CODEPENDENCY: A Consumer's Guide to Psychological Treatment
THE COMMON INGREDIENTS OF THERAPY
Psychological therapy consists of a systematic series of interactions between
a trained therapist who has been authorized by society to minister to psychological
problems, and one or more clients who are troubled, or troubling
others, because of such problems.
The goal of psychological therapy is to
produce cognitive, emotional, and behavioral changes that will alleviate
those problems. While professional therapists are trained for the job, and
paid as well, that should not blind us to the fact that there are strong similarities
between the ways they function and the manner in which friends, relatives,
and clergy dealt with those problems in earlier times and continue to
deal with them today.
In fact, it would be a serious mistake to identify treatment wholly with the
training of the therapist and the nature of the treatment he or she dispenses,
for there is much more to treatment than that. In order for treatment to be
maximally effective, a therapeutic relationship needs to be established, one
that is voluntary and cooperative and that maximally fulfills the expectations
of each participant. For only rarely do clients enter treatment suddenly
or lightly. The decision to seek professional help is commonly preceded by agonizing conflict, conflict that may last for months or years. To begin with,
most people try to solve their problems by themselves. Then, they may seek
out parents, teachers, ministers, and friends. But it is only when all else fails
that they seek professional treatment. And then, they come with a headful of
hopes, expectations, and information; some of it accurate, some inaccurate,
and much of it likely to affect the course of treatment.
Unlike many other transactions, the effectiveness of the therapeutic relationship depends heavily for its success on the free choices, hopes, expectations, and relationships of the participants.
You can have your shoes redone by the neighborhood cobbler and neither your personal view of him nor his of you matters for the success of that venture; only his cobbling skill counts.
Not so in psychological treatment. There, a host of "common treatment
factors" playa large role in determining outcome (Kazdin, 1979). The success
of highly skilled therapists is augmented massively, or greatly reduced,
by the interplay of such common treatment factors as the free choices of the
client, his or her hopes and expectations, the personal qualities of the therapist,
and the match between those qualities and the needs of the client. We
begin with the matter of free choice because choice affects the therapeutic
relationship from the very outset.
FREE CHOICE AND TREATMENT
You can bring a horse to water, the saying goes, but you can't make it drink.
That adage holds for psychological treatment, too. Clinical experience
strongly suggests that children who are dragged unwillingly into treatment,
spouses who enter marriage therapy under threat of divorce, and patients
who are involuntarily committed to psychiatric hospitals, all suffer substantial
deficits in motivation and understanding that make treatment less effective.
The best way to enter treatment is willingly and fully informed; any
other way substantially diminishes the likelihood of successful outcome, regardless
of the kind of therapy.
The role of choice and volition in therapeutic outcome was splendidly
demonstrated by Devine and Fernald (1973). Clients who suffered snake
phobias were shown films of four possible treatments. Some clients were
permitted to choose the treatment they preferred; others were randomly assigned
to treatment; and yet a third group was required to undergo a non preferred
treatment. Those who received the treatment they preferred had
the more successful therapeutic experience. Of course, each of the treatments
was known to be useful with phobias of this sort. What would have
happened if the clients chose a treatment that was inappropriate for the disorder?
We do not presently know, nor for obvious ethical reasons can we
find out directly. But quite probably, even clients who choose an inappropriate
treatment will fare better than clients who are compelled to undertake
that treatment.
Clients who are forced into treatment likely will view it as a mere exercise
in compliance, or a punishment. Unless time and effort are taken to convince
them otherwise, treatment will fail. Conversely, those who enter
treatment of their own free choice are more likely to benefit from it. Their
hopes and expectations are themselves curative, greatly augmenting the effectiveness of any treatment. We therefore turn to the nature of hopes and
expectations in therapy.
HOPES AND EXPECTATIONS
A unique characteristic of humans is that their expectations about the future
powerfully affect their experiences and behaviors in the present (Frank,
1978). The hope of eventual salvation has sustained countless people, enabling
them to endure lifetimes of misery. For others, as we saw in Chapter
13, the belief that the future is hopeless has intensified their depression. In
similar fashion, expectations strongly affect psychological treatment. "Expectation
... colored by hope and faith," Freud wrote, "is an effective
force with which we have to reckon ... in all our attempts at treatment and
cure" (Freud, 1905/1976, p. 289).
Molding Client Expectations
Clients and therapists often have distorted expectations of each other that
may impede therapeutic progress. Insight therapists, for example, expect
clients to talk about their feelings, experiences, and often, their dreams. But
clients, especially those from lower-class backgrounds, tend to talk about
their psychological symptoms precisely as they might describe a sore throat
to a physician. Their expectations about how therapists behave are frustrated
when they are asked about feelings and dreams. Conversely, therapists
gain the impression that clients will not profit from treatment when the
clients persist in merely describing their ailments and when they continue to
be reluctant to discuss feelings and dreams. One result of these jointly disappointed expectations is that lower-class clients drop out of insight therapy
at a considerably higher rate than middle- and upper-class clients.
To deal with this problem, Jerome Frank and his colleagues devised a
Role Induction Interview, during which clients' expectations about treatment
could be molded (Hoehn-Saric, Frank, Imber, Nash, Stone, and Battle,
1964; Nash, Hoehn-Saric, Battle, Stone, Imber, and Frank, 1965; Orne
and Wender, 1968).
In a controlled study, lower-class clients were interviewed
briefly before entering treatment and told what they could expect.
Psychotherapy, they were told, is a way of learning to deal more effectively
with life's problems, but it takes time and practice to implement what is
learned. They were told that four months would be needed before improvement
was seen, and even then, that they would still have problems, though
they would be coping more effectively. Further, they were told that the therapist
would talk very little, but would listen carefully and try to understand
the problems. They were advised that they were to talk freely, describe fantasies
and daydreams, express feelings, and especially, feelings toward the
therapist. The concept of resistance was explained in everyday language and
was described to them as evidence that the client was approaching and
dealing with issues that were both significant for progress and difficult to
face. Such difficulties were to be viewed as a positive sign of progress. A second
group of clients was given no information on what they might expect
during treatment.
The therapeutic results for clients who participated in the brief interview
were remarkable. First, their drop-out rate declined precipitously. Therapists
were behaving the way they were supposed to behave, so clients experienced
less need to terminate. Second, therapist ratings of clients'
improvement were considerably higher for these clients than for the control group that had not gone through the Role Induction Interview. Finally,
clients rated themselves as considerably more improved on their target
complaints if they had experienced the Role Induction Interview, than if
they had not.
The Role Induction Interview may have brought client expectations in
line with their therapists' expectations, led clients to behave in ways that increased therapist optimism about, and liking for, them. These considerations
correlate highly with clients' tendency to remain in therapy
(Rosenzweig and Forman, 1974; Shapiro, 1974), and with therapist ratings
of client improvement (Shapiro, Struening, Shapiro, and Barten, 1976).
Anticipatory socialization of the sort that is conveyed in such interviews
has been found to affect clients and therapists in a wide variety of settings.
Hospitalized lower-class patients benefit from it (Heitler, 1973), as do
clients in group therapy (Yalom, Houts, Newell, and Rand, 1967). Moreover,
films that portray therapy sessions, and even tape recordings of therapy
sessions, work as well as informative interviews to prepare clients for
treatment (Truax, Shapiro, and Wargo, 1968;Strupp and Bloxom, 1973). In
short, any information that enables clients to develop reasonable expectations
about treatment facilitates treatment.
While shared expectations of clients and therapists regarding the process
of treatment clearly affect its outcome, so too do expectations regarding the
outcome itself. Indeed, the belief that treatment will be effective is itself such
a powerful treatment that the mere anticipation of cure often brings at least
momentary relief and, not uncommonly, permanent gains. Such cures are
termed "placebo effects."
The Placebo Effect
&
Codependency/Love addiction
A placebo is a pharmacologically inert substance, and the placebo effect describes
positive treatment outcomes that result from the administration of
such substances. Placebo effects, as we have seen in Chapter 8, occur with
surprising regularity in a variety of settings. Beecher (1961) reported that
about 40 percent of patients who were suffering from a painful heart disease
called angina pectoris experienced marked relief from their symptoms after
merely undergoing a mock operation! In a late study, Ross found that 60
percent of patients who had undergone surgery to improve their blood circulation
showed clinical improvement, even though the surgery may have
left the blood supply to the heart unchanged and, in fact, may have reduced
it (Ross, 1976, cited in Frank, 1978).
Placebos are often as effective as psychotropic medications in treating
psychological disorders, and their dosage curves show similar characteristics.
In the first part of a double-blind study, about 35 percent of patients
who were given either drugs or placebos at a particular dosage level improved.
Subsequently, the dosages of drugs and placebos were doubled in
the second part of the study, and improvement rates jumped to 66 percent
for patients on active drugs, and 76 percent for those on placebos (Lowinger
and Dobie, 1969).
What is it that makes the placebo, a mere inert substance, so powerful?
The power of the placebo resides in the expectation that positive results will accrue from a particular treatment (Cousins, 1979). So long as the client believes
that the treatment works, it will likely have some positive effect. In no
way are these effects shams or fakes, or merely the results of the gullibility
of impressionable clients. Rather, they appear to be powerful treatments in
themselves for reasons that are not yet fully understood. Current speculation
suggests that the effects of placebos are mediated through a group of
enzymes called endorphins. Endorphins have been called "the brain's
opiates." They affect how individuals subjectively experience pain and
mood, and they may be produced when one expects to become well and able
to cope.
Free choice, rational expectations, and effective hope are crucial for therapeutic success. But they are not sufficient. The therapist's personal characteristics, and how those characteristics fulfill the needs and expectations of the clients, are necessary ingredients for successful therapy. Not all characteristics play a central role in treatment, but some, such as empathy, warmth, and genuineness seem absolutely necessary. We turn to those characteristics in another article.
Psychological therapy consists of a systematic series of interactions between
a trained therapist who has been authorized by society to minister to psychological
problems, and one or more clients who are troubled, or troubling
others, because of such problems.
The goal of psychological therapy is to
produce cognitive, emotional, and behavioral changes that will alleviate
those problems. While professional therapists are trained for the job, and
paid as well, that should not blind us to the fact that there are strong similarities
between the ways they function and the manner in which friends, relatives,
and clergy dealt with those problems in earlier times and continue to
deal with them today.
In fact, it would be a serious mistake to identify treatment wholly with the
training of the therapist and the nature of the treatment he or she dispenses,
for there is much more to treatment than that. In order for treatment to be
maximally effective, a therapeutic relationship needs to be established, one
that is voluntary and cooperative and that maximally fulfills the expectations
of each participant. For only rarely do clients enter treatment suddenly
or lightly. The decision to seek professional help is commonly preceded by agonizing conflict, conflict that may last for months or years. To begin with,
most people try to solve their problems by themselves. Then, they may seek
out parents, teachers, ministers, and friends. But it is only when all else fails
that they seek professional treatment. And then, they come with a headful of
hopes, expectations, and information; some of it accurate, some inaccurate,
and much of it likely to affect the course of treatment.
Unlike many other transactions, the effectiveness of the therapeutic relationship depends heavily for its success on the free choices, hopes, expectations, and relationships of the participants.
You can have your shoes redone by the neighborhood cobbler and neither your personal view of him nor his of you matters for the success of that venture; only his cobbling skill counts.
Not so in psychological treatment. There, a host of "common treatment
factors" playa large role in determining outcome (Kazdin, 1979). The success
of highly skilled therapists is augmented massively, or greatly reduced,
by the interplay of such common treatment factors as the free choices of the
client, his or her hopes and expectations, the personal qualities of the therapist,
and the match between those qualities and the needs of the client. We
begin with the matter of free choice because choice affects the therapeutic
relationship from the very outset.
FREE CHOICE AND TREATMENT
You can bring a horse to water, the saying goes, but you can't make it drink.
That adage holds for psychological treatment, too. Clinical experience
strongly suggests that children who are dragged unwillingly into treatment,
spouses who enter marriage therapy under threat of divorce, and patients
who are involuntarily committed to psychiatric hospitals, all suffer substantial
deficits in motivation and understanding that make treatment less effective.
The best way to enter treatment is willingly and fully informed; any
other way substantially diminishes the likelihood of successful outcome, regardless
of the kind of therapy.
The role of choice and volition in therapeutic outcome was splendidly
demonstrated by Devine and Fernald (1973). Clients who suffered snake
phobias were shown films of four possible treatments. Some clients were
permitted to choose the treatment they preferred; others were randomly assigned
to treatment; and yet a third group was required to undergo a non preferred
treatment. Those who received the treatment they preferred had
the more successful therapeutic experience. Of course, each of the treatments
was known to be useful with phobias of this sort. What would have
happened if the clients chose a treatment that was inappropriate for the disorder?
We do not presently know, nor for obvious ethical reasons can we
find out directly. But quite probably, even clients who choose an inappropriate
treatment will fare better than clients who are compelled to undertake
that treatment.
Clients who are forced into treatment likely will view it as a mere exercise
in compliance, or a punishment. Unless time and effort are taken to convince
them otherwise, treatment will fail. Conversely, those who enter
treatment of their own free choice are more likely to benefit from it. Their
hopes and expectations are themselves curative, greatly augmenting the effectiveness of any treatment. We therefore turn to the nature of hopes and
expectations in therapy.
HOPES AND EXPECTATIONS
A unique characteristic of humans is that their expectations about the future
powerfully affect their experiences and behaviors in the present (Frank,
1978). The hope of eventual salvation has sustained countless people, enabling
them to endure lifetimes of misery. For others, as we saw in Chapter
13, the belief that the future is hopeless has intensified their depression. In
similar fashion, expectations strongly affect psychological treatment. "Expectation
... colored by hope and faith," Freud wrote, "is an effective
force with which we have to reckon ... in all our attempts at treatment and
cure" (Freud, 1905/1976, p. 289).
Molding Client Expectations
Clients and therapists often have distorted expectations of each other that
may impede therapeutic progress. Insight therapists, for example, expect
clients to talk about their feelings, experiences, and often, their dreams. But
clients, especially those from lower-class backgrounds, tend to talk about
their psychological symptoms precisely as they might describe a sore throat
to a physician. Their expectations about how therapists behave are frustrated
when they are asked about feelings and dreams. Conversely, therapists
gain the impression that clients will not profit from treatment when the
clients persist in merely describing their ailments and when they continue to
be reluctant to discuss feelings and dreams. One result of these jointly disappointed expectations is that lower-class clients drop out of insight therapy
at a considerably higher rate than middle- and upper-class clients.
To deal with this problem, Jerome Frank and his colleagues devised a
Role Induction Interview, during which clients' expectations about treatment
could be molded (Hoehn-Saric, Frank, Imber, Nash, Stone, and Battle,
1964; Nash, Hoehn-Saric, Battle, Stone, Imber, and Frank, 1965; Orne
and Wender, 1968).
In a controlled study, lower-class clients were interviewed
briefly before entering treatment and told what they could expect.
Psychotherapy, they were told, is a way of learning to deal more effectively
with life's problems, but it takes time and practice to implement what is
learned. They were told that four months would be needed before improvement
was seen, and even then, that they would still have problems, though
they would be coping more effectively. Further, they were told that the therapist
would talk very little, but would listen carefully and try to understand
the problems. They were advised that they were to talk freely, describe fantasies
and daydreams, express feelings, and especially, feelings toward the
therapist. The concept of resistance was explained in everyday language and
was described to them as evidence that the client was approaching and
dealing with issues that were both significant for progress and difficult to
face. Such difficulties were to be viewed as a positive sign of progress. A second
group of clients was given no information on what they might expect
during treatment.
The therapeutic results for clients who participated in the brief interview
were remarkable. First, their drop-out rate declined precipitously. Therapists
were behaving the way they were supposed to behave, so clients experienced
less need to terminate. Second, therapist ratings of clients'
improvement were considerably higher for these clients than for the control group that had not gone through the Role Induction Interview. Finally,
clients rated themselves as considerably more improved on their target
complaints if they had experienced the Role Induction Interview, than if
they had not.
The Role Induction Interview may have brought client expectations in
line with their therapists' expectations, led clients to behave in ways that increased therapist optimism about, and liking for, them. These considerations
correlate highly with clients' tendency to remain in therapy
(Rosenzweig and Forman, 1974; Shapiro, 1974), and with therapist ratings
of client improvement (Shapiro, Struening, Shapiro, and Barten, 1976).
Anticipatory socialization of the sort that is conveyed in such interviews
has been found to affect clients and therapists in a wide variety of settings.
Hospitalized lower-class patients benefit from it (Heitler, 1973), as do
clients in group therapy (Yalom, Houts, Newell, and Rand, 1967). Moreover,
films that portray therapy sessions, and even tape recordings of therapy
sessions, work as well as informative interviews to prepare clients for
treatment (Truax, Shapiro, and Wargo, 1968;Strupp and Bloxom, 1973). In
short, any information that enables clients to develop reasonable expectations
about treatment facilitates treatment.
While shared expectations of clients and therapists regarding the process
of treatment clearly affect its outcome, so too do expectations regarding the
outcome itself. Indeed, the belief that treatment will be effective is itself such
a powerful treatment that the mere anticipation of cure often brings at least
momentary relief and, not uncommonly, permanent gains. Such cures are
termed "placebo effects."
The Placebo Effect
&
Codependency/Love addiction
A placebo is a pharmacologically inert substance, and the placebo effect describes
positive treatment outcomes that result from the administration of
such substances. Placebo effects, as we have seen in Chapter 8, occur with
surprising regularity in a variety of settings. Beecher (1961) reported that
about 40 percent of patients who were suffering from a painful heart disease
called angina pectoris experienced marked relief from their symptoms after
merely undergoing a mock operation! In a late study, Ross found that 60
percent of patients who had undergone surgery to improve their blood circulation
showed clinical improvement, even though the surgery may have
left the blood supply to the heart unchanged and, in fact, may have reduced
it (Ross, 1976, cited in Frank, 1978).
Placebos are often as effective as psychotropic medications in treating
psychological disorders, and their dosage curves show similar characteristics.
In the first part of a double-blind study, about 35 percent of patients
who were given either drugs or placebos at a particular dosage level improved.
Subsequently, the dosages of drugs and placebos were doubled in
the second part of the study, and improvement rates jumped to 66 percent
for patients on active drugs, and 76 percent for those on placebos (Lowinger
and Dobie, 1969).
What is it that makes the placebo, a mere inert substance, so powerful?
The power of the placebo resides in the expectation that positive results will accrue from a particular treatment (Cousins, 1979). So long as the client believes
that the treatment works, it will likely have some positive effect. In no
way are these effects shams or fakes, or merely the results of the gullibility
of impressionable clients. Rather, they appear to be powerful treatments in
themselves for reasons that are not yet fully understood. Current speculation
suggests that the effects of placebos are mediated through a group of
enzymes called endorphins. Endorphins have been called "the brain's
opiates." They affect how individuals subjectively experience pain and
mood, and they may be produced when one expects to become well and able
to cope.
Free choice, rational expectations, and effective hope are crucial for therapeutic success. But they are not sufficient. The therapist's personal characteristics, and how those characteristics fulfill the needs and expectations of the clients, are necessary ingredients for successful therapy. Not all characteristics play a central role in treatment, but some, such as empathy, warmth, and genuineness seem absolutely necessary. We turn to those characteristics in another article.
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http://theliberatormethod.com/Welcome.html
More Codependency Treatment info:
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