The Challenge to Psychoanalysis and Psychotherapy

The Future of Symptom Removal

A common experience among psychoanalysts is that a number of their patients who responded well to psychoanalytic therapy continue to suffer from one or two distressing symptoms on termination. In some cases, the symptoms are reflections of such conditions as migraine, asthma, Raynaud’s or hypertension and are not likely to have been caused solely by psychological conflicts or trauma (Weiner 1977). Some symptoms, often classically neurotic, such as chronic muscle spasms, phobias, sexual dysfunctions or other symptoms similarly anxiety related, can also persist throughout an otherwise successful analysis.

Usually, the analytic therapy reduces anxiety levels and stress reactions so that such symptoms will have diminished in degree of discomfort or even in frequency of occurrence. Unfortunately, some symptoms frequently persist.

Symptom reduction remains a major theoretical and clinical issue alongside the issues of insight, character change and ego improvement (Wentworth-Rohr 1970). When the analysis is terminating and symptoms inexplicably persist, the question arises as to the adequacy of the analytic explanations and the clinical procedure. Obviously, the traditional explanations that the symptoms arose solely from conflicts or trauma are insufficient. If hundreds of analytic hours have not resolved such neurotic symptoms, other methods must be found and used, regardless of the reasonableness of the explanations concerning the functions of symptoms.

Ample evidence has accumulated to demonstrate that not all symptoms of an apparent psychological origin and nature are, in fact, reflections of conflicts or psychic trauma (Cattell 1966; Lazarus 1971; Selye 1974; Weiner 1977). Some of these kinds of symptoms are learned responses to environmental stimuli, as both Pavlov (1927) and Skinner (1974) postulated. Also, other symptoms that classical psychoanalysts would attribute to conflicts fully explainable within the framework of their theoretical system can persist as a result of either physiological or unconscious learning. Sometimes, the autonomous nature of many symptoms is not determined until direct treatment of the symptoms is attempted.

Fortunately, a number of methods have been developed over the last several decades that do not involve drugs, are relatively non-invasive and are easily applied, and many can be utilized in conjunction with, or independently of, intensive psychotherapy. These clinical procedures are currently the most successful ones available for reducing symptoms, whether used alone or adjunctive to intensive, verbal psychotherapy or other long-term procedures.

Hypnotherapy, hardly a new technique, has resurged as an auxiliary modality in psychotherapy (Hilgard 1955; Erickson and Rossi 1979; Spiegel and Spiegel 1978). The success of hypnotherapy is probably attributable to the effective therapy techniques that are applied during the trance state. Therapists have learned that the trance state itself is rarely therapeutic and that its real function is to enhance the potency of the therapy techniques applied during the trance. Hypnosis can manipulate the patient’s sense of time, as in planned regressions, or the degree of anxiety to be made conscious or the re-experiencing of early traumas. Virtually any technique used in the waking state can be applied in the trance state.

The fear voiced by some analysts that trance induction would contaminate the transference overlooks the fact that all activity, including minimal activity, during therapy affects the transference. Analytic-minded hypnotherapists simply accept the reality of transference modifications and undertake appropriate clinical management as they would during intensive psychotherapy. As the use of the procedure continues, and as psychotherapists report its value and limitations, it will undoubtedly become a standard method used in the routine practice of psychotherapy.

Behavior therapy
Behaviorism has become a widely accepted theory of psychopathology (Watson and Rayner 1920; Mowrer 1950; Cattell 1966; Rachman and Teasdale 1969) and has developed a group of therapy techniques that are quite useful in symptomatic therapy (Lazarus 1971; Wolpe 1973; Meichenbaum 1976; Meyer and Chesse 1980; Fensterheim and Glazer 1983; Papajohn 1982). As indicated earlier, many of these techniques can be applied during an hypnotic trance that has induced relaxation. For example, systematic desensitization of fears and phobias is easily applied during a trance in which the patient is deeply relaxed. Assertiveness training, applying anti-pain imagery, increasing emotionality through visualizing one’s self in appropriate, emotion-producing situations, and the loosening of free association are among the many techniques available.

One of the major advantages of behavior therapy and other direct techniques is their efficiency in reducing symptoms that are autonomous—that is, not reflective of severe ego defects or unconscious conflicts. These symptom-reduction procedures are also relatively uncomplicated, easily applied, comprehensible to the patient and quite safe. And when any anxiety that is supporting a symptom is reduced, there is little chance of symptom substitution occurring.

Short-term verbal psychotherapy
Sharing the goal of the reduction of symptoms with the behavioral therapies, but maintaining the analysis of interpersonal relations, is short-term verbal psychotherapy (Ferenczi 1920; Ferenczi and Rank 1925; Wolberg 1965; Sifneos 1979; Rush 1982). Malan (1975) noted that Ferenczi’s technique was opposite to the ‘passivity’ that had evolved in psychoanalysis. All advocates of short-term therapies assert that the techniques used are meant to be focused and active and that often the patient himself takes specific, consciously-directed steps to counteract the presenting symptoms. Moreover, more recent expositions (Lazarus 1981; Wentworth-Rohr 1984) are noting the advantages of utilizing several therapy techniques during the course of either longor short-term psychotherapy.

Short-term psychotherapy has been refined and successfully applied to a variety of disorders: drug addiction, poor social relations, sexual dysfunctions, the consequences of rape, schizophrenias, depressions and neuroticism. It is also used in crisis intervention. As a matter of fact, one purpose of short-term psychotherapy, group or individual, is to focus on the patient’s presenting problem with minimal excursion into other areas and to enhance ego development. When used as a group procedure, the approach is especially useful in supplementing individual psychotherapy—the group therapy setting provides patients with multiple relationships in which to re-experience the conflicts and traumata of both earlier and current patterns of relationships. The groups can also serve as supportive peer groups that frequently are able to communicate with patients who cannot tolerate similar expressions from any authority figure, including therapists.

Clinical biofeedback
Most recently, clinical biofeedback has emerged as a treatment technique adjunctive to psychotherapy (Budzinski and Stoyva 1969; Wentworth-Rohr 1978, 1984; Fair 1979), psychiatry (Sarris, Stone and Berman 1976), learning disabilities (Braud, Lupin and Brand 1985) and other areas of medicine, psychology and education:

The biofeedback procedure itself is a straightforward method of training persons to use the instruments as self-teaching devices to the end of self-regulation of their psychophysiological functioning. Specifically, the procedure consists of the operations, or electronic machine applications, that target psychophysiological processes, with the goal of revising selected parameters of physiological and psychological functioning. (Wentworth-Rohr 1984, p. 18)

The wide use of the technique may be explained by its unique character of direct application to the physiological system implicated in the symptom formation targeted for treatment. That is, if the symptom resides in the vascular system, such as migraine headaches, the goal of the biofeedback would be the dilation of the peripheral blood vessels in order to increase blood volume at the periphery. Usually, the operations are placing a thermistor sensor on the middle digit of each hand—thus feeding back the signal of changes in temperature—relaxing the patient—thereby lowering sympathetic tone—and having the patient visualize the hands (and feet, if implicated) in warm gloves.

The placement of the sensors of the electromyograph (EMG) on the muscles of the frontales is a routine first step in all biofeedback applications inasmuch as many facial neuromotor circuits interact directly with the brain. Therefore, reducing facial tension through EMG frontal placement, along with application of a simple psychophysiological relaxation technique (Pascal 1947; Wentworth-Rohr 1984) that lowers sympathetic tone, trains the patient in self-concentration and is preliminary to achieving general relaxation. In the event of there being spasms in other regions—for example the scalp, temperomandibular joints, lower back—general relaxation is usually crucial for achieving relaxation in the regions as well as feeding back, alternately, the electronic signal from EMG sensors placed at those sites.

The Galvanic skin response (GSR) feedback instrument is a sensitive measuring device of sweat gland production which is ordinarily dependent on sympathetic nervous system functioning. For those persons who respond with sweaty hands when anxious or stressed, the GSR is useful in dealing with sympathetic hyperarousal—specifically including the physiological manifestation of anxiety expressed through increased sweat production.

The electroencephalogram (EEG) has been applied with variable success in the reduction of petit mal and grand mal seizures in epilepsy and through EMG augmented relaxation (Banford 1986). The normalization of brain waves appears to be the effective agent and the most efficient procedure is to apply the EEG and relaxation.

The effectiveness of the clinical application of biofeedback techniques varies. Research and clinical studies report 30 per cent to 90 per cent remission rates, usually correlated with the kind of symptoms treated and the clinical procedures used. There is little doubt that a simple muscle spasm caused by repeated stress is relatively easy to reduce (hence the 90 per cent) in comparison with relieving severe agoraphobia, vasoconstriction, chronic anxiety, asthma attacks, hypertension or other complex dysfunctions of psychophysiology—hence the lower rates of improvement for these complaints. However, often enough, these patients have had many other kinds of medical, psychiatric and psychological treatment with no or limited success. When, after the failure of other approaches, even 30 per cent of a treatment population responds to a quick, safe procedure of only a dozen sessions, its use may well be a clinical necessity.

A simple example of the biofeedback treatment of a psychophysiological symptom is the case of a male college student who was referred by his psychiatrist with the complaint of intractable frontal headaches. He had entered psychotherapy a year previously for the complaint without finding relief. Examinations had ruled out cardiovascular or other organic causes. The adjunctive treatment plan was EMG biofeedback from the frontales to augment relaxation and achieve stress reduction and placement of the EMG on the temperomandibular joints and the neck and shoulder regions—all of which were in mild spasm. He learned self-relaxation quickly and practised the techniques as scheduled. Within six sessions he had begun to abort the onset of headaches whenever he was stressed. He was able to achieve this success through self-relaxation of various muscle groups in the head and shoulder regions. The complaints were alleviated in 12 weekly sessions.

The application of biofeedback itself is not usually sufficient to reduce symptoms that are closely related to conflicts, early traumas or complex mental, emotional or physiological processes. Under such complex psychodiagnostic circumstances, the therapist applies a variety of established psychotherapy and stress-reduction procedures to alleviate the symptom and the stress or anxiety supporting it and, frequently, other symptoms that have developed as reactions to the primary symptom.

Clinical biofeedback entails the application of the instruments to the physiological systems that are the residences of the stress or anxiety and the application of appropriate psychotherapeutic techniques to reduce both the physiological and psychological parameters of the targeted symptom.

Relaxation and stress reduction
Relaxation and stress reduction are basic to the application of therapy techniques in the psychophysiological, symptom-oriented procedures of clinical biofeedback Oacobson 1938, 1970; Rickles 1972; Brown 1974; Whatmore and Kohli 1974; Hume 1976; Fuller 1977). With the exception of Jacobson, who restricted his treatment procedure solely to achieving deep states of mental and physical relaxation, these biofeedback approaches use varieties of behavioral and other kinds of therapy techniques while the patient is in a relaxed state. As Wolpe (1973) demonstrated through systematic desensitization, patients reduce anxiety-related symptoms most efficiently while in a deep state of relaxation. The use of relaxation methods such as Jacobson’s, or a passive letting-go of muscle contractions augmented by biofeedback instruments, accelerates
the efficacy of various therapy procedures (Pascal 1947; Fuller 1977; Wentworth-Rohr 1978, 1984).

As Cameron (1944) observed, anxiety tends to reside in either striate or smooth muscle systems. Both Jacobson and Wolpe have established the value, and sometimes the imperative need, to reduce muscle tension as a cause or an exacerbation of neurotic symptomatology. Physiological over-activation can be one of the components of neuroticism, and such over-activation can be caused by, or result in, a variety of symptoms—mental, physical or both. Direct biofeedback interventions in the physiological dysfunction to reduce the physical aspect of the anxiety invested in a symptom allows for a smoother access to the mental aspects. When consciousness has been freed of the distractions of the symptoms through relaxation, the ego is then able to concentrate more efficiently and more appropriately. The particular value of the use of biofeedback instruments in this process is the efficiency of the instruments’ sensors in feeding back to the patient the precise, dysfunctional, physiological basis for the symptoms. Such sensors are more sensitive and effective in the patient’s self-examination of the physical and mental attributes of most neurotic symptoms than unassisted introspection.

Application of psychotherapy techniques such as free association, controlled regression, analysis of transference, desensitization, self-statements, analysis of imagery and so forth are more efficacious under relaxation than under tension (Wentworth-Rohr 1978, 1984). With the ego freed from the ongoing ravages of anxiety of the fragmentation of dissociation, the mind can cope more effectively with the complexities of self-analysis in and out of the analytic sessions.

Multiple techniques—case examples
Some examples of symptom reduction through the application of multiple techniques include the case of a woman who occasionally suffered episodes of derealization. Her seven-year analysis had not reduced the symptom, although most of her other complaints had remitted. Since she still complained offear of water, we agreed to focus on the phobia first and to reduce any other areas of anxiety concurrently. Preparing her for the onslaught of an episode of dissociation would be by reducing her anxiety as much as possible through clinical biofeedback.

She was deeply relaxed with a standard verbal procedure, augmented by use of the EMG frontal placement and the GSR, preparatory to desensitization to her fear of water. While she used the imagery of approaching the water at a seashore, the GSR signal began to increase in amplitude and pitch—an indication of the onset of severe anxiety expressed through the over-activation of the sympathetic nervous system. The relaxation procedure was interrupted and she was asked to report her current experience. Although quite anxious, she managed to explain that as she was imagining approaching the beach, an enormous wave suddenly rushed across the water toward her. She then recalled a childhood dream of that nature and associated the tidal wave with being overwhelmed by her mother’s psychotic episodes of rage and violence throughout her childhood.

She told me that during her seven-year analysis she had reported her childhood terror and the dreams, but evidently the terror had not been sufficiently released to consciousness as she would depersonalize. Our treatment procedure was to induce a mild level of relaxation, monitor physiological activation levels, and return her through recall to the traumatic events of her mother’s psychotic rages for increasingly longer periods. The procedure released the anxiety in amounts manageable by the ego and, as the anxiety diminished, the episode of dissociation decreased. The primary pathway to the anxiety was the cognitive awareness of the psychophysiological component of her anxiety by way of the biofeedback signal. Other cases of treating dissociation with the ‘mind-body’ technique have met with similar success (Wentworth-Rohr 1978, 1984).

In the symptomatic treatment of a post-analytic patient referred for fear of mutilation during intercourse, we planned to approach the fear as we would any phobia. The analysis had relieved the patient of her social anxiety, her fear of men and other interpersonal problems, but her obsessive fear of being split during intercourse persisted. The symptom-reduction treatment plan began with her achieving a deep state of mental and physical relaxation and then our applying systematic desensitization concerning sexual intercourse to reduce the sexual phobia.

The patient’s psychophysiological responses were monitored by both the EMG (forehead placement) and the GSR (fingertip placement) inasmuch as the phobic anxiety was reflected in both striate muscles of the face and in sympathetic hyperarousal. Whenever the patient responded with increased facial tension or sweat production to the visualization of some aspect of intercourse as stimulated by each item in the desensitization hierarchy, she would be relaxed again to counter the onset of anxiety. After a few weeks of the application of the treatment procedure, she reported a cessation of the vaginal spasm and the anxiety upon participating in sexual activity, and within 10 sessions of treatment she was having satisfying intercourse.

The application of short-term symptom-oriented techniques does not solve patients’ problems in living. These techniques do what they are designed to do: to provide relatively quick, non-invasive treatment procedures for anxiety-related symptoms and undesired, learned behaviors. Therapeutic analysis of the ‘person’, the ‘self’, as opposed to a symptom, is not the goal of the techniques. Such analysis most likely requires intensive verbal psychotherapy and many patients continue in psychotherapy.

What does the future hold for these symptom-oriented techniques and what impact will their use have on the forms of psychotherapy? It is probable that in the future these methods will be standard techniques, routinely applied to learned or anxiety-related symptoms. Such applications will be done early in cases of long-term psychodynamic psychotherapy and will be offered to the public as primary treatment procedures by behavioral and biofeedback therapists. These techniques have considerable value not only in reducing appropriately diagnosed symptoms but also in providing short-term and, therefore, relatively inexpensive, treatment of large numbers of sufferers. It is also probable that some of the stress reduction -or self-relaxation—methods will be offered in schools as measures to prevent the development of chronic tension. Applications with children are being done with good results by some educators and clinicians (Landis 1983; Stroebel 1983).

Using relaxation therapy and symptom-reduction techniques as part of general patient care is being practised in many hospitals, as well as in private practice, under the label of behavioral medicine (Golden etal. 1971; Birk 1973; Pinkerton, Hughes and Wenrich 1982). The principle of stress reduction being part of virtually any treatment program for virtually any medical or psychological complaint, all of which invariably cause stress as a by-product of the complaint, is becoming more widely accepted in the helping professions (Wentworth-Rohr 1975; Barber and Adrian 1982). As the interaction between stress and physiological dysfunctions is more frequently exposed and taken into account in training primary complaints, these direct methods of treatment will be used more often as part of patients’ general treatment plans.

The future of symptom reduction appears to lie within the realm of the active, symptom-oriented direct treatment procedures. The future will also reveal more of their assets and limitations. Gradually, such techniques will find their proper and indispensable position in the armamentarium of the clinician. Perhaps the central diagnostic questions to be asked when selecting a technique will be: What is to be treated? What are the priorities of this patient? What symptoms that are related to learning or to anxiety can be directly treated and reduced without endangering the patient? Realistic answers will lead to the appropriate selection and application of techniques. Fortunately, the present already offers many useful procedures to clinicians whenever they answer the questions and decide that direct methods of symptom reduction are clinically appropriate.

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