When You Don't Know Where to Turn
by Steven J. Bartlett · English · Gutenberg #44926 · 612,185 chars · public domain (US)
The Project Gutenberg eBook of When You Don't Know Where to Turn
This eBook is for the use of anyone anywhere in the United States and
most other parts of the world at no cost and with almost no restrictions
whatsoever. You may copy it, give it away or re-use it under the terms
of the Project Gutenberg License included with this eBook or online
at www.gutenberg.org. If you are not located in the United States,
you will have to check the laws of the country where you are located
before using this eBook.
*** This is a COPYRIGHTED Project Gutenberg eBook. Details Below. ***
*** Please follow the copyright guidelines in this file. ***
Title: When You Don't Know Where to Turn
Author: Steven J. Bartlett
Release date: February 15, 2014 [eBook #44926]
Most recently updated: October 24, 2024
Language: English
Other information and formats: www.gutenberg.org/ebooks/44926
Credits: Produced by Al Haines
*** START OF THE PROJECT GUTENBERG EBOOK WHEN YOU DON'T KNOW WHERE TO TURN ***
WHEN YOU
DON'T KNOW
WHERE
TO TURN
_A Self-Diagnosing Guide
to Counseling and Therapy_
Steven J. Bartlett, Ph.D.
Contemporary
Books, Inc.
Chicago -- New York
* * * * *
ALSO BY STEVEN JAMES BARTLETT
_Normality Does Not Equal Mental Health: The Need to Look Elsewhere for
Standards of Good Psychological Health_
_The Pathology of Man: A Study of Human Evil_
_Reflexivity: A Source Book in Self-Reference_
_Self-Reference: Reflections on Reflexivity_ (co-edited with Peter
Suber)
_Conceptual Therapy: An Introduction to Framework-Relative Epistemology_
_Metalogic of Reference: A Study in the Foundations of Possibility_
_VALIDITY: A Learning Game Approach to Mathematical Logic_
As editor of these books
by Paul Alexander Bartlett:
_Voices from the Past -- A Quintet of Novels_:
_Sappho's Journal_
_Christ's Journal_
_Leonardo da Vinci's Journal_
_Shakespeare's Journal_
_Lincoln's Journal_
Library of Congress Cataloging-in-Publication Data
Bartlett, Steven J.
When you don't know where to turn.
Bibliography: p.
1. Psychotherapy. 2. Counseling. 3. Consumer
education. I. Title.
RC460.B28 1987 616.89'14 87-20045
ISBN 0-8092-4829-8
Copyright © 1987 by Steven J. Bartlett, Ph.D.
All rights reserved
Published by Contemporary Books, Inc.
180 North Michigan Avenue, Chicago, Illinois 60601
Manufactured in the United States of America
Library of Congress Catalog Card Number: 87-20045
International Standard Book Number: 0-8092-4829-8
Published simultaneously in Canada by Beaverbooks, Ltd.
195 Allstate Parkway, Valleywood Business Park
Markham, Ontario L3R 4T8 Canada
Project Gutenberg 2014 edition
Note that this is a _copyrighted_ Project Gutenberg eBook; it is _not_
in the public domain. Its license, see below, allows for free
non-commercial distribution and prohibits its sale or use in derivative
works by anyone without the copyright holder's written consent.
_When You Don't Know Where to Turn_ was originally published in 1987 by
Contemporary Books. All rights to the book have now reverted to the
author, who has decided to make the book available as an open access
publication, freely available to readers through Project Gutenberg
under the terms of the Creative Commons
*Attribution-NonCommercial-NoDerivs license*, which allows anyone to
distribute this work without changes to its content, provided that both
the author and the original URL from which this work was obtained are
mentioned, that the contents of this work are not used for commercial
purposes or profit, and that this work will not be used without the
copyright holder's written permission in derivative works (i.e., you
may not alter, transform, or build upon this work without such
permission). The full legal statement of this license may be found at
http://creativecommons.org/licenses/by-nc-nd/3.0/legalcode
[Illustration: CreativeCommonsLogo.jpg]
This book is dedicated to Karen,
my love, wife, and friend.
Preface to the Project Gutenberg Edition
Nearly three decades have passed since _When You Don't Know Where to
Turn_ was first published. In that time, psychiatry, clinical
psychology, and counseling have changed a good deal.
Psychiatry has continued on a now well-worn path leading to a more and
more inflated universe of diagnostic labels, the majority of which have
no known organic basis. Few readers who are not themselves mental
health professionals realize that these diagnostic classifications are
_voted into existence_ by committees of psychiatrists whose
pronouncements magically summon into being a lengthening list of
so-called "mental disorders." These pronouncements are then applied to
people in order to label their problems (as well as the people who have
them), to match their problems with allegedly effective treatments, and
in the process to give the impression that a respectable medical
process of diagnosis and intervention has been undertaken.
And yet these so-called "mental disorders" do little more than equate
designated patterns of behavior, emotion, or thought--called
syndromes--with alleged psychological malfunctioning. Such syndromes
are no more than sets of symptoms that can be collected together in a
wide variety of different ways, but depending upon how they are
grouped, distinguishable syndromes can be pointed to and named. This is
a highly arbitrary process very much like fortune-telling using tea
leaves, which depends on the pattern seen or imagined in the tea leaves
at the bottom of a cup.
During the past three decades, clinical psychology and its less formal
cousin, counseling, have also undergone noticeable change. They have
been the traditional sources of a large number of diverse approaches to
psychotherapy and counseling. But in the past thirty years, the large
number of approaches to psychotherapy and counseling has, in practical
reality, shrunk considerably. This has been due to the rapid dominance
and virtual monopoly that has been gained by cognitive-behavioral
therapy, also known as rational-emotive therapy. Insurance companies
have been attracted like flies to the sweetness of the comparatively
brief treatment period touted by cognitive-behavioral therapy, and
practitioners have similarly been attracted by the ease of using its
one-size-fits-all approach.
And so where the changes in psychiatry have been inflationary in its
authorized catalogue of "mental disorders" known as the _DSM_
(_Diagnostic and Statistical Manual of Mental Disorders_), clinical
psychology and counseling have been on a deflationary course that has
progressively narrowed the treatment options available to many people.
Despite the passage of time, _When You Don't Know Where to Turn_
remains the only step-by-step self-diagnosing guide to counseling and
therapy, a guide that seeks to direct individuals--by respecting and
responding to the very great differences that exist among
individuals--to approaches to counseling and therapy that may be most
likely to benefit them--taking into account the nature of their own
individual problems, their different degrees of willingness and
abilities to learn and to change, and their differing individual
situations in life, including their financial resources and the amount
of time that they are willing to devote to therapy.
Such a customized, individually-centered perspective is not popular
today. The human population continues inexorably to expand while our
healthcare system insists on general applicability and streamlined
efficiency. Individual problems in living are more easily and rapidly
"processed" when they can be subsumed under specifiable diagnostic and
treatment codes. In this increasingly mechanized process, the
individual person and the individual problems of living he or she is
attempting to cope with tend more and more to be ignored or neglected,
and his or her diagnosable "disease entity" becomes the object of
attention.
These comments are not a polemic against current trends and fashions;
they are rather intended to place in perspective the changes that have
occurred in the mental health field during the past three decades since
the first edition of this book came off the press. What a reader might
take away from these preliminary remarks are these suggestions:
* to recognize that, like so much that is a human production, today's
classification system of mental disorders is unlikely to be the final
word about the human condition, but that its proliferating list of
mental disorders should be taken by the humble at least with a grain of
salt, and rejected wholesale by those who are more critically inclined;
* to accept the fact that it is becoming harder with the passage of
time to find one's way to a mental health clinician who is _not_
recipe-oriented, due to the in-fashion monopoly that prescribes
cognitive-behavioral therapy, and due to the pressures on the
healthcare system to process people and their problems faster and at
lower cost; and, finally,
* to realize that, when it comes to problems of living, those who are
willing to accept a healthy measure of responsibility for their own
choice of practitioner and treatment are most likely to find a
practitioner and a treatment that meet their individual needs.
From this point of view, _When You Don't Know Where to Turn_ continues
to offer readers a heightened consciousness of alternatives to
treatment that do still continue to available, though they can be
somewhat harder to find in some areas of the country, and to give
readers a sense of what those alternatives have to offer and for which
kinds of problems and personalities they may best be suited.
Readers interested in learning more about the author, his research, and
publications by him, many of which can now be downloaded at no cost,
may like to visit the author's website:
http://www.willamette.edu/~sbartlet
Steven James Bartlett
Salem, Oregon
2014
* * * * *
This book offers counseling observations based on the author's
experience only and makes no specific recommendations for any
individual or group.
It is intended and has been written to offer the author's understanding
and opinions in regard to the subject matter. The author and publisher
are not here engaged in providing personal psychological or psychiatric
or other professional advice. For such advice, the reader should seek
the services of a qualified professional.
The author and the publisher cannot be held responsible for any loss
incurred as a result of the application of any of the information
contained in this book.
CONTENTS
Before We Begin ... xi
Acknowledgments xv
The Purpose of This Book 1
PART I: GETTING STARTED 7
1 Prisons We Make for Ourselves 9
2 Paths to Help 17
3 Bridges from Here to There 29
4 The Therapeutic Jungle, Part I:
Social Workers, Psychologists, and Psychiatrists 39
5 The Therapeutic Jungle, Part II:
Outside the Mainstream 48
6 Where You Can Find Help 54
7 Self-Diagnosis: Mapping Your Way to a Therapy 59
8 Emotional Problems That May Have Physical Causes 99
PART II: EXPERIENCING THERAPY 111
9 Psychoanalysis 113
10 Psychotherapy, Part I:
Client-Centered Therapy, Gestalt Therapy,
Transactional Analysis, Rational-Emotive Therapy, and
Existential-Humanistic Therapy 123
11 Psychotherapy, Part II:
Logotherapy, Reality Therapy, Adlerian Therapy,
Emotional Flooding Therapies, Direct Decision Therapy 150
12 Behavioral Psychotherapy 173
13 Group Therapy 184
14 Marriage and Family Therapy 194
15 Channeling Awareness: Exercise, Biofeedback,
Relaxation Training, Hypnosis, and Meditation 204
16 Drug and Nutrition Therapies 227
PART III: IMPORTANT QUESTIONS 239
17 Locating a Therapist 241
18 Should You Be Hospitalized? 252
19 Confidentiality: Your Privacy 257
20 Does Therapy Work? 267
21 Life After Therapy 282
PART IV: APPENDIXES 287
Appendix A: Agencies and Organizations That Can Help
(United States and Canada) 289
Appendix B: Suggestions for Further Reading 298
Index 307
ABOUT THE AUTHOR 313
{xi}
BEFORE WE BEGIN ...
* A recent study by the National Institute of Mental Health shows that
one American in five suffers from some type of psychiatric disorder:
50.5 million Americans have one or another of eight serious psychiatric
disorders, ranging from anxiety disorders and phobias to depression and
schizophrenia.
* Of these, only one person in five seeks professional help. More than
40,400,000 severely troubled people do not receive any treatment.
* An unknown number of healthy, emotionally untroubled Americans enter
therapy for reasons of self-development.
* More than 130 distinguishable therapies now exist.
* These therapies are offered by a variety of health care
professionals, including social work counselors, clinical and
counseling psychologists, psychiatrists, biofeedback therapists, and
others. Their backgrounds, training, fees, and durations of treatment
vary considerably.
* These professionals practice in a number of different settings: in
private practice, group sessions, public and private agencies,
hospitals, newly established nonhospital {xii} inpatient facilities,
and in the context of educational programs.
* Most people who enter therapy do not know what alternative approaches
to therapy exist or how to choose among them. They usually locate a
therapist in a more or less random way.
* Most people fear the idea of entering counseling or psychotherapy.
They do not have a clear conception of what to expect: they do not know
in advance what the _experience_ of therapy is like.
* For a variety of reasons, many people who think of going to a
therapist are concerned about whether their relationship with the
therapist will really be confidential. If you are especially concerned
about privacy, you should be aware of several ways that confidentiality
may be broken, what the laws concerning confidentiality are, and, in
particular (what few people realize), how insurance claims for
psychological care can invade an individual's privacy.
* Counselors and therapists tend to specialize in one or a small number
of alternative approaches to therapy. Some approaches to therapy are
most appropriate for treating certain problems or responding to certain
personal interests; others are better suited to providing help with
other problems and concerns. Choosing a therapist with an orientation
that is right for _you_ can be extremely helpful and can help you save
much time, money, and energy.
These facts highlight the situation in counseling and psychotherapy
that anyone faces who enters therapy today.
From them, you can see that there is a bewildering array of counseling
professions, of distinct approaches to therapy, and of settings in
which help is offered. This guide's intention and hope is to help you
understand the alternatives, and to help you form your own judgment how
it may be best to proceed.
The book hopes to give you real assistance so you may make a good
choice--thereby saving you emotional investment, time, money, and the
potential discouragement of avoidable false starts with therapies that
may not help because they are not relevant to your goals, values, and
personality.
{xiii}
Be patient. Take the time to think about yourself, your life, and your
hopes for a better life. This book was written for you, to help you to
improve your life, your self-esteem, and your relationships with
others. They are worthy goals.
Nothing in this world can mean as much.
May you have the energy, courage, and perseverance to achieve them!
{xv}
ACKNOWLEDGMENTS
I would like to express my gratitude to Dr. William Altus, then
Professor of Psychology at the University of California, Santa Barbara,
who went out of his way to encourage my first interests in
psychotherapy when I was a graduate student there twenty years ago. To
Professor Paul Ricoeur, I would like to express my admiration for his
original contributions to Freud scholarship and my enduring gratitude
for his willingness to direct my doctoral research at the Université de
Paris.
I am indebted to Dr. Raphael Becvar, Professor, Marriage and Family
Therapy, Saint Louis University, both for making it possible for a
faculty colleague to learn from him in several of his excellent
seminars and for his later comradeship. To my good friend, Dr. Thomas
Maloney, clinical psychologist in Clayton, Missouri, I want to extend
my warmest appreciation for his personal guidance and voluntary
supervision of my first efforts in counseling. If ever the qualities
of compassion, depth of understanding, humor, and genuine care are to
be found in one person, they are in him. I would also like to thank
Professor Lillian Weger, George Warren Brown School of Social Work,
Washington University, St. Louis, for generously welcoming me into her
fine seminar in psychodynamic models.
{xvi}
I especially thank Dr. Renate Tesch and Professor Hallock Hoffman, of
the Psychology Faculty of the Fielding Institute in Santa Barbara, for
making possible a writer's retreat in the California desert: the loan
of their home in Sky Valley made writing the last group of chapters a
special and memorable pleasure. One is fortunate to have such friends.
If this book became more readable after its first draft, it was due in
great part to the conscientious energy of my wife, Karen, in spotting
the weeds of obfuscation that seem to grow effortlessly in an
academic's garden. I want to thank her for her patience, with both me
and the book.
I would also like to take this opportunity to thank Miss Libby
McGreevy, Assistant Editor, Contemporary Books, Inc., for her helpful
suggestions and for her regular doses of encouragement that made
writing this book a happy experience.
{1}
_When You
Don't Know
Where
To Turn_
THE PURPOSE OF THIS BOOK
I would like to introduce this book by telling you what happened to a
real and likable person who ran into some very difficult times and as a
result entered therapy.
Frank is a large man, a former college football player, powerfully
built. He has always prided himself on his strength and determination.
He used to be friendly and outgoing. He had a pleasant smile,
complemented by his clear blue eyes.
Frank had worked for eleven years for a manufacturer of tools. Not
long ago, he was promoted to the position of managing the company's
sales division in a large midwestern city. Soon after Frank and his
wife moved, his wife became pregnant with their third child. Frank had
a well-paying job, excellent benefits, a pleasant home they had just
bought, and a contented relationship with his wife. But in spite of
these things, he became severely depressed. And he began to feel
terribly frightened: he had to leave his desk several times each
morning and again in the afternoon. He would go to the men's room,
lock the door, turn on the water faucets, and cry.
Frank lost fifteen pounds in three months. He had a poor appetite,
slept badly, and was very anxious around his {2} co-workers. He
couldn't understand what had happened to him, and he was unwilling to
let others know how unhappy he felt. He was ashamed of what he took to
be a weakness in himself: like many men, he was raised to believe that
men shouldn't cry, and his crying bouts shook his sense of identity and
stability. His marriage began to suffer. Frank and his wife seldom
made love. Frank was irritable and impatient with his wife and his
children. Frank's wife knew he was very troubled, but he refused to
talk to her about it.
For several months, Frank fought against his depression. (If only he
had been aware of the _strength_ that he mustered to do this!) Then he
reached a crisis and could not force himself to go to work. He stayed
home with a bad cold, slept as much as he could, and was very
short-tempered. He was crying a good deal. Frank's wife persuaded him
to see a doctor. The doctor referred him to a psychiatrist. The
psychiatrist saw Frank twice a week for two-and-a-half months, but
Frank was troubled by side effects from the antidepressant medication
he took under the psychiatrist's supervision. He resisted the idea of
"taking drugs," so he decided to see a psychotherapist who, in
cooperation with the psychiatrist, monitored Frank's condition as he
gradually went off the antidepressants.
However, after five months, Frank did not feel he was making any real
progress. He changed to another therapist who, his wife had heard,
specialized in the treatment of depression.
Together, Frank and his new therapist came, over a period of months, to
recognize that Frank's depression had resulted from two conflicts:
Frank had hated his job but had refused to admit this to himself, and
now his wife was pregnant again, and because of this added financial
responsibility he felt forced to stay with his present job, where he
had seniority, good salary, and benefits.
Once the basis for his depression was made clear, it was possible to
begin to treat Frank's problem. His wife was very willing to encourage
him to plan for a change of jobs, even though this would mean a
temporary reduction in his income. Frank saw a vocational therapist
and received guidance that led him to take some evening classes and
then to become a computer programmer for a rapidly growing local
company. His {3} depression faded away, and he now seems genuinely to
be content.
WHAT YOU CAN EXPECT FROM THIS BOOK
I knew Frank personally, as his therapist in a group. (His name, like
all others in this book, has been changed, along with certain details
about his situation.) With professional help, Frank was able to
improve his life--his sense of self-esteem, his marriage, and his
family life. It was a long and painful process, as much self-change
can be. But perhaps Frank's experience might have been _less_ painful,
perhaps Frank might have felt less devastating isolation, and perhaps
his path to a resolution of his difficulties could have been shortened
if a practical guide to counseling and therapy had been available to
him when he first decided to find help.
MAKING INTELLIGENT CHOICES
This book is about how you can get the most appropriate kind of help
for your problems, goals, and personality. Specifically, _When You
Don't Know Where to Turn_ sets out to help you become adequately
informed about the range of therapists and therapies--_as these relate
to your own assessment of your goals and interests_--so that you will
be able to make intelligent decisions about these issues:
* the _kind of professional_ to seek out
* the _type of therapy_ most likely to help you with a certain
complaint or set of interests and values
* how to locate the form of therapy that seems most promising to you at
_a price you can afford_ and with _an expected duration_ you can live
with
* what _setting_ to look for in which the help you would like is offered
This book uses two approaches, both presented here for the first time
and both based on common sense and intelligent advance planning.
{4}
First, you will be able, through a series of carefully organized
questions and easily followed instructions in Part I, to pinpoint one
or more approaches to therapy that may be most promising given your
initial objectives, problems, or interests. For the first time, a
_self-diagnosing map_ to the major approaches to therapy is made
available.
Second, you will have the opportunity to glimpse what typically happens
during the sessions of counselors, psychologists, and psychiatrists as
they treat clients or patients using the different main approaches to
therapy. You will come to see what the _experience_ of therapy is like
in these different approaches.
In other words, the self-diagnosing map will point you in the direction
of one, and sometimes more than one, approach to therapy that may be
most promising for you to begin the process of self-change, and you
will then be able to gain an insider's perspective on that approach so
that you can judge how well suited to you the approach is and how it
compares to the other main approaches to therapy.
If this guide helps you choose a path to the kind of therapy that will
be appropriate and useful to you, it will have done something
worthwhile. A guide to counseling and psychotherapy should, however, do
more than this.
OVERCOMING ISOLATION AND GETTING STARTED
People who are troubled tend to try to hide it. They frequently isolate
themselves when they are distressed, so overcoming the desire to
withdraw is the first order of business if they are to improve their
lives and feelings.
One of the things this book sets out to do is to help you see that very
likely the problems you are facing are not one of a kind. You have a
lot of company; the difficulties you are having are probably very
familiar to counselors and therapists. Realize that there are ways of
resolving most problems and that doing so often is easier with the
sympathy, empathy, moral support, friendship, or direction of a
counselor or therapist than by yourself.
CAN YOU HELP YOURSELF?
However, sometimes it _is_ possible to help yourself a great deal {5}
through your own initiative. This book will describe ways that you can
be your own source of help and will pay particular attention to _when_
it may be appropriate and safe to rely upon inner resources.
CLEARING THE CONFUSING JUNGLE
Most people are not familiar with the differences among the main kinds
of "psychosocial" helping professionals--the various types of
counselors, clinical psychologists, psychiatrists, psychotherapists,
psychoanalysts, social workers, etc. Another purpose of this book is
to clarify these labels, to describe how the approaches used by their
practitioners are distinct and how they are similar, and to give an
idea of how their fees and durations of treatment vary.
Individual chapters in Part II are devoted to describing the main
varieties of therapy available today: psychoanalysis; psychotherapies;
behavior-changing therapies; marriage and family therapy; group
therapies; exercise, biofeedback, relaxation, hypnosis, and meditation;
and drug therapy. Each approach will be described in the context of
experiencing professional help _and_ in terms of how and when it may be
possible to apply the approach on your own. These chapters will help
you understand what in general to expect if you choose a particular
kind of treatment, how the course of treatment may go, and what point
of view is shared by professionals who use it.
FINDING SOMEONE TO HELP
Part III of this book will describe how you can go about locating good
professional care, whether from a family therapist, an analyst, a
social worker, a psychiatrist, a clinical psychologist, or another kind
of therapist. You will learn how you can find a reputable professional
with a particular specialization, and you will be encouraged to ask him
or her some useful questions before beginning treatment.
As we will see in detail later on, there are numerous settings in which
counselors and therapists work. Many are in private practice, but many
also work for a variety of agencies, both public and private, for
hospitals and newly established nonhospital residential facilities, and
even for educational institutions. We {6} will discuss each of these
settings in Part III so that you will have a clear idea both of the
alternatives that exist and of important factors to consider when
deciding among them.
SHOULD YOU BE HOSPITALIZED?
"Should I consent to hospitalization?" "What will I encounter if I
accept hospitalization?" "Is it necessary, is it desirable?" Another
chapter in Part III is devoted to answering these and related questions.
IS YOUR PRIVACY PROTECTED?
In many ways it will be, and in other ways it may not be.
Confidentiality as it relates to the treatment of emotional or
psychological difficulties is a thorny issue, one that worries many
people. In Part III, a chapter is devoted to a discussion of this
potentially important area of personal concern.
DOES THERAPY WORK?
You may, of course, feel a certain amount of skepticism about the real
utility and effectiveness of any one of the many therapies that now
exist. This is, in my judgment, a healthy skepticism. A chapter in
Part III will review what you may be able to expect, and perhaps should
not expect, in the light of recent evaluations of the effectiveness of
the main therapies. To complement these as yet incomplete scientific
findings, I will emphasize a measure of ordinary common sense as we go
along.
LIFE AFTER THERAPY
The last chapter in this book deals with what to expect _after_
therapy. Recurrences, future crises--they often come with the package:
life! Relapses--re-experiencing feelings of distress--have received
too little attention. Often, old habits and feelings remain with us
and reappear during times of stress. Too, we know that as life goes
on, we need to be able to tackle new problems and new situations and
sometimes must handle unexpected crises. Chapter 21 tells you how the
experience of therapy will help you cope with possible setbacks and the
uncertainties of the future.
{7}
PARTI
GETTING STARTED
{9}
1
PRISONS WE MAKE FOR OURSELVES
Which of us is not forever a stranger and alone?
Thomas Wolfe, _Look Homeward, Angel_
What other dungeon is so dark as one's own heart! What jailer so
inexorable as one's self!
Nathaniel Hawthorne, _The House of the Seven Gables_
When you have shut your doors, and darkened your room, remember
never to say you are alone, for you are not alone, but God is
within, and your genius is within.
Epictetus, _Discourses_
When people are in pain and most need others, many wall themselves in.
This very human tendency is illustrated by a famous story.
In 1934, Admiral Richard Byrd led an expedition to Antarctica, where he
established a base on the edge of the Ross Ice Barrier, 700 miles north
of the South Pole. Byrd then decided to set up a small weather
observation post closer to the pole, which he chose to man alone. He
would stay in a one-room cabin, a box {10} that measured nine feet by
thirteen feet, lowered into a rectangular hole cut into the ice to
protect the cabin from gale-force winds during the coming winter months.
Byrd was committing himself to a degree of personal isolation few men
have ever taken on. What happened to him in the months ahead reveals
something important to psychologists that all of us should bear in mind.
Byrd's men left him in his tiny station and returned across the ice to
the main base 123 miles to the north. Winter blizzard conditions soon
surrounded Byrd. He knew he was in for a long period of solitary
confinement, with no hope of returning to the base, even if a medical
emergency demanded this. He could never make the return trip to the
base on his own, and it would be too dangerous for a team of men to try
to get to him in the winter darkness across the miles of ice.
After several months of isolation, Byrd became very ill. He was
distressed and confused about his condition--nausea, vomiting, terrible
headaches, blurred vision, great weakness. Days would go by, and he
would cling to life by a thread, his mind wandering, drifting in and
out of the dizzying incoherence of frequent comas. He would, by sheer
force of will, gather his reserve of fading energy and stagger across
the tiny room to light the stove and open a can of food, which he soon
lost from his stomach. Gradually, he came to realize that the fumes
from his kerosene stove and from the gasoline-powered generator for the
telegraph were poisoning him. But if he turned off the stove, he would
freeze to death, and the telegraph was his only contact with others.
He knew his life was in real danger, yet he refused to let his men know
of his desperate situation. Nor could he _admit_ to _himself_ that he
was in trouble.
Listen to his own words, written half a century ago, in his snow-buried
room with the air heavy with fumes and the inside walls encrusted with
glistening ice:
It is painful for me to dwell on the details of my collapse....
The subject is one that does not easily bear discussion, if only
because a man's hurt, like his love, is most seemly when concealed.
From my youth I have believed that sickness was somehow
humiliating, something to be kept hidden....
To some men sickness brings a desire to be left alone; animal-like,
their instinct is to crawl into a hole and lick the hurt.
{11}
There were aspects of this situation which I would rather not
mention at all, since they involve that queer business called
self-respect....
For a reason I can't wholly explain, except in terms of pride, I
concealed from [my] men, as best I could, the true extent of my
weakness. I never mentioned and, therefore, never acknowledged
it.... I wanted no one to be able to look over the wall....[1]
[1] Richard E. Byrd, _Alone_ (New York: G. P. Putnam's Sons, 1938), pp.
166, viii, 294-295.
In spite of his efforts to keep his condition to himself, Byrd's radio
operator at the main base seems to have intuited that Byrd was in
danger. A rescue party was sent as the winter weather became less
harsh, and Byrd was brought back to the base, probably just in time,
before the fumes killed or permanently injured him.
In many ways, Byrd's Antarctic experience parallels that of many of us
who, because of our own pain and hardship, isolate ourselves from
others. Our lives become cold, desolate, despairing. Our suffering is
real, but for one reason or another we cannot or will not reach out to
others.
WALLING YOURSELF OFF FROM OTHERS
Most of us are aware of a need for human company and companionship.
But when we are in pain or are severely troubled, we often forget what
has been recognized for a long time:
Frederick II, the thirteenth-century ruler of Sicily, believed that all
children were born with a knowledge of an ancient language. When they
were taught the language of their parents, however, he theorized, their
knowledge of the older language was overridden and blotted out. King
Frederick hypothesized that if children were raised without being
taught a language, they would, in time, spontaneously begin to speak in
some ancient tongue.
He therefore appointed a group of foster mothers, had new-born infants
taken from their natural mothers, and ordered the foster mothers to
raise the children in silence.
The upshot of this early experiment--as the legend goes--was {12} that
Frederick never found out whether his theory was true. All of the
babies died. They could not live without affection, touching, and
loving words. Apparently, the foster mothers withdrew all human warmth
when they sought to obey the king's order.
Today, we are aware of a baby's vital need for affection, for human
contact--and even so, in our adult lives, when human contact is equally
essential, we sometimes cut ourselves off from others.
THE MYTH OF SELF-SUFFICIENCY
As adults, we tend to emphasize self-control. We think of ourselves as
_responsible_--to ourselves, our parents, our employers, our children.
All this responsibility can sometimes be a heavy load! During periods
of illness or emotional crisis, the emphasis on _control_ can be
excessive. It can create the bars of a prison, a grillwork of defenses
that stands between us and others who are able to offer encouragement,
warmth, understanding, and direction.
There is no lonelier person than someone who has decided to take his or
her own life. The decision is the ultimate form of self-isolation. It
is the ultimate admission that one's imprisonment is final and that
there is no escape.
Fortunately, the decision to take one's life is reversible, if the
person is helped in time. The help may come from within or from
without, but it always involves the _recognition of hope_ that the
self-imprisonment may not be final, that there are others who would
help, that, even for someone who is terminally ill, there may be
periods of satisfaction and joy that make living worthwhile.
Western European, American, and Japanese societies are very
control-oriented. There is much evidence that when members of these
societies are emotionally troubled they often perceive a fault within
themselves. They see their troubles as springing from a loss of
self-control: "Just pull yourself together!" "It's just a matter of
self-discipline, of _will_!"
The greater our sense of responsibility--the more we emphasize personal
control over our inner and outer affairs, the more we see ourselves as
individualists whose individualism is based on strength of will,
discipline, guts--the more we are _trapped by the myth of
self-sufficiency_.
{13}
People who as children were forced to become independent too early, who
lacked a long enough period of closeness to their mothers, whose
parents were immature and self-absorbed frequently develop what is
called _pseudo-self-sufficiency_ or _premature ego development_. Such
a person is the neurotically extreme form of the "do-it-yourselfer."
He or she refuses to relinquish control, whether to the car mechanic,
the sewer cleaner, or a lover. There is an urgent and obsessive need
to maintain control, never to be "out of control."
For such people, anxiety, depression, and loneliness can be especially
devastating because they have walled themselves in to such an extent
that emotional growth and change are blocked.
Yet most of us share, to some extent, this belief in self-sufficiency.
It is one of the most tenacious forms of self-imprisonment that we have
available to us, literally at our own disposal. It is a prison we
often take great pride in. Pride, control, and self-sufficiency are
usually close friends. They keep us from having _real_ friends and
stand in the way of our being good friends to ourselves.
THE FEAR OF BEING LABELED EMOTIONALLY DISTURBED
It is woven into the fabric of our society that we should conform. A
young teenager from Australia now in a California high school tries as
quickly as possible to lose the accent that differentiates her, that
makes her the object of laughter. The same pressures motivate the
stutterer to keep quiet, speaking only when absolutely necessary. The
National Merit Scholar says "ain't" among his school friends to be one
of them.
Children are especially sensitive to covert expectations, the implicit
_shoulds_ that are handed down from the adult world and are frequently
refashioned to fit the stages children move through.
At each stage, the implicit maxims are _dress alike, talk alike, think
alike_. Be "in." Especially, have the same feelings, values, and
hopes. Most of us are raised to fear being different because we might
come to be a lonely minority of one.
But when we become ill, especially if we are emotionally troubled, the
rules change radically. Animals, from the aquarium angelfish to the
household dog or cat, seem to have an instinct to {14} seek isolation
when ill. This tendency probably has evolved because it contributes to
survival: the sick animal can more easily rally its energy for
self-healing in quiet, undisturbed by others of its kind. And going
off to be alone reduces the chance that the animal will spread any
disease it has.
Added to an animal's self-isolating tendency is the tendency to hide
the very _signs_ of illness or injury. An animal that shows signs of
injury or illness is immediately a target for predators who look for
the weaker members of the species.
We human beings also tend to choose solitude and to hide the revealing
symptoms of sickness or injury. Admiral Byrd admitted to these
defenses only in his loneliness. But it is important to realize that
hiding our feelings and isolating ourselves frequently are not in our
best interests.
Animals do not practice medicine, though many species are capable of
offering moral support and even a certain amount of physical
assistance, as in the case of a sick whale who may be supported by its
fellows in the water in order to breathe. But only we have developed
medicine, and we have more recently begun to develop ways to treat
problems that affect our emotions, attitudes, and behavior. When
individuals, perhaps instinctively, distance themselves from others and
bottle up their malaise, they turn their backs on the educated
assistance and goodwill that are available.
Sometimes we do so out of fear of treatment coupled with fear of
admitting that we are not as self-sufficient as we want to believe.
But more often in the case of problems that directly affect our
moods--i.e., "psychological problems"--we feel ashamed and afraid of
the stigma, the disgrace, that our society attaches to those who admit
they have unhappy or confused feelings.
There can be little doubt that society is unbalanced in legitimating
physical sickness while reacting with alarm and repugnance to problems
of a psychological nature. Think of the discrimination _against_
psychological disorders, in favor of physical complaints, practiced
openly by nearly all health insurance companies, offering reduced
benefits for mental health. Psychological pain does not hurt any less
because it is emotionally based. Even so, emotional distress is held
suspect, and insurance coverage for it, if not ruled out completely, is
frequently only partial. It was, after all, not more than a century
ago that our mental hospitals were run with an inhumanity that {15}
still can send shivers down one's spine. Unhappily, it is clear that
we have not entirely left this phase of our development: the film _One
Flew over the Cuckoo's Nest_, for example, points to continuing
inhumanity in some psychiatric hospitals. And there is the alleged
case of a Ukrainian woman who was involuntarily committed and held for
some thirty years in a mental hospital. She was thought to be insane
because, unfortunately, no one involved in her case recognized her
"gibberish" as Ukrainian!
Emotional and mental problems are still not accepted by many. There is
a fear of the unknown and a skepticism that psychological problems are
nothing more than signs that a person is malingering, simply does not
want to try to get better. And there is a gut-level anxiety when
confronted by someone who, we worry, "may be close to going over the
edge."
TEARING DOWN PRISON WALLS
What undue hardship this causes! As wonderful as the body is, we
accept its imperfections, its susceptibility to disease and injury.
But our brains, our minds, our spiritual dimension--how less well we
understand these in their greater complexity! Is it so strange and
unacceptable that they should be prone to their own problems, that
they, too, may bring suffering?
Because society does not legitimate emotional pain, many people are not
able to see their own pain as legitimate. So they deny it, to
themselves and to others. But pain is usually a healthy signal; it
tells you that something is wrong: Withdraw your hand from the fire!
Move your cramping legs! Do something about your abusive, alcoholic
husband! Get help for your depression!
Every one of these pains is a warning. To ignore all except those that
are physical would be like saying that we are only bodies, without
feelings, without humanity.
When you are in pain, whatever its source and kind, pay attention to
it! Pain is often what points to a better life.
It is surely better to cope with a label applied in ignorance by some
members of society, if this must be, than to live an unsatisfying and
painful life. You must not manage your life just to avoid the
potentially critical judgment of people who are ignorant of, or who
refuse to acknowledge, the realities of human psychology. You can feel
sure that among well-informed people, if you have had to deal with
alcoholism, drug abuse, a difficult {16} marriage, job depression, or
any other "psychological" problem, you will be thought to be just as
"respectable" as if you had coped with major surgery after an
automobile accident. In fact, since overcoming a psychological
difficulty demands a great deal more of your own voluntary effort,
coming up a winner will increase your own self-respect and the respect,
and even admiration, of those whose judgment is meaningful.
The first step to freedom from pain is to become aware of the walls of
the prison that shut you in. Only then can you begin to tear them down.
{17}
2
PATHS TO HELP
To wrench anything out of its accustomed course takes energy,
effort and pain. It does great violence to the existing pattern.
Many people want change, both in the external world and in their
own internal world, but they are unwilling to undergo the severe
pain that must precede it.
Rivers in extremely cold climates freeze over in winter. In the
spring, when they thaw, the sound of ice cracking is an incredibly
violent sound. The more extensive and severe the freeze, the more
thunderous the thaw. Yet, at the end of the cracking, breaking,
violent period, the river is open, life-giving, life-carrying. No
one says, "Let's not suffer the thaw; let's keep the freeze;
everything is quiet now."
Mary E. Mebane, _Mary, Wayfarer_
If you decide to enter therapy, your therapist will probably ask you to
think about two interrelated questions (they may be expressed in a
variety of ways): "Where are you now?" and "Where do you want to go?"
Your therapist or counselor will, as he comes to know you, often be
able to help you to answer these by sharing his perceptions of you.
One of the main tasks of the counseling process is to help a person
gain improved self-understanding that embraces both present problems
and future goals.
{18}
Yet if you can gain a certain measure of self-understanding and
self-direction _before_ entering counseling or therapy, it will be
easier for you to choose an approach to counseling or therapy that more
closely fits your problems, values, objectives, available time, and
even your financial needs. You should find in this book a basis for
preliminary _self_-counseling that will give you a sense of how and
where best to begin therapy.
It is important to recognize that none of us ever reaches a final state
of self-knowledge: as long as we live, our self-understanding is
capable of growing. What we really understand about ourselves and what
we believe ourselves to need and want are never more than provisional,
tentative. Additional experience, just the fact of living longer, very
likely will lead you to perceive yourself differently and motivate you
to modify your priorities and change your goals.
WHERE ARE YOU NOW?
Late in 1984, the National Institute of Mental Health released the
first published results of the largest mental health survey ever
conducted. The results are startling and are an unhappy commentary on
our society and world.
The report shows that 20 percent of Americans suffer from psychiatric
disorders. Yet only one in five of these seeks help. The others live
with their suffering.
The most common problems are these:
_Millions of Americans_
_Psychiatric Name of Condition_ _with This Disorder_
Anxiety disorders 13.1
Phobias 11.1
Substance abuse (alcohol, drugs, etc.) 10.0
Affective disorders (including
depression and manic depression) 9.4
Obsessive-compulsive disorders 2.4
Cognitive impairment 1.6
Schizophrenia 1.5
Antisocial personality 1.4
The NIMH study also shows that women are twice as likely to seek help
as men. Two interrelated inferences are commonly made from this
previously known fact: women are often more accepting of their
emotional state (men in our society are taught to disregard their
feelings, part of _machismo_), and women are less willing to allow
pride to stand in their way of getting help (women are less affected by
the myth of self-sufficiency).
{19}
The NIMH report indicates, too, that the incidence of psychological
problems drops by approximately half after the age of forty-five. The
below-forty-five years are usually those of highest stress. Above
forty-five, individuals tend to become psychologically better
integrated. This probably reflects increased maturity and a more
accepting, calmer attitude toward life. The lowest rate of emotional
disturbance appears to be in people over sixty-five. Yet there are
many thousands of individuals over forty-five, and indeed over
sixty-five, for whom life remains a difficult inner struggle.
The statistics from the NIMH study reveal how very wide-spread personal
psychological difficulties are. Given the degree of complexity of our
mental, emotional, and spiritual makeup, this should be understandable,
especially when we take into account twentieth-century stresses that
wear us down. Caught up as most of us are in our jobs, families, and
daily worries, we are unaware that, in a very real sense, mental and
emotional health problems have assumed epidemic proportions. If you
bear in mind how fearful our society encourages us to be of admitting
such difficulties, you can perhaps imagine how substantial the
"iceberg" of psychological suffering is: most of it lies below the
waterline of public consciousness.
The NIMH study results should encourage you, if you suffer from
personal emotional difficulties, to realize that you are not alone in
the problems you face. Knowing that there are many good and fine
individuals with very likely similar problems may urge you to take an
honest look at where you are now and then to try to decide what changes
may be helpful to you: where you want to go from here.
If you are fortunate, you may already be aware of the main things in
you and in your life that bring you distress. If so, you are one step
closer to being able to do something about them. Many of us, however,
have become so clever and effective in denying what we really feel that
we have lost touch with our true selves. {20} Desires to repair an
unhappy marriage are shelved while the children are growing up; the
unrewarding nature of a job is ignored because priority is given to
financial security; you may be unable or unwilling to face the pain you
bring to yourself and others as a result of a drug- or alcohol-abuse
habit.
In most cases, it is not possible to gain the motivation and means to
solve a problem until you are willing to accept that there is a problem
that needs to be solved.
Because of the blinding nature of the habits you may have established,
and because of your defensive desires to disregard what disturbs the
equilibrium of habit, it may be hard to acquire a clear picture of
where you stand right now. Sometimes it can be useful to check with
others: how do they see you?
A close friend of mine, after years in her profession, began rather
suddenly to feel how unrewarding her job was, and she began to suspect
that she may have hidden these feelings for a long time. She had
maintained a regular, almost once-a-week exchange of letters with her
mother for twelve years. She knew that her mother kept her letters, so
she went to visit her and asked if she might skim through them, paying
attention to comments she had made over the years about her work. It
quickly became clear to her that, consistently, she had had only very
negative things to say about her job. After skimming through dozens of
letters written over a period of years, she became convinced of her
real and enduring feelings and changed her line of work.
Such self-knowledge does not usually come this easily. We may pride
ourselves on honesty, but there are few of us who permit ourselves
self-honesty to any real degree. Existential-humanistic psychologists
have paid much attention to these ways that we live "in bad
faith"--each of us trying to be a person he or she really is not and
denying the person he or she really is.
We live in a society that emphasizes conformity, "being somebody,"
gaining status and wealth and a good position--yet these values may not
coincide with being true to ourselves. Parental influences can be
strong, as can expectations from our spouses. We internalize many of
these values so that it becomes difficult to see who we really are and
what we really want from life and from our efforts.
There are no easy routes to self-realization. We must all do a certain
amount of hunting in the dark--or, as a colleague of mine {21} likes to
say, "scrabbling about"--for a sense of real identity.
Recognizing that your self-understanding is probably always imperfect
does not mean that it is of little value. It is, in the end, all any
of us has to go on.
It may be useful to ask people close to you what they perceive about
you. Reading through a group of old letters, keeping a journal, or
simply setting aside a few minutes for self-appraisal at the end of
each day or week may also be enlightening. If you do this
self-examination, gradually where you are and what you feel will become
clearer, and then it will be natural and appropriate to ask what the
next step is.
WHERE DO YOU WANT TO GO? WHAT KIND OF
PERSON DO YOU WANT TO BECOME?
Influences from society, your parents, your spouse, or your close
friends make it difficult for you to know yourself. Defensive habits
and fear of change also stand in the way. These are significant blocks
to self-understanding.
When you turn your attention to the future, to what kind of person you
want to become, you will encounter more blocks to overcome. Life is
like that! It seems that few things come without effort and
perseverance.
There are two major obstacles to designing the model of the person you
would like to become. Because they can be so important, I want to
introduce them early in this book. They are blame and guilt, and they
are like the two ends of a seesaw.
When we appraise what we have done in our lives, we usually find
reasons to blame others, or perhaps to blame limited educational
opportunities, or social pressures, or discrimination--in short, our
past environment: all the factors that limited our lives, interfered
with the attainment of our hopes, and were not under our control.
On the other end of the seesaw sits guilt. And guilt is really blame
turned inward.
If we try to pinpoint the factors that have been responsible for our
lives not having turned out better, we tend to blame environmental
limitations, or else we feel guilt for what we see as our own failings.
Usually, we locate responsibility in both areas.
Most of us, however, have unbalanced seesaws. We usually {22} blame
things _outside ourselves_ for our disappointments. Doing so is a
habit that allows us to avoid responsibility for ourselves and, in
turn, limits our future development.
On the other hand, some of us blame ourselves much too readily: we
carry an exaggerated burden of responsibility, which weighs us down and
also limits our growth as individuals.
Ideally, psychotherapy would like us to let go of so-called "past
negative conditioning"--blame as well as guilt--so that we are free to
choose who we are and will become. Even though this is certainly a
desirable attitude, most of us cannot really forget and let go. We are
all inheritors of a tenacious past: the influences of past events have
a certain power over us, and we must either resign ourselves to being
controlled by the past or fight its influence. The _attitude_ we take
toward the past will usually affect how we meet the future, often
diminishing our freedom to change old habits and undermining our hope
and faith in ourselves.
For example, if Jeff blames his limitations today on his parents, on
the ways they influenced him, he may set goals for himself that are far
from being freely chosen. Jeff may choose them _in reaction to_
domination by his parents years ago. His parents may have tried to
influence him to be a gentle, courteous person with artistic interests.
But as a result of other past influences--for example, because of
frequent moves of the family and repeatedly being bullied as the "new
kid" at different schools--Jeff may feel hostile toward others, so (in
reaction to his parents' influence and because of pent-up hostility) he
decides to go into science (rather than art, for which he perhaps has a
talent) and rejects gentle, courteous qualities in himself.
It is difficult to choose freely. Some psychologists do not believe it
actually is possible. And yet, whether we are ever truly free or not,
we still try to plan our lives, and we believe our plans (and
frequently the lack of them) have something to do with what we make of
living.
Most people who enter counseling or psychotherapy want to improve some
aspect of their living. Individuals whose seesaw is weighted on the
side of blaming outside influences too often come to feel it is too
much work and quit therapy because they cannot accept the need to make
choices and decisions _in spite of_ past influences. On the other
hand, people who blame {23} themselves may be so guilt-ridden that they
are impaired in their openness to the future and feel unable to
initiate fundamental changes in their lives.
When you ask yourself, "What kind of person do I want to become?," try
to be aware of the extent that your answer may be weighed down by
feelings of blame and guilt. All too often we continue to perpetuate,
unknowingly, the same old unsatisfying patterns because we are trapped
by our habits of blaming others or ourselves.
If you feel bogged down by feelings of guilt or burdened by the
limitations of an unfair past, it may be difficult for you to develop a
freely chosen sense of direction. But perhaps you will be able to
acknowledge that the guilt or blame you feel is an obstacle to be
overcome. If so, you have defined an objective that you may use to
decide what type of counseling or therapy may be a most promising first
step.
What I am suggesting is that an obstacle that makes it hard for you to
gain a sense of direction can _itself_ point you in a direction. If
there are blocks, it can be helpful to meet them head-on. In therapy,
the phrase _working through a problem_ often means exactly this.
Choosing what kind of person you wish to be is a _process_, not an
event. It is not something that happens and then is over. Choice is
something implicit in each day of your life; sometimes it is quite
conscious, but it is often dulled by the unconsciousness of habit.
Your personal goals may undergo gradual or abrupt change.
Psychological growth is your response to these changes in outlook.
WHAT DOES THERAPY TRY TO DO?
Individual therapy or counseling (therapy for groups and families will
be discussed in detail later) is really an attempt to build a bridge
between answers to these two now familiar questions: "Where are you
now, or what kind of person are you now?" and "Where do you want to go,
or what kind of person do you want to become?" Think of therapy as an
attempt to build a bridge so that you can pass from a present situation
to a desired way of being.
Carl Rogers defines therapy as "a relationship in which at least {24}
one of the parties has the intent of promoting the growth, development,
maturity, improved functioning, improved coping with life of the
other."[1]
[1] Carl Rogers, _On Becoming a Person: A Therapist's View of
Psychotherapy_ (New York: Houghton Mifflin, 1961), pp. 39-40.
Psychiatrist Allen Wheelis takes this definition further:
Therapy may offer insights into bewildering experience, help with
the making of connections, give comfort and encouragement, assist
in the always slippery decision of whether to hang on and try
harder or to look for a different way to try....
The place of insight is to illumine: to ascertain where one is, how
one got there, how now to proceed, and to what end. It is a
blueprint, as in building a house, and may be essential, but no one
achieves a house by blueprints alone, no matter how accurate or
detailed. A time comes when one must take up hammer and
nails....[2]
[2] Allen Wheelis, _How People Change_ (New York: Harper and Row,
1973), pp. 101, 107.
Therapy involves a three-fold relationship among a helping
professional, the approach to therapy used by him or her, and, what is
most important, the outlook of the individual client. In this book we
will examine each of these three dimensions of therapy in some detail,
but here we will concentrate on the one therapists generally agree is
the most important: you--the kind of person you are, what your
attitudes and outlook are, and, of course, how much you really want to
develop or change. Your attitudes will determine, probably more than
anything else, what variety of therapy you will most benefit from.
Therapists, like teachers (which they really are), find that their
clients or patients can be divided into two groups: active and passive
learners. When you go to a doctor with a broken arm, your relationship
to your doctor is a _passive_ one: you need only to cooperate as he
examines your arm, perhaps administers an anesthetic, and sets the
break. You may take medication for pain, and then you simply _wait_
until, thanks to the body's automatic healing processes, the break is
fused. The public's conception of medicine is predominately a passive
one. To be a "patient" is for the most part to be a passive bystander:
the physician is the active agent who brings about healing. There are
occasional {25} exceptions--for example, physical therapy and
rehabilitation therapy after a serious injury or illness, when the
patient must become more active and accept more responsibility.
As we will see, a few approaches to counseling and psychotherapy
preserve, to some extent, the traditionally passive role of the
patient. Most of them, however, require a good deal of initiative and
just plain hard work on the part of the patient or client.
In building the house of one's life or in its remodeling, one may
delegate nothing; for the task can be done, if at all, only in the
workshop of one's own mind and heart, in the most intimate rooms of
thinking and feeling where none but one's self has freedom of
movement or competence or authority. The responsibility lies with
him who suffers, originates with him, remains with him to the end.
It will be no less his if he enlists the aid of a therapist; we are
no more the product of our therapist than of our genes; we create
ourselves. The sequence is suffering, insight, will, action,
change. The one who suffers, who wants to change, must bear
responsibility all the way. "Must" because so soon as
responsibility is ascribed [outside oneself] the forces resisting
change occupy the whole of one's being, and the process of change
comes to a halt. A psychiatrist may help, perhaps crucially, but
his best help will be of no avail if he is required to provide a
degree of insight which will of itself achieve change.[3]
[3] Wheelis, _How People Change_, pp. 101-102.
WHY IS IT SO COMPLICATED?
For better or for worse, human nature is a many-splendored thing. It
doesn't take an advanced degree in psychotherapy to know that people
can have many different kinds of personal problems. This fact, if we
appreciate it fully, makes more understandable why there are so many
alternative approaches to helping people with their difficulties.
In the world of theory, a _model_ is a simplified representation of
reality. Your checking account record is a model, in just this sense,
of how many real dollars and cents you have in the bank.
Here is a much simplified model that represents five main
psychological, emotion-laden dimensions of a person:
{26}
[Illustration: Five main psychological dimensions of a person:
feelings, hopes, abilities, relationships with others, and behavior]
We see right away that, for the same reasons that there are specialties
in medicine--e.g., orthopedy for bones, neurology for nerves, dentistry
for teeth--there should be special approaches that focus on different
psychological dimensions of the person.
Something else you may see is that the five dimensions in the model are
not isolated from one another. They interrelate and overlap a good
deal. Just as a dentist must know about the orthopedy of the jaw and
skull and the neurology of the teeth a neurologist and an orthopedist
are expected to know something, though not in great detail, about
dentition. Each of us is a unity of what all the medical and
psychological specialties study in different ways, plus a good deal
more, as artists, writers, theologians, and musicians make evident.
That more than 130 distinguishable therapies have now been developed
may perhaps strike us, even so, as excessive. But efforts are being
made to unify many of these approaches, and this book is one of them.
Rather than talking about 130 different approaches, we will center our
attention on the main categories into which the many approaches can be
sorted.
One of the interesting and hopeful things that can be said {27} about
the multiplicity of approaches to therapy and counseling is that
treatment by any one of them can often be of some help. For example,
Helen may wish to stop drinking (a habit in the behavior category), and
she may be helped by means of behavior modification. She may then find
that, as a direct result, her self-concept (feeling category) has grown
stronger, while her marriage (relationship category) has also improved.
Or, Ralph may go to a vocational counselor who helps him define a
direction (hope category) in keeping with his interests and aptitudes.
Ralph goes back to school and develops a background (abilities
category) that reflects these aptitudes and interests. The sense of
direction he has gained helps Ralph stop using drugs (behavior),
reduces his hostility and anxiety (feelings), and improves his
relationships with others. In other words, a helpful change in one
direction can often lead to noticeable changes in others.
However, there also are risks that we should not ignore: Sue goes to an
analyst and learns over a period of months that her marriage to Fred
was based on a sense of inadequacy Sue learned during her childhood.
Her father was so highly controlling and critical of her that she was
never able to develop a sense of her own value. Her husband, Fred, is
also domineering and authoritarian, and he abuses Sue frequently,
usually mistreating her through criticism, but he has sometimes also
beaten her physically. Sue has accepted this without question for a
long time, but due to the emotional support received from her analyst,
she is beginning to develop a sense of self-esteem. As her self-esteem
grows, she comes to realize that her marriage is a self-destructive
relationship and decides to divorce Fred. Her therapy has been helpful
to Sue, but it has, indirectly, resulted in a breakdown of her
admittedly unhappy marriage. A change in one dimension can sometimes
lead to an initially unintended change in another area.
IF IT HURTS, DON'T PROCRASTINATE!
One of the marvelous things about human nature is the ability to feel
pain. This may seem like an odd thing to say, but reflect for a
moment. Pain is frequently what spurs us on from an unsatisfying and
even destructive situation to a better future. Pain tells you to jerk
your hand away from a hot stove. A different kind of pain tells you it
is time to get on with living, time to {28} initiate some positive
changes. Anxiety, sleeplessness, irritability, resentment,
depression--they all can be painful inner feelings that tell us that
all is not well in our inner selves.
It is well-known to counselors and therapists that, in general, the
longer these signs of need are ignored, the longer it may take to help
a person resolve the difficulties that have been pressing for
attention. Distress is not easily buried. When suppressed, it tends
to pop up again later, sometimes with increased severity.
We can, ironically, choose to be "strong" and ignore these messages
from within, or we can listen to our feelings, pay attention to our
hopes, develop needed abilities, seek to improve our relationships with
others, and work to change some ways we behave that block our happiness.
Problems that concern your inner well-being and the health of your
relationships with others who are important to you are better resolved
than buried, and the earlier they are given the attention they deserve,
the easier your path through change to a better life will be.
{29}
3
BRIDGES FROM HERE TO THERE
AN OVERVIEW OF THE FIELD OF THERAPY
THE HELPING PROFESSIONAL
Professionals in the fields of counseling and psychotherapy have a wide
range of different backgrounds and perspectives. They can be broken
down into these categories:
_Social work counselors_: counselors for individuals; marriage and
family counselors; group counselors; and vocational guidance counselors
_Psychologists_: clinical psychologists; counseling psychologists; and
psychometrists
_Psychiatrists_
_Other therapists_: religious counselors; biofeedback therapists;
hypnotherapists; relaxation and meditation instructors; holistic
therapists such as bioenergetics therapists, yoga instructors, and
exercise therapists; etc.
The education, supervised training, and outlooks of these professionals
vary greatly, as do their fees and the average length of time therapy
can be expected to last. We will look more closely at these
differences later on.
{30}
THE RANGE OF APPROACHES TO THERAPY
Because of their differences in training and personal or theoretical
preferences, the distinct classes of therapists represent a diversity
of approaches to therapy. There are numerous schools of
psychoanalysis, psychotherapy, behavioral therapy, group therapy, and
marriage and family therapy, and a range of approaches to personal
adjustment, including exercise therapies, relaxation techniques, forms
of meditation, and drug and nutrition therapies.
From any one of these, a multitude of schools of thought branches out.
For example, psychoanalysis has, since Freud, developed along a number
of different lines: each major psychoanalyst has formulated his or her
own approach to analysis that distinguishes itself from Freud's.
Psychotherapy, to take another example, is not a single approach to
therapy, but rather makes up an entire field. It is the largest and
most rapidly growing area relating to mental health. In it are
included distinct approaches, such as client-centered therapy, Gestalt
therapy, transactional analysis, rational-emotive therapy,
existential-humanistic therapy, reality therapy, logotherapy, Adlerian
therapy, emotional flooding therapies, and direct decision therapy.
In later chapters, we will look at these approaches to psychotherapy
more closely. The goal throughout this book will be to enable you to
understand enough about each of the major therapies to make an informed
decision in choosing an approach (and there may be more than one) that
will be most useful in relation to your own understanding of your
objectives, whether they are long-range or focused on the need to
eliminate immediate obstacles to growth.
THE DIFFERENCE BETWEEN COUNSELING AND PSYCHOTHERAPY
Counseling and psychotherapy have developed a great deal in recent
years--so much so that their boundaries have often overlapped.
Clear-cut distinctions between the two fields are increasingly hard to
draw. Nevertheless, some professionals prefer to call themselves by
one name and some by the other.
In general terms, _counseling_ tends to be a short-term process the
purpose of which is to help the client, couple, or family {31} overcome
specific problems and eliminate blocks to growth. Counseling gives
individuals a chance to resolve personal problems and concerns. Most
counselors attempt to help their clients become aware of a widened
range of possibilities of choice; from this perspective, counseling
tries to free clients from rigid patterns of habit.
Habits can be useful, but they can also interfere with life. The
technical habits of a pianist, for example, are essential in
performance. Similarly, only when language skills become habitual does
a speaker of a foreign language achieve command of it. On the other
hand, fears can also become habitual, and they may come to interfere
with everyday activities. Anxiety over public speaking may become
habitual. There are many personally destructive habits--alcoholism,
smoking, over- or under-eating, abusive behavior, shyness and social
withdrawal--and all can become self-perpetuating patterns. Counseling
can help people break out of these habits, often in part by helping
clients become aware of unrecognized alternatives.
_Psychotherapy_ tends to be more concerned than counseling with
fundamental personality-structure changes. Frequently, psychotherapy
is a longer-term process. Frequently, too, the problems treated in
psychotherapy are hard to pin down and are less specific. They include
chronic depression, pervasive ("free-floating") anxiety, generalized
lack of self-esteem, and so on. Such difficulties are not well
defined; their causes may be vague or uncertain, and often much time
must be spent to get at their basis. Psychotherapy seeks to bring
about an intensive self-awareness of the _inner dynamics_--the internal
forces and the principles that govern them--that are involved in
chronic forms of personal distress. Sometimes, as in analytical
psychotherapy or psychoanalysis, attention is focused on the role of
unconscious processes in inner conflicts; treatment attempts to resolve
these conflicts by understanding the unconscious forces involved.
The term _psychotherapy_ is often used to imply more advanced
professional training, whereas counseling is something individuals with
more modest academic credentials may practice. Whether a professional
is called a counselor or a therapist has to do with his or her level of
training, with the setting in which services are offered, and, to a
certain degree, with that person's theoretical orientation.
{32}
In practice, these differences in outlook frequently amount to
differences in _emphasis_ rather than approach. In this book, I will
speak of counseling and psychotherapy interchangeably unless there is a
need to be especially restrictive.
THERAPY: THE ART OF CHANGE
HOW WE ARE ABLE TO CHANGE
We are what we do ... and may do what we choose.
Allen Wheelis, _How People Change_
Freud identified five causes of personality development:
* growth and maturation
* frustration
* conflict
* inadequacy
* anxiety
By the time we become adults, most of us have developed sets of
defenses to enable us to cope with everyday problems _in spite of_
feelings of frustration, conflict, inadequacy, and anxiety. But as
these feelings become more pronounced, when we encounter situations
that intensify these feelings, we must put more and more energy into
our defenses. They allow us to continue living and acting in habitual
ways, usually by hiding, by denying, and sometimes by distorting our
perceptions of reality.
Facing the inadequacies of a marriage, the unrewarding nature of a job,
the extent of conflicts with a child, or difficulties relating to
friends can cause intense anxiety. So, to avoid this anxiety, we
frequently "defend against" these realizations: we try to uphold the
belief that our marriages are just fine, that things are OK between us
and our children, that our jobs are at least tolerable--that, in spite
of some problems "here and there," we can get along all right. We do,
in short, try to see our lives through rose-tinted glasses.
We continue to do this until our negative feelings become too strong,
until we have expended so much energy to maintain our defenses that we
are _emotionally exhausted_. If we reach such a state of real
depletion, and our defenses can no longer hold against the building
pressure of our feelings, the result is {33} _nervous breakdown_. This
is the layman's name for a variety of psychological conditions that
develop due to _a burned-out emotional fuse_.
A fuse is a protective device that prevents an overload of electricity.
Our defense mechanisms are analogous devices that protect us against
emotional overload. When an emotional fuse burns out, it is often
because we have maintained defenses too long in the face of increasing
inner frustration and pain. The result may involve severe depression,
incapacitating anxiety, or serious withdrawal.
Now, when you decide to change in some psychologically fundamental way,
you must push against the rigid framework of certain of these
protective defenses. When you do this, you will feel anxiety. You are
forcing your emotional fuses to adjust to a different pattern of
behavior and feelings.
Your sense of personal identity is made up of a network of ways you
have come to perceive yourself, your loved ones, your work, and your
world. Any attempt--even if it is your own, entered into through your
own choosing--to change patterns that are psychologically basic to your
sense of identity will threaten that established identity and produce a
measure of anxiety.
The longer these habitual patterns of behavior and feeling have been in
force, the more deeply rooted they become in your sense of identity,
and the more unsettling and anxiety-producing an attempt to change them
will be.
Although your defenses protect against emotional overload, they also
stand in your way of change. They are fundamentally _conservative_
mechanisms: established habits of thought, feeling, and behavior are
_familiar_, and familiarity reduces the anxiety brought about by
uncertainty. If you are considering making significant changes in your
life, your defenses will rally to protect the equilibrium of habits you
have formed in the past. If you push yourself to change, you will face
a predictable degree of anxiety. Fortunately, there are, as we shall
see, many ways of coping with the anxiety brought about by change;
therapy offers some of these, and some are available to us all if we
draw on inner resources.
As long as you are alive it is possible to change. Ultimately, the
decision to change is an expression of your choice and will. When
change _is_ achieved, it usually comes after long and arduous trying.
We are all aware of the heroic efforts some {34} people can and do make
to overcome a physical handicap. Overcoming deeply entrenched
emotional habits can require similar tenacity and commitment. If you
want to bring about some basic changes in yourself or in your
relationships with others, your inner strength and resolve will be
essential.
Frequently, individuals expect a therapist to accomplish change _for_
them: they are willing to come for an hour's consultation once or twice
a week, and they will be very cooperative during each visit, but they
seem unwilling or unable to develop the initiative to carry on efforts
begun in the therapist's office.
Some clients, in spite of what they say, do not really _want_ to
change. Their habits are deeply ingrained, serving purposes they may
be only dimly aware of at the beginning of therapy. Sometimes it
becomes necessary in therapy to reappraise the goals that have been
set. The decision to pursue a certain course of change may result in
so much anxiety and upset that both therapist and client must pause to
reconsider. Some changes may turn out to be too difficult, too taxing;
some clients may be unwilling to put in the work required to bring
about a certain change.
Most changes of the kind I am referring to--fundamental changes in
outlook, in daily thoughts and feelings, in behavior--can be made only
gradually. Since any move in the direction of change will threaten
your existing defenses, resistance and protest are likely to well up
from within you. New ways of _being_ will feel intimidating,
unpleasant, or just plain _unnatural_. And this is understandable, is
it not? You must confront and do battle against habits that may have
been with you for a long time. _The longer that undesirable patterns
have been in force, the more control they acquire over you, and the
more your defenses become committed to preserving them_. Change is
made steadily more difficult.
Always remember, however, that change can be brought about. You need
to be patient with yourself; it will not come overnight. Long-standing
habits take time to be replaced, You must have patience, and you must
feel hope and encouragement. If you are depressed now, if maintaining
your defenses has exhausted you, then it will be difficult to feel the
measure of hope that you need to begin the process of therapy.
This, perhaps more than anything else, is the most immediate and
perceptible benefit of therapy: a good therapist is a source {35} for
hope and encouragement when you cannot sustain these yourself.
Therapists are trained to help people who want to change, to bring it
about.
THE RESULTS OF THERAPY
In the past twenty to thirty years, there has been a gradual shift away
from a medical, illness-based orientation in therapy to one that
focuses on personal growth. By no means everyone enters therapy
because of emotional pain. Increasingly, therapists are seeing clients
who enjoy psychological and emotional good health but believe that
therapy can help them lead fuller, richer, more satisfying lives. As a
consequence, the objectives of many current approaches to therapy
involve more than only the resolution of personal difficulties and
crises.
There are many potential benefits of therapy. To varying degrees, all
the therapies we will discuss in this book claim to assist you in
achieving the following goals.
_Resilience and Tolerance to Stress_
As a consequence of therapy, you come to be less frustrated by stress,
able to recover from stressful experiences more quickly. You become
less defensive and more accepting of others and yourself, able to
adjust more easily to unexpected demands in living. You have a
decreased tendency to hold rigid expectations of the world, so you feel
less disappointment and frustration.
_Congruence_
You come to be more unified in the present moment, aware of your
feelings, and less disposed to ignore, deny, or distort your
perceptions out of defensive needs. Congruence means a close match
between what you feel and how you think and act. Congruent people are
well integrated, no longer in need of "masks." When we admire a
person's sense of "integrity," we often feel that the person not only
behaves in ways that show self-respect, but that he or she is
self-accepting, is genuine, and appears to be comparatively free of
inner conflict. Such individuals are, in short, able to be themselves.
People who no longer are engaged in a battle against themselves and
against others will tend to show congruence.
{36}
_Self-Esteem_
People with high self-esteem can allow themselves to feel modest and to
behave with modesty. High self-esteem does not imply pride or
arrogance. Self-esteem and self-acceptance (and hence congruence) are
interrelated. Individuals with strong self-esteem no longer need to
prove themselves. They value the kind of people they are and are not
inclined to be self-undermining through perfectionistic self-criticism.
_Openness and Love_
Ideally, if you undergo therapy, you become less defensive and less
uptight about yourself; you will therefore have less need for
self-absorption, so you will be able to develop an increased capacity
to feel warmth for others. You may become more giving, and less hooked
on the need to recover for what you do give, tit for tat. There are
fewer "shoulds" to stand in your way, to use to blame yourself, or to
use to criticize others. You can let go of these requirements and
accept others for what they are, for what they can do, and for what
they may feel. You feel less disappointment and resentment about your
relationships and more of a sense of ease and peace.
_Freedom_
Since you are less hooked by the expectations and values of others, and
you have reduced the list of requirements that others must fulfill in
order to be acceptable, you gain a great measure of personal freedom.
The habitual process of sizing others up and comparing them with
yourself, which many of us expend so much time and energy doing, is no
longer needed. You can more freely set your life goals. You will
probably feel more real, meaningful satisfaction with your life, since
you are no longer imprisoned by uptight standards of judgment. You are
able to be much more relaxed because you are able to feel more
accepting toward others and toward yourself.
_Displacing the Negative with the Positive_
These are among the major potential positive benefits of therapy. They
make up one way of describing the _ideal outcomes_ of therapy. They
are one side of the coin; the other side consists of the many negative
feelings and ways of behaving that are {37} eliminated when they are
_displaced_ by these positive personality qualities. The negatives
that make up such a familiar part of "normal" life include these:
* fears that stand in the way of desired goals
* anxiety and depression that cripple normal living
* low self-esteem, resentment, and hostility that poison the formation
and development of satisfying relationships
* incapacity to deal with stress, and dependence on alcohol, drugs, or
other means to reduce anxiety
* inability to accept yourself, your family, or your present place in
the world--which often leads to bitterness, withdrawal, and even the
cultivation of fantasies that further isolate
* confusion, disorientation, and perhaps even physical signs of poor
health, as a result of emotions that have assumed a magnitude that can
no longer be held in check by tired defenses
We tend to think of these as the usual reasons for entering therapy.
But, again, the positive qualities we have described are attracting
clients increasingly to therapy. Whether you need to eliminate
emotional pain or are fortunate to be comparatively untroubled but are
searching for certain positive qualities of perspective and character
that you believe will bring increased satisfaction to your living,
therapy may offer what you are seeking.
WHAT MAKES A GOOD THERAPIST?
According to several studies, certain qualities in therapists are
associated with effective therapy. The kind of person who is able to
help others bring about important life changes has these qualities:
* the ability to understand the client's feelings and life world
* heightened sensitivity to the client's feelings and attitudes so that
the therapist frequently is able to uncover significant aspects of the
client's outlook and personality of which the client would probably
remain unaware
{38}
* warmth of interest in the client's well-being, without emotional
overinvolvement
* psychological maturity, characterized by self-acceptance,
genuineness, and congruence
* a sense of acceptance toward the client: a nonjudgmental,
noncritical, positive regard for the client, his separateness, and
individuality
* an attitude, conveyed by the therapist's behavior and approach, that
encourages positive change, independence, and freely made choices and
decisions, and implicitly discourages the formation of long-term
dependence of the client on the therapist
These studies also identified several attitudes that clients,
regardless of the orientation of their therapists, felt were especially
_counterproductive_ in some therapists:
* lack of interest
* remoteness or distance
* excessive sympathy
In general, clients whose evaluations of therapy have been studied
appear to be in agreement that the personal character, attitudes, and
feelings of therapists are more important than a therapist's technique,
procedures, and theoretical orientation. Therapy is an intrinsically
human process, one that is especially sensitive to the human dimensions
of therapists. Later we will look at objective evaluations of the
effectiveness of various approaches to therapy and weigh them against
the emphasis that clients place on the personal qualities of therapists.
{39}
4
THE THERAPEUTIC JUNGLE,
PART I
Social Workers, Psychologists, and Psychiatrists
I have reluctantly come to concede the possibility that the
process, direction, and end points of therapy may differ in
different therapeutic orientations.
Carl Rogers, _On Becoming a Person_
Fifty years ago, people with personal or marital problems had a choice
between two main kinds of assistance: psychoanalysis and religion.
Freud's approach to psychiatry had gained popularity among physicians,
psychoanalytic training was being made available to clinical
psychologists, and the ideas of Freudian analysis had come to dominate
the public's conception of therapy. And, sometimes overlooked in this
context, the church--the world's faithful and oldest
psychiatrist--continued to offer spiritual and personal guidance.
These two basic choices have expanded into an impressive--and
confusing--array of different therapies. The more than one hundred
varieties of counseling, even when they are grouped together, cannot be
reduced to fewer than perhaps twenty families of therapies.
Different counseling professions have evolved that now range from
social work to psychotherapy to psychiatry; religious counseling is
still offered; and there are the newer therapies of {40} relaxation
training, biofeedback, bioenergetics, etc., as well as a renaissance of
older approaches such as meditation, yoga, and holistic practice. The
choices of fifty years ago seem modest, limited, and certainly less
perplexing. However, the recent proliferation of therapies has brought
with it increased sensitivity, sophistication, and effectiveness.
In spite of this growth of therapeutic options, most people who decide
to enter therapy are unaware of the choices open to them and so cannot
intelligently weigh their alternatives. This and the next chapter will
help you to see clearly what alternatives exist. As the book helps you
to clarify your personal objectives, you will be able to home in on one
or more approaches to therapy that may be especially promising for you,
your temperament, interests, and goals. You will be encouraged to
follow a "map" that will guide you to several approaches to therapy, to
help you find the shortest and most effective route to where you want
to go.
SOCIAL WORK COUNSELORS
As we have seen, the four main categories of social work counselors are
counselors for individuals, marriage and family counselors, group
counselors, and vocational guidance counselors.
ORIENTATION AND TRAINING
The main purpose of social work is to help people cope with stress from
interpersonal or social problems. The focus of the social worker may
therefore be on individuals, families, or groups or on their social and
work environments, their organizations, and their communities.
Social workers are trained to deal with developmental problems, life
crises, and emotional problems that arise in a variety of social
situations.
Graduate schools of social work require varying periods of supervised
internship; they usually offer specializations within the field--e.g.,
drug and alcohol abuse, developmental disabilities, child welfare,
correctional approaches, family services, care of the aged, and others.
It is now possible to find social workers whose training is quite
specialized.
{41}
In some states, social workers may practice with a bachelor's degree;
in many states, a master's degree is required. In addition, counselors
are usually required to put in a substantial number of hours of
counseling under the supervision of a licensed counselor.
FEES
Social workers in private practice normally charge on an hourly basis
for their services, with sessions lasting thirty to fifty minutes.
Rates vary considerably, in direct relation to other health care costs.
Rates are higher in larger metropolitan areas and also higher in New
England and California than in the South and Midwest. An approximate
range of $35 to $65 per counseling session is normal at the time of
this writing.
Costs for marriage and family counseling and for vocational guidance
counseling are similar to rates for individual counseling.
The charge for group therapy is frequently made for a block of
sessions. The group therapist may, for example, recommend that a group
meet for ten sessions. The resulting per-session cost is normally
significantly lower than is individual counseling. (However, the goals
of individual and group therapy are in general different, as we will
see; neither can automatically be substituted for the other.)
Many social workers offer their services through a counseling agency.
Some of these are privately run; others are funded by the county or
state. Frequently, agencies charge for counseling services based on a
sliding scale, which takes into account the financial situation of
clients. Sliding scale rates can be very economical for lower-income
individuals. Bills for services in some county and state agencies are
made on a monthly basis; individual counseling may cost only a few
dollars per session for individuals with restricted budgets.
There are many opportunities for clients to obtain economical care,
especially in metropolitan areas where counseling services are
widespread.
DURATION OF TREATMENT
It is impossible to give any hard and fast rules as to how long {42}
counseling will take. Obviously, much has to do with an individual's
objectives, the severity of the problem, and, frequently, how long the
problem has been neglected or ignored. On the other hand, much also
has to do with the counselor's own orientation.
Today, many counselors receive training that emphasizes "brief"
therapy. Specific goals of therapy are set, and it is frequently
possible to reach those goals within a matter of a few months. On the
other hand, some counselors prefer, or have been trained, to offer
long-term individual psychotherapy. Some counselors have been
influenced by the psychoanalytic approach, which is usually of long
duration, frequently requiring one to several years.
There is no reason you, as a prospective client, should not ask a
counselor what kind of approach he or she uses and approximately how
long therapy can be expected to last. You should not hesitate to ask a
counselor questions that reflect your concerns. As you read further,
this book will provide you with a frame of reference so that you may
evaluate more fully the answers a counselor gives you.
PSYCHOLOGISTS
As mentioned in the last chapter, there are three kinds of
psychologists who are involved in different aspects of therapy:
clinical psychologists, counseling psychologists, and psychometrists.
ORIENTATION AND TRAINING
_Clinical psychology_ emphasizes the understanding, diagnosis, and
treatment of individuals in psychological distress. Clinical
psychology is historically based on laboratory work that stressed
psychological assessment tests, and experimental and statistical
analysis.
Clinical psychologists generally have a Ph.D. and complete a lengthy
internship in a clinical setting. Most clinical psychologists develop
competence in both diagnostics and intervention. The area of
diagnostics includes individual interviews, psychological testing, and
personality assessment (psychological evaluation to determine what a
client's difficulties are). Intervention (the actual approach used to
help a person) includes individual psychotherapy, group therapy, and
marriage and family therapy.
{43}
The objective of _counseling psychology_ is to encourage growth in the
three major life areas of family, work, and education and to prevent
excessive psychological stress in them. Like clinical psychologists,
counseling psychologists receive training in individual, group, and
marriage and family counseling as well as in vocational counseling,
assessment, and rehabilitation.
Often, you will find clinical psychologists in private practice, while
many counseling psychologists hold positions in organizations, schools,
and social service agencies. Counseling psychologists generally have a
master's degree or Ph.D. and also are required to complete internships
in supervised counseling.
_Psychometrists_ are specifically trained to give and to evaluate
psychological tests. They are, so to speak, the "radiologists" of the
fields of counseling and psychotherapy. Clients may be referred to a
psychometrist in order to take one or more psychological tests; the
psychometrist's interpretation of the results is then forwarded to the
client's therapist or counselor. Increasingly, psychologists are being
trained to do much of this work themselves, so it has become less
common to refer clients to psychometrists unless an extensive amount of
testing is desired.
If you are advised to take one or more psychological tests, you may be
interested in knowing what to expect. Many psychological tests are
multiple-choice. You are given a printed list of questions and an
answer sheet. There are no "right" answers. You answer such questions
as "Would you rather go to a party or stay home and read a good book?"
Tests like this attempt to provide insight into a client's outlook,
personality, concerns, values, and interests. Some tests help to
assess concentration, coordination, and problem-solving ability.
Results of psychological tests can be helpful to a counselor in
deciding how best to treat a client's problems. Testing can be a great
time- and money-saver in therapy: the results of a twenty-minute test
can give a counselor information about a client that might otherwise be
gained only through a number of sessions.
FEES
Because of their more advanced training, clinical psychologists can be
expected to charge fees that are somewhat higher than what social
workers in private practice receive. Charges for {44} the services of
a clinical psychologist are made on an hourly basis; counseling
sessions usually last forty-five to fifty minutes, although some
psychologists will see clients for shorter periods.
Rates vary considerably according to geographical area. An approximate
range of $50 to $80 per private session is normal at this time. Group
session rates tend to be significantly lower.
If you consult a clinical or counseling psychologist who works through
an agency, you will often find that a sliding scale is used to
determine charges, as in social work. If you have limited or no health
insurance, and financial concerns are a problem, you can telephone
counseling agencies in your area to ask whether a sliding scale is used
and, if so, what charges correspond to your monthly income. Later, we
will look at how to locate counseling agencies, as well as
professionals in private practice.
Fees for psychological testing, whether through a psychologist or a
psychometrist, are usually billed on the basis of the tests
administered. To give some idea, many tests cost $15 to $20 for a
psychologist to administer. This charge is passed on to the client.
The test results can sometimes be reviewed during a counseling session
so that no additional charge may be made for the evaluation of the
results.
DURATION OF TREATMENT
Duration of treatment under a clinical or counseling psychologist is
similar to that of a social work counselor. The best way to proceed is
to ask prospective therapists how long they believe it will be
necessary to see them. Most professionals will be open and candid; if
the client's goals are specific and lend themselves to "brief" therapy,
a psychologist will make this clear. And, as we have already observed,
much depends on the type of therapy practiced by the psychologist.
Behavioral therapies tend to be of shorter duration; psychoanalysis is
longer-term. In between these there are, as we will see, many
therapies that have different emphases, methods, and goals.
PSYCHIATRISTS
ORIENTATION AND TRAINING
Before they specialize in psychiatry, psychiatrists receive the {45}
training required of any physician. After this, there is specialized
course work followed by a period of psychiatric internship. The
educational background of psychiatrists enables them sometimes to
identify physical bases for emotional difficulties. A later chapter
discusses this growing area of awareness.
Until fairly recently, the therapeutic training of psychiatrists
emphasized almost exclusively the approach of psychoanalysis.
Psychoanalysis developed within a medical context: Freud was a
physician, and his outlook was influenced by his medical orientation.
His approach was therefore felt to be the special province of
psychiatric medicine. Eventually, as we have already noticed, the
methods of psychoanalysis came to be used by psychologists and some
social workers. But for a long period, analysis was the primary and
exclusive focus of medical psychiatry.
The psychoanalytical orientation still dominates much psychiatry, and
many psychiatrists in private practice use psychoanalysis as their
therapy of choice. However, there has been a general broadening of the
perspective of psychiatrists. Other approaches to psychotherapy are
increasingly being used by psychiatrists. Cognitive therapy is
important among these; we will discuss its purpose and methods later.
Psychiatrists are the only therapists who may prescribe medication, and
some of the most important recent advances in psychiatry have come in
this area. Many emotional problems appear to have a biochemical basis.
Many forms of anxiety, panic disorders, and depression respond well to
the growing family of psychopharmaceutical drugs. Other emotional
difficulties, including alcohol and drug abuse, can be moderated by
pharmaceutical therapy.
Psychiatrists, then, can be especially helpful in these ways:
* to provide a medical evaluation for complaints that sometimes have a
physical basis
* to give assistance especially by means of psychoanalysis and by means
of an increasing number of alternative therapies
* to help patients with medication to acquire a degree of emotional
equilibrium that will allow them to begin to solve personal problems so
that, in time, they may no longer require medication
{46}
Although an M.D. may call herself or himself a psychiatrist, most
psychiatrists have had specialized advanced training in psychiatry.
Full qualifications involve completion of a residency in psychiatry,
full membership in the American Psychiatric Association, completion of
a program of study at an institute of psychotherapy, and board
certification. Many psychiatrists who practice are eligible for board
certification but simply have not yet taken the national examinations
that are required in order to be certified by a national examining
board. Although apparently many of us need to be reassured of this,
you need not feel that there is anything wrong or embarrassing about
asking a prospective psychiatrist, or his or her secretary, to describe
the doctor's background and training.
FEES
At the time of this writing, the fees of psychiatrists in private
practice range approximately from $75 up to $100 and occasionally more
per session. Private psychiatric assistance is therefore largely
reserved for the fairly well-to-do or for those who have health
insurance with substantial psychiatric benefits.
Fortunately, psychiatric care is available through many agencies; those
that are run by counties and states normally have sliding scales (some
private agencies will also take an individual's finances into account
when setting fees). Rates for consultation with a psychiatrist at a
public agency can be very reasonable (as little as a few dollars per
visit, depending on the patient's income). This makes the services of
psychiatrists available to those with modest or low incomes.
DURATION OF TREATMENT
If a psychiatrist finds that an emotional problem has a physical basis,
or that it is due to biochemical depletion or imbalance in the body,
successful treatment may be relatively short, sometimes a matter of a
few months.
If you choose to enter psychoanalysis, then the duration of treatment
generally will be longer, often lasting a year and more; during this
time, psychoanalysts may expect you to come for two or three sessions
each week.
Shorter-term therapies, such as cognitive therapy, are--in part because
of the normal long duration required by psychoanalysis--increasingly
advocated by psychiatrists. Biofeedback and relaxation training (see
Chapter 5) are also among these shorter-term approaches. They may be
effective within a period of several months.
In this chapter, we have discussed the professions that make up the
mainstream of professional practice in counseling and psychotherapy.
However, beyond the established and more closely regulated professions
of social worker, psychologist, and psychiatrist, there are a number of
other kinds of therapists who offer services that are sufficiently
different in nature that they deserve to be treated in a separate
chapter. The next chapter describes their contributions to therapy.
{48}
5
THE THERAPEUTIC JUNGLE,
PART II
Outside the Mainstream
Outside of any profession's frame of reference that defines what
problems it will handle and how, we usually find a group of approaches
that do not completely fit the established mold. They often can
contribute creative and innovative ideas, and yet they often lead to
abuses in the name of novelty and experimentation. And sometimes an
older approach that fails to fit the newer frame of reference is left
behind, to keep company with more radical approaches.
Just these things have happened in the practice of counseling and
psychotherapy, as we will see.
RELIGIOUS COUNSELORS
The world's first professional counselors were religious. Guidance
from priests, rabbis, and pastors has a long tradition. The tradition
is such an old one, in fact, that going to talk to a religious
counselor has a respectability that the public has generally not yet
extended to other forms of counseling.
Many people with problems, even people with a religious attitude or
upbringing, tend to ignore the kind of help religious counselors may be
able to give. This probably stems from the {49} belief that social
workers, psychologists, psychiatrists, and some other certified
therapists whom we will discuss in a moment have received special
training in helping people with personal, emotional problems, whereas
religious advisors have not.
However, this is not universally true. Many professional religious
representatives now _do_ receive training in contemporary therapies.
Increasingly, Catholic, Protestant, and Jewish educational institutions
are incorporating course work and workshops in modern counseling
methods into programs of study for priests, pastors, and rabbis.
Individuals who have been trained in this way are easily located within
a religious organization; a telephone call to the organization should
give you leads to follow.
In spite of the widespread attempt many religious institutions are
making to remain up to date on contemporary approaches to counseling,
there is probably something also to be said for traditional guidance.
All religious views seek to fulfill the needs of men and women to find
meaning in everyday life and to cope effectively with life's hardships.
Contemporary approaches to psychotherapy and counseling can offer much;
their history, however, is comparatively brief, extending over just the
last century. For many people--depending on their inclinations,
values, and sympathies--traditional religious guidance may provide much
that is as yet not to be found in the more scientific and systematic
schools of contemporary therapy.
If you decide to go to a religious professional for counseling, you
will probably find the process relatively informal and friendly. Also,
religious professionals generally expect that their private counseling
services will not be remunerated; contributions to the supporting
religious organization are of course hoped for but are often not
required in exchange for guidance.
In contrast to the authorized community of social workers,
psychologists, and psychiatrists, it can be more difficult to locate a
religious professional who _specializes_ in a particular approach to
counseling. The background in modern approaches to counseling that
religious professionals tend to receive is "eclectic." They normally
receive training in a variety of approaches; their programs of study
are based on the belief that flexibility in counseling is essential,
that nothing works well for everyone. This openness can be of value to
many people. But, as you read this book, you may decide to locate a
therapist who has a certain {50} specific orientation. He or she may
be a religious counselor, a psychologist, or another qualified
professional. In general, if you have a specific form of therapy in
mind, you will have to ask a prospective therapist whether he or she
has the training to give you the kind of help you are looking for.
This is especially true of religious counselors.
BIOFEEDBACK THERAPISTS
Biofeedback is a newcomer to the therapeutic world that has grown
tremendously in popularity in the last ten years or so. Biofeedback
therapy gradually enables individuals to become aware of certain
physical changes in their bodies. These physical changes are detected
by means of sensitive measuring instruments that give information back
to clients so they can learn to control a particular physical response.
Biofeedback is used by therapists who have been specially trained in
its use, as well as by some licensed psychologists, psychiatrists,
social workers, physical therapists, speech pathologists, and even some
dentists. Some psychiatrists now work jointly with a biofeedback
therapist: the psychiatrist can prescribe medication and provide
psychotherapy or analysis, while the associated biofeedback therapist
can teach patients how to lessen their responses to pain and
stress-related problems.
The Biofeedback Society of America is an interdisciplinary group of
healthcare professionals; it is presently developing training standards
and guidelines for certification of biofeedback practitioners.
RELAXATION, HYPNOSIS, AND MEDITATION THERAPISTS
Relaxation training, hypnosis, and meditation all seek to bring about a
deep sense of relaxation in a person. We will examine each in greater
detail later; a short overview of these approaches is given here.
RELAXATION TRAINING
Relaxation training involves exercises that enable a person to learn to
induce _at will_ a state of physical and mental calm. Relaxation
training is a practical skill--it can be very effective {51} and useful
in coping with stressful situations. Like any learned skill, control
comes only with practice, usually over a period of several months.
Many social workers and psychologists teach clients relaxation
techniques. Certification standards specifically for relaxation
training have not been established.
HYPNOSIS
Hypnosis involves two stages: (1) progressive, deep relaxation to a
point at which an individual is in a peaceful, trancelike state, still
self-aware but profoundly relaxed; and (2) suggestion, which persuades
the person to adopt certain future attitudes, thoughts, or behavior.
Hypnosis, like relaxation training, can be learned. Most people
treated by means of hypnosis steadily improve in their ability to be
hypnotized so that they can more effectively allow themselves to be
influenced by means of carefully planned suggestions. Many
psychologists and psychiatrists make use of hypnosis in the context of
therapy; some practitioners treat patients exclusively by means of
hypnosis.
The certification of therapists trained in hypnosis is still unsettled
in many states, where anyone can hang out a shingle. Since many
licensed psychologists and psychiatrists and some certified social
workers _do_ receive professional training in hypnosis, these are the
professions to which it is most reliable to go for hypnotherapy.
MEDITATION
Meditation is still a "fringe" therapy. Techniques of meditation tend
seldom to be taught to clients in psychotherapy, although there is a
growing body of evidence that meditation is able to bring about great
resistance to stress, an increased sense of inner calm, and even actual
changes in brain-wave patterns associated with deep relaxation. These
effects of meditation are now being studied, with encouraging results.
The practice of meditation is, in the author's view, at present best
learned on one's own, although some commercial organizations provide
instruction. A later chapter discusses approaches to meditation and
suggests some of the ways meditation can be of value.
{52}
HOLISTIC THERAPIES:
BIOENERGETICS, YOGA, AND EXERCISE
Holism views man as a unity of body and mind. The established
approaches to therapy and counseling, represented by social workers,
psychologists, psychiatrists, and to a certain extent by some religious
professionals, all focus attention on our mental-psychological
dimension. Similarly, biofeedback, hypnosis, and meditation emphasize
the central role of _mental_ control.
Holistic approaches, on the other hand, attempt to bring about positive
change by means of emphasis on physical factors that are believed to
have a close connection to mental processes. Although holism sees
human beings as integral organisms, holistic approaches are inclined to
have this physical focus.
Holistic therapies, like meditation, are "fringe" therapies. They are
not generally employed by members of the "authorized" community of
health practitioners, for two reasons: First, a kind of professional
respectability and elitism have come to be associated with the
psychological approach; social work, psychology, and psychiatry have an
established place in institutions of higher learning, whereas fringe
therapies do not. Second, since physicians treat the body, there is an
institutionalized prejudice against nonmedical treatment that has the
same focus.
Chiropractic has encountered this problem, as have other forms of
holism, such as bioenergetics, yoga, diet therapy, and rolfing.
Although much of value may be offered by these fringe therapies, they
have also resulted in abuse to consumers. Because of a general absence
of licensing standards and of scientific credibility, people frequently
are drawn in by the sometimes extravagant promises of unscrupulous or
overly enthusiastic fringe therapists. In this area, as in all others
that affect the consumer, the proper attitude is one of healthy
skepticism and restraint.
BIOENERGETICS
Of these holistic therapies, bioenergetics is perhaps considered the
most respectable because it _is_ used by some psychologists.
Bioenergetics attempts to diminish an individual's psychological
defenses by means of sequences of specially designed {53} physical
exercises that, in a controlled and deliberate way, stress the person
physically. Practitioners of bioenergetics believe that physical
exercises of this kind rapidly put a person in touch with buried
(repressed) feelings and speed up the process of inner integration that
all holistic practices, as well as traditional therapy, wish to achieve.
YOGA
Yoga exists in various forms. The two main varieties are hatha yoga
and raja yoga. Hatha yoga emphasizes physical flexibility; raja yoga
teaches breathing techniques and meditation. Hatha yoga, because of
its focus on the body, belongs to the family of approaches we are
considering here.
Hatha yoga practitioners believe that the physical flexibility and
control that are acquired through an extended period of physical
training in yoga exercise tend to influence your mental orientation.
You become, in this view, more flexible, less rigid, less defensive,
less subject to stress, more open, responsive, alert, and capable of
warmth in human relationships.
EXERCISE THERAPY
Counselors and therapists are starting to take very seriously the idea
that exercise brings emotional benefits. Exercise therapy, more so
than other physically based approaches discussed in this chapter, has
been tested in various ways. Many emotional conditions--for example,
anxiety and depression--seem to be significantly reduced thanks to
periods of sustained vigorous exercise. Tolerance to stress and to
pain appears to be increased. Physical exercise can be an outlet for
pent-up hostility and aggression that, according to many theorists, may
be turned inward, then fester, and eventually take the form of a
variety of psychological disorders. Furthermore, vigorous, sustained
aerobic exercise--like running or swimming--appears to have a calming
effect as a result of certain chemical compounds that are released into
the bloodstream. We will look at some of the interesting recent
studies of the therapeutic value of exercise later on.
{54}
6
WHERE YOU CAN FIND HELP
PRIVATE PRACTICE
As we have seen, social work counselors, psychologists, psychiatrists,
biofeedback therapists, hypnotherapists, and other therapists may all
offer their services through private practice. In general, there can
be definite advantages to counseling in the setting of a therapist's
private practice. You are given a degree of personal care that, as an
individual paying customer, you are less likely to receive in
counseling provided by agencies. You become part of a therapist's own
practice, so it is natural for him or her to devote special attention
to you. Therapists are likely to be more personally involved in their
private practice and in the quality of care they try to give their
private clients than it is possible or even personally desirable for
them to be when they work by the hour for an agency.
On the other hand, private sessions with a therapist tend to be
considerably more expensive than counseling can be through many
agencies. You ought not to take too seriously general comparisons
between therapy as you may encounter it privately and therapy in the
setting of an agency. You can often find a counselor who is congenial,
interested, attentive, and skilled; whose services will be easier for
you to bear financially; and who {55} offers his or her services
through an agency. If finances are restrictive for you, you should
look into agency-sponsored counseling.
Many social work counselors, psychologists, and some psychiatrists who
maintain private practices intended mainly for individual therapy also
offer group therapy. Often, a therapist will observe that a number of
individual clients share certain problems and experiences, and he or
she will suggest that these people meet together as a group. The
per-session price can be expected to be a good deal lower than for
individual sessions; the rate usually reflects the number of people who
meet in the group and the length of time the group is expected to
continue.
Some social workers and some psychologists _specialize_ in group
therapy. Groups are formed periodically, run a set number of weeks,
and may or may not bring together individuals with common problems.
Some group therapists believe that diversity in a counseling group is
valuable: in such a group, you might find one person combating
alcoholism, another trying to cope with loneliness and grief after the
death of a spouse, someone trying to break out of the confines of
shyness, a person suffering from public speaking anxiety, someone
wanting to change careers but who is blocked by fear, and others. An
exchange of views among participants with diverse backgrounds can
frequently encourage growth in the group members.
Most counseling agencies also offer group therapy, as do many hospitals
and schools. We will take a look at each of these settings in turn.
COUNTY, STATE, AND PRIVATE AGENCIES
Individual, marriage and family, and group counseling are all offered
by many counseling agencies.
County and state agencies receive public funding and usually have
sliding scales for the rates they charge. Often, one or more
psychiatrists work in association with counselors, who may be social
workers or psychologists. If you go to a county or state agency, you
will probably be interviewed initially by a receptionist or nurse. You
will be asked questions about your financial situation and health
insurance coverage, if you have any, and you will be asked to agree to
a proposed rate for the services of the agency. Some county and state
agencies make a monthly charge {56} for their services; you may consult
regularly with members of the staff, counselors and/or psychiatrists,
in accordance with your individual needs.
Private counseling agencies function in a similar way. Their services
tend to be more expensive because they do not receive public financial
support, as do county and state agencies.
Many health insurance plans that provide psychological benefits can be
used to pay for the services of a private or a public counseling agency.
HOSPITALS AND OTHER INPATIENT SERVICES
Individuals with severe problems who need complete care can enter
private, county, or state hospitals that offer psychiatric services. A
separate chapter discusses pros and cons of the sometimes frightening
alternative of hospitalization.
Again, publicly funded hospitals tend to charge on the basis of a
sliding scale, which takes a person's financial situation into account.
Where financial concerns are not pressing, private hospitals in general
tend to offer a greater degree of individual attention and higher
quality of care and physical facilities.
In addition to hospital facilities, many metropolitan areas have
established organizations to provide counseling services on an
inpatient basis. Some are private; some are public. They offer an
alternative to hospitalization. They tend to be more informal and open
and are managed by their own staffs of professional counselors and
psychiatrists. These residential care facilities usually are intended
for stays of from one to several weeks. They have a variety of
counseling programs, ranging from individual therapy to group
counseling and vocational guidance.
One way to locate such an inpatient organization is to telephone a
crisis intervention (sometimes called _suicide prevention_) number
likely to be listed at the beginning of your telephone directory. A
volunteer probably will answer your call and should be able to direct
you to inpatient facilities available in your area.
ACADEMIC SOURCES OF COUNSELING
Counseling is one of the services available to full- and part-time {57}
students who are enrolled in junior or four-year colleges and graduate
schools. Many educational institutions offer individual counseling,
normally by counseling psychologists, and all colleges offer academic
advising in the context of a certain amount of vocational guidance.
Colleges with programs in counseling and psychology usually also offer
certain classes with a practical, problem-solving focus. Although they
may not be specifically intended to help individual students with life
problems, this is in fact what they frequently end up doing. It is
inevitable for students in a practically oriented counseling class to
apply much that they learn to their own problems. Many class meetings
of this kind tend to be almost indistinguishable from group therapy
sessions: students receive guidance from a professionally trained
instructor, exchange views, and express personal concerns. You might
think of college classes with a practical, psychological emphasis
especially if you are drawn to therapy as an opportunity for general
personal growth.
Classes of this kind may be offered in a college's regular programs,
which are sometimes open only to students working toward a degree.
Other similar opportunities, however, are available through many
continuing education, or adult education, programs. Many secondary
school districts offer practical, psychologically-focused classes for
adults who do not choose to enter a degree program. This is also true
of community, state, and many private colleges.
Colleges and private professionals offer intensive workshops with a
variety of counseling emphases. Two-day weekend workshops have become
especially popular. Topics range from alcoholism, drug abuse,
child-rearing problems, and separation and divorce to illness and
chronic pain, marital concerns, depression, stress control, and so on.
Newspapers announce counseling workshops; you will often find notices
about them posted in public and college libraries.
SOME REFLECTIONS ON WHERE YOU GO FOR COUNSELING
You should bear in mind that where you go for counseling or therapy is
nothing more than an address. What is important is what happens in
your relationship with your counselor or {58} therapist. If you have
found a therapist whom you respect and feel motivated to work with, it
makes little difference, as far as the benefits you obtain from therapy
are concerned, whether your therapist works in private practice or
offers his or her services through an agency, school, hospital, or
residential facility.
On the other hand, where you go for counseling _will_ greatly determine
the price you will pay for services and frequently whether health
insurance will cover your expenses. To some extent, where you go can
sometimes, as we have noted, influence the quality of care and
individual attention you receive. But this is a generalization; you
frequently will be able to locate excellent care through less expensive
facilities. This will depend to some extent on luck, but more on the
amount of effort you put into locating the kind of help you may need.
Since you are reading this book, you already have initiative like this:
you have the ability to influence what kind and quality of therapy you
will receive. For you, it will be less a matter of pure luck than it
is for people who choose a therapy and therapist arbitrarily.
{59}
7
SELF-DIAGNOSIS
Mapping Your Way to a Therapy
This chapter is central to your use of this book as a guide. There are
two main ways to use this book to help you to choose a therapy:
1. You can familiarize yourself with all of the major approaches to
therapy, weigh their advantages and disadvantages in relation to your
needs, and then make a choice. Twenty-six approaches to therapy are
discussed and evaluated in this book, so keeping your judgments of
their pros and cons clearly in mind can be challenging. Although
comprehensive understanding has a value of its own, it may not be
essential to you.
2. You may prefer to go through three simple steps to narrow the
alternatives down to a small number of therapies that have been most
successful for specific goals, problems, and personal attributes that
most closely approximate your own. This is a less time-consuming
process, and it will take into account professional evaluations of the
different therapies.
In either case, your informed judgment will be the basis for your
eventual choice. This chapter is intended to help you if you prefer
the second route--to narrow down the alternatives in a clear and
logical way. If you prefer, however, to become acquainted with all of
the major therapies discussed in this book, {60} you might skim through
sections of this chapter to give you a framework for more efficient
understanding.
The information in this chapter relates to many different sets of
goals, problems, and kinds of people. Not all of this information will
be relevant to you, so you will find instructions to direct you to
specific recommendations that take into account your own needs and
interests.
This chapter is where practical and prudent planning can begin. In
fact, this book represents the first attempt to match you, your
personal qualities, and your goals with the most effective therapy or
therapies available to you.
Even though nearly all of the main approaches to counseling and therapy
are creations of the past century, it may seem surprising that no
unified effort has been made to identify what specific kinds of
problems each approach is especially useful for treating and for what
types of clients. In this respect, the field of medicine is much
better developed. The discipline of medical diagnostics is now on the
verge of becoming scientific, and it is now possible to identify for
many conditions and in individual cases very concrete and well-defined
treatment procedures that are likely to be effective. This has not
been true in the field of psychology: most research efforts have so far
gone into formulating definitions of the various mental and emotional
disorders. But the important work, from the prospective client's point
of view, had yet to be done: to make it possible for him to know--in
relation to his individual problems, goals, interests, abilities, and
temperament--which approaches to therapy are likely to help him the
most.
If you are in serious emotional pain, waiting until all of the research
results are in is just not possible; you need help _now_. In spite of
incomplete knowledge in psychotherapy, a large body of information has
come from studies of the effectiveness of therapies for different
problems and for different kinds of people. But until now this
information existed only in fragmented form and was familiar only to
professional psychologists. Enough data are in to begin to draw
reasonable guidelines for individuals who seek psychological help.
The mapping process described in this chapter is the result of
assembling and then organizing large quantities of data from many
sources. It was then necessary to design an easily followed {61}
step-by-step approach to enable you to narrow down the many therapeutic
alternatives to a small number that, through your efforts and the
assistance of a therapist, can be of help to you. Guidelines of this
kind are never static; they will change to some extent as time and
knowledge advance.
OBSTACLES TO FINDING A THERAPY THAT FITS YOU
There are real obstacles to efficient treatment in psychotherapy. They
cost people much time, energy, hope, and money as they try to find
appropriate help. Psychotherapy is not yet a systematic field.
There are three main reasons why it is so difficult to find approaches
to therapy that will fit individual clients and their needs:
* Emotional and mental difficulties vary tremendously. Psychologists
and psychiatrists are still in the process of classifying the kinds of
emotional and mental problems people have.
* People are individuals. Their personalities, likes and dislikes, and
motivations for entering therapy differ greatly.
* Therapists, too, are individuals. Their personalities, interests,
values, and motivations for _offering_ therapy differ greatly. Their
professional training and preferences in favor of one or several
approaches to therapy also vary significantly.
As a result, what works for one patient will not necessarily work for
another. _What_ helps and _who_ helps in one person's situation may
not help in another's. Yet all three of the factors on which effective
treatment depends--a patient's goals and problems, his or her
personality traits, and the approach of the therapist--in many cases
_can_ be matched intelligently. You, as a prospective client, know a
great deal about yourself; it doesn't make sense to choose arbitrarily
among the many therapies. It takes very little time to map your way:
in the process, you will learn more about yourself, what to anticipate
in therapy, and in what direction to start.
{62}
REALISM: A GOOD BEGINNING
In order to identify one or more therapies that may be most promising
in relation to _your_ goals, _your_ problems, and _the kind of person
you understand yourself to be_, you must begin your search with a good
measure of realism.
SETTING GOALS
It can be very difficult for anyone who is seriously troubled to think
clearly and use good judgment. You may find it hard, perhaps
impossible, at this time to identify your goals. You may feel
confused, anxious, depressed, and not know why you feel that way. Even
so, you will find as you read on that you can set important goals for
yourself.
If you are at a loss and have no sense of purpose, _that_ fact gives
you a goal to work toward in therapy: to develop clearly thought-out
goals. Though you may not know what precipitated your feelings of
confusion, anxiety, or depression, you at least _know_ that you feel
confused, anxious, or depressed, and you will find recommendations in
this chapter on how to find appropriate help for your suffering. Do
not judge yourself harshly if you lack a sense of direction or if you
are troubled but do not know why. Just keep reading.
OPENING YOURSELF TO CHANGE
There is a second thing you should be realistic about when you do know
what you want and what your problems are. Our experiences and what we
learn about ourselves _change_ us. If you enter therapy based on your
present perceptions of yourself, it is likely that these are going to
change to some extent as a result of your experiences in therapy. Does
that mean that you cannot plan or select a therapy intelligently?
Clearly, it doesn't. _Everyone has to start where he or she is_.
There is no other choice. But you should try to persuade yourself to
be open to changes in your views and feelings. If you feel rigid about
your own perceptions of yourself, it is just possible that your
rigidity may be contributing to the problems you want to resolve. As
in any attempt to learn or to change, it is important periodically to
reevaluate your needs, values, and the results you may have achieved so
far. If you select a therapy using the structured {63} approach in
this chapter, you may decide to retrace your footsteps a few months in
the future. You may find that you would take a different path in the
light of what you then see.
BEING HONEST ABOUT YOURSELF
There is a third piece of realism that I would like you to consider,
and this is _very_ hard for anyone to take to heart. If you can, you
are a very unusual person. Answering the following questions honestly
takes some real courage. But you must ask yourself: "To what extent do
I _need_ my present symptoms? Is it useful to me _not_ to have a sense
of direction? Am I somehow _benefiting_ from feeling depressed? Is my
anxiety _helpful_ to me in some way?"
You may think these suggestions are no more than contrived and unkind
psychologizing. After all, who _chooses_ to suffer? Does anyone
_want_ to wake up at 4:00 A.M. shaking and crying? Yet, again and
again, therapists who care very much about their patients find that
many of them "cling to their symptoms with the desperation of a
drowning man hanging onto a raft."[1]
[1] Lewis R. Wolberg, _Hypnosis_ (New York: Harcourt Brace Jovanovich,
1972), p. 238. (In this guide, see Chapter 15, on hypnosis.)
For diverse reasons, many people--even people who are suffering
greatly--do not _want_ to change. Their unhappiness, pain, and
confusion can serve numerous functions. You may not believe this right
now, but from time to time as you read this book, and later in your
life, this question may occur to you, if only for a moment: "How may
this unresolved problem benefit me?"
The plain truth is that even suffering can confer benefits on us. This
is at the root of much of the tragedy of emotional problems that prove
to be resistant to treatment. The distressed, despondent, overwrought,
and trembling person seated before the therapist may have found a way
to gain the attention he was unable to get otherwise. Or perhaps his
suffering is a way to lighten a burden of guilt that eventually caused
an inner collapse. There are many "benefits," many very good reasons
to want _not_ to change but to try _anyway_.
So, before you begin to seek a specific type of therapy, try to be
realistic and keep these thoughts in mind:
{64}
1. Specifying clear-cut goals and understanding why you feel troubled
are not essential now. Certainly it will be helpful if you can
translate vague complaints into concrete problems, to help both your
own understanding and eventually your therapist's. The more specific
you can be about what is troubling you, what situations especially
distress you, and what has motivated you to come to therapy, the easier
it will be for you to find help and for the therapist you choose to
help you. But in times of crisis, clarity can be very hard to gain, so
be patient.
2. If you do have clear-cut goals and a good understanding of yourself
now, use these to plan how to proceed, remembering that openness to
change will profit you and that, in all likelihood, your initial
perceptions of yourself will change as you become involved in therapy.
3. You may, at least now, need your symptoms, however painful they may
be. How successful therapy will be for you may have a great deal to do
with your willingness to let go of the possible benefits of being
troubled, in pain, or disabled.
4. Resist digging ruts for yourself. Try to refrain from locking into
a particular course of action until you have given yourself time to
consider alternatives. Once you have chosen a direction, if after a
reasonable time the therapy and the therapist you have selected do not
seem to be helping you, it is essential to try another approach. This
is especially difficult once you have invested your time, energy, and
money and perhaps have developed a good relationship with your
therapist. You may like him or her, feel comfortable and comforted,
but if you are not gaining what you want, you have to stop and try
again.
5. Finally, have a thorough physical examination before entering
therapy, if you have not had one recently. Be truthful and open with
your physician. Some emotional and mental problems are produced by
underlying physical conditions, many of which can be treated
effectively (see Chapter 8).
HOW TO MAP YOUR WAY TO A THERAPY
The remainder of this chapter presents a three-step process {65} for
choosing an approach to therapy that is potentially best-suited to your
personal needs and personality.
In the first step, you become familiar with the main kinds of goals and
problems that motivate people to enter therapy. You check those that
seem to be most relevant to you and then try to confirm the accuracy of
your choices. This will point you in the direction of one or more
promising therapies.
In the second step, you consider a list of the main personality traits
that are relevant to your choice of therapy. Again, you check those
that seem most to apply to you and then confirm your
self-understanding. Step 2 will also direct you to one or more
therapies.
In the third step, you use your results from Step 1 and Step 2 to
select an approach to therapy that most closely matches your needs,
interests, and personality.
Let's begin.
STEP 1. DIAGNOSING YOUR PROBLEMS AND SETTING YOUR
GOALS: IDENTIFYING APPROPRIATE THERAPIES
a. Read through Table 1 (pages 67-69).
b. Check the goals or problems most applicable to you. If you are in
doubt, refer to the numbered short descriptions in the section
"Matching Your Goals and Problems with Most Promising Therapies"
following Table 1.
c. Choose one or two goals or problems that are the most important to
you.
d. Confirm your choices: Refer to the section "Matching Your Goals and
Problems with Most Promising Therapies" that follows Table 1. In that
section, read the corresponding short descriptions of the one or two
goals or problems you checked in Table 1 and ask yourself whether, in
fact, these accurately apply to you. For example, if you checked §7 in
Table 1, then read the corresponding §7 in "Matching Your Goals and
Problems with Most Promising Therapies."
e. If, after doing this, you continue to believe that the goals or
problems you checked relate to you, make a record of the therapy letter
codes given at the end of each description. You will find that
occasionally letter codes are divided into two groups: those judged to
be generally more effective (called "primary"), and a set of
alternatives ("secondary"). Now go directly to Step 2. On the other
hand, if you come to feel that the goals or problems you checked really
do _not_ apply to you, go back to Table 1 and consider other
alternatives.
{66}
STEP 2. SELF-UNDERSTANDING:
IDENTIFYING APPROPRIATE THERAPIES
a. Read through Table 2 (page 79).
b. Check the personal qualities that seem best to describe you.
c. Choose one or two of these that are the most significant to you.
d. Confirm your self-understanding: Refer to the section "Matching Your
Personality with the Most Promising Therapies" following Table 2. Read
the short descriptions of the one or two personal qualities you checked
and respond to the questions you will find there.
e. If, after doing this, you believe that the personal qualities you
checked in Table 2 do, in fact, describe you accurately, make a record
of the therapy letter codes given at the end of the questions. Now go
directly to Step 3. If, on the other hand, judging from your responses
to the questions you answered, you do _not_ feel that the personal
qualities you checked are true of you, return to Table 2 and consider
other alternatives.
STEP 3. CHOOSING A THERAPY
a. Compare the two sets of letter codes you recorded as a result of
Steps 1 and 2. If one or more letter codes are common to both sets,
make a special note of the common code(s); otherwise, group the letter
codes together.
b. Refer to Table 3 (pages 86-87), which summarizes the letter codes of
all the therapies discussed in this guide. Check the code(s) you just
listed.
c. If you feel that you have taken your time, have been thoughtful
about yourself, and now feel reasonably confident about the tentative
conclusions you have reached, turn to the chapter(s) in this book that
discuss the approaches to therapy you checked. As you read these, try
to imagine yourself as a client in each of the therapy situations
described. Which approach seems most appropriate given your goals or
problems? Do you feel that _you_ have the personal traits that the
therapy is most suited for? If so, give that approach to therapy a
reasonable trial period. If not, consider other alternatives you
checked.
{67}
AN EXAMPLE OF FOLLOWING STEPS 1, 2, AND 3
Suppose you check §3.1, shyness passivity, in Table 1. You refer to
the section following Table 1, relating to personality trait problems.
You feel that shyness _is_ something that interferes significantly with
your life, interests, and desires, and you want to do something to
overcome it. Therapies Q, C, N, and D are recommended to you as
potentially useful. Then, in Table 2, you check §7. You refer to §7
following Table 2, and you decide that you especially need to work on
pent-up feelings in need of release. Therapies C and J are suggested
there as potentially appropriate for you.
You now have two sets of therapy letter codes to consider: Q, C, N, and
D; and C and J.
Therapy C is common to both recommended groups of therapies, but you
are interested in comparing the other therapies with C. In addition to
reading about C, you decide to read the discussions of therapies D, J,
N, and Q. From Table 3, the five letter codes C, D, J, N, and Q denote
Gestalt therapy, transactional analysis, bioenergetics,
counter-conditioning, and group therapy, respectively. After reading
about these therapies, you come to feel that Gestalt therapy probably
would challenge you in especially needed ways, so you decide to locate
a therapist with training in Gestalt therapy. (For information on
locating a therapist, see Chapter 17.)
STEP 1
_TABLE 1:_
_AN OVERVIEW OF PRINCIPAL GOALS AND
MAIN EMOTIONAL AND MENTAL DISORDERS
THAT LEAD PEOPLE TO ENTER THERAPY_
§1 Personal development goals
[ ] §1.1 developing new skills and personal traits: education leading
to growth
[ ] §1.2 eliminating self-destructive habits or undesirable personality
traits: re-education leading to change (see §3 below)
{68}
§2 Disorders usually first noticed in childhood or adolescence
[ ] §2.1 mental retardation
[ ] §2.2 autism
[ ] §2.3 emotional disturbances: separation anxiety, sleep terror and
sleepwalking disorders, etc.
[ ] §2.4 suffering from childhood pain, neglect, or abuse; traumatic
experiences from childhood, unmet childhood needs
[ ] §2.5 behavior problems: hyperactivity, antisocial behavior,
movement disorders (see §10 below)
[ ] §2.6 delinquency and criminal behavior
[ ] §2.7 eating disorders: obesity, bulimia, anorexia nervosa
§3 Personality trait problems
[ ] §3.1 shyness/passivity
[ ] §3.2 loneliness/emptiness
[ ] §3.3 hostility/overbearing personality
[ ] §3.4 fear of withdrawal of affection and of abandonment
[ ] §3.5 general interpersonal problems
[ ] §3.6 need to improve effectiveness of communication skills
[ ] §3.7 difficulties in coping with persons in authority
[ ] §3.8 loss of faith in oneself or in others, or in life's purpose
or end
[ ] §3.9 low self-worth, desire for a success-identity (self-esteem
resulting from a sense of achievement)
[ ] §3.10 deep discouragement with life (see §5 below)
§4 Neuroses
[ ] §4.1 anxiety disorders, panic disorders, post-traumatic stress
disorders, etc.
[ ] §4.2 phobias
[ ] §4.3 compulsions
[ ] §4.4 noögenic neuroses (resulting from serious conflicts between
opposing values)
[ ] §4.5 psychosomatic disorders, hypochondria
[ ] §4.6 sexual disorders
[ ] §4.7 impulse control disorders: e.g., pathological gambling,
kleptomania, pyromania
{69}
§5 Mood disturbances (affective disorders)
[ ] §5.1 depression
[ ] §5.2 mania
[ ] §5.3 manic depression
§6 Adjustment problems
[ ] §6.1 in relation to a new environment or an already familiar one;
work inhibitions
[ ] §6.2 in persons with counterculture attitudes and values
[ ] §6.3 emotional difficulties arising from poverty and from the
deprivations suffered by minority groups
[ ] §6.4 inability to accept realities that limit life: e.g.,
financial limitations, restricted opportunities, aging and death (see
§9 below), jobs with "no future," responsibilities that stand in the
way of personal development
[ ] §7 Marital problems
[ ] §8 Family problems
§9 Problems related to aging
[ ] §9.1 emotional problems in facing old age
[ ] §9.2 problems facing the recently widowed
[ ] §9.3 coping with physical pain and disability
§10 Involuntary behaviors
[ ] §10.1 stuttering
[ ] §10.2 shaking or motor tic disorders
[ ] §10.3 insomnia
§11 Crisis intervention: a need for _prompt_ relief from severe
symptoms
§12 Psychoses: schizophrenia, manic and paranoid psychoses, hysterical
psychoses, etc.
§13 Organic disorders
[ ] §13.1 senescence, Alzheimer's disease
[ ] §13.2 Parkinsonism/Huntington's chorea
[ ] §13.3 substance-induced: alcoholism, drug addiction, smoking
[ ] §13.4 organic brain dysfunctions: epilepsy, narcolepsy, amnesia,
dementia, delirium
{70}
MATCHING YOUR GOALS AND PROBLEMS WITH MOST
PROMISING THERAPIES
§_1 Personal Development Goals_
These may involve either (§1.1) _adding_ new skills or qualities or
(§1.2) _subtracting_ habits or undesirable traits.
§1.1. There are basically two different approaches to achieving the
first goal:
* You identify a specific skill or personality trait you would like to
develop--see Table 1, §3. For example, you may want to develop a
stronger success-identity (§3.9), improve your communication skills
(§3.6), gain a stronger sense of life's purpose (§3.8), or become more
assertive (i.e., overcome a degree of shyness, §3.1). For references
to recommended therapies for these goals, see §3 below. For vocational
counseling and therapy: H, I, M
* Alternatively, you decide to approach self-development with a desire
for _broad-spectrum_ improvements. Therapies with this orientation are
not especially concerned with highly specific behaviors or problems but
attempt to treat the whole person so that self-esteem is gradually
increased, as are a sense of satisfaction in daily living, enjoyment of
others, and a feeling of being at ease with them.
Primary therapy (judged to be generally more effective): A, B
Secondary therapy (somewhat less effective): J
§1.2. Refer to §3 below.
§_2 Disorders Usually First Noticed in
Childhood or Adolescence_
§2.1. Mental retardation: O
§2.2. Autism: self-injuring behavior, withdrawal from reality: O, Y
§2.3. Emotional disturbances in children: S, W
§2.4. Suffering from childhood pain, neglect, or abuse: traumatic
experiences from childhood, unmet childhood needs (see §3.4): A, K
{71}
§2.5. Behavior problems in children: O, C
Hyperkinetic behavior:
Primary: Y, O
Secondary: Z
§2.6. Delinquency and criminal behavior: O, E, H, I
§2.7. Eating disorders: obesity, bulimia, anorexia nervosa: O, W
§_3 Personality Trait Problems_
§3.1. Shyness/passivity: Q, C, N, D
§3.2. Loneliness/emptiness: F, Q, D
Sense of estrangement, alienation from others: G
§3.3. Hostility/overbearing personality: E, D, N, Q
§3.4. Fear of withdrawal of affection and of abandonment (also see
§3.2 above): R or S, D, A
§3.5. General interpersonal problems:
If you are willing to work on these within a wider focus: A
Involved in relating to others on an individual basis: E, P, W
§3.6. Need to improve effectiveness of communication skills: D
In groups of people: Q
§3.7. Difficulties in coping with persons in authority: C, D
§3.8. Loss of faith in yourself or in others or in life's purpose or
end: F, G, X
§3.9. Low self-worth: B
Desire for a success-identity: H, M
§3.10. Deep discouragement with life (see §5 below): I
§_4 Neuroses_
A person is said to suffer from a neurosis if he or she has exaggerated
emotional responses or ideas of reality that blow things out of
proportion. Individuals with neuroses are able to communicate normally
or with mild emotional interference. Their emotional problems
interfere with normal living but do not impair them so that their lives
are clearly out of control (as in psychoses, alcoholism, drug
addiction, etc.).
§4.1. Anxiety disorders, panic disorders, post-traumatic stress
disorders, etc.:
{72}
_Anxiety and panic attacks_ are characterized by feelings of fear,
dread, and tension. You may have a sense of imminent disaster or
death, a feeling of helplessness often followed by depression. (These
are also symptoms of _chronic anxiety_.) Other symptoms of anxiety and
panic attacks include dizziness, dry mouth, sweating, headaches, heart
palpitations, increased blood pressure, rapid breathing, weakness,
insomnia, increased urination, a feeling of unreality, diminished
concentration, memory difficulties, indecision, obsessive thinking
about anxiety symptoms, second-order anxiety (anxiety that you are or
will be anxious), and desperation to obtain relief.
Primary: Y, H, F, V, T, W, X Secondary: H, K, U
_Post-traumatic stress disorders_ are frequently misdiagnosed as
anxiety disorders. Patients suffering from post-traumatic stress have
been exposed to situations of great stress--e.g., battlefront
conditions, rape, imprisonment in a concentration camp. These
situations are perceived as inescapable, and they leave long-lasting
emotional scars. Symptoms include reactions delayed until days or
months have passed since the trauma situation, emotional numbing,
chronic anxiety, restlessness, irritability, recurrent nightmares,
increased startle responses, impulsive behavior, and depression.
Primary: Y, in conjunction with therapies recommended for anxiety
and panic attacks.
§4.2. Phobias: Phobias are fears that are disproportionate to the
threat of a situation. They are involuntary and cannot be reasoned
away. They lead to avoidance of the feared situation.
Primary: N, L, Y, W, V Secondary: U, A, K, D
For fears of public speaking, especially: E
§4.3. Compulsions: People with neurotic compulsions engage in
repetitive rituals that give them temporary relief from anxiety.
Compulsive behaviors are often motivated by a desire for exactness and
perfection--for example, compulsive hygiene, washing, counting,
praying, reflecting about yourself, repetitive isolated thoughts,
preoccupation with trifling details, etc.
Primary: E, M, O, A Secondary: Y, T, K
Compulsions that arise, or may be resolved, in relation to your family:
S
{73}
§4.4. Noögenic neuroses: A person can be emotionally disabled by
serious conflicts between opposing personal, ethical, or religious
values. This problem has not gained widespread recognition among
psychiatrists and therapists. It is a focus of logotherapy (see
Chapter 11): G
§4.5. Psychosomatic disorders, hypochondria: Physical disorders caused
by emotional problems are psychosomatic. Examples include some cases
of colitis, stomach cramps, diarrhea, constipation, ulcers, cardiac
arrhythmias, impotence, back and neck spasms, and migraines.
Hypochondria involves an exaggerated concern over potential and
imagined symptoms of disease.
Physical examination followed by: P, C, N, W, X
§4.6. Sexual disorders: These include impotence, frigidity, vaginismus
(vaginal muscle spasm), premature ejaculation, and sexual role
disturbances when accompanied by emotional disorders or poor social
functioning (some cases of homosexuality, transsexualism): P, E, O, N,
W; sometimes with Y
If you are willing to work on this within a wider focus: A
§4.7. Impulse control disorders: e.g., pathological gambling,
kleptomania, pyromania: O, M, E, Q
§_5 Mood Disturbances (Affective Disorders)_
There are three primary mood disorders: depression, mania, and manic
depression. They may be neurotic, or they may be psychotic, in which
you experience hallucinations, delusions, and withdrawal from reality.
Each disorder may be situational or nonsituational, depending on the
role of precipitating events, such as the death of a loved one, loss of
a job, diagnosis of terminal illness, etc. Situational mood disorders
usually disappear with time. All three disorders may appear as
isolated episodes, or they may be recurrent.
§5.1. Depression: Clinical depression is not simple sadness or grief.
Severely depressed people speak slowly, laboriously. It is difficult
for you to maintain attention and concentration. You may have feelings
of hopelessness, despair, heaviness, self-blame, heightened
self-criticism, great pessimism about the future, inability to make
decisions, tendencies to think of suicide and sometimes to commit it.
Dependence on loved ones increases as you feel helpless. Interests
diminish in work, hobbies, and friends. You may cry frequently; you
may be irritable and {74} inclined to have angry outbursts. You
probably sleep poorly and awaken frequently, particularly in early
morning. Anxiety is common in about 50 percent of patients. There is
frequently little appetite for food or for sex: Y, E, P, U, T, W, X
As a sense of deep discouragement with life: H
Depressed as a result of a conflict in personal values: G
If you are willing to work on your problems within a wider focus (also
see §1.1): A
§5.2. Mania: You tend to have exaggerated beliefs in your
capabilities; you tend to be euphoric and may fall in love easily and
repeatedly. You suffer from impulsiveness, poor judgment, racing
thoughts, sometimes explosive anger. Milder degrees of mania are often
welcomed by you, family, and friends, who admire your enormous energy
and your many "irons in the fire." Only when family and friends become
aware of your poor judgment in buying sprees, delusions of grandeur, or
sexual excesses do they try to encourage you to seek treatment, usually
against your own wishes: Y (especially lithium therapy), E, P, T, W, X
§5.3. Manic depression: You are trapped on an emotional roller coaster:
at times you are depressed (see §5.1), and at other times you
experience the highs of mania (see §5.2): Y (especially lithium
therapy), and therapies listed under §5.1.
§_6 Adjustment Problems_
Some critics of psychotherapy have argued that its main purpose is to
serve the interests and values of society: a person is judged to be
"abnormal" if he does not want, or refuses, for example, to work from
nine to five all but two weeks of the year; if he does not accept the
responsibilities society claims he should respond to as an adult, a
citizen, a husband, or a father. These social demands--so critics of
therapy have argued--have been internalized by most therapists so that
therapies often do not really serve the individual's needs but rather
the prevailing belief-system of society. Whatever validity the
critics' argument may have, it relates particularly to this area of
emotional suffering that falls under the heading of adjustment
disorders.
Some adjustment disorders clearly lie outside the boundaries of this
criticism. For example, a woman faces the loss of her husband and
resulting poverty. She becomes anxious and depressed, {75} and these
feelings do not go away with time. Or, a man agrees to a job transfer,
wants to succeed at his new position, but is overwhelmed by anxiety in
his new environment. His anxiety doesn't go away.
§6.1. In relation to a new environment or an already familiar one;
work inhibitions: H, M, E, P, N
§6.2. In persons with counterculture attitudes and values: H, D
§6.3. Emotional difficulties arising from poverty and from the
deprivations suffered by minority groups: C
§6.4. Inability to accept realities that limit life: e.g., financial
limitations, restricted opportunities, aging and death (see §9 below),
jobs with "no future," responsibilities that stand in the way of
personal development: F, H
§_7 Marital Problems_
It may be worth mentioning that after a period of therapy some problems
turn out to be marital in nature even though both husband and wife
believed them to be an individual's emotional problem--the man's
problem, not the wife's, or vice-versa, and certainly not a "marital
problem." Sometimes it is only after many individual sessions of
therapy that the marital basis of a problem becomes clear. When
appropriate, the expressed willingness of a spouse to become involved
in his or her partner's individual therapy can be a real help,
providing emotional and treatment support and also saving time when in
fact the marital relationship itself contributes to the individual's
problems.
General marriage therapy: Primary: R, D, E, H, I
Secondary: P, N, I
For communication problems: R, D
§_8 Family Problems_
There is a growing realization among therapists that many individual
problems are produced by families torn by conflict. Often, family
therapy can provide more effective help to a troubled individual than
therapy that treats the individual alone. This seems to be especially
true in many cases of schizophrenia (see §12 below) and in fears of
withdrawal of affection and of abandonment (see §3.4 above).
General family therapy: S, D, C, I, N
{76}
§_9 Problems Related to Aging_
§9.1. Emotional problems in facing old age: E, G
§9.2. Problems facing the recently widowed: H, G
§9.3. Coping with physical pain and disability: U, V, W, Y, X
§_10 Involuntary Behaviors_ (see §13 below)
§10.1. Stuttering: U, G, I, O, W
§10.2. Shaking or motor tic disorders: U, G, I, Y, W
§10.3. Insomnia: V, U, W, Y
§_11. Crisis Intervention:_ _A Need for_ Prompt _Relief from Severe
Symptoms_
Crisis telephone hotlines are available in most metropolitan areas for
immediate counseling and referrals. If such services do not exist in
your area, your family physician, minister, local clinic, hospital, and
even police can be of assistance.
Primary: usually Y followed by B, C, F, or G
Secondary: W, N, O, or P
§_12 Psychoses_
If you have a psychosis, you behave in response to delusions or
hallucinations. Your behavior is seen by others as strange and
inappropriate; you are inclined to withdraw from social groups. You
are severely impaired, out of touch with reality, often unable to
communicate, illogical, rambling, incoherent. Your emotional responses
are greatly out of proportion, even inconsistent, with external events.
There are numerous forms of psychosis, including types of
schizophrenia, manic and paranoid psychoses, hysterical psychoses, and
others. Since self-diagnosis for these conditions is neither
appropriate nor likely to be accurate, no detailed discussion of the
distinct forms of psychosis will be given here. Any diagnosis of
psychosis requires a careful evaluation by a psychiatrist, clinical
psychologist, or psychotherapist.
Primary: Y (antipsychotic drugs) in conjunction with M, O, or H
Secondary: Y with S or A; Y with T
{77}
§_13 Organic Disorders_
§13.1. Senescence, Alzheimer's disease: Senescence is associated with
aging. Three-quarters of persons sixty-five years old and older have a
chronic, disabling condition such as emphysema, heart disease, or
hypertension. Most elderly individuals are able to cope with these
disabilities for the rest of their lives. Some, however, begin to have
psychological problems associated with senescence--e.g., confusion,
depression, paranoia, and sometimes delirious states: supportive
therapies: (e.g., B) and sometimes Y
In Alzheimer's disease, which is a distinct disease and not simply a
sign of aging, you may have numerous physical complaints that cannot be
traced to a physical illness. You may be irritable, lack energy, be
apprehensive, show increasing forgetfulness and changes of personality.
Family members may complain that you "are not yourself." Presenile and
senile dementia are two forms of Alzheimer's disease; both are
progressively degenerative: Y, care by family or by nursing home to
provide supportive environment, planning of daily activities, etc.
§13.2. Parkinsonism/Huntington's chorea: Both are movement disorders
that can produce psychiatric problems, including depression and
schizophrenic disturbances.
§13.3. Substance-induced: alcoholism, drug addiction, smoking.
Alcoholism: Y, O, Alcoholics Anonymous
Drug abuse: Primary: Y, Synanon, O
Secondary: M, D, K
Smoking: O, W
Potentially useful for all of the above as adjunctive treatments: T, X
§13.4. Organic brain dysfunctions: epilepsy, narcolepsy, amnesia,
dementia, delirium. There are numerous conditions caused by
abnormalities in brain function. They do not lend themselves to
self-diagnosis or treatment. The main treatment is: Y
{78}
STEP 2
TAKING YOUR PERSONALITY INTO ACCOUNT
What is challenging for a therapist is discerning the form of
learning that each patient can best utilize and then working to
adopt techniques that are best suited for the patient.... An
important area of research is a way of detecting in a patient his
optimal modes of learning. If we can pinpoint these, we can then
more precisely determine the best means of therapeutic operation.[2]
[2] Lewis R. Wolberg, _The Technique of Psychotherapy_, 2 vols. (New
York: Grune & Stratton, 1977), vol. I, p. 271.
Some people are more amenable to certain approaches to therapy than
others; for example, some people like and benefit from group therapy,
while others hate it. Sometimes what a person likes or would prefer
needs to be overlooked in favor of treatment that is believed to be
effective. But the vast majority of people who enter therapy do this
of their own volition. If the therapy they enter is unsatisfying or
downright distasteful to them, they will soon give it up. We simply
tend not to learn and profit from experiences we dislike or that don't
fit the kinds of people we are.
For some time now therapists have recognized that a client's
personality often tends to incline him or her toward certain approaches
and away from others. In the second step in identifying a potentially
promising approach to therapy, you are encouraged to take traits of
your own personality into consideration. It is not merely the goal or
problem that suggests a particular approach to therapy, but--what is
often more important--the nature of the person. Too little attention
is given to the appropriateness of an individual for a given kind of
therapy.
{79}
_TABLE 2:_
_AN OVERVIEW OF MAIN PERSONALITY TRAITS
RELEVANT TO THE CHOICE OF A THERAPY_
Choose no more than three of the following that you believe influence
most strongly the way you approach day-to-day living:
[ ] §1 Self-discipline
[ ] §2 Commitment to tasks you set for yourself
[ ] §3 Patience
[ ] §4 Initiative
[ ] §5 Tolerance to frustration
[ ] §6 Rigidity
[ ] §7 Inhibition
[ ] §8 Introversion or extroversion
[ ] §9 Motivation and capacity for physical exercise
[ ] §10 Need for acceptance, human warmth, and gentle encouragement
[ ] §11 Articulateness and analytical attitude
[ ] §12 Reflectiveness--thinking about your own feelings, thoughts, and
behavior
[ ] §13 Imagination
[ ] §14 Sensitivity to values
[ ] §15 Comfort in a group setting
[ ] §16 Severe impairments--learning, communication, or emotional
disabilities, including addictions that seriously disrupt your daily
life
{80}
In the following section, you will find questions relating to the
sixteen personal qualities listed in Table 2. For those qualities you
check, answer the questions as realistically as you can. If, for the
most part, you answer "yes" to a given group of questions, then the
approach(es) to therapy identified there may be especially appropriate
for the kind of person you are. If you answer "no" to most of the
questions in a group, then the listed therapy or therapies may not be
especially well suited to you.
MATCHING YOUR PERSONALITY WITH
THE MOST PROMISING THERAPIES
§_1 Self-Discipline_
Therapies rely on self-discipline in clients in several ways:
Are you able to _stick_ to a prescribed routine and do practical
assignments on your own outside of therapy sessions to practice
attitudes, communication skills, or behaviors?
Will you take _personal responsibility_ for coming to regular
appointments on time?
Can you _give up_ any real payoffs of being emotionally troubled?
When _any_ approach to therapy is successful, it is in large measure
because a client has strong personal motivation, a strong will.
However, some approaches to therapy depend more heavily than others on
a client's strength of determination. They include: M, O, E, P, I, N,
H, A, X, T
§2 Commitment to the Process of Therapy
Do you believe you can commit yourself to therapy that spans many
months and sometimes several years? If you hope to gain long-lasting
benefits from your experience in therapy, you will need to commit
yourself to certain practices and ways of thinking _after_ formal
therapy has ended. Do you feel that you have this kind of _tenacity_
and _ability to follow through_?
These are both qualities related to self-discipline, but they have more
to do with sustaining a process over a long period of time: in a word,
_commitment_.
Do you feel you can develop a strong sense of commitment to long-term
therapy? A
To a long-range plan for life improvement? H, M
{81}
§_3 Patience_
If you are suffering from incapacitating anxiety or depression, being
patient about the process of therapy can be very demanding. Long-term
therapies require more patience, endurance, and tolerance than do
short-term therapies.
Are you able to put your trust in a process where results are noticed
only very gradually? (If not, you may feel that what is most urgent
now is to obtain prompt relief from symptoms--see the "Summary of Main
Approaches to Psychotherapy," at the end of this chapter, to get some
idea of the average durations of the different therapies.)
Therapies especially requiring patience--with yourself, with the
challenge, or with the duration of therapy--include: A, H, M, X
§4 Initiative
Some approaches to therapy offer very little direction or specific
advice from the therapist.
Do you feel that you have the initiative to proceed without explicit
direction from the therapist? If so, what you probably need in a
therapist is primarily the capacity to understand you well, to accept
you as a person, and to encourage you in a warm and positive way to do
what you think is best: B
§_5 Tolerance to Frustration_
Do you have a fairly high threshold of frustration when your beliefs
and ideas are challenged? When you do not immediately get what you
want, can you tolerate fairly well what may seem like a long route to
get where you want to go? (Do you cope well with the frustration of
getting lost in your car, for example?) Can you tolerate, without
serious irritation, anger, or hurt, being pushed to confront some of
the pretenses or distortions or illusions you may have lived by?
Can you accept, with some calmness of mind, having someone point out to
you that you have not been as clear about things as you thought, and
that sometimes your attitudes are not consistent, that you are, to some
extent, confused? A, C, E, P
§_6 Rigidity_
Do you often find yourself trying to be, or wishing you were someone
you're not? C
{82}
Are you perfectionistic? Upset when you make even fairly minor
mistakes? Concerned that "things be in their proper place"? Are you
frequently intense and uptight? C, J
Are you "overcontrolling"--anxious when you do not feel you have things
clearly under control?
Are you depressed (see §5, Table 1) or phobic (see §4.2, Table 1)?
Do you suspect that other people think that you magnify evils, blowing
negative things out of proportion? Are you inclined to be moralistic,
dogmatic, critical, or judgmental?
Are you an uncompromising person?
Do you feel, deep down, that perhaps your expectations and demands
(concerning others, yourself, and the world) may be unrealistic?
Do you think you are often inclined to confuse what you would like with
what you need? E, P, H
§_7 Inhibition_
Do you feel blocked, inhibited, or held in check by an overly critical
self? B
Do you feel that you have pent-up feelings that are in need of release?
Do you feel stultified or oppressed by your relationships with your
spouse, friends, or family? Does your life lack emotional intensity?
Do you obtain little joy or satisfaction from living? C, J
Do you feel that somehow there are blocks _in you_ that are standing in
the way of your self-realization, of fulfilling your potential? H
§_8 Introversion or Extroversion_
Are you inner-directed? Would you rather be alone or with one or two
friends than attend a party? Are you impatient, or do you even resent
receiving unsolicited suggestions? A, F
On the other hand, are you at ease with groups of people? Is it
important to your self-image what other people think of you? (Are you
perhaps status-oriented?) Do you often find it useful or helpful to
receive advice? Q
§_9 Motivation and Capacity for Physical Exercise_
Are you free of physical handicaps?
Do you _like_ to be physically active, to exercise?
{83}
Do you begin to feel restless when a week or more goes by and you have
been sedentary?
If you are not physically fit now but are healthy, does it appeal to
you to work regularly and hard to become physically stronger and to
improve your endurance? T, J, yoga (see U)
§_10 Need for Acceptance, Human Warmth,
and Gentle Encouragement_
Do you feel that perhaps no one has ever taken the time to listen to
you, to take a genuine interest in you and in your problems as a person?
Do you feel, perhaps because of circumstances or problems over which
you've had no control, that you have received rather little human
warmth from others?
Would you prefer encouragement that is patient and warm rather than a
forceful push to change your life? B
§_11 Articulateness and Analytical Attitude_
Can you talk openly and clearly about your feelings, about what is
troubling you? Can you fairly readily describe examples of situations
that may bother you?
If you were asked to describe the _personality_ (not his or her
physical features and behavior) of someone you talked with last night
for half an hour at a party, could you do this without a lot of
hesitation and brow-furrowing?
Do you _like_ to talk about personal problem solving, about your
feelings, past events, and why you have come to feel as you do? Do you
feel a _need_ to acquire an overall sense of understanding of yourself,
your family, and how they have influenced you? A
§_12 Reflectiveness_
Do you often find yourself thinking about your feelings, about the
purpose of life, and about whether yours has a meaningful direction?
Do you tend to come home from a visit with friends or family and go
over in your mind what went on and wonder why people said and did
certain things?
Do you have a mental habit of standing apart from what you're doing and
judging yourself and your work?
Do you spend much time just "thinking about things," even dwelling on
problems that concern you? A, G
{84}
§_13 Imagination_
As a child, did you have an imaginary friend?
When you sit on a rock by a brook in the woods, do you quickly begin to
feel a special sense of relaxation? Or, watching the waves breaking on
the beach, do you find yourself lulled into a sense of absorption in
nature?
Do you enjoy reading? As you read a descriptive novel, do you tend to
"see" many of the places and people? Do the events come alive for you?
Do you find yourself thinking about the events in the book as though
they make up a real world of their own? W
§_14 Sensitivity to Values_
Are personal values very important to you? For example, do you
sometimes find yourself thinking that so much of television programming
is mediocre, trash, a waste of time? Do you _feel_ that there are
human values that are more important than how much money you make, what
model car you drive, and the luxuriousness of your home?
Are you a religious or spiritual person, whether you attend church or
not?
Do you like art, music, or literature?
Do you feel, really feel, a sense of compassion or empathy for people
who face poverty and misfortune? Do you sometimes feel guilty because
of your own situation, that there always seem to be others who are
worse off?
Have you ever faced the opportunity to take advantage of someone or of
a situation and simply decided not to (even though you _knew_ you could
do this without risk) because you simply wanted to feel honest or
retain a sense of your own integrity?
Are you in search of a richer meaning in life? Do you wonder whether
what you are doing with your life is really right for you? G
§_15 Comfort in a Group Setting_
Do you feel comfortable and safe in groups?
Do you feel friendly when you pass a house where a party is going on?
Do you enjoy parties or social gatherings?
Did you come from a family with several children? Q, C
{85}
§_16 Severe Impairments_
Do you have any learning or communication disabilities?
Are you so troubled because of emotional upheaval that you cannot work
or maintain your family responsibilities?
Do you have any addictions that are causing grief for you or others
close to you?
Do you sometimes have to "let off steam," even though you know you are
hurting others, damaging their property, or injuring yourself?
{86}
STEP 3
_TABLE 3:_
_THE APPROACHES TO THERAPY
DISCUSSED IN THIS BOOK_
In the left column are the letters used in this chapter to identify
each approach to therapy:
_Letter
Code_ _Approach to Therapy_ _Chapter_
[ ] A Psychoanalysis 9
[ ] B Client-centered therapy 10
[ ] C Gestalt therapy 10
[ ] D Transactional analysis 10
[ ] E Rational-emotive therapy 10
[ ] F Existential-humanistic therapy 10
[ ] G Logotherapy 11
[ ] H Reality therapy 11
[ ] I Adlerian therapy 11
[ ] J Bioenergetics } 11
} Emotional
[ ] K Primal therapy } flooding 11
} therapies
[ ] L Implosive therapy } 11
[ ] M Direct decision therapy 11
[ ] N Counter-conditioning } 12
}
[ ] O Behavior modification } Behavioral 12
} psychotherapies
[ ] P Cognitive approaches }
to behavior change } 12
[ ] Q Group therapy 13
[ ] R Marriage therapy 14
[ ] S Family therapy 14
[ ] T Therapeutic exercise 15
[ ] U Biofeedback 15
{87}
[ ] V Relaxation training 15
[ ] W Hypnosis 15
[ ] X Meditation 15
[ ] Y Drug therapy 16
[ ] Z Nutrition therapy 15
HOW TO USE THE INFORMATION YOU NOW HAVE
If you have followed the instructions for Steps 1, 2, and 3, you should
have identified a potentially promising therapy, or group of therapies,
in relation both to your goals or problems and to your own estimation
of certain important traits of your personality or character.
The therapy or approaches to therapy you have identified now need to be
tested, first, in your imagination as you read the chapters of this
book, which will give you an idea of what each major approach to
therapy is like, and then, if you decide to proceed, in reality, when
you have located a suitable therapist (see Chapter 17).
The need for this testing is a matter of simple realism: you now have a
sense of direction, or perhaps several alternative directions, to
consider. The approach to self-diagnosis described in this chapter is
intended to be useful, but it is not infallible; much depends on the
accuracy of your problem diagnosis, the appropriateness of the goals
you have set, and your self-understanding. Much also will depend on
the therapist you locate and how well you are able to work together.
The recommended therapies listed by letter codes for Steps 1 and 2
reflect evaluations from several sources: (1) Therapists themselves
claim that certain approaches favored by them have been shown to be
useful for treating certain problems, for realizing certain goals, and
for clients with certain personal qualities. (2) Various studies also
have attempted to demonstrate for what and sometimes for whom many of
the major therapies are most successful (see Chapter 20). (3)
Primarily in the _ordering_ of letter codes in connection with the
specific {88} goals, problems, and personal qualities listed in Steps 1
and 2, I have relied on my own experience and judgment. Letter codes
_listed first_ designate therapies that, in general, are commonly
regarded by therapists and psychologists as most useful. At times,
when general consensus appeared to be lacking, I have used my own
evaluation.
The intention in this chapter is to make explicit a simple and
reasonable process of choosing a therapy. Many therapies are not
mentioned in connection with specific goals, problems, or personality
traits. To be sure, some of the therapies that are not mentioned _can_
be useful to certain individuals who have a given goal, problem, or
trait. But the objective of this book is to improve the _general
reliability_ of a person's self-diagnosis and self-understanding. The
book is a _guide_, not a bible.
COMBINING APPROACHES
There is evidence that combining two therapies for certain problems can
frequently be more effective than using either in isolation. Treatment
for individuals suffering from severe anxiety or depression often will
combine drug therapy, for example, with one of the fourteen approaches
to therapy described in Chapters 9-12 and 14 (and listed below, under
"A"). Or, individuals who have problems due to excessive stress may,
for example, be advised to combine biofeedback, relaxation training,
hypnosis, meditation, or exercise therapy with a form of psychotherapy.
Usually, when therapies are combined, one is a formal psychotherapy and
the other is an _adjunctive_ therapy--that is, a therapy that most
often is not relied on exclusively. Some adjunctive therapies lend
themselves very well to use by individuals on their own. Combined
treatments tend, then, to employ one approach taken from list A and one
from list B:
_A (Main Therapies)_
Psychoanalysis
Client-centered therapy
Gestalt therapy
Transactional analysis
Rational-emotive therapy
Existential-humanistic therapy
{89}
Logotherapy
Reality therapy
Adlerian therapy
Direct decision therapy
Behavior modification
Cognitive approaches to behavior change
Marriage and family therapy
_B (Adjunctive Therapies)_
Drug therapy
Meditation
Hypnosis
Relaxation training
Biofeedback
Therapeutic exercise
_Approaches That May Appear Under Either A or B_
Bioenergetics
Primal therapy
Implosive therapy
Counter-conditioning
Group therapy
{90}
_A SUMMARY OF THE MAIN APPROACHES TO PSYCHOTHERAPY_
_Average_
_Therapy_ _Best Suited For:_ _Duration_[*] _Cost_[**]
--------------------------------------------------------------
_Client's Personality (not_
_all traits may apply to a_
_Problems or Goals_ _single person)_
-------------------------------------------------------------------------------------------------------------
[*] 1 = Brief therapies, frequently 12 weekly sessions or less; 2 = 3-6
months; 3 = long-term therapies, 6 months to several years
[**] = initially expensive, then $10-25/hr.; ++ = expensive
$50-100+/hr.; + = moderate, $25-50/hr.; 0 = inexpensive, $10-25/hr.; #
= often available on a sliding scale basis (see Chapter 4) through
county clinics, agencies etc
A. Psychoanalysis self-development: broad-spectrum self-disciplined 3 ++ #
improvements committed
suffering from childhood traumas patient
fear of withdrawal of affection tolerant to frustration
and of abandonment introverted
interpersonal problems articulate
phobias analytical
compulsions reflective
sexual disorders
depression
mania
manic depression
psychoses
B. Client-centered self-development: broad-spectrum inhibited 2 + #
improvements possessing initiative
low self-worth needing acceptance,
crisis intervention human warmth, and
gentle encouragement
C. Gestalt behavior problems in children tolerant to frustration 1-2 + to 0
shyness/passivity rigid
coping with persons in authority inhibited
psychosomatic disorders able to work in a group
adjustment problems: minorities setting
and the poor
family conflicts
crisis intervention
{91}
D. Transactional shyness/passivity interested in effective 1-2 0 #
analysis loneliness/emptiness communication
hostility/overbearing personality
fear of withdrawal of affection
and of abandonment
improving effectiveness of
communication
coping with persons in authority
phobias
adjustment problems
marital problems, especially
those involving communication
difficulties
family conflicts
drug abuse
E. Rational- hostility/overbearing self-disciplined 2 +
emotive personality rigid
interpersonal problems
anxiety disorders
post-traumatic stress
phobias
compulsions
sexual disorders
impulse control disorders
depression
mania and manic depression
adjustment problems
marital problems
delinquency and criminal behavior
{92}
F. Existential- loneliness/emptiness introverted 2 +
humanistic loss of faith in yourself, sensitive to existential
in others, or in life's purpose issues
inability to accept life's
limitations
crisis intervention
G. Logotherapy estrangement/alienation from reflective 2 +
others sensitive to values
loss of faith in yourself, in
others, or in life's purpose
noögenic neuroses
depression due to value conflicts
inability to accept life's
limitations
emotional problems in facing
old age
problems of the recently widowed
stuttering
shaking and motor tic disorders
crisis intervention
H. Reality desire for a success-identity self-disciplined 1-2 +
anxiety disorders committed
post-traumatic stress patient
adjustment problems rigid
marital problems
problems of the recently widowed
vocational problems
delinquency and criminal behavior
psychoses
{93}
I. Adlerian deep discouragement with life self-disciplined 1-2 + #
marital problems inhibited
family conflicts
stuttering
shaking and motor tic disorders
vocational problems
delinquency and criminal behavior
J. Bioenergetics self-development: broad-spectrum inhibited 1-2 +
improvements motivated and able to
suffering from childhood pain undertake physical
exercise
K. Primal anxiety disorders pent-up feelings 1-2 =
post-traumatic stress
phobias
compulsions
drug abuse
L. Implosive phobias (nonspecific) 1 +
M. Direct decision desire for a success-identity self-disciplined 1 +
compulsions committed
impulse control disorders patient
vocational problems
adjustment problems
psychoses
drug abuse
{94}
N. Counter- shyness/passivity self-disciplined 1-2 + #
conditioning hostility/overbearing personality
phobias
psychosomatic disorders
sexual disorders
adjustment problems
marital problems
family conflicts
crisis intervention
O. Behavior mental retardation self-disciplined 1-2 + #
modification autism possibly impaired
behavior problems in children
hyperkinetic behavior
delinquency and criminal behavior
eating disorders
compulsions
sexual disorders
impulse control disorders
stuttering
crisis intervention
psychoses
{95}
P. Cognitive interpersonal problems self-disciplined 1-2 + #
approaches anxiety disorders rigid
to behavior post-traumatic stress
change psychosomatic disorders
sexual disorders
depression
mania and manic depression
adjustment problems
marital problems
crisis intervention
Q. Group shyness/passivity extroverted 1 0 #
loneliness/emptiness tolerant to group
hostility/overbearing involvement
personality
improving communication
effectiveness
impulse control disorders
R. Marriage marital problems
supportive therapy for individual (nonspecific) 1-2 + #
problems
fear of withdrawal of affection
and of abandonment
S. Family family conflicts (nonspecific) 1-2 + #
supportive therapy for individual
problems
emotional disturbances in children
fear of withdrawal of affection
and of abandonment
family-based compulsions
psychoses
{96}
T. Therapeutic depression self-disciplined 2-3 0 or
exercise anxiety disorders motivated and able to no
post-traumatic stress undertake physical cost
marital problems exercise
alcoholism
drug abuse
smoking
psychoses
U. Biofeedback physical pain and disability (nonspecific) 1-2 + #
shaking and motor tic disorders
stuttering
insomnia
anxiety disorders
post-traumatic stress
phobias
depression
V. Relaxation anxiety disorders (nonspecific) 1-2 + #
training post-traumatic stress
phobias
physical pain and disability
insomnia
{97}
W. Hypnosis emotional disturbances in imaginative 1-2 +
children trusting
eating disorders
interpersonal problems
anxiety disorders
post-traumatic stress
phobias
psychosomatic disorders
sexual disorders
depression
mania and manic depression
physical pain and disability
stuttering
shaking and motor tic disorders
X. Meditation loss of faith in yourself, in self-disciplined 3 0 or
others, or in life's purpose patient no
anxiety disorders cost
post-traumatic stress
depression
mania and manic depression
physical pain and disability
alcoholism
drug abuse
smoking
{96}
Y. Drug autism possibly impaired 1-3 + + #
hyperkinetic disturbances
anxiety disorders
post-traumatic stress
phobias
compulsions
sexual disorders
depression
mania and manic depression
physical pain and disability
shaking and motor tic disorders
insomnia
crisis intervention
Z. Nutrition possibly hyperkinetic behavior no data available -- --
as well as other
problems (see Chapter 14)
[*] 1 = Brief therapies, frequently 12 weekly sessions or less; 2 = 3-6
months; 3--long-term therapies, 6 months to several years
[**] = initially expensive, then $10-25/hr.; ++ = expensive
$50-100-f/hr.; + = moderate, $25-50/hr.; 0 = inexpensive, $10-25/hr.; #
= often available on a sliding scale basis (see Chapter 4) through
county clinics, agencies, etc.
{99}
8
EMOTIONAL PROBLEMS
THAT MAY HAVE
PHYSICAL CAUSES
This chapter has a single important purpose: to persuade you, if you
are in serious emotional distress, to have a comprehensive physical
examination _before_ beginning psychotherapy. Imagine how disheartened
and frustrated you might feel after a period of unsuccessful therapy,
only to find out afterward that your problems could be traced to a
physical cause. It is essential that you eliminate the possibility of
a physical basis for your problems before seeking therapy. In fact,
most therapists routinely recommend that you have a complete physical
before entering therapy.
Rest assured that doing so will _not_ be a waste of time. Richard
Rada, Director of College Hospital in Cerritos, California, estimates
that between five and ten percent of clients with depression, anxiety,
or unusual thoughts and behavior may have underlying physical
conditions that are responsible, including gland {100} dysfunction, an
epileptic abnormality, heart disease, cancer, and so on. The following
facts, too, should convince you that having a comprehensive physical is
paramount:
* As many as one patient in every ten who suffer from serious
depression has a thyroid disorder.
* One person in every four who are diagnosed as having psychiatric
disorders and who are over sixty-five has an underlying physical
illness that is responsible.
* An equal number of individuals over sixty-five have emotional
problems that are made worse by underlying physical disorders.
* Three percent of people who regularly take prescription medication
develop mental symptoms.
Dr. Leonard Small, a specialist in the field of neuropsychodiagnosis,
has found that the more severe emotional or mental symptoms are, the
more likely it is that therapists (and patients) will overlook the
possibility of underlying physical disorders.[1]
[1] Leonard Small, _Neuropsychodiagnosis in Psychotherapy_ (New York
Brunner/Mazel, 1980), p. vii.
It isn't necessary or possible to give a detailed or comprehensive
catalog of physical causes of emotional and mental disturbances here,
but it may be helpful to many people to see some of the principal ways
in which psychological symptoms can be produced by physical problems.
Hopefully, these illustrations will persuade you, if you are
emotionally or mentally troubled, of the wisdom of a thorough physical.
It is a small price to pay if emotional symptoms can be traced to a
physical cause.
It is well known that virtually any serious organic illness or injury
can produce emotional suffering, either in the form of physical pain or
in the form of anxiety and depression. Chronic pain is a chronic
stress and can lead to the same emotional problems as prolonged stress
of any variety: anxiety or depression. Similarly, prolonged severe
anxiety or depression can cause physical deterioration and make the
body more susceptible to disease.
{101}
There are, then, two "vicious circles," or feedback loops, that can
play a role in causing or aggravating emotional disturba
Showing first 200,000 characters. Full text: gutenberg.org/ebooks/44926