The Story of Psychology

by Morton Hunt

  Still, the many disadvantages of psychoanalysis, even in modified form, and the development of briefer, less costly treatments, brought about a decline in its prestige and popularity during the 1960s. There were also larger reasons for its loss of status. As Glen O. Gabbard, then at the Menninger Foundation, wrote in 1990, “The post–World War II enthusiasm for psychoanalysis as a panacea for social problems led to a bitter disenchantment in the 1960s”32—unjustly, since psychoanalysis had never been presented as a remedy for social ills but only for individual problems. Scores of articles in professional journals and popular magazines spoke of the “crisis in psychoanalysis,” of its “status decline,” and of the lack of evidence that it was an effective treatment. Summing up, Dr. Judd Marmor, an eminent psychoanalyst, wrote that “the handwriting is on the wall for all to see. Psychoanalysis is in serious danger.”

  That was in the 1960s, and psychoanalysis has not yet disappeared. But for many years it dwindled steadily in prestige and use. By the late 1980s Helen Fischer, administrative director of the American Psychoanalytic Association, ruefully admitted that “almost no one”—she was speaking of medical psychoanalysts—“is now in the full-time practice of psychoanalysis.” As for psychologists, by 1990 the American Psychological Association reported that only 2.5 percent of its clinical members considered themselves primarily psychoanalysts. Some psychotherapists, both medical and nonmedical, were still using analysis with certain patients—those who could afford it—for whom major character change, reaching deep into the unconscious, was the goal, but psychoanalysis was no longer the model and ideal of therapy, nor was it at the frontier of therapeutic knowledge and research.33

  But as noted in the earlier discussion of Freud’s life and work, the ranks of psychoanalysts, though still very small, have swelled somewhat in the past half dozen years, and psychoanalysis, gleefully pronounced dead many times in recent decades by its enemies, has regained some of its éclat, particularly because most of its practitioners have greatly modified their procedures.

  True, a few hard-liners such as Glen Gabbard, who is now professor of psychiatry and director of the Baylor Psychiatry Clinic at the Baylor College of Medicine, still define psychoanalysis as “an intense treatment, four to five times per week for 45–50 minutes, generally lasting between three to eight years, [in which] the patient generally lies on the couch and free associates—that is, says whatever comes to mind—facing the ceiling, and not the therapist.”34 But even Dr. Gabbard says that Freud wouldn’t recognize psychoanalysis today: “Freud believed that just recalling repressed memories would be curative, but now we understand that recollection alone is not sufficient. Also, Freud conceived of the unconscious as a sort of reservoir of sexual and aggressive impulses.

  Now, thanks in part to modern neuroscience, we think of unconscious mental processes as, at least in part, procedural memory, also known as habit memory or muscle memory. The way we relate to people in early life gets internalized and repeated, in much the same, automatic way our fingers ‘remember’ how to play the piano. The analyst will point out these patterns of behavior—an approach quite different from Freud’s notion that repressed memories will simply pop over the repression barrier.”35

  Most present-day medical psychoanalysts and the small percentage of psychologists who do psychoanalysis operate very differently from the way their predecessors in the profession did. Their practice, though the core psychoanalytic conception of the human personality and of neurotic disorders lives on in it, takes other forms that are less expensive, easier, and briefer. In one important group of variations, known as psychoanalytic, psychoanalytically oriented, or dynamic psychotherapy, typically the therapist sees the patient only once or twice a week (and sometimes less often); the patient sits and faces the therapist (Freud, you recall, could not tolerate that); and the therapist becomes a real person to the patient, discussing, querying, advising, sharing experience and knowledge, and in general being as much an educator as an elicitor and interpreter of unconscious material.

  (In addition, many M.D. psychoanalysts now supplement therapy with medication and many non-M.D. psychoanalysts refer their patients to an M.D. for medication. In fact, a number of psychiatrists now practice psychopharmacology, all but laying aside psychotherapy except for enough patient-physician talk to establish diagnosis.)

  The bottom line of all this is that for many of the psychologists who practice various forms of nonanalytic psychotherapy, it remains the case that psychodynamic concepts prevail and are the heart of the treatment process. Transference, for instance, can exist and be used even in weekly face-to-face therapy, though differently from the way it is in classical analysis, as in this description by the clinical mental health counselor Bernice Hunt of her relationship to a young woman she treated several years ago (the case, though relatively recent, is typical of what has been taking place in dynamic therapies for a number of decades):

  She had no mothering beyond infancy—in fact, she became a caretaker before she was three, when her mother was permanently paralyzed as the result of an accident. In the therapeutic relationship I soon became the good mother hers hadn’t been able to be. I sympathized, I supported, I consoled, I “gave her permission” to play as well as work, and to express her anger to others and to me. She underwent what Franz Alexander [of the Chicago Psychoanalytic Institute] called a “corrective emotional experience” and more or less relived her childhood in different form. When, as in normal development, she began to internalize our relationship, she became able, like any healthy adult, to individuate—to be mother to herself.36

  By the 1970s and 1980s a handful of psychiatrists and psychologists were developing the techniques of “short-term dynamic therapy” based on psychoanalytic principles. The distinguished science writer Dava Sobel reported in 1982 that although short-term dynamic psychotherapy had existed in various stages of research and refinement for about twenty years, it was now “burgeoning into a recognizable force, drawing converts and controversy.”37 Focusing on a single current problem troubling the patient, these methods do not use free association, probe the unconscious, strive for insight, or overhaul the personality; they rely chiefly on the patient’s transference.38 Unlike the psychoanalyst, the therapist actively confronts the patient with the evidence that he or she is behaving toward the therapist in an unrealistic way carried over from other relationships. The therapist sometimes does this even in the first session, as described (in abridged form here) by Peter E. Sifneos, a Boston psychiatrist:

  PATIENT: I put on an act. I wear a mask. I give the impression that I’m different from what I really am. Before my girlfriend broke off our relationship, she said that she didn’t like going out with someone who is “a phony.” Mary, my previous girlfriend, had said the same thing, using different words, and so did Bob, my best friend. I know what they are all talking about. At times, even here, I have this great urge to show off and make you admire me.

  THERAPIST: And where does this urge come from?

  P: From very long ago. I used to put on an act to impress my mother. I remember one time when I made up a whole story about school. I told her that the teacher had said I was the best student she ever had. My mother was impressed, but you know, doctor, it wasn’t true. The teacher had complimented me, but I exaggerated it. I blew it out of proportion.

  T: So you were trying to impress your mother, you are trying to impress your girlfriends, and Bob, and even here—

  P: What do you mean by “even here”?

  T: A minute ago you said that even here you had such a tendency.

  P: Did I say that?

  T: Yes, you did. Furthermore, why does it surprise you? If you put on an act with everyone else, why wouldn’t you put on an act with me?

  P: It did occur to me that it was possible, but this is precisely what I don’t want to do. I’m here to understand why I do it so I can stop pretending. I want you to help me.39

  In classical psychoanalysis, that point might not have
been reached for months.

  Going still further with this approach, in 1990 Moshe Talmon, a clinical psychologist at the Kaiser Permanente Medical Center in Hayward, California, wrote a book called Single-Session Therapy, in which he discussed how much could be achieved with some patients in the first session—often, especially in clinics, the only session—not by the offer of advice but by dynamic interactions.

  In general, however, short-term psychodynamic therapy takes between six and twenty weekly sessions to achieve its limited goal, and has been reported effective for stress and bereavement disorders, late-life depression, and for certain emotional and personality disorders.40 For many psychotherapists, dynamic therapies, especially the shorter and more interactive forms, are now the treatment of choice for most neurotic disorders and problems of living. There is good evidence, in fact, that much benefit takes place within a relatively few hours of therapy. A typical study shows that half of all weekly patients are significantly relieved of their acute symptoms of distress by the eighth session, although chronic and more fundamental problems take much longer.41

  In recent years, partly due to the tight-purse policies of managed care administrators, short-term psychotherapy has established a firm place in the therapy world. A number of studies have dealt with doubts about its effectiveness; in 2001 a careful review of such studies by Bernard L. Bloom, a psychologist at the University of Colorado, found “brief psychotherapy consistently helpful, particularly for mild to moderate levels of depression… The frequent severity and chronicity of these conditions suggests, however, that several brief episodes of care may be necessary to achieve optimal effect.”42

  In 1990, about a third of all psychotherapists in the APA were basically psychodynamic in orientation,43 but ever since the 1960s a number of other therapeutic approaches, very different from the psychodynamic, have been attracting sizable followings. Some of these methods seemed, when new, to be the ultimate challenge to dynamic therapy, but none has ousted it; all methods, the old and the new, continue to be practiced. Some therapists use only or mainly one; many others classify themselves as eclectic and use any of several different methods of treatment, according to need. In recent years there has been an interest in “psychotherapy integration”—the harmonizing of the several major theories of psychotherapy and the use of any and all of the major methods, depending on the nature of the problem and the needs of the patient.44

  Let us look at these newer therapies and try to find out why, despite their profound differences, they are all, most improbably, credited with similar rates of success.

  The Patient as Laboratory Animal: Behavior Therapy

  In 1951 Howard Liddell, a benign, gentle, gray-haired professor of psychobiology at Cornell, was doing research that any outsider would have considered sadistic. He was systematically creating neuroses—or symptoms analogous to those of neurotic human beings—in sheep, goats, and a large pig named Tiny. On a farm outside Ithaca, Liddell or one of his several helpers would attach a wire to one leg of a sheep in a small chamber; then he would flash a light in the chamber, and ten seconds later give the sheep a jolt of current.

  At first the sheep would merely jump, but after scores of shocks it learned the meaning of the signal, and when the light flashed, it would race about the chamber as if to avoid the shock—to no avail. After about a thousand such cycles, as soon as the sheep was led into the test chamber it would begin twitching and jerking, and at the first signal would grind its teeth, pant, roll its eyes, and become rigid, staring at the floor. At this stage, even when it was turned out to pasture, it behaved abnormally; it stayed as far from its fellows as possible. It had developed the animal equivalent of a full-blown stress neurosis.45

  Liddell also sought to reverse the process. A badly traumatized sheep would be wired up in the test chamber and would see the light flash but not experience any subsequent shock. Since a sheep is not a particularly intelligent animal, a great many innocuous flashings were necessary before it began unlearning its fear responses to the signal; eventually it would be thoroughly deconditioned.

  Pigs, in contrast, are smart. Tiny had become phobic about her laboratory feed box after getting shocked a few times when she lifted the lid, so she would not go near it even when she saw food being put into it. To dispel her phobia, a graduate student fed her outside the pen, where she felt safe, until she came to trust him; then he took her into the laboratory, put a juicy piece of apple in her feed box, and talked to her soothingly while scratching her back. “What’s the matter, Tiny?” he said. “Why don’t you eat your apple? Go ahead, try it.” He pointed to it and continued to talk softly and to pat her. Tiny grunted, tentatively tried the box, and got the apple without being shocked. After only a few such sessions she would open the box and eat from it as long as the student was near; later, if anyone was near; and finally when no one was near. She had been cured.

  The induction of neurosis in animals was standard Pavlovian psychology—Pavlov himself had done something like it, and so had other experimenters in the United States—but Liddell was going further by studying deconditioning to cure the neurosis. (“Rest cures”—time spent away from the laboratory—were ineffective; the animal would improve, but on re-entering the laboratory would immediately relapse.) Liddell pursued his work and published his findings for over two decades without suggesting to any clinical therapist that the method might be applicable to human beings. When I queried him in 1952, he was reluctant to speculate but admitted that he hoped it would prove to be useful.*

  It did so far sooner than he expected it to. In Johannesburg, South Africa, a general practitioner named Joseph Wolpe read the Pavlovian literature while studying psychiatry at the University of Witwatersrand in 1947 and 1948, and was greatly impressed. He conducted experiments of his own similar to Liddell’s but using cats, which he made neurotic by shocking them while feeding them in a cage in the experiment room; after a while they would not eat in the cage even when half-starved. Wolpe then sought to reverse the conditioning by offering them food pellets in a room that looked quite different. Their anxiety was low there because of the surroundings, and they soon learned to eat in a cage in that room. Wolpe then fed them in a cage in a room somewhat like the experiment room, then in a third still more like it, and finally in the experiment room itself.46

  He called this method “reciprocal inhibition” or “desensitization”; his theory was that if a pleasurable response (such as feeding) that inhibits anxiety occurs in the presence of anxiety-producing stimuli, it will weaken the power of those stimuli.47 In the case of his cats, the pleasurable response to food became associated with the cage and eventually with the cage in the experiment room, overcoming the anxiety that had been created there.

  Wolpe began seeking a comparable technique that might be used with his human patients. (The feeding response would rarely be strong enough in humans, and in any case would not be practical in office visits.) Retraining human beings by desensitization seemed to him an obviously more scientific way to treat neurosis than by dynamic psychotherapy. It may also have appealed to Wolpe, a small, chilly, authoritarian man, for other reasons. Many years later, a study of the personalities of therapists would find that behavior therapists—those whose methods are based on behaviorist principles—tend to be unemotional and to prefer objectivity and distance, while dynamic therapists tend to be emotional and to prefer subjectivity and interpersonal involvement.48 Wolpe’s dislike of and contempt for psychodynamic psychotherapy was absolute; as he later wrote, “There is no scientific evidence for the Freudian conception of neurosis … A neurosis is just a habit—a persistent habit of unadaptive behavior, acquired by learning.”49

  After some years of experimenting and reading, Wolpe found a method he thought would work; it became the basis of most of his practice from then on. He would induce a pleasant trancelike state in the patient, link its agreeable feelings by associative training with the fear-inducing stimulus, and thereby overcome the fear. (This per
tains only to a neurotic fear; the procedure would be useless against fear aroused by a real and continuing danger, like living in a city under enemy bombardment.)

  Wolpe would begin such treatment by spending a few hours taking a new patient’s history and indoctrinating him or her with the theory that the neurosis was only one or more habits induced by experience and easily replaceable by new habits, without any need to dig into the unconscious or childhood traumas.

  He would then teach the patient deep muscle relaxation, which involves the “letting go” of muscle groups first in the forehead, then the face, and so on down to the toes, until a fully relaxed, half-trancelike state is achieved. While the patient was becoming adept at achieving this, he or she and Wolpe would construct a “hierarchy,” or graded list of stimuli, according to their power to arouse anxiety. Wolpe would have the patient envision the feeblest of them while in the relaxed state. Once it no longer caused any discomfort, they would tackle the next one. The patient would become progressively deconditioned, until the last and worst stimulus was associated with the relaxed state and rendered innocuous.

  In a typical case report, Wolpe told of Mrs. C.W., a fifty-two-year-old Johannesburg housewife, who came to him because of overpowering fears of rejection, illness, and death, along with fears of the symptoms created by these feelings. He and she assembled a hierarchy for each of her fears. That for physical symptoms comprised nine items, the mildest of which was fear of pain in the left hand (caused by an old injury); the most severe, fear of irregular heartbeats. By her eighteenth desensitization session, he had deconditioned her to all but the three most severe items on the list, and at that session worked on her third worst fear, that of pain in her left shoulder. First, he got her deeply relaxed and had her concentrate on her pleasant feelings. Then he proceeded as follows: