The Story of Psychology

by Morton Hunt

  P: Well, come to think of it, he did say that he had been working late those two nights. Also, he has been considerate in a lot of other ways.87

  The patient later found out that her son was, in fact, willing to go to the movies with her.

  As this example illustrates, the crucial aspect of Beck’s style of cognitive therapy is Socratic questioning to get the patient to produce information contradicting his or her assumptions or conclusions, thereby correcting these cognitive distortions. The technique is even more apparent in this excerpt from a therapy session with a twenty-five-year-old woman who wanted to commit suicide because her husband was unfaithful and she regarded her life as “finished”:

  T: Why do you want to end your life?

  P: Without Raymond I am nothing…I can’t be happy without Raymond. But I can’t save our marriage.

  T: What has your marriage been like?

  P: It has been miserable from the very beginning. Raymond has always been unfaithful. I have hardly seen him for the past five years.

  T: You say that you can’t be happy without Raymond. Have you found yourself happy when you are with Raymond?

  P: No, we fight all the time and I feel worse.

  T: Then why do you feel that Raymond is essential for your living?

  P: I guess it’s because without Raymond I am nothing.

  T: Before you met Raymond, did you feel you were “nothing”?

  P: No, I felt I was somebody.

  T: If you were somebody before you knew Raymond, why do you need him to be somebody now?

  P: (puzzled) Hmmm…

  T: Have any men shown an interest in you since you have been married?

  P: A lot of men have made passes at me but I ignore them.

  T: Do you think there are other men as good as Raymond around?

  P: I guess there are men who are better than Raymond because Raymond doesn’t love me.

  T: Is there any chance of your getting back together with him?

  P: No…he has another woman. He doesn’t want me.

  T: Then what have you actually lost if you break up the marriage?

  P: I don’t know (crying). I guess the thing to do is just make a clean break.

  T: Do you think that if you make a clean break, you will be able to get attached to another man?

  P: I’ve been able to fall in love with other men before.88

  Following this session the patient no longer felt suicidal; she began questioning her assumption “Unless I am loved, I am nothing,” and after thinking over the questions Beck had asked her, she decided to seek a legal separation. Eventually she got a divorce and went on to lead a normal life.

  Although by the 1970s many therapists had tinkered with Beck’s detailed prescriptions, cognitive therapy technique had become fairly standardized. It generally required anywhere from six sessions (Beck prefers to call them “interviews”) to many months. At each one, the therapist and patient review the latter’s reactions to the previous session and its results, plan the coming steps in therapy, agree on the next tasks and homework, and apply logic, investigation, and reality testing to the patient’s current perceptions and thoughts about what is happening to him or her.

  By the 1980s, cognitive psychotherapy had become part of the mainstream, and in addition to the one third of all psychotherapists who were primarily cognitive-behavioral, about another third were eclectic, most of them using cognitive-behavior therapy at times.89 It had become widely considered the treatment of choice for certain problems, particularly depression and low self-esteem. Beck, by then white-haired and benign, had become a doyen of psychotherapy. In 1989 the American Psychological Association gave him its Distinguished Scientific Award for Applications of Psychology, citing him thus:

  For advancing our understanding and treatment of psychopathology. His pioneering work on depression has profoundly altered the way this disorder is conceptualized. His influential book, Cognitive Therapy of Depression, is a widely cited, definitive text on the subject. The systematic extension of his approach to conditions as diverse as anxiety and phobias, personality disorders, and marital discord demonstrates that his model is as comprehensive as it is rigorously empirical.90

  That’s not all. In 2004 the Grawemeyer Foundation of the University of Louisville gave him its annual $200,000 prize for outstanding ideas in the field of psychology—and in 2006 he was the recipient of the prestigious Lasker Award for Clinical Medical Research, which consisted of $100,000 and acknowledgment of the “major advance” he had made in psychotherapy.

  By the time of Beck’s APA award in 1989, cognitive therapy and cognitive-behavior therapy were on the rise, and since then their use has caught on almost throughout the field among professionals of many orientations. For several decades, but especially the past one, Beck, his colleagues, and other cognitive therapists have been modifying and expanding cognitive therapy to enable them to apply it to a wide variety of disorders. His original focus was on the use of cognitive therapy (CT) to treat depression, but by now special variants of it have been developed to treat such disparate problems as suicidal tendencies, anxiety disorders and phobias, panic disorder, personality disorders, substance abuse, and the psychical miseries engendered by a variety of physical ailments.

  Among these variant forms of cognitive therapy are, for instance, teaching emotional regulation skills to highly reactive patients, having phobic or anxious patients expose themselves to feared situations, restructuring the meaning of early trauma through imagery, and working through a fear hierarchy with a panic disorder patient (getting the patient to tolerate a minimal fear object, then a slightly worse one, and so on step by step).91

  A mass of research has validated the use of CT, CBT (cognitive behavior therapy), and their variants. There are now some four hundred research reports of outcome studies of CT and nearly as many of CBT.92 Summing up the results, a number of meta-analyses—sophisticated statistical poolings of the results of these research studies—have reported various levels of positive effects, most of them relatively large. A few of the findings: large effect sizes for unipolar depression, generalized anxiety disorder, panic disorder, and a few other disorders; moderate effect sizes for CBT of marital distress, anger, and chronic pain; and small effect sizes for sexual offenders.93

  There is no available statistic concerning the total number of people currently receiving CT and CBT, but it is undoubtedly large—and would be considerably larger except for the recent trend toward the medication of mood disorders. “Where have all the ‘easy cases’ gone?”

  Aaron Beck recently mused. “Our hunch is that most patients respond reasonably well to their first-line treatment—by primary care doctors or psychopharmacologists. The relative nonresponders eventually may be referred to cognitive therapy—which now represents a secondary or even a tertiary—level of care.”94

  But in his introduction to a book by Judith Beck about treating these more difficult cases, he points out that she regards them as a challenge rather than a burden. Such is the admirable ethos of the cognitive therapist.95

  A Miscellany of Therapies

  The three families of therapy we have looked at—dynamic, behavior, and cognitive—are presently the major forms of psychotherapy, but a great many other kinds are available, nearly all said by their developers to be more effective, cheaper, quicker, or better in various ways than any of the big three. Before 1950, there were only about a dozen or so versions of psychotherapy, but by the early 1970s Morris Parloff, then director of psychotherapy research at the National Institute of Mental Health, counted 130; by 1988 Alan Kazdin, of the University of Pittsburgh School of Medicine, searched the key resource material and offered “a conservative estimate” of over 230 alternative treatments; and currently Paul Crits-Christoph, who, you will recall, is the director of the Center for Psychotherapy Research at the University of Pennsylvania, says that recent estimates have put the number at around 600.96

  Bewildering as this may seem, the thera
pies actually fit into a relatively small number of categories: the three we have already seen, a few others that have had some significant impact on psychotherapeutic thinking and practice, and a host of others that have been flashy and newsworthy but account for very little in the real world of psychological treatment.

  First, then, some of the few that are serious entrants in the historical record:

  Humanistic therapies: In the 1950s humanistic psychology, the core of the “human potential movement”—whose leading spokesman was Maslow—emerged as a “Third Force” or alternative to Freudian psychoanalysis on the one hand and behaviorist psychology on the other.

  The humanists, more philosophic than scientific, objected to the psychoanalytic doctrine that the individual’s personality and behavior are totally determined by his or her life experiences, especially those of childhood, and also to the behaviorist view that the individual’s behavior is only a set of conditioned responses to stimuli. Humanistic psychology stressed the individual’s power to choose how to behave and the right to fulfill oneself in one’s own way; it held that behavior should be judged not in terms of supposedly objective scientific standards but in terms of the individual’s own frame of reference. If a person considered an easygoing, noncompetitive, “laid-back” life ideal, that was a valid goal for him or her, not a symptom of a character flaw; so, too, with singleness rather than marriage, sexual freedom rather than monogamy, and other departures from social norms. Humanist psychology therefore had great appeal, especially for the young, during the individualistic, rebellious 1960s.

  Out of this psychology emerged a crop of variant related therapies. Though widely disparate, they are all based on the doctrine that everyone possesses inner resources for growth and self-healing and that the goal of therapy is not to change the client but to remove obstacles, such as poor self-image or the denial of feelings, to the client’s use of these inner resources. The therapist does not guide clients toward a scientific ideal of mental health but helps them grow toward their own best selves. In the late 1980s about 6 percent of clinical psychologists and probably a like percentage of other psychotherapists considered themselves primarily humanistic.97 Today the figure is undoubtedly smaller because of the dominance of the big three and the availability of psychotropic medications.

  Client-centered therapy: This, the most important of the humanistic therapies, was the creation of Carl Rogers, who, born and raised on a midwestern farm, started out to become a minister. He switched to psychology and was trained in psychoanalysis but after some years concluded that it was unproductive, and made another major switch to a very different form of therapy of his own devising. A chronically optimistic man, Rogers felt that therapy should focus on present problems, not past causative factors. He also believed that people are naturally good and can solve their own problems once they accept that they are in charge of their fate, and he translated these views into a technique in which the therapist echoes or reflects what the client—Rogers rejected the term “patient”—says. This is supposed to convey a sense of respect of the client and “faith or belief in the capacity of the individual to deal with his psychological situation and with himself.”98 Here is a sample of the process from a session (abridged here) with a depressed twenty-year-old woman:

  CLIENT: It’s an effort for me to walk down the street sometimes. It’s a crazy thing, really.

  THERAPIST: Even just little things—just ordinary things, give you a lot of trouble.

  C: M-hm, that’s right. And I don’t seem to be able to conquer it. I mean it just—every day seems to be over and over again the same little things that shouldn’t matter.

  T: So, instead of making progress, [you find that] things don’t really get any better at all.

  C: I sort of persecute myself in a sort of way—sort of self-condemnation all the way through.

  T: So that you—condemn yourself and don’t think much of yourself and that’s gradually getting worse.

  C: That’s right. I don’t even like to attempt things. I feel like I am going to fail.

  T: You feel that you’re whipped before you start in.99

  This may sound like a parody of therapy, but Rogers deeply believed that by his method he created “a facilitative climate in which [the client] can explore her feelings in the way that she desires and move toward the goals that she wishes to achieve.”100 Most dynamically oriented therapists were unimpressed with Rogers’s method, but in the 1950s and 1960s client-centered therapy was widely adopted and practiced by those psychologists and other psychotherapists who had not had training in dealing with unconscious processes.101 Thereafter its influence waned; today it is the preferred technique of only a few clinical psychologists and other psychotherapists, although its humane philosophy is said to affect the way many therapists treat their clients.102

  Gestalt therapy: Quite unlike Rogers’s method, though sharing its philosophy of human health and self-direction, this is the technique developed by Frederick (Fritz) Perls, a psychiatrist. He called it Gestalt therapy, although, as noted earlier, it has little in common with Gestalt psychology. Perls’s aim was to make patients aware of feelings, desires, and impulses they had “disowned” but that were actually part of them, and to get them to recognize those they think are a genuine part of themselves but were actually borrowed or adopted from others.103

  Perls’s technique for achieving this was vigorously confrontational and often harsh, and included a variety of “experiments,” “games,” and “gimmicks” designed to provoke, challenge, and force the patient to acknowledge the truth about his or her feelings. In filmed episodes of therapy, Perls seems at times almost sadistic, but with some patients he was very effective. Gestalt therapy was popular and deemed important in humanistic circles during the 1960s and 1970s; today it plays only a very minor part in the world of psychotherapy.

  Transactional analysis: TA was in vogue in the 1960s and is the only recognized psychotherapy to have been the subject of two books on the national best-seller list for over a year (Eric Berne’s Games People Play and Thomas A. Harris’s I’m Okay—You’re Okay). TA is based on dynamic principles, is concerned with interpersonal behavior, and deals with neurotic problems on a “rational” basis—not, however, through reasoning, like RET and cognitive therapy. It works through the therapist’s interpretations of which of three ego states are responsible for a particular behavior by the patient.

  These ego states or selves are the ways in which the patient acts in his or her “transactions.” In any given transaction—the basic unit of social interaction—each person behaves toward another either as Child (the child self, largely emotional, that remains embedded within each of us), Parent (the set of precepts and beliefs—the “shoulds” and “should nots”—we internalized from our childhood perceptions of our parents), or Adult (the cognitive self, the mature and rational ego).

  Although the three ego states are based on unconscious feelings, in TA the therapist deals with them on a conscious level, pointing out the ways in which the patient and the people he or she is dealing with are either communicating successfully or engaging in “crossed transactions.” The therapist also spells out the many “games”—fraudulent or ulterior transactions that conceal the real meaning of the interaction— they play in their inappropriate roles. Patients learn to recognize which self they are being in their transactions with others (and with the therapist), and which the others are being with them. Under the therapist’s guidance, they learn to utilize their Child for fun but have their Adult in charge of their serious behavior.104 Today, TA is one of many special techniques used occasionally by some therapists.

  Interpersonal psychotherapy: This short-term insight-oriented (psycho-dynamic) therapy has proven particularly useful in treating depression. It focuses on the client’s current relationships with peers and family members and aims to discover how what happens in them is connected to the client’s mood; its goal is to improve the way those relationships work on the assump
tion that this will improve the client’s emotional state. The therapist helps the client think about the consequences of how he or she behaves in those relationships, alter those actions, improve communication and openness with the others, and thus modify the relationships in a beneficial fashion, all toward the end of relieving the client’s symptoms.105

  Group, couples, and family therapy: These are not specific therapeutic techniques but “modalities”; a modality is a type of therapy classified by the unit of treatment (individual, couple, family, group).

  Group therapy: At least a hundred varieties exist or have existed; new ones appear every year, but many soon die out.

  In the 1960s and 1970s, in keeping with the spirit of the times and the idealization of communes, “encounter groups” flourished and the group milieu was seen in humanistic circles as more therapeutic than one-on-one therapy. Later, the general view came to be that group therapy is useful primarily for interpersonal and social problems, although it does also address internal ones; members of a group provide one another with support and empathy as well as with feedback on how the social self each presents is perceived and which aspects of it are welcomed and which not.106

  Group activities can range from discussion of one another’s problems and self-revelation to role playing, and from group support of a grieving or troubled member to group attack of a member whose behavior is objectionable. In most groups the therapist steers interactions to some extent and actively intervenes to prevent the group from attacking a member destructively.

  Groups range in size, although most therapists consider eight an ideal number. They usually meet once a week, cost only a fraction of what individual therapy costs, and last anywhere from eight weeks to years, depending on their goals and the therapists’ orientations. Group psychotherapy used to be an American specialty but now is practiced in many countries; there are still, however, more group therapists in this country than any other. The American Group Psychotherapy Association has close to three thousand members; probably ten times that many therapists not in the association conduct groups at least part of the time.107