Downloaded by [New York University] at 02:06 15 August 2016 O

Downloaded by [New York University] at 02:06 15 August 2016 O. H. MOWRER’S THEORY OF INTEGRITY THERAPY REVISITED

In the mid-20th century, O. H. Mowrer was a celebrated academic psychologist, owing largely to his experiments with animals and humans that led to breakthrough theories on how we learn. His numerous publications in this arena propelled him to the post of President of the American Psychological Association in 1954. His own battles with depression led him to develop a new theory of psychotherapy, which he called Integrity Therapy. The premise of this modality is that the client’s deception with people they care about is the source of conscience pangs, but the client resists or represses the prompting of the conscience, and this causes his or her psychological symptoms. Treat- ment, therefore, consists of urging the clients to acknowledge their hidden behaviors to themselves and to signiﬁ cant others that they might both gain restored community with intimates and the fruits of personal integrity and inner peace (to come clean about their deceptions and rewarding the confession with approval.) This book explores the conceptual underpinnings of Integrity Therapy and Mowrer’s unique treatment approach, detailing his methods for setting conditions for therapy, assessing clinical data, rules of engagement for transference and countertransference, and handling client resistance. Case examples and transcripts are included to demonstrate key points of this technique. Mental health professionals interested in Mowrer’s ideas or the history of psychotherapy will ﬁ nd this book to be a valuable and interesting resource.

V. Edwin Bixenstine, Ph.D., ABEPP, is Emeritus Professor of Psychology,

Downloaded by [New York University] at 02:06 15 August 2016 Kent State University, Ohio. He obtained his doctorate under the mentoring of Dr. O. H. Mowrer at the University of Illinois in 1953. After working as a clinician at a neuropsychiatric hospital and later at an outpatient clinic, he accepted an appointment as clinical instructor at Kent State. In due course, he inaugurated a therapeutic community, called Community House, based on the concept that those receiving help were also purveyors of help. Downloaded by [New York University] at 02:06 15 August 2016 O. H. MOWRER’S THEORY OF INTEGRITY THERAPY REVISITED

V. Edwin Bixenstine Downloaded by [New York University] at 02:06 15 August 2016 First published 2014 by Routledge 711 Third Avenue, New York, NY 10017 and by Routledge 27 Church Road, Hove, East Sussex BN3 2FA Routledge is an imprint of the Taylor & Francis Group, an informa business © 2014 Taylor and Francis The right of V. Edwin Bixenstine to be identiﬁ ed as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identiﬁ cation and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Bixenstine, V. Edwin. O.H. Mowrer’s theory of integrity therapy revisited / by V. Edwin Bixenstine. pages cm Includes bibliographical references and index. 1. Mowrer, Orval Hobart, 1907–1982. 2. Psychoanalysts— United States—Biography. 3. Psychotherapist and patient. 4. Psychotherapy—Methodology. 5. Confession— Psychology. I. Title. II. Title: Mowrer’s theory of integrity therapy revisited. RC480.5.B573 2014 616.89′14—dc23 2013043918 ISBN: 978-0-415-72155-4 (hbk) ISBN: 978-1-315-86308-5 (ebk)

Typeset in Galliard by Apex CoVantage, LLC Downloaded by [New York University] at 02:06 15 August 2016 CONTENTS

Acknowledgments xi

Introduction 1 Who Was O. H. Mowrer and What Were His Theories? 1 Mowrer’s Learning Theories 1 Mowrer’s Shift to Focusing on Psychotherapy 2 Why Do It? 4 Reason One 4 Reason Two 7 Reason Three 7 Reason Four 9 Reason Five 10 Conclusion 11

PART I The Therapeutic Process 15

1 Preview of Concept: A Point of Departure 17 Conceiving the Normal 18 Conceiving Psychopathology 19 Pathology as Addiction 20 Downloaded by [New York University] at 02:06 15 August 2016 Implications for Psychotherapy 21

2 The Introduction Stage: Establishing Contact 23 Choosing Your Perspective 23 Pain and Its Relief 25 Conclusion 28

v CONTENTS

3 The Introduction Stage: Establishing Conditions 31 The First Hour 31 Establishing Conditions: What to Avoid 31 Establishing Conditions: What to Embrace 33 The Typical Opening 34 Less Typical Cases: The “Helpless Person” 36 Other Atypical First Hours 40 Ending the First Hour 43 The Second Hour 46 Opening the Second Hour 46 Reinforcing the Conditions 46 Other Considerations 48 More on Taking Notes 48 How to Take Notes 50 The Use of Recordings 51 Conclusion 52

4 Engagement: The Clinical Data 55 The Clinical Data 56 Subjective Responses as Raw Clinical Data 56 Learning to Rely on Your Clinical Data 56 Clinical Data and Empiricism 57 First Steps in Processing the Clinical Data 58 The Perceptual Orientation of the Therapist 58 The First Message Detected: Acknowledging Pain 60 The First Message Detected: Primal Ambivalence 60 Resistance 62 Conclusion 63

5 Engagement: Some Useful Rules 65 Transference and Countertransference Revised 65 Transference and Ambivalence 65

Downloaded by [New York University] at 02:06 15 August 2016 Unavoidable Countertransference 66 Processing Countertransference as Clinical Data 67 Rule 1: Divergent Attention 67 Rule 2: Acknowledge Feelings and Tendencies 67 Rule 3: Is It Me? 70 Rule 4: Refrain from Acting Out Your Feelings and Tendencies 72

vi CONTENTS

Don’t Rules in Working with Countertransference 73 Don’t Rule 1: Don’t Act Out Being AFRAID 74 Don’t Rule 2: Don’t Act Out Being ANGRY 77 Don’t Rule 3: Don’t Act Out Being AMOROUS 79 Don’t Rule 4: Don’t Act Out Being AMUSED 80 Don’t Rule 5: Don’t Act On APATHY 82 Don’t Rule 6: Don’t AGONIZE 83 Don’t Rule 7: Don’t ASK Questions 87 Don’t Rule 8: Don’t ANSWER Questions 89 Conclusion 90

6 From Insight to Action 91 Insight as a Map 91 A Less Than Perfect Fit 91 Insight and Effort 92 The Truth in Insight 92 The Test of Action: A Case Illustration 92 Whose Insight and When? 94 Conclusion 96

7 Client Actions 99 Client Disclosure 99 Disclosure as the First Action Taken 99 The Insistent Secret: A Case Study 100 Resistance to Disclosure 104 Disclosure Will Harm Others: The Primary Theme 104 The Intellectual Resistance: A Secondary Theme 111 It’s None of Their Business: A Secondary Theme 113 Conclusion 116 Endnote 117

8 Additional Client Actions 120 Compensation 120 Downloaded by [New York University] at 02:06 15 August 2016 The Subjectivity in Compensation 121 Enacting New Roles 126 Role-Play 126 Role-Play and Assertion 130 A Case of “Assertion Deﬁ ciency” 132

vii CONTENTS

Other Client Actions 136 Drawing on Micro-Behavioral and Cognitive Techniques 136 Case Examples Where Classical Conditioning May Be Applied 137 Joining a Group 138 Terminating Therapy 139 Conclusion 140

PART II The Nature of the Problem 143

9 Linking Psychotherapy to Pathology 145 The Goal of Psychotherapy 145 Goals Express Concept 145 The Means to Achieve the Goal of Psychotherapy 146 Recapturing Guilt 146 Faith and Hope 147 Restoring Community 149 A Graphic Rendering 151 Conclusion 155

10 The Nature of Normality 158 As Absence of Pathology 158 Are Normality and Pathology Independent? 158 A Limited Independence 159 An Otherworld Perspective 160 A Report to a Distant Planet 160 Human Interdependence 160 The Joys of the Moment 161 The Engineering of Integrative Behavior 162 Integrative Versus Adjustive Behavior 162 The Power of the Sign 163 A Matter of Passion 164

Downloaded by [New York University] at 02:06 15 August 2016 The Human as the Worrying Animal 165 The Normality of Worry 165 The Mystery of Worry 165 Worry: Omnipresent and Complex 167 Worry and Humor 168 The Benevolent Circle of Integration 169 A Continuing Mystery 169 Parent Mediation of Future Outcomes 170

viii CONTENTS

“Priming the Pump” of Integrative Behavior 170 The Signiﬁ cance of One’s Personal History 173 The Intimate Other 174 The “Improbable Flight” of Integrative Behavior 174 A Final Contributor: Intimate Community 176 A Special Kind of Conformity 178 Conclusion 179

11 The Nature of Pathology 183 On the Absence of or Departure from Normality 183 Integrative Behavior and Survival 183 Integrative and Adjustive Behavior 184 The Role of Guilt 185 The Law of Effects Over Time 186 Distinguishing Psychological From Biomedical Problems 186 Introducing the Dimension of Psychopathology 187 Psychopathology Deﬁ ned 187 Pathological Deception 188 The Widespread Contempt for Guilt 189 The Dynamic Versus the Manifest in Psychopathology 190 A Classiﬁ cation System 191 Nature of the Independence of Normality and Pathology 191 Commonly Used Labels 192 Characteristics Distinguishing Normality and Pathology 194 Ordering Quadrants According to Psychological Health 194 The Primitive Person 195 Psychopathology as Negative Addiction 197 Addiction: An Expanded Concept 197 Explaining Negative Addiction 198 The Precondition to the Development of Pathology 199 Failed Efforts at Self “Cure” 201 The Barrier of Despair 203 Conclusion 204 Downloaded by [New York University] at 02:06 15 August 2016

Postscript 207 Appendix 210 Bibliography 244 Index 249

ix This page intentionally left blank Downloaded by [New York University] at 02:06 15 August 2016 ACKNOWLEDGMENTS

It is my good fortune to have a wife forever interested in my endeavors, but also herself a voracious reader, an English teacher, with an unerring appreciation for the spelling, placement, and choice of words. Anita has graciously laid aside her projects to read, edit, and offer advice on all my writing efforts, including the various versions through which this current work has passed. Needless to say, I’m most grateful and forever indebted to her. Other members of my family have read earlier versions of this work. Special mention goes to my grandson, Mathew Bixenstine, who employed his editing skills to shed some of my grammatical ﬂ aws. Platt Safford, my son-in-law, from his vantage of book lover extraordinaire rendered unusual praise for my introductory treatment. Also offering constant encouragement has been my son, Michael, who has fashioned, with the help of my grandson Edward Bixenstine, a web site designed to advance the cause of my books. A number of persons outside my family requested copies of my manuscript, but I will mention those who communicated their response. Dr. Brent Slife offered early words of encouragement commending my pursuit of a publisher for the work. Two associates in my group work of earlier times, Wendy Ford and Greg Veal, lent their endorsement to the manuscript. This was true also of Gudrun Büxenstein, a German psychotherapist (and distant relative) who employed parts of the work in lectures she gave to therapist colleagues. Gudrun is hopeful that a German translation may soon be available. I had a running exchange about various parts of the manuscript with Dr. George Steinfeld, whose interest in and observations about the work reinforced my belief that

Downloaded by [New York University] at 02:06 15 August 2016 it was deserving. Finally, I am most grateful to two colleagues in the Depart- ment of Psychology at Kent State University who gave the work a meticulous reading and rendered valuable critical comments. Dr. Beth Wildman was very positive about the conceptual structure of the book and agreed that the current state of both theory and practice of psychotherapy cried out for a basic restructuring. Dr. E. Thomas Dowd, invested in and himself well published in the area of cognitive psychology, gave me a persuasive criticism about the architecture of the manuscript that prompted a signiﬁ cant rewrite, which I believe much improved the book’s structure.

xi ACKNOWLEDGMENTS

Two additional readers are critical to the fi nal character and quality of this book. They are Dr. George Zimmar, Taylor and Francis publisher, and Dr. Richard Wessler, author and Taylor and Francis consultant. I was most fortunate in making connections with Dr. Zimmar. He had studied O. H. Mowrer’s works both extensively and intensively and even edited Mowrer’s last book Leaves From Many Seasons: Selected Papers. George brought in Dr. Wessler to read and evaluate my manuscript, and again I was fortunate to have a reader offer advice based on wide and seasoned experience as a psychologist, acade- mician, and author. I admit to some initial reluctance to effect Zimmar’s and Wessler’s suggestions, but they harked back to some of the same advice Tom Dowd had imparted. In the end, having signifi cantly reduced the manuscript length while simplifying its format, I was pleased with the product and most grateful for the advice I received. I cannot leave off acknowledgment of those who have contributed to the production of this book without a fi nal reference to Mowrer himself. First, I want to thank Mowrer’s three accomplished offspring, Linda Carlston, Katie Phillips, and Todd Mowrer, for having graciously granted me permission to employ his name in the title of this book. Certainly, in my estimation his name imparts a weight that few other names might lend to the title. Mowrer was simply the Renaissance psychologist of the mid-20th century. Perhaps Dr. O. Ivar Lovaas, while lecturing around 1968 at Kent State on teaching language to autistic children, captured it best: “No matter what new path you think you’re cutting, you discover before long that Mowrer has preceded you. His range of inquiry and scholarship is simply amazing.” I like to think that by standing on Mowrer’s shoulders I have been able to see a little further. I shall always be grateful for his instructions, mentorship, and friendship. Downloaded by [New York University] at 02:06 15 August 2016

xii INTRODUCTION

This above all: to thine own self be true, And it must follow, as the night the day, Thou canst not then be false to any man. —William Shakespeare Shakespeare’s words are immortal, but I believe he may have employed the wrong order. I prefer, “This above all: Be true in word to all men, and it must follow as the night the day, Thou canst not then be false to thine own self.” —O. H. Mowrer

Who Was O. H. Mowrer and What Were His Theories?

Mowrer’s Learning Theories In the mid-20th century, O. H. Mowrer was a celebrated academic psychologist, owing largely to his experiments with animals and humans, which led to breakthrough theories on how we learn.1 His numerous publications in this arena propelled him to the post of President of the American Psychological Association in 1954. Many colleagues believed that his two-factor theory of learning reconciled a long unresolved contest between advocates of Pavlov’s (1927) view of learning as conditioned reﬂ ex and those endorsing Thorndike’s (1911) theory of learning as response selection. Mowrer concluded that both

Downloaded by [New York University] at 02:06 15 August 2016 sign substitution (conditioning) and response selection (habit learning) were correct, but not for all learning. The ﬁ rst explained the learning of anticipatory states (fears and hopes or secondary drives and secondary reinforcements), while the second explained the learning of motoric, voluntary actions (habits). Mowrer, however, had a restless, inquisitive mind, and while others were hailing his two-factor theory, he began to have doubts, in particular about how we learn and execute habits. He was troubled by the stimulus–response (S–R) “connection” formula endemic to Thorndike’s position where habits were conceived as “ﬁ xed” and invariant, coded in a library of individual

1 INTRODUCTION

templates located somewhere in the central nervous system. Thus, when a stimulus (or stimulus complex) occurred, it evoked its own particular tem- plate, which unfolded the specifi c motoric habit coded thereon. I remember Mowrer’s excitement as he presented to a small group of his assistants and students (circa 1952) the outline of his new “revised two-factor theory” of learning. He sketched on a blackboard a stick drawing of a servo- driven antiaircraft gun he had recently seen demonstrated. The gun system had an external sensor (radar), internal positional sensors, a motor, a computer, and a dedicated goal (or prime directive). When the system is turned on, the gun complies with its prime directive, which is to fi nd a target in the sky and close on and track that target, employing the stream of information fl owing into its computer from radar and positional sensors. The computer then calculates the discrepance between the gun’s line of fi re and the target’s position. If in the next instant the discrepance increases, negative feedback causes the gun to change course. If the discrepance still increases, the feedback again prompts a change. This occurs at electronic speeds, so to the human observer the gun appears rapidly and smoothly to lock on and track the target. Mowrer had been intrigued by the demonstration. When turned on without a target present, the gun meandered in various directions “looking for something to target.” Once, he said, it began tracking in an uncertain manner a fl ock of birds. But when a plane fl ew by, it jumped quickly to hone in on the plane. This, Mowrer asserted, was a valuable analogue to better understand the smooth but variable behaviors we learn to produce in pursuit of our human aims. Rewarding effects, he noted, do not build fi xed S–R ties, nor do punishing effects extinguish those ties, because neither external nor internal stimuli get connected directly through learning to our behavior. All learning is sign learning (a bow to Pavlov). We learn to be aroused and fearful in the presence of stimuli (signs) that precede and accompany the appearance of pain, hunger, and fear itself. When these stimuli are produced by our behavior, the behavior is inhibited (not “extinguished”). We learn to feel relief and hope in response to stimuli that precede reduction in pain, hunger, and fear. So the fl ow of signs (both external and internal) feeding back to our central nervous system results in a calculation (carried on at neural speeds) in accordance with the prime directive to shape our behavior moment to moment so as to approach the maximization of our hopes and minimization of our fears—the basic outline

Downloaded by [New York University] at 02:06 15 August 2016 of Mowrer’s revised two-factor theory of learning.

Mowrer’s Shift to Focusing on Psychotherapy Mowrer’s accomplishments in research and learning theory would alone have been enough to secure his place in psychology’s roster of outstanding con- tributors.2 However, the source of Mowrer’s (1974) restless searching lay in his personal battles with depression. He was a committed behaviorist by training and by choice, but he was dissatisﬁ ed with behaviorism’s shunning of

2 INTRODUCTION

“intervening variables” (internal states) and of anything that hinted at an exercise of choice, values, or morals, apparently because such implied a departure from strict cause–effect determinacy. His early explorations addressing theories of psychotherapy and psychopathology stemmed from his enduring desire to fi nd an explanation of and solution for his recurrent states of depression about which behaviorism was essentially silent. His revised two-factor theory was an effort to fi nd a language to address his personal problems while still remaining conversant with behaviorism’s distinctive, identifi able idioms and constructs. Another source of the unique direction his theorizing about chronic psychic problems took was a series of three psychoanalytic treatments he under- went beginning in 1940 while he was an Assistant Professor at Harvard. The last analytic therapist he saw was the prominent Freudian analyst Hans Sachs. While each treatment series resulted in some relief, episodes of depression each time soon returned. Having invested so much hope, time, and money to no very lasting avail, he lost faith in the Freudian approach. In 1944 he took a position in the Offi ce of Strategic Services, the forerun- ner of the Central Intelligence Agency. There he came under the infl uence of Harry Stack Sullivan, also an analyst, but one who downplayed the signifi cance of sexual issues and accented instead the importance of interpersonal relationships. Sullivan believed that the most painful event in one’s life is to experience a rupture in relations with “signifi cant others.” Sullivan’s seminars cast the mold for the development of Mowrer’s subsequent views on the nature of human “problems in living” and on the kind of psychotherapy appropriate to addressing those problems. Upon returning to Harvard after the war, he began to devote time to counseling students. After taking the position of Research Professor in 1948 at the University of Illinois, he continued his clinical work, and drawing upon Sullivan’s observations, his accumulating experience administering therapy, and what he had learned as a client of psychoanalysis, he fashioned the basics of his Integrity Therapy (IT). He acknowledged that he had borrowed much from the analytic tradition, but carefully contrasted his approach with that of Freud and his followers. Freud’s was a “repressed impulse” theory in which the roots of “neurosis” were established in infancy and childhood. The repressive force originated with the moral preachments of parents, family, and society, which in turn brought to pass in his patients the formation of a strict, infl ex-

Downloaded by [New York University] at 02:06 15 August 2016 ible, and unforgiving conscience—the superego. Biologically based desires, the id, were often forbidden to such a degree that the conﬂ icted person tended to confuse the repressed desire with the overt act satisfying it, suffering in consequence a condemning guilt all the more frequent. The analysts’ objective was to expose via interpretation how suffering persons were victims of “false guilt” about acts they had yet to commit and, in any case, being no longer children, might with reason be able to commit free of guilt. By contrast, Mowrer asserted that his was a “repressed guilt” theory, which might well have some early roots in the generally permissive trends in current

3 INTRODUCTION

child-rearing culture, but was more directly a product of our being “all too human” in that we are tempted to satisfy our appetites even when doing so proves contrary to our own values. We then seek to elude the residual guilt this brings by disguising and denying our actions both to others and to ourselves. The objective of IT then is to help troubled people discover what it is they value (loyalty, honesty, caring, effort, etc.) and what they are doing contrary to those values that explain the various self-derogating symptoms they present. Of course, insight is not enough; the therapist has the additional chore of helping troubled people fi nd ways to change their lives, diffi cult as that will be, in order to fi nd personal integrity, restore community with signifi cant others, and promote a different, more hopeful outlook. The procedures and processes presented in Part I answer the question “How do we do Integrity Therapy?” and both recapitulate and elaborate the essentials of what Mowrer was teaching and applying in individual therapy circa 1948 to well into the 1950s, before he turned his attention to group work. It is entirely congruent with his search that Mowrer applied his theory to himself. As a result, he confessed to his wife guilty incidents of previously hidden adolescent sexual behavior and, more relevant to her, an affair he had had outside their marriage. This exercise of openness apparently promoted the lon- gest period of freedom from depression he had experienced since adolescence. However, nine years later he suffered a serious depressive episode leading to hospitalization. This experience led to his redirecting his energies from individual therapy, where he was the therapist , to his forming a therapy group, inspired by his high regard for AA, in which he participated as a member regularly subject to review by the group of his own actions and foibles.

Why Do It?

Reason One IT is that particular approach that rests on a base premise clearly different from that of other approaches and a base premise, most importantly, that will be conﬁ rmed by empirical reality.

For background, let me note that the materials presented in Parts I and II

Downloaded by [New York University] at 02:06 15 August 2016 have been revised and expanded from a mimeographed text I prepared for graduate clinical students whose therapy work I supervised in the late 1970s and 1980s. I thought to revise and publish the text, but various reasons led me to put that effort on the shelf. Much later, ﬁ nding time more plentiful, I revisited the manuscript and transformed it to digital format. After making revisions, I decided that I must return to a review of the relevant literature on psychotherapy that I had but distantly followed for about 30 years.3 The exercise has caused me to feel a bit like Rip Van Winkle down from the mountains. The state of psychology today, as regards its clinical applications,

4 INTRODUCTION

is not at all as I expected! I had expected convergence of theory, agreement on treatment procedures, and a more confi dent base in empirical knowledge. Instead, I fi nd divergence, contradiction, and uncertainty. The energizing nucleus of this chaos is repeated meta-analytic studies launched to wrest meaningful generalities from thousands of diverse researches on psychotherapy but which, instead, have brought a reliable but perplexing if not confounding conclusion: No theory-based approach has been found reliably more effective than any other. Psychotherapy in general does show modest benefi ts over no therapy at all, although there is a risk that some (5 to 10 percent) will fare less well than had they not received therapy. This is about where we were years ago when Saul Rosenzweig (1936) introduced his wry “Dodo Bird Hypothesis” that different therapy approaches, like contestants in Alice in Wonderland’s foot race, are all winners “and all must have prizes.” Yet, in spite of the substantial empirical support the Dodo Bird Hypothesis has received, most psychologists hold to the idea that some therapy approach will be found to excel over all others. Inventive explorers continue searching afi eld for new approaches, such as “mindfulness” (borrowed from Buddhists thinking) or “narrative therapy,” all adding to the burgeoning numbers of divergent approaches (estimated at 400 or more; see Seligman & Reichenberg, 2007). Many psychologists act, however, as if these meta-analytic results did not exist! For example, there is a strong professional APA (American Psycho- logical Association)-backed movement to emulate medicine and sanction only EST (Evidence Supported Treatments), which sounds good but on its face simply denies the relevancy of meta-analytic results! We do not have reliable evidence supportive of this-over-that procedure. In addition, imposing an EST restriction would discourage those explorers I mentioned above from clinically trying out new theoretical approaches that may excel over the old. One other problem is that psychotherapy of whatever approach utilizes a human relationship rather than a pill to carry the active ingredient to the distressed person. This makes psychotherapy research far more challenging than drug research. For example, how does a blind control (placebo) therapist not know the facts and knowing, how participate in an authentic helping relationship? There are those seeking to calm insecurities of professionals who are doing

Downloaded by [New York University] at 02:06 15 August 2016 therapy or teaching it by assuring them that psychotherapy in general works, if not always well, at least better than no therapy (cf. Wampold, 2001, 2010). They advise dispensing with endless and futile efforts to conﬁ rm some superior therapy theory. Even if the beneﬁ t of therapies we conduct boils down to a placebo effect, as long as those effects over all are positive and the therapy is construed in psychological terminology, then it remains a legitimate application and province of our discipline. Unfortunately, this position simply surrenders to the Dodo Bird Hypoth- esis. Yes, it may give some succor to beleaguered professionals, but such aid

5 INTRODUCTION

comes at the cost of abandoning psychology the science. Theory in science is more than mere suasion, more than a convincing narrative. Theory suffi ciently undergirded in empirical evidence is what we call knowledge. However, the Dodo Bird essentially says theory is irrelevant. But why would all these therapy theories, so varied in terms and concepts, be alike in bringing indistinguishable results? I would argue that there is a fundamental way all the researched approaches are indeed the same. They all advance, often implicitly, the same starting premise—that the basic cause of human psychological distress is negative emotions that inspire various obsessive, ameliorative efforts (symptoms) and that have been seared into our psyches by both distant and current traumas. The goal, then, of psychotherapy is to annul these negative, victimizing emotions. This common premise, moreover, is so prevalent and unquestioned that you may well fi nd my rendering of it merely a statement of the obvious, a fact rather than an assumption. Unless you are nearly as old as I am, you might not know that Mowrer more than 60 years ago explicitly challenged this assumption and advanced a sharply contrasting premise—that the basic cause of human distress is not “negative emotions ” but “negative behaviors, ” behaviors contrary to troubled persons’ values.4 These behaviors represent departures from personal integrity and prompt those painful emotions (viz., guilt) and subsequent efforts to deny and minimize them. It follows that the goal of psychotherapy is not to annul and dismiss emotions but, instead, to attend to them, be instructed by them, and to discover from them what behaviors troubled people may be well advised to change. As a clinician, I applied IT for over 45 years with results satisfactory to me, but I did not empirically and systematically compare IT results with those of other therapy approaches. If Mowrer’s integrity theory focusing on changing behavior is right, and the trauma theory focusing on changing emotions is wrong, then no matter how a therapy is specifi cally construed as it endeavors to annul negative emotions, it will be less useful than it could be and perhaps even harmful—precisely the results of the meta-analyses. On its face, the meta- analysis results upholding the Dodo Bird Hypothesis are puzzling, but not if you agree that the therapies so far researched indeed rest on a common but fallacious starting premise. We may then conclude that all the therapies tested so far are simply more alike in being wrong than they are different in being right. We do not need research on yet another “new” therapy variation fl owing

Downloaded by [New York University] at 02:06 15 August 2016 from the same underlying premise. We should be fairly conﬁ dent now based on meta-analyses that the results will be unremarkable. What we do need is a widespread research effort to examine an “old” therapy, now all but forgotten, but grounded in a truly different presumption about the nature of human psychic misery and the consequent focus of psychological intervention. As other therapies have proven not particularly better or worse by outcome measures, a head-to-head comparison of IT with any or a number of such therapies, conducted on common kinds of problems by therapists of equivalent preparation, experience, and conviction, would be a logical and potentially breakthrough

6 INTRODUCTION

event in the course of applying the science of psychology to human psychological problems.

Reason Two IT theory is coherent, well integrated, and persuasive in offering a conceptual frame of reference that the student, mental health professional, and interested laity may, if they so desire, comprehend and apply.

A common problem expressed by student clinicians I supervised was that in spite of extensive prior academic study of psychotherapy, they felt hard-pressed to have at hand a conceptual framework guiding and informing their interventions with clients. My students found the mimeographed text I prepared of value in this regard and urged me to expand and publish it. Having no serious commitment to any other approach perhaps made easier their application of IT tenets to their cases. This ease of adoption and understanding was also evident with my clients, although the “instruction” ﬂ owing from the therapy was not presented in an academic or organized manner, but was a byproduct of the therapeutic exchange constantly focused on communications initiated by the client. How- ever, I did author a number of pamphlets that were didactic in character and that were made available to clients (see the Appendix). Also, I helped organize and initiate a “therapeutic community” (called Community House), which supplemented the help available to my individual therapy clients, but also welcomed membership to anyone who sought help. The members of this self- governing body, whether initially seeing me or not, all readily comprehended and applied the conceptual framework that guided IT.

Reason Three IT theory draws more effectively on commonplace observations of the human condition than do theories that rest on the premise that trauma- induced, chronic negative emotions are the issue.

Life routinely brings loss, frustrations, failures, pain, and threatening events.

Downloaded by [New York University] at 02:06 15 August 2016 There is abundant trauma in life, but most persons do not emerge from these events with chronic anxiety, depression, and guilt. Perhaps it is not trauma, then, that accounts for enduring negative emotions, but it is, rather, with what lack of forbearance and integrity we respond to such events. The notion that we live in an over-moralizing, inhibitive society that puts us at risk of developing repressive consciences and self-punishing emotions simply does not ﬁ t with the manifest and widespread pursuits of self-interest encouraged by the consumer culture long dominant in the USA and now taking hold worldwide. As Donald Campbell (1975) has made clear, our survival depends on two

7 INTRODUCTION

sometimes contesting evolutionary processes: one is satisfying our individual biological needs in a harshly competitive, uncertain world and the other is maintaining the sociocultural structure without which, being interdependent social animals, we perish but that also sometimes frustrates instant attention to biological needs. Karl Menninger (1973) has persuasively asserted, in his Whatever Happened to Sin, that the human family has wrestled with questions of right and wrong, self-interest versus social interest, unfettered freedom versus duty, or, in short, with morality since the dawning of historical time and, arguably, well before that. And of course these questions were the central concern of philosophers and theologians and have remained so since antiquity. With the advent of empirical, institutional science, a kind of modus vivendi was forged in which it was understood that science ruled the world of facts, a domain no longer established by revelation or by logic, while philosophers and theologians held sway in the world of morals and values. One reason IT has essentially vanished since Mowrer’s death in 1982 is that it seriously challenged what had become an axiom of applied psychology and the “medical model”—therapists do not cross over into matters of morality and ethics. If you do, you are leaving the confi nes of applied science and entering those of philosophy and theology. By the end of the 19th century, when Sigmund Freud arrived on the scene, medicine was fi rmly ensconced as an application of scientifi cally derived facts about biology and disease. But many physicians were, from time to time, challenged by a variety of symptoms with no clear underlying disease. Hysteria was the term applied to these symptoms, especially if they involved inexplicable physical limitations such as “hysterical” blindness or physical paralysis. Some, including Freud, experimented with hypnosis as a way to treat these “ills.” Freud, however, turned from hypnosis to free association (talk therapy), and from there developed a theory of what was behind such a variety of symptoms and complaints. His patients expressed vague guilts, shame, and self-derogation. They also often spoke of early confl icts with parents. This led Freud to conclude that, fi rst, parents and, later, society had too vigorously instilled into his patients an excess of inhibitory, self-critical judgments (the overdeveloped Superego), which grew so overbearing that appetitive (particularly sexual and aggressive) impulses (the Id) were repressed from consciousness. Subsequently, any long- denied impulse that managed to intrude into consciousness brought immediate

Downloaded by [New York University] at 02:06 15 August 2016 censure by the Superego in the guise of a crisis of anxiety and a sense of doom. Symptoms were then developed to pacify the Superego and moderate anxiety. In his book Civilization and its Discontents, Freud (1957) made clear that it was society’s moral pressures that placed at risk the mental health of all. In effect, he was saying that troubled people were attempting to be “too good” for the good of their own mental health. In this manner, Freud did not cross the line into directly evaluating the rightness or wrongness of moral tenets as such. He was dealing with “neurosis” (a nerve sickness) caused by a traumatic excess of discipline and instruction. That perspective has remained dominant,

8 INTRODUCTION

if often muted or differently stated, among helping professionals since, as evident, for example, in Albert Ellis’ (Ellis & Dryden, 1997) assertion that feeling guilty is, in general, pathological. Meanwhile, it is manifestly evident, what with the constant news of ethical departures practiced by models of propriety and uprightness, scions of business and fi nance, as well as everyday folks, that we are not currently bowed over in self-sacrifi cial piety. Indeed, Menninger’s review of human ethical conduct through the ages encourages doubt that there was ever a time when we were overburdened with scruples. If we grant that people do acquire moral tenets of importance to them from which they depart more or less often, then it makes sense to conclude that those folks must contend with real guilt. And if they continue these dissonant actions in spite of their guilt, what do they do with that guilt? Mowrer asserted that if they do not abstain from the guilt- provoking actions, they will attempt to disavow or deny their guilt. Guilt is a form of anticipatory fear conditioned to the stimuli produced by the guilty behavior. Will not that fear dissipate in time if persons stubbornly repeat the actions? Conceivably so, but only if these actions remain undiscovered by signifi cant associates who condemn them and/or they fail to bring about other negative effects in time (e.g., bad health or heightened physical threat). Oth- erwise, these painful consequences will continue to reinforce the guilt. In this manner, Mowrer was able to explain the “neurotic paradox”—why do troubled people continue to experience moral fear (guilt) if it is false and no longer relevant (no longer being reinforced)? Mowrer’s answer: the guilt is neither false nor irrelevant; it is reinforced by the ongoing realities of people’s lives.

Reason Four In contrast to IT, therapies resting on the trauma/negative emotions premise ordinarily place therapists in a position of power and decision while troubled persons assume the passive role of patient, awaiting sal- vation at the hands of the powerful therapist.

Behavior therapists generally seek to undo negative emotions via decondition- ing or fl ooding; cognitive therapists attempt to alter the “stinking thinking” presumed to produce negative emotions; a recently new approach (Hayes, Strosahl, & Wilson, 2012) called ACT (Acceptance and Commitment Ther- Downloaded by [New York University] at 02:06 15 August 2016 apy) departs from a program of undoing negative emotions (which ACT views as recurrent and inevitable), but ACT therapists instruct troubled persons how to accept life’s pains by mindfully centering on pure consciousness so that they might proceed fl exibly and unencumbered by their emotions to commit to and fulfi ll their values and life goals. Rogerian nondirective therapists are exceptions to this rule of therapist direct action. Instead, they pointedly hold back directive or other guiding interventions. However, Rogers (1942, 1961) did embrace the trauma/negative

9 INTRODUCTION

emotion assumption in the guise of his “conditions of worth.” These conditions are internalized in childhood because of parental and societal lack of uncondi- tional positive regard, leading to the development of a disabling, painful sense of worthlessness. This position is not too distant from that of Ellis previously noted. Rogers, however, believed that troubled persons would discover the source of their negative emotions and move to exert corrective changes themselves if awarded the enduring kind regard and nonjudgmental acceptance of another human being, the therapist. IT therapists, by contrast, defer from the outset of therapy to the choice and judgment of troubled persons. They seek to build with troubled persons an understanding of their distress. IT therapists view chronic emotional issues presented by people as a product of their choices and actions, and that it is in their power to change that behavior if they so choose. As this understanding emerges through the therapeutic dialog, troubled persons express both early resistance to accepting their power to choose and to change and, in time, an empowering hopefulness and reassurance that by their own hand they can effect a new life. IT therapists are responsible for “listening through” and understanding what troubled people communicate in words and other signs, and are responsible for communicating respectfully, clearly, and persuasively their understanding to them. However, therapists are not responsible for changing troubled persons. That responsibility rests with those individuals alone. As the choices and changes they make are always difﬁ cult, they have every right to feel proud and deserving of whatever achievements they come to enjoy. They own them. The therapist does not. This is a more preferable endpoint than one dependent upon the therapist’s interposing powers, since it reinforces the connection between the individuals’ choices, actions, and their life outcomes.

Reason Five While no outcome research comparing IT with other approaches has been done, Mowrer presented a collection of a dozen researches that he believed, in total, gave clear empirical support to IT theory over the prevailing view (PV), the trauma/negative emotion view of psychologically troubled persons.

Downloaded by [New York University] at 02:06 15 August 2016 In his last published work, Mowrer (1983) expressed disappointment that a paper (ﬁ rst published in 1968) had not received the attention it deserved. Mowrer had made public prior to 1968 a testable hypothesis regarding implications of IT compared to PV theory. He reasoned that various classes of persons would fall along a continuum of low to high socialization. He construed socialization to be revealed in how afﬁ liative, socially responsible, and observant of social contracts persons would be. His hypothesis was that the commonplace, PV position would assign those with personality disorders (sociopaths/psychopaths) to the lowest end of the socialization scale, while

10 INTRODUCTION

individuals with emotional disorders (neurotics/psychotics), being viewed as oversensitive to social judgments and to rule observance, would clump at the highest end. The more numerous normal or mentally healthy persons would fall in the mid-range. Note that this distribution of classes of people observes the Gaussian or normal curve distribution—a fact lending some credence to PV because the normal curve so regularly describes naturally occurring events. Nevertheless, Mowrer believed this normal curve hypothesis was wrong in the placement of these classes of persons along the socialization continuum. He had no argument with the personality disorders occupying the very low end of the scale, but he did with the positioning of the other two classes. He believed that emotionally disordered persons would fall someplace in the middle or below and closer to the personality disorders rather than the furthest away from them. The distribution then would assume the characteristics of the less commonly seen J-curve, where observed frequencies go from a minimum at one end to a maximum at the other. (Interesting, however, is that the J-curve is more common in describing human behaviors under pressure of rules, such as how frequently auto drivers come to a full stop versus creeping, slowing, or charging through the stop sign.) The evidence reviewed, as noted, favored the J-curve distribution in keeping with IT theory. Therapy congruent with the PV normal-curve position would attempt to move both extremes toward the middle or normal, mentally healthy region of socialization. At that point, the emotionally disordered would ﬁ nd their presumably over-developed sense of scruples and “moral intimidation” moderated into a normal measure of self-permission and willingness to behave free of inhibitions and moral fears. However, the therapeutic design for the personality disordered would be not to moderate, but to jack up their scruples, observance of rules, and sensitivity to others. Thus while emotionally disordered persons would be made “less socialized,” the personality disordered would be made “more socialized.” By contrast, the IT J-curve theory would have therapeutic intervention seek ways to move both personality and emotionally disordered persons in the same direction, i.e., toward greater measures of socialization. Mowrer never assumed we can be too socialized nor that persons highly socialized would be entirely free of certain risks. Persons at very high levels may place themselves in danger out of their very devotion to others (such as did Mahatma Gandhi, Mother Teresa, or Martin Luther King). These persons, however, in Mowrer’s

Downloaded by [New York University] at 02:06 15 August 2016 view, would not be in danger of mental disorder.

Conclusion Mowrer’s fall from grace among the psychological community may puzzle, and I feel obliged to examine it with you further in concluding this introduction. To facilitate my literature search, I turned mostly to books edited by leading scholars, depending on their judgments to screen, select, and provide me a representative range of views and authors. I found allusion to Mowrer

11 INTRODUCTION

was rare, his name infrequently appearing in reference indexes, and when so, mostly in connection with his contributions to learning theory. Almost none referred to his observations about disorders, their origins, and their treatment. An exception was Christopher C. Wagner and Francisco P. Sanchez (2002), who referred approvingly to Mowrer and noted (p. 290) Mowrer’s observation that it is the truth we ourselves speak rather than the treatment we receive that is healing. Their understanding, however, of what Mowrer was getting at was not complete because they then suggested that simply disclosing the truth brought healing to the discloser rather than opening a portal to a sometimes diffi cult journey recovering community with signifi cant others. Another positive observation I found was tendered by George Albee (1998) who com- mended Mowrer to student clinicians, particularly his application of learning concepts to human behavioral problems. Two authors, Nedra Lander and Danielle Nahon, through books and work- shops (2000, 2005, 2009), are passionate advocates of Integrity Therapy and have set about to restore to Mowrer the recognition and place of honor in the halls of learning and clinical practice that history seems to have denied him. Their publications are well worth reading, especially so because they have somewhat contrasting ways of presenting Integrity Therapy to that taken in this book. I hope that my efforts, however, supplement and usefully advance their goal of returning Mowrer’s theories and practices to the serious consideration of both academics and practitioners. As attested by the many authors, psychologists, sociologists, religious fi g- ures, and others that joined Mowrer (1967) to examine the relationship of morality to mental health, Mowrer most certainly was not always ignored. Moreover, he was very warmly endorsed by two prominent authors previously mentioned. The fi rst, psychoanalyst Karl Menninger (1973), made quite clear (p. 180–181) that he was in full accord with Mowrer’s IT views as he presented his own program for addressing the psychic ills of mankind. The second, Donald Campbell (1975), in his Presidential address to the APA, praised Mowrer and Menninger for their similar positions because Campbell believed that “present-day psychology and psychiatry in all their major forms are more hostile to the inhibitory messages of traditional religious moralizing than is scientifi cally justifi ed” (p. 1103). Campbell was not a clinician, but instead was speaking as an “evolutionary psychologist” who expressed hopes that his

Downloaded by [New York University] at 02:06 15 August 2016 sterling non-clinical, scientiﬁ c credentials might better persuade fellow psychologists than had Mowrer and Menninger to view moral tradition as hard- won precepts contributing to our social survival. Needless to say, it appears his hopes were at best premature. But of those making reference to Mowrer, Perry London (1984) was that prominent author who reached furthest to give Mowrer’s views both a con- textual perspective compared with current, contrasting positions and a historical perspective. First, let me note that London was also convinced that all therapies (at that date) were captured by the medical model—that in their

12 INTRODUCTION

practice they must observe a division between (applied) science on the one hand and philosophy and theology on the other; and that the object of therapy is to directly annul pain and distress free of value judgments. London noted that psychotherapists were “nobly moved to adapt this idea to their craft” (p. 5) and refrain from moralizing or making value judgments. He added, “Therapy’s purpose is to relieve their suffering . . . not to change their lives along some moral lines. . . .” From these observations, it appears that London took no issue with the embedded trauma/negative emotion premise, even though he subsequently lavished praise on Mowrer who did take issue with it. He noted that many others have tried to integrate insight (client understanding) with action (problem solving). He praised Mowrer for being the fi rst to do so while also binding “ideas of meaning and action and to a social order for their fulfi llment” (p. 120). Later, London went even further in salut- ing Mowrer’s accomplishments. He opined that Mowrer’s was the “most pre- tentious mental health theory since Freud’s” and the most “integrative of all therapies we have seen” (p. 130). Then no doubt in recognition that Mowrer’s theory in contradiction to the medical model places morality and moral judgment front and center, London observed that Mowrer “forces us to entertain some problems that therapists fi nd hard to fl ee and must be loathe to face” (p. 130). IT does so by asserting that what troubles people is a “disease of their relationship with each other and society,” and that therapy should help “re-connect” and reintegrate these estranged, troubled people into community with others. Finally, London placed a somewhat different face on Mowrer’s fall from grace, particularly among academics but also practitioners. Not only did Mowrer raise the ticklish problem that people inevitably bring their moral concerns into their therapy, making strained an application of the “value free” medical model; in addition, Mowrer seemed in his speech and writing to put a painful twist to the point. London thought Mowrer impolitic because he “had some genius for sensing the rawest intellectual nerve of his audience and then addressing himself to it in a way that incited to riot . . . he would fi rst use conventional religious language to advocate secular ideas; thus endeared to the clergy, he would then assault choice bits of their theologies with gusto, wit, and venom” (p. 121). London’s observation was that Mowrer in this manner erected barriers, both with his psychology colleagues and with the clergy, which a more politic

Downloaded by [New York University] at 02:06 15 August 2016 approach might have avoided. He believed Mowrer alienated more than a few, even those who esteemed his contributions, “because of the foreign sounds religious language makes in scientiﬁ c ears, many of them failed to recognize the important and sophisticated argument expressed” (p. 122). But London then concludes that perhaps Mowrer’s manner and language use were not critical in the negative response many expressed to his views. That response was more from the gut, as if what he claimed to be the cause of people’s negative emotions and how to treat those concerns simply threatened psychologists’ sense of professional propriety. “It seemed scandalous. It looked

13 INTRODUCTION

simple-minded, cruel, and opposed to all the scientiﬁ c and humane ideas of mental health which had won the minds of experts everywhere. A few colleagues thought he had lost his mind” (p. 122). I have observed that Mowrer was passionate in his efforts to persuade others to his views. As regards the somewhat intemperate remarks some made to London as quoted above, passion clearly plays a large role in our holding to views we form and then feel obliged to defend. We may be scholars and scientists, but that only means we devote all the more effort to formulating our theories which, inevitably, become a living part of our person. However, I can add one further historical note to Mowrer’s use of religious terms. He often pointed out to his assistants and students that he viewed the large physical plant, clerical numbers, and membership of the Church as a potentially massive resource for addressing the mental dis-ease of people across the country and even the world. In view of the Church’s prior allegiance to moral rectitude, he thought it quite likely that he could persuade the Church to focus on and do more with its outreach to mentally troubled people. His efforts in this regard were unstinting, but success was not easy and only partially realized. The issues he faced he sets out in a small thought- provoking book The Crisis in Psychiatry and Religion (1961). Now, having brieﬂ y acquainted you with the man, his theories, and the reason why psychology should revisit and test the comparative effectiveness of Integrity Therapy, we turn to the question “How do we do Integrity Therapy?”, which will be addressed next in Part I .

Notes 1. Biographical and learning theory may be found in the following texts: Mowrer and Ullman (1945) and Mowrer (1950, 1960a, 1960b, 1974, 1980). 2. For texts on psychotherapy, consult Mowrer (1948, 1961, 1967, 1972, 1972 [with Johnson & Dokecki], 1983). 3. I read more than a hundred chapters, papers, and books and found a fair measure of redundancy in facts, views, and theories. While this represents a tiny fraction of publications of relevance to the topic of psychotherapy, careful attribution to sources helping me form the generalizations I present here might well do more to hide and encumber my narrative than to inform the reader. For any wishing to examine sources that have gone unreferenced in this Introduction but which I relied on to inform my presentation, I have placed an Arabic star (۞) before the references in the Bibliography.

Downloaded by [New York University] at 02:06 15 August 2016 4. The only theorist I found of recent note that appears to endorse and advance Mowrer’s premise is Brent Slife (2004), who asserts that to deny values in science and psychotherapy actually risks imposing them without full acknowledgment and recognition (cf. Bixenstine, 1976). With Mitchell and Whoolery (2004) he outlined a therapeutic community, Alldredge Academe, focused not on relieving emotional distress, but upon the exercise of “agency”; that is, choosing new behaviors. Step- wise procedures they employed were well conceived to prompt troubled youth to discontinue acting out self-centered indulgences and opt instead for expressing gratitude and integrating into a community of mutual support with peers undergo- ing a similar change of lifestyle.

14 Part I

THE THERAPEUTIC PROCESS Downloaded by [New York University] at 02:06 15 August 2016 This page intentionally left blank Downloaded by [New York University] at 02:06 15 August 2016 1 PREVIEW OF CONCEPT A Point of Departure

We may think there is willpower involved, but more likely the change is due to wanting the new addiction more than the old one. Wanting the new me in preference to the person I am now. —Dr. George Sheehan, running guru

Part I (“The Therapeutic Process”) is focused on clinical experience, while Part II (“The Nature of the Problem”) turns to concept. Experience and concept never stand alone. Pure concept has no substance, and pure experience has no meaning. The challenge is to mix concept and experience such that instructor and student communicate with each other. In my earliest draft of this book, I placed the more conceptual focus (Part II ) fi rst. The rationale was that concept would serve as a clarifying framework for the process that was to follow. Students who used the fi rst draft as a text persuaded me to change the order. Their argument was that reading the “hands on” therapy process chapters helped them to better understand and evaluate the more abstract (conceptual) matters. Besides, they pointed out, the process chapters were closer to their initial concerns and interests. They had already read quite enough theory. They wanted the raw, experiential stuff of clinical application. Two additional reasons for the present order came to the fore. First, it more nearly replicates the instructional sequence, which I found valuable in clinical training, where you immerse the student in actual clinical work and then place that practical experience into a conceptual context. Second, few start with theory and deduce clinical applications from it, though that does have an Downloaded by [New York University] at 02:06 15 August 2016 appeal to logic. Human nature is more experience-bound so that, ordinarily, we start with specifi c clinical circumstances and build or adopt theory to accommodate those experiences. The revised order, however, left me with a minor dilemma. Readers need some initial and explicit framework against which to evaluate the process chapters. Might this dilemma be resolved by presenting a conceptual synopsis of Mowrerian theory, telling the reader in base essentials what is told in detail later? While we have touched on critical aspects of Mowrer’s theory in the

17 THE THERAPEUTIC PROCESS

Introduction, we do well to draw together here what might be termed a basic scaffolding to facilitate a better and earlier grasp of the processes distinctive to applying Integrity Therapy. While this may not recapitulate the rich, interactive spiral between experience and concept permitted in a clinical practicum, hopefully it does move us a step closer.

Conceiving the Normal Psychotherapy is designed to restore psychological health or normality . What is that? Normality is the absence of psychopathology, or so it has been assumed. Such is the legacy of the medical model. In medicine, health is assumed when laboratory tests are negative . Would it not be valuable to have a positive test for health? In the fi eld of human behavior, such has been the aspiration of many. Before essaying a defi nition, let us set forth the conceptual standard against which to measure the positive presence of normality. That standard we will call the integrative principle.1 Simply put, integration is the choice of actions that bring maximum satisfaction of one’s interests and values over time even though that choice may incur considerable dissatisfaction immediately. Commonplace examples of such behaviors are eating a healthy diet, forgoing a pleasure gained at an associate’s expense, exercising regularly, and engaging in effortful work. Integration is sometimes, though not always, in contest with another behavioral standard that we will call the adjustment principle. Adjustment promotes choices that lead to maximum immediate satisfaction. Obviously, there will be occasions when what is instantly most rewarding to do will at the same time endanger long- term goals and values. Commonplace examples of behaviors where adjustment is in confl ict with integration are overeating or eating unhealthy foods, taking advantage of an associate, sedentary pursuits, and work avoidance. We could employ the integrative standard unconditionally and say that persons are normal who behave integratively and non-normal if they depart from integrative behavior. Such stringency in applying our positive test, however, would restrict normality to a small if not vanishing class of persons. In adjusting (seeking immediate satisfaction), everyone fails to integrate at least part of the time and for a number of reasons. For one, we do not always discern which choice before us serves our basic interests and values and, as a result, choose whatever immediately costs least or satisfi es most. Another factor is that we may

Downloaded by [New York University] at 02:06 15 August 2016 not yet have learned that a class of choices has consequences of importance to us beyond the moment. Still another is that we may not have articulated our interests and values, leading to ambiguity about choice. Finally, we may have developed cognitive and perceptual habits that serve to negate, distort, or simply fail to attend to long-term values that are in confl ict with momentary wishes. In light of these considerations, we advance a positive test for normality that rests on the integrative principle but does so conditionally. Normality is that set of behaviors (including emotions, attitudes, and cognitions) that results in a preponderance of integrative over confl icting adjustive choices. This defi nition

18 PREVIEW OF CONCEPT: A POINT OF DEPARTURE

permits some adjustive but non-integrative choices to be present in the life of the normal person so long as the predominant feature is integrative behavior. Thus, using our commonplace examples, one may remain normal and yet occasionally overeat or eat unhealthy foods, abuse a friend, loaf around, and skip work. Non-normality enters when such actions predominate, leading, over time, to cumulative life outcomes more dissatisfying than rewarding.

Conceiving Psychopathology Having advanced a defi nition of normality, are we at liberty to reverse custom and defi ne pathology as the absence of normality? If we did so, we would fi nd that we exclude a class of persons whose actions observe the integrative principle in the main but who have pockets of chronic adjustive/non-integrative habits. We would be on shaky ground to claim they are non-normal, but equally so to claim they are free of pathology. Here, we seem to have persons who are both normal and pathological. All right, we may not claim that all normals are free of psychopathology, but can we claim that all non-normals suffer psychopathology? We can answer this question by posing another. Do we not have persons who are free of guilt, anxiety, depression, perceptual and cognitive distortions, and other such symptoms of psychopathology, yet who are predominantly adjustive/ non-integrative in their life course? Yes, we do, and these persons have been a thorn in the side of behavioral taxonomists from the beginning. They are defi nitely not normal, yet they have a “mask of sanity” (Cleckley, 1982) that confounds those who would assign pathology to them. They are both non- normal and pathology-free. Are we saying that normality and pathology are independent dimensions? Yes, they are in some measure, but not entirely so. Advancing a positive test for normality teaches us that violence is done to either classifi cation concept when defi ned as the absence of the other. Clearly, we need to have a positive test for both normality and psychopathology. Let us proceed to a defi nition of the latter. While the integrative principle usefully serves as our standard for measuring normality, it is the adjustment principle that serves well as the standard for psychopathology. Not all behaviors maximizing immediate satisfactions are relevant, only those which also result in eventual, cumulative dissatisfaction. In other words,

Downloaded by [New York University] at 02:06 15 August 2016 psychopathology springs from adjustive but non-integrative choices and actions. However, psychopathology is not identical to adjustive/non-integrative behaviors because it applies only to a particular class of such actions. Psychopathology is, ﬁ rst, the repeated or habitual choice of adjustive/non-integrative behavior where, second, that repetition is aided and maintained by behaviors chosen to minimize or avoid detection and sanction by others as well as to avoid the individual’s own self-monitoring ( guilt, anxiety). It is important to note that chronic choice of adjustive behavior, even when it eventuates in undesirable costs, is not per se pathological. It is the presence of self -deception, aimed at

19 THE THERAPEUTIC PROCESS

avoiding guilt, and other -deception, designed to avoid social sanctions, which transports such behavior into the domain of psychopathology. In other words, psychopathology rests in behavior designed to protect adjustive choices from the corrective and inhibitive application of consequences. It is also important to note that these habits of deception of self and others are themselves classifi ed as adjustive but non-integrative in nature. Psycho- pathology is never a simple departure from integrative, future-serving behavior in favor of adjustive, impulse-serving actions. It is always a compound of adjustive/non-integrative behaviors built on the hope that life’s consequences, one’s reality, may at last submit to one’s wishes. Of course, persons who engage in chronic adjustive/non-integrative behavior, even when not psychopathological, are often disturbing to us. We fi nd them unreliable, self-serving, immature, manipulative, and, sometimes, dangerous. As a result, we often conclude that there must be something psychologically wrong with them and assign them a place in our taxonomy of psychopathologies. This conclusion has played havoc with our better understanding of the psychopathology concept and, consequently, with a clear and powerful classifi cation system. The truth is, not all persons who disturb us are themselves disturbed. That does not mean they are normal. It may mean that their development is so abnormally arrested and primitive that they fail to entertain outcomes not immediately evident to them and therefore fail to experience that anticipatory sense of consequence that we call guilt. Theirs is not a problem for a psychotherapist addressing psychopathology. Theirs is a problem for the school, the family, the church, and the criminal justice system. Psychologists and other social scientists may usefully contribute to helping these social institutions address the challenges posed by such non-normal but pathology-free persons, but not in the role of psychotherapists.

Pathology as Addiction The Mowrerian conceptions rendered above comprise, in essence, an addiction theory of psychopathology. An addiction is actually composed of two sets of compulsive habits. One set secures some immediate and relatively momentary satisfaction or relief. The other set facilitates access to and reduces the experienced

Downloaded by [New York University] at 02:06 15 August 2016 costs of the fi rst set. For example, alcoholism is not only a matter of compulsive drinking and inebriation. It is also those rationalizations that minimize personal responsibility, those plans that merge alcohol with ordinary work or social pursuits, and those arguments arrayed to deny alcohol dependence or alcoholism. I offer the following defi nition: An addiction is (1) the repetitive choice of behavior that brings momentary pleasure, comfort, and relief at a postponed cost greater than those momentary gains and (2) the presence of habits designed to secure access to the addictive act while minimizing the anticipation of costs. Let me repeat in juxtaposition here the defi nition of psychopathology offered

20 PREVIEW OF CONCEPT: A POINT OF DEPARTURE

previously: Psychopathology is, fi rst, the repeated or habitual choice of adjustive/ non-integrative behavior where, second, that repetition is aided and maintained by behaviors chosen to minimize or avoid detection and sanction by others as well as to avoid the individual’s own self-monitoring ( guilt, anxiety). While we deliberately constructed the defi nition of addiction using language common to that metaphor, it is clear that the substructure of these two defi nitions is of the same genre. The classical addictions, such as alcoholism and smoking, are specimens of psychopathology that also serve well to illustrate the essential features of the class to which they belong. Alcoholics and smokers gain satisfaction immediately but at a serious, delayed price. They minimize that cost through managing the response of others and distorting their own personal judgment. For example, alcoholics often hide and disguise their drinking as incidental to normal social intercourse. Smokers often smoke away from the oversight of signifi cant others. Self-deception is illustrated when alcoholics insist they have drunk less than is actually the case, while smokers are quick to exploit through self-delusion whatever uncertainty exists that smoking injures health. What sets apart the classical addictions from other psychopathologies is a relatively minor feature. The classical addictions involve the ingestion of a substance that in time alters body metabolism. The altered metabolism causes distress experienced for a measured period following deprivation of the substance. Many have relied on substance withdrawal pain as the key to understanding the compulsion in addictions. This reliance is misplaced. Far more pertinent is the loss of psychic income lasting much longer into the future than the two-week span it takes for substance withdrawal pain to subside. When addicts substitute integrative for adjustive/non-integrative behavior, they incur a loss of real and immediate satisfaction in exchange for the promise of a distant reward. The sober alcoholic, for example, must endure moment to moment the deprivation of alcohol’s comfort while waiting for the slow return of his employer’s trust or the gradual thawing of icy human relationships. It is the exchange of real and palpable comfort for only the promise of a better tomorrow that explains how frequently abstinence, whether from alcohol intake, procrastination, prevarication, satyromania, or other addictive behaviors so often gives way to renewed use.

Implications for Psychotherapy Downloaded by [New York University] at 02:06 15 August 2016 The observations about normality, non-normality, psychopathology, and psychopathology-as-addiction have direct implications for the way Mowrer composed the treatment of psychopathology.

1 Negative emotions (fear, anxiety, worry, and guilt) are not per se the enemies of psychological health or the measure of the presence and severity of psychopathology. It follows that psychotherapy is not directed at extinguishing fear and anxiety or banishing worry and guilt. Actually, while somewhat

21 THE THERAPEUTIC PROCESS

misleading, it would be closer to truth to say that psychotherapy is directed at enhancing guilt and promoting the growth of normal worry. 2 That psychotherapy would seek to enhance guilt and worry rests on the nature of psychopathology, which employs strategies minimizing one’s self-judgment and awareness of consequences in the interest of maintaining adjustive/non-integrative behaviors. In order to promote change to integrative behaviors, psychotherapy will inevitably promote awareness and, thereby, nourish new levels of negative emotions. These emotions provide the motive force for change, but they also excite resistance and raise a risk of fl ight from therapy. 3 Because misrepresentation to and deception of intimate others are also central to maintaining pathological behaviors, psychotherapy will promote communications with others and restoration of community with them. 4 Because change is fraught with an extended period of marginal returns for the effort invested, the psychotherapist will frequently promote participation in support groups designed to provide interim rewards (social approval). This form of immediate payoff in some degree compensates the individual in the moment for initiating and maintaining behavior that promotes positive payoff only after long delay. 5 Because a critical feature in client transformative change is the strength of the individual’s hopeful anticipation of delayed benefi ts, the psychotherapist will seek to encourage that hope by making clear the connection between act and outcome. Again, support communities, either designed or indigenous to the client’s life, are valuable in providing immediate social reward as well as providing change models who serve to reinforce hope. 6 The psychotherapist will place at the client’s disposal those procedures among cognitive and behavioral lore that will aid the client in inaugurating and establishing integrative behaviors and displacing addictive and non- integrative behaviors. It should be noted that clients often already utilize techniques like these (e.g., cognitive rehearsal, thought stopping, fl ooding, etc.) of their own invention for the opposite purpose. That is, they are busy attempting to manage their thoughts and feelings to protect their investment in adjustive/non-integrative behaviors at the expense of integrative actions.

Note Downloaded by [New York University] at 02:06 15 August 2016 1. Mowrer (1950) distinguished three frames of reference in behavior theory: the adap- tational, or biological; the adjustive, or hedonistic; and the integrative or ethical. Adjustment is a fi xture in everyday parlance both by lay and professional persons. Commonly, the term broadly connotes health, normality, and freedom from pathology. However, adjustment, as defi ned by Mowrer, while clearly always promoting satisfaction, does not always culminate in psychological health and normality. This more limited use of the term may confl ict with your habits of thought. I ask your indulgence because I believe that Mowrer’s adjustment concept in tandem with his integration concept makes possible a more powerful treatment of human behavior failure and success than either notion alone.

22 2 THE INTRODUCTION STAGE Establishing Contact

We must all suffer one of two things: the pain of discipline or the pain of regret or disappointment. —Jim Rohn, author, entrepreneur, motivational speaker

There are three major stages through which psychotherapy passes. They are the introduction, the engagement, and the action stages.1 The introduction stage is critical in establishing a human bond with your client and developing the conditions under which you will help him or her. The bonding comes fi rst, and necessarily so, because it helps cushion the disappointment clients often feel as the conditions of therapy emerge. Clients regularly hope for more than you and the therapy can offer. So we must arrive at an understanding with them in the beginning regarding what therapy will and will not deliver. We touch on the bonding question in this chapter and return to it again in Chapter 6. We address the conditions of therapy, still part of the introduction stage, in Chapter 3. We will address the engagement stage in Chapters 4, 5, and 6 and deal with the action stage in Chapters 7 and 8. During the engagement stage, the focus of therapy is on gaining insight into the client’s addictive behaviors, confronting habits of justifi cation and defense, and working through resistance. During the action stage, the focus shifts to steps in behavioral experimentation and change fl owing from the insights that have emerged from the engagement stage. Downloaded by [New York University] at 02:06 15 August 2016 Choosing Your Perspective How do you approach the introduction stage and the fi rst contact with troubled persons? What is your initial perspective as you invite persons to relate why they have sought your help? Should you have a diagnostic classifi cation grid spread out in your mind for ready reference? Or is it preferable to approach the fi rst contact with an “open mind” and, thus, be ready to hear the unexpected? These are questions that require answers before you meet with your fi rst client.

23 THE THERAPEUTIC PROCESS

The medical model has exercised an immense infl uence on the evolution of concept and procedure in the helping professions. It is a model that nearly all helpers have adopted to some degree. Third-party payers insist on its explicit language in honoring claims. Practitioners become engrossed in differential diagnosis that is viewed traditionally as a necessary fi rst step in proffering help. Those seeking help frequently phrase that effort as a search for a label and a prescription. If problems in living are, indeed, analogous to disease, and if solutions to those problems are analogous to treatment, then we must conclude that there are many varieties of mental ills and linked varieties of treatments. It can be comforting to have at hand the medical model’s broad scope of problem classifi cation because, to the novice helper, those who present themselves for help do so in enormously varied ways. How reassuring to be able to begin by charting here a symptom that belongs to that syndrome and there a theme classically identifi ed with another. Unfortunately, effective psychotherapy and the therapist’s momentary comfort are not always convergent. Indeed, there is a certain sense in which the two diverge, a matter we will discuss in detail later. For the moment, I merely wish to acknowledge that there is comfort in having a classifi catory system that appears able to cope with the raw profusion humans are capable of presenting and return a manageable, simple structure. Harry Stack Sullivan is supposed to have exclaimed to his students from time to time, “Today we have made progress! I have a new term, a new label!”2 The illusion that we understand and gain control over nature and events by assigning them names is as old as humankind and as language itself. Incantation may well have been the fi rst step to science, but obviously a step tiny compared to the aspirations inspiring it. Differential diagnosis and the medical classifi cation system have had their detractors within medicine. Hans Selye (1956) believed that the reason medicine long ignored the place of stress in disease and human suffering was its fascination with differential diagnosis. Lost from sight in this pursuit was a prior recognition of the ways illnesses were alike. Fever, vomiting, diarrhea, chills, congestion, gastro-intestinal distress, and swelling of extremities are routinely found in nearly all illnesses. They are a part of Selye’s adapta- tional syndrome, the body’s way of dealing with an attack on its functional

Downloaded by [New York University] at 02:06 15 August 2016 integrity. From which perspective do we approach the multifaceted presentations of those seeking our help? Our need for clarity and control may be best served by classifying their presentations into familiar diagnostic, psychiatric terms. Does this speak to their needs? Do we help them in this exercise? I am doubtful. The preferred perspective asks the therapist to defer classifying and labeling what the troubled person is presenting in the interest of “listening through” the welter of particulars and emerging with the general and the essential.

24 INTRODUCTION: ESTABLISHING CONTACT

I advocate this, ﬁ rst, because I believe there is a common factor in most if not all the problems-in-living people present in spite of the manifest multiver- sity and, second, because addressing that essential, common factor ultimately enables the troubled person and the helper to close in on the problem with coordinated effort. The price for the therapist is, at least initially, the discomfort of ambiguity. But in the end, one has something more than a label. One has a picture, perhaps I should say, a motion picture of the essential person as situated in his or her life.

Pain and Its Relief If you “listen through” what troubled people present, what do you “hear?” First, of course, you hear the distress, confusion, anxiety, disappointment, frustration, anger, bitterness, loneliness, bewilderment, and pessimism—in short, the pain that motivates their search for help. This is a moment of critical importance in establishing a human contact with your client. Never short- circuit “ hearing” and acknowledging the pain that the troubled person presents. Yes, it is so common, and, yes, you may become inured to the constant litany. Guard against that tendency. You will never communicate with troubled persons if you do not fi rst communicate your awareness of and appreciation for their pain. What next do you “hear?” You then hear an explanation. Troubled persons express, not always or merely in words, a justifi cation thema, a way of making sense of where they are and what they feel even when they are lost and feel nothing. Presenting this self-explanation thema may take time, as some persons are quite indirect. But whether it is presented directly or indirectly, in words or by body language, the justifi cation thema essentially serves to refute the proposition that troubled persons are responsible for their state. 3 In one guise or another, they seek to present themselves as the victim. Their pain is a function of forces conspiring both within and outside of themselves over which they have no control. Once again, in the interest of advancing the bond you have with your clients, do not fail to recognize and acknowledge their sense of victimization and helplessness. In keeping with the justifi cation thema, you next “hear,” again more or less directly, an appeal:

Downloaded by [New York University] at 02:06 15 August 2016 Pain (anxiety, guilt, depression, etc.) is my enemy. It is unfair (mystifying, pointless, undeserved). I want you to relieve me of this pain that interferes so with my freedom. I want to be able to be myself and live my life without being hounded by this debilitating pain! Please help me ﬁ nd a way to live as I wish free of these emotional accompaniments.

Once more, before any other step and in the interest of encouraging the human connection between you and your client, acknowledge the substance

25 THE THERAPEUTIC PROCESS

of this appeal. Let your clients know that you hear their pain, their sense of victimization, and their hope that you may deliver them from pain without cost to their way of life. Acknowledging and giving full credence to clients’ pain, hearing their justifi cation themata, and hearing out their wish that you will remove their pain without cost to their way of life are critical fi rst steps in forming a bond with your clients. These various steps may be taken in the very fi rst hour, or they may take several additional hours. Soon after you have heard and acknowledged their messages, however, your clients will press for something more than being empathically heard and understood. They will want a commitment from you that you will comply with their wish (remove pain without behavioral cost). This is a condition to which you cannot accede and, consequently, the fi rst occasion for client disappointment in the therapy process. Unfortunately, many practitioners do accede directly to the client’s appeal. That is, they agree to help the troubled person on the very terms proposed by that person. They agree that the issue is pain, debilitating pain, and that the individual is victimized. They then search for ways to permit the person to live without emotional pain. Foremost among those who, in effect, adopted the justifi cation themata of troubled persons was Sigmund Freud.4 His theory, in essence, was a version of the justifi cation themata he heard advanced by his typical patients, the “neurotic” housewives of late 19th-century Vienna. Their emotional pain was a result of traumas they suffered as they grew up, traumas delivered mainly by their parents. They were inhibited by this pain from being free, from being themselves. Freud’s therapy was designed to undo this “repression” by exposing the irrelevancy of its source (early childhood and the irrational superego). I do not wish to dwell on a criticism of Freud here. He was wrong in taking the justifi cation themata of his patients at face value. His theory frees the individual of responsibility at the cost of assigning cause to the distant past. Integrity Therapy views the repetitious behaviors and feelings that so mystify and aggravate those who seek help as being maintained by economies very much in the here and now. The past may shed light on the form that current behaviors take, but the aggravating continuation of those actions rests in circumstances that characterize the individual’s life now. When help seekers express their pain, introduce their justifi cation, and then

Downloaded by [New York University] at 02:06 15 August 2016 appeal for relief, you are under great pressure to respond in the context of the sufferer’s frame of reference. Medically trained psychotherapists operate under a serious handicap at this juncture. Training, pharmacology, and medical lore have placed in their hands not only a history dedicated to pain alleviation, but a plethora of techniques for assuaging pain. A psychiatrist colleague on one occasion defended her prescription of Valium by noting, “You must understand that my training has instilled the view that you must ﬁ rst bring relief, offer comfort if you can; and you most assuredly promote relief if you are uncertain what else to do!”

26 INTRODUCTION: ESTABLISHING CONTACT

But the medically trained are not alone in responding to the appeal to alleviate pain and emotional discomfort. A therapist trainee, in spite of being wary of her “nurturing” tendencies, hurried to reassure a client that the latter was not as despicable as she thought. We stopped the audio recording and reviewed what was transpiring. The student therapist was not comfortable with her actions but opined that probably no harm was done since her input had at least been “supportive.” “It made you feel better,” I suggested. “Yes, indeed,” she replied. “But what if the painful self-regard that this person has is a valid indicator of choices in her life she has good reason to regret?” “I think that it is. She is behaving so badly, really childishly.” She paused in thought. “And I, in effect, was telling her not to feel badly about that. I am made comfortable by reassuring her, but what have I done to help her? What will she do with my reassurance?” “One of two things,” I thought aloud. “She might fi nd your reassurance something she will learn to depend on to lift her spirits, in which case, you may have a client for life!5 Or the assurance you offer will be short lived, and she will be back at your door trying to fi nd out why she continues to feel that she is despicable.” This therapist-in-training had referred to “support” that she had provided the client. For years, so-called supportive therapy has been advocated as an alternative to more ambitious therapeutic programs. When persons appear to lack suffi cient time, resolve, or ability to effect change in themselves and their actions, supportive therapy was seen as an acceptable, perhaps an only recourse. Integrity Therapy does not rely on this distinction nor does it advocate supportive therapy. Integrity Therapy takes issue with the notion that what it advocates is not supportive of the individual, especially when that person’s more sensitive issues are being addressed. In the instance cited above, the client was not supported by the reassurance that she was not as despicable as she expressed herself to be. If she were to have felt “better” (less self-critical) by the reassurance and, because of that, turned away from examining herself and her life, would she be the better for it? People in quandaries need help in sorting out the issues and in designing

Downloaded by [New York University] at 02:06 15 August 2016 actions that engage the real dimensions of their confusion and distress. That kind of help is truly supportive. Help that speaks only to their feelings and ignores their life realities offers ﬂ eeting support at best. Moreover, it will in time only promote disillusionment in the prospect that help may at last be found and quandaries resolved. Mowrer often observed that pain in all its various guises is not the enemy. He noted that it is analogous to a fever when we are ill. The fever is an indication that something is wrong and the body is endeavoring through increased temperature to do battle with an invader. One can reduce a fever by placing

27 THE THERAPEUTIC PROCESS

a person in cold water. Ordinarily that would be a disaster. Emotional pain is also an indicator that something is amiss. It speaks to contradictions that deserve to be battled through and resolved. Reassurances, tranquilizers, the reinforcement (or adoption) of justiﬁ cation myths all reduce the pain. Usually they also are disasters.

Conclusion Integrity Therapy brings you a paradoxical injunction. It is, fi rst, to attend most earnestly to troubled persons’ expressions of hurt and distress. Their emotions are real. They should never be slighted. Offering explanation and interpretation too early will often come across to troubled persons as a minimization of their hurt. They may conclude that you do not truly give credence to their pain because you are so quick to “explain it away.” Better to swallow insight than to send such a message. Better yet is to make sure that you communicate quite a different message: “I hear how troubled and distressed you are. This is not just in your mind. It is real. It is signifi cant. You are here in an attempt to confront a matter of great importance and consequence in your life.” It is by this early recognition and acknowledgment of their pain that you form your initial bond with your clients. The second injunction, however, may appear to contradict the fi rst. It is that you guard against accepting the troubled person’s justifi cation thema as the framework within which you offer help. Keep in the back of your mind that in spite of how real their pain, troubled persons seek, in the end, an impossible dream. They want to hold onto who they are and how they live while springing free of the pain that is attendant to who they are and how they live. It is as if they asked, “Make my problematic lifestyle work for me. Permit me to live as I am without suffering the emotional costs now exacted of me.” The therapist has an initial challenge, then. It is to convey, fi rst, an authentic regard for the pain the person experiences and, subsequent to this, to convey the reality that no justifi cation will permit one to escape the consequences of how one conducts one’s life. In fact, it is troubled persons who are guilty of minimizing their pain. While they are quick to detect in the therapist’s words less than full acknowl-

Downloaded by [New York University] at 02:06 15 August 2016 edgment of the depth and reality of their suffering, for their own part they immediately mount an often angry dismissal of their pain. It has no redeeming value, no message, no rhyme or reason. It is irrelevant. They have nothing to learn or gain from their pain. These assertions are a part of the justiﬁ cation thema, which you, as therapist, will oppose, not conten- tiously, but resolutely and often in the face of your client’s disappointment, opposition, and anger.

28 INTRODUCTION: ESTABLISHING CONTACT

Integrity therapists are often moved to observe,

It is you who do not respect your pain. It is not trivial, inconsequential. I believe we have much to learn from it. Your pain is not your enemy. It is not a foreign spirit worthy only of exorcism. Instead, it is a resource, an expression of who you are, and an index of a contradiction that deserves your thoughtful attention. You may, through tranquilizers, alcohol, or justiﬁ cation, minimize your pain, but you will be the lesser for it. Energized by it and appreciative of it, you can grow. You can be free of pain, yes, but not by eradicating it. Instead, you must permit your pain to inform you and transform you into a person deserving a different emotional outcome.

Notes 1. My treatment of the stages is from the perspective of the therapist. In the Appen- dix, I present Using Counseling and Psychotherapy, which briefl y references these stages but from the client’s perspective and, in pamphlet or audio recording form, was given to my clients. The objective is to reinforce basic conditions of therapy and to provide a framework to help the client “tell time.” I divide the three stages presented above each again into three. Thus the introduction stage embraces (1) exploration, (2) understanding/acceptance, and (3) bonding. The engagement stage comprises (4) revealing, (5) confrontation, and (6) resistance. The action stage breaks into (7) reconciliation and initiative, (8) effort and hope, and (9) consolidation. In the pamphlet, I add termination and commencement as a closing punctuation. This provides the client a rough 10-houred clock to aid in estimating passage through the therapy process. 2. A favorite reference made by Mowrer from his studies with Sullivan. 3. You may ask, “But what about persons who richly catalog their abject failures, wal- low in self-blame, and cite ad nauseam the reasons that both they and others should loathe them?” Indeed, on their face, such actions appear to embrace responsibility rather than avoid it, and no doubt were the very behaviors Sigmund Freud had in mind in advancing his theory of the overdeveloped superego (conscience) bent on stifl ing even the most innocent desires! If this question did indeed cross your mind, let me ask you another question. How are you inclined to respond to a person beating him or herself up? Probably your fi rst impulse is to say, “You’re not all that bad! You’re making a case against yourself. Give yourself a break!” As a matter of fact, this is pretty much what Freud communicated to his self-fl agellating neurotic patients. Catholic priests also report instances where apparently devout persons regularly confess a host of mundane sins and have concluded that these persons suffer from overweening “scrupulosity” (e.g., see “Scrupulosity and How to Overcome Downloaded by [New York University] at 02:06 15 August 2016 It” by Rev. Thomas M. Santa, CSSR, at www.catholicculture.org/culture/library/ view.cfm?recnum=3739). It would appear that these individuals advance a very subtle justifi cation thema in which they avoid directly refuting that they are responsible for their state by inducing others to mount that refutation for them. “Relax! You are far too scrupulous!” 4. Several small, readable volumes by Freud amply reveal these features: New Introductory Lectures on Psychoanalysis (1965); The Problem of Anxiety (1936); and Civilization and Its Discontents (1957).

29 THE THERAPEUTIC PROCESS

5. Mowrer used to observe that the psychoanalyst Frieda Fromm-Reichmann had concluded, rather pessimistically, that psychoanalysis seemed too often to have one of two outcomes: interminable therapy or emergent and relatively uncomplicated psychopathy. No doubt a third outcome, those who in disillusionment abandon their therapy, was discounted as not a real product of the therapy. In the context of our thinking here, this makes perfectly good sense. If you adopt the person’s justiﬁ cation thema (and the person does not abandon you because of it), then you might expect one of two outcomes. The person may come to depend on you to reinforce his or her defense against the contradictions which life offers (interminable therapy), or the person may learn at last to be indifferent to or callous about those contradictions (psychopathy). Downloaded by [New York University] at 02:06 15 August 2016

30 3 THE INTRODUCTION STAGE Establishing Conditions

Listening is a magnetic and strange thing, a creative force. The friends who listen to us are the ones we move toward. When we are listened to, it creates us, makes us unfold and expand. —Dr. Karl Augustus Menninger

The First Hour

Establishing Conditions: What to Avoid You have just introduced yourself to your ﬁ rst client. You invite him or her to be seated. Now what? You have read extensively. You have a head full of ready associations, concepts, and images. But do not be dismayed if you are, nonetheless, uncertain about what to do next. You need information. Of course! Then, the next step is to do an assessment, conduct an interrogatory interview and/or administer a test. Let us say you proceed in this fashion and several sessions later you once again meet with your client. Now what? Perhaps you now indicate to the client, “Alright. We’ve conducted an assessment procedure. Now, it’s time to get started with psychotherapy. Why don’t you tell me about your fear of open places?” “Wait just a minute,” your client says with, perhaps, some heat. “You have spent several hours of my time (and money) poking around in all the nooks

Downloaded by [New York University] at 02:06 15 August 2016 and crannies of my psyche. Why don’t you tell me about my fear of open places! Surely you know more than I do about it by now!” You are feeling rather uncomfortable with this shift in direction. You try to think it through:

If I share some of what I have found or suspect, will that be helpful? But my client seems to be upset, angry. Maybe, I should take note of that. Perhaps, the anger is related to the hostility indicated in my tests. Of course, this could be an expression of resistance. Perhaps

31 THE THERAPEUTIC PROCESS

I should address the resistance. Then, again, I’d rather not do any of these things. Maybe the thing to do is to begin instruction in an appropriate microtechnique directed at extinguishing the fear . . . or managing the hostility.1

Your mind awhirl with these possibilities, one possibility does not occur to you. It is, simply, that the client is right in his or her vexation. You have brought out, from the client’s point of view, an imposing array of probing techniques. The client is more than willing to confess being in the dark. Your client comes to you, a professional. You ask questions, probe history, give tests; surely, you have gleaned matters that your client either does not know or does not comprehend. So, enlighten your client! For heaven sakes, do something about the problem your client has presented! Your assumption no doubt was that your client knew something about the difference between the pre-helping phase, the assessment or diagnosis, and the helping or treatment phase. You expected that the client would patiently endure this pre-therapy phase as if he or she were insensitive to the ongoing, human interactions already underway. Thus, the client would respond to the post-assessment, treatment phase as if that interaction was newly begun. Your thinking has been conditioned by the ubiquitous medical model embedded in so much of the clinical psychology curriculum you have encountered (Assessment I: Psychology 525, Introduction to Psychotherapy: Psychology 540, etc.). Your client has not shared your conditioning or, consequently, your expectations. From the client’s vantage, you are engaged in a human interaction, sending and receiving messages, from the ﬁ rst contact. Therapy, as an interactive human enterprise, which it is, begins immediately. Of course, an integral part of that therapy will be your assessment of clients, their person, and their circumstances, which is being constantly formed, revised, and reﬁ ned. But your clients will never treat your assessments as inert or impersonal. Moreover, clients are at the same time also engaged in assessment of you, your actions, and the messages you send verbally, nonverbally, and contextually. This ongoing interactive exchange of messages will give you far more intimate and relevant clinical material than you would have obtained from a bat-

Downloaded by [New York University] at 02:06 15 August 2016 tery of tests. But the main reason for eschewing “pre-therapy ” testing is that it simply sends the wrong messages to your client at the start of a potentially very signiﬁ cant message-exchanging process. Let us examine what these troublesome messages are:

1 There is information that I, the therapist, need which you are unable or unwilling to impart. 2 At the end of my testing, I will know pertinent and critical matters about you that you may not or cannot know about yourself.

32 INTRODUCTION: ESTABLISHING CONDITIONS

3 Because of this knowledge advantage, the decision about what to do rests with me. 4 The relationship that exists between us is one where I am dominant and you are submissive as in the classic doctor–patient interaction (i.e., the medical model).

All four of these messages subvert your intent as they will work to establish a framework that will impede therapeutic progress. You should recognize that the ﬁ rst contact with your client is probably the most important. Fundamental propositions are being exchanged regarding just what each party will do and will expect of the other. Special attention should be paid to what you, as therapist, convey, what agreements, explicit and implicit, you enter into, and what conditions you establish under which therapy will proceed.

Establishing Conditions: What to Embrace You need not sit down and lecture your client about the “conditions of therapy” under which you both will operate. Allow the conditions to emerge in the course of the ongoing exchange. Actually, many clients would fi nd the four messages listed above much to their liking. During the fi rst hour or so, those clients will endeavor to enlist you into taking on the role of the powerful seer who knows all and will “take over” the running of their lives. But you would convey far too much concern for process and form were you to begin by focusing on this possibility, among others, and laying out your conditions. 2 But here, once again, is your client whom you have just met and are about to seat in your offi ce. Now what? First, let me ask if you have given thought to the seating arrangements? Messages are contained there as well! I suggest that your client’s seat be fairly large and comfortable. Angle the client’s seat so that, instead of being directly opposite you (facing you head-on), it is angled about 40° to your left or right (depending on the composition of the room). If you have a picture or art object on the wall before the client, this arrangement permits both eye-to-eye engagements with the therapist and disengagements as well. The messages are: “You may attend to how I am listening and responding to you, you may disen-

Downloaded by [New York University] at 02:06 15 August 2016 gage and focus on your own thoughts, or you may shift from one to the other. Take your time. Your seat is designed to accommodate your contact preference.”3 The messages in the seating arrangements are subtle. What else will you convey? I suggest that you seat your client, seat yourself, then retrieve a pad of paper on a clipboard and write your client’s name and date in preparation for taking notes. There are additional messages here, although my reasons for advocating note-taking embrace other factors, which I will address later. But the messages are: “I am prepared to give you my whole attention, to make

33 THE THERAPEUTIC PROCESS

sure I will not forget what you relate to me, and to recognize we are not engaged in mere social chit-chat.” Next, convey verbally something like the following:

T : I don’t know why you are here or what is on your mind. Why don’t you start with that, and we can work from there.

This is a point of peak uneasy self-consciousness for most clients and one of acute social discomfort for many novice therapists. Sensing and being anxious about the dis-ease of the client, novice therapists are often impelled by “common courtesy” to relieve client distress in some manner. The ordinary course is to take the verbal ball back from the client in some way, perhaps by expanding on what it is that the therapist wants to hear, or by asking questions. The most difﬁ cult challenge for beginning therapists is to endure their own anxiety in the interest of advancing the therapy. For some, remaining quiet is like climbing a high mountain. There is no way to avoid the discomfort clients feel about being there, asking for help, and being faced with the need to communicate about what troubles them. Let them resolve that as they will. Of course, clients may seek to directly avoid that responsibility. Perhaps, they attempt to engage the therapist in small talk. Or with a look expressing an appeal for help, they say, “I don’t know what to say.” Maybe they suggest that they are not there entirely voluntarily. Someone else has pressured them. Consequently, they are not actually responsible, implying, “They forced me to come. You will have to force me to participate.” Then, there is always the client who says, “Why don’t you ask me some questions?” These direct efforts to avoid responsibility for confronting their thoughts and problems are akin to the primal ambivalence that all clients feel whether or not they display these particular behaviors. Every client both wants and does not want to acknowledge that something is wrong. Their wish to inform is checked by a wish to remain unknown. They are apprehensive that they will not be understood, yet they also fear that the therapist will understand them all too well. Those who proceed unhesitatingly to relate what troubles them and what is on their minds will reveal their ambivalence in other, sometimes more subtle ways. We will return to this matter again. Downloaded by [New York University] at 02:06 15 August 2016 The Typical Opening Usually, your clients will respond to your invitation to speak their mind by doing just that. We are going to treat at length in another chapter how to listen to and process clients’ communications both verbal and nonverbal. For now, let us assume you are listening and making notes. You do not interrupt or comment, save, perhaps, a nod of comprehension from time to time. If the client falls silent, you are slow to assume he or she is ﬁ nished and are content

34 INTRODUCTION: ESTABLISHING CONDITIONS

to wait as much as a minute before offering comment. A minute, incidentally, is a long time in a one-on-one exchange. Most novice therapists ﬁ nd that 10 seconds seems interminable. Ordinarily, clients will “run their story” for about 15 minutes, with occasional pauses of about 5 to 10 seconds. It is not that they could not relate more after the ﬁ rst run period. It is, rather, that they feel an opening statement has been made, and they are interested in what you have to say. This is contained in nonverbal messages, in the way they have packaged their verbal presentation, and/or in a direct notice.

C : Now, it’s your turn. I’m wondering what you think about all this.

The ball is back in your court. Now, what do you do? You have been listening in a special way (which we will examine in greater depth later). You have been making notes. If you are making optimum use of notes, you will have registered some of your budding feelings, associations, and intuitions related to what your client has communicated. Here is your fi rst opportunity to have a signifi cant input. That input should be one recognizing the client’s expressions of pain, confusion, and mystifi cation. It may also acknowledge the client’s often groping efforts to explain and justify him- or herself. Inevitably, as you communicate your appreciation of these matters, you will to some degree advance the conditions under which you and your client will proceed. What form might this fi rst signifi cant therapist input take?

T: You are in the dark about yourself in some critical respects. That’s understandable. It explains why you are here. But I start in the dark as well. We are in the dark together. The hope is that by pooling our resources, we can together shed some light on these matters. But that means that I am going to be quite tentative about what I have to say at ﬁ rst. Some things I say may be little more than guesses. However, let me start with what seems most clear . . .

You can then speak to your perception of the client’s feelings of mystiﬁ cation, distress, alienation, or whatever you have discerned regarding the client’s presenting state of emotions and concerns. It is useful at the end of this appraisal,

Downloaded by [New York University] at 02:06 15 August 2016 which communicates to your clients that you have, indeed, attended to them and empathically followed their account, that you advance your fi rst tentative effort to “go beyond” simply recapitulating their presenting state. This fi rst “interpretative” comment should be fairly simple and rather closely tied to the clinical material your client has made available. For example, let us assume your client has spoken about his problems at work, worrying that work associates are critical of him. He has also related a series of misadventures in establishing a heterosexual relationship and has expressed apprehension that a woman would fi nd him attractive or worth her time. He is a physically

35 THE THERAPEUTIC PROCESS

attractive young man, but his manner is somewhat haunted, difﬁ dent, and anxious. You might conclude your ﬁ rst exchange with this client as follows:

T : You seem to work hard. You try to accommodate people. Certainly, you are far from unattractive. You might expect to ﬁ nd favor with eligible young women. Yet, you seem haunted. It sounds as if you have very low self-esteem. A guess is that, for some reason, you are down on yourself and, thus, you seem to expect the worst from others.

It is possible that your client has been very forthcoming. He may have advanced enough material for you to have some ideas why he is down on himself. But, it does not hurt to stop short of an extended interpretive input at this stage. It permits your client to grapple with what he might have said about feeling low about himself, but has not. It permits him to correct your fi rst constructions before they become prematurely elaborated. Finally, it usually stimulates additional material that fi lls out the clinical picture and helps you select what further inferences you might usefully convey. In any case, with your fi rst interpretative input, you stop and return the initiative to the client. Let us review the essentials, now, of what in this manner you have accomplished in establishing the conditions under which the therapy shall proceed. First, you have given notice to your client that he has initiatives you respect and responsibilities that you rely on. You do not intend to prejudge what is important for your client to relate. The importance of such matters is decided by the client. Second, you have a role to play, but advancing the therapy does not rest on you alone. You are a collaborator in the client’s attempt to confront the issues in his life and, subsequently, to work change. Finally, you have communicated that the fi nal judgment about the accuracy of your collaborative efforts to understand the client will be his or hers. You offer a possible construction or way of understanding the client’s person and circumstances, but it is up to the client to accept or reject that construction. Now, these messages may not come across as clearly to the client as I have related them above. However, you will have opportunities throughout the course of therapy to reprise these messages and reaffi rm the conditions of therapy.

Downloaded by [New York University] at 02:06 15 August 2016 Less Typical Cases: The “Helpless Person” Infrequently, your client does not proceed in the typical manner but, instead, enacts some of the responsibility-evading behaviors identiﬁ ed previously:

C: I don’t know what to say. I don’t know what you want. Why don’t you ask me some questions?

So saying, the client passes you the ball and waits. What will you say or do?

36 INTRODUCTION: ESTABLISHING CONDITIONS

This is a rather straightforward request, you might think. In the interest of breaking the ice and getting things going, why not simply comply? Why make an issue at the fi rst crack of the bat? Is it so simple? You have invited clients to do something clearly both within their power to do and surely within reason, i.e., speak their minds. Your request is certainly plain enough. So, what is the issue? What does it mean that a client is contesting the conditions of therapy being proposed by your opening comments? It may strike you as a paradox that the client, on the one hand, is saying, “I’m helpless here. I don’t know what you want. I need guidance. Please direct me,” and, on the other hand, is assertively seeking to strike a bargain with you about how you will conduct the therapy that the client has asked for! Are we dealing with uncertainty, hesitancy, dependency, and helplessness, or is this individual seeking to dictate the conditions under which he will accept help? Ninety-nine times in a hundred, I can assure you, you have no shrinking violet on your hands. This client has correctly grasped the messages in your manner of opening the hour and has a premonition of what is in store. The client is challenging you in this regard before committing anything to the therapy process. The message is, “Am I going to have to reveal myself to you? Must I be responsible for identifying what troubles me? Will I be obliged to confront my life and, through my own energies, work to change my life? I would rather that you take over, liquidate my negative emotions, and let me know when you are fi nished.”4 If this is the message, you can see there is no way to sidestep this challenge. However, it is advisable to make sure that confrontation in the fi rst minutes is, indeed, unavoidable. To accomplish this, the therapist might say (with kudos to Carl Rogers):

T: You feel unable to relate what brings you here and what you have on your mind.

This you deliver as a statement (“reﬂ ection”) rather than a question. It is amazing how much irony can be packed into a Rogerian reﬂ ection. Feeling a bit foolish with the matter placed in this light, some clients break off their challenge, at least for the moment, and proceed along the more typical route described in the previous section. Others, however, may say: Downloaded by [New York University] at 02:06 15 August 2016 C: Well, no, it’s not that. It’s just that I thought that you, being the professional and having studied these matters would know best what is called for. You know what you want. Your directions would help me avoid wasting time on matters that aren’t important.

The novice therapist may ﬁ nd this kind of client tactic rather threatening in this early contest over the conditions of the therapy. Only partially veiled in the client’s comeback is a question about the therapist’s credentials. Between the

37 THE THERAPEUTIC PROCESS

lines, you might read, “You look pretty young. Are you competent? Are you really professional and knowledgeable?” If new therapists have any particular vulnerability, it is surely anxiety about their preparedness to conduct therapy. You do well fully to recognize your anxiety, and then proceed, not according to what one typically does to relieve anxieties (whether that be denying, attacking, running, ignoring, etc.), but according to what will serve your client and your professional responsibility toward your client. You will not serve your client if you fail to recognize, unwelcome though the realization may be, that you are at a critical point already in the therapy. You have been drawn into a struggle. Do not presume that the struggle is solely between you and your client. Your client has been engaged in this struggle with himself long before he entered your offi ce. Had the client already resolved the issue with himself in the direction of insisting that therapy eliminate distress without costing effort or change, then he would probably not be in your presence. He might be seeking a medical prescription, or he might be self-medicating with alcohol or drugs, but he would probably not be in the offi ce of a psychotherapist. That the client is in your offi ce and struggling with you in this manner implies that he still nourishes a false hope. It is an eleventh-hour hope, lacking in conviction, that he may yet wring a concession from life. You, the therapist, are endowed with the mantle of spokesperson for life’s realities. If you concede, then hope is rescued. Perhaps, in spite of all past setbacks, the client can, with your help, fi nd a way to save and maintain his way of life without suffering its costs. That is what this curtain-opening battle is all about. Now, back to your response to the client’s last utterances which, to recapitulate, were:

C: Well, no, it’s not that. It’s just that I thought that you, being the professional and having studied these matters would know best what is called for. You know what you want. Your directions would help me avoid wasting time on matters that aren’t important. (expectant waiting) T : It sounds like this is very important to you. It is early for me to feel con- ﬁ dent that I understand why. But I would speculate that you are hopeful that I might concede in some way how we will go about dealing with whatever you are troubled about. It appears that you would prefer a ther-

Downloaded by [New York University] at 02:06 15 August 2016 apy that would permit you to remain on the sidelines.

This form of response by the therapist serves to bring to the surface what underlies the client’s “helplessness.” It also tells the client that the therapist, in the interest of politeness or accommodation, is not about to misrepresent reality. Of course, you, the therapist, do represent reality. Your assignment by the client as a spokesperson for reality was accurate. At this point, your client may go in one of two directions. First, and more commonly, he may simply capitulate and move to the more typical course outlined in

38 INTRODUCTION: ESTABLISHING CONDITIONS

the previous section. However, the client might endeavor to advance the battle. The most likely tactic in the latter case is to plead lack of comprehension:

C : I don’t understand what you mean. I don’t understand what you would be conceding. It’s just that you’re the expert here. You’re the one who knows what’s relevant. I don’t see how using your expertise would be conceding anything.

It is tempting in this combative atmosphere to vanquish your client. Remember, however, your job is to serve your client, not to best him. You may strongly suspect that your client understands well what you are saying. But communication is never perfect. Give your client the beneﬁ t of the doubt and clarify your message.

T : I may not have been clear. And, of course, apart from how clear I may be, I may not be correct. You will be the judge of that. But, let me attempt to rephrase what I was trying to say. When I suggested that you begin by relating whatever brings you here and whatever is on your mind, I was setting the stage for what, in my judgment as your therapist, was the best way to proceed with our efforts here. It would seem that you don’t agree with that judgment. It sounds like you want us to proceed in a different manner. That manner appears to be one where I will take charge and relieve you of the responsibility for deciding what is important to you, what you will relate, and, perhaps, what you will choose to do about your problems.

Again the client may decide to abandon his unrealistic hope and proceed along the more typical route, or he may sustain the struggle. That struggle may continue to be expressed as client confusion, helplessness, and an ostensibly innocent search for direction. It may transform into silence, expressions of disappointment and anger, or agitation and mounting discomfort. If the struggle is carried by the client to a point that suggests that you are at an impasse, then it is appropriate for you to recognize that fact.

T: We appear to be locked in a struggle right at the start. If I make sense of it, it is a struggle about how we shall proceed. It sounds like, at this point,

Downloaded by [New York University] at 02:06 15 August 2016 this is a very serious issue for you. The matter is so serious that I am beginning to wonder whether what you are looking for will be available to you in psychotherapy. I can understand that discovering this is a disappointment to you. While I do not know of a therapist who would attempt to take over and solve your problems for you without involving you in the process, it may be that you would prefer to look for someone willing to try to do that.

With this kind of statement you have, as a last resort, made perfectly clear to the client that you will not concede. You have also made clear that, while the

39 THE THERAPEUTIC PROCESS

method for helping is your choice, whether the client asks for and receives that help is his or her choice. If the client appears to be suspended, unable to go on and unable to withdraw, you may observe:

T : You seem to be struggling with yourself. Will you proceed, get involved, disclose yourself, or will you continue to look for another way? It seems to me that the forces within you that are lined up on either side of this inner conﬂ ict are pretty balanced.

Most of the time, clients will work their way to abandoning their hope that you, as a spokesperson for reality, will concede to them their wish—the wish that they can ﬁ nd relief from their distress without changing their style of life. Resignedly, they will begin to embrace a process that examines what it is that they will have to do to achieve the personal wellbeing desired. But there are some whose hope will not die. They may battle with you not merely during the ﬁ rst hour, but additional hours as well. Believing you will never become a servant of their wish, sooner or later they will break off and seek elsewhere or in some other way to realize their hope. As long as the old, false hope lives, they will not be subject to adopting a new hope that both inspires and is fueled by a different way of living. It is in this sense that Alcoholics Anonymous is correct when it claims that individuals must “hit bottom” before they will truly change.

Other Atypical First Hours Very rarely, you will have clients who are truly helpless and simply arrested at the invitation to speak their mind. It is well not to confuse them with persons described in the previous section. The differences are clear, indeed, may be stark. These persons emanate fear and pain. Their faces are drawn, haunted. They speak with difﬁ culty, as if pulling words from a tangled net. They cast their eyes away and may seem to be lost in thought. Pauses, long pauses, and then silence are the mode. What does one say to this person at the end of a long pause?

T: You ﬁ nd it difﬁ cult to talk. It is as if you have things you might say which

Downloaded by [New York University] at 02:06 15 August 2016 you fear to say.

This form of therapist observation will often be productive, sometimes immediately so, sometimes only after additional moments of tension and apparent arrest. No matter, once these persons begin to open up, they gather momentum and often end in an avalanche of disclosure and revelation. These confessions nearly always revolve around behaviors that cause the individual much shame and pain. For example, I saw a college student once who was a prototype of the picture sketched above. Most of the hour was spent in halting, mostly irrelevant

40 INTRODUCTION: ESTABLISHING CONDITIONS

references to home life and school. The hour ended with the student expressing, if anything, more distress than when he had come in. However, he made another appointment. At the second appointment, he was essentially unable to speak about anything. Apparently, he had exhausted his fund of irrelevancies during the ﬁ rst hour. Finally, I said:

T : You seem to have become more and more distraught as our time together has gone on. It seems to me there are matters you are ﬁ nding very difﬁ cult and painful to relate. You seem to be unable to speak and equally unable not to. Here you are a second time deeply struggling with the matter.

The client began to twist and turn, almost writhing in his seat. He looked at me, then, looked away several times. Then, he blurted:

C: I’ve been going to my sister’s room at night and doing things to her.

The story unfolded in a rush. He had been living at home. A 12 year old sister, 7 years his junior, lived there too. He had gone to her room over the past year, fondling her genitals, kissing her, masturbating himself, but not making penetration. The sister had kept his secret, though he had grown increasingly fearful that she would tell. More agonizing to him was the realization that he was damaging her, making her an accessory to his crime. Not all revelations from these clients deal with such verboten topics as incest, but the signiﬁ cance of the hidden behavior is usually no less gripping to the individual involved. Do not attempt to persuade these persons to disclose to you by reassuring them of your conﬁ dence, how much better they will feel, or other such ploy. Do not probe or interrogate them. They will get to it. That is why they are there. Recognize their distress and that they are sitting on something and let them do their job. In that way, you will be doing your job. Finally, there are those folks who are there, in their own sensibilities, not by choice. Adolescents often introduce themselves in this manner. Their actions convey a weary resignation to pressure from parents or some other authority. The message: “Here I am. I don’t want to be here. I don’t need a shrink. This is embarrassing. I am a victim of coercion.” If you suggest that this is, indeed, their message, they readily agree, grateful that you have been so perceptive,

Downloaded by [New York University] at 02:06 15 August 2016 and fall silent. They are prepared to wait the hour out. They assume that, since you are being compensated for your time, you are similarly prepared. They are nonplussed when you say:

T: I will not agree merely to sit here with you counting minutes. You say you are not here by choice. But you are. You chose to come here rather than irritate your parents [school authority] or, perhaps, you came to cajole them into not penalizing you in some way. It’s still your choice. But I have a choice, too. As a matter of principle, I don’t see people, even if they do

41 THE THERAPEUTIC PROCESS

choose to be here, if they don’t also choose to work on something. If you have nothing to work on, then let’s call it a day.

This presents them with a choice, indeed! They might wish to jump on this chance for an early exit from an unwanted hour. However, that returns them to their parents, or other authority, made possibly even more irate by their actions. On the other hand, you have become another force to contend with. Can they ﬁ nesse you? Can they “work on something” and satisfy both you and their parents? They usually conclude that they cannot. (At least, I rarely had anyone try.) That leaves them with the questions: Do they have something to work on, and will they take the opportunity to do so? Sometimes they acknowledge there is something they would work on in their own selves and behavior. More often, they withdraw from the therapy and return to the battle with parents or other authority.5 Another group of forced clients are those under court order to seek psychotherapy. These clients do not ordinarily present the simple unwillingness to participate that you occasionally see in adolescents. They often come having prepared themselves to comply with the process, as they understand it. Thus, they readily speak about themselves and about their life circumstances. Nevertheless, you begin to sense a reserve. Something is being held back. What is it? It is the expression of the inner judgment that they are not there by choice. In spite of their resolve to comply with their understanding of what is called for, their efforts lack conviction. Key to recognizing this state is that they either do not identify anything about themselves that distresses them or do so in a perfunctory manner:

C: Oh, here is something you might be interested in. I have a heck of time going to the toilet in a public bathroom. I just feel very uncomfortable. I don’t know. Maybe it means something. T : You know, I may be wrong, but I get the impression as we go along that you are holding back. You said you were under court order to seek counseling. And certainly I feel that you are trying to comply here with that. But I also feel that, in your heart, you look upon this as something you have not chosen to do. You feel that you are here by force of the court, not of your own volition.

Downloaded by [New York University] at 02:06 15 August 2016 While clients usually acknowledge the accuracy of these observations, they may gently protest, saying that they know the therapy would be good for them.

C: Who can’t use a little improvement? Really, I welcome this opportunity!

The client is seeking to avoid antagonizing you.

T : Maybe everyone who comes to a therapist feels forced to do so by their family and associates, their life circumstances, or their emotional distress.

42 INTRODUCTION: ESTABLISHING CONDITIONS

It is not something one chooses pressure-free. But there may be a difference with you. These other people are pressured by their lives, but they, nonetheless, choose to go to a psychotherapist. They could choose some other course. I think you feel that you have not chosen. There was no other course. The court said, “Do it.” C : Yes, I do feel that. T : The truth, however, is that you do have a choice. You may choose to go to a therapist and suffer whatever that entails, or you could choose not to and suffer whatever penalty the court might impose on you. I can assure you that those who come to therapy under pressures different from yours feel no less the negative implications of their choices to come or not to come. I think what it means that you feel you have not chosen is that you actually have chosen to come, rather than accept the penalty of the court, but you have also chosen to withhold yourself from the process. The old story about leading a horse to water! I suspect you are attempting to both avoid actually entering into the therapy process and, also avoid being found in contempt of court.

By this time, these clients have a pretty good idea that you will not go along with their strategy of “having their cake and eating it too.” You may want to make the matter quite clear as the hour progresses, saying at some point:

T: I can certainly appreciate your affront if you feel the court has determined that you need counseling when you do not concur. After all, such matters must, in the end, be decided by the individual. But if you truly believe that there is nothing about yourself that needs ﬁ xing, then we have nothing to do here. I could not, in good professional conscience, meet with you just to help you satisfy the court order. Of course, I will be pleased to continue to meet with you if it is your judgment and choice to enter fully into the therapy process.

Sometimes these clients bail out and look for another therapist more congenial to their design. It is unfortunate that there are practitioners who will accommodate them. I cannot but think that they leave such therapy without proﬁ t and with a cynical view of what our profession is about. True, if we all presented to them the same face, some of them might ultimately refuse to participate, be

Downloaded by [New York University] at 02:06 15 August 2016 found in contempt, and receive time in jail. But most would abandon their strategy of non-involvement and experience a real proﬁ t from the therapy. Those that choose to endure the court’s penalty would at least earn the right to celebrate the fact that they have been true to their own judgment. That is no small matter.

Ending the First Hour The ﬁ rst hour establishes the conditions for continuing or not continuing with the therapy. In my private practice, I did not charge a fee for the ﬁ rst hour.

43 THE THERAPEUTIC PROCESS

I found that the fee acted like a precommitment to continuing the therapy. It is diffi cult to come to the end of the fi rst hour and conclude, “I don’t believe I can help you” or “I don’t believe we can work together” and then request payment. I found my own peace of mind was better served if I gave notice that the fi rst hour was fee-free and a time for mutually exploring whether therapy would be helpful or indicated. Clients found this practice to their liking also. They often approached the hour with apprehension and much uncertainty. They, too, were wary of committing themselves to a process about which there is much mystery. If you are a student therapist seeing your client in a training clinic, you will have little to say about fees (and there may not be any). However, you may still approach the end of the hour seeking to resolve the question of whether or not you and your client fi t, whether or not it is advisable to continue. How do you approach this matter?

T : We have a few minutes left before our hour is over. I think it is time to step back from considering your issues and look together at what happens next. We will need to consider the nitty gritty of fees and whether we will have to adjust fees. But even before that, we will want to ask whether to carry on together in working on what we have been looking at in this hour. Now, you have presented a real and difﬁ cult personal problem. Your judgment has been to seek help, and I concur that you need help. Can I help you? I think that is something we both need to answer. In thinking about that question, I usually ask two other questions: First, have we communicated? Have we been able to make contact, to get across to each other during this hour what we wanted to say? Second, has that communication contributed to a sense of movement? Obviously, I am not talking about solving in one hour what you have found so puzzling and obscure, but has there been a degree of movement in that direction? Have we been on track? Now, I have my sense about these questions. And you have yours. Do they match?

Rarely do our answers to these questions fail to match. When clients get across their concerns, ﬁ nd that the therapist picks up on their distress, mysti- ﬁ cation, and ambivalence, and are presented with some possibilities for rede-

Downloaded by [New York University] at 02:06 15 August 2016 fi ning and newly perceiving their lives, they fi nd in that experience a basic reassurance that something can, indeed, be done. If communication has been diffi cult, lacking in a sense that contact has been made, then the therapist does well to point that out, even when clients indicate, as they do from time to time, that all is well. Occasionally, if the client desires it, you may want to see this kind of individual for another “fi rst hour.” Perhaps the communication process will become unstuck, and you will make progress. However, do not avoid or ignore the need to refer. Some clients will not bond with us but will with another.

44 INTRODUCTION: ESTABLISHING CONDITIONS

Once client and therapist have concluded that additional meetings are in order, then you can turn to basic contractual issues that remain. What will be the fee? Many clinics and private practices employ a fi xed fee. Clients either pay or seek help elsewhere. Others, as was my practice, attempt to adjust fees to the ability to pay. Third-party payment resources sometimes make this an easier question to resolve. I found that clients, if anything, set their payment obligation as near to your “usual fee” as possible. They err more in the direction of overextending than underpayment. Frequently, for example, they will attempt to negotiate fewer sessions in order to make full payment. You may, however, believe that your client is under considerable pressure and needs more frequent contacts. I have occasionally been in the paradoxical position of proposing that clients see me more often at a lesser fee than less frequently at full fee. The frequency of therapy contact is another basic parameter. Very troubled, alarmed persons who seem to be expending much energy to cope may require visits more often than once per week, at least until their acute emotional distress has abated. Most persons profi t from weekly contacts. It appears to be a cadence that permits a close pursuit of the focal problems. Yet, it also permits “homework” and suffi cient time for clients to review and consolidate whatever was advanced in the previous hour. When clients have made major changes, yet still have matters to address, visits might be reduced to biweekly or even less frequent sessions. Another issue to address at the end of the fi rst hour is an understanding about missed meetings.

T : I will ask you to give me 24 hours notice if you are unable to make a meeting. The hour we agree upon will be dedicated to you. We do not over- schedule, as is often the case in medical practice, because we need to have not 10 or 20 minutes, but the whole 50 minute hour. While emergencies happen that would prove an exception to the rule, we reserve the right to bill for an hour missed without notice.

It is always useful to give clients a card with the date, day, and time of the next appointment. I recommend that clients be scheduled to come in 30 minutes early for

Downloaded by [New York University] at 02:06 15 August 2016 the second session in order to listen to Using Counseling and Psychotherapy (see the Appendix for this and other offerings). If the client’s issues call for it, one or more of the auxiliary audio recordings may be assigned at the client’s convenience. These audio recordings are valuable in helping to demystify therapy, give clients a rudimentary framework for understanding the process, and help them get a leg up on understanding their particular kind of problem. Clients have invariably advanced favorable comment about these materials and often bring up matters from their reading to discuss with the therapist.

45 THE THERAPEUTIC PROCESS

The Second Hour

Opening the Second Hour The second hour continues to be a time for advancing the conditions under which you and your clients will proceed. By the time the third hour arrives, clients, in most instances, will have accepted the conditions and will be proceeding into a collaborative engagement regarding their life issues. How do you open the second hour in a manner compatible with your efforts thus far?

T : [after seating your client and preparing your note pad] All right, it looks like we’re ready to go. You may want to return to matters you brought up last time we met. Perhaps you would like to enlarge on one or another of those concerns. It may be that you have had some additional experiences, had some new feelings since we met, or perhaps you have been doing some thinking. Whatever you have on your mind, we can start with that and proceed from there.

Typically, clients pick right up and begin relating their thoughts and feelings about issues touched on before. Frequently, they address the thoughts they have had during the interim period regarding the signifi cance of the fi rst hour. If new perspectives were examined in that fi rst hour, they will usually report on their judgment about and degree of acceptance of those perspectives. Often, intervening experiences will be brought in, particularly as these illustrate or elaborate the problems presented in the fi rst hour. They will disclose for about 15 to 20 minutes, with occasional pauses, before indicating (largely in nonverbal ways) that they have run their course and it is your turn. If you have been “listening through”6 what they have presented, you will have more to say extending, revising, or moving away from that relatively rudimentary understanding that you communicated in the fi rst hour. Your comments will usually take a few minutes to relate, rarely more than three or four minutes. Your clients will ordinarily respond in a period measurably less than their opening presentation. So it is that the cadence of the hour grows somewhat faster as the hour progresses. This kind of exchange profi le will continue throughout the course of the therapy. Downloaded by [New York University] at 02:06 15 August 2016

Reinforcing the Conditions The same atypical experiences may emerge that we examined earlier. Some clients continue over from the ﬁ rst hour their struggle with taking responsibility for themselves. They again refer to not knowing what to speak about or in other ways seek to bestow responsibility on you. Some who have conducted a rather typical ﬁ rst hour, producing a considerable amount of personal material,

46 INTRODUCTION: ESTABLISHING CONDITIONS

may, in the second hour, give notice that, having complied with your request to express themselves and inform you, they now expect you to take charge and effect a solution. Their essential message is, “Look, I came through in the ﬁ rst hour and gave you all I know about this issue. Having done so, I turn it over to you. You know the facts, now let’s see some action.” Again, the therapist acknowledges the messages being sent and then states or restates the conditions under which he or she will conduct the therapy. About the client continuing this struggle from the ﬁ rst hour, the therapist might say:

T : You return to this hope that I might take responsibility for deciding what is important to you and for conducting changes in your life while you look on. This is, clearly, a strong wish, a wish that seeks to express itself in spite of all. Maybe we have something to learn from this fact. Perhaps, this force is closely tied in with the very issues that distress you and have brought you here. We could ask, is your anxiety [depression, phobia, etc.] in some way related to a wish to deny responsibility for yourself ?

Regarding the client who introduces this wish in the second hour after having produced a typical ﬁ rst hour, the therapist might say:

T: It sounds like you feel you have complied with the request to inform me. You have done that throughout the ﬁ rst hour. Now, you are saying, having done so, you wish to turn the matter over to me. You are placing your life in my hands and saying, “Fix it. I wish you well, and I’ll watch with interest.” I can understand how that sounds like a very desirable program. But one’s life and one’s self are not exactly comparable to a heart, for example, which if ail- ing, one can ask the cardiologist to operate on and ﬁ x. You just can’t divorce yourself from you or your life while someone else works on it. Your decisions, your judgments, your actions are indivisible from you and your life.

Perhaps the most trying examples of those who communicate at length but then attempt to transfer responsibility to the therapist are clients who dwell on the physical aspects of their distress. Often they have been referred by an exasperated physician no longer willing to renew a prescription for a mood-altering drug. These individuals are usually rather sophisticated about

Downloaded by [New York University] at 02:06 15 August 2016 symptomatology. They tell of stress, hyperventilation, tachycardia, etc. They speak of their visits for emergency medical treatment, the negative status of heart and neurological tests, and their eventual reluctant conclusion that there must be a psychological contribution to their state. While nearly all of their attention is on their physical symptoms, very little reference is made to how they are conducting their lives. The message seems to be, “Medicine has given up on me. Meds are no help. Now I know that you are a psychologist. But, as I see it, your job is to ﬁ nd a way, which medicine did not ﬁ nd, to eradicate my symptoms. I will be

47 THE THERAPEUTIC PROCESS

as informative about my symptoms as I know how. Then it is up to you to eliminate these vexations!” Frequently, that message is delivered in words very much as rendered here. At other times, it underlies the words. How does one respond to such an insistent proposal?

T : It sounds like you have a rather specifi c program in mind for dealing with your diffi culties. Indeed, this program has been, it would appear, a guide for your actions for some time. That is, you have given medicines and the treatment of your symptoms a very considerable chance to help you. No doubt, you hoped that medicine could fi nd a way to cure you of your symptoms without signifi cantly encroaching upon your life and conduct. But it hasn’t worked. Now, you have come to me. But instead of coming with a new program in mind, it appears you are still seeking to affect the old. That is, you might have been thinking, “Maybe I need to approach my discomforts from a different angle. Maybe I need to look at my life circumstances, examine how I am conducting my life, and ask in what way my circumstances and conduct contribute to my distress. Perhaps I need a psychologist rather than a physician.” Instead, you are thinking, “I’ll just substitute this psychologist for my physician and ask of her what I asked of my physician. Namely, please do away with my symptoms, but let’s not bother with me, my life, and my behavior.”7

Persons with a long history of seeking medical intervention will strongly resist giving up their old program. You can expect a lively struggle, and rather often this kind of person will chose to break off and seek yet another physician to reenergize the old program. They also gravitate to mental health professionals who subscribe to “the symptom is the problem” perspective and who offer hypnosis, biofeedback, and other behavior modiﬁ cation techniques aimed at symptom eradication. When they have run the gamut of both medical and behavioral efforts to eradicate symptoms without relief, they sometimes lose hope in the old program. If now they appear at your door still symptomatic, they may be ready to examine a new perspective.

Other Considerations

More on Taking Notes Downloaded by [New York University] at 02:06 15 August 2016 Views vary on note-taking. Those opposed believe that note-taking interferes with the spontaneity of response by the therapist. It sets the therapist apart in what would otherwise be a natural give-and-take between two interacting human beings. These critics argue that if therapists open themselves to the client, then what is relevant and essential will be processed and will be available to the therapist at the appropriate time. Note-taking, therefore, represents a lack of conﬁ dence in one’s basic instincts and in one’s self as an instrument of therapeutic change.

48 INTRODUCTION: ESTABLISHING CONDITIONS

There may be truth in these views. There is room for honest differences. It also may be that some of us process information differently, so, for one person, note-taking may add, for another, it may subtract. You may want to experiment with what seems to fi t in your practice. For my part, I freely admit that I do not have confi dence that I would do as well not taking notes as I do taking them. I have found that note-taking frees me from concern about remembering. Per- haps, this concern is unfounded. Perhaps, if I were to have faith in my basic processing and retention capabilities, I would fi nd available what is necessary at the appropriate time. I do not have that faith, and consequently, I am left when without notes worrying about hanging onto things I believe important to remember. The result is that I have less energy to devote to the moment, the moving current. When I take notes, my scribbled shorthand assures me that I have logged something that I may want to retrieve. I can then dismiss the matter from absorbing further thought. I can return to a state of unfocused attention, where nothing in particular is on my mind, certainly not an effort to rehearse, for memory’s sake, something already past. This kind of attention is wide gauged impartial, and “ready” for the client’s messages in whatever guise they emerge. In this sense, note-taking places me in greater, not lesser, contact with my clients. My observation is that most novice therapists share my concern about remembering. Often, however, they come under my supervision already persuaded that it is best to proceed unencumbered by notes. As we proceed in review of their casework, what emerges rather routinely is their concern about the piecemeal nature of the hour with their clients. The most diffi cult task for them is to wait out the full presentation of their clients. They break in before clients have developed their thoughts and fully expressed themselves. “There is so much being communicated. I feel that if I don’t pick up and deal with what fi rst emerges as a pertinent item, then, I’ll lose it,” is an observation made, if in different words, by most new therapists. They do not trust that if they bide their time, associations germane to matters presented earlier will be available for recall at a more appropriate point later in the hour. I am able to comment to them on how my note-taking frees me from this concern and enables me to draw upon earlier impressions in the light of material produced later by clients. Usually, they discover the same benefi ts from note-taking. Those who oppose note-taking often process the information communicated by clients from a perspective different from that of Integrity Therapy.

Downloaded by [New York University] at 02:06 15 August 2016 Their focus appears to be on the immediate sensibilities of their clients. They encourage expression of these and assume that self-understanding and change will emerge as a function of this exercise. They believe the therapist acts as a catalyst for awareness and growth in the client. The therapist achieves this effect less by understanding the client than by the nature of his or her person as a force in the continuing interpersonal transaction. Consequently, the rhythm of the therapy is rapid, with client and therapist having almost equal time in give-and-take. These exchanges are of relatively short duration. With such a cadence and from such an orientation there is no place for note-taking.

49 THE THERAPEUTIC PROCESS

Integrity Therapy places far less emphasis on the personal force of the therapist. To be sure, the discussion in Chapter 7 should make clear that the interpersonal plays a signifi cant role. However, Integrity Therapy holds that change is, fi rst, something the individual does largely outside of the therapy and away from the therapist rather than within the therapy in interaction with the therapist. Second, change is more a function of what actions the individual takes than what he or she feels and expresses. Actions with therapeutic promise rest on two developments: (1) a persuasive “map” that guides what changes should prove valuable and (2) hope that this experiment in change will bring about desirable ends. The therapist helps the client construct the map, which locates clients in their life space and identifi es what routes are available and at what point, in that space, they hope to arrive. The therapist also cultivates the hope that, with the use of the map, actions by clients will see them to their hoped-for destination. The rhythm of the therapy is slow with relatively long communications from the client and less long but often still extensive communications from the therapist. Note- taking is obviously a valuable adjunct to this approach.

How to Take Notes It may be that those who object to taking notes have in mind a particular kind of note-taking. That kind consists of a careful recording in as much detail as possible all of what the client says. This form of note-taking is, indeed, objec- tionable. It places emphasis on only one dimension of communication (the denotative and verbal) while very much preoccupying the attention of the note-taker. Therapists turn themselves into little more than transcribers and condensers of the verbal message. It’s better not to take notes than to employ this kind of note-taking. The denotative meaning of a message lies essentially in its verbal structure. Of course, inﬂ ection, context, and gesture may be important in specifying particular denotative meaning for terms with multiple meanings. For example, take the declaration, “I wanted so much to say something to her.” The denotative meaning would be uncertain did we not know that the speaker wore an angry look, placed considerable emphasis on so, and was referring to a rival. Once reference and context are clariﬁ ed, the denotative message becomes, “I

Downloaded by [New York University] at 02:06 15 August 2016 wanted to speak to my rival in a critical and derogatory manner.” We ordinarily decode such messages quite confi dently. Connotative messages are of equal, if not more, signifi cance to the therapist. These messages lie “between the lines” of what is communicated. They are carried by body language, by what is left unsaid, by the choice of terms and idioms, by the match between gesture and terms, in short, by all the ground or fi eld factors against which the denotative message is the fi gure. How do we attend to the connotative, largely nonverbal dimension of communication? How do we recognize it?

50 INTRODUCTION: ESTABLISHING CONDITIONS

The way to encourage attention to the connotative is to refrain from too much attention to the denotative. This ﬂ ies in the face of how we are taught to take notes throughout all of our schooling. A lecturer may assail us with a voice tinged with sarcasm as he impatiently places a statistical formula on the blackboard. Connotatively, we might receive the message, “What dummies you all are. How superior I am. It is beneath me to be teaching statistics at this level.” These messages are immaterial. What matters on a test is the formula, not the lecturer’s metalanguage. In the therapy hour, however, things are reversed. Take the person who said, “I wanted so much to say something to her,” which denoted her wish to direct critical words to her rival. However, we have a wary, uncomfortable feeling. We have been aware of being scrutinized by this client during the hour. The client’s references to this rival have been fairly unemotional in the past compared to the heat evident now. Meanwhile, we have been confronting the client, no doubt being a rival to her peace of mind. Musing over this, we begin to feel that the denotative message is not the only one, perhaps not the important one. The connotative message we begin to hear is, “Take care! You are angering me. I can be cutting to those who rival and contest with me!” What kind of notes would serve well in this instance? A condensation of what was said (“Wants to speak to rival”), a recap of what was denoted (“Wants to berate rival”), or reference to what was connoted (“Anger at rival screen for warning me”)? I would urge the last. Sometimes, however, we do not receive the connotative message all that clearly. Instead, we are aware of our wariness, of the client’s scrutiny, and of the unusual bite in those words about the rival. What do we jot down, if anything, under this circumstance? I will sometimes write, “Wants to berate rival [feel wary, watching me].” Here, I have not quite received the connotative message, but I have some of the ingredients through which it is being conveyed. Those ingredients, the material in the bracket, are the critical items I am noting. The denotative message (“Wants to berate rival”) is a reference point when, later, I try to decode the essential message. At that time, of course, I have a few more ingredients to help bring the message to its manifest form. Notes, then, are recordings of the associations, feelings, impressions, and intuitions of the therapist rather than a recapitulation of what the client uttered. Usually, you are able, with the aid of your notes, to do a good job of

Downloaded by [New York University] at 02:06 15 August 2016 reconstructing the client’s utterings. However, the notes are of most value in aiding you to emerge with what the client means whether by way of or in spite of what he or she says.

The Use of Recordings Video or audio recording is essential to effective supervision. It is preferable to the supervisor’s physical presence with therapist and client, which frequently unnerves both and creates an interactive catalyst difﬁ cult to assess and

51 THE THERAPEUTIC PROCESS

impossible to remove. Even past the time of your supervision, there are excellent reasons to maintain the habit of recording the therapy hour. Occasion- ally, you may want to consult a professional associate regarding a diffi cult or puzzling hour. More frequently, you are interested in reviewing the hour as a check on some particular exchange. Finally, and most usefully, it is valuable for your clients to review the hour and visit again what are sometimes very challenging and instructive revelations. You can simply give them the recording for use on their own playback device at a time convenient to them. Clients fi nd this opportunity to go over their sessions a bonus value for the time and money spent on the therapy. Often clients are struggling to “hear” and comprehend what, to them, may be unexpected if not perplexing observations conveyed by the therapist. When you focus on their justifi cation themata, they may fi nd what you say so foreign that it is like hearing a new tongue. It is not unusual to have clients spend several hours listening and re-listening to a particularly signifi cant therapy hour. They are always grateful for the opportunity. While it is conceivable that they may evolve, as a result, a more studied defense, in reality they use the occasion to work through their defenses and problems in comprehension. Listening to themselves in interaction with the therapist enables them to take the role of a third person in rendering judgments about themselves and the exchange. The result is that they arrive at the next hour better prepared to advance the therapy. Obviously, one need not keep a library of tapes or disks for each hour and client. Storage would be one problem and security another. Recordings of the last hour or two are suffi cient to fulfi ll the needs that we have reviewed here. I can imagine nothing, however, that would serve the therapy better for so little cost and effort.8

Conclusion It is unfortunate that in many training clinics the ﬁ rst hour of client contact is treated somewhat casually. It is often assigned to a novice therapist under the assumption that it provides a relatively safe point for them to gain experience. Little more may be provided than an intake form as preparation for this assignment. In addition to demographic information, the form may suggest gathering information on the nature of the presenting problem, client appear-

Downloaded by [New York University] at 02:06 15 August 2016 ance, history of or background to the problem, previous treatment, diagnostic impressions, and recommendations for assessment or treatment. The form at no point advises students that clients will probably look upon them as professionals empowered therapeutically to engage their issues. On the contrary, the form, along with the casual assignment and lack of preparation, suggests that this ﬁ rst client contact has no immediate and critical therapeutic implications. How very wrong this approach is! It is understandable that training clinics would like to have some safe point to insert trainees, safe for both them and clients. The ﬁ rst hour or hours, given

52 INTRODUCTION: ESTABLISHING CONDITIONS

over to history taking and assessment, may seem to fi ll the bill. This is simply not advisable. The fi rst hour is pregnant with ground-setting portent. Clients do not treat this experience as an inert, preparatory stage prelimi- nary to inaugurating therapy. Rather, their attention is at a peak level. They come to this new situation having overcome apprehensions and reluctance. They are often anxiously attentive to nuances regarding what is in store, what they will go through. They are at the most impressionable point in their contact with you. They read much into what you say and do. You should be cog- nizant of that fact and of what messages are exchanged, agreements entered into, and expectancies established. Several conditions will be the subject of your communication with clients during the fi rst contact. Some of these will be directly addressed, others only indirectly, although you may have occasion to explicate them at various points later in the therapy. Let us review what these conditions are:

1 The role of clients is not passive; they have initiatives and responsibilities that are critical to the therapy. 2 Clients decide what is important to them. 3 The therapist is a collaborator with clients in confronting clients’ issues. 4 Final judgment about the therapist’s contributions and clients’ behavioral changes rest with the client. 5 The therapist does not have the power to subvert clients’ will. 6 Only clients can take responsibility for what they decide and what they do. 7 The therapist is not responsible for clients’ choices and actions, but is responsible to clients for his or her professional conduct. 8 The therapist decides the method and manner of his or her help and does not permit clients to dictate these to the therapist. 9 The therapist is responsible for representing to clients the nature of reality to the best of his or her ability and judgment.

A therapist risks confusion and failure if he or she moves to establish these conditions at one level of communication but disputes them at another level. This is what happens when assessment procedures are introduced. In the view of the assessor, therapy has yet to begin. From the perspective of clients,

Downloaded by [New York University] at 02:06 15 August 2016 expectations are being raised about their role and that of the therapist that are at variance with several of the above conditions. Note-taking and recordings are valuable adjuncts to understanding clients and formulating communications to clients that effectively share those understandings. As noted previously, however, while understanding is necessary, it is not sufﬁ cient. Without understanding, we have no map, no sense of where to go. With it, we have yet to see our clients traverse that space that separates them from their goals of behavioral change and personal growth.

53 THE THERAPEUTIC PROCESS

Notes 1. This sequence is not entirely hypothetical. I have witnessed a number of exchanges rather like this between novice therapists and new clients. Needless to say, the client is frustrated and the therapist is uncomfortable. Neither fi nds the other acting quite as anticipated. The client expected that the therapist would immediately begin to address his or her presenting concerns. The therapist expected that the client would begin to present his or her associations and thoughts after permitting the therapist to gather a stock of relevant clinical information. The therapist had hoped that, equipped with this information, the therapist could proceed more ably to understand and help the client understand whatever was at issue. 2. As referenced by note 1 in the preceding chapter, I have composed a number of brief preparations presented both in audio recording and pamphlet form to clients. One of these, Using Counseling and Psychotherapy, was given to all my clients. It sets forth, in rudimentary terms, what they could expect from psychotherapy and provides them in consequence a rough measure of progress in route. I have placed these presentations in the Appendix for your consideration. These were made available to my clients as relevant after the fi rst interview. I did not review them with clients, although they often made references to their content in subsequent therapy contacts. 3. I have reinforced the messages represented in seating arrangements sometimes verbally. For example, if a client remains nervous, uncertain what to say, I sometimes say, “Your uncertainty is not uncommon. We’re in no hurry. You’ll fi nd a way to phrase what’s on your mind.” Or, “Sometimes a person has to take the time to look around inside their own feelings and thoughts before they speak.” 4. Clients do not ordinarily express themselves in such a bald manner. However, some come quite close to these terms. Mowrer often observed that “clients frequently seek assurance that the therapist will help them make their neuroses work.” 5. When this happens, those parties usually make inquiries. Why, they ask in effect, did you not work the magic that we expected? Frequently, these parties are willing, after some discussion of the realities, to look at their own distress and what they are able to do about it. Often, this leads to a convening of the parents or other parties in which the balking adolescent is much more willing to partake. 6. Mowrer was fond of favorably referencing “listening with the third ear,” the title of Theodore Reik’s (1948) book. He observed that the third ear was located in the middle of the stomach. In Chapter 8 we examine Mowrer’s methods for keening that ear. 7. This example of proposed therapist intervention should not be understood as the fi rst input by the therapist. This is a challenging and confronting communication. It would come only after the therapist has communicated in a more tentative manner her understanding of the distress, pain, and unhappiness that the client is experiencing. We have here a basic rule: Never challenge until you know that your clients know that you understand and appreciate the reality and extent of their pain and distress. 8. The amazing advances in digital recording and storage over the recent past may all Downloaded by [New York University] at 02:06 15 August 2016 but eliminate concern about cost and inconvenience.

54 4 ENGAGEMENT The Clinical Data

The intuitive mind is a sacred gift and the rational mind is a faithful servant. We have created a society that honors the servant and has forgotten the gift. —Albert Einstein

From the client’s point of view, the engagement stage is one where persons often feel revealed, even naked, as they move to explore their issues. This can be very uncomfortable. Discomfort grows as the therapy moves past what they willingly reveal into uncovering what may seem alien to them. Can these uncomfortable, alien observations be true? Surely not, and they act one way or another to dissuade or discredit the therapist. From the therapist’s vantage, the engagement stage emerges when the therapist begins to advance insights based upon the clinical data at hand. Those insights address the payoff economy inhering in clients’ repetitive (addictive) behaviors and the justiﬁ cation themata protective of that economy. The therapist anticipates that sharing these insights will promote resistance in one guise or another. Engagement constantly pits the discomfort of the insights against the bonding and trust that were established in the introduction stage and the emerging hope that the insights nourish. If the insights are true, they provide clients with a behavioral map. The map gives them a view of where they are and a reconstruction of how they got there. However, its most critical value lies in projecting a route to follow in arriving at a different place accompanied by different and more desirable Downloaded by [New York University] at 02:06 15 August 2016 behavioral consequences. Insights may hurt, but they lay the bases for a hard won hope that something can be done. From what does the therapist harvest true and useful insights that, when shared with the client, are capable in time of inspiring an enduring and sustaining hope?

55 THE THERAPEUTIC PROCESS

The Clinical Data

Subjective Responses as Raw Clinical Data I cannot teach you what feelings to have, what images, songs, sayings, or other sundry snatches of subjective stuff to produce as you listen to and observe your client. Maybe the stuff that bubbles to the surface of my consciousness is richer and more clinically useful than your stuff. Maybe it is the reverse. Never mind. You will have what is yours to experience. It is yours. You can do essentially nothing directly to improve on it. Indeed, no one has any idea what improvement would mean! Of course, that subjective stuff does change with experience, age, study, and contemplation. We do not know in what way. It is just that we recognize, as time goes on, that events that fostered a certain set of impressions some years ago now give rise to a different set. What does it mean? Does it mean that our subjective responses now more accurately measure the real event? It might if we prove more accurate in our judgments, descriptions, and predictions. On the other hand, judgments, descriptions, and predictions may improve because of changes in the way we process our raw subjective stuff, not because of the quality of the stuff itself. I go into this, in part, to reassure you. The raw subjective impressions, the basic clinical data, emerge from the given resources of your person as you interact with your client. Do not worry about whether those impressions are good or bad, deep or superfi cial, accurate or inaccurate. Those concerns are truly a waste of time. Better to adopt the view that what you have is always suffi cient for the moment. The question is not, Why am I not more richly endowed? Or, Do I have enough clinical information? It is instead, What is my response? And, What can I make of it? Novice therapists regularly voice their sense that they do not know enough, that they lack information about their clients. What they reveal is a lack of confi dence in the adequacy of their subjective responses. They lack trust in their clinical data. When students have expressed these reservations, I have responded in two ways. First, I review with them the client interactions that they have had with an eye to identifying their subjective responses to the client. What have they felt? What associations have they experienced? Usually, I fi nd that my own subjective reactions are similar.1 Second, using this consensual Downloaded by [New York University] at 02:06 15 August 2016 clinical data, I take them through an exercise in evolving inferential possibilities. What do they make of their responses?

Learning to Rely on Your Clinical Data The question of what to make of your responses is where we have sometimes parted company. Students struggle, but do advance some hypotheses. They do not have a practiced set of conceptual paths and options from which to draw.

56 ENGAGEMENT: THE CLINICAL DATA

After we have pooled our constructions, however, student therapists are always pleasantly surprised at how much we can gather from a few minutes of interaction with a client. What is particularly valuable, as time goes on in the training, is fi nding opportunity to test predictions from earlier constructions against later developments in therapy. Confi dence grows both in the clinical data and in its inferential processing when, later, clients act in ways that confi rm the hypotheses. “But,” my students often noted, “surely you won’t know everything about the client, everything you need to know, during one or two interviews.” “Of course,” I responded, “you will not know everything about the client no matter after how many hours or how you proceed. But, you will know everything you need to know at any particular moment. Indeed, I would suggest to you that if you found some way to know more about your client than he or she is prepared or able to communicate to you, that knowledge would subvert rather than aid the progress of therapy. Why? Because therapy, in good measure, is a communications process. When you short circuit the process to gain information, you may feel more secure in your knowledge. However, you will have lost contact with the necessary groping, the trial and error that transforms the process into a learning experience for both you and your client.” “I don’t close my eyes and ears to information of that kind or any kind, really. I do take pains to review with my clients, carefully and in non-technical terms, any information I have about them, good or bad, valid or questionable. In this way, we start with everything in the open. The client then knows what I know or believe I know, and we begin on equal footing. We are prepared to address the client’s issues as partners and collaborators in gaining understanding and evolving solutions.”

Clinical Data and Empiricism Is it correct to claim that the clinical data are your subjective responses to the client? We speak of the sensory data as the empirical base of science. However, the paradigm that comes most readily to mind when we think of empirical data is the kymograph drum, that classic event-recorder of laboratory experimentation. Are the markings on the drum the sensory data? Not really. They are merely ways we have found for sampling, representing, and storing events. Audio and video recordings, polygraphs, and tests results are also ways of sampling, repre-

Downloaded by [New York University] at 02:06 15 August 2016 senting, and storing events. In spite of our usage to the contrary, none of these scratches, arrangements of ferric oxide, microscopic bumps and light-reﬂ ecting dye, or marks on a paper are the sensory data of applied or basic science. The paradox of objective, empirical science is that the raw data are not those stores that our conventions of event recording have made available. The raw data are the living, fallible, subjective responses of human beings either to the event directly, or to the event as represented through some sampling convention. Clinicians practicing the art of applying science to human behavioral disorders often apologize for their reliance on subjective impressions. And, of

57 THE THERAPEUTIC PROCESS

course, non-clinicians often fault them for this reliance. Both parties mistake the nature of empirical data. Integrity therapists do not oppose using testing in psychotherapy because we are against “objective” data and for “subjective” data. That distinction ignores the actuality that the data, in the end, are all subjective. If our concern were to sample and represent client behavior in order to compare it with behavior of others, then we would choose a test, or some other systematic event-gathering procedure. This is our concern, for example, when evaluating someone for a court, job placement, etc. It would be our concern, also, if we were attempting to determine the outcome of different therapy procedures. It is not our concern when engaged in psychotherapy. Then, we are concerned with avoiding the establishment of anti-therapeutic conditions and with embracing a process most conducive to behavior change. Integrity therapists, additionally, are unwilling to accept the necessary reduction in information that any event-recording convention imposes. Take the twitching of the frog leg as recorded on the kymograph drum. The frequency and intensity of those movements are transformed into numbers and heights of marks on the drum. However, you do not have any record of the quivering of the frog’s limb that is too slight to activate the tambour. You do not record what occurs in the frog’s other limbs, the nature of the frog’s breathing, or whether the frog speaks to you about being a hexed prince. For science and behavioral comparison, reducing behavior to a selected event is very valuable. For psychotherapy and interpersonal communication it is anathema. Imposing reductions on the sensory information we gather in science is our way of fi nessing the fact that all our data are subjective. Objectivity in science occurs when we observe events and represent those experiences in such a manner that some other observer could, by reproducing our procedures and retrac- ing our steps, confi rm or not the same subjective experiences that we report. The psychoanalytic school believes that therapy is not only a treatment process; it is also a method of science by which objective truth may be confi rmed. That is a confusing notion. We do not report our procedures with a client in therapy so another therapist can retrace our steps. And even if we were to attempt to do so, the second therapist could not retrace those steps with our client. Therapist–client interactive events are unique. Therapy is just not a method of science; it is, instead, an art that applies science. Therapy does not

Downloaded by [New York University] at 02:06 15 August 2016 conﬁ rm the objective truth of propositions, though it may richly germinate propositions worthy of submission to scientiﬁ c test.

First Steps in Processing the Clinical Data

The Perceptual Orientation of the Therapist What we ﬁ rst draw to your attention has less to do with processing your clinical data than it does with insuring that you obtain it. Doing so with maximum

58 ENGAGEMENT: THE CLINICAL DATA

effectiveness depends upon your adopting the appropriate perceptual orientation. If you have a good bit of training in scientifi c methodology, the therapeutic orientation may not come easily or naturally to you. Both science and psychotherapy start with the same data, the observer’s subjective responses. The scientifi c method, guided by the concern for replicability of experience, reduces and conventionalizes exploration of the sensory data. Psychotherapy, guided by the concern for detecting meaning, expands and liberates exploration of the sensory data. If, as is likely, you have been well schooled in scientifi c methodology, you may fi nd it diffi cult to adopt the contrary orientation that accompanies the art of psychotherapy. We do not imply that there is a contradiction between science and psychotherapy. They are different enterprises that richly complement each other. 2 Rather, there is a defi nite contrariness between the perceptual orientation of someone engaged in pursuing science and that of someone engaged in psychotherapy. Many have learned to be profi cient in switching orientations as they play the role of scientist at one moment and psychotherapist at another. Some have suggested that it is analogous to shifting from one language to another. But perhaps it is more analogous to shifting membership from one culture to another. It is not impossible, but it does require that you learn to “keep in character.” The rule for keeping in the character of the therapist is to exercise what we might call divergent attention. This perceptual orientation contrasts with convergent attention. The distinction between connotative and denotative meanings was already discussed in the previous chapter. Convergent attention fastens to denotative meanings in the client’s communications. That is, given the context, infl ection, and word selection, there is one basic meaning to the client’s message on which our attention converges. No doubt, while it may pose some diffi culties, we will have, if we do not already have, computers that can decipher denotative messages and carry on, according to a designed program, interactive verbal communications with us or with other computers! While we might program convergent attending into a computer, we will probably be unable, at least for now, to program divergent attending. The latter asks us to “go away” from the convergent message. We are to expand our range of attention and notice those noisy detractions, the background blur of feelings, images, and thoughts, which, on the face of it, only interfere

Downloaded by [New York University] at 02:06 15 August 2016 with the denotative message reception. How can we program a computer to feel “funny,” anxious, bored, frustrated, sexually piqued, put down, or any of a myriad other states that you learn quickly to recognize in the byways of your reactions to a client’s presentation? Your feelings are your main avenue of access to connotative meanings. Insight into the client’s make-up and detecting the meaning of client communications will rest largely upon the degree to which you harvest your subjective responses to all that transpires. The watchword is openness. Be open to what you feel. Be open to the fragmentary wisps of imagery and thought that eddy

59 THE THERAPEUTIC PROCESS

around the denotative messages that your client imparts. Be open to yourself. Give yourself time. Be patient. At worst, you are a marvel at connotative signal detection. Probably, you have learned to dismiss and ignore these signals as so much background noise. No more. Now, the goal is to maximize your consciousness of these signals. If in science the object is to carefully narrow your attention to one “wave length” of the sensory data, in psychotherapy the object is to extend your antennae to the furthest reach and widest sweep of the sensory range.

The First Message Detected: Acknowledging Pain As noted earlier, clients’ ﬁ rst message to you will be about their pain. How- ever, this is not always presented in neat, denotative terms. Clients often, and men in particular, attempt to present themselves “at a distance.” In their uncertainty about this new enterprise, they will relate their situation attempting to downplay the sense of their despair. On the face of it, they may sound mildly perplexed, intellectually piqued. However, if you are practicing divergent attending, you may “hear” the hollowness in this presentation. You may notice their guardedness. Perhaps you hear a “whistling past the graveyard” bravado in their delivery. If your feelings tell you that this person is glossing over his or her own feelings, do not allow the matter to pass. It is crucial that you let your client know that you hear his or her pain. Ordinarily, a simple observation will be enough to loosen the ﬂ ow of their expression of feeling:

T : What you are telling me must be very difﬁ cult for you. It sounds very painful.

At other times, you may need to say:

T: You seem to want to control your expression of feeling about all this. But I sense that you are, actually, quite troubled [anxious, alarmed, vexed, etc.].

When you have made clear that you perceive their hurt, they will come forth in acknowledgment and a more complete expression. It will be difﬁ cult to

Downloaded by [New York University] at 02:06 15 August 2016 advance in the therapy unless your clients are assured that you understand how they feel.

The First Message Detected: Primal Ambivalence If you give yourself over to divergent attention and connotative signal detection, you will ﬁ nd that all clients communicate a common theme. It is ambivalence. It is the most predictable message that you will detect. If you begin therapy unprepared for the ubiquity of your client’s ambivalence, you will

60 ENGAGEMENT: THE CLINICAL DATA

suffer recurrent confusion and mystiﬁ cation. Indeed, client ambivalence often announces itself in the guise of your mystiﬁ cation even when you are prepared for its expression. Ambivalence is expressed at different levels of client communications. Clients begin by indicating, frequently quite directly, their ambivalence about beginning therapy.

C : I’m not sure this is what I need. Maybe everybody deals with problems like mine without seeing a psychologist.

In the previous chapter, we examined how ambivalence is expressed often in an opening struggle over the conditions under which therapy will proceed. Clients in effect are asking, Must I acknowledge that something is wrong? Must I inform? Can’t I remain undisclosed? Must I take responsibility for ordering values, choosing what I want, and changing my life? The wellspring of their ambivalence is the clash between the wish, on the one hand, that life accommodate to them and the emergent realization, on the other hand, that they have not accommodated to life. In truth, life has not been accommodating to them. On the contrary, life has been punishing them in various ways, which accounts for the pain and disappointment that motivates their seeking help. They do not come easily and willingly to the realization that their pain is self-infl icted. They dispute the connection between their own non-integrative behavior and the cumulating negative outcomes they experience. They seek ways to justify their lifestyle and minimize its attendant guilt. Essentially, they seek to present themselves as victims of forces that should not be. In Chapter 2, we briefl y discussed the justifi cation themata that seek to place responsibility for one’s distress on someone or something other than one’s self. In Chapter 10 , we will develop this matter further by noting that Freud’s mechanisms of defense (rationalization, denial, projection, etc.) are strategies of self-deception that form the building blocks of the justifi cation themata. If defense mechanisms worked fl awlessly and individuals felt fully justifi ed in their style of life, then they would not be asking for help. Psychotherapy becomes a recourse when justifi cation fails. And justifi cation fails because reality keeps delivering outcomes that contradict the complacence and tranquility that 3

Downloaded by [New York University] at 02:06 15 August 2016 the justiﬁ cation thema is designed to promote. The fabric of self-approval is rent as nebulous guilt, nourished anew by consequences in which the costs will not be denied, rises above one’s level of personal tolerance. As with pain, it is well to communicate your understanding of clients’ explanation of their state. As noted in the previous chapter, you may not be able to avoid confrontation when the basic conditions of the therapy are at issue. However, it is wise to attempt to assure your clients that you understand how they construe their lives before offering views that depart from their constructions.

61 THE THERAPEUTIC PROCESS

T : You are pretty mystiﬁ ed by your unhappiness. Still, it sounds like you have a certain way of explaining it if I get you right. You believe a large part is assignable to the stress you feel as you work with your demanding boss. Yet, I hear you saying that this is your third job, and it’s been the same story on the other jobs. You’re wondering whether your explanation accounts for the whole story.

Again:

T: While you really feel you need help here, it does sound like you already have a certain way of explaining what is going on. If I follow, you suspect that it’s your tendency to want things to be just right, to conform to a rather high ideal, which promotes a lot of friction at home. And this friction has prompted your sleeping problems and hypervigilance. Your efforts to get your family to conform to your standards are often frustrated. At the same time, your efforts to relax your standards have also been unsuccessful.

Offering an abrupt interpretation contradicting clients’ views before they are assured that you have heard and understand those views is to invite resistance, if not therapeutic disaster! Resistance is something endemic to the process. There is no need to provoke it! Only after making clear your reception of their explanation do you venture views that may invite an entirely new perspective for clients. Do so tentatively, in the spirit of examining with them hypotheses which, if unworthy, may be discarded and, if worthy, may be a starting point for an experiment in change.

Resistance Mowrer concluded that all transference is negative because it fl ows out of resistance to the amorphous promptings of conscience subsequently transferred to the therapist. The inner confl ict is played out in a confl ict with the person clients have turned to for help. This is understandable since the therapist moves to throw light on justifi cation themata and in course uncover conscience’s promptings. Clients begin to see that the therapist is asking them to do what is, for them, the most diffi cult task of all. It is what they have struggled

Downloaded by [New York University] at 02:06 15 August 2016 against acknowledging to themselves. It is what contradicts the hope, which they have and cherish, that life may yet conform to their wish. The therapist gives voice to and becomes an ally of clients’ own emergent realization that they have not accommodated to life. The therapist’s message, in one guise or another, is:

T: I cannot help you escape from the realities of your life, the consequences that your lifestyle brings you. Your hope that a way may be discovered to accomplish this is an enemy to your growing. Let that hope die so you may

62 ENGAGEMENT: THE CLINICAL DATA

give birth to a new hope. Nurtured by this new hope, you can discover what your life asks of you and what you must do to bring about, ultimately, the desired ends which you seek now but that elude you.

The old hope does not, however, die easily. The client’s hope feeds on the comfort that resides so surely and immediately in his or her addictive habit(s). The client’s hope is expressed in the wish, “If only my comfort could be sev- ered from the invisible fetters that link it to the costs of the future.”

Conclusion Scientist and clinician start with the same data: the subjective, perceptual responses of the observer. If, however, scientist and clinician begin with the same data, they proceed by different methods and with different purposes. Scientists wish to carry out observations and then describe them so anyone can repeat the steps involved and enjoy a similar subjective experience. If no one can repeat the scientist’s steps, then these observations fail to become part of the body of science. Failure to repeat the steps is repugnant to the scientist because it is a departure from the scientifi c method. Failure to observe, while frustrating, may be dismissible as observer error. Of course, scientists hope that others will both be able to repeat their operations and report results very similar to those they already reported. By such steps, scientifi c knowledge advances. The methods of science are designed to minimize failure to confi rm. They do so by selecting and reducing the fi eld of observer experience. Elegance in science is achieved when the truth or falsity of a proposition rests on observing the presence or absence of the single, crucial event. Clinicians, by contrast, have a very different purpose and judge their success by different criteria. Clinicians do not subordinate all to verifi ability, as do scientists. Indeed, in the interest of replicability, scientists sacrifi ce information that clinicians view as vital. For clinicians, the goal of observation is the maximization of rather than the replication of information. So it is that each subordinates what the other holds sacred. Yet, clinical practice and science are not antagonistic. Clinicians are guided by scientifi c fi ndings. Scientists are inspired to test clinical hypotheses. It is,

Downloaded by [New York University] at 02:06 15 August 2016 however, true that one cannot operate at the same moment as both clinician and scientist. The perceptual orientations assigned to each role inevitably clash. It also follows that psychotherapy is not an alternative method for establishing scientifi c knowledge as has been held by psychoanalysts. Analogously, blend- ing scientifi c methods into the methods of therapy does not render therapy more objective or scientifi c as suggested by some in the behavioral school. Those who take up clinical work often come to the task already steeped in the science credo. That is all right. It does, however, get in the way frequently of their performance as clinicians. First, their scientifi c training makes them

63 THE THERAPEUTIC PROCESS

uncomfortable with the nether land of feelings and fantasy that endow therapists with their most valuable dimensions of response to the client. Second, and perhaps partially as a result, they often feel apologetic about engaging in the clinical arts. Clinical practice, they feel, is inferior. Compared to clinical treatment, scientifi c study of human behavior, regardless of the many uncertainties and complexities, is a paragon of exactitude and order. I hope our discussion of science and therapy has made clear how fruitless such comparisons are. It is wrong to fault the clinical arts because they have their own valuable credo and that credo is not that of science. It is as wrong to fault science because it says little about the individual and narrows attention to one or a few factors abstracted from the infi nitely varied, seamless world of subjective experience. Let me repeat, there is no antagonism between clinical art and science. One can be a scientist and a clinician, but not simultaneously. Failure to recognize the different perspectives of science and clinical art is bound to interfere with one’s undertaking the role of one or the other. Clinician psychotherapists, then, open themselves to the full range of subjective response to the client. Certain matters are characteristically communicated. The client’s basic ambivalence is expressed. “Help me, but don’t involve me or touch me. Help me, but help me on my terms.” Also expressed, in one manner or another, is a justifi cation of the individual’s actions, feelings, and thoughts. The individual’s presence in therapy, however, bears witness that justifi cation has failed.

Notes 1. I liked to employ small groups of therapists in training. It permitted them to discover that consensual responses to client productions are common. The clinical data are there! The question becomes what to make of it and do with it. 2. There has been considerable confusion in our fi eld about this distinction. The psychoanalysts, as I have noted, insist that psychotherapy is, also, a method of science. Enthralled by the rich meanings harvested from the therapeutic interaction, they have made the mistake of assuming that science, also ostensibly designed to harvest the rhyme and reason behind events (including human events), is, at base, no different in method. Meanwhile, we have had behaviorists steeped in the science tradition who have made the opposite, and equally erroneous, assumption. That is, they have decided that psychotherapy is or should be, at base, no different in method from science. Some have suggested that the ideal for effective therapy would be to remove the human, subjective element altogether. This might be accomplished, for example, by rendering the therapy process into a program served by a computer interacting with the client. Psychoanalysts misunderstand what is necessary to vali- Downloaded by [New York University] at 02:06 15 August 2016 date scientifi c propositions; behaviorists risk misunderstanding what is necessary to detect meanings in interpersonal communications. 3. The language employed here serves to recognize that persons whose behavior is largely integrative in nature often, nonetheless, seek psychotherapy. Tolerance for guilt varies from one person to another. Some persons accept more, others less. In Chapter 10, we will examine further the thesis that one can be both normal and pathological. This thesis rests on the notion that persons may generate a net positive payoff for their lifestyle even though practicing some limited and chronic non- integrative behaviors. The fact that these persons seek help means that they fi nd intolerable the relative loss of payoff that their non-integrative behavior costs them.

64 5 ENGAGEMENT Some Useful Rules

Never ignore a gut feeling, but never believe that it’s enough. —Robert Heller, ﬁ nancier

Transference and Countertransference Revised

Transference and Ambivalence At the end of the last chapter, we referred to clients’ hope that they might cling to their current habits, their way of life, and achieve, nonetheless, freedom from pain. By the time they come to see you, they have cause to question their hope. Emerging within them is a ﬂ ickering realization that their hope is false, a dawning, however, which they struggle ambivalently to ignore. Mowrer viewed this inner struggle as one transferred to the therapist, as the latter becomes an ally to the ambivalent realization that their hope is doomed. Where once they worked to minimize their own awareness, discredit guilt, and derogate their own judgment, now they work to minimize, discredit, and derogate the therapist. This effort is pursued with both reckless abandon and anxious contrition. At one moment, clients will appear to desire nothing more than your defeat and the right to dismiss you and all you have communicated to them. In the next moment, they will reveal how important it is that you remain steadfast as someone they can rely on not to falter before their ambivalent machinations. The more conﬂ icted, divided, and distressed your client is, the more you are Downloaded by [New York University] at 02:06 15 August 2016 likely to be tested in this manner. Mowrer spoke of transferring an inner struggle, present as the client enters therapy, to a struggle between client and therapist as therapy proceeds. Freud and the analysts introduced the term transference. Was Mowrer referencing the same matter? Yes and no. We may well be addressing the same phenomenon, but we are not speaking of the same concept. Freud believed the troubled persons transferred to the person of the therapist feelings and tendencies that had originated from interactions with critical

65 THE THERAPEUTIC PROCESS

fi gures from their developmental past. Usually, these fi gures were parents. This transference was viewed as special, brought to surface by the long, emotionally saturated analysis. “Working through the transference neurosis” was deemed kernel to effective psychoanalysis. What this process taught clients was that their transferred feelings and tendencies were an inappropriate residue of the past. The therapist, as a new parent fi gure, did not judge and punish them. They learned from this that they could cast off, consequently, the anger, guilt, and inferiority feelings that had locked them into neurotic misery. As we have already noted, however, dismissing feelings rather than changing behavior conforms to the client’s justifi cation themata. It may sound like an attractive idea, very much in keeping with the client’s wish, but it does not coincide with the client’s reality. The transference concept Mowrer introduced differs from the analytic notion. The therapist has no special claim as the target of transference. Trou- bled, addicted people as they seek maximum value from their lifestyle evolve strategies for discrediting their own and others’ opposition to that lifestyle. They are engaged in these strategies daily. When the therapist reveals that he or she is also an opponent of their addictive lifestyle, they train their derogation stratagems on the therapist. They are not necessarily projecting on the therapist critical fi gures of their developmental past, a projection concept peculiar to the analytic process. Instead, they habitually and automatically employ these stratagems toward any who oppose their style of life.

Unavoidable Countertransference Of course, we all have developed ways of dealing with our own inner judgment and the judgment of others. These become habitual and automatic, an expression of our make-up no less than our clients’ stratagems are expressions of their make-up. Do therapists risk transferring to clients, particularly when clients derogate and resist, their own habitual ways of meeting and beating opposition? Bet on it! Analysts have introduced the term countertransference, and, once again, the phenomenon referred to may be the same, but the concept as rendered by Mowrer and Integrity Therapy is different. For psychoanalysts, countertransference grows out of the therapist’s neurosis. It mirrors the client’s transfer-

Downloaded by [New York University] at 02:06 15 August 2016 ence, and it is the basis of much mischief for the therapist and the therapy. The psychoanalytic school has insisted that therapists themselves be psychoanalyzed in order to remove countertransference as a complicating factor in the therapy. From the Integrity Therapy vantage, however, there is no way to avoid experiencing those habitual, automatic tendencies for dealing with others that we have formed over the years. They deﬁ ne you. They are a part of you. They are not merely a manifestation of your “neurosis.” Yes, you could with supreme effort probably change them, but you would, then, only have a new set, a new deﬁ nition whether or not you suffered a neurosis.

66 ENGAGEMENT: SOME USEFUL RULES

Moreover, you should not even try to avoid expressing the response tendencies that are distinctly yours as a preparation for doing therapy. On the contrary, vital to the development of insight into clients is your attending closely to your countertransference tendencies. Indeed, it is not “ working through the transference ” that is the premier activity in therapy; it is, instead, “ working with one’s countertransference” that takes top billing! One’s countertransference tendencies are the richest source of clinical data available to us. No other subjective response is as likely to reveal the hidden person of the client to us as do those residing in our countertransference tendencies. More on this in the next section.

Processing Countertransference as Clinical Data Mowrer promulgated a series of rules to aid in processing countertransference. I invite you to look upon these rules in a tolerant, relaxed frame of mind. You will probably break every one of them, sometimes by design! Do not fret. More important is that you remain alert to what you do and review your actions within a framework conducive to helping your client rather than that you remain steadfastly rule-bound. What I will present below recapitulates, in some measure, what we have discussed above. I risk redundancy to help you pull together in one package the tools for processing the clinical data and capturing the insight and understanding resident in that data.

Rule 1: Divergent Attention We have discussed at some length the importance of divergent attention. Lit- tle need be further said except to assure you that it is an approach you can cultivate. Your focus is on expanding awareness of your own subjective condition. There is a precaution: Do not become so self-preoccupied that your attention is more on yourself than on the client. Instead, let your attention be diffuse, paying heed to nothing in particular. Then, from time to time, check in on your own subjective state. “What am I feeling? What has been running through my mind? Are there lingering or recurrent images, impressions, associations? Do I feel a need to act?” Having sampled your subjective condition,

Downloaded by [New York University] at 02:06 15 August 2016 then return to the diffused state of attending already described.

Rule 2: Acknowledge Feelings and Tendencies We said that countertransference consists of habitual and automatic response tendencies. What is customary with such habits is that we also develop a functional blindness to their presence in our make-up. For example, ordinarily we take little note that we are feeling angry, desirous of striking out or running away. What we are more focally aware of is this difﬁ cult person before us, this

67 THE THERAPEUTIC PROCESS

frustrating situation surrounding us. Our actions, to us, seem to hinge directly on what others do or the nature of the situation. Our response is dictated, not by our way of feeling about and viewing the event, but by the event itself. In effect, we take ourselves, or rather, our habitual ways of responding, for granted. Those ways of responding are treated as constants in our behavioral equation. The world’s events are seen as those variables in our equation that really determine our actions. Merely recognizing that we all develop this functional blindness does not eliminate it as a problem for therapists. The most we can hope for is that, in time, we develop a more acute awareness of our response tendencies. In spite of all, there will be times when we awaken, belatedly, to our responding in habitual ways that, previously, we had not acknowledged, and which may not be conducive to helping our client. Still, better late than never. In addition to the workings of functional blindness, there is another reason why acknowledging our response tendencies may be diffi cult. That acknowledgment may be contrary to the image we would like to convey to ourselves and to clients. If competence is important to us, then feeling at sea will be diffi cult to acknowledge. If we prize our humanity and acceptance of others, then a sense of repugnance and condemnation will trouble us. If we have a strong wish to approach our client with ethically appropriate motives, then we will tend to ignore or deny being sexually aroused. We could continue this listing. We are subject to responding in all manner of ways to our client. Many of these tendencies will contradict our wishes and, in our view, refl ect badly upon us. To whom do we acknowledge these usually obscure, often disavowed, and embarrassing response tendencies? Well, to ourselves to be sure. That is not so bad, we may think. “It might not leave me as comfortable as I would like to be. Still, I can usually fi nd a way to accommodate in relative comfort to my own private thoughts and feelings.” Unfortunately, as regards our personal comfort, acknowledgement means more than simply admitting to ourselves how we feel. While for reason of economy in communications we may not acknowledge particular response tendencies to our clients, we will always be prepared to do so. At any moment, we may conclude that, to advance the therapy, we will be obliged to make clear just how we have responded to the client, just what the clinical data are.

Downloaded by [New York University] at 02:06 15 August 2016 Consequently, we are not able to treat our tendencies as purely private matters. It may be critically valuable to disclose our most unsettling reaction in the interest of advancing the therapy. Let me give a case example. One of my clients was a middle-aged, short, overweight woman with plain features. Not a beauty. She must have been more attractive and vivacious as a young woman. She recounted numerous affairs when younger, and a life ﬁ lled with partying, meeting people, and having fun. Now, at age 52 years, she was alone, bitter, and reclusive. She came across, over several hours of therapy contacts, as an over-aged, pouting child,

68 ENGAGEMENT: SOME USEFUL RULES

one who viewed the world as ﬁ ckle, having once been her “bowl of cherries,” and one who would not now forgive the world for not continuing to be so. I acknowledged her pain, a pain of disappointment, sense of abandonment and ill will from family, former friends, and acquaintances. Then I began to speculate with her that her unhappiness might be perpetuated by her own angry charges against one and all:

T: It sounds as if you are insisting that, somehow, your friends and family make up to you for your having aged and not being the engaging party girl you once were. If you come at them in this way, then we might understand that they would ﬁ nd you difﬁ cult. May want to avoid you.

During the several sessions in which we developed and explored this theme, I grew steadily more uneasy. My client had been dressing more carefully, grooming herself rather tastefully, and had become upbeat, smiling, and attentive. She seemed to follow ever more appreciatively my words and joined in considering the possibility, for example, that she might ﬁ nd ways to resume contact with estranged family and friends. However, she made no commitments nor did she report any change in her life patterns. After about three sessions of this kind, the matter ﬁ nally came to a head. I had been feeling frustrated, on the one hand, along with a mix of intrigue and embarrassment on the other. These feelings must have been showing. My client suddenly said, with a smile both coy and triumphant:

C: You know, you worry too much. You’re so serious. Don’t you ever have a good time?

With that I became aware of the feelings that I had not been acknowledging except as unease. I was sexually aroused! My client, over the course of a handful of meetings, had transformed herself from dull bitterness into suggestive sensuality. She was like a ﬂ ower with pet- als closed against the cold and dark suddenly unfolding before the sun. It was not that I had been unaware of these changes. It was, instead, that I had been unwilling to acknowledge the effect on me. How could I admit to myself or to anyone an erotic response to this woman? She was, after all, a gravely troubled,

Downloaded by [New York University] at 02:06 15 August 2016 rather dumpy, far-from-physically-attractive woman whom I was professionally obliged to help. Surely I could not harbor such incongruous desire! After the fact, it was clear that the way I had responded, my lack of acknowledgment, had only encouraged my client’s efforts at seduction. She had read the signs of my responding to her sexual signals. She interpreted my confusion and failure to deal with the seduction as evidence that I was retreating before if not succumbing to her charms. She was not too far wrong. Certainly I was in retreat! The only matter she probably did not see was that my retreat was due to my vanity. I did not want to admit that I was the kind of person who

69 THE THERAPEUTIC PROCESS

could be “turned on” by the kind of person she was. It is difﬁ cult to be a prig and a good therapist. Acknowledging my sexual arousal permitted me to understand important facts about my client. First, it revealed to what length she was prepared to go to discredit and set aside the therapeutic course we had developed. Her hope that the world would accommodate to her was strong. She did not want to hear how she might be called upon to accommodate to the world. Second, it revealed what role sex had played in her life. She was clearly very able and practiced at sexual enticement. Yet, she was unwed, alone, and reluctant to make contact with anyone. Her sexual overtures toward me were not designed for getting close. They were designed to defeat my efforts to oppose her hope and move her toward dealing with her realities. Apparently, sex had been a tool in her life for controlling people. It was not a way to achieve closeness. On the contrary, it was a way to keep emotionally distant. Now, in midlife, she was reaping the bitter fruit of her manipulative, non-integrative lifestyle. Unable any longer to make it work as she once had, she remained stubbornly hopeful. She did not want to change.

Rule 3: Is It Me? After you have acknowledged to yourself what you are feeling and what your response tendencies are, the next step is to ask, Is it me? Are my feelings and tendencies essentially a function of me, my life, my concerns, and my circumstances? Do they reﬂ ect the measure to which I am mobilized and ready to resonate to particular events no matter what else is true? If, for example, my client speaks about his wife mortifying him before friends, does my anger with his passivity spring from my recent marital problems? Is my very perception of his attitude as passive a function of my own unresolved outrage? A male student therapist was counseling a female freshman undergraduate who was troubled by depression and by anxious uncertainty about her relationship with a close friend who seemed to be going a bit wild with her new freedom. His client had purchased an automobile (a red sports car) with money earned in various pre-college jobs. Her parents had been against her taking it to the campus. She bowed to her parents’ wishes. From time to time,

Downloaded by [New York University] at 02:06 15 August 2016 her sister used the client’s auto. The parents seemed to be rather ineffectual in supervising the sister’s taking liberties with the client’s car. The therapist was incensed for his client. He found her acceptance of these arrangements evidence that she had been browbeaten and robbed of spirit by insensitive parents. He urged assertiveness. After several hours, I was fairly certain that the therapist was off course:

I don’t hear description of the parents as power-wielding oppressors. If anything, they come across as somewhat passive, certainly as regards

70 ENGAGEMENT: SOME USEFUL RULES

the sister. They did suggest leaving the car. Your client assented. She also gave permission to her sister to use the car. Meanwhile, she has this troubled relationship with her friend here on campus—a friend who seems to be living a sexually adventurous life. Does the friend model an alternative lifestyle?

I continued,

You know, a red sports car is loaded with connotations of freedom, sexual and otherwise. It sounds to me as if she is struggling with disparate tendencies in her own make-up. I get the feeling that this girl assented to her parents as a form of penitence. What, indeed, would cause someone to leave behind a car that she had purchased? What would explain her recurrent depression and her fascination mixed with revulsion at a friend’s sexual freedom? I would hunch that she has some sense of debt and moral obligation. It sounds like the kind of confused, contrite feelings I’ve witnessed in young women with post-abortion depression.

I do not usually advance speculations as speciﬁ c as this. However, it felt right. In the sessions following, the client welcomed her therapist’s critical attention to her parents, but she continued expressing her self-belittling, depressed mood and ambivalence toward her friend. The therapist did advance some of our conjectures, those related to the ambivalent attraction of the friend. However, he continued to hear and comment on oppression on the part of parents. Then, during one session, his client broke into tears. She told of having been rather wild and rebellious through her teens. She had become pregnant. She told her parents. They had been distraught, but they had stuck with her and supported her in her decision to have an abortion. The experience had changed her life. His client’s revelations changed the student therapist’s life, if not on the same scale. Besides making me now appear to him unusually prescient, they prompted him to some serious soul searching. While he did not go into detail, he told of a tense bout, not yet resolved, with his own parents to establish his independence from them. Any time he thought about his client’s forfeiting

Downloaded by [New York University] at 02:06 15 August 2016 the use of her car and her meek acquiescence to parental wishes, it made him angry. After his client’s revelations, he recognized how much he had forced onto her and her parents his own unresolved feelings. He had not asked himself, “Is it me?” The question is not easily answered. It must be asked. Sometimes, you will have to proceed with only a partial answer. Having asked and answered the question as you are able, you can then proceed to ask, “Is it my client?” That is, do your feelings, images, and inclinations ﬂ ow from the signals and messages emanating from your client? Do they serve to detect and give dimension

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to the client’s multidimensional messages? Only after acknowledging what you feel and admitting how your reactions may spring from your own life experiences are you able to explore your reactions to better understand your client. When you feel that some of your response springs from your own life circumstances, you do well to bring that out in the introduction to what you have to say to your client:

T: I’ve been feeling awkward, a kind of sense of embarrassment. It may be that my feelings say more about me than about you. That is, when you talk about your disappointment as a parent and you don’t seem to have your son’s respect, I can identify. I’ve been having some problems getting things to come out right with my kids recently. But my feelings may say something about your circumstances. I think my embarrassment may also come from a sense that, in spite of your earnest wish to be the parent, you really seem to reverse roles with your son. You seem to want the child to be the stable, reliable one leaving you free of responsibility, free to behave more like a kid.

What does disclosing your subjective response and possible personal origins of that response accomplish? First, it acknowledges what, if held back, a perceptive client may sense or be suspicious about in any case. Second, it relieves you of the feeling that you are holding back or trying to look good, a feeling that usually contributes to defensiveness. Third, it enables your client to assess the basis of your perceptions and insights. Finally, it models for the client the kind of self-confrontation and analysis that the client will ﬁ nd valuable to adopt in understanding his or her own behavior. I have found that clients do not jump at this apparent opportunity to dismiss your reactions as a mere manifestation of your own personal concerns. They invariably consider carefully the implications you draw about them. Often they express appreciation for your candidness and are more closely bonded, thereafter, to you.

Rule 4: Refrain from Acting Out Your Feelings and Tendencies This is tough. Here I have been telling you to go ahead and respond to your client with your own feelings and tendencies. Do not suppress, ignore, deny,

Downloaded by [New York University] at 02:06 15 August 2016 or distort your subjective responses. Let them surface. Now, I am telling you to “check in” from time to time. Monitor how you are responding and fully acknowledge to yourself the nature of your responses. It is difﬁ cult enough to respond freely while exercising self-monitoring. It is even more difﬁ cult to truly respond with your feelings and tendencies and refrain from acting them out! That, however, is the prime directive you follow as a therapist. It is not that the behaviors that you are inclined habitually to express are wrong or inappropriate outside of your role as a therapist. And, for heaven sakes, do not play therapist except where appropriate to do so! If you

72 ENGAGEMENT: SOME USEFUL RULES

habitually assert your rights, argue your case, and “put people in their place” when aggrieved, becoming a therapist should not transform you. The behavior we act out serves our basic wishes and values. Outside the role of therapist, acting on those wishes and values ordinarily promotes our self-approval and personal comfort. As therapists, however, we adopt a new, basic wish. That wish is to serve the welfare of our client. In the role of therapist, frustrating our usual manner of acting on our feelings and tendencies becomes the way we achieve a new self-approval and comfort. It is based on fulfi lling the wish to serve our clients. Becoming a therapist does not require you to change how you feel, think, and behave in your non-professional life. It does require, however, that you learn and adopt a transcending objective and basis for comfort in your role as therapist. Becoming a therapist does not ask something foreign of us. Grafting new roles and habits onto existing ways of behaving is not novel. For example, any time we rise from the ranks to a position of authority we had better quickly accept the requirements of our new role. When persons fail to do so and continue interacting according to old, peer-based expectations, they usually perform unsatisfactorily for all concerned. Another example that most of us have experienced or will experience is becoming a parent. In adopting the role of parent we will take on a new, transcending wish and basis for comfort. Persons who struggle with the new requirements of the parental role often want to be friends with their children. They urge their children to address them by their fi rst names, and interact with their children as if they were peers. When they seek obedience, the child is seriously confused. You do not have to become a boss or a parent. You do not have to become a therapist. If you choose one of these roles, to be successful, you will behave toward subordinate, child, or client differently from behavior practiced in other roles that you choose. It is not always easy. It requires dedication, application, and practice. It also has a cost. Once you have adopted a particular role relative to a specifi c person, it is diffi cult to play a different role with that same person. It is not impossible for a therapist to interact with a client as a friend or associate outside of therapy. It takes discipline. You nearly always experience some measure of restraint in the free exercise of your non-therapist roles in such cases. Downloaded by [New York University] at 02:06 15 August 2016 Don’t Rules in Working with Countertransference Mowrer’s don’t rules are presented separately from the above do rules. Actu- ally, the object is less what not to do than what to substitute for acting out that which Rule 4 above asks that you inhibit. In general, what you substitute is a question: What do my feelings and inclinations reveal about me, about my client, and about what is happening? Answering this recurrent question is the way you harvest insight from countertransference.

73 THE THERAPEUTIC PROCESS

Don’t Rule 1: Don’t Act Out Being AFRAID I saw a man in his early forties. Dominant, assertive, bright, he packed a lot of intimidating power. He had had a passionate affair with his secretary. His wife divorced him, obtaining custody of their two children. He married the secretary. Their marriage was a series of outrageous ﬁ ghts, with physical blows often being exchanged, followed by passionately tender reconciliations. This man resisted taking any steps that would introduce a leveling in the tumultuous swings he pursued in his life. He appeared to enjoy the whole gyrating ride. He was on a life-long roller coaster. He was in love with passion, be it anger, jealousy, triumph, or lust. After some discussion of these matters, at one point, I said:

T: You come in heavy with remorse about your excesses. You regret being separated from your children. You are awash with guilt at knocking your new wife around. You complain that your life is a disaster. You long to be normal. Yet, at every turn you oppose the least act that would change your circumstances or commit you to some restraint on your behavior. No, you say, such petty limits would go against your macho image, your Hemingway ideal. You are addicted to passion. You have to have your ﬁ x of adrenalin. You must have your emotional high. You defend your actions as expressions of a man of strong desire, strong feeling. But do we speak of strength, or do we have someone giving in to addiction?

This man’s fi rst response to my observations was somewhat controlled and mildly in agreement. Then, he moved away from the topic and talked of his fi rst marriage and the work he had done before he ran off with his secretary. He began talking of how much effort he had expended to make his conventional fi rst marriage work, how much he had sacrifi ced to placate a wife never satisfi ed. Abruptly, near the end of the hour, he shifted:

C: What in the hell do you know about life! Why, you’re a Goddamned Casper Milquetoast and that, apparently, is what you want me to be!

He got up from his chair, pacing back and forth, leaning over me as he emphasized his words, which grew louder: Downloaded by [New York University] at 02:06 15 August 2016

C: I don’t know how in hell you can help me. You have got to live life before you can understand someone with real blood in his veins. Do you know what I mean? Christ, you’ve got to have balls to deal with ﬂ esh and blood issues. I don’t think you’ve got the balls!

His eyes were glaring as leaned over in my face. His hands were balled in ﬁ sts. His whole aspect suggested that at any moment he would lash out and

74 ENGAGEMENT: SOME USEFUL RULES

physically attack me. My heart was pumping. My mouth was dry. I did not need much self-monitoring to know that I was scared. I also felt matters were out of control. The usual pattern of the hour was completely disrupted. My client had taken over. I wanted out of there. I wanted to rid myself of this client! I did not do what I wanted. Instead, I said:

T: You are scaring me. I’d like to just bow out. Just pass you along to someone else to deal with. But maybe that’s what a part of you wants. To scare me into abandoning you. Or to scare me into laying off of what I was saying earlier. We must have really hit a nerve.

The client fumed. Shortly thereafter, however, he made an appointment for the next hour. Physical intimidation or threat is actually quite rare. Clients are capable of causing fear through more indirect means. What do you value? Whatever it is, a client is capable of ﬁ nding a way to threaten what you hold dear. Most therapists value feeling and being seen as competent. Beginning therapists under supervision are particularly sensitive on this score. Clients will frequently probe your responses with inquiry about your training and experience. If they sense you are touchy and if, also, they seek to neutralize you as a force in their lives, then they will advance a direct attack on your competence:

C: I’m not sure you have enough experience. You’re pretty young. I don’t want to hurt your feelings, but I just wonder if you know what you’re doing. For instance, the last time we met you said I sounded like I was afraid my marriage was ending. Now, today, you’re saying maybe I have been baiting my wife into divorcing me. I think a more seasoned therapist would not have said these things.

Such comments will produce apprehension in the most secure student therapist. They will create panic in the novice who is thinking, “Oh my God, here goes my grade. Here goes my career! And he’s right. I am inexperienced. Maybe, I shouldn’t be handling this person. Maybe I should refer him to someone else.” What do you say? How do you respond to your fear and your wish to run

Downloaded by [New York University] at 02:06 15 August 2016 while remaining devoted to your client’s welfare? You might say:

T: Yes, I am inexperienced. As you were informed when you ﬁ rst came in, we are a training clinic. I am a graduate clinical student under the supervision of an experienced therapist. A graduate student’s anxieties are high. And maybe mine are particularly high because I really feel anxious because of what you have said. My inclination is to just go to my supervisor and say, “Maybe he needs to be seen by someone else.” And, when I discuss all this with my supervisor, she may agree!

75 THE THERAPEUTIC PROCESS

But, there may be another reason why I’m feeling so on the spot. That is because you have been put on the spot, too, by some of the things we’ve been looking at. I’ve had this feeling that you’re deeply divided. Part of you is, indeed, troubled about your marriage ending. Part of you would welcome it. If this is something hard to face, something you don’t want to face, you may be putting me on the spot so I’ll become focused on myself and stop putting you on the spot.

Another related value that therapists have in common is that their clients thrive under the therapy. The most serious departure from that outcome would be a client’s suicide. Occasionally, you will have a person threaten bodily harm, not to you, but to themselves. You are the target, nonetheless. I once had a young woman I was seeing confront me in the hall of a public building. She had been hospitalized three times previously for withdrawal and depression. Some weeks earlier she had revealed something that she had concealed from several therapists she had seen prior to me. From her mid- adolescence on she had engaged in daily fantasizing about teachers or older male acquaintances, accompanied by prolonged masturbation. No actual male companion ever measured up to her fantasized companions. Her hospitalizations in the past had been precipitated by her attempt to act out her fantasy. She would approach the object of her ﬁ xation with high expectations of passionate and amorous outcomes. These unfortunate persons were completely confused by her rather bizarre overtures. They ﬂ ed from or rejected her advances. Her disappointment was profound. She was very accepting of the idea that her secret fantasy life was at the heart of her past emotional plunges and hospitalizations. She set about to reverse her actions. Not only did she disclose fully to a group she joined, but she told all to her parents. They were relieved to discover that her mysterious symptoms had an understandable basis. For several weeks she was buoyed up by the initial acceptance and understanding of others and the promise of an entirely new, more rewarding life. Then, she had a few reverses at her work and was facing a review about which she was apprehensive. When she confronted me in the hall, her features were much changed from when I had seen her last. Her hair was hanging in dull clumps. Her face was sallow. There were dark circles under her eyes, which were wide and wild. Downloaded by [New York University] at 02:06 15 August 2016 C: You bastard [almost screaming]! You are driving me insane. Do you hear me! I can’t stand it. I can’t do what you think I can do. I can’t! I might as well end it now. There is no reason to prolong this agony. I’m going to end it, do you hear!

I was stunned. A series of images went through my mind. Images of her dead body in various positions. I anxiously noticed some passersby viewing us from the corner of their eyes. I visualized headlines in the newspapers—LOCAL

76 ENGAGEMENT: SOME USEFUL RULES

PSYCHOLOGIST’S CLIENT FOUND DEAD. BOARD OF INQUIRY IMPANELED . I wanted to ﬁ nd some way to shush her. I wanted to shrink into the wall. I thought about turning her over to the psychiatric hospital serving our area. Again, I did not act on any of these tendencies.

T: You’ve really got me scared. And maybe, as things move on here, I’ll be scared enough to call in the guys with the white coats. But, I am not going to back down from my belief that, yes, you can make it. Here you’ve come against some reverses, and you want to retreat into the old pattern. But I do think you can make it, and no amount of being scared is going to change that!

We spoke further, enough for me to discover that she had no speciﬁ c suicidal plan. Although she was still wild and full of dread, she agreed to come in at the ﬁ rst opportunity, and we parted. I kept a worried ear trained on the phone over the weekend intervening. No call came. When we met next, her whole person was changed. Some years later she visited me. “You didn’t back down,” she said. “You saved my life.”

Don’t Rule 2: Don’t Act Out Being ANGRY If the evoker of fear attempts to “put you on the run,” the evoker of anger is trying to “get your goat.” I am not sure of the origin of the “get your goat” metaphor (there are several speculations), but I do have an image of a red-eyed animal, head down, charging around blindly. Not a very therapeutic strategy! A woman therapist under my supervision was seeing a younger woman who complained of depression and general unhappiness. The client lived with two other young women while she went to college. Her relationship with her roommates was tempestuous. She was constantly talking about difﬁ culties with her boyfriend, seeking their sympathy and condolences. They had grown intolerant of the interminable attention she demanded. They were relieved when she revealed she had sought psychotherapy. In time, the therapist began to elaborate the theme that this young woman was immensely self-centered. She went through life seeking and expecting attention, adulation, and special favor. Such had been her lot as the favored

Downloaded by [New York University] at 02:06 15 August 2016 and beautiful child of uncritical parents. Now, though still very attractive physically, she was no longer little, forgivable, cute. Roommates found her a burden. Boyfriends were soon exhausted by her wish to monopolize their time and energies. In short, what had once been a perfectly successful approach to life was now recurrently failing to gain what she sought. She was frustrated, upset, and angry. The therapist did a good job sketching this picture for the client to see. The therapist pointed out how the client’s behavior promoted a vicious circle. Her wish for attention led to her demanding behavior. Her demanding behavior

77 THE THERAPEUTIC PROCESS

led to withdrawal of attention. Withdrawal of attention made her unhappy. Her unhappiness increased her demanding behavior, and so on. The client paid lip service to understanding her situation. However, she would somehow circle back to lamenting the unfair, unloving actions of her boyfriend. Several times the therapist reported feeling aggravated and put out by her client’s persisting egocentric actions. “Sometimes, I’m not sure I can stand her,” she remarked with a wry smile. One evening, one of the roommates called the therapist. The message was, essentially, “Your client has taken a bunch of aspirin. We are sick of her show- boating. We’re calling because she asked it. But that’s it! We leave it to you.” The therapist went to the client’s rooms, found her obviously sick, and called an ambulance. The therapist accompanied the young woman to the hospital. Later, with the client’s concurrence, she called the client’s parents. “I was angry,” the therapist reported:

It was so clear that this was a gesture! It was designed to get her roommates, me, the health system, and her parents mobilized. All of us were waiting on her, paying attention to her. Meanwhile, she took just enough aspirin to get sick, to trip the system into red alert. I suspect we’re all feeling had. She is wearing out all the residual good will people ordinarily have for each other. I know what her roommates feel. Aggravated to the point of intolerance! Yet, she appears to be completely blind to her impact on others. She was saying she knew her roommates were worried and hoped they would not be too worried!

However, the client had secured an appointment to renew her therapy contact at the ﬁ rst opportunity. The therapist looked forward to that contact without enthusiasm. “You have done a good job of acknowledging your feelings,” I noted. “But it appears to put you in a bind. You seem to feel that if you don’t view your client in a positive light, you can’t help her.” “Well, how can I help her and feel so unsympathetic? Maybe it relates to where I am in life. I have had to struggle so to pursue my studies. She has it given to her, yet she is constantly mucking it up. She creates problems for herself and everyone else when she could be doing something positive.”

Downloaded by [New York University] at 02:06 15 August 2016 It was clear that this therapist, a sensitive and very honest somewhat older graduate student, was quite concerned about her own responses. It troubled her deeply that she did not have a kinder regard for her client. How can one help people who are frequently far from admirable, who often have a veritable basket full of negative, aggravating characteristics? What a dilemma! If you are particularly sensitive to and unforgiving of the client’s negative factors, you may be able only to help the healthy. If, on the other hand, you are too forgiving and tolerant of the other’s actions, you may not recognize and confront what troubles them.

78 ENGAGEMENT: SOME USEFUL RULES

After some discussion about these matters, I said, “I do believe that you must have at least a minimum positive feeling for your client. I believe you can help someone whose actions you fi nd personally deplorable. However, I don’t think you can help someone for whom you are unable to feel any positive regard. Maybe, the problem here is that you give relatively too much weight, in your own thinking, to this woman’s negative features and have overlooked some critically positive ones.” The therapist looked her bewilderment. “Well, she is bright. She’s attractive. She knows how to be ingratiating, at least on fi rst meeting. But these positives only cause me anger! With these assets, she should be on her way rather than being the pain in the butt she constantly is!” “Oh, I agree,” I said. “But that she’s bright and pretty, in her case, aren’t really positive features. Yet, in spite of refusing to recognize how she impacts on others, she knows she is hurting! What of the fact that she has come to you to begin with? She is indicating that she recognizes that something is wrong with her, with her life, with her way of doing her life’s business. And what about the fact that even after you have hit her pretty hard with your observations about her self-centeredness, she has come back for more? She is fi ghting hard to make her old life work. She is fi ghting to ward you off, get your goat, and get you, perhaps, to turn from her in disgust. But she hasn’t turned away from you. Does she hope that you will stick in there and be a force for growth, be a force helping her come to terms with her manipulativeness and immaturity?” The therapist apparently found this perspective of value. She went into the next hour with less reluctance and usefully broached with the client her habit of discounting the negative impact she had on those around her. The client fought against these observations, but continued to request help. The resistance battle was joined, and the therapist was not defeated by her own anger.

Don’t Rule 3: Don’t Act Out Being AMOROUS Under Rule 2 (Acknowledging Feelings and Tendencies) I presented a case of client seduction and the therapist’s amorous inclinations. The titillating actions of this seductive client were in the service, not of sexual conquest as such, but of removing the therapist from his role as helper. The seducer seeks to disempower you. How can you ask this person to do something difﬁ cult,

Downloaded by [New York University] at 02:06 15 August 2016 calling for persistence and resistance to the temptation to resume old satisfactions, if you do not curb your own appetites and desires? If you succumb to your client’s seductions, be assured you have lost for all time any force you may have had for therapeutic change. Surveys and the experience of professional liability insurance companies have shown that the incidence of sexual contact between therapist and client is, sadly, rather high. I understand that sexual relations between pastoral coun- selors and counselees are viewed among church leaders as almost epidemic. Perhaps, these indiscretions merely reﬂ ect the times.

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The sexual revolution, so called, has urged the uninhibited pursuit of sexual interest. There are schools of thought, not too distant from the analytic model, which view sexual restraint as akin to psychopathology and sexual freedom as the epitome of robust health. We even have a fundamentalist Christian religious sect that advocates seduction and incestuous sexual stimulation of children as bait to bring in converts young and old! Similarly, psychotherapists charged with improper sexual contact with clients routinely defend their actions as being in the interest of therapy. There is something incestuous about sexual relations between a therapist and a client. The therapist’s role is parental in certain fundamental respects. First, as an act of faith, clients place their unreserved trust in the therapist. “This professional is someone I can trust to help and not harm me.” That is the same kind of trust the child places in parents. “Mommy and Daddy will always help, never harm, me.” Second, clients expect the therapist to represent reality much as children rely on parents to represent reality. Finally, clients rely on therapists to remain unmoved by clients’ derogating strategies, much as children are reassured when parents remain steadfast in the face of childish opposition. The incest taboo has been viewed as one of the universal rules of human society. Our attention to incest as child sexual abuse may have obscured how it is that the incest taboo has been historically so evident and widespread. The taboo was not authored by children to protect them from venal parents. Children do not have that kind of social leverage. It was authored by adults in the interest of securing their authority and beneﬁ cial powers as parents. Living in extended families throughout most of history, humans found that incestuous relationships destroyed the family structure. Incest rendered parents impotent, not sexually, but as persons of authority and power. The major abuse endured by child victims of incest is not the aftereffects of the sexual experience as such. Rather, it is the collapse of faith in the parent as a person who protects, helps, guides, and remains constant as a force in their lives.

Don’t Rule 4: Don’t Act Out Being AMUSED Clients will often present themselves in ways that may amuse you. If you ﬁ nd

Downloaded by [New York University] at 02:06 15 August 2016 yourself recurrently tickled by your client, you need to ask what this reveals about you and about your client. There are persons who have developed comedy to an art. It can be an excellent method for warding off critical inquiry. I saw a woman of middle age. She came in suffering from recurrent panic attacks that had, on several occasions, precipitated emergency hospitalization for possible heart problems. No physical basis was found. In spite of being highly mobilized by her condition, this woman presented herself in a guarded manner. It was important to her to be seen as pure and noble. Any inferences

80 ENGAGEMENT: SOME USEFUL RULES

that probed into her actions or motives were met by gentle, amused irony. The possibility that she had for years dominated her husband and children under the cloak of purity and high ideals inspired her to incredulity and artful comedy.

C: My husband asked me how things were going. I told him, “Oh ﬁ ne. I go in, and we talk. He is very attentive. He listens carefully. Then, every once in a while, he picks up a stick he has laying beside his chair and beats me over the head with it!”

The image was infectious. I broke Rule 4 and joined her in laughter in spite of myself. Later, I recovered somewhat, saying:

T: You certainly do a great job of making it seem absurd that I or anyone would suggest that you dominate your husband and kids.

Sometime later she revealed that the emergence of her physical symptoms coincided with receiving a long, preachy letter from her daughter’s boyfriend written about two years previous. She had the letter still. It had challenged her dominion over her daughter and had left her shaken, angry, and confused. Skilled as she was at using humor and charm to effect denial, reality kept contradicting the image she carefully nurtured. Mowrer1 saw a man who made his living as a nightclub comedian. The man was often depressed. He had bouts during which he thought himself worthless. He felt very alone. His efforts at establishing intimacy were fruitless. Yet he told of himself and his life often in hilarious terms, featuring himself as the bumbling clown stumbling from one precarious situation to another. The therapist was well aware of the pull of these absurd images:

T: I am often amused by how you speak and present yourself. But actually, in substance, it isn’t funny. It sounds like you are always on stage, working for the laugh. And even though you are sober here in good part, I have the impression that when we begin to really get close to things and open you up for a critical look, you turn up the laugh machine. C: You’re right, Doc [unsmiling]. I am always on stage. I’m afraid if I don’t

Downloaded by [New York University] at 02:06 15 August 2016 tickle people, they will ﬁ nd me ridiculous. I hurry to get them to laughing. That way I control it. It would be terrible if people were to laugh at me when I wasn’t controlling it, when I wasn’t being funny. T: So, you use comedy to control, to be comfortable. It’s a well-honed and powerful skill. But, in the meantime, you are never real. Never open to another human being as just yourself. You hide behind a clown’s mask. No one can get close to you because no one can know you. What you may fear is not so much ridicule as the kind of rejection we show things alien. To be sure, you’ve done some things about which you’re not proud. But the

81 THE THERAPEUTIC PROCESS

furtive sense of hiding itself may well be the more critical factor accounting for your guilt and depression.

This man discovered that he could not continue his career as a comedian. It was a bit like an alcoholic following the career of a wine taster. Determined to alter the course of his life and to establish real contact with others, he shifted his career to another department of the entertainment business.

Don’t Rule 5: Don’t Act on APATHY Having trouble staying awake? Bored? Clock watching? Finding that your attention drifts from divergent and diffuse to absent altogether? This response is one we are more likely than others to assign to ourselves. “Wake up,” we command ourselves. “Pay attention. Get with the program!” But do not overlook the possibility that the program is the boredom itself. Some persons have developed the capacity to turn us off, to erode our interest in and attention to them. They adopt a strategy expressed widely in nature. It is sometimes called tonic immobility by researchers, but, in commonplace terms, it is called playing possum. It is seen in many animals that are often the target of predators. Usu- ally it occurs when the animal has been caught or trapped so ﬂ ight or ﬁ ght is no longer feasible, or has been exhausted. The animal goes limp. While such a tactic may appear foolish, if, indeed, you dignify it as a tactic at all, it does have survival value. Many predators are acutely sensitive to movement. They are excited to attack by the motion and struggles of the prey. When all else fails, the animal that “plays dead” just may survive if the predator is not all that hungry and, growing bored, walks away from the game. It is a case where, being caught, things are bad. However, they are worse if you move. Of course, clients who effect this strategy usually display it from the beginning. It is as if they come in already feeling caught. They immediately display tonic immobility in the guise of either very limited communications or communications that are dull, humdrum, and tedious—in short, boring. Perhaps, the therapist like the predator will grow weary of the game and permit the client to continue to live undisturbed. I said to one such person I was seeing: Downloaded by [New York University] at 02:06 15 August 2016 T: I have just become aware that my attention has been wandering, and I was all but nodding off. That doesn’t ordinarily occur to me. Earlier, you spoke of feelings of alienation, of your hospitalization, and of fear that you may grow so out of it that you will require hospitalization once again. Such matters ordinarily mobilize my attention. Maybe I’m tired, or it’s the time of the day. But, it may be that my reaction informs us about you and how you are attempting to deal with your life. Have you learned to present yourself in such a way as to dull the

82 ENGAGEMENT: SOME USEFUL RULES

interest in and attention of others to you? Does this habit or method help explain your sense of distance and alienation from others? Finally, do you feel caught by life, and feel that, if you can put people to sleep, they won’t pounce on you? These are questions we might ﬁ nd useful to explore.

Don’t Rule 6: Don’t AGONIZE To be sure, the people you see are in trouble. They suffer. They deserve your concern and sympathy. They also deserve and, if they are to progress, require your critical judgment. Now, one can sympathize or agonize with another without losing one’s critical judgment. Sometimes, however, sympathy and judgment compete. Two rather different cases come to mind in illustration of this rule. The fi rst was a woman of about 32 years. She was being seen in a group. The members of the group and the therapist were all sympathetically disposed to her and her plight. She was a mother of four young children. Her husband, who had accompanied her to the group on some occasions, was often drunk. He loved her, or so he proclaimed, but he was frequently off hunting, with “the boys,” and enjoying the company at his favorite bar. He was extroverted, convivial, but he was selfi sh, irresponsible, and uncaring. These matters he acknowledged. He made some real but modest efforts to change. The therapist and the group arrived at a point of arrested progress with the woman. Week after week she presented the same dreary picture. In spite of his limited changes, her husband continued in large part his excesses and his neglect of her and their children. Through these accounts, she remained uncomplaining, gentle, and enduring. She was always sweetly grateful for our efforts to help her fi nd some way to deal with her life. There was a consensus of condemnation in the group for her toad of a husband. There was unanimous kind regard and admiration for this quietly suffering wife and mother who held on so faithfully to her family. Not once did she lose her composure and respond in kind to her husband. She was always there for her children, and there for her husband when he was attentive enough to turn to her. She was virtuous and deserving. She received frequent votes of approval and words of encouragement. As the group’s frustration grew at its failure to fi nd a way to help her advance her life, its condemnation of her

Downloaded by [New York University] at 02:06 15 August 2016 husband grew also. Everyone agonized with and for her. The therapist, a bit belatedly, got in contact with his own abundance of sympathy. Did his and the group’s failure to move ahead with this woman rest on how well she had mobilized their sympathies for her and their condemnation for her husband? Yes:

T: We have all been drawn to you. You don’t deserve the treatment your husband accords you. You are enduring and long-suffering but without bitterness. It’s clear that you have simply mobilized to the fullest our sympathy

83 THE THERAPEUTIC PROCESS

for you and our agony at the unfair life you endure. But maybe we would proﬁ t if, in effect, we looked behind this sympathetic reaction, which, I would hunch, you get from everyone. Is there a kind of design here? To a person, we all turn and go after your husband. He has to change. To date, no one has found anything in you that might be the focus of change. We are so drawn into our sympathy for you that, perhaps, we have failed to examine critically what’s going on. And what might that be? Could it be that, in spite of the appearance of helpless suffering you project, there is a stubborn and rather effective campaign to mobilize a force directed at getting this toad of a husband to change? In your own gentle way, you are not going to settle for anything less than his turning from a toad to a prince! Are you a martyr? And like the classic martyr, are you seeking, not something small and partial, but something revolutionary? Martyrs forfeit their lives in the faith that some grand realization may come to pass. Your grand realization is having your husband transform from his callous ways to a person of virtue to match your own.

This rendering immediately altered the course of the group’s exchange with this woman. Group consensus formed around the “toad into a prince” thesis, and the woman, herself, joined that consensus. Attention began to ﬂ ow toward what realistic steps were available to the woman. Would she be willing to accept less than revolutionary change? Would she be willing to “mix it up” with her husband and directly oppose and tax him for his undesirable actions? If she would not accept what her husband would do to mend his ways, would she decide to divorce her life from his, or would she continue to play the martyr? The group was no longer stuck in recurrent cycles of sympathy and frustration. I saw a man of about the same age as the woman above. He was subject to attacks of light-headedness and chest pains on his way to and from work. These attacks would occur occasionally at work and under other circumstances as well. His physician, who had prescribed Xanax, a mild tranquilizer, had referred him. His physician did not want him to depend on Xanax, which, however, seemed to work to minimize the symptoms and permit him to go to work. The man complained of a poor relationship with his superior and

Downloaded by [New York University] at 02:06 15 August 2016 reasoned that his symptoms might relate to anxiety over this matter. A change of companies left him feeling better, and he broke off his therapy contacts. However, he resumed sometime later, again following the advice of his physician who had re-prescribed Xanax. The man was married and had a young child. He was devoted to his family. He was very concerned about his ailment. To him it was mysterious, but biologically based. Yet, he had had a thorough physical examination that was negative. He was troubled about relying on Xanax and ready to try anything that would help free him of his ailment and of his dependence on Xanax.

84 ENGAGEMENT: SOME USEFUL RULES

He was open and forthcoming, although he had no idea how his ailment might have grown out of the circumstances of his life and behavior. He had been entirely free of problems until he had moved to this area. Indeed, the fi rst such attack had occurred while en route to the area. It had been a mild attack, but had the elements of lightness in his head and pains in his chest and throat that troubled him later. He had moved with a woman with whom he had been living. They were determined to fi nd work and start a new life. He and the woman married and, shortly after, had their fi rst child. In the region from which they had migrated, his life had been quite different. He had never had a care. He and his friends had lived for the moment. He had been rather heavily into marijuana use and had also used alcohol in excess. Since moving to this area, however, he had reduced his smoking marijuana to only rare use and imbibed in alcohol less often. The emergence of his symptoms on his way to a new life was intriguing. My fi rst efforts placed considerable weight on this transition point. Perhaps this man had crossed a threshold in his personal development that had opened him to apprehension. Here he had been a party guy, engaged in good times and living for the moment. Then, perhaps, under the infl uence of his wife to be, he had decided it was time to put such frivolous ways behind him. So, off to a different place where he could fi nd work, settle down, and have a family. And on came his symptoms. Perhaps the symptoms spoke to a confl ict within him between the old party guy and the new, responsible husband and father. His panic might emerge from the thought that he was giving up familiar pleasures and comforts. Perhaps, he recoiled emotionally from embracing a life of responsibility with its worries and cares. Thus, his attempt at change prompted inner opposition, seeking to annul his efforts. Exploring these themes was productive. The man clearly found them revealing and related relevant and confi rming associations. However, these insights produced understanding but did not produce any evidence of movement.

C: I think you’re probably on track. It sounds, indeed, like I’m struggling between two ways of life. But what can I do about it? I smoke a joint once in a blue moon. Sometimes I’ll drink when out with friends, but nothing big. So, my old life is gone. Yet here I am unable to go to work unless I

Downloaded by [New York University] at 02:06 15 August 2016 take these pills. You know, we’ve tried taking them away, but I just can’t function. And I’ve got to. I can’t take off from work. I’ve got to have that job. My family depends on me. It’s that simple. With the Xanax, I work. Without it, I don’t. That, of course, is what makes me think it’s physical. There is something about my chemistry that’s wrong.

The man’s bewilderment was real. He came across as deeply concerned about his new responsibilities. His demeanor was that of a man embattled,

85 THE THERAPEUTIC PROCESS

struggling to cope. My sympathy went out to him. But had it gone out too uncritically? I began to review his presentation with that thought in mind.

T: You were heavily into marijuana before coming here. C: Oh yes. I smoked all the time. T: You also frequently used alcohol. C: Right. We would party, and I would drink pretty heavily on those occasions. But after I came up here, as I said, I basically stopped smoking and have done very little partying. T: Soon after you got here, you went to the doctor and got a prescription for Xanax. C: Yes. I was scared. I thought I was having some kind of heart failure. The Xanax really worked. Then after awhile he took me off of it. I was off for several months. T: I don’t remember your relating that before. C: Yes. During the time I was off, though, I got those attacks again. I began to drink more and more. I was drinking quite a bit every day. T: I take it that worked to check the attacks. C: Yes, but I was worried I was going to become alcoholic. So I went back to the doctor and got another prescription for Xanax. T: OK. I think it’s time to look at a slightly different way of understanding this. Sure, coming up here was a transition. You were setting out to radically revise your life. You were going to stop smoking, carousing around, and settle down. And you had this attack. What was it? Is it possible that it was a kind of withdrawal pain? Here you had been a regular user of marijuana and alcohol. Each day, day in and out, you had relied on these substances to take the edge off, to tranquilize and pleasurize your existence. Like so many who become addicted to a substance, the thought is, “Well, I can stop any time. No problem.’ But, you did not ﬁ nd it so. You began to suffer withdrawal pains. You did not want to confront the possibility that you were deeply dependent on marijuana and alcohol to make things seem right. So, you went to the doctor looking for a different course. Stress was the issue. Xanax was the remedy. However, Xanax is just another substance to depend on

Downloaded by [New York University] at 02:06 15 August 2016 to smooth off the edges. When it wasn’t around, you returned to alcohol. You have been dependent on one thing or another both well before and since your effort to transform your life. If this is on track, then the issue is not stress as such. It is rather your way of dealing with stress. You have relied so long on some drug to take the edge off life that you are unprepared and, perhaps, unwilling to deal with life and its stresses directly. In other words, it isn’t that you’re a man plagued by some mysterious ailment, or one victimized by unusual stresses. Instead, you’re a multiuser addict, protecting his addiction.

86 ENGAGEMENT: SOME USEFUL RULES

Agonizing for and sympathizing with your clients are perfectly human responses. Do not permit them to blind you to the realities of your client’s person and situation. Whatever the nature of your client’s addiction, he or she will attempt to defend it. A very good defense is denial through disguise such as the client above illustrated. “I am not an addict. I am a victim of stress, under a doctor’s prescription, and deserving sympathetic understanding.”

Don’t Rule 7: Don’t ASK Questions Asking questions is a natural technique for opening a social contact. Where are you from? What do you do? How long have you lived here? Do you like the weather? How many children have you? These are commonplace questions we have all asked to make contact, to loosen the conversational ﬂ ow, to place the other and ourselves at ease. Why refrain from using the technique in therapy? Therapy is not a normal social contact. Two strangers have not met accidentally and proceeded from there to seek common ground for a comfortable social exchange. Each already has important knowledge about the other: One person is a trained helper who is expecting payment for his or her time. The other person needs help and is ready to pay to receive it. This knowledge will not permit the contact to evolve as a comfortable social exchange. In so far as it takes on such proportions, we know that something is wrong. We already know, also, that the other person, the client, is troubled and mystiﬁ ed about something. The client expects to tell about this problem and expects that the therapist will listen. The therapist will share these expectations. Both may have other expectations less in common. However, they start, at least, in synchrony. Thus, all the therapist has to say, for openers, is:

T: Well, I don’t know what’s on your mind, what brings you here. You may begin with that, and we can work from there.

As I have indicated elsewhere, this is usually suffi cient to loosen a fl ow of from 10 to 20 minutes of verbal output from the client. Not one question is needed for this fl ow to emerge. This development is far different from a normal social exchange that is marked by many brief inquiries and responses back and forth. Asking questions as a format suggests a normal social exchange, and

Downloaded by [New York University] at 02:06 15 August 2016 we do well to avoid that format. We are not interested in sending the message, “I want to get to know you, know your likes, dislikes, your work, and so forth so we can have a comfortable conversation.” Remember, our overriding goal is not to provide or to gain comfort. It is to provide help to a troubled person. There are other reasons for avoiding the format. Questions lead. Let us say that you ask the client, “What is your relationship with your mother?” You will get an answer, but you will never know what the client would have chosen to say unguided by your question. Maybe the ﬁ rst topic would have been mother. Maybe mother would fail to appear in several hours of exchange. In the latter

87 THE THERAPEUTIC PROCESS

case, and in the context of what the client has already imparted, this might be a conspicuous absence. The point is, what the client chooses to present or not, in what order, with what relative emphasis, and with what relative ease or difﬁ culty are cogent pieces of information you will miss if you ask questions. Finally, there is the matter of responsibility. As noted elsewhere, all clients are ambivalent. They begin being ambivalent about whether to seek your help. Once in your ofﬁ ce, they are ambivalent about revealing themselves. As they reveal, they are ambivalent about whether they are responsible for doing so. Later, they are ambivalent about whether they are responsible for effecting solutions to their problems. What better way to realize the ambivalent wish to avoid responsibility for revealing and for change than to get you to take charge? One way to get you to take charge is to induce you to ask questions. Some clients express this wish quite directly:

C: I don’t know where to start. Why don’t you ask me some questions?

Again:

C: I wish you would ask questions. It makes me uneasy just to say whatever is on my mind.

Other clients attempt to get you to take charge by refusing to come forth. Their silence places pressure on you to bring them out. They hide, and they assign to you the responsibility for both ﬁ nding them out and, then, for doing something about it. How does the therapist respond? To the direct request to ask questions the therapist might say:

T: I think everyone feels apprehension about imparting personal matters to a stranger. I expect just deciding to come in took a lot of resolve. When you ask me to ask you questions, I suspect you’re trying to bide your time while you ﬁ gure out whether this is a process you really want to undertake.

To the pressure of silence, the therapist might say:

T: Downloaded by [New York University] at 02:06 15 August 2016 I’m feeling a real urge to ask questions so we won’t have this awkward silence. We might both be more comfortable if I did. But, would that be useful for us? I don’t know what is bothering you, what’s important to you, what you’re feeling and thinking. My questions could very well lead us astray. Besides, it would imply that I am the information gatherer who will, once I get all the facts, take charge and take action.

The client’s response to these remarks may range considerably. Whatever it is, it will carry you both someplace upstream of the pressure to ask questions.

88 ENGAGEMENT: SOME USEFUL RULES

Don’t Rule 8: Don’t ANSWER Questions

C: Doctor, why do these things happen? Can you please explain to me why my friends act this way?

Or:

C: How are you doing today, Doctor? Is that cold better? I saw you out running the other day. Do you advocate running for mental health?

It is ﬂ attering to be the expert. However, being the answer-giver shifts responsibility to you in much the same manner as being the question-asker. If you fall in with being the expert and having all the answers, you soon learn that the focus is very much on you. You are the performer. The client is sitting in the bleachers watching the game. In actual fact, I answer questions that clients pose. I do so alert to the possibility that they may be less interested in my knowledge or judgment than they are in establishing an implicit agreement. The terms of that agreement are these: They have no useful information while I do. They are lacking knowledge but I am not. They are not responsible for inquiry and solution, I am. A variation on this ploy by clients has always amused me. When student therapists listen to my recorded exchanges with clients, the consensus is that I am direct and full of observations, opinions, and judgments for my clients. Yet, from time to time a client will complain:

C: Why don’t you just tell me what you think? I don’t know whether you want me to dump this guy or stick in there!

Or:

C: It’s unclear to me whether I should confront my boss or somehow quit being mad about things. What do you think? Just what should I do?

In response to this kind of inquiry, I might say the following:

T: Downloaded by [New York University] at 02:06 15 August 2016 I ﬁ nd it hard to believe that you are unclear on what I think. I pretty much let you know what I know even when I am relatively uncertain. So I think something else is going on here. What you may be fussing about is not my failure to tell you what I think, but what it is I have told you. You’d like a different message. And what you may not like is that I’ve said that nobody can decide for you what you value. I can’t live your life for you. I can’t tell you what to do. I can examine the matter with you, look at alternatives, and help weigh consequences. But whether one thing is more important to you than another is yours to decide.

89 THE THERAPEUTIC PROCESS

Conclusion How is it that the therapist understands the messages sent by clients, which are so often indirect and enigmatic? How does he or she gain insight into the client’s behavior? The client enters therapy a bit like the famous invisible man, not manifest to normal scrutiny. We could reveal the invisible man by spray- ing him with paint, making him partially visible. That is what our subjective responses do. They sweep over the vacant spaces inhabited by our client and make at least partially visible the identity hidden therein. This process is not always clear or serene. Indeed, the therapist may learn most from moments of confusion and discomfort marked by unwelcome tendencies alien to helping the client. Analysts called these moments countertransference and worked to erase them from the therapist’s make-up. This is impossible, and even if possible, wasteful. It is by attending to and being informed by the countertransference that the empty spaces in the client’s person are fi lled. Insight into clients begins with the struggle to understand one’s self and how one is prompted to depart in various ways from the role of helper. The rules we have examined in this chapter will not substitute for your subjective responses. They will not make richer those responses or assure that your intuitions are true. They are designed instead to help you husband and harvest your responses in the interest of making them maximally available to you. Whether or not your responses truly reveal your client will be answered by the outcome. Confi rmation comes when your responses help uncover vistas for change which, once undertaken, result in desirable effects. I have sometimes said to clients that insight is like a map. Before taking a trip, we consult a map to get some idea of where we are and what we must do to get where we are going. If we begin not at all sure where we are, then we will have to look around us for road signs or other prominent geographic markers. These we attempt to match with the features of our map. In this manner, we hope to establish our whereabouts. Without the map, we would be uncertain about the origin of our trip and uncertain which way to go. However, even when we are confi dent that we know where we are and clear about what to do to begin our journey, the trip itself remains before us. Insight and maps are invaluable in readying one for an effort, be it a journey or changing one’s life. Neither, however, as such, constitutes the fi rst step in the journey or in changing one’s behavior. Downloaded by [New York University] at 02:06 15 August 2016

Note 1. As Mowrer’s research assistant while a graduate student at Illinois in 1951, I attempted with others to ﬁ nd ways to render Mowrer’s transcribed therapy hours with a number of his clients into quantiﬁ able categories and dimensions. This was one of those cases. The process alas did not, in the time I acted as Mowrer’s assistant, bring about publishable results. It did, however, leave me most grateful for the opportunity to examine and incorporate a master therapist’s approach.

90 6 FROM INSIGHT TO ACTION

No one wants to know how clever you are. They don’t want an insight into your mind, thrilling as it might be. They want an insight into their own. —Mark Haddon, author and poet

Insight as a Map

A Less Than Perfect Fit Concluding the last chapter, we noted that insight could be compared to a map. Lacking a map, we may never get where we want to go. Lacking insight, we run a similar risk arriving at the goal of personal growth and change. The map is a valuable metaphor. However, we no sooner use it than we must draw attention to certain ways it does not ﬁ t. Picking up a map and looking at it is usually uncomplicated. Of course, we might discover that our trip involves crossing very rugged terrain and wish the map were wrong. We might, if troubled enough by the idea, check with a different map to make sure. However, normally we accept the map without issue. This is not the case with insight. Insight usually entails a contest. The client resists seeing what the therapist may ﬁ nd obvious. Why? Because the client has a heavy emotional investment in making the unworkable work. At an earlier time in the client’s life, it did work! Life would be so much more satisfying if that had continued to be

Downloaded by [New York University] at 02:06 15 August 2016 the case. Not that the client’s ways of acting have ceased altogether to bring comfort because, in the near term, they continue to do so. The problem is, however, the mounting costs this lifestyle also brings. These costs have been tardy in making their appearance. Now, as time goes on, they gather like angry, black clouds marching across life’s horizon. Insight has revealed the link between the accumulating costs and the faulty lifestyle. To clients, this is unwelcome news. They have worked to keep apart or dissociate the linkage between act and outcome using strategies that rely on deception both of others and of themselves.

91 THE THERAPEUTIC PROCESS

Insight and Effort So it is that developing insight in therapy is not precisely like spreading out a map in preparation for a trip. It is more effortful. It is born in a struggle between opposing camps existing within clients. In one camp are those forces fed by addictive dependence and by the false hope that the unworkable lifestyle will yet work. In the other camp are those forces fueled by emerging personal alarm but also by another, quite different form of hope. The new hope grows from the prospect that a different brighter future is possible if only addictions are conquered. Still, there remains a key identity between the map metaphor and client insight. Both are necessary preludes to beginning a journey, whether geographic or psychological. We do well, however, to keep the accomplishment of insight in perspective. Clients often experience the gaining of insight as a major victory. For persons who have long wandered in confusion and despair, perhaps it is. However, we know that, in spite of understandable exhilaration fostered by insight, the task of changing their lives still awaits them. Be wary of joining your clients in celebrating the victory of insight. Be wary as well of clients who seem to be content with their insights and who revel in their newfound honesty. The world is ﬁ lled with people who proclaim their candid understanding of themselves, who appear to know full well what troubles them, and do nothing about it.

The Truth in Insight

The Test of Action: A Case Illustration Insight that does not bring with it a more urgent sense of guilt and personal responsibility is probably faulty. True insight exacts a cost. It is, also, inher- ently volatile. That is, the discomfort it generates tends to bring either an advance or a retreat. It is the therapist’s job, as insight emerges, to push for an advance, to load the scale, if possible, for growth and against regression into pathology. In this spirit, the therapist constantly seeks, with the client, ways to test insights and to transform client insights into client actions. In the end, acting on insights is the only way to test them. Take, for example, a man, call him Ted, who complained of obsessive thoughts about doing

Downloaded by [New York University] at 02:06 15 August 2016 harm to his fi ancée. These thoughts bothered him deeply. Ted had always been a shy man and marginally successful with women. Then he met and wooed an attractive young woman who agreed to be his wife. Ted was fi lled with joy and a new sense of confi dence in himself and in life. The appearance of thoughts of doing harm to this wonderful girl dismayed and mystifi ed him. How could any thought of harm to one whose presence had so enriched his life be present at all, much less repeatedly so! Ted had experienced similar violent thoughts directed at a business partner who often dominated him and was unfairly critical of him. Dwelling on these

92 FROM INSIGHT TO ACTION

thoughts, however, had troubled him little. Apparently he believed it was all right to indulge in such thoughts about his partner, but not about his fi ancée! Yet, here he was doing just that. How could we explain it? Insight is usually achieved in stages. A rough fi rst approximation is advanced. This brings on an exchange in which additional information surfaces. This information may be revealed by what the client says, does not say, how he or she acts, and what is expressed. Based on this new information, corrections or refi nements are made in the insight. In this instance, the fi rst approximation advanced was that Ted had developed his “doing harm” thoughts as a way of contending with critics. He was able to avoid direct confrontation with a critic, yet destroy the critic without risk of being destroyed. Ted must have felt, as he grew closer to his fi ancée, that she was becoming more critical in her appraisal of him. Ted acknowledged that he had been worried that this was true. So far, so good, but some refi nements were needed before we emerged with an understanding that seemed truly insightful to Ted. As his fi ancée grew to know him better, he feared she would become aware specifi cally of the way he behaved at work. In all likelihood, it was Ted’s own self-criticism that fueled his conjecture. He felt himself to be too passive in his dealings with his business partner. His tendency was to swallow his feelings, avoid dealing directly with his partner, and, then, fantasize some calamity visited upon that partner. Ted imagined that the love and respect of this young woman was changing into the same contempt in which his partner held him. This was intolerable. Even more intolerable, however, was the intrusion into his mind of venomous thoughts now directed at someone he loved.

T : So, for some years now you have behaved in a wimpy fashion to avoid the risks of confrontation. You’ve felt bad about it. You’ve felt your partner’s contempt. To gain relief, you practiced a kind of voodoo. You stuck pins in your partner by thoughts of harm and retribution. You grew concerned that your ﬁ ancée would see all this and become disillusioned with you as a person worthy of her love. Yet you have continued your ways, continued to hang onto this strategy of warding off criticism with murderous thoughts. And what has been the result? Why seemingly in spite of yourself, you have trained your thoughts on your ﬁ ancée! Your thoughts betray you. Won’t let you hide. That which when aimed

Downloaded by [New York University] at 02:06 15 August 2016 at your partner provided some inner solace has now become a source of alarm and shame. OK. What are you going to do about it? C: I don’t know. [sounding uneasy] T : Now wait. You see what you are doing. You see how avoidance of asserting what you think is right leads to feeling that your partner holds you in contempt and to your own self-contempt. You see that you worry that those work-related actions have caused your ﬁ ancée to become critical. You invented your obsessions to ﬁ ght off incoming criticism. It worked, apparently, or worked enough with your partner, but it is a disaster with

93 THE THERAPEUTIC PROCESS

your ﬁ ancée. Of course, the more you have relied on this mechanism to deal with critics, the more unprepared and unable you have felt to stop the wimpy behavior. Each step along here you have acted, made choices. It’s a vicious circle, yes, but it’s one of your own construction. OK, I ask again, what are you going to do about it?

After a long pause and a good bit of heavy thinking, Ted ﬁ nally said:

C : I am going to stop running from issues with my partner. I’m not sure I can always stop. It’s such a habit! But, I’m going to make it my goal to confront him when I disagree or think something should be done differently. T : Bingo.

Several weeks later Ted reported that his obsessive thinking toward both partner and fi ancée had all but disappeared. As he had suspected, it was not easy to replace his old behavior with new, forthright interactions with his partner. However, he had done so enough to win relief from his obsessions. The insight tested positive. His action provided a confi rmation of the hypotheses we had together advanced. Had Ted not experienced this confi rmation, we would have had to return to the drawing board. We would have had but one small advantage in doing so. We would have known that the obsessive thinking did not, in the end, stem from nonassertive interactions with his partner in the work place.

Whose Insight and When? There is another way insight departs from our map metaphor. The metaphor implies that the map belongs to the traveler. In therapy, insight does not always belong to the client. It works best when it does, but sometimes the client does not see what the therapist sees. Perhaps this is resistance. Perhaps it is a blindness arising from old habits protecting and justifying the addictive lifestyle. Perhaps, you, the therapist, are wrong. However, if you have examined your perceptions and judgment and persist in your view, then stay with it. Your clients expect and deserve your stead- fastness, particularly in the face of their resistance. This does not mean that

Downloaded by [New York University] at 02:06 15 August 2016 you insist on your way. It does mean, however, that you will keep important matters before clients. It means that you will not permit client opposition to dictate to you what you see. Clients distort reality already. Do not permit them to distort you, the representative of reality. How does the therapist avoid an impasse under such conditions? You appeal to clients’ basic desperation and to their residual faith in you:

T: Yes, I may be wrong. I’m human. But you have come to me to give you my best shot. You don’t want me to back away from what I see. If I’m right,

94 FROM INSIGHT TO ACTION

then I would be doing you a disservice to back off. If I’m right, then the way out for you has certain deﬁ nite requirements. Now, you want to ﬁ nd that way out. It may come down to a matter of faith in me and just how badly you want out. You see, you have lots of reasons not to trust your own judgment. You’ve come to me having lost faith in your judgment. You’ve said you just don’t see this, and how can you act if you don’t see it? But the paradoxical truth is you may never see it until after you have acted. Sometimes we learn the reason why to act only after we do so!

I spoke in this manner to a woman of 35 years whom we will call Ann. We had spent many hours going over Ann’s phobias and her dependence on a female companion, her ex-husband, and her parents. Without these security fi gures she was virtually motionless. Ann had a furtive air, as if she were an animal being stalked. She remained immobile except when under the “protective custody” of her security people. Ann explained that she had always been a rather mousy, retiring person. In her adolescence she had had few friends and was not active in dating. After 15 sessions, she made a revelation. Starting at age 14 and lasting for four years, she had engaged in regular sexual relations with a man whose children she watched as a babysitter. The man had come up behind her during a neighbor- hood party and suggested that she come to his home while his wife and family were away. She did. Their meetings followed a similar pattern after that. He would let her know that he was alone and she would come to his home. At fi rst, Ann defi ned their intercourse as a form of rape. She also was unable to recall details particularly having to do with her own initiatives in the affair. In spite of a former therapy of some several years, she had not revealed the matter previously. Indeed, the only person to whom she had made known her secret was her female companion, her prime security person, with whom she lived. Yet Ann was curiously empty of feeling about the matter. She felt no guilt. She felt nothing. She saw no relationship between her phobias and this revelation. This was true even though her fi rst panic attack occurred soon after she had discontinued the affair and as she was entering her adult years. The implications of this dark secret so long submerged by this intensely phobic woman

Downloaded by [New York University] at 02:06 15 August 2016 were enormous. We began to examine these implications:

T : First, I am struck by how concealed your actions were. What a contrast between your outer appearance and the reality! You were not popular, did not date. Yet, behind the screen of your retiring ways you carried on this lusty adventure. Something you hid from all and essentially have kept hidden to this time. Indeed, you have disguised it from yourself! You have thought of it as rape. You have harbored accusative thoughts toward the man. Yet, on the

95 THE THERAPEUTIC PROCESS

face of your description, it was entered into by choice, consent, and by your initiative. You came to him. True, it was statutory rape. And had your parents learned about it, they could have brought charges. But you were careful that no one learned about it.

My comments prompted a period in which Ann protested the wickedness of the man. Then, ﬁ nally, she said:

C : You’re right. It wasn’t rape. But men like him are so despicable. I was naive, barely more than a child! T : You practice such deception on yourself. You bleach this experience of meaning. I have no brief for this man at all. He was an adult. You were a child. What he did was despicable, illegal, wrong. There is no issue about his behavior. But what of your behavior? Perhaps had it been a single episode, you could console yourself with your naiveté and innocence. But were you innocent for four years?

Considerable discussion was directed at the distortion this woman created about her affair and her emotional distance from it. We then began to examine next steps.

T: You have wrapped this matter in a blanket of secrecy. What does it mean to you? You don’t know. What would people do if they knew? Is it this guilty knowledge that powers your fear of strangers met in public places? You don’t know. However, you might learn about yourself and about others if you no longer protected this dark secret.

Ann was resistive to the notion of disclosure to anyone other than her female companion. Her ex-husband continued to occupy a signal role in her life and was in daily contact with her. He and her parents represented two of the three security sources so important to her. Finally, she disclosed to her ex-husband largely on faith and very little out of personal conviction of its value. Later, after much reluctance, she told her parents. With each telling she demonstrated a new measure of self-awareness. Insight into the relationship between her habit of hiding the truth and her furtive life of panic grew only after 1

Downloaded by [New York University] at 02:06 15 August 2016 she had acted.

Conclusion The map metaphor is a useful way to characterize insight, but there are speciﬁ c exceptions worth noting. Looking at a map ordinarily is an uncomplicated act free of conﬂ icts of interest. We want to go someplace, so what route do we take to get there? Such is not the case with gaining insight in therapy. Ordinarily,

96 FROM INSIGHT TO ACTION

insight is complicated by a stubborn confl ict of interest that clients bring right from the beginning. Clients want to go someplace, yes, but they hope to get there without the effort and sacrifi ce that insight inevitably illuminates. They wish to achieve a life free of pain, but they do not want to relinquish their current manner of conducting their lives. Another exception to the metaphor resides in the question of whose insight will prevail. Usually, maps belong to the traveler; but in therapy, insight is not always the client/traveler’s. On some occasions, actions, if they are taken, will precede insight by the client. What drives such action, then, absent client insight? Two factors: Desperation over the worsening state of one’s life, and faith or trust in the good will and vision of the therapist. Be wary of cheap and easy insights. Be suspicious of times when you and/ or your client feel victorious in achieving insight. For you, the therapist, of course there is real satisfaction in emerging with a clear sense of understanding of clients and their problems. However, the map metaphor should tell you that the more challenging issues still lie ahead. The journey itself has not yet begun. Similarly, clients may fi nd relief in and gain hope from having a new understanding of and a new perspective on their lives. However, this relief and hope are always mitigated by the costs of insight. A fresh and urgent sense of self-criticism and personal responsibility accompanies true client insight. Whether an insight is true or not is yet another reason for caution in its celebration. Truth awaits the test of action just as we might validate a map when, aided by it, we arrive truly at our destination. I referred above to clients acting on faith when they do not see what the therapist sees. There is, however, another sense in which actions quite routinely precede insights. This is revealed if we examine assumptions about the three stages (introduction, engagement, and action ) through which therapy passes. You might well assume that these stages proceed in a linear sequence ending in termination of therapy. Accordingly, you will expect insight (emerging in the second stage) always to precede action. That is, the therapy fi rst establishes a bond between client and therapist, following which the therapy generates insights. Finally, it promotes action by the client based on these insights, bringing the therapy to a conclusion. In actuality, bonding, insight, and action advance in fragments or partials

Downloaded by [New York University] at 02:06 15 August 2016 rather than wholes, and these fragments spiral into larger fragments that in time converge toward a whole. However, at any particular moment, clients may undertake some less than total behavioral changes based on a less than full understanding of themselves and their problem. The aftereffects of these action fragments feed back into the sequence ﬂ ow and serve usually to strengthen the client–therapist bond and to clarify and promote insight. This feedback spiral makes clear that clients ordinarily gain insight almost as much from actions they take as they launch actions from the insights they gain.

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Note 1. This brief summary skips quickly over numerous barriers and delays this woman fashioned to avoid disclosing. Not only did she resist initiating disclosure, she rather skillfully worked to eviscerate what disclosing she did undertake. As a result, her gains were initially modest. Yes, she grew more insightful. She began to see how her phobias worked to create a small colony of persons joined in helping her retreat from life. However, she remained for some time curiously unable to put those insights into action. She remained self-aware yet stubbornly agoraphobic. A recess from therapy was helpful in promoting a reexamination of her past disclosures and how she had impaired them. This helped her take further action to dissolve her reliance on fear. We will return to this woman’s experience with disclosure in the next chapter. Downloaded by [New York University] at 02:06 15 August 2016

98 7 CLIENT ACTIONS

I don’t think telling the truth ever gets anyone in trouble in the long run. Maybe the day after, but not in the long run. —Steve Spurrier, celebrated coach and social critic

Client Disclosure

Disclosure as the First Action Taken Ann, introduced in Chapter 6 , had been seen in a previous therapy an unusually long time for a behaviorally oriented approach. She was well versed in systematic desensitization and other procedures designed to extinguish her fears. These had worked to a point. However, she had regressed because her phobias were more than mere unrealistic fears. They were the fabric of her justifi cation for hiding. As she said, “My phobias were my identity. I grew apprehensive at the prospect of giving them up.” As long as she remained a person in hiding, then her phobias would stubbornly persist. Recall Ted, the obsessive man, also discussed in Chapter 6 . For Ted, insight led to changes in the way he acted toward a close associate. Ted took steps to admit and express something he had previously kept hidden. That hidden something was his differences with and opposition to his partner, matters he usually kept to himself. The reason he turned his voodoo thoughts against his fi ancée was not only his fear that she saw that he did not stand up for himself. He also imagined that she grew aware that he hid this failing from Downloaded by [New York University] at 02:06 15 August 2016 her and others. Ted was able to free himself of symptoms by disclosing his opposition to his partner and taking the consequences of his partner’s occasional displeasure over this fact. Disclosure in this case was, somewhat uniquely, both the fi rst and last step Ted needed to make as far as resolving the problem fi rst presented. In nearly all cases, acknowledgment to signifi cant other persons of matters hidden from them is, generically speaking, the fi rst and most seminal action to undertake. Other steps, however, usually follow.

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Why does client disclosure to signifi cant others constitute the starting point in transforming insight into action? In pursuing this question, attend fi rst to the weight clients give to the question of telling or not telling others. Clients convey clear and anxious signals of the power that disclosure holds for them. For example, clients will sometimes elicit from the therapist assurances that all they tell the therapist will be held in confi dence. I always provide that assurance without interpretative comment. However, at some later date I am likely to say:

T: To be sure, I will never tell anyone what you have told me. But I can’t assure you that you won’t. You may not be able to deal with these problems that you’ve presented and keep secret from others what you have told me.

The Insistent Secret: A Case Study A woman, let us call her Ellen, suffering from depression and marital unhappiness, illustrates the critical role played by client disclosure. Ellen and her husband, Jack, had originally come in together for conjoint therapy. It soon became evident that Ellen was personally distraught and wished to be seen alone. Individual contacts were begun. Jack was some 10 years older than Ellen. They were married when she was 18 years old and had been married about 10 years. Jack was dominant, tem- peramental, and full of anger toward work associates. He brought home his anger and visited it on Ellen. She had initially been in awe of her husband. Early in their marriage she had submitted meekly to her husband’s dominance. As time wore on, she felt less the child to his adult, and awe gave way to resentment. However, the habits of submission were strong. Thus, while she grew to feel that her husband had not noticed her personal development and maturity, she did not confront him. Instead, she withdrew into moody silence. Now matters had grown intolerable. After a couple of sessions, I observed that Ellen painted such a picture of personal misery that one would wonder why she remained in the marriage. After some moments of reﬂ ection, she acknowledged that she had entertained the same question. She then told of

Downloaded by [New York University] at 02:06 15 August 2016 an affair she was conducting with a work associate, also married. The matter was rather sticky. The man was her ofﬁ ce superior. She had duplicated with him the same role she had with her husband except that, this time, the older, accomplished man was attentive to and appreciative of her and her talents. As we examined her behavior, Ellen shifted in her view of the affair. Initially, she had put it out with an air of deﬁ ance. It became clear that part of the motivation for the affair was to enjoy a secret advantage over her husband.

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The more she looked at it, the less glowing was her view of the other man and the more shame she expressed about her affair. She translated these insights into action. Ellen approached the other man and informed him she was seeing a psychotherapist. She shared with him the sense of shame that had surfaced and declared the affair ended. To her surprise and dismay, the man abruptly shifted from the understanding, appreciative person he had been. He was upset to hear that she had talked about their affair with anyone. He suggested to her that it would be disastrous if she told her husband. He let her know that her job might be in jeopardy. Shortly after reporting this development, Ellen said:

C: I’ve learned a lot about myself. I’ve wanted Jack to understand me and appreciate me, but I’ve done little to make myself understood. Some of his actions just set my teeth on edge. I can see, though, that my actions have not made his life easier. Earlier, you and I talked about my options. We listed three. How I might think of making something with Ralph [the secret lover]. That’s a laugh! Then, I might decide to simply end the marriage. I’ve been very drawn to that option. You know, just to get out from under. Then, ﬁ nally, trying to make a go of our marriage. Really make it a marriage. Work it out with Jack. The thing is, I don’t think I could just leave the marriage and feel all right. I’d be ﬁ lled with guilt. So, I’ve decided that it’s time to get back in there with Jack and see what we can honestly make together. It’s time that we come together and work things out. T: So you’ve decided you want an authentic marriage. One with real sharing, real intimacy. C: Yes! If that can be had. T: I think I can understand that. But we have a problem right up front. You have said repeatedly that under no circumstances will you disclose to Jack the matter of your affair. That sounds contrary to your chosen goal—an honest, open marriage starting with a critical deception. C: [clearly upset] I know, but I just feel it would be an incredible barrier to coming together. Jack would be hurt, really hurt. He’d want to do something to Ralph. He doesn’t like him anyway. Besides, it’s done. It’s behind

Downloaded by [New York University] at 02:06 15 August 2016 me. I’m truly ashamed of what I’ve done. I don’t think I’d be any more ashamed if I told Jack. T: You have come to recognize that you have been unwilling to be open with Jack, unwilling to really “mix it up” and struggle through issues in your marriage. Now, you say that you want to reverse all that with one exception. It is, however, not a minor exception. C: Maybe, but it’s my life. I just don’t believe we can make a go of it if I hit him with that. Things are too fragile. Won’t you see us if I don’t tell?

101 THE THERAPEUTIC PROCESS

T: It is your life. And I respect your wish to grow and to quit behaviors that you have identiﬁ ed as unworthy. No, I won’t make telling your husband a condition of my seeing the two of you. But I owe you my best judgment. That judgment is that you will struggle with the contradiction between your goals and your actions. You believe you would erect a barrier to successfully pursuing your goal of an authentic marriage if you tell. I believe you erect a barrier to that goal by not telling.

Ellen and Jack came in together for a series of conjoint sessions. They worked hard and well. They hammered out agreements about the conditions of their lives together, about how they would behave toward each other in a variety of ways. They concluded the conjoint therapy in a mood of optimism. Not quite two months later, Ellen came in to see me alone. It was not going well although Jack was clearly giving his all. She was puz- zled about why she was unmoved by his sincere efforts, why she was so angry with him. I reasoned that her feelings might have some connection to her secret. Jack’s efforts could be causing a sense of inequity. Perhaps she nagged herself with the question of whether he would make such efforts if he knew about the affair. She gave sober thought to this notion, but concluded that their problems rested more in Jack’s work, which had been extremely demanding. They had talked of separating during this time of stress and, then, coming back together (after a six-week period) when her husband was free of work demands. They did this, but at the end of the period, she announced to Jack that she wanted a divorce. The following day, after spasms of indecision, she wrote him, saying she now had second thoughts. At that point, they both returned to see me. Ellen opened the session declaring that she had told Jack about Ralph! It had been, she related, a matter of personal integrity.

E: I felt that I could not leave this marriage feeling that I had held back, feeling that I had not taken every step available.

The disclosure was not received in a fashion often seen in my experience. Instead of being appreciative of the pain and remorse expressed by Ellen and

Downloaded by [New York University] at 02:06 15 August 2016 encouraged that she was on a new course of openness, Jack was testy and unforgiving.

J: Certain things are unacceptable. One is deception. While I was working to make things go, she had her secret affair. I look back at the times we were having problems with sex. She was going to this man. Hell, I had the same kind of chances. I was propositioned! Tempted too! Hell, I even confessed my temptation to Ellen. But I turned it down. No, I wanted this marriage to go!

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It turned out Jack’s atypical response was provoked by the unusual way in which Ellen had presented her disclosure. She had, she said, worked through her shame and had forgiven herself.

J: That leaves me without a right to forgive!

That she had disclosed her affair to Jack as an act of “personal integrity” did indeed send a strong message that she sought no forgiveness from Jack and expressed no regret to him. She did it perhaps more to clear the deck for possibly breaking off her marriage than to advance a new openness with Jack. Supporting her unrepentant attitude was the conviction that Jack had caused her affair.

E: I do blame you! But I can’t say that you deserve what I did.

However, that was exactly what her words and manner conveyed—her husband deserved her disloyalty. Each was perilously close to becoming locked in an unforgiving view of the other. While each acknowledged failings, each was reserving the major blame for the other. To my eye, matters appeared grim, and our effort to reconcile this marriage hung by a thread. These impressions, of course, I shared with the couple. They brought the conjoint therapy to a close in this brittle and electric atmosphere. I confess that I expected to hear later that they had separated or divorced. Jack spoke with me several months afterward, however, and related that they were “hanging in there.” “It’s not a Garden of Eden,” he said. “But we are plugging away.” His feelings were mixed. He was somewhat weary and resigned. He conveyed a measure of uncertainty about the future. Yet, he also got across a stubborn unwillingness to permit their anger to rule the day. He did not attribute their “hanging in there” to his wife’s belated honesty. He did, however, express his gratitude for the conjoint therapy. On reﬂ ection, I question the wisdom of not making disclosure to Ellen’s husband a condition of resuming the conjoint therapy. It was my conviction then, as now, that not disclosing was a barrier to establishing a working and lasting intimacy in their marriage. I did not require disclosure for two reasons. First, I believed that, if I did so, there was a 50–50 chance she would not con-

Downloaded by [New York University] at 02:06 15 August 2016 tinue in the therapy. Second, I reasoned that this woman would discover the need for disclosure during her effort to reconcile with her husband. Perhaps, she did. She did disclose ﬁ nally, but in a way which all but defeated the purpose. Her disclosure was as much an attack on her husband as an act acknowledging a personal debt and searching to restore equity between them. Of course, had I made disclosure a condition of meeting with this couple, two results were possible. First, she might, indeed, have broken off therapy. The most likely outcome of this would have been marriage failure and divorce. However, a less likely but possible outcome would have been a later return

103 THE THERAPEUTIC PROCESS

to the therapy. The motive for return would have been her sense of inequity. (This same force actually did twice bring her back and played a part in her belated disclosure.) The probable result of returning would have been very like what we had in fact achieved. Second, she might have responded to my condition by coming in with her husband. This would have meant that she would have begun reconciliation “in the open” giving me the opportunity to have input. The outcome of the conjoint therapy in this case would have been more promising. I place at the end of this chapter a reconstruction of the subjective probabilities that I attached to all these eventualities (see the Endnote at the end of this chapter). Had I undertaken the exercise as presented in the Endnote before waving the disclosure condition, I would have made a different choice! Why would disclosure at the start of conjoint therapy have encouraged a favorable outcome? First, in the beginning, this client was clearly remorseful about her affair. Her feelings hardened as the pair continued to experience marital problems. The result was that her belated disclosure lacked an acknowledgement of debt and remorse. Second, their initial efforts to establish a new, authentic marriage relationship were undermined by the presence of her secret knowledge. Her mystifying critical regard of her husband’s efforts arose from that knowledge. That angry regard was a way of justifying what she had done and her continued protection of it through secrecy. Belated though it was, her disclosure was necessary to laying whatever real basis this couple had for reconciling their marriage. She found that disclosure was also necessary to reconcile with herself. The secret was an insistent force in provoking both external conﬂ ict and internal unrest.

Resistance to Disclosure It is rare, indeed, for clients to greet the idea of disclosing with open arms. More predictable is opposition, sometimes strong and persisting. For example, in the three case illustrations above, only one (the obsessive man) took readily and with little resistance to the idea of disclosing. Because this step is always important and often crucial to the progress of the therapy, let us examine the guises that resistance assumes. As we shall see, there is one primary and two secondary themes in the course that resistance takes. As we examine

Downloaded by [New York University] at 02:06 15 August 2016 these, we will also review how the therapist may respond to client resistance to disclosure.

Disclosure Will Harm Others: The Primary Theme The dominant form that resistance takes is the objection that disclosing to others will harm them. Ellen, as already noted, strongly objected to telling her husband of her affair out of concern that it would cause grave hurt. She made much of the fragility of their relationship and reasoned that disclosure would

104 CLIENT ACTIONS

stress it to the point of collapse. Ann, the phobic woman, similarly objected to telling her ex-husband and parents out of concern for their sensibilities. Ann was at fi rst particularly adamant in her objections to disclosing to her parents, fearing profoundly adverse effects on them. Before employing Ann further as a case illustration, additional information is needed. The secret sex life of Ann’s adolescent years was not her only secret. After her divorce, she had become pregnant by her ex-husband. She had terminated this pregnancy in abortion. Afterward, she had persuaded her female live-in companion and security person, Mary, to become her lover. This was a short-lived episode as Mary was deeply confl icted and soon refused to continue their sexual relationship. However, Ann remained desirous of resuming it. Mary was Ann’s only confi dant. Mary was fully sympathetic with Ann and accepted Ann’s self-justifying version of the adolescent sexual experience. Meanwhile, Ann targeted her ex-husband, Bill, as another signifi cant person in her life from whom she withheld critical information. Bill, Mary, and Ann owned a home and lived essentially as platonic cohabitants. I say essentially because on an infrequent basis Ann would favor Bill with sexual intimacy, although neither possessed a passionate interest in the other. Both, however, kept alive a vague possibility of reconciliation and remarriage. Bill, Mary, and Ann’s parents were critical security persons whose presence warded off panic and enabled Ann to function in her work and daily life. Ann strongly resisted disclosing to Bill her adolescent affair and homosexual behavior. Her logic in objecting to disclosing to her ex-husband was patently self-serving:

C: Telling Bill is going to be very hurtful to him. Bill is not a strong person.

Since disclosing to Bill appeared more accessible to Ann than disclosing to her parents, I decided to focus my observations on the resistance to telling Bill. What does one say to a client who utilizes the “concern for others” as resistance to being honest? Usually, you explore the self-serving, if eventually self-defeating, nature of the resistance. In Ann’s case, I proceeded as follows:

T: Downloaded by [New York University] at 02:06 15 August 2016 Is your reluctance to telling Bill indeed out of concern that his knowing will do him harm? I suspect there is another reason. If I were in your boots, I might fear that I’d suffer a loss of stature in Bill’s eyes. What would Bill think if he knew that you, his once wife, now friend and occasional lover, someone who has made repeatedly such anguished appeals for his protection, were in truth a bold sexual adventurer? While he has been very sympathetic to you, his views are pretty moral, pretty conventional. Would Bill condemn you if he knew about your adolescent sexual conduct? Would he feel betrayed if he knew about your

105 THE THERAPEUTIC PROCESS

homosexual episode with Mary? I suspect it is fear of his feeling betrayed, of his condemnation, and of losing Bill’s sympathetic view of and attentions to you that compose the true hurt you seek to avoid. Underneath all is the wish to keep this security person close and to protect your phobic lifestyle.

Soon after this critical examination of the harm in disclosing to Bill, Ann did speak with him. The way she proceeded, however, illustrates another feature for which the therapist should be prepared. The fact that a client reluc- tantly decides to communicate with signifi cant others and does do so does not mean the authentic story gets told. As Ann later related the matter, it was clear she both withheld information and related other matters so as to emphasize Ann’s role as victim. Bill accepted what she did relate without judgment of her. Instead, he directed very harsh criticism at the neighbor as a man who would “take advantage of a child.” He was also understanding of her abortion that he agreed was, at that point in Ann’s life, a diffi cult but necessary choice. Ann was relieved and did not proceed to disclose her homosexual behavior. Ann had simply compromised with the goal of accepting responsibility for her own actions through authentic disclosure to a signifi cant other. While Bill’s response was reassuring to Ann in the short term, it proved to be a problem for her in the long run. Why? Because disclosing to Bill had been an attempt to inaugurate a new course of personal accountability in interactions with signifi cant other persons in Ann’s life. How is this end accomplished when that opening step is subtly elaborated to play to the other’s sympathies rather than simply present the unvarnished truth? Ann felt obliged later to remedy this fl aw. It may be tempting to the therapist to “look the other way” and accept the client’s sometimes compromised efforts as “good enough.” Don’t do it. The client’s addictive and faulted lifestyle has been constantly a search for a compro- mise with personal responsibility. To accept a token and inferior effort as authentic disclosure is to accept and condone that faulty lifestyle. How, then, does the therapist deal with this insidious form of resistance to disclosure? What would you have said to Ann after her account of her communications with Bill? Here were my comments:

T: You permitted Bill to excuse you. You did not offer to correct his impres-

Downloaded by [New York University] at 02:06 15 August 2016 sion that you were the innocent victim. C: Yes. That’s true. T: Nor did you tell him of the lesbian episode. C: I just couldn’t. I’ve told you already about Bill’s drinking. He is a troubled person. I couldn’t load him down with that. I know it would be very hurtful to him. It would make our living together difﬁ cult if not impossible. I just couldn’t do that to him! T: I can see where it could undermine his assumption that you and he might resume your marriage. He might wonder whether you have a real interest

106 CLIENT ACTIONS

in marriage, and he might lower his own interest in it as well. The result could be that you would lose a critical support person. If this is what you fear, are you prepared to keep him in the dark in order to hang onto him?

She was not. After a period of delaying, Ann told Bill all and endeavored also to correct the mistaken impression left from her previous efforts that she was an innocent victim. The effect on Bill was initially adverse, at least as far as Ann was concerned. He withdrew from the company of both her and Mary for a period while he assimilated what this information meant to him. Eventually, however, he resumed his interactions with them, displaying much the same personal involvement as before the disclosure. Not once did he reprove Ann or express regret that she had informed him. What were the effects on Ann of these excursions into openness? She began to feel a surge of conﬁ dence and, as a result, began to examine the notion of telling her parents. The prospects gave rise to intensely conﬂ ictful feeling:

C: How can I do this to them? Will any possible gain I feel really be enough to offset the shock and bewilderment they’ll suffer? You just don’t know them. All my life my mother has cautioned against any form of risk. She taught me to fear. She has been preoccupied with calamity. Telling her will bring home all her apprehensions for me. And my father! It would kill him! He takes medicine for his heart, you know. He would simply explode. My father is reactionary to the extreme. He’d probably want to kill James [the partner of her adolescent sex life]. They both have spoken of him with such high regard through the years. What a shock it will be for them to learn what he’s really like. And telling them about me and Mary? I absolutely can’t do that. It would devastate them. They both now treat Mary as if she were their own daughter. How can I do this to them!

By the time Ann had ﬁ nished speaking, she sounded like she was fully convinced that disclosure to her parents was out of the question. Yet, it was also clear that she looked forward to my response to her objections. Clients soon project their ambivalence and inner division onto their relationship with the therapist. They challenge you to take sides, and in the end you will take sides,

Downloaded by [New York University] at 02:06 15 August 2016 indeed, you must. The side you take is that force within the person for growth and integrity. Again, you might pause at this point to think how, as therapist, you might respond to Ann. What I said was:

T: You are fascinated by the idea of disclosing to your parents. You want badly to begin to move from this phobic lifestyle you’ve created. Disclos- ing to Bill apparently has left you feeling encouraged. Perhaps, after all, you can emerge from a life of hiding, being afraid, and feeling guilty. The possibility is exciting. Yet, the idea repels you as well. It goes against your

107 THE THERAPEUTIC PROCESS

instincts. To be in the open, to be undisguised, and simply yourself. The idea is alien! I suspect it is this repugnance rather than concern for your parents and how they will cope that motivates your opposition to it.

Then I proceeded to sketch how Ann used her parents to rationalize her lifestyle and avoid personal responsibility:

T: Repeatedly you have placed the burden of your phobic nature on them, particularly your mother. She planted the seeds of your fear. Your father’s harshly judgmental nature frightened you into silence and secrecy. Together, they have saddled you with fear. It is remarkable that you depend on them for security and, at the same time, blame them for the fact that you do depend on them. Because of them you are not responsible for your condition. What you have done and kept secret has had nothing to do with it.

Ann’s resistance to disclosing to her parents was not quickly dissolved. Yet, she would not relinquish disclosing as a goal and challenge. At one point I said to her:

T: You say you feel you must do this. No, you don’t. No one is forcing you to do this. You do not have to do this to satisfy me. There is no compulsion to disclose to your parents. If you do so it is because you decide to do it. Why would you decide to do it? Perhaps, because you have placed faith in me, and you decide based on that faith that disclosure will be valuable to you. Perhaps, because based on the strength of your own perceptions and convictions you see that to do so will advance your life. But your faith, your perceptions, your convictions belong to you, and any decisions you make based upon them belong to you. C: Oh, I think it is my decision. I don’t want to do it, yet I feel I must. T: You’re talking about a deep division you’re feeling here. On the one side are the comforts of your phobic life, a life of retreat in which you feel you control and reduce the risks which are out there in the world. Those comforts come at the cost of a sense of autonomy and personal power. You relinquish your freedom to move in space, to make contacts, to adventure.

Downloaded by [New York University] at 02:06 15 August 2016 It boils down to a question of which side is more important to you. It would be true to say that you must not disclose if your phobic life is more valuable, more central to your person.”

In a later session after reporting that, once again, she had not accomplished the goal of disclosing to her parents, she noted:

C: Yes, I do believe it would help me to tell them. But can I really justify doing that to them because it will help me?

108 CLIENT ACTIONS

Ann then went into a long discourse about how constantly tormented her parents were by the recurrent problems dumped upon them by her sister. Her sister had always been a source of heartache to her parents because of her impulsive, sometimes manic behavior. Ann was, by contrast, the “good daughter” upon whom the parents relied and in whom they found compensa- tory satisfaction. What a calamity, then, she would visit upon her parents! She would be denying them any sense of success about their two daughters. Her disclosure would shatter their brittle, precarious lives! After hearing her out, I said:

T: I can understand your reluctance to destroy the illusions your parents may have about you. Those illusions are advantageous to you, indeed, compared to the views held about your sister. However, will the truth shatter them? Or is this yet another way in which you blame them and diminish them? If you could give them the choice between living with an illusion and living with a real daughter, what do you think they would choose? Would they prefer illusion over reality? Would they prefer that you remain a closed, hidden person who, among other things hidden, secretly blames them for her unhappy state, or would they want a real daughter whom they honestly know? I suspect your parents have a lot more capacity for reality and humanity than you credit them with.

At last Ann did tell her parents. She had rehearsed what she would say to them and had gone over that in our sessions. When she did carry through, it was, by contrast with her halting efforts with Bill, a relatively complete and quite moving exercise in disclosure:

C: I told them that I wanted to speak with them. We met at home. I told them that, as they knew, I had been struggling with phobia for years. I said that I was speaking to them now in an effort to lay aside behavior that probably has contributed to my phobias. That behavior has been a long practice of hiding from them and others what I was about. It was also a long practice of avoiding responsibility for myself. I told them that one of the ways I did this was to blame them for being

Downloaded by [New York University] at 02:06 15 August 2016 a fearful person, and that I even blamed them for being a hidden person. Then I just laid it out. I told them about the four-year relationship with James and how I had tried to justify it as a kind of rape, which it was not. I told them that I had taken critical initiatives, which I had long hidden, from myself as well as them. Then I told them about the pregnancy and the abortion. It was hard telling them about Mary. But I told them that I had started that [the lesbian affair] and that Mary had broken it off because it went against her principles. I told them that I had lived for years in guilt and

109 THE THERAPEUTIC PROCESS

remorse over my behavior, that I was telling them in order to launch a new life of responsibility for myself and my actions. I told them that I was ashamed of having blamed them for the things I had done and experienced. I said I was sorry. T: Well. That sounds like a very thorough job! C: I feel so different about them now [smiling broadly]. None of the dire predictions I made came true. They were warm, concerned, and supportive. My father didn’t blow up. He expressed no blind rage toward James. My mother’s only comment was that she hoped that I had got expert medical attention when I got the abortion. My father said something to the effect that we must learn to put the past behind us, and that he hoped what I had done would help me do that. And later they greeted Mary as warmly as ever. All these years of harboring these hateful feelings for them! That’s what I feel I am now able to lay aside!

This was a dramatic and transforming moment in Ann’s life. It was as well a moment reconﬁ rming my conceptual framework about people, their quandaries, and how one helps them deal with those quandaries. But before passing on to the next section, let me present yet another tack I have taken in meeting the hurting others form of resistance. It is illustrated by Ellen and her disclosure resistance discussed earlier:

T: “You say you do not want to hurt your husband by telling him about your affair. You have already hurt him. Persons infected by a deadly disease are not less victimized because they are ignorant of having been infected. Sure, telling them will upset them, but we usually feel that victims ought to know. Without knowledge, they are unable to act prudently to safeguard themselves against the effects of the infection. You may not want your husband taking certain steps to safeguard himself against a recurrence of your disloyalty. You may not like his expressions of anger or dismay once he has learned he has been hurt. But the hurt to him and to your relationship is something he can’t address effectively with you while he is in the dark about it.

Hidden injuries about which the victim is ignorant actually do more harm

Downloaded by [New York University] at 02:06 15 August 2016 than those known to the victim. How is this true? First, as just noted, the injured party lacks information that would be useful in protecting him/her or affecting a remedy. Second, if the injurer is cloaked, he or she is under less restraint to repeat the injury. The victim is, consequently, at greater risk for added injury. Third, if the injury remains unacknowledged and unremedied, it also remains, as a result, a source of inequity between injurer and victim. This inequity causes guilt in the injurer that promotes self-justiﬁ cation through viliﬁ cation of the victim—“He/she deserves it.” This constitutes additional injury to the victim.

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Finally, if injurer and unknowing victim have a continuing relationship, the secret injury becomes a hidden agenda that biases and sullies the transac- tions between them. “Why is she so angry at me,” the ignorant victim thinks, and proceeds to defend, attack, compensate, or withdraw. “Aha,” thinks the injurer “see how he behaves! He is proving how right I was to act as I did [in hurting him] and how necessary to keep it secret!” Communications between injurer and victim are chronically misdirected, misinterpreted, and problem- making rather than problem-solving.

The Intellectual Resistance: A Secondary Theme This theme usually occurs along with the primary hurting others theme. It consists of an abstract and intellectual questioning of the logic of openness. It has two parts. The fi rst is an effort to transform the issue from one regarding a specifi c act of disclosure to a specifi c person into one regarding disclosing in general. The second part is then to raise questions of logic about the principle of following a transparent life. I may invite this form of resistance by my practice of giving clients a pamphlet entitled Disclosing Secrets (see the Appendix) when the question of disclosure arises. I am not sure the pamphlet is critical because the same resistance tactic was present before I composed the pamphlet. However, in the pamphlet I examine the rationale for disclosing, to whom to disclose, and how to disclose. The essential reason advanced in the pamphlet for disclosing is “. . . to regain a clear sense of ourselves, to regain our identity. . . . Disclosing moves us toward reestablishing both our social and personal integrity” (see the Appendix, Disclosing Secrets ). Hard on the heels of this I write, “If what I have said regarding Why disclose is applied to the question To whom disclose, then the answer is simple. Everyone.” Whether clients fasten on this passage in the pamphlet or not, the focus of this form of resistance is the logical absurdity of “radical openness.” How can you tell everyone? We do not have enough time to conduct the necessary commerce of our lives and spill all. Besides, is this not patently foolhardy? People do take advantage of those who expose themselves! Tell a boss already angry at or critical of you some damaging secret and he or she will use it to fi re you. Tell a competitor about your “hole card” and you lose

Downloaded by [New York University] at 02:06 15 August 2016 a business advantage, which may be disastrous to your employer, your company, and your co-workers. Tell a friend that you really think his effort to act and look younger than his years makes him appear desperate and pathetic and you lose a friend. Does not a certain amount of deception have its place in normal, everyday human commerce? Are we not forced out of prudence, if not kindness and consideration, to misrepresent ourselves to others? These are among the arguments advanced by those mounting an intellectual resistance to disclosing. These arguments are logically persuasive and not without relevance to the question of whether one embraces in principle an open, transparent life.

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However, as a therapist, you must keep in mind that this logical opposition to disclosing in general is motivated by the client’s opposition to a very particular disclosure. While you may be tempted to join the debate on the level of principle, that would be a serious error. The question is not whether your clients accept some abstract principle, but whether they disclose a particular matter to a speciﬁ c party or parties. The deciding point is not whether one can logically be open in all things to all people. It is, rather, whether it advances your clients’ mental health and personal growth to disclose some particular matter to speciﬁ c persons. What do you say, then, to clients advancing such intellectual resistance to disclosure?

T: You are making some good points about transparency and openness. We could debate the matter and perhaps come up with a principle of something less than absolute honesty. But I suspect that to do so would lead us away from what is of real importance to you. I suggest that what is important to you is what you have kept secret from your intimate others. And what is at issue is whether you tell them and accept the costs for your actions. I suspect that it is your reluctance to confront this issue of speciﬁ c disclosures to speciﬁ c persons which prompts you to divert attention to the issue of whether to disclose all to everyone.

Actually, something less than absolute honesty, or disclosing all to everyone, is proffered in Disclosing Secrets (see Appendix). Indiscriminate disclosers are usually troubled persons who “. . . hit upon disclosure in the search for relief from guilt or for attention. This abuse of disclosure and of the sensibilities of others is not what [Sidney] Jourard 1 had in mind when he spoke of transparency. The only time you would ever literally tell everyone is when everyone has an interest in listening. This might be the case if you were famous and had a disclosure about a public trust, or when you might wish to entertain or instruct” (p. 239). Disclosing Secrets advances a conditional principle of disclosure: “Be prepared to disclose to anyone, but initiate disclosure only to those whose interests are affected by what you disclose” (p. 239, italics added). Put into effect, this

Downloaded by [New York University] at 02:06 15 August 2016 is a robust principle. Its observance would not result in compulsive confession but in prudent and appropriate communications with signifi cant other persons. Someone adopting such a principle would be untroubled by cancerous secrets and by complicating strategies of denial and justifi cation. There is, however, often no single or simple answer to complex confl icts of principle. Fortunately, we are saved from weaving a course through diffi cult and ambiguous moral judgments because, ordinarily, the client’s secret departures are not composed of such subtle fabric. Instead, we deal with base materials, with actions about which there is broad consensus and clear judgment. For

112 CLIENT ACTIONS

instance, Ted’s case was that of a business partner unwilling simply to declare his honest opposition to courses that his own business venture was taking. Ted permitted his partner to decide matters, then would grumble internally, sulk, and practice his obsessive mental voodoo. Elemental to a partnership venture is the rule of shared decisions and shared responsibility. Ted was shirking both. Ellen was involved in the age-old sin of adultery. She wrapped her disloyalty in modern terms, speaking of a dominating, insensitive husband unwilling to pay heed to her distress about their marriage. However, her way of expressing her distress was destructive and hurtful. Ann, for her part, kept secret chronic sexual delinquencies of her adolescence, which, if known to her parents, probably would have provoked their serious remedial intervention. She then hid an abortion and an excursion into homosexuality, both of which conceivably were critical to those constituting her intimate support system. In hiding these matters, she sought to insure their protective and nurturing attentions by denying them information that might have prompted them to distance themselves from her. In all three cases, we deal with the “meat and potato” issues of interpersonal relations. We deal with honoring interpersonal contracts, with basic human loyalty, with gaining at another’s expense, and ﬁ nally, with deceit practiced on signiﬁ cant intimates. With few exceptions, these are the kind of matters that comprise the dilemmas brought by clients into therapy. Only rarely do we advance from these elemental issues into the upper reaches of human moral concern. When this happens, it indicates one of two conditions. It may mean that your client is attempting to transform what are actually basic issues into subtle and ambiguous ones as a stratagem of resistance. However, it may be that your client has grown and developed to a point where he or she is left to wrestle with more profound realities of good and bad, right and wrong in his or her life. These are issues that we all face as mature adults, psychotherapists included. Wise though they may be, psychotherapists have no greater understanding and direction in these matters than other thoughtful persons. When your client has progressed to such a level, it may be, having shared whatever wisdom you have, that it is time to consider that the therapy has gone about as far as it can go.

It’s None of Their Business: A Secondary Theme Downloaded by [New York University] at 02:06 15 August 2016 Some individuals express high regard for their own privacy and separateness from others. They ﬁ nd the idea of disclosing to anyone tantamount to com- promising their personal boundaries, their sense of self. While often expressed in company with the hurt others theme, the it’s none of their business theme is sometimes put forth alone. Such was true in the following case that may help illustrate this resistance theme. Janice was a tall, slender, strikingly attractive woman in her middle years. A highly placed company executive, she lived alone with her college-going

113 THE THERAPEUTIC PROCESS

daughter. Janice made a strong initial impression. She was impeccably attired, and dress and manner came together in a picture of competent control placed in a frame of cool reserve. She came in because she had just experienced failure in a romantic relationship.

C: I just could not perform in bed.

So strong was her presenting image that it was, indeed, diffi cult to imagine this woman abandoning herself to the act of love. Janice had a theory. A stepfather throughout childhood had sexually abused her. At age 16, she brought it to a halt by taking a knife and slashing her abuser. Her theory was that her sexual inhibitions arose from fear conditioned by the abuse that she endured from age 4 to 16 years. That abuse started as fondling and advanced to regular intercourse by the time she was 13. The theory had obvious support, but it also had detractions. The major detraction was that Janice had engaged in prior satisfactory sexual intercourse, had a daughter while single, and had married when the daughter was in adolescence. Marital sex was, at fi rst, enjoyed but gradually lost its attraction and became something she endured. She concluded that she did not like her husband and, after fi ve years of marriage, divorced him some four years past. She had not been attracted to anyone else until she met the man whose company she had just lost because of “failure to perform in bed.” If conditioned fear explained her failure, it was curiously delayed in expressing itself. What better explanation was at hand? What emerged as a critical feature of her life as a child and adult was Janice’s profound reliance on secrecy. As a child and adolescent, she often blamed her mother for not discerning the abuse practiced by Janice’s stepfather. Yet, she decided not to tell her mother. She had two half-sisters and feared that, if she told, it would break up a “happy family.” At another point, she remembered that, as a young child, her stepfather’s fondling had felt good. She could not remember if or when it ceased feeling good. Janice did not remember that her stepfather threatened her or coerced her. Apparently, he came to her fully expecting her cooperation and ceased coming when she dramatically convinced him she was no longer cooperative.

T: Downloaded by [New York University] at 02:06 15 August 2016 What a terrible dilemma this must have been for you as a child. Some- thing that started, perhaps, as a kind of secret pleasure you had with your stepfather grew into something else as the years passed. You became more acutely conscious of the forbidden, wrongful nature of this behavior. Yet, the enormity of telling your mother grew with each passing act. So you did not tell. And ﬁ nally, in desperation, you drove your stepfather away with a knife! We speak of sexual abuse, implying that the victim is physically injured or hurt or frightened. But your stepfather didn’t do that. He injured you

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in another way. He put you in a desperate moral dilemma. He left you feeling both wronged and wrong. And in struggling with this dilemma, you decided to keep things to yourself. You decided to create an image for others to see, an image of correctness, control, competence, and distance. It is this that has carried over from that early experience. You learned to hold yourself back from others, from revealing anything about yourself. The result is that you feel inside that you are empty and worthless. C: Yes. I feel like a fraud. The world sees this outer Janice, controlled and competent. But, inside I feel just the opposite. Inside I have no control. I am nothing. T: You must feel very lonely. C: Yes, I do.

In the next hour, I suggested that Janice take steps to reverse her dependence on secrecy and image-making. Her problems with sexual intimacy were probably secondary to her unwillingness to engage in personal intimacy, to share and disclose herself to those with whom she would be close. However, while Janice found that disclosing to me in the protective conﬁ nes of the therapy was rewarding and reassuring, she was most unwilling to expand that practice beyond the therapy.

T: You are treating the therapy as an oasis, a place set apart from life. Here you can be yourself, you can admit who you are and let down your guard. You are more intimate with me than you are with your own daughter! C: You may be right. But how can I start telling people what I have told you? It’s just none of their business! [long pause] I think it may be time for me to move on. I have never been in one place more than ﬁ ve years. I’ve been here almost four already. I always feel so much better when I go to a new place. When I am in a place for several years, I begin to feel like it takes all my energy to keep going.

In two succeeding hours we never got past Janice’s resistance to disclosing anything to anyone. We never discussed with what particular person she

Downloaded by [New York University] at 02:06 15 August 2016 might disclose some particular matter. We discussed the possibility that Janice take part in a group where she might explore disclosing herself to others in a relatively controlled atmosphere reminiscent of the therapy. She was clearly unwilling to explore such a path. Repeatedly, she resorted to her pet phrase, “Why should they know. It’s just none of their business.” In this manner, she kept redirecting the issue away from her reliance on image-making and hiding. She did not seem to attend to my effort to focus the matter on her need to tell rather than others’ need to know. Unlike the other cases I have discussed illus- trating resistance to disclosing, Janice discontinued therapy at this juncture.

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As always, I agonized over the withdrawal of a client in whom I had invested myself. Did she decide to rely on her “geographic cure”? Obviously she thrived on the reception others accorded the image she was able to project of model-perfect composure. Apparently, the payoff she realized was integral to her daily living so that the thought of relinquishing the outer image for the inner reality was too awful to pursue. Had I failed to recognize with her how very wrenching was the prospect of being without her image? On reﬂ ection, I would have to say, yes. I assumed that her loneliness, sense of fraud, and deprivation of intimacy left her ready to suffer a different kind of discomfort in hope of a new life. Did I underestimate the satisfactions she gained from her image and the accompanying successes it brought, such as her obviously high employability? Did I overestimate the pain of her loneliness and interpersonal distance? Did I overestimate the measure of hope that the potential for dissolving loneliness and distance would bring to her? Of course, the kernel question is, if I had been aware of these possible misjudgments, would I have acted differently? Yes and no. Yes, had I believed her more protective of her image, I might have recognized with her how dif- ﬁ cult giving it up would be. Yes, had I judged her only moderately troubled by interpersonal distance and lack of intimacy, I would have examined with her the depth of her desire to change. Yes, had she appeared to lack hope of achieving intimacy, I could have explored with her the value of interim steps (such as disclosing in a group). But no, I would have, in any case, confronted her with her addictive dependence on image projecting. No, I would have continued by, perhaps, other means, to point in the direction of self-acknowledgement and the exercise of openness with intimate others. I once consoled myself with the thought that she may return, but now I am no longer professionally active, and I believe she has long since effected her “geographic cure.” Other clients have withdrawn from therapy and later returned, and when they do they are usually the better for it. They return more resolved to endure the costs of change.

Conclusion Clients have taken signiﬁ cant actions well before the action phase of therapy

Downloaded by [New York University] at 02:06 15 August 2016 comes to pass. They have decided to seek help and have acted on that decision. They have decided to reveal themselves to you and have acted on that decision. They have decided to view themselves from a new perspective (insight). That perspective embraces rather than avoids personal responsibility. The good news is that they begin to see hopeful possibilities in their own choices and actions for resolution of the problems attendant on their current lifestyle. The bad news is that insight into their justiﬁ cation strategies, their mechanisms of defense, brings an experience of guilt and interpersonal indebtedness more sharply felt than before.

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All these actions, however, are preparatory to the substantive actions to follow. They represent acquiring the map in readiness for the trip yet to come. With few exceptions, the virginal fi rst step of that trip is the act of disclosure to signifi cant other persons. Let’s examine why. First, disclosure actualizes insight. If we come to see that our justifi cation themata have blinded us to our own actions, then disclosing to signifi cant others is a declaration of new sight. “I now see what I have done. I see myself in a new light. I wish to let you know what I have done, who I am, and acknowledge and register with you this reformation of my sight.” Second, disclosure reveals to signifi cant others actions that have been hidden or disguised. These actions are often injurious to the other and have contributed to inequity and to a chronically dysfunctional relationship. Their acknowledgement is a necessary prelude to any real resolution of interpersonal confl icts. The message to signifi cant others is “I have come to recognize that I have injured you by behaving as I have. I declare my intent to quit these behaviors and to make amends to you.” That this is the basic message in disclosure explains why others are rarely hurt by the disclosures. Instead, the commonplace response is one of relief, acceptance, and forgiveness. Third, disclosure is an exercise of courage and personal integrity. Client self-esteem, often low and falsely protected by hiding and deception, is given a tangible boost. Clients routinely report feeling a new satisfaction for having undertaken diffi cult disclosures. Finally, the disclosure step introduces a possible new approach to life for clients. As they effect their disclosures, they are experimenting with the possibility of shifting from strategies of deception and justifi cation to openness and accountability as a way of life. If this experiment is positive and the shift continues, they will have opened themselves to social consequences that they have sought to avoid in the past. These consequences, if sometimes unpleasant, will be corrective and will reinforce behaviors appropriate to the realities of clients’ lives.

Endnote Any decision we make should be guided by our judgment about probable events and their bearing on the client’s welfare. My decision not to make disclosure by

Downloaded by [New York University] at 02:06 15 August 2016 Ellen a condition of conjoint therapy was guided too much by the prospect of losing my client. A studied evaluation reveals that here is a case where the decision to risk such a loss was actually in the best interest of the client. Examine the probabilities I assigned the events in Tables 7.1 and 7. 2 . If we consider only the risk of losing this client, then clearly not imposing the disclosure condition sensibly reduces that risk (there is a risk reduction from p = .5 to p = .1). However, assigning probabilities to outcomes under all four combinations of disclosure conditions and leaving/continuing reveals a different order of risk. The combined outcome probabilities for both disclosure

117 THE THERAPEUTIC PROCESS

Table 7.1 Choosing to Impose the Condition to Disclose

Leave Therapy Probability Continue Therapy Probability P L = .5 Pc = .5

Failure Mixed Good

Leave outcome probability .7 .3 .0 Continue outcome probability .0 .3 .7 Outcome probabilities over leave conditions .35 .15 .0 Outcome probabilities over continue conditions .0 .15 .35 Combined outcome probabilities for imposing .35 .30 .35 disclosure

Table 7.2 Choosing Not to Impose the Condition to Disclose

Leave Therapy Probability Continue Therapy Probability PL = .1 Pc = .9 Failure Mixed Good Leave outcome probability .8 .2 .0 Continue outcome probability .3 .6 .1 Outcome probabilities over leave conditions .08 .02 .0 Outcome probabilities over continue conditions .27 .54 .09 Combined outcome probabilities for not .35 .56 .09 imposing disclosure

conditions results in the same estimated risk of marriage failure ( p = .35). If concern for avoiding marriage failure were paramount, then one condition is no more desirable than the other. If, however, we wish to insure the best marital adjustment, then we would impose the disclosure condition. That choice would have raised the combined probability for the good outcome from .09 to .35. You will often face a conﬂ ict between what choice will retain your client and what will best serve the client’s

Downloaded by [New York University] at 02:06 15 August 2016 welfare. True, you cannot inﬂ uence clients’ behavior if they leave therapy. However, it is dangerously self-serving to assume that reducing the risk of leaving is always in the client’s best interest. Obviously, a different set of probability estimates would result in a different order of choice preferences. As you scan the probabilities assigned above, you may question my estimates. For example, you may wonder why p is .8 for failure if the client leaves under the non-disclosure condition. You might point out that p is only .7 for failure if the client leaves under the disclosure condition. Why the difference?

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I reasoned that the client’s leaving under the disclosure condition would be less ominous than leaving under the non-disclosure condition. In the former case, the client may retain a strong wish to reconcile the marriage. There is some chance she would have returned or continued reconciliatory efforts in some manner. Under the non-disclosure condition, however, the client probably leaves from despair that the process can work or that reconciliation is possible. It would take us afi eld for me to detail further my thinking for the assignments I made. Suffi ce it to say that the bases in principle for my assignments have already been advanced in previous pages of this text. The point I wish to make in this Endnote is that this kind of exercise is often of value in weighing choices. It may help you get acquainted with your own judgments and values as a therapist. One fi nal caveat: It should not be assumed that one always looks upon divorce as an outcome failure. In this case it was. I could draw on other cases where it was not.

Note 1. Reference here is to Jourard’s The Transparent Self: Self-Disclosure and Well-Being (1964) although this amazingly proliﬁ c thinker wrote many books and articles before his untimely death in 1974. Downloaded by [New York University] at 02:06 15 August 2016

119 8 ADDITIONAL CLIENT ACTIONS

Debts and lies are generally mixed together. —Francois Rabelais

Compensation If disclosure is ordinarily the ﬁ rst action taken, compensation is the second. Often the act of disclosure to others carries with it compensation. When Ann (see Chapter 7 ) disclosed to her ex-husband and to her parents, her expression of remorse about her sexual misconduct served in some measure to compensate them for the trust she had violated. Of course, her consequent treatment of her parents, where respect and warmth replaced earlier impatience and distance, also provided compensation. Compensation, or what members of Alcoholics Anonymous call amends, is often very subjective. How does one compensate those like Ann’s parents who gave their money, devotion, and concern over a lifetime, unaware of disloyalty and hidden abuse? One of the apprehensions clients frequently have is that their departures have been so enormous or prolonged that repayment is all but impossible. This perception enfeebles their attempts to compensate and may even provoke abandonment of the effort. I recall a man who discontinued therapy because he saw no way to repay the thousands of dollars stolen or bilked from his parents over years of alcohol abuse. His sobriety, though extended, remained a fragile achievement. There was a strong possibility that his actions had an additional, less obvious motive. Downloaded by [New York University] at 02:06 15 August 2016 Compensating others for injuries done them becomes a strong deterrent to resuming the injurious behavior. If we are uncertain we want to abandon the option to act injuriously and abandon the associated lifestyle, then we avoid accepting their costs. While many clients anticipate, however, that the injured other will exact from them a costly repayment, experience regularly refutes this expectation. With few exceptions (such as Jack’s uncharitable response to Ellen’s revelations discussed in Chapter 7), the injured other turns a forgiving face. Often it is enough that

120 ADDITIONAL CLIENT ACTIONS

harm-doers acknowledge debt, express remorse, and indicate commitment to new, considerate behavior. For example, the parents of the man who discontinued therapy probably would have refused to accept money as repayment for their past investments in their son. Chances are they would have urged that he use that money to get on with his life by investing it in the home and family he wanted. That would probably have been repayment enough for them.

The Subjectivity in Compensation The following case illustrates how very subjectively compensation may be measured. Nancy came in with a threatening ulcer and fatiguing tensions both at work and in the home. A young woman, her manner and presentation were, however, sophisticated and aware. She was married and had two infant children by her current husband, and a third, her ﬁ rst child, whom her husband was adopting. This child, now 6 years old, was born out of wedlock when she was only 17. It soon became evident that the focus of her emotional distress was this child and the circumstances of his birth.

C : Some people want me to wear a scarlet letter A. But I have accepted my responsibility. I have paid my dues. Yes, my mother helped me, but I ﬁ nished high school, worked, and went to college and got my degree. I have done it in spite of the ﬁ nger-pointing and in spite of the burden of caring for my child. I’ve paid a heavy price. Once I thought of becoming a doctor. It was something I could have done had I not had the responsibility of my son. So I have been punished, and I accept that. But I am just unwilling to accept the sanctimonious condemnation of narrow-minded people.

As the story unfolded, it became clear that the narrow-minded people about whom she spoke inhabited the places of her youth, going back well before her pregnancy and its immediate aftermath. Yet, her feelings of anger and outrage were as vivid as if these events occurred quite recently. At one point, she spoke of being ostracized as a girl of 13 by peers who thought her bookish and “too good.” Tears rolled down her cheeks as she spoke, and her voice choked with anger.

Downloaded by [New York University] at 02:06 15 August 2016 T : I like you. You’ve indeed struggled through difﬁ cult times! And now, you have a loving husband, a very responsible job, and a lovely family. You have much to be proud of. Yet, you are preoccupied with a need to mount an angry defense. You express emotions about slights and rejections as if they occurred minutes ago rather than a decade ago. Why? What keeps alive these feelings, this angry need to defend? It sounds like you ought easily to dismiss the critics of your past in view of your current accomplishments. That you do not

121 THE THERAPEUTIC PROCESS

suggests that there is an inner critic that, perhaps, you seek to dismiss but who will not leave.

At ﬁ rst Nancy offered objections to this idea, but after some exchange she said:

C: Yes. It’s true. Everyone I know now thinks well of me, yet I keep going over these things. I am keeping it alive. I am my own worst critic.

Her father had critically received the young man who subsequently fathered her fi rst child. Her father had objected to his slovenly appearance and the company he kept. Suddenly and unexpectedly, however, her father died. It was a point for Nancy of immense grief mixed with resentment. How could her father leave them at such a point? To further complicate matters, the young man, an orphan living under diffi cult circumstances, was invited by her mother to occupy a room in their home. It was as if he came to supplant her father and to fi ll the emotional vacuum left by her father’s death. His urging overcame the inhibitions instilled by parents, and she succumbed to his advances. The child was conceived in her father’s house. The young man was prepared to marry her, but she knew she did not love him. Actually, she was rather afraid of him. As she explored the events surrounding the time, she gradually opened herself to her denied culpability, the sense of indebtedness to her family, and to her shame. It was not easy. She had built a rich net of rationales for denying guilt. At one point, she lamented:

C : I never wanted Jimmy [her ﬁ rst son] to feel ashamed. How can I protect him from shame if I am ashamed? What possible value is there in shame? I have refused to bow my head and play the fallen woman! T : You appear to have resolved life into a choice of one or the other—shame or pride. We often note that people must mourn and work through their sense of loss upon the death of someone close. Well, guilt is very similar to mourning. We have acted in some way that we come to view as a loss of our integrity. It was very important to you then and now that you are a person of high standards. You have characterized yourself as a good girl: the studious, high-minded girl whom no one would

Downloaded by [New York University] at 02:06 15 August 2016 have imagined would get herself pregnant. You have refused to be humbled by what you did. You have resisted mourning the loss of your integrity. And having not worked through mourning the loss of integrity, you battle against guilt and shame as if the event in question had just happened. Your unwillingness to work through your guilt has not left you free of it. Instead, it has left you in a state of vigilance, ready to do battle with any critic, including your husband, even though present day critics know nothing about your past or have long since forgiven you.

122 ADDITIONAL CLIENT ACTIONS

C : Yes [sobbing]. I have been at war. No wonder I have all these stress symptoms. No wonder I have ulcers. OK. But how do you work through guilt? T : You might start with what AA has called a “searching moral inventory.” Whom have you hurt? How might you make amends?

In the next session, Nancy spoke at length about the diffi culty she had created for a younger sister and, of course, for her mother. Her mother had been uncomplaining and entirely supportive of her. Nancy long ago had expressed to her sister and mother her regret and apologies. That she had worked to pay her own way through school and to minimize the burden on her mother and sister already had a strong fl avor of making amends. Of course, there was the son she had conceived and borne and the other children she now had produced that were burdened by her actions. There was also her husband upon whom her acts had necessarily imposed the burden of being a parent to a son he had not fathered. Yet, upon reviewing it, she concluded she had bent her efforts already to compensating them by attempting to be as good a mother and wife as she could be. During her examination of her guilt and indebtedness, she spoke of her conscience and referred to it as he. It was a startling and signifi cant revelation!

T: You know, the harm we do others need not be to the living. It sounds like it is your father’s hurt, your father’s judgment that may remain an outstanding issue with which you have not dealt.

With that, Nancy produced entirely new information bearing directly on her sense that she had disgraced her father. She remembered how outraged he had become when her older sister had been caught in a minor act of thievery. It brought home to her how insistent her father was on upright and accountable behavior. She had adored her father. She had been strongly motivated to gain his approval. His death left her feeling abandoned. The thought that she, in turn, had abandoned his moral judgments to the per- suasions of the young man who replaced him in his house left Nancy full of remorse. Downloaded by [New York University] at 02:06 15 August 2016 C: Why did I do it? I remember thinking when my father died, “Who’s going to give me away at my wedding?” Conrad [the young man] would never have got in the house if my father were there. But my father was gone and Conrad was there, and I gave in to him. I wanted so to be accepted. I wanted to be a part of what everyone else was supposedly enjoying. You know, I remember once saying to Conrad, “You’re not my father! You’re not half the man he was!”

123 THE THERAPEUTIC PROCESS

Later, she said:

C : I didn’t love him. I had decided to break with him before I discovered I was pregnant. He had made a pass at my [younger] sister! He had the habit of putting me down to build himself up. He was big and muscular. He put out veiled threats, and I made love with him I think partly out of fear of what he’d do if I didn’t. And then I was disgusted by the fact that he liked to dress in women’s clothing. In the end, I found him repulsive. T : Your mother was not judging. She accepted you. She even went to battle for you [referring to an instance when her mother had rebuked a distant relative for being critical of Nancy’s condition]. But it’s your father’s judgment that haunts you. And how would your father have responded to your becoming pregnant by this young man he so distrusted?

Nancy’s tears were ﬂ owing. Her face was drawn and grieving.

C: He would have been so humiliated, so ashamed [whispering]. He used to say there are two kinds of girls. I wanted so to be the kind that he would approve of. Instead . . .

She put her face in her hands. For the ﬁ rst time, she expressed and acknowledged directly and without being defensive the shame and guilt she felt. It was the recurring image of her father’s face, anguished and hurt, which she could not shake no matter how artful her dismissal of guilt. From there, her therapy advanced with amazing rapidity. Several weeks earlier she spoke of being on a religious retreat and having resorted to prayer to deal with her distress. It had not been very comforting. However, I suggested that she might want to speak directly to her father’s spirit. She could talk (or pray) to him laying aside her defenses. In humble and abject honesty she could speak of her shame at what she had done.

C : Yes! I want to tell him that I didn’t mean it. That it was a mistake. And I want to ask him to forgive me and to love me. You know, I had a dream the other night. My father came to me. I knew he was dead, but I said, “Dad! You’re here!” He said he couldn’t stay long. But he reached out

Downloaded by [New York University] at 02:06 15 August 2016 and gave me a great bear hug, and I felt so safe and loved!

Several weeks passed before I saw Nancy again. When she came in, it was as a new person.

C : You know, I was feeling better well before our last session. I knew we were getting somewhere. But the last session was dramatic. I didn’t have to pray to or talk to my dad. I did it in the session. I knew he was listening. I knew

124 ADDITIONAL CLIENT ACTIONS

he was forgiving. When I left, I felt a heavy weight lifting. It was like a release. And the two weeks since have been remarkable. No more stress at work. No more petty arguments with my husband. No more rehearsal of the old slights and hurts. It’s wonderful!

We knew this was our last hour. We used the time remaining to review and consolidate what we understood about her and what she had done to change her life around.

T: You put aside your defenses and came to an honest realization about your own judgment—a judgment you projected into your father. It seems to me what you ultimately acknowledged to yourself and your father was that you had entered into sexual intimacy and conceived your child not out of love, not even out of passion, but out of cowardice. This was what you could not accept in yourself. That out of fear of not being accepted and fear that this young man might leave you or, perhaps, assault you, you submitted to him. How very far from your ideal was this introduction into motherhood. It has taken immense courage for you to acknowledge this departure from integrity.

Nancy’s case illustrates how creative and unique can be the course people fi nd to compensate those they have hurt. Nancy’s mother and sister quickly forgave her and accepted her in a loving and uncritical way. There was no debt outstanding from that quarter. However, an important fi gure in Nancy’s inner world was her father. As she viewed herself from his vantage, she was fi lled with self-lacerating pain. It was a pain that she felt unable to resolve. Her father was dead! So she moved stubbornly to dismiss her inner critic and convince herself that she was guiltless. When she came into therapy she bristled with indignation at a narrow-minded world that surrounded her. Her better judgment told her that she was over- reacting to work associates and to intimates, particularly her husband. Anger had become her drug. It enabled her to weather the storms of inner unrest and be deaf to her father’s voice. When at last she opened herself to her guilt and acknowledged the father- inspired judgment of her moral cowardice, how to proceed was revealed to her.

Downloaded by [New York University] at 02:06 15 August 2016 The concept of coming to terms with her father’s spirit opened for her a course that had appeared closed. Now she could acknowledge her debt and seek to compensate her father for the humiliation and shame he would have felt. Her father had been very much alive in her view of herself and her actions. At last she reached through to that very living part of her own make-up. Her father forgave her. She forgave herself. All this took place not in the observable interactions between signiﬁ cant parties, but in the subjective domain where a dead father may yet have a forceful, living presence.

125 THE THERAPEUTIC PROCESS

Enacting New Roles

Role-Play Earlier, I mentioned the value of rehearsing with clients the disclosures they were preparing to make. Clients often are quicker to grasp the value of disclosure than they are to accept what that means in practical steps and verbal dia- logue. Moreover, they inevitably struggle with habits of words and thoughts that have been a part of their hiding and disguise. When they approach the actual disclosure even with clear intent, their habits frequently intrude with contrary language and acts. Insight does not mean that the inner struggle is resolved. It does mean that the forces of resistance have fallen back, but these forces continue to wield power in the client’s everyday behavior. Let us turn to a case example to illustrate the matter. In this instance, we need fi rst to sketch the background to give context to a disclosure initially fl awed by resistance but subsequently refashioned through role-play. Craig, a man of 28 years, came into therapy troubled by dysphoria, uncertainty about the future, and a sense of distance from himself and life events. He had recently undergone an amicable divorce from his wife of four years. He had continued to maintain a close relationship with her, seeing her frequently, exchanging calls, and worrying about her welfare. While this served to indicate a considerable measure of unresolved feeling for his ex-wife, Craig was singularly free of direct expression of such feeling. In manner he was cool, laid-back, and maintained a smiling, somewhat analytic distance from the matters he reviewed. He was initially a very diffi cult man to engage because he was well practiced in presenting whatever he conceived was desired from another. Consequently, there was an insubstantial and chame- leon quality to his presentation and his person. In response to my observations about his manner, he began to speak about the part that his wife’s desire for children had played in their divorce. His own opposition to having a child had not been initially apparent to him. They had conceived several years before the divorce, but the pregnancy was cut short by miscarriage. After this, his opposition grew. That opposition and his wife’s mounting frustrations in the face of it were central to the marriage failure. On the heels of introducing this information, Craig began to speak about his own family of origin. Apparently, he sought some explanation to his puz- Downloaded by [New York University] at 02:06 15 August 2016 zling reluctance to conceive a child. There had been interpersonal distance in his family accented by his parents divorcing when he was about 17 years old. His mother had favored him over his two younger brothers and had conditioned him to expect much from intimates. He had developed a conviction that his father had abandoned him and had not awarded him the love and attention that was his due. Craig speculated that he might have shown toward his potential son the same rejection he felt he had experienced at the hands of his own father.

126 ADDITIONAL CLIENT ACTIONS

Not long after Craig opened this examination of his family, an instructive event took place. One of Craig’s brothers got drunk and was not at his wife’s side upon the birth of their child. This breech of marital duty resulted in a terrible row with the wife’s parents. Craig’s father got wind of the matter and took pains to call on Craig’s brother, expressing concern and attempting to promote peace.

T : This sounds foreign to the image of a distant, uncaring father that you have painted. C: Yes, it does!

We then examined the possibility that Craig’s critical view of his father was developed and maintained to serve his own ends. Perhaps there was an advantage in ﬁ ltering his experiences through this sense of himself as an abandoned son still waiting for a father’s blessings. This perspective on his relationship with his father intrigued Craig. After some discussion, he decided he would talk with his father, express his feelings, and also explore with him Craig’s unresolved feelings about his marriage. Later, he phoned his father, who was pleased to hear from him. The father was eager to meet with him and encouraged him to express himself both about his failed marriage and his feelings about his father. Craig reported that the meeting went well and that he was warmed by his father’s attention.

C: Something very signifi cant happened, I think. When I was a boy of about six, I would always go through my father’s change, which he left on the dresser. I collected coins, and if I found one I wanted, I’d ask for it, and he would give it to me. One day I was going through his coins and came across an Indian-head nickel, which I knew was valuable. I took it, but I didn’t say anything to my dad. I felt like a thief. Well, I kept the coin all these years. [long pause] I told my father the story. I was actually trembling in fear. It sounds crazy. But it seemed so monumental. When I fi nished, I gave him the coin and told him I was returning it. He laughed and told me he was very touched. He gave it back to me. He seemed to know that it was important and had great meaning. But I am not sure just what it means! T : I quite agree with you that this sounds signifi cant and meaningful. Let’s Downloaded by [New York University] at 02:06 15 August 2016 puzzle with it and see what we have. I suspect that the coin represents the blessings you received from your father, which you have denied you’ve received. Giving the coin back to your father was a gesture that says that you were attempting to correct your portrayal of him. It says that you are seeking to grow out of the reliance on what we might call an inner fi lter through which you have viewed yourself and your life. This fi lter permitted you to constantly bias your experiences in the direction of expecting more from life while, perhaps, requiring less from

127 THE THERAPEUTIC PROCESS

yourself. It has been a hidden edge in life’s contest with all those other persons who you perceived as not abandoned and who had received the blessing of loving parents.

This rendering of Craig’s relationship with his father was quite productive. In a later session, Craig elaborated how he tilted the plane of life. The tilt permitted him to expect more attention and praise for his accomplishments and to excuse more his failures than he allowed in his judgments of others. He recalled how during the divorce he had thought, “I haven’t done so badly considering the adversity of my past.” Then he recalled how high had been his expectations for his marriage. His wife had adored him and showered on him loving attention during their courtship and early days of marriage. Later, the normal settling-in of the post- honeymoon period brought an unwelcome reduction in the level of her loving attentions, which he permitted himself to expect should continue forever. When his wife began to talk of having children, he had felt a stab of apprehension. His thought had been, “If I am now deprived of the loving attention I want and deserve, how much more deprived will I be with a child present to siphon her attentions?” He set about, if not with conscious intent, to sabotage their marriage. He built cases against his wife in which, one way or another, he found fault and questioned her love. Finally, disillusioned, confused, and emotionally bruised, she consented to divorce. At last he had uncovered the reason for his inability to walk away from his marriage and a major reason for beginning therapy. Beneath his obsession with his wife and failed marriage was a very real and gnawing guilt. By the time we had arrived at this understanding, Craig was contemplating action on two fronts. He began to question whether his divorce was “genuine” and whether he should seek reconciliation with his wife. Second, he began to see that, in the interest of his own wholeness and personal growth, he should disclose to his wife. He would inform her of his hidden inner ﬁ lter, his resultant, unrealistic expectations of her, and his strategy of discrediting her to force their divorce. He decided that in the interval between sessions he would prepare a script so he might role-play what he would say. However, at the next session he announced that he had “jumped the gun” and had talked with his wife already. Her father had been ill, prompting a solicitous

Downloaded by [New York University] at 02:06 15 August 2016 visit from him, and, while with her, he sought to ﬁ nd the words to disclose to her.

C : I told her that the reason I was talking to her was so she would not be blaming herself, as she has, for the failure of our marriage. Then, I told her the ways I had sabotaged our marriage, how I had exaggerated our differences and made a case for divorce. [brief pause] She didn’t respond as I thought she would. She said, ‘I don’t want to hear how wonderful you are becoming [as a function of his psychotherapy]. I want to know whether or not we have anything going

128 ADDITIONAL CLIENT ACTIONS

for us. I need to make up my mind whether to keep that idea alive or to look elsewhere.’ She pretty much made it clear that what she wanted was for me to talk to her about resuming our marriage or else don’t talk to her. T : I think I have some sense of where your wife was coming from. To my ears, what you had to say to her came across as pretty magnanimous. “I’m disclosing to you for altruistic reasons. Here, let me take the burden of guilt off your shoulders. I’ll accept the blame for our marriage failure and free you of it.” Meanwhile, you do not inform her of your struggle with your inner ﬁ lter and the exacting demands you placed on her to compensate you for the deprivations you had suffered.

Craig acknowledged the correctness of these observations, and, after some discussion, we turned to role-playing how he might approach his wife in an effort to repair matters. Craig struggled with composing a script for himself. Finally, with a look of chagrin, he said:

C: I really blew it. But now I’m in a hole. She doesn’t want to hear from me unless I’m ready to examine with her our prospects of reconciling. Frankly, I just don’t know. She is still where she was about having children. I would have to go back on her terms, and I don’t know where I am about that. I guess I just don’t know how to approach her or what to say. T : Let me play your part, and you play the part of your wife. I’ll call on the phone. Ready? C: OK. T : Hello Edith, this is Craig. C: Hello Craig. T : When I spoke with you the other day, I did not say what I wanted to. Now, I am mindful that you did not want to hear from me unless I was ready to speak seriously with you about reconciling. At this point, I frankly don’t know how I feel about that. What I want to talk with you about may or may not advance us in that connection, but for me it is something that is necessary and comes before any such discussion. May I come over and speak with you now? C: Yes, come on over. T : Knock, knock. C Downloaded by [New York University] at 02:06 15 August 2016 : Hello Craig, come in. T : Hello Edith, thank you for agreeing to hear me out. Edith, when I spoke with you the other day, I said my intent was to relieve you of blame for the failure of our marriage. I misspoke. My reason then and now is much more self-centered. I am attempting to come to terms with who I am and what I have done. My talking with you now is to serve that end. By disclosing to you what I have been about, I am trying to ﬁ nd a way to grow out of some pretty destructive habits, which I have kept hidden from others and, in some measure, myself as well.

129 THE THERAPEUTIC PROCESS

You see, well before I met you I had erected a myth, a very self-serving myth, about my father. I was an abandoned son. This has been so well practiced a myth that it has colored everything about me. In my mind’s eye, I was an emotional cripple who deserved compensation in the name of justice. Any accomplishment I had should be given a higher reward owing to my handicap. Any failure should be excused for the same reason. When I met you and you were so loving and attentive to me, I took it as my rightful due. You were an instrument of justice bringing to me what had been deprived me. When the honeymoon was over and you settled into a natural moderation of your attentions to me, I experienced it as a reinstatement of deprivation. And when you begin to speak of children, I was forlorn at the thought that your attention to me, already reduced, would be siphoned off to my son or daughter. I was jealous of my unborn child. As you pressed your wish for children, I began a campaign to dissuade you, to get you to turn your undivided attention to me again. When that didn’t work, I begin to discredit you and to ﬁ nd ways to bring our marriage to an end. I sought psychotherapy not focally aware of all this. Oh, it was there, but I had kept it diffused, unclear. I knew I was hurting. I knew that the divorce haunted me, but I was confused about why. Now I know I was simply guilty for my self-centeredness and for my destructive behavior. I am sorry, Edith. I am sorry for what I did to you.

Craig took the recording of our hour and of the role I had scripted for him and, using it, composed his own script. He made notes of what he wanted to say, rehearsed his script, and then carried it out. He was well pleased with his effort. Moreover, the exercise had immense signiﬁ cance for him and proved a veritable deliverance from the shackles of his guilt. Of interest was that, rather than freeing him to reconcile with his ex-wife, it freed him at last to move away from her.

C : For the ﬁ rst time after talking with her, I did not leave crying and full of remorse. I felt like at last I can get on with my life. I do not feel that I must marry her again and devote a lifetime to repaying her for the damage I did her in our marriage. I married her once for the wrong reasons. That would

Downloaded by [New York University] at 02:06 15 August 2016 be like marrying her a second time for the wrong reasons. The truth is, we are not terribly compatible people.

Role-Play and Assertion The next most frequent use of role-play I ﬁ nd relates to assertion, which, at base, is but another form of disclosure. This was illustrated earlier (in Chapter 7) by Ted and his timid acquiescence to his business partner. Ted was unwilling to disclose his real differences with his partner and attempted to manage his resultant

130 ADDITIONAL CLIENT ACTIONS

frustration and guilt by obsessive, violent thoughts. We ordinarily speak of disclosure when we tell another about our behavior, which we have omitted to relate or have falsely represented. We speak of assertion when we tell another about our feelings or thoughts, which we have omitted to relate or have falsely represented. Disclosing all we do to everyone is a logical impossibility, even if it were psychologically of value. Under pressure of fi nite time and energy, we are left with the question, To whom disclose what? We have essentially answered that question by saying: Disclose to signifi cant others and disclose whatever is relevant to them and your relationship with them. Assertion defi ned as disclosure of all we feel and think to everyone would also be logically impossible. So, to whom do we assert what? Let us endeavor a working answer to this diffi cult question. There is, of course, no problem in revealing our feelings and thoughts to sympathetic others who are unlikely to fi nd them discordant or offensive. Assertion problems arise when we surmise that communicating to others about our feelings and thoughts would provoke a negative reaction from them. To avoid this negative response we omit to inform or may even misinform them about our thoughts and feelings. Let us imagine we come into the company of a person with a serious facial scar. The distorted features automatically jump to our attention, and we experience a mix of feelings and thoughts. We feel morbid attraction, sympathy, revulsion, and shame (at our morbidity and revulsion). We might think, “How grotesque! I wonder how that awful injury happened. Oh, I’m staring. What is this person thinking of my staring? Can I interact with this person on a human level, as a person apart from this facial disfi gurement? This is embarrassing, and I would really rather just leave.” We can surmise that asserting these thoughts and feelings might be a welcome change from the awkward omission most of us would practice. However, we can also surmise that such assertions would probably become an enormous burden for the disfi gured person to bear at each new encounter. Would we be suffering an “assertion defi cit” were we to omit informing the person about our feelings and thoughts? Defi cit or not, most would agree that these are not appropriate thoughts and feelings to assert. Or what if we are in a restaurant and a mother at the adjacent table repri- mands her child, “You eat like a pig! I think I’ll start calling you Piggy.” And

Downloaded by [New York University] at 02:06 15 August 2016 we think, “That’s a terrible way to deal with the child’s table manners. She’s going to establish a negative self-image in the child.” Do we assert in this instance? There are pros and cons. On the one hand, who are we to set about correcting the actions of strangers? This woman is doing nothing that directly interferes with our prerogatives. With what reason do we seek to intervene in the exercise of her prerogatives? On the other hand, what about the rights of the child? Is it not possible that a timely observation by a stranger would have a sober- ing effect on the mother beneﬁ cial to the child? Whether we assert here will

131 THE THERAPEUTIC PROCESS

depend largely on whether we weigh the benefi t to the child above respect for the mother’s prerogatives to instruct as she sees fi t. Of course, should we value more the benefi t to the child than the mother’s prerogatives, what remains is whether we have the courage to assert in the face of possible hostile reactions. Finally, consider the following scene. We are sitting at a bus-stop enclosure waiting for the bus. A man sits down nearby and lights a cigarette. The smoke is offensive, and we feel our space has been compromised. Here there will be little disagreement that assertion of our thoughts and feelings is quite appropriate. “Please don’t smoke. This waiting area is small, and I do not want to breathe the smoke.” Can we generalize a principle or principles about assertion from these instances? Yes we can. First, unlike disclosure (of our actions), assertion may involve revealing thoughts and feelings to persons who are not nor would we wish to be signifi cant to us. Disclosure delegates to the other the right to render judgment on us and on what we do. It invites the other to exercise infl uence in our lives. It takes on the quality of an investment in the other. By contrast, assertion usually involves a judgment we render on others. Rather than inviting the other into our lives, it often acts as a posting, DO NOT TRESPASS . Assertion represents an investment we make in ourselves and our boundaries, which the other, whether stranger or intimate, is advised to honor. Second, assertion is appropriate when another’s actions alter or violate a signifi cant value that we hold. If disclosing opens us to the potential for change facilitated by the reaction of others, assertion affi rms what we would not change despite another’s actions or reactions. To assert or not to assert rests on a critical self-assessment. What is important to us? Do the other’s actions violate or threaten our important values? Would failure to assert obscure important boundaries that serve to identify us and advance our self-preservation? Since assertion, by defi nition, always exacts a cost, the question is whether the gain is worth the cost. Both (gain and cost) represent our own values. It is abundantly clear that unvaried restraint (non- assertion) will surely do violence to our values and self-boundaries. Less clear is that heedless assertion, which may seem to celebrate self above all, also and as surely does violence to our values and self-defi nition. A person who does not assess costs is as careless with the dimensions of self as one who is overawed by costs. The true exercise of self-defi nition and identity resides neither with assertion or restraint. It springs, fi rst from the conscious assess-

Downloaded by [New York University] at 02:06 15 August 2016 ment and ordering of one’s values. Then, as events create a conﬂ ict of values, it comes to rest in the deliberate choice of that action, whether assertion or restraint, which serves the more important value.

A Case of “Assertion Deﬁ ciency” Andy, 38 years old, described himself as “constantly angry, hostile, depressed.” He worked for a small company as production manger. While his job title sounded elevated, he felt that he was perennially on the bottom. His

132 ADDITIONAL CLIENT ACTIONS

employer-owner “dumped” on him. The owner constantly assigned him poorly conceived projects expecting him to work late, laboring more than 60 hours per week. In this way, he was pulling the owner’s chestnuts out of the fi re in time for some degree of profi t to the business. For this devotion of effort and time, he was paid a modest salary and given no recognition or appreciation. Instead, considering business conditions in general, he was anxious that he might be let go, particularly were he to complain. Rounding out this dysphoric picture was a distant, unsatisfactory relationship with a woman and a variety of problems with his health. He was overweight by about 40 pounds and subject to feelings of fatigue. He was, fi nally, very isolated from others and alone. Andy approached his problems intellectually and analytically.

C: I’m not sure my problems are a function of me, or a function of the work and the people I work for. My girlfriend has pointed out how non-assertive I am. The result is that I am subject to these repeated abuses by my employer. Then I get angrier than hell. But I swallow my anger. I’ve considered leaving this business, but there is no place to go. Or at least, that’s how I think. Then I realize that I don’t do anything to ﬁ nd other possible employment. I just go home and crash and feel miserable.

In the second hour, Andy elaborated on the work scene and his frustrations in it. All employees there were afraid to express themselves. His employer dominated everyone, so he felt like a slave among slaves.

C: Yet, when I boil it down, what it comes down to is that I just don’t assert myself. Then I resent like hell what is happening to me. T : You’re a victim. C: Yes, indeed! T : All right. It sounds like you are unwilling to assign your plight entirely to your circumstances. You have recognized that you play the part of the victim, and that there is an element of choice, which you exercise to accept and maintain that role. But what is the payoff? Ordinarily, we don’t choose repeatedly to act in some way without it giving us some kind of advantage, at least in a relative sense. C: [long pause] I don’t know. Maybe it’s just avoidance. Half of my time is

Downloaded by [New York University] at 02:06 15 August 2016 devoted to ﬁ guring out ways to avoid being hassled. I am constantly lying low, fading into the background. And, as a matter of fact, I probably get the least amount of gaff at work compared to others. Sometimes I think I’m trying to convince them that I’m unstable and they should leave me alone. But at other times, I think they don’t even notice. They treat me as a nonentity. T: I’m reminded of the movies about the invisible man. There is real power in being invisible. You can come and go and do things without risk of notice.

133 THE THERAPEUTIC PROCESS

Of course, there is a down side. You have no reality in the response of others. You have no identity. You seem to have announced two themes in your approach to life. One is that you play the role of victim, which, whatever its advantages, leaves you feeling powerless. The second is that you act so as to be invisible, which gives you, perhaps, a sense of power, but at the cost of feeling like a nonentity. You can exercise power as long as you’re invisible, but when you surface, the identity you assume is that of the powerless victim. C : You know, it goes all the way back to my childhood. My parents were passive. They were provincial people, not at all intellectual. They were withdrawn.

Andy went on to elaborate how his parents had conditioned him to his characteristic pattern of behavior, picking up their avoidant, retiring ways. He spoke of a brother and of his girlfriend with the same theme emerging. Those close to him either encouraged his non-assertive, avoidant ways or did not inspire him to behave differently. In this manner, he viewed family and intimates as parties to the pattern of victimization practiced by the rest of the world on him. Andy was quick to see this pattern of thought as self-deceptive and self- debilitating and was eager to effect a revision in his ways of thinking and acting. One of his ﬁ rst actions was to speak candidly with his girlfriend about what he was learning about himself. This energized him and strengthened his wish to do more. He began to examine his day-to-day actions at work with an eye to surfacing the ways in which he participated in his own victimization.

C : [telling of the account executive’s mismanaging at the business costing Andy additional work] I was livid. This goof-off! He fouls up, but he’s in good with the owner. So I have to work overtime to straighten out the accounting so the project will ﬂ y. I wanted to attack him. To cry out against his wasteful incompetence! But then, I thought, what the hell. The simplest approach is just to do my job, and lay low. Just avoid as much as possible getting entangled in the mess. T : It sounds like you’re at one extreme or the other. Either annihilate him or completely withdraw. I don’t hear any room for simply and consistently

Downloaded by [New York University] at 02:06 15 August 2016 asserting your views, for calling this man’s attention to whatever you see is a problem. You seem to run from the every-day, nitty-gritty business of standing up, being visible and run into murderous anger or into invisibility and withdrawal. C: Yes. You know, when we look over these things here, it seems so simple. Of course, I could have gone to this guy and said, “Look, this project has not been budgeted, and I can’t proceed until I know what I can spend.” But when I am there, in the situation, I feel like I am tied down by an army of midgets. The moment for acting passes, and the further away such a moment

134 ADDITIONAL CLIENT ACTIONS

appears to be, the less able I am to see any new opportunities except when they, too, are past. Soon I have a mountain of lost opportunities, which weigh me down. And I say, “What the hell,” and fade into the wall.

Andy agreed to keep a journal of all such opportunities to assert himself through the week and to register what in fact he did do. At the next session, he came in rather disconsolate. He was fi nding it diffi cult to recognize the opportunities to assert and feeling overwhelmed by the task. Finally, he began to detail an event at work that illustrated his baffl ement. His employer had assigned him a project with a deadline but did not provide him with the necessary information and specifi cations. Andy then detailed a series of inquiries he had directed at various persons in the business, including the owner, endeavoring to obtain the missing specifi cations. No matter whom he approached, he was given either insuffi cient information or was told the information would be forthcoming. Always it was Andy who was obliged to follow up and attempt to stimulate a response. He was frustrated, angry, and bewildered.

T : Your approach to the owner or others is always low-key, pretty deferential and patient, it sounds like. C: Yes. I suppose so. I keep trying to get all that’s necessary so I can proceed. But, they keep putting me off. They act like I don’t even exist. This morn- ing I had to ask Roger [from another department] several times what was on the request statement. It’s maddening. T : I’m reminded of a secretary who worked in my wife’s department some years ago. Everyone was afraid of her. She insisted that work coming to her be prepared just so. If her speciﬁ cations weren’t met, the work was set aside. Later, if an inquiry were made, she would point out quite unapolo- getically that when the work was presented correctly, she would get to it. She angered a lot of people but nobody dreamed of ﬁ ring her or even disciplining her in any way. Now, she seems to represent the mirror opposite of you. Where she conditioned the system to be very attentive to her boundaries, you encourage the system to expect that you will constantly accommodate to it. It may be that no one is consciously ignoring you. Rather, it may be that over time people have grown habitually to off-load their responsibilities onto you

Downloaded by [New York University] at 02:06 15 August 2016 because that’s what has developed. If someone is going to do all the worrying, backtracking, reminding, and is going to do it uncomplainingly and invisibly, it is very comfortable for others to pass those matters along. C: I see what you mean [pause]. I do bring these things on myself. It seems so obvious when you point it out. It seems so simple. T : Right. What would have happened had you told your boss, “I will get promptly to the project the instant I receive from you or from the other ofﬁ cers the speciﬁ cations I need”? Then, just proceed with your work. If later your boss were to have made an inquiry, you could have said, “I’ve

135 THE THERAPEUTIC PROCESS

been unable to start the project because I have not received the necessary speciﬁ cations. As soon as I have them, I will proceed.” If your boss were to get angry that you had not reminded him, you could have said, “Well, in the future, if you want me to remind you of what is needed before a project can begin, I will certainly do that. I can send you a memo each day the project is delayed for lack of sufﬁ cient information.” The point is, no self-respecting boss is going to ask someone to do his thinking for him even though that same boss may come to depend on someone to nudge and worry for him. If you really don’t want to play that role, you can stop it. You can begin to build other expectations and implicit understandings.

Andy’s reliance on invisibility, withdrawal, victimization, and the exercise of seething inner anger gave way grudgingly. His use of assertion was halting and often compromised. Gradually, however, by reviewing his behavior and rehearsing planned changes, he advanced. His advances were aided along the way by his joining a support group that helped him avoid retreating into helplessness and confusion and provided instant reinforcement for his efforts. His own early conviction that he invited and controlled his victim status was, however, the key to his progress.

Other Client Actions

Drawing on Micro-Behavioral and Cognitive Techniques Psychologists have been extremely inventive in applying to human issues principles of learning and cognition often based in human and animal experimentation and developed in the laboratory. A therapist needs to be fully conversant with both principles and applications to provide clients with information helpful in their efforts to change their behavior. Too frequently, however, these techniques are employed prematurely and in rote fashion. We should observe certain precautions. First, any effort to effect behavior change logically follows achievement of insight. If, in haste, you respond to the client’s initial constructions and appeal, you may be placing your expertise at the disposal of the person’s justiﬁ cation strategies.

Downloaded by [New York University] at 02:06 15 August 2016 For example, a client describes a distressing tendency to engage in self- deprecatory thoughts, which, in turn, cause a sense of social unease. You immediately begin teaching the client how to discriminate, identify, and inhibit these thoughts while substituting more self-approving statements. Your focus is on freeing the client to engage more comfortably in social exchanges. How- ever, this client’s deprecatory thoughts, let us say, actually spring from his taking advantage of an intimate, which he justiﬁ es (e.g., “She doesn’t know what she’s doing so I am forced to take over and decide for her”). His guilt-based thoughts occur because the justiﬁ cations do not fully work. With your help,

136 ADDITIONAL CLIENT ACTIONS

however, the client can now reinforce his justifi cations. He can say to himself, “My therapist does not fi nd me at fault. My therapist has urged me to approve of myself.” If later, this client is free of self-deprecatory thoughts, is this truly a measure of therapeutic change? To advance another precaution requires that we identify two paradigms with learning psychology. These paradigms have been around for a long time and have been distinguished in various ways. However, they go back to the habit-learning studies of Robert Thorndike contrasted with the sign-learning approach of Ivan Pavlov.1 Currently, we are likely to distinguish these as operant versus classical conditioning. The former addresses acts under a large measure of voluntary control which are strengthened by reinforcement (rewarding outcomes). The latter addresses responses, usually emotional in nature, over which we do not ordinarily have voluntary control. As a rule of thumb, one may employ operant procedures less cautiously than procedures fl owing from the classical paradigm. Operant procedures usually are aimed at “bad habits,” such as smoking, overeating, biting one’s nails, etc. Rein- forcement programs that bring to bear systematic rewards for “good habits” and penalize occurrence of the “bad habits” usefully aid clients who wish to change. There is one precaution a therapist should observe in applying operant concepts: Be alert to the possibility that the client’s “bad habits” are serving some personal economy not altogether apparent at fi rst blush. Lacking insight into this hidden reward may result in a poorly conceived operant reinforcement program. Particular caution should be observed in applying the classical conditioning paradigm. As I make clear in other chapters, the negative emotions (fear, anxiety, worry, and guilt) are not per se the enemies of normality and psychological health. They should not be summarily extinguished and dismissed. Moreover, what is characteristically true is that clients already practice techniques of their own invention designed to minimize, counter-condition, and extinguish negative emotions. They use these techniques to free themselves from the emotional consequences of their behavior, their way of life. To join them uncritically in pursuing such ends is to become a part of the problem rather than a party to the solution. In these cases, the therapeutic course is to undo not the negative emotions, but the negative lifestyle that fosters such emotions. Downloaded by [New York University] at 02:06 15 August 2016 Case Examples Where Classical Conditioning May Be Applied However, there are occasions when such procedures are appropriate. I will briefl y refer to two cases that illustrate the point. A man of 43 years complained of fear that had emerged in the last year and threatened his work. The man worked for building contractors specializing in erecting multistory, commercial buildings. He was obliged to walk gird- ers sometimes only six inches wide several stories above the ground. He had

137 THE THERAPEUTIC PROCESS

begun to have attacks of fear that interrupted the smooth, confi dent, coordinated behaviors that he had practiced for 20 years. There was no evidence of contribution from any other aspect of his life to the growth of his fear other than the hazard of the work itself. He had never fallen and was in excellent physical health, but he knew of injuries and fatalities in the business. He did not wish other employment because he would be unable to earn what he did as a high-rise builder, and he had growing family expenses to meet. He had begun to dwell on the risk features of his work (height, width, and length of the girder; presence of jagged machinery below; wind; etc.) and actively stimulated his fear with this preoccupation. I introduced him to a systematic desensitization program in which he practiced visualizing, starting with lesser but moving gradually up the scale to the most high-risk job-related acts and scenes he could imagine, while fully relaxed throughout. The program worked quite well, and the man resumed his work erecting tall buildings without incident or further anxiety. Another case is more complicated, but still suggests the appropriate use of fear-reducing procedures. A 41-year-old woman, divorced for 11 years and living alone, was the victim of a burglary and rape followed by two other burglaries while she was not home. She became panic-stricken at night by noises of any kind. We proceeded on two fronts. First, she installed a perimeter security system, which assured her that any intruder would set off a distinct alarm sound. This permitted her to discriminate dangerous from ordinary night sounds. Second, we instituted a program of systematic desensitization designed to moderate the ruminations that obsessed her. In this case, there were indicators that other aspects of her life contributed to her fearfulness. Her long period of singleness helped produce feelings of reduced worth and promoted her sense of vulnerability. Her fearfulness served a purpose. It justifi ed her readiness to shrink from social contact and from venturing out into a risky world of heterosexual relations. These factors set the stage for her readiness to fear, but the precipitating events were suffi ciently traumatic to explain the appearance of the fear as such. We employed risk discrimination (with the help of the perimeter alarm system) and systematic desensitization (reciprocal inhibition) to address the acute character of her fear. Later, and with good results, we explored the long- term features of her lifestyle that contributed to her vulnerability to being

Downloaded by [New York University] at 02:06 15 August 2016 fearful.

Joining a Group Viewing behavior disorder as addiction inspires a natural harmony with the use of self-help groups as an adjunct to treatment. Self-help groups tend naturally to focus on conduct and to be impatient with excuses (justiﬁ cation). Yet, they also look upon past mis conduct as an expression of fallibility to which we are all susceptible. Thus, while they condemn the conduct, they

138 ADDITIONAL CLIENT ACTIONS

warmly accept the person and welcome into community any who seek to grow and change. Members of self-help groups have “been there.” They are quick to pick up justifi cation themes that diffuse personal responsibility through projection onto circumstances or others. They battle with these tendencies in their own lives. They invite other members to help them in their battles, and they are ready to offer help to the new member. New members fi nd that they, too, are quickly able to detect justifi cation themes in the productions of others, though they may have problems recognizing their own. This experience teaches them to come to rely on group consensus as an accurate mirror. They learn that the deceptions they practice work more effectively upon themselves than they do on others. Another function fi lled by the group is that of providing inspiration or “positive modeling.” An effective group will have members who have “blazed the trail” and serve as living proof that diffi cult challenges can be met. Inspira- tion may not weigh heavily measured against other factors leading to change. However, as our analysis will reveal in a chapter to follow, the net difference between negative and positive factors supporting change is often small. Thus, even a marginal positive quantity may play a crucial role. Finally, members of groups not only inspire by example, they bring to bear direct social reinforcement. Changes, which may go unnoticed by others, will be cause for celebration and recognition in the group. Why? Because members of self-help groups know how diffi cult actions are that others may view as unremarkable and quite ordinary. What is so diffi cult about not procrastinat- ing? Why applaud someone who no longer lies? Must we celebrate someone who has managed to go shopping alone? Those not addicted are unlikely to appreciate the allure addictive behaviors hold and the effort it takes to resist the urge to resume old comforts. In sum, self-help groups focus on behavior, detect and resist self-deception strategies, accept the person, inspire change, and directly reward and sustain change already begun. Those seeking to fi nd support for the inauguration and maintenance of diffi cult behavioral change do well to utilize a group. While not always, I usually recommend such a step as the client begins to make changes.

Terminating Therapy Downloaded by [New York University] at 02:06 15 August 2016 Commonly it is the therapist who introduces termination of therapy. However, the decision to end, like the decision to begin therapy, is the client’s. Ending therapy is an action that has considerable signiﬁ cance to clients. They signal by this action that they have learned what they can from the therapy. They have, perhaps with much effort, inaugurated new behaviors. As a result, they have enjoyed a reduction in negative emotions and an increase in hope. Their new behaviors, however, will exact a cost. Therefore, a remaining challenge for clients is to maintain these behavioral changes.

139 THE THERAPEUTIC PROCESS

There is usually an explicit understanding that if they run into problems maintaining their gains, they will resume psychotherapy. Often they look to a group to provide support in maintaining new behaviors and guarding against the subtle reintroduction of old strategies and actions. In my experience, a sizable number of clients, about one in fi ve, who have pursued therapy past the fi rst phase (the Introduction Stage) will terminate before the therapy is complete. The reasons for these unexpected terminations are many and generalization is diffi cult. Some of these persons are not ready for the rigors of therapy as they move into the Engagement and Action stages. Others have made a judgment earlier than the therapist that they are ready to move ahead without additional therapy. No doubt practical considerations often play a part since psychotherapy taxes clients’ time, energy, and money. Those of the psychoanalytic persuasion frequently warn of the interminable client and deal at length with resistance to termination. I have found that clients often express nostalgic feelings as termination approaches, but almost never does a client disagree with me and evince a wish to continue. For a client and therapist to dispute that the client is fi nished indicates that a serious discrepancy exists between the client’s state and the therapist’s judgment of it. For clients to resist ending or display a return of symptoms immediately after termination is broached provides evidence that therapy is, perhaps, no longer the solution. It may now be the problem. What might account for such client–therapist misalignment, and in what way may therapy become the problem rather than the answer? This may occur when therapists, either unwittingly or through misconstruction, have acted to reinforce the justifi cation stratagems already present in clients. Troubled individuals come to therapy because justifi cation has failed. They secretly hope that the therapy will permit the conservation of their lifestyle while dissolving its costs. If therapists accept that hope as their charge and, with the weight of their prestige and authority, succeed in shoring up the faltering justifi cation structure, then clients will feel better and become free of symptoms. At that point, therapists wrongly judge therapy to be a success, the client to be psychologically healthy, and the therapy at its end. In actuality, clients have grown to depend on the therapy and the therapist to make their lifestyle work, free of its emotional costs as expressed through various symptoms. Away from therapy we are not surprised that the costs of their faulty, non-integrative lifestyle will

Downloaded by [New York University] at 02:06 15 August 2016 reemerge and symptoms return.

Conclusion In this chapter we have examined client actions additional to and often com- plementary to client disclosure. When we disclose behavior injurious or costly to signiﬁ cant others, we inevitably acknowledge debt. Compensating the

140 ADDITIONAL CLIENT ACTIONS

injured party and liquidating debt is more diffi cult than it sounds. How do people resolve indebtedness that has accrued over many acts of hidden neglect or abuse? In time, clients may look upon this cumulative debt as something impossible to make right. The apparent enormity of the debt contributes to resistance to change, and, ironically, to the repetition of those actions that add to the debt. The forces of change must break through this logjam of debt, guilt, and denial. To achieve this, the client must fi nd a way to follow disclosure and acknowledgement with actions that relieve him or her of debt. Repayment or compensation may come in as many guises as the numbers of clients involved. This marks a time when the therapist is obliged to be creative in exploring possibilities with clients. It also requires an abiding sensitivity to those core client values that drive the eventual compensation formula. The therapist does well to constantly encourage a spirit of experimentation. What will disclosure do to or for you? Experiment and see. Will compensating someone make any difference in how you feel about yourself, how you view others, how others act toward you? Do it and then keep careful record of the effects. Will playing the role of whom you would like to be in any way move you to become that person? You bet your life. And you bet your life in two meanings of the phrase. First, yes indeed, it is an excellent bet that changing your behavior will change you and your circumstances in some way. Second, you are betting your life in that you are putting your way of life on the line. You are experimenting with you. You are betting that the new acts, the new role, will not only produce changed perceptions, feelings, and responses, but these will be changes you can live with! You are betting that these changes will eventually bring about the ends you most crave. Once insight has established the map, therapists are obliged to make available their lore and knowledge to aid clients in their journey. Any behavioral and cognitive techniques that may prove helpful should be shared with clients. Helping clients see the value of self-help support systems and smoothing the way for participation therein is often a step just preceding termination of the therapy. Termination implies fi nality. However, some of my clients have returned following the closing of their fi rst set of contacts. Ordinarily, this attends

Downloaded by [New York University] at 02:06 15 August 2016 changes in life circumstances that bring to surface new life issues. Sometimes old, faulty strategies creep back into the new and changing fabric of their lives, which they fi nd diffi cult clearly to see and address. Or with typical human inventiveness, they fi nd entirely new ways to bring confusion to their lives. In any case, helping others through psychotherapy should not be viewed as a single discrete sequence ending in a fi xed and lasting state of mental tranquility and freedom from life issues.

141 THE THERAPEUTIC PROCESS

Note 1. The Introduction recapped these matters, but readers seeking a thorough treatment of this topic may want to consult Mowrer’s (1960a, 1960b) books, which recapitulate his effort to wed these previously contesting learning paradigms into a single comprehensive theory of learning, cognition, and behavior. His ﬁ rst two-factor theory was revised to further explain the role of cognitive (symbolic) processes in producing the ﬂ uid and often original (insightful) departures from invariant habits that caused critics to fault Thorndike’s views of habit learning. Downloaded by [New York University] at 02:06 15 August 2016

142 Part II

THE NATURE OF THE PROBLEM Downloaded by [New York University] at 02:06 15 August 2016 This page intentionally left blank Downloaded by [New York University] at 02:06 15 August 2016 9 LINKING PSYCHOTHERAPY TO PATHOLOGY

A problem well stated is a problem half solved. —John Dewey

The Goal of Psychotherapy

Goals Express Concept Integrity Therapy clearly links the goal or goals of psychotherapy with an explicit conception of psychopathology. Do not be misled by those of pragmatist and positivist persuasion who suggest that one’s efforts as a therapist may proceed absent a conceptual framework. Lurking in the shadows of every choice we make as therapists are one or more assumptions. Choices do not emerge as products of the moment, inhering in the empirical, clinical data and springing full blown, as it were, from the head of Zeus. They are, instead, products of a lifetime of experience and the way, hopefully guided by study and research, that we organize and explain that experience. All that pragmatist/positivists succeed in doing by their attack on the conceptual is either placing a distance between themselves and their own conceptual assumptions or mistaking their assumptions for what is given and immutable. The more clearly we enunciate our concepts and assumptions, the more critically we can treat them and the choices that ﬂ ow from them. Explicit theory does not rule its advocate. Rather, it is the failure to explicate assump- Downloaded by [New York University] at 02:06 15 August 2016 tions and inferential structures that leave one locked in conceptual straight- jackets. There is yet another cost: Failure to explicate theory leaves one lost in a sea of muchness. Resisting theory, we end up touting eclecticism and struggle to bring forth that transcending connection that knits disparate events together. This tyranny of muchness, perhaps, accounts for the fact that when pragmatist/positivists speak of goals of psychotherapy, it is always in the plural.

145 THE NATURE OF THE PROBLEM

If Integrity Therapy is correct, there is but one goal, which, however, may be stated in various ways. Let us run through the facets of this single goal:

1 To bring to completion the interrupted development of normal, integrative behavior. 2 To help the person transform guilt, in its various clinical manifestations, into normal worry. 3 To liquidate negative addictive behavior and replace it with positive addictive behavior. 4 To help the individual make contact with the reality of his or her life contingencies both immediate and eventual. 5 To help establish a new recent personal history, a new past, which generates a harvest of good results now and day by day, and, thereby, supports those difﬁ cult actions that sow seeds for favorable harvests to come.

As we proceed through this and remaining chapters, we will expose ﬁ rst one and then another of these facets to view as we consider the nature of pathology.

The Means to Achieve the Goal of Psychotherapy

Recapturing Guilt The above are different statements of the same goal. What, however, about the means to achieve the goal? The means again take their character from the Mowrerian conception of psychopathology. There are three basic means that are employed in furthering the goal of psychotherapy. For therapy to be effective, all three means must be utilized. The fi rst two means are instituted essentially in tandem; the third is usually introduced later. The fi rst of the tandem pair is the recapturing of and re-nurturing of guilt. This is accomplished largely by advancing insight into the nature of the individual’s distress and the pathology causing that distress. There are schools of thought that view guilt unabashedly as worthy only of erasure. We already identifi ed Freudian psychology as one such school. Neu- rotic guilt is assumed to be false guilt. That is, it arises either from a confusion of act with its mere contemplation, or it emerges from a scrupulously

Downloaded by [New York University] at 02:06 15 August 2016 harsh judgment levied on basically innocent deeds. In either case, neurotic guilt is baseless. Consequently, the whole ediﬁ ce of psychopathology, built in defense against something essentially unreal, will collapse as the therapist exposes the falseness of guilt. This is why analytic psychology has placed such heavy emphasis on insight alone as the answer. However, the wearying presence of guilt is not evidence of its excess. Nevertheless, it is appropriate to be sympathetic with those who criticize pathological guilt as nonfunctional. If we repeatedly act in a way that prompts anxious forebodings of a punishing future, then, certainly, the guilt we feel

146 LINKING PSYCHOTHERAPY TO PATHOLOGY

is suspect. The rationalists among us will say, “Either change your behavior or quit feeling bad about it!” Too often, however, those same rationalists, as therapists, weigh in on the side of erasing guilt rather than changing the guilt- provoking behavior. From the perspective of what serves the individual and society best, these two alternatives are just not equivalent! Pathological guilt is suspect not because it is inappropriate and excessively present. Nor is it suspect because it brings “secondary gains,” such as sympathy from others or a sense of atonement, even though these may be present. It is suspect because it is weak and ineffectual. It is weak and ineffectual because of the deceptive strategies the individual has employed to avoid consequences both social and intrapsychic. It is the therapist’s job to uncover these strategies and move, in this manner, to neutralize their enfeebling effects on guilt.

Faith and Hope If the therapist’s job, however, were merely interpretive and uncovering, it would be relatively easy and soon ﬁ nished. Ordinarily, I have felt fairly assured that I “see through” the client’s essential problems after perhaps a half-dozen interviews. What happens, however, as therapists uncover and clients stand self-revealed in spite of disguise, subterfuge, and misrepresentation? Why, of course, guilt grows (which is what we were looking for)! And as it grows, our clients feel worse. I do not believe one will maintain a course that subjectively costs more if there is an alternative that costs less. The alternative to coming to a therapist who only makes you feel worse is to stop coming. We could, of course, go slow, be supportive, or even temporarily “try out” a Freudian frame of reference and suggest that the clients’ guilts are groundless! 1 Sooner or later, however, the uncovering will proceed, and, when it does, we, and our clients, are faced with that basic dilemma already referenced: Clients will not continue seeking our help, as they will not continue integrative behavior (abstinence), if, as a result and for a prolonged time, they feel worse. How do we escape this dilemma? The answer brings us to the second of our three basic means for achieving the goal of psychotherapy. Even while as therapist you uncover and, as a result, cause distress, you will also engage in

Downloaded by [New York University] at 02:06 15 August 2016 this second means, or you will simply not have a client. You will be exciting the troubled person to have faith in and to hope for a new, eventual outcome, a new and rewarding life. Paradoxically, while I am convinced that this development of faith and hope is absolutely essential to psychotherapeutic progress, I fear I may be least persuasive at this point in my presentation to you. The reason for my fear is that I feel less able to relate to you how this means is brought about than I am the other two. How does one promote faith and hope? Let me start with two easy answers to this question. First, you are a professional. Those diplomas on your wall do

147 THE NATURE OF THE PROBLEM

inspire a measure of faith and hope. They are supposed to. It may not be suffi cient (or necessary!), but it contributes. Next, your “technical performance” in the guise of accurate perceptions, cogent constructions, and coherent projections regarding desired outcomes will contribute in some measure to the growth of faith and hope. The client might well think: “What I’m hearing upsets me. I’m not sure I buy it, nor do I want to. But it does hang together!” I suspect, however, the more you rely on these two obvious sources to imbue faith and hope, the less ably will you tap a much greater source. This source, however, defi es clear description and explanation. Carl Rogers spoke of genuineness. Others have referred to charisma. We hear of bonding, an interpersonal chemistry that connects one person to the other. I have found no one who can explain how one exercises genuineness without bordering on something “put on” and, consequently, not genuine. “Be yourself?” Well, of course, who else would you be? The problem is, you may be yourself quite thoroughly and fail to inspire another’s faith in you and hope in the future you envision for them. The truth is, I do not know what caused others to invest that critical level of personal trust and faith in me necessary to advance hopefully to a changed way of life. I can only share some observed correlations between the growth of client faith and prior characteristics of myself, which, unfortunately perhaps, I did not control. First, I found that when I liked the person, faith developed more readily. When I believed that the person was redeemable, even if contemptible, faith emerged. I am aware that the measure of my conviction in the eventual value of the individual’s behavioral change excited hope in the outcome. Finally, when I cared personally about the outcome and found the prospect of not achieving a valued outcome personally distressing, faith and hope emerged the better. Why am I so convinced of the importance of this interpersonal, faith/hope- invoking factor to the outcome of therapy? A good many years ago, I collected my case fi les over about eight years of psychotherapy. I made judgments about the changes rendered and degree of outcome success realized by each person. Many of my case fi les were of persons seen less than three times. I classed them as failures. Indeed, to my chagrin what I found was that, overall, most of my cases were failures. Later, I discovered that my results were not unusual. Of course, my research method was suspect as there was no way to calibrate the relative stringency of my judgments.

Downloaded by [New York University] at 02:06 15 August 2016 However, the exercise proved extremely valuable to me, not as research on my “success rate,” but from an entirely different, and for me, surprising angle. I began to cast about for reasons why I had failed so many people. This review encouraged only my doubts. Finally, I turned my gaze on my successes. Was there anything to be gleaned there? The answer was immediate, convincing, and disconcerting. Those success cases all had developed an early and prominent warm regard for me which was tinged with great respect and some awe. I was a salient in their lives. I was no mere professional, objectively analyzing their personal problems, and impersonally sharing the product of that effort.

148 LINKING PSYCHOTHERAPY TO PATHOLOGY

This image of the impersonal professional had, as you might surmise, been my own construction built along neo-analytic lines. It was, when I stopped to look at the record, not consistent with my client’s views. They often wrote me letters or communicated by other means in praise of my virtues. It confounded and embarrassed me, so I had not taken appropriate note of it except secretly to enjoy it. However, after this exercise, I was never further able to assume that psychotherapy rested on the interpretive acumen and communication skills of the therapist. My cases had improved in spite of my analytic professionalism and personal distance, not because of these characteristics. The nature of client change may have depended on the objective accuracy of my insights, but the change itself rested on my clients’ very subjective readiness to take a chance on me. It springs from a willingness to invest faith in me so that they might endure in hope the pain of change.2

Restoring Community We come, ﬁ nally, to our third means. The therapist must, sooner or later, promote the restoration and revitalization of the individual’s intimate community. How does this means advance the goal of psychotherapy, and, of course, how do we accomplish it? Let us address the ﬁ rst of these questions. Indi- viduals suffering psychopathology (engaged in negative addiction) always endure some degree of rupture in their intimate relations. Their adjustive/ non-integrative behavior may cost intimate others in a variety of ways, including direct exploitation of them as well as failure to honor implicit and explicit contracts. Additionally, even when not directly exploiting intimates, people tax intimates through hiding and deceptions. The result is a state of inequity both real and felt. Psychopathology (see Chapter 11) is associated with a tendency to be either independent of or dependent upon others. Addicts, by turns, feel indebted and subservient, seeking some way to restore a sense of equity and closeness with intimates; or, they move to deny any debt while holding themselves critically aloof from intimates. The reason they vacillate thus is that their efforts at compensation are token. They do not actually undo their behavior nor genuinely assure intimates that the latter will cease being injured. Consequently, they never truly emerge from the estranged, inequitable state their behavior has

Downloaded by [New York University] at 02:06 15 August 2016 generated. This inequity contributes to the vicious circle of addiction. With the accu- mulation of psychological indebtedness to others comes a growing reluctance to attempt a real compensation. The enormity of the repayment discourages taking the ﬁ rst step. Estrangement from intimates is a cost individuals pay for their non-integrative lifestyle. There is no easy way to bring about a real rapprochement with intimates. Fundamentally, to do so means acknowledging one’s indebtedness, making some kind of restitution agreeable to the injured intimate, and discontinuing any repetition of the injurious behavior. Only time will

149 THE NATURE OF THE PROBLEM

permit the intimate to grow confi dent of the validity of the last step. Full restoration of intimacy will, as a result, not be immediate. It represents a delayed outcome. Earning the trust and warm regard of intimates, at last, is a positive payoff for taking these steps. This is not the only value, however, as regards furthering the goal of psychotherapy. Disclosing to intimates and accepting a commitment to remain indefi nitely transparent with intimates opens clients to judgment and response, something their deceptive strategies were designed to avoid. In this manner, clients permit social consequences to come through unfi ltered. These consequences, in turn, reinforce the individual’s capacity for both hope and guilt. Informed intimates become vigilant on the individual’s behalf, standing guard over the possible resumption of old ways and ready to encourage continuation of newly adopted behaviors. We conclude that clients’ progress toward recovery of their intimate community works back to reinforce the therapist’s efforts to effect the fi rst and second means discussed above. The effort of the therapist and the impact of intimates ordinarily converge rather than confl ict.3 I have found another step to be often of signal value regarding this matter of intimate community. Intimates as a resource are a variable quantity. The individual may have so alienated others that little readiness remains for restoring community. What passes for intimates may actually be bad company as, for example, drinking buddies. Intimates may be enablers and, even with the best intent, maintain interactions with the client that endanger or defeat the effort to change. For these reasons, I usually suggest to clients that they join a self- help or support group. The object is to permit clients to develop a new, therapeutic community of intimates that will complement and reinforce their preexisting circle or, where indicated, substitute for it. Unfortunately, there are problems here as well. One could do far worse than rely on Alcoholics Anonymous, and certain of the clones, like Over- eaters Anonymous and (Drug) Addicts Anonymous, may serve fairly well. However, there is variability in the conduct of these groups, and they do not always provide enough stability to permit the formation of an intimate support system. Moreover, they are limited to persons professing particular kinds of problems. This means that individuals struggling with negative addictions like procrastination, martyrism, or explosive temper may feel they have no

Downloaded by [New York University] at 02:06 15 August 2016 place to go. One possible answer to the unevenness and limitations of extant self-help groups is to inaugurate a practice- or clinic-based group. The therapist can participate in structuring such a group and supervise its functioning. Another, which may grow out of the ﬁ rst, is to help establish an independent, “general purpose” self-help support enterprise. I have done the latter. By virtue of establishing an in-house training program, “quality control” and stability can be better assured. Enthusiasm and commitment by participants was high, and it worked very well.4

150 LINKING PSYCHOTHERAPY TO PATHOLOGY

A Graphic Rendering Let us formalize and transcribe our treatment of the three means for achieving the goal of psychotherapy into a graphic model. (We will explore the model further in Chapters 10 and 11. ) I fear the directions for this model are like those accompanying common games that we play (like Monopoly or Back- gammon); that is, much more complicated in telling than implementing. So please bear with me. Once you “get the hang” of the model, I believe you will fi nd it straightforward. The critical elements of the model are: (1) the passage of time; (2) integrative (RI ) or adjustive/non-integrative (RA ) behavioral choices; (3) positive or negative remote consequences of behavioral choices; (4) positive or negative immediate consequences of behavioral choices; and fi nally (5) an analysis of three kinds of immediate consequences—intrinsic, socially mediated, and internally mediated. A word of explanation regarding the last point: Intrinsic consequences are those that inhere in our nature such as the pleasure of water to a thirsty person or the pain from burning one’s hand. Socially mediated consequences consist of rewards and punishments delivered by others. Inter- nally mediated consequences are the hopes and fears (guilts) generated by our own self-appraisal.5 In Figure 9.1 , we have a hypothetical and, as we will see, improbable case of a person midstream in his or her timeline. We pick this person up at Time 7. The fi gure makes evident six prior periods and attendant payoff features. At the point in the past that we fi rst observe this person (Time 1 and 2), he/ she has been chronically engaged in adjustive/non-integrative behaviors. These have immediate intrinsic positive payoff (represented by the pale [dotted] rectangles), negative socially mediated payoff, negative internally mediated payoff, and negative remote payoff (all represented by various sizes of black

REMOTE OUTCOME

IMMEDIATE OUTCOME Mediated Cognitive Downloaded by [New York University] at 02:06 15 August 2016

Intimates

Intrinsic

RA RA RI RI RI RI RI (Timeline) 1 2 3 4 5 6 7

Figure 9.1 Graphic Payoff During a Prolonged Attempt to Abstain From Negative Addiction Behavior (RA)

151 THE NATURE OF THE PROBLEM

rectangles). However, as represented in Figure 9.1, the immediate mediated payoff values, from both social and internal sources, do not sum to a negative magnitude as great as the positive magnitude of the immediate intrinsic payoff value. That is, the net immediate payoff is positive. Thus, if we view the matter considering only immediate payoff, the behavioral choice (RA) is clearly reinforced. This outcome sum explains the adoption and continuation of that behavior. However, our hypothetical case has a history of RA choices antedating Time 1. Those past actions have set in motion negative remote consequences, which emerge or “come due” in Time periods 1 to 5. When the emergent negative payoff for past actions is factored into the total, we see that the resultant total net payoff summed over the four currently active factors is negative. Figure 9.2 is presented to help the reader track the net payoff summed over all four factors at each period. At Time 3, our hypothetical person, having connected the dots from his past actions to his current generally unrewarding lifestyle, decides to abstain from RA behavior with its immediate positive intrinsic payoff. He resolves to inaugurate RI behavior. Of course, the result is not immediate relief. If, for example, RA were recurrent alcohol intake, then he or she will have embraced abstinence at Time 3. When this occurs, Figure 9.2 tells us that our abstinent person experiences a net reduction in the payoff value that lasts for a considerable time period. Simply put, our person suffers a serious period of feeling worse (through Time periods 3, 4, and 5). This case is hypothetical in more ways than one! It represents a course that will not occur even though the outcome (see Time periods 6 and 7 in Figure 9.2 ) eventually turns quite positive. True, persons suffering psychopathologies frequently endeavor such changes. However, they do not successfully maintain these changes when circumstances are like those presented in Figures 9.1 and 9.2 .

POSITIVE SUBJECTIVE LIFE INCOME

NEGATIVE Downloaded by [New York University] at 02:06 15 August 2016 SUBJECTIVE LIFE < DESPAIR > INCOME

RA RA RI RI RI RI RI (Timeline) 1 2 3 4 5 6 7

Figure 9.2 Net Payoff Values Derived From Immediate and Delayed Payoff Depicted in Figure 9.1

152 LINKING PSYCHOTHERAPY TO PATHOLOGY

The reason for failure is that no one will continue under a worsening state of subjective income if it is within their power to choose otherwise. No one will endure despair when immediately at hand is a familiar means to produce a subjective lift and relative gain in comfort. All persons have to do to restore that relative comfort level is return to the RA behavior just abandoned. The challenge to the psychotherapist, of course, is to help people change without despairing. What is it that the psychotherapist does, as rendered in the components of our model, that enables individuals to avoid this “valley of despair?” How does psychotherapy help them avoid the downward spiral and, thus, escape the pullback hook of addiction? To address these questions, consider Figures 9.3 and 9.4. In these ﬁ gures are the four payoff factors as they

REMOTE OUTCOME

IMMEDIATE OUTCOME Mediated Cognitive

Intimates

Intrinsic < > (CRISIS OF FAITH)

RA RA RI RI RI RI RI (Timeline) 1 2 3 4 5 6 7

Figure 9.3 Graphic Payoff During a Therapy-Aided Attempt to Abstain (RI) from Negative Addiction Behavior

POSITIVE SUBJECTIVE LIFE INCOME

NEGATIVE Downloaded by [New York University] at 02:06 15 August 2016 SUBJECTIVE LIFE INCOME < >(CRISIS OF FAITH)

RA RA RI RI RI RI RI (Timeline) 1 2 3 4 5 6 7

Figure 9.4 Net Payoff Values Derived from Immediate and Delayed Payoff Depicted in Figure 9.3

153 THE NATURE OF THE PROBLEM

exist before therapy (Time 1), beginning therapy (Time 2), beginning behavior change (Time 3), and following behavior change (Time periods 4, 5, 6, and 7). Upon beginning therapy (Time 2), the negative payoff magnitude mediated cognitively by our clients increases (note in Figure 9.3 the somewhat larger black rectangle at Time 2 compared to Time 1). This increase represents the recapturing and re-nurturing of guilt fostered by the therapy. Defenses are being exposed and, as a result, persons become vulnerable to guilt long denied. This point, though of limited term, will be the most tenuous and fragile of the entire therapy. I refer to it as the crisis of faith, and it typically comes at the beginning of uncovering in therapy. Note, however, that the extent and depth of the discomfort associated with the crisis of faith is far less than that associated with the period of despair represented in Figures 9.1 and 9.2 . This is because the worsening of comfort caused by insight is balanced by the concurrent emergence of the second payoff factor, the infusion of faith and hope. Faith in the therapist encourages beginning steps in change (to integrative behavior). Both the change and faith in the therapist inspire hope in the future. This growth in hope is represented by a relative increase in internally (cognitively) mediated positive payoff (the relatively larger white rectangle at Time 3). We have represented the therapy-induced increase in hope as a very modest quantity. (Compare the larger white rectangles representing the mediated positive value in Figure 9.3 with the slightly smaller rectangles in Figure 9.1. ) Therapy-induced hope is not a robust, compelling force able to stand alone in producing change. However, in spite of how modest the role it plays, that role, nonetheless, is critical. It spells the difference between a therapy failure and a success. Note that the level of discomfort at beginning therapy, Time 2, is greater than that present as changes begin, Time 3 (see Figure 9.4 ). This is a function of therapy-enhanced guilt emerging at Time 2 that is modulated by therapy- enhanced hope emerging at Time 3. As we present the matter, however, the net subjective income at Time 3 is only marginally more favorable than is that experienced at Time 1 before therapy was begun. In any case, if our hypothetical clients respond to the crisis of faith by discontinuing therapy in advance of behavior change and resume guilt-reducing defensive strategies, they will feel a gain in subjective comfort from that felt at Time 2. If change (abstinence) does

Downloaded by [New York University] at 02:06 15 August 2016 not produce an increase in comfort as favorable or, hopefully, more favorable than stopping therapy, change will be interrupted, and we will have lost our client. It is fair to characterize therapy as a second chance for the individual to complete the unﬁ nished business of growing up. In this sense, the therapist picks up the function that parents and intimates have served, if, perhaps, not always well, in advancing clients’ previous development. Of course, the therapist lacks the control over life consequences that parents or parental surrogates possessed during clients’ childhood and also lacks the shared destiny with clients that enhances the inﬂ uence intimates may wield. The therapist must,

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consequently, draw more on what clients bring to therapy than what the therapist brings through the powers of insight, persuasion, and charisma. What clients bring are three critical characteristics that provide the therapist with the resources to effect the goal of therapy: Clients bring their desperation, the basic driving force for change. They bring their own resident capacity for guilt which, when loosened, raises the cost of the old, non-integrative behaviors. Finally, they bring the capacity for hope, which sustains the move away from addictive comforts toward a life of promise not yet fulfi lled. The limitations on the therapist’s powers of infl uence and control make critical the therapist’s effort to revive and loosen the forces residing in clients’ intimate community. This effort, of course, represents the third means we have identifi ed for accomplishing the goal of psychotherapy. In Figures 9.3 and 9. 4 , the third means, restoring the client’s intimate community, begins with, perhaps, reservations at Time 3, but grows in subsequent periods as change is consolidated. This factor is evident in the shift from negative (black rectangle) to positive (white rectangle) in Time 3 and thereafter (view in Figure 9.3 the payoff mediated by intimate others). The result is another elevation in net, relative subjective comfort (see Figure 9.4 , Time periods 3, 4, 5, 6, and 7). Individuals still hurt, still suffer net negative income as a result of their own recent history. However, life is “looking up,” and, with perseverance in the new behavior, they will emerge at Time 6 with a radically different level of subjective satisfaction.

Conclusion This chapter represents a transition or bridge between the central topic of Part I of this volume and that of Part II. Inevitably, our concept of the nature of psychopathology dictates what we propose to do to treat it. If we adopt the medical model, we basically believe that the problem resides in some kind of neurochemical dysfunction or aberration. Treatment, therefore, will target, one way or another, the hypothetical aberration. Usually, prescriptive drugs or surgical intervention accomplishes this. When other techniques are employed, such as psychotherapy, these continue to seek a neurochemical target. Thus, the assumption is that inducing behavioral change works, when it does, because it affects the neurochemical status of the individual.

Downloaded by [New York University] at 02:06 15 August 2016 For example, norepinephrine depletion results in depression and associated behaviors (retardation, withdrawal, listlessness). Inducing the person to reverse the depressed behaviors has been thought to promote norepinephrine production.6 A vicious circle (norepinephrine depletion → depression syndrome → further norepinephrine depletion → etc.) is turned around (behavioral initiative → increased norepinephrine production → lifting of depressive mood → etc.). Since psychotherapy is viewed as an adjunct to effecting neurochemical changes, advocates of the medical model insist that its practice should generally be under medical supervision.

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Similarly, if we adopt an analytic model, we construe psychopathology as a function of repressed desire stiﬂ ed by inappropriate moral fears (guilt). Those repressed desires occasionally surface, causing a spasm of anxiety. This anxiety, in turn, motivates symptomatic behavior, such as obsessions and compulsions, which serves to reduce the (neurotic) anxiety. Treatment consists of exposing the inappropriateness of the fear. This causes the pathology (symptom structure) to collapse. A related perspective resides in the trauma model. It asserts that the problem is unrelenting fear conditioned by past trauma. Treat- ment consists of counter-conditioning procedures designed to extinguish or replace the fear. Another perspective with variants is the social contingency model. It holds that pathology is a function of the contingency medium in which the individual resides. This means pathology does not rest within the individual so much as in the contingencies that serve to elicit and reinforce the individual’s behavior. Treatment calls for engineering a change in the social and environmental contingencies. We could go on. I think the point is made, however, that one’s conceptual assumptions are ineluctably wed to the treatment path one chooses. This profusion of perspectives and models is good and bad. It is good because it permits a vigorous exploration of ways of construing and organizing the phenomenon of human psychopathology and its cure. It is bad because it is confusing, an embarrassment of conceptual riches. Is eclecticism a sensible answer? What could be more sensible, under the pressure of this cacophony of voices, than to say, “I count myself an advocate of none. I will employ whichever is most relevant at the time!” Fine. But what assumptions compose your concept of relevancy? Must not the eclectic have an implicit model in order, momentarily, to choose this or that perspective? Of course! And this means that in actuality, the eclectic is merely one who has chosen to keep his or her own conceptual model unstated! Do not get me wrong. You have every right to be an eclectic if you so wish. I just hope you will agree that explicit theory is better than implicit theory and choose otherwise. Karen Horney’s (1950) neo-analytic approach provided the concept of vicious circles, which we employ so liberally. Cognitive processes are also prominent, as well as contingency considerations such as immediate and long- term reinforcers. The addiction model espoused in these pages is eclectic in a

Downloaded by [New York University] at 02:06 15 August 2016 certain sense. It borrows from other perspectives. The analytic position models for us defense mechanisms, symptoms as anxiety alleviators, and the interpretive approach to psychotherapy. These borrowings, however, are imbedded in an explicit conceptual structure, which rationalizes why we choose these notions and in what way we apply them. I am, of course, convinced of the superiority of this model over those from which it has borrowed. You must ask whether it conforms to the facts of human behavior, as you know them, and whether it simpliﬁ es, orga- nizes, and informs your thoughts about behavior pathology and its treatment.

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Notes 1. These suggestions have all been made by students at one time or another in puzzling over this dilemma. Going slow or being supportive (which seems to be a distinction without a difference) may permit the human bond between therapist and clients to grow, which is absolutely necessary. However, in so far as we merely delay the inevitable, the client may be prompted to stop seeing us and made to feel worse by us only after we have collected a larger fee. Finally, being “temporarily Freudian” sounds very much like a “bait and switch” tactic. Clients are likely to say, “Not only are you now pointing out things that make me feel bad, you’ve been leading me on!” One less client. 2. I don’t recall Mowrer speaking to this necessary investment by the client of faith and hope in the person of the therapist. He did speak often about client resistance to uncovering justifi cation strategies and to restoring guilt, but he moved more quickly than I to the utilization of groups and the power of social reinforcement resting in groups as the bridge to change. That power is given attention in the section Restoring Community above. However, had Mowrer remained focused in individual psychotherapy, I believe he would have come to recognize the critical function of the faith/hope factor in client change and progress in that venue. 3. This may sound strange. Historically, intimate associates of the client and psychotherapists have viewed each other with wary if not hostile regard. This has been a function of the tendency by psychotherapists, not limited to those in the analytic tradition, to fi x intimates with blame while viewing the client as victim. In Integrity Therapy there is, in a certain sense, a reversal of this formula. Intimates will have done various injuries to our client, there is no doubt. And, certainly, we do not exonerate parents in our examination of the preconditions to the development of psychopathology (see Chapter 11). However, what is fundamental to that pathology is the emergence of behavior, often disguised, that taxes and injures intimate others. What is fundamental to resolving the pathology is a cessation of such behaviors while being replaced by actions that intimates are likely to welcome. 4. The enterprise I helped establish was called Community House. It was incorporated as a non-profi t organization, had its own indigenous staff, and boasted an explicit, participant-evolved therapeutic culture. It emphasized personal growth through member openness, accountability, and interpersonal contract formation. More than one member of a family could participate. Indeed, whole families have taken part. There was no limit on time involved, as is true of most self-help groups. It was underway for more than 30 years, and some members took part for most of that span. Members viewed each other as extended family. It proved to be a powerful ally to my psychotherapy. The group gradually disbanded with the closure of my practice. Exploring how one inaugurates and composes such an enterprise might be of interest but would take us afi eld of our current focus. Perhaps the topic can be addressed in another, future work. 5. Remote consequences are also intrinsic, socially mediated, and internally mediated in kind. Besides the material benefi ts our past integrative actions might provide in the future are critical intangibles such as social gratitude, approval, and interper- Downloaded by [New York University] at 02:06 15 August 2016 sonal credit. Other nonmaterial but very real benefi ts fl ow from self-administered approval as an emergent sense of accomplishment and self-actualization. It would needlessly complicate our graphic model to separate these components of the remote consequence factor. Therefore, we represent the remote factor as one lump sum. 6. Actually, the neurochemical basis of mood continues to be elusive. Serotonin has been more the target than norepinephrine of recent research and drug treatment. Consider the circle of effects here merely illustrative of what medical research would seek to establish.

157 10 THE NATURE OF NORMALITY

You want to ﬁ nd out a mode of renunciation that will be an escape from pain. I tell you again, there is no such escape possible except by perverting or mutilating one’s nature. —George Eliot, The Mill on the Floss

As Absence of Pathology Mowrer and others have raised objections to the tendency to deﬁ ne normality as the absence of pathology. That tendency arises from our preoccupation with problems in behavior, which we proceed to classify, dissect, and ramify with tireless zeal. The result is that we often appear to have constructed a rich, ﬁ ne-grained world of human disorder in contrast to a normal world both nondescript and lackluster. An analog is the commonplace illustration of depth perception in which railroad tracks, wide and detailed close to the observer, converge with distance to a single, disappearing point. Normality, as the absence of pathology, becomes that vanishing point.

Are Normality and Pathology Independent? More problematic than this short-shrifting of normality is the assumption of a dichotomy. One is either normal (free of pathology) or one is disordered. Assume, instead, that a class of positive factors (normality) and of negative factors (pathology) varies in some measure independently (non-dichotomously).

Downloaded by [New York University] at 02:06 15 August 2016 Would this bring a new perspective on normality and pathology, and would this perspective offer any advantages? If a hypothetical person were to load positively on both normality and pathology factors, would it do more than make one’s head swim? Well, it would relieve us of that confusion we have when a well-functioning, able, and personable individual does produce a personality test battery with surprising signs of psychological issues. This is a commonplace occurrence that we rationalize by dismissing the pathology indicators as statistical accidents or

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by reinterpreting the positive signs as a covering of false health. Our dichoto- mous thinking keeps us from entertaining the proposition that this person may be both normal and pathological at the same time. Equally puzzling to us are cases in which a marginally functioning, incom- petent, and gauche individual produces a personality test battery uniformly free of signs of pathology. Again, we are likely to explain this away as an instance of a false positive test battery or a false negative clinical impression. That is, we assume pathology is present that the tests do not detect, or we have anomalous clinical signs of pathology in a fundamentally health person. An example might be an otherwise normal and healthy person experiencing intense situational stress that causes transitory symptoms. The possibility that this person is neither normal nor pathological is rarely examined. Naturally, we have no problems with the well functioning person free of test-revealed signs of pathology, or the poorly functioning person replete with pathology indicators. They accommodate our dichotomy.

A Limited Independence Let us not push the independence of normality and pathology too far. There are obvious ways in which dichotomy applies. Perceptual clarity, effective communications, and high interpersonal consensus are not compatible with hallu- cinations and delusions. However, they may coexist with depression, paranoia, obsessions, and anxiety states. The point is, we do violence to nature if by habit of mind we impose a dichotomy. When some index of pathology appears in the context of a picture of normality, we ignore the index or revise our judgment of the person’s positive nature. Certainly, sometimes we may have good reason to ignore a pathology sign, and sometimes we will reason that such a sign does alter our evaluation of a person’s positive attributes. However, these conclusions should be based on reasons other than a mindset. Meanwhile, it behooves us to start, not with our theory of pathology, but with our grasp of normality. Having done so, we can then ask, “In what way may pathology coexist with normality? In what manner does it subtract from normality?” Mowrerian theory advances a relatively simple and singular construct for pathology. Let us see if it renders a similarly unencumbered concep-

Downloaded by [New York University] at 02:06 15 August 2016 tion of normality. In Chapter 1, as a point of departure, the following defi nition was offered: Normality is that set of behaviors (including emotions, attitudes, and cognitions) that promotes a preponderance of integrative over confl icting adjustive choices. It was further observed, “This defi nition permits some adjustive but non-integrative choices to be present . . . so long as the predominant feature is integrative behavior.” As integrative behavior is the standard against which we measure normality, let us examine more carefully the integration concept.

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An Otherworld Perspective

A Report to a Distant Planet To understand normal human personality development, we must, ﬁ rst, step back and look upon our human condition as would that proverbial visitor from another planet. He (she or it), if permitted to catalog earth’s fauna, would probably have much to say about the various animals that still inhabit limited areas of the earth. However, the bulk of his report would pertain to the furless, tool-using biped occupying the greater part of the earth’s habit- able surface. We might imagine he would report the following:

All the living units of this planet have ﬁ nite life spans. They are replaced by new units, which, with some variation, approximate the appearance and capabilities of their predecessors. The furless bipeds, which are most abundant in number, live under conditions that are distinct from the wide variety of those less numerous units, which occupy particular habitats. The latter maintain their lives and reproduce their kind in a simple and direct interaction with their kind and their environment. That is, the effects of their actions emerge immediately, at one point in time, and are compatible with their life support systems. Of course, when conditions change such that their actions produce delayed and negative effects, they usually fail to survive. However, the furless bipeds are different. They live under conditions that ordinarily call for actions with compound effects across time. The main reason for this is that they rely profoundly on biped interactive exchange systems to provide life support. Consequently, the effects of biped actions emerge not only at an immediate point in time, but at various later points as well. As newly reproduced units, these bipeds are not equipped with a preset program enabling them to cope with these conditions. Instead, they appear to rely on the induction of a program for this purpose by a series of interactive contacts usually with the units that reproduced them. This induction process is surprisingly effective. However, failures, while impressively few, are still evident. Failures are manifest in several ways: Some units self-destruct. Some are placed by other Downloaded by [New York University] at 02:06 15 August 2016 units under conditions that restrict their actions. Some disrupt the exchange system, which may result in local and, sometimes, widespread unit destruction each by the other.

Human Interdependence As are most communications from space visitors, the above may sound strange and different from observations we might make about ourselves. Still, let us see if we can make sense of what our visitor has written. He seems to be

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suggesting that what is essential to the human condition is that we live in interdependent social arrangements embracing considerable interpersonal commerce and exchange. These circumstances require that we act not alone for momentary satisfactions, but with cognizance of numerous later effects reverberating through our “life support system.” When we have eyes only for the attractions of the moment, we can expect that when tomorrow arrives it may bring some nasty surprises. Our visitor certainly implies that this is universally true of us whether we live in cities or under primitive conditions. This means that, in all likelihood, there has never been a time when such has not been true of the human condition. We have always and everywhere been interdependent, and, as such, have faced the necessity of ordering and, thus, sometimes delaying the expression and satisfaction of our needs. Freud was so impressed with this aspect of the human condition that he called it the “reality principle.” That Freud elected to grapple with this essential human condition may help explain how, in spite of their limitations, his constructions have had such lasting impact.

The Joys of the Moment Our space visitor was impressed by the success humans have in installing within new members of society a program enabling them to cope with their human condition and to observe the “reality principle.” He must have duly noted that children are strongly tempted by the joys of the moment. He may also have observed that adults often ﬁ nd the short-term gain so seductive that they elect to squander their claim on future securities in the interest of the moment. Mowrer often referred to an ancient cliché, “Eat, drink, and be merry, for tomorrow we die!” which, he noted, was an understandable exhortation on the part of doomed soldiers. Others have adopted it using a slight alteration of terms: “Eat, drink, and be merry, for tomorrow never comes!” This is a cute piece of sophistry on the part of those who are not doomed to immediate death. Tomorrow may never come (since it would then be today), but that does not mean that time stands still or that the remote effects of our actions will not be experienced by us. In that sense, tomorrow does come! And what if we still live? What does yesterday’s merry maker say when he sees others, who have toiled while he played, in positions of security and bounty while he

Downloaded by [New York University] at 02:06 15 August 2016 is dissipated and destitute? Our visitor must have been impressed with the obstacles we face in consistently acting to eschew temptations of the moment while maximizing life’s payoffs over time. These obstacles are met both at the inception of such behavior in childhood and during its maintenance through adulthood. However, let us concentrate on the “new unit,” the infant child. The newborn is wedded to the immediate with its whole being. The sheer ferocity of the newborn’s protest to any delay speaks to its basic attitude which is “Eat, drink, and be merry; there is no tomorrow!” And, consequently, any delay is cruel, unacceptable

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torture. Delay serves no end because there is none to serve. How move such a monomaniacal creature from its blind reliance on the now? Of course, our visitor was only partly right in assessing that the human has no set program. He could not know from relatively brief observation how much the infant’s devotion to the immediate was a function of its physiological immaturity, since its central nervous system continues to develop immensely during the ﬁ rst year, and is not fully developed before the next 20-plus years are out. Nor would he have data enough to conclude that language develops in an invariant sequence regardless of child rearing modes (except only that language be used by those around the child). Now, language does not insure the shift from behavior that maximizes one’s momentary gain to behavior that maximizes gain over time, but it makes that shift possible. Without a means to represent the not-here and not-now, there is no way to factor in remote consequences and, therefore, no way to avoid dominance by momentary concerns.

The Engineering of Integrative Behavior

Integrative Versus Adjustive Behavior Many years ago, I attempted to study the elements of this shift using the lowly laboratory rat (Bixenstine, 1956). Mowrer called behavior that maximized gain over time integrative behavior. He contrasted it with behavior that maximized immediate gain, which he called adjustive. Animals, such as the laboratory rat, show little capacity to act integratively (though they can often be taught rather complex adjustive habits). Why? Because they apparently lack the ability to represent remote outcomes of current actions. They have but limited capacity to capture in their response systems what is not here and now. For example, if a hungry laboratory rat alone in a box receives a pellet of food upon accidentally pressing a bar, the likelihood of bar pressing is increased. With repeated coupling of bar press and food, the rat becomes so proﬁ cient that it will consistently press the bar within one-half second of a signal regularly announc- ing the availability of the food. Now, Mowrer (with Ullman, 1945) found that if, following the food signal, the rat must sustain a wait time of only three seconds before pressing the bar and taking the food or else receive a painful shock, it can learn to wait only if shock closely follows the bar press. If shock follows

Downloaded by [New York University] at 02:06 15 August 2016 forbidden actions by more than 15 seconds, the rat will not learn to delay before pressing the bar and taking food. 1 That is, it can integrate consequences separated by no more than 15 seconds, a very limited sense of future indeed! The rat’s capacity to represent events limits it to integrating outcomes separated by no more than 15 seconds. Actually, the passage of half of that amount of time seriously compromised the rat’s ability to learn to delay before pressing the bar. It is fair to say that, for all practical purposes, if unaided and relying on its own resources, the rat cannot solve this kind of problem. That realization prompts a question: What form of environmental engineering would we

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have to do to compensate the rat’s limited resources and enable it to perform integratively?

The Power of the Sign The answer is rather straightforward and immensely instructive. I taught the rat to approach and press a bar at a signal (a buzzer sounding). After this behavior was well established, I changed the rules of the game. Now the rat not only obtains food when it promptly presses the bar, it also incurs punishment (electric shock). However, while the food is immediately presented, the shock is delayed in time. All the rat must do to maximize the most desirable outcome (get food, avoid punishment) is delay bar pressing for three seconds. We know, of course, that it fails to do this. What, however, if we introduce another, different signal (a blinking light) that we present, if briefl y, in close association with each instance of punishment (shock)? Further, during the period following the buzzer, the blinking light will come on whenever the rat approaches near the bar. The blinking will cease if the rat retreats. You see we have engineered it so that the blinking light, being briefl y emitted with each shock, comes to “stand for” the shock. Thus, when the rat in customary haste, following the buzzer sounding moves toward the bar, the blinking light appears, very much like Pinocchio’s Jiminy Cricket, warning against such a non-integrative action! With the environment engineered in this fashion to compensate for the rat’s inability to conceive eventual outcomes, we found that the rat’s performance was amazingly “human like.” At fi rst, after the taboo was initially introduced, the rat ignored the blinking light. It promptly pushed the bar, took and ate its pellet of food, then suffered the painful shock some time later. The shock was, however, immediately preceded by a brief (two-second) emission of the blinking light. This sequence was repeated as trial followed trial perhaps a dozen times, but a new pattern emerged gradually to replace it. The rat began to pause in its rush to the bar when its approach elicited the blinking light. As trial followed trial, that behavior changed to a defi nite probing. That is, the animal would come forth and stick its nose into the infrared beam, which caused the light to blink while the taboo period was in force. Typically, the rat would draw back at the blinking, wait a moment, and then

Downloaded by [New York University] at 02:06 15 August 2016 cautiously probe again. It would repeat this probe/withdrawal pattern until the taboo had elapsed and the light no longer blinked with another probe. As soon as this was so, the animal would jump forward, press the bar and eat. Of particular note is that the rat could wait as long as 40 seconds (the lon- gest period tested) without serious loss in ability to delay the bar press and food consumption. Before introducing the blinking light signal, anything over three seconds of waiting was too great a challenge and resulted in integrative failure. Moreover, how long after the bar press one delayed the shock, whether 20 seconds or several minutes, was immaterial! The blinking light not

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only enhanced the rat’s capacity to endure what had previously been an intolerable wait time, but rendered the time between act (bar press) and delayed effect inconsequential! So long as distant outcomes were clearly represented (via the blinking light), then how distant they were, at least for periods up to 120 seconds, was irrelevant! Intriguing to me, Mowrer, and other observers was how “intelligent,” “deliberate,” and “autonomous” the animal’s behavior appeared to be. “It reminds me of a child told not to take a cookie until after dinner, but being drawn, nonetheless, to hover near the cookie jar,” one observer noted. I have observed my own child, then about eight years old, start toward his bicycle, then halt saying to himself, “Oops. Mom said I’d get a treat if I stuck around here with Mike.” The rat’s behavior was reminiscent of these kinds of deliber- ative human actions integrating disparate consequences. But, of course, there is a world of difference. Human children (and adults) struggling to integrate effects often have no carefully engineered environment providing conspicuous signals of future outcomes as they begin to act. Those signals must be provided from their own representational, cognitive processing.

A Matter of Passion This accounting may mislead you into concluding that integrative behavior is the result of an entirely intellectual exercise. The child begins to think, “If I act thus and so, the result will be this now, that latter. This is desirable, but that is extremely undesirable. Therefore, I will not act thus and so. I will seek a different course with a more desirable over-all outcome.” Pretty cerebral, right? What is necessary, then, to acting integratively is to be blessed with the cognitive capacity to apprehend, to foresee the outcomes that are not clear and present. This is something we humans, with our capacity for symbol and language, have in abundance while the rat and other language-limited animals do not. However, it does not take much clinical experience to recognize that there is a great difference between knowing what follows what and acting on that knowledge. There are persons, sometimes labeled psychopaths or sociopaths, who impress us with their bright verbal knowledge of consequences and “right and wrong.” Nonetheless, they are chronically captives of the momentary. In spite of their gift of symbol and language, their verbal “knowledge,” they are

Downloaded by [New York University] at 02:06 15 August 2016 behaviorally stuck at the adjustive level, no better off than dumb animals. We provided the rat in our study with a sign, which it could not reproduce either directly or symbolically. Nor did the rat respond to this sign in a cognitive manner. Rather, its response was marked by fear . It found that signal powerfully motivating and was aroused to act to quiet that agitating light! It is the arousing, disturbing potential in the sign that caused the animal to delay and, thus, to achieve the most desirable outcome over time. We can conclude that the same is true with humans who behave integratively. That is, quite apart from the fact that humans produce signs representing

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future outcomes, they also respond to their signs with fear or relief and satisfaction. Their responses, in some measure, recapitulate the event being represented in signs. It is not enough to know the future and represent or symbolize outcomes. One must also respond to those symbols with emotions powerful enough to inhibit the impulse of the moment or to sustain an effort lacking momentary encouragement or reward. This business of sticking out one’s cognitive probe in order to sample the future is not something done casually or impersonally. It is a passionate affair. Otherwise, it will lack the force necessary to free one’s course from the dominion of the moment.

The Human as the Worrying Animal

The Normality of Worry René Descartes (1960) emerged from the stove and declared, “I think, therefore, I am!” Not quite, René. Thinking is necessary, but it is not enough to capture the essential human. That essence we capture by a certain kind of thinking, emotional and passionate, which probes the future and ﬁ lls us with distant pains and remote pleasures. Descartes would have been closer to the truth had he declared, “I worry, therefore, I am!” Worry is what captures the nature and spirit of the healthy, normal human. We are the worrying animals! Contrary to popular belief, we are not normal when “free of worry.” The psychopath is free of worry. We are normal because we worry. Nor is this worry obsessive, nonproductive, and trivial as it sometimes is when the worrier pro- tests his choices. We are normal because, through worry, we assess the real and critical options before us measured against values extended from this moment well into the future. It is a process at once cognitive and replete with emotion. It is also a process, which, as we look at it more closely, is full of mystery!

The Mystery of Worry The mystery is this: How do humans learn to subject themselves to the representation of events that scare and distress them? We have already noted that representing future events in symbols unaccompanied by an emotional response to those representations would be “empty knowledge.” To make a difference in

Downloaded by [New York University] at 02:06 15 August 2016 what we do, the future must move us with a force that proves no less than that of the present. There is, however, a catch. The present is here. Its attractions or its menace reaches us directly and sensually. It needs no cognitive reconstruction. By contrast, the future is captured by an act of volition, by a studied, cognitive manipulation of signs, the use of which we can as easily dismiss. The dilemma is well illustrated again by reference to our laboratory rat. We have described above how to compensate the rat’s lack of representational skill by providing a sign (blinking light) linking present act with future outcome. We decided next to see if the rat would learn to prefer the presence or absence of

165 THE NATURE OF THE PROBLEM

this sign. If given a choice, will the rat act to “call out” the blinking light? Will it choose to experience the sign as an aid in integration and the maximization of positive outcomes? Or will it act to avoid contact with this fear-invoking signal of painful eventualities? We tested the matter by teaching rats to come quickly at the sound of a buzzer, press a bar, and eat. Then we introduced a taboo: The rat must wait 10 seconds before pressing the bar or else be shocked one minute later. If it approached close to the bar, the light blinked, and then, grew steady upon its retreat. The blinking light came on for two seconds just before any shock was administered. These procedures, as before, soon had rats emitting a high level of integrative behavior (obtaining food and avoiding shock at the cost of 10 seconds of waiting). Now, a new wrinkle. We introduced a clearly distinguishable alternative approach to the bar and food trough. Choice of one path continued to elicit the blinking light as the animal got close to the bar during the taboo period. Choice of the other path was free of the blinking light. Will the rat choose the approach that will help it solve the integrative problem, or will it choose the path that saves it from experiencing the fear-provoking blinking light signal? Will it choose to worry, or will it play ostrich? We believed we knew the answer beforehand, but we had to ask. We found that the rat refused to use a fear-provoking signal when given the choice not to do so. This was true even though the result was a precipitous failure in the level of integrative behavior and, of course, an abrupt return of periodic, painful shock. Choice permitted the reassertion of the basic rat nature. If one wants the rat to behave integratively, one cannot leave the matter to the rat. The rat is not a worrying animal. 2 It is not that animals other than humans demonstrate no worry-like behavior. They do. Rats, for example, have been observed to learn from a single experience of food poisoning to probe, taste, sniff, and worry over any new food made available. They will avoid eating if the food is tainted. The poi- soned food was ingested minutes or hours before the rats grew sick, so we have a limited example of integrative behavior in rats. While they do not probe the future with cognitive representation, they appear especially able to link remote gastric calamities with the particular taste and smell of food. Take, also, the approach of thirsty deer to a water hole in the wild. The deer

Downloaded by [New York University] at 02:06 15 August 2016 do not bolt heedlessly to the water. Instead, they circle the hole, sniff the wind, and give every indication that they are “looking for” a lion or other beast of prey hidden in the bush. Their actions betray their state of discomfort and high arousal. The least sound or movement will send them crashing away still thirsty. Why would they choose to worry themselves thus when they could as easily ignore the dark shadows in the bush and rush directly to slake their thirst? You might answer by pointing out that such skittish behavior in deer and ﬁ nicky eating habits in rats have obvious survival value. Skittish deer may suffer occasional bouts of prolonged thirst, but bold ones are feed for lions.

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Are the rat and the deer, then, programmed by nature to worry in these particular ways? If so, may we also conclude that humans are similarly programmed to taste and seek out through cognitive probing the dangers waiting in the future? Are we born worriers? Or does this answer to the mystery merely beg the questions? In our study, the rat would not freely choose to worry, to subject itself to a sign that elicited fear. Apparently, it lacked the capacity to weigh the long- term outcome of sign-using (worrying) against that of sign-avoiding. What is involved in weighing long-term outcomes? Why sign-using, of course! Imag- ine that the rat were able to symbolize the elements of these events. It might, then, reason as follows: “If I use the blinking light to help me delay taking food in spite of how discomforted I feel when the light blinks, I will avoid being shocked and still enjoy the food.” Of course, if the rat could employ symbols in this manner, we would not have been obliged to provide it with the blinking light in the fi rst place! That humans learn to symbolize and thereby weigh outcomes helps resolve our mystery. We learn to worry in tiny steps. At fi rst, the symbol represents events only moments away. Peek-a-boo, that universal game, is among the fi rst lessons we undergo, learning fi rst the label (“Peek-a-boo”) and the outcome (the startling appearance of the player). It is a lesson in controlled worry. The learner anxiously makes ready for the surprise, and fi nds that readiness rewarded. The peals of laughter should not be misunderstood. The fright is not intrinsically funny. Rather, it is the sense of conquest over the future that prompts that excited laughter. The worrier in this manner discovers the value of worry: how through it, we arrive prepared. In this manner we learn, in incremental steps, that worry is productive, that it enables us to maximize the good and minimize the bad.

Worry: Omnipresent and Complex I mentioned earlier that the present reaches us directly and sensually. It does not have to be cognitively reconstructed. That is true. Humans, nonetheless, learn to fi lter most, if not all, immediate happenings through a cognitive reconstruction process. What lies immediately before us does not provoke a thoughtless response except under unusual conditions. Instead, it is codifi ed and classifi ed to wring from the experience the signifi cant implications to us

Downloaded by [New York University] at 02:06 15 August 2016 for now and for the future. Our choices and responses are, in large measure, then, delayed by and cushioned within this ongoing evaluative, cognitive process. In this sense, we do not worry just sometimes. We worry most if not all the time we are awake and spend a fair measure of our sleep pursuing our worries through dreams. Do not presume that worry merely probes the remote harmful potentialities of succumbing to attractions of the moment. Worry also attends the imminent embrace of agonizing duty that we endure comforted and consoled by our vision of the morrow. We probe the future both to empower us to resist dangerous

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temptations and to gird us to sacrifi ce the price that must be paid for the “ good life. ” This constant “time-binding” and worrying is normal to us, but that does not mean that the futures that we envision are standard replicas. They are not, and this is true in part because our life-circumstances differ. 3 However, even where our circumstances are closely similar, our projections may be quite dissimilar for two reasons. One is that our understanding or beliefs differ about what follows what. The second is that our values differ, so what might be the “good life” for one is a matter of indifference to another. Thus, variable circumstances, differing schemas of what follows what, and contrasting values ensure that being normal does not mean regression to the commonplace. Humans as worriers do not conform well to those defi nitions of normality that stress ordinariness, stolidity, invisibility, and, of course, freedom from worry. We emerge with a view of normality somewhat different from that more commonly held. The normal, fi rst, is a person of passion. Without passion, the worrying animal will not be moved to act on the basis of events merely conceived and not here and now. The normal, second, is a person of convictions. Without a belief system, the worrying animal would have no basis for projecting outcomes. The normal, third, is a person of distinct values. Unless some eventualities are more valued than others, the worrying animal would never elevate a remote, more valued end above one conveniently at hand. Passions, beliefs, and values interplay constantly in the everyday life of the healthy, normal individual. The absence of these ingredients of the worrying animal does not necessarily produce a picture of pathology. Indeed, their absence may bring about a result that conforms more to the popular picture of normality (stolidity, ordinariness, “freedom from worry”) than does that advanced here! On the other hand, some have reserved the title “existential neurotic” for the passionless, valueless, beliefl ess people. And their actions sometimes encourage labels like “personality disorder” and, that most ambiguous label of all, “borderline.” We know, however, that we deal not so much with a person of active pathology as we do with one lacking in normality.

Worry and Humor Before leaving this section on worry, I should note another human characteristic that springs from the same loins as worry. Worry rests on that essentially

Downloaded by [New York University] at 02:06 15 August 2016 human capacity to conceive, to treat ourselves as actors behaving and experiencing in places and times not here and now. So does humor. Worry may be seen as a somber exercise. We project ourselves as actors on life’s stage, grappling with Hamlet’s aching question, “To be or not to be.” Will we boldly assert our wish and drink now from life’s cup at the risk of eventual catastrophe? Or will we forgo our desire, push away the cup in galling obeisance to reality and, thus, conserve in some distant time and place a richer bounty yet? The very factors that make this melancholy exercise possible, of course, make equally possible the appreciation and discovery of the comic. As we play

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conceptually on the possibilities that attend the realization of our wishes, we inevitably gain distance from ourselves as the actor on our stage. We measure our moment in time, our hopes, against the sweep of fortunes we have observed around us. This exercise often leads to a rapid defl ation in the grav- ity with which we hold our plight. The result is a paradox of feeling. We are relieved, on the one hand, that matters, by contrast, are not as ponderous as fi rst we felt, but, on the other hand, we regret the accompanying loss of self- importance. The momentary clash between the wish for perspective and that for importance is resolved in mirth. Humor attends the abrupt, non-tragic defl ation of self-assigned importance. The very capability that permits us to wrestle with implications not immediately evident or of immediate menace to us is the same capability that spawns humor. It is as if nature found a way to compensate the worrying animal. If, by granting the powers of conceptualization, it assigned us a life of worry, it also provided us, in the same step, the delicious gift of laughter.

The Benevolent Circle of Integration

A Continuing Mystery Our space visitor was impressed by the relative success we humans have in inculcating integrative, worrying behavior in our children. The future is so distant. The present is so powerful. How do we learn to “look past” the impulse of the moment and act in keeping with more valued outcomes remote in time? As we noted, the key is the symbol, but mystery remains. True, without the cognitive capacity to represent events not here and now, we would, indeed, be unable to learn to integrate at all. We are still faced, however, with a puzzle. Will not distant events always be underrepresented in a contest with immediate consequences? Suppose we measure the subjective value of an outcome occurring now. Then, match it against the subjective value of a somewhat more prized outcome, represented in symbols, occurring in the future. Will there not be a value gradient always favoring the outcomes now compared to those occurring in the future? Are we not here dealing with a truism captured in the old saying, “A bird in the hand is worth two in the bush?” If there is this “value loss factor” with events temporally distant, would

Downloaded by [New York University] at 02:06 15 August 2016 it not mean that we will fail to maximize positive outcomes over time, i.e., fail to act integratively? And if the answer is yes to these questions, will we not inevitably reap in increasing measure the ill consequences that our past actions and choices beget? Certainly, some do seem to grow bitter and punished by life as they advance in years. Examination of their lives may lead to the conclusion that, indeed, they have not behaved in a manner to maximize positive outcomes over time, and they suffer accordingly. Most persons, however, do not ﬁ t this picture. How can we explain this? On the face of it there are two possible explanations. The ﬁ rst

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is that, in spite of logic, distant events cognitively represented are as subjectively intense as they would be if they were actually present in time. Thus, a failure to integrate always rests on a failure to represent, not a bleaching of response to the sign or symbol compared to the response to the event itself. I am not much impressed by this explanation, and will pass to the second. It will require some elaboration, which we will undertake next.

Parent Mediation of Future Outcomes There are two essential functions of the human parent (or parent surrogate). The fi rst, of course, is to nurture, an obvious necessity for offspring enduring prolonged physical dependency. However, it is the second function to which I call special attention. That function is to represent the consequences that attend the child’s explorations but that are not evident to the child. It is the job of those rearing the child to reveal the future to the child, to represent what the child, in his/her innocence and ignorance, does not weigh into the equation of his/her choices and actions. In doing this, parents inevitably draw on their own values and schemas about what follows what. So it is that the child fi rst peers into the future through lenses provided by the parent. How does the parent represent the future? By directly rewarding actions that the child otherwise fi nds immediately unrewarding, but which eventuate in positive outcomes at some later date. For example, children do not fi nd putting toys away rewarding. Such actions often frustrate the child’s wish to be elsewhere and, consequently are experienced as immediately frustrating or punishing. The payoff of orderliness—being able to fi nd a desired toy and avoiding loss of possessions—is experienced only cumulatively and over time by the child. The parent, however, acts to bridge the gap between now and later, re-presenting the positive future in immediate, rewarding terms. The parent, also, directly punishes actions that the child fi nds instantly gratifying but which eventuate in serious delayed cost to the child. For example, soon after language develops, children stumble onto the exciting power of words to effect gain and avoid loss, even when those words misrepresent. Using words dishonestly is so easy and so promptly gratifying that the child may become relatively well practiced before the parent discovers the emerging habit. The long-term consequences in mistrust, loss of credibility, and

Downloaded by [New York University] at 02:06 15 August 2016 social ostracism are mere abstractions to the young prevaricator. Again, the parent serves to represent those costly consequences in terms both concrete and direct.

“Priming the Pump” of Integrative Behavior You may never have had to bring water from a deep well where the pump has “lost its prime.” There is no water in the pipe leading to the pump. No amount of pumping will bring the water. One must have a primer, a quantity of water,

170 THE NATURE OF NORMALITY

to pour into the pump head to establish a seal between the pump head and the water below. Once the water ﬁ lls the pipe, vacuum exerted by the pump will raise water at each stroke. At that point, the pump becomes “self-priming.” This is an excellent model of the action of a parent who serves to prime the pump of integrative behavior, which, once underway, becomes self-priming. However, let us present this in yet another manner. In Figures 10.1 and 10.2 , the essential elements of the matter have been presented graphically in a manner introduced in Chapter 6 . We see two basic kinds of outcomes, immediate and delayed in time. Immediate outcomes consist also of two kinds— mediated, either cognitively or by the actions of others, and intrinsic to our nature and the nature of the event.

REMOTE OUTCOME

IMMEDIATE OUTCOME Mediated Cognitive

Parental

Intrinsic

RA RI RI RI RI RI (Timeline) 1 2 3 4 5 6

Figure 10.1 Components of Payoff During Development of Integrative Behavior (RI) in Contest with Adjustive Behavior (RA)

POSITIVE SUBJECTIVE LIFE INCOME

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RA RI RI RI RI RI (Timeline) 1 2 3 4 5 6

Figure 10.2 Net Payoff Values Derived from Immediate and Delayed Payoff Depicted in Figure 10.1

171 THE NATURE OF THE PROBLEM

We do not represent in Figure 10.1 that class of behaviors and outcomes that are numerous but do not pose integrative problems for us. I speak here of actions that produce immediately negative effects or immediately positive effects absent long-term effects or with long-term effects of the same valence. Eating a nutritious meal has immediate and long-term positive outcomes. Being careless about a hot stove may have immediate and long-term negative consequences. We have little problem adjusting with appropriate behavior under these conditions. However, the lure of sweets and the fascination in “playing with matches” are integrative challenges. Both are immediately attractive or rewarding, but both invite long-term risks to health and life. It is with such issues that we deal in Figure 10.1 . Note in Figure 10.1 that different size rectangles indicate different effect strengths. The color of the rectangles indicates whether the effect is positive (white/pale) or negative (black). Figure 10.1 represents a child at the beginning of his life or timeline. His ﬁ rst non-integrative but adjustive behaviors (at Time 1) are intrinsically rewarding as, for example, eating sweets. The child does not, in his innocence, cognitively mediate long-term costs. The parent is the countervailing force bringing directly to bear negative consequences of the child’s pursuit of sweets. In this manner, the parent mediates long-term costs (or rewards). Summing the immediate intrinsic outcome (moderately positive) with the parent-mediated outcome (more strongly negative) results in a net negative return to the child. Since one will not maintain an action where an alternative action costs less or pays more, the child avoids sweets (the RI at Time 2). The immediate intrinsic outcome at Time 2 is frustration, a negative value, but the parent-mediated outcome is strongly positive (“What a ﬁ ne, determined boy! Now, you will grow with healthy teeth and a strong body!”). The new, integrative behavior wins in the contest with former adjustive behavior because the parent’s reward balances out the child’s frustration in foregoing the sweets. In other words, the net outcome value at Time 2 is positive. Later, at Time 3, a new factor enters the picture. The child begins to mediate the remote, absent outcome (“I’ll be healthy and strong, not like Billy, whose mom lets him have candy all the time”). We depict the child’s mediated outcome as quite minor compared to other values, which conforms with the immaturity of the child’s mediating processes and also with the idea that medi-

Downloaded by [New York University] at 02:06 15 August 2016 ated events are not as consequential as directly experienced events. However, it enters into the equation and adds, along with parent-mediated reward, to the net positive return the child experiences in his sweets-avoiding behavior. At Time 4, yet another factor enters into the equation. Perhaps some of the early indulgence in sweets has hurried the appearance of dental caries and the child must suffer toothache, dental needle, and drill. This represents a delayed outcome of behavior practiced at Time 1. At Time 4, then, the child is still behaving integratively, but now several sources of payoff operate at the same time: (1) There is the serious negative outcome (toothache and dentist)

172 THE NATURE OF NORMALITY

resulting from eating sweets at Time 1; (2) next is the immediate, moderately negative sweets-avoidance intrinsic cost in frustration; (3) then, there is the immediate, parent-mediated, highly positive outcome in praise and recognition for continued self-discipline (e.g., sweets avoidance and other integrative acts); and ﬁ nally, (4) there is the immediate, cognitively mediated but rather modest positive outcome (“I’ll grow up healthy, strong, learned, prepared, etc.). The net payoff over these four components is, however, moderately negative. The child may be discouraged by this payoff down draft and be tempted to seek compensation via some momentary self-indulgence. However, parents are likely to be hovering nearby and ready, not only to make hazardous a return to sweets or other denied pleasures, but to take the opportunity to connect the child’s “bad” time to the “bad” past consumption of sweets. In this manner the child’s mediated faculties are strengthened, helping him to endure his reverses while continuing his integrative behavior in good faith. At Times 5 and 6 in Figures 10.1 and 10.2 , we come at last to the time when the “pump” has been primed. The input from parents is reduced both because the child’s emerging autonomy permits it and because parents exercise gradually reduced control over the contingencies affecting the child. The child continues integrative behavior no longer entirely dependent on parental reward, but as a function of “self-priming.” What does this self-priming consist of? Is it the result of emerging cognitive representation of the future grown to such a magnitude that it renders the not-now as if it were now? That is not how the model portrayed in Figures 10.1 and 10.2 resolves the matter. Our model, instead, takes the “worst case” scenarios in that the force of represented future is modest and not strong enough to compete with the force of immediately present contingencies. We know that many persons do develop representational skills that render future outcomes in relatively passionate, vivid terms. Observation and logic, however, tell us that if integrative behavior depended upon such superlative levels of future reading, few would display such behavior. Yet, most of us manage this achievement relatively routinely! We are forced to conclude that mechanisms other than cognitive representation must be at work to insure the success we enjoy in learning to maximize positive outcomes over time. The model in Figure 10.1 suggests that these are of two kinds: 1) the continuing, if lessening, force of parents and 2) the current consequences of those integrative actions that were undertaken in the past. Let us

Downloaded by [New York University] at 02:06 15 August 2016 examine a bit more carefully the second of these.

The Signiﬁ cance of One’s Personal History Our sweets-avoiding child does become more healthy, active, and vigorous, particularly if his sweets-avoidance has been in force for quite some time. If neighbor Billy (whose mother permits the eating of sweets unchecked) is dis- advantaged by comparison, that will help bring home the positive payoff of past discipline with food. The cost of his current integrative efforts, then, is

173 THE NATURE OF THE PROBLEM

covered in part by internally mediated and parent-mediated outcomes (representing his future health and vigor). However, just as critical are the positive current consequences of his past actions. Integrative behavior, then, depends signifi cantly on having a history of integrative behavior extending far enough into the past to project the positive outcomes into the present. Of course, present payoff from behavioral investments long since past not only helps maintain current integrative behavior, it also reinforces the cognitive schemata employed by the individual. Good things have, indeed, eventu- ated from past behavioral investments. Those benefi ts strengthen the hope that good things will emerge in the future from efforts expended and frustrations endured now. With successive experiences of this kind, the person should feel less inner resistance to and less burdened by integrative behavior. This fl ows from the fact that the mediated factor grows more prominent as a component in the payoff equation (a gain represented in Figure 10.1 by the somewhat larger cognitive-mediated, positive sign at Time 6). Finally, persons behaving integratively have cause to approach life with optimism. Projected into the future are the positive valences that their near past and current actions place in “layaway.” Those values stand alone. They are unreduced by components that come to bear in the present. The result is that persons view the future in an idealized sense. (This is represented in Figure 10.2 by the heart shapes that are values projected into the future.) For the healthy, worrying person caught up in self-priming integrative behavior, the present is quite acceptable and the future looks better yet! Had I said in the beginning of this chapter that worry and vibrant optimism ordinarily go hand in glove, it would have sounded like a paradox. It is not a paradox. It is the nature of normal, human behavior.

The Intimate Other

The “Improbable Flight” of Integrative Behavior Meanwhile, there are implications of our model ( Figures 10.1 and 10.2 ) that deserve to be spelled out. Normal, integrative behavior depends on the timely priming role of the parent socializer. Not only do parents prime the values and cognitive schemata, enabling the child to have his or her ﬁ rst primitive sense

Downloaded by [New York University] at 02:06 15 August 2016 of future, they also help establish the initial history of integrative actions. The delayed, positive outcomes of these now past actions serve, as they come to season, to maintain and reinforce the integrative actions of the present. Both cognitive mediation and past actions are critical to the development of self- priming, autonomous integrative behavior. Our visitor from outer space had a right to be impressed with the measure of success we humans enjoy in this enterprise. It appears to depend on such relatively precise contingencies that its routine success leaves us somewhat in awe. It is reminiscent of the bumble- bee: It ﬂ ies, although aerodynamically, ﬂ ight seems improbable!

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The concept of “critical period” certainly applies. Time is brief during which the parent can exercise suffi cient control over contingencies affecting the child to permit an effective representation of future. If parent or surrogate has primed no or little history of integrative behavior by the time the child is six years old, the outlook for remedial action is already cloudy. By the time the child is 12 years of age, remedial effort is probably doomed. The parent has relatively limited powers to affect the outcomes experienced by the child at this age. Consider yet another threat to the fl ight of our bee. Go back to Figure 10.1 and ask what will happen if, once integrative behavior has become self-priming, the individual regresses to adjustive/non-integrative choices and actions? This circumstance is represented in Figure 10.3, depicting a shift from integrative (RI) to adjustive and non-integrative behavior (RA) at Time 3. We see that good returns from past integrative actions continue to come due and will continue to do so through Times 4 and 5. The immediate payoff, however, turns from intrinsic negative (associated with effort, frustration, etc.) to intrinsic positive (fl owing from the pleasures of “forbidden fruits”). For a period of time, the departure from integrative behavior will result in greater reward and subjective satisfaction than before. The person is “having his cake and eating it too.” It is as if the child who has avoided eating sweets, with desirable long- term consequences in dental and physical health, begins to depart, permitting himself to lapse into his old indulgences. The immediate result is that he will continue to enjoy good health for some time and the pleasure of satisfying a denied appetite. Integrative behavior always labors under this temptation to quit the effort, put aside frustration, and “ cash in ” on stores of benefi cial consequences laid by from past efforts and enjoy a net gain in subjective satisfaction. Would not the presence of such temptation, as a constant bias toward defection from integrative behavior, imply that, sooner or later, we would all succumb to adjustive, non-integrative actions? It would appear so. Yet,

REMOTE OUTCOME

IMMEDIATE OUTCOME Mediated

Downloaded by [New York University] at 02:06 15 August 2016 Cognitive

Intimate C.

Intrinsic

RI RI RA RA RA (Timeline) 1 2 3 4 5

Figure 10.3 Payoff Following Development of Integrative Behavior (RI) in Contest with Adjustive Behavior (RA)

175 THE NATURE OF THE PROBLEM

POSITIVE SUBJECTIVE LIFE INCOME

NEGATIVE SUBJECTIVE LIFE INCOME

RA RA RI RI RI (Timeline) 1 2 3 4 5

Figure 10.4 Net Payoff Values Derived from Immediate and Delayed Payoff Depicted in Figure 10.3

while there are examples of such departures, people commonly remain relatively devoted to the integrative lifestyle in spite of ever-present temptation to defect. Then, what serves to help us “stay the course” and resist that ever- present temptation?

A Final Contributor: Intimate Community Obviously, the cognitive representation of a future imperiled by defection would stand in the way of such departures. However, as we have reasoned previously, the symbolized event only rarely evokes a response of the same intensity as the event itself. That reasoning is presented in Figure 10.3 in the guise of the cognitively represented future evoking an aversion that is slight in comparison to the immediate reward. Thus, the cognitive appraisal of a negative future ordinarily will not render an aversive value sufﬁ cient to offset the prompt rewards of defection to adjustive behavior. The answer may rest in a force that, to this point, we have represented by parents but that becomes a more general factor as time wears on. That force is the individual’s intimate community. When parents have done with

Downloaded by [New York University] at 02:06 15 August 2016 “pump priming,” that does not mean that they and others no longer play a role in the equation leading to continued integrative behavior. When I speak of intimate community, I refer to that congregation of persons who exercise tangible, personal infl uence on us. For the most part, these are persons signifi cant to us because they are physically in contact with us, directly transact with us, and serve to buffer and support us in our life processes. Parents saliently functioned in these ways in the beginning, but in time others fi ll in to people our intimate community, such as extended family, peer friends,

176 THE NATURE OF NORMALITY

spouses, and work associates. Indeed, certain prominent members of our society and the human race, though with whom we may have no physical interaction, have always moved into the sphere of intimate associates. I refer to respected community and state leaders as well as certain celebrity fi gures who may impact us, probably in part because they impact the other members of our intimate community. In this age of instant, global video communications, the potential for expanding our intimate community with such persons has grown immensely. In traditional societies where values are stable and there is continuity between generations, one’s intimate community and one’s parents exert a consonant, unifi ed effect. Thus, the intimate community will directly reward and punish the individual by representing future contingencies in a manner reminiscent of parents at an earlier age. Of course, the impact of the intimate community may be more diffuse and have relatively less power or infl uence than that enjoyed by parents over the child. However, as indicated in Figures 10.3 and 10.4 , the force exerted by intimate others does not have to be of major dimensions. It suffi ces so long as it is additive to that of cognitive representation suffi cient to negate the tempting gain of defection to adjustive/non-integrative actions. Are there conditions that enhance temptations to defect from integrative behavior? Yes, anything that mutes the voice of future as mediated either cognitively or via one’s intimate community. Ordinarily these two mediational forces serve mutually to reinforce each other. Intimate others generally have an investment in us and our life outcomes. Moreover, they directly profi t from our behaving integratively. They rise to celebrate our “good works,” our integrative efforts in pursuit of valued ends, which are common to the community. They are also quick to take us to task for departures. Indeed, others are more ready to censure our defections than they are to reward our continued observance of integrative behavior! ( Figure 10.3 captures this tendency in the slightly larger negative compared to positive rectangles representing the response of intimate others.) This is not mere human perversity. It arises from the fact that integrative behavior is relatively commonplace, while defection is the exception. It is also a matter of effi ciency since rewarding integrative actions is more effortful and time consuming than punishing departures. 4 The rewarding and punishing input of others serves to strengthen our cog-

Downloaded by [New York University] at 02:06 15 August 2016 nitive representational processes. Those processes rest on our ability, through using symbols, to adopt the view of the other and to treat ourselves as an abstraction (an object). Our intimate community provides us with a constantly updated reservoir of images from which we draw to construct an inner audience. We move forth, the central actor on our mind’s stage, and provoke our inner audience to boo or cheer or in some other manner give context and reference to our designs. A clear, articulate sense of intimate others helps form an equally clear, articulate judgment about ourselves and our valued ends.

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This makes understandable how the intimate community reinforces cognitive representational processes, but how does the latter reinforce the former? Stated differently, in what way do our values and beliefs strengthen the part that others play in our lives? In two ways: First, we exercise, as we grow to adulthood, more and more choice over who peoples our intimate community. We usually select intimates whose views and values are compatible with our own. Of course, if we are at war with ourselves, of “two minds,” we may choose someone ostensibly incompatible with us but actually resonant with our inner opposition. In either case, the company we choose expresses, in some measure, either what we are or what, perhaps ambivalently, we seek to be. The second way that we reinforce the role of intimate others is by the act of making ourselves known to them and their evaluative reaction to us. It is not enough to have an intimate as a corporeal part of our social landscape or merely as companion. We want our intimates to truly know us, and knowing us, to honor us with their respect, concern, and love. In the measure that they know us not, we feel a reduction of the psychic income which intimates generate for us. At base, intimates ennoble us by their regard because it does not rest on our public persona, which may be artful, but rests rather on our authentic private identity.

A Special Kind of Conformity If I seem to be presenting an image of the normal human not only as the “worrying animal,” but also, perhaps, as the “conforming animal,” that is true. However, the normal does not blindly conform nor conform necessarily to “social norms.” Rather, conformity is to a group of numbered persons who, in the end, the individual chooses to populate his or her intimate community and to whom he or she stands revealed. We are not willy-nilly the outcome of social forces around us. We choose in good measure those to whom we are most responsive. When a member of that group proves, through change or error of selection, to be at odds with our values and beliefs, ultimately we drop that person from the rolls. Our intimate community has a powerful potential to exert control over us, but in the end, that represents a control we embrace. Our intimate community helps us afﬁ rm our own ends. Conformity proves

Downloaded by [New York University] at 02:06 15 August 2016 closely akin to afﬁ rmation of our selves. I mentioned above that there is great continuity in traditional societies between the effort of parents and the impact later of the individual’s intimate community. Such continuity insures the continuation of integrative behavior. However, our modern society is not anywhere stable and traditional. We endure a wide cleavage between the efforts of parents and those of the “peer group” that emerges as a rapidly growing force in the lives of our children. Our society appears to invite discontinuity into the life of the developing child. Children become convinced that they must displace their parents with peers and their

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parents’ values and schemata with peer-supported “counterculture” values. If not, they become fearful they will fail altogether to achieve a credible role or place of regard in the world of peers. Little wonder, then, that, in our society, adolescence should be a time of consternation to all concerned. Integrative modes of behavior established while parental powers were at the zenith may, with the emerging cross winds within the intimate community, falter and be replaced. The replacement is not a new level of integrative action based on a transcending or contrasting set of values and schemata. Too often it dissolves into a “new freedom” to enjoy the here and now, a fresh maximization of expression, experiences, and expedi- ency made fashionable by the music, manner, and dress of a commercially proﬁ table and, thus, subsidized peer revolution. Adolescent peer intimates often depart from the traditional role of mediating future consequences and, instead, renounce the future as an invention of those seeking to curtail their freedoms. The consequences to the individual of this raw denial of reality can be disastrous. We will reserve further treatment of the matter, however, until the next chapter.

Conclusion If a preponderance of integrative behavior defi nes normality, then we must conclude that the fi rst occupation of normal, healthy human beings is worry. Being a normal human being is not easy. You must recognize the redeeming value of embracing worry, that critical cognitive process of probing and patrolling our future that grows out of, transforms, and transcends guilt. It is an invitation to the future to rouse us with the passions of fear, hope, awe, and inspiration that we may truly know, as best we are able, what lies in store, what exists in the darkling bush surrounding our current desires or the risks we incur and dedication required to reach at last our most cherished goals. Worry is not some niggling, pesky, mantle composed of many insignifi cant threads that serves only to wrinkle our brow and bow us in precocious age. Worry spreads before us the greatest range of choices that we may exercise, which, yes, weighs upon us our human capacity for consciousness. When Eric Fromm wrote of “Escape from Freedom” he could as well have written, “Escape from Worry,” that is, escape from confronting the choices before us. 5 Yet, worry

Downloaded by [New York University] at 02:06 15 August 2016 and confronting choices are those pursuits that most set us apart from other animals and are the main impetus for our arts, explorations, and our science. The worrying animal is passionately involved with matters yet to be. This capacity for worry does, indeed, set us apart from other animals not because it is unique to us, but because we engage in it so routinely. Worry translates into integrative behavior in which future outcomes guide current choices. Integra- tive behavior banks values, which we realize in the passage of time. This store of banked values promotes what might, on ﬁ rst brush, seem curious if not contradictory in the worrying animal. It promotes an undercurrent of hope, a

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forward-looking readiness to move ahead, to experience and enjoy one’s life. Indeed, for the worrying animal, the future tends to be apprehended in idealized terms because it is unreduced by the cost of current integrative efforts. However, that rosy future is not mere wishful fantasy. It is a projection based on the reality of an integrative lifestyle reliably underway. The absence of normality is not equivalent to the presence of pathology. Absence of normality means absence of worry, of self-imposed frustrations, and of the frequent refusal to enjoy available pleasures of the moment. In certain quarters, the presence of these features would be regarded as essential to robust mental health, and not at all a cause for alarm. However, we know that one whose actions are chronically adjustive but non-integrative bears in time a burden that grows painfully heavy. Freud noted that unheeding pursuit of the pleasure principle was a life fraught with risk and with the eventual loss of pleasure. He observed that the reality principle did not so much replace the pleasure principle as it preserved it. In the next chapter, we will examine how the absence of normality may be a more profound threat to the individual and society than is the presence of pathology. Integrative behavior, that style of life that maximizes positive outcomes over time, appears on the face of it to be remarkably fragile. If it depends on the capacity to represent the not-now as if it were now, only a few vivid worriers or future probers would prevail. They alone would have suffi cient awe of the future to forgo the pleasures of the moment and embrace whatever discipline will insure the integrative outcome. Fortunately, integrative behavior does not depend on such exceptional capacity to cognitively transform the future into the now. There are two other factors determining integrative behavior. The fi rst is that payoff delayed from the past practice of integrative behavior defrays the cost of its current practice. Parents have primed the integrative pump at a time in life when they are able to represent future consequences directly and signifi - cantly. It is a brief window of opportunity and critical to both developing the child’s cognitive representational processes and establishing a personal history of integrative actions. The second factor explaining the magnitude and dura- bility of integrative behavior is the role of intimates. They continue, though not in all cases, the direct representation of future consequences that parents fi rst undertook. While their impact may not match in measure that of parents,

Downloaded by [New York University] at 02:06 15 August 2016 it may serve the same end. As noted in the beginning of this chapter, not all our actions forecast long- range effects opposite in nature and more substantial in subjective value than immediate effects. Much of our lives revolve around “simple pleasures” that have no contradicting future implications. Since these constitute no integrative issue for us, they were not factored into the model represented in Figures 10.1 , 10.2 , 10.3 , and 10.4 . The presence of this class of behaviors and outcomes relieves somewhat the strain otherwise present in the picture we have painted of the worrying animal. Moreover, the outcome of past

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integrative behavior currently feeds into our worrier’s life in the form of valued benefi ts such as leisure, material security, and social status. Finally, keep in mind that the positive outcomes projected into the future promote a platform of optimism in the attitude of the worrier. The future appears brighter than the present and the past. Between the simple pleasures, the delayed payoff of past integrative behavior, and the promise of the future, the worrying animal is far from melancholy. It is not easy to convey a properly balanced picture of the worrying animal. The term worry, of course, connotes tension and absence of pleasure, which is apt. The worrier does assess costs that must be embraced and identify pleasures that must be forsworn, tense matters to be sure. Yet, while worry is what distinguishes human animals, it is not their single occupation! Far from it. Worry is like a silver thread woven in and out of a larger garment, providing it with highlights and giving it pattern and design. The present and its manifold sensations and delights are textured within the recurring reach for the not- here and not-now. Inevitably, the normal human being is religious, though not necessarily sec- tarian. Rather, religion emerges from that transcending concern with future and the attitude of reverent hope that powers that concern. Once having conceived of events not yet, it is a brief step to conceive of one’s self as different, better, more deserving. As experience tempers such ideal images with the humbling realization of mortality and one’s fi nite limitations, another step in conception emerges. One moves past one’s own self, one’s own life, and strives to peer into a future not so mortally limited. The capacity to conceive inevitably moves us from one level to the next. We are unable to halt the pro- gression at a point short of the furthest reaches the mind’s eye will see. So at last we have the picture of the normal, psychologically healthy human being. It is a picture of one who, to be sure enjoys life’s simple pleasures, enjoys its immediately apprehended experience. This enjoyment, however, is always subordinate to a consciousness, fi rst of one’s self acting before an audience of intimate others, and second, of the cascading implications of one’s actions over time. As individuals mature, they learn in increasing measure to derive gratifi cation from conceiving matters not present but impending. They learn to value worry. The domain of values is constantly being stretched to sharpen distinctions and more clearly order priorities.

Downloaded by [New York University] at 02:06 15 August 2016 Normal, healthy individuals do not seek independence, nor are they dependent. They embrace the condition of interdependence as a natural basis of human survival and satisfaction. They seek to be known to intimates and do not hide. They choose intimates as a form of self-identiﬁ cation and self- assertion. They welcome guidance from intimates in no less a measure than they accept responsibility to offer guidance to others. They feel rewarded by life and are optimistic about the future. They are, ﬁ nally, reverent. They may be traditionally religious, but not necessarily so. They are, however, theistic in the most fundamental sense of the

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term. That is, they entertain their own mortality, their limits, and conceptually seek, in one way or another, to move beyond those limits.

Notes 1. Some rats do not profi t from shock by delaying bar pressing and, then, obtaining food free of shock. Instead, these animals stop acting altogether. They withdraw. The long-term outcome of such behavior is death through starvation, so is not considered integrative. Not to eat at all or to bar press and take food promptly are both adjustive. Both offer comfort, one by avoiding pain at the cost of hunger, the other by avoiding hunger at the cost of pain. The integrative act, however, permits both avoidance of pain and hunger at the minor cost of a three second period of waiting. 2. This analog experiment was carried out very competently by Elaine Barker, an undergraduate major in psychology at Kent State University in 1964. 3. This use of the term “worry” may strike you as strange, particularly as I emphasize the near constant inclination we humans display for worry. I suspect if you balk at this concept of humans as worriers, it is because our culture commonly characterizes worry as something worthy of minimizing and often indicative of disorder. Yet, if I were to suggest that it is the nature of humans almost constantly to be examining their experiences and life events for meaning, you might be more accepting of my argument. A poet sitting beneath the shade of a tree on a lovely summer day searches to express in poetry the signifi cance of this moment. Yes, he is searching for meaning. He is fi ltering through a vast complex of emotionally charged cognitive particles within him for the implications of the moment, for him, for the present, for the future. And yes, that is worry. 4. This logic applies, also, to the “lost sheep” phenomenon. Why do we sometimes seem to celebrate more the conversion to good behavior of the strayer than we do the continued good works of the chaste? We celebrate because in the “lost sheep” non-integrative behavior is the more commonplace. Punishing such behavior is more effortful with the “lost sheep” than is rewarding the less common “return to the fold.” 5. The year 1941, the publication date of Escape from Freedom, was a ghastly time for conscious, thinking Germans who “went along” rather than face choices of grave risk, which their conscience may yet have dictated. If worry, as noted, is a tran- scendence of guilt, then avoiding worry and its array of options brings a regression to guilt. Modern Germany is burdened by cultural-wide efforts to expiate its 70-year-old guilt.

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182 11 THE NATURE OF PATHOLOGY

To regard such a positive mental science [psychology] as rising above the sphere of history, and establishing the permanent and unchanging laws of human nature, is therefore possible only to a person who mistakes the transient conditions of a certain historical age for the permanent conditions of human life. —R. G. Collingwood, The Idea of History

On the Absence of or Departure from Normality

Integrative Behavior and Survival A number of observations fl ow from Mowrerian Integrity theory. One is that normality and pathology are independent if less than completely so. In the previous chapter, we identifi ed normality with the development and maintenance of integrative coping behavior. Such behavior maximizes subjective values over time in contrast to adjustive coping behaviors that maximize subjective values for the moment. Integrative behavior conforms to the reality of the human condition in which security, satisfaction, and survival depend on an interdependent, social exchange system. For this system to be successful, participants must learn to delay gratifi cation and act to secure gains that are remote in time. A social system will falter when its members depart from integrative behavior. The value of a social system to its members rests on their capacity to promote the wellbeing of others even when this incurs cost in risk, energy,

Downloaded by [New York University] at 02:06 15 August 2016 and frustration. The survival of the human social system and the survival of the individual are both dependent on the development of integrative coping behavior. The psychologically healthy, normal human being is a practitioner of integrative behavior. The sociologically healthy, normal society has evolved institutions that promote and help sustain the practice of integrative behaviors on the part of its members. In Chapters 1 and 10 preceding, we observed that the normal person dis- plays a preponderance of integrative behavior. Persons routinely depart from an integrative coping style to some degree without suffering net cumulative

183 THE NATURE OF THE PROBLEM

outcomes of negative subjective value. We could say that there is room in the life of the normal individual for a certain amount of non-integrative actions before overall costs outweigh gain. Similarly, the social system is tolerant of a certain number of participants who behave non-integratively without suffering a breakdown in social cohesion and interpersonal commerce. However, most people behave integratively most of the time. If they did not, we would have a signiﬁ cant number of failed lives in the midst of a crumbling society. What determines the individual’s tolerance for departure? That such departures (1) are sporadic or random rather than habitual; (2) cause less negative outcomes than the positive ones ﬂ owing from the individual’s concurrent integrative actions; and (3) rest on inattention, misperception, or misjudgment, which the individual regrets and seeks to correct. What determines society’s tolerance for participants engaged in non-integrative behavior? That these members of society are (1) few in number compared to participants practicing integrative behavior; (2) not occupants of key roles in the social system; and (3) in the long run, are objects more of pity than envy.

Integrative and Adjustive Behavior Departure from integrative behavior that passes the boundaries of individual and societal tolerance is, of course, the target of our concern in this chapter. To assist our thinking in this connection, let us examine the two- dimensional matrix presented in Table 11.1 . In this table, we have identiﬁ ed two degrees of adjustive behaviors (presence or absence) and two degrees of

Table 11.1 Payoff Matrix Deﬁ ned by Adjustive and Integrative Modes of Behavior

Adjustive Behavior Non-Adjustive Behavior

Integrative (1) (2) Behavior Maximizes immediate positive Immediate payoff is negative. payoff. Maximizes positive payoff over Maximizes positive payoff over time. time. Internal conflict. Conflict-free. Life’s complex values. Life’s “simple joys.” Normal worrying behavior. Normal worry-free behavior. Downloaded by [New York University] at 02:06 15 August 2016 Non- (3) (4) Integrative Maximizes immediate positive Immediate payoff is negative. Behavior payoff. Payoff is negative summed Payoff is negative summed over over time. time. Inner confusion is probable. Inner conflict may be present. Anhedonia. Focus on joys of the moment. Non-normal worry-free Guilt may be strong. behavior. Non-normal worry-free behavior.

184 THE NATURE OF PATHOLOGY

integrative behaviors (presence or absence) defi ning four categories. These are (1) adjustive/integrative, (2) non-adjustive/integrative, (3) adjustive/non- integrative, and (4) non-adjustive/non-integrative. The fi rst of these (presented in quadrant 1) is that felicitous class of actions which, at little cost, provides us the “simple joys” of life, uncomplicated and worry-free. These are available to all through the consumption of good food, the pleasure of company, the glow of a warm summer day, the fun of play, and other such uncomplicated pursuits of the good life. The “Garden of Eden” was a conception of life confi ned entirely to quadrant 1 of Table 11.1 . Of course, life is not limited to this quadrant as some actions bear signifi cant cost implications for the future. In these instances, we are faced with choosing behaviors that move us either toward quadrant 2 or quadrant 3. Choosing quadrant 3 behaviors requires the least of us cognitively and char- acterologically. We act in keeping with nature’s “Law of Effect,” so labeled by Robert L. Thorndike (1911), which holds that behavior adjusts to increase the likelihood of maximum momentary gratifi cation. The delayed cost may remain entirely undetected. This permits the individual, at least for the time being, to enjoy guilt- and worry-free pleasures quite like those in the “Garden of Eden” (quadrant 1) in spite of eventual reality.

The Role of Guilt Reality, however, will not long be denied, so those who opt for quadrant 3 behaviors are subject to a belated, impotent form of worry we call guilt. I do not mean to suggest that guilt itself is belated or impotent. Rather, I am drawing attention to the distinction between worry and guilt. Worry is that anxious anticipation which precedes action and informs us of what action to take. Guilt is that anxious anticipation which follows action and informs of what consequences await. Ontogenetically, guilt comes fi rst. It represents that more primitive emotional state that stalks our pleasure and disturbs our quiet. There are two strategies for dealing with guilt as it increases in strength. The fi rst strategy is to seek ways to diminish guilt through what we have tagged as justifi cation themata in Chapter 2 and what Freud has called the “mechanisms of defense.” The second strategy is to amplify guilt by permitting it to “move forward” a couple of stages in time. Thus, from its belated appearance

Downloaded by [New York University] at 02:06 15 August 2016 well after the act, it moves to a point immediately following the act. Finally, it occurs in response to an intention to commit the act, i.e., prior to the act. It is the employment of the ﬁ rst rather than the second strategy that constitutes psychopathology. I go, however, ahead of my development. For now, let us note that when guilt moves to a point preceding the act, it transforms to worry. Worry is a more cognitively effortful and evolved representation of consequences. Guilt is valuable because without it we would not learn to worry. Worry is valuable because without it we would not learn to behave integratively.

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If consequences are punishing and, thereby, nurture the development of guilt; if guilt, in turn, nurtures the growth of worry; and, fi nally, if worry serves to offset the temptations of the moment, then we will have the good fortune to move from quadrant 3 to quadrant 2. Life in quadrant 2 with its worry, delay of gratifi cation, and inner confl ict is clearly less preferred than life in quadrant 1. However, over time positive subjective values are conserved, which is not true in the lives of those vainly pursuing the “Garden of Eden” in quadrant 3.

The Law of Effects Over Time As noted, life is not limited to quadrant 1. A predominant Law of Effect dictates that we pursue adjustive behavior and, consequently, occupy both quadrants 1 and 3. Non-adjustive behavior, according to the Law of Effect, is a momentary accident of ignorance. The ignorance is remedied, sooner or later, through learning what behavioral adjustments will maximize immediate positive consequences or effects. Integrative behavior transcends the Law of Effect. It observes a different law— the Law of Effects Over Time. The Law of Effect asserts that we learn to behave according to which of a host of current possible actions produce immediate reward. This learning depends on a readiness to explore and the powers of generalization, discrimination, and retention. The Law of Effects Over Time asserts that we learn to behave according to which current action precedes long-term reward even when the immediate effect is negative. It, too, depends on the readiness to explore and the powers of generalization, discrimination, and retention. It depends additionally, however, on the ability cognitively to represent what is not-here and not-now, a history of past integrative actions, and the support of one’s intimate community. If the integrative Law of Effects Over Time guides our behavior, we will occupy quadrants 1 and 2. If the adjustive Law of Effect predominates, we will occupy quadrants 1 and 3.

Distinguishing Psychological From Biomedical Problems The absence of or departure from psychologically normal, healthy, integrative behavior is expressed as adjustive/non-integrative behavior. If you have examined the logical implications of the model present in Table 11.1 , however, you

Downloaded by [New York University] at 02:06 15 August 2016 are aware that there are two other lifestyles that we might conceivably choose in departing from the normal, integrative mode. The fi rst is non-adjustive though unrelated to whether remote consequences are positive or negative (identifi ed by quadrants 2 and 4). The second is non-integrative (behavior followed by delayed negative effects) whether or not positive immediate effects are obtained (identifi ed by quadrants 3 and 4). These two possibilities contradict the Law of Effect and the Law of Effects Over Time, respectively! Are there actual manifestations of these hypothetical types? Indeed, yes, for the fi rst of the two. Accident, misperception, and ignorance result in this form

186 THE NATURE OF PATHOLOGY

of behavior rather often. However, these manifestations should be of relatively fl eeting duration. Under pressure of immediately punishing consequences, we would learn our way out of such unrewarding conditions and become adjustive if not, eventually, integrative in our style of behavior. Is it possible that some persons exhibit this kind of behavior more than fl eetingly and seem unable to limit or correct such actions? Yes. Individuals who have suffered damage to certain areas of the brain are unable to profi t from experience. Their capacity to retain is absent, which nullifi es the capacity to learn. Still others appear to suffer biochemical failure leading to mispercep- tions, on the one hand, and aberrations in the sense of pleasure and pain, on the other. The result is the same though the causes differ: The individual does not learn to act, even after repeated trials, according either to an adjustive or an integrative principle. Regarding the second hypothetical type, there are no examples. To choose non-integrative actions even where immediate consequences are punishing implies an intact cognitive apprehension of future consequences. Why? Because only with such cognitive representation could one be guided per- versely to choose ultimate calamity! People do not plan for their delayed destruction. If they are bent on self-punishment, they fi nd ways to realize their wish immediately. However, our discussion provides a basis for an important distinction. When the Law of Effect or the Law of Effects Over Time governs behavior, we classify problems in human conduct as psychological and social in nature. Where these problem behaviors are chronic and persisting, it is appropriate to speak of psychopathology or sociopathology. When our two Laws do not gov- ern behavior (owing to inability to learn), behavioral problems deserve to be classed as neurological and biological in nature. Some, but by no means all, individuals who have been labeled schizophrenics are affl icted with neurological and biological pathologies. The same can be said of some who are labeled manic-depressives. The reason I say some in each case is because we have many persons who express their psychopathologies in ways that mimic these neurological and biological problems. We will say more on this later.

Introducing the Dimension of Psychopathology

Downloaded by [New York University] at 02:06 15 August 2016 Psychopathology Defi ned We have endeavored to defi ne normality. We have suggested that psychopathology is, at least in some measure, an independent dimension. We made allusion earlier to the nature of this dimension by suggesting that it consisted of the strategy of reducing guilt rather than transforming guilt to worry. That is correct, but it is incomplete. Let us expand. In Chapter 1 , we offered the following defi nition: Psychopathology is, fi rst, the repeated choice of adjustive/non-integrative behavior where, second, that

187 THE NATURE OF THE PROBLEM

repetition is aided and maintained by behaviors chosen to minimize or avoid detection and sanction by others as well as to avoid the individual’s own self- monitoring (guilt, anxiety). Actually, before psychopathology can emerge, a habitual exercise of adjustive/non-integrative actions must ﬁ rst develop. Another development that also antedates psychopathology is the anxious anticipation of the delayed cost attending the now habitual adjustive/non-integrative behavior. Given these two prior developments, psychopathology inheres in the individual’s efforts to accomplish the two objectives noted above. Thus, psychopathology becomes manifest when the individual takes steps to secure his or her adjustive lifestyle from the corrective inﬂ uence of social sanction and self-judgment. Take note that seeking to minimize negative social consequences does not necessarily stamp the behavior as pathological. Such may be only reasonable and prudent. We can think of actions to this end that would hardly deserve to be classed as aberrant. Let us say, for example, you have enjoyed an advantage gained at another’s considerable expense. Later, you seek to compensate the injured party in some manner rather than permit ill will to threaten future relations. This would be wise and thoughtful of you, not an index of pathology. The cost of the effort to minimize negative consequences may actually eliminate the advantage gained by the original adjustive behavior. If so, rather than repeating those actions and contending with resultant, if delayed, negative consequences, one may simply choose to discontinue the original adjustive behavior. Of course, if minimizing or managing consequences were easy, one might very well continue the adjustive behavior and, thereby, enjoy up-front gains at favorably reduced long-term costs. Unfortunately, the easy way to manage the consequences of our behavior is usually also the way that courts psychopathology.

Pathological Deception That easy, pathogenic course is deception. 1 The reason deception plays so prominent a role is that the bulk of the delayed, negative consequences of our actions is social in nature. Among the ﬁ rst discoveries we make in life is the captivating ease with which deception sees us safely through the gathering storm of social costs and consequences. What child has not learned that a simple “No, I didn’t do it” insures avoidance of social censure. Undoubtedly, the ﬁ rst act of deception in our lives is a denial of something we have done

Downloaded by [New York University] at 02:06 15 August 2016 in order to avoid social censure. Much later, particularly if denials go unchal- lenged, we learn to assert that we have accomplished deeds that we have not done to garner the social reward. It is fortunate that we ﬁ rst employ deception at a time in our lives when such is so transparent to others. The result is that we are soon taught that deception promotes a heavy social censure and is a serious non-integrative act. If we were to stumble across deception as a new and powerful resource only after fully developing our mental capacities, the result might well be cata- strophic. Clever, believable deception does much more harm to viable social

188 THE NATURE OF PATHOLOGY

commerce than does the clumsy deception of the immature. And, of course, being clever, the deceiver is more resistive to instructive corrections administered by others. Reliance on deception as the means to minimize the consequences of adjustive/non-integrative behaviors is the fi rst step to manifest pathology. In so far as deception works, we are safe from consequences. Being safe from social consequences, however, is not an unalloyed boon. Social consequences teach us about reality. Negative social consequences teach us to respond to our own previously penalized behavior with anxious anticipation; that is, fi rst guilt, and then worry, which in turn helps enable us to behave integratively. We conclude that being safe from consequences through deception makes us vulnerable to a kind of emotional ignorance. Effective deceivers fail to learn those anxious anticipations that instruct and guide the rest of us. Do not envy them. Deception, even when honed to the keenest measure of effectiveness, can never escape a basic fl aw—it is not true. Sooner or later others put together the contradictions, and, as a result, long-averted consequences are brought to bear. Because of this, guilt does not go entirely unreinforced. No matter how clever, deceivers never completely eliminate negative social consequences serving to condition guilt. The guilt of the deceiver may have much less force than that of the non-deceiver, but it will still be there. Moreover, deceivers usually have more to be guilty about. First, under the cloak of deception, they engage in more acts that result in negative social consequences. Second, to the original act transgressing social rules and the integrative principle, they add inevitably a second, the act of deception itself. In this manner, they always compound their error and their culpability.

The Widespread Contempt for Guilt Having deceived others to avoid social censure, it is a short step for individuals to practice the same strategy regarding their own internal self-censuring processes. Guilt, remember, in the deceiver is a rather pallid force compared to what it is in the non-deceiver who has acted similarly. Deception of others has deprived guilt of reinforcement, the sanction that nourishes guilt in those forthright persons who boldly “face the music.” Therefore, guilt takes on more the role of a nag, feebly whining to be heard, than it does the ringing

Downloaded by [New York University] at 02:06 15 August 2016 voice of judgment commanding reverent attention. Deceivers characteristically hold guilt in contempt. It is a mere detraction from their assertions of self-interest, from living life “to the fullest,” and from their peace of mind. This attitude also encourages emergence of that array of self-deceptions (defense mechanisms) designed to quash guilt and justify one’s self. Rationalization, denial, blaming others, projection, and so on, are, in essence, all ways of avoiding guilt and justifying one’s actions. It is unfortunate, if not tragic, that while Freud basically recognized this fact, he joined with his neurotic clientele in viewing guilt with contempt. The

189 THE NATURE OF THE PROBLEM

psychoanalytic answer to neurotic anxiety was to declare guilt to be false, an unnecessary legacy of a time long past and now irrelevant. From the psychoanalytic perspective, self-deception becomes superfl uous because one does not have to defend against false and empty inner accusations. A legion of neurotics whose justifi cation strategies were wearing thin must have found this authori- tative pronouncement a shot of new life! No wonder “interminable analysis” became such a problem for analytic therapists. This new method of quashing guilt depended upon the constant re-infusion of assurance by the therapist authority. Psychoanalysis became a substitute for the justifi cation themata. Freud and many others mistook their clients’ fullness of guilt as evidence that they had too much guilt. It was clear to the analysts that self-deception was present and was a part of the pathology. What they did not see was that deception of self sprang from deception of signifi cant others, which, in turn, emerged from the desire to defend against social consequences. The muchness of guilt suffered by disordered persons is, as we have already seen, a function of factors, none of which disqualifi es that guilt in the least! Reliance on deception invites a repetition and an expansion of behaviors that bring long-term costs, including social censure. Deceivers, other things being equal, just commit more guilt-provoking acts than non-deceivers. And the constant throughout is yet an added guilt-provoking act, the deception itself. What is noteworthy, however, is not the muchness of guilt, but its impotence and shallowness. Pathological guilt is not false or irrelevant; rather, it is watered down and spread thin. It is everywhere, but, because of deception of self and others, it is nowhere intense enough to interrupt those hidden or disguised actions that spawn it.

The Dynamic Versus the Manifest in Psychopathology To recapitulate, we identify psychopathology with two sets of actions. The ﬁ rst set is efforts to reduce or avoid the social consequences of adjustive/ non-integrative behavior using deception of others. The second set is efforts to mute or avoid inner consequences (guilt) employing self-deception achieved through rationalization, denial, projection, and other “mechanisms of defense.” In advancing these identities, we are referring to the source and function of pathology, or, if you will, the dynamics of psychopathology. To complete the picture, we need also to consider psychopathology as expressed or manifest.

Downloaded by [New York University] at 02:06 15 August 2016 It is regarding the manifestations of psychopathology that we have a profusion of classiﬁ cation schemes. Integrity theory does not view a minute attention to the wide variety of manifestations as instructive. We can say this: Manifest pathology is a testament to the failure of deception, as time wears on, to avert both social and inner consequences. The result is that individuals begin to feel punished by life and by their emotions. Pessimism is common and exhibited as depression. Somatization of distress represents both an extension of self-deceptive strategies and an attempt to deﬁ ne the matter in hopefully treatable and impersonal terms. Phobias,

190 THE NATURE OF PATHOLOGY

likewise, represent an attempt to contain guilt no longer neutralized by deception. Obsessions and compulsions emerge to stave off the premonition of eventual catastrophe. Where extensive self-deception promotes confusion about one’s identity, failures of basic perceptual and cognitive processes may produce symptoms similar to those accompanying organic failure, as noted earlier. In consequence, Integrity theory does not assign great weight to classifi cation schemes based on pathology as manifest. People too often shift the manifest expression of their pathology. A science of behavior disorder resting on classifi cation of manifest pathology will be uncertain at best. However, in the section to follow we examine a rudimentary classifi cation system consonant with the Integrity model developed in prior pages.

A Classiﬁ cation System

Nature of the Independence of Normality and Pathology Now that we have deﬁ ned both normality and pathology, it is time to clarify in what particular way or ways pathology is and is not independent of normality. To advance this effort and to clarify the logical relationships between the basic conceptual categories that we have introduced, examine Table 11.2 .

Table 11.2 Nesting Diagram of Behavioral Instances Assignable to Integrative vs. Adjustive/Nonintegrative, Normal vs. Nonnormal, and Pathological State vs. Pathology-Free State (Size of box is only roughly proportional to frequency)

NON-INTEGRATIVE NON-INTEGRATIVE PATHOLOGY-FREE PATHOLOGY-FREE NON-NORMAL INTEGRATIVE NORMAL [GUILT-FREE] PATHOLOGY-FREE “SOCIOPATH” [ERROR] “PSYCHOPATH” [GUILTY] NORMAL

[GUILT-FREE]

Downloaded by [New York University] at 02:06 15 August 2016 NON-INTEGRATIVE NON-INTEGRATIVE

PATHOLOGICAL PATHOLOGICAL NON-NORMAL NORMAL [GUILT-TRANSMUTING] [GUILT-TRANSMUTING] “PSYCHOTIC’ “NEURTOTIC”

191 THE NATURE OF THE PROBLEM

Here we present a nesting diagram of behavioral instances categorized along the conceptual dimensions we have already defi ned. Note that there are two conceptual categories with large and approximately equal frequencies of behavior instances. One is the normal and the other the pathology-free. Nested within the normal class are three boxes (classes). The largest nested box or class is the integrative and pathology-free. Two classes of lesser frequency nested within the normal are the non-integrative and pathology-free and the non-integrative and pathological.2 The fi rst of these two lesser classes contains integrative error, i.e., departures from integrative behavior as a function of inattention, misperception, or misjudgment. These departures from integrative behavior are random or non-habitual and usually either do not recur or are self-correcting. The second lesser class, by contrast, is made up of habitual behavioral instances that prompt guilty anticipation defended against by deception of others and by self-deception. The classical neurotic is a normal person, evincing a predominance of integrative behavior, but a normal person hounded by a pocket of pathology. The large pathology-free category in Table 11.2 also has three nested classes within it. Two of these are coincident with the normal class, the integrative and normal and non-integrative and normal, which makes understandable that normality and pathology are in some measure coextensive. However, unlike the normal category, it also nests the non-integrative and non-normal class, which contributes to the independence of the normality and pathology concepts. Containing smaller numbers of behavioral instances are the pathological and non-normal categories. These categories have one box nested in common, and each has a second nested class that is not common (a normal box within the pathological class and a pathology-free box within the non-normal class). Again, this refl ects that pathology and normality are in some respects correlated and in other respects independent of each other. The two classes nested within the pathological category are distinguished by behaviors that seek to avoid social sanctions and personal judgment (guilt). The two classes nested within the non-normal category are marked by a predominance of non-integrative behaviors. The consequence is that the net subjective payoff is negative and punishing. Downloaded by [New York University] at 02:06 15 August 2016 Commonly Used Labels Let us extend our discussion of these matters with the help of Table 11.3 . Listed in each quadrant is the disposition of persons regarding nine different factors. They are worrying, valuing, compulsions (positive or negative addictions), intimacy, self-judgment, interrelationship, life payoff, future outlook, and attitude toward life.

192 THE NATURE OF PATHOLOGY

Labels have, characteristically, though not always, been applied to individuals evincing behaviors described in the four quadrants of Table 11.3 . Quadrant 1 represents the psychologically healthy normal. Quadrant 2 classically describes the neurotic. Quadrant 3 frequently confounds classiﬁ ers who attempt to identify such individuals as psychopathological (witness the various versions of the American Psychiatric Association’s Diagnostic and Statis- tical Manual ). Individuals in this quadrant, while not normal, are also not

Table 11.3 Signal Characteristics of Persons at the Extremes of the Pathology and Normality Poles

Pathology-Free Pathology

(1) (2) Worries. Worries. Orders values. Some value confusion. Evinces positive Evinces positive and addictions. negative addictions. Discloses to intimates. Significant matters not Normality Self aware. disclosed. Interdependent with Guilty. others. Independent of or Life outcomes are dependent on others. positive. Life outcomes are Optimistic. sometimes negative. Reverent. Sometimes pessimistic. Anti-religious or super- religious tendencies.

(3) (4) Worry free. Worry free. Lacking values. Lacking values. Few positive addictions. Evinces negative Superficial intimacy. addictions. Non-disclosing. Feels alienated. Manipulative. Guilty (which may be Non-Normality Lacking self awareness. “cosmic” in nature). Independent of others. Independent of or

Downloaded by [New York University] at 02:06 15 August 2016 Life outcomes grow dependent on others. increasingly negative. Life outcomes grow Neither optimistic or increasingly negative. pessimistic. Pessimistic (may be Irreverent. suicidal or homicidal). Anti-religious or super- religious tendencies.

193 THE NATURE OF THE PROBLEM

psychopathological although we might think of them as evincing a social pathology. Indeed, they have often been called sociopaths, which is preferred to personality disordered, the common label. Finally, in quadrant 4 are found individuals often labeled psychotic. These observations are offered to aid your study of the four types of persons deﬁ ned by Table 11.3 rather than labels so often used. We are saddled with the term pathology that we use rather than inventing terms presumably free of biomedical implications. It has already been noted that, in psychopathology, behaviors observe psychology’s Law of Effect and Law of Effects Over Time. These behaviors can and should be distinguished from those indicative of biomedical pathology in which these two Laws of behavior do not reliably apply.

Characteristics Distinguishing Normality and Pathology Examination of Table 11.3 will reveal that there are fi ve characteristics that distinguish pathology from its absence. They are the presence of negative addictions, guilt, a tendency to express independence from or dependence on others, some measure of pessimism about the future, and a tendency to be either anti-religious or super-religious. Absence of normality is distinguished in three ways from its presence: freedom from worry, lack of values, and the steady worsening of life outcomes. One characteristic does not clearly distinguish pathology or normality, namely, intimacy behaviors. Only in the normal/pathology-free quadrant do relations approach unrestrained openness between intimates. Those who are normal but pathological always have secrets reserved, even from intimates. Indeed, deceptions that are central to the individual’s pathology are directed particularly at intimates! Individuals free of pathology but non-normal are unable to achieve more than superfi cial intimacy because they will not or cannot commit themselves to another. Commitment inevitably requires restraint of immediate gratifi cation in the interest of loyalty to and consideration of the intimate. Thus, commitment rests on the ability to behave integratively.

Ordering Quadrants According to Psychological Health

Downloaded by [New York University] at 02:06 15 August 2016 Before leaving consideration of our rudimentary classiﬁ cation scheme, let us pick up a point we promised to explore in the previous chapter. If we were to order the quadrants in Table 11.3 according to a single dimension of “psychological health” or, perhaps, “personality/character development,” what might the order be? Most persons would suggest the order 1-2-3-4, placing the normal/pathology-free as most healthy or developmentally advanced and the non-normal/pathology quadrant as least so. To be sure, persons in quadrant 4 manifest more symptomatic behaviors ranging from unusual thinking to delusions and from aloofness to hallucinatory detachment. By

194 THE NATURE OF PATHOLOGY

contrast, persons in quadrant 3 are usually free of gross thinking and affec- tive problems. On what basis, then, do we hold that quadrant 3 people are the least developed and psychologically healthy with the correct order being 1-2-4-3? The answer is that psychopathology is an indication of a certain measure of personality and character development. In defi ning pathology, you may recall that we stipulated a precondition to its emergence. That precondition is the prior development of the capacity to anticipate negative consequences, i.e., guilt, in the wake of non-integrative actions. The guilt must be of suffi cient measure to move the individual to act.3 As we saw, persons can act in one of two ways to address the emotional problem that guilt presents. They can, by transforming guilt into worry, learn to anticipate consequences before enacting non-integrative choices and, so equipped, learn to avoid acting in guilt-provoking ways. Choice of that path results in the normal, pathology-free outcome. Or they can seek to minimize guilt by avoiding negative social consequences through deception of others and avoiding inner emotional consequences by deception of self. That set of choices results in pathology. Always antedating the emergence of pathology, however, is development of the capacity to anticipate those negative consequences of one’s actions. Persons in both quadrants 3 and 4 lack a value structure. That is, very little that is not here and now is valued greater than matters immediately experienced. However, the value-lacking feature in quadrant 4 is qualitatively different from that in quadrant 3. In quadrant 4, the lack of a value structure is both a result of and a part of the strategy of self-deception. Extensive self-deception undermines one’s value structure because those deceptions, in essence, contradict the value, negative or positive, one places on the not here and now. As time goes on, the dimensions of one’s core identity and the point one occupies in time and interpersonal space grows increasingly blurred. The message in deception of others is, “Your knowing and responding to my actions is not signifi cant, not of value.” The message in deception of self is, “What I know (anticipate) about the future is not signifi cant, not of value.” These inherent assertions resident in deception lead, in time, to mounting doubts and to questions progressively more morbid: Is anyone important to me? Is any

Downloaded by [New York University] at 02:06 15 August 2016 outcome important to me? If I am loyal to no one and value no outcome, then who am I? Does the world really exist? Do I exist? Am I dead? Is my body rotting? Do worms infest my brain?

The Primitive Person Persons in quadrant 3 are also value-lacking but for different reasons and with a different outcome. Their lack of value structure is a function of a more primitive characterological development than persons in quadrant 4. The

195 THE NATURE OF THE PROBLEM

basic reason is that they have never learned to depend on another human being. It is not that, in reality, their survival did not depend on others. It did. It is instead that the nature of succor provided them as infant and child was such that they did not learn to depend on another. What they did learn from the sometimes inconsistent care given by often varied and indifferent providers was to rely on no particular person other than themselves. Having survived in spite of an indifferent world, they have also learned to be unconcerned for the future. Quadrant 3 persons identify with no one. Because they were not dependent upon a parent-authority fi gure, they never felt obliged to rehearse how another, with power over them, might react to their actions. They did not internalize and, as a result, learn to value the internal voice of signifi cant others regarding social consequences. They may, if queried, indicate that they know how another will respond to them. However, that response per se is of value to them only if it bears directly on their immediate comfort or pain. The distress of another does not distress them. Social consequences, understood as another’s anger, distress, shame, pleasure, or pain, do not exist. Only if social consequences are manifest in their own physical pleasure or pain does it merit their attention. They employ deception of others with ease. Yet, lacking anticipatory concern for eventual social consequences, they have no interest in self-deception. They are simply at too primitive a level of personality and character development to express the pathologies present in quadrants 2 and 4. As Mowrer was fond of saying, they do not have enough character to go crazy. Primitive though they are, they still fascinate us. They are often subjects of books and plays. They can be delightfully innocent and open, ruefully ready to confess to their deeds and misdeeds. They can be “the life of the party.” Many of us fi nd their “rugged individualism” and their tough go-it-alone, every-man-for-himself approach to life traits to admire, and, unfortunately, when they are very bright, they often capitalize on this acclaim to win positions of power such as in political offi ce. They fascinate because they appeal to the lingering primitive within us, which is invigorated by these “free spirits” so unfettered by conscience and by complicating commitments and loyalties. As indicated in Chapter 2, a commonplace message from occupants of quadrants 2 and 4 when seeking therapeutic help is, in essence, “Make my

Downloaded by [New York University] at 02:06 15 August 2016 ‘neurosis,’ my problematic lifestyle, work for me. Permit me to live as I am without suffering the emotional costs now exacted of me.” Many have quite directly asked, “Why am I hounded by guilt? Why can’t I get away with what I see others doing apparently without a care?” We see occupants of quadrant 3 through a prism distorted by our own wish. We see their freedom from guilt, their fatalistic unconcern, and their ready enjoyment of the moment. We do not see the mounting costs in the shape of isolation, mistrust, social ostracism, and, at last, the loss of that very freedom that intrigues us so. I repeat, do not envy them.

196 THE NATURE OF PATHOLOGY

Psychopathology as Negative Addiction

Addiction: An Expanded Concept Where once the term addiction referred to actions dictated by a limited set of chemical dependencies, it has broadened in scope over time. One way the concept has been expanded is the recognition that it may result in benefi ts as well as costs to the addict. Positive addictions presumably have the same features as do negative addictions except that the former, compared to the latter, bring desirable long-term consequences for the individual and society. Running is a prime example. Here, individuals, for whatever reason, inaugurate behavior for which many of us fi nd little or no appetite. After weeks or months of pursuing this sometimes exhausting course, these persons appear to develop a dependence on running. They suffer “withdrawal pain” and regularly satisfy their craving with a “running fi x,” which serves to appease them temporarily. Before long, however, the craving returns, and they feel obliged to resume their addictive behavior. Of course, positive addictions are the mirror image of negative addictions. The immediate effect of the former is negative in valence, while that of the latter is positive. Conversely, the long-term effects of the former are rewarding; those of the latter are punishing. In Chapter 10 , in the section entitled The Benevolent Circle of Integration, we graphically presented a model of integrative behavior. The model explained how integrative behavior develops in spite of its short-term cost and apparent fragility. Three factors were highlighted as critical to this development: (1) The mediating, “pump-priming” effects parents (or parent surrogates) bring to bear in infancy and childhood, and the continued mediating input of intimates following childhood; (2) the mediating effects of cognitive representation of future outcomes; and (3) the current positive payoff resulting from past integrative actions. Might not this model apply as well to positive addictions? May we not conclude that positive addictions and integrative behavior are similar if not identical? I believe the answer is yes to both questions. Let us return to running. We observe that people take up this taxing behavior, fi rst, under direct encouragement from signifi cant associates and second, spurred by the inviting promise of health and vigor. Finally, this behavior becomes notice- ably self-sustaining once benefi ts from past efforts emerge in discernible health and cosmetic gains. These are specifi c expressions of the three general factors that Downloaded by [New York University] at 02:06 15 August 2016 account for the emergence and maintenance of integrative behavior. However, the constellation of factors promoting integrative behavior or positive addictions is not the same as that which brings out and sustains negative addiction. Many observers use classical negative addiction, such as heroin use, as a prototype for explaining positive addictions. It is possible that behavior, such as running, becomes addictive because, in time, it produces an immediate, intrinsic (non-mediated) payoff, the “runner’s high.” Some have suggested that brain endorphins, the body’s own opiates, may be released by the stress of

197 THE NATURE OF THE PROBLEM

running. I am not much impressed with these attempts to cast positive addiction in the mold of classical substance addiction. True, the body does initially resist tapping its store of energy. It takes some 8 to 12 minutes of running before runners get their “second wind” and settle into the easy looseness of the mid-course run. This experience may encourage a sense of exhilaration ﬂ owing from the conﬁ dence the runner gains that he or she can indeed accomplish that 5- or 10- or 20-mile effort. As a runner of some years, I have experienced this form of mediated lift many times. Oth- ers have reported the same. However, I have never experienced nor has anyone ever reported a morphine-like thrill (the “endorphin effect” or “runner’s high”) well into a long and energy-draining run.

Explaining Negative Addiction Classical negative addiction does not provide a satisfying paradigm for positive addictions, such as running. Let us examine why as we set forth the commonly understood ingredients of classical negative addiction: The addictive substance is critical to the explanation of addiction. Certain substances have the facil- ity, with regular use and intake, to alter our physiology and create a new and unnatural need. This new need comes to have a force even greater than natural needs, such as hunger or thirst. Deprivation of the substance generates a desire of exceptional intensity resulting in the prototypical withdrawal pain. Resum- ing intake of the substance immediately ﬁ xes the need and restores comfort. This classical but narrow conception of addiction based on a use-built, unnatural need is burdened by exceptions. First, some substances do not ﬁ t into the classical picture. Regular users of marijuana, cocaine, LSD, and amphetamines do not experience a typical course of withdrawal pain. Yet addictive users of these substances are as hooked as users of opiates, alcohol, and barbiturates, the classically addictive drugs. Second, there are many behaviors that have all the earmarks of addiction but do not involve substance use at all. Gambling, exhibitionism, voyeurism, and shoplifting are diverse examples. They are performed at intervals with that compulsive necessity that characterizes all addictions. Finally, drying out and withdrawal programs are notorious for their immediate success and later failure. Removing the unnatural need and the withdrawal pain is rarely equivalent to cure. If these factors

Downloaded by [New York University] at 02:06 15 August 2016 were central, as averred by the classical concept, this would not be the case. Thus, the classical view of addiction does not account for all substances used, all negative addictions, and the frequent resumption of addictive behavior following the removal of physical dependence (detoxiﬁ cation). If we proceed to advance a more comprehensive explanation of negative addiction, we will ﬁ nd that there is an identity between negative addictions and psychopathology. This identity parallels that between positive addiction and normal, integrative behavior, which we examined above. It will also become evident that while the explanations for positive and negative addictions differ, they are composed of

198 THE NATURE OF PATHOLOGY

the same basic elements. These are immediate payoff, long-term payoff, the cognitive representation of these events, and the role played by intimate others. The challenge in positive addiction is to explain how the behavior gets started and, once started, is maintained. By contrast, the challenge in negative addiction is to explain why the behavior, as its costs mount, is not discontinued. The latter is another version of Mowrer’s “neurotic paradox.” Why do people persist in actions that are self-destructive? Does not this behavior contradict basic principles of learning psychology in force almost since the advent of our science? You may not know how real the paradox is unless you have witnessed the agony and personal hell of alcoholics or drug addicts. They loathe their habit and are ﬁ lled with remorse at the chaos it costs, yet they also know they will use again. Their dilemma is no mere abstraction.

The Precondition to the Development of Pathology However, let us see if, in the abstract, we can understand what it is that is likely to precondition the development of pathology or negative addiction. Remem- ber (see Chapter 10 and discussion of Figure 10.1) how signifi cant the role of parent fi gures in “priming the pump” of integrative behavior. The precondition to negative addiction is ordinarily some degree of failure by parent or parent fi gure to mediate the future consequences of current actions. During that critical period when parents exert maximum control over contingencies bearing on the child, one or both of two critical omissions can occur. First, parents could omit applying effective rewards for useful, integrative behavior that otherwise would be effortful (unpleasant) or go without immediate reward. Second, parents could omit effectively to penalize behavior that is intrinsically rewarding but that eventuates in serious negative consequences to the child. The result is graphically presented in Figures 11.1 and 11.2 . 4

REMOTE OUTCOME

IMMEDIATE OUTCOME Mediated Cognitive Downloaded by [New York University] at 02:06 15 August 2016 Parental

Intrinsic

RI RA RA RA RA RA RA (Timeline) 1 2 3 4 5 6 7

Figure 11.1 Graphic Payoff During Development of Adjustive/Nonintegrative Behavior Precursor of Negative Addition (Size of positive or negative payoff values is proportional to size of the positive [white/pale] or negative [black] rectangles)

199 THE NATURE OF THE PROBLEM

POSITIVE SUBJECTIVE LIFE INCOME

NEGATIVE SUBJECTIVE LIFE INCOME

RI RA RA RA RA RA RA (Timeline) 1 2 3 4 5 6 7

Figure 11.2 Net Payoff Values Derived From Immediate and Delayed Payoff Depicted in Figure 11.1 (Spade symbols represent projections of valences into the future)

Figures 11.1 and 11.2 pick up the timeline of the child early in life. They indicate that integrative acts did not receive rewarding notice by parents suffi cient to result in a net gain, while adjustive/non-integrative acts did not receive a penalizing response from parents suffi cient to result in a net cost. As the child compares outcomes from his own limited perspective, the choice of that behavior leading to immediate payoff is compelling. Yet, while parental efforts are not adequate to determine reliably what the child does, they are suffi cient to infl uence what the child thinks and feels. The pathogenic aspect of formative parent–child interactions could be reduced to this: Parents lack the consistency, clarity, or forcefulness to reliably “ prime the pump” of integrative behavior, but they do manage to infl uence, at least in some measure, how the child thinks and feels about that behavior. The result is that the child does not learn to avoid acting in ways that, while immediately gratifying, are costly over time. However, the child does learn to anticipate negative consequences tied to his or her actions. The child learns guilt. A word, before proceeding, about the quality of that guilt: If the pathogenic child learns guilt, still it will not be of the same vigor as that in the non- pathogenic child. In the latter case, consistent, effective parental pump-priming will promote sharp and arresting guilt feelings whenever the child behaves non- integratively. Of course, parental infl uence and the child’s guilt both work to

Downloaded by [New York University] at 02:06 15 August 2016 reduce the occurrence of such actions. The result is that non-pathogenic children experience guilt infrequently even if sharply when they do. Not so with the pathogenic child. Here, typically, the child is engaged in non- integrative actions and frequently, as a result, troubled by guilt, but of a vague and uncompelling nature. Earlier in this chapter, we saw that deception serves to undermine the force that guilt might otherwise have in the pathological person. Now we see that, developmentally, before deception will have worked this effect, guilt in the pathogenic child already lacks the sharp delineation of guilt experienced by the non-pathogenic child. The hallmark of emerging pathology

200 THE NATURE OF PATHOLOGY

is absence of worry, but presence of vague, recurrent apprehension about the future, fl owing from the child’s own actions. When deception is employed later to reduce the breadth and frequency of the apprehension, guilt becomes even less a force for transforming non-integrative into integrative behavior. Times 1 to 5 in Figures 11.1 and 11.2 are relatively foreshortened for our graphic presentation. Actually, childhood represents a time during which others grant considerable tolerance. As time goes on, they gradually withdraw this tolerance. We mute social consequences to children, and hold parents responsible for the delinquencies of their children. Parents often voluntarily “pay the fi ne,” make the apologies, or, in other ways, bear the cost of the child’s actions. This cultural leniency has its uses. It permits the young and immature to make mistakes without suffering outcomes that might prematurely scar them and arrest their development. This grant of leniency, however, begins to run out in adolescence. Society shifts judgment to the individual and away from parents, and parents are less willing to intervene and less able even when willing. Thus, Time 5 typically makes its appearance in mid- to late adolescence. Delayed, negative payoff attendant on earlier non-integrative acts emerges at this time relatively un-modulated by parental interventions. At Time 5, the individual begins to experience life’s net payoff from continued non-integrative acts as more negative than positive. In addition, the future is anticipated in terms even more negative than the present. One is no longer happy with his or her lot. Discontent becomes a motive for change, although the initial focus is on changing the world grown no longer tolerant. The world resists, however, and the individual casts about for other ways to diminish the negative income. One such way, to which individuals by this time are not strangers, is deception. Insofar as consequences are social, individuals may, through deception, defray their cost. In terms of the elements composing the model presented here and elaborated further in the next section, deception seeks to accomplish this end using three strategies of avoidance. These are to avoid fi rst, delayed (social) consequences, second, the immediate judgment of intimates, and third, immediate self-judgment. We have dealt with these matters at length in a previous section.

Failed Efforts at Self “Cure”

Downloaded by [New York University] at 02:06 15 August 2016 Sooner or later, however, individuals grow distressed enough to focus the attempts to change on themselves. Because they deceive themselves, must they guess what, in their disguised and veiled actions, it is that produces the negative outcomes that have overtaken them? Yes, in some measure, but it is also true that, in a moment of anxious honesty, they merely acknowledge what they have always known. In Figure 11.3, we pick up the timeline well into a life featuring the practice of adjustive/non-integrative behavior. At Time 3, the individual inaugurates an experiment in changing the style of behavior that has been practiced. For a period, integrative behavior is substituted for

201 THE NATURE OF THE PROBLEM

REMOTE OUTCOME

IMMEDIATE OUTCOME Mediated Cognitive

Intimates

Intrinsic

RA RA RI RA RA RA RA (Timeline) 1 2 3 4 5 6 7

Figure 11.3 Graphic Payoff During an Attempt to Abstain From Negative Addiction Behavior (Size of payoff values is proportional to size of the positive [white/ pale] or negative [black] rectangles)

POSITIVE SUBJECTIVE LIFE INCOME

NEGATIVE SUBJECTIVE LIFE INCOME

RA RA RI RA RA RA RA (Timeline) 1 2 3 4 5 6 7 Figure 11.4 Net Payoff Values Derived From Immediate and Delayed Payoff Components in Figure 11.3 (Spade symbols represent projections of negative valences into the future)

the adjustive/non-integrative acts of the past. It is the ﬁ rst of, perhaps, a long series of efforts by the individual to “get control” of and change his or her life. Instantly, there are shifts in the components of the payoff structure. Immedi- ate intrinsic payoff becomes quite negative, reﬂ ecting the frustration, risk, and

Downloaded by [New York University] at 02:06 15 August 2016 effort involved in the integrative choice. Intimates who are observant of this change may cease their customary critical appraisal and offer encouragement, which produces a shift to a modest positive valance. Similarly, the individual will experience a shift from guilt to a modest surge of hope or self approval. The long-term payoff ﬂ owing from past actions, however, remains a strong negative valance and will for some time. The net outcome of the four components of payoff results in a worsening of the subjective income experienced by the individual! More- over, this unfortunate state of affairs is destined to persist for a considerable time (until Time 6 in Figures 11.3 and 11. 4 when delayed positive payoff kicks in).

202 THE NATURE OF PATHOLOGY

The Barrier of Despair Why would addicts not persevere (as shown later in Figure 11.5 )? Why would they not persist in new (abstinent) behavior to arrive fi nally at Time 6 where life takes on an entirely new, desirable level of satisfaction and reward? Because, to do so, they would have to endure a prolonged span of time during which their own hope and the encouragement of intimates are ordinarily not suffi cient to offset the cost of abstinence. When hope is lacking, we usually speak of despair, and that describes the state of addicts who endeavor to change. They despair when they fi nd that their efforts are met with a worsening state of subjective satisfaction, which has no immediate prospects of improvement (see Figure 11.6 ). As I noted

REMOTE OUTCOME

IMMEDIATE OUTCOME Mediated Cognitive

Intimates

Intrinsic

RA RA RI RI RI RI RI (Timeline) 1 2 3 4 5 6 7

Figure 11.5 Graphic Payoff During a Prolonged Attempt to Abstain from Negative Addiction Behavior (Size of payoff values is proportional to size of the positive [white/pale] or negative [black] rectangles)

POSITIVE SUBJECTIVE LIFE INCOME

NEGATIVE Downloaded by [New York University] at 02:06 15 August 2016 SUBJECTIVE LIFE INCOME DESPAIR

RI RA RA RA RA RA RA (Timeline) 1 2 3 4 5 6 7

Figure 11.6 Net Payoff Values Derived From Immediate and Delayed Payoff Components in Figure 11.5 (Heart symbols represent projections of positive valences into the future)

203 THE NATURE OF THE PROBLEM

in Chapter 10 , one will not maintain an action where an alternative action subjectively costs less or pays more. In spite of displaced and gathering pen- alties accruing to long-practiced non-integrative behavior, the immediately experienced cost of abstinence from this behavior is simply greater. Addictive behavior, in the addict’s world of experience, looms as the most assured, immediate comfort available to one whose life under abstinence has only grown darker.5 We conclude that the course depicted in Figures 11.5 and 11.6 , in actuality, will not occur. It goes contrary to nature. Instead, what does occur is reﬂ ected in what we have rendered in Figures 11.3 and 11.4 . No sooner do persons begin to experience a worsening of subjective income than they cast about for a way to remedy that circumstance. Addictive using is the remedy. The result is that the individual is locked into a downward spiral of use, whatever the habit, which seeks to restore comfort by constantly postponing a cumulative subjective cost.

Conclusion We see in this chapter that pathology and normality are independent, but only in a limited manner. Normal human behavior prominently features the exercise of worry about future outcomes and the choice of actions designed to maximize positive outcomes over time. We call this integrative behavior. None of us behaves integratively under all circumstances, even though we may, all things considered, be mostly integrative in our conduct. If we grant that the “mostly integrative” are normal, even if they suffer some departures, then we permit the coexistence of pathology and essential normality. When the individual compulsively pursues some non-integrative behavior that represents a relatively restricted feature in his behavioral landscape, we have a pathology embedded in normality. Of course, no integrative behavior considered alone is pathological. This fact contributes strongly to the limited polarity of normality and pathology. How- ever, some who behave non-integratively are pathology-free, which explains why normality and pathology could never order along a single dimension. A good proportion of these instances arise from the inevitable trial and error accompanying the attempt to cope with what life brings. The core of pathol-

Downloaded by [New York University] at 02:06 15 August 2016 ogy rests in those non-integrative behaviors that we protect from the corrective inﬂ uence of others and from our own judgment. Those core behaviors are compulsive, being repeated over and over even in the face of accumulating costs. At base, pathology and (negative) addiction are equivalent concepts. Earlier it was noted that the factors promoting integrative behavior or positive additions are not the same as those that bring out and sustain negative addictions. Also noted was that the challenge in positive addiction is to explain how the behavior gets started and, once started, is maintained. By contrast, the challenge in negative addiction is to explain why the behavior, as its costs

204 THE NATURE OF PATHOLOGY

mount, is not discontinued. However, the explanation for each, while different, was composed of the same basic elements. These are immediate payoff, long-term payoff, the cognitive representation of these events, and the role played by intimate others. Having already presented a step-wise explanation of both, let us here review the distinctions and the common elements. Positive addictions are begun because of the pump-priming reinforcements administered by intimate others that defray the intrinsic cost of these behaviors. Negative addictions are begun because these actions are intrinsically rewarding and bear, by contrast, only modest initial cost. Positive addictions become self-sustaining as the pump- priming of others helps the individual fi rst begin and sustain integrative behavior. When the individual has practiced this behavior long enough to enjoy the delayed benefi ts it brings, then those benefi ts reinforce repetitions of the behavior. Negative addictions are self-sustaining because of the immediate, positive payoff, which, of course, is no puzzle. The diffi cult question to answer is why negative addictions do not stop once delayed costs emerge and overshadow their gain. They do not stop because, once delayed costs mount, abstinence becomes more costly, moment by moment and for a prolonged period, than practicing the addictive habit. Con- tributing signifi cantly to the cost advantage of the addictive choice is the fact that the addict has learned to employ deceptive strategies that diminish the perceived overall cost. The essence of psychopathology is not per se the choice of adjustive/non-integrative behaviors. It is, instead, the individual’s self- deceiving and self-defeating efforts to alter the outcomes of that choice. We sometimes distinguish psychosis as that pathological condition in which the individual is no longer in contact with reality. In actuality, all psychopathology (negative addictions) is, at base, a distortion of and departure from the reality of consequences.

Notes 1. Mowrer frequently made reference to the pathogenic secret. It is fair to say that he believed human pathology emerged essentially from the use and abuse of language. In his Psychology of Learning and Language (1980), he noted that he had addressed this matter in no less than nine different publications between 1960 and 1970. 2. Keep in mind that non-integrative behaviors may be present in the normal per-

Downloaded by [New York University] at 02:06 15 August 2016 son even though integrative actions deﬁ ne what is healthy and normal. Most of these non-integrative departures arise from inattention, misperception, or misjudgment and sooner or later provoke guilt and regret. When the negative emotional responses (of guilt and regret) “move forward” and become conditioned to the anticipation of enacting such non-integrative acts, guilt and regret are transformed into normal worry. Worry permits the expressions of non-integrative behavior to be inhibited or selected out before enactment takes place. Meanwhile, the remaining instances of normal but non-integrative behaviors belong to those who learn to diminish guilt and regret through self-deception (the mechanisms of defense). In so doing, they arrest guilt, even while they diminish it, so that normal worry does not develop. In this manner, the non-integrative departures

205 THE NATURE OF THE PROBLEM

become habitual. However, these departures are a minor, not a major, part of these individuals’ total behavioral plate. Consequently, while the future payoff for these departures, considered apart, is negative and punishing, the cost is absorbed by the credit earned from the predominantly integrative lifestyle of these persons. 3. Mowrer was convinced that the ordering of these character types along a continuum of personal development and socialization clearly confi rmed the Integrity approach to understanding and treating troubled people. We addressed this matter in Chapter 1. 4. The graphs presented are generic and designed to aid your grasp of the basic dynamics of normal (integrative) behavior and pathological (non-integrative) behavior. For simplicity, the graphic presentations are limited to a consideration only of the cumulative outcomes of pathological, non-integrative behavior, which are negative. Obviously, everyday behavior is more complex. In Time 1 (Figure 11.1), we have a toddler at an age where, ordinarily, the world is kind. The toddler earns parental love and nurturance with only little attention to eventual realities. But as time passes (see Times 2 and 3), the child, no longer a toddler, becomes more an explorer of the world’s pleasures, and parents give more attention to not-here and not-now eventualities as they relate to those explorations in (often verboten) pleasure. For the child who is under-rewarded for integrative behavior and under-penalized for non-integrative actions, the world may be, for a brief interlude, a daily adventure on “Pleasure Island.” Understandably, the child may develop strategies protecting a pleasure-centered lifestyle from parental inter- ference. But by Times 5, 6, and 7 (Figure 11.4), the child is passing through adolescence and the world of consequences tied to past behaviors is unkind. Parental representational powers, never adequate, wane, but the child’s own mediating faculties grow, if not, however, suffi cient to inhibit non-integrative (adjustive) actions in the promotion of integrative behavior. 5. In a sense, individuals are not addicts until they attempt to change! Before that point, they may have practiced adjustive/non-integrative behavior and may have developed strategies of deception to insulate that behavior from the judgment of self and others. However, until they attempt to stop the adjustive/non-integrative behavior, they will not have had evidence that they depend on this behavior for comfort in a life now grown, in some critical respects, signifi cantly lacking in comfort. Downloaded by [New York University] at 02:06 15 August 2016

206 POSTSCRIPT

In formal logic, a contradiction is the signal of defeat, but in the evolution of real knowledge it marks the ﬁ rst step in progress toward a victory. —Alfred North Whitehead

As I look back over the contents of this book and consider the challenge that I seek to bring to you, the reader, and to psychology as professionally applied, I am struck not only by the fi eld’s growing diversity of contesting therapies but by the emergence of prominent trends that seem blind to the contradictions they pose each to the other. One of these is the repeated assertion that we must apply only empirically supported treatments, which appears to ignore the even more widely accepted conclusion that no treatment approach is signifi - cantly and empirically superior to any other. Another development embraces the Dodo Bird Hypothesis as a way to end the “therapy wars,” which may or may not secure professional psychology’s investment in the licensed practice of psychotherapy, but most certainly runs afoul of those persuaded that scientifi c theories are more than convenient myths. I believe, and I hope I have persuaded you to believe, that the same unquestioned yet critical premise is assumed by essentially all approaches otherwise claiming to be different from and also more effective than any other. That premise is that psychologically troubled persons suffer from unrealistic, inappropriate, and unnecessary negative emotions that psychotherapy must be designed to eliminate. The only theorist to explicitly identify this premise as

Downloaded by [New York University] at 02:06 15 August 2016 a conceptual error was O. H. Mowrer, who asserted that it is not emotions that are at fault for the unrelieved distress of troubled people; instead, it is the faulty choices they make and errant conduct they habitually pursue. The therapeutic solution is not to do battle with the painful emotions, but to help troubled people be guided and motivated by those emotions to change the way they behave. It is somewhat puzzling that Mowrer prominently questioned this reign- ing premise now more than 60 years ago and offered a rational alternative construct and consequent distinctive therapeutic solution, yet those searching

207 POSTSCRIPT

for a new and, presumably, different paradigm have looked elsewhere. Yes, Mowrer tried to enlist, or re-enlist the Church to address these problems of human choice and conduct, and in so endeavoring slipped into the use of certain metaphors that alarmed many psychologists. But I think Perry London (1984) may have been closer to the more central reason for the blanket shunning of Mowrer’s Integrity approach and the conservation of the old, shared premise when he wrote (previously quoted in part on page 13) of psychology’s adoption of the medical model:

Psychotherapists have been nobly moved to adapt this idea to their craft. In so doing, they think the mental therapist is not a moral- ist, should not speak to the morals, religion, business, or politics of patients, and has no right, in course of practice, to make value judgments of them, to preach at them or to promise to them some “good” way of life. Therapy’s purpose is to relieve their suffering, their anxiety, their guilt, their mental aberrations, their helpless actions, their neuroses or psychoses, not to change their lives along some moral lines or toward some ideology. (pp. 5–6)

Starting with Freud, therapists may have, indeed, felt nobly called to free troubled people from the fetters of conscience and social obligations while avoiding any attempt “to change their lives along some moral lines or toward some ideology.” To adopt Mowrer’s new and different premise faulting conduct rather than emotions may have struck many as a kind of moral retreat from the high ground of nonjudgmental professionalism devoted to relieving pain and suffering. But how noble is nonjudgmental professionalism if Mow- rer is right and the direct therapeutic efforts to rid people of their guilt may give only passing relief while putting them at risk for feeling even worse? The answer to this conﬂ ict of values—this moral conﬂ ict—is to bring to the fore yet another noble calling. Psychology the science and psychologists as scientists and appliers of science have a transcending devotion—the empirical method, the search for truth based on observation. If we cling to a premise because it feels right or promotes within us a sense of the noble and, as a result, fail to examine empirically a contesting premise (which may repulse us), how are we honoring our devotion to science?

Downloaded by [New York University] at 02:06 15 August 2016 I believe that many professionals and students are today in search of a theoretical framework and remain uncertain whether or how much to commit allegiance to one or another of the many extant approaches. If I have persuaded you at least in some degree that the theoretic differences distinguishing various approaches may be far less relevant to their therapeutic efﬁ cacy or lack thereof than are the atheoretical features they hold in common, then you may be prepared to examine seriously an approach that is truly and substan- tially different in theory. Moreover, if I have served well my cause in the contents presented in this book, then you uncommitted readers will have found

208 POSTSCRIPT

herein a coherent theory and a clear and comprehensive manual of procedures and methods. Assuming these conditions have all been met, what remains is that your very natural curiosity will move you to giving Integrity Therapy an authentic trial and test. I know that this therapy process is not easy to master. But I also know it is not at all impossible to do so. What one mostly requires is a prior devotion to helping troubled people who both need and deserve your help. The rest depends on the often uncharted resources of your own person as you plumb the depth of your inner responses in seeking the better to know and understand the troubled persons who come to you for help. Downloaded by [New York University] at 02:06 15 August 2016

209 APPENDIX

Indeed, much of human life is best described as impersonation. We are role players, every one of us. We say that we feel things we do not feel. We say things we did not do. We say that we believe things we do not believe. We pretend that we are loving when we are full of hostility. We pretend that we are calm and indifferent when we are actually trembling with anxiety and fear. Of course we cannot tell even the people we know and love everything we think or feel. But our mistakes are nearly always in the other direction. Even in families—good families—people wear masks a great deal of the time. —S idney Jourard, The Transparent Self

On the following pages are fi ve brief preparations drawn from a total of 11 that I composed to inform and aid clients in their use of help. The contents of each were presented to clients in pamphlet form and were also made available through audio presentation. The preparations are presented in this appendix alphabetically by title. In my practice, the most frequently employed work was Using Counseling and Psy- chotherapy. The next most frequently used was Using Help With Marital Prob- lems. The works on addiction, anxiety, and depression were also quite popular. Clients frequently reported that they felt as if the pamphlets were especially written for them. They often noted that the pamphlets helped them put into words what they had been struggling to express about themselves. I believe employing the pamphlets and introducing them upon fi rst contact defi nitely

Downloaded by [New York University] at 02:06 15 August 2016 advanced understanding and communication with clients. Space prohibits presenting all 11 works. Those not contained in this appendix are:

Using Help With Marital Problems Using Help With Parenting Problems The Challenge of Parenting A Program for Parenting A Primer on Stress Using Help With Worry

210 APPENDIX

USING HELP WITH ADDICTION

By V. Edwin Bixenstine, Ph.D.

Prepared for clients and subscribers. Not for copy or redistribution without the express permission of the author.

Preface I designed this brief presentation for persons seeking help for problems with addiction. We believe that some degree of information and orientation about addiction and the helping process will assist that undertaking. Research supports this belief. For maximum preparation we suggest you also read Using Counseling and Psychotherapy, which addresses the nature of the helping process.

A Problem With Defi nition So you are an addict? What does being an addict mean? Commonly, the term, addict, applies to persons who depend upon a substance of some kind. The substance enables them to pass through each day in some degree of ease and comfort. Use of the substance is regular, compulsive, and they arrange their life to assure access to the substance. Does this common sense defi nition cover all bases? Not really. In fact, there are a handful of exceptions we may take with this way of defi ning the addict and addiction. First, using this defi nition, how can we distinguish addictions from commonplace actions and substances, such as eating food or drinking water? These acts are also regular and compulsive. The substances undergird our daily comfort and defi nitely shape our lives to assure their ready access. Should we view ordinary eating and drinking as a form of addiction? No, you are likely to say, because addictions are harmful. The substance used or ingested is in some way harmful to health or to healthy and effective living. Capitalizing on this idea of harmfulness, some biologically oriented thinkers,

Downloaded by [New York University] at 02:06 15 August 2016 seeking to simplify matters, have focused on the nature of the substance. They suggest that certain substances have the power, with regular use and intake, to alter our physical systems. Regular use of these substances creates a new and unnatural need. That new need comes to have the same compelling force as does hunger or thirst. However, this new addictive need does not serve to motivate us into those necessary and natural acts that sustain our lives. Instead, it goads us into acts that threaten our health and endanger our lives. From this biological point of view, what makes an addictive substance recog- nizable are two factors. First, its use serves an unnatural need. Second, denial

211 APPENDIX

of the substance results in mounting distress and pain. The addict experiences a course of withdrawal pain of increasing intensity with characteristics associated with the particular substance. Thus, the heroin addict begins to feel uneasy, sweaty, and shaky often after 8 to 12 hours of abstinence. By 48 to 72 hours, he or she reaches a peak of withdrawal distress. Nausea, cramps, diarrhea, vomiting, and muscle spasms may accompany the withdrawal experience. During this period, resuming use of heroin will quickly erase the withdrawal pain. How- ever, if the person persists in abstinence, the physical distress begins to dissipate and is over in 7 to 10 days. Unfortunately, exceptions also burden this view of addiction as a use-built, unnatural, physical need. Regular users of marijuana, cocaine, LSD, and amphetamines do not experience a typical course of physical withdrawal pain. Yet, many seem as seriously addicted to these substances as others are to alcohol, heroin, or barbiturates, the clearly “addictive” drugs. Yet another exception would seem to be those activities that have all the earmarks of addiction but do not at all involve a substance and its ingestion in the usual sense. Addictive gambling is an example. In addition, a whole host of sexual behaviors—exhibitionism, voyeurism, pedophilia, masochism, and sadism—show the characteristic addictive compulsion to repeat the act. Finally, to further complicate and obscure the picture, we see frequent reference these days to “positive addictions.” They exert the same repetition compulsion as do the “negative addictions” such as alcoholism. However, the compulsive activities composing the “positive addiction” promote health and secure life in contrast to actions falling under the “negative addictions” label. In this regard, they are like the compulsion to satisfy the natural needs for food and water. The most celebrated positive addiction is running—but other daily compulsive exercise programs, like walking, bicycling, and swimming, also ﬁ t the bill.

The Basic Dynamic of Addiction Let us see if we cannot bring order to this confusion of labels and deﬁ nitions. In so doing, we hope to make clear what it is that the addict faces. Histori- cally, health professionals ﬁ rst applied the terms addict and addiction to the classic abuses of substances like alcohol and morphine. However, a close look at addictive behaviors reveals mechanisms that are similar to those found in a

Downloaded by [New York University] at 02:06 15 August 2016 range of disordered human actions. Let me draw the matter out. Common to all negative addictions is the repetition of some action whether it involves substance abuse or not. The individual acts again and again because that action brings psychological satisfaction. The satisfaction may be physical, but the critical factor is that it is satisfaction experienced by the actor. Thus, I emphasize its psychological, or experiential, aspects. Moreover, the satisfaction experienced, whether in the form of reduction of pain and anxiety or the thrill of a “high,” is immediate. The payoff is now, up front, and is directly produced by the addictive act.

212 APPENDIX

Now consider one ﬁ nal, additional factor. The addictive act always causes another kind of outcome, which, however, is not immediate and up front. Nature often delays and spreads out this outcome over a considerable time and, thus, diffuses rather than makes sharp its impact. This delayed outcome is unpleasant and hurtful to a degree more negative in value than the immediate outcome is positive in value. Consequently, summing the positive immediate payoff and the negative delayed payoff of the addictive act will result in a negative overall (net) outcome. These, then, are the ingredients of an addiction: An act that brings clear, immediate, concentrated advantage and satisfaction but incurs the costs of slowly unfolding, long-term dissatisfaction and harm. Of course, if that immediate gain is really worth the delayed cost, we do not have an addiction. Tobacco users sometimes say, “I know tobacco shortens life by seven years or more. I know it causes lung congestion, circulatory problems, and the like. But I enjoy it so much that it’s worth it. I’d rather have a short, happy life, than a long unhappy one!” This may, of course, be sheer self-deception that is so characteristic of addicts. However, if we grant that this is an honest and accurate self-appraisal, then this particular tobacco user is not addicted. When the immediate gain is not worth the long-term cost but the individual continues the act regardless, then we have addiction. Fundamentally, addicts do not want the life they repeatedly choose. Their own values are such that the immediate gain simply does not justify the long-term costs.

The Nature of the Hook Why, then, does the addict continue to choose this self-defeating behavior? Is it because the withdrawal pains are so severe? No, that is only a small part of what locks the addict in. Remember, only a few forms of addiction rest on substance use that creates withdrawal pain. More basic is another kind of pain that comes with changing and giving up that immediate payoff. Let me explain. If you just begin some habit that brings immediate satisfaction but also entails serious delayed costs, you can easily dismiss these costs. After all, they are not here or now. They are someplace down the line, in the future. Being young and optimistic, you have faith that you can undo those

Downloaded by [New York University] at 02:06 15 August 2016 negative future events if they ever appear at all. “Eat, drink, and be merry, for tomorrow we die!” “Enjoy the moment, for tomorrow never comes!” Familiar old sayings, of course, but what happens if one does not die and tomorrow does come? What happens as one settles into a habitual practice bringing repeatedly those desirable immediate satisfactions? What happens in time as the costs trailing along in the wake of each satisfaction gather in imposing size and intensity? As time goes by, as tomorrow does come in spite of all, what was once one’s present moves gradually into one’s past. What was once a distant future moves

213 APPENDIX

gradually into one’s present. And the delayed cost of those now past actions is coming due. One is beginning to pay in a host of bitter, unpleasant ways. Let us say that you are an alcoholic. After years of robbing your body of nutrients, not only will your health be in jeopardy, but your drinking has probably played hob with interpersonal relations. You have provoked your employer. You may have already lost one or more jobs. You have exhausted the patience and good will of your friends. You have made sullen sufferers of your family. Indeed, the negative payoffs that you experience now from acts of your immediate and more distant past may have assumed dominant proportions. They may be so extensive that the sum of both positive and negative effects in your life tilts decidedly to the negative. You hurt most of the time. And because you are addicted, your future holds promise only of more hurt to come. You may be desperate. Quite likely, as desperation grows, you try to stop your addictive behaviors. Then what happens? Whatever you substitute for your addicted behavior is likely to incur not immediate-payoff/delayed-cost, but, instead, immediate-cost/ delayed-payoff. Consider the costs of stopping. You are stone cold sober. You are trying to mend the fences of your broken relationships. You are striving to pick up neglected study or work. You suffer minutes, hours, and days battling the urge to drink. You struggle to push aside the well-practiced anticipations of the glowing calm, the freedom from worry, which drink so readily brings. You plod along in this effort for what will feel like endless time. It will be a life of relentless postponement, a life that, moment to moment, is gray with effort, frustration, and satisfactions promised but not here. It is the old “nose to the grindstone.” It is a pay-ﬁ rst-to-enjoy-later life. It is the opposite of addiction, which is an enjoy-now-hope-to-avoid-payment-later life. Here, then, is the catch. Your addiction has become the central source of positive outcome and satisfaction. Your life has moved into the season where you now constantly reap the bitter fruit of your past addictive behaviors. As this period develops, you rely all the more on your addiction for comfort. A paradox makes its appearance the more painful and desperate your life becomes. The paradox is that your addiction comes to represent an island of comfort and relief. It becomes that single positive solace to weigh against all

Downloaded by [New York University] at 02:06 15 August 2016 the negatives that constantly wash in against the shores of your life. So, not only do you give up your single, assured source of solace, but also you take on the burdens of going straight. You embrace the effort, accept the worry, and endure the strain. The result is that you are probably going to feel worse, perhaps even much worse, than you did when you were using. And it is so easy to feel better, even if only in relative terms, by falling. People are not going to choose a way that makes them feel worse if they have at hand another choice. That fact accounts for the hook, the vicious circle of addition.

214 APPENDIX

Overcoming Addiction How can you win? How can you, once caught in the circle, hope to break out? The answer is simple enough to state. You must fi nd a way to go straight without experiencing more pain than incurred in the addicted life you wish to leave. The problem is that you must sustain the straight life for a signifi cant length of time. The time must be long enough for the delayed, positive effects of the nose-to-the-grindstone straight life at last to emerge. At that time you will start to reap the benefi ts of your past efforts. The delayed payoff from a sustaining past of sobriety, work, mending fences, and being straight with people begins to show up. That payoff takes the form of new respect, emerging trust, personal acceptance, recognition, and other material rewards. The question is how do you continue being straight until that future comes about? How do you keep going constantly enough and long enough to change your past? How do you endure until the benefi cial effects of that past come to fruition and shift your life’s scales from negative to positive? How do you suffer the loss of your addictive comforts well before anything very good comes your way from being straight? There are three ways. First, hope. You must offset at least part of the pain of the frustration of postponement by fi nding ways to grow hope. The hope looks to a future that will be better and will come. Second, fear. You must cast aside the defenses, rationalizations, and self- deceptions that you have built to protect your addiction and reduce its costs. You will call upon your fear of what will happen if you return to and continue your addictive life. If you are now desperate, consider the hell you will experience as life grows worse while you remain stubbornly addicted. Third, people. Join forces with others who are struggling to be straight. Look at what others have done. It can be done. And invite others who know how it feels to care. Invite them to be with you, to celebrate the moment, the hour, the day, the week, the year.

Addiction: The Generic Disorder Finally, let me make clear something that may already be obvious to you. Addiction, in the sense we have deﬁ ned it here, is actually what most mixed-

Downloaded by [New York University] at 02:06 15 August 2016 up, troubled people suffer. This is true even when their “addictions” may involve no substance or classical physical withdrawal pains. Take people who procrastinate, who put off doing, deciding, and acting to a point where all is near a complete stall. They procrastinate in a compulsive fashion. Procrastination occurs even though they put off important decisions, leave undone critical work, and make angry and frustrated those dependent upon their performance. Procrastination may puzzle you, however, because, while its costs are clear, it may not be clear how it brings immediate satisfaction.

215 APPENDIX

To understand, you must get inside the world of procrastinators. You must sense their serious discomfort with responsibility. You must appreciate the fertile interest the procrastinator develops for poring over some special area of expertise. Endless hours are lavished on a stamp collection, crossword puzzles, high fi delity equipment, civil war history, or just plain, unhampered fantasy. You must understand that when a life challenge rears its head, thorny with uncertainties, procrastinators retreat into the comfort of their preoccupation. How much more safe, manageable, and reassuring is the stamp collection or the daydream than is wrestling with family or work problems! Put it off and enjoy the moment. This is the stuff of addiction— enjoy now, pay later. If governments can make defi cit economies work, why cannot people? The same addictive pattern appears in those who compulsively lie and misrepresent. They gain immediate advantage but at the cost of personal integrity and social trust. Sexual conquest may, for another group, come to have addictive qualities. Lose yourself in the heady adventure of romance or the stalk- ing excitement of erotic conquest. Sweep away the growing pile of mundane demands made by an indulged wife or complacent husband. Banish thoughts of a daughter or son needing braces, wanting a car, and threatening the awful expense of college. We have only touched the surface of the various ways people express addiction. What of the workaholic, the foodaholic, the compulsive stimulus seeker, and the tireless status seeker? If you asked what in a word is common to addictions and to most behavior disorders, that word would be inauthen- ticity. The drug user calls upon illusion, a false state of physical wellbeing. The procrastinator, fantasizer, deluder, philanderer, and workaholic all try to misrepresent their reality both to others and to themselves. They would have you and themselves believe that the solution to life’s challenges is some single, repetitive formula for comfort and satisfaction. In the end, what they suffer most is not withdrawal pains or the direct cost of the addiction as such. It is instead the growing sense of failed authenticity and personal integrity. Recovery means that addicts, fi rst, give up their reliance on illusion no matter how illusion is achieved. However, while this is a necessary fi rst step, it is not the end. The goal lying in the future is an emergence of a sense of one’s self as ready and able to cope directly and honestly with life.

Downloaded by [New York University] at 02:06 15 August 2016 The goal is to live without slavish dependence on drugs or other forms of life- diminishing illusion. The goal is not easy to achieve or quick in coming, but it is reachable, and it is worth the effort.

Concluding Remarks Just how far can one take the assertion that addiction may be basic to most or all human behavior disorders? Does this apply to anxiety states, phobias, and depressive disorders? I happen to believe it does!

216 APPENDIX

In these “disorders of feeling,” what we often fi nd just below the surface is the familiar pattern of compulsive repetition of actions. However, on close inspection, these prove to provide comfort or gain but at mounting long-term costs. Take, for example, the case of a young woman suffering from debilitating panic attacks in public places (called agoraphobia). Was she in any way “addicted” to fear? Well, yes she was! She had learned to “be afraid” to the point of utter helplessness. She compulsively enacted her fear in public places when unaccompanied by one of her “security persons.” What did she gain? She gained the devoted attention and sympathy of her small community of helpers. In this way she arrested and suspended her life in perpetual child-like dependency, never venturing anywhere alone or unprotected. What were her gathering costs? Isolation, a sense of being a fraud, a sense of missed opportunity, and, of course, a bitter feeling of helplessness. What does it mean to you that addiction may actually be the basic nature of all psychological disorder? Actually, the implications are a mix of “bad news” and “good news.” The “good news” is that these problems all revolve around habits. We have learned habits—behaviors, thoughts, and feelings—which give comfort or advantage at a long-range price much too dear. We can, however, learn to behave, think, and feel differently! We can change and grow out of these vicious circles of compulsively self-destructive habits! We do not have to suffer this condition a whole life long! The “bad news” is that it “ain’t easy.” It will take diligence, perseverance, and hope. It will depend on our persisting long enough in non-addictive, straight behavior to alter materially our immediate past, our personal history. In this manner we act to reverse the fl ow of our payoff system. If we have persisted long enough, our past actions will have laid the groundwork for an infl ux now of good and welcomed effects. These benefi ts of a revised past, at last, replace the swelling mountain of psychological debt and interpersonal discredit following in the wake of addictions.

USING HELP WITH FEAR AND ANXIETY

By V. Edwin Bixenstine, Ph.D. Downloaded by [New York University] at 02:06 15 August 2016 Prepared for clients and subscribers. Not for copy or redistribution without the express permission of the author.

Preface This brief work is designed to help persons think about their difﬁ culties with anxiety and fear as they approach seeking help from a psychologist. It is our belief, supported by research, that some degree of information and orientation

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regarding these emotional problems and the helping process will facilitate that process For maximum preparation, you are advised to also read the pamphlet entitled Using Counseling and Psychotherapy, which addresses the general nature of the helping process.

The Use and Misuse of Anxiety and Fear If you have experienced anxiety and fear, you are not alone. These states, while unpleasant, are commonplace and understandable. True, most persons lead lives in which they avoid very intense experiences of anxiety or fear on a daily basis. Of course, a modest amount of worrisome anticipation is an everyday event for most. When does anxiety and fear cross the line from commonplace to extraordinary? Why are you unwilling to tolerate your anxious, fearful feelings as a normal part of your life? The answer has to do usually with both the intensity of your feeling and its appropriateness. Up to a certain point, increasing anxiety and fear help promote alertness, attention, coordination, and effort. That is, these rather unpleasant feelings deﬁ nitely contribute to our getting things done, indeed, often to our best performance and accomplishment! However, when these emotions become very intense, they begin to have an opposite effect the more intense they become. That is, they begin to interfere with and detract from our best performance, particularly as that depends upon ﬁ ne muscle coordination and concentrated attention. As anxiety grows extreme, we begin to be alert to the point that irrelevant cues or events capture our attention, at least momentarily, causing a reduction in concentration. We become so keyed up that we cannot relax our muscles enough to execute coordinated actions. At the extreme, our efforts to cope may completely give way to a state of panic and hypertension. Such intense states of anxiety and fear have been observed in persons experiencing extraordinary stress, such as being shipwrecked or subjected to the outrages of war. Of course, to feel intense anxiety and fear in response to intense stress is understandable. If anything, what is remarkable about the human response is how capably we cope with extraordinary stress. There are enumerable accounts of persons contending with the terrible pressures of war with anxiety and fear held in check by a sense of courage and inner strength. We can make two

Downloaded by [New York University] at 02:06 15 August 2016 points about the combat exhaustion or panic break, which extraordinary stress sometimes causes. First, in a sense, these reactions are normal to those abnormal circumstances. Second, usually they are successfully resolved or treated by removal of the immediate stress and by rest. If you are troubled by anxiety and fear, however, in all likelihood it is a different matter than that just discussed. It is probably not clearly or at all directly related to intense stress. It is inappropriate, in that sense, to your life circumstances. You are anxious and fearful, but the threat or stress that you perceive in your life does not seem fully adequate to explain your feeling.

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Anxiety Distinguished From Fear We have treated anxiety and fear as if they were identical and as if felt along a single dimension. Such is not the case. Anxiety is a general, internal state of apprehension in which you as a person are under threat. Perhaps, some value central to your identity is under attack, so anxiety is experienced as an attack on your very worth. For example, it may be important to you that you be viewed as a respected and well-regarded member of your circle. But you may have a recurrent and very unsettling impression that your friends laugh at you, ridicule you. Or maybe a core value is your attractiveness and sex appeal. Yet, you are troubled that your lover may ﬁ nd another more attractive. The ingredients of anxiety are many, but all represent a threat from within, from the elements that make up your person. Consequently, anxiety may occur at any time and under any circumstance. Also, it is something that resists what some call a “geographic cure.” That is, you cannot easily run away from it. Anxiety becomes particularly disabling when it is not at all clear what constitutes the threat. Consider, for example, wanting to be respected by a certain group, but knowing that you have not performed up to that group’s norms. Your anxiety revolves around the question of whether you are good enough, can perform well enough, to earn the group’s respect. It may be quite painful but is resolvable by either improving your performance or seeking acceptance from some other group. Contrast having no such clear sense of wanting anyone’s respect or giving no conscious attention to the question of the goodness of your performance; yet, you are vulnerable from time to time, to a heavy, aching sense of being excluded, without respect, lacking in worth. The latter state of nameless, formless anxiety has been judged to be the most painful of all because, not only is one under threat, but that threat is from an unknown, nameless, mysterious source. We are less distressed if we know, at least, from what issues our threat. That knowledge places our experience in perspective and suggests the outlines of a possible solution. However, suddenly to feel threatened without knowledge of source, nature, and possible duration, is to experience the darkest, most terrifying of all fears—the fear of the unknown. Some believe that such nameless, formless anxiety brings about primitive images, which have been imprinted into our nervous systems over ages of human evolution. These are the images of those crawling, venomous, danger- Downloaded by [New York University] at 02:06 15 August 2016 ous creatures that lurked in the dark of the cave or under the cover of night. Those of our ancestors who lacked these innate fears of dark-mantled, lurking animals of prey did not survive the dark of the cave and of the night. Fear of the dark and the unknown was important to our human survival. However, it ﬁ lls our mind’s eye with furtive, stealthy, terrifying shadows, which often amplify our modern anxieties to the point of panic. These considerations bring us to fear as a state in contrast to anxiety. If anxiety is a response to an internal threat to one’s self, fear is a response to the

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external threat to one’s safety. Those primitive images that we noted earlier may be set off by anxiety, particularly nameless anxiety. However, they refer back to some external danger to our physical safety. It is for this reason that we tend to link anxiety and fear. Anxiety heightens our sense of physical vulnerability, our fears. On the other hand, fear sometimes spills over into an anxiety state. How? When a strong fear prompts us to act to protect our physical wellbeing but in a manner that confl icts with our basic values, we may fi nd emerging from the fear a new state of anxiety. For example, a soldier in fear drops his gun and runs away. He may, then, begin to suffer anxiety about the threat he feels to his image as a man of courage, or one who does not desert his comrades. His anxiety may become so intense that he feels compelled to return to the battle, rearm himself, and expose himself to the terrible threat of injury or death. As the battle grows in ferocity, one’s fears understandably escalate. The temptation to run, which grows with one’s fears, introduces a basic threat to one’s manhood and loyalty to comrades. Those friends may die if one leaves his post and exposes them to the enemy. Fear and anxiety cascade in waves against one another. War is hell. Yet we may fi nd ourselves caught in just such dilemmas far from scenes of battle.

Phobias Again, fears that rest on obvious physical danger are unremarkable. We would probably be suspicious of someone who seems untroubled by imminent physical harm. Fears draw attention when they occur more frequently and intensely than seems appropriate to the danger. Phobia is the term we apply to such “unreasonable” fear. Many phobias are expressed in those primitive images that we have already noted. For example, we tend to develop phobias about dark, watery, enclosed, exposed, and high places more frequently than lighted, dry, roomy, protected, or level places. This is true even though we may never have been harmed near the ﬁ rst set of places and have been injured near the second. We also tend to develop fears of snakes, crawling insects, and other animals even though we may have little or no experience with many such creatures, particularly those of a harmful nature. By contrast, we rarely develop phobias in response to automobiles, high-level noise, intense sunlight, electrical appli- Downloaded by [New York University] at 02:06 15 August 2016 ances, and a host of other frequently lethal features of life. How ironic that we have relatively little fear for aspects of our lives that do us far more injury and harm than do small crawly creatures. We can thank our evolutionary history for this! These facts make it difﬁ cult to understand phobias as a simple result of fear conditioning or learning. Many experts have placed great emphasis on conditioning. They have suggested that phobias result from some early, usually very dramatic injury experience, which often conditions or teaches the phobic

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person to fear an otherwise innocent event. The fear is so strongly conditioned that it fails to fade away even when that event has repeatedly recurred unaccompanied by injury. For example, my dog had his feeding dish in a nook near our white kitchen stove. At one point, the spring to the oven door broke causing the door to fall at the least touch with a startling loud noise and ﬂ oor-shaking energy. Before it was ﬁ xed, the door happened to fall at least three times on different days, but in fairly close succession, as Pete, our dog, was feeding. Once the door brushed his tail, which, at the same time, was sore and sensitive. Shortly after these experiences, Pete began to show great fear of the stove, but also, of two other white appliances in the kitchen. His fearful and careful skirting of these items remained essentially unabated for several years after the door-falling experience even though no further such event occurred or injury was sustained. His fear subsided somewhat with time, but he remained cau- tious and alert in the presence of the white stove, white refrigerator, and white freezer. Here is a classic case of fairly lasting fear conditioned to an innocent feature—white, boxy objects.

Conditioning or Displacement Some human phobias seem to follow such classic form as that illustrated in Pete’s case above. A man told of his extreme aversion to and feeling of nausea at the sight or sound of a cat. This phobic reaction had been with him unchanged for 30 years since childhood friends threw a terriﬁ ed cat on his bare back while he was looking in another direction. The cat spread its claws to catch itself and caused him a startling and very painful injury, which remained a vivid memory from that moment on. One wonders whether this man would have similarly sustained a phobic fear had the same injury been done by, say, a thrown pair of sharp pliers. Quite likely, the primitive fear of small, furry creatures helps explain the intensity and longevity of this particular fear. Most phobias, however, do not have a clear injury episode, which explains, through fear conditioning, the persisting fear. Another man complained of a fear of small, closed places, especially elevators, and was forced to climb many ﬂ ights of stairs to placate his fear. This man searched his childhood memories for any experiences in which some kind of injury was associated with being

Downloaded by [New York University] at 02:06 15 August 2016 in a close, enclosed space. He could recall nothing. No, he had never been punished by being placed in a closet. He had never been locked in a small shed or other enclosure. He had never been caught in an abandoned refrigerator, a deep hole in the ground, or any other experience we hear about that might explain his fear. Was his fear, then, entirely whimsical and without rhyme or reason? It would seem not. He had experienced his fear for the ﬁ rst time shortly after his father died. He remembered looking at his father’s body, watching the casket lid being closed, and the casket lowered into the grave. He had felt nothing at the

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time except, perhaps, a kind of relief. At age 18, he was at last free to live his own life. For a period, he sowed a variety of wild oats, such as barhopping and sexual adventuring, which his father’s living presence had previously inhibited. At some point in this period, his phobia grew. Now, at age 28, married and attempting to lead a responsible, adult life, his phobia continued strong. A clue to the nature and meaning of his phobia at last emerged. He noted that, in an elevator, he would sometimes have a vision of a casket and the sense of his father’s presence. Finally, the issue became lucid. Because of his mother’s early death, his father had raised him with rough but loving care. His bold actions soon after his father’s death and more subtle behaviors since had left him feeling disloyal to his father’s memory. However, he fought off this feeling and his anxiety, denying them in various ways. No sooner had he achieved success in being indifferent to his feelings than he began to have fear of closed places. Anxiety had been pushed off only to be transformed into fear. It was a primitive fear of being trapped in a dark, casket-like box where his father’s uneasy spirit, no doubt, waited to deal with him. This case may sound dramatic, but it actually illustrates the most common basis of phobias. That basis is not a simple fear conditioning. It is, rather, the displacement of anxiety. From its origins in a conﬂ ict of values, anxiety is displaced to one of those primitive images so ready to haunt us with the fear of physical harm. Below the surface of the usual phobia with its uncomplicated fear for physical safety is the more complex anxiety experience. The basic threat resides, however, not in an external danger. Instead, it rests in the inner contradictions of those core values or loyalties that are central to the person’s very identity. Fear is the emotional signature of threat to one’s safety, one’s physical life. Anxiety is the emotional signature of threat to one’s being, one’s existence, and one’s psychological life. In phobias, anxiety is misidentiﬁ ed and expressed in the “language” of fear.

Other Ways of Coping With Anxiety Phobias, then, appear to derive their staying power from the fact that they express but also circumscribe and delimit an underlying, unresolved anxiety state. There are other ways we have of expressing and limiting the pain of

Downloaded by [New York University] at 02:06 15 August 2016 anxiety. Before addressing these, however, I should say a word about guilt. Guilt is a subclass of anxiety. We may be anxious about an impending or potential conﬂ ict between a tempting choice of action and basic values. When we are anxious about choices already made and acts already committed, which are in conﬂ ict with core values, we speak of guilt. The sense of mystifying guilt and shame, a formless mood of self-despairing depression, is a variation of nameless anxiety. The effort to deny and annul anxiety and guilt may, as we noted above, generate responses other than phobic fear. One response is what we call obsession,

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which is a close cousin to another that we call compulsion. The obsession represents an effort to control our thinking and our attention so the anxiety is cir- cumscribed and tied off. Maybe we concentrate on a single, simple, dangerous thought—the danger of infections from germs (more primitive fear of creepy, crawly things). The result is that we become subject to recurrent thoughts about possible bacterial infection of our food, air, clothing, and so on. This can graduate into a compulsion if we begin to ﬁ nd it necessary to wash and rewash our clothing, ﬁ lter our air, boil our water, and so forth. Also, sometimes our thoughts settle into a preoccupation with our health or, more correctly, ill health. This form of obsessional thinking may develop into a hypochondriasis, which is a conviction of illness and of the need for medical treatment.

Positive Value of Negative Emotions It is understandable that we might wish to annul pain, fear, anxiety, and guilt and might view these unpleasant states as enemies of a happy and fulfi lled life. History is replete with search for anesthetic and tranquilizer. Opiates and alcohol are age-old prescriptions in the war against negative emotions. In very recent time, we have become extremely versatile and successful in fi nding effective tranquilization via prescriptive drugs. We have become so heavily dependent on Valium, for example, that the medical profession has become alarmed. Indeed, it is unfortunate that experts have so often seemed to join in denun- ciation of these distressful emotions. “Unrealistic fears,” “groundless guilts,” “needless anxiety” are terms in some quarters synonymous with a defi nition of the problem. We are beginning to doubt, however, that these emotions are deserving of such contempt. We now question whether fi nding ways to annul them, to tranquilize ourselves from their bite, is a part of the solution or a part of the problem itself. Without pain, we lack a measure of those injurious events that may maim or destroy us. Without fear, we lack a sense of emotional forewarning of what may give us pain. Without anxiety, we lack a sense of any discrepancy between our lesser selves and our higher selves and any impetus to grow. Without guilt, we lack any sense of error or desire to correct our course. If only we could invent a substitute for nature’s way of helping us avoid physical folly and

Downloaded by [New York University] at 02:06 15 August 2016 psychic dissolution that would not give us emotional pain or distress us! We have not. Alcohol, opium, and Valium merely dull the sensibilities nature has provided. They become a part of our folly rather than a solution for it.

Conclusion Fear and anxiety are not the enemies, just as fever is not the culprit in illness. Fever is a sign that something is wrong, that the body is struggling to adjust to a serious assault. Likewise, fear and anxiety are signs that something is wrong

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in one’s life. One is aroused in a struggle to accommodate to some signiﬁ cant threat or inner discrepancy. We do well to attend to, measure, and give due regard to a fever to help us understand an illness. Similarly, we should heed and pay attention to our fear and anxiety to understand the nature of our life issues. In our work to help people troubled by fear and anxiety, we will foster an attitude of receptivity to the lessons to be learned from our emotions. Rarely will we advise dismissing these emotions as uninstructive and “groundless.” Do not assume that this is a preparation for a philosophy of “living with fear.” We do not believe one must “adjust” to a phobia or accept one’s obsessions. It is, after all, the ostrich with head in sand that is trying to bargain with fear through denial and self-delusion. The ostrich prefers this action to looking up, confronting danger, and taking appropriate action to deal realistically with that danger and, thereby, bring an end to fear. Fear and anxiety tell us something about ourselves and our reality. They represent that mode through which our lives and circumstances ask something of us. We are not likely to lay fear and anxiety to rest while insisting that our lives remain unchanged. Persons suffering chronic fear and anxiety are, like the ostrich, insisting that the world accommodate them, that they not be bothered by the realities of their life. They want their fears to go away and leave them unchanged. This is a failed strategy. The preferred strategy is to ask what it is one must do, what choices make, to confront and cope with the real dangers, contradictions, and issues of one’s life.

USING COUNSELING AND PSYCHOTHERAPY

By V. Edwin Bixenstine, Ph.D.

Prepared for clients and subscribers. Not for copy or redistribution without the express permission of the author.

Preface I have designed this brief work to accomplish several ends. First, while people

Downloaded by [New York University] at 02:06 15 August 2016 are unique and often seek quite different goals in asking for counseling or psychotherapy, they also share common concerns. These emerge as questions about the person of the therapist and the process of therapy. Nothing prevents us from trying to anticipate and to answer some of these questions. Presenting your thoughts in this pamphlet permits you to review them at your leisure and at a savings of time and money. Research has found that people given pre-therapy information, such as this, proﬁ t more from their subsequent contact with the psychotherapist. This being the case, it would be foolish not to capitalize on this ﬁ nding.

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Finally, the pamphlet provides yet another “window” of contact with something that may be new and a bit strange to you. In the interest of your sense of conﬁ dence about the matter, you cannot have too much information. We have prepared other brief works designed to accompany this pamphlet where it is appropriate to do so. These works address questions about particular kinds of issues in which you may have interest. Consequently, you may want to obtain Using Help With Parenting Problems, Using Help With Fear and Anxiety, Using Help With Marital Problems, Using Help With Depression, Using Help With Worry, or Using Help With Addiction.1

Is Something Shamefully Wrong? Let us begin by addressing the most common misgivings that people have, and you may also have, about seeing a psychotherapist. Doesn’t it inevitably mean that there is something wrong, shamefully wrong, with you? Isn’t there something you lack that everyone else—every normal person—has? We don’t want to offer any blanket or automatic assurance, ﬁ rst, that such feelings are entirely groundless. On the contrary, it is nearly always true that there is something wrong, something amiss in your life, something you want to change, or you would not have contacted us. However, it is certainly not appropriate to believe that all those persons not seeking a psychotherapist are problem-free and happy. Research shows that for every person who contacts a psychotherapist, anywhere from 20 to 100 individuals having similar or even more serious personal problems do not. They either do not recognize or do not wish to acknowledge and address those problems by contacting a mental health professional. In this light, you may not be different from many others because something is troubling you while they are trouble free. Instead, you are different because you have seen and acknowledged your troubles and are trying to do something about them. True, you may indeed have your failings. However, admitting that fact and trying to do something corrective about it is itself a sign of personal strength. This fact has caused some observers to point out a paradox. Psychotherapy, they note, often treats those who need it less than the many who fail to make use of the service!

Downloaded by [New York University] at 02:06 15 August 2016 The Powers of the Therapist Let us look at another frequent question people have as they start psychotherapy. Do not psychotherapists have some pretty mystifying powers? For example, aren’t they able to see into one and to gain knowledge that the person himself or herself cannot know? And don’t they use these powers, then, to bring about the solution or cure that the person, of course, is seeking? The answer to these questions is neither a ﬁ rm yes nor no. The powers of observation that the psychotherapist has are really no different from those you

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have or, actually, that anyone may exercise. Of course, two matters are true: First, the psychotherapist makes it his or her business constantly to practice observational skills. It is analogous to the blind person’s special use of hearing, which is really no better than sighted people’s hearing. The constant practice and use, however, trains the blind person to attend to subtle signals, which are there for all hearing people. Second, any impartial, third party can often see what we have become blind to. It’s a little like persons who apply cologne no longer smell it after a while, and then apply more. Someone who comes anew into their presence immediately knows that they have on too much perfume. It may seem that the new- comer has special olfactory powers. Not so. Instead, the sense of smell of the cologne wearer has grown dull through habituation. We all become habituated to ourselves and to our own behavior. Thus, we often fail to attend to cause–effect relations between our behavior and its results, which are obvious to another. If our friends or acquaintances don’t tell us about this, it may be to avoid hurting us or creating ill will. Or it may be because, being around us so much, they too have habituated to our usual ways of acting. Like us, they just don’t “see it.” A psychotherapist should be skilled at observing and communicating his or her perceptions, as time goes by, clearly and helpfully to you. However, does this produce the desired cure, the hoped-for solution of the issues that bring one to the therapist? Such an idea was once the design, in large part, of so- called psychoanalytic psychotherapy. Unfortunately, perhaps (depending on your frame of reference) that view of the therapist’s powers was overdrawn. This is true for two reasons. First, there is an additional cause, beyond simple habituation to one’s self, not to see one’s self as does an impartial third party. That is, we simply do not want to! We are strongly motivated actively to oppose seeing ourselves as others see us. So, we meet any suggestion that contradicts our self perception with a wide variety of refutations. These may range from outrage to hurt, from bland denial to skilled demonstration of incompetence or bias in the other person. Second, let us say that the therapist with much skill works through this active resistance. The result is that the person does now see himself or herself clearly and realistically. Is this the end? Have we brought about a “cure,” a solution? Not at all. Knowing one’s self may be necessary, but it is not all there

Downloaded by [New York University] at 02:06 15 August 2016 is. One can know that he is a drug addict, for example, and yet continue to rely on drugs. A person can see that she is a procrastinator, yet continue to put off and delay action. There is no magic. The psychotherapist can help you see yourself, help you struggle through to a new knowledge about yourself. However, in a very real sense, at that point you have just begun. At that point the challenge is to do something, to put your new self-knowledge to work to change your life. And that action, that initiative is not the therapist’s or any other third party’s—it is yours. It comes to this: Only you can act for you.

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Interminable Therapy You may be thinking now that this sounds like a very difﬁ cult and lengthy undertaking. Don’t we hear of psychoanalytic psychotherapy lasting years and years and costing thousands of dollars? You may ask, am I faced with such a prospect? I can well understand your apprehension on this score, but again the answer is not found in a simple yes or no. On the one hand, you can think along the following line. You have spent your life becoming whoever you are. You have been a long time learning to act in whatever ways you do, including ways you may want very much to change. It’s not too unreasonable to suspect that, while you may make certain changes rapidly, other changes will take some time. In a general sense, you will take the rest of your life arriving at the person that you become hopefully in keeping with your basic values. On the other hand, that fact does not mean that you should expect an interminable therapy process. Yes, you may take the rest of your life becoming what you want to be and developing a different way of living. However, while we hope to see that process begun in psychotherapy, it does not remain contained there. Psychotherapy itself should not become your way of life. Where that happens, and it does happen, psychotherapy is no longer a part of the solution, it is part of the problem! I can assure you that the process is not endless, but can I say just how long it will be? Here is a question that permits a simple answer. No. No, there are too many variables to make a sure prediction of length. How deep is the problem? How difﬁ cult is it for you to see and accept it? How resistive to changing your ways will you be? What will be involved? That is, will it involve your relationships with others? Your beliefs and perceptions? Your self-concept? Will it involve factors in the web of your daily living that call forth and even reward your problem behaviors? Or will it consist of some combination of these? You can see that the bases for prediction have too many variables.

A Psychotherapy Clock We cannot make a ﬁ rm prediction about time. However, we can identify some “road signs.” These help tell where we are and how far, in a stepwise sense, we

Downloaded by [New York University] at 02:06 15 August 2016 are from the end of the process. There are 10 sequential stages in psychotherapy. Some of these stages can be quite short in duration. Others may be long though not necessarily so. Let me name them and then comment on them.

First is the Exploration stage. Second, the Understanding/Acceptance stage. Third, the Bonding stage. Fourth, the Revealing stage. Fifth, the stage of Confrontation.

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Sixth, the stage of Resistance. Seventh, the stage of Reconciliation and Initiative. Eighth, the stage of Effort and Hope. Ninth, the Consolidation stage. Tenth, the stage of Termination and Commencement.

I suspect that you have already guessed correctly about the nature of certain of these stages just by name alone. Others may be puzzling. Let us take a closer look. The fi rst stage, Exploration, is where the therapist gets his or her fi rst idea of what you are looking for. It is also where you get your fi rst idea of what the therapist is looking for. This stage can be fairly rapid, and this pamphlet may enable a somewhat accelerated passage through it. The second stage, Understanding/Acceptance, emerges as the therapist begins to grasp how you view matters and how you feel. Then, the therapist lets you know that he or she understands how you are thinking and feeling in clear, nonjudgmental, and empathic terms. You are likely to feel pretty good about your therapist for doing this because we all like to be understood and accepted. That helps produce the third stage, Bonding. We must note that bonding is mutual as it happens to both parties—you and your therapist. What is taking place is the forming of a human relationship. It is not unique to psychotherapy. It happens with your physician or dentist or lawyer and, of course, is obvious with family and friends. You begin to have a sense of trust and reliance in the other person, the therapist. And he or she begins to have a sense of identity with and investment in you. Your therapist may be fairly cool and objective. However, he or she is far from indifferent to you and to your fortunes as that bond with you grows. I do not believe a therapist can bond to you as can a friend or relative. Still, that human connection, which you both share, is vital to your progress and to his or her effectiveness. If the two of you cannot bond, then progress will not occur, and we may have to seek another arrangement. Sometimes one’s central problem is simply trusting another, developing a feeling of being “connected” with another human being. In that case, there may be a slow movement through the bonding stage. However, once it occurs, a relatively rapid movement may follow through the remaining stages. Usually,

Downloaded by [New York University] at 02:06 15 August 2016 however, the bonding stage is fairly brief in duration and may be well underway in the ﬁ rst contact with the therapist. Having bonded and extended trust, one passes to the Revealing stage. That is, one begins to disclose even more sensitive matters about one’s life than in the beginning. This enables the therapist to evolve a more and more accurate perception of you and your issues. This perception he or she begins to share through a series of comments and observations. These therapist observations usher in the ﬁ fth stage of Confrontation. Usually you feel very divided about your disclosures. You both want to get

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everything out in the open, but you may also want to hold back or disguise matters. If the therapist is uncertain and fails to see what you are revealing, a part of you would feel safe, even pleased. However, another part of you would feel disappointed and apprehensive. You would like it if the therapist were to tell you that everything is OK. Yet, if in your heart you know everything is not OK, the therapist’s saying that would also leave you uneasy. You do not want this person whom you count on for help to be confused. With mixed feelings you reveal yourself, permitting the therapist to see you more and more clearly. Thus you ﬁ nd the growing clarity and accuracy of the therapist’s perceptions both desirable and, yet, a form of confrontation and challenge. That brings stage six, Resistance, and brings us to something that may sound strange. The more reliance you feel in the therapist’s capacities and competence, the more likely you will experience and show resistance Why would this be? Why would you resist hearing or accepting what your therapist is telling you? It is like feelings we have had as children when a teacher or parent opposed us or insisted on something from us. Even though we knew they were right, we would do our utmost to shake them, change them, and get them to back away. We seemed to be testing and challenging them to prevail and prove to us what had to be really had to be! Reality testing is what some have called this kind of behavior. Obviously, stage six can be rather eventful! It can also be a difﬁ cult one to pass through. It depends on how strongly attached one is to the beliefs or actions and habits which emerge as necessary to change. Resistance revolves around an inescapable fact. Even though we may see what about us needs changing, that matter remains an aspect of our lives. It is a piece of what we have been, what we are, a feature of our identity. One does not easily change his or her life and identity. This is true even when changing only a part, and even when the cost of holding onto that part is quite high. Considering all, one does not want to defeat his or her therapist in spite of resistance shown and felt. So as the resistance itself is understood, the next or seventh stage, Reconciliation and Initiative, emerges. One begins to see that one cannot defend or save old ways and becomes reconciled to the necessity for change. One begins to construct in life and in one’s self new, tentative

Downloaded by [New York University] at 02:06 15 August 2016 possibilities. When this gets underway, there is a shift of energy from effort by the therapist to effort by you, the client. The result is stage eight, which we call Effort and Hope. We can all recall learning something entirely novel and different, something for which our past habits have not well prepared us. In my experience, learning to type was such an experience. I had never tried to produce words by striking keys with the ﬁ ngers of both hands. It was frustrating, slow, and, initially, sheer labor. I would never have begun it or kept it up but for one consideration. Once past the effort stage, I knew I would be able to produce

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written papers much more quickly and legibly than before. It was that hope, that faith in the potential, which made the effort, and its attendant frustrations, tolerable. When you see some positive return for your effort, the ninth stage of Consoli- dation is at hand. You have sustained effort long enough to bring about a new skill, a new habit, a new way of seeing and behaving. When this stage arrives, we will want to begin to think about how to maintain and consolidate your gains. If you have not participated in a group before this point, it is here where joining with others is a worthwhile consideration. Stage ten, Termination and Commencement, represents that point when you and your therapist have concluded that the therapy has run its course. You are now ready to terminate therapy and to commence life in a new key. This may be a nostalgic moment, but one you will have little problem recognizing. These 10 stages are like moments on a 10-houred clock. We can tell time approximately in this manner. However, time-telling is not exact. The passage through each hour, or stage, may be at different rates for each person.

Concluding Remarks I am not sure that we have exhausted the topics that we might have included in this pamphlet. In addition, the topics we have covered we have touched but lightly. Books have been written about managing resistance, for example. Obviously, we could have said much more about the sequence and the whole process of psychotherapy. However, I do not believe it necessary for one to become expert in psychotherapeutic procedures to make use of them. On the other hand, some sense of the process enables one to proﬁ t more from psychotherapy than no information at all. I should not leave you with the impression that the “psychotherapy clock” is a timepiece which all helpers would adopt. It is, however, something about which most would agree. It does provide you with a useful reference for the measure of your progress. Look upon it as a convenient guide, not an absolute or invariable format. How does psychotherapy differ from other experiences you may have? After all, people grow and change throughout the course of their lives. Change, then, is not unusual. It is the norm. Also, people change constantly as a

Downloaded by [New York University] at 02:06 15 August 2016 function of other people. Teachers, parents, friends, employers—the list is endless—all work change in us. Finally, we do judge ourselves, make resolu- tions based on self-judgment, and change ourselves accordingly. What, then, is distinctive about change through psychotherapy? Clearly, the distinction is not change as such, change prompted by another, or change advanced by ourselves. Psychotherapy is a process designed to help bring change when that change is both appealing and repelling. When you wish to change and grow but ﬁ nd yourself a major stumbling block, then psychotherapy is a valuable path to explore.

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It is a process designed to help people ﬁ nd what it is they are asking of themselves. It examines how it is that they do not clearly hear their own requests. Finally, it explores what it is they can do to emerge from this state of ambivalence. Psychotherapy is not so much a force in itself for change. Instead, it is a way to release the frustrated power for change and growth that are yours and yours alone.

Note 1. This pamphlet mentions only the “Using Help” pamphlets designed to be made available before or at the beginning of therapy contacts. Four other pamphlets constituted our stable but were designed to be given to clients if and when they appeared to be appropriate. One of these, Disclosing Secrets, appears later in this Appendix. Others were: The Challenge of Parenting, A Program for Parenting, and A Primer On Stress.

USING HELP WITH DEPRESSION

By V. Edwin Bixenstine, Ph.D.

Prepared for clients and subscribers. Not for copy or redistribution without the express permission of the author.

Preface This brief work is designed to assist persons in thinking about their problems with mood and depression as they approach seeking help from a psychologist. Research indicates that some degree of information and orientation regarding mood problems and the helping process will facilitate that process. For maximum preparation, you are advised to also read the pamphlet entitled Using Counseling and Psychotherapy, which addresses the general nature of the helping process.

The “Common Cold” of Psychological Disorders Downloaded by [New York University] at 02:06 15 August 2016 Are you “blue”? Down in the dumps? Moody and depressed? Almost everyone is at some point or other. If you are, you are joining a company of some 30 million or more fellow Americans. All depression is not alike, even though many features are common: a heavy, somber, unhappy mood; a negative, critical, pessimistic view of one’s circumstances, one’s future, and one’s very self; a lack of zest and appetite, an apparent resonance to the negative or black but an oblivion to the positive and upbeat.

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The seriously depressed person has a sense of being alone and uniquely victimized by despair. Yet, in spite of this sense, one expert has observed that depression is the “common cold” of psychological disorders. Indeed, one is not likely to pass through life escaping those matters that characteristically precipitate depression or its twin, mourning. All of us lose that which we prize, sometimes prize above all else. We lose our innocence and childlike faith as we mature. Later, we lose our youth, often our strength or health. Also, with age, we often lose the uplifting vision of what we might become or accomplish as uncompromising time passes on. And, of course, as time winds its way, we all lose loved ones to growing indifference, to the passionless cold of age, or to death. So it is that depression is a frequent form of suffering to which we are all subject.

Mourning Mourning is a term reserved by us to denote a form of normal, expected, or unremarkable depression. The wake is an institution of mourning in which black depression is invited to be expressed without restraint. Many feel that our society lacks institutions of mourning in which loss or grief may be fully felt, expressed, and acknowledged as a normal feature of life. For example, divorce has become a common form of serious loss to persons whose circumstances, age, and vitality might otherwise suggest considerable optimism is in order. Perhaps because depression is so contrary to that picture, family and friends often discourage divorcees from expressing grief. “Good riddance!” “You should be happy you’ve ﬁ nally ended your misery.” “Put it behind you. You’re young. Now, you’ll have a chance to meet the right person for you.” Such ill-advised efforts to foreshorten a normal grief or mourning reaction can mean that people never fully “work through” their sense of loss. They do not emerge from the aftermath of their loss reconciled with their new state, with life as it is rather than as it was or as they wish it were. Another prime example of our society’s failure to provide appropriate mourning rituals is the loss of a job. Even though many are willing to recognize that a person’s work may be a central part of his or her identity, a key resource of relevance and meaning, there is a strong tendency to discourage

Downloaded by [New York University] at 02:06 15 August 2016 the job loser from grieving. “Buck up,” we say. “You can’t let it get you down. You’ve got to ﬁ nd some other employment. If you let it get you down, who will hire you?” Mourning is the price we pay for loving and for investing ourselves in life, in causes, people, and goals. If we were to hold back from these emotional investments, then we would be fairly safe from mourning and depression. That is why, paradoxically, depression is always a sign of life and vitality. It has long been remarked that the prognosis, the recovery potential, for the depressed person is much better than that for many other kinds of psychological

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problems. Depression is an inverted measure of a person’s readiness to invest in life and, thus, risk the inevitable losses that attend life. Consequently, in most instances mourning or depression runs a recognized course. The initial reaction to loss is usually denial, and then anger followed by depression, which has been likened to self-anger. Finally, there emerges a phase of accommodation and reconciliation to life. Loss events require that this course wind its way rather than be squelched and ignored.

Clinical Depression But what if one seems to have recurrent depression, perhaps on the anniver- sary of some loss event? Or what if depression seems to linger much longer than is normal for mourning? Or what if we grow depressed without any very clear loss event having occurred? There are two broad explanatory concepts, not of necessity mutually exclusive, which we may consider. First, some persons as a function of their constitutional make-up are subject to emotional swings. They sometimes go from a high of energy and optimism to a low of initiative and a deep pessimism, and back again. Evidence for this lies in a tendency for depression to run in families. Also, we have found that depression is associated with a depletion of certain brain transmitter chemicals. It is not clear whether the depletion produces depression, or depression (or, more exactly, the stress of loss) produces the chemical depletion. However, certain drugs, which are now available, work fairly well to restore this depletion, and many persons have learned to turn to direct medical assistance when depressed. Medical intervention is indicated when one has become so chemically unbalanced by prolonged depression that certain signs are at hand. One no longer sleeps, or sleeps ﬁ tfully and only for short periods. Also, one has very little appetite or, for that matter, very little energy simply for addressing life’s necessities. However, reliance on drug treatment alone may mean one over- looks important matters productive of depression residing in the warp and weave of one’s daily life. This consideration leads us to the second broad explanatory concept, which, as I noted, does not contradict nor is contradicted by the ﬁ rst already examined. The second concept proposes that depression acts, as we say, instru-

Downloaded by [New York University] at 02:06 15 August 2016 mentally or functionally in our lives. It serves a purpose. What conceivable “purpose,” what possible gain would ﬂ ow from one’s suffering the agonies of prolonged or recurrent depression? Think a moment. There are circumstances under which we are prepared to experience pain or emotional distress. Doing so helps us avoid something even more painful or helps us realize something very desirable which we would not otherwise have to enjoy. Soldiers have shot themselves, painful as that may be, to avoid the necessity of battle. Children often cry copious tears of distress and grief to avoid imminent punishment.

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Consider this case if you will: What if a person is caught in a conﬂ ict of values, of divided loyalties. Let us say that this person is living with someone outside of marriage, which is against his religious and family convictions. He does not want to give up this life with the loved one. However, as time goes on, he feels a cumulative sense of guilt and wrong because he does not want to be cut off from his religious or familial anchorage. Recurrent depression of a limited if severe nature might be an understandable trade-off. He expiates. He suffers. He pays emotionally for his forbidden fruits. However, he is thereby freed to incur yet another round of emotional indebtedness by continuing to enjoy those same fruits. Such an arrangement might be very resistive to any prospects of permanent solution. Resolution means that he chooses either to alter his religious and family loyalties or to come into conformity with them. In conforming, he would bring to a close those ways of behaving that are contrary to his loyalties such as leaving his lover (or marrying her if possible). He resists doing either of these, so depression is the price of having his cake and eating it too. He may well prefer to pay that price than to choose. At base, depressed persons, who appear so lifeless and prostrate, always express temper. They are making, through depression, a kind of demand and a judgment on their life, its circumstances, and on themselves. They are saying, in effect, that life has not measured up, has fallen short. And that judgment also goes for themselves—they have proven less worthy than they had hoped to be. They are demanding that life, circumstances, and their own makeup conform to their hopes and expectations. Thus, as a mode of coping, depression may have two purposes or functions. The ﬁ rst is to pay for some gain or value that we feel is wrong to have but we are loath to forgo. The second is to preserve the right to demand something that we want of our lives. What we want is not forthcoming, but the desire for it we are, again, loath to forgo. It is clear, also, from what we are considering that the person subject to this recurrent and chronic depression is at core strong, persisting, and determined. Not bad qualities at all.

The Learned Helplessness Theory

Downloaded by [New York University] at 02:06 15 August 2016 It is appropriate to comment at this point on a popular explanation of depression, which you may have heard about, called the learned helplessness theory. This notion has emerged from interesting research on animals and goes something like this: When animals or humans experience prolonged or repeated loss or trauma (injury) that cannot be controlled or amelio- rated by voluntary action, they learn to be helpless, a state that appears in many respects no different than what is otherwise called depression. What they learn is to expect that no action or initiative will avail them of any relief. Thus, if a devoted wife, who has centered her life on serving her

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husband, is suddenly widowed, she may ﬁ nd that none of her husband- centered thoughts or actions relieves the pain of his absence. She sees no way that she can affect her state since she can never revive nor replace this unique ﬁ gure in her life. Mourning passes to a prolonged depression because of the helplessness she experiences in affecting any remedy to a life without her lost husband. Indeed, suicide may appear to her as the only remedy to a hopeless and helpless life. Now the explanation we presented before introducing “learned helplessness” actually incorporates rather than refutes the role of helplessness in depression. How is this? Well, essential to the persistence of depression is the conviction by depressed persons that they cannot change the source of their despair just as our widow above cannot recover her dear husband. Similarly, the man I spoke about earlier was helpless both to maintain his unsanctioned mate and gain the approval of his family and church. However, our functional explanation says there is more to prolonged or recurrent depression than just this sense of helplessness. There is also the central insistence, the determined demand. The wife must have her life and husband restored. The man must have both mate and blessing. In short, the impossible must be rendered possible.

What Must Be Done The helplessness theory says that to get over a depression one must learn that he or she can act, can control his or her world. But can the widow bring her husband back to life? Can the man reconcile his living conditions with family and church precepts? No. The widow and the man will have to give up their strong-willed insistence that these matters conform to their wish. They will have to turn their qualities of determination and persistence toward learning to forgo what in all reality they cannot have or retain. I am reminded of the Serenity Prayer regularly observed by members of Alcohol- ics Anonymous:

Lord, give me the courage to change what I can change. Grant me the serenity to accept what I cannot change. And please give me the wisdom to know the difference. Downloaded by [New York University] at 02:06 15 August 2016 What is lacking in the life of the depressed person is the second grant—the serenity to accept what will not give way before one’s strongest desire. While the depressed person may be manifestly pessimistic about everything, buried within that outer layer of black mood is a core of stubborn, hopeful insistence. Depression is the expression of an abiding protest against certain matters in one’s life which, however, one feels, at least for the foreseeable future, unable to alter. The continuance of the depression is in step with the protest, the undaunted wish to change events, as much as it is an expression of helplessness

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to effect that wish. As long as the wish lives and no realization is possible, then the depression will remain or remain as a recurrent possibility.

Concluding Remarks The helplessness theory and several closely related notions provide guidance in helping depressed persons. They are to discover bit-by-bit ways in which they are not helpless, ways they can act on their world and establish control of their lives. Such efforts are often in fact very useful. Why are they useful? The explanation advanced by the helplessness theory is that they are useful because they enable the person to experience anew that some things, perhaps many things, are still subject to being altered and controlled by appropriate initiatives and actions. There are pleasures and accomplishments that a state of helplessness and an attitude of pessimism deny them. This explanation is, as far as it goes, probably correct but, also, probably secondary to the more essential consideration. That consideration is the depressed persons’ willingness to accept their lives. Before depressed persons permit themselves to consider other goals, other forms of gratifi cation and contentment, they must give up the impossible goal upon which their heart is set. To gradually interest depressed persons in alternative sources of satisfaction in life is actually a way of helping them accept their loss. Slowly they come to accept their inability to have what they cannot have, to accept the reality of their lives. Take our widow, for example. As we help her consider one option after another, she is forced at each juncture to make a choice. She may go on insisting on the impossible pleasure of the company of her dead husband, or be open to whatever pleasure she may fi nd in the company of others. That company may comprise family, friends, or, just possibly, another man. She will not permit herself to enjoy another’s company until she has in some measure relinquished the insistence that she have back her husband’s company. Put differently, she will not do what she can do or obtain what she can have until she has accepted in serenity that which she cannot do and cannot have. The same applies to our confl icted man. He will not live at peace with the woman of his choice until he is willing to surrender his desire for family/church acceptance. Like the widow, he must come to accept in serenity that which he

Downloaded by [New York University] at 02:06 15 August 2016 cannot do and cannot have. It is the lack of such acceptance that promotes a sense of helplessness and is the key to the recurrence and persistence of the depression. To place emphasis on the act of acceptance is not to suggest that this is either simple or easy. We are dealing with hopes and perceptions that emerge from core values. That which depressed persons must accept is experienced as alien to their very identity. For the widow to accept the reality of her husband’s non-existence may feel to her like an act of disloyalty and abandonment. She must learn to feel differently. Freeing one’s self of persisting and recurrent depression means changing one’s self. Acceptance is just such a change.

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DISCLOSING SECRETS

By V. Edwin Bixenstine, Ph.D.

Prepared for clients and subscribers. Not for copy or redistribution without the express permission of the author.

Preface This brief work is designed to aid those who may have discovered that their distress arises from secrets kept from persons who are important to them. In this pamphlet we take up the question of disclosure of such secrets. We will examine why, to whom, and how to disclose to another. We hope to provide you with a framework that will allow you to weigh your decision about revealing a secret and aid you to prepare your disclosure.

Introduction The need for disclosure arises when it is found that a person harbors what O. H. Mowrer called the “pathognomonic secret.” This is a secret the keeping of which causes the growth of one’s “pathology,” that is, one’s personal and psychological discomforts. Mowrer thought that such a secret was nearly always the source of recurring bouts of anxiety, guilt, depression, or other forms of personal distress. I am not sure that secrets are always present as a basic cause of psychological discomfort. However, the coupling of secrets and distress does occur quite frequently. When it does, disclosure deserves serious consideration as a method for an often radical and far-reaching resolution of the distress. The logic here is quite straightforward: Secrets cause the distress, therefore do away with those secrets. Easy said! Far from easy to do! Why? There are several reasons. First, such secrets are usually “close to the heart.” They represent matters we do not want others to know. They may, if known, seriously change our image in the eyes of persons whom we have an interest to deceive. Second, these secrets are

Downloaded by [New York University] at 02:06 15 August 2016 well defended. We have carefully crafted justifi cations for the secrets and for the disguises, omissions, and misrepresentations that have been employed in keeping the secrets. These justifi cations may be so habitual to us that the idea of disclosing seems like a betrayal of our nature! Finally, the secrets bring profi t. We profi t from holding secret something which, if known, would cost us. We profi t in that the secret provides us with a kind of freedom and power. What others do not know about us leaves them less able to control or infl uence us. We do not have to answer to them or face their displeasure. Even though secrets are “pathognomonic” and generate distress

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and unhappiness, giving them up is to give up power to those who learn the truth about us.

Why Disclose? In essence, we disclose as a way of defi ning ourselves. The main reason the secret is pathognomonic is that hiding blurs our identity. The safety, profi t, power, and freedom that hiding brings us have a secret of their own! That secret is that we pay a price. The price is not initially apparent and, because of our justifi cation of hiding, we learn not to see it as time goes on. We are, consequently, mystifi ed by the costs we suddenly begin to endure. Why are we in such distress? Why are we so anxious? Why are we pursued by black depression? Why are we unsure of ourselves? Why do we feel weak, indecisive, and fearful? These costs boil down to this: A secret waters down our identity. Who are we? We are, fi rst, who others know us to be. Others constantly affi rm who we are by the fashion in which they treat us, what they expect of us, what they say about us. When others are uninformed or misinformed about some central feature about us, then they give us unclear signals about who we are. They treat us with uncertainty, expect of us actions not always true of us, and describe us in ways that do not represent who we really are. We are, in addition, who we know ourselves to be. Well, of course, we know what we hide. We know who we really are in secret. Two matters, however, wash out the clear boundaries of our own self-knowledge. First, think what happens as a result of the constant, day-by-day practice of hiding, denying, appearing as something we are not. For example, let us assume you dislike spinach. Nevertheless, it is good for you, and each day you repeat, “I like spinach very much” to someone or other. The fact you do not like spinach is your secret that you hide by asserting the contrary. What do you think will happen by and by to your attitude toward spinach? Do you think it remains the same? No, your attitude will change. You may come to question whether you dislike spinach as much as you once thought. Indeed, you may grow to accept if not enjoy spinach, particularly if friends, out of respect for your declared taste for spinach, see to it that you are served spinach often! What we present about ourselves, if different from what we

Downloaded by [New York University] at 02:06 15 August 2016 know, tends to cloud our sense of self, our identity. We grow unsure of what we know about ourselves. The second development is that we begin to believe our justiﬁ cations, those reasons we advance to ourselves to keep from feeling bad about hiding. Maybe we have hidden something from an intimate, a loved one. The hoariest jus- tiﬁ cation of all is, “I cannot let him (her) know because it would hurt him (her). I will suffer my secret so he (she) does not suffer.” And we become half convinced that our secrecy is really noble, an act of care and concern for a loved one. Then in a cold moment of truth, we see our self-deception in the

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acceptance of our justiﬁ cation myth. It ﬁ lls us with uncertainty. What do we believe? Indeed, why do we hide? What is true of us? Who are we? In the end, the reason we disclose is to regain a clear sense of ourselves, to regain our identity. Perhaps, the term integrity would be even more to the point. Deceiving others reduces our social integrity: We are not believable. It also tarnishes our personal integrity: We do not know what we believe. Disclosing moves us toward reestablishing both our social and personal integrity.

To Whom Disclose? If what I have said regarding why disclose is applied to the question to whom disclose, then the answer is simple. Everyone. Sidney Jourard has written of the “transparent self.” The open transparent person who hides nothing and engages in no deceits is, according to Jourard, remarkably resilient and psychologically healthy. He knows who he is. Others know him. He has integrity, both social and personal. Those who wish to protect their secrets often jump on this “radical openness” idea. They point out that they have seen others who spill their guts to any and everyone with no sense of the appropriate. And that is true. Some very troubled people hit upon disclosure in the search for relief from guilt or for attention. This abuse of disclosure and the sensibilities of others is not what Jourard had in mind when he spoke of transparency. The only time you would ever literally tell everyone is when everyone has an interest in listening. This might be the case if you were famous and had a disclosure about a public trust, or when you might wish to entertain or instruct. Here is the principle: Be prepared to disclose to anyone, but initiate disclosure only to those whose interests are affected by what you disclose. Let me illustrate by example. Take the case of a spouse from whom one has kept secret an adulterous affair. The spouse clearly has an interest in his or her mate’s sexual loyalty. She or he probably considers the mate’s sexual behavior an asset to which she or he has an exclusive right. In giving that asset away to another, the mate has devalued the spouse’s rights and interests. Or take the case of the college student who is receiving support from parents and who hides that he or she has taken in a live-in mate. The parents and

Downloaded by [New York University] at 02:06 15 August 2016 the college student have a prior (probably unspoken) understanding. Parents will underwrite the cost of their grown son’s living and schooling expenses if the son honors certain values dear to parents. Ordinarily these are to do well in college and, perhaps, to establish a spousal or mating relationship in a certain way. By hiding his or her living arrangements, the college student denies to the parents their right to withdraw their support should they view their interests to have been violated. If you apply this principle and are open with those important to you and with investment in you, then you will have little to fear in disclosing to anyone or

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everyone. Moreover, you will have little reason to disclose compulsively to strangers or someone who has but little signifi cance for you. You will not be unloading on strangers what you keep in guilty secret from the people who count. And if you do disclose to a stranger, it will be because you wish to promote that person to a place of greater signifi cance to you and promote yourself to a place of greater signifi cance to him or her. Such use of disclosure should occur only when you believe that the other will welcome your invitation to move from a formal, casual relationship into one more personal and intimate. To invite intimacy through disclosure to someone with no such interest is to risk embarrassment to you both.

How to Disclose I have been midwife to literally hundreds of disclosures. Most have gone well. Some have not or have had to run through a second “take.” The experience has taught me something about what makes disclosures work or not. Let us attend to some of the pitfalls fi rst. Pitfall one occurs when those to whom we disclose appear to fi nd our disclosure a criticism of or burden to them. Usually this arises because we have, at least in part, adopted disclosure because we want to change or correct the person to whom we are disclosing. This objective, even if only a small part of what we are trying to do, will detract from our effort. A don’t: Do not expect or try to change the attitudes, feelings, or behavior of others by your act of disclosing to them. Another reason why persons to whom we disclose fi nd our disclosure a burden is because we are angry with them and wish to “set them straight.” It is possible to turn a disclosure into an accusation. Our words serve to charge the other with driving us to do what we did, failing to encourage us to trust, making us afraid to be honest, etc. Another don’t: Do not use disclosure to fi x blame on another—“brutal honesty” is always brutal but rarely really honest. Pitfall two occurs when the person to whom we disclose appears confused by our disclosure. Usually this is because we are deeply divided about disclosing. We proceed guardedly, approaching matters in a sideways manner. The result is that we persuade ourselves that we have disclosed but actually fail to do so. Some more don’ts: Do not approach disclosing without knowing what you will disclose and without rehearsing the matter fully. Do not speak in metaphor, as does the embarrassed parent talking of birds and bees. Do not

Downloaded by [New York University] at 02:06 15 August 2016 put out the substance of your disclosure in disconnected pieces. Pitfall three occurs when the person to whom we disclose seems unwilling to hear us out or jumps in to reassure us that we need not say more. In this case, it just may be that our disclosure, quite apart from how we do it, is causing the listener discomfort. It may be that our honesty stirs up the listener’s concerns about his or her own secrets. However, it is also possible that we have framed the matter in such a manner as to invite the listener’s sympathy with our pain and reluctance to carry on. “I wish I did not have to tell this. It’s probably nothing you want to hear any more than I want to tell.” Of

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course, our manner may convey the same message. The listener is prompted to jump in and reassure the discloser that he or she surely does not have to say anything, at least, not on the listener’s account. A fi nal don’t: Do not invite the listener to stop you and do not approach the disclosure with the mixed message that you do not wish to do what you are doing. Having warned of pitfalls and what not to do, let’s look at what to do. First, work through your own unwillingness to disclose. You may shrink from it right down to the last word, but if you do it, you do it because you want to and decide to do it. You may shrink from going to the dentist, but the pain in your tooth is real, and, in the end, you go because you want to. You do not tell the dentist that he lacks the training to treat you. You do not assert that it is his fault your tooth has decayed and he could have saved you this trip. You do not begin by saying that you are not sure you have a toothache, and the dentist would be better off if he just sent you home. By the time you get to the dentist’s offi ce, you are resolved to have this aching tooth attended to. It is your decision. It is what you want. Second, work through your justifi cations and excuses. Lay them aside. For- mulate your disclosure in its most simple and direct nature. Stick to what you have done entirely without explanations. Actually, you yourself may not be clear about why you have behaved as you have. You may have hidden for so long and rationalized so much that the reasons are obscure. The listener will be able to assess your reason if you disclose just the facts of your hidden actions. Third, think over what you have hidden. Order the items from those you are least uncomfortable to tell to those you are most uncomfortable to tell. Start with the latter. Disclose it. You will fi nd that from there it is all downhill! If you start at the other end, you are going to fi nd that you are working uphill against your own reluctance throughout the whole effort. Fourth, there is an introduction to your disclosures that you need to make, which is not, however, your justifi cations and excuses. It might go like this: “I want to tell you something that I have kept secret from you. I tell you now because, as time has gone on, I discover there is more cost to me in keeping my secret than there is gain. The cost I speak about has been depression, guilt, and growing personal uncertainty. I tell you because I want to regain my integrity.”

Downloaded by [New York University] at 02:06 15 August 2016 Finally, after you have told all, there is usually the question of responsibility for harming the persons disclosed to. That harm may have been simply that you misled them and, perhaps, wasted their time. Or it may have been an abuse of their trust that permitted you some gain, freedom, or advantage at their cost. Whatever it is, after your disclosure, you are obliged to indicate that you accept responsibility, that you regret the harm done, and that you will repay them. The manner of that compensation or repayment is something you should have thought through as much as possible. It should be appropriate to the circumstances. You need to propose to the persons disclosed to what

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you have in mind. But be prepared to listen carefully to how they judge the harm. You may feel obliged to revise your repayment plan so that they are not left with the conviction that justice remains to be done. Take heart. The usual reaction is to forgive you your debt, not to suggest that your estimate of it is too low.

Conclusion Earlier I noted that secrets etch away the clear boundaries of our identities. Our integrity—who we are, what we stand for, what we represent—suffers both as others know us and as we know ourselves. No matter how hard we try to assert our identity, there will be inconsistency, a contradiction between what we appear to be and what is hidden from view. Something else happens that I have not touched upon. Even while the clear sense of our own selves suffers, as time goes on the center of our identify shifts. Before hiding, we may have experienced our core person as outgoing, generous, and interested in serving others. As time passes, however, the secret becomes more and more the focus of our attention. Bit by bit, the secret rear- ranges the nature of our sense of self. Guardedness replaces outgoingness. Our generosity clashes with the fact that we have a secret advantage we do not acknowledge. That we deceive others contradicts our wish to serve them. Not only, then, does the secret undo the clear outlines of self, but it become central to what sense of self we now have. Do we fi nally “become our secrets?” The author, Lloyd Douglas, concluded that, yes indeed, “You are your secrets.” He observed that most secrets are mean, little, self-serving, and, of course, hidden just because of these negative characteristics. If such secrets move into our core self, then we develop a negative identity. The secret is like an inner garden, and what we plant there grows and multiplies. If we plant seeds of selfi shness and littleness, that is what we reap in our self-experience. Thinking this, Douglas was inspired by a novel ideal. Is it possible that hiding may, under certain circumstances, be benefi cial to us psychologically? What if one kept secret not mean, little acts, but generous, honorable acts? What if one made known any negative, selfi sh deed, but kept quiet about the positive, selfl ess acts? If we are our secrets, and our secrets are the noblest of

Downloaded by [New York University] at 02:06 15 August 2016 the acts we commit, then we will experience our core selves as positive and noble in spirit. Douglas concluded, ‘Here is the key!’ Who is not seeking to be positive in his or her self-appraisal? Are not the pursuits of achievement, success, power, and fame all in the service of experiencing one’s self as worthy, positive, and honorable? If one attempts to reach success or power by hiding failures or using hidden advantages, he or she may succeed but remain trapped in a negative identity haunted by a sense of inner fault. On the other hand, one may fail miserably to keep up with the Jones, but if he or she hides noble acts and

242 APPENDIX

admits lesser ones, he or she will enjoy that inner sense of positive identity that we all seek and some seek desperately. This program of keeping the positive secret and disclosing the negative, Douglas believed, should be our “magnifi cent obsession” (the title of his most famous book). In this way, we lay the basis for true person power. Power, after all, lies in experiencing our own inner resources that generate in us the confi - dence that we are worthy and capable of meeting whatever life brings. Although I believe it deserves very serious attention, I do have a reserva- tion about Douglas’ “magnifi cent obsession.” I am not sure I trust hiding, even the hiding of good deeds. Might we be tempted to pore over our “secret journal” of noble acts and gloat at our inner superiority? Might we look upon our hoard of good deeds as a kind of debt others have toward us. Might they become a store of IOUs that others have a duty to pay, if not now, then at some time? I think if one were to apply the idea for these ends, then it would defeat Douglas’ objective. Avoiding such perversions of the idea, however, should produce results very like those Douglas wrote about. I leave it to you.

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248 INDEX

acknowledging the pain 25 conformity 178; diverging intimate action by client 92; disclosure, the ﬁ rst communities 178–9 action 99 confronting 23, 51 addiction 20; addiction theory of Constantino, M. J. 245 psychopathology 20–1, 199; classical Cooper, M. 245 addiction 21, 211–12; negative vs. countertransference 65; processing positive addiction 197–9 rules 67 adjustment principle 18 crisis of faith 154 administering assessments procedures 31 Crits-Christoph, P. 246 Albee, G. W. 12, 244 Alcoholics Anonymous 40, 120, 150, deception 19–22, 61, 91, 117, 139, 235 188–201 Alimohamed, S. 244 defection from integration 176–7; anger as a drug 125 rescued by intimate community 176 Arkowitz, H. 244 delayed consequences mostly social 188 audio recording 45; client use of 51 Descartes, R. 165, 245 Diagnostic and Statistical Manual Baer, R. A. 244 (DSM) 193, 244 Barlow, D. H. 244 disclosing secrets 99–112, 140–1, 237; behavioral techniques 136–7; precautions assertion as disclosure 132; why in using 137–8 disclose 117, 238 behavior payoff, four classes 172–3 disclosure as investment in others Benson, K. 248 assertion as investment in self 132 Bergin, A. E. 244 dissociation from reality 205 Beutler, L. E. 244 Divergent vs. Convergent attention 59 biologically based problems 186–7 Dodo Bird 5–6, 207 Bixenstine, V. E. 162, 209, 217, 224, Dokecki, P. 14, 246 231, 237, 244 Dryden, W. 9, 245 bonding 23, 55, 97, 148, 227–8 Duncan, B. L. 247

Downloaded by [New York University] at 02:06 15 August 2016 Boswell, J. F. 245 Buzzella, B. A. 245 Ehrenreich, J. T. 245 Ellis, A. 11, 12, 245 Campbell, D. T. 7, 12, 244 Emmelkamp, P.M.G. 245 Carlson, J. 244 Englar-Carlson, M. 244 Castonquay, L. G. 245 Engle, D. 244 Cleckley, H. 19, 245 Erickson, T. M. 246 Community House 7, 157 Eysenck, H. J. 245 compensation (amends) 130, 141, 149, 241; measured subjectively 120–5 false hope 38, 40, 92 conditions of therapy, review of 53 Follette, W. C. 245

249 INDEX

Frank, J. B. 245 Malik, M. 244 Frank, J. D. 245 MacHugh, R. K. 246 Freud, S. 4, 8, 26, 29, 65, 161, 180, medical model 8, 12–3, 18, 24, 32–3, 185, 189–90, 208, 245 155, 208 Fromm, E. 179, 245 Menninger, K. 8, 12, 31, 246 Fromm-Reichmann, F. 30 messages therapists avoid 32–3 meta-analysis 5–6 Garfi eld, S. L. 244, 245, 246 Miller, S. D. 247 Gibbons, M.B.C. 246 Miller, T. I. 247 Glass, G. V. 247 Miller, W. R. 246 Glasser, W. 245 mindfulness 5, 244 Goldfried, M. R. 245, 247 Mitchell, L. J. 14, 247 Greenberg, L. S. 245 Mondin, G. W. 248 guilt 3, 9, 19, 21, 61; contempt for Moody, M. 248 guilt 189–90; and faith, how inspired moral ambiguity 113 147–9; ontogenetically precedes worry moral inventory 123 185–6; recapturing and renurturing Mowrer, O. H. 1–4, 6, 9–14, 21–2, 27, 146–7, 154 29-30, 54, 62, 65–7, 157–8, 161–2, 194, 205–8, 237, 245–6 Harwood, T. M. 244 Hayes, S. C. 12, 318 Nahon, D. 12, 246 Hill, C. E. 319, 245 negative emotions 6–7, 9–10, 13, 21–2, hope 2, 22, 38, 50, 55, 62; faith 37, 137, 139, 207, 223 and hope 147–9 neurotic paradox 9, 199, 246 Horney, K. 12, 245 Newman, M. G. 246 Hunt, J. McV. 245 Nobele, S. 244 Huss, D. B. 244 normal (Gaussian) curve hypothesis 11; versus the “J” curve hypothesis 11 incest taboo 41, 80 normality 18–9, 21–2, 137, 158–9, insight 4, 23, 67, 73, 90; Be wary of 165, 168, 179–80, 183, 187, 191–4, joining . . . in celebration 92; feedback 204; as absence of pathology 158; spiral 97; as a map 91; test of action 92–4 as independent of pathology 158–9; integrative behavior and survival 182–3 interdependent 160–1, 183, 192; integrative principle 18; benevolent circle reverent 181; three ingredients— and value gradient 169; as a function of passion, beliefs, values 168 signs, passion, and worry 180–1; and normal worry 22, 146, 184, 205; inner audience 177–78 ; past behavior capacity to conceive 168, 181; effects present outcomes 174–75 learning to worry 167; mystery of intimate community 149–50, 155, 176–8 worry 165–7 note-taking, pros and cons 33, 48–50, Johnson, R. C. 14, 246 53; denotative vs. connotative 50–1 Jourard, S. M. 112, 210, 239, 245 justifi cation 23, 25–6, 28–30, 55, 62, objectivity vs. subjectivity 56–58 66, 99, 110–2, 116–7, 136, 138–9, Ogles, B. M. 246 157, 185, 189–90, 238 Orlinsky, D. E. 246 Downloaded by [New York University] at 02:06 15 August 2016 justifi cation failure 61, 64 Pachankis, J. E. 247 Kazdin, A. E. 245 pain 25–9; acknowledge pain 60; not the Klein, D. F. 245 enemy 29 pamphlet use 45, 111–139 Lambert, M. J. 244, 245, 246, 247 parents as pump primers 170–3, 199; Lander, N. R. 12, 246 other pump primers 176 law of effect 186–7, 194 perceptual orientation 58–60; scientist vs. law of effects over time 186–7, 194 therapist 59 London, P. 12–4, 208, 246 primal ambivalence 34, 60–2

250 INDEX

“primitive person,” 195 Sparks, J. A. 247 psychopathology 19–22; as defense Stich, F. 248 against sanctions and judgment 185; Strosahl, K. D. 9, 245 classifi cation 190–5; common labels Sullivan, H. S. 3, 24, 29 192–3; defi ned 19, 187–8; dynamics vs. supportive therapy 27 manifestation 190–1; least to most pathologic 194–5; signal characteristics Talebi, H. 244 194; therapy goals 145–6 termination 139–40; resistance to 140 psychotherapy stages 23, 227–31 therapist subjective response 56–9; always suffi cient 56; and raw clinical Rachman, S. J. 248 data 56–7; and storage conventions Reichenberg, L. W. 5, 248 57–8 Reik, T. 54, 247 therapy, a communications process 57; resistance 22, 55, 62; forms of, to a single goal 145–6 disclosure 104–16; to disclosure 104 Thorndike, R. L. i, 137, 185, 247 restoring community 57, 149–50 transference 62, 65–73; countertransference Rogers, C. 9, 10, 37, 148, 247 processing 66–73 role-play 126–30 Rollnick, S. 247 Ullman, A. D. 14, 162, 246 Rønnestad, M. H. 246 Rosenzweig, S. 6, 247 Wachtel, P. L. 247 Ruiz-Cordell, K. D. 247 Wagner, C. C. 15, 247 Walsh, R. 247 Safran, J. D. 247 Wampold, B. E. 5, 244, 248 Sanchez, F. P. 12, 247 Westen, D. 248 seating arrangements 33 Whoolery, M. 14, 247 self-cure 201; despair as barrier to 203–4 Willutzki, U. 246 self-help groups 138–9, 150 Wilson, G. T. 248 Seligman, L. 5, 247 Wilson, K. G. 9, 245 Seligman, M.E.P. 247 Wong, E. 244 Shedler, J. 247 worry 21–2, 137, 146, 165–9, 174, Slife, B. D. xi, 14, 247 179–82, 184–7, 194–5, 200, Smith, M. L. 247 204–5, 214 Downloaded by [New York University] at 02:06 15 August 2016

251