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REFLECTIONS on the HISTORY
OF PSYCHOTHERAPY (Part 4:)
Developments since the 1980s
Adam Blatner, M.D.
Part 1 : Overview through Freud,
Jung, Adler, Rank and Others Active Before 1940
Part 2: including the American
Psychoanalytic "Neo-Freudians," the beginnings of Group
Psychotherapy, Moreno, others.
Part 3. Innovators, the "New
Psychotherapies" in the 1960s-1980s.
This is Part 4. Developments since the 1980s.
Part 5: Further Reflections on the
History of Psychotherapy
The Later Evolution of Psychoanalysis
I described the earlier history of psychoanalysis
in the first part (webpage)
and the middle history around the 1940s in the second part. The field has
continued to evolve in the 1960s to the present. Even though the
percentage of psychoanalyts has declined (while there has been a
sharp rise in the variety and number of psychotherapists and
counselors); now a great majority of psychoanalysts nowadays are
not psychiatrists---that is, not MDs, physicians. Still, in
contrast to the overall submersion of depth psychology as
inefficient in the eyes of managed care and insurance companies,
there continues to be an interest in really digging down as part
of personal development or in the reatment of mild
neuroses---some folks are willing to pay for this. In turn, the
field continues to integrate its various sub-type. The chart at
the left, near the top, after the 1990s, should be modified a
bit at the top to take into consideration several new trends.Following the Vietnam War, and more, the emergence of Feminism, much more has come to the surface about trauma, low-grade trauma, chronic trauma, physical, emotional, and sexual abuse. The key point is that trauma is different from stress. It's not only more intense, but it's more disorienting. Were the perpetrators to be blamed or was it the victim's fault? Victims get manipulated and confused, which adds to the disorientation and overload. With bad stress you still know what's going on; with trauma you lose your bearings, and this makes it a different type of stress---the difference, in physical trauma between getting a cut or the kind of wound that sends a person into shock. So the psychology of trauma continues to be explored.
Another major theme has been the sensitivity brought to subtle patriarchy, authority, domination, power gradients in therapy; and as a result, the early practice of the analyst being a blank screen was recognized as not being just neutral, but rather a strong negative stimulus. Analysts joined other types of therapists----such as Person-Centered therapists influenced by Carl Rogers (see previous webpage) and became more self-disclosing and authentic. It was sufficient to explore what was going on between people using both sides' point of view---"Inter-subjectivity."
(To learn more about these topics, google key words on the internet web-search engines and browse around!)
We talked about psychoanalysis in the 1940s, but as seen on the left, several other movements came in to the field---and from there, out into the general discourse of psychotherapy---during the mid-1960s through the early 1990s: Object relations theory and "self psychology."
Object Relations Theory
From a foundation in some of Melanie Klein's ideas, but profoundly re-worked by Fairbairn, and then Harry Guntrip in England, the idea grew more compelling: People are motivated as much and really more (than Freud's sexual drive theory) by a desire to feel secure in relationshipsBowlby's research on attachment added to this, working off the pioneering efforts of Rene Spitz on hospitalism and marasmus in orphanages
. Otto Kernberg and others applied these perspectives in thinking about an especially difficult type of neurotic, the "borderline." (In retrospect, this category of problem is a mixture of special sensitivity, post-traumatic disorders, disguised addictions, and other issues.) Kernberg was an objects-relations psychoanalyst who immigrated from Chile to the United States, to the Menninger foundation, and so around the early 1970s, at the time when the problems of dealing with severe character pathology, such as the borderline syndrome, was getting a lot of attention in the literature. Object relations theory described some of the behaviors more effectively than ego psychology, and so object relations theory became rather fashionable in psychoanalytic circles. (My latest thinking is that many of these people were suffering from subtle forms of undiagnosed PTSD, often as a result of sexual or severe emotional abuse.)
Heinz Kohut, M.D. (photo at left) was
another innovator who became interested in the problem of
patients in analysis who would become furious if their therapist
wouldn't be accurately empathic with them. From this he
gradually developed an interesting offshoot called "self
psychology" that made the task of constructing and maintaining a
sense of self as coherent and valued as a primary motive. This
was an important deviation from Freud and even from the Object
Relations school, but I think it illustrates the simple reality
that Jung pointed at and Adler hinted at: Trying to identify a
single primary dynamic is reductionistic and unnecessary. But
Kohut and many others who found his arguments compelling
certainly did have a point. More recent developments in
psychoanalysis are participating in the synthesis of these
various theories---once again dialectic is working! Developments in Other Types of Psychotherapy
Proliferation continues. A thorough exploration of the many kinds of fields would take many more webpages, and I fear I might not be able to do them all justices: Here are some general categories:The Creative Arts Therapies: Since the 1960s professionals have formed organizations of considerable size in the following fields: Art Therapy; Dance-Movement Therapy; Music Therapy; Poetry Therapy ; Drama Therapy, and an approach that mixes different arts approaches called "Expressive Therapy." Psychodrama has affiliated with these approaches although technically it's only the use of action exploration or some elements of the drama form to do deeper types of therapies. (I have written books and many articles on psychodrama, noted elsewhere on this website.) Drama Therapy has integrated increasing amounts of psychodrama, and the Arts therapies in general have moved from creating art more like a hobby-adjunct to a core method, and in this, integrating more principles of improvisation rather than trying to "do it right" the way they taught in standard art classes in school. Improvisation is also a key to the other approaches.
The Imagination Therapies
Starting back in the 1920s with Roberto Assagioli's method of Psychosynthesis, and later Carl Jung's analytical psychology, cultivating imagery and allowing the imagery to play out has been a powerful form of therapy used by a number of professionals. HansCarl Leuner wrote about the Guided Daydream. Akhter Ahsen and Anees Sheikh wrote books about the use of imagery in therapy, and others have built on it. Imagining scenes is an important part of drama therapy and psychodrama, and even dreams can be worked with in this way. There's an overlap here with hypnosis and also with biofeedback: "Imagine your hand in a pool of warm water." That sort of thing.Transpersonal Psychology
With a few exceptions, religion had been kept away from the mainstream of psychotherapy. In the early 20th century, major religions were still claiming that only their way was true, and the rules had to be followed carefully. Often they were fear-based, threatening hell---and being blind to the idea that some kids might take this seriously. (Frankly, I think the concept of eternal torture is as toxic as mercury poisoning---a public health hazard that needs to be talked about!) However, in moving away from spirituality in general, apart from the particulars from dogma, psychiatry threw away the proverbial "baby with the bathwater." By the later 1960s, more psychological-mindedness was entering programs of pastoral counseling, and more thinking about the role of spirituality was penetrating humanistic psychology. Writings about Zen Buddhism and Psychoanalysis helped, and also psychedelic experiences by people who were otherwise fairly clear thinkers. Jung's psychology became more relevant, and Houston Smith and Joseph Campbell were building bridges between comparative religion, mythology, and psychology.
Around 1969 several professionals began to organize the Association for Transpersonal Psychology including (from the left, Roger Walsh, M.D., Francis Vaughan, Ph.D., James Fadiman, Ph.D.. Other leaders in this sub-field have included Stanislav Grof, M.D. Of course there were many others, such as Anthony "Tony" Sutich, one of the pioneers---but I haven't found a photo of him. Fascinating folks.
More
about others, including the work of one of the philosophers who
provided more theoretical foundations to all this was Ken
Wilber, about whom you can read more on this website and others.The key issue here is the growing recognition that spirituality is indeed an important part of psychology. It need not be in the form of any particular religion---choose what works for you. But the question, echoing the earlier work of Viktor Frankl and many others, is that what gives life meaning and lifts you beyond yourself is also an important part of what grounds you, what offers resiliency! Increasingly various forms of psychotherapy have included such considerations, and there has been a significant increase in the numbers and activities of pastoral counselors. Chaplains, too, have become more like psychotherapists as they deal with issues of the psychosocial aspects of hospitalization, and chaplaincy has needed to be ever-more non-denominational as the population becomes more heterogenous. For those not in the sick role, an equivalent to personal coaching has emerged---the role of the spiritual guidance counselor. Interesting!
Positive Psychology
With precursors among the humanistic psychologists, Moreno,
Assagioli, and others, the idea has been around that just
untying the "knots" people get into isn't enough. The assumption
that people have sufficient residual health to bounce back is a
bit more valid for people whose history has been rather
successful, but many people have never really developed the
skills for being truly healthy to begin with. So what's needed
in addition to whatever methods are used to reduce confusion and
misunderstanding and ineffective or counter-productive reaction
patterns is a compensatory effort at building up healthy habits
of mind and body. In the metaphor of the garden, it's not enough
to take the weeds out. Unless you plant healthy plants, the
weeds will grow back! Martin Seligman (far right) and Barbara
Frederickson (near right) (who wrote a good book about all
this), have been exponents of a trend in psychology that's grown
in the last decade: Positive psychology. It's not a separate
type of therapy, but rather a focus that balances the tendency
to only focus on "problems.)Addictions Therapy
Increasingly since the 1960s programs for the treatment of alcoholics, drug abusers, and other "addictions"---eating disorders, sex addiction---have cropped up around the country. A whole profession of "addictions counselors" has emerged, with a very wide range of training involved. The tradition of Alcoholics Anonymous (AA,), formed in the mid 1930s, developed a "Twelve Step" method, and many variations of this have emerged. There's a transpersonal element in this approach, too.Self-Help Groups
People can help people without there being a professional group leader. Support groups for grief, diabetes, post-polio syndromes, parents of adult children with mental illness, and so forth have all had me come and talk with them about such topics as how to talk with the doctor, what other resources can be used, and what are the mental health issues involved. A related theme beyond the medical model are the numerous forms of groups people engage in for self-development---offshoots of the encounter groups. These interpenetrate with religious movements, followers of various teachers, yoga groups (which may or may not emphasize the spiritual dimension besides the benefits for health), and so forth.Finding Common Denominators Among the Psychotherapies
First, there have emerged increasing trends away from the idea that any single approach can encompass the whole of how the mind works or how best to help it resolve its blocks and move forward. Being a physician and enjoying also the history of medicine (as can be seen elsewhere on this website), I am inclined to see an analogy to the great complexity that it medicine, and even more so. What affects people's minds can involve the body (neuro-psychiatry); intra-psychic conflict, which can also be influenced by various abilities and disabilities and temperamental variables; interpersonal conflicts with spouse, friends, and family; social norms within community and roles in the community; cultural norms and common values of words (semantics); and world-view, spiritual or philosophical outlook, which may be largely unconscious and affected by ethnic and religious background, historical era, and so forth. At times these more general themes may become dominant, such as in the problem of morale and the vulnerability to post-traumatic disorder. The particularities of theory and techniques of practitioners of this or that approach may not be all that important. Research has emerged that supports that other variables may be far more relevant to a client's improvement.Furthermore, there have been efforts to identify the common denominators among the scores of major therapies and hundreds of minor variations and innovations! As yet there is no great consensus about how to generate a more widely acceptable general approach to psychotherapy. I confess that I'm inclined in this direction and have my own ideas, but I don't think they're the final answer. Different people require different approaches depending on key variables I describe on another website: How voluntary are they, and how much can they exercise psychological-mindedness or meta-cognition? That is, can they get a little distance between their sense of self and how they think? If they're like Popeye the Sailor Man, who says, "I yam what I yam and that's what I yam," that's a pretty low level of meta-cognition.
Other variables involve overall strengths to build upon and various other supports. If the person has "co-morbidity," such as a concurrent addiction, it's not twice as hard to work with him, but more like four times as hard, as the addiction tends to pull them into escape from symptoms which then often creates more problems; and their basic psychological problem is "buffered" or protected by their addiction.
3. I mentioned Arnold Lazarus at the end of the last webpage: Multi-modal, eclectic treatment based on rational, multi-leveled formulation
4. Extension of understanding to inform education, parenting, religious training, management, physician-patient relations, community relations, and perhaps even political and social science
Regarding Eclecticism and the Challenge of Psychotherapy Integration
First, the more different types of therapy there are, the more we can begin to seek common denominators. This happened in the field of chemistry about a hundred years ago, as the various elements were being discovered. Gradually, our technology improved so that we could explore the reason for all the variety, and it turned out to be the dynamics of electrons, their shells, the angles and strengths with which they bond, etc. In a similar sense, there have been efforts to understand the underlying dynamics in psychotherapy, as described by such figures as Jerome Frank, Judd Marmor, Fuller Torrey, and many others.
The next step is to utilize this growing understanding to construct a viable general theory. I believe what's needed is a meta-theory which will stand in relation to all the methods I've been describing this morning the way a general idea about physiology relates to the particular physiologies of the various organs and levels of organization. I've developed a modification of role theory that allows for the integration of the different therapies in this fashion.
The third step is to use this integrative theory to encourage a more multi-modal diagnostic and treatment approach which is based on a committment at rational planning and followup, on a thought out formulation.
Finally, if we do develop a simpler, more comprehensive psychology, and more effective methods for applying them in the service of maturation and personal growth, then it's logical to apply these findings in a preventive fashion, teaching it in schools, on television, extending it to the public. Adler had this dream, as did Satir and Menninger and Moreno and many others.
Future Prospects
I am hopeful that increasingly the problems psychotherapists are faced with are eased somewhat by increasing numbers of people knowing more about psychology, so that therapy doesn't have to wade through layers of ignorance and denial just to get the process cooking. Right now it's a bit like trying to organize a navy in a country where most sailors-in-training don't even know that swimming is possible. Many people, perhaps most, are not psychologically literate, a condition that involves many components---just as actual literacy involves more than bare skills of reading and writing. In psychology In envision the following elements:
1. More people know that they are inclined to fool themselves and take steps to watch for and respond to self-deceptive maneuvers. (Right now there's more of a lapsing into the powerful illusion that "we seem to know what we're doing, so we do know what we're doing." Stupidity is in my definition the illusion that what we know is sufficient, there's no need to check out what feels to be real. Ignorance is morally neutral---it's just not knowing. Wisdom is knowing that there may actually be more to learn about a given situation, and that we shouldn't give in to the feeling that we know enough---especially if someone else is disagreeing with us. In other words, just being a bit intellectually humble is a good thing.
2. Having a little exposure to the many ways we fool ourselves would help. Including classes in psychological defensive maneuvers and how to defend oneself against one's own tendencies---this can become an edge of growth.
3. It's good to recognize that we play many roles and that we can learn to play with some of our roles, or modify that role playing to make it more conscious and explicit. It's good to learn to manage the complexity of the hundreds of roles played, along with learning how to find others in one's social network with whom one
I consider psychological literacy a plausible goal for the 21st century. This would include some of the following: mental flexibility, the ability to shift
frames of reference, play many roles; empathy, taking the other's point of view; skills of communications, problem-solving, and self-awareness. Knowing a bit about these categories would be a type of mental hygiene---prevention in mental health.
Four Psychiatric Revolutions
Different writers have written about the history of psychiatry. Around 1940, when psychoanalysis was considered most promising as a way to cure mental illness, a historian of psychiatry, Gregory Zilboorg, described two "psychiatric revolutions: The first revolution involved the shift away from punitive approaches and towards more humane treatment, beginning with Pinel's releasing the patients at the Salpietre asylum in Paris from their chains around 1793 and continuing well into the 19th century with the campaigns of Dorothea Dix. The second revolution was that of the integration of psychology into psychiatry, a real opening of the mysterious realm of the mind, especially those dimensions not so easily responsive to mere exhortation and instruction. This began even before Freud, but his work made the whole endeavor more systematic.Others disagree about what should be considered the third revolution. Moreno, thought that group therapy and support groups would constitute a revolution, but he underestimated the power of hyper-individualism and other factors. After psychotropic medicines that were specifically for major mental illnesses were introduced---the anti-psychotic and anti-depressive drugs---some though that would constitute the third revolution. Associated with that has been a dream that advances in neuroscience would make a big difference. Others yet have wondered if significant progress would be made as:
- spirituality became reconciled with science and yet separated from the exclusivist and rigid demands of traditionalism
- hypnosis would be understood and even children would learn self-hypnotic techniques as early as they learn reading and writing
- ?
At present part of the problem is economic and social.
Three Categories
I perceive three categories of psychiatric disorders:
1. The major mental illnesses seem to be primarily biological and medicines and other treatments offer the main promise. However, psychotherapy that addresses the fear and disorientation caused by these problems and that also address problems of rehabilitation and connection with family, occupation, and society also need to be part of the mix, as much as, say, a soldier who gets his leg blown off by a mine needs not just surgery, but later physical, occupational, and psychological rehabilitation, and this might take much longer and be more involved than the specific surgical treatment.
2. The minor conditions of anxiety and depression, if mild, need to be recognized as qualitatively different. In most cases, they involve the person having learned wrong lessons about what life is about, having build bad habits of thought, and the work here is mainly through psychotherapy.
3. There's a fuzzy middle area that is more severe and resistant than 2 and at times borders on severe illness. These typically involve people who have quite deep habits of negative thinking. Often they have been traumatized by events associated with war or catastrophe, but even more common are people who have suffered from intense or chronic physical, emotional, or sexual abuse. More sensitive people are more vulnerable. Such conditions are very difficult and often they involve co-morbidity---a term that means that there are more than one type of disorder operating. When these include habituation or addiction to any chronic escape pattern, alcohol, any drugs, other patterns, these forms of temporary relief tend to undercut the recovery from the stress that generates the symptoms and the addiction.
The third psychiatric revolution involves both the development of powerful somatic treatments and the emergence of group methods which continue to have great promise.
We'll be emphasizing those approaches which involve interpersonal interactions. And these have evolved, just as those charts you may have seen describing how life evolved from the simpler to the more complex organisms.
Psychotherapy as I'm using the term refers to only a part of the overall enterprise of psychiatry. Other treatment modalities are used synergistically with this general approach.
I'll be coming back to this diagram later. As you can see, beginning with Freud, offshoots emerged. Psychoanalysis flourished in mid-century. Other types arose to complement or compete with the mainstream--behavior therapy, existential therapy, Berne's Transactional Analysis, etc.
Since the 1990s a number of approaches to therapy have become more prominent:
- Voice Dialogue (Hal and Sidra Stone)
- Hermans...
- Family Constellations
- Internal Family Systems Therapy
- Dialectical Behavior Therapy (Marsha Linehan)
- etc.
Competition versus Collaboration in the Theory of Psychology
As it is with religion, there is a good argument to suggest that the mind is complex enough to suggest that Adler is right, and so in many ways is Jung, or Freud, or Rank, or the others to be discussed. The story of the blind men and the elephant is cross-cultural and suggestive. The point is to realize that highly complex, mind-like phenomena may have many points of view! These are multi-dimensional.Depending on what feature of the elephant is felt by the blind man, they may say, "An Elephant is very like a (whatever they touch)." One may feel the trunk and say elephants are like snakes; or if another feels the tusk, an elephant is like a sword, etc. If they say, "No, you're wrong, it's not that, it's this!" then they are fools who can't imagine a multi-perspectival form of knowing. If they pool their impressions they yet might generate a composite picture and to that extent be relatively wiser. Perhaps we need to take a more collaborative approach to psychology, too. As a physician, I'm drawn to another analogy: "physiology," the workings of the human body. It turns out that there are many different physiologies for the various organs, organ systems, and different levels of function--chemical, macro-molecular, cellular, tissue, organ, etc. Principles relating to gas pressure attend the study of the lungs and blood, hydrodynamics for the heart, optics for the eyes, electrophysiology for nerves, etc.
My own thought is that this can be accomplished through the use of action methods, group methods, experiential learning in classes. More, I believe this is as necessary for helping people to adapt to the conditions in the next century as learning how to read and write has become for functioning in this century.
All these therapies should be thought of, then, almost as different classes or tracks in what I call "the university of yourself," a multi-dimensional program for consciousness raising.
In conclusion, then, I find the wealth of concepts in the many approaches to therapy to have practical implications in revitalizing the psychodynamic aspects of psychiatric diagnosis and treatment.
For Further Reflections, go on to Part 5, my own recent thoughts.
Jung, Carl G. (1948). Foreword. In Esther G. Harding, Psychic energy: Its source and its transformation (p. xi). New York: Pantheon Books.
So, though there are no short cuts in the process of personal growth and healing, there are some methods that are less inefficient, more direct, and more powerful. The challenge is to orchestrate their use in a rational manner.
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. Email to adam@blatner.com
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