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BRIEF THERAPY: DOING THERAPY QUICKLY AND EFFECTIVELY THIRTY YEARS AGO
In that year only one per cent of Americans used any kind of mental health services. By 1980 this fraction of Americans buying mental health services grew from one to ten per cent. The proportion of funds spent in mental health for outpatient services grew from one per cent in 1966 to twelve in 1980. Given that one per cent of all populations studied are schizophrenic it is obvious that before 1966 most mental health services were addressed to the seriously ill or at least to the heavily treated. I made my own survey because I was a major consumer of mental health services as the superintendent of three schools for children in trouble. My findings echoed the conclusions of Eysenck, Slack and others that there were no services with demonstrable benefits for the price. When clients were put on a waiting list they got well as soon as the clients receiving therapy. Fortunately, in the intervening 31 years there have been measureable changes in psychological services and in the measurement of the efficiency of mental health professionals. THIS ISN'T THE WAY I WAS TRAINED! Recently I was piqued by the comments of a number of relatively senior therapists who had paid to attend a workshop on managed care. Most of the therapists had been trained before 1975 and nearly every one expressed unhappiness, repeating the phrase again and again, "this isn't the way I was trained." Consider what our training was based on in 1965-75.
POOR PROOF, IF ANY, OF EFFICACY The most encouraging report published before 1966 was not comparative. The Group Health Insurance of New York, NIMH, the American Psychiatric Association, and the National Association for Mental Health (Avnet, 1965) cooperated in a very large study involving more than 1200 of 2100 New York psychiatrists. Treatment was limited to 15 sessions. The psychiatrists rated 76% of the patients as improved and 10.5% as recovered. Thirty months after the treatment 81% of patients stated they had improved, and 17% stated they had recovered as a result of treatment. These results are certainly as good as those reported for longer forms of therapy even though the psychiatrists had recommended that 94% of the patients in the study continue in therapy. The bias of psychiatrists against brief therapy was well documented in this study - and yet, brief therapy in the hands of these same biased therapists worked well! Nobody knew what would happen to an equivalent number of patients seen by psychics, painted green or left alone. Consider that all through the period of our training Tom Szasz, Hans Eysenck, Ivan Illich, E. Fuller Torrey and other critics of the basic world view of psychotherapy were widely read and believed. One wonders why it took government and insurance companies so long to inquire about what they were getting for their dollar, and why it took so long for the institutions of managed care to develop. SUGGESTIONS THAT PSYCHOTHERAPY ACTUALLY WORKS! In 1980 the OTA published a report of a substantial study which proved that psychotherapy was effective. This cause to cheer, alas, was diminished as there was no evidence suggesting which of the 150 identified forms of psychotherapy was more useful, or which was applicable to which problem. No such guide has been developed (Luborsky, 1988). Senators Inouye and Matsunaga proposed that an independent, interdisciplinary commission be set up to decide which therapies would be reimbursable under Federal programs. Practitioners were horrified. What will happen to us? (DeLeon, VandenBos & Cummings, 1983; Strupp, 1986). BIG THICK BOOKS ON HOW TO DO IT, BUT NO PROOF IT WORKS! An example of the problem psychotherapists have in convincing insurers to pay for "treatment" is made by the research on treating Post Traumatic Stress Disorder. One might consider that 30-15 years after the trauma victims were shipped back from Viet Nam that there would be a rich and rigorous literature. Rich, yes. Peterson (et al) published an exhaustive summary of treatment of Post Traumatic Stress Disorder in 1991. The best they could say in their review of published reports is that behavior therapy looks pretty good "there is even an example of a quasi-experimental control group design (p.169). " One might guess what "quasi-experimental" means. Over time there was no difference between untreated controls and dynamically treated PTSD victims. These authors' conclusion in 1991 is that there is no good basis in research for treating PTSD. In this pathetic conclusion they echo Fairbank and Nicholson (1987) in an exhaustive review (the entire issue of the journal, CLINICAL PSYCHOTHERAPY, is devoted to PTSD) "published reports of group outcome studies have yet to appear in the literature (p.47)"..."the efficacy of behavior therapy for combat-related PTSD is still a long way from being firmly established (p.48)." The general conclusion is that 30 years after the beginnings of the Viet Nam war the issue of PTSD treatment is scientifically in its infancy. Will we wait until the veterans are all dead before dealing with the outcome of their treatment by professionally competent studies? WHO SAYS THE TRAINING WORKS? Unfortunately, the literature is not much richer than it was in 1965 regarding comparisons of therapist training, therapist technique, and cost effectiveness of comparable methods. Piper (1988) concludes that the NIMH study (Elkin et al 1985) is the best of multi center studies, but the "results are disappointing to practitioners." The effects of therapy are not proven to be robust and no permutation of therapy proves better than any other permutation. EDUCATORS GAVE UP RESEARCHING METHODS The reason that comparisons of teaching methods are rarely seen in educational research, according to Gage (et al, 1963) is that all the earlier research could not demonstrate any significant difference. Indeed, noneducational variables have repeatedly been shown to be more important than what it is that schoolmen do (Coleman, J.S. et al, 1966). It may be that psychotherapy is equivalently irrelevant. LICENSING AND CERTIFICATION ARE ECONOMIC PLOYS NOT GUARANTEES OF COMPETENCE In his aptly named FOXES IN THE HENHOUSES Gross (1984) gave us a scholarly review of the literature on licensing in the professions. Gross could find no objective evidence of a scientific basis for licensing or evidence of protection of the public by licensing. Likewise, a review of the certification literature failed to show a shred of evidence that a certified practitioner differs in any important respect from an uncertified practitioner. Ziskin (1981) has been destroying professionals in court with these findings for years. The research does document that therapists make errors (Suh et al, 1986); that therapists differ significantly in effectiveness (Lafferty, Beutler Crago, 1989); and that some patients are hard to help (Aronson, 1989). Experienced consumers of psychotherapy are likely to ask what has been done to demonstrate the value of therapist education (Shaw & Dobson, 1988); to reduce therapist errors; to improve or eliminate unsuccessful therapists; and to deliver services to patients likely to benefit from them. When Beutler & Crago (1991) surveyed international psychotherapy research they found that only 1 of 40 studies considered "cost-effectiveness" or evaluated services. Most psychotherapy research aims to understand the process by which therapy outcome is achieved, and not if the outcome is in fact achieved or if it is achieved efficiently (Parry, 1992). Parry (1992) concludes that "psychotherapists are often sceptical" ...but, ..." unmonitored practice is no longer defensible." The reality that managed care is an unproved, unwanted, undemocratically imposed interference with our professional independence may be too bad, but it is the reality within which we are going to make our livings. For decades mental health clinicians could believe that the costs of services are the business of business and not at all a clinical concern. Newman & Howard (1986) conclude that this attitude is the most pervasive myth in the clinical community. The myth is no longer viable. He who pays the piper calls the tune and the tune is "Axis I, Axis II, Axis III, and IV and V." ON THE OTHER HAND WHO DOES THE RESEARCH AND HOW? There are many problems with outcome research. The extensive measurements used by researchers don't resemble what happens in the clinical setting. Worse, the measurement itself may change the result for the worse (Firth, et al, 1986). The way in which randomization is done in outcome studies is often not random and creates client attrition which is usually not reported. No studies examine the modal patient in psychotherapy. More than half of those who make first appointments do not keep them. The next most modal patient is the patient who comes once, the next comes twice, the next three times. The most common event in psychotherapy is the "no session" patient who makes an initial appointment and never appears. Nobody knows anything about these people and what happens to them. Three of three studies have shown that a long wait before receiving psychotherapy equals a poor outcome (Luborsky et al, 1988). Since many studies are self controlled using waiting patients, these studies may be self-fulfilling the prediction of "poor outcome". There are many criticisms of the experimental research which has been done on naturally occuring systems (Willems & Raush, 1969). Generally, studies ignore the natural interactions in complex systems. This oversight is particulary true of psychological research. GOALS - NOT CHANGES IN TEST SCORES Measured changes are often trivial. What does a reduction of 20 scaled points on the MMPI Scale 4 mean - behaviorally, emotionally or cognitively? Fortunately, more workers are attempting to estimate the clinical significance of measured change (Jacobson and Truax, 1991). Strupp (1986) makes the cogent observation that the improvement which may be a disappointing result for one patient may be an extraordinary achievement for another. Despite the influence of Skinner psychologists remain preoccupied with statistical significance and not with the significance of a change in real terms in the natural world. Attainment of goals (Kiresuk & Lund, 1978) may be a robust way to measure therapist's effect. Certainly the method of "progress to goals" has been adopted in the rhetoric of CHAMPUS and other managed payors. However, there are robust forms of therapy which vigorously dispute the value of "goals" and "problem" orientation (de Shazer, 1985). Othmer (1991) has argued that outcome is a superior method of proving value, especially when a profound change reliably occurs. Skinner argued that science proceeds by prediction and control, not merely by observation and comparison. It seems reasonable to conclude that if all known forms of therapy fail to change a condition, and a procedure reliably changes the condition, there is no need for elaborate study. The results of a .45 caliber bullet through the brain do not require subtle analysis. IS A DIAGNOSIS A SYNDROME? A CONDITION? A PROBLEM? A DISEASE? One of the motives for the radical changes represented in DSM III was to move from highly theoretical categories to functional descriptions of syndromes. Originally clinical psychologists thought of themselves as different from psychiatrists because psychologists used a learning model and psychiatrists used a disease model. Psychologists eschewed the medical model and did not diagnosis a disease or a condition. Psychologists described patterns of emotion, perception, learning, memory and behavior. We called the subject of our efforts a 'client' and not a patient. In those days most of us were paid by universities, the next largest group by government agencies and a few stars were paid by well-to-do private individuals. Today the majority of psychotherapists are paid by insurers. These economic realities have forced us all to become fluent in the use of the latest incarnation of the DSM. Psychotherapists get paid by playing the "pick a condition" game. The fact that the DSM has evolved toward a descriptive basis with little theory doesn't change the fact that most of us feel impelled to act like 'real doctors' and to 'treat' 'patients' for 'diseases'. Strupp (1986) congently reflected that the medical drug metaphor used by government and insurers fundamentally distorts the purpose and methods of psychotherapy. Many, if not most, medical procedures have never been submitted to double blind evaluation (Wortman & Saxe, 1983). Medicine is the one true religion in our culture and doesn't seem to require validation. We have benefited by being minor clerics but now the payor wants to look at our pipes. Managed care is here to stay. DO OUTCOME STUDIES LOOK AT THE RIGHT OUTCOME? It can be that researchers have been asking the wrong questions. Therapy is a kind of natural system and ethological techniques may be more useful than those evolved in the rat lab (ibid.). Outcome research has ignored the process by which outcome is achieved. Tests of statistical significance may endorse as significant results which are clinically trivial. It seems reasonable to argue that the clinical significance of measured change is more important than the measurement. Exner reported (1992) that improvement in Rorschach responses were confirmed after therapy by the self reports of patients. Are these results more valid than when only the patient's opinion is relied upon without a Rorschach? Speer (1992) reported that when outcome criteria are tested for relevance the results of such outcome studies tend to verify that therapy resulted in an improvement in general well-being. Campbell et al (1982) applied a systems analysis to the evaluation of therapy services insisting that the interests of all the stakeholders in the process of therapy have to be be integrated in any meaningful study. The psychotherapist has a different focus of interests and goals than the patient, her family, her insurer, the professional who referred her, the professionals interacting with her for other purposes, the licensing, accrediting and policing agencies and all the other agencies with a stake not only in helping the patient, but in maintaining their own interests, not to neglect consideration of their share of the health care dollar. Rosenthal & Weiss (1966) anticipated that soon there would be a great demand for proof of the quality of therapy and reported that performance feedback within therapy organizations is critical at anytime there are new services, or turbulence or crisis in the system, or when the organization has to justify itself to outsiders. Smith (1990) reported that the model for proof of quality often adopted by third parties has been 'standards and inspection' making an assumption that the provider is a fraud. Total Quality Management was proposed by Smith (ibid) and others (Collard, 1989; Juran, 1988) as an alternative to those methods which presume that bad results are due to bad people. They suggest that we substitute a climate where therapists are enthusiastic about identifying problems and about working to improve quality. Total Quality Management assumes that poor quality results from bad systems and not from bad people. Organizations with self evaluation built in (Wildavsky, 1972); and organizations which can learn (Garrat, 1986); and reflective practitioners (Schon, 1983) can be combined in a system which by learning from experience can serve the needs of managers to increase cost-effectiveness (Berwick, 1990). However, the culture of independent practitioners working in more or less isolation (required only to attend 20 hours of continuing education each year) is not a "system" with a lot of connectivity or energy in it. The system of medicine is sluggish enough, it may be that the system of psychotherapy is comatose. Payors are now demanding that a vigorous system be created. It is the birth pangs of this dynamic which are so distressing to colleagues still in denial that the same thing can happen to them as happened to small towns when their Mom and Pop merchants bankrupted because of Walmart and its competitors. The people who pay are demanding that psychotherapy services be relevant, appropriate, equitable, accessible, acceptable, effective and efficient (Maxwell 1984). In 1966 it was already a cliche that the patients who did best in psychotherapy were those who did not need it. The YAVIS criterion was an inside joke. Young, attractive, vital, intelligent, successful individuals benefit best from psychotherapy. In other words, the patients we work best with are the ones who need us least. There is a mild consensus that poorly integrated patients can be made worse by expressive and exploratory psychotherapy, and will do better in structured supportive therapies (Horowitz et al, 1984; Jones, Cumming & Horowitz, 1988); while well integrated patients who are highly distressed may do well in exploratory psychotherapy (Luborsky et al, 1971; Mohr et al, 1990). There is nearly universal agreement that defensiveness in a client who has little or no support system augurs poorly for the therapeutic outcome (Gaton et al, 1988). Perhaps the most universally agreed predictor is that some patients are 'hard to help', viz. the borderline personality (Aronson, 1989). No one has disproved Malan's (1979) report that even experienced clinicians acknowledge that their clinical predictions are often wrong. Parry (1991) insists (p.13) ..."we await well-designed cost-effectiveness studies to compare brief therapies, to which some patients may require repeated access, with long-term approaches." There is no shortage of proposals to estimate cost effectiveness in psychotherapy services; but in practice the research has not been done (Weinstein, 1990). Moreover, effectiveness, efficiency and acceptabiity are highly subjective and the values of consumers, providers and funders all shape the targets and methods of research (Vuori, 1982). It is telling that psychotherapy research is not imbedded into the delivery system. Piper (1988) concluded that most psychologists agreed that good research should have some congruence with reality; not only using matched controls and randomized selection of clients; but also using real clients and real therapists in the real world; the techniques used should be authentic and the therapists should be experienced. Outcome variables need not only to be sensitive but they need to make some sense in the real world. Samples should be large enough to make assessment robust and not merely statistically significant. Relevant and rigorous research tends to have a healthy effect in and of itself changing the way clinicians behave by reducing dogmatism and authoritarianism and by encouraging a willingness among therapy staffs to change hypotheses and to respect evidence (Safran et al, 1990; Jacobson & Truax, 1991; Newman & Howard, 1991; Strupp, 1986). Difficult and unacceptable as external monitoring may be the needs of the many funders will prevail. Useless, even wasteful, third and fourth party management is inevitable. Finally, it is important to say that no one has demonstrated that managing care is itself cost effective. Nonetheless, professional auditing systems are a reality in the market. Application of managed care is a political judgement and no one consulted patients, practitioners or the public before setting into place a gigantic machine which profoundly shapes how care is delivered and changes the quality of that care (Parry, 1991). ARE CRITICISMS REALLY CRITICISMS? Major criticisms of the judgement of psychologists (Faust and Ziskin) are often better known (especially to managers, jurists and lawyers) than some more sober and competent studies (Matarazzo, 1983; Dawes, Faust & Meehl, 1989). Farber (et al, 1986) reported that psychologists achieved an accurate hit rate of 81% assessing severely ill patients. Another 15% who missed the textbook "condition" assessed the patient in a reasonably close category (paranoid schizophrenia, missed as schizoid personality or paranoia; paranoia missed as paranoid schizophrenia). Such studies as Farber's are not glamourous and do not achieve a vogue and tend to be buried in the technical literature. But they do demonstrate a 96% agreement among psychologists assessing patients. Studies which do not, per se, focus on competence often, in passing, actually address the issue more effectively. This is particularly true when outcome researchers are proceeding from a notorious bias. ARE PSYCHOLOGISTS REALLY AS INCOMPETENT AS ZISKIN SAYS? Faust and Ziskin operate a lucrative consulting business showing lawyers how to to demolish psychological evaluations in litigation. They have a highly vested interest in maintaining proof that psychological opinions are worthless. Ziskin mailed dittoed sheets listing raw data of patients' performance on the subtests of the Halstead Reitan battery to those psychologists who listed an interest in neuropsychology in the APA membership directory. His psychologists were self selected from that mailing. The Ziskin study amounted to a test of the diagnostic skill of psychologists with the ego needs, surplus time, and sufficient fluency with the Halstead readily to translate raw data on a badly dittoed sheet into some more manageable form. Almost certainly these psychologists did not use actuarial rules. But no one knows as they were not asked. Ziskin's self selected "authorities" did no better than chance at diagnosing brain disorders. However, Ziskin reported that "neuropsychologists" had failed. His conclusion is about as cheap as his dittoed sheets - in a day of xerox! Farber looked at how well we detect partial seizure with complex symptomatology (PSCS). Not surprisingly she found that only 5% of the experts accurately diagnosed a single case of PSCS from sketchy written notes. However, 83% accurately diagnosed the bipolar case; 81% the paranoid schizoprhenic; 76% the simple paranoid case; 72% the major depressive episode with psychotic features. Only 56% accurately diagnosed the organic personality syndrome; but 23% did not attempt to diagnose that case at all, responding with a respectable "I do not know". Only 21% gave an alternate and faulty diagnosis. Since Farber's study was not published as an evaluation of psychological ability to agree on general diagnoses, but as a special study of recognition of PSCS it is not widely cited when accuracy is at issue. Almost casually Farber gave us robust evidence of the reliability of psychological judgement. IS ANOTHER MODEL FOR EVALUATING THERAPY MORE EFFICIENT? A famous case of psychological detective work is reported in the famous CLEVER HANS (Rosenthal, 1965). Oskar Pfungst made a series of successive analyses of the behavior of a horse which had been certified by 12 outstanding experts to be genuinely intelligent and not controlled or guided by conscious or unconscious means. Oskar Pfungst did not have a series of Clever Hansies on which to do a statistical analysis. His discovery of the manner in which Hans was cued unconsciously by his master and in his master's absence by naive querents is an elegant example of scientific method. We are not stuck with double blind trials analyzed by statistics. If we can predict what will happen, and by taking consistent action cause the predicted event we have proved the principle. Behavior therapy has tended to rely on single case analysis without controls. On the whole, this approach seems valid in cases of long standing disability and where many therapeutic trials have proved useless. It seems important to grasp firmly the principle that very few advances in science have been made by statistical comparisons. Outcome studies without prospective double blind and crossover designs are more applicable in the real world that this recent technique which has not been productive of much work outside of drug studies for which it is admirably suited. How do you do a double blind crossover study of using a rectal plethysmograph to give EMG signals to train a post stroke patient in regaining bowel control? Why bother? When for 2500 years of recorded medical history these patients have rarely improved after several months of incontinence? For that matter, why bother to do a comparative study on treating alcoholics when you have a 2500 year data base for comparison. Get me 30% sober drunks for 5 years and you have proof positive of a valuable technique. Peniston's (op cit) 85% is astonishing, and the control was a waste of money except that in the real world of precious academicians without the control the study would really have been ignored. As it is it is an ethical fiasco that the method is not used in every center in the country. It is truly puzzling that insurers are still paying for any other "treatment" of alcoholics. I first typed this sentence in 1993 and it is now 1998 and there is no wider use of the Peniston method, despite six studies replicating Peniston's work and producing the same 85% sobriety. Alcoholism is a ghetto field, Peniston is an Afro American, and his degree is an Ed.D.; if you regard these as irrelevant data points then you don't really grasp what is going on in the real world. DOING THERAPY QUICKLY AND EFFECTIVELY: WHAT WORKS? In 1970 Rosenhan wrote ON BEING SANE IN INSANE PLACES offering a brilliant challenge to mental hospitals by showing that the label "schizophrenia" was all that was needed to justify expensive treatment. He also showed that you could get the label "schizophrenic" just by stating that you had heard a voice saying "thud" and nothing else was wrong with you, but that the event concerned you. Polak and his colleagues responded to Rosenhan's challenge and wrote ON BEING INSANE IN SANE PLACES and demonstrated that at least one mental hospital could be made responsive to patient needs. In their hospital clinical staff offices were abolished; psychiatric diagnosis was relegated to a secondary position; it was made a firm policy that the need for inpatient care had to be proved. The Southwest Denver Community Mental Health Services pioneered in the use of private homes and informal care to replace hospitalization. The cost of care plummetted and money could no longer be squandered on sham patients. Psychologists, taking their science seriously can make real differences to real people. ROBUST PSYCHOTHERAPIES: CLINICAL HEALTH PSYCHOLOGY The effect of psychotherapy on such intangibles as "well being" or "improvement" is moderately supported by outcome research. However, the effect of psychotherapists on more readily measured variables is unabiguously positive. We should not be ashamed of having a tangible impact on mundane events. I read about twenty books and a hundred papers on outcome and brief therapy preparing this paper. If a report is primarily about psychotherapy and its outcome there is no discussion of clinical health psychology, even when there are strong conclusions made about no variation among types of therapy on outcome. It is as if the two fields exist in different universes. This mutual exclusion may be one of the reasons that the primary tactics used in clinical health psychology - focusing on relaxation - are seldom cited as techniques to use in brief therapy - except by Salter, and Ellis and by implication in Strategic Therapy. An NIMH Consensus Study proved that a mere six hours of office consultation was just as effective a treatment for alcoholism as a 28 or 42 day in-patient treatment program. To be sure this reality reflects less on the power of psychotherapy than on the poverty of inpatient treatment of alcoholism. However, the effectiveness of a mere six office visits on alcoholic behavior is consistent with the results of research on the effectiveness of clinical health psychology in general. Regardless of the physical disease studied, a psychological consultation results in spending fewer dollars, spending less time seeing doctors and getting treated, and in getting well faster and more thoroughly. Seeing a psychologist results in saving money, and time and discomfort. BEHAVIORAL MEDICINE MEANS FEWER HOSPITAL DAYS The outcome literature on "behavioral medicine" is unambiguously positive about the value of psychological interventions. When patients receive psychotherapy they consult physicians much less often and are hospitalized much less than similar patients who do not engage in psychotherapy (Schlesinger, Mumford and Glass, 1980; Mumford & Schlesinger, 1987). This finding has been replicated more than a dozen times and represents a fundamental research benchmark on the value of psychotherapy. In virtually all studies published patients who started psychotherapy enjoy a reduction in visits to physicians and a reduction in hospitalizations. Reviews of studies examining medical regimens which include psychotherapy compared to those which do not revealed that 9 of 10 report significant improvements in physical illnesses through the addition of psychotherapy (Luborsky, Singer & Luborsky, 1975; Smith & Glass, 1977;Schlesinger, Mumford & Glass, 1980; Mumford et al, 1984; Mumford & Schlesinger, 1987; Luborski, et al, 1988) In a broad survey of clinical behavioral medicine Sobel (1992) reviewed studies which proved that brief psychotherapy results in substantial measurable results:
Patients complaining of psychosomatic illness (SOB, palpitations, GI complaints, headache, insomnia, vague muscular or bone pain, malaise, anxiety, tension, stress, etc.) had less discomfort and less psychological distress and 2 fewer office visits in the 6 months after psychological treatment. The intervention cost $3000 (including a control group) and saved $4000 in 6 months for 50 patients (Hellman et al, 1990). Patients can be happier and healthier for less money by using psychologists. David Spiegel and his colleagues in a series of papers (1983, 1981, 1978) reported that regular psychotherapy reduced reliance on pain medication, improved well being, and extended life span of women with metastacized cancer. Hypnosis intensified the effect of psychotherapy. The patients were significantly less disturbed in mood, had fewer maladaptive responses, and were less phobic than the controls. After a behavioral medicine program 141 patients examined 15 months post treatment had used less medication, enjoyed more activity, and a better body image, suffered less anxiety and depression, and enjoyed increased feelings of self esteem compared to their controls (Kabat-Zinn et al 1985, 1984). Psychotherapy is more effective than simply giving information. Patients who were trained in relaxation or in reinterpreting their experiences visited an HMO two fewer times on average than did patients simply given information (Behavioral Medicine, 1990, 16(4)). In a study of 15,000 employees of a major corporation (EBRI 1991) those who did not adopt the intervention spent 114% more on medical claims than those who adopted the exercise program instituted by a psychological team. St Paul (1987) reported a significant drop in paid bodily injury and medical costs after a stress management program. Pennebaker (1993) demonstrated that a brief appropriate psychological intervention resulted in unemployed men finding better jobs, faster, than their controls who were given an inappropriate intervention. The studies on clinical health psychology are seldom cited in review reports on the outcome of psychotherapy. Researchers are often asking the wrong questions in outcome studies. It might be considered, too, that three of three studies have shown that a long wait before receiving psychotherapy equals a poor outcome (Luborsky et al, 1988). Since many studies are self controlled using waiting patients, these studies may be self-fulfilling the prediction of "poor outcome. Clearly, when considering physical dysfunction and disease psychotherapy works, and psychotherapy is cost effective. EPILEPSY, ATTENTION DEFICIT DISORDER AND ALCOHOLISM Barry Sterman and his colleague Wyrwicka (1967) demonstrated that the sensorimotor rhythm over the Rolandic Fissure could be increased by operant conditioning in cats. Subsequently a long line of replications of this effect in human beings has been demonstrated with the result that epileptics can reduce or eliminate their dependence on anti-convulsive medication (Sterman, 1972, 1974, 1982). Neurotraining with EEG operant conditioning is superior to relaxation training in relief of seizures (Tozzo, 1988). This effect does not occur with sham or random signals (Finley, 1976; Wyler, 1976). With a range of 0-100% an overall reduction in seizures of 61% was enjoyed in 24 medicine resistant epileptics (Lantz & Sterman, 1988). There was also significant improvement in cognitive and motor function when seizures were reduced and psychosocial improvements which seemed uncorrelated with seizure reduction. For twenty years Quirk (1995) has applied Sterman's technique to violent criminals at the Ontario Institute of Correction with markedly good results. Comparing 77 dangerous felons 65% of the untrained felons from OCI were rearrested where only 20% of the treated felons were arrested again. In some studies the comparative rates were as high as 85% untreated to 40% treated. Since, in common penal practice 98% are typically rearrested within two years it is obvious that the OCI is a superior correctional facility, and it is equally obvious that the process at OCI was significantly improved by EEG biofeedback. It seems useful to comment that the OCI has been closed as an economy measure, despite the sure fact that at least 5000 innocent citizens were not attacked and killed by the felons treated by D.A. Quirk. ATTENTION DEFICIT DISORDER, LEARNING DISABILITY, HYPERACTIVITY AND SLEEP TERROR Joel Lubar (1991) reviewed the work he and his colleagues have done since 1975 using EEG contingency training of sensorimotor rhythm and the beta electrical activity of the brain. Lubar demonstrated that children with problem behaviors, attention deficits, learning disabilities and other problems demonstrate significantly more theta activity than beta, with significantly more power in slow wave activity. Lubar also reports that Alpha persists during academic tasks where Alpha blocking is the norm in such children. More to the point Lubar demonstrated that about 85% of children improved markedly on a wide number of measures. In 1981 Lubar reported on a small double blind crossover study and the work has been replicated by the end of 1992 in more than 75 centers on more than 1000 children. Othmer (1992) reported on more than 500 children in whom attention deficit disorder, hyperkinesis, sleep disorder, and headache were relieved by a method similar to that of Lubar and of Sterman. This research and related studies are duplicated at www.eegspectrum.com. ALCOHOLISM One of the disorders most resistant to psychotherapy has been alcoholism. Peniston (1989, 1990, 1991) reported that EEG training for Alpha and Theta combined with pretraining for relaxation and increase in hand temperature produced an 85% abstinence rate in alcoholics with a long follow-up without relapse. These studies are particularly impressive in that Peniston treated mature alcoholics who were in their third or fourth 28 day treatment program. Needless to add, none of the matched controls managed to remain abstinent. There have been six replications of Peniston's study (by May 1998). Quirk had a report on successful treatment of epileptic alcoholics in 1976. BIOFEEDBACK There are a wide number of applications of biofeedback now well established with much better criteria than, say, bypass heart surgery. I am not reviewing that literature here as the EEG literature is an adequate sample to demonstrate that biofeedback techniques are robust, effective and well proved. It is interesting that society continues to pay for vague methods which are totally unproven. The NIH Consensus Report on by-pass surgery proved that it was more effective to manage cardiac patients medically and that there was no advantage to by-pass surgery. The technique has certainly not been subjected to double blind comparative study. On the other hand it is often difficult to obtain insurance approval for restoration of limb movement after injury, restoration of bowel and bladder control and other straightforward applications of biofeedback. Even more depressing is the healing profession's slowness in adopting methods which are light years beyond common practice in the treatment of ADD or alcoholism. Excellent reviews of efficacy are available at www.eegsspectrum.com and at www.incontinet.com where a copy of The Ghost in the Box can be downloaded as shareware for $5.00. Anyone contemplating doing EEG biofeedback should read this book. WHY IS BRIEF THERAPY BEING JAMMED DOWN OUR THROATS? DOES IT REALLY TAKE SO LONG? Even Papa Freud was somewhat defensive about the 6 months to a year that he regarded as necessary for a successful psychoanalysis. But by 1958 Schmideberg commented that "the lenghth of individual treatment has become longer and longer, amounting sometimes to 5, 10 and 15 years (p. 236)." Ferenczi and Rank (1925) toyed with shorter forms of psychoanalysis and Rank, in particular, gave rise to a rich tradition of social work as therapy. Alexander (1944, p. 3) intensified the heresy by reporting that some patients could benefit dramatically from as few as one or two interviews and have a better outcome than many patients after a long analysis. Therapists cannot too often ponder the reality that people change, improve and get well all by themselves. People survive quite horrible experiences and are even strenghthened by them. There is a style of surviving and prospering which Siebert has described in THE SURVIVOR PERSONALITY (1993) which therapists will do well to study. Herzberg (1946) described an active prescriptive role for the therapist which resulted in brief consultations. In 1948 Frohman stated that his eclectic therapy required only 20 to 30 hours. The most widely known critic of Freud and psychoanalysis, Salter (1944, 1949), described a conditioning therapy using very brief consultations and highly prescriptive interactions. Salter (1965) insisted that the contributions of Thorndike, Lashley, and Pavlov were far more productive for psychotherapy than those of Freud. Yates' (1970) table of 27 early therapists using brief symptom focused therapy is reproduced below. Brief therapy has become much more common and some early studies demonstrated that "anything you can do I can do briefer" (Schlien, 1957; Schlien, Mosak & Dreikurs, 1962; Muench, 1965. Avnet, op cit). It occurs that experienced therapists, asked to do brief therapy, had no better outcome than untrained "natural helpers" (Gomes-Schwartz, 1978; Strupp & Hadley, 1979). Sol Garfield was perhaps the first to report that most psychotherapy actually is brief therapy (Garfield & Kurz, 1952). His clinic had 1,216 contacts resulting in the creation of a file. 560 patients actually began therapy. Two-thirds of the 560 remained for fewer than 10 sessions; one-fifth for 10-19 sessions; about one eighth remained for 20 or more sessions. Only 7 cases had more than 50 sessions. Garfield (1986) reports that many additional studies have essentially replicated his 41 year old report. Garfield's (1989) THE PRACTICE OF BRIEF PSYCHOTHERAPY thoroughly reviews the marked increase in the acceptance and utilization of brief therapy. SOL GARFIELD SAYS, WE ACTUALLY DO A LOT OF THE SAME THINGS THE SAME WAY Garfield remarks that he has been urging the point of view that the common elements of psychotherapy are more important than their differences for more than 30 years (1957, 1974, 1980, 1989). Sloan's (1975) report that no difference in effect can be proved for any form of therapy has been replicated many times (Luborsky, 1988). Sloan showed that experts could reliably tell which therapy had been given. Despite the significance placed by adherants of the therapeutic schools on the importance of their differences and on "doing it the right way" no proof exists. Garfield (1989) contends that it is the commonalities among therapies which are important to success and that this finding is especially true in brief therapy. Garfield's otherwise excellent book, THE PRACTICE OF BRIEF PSYCHOTHERAPY (1989), ignores the issues of relaxation, and ignores change in habitual activities of daily life and exercise. Equally neglected is the technique of hypnosis. When Garfield is talking about suggestion he seems to be talking about instructions given mildly and permissively, and not hypnotic suggestion. THE THERAPEUTIC RELATIONSHIP Garfield remarks that every therapeutic relationship contains at least one therapist and one client. The client is the one who controls the possibility of improvement. The therapist cannot step out of the boundaries of the client's expectations and tolerance for therapist behavior. The therapist has to seem to the client to be a plausible healer. The therapist has to have at least a minimum belief in the motivation, cooperation, competence and resources of the patient. A good relationship is an important requirement for progress in all forms of psychotherapy. REINFORCEMENT Garfield lists the importance of positive support and reward lower in his recitation on factors effecting the success of psychotherapy. I suggest that reinforcement is central to therapeutic efficiency. Lashley (1930) pointed out that in his and in Pavlov's lab the simple physical presence of some individuals radically changed the behavior of a wide variety of animals. He called this "the effect of person". Gannt (1941) imported this perception into psychotherapy, and Salter (1940) made actively rewarding and interacting with the patient an important role for the psychotherapist. Robert Rosenthal (1965, 1964) did a series of studies on the effect of telling teachers that certain students were gifted but had had poor school experiences - the children invariably did well. His presentation of CLEVER HANS, the classic book by German psychologist Oskar Pfungst, includes a review of not only reports on animals mistakenly thought to be clever, but also of the effect of expectancy on teachers' and researchers' unconscious behavior effecting outcome. POSITIVE CONVICTION, "THE THERAPY IS GOING TO WORK" Expecting the client to improve must play a large role in what actually happens. In every successful psychotherapy the therapist plays the role of letting the client know that she is not alone in her problems, and the therapists positively supports the patient. Garfield says that creating in the first few sessions a positive conviction that the therapy is going to work results a good outcome. He insists that reinforcement by the therapist is especially important in brief therapy and is common to all psychotherapies. EMOTIONAL RELEASE Pavlov taught that "talk" is the "secretion of the brain" and that speech is what separates men from animals and completely changes the nature of learning in humans. Gantt and Salter commented that the formulations of conditioned reflex therapy often seemed oversimplified, but that it made sense to think of what they did with patients was to encourage "blah blah blah". Salter commented that "we listen, but not much", but Gerbode (1989) has described a therapy (Trauma Incidence Reduction [TIR]) in which a rational therapist is restricted to as uncommunicative a role as a classically strict psychoanalyst. The TIR therapist does strongly direct the sequence and process of talk in the therapy but does not intrude. All therapies have in common the fact that the client can talk about experiences and thoughts which are highly charged with emotion in an atmosphere of acceptance and safety. Garfield states that emotional release is of lesser importance than other processes; but that emotional catharsis is an important commonality of all forms of therapy. DESENSITIZATION The term "disinhibition" is less often heard than in the past, and "desensitization" is often understood only as Wolpe's method of "Reciprocal Inhibition Therapy". Salter stated that the term translated from Pavlov's writings as "disinhibition" literally translated from the Russian used by Pavlov as "unbraking" or "taking the brakes off". The process of reducing fear, making concepts and thoughts more tolerable, and increasing the client's willingness to experiment and try new experiences seems to be common to all forms of psychotherapy. Salter suggested that the inhibition of the orienting reflex, and inhibiting of the ability to notice other's reaction was the central factor in neurotic behavior. Salter contended that the therapist's job was to help the client to get the brakes off, especially off the ability to reorient and the ability to notice how other people are reacting to you. INTERPRETATION, INSIGHT AND UNDERSTANDING From Pavlov, through Gannt to Salter and Ellis, including therapists as diverse as Dreikurs, Rogers and Milton Erickson, every therapy provides means to shape the patient's learning to understand what has happened. The means of understanding may be schematic and rational, insightful or fanciful and metaphorical but all therapists provide a world view for the client. Garfield insists that it does not seem to matter what the rationale is as long as the therapist presents the concept in a confident and knowledgeable manner and that the patient accepts the explanation as meaningful. Garfield also says that it is too bad that this finding seems unprofessional and quackish, it has been proved to be true! (1989, p.28). Garfield's language reminds me of Erickson in NOW YOU WANTED A TRANCE DEMONSTRATED TODAY (1991, p.41), "..your attitude of confidence and complete expectation, no urgency in your voice, no doubt in your voice. You simply know they're going to go into a trance. You simply know that they're going to do things you want and the things that they need to do." Lieberman and his colleagues (1973) reported that encounter groups had more profound effect on participants when the groups emphasized the explanations and understandings which had been secured in the groups. Garfield (1980) and others (Frank, 1971, van Kalmthout et al, 1985) have argued that what is of therapeutic consequence is that the client accepts the explanation and organizes her behavior around it - what is important is not the validity of the explanation. After all there are at least 500 schools of psychotherapy. CONFRONTATION Avoidance, denial, embarrassment and shyness are common experiences. Psychotherapy commonly helps the client confront those areas of denial which are blocking progress and to change emotional responses which inhibit behavior. The client's emotional or cognitive prediction of catastrophy following some avoidant is defused by techniques including psychodynamic psychotherapy, Rational Emotive Therapy or other cognitive approachs, implosion, desensitization or modeling. As with other forms of psychotherapy they all work about the same (Erdwins, 1975). HOW DO ALL THESE GOOD THINGS HAPPEN? Garfield contends that all therapists take at least some similar actions with patients. All therapists believe that they are trained listeners who are attuned to all the subtle communications the patient gives. In brief therapy this listening is an active process and the therapist has to make quick decisions and to respond effectively. On the other hand see Gerbode's (op cit) method of dealing with trauma where the therapist follows a strict protocol and, according to Moore (personal communication) effectively relieves Viet Nam veterans of their symptoms in an average of 16 hours. Gerbode trains his therapists to give verifying evidence that they are listening. Garfield puts questioning just before the end of his list of therapist activities; clearly, however, with many clients there is little to listen to if the therapist does not ask questions. Interactive listening characterizes most of psychotherapy. Garfield recommends listening to tapes with a supervisor and judging when you should have responded and when you should have kept silent. All therapists believe that they are sensitive to what the patient is saying and that they reflect with high accurate empathy what the patient is trying to communicate. High accurate empathy used to be regarded as a central variable in outcome - alas, the research does not support this happy idea. All therapists lead clients by suggestion, whether therapists like to admit it or not. The effect of person is strong, and most therapists are very busy continually making suggestions. There is no systematic research on suggestion per se and it is impossible to evaluate suggestion on an objective basis from completed research any more than any other elements of psychotherapy. Explanation and interpretation seem universally applied in all forms of psychotherapy - perhaps the purest Rogerian will avoid explicit interpretation. Even Carl Rogers would offer reflections which, will ye or nill ye, embed a world view and an explanation. Therapists as different as Pavlov and Milton Erickson explain and interprete to provide the client with a new world view, a conceptual framework for understanding her problems. Salter insisted that the explanation and interpretation he provided was in the nature of providing information. He contended there was basically only one diagnosis, inhibition, and when you merely explained the basic principle people got better. Perhaps the most useful information the client derives from a therapist is the awareness that she is not the only person in the world with her problems, and that what she experiences is not "crazy" but is fairly commonly shared by others. CONFRONTATION Therapists seem more ambivalent about confrontation than about any other shared aspects of therapy. Moreover, there are some studies which suggest that denial is actually a positive life preserving mechanism in diseases like cancer. On the one hand, effective confrontation seems to shorten therapy time and it is generally regarded as an indispensable tool of therapy. On the other hand, confrontation is also generally regarded as among the most dangerous of all the tactics available to the therapist. SUPPORT AND REASSURANCE Support and reassurance are also regarded with some ambivalence, psychodynamic therapists being particularly opposed to supportive tactics. In a sense, reassurance is a confrontational technique and is certainly intended to shape feelings and behavior. HOMEWORK AND JOURNALLING Generally, keeping a notebook or journal is regarded as the gold standard of care by behavioral therapists, especially in issues such as headache, weight loss and other more or less countable phenomena. The use of homework assignments has become widespread and may be regarded as an absolute requirement in brief therapy. Interaction around the issue of "forgetting" the diary or failing to do homework can provide energy in the therapy which otherwise would be missing. Writing, in and of itself, may be more relieving of trauma than talking. Writing uses a larger area of the brain, connecting speech to motor tracts. In general, the more of the brain which is used in a task the more flexibly, coherently and effectively the task will be done. Psychophysiological measures will normalize during writing about emotional memories of a trauma. Shellenberger and Green (1986) insist that doing biofeedback without assigning homework misses the whole point of how biofeedback works (through learning relaxation). Psychoanalysis forbade the authentic reaction of the therapist and self-disclosure by the therapist. But in the present work of therapy increasingly therapists view themselves as models for patients, and encourage the client's own self disclosure by sharing from the therapist's life. Role-playing is widely used outside psychoanalytic circles and increasingly such tactics as the "empty chair" pioneered by Perls, Hefferline and Goodman (1951) in GESTALT THERAPY are becoming universally used techniques. I hope that Sol Garfield would recognize my abstract of his excellent THE PRACTICE OF BRIEF PSYCHOTHERAPY (op cit). His is a rational model for what all of us do, and we can reflect on these commonalities while looking at some models which vary widely. A MODEL FROM BUTCHER AND KOSS Butcher and Koss (1978) say there are nine common technical elements of brief therapy:
Of the YAVIS choose those with
Strupp (1981, p.221) describes these favored patients as having a "high level of emotional maturity, responsibility, autonomy, success in mastering and adapting to life's challenges (including stability in interpersonal relations), and ability and commitment to work collaboratively with a therapist..." "patients who are unsuitable for time-limited dynamic psychotherapy can be characterized as showing profound dependence, persistent acting out (impulse disorders), self-centeredness, masochism, and self destructiveness" ... "pervasive characterological disturbances, profound negativism, and rigidity." DIFFERENT PERSPECTIVES ON BRIEF THERAPY Doing Brief Therapy On Purpose: The Grandfathers of Us All Jay Haley remarks in ORDEAL THERAPY (1984) that in 1952 when he made an unconventional response to a patient which resulted in an immediate improvement, there was no theoretical framework in which to organize this experience. His statement is indeed odd because he, himself, was a student of Dunlap whose HABITS: THEIR MAKING AND UNMAKING was published in 1932. Dunlap's "beta" phenomenon is widely recognized by the public as "psychology". When an ordinary person says "Oh, you are trying to use psychology on me." she means you are giving her a paradoxical order or suggestion. Mark Twain had Tom Sawyer use the paradoxical tactic - "No, you can't paint my Aunt's fence". Homer Lane institutionalized paradoxical instruction in the Little Commonwealth (by 1914), and A.S. Neill elevated the tactic by rewarding for "bad" behavior. Jesus, of course, advised "when a man strikes you turn the other cheek, if he takes your cloak, give him your cloak also, if he compells you to go a mile with him, go with him twain...be kind to those who despitefully use you." Gilgamesh reliably used the tactic in ancient Sumer or so his Epic tells us. There are so many claims of "inventions" in psychotherapy that I often wonder if any of the authors of them have ever read CHARACTER ANALYSIS (Reich) or any of Rank, or were exposed to the work of Dreikurs and his mentor Adler, or to the schools run by August Aichorn, Makarenko, Lyward, Korczac and a host of other creative therapists who believed problems could be solved quickly, without too much reference to history, by using dramatic techniques which challenge the acquired culture of failure. The dreary manufacturing of "schools" by weak egos seeking glory is a sad commentary on our profession. When the apologists for the Mental Research Institute or the Milan Systemic Family Group prescribe bedwetting, nowhere do they remark that these paradoxical techniques are well established in our literature, are described in loving detail in Talmudic tradition and are at least as ancient as the Epic of Gilgamesh. Methods which briefly and dramatically induce change in maladaptive people have been around since the towers of Sumer were built. The Milan people actually take credit for the "empty chair" techniques used in Gestalt therapy at least since the late 40's - in fact Jay Haley could have talked to Fritzie or Paul Goodman in 1952 and found himself a theory (Gestalt Therapy) which explained why his crazy methods work. APPLYING THE PRINCIPLES OF LEARNING "Does it not follow from our point of view that man is the supreme creation of nature, the highest embodiment of the resources of infinite nature, the realization of her mighty and still unexplored laws? Is not this enough to enhance the dignity of man, to afford him the deepest satisfaction? And practically everything vital is retained that is implied in the idea of free will, with its personal, social and civic responsibility; for me there remains the obligation to know myself, and using this knowledge always to maintain myself at the highest possible level of my abilities." -- I.P. Pavlov Despite surface differences brief therapists in the conditioning or behavioral tradition share several central principles:
Perhaps the earliest well known psychotherapist to oppose psychoanalysis, particularly over the issue of the intolerable lenghth of therapy, as well as over the issue of effectiveness was Andrew Salter. Salter was the first nationally recognized opponent of psychoanalysis. He was a dedicated and bombastic critic of Freud. He particularly despised the Freudian's fearfulness of harming clients, their insistence on long therapies, and the notion of symptom substitution. Salter believed strongly in "autokinesis", or the powerful self correcting force of self regulation - the natural orienting reflex. He respected the "effect of person" which had been demonstrated by Gannt and others. Different individual therapists have strongly variable effects by their presence alone on the autonomic activity of clients and research subjects. This effect of person works powerfully on dogs, cats, rabbits and people. Salter repeatedly demonstrated the ability of a disciplined therapist helping a committed client quickly to effect radical change. Pavlov's work formed the basis of Salter's therapeutic skills and he insisted that all neurosis has the same basis, inhibition - literally putting on brakes. It follows that therapy occurs when inhibition is unbraked by excitation. Salter imported Pavlov's principle that acquired neurosis represents a strongly elaborated system of inhibition. Or as Pavlov would have said habits which are self destructive are the results of series of active brakes which have been jammed on in the brain. Neurotics continually expend energy on the internal reverberations of trauma. Brakes upon brakes. "Inhibition" does not mean passivity. Salter pointed out that active and mobile behaviors and stereotypes can be products of inhibition. In fact, he insisted that compulsive chatterboxes are an example of dynamic brakes. Salter went about the job of disinhibition in a number of ways.
Relaxation is a form of excitation which overcomes anxiety, a form of inhibition. Relaxation is a way of taking off brakes. Relaxation is less mobile in its expression than some anxiety. Paul Goodman's (Perls, Hefferline & Goodman, 1951) practical definition of anxiety (holding breath) demonstrates the inhibitory nature of the emotion. Even though an anxious person may also be agitated, the agitation is a form of inhibition. If you think of the quick inhalation the bunny makes when it senses the fox, poising itself to run or fight, you have the perfect model for anxiety. Salter associated relaxation to the eyeblink, repeating "relax" or "be calm" about 40 times as the client exhaled and closed her eyes. He followed Pavlov in believing that hypnosis, in its many forms, formed the fundamental basis for psychotherapy. Salter included in the range of hypnosis such phenomena as association. That is if you turn on a light while you ring a bell, and repeat this association about 20 times most clients will tell you the bell is ringing when you turn on the light alone, or that the light is on when you ring the bell. Like Pavlov, Salter recognized that the human quality of speech transforms the laws of conditioning and that associations are richly stimulated by speech. Salter reported that many successful individuals became even more highly successful through the use of simple hypnotic techniques. A powerful technique in Salter's Brief Therapy was to use guided mental imagery to help the client recover detailed memories of unusual physiological conditions. For example, he encouraged the client to remember the coldest time she had ever experienced. He was careful to encourage an indirect approach to the induction of cold by having the client remember everything possible regarding her coldest experience - the texture of clothing, smells, sounds, sights. He emphasized that the direct attempt to "be cold" was doomed to failure. He would then reverse the emphasis and have the client remember her hottest experience. Salter described clients for whom the only method he used was mental imagery - sometimes only of recovering memories of cold experiences alternating with hot experences. End of treatment. Salter insisted that therapists could effectively use all the varieties of hypnosis - verbal suggestion; association; extraordinary or very strong stimulation; excitation of the motor-sensory system through inhibition of the verbal system; reciprocal inhibition and so on. William Jennings Bryan, Jr., M.D., used this extraordinary stimulation in his famous "Oriental Induction" as when a dog is suddenly turned on its back and held immobile - and remains so for a long time. Milton Erickson sneered at Salter's methods as too simple-minded; but I have not been able to find any straightforward technique used by Erickson which Salter did not use before him. Salter based his use of reciprocal inhibition - then called by a more naturalistic term "reconditioning or unconditioning" - on solid psychological observations. John B. Watson (1924) had traumatized "Little Albert" an 11 month old baby by suddenly striking an iron bar as he was presented with a white rat Albert liked to play with. Seven pairs of associations were sufficient to condition Albert not only to be traumatized by the rat alone, but to avoid, and be shocked by the appearance of a number of objects he had loved to play with, viz. a rabbit, a dog, a sealskin coat, cotton wool, human hair and a Santa Claus mask. It is interesting that Watson (op cit p 176) refers to "stroking, petting and rocking" a child as "sexual stimulation" which would retrain learned visceral fear reactions. Mary Cover Jones (1924) demonstrated that a generalized fear neurosis which had naturally occured in her client, "Peter", could be desensitized quickly by a combination of socialization (letting Peter watch other children play with rabbits and mice), and by graduated presentation of the feared object. Jones listed 12 major and a total of 100 causes for children to cry; and 7 major with a total of 85 situations which elicited laughter and smiling. The excitation stimulated by laughter and smiling were used to disinhibit the response of crying. "On one occasion the introduction of a mouth organ altered the whole tenor of the room, changing distress into laughter." Jones worked out the whole principle of reciprocal inhibition and laid out rules and conditions for handling cases of pathological fear before 1924. These principles have not changed and are an integral part of brief therapies. Salter also trained the client in "feeling talk". Deliberate expression of felt emotions of all types was stimulated and directed in every session. At the same time Salter trained the client in facial mimicry - nonverbal feeling talk encouraging mobilization of emotions. "Be Gallic" was a favorite instruction of Salter's. In a lecture in Orlando in 1992 Albert Ellis said that the biggest contrast between his use of RET and Meichenbaum's use of cognitive therapy is the application in RET of the disputation of superstitious beliefs. Davidenkov, in THE TREATMENT OF NEUROSIS BY PAVLOVIAN METHODS (1953) explained that the technique of disputation was established in Pavlovian therapy as early as 1935. He summarized that "the explanatory or rational psychotherapy is naturally fundamental to the treatment of all neuroses." Salter agreed with the Pavlovian view that the client has to understand the essence of her ailment. The comprehension the client has to achieve is not Freudian insight into the roots of her ailment. The client is taught a simple hypothesis about how inhbition is acquired and how the fear response is maintained - by lawful processes. The client is led to understand how valueable her reconditioning will be to her. Her agreement with this prediction is therapeutic. The client is led to believe that her illness is understandable and curable and is completely subject to known laws. Davidenkov gives a thoroughly contemporary description of the modern cognitive behavior modification approach to anxiety used by Pavlovians as early as 1934. Salter used the same kind of instruction. He led clients to understand their physical sensations to disinhibit the clients' overreaction to minor physical indicators of fear. He trained the client exactly as contemporary cognitive therapists treat panic. It is unfortunate that decades of persistent misrepresentation about Pavlov have left most Americans thinking that "classical conditioning" or salivating dogs responding to bells constitute the entire contribution of I. P. Pavlov. Now that the Cold War is over perhaps we can examine the profoundly humane and effective psychiatric clinic run by Pavlov beginning in his 80th year. Pavlov himself did not think behavior was organized by simple reflexes. In commenting on the complex learning of the dog in response to all the accidental business around the experimental station he grumbled "why this (the response of the dog) is only a simple association, as psychologists usually affirm, and not an act of comprehension, of sagacity, even though elementary, remains obscure to me. " ... "The chief, the strongest and the lasting impression gained from the study of the higher nervous activity by our method is the extraordinary plasticity of this activity, its immense potentialities; nothing is immobile, unyielding; everything can always be attained, changed for the better ... (Pavlov, 1932)." Dunlap, in HABITS: THEIR MAKING AND UNMAKING (1932), applied learning principles to rational therapy in the first decade of this century. His use of paradoxical instruction is an obvious Pavlovian tactic - flooding the dominant "brake" with excitation and resolving the pathology. Jay Haley was a student of Dunlap's and Haley's use of paradoxes, ordeals and brief therapy is a direct result of Dunlap's success with the "beta phenomenon". Simply put, if you do something on purpose you are less likely to do it habitually. Homer Lane, and his client, A.S.Neill, used paradoxical instruction in their schools, The Little Commonwealth and Summerhill. The notion of using social therapy based on self regulation and freedom from ordinary trivial restraints closely resembles the techniques used in Pavlov's treatment ward more than half a century ago. Homer Lane ran the first self-consciously psychotherapeutic school in the world and every element of modern cognitive and behavioral therapy can be found in the records of The Little Commonweath. From a token economy to paradoxes and ordeals, Homer Lane creatively applied all the insights of psychology in an effective treatment model before 1920. Salter introduced to American therapy the Pavlovian method of contradicting, opposing, and attacking beliefs. In the treatment of homosexuality he called this technique "bemerding the boys". He would create elaborate scripts denigrating pathologically attractive objects and enhancing pathologically avoided objects. Salter described homosexuality as a special case of dominant inhibition. Salter encouraged "I" talk. He encouraged continual talk about self and use of the the pronoun, "I", of naming individuals and of reducing abstractions. Salter insisted that his clients agree with praise of themselves, and learn to praise themselves, to seek out praise, and offer compliments to themselves and others. Salter taught his clients to accept "improvisation". He taught them to forget worrying about concrete plans and to express themselves spontaneously and selfishly. The contemporary forms of Assertion Training, or such books as "When I Say No I Feel Guilty" owe their content to Salter and through him to Pavlov. SYSTEMATIC DISINHIBITION Wolpe may represent the first thoroughly systematic American exponent of conditioning therapies. Reciprocal Inhibition therapy is based on the observations that any response which is antagonistic to anxiety can be made to occur in the presence of anxiety. If the anxiolytic response diminishes or suppresses anxiety, then improvement follows. Wolpe's therapy uses:
While Wolpe doesn't describe much use of suggestion in his reports several psychologists watched Joseph Wolpe and Arnold Lazarus work with clients for five days and commented "Perhaps the most striking impression we came away with was of how much use behavior therapists make of suggestion and of how much the client's expectations and attitudes are manipulated" (Klein, Dittman, Parloff, & Gill, 1969, p. 262). DOING THERAPY QUICKLY AND EFFECTIVELY (Learning Therapies) SCIENCE NEWS recently described Beck as the father of cognitive therapy. In response to a letter complaining that Albert Ellis should receive that honor, SCIENCE NEWS replied "we think Ellis is the grandfather of cognitive therapy." It is odd how quickly Americans discard their antecedents. If Ellis is the grandfather, then Salter is the great-grandfather, and Pavlov and Thorndike and others are the great-great-grandfathers of cognitive therapy. We didn't start doing rational therapy yesterday. Alas for accuracy, Ellis, like Haley, and others ignores his predecessors stating "RET was the original cognitive-behavior therapy (op cit, p. 16)." Nearly every technique used by Ellis was in use by Pavlovians and especially by Salter and by Dunlap. Regardless of primacy Albert Ellis (1992) was certainly in the lists before Beck with an intrinsically brief therapy and remains a monumental figure in our profession. He is the founder and leading theorist of Rational-Emotive Therapy (RET) a widely practiced therapy which has been widely validated as effective. Ellis urges a fundamental point of view, "People choose to disturb themselves and they can choose to undisturb themselves." People start with goals to remain alive, undisturbed, happy. On the way to their goals they acquire rational beliefs, which are wishes and preferences. People also acquire irrational beliefs which are dogmatic imperatives, absolute demands (must, should). On the way to reaching their goals people encounter adversities. They can respond to these adversities by applying rational beliefs - adjusting, adapting, planning, deferring. Or they can respond with self defeating emotions based on irrational beliefs, "I must, I should, I cannot therefore I have to be anxious, angry, frustrated, depressed, enraged, morose." Ellis says that if people chose only rational beliefs by which to respond to adversity then they would have appropriate feelings of sorrow, regret, discomfort, frustration and grief, but rarely would they have inappropriate and self defeating neurotic feelings. Adversities, beliefs and consequences interact complexly and actively; and as if the first order interactions weren't already complicated enough, people form secondary consequences about their primay consequences. "I must not panic! I'm a no good for nothing if I panic." "I must not procrastinate, if I procrastinate I am rotten." Activating events are perceived and thought about and so have beliefs and consequences imbedded in them. No element is ever simple. RET agrees with the people who talk in systems language that people create systems of belief. However, RET teaches that people are innately teachable and gullible and so they are always adopting and adapting beliefs and consequences. The basic point of view in RET is that when preferences are transformed into absolute demands the self managing system is perverted and creates neurotic unhappiness and self-defeating habits. RET recognizes that many or most of the absolutist rules which form the habitual response of a person were learned in childhood when thinking is not too effective. These child formed rules are carried around despite evidence that they do not work. Ellis insists that individuals actively accept, actively create, and actively use self-disturbing and antisocial commands. Ellis revised his original 10 superstitious beliefs to only three:
RET postulates that when you are emotionally disturbed your wrong conclusions stem from your dogmatic imperatives. Ellis calls neurotics "musturbators". I think it was Karen Horney who first said "People will 'should' all over you if you let them." RET assumes that neurotics have two or three underlying imperatives. "Disputing" these imperatives enables the client to transform imperatives into preferences. RET teaches that clients have primary and secondary superstitious problems, and helps uproot both. Ellis contends that low frustration tolerance (he also calls it "discomfort disturbance") is the basis of ego disturbance. Denigration of the self is not merely due to poor performance but due to low frustration tolerance. Neurotics demand that people and conditions absolutely must act in a prescribed way or else horrible things will happen. The client creates a conviction "I can't stand driving across a bridge, its too uncomfortable." This conviction creates a low frustration tolerance, which leads to an ego disturbance, viz. "I must not avoid bridges, I am a terrible, weak person for avoiding bridges." Then she can proceed to "MY life is unbearable when I avoid bridges, and when I hate myself for having this weakness, how horrible for me to be incapacitated." From this she moves to "Its too hard for me to work on my problems! Its unfair for me to have to use so much energy to function." RET therapists assume that most clients have superstitious beliefs, low frustration tolerance, and self-damnation. RET postulates that much emotional disturbance is essentially the same thing as antiscientific, inflexible absolutist thinking and that the main attributes of mental health are flexibility, open mindedness and willingness to explore alternatives. In other words, mental health is like using science, 1. check ideas against facts; 2. logically compare ideas to see if they are consistent and if better ideas are available; 3. keep looking for better ideas and never believe that any idea explains everything all the time. Therapy consists of "Disputing" irrational beliefs. The more strongly held a superstition, the more strongly it must be Disputed. Preferentially RET employs vigor, force, emotional, cognitive and behavioral methods of therapy. RET is active, directive, questioning and challenging, didactic, and prescriptive. Ellis insists that RET is an efficient 'self' psychology. For example, RET contends that psychosis and 'borderline personality disorder' are primarily biologically induced and that the patient has to be taught to accept herself in the context of her illness. RET treats the neurosis about the illness and enables the client to live more happily. Ellis differentiates himself from other cognitive therapists by affirming himself to be an existential humanist. Ellis uses RET to deal with disturbed human events; using rationality in the service of humans for enlightened hedonism with maximal freedom and discipline; he eschewes supernatural assistance; believes no human, no matter how awful, is subhuman. Ellis attempts to maximize individuals rather than submit them to any authority including that of the therapist. He involves clients in a committed and loving manner with other humans. He emphasizes the importance of will and choice. Ellis opines that nearly everyone has some neurotic tendencies; that these self-defeating habits are more likely in dysfunctional settings; but no setting is so benign that all the individuals raised in it will be self actualizing. RET affirms biological determinism; unfortunately, effective therapy especially of borderlines and psychotics is often undone because of biological processes which distort perception and feelings. Ellis remarks that most therapists and their children demonstrate neurotic habits; solutions are often a part of the problem. He reflects that people will disturb themselves and then depress themselves about their disturbances. RET teaches that people usually resist working to change superstitions and their effects even when they recognized the faulty rule. The use of absolute imperatives, mistaken attributions, inferences and overgeneralizations seem universal among humans. RET assumes that many clients can actively and directively be taught the ABC method and that at least a third can improve in a few weeks. Ellis states that RET is one of the few intrinsically brief therapies.
Of course, clients have to learn these unhappy realities.
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In
1966 when I published IS THERE A SCIENCE OF BEHAVIOR?, Hans
Eysenck published THE EFFECTS OF PSYCHOTHERAPY and Goldstein
and Dean published THE INVESTIGATION OF PSYCHOTHERAPY. All
three of us reached more or less the same conclusion. There was
little direct application of science in psychotherapy and precious
little application of psychology in education and therapy.