Typically, fifteen to twenty-five patien_When You Don't Know Where to Turn A Self-Diagnosing Guide to Counseling and Therapy

a hospital unit. Often a ward is divided, with men living on one side

and women on the other. In private and many public hospitals, private

and semiprivate rooms are available, depending on your ability to pay

or your insurance coverage.

Frequently, patients dress in everyday clothes rather than in hospital

gowns and pajamas. There is usually a common dining area where

patients can eat at tables seating two to four people. Day rooms are

common--large areas with comfortable chairs and couches, a television,

stereo, books, and games.

If you were admitted to a hospital unit specializing in psychiatric

care, you would probably see a psychologist or psychiatrist two or

three times a week in individual sessions. It is likely, since your

condition was serious enough to warrant hospitalization, that you will

receive medication during at least part of your stay (see Chapter 16).

If you are a voluntary admission, you will be asked to sign consent

forms for treatment that is recommended to you. You do have a right to

refuse treatment you do not want.

A complete physical examination is routinely required to rule out

underlying physical disorders. You may also be asked to take some

written psychological tests, most being of the multiple-choice variety.

Group sessions in hospitals are common. In forming groups attempts are

made to choose people in ways that will be mutually beneficial. In

part, these periods "in group" help to offset feelings of being alone

in a strange environment.

Activities are planned to combat monotony. They may, for example,

include arts and crafts, sports, dancing, and day trips to museums or

the movies.

Staff members with whom you would have the most personal contact are

members of the psychiatric nursing staff. Often, when former patients

are asked who helped them while in the hospital, instead of mentioning

the therapist, they name a {255} member of the nursing staff.

Psychiatric nurses have received special training in psychiatry and

often are a major source of human warmth and caring.

Depending on your progress, you may be encouraged to return home during

the day, or overnight, or for a weekend. As it becomes clear that you

are improving, these periods may be lengthened to see how you handle

the transition from the hospital, before being discharged.

Although hospitals expect patients to choose to remain until they are

discharged, few hospitals actively confine voluntary psychiatric

patients to prevent them from leaving early--and then generally only in

cases judged to be very serious. The only restrictions and rules you

would likely encounter are those of any hospital: to respect the rights

of others, to be considerate, to refrain from taking drugs unless they

are prescribed, to smoke only in smoking areas, and to maintain

socially acceptable behavior.

Inpatient hospital programs specializing in stress management,

depression, eating disorders, and so on, are normally intended for one-

to two-week stays. Residential treatment centers for problems

requiring longer treatment--e.g., drug and alcohol rehabilitation

programs--are less formal than hospitals. Often, residential treatment

centers are located in the country and may consist of a cluster of

cottage-like buildings. The program is usually under the direction of

a psychiatrist.

Hospital care and residential treatment are very expensive. Most

health insurance programs cover most of the costs of inpatient

psychiatric hospitalization, for several weeks or months. Public

psychiatric hospitals must be relied on by many people for longer

stays, unless they bear the costs of private hospital treatment

themselves. Physical conditions at state psychiatric hospitals have in

general improved in recent years but still tend to fall short of

private facilities, for lack of adequate public funding.

LEAVING

Probably the most difficult experience if you are hospitalized for a

psychiatric condition is leaving, not entering, the hospital. There is

frequently a sense of relief and comfort that comes once you have made

the decision to enter a hospital. You have a {256} "legitimate" reason

for leaving your normal responsibilities; you may feel "rescued" from

family or work situations you could no longer cope with. Once you have

begun to feel more at home in the hospital setting, you begin to relax,

to participate in activities with less restraint or reluctance. Then,

as you improve, thanks in great part to the concentrated attention and

care you are receiving, you realize that you must begin to think of

reentering life "outside."

Returning to your familiar life can be frightening. It is usual to

wonder whether it will, perhaps again, prove to be too much of a

strain. Leaving the hospital frequently means returning home or going

back to work, to shoulder the same burdens again, trying to pick up

where you left off.

Hospitalization is often a positive, reassuring experience. Patients

become aware that others do care and that, if life becomes especially

stressful, there _are_ sources of professional help and encouragement

available to fall back on. Most hospitals encourage former patients to

maintain contact through follow-up services of some kind. Leaving the

hospital is made easier for many people, for example, knowing that the

psychologist or psychiatrist is still there and that they will be seen

on an outpatient basis. To help former hospital patients ease back

into more normal lives, groups that were formed in the hospital

sometimes will also continue to meet on an outpatient basis for a time.

The decision to be hospitalized is difficult for anyone. Hospital care

may help turn your life around and put you back on your feet. Or it

can, if you are your own worst critic, give you another burden to

carry. It is important to try not to block potentially helpful

treatment with excessive pride and to try to listen to people who care

about you. If they are in favor of the decision, their convictions

should be considered. If your doctor or minister agrees, this adds

weight to their advice. Once you have listened, try to make your

decision your own, not anyone else's.

{257}

CONFIDENTIALITY

Your Privacy

THE NEGATIVE LABEL OF EMOTIONAL ILLNESS

Society has attached an undeniable stigma to so-called emotional or

mental illness. The public is afraid of conditions that are not

concrete and physical and are less easily understood. Emotional or

mental difficulties seem more "hidden" and mysterious. The body is

_tangible_, and we feel we have more control over it. Setting a broken

leg, having your appendix removed, even open-heart surgery--they are

not difficult for the public to grasp.

However, depression, anxiety, intolerance to stress, disorientation,

unsettling fears, unusual behavior--these are much less readily

understood by nonspecialists. There is a tendency for many people to

judge rather harshly what they do not comprehend. When many

individuals who are ignorant of psychology hear of someone in emotional

distress, the inclination is often to condemn. Condemnation is

frequently an expression of fear--fear of what is not understood.

During the last two to three decades, society has gradually become more

psychologically aware and more intelligent about nonphysical problems.

And yet, the stigma of emotional or mental illness has still not been

erased. It will take time.

{258}

As a result, many people who are in serious emotional distress hesitate

to go to a therapist. They are afraid of the negative label that

others may apply to them, if information about them ever "got out."

Sometimes this is a justifiable worry. Some employers are bigoted and

may discriminate against employees with known emotional problems (even

though this is blatantly illegal). And some families, in which there

is little psychological understanding and much fear, may withdraw from

a family member who lets it be known that he or she is in emotional

distress.

On the other hand, most people like to feel that they have a certain

degree of compassion and openness--even those who are judgmental! If

you are willing to face ignorant attitudes head-on, unflinchingly (and

this can take a great deal of courage), you will frequently gain the

respect of others through your honesty. They will perceive your

unwillingness to judge yourself negatively and may even come to admire

the strength and determination you have to improve your life.

If you are in emotional distress, you may have to face a dilemma:

whether it is _prudent_ to try to conceal your difficulties from people

because you believe that some of them may judge you harshly and

critically if they find out you are in therapy, or whether it is likely

that they would understand, and perhaps even sympathize, if you were

able to be open and had the courage and self-confidence to help educate

others on a psychological level. Unfortunately, people in real

emotional distress don't have the energy, the courage, or the

self-confidence to fight social battles! It therefore usually seems to

be a great deal easier to try to keep your own affairs _private_. But

this is not always simple to do.

THE CONFIDENTIALITY OF PSYCHOTHERAPY

Confidentiality as it relates to counseling and psychotherapy is not a

straightforward thing; much that has to do with confidentiality is

still an unsettled and still debated issue. In reality, there are as

yet few laws that fully and genuinely protect personal privacy.

There are two central questions relating to confidentiality that I want

to raise here. The first is a question only you can answer. I will

try to discuss some of the answers to the second.

{259}

HOW IMPORTANT IS CONFIDENTIALITY TO YOU?

Only you can answer this. It may be reassuring to know that, usually,

the safeguards observed by therapists are sufficient to protect the

personal affairs of clients. And it is unusual for any real or lasting

harm come to a client if information about him or her is released.

Many individuals, when they are trapped in a prison of self-concern and

self-involvement, are prone to exaggerate or magnify the ultimate

significance of being "discovered" in therapy, believing that a release

of information about them will be potentially explosive and damaging.

Individuals who are emotionally very upset are inclined to focus on

threatening aspects of therapy.

We have already looked at some of the ways that a heightened

sensitivity to maintain secrecy about your problems can lead to

self-imprisonment, to blocks that stand in the way of positive change

(see Chapter 1). Most of the information you may want kept secret may

not really be as damaging as you first were inclined to think. Much

depends on how _you_ respond to information that might be released

about you. Let's look at an example.

A little more than a year ago, George Malcolm became seriously

depressed. He was forced to resign from his job, and then he received

disability income for ten months. During this time he entered therapy.

His experience helped him to understand a number of important things

about himself that he had ignored in the past. He discovered that he

had felt very unsatisfied in his previous job; he had buried his

frustrations and had suppressed the anger he felt at being trapped in a

situation he disliked. It was a situation he felt he had no control

over because of his concern for his and his family's financial

security. He was also worried about his mother, who would probably

have to be admitted to a nursing home in the near future. Her

situation was an added reason for George's financial worry.

He also came to realize that his marriage was suffering because of his

insistence that his wife not work. She, on the other hand, felt

overcontrolled by her husband: she felt that he stood in the way of her

personal growth.

As a result of his increased awareness, George came to see that losing

his former job was really a blessing in disguise. His marriage began

to improve when George's depression for the {260} first time put him in

a _dependent_ position; he needed his wife's emotional support, and

she, in turn, began to see him as a _person_, with weaknesses of his

own, and not as she had idealized him.

George's depression allowed him to understand and appreciate his wife's

previously frustrated sense of initiative. He now encouraged her to do

what she had long wanted to do, to develop a career.

Because George received disability during his depression, his insurance

company had information about him on file. When George was interviewed

for a new job a year after he became depressed, he was asked at the

interview if he had been ill during the preceding year, when he had not

worked.

George decided to be truthful and said that he had become depressed and

that as a result of the experience had learned much about himself. In

particular, he had learned what kind of work really interested him and

gave him a sense of satisfaction. Although it had been a difficult

period, George said that he felt he had gained a great deal from the

experience.

George's prospective employer was impressed by George's honesty and

evident sincerity. George got the job--in large part because of the

attitude he took toward his depression.

WHAT LAWS PROTECT CONFIDENTIALITY?

To what extent is your privacy protected? What situations legally

justify your therapist to release information about you?[1]

[1] Since the first edition of this book, the Health Insurance

Portability and Accountability Act (HIPAA) was passed in 1996, bringing

with it a mass of complexities relating to patient privacy. There

remain many still unsettled legal questions and issues relating to the

so-called Privacy Rule, which there is not space here to discuss. If

you wish to know more about the legal status and interpretation of

patient privacy, see Wikipedia's article about HIPAA at:

http://en.wikipedia.org/wiki/HIPAA.

These questions do not always have clear-cut answers. There may or may

not be special laws in your state to protect the confidentiality of

psychotherapy. The legal status of therapy is still ambiguous in many

states. Even in those where laws have been passed, legal protection is

sometimes not reliable unless your therapist is willing to face a jail

sentence if need be to maintain the confidence you have entrusted in

him. If you feel a situation is likely to arise that would put legal

pressure on your therapist to release information about you (for

example, in a child-custody hearing), you should ask your therapist

what his or her commitments to confidentiality are.

"_Leaks_"

More frequently, confidentiality is broken due to informality {261}

rather than due to an intentional release of information. For example,

if you are referred to another therapist or to a physician, the chances

are that information about you will be shared by your original

therapist with the new therapist or doctor. You can ask your therapist

_not_ to release information in this way, but if you do, the care you

receive as a result of the referral cannot benefit from your first

therapist's understanding of you. On the other hand, if you do permit

your file to be shared with a new therapist or doctor, you will

probably not know in advance know what his or her own policies about

confidentiality are.

There is a second way that information about you may be released.

Often, therapists discuss information about their clients with

colleagues in an effort to provide better help for them. It is often

to your definite advantage to have other therapists share their

assessments and ideas with your therapist. But if you ask your

therapist to refrain from discussing your case with professional

colleagues, he or she will very likely agree to cooperate with you.

If you believe you have special reasons to be concerned about

protecting the confidentiality of your relationship with your

therapist, it will help him or her to know this, and it may be possible

to request that special precautions be taken to protect your file from

access by others.

Accidental or inadvertent breaks of confidentiality sometimes can also

occur. For example, billings may be mailed to your address and then be

opened by a spouse, child, or parent whom you may not have wanted told

that you were in therapy.

Here is another example: If you enter group therapy, other members of

the group are not professionally bound by rules governing

confidentiality. Because they are not counseling {262} professionals

themselves, they will be less attentive to matters involving

confidentiality--although most group therapists try, when a group is

first formed, to get group members to agree not to disclose privileged

information outside of sessions.

_Exceptions_

Beyond the kinds of possible breaks of confidentiality that are due to

inattention, informality, and access of information about you by

others, there are a number of legal exceptions to confidentiality.

Examination by court order is one. If a judge orders you to be

examined by a psychiatrist or psychologist, his findings will be

transmitted to the court and so be made public.

If a client reveals his or her intention and decision to commit a

crime, a therapist is legally required to report this to authorities.

If a patient plans to commit homicide, therapists are required by law

to take whatever action is necessary to prevent the murder. In

California, in addition to warning the police of the homicidal

intentions of a client, therapists must also take steps to warn the

intended victim, if this is possible.

If a patient is seriously suicidal--that is, has decided on a means to

commit suicide, has decided when to do this, and cannot be persuaded to

hold off while in therapy--the therapist is legally bound to take

whatever action may be necessary to prevent the patient's suicide,

including the disclosure of pertinent information to public officials.

Similarly, in cases of child abuse or neglect, the law requires that a

client's confidential relationship with his or her therapist be set to

one side in order to provide adequate protection and care for the child.

THREATS TO PRIVACY FROM

HEALTH INSURANCE COMPANIES

There is another way that privacy can be invaded, and for many people

it is little known and more significant than the breaks of

confidentiality we have already discussed. It comes about as a result

of recently formed _data banks_ that are maintained and continuously

updated by insurance companies. Information about insurance claims and

payments not only are kept on file by individual insurance companies,

but a number of national data banks have been established to provide

insurance {263} companies with information about the health histories

of individuals.

For example, if you file a health insurance application or a claim for

benefits with many insurance companies, they often will run a check on

your health history through a national computerized clearinghouse that

maintains insurance information. This information includes data about

previous insurance claims you may have made. Insurance companies

believe that they have a right to data of this kind, since the

information protects them from having to pay for health care costs that

come about due to "preexisting conditions," which many insurance

policies limit or exclude. Too, if you have suffered from poor health

in the past, and were covered by insurance, there are probably data

about your health history on file in such a national computerized

clearinghouse; by accessing information about you, an insurance company

is able to form a judgment as to whether you are an excessive risk.

Like any information about you that has been compiled and is furnished

without your consent, these data about your health history--maintained

by agencies that service insurance companies--are subject to possible

abuse. Information on file can and is used to protect the interests of

subscribing insurance companies; your own interests may not be served

in the process. Not only might you be denied future insurance

benefits, but the information maintained about you is subject to

whatever use the insurance clearinghouse believes is appropriate.

As yet, laws to secure a true measure of personal privacy have not been

passed. This has been one of the goals of organizations like the

American Civil Liberties Union.

There is a second insurance-related issue that has to do with

confidentiality. If you have group health insurance through your

employer, it will be necessary for your therapist to complete reports

about you in order for you to receive benefits under your insurance

plan. (I am assuming here that your insurance offers coverage for

counseling, psychotherapy, or psychiatry.) The reports filed by your

therapist with the group health insurance company are sometimes filed

_through your employer_, and sometimes employers require their group

health companies to provide _them_ with information about health care

supplied to their employees. In either way, the fact that you are in

therapy and the general reasons for your need for therapy may come to

the attention of your employer.

{264}

If your employer is a large company or organization, such information

will probably be filed in your employer's business or insurance office

and laid to rest; it will probably not come to the attention of

individuals you actually deal with in your work. But it may. In a

smaller company, there is a greater risk.

If you are really concerned about this possibility, ask your insurance

officer how health claims are handled and whether health information is

requested by your employer from the insurance company.

If you are then still concerned and feel that you need to avoid

potential complications at work, you may prefer to see a therapist on

your own _and refrain from using your employer's insurance coverage_.

If you see a therapist in private practice, your decision to pay your

own bill may be expensive for you. If finances are a problem, bear in

mind that you can frequently locate competent help through county,

state, or private counseling agencies. If you go to an agency,

remember that you will almost certainly be asked whether you have

insurance coverage. If you admit that you do, you will have defeated

your purpose in going to an agency on your own to protect your privacy.

It is, after all, your right to obtain treatment that _you_ elect to

pay for.

MAGNIFYING YOUR NEED FOR SECRECY

After reviewing these ways in which confidentiality may be broken--by

accident or sometimes excessive informality, by legal requirements, or

by what to many of us constitutes an invasion of personal privacy by

insurance companies--you may wonder to what extent information that you

disclose in therapy really _is_ protected.

In fact, very seldom are the _details_ of therapy divulged to others

without a client's advance consent. Most of us do not need to be

worried by legal exceptions to confidentiality: most of us are not

actually homicidal (though we may feel very angry at times!); most of

us are not determined to take our lives (though we may at times feel

very disheartened); most of us are not concerned that a court will

order us to be examined by a psychiatrist.

I have tried to give a realistic picture of confidentiality in therapy.

The fact that you receive mental health counseling or therapy may

inadvertently be disclosed by such things as a billing that goes astray

or {265} by a fellow group member's inclination to talk too much

outside of the group. If you decide to make use of insurance coverage,

there are possible consequences you ought to be aware of.

I have tried to underline the fact that most people who enter therapy

blow out of proportion the real significance of these possible, but

comparatively infrequent, "leaks."

Karl A. Menninger, a renowned and original contributor to psychiatry,

quotes one of his patients who shared her intelligent reflections with

him:

"When I look back upon the many months I pondered as to how I might

get here without anyone knowing, and the devious routes I

considered and actually took to accomplish this, only to realize

that some of the symptoms from which I suffer are respectable

enough to be acknowledged anywhere and valid enough to explain my

coming here, it all seems so utterly ridiculous. I looked

furtively out of the corner of my eye at the people I met here,

expecting them to betray their shame or their queerness, only to

discover that I often could not distinguish the patients from the

physicians, or from other visitors. I suppose it is such a

commonplace experience to you that you cannot realize how startling

that is to a naive layman, like myself, even one who thinks he has

read a little and laid aside some of the provincialism and

prejudice which to some extent blind us all. I see how there is

something emotional in it; if the patient feels only depressed or

guilty or confused, then one looks upon his consulting the

psychiatrist as a disgraceful recourse; but if some of the symptoms

take form in one of the bodily organs, all the shame vanishes.

There is no sense to it, but that's how it is. I have written a

dozen letters to tell people where I am, the very people from whom

in the past six months I have tried to conceal my need of this."[2]

[2] Karl A. Menninger, _Man Against Himself_ (New York: Harcourt, Brace

and Company, 1938), pp. 455-456.

DON'T LET EXAGGERATED WORRIES HOLD YOU BACK

When you stop for a moment to consider how widespread personal problems

are--20 percent of Americans have serious emotional difficulties--isn't

there something silly, ridiculous, and, frequently, self-defeating in

being overly concerned about {266} keeping others from knowing that,

for a time, you were depressed, anxious, unsatisfied, and frustrated to

the point that you _decided_ to do something about these unhappy

feelings?

To be sure, discretion is sometimes prudent. An employer, your family,

or some of your friends may be so provincial or bigoted as to think

that counseling is close to a misdemeanor. Ignorant or uninformed

people do tend to judge hastily and to condemn. But often, if you do

have the endurance, many of them are also willing to change their minds

when they have the opportunity to understand a little bit about what

they fear.

You cannot live for the approval of others. If you believe therapy may

help you improve your life, don't allow yourself to be held back by

exaggerated worries.

It usually _is_ possible to keep confidential the fact that you have

entered therapy when there are especially compelling reasons to

exercise foresight and caution. _Explain_ your concerns to your

therapist; he or she can then make every effort to help you.

{267}

DOES THERAPY WORK?

Whether or not therapy works is a question that has hounded

psychotherapists for more than thirty years, when evaluative studies

began to cast doubts on its effectiveness. Since then, several hundred

studies of the effectiveness of psychotherapy have been made. Some of

them appear to show that psychotherapy is highly successful, and many

have pointed to evidence that psychotherapy is no more effective than

no treatment at all.

The ambiguity about this issue has been very troublesome to therapists

and tends not to be openly discussed with clients, for obvious reasons.

Why reports about psychotherapy's effectiveness have been so

contradictory and ambiguous has never been made clear. But

understanding the reasons behind these opposing claims will give us a

basis for optimism.

CLAIMS AGAINST THE EFFECTIVENESS OF PSYCHOTHERAPY

If people who are emotionally troubled "get well" through psychotherapy

in about the same length of time as those who are not given any

treatment at all, we would be inclined to say that {268} psychotherapy

didn't help. Several studies have shown that the majority of people

with "neurotic disorders" improve spontaneously, on the average, in one

to two years.[1] When people with similar problems _are_ treated with

psychotherapy, the outcome is virtually the same: the spontaneous

remission rate for all practical purposes is the same as the rate of

success due to therapy. Psychotherapy doesn't seem to make a

difference. We'll call this the _spontaneous remission criticism_ and

will come back to it in a moment.

[1] S. Rachman, _The Effects of Psychotherapy_ (New York: Pergamon

Press, 1971) p. 18.

Most studies of the effectiveness of psychotherapy make use of "placebo

treatments": a group of emotionally troubled individuals is treated

with one of the major approaches to psychotherapy by well-trained

therapists, and another group of similarly troubled people is treated

by untrained "therapists" who offer their clients a "therapy" that is

simply _made up_ but is carefully presented so as to be believable.

And, again, it turns out that clients treated with the legitimate

therapy improve, but not significantly more than those in the placebo

group. We'll call this the _placebo criticism_ and will come back to

it, too, in a moment.

A few studies have shown that psychotherapy can actually be _injurious_

to clients. A disorder _brought about_ by medical treatment is called

an _iatrogenic disturbance_. _Iatrogenesis_ is the Greek word for

"brought about by doctors." If the iatrogenesis criticism is valid,

then therapy may be not only ineffective but sometimes actually

_harmful_.[2]

[2] See, for example, Thomas J. Nardi, "Psychotherapy: Cui Bono?," in

Jusuf Hariman, ed., _Does Psychotherapy Really Help People?_

(Springfield, IL: Charles C. Thomas, 1984), pp. 154-164.

Together, these three criticisms have made therapists feel very

defensive--and rightly so. If fictitious treatment by a mock therapist

works as well as treatment provided by a man or woman who has trained

long and hard for a Ph.D. or M.D., wouldn't _you_ feel ill at

ease--perhaps very much ill at ease!--charging your clients $75 to $100

an hour for your time for a service that is no better than none at all

and may even cause your clients to get worse?

These are not trumped-up charges against psychotherapy that we can

afford to ignore. Therapists don't like to confront them. Here are

some of the results of research studies:

{269}

... [A]s compared with spontaneous remission, there is no good

evidence to suggest that psychotherapy and psychoanalysis have

effects that are in any way superior.[3]

[3] Hans J. Eysenck, "The Battle over Therapeutic Effectiveness," in J.

Hariman, ed., _Does Psychotherapy Really Help People?_, p. 59.

... [M]ost of the verbal psychotherapies have an effect size that

is only marginally greater than the effect size for ... a "placebo

treatment."[4]

[4] Edward Erwin, "Is Psychotherapy More Effective Than a Placebo?," in

_Does Psychotherapy Really Help People?_, p. 39.

Most writers ... agree that the therapeutic claims made for

psychotherapy range from the abysmally low to the astonishingly

high and, furthermore, they would tend to agree that on the average

psychotherapy appears to produce approximately the same amount of

improvement as can be observed in patients who have not received

this type of treatment.[5]

[5] Rachman, _The Effects of Psychotherapy_, p. 84.

... [U]sing placebo treatment as a proper control (which it

undoubtedly is), we find that the alleged effectiveness of

psychodynamic therapy [i.e., psychoanalysis] vanishes almost

completely.[6]

[6] Eysenck, "The Battle over Therapeutic Effectiveness," p. 56.

There is still no acceptable evidence to support the view that

psychoanalytic treatment is effective.[7]

[7] Rachman, _The Effects of Psychotherapy_, p. 63.

... [T]here is no relationship between duration of therapy and

effectiveness of therapy.[8]

[8] Eysenck, "The Battle over Therapeutic Effectiveness," p. 57.

Psychotherapy of any kind applies techniques that are based on

certain theories, and these theories demand not only that there

should be correlation between success and length of treatment, but

also that the training and experience of the therapist should be

extremely important. To find that neither of these corollaries is

in fact borne out must be an absolute death blow to any claims to

have demonstrated the effectiveness of psychotherapy.[9]

[9] _Ibid._

The pessimism produced by these conclusions was summed up by Hans J.

Eysenck, professor at the Institute of Psychiatry in London:

{270}

I have always felt that it is completely unethical to subject

neurotic patients to a treatment the efficacy of which has not been

proven, and indeed, the efficacy of which is very much in doubt--so

much so that there is no good evidence for it, in spite of hundreds

of studies devoted to the question. Patients are asked to spend

money and time they can ill afford, and subject themselves to a

gruelling experience, to no good purpose at all; this surely cannot

be right. At least there should be a statutory warning to the

effect that the treatment they are proposing to enter has never

been shown to be effective, is very lengthy and costly, and may

indeed do harm to the patient.[10]

[10] Eysenck, "The Battle over Therapeutic Effectiveness," in _Does

Psychotherapy Really Help People?_, p. 59.

WHY PESSIMISM IS UNFOUNDED

I hold all contemporary psychiatric approaches--all "mental-health"

methods--as basically flawed because they all search for solutions

along medical-technical lines. But solutions for what? For life!

But life is not a problem to be solved. Life is something to be

lived, as intelligently, as competently, as well as we can, day in

and day out. Life is something we must endure. There is no

solution for it.[11]

[11] Thomas Szasz, interviewed in Jonathan Miller, _States of Mind_

(New York: Pantheon Books, 1983), p. 290.

We must grab the bull by the horns. Thousands upon thousands of people

continue to enter psychotherapy. How long would any service last if it

failed to serve the needs of its market? It is tempting to suppose

that something constructive, at least sometimes, happens as a result of

psychotherapy to justify the time, expense, and faith of clients. Or

is their faith really misplaced?

One of the most outspoken critics of psychotherapy is psychiatrist

Thomas Szasz. His views are an unlikely source for a defense of

psychotherapy, but its defense, oddly enough, can be found there.

Szasz argues that psychology has been influenced by the disease model

that dominates medicine. Medicine bases its conception of treatment on

the fact that there are diseases (or {271} injuries) that can be helped

by means of drugs or surgery. Illnesses and injuries are _treatable

conditions_. Treatment is applied from outside by the physician, and

the condition, when the treatment is effective, improves.

But psychiatry goes a step too far when it claims that people who

become emotionally helpless, hopeless, lonely, or agitated are actually

_sick_. Szasz claims that they are not sick; they are helpless,

hopeless, lonely, or agitated. These are not "illnesses" but, rather,

some of the tragic conditions of life. They are _problems of living_.

For Szasz--and for therapists like Viktor Frankl and Alfred

Adler--psychological problems resemble "moral problems" much more than

they do "physical diseases." They involve discouragement, loss of

morale, loss of moral courage. They are _states of demoralization_.

Now, demoralization is not a _treatable condition_--not, certainly, in

the medical sense. You cannot apply treatment from without and expect

that the patient will get better. The situation is much more complex

than this. The patient--let's shift at this point to calling him or

her the _client_--is much more actively involved in the process of

psychotherapy than is a _patient_ in medicine. A woman who contracts

pneumonia can be cured with antibiotics while she lies in bed watching

television or sleeping. But an emotionally troubled woman--who has had

a succession of unhappy marriages, who has lost job after job, whose

personality is offensive to others, who has a low sense of self-worth,

and who has lost a sense of meaning and direction in life--cannot be

cured while she lies in bed and is treated with appropriate medication.

"Effective treatment" just isn't possible; too much is up to the client

herself.

Basically, this is why studies of the effectiveness of psychotherapy

have generally led to discouraging results. Most psychological

conditions (there are exceptions, as we will see) are not, at least at

present, _treatable in the medical sense_. To combat them requires of

the client a great deal of his or her own effort and even exertion.

They require self-discipline, moral courage, faith in oneself--all the

things emotional distress tends to undermine. No approach to

psychotherapy can itself be medically effective in treating conditions

like these. Somehow, the client must reach a point where he can lift

himself by the bootstraps. He can be _encouraged_ by the therapist, he

can be _reasoned with_, he can be {272} _manipulated in strategic

therapeutic ways_, the therapist can exhort him to be rational, but the

focus always comes back to the client. Is he or she motivated to learn

how to change? Is he or she an "effective learner"--that is, a "good

student"?

The hundreds of attempts to evaluate the effectiveness of approaches to

psychotherapy have, incredibly, left out this essential reference to

the clients themselves: What kind of people are they? What encourages

_them_? What can act as a source for their motivation, for the

strength they have lost?

Ironically, the answer to these questions also lies unwittingly in the

hands of psychotherapy's harshest critics.

The worst blow to fall on the shoulders of psychotherapists was dealt

by placebo studies. Experiments were designed that would _convince_ a

group of emotionally troubled clients that taking a pink pill (in

reality, a sugar-filled placebo) would reduce their symptoms. In fact,

their symptoms were, in general, reduced, and often by as much as

treatment in formal psychotherapy. This fact has been interpreted by

most therapists to mean that psychotherapy must therefore have been

ineffective. If a pink and useless pill could equal the effects of

therapy, then therapy was equally useless.

But this involved a huge oversight and a mistake in logic. The therapy

_did_ work, _as did_ the placebo. But why?

The placebo effect has become increasingly interesting to psychological

as well as medical researchers. Apparently, a client's or patient's

strong _belief_ in the therapeutic value of a process sometimes has a

measurable influence on his future health. The way belief can act in

this way is not necessarily mysterious or mystical. If we are prepared

to see emotional difficulties in terms of demoralization, then belief

in therapeutic effectiveness is the most clear-cut counterbalancing

force. Strong belief of this kind may be enough--_if_ the client

really wishes to change and _if_ the therapist and the approach to

therapy together can inspire the client's confidence in his own ability

to regain control of his life--to help the client begin to lift himself

by the bootstraps. Just what the necessary ingredients are to make

this possible is not yet definitely known. Some approaches to therapy,

however, seem to be more successful than others in inspiring confidence

in clients with certain personality traits and with certain goals or

problems. The best evidence for this comes from clients themselves,

whose evaluations {273} of their own experiences in therapy we will

look at in a moment.

The second blow that fell on psychotherapy came from the spontaneous

remission critics. Again, studies demonstrated certain facts:

* How long it takes for spontaneous remission to occur depends greatly

on what sorts of emotional difficulties clients have. People with

depressive or anxiety reactions tend, for example, to have spontaneous

remissions faster than persons with obsessive-compulsive or

hypochondriacal symptoms.

* The percentages of clients who do experience spontaneous remissions

are related to the period of time a study uses as a basis. (The

follow-up periods of different studies vary a great deal, from months

to many years. As one researcher commented, "It is doubtful whether

life can guarantee five years of stability to any person."[12])

[12] Eisenbud, quoted in H. H. Mosak, "Problems in the Definition and

Measurement of Success in Psychotherapy," in Werner Wolff and Joseph A.

Precker, eds., _Success in Psychotherapy_ (New York: Grime & Stratton,

1952), p. 13.

* Spontaneous remissions frequently happen to clients whose lives

improve because of fortunate events, such as an improved position at

work, successful marriages and personal relationships, and periods

during which pressing problems become fewer and life more stable.

Given these facts, spontaneous remission critics argued that, since

many troubled individuals will get better anyway, _without

psychotherapy_, we cannot know that psychotherapy caused any beneficial

effects.

Again, poor logic. It is like saying that since certain bone fractures

will eventually heal themselves in correct alignment, without being set

in a cast, we cannot know for these cases that a cast had any

beneficial effects. Well, for many people, a suitable psychotherapy

serves much the same function as a cast does for a broken bone: it

supports, lessens vulnerability, reduces pain, and makes life a little

more comfortable until natural healing can take place. Again, whom do

we ask to determine whether this is the case? We must ask the person

with the fractured arm whether the cast made him or her more

comfortable.

{274}

HOW PSYCHOTHERAPY CAN BE INJURIOUS TO YOUR HEALTH

/#] Is there substantial evidence that psychotherapists sometimes harm,

as well as benefit, their clients? I think that there definitely is

and that this has been fairly well demonstrated.[13]

[13] Albert Ellis, "Must Most Psychotherapists Remain as Incompetent as

They Now Are?," in J. Hariman, ed., _Does Psychotherapy Really Help

People?_, p. 240.

Even love can harm, and psychotherapy is no exception. Ellis

identifies some of the main ways psychotherapists can make clients

worse:[14]

[14] _Ibid._, pp. 24-36.

* Therapists may encourage clients to be dependent on them. Directly

or indirectly a therapist can convey to a client, "You cannot get along

without me," "You will probably need to spend at least two more years

in therapy," etc.

* Therapists may overemphasize the significance of the client's past

experience to the point that they persuade the client to feel

unjustifiably weighed down and controlled by past events and

circumstances.

* Therapists may become so hooked on the importance of modeling

positive personal qualities (warmth, positive regard, congruence,

empathy) for a client that they will not provide any active-directive

leadership during a time when the client is floundering and needs

strong recommendations.

* Therapists may place too much importance on the role of insight. The

search for insight can be never-ending. It is useful only to some

clients; for others, insight is irrelevant to helping them change.

* Many therapists feel that therapy gives clients a chance to vent

their feelings. But catharsis by itself is not enough to replace

destructive patterns of behavior and thinking with constructive ones.

* Therapists may rely excessively on distracting the client from issues

that trouble him; e.g., relaxation training, meditation, or therapeutic

exercise can help clients break out of a cycle of self-preoccupation.

Self-absorption {275} perpetuates emotional suffering; distractions can

therefore be invaluable. But if a client's underlying self-defeating

attitudes are not confronted, distraction alone will not be enough to

bring about lasting change.

* Therapists may rely too heavily on getting clients to "think

positively." Positive thinking can undermine a client's already shaky

confidence if he fails to achieve the goals that positive thinking led

him to expect.

These are undeniable shortcomings of therapy. They can reduce the

effectiveness of therapy, or negate its constructive effects, or even

cause clients to accept the therapist's belief that their condition is

worse than they thought and so persuade them to feel, and to be, even

more troubled.

It is important to be aware of these signs of what Ellis rightly calls

incompetence in therapists. It is also important to realize that

psychotherapy is not unique in having to deal with professional

incompetence. Physicians can and do fall victim to many of the same

excesses: needlessly alarming patients, misdiagnosing their conditions,

and sometimes treating them in ways that lead to a general worsening of

their health. Iatrogenesis exists in medicine as well as in

psychotherapy.

Until the day when the world is a perfect place, we simply have to take

_caveat emptor_ to heart--let the buyer beware. A Ph.D. in clinical

psychology, certification in marriage and family counseling, or an M.D.

with specialization in psychiatry unfortunately does not guarantee

against human fallibility and lack of wisdom.

WHEN PSYCHOTHERAPY IS SUCCESSFUL

It might be argued, then, that the worth of psychotherapy to the

consumer (the client) does not depend on its being superior to a

placebo. Whether it is or is not superior is a theoretical question of

interest to theoreticians; in judging the practical worth of

psychotherapy, what matters is consumer satisfaction. Judged by the

latter criterion, psychotherapy is indeed worthwhile.[15]

[15] Edward Erwin, "Is Psychotherapy More Effective Than a Placebo?,"

in J. Hariman, ed., _Does Psychotherapy Really Help People?_, p. 48.

{276}

There is a world of difference between popularity and effectiveness.

Is psychotherapy only popular and simply ineffective?

All approaches to therapy have a built-in expectation that positive

change will result. This belief implicitly is communicated to clients,

and it can provide them with a sense of hope that replaces the helpless

and demoralized state that has motivated them to seek therapy.

This happens in several ways. For example, paying attention to a

person increases his morale and self-esteem. This is called the

_Hawthorne effect_. "Anyone who has been in therapy can appreciate the

gratification that comes from having a competent professional give

undivided attention for an hour."[16] Also, the expectation on the

part of a therapist that positive results will follow itself can

influence a client's attitudes and his belief that he will get better,

that emotional suffering will lessen and end.

[16] James O. Prochaska, _Systems of Psychotherapy: A Transtheoretical

Analysis_ (Homewood, IL: The Dorsey Press, 1979), p. 5.

The strength of a client's _belief_ that he _can_ change, that he _can_

improve, is the major single force in psychotherapy. The client has to

feel that his belief is _warranted_. Many factors play a role here:

the client's education level and the respect he may feel toward the

therapist's training and experience; the intangibles of therapy--the

therapist's integrity, authenticity or convincingness, the client's

sense that he is understood, that the therapist cares, that the

therapist himself has learned how to cope with living and can

communicate this, etc. Psychotherapy can be successful when this sense

of _promise_ is present in therapy sessions.

CLIENTS LOOK BACK

I know myself better than any doctor can.

Ovid

If most emotional difficulties are not illnesses at all but problems of

living, and if problems of living cannot be treated medically, then the

hundreds of evaluative studies of therapeutic effectiveness have been

looking for something that simply is not there: an objective standard

against which to judge therapeutic {277} success. It makes very little

sense to speak of standards in connection with problems of living that

come about from demoralization. The only standard we can reasonably

appeal to is the subjective judgment of clients themselves, who have

experienced periods in therapy.

[Therapy] is a purely individual affair and can be measured only in

terms of its meaning to the person, child, or adult, of its value,

not for happiness, not for virtue, not for social adjustment but

for growth and development in terms of a purely individual norm.[17]

[17] J. Taft, _The Dynamics of Therapy in a Controlled Relationship_

(New York: Macmillan, 1933), quoted in H. H. Mosak, "Problems in the

Definition and Measurement of Success in Psychotherapy," in Wolff and

Precker, eds., _Success in Psychotherapy_, p. 7.

A few representative and specific evaluations of their experiences in

psychotherapy by former clients follow. They are included here not as

proof of the effectiveness of psychotherapy, because to search for

objective proof in this area is a mistake, but rather as illustrations

of different ways people believe themselves to have been helped:[18]

[18] Most evaluative studies of psychotherapy have attempted in some

way to take into account the judgment of clients. One study in

particular, however, has made clients' evaluations of their experiences

in therapy its main focus, in fact, for a book-length treatment. That

is Hans H. Strupp, Ronald E. Fox, and Ken Lessler, _Patients View Their

Psychotherapy_ (Baltimore: Johns Hopkins Press, 1969). Some of the

patient evaluations included here are based on transcripts from the

Strupp-Fox-Lessler study; they have been paraphrased and condensed for

use here.

After being in therapy, I have learned to accept myself more easily

and believe that many of the people whose opinions about me matter

to me also accept me for what I am. I have come to realize that

what I have in my life, in the way of my marriage, my children, my

work is what I have decided to settle with. It is easier and more

satisfying for me to do this than always to be fighting the present

and straining for things I haven't got.

I still have problems with my own self-confidence. I accept some

volunteer work at my church, in spite of these feelings of

self-doubt, believing that I really am mentally capable and feeling

that I can, in time, and with patience, overcome my feelings of

inadequacy.

{278}

I now love my daughter without qualifications. I have much less

hostility toward my mother. I'm much less afraid now to feel

unpleasant emotions and feel less guilt than I did. I'm not afraid

to stand up for myself and say what I feel.

I feel more patient now with myself and with others. I lose my

temper much less often. I enjoy life much more, feel more content

and happy over small things. I'm much more aware now of the

feelings of others.

I didn't like being around people. Now I actually can enjoy their

company. Even parties do not make me nervous like they used to. I

am less inclined to condemn others when they are not like me, and I

find myself offering suggestions and advice less frequently.

The greatest change that therapy has brought me has been to help me

get my confidence again. I have gone through periods of grief

three times since I left therapy, when members of my family have

died. I do not feel I could have maintained a sense of balance

during these times if I had not had the experience of therapy. I

feel I am better able to trust my judgment now and can cope with

living more effectively.

I feel better about myself, though I do often still feel a sense of

guilt. My problems [having to do with a strong father who has

condemned the client because of her style of living and has cut off

relations with her] are still with me, but I feel that I have

learned to face life more squarely and head-on without so much

fear. I'm sure that therapy was the most important part of this

change.

I feel much more able to relate to my fussy and neurotic parents.

Their dark moods and bitterness don't plunge me into the dumps like

they used to. Now, when I do get depressed, instead of just

wanting to give up, I ask myself what it is that has depressed me,

and often I can reason my way out of the negative state I'm in. I

can cope with responsibilities much better now. I have fewer

doubts now about my abilities.

I feel more inner calm and can cope with daily problems more

easily. I have learned that it doesn't pay for me to be a

perfectionist about everything. I still admire my desire for

perfection in some things that are really important to me, but I no

longer fuss with doing a perfect job, for example, patching the

trash can.

{279}

I've accepted myself as a homosexual, and am happy at work, and

feel productive. I am less anxious in relationships with others

now. Although I still feel negative judgment from my family, I no

longer have suicidal thoughts. I realize that I should live in a

way that is true to myself and that others may differ, but I'm OK

myself.

I sometimes will give myself a treat, something I never used to do.

I will buy myself something that maybe is a little bit frivolous,

but I think of this as my own therapy. I feel better about myself

and deny myself less. I was almost a stoical nun before. Now I

care more about myself. I used to think that spending money to

have my hair done was silly and a waste of money. Now I think that

if it makes me feel good about myself, and I want to treat myself

to it, why not?

I used to analyze everything to the point that I didn't enjoy much

and was always asking myself, like the bumper-sticker, am I having

fun yet? Now, I just let some things be. It doesn't pay for me to

question everything all the time. Now, when I don't like a person,

I just accept this. I don't feel guilty because I couldn't see

their better side, and I don't feel hostile just because for me the

person isn't more likable.

WHAT MAKES PSYCHOTHERAPY SUCCESSFUL

_It is not so much the teacher who teaches but

the student who learns._

Whether or not the client gets value for fee paid to a psychotherapist

depends largely on the client.

Don Diespecker in

_Does Psychotherapy Really Help People?_

Psychotherapy is much more like education than it is like medicine. In

education, certain students--no more or less intelligent than

others--will nevertheless be more successful. They have well-known

characteristics: they are interested in what the experience of

education can offer them, and they work hard and regularly.

Very much the same thing holds true in psychotherapy: some clients

simply get more from therapy than others. Why? In part it has to do

with how well matched a client and the approach of the {280} therapist

are. In part it is the amount of confidence the client comes to feel

toward the therapist as a person. Beyond these, the qualities of a

successful client are very similar to those of a successful student.

Specifically, clients who have successful experiences in therapy tend

to share these characteristics:

* While in therapy, they are motivated to change: They feel

considerable internal pressure to do something to resolve their

problems. They come to feel a sense of initiative and determination.

They come to believe in the process of therapy and feel it can be of

help to them.

* They are self-disciplined. They keep appointments regularly, they

attempt to implement the therapist's recommendations, and they are less

incapacitated by their difficulties than other clients with similar

problems.

* They have a level of emotional maturity that is high enough to

withstand some of the painful feelings or frustrations they encounter

in therapy.

* Frequently they come to _enjoy_ therapy.

Obviously, a great deal does depend on the therapist. And yet, while a

good student can learn much in spite of a poor teacher, a poor student

learns little from an excellent teacher. Successful therapy depends

primarily on the client.

Other factors can affect your ability to succeed in therapy, but these

are factors over which you have no control:

* whether you have the emotional support and sympathy of an

understanding and tolerant spouse or family

* whether you have had a long history of emotional problems in

connection with work and interpersonal relations (deeply ingrained

habits are harder to break)

* whether precipitating factors brought about your present difficulties

or they just appeared "out of the blue"

* how long you have had your present problem

* what the problem is: whether it is purely emotional or it has

affected your capacity to think coherently and realistically

* whether there have been fortunate or unfortunate events in your life

before and during therapy

{281}

What the future holds in store for you after therapy relies greatly on

many of these same factors and on many of the personality qualities

that helped you, or hindered you, as a client in therapy (see Chapter

21).

SO, DOES PSYCHOTHERAPY WORK?

Yes, for certain clients and under certain circumstances. The main

changes that psychotherapies aim for are either to eliminate

destructive habits of thought, attitude, or behavior or to establish

new, constructive habits. Neither one can be accomplished by means of

a medically effective treatment that is applied to the patient until a

cure occurs.

A few emotional problems fall under the heading of true psychiatric

disorders and result from physical causes. They include, for example,

epilepsy, drug addiction, and Alzheimer's disease. But these

conditions are in the minority; most emotional "disorders" have not

been traced to underlying organic causes. There are several currently

competing hypotheses relating to possible biochemical bases of

schizophrenia, mania, depression, and anxiety disorders. As time goes

by and medical research progresses, more emotional conditions will very

likely be tied to underlying physical problems.

Until that time, however, they remain _medically_ incurable conditions.

At present, the possibility of overcoming them depends heavily on

clients themselves, their ability to find an approach to therapy that

is appropriate for their personality and their goals or problems, and

their good fortune in locating a therapist who is able to help them to

summon the faith, energy, determination, and courage necessary to

overcome their sense of demoralization.

{282}

LIFE AFTER THERAPY

Theoretically, psychotherapy is never-ending, since emotional

growth can go on as long as one lives.

Lewis R. Wolberg,

_The Technique of Psychotherapy_

It can be difficult to know when to terminate therapy: difficult for

you, the client, and sometimes also difficult for the therapist. Some

periods in therapy do not lead to a successful outcome. You may become

dissatisfied with the process of therapy or with the therapist. Or,

the therapist may become disappointed in your willingness to work and

to change. An impasse may be reached where it seems no progress can be

made. When this happens, it can be hard to know when to draw a line,

to say: "We've tried, but we have to face the fact that we're not

getting anywhere." But sometimes this has to be said, and then you may

decide to look elsewhere for help.

On the other hand, when your therapy has been successful and has led to

clear, constructive results, it may also be difficult to know when to

stop. To most clients, what tends to be most important is _relief from

symptoms_. When this is achieved, you may be tempted to terminate.

But relief from troubling symptoms is not always a sign that problems

have been resolved. {283} Frequently, relief from distress comes about

because of _problem avoidance_. You may have structured your life in a

way that circumvents, rather than faces, the things that trouble you.

There are times when this is indeed the best solution. However, the

tendency is for clients to associate relief with effective therapy, and

often this is not the case.

The therapist, on the other hand, may have certain personal values that

he wishes to satisfy before ending therapy with you: he may favor, for

example, qualities of assertiveness and ambitiousness (or qualities of

submissiveness and compliance), want you to develop these traits, and

feel reluctant to end therapy until you have done this.

In general, the decision to terminate therapy should be made with a

number of objectives in mind:

* Have your troubling symptoms disappeared or at least been reduced to

a level that is tolerable?

* Have you improved your understanding of yourself so that you feel a

healthy measure of self-acceptance?

* Do you now have a greater tolerance to frustration?

* Have you developed realistic life goals?

* Are you able to function relatively well in social groups?

* Are you better able to enjoy life and work?

These goals need always to be _tempered_; they all involve comparative

judgments that should take into account where you started and what you

have accomplished. There is no perfection here, only degrees of

adjustment, compromise, and a willingness to accept yourself as a

mixture of human weaknesses and strengths.

... [W]e have to content ourselves with the modest objective of

freedom from disturbing symptoms, the capacity to function

reasonably well, and to experience a modicum of happiness in

living.[1]

[1] Lewis R. Wolberg, _The Technique of Psychotherapy_, vol. 2, p. 747.

FACING RELAPSES

Some therapists believe that therapy cannot be called successful until

you have had a relapse and have been able to get {284} through it on

your own. Shadows of old habits linger on. They are especially likely

to resurface during periods of insecurity, disappointment, and

frustration. They represent a part of you--perhaps a part you would

just as soon were not there, but a part of you, nonetheless, that you

cannot expect to eradicate completely.

You are much better prepared to face the challenges of the future, of

events that cannot be anticipated, and of uncertainties that cannot be

avoided, if you do not demand a total change in yourself to the point

that old reactions never recur. You are better prepared if you realize

that it is likely some will return for brief visits during periods of

particular stress. If and when this happens, you can render these

visits less distressing and less able to throw you by using the

understanding you have gained from therapy.

You are apt to get a flurry of anxiety and a return of symptoms

from time to time. Don't be upset or intimidated by this. The

best way to handle yourself is first to realize that your relapse

is self-limited. It will eventually come to a halt. Nothing

terrible will happen to you. Second, ask yourself what has been

going on. Try to figure out what created your upset, what aroused

your tension. Relate this to the general patterns that you have

been pursuing.... Old habits hold on, but they will eventually get

less and less provoking.[2]

[2] Wolberg, _The Technique of Psychotherapy_, vol. 2, p. 754.

HOW TO CARRY ON

Therapy is a temporary crutch or a cast in which to heal, a comfort, a

source for renewed faith in yourself, and an experience of learning.

It cannot solve all the problems of future living, for these pose new

challenges that require of us all that we readjust our goals and

expectations, become more resilient and less easily troubled or broken.

(The flexible bamboo is more likely to survive a storm than the mighty

oak.)

Reducing an individual's rigidity is an objective of all

psychotherapies. Becoming less rigid allows you to accommodate to

changes and to tolerate external stress more easily. Decreased

rigidity helps you adjust to new demands placed on you by your

surroundings.

{285}

But there is another side to living successfully, and that is, first,

the ability to recognize situations and circumstances that cause you

excessive stress and, second, the willingness to leave them before it

is too late. We tend to place _all_ of the responsibility for

adjustment to stress on ourselves, on our inner strengths. But often

this is unnecessary, unreasonable, and even self-destructive. Often it

is the _situation_ that is not desirable or tolerable, not a "weakness"

in ourselves in being unable to cope with it. It can sometimes take

more strength and courage to break free from a pattern of frustration

and unhappiness than to remain on, slowly wearing down your resources

and growing older fast.

Much of successful living after therapy is a matter of _prevention_: of

being aware when you begin to tax yourself more than you need to, when

your body and mind begin to tell you that you are developing new habits

of anxiety or depression or are starting to reinforce old ones. At

these times, take stock of what you are doing, of how your daily living

may be in conflict with your values and attitudes. Prevention here

means being willing to change an undesirable situation, not just

enduring it while trying to change its consequences _in you_.

This is largely a matter of knowing and respecting yourself, of _not_

requiring yourself to accept conditions that you feel will lead you to

grief. Therapy may help you tolerate stress more easily, but this is

one-sided if you do not also learn to protect yourself from stress that

is excessive. (Even bamboos can be broken.)

Therapy is an opportunity for you to learn how to cope better with the

problems of living. You learn that you can face the demands of life

successfully in these ways:

* through belief in yourself and through strength of will

* by diminishing your preoccupation with yourself and developing

interests outside yourself

* by understanding your reactions and accepting them rather than

fighting yourself

* by living in the present

* by taking yourself less seriously, by developing a sense of humor and

perspective

Having learned these things, you then simply do the best you can within

the limitations of life.

{287}

PART IV

APPENDIXES

{289}

[N.B. Since the first edition of this book, the majority of the groups

and organizations listed in the following appendix may be readily

contacted by e-mail. For current e-mail addresses, Google the names of

any organizations you wish to contact.]

APPENDIX A:

Agencies and Organizations

That Can Help

(United States and Canada)

PART I: UNITED STATES

SELF-HELP ORGANIZATIONS

_For General Information_

Self-help groups exist for many different kinds of problems. They are

listed in many communities by local branches of the Self-Help

Clearinghouse. If a branch is not listed in your telephone directory

and you would like a listing of self-help groups in your area, contact:

National Self-Help Clearinghouse

25 W. 43rd St.

New York, NY 10036

(212) 840-1259

A fact sheet on self-help groups prepared by the National Institute of

Mental Health is available at no charge from:

Consumer Information Center

Department 609K

Pueblo, CO 81009

{290}

Also, you may wish to contact:

National Self-Help Resource Center

1729-31 Connecticut Ave., NW

Washington, DC 20009

(202) 387-0194

For a detailed guide to self-help groups, consult _HELP: A Working

Guide to Self-Help Groups_, by Alan Gartner and Frank Riessman (New

York: New Viewpoints/Vision Books, 1980).

_For Specific Problems_

_For alcoholics:_

Alcoholics Anonymous World Services

PO Box 459, Grand Central Station

New York, NY 10163

(212) 686-1100

_For families of alcoholics:_

Al-Anon Family Group Headquarters

1 Park Ave.

New York, NY 10016

(212) 683-1771

_For individuals with emotional problems:_

Emotions Anonymous International

1595 Selby Ave.

St. Paul, MN 55104

(612) 647-9712

Neurotics Anonymous

3636 16th St., NW

Washington, DC 20005

(202) 628-4379

_For individuals who have been treated for emotional

or mental difficulties:_

Recovery, Inc.

802 N. Dearborn St.

Chicago, IL 60603

(312) 337-5661

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National Alliance for the Mentally Ill

1901 N. Fort Myer Dr.

Ste. 500

Arlington, VA 22209

(703) 524-7600

_Autism:_

National Society for Autistic Children

Information & Referral Service

1234 Massachusetts Ave., NW

Washington, DC 20005

(202) 783-0125

_Epilepsy:_

Epilepsy Foundation of America

4351 Garden City Dr.

Landover, MD 20785

(301) 459-3700

_Learning disorders:_

Council for Exceptional Children

1920 Association Dr.

Reston, VA 22091

(703) 620-3660

_For families who have children with behavior problems:_

Families Anonymous

PO Box 528

Van Nuys, CA 91426

(818) 989-7841

_For single parents with children:_

Parents Without Partners International

7910 Woodmont Ave.

Washington, DC 20014

(301) 654-8850

_For parents of abused children:_

Parents Anonymous

7120 Franklin Ave.

Los Angeles, CA 90046

(213) 876-9642

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_For pathological gamblers:_

Gamblers Anonymous

PO Box 17173

Los Angeles, CA 90017

(213) 386-8789

_For families of pathological gamblers:_

Gam-Anon

PO Box 4549

Downey, CA 90241

(213) 469-2751

_For individuals with phobias:_

TERRAP

1010 Doyle St.

Menlo Park, CA 94025

(415) 329-1233

_For obesity:_

Overeaters Anonymous

2190 W. 190th St.

Torrance, CA 90504

(213) 320-7941

Weight Watchers International

800 Community Dr.

Manhasset, NY 11030

(516) 627-9200

_For narcotics addicts:_

Narcotics Anonymous

8061 Vineland Ave.

Sun Valley, CA 91352

(213) 768-6203

National Association on Drug Abuse Problems

160 N. Franklin

Hempstead, NY 11550

(516) 481-0220

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PROFESSIONAL ASSOCIATIONS

American Academy of Psychoanalysis

30 E. 40th St.

New York, NY 10016

(212) 679-4105

American Association for Marriage and Family Therapy

1717 K St., NW

Suite 407

Washington, DC 20006

(202) 429-1825

American Association of Sex Educators, Counselors

and Therapists

11 Dupont Circle, NW

Suite 220

Washington, DC 20036

(202) 462-1171

American Psychiatric Association

1400 K St., NW

Washington, DC 20005

(202) 682-6000

American Psychological Association

1200 17th St., NW

Washington, DC 20036

(202) 955-7686

Association for Advancement of Behavioral Therapy

15 W. 36th St.

New York, NY 10011

(212) 279-7970

National Association of Social Workers

7981 Eastern Ave.

Silver Spring, MD 20907

(301) 565-0333

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PART II: CANADA

SELF-HELP ORGANIZATIONS

_For General Information_

The Centre for Service to the Public publishes the annual _Index to

Federal Programs & Services_, which contains descriptions of more than

1,100 programs and services administered by federal departments,

agencies, and Crown Corporations. The Centre also operates the Canada

Service Bureaus throughout Canada, which provide telephone referral

services for individuals interested in locating federal agencies and

programs. Contact:

Centre for Service to the Public

365 Laurier Ave., W.

Ottawa, ON KlA 0S5

(613) 993-6342

Also, you may wish to contact:

Department of National Health and Welfare

Social Service Programs Branch

National Welfare Grants Program, 7th fl.

Brooke Claxton Building

Tunney's Pasture

Ottawa, ON K1A 1B5

(613) 990-9563

Canadian Mental Health Association

2160 Yonge St.

Toronto, ON M4S 2Z3

(416) 484-7750

For information about community services, contact:

Voluntary Action

Department of Secretary of State

15 Eddy St., Hull

Ottawa, ON K1A OM5

(819) 994-2255

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_For Specific Problems_

For alcoholics:

Alcoholics Anonymous

Intergroup Office

272 Eglinton Ave., W.

Toronto, ON M4R 1B2

(416) 487-5591

ADDICS (Alcohol & Drug Dependency

Information & Counselling Services)

818 Portage Ave., #209

Winnipeg, MB R3G 0N4

(204) 775-1233

_For individuals who are mentally or physically disabled:_

Disabled Peoples' International (DPI)

207-294 Portage Ave.

Winnipeg, MB R3C 1K2

(204) 942-3604

_For individuals who have been treated for emotional

or mental difficulties:_

Mental Patients Association

2146 Yew St.

Vancouver, BC V6K 3G7

(604) 738-5177

_Autism:_

Autism Society Canada

Box 472, Sta. A

Scarborough, ON M1K 5C3

(416) 444-8528

_Epilepsy:_

Epilepsy Ontario

2160 Yonge St., 1st fl.

Toronto, ON M4S 2A9

(416) 489-2825

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_Learning disorders:_

Canadian Association for Children

and Adults with Learning Disabilities

323 Chapel St.

Ottawa, ON K1N 7Z2

(613) 238-5721

_For families who have children with emotional and

behavior problems:_

Ontario Association of Children's Mental Health Centres

40 St. Clair Ave., E., #309

Toronto, ON M4T 1M9

(416) 921-2109

_For single parents with children:_

One Parent Families Association of Canada

2279 Yonge St., #17

Toronto, ON M4P 2C7

(416) 487-7976

_For narcotics addicts:_

ADDICS (Alcohol & Drug Dependency

Information & Counseling Services)

818 Portage Ave., #209

Winnipeg, MB R3G 0N4

(204) 775-1233

PROFESSIONAL ASSOCIATIONS

Canadian Psychiatric Association

225 Lisgar St., #103

Ottawa, ON K2P 0C6

(613) 234-2815

Canadian Psychoanalytic Society

7000 Côte des Neiges Rd.

Montreal, QC H3S 2C1

(514) 738-6105

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Canadian Psychological Association

558 King Edward Ave.

Ottawa, ON K1N 7N6

(613) 238-4409

Council of Provincial Associations of Psychology

558 King Edward Ave.

Ottawa, ON K1N 7N6

(613) 238-4409

Ontario Psychological Association

1407 Yonge St., #402

Toronto, ON M4T 1Y7

(416) 961-5552

Ontario Association for Marriage and Family Therapy

271 Russell Hill Rd.

Toronto, ON M4V 2T5

(416) 968-7779

Canadian Association of Social Workers

55 Parkdale Ave., #3l6

Ottawa, ON K1Y 1E5

(613) 728-1865

Corporation Professionnelle des Travailleurs Sociaux du Quebec

5757 Decelles Ave., Ch. 335

Montreal, QC H3S 2C3

(514) 731-2749

Canadian Guidance & Counseling Association

Faculty of Education

University of Ottawa

651 Cumberland St., Rm. 427

Ottawa, ON K1N 6N5

(613) 234-2572

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APPENDIX B:

Suggestions for

Typically, fifteen to twenty-five patients of both sexes will reside in