Psychotherapy - Out of the Maze
by Pulkit Sharma
Twenty-year-old Anuj (name changed) broke into wracking sobs on the first day of his counseling session. Part of his turmoil was an emotional disorder based on strong conflicts in his needs and desires. More poignantly, though, the mental health fraternity of which I was a member had aggravated his problem.
Anuj had been seeking help for five years and had been diagnosed variously as suffering from depression, obsessive-compulsive disorder, trichotillo mania, generalized anxiety disorder and social phobia. Anuj had already been prescribed a cocktail of treatments ranging from psychiatric drugs, meditation, yoga, and behavior and cognitive therapy, without lasting results.
Informed by my psychoanalytic perspective, I started a weekly psychotherapy session with him. Although he found the first five sessions beneficial, he expressed discontent and confusion over the fact that all psychiatrists did different things.
I realized with a start that most practitioners have a blind spot that prevent them from acknowledging that the mode of treatment followed is just one of several, a fact that a patient is unlikely to be aware of. Often, our preferred treatment becomes a part of us and we believe it to be the best. But is it best for the patient?
Are we being ethical in hiding our personal preferences from our patients and presenting our approaches as not relative but universal truths? The patient has the right to know of various treatment options, how they differ and their relative effectiveness. Anuj, for instance, did not benefit from relaxation techniques and behavior therapy - yet the treating clinician persisted. Here below are some of the main lines of treatment followed by Indian psychiatrists and therapists. However, there exist scores of other relatively unused therapies.
Psychiatry believes that a disordered mind can be corrected by treating the body or brain. Till date, a mystery exists: Are mind and brain one and the same? Are they different? Is mind simply an illusion?
Psychiatry attempts to treat observable chemical and neurotransmitter abnormalities in brain and body, believing that this would have a consequent impact on the mind. One can see a crucial divide between psychiatry and psychotherapy - the former focuses on the body, while the latter on the mind. Nevertheless, both psychiatry and psychotherapy support each other.
Take the case of a patient who's so driven by fear that he hides under a table. Before attempting psychotherapy, his anxiety levels must be reduced through psychiatric medication.
But complications may arise in following a strictly psychiatric approach. There is no doubt that the brain and mind are related; the brain relates to the structural aspects of human behavior while the mind deals with the functional ones. However, examining its structure may not help us understand a system. Psychological problems are not organic diseases or contagious ailments caused by viruses and bacteria. They are basically difficulties and problems of living, conflicts of desires and struggles within relationships.
Psychiatric medicines do not 'cure' the patient; they only lead to biochemical changes, which 'control' the patient.
Consider the case of 24-year-old Ejaz (name changed), who was hospitalized after being diagnosed with paranoid schizophrenia. He accused his family of mistreating him, and believed that his father wanted to kill him. He was prescribed anti-psychotic drugs for a year, which certainly reduced his anxiety levels. However, were he to discontinue the medicine, chances are that he might revert to his previous condition. Moreover, his psychic fears remained unresolved, which stopped him from living fully. He could not relate to people; nor could he realize his creative potential or capacity for work.
Furthermore, the attribution of schizophrenia to chemical changes in the brain effectively stopped any attempt at introspection either by Ejaz or his family members.
As I interacted with Ejaz and his family, I learnt that his father was extremely dominating, and often flogged and ridiculed his son.
I believe that Ejaz's problems stem from his compliance and extreme fear of his father. For healing to occur, both Ejaz and his family need to develop an insight into themselves. This is a difficult task and attributing the cause to chemical changes may have supported them in avoiding it.
There is no denying that Ejaz was afflicted by neurotransmitter abnormalities in the brain, but the big question is whether these abnormalities caused schizophrenia, or were they caused by it?
Behaviorism as a theory and as a therapy has its foundation in laboratory experiments conducted on animals. It interprets human behavior as a mechanical set of reflexes and habits expressed in terms of 'stimulus-response' patterns. Behavioral therapy ignores the subjective inner experience. Thoughts, feelings and emotions are intangible, and are thus considered either non-existent or illusory. Behaviorists usually follow a philosophy of 'external determinism' that perceives human beings as only influenced by environmental factors.
It involves methods like rewarding good behavior, correction through punishment, and exposing people to feared stimuli in order to develop new response patterns. Its strong suit includes precision and ability to directly target the symptom. However, this very strength can be its greatest weakness. Many times diffuse and diverse symptoms are just an expression of a deeper conflict that often goes unnoticed. Removal of a symptom may offer temporary relief, but it would soon be replaced by another symptom. And, when reason impinges upon free will, policing behavior and responses, it's perhaps more rational to seek the freedom of insanity.
Clinicians often become guardians of the establishment values rather than challenging them
A behavior therapy program attempted to convert a homosexual male into a heterosexual by administering electric shocks while he was shown photographs of attractive males. The clinician assured his family that he would be 'cured' by electric shocks, which they agreed to as they were unwilling to challenge larger social structures that pathologise homosexuality. The clinician thus becomes a guardian of establishment values rather than one who challenges them.
Cognitive therapy and its sister concern, cognitive behavior therapy, strive to undo the damage caused by behavior therapy. Cognitive therapy encourages an individual to exercise control on his 'maladaptive' emotions through rational thinking. It's believed that emotions are separate from thought patterns, and that by encouraging logical thinking the individual would be less overwhelmed by his/her 'maladaptive' emotions.
Cognitive therapists help the patients refocus on their expectations and evaluations. Although a welcome change from behavior therapy, it replicates a similar pattern - to impose reason, gradually obliterating any traces of irrationality.
During my training, I observed a cognitive therapy session with a man who suspected his wife to be sexually promiscuous. The session took on a Socratic dialog with the man and asked him to furnish evidence to support his belief. His inability to do so was offered as proof that his was only a hypothesis, unreasonable and irrational. And that he must think rationally.
Therapy thus becomes a call for reason to take over and obliterate unreason. Ten sessions past, the patient was still unconvinced. He said: "I know what you are saying is right. I don't have any evidence to support the claim that my wife is unfaithful. And yet I cannot refrain from thinking otherwise."
Psychoanalysis and Existential Analysis
These depth-oriented therapies do not focus on removing the symptoms of mental illness; rather they try to find out why a symptom occurs and to what purpose it serves the patient.
Psychoanalysis, unlike other psychic approaches, does not dismiss symptoms, but believes that behind seemingly irrational acts and thoughts exist deep-seated existential truths.
Psychoanalysis is predicated on the doctrine that we continue to interpret the world in terms of our early experiences, and often suffer due to unresolved childhood conflicts.
For instance, a boy who felt neglected by his mother, would carry this feeling into his later life and perceive his wife, his children, his boss, his friends as neglecting him. Through the awareness of this unconscious drive and integration of split parts, there comes relief and a potential for free, creative and honest living.
Psychoanalysis attempts a 'rational reconstruction' of the seemingly irrational. Taking the same example of the man who doubted his wife's fidelity, psychoanalysis would not simply impose reason on the patient, but explore the origin of the suspicion, gradually bringing his 'repressed content' to surface. Once this happens successfully, the patient would become more receptive, trusting and loving, not only to his wife but also in other human relationships.
The methods used in psychoanalysis include 'free association' (allowing the patient to talk of just whatever comes to his mind, no matter how trivial), and 'interpretation' (where the psychoanalyst interprets the patient's free associations in a wider perspective).
The major limitation of psychoanalysis is the time factor. Because it aims to integrate the unconscious with the conscious waking mind for lasting change, an analysis may take as many as 300 sessions to complete successfully. Also, frequently, psychoanalysis focuses on the inner world, often ignoring external contingencies.
Existential analysis lays emphasis on understanding the subjective world of the patient, as he or she perceives it. The existential therapist abandons rigid theoretical frameworks in order to relate with a fully alive human being.
Family therapy understands the family as a system divided into various subsystems on the basis of intimacy levels between the members, and how decision-making is executed within the family.
Broadly, it understands the family on the basis of two basic concepts: enmeshment and disengagement. In an enmeshed family, familial roles are blurred; there is very little privacy, and it is not clear who exactly makes the decisions. In contrast, a disengaged family is characterized by loose personal ties, where the needs and personal concerns of most of the members go unnoticed. Between the two polarities, there exists a broad spectrum of varying family patterns.
Mental health professionals must inform their patients of their condition, treatments, and if need be, offer other treatments that could work better and arrange referrals
Family therapy seeks to modify a 'maladaptive' structural pattern by redefining rules, negotiating power and decision-making issues, eventually leading to a better functioning of the family unit. Family therapy, in fact, has a lot to offer provided it is used as an adjunct to individual therapy. In Ejaz's case, family therapy alone would not have repaired the damages to his psyche.
A therapist organizes and presides over a homogeneous or heterogeneous group of members seeking therapy. This group meets at a specified time and place, and the members take turns to discuss their problems and grievances.
Group therapy has several benefits. Firstly, the group acts as a support system catering to the relational needs of one another. The individual is also offered immense opportunity to balance his/her needs vis-à-vis other group members, and collective requirements. Besides, group therapy is more economical than individual therapy. However, an individual may be hesitant to reveal his/her deeper dilemmas in a group. Thus, like family therapy, group therapy is best suited as an adjunct to individual therapy.
Many therapists seek to combine the benefits of various psychotherapies. This idea can only work if complementary therapies are used and not ones that have contradictory perspectives.
Besides medically treating the patients, all psychiatrists are also ethically responsible for their welfare. They must inform their patients about what they are suffering from, its causes, the various possible treatments, why a particular treatment is best for them, and the one in which they specialize. In course of the treatment, if the clinicians feel that there is no remarkable improvement in the patient's condition, he/she must be offered opportunities to seek another treatment, and a consequent referral must be arranged.
Mental health professionals also have another ethical responsibility. Are they co-opting patients to conform to status quo? Or do they wish to be catalysts in social change by enabling their patients to live an authentic and creative life and develop their own ethical and social norms?
Pulkit Sharma is a postgraduate in Psychology,
Department of Psychology, University of Delhi.
He is interested in clinical work and related ethical concerns.
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