Psychotherapies, Part 1
A Different Perspective
All psychotherapeutic methods are elaborations and variations of age-old procedures of psychological healing. These include confession, atonement and absolution, encouragement, positive and negative reinforcements, modeling, and promulgation of a particular set of values. These methods become embedded in theories as to the causes and cures of various conditions which often become highly elaborated.
In view of their use of time-tested healing procedures, it is not surprising that all psychotherapies have many features in common. Those features which distinguish them from each other, however, receive special emphasis in pluralistic, competitive society. Since the prestige and financial security of psychotherapists depend to a considerable extent on their being able to show that their particular theory and method is more successful than that of their rivals, they inevitably emphasize their differences; and each therapist attributes his or her successes to those conceptual and procedural features that distinguish that theory and method from its competitors rather than to the features that all share.
The field of psychotherapy has presented a bewildering array of theories and techniques, accompanied by a deafening cacophony of rival claims. A comprehensive review of the field required over 250 pages simply to describe extant approaches (Wolberg 1977). Recently, however, observers are beginning to detect increasing signs that representatives of different schools are willing to acknowledge the potential value of a range of techniques and to show increasing flexibility in applying them (Norcross and Goldfried 1992).
These stirrings of rapprochement reflect a growing recognition that all psychotherapeutic procedures share certain healing components which account for a considerable proportion of their effectiveness. In order to contribute to this welcome development, in this chapter I shall consider healing components mobilized by all forms of psychotherapy and the ways these components may work.
Let me now offer a definition of psychotherapy that is sufficiently broad to include everything that goes by that term but excludes informal help from relatives, friends and bartenders. Psychotherapy is a planned, emotionally charged, confiding interaction between a trained socially-sanctioned healer and a sufferer. During this interaction the healer seeks to relieve the sufferer’s distress and disability through symbolic communications, primarily words but also, sometimes, bodily activities. The healer may or may not involve the patient’s relatives and others in the healing rituals. Psychotherapy also often includes helping the patient to accept and endure suffering as an inevitable aspect of life that can be used as an opportunity for personal growth.
Distinguishing features of psychotherapy
Before proceeding further, let us pause briefly to consider the features that distinguish psychotherapy, thus defined, from other forms of giving and receiving help. The psychotherapist has credentials as a healer. These are provided by society at large in the form of licensure or other official recognition. The therapist has earned this recognition by having undergone special training, usually prolonged, which entitles him or her to the status symbol of an academic degree. Therapists lacking such generally recognized credentials are sanctioned by the particular sect or cult they represent. Persons who go to them thereby imply that they accept the validity of these sanctions.
It is assumed that, whatever his or her credentials, the therapist is not attempting to gratify any personal needs or make any personal emotional demands on the patient. Nor need the patient guard his own responses for fear of hurting the therapist. In these respects the therapist differs fundamentally from family members or friends. Finally, psychotherapeutic procedures, in contrast to informal help, are guided by conceptual schemes which prescribe specific rituals.
In different societies psychotherapy reflects not only a society’s conceptualizations of illness and health but also its values. Patient and therapist are generally required to work at some form of mutual activity to justify their spending time together, and increased autonomy is regarded as an important feature of mental health.
An aspect of the world view shared by most psychotherapists is the high prestige accorded to science. As a result, psychotherapists of most schools, from psychoanalysis to behavior modification, claim that their procedures are grounded on scientific evidence. The extent to which psychotherapists view themselves as applied scientists, or at least wish to be seen as such, was brought home to me many years ago at a conference attended by leading exponents of different psychotherapeutic schools. Each speaker introduced his or her presentation by a genuflection toward science. One showed kymographic tracings, another referred to work on rats and a third displayed anatomical charts—all of which had only tenuous relevance to the therapies they were presenting.
The scientific world view assumes that man is part of the animal kingdom, which, like all nature, is ruled by natural laws. Human behavior, thinking and feeling are determined and constrained by genetic endowment, biologically-based needs and the effects of beneficial and harmful environmental influences. Therapy consists of the application of special techniques to combat maladaptive patterns and encourage more appropriate ones.
The American psychotherapeutic scene, while dominated by the scientific world view, also includes a small number of increasingly influential therapies based primarily on the teachings of recent European philosophers, psychologists and philosophers who reject this position (Chessick 1992). Referred to by such terms as humanism, existentialism and phenomenology, these teachings are so various as to defy any simple characterization. Most hold the view that the essence of being human is the right and the capacity of self-determination, guided by purposes, values and options. Out of our free will we can give our lives meaning, even in the face of inevitable death. Therapy is a particular kind of relationship, the ‘encounter’ which existential-humanist therapists describe in such terms as ‘relating to the patient as one existence communicating with another’ or ‘entering the world of the patient with reverent love’ or ‘merging with the patient’. Through this total acceptance, the patient comes to value his or her own uniqueness, becomes free to exert choice, to make commitments and to find a meaning
in life (Seguin 1965).
A basic assumption of all psychotherapies is that humans react to their interpretation of events, which may not correspond to events as they are in reality. All psychotherapies, therefore, try to alter favorably patients’ views of themselves, their relations with others and their system of values. To this extent psychotherapies resemble both religion (Szasz 1978) and rhetoric (Frank 1986, 1987). To enhance their credibility, psychotherapists try to project the same personal qualities as rhetoricians—such as perceived expertness, trustworthiness and attractiveness—and they use many of the same rhetorical devices such as metaphors and sensory images—to focus the patients’ attention ‘on ideas central to the therapeutic message and … [make them] appear more … believable’ (Glaser 1980, p. 331).
Limitations of research
Now a brief consideration of the limitations of research in psychotherapy. An authority on research in psychology has concluded that ‘psychology is …. a collectivity of studies of various cast, some few of which may qualify as science, while most do not. ..Extensive and important sectors of psychological study require modes of inquiry rather more like those of the humanities than the sciences’ (Koch 1981, pp. 268-269).
One of these important sectors is psychotherapy, which presents special difficulties to the researcher. These difficulties permit only modest hopes as to the extent to which application of the scientific method will lead to insights that will improve psychotherapies.
As mentioned earlier, a general problem which plagues all psychological experiments is that humans respond to their interpretations of situations and the subject’s interpretation of the experimental situation may differ strikingly from the one that the experimenter thinks has been created (Orne 1969). Thus the experimental findings may reflect the subject’s efforts to comply with what he or she thinks the experimenter wants rather than reflecting a response to the experimental conditions. In psychotherapy this problem is aggravated because the patient typically experiences strong ‘evaluation apprehension’, which has been shown to increase a psychological subject’s susceptibility to influence by the experimenter’s unspoken expectations (Rosenberg 1969). In psychotherapy the patient depends on the therapist for relief, which would be expected to enhance this susceptibility. Therefore, it is particularly difficult to disentangle how much of a patient’s apparent response to psychotherapy is an effort to meet the therapist’s expectations.
Psychotherapy is just one more influence operating briefly and intermittently on the patient in the context of his ongoing life experiences. At best, psychotherapeutic interviews represent only infrequent, intermittent, brief personal contacts wedged in among innumerable others. What goes on between sessions may be more important in determining outcome than what occurs during sessions. Also, psychotherapy and ongoing life experiences may interact in complex ways because a change in the patient’s outlook or behavior brought about by psychotherapy inevitably affects the attitudes of others toward him and these attitudes may reinforce or counteract the changes induced by therapy. Mere acceptance of the patient for psychiatric treatment, for example, may lead family members to change their view of the individual from a person who is lazy or bad to one who is sick, with corresponding favorable changes in their attitudes toward the patient. Conversely, if the patient’s symptoms or deviant behaviors contribute to the equilibrium of the family, fear of the patient losing these symptoms or behaviors might lead other family members to sabotage treatment. Thus it may be difficult to assess the relative extent to which patients’ changes during psychotherapy are attributable to the treatment itself, to factors outside it and to the interaction between treatment and outside factors.
At a more fundamental level, some important experiences in psychotherapy may in principle be unamenable to scientific study because they occur in altered states of consciousness, in ways not accessible to the senses and in levels of reality differing from the everyday one (Smith 1977; LeShan 1974).
When we return from this uncomfortable line of thought to more familiar ground, we find that psychotherapy research bristles with practical difficulties—such as the dearth of suitable patients and experienced therapists, inadequate ways of classifying patients and describing therapies, and problems of measuring outcome. These difficulties create an often irresistible temptation to choose research problems on the basis of methodological simplicity rather than on that of intrinsic interest.
Finally, motivational problems, especially in therapists, create difficulties. Not only are therapists’ personal and financial security and status wrapped up in the success of their methods but much of their success may depend on personal qualities. So therapists are understandably reluctant to submit themselves to investigations which could reveal that they have attributes which militate against therapeutic success. Such a finding could be devastating not only to their pocketbooks but also to their self-esteem.
All in all, it is no wonder that, despite the outstanding ability of many researchers in psychotherapy, findings by and large have been tentative and disappointing. Reviews of psychotherapy research studies characteristically bemoan their lack of impact on practice and conclude with comments on their inadequacies and the need for further research.
Perhaps the greatest contribution of the scientific method is that it requires the experimenter to take negative findings seriously. As a result, the scientific study of psychotherapy has performed a useful function by rescuing common sense from the clutches of dogmatic theories. A good example of such a rescue has been the over-emphasis on unconscious processes by certain schools and the insistence by others that subjective symbolic processes are irrelevant, both of which have had to yield to scientific evidence that conscious cognitive processes are important features of human functioning—a blatant truism, one might say, but one that certain people have been reluctant to accept.
The preceding discussion is by way of justifying that in this chapter, although I shall cite research findings as far as possible, I shamelessly admit that my conclusions are based at least as much on reflection about my own and others’ clinical experience as they are on experiments. Research findings are offered as illustrations of points rather than as proofs of their validity.
Generalizations about outcomes of psychotherapies
To open discussion of therapeutic features common to all types of psychotherapy let me briefly state four generalizations that are relatively firmly established. The first is that patients who receive any form of psychotherapy do somewhat better than controls observed over the same period of time who have received no formal psychotherapy, which does not, of course, exclude their having benefit from informal helping contacts with others (Smith, Glass and Miller 1980). Second, follow-up studies seem to show consistently that, whatever the form of therapy, most patients who show initial improvement maintain it (Liberman 1978). Moreover, when two therapies yield differences in outcome at the close of treatment, with rare exceptions, these differences disappear over time and the closing of the gap seems to depend more on patients who receive the less successful therapy catching up than on both groups regressing equally toward the mean (Gelder, Marks and Wolf 1967; Liberman 1978). This result suggests that the main beneficial effect of psychotherapy with many patients may be to accelerate improvement that would have occurred eventually in any case (McNeilly and Howard 1991). Third, more of the determinants of therapeutic success lie in the personal qualities of and the interaction between patient and therapist than the particular therapeutic method used. Finally, there are a few conditions in which the therapeutic method does make a significant difference in outcome. Behavior therapies seem to be somewhat more effective for phobias, compulsions, obesity and sexual problems than are less focused therapies.
Abreactive therapies seem to be specifically helpful in resolving the after-effects of post-traumatic stress reactions, following not only combat (Kolb 1985) but a wide range of frequent childhood and adult stressful experiences (Horowitz 1988).
Of particular interest from the standpoint of the hypothesis to be offered presently is that cognitive therapy, which seeks to combat negative cognitions about oneself, the future and one’s relationships with other people, seems particularly effective with depressed patients (Burns 1980). The efficacy of all procedures, however, depends on the establishment of a good therapeutic relationship between the patient and the therapist. No method works in the absence of this relationship.
With increasing refinement of categorization of patients and their symptom pictures, more precise delineation of therapies and more differentiated measures of outcome, further advantages of specific therapies for specific conditions may yet be found. It does seem safe to conclude, however, that features shared by all therapies account for an appreciable amount of the improvement observed in most psychiatric patients who respond at all (Frank 1973).
If the preceding conclusion is valid, patients, whatever their symptoms, must share a type of distress that responds to the components common to all schools of psychotherapy. A plausible hypothesis is that patients seek psychotherapy not for symptoms alone but for symptoms coupled with demoralization, a state of mind characterized by one or more of the following: subjective incompetence, loss of self-esteem, alienation, hopelessness (feeling that no one can help) or helplessness (feeling that other people could help but will not). These states of mind are often aggravated by cognitive unclarity as to the meaning of seriousness of the symptoms, not uncommonly accompanied by a sense of loss of control, leading to fear of going crazy.
Demoralization occurs when, because of lack of certain skills or confusion of goals, an individual becomes persistently unable to master situations which both the individual and others expect him or her to handle or when the individual experiences continued distress which he or she cannot adequately explain or alleviate. Demoralization may be summed up as a feeling of subjective incompetence coupled with distress (Frank and Frank 1991; deFigueiredo and Frank 1982).
One must add that not all demoralized people get into treatment and not all patients in psychotherapy are demoralized. Sometimes patients are brought to treatment not because they are demoralized but because people around them are—for example, the parents of sociopaths or the spouses of alcoholics. This mention of alcoholics is a reminder that some people, such as skid row alcoholics, are too demoralized even to seek help. Finally, of course, a small proportion of patients seek treatment for specific symptoms without otherwise being demoralized because they have heard that, for example, behavior therapy will cure their phobia of heights.
The most common symptoms of demoralization presented by patients in psychotherapy are subjective or behavioral manifestations, such as, on the one hand, anxiety, depression, loneliness or, on the other, conflict with significant persons such as spouse, boss or children. Anxiety and depression or loss of self-esteem are the symptoms most common among psychiatric outpatients and most responsive to treatment (Smith, Glass and Miller 1980).
Whatever their source or nature, all symptoms interact with demoralization in various ways. They reduce a person’s coping capacity, predisposing the individual to demoralizing failures. Whether the symptom be schizophrenic thought disorder, reactive depression or obsessional ritual, it may cause the patient to be defeated by problems of living that asymptomatic persons handle with ease. Furthermore, to the extent that the patient believes them to be unique, psychiatric symptoms contribute to demoralization by heightening feelings of alienation. Finally, symptoms wax and wane with the degree of demoralization. Thus schizophrenics’ thinking becomes more disorganized when they are anxious and obsessions and compulsions become worse when the patients are depressed.
Most patients present themselves with specific symptoms, and both they and their therapists assume that psychotherapy is aimed primarily at relieving these. Such patients do indeed exist, but for the great bulk, I suggest, much of the improvement resulting from any form of psychotherapy lies in its ability to restore the patient’s morale, with the resulting diminution or disappearance of symptoms. One must add, of course, that alleviation of the patient’s symptoms may be the best way to restore morale.
Indirect evidence for the demoralization hypothesis comes from several sources. One source consists of studies comparing cohorts of persons who seek or have sought psychotherapy with those who have not. Studies of college students (Galassi and Galassi 1973), alumni out of college for 25 years (Vaillant 1972) and ordinary citizens in England and America (Kellner and Sheffield 1973) showed that the treated had a higher incidence or greater severity of social isolation, helplessness or sense of failure or unworthiness—all symptoms of demoralization—than the untreated.
The strongest empirical support has been supplied by the surveys of Bruce and Barbara Dohrenwend, who have devised a set of scales to determine the extent of psychiatric symptoms and clinical impairment in the general population (Dohrenwend et al. 1980). To their surprise, they found that eight of their scales correlated as highly with each other as their internal reliabilities would permit—that is, they all seemed to measure a single dimension. These scales included features of demoralization such as anxiety, sadness, hopelessness and low self-esteem (Dohrenwend et al. 1979). About one-fourth of the persons in the population they surveyed were estimated to be demoralized according to this criterion. Of these, about one-half were also clinically impaired (Link and Dohrenwend 1980). The finding most supportive of the hypothesis was that about four-fifths of clinically impaired outpatients scored above the cut-off point on a scale that later was found to correlate above 0.90 with the demoralization scales (Dohrenwend and Crandall 1970).
Surveys of reported emotional distress and presence or absence of supportive social networks provide further indirect evidence for the demoralization hypothesis. A general population survey found that persons who possess such a network are much less likely to be distressed by severe environmental stresses than those who are not so supported (Henderson, Byrne and Duncan-Jones 1981). In response to a similar survey, members who had joined a religious cult reported a sharp decline in anxiety, depression and general emotional problems and attributed this decline primarily to emotional support from all the group members (Galanter 1978). Apparently, emotional support from others protects individuals from demoralization.
Further indirect support for the demoralization hypothesis is that many patients improve very quickly in therapy, suggesting that their favorable response is to the reassuring aspects of the therapeutic situation itself rather than to the particular procedure (Talmon 1990).
Shared therapeutic components
Turning at last to the shared therapeutic components of all forms of psychotherapy (Frank et al.), we find that most forms can be viewed as a means of directly or indirectly combating demoralization:
1. An emotionally charged, confiding relationship with a helping person, often with the participation of a group. With some possible minor exceptions, the relationship with the therapist is a necessary, and perhaps often a sufficient, condition for improvement in any kind of psychotherapy (Rogers 1957). As Sloane et al. (1975) found, ‘Successful patients rated the personal interaction with the therapist as the single most important part of their treatment’ (p. 225).
2. A healing setting, which has at least two therapeutic functions in itself. First, it heightens the therapist’s prestige and strengthens the patient’s expectation of help by symbolizing the therapist’s role as a healer, whether the setting is a clinic in a prestigious hospital or a private office complete with bookshelves, impressive desk, couch and easy chair. Often, the setting also contains evidences of the therapist’s training, such as diplomas and pictures of his or her teachers. Second, the setting provides safety. Surrounded by walls, patients know they can let themselves go within wide limits, dare to reveal aspects of themselves that they have concealed from others and discuss various alternatives for future behavior without commitment and without any consequences outside the office.
3. A rationale, conceptual scheme, or myth that provides a plausible explanation for the patient’s symptoms and prescribes a ritual or procedure for resolving them.
4. A ritual that requires active participation of both patient and therapist and that is believed by both to be the means of restoring the patient’s health.
The words ‘myth’ and ‘ritual’ are used advisedly to emphasize that, although typically expressed in scientific terms, therapeutic rationales and procedures cannot be disproved. Successes are taken as proof of their validity ‘often’ erroneously, while failures are explained away. ‘No form of therapy has ever been initiated without a claim that it had unique therapeutic advantages. And no form of therapy has ever been abandoned because of its failure to live up to these claims’ (M.B. Parloff quoted in Hilts 1980). To my knowledge, no therapeutic school has ever disbanded because it concluded that another’s doctrine and method was superior.
An often overlooked function of therapeutic rituals is to provide a face-saving excuse for the patient to abandon a symptom or complaint when ready to do so. To relinquish a symptom without an adequate external reason would carry the implication that it was trivial or that the patient had produced it for some ulterior motive. The more spectacular the ritual, the greater its usefulness from the individual’s standpoint. This circumstance necessitates caution in attributing remission of a symptom to a particular maneuver. The patient might have been ready to relinquish the symptom for other reasons and the role of the procedure may simply have been to serve as the occasion for doing so.