The Context of Therapy
In attempting to discuss some basic issues of counseling, I shall limit myself to five or six central issues. The theoretical approach will be holistic and will follow generally that elaborated by Dr. Andreus Angyal in his book, Neurosis and Treatment published by John Wiley and Son.
Basically, the holistic approach assumes that personality is an organized whole and not an aggregate of discreet parts. Its functioning does not derive from the functioning of its parts; rather the parts must be viewed in the light of the organizational principles born in the whole. We will attempt to look at neurosis in this context after introducing two basic human trends that are often blocked in their development. The first is a trend toward autonomy. Basically, this is a trend to be spontaneous and self-governing. Many factors press on a person in his development to allow his life to be determined by outside expectations rather than by inner conviction. Probably, the simplest form of this trend is to act for the sheer fun of action and to get a kick out of making something happen. Curiosity and the push to know about the world and how things work is another manifestation. When the push for expansion and mastery is toward another person, we may see a tendency to compete with or gain superiority over another. A little child soon reaches the point where he wants to Ado it for himself.” The permitting of freedom to experiment helps in the trip from total dependency to independence and self-government.
Disturbances in the autonomous trend tend to show up with the lack of excess of autonomous strivings. These are really different faces of the same thing. Freedom or the absence of expectations - allows the development of autonomy and, along with that, responsibility. The person who has been subjected to excessive demands and expectations does not become self-governing and can only react to what’s expected. So he can either conform or rebel. Both of these choices, however, hinged on external expectations, are reactive to the external rather than responsive to the internal. The implication for counseling with growth as a goal are clear. If you are going to help a person become free and responsible, the setting in which it will occur must be free of expectations. This is so simple and so basic that we can easily forget that without it we will not get growth. (Tillich struggles with this in The Courage to Be as does Fromm in Escape From Freedom. I also find much interesting implication in Paul's letter to the Galations.)
The other major human trend we will look at is the trend towards homonymy. This applies to the striving to give oneself harmoniously to something that extends beyond one’s individual self. What we call "love” certainly is a manifestation of this trend. At one level being is meaning something to someone else. This is something we cannot provide. It can only be given to us. The need is a need of everyone, regardless of who he is and regardless of his level of maturity. So the possibilities of neurotic dependent distortion are there. You see the importance of a good balance of autonomy to prevent the establishment of sick relationships.
Besides having needs, people want to be needed. This is not usually there in pure form, but it is there. Self-respect is heightened by a feeling of value to another. The chief danger in this situation is that, out of the fear of rejection, a person takes on more responsibility than he wants or can handle and winds up resenting the whole situation. The dread of isolation asserts that for man, individual survival is meaningless as such. The human life is lived, not in oneself alone, but also in others. There is also an aspect termed "possession.” When we say, "It is mine”, we can mean a number of different things. All the way from “I can do with it what I will because it’s min” to AI will give you this, but I shall take from you that.” These are the possessives that are basically selfish and impersonal. On the other hand, if you can give yourself to an activity, person or goal, it is yours not through anybody being deprived of it. You possess it by giving yourself to it, not be taking from it, and in giving yourself to it, you can still remain whole. Nothing of you gets lost.
We do not exist on the specifically human level unless we are noticed, loved, and loved right by someone. Angyal sees the loving relationships as having three main characteristics: (1) The experience of a certain fundamental belongingness, (2) immunity between lover and loved (the recognition and acceptance of the difference of the otherness of the loved person), and (3) the understanding of the other and understanding of a special kind. The special kind being, I think, a seeing past the surface to the inner being. The therapist in someway must provide a relationship with many of these qualities if growth is to occur. These then are the two strivings that we were to consider: Autonomy - towards mastery and self-government; homonymy - towards love.
Now, staying with Angyal, what is a neurosis? It is such an encompassing thing that it is a way of life. It involves the entirety of a person’s capacities caught up in the service of a myth. This begins as the child begins to separate self and other. If this proceeds normally, and enough freedom is allowed for autonomy to develop, a sense of self develops separating self from other so that first the possibility of a love relationship with other exists. If freedom and love are lacking, then the child experiences a sense of isolation, which, if it persists, is the basic for neurosis. In other words, it is a world that can neither be mastered nor communicated with. This, in time, leads the child to cease his efforts in the natural direction and place his efforts in developing ways to defend himself from the world. This then leads to his becoming the source of maintaining and increasing his isolation. He begins to see himself as small and inadequate, and the world as large, powerful and threatening. In attempting to keep the world less threatening, he begins to look at the world as not unloving, but himself as unlovable. This then is the mythology of neurosis. It is interesting that, in spite of the horrible world-view stated above, there is also a trace of doubt. Some kind of hope that, in spite of the bleak outlook, there is an outside chance of something better even if it’s achieved by indirect means.
We are now left with some of the general considerations of a neurosis:
1. There is an overemphasis on security, a tendency to really play it safe. Don’t’ take a chance.
2. Compulsivity - the individual doesn't want to do something, he has to do it.
3. An absence of real fulfillment. There is no ability to really enjoy his successes.
4. Life is not lived in the present, but the preoccupation is with the past and future.
5. The mythology of the neurosis: an irrational attitude about people and the world.
6. Responses to situations are inadequate.
7. Repetitiveness of certain interpretations or responses not called for by the varying circumstances. There is a tendency for the interpretations or responses to remain consistent even when the people involved are different.
8. Alienation from the self. Develops a false image, loses track of what he really thinks, feels and wants.
9. A limitation of performance due to hesitancy.
This concludes the general consideration of neurosis. We will go on to consider two specific types of neurotic personality.
Angyal identifies two basic neurotic systems: (1) Hysteria - the pattern of vicarious living, and (2) compulsivity - the pattern of noncommitment. The usual client is seen as some kind of a mixture of the elements of both patterns. Probably these are better seen as two types of neurotic character structure rather than as neuroses. Basically, the pattern of vicarious living is repression of the real self and the taking of a substitute, false self. This can arise in childhood from any set of circumstances in which the natural thought, feelings, and actions are not acceptable to the environment. The repression which contribute to this include being disregarded, belittled, ridiculed, threatened with abandonment, imposed expectations that ignore the child's needs, adult responsibility imposed prematurely, parental oversolicitude, and so forth. These all carry the message, "what you are is not acceptable.” This creates a situation in which the child must create a false personality to survive. But being false, this is not a solid construct and must constantly be validated from outside. Ironically, this system makes it impossible for them to feel loved because at some level they sense that what is being loved is not real. The main, way, therefore, to be validated, is to be noticed. One way of being noticed is to be dependent or sick so that the other party is locked in to a caretaking role. Another way is to seduce another person into feeling important by being childishly compliant. Other seductions include obligation through gifts and guilt by acting abused. But always there is the fear that the surface personality will be exposed as a fraud and the inner "nothingness” seen. One other common manifestation of this condition is the tendency to overdramatize. This seems to be fed by the fact that so little is real in their emotional life that the pattern of noncommitment shows itself in the constant struggle and confusion as to whether the world is friendly or hostile. The origin seems to be in inconsistent parental behavior which makes it impossible for the child to find acceptance.
The hysteric is able to gain acceptance by self-obliteration, but the compulsive finds no way. The paradox is that he learns to react to the same people with both hostility and love and, at times, with both at the same time. The confusion is enormous. Most cases have had periodic drastic treatment at the hands of an adult who is also a source of affection. Radical or frequent changes of mind about how to treat the child, periodic sadistic punishment, keeping a child in doubt about hopes or plans until the very last minute are a few examples of the things that finally drive him to believe that the parent is against him, not against specific behavior. The basic issue of noncommitment is the confusion arising from a traumatic situation of inconsistency. Characteristically, the loving feels get buried deeper than the hostile feelings because it is safer to be hostile. To reveal the loving side is to risk being hurt. Since both feelings can be aimed at the same person, sharply conflicting attitudes can exist at the same time. This is called ambivalence and is characteristic of this condition. This then gives rise to doubt and indecision. An example of this would be a person who turns off the gas, leaves the house, then is tormented with whether or not he turned it off. He returns, checks it, leaves again, and again the doubt appears. Another factor is that at times small tasks loom large. Sorting them out represents conformity. Another part resents conforming, so the battle between being good or bad makes it almost impossible to do anything. The chronic ambivalence keeps the person in a state of tension so that even sleep is difficult. In time, the opposing feelings and their inhibitions lead to a highly restricted emotional range and they often appear to be highly rational people who frown on feeling.
Hostility is manifested in many ways: Looking into peoples’ eyes is often difficult, destructive criticism, spiteful disobedience, thinking forbidden thoughts, and so forth.
The person alternates between feeling himself to be worthless or valuable, a polarity which is usually equated in his mind with being weak or being strong. The situation is made worse by frequent experiences of inhibition or impotence. They also tend to be highly self-derogatory. Loving and wanting to be loved are considered weaknesses. Sometimes it comes out in abstract idealism or an image or a worthwhile world, but very seldom does it come out directly.
Methods by which the noncommittal person deals with confused images of the good/bad world are as follows: (1) you can divide it sharply in two making one part good and one part bad. There is black and white with on gray, (2) Reconciling the opposites. This is the search for love and regularities for explanations of what seem to be chance for what is to reconcile what seems to be mutually exclusive. Some of these individuals make excellent scientists. (3) Rules to live by. Always do this and never do that. This suppresses spontaneity and causes ability to shrink. Dogmatism helps to escape confusion while it works. It may help to get a better level of practical adjustment.
In the holistic theory I think it becomes rather obvious that there is less preoccupation with the surface manifestations. The real importance is on, in some way, being able to get a hold of and change the central world-view. In the hysteric, that world-view centers on the idea that they are unacceptable, and therefore, have to take on a false personality. However, in the therapeutic process the thing that must be gotten a hold of and recaptured is the real self. In the compulsive, on the other hand, the confused world-view centers on the notion that it’s either a good world or a bad world, but the bad world is more acceptable because the hostility does not place the person in jeopardy. Therefore, in some manner the central issue would seem to center on the idea of trust. In some fashion, the therapist must come to be a person that can be trusted.
These are basically the two things that go into a mixture that we call "the client” that comes to seek counseling. I would like to make it clear that the whole theoretical construct I have used up to this point is entirely Angyal’s. I think for anybody who wishes to get more seriously involved in the study of counseling that buying his book, Neurosis and Treatment, is a worthwhile investment. I like his system because it gets away from much of the traditional language of psychiatry and psychology, and I think actually it could be quite a useful construct for those with a theological background.
Before we go further into the context in which therapy occurs, I would like to mention that therapy does occur in the presence of another human being. Therefore, we would have to assume that the presence and the makeup of that human being would have something to do with what happens in the relationship.
Most clients present one of two problems to a counselor. They either present a dependent, false self or they tend to talk about themselves in abstractions and generalities. This roughly corresponds to the hysteric and the compulsive. The first significant factor in the counseling relationship is that the relationship be free from expectations. This environment enhances the possibility that autonomy can develop, and this is crucial. The responsibility must rest on the client. This, of course, frightens the poor hysteric whose false self needs validating from outside or he becomes anxious. He works very hard at first to maneuver you into the responsible role. There has to be some judgment in not allowing unbearable anxiety to arise, but as fast as possible you get the responsibility on him. This is a demonstrable act of faith on the counselor’s part.
The compulsive is a different ball game in the beginning. You often sit for hours and not one tangible fact that identifies his uniqueness comes forth. Only abstractions about what it is like to be him. This is usually without emotion. To treat him, you have to know him, not about him. Part of his isolation comes from not being understandable. Over and over you have to ask for examples to concretize him into a distinctly unique human being. He begins to realize you want to know him and also, in being concrete, his emotions come closer to the surface. This may takes months. You put the responsibility on him and try to concretize the abstractions produced. Parallel to these functions it is necessary to listen with concentration take seriously what is said, but above all, throw inference out the window. If somebody says, AI hat my husband” your question is "What do you mean?” Then when they describe what he did, find out what it meant to them. In your attempt to know and understand this person in depth, you will get to look deeper and also teach him how to be understandable. If I were limited to three questions, they would be: What do you mean?, What does it mean to you?, and Could you give me an example?. The implications of this are that you have enough faith in him to let him chart the course, enough respect for him to listen, take him seriously, and want to know him in depth and in his uniqueness.
If you can see growth in people in the same light as you can see the nurture of a seed, it would help. You plant a seed and watch over its environment, and it becomes what it was intended to be. There is a growth process in people that will happen if it is given the context in which to grow.
The longer I do this work, the more I am convinced that the context is a religious question and it relates to unselfish love - love that lets be. So far, this is the best definition I have found: "Love is patient, love is kind and envies no one. Love is never boastful nor conceited, nor rude, never selfish, not quick to take offense. Love keeps no score of wrongs, does not gloat over other men’s sins, but delights in the truth. There is nothing love cannot face. There is no limit to its faith, its hope and its endurance.
Some Fundamentals of Counseling
In this instance we are dealing primarily with considerations having to do with counseling that is oriented toward human growth. In order to deal with this, it will be necessary to consider a few general things regarding human growth. One of the rather unfortunate things is the theoretical literature about human growth is that it has tended to be oriented more towards the study of pathology or, even more directly, psychopathology, than it has been oriented towards growth. It would seem rather apparent that growth or pathology both result from relationships with a significant people in the lives of developing persons. As obvious as this would appear there is very little actually written about the capacity of relationships in therapy as the factor which tends to undo the pathology or to release the fixations so that the person’s development can continue.
Our orientation at the Institutes of Religion and Health tends to be primarily a growth-oriented and a relationship-oriented approach to counseling. In many ways the process of growth occurs in what could just as well be described as a "healing” relationship as it could be called a therapeutic relationship. It is interesting that in doing followup studies about a year after treatment we found in the interviews with the patients that they said very little about the actual insight that they might have developed during the period that they were in treatment; but we found words like "the therapist had a great deal of respect for me” or "the therapist really believed in me and this meant a great deal to me” or that "the therapist really cared” or that ""by the way he treated me, I came to trust him and felt that this factor was important in what happened that freed me from the difficulty I'd had previously”.
Actually, I believe one of the best descriptions of the qualities of a healing relationship is found in Corinthians 1:13. The portion of that says that "Love is patient, love is kind and envies no one, love is never boastful, nor conceited, nor rude, never selfish, not quick to take offense. Love keeps no score of wrong, does not gloat over other men’s sins, but delights in the truth. There is nothing love cannot face. There is no limit to its faith, its hope and its endurance”. As you can see, the factors covered in that quote are common, ordinary human qualities. But it brings an interesting point to my mind that probably, as a counselor, a person’s ability is based more upon what he is than upon what he knows. Certainly there are things that we can learn and that are quite useful, but the basic quality of the relationship often turns out to be more a function of what the human being is than what he knows.
The absolute fundamental of counseling is listening. Without this, no therapy will occur regardless of what else is present. It is both a happy and frightening experience to be listened to. On the one hand, to be taken seriously (everything that the person says has an importance) has a lot of meaning to most people. However, the fact that the therapist is a listener is also frightening because the person in treatment gets pretty uncomfortable with the responsibility of producing something to be listened to. Listening brings across the idea that the listener is a person who wants to understand. This is where a number of interesting side benefits accrue. Just to sit and listen is not enough, because to listen and not understand is disrespectful.
This brings up another interesting point and that is the relative importance of understanding on the part of the therapist as opposed to the development of the capacity to be understandable on the part of the client. I feel that most patients are searching more for someone who can understand them and have never really reckoned with the problem of becoming understandable. In listening to some of my own tapes, I was somewhat appalled by how little I actually said but how two questions repeatedly came up almost to the exclusion of any other question. These were, "What do you mean?” and "What did it mean to you?” After seeing how restricted my questioning had become, I thought I ought to look into it a little bit to see why I’d gotten into this habit in doing treatment. The thing I began to notice was that in ordinary conversations we depend so much on inference that we very often don’t really understand what another person does mean. We accept the symbols by which he expresses himself and then through a process of inference assume that we know what he meant. And during counseling this becomes so obvious that when you pick up a simple statement like, "I hate my mother” and say, "What do you mean?” and as the patient tries to explain that, you get an altogether different sense of knowing that person than you would if you just assumed that when he says, AI hate my mother” that I know what he means. Of if a patient is describing all kinds of horrible deeds that have been done by his husband or wife, if you begin to ask, "What did it mean to you?” nine times out of ten in that specific instance, you'll find out that the reason they're angry and critical of the other person is that, in the incident described, they didn't feel important. Also, I think it’s obvious from these two simple questions that this is a wonderful experience in which a client can begin to be understandable. It’s really appalling to me how much we deal with one another and how little we really make ourselves known. That brings me to another point that I’m chronically hasseling my students about, and that's the difference between knowing and knowing about people. Because we've all had a fairly high level of education, we've developed considerable skill with handling abstractions and dealing in concepts. We've also learned quite a bit about taking the specific and then attaching it to the general. This, unfortunately, doesn't work when you're dealing with clients. The real benefit comes from the capacity to know the uniqueness of each individual - in other words, that about him which makes him different from any other living soul. Our tendency, if we’re not careful, is to take the specific and the unique and then try to fit that into some theoretical category so that we can put a label on that person instead of dealing with him as a human being.
The tendency to deal in abstraction shows up probably most noticeably in working with the obsessive compulsive schizoid personalities who tend to with their subjective experiences by abstracting and generalizing them and then when they try to tell you who they are, they speak in abstractions and generalities. So another basic issue is helping these people to begin to take their abstractions and make them specific reports of actual experiences. Also, as you get specificity, you soon discover that with that person, the more specific he is, the more of an emotional or affective response you get, while when he deals in abstractions and generalities, he’s pretty well insulated from his feelings.
Basically, what we have been talking about is the context in which growth is possible. Much in the same light as if we were to take a seed and try to grow a plant, we would be apt to provide an environment in which it was possible for that seed to become what it was intended to be. In the same sense, in counseling, we provide an environment in which a person can become what he is capable of being. I think, in brief, we could say that in giving a patient the responsibility for what happens with the (therapy) time that we're showing him "respect”. The fact that we have some belief that a process of growth can occur, we could call "faith”. The fact that we have no expectations could be called "love” in the sense of agape, and in the testing that the patient does on us, "trust” can possibly develop. So it is within the context of respect, faith, love and trust that the possibility for growth exists.
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