As we have already seen, existential therapists very commonly regard anxiety and depression aspromisingsymptoms because they can shake clients out of unfulfilling patterns of living. Anxiety and depression, instead of being viewed as undesirable symptoms to be eliminated, can motivate people to change and grow. Consequently, existential therapists tend to disapprove of the use of drugs in therapy. If clients take pills to reduce anxiety, for example, they will reduce the awareness of motivating pain that, if faced squarely, may bring about a more meaningful, satisfying life.
Here is an example of the way an existential therapist forces a client to face issues head-on. What the therapist is thinking is in brackets.
CLIENT: I don't know why I stay with my job. It just makes me depressed. All I do is tell you the same things over and over. I'm not getting anywhere.
THERAPIST: [She is complaining because I'm not curing her. She has to do this herself.] To be frank, I'm impatient,too. We talk, but you're not able to act. [She has to see that I can't take responsibility for her procrastinating].
CLIENT: What do you think I ought to do? I can't keep living like this.
THERAPIST: [I can't make her decisions for her.] I can't tell you which way to go. I do know that you've been avoiding a decision. I believe you're going to take charge of your life but, until then, we may both feel impatient....Whatdoyou want to do? [She has to be pushed to make up her mind. She's ready now to decide but is understandably scared.]
CLIENT: I want to stop worrying, stop feeling so anxious and upset.
THERAPIST: [She'd like me to mother her.] Look, Diane, you've been coming to see me for three months now. You know what I think about feeling upset: if you're upset, there's something bothering you that you need to pay attention to. We both know you dislike your job and that you stay on mainly because you're afraid of a change. We can talk a long time about your unhappiness at work and about your fear of change, but eventually it will be time to stop talking and to try some alternatives. Do you think you're ready? I think you are.
CLIENT: (Sighs.) I guess you're right. I seem to be dragging my feet. If I want a satisfying job, I'm just going to have to try something else. Can we talk about some of my alternatives, then, and I'll try to stop complaining!
THERAPIST: [Now she's starting to face up to the challenge.]
APPLICATIONS OF EXISTENTIAL PSYCHOTHERAPY
These are some of the difficulties existential psychotherapy is designed to treat:
* feelings ofreal estrangement or alienationfrom others—from your immediate family and friends or from neighbors or colleagues at work
* a sense ofacute loneliness, of being cut off from humanity and from normal everyday activities and interactions
* an awareness that your life has become anempty patternof habit, that your activities or work no longer feel meaningful or valuable
* an inability toacceptthe realities that limit life; for example, anxiety experienced by older persons as they become more aware of the need to face the reality that life will end or anger and frustration experienced by individuals who must cope with real limitations—persons with physical impairments and chronic pain, individuals whose opportunities are limited by poverty, by their ties of responsibility to others, or by social disadvantage
Individuals who benefit most from existential psychotherapy tend to have these characteristics:
* They are reflective and analytical.
* They tend to be introverted.
* They havelost faith—in their sense of social commitment, in their identity and role within their families, in their belief that their work is of value, or in their religion.
11PSYCHOTHERAPY, PART IILogotherapy, Reality TherapyAdlerian Therapy,Emotional Flooding Therapies,Direct Decision Therapy
In this second chapter devoted to major approaches to psychotherapy, we will look at logotherapy, reality therapy, Adlerian therapy, the family of emotional flooding therapies, and direct decision therapy. Like the five psychotherapies described in Chapter 10, these focus special attention on a client's personal style of relating to the world and others. They all seek to help a person to free himself or herself from troubling feelings and negative attitudes and to replace these with a stronger and more confident self-concept. Each therapy is a different path to that goal.
LOGOTHERAPYFor reflective individuals who are sensitive tovalues and who are in search of a richer senseof meaning in life.
He who has awhyto live for can bear with almost anyhow.Friedrich Nietzsche
Viktor Frankl (1905-1997) is worthy of much respect and admiration. Out of three terrible years of suffering in a concentration camp, during which his mother, father, brother, and wife were taken from him, Dr. Frankl developed logotherapy (from the Greeklogos, roughly equivalent to "meaning"). Logotherapy is an approach to therapy that addresses our inherent need for meaning and value in living. The belief that sustained Dr. Frankl during this period of intense suffering was the conviction that people, in spite of great adversity, anguish, and the loss of all they hold dear, can remain free within themselves and are able to maintain, and even to strengthen, their sense of self-respect and integrity. To communicate how it is possible to do this became Dr. Frankl's lifework.
Logotherapy is a therapy of meaning for those who are unable to find a reason for living. It is a form of therapy related to existential analysis (see Chapter 10), but it is specific in its concern for helping clients find what it is that really matters to them, that makes hardships and pain worthwhile.
If Freudian psychoanalysis looks to the past for insight, logotherapy focuses instead on the future, on a person'slife task. In this, there is no abstract and general answer to the question "What is the meaning of life?"
For the meaning of life differs from man to man, from day to day and from hour to hour. What matters, therefore, is not the meaning of life in general but rather the specific meaning of a person's life at a given moment. To put the question in general terms would be comparable to the question posed to a chess master, "Tell me, Master, what is the best move in the world?" There simply is no such thing as the best or even a good move apart from a particular situation in a game and the particular personality of one's opponent. The same holds for human existence.... Everyone has his own specific vocation or mission in life; everyone must carry out a concrete assignment that demands fulfillment.... Ultimately, a man should not ask what the meaning of life is, but rather must recognize that it is he who is asked. In a word, each man is questioned by life; and he can only answer to life byanswering forhis own life; to life he can only respond by being responsible.[1]
[1] Viktor E. Frankl,Man's Search for Meaning: An Introduction to Logotherapy(New York: Washington Square Press, 1963), pp. 170-171.
Dr. Frankl liked to compare logotherapy to the role of the eye specialist: the logotherapist's role is to help the patient see more clearly the range of lived values and meaning available to him.
WHAT LOGOTHERAPY IS LIKE
An elderly physician came to Viktor Frankl to ask for help with severe depression. His wife, whom he loved above all else, had died two years before. His sense of loss would not heal. Could Dr. Frankl help him?
Dr. Frankl responded with a question: "What would have happened, Doctor, if you had died first, and your wife had had to survive you?"
"Oh," he said, "for her this would have been terrible; how she would have suffered!"
"You see, Doctor, such a suffering has been spared her, and it is you who have spared her this suffering; but now, you have to pay for it by surviving and mourning her."
The physician said nothing, but rose to his feet, shook Dr. Frankl's hand, and calmly left his office. "Suffering ceases to be suffering in some way at the moment it finds a meaning, such as the meaning of sacrifice."[2] It is the basic concern of logotherapy to help patients see the meaning in their lives.
[2] Frankl,Man's Search for Meaning, pp. 178-179.
Logotherapy is known for two techniques endorsed by Viktor Frankl. He called themdereflectionandparadoxical intention.
Many emotional problems have their roots in what psychotherapists callanticipatory anxiety: a woman who is afraid of blushing when she enters a room filled with people will tend to blush. A man who fears impotence and who tries to achieve an erection will often fail. A woman who willfully tries to achieve orgasm also will frequently fail. These are examples of excessive, or hyper-, reflection. Excessive, anxious attention is paid to what we fear or wish, bringing about the very thing we are trying to avoid.
Frankl developed specific ways of refocusing or rechanneling this excessive attention.Dereflectioncould take the form, for example, of persuading the blushing woman to concentrate on particular things when she enters a crowded room: to look for acquaintances, to admire what someone may be wearing, or tolook for objects in the room to appreciate, for example. In the case of impotence or frigidity, often a shift of attention from yourself to your partner's pleasure will eliminate anticipatory anxiety.
Frankl describes an attempt to help a bookkeeper who was in real despair and close to suicide. For several years he had suffered from writer's cramp: very real muscular cramps that reduced his legible script to an illegible scrawl. He was in danger of losing his job.
He was treated withparadoxical intention. He was asked to write in an intentionally illegible scrawl. But he found that when he deliberately tried to scrawl, he could not. Within two days, his writer's cramp had vanished. Similar approaches have been very effective—and long-lasting—in certain cases of severe stuttering, uncontrolled shaking, washing compulsions, insomnia, sexual difficulties, and other problems.
Logotherapists tend to be warm, accepting individuals. They will often use humor. Yet they are trained to confront individuals: to push their clients to face their inner feelings of futility and despair, and then, out of their often overlooked and underestimated inner resources and moral strength, towillthat their lives become meaningful. Logotherapists try to encourage clients to see more clearly what it is that gives them a sense of value in living and to use what they see to direct themselves toward more satisfying and personally fulfilling lives.
APPLICATIONS OF LOGOTHERAPY
As we have already observed, logotherapy has been used to treat a wide range of individual problems involving a loss of faith in the value of living, behavior that no longer is under voluntary control, or behavior that frustrates your desires.
Logotherapy is especially well-suited to helping individuals withnoögenic neuroses, Frankl's term for personal problems that have their basis in conflicts between opposing values. Noögenic (from the Greeknous, meaning "spirit" or "mind") neuroses have their origin in personal moral or spiritual, but not necessarily religious, conflicts. They lead to a feeling of existential frustration: a person's will to find meaning is blocked. When sufficient pressure is built up, anxiety and depression can follow. You can imagine how pressure might build up in the inner livesof a business executive who wishes she had a family instead of a career identity, a university professor who yearns to be an independent artist, or a financially successful businessman who despises his own pretenses and opportunism.
I asked the poor creatures who listened to me attentively in the darkness of the hut to face up to the seriousness of our position. They must not lose hope but should keep their courage in the certainty that the hopelessness of our struggle did not detract from its dignity and meaning. I said that someone looks down on each of us in difficult hours—a friend, a wife, somebody alive or dead, or a God—and he would not expect us to disappoint him. He would hope to find us suffering proudly—not miserably.[3]
[3] Frankl,Man's Search for Meaning, p. 132.
REALITY THERAPYFor persons able to make a commitment to aplan for life improvement, whether they haveemotional or behavioral problems or simplywant to develop a success-identity.
... [U]nhappiness is the result and not the cause of irresponsibility.William Glasser,Reality Therapy
Reality therapy was developed in the 1950s by psychiatrist William Glasser (1925-2013). His approach to therapy evolved as a result of his work with delinquent teenage girls, with clients in private practice, and with severely troubled patients in a VA hospital.
Reality therapy, as the name implies, attempts to help by strengthening a person's practical understanding of reality and by encouraging concrete planning that will bring about an improved sense of personal adjustment to reality. It emphasizes a very practical, feet-on-the-ground focus on the present: a person's past experience cannot be rewritten. Reality therapists do not believe in the essential value of psychoanalytic interpretation, dream analysis, nondirective counseling, or intellectualinsight. A reality therapist focuses on the present, specifically on attempts patients may now be making to become more successfulfrom their own points of view. If a patient is not able to make definite plans of this kind and cannot sustain a commitment to them, the focus of reality therapy will be to encourage the patient to begin to do this. It is an approach that believes that a strong sense of personal identity can come only fromdoing: if an individual is able to develop a degree of self-responsibility that is solid and enterprising, a feeling of personal success and effectiveness will follow.
Reality therapists are opposed to making diagnoses. A diagnostic label frequently adds a burden to individuals who are already burdened by emotional, family, or adjustment problems. Glasser notes, for example, that being labeled a schizophrenic "can be worse than the disease as far as incapacitating one in the course of life's activities."[4]
[4] William Glasser and Leonard M. Zunin, "Reality Therapy," in Raymond J. Corsini, ed.,Current Psychotherapies(Itasca, IL: F. E. Peacock Publishers, 1979), p. 329.
Reality therapists can resist diagnosing and labeling their clients because their approach claims that personal psychological difficulties, except those due to physical illness (see Chapter 8), result from a lack of personal discipline and responsibility. People are often caught in the habit of blaming their failures on their families, their lack of opportunity, their race, poverty, and other outside forces. It is a habit with a dead end: it ignores the potential success that can come from initiative motivated by responsibility and moral courage. As Ernest Hemingway said when asked if he ever anticipated failure, "If you anticipate failure, you'll have it."
THE EXPERIENCE OF REALITY THERAPY
It isn't hard to gain a feeling for what reality therapy is like. These are the basic principles of the approach:
The relationship between therapist and client must be personal. The therapist tries to make clear that he is a genuine person who has, in some areas of his life, been able to plan effectively and to develop a sense of personal success.
The focus of individual sessions is on what the clientdoes, not on what he or she mayfeel. Behavior can be changed much moredirectly than feelings, and feelings soon fall into place once behavior is more satisfying. What is important is for the client to develop intelligent plans and then to work to carry them through. If certain goals are not realized, the therapist's concern is to encourage the client to take the next practical step, rather than to spend time and energy analyzing what went wrong.
The reality therapist accepts that the first steps are often halting ones. It is important not to be disconcerted by occasional stumbling and a few falls. What is essential is a commitment to self-discipline and progress, refusing to punish yourself when a plan may not succeed, but going beyond it with a positive attitude that eventually can become a habit.
Glasser gives this illustration of the persistent refocusing on practical issues that characterizes reality therapy: a teenage girl expresses to her therapist that she would like to look for a job. The therapist does not respond, "Good, let me know how it works out," but instead begins the following exchange.[5]
THERAPIST: What day next week?GIRL: I don't know. I thought Monday or Tuesday.THERAPIST: Which day? Monday or Tuesday?GIRL: Well, I guess Tuesday.THERAPIST: You guess, or will it be Tuesday?GIRL: Tuesday.THERAPIST: What time Tuesday?GIRL: Well, sometime in the morning.THERAPIST: What time in the morning?GIRL: Oh, well, 9:30.THERAPIST: Fine, that is a good time to begin looking for a job.What do you plan to wear?
[5] Glasser and Zunin, "Reality Therapy,"Current Psychotherapies, p. 324.
In another example of reality therapy, a patient says, "I feel depressed and miserable." Instead of responding, "How long have you felt this way?" or "What have you been feeling depressed about?," a reality therapist might ask, "What have you been doing that continues to make you depressed?" or "Why aren't you evenmoredepressed?" With both of these responses, the therapist makes it clear that he believes the client can influence his or her feelings.
Often therapists, no matter what their approach, will say toclients who are going through a difficult time that they may phone after hours if there is an emergency. A reality therapist may, in addition, also say, "I hope you'll call me if you have had a special success."
APPLICATIONS OF REALITY THERAPY
Reality therapy has been used in connection with these types of problems:
* individual problems involving anxiety, marital conflicts, maladjustment, and some psychoses where a person is comparatively out of touch with reality and may have hallucinations or delusions
* teenage delinquency
* difficulties faced by women who have recently been widowed
* designing school programs that stress the development of individual identity based on a sense of personal success
Reality therapists believe that their approach is of value to people who want to develop a more successful pattern of living, of managing their own affairs, and of coping effectively with challenges at work and with problems of everyday living. Reality therapy has also been used in industry with organizational problems and with difficulties experienced by individual employees.
Reality therapy is not useful in treating problems in which there is severe withdrawal (as in autism) or cases involving serious mental retardation. To be effective, reality therapy presupposes that clients are able to communicate and are both willing and able to cultivate habits of self-discipline and personal responsibility.
ADLERIAN PSYCHOTHERAPYFor individuals interested in personal growth,especially in social directions, and for personswith low self-esteem who feel blocked anddiscouraged about life.
The greatest principle of living is to love one's neighbor as oneself.Rabbi Akiva, writing 2,000 years ago
Alfred Adler (1870-1937) was a contemporary of Freud. Early in his career, Adler was invited by Freud to participate in his special circle of professionals interested in the development of psychoanalysis. Adler's already formulated views were not in accord with Freud's, their differences became more pronounced, and Adler eventually separated himself from psychoanalysis. Freud was embittered and became a lifelong enemy of Adler.
In contrast to Freud's technical and abstract theory, Adler's is humanistic, open, and concrete. Where Freudian analysis believes that emotional disturbances have a sexual basis, Adlerian therapy claims that neurosis comes about through distorted perceptions and from habits and attitudes that arelearned. In Adler's system ofindividual psychology, there is no concern for unconscious processes or for internal divisions of the self into id, superego, and ego. Adlerians stress that a person forms a unity and must be treated as a whole.
Adler's approach to psychotherapy is based on the view that feelings of inferiority are normal. They exist in children, and they continue to be present in adults who may feel weak psychologically, socially, or because of physical limitations. To compensate for feelings of inferiority, adults strive for superiority by dealing effectively with the world, or they become deeply discouraged (however, they are not considered to be "sick") and lose contact with positive, constructive activities.
Adler also postulated that emotional difficulties come about when you are convinced that you simply cannot solve the problems of life in a way that is compatible with a need to be superior in some way. Certain attempts to compensate for feelings of inferiority can lead to emotional problems later. They include seeking a feeling of superiority by requiring attention from others, striving for power over others, taking revenge, and giving up—declaring that you cannot cope because of personal deficiencies and weakness. Children from families where there is distrust, domination, abuse, or neglect tend to choose these paths.
Another facet of Adler's approach is that individuals whocannot compensate for feelings of inferiority are inclined to make a number of "basic mistakes" in perceiving the world. They will overgeneralize ("Nobody cares about me."), depreciate their worth ("I'm just a housewife."), set unrealistic goals ("I should please everyone."), distort ("You have to lie to get ahead."), and hold faulty values ("Win, even if you have to climb over others.").
Finally, Adler felt that, over the course of their lives, many people strengthen these basic mistakes while in pursuit of the ultimately unsatisfying desires for attention, power, revenge, or escape. Their styles of living may lead to depression, chronic anxiety, crime, alcoholism, drug abuse, and other problems.
WHAT ADLERIAN THERAPY IS LIKE
Adlerian therapists try to help people change unfulfilling patterns of living in several ways.
First, and perhaps most important, is the belief that therapy should do more than help clients with immediate problems. It should help them develop an adequate philosophy of life, encourage them to cultivate an approach to living that is self-sustaining, positive, and inherentlysocialin focus. The paradox of inferiority and low self-esteem is that the suffering they cause disappears once people can forget themselves and begin living to some extent for others. Adler would remind his clients to "consider from time to time how you can give another person pleasure."[6] Adlerian therapy stresses the importance of social goals. For Adler, we are foremost social creatures; our individual identities can be developed and our problems resolved only in a social context.
[6] Alfred Adler,Problems of Neurosis(New York: Harper and Row, 1964), p. 101.
Since Adler believed that most emotional difficulties we experience result from feelings of inferiority that have led to discouragement, the second goal of Adlerian therapists is to offerencouragement. They are as much concerned with mirroring clients' strengths as they are with analyzing their problems. Adlerian therapists will devote a good deal of attention to identifying and encouraging the personal assets of each client.
Adler suggested several techniques that have also come to be used by other schools of psychotherapy:
Acting "As If"
Frequently, clients express a wish to begin acting in new ways—to be more assertive, to make an effort to break out of confining patterns of living, to conquer certain fears. However, they usually feel that the new behaviors are phony, so they are reluctant to try. Adler suggested that clients try a new behavior for the next week only as they would try on new clothing: they need only actas if. Adler found that, as clients began to act differently, they would begin to feel differently. When their feelings were positive, they tended to make new ways of behaving part of themselves. (Behavior modification, described in the next chapter, builds on this idea.)
Paradoxical Intention
We encountered this technique, also callednegative practice, in the preceding section on logotherapy. It can be a very effective technique when certain habits can no longer be controlled. If you suffered from insomnia, you would be asked to focus your attention on staying awake: to put an end to the habit, you would be asked to amplify it. Oddly enough, in many cases, this judo-like dropping of resistance and redirection of attention can bring involuntary behavior back under control.
The Push-Button Technique
Many of us have unpleasant thoughts and emotions that refuse to leave us. We find ourselves on familiar tracks that we know lead to sadness, regret, anger, panic, or frustration. But we can't seem to subdue what Zen calls "these chattering monkeys of the mind." Adler taught clients that theycouldcreate whatever feelings in themselves they wished, simply by deciding what to think. It is possible, with some practice, to imagine a happy or peaceful memory or scene and to direct your attention to it when negative thoughts try to dominate. We all have this push button available. Like all exercises in self-discipline, it strengthens us the more we use it. (Cognitive therapy, discussed in Chapter 10, is especially concerned with this influence of thoughts on emotions.)
SETTINGS FOR THERAPY
Adlerians use a variety of settings for therapy. Individualtherapy is common, but sometimes two therapists may work together with one client, an approach that gives clients an experience of cooperation between professionals who may perceive them differently. Adlerian workshops are popular with parents concerned with problems in rearing children. Other workshops exist for married couples. Adlerians have often been innovative: Rudolf Dreikurs, a well-known student of Adler, was, for example, one of the first therapists to use group therapy in private practice.
APPLICATIONS OF ADLERIAN PSYCHOTHERAPY
Because Adler did not view human problems as forms of sickness, Adlerians see emotional and behavioral difficulties as blocks that people encounter in their attempts to realize themselves. Many of the problems Adlerian therapists treat are therefore considered to benormalproblems of living faced bynormalpeople. Many clients enter therapy to learn about themselves and to grow.
Adlerians have worked with a wide range of clients with a wide range of human problems:
* clients interested in personal development
* individuals who have become deeply discouraged about their lives
* couples and families
* delinquents and criminals
EMOTIONAL FLOODING THERAPIES
Today there are three main varieties of emotional flooding therapies: bioenergetics, primal therapy, and implosive therapy. They share the central belief that, by taxing you, pushing you to experience frustration, anger, or anxiety, the therapist may help you achieve a lasting sense of emotional relief and well-being.
These three therapies do, however, vary a good deal in the techniques they use to encourage clients to experience strong emotions. Bioenergetics makes use of an unusual approach to physical exercise. Primal therapy encourages clients to relive early painful memories. Implosive therapy asks clients to use imagery to increase, in a controlled manner, feelings that cause emotional distress. These approaches share the assumption thatemotional difficulties can be helped by a direct release of feelings that have come to be blocked.
BIOENERGETICSFor rigid, inhibited people who have pent-upfeelings in need of release.
Alexander Lowen (1910-2008) was trained as a physician and then as a psychoanalyst under the direction of Austrian psychoanalyst Wilhelm Reich (1897-1957). Reich believed that emotional problems resulted from sexual repression. He was a social revolutionary in his attempts to bring about sexual freedom. He became a controversial figure and was not able to put his ideas on a serious and professionally respectable footing.
Lowen was interested in the therapeutic implications of Reich's work. He developed an approach to therapy that emphasizes not sexual liberation and pleasure as Reich did, but a sense of freedom that he felt could result only from an approach to the body that allows you to drop tense muscular armor and to feel integrated and fully alive. Lowen found that emotionally troubled people were physically knotted and rigid and tended to breathe in a shallow and constricted way.
Lowen devised a variety of physical exercises, such as holding your body in an arched position until exhaustion sets in, making contact with the floor only with hands, head, and feet. These exercises can cause enough stress to arouse intense emotions: crying out, collapsing, feeling rage or tenderness. As these pent-up feelings are released, many clients often discover an increase in positive emotional strength.
Bioenergetic therapists offer individual therapy as well as workshops. They tend to act as teachers, pointing out very bluntly how a client's physical rigidities reflect rigid qualities of personality: "Your chest muscles are this tense because you have been defending yourself so long, like a boxer," or "Your jaw muscles ache because you've been biting back angry impulses."
Because of its physical approach to human emotions, bioenergetics is sometimes regarded as the West's therapeutic version of yoga. (For a discussion of yoga, see Chapter 15.)
Applications of Bioenergetics
Bioenergetics appears to be most useful for people with any of these characteristics:
* Their feelings are markedly inhibited, or they feel deadened emotionally.
* They feel impaired sexually or do not experience orgasm for nonphysical reasons.
* They are rigid, uptight, and inclined to be obsessive perfectionists.
* They have pent-up feelings of anger, hostility, or grief that are in need of an outlet.
Bioenergetics is not the treatment of choice when deeper insight and self-knowledge are important. Bioenergetic therapists are not in general especially concerned with a client's personal history, family and work environment, or specific adaptation problems.
PRIMAL THERAPYFor individuals who continue to suffer fromchildhood pain.
Arthur Janov (1924- ) was psychoanalytically trained as a clinical psychologist and psychiatric social worker. He had been practicing for seventeen years when a shy and withdrawn client in a group therapy session let out a piercing, primitive scream. The inhibited client experienced a sense of release and insight. This event fascinated Janov and eventually transformed his professional perspective.
He developed an approach to therapy that encourages patients to re-experience repressed painful memories from childhood. Janov calls theseprimalpains: they come about when a child's emotional needs repeatedly are not met. The inner suffering that results is suppressed; the pain cannot be dissipated. It takes energy to continue to block out painful feelings. The constant expenditure of energy then shows up in conscious tension. Janov came to believe that emotional problems in adults stem fromtheir unwillingness to experience feelings that a child would find crushing but—though painful—can now be faced. When primal pain is faced, Janov claims, individuals gain a degree of freedom and maturity they could not otherwise achieve.
Janov's primal therapy is best known for the "primal scream" we mentioned above that some patients let out when they confront the pain they have suppressed for so long. Primal therapy encourages a repeated cathartic release of pent-up feelings. During the first three critical weeks of therapy (which normally cost in excess of $2,000), the primal therapist is on call twenty-four hours a day for a single patient. The patient is isolated for the first week in a hotel room, without TV, cigarettes, alcohol, sex, or companionship, and has daily therapy sessions with the therapist that last from two to three-and-a-half hours. Patients then spend six to twelve months in a primal therapy group.
Janov has been criticized for his apparent desire for public charisma and for capitalizing on advertising hype. He tends not to reveal in writing details of his procedures in therapy and will share his professional secrets only with initiates at his primal therapy institute. Comparatively few therapists have had this special training. However, many therapists offer what they claim is the equivalent of primal therapy, which they callintensive feeling therapy. They have the same format for therapy: isolation in a hotel room, three weeks' exclusive attention to each client, and the resulting high fees.
Applications of Primal Therapy
Primal therapy has been used to treat these problems:
* chronic depression and anxiety
* compulsions
* phobias
* drug addiction
* problems of homosexuals
* marital problems
Like bioenergetics, primal therapy is best suited for individuals who have repressed or pent-up feelings they have not found ways to release.
It is important to bear in mind that primal therapy is initially one of the most expensive therapies, since it devotes exclusive attention to each client at the beginning of therapy. It may not be the therapy of choice for more verbal, intellectual clients who want to develop an understanding of themselves beyond an experience of catharsis.
IMPLOSIVE THERAPYFor people with phobias.
This emotional flooding therapy was developed by Thomas Stampfl (1923- ). Stampfl was trained as a clinical psychologist at Loyola of Chicago and was influenced by both psychoanalysis and the psychology of learning. Early in his career, he became convinced that clients with phobias tend to reinforce their fears by automatically avoiding what they fear. He developed an approach to help people face the situations, feelings, or memories they most fear.
Stampfl's approach is most easily understood in the light of recent experimental work on animal avoidance behavior. A dog, for example, is confined in a cage that is divided in two. A low wall separates the two halves of the cage, over which the dog can jump. On one side there is a bell that rings just before the dog receives an electric shock. The dog promptly learns that he can avoid the shock by jumping to the other side of the cage. Soon he will learn to do this automatically, whenever the bell rings. What is significant from a psychologist's point of view is that the dog will continue for a long time to jump to the opposite side of the cage, even once no further shocks are given. The dog's fear is maintained in force only by his own memory.
Animal psychologists have found a quick way to end the dog's fear: ring the bell, butpreventthe dog from jumping to the other side of the cage. Once the anxiety-stricken animal realizes that he is no longer going to be shocked, the old habit based on fear simply disappears.
Implosive therapists make use of an equivalent technique with human beings. Patients are asked to imagine, as vividly aspossible, that they are facing the very thing they chronically have tried to avoid. For example, an individual may have suffered from a terrifying fear of elevators for years. The therapist tries to use exaggerated imagery to produce maximum anxiety. He might ask the patient to imagine being stuck in an elevator fifty floors up, having the elevator shake and abruptly fall a foot, then have the lights go out, and so on. Bymaintainingthis contrived elevator nightmare long enough, implosive therapists claim that, frequently, the level of anxiety of patients quickly and dramatically falls, and they lose their exaggerated fears.
Implosive therapists are therefore not primarily concerned with being genuine, sympathetic, or mothering. They focus their energy and attention on pushing clients to confront the worst fears and catastrophes they can imagine. All the while, clients are aware both that the intense anxiety they experience is anintendedgoal of therapy and that the therapist is convinced they are much stronger than they have thought.
Implosive therapy is usually done on an individual basis and is comparatively brief, usually lasting less than a dozen sessions. It should be mentioned that, when not successful, implosive therapy may occasionallysensitizeclients to feel even more anxiety than they did at the outset. It therefore tends to be a higher-risk treatment, but it can be remarkably effective. Visualizing anxiety-producing events also has successfully been used by individuals on their own. (For more information, see "Appendix B: Suggestions for Further Reading.")
Applications of Implosive Therapy
Implosive therapy is especially appropriate for the treatment of phobic individuals who characteristically tend to avoid certain kinds of behavior, situations, or objects because of the severe anxiety and agitation these produce in them. Implosive therapy, when effective, can be dramatically effective in a comparatively short time. However, less arduous approaches to therapy can often be as effective and may involve less risk of increasing a client's existing anxiety. Alternative short-term therapies especially well-suited to the treatment of phobias include behavior modification (Chapter 12), Gestalt therapy (Chapter 10), reality therapy (earlier in this chapter), primaltherapy (earlier in this chapter), and biofeedback, relaxation training, and hypnosis (Chapter 15).
DIRECT DECISION THERAPYFor individuals capable of exercisingdetermination and self-discipline whoearnestly desire to change.
[I]f there's one thing my experience as a psychotherapist has taught me, it is that no one has to be a victim. However important external factors like health, physical appearance, and upbringing may be, they don't have to determine the happiness quotient in anyone's life story. The way we experience our lives is, quite simply, up to us.Harold Greenwald,The Happy Person
At the time of this writing, the majority of academic and research psychologists regard themselves basically as Freudians. Yet most psychiatrists, psychotherapists, social workers, and counselors have moved beyond Freud's formal categories and made use of their own common sense and interpretive abilities. Harold Greenwald's emphasis on the central role ofchoicein making fundamental life decisions implicitly represents the approach of a great many therapists and counselors today. His conception of therapy is casual, simple, and often good-humored.
Greenwald (1910-2011) was originally trained as a psychoanalyst. As Greenwald gained professional experience, however, his perspective began to change. He gradually came to believe that many patients had, at some critical moment, made adecisionto "go crazy." There was a point when they could exercise control, and at that moment, they chose to be depressed or anxious, to withdraw completely into catatonia, to become schizophrenic, alcoholic, or whatever their decision might be.
I discovered in working with people who have had psychotic breaks ... that most of them described a particular moment when there was a choice of whether to stay in control or let go.... You will find, again and again, if you speak to patients who have broken down, and if you search for it, that there is alwaysa point at which they had a choice, and it is at that point that they still have the possibility of controlling themselves. If they have confidence in their ability to control themselves they can exercise it.[7]
[7] Harold Greenwald, "Treatment of the Psychopath," in Raymond J. Corsini, ed.,Readings in Current Personality Theory(Itasca, IL: F. E. Peacock Publishers, 1978), p. 355.
Thischoice pointthat people experience became the focus of Dr. Greenwald's direct decision therapy.
AN EXAMPLE
Here is one of the most dramatic examples of his approach: Dr. Greenwald had been invited to give a demonstration of direct decision therapy at a mental hospital in Norway. He asked for a volunteer from the inmates, someone who could speak English. A twenty-year-old patient named Marie came forward. She had the appearance of a back ward schizophrenic. She was haggard, wild-eyed, and unkempt. Here is Dr. Greenwald's description of their opening conversation:[8]
[8] Harold Greenwald and Elizabeth Rich, The Happy Person (New York: Stein and Day, 1984), pp. 180-181.
I gestured toward a chair. "Won't you sit down, please?"
"When I'm ready. I'll sit when I'm ready."
"Would you tell me your name?"
She waved an arm toward the staff member seated behind me. "You heard him. Marie, my name is MARIE!"
"I'm sorry, Marie, I didn't catch it at first. Now I wonder if there is anything I can do for you. Would you like me to help you?"
"You can't help me, none of you can help me. Why don't youleave me alone? WHY ARE YOU ALWAYS AT ME?..."
She rushed on, shouting at the top of her voice and using a mixture of expletives and obscenities that showed an admirable command of English as well as Norwegian.
Nothing I could do could make the situation worse, so I decided to try something drastic. I outshouted her.
"CUT IT OUT, MARIE! YOU KNOW YOU DON'T HAVE TO TALK LIKE THAT."
She stopped suddenly and focused on me for the first time. The muscles in her face relaxed ever so slightly, and her eyesshowed awareness and intelligence.
"How'd you know?"
I stared at her for a minute, giving her my best foxy-grandpa look. "It takes one to know one," I said finally—at which point Marie's face broke into a grin.
"You meanyou'recrazy? You too?"
"Perhaps. And perhaps the only difference between you and me is that I know how to act sane."
Marie seemed to like the sound of that. She tightened the sash of her bathrobe and sat down.
As Marie calmed down, she agreed that she would like Dr. Greenwald to help her. She wanted badly to leave the institution.
DR. G.: If you really want to get out, Marie, you'll have to make a very simple decision.
MARIE: What's that?
DR. G: Decide to act sane.
Dr. Greenwald asked her to think of the benefits, the payoffs, that came to her as a result of her crazy behavior. There were a number of major payoffs: she didn't have to look after herself, didn't have to look for a job, didn't have to listen to her mother.
The upshot was that Marie decided to give up being crazy and to return to everyday living. It would have been easy for Dr. Greenwald to conclude that she had been faking all the years she was in the mental institution. But she had not been play-acting. Yet her illness began through achoiceshe had made, and it ended the same way.
Leaving the hospital world was not easy for her. In fact, it was often very difficult. But she stayed with her decision and often had to reaffirm it. She married and had a child. She wrote to Dr. Greenwald:
I found myself beginning to drift off, drift out of my life, the way I used to. And—I didn't! I decided to be the kind of person, the kind of wife and mother, that I want to be. Not perfect, just what's possible. And if I drift off, I won't be able to hear my daughter, I'll be just like my mother was with me.
Marie went back to school and earned a degree in psychology. After her experience, she was, she felt (as did Dr. Greenwald), ina special position to be helpful to other people in suffering.
WHAT DIRECT DECISION THERAPY IS LIKE
On your own or with professional help, the truth about you—whoever you are—is that you carry within yourself the resources to heal your most grievous pains, overcome your most paralyzing fears, devise ingenious solutions to your most burdensome problems.Harold Greenwald,The Happy Person
During the first session with a client, Dr. Greenwald often says something like, "Do you want me to concentrate on your problems, or would you like us to work together in making you happy?" Immediately, he suggests to clients that in fact they are able to change and become happier.
Dr. Greenwald describes seven phases that direct decision therapy involves:
1. Decide what you want in order to be happy (or happier).
2. Find the decision behind the problem: what has your implicit decision been in your life that has established an unhappy, or less happy, pattern? Greenwald calls theselife decisions: they form the center around which you organize your life. They are responsible for your attitudes, perceptions, what you value most, and your behavior.
If your life decision is to suffer, you will interpret everything that happens to you as more suffering-to-be-endured. If you are praised, you may question whether the praise has an ulterior motive. "Sufferers ... have the ability to snatch disaster from every victory."[9]
3. When was the original decision made? Did your life decision come from your upbringing? Did you inherit it from your parents?
4. Identify the payoffs for the decision. Even extreme unhappiness—chronic clinical depression—can have real payoffs: release you from responsibilities, gain you attention from others, allow you to return to the comfort of childhood dependency, etc. Anxiety can give you good reasons fordisqualifying yourself from stressful situations and reinforce your belief that you cannot cope.
5. What are your alternatives to the behavior that is causing a problem? It is often hard to see that you arenotreally trapped in a state of unhappiness. There are always alternatives.
6. Choose your alternative and put it into practice. Trust yourself. "[H]appy people have a sense that whatever happens, things will eventually work out. In short, they trust themselves to react in their own best interest."[10]
7. Support yourself in carrying out your decision. Habits die slowly. You must be patient. Your decision has to be made over and over again, just as an overweight person who loves food must decide again and again to say "No" to this dessert today, the baked potato tomorrow. Gradually, the strength of your decision builds asyoubuild strength into it.
[9] Greenwald and Rich,The Happy Person, p. 29.
[10] Greenwald and Rich,The Happy Person, p. 29.
APPLICATIONS OF DIRECT DECISION THERAPY
As we have seen, direct decision therapy is based on the assumption that you areableto begin to exercise self-discipline and that you arewillingto give up the real payoffs that being emotionally troubled frequently does achieve.
These interrelated things—ability and willingness to change—simply are not present in many people who enter therapy. They come to therapy for a variety of other, often unconscious, reasons: for temporary comforting, for escape from an upsetting situation or environment, or for a chance to release painful feelings and to express painful thoughts. Clients come in order to procrastinate; they come to prove to themselves that they simplycan'tchange and that the therapist just isn't good enough. They come out of anger, frustration, despair. But comparatively few enter therapy because they really are persuaded theycanchange and are committed to bringing change about.
These people are unquestionably the most promising candidates foranyapproach to psychotherapy. Clients who come to therapy for other reasons make up the daily challenge and the daily frustration, concern, worry, and hope of the therapist. The therapist believes that, in time, and with proper treatment,people who are imprisoned within walls of their own habits can rally the determination and faith to tear them down and to gain a measure of personal freedom.
In this author's judgment, direct decision therapy, perhaps more than any other approach, relies on a client's determination and perseverance. If these personality qualities are there, or if they can successfully be encouraged by a good therapist, the approach can be effective with a very wide range of problems.
[W]hat ... many ... patients proved to me is that, given the choice to be happy, many unhappy people are able to decide that happiness is what they want. Then ... they develop the ability to experience their problems in a different way.[11]
[11] Greenwald and Rich,The Happy Person, p. 53.
12BEHAVIORALPSYCHOTHERAPYFor people who want prompt relieffrom specific symptoms and who havethe incentive and discipline to practicenew patterns of behavior.
[M]uch of our suffering is just so obscure ... frigidity, social anxiety, isolation, boredom, dissatisfaction with life—in all such states we may see no correlation between the inner feeling and the way we live, yet no such feeling can be independent of behavior; and if only we find connections we may begin to see how a change in the way we live will make for a change in the way we feel.Alan Wheelis,The Desert
Many of us today feel forced to adapt to ways of living that will lead to unhappiness, loneliness, fear, and illness. Is unlocking all five bolts on one's apartment door in the morning, checking that the can of Mace is in your purse, joining the sidewalk crowd to the subway, hoping you are not mugged (or worse), and then spending the daylight hours in a windowless office, in an atmosphere of tension, pressure, competitiveness, and cigarettesmoke, with time out for caffeine (or, again, worse) and then a lunch soaked in alcohol a desirable and healthy way to live?
Behavioral psychotherapy seems to have been developed to respond especially to present needs.
Clients usually respond ... with a great sense of relief on finding they are not seen as sick or weak; they appreciate the positive orientation toward changing the problematic situation rather than dwelling on it.[1]
[1] Dianne L. Chambless and Alan J. Goldstein, "Behavioral Psychotherapy," in Raymond J. Corsini, ed.,Current Psychotherapies(Itasca, Il.: F. E. Peacock Publishers, 1979), p. 234.
Behavioral psychotherapy is best known for focusing on symptoms as its main target, rather than viewing symptoms as signs of underlying problems. Like most generalities, this one has its exceptions; some behavioral psychotherapists are very much concerned with understanding the underlying causes of an individual's difficulties. Nevertheless, behavioral therapies do tend to aim for concrete, specific, and prompt relief of symptoms. They frequently are effective, and they are based on techniques that have been tested extensively.
THE THREE SCHOOLS
Today there are three main schools of behavioral psychotherapy:
COUNTER-CONDITIONING
Also calledreciprocal inhibition, this approach was developed by Joseph Wolpe (1915-1997), a Jewish psychiatrist trained in South Africa. Anxiety is offset by means of desensitization, assertiveness training, and sex therapy. As the basis for desensitization, deep relaxation is used to inhibit anxiety. Assertiveness training is used to counteract anxiety due to excessive shyness or aggressiveness by helping individuals form balanced habits of assertiveness that are neither submissive nor hostile. Sex therapy makes use of techniques of relaxation and desensitization to permit clients to feel sexual arousal and, in this way, to overcome sexual anxiety.
BEHAVIOR MODIFICATION
This approach was derived from the work of American behaviorist B. F. Skinner (1904-1990) and others, who attempted to show that a great many emotional problems result from situations in which a person has been punished. He or she comes to fear these situations and develops emotional symptoms in an effort to escape from them. In behavior modification, attempts are made to change behavior through the use of rewards or punishments.
COGNITIVE APPROACHES TO BEHAVIOR CHANGE
These approaches make use of techniques developed outside of behavioral psychotherapy, especially those of Albert Ellis's rational-emotive therapy (see Chapter 10). These cognitive approaches are based on the belief that a person can gain control over undesirable behavior and psychosomatic problems by learning new habits of thinking.
These three schools of behavioral psychotherapy claim that the problems leading people to enter therapy arelearnedand can be unlearned through systematic training. In particular, anxiety—the primary source of emotional discomfort—can become a learned habit. When this happens, anxiety is linked to stimuli that in themselves are usually harmless. A person may come to feel extremely anxious, for example, when in the presence of people in authority, when in bed with a sex partner, when near dogs or insects, when criticized by others, when in a confined space, or in any number of other situations. Anxiety in these situations is learned, and it gradually becomes an involuntary habit. But the habit frequently can be broken and eliminated.
WHAT BEHAVIORAL PSYCHOTHERAPY IS LIKE
COUNTER-CONDITIONING
When you are exposed to a situation that you believe is threatening, your blood pressure and pulse rate go up, your muscle tension increases, the blood supply to your large muscle groups increases, circulation to your stomach and genitals isreduced, your pupils may dilate, your mouth may get dry. A startling noise or a physical shock can produce these symptoms. They are the physical manifestations of anxiety, and they are the focus of counter-conditioning techniques.
Anxietygeneralizesvery easily. If you were repeatedly punished for playing with dirt as a child, dirt can evoke strong anxiety in you as an adult. If you were bitten by a dog, the sight of a dog years later may make you feel anxious. Anxiety can come to be associated with almost any experience. What is particularly destructive about this is that you soon find yourself caught in a vicious circle: a certain situation makes you anxious, you try to avoid the situation and the anxiety it produces in you, and as you do this, you build upsecondaryanxiety—you get anxious that you'll get anxious. So anxiety compounds, feeding on itself, fueling itself.
Counter-conditioning therapists have found that, to varying degrees, we are all capable of inhibiting anxiety. A behavior therapist tries to teach you how to do this, eventually so that you can use relaxation techniques on your own.
The following are the main phases of desensitization therapy—assertiveness training and sex therapy are similar, gradual, and reassuring processes:
1. You are taught how to achieve a state of relatively complete physical relaxation. Many therapists will tape relaxation instructions so that you can practice daily at home for twenty to thirty minutes. Some therapists will instruct you totenseyour arms, hold the tension for ten seconds or so, then relax and feel the resulting sense of relaxation, the sense of relief from tension and strain. Or, some therapists usesuggestion, asking you to imagine that your arms are becoming heavier and heavier, encouraging you to relax deeply. Each of your major muscle groups is relaxed in turn until you feel fully relaxed. This first phase of therapy usually takes from two to six sessions.
2. Next a hierarchy is constructed by the therapist for each individual client, ranking situations or stimuli from most to least anxiety-producing. A person who fears to leave the sense of security of home already is aware of such a hierarchy: low anxiety may be felt on the front steps, greater anxiety when going out to the mailbox, moreanxiety in walking around the block, and extreme anxiety when facing a trip or a move to another residence.
3. The last phase is the actual process of desensitization. You are asked to relax deeply with eyes closed, usually in a recliner in the therapist's office. You are asked to imagine a scene taken from the low-anxiety end of your hierarchy. The therapist tries to describe the scene as realistically and vividly as possible. If you begin to feel anxious, you can raise an index finger, and then the therapist will shift away from the imagined scene and will turn back to relaxation instructions. When you are again relaxed, the process continues until, in time, you are able to imagine a scene high on the hierarchy, but still sustain deep relaxation.
Once this process of desensitization can be accomplished in the office, you begin anew, but now with actual situations—first with those low on your hierarchy and then working your way toward situations that used to cause you high anxiety. Frequently, behavior therapists will accompany their clients outside the office, helping them to remain relaxed—e.g., while riding elevators, in crowds, even sometimes on airline flights if fear of flying is the problem.
BEHAVIOR MODIFICATION
The central idea behind behavior modification is that undesirable habits of behavior will gradually be eliminated if, consistently, they are not rewarded or even are punished. Conversely, desirable habits are encouraged when they consistently are reinforced or rewarded.
Therapists who use behavior modification techniques may recommend both punishments and rewards to clients. If you are a chronic smoker or overeater, for example, you may be given a small device with which to shock yourself moderately each time you reach for a cigarette or a second helping. Or, you may be asked to deposit $100 with the therapist, and a certain amount will be donated to your most disliked political group each time you go astray.
Rewards, on the other hand, include material rewards that clients may promise themselves once a habit is successfully under control for a certain length of time. Most therapistsencourage you eventually to substitute inner satisfactions: pride in your slim appearance or improved health, strengthened self-confidence, growth of sexual satisfaction, and, most importantly, a developing sense of self-respect as you learn to gain control over anxiety, frustration, or dissatisfaction.