The best way to classify psychotherapy is the way Wollberg (who has authored a 2 volume text book on the subject) has done it. He divides psychotherapies into 3 - Reconstructive, Re educative and Supportive.
1) Reconstructive: These are the highly ambitious approaches claiming to completely reconstruct the personality of a person after understanding everything about him including long forgotten (or buried within unconscious) childhood memories. The gold standard came from the master - Sigmund Freud himself. But there are many variants.
The problem with these kind is that they are time consuming and costly (how many can afford a 50 minute, five days a week therapy for months or even years) and have poor empirical evidence for efficacy.
2) The re educative therapies: Their claims are modest - helping individuals to lead a better life by changing certain maladaptive behaviors and attitudes. Behaviorism, C B T and the Humanistic- existential therapies come under this. Behaviorism emerged as a reaction to the emphasis of the former on 'unconscious processes' of dubious nature. But John B Watson certainly went overboard with his claims that he can make a genius or a criminal out of any individual infant given to him.
Cognitive therapies appear to bridge the gap between the extreme emphasis on 'unconscious only' of the first group and the other extreme of 'looking at overt behavior only' style of behaviorism.
Though C B T uses cognitive terms - negative automatic thoughts, cognitive errors etc - its concepts can also understood using concepts of psychoanalysis. Both agree that behavior and mood states have underlying causes within the psyche of the person, more than the external events. They also agree that an individual is not always fully able to explain his behaviors at all times. In other words we are not always our own masters. For psychoanalysts the culprit is the hidden conflict in the unconscious. For C B T experts it is the hidden biases and cognitive errors. Both agree that the origins of these may be past experiences.
Both C B T and behaviorism exponents have garnered objective evidence for the efficacy of their approaches. C B T has been found to be equal in efficacy to drugs in the treatment of moderate depression, with lesser chances of recurrence.
But the fundamental question raised in the 'Guardian' article - whether we need to try to change the subjective world of another human being, even as part of therapy - is still valid.
ഇന്ത്യ
7 months ago
5 comments:
Whether or not therapy aims to change a person's subjective world depends upon two very important factors.The first being distress caused to the subject in that world they see or percieve.The second being motivation to change.If the distress is immense and the resulting motivation to change it is high (resulting in good insight) then yes it is worth trying to effect some change.But if the distress is limited (as happens in personality problems) or if the motivation is poor (as happens in chronic addictions) then changing the subjective world becomes extremely difficult as only others seem to have the problem not the self.
I suppose that sums up the whole idea of suitabiliy for talking therapies and clealry it is not a one size fits all treatment modality.
Well said Sashi and Dimple. I agree to both of your views. I think we are trying to change the world of a person who seeks help to effect this change, which he realizes he alone is unable to accomplish. Personality disorders are ego syntonic (meaning that the person is happy to be this way and does not seek change)and hence they do not accept the therapy offered. The worst secnario is that of chemical addiction. Here the person is ambivalent, his kith and kin are suffering, but it is difficult to help the person because of his ambivalence and the chemical dependence.
I think, the fundamental question in the guardian is invalid, unnecessary and wrong. We forget some simple basics. What is 'subjective' and what is objective. These are two words in a language, made by us to convey two different ideas or simply put, for better communication. These two things are relative, you can't make any exact division between them. Subjective is a part of what is objective as nurture is always a part of nature. Environment is a model in our brain and it entirely depends on the structural - chemical make up there. There may be an absolute reality outside, but the world what we know is our own model, a model created by us. Environment is an extension of the brain. As you know all people who see a terrific incident do not develop PTSD. There must be a predisposition. What is more important is not the incident but how we perceive it. Right ?
I am coming back to the question. Should we change a persons' subjective world?
I want to ask you more questions. Should we change a person's insulin levels if he has type 1 diabetes? Should we suppress the immune system in severe allergic cases? We do all these things to help improve a person’s health or life. Things get highly complicated when we deal with mental health. It is easy to define what is normal or what is abnormal in physiological problems. We can say for sure that a broken leg is abnormal and should be corrected. But we can't be so sure in mental disorders. An adult who draws cartoons in the wall of his living room may be both a psychopath and an artist. We may not change his subjective world if he doesn't do any harm to other people. A lot of famous artists are known to have mental disorders.
We should not treat mild fever or common cold. The same practice should be applied to mental disorders also. All these things are relative. Nothing wrong in changing a person's subjective or objective world if it is for good. But who is going to decide what is bad or what is good, and what is the standard of doing all these things, to be frank, I do not know. Nothing special with "subjective world". So the fundamental question raised in Guardian is invalid and unnecessary.
We are living with some necessary illusions. Language and logic have some inherent problems or deficiencies. It is interesting to see that the words or language we create for our convenience play tricks on our brain. I always used to wonder in my childhood that what lies outside the universe. Now I know how stupid the question is. Outside or inside, space or time all these are the properties our universe. How can I apply a property of the universe to something beyond that?
As a doctor you know that a lot of drugs, some foods, alcohol or ganja can alter a person's subjective world. Psychotherapists use different tools, that's the only difference. Media, Govt policies, Religion etc.. are also affecting or modifying our subjective world. Should we raise a question only in the case of psychotherapy?
Neurons should be respected and treated like other things in the body, all working together to successfully pass genes from one generation to another. We are just survival machines for them.
I know, no newspaper will discuss about the ethics of altering temperature in fever.
Keep writing. Food for thoughts.
The responses/heat of generated by the debate indicate that something has touched we all..! what is it? ..!
we love our "self" normal or abnormal...& we(not everybody) are afraid of/worried about something that can alter our thoughts/mind or identity,even at the pretext of abnormality. .
the question is,as ajeesh said ..who will decide the grade of abnormality, is indeed valid...! and nobody expect a satisfactory annswer!
Dear Devadas,
We are not only worried about someone altering our self or thoughts but we also do not like someone to hit us or take away our property. We are worried about our body, house, family, income etc... We are also worried about our self or subjective world. I think I said there's nothing special in treating mental disorders or changing a person's subjective world. We advise or help people to avoid some habits both in the case of physical and mental disorders. May be we can compare "Exposure with Response Prevention" in OCD to "Dieting" in Obesity or Hypertension. Society gives a special status or concern to mental disorders. My efforts are to prove that people with mental disorders should be treated and respected like others.
The philosophical question of what is bad or what is good, and who decides all these things are still there. But we all like to live a happy comfortable life here. So we have made some law, some rules, science, art and a lot of other things. We have to cooperate. So if some psychotic is going to disrupt the normal life of ours we will, of course grade the abnormality. I do not have any difficulty in grading the abnormality when someone rape and kill school children, or when a drunk man hit everybody on the road, when someone cut his own vein or when someone believes that he got special powers and going to jump from a tall building. Dear friends, we all are going to join hands together if someone is going to disrupt our happy life.
I have said in my last comment that we do not treat common cold or mild fever. We get the problem of grading the abnormality only in mild cases. Doctors use some tools like DSM IV TR, ICD etc... to grade and decide the problems. It is proven that these tools have provided great help in psychiatry, i.e. altering a subjective world for good. Media, books, friends and a lot of other things influence or change our self, the difference is that we are not conscious of the process. But with psychotherapy we become aware about the process of changing the subjective world and we pose so many ethical questions. Leave the philosophical question of good and bad for practical purposes or we will not accomplish anything. We can argue for ever.
Thank you Devadas. It is good more people join us and open up some nice conversations
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