When You Don't Know Where to Turn

By Steven J. Bartlett

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Title: When You Don't Know Where to Turn
A Self-Diagnosing Guide to Counseling and Therapy

Author: Steven J. Bartlett

Release Date: February 15, 2014 [EBook #44926]

Language: English

*** START OF THIS PROJECT GUTENBERG EBOOK WHEN YOU DON'T KNOW WHERE TO TURN ***

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WHEN YOU
DON'T KNOW
WHERE
TO TURN

_A Self-Diagnosing Guide
to Counseling and Therapy_

Steven J. Bartlett, Ph.D.

Contemporary
Books, Inc.
Chicago -- New York

* * * * *

ALSO BY STEVEN JAMES BARTLETT

_Normality Does Not Equal Mental Health: The Need to Look Elsewhere for
Standards of Good Psychological Health_

_The Pathology of Man: A Study of Human Evil_

_Reflexivity: A Source Book in Self-Reference_

_Self-Reference: Reflections on Reflexivity_ (co-edited with Peter
Suber)

_Conceptual Therapy: An Introduction to Framework-Relative Epistemology_

_Metalogic of Reference: A Study in the Foundations of Possibility_

_VALIDITY: A Learning Game Approach to Mathematical Logic_

As editor of these books
by Paul Alexander Bartlett:

_Voices from the Past -- A Quintet of Novels_:

_Sappho's Journal_

_Christ's Journal_

_Leonardo da Vinci's Journal_

_Shakespeare's Journal_

_Lincoln's Journal_

Library of Congress Cataloging-in-Publication Data

Bartlett, Steven J.
When you don't know where to turn.

Bibliography: p.
1. Psychotherapy. 2. Counseling. 3. Consumer
education. I. Title.

RC460.B28 1987 616.89'14 87-20045
ISBN 0-8092-4829-8

Copyright © 1987 by Steven J. Bartlett, Ph.D.
All rights reserved
Published by Contemporary Books, Inc.
180 North Michigan Avenue, Chicago, Illinois 60601
Manufactured in the United States of America
Library of Congress Catalog Card Number: 87-20045
International Standard Book Number: 0-8092-4829-8

Published simultaneously in Canada by Beaverbooks, Ltd.
195 Allstate Parkway, Valleywood Business Park
Markham, Ontario L3R 4T8 Canada

Project Gutenberg 2014 edition

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_When You Don't Know Where to Turn_ was originally published in 1987 by
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[Illustration: CreativeCommonsLogo.jpg]

This book is dedicated to Karen,
my love, wife, and friend.

Preface to the Project Gutenberg Edition

Nearly three decades have passed since _When You Don't Know Where to
Turn_ was first published. In that time, psychiatry, clinical
psychology, and counseling have changed a good deal.

Psychiatry has continued on a now well-worn path leading to a more and
more inflated universe of diagnostic labels, the majority of which have
no known organic basis. Few readers who are not themselves mental
health professionals realize that these diagnostic classifications are
_voted into existence_ by committees of psychiatrists whose
pronouncements magically summon into being a lengthening list of
so-called "mental disorders." These pronouncements are then applied to
people in order to label their problems (as well as the people who have
them), to match their problems with allegedly effective treatments, and
in the process to give the impression that a respectable medical
process of diagnosis and intervention has been undertaken.

And yet these so-called "mental disorders" do little more than equate
designated patterns of behavior, emotion, or thought--called
syndromes--with alleged psychological malfunctioning. Such syndromes
are no more than sets of symptoms that can be collected together in a
wide variety of different ways, but depending upon how they are
grouped, distinguishable syndromes can be pointed to and named. This is
a highly arbitrary process very much like fortune-telling using tea
leaves, which depends on the pattern seen or imagined in the tea leaves
at the bottom of a cup.

During the past three decades, clinical psychology and its less formal
cousin, counseling, have also undergone noticeable change. They have
been the traditional sources of a large number of diverse approaches to
psychotherapy and counseling. But in the past thirty years, the large
number of approaches to psychotherapy and counseling has, in practical
reality, shrunk considerably. This has been due to the rapid dominance
and virtual monopoly that has been gained by cognitive-behavioral
therapy, also known as rational-emotive therapy. Insurance companies
have been attracted like flies to the sweetness of the comparatively
brief treatment period touted by cognitive-behavioral therapy, and
practitioners have similarly been attracted by the ease of using its
one-size-fits-all approach.

And so where the changes in psychiatry have been inflationary in its
authorized catalogue of "mental disorders" known as the _DSM_
(_Diagnostic and Statistical Manual of Mental Disorders_), clinical
psychology and counseling have been on a deflationary course that has
progressively narrowed the treatment options available to many people.

Despite the passage of time, _When You Don't Know Where to Turn_
remains the only step-by-step self-diagnosing guide to counseling and
therapy, a guide that seeks to direct individuals--by respecting and
responding to the very great differences that exist among
individuals--to approaches to counseling and therapy that may be most
likely to benefit them--taking into account the nature of their own
individual problems, their different degrees of willingness and
abilities to learn and to change, and their differing individual
situations in life, including their financial resources and the amount
of time that they are willing to devote to therapy.

Such a customized, individually-centered perspective is not popular
today. The human population continues inexorably to expand while our
healthcare system insists on general applicability and streamlined
efficiency. Individual problems in living are more easily and rapidly
"processed" when they can be subsumed under specifiable diagnostic and
treatment codes. In this increasingly mechanized process, the
individual person and the individual problems of living he or she is
attempting to cope with tend more and more to be ignored or neglected,
and his or her diagnosable "disease entity" becomes the object of
attention.

These comments are not a polemic against current trends and fashions;
they are rather intended to place in perspective the changes that have
occurred in the mental health field during the past three decades since
the first edition of this book came off the press. What a reader might
take away from these preliminary remarks are these suggestions:

* to recognize that, like so much that is a human production, today's
classification system of mental disorders is unlikely to be the final
word about the human condition, but that its proliferating list of
mental disorders should be taken by the humble at least with a grain of
salt, and rejected wholesale by those who are more critically inclined;

* to accept the fact that it is becoming harder with the passage of
time to find one's way to a mental health clinician who is _not_
recipe-oriented, due to the in-fashion monopoly that prescribes
cognitive-behavioral therapy, and due to the pressures on the
healthcare system to process people and their problems faster and at
lower cost; and, finally,

* to realize that, when it comes to problems of living, those who are
willing to accept a healthy measure of responsibility for their own
choice of practitioner and treatment are most likely to find a
practitioner and a treatment that meet their individual needs.

From this point of view, _When You Don't Know Where to Turn_ continues
to offer readers a heightened consciousness of alternatives to
treatment that do still continue to available, though they can be
somewhat harder to find in some areas of the country, and to give
readers a sense of what those alternatives have to offer and for which
kinds of problems and personalities they may best be suited.

Readers interested in learning more about the author, his research, and
publications by him, many of which can now be downloaded at no cost,
may like to visit the author's website:

http://www.willamette.edu/~sbartlet

Steven James Bartlett
Salem, Oregon
2014

* * * * *

This book offers counseling observations based on the author's
experience only and makes no specific recommendations for any
individual or group.

It is intended and has been written to offer the author's understanding
and opinions in regard to the subject matter. The author and publisher
are not here engaged in providing personal psychological or psychiatric
or other professional advice. For such advice, the reader should seek
the services of a qualified professional.

The author and the publisher cannot be held responsible for any loss
incurred as a result of the application of any of the information
contained in this book.

CONTENTS

Before We Begin ... xi
Acknowledgments xv
The Purpose of This Book 1

PART I: GETTING STARTED 7

1 Prisons We Make for Ourselves 9
2 Paths to Help 17
3 Bridges from Here to There 29
4 The Therapeutic Jungle, Part I:
Social Workers, Psychologists, and Psychiatrists 39
5 The Therapeutic Jungle, Part II:
Outside the Mainstream 48
6 Where You Can Find Help 54
7 Self-Diagnosis: Mapping Your Way to a Therapy 59
8 Emotional Problems That May Have Physical Causes 99

PART II: EXPERIENCING THERAPY 111

9 Psychoanalysis 113
10 Psychotherapy, Part I:
Client-Centered Therapy, Gestalt Therapy,
Transactional Analysis, Rational-Emotive Therapy, and
Existential-Humanistic Therapy 123
11 Psychotherapy, Part II:
Logotherapy, Reality Therapy, Adlerian Therapy,
Emotional Flooding Therapies, Direct Decision Therapy 150
12 Behavioral Psychotherapy 173
13 Group Therapy 184
14 Marriage and Family Therapy 194
15 Channeling Awareness: Exercise, Biofeedback,
Relaxation Training, Hypnosis, and Meditation 204
16 Drug and Nutrition Therapies 227

PART III: IMPORTANT QUESTIONS 239

17 Locating a Therapist 241
18 Should You Be Hospitalized? 252
19 Confidentiality: Your Privacy 257
20 Does Therapy Work? 267
21 Life After Therapy 282

PART IV: APPENDIXES 287

Appendix A: Agencies and Organizations That Can Help
(United States and Canada) 289
Appendix B: Suggestions for Further Reading 298
Index 307

ABOUT THE AUTHOR 313

{xi}

BEFORE WE BEGIN ...

* A recent study by the National Institute of Mental Health shows that
one American in five suffers from some type of psychiatric disorder:
50.5 million Americans have one or another of eight serious psychiatric
disorders, ranging from anxiety disorders and phobias to depression and
schizophrenia.

* Of these, only one person in five seeks professional help. More than
40,400,000 severely troubled people do not receive any treatment.

* An unknown number of healthy, emotionally untroubled Americans enter
therapy for reasons of self-development.

* More than 130 distinguishable therapies now exist.

* These therapies are offered by a variety of health care
professionals, including social work counselors, clinical and
counseling psychologists, psychiatrists, biofeedback therapists, and
others. Their backgrounds, training, fees, and durations of treatment
vary considerably.

* These professionals practice in a number of different settings: in
private practice, group sessions, public and private agencies,
hospitals, newly established nonhospital {xii} inpatient facilities,
and in the context of educational programs.

* Most people who enter therapy do not know what alternative approaches
to therapy exist or how to choose among them. They usually locate a
therapist in a more or less random way.

* Most people fear the idea of entering counseling or psychotherapy.
They do not have a clear conception of what to expect: they do not know
in advance what the _experience_ of therapy is like.

* For a variety of reasons, many people who think of going to a
therapist are concerned about whether their relationship with the
therapist will really be confidential. If you are especially concerned
about privacy, you should be aware of several ways that confidentiality
may be broken, what the laws concerning confidentiality are, and, in
particular (what few people realize), how insurance claims for
psychological care can invade an individual's privacy.

* Counselors and therapists tend to specialize in one or a small number
of alternative approaches to therapy. Some approaches to therapy are
most appropriate for treating certain problems or responding to certain
personal interests; others are better suited to providing help with
other problems and concerns. Choosing a therapist with an orientation
that is right for _you_ can be extremely helpful and can help you save
much time, money, and energy.

These facts highlight the situation in counseling and psychotherapy
that anyone faces who enters therapy today.

From them, you can see that there is a bewildering array of counseling
professions, of distinct approaches to therapy, and of settings in
which help is offered. This guide's intention and hope is to help you
understand the alternatives, and to help you form your own judgment how
it may be best to proceed.

The book hopes to give you real assistance so you may make a good
choice--thereby saving you emotional investment, time, money, and the
potential discouragement of avoidable false starts with therapies that
may not help because they are not relevant to your goals, values, and
personality.

{xiii}

Be patient. Take the time to think about yourself, your life, and your
hopes for a better life. This book was written for you, to help you to
improve your life, your self-esteem, and your relationships with
others. They are worthy goals.

Nothing in this world can mean as much.

May you have the energy, courage, and perseverance to achieve them!

{xv}

ACKNOWLEDGMENTS

I would like to express my gratitude to Dr. William Altus, then
Professor of Psychology at the University of California, Santa Barbara,
who went out of his way to encourage my first interests in
psychotherapy when I was a graduate student there twenty years ago. To
Professor Paul Ricoeur, I would like to express my admiration for his
original contributions to Freud scholarship and my enduring gratitude
for his willingness to direct my doctoral research at the Université de
Paris.

I am indebted to Dr. Raphael Becvar, Professor, Marriage and Family
Therapy, Saint Louis University, both for making it possible for a
faculty colleague to learn from him in several of his excellent
seminars and for his later comradeship. To my good friend, Dr. Thomas
Maloney, clinical psychologist in Clayton, Missouri, I want to extend
my warmest appreciation for his personal guidance and voluntary
supervision of my first efforts in counseling. If ever the qualities
of compassion, depth of understanding, humor, and genuine care are to
be found in one person, they are in him. I would also like to thank
Professor Lillian Weger, George Warren Brown School of Social Work,
Washington University, St. Louis, for generously welcoming me into her
fine seminar in psychodynamic models.

{xvi}

I especially thank Dr. Renate Tesch and Professor Hallock Hoffman, of
the Psychology Faculty of the Fielding Institute in Santa Barbara, for
making possible a writer's retreat in the California desert: the loan
of their home in Sky Valley made writing the last group of chapters a
special and memorable pleasure. One is fortunate to have such friends.

If this book became more readable after its first draft, it was due in
great part to the conscientious energy of my wife, Karen, in spotting
the weeds of obfuscation that seem to grow effortlessly in an
academic's garden. I want to thank her for her patience, with both me
and the book.

I would also like to take this opportunity to thank Miss Libby
McGreevy, Assistant Editor, Contemporary Books, Inc., for her helpful
suggestions and for her regular doses of encouragement that made
writing this book a happy experience.

{1}

_When You
Don't Know
Where
To Turn_

THE PURPOSE OF THIS BOOK

I would like to introduce this book by telling you what happened to a
real and likable person who ran into some very difficult times and as a
result entered therapy.

Frank is a large man, a former college football player, powerfully
built. He has always prided himself on his strength and determination.
He used to be friendly and outgoing. He had a pleasant smile,
complemented by his clear blue eyes.

Frank had worked for eleven years for a manufacturer of tools. Not
long ago, he was promoted to the position of managing the company's
sales division in a large midwestern city. Soon after Frank and his
wife moved, his wife became pregnant with their third child. Frank had
a well-paying job, excellent benefits, a pleasant home they had just
bought, and a contented relationship with his wife. But in spite of
these things, he became severely depressed. And he began to feel
terribly frightened: he had to leave his desk several times each
morning and again in the afternoon. He would go to the men's room,
lock the door, turn on the water faucets, and cry.

Frank lost fifteen pounds in three months. He had a poor appetite,
slept badly, and was very anxious around his {2} co-workers. He
couldn't understand what had happened to him, and he was unwilling to
let others know how unhappy he felt. He was ashamed of what he took to
be a weakness in himself: like many men, he was raised to believe that
men shouldn't cry, and his crying bouts shook his sense of identity and
stability. His marriage began to suffer. Frank and his wife seldom
made love. Frank was irritable and impatient with his wife and his
children. Frank's wife knew he was very troubled, but he refused to
talk to her about it.

For several months, Frank fought against his depression. (If only he
had been aware of the _strength_ that he mustered to do this!) Then he
reached a crisis and could not force himself to go to work. He stayed
home with a bad cold, slept as much as he could, and was very
short-tempered. He was crying a good deal. Frank's wife persuaded him
to see a doctor. The doctor referred him to a psychiatrist. The
psychiatrist saw Frank twice a week for two-and-a-half months, but
Frank was troubled by side effects from the antidepressant medication
he took under the psychiatrist's supervision. He resisted the idea of
"taking drugs," so he decided to see a psychotherapist who, in
cooperation with the psychiatrist, monitored Frank's condition as he
gradually went off the antidepressants.

However, after five months, Frank did not feel he was making any real
progress. He changed to another therapist who, his wife had heard,
specialized in the treatment of depression.

Together, Frank and his new therapist came, over a period of months, to
recognize that Frank's depression had resulted from two conflicts:
Frank had hated his job but had refused to admit this to himself, and
now his wife was pregnant again, and because of this added financial
responsibility he felt forced to stay with his present job, where he
had seniority, good salary, and benefits.

Once the basis for his depression was made clear, it was possible to
begin to treat Frank's problem. His wife was very willing to encourage
him to plan for a change of jobs, even though this would mean a
temporary reduction in his income. Frank saw a vocational therapist
and received guidance that led him to take some evening classes and
then to become a computer programmer for a rapidly growing local
company. His {3} depression faded away, and he now seems genuinely to
be content.

WHAT YOU CAN EXPECT FROM THIS BOOK

I knew Frank personally, as his therapist in a group. (His name, like
all others in this book, has been changed, along with certain details
about his situation.) With professional help, Frank was able to
improve his life--his sense of self-esteem, his marriage, and his
family life. It was a long and painful process, as much self-change
can be. But perhaps Frank's experience might have been _less_ painful,
perhaps Frank might have felt less devastating isolation, and perhaps
his path to a resolution of his difficulties could have been shortened
if a practical guide to counseling and therapy had been available to
him when he first decided to find help.

MAKING INTELLIGENT CHOICES

This book is about how you can get the most appropriate kind of help
for your problems, goals, and personality. Specifically, _When You
Don't Know Where to Turn_ sets out to help you become adequately
informed about the range of therapists and therapies--_as these relate
to your own assessment of your goals and interests_--so that you will
be able to make intelligent decisions about these issues:

* the _kind of professional_ to seek out

* the _type of therapy_ most likely to help you with a certain
complaint or set of interests and values

* how to locate the form of therapy that seems most promising to you at
_a price you can afford_ and with _an expected duration_ you can live
with

* what _setting_ to look for in which the help you would like is offered

This book uses two approaches, both presented here for the first time
and both based on common sense and intelligent advance planning.

{4}

First, you will be able, through a series of carefully organized
questions and easily followed instructions in Part I, to pinpoint one
or more approaches to therapy that may be most promising given your
initial objectives, problems, or interests. For the first time, a
_self-diagnosing map_ to the major approaches to therapy is made
available.

Second, you will have the opportunity to glimpse what typically happens
during the sessions of counselors, psychologists, and psychiatrists as
they treat clients or patients using the different main approaches to
therapy. You will come to see what the _experience_ of therapy is like
in these different approaches.

In other words, the self-diagnosing map will point you in the direction
of one, and sometimes more than one, approach to therapy that may be
most promising for you to begin the process of self-change, and you
will then be able to gain an insider's perspective on that approach so
that you can judge how well suited to you the approach is and how it
compares to the other main approaches to therapy.

If this guide helps you choose a path to the kind of therapy that will
be appropriate and useful to you, it will have done something
worthwhile. A guide to counseling and psychotherapy should, however, do
more than this.

OVERCOMING ISOLATION AND GETTING STARTED

People who are troubled tend to try to hide it. They frequently isolate
themselves when they are distressed, so overcoming the desire to
withdraw is the first order of business if they are to improve their
lives and feelings.

One of the things this book sets out to do is to help you see that very
likely the problems you are facing are not one of a kind. You have a
lot of company; the difficulties you are having are probably very
familiar to counselors and therapists. Realize that there are ways of
resolving most problems and that doing so often is easier with the
sympathy, empathy, moral support, friendship, or direction of a
counselor or therapist than by yourself.

CAN YOU HELP YOURSELF?

However, sometimes it _is_ possible to help yourself a great deal {5}
through your own initiative. This book will describe ways that you can
be your own source of help and will pay particular attention to _when_
it may be appropriate and safe to rely upon inner resources.

CLEARING THE CONFUSING JUNGLE

Most people are not familiar with the differences among the main kinds
of "psychosocial" helping professionals--the various types of
counselors, clinical psychologists, psychiatrists, psychotherapists,
psychoanalysts, social workers, etc. Another purpose of this book is
to clarify these labels, to describe how the approaches used by their
practitioners are distinct and how they are similar, and to give an
idea of how their fees and durations of treatment vary.

Individual chapters in Part II are devoted to describing the main
varieties of therapy available today: psychoanalysis; psychotherapies;
behavior-changing therapies; marriage and family therapy; group
therapies; exercise, biofeedback, relaxation, hypnosis, and meditation;
and drug therapy. Each approach will be described in the context of
experiencing professional help _and_ in terms of how and when it may be
possible to apply the approach on your own. These chapters will help
you understand what in general to expect if you choose a particular
kind of treatment, how the course of treatment may go, and what point
of view is shared by professionals who use it.

FINDING SOMEONE TO HELP

Part III of this book will describe how you can go about locating good
professional care, whether from a family therapist, an analyst, a
social worker, a psychiatrist, a clinical psychologist, or another kind
of therapist. You will learn how you can find a reputable professional
with a particular specialization, and you will be encouraged to ask him
or her some useful questions before beginning treatment.

As we will see in detail later on, there are numerous settings in which
counselors and therapists work. Many are in private practice, but many
also work for a variety of agencies, both public and private, for
hospitals and newly established nonhospital residential facilities, and
even for educational institutions. We {6} will discuss each of these
settings in Part III so that you will have a clear idea both of the
alternatives that exist and of important factors to consider when
deciding among them.

SHOULD YOU BE HOSPITALIZED?

"Should I consent to hospitalization?" "What will I encounter if I
accept hospitalization?" "Is it necessary, is it desirable?" Another
chapter in Part III is devoted to answering these and related questions.

IS YOUR PRIVACY PROTECTED?

In many ways it will be, and in other ways it may not be.
Confidentiality as it relates to the treatment of emotional or
psychological difficulties is a thorny issue, one that worries many
people. In Part III, a chapter is devoted to a discussion of this
potentially important area of personal concern.

DOES THERAPY WORK?

You may, of course, feel a certain amount of skepticism about the real
utility and effectiveness of any one of the many therapies that now
exist. This is, in my judgment, a healthy skepticism. A chapter in
Part III will review what you may be able to expect, and perhaps should
not expect, in the light of recent evaluations of the effectiveness of
the main therapies. To complement these as yet incomplete scientific
findings, I will emphasize a measure of ordinary common sense as we go
along.

LIFE AFTER THERAPY

The last chapter in this book deals with what to expect _after_
therapy. Recurrences, future crises--they often come with the package:
life! Relapses--re-experiencing feelings of distress--have received
too little attention. Often, old habits and feelings remain with us
and reappear during times of stress. Too, we know that as life goes
on, we need to be able to tackle new problems and new situations and
sometimes must handle unexpected crises. Chapter 21 tells you how the
experience of therapy will help you cope with possible setbacks and the
uncertainties of the future.

{7}

PARTI

GETTING STARTED

{9}

PRISONS WE MAKE FOR OURSELVES

Which of us is not forever a stranger and alone?

Thomas Wolfe, _Look Homeward, Angel_

What other dungeon is so dark as one's own heart! What jailer so
inexorable as one's self!

Nathaniel Hawthorne, _The House of the Seven Gables_

When you have shut your doors, and darkened your room, remember
never to say you are alone, for you are not alone, but God is
within, and your genius is within.

Epictetus, _Discourses_

When people are in pain and most need others, many wall themselves in.
This very human tendency is illustrated by a famous story.

In 1934, Admiral Richard Byrd led an expedition to Antarctica, where he
established a base on the edge of the Ross Ice Barrier, 700 miles north
of the South Pole. Byrd then decided to set up a small weather
observation post closer to the pole, which he chose to man alone. He
would stay in a one-room cabin, a box {10} that measured nine feet by
thirteen feet, lowered into a rectangular hole cut into the ice to
protect the cabin from gale-force winds during the coming winter months.

Byrd was committing himself to a degree of personal isolation few men
have ever taken on. What happened to him in the months ahead reveals
something important to psychologists that all of us should bear in mind.

Byrd's men left him in his tiny station and returned across the ice to
the main base 123 miles to the north. Winter blizzard conditions soon
surrounded Byrd. He knew he was in for a long period of solitary
confinement, with no hope of returning to the base, even if a medical
emergency demanded this. He could never make the return trip to the
base on his own, and it would be too dangerous for a team of men to try
to get to him in the winter darkness across the miles of ice.

After several months of isolation, Byrd became very ill. He was
distressed and confused about his condition--nausea, vomiting, terrible
headaches, blurred vision, great weakness. Days would go by, and he
would cling to life by a thread, his mind wandering, drifting in and
out of the dizzying incoherence of frequent comas. He would, by sheer
force of will, gather his reserve of fading energy and stagger across
the tiny room to light the stove and open a can of food, which he soon
lost from his stomach. Gradually, he came to realize that the fumes
from his kerosene stove and from the gasoline-powered generator for the
telegraph were poisoning him. But if he turned off the stove, he would
freeze to death, and the telegraph was his only contact with others.

He knew his life was in real danger, yet he refused to let his men know
of his desperate situation. Nor could he _admit_ to _himself_ that he
was in trouble.

Listen to his own words, written half a century ago, in his snow-buried
room with the air heavy with fumes and the inside walls encrusted with
glistening ice:

It is painful for me to dwell on the details of my collapse....
The subject is one that does not easily bear discussion, if only
because a man's hurt, like his love, is most seemly when concealed.
From my youth I have believed that sickness was somehow
humiliating, something to be kept hidden....

To some men sickness brings a desire to be left alone; animal-like,
their instinct is to crawl into a hole and lick the hurt.

{11}

There were aspects of this situation which I would rather not
mention at all, since they involve that queer business called
self-respect....

For a reason I can't wholly explain, except in terms of pride, I
concealed from [my] men, as best I could, the true extent of my
weakness. I never mentioned and, therefore, never acknowledged
it.... I wanted no one to be able to look over the wall....[1]

[1] Richard E. Byrd, _Alone_ (New York: G. P. Putnam's Sons, 1938), pp.
166, viii, 294-295.

In spite of his efforts to keep his condition to himself, Byrd's radio
operator at the main base seems to have intuited that Byrd was in
danger. A rescue party was sent as the winter weather became less
harsh, and Byrd was brought back to the base, probably just in time,
before the fumes killed or permanently injured him.

In many ways, Byrd's Antarctic experience parallels that of many of us
who, because of our own pain and hardship, isolate ourselves from
others. Our lives become cold, desolate, despairing. Our suffering is
real, but for one reason or another we cannot or will not reach out to
others.

WALLING YOURSELF OFF FROM OTHERS

Most of us are aware of a need for human company and companionship.
But when we are in pain or are severely troubled, we often forget what
has been recognized for a long time:

Frederick II, the thirteenth-century ruler of Sicily, believed that all
children were born with a knowledge of an ancient language. When they
were taught the language of their parents, however, he theorized, their
knowledge of the older language was overridden and blotted out. King
Frederick hypothesized that if children were raised without being
taught a language, they would, in time, spontaneously begin to speak in
some ancient tongue.

He therefore appointed a group of foster mothers, had new-born infants
taken from their natural mothers, and ordered the foster mothers to
raise the children in silence.

The upshot of this early experiment--as the legend goes--was {12} that
Frederick never found out whether his theory was true. All of the
babies died. They could not live without affection, touching, and
loving words. Apparently, the foster mothers withdrew all human warmth
when they sought to obey the king's order.

Today, we are aware of a baby's vital need for affection, for human
contact--and even so, in our adult lives, when human contact is equally
essential, we sometimes cut ourselves off from others.

THE MYTH OF SELF-SUFFICIENCY

As adults, we tend to emphasize self-control. We think of ourselves as
_responsible_--to ourselves, our parents, our employers, our children.
All this responsibility can sometimes be a heavy load! During periods
of illness or emotional crisis, the emphasis on _control_ can be
excessive. It can create the bars of a prison, a grillwork of defenses
that stands between us and others who are able to offer encouragement,
warmth, understanding, and direction.

There is no lonelier person than someone who has decided to take his or
her own life. The decision is the ultimate form of self-isolation. It
is the ultimate admission that one's imprisonment is final and that
there is no escape.

Fortunately, the decision to take one's life is reversible, if the
person is helped in time. The help may come from within or from
without, but it always involves the _recognition of hope_ that the
self-imprisonment may not be final, that there are others who would
help, that, even for someone who is terminally ill, there may be
periods of satisfaction and joy that make living worthwhile.

Western European, American, and Japanese societies are very
control-oriented. There is much evidence that when members of these
societies are emotionally troubled they often perceive a fault within
themselves. They see their troubles as springing from a loss of
self-control: "Just pull yourself together!" "It's just a matter of
self-discipline, of _will_!"

The greater our sense of responsibility--the more we emphasize personal
control over our inner and outer affairs, the more we see ourselves as
individualists whose individualism is based on strength of will,
discipline, guts--the more we are _trapped by the myth of
self-sufficiency_.

{13}

People who as children were forced to become independent too early, who
lacked a long enough period of closeness to their mothers, whose
parents were immature and self-absorbed frequently develop what is
called _pseudo-self-sufficiency_ or _premature ego development_. Such
a person is the neurotically extreme form of the "do-it-yourselfer."
He or she refuses to relinquish control, whether to the car mechanic,
the sewer cleaner, or a lover. There is an urgent and obsessive need
to maintain control, never to be "out of control."

For such people, anxiety, depression, and loneliness can be especially
devastating because they have walled themselves in to such an extent
that emotional growth and change are blocked.

Yet most of us share, to some extent, this belief in self-sufficiency.
It is one of the most tenacious forms of self-imprisonment that we have
available to us, literally at our own disposal. It is a prison we
often take great pride in. Pride, control, and self-sufficiency are
usually close friends. They keep us from having _real_ friends and
stand in the way of our being good friends to ourselves.

THE FEAR OF BEING LABELED EMOTIONALLY DISTURBED

It is woven into the fabric of our society that we should conform. A
young teenager from Australia now in a California high school tries as
quickly as possible to lose the accent that differentiates her, that
makes her the object of laughter. The same pressures motivate the
stutterer to keep quiet, speaking only when absolutely necessary. The
National Merit Scholar says "ain't" among his school friends to be one
of them.

Children are especially sensitive to covert expectations, the implicit
_shoulds_ that are handed down from the adult world and are frequently
refashioned to fit the stages children move through.

At each stage, the implicit maxims are _dress alike, talk alike, think
alike_. Be "in." Especially, have the same feelings, values, and
hopes. Most of us are raised to fear being different because we might
come to be a lonely minority of one.

But when we become ill, especially if we are emotionally troubled, the
rules change radically. Animals, from the aquarium angelfish to the
household dog or cat, seem to have an instinct to {14} seek isolation
when ill. This tendency probably has evolved because it contributes to
survival: the sick animal can more easily rally its energy for
self-healing in quiet, undisturbed by others of its kind. And going
off to be alone reduces the chance that the animal will spread any
disease it has.

Added to an animal's self-isolating tendency is the tendency to hide
the very _signs_ of illness or injury. An animal that shows signs of
injury or illness is immediately a target for predators who look for
the weaker members of the species.

We human beings also tend to choose solitude and to hide the revealing
symptoms of sickness or injury. Admiral Byrd admitted to these
defenses only in his loneliness. But it is important to realize that
hiding our feelings and isolating ourselves frequently are not in our
best interests.

Animals do not practice medicine, though many species are capable of
offering moral support and even a certain amount of physical
assistance, as in the case of a sick whale who may be supported by its
fellows in the water in order to breathe. But only we have developed
medicine, and we have more recently begun to develop ways to treat
problems that affect our emotions, attitudes, and behavior. When
individuals, perhaps instinctively, distance themselves from others and
bottle up their malaise, they turn their backs on the educated
assistance and goodwill that are available.

Sometimes we do so out of fear of treatment coupled with fear of
admitting that we are not as self-sufficient as we want to believe.
But more often in the case of problems that directly affect our
moods--i.e., "psychological problems"--we feel ashamed and afraid of
the stigma, the disgrace, that our society attaches to those who admit
they have unhappy or confused feelings.

There can be little doubt that society is unbalanced in legitimating
physical sickness while reacting with alarm and repugnance to problems
of a psychological nature. Think of the discrimination _against_
psychological disorders, in favor of physical complaints, practiced
openly by nearly all health insurance companies, offering reduced
benefits for mental health. Psychological pain does not hurt any less
because it is emotionally based. Even so, emotional distress is held
suspect, and insurance coverage for it, if not ruled out completely, is
frequently only partial. It was, after all, not more than a century
ago that our mental hospitals were run with an inhumanity that {15}
still can send shivers down one's spine. Unhappily, it is clear that
we have not entirely left this phase of our development: the film _One
Flew over the Cuckoo's Nest_, for example, points to continuing
inhumanity in some psychiatric hospitals. And there is the alleged
case of a Ukrainian woman who was involuntarily committed and held for
some thirty years in a mental hospital. She was thought to be insane
because, unfortunately, no one involved in her case recognized her
"gibberish" as Ukrainian!

Emotional and mental problems are still not accepted by many. There is
a fear of the unknown and a skepticism that psychological problems are
nothing more than signs that a person is malingering, simply does not
want to try to get better. And there is a gut-level anxiety when
confronted by someone who, we worry, "may be close to going over the
edge."

TEARING DOWN PRISON WALLS

What undue hardship this causes! As wonderful as the body is, we
accept its imperfections, its susceptibility to disease and injury.
But our brains, our minds, our spiritual dimension--how less well we
understand these in their greater complexity! Is it so strange and
unacceptable that they should be prone to their own problems, that
they, too, may bring suffering?

Because society does not legitimate emotional pain, many people are not
able to see their own pain as legitimate. So they deny it, to
themselves and to others. But pain is usually a healthy signal; it
tells you that something is wrong: Withdraw your hand from the fire!
Move your cramping legs! Do something about your abusive, alcoholic
husband! Get help for your depression!

Every one of these pains is a warning. To ignore all except those that
are physical would be like saying that we are only bodies, without
feelings, without humanity.

When you are in pain, whatever its source and kind, pay attention to
it! Pain is often what points to a better life.

It is surely better to cope with a label applied in ignorance by some
members of society, if this must be, than to live an unsatisfying and
painful life. You must not manage your life just to avoid the
potentially critical judgment of people who are ignorant of, or who
refuse to acknowledge, the realities of human psychology. You can feel
sure that among well-informed people, if you have had to deal with
alcoholism, drug abuse, a difficult {16} marriage, job depression, or
any other "psychological" problem, you will be thought to be just as
"respectable" as if you had coped with major surgery after an
automobile accident. In fact, since overcoming a psychological
difficulty demands a great deal more of your own voluntary effort,
coming up a winner will increase your own self-respect and the respect,
and even admiration, of those whose judgment is meaningful.

The first step to freedom from pain is to become aware of the walls of
the prison that shut you in. Only then can you begin to tear them down.

{17}

PATHS TO HELP

To wrench anything out of its accustomed course takes energy,
effort and pain. It does great violence to the existing pattern.
Many people want change, both in the external world and in their
own internal world, but they are unwilling to undergo the severe
pain that must precede it.

Rivers in extremely cold climates freeze over in winter. In the
spring, when they thaw, the sound of ice cracking is an incredibly
violent sound. The more extensive and severe the freeze, the more
thunderous the thaw. Yet, at the end of the cracking, breaking,
violent period, the river is open, life-giving, life-carrying. No
one says, "Let's not suffer the thaw; let's keep the freeze;
everything is quiet now."

Mary E. Mebane, _Mary, Wayfarer_

If you decide to enter therapy, your therapist will probably ask you to
think about two interrelated questions (they may be expressed in a
variety of ways): "Where are you now?" and "Where do you want to go?"
Your therapist or counselor will, as he comes to know you, often be
able to help you to answer these by sharing his perceptions of you.
One of the main tasks of the counseling process is to help a person
gain improved self-understanding that embraces both present problems
and future goals.

{18}

Yet if you can gain a certain measure of self-understanding and
self-direction _before_ entering counseling or therapy, it will be
easier for you to choose an approach to counseling or therapy that more
closely fits your problems, values, objectives, available time, and
even your financial needs. You should find in this book a basis for
preliminary _self_-counseling that will give you a sense of how and
where best to begin therapy.

It is important to recognize that none of us ever reaches a final state
of self-knowledge: as long as we live, our self-understanding is
capable of growing. What we really understand about ourselves and what
we believe ourselves to need and want are never more than provisional,
tentative. Additional experience, just the fact of living longer, very
likely will lead you to perceive yourself differently and motivate you
to modify your priorities and change your goals.

WHERE ARE YOU NOW?

Late in 1984, the National Institute of Mental Health released the
first published results of the largest mental health survey ever
conducted. The results are startling and are an unhappy commentary on
our society and world.

The report shows that 20 percent of Americans suffer from psychiatric
disorders. Yet only one in five of these seeks help. The others live
with their suffering.

The most common problems are these:

_Millions of Americans_
_Psychiatric Name of Condition_ _with This Disorder_

Anxiety disorders 13.1
Phobias 11.1
Substance abuse (alcohol, drugs, etc.) 10.0
Affective disorders (including
depression and manic depression) 9.4
Obsessive-compulsive disorders 2.4
Cognitive impairment 1.6
Schizophrenia 1.5
Antisocial personality 1.4

The NIMH study also shows that women are twice as likely to seek help
as men. Two interrelated inferences are commonly made from this
previously known fact: women are often more accepting of their
emotional state (men in our society are taught to disregard their
feelings, part of _machismo_), and women are less willing to allow
pride to stand in their way of getting help (women are less affected by
the myth of self-sufficiency).

{19}

The NIMH report indicates, too, that the incidence of psychological
problems drops by approximately half after the age of forty-five. The
below-forty-five years are usually those of highest stress. Above
forty-five, individuals tend to become psychologically better
integrated. This probably reflects increased maturity and a more
accepting, calmer attitude toward life. The lowest rate of emotional
disturbance appears to be in people over sixty-five. Yet there are
many thousands of individuals over forty-five, and indeed over
sixty-five, for whom life remains a difficult inner struggle.

The statistics from the NIMH study reveal how very wide-spread personal
psychological difficulties are. Given the degree of complexity of our
mental, emotional, and spiritual makeup, this should be understandable,
especially when we take into account twentieth-century stresses that
wear us down. Caught up as most of us are in our jobs, families, and
daily worries, we are unaware that, in a very real sense, mental and
emotional health problems have assumed epidemic proportions. If you
bear in mind how fearful our society encourages us to be of admitting
such difficulties, you can perhaps imagine how substantial the
"iceberg" of psychological suffering is: most of it lies below the
waterline of public consciousness.

The NIMH study results should encourage you, if you suffer from
personal emotional difficulties, to realize that you are not alone in
the problems you face. Knowing that there are many good and fine
individuals with very likely similar problems may urge you to take an
honest look at where you are now and then to try to decide what changes
may be helpful to you: where you want to go from here.

If you are fortunate, you may already be aware of the main things in
you and in your life that bring you distress. If so, you are one step
closer to being able to do something about them. Many of us, however,
have become so clever and effective in denying what we really feel that
we have lost touch with our true selves. {20} Desires to repair an
unhappy marriage are shelved while the children are growing up; the
unrewarding nature of a job is ignored because priority is given to
financial security; you may be unable or unwilling to face the pain you
bring to yourself and others as a result of a drug- or alcohol-abuse
habit.

In most cases, it is not possible to gain the motivation and means to
solve a problem until you are willing to accept that there is a problem
that needs to be solved.

Because of the blinding nature of the habits you may have established,
and because of your defensive desires to disregard what disturbs the
equilibrium of habit, it may be hard to acquire a clear picture of
where you stand right now. Sometimes it can be useful to check with
others: how do they see you?

A close friend of mine, after years in her profession, began rather
suddenly to feel how unrewarding her job was, and she began to suspect
that she may have hidden these feelings for a long time. She had
maintained a regular, almost once-a-week exchange of letters with her
mother for twelve years. She knew that her mother kept her letters, so
she went to visit her and asked if she might skim through them, paying
attention to comments she had made over the years about her work. It
quickly became clear to her that, consistently, she had had only very
negative things to say about her job. After skimming through dozens of
letters written over a period of years, she became convinced of her
real and enduring feelings and changed her line of work.

Such self-knowledge does not usually come this easily. We may pride
ourselves on honesty, but there are few of us who permit ourselves
self-honesty to any real degree. Existential-humanistic psychologists
have paid much attention to these ways that we live "in bad
faith"--each of us trying to be a person he or she really is not and
denying the person he or she really is.

We live in a society that emphasizes conformity, "being somebody,"
gaining status and wealth and a good position--yet these values may not
coincide with being true to ourselves. Parental influences can be
strong, as can expectations from our spouses. We internalize many of
these values so that it becomes difficult to see who we really are and
what we really want from life and from our efforts.

There are no easy routes to self-realization. We must all do a certain
amount of hunting in the dark--or, as a colleague of mine {21} likes to
say, "scrabbling about"--for a sense of real identity.

Recognizing that your self-understanding is probably always imperfect
does not mean that it is of little value. It is, in the end, all any
of us has to go on.

It may be useful to ask people close to you what they perceive about
you. Reading through a group of old letters, keeping a journal, or
simply setting aside a few minutes for self-appraisal at the end of
each day or week may also be enlightening. If you do this
self-examination, gradually where you are and what you feel will become
clearer, and then it will be natural and appropriate to ask what the
next step is.

WHERE DO YOU WANT TO GO? WHAT KIND OF
PERSON DO YOU WANT TO BECOME?

Influences from society, your parents, your spouse, or your close
friends make it difficult for you to know yourself. Defensive habits
and fear of change also stand in the way. These are significant blocks
to self-understanding.

When you turn your attention to the future, to what kind of person you
want to become, you will encounter more blocks to overcome. Life is
like that! It seems that few things come without effort and
perseverance.

There are two major obstacles to designing the model of the person you
would like to become. Because they can be so important, I want to
introduce them early in this book. They are blame and guilt, and they
are like the two ends of a seesaw.

When we appraise what we have done in our lives, we usually find
reasons to blame others, or perhaps to blame limited educational
opportunities, or social pressures, or discrimination--in short, our
past environment: all the factors that limited our lives, interfered
with the attainment of our hopes, and were not under our control.

On the other end of the seesaw sits guilt. And guilt is really blame
turned inward.

If we try to pinpoint the factors that have been responsible for our
lives not having turned out better, we tend to blame environmental
limitations, or else we feel guilt for what we see as our own failings.
Usually, we locate responsibility in both areas.

Most of us, however, have unbalanced seesaws. We usually {22} blame
things _outside ourselves_ for our disappointments. Doing so is a
habit that allows us to avoid responsibility for ourselves and, in
turn, limits our future development.

On the other hand, some of us blame ourselves much too readily: we
carry an exaggerated burden of responsibility, which weighs us down and
also limits our growth as individuals.

Ideally, psychotherapy would like us to let go of so-called "past
negative conditioning"--blame as well as guilt--so that we are free to
choose who we are and will become. Even though this is certainly a
desirable attitude, most of us cannot really forget and let go. We are
all inheritors of a tenacious past: the influences of past events have
a certain power over us, and we must either resign ourselves to being
controlled by the past or fight its influence. The _attitude_ we take
toward the past will usually affect how we meet the future, often
diminishing our freedom to change old habits and undermining our hope
and faith in ourselves.

For example, if Jeff blames his limitations today on his parents, on
the ways they influenced him, he may set goals for himself that are far
from being freely chosen. Jeff may choose them _in reaction to_
domination by his parents years ago. His parents may have tried to
influence him to be a gentle, courteous person with artistic interests.
But as a result of other past influences--for example, because of
frequent moves of the family and repeatedly being bullied as the "new
kid" at different schools--Jeff may feel hostile toward others, so (in
reaction to his parents' influence and because of pent-up hostility) he
decides to go into science (rather than art, for which he perhaps has a
talent) and rejects gentle, courteous qualities in himself.

It is difficult to choose freely. Some psychologists do not believe it
actually is possible. And yet, whether we are ever truly free or not,
we still try to plan our lives, and we believe our plans (and
frequently the lack of them) have something to do with what we make of
living.

Most people who enter counseling or psychotherapy want to improve some
aspect of their living. Individuals whose seesaw is weighted on the
side of blaming outside influences too often come to feel it is too
much work and quit therapy because they cannot accept the need to make
choices and decisions _in spite of_ past influences. On the other
hand, people who blame {23} themselves may be so guilt-ridden that they
are impaired in their openness to the future and feel unable to
initiate fundamental changes in their lives.

When you ask yourself, "What kind of person do I want to become?," try
to be aware of the extent that your answer may be weighed down by
feelings of blame and guilt. All too often we continue to perpetuate,
unknowingly, the same old unsatisfying patterns because we are trapped
by our habits of blaming others or ourselves.

If you feel bogged down by feelings of guilt or burdened by the
limitations of an unfair past, it may be difficult for you to develop a
freely chosen sense of direction. But perhaps you will be able to
acknowledge that the guilt or blame you feel is an obstacle to be
overcome. If so, you have defined an objective that you may use to
decide what type of counseling or therapy may be a most promising first
step.

What I am suggesting is that an obstacle that makes it hard for you to
gain a sense of direction can _itself_ point you in a direction. If
there are blocks, it can be helpful to meet them head-on. In therapy,
the phrase _working through a problem_ often means exactly this.

Choosing what kind of person you wish to be is a _process_, not an
event. It is not something that happens and then is over. Choice is
something implicit in each day of your life; sometimes it is quite
conscious, but it is often dulled by the unconsciousness of habit.
Your personal goals may undergo gradual or abrupt change.
Psychological growth is your response to these changes in outlook.

WHAT DOES THERAPY TRY TO DO?

Individual therapy or counseling (therapy for groups and families will
be discussed in detail later) is really an attempt to build a bridge
between answers to these two now familiar questions: "Where are you
now, or what kind of person are you now?" and "Where do you want to go,
or what kind of person do you want to become?" Think of therapy as an
attempt to build a bridge so that you can pass from a present situation
to a desired way of being.

Carl Rogers defines therapy as "a relationship in which at least {24}
one of the parties has the intent of promoting the growth, development,
maturity, improved functioning, improved coping with life of the
other."[1]

[1] Carl Rogers, _On Becoming a Person: A Therapist's View of
Psychotherapy_ (New York: Houghton Mifflin, 1961), pp. 39-40.

Psychiatrist Allen Wheelis takes this definition further:

Therapy may offer insights into bewildering experience, help with
the making of connections, give comfort and encouragement, assist
in the always slippery decision of whether to hang on and try
harder or to look for a different way to try....

The place of insight is to illumine: to ascertain where one is, how
one got there, how now to proceed, and to what end. It is a
blueprint, as in building a house, and may be essential, but no one
achieves a house by blueprints alone, no matter how accurate or
detailed. A time comes when one must take up hammer and
nails....[2]

[2] Allen Wheelis, _How People Change_ (New York: Harper and Row,
1973), pp. 101, 107.

Therapy involves a three-fold relationship among a helping
professional, the approach to therapy used by him or her, and, what is
most important, the outlook of the individual client. In this book we
will examine each of these three dimensions of therapy in some detail,
but here we will concentrate on the one therapists generally agree is
the most important: you--the kind of person you are, what your
attitudes and outlook are, and, of course, how much you really want to
develop or change. Your attitudes will determine, probably more than
anything else, what variety of therapy you will most benefit from.

Therapists, like teachers (which they really are), find that their
clients or patients can be divided into two groups: active and passive
learners. When you go to a doctor with a broken arm, your relationship
to your doctor is a _passive_ one: you need only to cooperate as he
examines your arm, perhaps administers an anesthetic, and sets the
break. You may take medication for pain, and then you simply _wait_
until, thanks to the body's automatic healing processes, the break is
fused. The public's conception of medicine is predominately a passive
one. To be a "patient" is for the most part to be a passive bystander:
the physician is the active agent who brings about healing. There are
occasional {25} exceptions--for example, physical therapy and
rehabilitation therapy after a serious injury or illness, when the
patient must become more active and accept more responsibility.

As we will see, a few approaches to counseling and psychotherapy
preserve, to some extent, the traditionally passive role of the
patient. Most of them, however, require a good deal of initiative and
just plain hard work on the part of the patient or client.

In building the house of one's life or in its remodeling, one may
delegate nothing; for the task can be done, if at all, only in the
workshop of one's own mind and heart, in the most intimate rooms of
thinking and feeling where none but one's self has freedom of
movement or competence or authority. The responsibility lies with
him who suffers, originates with him, remains with him to the end.
It will be no less his if he enlists the aid of a therapist; we are
no more the product of our therapist than of our genes; we create
ourselves. The sequence is suffering, insight, will, action,
change. The one who suffers, who wants to change, must bear
responsibility all the way. "Must" because so soon as
responsibility is ascribed [outside oneself] the forces resisting
change occupy the whole of one's being, and the process of change
comes to a halt. A psychiatrist may help, perhaps crucially, but
his best help will be of no avail if he is required to provide a
degree of insight which will of itself achieve change.[3]

[3] Wheelis, _How People Change_, pp. 101-102.

WHY IS IT SO COMPLICATED?

For better or for worse, human nature is a many-splendored thing. It
doesn't take an advanced degree in psychotherapy to know that people
can have many different kinds of personal problems. This fact, if we
appreciate it fully, makes more understandable why there are so many
alternative approaches to helping people with their difficulties.

In the world of theory, a _model_ is a simplified representation of
reality. Your checking account record is a model, in just this sense,
of how many real dollars and cents you have in the bank.

Here is a much simplified model that represents five main
psychological, emotion-laden dimensions of a person:

{26}

[Illustration: Five main psychological dimensions of a person:
feelings, hopes, abilities, relationships with others, and behavior]

We see right away that, for the same reasons that there are specialties
in medicine--e.g., orthopedy for bones, neurology for nerves, dentistry
for teeth--there should be special approaches that focus on different
psychological dimensions of the person.

Something else you may see is that the five dimensions in the model are
not isolated from one another. They interrelate and overlap a good
deal. Just as a dentist must know about the orthopedy of the jaw and
skull and the neurology of the teeth a neurologist and an orthopedist
are expected to know something, though not in great detail, about
dentition. Each of us is a unity of what all the medical and
psychological specialties study in different ways, plus a good deal
more, as artists, writers, theologians, and musicians make evident.

That more than 130 distinguishable therapies have now been developed
may perhaps strike us, even so, as excessive. But efforts are being
made to unify many of these approaches, and this book is one of them.
Rather than talking about 130 different approaches, we will center our
attention on the main categories into which the many approaches can be
sorted.

One of the interesting and hopeful things that can be said {27} about
the multiplicity of approaches to therapy and counseling is that
treatment by any one of them can often be of some help. For example,
Helen may wish to stop drinking (a habit in the behavior category), and
she may be helped by means of behavior modification. She may then find
that, as a direct result, her self-concept (feeling category) has grown
stronger, while her marriage (relationship category) has also improved.
Or, Ralph may go to a vocational counselor who helps him define a
direction (hope category) in keeping with his interests and aptitudes.
Ralph goes back to school and develops a background (abilities
category) that reflects these aptitudes and interests. The sense of
direction he has gained helps Ralph stop using drugs (behavior),
reduces his hostility and anxiety (feelings), and improves his
relationships with others. In other words, a helpful change in one
direction can often lead to noticeable changes in others.

However, there also are risks that we should not ignore: Sue goes to an
analyst and learns over a period of months that her marriage to Fred
was based on a sense of inadequacy Sue learned during her childhood.
Her father was so highly controlling and critical of her that she was
never able to develop a sense of her own value. Her husband, Fred, is
also domineering and authoritarian, and he abuses Sue frequently,
usually mistreating her through criticism, but he has sometimes also
beaten her physically. Sue has accepted this without question for a
long time, but due to the emotional support received from her analyst,
she is beginning to develop a sense of self-esteem. As her self-esteem
grows, she comes to realize that her marriage is a self-destructive
relationship and decides to divorce Fred. Her therapy has been helpful
to Sue, but it has, indirectly, resulted in a breakdown of her
admittedly unhappy marriage. A change in one dimension can sometimes
lead to an initially unintended change in another area.

IF IT HURTS, DON'T PROCRASTINATE!

One of the marvelous things about human nature is the ability to feel
pain. This may seem like an odd thing to say, but reflect for a
moment. Pain is frequently what spurs us on from an unsatisfying and
even destructive situation to a better future. Pain tells you to jerk
your hand away from a hot stove. A different kind of pain tells you it
is time to get on with living, time to {28} initiate some positive
changes. Anxiety, sleeplessness, irritability, resentment,
depression--they all can be painful inner feelings that tell us that
all is not well in our inner selves.

It is well-known to counselors and therapists that, in general, the
longer these signs of need are ignored, the longer it may take to help
a person resolve the difficulties that have been pressing for
attention. Distress is not easily buried. When suppressed, it tends
to pop up again later, sometimes with increased severity.

We can, ironically, choose to be "strong" and ignore these messages
from within, or we can listen to our feelings, pay attention to our
hopes, develop needed abilities, seek to improve our relationships with
others, and work to change some ways we behave that block our happiness.

Problems that concern your inner well-being and the health of your
relationships with others who are important to you are better resolved
than buried, and the earlier they are given the attention they deserve,
the easier your path through change to a better life will be.

{29}

BRIDGES FROM HERE TO THERE

AN OVERVIEW OF THE FIELD OF THERAPY

THE HELPING PROFESSIONAL

Professionals in the fields of counseling and psychotherapy have a wide
range of different backgrounds and perspectives. They can be broken
down into these categories:

_Social work counselors_: counselors for individuals; marriage and
family counselors; group counselors; and vocational guidance counselors

_Psychologists_: clinical psychologists; counseling psychologists; and
psychometrists

_Psychiatrists_

_Other therapists_: religious counselors; biofeedback therapists;
hypnotherapists; relaxation and meditation instructors; holistic
therapists such as bioenergetics therapists, yoga instructors, and
exercise therapists; etc.

The education, supervised training, and outlooks of these professionals
vary greatly, as do their fees and the average length of time therapy
can be expected to last. We will look more closely at these
differences later on.

{30}

THE RANGE OF APPROACHES TO THERAPY

Because of their differences in training and personal or theoretical
preferences, the distinct classes of therapists represent a diversity
of approaches to therapy. There are numerous schools of
psychoanalysis, psychotherapy, behavioral therapy, group therapy, and
marriage and family therapy, and a range of approaches to personal
adjustment, including exercise therapies, relaxation techniques, forms
of meditation, and drug and nutrition therapies.

From any one of these, a multitude of schools of thought branches out.
For example, psychoanalysis has, since Freud, developed along a number
of different lines: each major psychoanalyst has formulated his or her
own approach to analysis that distinguishes itself from Freud's.
Psychotherapy, to take another example, is not a single approach to
therapy, but rather makes up an entire field. It is the largest and
most rapidly growing area relating to mental health. In it are
included distinct approaches, such as client-centered therapy, Gestalt
therapy, transactional analysis, rational-emotive therapy,
existential-humanistic therapy, reality therapy, logotherapy, Adlerian
therapy, emotional flooding therapies, and direct decision therapy.

In later chapters, we will look at these approaches to psychotherapy
more closely. The goal throughout this book will be to enable you to
understand enough about each of the major therapies to make an informed
decision in choosing an approach (and there may be more than one) that
will be most useful in relation to your own understanding of your
objectives, whether they are long-range or focused on the need to
eliminate immediate obstacles to growth.

THE DIFFERENCE BETWEEN COUNSELING AND PSYCHOTHERAPY

Counseling and psychotherapy have developed a great deal in recent
years--so much so that their boundaries have often overlapped.
Clear-cut distinctions between the two fields are increasingly hard to
draw. Nevertheless, some professionals prefer to call themselves by
one name and some by the other.

In general terms, _counseling_ tends to be a short-term process the
purpose of which is to help the client, couple, or family {31} overcome
specific problems and eliminate blocks to growth. Counseling gives
individuals a chance to resolve personal problems and concerns. Most
counselors attempt to help their clients become aware of a widened
range of possibilities of choice; from this perspective, counseling
tries to free clients from rigid patterns of habit.

Habits can be useful, but they can also interfere with life. The
technical habits of a pianist, for example, are essential in
performance. Similarly, only when language skills become habitual does
a speaker of a foreign language achieve command of it. On the other
hand, fears can also become habitual, and they may come to interfere
with everyday activities. Anxiety over public speaking may become
habitual. There are many personally destructive habits--alcoholism,
smoking, over- or under-eating, abusive behavior, shyness and social
withdrawal--and all can become self-perpetuating patterns. Counseling
can help people break out of these habits, often in part by helping
clients become aware of unrecognized alternatives.

_Psychotherapy_ tends to be more concerned than counseling with
fundamental personality-structure changes. Frequently, psychotherapy
is a longer-term process. Frequently, too, the problems treated in
psychotherapy are hard to pin down and are less specific. They include
chronic depression, pervasive ("free-floating") anxiety, generalized
lack of self-esteem, and so on. Such difficulties are not well
defined; their causes may be vague or uncertain, and often much time
must be spent to get at their basis. Psychotherapy seeks to bring
about an intensive self-awareness of the _inner dynamics_--the internal
forces and the principles that govern them--that are involved in
chronic forms of personal distress. Sometimes, as in analytical
psychotherapy or psychoanalysis, attention is focused on the role of
unconscious processes in inner conflicts; treatment attempts to resolve
these conflicts by understanding the unconscious forces involved.

The term _psychotherapy_ is often used to imply more advanced
professional training, whereas counseling is something individuals with
more modest academic credentials may practice. Whether a professional
is called a counselor or a therapist has to do with his or her level of
training, with the setting in which services are offered, and, to a
certain degree, with that person's theoretical orientation.

{32}

In practice, these differences in outlook frequently amount to
differences in _emphasis_ rather than approach. In this book, I will
speak of counseling and psychotherapy interchangeably unless there is a
need to be especially restrictive.

THERAPY: THE ART OF CHANGE

HOW WE ARE ABLE TO CHANGE

We are what we do ... and may do what we choose.

Allen Wheelis, _How People Change_

Freud identified five causes of personality development:

* growth and maturation
* frustration
* conflict
* inadequacy
* anxiety

By the time we become adults, most of us have developed sets of
defenses to enable us to cope with everyday problems _in spite of_
feelings of frustration, conflict, inadequacy, and anxiety. But as
these feelings become more pronounced, when we encounter situations
that intensify these feelings, we must put more and more energy into
our defenses. They allow us to continue living and acting in habitual
ways, usually by hiding, by denying, and sometimes by distorting our
perceptions of reality.

Facing the inadequacies of a marriage, the unrewarding nature of a job,
the extent of conflicts with a child, or difficulties relating to
friends can cause intense anxiety. So, to avoid this anxiety, we
frequently "defend against" these realizations: we try to uphold the
belief that our marriages are just fine, that things are OK between us
and our children, that our jobs are at least tolerable--that, in spite
of some problems "here and there," we can get along all right. We do,
in short, try to see our lives through rose-tinted glasses.

We continue to do this until our negative feelings become too strong,
until we have expended so much energy to maintain our defenses that we
are _emotionally exhausted_. If we reach such a state of real
depletion, and our defenses can no longer hold against the building
pressure of our feelings, the result is {33} _nervous breakdown_. This
is the layman's name for a variety of psychological conditions that
develop due to _a burned-out emotional fuse_.

A fuse is a protective device that prevents an overload of electricity.
Our defense mechanisms are analogous devices that protect us against
emotional overload. When an emotional fuse burns out, it is often
because we have maintained defenses too long in the face of increasing
inner frustration and pain. The result may involve severe depression,
incapacitating anxiety, or serious withdrawal.

Now, when you decide to change in some psychologically fundamental way,
you must push against the rigid framework of certain of these
protective defenses. When you do this, you will feel anxiety. You are
forcing your emotional fuses to adjust to a different pattern of
behavior and feelings.

Your sense of personal identity is made up of a network of ways you
have come to perceive yourself, your loved ones, your work, and your
world. Any attempt--even if it is your own, entered into through your
own choosing--to change patterns that are psychologically basic to your
sense of identity will threaten that established identity and produce a
measure of anxiety.

The longer these habitual patterns of behavior and feeling have been in
force, the more deeply rooted they become in your sense of identity,
and the more unsettling and anxiety-producing an attempt to change them
will be.

Although your defenses protect against emotional overload, they also
stand in your way of change. They are fundamentally _conservative_
mechanisms: established habits of thought, feeling, and behavior are
_familiar_, and familiarity reduces the anxiety brought about by
uncertainty. If you are considering making significant changes in your
life, your defenses will rally to protect the equilibrium of habits you
have formed in the past. If you push yourself to change, you will face
a predictable degree of anxiety. Fortunately, there are, as we shall
see, many ways of coping with the anxiety brought about by change;
therapy offers some of these, and some are available to us all if we
draw on inner resources.

As long as you are alive it is possible to change. Ultimately, the
decision to change is an expression of your choice and will. When
change _is_ achieved, it usually comes after long and arduous trying.
We are all aware of the heroic efforts some {34} people can and do make
to overcome a physical handicap. Overcoming deeply entrenched
emotional habits can require similar tenacity and commitment. If you
want to bring about some basic changes in yourself or in your
relationships with others, your inner strength and resolve will be
essential.

Frequently, individuals expect a therapist to accomplish change _for_
them: they are willing to come for an hour's consultation once or twice
a week, and they will be very cooperative during each visit, but they
seem unwilling or unable to develop the initiative to carry on efforts
begun in the therapist's office.

Some clients, in spite of what they say, do not really _want_ to
change. Their habits are deeply ingrained, serving purposes they may
be only dimly aware of at the beginning of therapy. Sometimes it
becomes necessary in therapy to reappraise the goals that have been
set. The decision to pursue a certain course of change may result in
so much anxiety and upset that both therapist and client must pause to
reconsider. Some changes may turn out to be too difficult, too taxing;
some clients may be unwilling to put in the work required to bring
about a certain change.

Most changes of the kind I am referring to--fundamental changes in
outlook, in daily thoughts and feelings, in behavior--can be made only
gradually. Since any move in the direction of change will threaten
your existing defenses, resistance and protest are likely to well up
from within you. New ways of _being_ will feel intimidating,
unpleasant, or just plain _unnatural_. And this is understandable, is
it not? You must confront and do battle against habits that may have
been with you for a long time. _The longer that undesirable patterns
have been in force, the more control they acquire over you, and the
more your defenses become committed to preserving them_. Change is
made steadily more difficult.

Always remember, however, that change can be brought about. You need
to be patient with yourself; it will not come overnight. Long-standing
habits take time to be replaced, You must have patience, and you must
feel hope and encouragement. If you are depressed now, if maintaining
your defenses has exhausted you, then it will be difficult to feel the
measure of hope that you need to begin the process of therapy.

This, perhaps more than anything else, is the most immediate and
perceptible benefit of therapy: a good therapist is a source {35} for
hope and encouragement when you cannot sustain these yourself.
Therapists are trained to help people who want to change, to bring it
about.

THE RESULTS OF THERAPY

In the past twenty to thirty years, there has been a gradual shift away
from a medical, illness-based orientation in therapy to one that
focuses on personal growth. By no means everyone enters therapy
because of emotional pain. Increasingly, therapists are seeing clients
who enjoy psychological and emotional good health but believe that
therapy can help them lead fuller, richer, more satisfying lives. As a
consequence, the objectives of many current approaches to therapy
involve more than only the resolution of personal difficulties and
crises.

There are many potential benefits of therapy. To varying degrees, all
the therapies we will discuss in this book claim to assist you in
achieving the following goals.

_Resilience and Tolerance to Stress_

As a consequence of therapy, you come to be less frustrated by stress,
able to recover from stressful experiences more quickly. You become
less defensive and more accepting of others and yourself, able to
adjust more easily to unexpected demands in living. You have a
decreased tendency to hold rigid expectations of the world, so you feel
less disappointment and frustration.

_Congruence_

You come to be more unified in the present moment, aware of your
feelings, and less disposed to ignore, deny, or distort your
perceptions out of defensive needs. Congruence means a close match
between what you feel and how you think and act. Congruent people are
well integrated, no longer in need of "masks." When we admire a
person's sense of "integrity," we often feel that the person not only
behaves in ways that show self-respect, but that he or she is
self-accepting, is genuine, and appears to be comparatively free of
inner conflict. Such individuals are, in short, able to be themselves.
People who no longer are engaged in a battle against themselves and
against others will tend to show congruence.

{36}

_Self-Esteem_

People with high self-esteem can allow themselves to feel modest and to
behave with modesty. High self-esteem does not imply pride or
arrogance. Self-esteem and self-acceptance (and hence congruence) are
interrelated. Individuals with strong self-esteem no longer need to
prove themselves. They value the kind of people they are and are not
inclined to be self-undermining through perfectionistic self-criticism.

_Openness and Love_

Ideally, if you undergo therapy, you become less defensive and less
uptight about yourself; you will therefore have less need for
self-absorption, so you will be able to develop an increased capacity
to feel warmth for others. You may become more giving, and less hooked
on the need to recover for what you do give, tit for tat. There are
fewer "shoulds" to stand in your way, to use to blame yourself, or to
use to criticize others. You can let go of these requirements and
accept others for what they are, for what they can do, and for what
they may feel. You feel less disappointment and resentment about your
relationships and more of a sense of ease and peace.

_Freedom_

Since you are less hooked by the expectations and values of others, and
you have reduced the list of requirements that others must fulfill in
order to be acceptable, you gain a great measure of personal freedom.
The habitual process of sizing others up and comparing them with
yourself, which many of us expend so much time and energy doing, is no
longer needed. You can more freely set your life goals. You will
probably feel more real, meaningful satisfaction with your life, since
you are no longer imprisoned by uptight standards of judgment. You are
able to be much more relaxed because you are able to feel more
accepting toward others and toward yourself.

_Displacing the Negative with the Positive_

These are among the major potential positive benefits of therapy. They
make up one way of describing the _ideal outcomes_ of therapy. They
are one side of the coin; the other side consists of the many negative
feelings and ways of behaving that are {37} eliminated when they are
_displaced_ by these positive personality qualities. The negatives
that make up such a familiar part of "normal" life include these:

* fears that stand in the way of desired goals

* anxiety and depression that cripple normal living

* low self-esteem, resentment, and hostility that poison the formation
and development of satisfying relationships

* incapacity to deal with stress, and dependence on alcohol, drugs, or
other means to reduce anxiety

* inability to accept yourself, your family, or your present place in
the world--which often leads to bitterness, withdrawal, and even the
cultivation of fantasies that further isolate

* confusion, disorientation, and perhaps even physical signs of poor
health, as a result of emotions that have assumed a magnitude that can
no longer be held in check by tired defenses

We tend to think of these as the usual reasons for entering therapy.
But, again, the positive qualities we have described are attracting
clients increasingly to therapy. Whether you need to eliminate
emotional pain or are fortunate to be comparatively untroubled but are
searching for certain positive qualities of perspective and character
that you believe will bring increased satisfaction to your living,
therapy may offer what you are seeking.

WHAT MAKES A GOOD THERAPIST?

According to several studies, certain qualities in therapists are
associated with effective therapy. The kind of person who is able to
help others bring about important life changes has these qualities:

* the ability to understand the client's feelings and life world

* heightened sensitivity to the client's feelings and attitudes so that
the therapist frequently is able to uncover significant aspects of the
client's outlook and personality of which the client would probably
remain unaware

{38}

* warmth of interest in the client's well-being, without emotional
overinvolvement

* psychological maturity, characterized by self-acceptance,
genuineness, and congruence

* a sense of acceptance toward the client: a nonjudgmental,
noncritical, positive regard for the client, his separateness, and
individuality

* an attitude, conveyed by the therapist's behavior and approach, that
encourages positive change, independence, and freely made choices and
decisions, and implicitly discourages the formation of long-term
dependence of the client on the therapist

These studies also identified several attitudes that clients,
regardless of the orientation of their therapists, felt were especially
_counterproductive_ in some therapists:

* lack of interest

* remoteness or distance

* excessive sympathy

In general, clients whose evaluations of therapy have been studied
appear to be in agreement that the personal character, attitudes, and
feelings of therapists are more important than a therapist's technique,
procedures, and theoretical orientation. Therapy is an intrinsically
human process, one that is especially sensitive to the human dimensions
of therapists. Later we will look at objective evaluations of the
effectiveness of various approaches to therapy and weigh them against
the emphasis that clients place on the personal qualities of therapists.

{39}

THE THERAPEUTIC JUNGLE,
PART I

Social Workers, Psychologists, and Psychiatrists

I have reluctantly come to concede the possibility that the
process, direction, and end points of therapy may differ in
different therapeutic orientations.

Carl Rogers, _On Becoming a Person_

Fifty years ago, people with personal or marital problems had a choice
between two main kinds of assistance: psychoanalysis and religion.
Freud's approach to psychiatry had gained popularity among physicians,
psychoanalytic training was being made available to clinical
psychologists, and the ideas of Freudian analysis had come to dominate
the public's conception of therapy. And, sometimes overlooked in this
context, the church--the world's faithful and oldest
psychiatrist--continued to offer spiritual and personal guidance.

These two basic choices have expanded into an impressive--and
confusing--array of different therapies. The more than one hundred
varieties of counseling, even when they are grouped together, cannot be
reduced to fewer than perhaps twenty families of therapies.

Different counseling professions have evolved that now range from
social work to psychotherapy to psychiatry; religious counseling is
still offered; and there are the newer therapies of {40} relaxation
training, biofeedback, bioenergetics, etc., as well as a renaissance of
older approaches such as meditation, yoga, and holistic practice. The
choices of fifty years ago seem modest, limited, and certainly less
perplexing. However, the recent proliferation of therapies has brought
with it increased sensitivity, sophistication, and effectiveness.

In spite of this growth of therapeutic options, most people who decide
to enter therapy are unaware of the choices open to them and so cannot
intelligently weigh their alternatives. This and the next chapter will
help you to see clearly what alternatives exist. As the book helps you
to clarify your personal objectives, you will be able to home in on one
or more approaches to therapy that may be especially promising for you,
your temperament, interests, and goals. You will be encouraged to
follow a "map" that will guide you to several approaches to therapy, to
help you find the shortest and most effective route to where you want
to go.

SOCIAL WORK COUNSELORS

As we have seen, the four main categories of social work counselors are
counselors for individuals, marriage and family counselors, group
counselors, and vocational guidance counselors.

ORIENTATION AND TRAINING

The main purpose of social work is to help people cope with stress from
interpersonal or social problems. The focus of the social worker may
therefore be on individuals, families, or groups or on their social and
work environments, their organizations, and their communities.

Social workers are trained to deal with developmental problems, life
crises, and emotional problems that arise in a variety of social
situations.

Graduate schools of social work require varying periods of supervised
internship; they usually offer specializations within the field--e.g.,
drug and alcohol abuse, developmental disabilities, child welfare,
correctional approaches, family services, care of the aged, and others.
It is now possible to find social workers whose training is quite
specialized.

{41}

In some states, social workers may practice with a bachelor's degree;
in many states, a master's degree is required. In addition, counselors
are usually required to put in a substantial number of hours of
counseling under the supervision of a licensed counselor.

FEES

Social workers in private practice normally charge on an hourly basis
for their services, with sessions lasting thirty to fifty minutes.
Rates vary considerably, in direct relation to other health care costs.
Rates are higher in larger metropolitan areas and also higher in New
England and California than in the South and Midwest. An approximate
range of $35 to $65 per counseling session is normal at the time of
this writing.

Costs for marriage and family counseling and for vocational guidance
counseling are similar to rates for individual counseling.

The charge for group therapy is frequently made for a block of
sessions. The group therapist may, for example, recommend that a group
meet for ten sessions. The resulting per-session cost is normally
significantly lower than is individual counseling. (However, the goals
of individual and group therapy are in general different, as we will
see; neither can automatically be substituted for the other.)

Many social workers offer their services through a counseling agency.
Some of these are privately run; others are funded by the county or
state. Frequently, agencies charge for counseling services based on a
sliding scale, which takes into account the financial situation of
clients. Sliding scale rates can be very economical for lower-income
individuals. Bills for services in some county and state agencies are
made on a monthly basis; individual counseling may cost only a few
dollars per session for individuals with restricted budgets.

There are many opportunities for clients to obtain economical care,
especially in metropolitan areas where counseling services are
widespread.

DURATION OF TREATMENT

It is impossible to give any hard and fast rules as to how long {42}
counseling will take. Obviously, much has to do with an individual's
objectives, the severity of the problem, and, frequently, how long the
problem has been neglected or ignored. On the other hand, much also
has to do with the counselor's own orientation.

Today, many counselors receive training that emphasizes "brief"
therapy. Specific goals of therapy are set, and it is frequently
possible to reach those goals within a matter of a few months. On the
other hand, some counselors prefer, or have been trained, to offer
long-term individual psychotherapy. Some counselors have been
influenced by the psychoanalytic approach, which is usually of long
duration, frequently requiring one to several years.

There is no reason you, as a prospective client, should not ask a
counselor what kind of approach he or she uses and approximately how
long therapy can be expected to last. You should not hesitate to ask a
counselor questions that reflect your concerns. As you read further,
this book will provide you with a frame of reference so that you may
evaluate more fully the answers a counselor gives you.

PSYCHOLOGISTS

As mentioned in the last chapter, there are three kinds of
psychologists who are involved in different aspects of therapy:
clinical psychologists, counseling psychologists, and psychometrists.

ORIENTATION AND TRAINING

_Clinical psychology_ emphasizes the understanding, diagnosis, and
treatment of individuals in psychological distress. Clinical
psychology is historically based on laboratory work that stressed
psychological assessment tests, and experimental and statistical
analysis.

Clinical psychologists generally have a Ph.D. and complete a lengthy
internship in a clinical setting. Most clinical psychologists develop
competence in both diagnostics and intervention. The area of
diagnostics includes individual interviews, psychological testing, and
personality assessment (psychological evaluation to determine what a
client's difficulties are). Intervention (the actual approach used to
help a person) includes individual psychotherapy, group therapy, and
marriage and family therapy.

{43}

The objective of _counseling psychology_ is to encourage growth in the
three major life areas of family, work, and education and to prevent
excessive psychological stress in them. Like clinical psychologists,
counseling psychologists receive training in individual, group, and
marriage and family counseling as well as in vocational counseling,
assessment, and rehabilitation.

Often, you will find clinical psychologists in private practice, while
many counseling psychologists hold positions in organizations, schools,
and social service agencies. Counseling psychologists generally have a
master's degree or Ph.D. and also are required to complete internships
in supervised counseling.

_Psychometrists_ are specifically trained to give and to evaluate
psychological tests. They are, so to speak, the "radiologists" of the
fields of counseling and psychotherapy. Clients may be referred to a
psychometrist in order to take one or more psychological tests; the
psychometrist's interpretation of the results is then forwarded to the
client's therapist or counselor. Increasingly, psychologists are being
trained to do much of this work themselves, so it has become less
common to refer clients to psychometrists unless an extensive amount of
testing is desired.

If you are advised to take one or more psychological tests, you may be
interested in knowing what to expect. Many psychological tests are
multiple-choice. You are given a printed list of questions and an
answer sheet. There are no "right" answers. You answer such questions
as "Would you rather go to a party or stay home and read a good book?"
Tests like this attempt to provide insight into a client's outlook,
personality, concerns, values, and interests. Some tests help to
assess concentration, coordination, and problem-solving ability.
Results of psychological tests can be helpful to a counselor in
deciding how best to treat a client's problems. Testing can be a great
time- and money-saver in therapy: the results of a twenty-minute test
can give a counselor information about a client that might otherwise be
gained only through a number of sessions.

FEES

Because of their more advanced training, clinical psychologists can be
expected to charge fees that are somewhat higher than what social
workers in private practice receive. Charges for {44} the services of
a clinical psychologist are made on an hourly basis; counseling
sessions usually last forty-five to fifty minutes, although some
psychologists will see clients for shorter periods.

Rates vary considerably according to geographical area. An approximate
range of $50 to $80 per private session is normal at this time. Group
session rates tend to be significantly lower.

If you consult a clinical or counseling psychologist who works through
an agency, you will often find that a sliding scale is used to
determine charges, as in social work. If you have limited or no health
insurance, and financial concerns are a problem, you can telephone
counseling agencies in your area to ask whether a sliding scale is used
and, if so, what charges correspond to your monthly income. Later, we
will look at how to locate counseling agencies, as well as
professionals in private practice.

Fees for psychological testing, whether through a psychologist or a
psychometrist, are usually billed on the basis of the tests
administered. To give some idea, many tests cost $15 to $20 for a
psychologist to administer. This charge is passed on to the client.
The test results can sometimes be reviewed during a counseling session
so that no additional charge may be made for the evaluation of the
results.

DURATION OF TREATMENT

Duration of treatment under a clinical or counseling psychologist is
similar to that of a social work counselor. The best way to proceed is
to ask prospective therapists how long they believe it will be
necessary to see them. Most professionals will be open and candid; if
the client's goals are specific and lend themselves to "brief" therapy,
a psychologist will make this clear. And, as we have already observed,
much depends on the type of therapy practiced by the psychologist.
Behavioral therapies tend to be of shorter duration; psychoanalysis is
longer-term. In between these there are, as we will see, many
therapies that have different emphases, methods, and goals.

PSYCHIATRISTS

ORIENTATION AND TRAINING

Before they specialize in psychiatry, psychiatrists receive the {45}
training required of any physician. After this, there is specialized
course work followed by a period of psychiatric internship. The
educational background of psychiatrists enables them sometimes to
identify physical bases for emotional difficulties. A later chapter
discusses this growing area of awareness.

Until fairly recently, the therapeutic training of psychiatrists
emphasized almost exclusively the approach of psychoanalysis.
Psychoanalysis developed within a medical context: Freud was a
physician, and his outlook was influenced by his medical orientation.
His approach was therefore felt to be the special province of
psychiatric medicine. Eventually, as we have already noticed, the
methods of psychoanalysis came to be used by psychologists and some
social workers. But for a long period, analysis was the primary and
exclusive focus of medical psychiatry.

The psychoanalytical orientation still dominates much psychiatry, and
many psychiatrists in private practice use psychoanalysis as their
therapy of choice. However, there has been a general broadening of the
perspective of psychiatrists. Other approaches to psychotherapy are
increasingly being used by psychiatrists. Cognitive therapy is
important among these; we will discuss its purpose and methods later.

Psychiatrists are the only therapists who may prescribe medication, and
some of the most important recent advances in psychiatry have come in
this area. Many emotional problems appear to have a biochemical basis.
Many forms of anxiety, panic disorders, and depression respond well to
the growing family of psychopharmaceutical drugs. Other emotional
difficulties, including alcohol and drug abuse, can be moderated by
pharmaceutical therapy.

Psychiatrists, then, can be especially helpful in these ways:

* to provide a medical evaluation for complaints that sometimes have a
physical basis

* to give assistance especially by means of psychoanalysis and by means
of an increasing number of alternative therapies

* to help patients with medication to acquire a degree of emotional
equilibrium that will allow them to begin to solve personal problems so
that, in time, they may no longer require medication

{46}

Although an M.D. may call herself or himself a psychiatrist, most
psychiatrists have had specialized advanced training in psychiatry.
Full qualifications involve completion of a residency in psychiatry,
full membership in the American Psychiatric Association, completion of
a program of study at an institute of psychotherapy, and board
certification. Many psychiatrists who practice are eligible for board
certification but simply have not yet taken the national examinations
that are required in order to be certified by a national examining
board. Although apparently many of us need to be reassured of this,
you need not feel that there is anything wrong or embarrassing about
asking a prospective psychiatrist, or his or her secretary, to describe
the doctor's background and training.

FEES

At the time of this writing, the fees of psychiatrists in private
practice range approximately from $75 up to $100 and occasionally more
per session. Private psychiatric assistance is therefore largely
reserved for the fairly well-to-do or for those who have health
insurance with substantial psychiatric benefits.

Fortunately, psychiatric care is available through many agencies; those
that are run by counties and states normally have sliding scales (some
private agencies will also take an individual's finances into account
when setting fees). Rates for consultation with a psychiatrist at a
public agency can be very reasonable (as little as a few dollars per
visit, depending on the patient's income). This makes the services of
psychiatrists available to those with modest or low incomes.

DURATION OF TREATMENT

If a psychiatrist finds that an emotional problem has a physical basis,
or that it is due to biochemical depletion or imbalance in the body,
successful treatment may be relatively short, sometimes a matter of a
few months.

If you choose to enter psychoanalysis, then the duration of treatment
generally will be longer, often lasting a year and more; during this
time, psychoanalysts may expect you to come for two or three sessions
each week.

Shorter-term therapies, such as cognitive therapy, are--in part because
of the normal long duration required by psychoanalysis--increasingly
advocated by psychiatrists. Biofeedback and relaxation training (see
Chapter 5) are also among these shorter-term approaches. They may be
effective within a period of several months.

In this chapter, we have discussed the professions that make up the
mainstream of professional practice in counseling and psychotherapy.
However, beyond the established and more closely regulated professions
of social worker, psychologist, and psychiatrist, there are a number of
other kinds of therapists who offer services that are sufficiently
different in nature that they deserve to be treated in a separate
chapter. The next chapter describes their contributions to therapy.

{48}

THE THERAPEUTIC JUNGLE,
PART II

Outside the Mainstream

Outside of any profession's frame of reference that defines what
problems it will handle and how, we usually find a group of approaches
that do not completely fit the established mold. They often can
contribute creative and innovative ideas, and yet they often lead to
abuses in the name of novelty and experimentation. And sometimes an
older approach that fails to fit the newer frame of reference is left
behind, to keep company with more radical approaches.

Just these things have happened in the practice of counseling and
psychotherapy, as we will see.

RELIGIOUS COUNSELORS

The world's first professional counselors were religious. Guidance
from priests, rabbis, and pastors has a long tradition. The tradition
is such an old one, in fact, that going to talk to a religious
counselor has a respectability that the public has generally not yet
extended to other forms of counseling.

Many people with problems, even people with a religious attitude or
upbringing, tend to ignore the kind of help religious counselors may be
able to give. This probably stems from the {49} belief that social
workers, psychologists, psychiatrists, and some other certified
therapists whom we will discuss in a moment have received special
training in helping people with personal, emotional problems, whereas
religious advisors have not.

However, this is not universally true. Many professional religious
representatives now _do_ receive training in contemporary therapies.
Increasingly, Catholic, Protestant, and Jewish educational institutions
are incorporating course work and workshops in modern counseling
methods into programs of study for priests, pastors, and rabbis.
Individuals who have been trained in this way are easily located within
a religious organization; a telephone call to the organization should
give you leads to follow.

In spite of the widespread attempt many religious institutions are
making to remain up to date on contemporary approaches to counseling,
there is probably something also to be said for traditional guidance.
All religious views seek to fulfill the needs of men and women to find
meaning in everyday life and to cope effectively with life's hardships.
Contemporary approaches to psychotherapy and counseling can offer much;
their history, however, is comparatively brief, extending over just the
last century. For many people--depending on their inclinations,
values, and sympathies--traditional religious guidance may provide much
that is as yet not to be found in the more scientific and systematic
schools of contemporary therapy.

If you decide to go to a religious professional for counseling, you
will probably find the process relatively informal and friendly. Also,
religious professionals generally expect that their private counseling
services will not be remunerated; contributions to the supporting
religious organization are of course hoped for but are often not
required in exchange for guidance.

In contrast to the authorized community of social workers,
psychologists, and psychiatrists, it can be more difficult to locate a
religious professional who _specializes_ in a particular approach to
counseling. The background in modern approaches to counseling that
religious professionals tend to receive is "eclectic." They normally
receive training in a variety of approaches; their programs of study
are based on the belief that flexibility in counseling is essential,
that nothing works well for everyone. This openness can be of value to
many people. But, as you read this book, you may decide to locate a
therapist who has a certain {50} specific orientation. He or she may
be a religious counselor, a psychologist, or another qualified
professional. In general, if you have a specific form of therapy in
mind, you will have to ask a prospective therapist whether he or she
has the training to give you the kind of help you are looking for.
This is especially true of religious counselors.

BIOFEEDBACK THERAPISTS

Biofeedback is a newcomer to the therapeutic world that has grown
tremendously in popularity in the last ten years or so. Biofeedback
therapy gradually enables individuals to become aware of certain
physical changes in their bodies. These physical changes are detected
by means of sensitive measuring instruments that give information back
to clients so they can learn to control a particular physical response.

Biofeedback is used by therapists who have been specially trained in
its use, as well as by some licensed psychologists, psychiatrists,
social workers, physical therapists, speech pathologists, and even some
dentists. Some psychiatrists now work jointly with a biofeedback
therapist: the psychiatrist can prescribe medication and provide
psychotherapy or analysis, while the associated biofeedback therapist
can teach patients how to lessen their responses to pain and
stress-related problems.

The Biofeedback Society of America is an interdisciplinary group of
healthcare professionals; it is presently developing training standards
and guidelines for certification of biofeedback practitioners.

RELAXATION, HYPNOSIS, AND MEDITATION THERAPISTS

Relaxation training, hypnosis, and meditation all seek to bring about a
deep sense of relaxation in a person. We will examine each in greater
detail later; a short overview of these approaches is given here.

RELAXATION TRAINING

Relaxation training involves exercises that enable a person to learn to
induce _at will_ a state of physical and mental calm. Relaxation
training is a practical skill--it can be very effective {51} and useful
in coping with stressful situations. Like any learned skill, control
comes only with practice, usually over a period of several months.
Many social workers and psychologists teach clients relaxation
techniques. Certification standards specifically for relaxation
training have not been established.

HYPNOSIS

Hypnosis involves two stages: (1) progressive, deep relaxation to a
point at which an individual is in a peaceful, trancelike state, still
self-aware but profoundly relaxed; and (2) suggestion, which persuades
the person to adopt certain future attitudes, thoughts, or behavior.

Hypnosis, like relaxation training, can be learned. Most people
treated by means of hypnosis steadily improve in their ability to be
hypnotized so that they can more effectively allow themselves to be
influenced by means of carefully planned suggestions. Many
psychologists and psychiatrists make use of hypnosis in the context of
therapy; some practitioners treat patients exclusively by means of
hypnosis.

The certification of therapists trained in hypnosis is still unsettled
in many states, where anyone can hang out a shingle. Since many
licensed psychologists and psychiatrists and some certified social
workers _do_ receive professional training in hypnosis, these are the
professions to which it is most reliable to go for hypnotherapy.

MEDITATION

Meditation is still a "fringe" therapy. Techniques of meditation tend
seldom to be taught to clients in psychotherapy, although there is a
growing body of evidence that meditation is able to bring about great
resistance to stress, an increased sense of inner calm, and even actual
changes in brain-wave patterns associated with deep relaxation. These
effects of meditation are now being studied, with encouraging results.

The practice of meditation is, in the author's view, at present best
learned on one's own, although some commercial organizations provide
instruction. A later chapter discusses approaches to meditation and
suggests some of the ways meditation can be of value.

{52}

HOLISTIC THERAPIES:
BIOENERGETICS, YOGA, AND EXERCISE

Holism views man as a unity of body and mind. The established
approaches to therapy and counseling, represented by social workers,
psychologists, psychiatrists, and to a certain extent by some religious
professionals, all focus attention on our mental-psychological
dimension. Similarly, biofeedback, hypnosis, and meditation emphasize
the central role of _mental_ control.

Holistic approaches, on the other hand, attempt to bring about positive
change by means of emphasis on physical factors that are believed to
have a close connection to mental processes. Although holism sees
human beings as integral organisms, holistic approaches are inclined to
have this physical focus.

Holistic therapies, like meditation, are "fringe" therapies. They are
not generally employed by members of the "authorized" community of
health practitioners, for two reasons: First, a kind of professional
respectability and elitism have come to be associated with the
psychological approach; social work, psychology, and psychiatry have an
established place in institutions of higher learning, whereas fringe
therapies do not. Second, since physicians treat the body, there is an
institutionalized prejudice against nonmedical treatment that has the
same focus.

Chiropractic has encountered this problem, as have other forms of
holism, such as bioenergetics, yoga, diet therapy, and rolfing.

Although much of value may be offered by these fringe therapies, they
have also resulted in abuse to consumers. Because of a general absence
of licensing standards and of scientific credibility, people frequently
are drawn in by the sometimes extravagant promises of unscrupulous or
overly enthusiastic fringe therapists. In this area, as in all others
that affect the consumer, the proper attitude is one of healthy
skepticism and restraint.

BIOENERGETICS

Of these holistic therapies, bioenergetics is perhaps considered the
most respectable because it _is_ used by some psychologists.
Bioenergetics attempts to diminish an individual's psychological
defenses by means of sequences of specially designed {53} physical
exercises that, in a controlled and deliberate way, stress the person
physically. Practitioners of bioenergetics believe that physical
exercises of this kind rapidly put a person in touch with buried
(repressed) feelings and speed up the process of inner integration that
all holistic practices, as well as traditional therapy, wish to achieve.

YOGA

Yoga exists in various forms. The two main varieties are hatha yoga
and raja yoga. Hatha yoga emphasizes physical flexibility; raja yoga
teaches breathing techniques and meditation. Hatha yoga, because of
its focus on the body, belongs to the family of approaches we are
considering here.

Hatha yoga practitioners believe that the physical flexibility and
control that are acquired through an extended period of physical
training in yoga exercise tend to influence your mental orientation.
You become, in this view, more flexible, less rigid, less defensive,
less subject to stress, more open, responsive, alert, and capable of
warmth in human relationships.

EXERCISE THERAPY

Counselors and therapists are starting to take very seriously the idea
that exercise brings emotional benefits. Exercise therapy, more so
than other physically based approaches discussed in this chapter, has
been tested in various ways. Many emotional conditions--for example,
anxiety and depression--seem to be significantly reduced thanks to
periods of sustained vigorous exercise. Tolerance to stress and to
pain appears to be increased. Physical exercise can be an outlet for
pent-up hostility and aggression that, according to many theorists, may
be turned inward, then fester, and eventually take the form of a
variety of psychological disorders. Furthermore, vigorous, sustained
aerobic exercise--like running or swimming--appears to have a calming
effect as a result of certain chemical compounds that are released into
the bloodstream. We will look at some of the interesting recent
studies of the therapeutic value of exercise later on.

{54}

WHERE YOU CAN FIND HELP

PRIVATE PRACTICE

As we have seen, social work counselors, psychologists, psychiatrists,
biofeedback therapists, hypnotherapists, and other therapists may all
offer their services through private practice. In general, there can
be definite advantages to counseling in the setting of a therapist's
private practice. You are given a degree of personal care that, as an
individual paying customer, you are less likely to receive in
counseling provided by agencies. You become part of a therapist's own
practice, so it is natural for him or her to devote special attention
to you. Therapists are likely to be more personally involved in their
private practice and in the quality of care they try to give their
private clients than it is possible or even personally desirable for
them to be when they work by the hour for an agency.

On the other hand, private sessions with a therapist tend to be
considerably more expensive than counseling can be through many
agencies. You ought not to take too seriously general comparisons
between therapy as you may encounter it privately and therapy in the
setting of an agency. You can often find a counselor who is congenial,
interested, attentive, and skilled; whose services will be easier for
you to bear financially; and who {55} offers his or her services
through an agency. If finances are restrictive for you, you should
look into agency-sponsored counseling.

Many social work counselors, psychologists, and some psychiatrists who
maintain private practices intended mainly for individual therapy also
offer group therapy. Often, a therapist will observe that a number of
individual clients share certain problems and experiences, and he or
she will suggest that these people meet together as a group. The
per-session price can be expected to be a good deal lower than for
individual sessions; the rate usually reflects the number of people who
meet in the group and the length of time the group is expected to
continue.

Some social workers and some psychologists _specialize_ in group
therapy. Groups are formed periodically, run a set number of weeks,
and may or may not bring together individuals with common problems.
Some group therapists believe that diversity in a counseling group is
valuable: in such a group, you might find one person combating
alcoholism, another trying to cope with loneliness and grief after the
death of a spouse, someone trying to break out of the confines of
shyness, a person suffering from public speaking anxiety, someone
wanting to change careers but who is blocked by fear, and others. An
exchange of views among participants with diverse backgrounds can
frequently encourage growth in the group members.

Most counseling agencies also offer group therapy, as do many hospitals
and schools. We will take a look at each of these settings in turn.

COUNTY, STATE, AND PRIVATE AGENCIES

Individual, marriage and family, and group counseling are all offered
by many counseling agencies.

County and state agencies receive public funding and usually have
sliding scales for the rates they charge. Often, one or more
psychiatrists work in association with counselors, who may be social
workers or psychologists. If you go to a county or state agency, you
will probably be interviewed initially by a receptionist or nurse. You
will be asked questions about your financial situation and health
insurance coverage, if you have any, and you will be asked to agree to
a proposed rate for the services of the agency. Some county and state
agencies make a monthly charge {56} for their services; you may consult
regularly with members of the staff, counselors and/or psychiatrists,
in accordance with your individual needs.

Private counseling agencies function in a similar way. Their services
tend to be more expensive because they do not receive public financial
support, as do county and state agencies.

Many health insurance plans that provide psychological benefits can be
used to pay for the services of a private or a public counseling agency.

HOSPITALS AND OTHER INPATIENT SERVICES

Individuals with severe problems who need complete care can enter
private, county, or state hospitals that offer psychiatric services. A
separate chapter discusses pros and cons of the sometimes frightening
alternative of hospitalization.

Again, publicly funded hospitals tend to charge on the basis of a
sliding scale, which takes a person's financial situation into account.
Where financial concerns are not pressing, private hospitals in general
tend to offer a greater degree of individual attention and higher
quality of care and physical facilities.

In addition to hospital facilities, many metropolitan areas have
established organizations to provide counseling services on an
inpatient basis. Some are private; some are public. They offer an
alternative to hospitalization. They tend to be more informal and open
and are managed by their own staffs of professional counselors and
psychiatrists. These residential care facilities usually are intended
for stays of from one to several weeks. They have a variety of
counseling programs, ranging from individual therapy to group
counseling and vocational guidance.

One way to locate such an inpatient organization is to telephone a
crisis intervention (sometimes called _suicide prevention_) number
likely to be listed at the beginning of your telephone directory. A
volunteer probably will answer your call and should be able to direct
you to inpatient facilities available in your area.

ACADEMIC SOURCES OF COUNSELING

Counseling is one of the services available to full- and part-time {57}
students who are enrolled in junior or four-year colleges and graduate
schools. Many educational institutions offer individual counseling,
normally by counseling psychologists, and all colleges offer academic
advising in the context of a certain amount of vocational guidance.

Colleges with programs in counseling and psychology usually also offer
certain classes with a practical, problem-solving focus. Although they
may not be specifically intended to help individual students with life
problems, this is in fact what they frequently end up doing. It is
inevitable for students in a practically oriented counseling class to
apply much that they learn to their own problems. Many class meetings
of this kind tend to be almost indistinguishable from group therapy
sessions: students receive guidance from a professionally trained
instructor, exchange views, and express personal concerns. You might
think of college classes with a practical, psychological emphasis
especially if you are drawn to therapy as an opportunity for general
personal growth.

Classes of this kind may be offered in a college's regular programs,
which are sometimes open only to students working toward a degree.
Other similar opportunities, however, are available through many
continuing education, or adult education, programs. Many secondary
school districts offer practical, psychologically-focused classes for
adults who do not choose to enter a degree program. This is also true
of community, state, and many private colleges.

Colleges and private professionals offer intensive workshops with a
variety of counseling emphases. Two-day weekend workshops have become
especially popular. Topics range from alcoholism, drug abuse,
child-rearing problems, and separation and divorce to illness and
chronic pain, marital concerns, depression, stress control, and so on.
Newspapers announce counseling workshops; you will often find notices
about them posted in public and college libraries.

SOME REFLECTIONS ON WHERE YOU GO FOR COUNSELING

You should bear in mind that where you go for counseling or therapy is
nothing more than an address. What is important is what happens in
your relationship with your counselor or {58} therapist. If you have
found a therapist whom you respect and feel motivated to work with, it
makes little difference, as far as the benefits you obtain from therapy
are concerned, whether your therapist works in private practice or
offers his or her services through an agency, school, hospital, or
residential facility.

On the other hand, where you go for counseling _will_ greatly determine
the price you will pay for services and frequently whether health
insurance will cover your expenses. To some extent, where you go can
sometimes, as we have noted, influence the quality of care and
individual attention you receive. But this is a generalization; you
frequently will be able to locate excellent care through less expensive
facilities. This will depend to some extent on luck, but more on the
amount of effort you put into locating the kind of help you may need.

Since you are reading this book, you already have initiative like this:
you have the ability to influence what kind and quality of therapy you
will receive. For you, it will be less a matter of pure luck than it
is for people who choose a therapy and therapist arbitrarily.

{59}

SELF-DIAGNOSIS

Mapping Your Way to a Therapy

This chapter is central to your use of this book as a guide. There are
two main ways to use this book to help you to choose a therapy:

1. You can familiarize yourself with all of the major approaches to
therapy, weigh their advantages and disadvantages in relation to your
needs, and then make a choice. Twenty-six approaches to therapy are
discussed and evaluated in this book, so keeping your judgments of
their pros and cons clearly in mind can be challenging. Although
comprehensive understanding has a value of its own, it may not be
essential to you.

2. You may prefer to go through three simple steps to narrow the
alternatives down to a small number of therapies that have been most
successful for specific goals, problems, and personal attributes that
most closely approximate your own. This is a less time-consuming
process, and it will take into account professional evaluations of the
different therapies.

In either case, your informed judgment will be the basis for your
eventual choice. This chapter is intended to help you if you prefer
the second route--to narrow down the alternatives in a clear and
logical way. If you prefer, however, to become acquainted with all of
the major therapies discussed in this book, {60} you might skim through
sections of this chapter to give you a framework for more efficient
understanding.

The information in this chapter relates to many different sets of
goals, problems, and kinds of people. Not all of this information will
be relevant to you, so you will find instructions to direct you to
specific recommendations that take into account your own needs and
interests.

This chapter is where practical and prudent planning can begin. In
fact, this book represents the first attempt to match you, your
personal qualities, and your goals with the most effective therapy or
therapies available to you.

Even though nearly all of the main approaches to counseling and therapy
are creations of the past century, it may seem surprising that no
unified effort has been made to identify what specific kinds of
problems each approach is especially useful for treating and for what
types of clients. In this respect, the field of medicine is much
better developed. The discipline of medical diagnostics is now on the
verge of becoming scientific, and it is now possible to identify for
many conditions and in individual cases very concrete and well-defined
treatment procedures that are likely to be effective. This has not
been true in the field of psychology: most research efforts have so far
gone into formulating definitions of the various mental and emotional
disorders. But the important work, from the prospective client's point
of view, had yet to be done: to make it possible for him to know--in
relation to his individual problems, goals, interests, abilities, and
temperament--which approaches to therapy are likely to help him the
most.

If you are in serious emotional pain, waiting until all of the research
results are in is just not possible; you need help _now_. In spite of
incomplete knowledge in psychotherapy, a large body of information has
come from studies of the effectiveness of therapies for different
problems and for different kinds of people. But until now this
information existed only in fragmented form and was familiar only to
professional psychologists. Enough data are in to begin to draw
reasonable guidelines for individuals who seek psychological help.

The mapping process described in this chapter is the result of
assembling and then organizing large quantities of data from many
sources. It was then necessary to design an easily followed {61}
step-by-step approach to enable you to narrow down the many therapeutic
alternatives to a small number that, through your efforts and the
assistance of a therapist, can be of help to you. Guidelines of this
kind are never static; they will change to some extent as time and
knowledge advance.

OBSTACLES TO FINDING A THERAPY THAT FITS YOU

There are real obstacles to efficient treatment in psychotherapy. They
cost people much time, energy, hope, and money as they try to find
appropriate help. Psychotherapy is not yet a systematic field.

There are three main reasons why it is so difficult to find approaches
to therapy that will fit individual clients and their needs:

* Emotional and mental difficulties vary tremendously. Psychologists
and psychiatrists are still in the process of classifying the kinds of
emotional and mental problems people have.

* People are individuals. Their personalities, likes and dislikes, and
motivations for entering therapy differ greatly.

* Therapists, too, are individuals. Their personalities, interests,
values, and motivations for _offering_ therapy differ greatly. Their
professional training and preferences in favor of one or several
approaches to therapy also vary significantly.

As a result, what works for one patient will not necessarily work for
another. _What_ helps and _who_ helps in one person's situation may
not help in another's. Yet all three of the factors on which effective
treatment depends--a patient's goals and problems, his or her
personality traits, and the approach of the therapist--in many cases
_can_ be matched intelligently. You, as a prospective client, know a
great deal about yourself; it doesn't make sense to choose arbitrarily
among the many therapies. It takes very little time to map your way:
in the process, you will learn more about yourself, what to anticipate
in therapy, and in what direction to start.

{62}

REALISM: A GOOD BEGINNING

In order to identify one or more therapies that may be most promising
in relation to _your_ goals, _your_ problems, and _the kind of person
you understand yourself to be_, you must begin your search with a good
measure of realism.

SETTING GOALS

It can be very difficult for anyone who is seriously troubled to think
clearly and use good judgment. You may find it hard, perhaps
impossible, at this time to identify your goals. You may feel
confused, anxious, depressed, and not know why you feel that way. Even
so, you will find as you read on that you can set important goals for
yourself.

If you are at a loss and have no sense of purpose, _that_ fact gives
you a goal to work toward in therapy: to develop clearly thought-out
goals. Though you may not know what precipitated your feelings of
confusion, anxiety, or depression, you at least _know_ that you feel
confused, anxious, or depressed, and you will find recommendations in
this chapter on how to find appropriate help for your suffering. Do
not judge yourself harshly if you lack a sense of direction or if you
are troubled but do not know why. Just keep reading.

OPENING YOURSELF TO CHANGE

There is a second thing you should be realistic about when you do know
what you want and what your problems are. Our experiences and what we
learn about ourselves _change_ us. If you enter therapy based on your
present perceptions of yourself, it is likely that these are going to
change to some extent as a result of your experiences in therapy. Does
that mean that you cannot plan or select a therapy intelligently?
Clearly, it doesn't. _Everyone has to start where he or she is_.
There is no other choice. But you should try to persuade yourself to
be open to changes in your views and feelings. If you feel rigid about
your own perceptions of yourself, it is just possible that your
rigidity may be contributing to the problems you want to resolve. As
in any attempt to learn or to change, it is important periodically to
reevaluate your needs, values, and the results you may have achieved so
far. If you select a therapy using the structured {63} approach in
this chapter, you may decide to retrace your footsteps a few months in
the future. You may find that you would take a different path in the
light of what you then see.

BEING HONEST ABOUT YOURSELF

There is a third piece of realism that I would like you to consider,
and this is _very_ hard for anyone to take to heart. If you can, you
are a very unusual person. Answering the following questions honestly
takes some real courage. But you must ask yourself: "To what extent do
I _need_ my present symptoms? Is it useful to me _not_ to have a sense
of direction? Am I somehow _benefiting_ from feeling depressed? Is my
anxiety _helpful_ to me in some way?"

You may think these suggestions are no more than contrived and unkind
psychologizing. After all, who _chooses_ to suffer? Does anyone
_want_ to wake up at 4:00 A.M. shaking and crying? Yet, again and
again, therapists who care very much about their patients find that
many of them "cling to their symptoms with the desperation of a
drowning man hanging onto a raft."[1]

[1] Lewis R. Wolberg, _Hypnosis_ (New York: Harcourt Brace Jovanovich,
1972), p. 238. (In this guide, see Chapter 15, on hypnosis.)

For diverse reasons, many people--even people who are suffering
greatly--do not _want_ to change. Their unhappiness, pain, and
confusion can serve numerous functions. You may not believe this right
now, but from time to time as you read this book, and later in your
life, this question may occur to you, if only for a moment: "How may
this unresolved problem benefit me?"

The plain truth is that even suffering can confer benefits on us. This
is at the root of much of the tragedy of emotional problems that prove
to be resistant to treatment. The distressed, despondent, overwrought,
and trembling person seated before the therapist may have found a way
to gain the attention he was unable to get otherwise. Or perhaps his
suffering is a way to lighten a burden of guilt that eventually caused
an inner collapse. There are many "benefits," many very good reasons
to want _not_ to change but to try _anyway_.

So, before you begin to seek a specific type of therapy, try to be
realistic and keep these thoughts in mind:

{64}

1. Specifying clear-cut goals and understanding why you feel troubled
are not essential now. Certainly it will be helpful if you can
translate vague complaints into concrete problems, to help both your
own understanding and eventually your therapist's. The more specific
you can be about what is troubling you, what situations especially
distress you, and what has motivated you to come to therapy, the easier
it will be for you to find help and for the therapist you choose to
help you. But in times of crisis, clarity can be very hard to gain, so
be patient.

2. If you do have clear-cut goals and a good understanding of yourself
now, use these to plan how to proceed, remembering that openness to
change will profit you and that, in all likelihood, your initial
perceptions of yourself will change as you become involved in therapy.

3. You may, at least now, need your symptoms, however painful they may
be. How successful therapy will be for you may have a great deal to do
with your willingness to let go of the possible benefits of being
troubled, in pain, or disabled.

4. Resist digging ruts for yourself. Try to refrain from locking into
a particular course of action until you have given yourself time to
consider alternatives. Once you have chosen a direction, if after a
reasonable time the therapy and the therapist you have selected do not
seem to be helping you, it is essential to try another approach. This
is especially difficult once you have invested your time, energy, and
money and perhaps have developed a good relationship with your
therapist. You may like him or her, feel comfortable and comforted,
but if you are not gaining what you want, you have to stop and try
again.

5. Finally, have a thorough physical examination before entering
therapy, if you have not had one recently. Be truthful and open with
your physician. Some emotional and mental problems are produced by
underlying physical conditions, many of which can be treated
effectively (see Chapter 8).

HOW TO MAP YOUR WAY TO A THERAPY

The remainder of this chapter presents a three-step process {65} for
choosing an approach to therapy that is potentially best-suited to your
personal needs and personality.

In the first step, you become familiar with the main kinds of goals and
problems that motivate people to enter therapy. You check those that
seem to be most relevant to you and then try to confirm the accuracy of
your choices. This will point you in the direction of one or more
promising therapies.

In the second step, you consider a list of the main personality traits
that are relevant to your choice of therapy. Again, you check those
that seem most to apply to you and then confirm your
self-understanding. Step 2 will also direct you to one or more
therapies.

In the third step, you use your results from Step 1 and Step 2 to
select an approach to therapy that most closely matches your needs,
interests, and personality.

Let's begin.

STEP 1. DIAGNOSING YOUR PROBLEMS AND SETTING YOUR
GOALS: IDENTIFYING APPROPRIATE THERAPIES

a. Read through Table 1 (pages 67-69).

b. Check the goals or problems most applicable to you. If you are in
doubt, refer to the numbered short descriptions in the section
"Matching Your Goals and Problems with Most Promising Therapies"
following Table 1.

c. Choose one or two goals or problems that are the most important to
you.

d. Confirm your choices: Refer to the section "Matching Your Goals and
Problems with Most Promising Therapies" that follows Table 1. In that
section, read the corresponding short descriptions of the one or two
goals or problems you checked in Table 1 and ask yourself whether, in
fact, these accurately apply to you. For example, if you checked §7 in
Table 1, then read the corresponding §7 in "Matching Your Goals and
Problems with Most Promising Therapies."

e. If, after doing this, you continue to believe that the goals or
problems you checked relate to you, make a record of the therapy letter
codes given at the end of each description. You will find that
occasionally letter codes are divided into two groups: those judged to
be generally more effective (called "primary"), and a set of
alternatives ("secondary"). Now go directly to Step 2. On the other
hand, if you come to feel that the goals or problems you checked really
do _not_ apply to you, go back to Table 1 and consider other
alternatives.

{66}

STEP 2. SELF-UNDERSTANDING:
IDENTIFYING APPROPRIATE THERAPIES

a. Read through Table 2 (page 79).

b. Check the personal qualities that seem best to describe you.

c. Choose one or two of these that are the most significant to you.

d. Confirm your self-understanding: Refer to the section "Matching Your
Personality with the Most Promising Therapies" following Table 2. Read
the short descriptions of the one or two personal qualities you checked
and respond to the questions you will find there.

e. If, after doing this, you believe that the personal qualities you
checked in Table 2 do, in fact, describe you accurately, make a record
of the therapy letter codes given at the end of the questions. Now go
directly to Step 3. If, on the other hand, judging from your responses
to the questions you answered, you do _not_ feel that the personal
qualities you checked are true of you, return to Table 2 and consider
other alternatives.

STEP 3. CHOOSING A THERAPY

a. Compare the two sets of letter codes you recorded as a result of
Steps 1 and 2. If one or more letter codes are common to both sets,
make a special note of the common code(s); otherwise, group the letter
codes together.

b. Refer to Table 3 (pages 86-87), which summarizes the letter codes of
all the therapies discussed in this guide. Check the code(s) you just
listed.

c. If you feel that you have taken your time, have been thoughtful
about yourself, and now feel reasonably confident about the tentative
conclusions you have reached, turn to the chapter(s) in this book that
discuss the approaches to therapy you checked. As you read these, try
to imagine yourself as a client in each of the therapy situations
described. Which approach seems most appropriate given your goals or
problems? Do you feel that _you_ have the personal traits that the
therapy is most suited for? If so, give that approach to therapy a
reasonable trial period. If not, consider other alternatives you
checked.

{67}

AN EXAMPLE OF FOLLOWING STEPS 1, 2, AND 3

Suppose you check §3.1, shyness passivity, in Table 1. You refer to
the section following Table 1, relating to personality trait problems.
You feel that shyness _is_ something that interferes significantly with
your life, interests, and desires, and you want to do something to
overcome it. Therapies Q, C, N, and D are recommended to you as
potentially useful. Then, in Table 2, you check §7. You refer to §7
following Table 2, and you decide that you especially need to work on
pent-up feelings in need of release. Therapies C and J are suggested
there as potentially appropriate for you.

You now have two sets of therapy letter codes to consider: Q, C, N, and
D; and C and J.

Therapy C is common to both recommended groups of therapies, but you
are interested in comparing the other therapies with C. In addition to
reading about C, you decide to read the discussions of therapies D, J,
N, and Q. From Table 3, the five letter codes C, D, J, N, and Q denote
Gestalt therapy, transactional analysis, bioenergetics,
counter-conditioning, and group therapy, respectively. After reading
about these therapies, you come to feel that Gestalt therapy probably
would challenge you in especially needed ways, so you decide to locate
a therapist with training in Gestalt therapy. (For information on
locating a therapist, see Chapter 17.)

STEP 1

_TABLE 1:_

_AN OVERVIEW OF PRINCIPAL GOALS AND
MAIN EMOTIONAL AND MENTAL DISORDERS
THAT LEAD PEOPLE TO ENTER THERAPY_

§1 Personal development goals

[ ] §1.1 developing new skills and personal traits: education leading
to growth

[ ] §1.2 eliminating self-destructive habits or undesirable personality
traits: re-education leading to change (see §3 below)

{68}

§2 Disorders usually first noticed in childhood or adolescence

[ ] §2.1 mental retardation

[ ] §2.2 autism

[ ] §2.3 emotional disturbances: separation anxiety, sleep terror and
sleepwalking disorders, etc.

[ ] §2.4 suffering from childhood pain, neglect, or abuse; traumatic
experiences from childhood, unmet childhood needs

[ ] §2.5 behavior problems: hyperactivity, antisocial behavior,
movement disorders (see §10 below)

[ ] §2.6 delinquency and criminal behavior

[ ] §2.7 eating disorders: obesity, bulimia, anorexia nervosa

§3 Personality trait problems

[ ] §3.1 shyness/passivity

[ ] §3.2 loneliness/emptiness

[ ] §3.3 hostility/overbearing personality

[ ] §3.4 fear of withdrawal of affection and of abandonment

[ ] §3.5 general interpersonal problems

[ ] §3.6 need to improve effectiveness of communication skills

[ ] §3.7 difficulties in coping with persons in authority

[ ] §3.8 loss of faith in oneself or in others, or in life's purpose
or end

[ ] §3.9 low self-worth, desire for a success-identity (self-esteem
resulting from a sense of achievement)

[ ] §3.10 deep discouragement with life (see §5 below)

§4 Neuroses

[ ] §4.1 anxiety disorders, panic disorders, post-traumatic stress
disorders, etc.

[ ] §4.2 phobias

[ ] §4.3 compulsions

[ ] §4.4 noögenic neuroses (resulting from serious conflicts between
opposing values)

[ ] §4.5 psychosomatic disorders, hypochondria

[ ] §4.6 sexual disorders

[ ] §4.7 impulse control disorders: e.g., pathological gambling,
kleptomania, pyromania

{69}

§5 Mood disturbances (affective disorders)

[ ] §5.1 depression

[ ] §5.2 mania

[ ] §5.3 manic depression

§6 Adjustment problems

[ ] §6.1 in relation to a new environment or an already familiar one;
work inhibitions

[ ] §6.2 in persons with counterculture attitudes and values

[ ] §6.3 emotional difficulties arising from poverty and from the
deprivations suffered by minority groups

[ ] §6.4 inability to accept realities that limit life: e.g.,
financial limitations, restricted opportunities, aging and death (see
§9 below), jobs with "no future," responsibilities that stand in the
way of personal development

[ ] §7 Marital problems

[ ] §8 Family problems

§9 Problems related to aging

[ ] §9.1 emotional problems in facing old age

[ ] §9.2 problems facing the recently widowed

[ ] §9.3 coping with physical pain and disability

§10 Involuntary behaviors

[ ] §10.1 stuttering

[ ] §10.2 shaking or motor tic disorders

[ ] §10.3 insomnia

§11 Crisis intervention: a need for _prompt_ relief from severe
symptoms

§12 Psychoses: schizophrenia, manic and paranoid psychoses, hysterical
psychoses, etc.

§13 Organic disorders

[ ] §13.1 senescence, Alzheimer's disease

[ ] §13.2 Parkinsonism/Huntington's chorea

[ ] §13.3 substance-induced: alcoholism, drug addiction, smoking

[ ] §13.4 organic brain dysfunctions: epilepsy, narcolepsy, amnesia,
dementia, delirium

{70}

MATCHING YOUR GOALS AND PROBLEMS WITH MOST
PROMISING THERAPIES

§_1 Personal Development Goals_

These may involve either (§1.1) _adding_ new skills or qualities or
(§1.2) _subtracting_ habits or undesirable traits.

§1.1. There are basically two different approaches to achieving the
first goal:

* You identify a specific skill or personality trait you would like to
develop--see Table 1, §3. For example, you may want to develop a
stronger success-identity (§3.9), improve your communication skills
(§3.6), gain a stronger sense of life's purpose (§3.8), or become more
assertive (i.e., overcome a degree of shyness, §3.1). For references
to recommended therapies for these goals, see §3 below. For vocational
counseling and therapy: H, I, M

* Alternatively, you decide to approach self-development with a desire
for _broad-spectrum_ improvements. Therapies with this orientation are
not especially concerned with highly specific behaviors or problems but
attempt to treat the whole person so that self-esteem is gradually
increased, as are a sense of satisfaction in daily living, enjoyment of
others, and a feeling of being at ease with them.

Primary therapy (judged to be generally more effective): A, B

Secondary therapy (somewhat less effective): J

§1.2. Refer to §3 below.

§_2 Disorders Usually First Noticed in
Childhood or Adolescence_

§2.1. Mental retardation: O

§2.2. Autism: self-injuring behavior, withdrawal from reality: O, Y

§2.3. Emotional disturbances in children: S, W

§2.4. Suffering from childhood pain, neglect, or abuse: traumatic
experiences from childhood, unmet childhood needs (see §3.4): A, K

{71}

§2.5. Behavior problems in children: O, C

Hyperkinetic behavior:
Primary: Y, O
Secondary: Z

§2.6. Delinquency and criminal behavior: O, E, H, I

§2.7. Eating disorders: obesity, bulimia, anorexia nervosa: O, W

§_3 Personality Trait Problems_

§3.1. Shyness/passivity: Q, C, N, D

§3.2. Loneliness/emptiness: F, Q, D

Sense of estrangement, alienation from others: G

§3.3. Hostility/overbearing personality: E, D, N, Q

§3.4. Fear of withdrawal of affection and of abandonment (also see
§3.2 above): R or S, D, A

§3.5. General interpersonal problems:

If you are willing to work on these within a wider focus: A

Involved in relating to others on an individual basis: E, P, W

§3.6. Need to improve effectiveness of communication skills: D

In groups of people: Q

§3.7. Difficulties in coping with persons in authority: C, D

§3.8. Loss of faith in yourself or in others or in life's purpose or
end: F, G, X

§3.9. Low self-worth: B

Desire for a success-identity: H, M

§3.10. Deep discouragement with life (see §5 below): I

§_4 Neuroses_

A person is said to suffer from a neurosis if he or she has exaggerated
emotional responses or ideas of reality that blow things out of
proportion. Individuals with neuroses are able to communicate normally
or with mild emotional interference. Their emotional problems
interfere with normal living but do not impair them so that their lives
are clearly out of control (as in psychoses, alcoholism, drug
addiction, etc.).

§4.1. Anxiety disorders, panic disorders, post-traumatic stress
disorders, etc.:

{72}

_Anxiety and panic attacks_ are characterized by feelings of fear,
dread, and tension. You may have a sense of imminent disaster or
death, a feeling of helplessness often followed by depression. (These
are also symptoms of _chronic anxiety_.) Other symptoms of anxiety and
panic attacks include dizziness, dry mouth, sweating, headaches, heart
palpitations, increased blood pressure, rapid breathing, weakness,
insomnia, increased urination, a feeling of unreality, diminished
concentration, memory difficulties, indecision, obsessive thinking
about anxiety symptoms, second-order anxiety (anxiety that you are or
will be anxious), and desperation to obtain relief.

Primary: Y, H, F, V, T, W, X Secondary: H, K, U

_Post-traumatic stress disorders_ are frequently misdiagnosed as
anxiety disorders. Patients suffering from post-traumatic stress have
been exposed to situations of great stress--e.g., battlefront
conditions, rape, imprisonment in a concentration camp. These
situations are perceived as inescapable, and they leave long-lasting
emotional scars. Symptoms include reactions delayed until days or
months have passed since the trauma situation, emotional numbing,
chronic anxiety, restlessness, irritability, recurrent nightmares,
increased startle responses, impulsive behavior, and depression.

Primary: Y, in conjunction with therapies recommended for anxiety
and panic attacks.

§4.2. Phobias: Phobias are fears that are disproportionate to the
threat of a situation. They are involuntary and cannot be reasoned
away. They lead to avoidance of the feared situation.

Primary: N, L, Y, W, V Secondary: U, A, K, D

For fears of public speaking, especially: E

§4.3. Compulsions: People with neurotic compulsions engage in
repetitive rituals that give them temporary relief from anxiety.
Compulsive behaviors are often motivated by a desire for exactness and
perfection--for example, compulsive hygiene, washing, counting,
praying, reflecting about yourself, repetitive isolated thoughts,
preoccupation with trifling details, etc.

Primary: E, M, O, A Secondary: Y, T, K

Compulsions that arise, or may be resolved, in relation to your family:
S

{73}

§4.4. Noögenic neuroses: A person can be emotionally disabled by
serious conflicts between opposing personal, ethical, or religious
values. This problem has not gained widespread recognition among
psychiatrists and therapists. It is a focus of logotherapy (see
Chapter 11): G

§4.5. Psychosomatic disorders, hypochondria: Physical disorders caused
by emotional problems are psychosomatic. Examples include some cases
of colitis, stomach cramps, diarrhea, constipation, ulcers, cardiac
arrhythmias, impotence, back and neck spasms, and migraines.
Hypochondria involves an exaggerated concern over potential and
imagined symptoms of disease.

Physical examination followed by: P, C, N, W, X

§4.6. Sexual disorders: These include impotence, frigidity, vaginismus
(vaginal muscle spasm), premature ejaculation, and sexual role
disturbances when accompanied by emotional disorders or poor social
functioning (some cases of homosexuality, transsexualism): P, E, O, N,
W; sometimes with Y

If you are willing to work on this within a wider focus: A

§4.7. Impulse control disorders: e.g., pathological gambling,
kleptomania, pyromania: O, M, E, Q

§_5 Mood Disturbances (Affective Disorders)_

There are three primary mood disorders: depression, mania, and manic
depression. They may be neurotic, or they may be psychotic, in which
you experience hallucinations, delusions, and withdrawal from reality.
Each disorder may be situational or nonsituational, depending on the
role of precipitating events, such as the death of a loved one, loss of
a job, diagnosis of terminal illness, etc. Situational mood disorders
usually disappear with time. All three disorders may appear as
isolated episodes, or they may be recurrent.

§5.1. Depression: Clinical depression is not simple sadness or grief.
Severely depressed people speak slowly, laboriously. It is difficult
for you to maintain attention and concentration. You may have feelings
of hopelessness, despair, heaviness, self-blame, heightened
self-criticism, great pessimism about the future, inability to make
decisions, tendencies to think of suicide and sometimes to commit it.
Dependence on loved ones increases as you feel helpless. Interests
diminish in work, hobbies, and friends. You may cry frequently; you
may be irritable and {74} inclined to have angry outbursts. You
probably sleep poorly and awaken frequently, particularly in early
morning. Anxiety is common in about 50 percent of patients. There is
frequently little appetite for food or for sex: Y, E, P, U, T, W, X

As a sense of deep discouragement with life: H

Depressed as a result of a conflict in personal values: G

If you are willing to work on your problems within a wider focus (also
see §1.1): A

§5.2. Mania: You tend to have exaggerated beliefs in your
capabilities; you tend to be euphoric and may fall in love easily and
repeatedly. You suffer from impulsiveness, poor judgment, racing
thoughts, sometimes explosive anger. Milder degrees of mania are often
welcomed by you, family, and friends, who admire your enormous energy
and your many "irons in the fire." Only when family and friends become
aware of your poor judgment in buying sprees, delusions of grandeur, or
sexual excesses do they try to encourage you to seek treatment, usually
against your own wishes: Y (especially lithium therapy), E, P, T, W, X

§5.3. Manic depression: You are trapped on an emotional roller coaster:
at times you are depressed (see §5.1), and at other times you
experience the highs of mania (see §5.2): Y (especially lithium
therapy), and therapies listed under §5.1.

§_6 Adjustment Problems_

Some critics of psychotherapy have argued that its main purpose is to
serve the interests and values of society: a person is judged to be
"abnormal" if he does not want, or refuses, for example, to work from
nine to five all but two weeks of the year; if he does not accept the
responsibilities society claims he should respond to as an adult, a
citizen, a husband, or a father. These social demands--so critics of
therapy have argued--have been internalized by most therapists so that
therapies often do not really serve the individual's needs but rather
the prevailing belief-system of society. Whatever validity the
critics' argument may have, it relates particularly to this area of
emotional suffering that falls under the heading of adjustment
disorders.

Some adjustment disorders clearly lie outside the boundaries of this
criticism. For example, a woman faces the loss of her husband and
resulting poverty. She becomes anxious and depressed, {75} and these
feelings do not go away with time. Or, a man agrees to a job transfer,
wants to succeed at his new position, but is overwhelmed by anxiety in
his new environment. His anxiety doesn't go away.

§6.1. In relation to a new environment or an already familiar one;
work inhibitions: H, M, E, P, N

§6.2. In persons with counterculture attitudes and values: H, D

§6.3. Emotional difficulties arising from poverty and from the
deprivations suffered by minority groups: C

§6.4. Inability to accept realities that limit life: e.g., financial
limitations, restricted opportunities, aging and death (see §9 below),
jobs with "no future," responsibilities that stand in the way of
personal development: F, H

§_7 Marital Problems_

It may be worth mentioning that after a period of therapy some problems
turn out to be marital in nature even though both husband and wife
believed them to be an individual's emotional problem--the man's
problem, not the wife's, or vice-versa, and certainly not a "marital
problem." Sometimes it is only after many individual sessions of
therapy that the marital basis of a problem becomes clear. When
appropriate, the expressed willingness of a spouse to become involved
in his or her partner's individual therapy can be a real help,
providing emotional and treatment support and also saving time when in
fact the marital relationship itself contributes to the individual's
problems.

General marriage therapy: Primary: R, D, E, H, I
Secondary: P, N, I

For communication problems: R, D

§_8 Family Problems_

There is a growing realization among therapists that many individual
problems are produced by families torn by conflict. Often, family
therapy can provide more effective help to a troubled individual than
therapy that treats the individual alone. This seems to be especially
true in many cases of schizophrenia (see §12 below) and in fears of
withdrawal of affection and of abandonment (see §3.4 above).

General family therapy: S, D, C, I, N

{76}

§_9 Problems Related to Aging_

§9.1. Emotional problems in facing old age: E, G

§9.2. Problems facing the recently widowed: H, G

§9.3. Coping with physical pain and disability: U, V, W, Y, X

§_10 Involuntary Behaviors_ (see §13 below)

§10.1. Stuttering: U, G, I, O, W

§10.2. Shaking or motor tic disorders: U, G, I, Y, W

§10.3. Insomnia: V, U, W, Y

§_11. Crisis Intervention:_ _A Need for_ Prompt _Relief from Severe
Symptoms_

Crisis telephone hotlines are available in most metropolitan areas for
immediate counseling and referrals. If such services do not exist in
your area, your family physician, minister, local clinic, hospital, and
even police can be of assistance.

Primary: usually Y followed by B, C, F, or G

Secondary: W, N, O, or P

§_12 Psychoses_

If you have a psychosis, you behave in response to delusions or
hallucinations. Your behavior is seen by others as strange and
inappropriate; you are inclined to withdraw from social groups. You
are severely impaired, out of touch with reality, often unable to
communicate, illogical, rambling, incoherent. Your emotional responses
are greatly out of proportion, even inconsistent, with external events.

There are numerous forms of psychosis, including types of
schizophrenia, manic and paranoid psychoses, hysterical psychoses, and
others. Since self-diagnosis for these conditions is neither
appropriate nor likely to be accurate, no detailed discussion of the
distinct forms of psychosis will be given here. Any diagnosis of
psychosis requires a careful evaluation by a psychiatrist, clinical
psychologist, or psychotherapist.

Primary: Y (antipsychotic drugs) in conjunction with M, O, or H

Secondary: Y with S or A; Y with T

{77}

§_13 Organic Disorders_

§13.1. Senescence, Alzheimer's disease: Senescence is associated with
aging. Three-quarters of persons sixty-five years old and older have a
chronic, disabling condition such as emphysema, heart disease, or
hypertension. Most elderly individuals are able to cope with these
disabilities for the rest of their lives. Some, however, begin to have
psychological problems associated with senescence--e.g., confusion,
depression, paranoia, and sometimes delirious states: supportive
therapies: (e.g., B) and sometimes Y

In Alzheimer's disease, which is a distinct disease and not simply a
sign of aging, you may have numerous physical complaints that cannot be
traced to a physical illness. You may be irritable, lack energy, be
apprehensive, show increasing forgetfulness and changes of personality.
Family members may complain that you "are not yourself." Presenile and
senile dementia are two forms of Alzheimer's disease; both are
progressively degenerative: Y, care by family or by nursing home to
provide supportive environment, planning of daily activities, etc.

§13.2. Parkinsonism/Huntington's chorea: Both are movement disorders
that can produce psychiatric problems, including depression and
schizophrenic disturbances.

§13.3. Substance-induced: alcoholism, drug addiction, smoking.

Alcoholism: Y, O, Alcoholics Anonymous

Drug abuse: Primary: Y, Synanon, O
Secondary: M, D, K

Smoking: O, W

Potentially useful for all of the above as adjunctive treatments: T, X

§13.4. Organic brain dysfunctions: epilepsy, narcolepsy, amnesia,
dementia, delirium. There are numerous conditions caused by
abnormalities in brain function. They do not lend themselves to
self-diagnosis or treatment. The main treatment is: Y

{78}

STEP 2

TAKING YOUR PERSONALITY INTO ACCOUNT

What is challenging for a therapist is discerning the form of
learning that each patient can best utilize and then working to
adopt techniques that are best suited for the patient.... An
important area of research is a way of detecting in a patient his
optimal modes of learning. If we can pinpoint these, we can then
more precisely determine the best means of therapeutic operation.[2]

[2] Lewis R. Wolberg, _The Technique of Psychotherapy_, 2 vols. (New
York: Grune & Stratton, 1977), vol. I, p. 271.

Some people are more amenable to certain approaches to therapy than
others; for example, some people like and benefit from group therapy,
while others hate it. Sometimes what a person likes or would prefer
needs to be overlooked in favor of treatment that is believed to be
effective. But the vast majority of people who enter therapy do this
of their own volition. If the therapy they enter is unsatisfying or
downright distasteful to them, they will soon give it up. We simply
tend not to learn and profit from experiences we dislike or that don't
fit the kinds of people we are.

For some time now therapists have recognized that a client's
personality often tends to incline him or her toward certain approaches
and away from others. In the second step in identifying a potentially
promising approach to therapy, you are encouraged to take traits of
your own personality into consideration. It is not merely the goal or
problem that suggests a particular approach to therapy, but--what is
often more important--the nature of the person. Too little attention
is given to the appropriateness of an individual for a given kind of
therapy.

{79}

_TABLE 2:_

_AN OVERVIEW OF MAIN PERSONALITY TRAITS
RELEVANT TO THE CHOICE OF A THERAPY_

Choose no more than three of the following that you believe influence
most strongly the way you approach day-to-day living:

[ ] §1 Self-discipline

[ ] §2 Commitment to tasks you set for yourself

[ ] §3 Patience

[ ] §4 Initiative

[ ] §5 Tolerance to frustration

[ ] §6 Rigidity

[ ] §7 Inhibition

[ ] §8 Introversion or extroversion

[ ] §9 Motivation and capacity for physical exercise

[ ] §10 Need for acceptance, human warmth, and gentle encouragement

[ ] §11 Articulateness and analytical attitude

[ ] §12 Reflectiveness--thinking about your own feelings, thoughts, and
behavior

[ ] §13 Imagination

[ ] §14 Sensitivity to values

[ ] §15 Comfort in a group setting

[ ] §16 Severe impairments--learning, communication, or emotional
disabilities, including addictions that seriously disrupt your daily
life

{80}

In the following section, you will find questions relating to the
sixteen personal qualities listed in Table 2. For those qualities you
check, answer the questions as realistically as you can. If, for the
most part, you answer "yes" to a given group of questions, then the
approach(es) to therapy identified there may be especially appropriate
for the kind of person you are. If you answer "no" to most of the
questions in a group, then the listed therapy or therapies may not be
especially well suited to you.

MATCHING YOUR PERSONALITY WITH
THE MOST PROMISING THERAPIES

§_1 Self-Discipline_

Therapies rely on self-discipline in clients in several ways:

Are you able to _stick_ to a prescribed routine and do practical
assignments on your own outside of therapy sessions to practice
attitudes, communication skills, or behaviors?

Will you take _personal responsibility_ for coming to regular
appointments on time?

Can you _give up_ any real payoffs of being emotionally troubled?

When _any_ approach to therapy is successful, it is in large measure
because a client has strong personal motivation, a strong will.
However, some approaches to therapy depend more heavily than others on
a client's strength of determination. They include: M, O, E, P, I, N,
H, A, X, T

§2 Commitment to the Process of Therapy

Do you believe you can commit yourself to therapy that spans many
months and sometimes several years? If you hope to gain long-lasting
benefits from your experience in therapy, you will need to commit
yourself to certain practices and ways of thinking _after_ formal
therapy has ended. Do you feel that you have this kind of _tenacity_
and _ability to follow through_?

These are both qualities related to self-discipline, but they have more
to do with sustaining a process over a long period of time: in a word,
_commitment_.

Do you feel you can develop a strong sense of commitment to long-term
therapy? A

To a long-range plan for life improvement? H, M

{81}

§_3 Patience_

If you are suffering from incapacitating anxiety or depression, being
patient about the process of therapy can be very demanding. Long-term
therapies require more patience, endurance, and tolerance than do
short-term therapies.

Are you able to put your trust in a process where results are noticed
only very gradually? (If not, you may feel that what is most urgent
now is to obtain prompt relief from symptoms--see the "Summary of Main
Approaches to Psychotherapy," at the end of this chapter, to get some
idea of the average durations of the different therapies.)

Therapies especially requiring patience--with yourself, with the
challenge, or with the duration of therapy--include: A, H, M, X

§4 Initiative

Some approaches to therapy offer very little direction or specific
advice from the therapist.

Do you feel that you have the initiative to proceed without explicit
direction from the therapist? If so, what you probably need in a
therapist is primarily the capacity to understand you well, to accept
you as a person, and to encourage you in a warm and positive way to do
what you think is best: B

§_5 Tolerance to Frustration_

Do you have a fairly high threshold of frustration when your beliefs
and ideas are challenged? When you do not immediately get what you
want, can you tolerate fairly well what may seem like a long route to
get where you want to go? (Do you cope well with the frustration of
getting lost in your car, for example?) Can you tolerate, without
serious irritation, anger, or hurt, being pushed to confront some of
the pretenses or distortions or illusions you may have lived by?

Can you accept, with some calmness of mind, having someone point out to
you that you have not been as clear about things as you thought, and
that sometimes your attitudes are not consistent, that you are, to some
extent, confused? A, C, E, P

§_6 Rigidity_

Do you often find yourself trying to be, or wishing you were someone
you're not? C

{82}

Are you perfectionistic? Upset when you make even fairly minor
mistakes? Concerned that "things be in their proper place"? Are you
frequently intense and uptight? C, J

Are you "overcontrolling"--anxious when you do not feel you have things
clearly under control?

Are you depressed (see §5, Table 1) or phobic (see §4.2, Table 1)?

Do you suspect that other people think that you magnify evils, blowing
negative things out of proportion? Are you inclined to be moralistic,
dogmatic, critical, or judgmental?

Are you an uncompromising person?

Do you feel, deep down, that perhaps your expectations and demands
(concerning others, yourself, and the world) may be unrealistic?

Do you think you are often inclined to confuse what you would like with
what you need? E, P, H

§_7 Inhibition_

Do you feel blocked, inhibited, or held in check by an overly critical
self? B

Do you feel that you have pent-up feelings that are in need of release?
Do you feel stultified or oppressed by your relationships with your
spouse, friends, or family? Does your life lack emotional intensity?
Do you obtain little joy or satisfaction from living? C, J

Do you feel that somehow there are blocks _in you_ that are standing in
the way of your self-realization, of fulfilling your potential? H

§_8 Introversion or Extroversion_

Are you inner-directed? Would you rather be alone or with one or two
friends than attend a party? Are you impatient, or do you even resent
receiving unsolicited suggestions? A, F

On the other hand, are you at ease with groups of people? Is it
important to your self-image what other people think of you? (Are you
perhaps status-oriented?) Do you often find it useful or helpful to
receive advice? Q

§_9 Motivation and Capacity for Physical Exercise_

Are you free of physical handicaps?

Do you _like_ to be physically active, to exercise?

{83}

Do you begin to feel restless when a week or more goes by and you have
been sedentary?

If you are not physically fit now but are healthy, does it appeal to
you to work regularly and hard to become physically stronger and to
improve your endurance? T, J, yoga (see U)

§_10 Need for Acceptance, Human Warmth,
and Gentle Encouragement_

Do you feel that perhaps no one has ever taken the time to listen to
you, to take a genuine interest in you and in your problems as a person?

Do you feel, perhaps because of circumstances or problems over which
you've had no control, that you have received rather little human
warmth from others?

Would you prefer encouragement that is patient and warm rather than a
forceful push to change your life? B

§_11 Articulateness and Analytical Attitude_

Can you talk openly and clearly about your feelings, about what is
troubling you? Can you fairly readily describe examples of situations
that may bother you?

If you were asked to describe the _personality_ (not his or her
physical features and behavior) of someone you talked with last night
for half an hour at a party, could you do this without a lot of
hesitation and brow-furrowing?

Do you _like_ to talk about personal problem solving, about your
feelings, past events, and why you have come to feel as you do? Do you
feel a _need_ to acquire an overall sense of understanding of yourself,
your family, and how they have influenced you? A

§_12 Reflectiveness_

Do you often find yourself thinking about your feelings, about the
purpose of life, and about whether yours has a meaningful direction?

Do you tend to come home from a visit with friends or family and go
over in your mind what went on and wonder why people said and did
certain things?

Do you have a mental habit of standing apart from what you're doing and
judging yourself and your work?

Do you spend much time just "thinking about things," even dwelling on
problems that concern you? A, G

{84}

§_13 Imagination_

As a child, did you have an imaginary friend?

When you sit on a rock by a brook in the woods, do you quickly begin to
feel a special sense of relaxation? Or, watching the waves breaking on
the beach, do you find yourself lulled into a sense of absorption in
nature?

Do you enjoy reading? As you read a descriptive novel, do you tend to
"see" many of the places and people? Do the events come alive for you?
Do you find yourself thinking about the events in the book as though
they make up a real world of their own? W

§_14 Sensitivity to Values_

Are personal values very important to you? For example, do you
sometimes find yourself thinking that so much of television programming
is mediocre, trash, a waste of time? Do you _feel_ that there are
human values that are more important than how much money you make, what
model car you drive, and the luxuriousness of your home?

Are you a religious or spiritual person, whether you attend church or
not?

Do you like art, music, or literature?

Do you feel, really feel, a sense of compassion or empathy for people
who face poverty and misfortune? Do you sometimes feel guilty because
of your own situation, that there always seem to be others who are
worse off?

Have you ever faced the opportunity to take advantage of someone or of
a situation and simply decided not to (even though you _knew_ you could
do this without risk) because you simply wanted to feel honest or
retain a sense of your own integrity?

Are you in search of a richer meaning in life? Do you wonder whether
what you are doing with your life is really right for you? G

§_15 Comfort in a Group Setting_

Do you feel comfortable and safe in groups?

Do you feel friendly when you pass a house where a party is going on?

Do you enjoy parties or social gatherings?

Did you come from a family with several children? Q, C

{85}

§_16 Severe Impairments_

Do you have any learning or communication disabilities?

Are you so troubled because of emotional upheaval that you cannot work
or maintain your family responsibilities?

Do you have any addictions that are causing grief for you or others
close to you?

Do you sometimes have to "let off steam," even though you know you are
hurting others, damaging their property, or injuring yourself?

{86}

STEP 3

_TABLE 3:_

_THE APPROACHES TO THERAPY
DISCUSSED IN THIS BOOK_

In the left column are the letters used in this chapter to identify
each approach to therapy:

_Letter
Code_ _Approach to Therapy_ _Chapter_

[ ] A Psychoanalysis 9

[ ] B Client-centered therapy 10

[ ] C Gestalt therapy 10

[ ] D Transactional analysis 10

[ ] E Rational-emotive therapy 10

[ ] F Existential-humanistic therapy 10

[ ] G Logotherapy 11

[ ] H Reality therapy 11

[ ] I Adlerian therapy 11

[ ] J Bioenergetics } 11
} Emotional
[ ] K Primal therapy } flooding 11
} therapies
[ ] L Implosive therapy } 11

[ ] M Direct decision therapy 11

[ ] N Counter-conditioning } 12
}
[ ] O Behavior modification } Behavioral 12
} psychotherapies
[ ] P Cognitive approaches }
to behavior change } 12

[ ] Q Group therapy 13

[ ] R Marriage therapy 14

[ ] S Family therapy 14

[ ] T Therapeutic exercise 15

[ ] U Biofeedback 15

{87}

[ ] V Relaxation training 15

[ ] W Hypnosis 15

[ ] X Meditation 15

[ ] Y Drug therapy 16

[ ] Z Nutrition therapy 15

HOW TO USE THE INFORMATION YOU NOW HAVE

If you have followed the instructions for Steps 1, 2, and 3, you should
have identified a potentially promising therapy, or group of therapies,
in relation both to your goals or problems and to your own estimation
of certain important traits of your personality or character.

The therapy or approaches to therapy you have identified now need to be
tested, first, in your imagination as you read the chapters of this
book, which will give you an idea of what each major approach to
therapy is like, and then, if you decide to proceed, in reality, when
you have located a suitable therapist (see Chapter 17).

The need for this testing is a matter of simple realism: you now have a
sense of direction, or perhaps several alternative directions, to
consider. The approach to self-diagnosis described in this chapter is
intended to be useful, but it is not infallible; much depends on the
accuracy of your problem diagnosis, the appropriateness of the goals
you have set, and your self-understanding. Much also will depend on
the therapist you locate and how well you are able to work together.

The recommended therapies listed by letter codes for Steps 1 and 2
reflect evaluations from several sources: (1) Therapists themselves
claim that certain approaches favored by them have been shown to be
useful for treating certain problems, for realizing certain goals, and
for clients with certain personal qualities. (2) Various studies also
have attempted to demonstrate for what and sometimes for whom many of
the major therapies are most successful (see Chapter 20). (3)
Primarily in the _ordering_ of letter codes in connection with the
specific {88} goals, problems, and personal qualities listed in Steps 1
and 2, I have relied on my own experience and judgment. Letter codes
_listed first_ designate therapies that, in general, are commonly
regarded by therapists and psychologists as most useful. At times,
when general consensus appeared to be lacking, I have used my own
evaluation.

The intention in this chapter is to make explicit a simple and
reasonable process of choosing a therapy. Many therapies are not
mentioned in connection with specific goals, problems, or personality
traits. To be sure, some of the therapies that are not mentioned _can_
be useful to certain individuals who have a given goal, problem, or
trait. But the objective of this book is to improve the _general
reliability_ of a person's self-diagnosis and self-understanding. The
book is a _guide_, not a bible.

COMBINING APPROACHES

There is evidence that combining two therapies for certain problems can
frequently be more effective than using either in isolation. Treatment
for individuals suffering from severe anxiety or depression often will
combine drug therapy, for example, with one of the fourteen approaches
to therapy described in Chapters 9-12 and 14 (and listed below, under
"A"). Or, individuals who have problems due to excessive stress may,
for example, be advised to combine biofeedback, relaxation training,
hypnosis, meditation, or exercise therapy with a form of psychotherapy.

Usually, when therapies are combined, one is a formal psychotherapy and
the other is an _adjunctive_ therapy--that is, a therapy that most
often is not relied on exclusively. Some adjunctive therapies lend
themselves very well to use by individuals on their own. Combined
treatments tend, then, to employ one approach taken from list A and one
from list B:

_A (Main Therapies)_

Psychoanalysis
Client-centered therapy
Gestalt therapy
Transactional analysis
Rational-emotive therapy
Existential-humanistic therapy

{89}

Logotherapy
Reality therapy
Adlerian therapy
Direct decision therapy
Behavior modification
Cognitive approaches to behavior change
Marriage and family therapy

_B (Adjunctive Therapies)_

Drug therapy
Meditation
Hypnosis
Relaxation training
Biofeedback
Therapeutic exercise

_Approaches That May Appear Under Either A or B_

Bioenergetics
Primal therapy
Implosive therapy
Counter-conditioning
Group therapy

{90}

_A SUMMARY OF THE MAIN APPROACHES TO PSYCHOTHERAPY_

_Average_
_Therapy_ _Best Suited For:_ _Duration_[*] _Cost_[**]
--------------------------------------------------------------
_Client's Personality (not_
_all traits may apply to a_
_Problems or Goals_ _single person)_
-------------------------------------------------------------------------------------------------------------

[*] 1 = Brief therapies, frequently 12 weekly sessions or less; 2 = 3-6
months; 3 = long-term therapies, 6 months to several years

[**] = initially expensive, then $10-25/hr.; ++ = expensive
$50-100+/hr.; + = moderate, $25-50/hr.; 0 = inexpensive, $10-25/hr.; #
= often available on a sliding scale basis (see Chapter 4) through
county clinics, agencies etc

A. Psychoanalysis self-development: broad-spectrum self-disciplined 3 ++ #
improvements committed
suffering from childhood traumas patient
fear of withdrawal of affection tolerant to frustration
and of abandonment introverted
interpersonal problems articulate
phobias analytical
compulsions reflective
sexual disorders
depression
mania
manic depression
psychoses

B. Client-centered self-development: broad-spectrum inhibited 2 + #
improvements possessing initiative
low self-worth needing acceptance,
crisis intervention human warmth, and
gentle encouragement

C. Gestalt behavior problems in children tolerant to frustration 1-2 + to 0
shyness/passivity rigid
coping with persons in authority inhibited
psychosomatic disorders able to work in a group
adjustment problems: minorities setting
and the poor
family conflicts
crisis intervention

{91}

D. Transactional shyness/passivity interested in effective 1-2 0 #
analysis loneliness/emptiness communication
hostility/overbearing personality
fear of withdrawal of affection
and of abandonment
improving effectiveness of
communication
coping with persons in authority
phobias
adjustment problems
marital problems, especially
those involving communication
difficulties
family conflicts
drug abuse

E. Rational- hostility/overbearing self-disciplined 2 +
emotive personality rigid
interpersonal problems
anxiety disorders
post-traumatic stress
phobias
compulsions
sexual disorders
impulse control disorders
depression
mania and manic depression
adjustment problems
marital problems
delinquency and criminal behavior

{92}

F. Existential- loneliness/emptiness introverted 2 +
humanistic loss of faith in yourself, sensitive to existential
in others, or in life's purpose issues
inability to accept life's
limitations
crisis intervention

G. Logotherapy estrangement/alienation from reflective 2 +
others sensitive to values
loss of faith in yourself, in
others, or in life's purpose
noögenic neuroses
depression due to value conflicts
inability to accept life's
limitations
emotional problems in facing
old age
problems of the recently widowed
stuttering
shaking and motor tic disorders
crisis intervention

H. Reality desire for a success-identity self-disciplined 1-2 +
anxiety disorders committed
post-traumatic stress patient
adjustment problems rigid
marital problems
problems of the recently widowed
vocational problems
delinquency and criminal behavior
psychoses

{93}

I. Adlerian deep discouragement with life self-disciplined 1-2 + #
marital problems inhibited
family conflicts
stuttering
shaking and motor tic disorders
vocational problems
delinquency and criminal behavior

J. Bioenergetics self-development: broad-spectrum inhibited 1-2 +
improvements motivated and able to
suffering from childhood pain undertake physical
exercise

K. Primal anxiety disorders pent-up feelings 1-2 =
post-traumatic stress
phobias
compulsions
drug abuse

L. Implosive phobias (nonspecific) 1 +

M. Direct decision desire for a success-identity self-disciplined 1 +
compulsions committed
impulse control disorders patient
vocational problems
adjustment problems
psychoses
drug abuse

{94}

N. Counter- shyness/passivity self-disciplined 1-2 + #
conditioning hostility/overbearing personality
phobias
psychosomatic disorders
sexual disorders
adjustment problems
marital problems
family conflicts
crisis intervention

O. Behavior mental retardation self-disciplined 1-2 + #
modification autism possibly impaired
behavior problems in children
hyperkinetic behavior
delinquency and criminal behavior
eating disorders
compulsions
sexual disorders
impulse control disorders
stuttering
crisis intervention
psychoses

{95}

P. Cognitive interpersonal problems self-disciplined 1-2 + #
approaches anxiety disorders rigid
to behavior post-traumatic stress
change psychosomatic disorders
sexual disorders
depression
mania and manic depression
adjustment problems
marital problems
crisis intervention

Q. Group shyness/passivity extroverted 1 0 #
loneliness/emptiness tolerant to group
hostility/overbearing involvement
personality
improving communication
effectiveness
impulse control disorders

R. Marriage marital problems
supportive therapy for individual (nonspecific) 1-2 + #
problems
fear of withdrawal of affection
and of abandonment

S. Family family conflicts (nonspecific) 1-2 + #
supportive therapy for individual
problems
emotional disturbances in children
fear of withdrawal of affection
and of abandonment
family-based compulsions
psychoses

{96}

T. Therapeutic depression self-disciplined 2-3 0 or
exercise anxiety disorders motivated and able to no
post-traumatic stress undertake physical cost
marital problems exercise
alcoholism
drug abuse
smoking
psychoses

U. Biofeedback physical pain and disability (nonspecific) 1-2 + #
shaking and motor tic disorders
stuttering
insomnia
anxiety disorders
post-traumatic stress
phobias
depression

V. Relaxation anxiety disorders (nonspecific) 1-2 + #
training post-traumatic stress
phobias
physical pain and disability
insomnia

{97}

W. Hypnosis emotional disturbances in imaginative 1-2 +
children trusting
eating disorders
interpersonal problems
anxiety disorders
post-traumatic stress
phobias
psychosomatic disorders
sexual disorders
depression
mania and manic depression
physical pain and disability
stuttering
shaking and motor tic disorders

X. Meditation loss of faith in yourself, in self-disciplined 3 0 or
others, or in life's purpose patient no
anxiety disorders cost
post-traumatic stress
depression
mania and manic depression
physical pain and disability
alcoholism
drug abuse
smoking

{96}

Y. Drug autism possibly impaired 1-3 + + #
hyperkinetic disturbances
anxiety disorders
post-traumatic stress
phobias
compulsions
sexual disorders
depression
mania and manic depression
physical pain and disability
shaking and motor tic disorders
insomnia
crisis intervention

Z. Nutrition possibly hyperkinetic behavior no data available -- --
as well as other
problems (see Chapter 14)

[*] 1 = Brief therapies, frequently 12 weekly sessions or less; 2 = 3-6
months; 3--long-term therapies, 6 months to several years

[**] = initially expensive, then $10-25/hr.; ++ = expensive
$50-100-f/hr.; + = moderate, $25-50/hr.; 0 = inexpensive, $10-25/hr.; #
= often available on a sliding scale basis (see Chapter 4) through
county clinics, agencies, etc.

{99}

EMOTIONAL PROBLEMS
THAT MAY HAVE
PHYSICAL CAUSES

This chapter has a single important purpose: to persuade you, if you
are in serious emotional distress, to have a comprehensive physical
examination _before_ beginning psychotherapy. Imagine how disheartened
and frustrated you might feel after a period of unsuccessful therapy,
only to find out afterward that your problems could be traced to a
physical cause. It is essential that you eliminate the possibility of
a physical basis for your problems before seeking therapy. In fact,
most therapists routinely recommend that you have a complete physical
before entering therapy.

Rest assured that doing so will _not_ be a waste of time. Richard
Rada, Director of College Hospital in Cerritos, California, estimates
that between five and ten percent of clients with depression, anxiety,
or unusual thoughts and behavior may have underlying physical
conditions that are responsible, including gland {100} dysfunction, an
epileptic abnormality, heart disease, cancer, and so on. The following
facts, too, should convince you that having a comprehensive physical is
paramount:

* As many as one patient in every ten who suffer from serious
depression has a thyroid disorder.

* One person in every four who are diagnosed as having psychiatric
disorders and who are over sixty-five has an underlying physical
illness that is responsible.

* An equal number of individuals over sixty-five have emotional
problems that are made worse by underlying physical disorders.

* Three percent of people who regularly take prescription medication
develop mental symptoms.

Dr. Leonard Small, a specialist in the field of neuropsychodiagnosis,
has found that the more severe emotional or mental symptoms are, the
more likely it is that therapists (and patients) will overlook the
possibility of underlying physical disorders.[1]

[1] Leonard Small, _Neuropsychodiagnosis in Psychotherapy_ (New York
Brunner/Mazel, 1980), p. vii.

It isn't necessary or possible to give a detailed or comprehensive
catalog of physical causes of emotional and mental disturbances here,
but it may be helpful to many people to see some of the principal ways
in which psychological symptoms can be produced by physical problems.
Hopefully, these illustrations will persuade you, if you are
emotionally or mentally troubled, of the wisdom of a thorough physical.
It is a small price to pay if emotional symptoms can be traced to a
physical cause.

It is well known that virtually any serious organic illness or injury
can produce emotional suffering, either in the form of physical pain or
in the form of anxiety and depression. Chronic pain is a chronic
stress and can lead to the same emotional problems as prolonged stress
of any variety: anxiety or depression. Similarly, prolonged severe
anxiety or depression can cause physical deterioration and make the
body more susceptible to disease.

{101}

There are, then, two "vicious circles," or feedback loops, that can
play a role in causing or aggravating emotional disturbance:

[Illustration: The two "vicious circle" or feedback loops that may
exist between physical disorders and emotional disturbances]

In the first loop, an underlying physical disorder, which may be a
disease or a physical injury, leads to emotional symptoms (and very
likely to physical symptoms as well, although these may not be as
pronounced). However, the emotional reactions that are produced can
themselves make the physical disorder worse, and certainly emotional
disturbance makes living with and treating the underlying physical
disorder more difficult.

In the second loop, emotional disturbances cause certain physical
disorders: a peptic ulcer, heart palpitations, ulcerative colitis,
backache, hypertension, or high blood pressure, etc., and may
predispose certain individuals to arthritis, cancer, or diseases of the
immune system. Once a psychosomatic link has been established between
a troubled mind and the body, and an organic disorder has come about,
the physical disorder, in turn, can produce stronger or more
exaggerated emotional reactions. Anxiety or depression may increase
because the person is now both physically ill and emotionally troubled.

These two so-called positive feedback loops can obviously {102} lead to
a runaway process that becomes worse and worse. Psychosomatic medicine
focuses on the second of these; our focus here is on the first:
physical origins of emotional disturbance.

Underlying physical disorders of this kind include metabolic diseases,
disorders and diseases affecting the brain and nervous system, head
injuries, other physical disorders and conditions, infectious diseases,
reactions to medication, and drug addiction and alcoholism. Each is
discussed in the remainder of this chapter.

METABOLIC DISEASES

Several well-known metabolic diseases can lead to emotional
disturbances:

HYPERTHYROIDISM

An overactive thyroid, known as _hyperthyroidism_, is usually caused by
the pituitary gland's overproduction of a hormone called _TSH_, or
_thyroid-stimulating hormone_. This causes the thyroid, a
butterfly-shaped gland in the lower part of the neck, to produce an
excess of the thyroid hormone thyroxine. Hyperthyroidism is eight
times more common in women than in men.

The emotional symptoms of hyperthyroidism include a more intense and
chronic nervousness than in hypothyroidism (discussed below),
overreactions to minor crises, moodiness, frequent fear without knowing
why, a sense of agitation, dread, and occasionally trembling or
shaking. Some patients with serious hyperthyroidism may have symptoms
resembling those of schizophrenia, in which there is little or no
contact with reality.

Physical symptoms include rapid loss of weight, unusual appetite, rapid
pulse, diarrhea, and muscle weakness (especially in the legs, as when
climbing stairs). The classical symptoms of hyperthyroidism are
staring eyes and enlargement of the neck, but these need not be present.

It is interesting to note that certain factors in upbringing and
personality seem to predispose people to hyperthyroidism (this would
mean that a feedback loop of the second type may precipitate the
disease in some people). Individuals who later develop hyperthyroidism
often have these characteristics:

{103}

* They were forced prematurely to become self-sufficient and
responsible.

* They felt rejected by one or both parents and feared a loss of
emotional support.

* Their early dependence needs (their needs for affection, mothering,
warmth, etc.) were frustrated, and this led to feelings of insecurity
and low self-esteem and to the belief that the world is a threatening
place.

* They often had dominant, tight-lipped, overcontrolling mothers.

HYPOTHYROIDISM

An underactive thyroid, known as _hypothyroidism_, is caused by an
inadequate production of thyroid hormone. It is most common in
middle-aged women.

The emotional symptoms of hypothyroidism include mental sluggishness,
nervousness, depression, irritability, impatience, and frequently
dislike of everyday activities.

Physical symptoms include a sense of heaviness and lethargy, dry skin,
sensitivity to cold, constipation, and thinning hair.

HYPER- AND HYPOPARATHYROIDISM

The parathyroid glands, which are four bean-size glands located on top
of the thyroid gland, manufacture hormones that regulate phosphorus and
calcium levels in the body. Excess hormone raises the calcium level
too high, and psychotic-like behavior can result. Too little hormone
lowers the calcium level to the point that a person may behave like an
alcoholic. These conditions are comparatively rare.

DIABETES

Diabetes, or hypoinsulism, which at the time of this writing affects as
many as 2.5 million Americans, results from underproduction of insulin,
which in turn causes an excess of sugar in the blood and urine.
Diabetes takes two forms: juvenile onset (or insulin-dependent) and
adult onset (or noninsulin-dependent) diabetes. The first type starts
in childhood or young adulthood, and is caused by the body's failure to
produce enough insulin. Juvenile onset diabetes is {104} usually
controlled by means of regular injections of insulin.

Adult onset diabetes is less serious than juvenile diabetes; it occurs
more often in the elderly and especially in people who are overweight.
Diabetes can appear in a person after a traumatic event: great stress,
a physical accident, surgery, infection, or a severe emotional
disturbance. It may also appear after a person has gone through a long
period of fatigue, depression, indecision, or sense of hopelessness.
Those who become diabetic may be individuals who felt strong resentment
toward their parents while growing up or who were "spoiled children."
Diabetic men often were dominated by their mothers while being
excessively dependent on them. Adult onset diabetes is usually
controlled without insulin injections, particularly during the early
stages of the disease. Treatment in about one-third of
noninsulin-dependent diabetics is possible by diet alone; in others, it
is necessary to take oral hypoglycemic drugs that stimulate the release
of insulin.

The emotional symptoms of both forms of diabetes may include apathy,
depression, personality disorders, or even psychosis as a result of
undersecretion of insulin.

Physical symptoms include the need to urinate frequently, day and
night, unusual fatigue and weakness, tingling in hands and feet,
reduced resistance to infections (especially of the urinary tract),
blurred vision, impotence in men, and lack of menstrual periods in
women.

HYPOGLYCEMIA

Hypoglycemia, or hyperinsulism, which affects perhaps as many as five
million Americans, is caused by overproduction of insulin. Excess
insulin leads to low blood sugar (literally, _hypoglycemia_).
Sometimes this overproduction of insulin is caused by a tumor of the
pancreas; the growth can often be removed surgically to correct the
condition.

The emotional symptoms of hypoglycemia include depression and anxiety.

Physical symptoms include fast pulse, palpitations, dizziness, general
weakness, faintness, stomach pain, blurred vision, and sweating. These
symptoms often occur a few hours after eating and disappear after
eating again.

{105}

Hypoglycemia has become almost a fad disease among
"psychonutritionists." The condition is believed by most physicians,
however, to be confined mainly to diabetics who have not kept to a
prescribed routine and have allowed their levels of insulin to become
too high. Sometimes stomach surgery, liver disease, pregnancy, and
periods of high fever can cause attacks of hypoglycemia.

DISORDERS AND DISEASES AFFECTING
THE BRAIN AND NERVOUS SYSTEM

EPILEPSY

The second most common physical cause of emotionally distressing
symptoms, after the metabolic disorders we have just discussed, is
epilepsy. Approximately 7 percent of mentally disturbed patients have
some form of epilepsy.

Epilepsy affects between 1 and 2 percent of the U.S. population. Of
people who have epilepsy, two-thirds appear to have no structural
abnormality of the brain; in the remaining third, the disease can be
traced to brain damage at birth, a severe head injury, an infection
that caused brain damage, or a brain tumor.

The emotional symptoms of epilepsy can involve either anxiety or
depression or both. Once a person has had a convulsive seizure, he or
she may live in constant apprehension that another seizure will occur.
There may be occasional, transient feelings of unreality.

Physical symptoms include peculiar stomach sensations, distorted
vision, occasional bizarre behavior such as laughing for no apparent
reason or sudden and unprovoked anger, loss of consciousness, and
convulsions.

PARKINSONISM

Parkinson's disease often causes anxiety or depression. Physical
symptoms early in the course of the disease include slowing of movement
and inability to write one's name without the handwriting becoming
smaller and smaller. Later symptoms include tremors, muscle stiffness
or rigidity, nervousness, and tension.

{106}

MULTIPLE SCLEROSIS

Multiple sclerosis usually begins in people between the ages of twenty
and forty, affecting slightly more women than men. Symptoms may
disappear after one or a number of attacks, or they may get
progressively worse and cause severe disability.

Emotional symptoms include anxiety, panic attacks, and depression.

Physical symptoms may involve a feeling of numbness or tingling
affecting one limb or one side of the body, temporary blurring of
vision, slurred speech, and difficulty or lack of control in urinating.

BRAIN TUMORS

Brain tumors may cause severe headaches, blurred or double vision,
vomiting without the warning of nausea, general weakness, and, in some
cases, epileptic seizures.

Emotional symptoms may involve nervousness, irritability, memory
problems, and personality changes.

HEAD INJURIES

Head injuries that damage the brain generally cause headaches and
dizziness.

Emotional symptoms usually involve nervousness and sometimes confusion.
In more serious injuries, there may be loss of memory, depression, and
decreased alertness. Severe damage to the brain can cause
unconsciousness that may persist for days or weeks.

OTHER PHYSICAL DISORDERS AND CONDITIONS

PANCREATIC CANCER

Cancer of the pancreas can cause severe depression and insomnia. These
emotional symptoms can occur early in the course of the disease. This
kind of cancer kills nine out of ten of its victims within a year of
being diagnosed. One reason for this tragedy is that pancreatic cancer
frequently reaches an advanced stage before the appearance of its
physical symptoms: loss of appetite and loss of weight, nausea,
vomiting, and upper abdominal {107} pain that may spread to the back.
It is believed that alert psychiatrists can save many lives that
otherwise would be lost as a result of pancreatic cancer by detecting
the disease in its early stages.

ANEMIA

Anemia is caused by an abnormal drop in either red blood cells or
hemoglobin (the main constituent of red blood cells). Iron deficiency
can cause anemia, as can vitamin B12 or folic acid deficiency.
Inherited blood disorders such as sickle-cell anemia can also lead to
anemia.

The main emotional symptom of anemia is depression.

Physical symptoms include weakness, breathlessness, and heart
palpitations, which may occur as the heart attempts to compensate for
anemia by circulating blood faster than normal.

HEART CONDITIONS

Mitral incompetence is a heart condition in which the flaps of the
mitral valve, separating the upper and lower chambers of the heart, do
not close properly. The heart of a person with this disorder must
therefore work harder than normal. Physical symptoms may involve
shortness of breath and fatigue.

Paroxysmal tachycardia is another heart condition, in which the
heartbeat suddenly speeds up to 160 beats per minute or more. An
attack may last for from several minutes to several days. Physical
symptoms include breathlessness, fainting, chest pain, and awareness of
the rapid heartbeats.

The emotional symptoms of both mitral incompetence and paroxysmal
tachycardia may involve anxiety and panic attacks.

MENOPAUSE

Menopause is not a disorder but a natural condition of aging that
involves changes in hormone levels in the body. Menopause in women can
cause intermittent periods of strong anxiety, chronic nervousness,
depression, irritability, lack of confidence, and headaches. Physical
symptoms include hot flashes, sweating, and palpitations. Male
menopause is increasingly being recognized by doctors; symptoms most
frequently appear when a man {108} is in his fifties. Emotional
symptoms may involve anxiety and depression; physical symptoms include
hot flashes, sweating, fatigue, and insomnia.

INFECTIOUS DISEASES

Frequently, emotional symptoms are the first warnings of infectious
disease. For example, fatigue and nervousness maybe the only early
complaints of patients who have hepatitis, infectious mononucleosis,
tuberculosis, and many other diseases. Anxiety and tiredness are
symptoms that deserve careful diagnostic judgment; they are not always
innocuous.

REACTIONS TO MEDICATION

Both over-the-counter and prescription medications can sometimes
produce emotional or mental side effects. Too, as the number of
manufactured drugs increases, the potential for interactions among
different medications increases greatly. Certain drug interactions
produce symptoms of marked agitation, restlessness, and anxiety.
Furthermore, patients who have regularly taken a particular medication
may sometimes find that it begins to cause unexpected side effects.
"False senility" in elderly patients, for example, is often induced by
medication; when the medication is stopped, the undesirable symptoms
disappear.

DRUG ADDICTION AND ALCOHOLISM

Both are runaway habits that can cause nervousness and overreactions to
small crises. Ironically, individuals are usually first attracted to
narcotics or alcohol in order to obtain _relief_ from anxiety. But
once the addictions have become firmly established, emotional symptoms
of depression, irritability, sudden changes of mood, nervousness, and
paranoia are common, as are memory loss and difficulty in concentrating.

Caffeine is an emotionally habit-forming drug. Real addiction--i.e.,
physical dependence with withdrawal symptoms--appears to be rare.
Nevertheless, coffee, tea, and cola drinkers can become emotionally
dependent on caffeine. The drug is a {109} frequent cause of chronic
nervousness in habitual caffeine users. Smoking is a habit that causes
a person to lose approximately 5½ minutes of life expectancy for each
cigarette smoked. Beyond this, smoking is also a common but
unrecognized cause of chronic nervousness, in spite of the fact that
many smokers believe smoking will help steady their nerves.

By now it should be evident that the two main signs of emotional
distress--anxiety and depression--can sometimes be the symptoms of
undetected physical disorders. Especially in cases of severe anxiety
or depression _without_ physical complaints, both therapists and
clients tend to overlook the possibility of physical illness.

It is true that, at present, the majority of such cases cannot be
traced to underlying physical causes; they are therefore treated by
means of psychotherapy or psychiatric drug therapy. As medicine and
biochemistry develop, however, mental and emotional complaints are
increasingly being understood in more physical terms.

Emotional distress clearly does sometimes mask or camouflage the
presence of physical disorders. If you are suffering from serious
anxiety or depression, it is important to have a comprehensive physical
before _beginning_ psychiatric treatment. This is true especially when
the onset of emotional symptoms was sudden--within a period of days or
one to two weeks. It may be most useful to see a diagnostic
specialist--for example, a doctor of internal medicine. But bear in
mind that physicians, even those who are familiar with psychiatric
problems, vary considerably in their diagnostic skills, and sometimes a
second opinion can be worthwhile before you decide that the most
appropriate treatment is psychotherapy.

{111}

PART II

EXPERIENCING THERAPY

In Part II you will be able to develop an overall understanding of the
main approaches to therapy available today. We will look at
psychoanalysis, the first of the psychotherapies, developed by Freud at
the beginning of the twentieth century; and then, in the next two
chapters, discuss ten major psychotherapies. Because of their
widespread use and value, individual chapters will then focus on
approaches to behavioral psychotherapy, group therapy, and marriage and
family counseling. The two final chapters in this section deal with
the therapeutic value of exercise, biofeedback, relaxation methods,
hypnosis, meditation, psychopharmacology or the use of drugs in
therapy, and dietary approaches.

In the discussion of each approach to therapy you will find:

* _a concise description_ of its special perspective

* information on _the kinds of problems_ it is thought to be most
useful in treating--and closely connected with this, but seldom taken
into account--

* a description of _the kinds of individuals_ who tend to profit most
from that approach; and

* an account of _a successful experience in therapy_, reconstructed
from the reports of clients as they look back on their treatment

{112}

HOW TO USE PART II

There are two ways you may find it profitable to use this section of
the book. Perhaps you may decide to combine both of them.

First, you can use the "map" in Chapter 7 to define your goals and to
suggest specific approaches to therapy that, based on your own
self-diagnosis, you might find most beneficial.

On the other hand, you may not feel that mapping out your problem or
goals in the way that Chapter 7 suggests is for you. Perhaps you are
simply curious about the field and would like to learn more about it,
or perhaps you are considering counseling or psychotherapy as an
opportunity for personal growth and do not have particular difficulties
or issues that you want to focus on. For you, it may be more relevant
to read about a wide range of approaches and by so doing gain a clearer
understanding of what the alternatives are, how they work, and what
they may offer you. This "window-shopping" can then form the basis for
a more informed decision later on if you want to enter counseling or
psychotherapy.

THE EXPERIENCES OF CLIENTS IN THERAPY

The reports in this book that describe the personal lives and
experience of real individuals in therapy have all been deliberately
recast to mask all traces of their identities. Their names, life
situations, ages, and other characteristics have been changed.

Descriptions of the experiences of clients in therapy have been greatly
abbreviated and sometimes simplified. As we have already seen,
counseling and psychotherapy last varying lengths of time. Even a very
short period of therapy, over a period of weeks, will bring to light
much more detail than it would be useful for us to discuss here. The
personal lives of the real persons that are portrayed here are
immeasurably more complex and multifaceted than short reports can bring
out.

Sometimes we will use a time-lapse strategy, describing the evolution
of a person's therapy over a period of many months by skipping over
weeks at a time. Always the intent will be to try to convey to you how
real people with real problems have come to deal with their
difficulties more effectively and often, in the process, have been able
to reach a richer understanding of themselves and of others.

{113}

PSYCHOANALYSIS

_For wide-range improvements in individuals
who are not severely impaired and who are
articulate, reflective, patient, self-disciplined,
and able to make a potentially long-term
commitment to therapy._

The past hides but is present....

Bernard Malamud, _A New Life_

Psychoanalysis is the root from which the large family of different
theories of psychotherapy and counseling has grown. Sigmund Freud's
first efforts to develop psychoanalysis began in the 1880s. He lived a
long life and was active into his eighties; he died in 1939. Freud
left behind one of the most important contributions to the field of
mental and emotional health. It formed the historical basis for the
diversity of approaches that would follow. Even when later thinkers
took issue with Freud, their work in different ways relied on the
foundation of his pioneering work.

Many of Freud's ideas have worked their way into our everyday
vocabulary: the unconscious, the ego, repression, the Oedipus {114}
complex, and so forth. His work has influenced the study of
anthropology, sociology, history, philosophy, and literature.

FREUD'S THEORY

During Freud's early medical training, he went to Paris to study with a
well-known neurologist, J. M. Charcot. Charcot had begun to use
hypnosis to treat patients with certain physical disorders--paralysis,
for example--for which there was no apparent physical cause (so-called
hysterical symptoms). Working with Charcot, and later with a
physician, Joseph Breuer, Freud began to suspect that these symptoms
were _motivated_ by earlier traumatic experiences that so distressed
the patients that they were forgotten (repressed).

Freud's theory of emotional and mental illness began then to take shape
around this central idea that neurotic behavior has a _purpose_: there
is an underlying _motive_, the motive itself is very upsetting to the
person, and so it is repressed from awareness. But it continues to
gnaw away below the level of conscious awareness and eventually leads
to the disturbance that brings the patient to the point at which he or
she is in need of professional help. Freud believed that recovery
would occur if a patient could be helped to gain insight into these
painful events and feelings that had been forgotten or suppressed. In
a moment, we will look at two real examples.

Freud's theory has several dimensions. First, his theory offers an
explanation of how the mind operates through its defense mechanisms: as
we have noted, excessively painful feelings and memories are repressed.
Second, his theory tries to identify the different psychologically
critical stages children go through on their way to adulthood: the
oral, anal, and genital stages. And third, his theory seeks to
distinguish the parts of the psyche, which together underlie an
individual's personality: the _ego_ (the rational portion of the mind
that deals with reality), the _id_ (made up of basic instincts that
press for gratification), and the _superego_ (formed from parental
influences that have been internalized).

HOW PSYCHOANALYSIS IS DONE

Together, these three so-called dynamic, developmental, and {115}
intrapsychic dimensions of Freud's theory make up the general framework
of psychoanalysis. The central technique of psychoanalysis is to help
the patient become aware of motives that are unconscious.
Psychoanalysis, or analysis for short, is basically an attempt to
extend self-control, bringing disturbing feelings and behavior under a
person's conscious management.

One of the principal techniques is free association. The patient is
made to feel relaxed and comfortable--one reason a couch is sometimes
used. He is encouraged to talk in an uninhibited way about his
concerns and feelings. During this process, the analyst usually
remains detached and restrained so as not to interfere with the
patient's free expression. From time to time, the analyst shares with
the patient certain of the interpretations he has developed on the
basis of the patient's reports and behavior. The analyst's objective
is to help the patient recover lost and painful memories that are
responsible for the conflicts, weaknesses, or inabilities that cause
the patient to suffer.

This process can be very hard on the patient: he or she must revisit
experiences that may be very painful. Analysis requires perseverance,
endurance, and courage. It is not, as we will see, for everyone or
every problem.

One of the most important developments in psychoanalysis has to do with
the increasing popularity of psychoanalytic psychotherapy (also called
_dynamic psychotherapy_), meaning psychoanalysis that is extremely
brief (12 to 20 sessions, for example). Considerably more patients are
now treated with psychoanalytic psychotherapy than with traditional,
intensive psychoanalysis.

TWO EXAMPLES OF PSYCHOANALYSIS

Other than the length and intensity of treatment, the main difference
between Freudian psychoanalysis and brief analysis has to do with the
amount of emphasis that is placed on sexual matters. Freud believed
that an infant's relationship to his environment and parents is
predominantly _sensual_: a baby seeks oral gratification; his attention
is absorbed by what he puts into his mouth. Later, attention is
focused on excretory processes; toilet-training requires the child to
exercise self-regulation for the first time. Later, genital sexuality
becomes the dominant {116} interest. These sexual phases of
development identify the dominant areas of attention that influence the
infant, the child, and then the adult in their behavior toward others.

Brief psychoanalysis generally does not affirm Freud's sexually based
(libido) theory of motivation. The second example that follows
illustrates this shift of emphasis. The first example was described by
Freud himself[1]; the second illustrates brief psychoanalysis.

[1] Sigmund Freud, "Lecture 17," _General Introduction to
Psychoanalysis_ (New York: Garden City Pub. Co., 1943).

A CASE FROM FREUD

Freud describes the analysis of a girl who has repressed a strong
desire for sexual intercourse with her father and has, as a result,
developed a bizarre pattern of behavior.

Unconsciously, the dread of actually making love with him has
generalized to a dread of sexual activity of any kind. Without any
conscious intent on her part, an association is formed between sexual
intercourse and breaking a vase. She is not aware of the unconscious
symbolic connection she has established between these acts. Similarly,
she begins to associate the bolster at the head of her bed with her
father and identifies her mother with the headboard.

The pressure of this repressed material impels her to go through an
elaborate ritual each night before she can get to sleep. First she
arranges the several vases in her room so that she feels they are well
protected against being broken (thereby guarding against sexual
intercourse). Then she makes sure that the bolster does not come into
contact with the headboard (in this way she gains the substitute
satisfaction of keeping her mother and father apart).

As her analysis proceeds, and the analyst is able--and here, timing is
important--to encourage her to become conscious of her repressed
feelings and generalized dread of sex, her need for the nightly ritual
is gradually eliminated.

It is not difficult to think of other problems, sometimes of a
handicapping kind, that, because of their obsessive or compulsive
nature, interfere with normal living. Compulsive handwashing is a
classical example; compulsive overeating, bulimia, {117} and its
opposite, anorexia nervosa, as well as nymphomania, a need for sexual
promiscuity, are a few others.

AN EXAMPLE OF BRIEF PSYCHOANALYSIS

Dr. Richard Chase is a psychiatrist who specializes in emotional
problems of children. John and Rachel Edmonton have come to see him
about their twelve-year-old son, Bobby, their only child. John is an
evangelical minister in his early forties who travels a great deal,
taking his family with him.

When Bobby was eight years old, he began to have strange and violent
nightmares. He would go to sleep and then apparently awaken about an
hour later, asking for a drink of water or expressing a need to go to
the bathroom. A few minutes later, Bobby would seem to lose his
balance and stumble over furniture, sometimes running into walls,
crying aloud that he was "turning inside out" and was dying. Often his
parents would have to restrain him to keep him from hurting himself.
After a few minutes, the nightmare would end and Bobby would come out
of it, a terrified, confused little boy in tears.

So far, John and Rachel, with their frequent moves, had not been able
to get professional help that had made a difference. Bobby had been
examined by a neurologist, and an electroencephalograph test was done
to determine if some kind of epileptic disorder might be involved. The
test was negative. They had also taken Bobby to a child psychologist,
who said that Bobby was bright, sensitive, and precocious, that this
kind of nightmare was called a _night terror_ (_pavor nocturnis_), and
that the problem would eventually subside.

Four years passed, and the night terrors did not. The family of three
was becoming battle-scarred. Bobby hated to go to bed at night,
fearing the inevitable. His parents, sometimes patient, sometimes not,
used whatever ways they could, even a prescribed sedative for Bobby, so
he could relax and get to sleep, to no avail.

Could Dr. Chase help?

Dr. Chase decided to meet with Bobby by himself. He found that Bobby
was very willing to talk about his "bad dreams." Dr. Chase asked him
to describe what happened each night.

"Oh, Doctor," Bobby began, "it's really awful. I know it's going to
happen, but I can't do anything to stop it. I stay up as late as {118}
I can, and I will do anything not to go to sleep. But when I do, I'll
_kind of_ wake up a little later, and I'll see Mother and Dad looking
very worried. At the same time, I'll see a box, with white walls,
glowing brightly, but not in the room where Mother and Dad are. It's
in some space, I guess it's in my mind, a black space, with that
white-colored cube just floating there. And then it begins to turn
inside out. My stomach feels like it's turning inside out, and it
hurts and scares me. It feels awful. I really think if the cube
turned all the way inside out, I'd die. But it never does; I always
wake up first."

Dr. Chase began to meet with Bobby three times a week. He gradually
gained his trust. At a session during the third week of treatment, he
asked Bobby if he would play a word association game with him.

DR. CHASE: Tell me what you think of when I say, "dog."
BOBBY: Cat.
DR. CHASE: Black.
BOBBY: White.
DR. CHASE: Chair.
BOBBY: Cushion.
DR. CHASE: Box.
BOBBY: House.
DR. CHASE: Angry
BOBBY: Mad.

Dr. Chase spent about fifteen minutes writing down some of Bobby's
associations. Bobby gave back associations in the rapid-fire way Dr.
Chase asked, doing this almost automatically, leaving no time to
deliberate. Gradually, Dr. Chase felt he saw a pattern emerging, and
he was able to confirm this from Bobby's associations in later sessions.

Toward the end of the sixth week, Dr. Chase sketched for Bobby's
parents the interpretation he had developed during Bobby's short-term
experience in psychoanalysis: "I believe Bobby has unconsciously been
trying to tell you something in a highly symbolic form: often the mind
expresses deep-seated fears in the imagery of dreams.

"I've tested Bobby in a variety of ways. Always, he appears to
associate the box in his dream with home or with a house. I'm fairly
certain that 'being turned inside out' symbolizes for him the process
of moving out of all the houses you have moved away {119} from. A
house really is turned inside out when you move: all of its contents
are taken out, usually in boxes.

"I believe Bobby is hurting because of your frequent moves. I think if
you will stay in one place, even though I realize that you, John, would
probably have to give up evangelical work, you will gradually see a
real improvement in Bobby."

Dr. Chase's advice was received with a good deal of disbelief by John
and Rachel, but they did, eventually, decide to try it. John became
assistant minister at a local church.

Two years later, Dr. Chase received the following letter:

Dear Dr. Chase:

Maybe you'll remember treating our son, Bobby, for what you called
his "recurrent night terrors." My wife and I followed your advice:
We told him we had decided to stay in Atlanta, so that he could go
to the same high school for all four years.

In about two months, Bobby's night terrors were down to about one a
week. After three months had passed, the suffering our family has
endured for more than five years came to an end. Bobby hasn't had
another episode since then. He's doing well in school, has
friends, and seems quite happy. We all are.

It's sure a pleasure to be freed from the experience that
terrorized us all.

Bless you,
John and Rachel Edmonton

AN ANALYST LOOKS BACK AT HIS OWN PSYCHOANALYSIS

Psychoanalysis is unique among approaches to counseling and
psychotherapy in that it requires analysts, as a part of their training
leading to certification, to undergo psychoanalysis themselves. Not
only is this intended to be an educational experience, but it is
considered essential to their competence in later professional
practice: it is important that they be completely aware of what are
called _countertransference_ feelings toward patients. Just as
patients develop toward their therapists feelings they had toward
significant persons in the past--called _transference_--the analysts,
no less human, do the same. Their relationships with their patients
can revive some of the analysts' own conflicts. They will be unable to
understand the patient clearly, free from distortions created by their
own {120} countertransference tendencies, unless they have come to
understand themselves as thoroughly as it is possible to do so by means
of their own psychoanalysis.

After undergoing a long and intensive period of personal analysis while
in psychoanalytic training, Dr. Tilmann Moser referred to his analysis
as "a successful life-saving operation for my soul." He sought relief
from depression, caused, he now believes, by a troubled relationship
with his parents. He describes his experience in these terms:

Psychoanalysis is a piece of the work of conciliation with one's
own origins. The important ability to be implacable, attached to
the wrong place in the neurotic unforgivingness toward ... [my]
parents, has been freed for aspects of life where it can be used
for efforts directed toward social change, the changing of
conditions that cause avoidable suffering to countless human
beings. The longtime impassable road of affection toward my
parents, based on humor, has been re-opened.[2]

[2] Tilmann Moser, _Years of Apprenticeship on the Couch: Fragments of
My Psychoanalysis_, trans. by Anselm Hollo (New York: Urizen Books,
1977), p. 18.

APPLICATIONS OF PSYCHOANALYSIS

In general, psychoanalysis is successful in bringing about what are
called _broad-spectrum improvements_. It is less intended for
abatement of specific symptoms. In other words, those with highly
_specific_ goals they wish to achieve through therapy tend not to be
good candidates for analysis. For example, a person seeking specific
and prompt relief from depression, public-speaking anxiety, or shyness
may not be appropriate for psychoanalysis. Long-term, intensive
psychoanalysis, because it is long-lasting and very detailed, can lead
to very broad improvements: a sense of increased satisfaction in daily
living; a stronger, more positive sense of self-esteem; a greater
capacity to enjoy and be at ease with others. In the process, specific
symptoms often do subside or disappear, but the focus is general, and
the patient must be willing to embrace a commitment to general
improvement.

On the other hand, _brief_ psychoanalysis may begin by focusing on
specific problems experienced by a patient, but treatment quickly
widens in scope to touch on matters that affect the {121} patient's
life in a general way. We saw this in Bobby's case, where recurrent
night terrors revealed his general need for the greater emotional
stability that comes from feeling settled, having friends, etc.

Psychoanalysis is best suited to problems that fall into two categories:

* Problems that are clearly "neurotic" in nature: they interfere with
living to some degree but do not totally impair you so that your life
is clearly out of control, as in cases involving psychoses (where you
are no longer able to distinguish reality from fantasies and
hallucinations), alcoholism, or drug addiction

* Problems that involve sexual difficulties, mood disturbances, and
impairment of personal relations, assuming that you are willing to work
on these problems within the wider focus that analysis usually requires

Psychoanalysis is _not_ generally considered to be the treatment of
choice for severe impairments, such as alcoholism, drug abuse, and
psychotic disturbances, when your life is clearly out of control.
Analysis is also _not_ generally an appropriate form of treatment for
immediate problems arising from sudden environmental changes, such as
the loss of a job, or loneliness after a transfer to a new job
location, or after a divorce or separation. In some instances, if
problems of this kind are not resolved after a reasonable adjustment
period, analysis might then be considered. Other approaches to therapy
lend themselves better to specific and immediate adjustment problems,
as we will see.

We have been describing the appropriateness of psychoanalysis for the
treatment of certain kinds of problems, but there is an equally
important, and frequently overlooked, question: whether psychoanalysis
is appropriate _for the kind of person you are_. Psychoanalysis is
best suited to individuals with these characteristics:

* They are verbally articulate.

* They have a sense of curiosity about themselves.

* They have a good reflective capacity and an interest in achieving
insight through a careful analysis of their thoughts, feelings,
behavior, and past history.

{122}

* They are comparatively unimpaired in their abilities to form
relationships.

* They are able to tolerate the frustration, and endure the pain, of
re-experiencing disturbing feelings and memories.

* They are willing to be patient through a potentially long period in
treatment and can sustain a commitment to that process.

{123}

PSYCHOTHERAPY, PART I

Client-Centered Therapy, Gestalt
Therapy, Transactional Analysis,
Rational-Emotive Therapy, and
Existential-Humanistic Therapy

The approaches to therapy we will look at in this chapter are called
_humanistic therapies_. They include client-centered therapy, Gestalt
therapy, transactional analysis (or TA), cognitive therapy, and
existential (or existential-humanistic) psychotherapy. These
approaches share the view that an effective therapist must be able to
become conscious of the world as it is for the client. Doing this
requires the therapist to have a heightened sensitivity to others, feel
a fundamental measure of respect for them, and ideally be able to
adjust to their very individual needs and concerns. All of the
therapies we will examine in this chapter place priority on the
client's subjective feelings and experiences.

{124}

CLIENT-CENTERED THERAPY

_For people who have not developed a sense of
personal worth; who are in need of
acceptance, human warmth, and gentle
encouragement; and who have the
initiative to proceed both in therapy
and outside of therapy without
explicit direction from the therapist._

The development of client-centered, or nondirective, therapy has
largely been the work of Carl Rogers (1902-1987). His clinical
experience as a child psychologist and his later work in training
students in therapy led him to believe that people frequently come to
have personal problems as a result of the _conditional_ love of their
parents. To receive love and approval from their parents, children
must satisfy certain _conditions of worth_ the parents lay down. If
the children do not live up to the parents' demands, they are punished
by the withdrawal of the parents' affection--a far more serious and
emotionally scarring punishment than a physical spanking. Raised in
this way, people later in life will tend to link their self-worth to
internalized parental standards. Rogers observed that the more the
love expressed by parents is conditional in this sense, the more it is
likely that a person will experience emotional difficulties later on.

As a result, Rogers gradually developed an approach to therapy that
emphasizes "unconditional positive regard." Ideally, a client-centered
therapist is able to express a sense of complete acceptance and respect
toward the client. The therapist does not associate positive regard
with implicit conditions of worth that the client must satisfy. In
other words, client-centered therapy attempts gradually to reverse a
habit that has come to undermine the client's sense of self-worth. It
is a habit that we all, to differing degrees, develop as parents and
society teach us to relinquish self-acceptance in favor of the
conditional love or appreciation of others. Eventually, the habit
becomes so ingrained that it can jeopardize our own feelings of
self-esteem.

Client-centered therapy encourages a client to grow in several ways:

{125}

1. by feeling comfortable enough in the company of the therapist to
express feelings freely and openly

2. by coming to recognize his own feelings of incongruence, of being
divided against himself, often due to experiences that have encouraged
a negative or insecure sense of self-worth

3. by perceiving that the therapist is an integrated, accepting person,
able to convey acceptance and warmth toward the client

4. by reintegrating a sense of self, freeing himself from the
distortions of self-worth brought about by love that has strings
attached

AN EXAMPLE

Melissa Adams is twenty-eight years old, the district manager of a
large pharmaceuticals marketing division in the Midwest. She is
slender, immaculately dressed, and--as Dr. Feldman could see
immediately--rigid and very uptight about herself.

Melissa came to see Dr. Feldman, a clinical psychologist, because of a
growing sense of estrangement toward her husband and tension and
anxiety at work. She described her upbringing in an extremely rigid,
judgmental atmosphere in which her self-worth was implicitly tied to
her parents' conditions of achievement. She was apparently encouraged
by her parents, who realized Melissa was a bright child, to skip a
grade and then to complete her undergraduate work in three years by
attending summer school each summer. Her parents were very proud of
her.

She admitted to having had little fun and would turn a vacation into an
opportunity for achievement. She frequently could not enjoy television
or the movies "because it felt frivolous." She was free from
self-doubts only when hard at work, so she worked virtually all the
time. Her husband wanted a family, but Melissa believed that children
would be an undesirable interruption and distraction.

Melissa quickly lost her fear of the weekly meetings with Dr. Feldman.
She was able to relax in his company. She felt that he cared about her
as a person, whether she achieved or did not. He would not make
active, directive suggestions, but rather listened {126} to her in a
genuine, positive way. During one session, Melissa asked him if he
would give her some "straight advice" about her relationship with her
husband. Dr. Feldman declined. He felt that telling another person
what to do did not show respect for that person's individuality. He
could see that Melissa was intelligent. He believed that she could
trust her own decision-making abilities, and he would encourage her to
believe in herself.

Over a period of a little more than a year, with weekly visits,
Melissa's personality began to soften. She dressed more casually. She
was more relaxed. She was beginning to enjoy herself more, although
occasionally the old self-doubts would come back to assail her. But
she usually was able to fend them off. Her marriage was improving, she
looked forward to "a real vacation" in the near future, and she was not
closed to discussing the possibility of children with her husband,
although they had not yet made a decision on that issue.

APPLICATIONS OF CLIENT-CENTERED THERAPY

Client-centered therapy focuses especially on difficulties that stem
from a client's negative feelings of self-worth. Client-centered
therapy may be the therapy of choice especially for individuals who
feel anxiety, uncertainty, and pain because of a low sense of
self-esteem. A client-centered therapist can be expected to value
personal genuineness, integrity, and honesty. The approach can be
helpful to persons who suffer from loneliness and isolation.

Client-centered therapy is most effective for individuals with these
characteristics:

* They are able to exercise initiative, both in expressing their
difficulties to the therapist and in attempting to make desired
changes. Most client-centered therapists will refrain from giving
direction.

* They are interested primarily in personal growth rather than the
removal of specific symptoms.

* They are blocked, inhibited, or rigid because they are too
self-critical.

* They are not severely impaired in their abilities to relate to others.

{127}

GESTALT THERAPY

_For very rigid people who are always trying to
be someone they are not, who will commit
themselves to a challenging and usually
frustrating process of growth leading to
personal integration and genuineness._

GESTALT PSYCHOLOGY

Gestalt therapy has its roots in Gestalt psychology, which was
established early in this century by the German psychologists Wolfgang
Köhler (1887-1967), Kurt Koffka (1886-1941), and Max Wertheimer
(1880-1943). The main contribution of Gestalt psychology consisted of
studies of human perception. Gestalt psychologists demonstrated that
perception reveals the existence of organized wholes that cannot be
reduced to the sum of their parts. They called such an organized
totality a _Gestalt_. (Outside of psychology, _Gestalt_ in German
means "form.")

A famous example, shown below, demonstrates how an object that you see
can be closely linked to its background. Here, the figure and the
ground can oscillate, depending on whether you concentrate on the faces
or the vase. The figure depends on its background for its identity,
and vice versa.

[Illustration: A famous illustration of a white vase set between the
black silhouettes of two faces in profile; at one moment you perceive
the vase, at another you see the two faces]

{128}

GESTALT THERAPY

Frederick (Fritz) Perls (1893-1970) brought together certain of the
basic concepts of Gestalt psychology, psychoanalysis, and psychodrama,
an approach to therapy developed by J. L. Moreno (1889-1974) that
emphasizes role-playing, acting out of fantasies, and group interaction.

Perls transformed the Gestalt psychologists' central idea so it would
serve as a basis for his approach to psychotherapy. Let's look at an
example.

A man has been stranded in the desert and has become severely
dehydrated. He has wandered for several days in search of water. He
stumbles along, nearly blinded by the sun, seeing only vaguely defined
shapes of rocks and cacti. Suddenly, out of this hazy world, something
becomes clearly defined: he sees a watering hole, surrounded by low
bushes. It is clearly etched in his eyes, set against the indistinct
background of the hot desert. Once he has plunged his head into the
water and quenched his thirst, his Gestalt is _closed_: the need that
caused him to struggle for days has performed its purpose.

In this derivative sense, _Gestalt_ means "a problem (figure) that
arises out of a situation (background) which motivates an individual to
action." If his action is successful, his Gestalt is closed: the
problem is resolved, and the motivation is fulfilled. Like the Gestalt
of the psychologists, the closed Gestalt of therapy signifies an
organized whole. In the example, the man suffering from thirst in the
desert has a Gestalt that impels him to find water. When he does, his
thirst is satisfied, and the Gestalt is resolved into a whole that no
longer stands in need of completion.

Perls saw life as a succession of unfinished situations, incomplete
Gestalts. No sooner is one closed than another takes its place. To
cope effectively with living, we must be able to deal with life's
problems and challenges, yet not all of us can.

Perls used the term _growth disorders_ to refer to what other
therapists might call _personality disorders_ or _neuroses_. He
believed that emotional problems result from "getting stuck" in the
natural process of growth. People get stuck in childish patterns of
dependency because of a variety of childhood experiences. For example,
a mother and father may withdraw the support of a stable environment,
while a child relies on this for a sense of security. (The example of
Bobby in the chapter on {129} psychoanalysis may come to mind.) Or,
parents may force a child to accept adult responsibilities prematurely.
It is as if a child were asked to walk before his sense of balance and
leg strength had developed sufficiently. The child will _learn_
uncertainty; his natural early fear of falling becomes pronounced and
will leave a mark that can stand in his way later. Perls called such
experiences _impasses_, and they form _blocks_ to a person's growth.

For Perls, human personality is like a multilayered onion: From the
most superficial, outside layer, moving inward, there is the usually
insincere _cliché_ layer ("How are you?," asked without real interest),
the _role-playing_ layer (the habitual masks of father, mother,
businessperson, homemaker, therapist, client), the _impasse_ layer (the
person stripped of clichés and masks, often very frightening), the
_implosive_ layer (where emotions are either vented or explode inward),
and the innermost layer, which makes up the _genuine_ personality as it
is, freed from learned pretensions. The goal of Gestalt therapy is to
reach this last layer. In a word, Gestalt therapy seeks to encourage
the growth of _authenticity_--a combination of a balanced sense of
reality, of inner integration complemented by its outward expression,
personal integrity, and of independence from the need for the approval
of others.

In Gestalt therapy, self-change seems paradoxical. As long as inner
conflicts continue, you try _not to be_ the person you are; you cannot
be genuine and are divided against yourself. Change, the Gestalt
therapist claims, is possible only when you give up, at least for a
time, trying not to be the person you are. There must be a firm place
to stand from which to initiate change, and that place can only be the
person you are right now.

WHAT GESTALT THERAPY IS LIKE

Gestalt therapy as it was developed by Perls is individual therapy done
in a group setting. Gestalt therapists since Perls most commonly
continue to practice therapy this way: individual members of a group
are asked to volunteer to take the "hot seat"; the volunteer then
becomes the focus of attention. This is not group therapy where
relationships among members of the group are most important (see
Chapter 13). In Gestalt therapy, emphasis is on the individual, who is
pushed to drop his or her masks and pretensions. Other members of the
group form an {130} audience and try to learn by example until it is
time to occupy the hot seat themselves.

Perls would ask for someone in the group to sit in a chair, facing him
and the audience. Then Perls would launch an attack on the client's
defenses. At times, he could be almost merciless. He did not believe
in mothering clients; this served only to keep their defenses intact.

Perls would notice nonverbal clues to the client's feelings. If the
client was an inhibited woman, he would comment about her thighs, which
were pressed firmly together. If the client was shy, he would remark
about how the client held one hand in the other: Did he feel a need to
have his hand held by Mother?

If the client burst into tears, Perls would make no attempt to stop the
tears with reassurance but would try to make the client aware of his
motivation in crying: Was it to elicit pity? Were the tears a way of
hiding from self-responsibility? Were the tears another mask, standing
in the way of self-acceptance, authenticity, and growth?

The objective of Gestalt therapists is to tear away clients' defensive
masks and roles that usually keep them from real, sometimes painful or
frightening, feelings. In this, the therapists' main technique is to
_frustrate_ the clients' attempts to hide behind their masks and roles
and to _block_ their attempts to control their therapist. Clients
often do this by trying to make the therapist feel sorry for them, give
them parental warmth, respond to their inadequacies, and so on.
Instead, Gestalt therapy is comparatively _tough_. Perls used these
instructions in beginning a workshop:

So if you want to go crazy, commit suicide, improve, get
"turned-on," or get an experience that will change your life, it's
up to you. I do my thing and you do your thing. Anybody who does
not want to take responsibility for this, please do not attend this
session. You come here out of your own free will. I don't know
how grown up you are, but the essence of a grown-up person is to be
able to take responsibility for himself--his thoughts, feelings,
and so on. Any objections? ... O.K.[1]

[1] Frederick Perls, _Gestalt Therapy Verbatim_ (Lafayette CA: Real
People Press, 1969), p. 79.

{131}

By refusing to give unnecessary emotional support even when clients cry
for it, Gestalt therapists convey through their behavior that clients
do have what it takes to stand on their own two feet. Ideally, Gestalt
therapists are genuine, mature people; they refrain from interfering in
the lives of others and expect them to be self-supporting. They try to
impress on their clients that they do not exist to live up to the
expectations of others, nor do others exist to live up to theirs.

APPLICATIONS OF GESTALT THERAPY

Gestalt therapy is most effective in treating persons with these
characteristics:

* They tend to be very rigid--restrained, overcontrolled,
perfectionist--or depressed, or phobic. That is, they have certain
well-defined fears; for example, fear of public speaking, of insects,
of sexual intercourse.

* They have become stultified in their relations with others and have
pent-up feelings in need of release.

* They obtain little joy or satisfaction from living; their lives lack
emotional intensity.

* They are not excessively frightened by group activity.

Specific conditions Gestalt therapy often treats include these:

* psychosomatic disorders, such as stomach pain, colitis, back and neck
spasms, and migraines

* behavior problems in children

* difficulties in coping with persons in authority

* shyness and passivity

* emotional difficulties arising from poverty and from the deprivations
suffered by minority groups

* rigid, conflict-torn family situations

* crisis intervention: treating individuals in despair who have lost
the will to live or are suicidal

Gestalt therapy is _not_ generally the treatment of choice for people
whose lives are out of control or who show signs of psychosis. Gestalt
therapy relies on your capacity to make your {132} own practical life
decisions, to tolerate the stress and frustration of being in the hot
seat, and to benefit from being challenged by the therapist to confront
your own pretenses, distortions, and confusions. People who have lost
these capacities for the time being due to problems such as alcoholism,
drugs, and loss of touch with reality tend not to benefit from Gestalt
techniques.

TRANSACTIONAL ANALYSIS

_For less troubled people who want to improve
the effectiveness of their communication skills
and break free from frustrating, self-destructive
patterns._

Transactional analysis has perhaps done more than any of the other main
approaches to therapy to increase the sensitivity of the public to the
psychological dimensions of human relationships. It has achieved
widespread popularity in a short time largely because of its simple,
commonsense vocabulary that is easy to apply to personal, family, and
group situations.

Eric Berne (1910-1970) completed his medical training in 1935, then
finished his psychiatric residency at Yale in 1941. He soon separated
himself from psychoanalysis and began to formulate his theory of
transactional analysis (TA).

By the mid-sixties, TA was gaining in popularity: Berne wrote his book,
_Games People Play_, primarily for professionals, but it became a
best-seller filling a need for an easy-to-understand and easy-to-apply
approach to therapy.

TA is based on the premise that human personality has three parts:
Berne called them the _Parent_, _Adult_, and _Child_. Although similar
in meaning to Freud's _superego_, _ego_, and _id_, Berne's terms were
intended to name dimensions of personality that could be observed
directly; his three "ego states" are not theoretical constructs.

The Child ego state is the source of fun, humor, creativity, wishful
thinking, and irresponsibility. It is impulsive and resists control.

The Parent ego state is the repository of values, attitudes, and
expectations inherited from one's parents. _Shoulds_, _oughts_, {133}
hands-on-hips, and finger-wagging gestures are common expressions of
the Parent.

The Adult ego state is the source of reason, logic, and unemotional
evaluation. It forms the basis for decision making and predicting
outcomes.

Only one ego state can be in control of our emotions or behavior at a
time.

Berne observed that many emotional difficulties in individual clients
result from problems involving their ego states. Some personality
problems come about because a person cannot separate his or her ego
states and switches from one to another erratically and uncontrollably.
For example, a young mother begins--in a calm rational way--to describe
the behavior of her nine-year-old son. She talks about his impertinent
and disrespectful behavior, and, as she does, she becomes enraged, her
face turns beet-red, and she yells at her therapist that someday she is
going to give her boy a beating he'll never forget! Transactional
analysis would try to show her that she tends to slip from her
reasonable Adult state to the state of an angry Parent who demands
complete respect and subservience. Berne called this structural
problem of the personality _confusion_.

[Illustration: PERSONALITIES: Normal Personality, Confused, Excluded,
Contaminated]

_Exclusion_ is another structural problem. An individual rigidly
adheres to one ego state, locking out the other two. A Don Juan gives
free expression to his Child, while his Adult and Parent states are
suppressed. A workaholic, on the other hand, permits {134} his Parent
to block the expression of his Adult and Child ego states.

_Contamination_ is a third personality problem. One ego state subverts
another. A woman cannot commit herself fully to her chosen profession
because her Child has undermined her sense of determination by
persuading her that a wealthy knight in white armor will soon appear to
relieve her of the need to exert herself.

WHAT TRANSACTIONAL ANALYSIS IS LIKE

Transactional analysis normally begins with "structural analysis" in
which clients are taught how to distinguish ego states that may be
confused, excluded, or contaminated. This phase of therapy is
sometimes done on an individual basis and sometimes in a group workshop
or classroom environment. Therapy then proceeds to transactional
analysis proper, in which frustrating or painful forms of communication
and unsatisfying life directions are discussed. Most commonly this is
done in a group setting, since a group encourages a variety of
different styles of communication.

TA teaches clients to determine which ego state is active at a given
moment--in themselves and in others with whom they are trying to
communicate. _Transactions_ or communication patterns between people
are the focus of TA. Some typical transactions are diagrammed on the
facing page.

In (a) on the facing page, person 1 communicates in an Adult mode and
receives an Adult response from person 2: "Where are you going?" "To
the cleaner's."

In (b), a Parental boss receives a petulant response from the Child ego
state of an employee: "What took you so long?" "My little boy is sick,
and there's just too much work for one secretary."

In (c), an Adult-to-Adult message receives a Child-to-Parent reply;
this is an example of _crossed transaction_. It is one of the most
common sources of frustration and conflict in family and professional
life. For example, a therapist says, "You seem to be late for your
appointment today." (Adult-to-Adult, or A-A.) The client replies,
"You're just like my father, always picking on me." (C-P.)

{135}

[Illustration: DIAGRAMS OF TYPICAL TRANSACTIONS]

{136}

Diagram (d) illustrates communication that involves an ulterior
message. For example, a psychologically clever salesman is showing
hair driers to a woman. She tells him how much she is prepared to
spend and then asks, "How much is that one?" The salesman (arrow 1 in
the diagram) replies: "You wouldn't be able to afford that model." His
response is based on his customer's stated budget limitations and
appears to be Adult-to-Adult. However, the hidden message (dotted
arrow [1]) is directed to his customer's Child state, which, as he
predicts, causes her to reply rebelliously (arrow 2), "That's the one I
want."

In (e), another example of this class of communications that are not
what they appear to be, there are two ulterior transactions. A
secretary returns a few minutes late from lunch. Her boss asks,
apparently Adult-to-Adult (arrow 1), "What time is it?" They both know
what the hidden message is. The secretary answers sharply (arrow 2):
"It's 1:15." The ulterior message from the boss is "Are you late
again?" (P-C: arrow [1].) The secretary's covert or hidden reply is
"Get off my back: you're always criticizing." (C-P: arrow [2].)

The central objective of TA, then, is to make clients aware of these
and other patterns or games that their habitual ways of communicating
reveal. By doing this, clients find that communication becomes less
problematic and more effective as they learn to control their responses.

AN EXAMPLE

Joyce was forty-one when she decided to take her seventeen-year-old
only son, Joe, to see Dr. Goldstein, a transactional analyst. For
about five years, ever since his father died, Joe and his mother had
quarreled a great deal.

Dr. Goldstein met with Joyce, then with her son, and then with them
both. After he listened to their complaints about one another, he
agreed to try to help.

For six weeks, Joe and his mother met once a week with Dr. Goldstein as
"TA students." They were to put family problems on a back burner;
their energy was devoted to learning to apply the concepts of
transactional analysis. Dr. Goldstein had them {137} analyze many
examples of communication.

During a second six-week period, Joyce and her son were coached to
learn to talk to one another more effectively. Here are some samples
of their automatic patterns of response _before_ they began to use TA:

SON: The soup's too salty. (A-A or C-P)
MOTHER: I don't know why I work so hard! All you do is
complain! I'm just not appreciated! (C-P)

SON: Mom, here's the sports jacket I bought for graduation. (A-A)
MOTHER: You can't go in _that_! We're taking that jacket back. I
can't trust you to buy clothes for yourself. Let's go! (P-C)

MOTHER: We're going to dinner tonight at Esther and Gary's. Get
out of those jeans; we have to leave in fifteen
minutes. (P-C)
SON: But Mom, I told you last Wednesday that Fred and I are
going camping this weekend. We're leaving in Fred's
car in just an hour. (A-A or C-P)
MOTHER: I don't remember anything like that. Esther and Gary
are _expecting_ us. You're always wrecking our plans! (C-P)

MOTHER: Mmm, isn't this the most delicious soufflé you've ever
tasted? (C-P)
SON: That's it, compliment yourself! (C-P)
MOTHER: Well, if I don't, no one else will! You don't know how
lucky you are, having a mother who really knows
how to cook. (C-P)
SON: I sure hope I don't learn how to be modest from you! (C-P)

The problems weren't hard for Dr. Goldstein to spot: Joyce had low
self-esteem, was easily hurt, and, when she was, put her son down (the
salty soup). She wanted to be indispensable to him and was unwilling
to let him grow up (the sports jacket). She had little respect for
Joe's plans, especially if they interfered with her desires (Joe's
camping trip). She felt unappreciated and had grown to be resentful of
her role as mother (the soufflé).

Joe, on the other hand, was feeling the natural rebelliousness {138} of
a seventeen-year-old. He needed some free rein, even if he made some
mistakes. His mother was always "getting in his hair" or "getting
under his skin."

The sample transactions above led each of them to anger and hurt.
Seldom did Dr. Goldstein see Joe and his mother communicate
Adult-to-Adult. Instead, their transactions crossed and re-crossed,
and resentments piled up.

Joyce saw Dr. Goldstein without Joe present for several weeks. She
learned from Dr. Goldstein that her expectations toward her son were
inappropriate; she needed to strengthen her sense of self-worth outside
of her family role. She was excessively dependent on her son for
recognition and appreciation. Especially since her husband died, she
was easily hurt when her desires for appreciation were not satisfied by
Joe, so she put him down. What she needed to do was to strengthen her
Adult and weaken the domination of her self-pitying Child and
overcritical Parent ego states.

Dr. Goldstein then met with Joe for several sessions. Joe began to see
his mother in a different light. Dr. Goldstein made him aware of his
mother's sadness in being left alone and of her needs to feel
worthwhile.

During the joint sessions that followed, Dr. Goldstein typically would
ask them to recall recent conversations or exchanges that had been
unpleasant. He would ask them to analyze these in TA terms and then
would push mother and son to imagine more appropriate and less uptight
ways of responding.

After several months of joint therapy, their former pattern of
transactions began to look very different:

SON: Mom, there's too much mustard on the ham. (A-A or C-P)
MOTHER: Well, then it's OK with me if you want to scrape some
off. (A-A or P-C)

SON: How do you like my new tie? (A-A)
MOTHER: I'd need a lot of courage to wear it myself, but I'm not
you! (A-A or C-C)

SON: Mom, your roast is delicious. It's great to have a
mother who's a good cook! (A-A)
MOTHER: Thanks, Joe. I guess now I've learned that you really
hate soufflé! (A-A)

{139}

APPLICATIONS OF TRANSACTIONAL ANALYSIS

TA has been used in individual and group therapy, in nonclinical
settings to help business executives improve communication skills, and
also in prisons. It has been used to treat a wide range of problems,
including these:

* personality trait problems: e.g., shy, lonely, depressed,
overbearing, or hostile individuals

* troubled relationships in couples and families

* fears of withdrawal of affection and of abandonment

* drug abuse

* phobias

* difficulties in relating to authority figures, such as a boss, a
teacher, a parent

* adaptation problems in individuals with counterculture attitudes and
values

Few controlled evaluative studies have been done to determine how
effective TA really is. At this time, and in this author's judgment,
TA is most useful as an _educational therapy_ to assist less severely
troubled individuals with communication problems by helping them
sharpen their perceptions of their own ego states and the ego states of
others. TA is most effective for clients who are able to exercise
responsibility for themselves. TA appears to be especially useful in
helping individuals who are caught in frustrating relationships to
break free from self-destructive patterns or games.

COGNITIVE THERAPY:
RATIONAL-EMOTIVE THERAPY

_For people who tend to think and judge in
very rigid ways, who are frequently intense
and uptight, and who tend to magnify and
exaggerate evils._

Man is not disturbed by events, but by the view he takes of them.

Epictetus, _Enchiridion_

{140}

"It is absolutely essential to you to be loved by members of your
family and to be appreciated by your friends and employer."

"You must be consistently competent and nearly perfect in all your
endeavors."

"Some people are really bad, their actions should be restricted, and
they should be punished when they do wrong."

"It is terrible when things are not the way you would like them to be."

"Events outside your control are largely responsible for how you feel."

"You should be anxious in relation to what is uncertain, unknown, or
potentially dangerous."

"It is much easier to avoid problems than to face life's difficulties
and responsibilities."

"It is necessary to have something greater or stronger than yourself to
rely on."

"The present is largely determined by past events."

"Happiness comes when one has complete leisure."

"If you don't work hard to please others, they will abandon you."

"If people don't approve of you, you ought to question your self-worth."

By telling ourselves things like these, we create our own unhappiness,
frustration, and anger; that is the point of view of cognitive therapy.
During the 1950s, Albert Ellis (1913-2007) developed a theory of
personality that claims that people are largely responsible for their
emotional reactions. They tell themselves that things _ought_ to be
different, that people _should_ do certain things, and that what they
desire they _must_ have. Life, for people whose thoughts are filled
with _shoulds_, _oughts_, and _musts_, is full of disappointment,
annoyance, and hurt.

Ellis observed that, as time goes by, we tend to reinforce an emotional
pattern that amplifies our sensitivities more and more. The emotional
reactions we create in ourselves become more exaggerated, distorted,
and self-destructive.

{141}

But, like any habits, these mental (or cognitive) habits can be broken.
Cognitive therapy attempts to do this.

Ellis called his own approach _rational-emotive therapy_. By this, he
acknowledged that people have both rational and emotional dimensions.
Their emotions and thoughts (cognitions) are so thoroughly intertwined
that they cannot be clearly separated. Yet mental evaluations and
ideas are given so much power that cognitive habits are responsible for
emotional responses. It is thinking that makes it so.

Rational-emotive therapy is the most widespread approach to cognitive
therapy, so we will examine Ellis's approach in some detail.

The main technique of rational-emotive therapy, and of cognitive
therapy in general, is to focus clients' attention on their belief
systems, their views about what "should" and "ought" to be, their
cognitive "filters" through which they interpret, in a semiautomatic
way, the world around them. If the "activating event" is a failure or
a rejection, for example, a client's _rational_ belief system will lead
to feelings of regret, sorrow, disappointment, or annoyance; if an
individual's beliefs are _irrational_, on the other hand, he or she may
instead feel depression, worthlessness, futility, and severe anxiety.
For rational-emotive therapy, emotional good health depends on the
rationality of the way a person receives and interprets events.

WHAT RATIONAL-EMOTIVE THERAPY IS LIKE

Therapy usually begins with individual sessions. Once clients have
learned how to identify mental habits that create disturbing emotions,
therapy is sometimes continued in groups, where new attitudes and forms
of behavior can be practiced in a kind of microcosm of the larger
world. Rational-emotive therapy that is done in a group context is
not, however, "group therapy," since the therapist's focus is on
individual styles of thinking, not on relationships among members of
the group.

During therapy, clients are very quickly challenged to give evidence
for their irrational beliefs. The rational-emotive therapist will
openly and ruthlessly oppose the foolish absolutes that clients express
and make it clear how they are upsetting themselves emotionally by
insisting on such nonsense. It is not considered essential that the
therapist be a kind, warm, {142} supportive person. In fact,
rational-emotive therapy encourages therapists to show their impatience
with irrational beliefs that cannot be defended empirically or
logically. Once clients are shown that many of their beliefs cause
them misery and disappointment, they are asked to _dispute_--silently,
in their own minds--their irrational beliefs whenever they find the old
habits taking over. It takes time to extinguish old habits; it doesn't
happen overnight. Clients need patience and tenacity to oppose their
old reflexes and replace them with rational, realistic beliefs.

An hour a week in rational-emotive therapy is really, then, like a
tutorial session with a teacher. The client-students talk about their
feelings; the therapist criticizes underlying irrational beliefs and
makes it clear to the clients what a rational response would be. Then
the clients are asked to practice applying rational beliefs on their
own, outside of therapy. Gradually, a more rational way of looking at
things takes the place of the old habits.

AN EXAMPLE

Joan Hendley is single, twenty-nine years old, and assistant manager of
a bank. She has come to Dr. Kovac because of chronic depression, a
sense of low self-worth, and feelings of insecurity and anxiety.
Lately, she has begun to drink heavily and regularly feels the need to
use sleeping tablets.

The following is a sample of their dialogue during their first session
of rational-emotive therapy:

DR. K.: Well, what would you like to start on?

JOAN: It's hard to put it into words. I guess it's that I've been
depressed a lot, about _everything_. I feel like there's no
purpose to my life. I don't know where to go or how to decide.

DR. K.: So, right now you don't know where you're headed. What's
so terrible about that? It would be _nice_ if you knew, but you
don't. Is that _awful_?

JOAN: Yes, it is! Everybody should have a purpose!

DR. K.: Why _should_ they? Most people go through life without
much of a sense of purpose.

JOAN: Well, that's what I believe in.

DR. K.: Look, Joan, you appear to me to be an intelligent person.
You and I can agree that it would be more satisfying for you to
have a sense of direction, but you take this {143} one more step,
and it's a _very_ big step! You think it's _terrible_ that you
don't feel there's a purpose to your life right now. You think you
_should_ have a purpose, and I suspect you're punishing yourself
because you don't live up to that _should_.

JOAN: But most people believe in things like that.

DR. K.: And a lot of them end up feeling miserable! I know: I've
seen dozens of people sitting where you are, and their thinking is
chock-full of _oughts_, _shoulds_, and _musts_. And that's what
makes them feel upset. They feel much better when they can come to
say to themselves, "It would be nicer, or more pleasant, or better
if things were different."

JOAN: You mean, if I can get rid of _shoulds_ and _musts_ in my
_thinking_, I'd feel better?

DR. K.: That's exactly what I'm saying. If you were to follow
what I've told you, you'd seldom be upset again, and probably never
enough to get yourself really depressed.

JOAN: Uh-huh. I'm not sure I really see how that can be. I feel
pretty stupid.

DR. K.: So here you go again! You think of yourself as a pretty
bright person, and so you say to yourself, "I ought to be able to
catch on to anything pretty fast." And now here you are, and
you're not all that sure you've followed everything already, and so
you tell yourself, "Oh my, I must be stupid."

JOAN: [Nods appreciatively, laughs.]

DR. K.: You don't _have_ to upset yourself. You can _choose_ what
you tell yourself, and then you'll have control over what you
_feel_. Tell me about your job. You're in the role of a leader,
aren't you?

JOAN: Yes.

DR. K.: But you don't think you're doing a great job?

JOAN: No, I don't.

DR. K.: But _they_ think you're doing OK, isn't that correct?

JOAN: Yes, but my job seems to be taking more and more out of me.
[Begins to cry.]

DR. K.: Well, it seems like you're doing your job OK; it's just
that you, from _your_ point of view, aren't perfect! So
_therefore_ it's all just empty pretense: you're just faking it!
But, if you'll give up your nutty perfectionism, you'd be in the
clear, because you're obviously satisfying people at work; you're
satisfying _their_ expectations. But since you feel bad about
yourself, you say to yourself, "Well, they just haven't found me
out! When {144} they do, I'm in for it." And so you live in a
state of fear.

JOAN: That's it.

DR. K.: It's all because of your unreasonable _expectations_. Can
you see that?

JOAN: [At least temporarily convinced.] Yes, I think I can!

DR. K.: This is what I'd like to work on with you. It's going to
take some self-discipline on your part, but together we can help
you get rid of some mental habits that bring you unhappiness. They
don't serve a useful purpose, and they drag you down. Why don't
you tell me more specifically what upsets you at work?

APPLICATIONS OF RATIONAL-EMOTIVE THERAPY

Although rational-emotive therapy has been used to treat many different
kinds of problems, Ellis admits that his approach is most effective for
the treatment of clients with a single major symptom or clients who are
only moderately disturbed. In addition, Ellis does advocate
rational-emotive therapy for individuals whose patterns of irrational
thought are severe, but for such individuals--when they can be
helped--therapy is a long-term process.

From evaluative studies completed so far, it appears that
rational-emotive therapy is especially effective in reducing anxieties
resulting from such things as public speaking, relating to others on an
individual basis, and facing old age. Other specific applications of
rational-emotive therapy include these:

* problems of maladjustment, where you have increasing difficulty
coping with either an already familiar environment or a situation new
to you

* marital problems and sexual difficulties

* psychosomatic problems

* anxiety

* depression

* problems of criminals and delinquents

Individuals who are most effectively treated with forms of cognitive
therapy tend to have one or more of these personal characteristics:

{145}

* They tend to think in very rigid ways.

* They are inclined to think in all-black, or all-white terms. They
are absolutists who think in terms of _what is right_ and _what is
wrong_. Life, for them, is an uncompromising affair.

* They are often perfectionists about themselves, so they tend to have
unrealistic expectations of others as well. They are idealistic.

* Their behavior is frequently uptight, intense, judgmental, and
intolerant _or_ shy, self-effacing, and inclined to self-condemnation.

* They tend to think that if there is one bad apple, the whole bushel
must be rotten. They tend to magnify and exaggerate evils.

* They confuse what they would like to have with what they believe they
absolutely _need_. They are demanding and exacting.

EXISTENTIAL-HUMANISTIC PSYCHOTHERAPY

_For individuals who suffer from feelings of
acute loneliness and emptiness, who have lost
faith in themselves or others, and who tend to
be analytical and introverted._

There is no single, well-defined theory accepted by most existential
therapists. Instead, existential psychotherapy is a point of view, a
general philosophy that attempts to describe what it means to be human
and to live meaningfully in the world.

There is, nevertheless, a consensus among existential therapists
concerning the objectives of the approach. Existential therapy seeks
to help clients achieve these goals:

* to accept and make constructive use of their own personal _freedom_

* to become _authentic_ individuals, shedding the conventions and
conformities that obscure the real persons they are

* to establish human relationships based on _honesty_ and _personal
integrity_

* to be _fully present_ in the immediacy of the moment

{146}

* to learn to _accept_ the natural limits of life

Existential therapy cannot be described in terms of a group of
techniques commonly used by therapists. In fact, existential
therapists are inclined to resist the formulation and application of
specific techniques of therapy, believing that psychotherapy is
essentially a human endeavor and that the drive to formulate techniques
is basically a dehumanizing, objectifying interest.

To understand existential therapy, then, we ought not to expect to
encounter a set of specific techniques. What really characterizes
existential therapy are its self-consciously endorsed attitudes about
life. They include these realizations:

* Anxiety frequently motivates individuals to change their lives.
Anxiety often is present to tell you that you need to change; it is not
necessarily a bad feeling from which no good will come.

* Eventually each of us will die, and clutching life anxiously will
stand in the way of finding real meaning in living.

* Past events need not control what you feel and do now; you are free
to change old, unsatisfying patterns.

* Guilt is often a sign that you have missed opportunities for personal
growth: you have not been true to yourself and have "sinned against
yourself" in some important way.

* If you are to become a mature and genuine person, you must discard
the _lies_ you have cultivated. Among these is living the lie of
trying _not to be_ the person you really are; another is the lie of
trying to be a person you are _not_, and there are many others.

* To be content within the limitations of life, it is vital that you
have a sense of your own value. You become inauthentic if you base
your sense of self-esteem on what others think of you.

It is obvious that _individual responsibility_ is central to
existential therapy. You are responsible for the person you choose to
become. You may choose to be genuine, or you may choose to lie to
yourself and others. It is when you abdicate responsibility for
becoming authentic that you will often come to feel anxiety and a sense
of guilt. Anxiety and guilt are often present, in other {147} words,
when there is a fundamental lack of congruence, of being whole, of
being in accord with yourself.

The main contributors to existential psychotherapy have been the Swiss
analysts Ludwig Binswanger (1881-1966) and Medard Boss (1903-1990),
along with Rollo May (1909-1994), who was the founder of existential
psychotherapy in America. Today, existential psychotherapy is
practiced under a variety of names: _humanistic psychology_,
_experiential psychotherapy_, and also in the context of the related
approaches, logotherapy and reality therapy (see Chapter 11).

WHAT EXISTENTIAL THERAPY IS LIKE

Existential psychotherapy is usually individual therapy, with sessions
commonly scheduled a few times a week, as in psychoanalysis.
Existential therapy often shows its psychoanalytic origins: as in
analysis, existential psychotherapy focuses largely on anxiety and the
suppressed issues that anxiety veils. Existential therapists will push
clients to confront anxiety directly; they will try to understand the
clients' anxiety in relation to the lies that clients tell themselves
in order to protect themselves from more anxiety.

As we have already seen, existential therapists very commonly regard
anxiety and depression as _promising_ symptoms because they can shake
clients out of unfulfilling patterns of living. Anxiety and
depression, instead of being viewed as undesirable symptoms to be
eliminated, can motivate people to change and grow. Consequently,
existential therapists tend to disapprove of the use of drugs in
therapy. If clients take pills to reduce anxiety, for example, they
will reduce the awareness of motivating pain that, if faced squarely,
may bring about a more meaningful, satisfying life.

Here is an example of the way an existential therapist forces a client
to face issues head-on. What the therapist is thinking is in brackets.

CLIENT: I don't know why I stay with my job. It just makes me
depressed. All I do is tell you the same things over and over.
I'm not getting anywhere.

THERAPIST: [She is complaining because I'm not curing her. She has
to do this herself.] To be frank, I'm impatient, {148} too. We
talk, but you're not able to act. [She has to see that I can't
take responsibility for her procrastinating].

CLIENT: What do you think I ought to do? I can't keep living like
this.

THERAPIST: [I can't make her decisions for her.] I can't tell you
which way to go. I do know that you've been avoiding a decision.
I believe you're going to take charge of your life but, until then,
we may both feel impatient....

What _do_ you want to do? [She has to be pushed to make up her
mind. She's ready now to decide but is understandably scared.]

CLIENT: I want to stop worrying, stop feeling so anxious and upset.

THERAPIST: [She'd like me to mother her.] Look, Diane, you've been
coming to see me for three months now. You know what I think about
feeling upset: if you're upset, there's something bothering you
that you need to pay attention to. We both know you dislike your
job and that you stay on mainly because you're afraid of a change.
We can talk a long time about your unhappiness at work and about
your fear of change, but eventually it will be time to stop talking
and to try some alternatives. Do you think you're ready? I think
you are.

CLIENT: (Sighs.) I guess you're right. I seem to be dragging my
feet. If I want a satisfying job, I'm just going to have to try
something else. Can we talk about some of my alternatives, then,
and I'll try to stop complaining!

THERAPIST: [Now she's starting to face up to the challenge.]

APPLICATIONS OF EXISTENTIAL PSYCHOTHERAPY

These are some of the difficulties existential psychotherapy is
designed to treat:

* feelings of _real estrangement or alienation_ from others--from your
immediate family and friends or from neighbors or colleagues at work

* a sense of _acute loneliness_, of being cut off from humanity and
from normal everyday activities and interactions

* an awareness that your life has become an _empty pattern_ {149} of
habit, that your activities or work no longer feel meaningful or
valuable

* an inability to _accept_ the realities that limit life; for example,
anxiety experienced by older persons as they become more aware of the
need to face the reality that life will end or anger and frustration
experienced by individuals who must cope with real limitations--persons
with physical impairments and chronic pain, individuals whose
opportunities are limited by poverty, by their ties of responsibility
to others, or by social disadvantage

Individuals who benefit most from existential psychotherapy tend to
have these characteristics:

* They are reflective and analytical.

* They tend to be introverted.

* They have _lost faith_--in their sense of social commitment, in their
identity and role within their families, in their belief that their
work is of value, or in their religion.

{150}

PSYCHOTHERAPY, PART II

Logotherapy, Reality Therapy
Adlerian Therapy,
Emotional Flooding Therapies,
Direct Decision Therapy

In this second chapter devoted to major approaches to psychotherapy, we
will look at logotherapy, reality therapy, Adlerian therapy, the family
of emotional flooding therapies, and direct decision therapy. Like the
five psychotherapies described in Chapter 10, these focus special
attention on a client's personal style of relating to the world and
others. They all seek to help a person to free himself or herself from
troubling feelings and negative attitudes and to replace these with a
stronger and more confident self-concept. Each therapy is a different
path to that goal.

LOGOTHERAPY

_For reflective individuals who are sensitive to
values and who are in search of a richer sense
of meaning in life._

He who has a _why_ to live for can bear with almost any _how_.

Friedrich Nietzsche

{151}

Viktor Frankl (1905-1997) is worthy of much respect and admiration.
Out of three terrible years of suffering in a concentration camp,
during which his mother, father, brother, and wife were taken from him,
Dr. Frankl developed logotherapy (from the Greek _logos_, roughly
equivalent to "meaning"). Logotherapy is an approach to therapy that
addresses our inherent need for meaning and value in living. The
belief that sustained Dr. Frankl during this period of intense
suffering was the conviction that people, in spite of great adversity,
anguish, and the loss of all they hold dear, can remain free within
themselves and are able to maintain, and even to strengthen, their
sense of self-respect and integrity. To communicate how it is possible
to do this became Dr. Frankl's lifework.

Logotherapy is a therapy of meaning for those who are unable to find a
reason for living. It is a form of therapy related to existential
analysis (see Chapter 10), but it is specific in its concern for
helping clients find what it is that really matters to them, that makes
hardships and pain worthwhile.

If Freudian psychoanalysis looks to the past for insight, logotherapy
focuses instead on the future, on a person's _life task_. In this,
there is no abstract and general answer to the question "What is the
meaning of life?"

For the meaning of life differs from man to man, from day to day
and from hour to hour. What matters, therefore, is not the meaning
of life in general but rather the specific meaning of a person's
life at a given moment. To put the question in general terms would
be comparable to the question posed to a chess master, "Tell me,
Master, what is the best move in the world?" There simply is no
such thing as the best or even a good move apart from a particular
situation in a game and the particular personality of one's
opponent. The same holds for human existence.... Everyone has his
own specific vocation or mission in life; everyone must carry out a
concrete assignment that demands fulfillment.... Ultimately, a man
should not ask what the meaning of life is, but rather must
recognize that it is he who is asked. In a word, each man is
questioned by life; and he can only answer to life by _answering
for_ his own life; to life he can only respond by being
responsible.[1]

[1] Viktor E. Frankl, _Man's Search for Meaning: An Introduction to
Logotherapy_ (New York: Washington Square Press, 1963), pp. 170-171.

{152}

Dr. Frankl liked to compare logotherapy to the role of the eye
specialist: the logotherapist's role is to help the patient see more
clearly the range of lived values and meaning available to him.

WHAT LOGOTHERAPY IS LIKE

An elderly physician came to Viktor Frankl to ask for help with severe
depression. His wife, whom he loved above all else, had died two years
before. His sense of loss would not heal. Could Dr. Frankl help him?

Dr. Frankl responded with a question: "What would have happened,
Doctor, if you had died first, and your wife had had to survive you?"

"Oh," he said, "for her this would have been terrible; how she would
have suffered!"

"You see, Doctor, such a suffering has been spared her, and it is you
who have spared her this suffering; but now, you have to pay for it by
surviving and mourning her."

The physician said nothing, but rose to his feet, shook Dr. Frankl's
hand, and calmly left his office. "Suffering ceases to be suffering in
some way at the moment it finds a meaning, such as the meaning of
sacrifice."[2] It is the basic concern of logotherapy to help patients
see the meaning in their lives.

[2] Frankl, _Man's Search for Meaning_, pp. 178-179.

Logotherapy is known for two techniques endorsed by Viktor Frankl. He
called them _dereflection_ and _paradoxical intention_.

Many emotional problems have their roots in what psychotherapists call
_anticipatory anxiety_: a woman who is afraid of blushing when she
enters a room filled with people will tend to blush. A man who fears
impotence and who tries to achieve an erection will often fail. A
woman who willfully tries to achieve orgasm also will frequently fail.
These are examples of excessive, or hyper-, reflection. Excessive,
anxious attention is paid to what we fear or wish, bringing about the
very thing we are trying to avoid.

Frankl developed specific ways of refocusing or rechanneling this
excessive attention. _Dereflection_ could take the form, for example,
of persuading the blushing woman to concentrate on particular things
when she enters a crowded room: to look for acquaintances, to admire
what someone may be wearing, or to {153} look for objects in the room
to appreciate, for example. In the case of impotence or frigidity,
often a shift of attention from yourself to your partner's pleasure
will eliminate anticipatory anxiety.

Frankl describes an attempt to help a bookkeeper who was in real
despair and close to suicide. For several years he had suffered from
writer's cramp: very real muscular cramps that reduced his legible
script to an illegible scrawl. He was in danger of losing his job.

He was treated with _paradoxical intention_. He was asked to write in
an intentionally illegible scrawl. But he found that when he
deliberately tried to scrawl, he could not. Within two days, his
writer's cramp had vanished. Similar approaches have been very
effective--and long-lasting--in certain cases of severe stuttering,
uncontrolled shaking, washing compulsions, insomnia, sexual
difficulties, and other problems.

Logotherapists tend to be warm, accepting individuals. They will often
use humor. Yet they are trained to confront individuals: to push their
clients to face their inner feelings of futility and despair, and then,
out of their often overlooked and underestimated inner resources and
moral strength, to _will_ that their lives become meaningful.
Logotherapists try to encourage clients to see more clearly what it is
that gives them a sense of value in living and to use what they see to
direct themselves toward more satisfying and personally fulfilling
lives.

APPLICATIONS OF LOGOTHERAPY

As we have already observed, logotherapy has been used to treat a wide
range of individual problems involving a loss of faith in the value of
living, behavior that no longer is under voluntary control, or behavior
that frustrates your desires.

Logotherapy is especially well-suited to helping individuals with
_noögenic neuroses_, Frankl's term for personal problems that have
their basis in conflicts between opposing values. Noögenic (from the
Greek _nous_, meaning "spirit" or "mind") neuroses have their origin in
personal moral or spiritual, but not necessarily religious, conflicts.
They lead to a feeling of existential frustration: a person's will to
find meaning is blocked. When sufficient pressure is built up, anxiety
and depression can follow. You can imagine how pressure might build up
in the inner lives {154} of a business executive who wishes she had a
family instead of a career identity, a university professor who yearns
to be an independent artist, or a financially successful businessman
who despises his own pretenses and opportunism.

I asked the poor creatures who listened to me attentively in the
darkness of the hut to face up to the seriousness of our position.
They must not lose hope but should keep their courage in the
certainty that the hopelessness of our struggle did not detract
from its dignity and meaning. I said that someone looks down on
each of us in difficult hours--a friend, a wife, somebody alive or
dead, or a God--and he would not expect us to disappoint him. He
would hope to find us suffering proudly--not miserably.[3]

[3] Frankl, _Man's Search for Meaning_, p. 132.

REALITY THERAPY

_For persons able to make a commitment to a
plan for life improvement, whether they have
emotional or behavioral problems or simply
want to develop a success-identity._

... [U]nhappiness is the result and not the cause of irresponsibility.

William Glasser, _Reality Therapy_

Reality therapy was developed in the 1950s by psychiatrist William
Glasser (1925-2013). His approach to therapy evolved as a result of
his work with delinquent teenage girls, with clients in private
practice, and with severely troubled patients in a VA hospital.

Reality therapy, as the name implies, attempts to help by strengthening
a person's practical understanding of reality and by encouraging
concrete planning that will bring about an improved sense of personal
adjustment to reality. It emphasizes a very practical,
feet-on-the-ground focus on the present: a person's past experience
cannot be rewritten. Reality therapists do not believe in the
essential value of psychoanalytic interpretation, dream analysis,
nondirective counseling, or intellectual {155} insight. A reality
therapist focuses on the present, specifically on attempts patients may
now be making to become more successful _from their own points of
view_. If a patient is not able to make definite plans of this kind
and cannot sustain a commitment to them, the focus of reality therapy
will be to encourage the patient to begin to do this. It is an
approach that believes that a strong sense of personal identity can
come only from _doing_: if an individual is able to develop a degree of
self-responsibility that is solid and enterprising, a feeling of
personal success and effectiveness will follow.

Reality therapists are opposed to making diagnoses. A diagnostic label
frequently adds a burden to individuals who are already burdened by
emotional, family, or adjustment problems. Glasser notes, for example,
that being labeled a schizophrenic "can be worse than the disease as
far as incapacitating one in the course of life's activities."[4]

[4] William Glasser and Leonard M. Zunin, "Reality Therapy," in Raymond
J. Corsini, ed., _Current Psychotherapies_ (Itasca, IL: F. E. Peacock
Publishers, 1979), p. 329.

Reality therapists can resist diagnosing and labeling their clients
because their approach claims that personal psychological difficulties,
except those due to physical illness (see Chapter 8), result from a
lack of personal discipline and responsibility. People are often
caught in the habit of blaming their failures on their families, their
lack of opportunity, their race, poverty, and other outside forces. It
is a habit with a dead end: it ignores the potential success that can
come from initiative motivated by responsibility and moral courage. As
Ernest Hemingway said when asked if he ever anticipated failure, "If
you anticipate failure, you'll have it."

THE EXPERIENCE OF REALITY THERAPY

It isn't hard to gain a feeling for what reality therapy is like.
These are the basic principles of the approach:

The relationship between therapist and client must be personal. The
therapist tries to make clear that he is a genuine person who has, in
some areas of his life, been able to plan effectively and to develop a
sense of personal success.

The focus of individual sessions is on what the client _does_, not on
what he or she may _feel_. Behavior can be changed much more {156}
directly than feelings, and feelings soon fall into place once behavior
is more satisfying. What is important is for the client to develop
intelligent plans and then to work to carry them through. If certain
goals are not realized, the therapist's concern is to encourage the
client to take the next practical step, rather than to spend time and
energy analyzing what went wrong.

The reality therapist accepts that the first steps are often halting
ones. It is important not to be disconcerted by occasional stumbling
and a few falls. What is essential is a commitment to self-discipline
and progress, refusing to punish yourself when a plan may not succeed,
but going beyond it with a positive attitude that eventually can become
a habit.

Glasser gives this illustration of the persistent refocusing on
practical issues that characterizes reality therapy: a teenage girl
expresses to her therapist that she would like to look for a job. The
therapist does not respond, "Good, let me know how it works out," but
instead begins the following exchange.[5]

THERAPIST: What day next week?
GIRL: I don't know. I thought Monday or Tuesday.
THERAPIST: Which day? Monday or Tuesday?
GIRL: Well, I guess Tuesday.
THERAPIST: You guess, or will it be Tuesday?
GIRL: Tuesday.
THERAPIST: What time Tuesday?
GIRL: Well, sometime in the morning.
THERAPIST: What time in the morning?
GIRL: Oh, well, 9:30.
THERAPIST: Fine, that is a good time to begin looking for a job.
What do you plan to wear?

[5] Glasser and Zunin, "Reality Therapy," _Current Psychotherapies_, p.
324.

In another example of reality therapy, a patient says, "I feel
depressed and miserable." Instead of responding, "How long have you
felt this way?" or "What have you been feeling depressed about?," a
reality therapist might ask, "What have you been doing that continues
to make you depressed?" or "Why aren't you even _more_ depressed?"
With both of these responses, the therapist makes it clear that he
believes the client can influence his or her feelings.

Often therapists, no matter what their approach, will say to {157}
clients who are going through a difficult time that they may phone
after hours if there is an emergency. A reality therapist may, in
addition, also say, "I hope you'll call me if you have had a special
success."

APPLICATIONS OF REALITY THERAPY

Reality therapy has been used in connection with these types of
problems:

* individual problems involving anxiety, marital conflicts,
maladjustment, and some psychoses where a person is comparatively out
of touch with reality and may have hallucinations or delusions

* teenage delinquency

* difficulties faced by women who have recently been widowed

* designing school programs that stress the development of individual
identity based on a sense of personal success

Reality therapists believe that their approach is of value to people
who want to develop a more successful pattern of living, of managing
their own affairs, and of coping effectively with challenges at work
and with problems of everyday living. Reality therapy has also been
used in industry with organizational problems and with difficulties
experienced by individual employees.

Reality therapy is not useful in treating problems in which there is
severe withdrawal (as in autism) or cases involving serious mental
retardation. To be effective, reality therapy presupposes that clients
are able to communicate and are both willing and able to cultivate
habits of self-discipline and personal responsibility.

ADLERIAN PSYCHOTHERAPY

_For individuals interested in personal growth,
especially in social directions, and for persons
with low self-esteem who feel blocked and
discouraged about life._

{158}

The greatest principle of living is to love one's neighbor as oneself.

Rabbi Akiva, writing 2,000 years ago

Alfred Adler (1870-1937) was a contemporary of Freud. Early in his
career, Adler was invited by Freud to participate in his special circle
of professionals interested in the development of psychoanalysis.
Adler's already formulated views were not in accord with Freud's, their
differences became more pronounced, and Adler eventually separated
himself from psychoanalysis. Freud was embittered and became a
lifelong enemy of Adler.

In contrast to Freud's technical and abstract theory, Adler's is
humanistic, open, and concrete. Where Freudian analysis believes that
emotional disturbances have a sexual basis, Adlerian therapy claims
that neurosis comes about through distorted perceptions and from habits
and attitudes that are _learned_. In Adler's system of _individual
psychology_, there is no concern for unconscious processes or for
internal divisions of the self into id, superego, and ego. Adlerians
stress that a person forms a unity and must be treated as a whole.

Adler's approach to psychotherapy is based on the view that feelings of
inferiority are normal. They exist in children, and they continue to
be present in adults who may feel weak psychologically, socially, or
because of physical limitations. To compensate for feelings of
inferiority, adults strive for superiority by dealing effectively with
the world, or they become deeply discouraged (however, they are not
considered to be "sick") and lose contact with positive, constructive
activities.

Adler also postulated that emotional difficulties come about when you
are convinced that you simply cannot solve the problems of life in a
way that is compatible with a need to be superior in some way. Certain
attempts to compensate for feelings of inferiority can lead to
emotional problems later. They include seeking a feeling of
superiority by requiring attention from others, striving for power over
others, taking revenge, and giving up--declaring that you cannot cope
because of personal deficiencies and weakness. Children from families
where there is distrust, domination, abuse, or neglect tend to choose
these paths.

Another facet of Adler's approach is that individuals who {159} cannot
compensate for feelings of inferiority are inclined to make a number of
"basic mistakes" in perceiving the world. They will overgeneralize
("Nobody cares about me."), depreciate their worth ("I'm just a
housewife."), set unrealistic goals ("I should please everyone."),
distort ("You have to lie to get ahead."), and hold faulty values
("Win, even if you have to climb over others.").

Finally, Adler felt that, over the course of their lives, many people
strengthen these basic mistakes while in pursuit of the ultimately
unsatisfying desires for attention, power, revenge, or escape. Their
styles of living may lead to depression, chronic anxiety, crime,
alcoholism, drug abuse, and other problems.

WHAT ADLERIAN THERAPY IS LIKE

Adlerian therapists try to help people change unfulfilling patterns of
living in several ways.

First, and perhaps most important, is the belief that therapy should do
more than help clients with immediate problems. It should help them
develop an adequate philosophy of life, encourage them to cultivate an
approach to living that is self-sustaining, positive, and inherently
_social_ in focus. The paradox of inferiority and low self-esteem is
that the suffering they cause disappears once people can forget
themselves and begin living to some extent for others. Adler would
remind his clients to "consider from time to time how you can give
another person pleasure."[6] Adlerian therapy stresses the importance
of social goals. For Adler, we are foremost social creatures; our
individual identities can be developed and our problems resolved only
in a social context.

[6] Alfred Adler, _Problems of Neurosis_ (New York: Harper and Row,
1964), p. 101.

Since Adler believed that most emotional difficulties we experience
result from feelings of inferiority that have led to discouragement,
the second goal of Adlerian therapists is to offer _encouragement_.
They are as much concerned with mirroring clients' strengths as they
are with analyzing their problems. Adlerian therapists will devote a
good deal of attention to identifying and encouraging the personal
assets of each client.

Adler suggested several techniques that have also come to be used by
other schools of psychotherapy:

{160}

_Acting "As If"_

Frequently, clients express a wish to begin acting in new ways--to be
more assertive, to make an effort to break out of confining patterns of
living, to conquer certain fears. However, they usually feel that the
new behaviors are phony, so they are reluctant to try. Adler suggested
that clients try a new behavior for the next week only as they would
try on new clothing: they need only act _as if_. Adler found that, as
clients began to act differently, they would begin to feel differently.
When their feelings were positive, they tended to make new ways of
behaving part of themselves. (Behavior modification, described in the
next chapter, builds on this idea.)

_Paradoxical Intention_

We encountered this technique, also called _negative practice_, in the
preceding section on logotherapy. It can be a very effective technique
when certain habits can no longer be controlled. If you suffered from
insomnia, you would be asked to focus your attention on staying awake:
to put an end to the habit, you would be asked to amplify it. Oddly
enough, in many cases, this judo-like dropping of resistance and
redirection of attention can bring involuntary behavior back under
control.

_The Push-Button Technique_

Many of us have unpleasant thoughts and emotions that refuse to leave
us. We find ourselves on familiar tracks that we know lead to sadness,
regret, anger, panic, or frustration. But we can't seem to subdue what
Zen calls "these chattering monkeys of the mind." Adler taught clients
that they _could_ create whatever feelings in themselves they wished,
simply by deciding what to think. It is possible, with some practice,
to imagine a happy or peaceful memory or scene and to direct your
attention to it when negative thoughts try to dominate. We all have
this push button available. Like all exercises in self-discipline, it
strengthens us the more we use it. (Cognitive therapy, discussed in
Chapter 10, is especially concerned with this influence of thoughts on
emotions.)

SETTINGS FOR THERAPY

Adlerians use a variety of settings for therapy. Individual {161}
therapy is common, but sometimes two therapists may work together with
one client, an approach that gives clients an experience of cooperation
between professionals who may perceive them differently. Adlerian
workshops are popular with parents concerned with problems in rearing
children. Other workshops exist for married couples. Adlerians have
often been innovative: Rudolf Dreikurs, a well-known student of Adler,
was, for example, one of the first therapists to use group therapy in
private practice.

APPLICATIONS OF ADLERIAN PSYCHOTHERAPY

Because Adler did not view human problems as forms of sickness,
Adlerians see emotional and behavioral difficulties as blocks that
people encounter in their attempts to realize themselves. Many of the
problems Adlerian therapists treat are therefore considered to be
_normal_ problems of living faced by _normal_ people. Many clients
enter therapy to learn about themselves and to grow.

Adlerians have worked with a wide range of clients with a wide range of
human problems:

* clients interested in personal development

* individuals who have become deeply discouraged about their lives

* couples and families

* delinquents and criminals

EMOTIONAL FLOODING THERAPIES

Today there are three main varieties of emotional flooding therapies:
bioenergetics, primal therapy, and implosive therapy. They share the
central belief that, by taxing you, pushing you to experience
frustration, anger, or anxiety, the therapist may help you achieve a
lasting sense of emotional relief and well-being.

These three therapies do, however, vary a good deal in the techniques
they use to encourage clients to experience strong emotions.
Bioenergetics makes use of an unusual approach to physical exercise.
Primal therapy encourages clients to relive early painful memories.
Implosive therapy asks clients to use imagery to increase, in a
controlled manner, feelings that cause emotional distress. These
approaches share the assumption that {162} emotional difficulties can
be helped by a direct release of feelings that have come to be blocked.

BIOENERGETICS

_For rigid, inhibited people who have pent-up
feelings in need of release._

Alexander Lowen (1910-2008) was trained as a physician and then as a
psychoanalyst under the direction of Austrian psychoanalyst Wilhelm
Reich (1897-1957). Reich believed that emotional problems resulted
from sexual repression. He was a social revolutionary in his attempts
to bring about sexual freedom. He became a controversial figure and
was not able to put his ideas on a serious and professionally
respectable footing.

Lowen was interested in the therapeutic implications of Reich's work.
He developed an approach to therapy that emphasizes not sexual
liberation and pleasure as Reich did, but a sense of freedom that he
felt could result only from an approach to the body that allows you to
drop tense muscular armor and to feel integrated and fully alive.
Lowen found that emotionally troubled people were physically knotted
and rigid and tended to breathe in a shallow and constricted way.

Lowen devised a variety of physical exercises, such as holding your
body in an arched position until exhaustion sets in, making contact
with the floor only with hands, head, and feet. These exercises can
cause enough stress to arouse intense emotions: crying out, collapsing,
feeling rage or tenderness. As these pent-up feelings are released,
many clients often discover an increase in positive emotional strength.

Bioenergetic therapists offer individual therapy as well as workshops.
They tend to act as teachers, pointing out very bluntly how a client's
physical rigidities reflect rigid qualities of personality: "Your chest
muscles are this tense because you have been defending yourself so
long, like a boxer," or "Your jaw muscles ache because you've been
biting back angry impulses."

Because of its physical approach to human emotions, bioenergetics is
sometimes regarded as the West's therapeutic version of yoga. (For a
discussion of yoga, see Chapter 15.)

{163}

_Applications of Bioenergetics_

Bioenergetics appears to be most useful for people with any of these
characteristics:

* Their feelings are markedly inhibited, or they feel deadened
emotionally.

* They feel impaired sexually or do not experience orgasm for
nonphysical reasons.

* They are rigid, uptight, and inclined to be obsessive perfectionists.

* They have pent-up feelings of anger, hostility, or grief that are in
need of an outlet.

Bioenergetics is not the treatment of choice when deeper insight and
self-knowledge are important. Bioenergetic therapists are not in
general especially concerned with a client's personal history, family
and work environment, or specific adaptation problems.

PRIMAL THERAPY

_For individuals who continue to suffer from
childhood pain._

Arthur Janov (1924- ) was psychoanalytically trained as a clinical
psychologist and psychiatric social worker. He had been practicing for
seventeen years when a shy and withdrawn client in a group therapy
session let out a piercing, primitive scream. The inhibited client
experienced a sense of release and insight. This event fascinated
Janov and eventually transformed his professional perspective.

He developed an approach to therapy that encourages patients to
re-experience repressed painful memories from childhood. Janov calls
these _primal_ pains: they come about when a child's emotional needs
repeatedly are not met. The inner suffering that results is
suppressed; the pain cannot be dissipated. It takes energy to continue
to block out painful feelings. The constant expenditure of energy then
shows up in conscious tension. Janov came to believe that emotional
problems in adults stem from {164} their unwillingness to experience
feelings that a child would find crushing but--though painful--can now
be faced. When primal pain is faced, Janov claims, individuals gain a
degree of freedom and maturity they could not otherwise achieve.

Janov's primal therapy is best known for the "primal scream" we
mentioned above that some patients let out when they confront the pain
they have suppressed for so long. Primal therapy encourages a repeated
cathartic release of pent-up feelings. During the first three critical
weeks of therapy (which normally cost in excess of $2,000), the primal
therapist is on call twenty-four hours a day for a single patient. The
patient is isolated for the first week in a hotel room, without TV,
cigarettes, alcohol, sex, or companionship, and has daily therapy
sessions with the therapist that last from two to three-and-a-half
hours. Patients then spend six to twelve months in a primal therapy
group.

Janov has been criticized for his apparent desire for public charisma
and for capitalizing on advertising hype. He tends not to reveal in
writing details of his procedures in therapy and will share his
professional secrets only with initiates at his primal therapy
institute. Comparatively few therapists have had this special
training. However, many therapists offer what they claim is the
equivalent of primal therapy, which they call _intensive feeling
therapy_. They have the same format for therapy: isolation in a hotel
room, three weeks' exclusive attention to each client, and the
resulting high fees.

_Applications of Primal Therapy_

Primal therapy has been used to treat these problems:

* chronic depression and anxiety

* compulsions

* phobias

* drug addiction

* problems of homosexuals

* marital problems

Like bioenergetics, primal therapy is best suited for individuals who
have repressed or pent-up feelings they have not found ways to release.

{165}

It is important to bear in mind that primal therapy is initially one of
the most expensive therapies, since it devotes exclusive attention to
each client at the beginning of therapy. It may not be the therapy of
choice for more verbal, intellectual clients who want to develop an
understanding of themselves beyond an experience of catharsis.

IMPLOSIVE THERAPY

_For people with phobias._

This emotional flooding therapy was developed by Thomas Stampfl (1923-
). Stampfl was trained as a clinical psychologist at Loyola of Chicago
and was influenced by both psychoanalysis and the psychology of
learning. Early in his career, he became convinced that clients with
phobias tend to reinforce their fears by automatically avoiding what
they fear. He developed an approach to help people face the
situations, feelings, or memories they most fear.

Stampfl's approach is most easily understood in the light of recent
experimental work on animal avoidance behavior. A dog, for example, is
confined in a cage that is divided in two. A low wall separates the
two halves of the cage, over which the dog can jump. On one side there
is a bell that rings just before the dog receives an electric shock.
The dog promptly learns that he can avoid the shock by jumping to the
other side of the cage. Soon he will learn to do this automatically,
whenever the bell rings. What is significant from a psychologist's
point of view is that the dog will continue for a long time to jump to
the opposite side of the cage, even once no further shocks are given.
The dog's fear is maintained in force only by his own memory.

Animal psychologists have found a quick way to end the dog's fear: ring
the bell, but _prevent_ the dog from jumping to the other side of the
cage. Once the anxiety-stricken animal realizes that he is no longer
going to be shocked, the old habit based on fear simply disappears.

Implosive therapists make use of an equivalent technique with human
beings. Patients are asked to imagine, as vividly as {166} possible,
that they are facing the very thing they chronically have tried to
avoid. For example, an individual may have suffered from a terrifying
fear of elevators for years. The therapist tries to use exaggerated
imagery to produce maximum anxiety. He might ask the patient to
imagine being stuck in an elevator fifty floors up, having the elevator
shake and abruptly fall a foot, then have the lights go out, and so on.
By _maintaining_ this contrived elevator nightmare long enough,
implosive therapists claim that, frequently, the level of anxiety of
patients quickly and dramatically falls, and they lose their
exaggerated fears.

Implosive therapists are therefore not primarily concerned with being
genuine, sympathetic, or mothering. They focus their energy and
attention on pushing clients to confront the worst fears and
catastrophes they can imagine. All the while, clients are aware both
that the intense anxiety they experience is an _intended_ goal of
therapy and that the therapist is convinced they are much stronger than
they have thought.

Implosive therapy is usually done on an individual basis and is
comparatively brief, usually lasting less than a dozen sessions. It
should be mentioned that, when not successful, implosive therapy may
occasionally _sensitize_ clients to feel even more anxiety than they
did at the outset. It therefore tends to be a higher-risk treatment,
but it can be remarkably effective. Visualizing anxiety-producing
events also has successfully been used by individuals on their own.
(For more information, see "Appendix B: Suggestions for Further
Reading.")

_Applications of Implosive Therapy_

Implosive therapy is especially appropriate for the treatment of phobic
individuals who characteristically tend to avoid certain kinds of
behavior, situations, or objects because of the severe anxiety and
agitation these produce in them. Implosive therapy, when effective,
can be dramatically effective in a comparatively short time. However,
less arduous approaches to therapy can often be as effective and may
involve less risk of increasing a client's existing anxiety.
Alternative short-term therapies especially well-suited to the
treatment of phobias include behavior modification (Chapter 12),
Gestalt therapy (Chapter 10), reality therapy (earlier in this
chapter), primal {167} therapy (earlier in this chapter), and
biofeedback, relaxation training, and hypnosis (Chapter 15).

DIRECT DECISION THERAPY

_For individuals capable of exercising
determination and self-discipline who
earnestly desire to change._

[I]f there's one thing my experience as a psychotherapist has
taught me, it is that no one has to be a victim. However important
external factors like health, physical appearance, and upbringing
may be, they don't have to determine the happiness quotient in
anyone's life story. The way we experience our lives is, quite
simply, up to us.

Harold Greenwald, _The Happy Person_

At the time of this writing, the majority of academic and research
psychologists regard themselves basically as Freudians. Yet most
psychiatrists, psychotherapists, social workers, and counselors have
moved beyond Freud's formal categories and made use of their own common
sense and interpretive abilities. Harold Greenwald's emphasis on the
central role of _choice_ in making fundamental life decisions
implicitly represents the approach of a great many therapists and
counselors today. His conception of therapy is casual, simple, and
often good-humored.

Greenwald (1910-2011) was originally trained as a psychoanalyst. As
Greenwald gained professional experience, however, his perspective
began to change. He gradually came to believe that many patients had,
at some critical moment, made a _decision_ to "go crazy." There was a
point when they could exercise control, and at that moment, they chose
to be depressed or anxious, to withdraw completely into catatonia, to
become schizophrenic, alcoholic, or whatever their decision might be.

I discovered in working with people who have had psychotic breaks
... that most of them described a particular moment when there was
a choice of whether to stay in control or let go.... You will
find, again and again, if you speak to patients who have broken
down, and if you search for it, that there is always {168} a point
at which they had a choice, and it is at that point that they still
have the possibility of controlling themselves. If they have
confidence in their ability to control themselves they can exercise
it.[7]

[7] Harold Greenwald, "Treatment of the Psychopath," in Raymond J.
Corsini, ed., _Readings in Current Personality Theory_ (Itasca, IL:
F. E. Peacock Publishers, 1978), p. 355.

This _choice point_ that people experience became the focus of Dr.
Greenwald's direct decision therapy.

AN EXAMPLE

Here is one of the most dramatic examples of his approach: Dr.
Greenwald had been invited to give a demonstration of direct
decision therapy at a mental hospital in Norway. He asked for a
volunteer from the inmates, someone who could speak English. A
twenty-year-old patient named Marie came forward. She had the
appearance of a back ward schizophrenic. She was haggard,
wild-eyed, and unkempt. Here is Dr. Greenwald's description of
their opening conversation:[8]

[8] Harold Greenwald and Elizabeth Rich, The Happy Person (New
York: Stein and Day, 1984), pp. 180-181.

I gestured toward a chair. "Won't you sit down, please?"

"When I'm ready. I'll sit when I'm ready."

"Would you tell me your name?"

She waved an arm toward the staff member seated behind me. "You
heard him. Marie, my name is MARIE!"

"I'm sorry, Marie, I didn't catch it at first. Now I wonder if
there is anything I can do for you. Would you like me to help you?"

"You can't help me, none of you can help me. Why don't you _leave
me alone_? WHY ARE YOU ALWAYS AT ME?..."

She rushed on, shouting at the top of her voice and using a mixture
of expletives and obscenities that showed an admirable command of
English as well as Norwegian.

Nothing I could do could make the situation worse, so I decided to
try something drastic. I outshouted her.

"CUT IT OUT, MARIE! YOU KNOW YOU DON'T HAVE TO TALK LIKE THAT."

She stopped suddenly and focused on me for the first time. The
muscles in her face relaxed ever so slightly, and her eyes {169}
showed awareness and intelligence.

"How'd you know?"

I stared at her for a minute, giving her my best foxy-grandpa look.
"It takes one to know one," I said finally--at which point Marie's
face broke into a grin.

"You mean _you're_ crazy? You too?"

"Perhaps. And perhaps the only difference between you and me is
that I know how to act sane."

Marie seemed to like the sound of that. She tightened the sash of
her bathrobe and sat down.

As Marie calmed down, she agreed that she would like Dr. Greenwald to
help her. She wanted badly to leave the institution.

DR. G.: If you really want to get out, Marie, you'll have to make a
very simple decision.

MARIE: What's that?

DR. G: Decide to act sane.

Dr. Greenwald asked her to think of the benefits, the payoffs, that
came to her as a result of her crazy behavior. There were a number of
major payoffs: she didn't have to look after herself, didn't have to
look for a job, didn't have to listen to her mother.

The upshot was that Marie decided to give up being crazy and to return
to everyday living. It would have been easy for Dr. Greenwald to
conclude that she had been faking all the years she was in the mental
institution. But she had not been play-acting. Yet her illness began
through a _choice_ she had made, and it ended the same way.

Leaving the hospital world was not easy for her. In fact, it was often
very difficult. But she stayed with her decision and often had to
reaffirm it. She married and had a child. She wrote to Dr. Greenwald:

I found myself beginning to drift off, drift out of my life, the
way I used to. And--I didn't! I decided to be the kind of person,
the kind of wife and mother, that I want to be. Not perfect, just
what's possible. And if I drift off, I won't be able to hear my
daughter, I'll be just like my mother was with me.

Marie went back to school and earned a degree in psychology. After her
experience, she was, she felt (as did Dr. Greenwald), in {170} a
special position to be helpful to other people in suffering.

WHAT DIRECT DECISION THERAPY IS LIKE

On your own or with professional help, the truth about you--whoever
you are--is that you carry within yourself the resources to heal
your most grievous pains, overcome your most paralyzing fears,
devise ingenious solutions to your most burdensome problems.

Harold Greenwald, _The Happy Person_

During the first session with a client, Dr. Greenwald often says
something like, "Do you want me to concentrate on your problems, or
would you like us to work together in making you happy?" Immediately,
he suggests to clients that in fact they are able to change and become
happier.

Dr. Greenwald describes seven phases that direct decision therapy
involves:

1. Decide what you want in order to be happy (or happier).

2. Find the decision behind the problem: what has your implicit
decision been in your life that has established an unhappy, or less
happy, pattern? Greenwald calls these _life decisions_: they form the
center around which you organize your life. They are responsible for
your attitudes, perceptions, what you value most, and your behavior.

If your life decision is to suffer, you will interpret everything that
happens to you as more suffering-to-be-endured. If you are praised,
you may question whether the praise has an ulterior motive. "Sufferers
... have the ability to snatch disaster from every victory."[9]

3. When was the original decision made? Did your life decision come
from your upbringing? Did you inherit it from your parents?

4. Identify the payoffs for the decision. Even extreme
unhappiness--chronic clinical depression--can have real payoffs:
release you from responsibilities, gain you attention from others,
allow you to return to the comfort of childhood dependency, etc.
Anxiety can give you good reasons for {171} disqualifying yourself from
stressful situations and reinforce your belief that you cannot cope.

5. What are your alternatives to the behavior that is causing a
problem? It is often hard to see that you are _not_ really trapped in
a state of unhappiness. There are always alternatives.

6. Choose your alternative and put it into practice. Trust yourself.
"[H]appy people have a sense that whatever happens, things will
eventually work out. In short, they trust themselves to react in their
own best interest."[10]

7. Support yourself in carrying out your decision. Habits die slowly.
You must be patient. Your decision has to be made over and over again,
just as an overweight person who loves food must decide again and again
to say "No" to this dessert today, the baked potato tomorrow.
Gradually, the strength of your decision builds as _you_ build strength
into it.

[9] Greenwald and Rich, _The Happy Person_, p. 29.

[10] Greenwald and Rich, _The Happy Person_, p. 29.

APPLICATIONS OF DIRECT DECISION THERAPY

As we have seen, direct decision therapy is based on the assumption
that you are _able_ to begin to exercise self-discipline and that you
are _willing_ to give up the real payoffs that being emotionally
troubled frequently does achieve.

These interrelated things--ability and willingness to change--simply
are not present in many people who enter therapy. They come to therapy
for a variety of other, often unconscious, reasons: for temporary
comforting, for escape from an upsetting situation or environment, or
for a chance to release painful feelings and to express painful
thoughts. Clients come in order to procrastinate; they come to prove
to themselves that they simply _can't_ change and that the therapist
just isn't good enough. They come out of anger, frustration, despair.
But comparatively few enter therapy because they really are persuaded
they _can_ change and are committed to bringing change about.

These people are unquestionably the most promising candidates for _any_
approach to psychotherapy. Clients who come to therapy for other
reasons make up the daily challenge and the daily frustration, concern,
worry, and hope of the therapist. The therapist believes that, in
time, and with proper treatment, {172} people who are imprisoned within
walls of their own habits can rally the determination and faith to tear
them down and to gain a measure of personal freedom.

In this author's judgment, direct decision therapy, perhaps more than
any other approach, relies on a client's determination and
perseverance. If these personality qualities are there, or if they can
successfully be encouraged by a good therapist, the approach can be
effective with a very wide range of problems.

[W]hat ... many ... patients proved to me is that, given the choice
to be happy, many unhappy people are able to decide that happiness
is what they want. Then ... they develop the ability to experience
their problems in a different way.[11]

[11] Greenwald and Rich, _The Happy Person_, p. 53.

{173}

BEHAVIORAL
PSYCHOTHERAPY

_For people who want prompt relief
from specific symptoms and who have
the incentive and discipline to practice
new patterns of behavior._

[M]uch of our suffering is just so obscure ... frigidity, social
anxiety, isolation, boredom, dissatisfaction with life--in all such
states we may see no correlation between the inner feeling and the
way we live, yet no such feeling can be independent of behavior;
and if only we find connections we may begin to see how a change in
the way we live will make for a change in the way we feel.

Alan Wheelis, _The Desert_

Many of us today feel forced to adapt to ways of living that will lead
to unhappiness, loneliness, fear, and illness. Is unlocking all five
bolts on one's apartment door in the morning, checking that the can of
Mace is in your purse, joining the sidewalk crowd to the subway, hoping
you are not mugged (or worse), and then spending the daylight hours in
a windowless office, in an atmosphere of tension, pressure,
competitiveness, and cigarette {174} smoke, with time out for caffeine
(or, again, worse) and then a lunch soaked in alcohol a desirable and
healthy way to live?

Behavioral psychotherapy seems to have been developed to respond
especially to present needs.

Clients usually respond ... with a great sense of relief on finding
they are not seen as sick or weak; they appreciate the positive
orientation toward changing the problematic situation rather than
dwelling on it.[1]

[1] Dianne L. Chambless and Alan J. Goldstein, "Behavioral
Psychotherapy," in Raymond J. Corsini, ed., _Current Psychotherapies_
(Itasca, Il.: F. E. Peacock Publishers, 1979), p. 234.

Behavioral psychotherapy is best known for focusing on symptoms as its
main target, rather than viewing symptoms as signs of underlying
problems. Like most generalities, this one has its exceptions; some
behavioral psychotherapists are very much concerned with understanding
the underlying causes of an individual's difficulties. Nevertheless,
behavioral therapies do tend to aim for concrete, specific, and prompt
relief of symptoms. They frequently are effective, and they are based
on techniques that have been tested extensively.

THE THREE SCHOOLS

Today there are three main schools of behavioral psychotherapy:

COUNTER-CONDITIONING

Also called _reciprocal inhibition_, this approach was developed by
Joseph Wolpe (1915-1997), a Jewish psychiatrist trained in South
Africa. Anxiety is offset by means of desensitization, assertiveness
training, and sex therapy. As the basis for desensitization, deep
relaxation is used to inhibit anxiety. Assertiveness training is used
to counteract anxiety due to excessive shyness or aggressiveness by
helping individuals form balanced habits of assertiveness that are
neither submissive nor hostile. Sex therapy makes use of techniques of
relaxation and desensitization to permit clients to feel sexual arousal
and, in this way, to overcome sexual anxiety.

{175}

BEHAVIOR MODIFICATION

This approach was derived from the work of American behaviorist B. F.
Skinner (1904-1990) and others, who attempted to show that a great many
emotional problems result from situations in which a person has been
punished. He or she comes to fear these situations and develops
emotional symptoms in an effort to escape from them. In behavior
modification, attempts are made to change behavior through the use of
rewards or punishments.

COGNITIVE APPROACHES TO BEHAVIOR CHANGE

These approaches make use of techniques developed outside of behavioral
psychotherapy, especially those of Albert Ellis's rational-emotive
therapy (see Chapter 10). These cognitive approaches are based on the
belief that a person can gain control over undesirable behavior and
psychosomatic problems by learning new habits of thinking.

These three schools of behavioral psychotherapy claim that the problems
leading people to enter therapy are _learned_ and can be unlearned
through systematic training. In particular, anxiety--the primary
source of emotional discomfort--can become a learned habit. When this
happens, anxiety is linked to stimuli that in themselves are usually
harmless. A person may come to feel extremely anxious, for example,
when in the presence of people in authority, when in bed with a sex
partner, when near dogs or insects, when criticized by others, when in
a confined space, or in any number of other situations. Anxiety in
these situations is learned, and it gradually becomes an involuntary
habit. But the habit frequently can be broken and eliminated.

WHAT BEHAVIORAL PSYCHOTHERAPY IS LIKE

COUNTER-CONDITIONING

When you are exposed to a situation that you believe is threatening,
your blood pressure and pulse rate go up, your muscle tension
increases, the blood supply to your large muscle groups increases,
circulation to your stomach and genitals is {176} reduced, your pupils
may dilate, your mouth may get dry. A startling noise or a physical
shock can produce these symptoms. They are the physical manifestations
of anxiety, and they are the focus of counter-conditioning techniques.

Anxiety _generalizes_ very easily. If you were repeatedly punished for
playing with dirt as a child, dirt can evoke strong anxiety in you as
an adult. If you were bitten by a dog, the sight of a dog years later
may make you feel anxious. Anxiety can come to be associated with
almost any experience. What is particularly destructive about this is
that you soon find yourself caught in a vicious circle: a certain
situation makes you anxious, you try to avoid the situation and the
anxiety it produces in you, and as you do this, you build up
_secondary_ anxiety--you get anxious that you'll get anxious. So
anxiety compounds, feeding on itself, fueling itself.

Counter-conditioning therapists have found that, to varying degrees, we
are all capable of inhibiting anxiety. A behavior therapist tries to
teach you how to do this, eventually so that you can use relaxation
techniques on your own.

The following are the main phases of desensitization
therapy--assertiveness training and sex therapy are similar, gradual,
and reassuring processes:

1. You are taught how to achieve a state of relatively complete
physical relaxation. Many therapists will tape relaxation instructions
so that you can practice daily at home for twenty to thirty minutes.
Some therapists will instruct you to _tense_ your arms, hold the
tension for ten seconds or so, then relax and feel the resulting sense
of relaxation, the sense of relief from tension and strain. Or, some
therapists use _suggestion_, asking you to imagine that your arms are
becoming heavier and heavier, encouraging you to relax deeply. Each of
your major muscle groups is relaxed in turn until you feel fully
relaxed. This first phase of therapy usually takes from two to six
sessions.

2. Next a hierarchy is constructed by the therapist for each individual
client, ranking situations or stimuli from most to least
anxiety-producing. A person who fears to leave the sense of security
of home already is aware of such a hierarchy: low anxiety may be felt
on the front steps, greater anxiety when going out to the mailbox, more
{177} anxiety in walking around the block, and extreme anxiety when
facing a trip or a move to another residence.

3. The last phase is the actual process of desensitization. You are
asked to relax deeply with eyes closed, usually in a recliner in the
therapist's office. You are asked to imagine a scene taken from the
low-anxiety end of your hierarchy. The therapist tries to describe the
scene as realistically and vividly as possible. If you begin to feel
anxious, you can raise an index finger, and then the therapist will
shift away from the imagined scene and will turn back to relaxation
instructions. When you are again relaxed, the process continues until,
in time, you are able to imagine a scene high on the hierarchy, but
still sustain deep relaxation.

Once this process of desensitization can be accomplished in the office,
you begin anew, but now with actual situations--first with those low on
your hierarchy and then working your way toward situations that used to
cause you high anxiety. Frequently, behavior therapists will accompany
their clients outside the office, helping them to remain relaxed--e.g.,
while riding elevators, in crowds, even sometimes on airline flights if
fear of flying is the problem.

BEHAVIOR MODIFICATION

The central idea behind behavior modification is that undesirable
habits of behavior will gradually be eliminated if, consistently, they
are not rewarded or even are punished. Conversely, desirable habits
are encouraged when they consistently are reinforced or rewarded.

Therapists who use behavior modification techniques may recommend both
punishments and rewards to clients. If you are a chronic smoker or
overeater, for example, you may be given a small device with which to
shock yourself moderately each time you reach for a cigarette or a
second helping. Or, you may be asked to deposit $100 with the
therapist, and a certain amount will be donated to your most disliked
political group each time you go astray.

Rewards, on the other hand, include material rewards that clients may
promise themselves once a habit is successfully under control for a
certain length of time. Most therapists {178} encourage you eventually
to substitute inner satisfactions: pride in your slim appearance or
improved health, strengthened self-confidence, growth of sexual
satisfaction, and, most importantly, a developing sense of self-respect
as you learn to gain control over anxiety, frustration, or
dissatisfaction.

Behavior therapists also use _distraction_ techniques. They encourage
you to do things that are incompatible with the problem you wish to
resolve. Bicycling or lovemaking may prove to be good antidotes for
some individuals who overeat. Hiking or jogging, or physical
reassurance, massage, or relaxing baths may lessen anxiety. Laughter
releases tensions and offers its own special kind of encouragement and
healthier perspective.

Behavior modification requires strong initiative and discipline on the
part of the client. More than these, it requires that you be willing
to let go of old habits that have been unsatisfying or destructive and
work to form new, more rewarding habits. In the beginning, forcing
yourself to behave in new ways may feel like pretense or dishonesty.
This is a common experience and should not be allowed to block your
desire to change. Unfamiliar and even uncomfortable ways of behaving
do become familiar and more comfortable the more they are practiced.
If these new ways of behaving come to offer satisfactions or
compensations that old habits did not, they will gradually be absorbed
into your own sense of personal identity. What at first may feel to
you like an act slowly is made a part of your personality until a habit
is established that feels entirely natural. This takes time, patience,
practice, and more practice.

COGNITIVE APPROACHES TO BEHAVIOR CHANGE

Behavioral psychotherapists use a variety of techniques designed to
help clients control their own behavior and individual physical
responses more effectively.

_Biofeedback_

Biofeedback can help many people gain control over habitual, automatic
processes. Biofeedback equipment can be used to teach you how to
reduce tension, develop skills to bring about relaxation, or cope more
successfully with chronic pain. (For a detailed discussion of
biofeedback, see Chapter 15.)

{179}

_Thought Stopping_

Thought stopping can help you break chains of negative and
self-undermining thoughts. Thought stopping is a technique that begins
by having you think out loud during therapy sessions. If you
repeatedly express negative, troubling thoughts, the therapist shouts,
"Stop!" In this way, you are made acutely aware of self-destructive
thinking habits. You gradually learn to stop yourself from trapping
yourself in upsetting thoughts by silently commanding your mind to
"stop!" It is a simple but often effective technique, related to two
techniques we have already discussed: the push-button technique of
Adlerian psychotherapy (see Chapter 11) and the technique of disputing
your own irrational beliefs in rational-emotive therapy (see Chapter
10).

_Problem Solving and Decision Making_

These techniques have been developed to help clients solve personal
problems and make life decisions more effectively. Behavioral
therapists who offer assistance of this kind emphasize the importance
in problem solving and decision making of several factors.

One is refraining from implementing solutions or decisions until you
have clearly defined and understood your problem or situation. Another
is becoming aware of emotional blocks to solving problems and making
decisions. For example, procrastinating serves to protect people from
facing risks. Individuals are frequently also deterred from solving
practical problems because they are emotionally distracted by other
difficulties that demand attention first. And people are inclined to
jump at one possible solution that then acts as a blinder to seeing
other potentially more promising alternatives.

Behavioral therapists also believe you must realize that, often,
difficulties you experience when trying to solve problems or make
decisions are due to conflicts between incompatible goals or values.
Sometimes one objective cannot be achieved without compromising
another. They also believe you must develop abilities to imagine a
wider range of alternatives. And finally, they believe you must become
better able both to foresee likely personal consequences of
implementing a particular solution or decision and to evaluate these in
relation to what is personally most important.

{180}

AN EXAMPLE OF BEHAVIORAL PSYCHOTHERAPY

Anne Holt was thirty-two when she came to see Dr. Cantwell. She was
noticeably anxious, wringing her hands, tense, and easily startled, as
when a car's exhaust backfired in the street below. She complained of
feeling unloved by her husband and was always in dread of his
criticisms. She also felt her mother-in-law was very critical of her.
Anne wanted to get away from the house but had quit two jobs in
succession, in each instance when her boss's criticism of her work
upset her.

Dr. Cantwell explained the rationale behind desensitization to her and
taught Anne how to practice systematic muscle relaxation, beginning by
tensing her hands, then relaxing them, tensing them, then relaxing them
again, and doing this with her arms, shoulders, calf muscles, thighs,
abdomen, jaw, neck muscles, cheek, and mouth muscles. He recorded his
instructions on a tape for her to use at home.

After five weeks of daily practice, Anne was usually able to relax
deeply in less than a minute. Dr. Cantwell, in the meantime, had
gained a clearer idea of what troubled Anne, and he had made up the
following hierarchy:

_Criticism directed at Anne from:_

High anxiety Her husband
| His mother
| A boss
| Anne's mother
Low anxiety Anne's neighbor

Dr. Cantwell decided to use a combination of desensitization and
assertiveness training with Anne. During half of each weekly session
with Dr. Cantwell, Anne was asked to relax in a recliner with her eyes
closed, and Dr. Cantwell would then describe situations low on her
hierarchy. Anne was to try to maintain her sense of relaxation _in
spite of_ Dr. Cantwell's description of an imagined situation involving
Anne's neighbor. She was to imagine that her neighbor, who was very
fastidious about her own yard, knocked at Anne's door to complain about
Anne's habit of setting the trash out the night before pickup.
Gradually, in a similarly concrete way, Dr. Cantwell had Anne imagine
her mother criticizing Anne for using the same sponge for wiping up
{181} in the kitchen as for washing the dishes; a boss asking Anne to
retype a business letter using another format that he preferred; Anne's
mother-in-law "dropping the hint" that her son liked to have his
T-shirts ironed; Anne's husband complaining because Anne always
overcooked the soft-boiled eggs.

During the second half of each session with Anne, Dr. Cantwell played
roles with Anne in which he taught her how to assert herself more in
situations involving criticism. In one session, for example, he took
the part of Anne's mother and chose a typical remark she might make:
"Annie, dear, don't you think it would be smarter to use a different
sponge for wiping the kitchen counter? You should use a separate one
for the dishes." Dr. Cantwell then asked Anne to think of a way she
could reply to her mother's "nice" criticism, without feeling bad about
herself, without "getting hooked."

ANNE: Well, one way you've taught me would be to use humor: I could
say to her, "Mom, anytime you'd like to come over to do the dishes,
it would be fine with me." And then laugh.

DR. C.: That's a good approach. But you don't want to be
offensive; you don't want to laugh _mockingly_. _How_ you do this
is important. You want to set a good-natured feeling. Humor can
be very useful to offset the sting of criticism. Can you think of
a different way to reply to your mother, in addition to humor?

ANNE: Well, let's see.... Yes, well, I could go with her
suggestion and not interpret what she says to me as criticism at
all. I could say, "Mom, thanks for the idea. Maybe I'll do that."

DR. C.: Sounds very good. That's another way. The more
alternatives you can prepare yourself with ahead of time, the less
likely she will hook you, leaving you with nothing to say and
simply feeling bad. Would you try to think of one more
alternative? What other tack could you take?

ANNE: (After a moment of silence.) I can't think of another.

DR. C.: How about telling your mother how you actually feel when
she criticizes you? How _do_ you feel?

ANNE: Well, I wish she'd say some positive things instead, at least
sometimes. That would be nice.

DR. C.: Great. How could you tell her that?

ANNE: Well, I could say, "Mom, you know, you give me a lot of
suggestions. Some are OK, now and then, but, to be {182} honest,
I'd really like to hear some praise sometimes. Do you think you
could find some things to compliment me on? I don't want any false
praise, but I need to hear some encouraging things from people I
love."

DR. C.: Anne, you're doing very well: ... Humor, reinterpreting so
you don't feel criticized, and talking about criticism from a more
detached point of view. You're definitely learning how to cope
with criticism much better.

APPLICATIONS OF BEHAVIORAL PSYCHOTHERAPY

Desensitization is normally used in the context of individual therapy.
Behavior modification and cognitive approaches to behavior change are
frequently used in groups. People with problems in common--smoking,
obesity, phobias, etc.--are sometimes grouped together. Often,
however, a mixture in groups is desirable. For example, it is
frequently helpful for shy people to be part of a group in which they
may watch others who can model more assertive ways of acting. (For
more about group therapy, see Chapter 13.)

Behavioral approaches to therapy must be tailored to the individuality
of each client; whatever goals are established have to be in accord
with the client's own desires. Behavioral psychotherapy presupposes
that clients will practice instructions and new behaviors between
sessions and that they can maintain an adequate level of motivation,
both while in treatment and after treatment ends, so that new habits of
behaving or thinking can become effective and reliable parts of their
own personalities.

In general, behavioral approaches to therapy have been less effective
in treating panic attacks, chronic depression, substance abuse
(smoking, for example, is one of the habits most resistant to formal
therapy), and psychosis.

COUNTER-CONDITIONING

This approach, which includes desensitization, assertiveness training,
and sex therapy, has been used effectively in treating these problems:

* phobias

* psychosomatic complaints

{183}

* sex, marriage, and family problems

* passivity and shyness

* personality trait problems: lonely, anxious, hostile, or overbearing
individuals

BEHAVIOR MODIFICATION

This approach has been used successfully in connection with these
problems:

* sexually deviant behavior

* children's problems, school discipline, academic performance, and
juvenile delinquency

* problems of the mentally retarded and of psychotically regressed
individuals

* some instances of obesity, alcoholism, and smoking

* schizophrenia

* stuttering

COGNITIVE APPROACHES TO BEHAVIOR CHANGE

These approaches have, for example, been used to treat such problems as:

* anxiety and depression

* adjustment problems

* marital and sexual difficulties

* psychosomatic problems

The popular conception of behavioral therapists is that they tend to be
coldly scientific and mechanical. Yet a number of studies show that
they are inclined to be warm individuals who show positive regard for
their clients. In general they tend to be empathetic and
self-congruent. These qualities are very much needed if we as clients
are to feel encouraged to face one of the most difficult challenges
life can pose for us: to change ourselves.

{184}

GROUP THERAPY

_Especially well-suited to people who are
outer-directed but lonely, who want to
develop their interpersonal skills,
and who would like to learn about
themselves from the perceptions of others._

Group therapy is ancient. For as long as men have gathered together to
share their experiences, thoughts, and feelings and to give one another
comfort, group therapy has existed. As an approach to modern
psychotherapy, however, it was in its infancy fifty years ago. No
single great mind stands behind group therapy; it has been and
continues to be innovative, flexible, and free from ties to any
particular orthodox school of thought.

Clients who are attracted to group therapy and who often benefit from
group experience tend to have these characteristics:

* They are passive in their interactions with others. They are more
comfortable being told what to do than facing the need to decide for
themselves.

* They are often lonely or socially isolated. Individual {185}
therapy, with its one-to-one relationship between therapist and client,
does not encourage some clients enough for them to feel like members of
humanity. They tend to feel sorry for themselves while in individual
therapy or to judge themselves harshly for their need for help. Being
with other clients in a group situation answers their needs better.

* They are outer-directed people: what others think of them is crucial
to how they think about themselves. Inner-directed individuals are
likely to feel more interested in and comfortable with individual
therapy.

For people who are relatively passive, lonely, yet outer-directed,
group therapy has some distinct advantages:

* It gives them a place within a group of people--they are no longer
alone.

* It gives them opportunities to express themselves freely, confront
other people, and say things that they otherwise might not be able to
express, thanks to the close and confidential environment of the group.

* They can hear how a variety of other people perceive them. They are
not limited to the observations, ideas, and recommendations of a single
therapist.

* They often feel more at ease in a group. They feel less fear or
intimidation in the presence of the authority figure the therapist
represents.

* They may benefit from the experiences of other group members who have
similar problems or who have very different kinds of difficulties.
Knowing that they are not troubled minorities of one can be a comfort;
knowing that other people have problems in areas where they don't can
be reassuring.

In general, group therapy can give you insight provided by the thoughts
and perceptions of others; it can help you develop social ties if you
feel isolated; and it can offer group support if you need emotional
bolstering in order to cope with difficult situations, undertake
decisions that may frighten you, and face more calmly and confidently
the many challenges life can present. But it can also help you deal
with more specific problems, such as facing an especially stressful
situation--the death of {186} someone very close to you, divorce or
separation, serious illness, unemployment, drug addiction, or
alcoholism. Or perhaps you have problems relating to others, such as
having a history of being fired from job after job despite your efforts
to hold them. For that matter, group therapy can even offer
information about job opportunities, how to develop occupational
skills, how to apply for a job, and how to keep a position you hold.

Some psychologists have commented that the popularity and the need for
the kind of experience that group therapy offers are due to the decline
of community life and to the virtual disappearance of extended families
living physically and emotionally close to one another.

Group therapy is offered in private practice, in hospitals, and in
halfway houses; in psychiatric and counseling centers, in clinics and
hospital wards for patients with diabetes, AIDS, epilepsy, arthritis,
heart conditions, paralysis, blindness; in prisons and juvenile
detention centers; and in schools, for students with behavior problems
and truancy. Group therapy is often used for marriage, family, and
child-guidance counseling and to help families in which a member is
physically or emotionally disabled. Group therapy is used by churches
for family guidance and for spiritual counseling. It is used in
virtually any area where people share problems: victims of crime and
physical abuse, former patients, the aged, children of the aged, those
who are discriminated against--the list goes on.

So, group therapy cuts across virtually the whole range of human
problems. Because it is used in so many areas, it is impossible to
define it as a single approach--many distinct approaches actually may
be involved.

Many of the approaches to psychotherapy we have already looked at are
used in groups. There are psychoanalytically oriented groups, Adlerian
groups, Gestalt groups, groups that use behavior modification, and
others. Perhaps the most useful way to understand group therapy is to
liken it to education. Many sorts of things can be taught, and many
can be learned. Group therapy may be understood most clearly in
relation to what kinds of learning and teaching really go on in it.

Since group approaches to problem solving include many applications
beyond our scope here--in industry, religion, schools, etc.--we will
look more closely at the following forms of group therapy that are used
in the context of psychotherapy: brief group psychotherapy, T-groups,
{187} human potential groups, self-help groups, and the use of
specialized approaches to psychotherapy in a group setting. (Marriage
and family therapy, which are special forms of group therapy, are of
interest to a large number of people, so they are discussed separately,
in Chapter 14.)

BRIEF GROUP PSYCHOTHERAPY

Also known as _short-term encounter groups_, brief group psychotherapy
is intended for people who face life crises, who are motivated to
change, and who are comparatively free of individual emotional
disorders. Normally, there are about ten sessions. People who find
short-term group therapy useful generally have well-defined problems to
solve. Their experience in group therapy encourages them to become
involved in new activities, join clubs, perhaps do volunteer work after
being recently widowed, divorced, or separated; to take specific steps
to find employment; or to practice new ways of behaving--to become more
assertive, to implement a weight-loss plan, to return to school after
raising a family, or to change careers.

T-GROUPS

Training groups were an outgrowth of the National Training
Laboratories, an organization formed in 1947 by social psychologists
who were interested in improving education. T-groups were made up of
"normally adjusted people" who were interested in improving their
communication skills so they could become more competent in difficult
interpersonal situations.

T-groups gradually widened their focus and became the basis for the
practical orientation of many therapy groups today. Clients who feel
isolated or alienated, find it hard to relate to others, lack a sense
of meaning and direction, and do not have strong self-discipline often
are attracted to T-groups.

HUMAN POTENTIAL GROUPS

These groups have probably done the most to give group therapy its
popular image. "Growth centers" are usually rural retreats where
psychological growth of participants is encouraged. Visits last from a
weekend to several weeks. The first {188} center was called Lifewynn,
organized in the 1920s at a summer camp in New York's Adirondack
Mountains. The best-known growth center is the Esalen Institute in Big
Sur, California, formed in 1962 by Michael Murphy. Its program
combines Gestalt therapy with Eastern meditation (see Chapter 15).
Other similar growth centers have sprung up across the country. In
addition to these, the est (Erhard Seminars Training) organization has
attracted a good deal of public attention and controversy. The est
approach is eclectic, combining Eastern thought, Gestalt therapy,
transactional analysis, psychoanalysis, Jungian philosophy, positive
thinking, meditation, and other approaches. Some est leaders have been
described as charismatic, proselytizing personalities who claim to be
able to lead participants to salvation.

SELF-HELP GROUPS

There are self-help groups to aid you with many different kinds of
problems. They provide group moral support for members with shared
problems. They are not intended to bring about deep-seated personality
change. Alcoholics Anonymous (AA), founded in 1934, probably is the
most well-known self-help organization. Recovery, Inc., also known as
the Association of Nervous and Former Mental Patients, was formed in
1936 by psychiatrist Abraham A. Low. Meetings focus on members'
conscious control of symptoms; Recovery, Inc., frequently encourages
members to become involved in volunteer social work.

There are many other self-help organizations--for the handicapped,
widows, battered wives, diabetics, victims of AIDS, hemophiliacs,
homosexuals, drug addicts, and others. (For further information see
"Appendix A: Agencies and Organizations That Can Help.")

PSYCHOTHERAPY IN A GROUP SETTING

Most of the approaches to psychotherapy that we have discussed provide
treatment in the form of group therapy in addition to individual
therapy. Group therapy is frequently offered, for example, by
psychoanalysts, client-centered therapists, Gestalt therapists,
transactional analysts, rational-emotive therapists and general
cognitive therapists, existential-humanistic {189} therapists, reality
therapists, Adlerian psychotherapists, emotional flooding therapists,
and behavior modification therapists. In the remainder of this
chapter, we will discuss how group therapy is handled by the main
psychotherapies.

WHAT GROUP THERAPY IS LIKE

Although your experience with group therapy will vary depending on
which school of therapy you have chosen, you will find some common
elements regardless of the approach.

Initially, there is likely to be a period of group confusion, awkward
periods of silence, some polite superficial conversation, and often a
frustrating lack of overall organization and continuity. Different
group members will speak up, and what they say may have absolutely
nothing to do with what the previous speaker has said; people are
waiting for the chance to talk about themselves and tend to concentrate
so much on what they are preparing to say that they don't pay attention
to what others have been saying.

Gradually, a more organized style of interacting comes into being
through the directive efforts of the therapist or as a result of
general group frustration over the lack of coherence. At the same
time, group members will begin to feel more at ease with one another
and will in time begin to lift their public masks and reveal more of
their private selves--their often hard-to-admit feelings of loneliness,
pain, anxiety, depression, etc.--and to express their personal needs.

Frequently, the first steps in the direction of expressing private
feelings will involve attacks on the therapist for not structuring the
group's interactions more or attacks on one member for monopolizing
group sessions. Experienced group therapists realize that these common
negative attacks are understandable tests of the trustworthiness and
the safety of the group as a place to express personal feelings. If an
atmosphere of acceptance is established, and these initial complaints
are allowed to occur without catastrophe, some group members will
usually then begin to open up, to reveal some deeper feelings. One
member may begin to talk about her unhappy marriage, a man about his
gambling obsession, another about his loneliness since his wife died.

At about this time it is common for group members to begin to {190}
tell one another how they feel about each other, how they see one
another. Some of these comments will be positive, some negative. Here
are some examples:

"You have a really nice smile."

"You remind me of my father, all these _shoulds_, _oughts_, and
rules!"

"You never say much, so I feel you're just sitting there judging
us."

"You make me nervous, biting your nails all the time."

"Every time you say something, you put yourself or somebody else
down."

As this process continues, one or two group members will begin to take
an interest in the personal problems of some of the others and express
a desire to help. They will ask questions for more information,
express sympathy or empathy, and begin to offer suggestions. It is at
this point that the process of group interaction begins to acquire a
focus on healing and problem solving. Frequently, these expressions of
desire to help one member will encourage him or her for the first time
to begin to accept the kind of person he or she has been, to realize
that "I _have_ been too hard on myself because I'm so damned
perfectionistic," "I _am_ a controller; I want other people to do
things _my_ way," or "I live in a suit of armor; I'm just afraid of
other people."

As members of the group come to know one another as real personalities,
they tend to become impatient whenever anyone tries to put on his
public mask again. The group demands and expects members to be honest
about themselves. Feelings can run hot whenever Fred tries to make
Alice accept his suggestions because he _knows_ what she really needs.
Group members can show quick impatience with Judy whenever she tries to
persuade herself, even though her husband has severely beaten her
several times, that her marriage is _really_ OK.

Group members quickly gain a good deal of information about how others
see them and feel about them. As a result of an implicit commitment to
honesty, some members' ways of behaving gradually change: a rough tone
of voice becomes less abrasive and calmer; offensive gestures and
judging looks {191} disappear; self-centeredness gives way to a certain
amount of sympathy and interest in other people.

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}

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}

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}

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}

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.

{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:

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}

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

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

{291}

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

{292}

_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

{293}

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

{294}

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

{295}

_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

{296}

_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

{297}

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

{298}

APPENDIX B:

Suggestions for
Further Reading

GENERAL INFORMATION

Greenberg, Bette. _How to Find Out in Psychiatry: A Guide to Sources
of Mental Health Information_. New York: Pergamon Press, 1978.

Powell, Barbara J. _A Layman's Guide to Mental Health Problems and
Treatments_. Springfield, IL: Charles C. Thomas, 1981.

Russell, Bertrand. _The Conquest of Happiness_. New York: Bantam,
1968 (first published in 1930). [One of the most psychologically
perceptive attempts to identify the basic ingredients for a happy life,
by a philosopher who made original contributions to whatever subjects
he touched.]

Strupp, Hans H. _Patients View Their Psychotherapy_. Baltimore: Johns
Hopkins Press, 1969. [Evaluations by patients of their experiences in
psychotherapy.]

------. _Psychotherapists in Action_. New York: Grune & Stratton,
1960. [Focuses on what the therapist actually does in the therapy
relationship.]

Watson, Robert I., Jr. _Psychotherapies: A Comparative Casebook_. New
York: Holt, Reinhart and Winston, 1977. [A collection {299} of cases
treated by means of different approaches to psychotherapy.]

Wheelis, Allen. _How People Change_. New York: Harper & Row, 1973.
[An insightful book about the process of therapy.]

A. PSYCHOANALYSIS (CHAPTER 9)

Brenner, Charles. _An Elementary Textbook of Psychoanalysis_. New
York: International Universities Press, 1973. [A world-famous
introduction to analysis that has now been translated into nine
languages.]

Hall, Calvin. _A Primer of Freudian Psychology_. New York: New
American Library, 1954. [Perhaps the clearest and most concise summary
of psychoanalytic concepts.]

Jones, Ernest. _The Life and Work of Sigmund Freud_. New York: Basic
Books, 1953-57. 3 volumes. [A biography of Freud that describes his
personal development and summarizes his main contributions.]

B. CLIENT-CENTERED THERAPY (CHAPTER 10)

Rogers, Carl Ronsom. _Client-Centered Therapy_. Boston: Houghton
Mifflin, 1951. [A good introduction to Rogers's approach to therapy.
It was his first major exposition of his theory.]

------. _On Becoming a Person: A Therapist's View of Psychotherapy_.
Boston: Houghton Mifflin, 1961. [Perhaps Rogers's best-known book. It
gives a very personal view of his approach.]

C. GESTALT THERAPY (CHAPTER 10)

Pagan, J., and I. L. Sheperd, eds. _Gestalt Therapy Now_. Palo Alto:
Science and Behavior Books, 1970. New York: Harper and Row, 1971. [A
collection of articles on Gestalt theory, technique, and applications
by well-known Gestalt therapists.]

Perls, Frederick S. _Gestalt Therapy Verbatim_. Moab, UT: Real People
Press, 1965. [Probably the most widely read of Perls's books
illustrating the Gestalt approach.]

{300}

D. TRANSACTIONAL ANALYSIS (CHAPTER 10)

Berne, Eric. _Games People Play_. New York: Grove Press, 1964. [A
simply written summary of the main concepts of TA: ego states,
transactions, games, etc.]

------. _What Do You Say After You Say Hello?_ New York: Grove Press,
1972. [Published after Berne's death, this is an outline of his
approach to therapy, focusing on his notion of life scripts.]

E. RATIONAL-EMOTIVE THERAPY (CHAPTER 10)

Ellis, Albert. _Humanistic Psychotherapy: The Rational-Emotive
Approach_. New York: McGraw-Hill, 1973. [A clear statement of the way
people can choose to make, or not make, themselves emotionally
disturbed.]

------, and Robert A. Harper. _A New Guide to Rational Living_.
Englewood Cliffs, NJ: Prentice Hall, 1975. [One of the best-known
self-help books dealing with rational-emotive therapy.]

F. EXISTENTIAL-HUMANISTIC THERAPY (CHAPTER 10)

Arbuckle, D. _Counseling and Psychotherapy: An Existential-Humanistic
View_. Boston: Allyn & Bacon, 1975. [A good introduction to this
approach to therapy.]

Binswanger, Ludwig. _Being-in-the-World: Selected Papers of Ludwig
Binswanger_. New York: Basic Books, 1963. [A less readable book that
nevertheless gives the reader a sense of how existentialism has been
applied to psychotherapy.]

May, Rollo, Ernst Angel, and Henri Ellenberger, eds. _Existence_. New
York: Basic Books, 1958. [A collection of essays dealing with basic
topics of existential-humanistic psychotherapy.]

G. LOGOTHERAPY (CHAPTER 11)

Frankl, Victor. _Man's Search for Meaning: An Introduction to
Logotherapy_. New York: Washington Square Press, 1959. [A clear and
gripping description of the development of logotherapy as a result of
concentration camp suffering.]

{301}

------. _The Doctor and the Soul_. New York: Knopf, 1963. [A further
description of logotherapy.]

H. REALITY THERAPY (CHAPTER 11)

Glasser, William. _Reality Therapy_. New York: Harper and Row, 1965.
[Glasser describes his view that, because of loneliness and feelings of
inadequacy, people tend to refuse to take responsibility for fulfilling
their needs for love and worth.]

See also Glasser's book, _Positive Addiction_, listed under "T.
Therapeutic Exercise."

I. ADLERIAN THERAPY (CHAPTER 11)

Adler, Alfred. _Problems of Neurosis: A Book of Case-Histories_. New
York: Harper Torchbooks, 1964 (first published in 1929). [These are
case examples illustrating Adler's theory of neurotic development. The
book contains an introduction by H. L. Ansbacher that summarizes basic
Adlerian theory.]

------. _Social Interest: A Challenge to Mankind_. New York:
Capricorn Books, 1964 (first published in 1929). [This is the last
exposition given by Adler of his thought. It is a good and simply
written summary of Adlerian psychology.]

J. BIOENERGETICS (CHAPTER 11)

Keleman, S. _Sexuality, Self and Survival_. San Francisco: Lodestar
Press, 1971.

Lowen, Alexander. _The Betrayal of the Body_. New York: Collier, 1967.

K. PRIMAL THERAPY (CHAPTER 11)

Janov, Arthur. _The Anatomy of Mental Illness: The Scientific Basis of
Primal Therapy_. New York: G. P. Putnam, 1971.

------. _Primal Scream_. New York: Dell, 1971.

{302}

L. IMPLOSIVE THERAPY (CHAPTER 11)

Stampfl, Thomas G., and D. Levis. _Implosive Therapy: Theory and
Technique_. Morristown, NJ: General Learning Press, 1973.

M. DIRECT DECISION THERAPY (CHAPTER 11)

Greenwald, Harold. _Decision Therapy_. New York: Peter H. Wyden, 1973.

------, and Elizabeth Rich. _The Happy Person_. New York: Stein and
Day, 1984. [A very readable summary of direct decision therapy.]

N. COUNTER-CONDITIONING (CHAPTER 12)

O. BEHAVIOR MODIFICATION (CHAPTER 12)

P. COGNITIVE APPROACHES TO BEHAVIOR CHANGE (CHAPTER 12)

Alberti, R. E., and M. L. Emmons. _Stand Up, Speak Out, Talk Back_.
New York: Pocket Books, 1975. [On assertiveness training.]

Burns, David. _Feeling Good: The New Mood Therapy_. New York: Signet,
1980. [A good self-help account of the general cognitive approach to
behavior change.]

Kanfer, F. H., and A. P. Goldstein, eds. _Helping People Change_. New
York: Pergamon Press, 1975. [This large book discusses operant,
cognitive change, and self-control methods. The emphasis is on how
these techniques of behavior change are used in a clinical setting.]

Wolpe, Joseph. _The Practice of Behavior Therapy_. New York: Pergamon
Press, 1973. [One of the major contributors to behavioral
psychotherapy describes the use of techniques to encourage behavior
change.]

Q. GROUP THERAPY (CHAPTER 13)

Grotjahn, Martin, Frank M. Kline, and Claude T. H. Friedman, eds.
_Handbook of Group Therapy_. New York: Van Nostrand, 1983.

Helmering, Doris W. _Group Therapy: Who Needs It?_ Millbrae, CA:
Celestial Arts, 1976. [A good informal summary of group therapy.]

{303}

R. MARRIAGE THERAPY (CHAPTER 14)

S. FAMILY THERAPY (CHAPTER 14)

Fay, Allen. _Making Things Better by Making Them Worse_. New York:
Hawthorne Books, 1978. [A variety of applications of therapeutic
paradoxical strategies in marriage communication, as well as in
connection with the treatment of anxiety, depression, fears, etc.]

Foley, Vincent D. _An Introduction to Family Therapy_. New York:
Grune & Stratton, 1974.

Haley, Jay, ed. _Changing Families: A Family Therapy Reader_. New
York: Grune & Stratton, 1971.

Watzlawick, Paul, John Weakland, and Richard Fisch. _Change:
Principles of Problem Formation and Problem Resolution_. New York:
Norton, 1974. [A readable and entertaining description of the tendency
of family and marriage systems to resist change and a good explanation
of the use of paradoxical strategies to encourage constructive change.]

T. THERAPEUTIC EXERCISE (CHAPTER 15)

Fixx, James F. _The Complete Book of Running_. New York: Random
House, 1977. [See Chapter 2, "What Happens to Your Mind."]

Glasser, William. _Positive Addiction_. New York: Harper and Row,
1976. [Glasser proposes that some activities such as running and
meditation are positive addictions; their practice can help a person
grow emotionally stronger.]

Glover, Bob, and Jack Shepherd. _The Runner's Handbook_. New York:
Viking Press, 1977. [See Chapter 15, "Stress and Tension," and Chapter
16, "Running Inside Your Head."]

Kostrubala, Thaddeus. _The Joy of Running_. Philadelphia: J. B.
Lippincott, 1976. [See Chapters 6, 7, and 8 on "Psychological
Effects," "Theory," and "Running and Therapy."]

U. BIOFEEDBACK (CHAPTER 15)

Brown, B. B. _Stress and the Art of Biofeedback_. New York: Harper
and Row, 1977. [Reviews the effectiveness of biofeedback.]

Weiss, Anne E. _Biofeedback: Fact or Fad?_ New York: Franklin Watts,
1984. [A clear, informal presentation of biofeedback.]

{304}

V. RELAXATION TRAINING (CHAPTER 15)

Benson, Herbert. _The Relaxation Response_. New York: Morrow, 1975.

Jacobson, E. _Progressive Relaxation_. Chicago: University of Chicago
Press, 1930. [One of the first studies to examine systematic muscle
relaxation.]

W. HYPNOSIS (CHAPTER 15)

Erickson, Milton, Ernest L. Rossi, and Sheila I. Rossi. _Hypnotic
Realities: The Induction of Clinical Hypnosis and Forms of Indirect
Suggestion_. New York: Irvington Publishers, 1976.

Wallace, Benjamin. _Applied Hypnosis: An Overview_. Chicago:
Nelson-Hall, 1979. [A general description of hypnosis.]

Wolberg, Lewis R. _Hypnosis: Is It for You?_ New York: Harcourt Brace
Jovanovich, 1972. [A good, general description of hypnosis and its use
in the context of psychotherapy.]

X. MEDITATION (CHAPTER 15)

Carrington, Patricia. _Freedom in Meditation_. Garden City, NY:
Anchor Press, 1977. [By a clinical psychologist who uses meditation
with her patients, a practical and comprehensive discussion of
meditation and its connection with the human problems that bring people
to psychotherapy.]

Glasser, William. _Positive Addiction_. New York: Harper and Row,
1976. [See Chapter 6, "Meditation."]

LeShan, Lawrence. _How to Meditate: A Guide to Self-Discovery_.
Boston: Little, Brown & Co., 1974. [An intelligent and modest
practical approach to meditation.]

Y. DRUG THERAPY (CHAPTER 16)

Leavitt, Fred. _Drugs and Behavior_. New York: Wiley, 1982.

_Physician's Desk Reference to Pharmaceutical Specialties and
Biologicals_. New Jersey: Medical Economics, Inc. [Published annually
with quarterly supplements. Gives detailed information about drugs,
side effects, potential risks, etc.]

Swonger, Alvin K., and Larry L. Constantine. _Drugs and Therapy: A
Psychotherapist's Handbook of Psychotropic Drugs_. Boston: Little,
Brown & Co., 1976.

{305}

Z. DIET THERAPY (CHAPTER 16)

Fredericks, Carlton. _Psycho-Nutrition_. New York: Grosset & Dunlap,
1976.

Watson, George. _Nutrition and Your Mind: The Psychochemical
Response_. New York: Harper and Row, 1972.

ON LEGAL ISSUES IN PSYCHOTHERAPY (CHAPTER 19)

Cohen, Ronald Jay. _Legal Guidebook in Mental Health_. New York: Free
Press, 1982.

Gutheil, Thomas G., and Paul S. Appelbaum. _Clinical Handbook of
Psychiatry and the Law_. New York: McGraw-Hill, 1982.

Hofling, Charles K., ed. _Law and Ethics in the Practice of
Psychiatry_. New York: Brunner/Mazel, 1981.

ON THE EFFECTIVENESS OF PSYCHOTHERAPY (CHAPTER 20)

Eysenck, Hans J. "The Battle over Therapeutic Effectiveness," in Jusuf
Hariman, ed., _Does Psychotherapy Really Help People?_ Springfield, IL:
Charles C. Thomas, 1984, pp. 52-61.

------. _The Effects of Psychotherapy_. New York: Inter-Science
Press, 1966.

Hariman, Jusuf, ed. _Does Psychotherapy Really Help People?_
Springfield, IL: Charles C. Thomas, 1984. [A collection of evaluative
articles about psychotherapy.]

------. _The Therapeutic Efficacy of the Major Psychotherapeutic
Techniques_. Springfield, IL: Charles C. Thomas, 1982. [A collection
of papers about the therapeutic effectiveness of a variety of
approaches to psychotherapy.]

Rachman, S., and G. T. Wilson. _The Effects of Psychological Therapy_.
Oxford: Pergamon Press, 1980.

Wolff, Werner, ed. _Success in Psychotherapy_. New York: Grune &
Stratton, 1952.

{307}

INDEX
NDX
Adjunctive therapies, 89
Adjustment problems, 69, 74
Adler, Alfred, 158
Adlerian therapy, 92, 157-61
Aerobic exercise, 205-8
Affective disorders, 69, 73-74
drug therapy and, 234
Agencies, 289-97
public, 55
Aging, problems of, 69, 76
Alcoholics Anonymous, 188
Alcoholism, 77, 108
Alzheimer's disease, 77
Anemia, 107
Anesthesia, hypnosis and, 221
Antianxiety drugs, 228, 231
Anticipatory anxiety, 152
Antidepressants, 229, 232
side effects of, 233
Antiepileptic drugs, 229
Antiparkinsonian drugs, 229
Antipsychotic drugs, 228, 235
Anxiety
anticipatory, 152
counter-conditioning and, 176
drug therapy and, 228, 230
running and, 210
Anxiety attacks, 72
Articulateness, 83
Associations, professional, 247-48, 293, 296

Behavior modification, 94, 175, 177, 180
family therapy and, 201
Behavioral therapy, 173-83
case history of, 180-82
Belief systems, 141
Berne, Eric, 132
Bioenergetics, 52, 93, 162
Biofeedback, 50, 96, 178, 211-14
how to find, 248
Blood sugar disorders, 103-5
Board eligibility, 46
Brain dysfunction, organic, 77
Brain tumors, 106

{308}

Breath counting, 224
Bubble, meditation of, 225
Byrd, Richard, 9-11

Caffeine, 108, 229
Cancer, pancreatic, 106
Childhood disorders, 68, 70
psychoanalysis and, 117
Children, conformity and, 13
Choice point, 168
Client-centered therapy, 90, 124-26
Clinical psychology, 42, 246
Cognitive therapy, 95, 139-45
behavior change and, 175, 178-79, 180
Commitment, 80
Compulsions, 72
Conditional love, 124
Confidentiality, 257-66
Conformity, 13
Congruence, 35
Contemplative meditation, 225
Content analysis, 192
Coping strategy, 217
Cost of therapy, 250
Counseling, academic, 56
Counseling psychology, 43
Counselors
social work, 29, 40-42, 246-48
religious, 48-50
Counter-conditioning therapy, 94, 174-77, 182
Countertransference, 119
County counseling agencies, 55
Crisis intervention, 69, 76

Decision making, 179
Defense mechanisms, 33
Delusions, 76
Demoralization, 271
Depression, 73-74
drug therapy and, 229, 231-34
electroconvulsive therapy and, 233
logotherapy and, 152
running and, 208
Dereflection, 152
Desensitization, 177, 216
Diabetes, 103
Diagnosis, self. _See_ Self-diagnosis
Direct decision therapy, 93, 167-72
case history of, 168
how to find, 248
Distraction techniques, 178
Drug addiction, 77, 108
Drug therapy, 227-36
appropriateness of, 235
drugs used in, 228-30
_See also_ Medication
Dynamic psychotherapy, 115
Dysphoria, 206

Ego, development of, 13
Ego states, 132
Electroconvulsive therapy, 233
Ellis, Albert, 140
Emotional flooding therapies, 161-67
how to find, 248
Encounter groups, 187
Endogenous depression, 229
Epilepsy, 105
drug therapy and, 229
Erickson, Milton H., 219
Esalen Institute, 188
est, 188
Exercise, 82
Exercise therapy, 53, 96, 204-11
how to find, 249
Existential-humanistic therapy, 92, 145-49
how to find, 248
Exogenous depression, 229
Extroversion, 82

Family problems, 75
Family therapy, 95, 194-203
Feedback loops, 101

{309}

Frankl, Viktor, 151
Free association, 115
Free choice, 22
Freedom, psychological, 36
Freud, Sigmund, 113-14
Frustration, 81

Gestalt therapy, 90, 127-32
Glasser, William, 154
Goals
family therapy and, 196
personal, 21, 67, 70
setting of, 62
Greenwald, Harold, 167
Group process, 192
Group settings, reaction to, 84
Group therapy, 95, 184-93
confidentiality and, 261
risks of, 191
Growth disorders, 128

Habits, 33
changes in, 34
Haley, Jay, 197
Hallucinations, 76
Hallucinogens, 230
Hatha yoga, 53
Hawthorne effect, 276
Head injuries, 106
Headache drugs, 230
Health insurance, confidentiality and, 262
Heart conditions, 107
Helpfulness of therapy, 267-81
Holism, 52
Home visits by therapist, 201
Hospitalization, 56, 252-56
Human potential groups, 187
Humanistic therapies, 123-49
Huntington's chorea, 77
Hyperthyroidism, 102
Hypnosis, 51, 97, 217-23
how to find, 249
Hypnotic drugs, 229
Hypoglycemia, 104
Hypothyroidism, 103

Iatrogenic disturbances, 268
Illness, solitude and, 13
Imagination, 84
Implosive therapy, 93, 165-67
Indirect induction hypnosis, 219
Infants, need for contact, 11
Infectious diseases, 108
Inferiority, Adlerian therapy and, 158
Inhibition, 82
reciprocal, 174
Initial consultation, 251
Initiative, 81
Injuries, head, 106
Inpatient therapy, 56, 252-56
Insurance, confidentiality and, 262
Intensive feeling therapy, 164
Introversion, 82
Involuntary behavior, 69, 76

Janov, Arthur, 163
Jogging, therapeutic, 205-7

Kostrubala, Thaddeus, 205

Law, confidentiality and, 260
Life decisions, 170
Lithium therapy, 229, 233
Logotherapy, 92, 150-54
how to find, 248
Long-distance running, 209
Love, 36
conditional, 124
Lowen, Alexander, 162

Mania, 74
Manic depression, 74
lithium therapy and, 229
MAO inhibitors, 232
Marital problems, 75
Marriage therapy, 95, 194-203
case history of, 199
Medication, 45, 98
reaction to, 108
_See also_ Drug therapy

{310}

Meditation, 51, 97, 223-26
how to find, 249
Menopause, 107
Metabolic diseases, 102-5
Migraine drugs, 230
Mitral incompetence, 107
Model, psychological, 25-27
Mood disturbances, 69, 73-74
Multifamily therapy, 201
Multiple sclerosis, 106

Need for therapy, 242
Negative practice, 160
Negative traits, 36
Nervous breakdown, 33
Nervous system disorders, 105-6
Neuralgia drugs, 230
Neuroleptic drugs, 228
Neuroses, 68, 71
noögenic, 73, 153
Nicotine, 229
Night terror, 117
NIMH mental health survey, 18
Nonverbal communication, 192
Noögenic neuroses, 73
logotherapy and, 153
Nursing, psychiatric, 254
Nutrition, 98, 236-37

Organic disorders, 69, 77
Organizations, 289-97
Orthomolecular psychiatry, 236
Outer-directedness, group therapy and, 184

Pain
biofeedback and, 213
emotional, 15, 27
hypnosis and, 221
Pancreatic cancer, 106
Panic attacks, 72
Paradoxical intention, 153, 160
family therapy and, 201
Parkinsonism, 77, 105
drug therapy and, 229
Paroxysmal tachycardia, 107
Patience, 81
Perfectionism, 82
Perls, Frederick, 128
Personality
development of, 32
model of, 25-27
therapy selection and, 78-85
Personality traits, 79-85
disorders of, 68, 71
Phobias, 72, 165
Physical illness, 99-109
Placebos, 268, 272
Post-therapy life, 282-8
Post-traumatic stress disorders, 72
Premature ego development, 13
Primal therapy, 93, 163-65
Privacy, 257-66
Private practice, 54
Problem avoidance, 283
Problem solving, 179
Professional associations, 247-48, 293, 296
Pseudo-self-sufficiency, 13
Psychedelic drugs, 230
Psychiatrists, 29, 44-47
how to find, 245
Psychoanalysis, 45, 90, 113-22
brief, 120
case histories in, 116-20
children and, 117
Psychological disorders
age and, 19
NIMH study of, 18
social views towards, 14
women's response to, 19
Psychological tests, 43
Psychologists, 29, 42-44
how to find, 246
Psychometrists, 43
Psychonutrition, 236
Psychoses, 69, 76
drug therapy and, 228, 234
Psychosomatic disorders, 73
Psychotherapy. _See_ Therapy listings
Psychotropic drugs, 228-30
_See also_ Drug therapy

{311}

Rational-emotive therapy, 91, 139-45
case history of, 142
Reality therapy, 92, 154-57
Reciprocal inhibition, 174
Recovery, Inc., 188
Referrals to therapist, 244
Reflectiveness, 83
Reich, Wilhelm, 162
Relapses, 283
Relaxation training, 50, 96, 176, 215-17
how to find, 249
Religious counselors, 48-50
Responsibility, 12
Reward and punishment, 177
Rigidity, 81
Rogers, Carl, 124
Role-playing, 128
Running, therapeutic, 205-7

Schizophrenia, running and, 210
Schools, counseling services in, 56
Secrecy, client's need for, 264
Sedatives, 229
Self-control, 12
Self-diagnosis, 59-98
obstacles to, 61
self-evaluation and, 62-64
_See also_ Therapy selection
Self-discipline, 80
Self-esteem, 36
client-centered therapy and, 126
Self-evaluation, 62-64
Self-help groups, 188, 289-92, 294-96
Self-sufficiency, 12
Senescence, 77
Sexual disorders, 73
marriage therapy and, 203
Short-term encounter groups, 187
Shortcomings of therapy, 274
Skinner, B. F., 175
Smoking, 77, 109
Social work counselors, 29, 40-42
how to find, 246-48
Spontaneous remission, 268, 273
Stampfl, Thomas, 165
State counseling agencies, 55
Stimulants, 229
Stress, 35
post-traumatic, 72
relaxation training and, 215
Structural analysis, 134
Substance abuse, 77
Suicide, 12
Symptoms, behavioral therapy and, 174
Szasz, Thomas, 270

Tachycardia, 107
Tests, psychological, 43
T-groups, 187
Therapeutic goals, 17, 23-25
Therapeutic results, 35-37
Therapists, 241-51
categories of, 29
cost of, 250
need for, 242
private _vs._ public, 54
qualities of, 37-38
referral to, 244
specialization by, 243
_See also_ under specific therapy
Therapy effectiveness, 267-81
Therapy selection
disorders and, 68-77
personal goals and, 67, 70
personality and, 78-85
steps in, 65-57
Therapy types, 86-98. _See also_ specific name of therapy
Thought stopping, 179
Thyroid disorders, 102
Tolerance, 81
Trance, hypnotic, 218
Tranquilizers, 228
Transactional analysis, 91, 132-39
case history of, 136

{312}

Transference, 119
Trauma, stress following, 72
Tumors, brain, 106

Values, personal, 84
Vitamins, 237

Wolberg, Lewis R., 222
Wolpe, Joseph, 174

Yoga, 53
ENDX

{313}

ABOUT THE AUTHOR

Steven James Bartlett was born in Mexico City and educated in Mexico,
the United States, and France. He did his undergraduate work at the
University of Santa Clara and at Raymond College, an Oxford-style
honors college of the University of the Pacific. He received his
master's degree from the University of California, Santa Barbara; his
doctorate from the Université de Paris, where his research was directed
by Paul Ricoeur; and has done post-doctoral study in psychology and
psychotherapy. He has been the recipient of many honors, awards,
grants, scholarships, and fellowships. His research has been supported
under contract or grant by the Alliance Française, the American
Association for the Advancement of Science, the Center for the Study of
Democratic Institutions, the Lilly Endowment, the
Max-Planck-Gesellschaft, the National Science Foundation, the Rand
Corporation, and others.

Bartlett brings to the present work an unusual background consisting of
training in clinical psychology, pathology, and epistemology. He is
the author and editor of fifteen books and monographs, and more than a
hundred papers and research studies in the fields of psychology,
epistemology, and philosophy of science. He has taught at Saint Louis
University and the University of Florida, and has held research
positions at the Max-Planck-Institute in Starnberg, Germany and at the
Center for the Study of Democratic Institutions in Santa Barbara. He
is currently Visiting Scholar in Psychology at Willamette University
and Senior Research Professor at Oregon State University.

Willamette University hosts a website that provides information about
the author and his research, and makes available a large number of his
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