One of the most important developments in psychoanalysis has to do with the increasing popularity of psychoanalytic psychotherapy (also calleddynamic psychotherapy), meaning psychoanalysis that is extremely brief (12 to 20 sessions, for example). Considerably more patients are now treated with psychoanalytic psychotherapy than with traditional, intensive psychoanalysis.
TWO EXAMPLES OF PSYCHOANALYSIS
Other than the length and intensity of treatment, the main difference between Freudian psychoanalysis and brief analysis has to do with the amount of emphasis that is placed on sexual matters. Freud believed that an infant's relationship to his environment and parents is predominantlysensual: a baby seeks oral gratification; his attention is absorbed by what he puts into his mouth. Later, attention is focused on excretory processes; toilet-training requires the child to exercise self-regulation for the first time. Later, genital sexuality becomes the dominantinterest. These sexual phases of development identify the dominant areas of attention that influence the infant, the child, and then the adult in their behavior toward others.
Brief psychoanalysis generally does not affirm Freud's sexually based (libido) theory of motivation. The second example that follows illustrates this shift of emphasis. The first example was described by Freud himself[1]; the second illustrates brief psychoanalysis.
[1] Sigmund Freud, "Lecture 17,"General Introduction to Psychoanalysis(New York: Garden City Pub. Co., 1943).
A CASE FROM FREUD
Freud describes the analysis of a girl who has repressed a strong desire for sexual intercourse with her father and has, as a result, developed a bizarre pattern of behavior.
Unconsciously, the dread of actually making love with him has generalized to a dread of sexual activity of any kind. Without any conscious intent on her part, an association is formed between sexual intercourse and breaking a vase. She is not aware of the unconscious symbolic connection she has established between these acts. Similarly, she begins to associate the bolster at the head of her bed with her father and identifies her mother with the headboard.
The pressure of this repressed material impels her to go through an elaborate ritual each night before she can get to sleep. First she arranges the several vases in her room so that she feels they are well protected against being broken (thereby guarding against sexual intercourse). Then she makes sure that the bolster does not come into contact with the headboard (in this way she gains the substitute satisfaction of keeping her mother and father apart).
As her analysis proceeds, and the analyst is able—and here, timing is important—to encourage her to become conscious of her repressed feelings and generalized dread of sex, her need for the nightly ritual is gradually eliminated.
It is not difficult to think of other problems, sometimes of a handicapping kind, that, because of their obsessive or compulsive nature, interfere with normal living. Compulsive handwashing is a classical example; compulsive overeating, bulimia,and its opposite, anorexia nervosa, as well as nymphomania, a need for sexual promiscuity, are a few others.
AN EXAMPLE OF BRIEF PSYCHOANALYSIS
Dr. Richard Chase is a psychiatrist who specializes in emotional problems of children. John and Rachel Edmonton have come to see him about their twelve-year-old son, Bobby, their only child. John is an evangelical minister in his early forties who travels a great deal, taking his family with him.
When Bobby was eight years old, he began to have strange and violent nightmares. He would go to sleep and then apparently awaken about an hour later, asking for a drink of water or expressing a need to go to the bathroom. A few minutes later, Bobby would seem to lose his balance and stumble over furniture, sometimes running into walls, crying aloud that he was "turning inside out" and was dying. Often his parents would have to restrain him to keep him from hurting himself. After a few minutes, the nightmare would end and Bobby would come out of it, a terrified, confused little boy in tears.
So far, John and Rachel, with their frequent moves, had not been able to get professional help that had made a difference. Bobby had been examined by a neurologist, and an electroencephalograph test was done to determine if some kind of epileptic disorder might be involved. The test was negative. They had also taken Bobby to a child psychologist, who said that Bobby was bright, sensitive, and precocious, that this kind of nightmare was called anight terror(pavor nocturnis), and that the problem would eventually subside.
Four years passed, and the night terrors did not. The family of three was becoming battle-scarred. Bobby hated to go to bed at night, fearing the inevitable. His parents, sometimes patient, sometimes not, used whatever ways they could, even a prescribed sedative for Bobby, so he could relax and get to sleep, to no avail.
Could Dr. Chase help?
Dr. Chase decided to meet with Bobby by himself. He found that Bobby was very willing to talk about his "bad dreams." Dr. Chase asked him to describe what happened each night.
"Oh, Doctor," Bobby began, "it's really awful. I know it's going to happen, but I can't do anything to stop it. I stay up as late asI can, and I will do anything not to go to sleep. But when I do, I'llkind ofwake up a little later, and I'll see Mother and Dad looking very worried. At the same time, I'll see a box, with white walls, glowing brightly, but not in the room where Mother and Dad are. It's in some space, I guess it's in my mind, a black space, with that white-colored cube just floating there. And then it begins to turn inside out. My stomach feels like it's turning inside out, and it hurts and scares me. It feels awful. I really think if the cube turned all the way inside out, I'd die. But it never does; I always wake up first."
Dr. Chase began to meet with Bobby three times a week. He gradually gained his trust. At a session during the third week of treatment, he asked Bobby if he would play a word association game with him.
DR. CHASE: Tell me what you think of when I say, "dog."BOBBY: Cat.DR. CHASE: Black.BOBBY: White.DR. CHASE: Chair.BOBBY: Cushion.DR. CHASE: Box.BOBBY: House.DR. CHASE: AngryBOBBY: Mad.
Dr. Chase spent about fifteen minutes writing down some of Bobby's associations. Bobby gave back associations in the rapid-fire way Dr. Chase asked, doing this almost automatically, leaving no time to deliberate. Gradually, Dr. Chase felt he saw a pattern emerging, and he was able to confirm this from Bobby's associations in later sessions.
Toward the end of the sixth week, Dr. Chase sketched for Bobby's parents the interpretation he had developed during Bobby's short-term experience in psychoanalysis: "I believe Bobby has unconsciously been trying to tell you something in a highly symbolic form: often the mind expresses deep-seated fears in the imagery of dreams.
"I've tested Bobby in a variety of ways. Always, he appears to associate the box in his dream with home or with a house. I'm fairly certain that 'being turned inside out' symbolizes for him the process of moving out of all the houses you have moved awayfrom. A house really is turned inside out when you move: all of its contents are taken out, usually in boxes.
"I believe Bobby is hurting because of your frequent moves. I think if you will stay in one place, even though I realize that you, John, would probably have to give up evangelical work, you will gradually see a real improvement in Bobby."
Dr. Chase's advice was received with a good deal of disbelief by John and Rachel, but they did, eventually, decide to try it. John became assistant minister at a local church.
Two years later, Dr. Chase received the following letter:
Dear Dr. Chase:
Maybe you'll remember treating our son, Bobby, for what you called his "recurrent night terrors." My wife and I followed your advice: We told him we had decided to stay in Atlanta, so that he could go to the same high school for all four years.
In about two months, Bobby's night terrors were down to about one a week. After three months had passed, the suffering our family has endured for more than five years came to an end. Bobby hasn't had another episode since then. He's doing well in school, has friends, and seems quite happy. We all are.
It's sure a pleasure to be freed from the experience that terrorized us all.
Bless you,John and Rachel Edmonton
AN ANALYST LOOKS BACK AT HIS OWN PSYCHOANALYSIS
Psychoanalysis is unique among approaches to counseling and psychotherapy in that it requires analysts, as a part of their training leading to certification, to undergo psychoanalysis themselves. Not only is this intended to be an educational experience, but it is considered essential to their competence in later professional practice: it is important that they be completely aware of what are calledcountertransferencefeelings toward patients. Just as patients develop toward their therapists feelings they had toward significant persons in the past—calledtransference—the analysts, no less human, do the same. Their relationships with their patients can revive some of the analysts' own conflicts. They will be unable to understand the patient clearly, free from distortions created by their owncountertransference tendencies, unless they have come to understand themselves as thoroughly as it is possible to do so by means of their own psychoanalysis.
After undergoing a long and intensive period of personal analysis while in psychoanalytic training, Dr. Tilmann Moser referred to his analysis as "a successful life-saving operation for my soul." He sought relief from depression, caused, he now believes, by a troubled relationship with his parents. He describes his experience in these terms:
Psychoanalysis is a piece of the work of conciliation with one's own origins. The important ability to be implacable, attached to the wrong place in the neurotic unforgivingness toward ... [my] parents, has been freed for aspects of life where it can be used for efforts directed toward social change, the changing of conditions that cause avoidable suffering to countless human beings. The longtime impassable road of affection toward my parents, based on humor, has been re-opened.[2]
[2] Tilmann Moser,Years of Apprenticeship on the Couch: Fragments of My Psychoanalysis, trans. by Anselm Hollo (New York: Urizen Books, 1977), p. 18.
APPLICATIONS OF PSYCHOANALYSIS
In general, psychoanalysis is successful in bringing about what are calledbroad-spectrum improvements. It is less intended for abatement of specific symptoms. In other words, those with highlyspecificgoals they wish to achieve through therapy tend not to be good candidates for analysis. For example, a person seeking specific and prompt relief from depression, public-speaking anxiety, or shyness may not be appropriate for psychoanalysis. Long-term, intensive psychoanalysis, because it is long-lasting and very detailed, can lead to very broad improvements: a sense of increased satisfaction in daily living; a stronger, more positive sense of self-esteem; a greater capacity to enjoy and be at ease with others. In the process, specific symptoms often do subside or disappear, but the focus is general, and the patient must be willing to embrace a commitment to general improvement.
On the other hand,briefpsychoanalysis may begin by focusing on specific problems experienced by a patient, but treatment quickly widens in scope to touch on matters that affect thepatient's life in a general way. We saw this in Bobby's case, where recurrent night terrors revealed his general need for the greater emotional stability that comes from feeling settled, having friends, etc.
Psychoanalysis is best suited to problems that fall into two categories:
* Problems that are clearly "neurotic" in nature: they interfere with living to some degree but do not totally impair you so that your life is clearly out of control, as in cases involving psychoses (where you are no longer able to distinguish reality from fantasies and hallucinations), alcoholism, or drug addiction
* Problems that involve sexual difficulties, mood disturbances, and impairment of personal relations, assuming that you are willing to work on these problems within the wider focus that analysis usually requires
Psychoanalysis isnotgenerally considered to be the treatment of choice for severe impairments, such as alcoholism, drug abuse, and psychotic disturbances, when your life is clearly out of control. Analysis is alsonotgenerally an appropriate form of treatment for immediate problems arising from sudden environmental changes, such as the loss of a job, or loneliness after a transfer to a new job location, or after a divorce or separation. In some instances, if problems of this kind are not resolved after a reasonable adjustment period, analysis might then be considered. Other approaches to therapy lend themselves better to specific and immediate adjustment problems, as we will see.
We have been describing the appropriateness of psychoanalysis for the treatment of certain kinds of problems, but there is an equally important, and frequently overlooked, question: whether psychoanalysis is appropriatefor the kind of person you are. Psychoanalysis is best suited to individuals with these characteristics:
* They are verbally articulate.
* They have a sense of curiosity about themselves.
* They have a good reflective capacity and an interest in achieving insight through a careful analysis of their thoughts, feelings, behavior, and past history.
* They are comparatively unimpaired in their abilities to form relationships.
* They are able to tolerate the frustration, and endure the pain, of re-experiencing disturbing feelings and memories.
* They are willing to be patient through a potentially long period in treatment and can sustain a commitment to that process.
10PSYCHOTHERAPY, PART IClient-Centered Therapy, GestaltTherapy, Transactional Analysis,Rational-Emotive Therapy, andExistential-Humanistic Therapy
The approaches to therapy we will look at in this chapter are calledhumanistic therapies. They include client-centered therapy, Gestalt therapy, transactional analysis (or TA), cognitive therapy, and existential (or existential-humanistic) psychotherapy. These approaches share the view that an effective therapist must be able to become conscious of the world as it is for the client. Doing this requires the therapist to have a heightened sensitivity to others, feel a fundamental measure of respect for them, and ideally be able to adjust to their very individual needs and concerns. All of the therapies we will examine in this chapter place priority on the client's subjective feelings and experiences.
CLIENT-CENTERED THERAPYFor people who have not developed a sense ofpersonal worth; who are in need ofacceptance, human warmth, and gentleencouragement; and who have theinitiative to proceed both in therapyand outside of therapy withoutexplicit direction from the therapist.
The development of client-centered, or nondirective, therapy has largely been the work of Carl Rogers (1902-1987). His clinical experience as a child psychologist and his later work in training students in therapy led him to believe that people frequently come to have personal problems as a result of theconditionallove of their parents. To receive love and approval from their parents, children must satisfy certainconditions of worththe parents lay down. If the children do not live up to the parents' demands, they are punished by the withdrawal of the parents' affection—a far more serious and emotionally scarring punishment than a physical spanking. Raised in this way, people later in life will tend to link their self-worth to internalized parental standards. Rogers observed that the more the love expressed by parents is conditional in this sense, the more it is likely that a person will experience emotional difficulties later on.
As a result, Rogers gradually developed an approach to therapy that emphasizes "unconditional positive regard." Ideally, a client-centered therapist is able to express a sense of complete acceptance and respect toward the client. The therapist does not associate positive regard with implicit conditions of worth that the client must satisfy. In other words, client-centered therapy attempts gradually to reverse a habit that has come to undermine the client's sense of self-worth. It is a habit that we all, to differing degrees, develop as parents and society teach us to relinquish self-acceptance in favor of the conditional love or appreciation of others. Eventually, the habit becomes so ingrained that it can jeopardize our own feelings of self-esteem.
Client-centered therapy encourages a client to grow in several ways:
1. by feeling comfortable enough in the company of the therapist to express feelings freely and openly
2. by coming to recognize his own feelings of incongruence, of being divided against himself, often due to experiences that have encouraged a negative or insecure sense of self-worth
3. by perceiving that the therapist is an integrated, accepting person, able to convey acceptance and warmth toward the client
4. by reintegrating a sense of self, freeing himself from the distortions of self-worth brought about by love that has strings attached
AN EXAMPLE
Melissa Adams is twenty-eight years old, the district manager of a large pharmaceuticals marketing division in the Midwest. She is slender, immaculately dressed, and—as Dr. Feldman could see immediately—rigid and very uptight about herself.
Melissa came to see Dr. Feldman, a clinical psychologist, because of a growing sense of estrangement toward her husband and tension and anxiety at work. She described her upbringing in an extremely rigid, judgmental atmosphere in which her self-worth was implicitly tied to her parents' conditions of achievement. She was apparently encouraged by her parents, who realized Melissa was a bright child, to skip a grade and then to complete her undergraduate work in three years by attending summer school each summer. Her parents were very proud of her.
She admitted to having had little fun and would turn a vacation into an opportunity for achievement. She frequently could not enjoy television or the movies "because it felt frivolous." She was free from self-doubts only when hard at work, so she worked virtually all the time. Her husband wanted a family, but Melissa believed that children would be an undesirable interruption and distraction.
Melissa quickly lost her fear of the weekly meetings with Dr. Feldman. She was able to relax in his company. She felt that he cared about her as a person, whether she achieved or did not. He would not make active, directive suggestions, but rather listenedto her in a genuine, positive way. During one session, Melissa asked him if he would give her some "straight advice" about her relationship with her husband. Dr. Feldman declined. He felt that telling another person what to do did not show respect for that person's individuality. He could see that Melissa was intelligent. He believed that she could trust her own decision-making abilities, and he would encourage her to believe in herself.
Over a period of a little more than a year, with weekly visits, Melissa's personality began to soften. She dressed more casually. She was more relaxed. She was beginning to enjoy herself more, although occasionally the old self-doubts would come back to assail her. But she usually was able to fend them off. Her marriage was improving, she looked forward to "a real vacation" in the near future, and she was not closed to discussing the possibility of children with her husband, although they had not yet made a decision on that issue.
APPLICATIONS OF CLIENT-CENTERED THERAPY
Client-centered therapy focuses especially on difficulties that stem from a client's negative feelings of self-worth. Client-centered therapy may be the therapy of choice especially for individuals who feel anxiety, uncertainty, and pain because of a low sense of self-esteem. A client-centered therapist can be expected to value personal genuineness, integrity, and honesty. The approach can be helpful to persons who suffer from loneliness and isolation.
Client-centered therapy is most effective for individuals with these characteristics:
* They are able to exercise initiative, both in expressing their difficulties to the therapist and in attempting to make desired changes. Most client-centered therapists will refrain from giving direction.
* They are interested primarily in personal growth rather than the removal of specific symptoms.
* They are blocked, inhibited, or rigid because they are too self-critical.
* They are not severely impaired in their abilities to relate to others.
GESTALT THERAPYFor very rigid people who are always trying tobe someone they are not, who will committhemselves to a challenging and usuallyfrustrating process of growth leading topersonal integration and genuineness.
GESTALT PSYCHOLOGY
Gestalt therapy has its roots in Gestalt psychology, which was established early in this century by the German psychologists Wolfgang Köhler (1887-1967), Kurt Koffka (1886-1941), and Max Wertheimer (1880-1943). The main contribution of Gestalt psychology consisted of studies of human perception. Gestalt psychologists demonstrated that perception reveals the existence of organized wholes that cannot be reduced to the sum of their parts. They called such an organized totality aGestalt. (Outside of psychology,Gestaltin German means "form.")
A famous example, shown below, demonstrates how an object that you see can be closely linked to its background. Here, the figure and the ground can oscillate, depending on whether you concentrate on the faces or the vase. The figure depends on its background for its identity, and vice versa.
A famous illustration of a white vase set between the black silhouettes of two faces in profile; at one moment you perceive the vase, at another you see the two facesA famous illustration of a white vase set between the black silhouettesof two faces in profile; at one moment you perceive the vase,at another you see the two faces
GESTALT THERAPY
Frederick (Fritz) Perls (1893-1970) brought together certain of the basic concepts of Gestalt psychology, psychoanalysis, and psychodrama, an approach to therapy developed by J. L. Moreno (1889-1974) that emphasizes role-playing, acting out of fantasies, and group interaction.
Perls transformed the Gestalt psychologists' central idea so it would serve as a basis for his approach to psychotherapy. Let's look at an example.
A man has been stranded in the desert and has become severely dehydrated. He has wandered for several days in search of water. He stumbles along, nearly blinded by the sun, seeing only vaguely defined shapes of rocks and cacti. Suddenly, out of this hazy world, something becomes clearly defined: he sees a watering hole, surrounded by low bushes. It is clearly etched in his eyes, set against the indistinct background of the hot desert. Once he has plunged his head into the water and quenched his thirst, his Gestalt isclosed: the need that caused him to struggle for days has performed its purpose.
In this derivative sense,Gestaltmeans "a problem (figure) that arises out of a situation (background) which motivates an individual to action." If his action is successful, his Gestalt is closed: the problem is resolved, and the motivation is fulfilled. Like the Gestalt of the psychologists, the closed Gestalt of therapy signifies an organized whole. In the example, the man suffering from thirst in the desert has a Gestalt that impels him to find water. When he does, his thirst is satisfied, and the Gestalt is resolved into a whole that no longer stands in need of completion.
Perls saw life as a succession of unfinished situations, incomplete Gestalts. No sooner is one closed than another takes its place. To cope effectively with living, we must be able to deal with life's problems and challenges, yet not all of us can.
Perls used the termgrowth disordersto refer to what other therapists might callpersonality disordersorneuroses. He believed that emotional problems result from "getting stuck" in the natural process of growth. People get stuck in childish patterns of dependency because of a variety of childhood experiences. For example, a mother and father may withdraw the support of a stable environment, while a child relies on this for a sense of security. (The example of Bobby in the chapter onpsychoanalysis may come to mind.) Or, parents may force a child to accept adult responsibilities prematurely. It is as if a child were asked to walk before his sense of balance and leg strength had developed sufficiently. The child willlearnuncertainty; his natural early fear of falling becomes pronounced and will leave a mark that can stand in his way later. Perls called such experiencesimpasses, and they formblocksto a person's growth.
For Perls, human personality is like a multilayered onion: From the most superficial, outside layer, moving inward, there is the usually insincereclichélayer ("How are you?," asked without real interest), therole-playinglayer (the habitual masks of father, mother, businessperson, homemaker, therapist, client), theimpasselayer (the person stripped of clichés and masks, often very frightening), theimplosivelayer (where emotions are either vented or explode inward), and the innermost layer, which makes up thegenuinepersonality as it is, freed from learned pretensions. The goal of Gestalt therapy is to reach this last layer. In a word, Gestalt therapy seeks to encourage the growth ofauthenticity—a combination of a balanced sense of reality, of inner integration complemented by its outward expression, personal integrity, and of independence from the need for the approval of others.
In Gestalt therapy, self-change seems paradoxical. As long as inner conflicts continue, you trynot to bethe person you are; you cannot be genuine and are divided against yourself. Change, the Gestalt therapist claims, is possible only when you give up, at least for a time, trying not to be the person you are. There must be a firm place to stand from which to initiate change, and that place can only be the person you are right now.
WHAT GESTALT THERAPY IS LIKE
Gestalt therapy as it was developed by Perls is individual therapy done in a group setting. Gestalt therapists since Perls most commonly continue to practice therapy this way: individual members of a group are asked to volunteer to take the "hot seat"; the volunteer then becomes the focus of attention. This is not group therapy where relationships among members of the group are most important (see Chapter 13). In Gestalt therapy, emphasis is on the individual, who is pushed to drop his or her masks and pretensions. Other members of the group form anaudience and try to learn by example until it is time to occupy the hot seat themselves.
Perls would ask for someone in the group to sit in a chair, facing him and the audience. Then Perls would launch an attack on the client's defenses. At times, he could be almost merciless. He did not believe in mothering clients; this served only to keep their defenses intact.
Perls would notice nonverbal clues to the client's feelings. If the client was an inhibited woman, he would comment about her thighs, which were pressed firmly together. If the client was shy, he would remark about how the client held one hand in the other: Did he feel a need to have his hand held by Mother?
If the client burst into tears, Perls would make no attempt to stop the tears with reassurance but would try to make the client aware of his motivation in crying: Was it to elicit pity? Were the tears a way of hiding from self-responsibility? Were the tears another mask, standing in the way of self-acceptance, authenticity, and growth?
The objective of Gestalt therapists is to tear away clients' defensive masks and roles that usually keep them from real, sometimes painful or frightening, feelings. In this, the therapists' main technique is tofrustratethe clients' attempts to hide behind their masks and roles and toblocktheir attempts to control their therapist. Clients often do this by trying to make the therapist feel sorry for them, give them parental warmth, respond to their inadequacies, and so on. Instead, Gestalt therapy is comparativelytough. Perls used these instructions in beginning a workshop:
So if you want to go crazy, commit suicide, improve, get "turned-on," or get an experience that will change your life, it's up to you. I do my thing and you do your thing. Anybody who does not want to take responsibility for this, please do not attend this session. You come here out of your own free will. I don't know how grown up you are, but the essence of a grown-up person is to be able to take responsibility for himself—his thoughts, feelings, and so on. Any objections? ... O.K.[1]
[1] Frederick Perls,Gestalt Therapy Verbatim(Lafayette CA: Real People Press, 1969), p. 79.
By refusing to give unnecessary emotional support even when clients cry for it, Gestalt therapists convey through their behavior that clients do have what it takes to stand on their own two feet. Ideally, Gestalt therapists are genuine, mature people; they refrain from interfering in the lives of others and expect them to be self-supporting. They try to impress on their clients that they do not exist to live up to the expectations of others, nor do others exist to live up to theirs.
APPLICATIONS OF GESTALT THERAPY
Gestalt therapy is most effective in treating persons with these characteristics:
* They tend to be very rigid—restrained, overcontrolled, perfectionist—or depressed, or phobic. That is, they have certain well-defined fears; for example, fear of public speaking, of insects, of sexual intercourse.
* They have become stultified in their relations with others and have pent-up feelings in need of release.
* They obtain little joy or satisfaction from living; their lives lack emotional intensity.
* They are not excessively frightened by group activity.
Specific conditions Gestalt therapy often treats include these:
* psychosomatic disorders, such as stomach pain, colitis, back and neck spasms, and migraines
* behavior problems in children
* difficulties in coping with persons in authority
* shyness and passivity
* emotional difficulties arising from poverty and from the deprivations suffered by minority groups
* rigid, conflict-torn family situations
* crisis intervention: treating individuals in despair who have lost the will to live or are suicidal
Gestalt therapy isnotgenerally the treatment of choice for people whose lives are out of control or who show signs of psychosis. Gestalt therapy relies on your capacity to make yourown practical life decisions, to tolerate the stress and frustration of being in the hot seat, and to benefit from being challenged by the therapist to confront your own pretenses, distortions, and confusions. People who have lost these capacities for the time being due to problems such as alcoholism, drugs, and loss of touch with reality tend not to benefit from Gestalt techniques.
TRANSACTIONAL ANALYSISFor less troubled people who want to improvethe effectiveness of their communication skillsand break free from frustrating, self-destructivepatterns.
Transactional analysis has perhaps done more than any of the other main approaches to therapy to increase the sensitivity of the public to the psychological dimensions of human relationships. It has achieved widespread popularity in a short time largely because of its simple, commonsense vocabulary that is easy to apply to personal, family, and group situations.
Eric Berne (1910-1970) completed his medical training in 1935, then finished his psychiatric residency at Yale in 1941. He soon separated himself from psychoanalysis and began to formulate his theory of transactional analysis (TA).
By the mid-sixties, TA was gaining in popularity: Berne wrote his book,Games People Play, primarily for professionals, but it became a best-seller filling a need for an easy-to-understand and easy-to-apply approach to therapy.
TA is based on the premise that human personality has three parts: Berne called them theParent,Adult, andChild. Although similar in meaning to Freud'ssuperego,ego, andid, Berne's terms were intended to name dimensions of personality that could be observed directly; his three "ego states" are not theoretical constructs.
The Child ego state is the source of fun, humor, creativity, wishful thinking, and irresponsibility. It is impulsive and resists control.
The Parent ego state is the repository of values, attitudes, and expectations inherited from one's parents.Shoulds,oughts,hands-on-hips, and finger-wagging gestures are common expressions of the Parent.
The Adult ego state is the source of reason, logic, and unemotional evaluation. It forms the basis for decision making and predicting outcomes.
Only one ego state can be in control of our emotions or behavior at a time.
Berne observed that many emotional difficulties in individual clients result from problems involving their ego states. Some personality problems come about because a person cannot separate his or her ego states and switches from one to another erratically and uncontrollably. For example, a young mother begins—in a calm rational way—to describe the behavior of her nine-year-old son. She talks about his impertinent and disrespectful behavior, and, as she does, she becomes enraged, her face turns beet-red, and she yells at her therapist that someday she is going to give her boy a beating he'll never forget! Transactional analysis would try to show her that she tends to slip from her reasonable Adult state to the state of an angry Parent who demands complete respect and subservience. Berne called this structural problem of the personalityconfusion.
PERSONALITIES: Normal Personality, Confused, Excluded, ContaminatedPERSONALITIES: Normal Personality, Confused, Excluded, Contaminated
Exclusionis another structural problem. An individual rigidly adheres to one ego state, locking out the other two. A Don Juan gives free expression to his Child, while his Adult and Parent states are suppressed. A workaholic, on the other hand, permitshis Parent to block the expression of his Adult and Child ego states.
Contaminationis a third personality problem. One ego state subverts another. A woman cannot commit herself fully to her chosen profession because her Child has undermined her sense of determination by persuading her that a wealthy knight in white armor will soon appear to relieve her of the need to exert herself.
WHAT TRANSACTIONAL ANALYSIS IS LIKE
Transactional analysis normally begins with "structural analysis" in which clients are taught how to distinguish ego states that may be confused, excluded, or contaminated. This phase of therapy is sometimes done on an individual basis and sometimes in a group workshop or classroom environment. Therapy then proceeds to transactional analysis proper, in which frustrating or painful forms of communication and unsatisfying life directions are discussed. Most commonly this is done in a group setting, since a group encourages a variety of different styles of communication.
TA teaches clients to determine which ego state is active at a given moment—in themselves and in others with whom they are trying to communicate.Transactionsor communication patterns between people are the focus of TA. Some typical transactions are diagrammed on the facing page.
In (a) on the facing page, person 1 communicates in an Adult mode and receives an Adult response from person 2: "Where are you going?" "To the cleaner's."
In (b), a Parental boss receives a petulant response from the Child ego state of an employee: "What took you so long?" "My little boy is sick, and there's just too much work for one secretary."
In (c), an Adult-to-Adult message receives a Child-to-Parent reply; this is an example ofcrossed transaction. It is one of the most common sources of frustration and conflict in family and professional life. For example, a therapist says, "You seem to be late for your appointment today." (Adult-to-Adult, or A-A.) The client replies, "You're just like my father, always picking on me." (C-P.)
DIAGRAMS OF TYPICAL TRANSACTIONSDIAGRAMS OF TYPICAL TRANSACTIONS
Diagram (d) illustrates communication that involves an ulterior message. For example, a psychologically clever salesman is showing hair driers to a woman. She tells him how much she is prepared to spend and then asks, "How much is that one?" The salesman (arrow 1 in the diagram) replies: "You wouldn't be able to afford that model." His response is based on his customer's stated budget limitations and appears to be Adult-to-Adult. However, the hidden message (dotted arrow [1) is directed to his customer's Child state, which, as he predicts, causes her to reply rebelliously (arrow 2), "That's the one I want."
In (e), another example of this class of communications that are not what they appear to be, there are two ulterior transactions. A secretary returns a few minutes late from lunch. Her boss asks, apparently Adult-to-Adult (arrow 1), "What time is it?" They both know what the hidden message is. The secretary answers sharply (arrow 2): "It's 1:15." The ulterior message from the boss is "Are you late again?" (P-C: arrow [1].) The secretary's covert or hidden reply is "Get off my back: you're always criticizing." (C-P: arrow [2].)
The central objective of TA, then, is to make clients aware of these and other patterns or games that their habitual ways of communicating reveal. By doing this, clients find that communication becomes less problematic and more effective as they learn to control their responses.
AN EXAMPLE
Joyce was forty-one when she decided to take her seventeen-year-old only son, Joe, to see Dr. Goldstein, a transactional analyst. For about five years, ever since his father died, Joe and his mother had quarreled a great deal.
Dr. Goldstein met with Joyce, then with her son, and then with them both. After he listened to their complaints about one another, he agreed to try to help.
For six weeks, Joe and his mother met once a week with Dr. Goldstein as "TA students." They were to put family problems on a back burner; their energy was devoted to learning to apply the concepts of transactional analysis. Dr. Goldstein had themanalyze many examples of communication.
During a second six-week period, Joyce and her son were coached to learn to talk to one another more effectively. Here are some samples of their automatic patterns of responsebeforethey began to use TA:
SON: The soup's too salty. (A-A or C-P)MOTHER: I don't know why I work so hard! All you do iscomplain! I'm just not appreciated! (C-P)
SON: Mom, here's the sports jacket I bought for graduation. (A-A)MOTHER: You can't go inthat! We're taking that jacket back. Ican't trust you to buy clothes for yourself. Let's go! (P-C)
MOTHER: We're going to dinner tonight at Esther and Gary's. Getout of those jeans; we have to leave in fifteenminutes. (P-C)SON: But Mom, I told you last Wednesday that Fred and I aregoing camping this weekend. We're leaving in Fred'scar in just an hour. (A-A or C-P)MOTHER: I don't remember anything like that. Esther and Garyareexpectingus. You're always wrecking our plans! (C-P)
MOTHER: Mmm, isn't this the most delicious soufflé you've evertasted? (C-P)SON: That's it, compliment yourself! (C-P)MOTHER: Well, if I don't, no one else will! You don't know howlucky you are, having a mother who really knowshow to cook. (C-P)SON: I sure hope I don't learn how to be modest from you! (C-P)
The problems weren't hard for Dr. Goldstein to spot: Joyce had low self-esteem, was easily hurt, and, when she was, put her son down (the salty soup). She wanted to be indispensable to him and was unwilling to let him grow up (the sports jacket). She had little respect for Joe's plans, especially if they interfered with her desires (Joe's camping trip). She felt unappreciated and had grown to be resentful of her role as mother (the soufflé).
Joe, on the other hand, was feeling the natural rebelliousnessof a seventeen-year-old. He needed some free rein, even if he made some mistakes. His mother was always "getting in his hair" or "getting under his skin."
The sample transactions above led each of them to anger and hurt. Seldom did Dr. Goldstein see Joe and his mother communicate Adult-to-Adult. Instead, their transactions crossed and re-crossed, and resentments piled up.
Joyce saw Dr. Goldstein without Joe present for several weeks. She learned from Dr. Goldstein that her expectations toward her son were inappropriate; she needed to strengthen her sense of self-worth outside of her family role. She was excessively dependent on her son for recognition and appreciation. Especially since her husband died, she was easily hurt when her desires for appreciation were not satisfied by Joe, so she put him down. What she needed to do was to strengthen her Adult and weaken the domination of her self-pitying Child and overcritical Parent ego states.
Dr. Goldstein then met with Joe for several sessions. Joe began to see his mother in a different light. Dr. Goldstein made him aware of his mother's sadness in being left alone and of her needs to feel worthwhile.
During the joint sessions that followed, Dr. Goldstein typically would ask them to recall recent conversations or exchanges that had been unpleasant. He would ask them to analyze these in TA terms and then would push mother and son to imagine more appropriate and less uptight ways of responding.
After several months of joint therapy, their former pattern of transactions began to look very different:
SON: Mom, there's too much mustard on the ham. (A-A or C-P)MOTHER: Well, then it's OK with me if you want to scrape someoff. (A-A or P-C)
SON: How do you like my new tie? (A-A)MOTHER: I'd need a lot of courage to wear it myself, but I'm notyou! (A-A or C-C)
SON: Mom, your roast is delicious. It's great to have amother who's a good cook! (A-A)MOTHER: Thanks, Joe. I guess now I've learned that you reallyhate soufflé! (A-A)
APPLICATIONS OF TRANSACTIONAL ANALYSIS
TA has been used in individual and group therapy, in nonclinical settings to help business executives improve communication skills, and also in prisons. It has been used to treat a wide range of problems, including these:
* personality trait problems: e.g., shy, lonely, depressed, overbearing, or hostile individuals
* troubled relationships in couples and families
* fears of withdrawal of affection and of abandonment
* drug abuse
* phobias
* difficulties in relating to authority figures, such as a boss, a teacher, a parent
* adaptation problems in individuals with counterculture attitudes and values
Few controlled evaluative studies have been done to determine how effective TA really is. At this time, and in this author's judgment, TA is most useful as aneducational therapyto assist less severely troubled individuals with communication problems by helping them sharpen their perceptions of their own ego states and the ego states of others. TA is most effective for clients who are able to exercise responsibility for themselves. TA appears to be especially useful in helping individuals who are caught in frustrating relationships to break free from self-destructive patterns or games.
COGNITIVE THERAPY:RATIONAL-EMOTIVE THERAPYFor people who tend to think and judge invery rigid ways, who are frequently intenseand uptight, and who tend to magnify andexaggerate evils.
Man is not disturbed by events, but by the view he takes of them.Epictetus,Enchiridion
"It is absolutely essential to you to be loved by members of your family and to be appreciated by your friends and employer."
"You must be consistently competent and nearly perfect in all your endeavors."
"Some people are really bad, their actions should be restricted, and they should be punished when they do wrong."
"It is terrible when things are not the way you would like them to be."
"Events outside your control are largely responsible for how you feel."
"You should be anxious in relation to what is uncertain, unknown, or potentially dangerous."
"It is much easier to avoid problems than to face life's difficulties and responsibilities."
"It is necessary to have something greater or stronger than yourself to rely on."
"The present is largely determined by past events."
"Happiness comes when one has complete leisure."
"If you don't work hard to please others, they will abandon you."
"If people don't approve of you, you ought to question your self-worth."
By telling ourselves things like these, we create our own unhappiness, frustration, and anger; that is the point of view of cognitive therapy. During the 1950s, Albert Ellis (1913-2007) developed a theory of personality that claims that people are largely responsible for their emotional reactions. They tell themselves that thingsoughtto be different, that peopleshoulddo certain things, and that what they desire theymusthave. Life, for people whose thoughts are filled withshoulds,oughts, andmusts, is full of disappointment, annoyance, and hurt.
Ellis observed that, as time goes by, we tend to reinforce an emotional pattern that amplifies our sensitivities more and more. The emotional reactions we create in ourselves become more exaggerated, distorted, and self-destructive.
But, like any habits, these mental (or cognitive) habits can be broken. Cognitive therapy attempts to do this.
Ellis called his own approachrational-emotive therapy. By this, he acknowledged that people have both rational and emotional dimensions. Their emotions and thoughts (cognitions) are so thoroughly intertwined that they cannot be clearly separated. Yet mental evaluations and ideas are given so much power that cognitive habits are responsible for emotional responses. It is thinking that makes it so.
Rational-emotive therapy is the most widespread approach to cognitive therapy, so we will examine Ellis's approach in some detail.
The main technique of rational-emotive therapy, and of cognitive therapy in general, is to focus clients' attention on their belief systems, their views about what "should" and "ought" to be, their cognitive "filters" through which they interpret, in a semiautomatic way, the world around them. If the "activating event" is a failure or a rejection, for example, a client'srationalbelief system will lead to feelings of regret, sorrow, disappointment, or annoyance; if an individual's beliefs areirrational, on the other hand, he or she may instead feel depression, worthlessness, futility, and severe anxiety. For rational-emotive therapy, emotional good health depends on the rationality of the way a person receives and interprets events.
WHAT RATIONAL-EMOTIVE THERAPY IS LIKE
Therapy usually begins with individual sessions. Once clients have learned how to identify mental habits that create disturbing emotions, therapy is sometimes continued in groups, where new attitudes and forms of behavior can be practiced in a kind of microcosm of the larger world. Rational-emotive therapy that is done in a group context is not, however, "group therapy," since the therapist's focus is on individual styles of thinking, not on relationships among members of the group.
During therapy, clients are very quickly challenged to give evidence for their irrational beliefs. The rational-emotive therapist will openly and ruthlessly oppose the foolish absolutes that clients express and make it clear how they are upsetting themselves emotionally by insisting on such nonsense. It is not considered essential that the therapist be a kind, warm,supportive person. In fact, rational-emotive therapy encourages therapists to show their impatience with irrational beliefs that cannot be defended empirically or logically. Once clients are shown that many of their beliefs cause them misery and disappointment, they are asked todispute—silently, in their own minds—their irrational beliefs whenever they find the old habits taking over. It takes time to extinguish old habits; it doesn't happen overnight. Clients need patience and tenacity to oppose their old reflexes and replace them with rational, realistic beliefs.
An hour a week in rational-emotive therapy is really, then, like a tutorial session with a teacher. The client-students talk about their feelings; the therapist criticizes underlying irrational beliefs and makes it clear to the clients what a rational response would be. Then the clients are asked to practice applying rational beliefs on their own, outside of therapy. Gradually, a more rational way of looking at things takes the place of the old habits.
AN EXAMPLE
Joan Hendley is single, twenty-nine years old, and assistant manager of a bank. She has come to Dr. Kovac because of chronic depression, a sense of low self-worth, and feelings of insecurity and anxiety. Lately, she has begun to drink heavily and regularly feels the need to use sleeping tablets.
The following is a sample of their dialogue during their first session of rational-emotive therapy:
DR. K.: Well, what would you like to start on?
JOAN: It's hard to put it into words. I guess it's that I've been depressed a lot, abouteverything. I feel like there's no purpose to my life. I don't know where to go or how to decide.
DR. K.: So, right now you don't know where you're headed. What's so terrible about that? It would beniceif you knew, but you don't. Is thatawful?
JOAN: Yes, it is! Everybody should have a purpose!
DR. K.: Whyshouldthey? Most people go through life without much of a sense of purpose.
JOAN: Well, that's what I believe in.
DR. K.: Look, Joan, you appear to me to be an intelligent person. You and I can agree that it would be more satisfying for you to have a sense of direction, but you take thisone more step, and it's averybig step! You think it'sterriblethat you don't feel there's a purpose to your life right now. You think youshouldhave a purpose, and I suspect you're punishing yourself because you don't live up to thatshould.
JOAN: But most people believe in things like that.
DR. K.: And a lot of them end up feeling miserable! I know: I've seen dozens of people sitting where you are, and their thinking is chock-full ofoughts,shoulds, andmusts. And that's what makes them feel upset. They feel much better when they can come to say to themselves, "It would be nicer, or more pleasant, or better if things were different."
JOAN: You mean, if I can get rid ofshouldsandmustsin mythinking, I'd feel better?
DR. K.: That's exactly what I'm saying. If you were to follow what I've told you, you'd seldom be upset again, and probably never enough to get yourself really depressed.
JOAN: Uh-huh. I'm not sure I really see how that can be. I feel pretty stupid.
DR. K.: So here you go again! You think of yourself as a pretty bright person, and so you say to yourself, "I ought to be able to catch on to anything pretty fast." And now here you are, and you're not all that sure you've followed everything already, and so you tell yourself, "Oh my, I must be stupid."
JOAN: [Nods appreciatively, laughs.]
DR. K.: You don'thaveto upset yourself. You canchoosewhat you tell yourself, and then you'll have control over what youfeel. Tell me about your job. You're in the role of a leader, aren't you?
JOAN: Yes.
DR. K.: But you don't think you're doing a great job?
JOAN: No, I don't.
DR. K.: Buttheythink you're doing OK, isn't that correct?
JOAN: Yes, but my job seems to be taking more and more out of me. [Begins to cry.]
DR. K.: Well, it seems like you're doing your job OK; it's just that you, fromyourpoint of view, aren't perfect! Sothereforeit's all just empty pretense: you're just faking it! But, if you'll give up your nutty perfectionism, you'd be in the clear, because you're obviously satisfying people at work; you're satisfyingtheirexpectations. But since you feel bad about yourself, you say to yourself, "Well, they just haven't found me out! Whenthey do, I'm in for it." And so you live in a state of fear.
JOAN: That's it.
DR. K.: It's all because of your unreasonableexpectations. Can you see that?
JOAN: [At least temporarily convinced.] Yes, I think I can!
DR. K.: This is what I'd like to work on with you. It's going to take some self-discipline on your part, but together we can help you get rid of some mental habits that bring you unhappiness. They don't serve a useful purpose, and they drag you down. Why don't you tell me more specifically what upsets you at work?
APPLICATIONS OF RATIONAL-EMOTIVE THERAPY
Although rational-emotive therapy has been used to treat many different kinds of problems, Ellis admits that his approach is most effective for the treatment of clients with a single major symptom or clients who are only moderately disturbed. In addition, Ellis does advocate rational-emotive therapy for individuals whose patterns of irrational thought are severe, but for such individuals—when they can be helped—therapy is a long-term process.
From evaluative studies completed so far, it appears that rational-emotive therapy is especially effective in reducing anxieties resulting from such things as public speaking, relating to others on an individual basis, and facing old age. Other specific applications of rational-emotive therapy include these:
* problems of maladjustment, where you have increasing difficulty coping with either an already familiar environment or a situation new to you
* marital problems and sexual difficulties
* psychosomatic problems
* anxiety
* depression
* problems of criminals and delinquents
Individuals who are most effectively treated with forms of cognitive therapy tend to have one or more of these personal characteristics:
* They tend to think in very rigid ways.
* They are inclined to think in all-black, or all-white terms. They are absolutists who think in terms ofwhat is rightandwhat is wrong. Life, for them, is an uncompromising affair.
* They are often perfectionists about themselves, so they tend to have unrealistic expectations of others as well. They are idealistic.
* Their behavior is frequently uptight, intense, judgmental, and intolerantorshy, self-effacing, and inclined to self-condemnation.
* They tend to think that if there is one bad apple, the whole bushel must be rotten. They tend to magnify and exaggerate evils.
* They confuse what they would like to have with what they believe they absolutelyneed. They are demanding and exacting.
EXISTENTIAL-HUMANISTIC PSYCHOTHERAPYFor individuals who suffer from feelings ofacute loneliness and emptiness, who have lostfaith in themselves or others, and who tend tobe analytical and introverted.
There is no single, well-defined theory accepted by most existential therapists. Instead, existential psychotherapy is a point of view, a general philosophy that attempts to describe what it means to be human and to live meaningfully in the world.
There is, nevertheless, a consensus among existential therapists concerning the objectives of the approach. Existential therapy seeks to help clients achieve these goals:
* to accept and make constructive use of their own personalfreedom
* to becomeauthenticindividuals, shedding the conventions and conformities that obscure the real persons they are
* to establish human relationships based onhonestyandpersonal integrity
* to befully presentin the immediacy of the moment
* to learn toacceptthe natural limits of life
Existential therapy cannot be described in terms of a group of techniques commonly used by therapists. In fact, existential therapists are inclined to resist the formulation and application of specific techniques of therapy, believing that psychotherapy is essentially a human endeavor and that the drive to formulate techniques is basically a dehumanizing, objectifying interest.
To understand existential therapy, then, we ought not to expect to encounter a set of specific techniques. What really characterizes existential therapy are its self-consciously endorsed attitudes about life. They include these realizations:
* Anxiety frequently motivates individuals to change their lives. Anxiety often is present to tell you that you need to change; it is not necessarily a bad feeling from which no good will come.
* Eventually each of us will die, and clutching life anxiously will stand in the way of finding real meaning in living.
* Past events need not control what you feel and do now; you are free to change old, unsatisfying patterns.
* Guilt is often a sign that you have missed opportunities for personal growth: you have not been true to yourself and have "sinned against yourself" in some important way.
* If you are to become a mature and genuine person, you must discard theliesyou have cultivated. Among these is living the lie of tryingnot to bethe person you really are; another is the lie of trying to be a person you arenot, and there are many others.
* To be content within the limitations of life, it is vital that you have a sense of your own value. You become inauthentic if you base your sense of self-esteem on what others think of you.
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It is obvious thatindividual responsibilityis central to existential therapy. You are responsible for the person you choose to become. You may choose to be genuine, or you may choose to lie to yourself and others. It is when you abdicate responsibility for becoming authentic that you will often come to feel anxiety and a sense of guilt. Anxiety and guilt are often present, in otherwords, when there is a fundamental lack of congruence, of being whole, of being in accord with yourself.
The main contributors to existential psychotherapy have been the Swiss analysts Ludwig Binswanger (1881-1966) and Medard Boss (1903-1990), along with Rollo May (1909-1994), who was the founder of existential psychotherapy in America. Today, existential psychotherapy is practiced under a variety of names:humanistic psychology,experiential psychotherapy, and also in the context of the related approaches, logotherapy and reality therapy (see Chapter 11).
WHAT EXISTENTIAL THERAPY IS LIKE
Existential psychotherapy is usually individual therapy, with sessions commonly scheduled a few times a week, as in psychoanalysis. Existential therapy often shows its psychoanalytic origins: as in analysis, existential psychotherapy focuses largely on anxiety and the suppressed issues that anxiety veils. Existential therapists will push clients to confront anxiety directly; they will try to understand the clients' anxiety in relation to the lies that clients tell themselves in order to protect themselves from more anxiety.