Psychotherapy

Dr. C. George Boeree
Shippensburg University

Psychotherapy is the generic term for any approach or set of techniques that attempts to help people who are suffering from a psychological disorder. It includes both the various "talk therapies" and the more physiological approaches, including the use of psychoactive medicines.

The talk therapies were essentially invented by Sigmund Freud, or, perhaps a little more historically honestly, by a woman called Anna O. Her real name was Bertha Pappenheim, and she was a patient of Freud's friend and colleague, Joseph Breuer.

Anna O. was Joseph Breuer's patient from 1880 through 1882. Twenty one years old, Anna spent most of her time nursing her ailing father. She developed a bad cough that proved to have no physical basis. She developed some speech difficulties, then became mute, and then began speaking only in English, rather than her usual German.

When her father died, she began to refuse food and developed an unusual set of problems. She lost the feeling in her hands and feet, developed some paralysis, and began to have involuntary spasms. She also had visual hallucinations and tunnel vision. But when specialists were consulted, no physical causes for these problems could be found.

If all this weren't enough, she had fairy-tale fantasies, dramatic mood swings, and made several suicide attempts. Breuer's diagnosis was that she was suffering from what was then called hysteria (now called conversion disorder), which meant she had symptoms that appeared to be physical, but were not.

In the evenings, Anna would sink into states of what Breuer called "spontaneous hypnosis," or what Anna herself called "clouds." Breuer found that, during these trancelike states, she could explain her daytime fantasies and other experiences, and she felt better afterwards. Anna called these episodes "chimney sweeping" and "the talking cure."

Sometimes during "chimney sweeping," some emotional event was recalled that gave meaning to some particular symptom. The first example came soon after she had refused to drink for a while: She recalled seeing a woman drink from a glass that a dog had just drunk from. While recalling this, she experienced strong feelings of disgust... and then had a drink of water! In other words, her symptom -- an avoidance of water -- disappeared as soon as she remembered its root event, and experienced the strong emotion that would be appropriate to that event. Breuer called this catharsis, from the Greek word for cleansing.

Eleven years later, Breuer and Freud wrote a book on hysteria. In it they explained their theory: Every hysteria is the result of a traumatic experience, one that cannot be integrated into the person's understanding of the world. The emotions appropriate to the trauma are not expressed in any direct fashion, but do not simply evaporate: They express themselves in behaviors that in a weak, vague way offer a response to the trauma. These symptoms are, in other words, meaningful. When the client can be made aware of the meanings of his or her symptoms, whether through hypnosis or by simply talking, then the unexpressed emotions are released and so no longer need to express themselves as symptoms.

In this way, Anna got rid of symptom after symptom. But it must be noted that she needed Breuer to do this: Whenever she was in one of her hypnotic states, she had to feel his hands to make sure it was him before talking! And sadly, new problems continued to arise.

Anna was later sent to a Sanatorium in Switzerland, where she slowly improved. Later, she became a well-respected and active figure -- the first social worker in Germany -- under her true name, Bertha Pappenheim. She died in 1936. She will be remembered, not only for her own accomplishments, but as the inspiration for the most influential personality theory we have ever had.

Freudian Therapy

Sigmund Freud's system of therapy, called psychoanalysis, has become the basic model for most therapies since. There are several key features:

1. A comfortable physical environment. Freud felt that it was important to make the patient comfortable. He had them lay down on a soft couch, and provided pillows and comforters to wrap themselves in, if they should feel the need. He put tapestries up on his walls to deaden the sounds of downtown Vienna. He would pull the drapes closed and provide soft lighting. His feeling was that, by providing a situation similar to sleep, he would be giving his patients a chance to relax and get in touch with their deeper unconscious mind.

2. An accepting social environment. Even more important was to make the patient feel at ease socially. They were permitted to express their emotions freely, and Freud made it clear to his patients that he was not there to judge them or scold them, no matter how odd their behaviors or thoughts might appear. This is in marked contrast to most people's day to day life, in which we are afraid to mention our true feelings or odd thoughts, and try to behave in a socially acceptable fashion. It is sometimes even difficult to talk to friends or family -- even they may judge us, and that is particularly hard to take!

3. Free association. Free association is the central "technique" of psychoanalysis. It is just a matter of the patient talking about whatever comes to mind. It's another way of getting a person to relax: Just talking about whatever you want makes you comfortable, and Freud believed that you would eventually move towards the things that trouble you the most. If you can imagine a therapist who pushes you to face things you would rather not face, you can see how many people would begin to back off, get angry, and probably leave the therapist! Unfortunately, for this reason, many forms of therapy are not exactly "efficient" and can take many months, even years. Contrary to popular belief, though, Freud felt that therapy should only last a month or two.

4. Resistance. The therapist, in the meantime, looks for clues to the patient's problems in their conversations. One of these clues is resistance. When you do get close to some difficult area, you might begin to become uncomfortable. You might change the topic suddenly, or forget what you were talking about. You might even begin coming in late, or missing an appointment altogether! In a way, this is a good sign: You are getting close to the problem.

5. Slips of the tongue. A slip of the tongue is technically called a parapraxis, and is commonly called a Freudian slip. Sometimes, we say things we didn't intend to say, and a little bit of what we are thinking about comes out by accident. Freud considered these clues very significant, but nowadays, we think that most slips are just accidents and little more. But a colleague of mine once referred to the cervix when he meant to say cortex, and may well have had an attractive student in mind when he made the slip, so....

6. Dream interpretation. Freud is, of course, famous for his views on dream interpretation. Basically, he believed that when we dream, our defenses are down, and things that we are deeply concerned about rise to the surface. You may have noticed that things happen in your dreams that you wouldn't even consider in the daytime, such as vicious acts of aggression, uncharacteristic sexual adventures, and horrible humiliations.

But people who are truly repressed may, even in their dreams, hide behind symbols rather than face such things directly. Freud's patients often had problems involving sexually repression -- a commonplace thing in his very conservative times -- and would dream about things that only hinted at their true desires. Things like snakes and swan necks might symbolize the penis, entering into a cave might represent the sex act, a burning fire might be sexual desire, and a floor collapsing underneath you might really refer to orgasm. Psychologists today don't consider dreams quite as important as Freud did, and are more likely to ask the patient what he or she thinks the dream means than try to interpret it for them. But dreams will always be an interesting part of life and therapy!

7. Transference. Transference is when the patient begins to feel feelings towards the therapist. It can be anger; it can be affection; it can even be sexual desire. Freud believed that these feelings were actually being transferred from their true object -- some important person in the patient's life -- onto the therapist. Transference is therefore an important clue. Freud also believed that transference was necessary to progress in therapy, in that it takes what is going on in the patient's unconscious and brings it out into the real world. It is only a matter of time until the patient comes to realize what those feelings truly represent.

Most therapists today don't make a very big deal about transference. Mind you, it happens a lot, but it makes pretty simple sense: Sometimes you get frustrated at your therapist, who, after all, represents your failures at life. Sometimes you begin to feel real affection (even a bit of physical attraction) to this person who is so patient and understanding, especially while you are so confused and miserable. One thing should be clear, though: Nearly everyone in psychology considers it a major breech of ethics for a therapist to take advantage of a patient who has these feelings. If your therapist makes sexual advances, it is time to get another therapist.

8. Catharsis. Catharsis is an outpouring of "pent-up" emotions. When the client makes a breakthrough, they may become very emotional -- whether it be ranting and raving and storming around the office, or the much more common outburst of crying. Freud considered this a very good sign indeed. He thought of our problems as being like an infection that has swollen way out of proportion, and that catharsis was like draining an infection to relieve the pain.

9. Insight. Ultimately, a patient will achieve insight into their problems. They will, as Freud put it, "make the unconscious conscious." This is the goal of therapy. Once a person can see the original trauma face-to-face, recognize it for what it is, come to understand it as an adult, and lay it back to rest, their symptoms should disappear, and they are on the road to recovery.

Although most psychologists today no longer see it as so important to find out what originally started your psychological problems -- or even that psychological problems necessarily have traumatic origins -- the idea of insight is a part of most approaches to therapy. Sometimes we refer to therapy as a kind of education, where you learn about how you as an individual actually work. Like you need to know how a car works before you can fix it, you need to know how you work before you can start to deal with your problems in a rational fashion, instead of suffering with a lot of useless and painful symptoms that get you nowhere.

Next, I would like to introduce you to three examples of modern therapy that have been demonstrated to be very effective and have been enormously influential. They were developed by psychologists who came from very different theoretical orientation, and yet are in no way mutually exclusive. Many modern therapists use all three in their work.

Carl Rogers' Client Centered Therapy.

Carl Rogers is one of the most influential theorists, therapists, and researchers in psychology. His approach to therapy involves allowing the patient, who he prefers to call the client, to be in control of their own therapy. Originally, he called it non-directive therapy, because he believed that the therapist should back off from trying to actively help the client. Instead, the therapist should be a caring helper who listens.

Listening is one of those skills that everyone thinks they have, but few actually do. Rogers introduced a "technique" known as reflection: The therapist listens to the client and "reflects" back significant thoughts and feelings by saying back to the client what he heard them say. Some therapists do this in a mechanical fashion, which makes them sound like parrots with a college degree, but that is not what Rogers intended. It should be a genuine communication of understanding and concern. Today, reflection is just a part of therapist training called active listening.

Rogers believed that the job of the therapist is not so much to do this or that, but to be a certain way for the client. He talks about three qualities that the therapist should exhibit during therapy sessions:

1. He or she should be congruent. Basically, this comes down to being honest, not phony. Rogers was particularly concerned that the therapist should be honest in regards to their feelings. He felt that clients can always tell when you are pretending, so in order to engender trust in the therapeutic relationship, congruence is a must.

2. He or she should be empathic. The therapist must be able to identify with the client, understand them not so much as a psychologist but as a person who has also seen their share of troubles. Therapist should be able to look into the client's eyes and see himself. Active listening is one way the therapist can show that he or she is truly trying to understand the client.

3. He or she should show the client unconditional positive regard. This doesn't mean that the therapist has to love the client, or even like them. It means he or she should respect them as a human being, and not judge them. This can be the most challenging thing for a therapist to do, but Rogers believed that only by feeling respected could a client get better.

Albert Ellis's Rational-Emotive Therapy

Elllis is a very different person from Rogers. While Rogers is a quiet, laid-back sort of therapist, Ellis is more dynamic and is as likely to argue with his clients as sympathize with them.

Basically, Ellis believes that a person's problems come from their mistaken beliefs about the world, others, and themselves. Your beliefs lead you to see things, feel things, and do things in a certain way, and if those beliefs are wrong, so will be your perceptions, your emotions, and your behaviors. Here are the twelve most common mistaken beliefs:

I must be loved.
Some acts are unredeemably wicked, and some people are damned.
It is absolutely horrible when things don't go right.
All my suffering comes from outside, from others.
I should get upset at problems and obsess about them.
I should avoid problems.
I need someone or something stronger to lean on.
I should be really competent at all things, because it is bad to be imperfect.
Once something bad happens, it will affect me forever.
I must have control over everything.
I can only be happy by avoiding all action.
I have no control over my emotions.

He simplifies the list a bit with three beliefs, about the world, others, and ourselves:

The world must give me happiness, or I will die.
People must treat me right, or they are rotten.
I must be completely competent, or I'm worthless.

His way of dealing with these mistaken beliefs is pretty straight forward: He argues with his clients! He asks them why they have this belief, what kind of evidence they have that they are true -- and what kind of evidence they might also have that they are not true! He asks them, what's the worst that can happen if you give up your particular beliefs -- and what is the best that can happen!

Although RET sounds very different from Rogers' therapy, it has a lot of commonalities as well. Ellis, like Rogers, strongly believes that all people should develop unconditional self-regard and should stop passing judgements on themselves. Many therapists that combine aspects of Rogers' and Ellis' begin with Rogers' quiet listening approach, and later, when therapist and client have developed trust and a real rapport, will start using Ellis' more aggressive approach.

A similar approach, simply called cognitive therapy, was formulated by Aaron Beck, has proven very effective with depression.

Joseph Wolpe's Systematic Desensitization

Joseph Wolpe was a behavioral psychologist in South Africa who was actually studying cats more than dealing with clients. Cats, like people, can get quite anxious. But Wolpe noticed that there were several things that cats could do that seemed to interfere with their anxiety. They could calm themselves, for example, by grooming themselves. Or they could eat. Eating and being nervous seemed to be incompatible.

You may have noticed this yourself: Some of us, when we are nervous, like to eat (maybe a quart of Rocky Road Ice Cream, for example). We feel better, at least for a while. Others, when they are nervous, can't eat, because their anxiety interferes with their digestion. It's one or the other!

Wolpe reasoned that the most obvious thing that is incompatible with anxiety is to be physically relaxed. So what if we taught people how to relax all their muscles -- they couldn't be anxious then, could they?

Systematic desensitization works like this: On your first session with therapist, he or she instructs you on how to physically relax: You are asked to tighten a muscle group such as your stomach muscles for several seconds, and then let go, and to pay close attention to how both those conditions feel -- tense and relaxed. You do this for all the major muscle groups in your body. With the help of a chart, you will practice this routine everyday for a week.

[I went through systematic desensitization many years ago. If you click here, you will be taken to the exercises that were given to me to practice!]

At that same session, you also develop an anxiety hierarchy. This consists of ten scenarios that cause you to get anxious, each one worse than the one before. For example, someone with a spider phobia may have as their first scenario seeing a small spider at some distance outdoors. Their last scenario may involve something like having a very large hairy spider crawling on your face.

After you have practiced relaxing for a week, you come back to the therapist. He or she will ask you to get as relaxed as possible, and then introduce the first scenario for you to imagine. You will try to get as good an image of the scenario as you can, all the while paying attention to your muscles to make sure they stay relaxed. If you stay relaxed, the therapist will move to the next scenario. There will be a predetermined signal, such as raising your finger, to tell the therapist that you are having trouble staying relaxed, at which time he or she will back off from the troublesome scenario and let you get back to relaxing your muscles.

Usually in that session, or at least in the second attempt, you will be able to imagine even your worst scenario and still manage to stay relaxed. Does it make any difference when you get outside in the real world and actually see, say, a nice fat spider? Yes, in nearly all cases the technique generalizes to the real world! It is one of the best techniques for dealing with anxiety problems we have.

There are, of course, many other approaches to therapy that we don't have the time to discuss. Some are respected and effective -- others are just plain wacky. One thing to keep in mind if you should ever seek therapy for yourself or someone close to you: Do not be afraid to ask questions about which approach a therapist uses or to check with people you trust or appropriate agencies about a therapist's qualifications. Psychological therapy is still more of an art than most medical therapies, and the buyer must beware!