Behavior therapists also usedistractiontechniques. They encourage you to do things that are incompatible with the problem you wish to resolve. Bicycling or lovemaking may prove to be good antidotes for some individuals who overeat. Hiking or jogging, or physical reassurance, massage, or relaxing baths may lessen anxiety. Laughter releases tensions and offers its own special kind of encouragement and healthier perspective.
Behavior modification requires strong initiative and discipline on the part of the client. More than these, it requires that you be willing to let go of old habits that have been unsatisfying or destructive and work to form new, more rewarding habits. In the beginning, forcing yourself to behave in new ways may feel like pretense or dishonesty. This is a common experience and should not be allowed to block your desire to change. Unfamiliar and even uncomfortable ways of behaving do become familiar and more comfortable the more they are practiced. If these new ways of behaving come to offer satisfactions or compensations that old habits did not, they will gradually be absorbed into your own sense of personal identity. What at first may feel to you like an act slowly is made a part of your personality until a habit is established that feels entirely natural. This takes time, patience, practice, and more practice.
COGNITIVE APPROACHES TO BEHAVIOR CHANGE
Behavioral psychotherapists use a variety of techniques designed to help clients control their own behavior and individual physical responses more effectively.
Biofeedback
Biofeedback can help many people gain control over habitual, automatic processes. Biofeedback equipment can be used to teach you how to reduce tension, develop skills to bring about relaxation, or cope more successfully with chronic pain. (For a detailed discussion of biofeedback, see Chapter 15.)
Thought Stopping
Thought stopping can help you break chains of negative and self-undermining thoughts. Thought stopping is a technique that begins by having you think out loud during therapy sessions. If you repeatedly express negative, troubling thoughts, the therapist shouts, "Stop!" In this way, you are made acutely aware of self-destructive thinking habits. You gradually learn to stop yourself from trapping yourself in upsetting thoughts by silently commanding your mind to "stop!" It is a simple but often effective technique, related to two techniques we have already discussed: the push-button technique of Adlerian psychotherapy (see Chapter 11) and the technique of disputing your own irrational beliefs in rational-emotive therapy (see Chapter 10).
Problem Solving and Decision Making
These techniques have been developed to help clients solve personal problems and make life decisions more effectively. Behavioral therapists who offer assistance of this kind emphasize the importance in problem solving and decision making of several factors.
One is refraining from implementing solutions or decisions until you have clearly defined and understood your problem or situation. Another is becoming aware of emotional blocks to solving problems and making decisions. For example, procrastinating serves to protect people from facing risks. Individuals are frequently also deterred from solving practical problems because they are emotionally distracted by other difficulties that demand attention first. And people are inclined to jump at one possible solution that then acts as a blinder to seeing other potentially more promising alternatives.
Behavioral therapists also believe you must realize that, often, difficulties you experience when trying to solve problems or make decisions are due to conflicts between incompatible goals or values. Sometimes one objective cannot be achieved without compromising another. They also believe you must develop abilities to imagine a wider range of alternatives. And finally, they believe you must become better able both to foresee likely personal consequences of implementing a particular solution or decision and to evaluate these in relation to what is personally most important.
AN EXAMPLE OF BEHAVIORAL PSYCHOTHERAPY
Anne Holt was thirty-two when she came to see Dr. Cantwell. She was noticeably anxious, wringing her hands, tense, and easily startled, as when a car's exhaust backfired in the street below. She complained of feeling unloved by her husband and was always in dread of his criticisms. She also felt her mother-in-law was very critical of her. Anne wanted to get away from the house but had quit two jobs in succession, in each instance when her boss's criticism of her work upset her.
Dr. Cantwell explained the rationale behind desensitization to her and taught Anne how to practice systematic muscle relaxation, beginning by tensing her hands, then relaxing them, tensing them, then relaxing them again, and doing this with her arms, shoulders, calf muscles, thighs, abdomen, jaw, neck muscles, cheek, and mouth muscles. He recorded his instructions on a tape for her to use at home.
After five weeks of daily practice, Anne was usually able to relax deeply in less than a minute. Dr. Cantwell, in the meantime, had gained a clearer idea of what troubled Anne, and he had made up the following hierarchy:
Criticism directed at Anne from:High anxiety Her husband| His mother| A boss| Anne's motherLow anxiety Anne's neighbor
Dr. Cantwell decided to use a combination of desensitization and assertiveness training with Anne. During half of each weekly session with Dr. Cantwell, Anne was asked to relax in a recliner with her eyes closed, and Dr. Cantwell would then describe situations low on her hierarchy. Anne was to try to maintain her sense of relaxationin spite ofDr. Cantwell's description of an imagined situation involving Anne's neighbor. She was to imagine that her neighbor, who was very fastidious about her own yard, knocked at Anne's door to complain about Anne's habit of setting the trash out the night before pickup. Gradually, in a similarly concrete way, Dr. Cantwell had Anne imagine her mother criticizing Anne for using the same sponge for wiping upin the kitchen as for washing the dishes; a boss asking Anne to retype a business letter using another format that he preferred; Anne's mother-in-law "dropping the hint" that her son liked to have his T-shirts ironed; Anne's husband complaining because Anne always overcooked the soft-boiled eggs.
During the second half of each session with Anne, Dr. Cantwell played roles with Anne in which he taught her how to assert herself more in situations involving criticism. In one session, for example, he took the part of Anne's mother and chose a typical remark she might make: "Annie, dear, don't you think it would be smarter to use a different sponge for wiping the kitchen counter? You should use a separate one for the dishes." Dr. Cantwell then asked Anne to think of a way she could reply to her mother's "nice" criticism, without feeling bad about herself, without "getting hooked."
ANNE: Well, one way you've taught me would be to use humor: I could say to her, "Mom, anytime you'd like to come over to do the dishes, it would be fine with me." And then laugh.
DR. C.: That's a good approach. But you don't want to be offensive; you don't want to laughmockingly.Howyou do this is important. You want to set a good-natured feeling. Humor can be very useful to offset the sting of criticism. Can you think of a different way to reply to your mother, in addition to humor?
ANNE: Well, let's see.... Yes, well, I could go with her suggestion and not interpret what she says to me as criticism at all. I could say, "Mom, thanks for the idea. Maybe I'll do that."
DR. C.: Sounds very good. That's another way. The more alternatives you can prepare yourself with ahead of time, the less likely she will hook you, leaving you with nothing to say and simply feeling bad. Would you try to think of one more alternative? What other tack could you take?
ANNE: (After a moment of silence.) I can't think of another.
DR. C.: How about telling your mother how you actually feel when she criticizes you? Howdoyou feel?
ANNE: Well, I wish she'd say some positive things instead, at least sometimes. That would be nice.
DR. C.: Great. How could you tell her that?
ANNE: Well, I could say, "Mom, you know, you give me a lot of suggestions. Some are OK, now and then, but, to behonest, I'd really like to hear some praise sometimes. Do you think you could find some things to compliment me on? I don't want any false praise, but I need to hear some encouraging things from people I love."
DR. C.: Anne, you're doing very well: ... Humor, reinterpreting so you don't feel criticized, and talking about criticism from a more detached point of view. You're definitely learning how to cope with criticism much better.
APPLICATIONS OF BEHAVIORAL PSYCHOTHERAPY
Desensitization is normally used in the context of individual therapy. Behavior modification and cognitive approaches to behavior change are frequently used in groups. People with problems in common—smoking, obesity, phobias, etc.—are sometimes grouped together. Often, however, a mixture in groups is desirable. For example, it is frequently helpful for shy people to be part of a group in which they may watch others who can model more assertive ways of acting. (For more about group therapy, see Chapter 13.)
Behavioral approaches to therapy must be tailored to the individuality of each client; whatever goals are established have to be in accord with the client's own desires. Behavioral psychotherapy presupposes that clients will practice instructions and new behaviors between sessions and that they can maintain an adequate level of motivation, both while in treatment and after treatment ends, so that new habits of behaving or thinking can become effective and reliable parts of their own personalities.
In general, behavioral approaches to therapy have been less effective in treating panic attacks, chronic depression, substance abuse (smoking, for example, is one of the habits most resistant to formal therapy), and psychosis.
COUNTER-CONDITIONING
This approach, which includes desensitization, assertiveness training, and sex therapy, has been used effectively in treating these problems:
* phobias
* psychosomatic complaints
* sex, marriage, and family problems
* passivity and shyness
* personality trait problems: lonely, anxious, hostile, or overbearing individuals
BEHAVIOR MODIFICATION
This approach has been used successfully in connection with these problems:
* sexually deviant behavior
* children's problems, school discipline, academic performance, and juvenile delinquency
* problems of the mentally retarded and of psychotically regressed individuals
* some instances of obesity, alcoholism, and smoking
* schizophrenia
* stuttering
COGNITIVE APPROACHES TO BEHAVIOR CHANGE
These approaches have, for example, been used to treat such problems as:
* anxiety and depression
* adjustment problems
* marital and sexual difficulties
* psychosomatic problems
The popular conception of behavioral therapists is that they tend to be coldly scientific and mechanical. Yet a number of studies show that they are inclined to be warm individuals who show positive regard for their clients. In general they tend to be empathetic and self-congruent. These qualities are very much needed if we as clients are to feel encouraged to face one of the most difficult challenges life can pose for us: to change ourselves.
13GROUP THERAPYEspecially well-suited to people who areouter-directed but lonely, who want todevelop their interpersonal skills,and who would like to learn aboutthemselves from the perceptions of others.
Group therapy is ancient. For as long as men have gathered together to share their experiences, thoughts, and feelings and to give one another comfort, group therapy has existed. As an approach to modern psychotherapy, however, it was in its infancy fifty years ago. No single great mind stands behind group therapy; it has been and continues to be innovative, flexible, and free from ties to any particular orthodox school of thought.
Clients who are attracted to group therapy and who often benefit from group experience tend to have these characteristics:
* They are passive in their interactions with others. They are more comfortable being told what to do than facing the need to decide for themselves.
* They are often lonely or socially isolated. Individualtherapy, with its one-to-one relationship between therapist and client, does not encourage some clients enough for them to feel like members of humanity. They tend to feel sorry for themselves while in individual therapy or to judge themselves harshly for their need for help. Being with other clients in a group situation answers their needs better.
* They are outer-directed people: what others think of them is crucial to how they think about themselves. Inner-directed individuals are likely to feel more interested in and comfortable with individual therapy.
For people who are relatively passive, lonely, yet outer-directed, group therapy has some distinct advantages:
* It gives them a place within a group of people—they are no longer alone.
* It gives them opportunities to express themselves freely, confront other people, and say things that they otherwise might not be able to express, thanks to the close and confidential environment of the group.
* They can hear how a variety of other people perceive them. They are not limited to the observations, ideas, and recommendations of a single therapist.
* They often feel more at ease in a group. They feel less fear or intimidation in the presence of the authority figure the therapist represents.
* They may benefit from the experiences of other group members who have similar problems or who have very different kinds of difficulties. Knowing that they are not troubled minorities of one can be a comfort; knowing that other people have problems in areas where they don't can be reassuring.
In general, group therapy can give you insight provided by the thoughts and perceptions of others; it can help you develop social ties if you feel isolated; and it can offer group support if you need emotional bolstering in order to cope with difficult situations, undertake decisions that may frighten you, and face more calmly and confidently the many challenges life can present. But it can also help you deal with more specific problems, such as facing an especially stressful situation—the death ofsomeone very close to you, divorce or separation, serious illness, unemployment, drug addiction, or alcoholism. Or perhaps you have problems relating to others, such as having a history of being fired from job after job despite your efforts to hold them. For that matter, group therapy can even offer information about job opportunities, how to develop occupational skills, how to apply for a job, and how to keep a position you hold.
Some psychologists have commented that the popularity and the need for the kind of experience that group therapy offers are due to the decline of community life and to the virtual disappearance of extended families living physically and emotionally close to one another.
Group therapy is offered in private practice, in hospitals, and in halfway houses; in psychiatric and counseling centers, in clinics and hospital wards for patients with diabetes, AIDS, epilepsy, arthritis, heart conditions, paralysis, blindness; in prisons and juvenile detention centers; and in schools, for students with behavior problems and truancy. Group therapy is often used for marriage, family, and child-guidance counseling and to help families in which a member is physically or emotionally disabled. Group therapy is used by churches for family guidance and for spiritual counseling. It is used in virtually any area where people share problems: victims of crime and physical abuse, former patients, the aged, children of the aged, those who are discriminated against—the list goes on.
So, group therapy cuts across virtually the whole range of human problems. Because it is used in so many areas, it is impossible to define it as a single approach—many distinct approaches actually may be involved.
Many of the approaches to psychotherapy we have already looked at are used in groups. There are psychoanalytically oriented groups, Adlerian groups, Gestalt groups, groups that use behavior modification, and others. Perhaps the most useful way to understand group therapy is to liken it to education. Many sorts of things can be taught, and many can be learned. Group therapy may be understood most clearly in relation to what kinds of learning and teaching really go on in it.
Since group approaches to problem solving include many applications beyond our scope here—in industry, religion, schools, etc.—we will look more closely at the following forms of group therapy that are used in the context of psychotherapy: brief group psychotherapy, T-groups,human potential groups, self-help groups, and the use of specialized approaches to psychotherapy in a group setting. (Marriage and family therapy, which are special forms of group therapy, are of interest to a large number of people, so they are discussed separately, in Chapter 14.)
BRIEF GROUP PSYCHOTHERAPY
Also known asshort-term encounter groups, brief group psychotherapy is intended for people who face life crises, who are motivated to change, and who are comparatively free of individual emotional disorders. Normally, there are about ten sessions. People who find short-term group therapy useful generally have well-defined problems to solve. Their experience in group therapy encourages them to become involved in new activities, join clubs, perhaps do volunteer work after being recently widowed, divorced, or separated; to take specific steps to find employment; or to practice new ways of behaving—to become more assertive, to implement a weight-loss plan, to return to school after raising a family, or to change careers.
T-GROUPS
Training groups were an outgrowth of the National Training Laboratories, an organization formed in 1947 by social psychologists who were interested in improving education. T-groups were made up of "normally adjusted people" who were interested in improving their communication skills so they could become more competent in difficult interpersonal situations.
T-groups gradually widened their focus and became the basis for the practical orientation of many therapy groups today. Clients who feel isolated or alienated, find it hard to relate to others, lack a sense of meaning and direction, and do not have strong self-discipline often are attracted to T-groups.
HUMAN POTENTIAL GROUPS
These groups have probably done the most to give group therapy its popular image. "Growth centers" are usually rural retreats where psychological growth of participants is encouraged. Visits last from a weekend to several weeks. The firstcenter was called Lifewynn, organized in the 1920s at a summer camp in New York's Adirondack Mountains. The best-known growth center is the Esalen Institute in Big Sur, California, formed in 1962 by Michael Murphy. Its program combines Gestalt therapy with Eastern meditation (see Chapter 15). Other similar growth centers have sprung up across the country. In addition to these, the est (Erhard Seminars Training) organization has attracted a good deal of public attention and controversy. The est approach is eclectic, combining Eastern thought, Gestalt therapy, transactional analysis, psychoanalysis, Jungian philosophy, positive thinking, meditation, and other approaches. Some est leaders have been described as charismatic, proselytizing personalities who claim to be able to lead participants to salvation.
SELF-HELP GROUPS
There are self-help groups to aid you with many different kinds of problems. They provide group moral support for members with shared problems. They are not intended to bring about deep-seated personality change. Alcoholics Anonymous (AA), founded in 1934, probably is the most well-known self-help organization. Recovery, Inc., also known as the Association of Nervous and Former Mental Patients, was formed in 1936 by psychiatrist Abraham A. Low. Meetings focus on members' conscious control of symptoms; Recovery, Inc., frequently encourages members to become involved in volunteer social work.
There are many other self-help organizations—for the handicapped, widows, battered wives, diabetics, victims of AIDS, hemophiliacs, homosexuals, drug addicts, and others. (For further information see "Appendix A: Agencies and Organizations That Can Help.")
PSYCHOTHERAPY IN A GROUP SETTING
Most of the approaches to psychotherapy that we have discussed provide treatment in the form of group therapy in addition to individual therapy. Group therapy is frequently offered, for example, by psychoanalysts, client-centered therapists, Gestalt therapists, transactional analysts, rational-emotive therapists and general cognitive therapists, existential-humanistictherapists, reality therapists, Adlerian psychotherapists, emotional flooding therapists, and behavior modification therapists. In the remainder of this chapter, we will discuss how group therapy is handled by the main psychotherapies.
WHAT GROUP THERAPY IS LIKE
Although your experience with group therapy will vary depending on which school of therapy you have chosen, you will find some common elements regardless of the approach.
Initially, there is likely to be a period of group confusion, awkward periods of silence, some polite superficial conversation, and often a frustrating lack of overall organization and continuity. Different group members will speak up, and what they say may have absolutely nothing to do with what the previous speaker has said; people are waiting for the chance to talk about themselves and tend to concentrate so much on what they are preparing to say that they don't pay attention to what others have been saying.
Gradually, a more organized style of interacting comes into being through the directive efforts of the therapist or as a result of general group frustration over the lack of coherence. At the same time, group members will begin to feel more at ease with one another and will in time begin to lift their public masks and reveal more of their private selves—their often hard-to-admit feelings of loneliness, pain, anxiety, depression, etc.—and to express their personal needs.
Frequently, the first steps in the direction of expressing private feelings will involve attacks on the therapist for not structuring the group's interactions more or attacks on one member for monopolizing group sessions. Experienced group therapists realize that these common negative attacks are understandable tests of the trustworthiness and the safety of the group as a place to express personal feelings. If an atmosphere of acceptance is established, and these initial complaints are allowed to occur without catastrophe, some group members will usually then begin to open up, to reveal some deeper feelings. One member may begin to talk about her unhappy marriage, a man about his gambling obsession, another about his loneliness since his wife died.
At about this time it is common for group members to begin totell one another how they feel about each other, how they see one another. Some of these comments will be positive, some negative. Here are some examples:
"You have a really nice smile."
"You remind me of my father, all theseshoulds,oughts, and rules!"
"You never say much, so I feel you're just sitting there judging us."
"You make me nervous, biting your nails all the time."
"Every time you say something, you put yourself or somebody else down."
As this process continues, one or two group members will begin to take an interest in the personal problems of some of the others and express a desire to help. They will ask questions for more information, express sympathy or empathy, and begin to offer suggestions. It is at this point that the process of group interaction begins to acquire a focus on healing and problem solving. Frequently, these expressions of desire to help one member will encourage him or her for the first time to begin to accept the kind of person he or she has been, to realize that "Ihavebeen too hard on myself because I'm so damned perfectionistic," "Iama controller; I want other people to do thingsmyway," or "I live in a suit of armor; I'm just afraid of other people."
As members of the group come to know one another as real personalities, they tend to become impatient whenever anyone tries to put on his public mask again. The group demands and expects members to be honest about themselves. Feelings can run hot whenever Fred tries to make Alice accept his suggestions because heknowswhat she really needs. Group members can show quick impatience with Judy whenever she tries to persuade herself, even though her husband has severely beaten her several times, that her marriage isreallyOK.
Group members quickly gain a good deal of information about how others see them and feel about them. As a result of an implicit commitment to honesty, some members' ways of behaving gradually change: a rough tone of voice becomes less abrasive and calmer; offensive gestures and judging looksdisappear; self-centeredness gives way to a certain amount of sympathy and interest in other people.
Some of the values of group therapy are sensitively expressed in this passage from a letter written by a client to his group:
"I have come to the conclusion that my experiences with you have profoundly affected me. I am truly grateful. This is different from personal therapy. None of youhadto care about me. None of you had to seek me out and let me know of things you thought would help me. Yet you did, and as a result it has far more meaning than anything I have so far experienced. When I feel the need to hold back and not live spontaneously for whatever reasons, I remember that twelve persons ... said to let go and ... be myself and of all the unbelievable things they even loved me.... This has given me thecourageto come out of myself many times since then...."[1]
[1] Quoted in Carl R. Rogers,Carl Rogers on Encounter Groups(New York: Harper and Row, 1970), p. 33.
THE RISKS
Unfortunately, like many healing processes, group therapy is not for everyone. There are recognizedrisksof entering group therapy.
When members leave the intimacy of their group and return to the "real world," they may feel disappointed and discouraged. Their experience has given them the opportunity to dispense with social masks, to become more authentic, to see the lies and pretenses of others more clearly. But the vast majority of people outside the group have not learned these things anddolive behind masks they are not even conscious of. When you gain from a learning experience a perspective you can share with comparatively few people, you're likely to feel discontented and alienated.
You should also be aware that some of the changes that occur in group therapy simply may not last very long after the group stops meeting because the emotional and moral support offered by the group are no longer there. Or, group therapy may make you aware for the first time of personal problems you had ignored or evaded, leaving you hanging when the group terminates. So group therapy may bring about a need to solve problems that, before the group experience, you didn't evenknow you had. These problems may then motivate you to enter individual therapy.
Finally, if you enter group therapy but your spouse does not, your experience could bring marital tensions into the open, leaving your spouse at a disadvantage. Your spouse, who is unfamiliar with what transpired during your group sessions, may react defensively and without empathy to your desire to talk about your feelings.
GROUP TECHNIQUES
The techniques discussed below are commonly used in group therapy.
Content Analysis
A member of the group describes a problem he or she is having, and the therapist and other members make problem-solving suggestions. Their focus may be on why the person does not want to solve the problem or on how the person brought the problem on and maintains it.
Group Process
After a series of interactions, comments, suggestions and personal observations by group members, the therapist will ask the group to stand back and look at the pattern of their communication. The group may become aware of the way one member is consistently overlooked and is not given a fair share of attention because of shyness or because another more forceful member dominates the group's attention.
Models
One member can work on personal problems in group therapy by noting how another member goes about handling a similar problem and then trying to learn from that example.
Analysis of Nonverbals
The group therapist and members of the group can often help make an individual better aware of how his or her behavior has contributed to personal problems. For example, Jim tends to be shy, makes poor eye contact with people, has bad posture, and speaks indistinctly because he has a habit of covering his mouthwith his fingers. The impression he makes on people is weak. By helping him pay attention to these nonverbal habits, group members can encourage Jim to change so he will be more successful, for example, at job interviews and generally feel more confident.
APPLICATIONS OF GROUP THERAPY
As we have seen, group therapy is most helpful to people with these characteristics:
* They are lonely, socially isolated, or passive.
* Their sense of worth depends greatly on what others think of them.
* They would like to improve their interpersonal skills.
* They may be drawn to group therapy for the practical reason that it tends to be less expensive than individual therapy.
Group therapy has the distinct advantage of providing clients with multiple points of view; they receive feedback from the therapist as well as from other members of the group.
Group therapy is potentially useful for a very wide range of problems. This is evident from the fact that most approaches to psychotherapy offer therapy in a group setting. Group therapy is generallynotthe treatment of choice for these individuals:
* persons lacking communication skills
* those who lack the motivation to attend group sessions regularly or who refuse to keep information about other group members confidential outside of the group
* people who are severely disturbed
* individuals who are intellectually impaired
* those suffering from chronic depression
* psychopathic or sociopathic adolescents (who do not have a sense of social conscience)
Group therapy, as we have noted, also appealslessto inner-directed individuals and is therefore less likely to be helpful to them.
14MARRIAGE AND FAMILY THERAPYFor couples and families with problems ofcommunication, strain, and conflict,and for individuals whose difficultiesare best resolved with the participationof other family members.
The family is the basic source of health or sickness.Vincent D. Foley,Current Psychotherapies
During the last forty years there has been a gradual shift away from an emphasis on individual therapy to a belief that many emotional difficulties people experience have their roots—and often, also their solutions—in their marriages or families. As this shift in emphasis grew, many therapists saw that marriage and family relationships make up units, or systems, each with a personality of its own. Members of a family gain their identities from their roles in the family system. This systems view made it possible for therapists to understand families and marriages more clearly as interdependent, interlocking, functioning wholes.
Marriage and family therapy treats emotional disorders in terms of the interdependent relationships among members. The marriage or family system is thought of as a unit with properties that reach beyond the sum of the personal qualities of the individuals who make it up. Usually, one person in a family or marriage is more troubled; his or her symptoms are more pronounced. The husband tends to feel his wife has "the problem," or vice versa. Mother and father feel that little Richard is "the problem." However, therapists believe that the problems experienced and expressed by the "sick" person are really signs that something is wrong with the whole system. A "heart problem" is frequently part of a larger problem, such as poor diet or excessive stress, and the same is true for couples or families. One person's distress tells the therapist that, often, something is troubling both husband and wife or all the members of a family.
This interdependence between partners of a marriage or members of a family system frequently leads to a complex situation in which emotional difficulties are contagious, one person's improvement is connected with another's getting worse, or treating one person separately draws the members of a relationship apart.
One of the very difficult problems troubled couples or families face is that emotional disturbance can often "spread." Repeatedly, therapists observe that there is a kind of subtle transmission from one generation to the next of inner conflicts and difficulties in coping with life. And beyond this, there are intimate connections between the emotional makeup and emotional balance of married partners or family members. For example, it is all too common for the partner of a chronically depressed person also to fall into a serious depression. Marriage and family therapists are therefore inclined to see the emotional disturbance of one member in terms of a troubled, ineffective pattern of interaction.
Because of their close ties, sometimes one person's behavior, attitudes, or feelings get better while another family member develops new symptoms or problems. We will look at a real example of this in a moment.
Marriage and family therapists have noticed that, when one person in a marriage or family is treated separately, the family members frequently are drawn apart instead of brought closertogether. Therefore, therapists generally feel it is essential to see husband and wife together or to involve both parents and children in therapy.
The purpose of marriage or family therapy is not only to resolve existing problems but also to help clients cultivate a new way of communicating and interacting together. Marriage therapy and family therapy of course seek to relieve emotional distress by helping to reduce or end conflicts and to lessen anxiety, frustration, anger, or resentments. But beyond these, marriage and family therapists try to show clients how to complement one another's personal needs. They also attempt to strengthen bonds between them so that they are able to face crises and emotional upsets with greater strength, balance, and courage. And they try to redirect clients' values in a way that will support the personal growth of each person.
How long marriage or family therapy will take depends primarily on the goals of the couple or family. Here are some estimates:
* to reduce tensions: perhaps six sessions
* to reduce symptoms such as emotional distress or behavioral problems: ten to fifteen sessions
* to improve communication habits: twenty-five to thirty sessions over six to eight months
* to restructure relationships so that members of the family system will have more independence and will cultivate an awareness that they do have separate identities: forty sessions or more
WHAT MARRIAGE ANDFAMILY THERAPIES ARE LIKE
Marriage therapy and family therapy are distinct from group therapy in two important ways. First, unlike in group therapy the clients in marriage or family therapy have a shared history and, if therapy is successful, will often be able to enjoy a shared future. Second, in marriage and family therapy, the therapist is more active and directive than in group therapy. Any changes made by members of a group come about because of interactions among the group members; a group therapist acts as a moderator or facilitator, while the role of a marriage or family therapist resembles that of a teacher.
Marriage and family therapy focuses onpresentinteractions between husband and wife or among family members. It is not that the past is judged to be unimportant, but it is not generally useful to pay a great deal of attention to what has already happened. What causes problemsnoware the current patterns and habits of interaction in the family or marriage. A wife may have been drinking for fifteen years because her mother undermined her sense of self-confidence, but the fact is that she no longer lives with her mother. However, shedidchoose to live with a man who continued her mother's pattern of undermining abuse. A marriage therapist will focus on present difficulties and, by doing this, may be able to help her resolve her drinking problem by improving a troubled relationship with her husband.
Jay Haley (1923-2007), a leading marriage and family therapist, has expressed the belief that concentrating on feelings and thinking will not lead to change, that empathy on the part of the therapist does not correct problems, and that insight often just provides an excuse for intellectual rationalization and game-playing.[1]
[1] Jay Haley, "Marriage Therapy," in Gerald D. Erickson and Terrance P. Hogan, eds.,Family Therapy: An Introduction to Theory and Technique(Monterey, CA: Brooks/Cole, 1972), pp. 180-210.
Because the patterns of behavior of a troubled couple or family tend to be very rigid, therapists have found that strongly directive techniques are most effective. Their focus is on developing interventions—or therapeutic strategies—that will have a real impact on the complex patterns of interaction that have come to paralyze a couple or a family.
What seems to help in marriage and family therapy is ingenuity on the part of the therapist that will give him or her power or control over a situation that is out of control. One way to do this is to force clients into a paradoxical situation. For example, the therapist may prescribe that a couple or members of a familycontinuetheir present unsatisfying behavior. As a result, they may (and very likely will) rebel so that desired change comes about.[2]
[2] As we have seen, logotherapy and Adlerian therapy both make use of this technique, as do family therapists, as we will see later on.
All family therapyismarriage therapy to a certain extent. And so, suppose we first look more closely at what marriage therapy is like.
MARRIAGE THERAPY
Marriage therapy is generally advisable[3] when the husband or wife has sought help in individual counseling but this has not been helpful. Sometimes the marital relationship itself inhibits, or even undermines, the improvement of the most troubled person. For example, individual therapy did nothing to help one woman who was suffering from severe chronic anxiety. When her husband was asked to participate in treatment, it was found that he abused his wife continuously but subtly. Whenever she spoke, he would criticize her views and indirectly slight her worth; when he lost something, he would often accuse her of misplacing it. The problem she had come for help with turned out to be marital rather than individual.
[3] See Jay Haley, "Marriage Therapy," pp. 180-210.
If you are unable or unwilling to communicate openly and adequately with a therapist, marriage therapy may encourage your spouse to become more involved in the process of therapy. Often, having the other marital partner present will stimulate an otherwise silent client to express himself or herself, especially to correct what the other partner has to say!
If you suddenly become severely troubled at the time of a marital conflict, marriage therapy may be useful. A spouse who falls into a deep depression immediately after a quarrel may be troubled in a way that marriage therapy can treat.
Finally, marriage therapy is of course essential if a husband and wife are in conflict and serious distress and cannot resolve their differences. Frequently, one spouse (usually the wife) will want marriage therapy; the other will come, but reluctantly. However, both oftenwillcome, because if one is in distress the other is affected.
Conflicts in marriage frequently come about because of disagreements having to do with the couple's rules for living together, especially regarding how each is to treat the other. Who sets the rules is often another area of conflict, as are incompatible rules. For example, a wife insists that her husband stop being a "mama's boy" and demeans him for being dominated by a woman; yet it isshewho seeks to dominate her husband by insisting thathebe more domineering.
In marriage therapy (and also in family therapy), therapistsencounter a great deal of resistance to change on the part of their clients. (Alas, so do all other therapists!) A main reason for resistance is that, in a marital relationship or family system, change in one member's feelings and behavior will tend to affect another's, often in unsuspected ways. Change disturbs the established balance of their system, a balance that does serve some purposes.
Jane Dowland, for example, went to see Dr. Carlton because of her husband's depression. Phil had lost his job and now spent most of his time at home, feeling sorry for himself and collecting unemployment benefits. Jane was easily upset and felt terribly insecure. Dr. Carlton recommended that Phil accompany Jane to the next session. After seeing Phil, Dr. Carlton referred him to a psychiatrist, who was able to treat Phil's depression effectively in four months' time with medication. Jane, however, continued to feel severely (and perhaps even more) anxious, although Phil's symptoms were now under control and he was back at work.
Dr. Carlton recommended marriage therapy to Jane and Phil. They saw Dr. Carlton once a week for three months. It became clear to Dr. Carlton, and eventually clear to Jane, that without realizing it she had used Phil's depression as an excuse for her own anxiety so that she could evade responsibility for herself. She came to realize that she had been unable to resolve her own conflicting needs—whether to have children in spite of Phil's disinterest in children or whether to commit herself to developing a career.
Treating Phil's depression led Jane to become aware of her own problems. The balance in their relationship was changed by therapy: Jane found out that Phil's depression was really a problem that served a purpose for her—without it, she needed help for herself.
Because of the complex, interwoven nature of a marital relationship, it is often difficult to separate the problems each partner may experience. One partner's symptoms may mask the other's problem. Or, one person's problem may be perpetuated by the other's behavior, interfering with the resolution of the problem. Further, each partner may encourage distress in the other as a result of differing expectations concerning rules of living together and who sets them.
FAMILY THERAPY
In family therapy, the "identified patient" is seen as but a symptom, and the system itself (the family) is viewed as the client.Vincent D. Foley,Current Psychotherapies
Very often, one family member is labeled the one with the problem, the one who is "sick." When the family decides to enter therapy, it is usual for family members to feel troubled, scared, and confused. They realize that something is wrong, but they are uncertain about what is amiss and don't know what to do. The usual response to this perplexity is to push the "identified patient" forward—usually a child who is "the problem"—and try to make him or her the focus of treatment.
As the members of the family are interviewed, individually and together, the therapist is able to assemble a coherent picture of the family, its typical ways of interacting, the habitual, automatic patterns of response of one family member to another, the family's values and beliefs. What one member tries to hide another often will express.
The family therapist has a difficult double role, as both observer and participant. He or she needs to be able to notice what the styles of interaction of individual family members are andat the same timeinteract with members of the family. The therapist tries to bring about meaningful emotional interchange, create an atmosphere of trust and rapport, and reduce the feeling that family members are threatened.
Over time, the therapist seeks to show the members of a family how they tend to interrelate inappropriately, how their own ineffective defenses cause them to hurt one another. To do this, the therapist has to be able to cut through the vicious circles of resentment, anger, blame, frustration, and intimidation that frequently hold families in a death grip.
THE THERAPIST'S FUNCTIONS
In both marriage and family therapy therapists must:
* establish a sense of rapport and trusting communication between clients and themselves
* use this rapport to bring out the conflicts, frustrations, and inadequate means of communication that burden their clients
* see through denials, rationalizations, and excuses
* push family members to put out in the open feelings and pains they have kept from one another
* bring to a halt the family's tendency to focus on one person as a scapegoat, "the problem"
* act in understanding, calm, and emotionally supportive ways and help supply the emotional stability that the couple or family temporarily lacks
* try to exemplify or personify for clients what it is to be adult, mature, caring, and able to relate openly and without feeling threatened
MARRIAGE AND FAMILY THERAPY TECHNIQUES
Marriage and family therapists may use a variety of techniques to encourage their clients to change in constructive ways. For example, it is becoming more common tovideotape sessionsso that couples and families may become more aware of their automatic, self-destructive patterns of interaction—which makes it easier to change them.
Family therapists also sometimes makehome visits: often, being in their own familiar surroundings will encourage family members to let down their defenses and more clearly define the problems that need to be resolved. Another innovation that is becoming more widespread ismultifamily therapy. Two or three families participate together in an especially modified form of group therapy so that each family can see its own problems in clearer perspective and learn by seeing more or less troubled interactions among members of another family.
Techniques drawn frombehavior modificationare frequently used in family therapy, especially when family difficulties seem to be localized around the behavior of rebellious or delinquent children.
Paradoxical intention, discussed in Chapter 11, can also be very helpful in marriage and family therapy. Instead of trying to restore a state of balance between husband and wife or among family members—something that usually stimulates the couple or family to fight to hold on to its old habits—a therapistencourages a state of imbalance so that the unbalanced system falls of its own weight. The cure, paradoxically, may lie in intensifying the problem. For example, a wife has migraines that prevent her from doing her family chores. A child throws up when he is forced to go to school. Both claim that they "just can't help it." The therapist's response might be, "I realize you can't help it. What I want you to do, Alice, when you feel household chores are just too much, is to go to bed and permit yourself to have a migraine. Don't fight it. Go ahead and have a bad headache. It gives you some relief, so I want you to do this through your own choice. And you, Johnny, I want you to go into the bathroom before you leave for school and throw up. It is unpleasant, but it hasn't hurt you. If you need to, stick your finger down your throat. I want you to take control and make yourself throw up each morning before going to school. And you, Alice, you won't interfere or try to mother him; let him alone. But do remind him to go and throw up." In a very short time, the results of these paradoxical strategies can be surprisingly effective.
APPLICATIONS OF MARRIAGE ANDFAMILY THERAPY
As in all approaches to therapy, the effectiveness of marriage and family therapy depends on the strength of the clients' desire to overcome the difficulties that have motivated them to ask for help. Goodwill and commitment to change may or may not be there. Sometimes a therapist can help clients become aware of their deep-seated but habitually ignored feelings of warmth toward one another. At other times, marriage therapy may lead to separation and divorce, if a couple comes to realize that their goals really are not compatible and what each needs or wants from the relationship the other is not able or willing to give. Marriage therapy and family therapy are not magic wands that can be waved over trouble to make things better. Therapists can make specific recommendations, they can help a couple or family become explicitly aware of destructive patterns, they can point to and illustrate constructive ways of interacting, and they can sometimes use therapeutic strategies to break old habits and make room for care and sensitivity to the needs of wife, husband, and children. These interventions from a therapist can be veryhelpful, perhaps even crucial, but they are, at most,catalystsfor change: real and lasting changes can only come from clients themselves. Marriage or family therapy is ideally an educational experience. What wife, husband, and children do with what they have learned is, in the end, up to them.
Family therapy has been especially effective in dealing with these problems:
* problems due to conflicts among family members
* emotional disturbances in children
* some cases of schizophrenia where members of the family are frequently not well-individuated—each person's identity is so bound up with the outlooks and behavior of other family members that no one has a clear sense of his or her own personal identity and separateness
* problems that are interlocking, where the difficulties of one member of the family cannot be resolved without the cooperation of the others
* problems experienced by a family when a child becomes old enough to leave home
Family therapy has been muchlesseffective in treating paranoia in one member of the family, and behavioral problems stemming from sexual disorders.
Marriage therapy has been effective in helping couples with any of these characteristics or problems:
* They communicate and interact in ways that lead to conflict, frustration, anger, and unhappiness.
* They are insufficiently sensitive to one another's needs.
* They have unstated and conflicting expectations concerning their relationships.
* They will work together to help one partner overcome individual difficulties.
15CHANNELING AWARENESS:Exercise, Biofeedback,Relaxation Training, Hypnosis,and Meditation
All of these approaches to therapy serve tochannelawareness in particular ways, to provide a point of focus for the mind. They are all processes that eliminate distractions and enable you to direct your awareness in ways that are basically different from normal, everyday waking consciousness. Special kinds of absorption or concentration characterize the therapeutic uses of exercise, biofeedback, relaxation training, hypnosis, and meditation.
THE PSYCHOTHERAPY OF EXERCISEFor some individuals who already are or whoare willing to become physically fit, sustainedvigorous exercise can significantly decreasesymptoms of tension, anxiety, and depression.
It is my contention that, just as prayer, meditation, dream analysis and some drug experiences open doors into these areas not usually accessible to us, under the appropriate circumstances slow long-distance running opens similar doors. The subjective experience of the runner appears the same, and he becomes revitalized or reenergized in a psychologicalor spiritual or creative sense.... It is clear to me that this is a distinct form of psychotherapy.Thaddeus Kostrubala,The Joy of Running
Many studies have been made and a small mountain of literature has accumulated about the physical effects of exercise. However, little attention has been paid to its psychological aspects, particularly in connection with the kinds of symptoms and problems that bring people to psychotherapy.
Psychiatrist Thaddeus Kostrubala (1930- ) has been one of the pioneering contributors to the study of exercise as a form of psychotherapy. Dr. Kostrubala is a dedicated runner who has completed many marathons and who uses running as a therapeutic approach in his practice.
Much of the modest amount of research on the psychotherapeutic value of exercise has focused on running, probably for the following reasons: First, slow long-distance running seems to be an anatomically natural activity for us, with our species' two relatively long legs. Second, running appears to be an especially effective way to derive specific therapeutic benefits from an aerobic activity. And, of course, running has recently become very popular.
Most exercise physiologists claim that the physical, and very likely also the psychological, effects of other aerobic forms of exercise, such as bicycling, swimming, and cross-country skiing, are essentially equivalent to running. So, until we know otherwise, we will assume that what is true of running is likely to be true of other types of exercise that make similar demands on the body, and we will focus here on running.
Dr. Kostrubala has attempted to describe a particular approach to running that seems to have definite psychotherapeutic value. More is involved than donning a pair of running shoes and starting out, as we will see.
Dr. Kostrubala has found that running is emotionally or mentally therapeutic under certain conditions. First, you need to make sure that you are inmedically good conditionto begin a therapeutic running program. It would be prudent to have a thorough physical and, if you are over forty, also a stress test. You need to do warm-up exercises, which any good book on running describes in detail, and then you need to build up your endurance—gradually and patiently—until you can run aminimumof three times a week for an hour each time, without stopping, andwith a pulse rate of at least 75 percent of your maximum heart rate. (Your maximum heart rate is 220 beats per minute minus your age. If you are 40 years old, your maximum heart rate is 180. Seventy-five percent of 180 yields a pulse rate of 135 beats per minute. If you are 40, you would want to run for an hour so as to maintain a pulse rate of 135 beats per minute during your run. By way of encouragement, you may want to know that 75 percent of a person's maximum heart rate represents, for almost everyone, a slow, easy jog.) Second, you must have anoncompetitive attitudetoward running. Whether you're comparing yourself to others or just trying to beat your own running record, a competitive drive rivets your attention on a goal separate from yourself. This misplaced emphasis will undermine the therapeutic value of the activity.
You also should either run alone or with someone who won't distract you by talking. Direct your attention within—to the rhythm of your pace, the regularity of your breathing, maintaining relaxation in your shoulders, back, and feet. To prevent distraction it is also important to run in an area or around a track that is familiar to you. For slow long-distance running to have a therapeutic effect, you cannot be a sightseer. The novelty of unfamiliar surroundings will distract you from being inner-directed, which is therapeutically important.
Finally, be aware of the physical risks. If you begin to feel dizzy, stop running. In hot weather, dizziness is a first warning sign of heat exhaustion, which can lead to heatstroke. If you feel a snap in one of your running muscles, stop. An internal snapping or popping noise can mean that a muscle or tendon has torn, or a small bone has broken. Make sure you are all right before resuming. If you have a cramp-like pain in your side, which is very common, try slowing down, exhaling forcefully, giving a yell, or singing. You can often keep going, and the pain will subside. If it does not, or it gets worse, you'll need to stop to rest.
WHAT RUNNING AS THERAPY FEELS LIKE
The psychological effects of regular, slow long-distance running can be impressive if you follow the directions above.
During the first twenty minutes, you may feel slow and stiff and not very inspired about the run. You may find yourself in a sour mood. (There is even a term for this phase:dysphoria.)Persuade yourself that it is not important and keep going.
Between twenty and thirty minutes, if you are dysphoric, that feeling may peak; some people even begin to cry. This is not necessarily depression; it may actually feel good. (Another reason to run alone: other people won't understand and may want to "rescue" you from your therapeutic endeavor.)
At some point, after about thirty minutes of running, you will probably find that your mind refuses to do any more problem solving. You stop worrying, problems you may have been dwelling on simply begin to feel distasteful, and your mind clears. (After a good run, when you do return to the problem, you may well find that it is less difficult to think through.)
Between thirty and forty minutes, many people begin to feel more "open"—their breathing begins to come more freely, and their whole system seems to work more smoothly and with less effort. This can be a wonderful feeling.
After you have been running for forty minutes, the first alterations in your consciousness may begin. Your senses begin to feel more alert, more alive. Things seem more vivid—the colors of leaves, the song of a bird, the freshness of the air. Runners who have experienced this say that this natural, vivid, fresh sense of perception is unique; to some extent it may resemble the experience that comes from meditation, biofeedback, or drugs. This experience seems not to occur before forty minutes of running. It may be an experience of mild euphoria, or you may feel it as a marked increase in aesthetic sensitivity or as a sense of growing inner serenity.
APPLICATIONS OF EXERCISE AS PSYCHOTHERAPY
I'm sure that these experiences are closely related to meditation. The clearing of consciousness, the ability to find a central focus within, the delight of a clear mind, the sense of refreshment of the soul are reported both by those who practice meditation and by long-distance runners. The difference between the two techniques is in the physical effects of the running. It is as if those who meditate have found one half of the picture. The runners who just compete and do not reach for the psychological aspects have found the other half. The runners who are able to slow down and search for the psychic aspects will have both—the soul and the body.Thaddeus Kostrubala,The Joy of Running
Even though aerobic exercise such as slow long-distance running can produce a feeling of moderate depression during the first thirty minutes, people who have moderate, lingering depressions in daily life often find that, as described above, depression disappears after about forty minutes. Anger and hostility also seem to be much reduced after about thirty minutes of running.
The repetitive rhythm and sustained exertion of slow long-distance running appear to tire the conscious mind. Many anxieties, tensions, worries, feelings of guilt, anger, and depression lift. The easily distracted, constantly nervous and shifting focus of everyday consciousness gives way to a sense of integration, of being one with yourself and the activity of running.
O chestnut tree, great rooted blossomer,Are you the leaf, the blossom or the bole?O body swayed to music, O brightening glance,How can we know the dancer from the dance?W. B. Yeats,Among School Children
The therapeutic use of running appears to offer the following benefits:
* increases mental energy, acuity, and concentration
* strengthens self-confidence and a sense of personal worth
* increases a capacity for work so that you feel less tired at the end of the day
* diminishes smoking, drinking, and other unhealthy habits
* helps those with eating disorders—who either are overweight or dangerously underweight—change their eating habits