§5 Tolerance to Frustration
Do you have a fairly high threshold of frustration when your beliefs and ideas are challenged? When you do not immediately get what you want, can you tolerate fairly well what may seem like a long route to get where you want to go? (Do you cope well with the frustration of getting lost in your car, for example?) Can you tolerate, without serious irritation, anger, or hurt, being pushed to confront some of the pretenses or distortions or illusions you may have lived by?
Can you accept, with some calmness of mind, having someone point out to you that you have not been as clear about things as you thought, and that sometimes your attitudes are not consistent, that you are, to some extent, confused? A, C, E, P
§6 Rigidity
Do you often find yourself trying to be, or wishing you were someone you're not? C
Are you perfectionistic? Upset when you make even fairly minor mistakes? Concerned that "things be in their proper place"? Are you frequently intense and uptight? C, J
Are you "overcontrolling"—anxious when you do not feel you have things clearly under control?
Are you depressed (see §5, Table 1) or phobic (see §4.2, Table 1)?
Do you suspect that other people think that you magnify evils, blowing negative things out of proportion? Are you inclined to be moralistic, dogmatic, critical, or judgmental?
Are you an uncompromising person?
Do you feel, deep down, that perhaps your expectations and demands (concerning others, yourself, and the world) may be unrealistic?
Do you think you are often inclined to confuse what you would like with what you need? E, P, H
§7 Inhibition
Do you feel blocked, inhibited, or held in check by an overly critical self? B
Do you feel that you have pent-up feelings that are in need of release? Do you feel stultified or oppressed by your relationships with your spouse, friends, or family? Does your life lack emotional intensity? Do you obtain little joy or satisfaction from living? C, J
Do you feel that somehow there are blocksin youthat are standing in the way of your self-realization, of fulfilling your potential? H
§8 Introversion or Extroversion
Are you inner-directed? Would you rather be alone or with one or two friends than attend a party? Are you impatient, or do you even resent receiving unsolicited suggestions? A, F
On the other hand, are you at ease with groups of people? Is it important to your self-image what other people think of you? (Are you perhaps status-oriented?) Do you often find it useful or helpful to receive advice? Q
§9 Motivation and Capacity for Physical Exercise
Are you free of physical handicaps?
Do youliketo be physically active, to exercise?
Do you begin to feel restless when a week or more goes by and you have been sedentary?
If you are not physically fit now but are healthy, does it appeal to you to work regularly and hard to become physically stronger and to improve your endurance? T, J, yoga (see U)
§10 Need for Acceptance, Human Warmth,and Gentle Encouragement
Do you feel that perhaps no one has ever taken the time to listen to you, to take a genuine interest in you and in your problems as a person?
Do you feel, perhaps because of circumstances or problems over which you've had no control, that you have received rather little human warmth from others?
Would you prefer encouragement that is patient and warm rather than a forceful push to change your life? B
§11 Articulateness and Analytical Attitude
Can you talk openly and clearly about your feelings, about what is troubling you? Can you fairly readily describe examples of situations that may bother you?
If you were asked to describe thepersonality(not his or her physical features and behavior) of someone you talked with last night for half an hour at a party, could you do this without a lot of hesitation and brow-furrowing?
Do youliketo talk about personal problem solving, about your feelings, past events, and why you have come to feel as you do? Do you feel aneedto acquire an overall sense of understanding of yourself, your family, and how they have influenced you? A
§12 Reflectiveness
Do you often find yourself thinking about your feelings, about the purpose of life, and about whether yours has a meaningful direction?
Do you tend to come home from a visit with friends or family and go over in your mind what went on and wonder why people said and did certain things?
Do you have a mental habit of standing apart from what you're doing and judging yourself and your work?
Do you spend much time just "thinking about things," even dwelling on problems that concern you? A, G
§13 Imagination
As a child, did you have an imaginary friend?
When you sit on a rock by a brook in the woods, do you quickly begin to feel a special sense of relaxation? Or, watching the waves breaking on the beach, do you find yourself lulled into a sense of absorption in nature?
Do you enjoy reading? As you read a descriptive novel, do you tend to "see" many of the places and people? Do the events come alive for you? Do you find yourself thinking about the events in the book as though they make up a real world of their own? W
§14 Sensitivity to Values
Are personal values very important to you? For example, do you sometimes find yourself thinking that so much of television programming is mediocre, trash, a waste of time? Do youfeelthat there are human values that are more important than how much money you make, what model car you drive, and the luxuriousness of your home?
Are you a religious or spiritual person, whether you attend church or not?
Do you like art, music, or literature?
Do you feel, really feel, a sense of compassion or empathy for people who face poverty and misfortune? Do you sometimes feel guilty because of your own situation, that there always seem to be others who are worse off?
Have you ever faced the opportunity to take advantage of someone or of a situation and simply decided not to (even though youknewyou could do this without risk) because you simply wanted to feel honest or retain a sense of your own integrity?
Are you in search of a richer meaning in life? Do you wonder whether what you are doing with your life is really right for you? G
§15 Comfort in a Group Setting
Do you feel comfortable and safe in groups?
Do you feel friendly when you pass a house where a party is going on?
Do you enjoy parties or social gatherings?
Did you come from a family with several children? Q, C
§16 Severe Impairments
Do you have any learning or communication disabilities?
Are you so troubled because of emotional upheaval that you cannot work or maintain your family responsibilities?
Do you have any addictions that are causing grief for you or others close to you?
Do you sometimes have to "let off steam," even though you know you are hurting others, damaging their property, or injuring yourself?
STEP 3
TABLE 3:THE APPROACHES TO THERAPYDISCUSSED IN THIS BOOK
In the left column are the letters used in this chapter to identify each approach to therapy:
LetterCode         Approach to Therapy                        Chapter[ ] A          Psychoanalysis                                 9[ ] B          Client-centered therapy                       10[ ] C          Gestalt therapy                               10[ ] D          Transactional analysis                        10[ ] E          Rational-emotive therapy                      10[ ] F          Existential-humanistic therapy                10[ ] G          Logotherapy                                   11[ ] H          Reality therapy                               11[ ] I          Adlerian therapy                              11[ ] J          Bioenergetics         }                      11} Emotional[ ] K          Primal therapy        } flooding            11} therapies[ ] L          Implosive therapy     }                      11[ ] M          Direct decision therapy                       11[ ] N          Counter-conditioning  }                      12}[ ] O          Behavior modification } Behavioral          12} psychotherapies[ ] P          Cognitive approaches  }to behavior change    }                      12[ ] Q          Group therapy                                 13[ ] R          Marriage therapy                              14[ ] S          Family therapy                                14[ ] T          Therapeutic exercise                          15[ ] U          Biofeedback                                   15
[ ] V          Relaxation training                           15[ ] W          Hypnosis                                      15[ ] X          Meditation                                    15[ ] Y          Drug therapy                                  16[ ] Z          Nutrition therapy                             15
HOW TO USE THE INFORMATION YOU NOW HAVE
If you have followed the instructions for Steps 1, 2, and 3, you should have identified a potentially promising therapy, or group of therapies, in relation both to your goals or problems and to your own estimation of certain important traits of your personality or character.
The therapy or approaches to therapy you have identified now need to be tested, first, in your imagination as you read the chapters of this book, which will give you an idea of what each major approach to therapy is like, and then, if you decide to proceed, in reality, when you have located a suitable therapist (see Chapter 17).
The need for this testing is a matter of simple realism: you now have a sense of direction, or perhaps several alternative directions, to consider. The approach to self-diagnosis described in this chapter is intended to be useful, but it is not infallible; much depends on the accuracy of your problem diagnosis, the appropriateness of the goals you have set, and your self-understanding. Much also will depend on the therapist you locate and how well you are able to work together.
The recommended therapies listed by letter codes for Steps 1 and 2 reflect evaluations from several sources: (1) Therapists themselves claim that certain approaches favored by them have been shown to be useful for treating certain problems, for realizing certain goals, and for clients with certain personal qualities. (2) Various studies also have attempted to demonstrate for what and sometimes for whom many of the major therapies are most successful (see Chapter 20). (3) Primarily in theorderingof letter codes in connection with the specificgoals, problems, and personal qualities listed in Steps 1 and 2, I have relied on my own experience and judgment. Letter codeslisted firstdesignate therapies that, in general, are commonly regarded by therapists and psychologists as most useful. At times, when general consensus appeared to be lacking, I have used my own evaluation.
The intention in this chapter is to make explicit a simple and reasonable process of choosing a therapy. Many therapies are not mentioned in connection with specific goals, problems, or personality traits. To be sure, some of the therapies that are not mentionedcanbe useful to certain individuals who have a given goal, problem, or trait. But the objective of this book is to improve thegeneral reliabilityof a person's self-diagnosis and self-understanding. The book is aguide, not a bible.
COMBINING APPROACHES
There is evidence that combining two therapies for certain problems can frequently be more effective than using either in isolation. Treatment for individuals suffering from severe anxiety or depression often will combine drug therapy, for example, with one of the fourteen approaches to therapy described in Chapters 9-12 and 14 (and listed below, under "A"). Or, individuals who have problems due to excessive stress may, for example, be advised to combine biofeedback, relaxation training, hypnosis, meditation, or exercise therapy with a form of psychotherapy.
Usually, when therapies are combined, one is a formal psychotherapy and the other is anadjunctivetherapy—that is, a therapy that most often is not relied on exclusively. Some adjunctive therapies lend themselves very well to use by individuals on their own. Combined treatments tend, then, to employ one approach taken from list A and one from list B:
A (Main Therapies)
PsychoanalysisClient-centered therapyGestalt therapyTransactional analysisRational-emotive therapyExistential-humanistic therapy
LogotherapyReality therapyAdlerian therapyDirect decision therapyBehavior modificationCognitive approaches to behavior changeMarriage and family therapy
B (Adjunctive Therapies)
Drug therapyMeditationHypnosisRelaxation trainingBiofeedbackTherapeutic exercise
Approaches That May Appear Under Either A or B
BioenergeticsPrimal therapyImplosive therapyCounter-conditioningGroup therapy
A SUMMARY OF THE MAIN APPROACHES TO PSYCHOTHERAPY
AverageTherapyBest Suited For:Duration[*]Cost[**]--------------------------------------------------------------Client's Personality (notall traits may apply to aProblems or Goalssingle person)-------------------------------------------------------------------------------------------------------------[*] 1 = Brief therapies, frequently 12 weekly sessions or less; 2 = 3-6 months;3 = long-term therapies, 6 months to several years[**] = initially expensive, then $10-25/hr.; ++ = expensive $50-100+/hr.;+ = moderate, $25-50/hr.; 0 = inexpensive, $10-25/hr.;# = often available on a sliding scale basis (see Chapter 4) throughcounty clinics, agencies etcA. Psychoanalysis   self-development: broad-spectrum  self-disciplined           3           ++ #improvements                    committedsuffering from childhood traumas  patientfear of withdrawal of affection   tolerant to frustrationand of abandonment              introvertedinterpersonal problems            articulatephobias                           analyticalcompulsions                       reflectivesexual disordersdepressionmaniamanic depressionpsychosesB. Client-centered  self-development: broad-spectrum  inhibited                  2           + #improvements                    possessing initiativelow self-worth                    needing acceptance,crisis intervention                 human warmth, andgentle encouragementC. Gestalt          behavior problems in children     tolerant to frustration    1-2         + to 0shyness/passivity                 rigidcoping with persons in authority  inhibitedpsychosomatic disorders           able to work in a groupadjustment problems: minorities   settingand the poorfamily conflictscrisis intervention
D. Transactional    shyness/passivity                 interested in effective    1-2         0 #analysis         loneliness/emptiness              communicationhostility/overbearing personalityfear of withdrawal of affectionand of abandonmentimproving effectiveness ofcommunicationcoping with persons in authorityphobiasadjustment problemsmarital problems, especiallythose involving communicationdifficultiesfamily conflictsdrug abuseE. Rational-        hostility/overbearing             self-disciplined           2           +emotive            personality                     rigidinterpersonal problemsanxiety disorderspost-traumatic stressphobiascompulsionssexual disordersimpulse control disordersdepressionmania and manic depressionadjustment problemsmarital problemsdelinquency and criminal behavior
F. Existential-     loneliness/emptiness              introverted                 2             +humanistic       loss of faith in yourself,        sensitive to existentialin others, or in life's purpose   issuesinability to accept life'slimitationscrisis interventionG. Logotherapy      estrangement/alienation from      reflective                  2             +others                          sensitive to valuesloss of faith in yourself, inothers, or in life's purposenoögenic neurosesdepression due to value conflictsinability to accept life'slimitationsemotional problems in facingold ageproblems of the recently widowedstutteringshaking and motor tic disorderscrisis interventionH. Reality          desire for a success-identity     self-disciplined            1-2           +anxiety disorders                 committedpost-traumatic stress             patientadjustment problems               rigidmarital problemsproblems of the recently widowedvocational problemsdelinquency and criminal behaviorpsychoses
I. Adlerian         deep discouragement with life     self-disciplined           1-2         + #marital problems                  inhibitedfamily conflictsstutteringshaking and motor tic disordersvocational problemsdelinquency and criminal behaviorJ. Bioenergetics    self-development: broad-spectrum  inhibited                  1-2         +improvements                    motivated and able tosuffering from childhood pain       undertake physicalexerciseK. Primal           anxiety disorders                 pent-up feelings           1-2         =post-traumatic stressphobiascompulsionsdrug abuseL. Implosive        phobias                           (nonspecific)              1           +M. Direct decision  desire for a success-identity     self-disciplined           1           +compulsions                       committedimpulse control disorders         patientvocational problemsadjustment problemspsychosesdrug abuse
N. Counter-         shyness/passivity                 self-disciplined           1-2           + #conditioning     hostility/overbearing personalityphobiaspsychosomatic disorderssexual disordersadjustment problemsmarital problemsfamily conflictscrisis interventionO. Behavior         mental retardation                self-disciplined           1-2           + #modification     autism                            possibly impairedbehavior problems in childrenhyperkinetic behaviordelinquency and criminal behavioreating disorderscompulsionssexual disordersimpulse control disordersstutteringcrisis interventionpsychoses
P. Cognitive        interpersonal problems            self-disciplined           1-2           + #approaches       anxiety disorders                 rigidto behavior      post-traumatic stresschange           psychosomatic disorderssexual disordersdepressionmania and manic depressionadjustment problemsmarital problemscrisis interventionQ. Group            shyness/passivity                 extroverted                1             0 #loneliness/emptiness              tolerant to grouphostility/overbearing               involvementpersonalityimproving communicationeffectivenessimpulse control disordersR. Marriage         marital problemssupportive therapy for individual (nonspecific)              1-2           + #problemsfear of withdrawal of affectionand of abandonmentS. Family           family conflicts                  (nonspecific)              1-2           + #supportive therapy for individualproblemsemotional disturbances in childrenfear of withdrawal of affectionand of abandonmentfamily-based compulsionspsychoses
T. Therapeutic      depression                          self-disciplined         2-3           0 orexercise         anxiety disorders                   motivated and able to                   nopost-traumatic stress                 undertake physical                    costmarital problems                      exercisealcoholismdrug abusesmokingpsychosesU. Biofeedback      physical pain and disability       (nonspecific)             1-2           + #shaking and motor tic disordersstutteringinsomniaanxiety disorderspost-traumatic stressphobiasdepressionV. Relaxation       anxiety disorders                  (nonspecific)             1-2           + #training         post-traumatic stressphobiasphysical pain and disabilityinsomnia
W. Hypnosis         emotional disturbances in         imaginative                1-2           +children                        trustingeating disordersinterpersonal problemsanxiety disorderspost-traumatic stressphobiaspsychosomatic disorderssexual disordersdepressionmania and manic depressionphysical pain and disabilitystutteringshaking and motor tic disordersX. Meditation       loss of faith in yourself, in     self-disciplined           3             0 orothers, or in life's purpose    patient                                   noanxiety disorders                                                            costpost-traumatic stressdepressionmania and manic depressionphysical pain and disabilityalcoholismdrug abusesmoking
Y. Drug             autism                            possibly impaired          1-3           + + #hyperkinetic disturbancesanxiety disorderspost-traumatic stressphobiascompulsionssexual disordersdepressionmania and manic depressionphysical pain and disabilityshaking and motor tic disordersinsomniacrisis interventionZ. Nutrition        possibly hyperkinetic behavior    no data available          --            --as well as otherproblems (see Chapter 14)[*] 1 = Brief therapies, frequently 12 weekly sessions or less;2 = 3-6 months; 3--long-term therapies, 6 months to several years[**] = initially expensive, then $10-25/hr.; ++ = expensive $50-100-f/hr.;+ = moderate, $25-50/hr.; 0 = inexpensive, $10-25/hr.;# = often available on a sliding scale basis (see Chapter 4)through county clinics, agencies, etc.
8EMOTIONAL PROBLEMSTHAT MAY HAVEPHYSICAL CAUSES
This chapter has a single important purpose: to persuade you, if you are in serious emotional distress, to have a comprehensive physical examinationbeforebeginning psychotherapy. Imagine how disheartened and frustrated you might feel after a period of unsuccessful therapy, only to find out afterward that your problems could be traced to a physical cause. It is essential that you eliminate the possibility of a physical basis for your problems before seeking therapy. In fact, most therapists routinely recommend that you have a complete physical before entering therapy.
Rest assured that doing so willnotbe a waste of time. Richard Rada, Director of College Hospital in Cerritos, California, estimates that between five and ten percent of clients with depression, anxiety, or unusual thoughts and behavior may have underlying physical conditions that are responsible, including glanddysfunction, an epileptic abnormality, heart disease, cancer, and so on. The following facts, too, should convince you that having a comprehensive physical is paramount:
* As many as one patient in every ten who suffer from serious depression has a thyroid disorder.
* One person in every four who are diagnosed as having psychiatric disorders and who are over sixty-five has an underlying physical illness that is responsible.
* An equal number of individuals over sixty-five have emotional problems that are made worse by underlying physical disorders.
* Three percent of people who regularly take prescription medication develop mental symptoms.
Dr. Leonard Small, a specialist in the field of neuropsychodiagnosis, has found that the more severe emotional or mental symptoms are, the more likely it is that therapists (and patients) will overlook the possibility of underlying physical disorders.[1]
[1] Leonard Small,Neuropsychodiagnosis in Psychotherapy(New York Brunner/Mazel, 1980), p. vii.
It isn't necessary or possible to give a detailed or comprehensive catalog of physical causes of emotional and mental disturbances here, but it may be helpful to many people to see some of the principal ways in which psychological symptoms can be produced by physical problems. Hopefully, these illustrations will persuade you, if you are emotionally or mentally troubled, of the wisdom of a thorough physical. It is a small price to pay if emotional symptoms can be traced to a physical cause.
It is well known that virtually any serious organic illness or injury can produce emotional suffering, either in the form of physical pain or in the form of anxiety and depression. Chronic pain is a chronic stress and can lead to the same emotional problems as prolonged stress of any variety: anxiety or depression. Similarly, prolonged severe anxiety or depression can cause physical deterioration and make the body more susceptible to disease.
There are, then, two "vicious circles," or feedback loops, that can play a role in causing or aggravating emotional disturbance:
The two "vicious circle" or feedback loops that may exist between physical disorders and emotional disturbancesThe two "vicious circle" or feedback loops that mayexist between physical disorders and emotional disturbances
In the first loop, an underlying physical disorder, which may be a disease or a physical injury, leads to emotional symptoms (and very likely to physical symptoms as well, although these may not be as pronounced). However, the emotional reactions that are produced can themselves make the physical disorder worse, and certainly emotional disturbance makes living with and treating the underlying physical disorder more difficult.
In the second loop, emotional disturbances cause certain physical disorders: a peptic ulcer, heart palpitations, ulcerative colitis, backache, hypertension, or high blood pressure, etc., and may predispose certain individuals to arthritis, cancer, or diseases of the immune system. Once a psychosomatic link has been established between a troubled mind and the body, and an organic disorder has come about, the physical disorder, in turn, can produce stronger or more exaggerated emotional reactions. Anxiety or depression may increase because the person is now both physically ill and emotionally troubled.
These two so-called positive feedback loops can obviouslylead to a runaway process that becomes worse and worse. Psychosomatic medicine focuses on the second of these; our focus here is on the first: physical origins of emotional disturbance.
Underlying physical disorders of this kind include metabolic diseases, disorders and diseases affecting the brain and nervous system, head injuries, other physical disorders and conditions, infectious diseases, reactions to medication, and drug addiction and alcoholism. Each is discussed in the remainder of this chapter.
METABOLIC DISEASES
Several well-known metabolic diseases can lead to emotional disturbances:
HYPERTHYROIDISM
An overactive thyroid, known ashyperthyroidism, is usually caused by the pituitary gland's overproduction of a hormone calledTSH, orthyroid-stimulating hormone. This causes the thyroid, a butterfly-shaped gland in the lower part of the neck, to produce an excess of the thyroid hormone thyroxine. Hyperthyroidism is eight times more common in women than in men.
The emotional symptoms of hyperthyroidism include a more intense and chronic nervousness than in hypothyroidism (discussed below), overreactions to minor crises, moodiness, frequent fear without knowing why, a sense of agitation, dread, and occasionally trembling or shaking. Some patients with serious hyperthyroidism may have symptoms resembling those of schizophrenia, in which there is little or no contact with reality.
Physical symptoms include rapid loss of weight, unusual appetite, rapid pulse, diarrhea, and muscle weakness (especially in the legs, as when climbing stairs). The classical symptoms of hyperthyroidism are staring eyes and enlargement of the neck, but these need not be present.
It is interesting to note that certain factors in upbringing and personality seem to predispose people to hyperthyroidism (this would mean that a feedback loop of the second type may precipitate the disease in some people). Individuals who later develop hyperthyroidism often have these characteristics:
* They were forced prematurely to become self-sufficient and responsible.
* They felt rejected by one or both parents and feared a loss of emotional support.
* Their early dependence needs (their needs for affection, mothering, warmth, etc.) were frustrated, and this led to feelings of insecurity and low self-esteem and to the belief that the world is a threatening place.
* They often had dominant, tight-lipped, overcontrolling mothers.
HYPOTHYROIDISM
An underactive thyroid, known ashypothyroidism, is caused by an inadequate production of thyroid hormone. It is most common in middle-aged women.
The emotional symptoms of hypothyroidism include mental sluggishness, nervousness, depression, irritability, impatience, and frequently dislike of everyday activities.
Physical symptoms include a sense of heaviness and lethargy, dry skin, sensitivity to cold, constipation, and thinning hair.
HYPER- AND HYPOPARATHYROIDISM
The parathyroid glands, which are four bean-size glands located on top of the thyroid gland, manufacture hormones that regulate phosphorus and calcium levels in the body. Excess hormone raises the calcium level too high, and psychotic-like behavior can result. Too little hormone lowers the calcium level to the point that a person may behave like an alcoholic. These conditions are comparatively rare.
DIABETES
Diabetes, or hypoinsulism, which at the time of this writing affects as many as 2.5 million Americans, results from underproduction of insulin, which in turn causes an excess of sugar in the blood and urine. Diabetes takes two forms: juvenile onset (or insulin-dependent) and adult onset (or noninsulin-dependent) diabetes. The first type starts in childhood or young adulthood, and is caused by the body's failure to produce enough insulin. Juvenile onset diabetes isusually controlled by means of regular injections of insulin.
Adult onset diabetes is less serious than juvenile diabetes; it occurs more often in the elderly and especially in people who are overweight. Diabetes can appear in a person after a traumatic event: great stress, a physical accident, surgery, infection, or a severe emotional disturbance. It may also appear after a person has gone through a long period of fatigue, depression, indecision, or sense of hopelessness. Those who become diabetic may be individuals who felt strong resentment toward their parents while growing up or who were "spoiled children." Diabetic men often were dominated by their mothers while being excessively dependent on them. Adult onset diabetes is usually controlled without insulin injections, particularly during the early stages of the disease. Treatment in about one-third of noninsulin-dependent diabetics is possible by diet alone; in others, it is necessary to take oral hypoglycemic drugs that stimulate the release of insulin.
The emotional symptoms of both forms of diabetes may include apathy, depression, personality disorders, or even psychosis as a result of undersecretion of insulin.
Physical symptoms include the need to urinate frequently, day and night, unusual fatigue and weakness, tingling in hands and feet, reduced resistance to infections (especially of the urinary tract), blurred vision, impotence in men, and lack of menstrual periods in women.
HYPOGLYCEMIA
Hypoglycemia, or hyperinsulism, which affects perhaps as many as five million Americans, is caused by overproduction of insulin. Excess insulin leads to low blood sugar (literally,hypoglycemia). Sometimes this overproduction of insulin is caused by a tumor of the pancreas; the growth can often be removed surgically to correct the condition.
The emotional symptoms of hypoglycemia include depression and anxiety.
Physical symptoms include fast pulse, palpitations, dizziness, general weakness, faintness, stomach pain, blurred vision, and sweating. These symptoms often occur a few hours after eating and disappear after eating again.
Hypoglycemia has become almost a fad disease among "psychonutritionists." The condition is believed by most physicians, however, to be confined mainly to diabetics who have not kept to a prescribed routine and have allowed their levels of insulin to become too high. Sometimes stomach surgery, liver disease, pregnancy, and periods of high fever can cause attacks of hypoglycemia.
DISORDERS AND DISEASES AFFECTINGTHE BRAIN AND NERVOUS SYSTEM
EPILEPSY
The second most common physical cause of emotionally distressing symptoms, after the metabolic disorders we have just discussed, is epilepsy. Approximately 7 percent of mentally disturbed patients have some form of epilepsy.
Epilepsy affects between 1 and 2 percent of the U.S. population. Of people who have epilepsy, two-thirds appear to have no structural abnormality of the brain; in the remaining third, the disease can be traced to brain damage at birth, a severe head injury, an infection that caused brain damage, or a brain tumor.
The emotional symptoms of epilepsy can involve either anxiety or depression or both. Once a person has had a convulsive seizure, he or she may live in constant apprehension that another seizure will occur. There may be occasional, transient feelings of unreality.
Physical symptoms include peculiar stomach sensations, distorted vision, occasional bizarre behavior such as laughing for no apparent reason or sudden and unprovoked anger, loss of consciousness, and convulsions.
PARKINSONISM
Parkinson's disease often causes anxiety or depression. Physical symptoms early in the course of the disease include slowing of movement and inability to write one's name without the handwriting becoming smaller and smaller. Later symptoms include tremors, muscle stiffness or rigidity, nervousness, and tension.
MULTIPLE SCLEROSIS
Multiple sclerosis usually begins in people between the ages of twenty and forty, affecting slightly more women than men. Symptoms may disappear after one or a number of attacks, or they may get progressively worse and cause severe disability.
Emotional symptoms include anxiety, panic attacks, and depression.
Physical symptoms may involve a feeling of numbness or tingling affecting one limb or one side of the body, temporary blurring of vision, slurred speech, and difficulty or lack of control in urinating.
BRAIN TUMORS
Brain tumors may cause severe headaches, blurred or double vision, vomiting without the warning of nausea, general weakness, and, in some cases, epileptic seizures.
Emotional symptoms may involve nervousness, irritability, memory problems, and personality changes.
HEAD INJURIES
Head injuries that damage the brain generally cause headaches and dizziness.
Emotional symptoms usually involve nervousness and sometimes confusion. In more serious injuries, there may be loss of memory, depression, and decreased alertness. Severe damage to the brain can cause unconsciousness that may persist for days or weeks.
OTHER PHYSICAL DISORDERS AND CONDITIONS
PANCREATIC CANCER
Cancer of the pancreas can cause severe depression and insomnia. These emotional symptoms can occur early in the course of the disease. This kind of cancer kills nine out of ten of its victims within a year of being diagnosed. One reason for this tragedy is that pancreatic cancer frequently reaches an advanced stage before the appearance of its physical symptoms: loss of appetite and loss of weight, nausea, vomiting, and upper abdominalpain that may spread to the back. It is believed that alert psychiatrists can save many lives that otherwise would be lost as a result of pancreatic cancer by detecting the disease in its early stages.
ANEMIA
Anemia is caused by an abnormal drop in either red blood cells or hemoglobin (the main constituent of red blood cells). Iron deficiency can cause anemia, as can vitamin B12 or folic acid deficiency. Inherited blood disorders such as sickle-cell anemia can also lead to anemia.
The main emotional symptom of anemia is depression.
Physical symptoms include weakness, breathlessness, and heart palpitations, which may occur as the heart attempts to compensate for anemia by circulating blood faster than normal.
HEART CONDITIONS
Mitral incompetence is a heart condition in which the flaps of the mitral valve, separating the upper and lower chambers of the heart, do not close properly. The heart of a person with this disorder must therefore work harder than normal. Physical symptoms may involve shortness of breath and fatigue.
Paroxysmal tachycardia is another heart condition, in which the heartbeat suddenly speeds up to 160 beats per minute or more. An attack may last for from several minutes to several days. Physical symptoms include breathlessness, fainting, chest pain, and awareness of the rapid heartbeats.
The emotional symptoms of both mitral incompetence and paroxysmal tachycardia may involve anxiety and panic attacks.
MENOPAUSE
Menopause is not a disorder but a natural condition of aging that involves changes in hormone levels in the body. Menopause in women can cause intermittent periods of strong anxiety, chronic nervousness, depression, irritability, lack of confidence, and headaches. Physical symptoms include hot flashes, sweating, and palpitations. Male menopause is increasingly being recognized by doctors; symptoms most frequently appear when a manis in his fifties. Emotional symptoms may involve anxiety and depression; physical symptoms include hot flashes, sweating, fatigue, and insomnia.
INFECTIOUS DISEASES
Frequently, emotional symptoms are the first warnings of infectious disease. For example, fatigue and nervousness maybe the only early complaints of patients who have hepatitis, infectious mononucleosis, tuberculosis, and many other diseases. Anxiety and tiredness are symptoms that deserve careful diagnostic judgment; they are not always innocuous.
REACTIONS TO MEDICATION
Both over-the-counter and prescription medications can sometimes produce emotional or mental side effects. Too, as the number of manufactured drugs increases, the potential for interactions among different medications increases greatly. Certain drug interactions produce symptoms of marked agitation, restlessness, and anxiety. Furthermore, patients who have regularly taken a particular medication may sometimes find that it begins to cause unexpected side effects. "False senility" in elderly patients, for example, is often induced by medication; when the medication is stopped, the undesirable symptoms disappear.
DRUG ADDICTION AND ALCOHOLISM
Both are runaway habits that can cause nervousness and overreactions to small crises. Ironically, individuals are usually first attracted to narcotics or alcohol in order to obtainrelieffrom anxiety. But once the addictions have become firmly established, emotional symptoms of depression, irritability, sudden changes of mood, nervousness, and paranoia are common, as are memory loss and difficulty in concentrating.
Caffeine is an emotionally habit-forming drug. Real addiction—i.e., physical dependence with withdrawal symptoms—appears to be rare. Nevertheless, coffee, tea, and cola drinkers can become emotionally dependent on caffeine. The drug is afrequent cause of chronic nervousness in habitual caffeine users. Smoking is a habit that causes a person to lose approximately 5½ minutes of life expectancy for each cigarette smoked. Beyond this, smoking is also a common but unrecognized cause of chronic nervousness, in spite of the fact that many smokers believe smoking will help steady their nerves.
By now it should be evident that the two main signs of emotional distress—anxiety and depression—can sometimes be the symptoms of undetected physical disorders. Especially in cases of severe anxiety or depressionwithoutphysical complaints, both therapists and clients tend to overlook the possibility of physical illness.
It is true that, at present, the majority of such cases cannot be traced to underlying physical causes; they are therefore treated by means of psychotherapy or psychiatric drug therapy. As medicine and biochemistry develop, however, mental and emotional complaints are increasingly being understood in more physical terms.
Emotional distress clearly does sometimes mask or camouflage the presence of physical disorders. If you are suffering from serious anxiety or depression, it is important to have a comprehensive physical beforebeginningpsychiatric treatment. This is true especially when the onset of emotional symptoms was sudden—within a period of days or one to two weeks. It may be most useful to see a diagnostic specialist—for example, a doctor of internal medicine. But bear in mind that physicians, even those who are familiar with psychiatric problems, vary considerably in their diagnostic skills, and sometimes a second opinion can be worthwhile before you decide that the most appropriate treatment is psychotherapy.
PART IIEXPERIENCING THERAPY
In Part II you will be able to develop an overall understanding of the main approaches to therapy available today. We will look at psychoanalysis, the first of the psychotherapies, developed by Freud at the beginning of the twentieth century; and then, in the next two chapters, discuss ten major psychotherapies. Because of their widespread use and value, individual chapters will then focus on approaches to behavioral psychotherapy, group therapy, and marriage and family counseling. The two final chapters in this section deal with the therapeutic value of exercise, biofeedback, relaxation methods, hypnosis, meditation, psychopharmacology or the use of drugs in therapy, and dietary approaches.
In the discussion of each approach to therapy you will find:
*a concise descriptionof its special perspective
* information onthe kinds of problemsit is thought to be most useful in treating—and closely connected with this, but seldom taken into account—
* a description ofthe kinds of individualswho tend to profit most from that approach; and
* an account ofa successful experience in therapy, reconstructed from the reports of clients as they look back on their treatment
HOW TO USE PART II
There are two ways you may find it profitable to use this section of the book. Perhaps you may decide to combine both of them.
First, you can use the "map" in Chapter 7 to define your goals and to suggest specific approaches to therapy that, based on your own self-diagnosis, you might find most beneficial.
On the other hand, you may not feel that mapping out your problem or goals in the way that Chapter 7 suggests is for you. Perhaps you are simply curious about the field and would like to learn more about it, or perhaps you are considering counseling or psychotherapy as an opportunity for personal growth and do not have particular difficulties or issues that you want to focus on. For you, it may be more relevant to read about a wide range of approaches and by so doing gain a clearer understanding of what the alternatives are, how they work, and what they may offer you. This "window-shopping" can then form the basis for a more informed decision later on if you want to enter counseling or psychotherapy.
THE EXPERIENCES OF CLIENTS IN THERAPY
The reports in this book that describe the personal lives and experience of real individuals in therapy have all been deliberately recast to mask all traces of their identities. Their names, life situations, ages, and other characteristics have been changed.
Descriptions of the experiences of clients in therapy have been greatly abbreviated and sometimes simplified. As we have already seen, counseling and psychotherapy last varying lengths of time. Even a very short period of therapy, over a period of weeks, will bring to light much more detail than it would be useful for us to discuss here. The personal lives of the real persons that are portrayed here are immeasurably more complex and multifaceted than short reports can bring out.
Sometimes we will use a time-lapse strategy, describing the evolution of a person's therapy over a period of many months by skipping over weeks at a time. Always the intent will be to try to convey to you how real people with real problems have come to deal with their difficulties more effectively and often, in the process, have been able to reach a richer understanding of themselves and of others.
9PSYCHOANALYSIS
For wide-range improvements in individualswho are not severely impaired and who arearticulate, reflective, patient, self-disciplined,and able to make a potentially long-termcommitment to therapy.
The past hides but is present....Bernard Malamud,A New Life
Psychoanalysis is the root from which the large family of different theories of psychotherapy and counseling has grown. Sigmund Freud's first efforts to develop psychoanalysis began in the 1880s. He lived a long life and was active into his eighties; he died in 1939. Freud left behind one of the most important contributions to the field of mental and emotional health. It formed the historical basis for the diversity of approaches that would follow. Even when later thinkers took issue with Freud, their work in different ways relied on the foundation of his pioneering work.
Many of Freud's ideas have worked their way into our everyday vocabulary: the unconscious, the ego, repression, the Oedipuscomplex, and so forth. His work has influenced the study of anthropology, sociology, history, philosophy, and literature.
FREUD'S THEORY
During Freud's early medical training, he went to Paris to study with a well-known neurologist, J. M. Charcot. Charcot had begun to use hypnosis to treat patients with certain physical disorders—paralysis, for example—for which there was no apparent physical cause (so-called hysterical symptoms). Working with Charcot, and later with a physician, Joseph Breuer, Freud began to suspect that these symptoms weremotivatedby earlier traumatic experiences that so distressed the patients that they were forgotten (repressed).
Freud's theory of emotional and mental illness began then to take shape around this central idea that neurotic behavior has apurpose: there is an underlyingmotive, the motive itself is very upsetting to the person, and so it is repressed from awareness. But it continues to gnaw away below the level of conscious awareness and eventually leads to the disturbance that brings the patient to the point at which he or she is in need of professional help. Freud believed that recovery would occur if a patient could be helped to gain insight into these painful events and feelings that had been forgotten or suppressed. In a moment, we will look at two real examples.
Freud's theory has several dimensions. First, his theory offers an explanation of how the mind operates through its defense mechanisms: as we have noted, excessively painful feelings and memories are repressed. Second, his theory tries to identify the different psychologically critical stages children go through on their way to adulthood: the oral, anal, and genital stages. And third, his theory seeks to distinguish the parts of the psyche, which together underlie an individual's personality: theego(the rational portion of the mind that deals with reality), theid(made up of basic instincts that press for gratification), and thesuperego(formed from parental influences that have been internalized).
HOW PSYCHOANALYSIS IS DONE
Together, these three so-called dynamic, developmental, andintrapsychic dimensions of Freud's theory make up the general framework of psychoanalysis. The central technique of psychoanalysis is to help the patient become aware of motives that are unconscious. Psychoanalysis, or analysis for short, is basically an attempt to extend self-control, bringing disturbing feelings and behavior under a person's conscious management.
One of the principal techniques is free association. The patient is made to feel relaxed and comfortable—one reason a couch is sometimes used. He is encouraged to talk in an uninhibited way about his concerns and feelings. During this process, the analyst usually remains detached and restrained so as not to interfere with the patient's free expression. From time to time, the analyst shares with the patient certain of the interpretations he has developed on the basis of the patient's reports and behavior. The analyst's objective is to help the patient recover lost and painful memories that are responsible for the conflicts, weaknesses, or inabilities that cause the patient to suffer.
This process can be very hard on the patient: he or she must revisit experiences that may be very painful. Analysis requires perseverance, endurance, and courage. It is not, as we will see, for everyone or every problem.