Buddy
The Living Force
The following excerpt is from the book 'Cognitive Therapy and the Emotional Disorders', by Aaron T. Beck M.D.
I thought it could be useful in the sense of establishing a perspective of the Therapeutic process that could benefit both the patient and the therapist.
[quote author=Beck]
THE THERAPEUTIC COLLABORATION
Certain factors are important in practically all forms of psychotherapy, but are crucial in cognitive therapy. An obvious primary component of effective psychotherapy is genuine collaboration between the therapist and patient. Moving blindly in separate directions, as sometimes happens, frustrates the therapist and distresses the patient. It is important to realize that the dispenser of the service (the therapist) and the recipient (the patient) may envision the therapeutic relationship quite differently.
The patient, for instance, may visualize therapy as a molding of a lump of clay by an omnipotent and omniscient God figure. To minimize such hazards, the patient and therapist should reach a consensus regarding what problem requires help, the goal of therapy, and how they plan to reach that goal. Agreement regarding the nature and duration of therapy is important in determining the outcome.
One study has shown, for instance, that a discrepancy between the patient's expectations and the kind of therapy he actually receives militates against a successful outcome. On the other hand, preliminary coaching of the patient about the type of therapy selected appeared to enhance its effectiveness (Orne and Wender, 1968).
Furthermore, the therapist needs to be tuned in to the vicissitudes of the patient's problems from session to session. Patients frequently formulate an "agenda" of topics they want to discuss at a particular session; if the therapist disregards this, he may impose an unnecessary strain on the relationship. For instance, a patient who is disturbed by a recent altercation with his wife may be alienated by the therapist's rigid adherence to a pre-determined format such as desensitizing him to his subway phobia.
It is useful to conceive of the patient-therapist relationship as a joint effort. It is not the therapist's function to try to reform the patient; rather his role is working with the patient against "it", the patient's problem. Placing the emphasis on solving problems, rather than his presumed defects or bad habits, helps the patient to examine his difficulties with more detachment and makes him less prone to experience shame, a sense of inferiority, and defensiveness. The partnership concept helps the therapist to obtain valuable "feedback" about the efficacy of therapeutic techniques and further detailed information about the patient's thoughts and feelings.
In employing systematic desensitization, for instance, I customarily ask for a detailed description of each image. The patient's report is often very informative and, on many occasions reveals new problems that had not previously been identified. The partnership arrangement also reduces the patient's tendency to cast the therapist in the role of a superman. Investigators (Rogers, 1951; Truax, 1963) have found that if the therapist shows the following characteristics, a successful outcome is facilitated: genuine warmth, acceptance, and accurate empathy. By working with the patient as a collaborator, the therapist is more likely to show these characteristics than if he assumes a Godlike role.
ESTABLISHING CREDIBILITY
Problems often arise with regard to and formulations offered by the therapist. Patients who view the therapist as a kind of superman are likely to accept his interpretations and suggestions as sacred pronouncements. Such bland ingestion of the therapist's hypotheses deprives the therapy of the corrective effect of critical evaluation by the patient.
A different type of problem is presented by patients who automatically react to the therapist's statements with suspicion or skepticism. Such a reaction is most pronounced in paranoid and severely depressed patients. In attempting to expose the distortions of reality, the therapist may become mired in the patient's deeply entrenched belief system.
The therapist, therefore, must establish some common ground, find some point of agreement, and then attempt to extend the area of consensus from there. Depressed patients are often concerned that their emotional disorder will persist or get worse, and that they will not respond to therapy. If the therapist assumes a hearty optimistic attitude, the patient may decide that the therapist is either faking, doesn't really understand the gravity of the disorder, or is simply a fool. Similarly, trying to talk a paranoid patient out of his distorted views of reality may drive him to stronger belief in his paranoid ideas. Also, if the paranoid patient begins to regard the therapist as a member of the "opposition," he may assign the therapist a key role in his delusional system.
A more appropriate approach in establishing credibility is to convey a message such as: "You have certain ideas that upset you. They may or they may not be correct. Now let us examine some of them." By assuming a neutral stance, the therapist may then encourage the patient to express his distorted ideas and listen to them attentively. Later he sends up some "trial balloons" to determine whether the patient is ready to examine the evidence regarding these distortions.
One of the reasons that persecutory ideas of paranoids and fixed self-debasement ideas of depressives have been regarded traditionally as impermeable to psychotherapy is that the therapist has attempted to correct the patient's thinking prematurely. Even fixed delusions, however, may eventually become amenable to modification if the therapist is sensitive and patient (Beck, 1952; Davison, 1966; Salzman, 1960; Schwartz, 1963).
Studies by social psychologists indicate that dogmatism tends to widen the gap between persons with different opinions, and to make them more extreme and rigid in their opposing views. A similar phenomenon occurs in psychotherapy. Because of the patient's reluctance openly to express his disagreement, a dogmatic therapist may be deceived into assuming they have reached a consensus. Even the careful therapist, however, needs to be vigilant to any cues indicative of the patient's disagreement. A method for determining whether the patient indeed does agree with statements by the therapist is illustrated in the following interchange:
Therapist: Now that you've heard my formulation of the problem, what do you think of it?
Patient: It sounds O.K. to me.
Therapist: While I was talking, did you have any feeling that there might be some parts that you disagree with?
Patient: I'm not sure.
Therapist: You would tell me if you were uncertain about some of the things I said, wouldn't you?... You know, some patients are reluctant to disagree with their doctor.
Patient: Well, I could see that what you said was logical, but I'm not really sure I believe it.
Statements such as this usually suggest that the patient disagrees, at least in part, with the therapist. The therapist should proceed to ascertain the patient's reservations and encourage him to rebut the therapist's formulation.
Many patients appear to agree with the therapist because of their fears of challenging him and their need to please him. A clue to such superficial consensus is provided by the patient who says, "I agree with you intellectually but not emotionally." Such a statement generally indicates that the therapist's comments or interpretations may seem logical to the patient, but that they do not penetrate the patient's basic belief system (Ellis, 1962).
The patient continues to operate according to his faulty ideas. Moreover, strongly authoritative remarks that appeal to the patient's yearning for explanations for his misery may set the stage for disillusionment when the patient finds loopholes in the therapist's formulations. The therapist's confidence in his role as an expert requires a strong admixture of humility.
Psychotherapy often involves a good deal of trial-and-error, experimenting with several approaches or formulations to determine which fit the best.
Delusional thinking obviously tests the confidence of a patient in the therapist. It is generally wise not to try to attack a delusion directly. Even if the therapist does not challenge it, he can help the patient cope with it. For example, an elderly man who had a serious physical illness developed the delusion that his elderly wife was carrying on an affair with his young physician. The patient therefore started to berate his wife and accuse her of infidelity. His accusations were so disturbing to his wife that she seriously considered leaving him.
The patient's psychiatrist said to him: "I have no evidence regarding the accuracy of your accusations about your wife, but you should consider the consequences of your behavior. What will happen to you if you continue to accuse her and berate her?" The patient initially replied that he didn't care. The psychiatrist then said, "If she leaves you, who will take care of you?" This question forced the patient to consider the possible consequences of his actions. He stopped making accusations and his relationship with his wife improved. In fact, the patient felt more friendly toward his wife. It is also possible that by his stopping his accusations, the delusion of infidelity may have become attenuated—although there is no direct evidence to support this conjecture.
In less extreme cases, it is possible to deal more directly with the irrational ideas. However, the therapist must assess the "latitude of acceptance" of the patient for statements challenging his distorted concepts. Being told that his ideas are wrong might antagonize the patient; but, he might respond favorably to a question such as "Is there another way of interpreting your wife's behavior?" As long as the therapist's attempts at clarification are within an acceptable range, the problem of a credibility gap is minimized.
PROBLEM REDUCTION
Many patients come to the therapist with a host of symptoms or problems. To solve each one of the problems in isolation from the others might very well take a lifetime. A patient may seek help for a variety of ailments such as headaches, insomnia, and anxiety, in addition to interpersonal problems. Identifying problems with similar causes and grouping them together is termed "problem reduction." Once the multifarious difficulties are condensed, the therapist can select the appropriate techniques for each group of problems.
Let us take as an example the patient with multiple phobias. A woman described in Chapter 7 was greatly handicapped by a fear of elevators, tunnels, hills, closed spaces, riding in an open car, riding in an airplane, swimming, walking fast or running, strong winds, and hot, muggy days. Treating each phobia separately with the technique of systematic desensitization might have required innumerable therapeutic sessions. However, it was possible to find a common denominator for her symptoms: an overriding fear of suffocation. She believed that each of the phobic situations presented substantial risk of deprivation of air and consequent suffocation. The therapy was focused directly on this central fear.
The principle of problem reduction is also applicable to a constellation of symptoms that comprise a specific disorder such as depression. By concentrating on certain key components of the disorder, such as low self-esteem or negative expectations, the therapy can produce improvement in mood, overt behavior, appetite, and sleeping pattern. One patient, for instance, revealed that whenever he was in a gratifying situation, he would get some kind of "kill-joy" thought: When he began to feel pleasure from listening to music, he would think, "This record will be over soon," and his pleasure would disappear. When he discovered that he was enjoying a movie, a date with a girl, or just walking, he would think: "This will end soon," and immediately his satisfaction was squelched. In this case, a thought pattern that he could not enjoy things because they would end became the focus of the therapy.
In another case the main focus was the patient's overabsorption in the negative aspects of her life and her selective inattention to positive occurrences. The therapy consisted of having her write down and report back positive experiences. She was surprised to find how many positive, gratifying experiences she had had and subsequently forgotten about.
Another form of problem reduction is the identification of the first link in a chain of symptoms. An interesting feature is that the first link may be a relatively small and easily eradicable problem that leads to consequences that are disabling. For analogy, a person may writhe with pain and be unable to walk, eat, talk at length, or perform minimal constructive activities— because of a speck in the eye. The "speck in the eye" syndrome probably occurs more frequently among psychiatric patients than is generally realized. Because of delay in identifying and dealing with the initial problem, however, the ensuing difficulties become deeply entrenched. A mother who was afraid to leave her children at home with a babysitter continued to be housebound long after the children reached maturity.
By a painstaking review of the patient's symptoms and past history it is often possible to delineate the causal sequences. It is generally most parsimonious to concentrate on those factors found to be primary, that is, that are causative in producing the other symptoms. A graduate student with a long-standing history of depression, for instance, had received psychotherapy consisting of fruitless attempts by the therapist to increase his self-esteem and to neutralize his self-criticisms. In addition, he received trials of practically every antide-pressant medication on the market. Nonetheless, the patient continued to feel sad and lonely, was preoccupied with self-derogatory thoughts, had sleep disturbance, loss of appetite, and a chronic state of fatigue.
After detailed analysis of the patient's past and present circumstances, the following pattern emerged. This young man had had a number of long-standing phobias: fears of going out alone, of open spaces, of social rejection. He had compensated for these during his school years by virtue of the fact that, since he was living at home, he had always been able to find someone to accompany him to school. Also, his friends had helped to buffer his fear of rejection by joining him in new social situations. Through this system of compensations and buffers, he had been able to go through college and have a satisfying social life. By circumventing his fears, he had not been disabled by his phobias.
His depression became manifest after he moved to a distant city to attend graduate school. Left on his own, he began to experience intense anxiety. When he would start to walk to class, he feared he would experience a physical catastrophe and that there would be nobody there to help him. He felt safer in his apartment where he was always close to a telephone and could call several physicians with whom he had made contact. Although he managed to force himself to go to his classes, traveling was accompanied by considerable anxiety, and he could barely wait to return to his room when classes were over.
He did not make new friends because his anxiety was stirred up whenever he attempted to form a relationship with another student. As a result, he avoided anxiety-producing situations as much as possible. The cumulative effect of the complete deprivation of social interaction was feelings of loneliness, pessimism, apathy, and physiological signs of depression.
On the basis of this reconstruction of the causal sequence, we concentrated primarily on the phobias rather than on the depression per se. Techniques used to help him overcome his phobias consisted of systematic desensitization in which he imaged scenes of physical catastrophe and also a separate set of scenes of social rejection. He was encouraged to resist his avoidance tendencies, and he exposed himself increasingly to the situations that frightened him. Eventually he was able to leave his apartment without anxiety and to engage in conversation with a stranger.
Although his symptoms of depression were somewhat alleviated by his sense of accomplishment, they were still present in significant amounts. As he overcame his phobic reactions, however, he was gradually able to establish new relationships and to obtain the gratification he missed. As his satisfactions from social activity increased, his depression disappeared.
LEARNING TO LEARN
As pointed out in the previous section, it is not necessary for a psychotherapist to help a patient solve every problem that troubles him. Nor is it necessary to anticipate all the problems that may occur after the termination of therapy and to try to work them out in advance. The kind of therapeutic collaboration previously described is conducive to the patient's developing new ways to learn from his experiences and to solve problems. In a sense the patient is "learning to learn." This process has been labeled deutero-learning (Bateson, 1942).
The problem-solving approach to psychotherapy removes much of the responsibility from the therapist and engages the patient more actively in working on his difficulties. By reducing the patient's dependency on the therapist, this approach increases the patient's self-confidence and self-esteem. More important, perhaps, is the fact that the patient's active participation in defining the problem and considering various options yields more ample information than would otherwise be available. His participation in making the decision helps him implement it.
I have explained the problem-solving concept to patients in somewhat the following way: "One of the goals of therapy is to help you learn new ways of approaching problems. Then, as problems come up, you can apply the formulas that you have already learned. For instance, in learning arithmetic you simply learned the fundamental rules. It was not necessary to learn every single possible addition and subtraction. Once you had learned the operations, you could apply them to any arithmetic problem."
To illustrate "learning to learn," let us consider the practical and interpersonal problems that contribute to a patient's various symptoms. A woman, for instance, discovered she was constantly plagued with headaches, feelings of tension, abdominal pain, and insomnia. By focusing on her problems at work and at home, the patient was able to find some solutions for them and became less prone to experience symptoms. As was hoped, she was able to generalize these practical lessons to solving other problems of living, so that it was not necessary for us to work on all her problems in therapy.
Among the types of problems that had caused the symptoms were the following. She always felt tense when she was at work because her supervisor was hypercritical. Although the patient's performance was at a high level, she was always afraid of making a mistake because of the wrath that it might evoke from the supervisor. The patient could not, on her own, devise a way out of this situation.
We rehearsed a number of approaches she might use in discussing the problem directly with her supervisor. When she felt ready, she told her supervisor: "I am always tense when you are around because I'm afraid you're going to jump on me. When you jump on me it only makes my performance worse. I was hoping I could talk to you about this." The supervisor was surprised to hear this, and subsequently was less critical of the patient.
The patient also learned from this experience that she could stand up to other people, and in other analogous situations was able to deal with her fear of criticism by being more assertive. In addition, her increasing self-esteem made her less sensitive to criticism.
"Learning to learn" consists of much more than the patient's adopting a few techniques that can be used in a wide variety of situations.
Basically, this approach attempts to remove obstacles that have prevented the patient from profiting from experience and from developing adequate ways of dealing with their internal and external problems. Most of the patients have been blocked in their psychosocial development by certain maladaptive attitudes and patterns of behavior. For instance, the woman with the numerous problems at work and at home had a characteristic response when she was confronted with sensitive interpersonal relations or new practical problems: "I don't know what to do." As a result of therapy, each successful experience tended to erode this negative attitude. Consequently, she was enabled to draw on her ingenuity in meeting and mastering completely different situations.
Patients generally try to avoid situations that cause them uneasiness. Consequently, they do not develop the trial-and-error techniques that are prerequisite to solving many problems. Or by staying out of difficult situations, they do not learn how to rid themselves of their tendency to distort or exaggerate. A person who stays close to home because he fears strangers does not learn how to test the validity of his fears or to discriminate between "safe" strangers and "dangerous" strangers. Through therapy he can learn to "reality-test" not only these fears but other fears as well.
The sense of mastery from solving one problem frequently inspires the patient to approach and solve other problems that he has long avoided. Thus, a bonus of successful therapy is not only freedom from the original problems, but a thorough psychological change that prepares him to meet new challenges.[/quote]
From Chapter 9 of "Cognitive Therapy", Aaron T. Beck, M.D., Meridian, 1979 pgs. 220-232
I thought it could be useful in the sense of establishing a perspective of the Therapeutic process that could benefit both the patient and the therapist.
[quote author=Beck]
THE THERAPEUTIC COLLABORATION
Certain factors are important in practically all forms of psychotherapy, but are crucial in cognitive therapy. An obvious primary component of effective psychotherapy is genuine collaboration between the therapist and patient. Moving blindly in separate directions, as sometimes happens, frustrates the therapist and distresses the patient. It is important to realize that the dispenser of the service (the therapist) and the recipient (the patient) may envision the therapeutic relationship quite differently.
The patient, for instance, may visualize therapy as a molding of a lump of clay by an omnipotent and omniscient God figure. To minimize such hazards, the patient and therapist should reach a consensus regarding what problem requires help, the goal of therapy, and how they plan to reach that goal. Agreement regarding the nature and duration of therapy is important in determining the outcome.
One study has shown, for instance, that a discrepancy between the patient's expectations and the kind of therapy he actually receives militates against a successful outcome. On the other hand, preliminary coaching of the patient about the type of therapy selected appeared to enhance its effectiveness (Orne and Wender, 1968).
Furthermore, the therapist needs to be tuned in to the vicissitudes of the patient's problems from session to session. Patients frequently formulate an "agenda" of topics they want to discuss at a particular session; if the therapist disregards this, he may impose an unnecessary strain on the relationship. For instance, a patient who is disturbed by a recent altercation with his wife may be alienated by the therapist's rigid adherence to a pre-determined format such as desensitizing him to his subway phobia.
It is useful to conceive of the patient-therapist relationship as a joint effort. It is not the therapist's function to try to reform the patient; rather his role is working with the patient against "it", the patient's problem. Placing the emphasis on solving problems, rather than his presumed defects or bad habits, helps the patient to examine his difficulties with more detachment and makes him less prone to experience shame, a sense of inferiority, and defensiveness. The partnership concept helps the therapist to obtain valuable "feedback" about the efficacy of therapeutic techniques and further detailed information about the patient's thoughts and feelings.
In employing systematic desensitization, for instance, I customarily ask for a detailed description of each image. The patient's report is often very informative and, on many occasions reveals new problems that had not previously been identified. The partnership arrangement also reduces the patient's tendency to cast the therapist in the role of a superman. Investigators (Rogers, 1951; Truax, 1963) have found that if the therapist shows the following characteristics, a successful outcome is facilitated: genuine warmth, acceptance, and accurate empathy. By working with the patient as a collaborator, the therapist is more likely to show these characteristics than if he assumes a Godlike role.
ESTABLISHING CREDIBILITY
Problems often arise with regard to and formulations offered by the therapist. Patients who view the therapist as a kind of superman are likely to accept his interpretations and suggestions as sacred pronouncements. Such bland ingestion of the therapist's hypotheses deprives the therapy of the corrective effect of critical evaluation by the patient.
A different type of problem is presented by patients who automatically react to the therapist's statements with suspicion or skepticism. Such a reaction is most pronounced in paranoid and severely depressed patients. In attempting to expose the distortions of reality, the therapist may become mired in the patient's deeply entrenched belief system.
The therapist, therefore, must establish some common ground, find some point of agreement, and then attempt to extend the area of consensus from there. Depressed patients are often concerned that their emotional disorder will persist or get worse, and that they will not respond to therapy. If the therapist assumes a hearty optimistic attitude, the patient may decide that the therapist is either faking, doesn't really understand the gravity of the disorder, or is simply a fool. Similarly, trying to talk a paranoid patient out of his distorted views of reality may drive him to stronger belief in his paranoid ideas. Also, if the paranoid patient begins to regard the therapist as a member of the "opposition," he may assign the therapist a key role in his delusional system.
A more appropriate approach in establishing credibility is to convey a message such as: "You have certain ideas that upset you. They may or they may not be correct. Now let us examine some of them." By assuming a neutral stance, the therapist may then encourage the patient to express his distorted ideas and listen to them attentively. Later he sends up some "trial balloons" to determine whether the patient is ready to examine the evidence regarding these distortions.
One of the reasons that persecutory ideas of paranoids and fixed self-debasement ideas of depressives have been regarded traditionally as impermeable to psychotherapy is that the therapist has attempted to correct the patient's thinking prematurely. Even fixed delusions, however, may eventually become amenable to modification if the therapist is sensitive and patient (Beck, 1952; Davison, 1966; Salzman, 1960; Schwartz, 1963).
Studies by social psychologists indicate that dogmatism tends to widen the gap between persons with different opinions, and to make them more extreme and rigid in their opposing views. A similar phenomenon occurs in psychotherapy. Because of the patient's reluctance openly to express his disagreement, a dogmatic therapist may be deceived into assuming they have reached a consensus. Even the careful therapist, however, needs to be vigilant to any cues indicative of the patient's disagreement. A method for determining whether the patient indeed does agree with statements by the therapist is illustrated in the following interchange:
Therapist: Now that you've heard my formulation of the problem, what do you think of it?
Patient: It sounds O.K. to me.
Therapist: While I was talking, did you have any feeling that there might be some parts that you disagree with?
Patient: I'm not sure.
Therapist: You would tell me if you were uncertain about some of the things I said, wouldn't you?... You know, some patients are reluctant to disagree with their doctor.
Patient: Well, I could see that what you said was logical, but I'm not really sure I believe it.
Statements such as this usually suggest that the patient disagrees, at least in part, with the therapist. The therapist should proceed to ascertain the patient's reservations and encourage him to rebut the therapist's formulation.
Many patients appear to agree with the therapist because of their fears of challenging him and their need to please him. A clue to such superficial consensus is provided by the patient who says, "I agree with you intellectually but not emotionally." Such a statement generally indicates that the therapist's comments or interpretations may seem logical to the patient, but that they do not penetrate the patient's basic belief system (Ellis, 1962).
The patient continues to operate according to his faulty ideas. Moreover, strongly authoritative remarks that appeal to the patient's yearning for explanations for his misery may set the stage for disillusionment when the patient finds loopholes in the therapist's formulations. The therapist's confidence in his role as an expert requires a strong admixture of humility.
Psychotherapy often involves a good deal of trial-and-error, experimenting with several approaches or formulations to determine which fit the best.
Delusional thinking obviously tests the confidence of a patient in the therapist. It is generally wise not to try to attack a delusion directly. Even if the therapist does not challenge it, he can help the patient cope with it. For example, an elderly man who had a serious physical illness developed the delusion that his elderly wife was carrying on an affair with his young physician. The patient therefore started to berate his wife and accuse her of infidelity. His accusations were so disturbing to his wife that she seriously considered leaving him.
The patient's psychiatrist said to him: "I have no evidence regarding the accuracy of your accusations about your wife, but you should consider the consequences of your behavior. What will happen to you if you continue to accuse her and berate her?" The patient initially replied that he didn't care. The psychiatrist then said, "If she leaves you, who will take care of you?" This question forced the patient to consider the possible consequences of his actions. He stopped making accusations and his relationship with his wife improved. In fact, the patient felt more friendly toward his wife. It is also possible that by his stopping his accusations, the delusion of infidelity may have become attenuated—although there is no direct evidence to support this conjecture.
In less extreme cases, it is possible to deal more directly with the irrational ideas. However, the therapist must assess the "latitude of acceptance" of the patient for statements challenging his distorted concepts. Being told that his ideas are wrong might antagonize the patient; but, he might respond favorably to a question such as "Is there another way of interpreting your wife's behavior?" As long as the therapist's attempts at clarification are within an acceptable range, the problem of a credibility gap is minimized.
PROBLEM REDUCTION
Many patients come to the therapist with a host of symptoms or problems. To solve each one of the problems in isolation from the others might very well take a lifetime. A patient may seek help for a variety of ailments such as headaches, insomnia, and anxiety, in addition to interpersonal problems. Identifying problems with similar causes and grouping them together is termed "problem reduction." Once the multifarious difficulties are condensed, the therapist can select the appropriate techniques for each group of problems.
Let us take as an example the patient with multiple phobias. A woman described in Chapter 7 was greatly handicapped by a fear of elevators, tunnels, hills, closed spaces, riding in an open car, riding in an airplane, swimming, walking fast or running, strong winds, and hot, muggy days. Treating each phobia separately with the technique of systematic desensitization might have required innumerable therapeutic sessions. However, it was possible to find a common denominator for her symptoms: an overriding fear of suffocation. She believed that each of the phobic situations presented substantial risk of deprivation of air and consequent suffocation. The therapy was focused directly on this central fear.
The principle of problem reduction is also applicable to a constellation of symptoms that comprise a specific disorder such as depression. By concentrating on certain key components of the disorder, such as low self-esteem or negative expectations, the therapy can produce improvement in mood, overt behavior, appetite, and sleeping pattern. One patient, for instance, revealed that whenever he was in a gratifying situation, he would get some kind of "kill-joy" thought: When he began to feel pleasure from listening to music, he would think, "This record will be over soon," and his pleasure would disappear. When he discovered that he was enjoying a movie, a date with a girl, or just walking, he would think: "This will end soon," and immediately his satisfaction was squelched. In this case, a thought pattern that he could not enjoy things because they would end became the focus of the therapy.
In another case the main focus was the patient's overabsorption in the negative aspects of her life and her selective inattention to positive occurrences. The therapy consisted of having her write down and report back positive experiences. She was surprised to find how many positive, gratifying experiences she had had and subsequently forgotten about.
Another form of problem reduction is the identification of the first link in a chain of symptoms. An interesting feature is that the first link may be a relatively small and easily eradicable problem that leads to consequences that are disabling. For analogy, a person may writhe with pain and be unable to walk, eat, talk at length, or perform minimal constructive activities— because of a speck in the eye. The "speck in the eye" syndrome probably occurs more frequently among psychiatric patients than is generally realized. Because of delay in identifying and dealing with the initial problem, however, the ensuing difficulties become deeply entrenched. A mother who was afraid to leave her children at home with a babysitter continued to be housebound long after the children reached maturity.
By a painstaking review of the patient's symptoms and past history it is often possible to delineate the causal sequences. It is generally most parsimonious to concentrate on those factors found to be primary, that is, that are causative in producing the other symptoms. A graduate student with a long-standing history of depression, for instance, had received psychotherapy consisting of fruitless attempts by the therapist to increase his self-esteem and to neutralize his self-criticisms. In addition, he received trials of practically every antide-pressant medication on the market. Nonetheless, the patient continued to feel sad and lonely, was preoccupied with self-derogatory thoughts, had sleep disturbance, loss of appetite, and a chronic state of fatigue.
After detailed analysis of the patient's past and present circumstances, the following pattern emerged. This young man had had a number of long-standing phobias: fears of going out alone, of open spaces, of social rejection. He had compensated for these during his school years by virtue of the fact that, since he was living at home, he had always been able to find someone to accompany him to school. Also, his friends had helped to buffer his fear of rejection by joining him in new social situations. Through this system of compensations and buffers, he had been able to go through college and have a satisfying social life. By circumventing his fears, he had not been disabled by his phobias.
His depression became manifest after he moved to a distant city to attend graduate school. Left on his own, he began to experience intense anxiety. When he would start to walk to class, he feared he would experience a physical catastrophe and that there would be nobody there to help him. He felt safer in his apartment where he was always close to a telephone and could call several physicians with whom he had made contact. Although he managed to force himself to go to his classes, traveling was accompanied by considerable anxiety, and he could barely wait to return to his room when classes were over.
He did not make new friends because his anxiety was stirred up whenever he attempted to form a relationship with another student. As a result, he avoided anxiety-producing situations as much as possible. The cumulative effect of the complete deprivation of social interaction was feelings of loneliness, pessimism, apathy, and physiological signs of depression.
On the basis of this reconstruction of the causal sequence, we concentrated primarily on the phobias rather than on the depression per se. Techniques used to help him overcome his phobias consisted of systematic desensitization in which he imaged scenes of physical catastrophe and also a separate set of scenes of social rejection. He was encouraged to resist his avoidance tendencies, and he exposed himself increasingly to the situations that frightened him. Eventually he was able to leave his apartment without anxiety and to engage in conversation with a stranger.
Although his symptoms of depression were somewhat alleviated by his sense of accomplishment, they were still present in significant amounts. As he overcame his phobic reactions, however, he was gradually able to establish new relationships and to obtain the gratification he missed. As his satisfactions from social activity increased, his depression disappeared.
LEARNING TO LEARN
As pointed out in the previous section, it is not necessary for a psychotherapist to help a patient solve every problem that troubles him. Nor is it necessary to anticipate all the problems that may occur after the termination of therapy and to try to work them out in advance. The kind of therapeutic collaboration previously described is conducive to the patient's developing new ways to learn from his experiences and to solve problems. In a sense the patient is "learning to learn." This process has been labeled deutero-learning (Bateson, 1942).
The problem-solving approach to psychotherapy removes much of the responsibility from the therapist and engages the patient more actively in working on his difficulties. By reducing the patient's dependency on the therapist, this approach increases the patient's self-confidence and self-esteem. More important, perhaps, is the fact that the patient's active participation in defining the problem and considering various options yields more ample information than would otherwise be available. His participation in making the decision helps him implement it.
I have explained the problem-solving concept to patients in somewhat the following way: "One of the goals of therapy is to help you learn new ways of approaching problems. Then, as problems come up, you can apply the formulas that you have already learned. For instance, in learning arithmetic you simply learned the fundamental rules. It was not necessary to learn every single possible addition and subtraction. Once you had learned the operations, you could apply them to any arithmetic problem."
To illustrate "learning to learn," let us consider the practical and interpersonal problems that contribute to a patient's various symptoms. A woman, for instance, discovered she was constantly plagued with headaches, feelings of tension, abdominal pain, and insomnia. By focusing on her problems at work and at home, the patient was able to find some solutions for them and became less prone to experience symptoms. As was hoped, she was able to generalize these practical lessons to solving other problems of living, so that it was not necessary for us to work on all her problems in therapy.
Among the types of problems that had caused the symptoms were the following. She always felt tense when she was at work because her supervisor was hypercritical. Although the patient's performance was at a high level, she was always afraid of making a mistake because of the wrath that it might evoke from the supervisor. The patient could not, on her own, devise a way out of this situation.
We rehearsed a number of approaches she might use in discussing the problem directly with her supervisor. When she felt ready, she told her supervisor: "I am always tense when you are around because I'm afraid you're going to jump on me. When you jump on me it only makes my performance worse. I was hoping I could talk to you about this." The supervisor was surprised to hear this, and subsequently was less critical of the patient.
The patient also learned from this experience that she could stand up to other people, and in other analogous situations was able to deal with her fear of criticism by being more assertive. In addition, her increasing self-esteem made her less sensitive to criticism.
"Learning to learn" consists of much more than the patient's adopting a few techniques that can be used in a wide variety of situations.
Basically, this approach attempts to remove obstacles that have prevented the patient from profiting from experience and from developing adequate ways of dealing with their internal and external problems. Most of the patients have been blocked in their psychosocial development by certain maladaptive attitudes and patterns of behavior. For instance, the woman with the numerous problems at work and at home had a characteristic response when she was confronted with sensitive interpersonal relations or new practical problems: "I don't know what to do." As a result of therapy, each successful experience tended to erode this negative attitude. Consequently, she was enabled to draw on her ingenuity in meeting and mastering completely different situations.
Patients generally try to avoid situations that cause them uneasiness. Consequently, they do not develop the trial-and-error techniques that are prerequisite to solving many problems. Or by staying out of difficult situations, they do not learn how to rid themselves of their tendency to distort or exaggerate. A person who stays close to home because he fears strangers does not learn how to test the validity of his fears or to discriminate between "safe" strangers and "dangerous" strangers. Through therapy he can learn to "reality-test" not only these fears but other fears as well.
The sense of mastery from solving one problem frequently inspires the patient to approach and solve other problems that he has long avoided. Thus, a bonus of successful therapy is not only freedom from the original problems, but a thorough psychological change that prepares him to meet new challenges.[/quote]
From Chapter 9 of "Cognitive Therapy", Aaron T. Beck, M.D., Meridian, 1979 pgs. 220-232
