Encyclopedia of psychotherapy - part 6 doc

Summary Further Reading GLOSSARY behavior therapy A systematic, direct, educational approach to therapy that uses principles and strategies that have been supported by research to change

American psychology journals has declined from a peak

of about 15 from 1975–1979 to a low of about 3 from

1990–1994 Reviews of the literature, including the 1977

reviews by Curran and Hal Arkowitz and the 1990 review

by Debra Hope and Richard Heimberg mentioned earlier,

generally conclude that HSST is effective for improving

scores on the various dependent measures used in the

re-search Unfortunately, the studies are also consistently

criticized for a number of reasons The first is that the

de-pendent and indede-pendent variables are not consistent

across studies, thus making it difficult to interpret the

findings and draw useful generalizations From an

inde-pendent variable perspective, participant selection and

categorization methods are often poor, consisting, for

ex-ample, of asking college students about their dating

fre-quency As several authors have mentioned, this

generates a “high-frequency dating” category that might

include someone who has gone out on 10 fun and

inter-esting dates with a number of different partners as well as

someone who has gone out on 10 minimal dates with a

partner whose basic appeal is that he or she is still around

after the first few dates In addition, the studies are

criti-cized because they typically have not included adequate

no-treatment control conditions, have assumed

general-ization of the relevant skills rather than testing for it, have

shown small effect sizes, and have inadequate assessment

and training of individual-specific skill deficits

Despite the criticisms, there are a number of sound

studies supporting the efficacy of HSST In 1975 James

Curran reported the results of a controlled study in

which minimally dating college men and women were

exposed to HSST, systematic desensitization (SD), or no

treatment Participants completed self-report instruments

and semistructured interactions (with an experimental

confederate) both before and after the interventions The

active interventions were in a group format with six

ses-sions (75 min each) over a 3-week period Specific

be-haviors (e.g., giving and receiving compliments, listening

skills, and nonverbal communication) were targeted by

HSST which consisted of instruction, modeling,

hearsal, coaching, and homework SD participants

re-ceived a comparable amount of therapist contact with a

procedure designed to reduce heterosocial anxiety via

graduated exposure exercises In the control conditions,

clients received no treatment at all, or relaxation training

not specifically geared toward heterosocial anxiety The

results indicated reductions in self-reports of anxiety and

increased social competence as rated in the

semistruc-tured interactions for both the HSST group and the SD

group, but not for either of the control groups

Elaborating on those results during the same year,

Curran and Francis Gilbert reported a similar study in

which the therapy was an individual format and in whichparticipants kept diary records to monitor “real-life”changes The design also included a 6-month follow-up.The results were as expected Self-reports and observerratings of anxiety decreased from pre- to posttesting forthe HSST and SD groups but not for controls HSST par-ticipants were rated as more socially skillful than SD par-ticipants and at 6 months the HSST were rated as moresocially competent than any other group Perhaps mostimportant, both HSST and SD participants reported in-creases in dating activity in their natural environments.Overall, the results indicate that HSST increases per-ceptions of social competence and decreases anxiety SDalso demonstrated that ability, but was outpaced by indi-vidualized HSST at 6-month follow-up in at least onestudy These well-designed studies, which include ade-quate controls, multifaceted assessment, and at leastsome follow-up provide a solid foundation for HSST effi-cacy claims Although that speaks in favor of specificHSST effects, there is some evidence that simple practiceimproves heterosocial skills as well In 1974, AndrewChristensen and Hal Arkowitz were able to generate im-provement in both self-report measures and actual datingfrequency by randomly pairing volunteer men andwomen for a number of practice dates; there was no ac-tual training or intervention on the part of the re-searchers Participants merely paired up, went out, and inthe end reported feeling and acting better in dating situa-tions In a series of three studies, one each in 1982, 1983,and 1984, Frances Haemmerlie and Robert Montgomerydemonstrated that largely unstructured but positively bi-ased interactions with members of the opposite sex was aviable option for treating dating anxiety Thus, one hy-pothesis that can be drawn from the literature—one thatgeneralizes across the different active treatment modali-ties (i.e., SST, SD, practice dating)—is that skill rehearsal

in and of itself, structured or unstructured (but in a tively safe and positive context), plays an important role

rela-in overcomrela-ing datrela-ing anxiety Of course, not all datrela-inganxiety is alike For some there will be more pronouncedbehavioral deficits while for others the skill set will be in-tact but the presence of dysfunctional cognitions will get

in the way of dating success The relative success of HSSTwill thus depend on how thoroughly each of these areashas been assessed and incorporated into the intervention.Regarding the use of HSST as an intervention forsexual deviance, the results indicate that self-reportsand observer ratings of social competence increasewith treatment compared to control However, non-HSST methods such as covert sensitization also affectsocial competence, a surprising finding that may speak

to the non-specific effects of structured therapeutic

interactions The results on actual physiological

arousal in target scenarios are inconclusive, and there

are no data on the ultimate impact on convicted

offend-ers Thus, HSST works in its direct application but has

not been conclusively shown to affect the related and

generally more important constructs of arousal and

re-cidivism

It is worth noting that other data exist that inform

questions of the efficacy of HSST as a treatment for

dat-ing anxiety For example, in 1993 Debra Hope and her

colleagues reviewed a number of studies that used SST to

treat social phobia These data are particularly relevant

because those studies assumed that social skills deficits

underlie social phobia (a diagnostic category under

which dating anxiety might properly be subsumed)

Ac-cording to Hope and her colleagues, all the studies

re-viewed showed skill improvement for social phobics

from before treatment to after Unfortunately, only one of

the studies compared SST to a reasonable no-treatment

control (specifically, wait-list control) and the results of

that study showed no difference between groups

IV SUMMARY

This article began with the notion that heterosocial

skills are difficult to define and that behavioral deficits

probably interact with other non-behavioral phenomena,especially emotion and cognition, to disrupt datingsuccess in some people HSST grew out of theoreticalinterests in social learning theory and approaches thatemphasize remediating deficits, not just eliminatingsymptoms The weight of the evidence suggests that min-imally dating individuals can find assistance with het-erosocial skills training HSST is not the only treatmentfor minimal dating, given that systematic desensitizationand practice dating show similar effects

See Also the Following Articles

Assertion Training ■ Behavior Rehearsal ■ Chaining ■

Communication Skills Training ■ Operant Conditioning ■

Role-Playing ■ Structural Analysis of Social Behavior

Further Reading

Curran, J P (1977) Skills training as an approach to the

treatment of heterosexual-social anxiety: A review logical Bulletin, 84, 140–157.

Psycho-Hersen, M., Eisler, R M., & Miller, P M (Eds.) (1977) Progress

in behavior modification (Vol 5) New York: Academic Press Hollin, C P., & Trower, P (Eds.) (1986) Handbook of social skills training (Vols 1 & 2) New York: Pergamon Kelly, J A (1982) Social skills training: A practical guide for interventions New York: Springer.

I Earliest Approaches

II The Christian Era

III Rationalism and Moral Therapy

IV The Psychoanalytic Movement

V Ego Psychology

VI The Object Relations School

VII Self Psychology

VIII Postanalytic Schools

IX Summary

Further Reading

GLOSSARY

moral therapy A system of treatment promoted in the early

19th century by Philippe Pinel in France and Samuel Tuke

in England Moral therapy stressed humane treatment of

the insane, and use of rational persuasion, occupational

activities, and recreational engagement Moral therapy was

most appropriately delivered in the philanthropic, tranquil

setting of the asylum.

psychological disaggregation In the schema of Pierre Janet, a

lowering of psychological energy and barriers, resulting

from psychological trauma, that produced symptoms and

other psychological phenomena including paralysis,

som-nambulism, and trance states.

structural model Sigmund Freud’s second model of the

human mind, including three mental apparatuses Id was

the domain of unmodified drive impulses and primitive

modes of thinking; ego was the executive agent of the

mind, using memory, perception, thought, emotion, and

motor activity; superego was the repository of parental and

societal ideals, morals, and restrictions.

topographic model Sigmund Freud’s first model of the mind.

The model described three systems System Cs, the scious, contained those ideas and feelings of which a per- son was overtly aware; system UCs, the unconscious, contained memories, ideas, and feelings which could not

con-be brought into awareness; system PCs, the preconscious, was the reservoir for thoughts that were not in awareness

at a given moment, but which could be called to awareness with effort.

From the dawn of civilization, human beings havebeen subject to disorders of thought, emotion, and be-havior The assumptions of modern society that suchproblems originate in the mind are fairly recent concepts.The development of current ideas about human psycho-logical development, the sources of psychopathology, andthe place and nature of psychotherapy begin in ancienttimes Following their path leads one through the magi-cal thinking of the Middle Ages, the rationalism of theEnlightenment, the drama of the psychoanalytic move-ment, and the splintering of psychoanalytic thought tomodern postanalytic ideas of the nature of mental distressand its treatment

I EARLIEST APPROACHES

Although evidence left by preliterate societies seems

to tell that shamans dealt with what we would today

identify as mental illness, and although Hindu

physi-cians as early as 1400 BC described various forms of

in-sanity and prescribed kindness and consideration, the

beginnings of planned therapy for mental disorders

probably lie in Greek culture Hippocrates was among

the first to view mental illness as a natural

phenome-non and approach it without superstition

Priest–physicians, who made Aesculapius their god,

enlisted his aid through “divine sleep, divine feasts, the

sacred performances.” In their temples, called

aescu-lapia, they used rest, diet, massage, baths, exercise, and

a hygienic life to achieve their desired ends In

particu-lar, they employed a type of mental suggestion called

incubation: The patient would lie down on the floor on

a pallet Aesculapius would reveal himself in a dream,

which either healed the disease or advised the

treat-ment to be followed Sometimes the attendants used

ventriloquism to aid the patient’s conversation with

Aesculapius The god’s dictates were interpreted

through the personal associations of the interpreter,

not the patient Hippocrates probably worked at one of

these temples

Plato suggested that mental disorders were the result

of love, great trouble, and interventions by the Muses

He advised the curative effect of words, their “beautiful

logic.” Greco-Roman tradition advocated analogous

therapies, and suggested innocuous deception to free

pa-tients from groundless fears They did permit and

rec-ommend more punitive approaches in severe cases

Later Roman practices, however, focused on herbs and

other somatic treatments With the spread of the Roman

empire, the Greek spiritual and psychological methods

virtually disappeared

II THE CHRISTIAN ERA

The early Christian church, through its first

mille-nium, emphasized the importance of forbearance to

pain and the mutability of earthly pursuits The Middle

Ages saw an evolution of faith-healing through

organ-ized theology Through this period, there was no

unify-ing theory of physiology or disease; barber-surgeons

and dentists practiced medieval medicine without

con-trol or regulation Magic and alchemy were the science

of the time Mental illness was most often regarded as a

defect of spirit divorced from therapeutic intervention

The Christian era did, however, bring about the

de-velopment of hospitals with a humanitarian

motiva-tion Religious doctrines of patience, pity, and the

possibility of absolution from guilt set in motion a

spirit that would later nurture the development of theprecursors of psychotherapy In the thirteenth century,Pope Innocent III initiated the medieval hospital move-ment, which brought humaneness and tranquility tothe treatment of simpletons and madmen The monas-tic tradition of treatment through loving care was di-rected to those suffering from mental afflictions

In 1725 the Franciscan monk Bartholomeus Anglicus

(Bartholomew) wrote De Proprietatibus Rerum (Of the

Nature of Things) The seventh book of this dic tome dealt entirely with mental illnesses For thetreatment of melancholics, Bartholomew recommended,such patients must be refreshed and comforted and withdrawn from cause of any matter of busy thoughts and they must be gladded with instruments of music and some deal be occupied.

encyclope-Although Bartholomew spoke for his fellow cans, his attitudes stood in opposition to the inquisi-tors of France and to the Dominican orders, who aidedlocal courts in adjudicating cases of sorcery and witch-craft, often directed against the insane The force of theChurch’s crusade against Satan fell disproportionately

Francis-on the mentally ill throughout the Middle Ages

III RATIONALISM AND MORAL THERAPY

By the 1700s, intellectualism had taken root in rope as a popular philosophy Adam Smith, JohannWolfgang vonGoethe, Jean-Jacques Rousseau, andother philosophical giants pled for the right of man toimprove his lot through the application of civilization’saccumulated knowledge In England, the Deists viewedGod as more benevolent than the punitive power oftheir medieval predecessors Humanitarianism encom-passed the aim of improving social relations at large,and hence conferred sanction on emotional and socialproblems as worthy of philosophical and scientific at-tention A similar curiosity about the nature of thehuman soul became a thread in early neurology andpsychology Medical science, however, was still far toounderdeveloped to make much progress even in themilieu of such open-minded attitudes

Eu-By the mid-eighteenth century in England, WilliamCullen viewed many diseases as the result of neurosis, in-cluding insanity, somnambulism, painful dreams, andhysteria The Quakers, a small but influential group, wereinstrumental in the treatment of the insane William

Tuke, a tea merchant, convinced the Society of Friends in

1796 to establish a retreat at York, where the mentally ill

could receive care on the basis of the humane spirit of

Quakerism Their afflictions were treated with a regimen

of personal encouragement and routine work

Across the English Channel, the philosophical and

political forces that drove the French Revolution in the

late eighteenth century also led to the emancipation of

the insane from incarceration Philippe Pinel was

partic-ularly influential Appointed superintendent of the

infa-mous Saltpêtrière, a prison for paupers and lunatics, he

released the inmates from their chains in 1793, and

treated them instead with kindness and respect Many

won their release from the institution Pinel forbade

vio-lence toward the inmates in favor of persuasion For

ma-niacal fury, for example, he prescribed, “bland arts of

conciliation or the tone of irresistible authority

pro-nouncing an irreversible mandate.”

In Europe and North America, the nineteenth century

was the era of asylums Germany built institutions at

Saxony, Schelswig, and Heidelberg; France featured

Bicêtre, Saltpêtrière, and Charenton; in the United

States, treatment occurred at Bloomingdale, McLean,

and the Friends’ Asylums The spread of moral therapy,

based in the approaches of the French and English

En-lightenment, convinced a number of physicians that

in-sanity could be cured In 1826, Dr Eli Todd of the

Hartford Retreat in Connecticut reported curing 21 of 23

cases he admitted Others reported similarly remarkable

outcomes In the flush of enthusiasm that all mental

ill-ness could be curable, more asylums were built

Eventu-ally, the statistics were found to be fraudulent and the

pendulum swung against the asylum movement But the

door had been irreversibly opened to earlier recognition

of mental illnesses and the allocation of resources for

their treatment Drs Thomas Kirkbridge and Isaac Ray,

at meetings of the Association of Medical

Superinten-dents of American Institutions (predecessor of the

American Psychiatric Association) between 1844 and

1875 enacted a series of resolutions embodying these

evolving attitudes Insanity, they resolved, is a disease to

which everyone is liable, and which is as curable as other

diseases They discouraged the use of physical restraint

and advocated activity, occupation, and amusement

Rudolf Virchow’s (1821–1902) cellular theory of

dis-ease established the nervous system as the seat of both

somatic and mental activity, and brought neurology

into the mainstream of nineteenth-century medicine

As a result, the nervous patient became one deserving

of medical recognition and attention Neurologists

began to accept hysterics and neurasthenics as patients

The restrictive social mores of the Victorian era gaverise to no shortage of such patients for care and study.These shifts in patient profile and clinical practice alsoserved to move the insane into the doctor’s office andaway from exclusive assignment to the asylum.Among those adventurous enough to undertake thetreatment of hysterical patients were two Parisians,Jean Martin Charcot (1825–1893) and Pierre Janet(1859–1947) Charcot, a pathologist, was instrumental

in initiating the scientific study of hypnotism Janet, hispupil at the Saltpêtrière, directed his studies towardneurology, and specifically to hysteria Under hypnosis,hysterical patients recalled long-forgotten memories,suggesting the existence of a separate type of con-sciousness from that which is active in everyday aware-ness Janet believed that trauma led to a “psychologicaldisaggregation,” a lowering of psychological energyand barriers, that produced symptoms and other psy-chological phenomena including paralysis, somnambu-lism, and trance states The split-off ideas became

“emancipated” from their original stimulus and gained

a life of their own as neurotic symptoms He used nosis as a means to enter this other world of conscious-ness and direct the patient’s perception and behavior

hyp-IV THE PSYCHOANALYTIC

MOVEMENT

Charcot and Janet attracted many students fromacross Europe Among these was the young SigmundFreud (1856–1939) After graduating from the Univer-sity of Vienna, Freud studied the biology of the nervoussystem under mentors including Ernst Brücke Unable

to support himself as a scientist, he opened a practice

in neurology and found himself fascinated by his tients with hysteria In 1885, he traveled to Paris tostudy with Charcot and Janet He learned how to usehypnosis to treat the symptoms of hysteria, but wasmore interested than his teachers in the stories his pa-tients related while in their trances Back in Vienna, hefound a kindred spirit in Josef Breuer, who believedthat the secret to unraveling hysteria lay in allowingthem to speak freely about their recollections, a tech-nique that would give rise to free association

pa-In listening to these tales, Freud went a step furtherthan Janet’s psychology of dissociation, and postulated

a dynamic quality of the mental apparatus throughwhich unacceptable ideas were split off by some yet-undefined mechanism to reappear as psychological andbehavioral symptoms The recall of these memories

under light hypnosis allowed the repressed emotions to

be expressed, resulting in at least transient relief of

symptoms He and Breuer took their first steps to

de-scribe the mechanisms of these processes in the cases

published as the Studies in Hysteria in 1894.

Freud postulated that painful ideas were turned away

from conscious awareness to avoid mental distress

(un-lust, or “un-pleasure”) The ideas were converted into

symptoms through pathology that was exclusively

psy-chological, not physiological He identified repression

as a mental activity that had to be overcome Freud and

Breuer eventually parted company over differences of

opinion about Freud’s emphasis on sexuality as a

driv-ing force behind emotion and behavior

By 1910, Freud had developed the major ideas that

would form the core of psychoanalytic thinking He

identified the unconscious as the seat of most mental

activity He postulated the pleasure principle, which

drove the human organism to maximize pleasure while

minimizing unpleasure He identified the mental

mech-anisms that yielded the tales and images of dreams

From these, he extrapolated the mechanisms of

psy-chological defenses He began to study not only dreams

but also parapraxes, wit, obsessions, and phobias for

the meaning of their content

In his first model of the human mind, the topographic

model, Freud divided mental activity into three domains:

The conscious, which he called the system Cs, contained

those ideas and feelings of which a person was overtly

aware More revolutionary was the larger system UCs, the

unconscious mind, which contained memories, ideas,

and feelings that could not be brought into awareness

The preconscious, the system PCs, was the reservoir for

thoughts that were not in awareness at a given moment,

but which could be called to awareness with effort The

energy source for this apparatus was the drive Originally,

the drive was considered to be an internal somatic entity,

aimed at self-preservation and sexual expression At this

early stage, the only drive was the libidinal drive

The human organism, Freud postulated, sought to

maintain a constancy of pleasure and a minimum of

suf-fering Drive would seek its own expression, but reality

would often impede its attainment of its desires Under

these circumstances, the mind would use memory and

dreams to fulfill drive wishes This model accounted for

much, but left many behaviors and emotions

unex-plained Two subsequent developments expanded the

theoretical and clinical power of psychoanalysis First,

Freud defined a second drive, the aggressive drive,

which sought destruction and separation Second, he

augmented the topographic model with the structural

model Now the mental apparatus included the id, ego,

and superego Id was the domain of unmodified driveimpulses and primitive modes of thinking Ego was theexecutive agent of the mind and the vehicle for the im-plementation of drives, using memory, perception,thought, emotion, and motor activity among its tools.Superego was the repository of parental and societalideals, morals, and restrictions on activity and thought.This schema allowed for a broad-ranging explana-tory model Drive impulses initiated in the id, demand-ing satisfaction Ego would try to gratify id, but mightrun into limitations of reality or restrictions of society

In such cases, ego would need to turn back and tamethe id This conflict between ego and id could generate

a panoply of unpleasant emotions and maladaptive havior In the opposite direction, ego’s confrontationswith reality on the behalf of id strivings would generateconflicts as well Superego represented an internaliza-tion of those elements of power and judgment from theenvironment It provided the mind with guideposts forideals and restraint However, superego could thusstand in opposition to ego, generating a different kind

be-of internal conflict

A Freud’s Followers

These powerful and revolutionary ideas, articulated

by the eloquent and charismatic Sigmund Freud, tracted much attention worldwide, and a dedicated cir-cle of followers in Vienna Karl Abraham extendedFreud’s sketchy ideas about human development intomajor contributions in the realm of character forma-tion Such contemporary designations as the easygoing

at-“oral” personality and its controlling, possessive “anal”counterpart, are products of Abraham’s work SandorFerenczi, a passionate follower of Freud, was less inter-ested in pure theory and urged experimentation withtreatment He advocated “active therapy,” in which theanalyst would deliberately promote or discourage thepatient’s specific activities He promoted deliberate mo-bilization of anxiety in the treatment to make it moreavailable for analysis

B The Dissenters

Others of the Vienna group found Freud’s ideas equate or limiting, and advocated dissenting view-points While Freud dreamed that mental activitywould one day be explainable on the basis of neurologicprinciples, his work remained exclusively psychologi-cal Alfred Adler sought actively for a unifying theory ofbiologic and psychological phenomena He postulatedthe aggressive drive as the source of energy used by an

individual to overcome organic inferiorities through

compensation (and hence gave birth to the phrase

infe-riority complex) Where Freud took sexuality and the

Oedipal situation as literal motivations for development

and behavior, Adler regarded them more in the

sym-bolic sense On the technical level, he engaged patients

face to face in free discussion, rather than free

associa-tion on the couch to an unseen analyst

Otto Rank stressed emotional experiences over the

intellectual constructs of psychoanalysis He postulated

that birth trauma was a universal human experience,

and that the individual was forever seeking to return to

intrauterine bliss Healthy development could occur

when, through later successful experiences of

separa-tion, the child is able to discharge this primal anxiety

Pathological states resulted from a fear of the womb

and conflict with the wish to return Rejecting the id

and superego, he postulated the existence of will and

counter-will as positive and negative guiding

influ-ences toward separateness He ultimately turned his

focus away from individual psychology and

psy-chopathology to the realm of art and the soul

Most prominent among the dissenters was Carl Jung,

who originally clung to the Freudian vision in the

ex-treme Freud became strongly invested in Jung as his

protègé and eventual heir to his position in the

psycho-analytic movement Jung began to extend Freudian

prin-ciples to ideas that had excited him earlier including

myth and legend Freud had certainly done the same,

in-voking the tales of Oedipus and Electra, and analyzing

the art of Michelangelo But where he saw parallels or

analogies, Jung saw a direct continuity of archaic

mate-rial gathered into the collective unconscious This

store-house of human experience, he posited, contains

primordial images and archetypes that represent modes

of thinking that have evolved over centuries Jung saw

Freud’s view as too limited Symbols, which were

vehi-cles for the expression of wish and conflict for Freud,

represented for Jung unconscious thoughts and feelings

that are able to transform libido into positive values The

techniques derived from these values include active

imagination, where the patient is encouraged to draw

fanatasied images and to associate more deeply by trying

to depict the fantasy precisely

Working at the forefront of the elucidation of the

un-conscious and the drives, Freud and his immediate

suc-cessors devoted their efforts to understanding and

analysis of the id The success of their psychoanalytic

techniques in addressing previously untreatable

prob-lems, brought broad appeal to psychoanalysis, and

brought to the analysts patients with conditions more

complex than hysteria Questions of how the id is

tamed and what happens to its drive energy propelledthe next generation of theoreticians and clinicians tofocus more directly on the ego

V EGO PSYCHOLOGY

In retrospect, it is Sigmund Freud’s daughter AnnaFreud (1895–1982) who is often identified as the firstvoice of ego psychology Encouraged by her father toextend the study and practice of psychoanalysis to chil-dren, she is best known for elucidating the defensemechanisms by which the ego masters the environ-ment, the id and the superego, and which are the shap-ing forces of each individual’s psychopathology Thenames and definitions she assigned are still the bench-mark terminology of psychoanalytic psychology: re-pression, suppression, denial, reaction formation,undoing, rationalization, intellectualization, sublima-tion, symbolization, and displacement Still, however,she maintained that analysis of the ego paled by com-parison with analysis of the id

The promulgation of ego psychological theory fell to ageneration of analysts who were mostly refugees fromHitler’s advance through Europe, and who had to post-pone their major work until they could resettle in the1930s: Ernst Kris, Rudolph Lowenstein, Rene Spitz, andchief among his peers, Heinz Hartmann (1894–1970) Atrainee of Freud’s, Hartmann undertook the expansion

of his mentor’s model to explain some of its lingeringquestions: What was the origin of ego? How did egotame id, which was powered by the potent energy of thedrives? What was the purpose of the aggressive drive?What role did these structures and forces play in normaldevelopment?

For Hartmann, the unifying process of human chological development was adaptation, a reciprocal re-lationship between the individual and his or herenvironment The outcome of successful adaptation is a

psy-“fitting together” of the individual with the ment Conflict is thus neither the cause nor the out-come of psychopathology, but a normal and necessarypart of the human condition In Hartmann’s model, theingredients of ego and id are present at birth in an un-differentiated matrix Normative conflicts with the envi-ronment separate out ego from id Defense mechanismsare tools for adaptation to the environment by either al-loplastic means (changing the environment) or auto-plastic ones (changing the self)

environ-Because psychic structures enable the individual to

be less dependent on the environment, structure mation serves adaptation Superego is one outcome of

adaptation to the social environment, a product of

tinuing ego development Id, ego, and superego

con-tinue to separate by the process of differentiation

Within the ego, primitive regulatory factors are

increas-ingly replaced or supplemented by more effective ones

There is also a conflict-free sphere of ego

develop-ment Certain capacities have an inherent capacity for

expression and growth, promoting adaptation to the

environment without need to invoke conflict In the

motor sphere, these capacities include grasping,

crawl-ing, and walking In the mental realm, they encompass

perception, object comprehension, thinking, language,

and memory

Ego psychology used the language of Freud’s original

drive–structure model, and maintained most of its core

assumptions It stretched the explanatory capacities of

the model and allowed for the treatment of cases

previ-ously impervious to psychoanalysis Because these

pa-tients exhibited more interpersonal problems than

strictly intrapsychic ones, and because the model of

ego development was contingent on interactions with

the personal and social environment, the door was

opened to schools of thought that described something

broader than a one-person psychology Even while ego

psychology was developing further in the 1930s, the

school of object relations was branching off

VI THE OBJECT RELATIONS SCHOOL

A Melanie Klein

Melanie Klein (1882–1960) studied under Sigmund

Freud With Freud’s encouragement, she undertook the

psychoanalysis of children Finding the free association

technique useless in such young patients, she

origi-nated the use of the content and style of children’s play

to understand their mental processes Like many early

psychoanalysts, she used her observations from the

clinical sphere to generate theories of human

develop-ment and psychopathology

Klein’s earliest papers shared and expanded Freud’s

emphasis on libidinal issues The child, she noted, spins

elaborate fantasies about food, feces, babies, and other

aspects of the mother’s body Attempting to explore these

curiosities, the child is inevitably frustrated, resulting in

rage and fears of castration Unlike her mentor, Klein

found the seeds of the oedipal constellation in the first

year of life as the disruption of weaning precipitates a

turn to the father In her view these urges take on a

gen-ital coloration The harsh self-criticism that accompaniesthese fantasies is a precursor of the superego She eagerlyadopted Freud’s emphasis on aggression in the 1920s

By the early 1930s, aggression had come to overwhelmall other motives in her schema Even the seeking ofpleasure and knowledge was defined as a desire for con-trol and possession: “The dominant aim is to possesshimself of the contents of the mother’s body and to de-stroy her by means of every weapon which sadism cancommand.” The oedipal conflict was recast as a strugglefor destruction and power, and a fear of retaliation,rather than a search for forbidden love

Freud had posited that fantasy was a defensive tute for real gratification Klein’s elaborate mental

substi-processes resided in a world of unconscious phantasy, one

which is inborn and constitutes the basic substrate of allmental processes In this world of phantasy, the childhouses vivid and detailed images of the insides of themother’s body and his or her own, filled with good andbad substances He or she becomes focused on attempts

to obtain good objects like milk, children, a penis, and toeliminate or neutralize bad objects such as feces

Over the decade from the mid-1930s to the mid-1940s,Klein elaborated a model of development The infant’searliest organization, which she called the paranoid posi-tion, involves the separation of good objects and feelingsfrom bad ones Mother is perceived only in terms of hergood (providing) and bad (withholding) parts By themiddle of the first year, the infant is able to perceive thewhole mother and experiences depressive anxiety as a re-sult of his or her aggressive feelings toward the mother’sbad parts The child attempts to compensate by way ofphantasy and reparative behavior The Oedipus complex

is a vehicle for such attempts at reparation

Klein’s ideas represented more than just a ance or modification of the Freudian model They wereentirely revolutionary Klein left Germany in 1925 forEngland, where she stayed until her death in 1960 Herprovocative ideas split the British Psychoanalytic Soci-ety, and eventually the entire international psychoana-lytic community, as they blossomed into the varioustheories of object relations

further-B Margaret Mahler

Margaret Mahler (1897–1985) began her career as apediatrician in Vienna Like many of her peers, she wasfascinated by the theories of the psychoanalytic move-ment and applied them to her work with children Shesoon found, however, that the classical model was un-able to explain much of what she observed The linearity

of the drive structure model failed to encompass the

richness and variety of emotional experience of the

de-veloping child Her model instead emphasized the

spe-cific relationship between child and mother, and

hypothesized that drives are not the root of interpersonal

relations, but the result of them

Just as Hartmann was proposing that id and ego

begin in one undifferentiated state, Mahler posited that

the child is born with an initial state of undifferentiated

energy It is by virtue of attachment to good and bad

self objects that this energy differentiates into libido

and aggression The central theme of the

developmen-tal process is the need for the child to differentiate

him-self or herhim-self from others to achieve autonomy and

individuation Such differentiation requires separation

from the object(s), entailing a struggle between the

wish for independence and the urge to return to the

comfortable state of fusion Mahler outlined a detailed

agenda for psychological development:

1 The normal autistic phase occupies the first few

weeks of life The newborn is oblivious to stimulation,

and lacks any capacity for awareness of other objects

He or she sleeps most of the time and is concerned only

with tension reduction and need satisfaction

2 The normal symbiotic phase lasts until about age

4 to 5 months, and is marked by an increased sensitivity

to external stimuli The infant is dimly aware of mother

as an external object able to reduce tension She is not

yet a separate object, but rather part of a dual unity

Ex-periences are either all bad or all good Nodes of good

and bad memory traces form in the undifferentiated

ma-trix of ego and id

3 The differentiation subphase lasts until about 10

months of age, and begins with what Mahler called

“hatching.” The child is alert, and begins to search and

explore the world beyond the mother–child orbit He

or she acquires the ability to differentiate internal and

external sensations With the developing ability to

dis-criminate between self and object comes the ability to

distinguish objects from each other Stranger anxiety at

about age 6 months is a marker of this capacity

4 The practicing subphase begins with the capacity

to crawl The child’s interests extend to inanimate

ob-jects For Mahler, “psychological birth” coincides with

the capacity for upright locomotion The child takes

pleasure not only in his or her own body, but also in the

acceptance and encouragement of adults In practicing

walking, the child uses mother as home base, going out

and returning For successful completion of this

sub-phase, mother must strike a balance between supportive

acceptance and a willingness to relinquish possession ofthe child

5 The rapprochement subphase (15 to 24 months) ismarked by the child’s realization that he or she is a smallperson in big world, and that mother is a separate per-son Language is a key skill in negotiating these currents,

as the child alternates between “wooing” mother withneedy clinging and rejecting her with hostile negativity.Mother’s reaction is again critical to the outcome of thestruggle Successful resolution of this subphase was asimportant to Mahler as Oedipal resolution was to Freud

6 The phase of libidinal object constancy, the idealoutcome of all earlier development, should be reached

by age 2 or 3 years Now the child forms a stable concept

of himself or herself and others These concepts requirethe unification of the heretofore divided perceptions ofgood and bad objects The libidinal and aggressive drivesthat have become cathected to these dichotomous repre-sentations must now be merged In a context of parentalresponse that reinforces the perception of constant ob-jects, the child is now in possession of stable and adapt-able psychic structures for the rest of his or her life

C W R D Fairbairn

Both Klein and Mahler elaborated schemes of opment and psychopathology that relied on the classi-cal unit of energy, the drive impulse, for theirmotivation By the early 1940s, W R D Fairbairnrethought the whole problem of motivation LikeKlein, he saw libido as inherently object-seeking, andconceived of ego structures as powered by object-di-rected energy Just as Hartmann had formulated theego in terms of natural adaptation, Fairbairn saw theroots of relation-seeking in biological survival Allhuman behavior, he concluded, derived from thesearch for others Psychopathology, in this scheme,was not the outcome of misdirected drives, but of dis-turbed relations with others

devel-Unsatisfactory relations with real objects (e.g., ents) would lead to the creation by the ego of compen-satory internal objects If the environment is filled withunsatisfying or frustrating objects, the ego becomesfilled with so many fabricated objects that it becomesfragmented Ego then splits this population into good orideal objects and bad (exciting or rejecting) objects.Splitting of the ego results from the child’s attempts tomaintain the best possible relations with a suboptimalmother, and continue through adult life if not somehowcorrected The psychoanalytic setting and process pro-vide the opportunity for restoring to the ego a capacity

to make full and direct contact with others, thereby

restoring psychological health

D D W Winnicott

D W Winnicott, who produced most of his work

be-tween about 1945 and 1970, took the object relations

movement yet a step further from the one-person

psy-chology of the classical model Some of the catch

phrases of his terminology have found their way into

the everyday language even of those who have heard of

their author

In Winnicott’s formulation, the infant begins life

un-able to integrate the disparate pieces of his or her

experi-ence with his or her environment Mother ideally

provides a holding environment for these early

experi-ences Mother, impelled by biologic dictates of

adapta-tion, is absorbed with her baby for the first few months of

its life When the infant is stimulated (by hunger or cold,

for example), he or she conjures up an image of an object

to meet those needs The sensitive and devoted mother

provides exactly that object; the infant believes he or she

has created it, and finds comfort in this power This

con-fidence is necessary for the emergence of the individual

Mother also sees the baby and reflects its emotions

and behavior, functioning as mirror of baby’s

experi-ence If the baby is seen, then he or she exists Finally,

mother must be sensitive to the developing child’s need

to be alone in a quiet, unintegrated state at times, in

order to integrate experience and to develop a

toler-ance for aloneness

By the end of the first few months, the child begins to

learn about reality of the external world, and the limits

of his or her own power Reality itself does much of this

work, but mother contributes through her gradual

withholding of actions shaping the world to her infant’s

needs Underlying these interactions is the child’s

natu-ral push toward separateness In order to adapt, the

child learns to express his or her needs through gestures

and utterances

Mother can fail here in two ways: She may fail to

pro-vide hallucinated objects, or she may fail to tolerate the

child’s formless quiet states The former failing leaves

the child insecure and anxious The latter fault

frag-ments the child’s experience As his or her personal

time is subjugated to parental intrusion, he or she

be-comes overly attuned to the claims of others, and his or

her person fragments into a true self and a false self

The latter force aims toward compliance The false self

protects the true by hiding it, but deprives the child of

a necessary sense of authenticity

A critical tool on this path of development is the sitional object Such an object, usually illustrated with ateddy bear or blanket, is one that the child believes he

tran-or she has created out of imagination to fill a need Theadult ideally does not question its origin, and simulta-neously acknowledges its existence in the real world.This deliberate or intuitive ambiguity helps the childnegotiate a transition from a world where he or she is atthe center to one where he or she coexists with others.Even as the child’s views of reality solidify, this configu-ration is never discarded It remains a state of mindvaluable for creativity and fantasy in healthy adult life.Interactions in Winnicott’s world are based not ondrive needs, but on the perceptiveness of the parentsand the developmental needs of their child The gratifi-cation of drive derivatives, to which he gives only lipservice, are less important than the attitude of theprovider Just fulfilling needs does not allow for the de-velopment of a healthy, true self He redefines aggressionnot as a destructive drive impulse, but as a general state

of vitality and motility The origin of psychopathology is

in conflict, not conflict between aggression and libido,

or among drives, psychic structures, and reality, but flict between the true and false selves The object of psy-chotherapy is to free the true self from its bondage andallow the emergence of the genuine person

con-VII SELF PSYCHOLOGY

The theories of object relations were successful in dressing the limited ability of ego psychology and defenseanalysis to address the problems of those patients whoseproblems lay deeper than those of the classical neuroses

ad-A different approach to the same challenge gave rise toself psychology In the 1960s, Heinz Kohut was a promi-nent figure in the mainstream of psychoanalysis Erudite,articulate, and charismatic, he was widely assumed to bethe heir to Heinz Hartmann’s mantle as the leadingspokesman for ego psychology But his disappointment inthe limitations of classical and ego psychologies led him

to follow his curiosity in a new direction

Kohut began by redefining the observational tion of the analyst Exploration of the external world,Kohut reasoned, requires an outwardly directed obser-vational stance Exploration of the internal world, therealm of psychotherapy, requires an empathic, intro-spective stance He rejected the objective mechanicalformulations of the ego and object relations psycholo-gies, promoting instead a vantage point from within thepatient’s experience

Psychopathologies, from this perspective as well as

from most object relations perspectives, were seen

not as the emergence of oedipal wishes, but as the

re-activation of early needs the satisfaction of which in

childhood should have served as the basis for healthy

development Self psychology went further to assert

that unempathic interventions in psychoanalysis

re-peated early traumata Symptoms and unpleasant

affects represented fragmentation products of an

in-jured self Psychoanalysis, then, should properly

focus not on the meaning of the products, but on the

reconstruction of what precipitated their emergence

in the transference, and on the genetic precursors of

this constellation

Whereas the object relations theorists continued at

least to pay lip service to the classical drives, and

main-tained their allegiance to the structural model, Kohut

ultimately rejected the need for the constructs of drive,

id, ego, and superego Instead, he formulated normal

and pathological development and function around the

single notion of the self The nuclear self, which is

present at birth, develops structures that allow it to

take over functions previously needed from outside

This structure building happens by maturational

trans-formation of what is internally given, and by the

process of transmuting internalization, whereby

func-tions of objects are metabolized into the self

Self psychology, like object relations psychology,

em-phasizes the primacy of objects in healthy and

patho-logical mental function The objects in self psychology,

however, are not separated from the self, but exist in

the context of a self-selfobject matrix The selfobject is

an intrapsychic concept, describing how the self

expe-riences the specific functions provided by others en

route to the attainment of development goals The need

for selfobjects never disappears, but matures from

in-fantile neediness to mature adult intimacy

The self that emerges was described by Kohut as the

bipolar self, bridging two poles The pole of self-assertive

ambitions contains the capacities for self-esteem

regula-tion, the enjoyment of mental and physical activity, and

the pursuit of goals and purposes Its development

re-quires a mirroring selfobject This pole is paired with

the pole of values and ideals, which is associated with

self-soothing, the regulation of feelings, the capacity

for enthusiasm and devotion to ideals larger than the

self The development of this pole is promoted by an

idealizable selfobject Between the poles there exists a

tension arc that gives rise to innate skills and talents,

including empathy, creativity, humor, wisdom, and the

acceptance of one’s own mortality

Psychopathology results from imbalances betweenthe poles of the self, and these imbalances are them-selves the product of deficient selfobject experiences.Psychotherapy identifies these deficits by empathicreading of the transference Therapeutic correction re-quires both interpretation of the selfobject needs andtheir successful reenactment in the therapeutic dyad

VIII POSTANALYTIC SCHOOLS

The evolution of classical psychoanalytic theory intoego psychology, object relations, and self psychology waspropelled by expanding clinical experience, and by fail-ures of older paradigms to explain a widening circle ofpsychopathologies encountered in therapy In the clos-ing decades of the twentieth century, forces outside theboundaries of the psychotherapy drove further changes.The culture of medicine demanded reproducible tech-niques and empirical validation Third-party fundingand the growing perception of the patient as a partner inthe therapeutic enterprise promoted briefer and more ac-tive forms of therapy The two most notable schools toarise in this context have been cognitive and interper-sonal therapies

A Cognitive Therapy

Cognitive therapy was developed by Aaron Beck at theUniversity of Pennsylvania in the early 1960s Trained intraditional psychoanalysis, he became impatient with itsresults, and devised a structured, short-term present-ori-ented psychotherapy for depression Other forms weredeveloped by Albert Ellis (rational emotive therapy),Arnold Lazarus (multimodal therapy), and Marcia Line-han (dialectic behavioral therapy)

The cognitive model proposes that distorted or functional thinking influences a person’s mood and be-havior, and that such distortions are common to allpsychological disturbances Realistic evaluation andmodification of thinking is used to produce rapid im-provement in mood and behavior Enduring improve-ment results from modification of the core beliefsunderlying the dysfunctional thinking

dys-In practice, cognitive therapy emphasizes the laboration and active participation of both patient andtherapist It is goal-oriented, problem-focused, andtime-limited, but ultimately aims to make the patienthis or her own therapist Highly structured sessionsteach the patient to identify, evaluate, and respond todysfunctional thoughts By elucidating patterns in

multiple circumstances, cognitive therapy offers the

opportunity to change the underlying core beliefs and

effect lasting change

B Interpersonal Psychotherapy

Interpersonal psychotherapy (IPT) was developed in

the 1970s by Gerald Klerman as a time-limited treatment

for depression, particularly for use in research Its initial

success in depression led to modifications for subtypes

of mood disorders, and for nonmood disorders

includ-ing substance abuse, eatinclud-ing disorders, social phobia,

panic disorder, and borderline personality disorder

IPT makes no etiologic assumptions about

psy-chopathology, but uses connections between current

depressive symptoms and interpersonal problems as a

pragmatic treatment focus The therapist links

symp-toms to the patient’s situation in the context of one of

four interpersonal problem areas: grief, interpersonal

role disputes, role transition, or interpersonal deficits

Grief may be the reaction to the loss of an individual,

or to a more abstract loss The therapeutic focus is to

facilitate mourning and the establishment of new

activ-ities and relationships Interpersonal role disputes

con-sist of conflicts with significant others IPT explores the

nature of the dispute and the relationship, and helps

the patient find options to resolve it If these efforts fail,

patient and therapist look for ways to circumvent the

conflict or end the relationship Role transition, a

change in life status, is addressed by helping the patient

recognize the benefits and challenges of the new role,

the positives and negatives of the old role

Interper-sonal deficits are traits and behaviors that prevent an

individual from establishing or maintaining satisfying

relationships IPT trains such a patient in means to

conduct more successful relationships

IX SUMMARY

Before the seventeenth century, insanity was attributed

to supernatural influences Although most responses

consisted of religious interventions or extrusion of the

sufferer from society, there were always some who sought

to provide treatment instead The rise of the scientific

method during the Enlightenment, and the social and

po-litical forces of democracy that accompanied, began to

foster an inclination to address mental disorders with

car-ing, activity, and communication In the nineteenth

cen-tury, the results included moral therapy and asylums

The closing decades of the 1800s brought the

atten-tion of neurologists to illnesses including hysteria and

schizophrenia Hypnosis represented a first step towardthe understanding of mind and brain Sigmund Freud,the most notable figure in this thread, listened carefullyand creatively to the hypnotic recollections of his hys-terical patients, and drafted the first theories of uncon-scious mental processes Over the course of decades,his thinking evolved into a complex and powerfulschema of psychic structures and their functions.Whereas Freud and his immediate associates focused

on the analysis of id urges and drive derivatives, thefirst generation of successors to the psychoanalyticmovement focused on the role of the ego Anna Freudand Heinz Hartmann elucidated its defensive and de-velopmental features Psychoanalysis became a morepowerful treatment as a result

The success of psychoanalysis, both in its originaldrive model and in the form of ego psychology, ledpractitioners to apply its principles to an ever-expand-ing patient population, including individuals with pre-oedipal problems, and to children The result was arethinking of the role of the human environment in thedevelopment of the individual and in the genesis ofpsychopathology The object relations school, repre-sented most significantly by Melanie Klein, MargaretMahler, W R D Fairbairn, and D.W Winnicott, elabo-rated theories of human interaction that furthered theexplanatory reach of psychoanalysis

In a later split from ego psychology, Heinz Kohutfound classical theories of structure and drive inade-quate to explain or treat too many of his patients Break-ing the classical mold completely, he rejected virtually allthe underpinnings of classical, ego, and object relationspsychologies, and defined self psychology This systemfocuses on the development of the bipolar self throughthe use of selfobjects, and defines all psychopathology interms of disturbed selfobject functions

The successes of psychoanalysis bred ically based psychotherapies from the 1940s on By theclosing decades of the twentieth century, clinical, sci-entific, and social forces propelled the emergence of

psychoanalyt-a number of nonpsychoanalyt-anpsychoanalyt-alytic psychotherpsychoanalyt-apies, includingcognitive therapy and interpersonal psychotherapy,which focus on contemporary issues of perceptionand response, while mapping a route to permanentpsychic change

See Also the Following Articles

Behavior Therapy: Theoretical Bases ■ Education:

Curriculum for Psychotherapy ■ Oedipus Complex ■

Psychoanalytic Psychotherapy and Psychoanalysis, Overview

■ Research in Psychotherapy

Further Reading

Alexander, F G., & Selesnick, S T (1996) The history of

psy-chiatry: An evaluation of psychiatric thought and practice from

prehistoric times to the present New York: Harper and Row.

Beck, J S (1995) Cognitive therapy: Basics and beyond New

York: Guilford Press.

Blanck, G., & Blanck, R (1994) Ego psychology: Theory and

practice (2nd ed) New York: Columbia University Press.

Brenner, C (1973) An elementary textbook of psychoanalysis.

New York: Anchor Doubleday.

Bromberg, W (1954) Man above humanity: A history of

psy-chotherapy Philadelphia: J B Lippincott.

Greenberg, J R., & Mitchell, S A (1983) Object relations in

psy-choanalytic theory Cambridge, MA: Harvard University Press.

Jackson, S W (1999) Care of the psyche: A history of logical healing New Haven, CT: Yale University Press.

Ornstein, P H., & Kay, J (1990) Development of analytic self psychology: A historical-conceptual overview In A Tasman, S M Goldfinger, & C A Kauf-

psycho-man (Eds.), American Psychiatric Press review of try, Vol 9 (pp 299–322) Washington, DC: American

psychia-Psychiatric Press.

Walker, N (1959) A short history of psychotherapy in theory and practice New York: Noonday Press.

Weissman, M M., & Markowitz, J C (1998) An overview of

interpersonal psychotherapy In J C Markowitz (Ed.), terpersonal psychotherapy (pp 1–33) Washington DC:

In-American Psychiatric Press.

I Description of Treatment

II Theoretical Basis

III Empirical Studies

IV Summary

Further Reading

GLOSSARY

fading The process of gradually removing prompts as the

be-havior continues to occur in the presence of a controlling

stimulus.

interval schedule A schedule in which a reinforcer is made

contingent on the passage of a particular duration of time

before the first response to occur after that period of time is

reinforced, (a) fixed-interval—schedule in which duration

is always the same (b) variable interval—schedule in which

the time interval varies about a given average duration.

reinforcement A process in which a behavior is followed by

the presentation of a stimulus and as a result, produces an

increase in the future probability of that behavior.

response cost A procedure in which a specified reinforcer is

lost contingent upon behavior and, as a result, decreases

the future probability of that behavior.

target behavior The behavior of interest, or the behavior to

be altered.

Home-based reinforcement is a procedure used to

modify the school-based behavior of children and

ado-lescents through the use of contingencies delivered in

the home This article presents a description of the cedure along with the theoretical basis and empiricalsupport for its use

pro-I DESCRIPTION OF TREATMENT

Home-based reinforcement (HBR) procedures involveproviding consequences for behavior that occurs inschool settings However, unlike traditional school-based contingency management procedures in whichconsequences are controlled and delivered by schoolpersonnel, consequences for school-based behavior inHBR are controlled and delivered by a parent, guardian,

or other caretaker in the child’s home environment HBR

is typically used with children and adolescents and isusually initiated by school personnel or clinicians whoseek an improvement in school attendance or academicperformance or seek a decrease in school-based disrup-tive behavior Although HBR has been implemented inmany different ways (described later in Section III), ageneral template for implementation is as follows.First, the clinician, with the help of the child, thechild’s teacher, and the child’s parent, identifies behav-iors targeted for acceleration or reduction Likewise,the teacher and parent (with input from the child)agree on daily goals for acceptable performance withrespect to each targeted behavior Each of the dailygoals is operationally defined so the teacher and childare clear as to whether or not the child has achieved the

goal for that particular day After target behaviors and

daily behavioral goals are identified, the clinician

estab-lishes a simple observation system In the observation

system, the teacher monitors the occurrence of the

tar-geted behavior(s) and determines if the daily

behav-ioral goals are achieved

After the targets, goals, and observation system are

established, the remainder of the HBR program is

ex-plained to the parent and teacher This is done by (1)

having the teacher send a letter to the parents

describ-ing the procedure, or (2) havdescrib-ing the clinician facilitate a

face-to-face meeting with the teacher and parent Using

either method, the program is explained as follows

Each of the daily goals, corresponding to the target

behaviors, is listed on an observation sheet that is given

to the teacher At the end of each school day, the

teacher indicates whether or not the child achieved

each of the daily goals The teacher shares this

informa-tion with the student and places the informainforma-tion on a

note that is sent home daily with the child The parent

receives the note, signs it, and returns it to the teacher

via the child on the next school day

On receiving the note, the parent(s) provides

conse-quences for school behavior If all daily goals are

suc-cessfully reached, the parent praises the child and

provides the child with a previously agreed-on

conse-quence such as snacks, privileges, or other tangible

items to which the child does not typically have access

If all daily goals are not successfully reached, the parent

and child discuss what could be done differently to

en-sure success the next day, and the parent provides a

previously agreed-on consequence such as a loss of

privileges If the child fails to bring a note home, this is

treated as a day in which all daily goals were not met

and should be consequented accordingly

Although the program is best implemented by

hav-ing the child receive feedback via the home note on a

daily basis, sustained good performance warrants the

gradual elimination of the feedback system to promote

treatment maintenance Although a variety of fading

procedures have been used, the clinician could

recom-mend that the frequency of notes being sent home first

decrease from daily to one note every second or third

day, to once per week, and finally to once per month

In using this fading procedure, the clinician should

plain to the teacher and parents that all behavior

ex-hibited by the child since the last home report is

considered when determining whether the child has

met his or her daily goals Again, a change in the

fre-quency of notes being sent home should only be

im-plemented if the child is consistently meeting his or

her target goals Fading should not be implemented ifthe child is not consistently meeting his or her dailybehavioral goals

II THEORETICAL BASIS

Home-based reinforcement is based on operant ing theory Specifically, it is thought that the presenta-tion or removal of certain stimuli have the ability toalter behavior when delivered in a response contingentformat Reinforcers are stimuli that produce increases inthe future probability of behavior Reinforcers can in-clude stimuli that are added to the environment (e.g.,providing praise contingent on a child’s good behav-ior) or removed from the environment (e.g., a parent’scandy-buying behavior is reinforced when his or herchild stops screaming “Buy me candy!”) In contrast,punishers are stimuli that produce decreases in the fu-ture probability of behavior However, like reinforcers,punishers can include stimuli that are added to the en-vironment (e.g., painful stimulation is received whenthe child touches a hot stove) or removed from the en-vironment (e.g., a child’s toy is briefly taken awaywhen he or she is destructive with the toy) In allcases, reinforcement and punishment are defined bytheir outcome on behavior If the behavior increases instrength, the stimulus following the behavior is classi-fied as a reinforcer, and if the behavior decreases instrength, the stimulus following the behavior is classi-fied as a punisher

learn-Reinforcers and punishers exert more or less control

on the behavior depending on various levels of tion, satiation, and other establishing operations expe-rienced by the person When paired with previouslyestablished reinforcers, neutral stimuli (i.e., noncon-trolling stimuli) can come to function as reinforcers orpunishers in their own right

depriva-In HBR, the reinforcers and punishers are initiallythe consequences provided at home (i.e., earned orlost privileges, snacks, tangibles) However, delivery ofthe reinforcing consequences is often paired withpraise or positive marks on the home note This pair-ing process results in such stimuli also becoming rein-forcers that may provide more proximal control overthe school behavior Although operant theory is quiteclear that learning will be most efficient if conse-quences immediately follow behavior, HBR beginswith a more temporally distal consequence becausethe children’s parents have better access and controlover a wider array of consequences for which the child

is likely to be under the control of a current

establish-ing operation Although the theoretical explanation

just provided is based on operant principles developed

from nonverbal organisms, it must be recognized that

much of the learning involved in HBR is occurring

within a verbal context and with verbal organisms

Thus, it is likely that behavioral processes unique to

verbal organisms, such as stimulus equivalence, play

perhaps an even greater role in explaining the

effec-tiveness of HBR Unfortunately, a description of such

procedures is outside the scope of this article

III EMPIRICAL STUDIES

Home-based reinforcement was first evaluated by

Jon Bailey and colleagues in 1970 Because this

origi-nal study demonstrated the effectiveness of

control-ling school-based behavior with home-based

consequences, a growing volume of research has

eval-uated various effective forms and uses of HBR This

body of research is briefly reviewed later and includes

discussions of behaviors targeted with HBR, methods

of implementation, effective consequences, child

vari-ables, maintenance programs, and treatment

accept-ability of HBR

A Behaviors Targeted with HBR

Home-based reinforcement has been successfully

used to increase academic skills and decrease disruptive

behaviors in the classroom Specifically, HBR has been

used to increase motivation, rule following, grades,

homework completion, listening, asking and answering

questions, staying on-task, and completing class work

It has also been used to successfully decrease

aggres-sion, name calling, making noise, talking without

permission, physically disturbing other children, and

out-of-seat behavior

The effects of the HBR procedure may also

general-ize to other nontargeted behaviors, persons, or

set-tings In 1983 Joseph C Witt and colleagues found

that when HBR was implemented to increase academic

behavior, decreases were also seen in disruptive

behav-ior In addition, it has been found that when a HBR

procedure is used on selected target students, the

pos-itive effects of the procedure may been seen in

nontar-geted students For example, if a teacher targets the

classroom behaviors of only half a class, it has been

found that the nontargeted half will also show

de-creases in disruptive behavior Likewise, data suggest

that the positive effects of HBR can generalize fromschool to home settings

B Methods of Implementation

Also of interest is the specific method that should beused when implementing HBR Issues such as how theplan should be communicated to parents, how oftenthe home notes should be sent home, what informa-tion should be included on the home note, and whoshould be in charge of the home note at school, allmust be considered

In 1972 R J Karraker investigated how much effortwas needed to instruct parents in the use of HBR Theresearchers taught the procedure to three groups of par-ents during either two, 1-hour conferences, a 15-min.conference, or by mailing the instructions home It wasfound that all three methods of implementation wereequally effective in increasing academic behavior

In 1997 Richard W Saudargas investigated the ratethat home notes should be sent home and found thatsending notes home daily was more effective in increas-ing academic behavior than sending the notes homeevery Friday In addition, research has shown that par-ents prefer daily school notes to both weekly and stan-dard report cards

There is considerable variation in the amount of formation that is included on the home notes Somehome notes only have information on performance in

in-a specific in-arein-a, such in-as min-ath completion or disruptivebehavior whereas others give a global rating of thechild’s behavior for the whole day Both methods havebeen shown to be effective in changing the student’sbehavior

Student involvement in HBR has also been fully varied In some cases, the teacher has completedthe home note without the student’s knowledge, and inothers, the teacher has instructed the student when tomark the home note and then signed it at the end of theclass To this date no studies have directly comparedthe effectiveness of the two methods

only after the home note was paired with some

re-warding consequence

Although it is clear that a home-based consequence

must be delivered, the most effective form of that

conse-quence is less clear A number of studies demonstrated

the effectiveness of praise and tangible reinforcers for

bringing home a note with good ratings, but not all

re-searchers have been successful with only praise In

1977, Jean B Schumacher found mixed results in

stu-dent behavior when using only praise but found

consis-tent increases in school conduct, class work, and daily

grades when praise and tangibles were contingent on a

satisfactory home note Some research also suggests that

using contingencies that affect a group of individuals in

the home, rather than just the target child, may also

en-hance the effectiveness of HBR

Researchers have also had success by adding response

cost to HBR In 1995, Mary Lou Kelly and colleagues

found that inappropriate behavior could be decreased

using normal a HBR procedure, giving points

exchange-able for rewards contingent on appropriate behavior,

but found greater effects by having the children cross a

“smiley” face off their home notes for inappropriate

be-havior In the response-cost phase of the experiment the

children needed to keep certain amount of smiley faces

or points to earn reinforcers

D Child Variables

The effectiveness of HBR has been demonstrated with

children from kindergarten to high school, in both

spe-cial and regular education classes, and with children

who have learning disabilities HBR has also been shown

to be effective in institutional or group home settings

E Maintenance Programs

As stated earlier, the goal of HBR is to have the child

eventually function independent of the reinforcement

program To do this, fading or other procedures are

often utilized Some research has suggested effective

ways to gradually reduce reliance on HBR procedures

In 1973 Richard Coleman demonstrated that increases

produced by HBR could be maintained while gradually

altering the procedure to make the child’s school

envi-ronment more natural Prior to the altering the

proce-dure, points were rewarded contingent on appropriate

behavior using a short, variable interval schedule The

teacher gradually made the child’s environment more

natural by (1) increasing the interval, (2) subtracting

points for inappropriate behaviors instead of reinforcing

appropriate behaviors, (3) extending the period of timeduring which points were taken away, (4) and makingthe child’s weekly allowance contingent on an acceptablereport from the teacher

Another successful method for removing HBR is togradually fade the procedure by increasing the crite-rion level required to receive reinforcement For exam-ple, going from daily reinforcement, reinforcementcould be made contingent on two consecutive days

of appropriate behavior, followed by three until theschedule has been thinned to the point where the pro-gram can be terminated

G Treatment Acceptability of HBR

Clinicians should not only consider treatment tiveness when choosing a procedure but should also at-tend to the acceptability of the intervention Aneffective, but unacceptable intervention will likelymeet with resistance and may produce negative emo-tional reactions in those involved Thus, the acceptabil-ity of HBR procedures are discussed next

effec-Research has been conducted to determine the acteristics of acceptable behavioral interventions.Thomas Reimers conducted a review of the acceptabil-ity literature of behavioral interventions and foundthat the most acceptable interventions were those that(1) did not require large amounts of time, (2) werepositive, (3) were less costly, and (4) did not producenegative side effects Given that these are all character-istics of HBR, one could predict that HBR is an accept-able procedure

char-In fact, many HBR investigations have assessed ent and teacher acceptability of HBR In all, resultsshowed that parents and teachers found HBR to be anacceptable way to deal with a student’s behavior or aca-demic problems In 1989 Brian Martens and Paul Mellerasked teachers to rate the acceptability of a response-cost procedure and a HBR procedure The researchersfound that the HBR procedure was rated as more accept-able than the response-cost procedure

par-IV SUMMARY

In summary, home-based reinforcement is an cient, effective, and acceptable behavior modificationprocedure that is used to improve school-based per-formance or behavior in children and adolescents Al-though there are many minor variations of the HBRprocedure, in general it involves the delivery of

home-based consequences by the child’s parents,

contingent on school-based behavior

See Also the Following Articles

Backward Chaining ■ Fading ■ Good Behavior Game ■

Homework ■ Minimal Therapist Contact Treatments ■

Parent–Child Interaction Therapy

Further Reading

Atkeson, B M., & Forehand, R (1979) Home-based

rein-forcement programs designed to modify classroom

behav-ior: A review and methodological evaluation Psychological

Bulletin, 86, 1298–1308.

Bailey, J S., Wolf, M M., & Phillips, E L (1970) Home-based inforcement and the modification of pre-delinquent classroom

re-behavior Journal of Applied Behavior Analysis, 3, 223–233.

Barth, R (1979) Home-based reinforcement of school

behav-ior: A review and analysis Review of Educational Research,

49, 436–458.

Kelley, M L., & McCain, A P (1995) Promoting academic

performance in inattentive children Behavior Modification,

19, 357–375.

Leach, D J., & Byrne, M K (1986) Some “spill-over” effects

of a home-based reinforcement programme in a secondary

school Educational Psychology, 6, 265–276.

Witt, J C., Hannafin, M J., & Martens, B K (1983) based reinforcement: Behavioral covariation between aca-

Home-demic performance and inappropriate behavior Journal of School Psychology, 21, 337–348.

I Description of Treatment

II Theoretical Bases

III Empirical Studies

IV Summary

Further Reading

GLOSSARY

behavior therapy A systematic, direct, educational approach

to therapy that uses principles and strategies that have

been supported by research to change thoughts, feelings

and behaviors to help clients.

cognitive therapy Very similar to behavior therapy but focuses

much more exclusively on altering problematic thoughts

and beliefs that are perceived as causing problems.

effect size A measure of how well therapy works.

meta-analysis A research methodology and set of statistical

techniques that combine the results of several individual

studies to get a more reliable answer to questions, such as

“Does homework help therapy outcome?”

Homework assigned to be done outside of therapy

sessions is believed to add to treatment effectiveness

or even to be necessary for treatment effectiveness by

therapists of most theoretical orientations This

arti-cle describes types of homework, the benefits of

homework, the evidence that homework is useful,

and some guidelines for increasing homework

assign-ment compliance

I DESCRIPTION OF TREATMENT

Homework refers to therapeutic assignments given by

a therapist to a client to complete between sessions Theuse of such assignments has a number of purposes First,homework is purported to enhance treatment general-

ization through in vivo practice Consider the example of

a client taught assertiveness skills in session From a havioral perspective, practice in a natural environmentallows for nascent skills to come under the control ofnaturally occurring contingencies Newly learned behav-

be-iors reinforced in vivo have a higher probability of

fur-ther generalizing to ofur-ther real-world settings than skillsmerely performed in the clinic with a therapist Even un-successful attempts have their uses: they may be dis-cussed with the therapist and used to shape newhomework assignments addressing more specific prob-lem areas Second, homework assignments are meant tooptimize treatment in a cost-effective way Rather thaninvesting in therapy for multiple sessions per week,clients are asked to practice skills on their own, leading

to a more comprehensive and seamless therapeutic rience In fact, many behavior therapy procedures, such

expe-as progressive muscle relaxation, depend on in vivopractice to attain meaningful treatment goals Finally,consistent with Albert Bandura’s theory of behaviorchange, experiences of success in homework assign-ments should increase clients’ self-efficacy and thus im-prove general motivation for persisting with treatment

A seminal work describing the importance of work assignments in cognitive-behavior therapy is the

1979 depression treatment manual, Cognitive Therapy

for Depression by Aaron T Beck, A John Rush Brian F.

Shaw, and Gary Emery These authors posit that

home-work plays a critical role in the therapeutic process

They conceptualize homework as a sort of trial in

which clients strive to gain new insights about their

thoughts, emotions, and behaviors that lead to the

negative thinking that precipitates and maintains their

depression Assignments develop from collaboration

between therapist and client, and their goal is not

per-fection, but practice The function of homework

as-signments is to assist clients to effectively transfer

skills learned in session to their home and work

envi-ronments With homework, progress made in session

may be more likely to be applied throughout a client’s

life, across both time and situations

Homework assignments first became incorporated

into psychotherapy during the 1950s in G A Kelly’s

fixed role therapy, which encouraged clients to adopt

dif-ferent, more adaptive interpersonal behavior patterns or

“roles” and to practice these patterns outside of the

ther-apeutic environment In recent years,

cognitive-behav-ioral and rational-emotive therapies, as well as some

psychodynamic therapies, have integrated systematic

homework into their treatment paradigms Homework

assignments have been incorporated into manualized

treatments for a wide variety of psychological problems,

including depression, anxiety, substance abuse and

de-pendence, personality disorders, posttraumatic stress

disorder, sexual dysfunction, and schizophrenia as well

as for parent training (child management)

Written assignments, self-monitoring procedures,

and skills practice are three broad types of homework

assignments However, the structure, content, and

quantity of homework assignments are a function of

several factors, including the therapist’s theoretical

ori-entation and the client’s particular problem and

com-mitment to therapy For example, in the 1979 Beck,

Rush, Shaw, and Emery depression treatment manual,

homework assignments are geared toward reducing the

incidence of (or eliminating) the negative thinking that

plays a role in depressive symptomatology In this type

of homework, a cognitive therapist might ask a client

to monitor and write down pessimistic thoughts related

to depressed mood, and then to practice replacing such

thoughts with more positive thoughts Similarly, a

ra-tional-emotive behavior therapist might direct a client

to identify irrational thoughts, and then to produce

ev-idence that both supports and counters their validity

With such evidence in hand, the client is instructed to

weigh these pros and cons and then judge the truth

value of the cognition A behavior therapist treating pression, on the other hand, might collaborate with theclient to identify maladaptive behavior patterns, such

de-as insufficient exercise or social withdrawal, and designhomework assignments to alter these behaviors It isnot uncommon for a depressed client under the treat-ment of a behavioral therapist to leave a session withinstructions to increase the frequency or duration ofexercise, to visit at least one friend once per week, or totake time away from serving others to do something forthemselves that they would ordinarily never do Othertypical homework assignments include exposure tofeared thoughts, images, or situations, practice of socialskills, biofeedback techniques, viewing videotapes, andpracticing progressive muscle relaxation

One clear example of the skills approach to work used in behavior therapy is teaching a client ap-plied muscle relaxation, which is often used for anxietydisorders Applied muscle relaxation is a treatment inwhich an individual is taught a behavior that is incom-patible with an existing response to specific situations

home-In the case of inappropriate or excessive anxiety, clientsare taught to monitor their anxiety responses to envi-ronmental cues, such as increased heart rate and mus-cle tension, so that they can discriminate when they arebecoming anxious At the same time they are taughtprogressive muscle relaxation For progressive musclerelaxation, therapists teach clients in a clinic session tofocus sequentially on a number of different musclegroups while they first tense and then relax these mus-cles This procedure is repeated until all muscle groupshave been addressed, and the client reports lower levels

of muscle tension and anxiety After presenting the gressive muscle relaxation procedure in session, theclient is typically provided with either verbal instruc-tions and/or an audiotape of the therapist conductingthe procedure along with homework instructions topractice the procedure at home Initially, practice isdone in a quiet, comfortable setting Once mastery isachieved under those conditions, practice is done inprogressively more distracting and less comfortable set-tings or situations For example, a cancer patient whobecomes anxious before and during chemotherapy ses-sions might first repeatedly practice relaxation at home,eventually add visualizing receiving cancer treatmentwhile practicing, and then utilize relaxation just beforeand during the treatment itself

pro-Another type of homework assignment is in vivo

ex-posure Exposure involves persistently and repeatedlyconfronting feared objects or situations until feelings ofanxiety subside For example, in a 1993 study by Ruth

Edelman and Dianne Chambless, clients diagnosed with

agoraphobia were assigned homework consisting of

self-directed exposure between sessions In comparison with

clients who complied less, those who complied more

with between-session exposure assignments reported

significantly lower fear levels and fewer avoidance

be-haviors By incorporating homework practice in

treat-ment, it is believed that both the speed of learning a skill

as well as the ease of acquiring that skill are enhanced

II THEORETICAL BASES

In general, homework assignments, as utilized in

cognitive-behavioral therapies, are believed to improve

client outcomes Specifically, they are believed to

in-crease the effectiveness and generalizability of treatment

via between-session practice This practice should both

optimize the intervention and increase cost

effective-ness for the consumer: homework, if adhered to,

en-sures multiple “sessions” per week for the price of one

The major questions asked about homework deal

with compliance with assignments One question is

whether the relationships found between homework

compliance and treatment outcome are causal That is,

does increased homework completion lead directly to

greater clinical improvement or is this simply a

correla-tional relationship that is actually the result of some

other factor or factors The second question is how can

therapists increase homework compliance and,

relat-edly, what factors are known to predict compliance

dif-ficulties Awareness of the latter can assist therapists to

be better prepared and have additional strategies in

hand to aid compliance

Several third-variable factors could account for the

relationship between homework compliance and

treat-ment outcome Clients who are more motivated, either

dispositionally or from early therapist interventions,

might work harder in all aspects of therapy, including

homework, and make more treatment gains Parallel

ef-fects could arise from a more optimistic attitude or more

openness to change In either case, the effect of

home-work compliance on outcome would be incidental

Also, the compliance–outcome relationship could

work in the reverse direction: severely depressed clients

might do little or no homework between sessions This

would imply that homework has no effect on outcome

The evidence from two recent studies indicates that

compliance does have a direct effect on treatment

out-come David Burns and Diane Spangler used structural

equation modeling to answer this question in a 2000

paper and found support for a causal effect of homeworkcompliance on outcome Using a very different researchstrategy, repeated assessments of homework complianceand of improvement in depression, Michael Addis andNeil Jacobson found that early compliance predictedfinal outcome Their results countered the reverse com-pliance–symptom severity alternative hypothesis andsupports a causal relationship Therefore, except for avery few studies that have found compliance unrelated

to outcome, it appears that the more clients followhomework assignments, the more they improve.Although homework is an integral part of many cog-nitive-behavioral therapies, it appears that client non-compliance may limit the benefits of assignments totreatment outcome In a 1999 review paper, JerushaDetweiler and Mark Whisman discuss failure to com-ply with homework assignments and possible methodsfor increasing compliance Their review lists severalfactors that contribute to poor compliance: unrealisticgoal setting (i.e., therapists making assignments toohard), lack of consideration of a given client’s ability tocomplete a particular assignment, poor client motiva-tion, client expectations that their role in therapy is apassive one, and poorly designed assignments (e.g.,those that do not come under the control of naturallyoccurring reinforcers) Other client-based reasons citedrange from client perfectionism and fear of failure tocomorbid personality disorders and high initial levels

of symptomatology These authors observe that, forhomework to be beneficial, practice, commitment, andjust plain hard work are required This points out theimportance of presenting to the client a sound, com-pelling treatment rationale to motivate this effort.Detweiler and Whisman identify a number of task,therapist, and client characteristics relevant to increas-ing compliance In terms of task characteristics, themore specific and concrete an assignment, the morelikely a client will understand and complete it For ex-ample, writing down assignments for the client mayelicit more compliance than just verbally describingwhat they are to do Providing concrete, specific details

of what they are to do and when they are to do it canprevent misunderstandings and frustration for both theclient and therapist Shaping the client’s assignments,starting with brief and simple tasks and gradually in-creasing homework demands should also help by build-ing self efficacy Client characteristics that bearconsideration include initial levels of symptomatology,motivation, or merely contextual barriers to completion.Consider a client who works on an assembly line andhas been asked to write down instances of an intrusive

thought Such an assignment is likely to end up a failure

due to its poor feasibility Using role plays with

role-re-versal, having the client act as the therapist and explain

why homework and its completion are important, may

enhance motivation Therapist characteristics that may

affect compliance are more difficult to define, as there

are gaps in the empirical literature concerning this

vari-able Nonetheless, the authors posit that factors such as

empathy and therapist behaviors related to

recommend-ing assignments may merit exploration

In other studies done to examine factors associated

with better homework outcomes, it has been found

that the quality of the homework product is far more

predictive of outcome than the quantity of homework

produced and that more thorough reviews of one

homework assignment will promote better compliance

with subsequent homework assignments

III EMPIRICAL STUDIES

The primary question for homework is “Do

home-work assignments improve therapeutic outcome over

and above in-session therapy effects alone?” In 2000,

Nikolaos Kazantzis, Frank P Deane, and Kevin R

Ronan conducted a meta-analysis of the literature on

this empirical question Combining 11 prior studies

with a total of 375 participants, their analysis found

strong effects of homework assignments on therapy

outcome Thus the answer seems to be a clear “yes.”

These authors’ results also showed that the effect of

homework was stronger for depression than for anxiety

disorders Homework assignments to practice social

skills and watch videotapes had stronger effects on

out-come than assignments to self-expose to feared objects

or situations and relaxation practice Finally, studies

that used a range of homework assignments appeared

to obtain better treatment effects than studies that used

only single, specific homework assignments

How large are the effects of homework on therapy

outcome? The meta-analysis above found an effect size

of r = 36 It is useful to see in more concrete terms how

large a change a therapist can expect to see on a common

measure of distress The Burns and Spangler study

scribed earlier separately examined two groups of

de-pressed patients for the effects of homework on change

in scores on the Beck Depression Inventory (BDI), a

short, reliable questionnaire that is used by both

re-searchers and private practitioners For each of their

groups, they found that homework accounted for a drop

in BDI scores of 14 to 16 points This improvement in

BDI scores was comparable to a 1988 study done in a

private practice setting by Jacqueline Persons, DavidBurns and Jeffery Perloff These authors found a 16.6point BDI change with homework but noted that thevast majority of improvement occurred in their more de-pressed clients, those with initial BDI scores over 20.Homework had very little effect for their clients who hadlower scores at the beginning of treatment In general,the degree of BDI change produced by homework alone

in these studies would move a client from being fied as “severely depressed” to “moderately depressed”

classi-or from “moderately depressed” to “mildly depressed.”Psychodynamic and systemic or family therapies alsooften require or recommend homework Althoughthere is no literature to date investigating homeworkeffectiveness within these therapies, there is no reason

to think that the cognitive-behavioral research findingsthat support the use of homework would not generalize

to these approaches

IV SUMMARY

Most theoretical orientations hold that what a clientdoes in the natural environment outside of therapy ses-sions is a necessary condition for producing therapeuticchange Typically, clients are seen for about 1 hour eachweek To extend what clients are taught in session to thetime intervening between sessions and to implementwhat clients learn in session, therapists give homeworkassignments Effective homework assignments can opti-mize the cost effectiveness of therapy for the consumer.Homework assignments first became incorporatedinto psychotherapy during the 1950s, and since then,have become an integral part of both behavioral andcognitive-behavioral treatment paradigms Other treat-ment modalities, such as systems therapy or psychody-namic interventions, also utilize homework Homework

is used in the treatment of a wide variety of disorders,which, along with factors such as therapist orientationand client commitment, may dictate the type of home-work assigned Common types of assignments includewritten assignments, self-monitoring procedures, andskills practice

Research clearly shows that homework improvestreatment outcome

See Also the Following Articles

Applied Relaxation ■ Behavior Rehearsal ■ Discrimination Training ■ Exposure in Vivo Therapy ■ Guided Master Therapy ■ Home-Based Reinforcement ■ Negative Practice

■ Panic Disorder and Agoraphobia ■ Self-Control Therapy

Further Reading

Addis, M E., & Jacobson, N S (2000) A closer look at the

treatment rationale and homework compliance in

cogni-tive-behavioral therapy for depression Cognitive Therapy

and Research, 24, 313–326.

Beck A T., Rush, A J., Shaw, B F., & Emery, G (1979)

Cog-nitive therapy for depression New York: Guilford Press.

Bergin, A E., & Garfield, S L (1994) Handbook of

psy-chotherapy and behavior change (4th ed.) New York: John

Wiley and Sons.

Bryant, M J., Simons, A D., & Thase, M E (1999)

Thera-pist skill and patient variables in homework compliance:

Controlling an uncontrolled variable in cognitive therapy

outcome research Cognitive Therapy and Research, 23,

381–399.

Burns, D D., & Spangler, D L (2000) Does psychotherapy homework lead to improvements in depression in cogni- tive-behavioral therapy or does improvement lead to in-

creased homework compliance? Journal of Consulting and Clinical Psychology, 68, 46–56.

Detweiler, J B., & Whisman, M A (1999) The role of work assignments in cognitive therapy for depression: Po-

home-tential methods for enhancing adherence Clinical Psychology: Science and Practice, 6, 267–282.

Edelman, R E., & Chambless, D L (1993) Compliance during sessions and homework in exposure-based treatment of ago-

raphobia Behaviour Research and Therapy, 31, 767–773.

Kazantzis, N., Deane, F P., & Ronan, K R (2000) work assignments in cognitive and behavioral therapy: A

Home-meta-analysis Clinical Psychology: Science and Practice, 7,

189–202.

I Humanistic Approaches: Description and Overview

II Existential Therapy

III Constructivist Therapy

IV Transpersonal Therapy

V Empirical Studies of Humanistic Therapy

VI Summary

Further Reading

GLOSSARY

constructivist therapy Humanistic approaches that stress

per-sonal and social constructions of psychological growth

processes.

existential therapy Humanistic approaches that emphasize

freedom, experiential reflection, and responsibility.

humanistic theory Comprises two overarching concerns:

What it means to be fully, experientially human, and how

that perspective illuminates the vital or fulfilled life.

humanistic therapy Conditions or stances that assist

peo-ple to grappeo-ple with and become more of who they aspire

to become.

transpersonal therapy Humanistic approaches that accent

spiritual and transcendent dimensions of psychological

well-being.

Humanistic psychotherapy is the applied branch of

humanistic psychology and philosophy Humanistic

psychology and philosophy are time-honored folk and

academic traditions that stress deep personal inquiry

into the meaning and purpose of life In particular, manistic psychology and philosophy pose two basicquestions: What does it mean to be fully, experientiallyhuman, and how does that understanding illuminatethe vital or fulfilled life? Correspondingly, humanisticpsychotherapy comprises the conditions or stances bywhich people can come to intimately know themselvesand, to the extent possible, to fulfill their aspirations.Humanistic psychotherapy is characterized by threemajor practice philosophies—the existential, the con-structivist, and the transpersonal

hu-I HUMANISTIC APPROACHES: DESCRIPTION AND OVERVIEW

Humanistic psychotherapy is a broad classificationthat embraces a diverse ensemble of approaches.1Each

of these approaches is like a spoke on a wheel, the hub

of which is the humanistic theoretical stance The manistic theoretical stance derives essentially from an-cient Greek, Renaissance, and even Asian sources,

1 The terms “approach,” “stance,” and “condition” are used instead

of “treatment” in humanistic nomenclature The reason for this tution is because “treatment” implies the medical-like application of a technique to a measurable and well-defined symptom; however hu- manistic psychotherapy emphasizes the significance of a relation- ship—a condition, atmosphere, or forum—within which not just symptoms but complex life issues can be explored and addressed.

substi-which all uphold the maxim, “know thyself.” Although

there have been many variations on this theme

throughout the development of psychology, let alone

humanistic psychology, it has come to acquire a core

humanistic meaning For humanists, to know thyself is

far from a simple project with trivial implications; to

the contrary, it is an intensive intra- and interpersonal

undertaking with world-historical significance In the

parlance of modern humanistic psychology the maxim

has come to be understood as a dialectic between

pro-found self-inquiry, and inquiry into the world Indeed,

the self cannot be separated from the world, according

to contemporary humanists, and must be understood

as a “self-world” process or construct as James Bugental

has put it A corollary to the humanistic stress on

in-quiry is engagement of potential It is not enough to

ask questions about life’s meaning, according to

hu-manists, one must also, at the appropriate time,

trans-late those questions into a meaningful life In short,

humanistic psychology has both an inquiring and

moral–ethical component that suffuses through every

mode of its application To learn more about the history

and development of humanistic philosophy and

psy-chology, see The Handbook of Humanistic Psychology:

Leading Edges in Theory, Research, and Practice and

Hu-manistic and Transpersonal Psychology: A Historical and

Biographical Sourcebook.

Contemporary humanistic psychotherapy is

com-posed of three basic practice traditions: the existential,

constructivist, and transpersonal We will now describe

the structure of these traditions, highlight their

con-ceptual underpinnings, and consider the empirical

evi-dence on which they are based

II EXISTENTIAL THERAPY

Existential psychotherapy derives from the

philo-sophical and literary writings of such thinkers as Søren

Kierkegaard, Friedrich Nietzsche, Martin Heidegger,

Jean Paul Sartre, and Maurice Merleau-Ponty; and from

the methodological formulations of investigators such

as Edmund Husserl, Wilhelm Dilthey, and William

James The basic thrust of existential psychotherapy, as

Rollo May, one of the leading contemporary

spokespeo-ple for the movement put it, is “to set clients free.”

Freedom is understood as the cultivation of the

capac-ity for choice within the natural and self-imposed (e.g.,

cultural) limits of living Choice is understood further

as responsibility; the “ability to respond” to the myriad

forces within and about one Although many forces are

recognized as restrictive of the human capacity forchoice, for example, influences that May terms “des-tiny”—genes, biology, culture, circumstance—they arenevertheless highly mutative, according to existential-ists, in the light of—and through the tussle with—choice For existentialists, choice is the key to anengaged and meaningful life

The second major concern of existential apy is the cultivation not just of intellectual or calcula-tive decision-making, but decision-making that is felt,sensed, or in short, experienced The stress on the expe-riential is one of the primary areas of distinction betweenexistential and other (e.g., cognitive-behavioral, psycho-analytic) modes of practice The experiential mode is de-fined by four basic dimensions—immediacy, affectivity,kinesthesia, and profundity By immediacy, we mean thatexperience is fresh, living, “here and now”, by affectivity,

psychother-we mean experience is characterized by feeling or sion; by kinesthesia, we mean experience is embodied orintensively sensed; and by profundity, we mean experi-ence has depth, impact, and transcendent significance.Another way to characterize the experiential is throughrecognition, as Arthur Bohart has put it To the degreethat a thought, feeling, or behavior is recognized, ac-cording to Bohart, it is experienced

pas-Existential therapists have a variety of means bywhich to facilitate freedom, experiential reflection, andresponsibility Some, such as Irvin Yalom, emphasize thesupport and challenges of the therapist–client relation-ship to facilitate liberation Yalom stresses the building

of rapport and repeated challenges to clients to take sponsibility for their difficulties Further, Yalom homes

re-in on the immediate and affective elements of his peutic contacts, but he refers little to kinesthetic compo-nents Following the philosopher Martin Buber, MauriceFriedman also homes in on the interpersonal relation-ship but stresses the dimension of authenticity or the “I-thou” encounter as the key therapeutic element TheI-thou encounter according to Friedman is the dialecti-cal process of being both present to and confirming ofoneself, while simultaneously being open to and con-firming of another The result of such an encounter is a

thera-“healing through meeting” as Friedman puts it in The

Psychology of Existence—which is a healing of trust, deep

self-searching, and responsibility Through the therapist’sI-thou encounter, in other words, the client is inspired totrust, enhance self-awareness, and take charge of his orher own distinct plight James Bugental, on the otherhand, accents the “intra” personal dimensions of free-dom, experiential reflection, and responsibility For Bu-gental, choice and responsibility are facilitated, not

merely or mainly through therapist and client encounter,

but through concerted invitations (and sometimes

chal-lenges) to clients to attend to their subtlest internal

processes—flashes of feeling, twinges of sensation, and

glimpses of imagination Via these means, according to

Bugental, clients discover their deepest yearnings, their

strongest desires, but also, and equally important, their

thorniest impediments to these impulses By grappling

with each side, however, Bugental maintains that clients

learn to negotiate their conflicts, elucidate their

mean-ing, and rechannel them into living fuller and more

em-powered lives

Similarly, Rollo May stresses the cultivation of what he

terms “intentionality” in the therapeutic relationship By

intentionality, May refers to the “whole bodied”

direc-tion, orientadirec-tion, or purpose that can result from

exis-tential therapy In his case examples, May shows how

intellectualized or behaviorally programmed

interven-tions persistently fall short with respect to the

cultiva-tion of intencultiva-tionality, whereas profound struggle, both

between the therapist and client and within the client,

can, if appropriately supported, lead to such a quality

For May (as with most of the existential therapists), the

struggle for identity is essential—enhancing clarity,

agency, and ultimately commitment or intentionality in

the engagement of one’s life

The client’s internal frame, and his or her own

subjec-tive wrestling is also a hallmark of Carl Rogers’

client-centered approach For Rogers, the therapist must create

the conditions for client freedom, searching, and

respon-sibility; he or she would not (except in rare instances)

at-tempt to dictate or teach these capacities The rationale

for this stance is foundational—clients must learn for

themselves what is meaningful or essential to their

growth In Rogers’ view, there are three facilitative

condi-tions necessary for optimal therapy—the therapist’s

warmth or caring, the degree to which he or she is

con-gruent or genuine, and the degree to which the therapist

communicates unconditional positive regard for the

client With the provision of these conditions, according

to Rogers, clients are freed to verbalize and embody

more of who they experience themselves to be, and by

implication, to eradicate the incongruities and pretenses

of who they have been By discovering more of who they

are, moreover, clients do not become licentious in

Rogers’ view; they become responsive, both to

them-selves and to those around them

With his Gestalt therapy, Frederick Perls also

empha-sizes the client’s side of the therapeutic encounter, but

through a very different means One might say that

whereas Rogers “alerts” clients about their liberating

po-tentials, Perls “alarms” them; and whereas Rogers cents therapeutic receptivity, Perls stresses therapeuticconfrontation For example, whereas Rogers might useactive listening or empathic reflection with a givenclient, Perls might encounter a client directly—“how is

ac-it that you continually meet men who are bad for you?”

Or Perls might refer to a client’s body position or manner

of speaking and concertedly encourage the client to plify and attend to those modalities

am-The upshot of this synopsis is that existential pists use diverse means by which to foster a similar re-sult—client empowerment and consciousness-raising

thera-In recent years, and partly as a response to the ethos ofmanaged care, existential therapists have endeavored toreassess and in some cases streamline their repertoires.Existential oriented investigators are increasingly raisingtwo questions: Which of the various existential practiceswork best, and under what general conditions? LeslieGreenberg, Laura Rice, and Robert Elliott, for example,have developed what they term “therapeutic markers” toguide their work Such markers are statements, gestures,

or signs that clients are experiencing specific kinds ofdifficulty, for example, identity conflicts, unfinishedbusiness with significant others, loss of meaning Byidentifying the markers, therapists are better able to bothidentify and specify the interventions (e.g., supportive-ness, uncovering) that address those markers Therapistssuch as those discussed earlier have also found that spe-cific Gestalt techniques, such as “chair work” and “sys-tematically building the scene” can be of particular value

in the appropriate circumstances Chair work entails arole-play between a client and an imagined other who

“sits” on an empty chair The client “works out” or ulates an actual encounter with the imagined other, andwith the assistance of the therapist, processes the feel-ings, thoughts, and implications of that experience Sys-tematically building the scene entails the use of vividand concrete language to help clients revive and workthrough suppressed or traumatizing material

sim-Eugene Gendlin’s “Focusing Therapy” and AlvinMahrer’s “Experiential Therapy” also provide methodi-cal and intensive guidelines to optimize existential prac-tice Gendlin, for example, homes in on that which heterms the “felt sense,” which is a preverbal, bodily expe-rience of a given concern, to facilitate therapeutic change.Very methodically, Gendlin encourages clients to iden-tify their felt sense, explore its nuances as it evolves, andclarify its meaning or implication for their lives Mahrerhas four basic aims in his experiential therapy: assistclients into moments of strong feeling, help them toalign with or integrate those moments, encourage them

to enact or embody the inner experiences associated

with those moments, and support them to live or

trans-late their discoveries into the present Mahrer’s approach

has two overarching goals: (1) to help clients access

deeper experiencing potential so that they can become

(to the degree possible) “qualitatively new persons,” and

(2) to help them free themselves from the limiting

feel-ings that have plagued them in the past, and with which

they grapple in the present

Kirk Schneider, with the assistance and inspiration of

Rollo May, has synthesized a range of existential

ap-proaches with his model “Existential-Integrative

Ther-apy.” Existential-integrative therapy draws on a diversity

of therapeutic approaches within a unitary existential or

experiential framework The aim of the

existential-inte-grative approach is to address clients at the level at

which they chiefly struggle—be that physiological,

envi-ronmental, cognitive, psychosexual, or interpersonal—

but all within an ever-deepening, ever-beckoning

experiential context By “experiential” Schneider refers

to four characteristic dimensions—the immediate, the

affective, the kinesthetic, and the profound (or cosmic)

The degree to which a client can be “met” within the

ex-periential context is a function of his or her desire and

capacity for change, but also, according to Schneider, an

assortment of therapist offerings Among these offerings

are “presence,” “invoking the actual,” “vivifying and

confronting resistance,” and “meaning creation (or

culti-vation).” Presence, for Schneider, holds and illuminates

that which is palpably (immediately, affectively,

kines-thetically, and profoundly) relevant, within the client

and between client and therapist Presence holds and

il-luminates that which is charged in the relationship and

implies the question, “What’s really going on here,

within the client and between me and the client?”

Pres-ence is the “soup” or atmosphere within which deep

dis-closure can occur, and based on this disdis-closure, the

client’s core battles become clarified Invoking the actual

refers to the invitation to the client to engage that which

is palpably relevant By invoking the actual, the therapist

calls attention to the part of the client that is attempting

to emerge, break through, and overcome stultifying

de-fenses Invoking the actual is characterized by such

invi-tations (and sometimes challenges) as, “What really

matters to you right now?”, or “I notice that your eye

moistened as you made that statement”, or “What

feel-ings come up as you speak with me?” At times, invoking

the actual calls attention to content/process

discrepan-cies, such as “You say that you are angry but you smile.”

If invoking the actual calls attention to that which is

emerging in the client’s experience, vivifying and

con-fronting resistance call attention to that which blockswhat is attempting to emerge These blocks or resist-ances are seen as life-lines from the existential-integra-tive point of view, but they are also acknowledged asprogressively defunct Vivifying resistance “alerts”clients to their defensive blocks, while confronting re-sistance “alarms” or “jars” them about those blocks To-gether, vivifying and confronting resistance serve tointensify and eventually mobilize clients’ counterresis-tances (the “counter-will” as Otto Rank has put it); it isthese counterresistances that liberate vitality, bolsterchoice, and incite change In the final stage of existen-tial-integrative encounter, therapists help clients to con-solidate the meanings, values, and directions of theirpresent lives Although meaning creation evolves natu-rally and spontaneously following breakthroughs overone’s resistance, sometimes it requires a gentle prod Forexample, a therapist might challenge a client to translateher newfound boldness into her constricted work rela-tionships

To sum, existential-integrative therapy, like tial therapy generally, assists clients to grapple withtheir experiences of life, not just their reports aboutlife, and through this illumination, supports their in-tentional and embodied engagement with life

existen-III CONSTRUCTIVIST THERAPY

“Constructivism”2refers to a group of theories holdingthe philosophical position that “reality” is, in some ways,created by (as opposed to thrust upon) persons Con-structivist therapists are faced with the challenge of un-derstanding the lived reality of each client, not imposingsome objective truths on all persons seeking their help

On this basis, constructivists believe that lives can betransformed and horrors transcended when we grasp theunique, personal, and richly powerful “realities” each of

us has created Therapy (and research, for that matter) is

a cocreated experience between therapist and client, tual experts on different aspects of the lived reality beingcreated between them This egalitarian relationship can

mu-be seen as more client empowering than approaches inwhich the more powerful therapist imposes diagnosticand treatment “realities” on the less powerful client.After briefly describing constructivism, we will discuss

2 See also postmodernism/postmodern or poststructural philosophy/ therapy.

some general aspects of constructivist therapy followed

by a brief illustration of a few constructivist approaches

Although all constructivists agree that reality cannot

be known directly, different theoretical groups disagree

on the exact nature of the relationship between the

per-son and the world Radical constructivists argue that it

makes no sense to even speak of a reality outside of the

meanings the person has created Because reality cannot

exist other than our construing it into existence, radical

constructivists would argue that the meanings we create

totally determine our experience of the world Social

constructivists would go to the other extreme We are

saturated with meanings created by cultures and

im-posed on us Occupying a middle ground between these

two extremes, critical constructivists argue that

mean-ings are created in the dynamic interaction between the

person and the world In other words, although we

can-not know it directly, the world is real, integral, and

un-folding around us

Constructivist therapies generally share certain

atti-tudes about therapy For example, most constructivists

will listen to clients from the assumption that

every-thing the client says is “true” in the sense of revealing

important aspects of the client’s experiential meaning

system (This attitude is termed the credulous

ap-proach by some constructivists.) Similarly, there is a

re-spect for contrast, oppositionality, or the dialectic as

integral to meaning making Most constructivists also

are very attuned to making the therapy room a safe

place for clients to experience life, explore, and grow

Without safety, creative encounter with the central

meanings of one’s life is hampered; without creativity,

reconstruing the bases of one’s existence is impossible

Finally, there is an emphasis on seeing the client as a

process of meaning creation, rather than a static entity

composed of specific meanings This emphasis on

see-ing persons as processes implies that constructivists are

always looking for the ways the client is changing from

moment to moment or session to session Art Bohart

has taken this focus on client change and argued that

therapy works because the self-healing client uses

whatever the therapist does to grow and change

As might be expected, different constructivist

thera-pists employ these attitudes in different therapeutic

ap-proaches Franz Epting, for example, is a leading

proponent of George Kelly’s fixed role therapy In fixed

role therapy, the client first writes a character sketch

that is open, revealing, yet sympathetic to the client’s

experience The therapist and client then cocreate an

alternate sketch for the client to enact, typically for a

2-week period Rather than being a behavioral

prescrip-tion, the procedure is designed to free the client to periment with differing ways of experiencing life

ex-On the other hand, constructivist therapists such asMiller Mair, Robert Neimeyer, and Oscar Goncalves em-ploy narrative approaches to therapy These therapistsbelieve that narratives give meaning and continuity tothe lived experience of clients Gaps, incompleteness,and incoherence in the client’s life story may indicatestruggles in creating an integrated experience of self-in-the-world Goncalves nicely illustrates constructivistnarrative therapy with his “moviola” technique This is

a technique in which the therapist’s attention scans thesettings of a client’s life, much like a camera in a movie.The therapist can zoom in on a detail or back off and get

a more panoramic view For example, a therapist mightstart by having the client describe the entire room inwhich a traumatic event occurred Eventually, the thera-pist might help the client zoom in on the faces in theroom, filled with fear and horror, while the abuse oc-curred Because people intimately create meanings tounderstand their experiences, the experience of review-ing the abuse with an empathic therapist allows for newconstructions to be created These newer meanings, inturn, allow for newer experiences as clients’ lives moveinto the future

Bruce Ecker and Laurel Hulley’s depth oriented brieftherapy (DOBT) applies constructivist principles to un-derstand and engage clients in radical change in a veryshort-term treatment DOBT understands the symptom

as painful because of the ways it invalidates importantaspects of our experience At the same time, there areother constructions, often at a lower level of conscious-ness, which makes the symptom absolutely necessaryfor the client DOBT uses specific experiential tech-niques to help the client gain access to these deepermeanings The client then can more consciously decidewhether to keep or abandon these more unconsciousmeanings For example, one client who described him-self as a complete failure uncovered the ways in whichhis failure was rewarding It served both as punishmentfor and proof to his parents that they had failed him inmany ways

Larry Leitner’s experiential personal construct chotherapy (EPCP) is based on the relational, experi-ential, and existential foundations of constructivism.EPCP construes persons as simultaneously needingand being terrified of depths of emotional closeness

psy-On the one hand, such intimate relationships can firm the meanings that have formed the very founda-tion of our existence On the other hand, we canexperience devastating disconfirmation in intimate

relationships Clients then struggle with needing to

connect with others, risking terror to gain profound

richness, versus retreating from intimacy, buying safety

at the cost of the empty objectification of self and

oth-ers EPCP engages this struggle in the live relationship

in the therapy room Therapeutic growth can occur as

the therapist offers optimal therapeutic distance, a

blending of profound connection and separatensess,

when the therapist is close enough to feel the client’s

experience, yet distant enough to recognize those

feel-ings as the client’s and not the therapist’s own

Constructivist therapy also has been applied to

spe-cial populations For example, EPCP was an approach

developed to understand and therapeutically engage the

experiences of more severely disturbed clients, often

those who have received DSM diagnoses such as

“schiz-ophrenia,” “borderline,” and “schizotypal.” (Terms most

constructivists would not countenance by the way.) Fay

Fransella has applied constructivist therapy to

stutter-ers A central aspect of her therapy involves the creation

of meaningful ways of encountering the world as a

flu-ent speaker

Tom Ravenette, using only blank sheets of paper and

pencils, uses constructivist techniques to access the

meaning-making system of children For example, he

will draw a bent line in the center of a page and have the

child draw a picture incorporating the line He then has

the child draw a second picture, depicting an opposite

to the one just drawn As the child talks about the

pic-tures, Ravenette enlarges the conversation to allow the

child to say what she knows (but could not express)

about her world Linda Viney and Sally Robbins,

work-ing on the other end of the age spectrum, successfully

utilize constructivist principles with elderly clients

Robbins, for example, has poignantly described using a

constructivist version of reminiscence to help elderly

clients come to terms with their lives and their deaths

Family system constructivists may use systemic

bow-ties to help each client understand how their actions,

based on their deepest fears, confirm the deepest fears

of other family members For example, in response to

his fears that his wife does not love him, a client may

re-spond vaguely to her when she is angry She interprets

the vagueness as his not respecting her, making her

even angrier

Finally, there is a growing literature empirically

sup-porting the use of constructivist therapies Linda Viney

(in a 1998 issue of the journal Psychotherapy: Theory,

Research, Practice, Training), for example, reviews 19

different studies exploring the effectiveness of personal

construct therapy across different countries, ages, and

types of problems Not only did she find substantialsupport for the effectiveness of constructivist therapy,she found effect sizes for client change to be at least aslarge as those reported in the cognitive-behavioral andpsychoanalytic literature In other words, good con-structivist therapy respects the lived experiences ofpersons while being empirically supported using stud-ies that meet the most rigorous of experimental criteria

IV TRANSPERSONAL THERAPY

The differences among the major humanistic proaches are certainly more of degree than of kind.There is a very wide overlap among transpersonal, exis-tential, and constructivist modalities However, whereasexistential and constructivist therapies emphasize theinterhuman, personal elements of client–therapist inter-action, the transpersonal approaches accent the spiri-tual, religious, or cosmic implications of thosedimensions It is not that an existential- or construc-tivist-oriented therapist would exclude any suchtranspersonal theorizing—indeed, a number of themwelcome such theorizing—however, on the whole,transpersonal therapists, above and beyond their exis-tential and constructivist counterparts, bring to bear intotheir practices two basic knowledge domains: (1) reli-gious faith traditions, and (2) mystical healing tradi-tions Religious faith traditions represent the sevenmajor religious systems of the world—Buddhism, Hin-duism, Islam, Judaism, Christianity, Taoism, and Confu-cianism—as well as the many indigenous lineages, such

ap-as Native American, Asiatic, and African traditions tical healing traditions encompass a breathtaking span ofindigenous, institutionalized, and individualized ele-ments, but they all converge on one basic pattern—theexperience of oneness with creation While transper-sonal therapists tend to be conversant with these tran-scendental viewpoints, it should be pointed out they donot draw on them to proselytize Their essential task, bycontrast—in accord with transpersonal pioneer C.G.Jung—is to facilitate client self-discovery

Mys-In his essay from the germinal Paths Beyond Ego,

ed-ited by Roger Walsh and Frances Vaughan, Bryan tine sets forth several “postulates” of transpersonalpsychotherapy The first postulate proposes thattranspersonal therapy embraces egoic, existential andtranspersonal levels of human consciousness This pos-tulate derives from a “spectrum” model of human con-sciousness, developed formally by Ken Wilber, andused broadly by transpersonal scholars and practition-

ers Roughly speaking, the spectrum model proposes a

hierarchy of developmental psychospiritual stages,

from the infantile “pre-egoic” stage to the culturally

competent “egoic” stage to the personally inquiring

“existential” stage to the unitive “transpersonal” stage

Although there are many nuances within this model,

and diverse interpretations of its accuracy, it is

never-theless a core view for many transpersonalists

The first postulate of transpersonal therapy then

as-sumes a sweeping scope—all developmental stages of

identity from the precultural (infantile) to the

transcul-tural (sagely or saintly) are embraced Moreover, for

some in the transpersonal community, each

develop-mental stage is a prerequisite to the next One cannot,

for example, simply “leap” from stage to stage, for

exam-ple, from the conventional egoic stage to the

transcon-ventional “subtle” or “soul” level, without predictable

difficulties and consequences Among these are various

kinds of regression, as manifested, for example, by the

accomplished meditator who also semiconsciously

in-dulges in alcohol, or the pious adept who concomitantly

exploits others, and so on Generally speaking, the more

that clients can address and work through the stage of

their developmental arrest, the greater their ability to

advance to an expanded or “higher” developmental

level Put another way, the transpersonal therapist (like

most depth therapists) must help clients “get through

the night,” or manage their dysfunctionality, before he

or she can assist them with profound or mystical

realiza-tions Although other transpersonalists, such as Brant

Cortright, believe that spiritual and mystical healing

can, and often does, occur alongside of the

dysfunc-tional, they do not discount the significance of

address-ing those dysfunctional states, and of supportaddress-ing healaddress-ing

processes generally

Wittine’s second postulate is that the therapist’s role

in transpersonal therapy is critical The therapist’s

abil-ity to hold and value psychospiritual healing refers

di-rectly back to his or her own psychospiritual work,

awareness, and capacity to translate that work and

awareness to the therapeutic setting To the extent that

therapists can “see” and acknowledge the unfolding

spiritual implications in client’s quandaries, they

em-brace a deeper and broader therapeutic possibility for

clients, a deeper and broader language within which to

engage that possibility Consider, for instance, the

thera-pist who works strictly within a psychoanalytic frame

and who views clients’ conflicts as derivative of

circum-scribed parental relationships; to what extent would

such a therapist be open to implicit spiritual strivings in

clients’ material—such as urges to wonder, yearnings to

transcend, or impulses to meld? The therapist’s ence to these spiritual possibilities is crucial—an entiretherapeutic direction may hinge on what therapists askabout, how they inquire, and what they imply or sug-gest when they inquire If a therapist is not attunedwithin himself or herself to the longing for or fear of anenlarged sense of spiritual meaning in a client’s rage ortearfulness, that client may never broach those motiva-tions, and may feel shortchanged as a result A con-scious transpersonal therapist, on the other hand, candetect and call attention to emerging affects, images,symbolisms, and the like, that are bell-weathers of pro-found spiritual or religious transformation; to the de-gree that one has not experienced and dealt with suchintensities within oneself, however, it is doubtful thatone could facilitate them in others Great care, finally,needs to be taken in calling attention to emerging spiri-tual concerns—as with all humanistic therapies, it is theclient, not the therapist, who must ultimately decide his

pres-or her fate, and the meaning pres-or significance of that fate.Wittine’s third postulate is that transpersonal therapy

is “a process of awakening from a lesser to a greateridentity.” By “awakening,” transpersonal therapistsmean enlarging or expanding one’s identity The enlarge-ment of one’s identity invariably entails disruption, pain,and relinquishment One cannot simply “leap over”one’s former way of living, particularly if it has been fa-miliar and “safe,” and fail to experience disturbance.This disturbance becomes particularly acute if one lacksthe means and resources to address it For example,there is a major difference between an identity crisis thatevolves gradually within familiar circumstances, andone that “shatters” or overtakes one abruptly The expe-rience that transpersonal therapists term “spiritualemergency” is an example of the latter variety of crisis

In spiritual emergency (which is to be distinguishedfrom brief psychotic episodes or nonspiritual “break-downs”), clients experience an acute transpersonal tear

or rupture in their conventional experience of theworld This rupture may take the form of psychic open-ings, for example, visions, voices, telepathic states; orshamanic-like alterations of consciousness, such aschanneling experiences, possession states, and UFO en-counters

According to Cortright, who draws on the tional work of Stanislav and Christina Grof, there arethree distinguishing features of those undergoing spiri-tual emergency: (1) They display changes in conscious-ness in which there is significant transpersonalconsciousness; (2) they have an ability to view the con-dition as an inner psychological process, amenable to

inner psychological resources; and (3) they have the

ca-pacity to form a sufficient working alliance with a

thera-pist Although these features stand in marked contrast

to relatively nontranspersonal, nonintrospective, and

oppositional crisis clients, there are many gradations

when it comes to spiritual emergency and there is as yet

no firm consensus as to which clients fit which criteria

The general consensus for treating spiritual emergency

clients, according to Cortright, is to help “ground” or

support them, to offer deep and abiding presence to

their struggle, and to draw on diet, exercise, massage,

proper rest, meditation, and (when necessary)

medica-tion, to begin their healing path Following these initial

steps, a more depth-experiential approach can be

imple-mented The goal of such an approach, as with most

transpersonal approaches, is to assist clients to integrate

and transform split-off parts of themselves, and to

facili-tate expanded consciousness

In general, transpersonal work proceeds through a

se-ries of steps that increase clients’ awareness The more

that clients can become aware of stifling or debilitating

patterns, the more they are in a position to question and

reshape those patterns Although most therapists

facili-tate expanded awareness, transpersonal therapists create

an atmosphere and make available methods that carry

clients beyond conventional change parameters Hence,

whereas a cognitive therapist might help clients to

de-construct maladaptive beliefs, a transpersonal therapist

would work with clients to deconstruct maladaptive

at-tachments—beliefs, values—any core investitures that

warp or curtail consciousness Among the means that

transpersonalists employ to facilitate such

emancipa-tions are meditative breathing, mindfulness and

concen-tration exercises, guided visualization, stress reduction

techniques, sustained self-observation, experiential

re-flection, disidentification exercises, demystifying

dia-logue, and somatic practices

To sum, transpersonal therapists tend to be

integra-tive therapists They employ egoic stances (e.g.,

med-ical, psychoanalytic, cognitive) when questions of

adjustment or personal identity are at stake, and

transpersonal modes (e.g., spiritual-existential,

contem-plative) when issues of emancipation, enlightenment, or

transpersonal identity arise The question as to “who am

I” is relentlessly pursued by transpersonal therapists

Al-though there are many gradations and variations among

transpersonal practices, several principles stand out:

Transpersonal therapy addresses the entire spectrum of

(purported) consciousness; the therapist’s personal role

is critical; and the enlarging or awakening of identity is

the core of transpersonal practice

V EMPIRICAL STUDIES OF HUMANISTIC THERAPY

Humanistic therapy occupies a unique positionamong organized psychological practices Whereas con-ventional therapies target overt and measurable symp-tom change as indicative of “effective” therapeuticoutcome, humanistic approaches recognize many alter-native criteria Among these are shifts, not just in symp-tomatology, but in values, attitudes, and approachestoward life To the extent that one becomes a “qualita-tively new person,” as Alvin Mahrer puts it, or developsnew talents, capacities, and appreciations for life, asRollo May has put it, one fulfills humanistic standards.For humanists, it is one thing to “return to a previouslevel of functioning,” or to adjust to one’s spouse, or tobecome more productive at work, and quite another tosupersede one’s previous level of functioning, to deepenone’s connection with one’s spouse, and to become pas-sionate about one’s vocation Whereas the latter tend to

be overt and quantifiable, the former tend to be tacit, timate, and qualitative Given the confines of conven-tional research methodology (e.g., randomizedcontrolled trials, objectified rating scales), humanistictherapies have become forgotten “stepchildren” in thecompetitive outcome battles The empirical challenge ofhumanistic therapies is formidable: How does one as-sess the depth and breadth of intimate humanisticchange? Or in short, how does one match the method-ology with the mission?

in-Given these thickets of difficulty, humanisticresearchers have turned to two basic investigativemodalities to study therapeutic outcome—innovativequantitative methodology, and that which humanistictrailblazer Amedeo Giorgi terms “human science re-search methodology.” Although quantitative methodol-ogy has been found to be wanting by many in thehumanistic community (e.g., because of its restrictiveprocedural requirements) for others, it has been con-sidered both adaptable and informative Since the1950s, for example, Carl Rogers and his successorshave undertaken a series of quantitative investigations

of client-centered therapies Among the prominentfindings from these studies, and continuing today, are(1) robust support for therapist relationship factors—e.g., empathy, warmth, and genuineness—over thera-pist technical offerings (e.g., skilled interpretations),and (2) support for client agency, as opposed to thera-pist directiveness, as central to successful therapeuticoutcome (as discussed in Bohart et al.’s 1997 review).Recent meta-analyses (large-scale analyses of aggre-

gated studies) confirm these findings These have

found, for example, that fully 30 to 35% of the variance

in general therapeutic outcome is accounted for by

therapist and relationship factors whereas only 15% of

the variance is accounted for by techniques or

thera-peutic approaches (as discussed in Bohart and

col-leagues’ 1997 review) Coupled with the research on

affective expression and therapeutic outcome (see, for

example, the studies in Greenberg et al.’s 1998 work),

these quantitative findings provide broad support for

humanistic practices

In addition to these broad findings, there is specific

quantitative evidence for the effectiveness of specific

hu-manistic outcome For example, there is specific

evi-dence for the effectiveness of client-centered therapy for

a variety of disorders; there is also evidence for the

effec-tiveness of Gestalt therapy; and there is considerable

ev-idence for the saliency of the underlying principles of

meditative, experiential, and existential modalities (See

the Cain & Seeman volume for an elaboration)

There have also been important quantitative

investi-gations of humanistic psychiatric practices Drawing

from the foundational work of R.D Laing, Loren

Mosher and his colleagues have studied numerous

psy-chiatric “safe-houses.” These facilities emphasize

rela-tional over medical and egalitarian over hierarchical

therapeutic environments Such programs, concluded

Mosher after a 25-year review, are as effective or more

effective than conventional hospital care, and on

aver-age, less expensive

With regard to human science or qualitative inquiry

into humanistic therapies, particularly therapeutic

out-come, there have been far fewer rigorous studies While

the reasons for this situation are beyond the scope of

this article, suffice it to say that there is a burgeoning

new interest in such inquiry Increasingly, sophisticated

qualitative designs are being developed, such as Robert

Elliott’s Hermeneutic Single Case Efficacy Design,

David Rennie’s Grounded Theory Method, Arthur

Bo-hart’s Adjudication Model, and Kirk Schneider’s

Multi-ple Case Depth Research These innovative formats

hold the promise for important new inroads into

out-come assessment In the meantime, humanistic

thera-pies enjoy wide qualitative support in a variety of case,

observational, and testimonial modalities; the current

emphasis is on formalizing those modalities

VI SUMMARY

Humanistic therapy is a multifaceted perspective thatemphasizes existential, constructivist, and transpersonalpractice philosophies Varied as they are, these philoso-phies explore (1) what it means to be fully, experientiallyhuman, and (2) how that understanding illuminates thevital or fulfilled life By assisting people to grapple withthese perspectives, humanistic therapies empower peo-ple to become more of who they profoundly aspire to be;and in consequencemore of who they are

See Also the Following Articles

Alternatives to Pyschotherapy ■ Existential Psychotherapy

■ Feminist Psychotherapy ■ Gestalt Therapy ■ Individual Psychotherapy ■ Integrative Approaches to Psychotherapy

■ Interpersonal Psychotherapy

Further Reading

Bohart, A C., O’Hara, M., Leitner, L M., Wertz, F J., Stern, E M., Schneider, K J., Serlin, I A., & Greening, T C (1997) Guidelines for the provision of humanistic psychosocial

services Humanistic Psychologist, 24, 64–107.

Cain, D J., & Seman, J (2002) Humanistic psychotherapies: Handbook of research and practice Washington, DC: Amer-

ican Psychological Association.

Cortright, B (1997) Psychotherapy and spirit: Theory and tice in transpersonal psychotherapy New York: SUNY Press Greenberg, L S., Watson, J C., & Lietaer, G (1998) Hand- book of experiential psychotherapy New York: Guilford May, R., Ellenberger, H., & Angel, E (1958) Existence: A new dimension in psychology and psychiatry New York: Basic

Washington, DC: American Psychological Association Press.

Schneider, K J & May, R (1995) The psychology of existence:

An integrative, clinical perspective New York: McGraw-Hill Schneider, K J., Bugental, J F T., & Pierson, J F (2001) The handbook of humanistic psychology: Leading edges in theory, research, and practice Thousand Oaks, CA: Sage.

Walsh, R., & Vaughan, F (Eds.) (1993) Paths beyond ego: The transpersonal vision Los Angeles, CA: Tarcher.

I Description of Treatment

II Theoretical Bases

III Empirical Studies

IV Summary

Further Reading

GLOSSARY

implosive therapy A technique that involves use of an in

vivo or imagery presentation procedure designed to

extin-guish via repetition those aversive conditioned cues

re-sponsible for eliciting and maintaining symptom

execution.

neurotic paradox Why neurotic behavior is at one and the

same time self-defeating and self-perpetrating.

imagery exposure Imaginal exposure of the feared or

anxiety-evoking stimulus, using flooding in implosive therapy

Implosive (flooding) therapy is a learning-based

ex-posure technique of psychotherapy designed to treat a

wide variety of maladaptive behaviors in a relatively

short time period The underlying theoretical model for

this behavioral cognitive treatment approach to therapy

is based on an extension of two-factor avoidance

is afraid to leave his home out of fear that dog fecesmay be in his yard His day becomes dominated withdisturbing thoughts that find relief only in repetitiouswashing of his hands, clothes, and body Perhaps it ishard to comprehend how one could become so fright-ened of bath water that a life preserver must be worn,

or that a sound of a locomotive whistle in the distanceevokes such terror in an individual that he runs around

in a circle screaming at the top of his voice The range

of human fears may be extended almost indefinitely.Some individuals break out in a cold sweat at the sight

of a car, an airplane, or a tall building Others become

so afraid of their own sexual feelings that they avoidthe opposite sex, having become convinced they will besent to hell for such feelings Still others fear failure,loss of control, taking responsibility, being angry, orgiving love and expressing compassion

Committed to the goal of seeking methods to liorate such psychological suffering, the mental health

worker is confronted with the difficult task of selecting

from hundreds of different treatment techniques The

rather chaotic state of the field today suggests the need

to isolate and maximize the central procedural

vari-ables that appear to be reliably correlated with behavior

change One factor common to most treatment

tech-niques stems from the observation that behavior

change appears to occur following the elicitation from

the patient of a strong emotional response to material

presented during the therapeutic interaction Implosive

therapy is a treatment technique that is designed to

maximize in a systematic manner the last-noted

com-mon denominator of therapeutic interaction, that of

emotional responding and its resulting effects

Disillu-sioned with the insight-oriented emphasis of the time

period, Thomas G Stampfl in the late 1950s developed

the technique of implosive therapy which some

au-thors today call flooding therapy or response

preven-tion therapy Each of these terms is frequently used

interchangeably in the literature since the goal of

thera-pists is to maximize emotional responding by getting

patients to confront their fears directly Stampfl was the

first investigator to extend systematically his

learning-based exposure treatment approach to the treatment of

a wide variety of clinical nosologies Borrowing a term

from physics he labeled his newly developed

cognitive-behavioral approach implosion, to reflect the inwardly

bursting (dynamic) energy process inherent in the

re-lease of affectively loaded environmental and memorial

stimuli encoded in the brain

Stampfl was initially influenced by the extensive

clinical experience he gained from conducting

“nondi-rective” play therapy with emotionally disturbed

chil-dren He concluded from this experience that exposure

to the emotional stimulus features of the play material

could account for virtually all the positive effects of

therapy Consistent with his clinical observations was

the insistence by Abraham Maslow and Bela Mittleman

in their 1951 abnormal text that the neurotic’s

symp-toms, defense mechanisms, and general maladaptive

behavior resulted from a state of anticipation or

expec-tation of an impending catastrophic event, which, in

turn, provided the motivating force for symptom

devel-opment These authors concluded that, although the

catastrophic even usually remained unspecifiable by

the patient, it generally involved fears associated with

anticipation of abandonment, injury, annihilation,

con-demnation and disapproval, humiliation, enslavement,

loss of love, and utter deprivation Stampfl reasoned

that if therapy was to succeed, these anticipatory fears,

as was the case for the children he treated, needed to be

confronted directly in order for the unlearning of theemotional response attached to these fears

B In Vivo Exposure Approach

Stampfl at first adopted an in vivo exposure approach

in which he instructed patients to confront directly inreal life their feared stimulus situation For example,one of his patients, a college student, reported a com-pulsive behavior he had engaged in for years Upon re-tiring at night, this patient reported an urge to check tosee if he had left the radio on Every night (without ex-ception) he checked the radio up to 50 times He re-ported that any time he failed to engage in radiochecking he developed much apprehension and anxi-ety and the feeling that something “terrible” or “cata-strophic” might happen He would fear, for example,that perhaps a short circuit would occur and a firewould result Stampfl then instructed the patient toconfront his fears directly by forcing himself not tocheck the radio and imagine that his worst fears wouldhappen He was asked to let himself tolerate as muchanxiety as possible The patient was able to follow thetherapist’s instruction; he reported seeing the radioburst into flames and hearing his father’s voice tellinghim to “turn off the radio.” Following additional repe-titions of the therapist’s instructions, the patient re-called a number of traumatic memories involving hisfather Once the affect associated with these memorieswas eliminated, his compulsive symptoms disappeared

C Imagery Exposure Approach

Thomas Stampfl recognized that although this

pa-tient followed his in vivo instructions to confront

di-rectly the anxiety he experienced, most patients avoid

engaging in an in vivo task because of the strength of

the fear response associated with the task He also ognized that many of the fears motivating the patient’s

rec-symptoms did not lend themselves readily to an in vivo

approach He then developed his implosive imageryprocedure, which was capable of being presentedwithin the context of a therapy session In an attempt

to illustrate the above point, consider the case of an plane phobic Although most phobic behavior is clearly

air-amenable to an in vivo exposure approach, the use of

this procedure with an airplane phobic would entail thetherapist’s accompanying the patient on repeated air-plane trips Stampfl recognized that his imagery expo-sure procedure had the advantage of presenting thefeared cues in the therapist’s office Furthermore, and

most importantly, the imagery technique has the

addi-tional advantage of introducing the more salient and

emotionally intense fear cues associated with the

pho-bic reaction that do not lend themselves to direct in

vivo presentation Examples of such fear cues include

the fear of the plane crashing, the fear of dying, and the

fear of being punished for guilt-producing behavior in

the after-life Imagery scenes involving the

incorpora-tion of these non in vivo presented fears have been

clin-ically shown to produce a powerful emotional

reactivity and subsequently a lasting therapeutic effect

In summary, the fundamental task of the implosive

therapist is to repeatedly re-present, reinstate, or

sym-bolically reproduce those stimulus situations to which

the anxiety response has been learned or conditioned

By exposing the patient to the stimulus complex of fear

cues that are being avoided, the patient will be

con-fronted with the full emotional impact of these cues As

a function of repetition, this emotional exposure

weak-ens and eventually eliminates the connection between

the eliciting stimulus and the resulting emotional

re-sponse For example, imagine a patient who is terrified

of viewing horror films and takes a job as a movie

pro-jectionist which requires him to show such a movie

Al-though terrified during the first showing, by the tenth

time he is exposed to watching the film little emotional

reactivity is left

It may at first seem that the goal of specifying the

aversive learned events in the patient’s life history

rep-resents a difficult, if not impossible, task Stampfl

noted that it is feasible for a trained clinician to locate

“key” stimuli associated with the patient’s problem

area following in-depth diagnostic clinical interviews

This information allows a trained clinician to

formu-late hypotheses as to the type of traumatic events that

may have contributed to the client’s problems Of

course, these initial hypotheses must be conceived as

only first approximations in the quest to determine

the aversive cues controlling the patient’s maladaptive

behavior As therapy progresses, it is usually possible

to obtain additional information as to the validity of

these cues and to generate new hypotheses The

elici-tation of these hypothesized cues in imagery

fre-quently results in the reactivation of the patient’s

memory regarding the initial historical events

associ-ated with development of the patient’s conflict and

fears However, it is not essential to present imagery

scenes that are completely accurate since some effects

of emotional unlearning or extinction effects will

occur through the established learning principle of

generalization of extinction Naturally, the more

accu-rate the hypothesized cues are and the more cally they are presented by the therapist, the greaterwill be the emotional arousal obtained and subse-quently the greater the emotional unlearning to thecues presented This process is continued until the pa-tient’s symptoms are reducd or eliminated

realisti-D Procedural Instructions

Following the completion of two to three interviewsessions, a treatment plan is developed Patients are pro-vided the rationale and theory behind the technique Acommonly used approach is to ask patients the follow-ing question: if they were learning to ride a horse andfell off the horse, what would the instructor have themdo? (The usual answer is to get back on the horse.) Thetherapist might then comment that failure to get back

on the horse might result in an increase in fear and sibly the generalization of that fear to events surround-ing riding horses The point is to illustrate that fears can

pos-be overcome by directly confronting them Patients aretold that the procedure being used involves an imagerytechneque and they will be asked to imagine variousscenes directed by the therapist Patients are instructed

to close their eyes and play the part of themselves Theyare asked, much as an actor or actress would be, to por-tray certain feelings and emotions that represent impor-tant parts of the process They are told that belief oracceptance, in a cognitive sense, of the themes intro-duced by the therapist is not requested, and little or noattempt is made to secure any admission from patientsthat the cues or hypotheses actually apply to them Fol-lowing the administration of neutral imagery practicesessions, the therapist is ready to start Once the implo-sive procedure is started, every effort is made to encour-age patients to “lose themselves” in the part that theyare playing and “live” or reenact the scenes with gen-uine emotion and affect Compliance with the tech-nique is readily obtained and rarely do patientsterminate therapy prematurely

Thomas Stampfl’s procedure encompasses an tional feedback approach that is self-correcting If thehypothesized cues introduced into a given scene pres-entation elicit emotional affect, support for their con-tinued use is obtained The greater the emotionalarousal elicited by these cues, the greater the supportfor their use Cues that do not elicit emotional arousalare abandoned and replaced by new hypothesized cues.This process is continued until the desired emotionalaffect is obtained and unlearned Therapy continuesuntil symptom reduction occurs Significant levels of

symptom reduction usually occur within 1 to 15 hours

of treatment

E Stimulus Cue Categories

As a guide in using the therapy, Thomas Stampfl has

outlined the use of four cue categories that can be

con-ceptualized in terms of progression along a continuum

that ranges from extremely concrete to hypothetical

These four cue categories, in order of their

presenta-tion, are as follows: (1) Symptom-contingent cues,

those cues correlated with the onset of the patient’s

symptoms; (2) reportable internally elicited cues, those

verbally reported thoughts, feelings, and physical

sen-sations elicited by presentation of the symptom

corre-lated cues; (3) unreported cues hypothesized by the

therapist to be related to the second cue category; and

(4) hypothesized dynamic cues, those fear cues

sus-pected to be associated with an unresolved conflict

sit-uation being avoided by the patient

As an illustration of the application of these cue

categories, consider the case of a woman who had to

wear a life preserver while taking a bath The

symp-tom-contingent cues would encompass the

presenta-tion in imagery of all those cues surrounding her

taking a bath without wearing a life preserver Upon

presentation of these cues, she reported the feeling

that the bathtub consisted of a “bottomless pit of

water,” the second category This in turn led to the

therapist’s hypothesis that she was afraid of drowning

(third category) Because the patient manifested

con-siderable feelings of guilt, the therapist hypothesized

that the patient’s fear of drowning related to her fear

of being punished in hell (the fourth cue category)

The systematic presentation and repetition of all these

fear cues led to the elimination of the patient’s phobic

response and to the recovery of a memory in which

she almost drowned in a bath tub when she was a

child Since repetition of the feared stimuli is

consid-ered an essential requirement in producing symptom

reduction and elimination, patients are expected to

conduct homework that involves 20 minutes daily of

repeatedly imagining the scenes assigned to them by

the therapist

II THEORETICAL BASES

Implosive theory is unique in its ability to integrate

areas of psychology, in its resolution of the neurotic

paradox, and in its ability to define complex behavior

according to basic principles of experimental chology To explain theoretically the development,maintenance, and unlearning (extinction) of psy-chopathology, Stampfl adopted and extended O HobartMowrer’s 1947 version of two-factor avoidance learn-ing Mowrer was influenced by Sigmund Freud’s con-clusion in 1936 that human symptoms reflectingpsychopathology resulted from patients’ attempts to es-cape and avoid the anxiety elicited by stimuli (“dangersignals”) associated with past exposure to traumatic ex-periences Mowrer then concluded that the develop-ment and maintenance of human and animal avoidance(symptom) behavior involved the learning of two re-sponse classes

psy-A Emotional Learning

The first response learned is how one becomes afraid

of a previously nonaversive stimulus situation To plain how fear is learned, Mowrer relied on the well-es-tablished laws of classical conditioning Fear and otheremotional conditioning result from the simple contigu-ity of pairing this nonemotional stimulation, in spaceand time, with an inherent primary (unlearned) aver-sive event resulting in the production of pain, fear, frus-tration, or severe deprivation This biologically reactive,pain-producing stimulus is referred to as the uncondi-tioned stimulus (UCS) Following sufficient repetition

ex-of the neutral stimulus with the UCS, the neutral ulus becomes capable of eliciting the emotional re-sponse with which it was paired Once the process islearned, the neutral stimulus is referred to as a condi-tioned stimulus (CS) and its elicitation of the emo-tional response (e.g., fear) as the conditioned response(CR) Stampfl believes the conditioning events of hu-mans to be multiple, involving a complex set of stimulicomprising both external and internal CS patterns.Such conditioning events are believed to be encoded inlong-term memory and capable of being reactivated at alater point in time

stim-B Avoidance (Symptom) Learning

Mowrer viewed the resulting conditioned emotionalresponse as a secondary or learned source of drive, pos-sessing motivational or energizing properties, as well asreinforcing properties These motivational properties ofthe conditioned emotional response set the stage for thelearning of the second class of responses, referred to asavoidance or escape behavior Avoidance or symptom

behavior is believed to be governed by the established

laws of instrumental learning Avoidance behavior is

learned because the response results in the termination

or reduction of the emotional state elicited by the CS It

is this reduction in aversiveness that serves as the

rein-forcing mechanism for the learning of the avoidance

behavior

C Emotional-Avoidance Unlearning

Finally, Mowrer’s two-factor theory argues that

both emotional responding and subsequent

avoid-ance behavior can be readily unlearned via the

well-established principle of Pavlovian extinction This

principle states that the repeated presentation of the

classically conditioned CS will weaken and cease to

elicit emotional responding via the principle of

non-reinforced CS exposure The extinction of the CS

re-sults in the extinction of its drive properties Without

any motivating state to elicit and reinforce the

avoid-ance behavior, it also will undergo an extinction effect

This is the therapeutic premise on which implosive

therapy is based

D The Neurotic Paradox and

Symptom Maintenance

Implosive theory has been instrumental in resolving

Freud’s expressed concern and puzzlement as to why

patient’s symptomatology may persist over the course

of a lifetime Mowrer labeled this concern the “neurotic

paradox.” In Mowrer’s words it is a question as to why

neurotic behavior is at one and the same time

self-de-feating and self-perpetuating In other words, why does

the neurotic’s neurosis persist to the point of seriously

incapacitating the individual when the behavior has

long outlived any real justification?

To resolve theoretically the issue of sustained

symp-tom maintenance, Thomas Stampfl developed his serial

CS hypothesis He observed that, although some

clini-cal symptoms do appear to last for lengthy periods, the

CSs initially eliciting the symptom frequently undergo

a change over time, with the cues originally triggering

the symptom failing to serve as an eliciting stimulus to

repeated CS exposure However, as they weaken, these

cues are replaced from memory by a new set of

previ-ously unexposed fear cues that upon exposure

recondi-tion secondarily the first set of cues When the new set

of released cues also undergo an extinction effect from

nonreinforced CS exposure, the stage is set for yet

an-other set of new cues to be released This process

con-tinues until all the encoded fear complex of cues dergo an extinction effect In other words, implosivetheory maintains that there is a network of cues repre-senting past conditioning events involving pain whichare stored in memory and which, upon reactivation, arecapable of motivating a symptom over time ThomasStampfl believes these conditioned cues are stored inmemory in a serial arrangement along a dimension ofstimulus intensity, with the more aversive cues beingleast accessible to memory reactivation Repeatedsymptom execution prevents further CS exposure tothese cues and to the elicitation of those cues stored inmemory As a result, the anxiety and fear level attached

un-to these unexposed CSs are conserved or maintaineduntil they are exposed by being released from memory.The presence of these unexposed cues stored in mem-ory, along with the intense emotional reactions condi-tioned to them, can be observed by preventingsymptom occurrence

III EMPIRICAL STUDIES

Over the last 50 years, O Hobart Mowrer’s two-factoravoidance theory and related fear theories have gener-ated an abundance of experimental support at both thehuman and animal level of analysis It still remains thedominant avoidance theory within the field Stampfl’sextension of the theory to the area of psychopathologyhas also received strong empirical support at thehuman, animal, and clinical levels of analysis This in-cludes his serial CS hypothesis and his extension of theconservation of anxiety hypothesis to explain symptommaintenance and the neurotic paradox Stampfl’s tech-

niques of in vivo and imagery implosive therapy and

re-lated CS-exposure techniques of treatment have beenexperimentally supported by a host of controlled clini-cal outcome studies, including studies involving thetreatment of phobias, anxiety reactions, obsessive com-pulsive behavior, trauma victims, depression, and psy-chotic behavior The procedure has also been shown to

be nonharmful Today, CS exposure techniques of ment are regularly recommended as the treatment ofchoice for a number of clinical nosologies

treat-IV SUMMARY

Implosive (flooding therapy) therapy is a cognitivebehavioral treatment approach to psychopathology Itwas first developed by Thomas G Stampfl and extended

to encompass the treatment of a wide variety of clinical

nosologies Treatment effects are regularly reported to

occur within 1 to 15 treatment sessions The technique

involves the use of an in vivo or imagery presentation

procedure designed to extinguish, via repetition, those

aversive conditioned cues responsible for eliciting and

maintaining symptom execution The therapist’s task is

to help the patient confront these cues directly within

and outside the therapist’s office The underlying

theo-retical framework behind this technique is based on

two-factor avoidance theory which Stampfl has

ex-tended to account for symptom maintenance and

symp-tom extinction Both the theory and treatment

technique has been supported by considerable

experi-mental research over the last 40 years at the human,

pa-tient, and animal level of analysis

See Also the Following Articles

Avoidance Training ■ Classical Conditioning ■ Coverant

Control ■ Emotive Imagery ■ Exposure in Vivo Therapy

Further Reading

Boudewyns, P A., & Shipley, R H Flooding and implosive

therapy: Direct therapeutic exposure in clinical practice New

York: Plenum Press.

Levis, D J (1985) Implosive theory: A comprehensive

extension of conditioning theory of fear/anxiety to

psy-chopathology In S Reiss, & R R Bootzin (Eds.),

Theoret-ical issues in behavior therapy (pp 49–82) New York:

sociates.

Levis, D J (1995) Decoding traumatic memory: implosive theory of psychopathology In W O Donohue, & L Krasner,

(Eds.), Theories of behavior therapy (pp 173–207)

Ameri-can Psychological Press, Washington, DC.

Levis, D J., & Boyd, T L (1985) The CS exposure approach

of implosive therapy: In R Turner, & S L M Ascher

(Eds.), Evaluation of behavior therapy outcome (pp 59–94).

New York: Springer.

Levis, D J., & Brewer, K E (2000) The neurotic paradox In

R R Mowrer, & C B Klein (Eds.), Handbook of porary learning theories (pp 561–597) Hillsdale, NJ: Erl-

ccontem-baum Associates.

Stampfl, T G (1970) Implosive therapy: An emphasis on

covert stimulation In D J Levis (Ed.), Learning proaches to therapeutic behavior change (pp 182–204).

ap-Chicago: Aldine.

Stampfl, T G (1991) Analysis of aversive events in human psychopathology, fear and avoidance In M R Denny

(Ed.), Fear, avoidance and phobias: A fundamental analysis

(pp 363–393) Hillsdale, NJ: Erlbaum Associates Stampfl, T G., & Levis, D J (1973) Implosive therapy In

R M Jurjevich (Ed.), The international handbook of direct psychotherapy Vol 1: Twenty-eight american originals (pp.

83–105) Coral Gables, FL: University of Miami Press.

I Development of Individual Psychotherapy

II Theoretical Models of Individual Psychotherapy

III The Effects of Individual Psychotherapy

IV Summary

Further Reading

GLOSSARY

behavior therapy A theory of psychotherapy in which

prob-lems are assumed to have been learned because the

conse-quences of problematic behavior and feelings are rewarding.

These treatments attempt to directly alter behavior and

feel-ings by changing the pattern of consequences The

develop-ment of these models of treatdevelop-ment is most closely associated

with Joseph Wolpe and B Fred Skinner.

cognitive therapy/cognitive-behavior therapy Models of

psy-chotherapy that attribute problematic feelings and

behav-iors to one’s inappropriate or dysfunctional ways of

thinking The most recognized of these approaches was

de-veloped by Aaron T Beck.

effectiveness studies Research designs that employ

represen-tative clinical populations of patients, as well as samples of

therapists and psychotherapy This type of research

typi-cally sacrifices some degree of experimental control for

procedures that are closer approximations of actual clinical

settings, procedures, and populations.

efficacy studies Research designs that employ randomized

as-signment, closely controlled and monitored treatments,

and carefully selected and homogeneous samples of

pa-tients This type of research typically sacrifices some

de-gree of generalizability for experimental control.

experiential therapy Approaches to psychotherapy that

em-phasize the positive role of feelings and current ence These approaches assume that efforts to stifle or avoid certain feeling states are at the basis of most human problems They emphasize the role of the present, of feel- ing recognition, and of the innate human drive to grow (self-actualization) as processes that produce beneficial change.

experi-exposure therapy Approaches to treatment that emphasize

the importance of systematic exposure to situations and objects that evoke avoidance This is a form of behavior therapy but has been incorporated into many models and approaches to cognitive and cognitive-behavior therapy as well.

integrative/eclectic psychotherapy Methods of intervention

that draw from multiple theories These approaches phasize that the effectiveness of the procedure rather than its theoretical framework should be the guide to its appli- cation These approaches range from those that blend dif- ferent theoretical constructs to those that develop a case mix of specific techniques Newer models are based on the development of cross-cutting principles of change rather than amalgamations of either specific techniques or gen- eral theories.

em-psychoanalysis The method of uncovering unconscious

im-pulses and wishes that was developed by Sigmund Freud.

psychodynamic therapy: Approaches to psychotherapy that

generally assume that behavior is caused by inner conflict and by disturbed psychic processes These models of indi- vidual psychotherapy are generally short-term or less in- tensive variations of psychoanalytic therapies Some of these variations include those built on object relations the- ory, ego psychology, and self-psychology.

Individual Psychotherapy

Larry E Beutler and T Mark Harwood

University of California, Santa Barbara

7

Encyclopedia of Psychotherapy

Individual psychotherapy is the most typical form

of psychotherapeutic treatment It consists of one

pa-tient and one therapist The psychotherapist,

assum-ing the role of healer, authority, facilitator, or guide,

employs a variety of theories and procedures to assist

the patient or client to modify behaviors and feelings,

gain understanding of self and others, change

percep-tions and beliefs, and reduce fears and anxieties This

entry will describe some of the more dominant

meth-ods of psychotherapy and the current status of

re-search on its effects

I DEVELOPMENT OF

INDIVIDUAL PSYCHOTHERAPY

The field of modern psychotherapy is over 100 years

old Freud is typically credited as the individual most

responsible for introducing contemporary

psychother-apy, in the form of psychoanalysis, to the Western world

at the end of the nineteenth century Almost from its

in-ception, the developmental history of modern

psy-chotherapy has been one of conflict, controversy, and

change Freud’s early views were under attack nearly

from the beginning, both from his students and from

the established medical system Conflict continues with

the trend of growth and the emergent influence of

vari-ous groups who present views that contrast with

estab-lished schools of thought In this environment, we have

seen the emergence of literally hundreds of different

theories and approaches to psychotherapy Presently,

psychotherapies differ in their theoretical constructs,

their mode of delivery, their techniques, and the

processes to which they attribute the patient’s problems

Those who are endowed by society with conducting

and overseeing the field are also diverse, ranging from

those with medical and psychological degrees to those

with degrees in sociology, human development, social

work, anthropology, group process, biology, and the

like Opinions about the nature of desirable credentials,

advantageous types of experience and training, and the

nature of psychotherapy itself are far from uniform Yet,

the prototype of “Individual Psychotherapy,” a process

that occurs between an individual person who has a

problem and an individual practitioner who offers

as-sistance, as originally set by Freud, continues to be the

dominant model Although there has been a good deal

of research and writing on group therapy and to a lesser

extent on marital and couples therapy, it is individual

psychotherapy that has stimulated the most research

and to which most conclusions are addressed

Psychotherapy has increasingly come to be defined

as a health-related activity and has thereby come underthe purview of third-party payers and political bodies.Cost containment concerns have placed increasingpressures on practitioners to justify their proceduresand to demonstrate that they are effective This, inturn, has led to increasing emphasis being placed onthose who conduct psychotherapy research to demon-strate the value of these procedures in ways that havescientific credibility

II Theoretical Models of Individual Psychotherapy

It has been estimated that there are over 400 ent theories of individual psychotherapy However,most of these fall within five general classes

differ-Cognitive psychotherapy models of interventionfocus on identifying specific problems and changingthe processes and mechanisms by which patients evalu-ate themselves, others, and their environments A cen-tral assumption of this model is that beliefs rather thanfacts determine how one will evaluate one’s own behav-ior, remember the past, and anticipate the future Ifone’s beliefs are distorted and inaccurate, then one’sevaluations and memories will be distorted as well.Moreover, one may develop behavioral or emotionaldisturbances in which the behavior and feelings, too,are inappropriate to one’s present situations Distor-tions and misperceptions of events are assumed to be atthe root of or associated with many problems that im-pair daily functioning Cognitive psychotherapy ap-plies methods that encourage re-inspection of theseassumptions and the application of rational analysis tocorrect distortions and cognitive errors This type oftreatment focuses on directly altering one’s symptomsthrough a process that involves the rational and realis-tic appraisal of situations and the application ofthoughtful and systematic problem solving strategies.Behavior therapy models of individual treatmentfocus on immediate events and consequences Symp-toms are thought simply to reflect patterns of learningthat are cued by the presence of evoking environmentalstimuli That is, behavioral models eschew the use ofmental or biological events as explanations for behavior.They look for both causes and consequences within theperson’s immediate environment or in the concomitantoccurrences of sequential cues that progress to more re-mote consequences The focus of such treatments is onthe development of new skills and on repeated exposure

to aversive stimuli leading to extinction of behaviors