The Challenge to Psychoanalysis and Psychotherapy

Psychotherapies, Part 2

A Different Perspective

Functions of myth and ritual
All therapeutic myths and rituals, irrespective of differences in specific content, have in common functions that combat demoralization by strengthening the therapeutic relationship, inspiring expectations of help, providing new learning experiences, arousing the patient emotionally, enhancing sense of mastery of self-efficacy and affording opportunities for rehearsal and practice. Let us consider each of these briefly in turn.

Strengthening the therapeutic relationship, thereby combating the patient’s sense of alienation
A shared belief system is essential to the formation and maintenance of groups, so the adherence of therapist and patient to the same therapeutic myth creates a powerful bond between them. Within this context, the therapist’s continued acceptance of the patient after the patient has ‘confessed’ to thoughts, feelings or behavior regarded as shameful combats the latter’s demoralizing feelings of alienation, especially if, as is usually the case, the therapist represents a group. The ritual serves to maintain the patient—therapist bond, especially over stretches when nothing much seems to be happening. By giving patient and therapist something to do together, the ritual sustains mutual interest.

Inspiring and maintaining the patients expectation of help
By inspiring expectations of help, myths and rituals not only keep the patient coming to treatment but also may be powerful morale builders and symptom relievers in themselves (Friedman 1963; Jacobson 1968; Ubienhuth and Duncan 1968). The arousal of hope may also account for the findings in several studies that ‘the best predictor of later benefits is … expectations of early benefits expressed in the early sessions’ (Luborsky 1976, p. 107).

To be therapeutically effective, hope for improvement must be linked in the patient’s mind to specific processes of therapy as well as outcome (Imber et at. 1970; Wilkins 1979). This link could be taken for granted by purveyors of traditional therapies like psychoanalysis because most patients came to them already familiarized with their procedure (Kadushin 1969). Introducers of new or unfamiliar therapies regularly spend considerable time and effort at the start teaching the patient their particular therapeutic game and shaping the patient’s expectations accordingly.

Providing new learning experiences
These new learning experiences can enhance morale by enabling patients to discover potentially helpful alternate ways of looking at themselves and their problems and to develop alternate values. In this connection, improvement in therapy seems to go along with movement of the patient’s values toward those of the therapist (Parloff, Goldstein and Iflund 1960; Rosenthal 1955).

Learning may occur in several ways, including instruction, modeling (Bandura 1977), operant conditioning (in which the therapist’s responses serve as positive or negative reinforcers) and exposure to new emotionally charged experiences—including transference reactions and emotional arousal by attempts to change contingencies governing behavior.

The more numerous and more intense the experiential, as opposed to the purely cognitive, components of learning, the more likely they are to be followed by changes in the patient attitudes or behavior. It is a truism that intellectual insight alone is essentially powerless to effect change. This brings us to the fourth therapeutic ingredient common to all therapeutic conceptualizations and rituals, emotional arousal.

Arousing emotions
Such arousal is essential to therapeutic change in at least three ways: it supplies the motive power to undertake the effort and to undergo the suffering usually involved in attempts to change one’s attitudes and behavior, facilitates attitude change and enhances sensitivity to environmental influences. If the emotional arousal is unpleasant, it leads the patient to search actively for relief. When this occurs in therapy, the patient naturally turns to the therapist. Arousal intense enough to be disorganizing further increases this dependence and, in addition, may facilitate the achievement of a better personality integration by breaking up old patterns.

The elicitation of intense emotions characterizes almost all healing rituals in non-industrialized societies. In the West the popularity of such approaches waxes and wanes. In the recent past these approaches emerged in Mesmerism and Freudian abreaction, and currently they are flourishing under various labels such as implosive therapy (Stampfl 197 6), primal therapy (Janov 1970), re-evaluation counseling (Jackins 1965), bioenergetics (Lowen 1975) and many, many more.

Although emotional arousal may facilitate attitude change, something else seems to be needed to maintain the change. If one may generalize from this observation, which is consistent with others, it may be important to distinguish factors that produce therapeutic change from those that sustain it (Liberman 1978).

From the perspective of the demoralization hypothesis, the therapeutic effect of intense emotional arousal may be in its demonstration to patients that they can stand, at high intensity, emotions which they feared and which, therefore, caused them to avoid or escape from situations that threatened to arouse them. Surviving such an experience would strengthen self-confidence directly and also encourage a patient to enter, and cope successfully with, these feared situations, thereby indirectly further bolstering morale.

Thus the maintenance of improvement following emotional flooding may depend on the ability of this procedure to enhance the patient’s sense of mastery (Liberman 1978) or self-efficacy (Bandura 1977), to which I now turn.

Enhancing the patient’s sense of mdStery or self-efficacy
Self-esteem and personal security depend to a considerable degree on a sense of being able to exert some control over the reactions of others toward oneself as well as over one’s own inner states. Inability to control feelings, thoughts and impulses not only is demoralizing in itself but also impedes one’s ability to control others by pre-empting too much attention and distorting one’s perceptions and behavior. The feeling of loss of control gives rise to emotions, such as anxiety, which aggravate and are aggravated by the specific symptoms or problems for which the person ostensibly seeks psychotherapy. All schools of psychotherapy seek to bolster the patient’s sense of mastery in at least two ways: by providing the patient with a conceptual scheme that labels and explains symptoms and supplies the rationale for the treatment program and by giving the individual experiences of success.

Since the verbal apparatus is a human being’s chief tool for analyzing and organizing experience, the conceptual scheme increases the patient’s sense of control by making sense out of experiences that had seemed haphazard, confusing or inexplicable and giving names to them. This effect has been termed the principle of Rumpelstiltskin (Torrey 1972) after the fairy tale in which the queen broke the wicked dwarf’s power over her by guessing his name.

To have this effect, interpretations, which are the primary means of transmitting the conceptual framework, need not necessarily be correct but may merely be plausible. One therapist demonstrated this concept by offering six ‘all-purpose’ interpretations to four patients in intensive psychotherapy. An example of such an interpretation is ‘You seem to live your life as though you are apologizing all the time.’ The same series of interpretations, spaced about a month apart, was given to all four patients. In 20- of these 24 instances the patients responded with a drop in anxiety level. All patients experienced this move from the ‘pre-interpreted’ to the ‘post-interpreted’ state at least once (Mendal 1964).

Experiences of success, a major source of enhanced self-efficacy, are implicit in all psychotherapeutic procedures. Verbally adept patients get them from achieving new insights; behaviorally-oriented patients from carrying out increasingly anxiety-laden behaviors. As already mentioned, by demonstrating to the patient that he or she can withstand at their maximal intensity the emotions he or she fears, emotional flooding techniques yield powerful experiences of success.

Furthermore, performances which the patient regards as due to his or her own efforts would be expected to reflect more strongly on an individual’s self-esteem than those which the patient attributes to factors beyond his or her control, such as a medication or the help of someone else. In recognition of this expectation, psychotherapists of all persuasions convey to the patient that progress is the result of the individual’s own efforts. Non-directive therapists disclaim any credit for the patient’s acquiring new insights and directive ones stress that the patient’s gains depend on his or her ability to carry out the prescribed procedures.

Providing opportunities for practice
A final morale-enhancing feature of all psychotherapies is that they provide opportunities and incentives for internalizing and reinforcing therapeutic gains through repeated testing both within and outside the therapeutic session.

For completeness, it should be mentioned that group therapies involve the same morale-building principles as individual ones, often to a greater degree. The presence of other patients and the emergence of processes specific to groups introduce additional ways of combating the alienation that accompanies demoralization and provide different opportunities for cognitive and experiential learning and for practising what has been” learned. They also provide more occasions for emotional arousal and more opportunities to achieve a sense of mastery through weathering the stresses of group interactions. Finally, as social microcosms more closely resembling real life than individual interview situations, groups facilitate transfer of what has been learned to daily living.

Determinants of therapeutic success
The most powerful determinants of the success of any therapeutic encounter probably lie in properties of the patient, the therapist and the particular patient-therapist pair rather than in the therapeutic procedure. Despite its importance, this area presents particular problems for research, as already indicated, so research findings are scanty and, for the most part, simply confirm clinical impressions. This situation enables me to be mercifully brief.

There is general agreement that the good patient is characterized by sufficient distress to be motivated for treatment and by the capacity to profit from a helping relationship. Strupp (1976) suggests that to be able to so profit the patient must have had sufficiently rewarding experiences with his or her own parents so that the patient has developed ‘the capacity to profit from any change as a result of the forces operating in a “good” human relationship’ (p. 99).

Patients with a good prognosis are characterized, in addition, by such terms as ‘good ego strength’, ‘coping capacity’ or ‘personality assets’. An illuminating approach to therapeutically favorable personal qualities is provided by Harrower (1965). On the basis of a follow-up study of 622 patients in psychoanalysis or analytically-oriented therapy, she was able to devise an index of mental-health potential based on score patterns on projective tests that correlated highly with improvement as judged retrospectively by the patients’ therapists. Mental-health potential included capacity for emotional warmth and friendliness, adequate intellectual control combined with freedom and spontaneity, inner resources, and intuitive empathy for others. In short, the psychologically healthier the patient is at the start, the better the prognosis for response
to treatment.

One would like to know much more about factors determining ability to profit from specific therapeutic procedures. For example, Malan (1976) presents evidence that ‘motivation for insight’ may be important for the success of brief psychoanalytically- oriented psychotherapy. A promising lead is classification of patients in terms of locus of control—that is, whether the person sees control of his or her life as lying primarily within or outside of self (Rotter 1966; Seeman and Evans 1962).

In examining the therapeutic qualities of therapists, we find that the success rate of therapists varies widely even within the same therapeutic school. For example, in a study of encounter groups that used at least two therapists from each of several therapeutic schools, Liberman, Yalom and Miles (1973) found that the best and the worst outcomes were in groups conducted by therapists belonging to the same school. Participants in encounter groups are sufficiently smaller to those in therapy groups to justify applying this finding to them. In a retrospective analysis of 150 women treated by 16male and 10 female therapists, Orlinsky and Howard (1980) found that two-thirds of the patients of the most successful therapists were much improved and none were worse—while for the least successful, only one-third were much improved and one-third were worse. The ability to generalize about such findings remains questionable (Parloff, Waskow and Wolfe 1978).

We find that psychotherapists, like musical performers, vary in innate talent—which, in most, can be enhanced by training. Almost anyone can learn to play the piano but no amount of training can produce a Horowitz or a Rubinstein, nor can it turn someone who is tone deaf into a piano player. Analogously, some therapists seem to obtain extraordinary results while the patients of a few do no better, or even fare worse, than if they had received no treatment at all. It would be highly desirable to weed out these ‘tone-deaf’ therapists early in training, thereby preventing harm to patients and sparing the therapists from misery, but, unfortunately, adequate screening methods for this purpose do not yet exist.

My own hunch, which I mention with some trepidation, is that the most gifted therapists may have telepathic, clairvoyant or other parapsychological abilities (Ehrenwald 1966, 1978; Freud 1964; Jung 1953). They may, in addition, possess something that is similar to the ability to speed plan growth (Grad 1967) and that can only be termed ‘healing power’. Any researcher who attempts to study such phenomena risks his reputation as a reliable scientist, so their pursuit can be recommended only to the most intrepid. The rewards, however, might be great.

Since the therapeutic relationship is a two-way street, efforts to determine aspects of patients and therapists which make good or poor therapeutic matches seem worth pursuing. Again, information about this is very scanty, but thought provoking. For example, it appears that with hospitalized chronic schizophrenics, composed therapists work best with anxious patients, therapists comfortable with aggression work well with hostile patients, grandparental therapists do well with seductive patients and therapists comfortable with depression do well with depressed schizophrenics (Gunderson 1978). Hardly a world-shaking finding, you will say, but it is a beginning.

The study of women in therapy mentioned earlier (Orlinsky and Howard 1980) unearthed some interesting leads. The differential success rate of therapists appeared to be due primarily to interaction of patient-therapist pairs rather than to properties of the therapist alone, except that experience seemed to operate across the board. Therapists with less than six years’ experience, compared with those with more, had twice as many patients who were unchanged or worse and only half as many who were considerably improved. The role of experience in therapeutic success, however, remains moot (Parloff et at. 1978). Of more interest is that although the sex of the therapist made no difference overall, young single women benefitted more from women therapists—suggesting that men may have been somewhat threatening to them. Conversely, the only female patients who did better with the men were parents without partners. Could it be that the therapist represented to them a potential new partner?

In this respect, one promising lead is the level of conceptualization (Carr 1970). Although no conclusive findings have emerged, it seems probable that persons who conceptualize at relatively concrete levels respond best with structured therapies in a structured environment. Furthermore, studies of smokers (Best 1975), psychiatric outpatients treated by medical students, alcoholics, college students and delinquents all found that patients whose conceptual level was similar to that of their therapist did better than those in which there was a mismatch (Posthuma and Carr 1975). For the rest, the relation of various characteristics of patients, therapists and their interaction to therapeutic process and outcome is still so complex and unclear as to defy
summarization (Beutler, Crago and Arizmendi 1988).

In concluding let me attempt to correct a common misunderstanding of the demoralization hypothesis, namely that since features shared by all therapies that combat demoralization account for much of their effectiveness, training is unnecessary. The point I have sought to make is that healing factors mobilized by all techniques contribute significantly to the outcome of any specific one.

Through personal characteristics and past experiences, however, some patients may be more attuned to behavioral, cognitive, abreactive, hypnotic or other procedures. Thus it remains probable that certain specific techniques are more effective for some patients, or even for some symptoms, than others.

But even in the unlikely eventuality that all therapeutic techniques prove to be fully interchangeable, this substitutability would not mean that mastery of one or more is unnecessary. Such an unwarranted conclusion confuses the content of therapeutic conceptualizations and procedures with their function. Some therapeutically gifted persons, to be sure, can be effective with very little formal training, but most of us need to master at least one therapeutic rationale and ritual. Because these are irrefutable and are supported by a like-minded group to which the therapist belongs (Festinger 1957), they maintain the therapist’s sense of competence, especially in the face of inevitable therapeutic failures. As one young adherent of a psychotherapeutic school remarked, ‘Even if the patient doesn’t get better, you know you are doing the right thing’. This attitude indirectly strengthens the patient’s confidence in the therapist as a person who knows what he or she is doing.

If any moral can be drawn from this chapter, it is that the choice of procedures should be guided by the therapist’s personal predilections. Some therapists are effective hypnotists, others are not. Some welcome emotional displays, others shy away from them. Some work best with groups, others in the privacy of the dyad. Some enjoy exploring psyches, others prefer to try to change behavior. Ideally, from this standpoint, training programs should expose trainees to a range of rationales and procedures and encourage them to select those which are most congenial to their own personalities. The greater the number of approaches that the therapist can handle, the wider the range of patients he or she will be able to help.

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