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 workersdoreceive 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.
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 ofmentalcontrol.
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 itisused by some psychologists. Bioenergetics attempts to diminish an individual's psychological defenses by means of sequences of specially designedphysical 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.
6WHERE 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 whooffers 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 psychologistsspecializein 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 chargefor 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 calledsuicide 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-timestudents 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 YOUGO 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 ortherapist. 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 counselingwillgreatly 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.
7SELF-DIAGNOSISMapping 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,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 helpnow. 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 followedstep-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 forofferingtherapy 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.Whathelps andwhohelps 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 casescanbe 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.
REALISM: A GOOD BEGINNING
In order to identify one or more therapies that may be most promising in relation toyourgoals,yourproblems, andthe 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,thatfact 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 leastknowthat 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 ourselveschangeus. 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 structuredapproach 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 isveryhard 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 Ineedmy present symptoms? Is it useful to menotto have a sense of direction? Am I somehowbenefitingfrom feeling depressed? Is my anxietyhelpfulto me in some way?"
You may think these suggestions are no more than contrived and unkind psychologizing. After all, whochoosesto suffer? Does anyonewantto 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 notwantto 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 wantnotto change but to tryanyway.
So, before you begin to seek a specific type of therapy, try to be realistic and keep these thoughts in mind:
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 processfor 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 YOURGOALS: 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 donotapply to you, go back to Table 1 and consider other alternatives.
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 donotfeel 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 thatyouhave 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.
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 shynessissomething 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 ANDMAIN EMOTIONAL AND MENTAL DISORDERSTHAT 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)
§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
§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 forpromptrelief 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
MATCHING YOUR GOALS AND PROBLEMS WITH MOSTPROMISING THERAPIES
§1 Personal Development Goals
These may involve either (§1.1)addingnew skills or qualities or (§1.2)subtractinghabits 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 forbroad-spectrumimprovements. 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 generallymore 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
§2.5. Behavior problems in children: O, C
Hyperkinetic behavior:Primary: Y, OSecondary: 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.:
Anxiety and panic attacksare 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 ofchronic 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, XSecondary: H, K, U
Post-traumatic stress disordersare 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, VSecondary: 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, ASecondary: Y, T, K
Compulsions that arise, or may be resolved, in relation to your family: S
§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 andinclined 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,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, ISecondary: 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
§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 forPromptRelief 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 GSecondary: 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
§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, OSecondary: 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
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.
TABLE 2:AN OVERVIEW OF MAIN PERSONALITY TRAITSRELEVANT 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
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 WITHTHE MOST PROMISING THERAPIES
§1 Self-Discipline
Therapies rely on self-discipline in clients in several ways:
Are you able tostickto a prescribed routine and do practical assignments on your own outside of therapy sessions to practice attitudes, communication skills, or behaviors?
Will you takepersonal responsibilityfor coming to regular appointments on time?
Can yougive upany real payoffs of being emotionally troubled?
Whenanyapproach 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 thinkingafterformal therapy has ended. Do you feel that you have this kind oftenacityandability 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
§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