Behavior Therapy Versus Psychoanalysis

Home , Behavior modification, Joseph Wolpe

Therapeutic and Social Implications

JOSEPH WOLPE Temple University School of Medicine

ABSTRACT: Although the specific efficacy of psycho- fundamental importance" (p. 159). Nevertheless, analytic therapy in the treatment of the neuroses has it is psychoanalytic theory that has continued to never been demonstrated, psychoanalytic theory and be the most pervasive influence in psychothera- practices continue to dominate the field of clinical psy- peutic practice. chology. That psychoanalytic theory has not been dis- placed by the behavioral theory of neurosis is remark- able in mew of the persuasive evidence that exists for the efficacy of behavior therapy. One reason for this The Reign of Psychoanalysis seems to be the persistence of widespread mispercep- tions of behavior therapy. It has been represented to According to psychoanalytic theory, mental activ- the public as an "inhuman" treatment that routinely resorts to electric shocks and other unpleasant agents ity is partly conscious and partly out of reach of and to the profession as a therapy incognizant of the consciousness in the "unconscious mind." Neurotic patient's feelings or thoughts and applicable only to symptoms are regarded as the manifestations of neuroses that are "simple," such as phobias—an image emotional forces that have been "repressed" in the regularly reinforced by "authorities" who are misin- unconscious. Freud (1922/1950) regarded these formed. This article attempts to correct these misper- symptoms as "compromise formations between the ceptions. It also draws attention to the suffering im- repressed sexual instincts and the repressive ego posed on many by years of psychoanalysis. The promise instincts" (p. 107). Psychoanalytic therapy aims to of widespread availability of behavior therapy as an overcome a neurosis by bringing the putative re- alternative will only be fulfilled when more high-quality pressed impulses into consciousness, through such training is funded. means as free association and dream analysis. All The present century has seen the birth (Jones, the derivatives of psychoanalysis (the theories of 1924) and the development (Ayllon & Azrin, 1968; Adler, Sullivan, and others) exert their main ther- Wolpe, 1958) of behavior therapy—methods of apeutic effort toward making the unconscious con- psychotherapeutic change founded on principles scious (Munroe, 1955). of learning established in the psychological labo- The clinical effectiveness of psychoanalytic ratory. Its results in the treatment of human neu- therapy has never been established. Eysenck (1966), roses have been quite impressive. Paul (1966), on in a review of 24 studies encompassing over 7,000 the basis of a survey of controlled studies on sys- cases, concluded that the data failed to show that tematic desensitization, has stated, "For the first psychoanalytic therapy facilitates the recovery of time in the history of psychological treatments, a neurotic patients. Erwin (1980) has convincingly specific therapeutic package reliably produced defended Eysenck's conclusion against challenges measurable benefits for clients across a broad range by Bergin (1971), Bergin and Suinn (1975), and of distressing problems in which anxiety was of Brown and Herrnstein (1975). A particularly note- worthy study is that of the Fact-Gathering Com- This article was the address of the recipient of the Distinguished mittee of the American Psychoanalytic Association Scientific Award for the Applications of Psychology at the meeting of the American Psychological Association, Montreal, Sep- (Note 1). Out of 595 patients, 306 were judged to tember 1980. have been "completely analyzed" (in a mean of Requests for reprints should be sent to Joseph Wolpe, De- about 600 sessions); 210 of these were followed up partment of Psychiatry, Temple University, c/o Eastern Penn- sylvania Psychiatric Institute, Henry Avenue, Philadelphia, afterwards, and 126 were stated to have been cured Pennsylvania 19129. or greatly improved. This is 60% of the completely

Vol. 36, No. 2, 159-164 AMERICAN PSYCHOLOGIST • FEBRUARY 1981 • 159 Copyright 1981 by tlic American Psychological Association, Inc. 0003-066X/81 /3602-0159S00.75 analyzed group but only about 31% of the original imental neuroses" in animals—a long-lasting sus- total. ceptibility to the triggering of strong anxiety It is customary to turn a blind eye to such poor responses by particular stimulus conditions, a sus- results and to contend that the treatment is nev- ceptibility in many respects similar to the neuroses ertheless on the right track because the psycho- of human beings (Wolpe, 1967). Many experi- analytic theory of neurosis is true. In actuality, not menters in the United States subsequently con- a single one of the theory's main propositions has firmed Pavlov's observations, often using variations ever been supported by scientifically acceptable of his procedure (for a review, see Wolpe, 1952). evidence (see, e.g., Bailey, 1964; Salter, 1952; Val- Using a method described by Dimmick, Ludlow, entine, 1946). But this too is brushed aside. That and Whiteman (1939), I produced experimental this happens is a tribute to the expository brilliance neuroses in cats by administering painful but non- with which Freud presented his theories. His writ- damaging electrical stimuli (high voltage, low am- ing weaves a magic web from which few can ex- perage) of two seconds' duration to an animal in tricate themselves once enmeshed. To the con- a small cage (Wolpe, 1952, 1958). This stimulation vinced it is sacrilegious to suggest the need for elicited strong fear reactions: The animal's pupils anything so mundane as empirical testing. dilated, its hair stood on end, and it breathed rap- After a phase of outraged opposition to psycho- idly. Repeating the stimulation at irregular inter- analysis early in the 20th century, converts to it vals of minutes resulted in the animal's becoming were legion. In 1939, it was officially approved by very fearful of the cage and surrounding stimuli the American Medical Association. By then it had in between 5 and 20 repetitions. The autonomous become widely accepted by Western intellectuals power of these stimuli strongly to arouse fear as a philosophy of life. They saw it, in vibrant would have lasted the life of the animal if left contrast to the dry abstractions of academic psy- untreated (Gantt, 1944). The fear was undimin- chology, as a psychology of reality, dealing with ished by exposures, short or long, to the experi- things that mattered and revealing dark and mys- mental cage, nor was it alleviated by months of terious aspects of the mind. absence from the cage. In every animal, however, Not everybody was persuaded. There were the fear could be systematically weakened, even- many who saw the flaws in the theory and some tually to zero, by arranging for small amounts of who vigorously criticized it. One of the most note- it (evoked at first by generalized stimuli) to be worthy critics was Wohlgemuth, whose Critical inhibited by the competition of eating behavior. Examination of Psychoanalysis appeared in 1923. This suggested that a therapeutic principle resided But critiques like his had little effect—illustrating in response competition. Clinical trials showed that Conant's (1947) maxim that theories are not aban- the competition of feeding also overcame chil- doned on the basis of contradictory evidence. On dren's fears (Jones, 1924) but not those of adults the other hand, Conant attests that they are aban- (Wolpe & Wolpe, in press). Fortunately, a consid- doned when better theories arrive on the scene. erable number of other responses were found to There was no better theory in 1923. But now, in have the ability to inhibit and consequently to 1981, a seemingly better theory—the behavioral overcome adults' fears. Fear can be inhibited by theory of neuroses—has been with us for a quarter the calmness generated by deep muscle relaxation, of a century. Yet psychoanalysis sits firmly in the by the expression of legitimate anger in the context clinical saddle. The first step in attempting to ex- of certain inappropriate social fears, and by the plain why this is so is to examine what evidence use of sexual responses in cases of sexual fear, as there is that behavioral theory and the therapy that well as by a number of more esoteric methods, emerged from it are really better. including flooding (Wolpe, 1973). The important question, however, is whether these experimentally derived methods actually Conceptual Origins and Therapeutic achieve an unusual percentage of favorable results Efficacy of Behavior Therapy of and are significantly more economical of time and Neuroses effort. The answer lies in a comparison with the well-documented fact that the practitioners of I shall now review the foundations of the behav- practically any system of psychotherapy obtain ioral theory of neurosis and the evidence of the recoveries or marked improvements in 40%-50% clinical efficacy of behavior therapy. At the be- of the cases they treat (e.g., Eysenck, 1966). If the ginning of this century, Pavlov produced "exper- followers of different systems—Freudian and Jung-

160 • FEBRUARY 1981 • AMERICAN PSYCHOLOGIST ian analysts, nondirective therapists, encounter psychotherapy and waiting-list groups, were con- groupers, and primal screamers—all achieve this sidered either improved or recovered, a difference percentage, there must be a common process work- significant at the .05 level. Patients treated by being for all of them that has nothing to do with havior therapy also showed significant improve- their respective techniques.. The distinctive pro- ment in work and social adjustment, while cedures of a therapeutic system cannot be said to psychotherapy patients showed only marginal be helpful unless a recovery rate significantly improvement in work and none in social adjust- above the common baseline can be shown. ment. At one year, only those who had been treated The question then becomes, Does behavior ther- by behavior therapy showed greater improvement apy improve on the common run of results? The in target symptoms than waiting-list subjects. first published statistical analysis of behavior therapy was based on my own uncontrolled clinical observations (Wolpe, 1958). In a mean of 30 ses- The False Image of Behavior Therapy sions, 188 (89%) out of 210 neurotic cases I had treated were either apparently recovered or at least The use of procedures similar to those successful 80% improved on the criteria proposed by Knight in extinguishing strong anxiety-response habits in (1941): symptomatic improvement, increased pro- experimental animals has thus increased our power ductiveness, improved adjustment in pleasure and to overcome unadaptive, learned anxiety-response .sex, improvement in interpersonal relationships, habits in humans. Behavior therapy does what had and ability to handle ordinary psychological con- been predicted on theoretical grounds. This is a flicts and reasonable reality stresses. It has since unique achievement in the field of psychotherapy that time been commonplace for skilled behavior that should surely entitle the behavioral approach therapists to report marked improvement in at to center stage. Why has that position been least 80% of their neurotic cases. A relatively recent denied it? development has been the striking success of flood- It is a matter of its image, which has been dis- ing and response prevention in the treatment of torted in two major ways. To the public, behavior those obsessive-compulsive neuroses in which the therapy has been represented as being made up patient is preoccupied with avoiding and washing of cruel and degrading treatments that emphasize away "contamination" (Foa & Steketee, 1979; aversive shocks and include sensory deprivation, Meyer, 1966; Rachman, Hodgson, & Marzillier, brainwashing, electroconvulsive therapy, and psy- 1970). These cases used to be one of psychiatry's chosurgery. This is the accepted newspaper image. knottiest problems; and now the great majority of Mitford's (1973) book, Kind and Usual Punish- patients can expect to recover or improve mark- ment: The Prison Business, is particularly derog- edly in a matter of weeks. atory. This kind of vilification began with reports Further support for behavior therapy comes of treatments in prisons that were actually con- from a large number of controlled studies, of which ducted by persons who were not behavior thera- I shall mention two of the more notable. Paul pists (for a review, see Friedman, 1975). Although (1966) had psychoanalytically oriented therapists the accusations against behavior therapy were re- treat severe fears of public speaking with three butted by Goldiamond (1975), the adverse impli- techniques—their own accustomed short-term in- cations have remained in the public mind. A par- sight therapy, systematic desensitization, and a ticularly baneful influence in the same direction control procedure called "attention placebo." The was the film Clockwork Orange, in which a re- therapists did significantly better with systematic pulsive and entirely fictional treatment was rep- desensitization than with their own techniques or resented as behavior therapy. with attention placebo. Within the fields of psychiatry and clinical psy- The second study is that of Sloane, Staples, Cris- chology, there is a widespread misperception of tol, Yorkston, and Whipple (1975). "Mild" and behavior therapy as a simplistic and perfunctory "moderately severe" neurotic patients were ran- enterprise applicable only to phobias and some sex- domly assigned to two treatments—behavior ther- ual difficulties. Its practitioners are supposed to be apy or brief psychoanalytically oriented psycho- insensitive to and uninterested in the subtleties and therapy—or to a waiting-list control group. At the complexities inherent in most human problems. end of the four-month treatment period, on a rat- One factor that has contributed to this image is ing scale of overall improvement, 93% of the be- the predominance of simple phobias, and espe- havior therapy patients, in contrast to 77% of the cially snake phobias, in reports of research. Most

AMERICAN PSYCHOLOGIST • FEBRUARY 1981 • 161 damaging have been the negative opinions fre- The process of acquiring the necessary infor- quently expressed by prominent but ill-informed mation, behavior analysis, identifies and defines psychiatrists and psychologists of various orienta- the stimulus sources of anxiety and establishes the tions. For example, Marmor (1980) recently de- causal connections between anxiety and any con- clared that behavior therapy's major emphasis is sequences it may have, such as sexual difficulties, on "removing the presenting symptom or symp- depression, obsessions and compulsions, or antiso- toms by behavior modification; and the patient's cial habits like exhibitionism and kleptomania. The subjective problems, feelings, or thoughts are con- behavior analysis determines which neurotic anx- sidered essentially irrelevant to the psychothera- ieties are based on autonomic conditioning and peutic process" (p. 410). Similarly, Lazarus (1977) which on cognitive errors or misinformation. It is asserted that behavior therapy is characterized by the therapist's skill in conducting this analysis that the "eschewal of most cognitive processes" and by makes it possible for behavior therapy to succeed a view of cognitive processes as "entirely secondary in even the most complex neuroses. to sub-cortical autonomic conditioning as the real However, it is unfortunate that a great many basis of emotional and behavioral change" (p. 552). people who use behavior therapy techniques have And Marks, a British psychiatrist who is very pop- not learned much about behavior analysis or have ular with American psychiatrists, has repeatedly not understood the need for it. They fail to identify proclaimed that behavior therapy is applicable to intricate stimulus-response relations, and they do "perhaps 10% of adult psychiatric outpatients," not distinguish conditioned anxiety from cogni- those with phobias, obsessions, and some sexual tively based anxiety. They have trouble with com- problems (Marks, 1975, p. 254). These examples plex cases. They give package treatments for di- typify the stream of inaccuracies about behavior agnoses like agoraphobia, a practice that Barlow therapy that pervade the literature. (1979) aptly deplored. Inevitably, these people That behavior therapy is neither indifferent to have much less success with patients than they patients' thoughts nor narrow in its clinical scope would with the help of behavior analysis; and then is quite evident from its own literature. It has been they write articles stating that the favorable reports applied with success not only to phobias and sexual of the efficacy of behavior therapy are exagger- problems but to the whole range of neurotic prob- ated. lems, including the most complex social neuroses and so-called existential problems. Again and Social Implications again, in a modest time span, it has secured recovery in neurotics for whom lengthy psycho- The failures of psychoanalysis and the rationali- analyses have failed (e.g., Wolpe, 1958, 1964). zations that are given for them have very serious The accusation that behavior therapists consider social consequences. One might complain that I their patients' "subjective problems, feelings, or am a biased judge, and of course I am. So let me thoughts" irrelevant to the psychotherapeutic pro- quote from Schmideberg (1970), a distinguished cess is a transparent absurdity, as I showed in detail psychoanalyst: in a previous article (Wolpe, 1978, p. 442). It is the subjective problem, the complaint, that drives From time to time patients come to one who have had the neurotic patient to seek treatment, no matter years of unsuccessful psychotherapy and are in desperate need of help. They have been made to feel that analysis of what kind. To the behavior therapist the pa- is the only worthwhile therapy, and that there must be tient's story is the primary data. The behavior ther- something quite specially wrong with them if it cannot apist carefully probes all seemingly relevant ex- help them as it has helped others; so their depression and periences because consequent therapeutic actions sense of failure are reinforced. Often it is not only their depend completely on an assessment of what trig- psychological condition but also their realistic situation that has deteriorated, sometimes beyond repair, (p. 195) gers what. The patient's "feelings and thoughts" are the main source of information, augmented by One of Schmideberg's illustrative examples con- various questionnaires that the patient thought- cerns a 54-year-old man who had first sought treat- fully answers. No therapy is more "personalized" ment in his early twenties for various anxieties and than behavior therapy; no other therapist knows inhibitions that were largely the manifestations of as much detail about the patient as the behavior the timidity of an inexperienced young man, the therapist does before commencing treatment; and son of poor parents. Thirty years of analysis with nobody else tailors the therapy as explicitly to the leading American analysts had not helped him. individual's problems. When he came to Schmideberg, he had spent all

162 • FEBRUARY 1981 • AMERICAN PSYCHOLOGIST his money on therapy, could not afford to have an tried to do, the iniquity of these practices. But office, and had to practice his, accountancy at people are unlikely to change course unless they home. Another of Schmideberg's cases was a have something to gain or to lose. Now a threat woman of 28 who had originally had no definite looms in the recent statements from the National symptoms, but had entered psychoanalysis in the Institute of Mental Health and the insurance com- hope of leading a fuller life and making a happy panies of their unwillingness to go on paying for marriage. During her analysis she developed an psychotherapy without evidence of its efficacy. agoraphobia, which steadily grew worse. She then So there is hope for tomorrow. But if tomorrow continued with two other analysts, steadily dete- were to give behavior therapy its rightful place in riorating. Schmideberg first saw her after 12 years the clinical world, would the abuses end, and of treatment, when she was very much overweight would the public be better off? In theory, the an- and had lost her looks and any chance of getting swer is yes. In practice, the answer is not yet. In married—the only thing she really wanted. the whole of North America there are no more I have seen many such cases. Psychoanalytically than 200 practitioners with adequate skills in be- oriented therapists rationalize lack of progress by havior analysis. High-quality training is very hard saddling the patient with the responsibility for it. to find. Only about a dozen programs out of more The patient is told that failure to improve is due than a hundred being offered include instruction to his or her "resistance" and not to anything and supervision by teachers skilled in behavior wrong or inappropriate about the therapy. An im- analysis. This can only be remedied by a rechan- partial observer would surely question the com- neling of the mainstream of financial support for petence or the integrity of a therapist whose skill psychotherapy so that the programs needed to is supposed to be to break down resistances but train good teachers and good therapists can be es- who fails to do this for a patient in 5 or 10 years tablished. Only then will the state of the art reach and recommends more of the same! and benefit the suffering public. To keep patients interminably in chancery is an immoral practice and a social blot on the psycho- REFERENCE NOTE logical profession. We are all tainted by it. Perhaps 1. American Psychoanalytic Association. Summary and final in years gone by, one could have argued that there report of the Central-Fact-Gathering Committee. Unpub- lished manuscript, 1958. (For a summary, see Brody, M. W. was nothing better to offer and that the still-suf- Prognosis and results of psychoanalysis. In J. H. Nodine & fering patient at least had the benefit of support. J. H. Moyer [Eds.], Psychosomatic medicine. Philadelphia: But it is a moral requirement of any health profes- Lea & Febiger, 1962.) sional to know the state of the art in his or her field and to be able to offer patients alternatives REFERENCES when the methods used have failed. Ayllon, T., & Azrin, N. H. The token economy: A motivational system for therapy and rehabilitation. New York: Appleton- At a symposium at the meeting of the American Century-Crofts, 1968. Psychiatric Association in May 1980, I asked 500 Bailey, P. Sigmund Freud: Scientific period (1873-1897). In J: psychiatrists how many of them had any acquaint- Wolpe, A. Salter, & L. J. Reyna (Eds.), The conditioning therapies. New York: Holt, Rinehart & Winston, 1964. ance with the literature of behavior therapy and Barlow, D. H. President's message. Behavior Therapist, 1979, about 25% raised their hands. If you had pneu- 2,8. monia, would you entrust yourself to an internist Bergin, A. The evaluation of therapeutic outcomes. In A. E. Bergin & S. L. Garfleld (Eds.), Handbook of psychotherapy who confessed not seriously to have read the lit- and behavior change: An empirical analysis. New York: erature on penicillin and who, when confronted Wiley, 1971. with evidence of its efficacy, expressed skepticism Bergin, A., & Suinn, R. M. Individualpsychotherapy and behavior therapy. Annual Review of Psychology, 1975,26, 509- of that kind of thing? 556. What is even worse is that the purveyors of the Brown, R., & Herrnstein, R. Psychology. Boston: Little, Brown, psychoanalytic philosophy continue to control the 1975. Conant, J. B. On understanding science. New Haven, Conn.: teaching of psychotherapy in most of our depart- Yale University Press, 1947. ments of psychiatry and clinical psychology. The Dirnmick, F. L., Ludlow, N., & Whiteman, A, A study of "ex- saving grace for, them is the 40% or more of neu- perimental neurosis" in cats. Journal of Comparative Psy- chology, 1939, 28, 39-43. rotic subjects who do well in any psychotherapeu- Erwin, E. Psychoanalytic therapy: The Eysenck argument. tic interview situation as a result of emotional American Psychologist, 1980, 35, 435-443. arousal by their therapists. Eysenck, H. J. The effects of psychotherapy. New York: In- terscience, 1966. How can this sorry state of affairs be changed? Foa, E. B., & Steketee, G. Obsessive-compulsives: Conceptual Perhaps to some extent by exposing, as I have here issues and treatment interventions, In M. Hersen, R. M. Eisler,

AMERICAN PSYCHOLOGIST • FEBRUARY 1981 • 163 & P. M, Miller (Eds.), Progress in behavior modification (Vol. Paul, G. L. Insight versus desensitization in psychotherapy. 8). New York: Academic Press, 1979. Stanford, Calif.: Stanford University Press, 1966. Freud, S. Psychoanalysis. In E. Jones (Ed.), Collected papers Rachman, S. J., Hodgson, R. J., & Marzillier, J. Treatment of (Vol. 5). London: Hogarth, 1950. (Originally published, an obsessional-compulsive disorder by modelling. Behaviour 1922.) Research and Therapy, 1970, 8, 385-390. Friedman, P. R. Legal regulation of applied behavior analysis Salter, A. The case against psychoanalysts. New York: Holt, in mental institutions and prisons. Arizona Law Review, 1975, Rinehart & Winston, 1952. 17, 39-104. Schmideberg, M. Psychotherapy with failures of psychoanalysis. Ganlt, W. H. Experimental basis for neurotic behavior. Psy- British Journal of Psychiatry, 1970, 116, 195-200. chosomatic Medicine Monograph, 1944, 3, Nos. 3 & 4. Sloane, R. B., Staples, F. R., Cristol, A. H., Yorkston, N. J., & Goldiamond, I. Singling out behavior modification for legal reg- Whipple, K. Psychotherapy versus behavior therapy. Cam- ulations: Some effects on patient care psychotherapy and re- bridge, Mass.:-Harvard University Press, 1975. search in general. Arizona Law Review, 1975, 17, 105-126. Valentine, C. W. The psychology of early childhood (3rd ed.). Jones, M. C. The elimination of children's fears. Journal of London: Methuen, 1946. Experimental Psychology, 1924, 7, 382-390. Wohlgemuth, A. A critical examination of psychoanalysis. Knight, R. P. Evaluation of the results of psychoanalytic ther- London: Allen & Unwin, 1923. apy. American Journal of Psychiatry, 1941, 98, 434. Wolpe, J. Experimental neurosis as learned behavior. British Lazarus, A. Has behavior therapy outlived its usefulness? Journal of Psychology, 1952, 43, 243-268. American Psychologist, 1977, 32, 550-554. Wolpe, J. Psychotherapy by reciprocal inhibition. Stanford, Marks, I. M. Behavioral treatments of phobic and obsessive- Calif.: Stanford University Press, 1958. compulsive disorders: A critical appraisal. In M, Hersen, Wolpe, J. Behavior therapy in complex neurotic states. British R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior Journal of Psychiatry, 1964, 110, 28-34. modification. New York: Academic Press, 1975. Wolpe, J. Parallels between animal and human neuroses. In J. Marrnor, J. Recent trends in psychotherapy. American Journal Zubin & H. F. Hunt (Eds.), Comparative psychopathology. of Psychiatry, 1980, 137, 409-416. New York: Grime & Stratton, 1967. Meyer, V. Modifications of expectations in cases with obsessional Wolpe, J. The practice of behavior therapy (2nd ed.). New rituals. Behaviour Research and Therapy, 1966, 4, 273-280. York: Pergamon Press, 1973. Mitford, J. Kind and usual punishment: The prison business. Wolpe, J. Cognition and causation in human behavior and its New York: Knopf, 1973. therapy. American Psychologist, 1978, 33, 437-446. Munroe, R. Schools of psychoanalytic thought. New York: Holt, Wolpe, J., & Wolpe, D. Our_useless fears. Boston: Houghton Rinehart & Winston, 1955. Mifflin, in press.

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