Millions of AmericansPsychiatric Name of Condition with This DisorderAnxiety disorders 13.1Phobias 11.1Substance abuse (alcohol, drugs, etc.) 10.0Affective disorders (includingdepression and manic depression) 9.4Obsessive-compulsive disorders 2.4Cognitive impairment 1.6Schizophrenia 1.5Antisocial 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 ofmachismo), 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).
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.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 minelikes 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 OFPERSON 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 usuallyblame thingsoutside ourselvesfor 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. Theattitudewe 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 themin reaction todomination 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 decisionsin spite ofpast influences. On the other hand, people who blamethemselves 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 canitselfpoint you in a direction. If there are blocks, it can be helpful to meet them head-on. In therapy, the phraseworking through a problemoften means exactly this.
Choosing what kind of person you wish to be is aprocess, 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 leastone 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 apassiveone: 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 simplywaituntil, 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 occasionalexceptions—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, amodelis 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:
Five main psychological dimensions of a person: feelings, hopes, abilities, relationships with others, and behaviorFive 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 saidabout 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 toinitiate 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.
3BRIDGES 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.
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,counselingtends to be a short-term process the purpose of which is to help the client, couple, or familyovercome 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.
Psychotherapytends 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 theinner 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 termpsychotherapyis 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.
In practice, these differences in outlook frequently amount to differences inemphasisrather 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 problemsin spite offeelings 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 areemotionally 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 isnervous breakdown. This is the layman's name for a variety of psychological conditions that develop due toa 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 fundamentallyconservativemechanisms: established habits of thought, feeling, and behavior arefamiliar, 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 changeisachieved, it usually comes after long and arduous trying. We are all aware of the heroic efforts somepeople 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 changeforthem: 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 reallywantto 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 ofbeingwill feel intimidating, unpleasant, or just plainunnatural. 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 sourcefor 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.
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 theideal outcomesof therapy. They are one side of the coin; the other side consists of the many negative feelings and ways of behaving that areeliminated when they aredisplacedby 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
* 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 especiallycounterproductivein 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.
4THE 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 ofrelaxation 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.
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 longcounseling 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 psychologyemphasizes 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.
The objective ofcounseling psychologyis 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.
Psychometristsare 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 forthe 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 thetraining 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
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.
5THE 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 thebelief 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 nowdoreceive 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 whospecializesin 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 certainspecific 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 induceat willa state of physical and mental calm. Relaxation training is a practical skill—it can be very effectiveand 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.