by Morton Hunt
If by chance any scene should disturb you, you will indicate it by raising your left hand. First, we are going to have something already familiar to you at these sessions—a pain in your left shoulder. [In previous sessions she had said she was disturbed at imagining this.] You will imagine this pain very clearly and you will not be at all disturbed… Stop imagining this pain and again concentrate on your relaxing…Now again imagine that you have this pain in your left shoulder… Stop imagining this pain and again relax…[A third cycle followed.] If you felt in the least disturbed by the third presentation of this scene, I want you now to indicate it by raising your left hand. (The hand does not rise.) [The patient later reported that the first presentation of the imagined pain had slightly disturbed her, but by the third presentation it had not done so at all.]50
By this method, Wolpe claimed, he had been able to cure not only phobias but neuroses of many sorts—usually in about one-twentieth the number of therapeutic sessions required by psychoanalytic therapy. Many of his cases were more dramatic than that of Mrs. C.W.; they ranged from an extreme fear of driving to an equally extreme fear of urine (by a youth who had been a bedwetter). Even when the presenting symptoms sounded like the kind of neurosis that would require dynamic therapy, Wolpe found explanations based on simple phobias. A twenty-seven-year-old woman came to him complaining of frigidity (Wolpe’s word) and serious problems in her marriage, notably an inability to assert herself. Wolpe, rather than searching for deep psychological fears of domination, as Freudians might have, concluded after questioning that her anxiety was triggered by situations involving the sight or touch of a penis, which she found revolting.
He and she then worked up a hierarchy in which the least fearful situation, for her, was seeing a nude male statue in a park thirty feet away. After she overcame anxiety at imagining this scene, he brought her closer and closer, until she could imagine herself handling the stone penis. He then switched to a series of scenes in which she imagined herself at one end of the bedroom, seeing her husband’s penis from a distance of fifteen feet. Through desensitization, she was brought closer and closer until she could imagine herself briefly touching the penis, and then doing so for longer periods of time. By about the twentieth session she reported that she was enjoying sexual relations with her husband and having orgasm about half the time.51
Such systematic desensitization, according to Wolpe, proved to be the method of choice for about 70 percent of his patients; for the other 30 percent he worked out other techniques. During the early 1950s, he began making his work known through journal articles, and in 1958 presented a full-scale treatment of it in the book Psychotherapy by Reciprocal Inhibition.
By then, a handful of other therapists had followed suit and begun practicing desensitization and developing other forms of behavior therapy. The most influential were Arnold Lazarus, another South African, who had come to the United States and was the first person to use the term “behavior therapy,”52 and H. J. Eysenck in England. For a while, behavior therapy of neurotic conditions remained a novelty and rarity. Few clinicians practiced it, because it was diametrically opposed to the dominant dynamic tradition, and, in any case, there was no place in the United States to get training in it. But in 1966, Wolpe, by then at Temple University School of Medicine in Philadelphia, launched a program of research and training in behavior therapy. The same year, a nonprofit clinic and training center called the Behavior Therapy Institute opened in Sausalito, California; a new book, Behavior Therapy Techniques, by Wolpe and Lazarus (by then his colleague at Temple), appeared; and the following year Wolpe and behavior therapy were introduced to the nation’s intelligentsia by an article in the New York Times Magazine. 53
From that point on, research on behavior therapy and publication of articles about it increased rapidly; by the 1970s it had become a leading method of therapy and has remained so, though it has never supplanted dynamic therapy, as Joseph Wolpe felt it should. Some psychotherapists practice it exclusively; many more use it in combination with cognitive therapy (which we will look at shortly and which they call cognitive behavioral therapy); and a number of others, including some whose primary allegiance is to dynamic therapy, use behavior therapy now and then for the treatment of specific phobias such as fear of driving, flying, cats, or crowded places, which often can be cured without concomitant dynamic treatment.
A particularly interesting use of the desensitization technique is in treating sexual dysfunctions, especially impotence and female lack of orgasm. In the late 1960s, William Masters and Virginia Johnson, both sex researchers but neither one a psychologist, developed what has ever since been one of the key treatments of such difficulties when they result from anxiety, not from an organic condition. The method pioneered by Masters and Johnson involved instruction in, and the practice of, step-by-step desensitization—the procedures were carried out by the couple at home over a period of days or weeks—starting with the partners touching each other’s bodies, gradually coming to fondle each other’s genitals (intercourse is barred, to prevent performance anxiety), eventually inserting the penis in the vagina but without coital movement, and finally, when that condition is anxiety-free, proceeding to full coition. Unlike treatment of the simpler phobias, however, sex therapy generally required discussion of and education in the couple’s relationship.54
The Masters and Johnson form of sex therapy was rapidly adopted and used by a wide variety of therapists. The results, however, were often less than hoped for, and over a number of years sex therapists modified the basic desensitization therapy into more of a cognitive-behavioral process, often including bibliotherapy. In one form or another, it continued to be one of the techniques used by some psychotherapists, especially those who specialize in treating sexual dysfunctions.55
Desensitization remains the most frequently used technique of behavior therapy, but for certain conditions different techniques developed by Wolpe and others work better. They are:
Aversive conditioning: The goal of this technique is to eliminate undesired behavior, such as alcoholism, drug use, or deviant sexuality. According to behaviorist theory, when a response to a stimulus is linked with pain or punishment, the response becomes weakened or inhibited. As a treatment, it calls for causing the patient discomfort when he or she does, or thinks of doing, whatever act is to be eliminated.
In an early form of aversive conditioning used with hospitalized alcoholics, mentioned earlier in this chapter, the patient would take a nausea-producing drug along with an alcoholic drink; the drink was followed by nausea and vomiting. After a number of such experiences, the patient might find the sight or even the thought of a drink repellent.
Later, electric shock became the preferred method for treating motivated alcoholics, heavy smokers, overeaters, persons plagued by obsessive-compulsive routines, and sexual deviants. An example: A thirty-three-year-old man sought treatment for his lifelong interest in women’s undergarments and his impotence with women. He would buy panties or steal them from clotheslines, put them on, and masturbate. In treatment, he would look at a pair of panties or a picture of them or would think of them; as he did so, the therapist would give him a brief but painful shock. After forty-one sessions and 492 shocks over a fourteen-week period, the patient said that panties no longer aroused him; with this obstacle cleared away, he and his therapist were able to treat his impotence by other methods.56
Some therapists used aversive conditioning to treat male homosexuals, delivering a shock to them when they looked at pictures of nude males but not when they looked at pictures of nude females.57 There were reports of modest success with this method, but when homosexuality came to be redefined during the 1970s as a sexual preference rather than a mental disorder, this use of aversive therapy was abandoned.
A mild form of aversive conditioning is called covert sensitization. Patients are trained to punish themselves by thinking some loathsome thought when they are about to do whatever it is they want to stop doing. A drinker, for
instance, may be taught that as soon as he walks into a bar to buy a drink, he should visualize himself becoming nauseated, vomiting all over his hands, shirt, and suit, and on the bar and the bartender, but, as soon as he turns away and heads out, feeling better. Evidence of this method’s usefulness has been scanty.
By and large, the stronger aversive methods have fallen into disfavor and now are rarely used. Not only did they involve risks to health, but aroused ethical concerns, patient resistance, and negative public perception of procedures that customarily (and intentionally) cause extremely uncomfortable consequences. These effects often lead to poor compliance with treatment, high dropout rates, potentially hostile and aggressive patients, and public relations problems. Social critics and members of the general public alike often consider this type of treatment punitive and morally objectionable.58 The benefits, moreover, have not proven long-lasting unless alternative ways of behaving replace the inhibited one. For such reasons, most psychotherapists consider aversive therapy a last resort.
Assertiveness training: This is not a single technique but several; all aim to help patients overcome social anxieties and inhibitions and act more assertively in situations in which they have been timid and passive. Treatment begins with education: The therapist and patient discuss threatening situations and identify appropriate responses. The patient is then encouraged to try out those behaviors in mildly threatening situations, and, as he begins to feel some control, extend them to more severe ones.
An important part of assertion training is “behavior rehearsal.” The patient enacts his or her role in a threatening situation, with the therapist playing the part of the threatening person (employer, spouse, neighbor). The patient has the opportunity to practice saying and doing whatever he or she needs to do in real life, with feedback and direction coming from the therapist, until the patient is skilled in the role and comfortable with the new behavior, and begins to see himself or herself in different terms.59
Modeling: Albert Bandura of Stanford University developed this technique based on his theory that most human behavior is learned by identifying with and imitating others of personal importance. The heart of the treatment consists of the patient’s watching the therapist behave in a particular way, learning by imitation, and modifying his or her behavior accordingly. As Bandura has pointed out, this is the process by which millions of people, watching and imitating others at Toastmasters Clubs, have overcome their fear of public speaking.60
Modeling, first used to change the behavior of children, was soon found useful in combating phobias in adults. Typically, treatment consists of having the patient watch the model in contact with the feared object in a relatively unthreatening situation, then in a series of increasingly threatening ones. In dealing with snake phobia, for instance, the model first touches the snake, then holds it, and finally allows it to crawl over his body. The therapist encourages the patient to go through the same series of activities, even guiding the patient’s hand and praising him for his efforts. Gradually, the therapist reduces the degree of demonstration, protection, and guidance until the patient, alone and without help, is able to confront the feared experience.61
Operant conditioning: After the success of the experiment in the 1960s and 1970s in which the behavior of hospitalized psychotics was modified by the use of rewards, many mental hospitals instituted programs based on such operant conditioning. Nurses and psychiatric technicians were trained to give tokens (poker chips, cards, or imitation coins) to patients for such desirable acts as grooming themselves, keeping their rooms neat and clean, behaving normally toward other patients, and taking on job responsibilities. The tokens were exchangeable for such privileges as a movie, a special food, a private room, or a weekend pass. Positive results were widely achieved, particularly with patients who had been withdrawn and apathetic for years. “Token economy” programs, as they are called, have also been used successfully with retarded persons, delinquents, and disturbed schoolchildren.62
All in the Mind: Cognitive Therapy
Nearly two thousand years ago, the Stoic philosopher Epictetus composed an apothegm that anticipated the theory behind a major form of current psychotherapy: “People are disturbed not by things but by the view which they take of them.”63
Some may find this shallow, others too pat, but its validity is shown by the effectiveness of cognitive psychotherapy. Albert Ellis, one of the originators of this form of therapy, has summed up its basic principle in what could almost be a rewording of Epictetus’s apothegm: “You largely feel the way you think, and you can change your thinking and thereby change your feeling.”64
Cognitive psychotherapy is often called “cognitive-behavior therapy,” since it incorporates elements of behavior therapy. But though the two forms overlap, they have a somewhat different focus. Behavior therapy often treats the patient like the sheep or pig whose behavior and reactions can be shaped by desensitization and other forms of conditioning; cognitive therapy seeks to modify the patient’s feelings and behavior by modifying his or her conscious thoughts.
The cognitive approach to mental disorders emerged in the early years of the cognitive revolution in psychology. In the 1940s and early 1950s, several psychologists theorized that flawed cognitive processes, rather than unconscious conflicts, were responsible for many neurotic conditions. One of the therapists was Julian Rotter (whose work on internal and external locus of control we looked at earlier); both an academic and a therapist, he devised “social learning” therapy, a method of getting the patient to rethink his or her faulty expectations and values.65
Albert Ellis, a cognitive therapist well known to the public, has said that he was “spurred on” by Rotter’s and others’ writings but that he began practicing and promoting his own rational-emotive therapy (RET), a form of cognitive therapy, in 1955, and was therefore “the first major cognitive-behavioral therapist” and “the father of RET and the grandfather of cognitive-behavioral therapy.”*66
Not exactly a modest statement, but Ellis was not a modest man. He has unblushingly written that he was “one of the most distinguished alumni of Teachers College” and “one of the best-known clinical psychologists, as well as one of the most famous sexologists, in the United States and in the world.” “My ‘old age,’ during the 1980s,” he wrote in 1991, when he was eighty-eight, “has seen my professional and public popularity, as well as that of rational-emotive therapy and cognitive-behavior therapy, steadily progress.”67 He said that “when not absorbed in something big, ongoing, and creative, [I am] easily bored,” and admitted to being a workaholic—but a healthy one—whose typical workday was seventeen hours long, running from 8:30 A.M. to 1:15 A.M.68 Not surprisingly, at ninety-three he was lean, even skinny; his long face was often saturnine but could break into a demonic grin, and except for the lack of a pointed black beard, he looked something like the operatic conception of Mephistopheles.
Even if one discounts the hyperbole, Ellis’s achievements and energy were extraordinary, considering the poor start he had.69 He has described his father as a spendthrift and runaround who gave him no fathering and his mother as given over to bridge, mah-jongg, and other diversions. Young Ellis, who grew up in the Bronx, was hospitalized eight times for nephritis between the ages of five and eight, and was forbidden to play active sports, developed into “something of a sissy” where such activities were concerned, and was shy, introverted, and phobic about speaking in public. All this, he has said, helped him become a “stubborn and pronounced problem solver”:
If life, I said to myself, is going to be so damned rough and hassle-filled, what the devil can I do to live successfully and happily nevertheless? I soon found the answer: use my head! So I figured out how to become my nutty mother’s favorite child, how to get along with both my brother and sister [despite] their continual warring with each other, and how to live fairly happily without giving up my shyness.70
In his teens and twenties, Ellis’s ambition was to become a writer; he prod
uced many unsuccessful manuscripts, but, being practical, took a degree in accounting and another in business and, despite the Depression, was able to get decent jobs. Among his unpublished manuscripts was a vast tome on sexuality, and friends often asked him for sexual advice. He liked counseling them so much that he decided to become a clinical psychologist, and, while holding down a job managing a gift-and-novelty firm, went to graduate school at Teachers College, Columbia University, and received his doctorate in 1947, at thirty-four.
For any normal man, so late an entry into the field would have meant a minor career, but not for Ellis. While working in the New Jersey mental health system for some years, he took four years of psychoanalytic training, began seeing patients of his own in 1948, and by 1952 had a full-time practice in Manhattan. He also began the abundant production of both professional and popular books on sexuality and allied matters; his radical views and frequent penchant for vulgar language made him something of a scalawag in psychotherapy, a role he seems to have delighted in all his life.
Between 1953 and 1955, Ellis began to rebel against psychoanalysis; he found it too slow, too passive (on the part of the analyst), and not suited to his personality. As he explained to Claire Warga, a psychologist who wrote about him in Psychology Today a few years ago:
Patients temporarily felt better from all the talk and attention but didn’t seem to get better…I began to wonder why I had to wait passively for weeks or months until a client showed through his or her own interpretive initiative that he or she was “ready” to accept my interpretation. Why, if clients were silent most of the hour, couldn’t I help them with some pointed questions or remarks? So I began to become a much more eclectic, exhortative-persuasive, active-directive kind of therapist.71
