A Reorientation in Psychotherapy
- Author:
Tendler
The College of the City of New York The differentiation drawn in neurology between organic and functional disturbances lias created a need for psychological concepts that bear upon psychopathology and psychotherapy. Rival schools have proposed such concepts and look to therapeutic success for proof of their doctrines. However, all that therapeutic success can demonstrate is that functional conditions respond to psychological treatment.
Choice of hypotheses as to these underlying psychological processes is to be understood as a matter of orientation. Dewey’s dictum, ‘1 In philosophy we do not solve any problems; we get over them,’’ has its application in the choice of psychological hypotheses. The significant issue involved is whether we shall adopt psychological concepts that fit in with a mystic or naturalistic point of view.
Modern psychotherapy, originating in the use of hypnotism for the treatment of hysteria, received a naturalistic interpretation by Janet1 when he restated both the phenomena of hysteria and hypnotism in terms of dissociation and proceeded to study the conditions under which dissociations took place. Unfortunately, and now regretfully, he used the term subconscious. It was his intention that the term be understood in a purely descriptive sense. Psychoanalysis dropped the hypnotic method, but took up the concept of subconsciousness as an explanatory principle, invested it with animistic potency and elevated it to a God-head. What may be termed a cultural reversal took place. Primitive, pagan, and theological concepts 2 were used to give content to the subconscious and Aesop’s Fables became the textbook of psychology. This became the self-styled “New Psychology.” * Paper presented at the 1932 meeting of the Association of Consulting Psychologists.
1 Pierre Janet, Major Symptoms of Hysteria, New York: Macmillan, 1907, Chaps. XII, XIV, XV; Subconscious Phenomena, Boston: Badger, 1910, pp. 54-70. 2 Signiund Freud, The Problem of Lay-Analyses, New York: Brentano’s, 1927, pp. 96-103.
The entrance of clinical psychology into the field of therapy is a necessary consequence of its diagnostic functions. The process of treatment, better termed as readjustment, must however be restated in terms of a naturalistic psychology. I propose that the factors at work in psychotherapy or readjustment be sought in the processes of emotional tension, intelligence, motivation, and learning. Briefly stated, psychological treatment is to be understood as involving a process of reducing tension, of stimulating a more adequate comprehension of disturbing factors, of establishing adequate responses. Therapeutic success depends upon effective progress in these directions regardless of what system the therapist follows.
The concept of tension provocation and tension reduction is basic. Tension may be defined as a psycho-biological interaction, as a disturbed state of the organism involving visceral, glandular, neural, motor, situational, and ideational factors. Tension, here, is not used in Janet’s sense of mental energy. The process of tension provocation is built around situations, ideas, persons. Situations evoking fear, anger, insecurity, uncertainties, rivalries, jealousies, hatreds, self depreciations, are tension provoking. Situations calling forth feelings and ideas of well-being, of security, of being liked, of personal recognition, achievement and worthwhileness, are tension reducing. Ideas and persons associated with the one or the other sort of situation become stimuli for provoking or reducing tension. For convenience we may apply the term tensors to tension provoking factors, detensors to those reducing tension. Broadly considered, a system of tensors and detensors are built up within the individual by the experiences life offers. Maladjustment may be regarded as the preponderance of tensors and inadequate detensors, the process of adjustment as an increasing adequacy of detensors, a process of tension reduction. It must be remembered that efforts at adjustment take place normally within the individual. The average person does not resort to psychiatric treatment when faced with difficulties. Current expressions as “Enough of that,” “I should worry,” “getting wise to ones self,” “snap out of it,” “cut out the sob stuff,” give indication of the hitting upon of tension reducing ideas. Everyday activity detensors may be illustrated by escapes from difficult situations as truancy from school, giving something up as a bad job, learning not to argue with some people, or more positively, by the deliberate use of distractions, turning to recreational outlets, taking a vacation, a trip to Europe, etc. The use of persons as detensors is fairly common, as confiding in friends, seeking advice from associates, cultivating a new set of friends, perusing the columns of advice to the lovelorn, etc. Instances of this sort provide the cue for the psychologist to follow. The psychologist tries to do more effectively what naturally goes on. He assists the process of adjustment by a more expert use of detensors?tension reducing ideas, situations, and persons. His knowledge of mental processes, unbiassed attitudes, and comprehension of life situations enable him to use detensors more adequately.
Conferences with the psychologist are directed towards tensor exploration diagnostically, and therapeutically towards a stimulation of insight and assistance in the establishment of the more adequate responses. Each of these phases deserve further analysis and the focussing of attention upon salient features. 1. Tensor exploration: Here instead of the roundabout methods of dream analysis, schemes for symptom interpretation, inferential free association techniques, or ink blot gazing, the modern substitute for crystal gazing, I use a more direct experiential approach. The Emotional Insight Test,3 reported on elsewhere, gives an indication of emotional difficulties. The stimuli include a major share of important emotional states: admiration, anger, happiness, love, hate, self-abasement, worry, make believe, regret, boastfulness, pride, grudge formation, negativism, pity, shame, fear, interest, disgust, evasion, desire. Personality questionnaires, the Psychoneurotic Inventory, conferences with parents and other interested individuals, all yield material which is taken up with the individual treated. Facts and attitudes are evoked, elaborated, connected up with significant life experiences. Methods of tensor exploration fall into three groups: field study?direct observation of the individual in actual situations, clinical study?application of tests and clinical devices, subjective report?statements made by the individual himself.
In the study of tensors, a basic factor to be considered is the inadequate ideation or comprehension of the individual. Individuals of dull and inferior intelligence are constitutionally prone to misunderstand situations, the motives of the people involved, and their own inadequate ways of dealing with difficulties as in the use of emotional outbursts instead of analysis and planfulness. s A. D. Tendler, Preliminary Report on a Test for Emotional Insight, J. of Appl. Psychol., 1930, 14, 122-136.
Complexity of situations is another barrier to effective management. Individuals of average and superior intelligence may face problems that are involved and difficult to manage. Often an analysis of their methods and ideas reveal responses of an inferior sort with resulting tensions.
Lack of adequate concepts and the presence of erroneous concepts make for misunderstanding of situations and tension provocation as instanced by an adolescent girl who mistakes her rapid heart beat in the presence of males as an indication of cardiac pathology, or one who can only think of punishment as a way of dealing with his misdeeds. In the neuroses a fundamental source of tension is the failure to understand and appreciate emotional upsets as functional disturbances. Other potent sources of inadequate thinking are the fixed mental sets that steer toward erroneous interpretation such as concern over health, self depreciation, grudge formation, ideas of persecution, self overvaluation. This principle, inadequate ideation results in tension provocation, and conversely, adequate ideation reduces tension, is the basis of the readjustment process, as I see it. Cumulative evidence appears to establish the principle. The military neurotic was shown by Hollingworth4 to be typically of inferior intelligence. The writer’s study 5 of the civil neurotic showed a similar result. Continued testing of psychoneurotics verifies these results. Slawson’s6 study of the Delinquent Boy found intellectual inferiority and a greater degree of emotional instability in the delinquent than in the normal. The writer’s study 7 of maladjusted children showed that those who responded to treatment were superior in intelligence to those who did not. Evidence from neuropathology is again in the direction of these findings?cortical control of lower emotional centers. There appears to be enough ground for regarding the principle of stimulating adequate ideation as a basic factor in psychotherapy or readjustment.
2. Special features in connection with the stimulation of insight are : 4 H. L. Hollingworth, The Psychology of Functioned Neuroses, New York: Appleton, 1920, pp. 80-99. s A. D. Tendler, The Mental Status of Psychoneurotics, Arch, of Psychol., 1923, 60, pp. 23-29. e J. Slawson, The Delinquent Boy, Boston: Badger, 1926, pp. 191, 268. 7 A. D. Tendler, The Role of Intelligence and Emotion in Maladjusted Children, Proceedings and Papers, Ninth International Congress of Psychology, Princeton, N. J., Psychological Review Co., p. 425. (a) The reanalysis of the difficulties encountered, this time not in the circular process that the subject has indulged in, but with the therapist bent upon directing attention to factors wrongly stressed or overlooked.
(b) The effort directed towards changing mental sets?for example, instead of blaming oneself to understanding the conditions under which responses were made, or changing a sense of impossibility to one of possibility.
(c) By explanation and teaching, efforts are directed towards building up an adequate set of concepts with which to comprehend the situation?such as the factor of habit, ideas as a means of control, the uselessness of certain erroneous interpretations, the difference between an organic and functional condition, the true attitudes of others. 3. The stimulation of insight glides into the third phase?that of assisting the establishment of more adequate responses. If the preceding has been properly conducted, the analysis has served to change the subject’s mental set, has brought out new aspects of the situation and has paved the way for finding a new solution to the difficulties encountered. A process of reasoning has been substituted for impulsive action. The conferences have habituated the subject to a thoughtful approach, and if skilfully conducted, have made it a satisfying affair. The subject has already involved himself in a controlling thought process and some plan of action has been evolved, a plan in which the subject has cooperatively shared.
The psychologist further seeks to induce a hopeful attitude and enthusiastic efforts from the subject. In this connection chart devices that can bring home to the subject an indication of the degree of progress he is making are of decided value. One type of chart I have used is the self estimate chart, aimed at stimulating better insight. The subject rates himself on some socially desirable traits. He usually overestimates himself. This paves the way for a consideration of the trait, its meaning and application in everyday situations, the justness and adequacy of the rating the subject has given himself. Another type of chart is aimed at establishing control. Thus, a child who has difficulty in controlling anger, or fear, or temptation to steal is asked to keep a record of such situations. He uses a stroke to indicate that he was about to respond the wrong way and crosses it if he catches himself in time. The device lends itself to the variety of problems one meets in maladjusted children. Full advantage of these techniques may be taken only when the underlying psychological factors are appreciated. The chart technique is to be regarded as an attention-getting, associative, and motivating device. It directs attention to specific features of a situation, provides an opportunity of associating ideas of control with specific performances, and motivates action by allowing for a measurement of successful effort. Before undertaking its use the subject must feel its significance and accept it wholeheartedly, the psychologist using all his skill to present it in such terms. The techniques and methods of dealing with children are fairly evident from the preceding. An illustration of the method with an adult case may be of value.
Patient, male, age 35, presents himself for treatment at a nerve clinic. He complains of numbness of fingers, especially evident at night and after tightly clasping fingers. Neurological examination proves to be negative. Diagnosis: Anxiety neurosis.
Tension exploration yields the following data: Recently a friend of the patient had suffered a paralytic stroke. Patient is in a state of fear lest he suffer a similar fate. He has begun to observe himself and has noted the phenomenon of numbness. Patient is very much disturbed over it and is unable to get his mind off the symptom. The detensor he had hit upon by himself was that if he takes preventive measures, he may save himself.
Tension reduction: Psychologist explains to patient in terms that he can understand the distinction between functional and organic disturbance, the neurologist’s diagnosis of his case as a functional disturbance. The story of the onset is retold to him. The error of thinking that because his friend became ill he would too, is pointed out to him. He is told that a paralysis does not come on without an adequate organic basis and that the neurologist had found nothing warranting any such fear, that the phenomenon of numbness is a normal physiological one, and that under the circumstances he would be justified in practicing the art of dismissal of troublesome thoughts. Some illustrations of this art are given and the mental gesture of dismissal evoked. Patient feels assured and is relieved of distress.
The case, although a fairly simple one, illustrates the principle of tension provocation, the inferior type of thinking involved, the process of tension reduction as a building up of a more adequate ideation process, and assistance in the formation of a technique that may be applied should the tensor recur. In more complicated cases the same factors are involved.
Attention has been directed to an analysis of the dynamic factors in psychological treatment or readjustment, a process in which the clinical psychologist must become adept. Failure to advance in this direction relegates the psychological clinician to the role of a laboratory assistant whose findings are significant to him alone, and whose usefulness in human adjustments must remain a misunderstood and debatable matter. On the other hand, the development of such skill must of necessity win recognition and increasing opportunities to be of service in an age in which appreciation of psychological factors is becoming a predominant force.
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