Lately, I've been doing a series of essays on psychotherapy technique. The idea is that I will survey a few of the more important technical contributions that each of four different psychotherapy schools-of-thought have contributed to the development of modern psychotherapy. In previous essays we covered the oldest school, psychodynamic psychotherapy. The most important technical contributions made by the psychodynamic school to the development of psychotherapy are, in my mind, the ideas of Repression and Transference. I'd love to talk about these topics some more, but in the interests of conserving space, I'll refer readers and listeners who aren't up on these very interesting topics to my earlier essays covering them.
Psychodynamic psychotherapists have always taken a rather philosophical approach to therapy, meaning that their methods are historically more akin to literature than to science. Psychodynamic psychotherapists are deeply concerned with life as it is experienced from the first-person interior, subjective perspective. They seek to have their patients tell stories about their interior experiences, to chart out interior landscapes, and to help people to become more aware of the real geography of their minds so as to better help them become master of all they survey. Psychodynamic psychotherapy is a compelling process for those who participate in it, I think ,most primarily because it offers patients the opportunity to understand themselves and their lives as though they were characters within a fascinating and important story; in the process becoming self-aware characters within the book of their own lives who learn to take their own reigns in hand and live life more intentionally and proactively rather than reactively. For sure there is grandeur in this process, and more than a little meaning, but until recently, very little science.
Psychodynamic culture, originally a European phenomenon, was transplanted to America during the teens and 20s a century ago. While it quickly attracted a native following who took it on its own terms, it also angered a number of academically based psychologists who were working as hard as they could to differentiate psychology from philosophy so as to make it into a real science that biologists, chemists and most importantly physicists wouldn't laugh at. At the time the field of psychology was only about 30 years old, and it was still quite unsure of its identity within the family of sciences.
These early psychologists who birthed the behavioral school of psychotherapy, hated the literature-esque aspects of psychodynamic psychotherapy. To understand why this occurred, you have to understand the tremendous envy that the then very new science of psychology had towards its older brothers physics and chemistry. Sciences like physics and chemistry were then centuries old and established, and also making rapid progress by using experimentation to create mathematically informed models of the world that actually predicted with great precision the outcomes of future experiments. The precision models of these older sciences were being used to build revolutionary technologies that were changing the world. New kinds of bridges and skyscrapers were being built for the first time, and electricity and telephones and antibiotics were coming on the scene as a result of the application of these sciences. They were effective and self-consistent and powerful and it is not hyperbole to say that psychologists of that time essentially developed a bad case of science envy and wanted more than anything to create a science of psychology that could similarly be effective, self-consistent and powerful. In this context, it is easy to see why fuzzy psychodynamic constructs like the ego and the id drove American psychologists absolutely crazy. Ego and Id could not be measured with any precision. They could not be assembled into a model that could yield mathematically accurate predictions about what a given individual person might do. The American psychologists basically decided that the psychodynamic project was fatally flawed and that they would create their own version of psychotherapy based on a more solid, more scientific, more measurable foundation.
The foundation that these early psychologists chose to build upon was that of learning theory, which is the topic of today's essay. As it's name suggests, learning theory is a theory of how people and animals learn. People have probably understood the basic underpinnings of learning theory ever since the since the first wolf-dog was domesticated thousands of years ago. Even so, whatever knowledge concerning how animals learn was available remained locked up in people's heads unsystematized. It wasn't until the late 1800s that scientists began to be interested in formally understanding how learning works. This interest in learning is owed in large part to the work of Dr. Ivan Pavlov, a Russian, and his famous drooling dogs experiments.
You have almost certainly heard of Dr. Pavlov. His name is one of those famous cultural-icon names that people have heard of but maybe don't know why whatever that person did was important. In a nutshell, here is what Pavlov did and why it was important. Pavlov was a physiologist, a sort of scientist who studied the body. He was studying the digestive systems of dogs when he made a fortuitous discovery, namely that his dog subjects were spontaneously learning to drool in anticipation of being fed when no actual food was present. Apparently, he figured out that the dogs were recognizing a subtle signal in their environment; that the person who fed them always wore a lab coat. The presence of this unintentional signal (e.g., the lab coat), which normally would not have caused dogs to think of food, was suddenly sufficient to get the dogs thinking of food. Recognizing the importance of this finding, Pavlov shifted his studies to focus on the means by which dogs could learn to predict food. He was later able to show that a variety of random signals (including the famous bell for which he is famous for ringing) could, through repetitive pairing with food, come over time to suggest to the dogs that food would shortly be on its way.
Pavlov was smart enough to see that there was a precise, regular and repeatable law of behavior underlying the dogs responses which appeared to govern how they learned. Food already had a well established meaning for the dogs, while bells and lab coats did not. By pairing the coat or bell with the food, the dogs were able to learn something entirely novel: that the presence of a coat or a bell tone means the same thing as food. The learning process through which the dogs made sense of their world could now be understood in terms of simple associations between things. Today, this sort of simple associational learning is called "Classical Conditioning", and it is one of the cornerstones of learning theory. Pavlov's simple insight into the significance of this finding earned him a Nobel prize.
By the time Pavlov's discoveries became known in the west it was already the 1920s and psychodyanmic forms of psychotherapy were well on their way towards becoming the dominant mode of therapy and popular psychological talk. Upset American psychologists were correspondingly receptive to Pavlov's work because he delivered to them a means and method for studying the learning process which was, well, scientific.
Psychologists ran with Pavlov's methods and began to experiment in earnest, rapidly expanding what was known about animal and human learning. For example, they varied the amount of time between the presentation of the bell (what is now called the conditioned stimulus or CS) and the food (what is now called the unconditioned stimulus or UCS) to see whether making the interval longer or shorter affected learning (it does – shorter parings create stronger associations between CS and UCS). Similarly, they varied whether the CS or UCS came first, how strong/loud/perceivable the CS and UCS were, and of course the number of times the CS and UCS were paired. These were only the first things they did. I could go on but the research rapidly got so sophisticated and specialized that I'd have to pull out and review about a dozen books before I could summarize even a quarter of it for you.
By doing all of these sorts of experimental manipulations many times over the new behavioral scientists were able to create a learning theory that allowed them to make precise predictions concerning how long it ought to take a given person to learn something new under a given set of circumstances, how strong the resulting learning ought to be, and even how long it ought to take for the learning to fade away. This sort of precise knowledge about learning made the scientists happy, while also establishing a firm foundation for an objective form of "behavioral psychotherapy" which appeared very shortly thereafter.
In 1920 or so, Dr. John Watson and Rosalie Rayner (originally his graduate student, later his wife) published their famous "Little Albert" study in which they suggested a purely behavioral explanation (based on principles of learning theory) of how phobias could be created, and presumably remediated as well. Essentially, they had taken a one-year old baby named Albert and gave him a furry white rat to play with. After establishing that Albert showed no default fear of the rat (and in fact played with it instead), the experimenters frightened him by making loud noises behind him while he played with the rat. After a short while of this pairing of the natural CS (the naturally startling loud noise) with the UCS ( the naturally benign rat), Albert apparently began to show signs of fear when the rat was around even when the noise was no longer present. He did not show the fear in the absence of the rat and the sound. What is more, Albert's fear response to the rat was shown to have generalized to more than just the rat. Many different furry things became frightening to the child. This rather cruel study would not have been permissible to perform today, but the point it makes is/was solid: learning theory alone could account for the development of a specific fear. The corollary to this assertion, that the psychodynamic model was now potentially unnecessary, was equally clear. Over the next decades, behavioral forms of psychotherapy exploded in popularity, at first merely challenging the dominant psychodyanmic approach, and ultimately (in the form of cognitive behavioral psychotherapy) replacing it as the most popular mainstream therapy approach.
This is an essay about psychotherapy technique so let me be clear. Learning theory is a sort of meta-psychotherapy technique. If you understand learning theory, you understand a map of how people get themselves into bad places behaviorally, and how you might help them to get out of those places. Learning theory is not an actual technique itself. Rather, it is the well from which a thousand behavioral psychotherapy techniques have been drawn.
A good example of the learning theory based behavioral psychotherapeutic approach is something called Systematic Desensitization, a technique that I believe dates back to the 1930s. Systematic Desensitization is a therapy protocol or set of coordinated exercises that are designed to help people with phobias get over their fears. A phobia is a specific fear of a particular situation or thing. Common phobias develop around blood, dogs, insects, heights, enclosed spaces, and public speaking. Phobic patients get panicked when they contemplate their feared event or thing, get all disorganized, and typically end up avoiding the event or thing. This avoidance can sometimes lead to a severe restriction of their lives and routines to the point where they become psychologically crippled.
In setting up sessions for Systematic Desensitization, a therapist meets with a phobic patient (say, someone who is afraid of dogs), and together they create a ranked list of things that make the patient feel afraid. When finished, this completed "fear hierarchy" contains maybe 10 items having to do with the phobia, ranked from least to most threatening. The therapist then teaches the patient a set of techniques for achieving drug-free muscular relaxation. While most any relaxation technique could work theoretically, the one commonly taught is known as Progressive Muscle Relaxation or PMR. PRM consists of teaching patients to first tighten and then release various muscle groups in their bodies, leaving each group relaxed once it has been let go of. When the fear hierarchy is completed and the patient has mastered the relaxation technique, the actual Systematic Desensitization can begin. Systematic Desensitization unfolds by having the phobic patient spend some time imagining the least threating item on the fear hierarchy list, and then having the patient practice the relaxation technique while continuing to imagine the fearful event. The patient is "done" with each event/level of his or her fear hierarchy when he or she is able to remain fully relaxed while contemplating that event. When a level is completed, the patient moves up a rung on the hierarchy and repeats the process of pairing the relaxation technique with the next feared event. The technique is completed when even the most feared event on the hierarchy no longer create the fear response.
The Systematic Desensitization technique sits atop some basic assumptions about the nature of anxieties and phobias that come directly from learning theory. A basic assumption that is made is that phobic responses start when people experience anxious physical arousal in a situation and then begin avoiding that situation so as to avoid feeling those feelings again. The avoided situation, originally a neutral stimulus, becomes paired with an unconditioned stimulus (a set of anxious feelings that feel horrible), and thereafter, any thought of the situation brings up an echo of those anxious feelings. The therapy, based squarely on learning theory, suggests that a new unconditioned stimulus (relaxation) which is soothing rather than frightening can be paired with the conditioned stimulus (the now feared phobic event or situation) so as to undo or overlay the original fear-learning with relaxation-learning. This stuff doesn't just make theoretical sense. It actually works.
There are a few other things to note about systematic desensitization. First of all, it occurs progressively, rather than all at once. This is because learning research has shown that an all-at-once approach is likely to result in overwhelm, which can reinforce phobic avoidance rather than break it down. Another thing to note is that it occurs in vitro (a fancy science term in this case referring to an experiment done in the imagination rather than one which is actually acted out). Systematic desensitization frequently uses imagined instances of feared situations rather than actual ones because while either can work, it is far more convenient to imagine things than to actually go out and experience them. These days a therapist might also use a video game environment or virtual reality to simulate actual experience, but the net effect is the same.
In instances where in vitro exposure is not sufficient to elicit the fear response necessary for Systematic Desensitization to work, therapists might choose an alternative behavioral technique called Exposure Therapy, which would essentially be the same thing as Systematic Desensitization, but where the feared events and situations are actually experienced (e.g., in vivo) rather than just being thought about. It is difficult to do a relaxation routine when you are afraid, so when Exposure Therapy is used, therapists will frequently pair a different sort of learning with the feared situation, namely Response Prevention. The phobic patient's first response to their fears is typically to want to get the hell away from those fears; to escape. In Exposure Therapy, the patient and therapist make a deal beforehand that the therapist will help the patient stay in and endure the feared situation for a long while and not escape, so that something called Habituation can occur. Years of learning research have established that fear and anxiety responses do not go on forever (as phobic patients fear is the case) but rather instead come on strong and then lose steam and power to influence after a little while. In essence, if you can face and endure your fears for a few minutes rather than running at the first sign of them, you will learn that the fear feelings tend to go away. This makes them less fear-provoking. Essentially, you get used to being afraid and its not so bad anymore. The process of habituation naturally breaks down and lessens the power of the phobia over the patient, often to the point where the phobic situation can be endured with reasonable comfort by the end of the treatment. At a certain end point of either systematic desensitization or exposure therapy, enough new learning has occurred that the phobia essentially dissolves and the patient is free of it.
First-generation anxiety therapies like systematic desensitization and exposure therapy with response prevention are only the beginning of behaviorally based psychotherapy. A vast array of more or less pure learning-theory based techniques have been developed and are currently in widespread use in helping to treat various conditions including mental retardation and autism, Alzheimer's, oppositional defiant disorder, conduct disorder, and other attachment disorders of childhood. They are widely used to teach parents how to discipline their children effectively. Of course, they are also widely used to teach dogs how to be obedient and to do tricks too). Second generation behavioral techniques (e.g., cognitive-behavioral techniques of which I will speak more of next time) are in very widespread use for the primary treatment of anxiety, panic and depression, and are very useful adjunctive therapies for more biologically driven illnesses such as bipolar disorder and schizophrenia. In fact, it is quite reasonable to say that the family of behaviorally based psychotherapies are the dominant form of therapy available today.
There is a reason for the current dominance of the behavioral school, and that is that the value system that gave rise to behaviorism is currently synchronized with the value system that has come to drive the western world. In this value system objective events are more important than subject ones, things can't really be said to exist until they are reliably measurable, and measurable results matter. Traditional psychodyanmic approaches were not historically evidence-based, being instead based on the aesthetic beauty and felt "rightness" of intellectual frameworks and theories created by bright theorists. While they undoubtedly helped people to have more insight into their problems and to grow as people, the insight that psychodynamically oriented therapies help to create does not necessarily translate into patients having fewer behavioral problems as a result. As far as I can tell, money for delivering therapy got tighter and tighter (starting in the 1980s), payers demanded more targeted and accountable forms of therapy as a result, and behavioral approaches were simply the more efficient accountable way to go and thus tended to be chosen over less accountable therapy forms. This is both a good situation and a bad one at the same time for while it is undoubtedly a good thing that phobic patients become free from anxiety rather than just understand why they are anxious, I think there is a real value to be had in understanding why you are anxious. I think it is a bad thing that the insights of talented psychodynamic therapists are less available today then they used to be.
Anyway, schools of therapy adapt to to the changing times. Today there are psychodyanmically informed therapies that are stripped down and made measurable and empirical. One of them in particular, "Interpersonal Psychotherapy" has been scientifically shown to be an effective treatment for depression, and I'm confident that there are more examples of this sort of thing out there that I haven't encountered yet. The empiricalization ("science-ification") of psychodyanmic psychotherapy has begun. On the other side of the equation, the behavioral school, which for years refused to entertain the utility of ideas like "mind" "thoughts" and "feelings", treating the entire mind as a sort of unimportant thing which could be discarded without affecting therapy efficacy, has now thoroughly embraced mentalism and the importance of subjective behaviors such as thinking and feeling; behaviors that psychodynamic therapies were calling attention to all the while. It took the behaviorists about 60 years to get it that subjective mental events were important, but they have gotten it now. I'll tell more about that story next month. Until then, thanks for reading.