy," in Gerald D. Erickson and Terrance

P. Hogan, eds., _Family Therapy: An Introduction to Theory and

Technique_ (Monterey, CA: Brooks/Cole, 1972), pp. 180-210.

Because the patterns of behavior of a troubled couple or family tend to

be very rigid, therapists have found that strongly directive techniques

are most effective. Their focus is on developing interventions--or

therapeutic strategies--that will have a real impact on the complex

patterns of interaction that have come to paralyze a couple or a family.

What seems to help in marriage and family therapy is ingenuity on the

part of the therapist that will give him or her power or control over a

situation that is out of control. One way to do this is to force

clients into a paradoxical situation. For example, the therapist may

prescribe that a couple or members of a family _continue_ their present

unsatisfying behavior. As a result, they may (and very likely will)

rebel so that desired change comes about.[2]

[2] As we have seen, logotherapy and Adlerian therapy both make use of

this technique, as do family therapists, as we will see later on.

All family therapy _is_ marriage therapy to a certain extent. And so,

suppose we first look more closely at what marriage therapy is like.

{198}

MARRIAGE THERAPY

Marriage therapy is generally advisable[3] when the husband or wife has

sought help in individual counseling but this has not been helpful.

Sometimes the marital relationship itself inhibits, or even undermines,

the improvement of the most troubled person. For example, individual

therapy did nothing to help one woman who was suffering from severe

chronic anxiety. When her husband was asked to participate in

treatment, it was found that he abused his wife continuously but

subtly. Whenever she spoke, he would criticize her views and

indirectly slight her worth; when he lost something, he would often

accuse her of misplacing it. The problem she had come for help with

turned out to be marital rather than individual.

[3] See Jay Haley, "_Marriage Therapy_," pp. 180-210.

If you are unable or unwilling to communicate openly and adequately

with a therapist, marriage therapy may encourage your spouse to become

more involved in the process of therapy. Often, having the other

marital partner present will stimulate an otherwise silent client to

express himself or herself, especially to correct what the other

partner has to say!

If you suddenly become severely troubled at the time of a marital

conflict, marriage therapy may be useful. A spouse who falls into a

deep depression immediately after a quarrel may be troubled in a way

that marriage therapy can treat.

Finally, marriage therapy is of course essential if a husband and wife

are in conflict and serious distress and cannot resolve their

differences. Frequently, one spouse (usually the wife) will want

marriage therapy; the other will come, but reluctantly. However, both

often _will_ come, because if one is in distress the other is affected.

Conflicts in marriage frequently come about because of disagreements

having to do with the couple's rules for living together, especially

regarding how each is to treat the other. Who sets the rules is often

another area of conflict, as are incompatible rules. For example, a

wife insists that her husband stop being a "mama's boy" and demeans him

for being dominated by a woman; yet it is _she_ who seeks to dominate

her husband by insisting that _he_ be more domineering.

In marriage therapy (and also in family therapy), therapists {199}

encounter a great deal of resistance to change on the part of their

clients. (Alas, so do all other therapists!) A main reason for

resistance is that, in a marital relationship or family system, change

in one member's feelings and behavior will tend to affect another's,

often in unsuspected ways. Change disturbs the established balance of

their system, a balance that does serve some purposes.

Jane Dowland, for example, went to see Dr. Carlton because of her

husband's depression. Phil had lost his job and now spent most of his

time at home, feeling sorry for himself and collecting unemployment

benefits. Jane was easily upset and felt terribly insecure. Dr.

Carlton recommended that Phil accompany Jane to the next session.

After seeing Phil, Dr. Carlton referred him to a psychiatrist, who was

able to treat Phil's depression effectively in four months' time with

medication. Jane, however, continued to feel severely (and perhaps

even more) anxious, although Phil's symptoms were now under control and

he was back at work.

Dr. Carlton recommended marriage therapy to Jane and Phil. They saw

Dr. Carlton once a week for three months. It became clear to Dr.

Carlton, and eventually clear to Jane, that without realizing it she

had used Phil's depression as an excuse for her own anxiety so that she

could evade responsibility for herself. She came to realize that she

had been unable to resolve her own conflicting needs--whether to have

children in spite of Phil's disinterest in children or whether to

commit herself to developing a career.

Treating Phil's depression led Jane to become aware of her own

problems. The balance in their relationship was changed by therapy:

Jane found out that Phil's depression was really a problem that served

a purpose for her--without it, she needed help for herself.

Because of the complex, interwoven nature of a marital relationship, it

is often difficult to separate the problems each partner may

experience. One partner's symptoms may mask the other's problem. Or,

one person's problem may be perpetuated by the other's behavior,

interfering with the resolution of the problem. Further, each partner

may encourage distress in the other as a result of differing

expectations concerning rules of living together and who sets them.

{200}

FAMILY THERAPY

In family therapy, the "identified patient" is seen as but a

symptom, and the system itself (the family) is viewed as the client.

Vincent D. Foley, _Current Psychotherapies_

Very often, one family member is labeled the one with the problem, the

one who is "sick." When the family decides to enter therapy, it is

usual for family members to feel troubled, scared, and confused. They

realize that something is wrong, but they are uncertain about what is

amiss and don't know what to do. The usual response to this perplexity

is to push the "identified patient" forward--usually a child who is

"the problem"--and try to make him or her the focus of treatment.

As the members of the family are interviewed, individually and

together, the therapist is able to assemble a coherent picture of the

family, its typical ways of interacting, the habitual, automatic

patterns of response of one family member to another, the family's

values and beliefs. What one member tries to hide another often will

express.

The family therapist has a difficult double role, as both observer and

participant. He or she needs to be able to notice what the styles of

interaction of individual family members are and _at the same time_

interact with members of the family. The therapist tries to bring

about meaningful emotional interchange, create an atmosphere of trust

and rapport, and reduce the feeling that family members are threatened.

Over time, the therapist seeks to show the members of a family how they

tend to interrelate inappropriately, how their own ineffective defenses

cause them to hurt one another. To do this, the therapist has to be

able to cut through the vicious circles of resentment, anger, blame,

frustration, and intimidation that frequently hold families in a death

grip.

THE THERAPIST'S FUNCTIONS

In both marriage and family therapy therapists must:

* establish a sense of rapport and trusting communication between

clients and themselves

{201}

* use this rapport to bring out the conflicts, frustrations, and

inadequate means of communication that burden their clients

* see through denials, rationalizations, and excuses

* push family members to put out in the open feelings and pains they

have kept from one another

* bring to a halt the family's tendency to focus on one person as a

scapegoat, "the problem"

* act in understanding, calm, and emotionally supportive ways and help

supply the emotional stability that the couple or family temporarily

lacks

* try to exemplify or personify for clients what it is to be adult,

mature, caring, and able to relate openly and without feeling threatened

MARRIAGE AND FAMILY THERAPY TECHNIQUES

Marriage and family therapists may use a variety of techniques to

encourage their clients to change in constructive ways. For example,

it is becoming more common to _videotape sessions_ so that couples and

families may become more aware of their automatic, self-destructive

patterns of interaction--which makes it easier to change them.

Family therapists also sometimes make _home visits_: often, being in

their own familiar surroundings will encourage family members to let

down their defenses and more clearly define the problems that need to

be resolved. Another innovation that is becoming more widespread is

_multifamily therapy_. Two or three families participate together in

an especially modified form of group therapy so that each family can

see its own problems in clearer perspective and learn by seeing more or

less troubled interactions among members of another family.

Techniques drawn from _behavior modification_ are frequently used in

family therapy, especially when family difficulties seem to be

localized around the behavior of rebellious or delinquent children.

_Paradoxical intention_, discussed in Chapter 11, can also be very

helpful in marriage and family therapy. Instead of trying to restore a

state of balance between husband and wife or among family

members--something that usually stimulates the couple or family to

fight to hold on to its old habits--a therapist {202} encourages a

state of imbalance so that the unbalanced system falls of its own

weight. The cure, paradoxically, may lie in intensifying the problem.

For example, a wife has migraines that prevent her from doing her

family chores. A child throws up when he is forced to go to school.

Both claim that they "just can't help it." The therapist's response

might be, "I realize you can't help it. What I want you to do, Alice,

when you feel household chores are just too much, is to go to bed and

permit yourself to have a migraine. Don't fight it. Go ahead and have

a bad headache. It gives you some relief, so I want you to do this

through your own choice. And you, Johnny, I want you to go into the

bathroom before you leave for school and throw up. It is unpleasant,

but it hasn't hurt you. If you need to, stick your finger down your

throat. I want you to take control and make yourself throw up each

morning before going to school. And you, Alice, you won't interfere or

try to mother him; let him alone. But do remind him to go and throw

up." In a very short time, the results of these paradoxical strategies

can be surprisingly effective.

APPLICATIONS OF MARRIAGE AND

FAMILY THERAPY

As in all approaches to therapy, the effectiveness of marriage and

family therapy depends on the strength of the clients' desire to

overcome the difficulties that have motivated them to ask for help.

Goodwill and commitment to change may or may not be there. Sometimes a

therapist can help clients become aware of their deep-seated but

habitually ignored feelings of warmth toward one another. At other

times, marriage therapy may lead to separation and divorce, if a couple

comes to realize that their goals really are not compatible and what

each needs or wants from the relationship the other is not able or

willing to give. Marriage therapy and family therapy are not magic

wands that can be waved over trouble to make things better. Therapists

can make specific recommendations, they can help a couple or family

become explicitly aware of destructive patterns, they can point to and

illustrate constructive ways of interacting, and they can sometimes use

therapeutic strategies to break old habits and make room for care and

sensitivity to the needs of wife, husband, and children. These

interventions from a therapist can be very {203} helpful, perhaps even

crucial, but they are, at most, _catalysts_ for change: real and

lasting changes can only come from clients themselves. Marriage or

family therapy is ideally an educational experience. What wife,

husband, and children do with what they have learned is, in the end, up

to them.

Family therapy has been especially effective in dealing with these

problems:

* problems due to conflicts among family members

* emotional disturbances in children

* some cases of schizophrenia where members of the family are

frequently not well-individuated--each person's identity is so bound up

with the outlooks and behavior of other family members that no one has

a clear sense of his or her own personal identity and separateness

* problems that are interlocking, where the difficulties of one member

of the family cannot be resolved without the cooperation of the others

* problems experienced by a family when a child becomes old enough to

leave home

Family therapy has been much _less_ effective in treating paranoia in

one member of the family, and behavioral problems stemming from sexual

disorders.

Marriage therapy has been effective in helping couples with any of

these characteristics or problems:

* They communicate and interact in ways that lead to conflict,

frustration, anger, and unhappiness.

* They are insufficiently sensitive to one another's needs.

* They have unstated and conflicting expectations concerning their

relationships.

* They will work together to help one partner overcome individual

difficulties.

{204}

15

CHANNELING AWARENESS:

Exercise, Biofeedback,

Relaxation Training, Hypnosis,

and Meditation

All of these approaches to therapy serve to _channel_ awareness in

particular ways, to provide a point of focus for the mind. They are

all processes that eliminate distractions and enable you to direct your

awareness in ways that are basically different from normal, everyday

waking consciousness. Special kinds of absorption or concentration

characterize the therapeutic uses of exercise, biofeedback, relaxation

training, hypnosis, and meditation.

THE PSYCHOTHERAPY OF EXERCISE

_For some individuals who already are or who

are willing to become physically fit, sustained

vigorous exercise can significantly decrease

symptoms of tension, anxiety, and depression._

It is my contention that, just as prayer, meditation, dream

analysis and some drug experiences open doors into these areas not

usually accessible to us, under the appropriate circumstances slow

long-distance running opens similar doors. The subjective

experience of the runner appears the same, and he becomes

revitalized or reenergized in a psychological {205} or spiritual or

creative sense.... It is clear to me that this is a distinct form

of psychotherapy.

Thaddeus Kostrubala, _The Joy of Running_

Many studies have been made and a small mountain of literature has

accumulated about the physical effects of exercise. However, little

attention has been paid to its psychological aspects, particularly in

connection with the kinds of symptoms and problems that bring people to

psychotherapy.

Psychiatrist Thaddeus Kostrubala (1930- ) has been one of the

pioneering contributors to the study of exercise as a form of

psychotherapy. Dr. Kostrubala is a dedicated runner who has completed

many marathons and who uses running as a therapeutic approach in his

practice.

Much of the modest amount of research on the psychotherapeutic value of

exercise has focused on running, probably for the following reasons:

First, slow long-distance running seems to be an anatomically natural

activity for us, with our species' two relatively long legs. Second,

running appears to be an especially effective way to derive specific

therapeutic benefits from an aerobic activity. And, of course, running

has recently become very popular.

Most exercise physiologists claim that the physical, and very likely

also the psychological, effects of other aerobic forms of exercise,

such as bicycling, swimming, and cross-country skiing, are essentially

equivalent to running. So, until we know otherwise, we will assume

that what is true of running is likely to be true of other types of

exercise that make similar demands on the body, and we will focus here

on running.

Dr. Kostrubala has attempted to describe a particular approach to

running that seems to have definite psychotherapeutic value. More is

involved than donning a pair of running shoes and starting out, as we

will see.

Dr. Kostrubala has found that running is emotionally or mentally

therapeutic under certain conditions. First, you need to make sure

that you are in _medically good condition_ to begin a therapeutic

running program. It would be prudent to have a thorough physical and,

if you are over forty, also a stress test. You need to do warm-up

exercises, which any good book on running describes in detail, and then

you need to build up your endurance--gradually and patiently--until you

can run a _minimum_ of three times a week for an hour each time,

without stopping, and {206} with a pulse rate of at least 75 percent of

your maximum heart rate. (Your maximum heart rate is 220 beats per

minute minus your age. If you are 40 years old, your maximum heart

rate is 180. Seventy-five percent of 180 yields a pulse rate of 135

beats per minute. If you are 40, you would want to run for an hour so

as to maintain a pulse rate of 135 beats per minute during your run.

By way of encouragement, you may want to know that 75 percent of a

person's maximum heart rate represents, for almost everyone, a slow,

easy jog.) Second, you must have a _noncompetitive attitude_ toward

running. Whether you're comparing yourself to others or just trying to

beat your own running record, a competitive drive rivets your attention

on a goal separate from yourself. This misplaced emphasis will

undermine the therapeutic value of the activity.

You also should either run alone or with someone who won't distract you

by talking. Direct your attention within--to the rhythm of your pace,

the regularity of your breathing, maintaining relaxation in your

shoulders, back, and feet. To prevent distraction it is also important

to run in an area or around a track that is familiar to you. For slow

long-distance running to have a therapeutic effect, you cannot be a

sightseer. The novelty of unfamiliar surroundings will distract you

from being inner-directed, which is therapeutically important.

Finally, be aware of the physical risks. If you begin to feel dizzy,

stop running. In hot weather, dizziness is a first warning sign of

heat exhaustion, which can lead to heatstroke. If you feel a snap in

one of your running muscles, stop. An internal snapping or popping

noise can mean that a muscle or tendon has torn, or a small bone has

broken. Make sure you are all right before resuming. If you have a

cramp-like pain in your side, which is very common, try slowing down,

exhaling forcefully, giving a yell, or singing. You can often keep

going, and the pain will subside. If it does not, or it gets worse,

you'll need to stop to rest.

WHAT RUNNING AS THERAPY FEELS LIKE

The psychological effects of regular, slow long-distance running can be

impressive if you follow the directions above.

During the first twenty minutes, you may feel slow and stiff and not

very inspired about the run. You may find yourself in a sour mood.

(There is even a term for this phase: _dysphoria_.) {207} Persuade

yourself that it is not important and keep going.

Between twenty and thirty minutes, if you are dysphoric, that feeling

may peak; some people even begin to cry. This is not necessarily

depression; it may actually feel good. (Another reason to run alone:

other people won't understand and may want to "rescue" you from your

therapeutic endeavor.)

At some point, after about thirty minutes of running, you will probably

find that your mind refuses to do any more problem solving. You stop

worrying, problems you may have been dwelling on simply begin to feel

distasteful, and your mind clears. (After a good run, when you do

return to the problem, you may well find that it is less difficult to

think through.)

Between thirty and forty minutes, many people begin to feel more

"open"--their breathing begins to come more freely, and their whole

system seems to work more smoothly and with less effort. This can be a

wonderful feeling.

After you have been running for forty minutes, the first alterations in

your consciousness may begin. Your senses begin to feel more alert,

more alive. Things seem more vivid--the colors of leaves, the song of

a bird, the freshness of the air. Runners who have experienced this

say that this natural, vivid, fresh sense of perception is unique; to

some extent it may resemble the experience that comes from meditation,

biofeedback, or drugs. This experience seems not to occur before forty

minutes of running. It may be an experience of mild euphoria, or you

may feel it as a marked increase in aesthetic sensitivity or as a sense

of growing inner serenity.

APPLICATIONS OF EXERCISE AS PSYCHOTHERAPY

I'm sure that these experiences are closely related to meditation.

The clearing of consciousness, the ability to find a central focus

within, the delight of a clear mind, the sense of refreshment of

the soul are reported both by those who practice meditation and by

long-distance runners. The difference between the two techniques

is in the physical effects of the running. It is as if those who

meditate have found one half of the picture. The runners who just

compete and do not reach for the psychological aspects have found

the other half. The runners who are able to slow down and search

for the psychic aspects will have both--the soul and the body.

Thaddeus Kostrubala, _The Joy of Running_

{208}

Even though aerobic exercise such as slow long-distance running can

produce a feeling of moderate depression during the first thirty

minutes, people who have moderate, lingering depressions in daily life

often find that, as described above, depression disappears after about

forty minutes. Anger and hostility also seem to be much reduced after

about thirty minutes of running.

The repetitive rhythm and sustained exertion of slow long-distance

running appear to tire the conscious mind. Many anxieties, tensions,

worries, feelings of guilt, anger, and depression lift. The easily

distracted, constantly nervous and shifting focus of everyday

consciousness gives way to a sense of integration, of being one with

yourself and the activity of running.

O chestnut tree, great rooted blossomer,

Are you the leaf, the blossom or the bole?

O body swayed to music, O brightening glance,

How can we know the dancer from the dance?

W. B. Yeats, _Among School Children_

The therapeutic use of running appears to offer the following benefits:

* increases mental energy, acuity, and concentration

* strengthens self-confidence and a sense of personal worth

* increases a capacity for work so that you feel less tired at the end

of the day

* diminishes smoking, drinking, and other unhealthy habits

* helps those with eating disorders--who either are overweight or

dangerously underweight--change their eating habits

* lessens or lifts depression

* improves relationships that were destructive or motivates people to

separate

* reduces or eliminates confused and irrational thought processes in

some schizophrenic patients

_Treating Depression_

In particular, running as described here appears to be especially

effective in treating depression: "... it's hard to run and {209} feel

sorry for yourself at the same time."[1] Running tends to increase

your sense of independence and self-confidence, which have been

weakened if you have been depressed. Psychotherapy and drug therapy,

in contrast, may encourage _dependency_ on the therapist or

psychiatrist.

[1] James Fixx, _The Complete Book of Running_ (New York: Random House,

1977), p. 16.

Dr. Kostrubala has noticed that long-distance running often greatly

reduces or even eliminates the typical early morning awakening and

insomnia of the chronically depressed person. This particularly

painful symptom involves jarring awake to a new day to be faced--a day

of anxiety, fears, and hopelessness to be combated. If you have

experienced this, you are probably familiar with waking up too early,

at what the Swedes call "the hour of the wolf," lying in bed,

exhausting yourself with crushing worries, despair, and tears, and

beginning the day in a state of emotional exhaustion. Kostrubala has

found that as depressed people cultivate the habit of long-distance

running, these early morning ordeals often gradually subside and

disappear.

A British medical group led by Dr. Malcolm Carruthers discovered that

individuals who exercise vigorously produce increased levels of the

hormone epinephrine, which counteracts depression. Apparently, strong

exercise for even ten minutes doubles the normal level of epinephrine;

the effects of the heightened level of the hormone can be fairly

long-lasting.

Another study, by psychiatrist John Greist at the University of

Wisconsin, revealed that one group of seriously depressed patients

benefited more from a ten-week session of therapeutic running than

another group benefited from traditional therapy.

To summarize research findings on exercise as a treatment for

depression:

* To be effective, vigorous exercise must be done regularly no less

than three times a week, and preferably at least five times a week, for

periods lasting between thirty minutes and an hour. (Dr. Kostrubala

uses an hour as a goal.)

* Although running and running combined with walking are the most

commonly used therapeutic forms of exercise, any regular aerobic

exercise is likely to produce the same {210} antidepressant effects

when done for proportional periods of exertion.

* Studies over the past ten years show that lessening depression by

means of exercise is most successful for persons with mild to moderate

depression, but vigorous exercise tends _not_ to benefit patients with

_severe_ depression.[2]

[2] John H. Griest and James W. Jefferson, _Depression and Its

Treatment _ (Washington, DC: American Psychiatric Press, 1984), p. 63.

_Lessening Anxiety_

Therapeutic running also tends appreciably to lessen anxiety. A

research study conducted by Dr. Herbert A. deVries of the University of

Southern California School of Medicine and Gene M. Adams of USC's

Gerontology Center found that fifteen minutes of moderate exercise

diminished anxiety more in people aged fifty-two to seventy than did

400-milligram doses of meprobamate, a widely prescribed tranquilizer.

_For Schizophrenics_

Therapeutic running also seems to benefit schizophrenic patients.

Schizophrenia is a complex, difficult-to-treat illness that affects

approximately 1 percent of the world's population. It is no respecter

of particular cultures. There are many forms of the illness, but all

are characterized by disabling blockages to normal human interrelation,

strange behavior, loss of contact with reality, and withdrawal,

paranoia, or hallucinations. Again, Dr. Kostrubala has attempted to

help patients with this condition through a combined program of

medication, psychotherapy, and therapeutic running. Although he is

careful to emphasize that controlled studies have yet to be made, his

judgment about the patients he has treated is that

... using this form of running therapy ... [I] have seen them

change dramatically. They begin to lose their symptoms; medication

can be reduced and often discontinued; and they have picked up the

course of their lives until several are no longer recognizable as

schizophrenics at all--even by professional observers.[3]

[3] Thaddeus Kostrubala, _The Joy of Running_ (Philadelphia: J. B.

Lippincott, 1976), p. 129.

{211}

... I have come to the conclusion that running, done in a

particular way, is a natural form of psychotherapy.[4]

[4] Kostrubala, _The Joy of Running_, p. 119

_The Risks_

Since therapeutic running appears to be of psychiatric value, it is not

surprising that it, like any attempt to heal, may have potential risks.

Aside from the obvious potential for sports-related injuries, there is

a specific risk: physical addiction. Dr. William Glasser, whose

approach to psychotherapy we discussed in the section dealing with

reality therapy (Chapter 11), agrees with Kostrubala that therapeutic

running is addictive. Glasser calls it a _positive_ addiction,

since--unlike the use of alcohol, barbiturates, and opiates--running is

constructive and therapeutic.[5] However, like alcoholism and drug

addiction, therapeutic running _does_ produce very real withdrawal

symptoms if a dedicated runner cannot continue to run, whether

temporarily because of an injury or illness, or permanently.

Withdrawal symptoms can be surprisingly severe: primarily, strong

anxiety and insomnia, but sometimes also restlessness, sweating, weight

gain or loss, and/or depression.

[5] William Glasser, _Positive Addiction_ (New York: Harper and Row,

1976), Chapter 5. (Chapter 6 of his book is devoted to another

positive addiction, meditation.)

BIOFEEDBACK

_In psychotherapy, especially useful for clients

with problems involving anxiety, depression,

phobias, and insomnia, who will benefit from

learning how to lessen their own tension._

Most of us can draw a relatively clear line between the physiological

processes we can control and those we cannot. Unless an illness or

accident or handicap interferes, we have voluntary control over many

muscles, but there are many that, fortunately, work without our

conscious intercession: the heart beats day and night, our lungs fill

and empty, our digestive processes are automatic. Except for people

who have voluntary control over the muscles that move their ears, we

are all more or {212} less equally endowed, and equally limited, in

what physical processes we are able to influence.

Until the development of biofeedback, there was only one way to extend

self-control beyond the normal range: through a disciplined and

time-consuming practice such as yoga. Experienced practitioners of

yoga claim that studying yoga over a period of years has given them a

sense of personal integration and mental centering similar to what we

will see in connection with the practice of meditation. Physical and

emotional flexibility also seem to result from long-term yoga practice.

Some yogis have extended their range of control over inner, normally

involuntary processes in dramatic ways. Some can cause their heart

rate to increase to five times its resting rate. Some are able to

cause a ten-degree temperature difference between the thumb and little

finger of the same hand: one side is flushed and hot, the other side

cool and pale. Many other forms of self-control have been

documented,[6] but acquiring these special skills through the practice

of yoga takes years of discipline, concentration, and tenacity. But

the years of dedication seem also to be indispensable if one is to

develop the qualities of inner tranquility and strength sought by yogis.

[6] See, e.g., Mircea Eliade, _Yoga: Immortality and Freedom_

(Princeton, NJ: Princeton University Press, 1958).

Biofeedback has greatly shortened the yogis' road to conscious control

of some physical processes, and, in turn, it has become the main

contribution technology has made so far to psychotherapy. Many of the

physical processes that biofeedback training can help you learn rather

quickly to control influence your emotional well-being. Biofeedback

equipment can enable you to learn, for example, how to _will_ a state

of muscular relaxation, how to gain a measure of control over your

physical response to stress or pain, even how to raise or lower your

blood pressure or heart or respiration rate.

To use biofeedback equipment, electrodes are taped to the areas of your

body that are to be monitored. They may measure such things as skin

temperature, skin moisture, muscle tension, pulse and breathing rates,

or brain wave patterns. The feedback from which you learn to control

normally involuntary processes occurs when the measurements made by the

instruments are externalized for you: you are able to _see_ a pattern

on a computer {213} monitor or oscilloscope or _hear_ a changing tone

that gives you immediate information about your physical responses. In

other words, biofeedback is an electronic way of representing inner

processes externally that are usually automatic, involuntary, and

unconscious.

PHYSICAL APPLICATIONS

Frequently, and relatively quickly, many people are able to learn how

to control many of their internal responses very well. Biofeedback can

sometimes be an alternative to using medication to reduce tension or

pain. Its range of applications has grown tremendously. Here are some

examples of its uses:

A woman was badly injured in an automobile accident. On one side of

her face her facial nerve was severed, leaving her unable to move any

part of the left side of her face and unable to close or blink her left

eye. Surgeons decided to splice the severed facial nerve to a nerve in

her neck-shoulder muscle. Once this was done, the woman could shrug or

twitch her shoulder, and in this way cause the paralyzed side of her

face to move, and blink her left eye. However, the movements of the

left side of her face were uncoordinated, spastic, and not synchronous

with the movements of the uninjured right side of her face.

Biofeedback training seemed to offer a possible solution. Electrodes

were taped to the injured side of her face. The electrical activity of

muscles in the damaged area was displayed on a screen, along with the

pattern that _would_ be produced by undamaged facial nerves and

muscles. The woman's task was to watch the two patterns and somehow

learn by inner experiment how to control the left side of her face so

its movements would match the normal pattern and would then coordinate

with movements of the other side.

Her training lasted for several months. Because of her persistence and

hard work, she was successful in learning to match the "normal"

pattern; she was now able to move the two sides of her face in

symmetrical harmony.

Other successful physical applications of biofeedback therapy include

these:

* controlling high blood pressure

* learning to raise blood pressure in cases of spinal injuries {214}

that block the automatic raising of blood pressure when a person stands

up (excessively low pressure causes them to faint)

* coping more effectively with asthma attacks

* eliminating migraine headaches

* helping children with cerebral palsy control muscle spasms

* helping stroke victims with proprioception problems (in which they

lose the sense of where their arms and legs are in space)

* teaching patients with circulation problems (e.g., blood clots in the

legs) to dilate their blood vessels, regaining movement and reducing

pain

* assisting stutterers by helping them become aware of unnecessary and

interfering muscle contractions they have come to make habitually when

they speak and teaching them how to relax these muscles

* reducing tension and pain in arthritis patients

To date, of all the areas to which it has been applied, biofeedback has

been _most_ successful for patients who are physically paralyzed or

have movement disorders.

PSYCHOTHERAPEUTIC APPLICATIONS

Biofeedback has been used successfully in psychotherapy in these ways:

* teaching general relaxation methods, which can be useful to many

people who have problems that involve anxiety, depression, or phobias

* assisting people with insomnia, also through relaxation techniques

* teaching people how to recognize effective meditation by making them

aware of periods during sessions of meditation when their brainwave

patterns slow (see the last section in this chapter, on meditation)

Increasingly, biofeedback is being used to treat emotional disorders in

conjunction with both psychotherapy and medication. It is one of the

ways available to us to enlarge the range of our conscious control over

ourselves and our lives.

{215}

RELAXATION TRAINING

_Primarily a coping strategy

to help people continue to function

in an environment of stress._

The pervasive phenomenon of stress is the hidden epidemic of the United

States and other highly industrialized countries. It is associated

with high blood pressure, hardening of the arteries, strokes, ulcers,

colitis, and a host of other physical conditions. And severe stress

endured too long leads to emotional breakdown.

All physical materials can be loaded or stressed to a certain point

beyond which they distort, snap, fracture, or break. Stress loads

human beings physically as well as emotionally. Any change--whether

for good or for ill--is a stressor. As human beings, we are not simple

engineering materials that form simple cracks or breaks, and when

stressful events are strong enough, we begin to crack or break in ways

that are considerably more complex. Physical disease, emotional

disorders, and mental illnesses are the cracks or breaks that occur in

human "material."

Statistics show that common forms of severe stress _do_ cause us to

break. For example, compared with others the same age, ten times more

people die during the year following the death of their husbands or

wives. In the year after a divorce, ex-spouses have an illness rate

twelve times higher than married people the same ages. In addition,

chronic anger, anxiety, and depression appear to weaken the body's

immune system, increasing the likelihood of serious disease.

Individuals do, of course, have different emotional breaking points,

but we know that prolonged high levels of anxiety erode a person's

psychological integration. What results is "nervous breakdown"--a term

that is vague and means little more than a blown fuse due to emotional

overload. The aftermath of such an overload may leave a person with

depression, anxiety, and the inability to function "as usual" for a

considerable period of time.

Relaxation training, along with the other therapies discussed in this

chapter, is an antidote or prevention for human breakage brought about

by excessive stress. The central belief on which relaxation training

is based is that you cannot be tense and anxious if you are physically

very relaxed.

{216}

There are two main approaches to relaxation training. (We have already

briefly discussed them in Chapter 12 in connection with

desensitization.) In both approaches you begin by reclining or lying

down in a quiet room. Relaxation can then be achieved through tension

and release or through suggestion. In the former, you tense a given

muscle group, holding the tension for five to ten seconds, then release

the tension and experience the relief from tension, or relaxation. In

the latter, you consciously suggest to yourself that a group of muscles

feels warm, heavy, very heavy, and relaxed, sinking into the recliner

or bed or floor. Both approaches aim to achieve two things: to bring

about deep, progressive muscular relaxation and to increase your

sensitivity to the presence of tension in your body when it exists.

Relaxation training is a learned skill. If you practice it

regularly--that is, daily, for at least several weeks--you can gain

increased control over your major muscle groups--those of the arms,

legs, shoulders, back, abdomen, neck, and face. You gradually learn to

recognize even low levels of tension in these muscles so that the

tension can be eliminated consciously.

Eventually, as you learn how to control physical relaxation, you are

able to achieve deep relaxation in increasingly shorter periods of

time. After regular practice over a period of months, many people,

when they face a suddenly upsetting situation, can quickly offset their

emotional and physical reactions to stress by inducing a calm and

relaxed state in themselves. They are able to neutralize the

stressor's potential for doing damage. If you can learn to do this,

you have learned a skill in controlling your own life that is of great

value. It is a survival skill that can help you protect yourself

against being worn down by stressful events that otherwise eventually

lead to learned habits of anxiety and tension. Once formed, these

habits can be very difficult to get rid of.

For emotionally disturbed persons, relaxation training techniques are

useful primarily as an adjunct to psychotherapy or drug therapy and can

be helpful in reducing tension and anxiety. They are ways of treating

_symptoms_; they can help you continue to cope with stressful

situations. It is another question whether it is in your best interest

to _continue_ in a situation that causes you enough stress that

relaxation training becomes a needed crutch. Sometimes it is wiser to

change an unsatisfactory situation or to attempt to change your

attitudes, values, or behavior {217} than it is to learn skills so that

you can keep doing the same stressful and perhaps unsatisfying thing

day after day. Relaxation training is a _coping strategy_. By itself,

it cannot resolve the fundamental question: whether it is better to

learn how to numb yourself to an unhappy situation, to leave it, or to

face the possibility that your stress is caused by inner conflicts and

unrealistic attitudes rather than external factors.

If you cannot or do not want to leave a stressful environment,

techniques of relaxation training may benefit you. If you feel the

main problems are within you, then psychotherapy may be the best

alternative. And sometimes, throwing in the towel, deciding in favor

of a change of career, marriage, place to live, or way of life may be

most therapeutic and personally fulfilling.

It can often be hard to know which alternative is best. Counseling may

help. Talking with good friends may help. Letting time pass may help.

Usually, ignoring discomfort will _not_ help; stress has a way of

compounding and wearing you down. Waiting too long, usually out of

fear of facing a need for some form of change, is itself a source of

internal stress--of worry and anxiety that will not go away until you

do something to put a stop to doing nothing.

HYPNOSIS

_An approach to therapy that can have

far-reaching beneficial effects for people with

many different kinds of problems, especially

useful for persons who are strongly motivated

to change and can feel a deep sense of

confidence in the humanity and competence

of their therapist._

Hypnosis is very old. Ancient Egyptian records indicate that priests

maintained temples of sleep devoted to healing the ill and troubled.

The priests are thought to have used hypnotic induction of sleep and to

have offered assurance that patients would get well.

Many centuries later, Franz Anton Mesmer (1734-1815) developed a method

for inducing a hypnotic trance state (he associated it with

sleepwalking) and claimed that therapy often {218} was more effective

when patients were in a trance. Hypnosis was later used by Jean-Martin

Charcot (1825-1893) at the Paris Hospital of Salpêtrière; Charcot was

one of Freud's teachers. During World War II, hypnosis was used to

treat soldiers with amnesia, paralysis, and pain. Since then, it has

been used frequently by clinical psychologists and psychotherapists.

Much is still not understood about the mental and physiological

mechanisms involved in hypnosis. They are difficult to define because

they seem to assume many different forms in different people, depending

on their personalities and their moods at the time.

Hypnosis probably occurs in daydreaming to some extent; it probably is

also involved when a mother lulls her child to sleep or when a customer

succumbs to suggestions from a salesperson. We all seem to be--vaguely

and to some degree--familiar with the phenomenon, yet we remain,

paradoxically, ignorant of its existence.

WHAT HYPNOSIS IS LIKE

For most people, the experience of hypnosis is something of a letdown.

They anticipate that they will have an extraordinary experience in a

trance state, and yet what actually happens is very similar to their

probably familiar experience of drifting into a state of relaxed

distraction from time to time when daydreaming. Often what happens

when we daydream is that our attention is focused on an object, and we

gradually relax and begin to drift into a state of partial awareness.

The phone may then ring, but for a moment it can be unclear whether we

are just imagining this.

The hypnotic state induced by a trained hypnotherapist is very similar.

When in a hypnotic trance, you never become unconscious; your mind

continues to be active. As you go gradually into a deeper trance, your

breathing and heart rates tend to slow, and you feel increasingly more

deeply relaxed. Usually, the experience is one of being lulled into a

state of calm repose. Sometimes--for example, in former surgery

patients who have had unpleasant experiences with anesthesia--hypnosis

may cause people to become anxious or frightened and to refuse to

continue.

You relax physically while in a hypnotic trance. You will slump in

your chair; your breathing becomes slow and deep; you move very little.

In other cultures, however, trance states take very {219} different

forms. Behavior may become ecstatic, even violent; individuals may

begin to dance frenetically and to spin about, as in the case of

Algerian dervishes. But in Western society, hypnotic trance usually

takes the form of deep, passive relaxation.

After their first experience with hypnosis, most people tend to

disbelieve that they have really been in a trance state. They realize

they have been pleasantly relaxed, but they feel that "hypnosis" has

not occurred. Clients who are suspicious, hostile, or feel threatened

by the experience, or who do not trust the therapist, tend to resist

hypnosis. Frequently, on the other hand, clients who are extremely

anxious and feel greatly in need of help turn out to be especially good

candidates for hypnosis.

If their first experience with hypnosis is comfortable, safe, and

pleasant, clients will usually allow themselves to drift into a deeper

trance state in subsequent sessions.

Many techniques exist to induce hypnosis. Commonly, they make use of

the well-known method in which you are asked to fix your attention on

an object--a coin, a stone, a pendant--while the hypnotherapist speaks

softly in a monotone, suggesting that you are relaxing ever more

deeply, that your eyes are getting heavy, and so on.

Milton H. Erickson (1901-1980) has been one of the leading American

contributors to recent developments in clinical hypnosis. His ideas

have been among the most creative, imaginative, and subtle in the

field. He is well known for his _indirect_ induction techniques,

which, because of the complex and unusual perspective they reflect, we

cannot deal with at any length here. They are techniques that

frequently induce a trance state _without_ the client's being in the

slightest way aware that this is happening. Dr. Erickson is often able

to induce hypnosis only by means of a _handshake_. An example may give

some general idea of his approach. Dr. Erickson describes this

technique:

When I begin shaking hands, I do so normally. The "hypnotic touch"

then begins when I let loose. The letting loose becomes

transformed from a firm grip into a gentle touch by the thumb, a

lingering drawing away of the little finger, the faint brushing of

the subject's hand with the middle finger--just enough vague

sensation to attract the attention. As the subject gives attention

to the touch with your thumb, you shift to a touch with your little

finger. As your subject's attention follows that, you shift to a

touch with your middle finger and then again to the thumb....

{220}

The subject's withdrawal from the handshake is arrested by his

attention arousal, which establishes ... an expectancy.

Then almost, but not quite simultaneously (to ensure separate

neural recognition), you touch the undersurface of the hand (wrist)

so gently that it barely suggests an upward push. This is followed

by a similar utterly slight downward touch, and then I sever

contact so gently that the subject does not know exactly when--and

the subject's hand is left going neither up nor down, but

cataleptic. Sometimes I give a lateral and medial touch so that

the hand is even more rigidly cataleptic....

There are several colleagues who won't shake hands with me, unless

I assure them first, because they developed a profound glove

anaesthesia when I used this procedure on them. I shook hands with

them, looked them in the eyes, ... rapidly immobilized my facial

expression, and then focused my eyes on a spot far behind them. I

then slowly and imperceptibly removed my hand from theirs and

slowly moved to one side out of their direct line of vision.[7]

Here is a characteristic reaction of one of Erickson's colleagues to

his procedure:

I had heard about you and I wanted to meet you and you looked so

interested and you shook hands so warmly. All of a sudden my arm

was gone and your face changed and got so far away. Then the left

side of your head began to disappear, and I could see only the

right side of your face until that slowly vanished also.... Your

face slowly came back, and you came close and smiled.... Then I

noticed my hand and asked you about it because I couldn't feel my

whole arm. You said to keep it that way just a little while for

the experience.[7]

[7] Milton H. Erickson, Ernest L. Rossi, and Sheila I. Rossi, _Hypnotic

Realities: The Induction of Clinical Hypnosis and Forms of Indirect

Suggestion_ (New York: Irvington Publishers, 1976), pp. 108-109.

APPLICATIONS OF HYPNOSIS

It is much easier to bring about a hypnotic trance than to know how to

make effective therapeutic use of the trance state once it is produced.

Depending on the depth of trance that you will accept, these are the

kinds of goals that can be achieved:

In a light trance, your eyes are closed, you are physically {221}

relaxed, and it is possible to convey to you, for example, that you are

unable to move an arm. At this stage, the therapist can often be

effective in offering you support and encouraging you to begin to make

changes in your behavior.

In a medium trance, relaxation is still deeper. A partial anesthesia

of a hand or arm can be achieved, and you will comply in a slow,

semiautomatic way with instructions from the therapist. In this state,

many clients can learn rather quickly how to bring about

_self_-hypnosis, which they can then practice on their own. At this

stage, it is sometimes possible to suggest gradual personality changes.

In a deep trance, more extensive anesthesias are possible. A therapist

can encourage you to experience emotional changes, to hallucinate, and

to regress to a younger age--i.e., to re-experience memories of past

events and to feel and behave as you did at that time. In a deep

trance state, it is possible to use hypnotic desensitization techniques

to help you overcome anxieties and fears.

Hypnotherapy lends itself well to use on your own. Once you have

learned how to induce light trance states on your own, you can begin to

suggest certain attitudes, feelings, or behavioral changes you would

like to bring about in yourself. Being successful at this--as with any

skill--requires regular practice and regular and gradual strengthening

of the habits that are being formed. Some psychotherapists will make a

audio recording for the individual client to use at home on a daily

basis.

Hypnosis has been used to treat many problems, including these:

ulcers

frigidity

impotence

headaches and migraines

insomnia

arthritic pain

colitis

tachycardia

obesity

depression

phobias

antisocial behavior

{222}

disturbed children

amnesia

stuttering

nervous tics

sexual inhibitions

dental anxiety and pain

heart palpitations

abdominal cramps

tension and anxiety

overeating

reduction or elimination of smoking

Both men and women are equally hypnotizable. Children are generally

better subjects than adults. As already noted, clients who are more

anxious tend to accept hypnotic suggestion more readily. Clients who

are motivated to change respond best to hypnotic suggestion.

Individuals who are imaginative, who had fictitious companions in

childhood, who read a good deal, and who can become readily absorbed in

nature are inclined to make good subjects. Good rapport between client

and therapist and a sense of trust in the therapist's goodwill and

ability contribute greatly to successful hypnotherapy.

Russian-born Lewis R. Wolberg (1905-1988) was a leading New York

hypnotherapist originally trained as a psychoanalyst. He is recognized

for the comprehensiveness and eclecticism of his approach. After forty

years of practice, he came to see its main limitation:

Because hypnosis is so dramatic a phenomenon, it is easy to

overestimate its potential. A great many things may be

accomplished with a subject in a trance, even the removal of

psychologically determined symptoms.... But almost immediately

after hypnosis has ended, or shortly thereafter, the symptoms will

return _if the subject has a psychological need for them_. [italics

added] ...

Quite often patients on disability compensation are sent to me by

insurance companies for hypnotic examination and treatment. Almost

invariably, these casualties cling to their symptoms with the

desperation of a drowning man hanging on to a raft....

There are other secondary gains a person may get out of holding

onto his symptoms. The need to punish himself for his guilt

feelings, the desire to abandon an adult adjustment and {223}

return to the protective blanket of infancy in order to be taken

care of.... Symptoms do not magically vanish; they must be worn

down. It is essential to replace them with productive habits."[8]

[8] Wolberg, _Hypnosis_, pp. 237-239.

MEDITATION

_For individuals who are able to make a

long-range commitment to the practice of a

discipline that, over a period of many months

and years, can strengthen them and help them

to become more fully integrated and centered._

/* Don't go outside yourself, return into yourself. The dwelling place

of truth is the inner man.

Saint Augustine, _The True Religion_

Meditation is a systematic discipline that attempts to help people move

toward the goal of self-realization. It is not the creation of one

individual or group. Techniques of meditation have evolved over many

centuries and in different parts of the world. And yet these

techniques bear striking similarities to each other, whether they

originated in the temples and monasteries of India, Japan, Europe, or

the Middle East.

Meditation is not a relaxed act of "contemplating one's navel"; it more

closely resembles athletic training. It is a form of progressive

mental exercise that has as its goal a strengthening of a person's

self-confidence, inner strength, and the mind's ability to focus and

concentrate. Meditation takes considerable endurance. It is

essentially a discipline. It requires fortitude, perseverance, and a

strong will. Like athletic ability, skills in meditation cannot be

developed without regular practice. Because its effects are felt only

gradually, meditation needs a long-term commitment to sustain it, and

this ultimately must be based on faith in its eventual value.

The disciplined and regular practice of meditation over a period of

many months appears to lead to a sense of personal integration, a sense

of being more firmly _centered_ in yourself, {224} more confident and

aware of your connection with all that is. Experienced practitioners

of meditation claim to feel a greater degree of personal security; they

feel more at ease with themselves. They claim to feel serenity, zest

in living, and inner peace and joy in work, which they seem to be able

to do more efficiently, with greater energy and interest.

WHAT THE PRACTICE OF MEDITATION IS LIKE

Techniques of meditation share the goal of disciplining the mind to do

one thing at a time. Until you have made a serious attempt to

meditate, you will very likely be unaware of how perpetually distracted

your attention is. We seldom make the effort to stand apart from our

thoughts, to take note of how numerous and varied they are and how

chaotically they tumble into and out of our consciousness. It is

exceedingly hard work to quiet these "chattering monkeys of the mind."

Quieting the overactive and undisciplined mind is a challenging task.

It takes energy and a great deal of practice.

There are many approaches to meditation. Here, we will look at

three.[9]

[9] See the excellent introduction to the practice of meditation by

Lawrence LeShan, _How to Meditate: A Guide to Self-Discovery_ (Boston:

Little, Brown & Co., 1974). Dr. LeShan is a psychotherapist in New

York City who teaches many of his clients meditation as part of their

therapy.

_Breath Counting_

Breath counting is one way to train your mind to control and focus

attention. The object is to be doing one thing, and one thing only,

becoming fully involved in that single purpose. Start by finding a

comfortable position, sitting or lying down. Place a clock or watch

where you can see it without having to turn your head. Usually with

eyes closed, you then begin to count your breaths, silently: "one" as

you slowly exhale the first breath, two as you exhale the second, etc.

After you get to "four" start with "one" again. The purpose is to be

doing _only_ this, only breathing and counting. You will quickly find

that your mind rebels; it will stray and wander whenever your

concentration and attention falter. It is a recalcitrant entity. You

will be doing well in the beginning if you can succeed for only a few

seconds {225} at a time in being conscious _only_ of your counting.

Distractions will subvert your will in a split second. You will find

yourself thinking of a host of things: what to do tomorrow morning,

whether you are doing well or badly at meditation, whether it is silly

to be doing this, what's for dinner, taxes, work, or that itch on your

forehead. Again and again you will have to return your mind to the

task at hand. Very quickly, you'll begin to realize that meditation

_is_ hard work. It is frustrating and demanding.

Practice doing this for fifteen minutes a day. After a few weeks,

increase to twenty minutes. After another four weeks, spend

twenty-five to thirty minutes a day. Once you can do this, continue to

practice daily for another month. It will take that long before you

will begin to sense whether this approach to meditation is going to be

useful to you.

_The Meditation of Contemplation_

This is an alternative approach to meditation. Again, the purpose is

to discipline your mind by means of focused attention. In this

approach, you try to focus attention on a physical object. Pick a

natural object--a shell, a small stone, a pressed leaf. Now, with the

object a foot or two from you, simply _look_ at it. The purpose is to

look at the object actively, to keep your attention fixed on it, but to

be wakeful and alert. Do not stare at one place on the object or

strain your eyes. Explore the object, _look_ at it, attend to it. As

usual, you'll find plenty to distract you--stiffness, the need to move,

sleepiness, slipping into thinking about problems you need to solve.

Each time your mind drifts out of track, gently bring your attention

back to the object. Try this for ten minutes a day for two weeks, then

fifteen minutes a day for a month, then twenty minutes for the next

month. By then, you will know if this approach will help you. Be

prepared for some effective sessions and some discouraging ones.

Remember that no one said meditation would be easy.

_The Meditation of the Bubble_

This is an ancient form of meditation that, again, seeks to discipline

the mind by developing your ability to focus on one thing at a time.

In this meditation, you concentrate on your own stream of

consciousness. Imagine yourself sitting quietly on the bottom of a

clear lake. Each of your thoughts and feelings forms a bubble that

slowly rises to the surface of the lake. As each {226} comes to your

mind, watch it closely and think only of it for the five seconds or so

that it takes to rise to the surface. Be aware of the slow rhythm of

the bubbles. Try to spend approximately equal amounts of time

attending to each bubble. If the same thought, the same bubble, rises

several times, this is OK. If you continue, the repetition will pass.

If nothing comes to mind for a time, this, too, is OK. Form an empty

bubble. Try this meditation for ten minutes a day for two weeks, then

increase to twenty minutes a day for one or two months. By then, you

will know if this approach to meditation is beneficial to you.

THE BENEFITS OF MEDITATION

How _will_ you recognize whether an approach to meditation has value

for you? Any changes that occur in you will be gradual; you must be

patient. If, after most sessions of meditation, you feel generally

more integrated, calmer, more at ease, this is a good sign. Over a

period of time, if you are working hard at an approach to meditation

that seems to fit your temperament, these periods of feeling peaceful,

alert, and comfortable in the world will gradually become more evident

to you.

Physiologically, meditation appears to lead to a deeply relaxed state

of alert concentration. Your respiration and heart rates slow, the

level of lactate in the blood (associated with tension and anxiety)

drops lower, and there is an increase in slow alpha brain waves,

associated with profound relaxation.

What is important, no matter what approach to meditation you try, is to

stay with that approach long enough to determine its potential value

for you. Doing a meditation once or a few times is like jogging once

or twice: you can't expect to derive any benefit from exercising a

couple of times. Meditation is the practice and expression of

discipline; deciding to practice regularly and then carrying out your

decision are just as important as the approach you take to meditation.

{227}

16

DRUG AND NUTRITION

THERAPIES

DRUG THERAPY:

BALANCING EMOTIONS WITH CHEMISTRY

_Often especially helpful to people who are

emotionally very upset so that they may begin

to benefit from psychotherapy._

During the past thirty years, biochemistry and pharmacology have made

many important contributions to the treatment of mental and emotional

disorders. There is no question that _psychotropic_--literally

"mind-turning" or mind-influencing--drugs can help many people during

periods of emotional or mental suffering.

Psychotropic drugs can be used by themselves or in conjunction with

psychotherapy. Frequently, drugs are used to help reduce the severity

of symptoms in patients so that they may benefit from psychotherapy.

Effective psychotherapy requires you to be comparatively calm,

rational, and able to make well-thought-out decisions. These things

are not possible if you are terribly agitated, are despondent and

crying much of the time, or {228} may, for example, have disturbing

hallucinations and are no longer in touch with reality.

The aim of drug therapy is, eventually, to eliminate the need for

medication. In this respect, psychopharmacology is similar to

psychotherapy: both would like to help the patient so that he or she no

longer needs either one. It is not always possible to do this,

however. Some disorders are, at present anyway, chronic conditions.

People with parkinsonism or epilepsy may have to take medication

indefinitely. But the general trend is to use psychotropic drugs as

temporary measures to bring symptoms quickly under control so that

psychotherapy can be started.

The only professionals who are legally authorized to prescribe

psychotropic drugs are physicians and, in particular, psychiatrists.

However, psychotherapists are now being trained to be sensitive to

conditions that may have an organic basis. Certainly, it is wise to

have a thorough physical exam to rule out organic problems that can

cause emotional or mental upset (see Chapter 8). Numerous studies have

shown that up to half of the individuals who are referred to a

psychotherapist have undiagnosed organic problems.[1] This is an

important caution to bear in mind.

[1] See, for example, L. Small, _Neuropsychodiagnosis in Psychotherapy_

(New York: Brunner/Mazel, 1980).

TYPES OF PSYCHOTROPIC DRUGS

There are nine main classes of psychotropic drugs:

_Antianxiety, or Anxiolytic, Drugs_

These are the so-called _minor tranquilizers_. They are sedatives for

the waking hours that are prescribed for people who have excessive

tension and anxiety.

_Neuroleptics, or Antipsychotics_

Psychosis is a disorder that impairs a person's abilities to think,

remember, communicate, respond with appropriate emotions, and interpret

reality without great distortion. People who have these difficulties

can often be treated effectively with neuroleptic or antipsychotic

drugs, also known as the _major tranquilizers_, which have specific

effects on the brain's activity.

{229}

_Sedative-Hypnotic Drugs_

These drugs act as sedatives at low doses and produce a "hypnotic"

action at higher doses. (The word _hypnotic_ as used by

pharmacologists does not refer to a hypnotic trance but means simply

that a drug causes drowsiness and reduces motor activity.) In even

larger doses, these drugs act as anesthetics. Antianxiety drugs, the

minor tranquilizers, can be grouped with these drugs because of their

sedative effect.

_Antidepressants_

These drugs are used primarily to treat what psychiatrists call

_endogenous_ depression--that is, major, incapacitating depression that

is not associated with an outside event or situation. Depressions that

occur after the loss of a job, the death of someone close, or some

other external event are called _exogenous_ depressions. They can

sometimes be treated effectively with antidepressants, but drug therapy

for _situation-induced depression_ generally is less successful.

Lithium therapy is a specific treatment primarily for manic-depressive

disorders. Lithium carbonate is a naturally occurring mineral salt.

For manic-depressive patients--with wide swings of mood from feeling

extremely energetic and emotionally high to feeling seriously

depressed--lithium therapy may offer help as a mood stabilizer.

_Stimulants_

Caffeine and nicotine are the best known of the stimulants. In

therapy, stimulants are used in the treatment of narcolepsy

(individuals suddenly fall asleep for short periods of time, even when

engaged in activities), some forms of epilepsy, and, paradoxically,

hyperkinetic children (who are excessively active and have short

attention spans and explosive irritability).

_Antiepileptic Drugs_

For many of the two million Americans with epilepsy, these antiseizure

drugs are very helpful. Epilepsy does not tend to shorten an

individual's life, but it is a severe, troubling, and often disabling

condition for which drug therapy can be a blessing.

_Antiparkinsonian Drugs_

These drugs have helped the lives of many people who are {230} affected

by the characteristic involuntary tremors of this disease, which can

cause abnormalities in gait and trembling of the voluntary muscles.

_Psychedelics_

Psychedelic drugs are also called _hallucinogens_. They produce

altered states of consciousness and sensory distortions. Psychedelics

have no established use in psychiatry at present in the United States.

Great Britain and Canada, however, have experimented with psychedelics

in the treatment of alcoholics, whom they sometimes appear to help.

Psychedelics have also sometimes been used for the terminally ill and

in certain cases of autism.

_Drugs for Headache, Migraine, and Neuralgia_

Drugs for these common kinds of pain are widespread. Migraines (which

may cause blurred vision, vertigo, and even temporary deafness) and

cluster headaches (which cause severe pain around the eyes, tearing and

reddening of the eyes, and runny nose) frequently can be treated

successfully with specific drugs. Neuralgias are recurrent knifelike

facial and head pains that can last for days and even months. They can

be difficult to treat successfully.

WHAT DRUG THERAPY IS LIKE

In this section, we'll look at some of the main emotional and mental

symptoms that are often helped by means of drug therapy. Since all

medications have potential side effects, we will look at these as well.

_Anxiety_

Excessive anxiety causes very unpleasant symptoms: dizziness or

light-headedness, sweating, pounding heart, vomiting, diarrhea,

shaking, muscle tension, inability to sleep. Many of these symptoms

can be controlled by antianxiety drugs. All of these drugs can lead to

psychological dependence when they are used regularly over periods of

time that vary with the person and the medication. For this reason,

they are normally used for short periods, often at the beginning of

psychotherapy.

{231}

The most commonly prescribed antianxiety drugs include these (trade

names):

Atarax

Ativan

Centrax

Clonopin

Dalmane

Doriden

Equanil

Librium

Loxitane

Paxipam

Restoril

Serax

Tranxene

Tybatran

Valium

Valmid

Xanax

Although relatively small percentages of patients experience them, as

with most drugs, there may be side effects, including drowsiness,

impaired judgment and performance, nausea/vomiting, ataxia (loss of

voluntary muscle coordination), and agitation (paradoxical

restlessness).

Patients who have taken an antianxiety drug for a period of time are

often instructed to reduce their dosage gradually to avoid mild,

infrequently severe, withdrawal symptoms.

Antianxiety drugs can reduce agitation and produce a relative sense of

calm. But, unfortunately, patients usually develop a tolerance to any

antianxiety drug after three to four months, and then the drug loses

its effectiveness. Antianxiety drugs are usually limited, then, to

short-term treatment. Long-term recovery from the symptoms of anxiety

is the task of psychotherapy: to help clients change their attitudes,

behavior, or way of life.

_Depression_

Depression can be a seriously incapacitating emotional disorder.

Depression can range from a lingering sense of sadness or grief to a

feeling of utter hopelessness, guilt, despondency, uncontrollable

crying, and suicidal thoughts. The following symptoms are typical:

insomnia or early waking, loss of appetite and loss of interest in sex,

inability to concentrate, great difficulty in making decisions, and a

reduced desire and ability to assume job and family responsibilities.

Though depression is called "the common cold of emotional illness," it

is not to be taken lightly, since severe depression is

life-threatening, as many {232} suicides testify. Depression affects

one out of five people during their lifetimes; more women suffer from

depression than men.

At the time of this writing,[2] the most widely prescribed

antidepressants are the tricyclics. They are most effective in

treating endogenous depressions; MAO inhibitors (see below) are more

useful in cases of "atypical" depression, which frequently is

associated with a situation the patient cannot come to terms with, such

as the loss of a job or of a loved one.

[2] Since this book was published, SSRIs or _s_elective _s_erotonin

_r_euptake _i_nhibitors, have become the most commonly prescribed

antidepressant medication in the U.S and many other countries. For

readers interested in more information about SSRIs, see Wikipedia's

article,

http://en.wikipedia.org/wiki/Selective-serotonin-reuptake-inhibitor.

Tricyclic antidepressants include these (trade names):

Avenyl

Elavil

Norpramin

Pamelor

Sinequan

Surmontil

Tofranil

Vivactil

Approximately 70 percent of patients who take tricyclics improve.

Several newer drugs--the tetracyclics, dibenzoxapines, and

triazolopyridenes--are similar to the tricyclics in their effects.

They include these (trade names):

Asedin

Desyrel

Ludiomil

If tricyclics do not help, MAO inhibitors (_m_onoamine _o_xidase

_i_nhibitors) are usually tried. MAO inhibitors must be used with

great caution because they can interact with certain foods, beverages,

or drugs to produce severe high blood pressure. Many foods and

beverages are prepared by fermentation processes; e.g., cheese,

anchovies, pickled herring, pastrami, olives, beer, and wine, all of

which patients who take MAO inhibitors must avoid. These foods and

beverages contain a chemical compound, an amine called _tyramine_,

which can cause dangerously high blood pressure, a hypertensive crisis,

in people taking an MAO inhibitor. Furthermore, MAO inhibitors cannot

be taken with antihistamines; patients who take MAO inhibitors may be

warned to avoid other drug interactions. These warnings should be

taken seriously because MAO inhibitors are one of the most potentially

_toxic_ groups of psychoactive drugs. Yet they can make the difference

between night and day for many cases of depression.

{233}

There are common side effects caused by all the antidepressants we've

mentioned, including an uncomfortably dry mouth, dizziness, especially

when standing up quickly, headaches, difficulty in urinating,

nausea/vomiting, constipation or diarrhea, impotence, inability to

reach orgasm, agitation/shaking, and rapid heartbeat.

Some of these side effects can be annoying but will often diminish or

disappear once the patient becomes accustomed to the medication. When

side effects are not tolerable, the physician or psychiatrist will

usually prescribe a different antidepressant that may have fewer, or

no, side effects for a given patient.

One of the drawbacks of antidepressants is that there is a waiting

period of days or weeks before physician and patient know whether a

particular drug is going to help. If, after four to six weeks, an

antidepressant has not reduced a patient's depression, then a second

drug may be tried, and, again, there will be a delay of days or weeks

before it is clear whether the medication is going to work. One needed

area of research in psychopharmacology is to devise tests that will

help to tell a doctor what antidepressant is most likely to be

effective for the individual patient. At present, though some general

guidelines exist, matching patient with an effective and tolerable

medication is a process of intelligent trial and error.

Lithium has been used to treat manic depression since 1954. Lithium is

absorbed quickly from the gastrointestinal tract, but it acts slowly,

so it also takes time to know if it is going to be of value. Blood

levels of lithium need to be checked once or twice a week during the

first month, twice a month for the next month or two, and then once

every one to two months.

Lithium is sometimes helpful in treating chronic simple depression,

that is, depression that is not associated with periodic "highs."

Unlike most drugs used in psychiatry, lithium usually has few

noticeable side effects and does not tend to produce a feeling of

sedation or stimulation. When side effects occur, it is usually

because the lithium level in the blood has become excessive. Side

effects then can include vomiting, lack of coordination, muscular

weakness, or drowsiness.

In addition to antidepressant drugs, electroconvulsive therapy (ECT) is

sometimes used to treat severe depression, as it is to treat some other

conditions, including schizophrenia. Although ECT is not itself a form

of drug therapy, it is important to {234} mention it here since it is

one of the main _medical_ treatments (as opposed to the "talk

therapies" of psychotherapy) used by psychiatry today. ECT is

administered after a patient has been sedated and given a general

anesthetic.

The main advantage of ECT is that it acts much faster than any of the

antidepressants. For a seriously suicidal patient, this can be

important.

The main disadvantages of ECT are that it can cause temporary memory

loss, temporary disorientation and confusion after treatment, and

possible permanent changes in brain function--regarded by many

psychiatrists as "subtle," i.e., fairly minor. Another discouraging

finding is that depression recurs after ECT in many patients--in up to

46 percent within six months after ECT.

ECT has received "poor press." As now administered, the actual

treatment is painless. It is, nevertheless, a forceful, "invasive"

approach, so many psychiatrists prefer not to use it if medication can

be successful. As more biochemical methods of treatment are

discovered, ECT very likely will be used less and less.

_Psychosis_

Psychosis is the most serious and incapacitating degree of mental

illness. Emotional problems with symptoms of anxiety or depression, or

both together, are called _affective disorders_. People who have

affective disorders make up the majority of clients seen by most

psychotherapists; these clients are _not_ out of touch with reality.

The problems that they have--though painful and sometimes obstacles to

normal living--are essentially different from the difficulties that

patients with psychoses have. Though there is no unanimity about this

among health care professionals, we will distinguish between these two

kinds of problems by calling a psychosis a _mental illness_, as opposed

to an _emotional disorder_. It is a matter not only of degree but of

kind. A person who is severely depressed or extremely anxious is

usually still able to communicate rationally, and distinguish what is

real from what is fantasy or delusion.

Psychoses, on the other hand, are disorders that impair a person's

abilities to think, remember, communicate, respond with appropriate

emotions, interpret reality coherently, and behave in a reasonably

"normal" way. People with psychoses {235} often have difficulty

controlling their impulses, and their moods may change quickly and

radically. Psychotic individuals often believe things to be true that

are not, and they may hear sounds or voices that are not there.

There are many theories about the causes of psychosis. Recently,

research studies in psychiatry have shown that psychosis may be due to

an excess of certain chemical substances called _neurotransmitters_

(such as norepinephrine or dopamine) in the brain. Another theory is

that the brain of a psychotic person may be excessively sensitive to

the action of certain neurotransmitters.

The antipsychotic drugs, or neuroleptics, reduce the brain's

sensitivity to one or more of these chemical substances. Some of the

best-known antipsychotic drugs are these (trade names):

Compazine

Haldol

Mellaril

Prolixin

Stelazine

Thorazine

Trilafon

Vesprin

Antipsychotic drugs frequently can clear thought processes, reduce or

end hallucinations, relieve agitation and anxiety, and generally help

patients return to the world of reality, communicate with others, and

behave in a more reasonable and stable way.

Antipsychotic drugs have many possible side effects. They may produce

drowsiness, dizziness and nausea, fainting, muscle tremors, a shuffling

gait, blurred vision, insomnia, sensitivity of the skin to sunlight,

and other effects. Particularly disturbing side effects can often be

avoided by changing to a different medication. Some people with

psychotic symptoms may need to take antipsychotic medication for only a

few weeks or months. Recurrent or chronic illnesses, however, may

require drug treatment over a long period.

WHEN DRUG THERAPY IS APPROPRIATE

Since psychotropic drugs can be prescribed only by a physician or

psychiatrist, his or her judgment will determine whether a patient's

difficulties seem to lend themselves to drug therapy. In cases

involving serious anxiety, depression, or psychosis, it is {236}

routine to expect drug therapy to be used, often in conjunction with

psychotherapy. As we noted earlier, it is the hope of drug therapy

that it will be needed only temporarily, but some chronic or

periodically recurring conditions may be best treated by continued

medication for a number of years. Since many of the psychotropic drugs

are new, it is not known whether long-term use by some patients may

ultimately affect their health adversely. Unless we decide to do

without medication that can be a blessing in relieving great suffering,

until long-term studies can be completed, the potential risks are

there. It is a matter of weighing alternatives: on the one hand,

perhaps incapacitating emotional or mental distress, and on the other,

side effects that cannot be fully predicted.

THERAPY THROUGH NUTRITION

There is no question that nutritional deficiencies can influence the

functioning of the brain and affect the personality. There are

clear-cut cases, for example, of vitamin deficiencies that result in

symptoms of psychological disturbance. The majority of these cases

involve people who suffer from very evident malnutrition.

Unfortunately, the connection between nutrition and mental health is

still vague; biochemists are becoming more aware of the need to take

into account _individual variations_. It is not always possible to

specify exactly how much of a mineral, a vitamin, or an amino acid a

person requires for good health. Some people, for many different

reasons, cannot effectively utilize the food they eat. Others have

allergic reactions to certain foods; some allergic reactions appear to

be subtle, affecting a person's moods. Still other people seem to be

especially sensitive to only moderate changes in their blood sugar

levels. We have a great deal in common as biological organisms. Yet

our biochemistries may be finely tuned in individual ways that would

require a detailed and sophisticated understanding of an immense number

of interrelated factors that boggle the mind in complexity.

_Psychonutrition_ has a long road to follow before it will be a

science. So-called holistic or orthomolecular (the "right" molecule)

physicians and psychiatrists attempt to take individual variations and

sensitivities into account. The need to do this may be essential in

many cases, but dependable and exact methods of {237} evaluation and

treatment simply do not exist as yet. Except in cases of outright

malnutrition, finding connections between nutrition and emotional

health is still an art.

Some orthomolecular psychiatrists appear to have been dramatically

successful in helping some patients with certain mental or emotional

problems. But because psychonutrition is still a borderline

discipline, it is an area where controversies abound and results are

often open to question.

Many physical conditions can be influenced greatly by nutrition. Among

these are the metabolic disorders diabetes and hypoglycemia, both of

which can affect a person's emotional life (see Chapter 8). In

addition, relationships have recently been discovered between lowered

blood pressure, reduced cholesterol and triglyceride levels, and a diet

high in fiber. A thiamine (vitamin B1) deficiency--which causes

pellagra, a chronic disease that leads to skin lesions and

gastrointestinal distress--can produce depression, mania, and paranoia.

Another example is pernicious anemia, in large part due to vitamin B12

shortage, which can cause moodiness, difficulty in remembering and

concentrating, violent behavior, depression, and hallucinations. But

the fact that many physical disorders, some of which can cause

psychological disturbances, are treatable in part through nutrition

does not, unfortunately, imply that emotional disorders in general can

be treated by means of diet. This may be the case for some individuals

for whom special diets can influence a specific biochemical imbalance.

But research is just beginning to develop tests that can detect these

sensitive individual variations. Once they can be identified a more

difficult step has to be made: to determine how this information can be

used to select an effective treatment.

Nutritionists and physicians agree that good physical and mental health

depend on a combination of proper body weight, adequate exercise, good

diet, and decreased stress. But beyond this, an emotionally disturbed

person who seeks help through dietary therapy--for example, through

megavitamin doses--should realize that he or she is really involved in

_self-experimentation_. Some orthomolecular psychiatrists may be very

talented in treating some of their patients. These patients are very

fortunate; it is hard to avoid saying they are lucky. The main problem

that faces this new area of psychonutrition is one of general

reliability and credibility.

{239}

PART III

IMPORTANT

QUESTIONS

{241}

17

LOCATING A THERAPIST

America is overcrowded with helpers; there are so many helpful

people out there, they are literally bumping into each other, and

must be regulated by laws and organizations to keep them from

helping so much that the average client in need of help isn't torn

to shreds.

Paul G. Quinnett, _The Troubled People Book_

This chapter assumes that you have used one of the two methods

described in Chapter 7, "Self-Diagnosis: Mapping Your Way to a

Therapy," and have now chosen an approach to therapy that seems most

promising in relation to your goals or problems and your personality.

You now face the practical problem of how to locate a therapist with

the professional expertise to offer you the kind of help you desire.

There are three factors that you need to take into account in order to

find a suitable therapist:

1. the degree of seriousness of your problem or need

2. any financial limitations you may have

3. the resources available where you live (or how far you are willing

to travel if you cannot locate the help you want in your area)

{242}

The seriousness of your problem or need may fall into one of three

general categories:

_Very urgent need_: You are severely upset, perhaps suicidal or

dangerous to others. Or, you are suffering from extreme changes of

mood or personality, major depression, delusions, or hallucinations.

In either of these cases, you should see a professional immediately.

You or a friend or relative should contact your family physician for a

referral to a _psychiatrist_ or call a crisis intervention center for a

referral to a psychiatrist. (Crisis intervention centers, sometimes

called _suicide prevention centers_ or _crisis hot lines_ are listed

among the emergency numbers on the inside front page of your White

Pages directory; otherwise, dial 911 for assistance.)

_Serious personal, marital, or family problems or goals_: You, you and

your spouse, or members of your family need help soon but can wait for

an appointment, if necessary, for a number of weeks.

_Moderate need_: There is no urgency. You are interested, before you

consider formal therapy, in exploring some alternatives--perhaps by

talking with a minister, priest, or rabbi or by trying one of the

adjunctive approaches to therapy (such as therapeutic exercise,

meditation, relaxation training) on its own, without individual therapy.

This chapter is intended primarily for people in the well-populated

middle category, people who have serious problems or goals and are able

to weigh alternatives carefully and without extreme pressure.

The seriousness of the problem and the cost of treatment go hand in

hand. The range of treatment alternatives is shown in the table below.

_Condition Cost Treatment by:_

---------------------------------------------------------------------

more serious more expensive Psychiatrists

| |

| | Psychologists

| |

| | Social work counselors

| |

| | Adjunctive therapists:

| | biofeedback, bioenergetics,

| | exercise, meditation, etc.

| |

| | Religious counselors

| |

less serious less expensive Self-help

{243}

In general, the less serious the problem, the lower the potential cost

of treatment. Also, the more serious the condition, the more advisable

it is to have at least a preliminary evaluation by a psychiatrist.

Similarly, the settings within which therapy is available vary widely:

_Condition Cost Setting:_

---------------------------------------------------------------------

more serious more expensive Hospitals

| |

| | Residential treatment

| | centers

| |

| | Private practice

| |

| | Agencies: private, state,

| | county

| |

| | Academic sources:

| | individual counseling for

| | enrolled students

| | vocational guidance

| | counseling

| | classes or workshops

| | adult extension or

| | continuing education

less serious less expensive programs

FINDING A THERAPIST WITH A

PARTICULAR SPECIALIZATION

During a time of increasing specialization in health care, many

psychotherapists have unfortunately been attracted to eclecticism--that

is, knowing a reasonable amount about a number of different forms of

therapy, but resisting specialization in any one of them. For some

individuals, especially people interested in wide-spectrum growth and

personal development, an eclectic therapist can be very beneficial.

Eclectic therapists believe that they are able to bring a wider scope

of understanding to bear on a problem and a more flexible outlook. If

you have fairly well-defined needs and interests, however, eclecticism

makes it difficult to locate a therapist who has formal training and

extensive experience specifically in treating, for example, depression,

alcoholism, family conflicts, or adjustment problems. No therapist

today can be an expert in the whole range of human {244} emotional

problems and in the many specialized techniques that have been

developed to help.

REFERRALS

There are a number of ways of going about locating a therapist. You

can start by asking for a recommendation from any of these sources:

* your family doctor, who will most likely suggest a colleague, another

M.D., a psychiatrist

* your minister, priest, or rabbi, who again will suggest someone he or

she happens to know or to have heard of

* personal friends

* referral services

All of these alternatives are, however, limited by the scope of

acquaintance of the person or service you have gone to. Referral

services commonly are run by groups of subscribing psychologists (or

social workers), so if you call one, you will be referred to a

participating psychologist (or social worker). Sometimes referral

services (which usually charge nothing for their referrals, unless you

request a preliminary consultation) maintain a listing of the areas of

specialization of their professional members, and this information can

be helpful.

If you have a specific approach to therapy in mind and want to find a

therapist with strong credentials in that approach, there are two

usually more promising roads to follow:

BY MAIL, OR E-MAIL (GOOGLE ANY OF THE

NAMES OF ORGANIZATIONS THAT FOLLOW):

First, depending on your own judgment of the seriousness of your

problems or goals and the extent to which the cost of treatment is

important to you, you can request a list of therapists in your area

from these organizations:

American Psychiatric Association

1400 K St., NW

Washington, DC 20005

Canadian Psychiatric Association

225 Lisgar St., #103

Ottawa, ON K2P 0C6

(for psychiatrists)

{245}

American Psychological Association

1200 17th St., NW

Washington, DC 20036

Canadian Psychological Association

558 King Edward Ave.

Ottawa, ON K1N 7N6

(for psychologists)

National Association of Social Workers

7981 Eastern Ave.

Silver Spring, MA 20907

Canadian Association of Social Workers

55 Parkdale Ave., #3l6

Ottawa, ON K1Y 1E5

Corporation Professionnelle des Travailleurs Sociaux du Quebec

5757 Decelles Ave., Ch. 335

Montreal, QC H3S 2C3

(for social work counselors)

Ask for a list that shows their specialties. If none is available, ask

for the address of the branch office nearest you, which you then can

contact for this information. If writing by mail, be sure to enclose a

stamped, self-addressed envelope to ensure a response.

BY TELEPHONE

A second way to locate a therapist with specialization in a particular

area is through careful use of your telephone directory. This may take

you some time, and also some preliminary calls, but it can give you a

good deal of information:

_Psychiatrists_

Psychiatrists are listed in the Yellow Pages under "Physicians and

Surgeons." In larger metropolitan directories, you will usually find

separate headings after the general listing, according to specialties.

Look there for "Physicians-Psychiatrists" or similar heading. Many

psychiatrists today will list their special focus there--for example,

psychoanalysis, psychoanalytic psychotherapy (brief analysis), marriage

and family therapy, hypnosis, chemical dependency treatment, child and

adolescent therapy. If you want to see a psychiatrist and do not find

one who indicates the specialized approach you want to try, then you

will need to make some calls. Most psychiatrists' secretaries or

receptionists are happy to tell {246} you what the doctor specializes

in. If the list of his or her areas of specialization is impressively

and overly long, perhaps it is best to look elsewhere for a more

realistic professional.

If, after locating a psychiatrist with the background you are looking

for, you want to double-check his or her credentials, ask the secretary

if the psychiatrist is a member of the American Psychiatric Association

(or, if in Canada, the Canadian Psychiatric Association), whether he or

she completed a program of study at an institute of psychotherapy or

psychoanalysis, and whether he or she is board certified. (Remember,

any M.D. can call himself or herself a psychiatrist, but not all have

the full qualifications of a certified psychiatrist.)

_Clinical Psychologists_

Clinical psychologists are listed in the Yellow Pages under

"Psychologists." Their specialties are often identified--e.g.,

marriage and family therapy, group therapy, bereavement, alcoholism,

eating disorders and addiction, psychological assessment (testing),

learning disorders, sexual dysfunction, depression, panic syndrome.

Again, if the list below a given psychologist's name is unreasonably

long, you may have come across either a genius or someone who favors

advertising. Psychologists less often mention the particular approach

to therapy they use, but some do; for example, behavior therapy,

Gestalt, hypnosis, or "analytical approach" may be listed. Again, it

will probably be necessary to make a few telephone calls.

If, after locating a psychologist with the background you are looking

for, you want to double-check his or her credentials, you can

frequently find a copy in your public library of the _National Register

of Health Services Providers_ or, in Canada, either the _Canadian

Registry of Health Service Providers in Psychology_ or the

_International Directory of Psychologists_. They list licensed

psychologists with Ph.D.s who have completed internships of supervised

therapy. Psychologists will often print their state license numbers in

their telephone directory listings.

_Social Work Counselors_

Social work counselors are listed under "Social Workers" in the Yellow

Pages. Usually, their listings are less specific than those for

psychiatrists and psychologists. Most commonly, you will see listings

indicating "licensed MFCC" (marriage, family, {247} and child

counseling), "MSW" (master's degree in social work), "LCSW" (licensed

clinical social worker), etc. State licensing numbers are often also

given.

The _Register of Clinical Social Workers_, published by the National

Association of Social Workers, lists members whose degrees and

supervised training were in counseling; it is available in many public

libraries.

Specific credentials you may also see in directory listings include the

following:

_For therapists with_

_Affiliation: specialties in:_

---------------------------------------------------------------------

Membership in American Psychoanalysis

Psychoanalytic Association

(all members are M.D.s)

In Canada: Membership in

Canadian Psychoanalytic

Society

Membership in International

Psychoanalytical Society

Membership in National

Psychological Association for

Psychoanalysis

Training from Center for Studies Client-centered therapy

of the Person, La Jolla, CA

Training from Gestalt Therapy Gestalt therapy

Institute of LA (or San Diego,

San Francisco, New York,

Boston, Chicago, Cleveland,

Dallas, Miami, Hawaii, etc.)

Training from Institute for Rational-emotive therapy

Rational-Emotive Therapy

(which maintains a register of

psychotherapists who have

received training in RET.

Address: 45 E. 65th St., New

York, NY 10021.)

Training from the Institute for Reality therapy

Reality Therapy (in LA, with

branches in other cities in the

U.S.)

{248}

Membership in North American Adlerian therapy

Society of Adlerian

Psychology

Membership in Association for Behavioral psychotherapies

the Advancement of Behavior

Therapy

Membership in American Marriage and family

Association of Marriage and therapy

Family Therapists

Membership in Biofeedback Biofeedback therapy

Society of America

Membership in American Hypnosis

Society of Clinical Hypnosis

In Canada: Membership in

Canadian Institute of

Hypnotism

Membership in American Treatment of sexual

Association of Sex Educators, disorders

Counselors, and Therapists

HARDER-TO-FIND THERAPIES

It can be especially difficult or confusing to locate therapists with

certain orientations, either because these approaches are less

widespread or because you do not know which kinds of health-care

professionals make the greatest use of them.

Frequently, an effective way to locate an _existential-humanistic

therapist_ or _logotherapist_ is through religious organizations. Call

to ask for the names of ministers, priests, or rabbis with training in

psychotherapy or counseling. These individuals, in turn, will often be

able to put you in touch with either existential-humanistic therapists

or logotherapists who may or may not be affiliated with the religious

organization in question.

_Emotional flooding therapists_ are usually found among psychologists,

whose telephone directory listings will normally indicate whether they

offer one of these therapies. The same is true for psychologists with

experience in _direct decision therapy_.

_Biofeedback therapists_ can be found in private practice; they will

also be found at pain and stress centers (which are often run by

hospitals on an outpatient basis). These offer private or publicly

funded programs to help people with chronic pain or {249}

stress-related difficulties. A number of counseling agencies have

begun to include biofeedback therapists on their staffs.

Biofeedback therapists in private practice, as well as pain and stress

centers, are listed in telephone directories. Try looking under

"Biofeedback Therapy and Training" and under "Psychologists" for those

who indicate that they offer biofeedback.

_Relaxation training_ (and sometimes also meditation) is frequently

offered by biofeedback therapists (as well as by many psychologists and

social workers).

Therapists who use _hypnosis_ are often listed under "Hypnosis" in

telephone directories. You will usually find a wide variety of

educational backgrounds represented among therapists in these listings.

Some are in private practice; some work for agencies. You will

probably see an array of credentials advertised, perhaps ranging from

therapists without degrees, to those with Ph.D.s and M.D.s. Here,

especially, is an area in which to exercise consumer caution.

Unfortunately, hypnotherapy is well populated by therapists who lack

professionally recognized credentials. It is wise to remember that

Ph.D.s can be granted in all sorts of fields--in education, theology,

librarianship, etc.--as well as psychology. Some "therapists" practice

with a Ph.D. after their names, yet their Ph.D.s may be in fields

totally unrelated to counseling and psychotherapy. Ph.D.s who are

_licensed psychologists_ and who are members of the American Society of

Clinical Hypnosis offer professional credibility as hypnotherapists.

The certification of therapists trained in hypnosis is still unsettled

in many states, where anyone can hang out a shingle. Since many

licensed psychologists, psychiatrists, and some certified social

workers _do_ receive professional training in hypnosis, these are the

professions to which it is most reliable to go for hypnotherapy.

_Meditation techniques_ may be learned on your own (see Chapter 15), or

you can seek out commercial or religious organizations that teach

meditation. They are sometimes found in the Yellow Pages under

"Meditation Instruction." Transcendental Meditation (TM) programs have

been popular and are widespread. Yoga instructors (raja yoga rather

than hatha yoga) also teach meditation.

Relatively few psychologists or social workers have actually received

training in the use of _therapeutic exercise_, since this area is

relatively new and its proponents are still small in {250} number.

However, most psychologists and many social workers are aware of the

exercise programs advocated by Kostrubala and Glasser (see Chapter 15)

and can help you plan intelligently.

ABOUT THE COST OF TREATMENT

Most health insurance plans offer at least partial coverage for

psychotherapy and counseling. Consult your policy to find out what

providers (psychiatrists, psychologists, or social workers) you may go

to for covered treatment and for how long. (If you have special

concerns about confidentiality in connection with treatment under an

insurance plan, see Chapter 19.)

As we noted earlier, it is possible to obtain treatment from many

psychiatrists, clinical psychologists, and social work counselors at

reduced cost, if you have definite financial limitations (see Chapter

4).

Many clinical psychologists and social workers indicate in their

directory listings in the Yellow Pages if fees are set on the basis of

a sliding scale-on the basis, that is, of ability to pay. It is worth

a telephone call to find out. Many public and some private counseling

agencies also set fees in this way. Reduced fees from psychiatrists

are more likely through agencies that offer psychiatric care than from

psychiatrists in private practice. For public agencies, look in the

White Pages under the name of your county; then look for the heading

"Mental Health Services" or "County Mental Health," or the equivalent.

You will frequently find one or more mental health centers or clinics

listed. In the Yellow Pages, look under "Clinics" for a listing of

private and sometimes also public clinics. It is usually clear from

their descriptions whether they offer psychotherapy or counseling or

only treatment for physical illness or injury.

Again, it may be worthwhile to mention that the costs of _group

therapy_, whether through a clinical psychologist or a social work

counselor, may be expected to be substantially less than the costs of

individual therapy. (On the appropriateness of group therapy, see

Chapter 13.)

ONCE YOU HAVE LOCATED A THERAPIST

If you believe you have found a therapist whose background, fees, and

location meet your needs, I recommend that, when you {251} telephone

for an appointment, you ask for an initial consultation. This will

make it clear, in the therapist's mind and your own, that your

appointment is for a trial session. (The fee is normally the same as

for a regular appointment, but check on this.)

When you go to this first session, it is very tempting to launch into

what is troubling you. If you can hold yourself back in order to ask a

few preliminary questions about the therapist's background, experience,

approach, and a likely duration of treatment--in other words, encourage

the therapist to talk to you a little bit about himself or herself--you

will get a better idea of the _person_ behind the professional title.

This will help you decide whether you want to continue with future

sessions. However, it may take several weeks, or even months, for you

to _know_ that the relationship will in fact benefit you.

{252}

18

SHOULD YOU BE HOSPITALIZED?

There are two main reasons for psychiatric hospitalization:

1. _You would be better off away from home_. Many things can play a

role here. Perhaps there is too much family conflict at home, too much

emotional strain, for you to improve. Or, your family may simply not

be calm enough to handle the crisis. Or, perhaps you have too many

strong and upsetting associations at home--e.g., if your spouse has

just died or your daughter just committed suicide at home. Or, you may

just have too little privacy at home; you feel forced to maintain a

stiff upper lip in front of children, your spouse, or other family

members, but you simply can do this no longer.

2. _Your condition may be too serious to be treated appropriately on an

outpatient basis_. If you are no longer in touch with reality, are

unable to communicate coherently, are hallucinating or have delusions,

you cannot be relied on to take care of yourself. If you are

psychotic, your behavior may hurt others or yourself. If you are

suffering from a major, incapacitating depression, you may become

suicidal. Finally, if you are unable to control an addiction to drugs

or alcohol, inpatient care is more likely to be effective.

You may, of course, have reasons to _resist_ hospitalization. Most

likely, your resistance will be based on fear--of the unknown, of {253}

the later stigma of having been hospitalized for a psychiatric

condition, or of the _inner_ stigma: that you must have been terribly

ill (or "weak") to justify hospitalization. Furthermore, if you have

been hospitalized before, you may recall that the hospital's supportive

environment encouraged you to feel dependent on it and to resist

returning to normal living, and you may fear falling prey to this again.

All of these are good reasons to proceed cautiously. Only the first

fear can be reasoned with in an objective way, by understanding what

psychiatric hospitalization is really like, something this chapter will

help you to do. Certainly, the other fears also may have some basis.

Discrimination _does_ still exist against former psychiatric hospital

patients. They may find it difficult, for example, to enter military

service or serve in an important political capacity.

The inner stigma can be even more damaging, if you are a highly

self-blaming person. If you are going to hold hospitalization as yet

another black mark against yourself, then you may want to avoid

hospitalization unless it means you are withholding treatment from

yourself that really is essential to your well-being.

If you have been hospitalized before for psychiatric care, the last

reason is very likely the most important one for you to weigh

carefully. In the light of your past dependency needs, you must decide

whether the problems you now face are serious enough to motivate you to

walk into a situation that in the past you found difficult to leave.

Most hospital admissions for psychiatric conditions today are

_voluntary_. Usually, either your own judgment leads you to accept

hospitalization, or you are persuaded by family, friends, family

doctor, minister, or psychiatrist that doing so is in your own best

interest. Involuntary hospitalization is legally difficult and occurs

primarily in cases in which, over a period of time, there is evidence

that a person's behavior is not responsible, that he cannot take care

of himself, or that he may injure himself or others.

WHAT HOSPITALIZATION IS LIKE

Several kinds of hospitalization are available to individuals who are

emotionally troubled:

{254}

* private or public hospitals in which there are special floors or

sections for psychiatric patients

* hospitals that treat only psychiatric problems

* inpatient programs that specialize in stress management or the

treatment of depression, alcoholism, drug abuse, and other problems