Mental Disorders, Treatment of
Mental Disorders, Treatment of
Mental Disorders, Treatment of
I. PSYCHOLOGICAL TREATMENTKenneth M. Colby
III. GROUP PSYCHOTHERAPYJerome D. Frank
IV. BEHAVIOR THERAPYJoseph Wolpe
V. SOMATIC TREATMENTHeinz E. Lehmann
VI. THE THERAPEUTIC COMMUNITYRobert N. Rapoport
Within the context of this article, the term “psychological treatment” means psychotherapy and “mental disorder” means mental distress. Psycho-therapy consists of a group of communicative methods for exchanging semantic information with the aim of relieving mental distress. Mental distress consists of behavior patterns subjectively experienced as painful and judged by subjective and objective observers to be inappropriate to a context.
Although there are now several psychotherapeutic approaches in Western culture, only a few can be considered as seriously developed alternatives whose methods continue to be evaluated and improved through systematic study. These approaches can be subdivided into three schools—psychoanalytic-psychodynamic, learning theory, and client-centered. Although manysimilarities and differences can be found among these schools, depending upon how one compares them, there is agreement regarding a number of essential components in mental distress and its treatment by psychotherapy (Ford © Urban 1963).
Modern psychotherapy was derived mainly from the efforts of Josef Breuerand Sigmund Freud, toward the end of the nineteenth century, to systematizea “talking cure” from the hypnotic techniques of the time. From this beginning several methods have evolved, none showing a clear-cut superiority over the others. They share many pre-suppositions regarding the nature of man and a delineation of individual psychotherapy as a private two-person relationship limited to talking and listening, the intent of which is to relieve the mental suffering of a patient in an enduring way. This private and intimate relationship, peculiar to Western man at this time, is notable as much for what it does not contain as for what it does. For example, it is a regularly repeated human communion that is unaccompanied by food and drink.
Presuppositions are vaguely held and seldom examined beliefs. Beliefs concerning the nature of man underlie the articulated suppositions of psychotherapy. This Menschanschauung, as it might be called, presupposes that man’s suffering is an outcome of his experience, that mental suffering should be relieved, that man has some degree of freedom of choice and decision, that he can control himself to some extent, that he canbe changed by experience, that one man can help another to change, and so on. A complete inventory of such presuppositions has never been attempted, and perhaps because of the tacit nature of such beliefs, no inventory could be complete. It is of obvious importance that these beliefs are held by both therapist and patient.
The more clearly held beliefs of therapists make up the specifiable suppositions and assumptions of psychotherapy theory. A therapist operates witha theory of the pathology (Greek, pathos, suffering) of mental processes and a theory regarding techniques that can bring about beneficial change in them.
Here the term “theory” refers to a rough frame-work of notions expressed in a language containing everyday and special terms. A therapist’s theories do not represent formal systematized bodies of tested and established hypotheses, such as those found in some natural sciences.This is not so much due to the youth of the field as to its nature.
Therapy is not a science but a practical healing art. Practical arts consist of techniques for achieving ends valued as good. Procedures and rulesfor achieving ends can be aided by basic scientific knowledge that increases our understanding of the subject matter or augments the power of techniques. The effective utilization of techniques remains in the hands of a skilled artisan whose work represents the conduct of an artistic rather than a scientific activity.
Theories of mental distress
A therapist’s theories begin with conceptual notions about the subject matter to which his techniques will be applied. Mental suffering involves a set of conditions judged to be qualitatively or quantitatively inappropriate to a context. This judgment is made both by an internal observer, a patient, and by an external observer, a therapist, both of whom hold beliefs about ideal or desirable types of behavior for various contexts. The judgments that something is out of order are arrived atnot by consulting experimental or statistical evidence, but by comparison of the patient’s behavior with ideal types. This comparative method uses a concept of desirable behavior that represents an idealization, a useful fiction, and not the extreme of an observable range.
The chief empirical indications of mental distress, some or all of whichare evident to both observers, are negative affects, thought distortions, and constrictions.
Common negative affects, subjectively experienced and reportable as intense and not in keeping with an external situation, are anxiety, anger, depression, shame, and guilt. For example, a person may experience great anxiety in a classroom where there is no evident threat. Or he may become repeatedly enraged at frustrations that he judges to be trivial. Or he may enter a prolonged depression over the death of a loved one and even feel, inexplicably, guilt over the loss.
Thought distortions have a great range of severity and variety of content. Common are beliefs that one is inferior, that one deserves admiration, that a disaster is about to occur, that one is being looked at or talked about, that people are dangerous, that one’s body is defective, and that the opposite sex is hostile. These beliefs are often accompanied by th patient’s own judgment that they are unwar-ranted or unjustified to this degree. Yet this judgment seems powerless to correct the thought distortion.
Constrictions involve limitations of feelings or behavior required by and congruent with contexts. These limitations include avoidance of the opposite sex, sexual impotence or frigidity, inability to enjoy life, and a incapacity to experience either joy or grief. Such constrictions have far-reaching consequences and lead to repetitions of old patterns in novel situations requiring discriminations and new behaviors.
There is great variation in how much distress an individual can stand. Most applicants for therapy have experienced enduring distress of more than mild severity which has not disappeared in the course of time. A patient seeks expert help for the negative affects, thought distortions, or constrictions that trouble him, and it is these phenomena from which a therapist attempts to release a patient by modifying the processes that generate them.
For more than five thousand years there have been attempts to classify symptoms, descriptions, and behaviogr patterns into disease categories (Menninger et al. 1963). All these efforts have failed to produce reliable categories. The growing modern view is that we are not dealing with disease entities in the medical sense but with states of experiencing that require conceptualizations different from those found in traditional medicine.
Today, various schools of psychotherapy have reached moderate agreement on which elements are essential in descriptions of mental distress.Theories of the underlying pathological processes also agree insofar as they consider mental conflict, anxiety and other negative affect processes, and the ontogenesis of distress in parent-child relations to be crucial variables. The current uncertainty and disputes center on the problem of determining the best techniques for relieving distress and producing change. Although a crude theory of distress exists, we lack a theory both of mentalchangeand of how change comes from external social influence. Hence there exists a profusion of techniques derived from clinical experience, but theylack a satisfactory theoretical underpinning.
Theories and techniques of therapy
Techniques of therapy are purely semantic, involving a communicative exchange of meaningful information. Treatment procedures are limited to conversations of various types, and there is a limit to what a therapist and patient can do with any purely semantic technique. These limitations are set bythe nature of the therapist-patient relations, by what can take place in talking and listening, and by the topics chosen to be talked about. The relation between therapist and patient represents a working collaboration guided by a contract with stated and implied terms, usually involving payment of a fee for the therapist’s services. Although the relation becomesintimate and emotionally arousing, it remains extremely one-sided, with thepatient doing most of the talking. Disclosure is exchanged for confidentiality and neutral interest. The therapist’s skills in listening and talking involve a general attitude of benevolent acceptance and specific acts of eliciting, focusing, clarifying, reflecting, and interpreting those relevant topics initiated by the patient. Criteria of relevancevary somewhat among therapy schools, but again there are limitations imposed by the regularities of deep human concerns—e.g., relations to significant other persons and the self to the self—and by what can in fact be said about them by therapists.
There exists a difficulty between and within schools of therapy in examining the facts of therapeutic conversation. When discussing therapeutic approaches, each school uses its own notions and language. But itis an open secret among cognoscenti that this talking about therapy is highly un-related to the talking that takes place in therapy.Official discussions about therapy tend to call up school allegiances and personal commitments. With an increasing use of tape recordings, movies, andtelevision, we are in a position to observe what therapists actually do rather than relying on what they say they do.
As already emphasized, theories regarding processes of mental change arenot as developed as theories of mental distress. Every therapy school coulduse a theoretically justified set of principles for achieving change. The technical rules and principles currently used have come from long clinical experience and common-sense knowledge about human behavior. As an example ofthe latter, if you want a person to tell you about his inner painful thoughts, do not frighten him. This simple but effective principle is used by allschools. For its skillful applications, a therapist must be able to acceptand control himself when stirred by feelings that can lead one person to attempt to frighten another.
Most of the rules for conducting therapeutic conversations are of this simple type. Some schools try to justify their techniques by appealing to fanciful metatheories or to animal experiments having no relevance to human behavior. But thus far technical rules are entirely empirical and justified only by clinical experience. This does not mean they are all wrong or can be easily dismissed, but because they lack a theoretical basis, it is difficult to sort out which techniques are truly effective and which can be dispensed with. For the time being, then, techniques must be learned through the oral tradition of apprenticeships in which empirical knowledge ispassed on from the more experienced to the less experienced in thecourse of studying representative examples of clinical problems. And like the skills of all practical arts,they are performed by some people better than by others.
Until theories of change are worked out, a therapist must rely, in his practice, on simple rules and on a tacit knowledge that comes with clinical experience. The type of guides he needs most are decision rules that tell him what to say and when and how to say it in order to achieve his short-range and long-range goals. It is important to distinguish techniques from goals. Much of the therapy literature is clear about goals (although what the language refers to may be obscured observationally), but it remains quite opaque as to how these ends are to be achieved technically. When one discusses the details of the therapist’s utterances, all therapists say much the same things. And it is these utterances to whicha patient responds, not the theory of the therapist’s school. It is also noteworthy that statements about goals often refer to the way the patientshould be rather than to what a therapist should do to help him become this way.
It is easy enough to state a goal of therapy as an enduring relief of the mental distress a patient suffers. With such relief comes a positive gain in the form of a new ability to enjoy experiences. All schools, inaddition, seek goals or sub goals assumed to be necessary to achieve the over-all end of enduring relief. They are variously termed as self-realization, personality growth, self-knowledge, full-functioning, enlightenment, etc. Here differing therapy approaches seem to be saying equivalent things about ideal types of mental functioning. Utopian or not, they play a part in the presuppositions and suppositions regarding therapy’s ends. Statements about goals represent assertions of value systems striving to achieve the good (London 1964). A therapist’s values regarding “the good” and “the right” in human conduct inevitably clashwith other value viewpoints. Each therapist-patient pair must work out this difficult problem of values in a manner that provides some consonance with the values of the patient and the community in which he wants to live.It is this problem of values about what constitutes proper conduct, bound up with the ends of therapy, that contributes great difficulties in answering questions about the effectiveness of psychotherapy.
How the techniques of psychotherapy actually work to affect a patient remains mysterious. Changes observable to both subjective and objective observers take place in the form of reduction of negative affect, correction of thought distortions, liberation from constrictions, or a combination of these. Processes that generate such changes are difficult to understand and facilitate in our present state of knowledge. For far-reaching and enduring mental changes to occur, we assume some sort of scrutiny, and revision in belief systems must take place in which information is used to counteract and correct other information. This process is facilitated by the haven andsupport provided by a benevolent therapist, who functions as an ideal friendor parent and who occasionally can offer alternative views to be tried out by the patient first in safe thought-experiments and later in actual behavior. This is about as much as we think we know of mental change, an area in which dependable knowledge is very difficult to obtain.
Historically, the treatment of mental distress has involved the use of physical methods, such as drugs and electric shock, and semantic methods, such as individual psychotherapy (Walker 1957). Hospital treatment has mainlyutilized the former methods, whereas outpatient clinics and private practice have relied mainly on the latter.
No great change in the techniques of semantic methods has gained much acceptance in the past few years. In classical psychoanalytic treatment a couch, free association, and several visits per week for two to three years, or more, are still used. In less-intensive therapies a patient is seen face-to-face for several weeks or months.
One trend in the field of psychotherapy concerns the matter of personnel and training. Since the early part of the twentieth century, the official (i.e., sanctioned by an accrediting organization) practice of psychotherapy has been by psychiatrists. But with the growing numbers of trained clinical psychologists and social workers, increasingly more therapeutic work is being carried on by individuals who do not have medical degrees. This trend is consistent with modern views regarding the nature of the “disease.” If persons who seek therapy are not viewed as suffering from diseases in the medical sense, then it does not require medically trained personnel to deal with them. Medicine must either redefine “disease” to include human behavior patterns or concede some ofits traditional territory to the nonmedical therapist. Since territorial dominance is what it is in male animals, the dispute will be a long one.
This issue will become crucial as more and more people seek therapy. Thegrowth of therapy is not so much associated with the prestige of science as it is with a growing change in attitude that facilitates criticism of socially acquired beliefs. Therapy provides a sanctioned way of participating in social criticism within the microcosm of the self, of repudiating acquired beliefs, and of liberating the self. With our increasing prosperity and with a rapid lessening in shame over seeking help, it is estimated that one out of seven persons will eventually apply for therapy. Medicine, psychology, and social work alone will not be able to meet the demand of millions of people. It is obvious that other manpower resources must be trained (Schofield 1964).
Whether there has been any progress in the field of therapy over the past several years is an open question, partly because “progress” is such an evaluative term. Through clinical experience therapists have slowly learned much about what is not considered progress, and this represents a gain of information. It is agreed that we need more powerful and efficient methods as well as more knowledge about the differential applicationof semantic techniques. Furthermore, because patients tend to select therapists from schools about which they feel more comfortable, the various therapy approaches may be dealing with different classes of psychological problems and patients, making outcome comparisons across schools worthless.
When a practical art tries to improve its methods, it often turns to science for help. Psychotherapy, relying purely on semantic techniques, turns to the behavioral sciences of psychology, sociology, ethology, etc. As yet there has been no great help for the therapist from these areas, but the hope is that scientific research can contribute to a therapist’s knowledge in order to make therapy more effective.
A historical example of mutually benefiting relations between science and practical art can be found in Louis Pasteur’s contribution to wine making. Although the process of fermentation was not well understood, wine had been made for thousands of years, and the results had been unpredictable. At the request of wine makers, Pasteur undertook a systematic study of the process of fermentation and discovered the role of bacteria. With this understanding it became possible to control fermentation by regulating the activity of bacteria. Nowa-days the making of a great wine stillrequires intuitive art, but the making of a predictably sound wine is rather straightforward.
Like a wine maker, a psychotherapist follows a set of rules for achieving his goal—the relief of mental distress. As mentioned, these rules come from a body of clinical knowledge accumulated through the empirical experience of thousands of practitioners over many years. Why does a therapist believe in these rules when so few (if any) of them rely on scientific knowledge? One must here consider the nature of scientific, clinical, and common-sense knowledge. Scientific knowledge consists of reliable data and tested and confirmed (i.e., not disproved) hypotheses. Depending heavily on measurement and replication, it is precise and highly plausible in the face of the evidence. But it is also limited, lacking in scope and full of errors as his-tory has demonstrated. Clinical knowledge stems from the slow accumulation of data and rough conceptions deriving from the astute observations and powerful intuition of generations of practitioners. Consensus develops through trial and error, and clinicians gradually come to agreement about the suitability of a technique. Common-sense knowledge consists of everyday observations and inferences at a low degree of refinement; it is often fallible and dubitable, but since it is not entirely unevaluated knowledge, it is indispensable. Refined common-sense knowledge becomes scientific knowledge, which then becomes part of common sense again. If we had no scientific or clinical knowledge, we would still be able to manage human affairs about as well as we do today, using only common-sense knowledge of human behavior. A person has powerful aids of introspection and empathy in thinking and feeling about the behavior of other persons.
Scientific research in the problems of therapy should be able to cast light on some of the difficulties in the art. Ideally, one would like to have explanations of everything regarding mental distress and its relief. But this is not likely, nor is it even necessary for the art to improve. Not everything in therapy is a major problem. Only certain aspects merit a scientific study, and only certain questions deserve the labor required to attain a satisfactory answer.
Is psychotherapy effective? A useful and apparently simple question to ask and answer would be, “Is psychotherapy effective?” This has turned out to be such a difficult question for research to answer thatwe now must consider the question unanswerable when posed in this form. Thousands of therapists by now have treated millions of patients. Some patients report they are better, a few that they are worse, and some say they are the same. Therapists believe they help a majority of their patients. Therapists continue to be trained and to practice, and patients continue to seek therapy. There seems to be no widespread doubt that therapy is helpful, or atleast that it is in some cases. Butthere is no satisfactory statistical evidence as yet that therapy benefits a population of patients. Are all these people, therapists and patients, unwittingly deceiving themselves and one another?
The issue is reduced to statistical evidence versus clinical knowledge with its elements of common sense. The failure of statistical evidence to demonstrate a phenomenon may reflect the weaknesses in our current tools of demonstration. Also a failure to reject the null hypothesis (which is what statistics attempts) does not establish the null hypothesis. On the other hand, therapists should realize better than anyone the weaknesses and un-certainty of clinical and common-sense knowledge.
The question of therapy effectiveness should be rephrased, because what the terms “therapy” and “effectiveness” refer to has never been operationally explicit. On the one hand, the term “therapy” does not refer to a homogeneous set of events. Unless the therapy can be observed by others, there is no guarantee that a therapist is doing what he should be doing and no estimate of how competently he is doing it.On the other hand, the term “effectiveness” also initiates a snarl, because patients enter therapy with varying severityof mental distress and what is judged improvement for one patient may not be judged improvement for another. Furthermore, therapeutic goals contain values about desirable behavior, and unless judges share similar value systems, it is impossible for them to agree on whether the result of therapy wasgood or right.
Certainly every therapist has had at least one experience in which the outcome was judged favorable by himself, other clinicians, the patient, andothers who know the patient. Such an experience carries the high conviction that therapy can benefit individual cases, and if it can happen to one patient, it should be able to happen to others.
But to how many others in a population and what population? And perhapsit would have happened anyway “spontaneously.” There is oftenmention of spontaneous remission in the literature, but as yet no one has presented any evidence that such a phenomenon exists.
Candid therapists admit they do not benefit all patients and wish that those who are helped could be helped more. The issue of effectiveness remains unsettled, but therapists are convinced that therapy has the potential to relieve mental distress. What is really needed is an improvement in methods to make therapy not only more powerful but more efficient.
Resistance and transference
If research is to help a practical art, it should address itself to crucial difficulties in that art. A crucial difficulty in all therapy involves a process known as “resistance.”This term was derived from nineteenth-century electrodynamics, whose terms Freud used metaphorically in conceptualizing mental processes in terms of a flow of current through a circuit. The term refers to those hindrances a patient presents to explorations, scrutiny, and change. Clinical theory explains this phenomenon on the ground that a patient, although suffering distress, has achieved a mental state that is almost tolerable in many respects. Because the patient views any change in this state as a threat of even greater suffering, attempts to change are warded off and the state is defended for a long time. It is this fear of change and of being hurt that therapists believe to be a major factor in limiting the efficiency and effectiveness of therapy. Greater knowledge is needed about this process and its relation to “transference,” i.e., the feelings and beliefs a patient develops about his therapist. Technical rules for dealing with transference and resistance may still be simple, but they should be based on a greater understanding of what we are dealing with. Animal ethology and experimental psychology has already begun to indicate much about social bonds and social influence, especially between adults and their offspring (Scott 1962).
Most research in therapy thus far has concentrated on the therapy situation itself, studying it directly as it exists in nature or studying experi-mental analogues. Naturalistic attempts to find common denominators among therapeutic approaches have not led us very far, because the comparisons have been too superficial and experimental attempts to duplicate the therapy situation have not brought about anything new. All this is ordinary research clearing up aspects of existing paradigms (Colby 1964). Sooner or later a new paradigm will appear, and extraordinary research will begin using surprisingly different presuppositions and suppositions. It is between the crevices of a Menschanschauung that new paradigms are discovered.
One attempts to forecast the future by extrapolating present trends and by predicting those discoveries or inventions needed to fulfill human wishes. The main trend in the profession of psychotherapy presently concerns the development of a therapist who is not a medical practitioner. With the admission that current training systems cannot meet the increasing social demand, a new type of therapist will emerge trained in the best way that can beagreed upon by psychiatry, clinical psychology, and social work. All kinds of impediments will be raised by organization officials, but the need is clear and reasonable men will eventually yield to it.
The second forecast involves discoveries and inventions needed by therapists who wish to im-prove their methods. The need for a theory of mental change has already been emphasized. This will be a fresh theory, not an amalgamation of current theories. For years there has been a demand for some sort of rapprochement between learning theory and psychoanalytic theory. A satisfactory combination seems unlikely as long as learning theory doesnot concern itself with such higher mental processes as symbol manipulatio or with the fact that people think, talk meaningfully, and have awareness. Also, unless psychoanalytic theory develops novel concepts, no further contributions can be expected from it. The sorts of discoveries needed are those that can be provided by basic behavioral science or by a genius in thefield of clinical observations and inference. Psycho- therapy, as we know itnow, will change markedly if vigorously and boldly worked on.
The inventions needed are recording apparatuses providing rapid information retrieval, voice-recognizing devices, automated analyses of natural language, and computerized training devices for the learning of therapy. There is also the interesting question of whether a future computer might do as well, if not better, than a person in providing individualized therapeutic conversation for certain classes of problems (Colby et al. 1966). If a computer will be able to treat with semantic techniques thousands of patients an hour, this would be one answer to the problems of (a) the countable hundreds of thousands of hospitalized patients who never have an opportunity to talk with a therapist and (b) the uncounted millions of patients who could benefit prophylactically or remedially from therapeutic conversation.
KENNETH M. COLBY
Colby, Kenneth M. 1964 Psychotherapeutic Processes. Annual Review of Psychology15: 347-370.
Colby, Kenneth m.; WATT, JAMES B.; and GILBERT, JOHN P. 1966 A Computer Method of Psychotherapy: Preliminary Communication. Journal of Nervous and Mental Disease142: 148-152.
Ford, Donald h.; and URBAN, HUGH B. 1963 Systems of Psychotherapy: A Comparative Study. New York: Wiley.
London, Perry 1964 The Modes and Morals of Psychotherapy. New York: Holt.
Menninger, Karl; Mayman, Martin; and Pruyser,paul 1963 The Vital Balance: The Life Processes in Mental Health and Illness. New York: Viking.
chofield, William1964 Psychotherapy: The Purchase of Friendship. Englewood Cliffs, N.J.: Prentice-Hall.
Scott, J. P. 1962 Critical Periods in Behavioral Development. Science New Series 138:949-958.
Walker, Nigel (1957) 1963 A Short History of Psychotherapy in Theory and Practice. New York: Noonday Press.
Client-centered counseling and psychotherapy as a distinctive point of view and as a radical departure from current practices can be dated rather precisely to December 1940, when Carl R. Rogers, its leading exponent, presented a paper at the University of Minnesota on the attitude and orientation of the counselor. The paper later became the second chapter of his controversial book, Counseling and Psychotherapy (1942). The controversy engendered by this book centered as much upon what the counselor or psychotherapist was not to do in the psychotherapeutic situation as upon what he was to do. According to Rogers, he was not to guide or to reassure or support; he was not to interpret and was not to use an entire armamentarium of what were labeled “directive” standard techniques. Psychotherapeutic interventions, particularly interpretive explanations, were categorized as dangerous. It was recommended instead that the therapist stress what were called nondirective techniques, responding directly to the present, expressed attitudes of the client (reflection of feeling), and that the therapist convey his unequivocal respect for and acceptance of the client as he presented himself in the immediate present.
Rogers postulated that when the therapist demonstrates acceptance and permissiveness and shows understanding of the client’s expressed attitudes and feelings, a process of personal change in the client would occur, in which the following stages could be observed: release of expression, achievement of insight, and development of capacities for making choices and of acting on the choices made. The main task of the therapist was to allow the stages to evolve, to facilitate a natural and inherent sequence, not to set the sequence into motion. Rogers also recognized that the therapist had his own propensities to become emotionally involved with his client in ways which resulted in directiveness and that, therefore, the therapist should work at circumscribing these propensities in himself. He stressed the complete abdication of power in the therapeutic relationship, in contrast with current and standard techniques, in a manner which seemed to many to strike directly at the heart of the current practice of psychotherapy in medicine, in social work, in nonmedical settings, and in vocational psychology as well. Pained and angry responses from the ranks of these helping professions were immediate, intense, and long-sustained.
Personal change in psychotherapy
Counseling and Psychotherapy was almost entirely theory-free and empirical in tone, and intentionally so. In 1942, Rogers was a clinical professor formulating his clinical experience for the benefit of clinical students; like many clinicians he was somewhat scornful of current psychological theories, regarding them as sparse and simplistic compared with the richness and complexity of the clients with whom he worked. The storm of controversy ensuing upon the publication of Counseling and Psychotherapy stimulated a flow of research and theoretical development by Rogers, his associates, and their students which has not yet abated. The development of theory and research in all areas until approximately 1956 was summarized and integrated by Rogers (1959, pp. 184-252). The approach to understanding personality, psychotherapy, and interpersonal relationships is entirely phenomenological. Technique is minimized and the necessary and sufficient conditions for inducing psychotherapeutic personality change are stated to be the following:
- Client and therapist are in contact.
- The client is in a state of incongruence: there is a discrepancy between his perceived self and his actual experience. He is vulnerable or anxious.
- The therapist is congruent in the relationship with his client: his perceptions of this relationship are accurate symbolizations of the actual experience.
- The therapist is experiencing unconditional favorable regard toward his client.
- The therapist is experiencing an empathic understanding of the client’s internal frame of reference.
- The client perceives, at least to a minimal degree, the unconditional favorable regard of the therapist for him as well as the empathic under-standing of the therapist.
It is noticeable that no techniques and no behavior prescriptions appear in this account. Everything is couched in terms of the experience of the client and of the therapist. Nonetheless, most responses of client-centered therapists continue to be reflections of feeling based on their perception of the internal frame of reference of the client. The behavior of client-centered therapists follows from this premise: The probability that the client will perceive the therapist as prizing (positively valuing) and understanding him is maximized when the therapist manages to convey his prizing attitude of unconditional favorable regard and when the therapist communicates his empathic understanding to the client in a consistent way.
The theory of personality presented is also phenomenological and shows the influence of gestalt theory. The only motive postulated in the theoretical system is the actualizing tendency: the inherent tendency of the organism to develop all of its capacities in ways serving to maintain or enhance the organism. The actualizing tendency reflects in large part the tendency to develop autonomy and to lessen heteronomy, or control by external forces. The actualizing tendency is a property of the total organism.
The self concept is the consistent conceptual gestalt (organization) derived from the perceptions of the “I” or the “me” that are developed in interaction with significant others. The ideal self concept denotes the self concept to which the individual aspires. The self-actualizing tendency is a subsystem of the basic organismic actualizing tendency and is a consequence of the development of the self concept. Self-actualization is the actualization of that portion of the experience of the organism which is symbolized in the self concept. When self-experience and the remainder of the experience of the organism are congruent, then the actualizing tendency remains relatively unified. If self concept and experience are incongruent, then self-actualization and actualization tendencies are incongruent. In this case, the individual is maladjusted: his self concept reflects a conflict between self-actualizing motives and actualizing motives. [SeeSelf Concept.]
The self concept does not direct the organism; indeed, the self concept derives from the actualizing tendency and is but one aspect of the tendency of the organism to react and behave so as to maintain and enhance itself. Motives or needs such as the need for favorable recognition from others and the need for self-esteem arise out of the organism’s experiences in relation to interpersonal transactions and their vicissitudes. In a broad sense, “experience,” in Rogers’ view, is the organism’s receiving the impact of sensory or physiological events happening at the moment; experience is what happens to the organism, including what happens within it. However, in a more restricted meaning “to experience” for Rogers also denotes the accurate symbolization in awareness of the sensory or physiological events.
The theory presented by Rogers, although containing many propositions, is basically simple. It concerns the development and self-development of the organism, the accurate symbolization in awareness of experience, and the perception of threat, with consequent defenses and effects upon interpersonal behavior. The development of an accurate self concept is held to be a basic capacity of the organism.
An inaccurately symbolized self concept emerges because the individual, in the course of development, begins to have a need for favorable regard from others and an analogous and consequent need for favorable self-regard but perceives himself as being only conditionally prized or loved by others. He incorporates this conditional prizing into his self concept and subsequently evaluates experiences on the basis of conditional prizings instead of in terms of the basic actualizing tendency. Perception of unconditional prizing by others leads, on the other hand, to satisfaction of the needs for favorable regard and self-regard in a way that is congruent with the basic actualization tendency. Development under optimal conditions of unconditional prizing leads to a person who is fully functioning, open to experience, and psychologically adjusted.
Some comments on the theory are in order. As stated before, it is relatively simple, having neither the comprehensiveness, say, of psychoanalytic theory nor the seemingly rigorous and elegant simplicity of behavior theory. Not too much is said about motivation, and the defense mechanisms, such as repression, denial, and reaction formation, are taken for granted: they have been discussed and investigated elsewhere. The theory was developed to account for what other theories neglected and to stress a view of human nature and experience not currently dominant in Western culture, namely, that the individual inherently actualizes and self-actualizes, is personal and subjective, is not at the mercy of individual drives, and has inherent capacities for realistic adaptation and unrestricted experiencing. He is often conditionally valued by significant others early in life and often responds by evaluating his self in terms of these conditional prizings. The individual has a history that results in various degrees of congruence between the actualization and the self-actualization tendencies: the lower degrees of congruence are maladjustive; the higher degrees approximate the fully functioning, fully experiencing individual, who evaluates autonomously and is personally creative. [SeeDefense Mechanisms.]
Clinical and empirical foundations
Despite its phenomenological language, Rogers’ theory has the virtue of being close to and being derived from clinical observation. When the client is in the psychotherapeutic situation, when he is unconditionally prized and is well understood by the therapist as he presents himself, he does change his self concepts, he does react more openly, he does abandon maladaptive strategies, maneuvers, and symptoms in relation to the therapist. He usually does not develop a “transference neurosis,” and his expressive style changes. The organization and use of language changes, and the individual comes to act differently with others than before. Observations of such changes led to the theory. What is not observationally based is the theoretical prediction of the increase in congruence between self concepts and experience. What is observed is that self concepts change and that the individual expresses himself as being in some ways more like the person he wants to be. However, the congruence of self concept and ideal concept is suspect because it is observed that some individuals claim to have congruent selves and ideals when obviously such is not the case; i.e., interpersonal behavior is not consistent with the claim, and worse, other persons, such as paranoid individuals, seem to have congruent self concepts and ideal concepts but are clearly psychologically maladjusted; thus the recourse by Rogers to the discrepancy between self concept and experience and between self-actualization and the actualization tendency, even though such discrepancies are not actually observed in the psychotherapeutic interaction.
In general, theoretical statements by writers within the client-centered orientation, with the exception perhaps of Raimy (1943) and Snygg and Combs (1949), have the same clinical-empirical and action-oriented flavor as those of Rogers. Complex behavior is considered. Little attempt is made to provide careful definitions in the sense in which terms such as stimulus, response, drive, and response generalization are carefully defined in, say, behavior theory because the primary referents can be pointed to in recordings, motion pictures, etc. This discriminability of primary referents is conceived to be an advantage. Considerable difficulty has been encountered by behavior theorists in defining such terms as stimulus, response, and response generalization unambiguously even for simple situations, and when they are applied as behavior therapy, the specification of reinforcing stimuli and of response generalization has been so vague that it seems safe to say that for some of the better-known studies it would be easy to obtain quite different results using the same reinforcing stimuli described by the investigators.
The therapy process
Rogers’ specifications of the necessary and sufficient conditions of personality change in psychotherapy are to a large extent understood by client-centered therapists in terms of the predominant conduct of therapists: unconditional prizing behavior, mostly expressed non-verbally, and reflections of feeling as communications of manifest themes that occurred in the client’s communications. The communicative behavior of clients includes the nonverbal, gestural, expressive components of communication which are linguistic in nature and which serve to modify the meaning of symbols and signs.
What happens in the psychotherapeutic hour when the therapist conducts himself in the manner mentioned above? Numerous studies, most of them cited by Rogers (1959), have been addressed to this question. While these studies are satisfactory in a certain sense, they do not really describe the events at all well. Hence, a naturalistic description will be attempted. The communicative behavior of the client usually, in contrast with psychotherapies in which the psychotherapist’s responses are interventive, shows thematic unity. Thematic unity is also evident in the sequence of responses. Along with this, the voice qualities change, and language usage also changes in such a way that the client appears to be more expressive and integrated in his communicative behavior, to be using a richer and more figurative language. When the therapist accurately symbolizes the themes in a client response, he is in actuality amplifying and developing them through his own language and voice qualities. Often these responses of the therapist are met by the client with “Yes, yes,” “That’s it exactly,” or “Exactly,” spoken with considerable emphasis. The theme voiced by the therapist (but voiced by the client immediately before) is then elaborated and developed with considerably more differentiation in both language and voice, creating an impression of supple and spontaneous flexibility. This is true even for quite disturbed clients communicating initially in a passive way and with the passive voice, and using such phrases as “This comes to mind.” As the therapist’s language becomes richer and more apt, as he makes more use of his voice, as his expressive gestures become more explicit, the more thematic is the development, the more figurative is the speech, and the more closely knit, congruent, and spontaneous become the interchanges of the client and the therapist. This behavioral process, so difficult to describe but so denotable in audio and photographic reproductions of psychotherapy interviews, at its best has the kind of literary quality one might ascribe to recitations of the ancient Greek bards, whose recitations were worked out anew in each encounter with an audience. Published reports of client-centered therapy are, unfortunately, poor representations of the process described.
Later theoretical development
Theory development since 1956 has largely concentrated upon developing the phenomenological perspective (Shlien 1962), with much stress on the experiencing process in relation to personality change (Gendlin 1964). Gendlin (1962) has written a philosophical treatise on personal experiencing that stresses the relation of experiencing to the creation of meaning. This work developed out of his training as a philosopher and his extensive encounters with client-centered psychotherapy. In extending his concept of experiencing to the under-standing of concepts and values (1963; 1964), psychotherapy (1961), and personality change (1964), Gendlin has concluded that changes may occur in psychotherapy even before concepts have been attained that accurately represent feelings referred to by the client. This occurs because the therapist’s responses themselves may lead to symbolic completions, closures, and elaborated themata even when the client does not perceive the therapist as prizingly understanding. In emphasizing the influence of the therapist in promoting closure, Gendlin is in effect changing Rogers’ conditions for personality change.
Dissatisfied with the postulational character of the actualization tendency, Butler and Rice (1963) have proposed that adient motivation, the need for experience, is the primitive base for the actualization and self-actualization tendencies. On the basis of studies of preference for complexity or novelty, of stimulus deprivation and of neurophysiological processes, they propose that adience is rewarded by thinking processes as well as by environmental transactions. The self-actualizing, fully functioning person autonomously creates experience for him-self, and he can autonomously reinforce and extinguish behavior (learn) without moving a muscle. [SeeStimulation Drives.]
With respect to psychotherapy, Butler and Rice maintain that a stimulating, expressive communicative style on the part of the psychotherapist enriches the experience of the client, focuses associations by reflections of feeling, and leads to symbolic completions and thema development. A “difficult” client with a poor prognosis may lower the responsive participation of the therapist, thus creating an experientially impoverished environment matching his inner experiencing, with the consequence that enrichment of experience may not ensue. Clients with poor prognosis are just those who, in the therapeutic interaction, are likely to create the conditions leading to lack of progress and no constructive personality change. Butler and Rice maintain that the therapist who can sustain a participative, stimulating, and responsive expressive style is likely to induce progress in therapy even when such progress seems improbable. Evidence supporting their hypotheses has been presented by Wagstaff (see Butler et al. 1963) and Rice (1965.)
Research on client-centered psychotherapy has been summarized or cited extensively in Rogers (1959; 1960), Seeman (1956; 1965), Butler (1958), and Grummon (1965). Attention here will be centered on the proposition that the changes noted in psychotherapy are due to the psychotherapeutic encounter rather than to spontaneous remission or other extrapsychotherapeutic agents. All work cited has been discussed in Rogers (1959), except when cited by year.
Early studies tended to be confined to content analyses of transcripts of therapy interviews. These studies showed that, to a considerable extent, therapists did, indeed, consistently employ the techniques they claimed to use (Porter, Snyder, Seeman, Strom). Furthermore, for clients it was demonstrated that there was a change in the proportion of responses indicating insight, self-exploration, and integration (Porter, Snyder, Curran, Stock, Hoffman); that there were decreasing proportions of distress and discomfort responses and increasing proportions of favorable responses to self (Raimy, Assum, & Levy; Kauffman & Raimy; Zimmerman); that decreasing self-exploration was exhibited when therapists complied with requests for guidance, information, and support (Bergman 1951); that there occurred an increasing acceptance of self and others (Sheerer); and that there was an increased correspondence between ideal self and self concept for cases evaluated as successful, whereas this did not occur in cases evaluated as unsuccessful (Aidman 1951; Bowman 1951).
In later studies, control techniques and measuring devices suggested by theory and research results were employed. Self-ideal relations were found to increase during the course of psychotherapy for the client group as a whole, the increase being greater for the group of clients judged to be definitely improved in terms of both therapist ratings and Thematic Apperception Test (TAT) ratings (Butler & Haigh 1954). The therapist’s judgments were made independently of the TAT ratings and of the tested self-ideal relations. There was a significant increase in the variability of the self-ideal correlations at the end of therapy and at the end of a follow-up period, indicating that self-acceptance was decreasing for some clients and increasing for others. The majority of the changes reflected increasingly self-ideal correspondence, however.
Butler showed that 11 of the clients serving as their own controls, to whom tests were administered 60 days prior to therapy, immediately before therapy, and 60 days or less after therapy began, changed their self-descriptions significantly more during the in-therapy period than during the no-therapy period (Butler 1964a).
Another control feature is the rating of clients on a scale measuring maturity of behavior (Rogers 1954). Friends of the clients who were not informed that the clients were in therapy and who knew nothing of the research, made these ratings. In general, mean ratings on these scores did not change significantly between pretherapy, therapy termination, and follow-up testing. However, when the clients were stratified on the basis of therapist rating on a nine-point scale of success, the mean increase on maturity scores from pretherapy to therapy termination was statistically significant for clients whose ratings were in the 7-9 range, while there was a statistically insignificant decrease for clients rated in the 1-5 range. For the period between pretherapy and follow-up testings there was a significant increase in average maturity ratings for clients in the 7-9 range and a significant decrease in average maturity ratings for clients in the 1-5 range.
The findings are remarkable because the groups used were very small and the therapist rated clients solely on the basis of interview behavior, while the lay observers presumably did not know their friends were in psychotherapy and knew nothing of the research. Comparable ratings on normal controls showed no mean change in score between testing periods.
In a later study of many of the same clients, Butler (1964b) related self-reports, ratings by independent lay observers, and ratings by therapists. His results indicate that the vantage points of clients, therapists, and observers provide similar information, although the judgments are made on different bases.
While this particular group was small, cross validation with another group yielded the same conclusion about the effects of psychotherapy on self-description. Cartwright and Vogel (1960) reported on a group of clients for whom they individually matched periods of waiting for therapy with in-therapy testing points. The wait periods varied from 4 to 24 weeks. They found statistically significant differences in the variability of self-descriptions indicative of adjustment (highly related to self-ideal correspondence) during the treatment period over and above those obtaining in the waiting period. Psychotherapy was held to account for the increase in the variability of self-description scores.
In another study reported by Butler (1964a), the self-ideal correlations of clients with good and poor prognoses were compared with those of clients with good and poor prognoses who were not receiving psychotherapy. The treatment group received ten weeks or less of psychotherapy, whereas the control group received no psychotherapy, for a ten-week period. Analysis of covariance of the self-ideal ideal correlations revealed that those of the treatment group changed more than those of the no-treatment control group and that the majority of the changes were in the direction of increased correspondence of self concepts and ideal concepts.
When clients are matched on prognosis and are randomly assigned, one can infer from these findings that self-acceptance does change in, and as a result of, client-centered psychotherapy. One can also infer that changes in self-acceptance are related in some way, not necessarily linearly, to changes in maturity of interpersonal behavior as seen by lay observers, to psychodynamic changes as reflected in indexes derived from projective tests, and to changes in personal integration and level of adjustment as perceived by therapists. No single study provides perfect control, but the progressive character of the results and the relationships of the measures lend considerable weight to the hypothesis that self-acceptance changes as a result of client-centered psychotherapy and that other changes, particularly maturity of interpersonal behavior, are associated with self-acceptance and the process of psychotherapy.
A particularly interesting study was conducted by Bills (1950). After a 30-day control period in which none of 18 third-graders who were retarded readers received play therapy, eight received client-centered play therapy and ten received no treatment. An analysis of covariance showed a statistically significant difference in gain in reading score for the treated group compared with the un-treated group. Bills’s study bears on the question of what kinds of behavior are affected by psychotherapy, adding reading to the list of self-regarding behavior, interpersonal behavior, and projective behavior. [SeeReading Disabilities.]
Research in client-centered psychotherapy since Rogers completed his survey (1959) has centered largely upon the conditions of psychotherapy as provided by the psychotherapist and upon therapist characteristics. Wagstaff has found three factors of expressive style in client verbal behavior, two of which are related to various criteria of outcome of psychotherapy (Butler et al. 1962; 1963); and Rice, analyzing responses of the therapists of the clients studied by Wagstaff, has found three factors of therapist vocal and lexical style, two of which are also related to various outcome criteria (1965). These studies support the hypothesis of Butler and Rice, alluded to earlier, that clients with poor prognoses deleteriously affect the responsiveness of their therapists.
Duncan (1965), studying a variety of discrete paralinguistic behaviors in both client and therapist, found significant relationships, on the one hand, between one aspect of therapy “process” (patterns of voice quality) and the therapist’s judgments of the process, and, on the other hand, between this process and client test performance both before therapy and after 20 interviews.
Gaylin (1965) devised a Rorschach function score designed to measure psychological health. Obtaining this score for pretherapy and post-twentieth-interview Rorschachs, he found that those clients with high ratings of improvement by their therapists exhibited improved scores; those with low ratings, poorer scores. Gaylin’s function score also correlated significantly with paralinguistic factors studied by Duncan.
Truax and Carkhuff (1963), working with Rogers, have presented evidence to show that when therapists dealing with hospitalized patients provided high levels of warmth, empathy, and congruence, patients improved; when they did not, patients became worse.
Client-centered psychotherapists hypothesize that the person is motivated largely by actualizing and self-actualizing tendencies which result in favorable personality change under proper interpersonal conditions initiated by the therapist. The results of studies of the psychotherapeutic situation and its effects strongly support these hypotheses. These studies also show that changes observed in psychotherapy are reflected in interpersonal relationships and in favorable and enduring changes in the structure of self concepts. In addition, the techniques and qualities of client-centered therapists significantly affect performances in other types of situations.
Although there are a few studies suggesting that client-centered psychotherapy compares favorably with other approaches (e.g., Shlien et al. 1962), it would be premature to claim that client-centered psychotherapy is more efficacious than other psychotherapies. This is due in part to the lack of systematic research on personal change in psychotherapy. Furthermore, different approaches to psychotherapeutic treatment, such as behavior therapy, apparently have goals somewhat different from those stated for client-centered psychotherapy. These circumstances render systematic comparisons difficult, if not impossible, at the present stage of development of research on psychotherapy. Currently, an opinion on the relative efficacy of various forms of psychotherapy must be regarded as just that and no more.
[Directly related are the entries Clinical Psychology; Counseling Psychology; Identity, Psychosocial; Self Concept. Other relevant material may be found in Gestalt Theory; Personality, article on Personality Development; personality: Con-Temporary Viewpoints, article on A Unique And Open System; Phenomenology; Psychology, article On Existential Psychology; Sympathy And Empathy; Thinking, article on Cognitive Organization And Processes.]
Aidman, Ted 1951 An Objective Study of the Changing Relationship Between the Present Self and Wanted Self-picture as Expressed by the Client in Client-centered Therapy. Ph.D. dissertation, Univ. of Chicago.
Axline, Virginia M. 1947 Play Therapy: The Inner Dynamics of Childhood. Boston: Houghton Mifflin.
Barrington, Byron 1961 Prediction From Counselor Behavior of Client Perception and of Case Outcome. Journal of Counseling Psychology 8:37-42.
Bergman, Daniel V. 1951 Counseling Method and Client Responses. Journal of Consulting Psychology 15:216-224.
Bills, Robert E. 1950 Non-directive Play Therapy With Retarded Readers. Journal of Consulting Psychology 14:140-149.
Bowman, Paul H. 1951 A Study of the Consistency of Current, Wish and Proper Self-concepts as a Measure of Therapeutic Progress. Ph.D. dissertation, Univ. of Chicago.
Butler, John M. 1952 The Interaction of Client and Therapist. Journal of Abnormal and Social Psychology 47:366-378.
Butler, John M. 1958 Client-centered Counseling and Psychotherapy. Volume 3, pages 93-106 in Progress in Clinical Psychology. Edited by Daniel Brower and Lawrence E. Abt. New York: Grune.
Butler, John M. 1964a Self-acceptance as a Measure of Outcome of Psychotherapy. Unpublished manuscript. → Paper delivered at the First International Congress of Social Psychiatry.
Butler, John M. 1964b Self Concept Change in Psychotherapy. Acta psychologica 23:119 only. → Volume 23 contains the Proceedings of the Seventeenth International Congress of Psychology held in Washington in 1963.
Butler, John M.; and Haigh, Gerard V. 1954 Changes in the Relation Between Self-concepts and Ideal Concepts Consequent Upon Client-centered Counseling. Pages 55-75 in Carl R. Rogers and Rosalind F. Dymond (editors), Psychotherapy and Personality Change: Co-ordinated Research Studies in the Client-centered Approach. Univ. of Chicago Press.
Butler, John M.; and Rice, Laura N. 1963 Adience, Self-actualization and Drive Theory. Pages 79-110 in Joseph M. Wepman and Ralph W. Heine (editors), Concepts of Personality. Chicago: Aldine.
Butler, John M.; Rice, Laura N.; and Wagstaff, Alice K. 1962 On the Naturalistic Definition of Variables: An Analogue of Clinical Analysis. Volume 2, pages 178-205 in Conference on Research in Psychotherapy, Research in Psychotherapy. Edited by Lester Luborsky and Hans Strupp. Washington: American Psychological Association.
Butler, John M.; Rice, Laura N.; and Wagstaff, Alice K. 1963 Quantitative Naturalistic Research: An Introduction to Naturalistic Observation and Investigation. Englewood Cliffs, N.J.: Prentice-Hall.
Cartwright, Desmond 1957 Annotated Bibliography of Research and Theory Construction in Client-centered Therapy. Journal of Counseling Psychology 4: 82-100.
Cartwright, Rosalind D.; and Vogel, John 1960 A Comparison of Changes in Psychoneurotic Patients During Matched Periods of Therapy and No Therapy. Journal of Consulting Psychology 24:121-127.
Duncan, Starkey D. JR. 1965 Paralinguistic Behaviors in Client-Therapist Communication in Psychotherapy. Ph.D. dissertation, Univ. of Chicago.
Gaylin, N. L. 1965 Psychotherapy and Psychological Health: A Rorschach Structure and Function Analysis. Ph.D. dissertation, Univ. of Chicago.
Gendlin, Eugene 1961 Experiencing: A Variable in the Process of Therapeutic Change. American Journal of Psychotherapy 15:233-245.
Gendlin, Eugene 1962 Experiencing and the Creation of Meaning: A Philosophical and Psychological Approach to the Subjective. New York: Free Press.
Gendlin, Eugene 1963 Experiencing and the Nature of Concepts. Christian Scholar 46:245-255.
Gendlin, Eugene 1964 A Theory of Personality Change. Pages 100-148 in Symposium on Personality Change, University of Texas, Personality Change. Edited by Philip Worchel and Donn Byrne. New York: Wiley.
Gendlin, Eugene 1965 Values and the Process of Experiencing. Unpublished manuscript.
Grummon, Donald L. 1965 Client-centered Therapy. Pages 30-90 in Buford Stefflre (editor), Theories of Counseling. New York: McGraw-Hill.
Raimy, Victor C. 1943 The Self-concept as a Factor in Counseling and Personality Organization. Ph.D. dissertation, Ohio State Univ.
Rice, Laura N. 1965 Therapist’s Style of Participation and Case Outcome. Journal of Consulting Psychology 29:155-160.
Rogers, Carl R. 1942 Counseling and Psychotherapy: Newer Concepts in Practice. Boston: Houghton Mifflin. → See especially pages 19-47, “Old and New Viewpoints in Counseling and Psychotherapy.”
Rogers, Carl R. 1954 Changes in the Maturity of Behavior as Related to Therapy. Pages 215-237 in Carl R. Rogers and Rosalind F. Dymond (editors), Psychotherapy and Personality Change: Co-ordinated Research Studies in the Client-centered Approach. Univ. of Chicago Press.
Rogers, Carl R. 1959 A Theory of Therapy, Personality, and Interpersonal Relationships, as Developed in the Client-centered Framework. Volume 3, pages 184-256 in Sigmund Koch (editor), Psychology: A Study of a Science. New York: McGraw-Hill.
Rogers, Carl R. 1960 Significant Trends in the Client-centered Orientation. Volume 4, pages 85-99 in Progress in Clinical Psychology. Edited by Lawrence E. Abt and Bernard F. Riess. New York: Grune.
Rogers, Carl R. 1961a On Becoming a Person: A Therapist’s View of Psychotherapy. Boston: Houghton Mifflin.
Rogers, Carl R. 1961b A Theory of Psychotherapy With Schizophrenics and a Proposal for Its Empirical Investigation. Pages 3-19 in J. G. Dawson, H. K. Stone, and N. P. Dellis (editors), Psychotherapy With Schizophrenics: A Reappraisal. Baton Rouge: Louisiana State Univ. Press.
Rogers, Carl R.; and Dymond, Rosalind F. (editors) 1954 Psychotherapy and Personality Change: CoordinatedResearch Studies in the Client-centered Approach. Univ. of Chicago Press.
Rogers, Carl R.; and Kinget, G. Marian 1960 Psychotherapie en menselijke verhoudingen: Theorie en praktijk van de non-directieve therapie. Utrecht (Netherlands): Spectrum. →; A French translation was published in Louvain by Presses Universitaires de France in 1962.
Seeman, Julius 1956 Client-centered Therapy. Volume 2, pages 98-113 in Progress in Clinical Psychology. Edited by Daniel Brower and Lawrence E. Abt. New York: Grune.
Seeman, Julius 1965 Perspectives in Client-centered Therapy. Pages 1215-1229 in Benjamin B. Wolman (editor), Handbook of Clinical Psychology. New York: McGraw-Hill.
Shlien, John M. 1961 A Client-centered Approach to Schizophrenia: First Approximation. Pages 285-317 in Arthur Burton (editor), Psychotherapy of the Psychoses, New York: Basic Books.
Shlien, John M. 1962 Toward What Level of Abstraction in Criteria? Pages 142-154 in Conference in Research in Psychotherapy 1961, Research in Psychotherapy. Washington: American Psychological Association.
Shlien, John M.; Mosak, Harold H.; and Dreikers, Rudolf 1962 Effect of Time-limits: A Comparison of Two Psychotherapies. Journal of Counseling Psychology 9:31-34.
Snygg, Donald; and Combs, Arthur W. 1949 Individual Behavior: A New Frame of Reference for Psychology. New York: Harper. → A revised edition was published in 1959.
Truax, Charles B.; and Carkhuff, Robert R. 1963 For Better or Worse: The Process of Psychotherapeutic Personality Change. Pages 118-157 in Academic Society on Clinical Psychology, Montreal, 1963, Recent Advances in the Study of Behaviour Change: Proceedings of the Academic Assembly on Clinical Psychology. . . . Montreal: McGill Univ. Press.
Group psychotherapies are based on the recognition that, with proper guidance, certain types of persons with psychiatric disorders can help each other. In all forms of group therapy, patients and a therapist repeatedly meet to conduct certain activities within the framework of a special group structure and code. Their emotionally charged interactions with the leader and with each other may help to correct their faulty communication behavior and their distorted perceptions of themselves and others, leading to improved social and personal functioning and to relief of psychic distress.
Group healing methods are as old as individual ones. From earliest times, sufferers have sought relief through group activities at religious shrines, and many continue to do so. Group therapies began to emerge as recognized and legitimate forms of psychotherapy, however, only in the 1920s. Many early practitioners exploited the instructional and inspirational potentialities of groups in a purely empirical way; but two pioneers, Trigant Burrow and J. L. Moreno, offered theoretical rationales that, although not in the mainstream of psychiatric thought, had considerable influence. According to Burrow (Riese & Syz 1963), mental disorder was a disturbance in communication, created largely by a person’s “privately cherished and secretly guarded” image of himself; the aim of group therapy was to enable him to express himself as he really was by exposing the socially determined basis of his self-image. Moreno (1959) stressed the freeing of spontaneity through encour-aging the patient to act out his problems, with the aid of other patients as well as of therapists, in the presence of a vicariously participating audience. In the 1930s psychoanalysts began to experiment with group therapy based on psychoanalytic theory. During World War II, psychotherapists in the armed forces were forced to resort to group methods to handle the enormous load of patients. These methods proved so successful that they spread with almost explosive rapidity. Many modifications were introduced and applied to an ever increasing variety of psychiatric conditions in many different settings. By the 1950s, group therapy in the United States had assumed the dimensions of a movement and had two professional associations, each with a journal devoted to promulgating it.
The wide popularity of group therapies may be partly due to the fact that they offer a type of intimacy characteristic of the family and other primary groups. The urbanization and mobility of modern life have reduced opportunities for such relationships, and the shallow, transient, competitive sociability of residential development, office, and club is not an adequate substitute.
Characteristics of group therapy
Therapeutic groups are conducted in outpatient clinics, private offices, social agencies, mental hospitals, and correctional institutions. Leaders are characteristically psychiatrists, psychologists, psychiatric social workers, or ministers. Some groups are conducted by their own members, without professional guidance. Most forms have a single leader, often with an observer to record what occurs; but some have cotherapists—usually a man and a woman—who try to take different functional roles, such as “father” and “mother.”
Composition of therapy groups
Most therapy groups consist of from 7 to 25 strangers selected according to a principle such as age, institutional residence, or diagnostic category. Examples are groups composed of children, adolescents, mature adults, or the aged; of alcoholics, psychotics, or neurotics; or of persons whose only common feature is residence in the same mental hospital or correctional institution.
Increasing efforts are being made to group patients within these broad categories in such a way as to maximize their communication potential. It has been noted that groups tend to elicit certain group roles in predisposed members. For example, one repeatedly finds monopolists, nonparticipants, therapist’s assistants, members who try to hold the stage by constantly complaining, and others who try to dominate by moralizing (Rosenthal et al. 1954). This raises the possibility of balancing groups by selecting prospective members with regard to their predilections for different group roles. Observation of patients’ actual group behavior seems to be a more reliable way of determining this than individual interviews and psychological tests. To this end, assignment of patients to therapeutic groups may be based on their behavior in a diagnostic group, to which all patients are briefly assigned, where this is administratively possible.
A recent trend toward treatment of family groups as a unit is based on the view that the member officially labeled the patient is in reality the victim of a disturbed communication network in which other family members are also involved (Bell 1961; Satir 1964). This approach seems especially promising when the patient is chronologically or psychologically immature, as in the case of a child, an adolescent, or a schizophrenic.
Therapists meet privately with patients before the first group meeting to determine their suitability for inclusion and to prepare them for the group; they meet again, later, to evaluate the patients’ readiness for discharge. The extent of private patient-therapist contacts at these and other times varies widely, depending on the therapist’s conceptualization of treatment; but it is generally agreed that such meetings must be limited if they are not to drain important material from the group sessions.
This limitation also holds for meetings of patients between formal sessions, since such informal meetings create opportunities for antitherapeutic as well as therapeutic encounters. With family groups and married couples, such meetings are of course unavoidable; and they seldom can be completely prevented in groups of strangers. Extra group meetings foster growth of group cohesiveness and give members opportunities to interact away from the inhibiting presence of the therapist, which may be advantageous. On the other hand, by diminishing the members’ “social incognito,” they may inhibit candid expression of feeling in the group and may foster “acting-out” of personal problems through, for example, exploitative or anxiety-relieving sexual behavior, thereby removing the problems from the helpful scrutiny of the group. Some therapists deal with this problem by prescribing meetings in their absence, so that these become part of treatment; all try to set the ground rule that there be no secrets from the group. The knowledge that anything occurring in an extra-group encounter may be reported to the group usually has an inhibitory effect on antitherapeutic activities.
Leader-centeredness or group-centeredness
Methods of group therapy can be ordered with reference to their degree of leader-centeredness or group-centeredness. Since group members are chosen by the therapist and initially expect help only from him, all groups begin as leader-centered. Throughout the duration of some groups the therapist continues to be seen as the sole therapeutic agent, and the group as merely the arena in which members interact with him and each other. Group-centered approaches attribute considerable therapeutic effects to properties of the group itself. Some groups have no official leader. In others, the leader encourages patients to rely increasingly on each other and deliberately tries to foster a group code and group attributes, such as cohesiveness, that have therapeutic potential. Actually, in therapy groups as in all others, leader behavior, member behavior, and group processes continuously interact. For example, a controlled study of group therapy with hospitalized patients found that intra-personal exploration by the patients was associated with certain aspects of the therapist’s style of leadership and with certain properties of the group itself (Truax 1961).
Degree of activity structure
Groups can also be roughly classified in terms of the extent to which their activities are organized. Some, such as Alcoholics Anonymous, therapeutic social clubs, and Recovery, Incorporated (Wechsler 1960), rely on tightly structured, prescribed activities; others, often termed interview or free-interaction groups, create an ambiguous situation and place responsibility for what occurs on the members. In general, the more structured the group, the larger its size can be.
Free-interaction groups. To illustrate the range of group therapies, three divergent types may be briefly described. Free-interaction groups typically consist of up to eight adult outpatients and a professional leader. These groups seek to create a code and a climate that foster development of greater self-reliance, spontaneity, and maturity in the members. They encourage free expression of feeling and discussion of personal problems, relying primarily on the shared experiences of the participants to help each find better solutions to his own problems. The responsibility for choice of topic and conduct of the meeting lies largely with the members. The therapist creates and maintains the ground rules and therapeutic atmosphere, facilitates members’ interactions, and clarifies the meanings of their behavior (Foulkes & Anthony 1957; Mullan & Rosenbaum 1962).
Alcoholics Anonymous. Alcoholics Anonymous is a self-selected, group-oriented organization based on the single criterion of self-confessed alcoholism. Meetings are conducted by the members in a highly structured fashion, and consist chiefly of testimonials about how wretched they were when they drank and how much better they are since they have stopped. Other prescribed activities include making restitution to persons they have harmed and being available to alcoholics who ask for help. The considerable therapeutic effect of these groups lies in the unique degree of support and mutual understanding that alcoholics can give each other.
Therapeutic social clubs. Therapeutic social clubs, used chiefly for hospitalized patients or those making the transition back to the community, are run along parliamentary lines, and plan and con-duct projects financed by dues. The therapist selects the members and attends all meetings, but remains in the background. The central purpose of these clubs is to combat the vicious circle of impaired social skills, withdrawal, and further social impairment by helping members to improve their social abilities (Bierer 1944).
Results of group therapies
Evaluation of the results of group therapies, as of all other forms of psychotherapy, is hampered by the absence of a satisfactory classification of psychiatric disorders and inadequate criteria of improvement, but certain clinical impressions are sufficiently widespread to warrant mention. Because of the tensions created by early meetings, especially in unstructured, group-centered approaches, the drop-out rate is higher than in individual psychotherapy, unless the therapist makes special efforts to maintain the patient’s commitment to treatment. Particularly prone to leave are patients with such socially unacceptable problems as sexual deviations; those needing strong support from an authority figure; the excessively shy, sensitive, or suspicious; and those with high dominance but low popularity (Taylor 1961).
About two-thirds of those who remain in treatment improve, as in individual psychotherapy. Group therapy may be especially helpful to patients who are inadequately socialized, including those who express their personal problems in somatic symptoms rather than words, schizophrenics, and sociopaths. Certain obsessional patients, whose verbal and conceptual skills act as defenses against experiencing emotions in analytic-type therapies, may profit from the strong emotional reactions triggered by group processes.
Group treatment may aid families and married couples whose communications have become frozen in self-perpetuating, self-aggravating patterns, and who have become so busy defending themselves that they no longer “hear” each other. As they repeatedly display their pathological interaction patterns in a setting that offers support and encourages self-examination, each family member may come to understand how he contributes to the problems of the others and learn to modify his behavior.
Therapy groups and group dynamics
Although controlled experimentation with therapy groups obviously is very difficult, they provide a source for hypotheses concerning all small-group functioning; and some data obtained from experimental studies of small groups may cast light on the phenomena of therapy groups. The following discussion reviews some possible relationships between the two fields that afford areas for research (Kelman 1963).
Most therapy groups rep-resent subcultures that are demarcated from the culture of the community at large in certain important respects. One is the ground rule that what is said or done in a group meeting is confidential with respect to the outside world. In contrast to other types of groups, admission is secured by confession of failure in some aspects of living. Status within the group is related to skill in playing the role of patient, as defined by the group code, and to demonstration of clinical improvement. Another distinguishing feature of most therapy groups is that members are expected to express their feelings about themselves, persons outside the group, other group members, and the leader candidly and freely. At the same time, acting on feelings is interdicted or carefully controlled, as in psychodrama. Finally, therapy groups demand that patients in conflict keep in communication.
Such a group code maximizes opportunities for learning and modification of attitudes and behavior. The protected atmosphere encourages patients to express their real feelings, uninhibited by the norms of ordinary social intercourse. Encouragement to verbalize feelings helps patients to differentiate them. Since the group is tolerant and there is little carry-over into daily life, penalties for failure are mitigated, thus encouraging freedom of experimentation. In daily life, antagonists customarily stop communicating, thereby leaving their mutual distortions unchanged. Maintenance of communication despite conflict encourages verbalization, enables each antagonist to gain fuller understanding of the other’s position and his own, and helps each to learn to stand his ground despite opposition.
Member-leader and member-member interactions
All forms of psychotherapy support patients’ self-esteem, arouse them emotionally, and offer them new cognitions. These features give them courage to examine and modify their habitual attitudes, supply the motive power for doing so, and guide their efforts, thereby enabling them to correct maladaptive attitudes and behavior and to progress in self-development. Therapeutic groups have certain potential advantages with respect to these goals.
Successful therapy groups overcome members’ demoralizing sense of isolation by enabling them to discover that others have similar problems. Furthermore, in contrast to private treatment, in which all help flows from therapist to patient, members of therapy groups find that they can help each other. This counteracts the damage to self-esteem resulting from having been derogated by family and friends.
An important aspect of both the supportive and the influencing power of therapy groups lies in the cohesiveness successful ones develop, growing out of members’ discovery of common problems, experience of mutual helpfulness, and a history of shared crises and triumphs. This is manifested by therapy groups’ reluctance to disband and their resistance to the admission of new members. The danger that cohesiveness will produce pressure on members toward artificial conformity of behavior is reduced by the fact that the group task is to help each member develop in accordance with his own inner needs, so that the group norms encourage diversity.
Therapy groups arouse members emotionally in ways not available to individual therapy. One is rivalry for the leader’s attention and approval, which, incidentally, seems to be more acute when the leader and members are of different sexes. The central initial position of the therapist is illustrated by the finding that in a given group those patients who experience a “better” relationship with him relative to other patients show more improvement and are less likely to drop out than are those who experience a “worse” one, regardless of the absolute goodness of the relationship (Parloff 1961). The protective atmosphere of therapy groups and their norm of open expression of feelings facilitate expressions of anger toward the therapist. However, since members depend on him for help, prolonged, unanimous condemnation of him cannot occur. Whether a phase of scapegoating the leader is a necessary step in the development of group cohesiveness, as some believe, remains a question for research.
Members also arouse a wide range of hostile and friendly feelings in each other, based on more or less unconscious distortions as well as genuine differences or similarities in background, life experience, and values. In addition, many patients seem to benefit from vicarious emotional participation in problems of others.
From the cognitive standpoint, members also serve as models for each other; as sources of feed-back, the value of which is increased by the fact that it is less distorted by the rules of social intercourse than are reactions from friends and acquaintances; and as representatives of attitudes existing outside the group. Acceptance by other members carries more weight than acceptance by the therapist, because they are viewed as being more like ordinary people.
Because group members represent the outside world, transfer of insights obtained through group experiences to daily life is easier than it is in private psychotherapy. Commitment to the group and awareness that one will report back to it help to sustain changes in attitude. On the other hand, the necessity of constantly dealing with the reactions of other members may hamper progress in patients who need to withdraw into reverie or fantasy or to subject their problems to leisurely scrutiny.
Group development and group issues
Well-established therapy groups differ from new ones in many ways, including greater freedom of expression among members and a greater tendency for topics to carry over from one session to the next; but whether therapy groups exhibit regularities of development similar to problem-solving groups remains open despite some experimental evidence in support of this possibility (Psathas 1960).
The developmental process in therapy groups can be viewed from the standpoint of the progression of group preoccupations, or issues influencing the members at more or less unconscious levels. It has been suggested, for example, that initial meetings of therapy groups are dominated by three antitherapeutic “basic assumptions”: dependency, fight-flight, and pairing, and that group progress can be judged by members’ success in overcoming the obstacles these “basic assumptions” present to achievement of the therapeutic goal of increased self-realization (Bion 1961). Another theory conceptualizes group progress in terms of the successive emergence and resolution of “focal group conflicts.” A well-nigh universal example of this in early meetings of free-interaction groups is the conflict between the desire to achieve therapeutic gain by becoming committed to the group and exposing one’s feelings to it and the fear that by so doing one is exposing oneself to rejection and ridicule (Whitaker & Lieberman 1964).
Viewed in a larger perspective, group therapies exploit the universal human tendency to validate subjective experiences by comparing them with experiences of other persons who are perceived as similar. The standards, structure, and processes of therapy groups facilitate these comparisons and help members to correct the distortions thus brought to light. Since each group member deviates in a different way but shares attitudes consistent with the social norms of the community, the attitudes and values of the group as a whole tend to foster improved social adjustment of each member.
The advantages and limitations of group psychotherapy as compared with private methods of psychotherapy require further exploration, but it seems probable that the potentialities of group approaches have not yet been fully realized.
Jerome D. Frank
[Other relevant material may be found in GroupsandSociometry.]
Bell, John E. 1961 Family Group Therapy: Methods for Psychological Treatment of Older Children, Adolescents, and Their Parents. U.S. Public Health Service Monograph. Publication No. 826. Washington: Government Printing Office.
Bierer, Joshua 1944 A New Form of Group Psycho-therapy. Mental Health (London) 5:23-26.
Bion, Wilfred R. 1961 Experiences in Groups, and Other Papers. New York: Basic Books. → Seven of these papers were published in Human Relations from 1948 to 1951.
Corsini, Raymond J. 1957 Methods of Group Psychotherapy. New York: McGraw-Hill.
Foulkes, Siegmund H.; and Anthony, E. J. 1957 Group Psychotherapy: The Psycho-analytic Approach. Baltimore: Penguin.
Kelman, Herbert C. 1963 The Role of the Group in the Induction of Therapeutic Change. International Journal of Group Psychotherapy 13:399-451. → Includes discussion by Saul Scheidlinger.
Moreno, Jacob L. 1959 Psychodrama. Volume 2, pages 1375-1396 in American Handbook of Psychiatry. Edited by Silvano Arieti. New York: Basic Books.
Mullan, Hugh; and Rosenbaum, Max 1962 Group Psychotherapy: Theory and Practice. New York: Free Press.
Parloff, Morris B. 1961 Therapist-Patient Relationships and Outcome of Psychotherapy. Journal of Consulting Psychology 25:29-38.
Powdermaker, Florence B.; and Frank, J. D. 1953 Group Psychotherapy: Studies in Methodology of Research and Therapy. Cambridge, Mass.: Harvard Univ. Press.
Psathas, G. 1960 Phase Movement and Equilibrium Tendencies in Interaction Process in Psychotherapy Groups. Sociometry 23:177-194.
Riese, W.; and Syz, H. 1963 Phyloanalysis: Theoretical and Practical Considerations on Burrow’s Group-analytic and Socio-therapeutic Method. Acta Psycho-therapeutica et Psychosomatica: International Journal of Psychotherapy and Psychosomatics (Basel) 11 (Supplement): 5-88. → Part 1, “Phyloanalysis (Burrow)—Its Historical and Philosophical Implications,” by W. Riese, is on pages 5-36. Part 2, “Reflections on Group- or Phylo-analysis,” by H. Syz, is on pages 37-88.
Rosenthal, David; Frank, J. D.; and Nash, E. H. 1954 The Self-righteous Moralist in Early Meetings of Therapeutic Groups. Psychiatry 17:215-223.
Satir, Virginia 1964 Conjoint Family Therapy. Palo Alto, Calif.: Science and Behavior Books.
Slavson, Samuel R. (editor) 1956 The Fields of Group Psychotherapy. New York: International Universities Press.
Taylor, Frederick K. 1961 The Analysis of Therapeutic Groups. Oxford Univ. Press.
Truax, Charles B. 1961 The Process of Group Psycho-therapy: Relationship Between Hypothesized Therapeutic Conditions and Intrapersonal Exploration. Psychological Monographs 75, no. 7.
Wechsler, Henry 1960 The Self-Help Organization in the Mental Health Field: Recovery, Inc.; A Case Study. Journal of Nervous and Mental Disease 130:297-314.
Whitaker, Dorothy Stock; and Lieberman, Morton A. 1964 Psychotherapy Through the Group Process. New York: Atherton.
The term “behavior therapy” was introduced by B.F. Skinner and O. R. Lindsley in 1954 and popularized by H.J. Eysenck (1960). It refers to psychotherapeutic methods directly based on experimentally established learning principles. Although “behavior therapy” is broadly synonymous with “conditioning therapy” and “behavioristic psychotherapy,” it more specifically denotes the methods that have developed from learning theory since the 1940s.
While the principles of learning upon which behavior therapy is based have stemmed mainly from the work of Clark L. Hull (1943)—who in many respects united the lines of study begun by Ivan P. Pavlov in Russia and by Edward L. Thorndike and John B. Watson in the United States—a distinctive group of techniques based on B. F. Skinner’s operant conditioning paradigm (1938) has been emerging in recent years. Experimental neuroses, first produced in Pavlov’s laboratories, provided the primary data from which Hullian learning theory evolved behavior therapy. Ironically, there could have been no such evolution in the Soviet Union because of the pervasive acceptance there of Pavlov’s view that a neurosis is due to the establishment of a chronic pathological focus in the central nervous system.
Among those who in the 1920s and 1930s tried to apply principles of learning to clinical problems, foremost mention must be made of Mary Cover Jones (1924), who was the first deliberately to invoke the counterconditioning method that dominates present-day behavior therapy (and whose work moldered in the dust for most of the ensuing quarter of a century). She treated children’s phobias by having the patient eat in the presence of a feared object. At first, the object was at a distance. Then, as his anxiety diminished, the patient was placed closer and closer to it. Guthrie (1935) realized the wide applicability of this principle, stating that the rule for overcoming an undesired response is to control the situation so that the cue to the undesired response is present while “other behavior prevails.” Dunlap (1932) originated the technique of negative practice, in which the extinction mechanism is used to overcome unadaptive motor habits like tics through instigating their repeated evocation in the absence of reinforcement.
Approaching experimental neuroses from the standpoint of modern learning theory, Wolpe (1952; 1958) demonstrated that the behavior observed in neurotic states had all the attributes of learned behavior. The manifestations of anxiety and agitation were similar in detail to the behavior originally evoked in the situations of conflict or noxious stimulation that were used to precipitate the neurosis; the neurotic responses were conditioned to and remained under the control of stimuli present at the time of causation; and neurotic responses of smaller intensity could be evoked, in accordance with the principle of primary stimulus generalization, by other stimuli similar to those to which the neurotic reaction had been directly attached. The most marked and constant neurotic responses were autonomic responses typical of anxiety. These failed to undergo extinction no matter how often or for how long the animal was exposed to the experimental situation, but they could consistently be removed if the animal could be induced to eat in the presence of anxiety-evoking stimuli. Since the animal’s eating was inhibited if anxiety was strong, food had to be offered first in the presence of generalized stimuli that aroused anxiety weakly; and then reciprocally, the eating would inhibit the anxiety, and repeated feedings would diminish it to zero. The same treatment in successively more “severe” situations eventually enabled the animal to eat without anxiety in the cage where the neurosis had been induced.
The methods of behavior therapy
These therapeutic experiments suggested the generalization that the reciprocal inhibition mechanism is the basis of the psychotherapeutic effects obtained by counterconditioning methods, so that if any response that inhibits anxiety can be made to occur in the presence of anxiety-evoking stimuli, it will on each occasion to some extent weaken the conditioned connection between these stimuli and the anxiety responses. This idea was subsequently widely applied in the treatment of human neuroses. Not only eating but a considerable number of other responses in human beings are incompatible with anxiety and thus lend themselves to therapeutic application. The use of some of these responses is briefly described below, followed by a short account of some methods employing different learning mechanisms. (For further details of many techniques of this type, see Wolpe 1958; Eysenck 1960; 1964; Wolpe ’ Lazarus 1966.)
The group of counterconditioning (reciprocal inhibition) methods is applied mainly, but by no means entirely, to the elimination of unadaptive anxiety-response habits such as fear of crowds, of praise, or of criticism. Such habits are the crux of most neuroses, and when they are overcome, treatment of “defenses against anxiety” and other secondary processes becomes irrelevant.
Assertive responses Assertive responses are used to countercondition neurotic fears aroused in interpersonal interchanges. The term “assertive” is employed here a good deal more broadly than in common parlance and includes not only responses of a more or less aggressive nature but also others expressing affection, liking, admiration, and revulsion—almost any feeling other than anxiety (Salter 1949; Wolpe 1958). Aggressive kinds of assertion are, however, very commonly required. For example, there are many patients whom unjust criticism renders hurt and helpless. The therapist applauds the anger and resentment that they inevitably feel in the situations they inadequately handle and gives detailed instructions for the appropriate expression of these feelings. Such expression reciprocally inhibits the anxiety, and repetition of such expression brings about a cumulative conditioned inhibition of anxiety.
Sexual responses Sexual responses are employed to overcome habits of anxiety inappropriately evoked in sexual situations. For example, the male patient usually complains of impotence or premature ejaculation, both of which are generally due to anxiety interfering with the predominantly parasympathetic responses that subserve penile erection. The emotional components of the sexual response (sexual feelings) usually remain adequate in the patient so afflicted. The therapist, having ascertained at what stage in the sexual approach anxiety begins to be experienced, instructs the patient (who must have secured the cooperation of his sexual partner) to take his sexual approach no further than this stage of minimal anxiety on repeated occasions—until the anxiety has decreased to zero. He is then directed to go on to the next stage in the same way. Advances continue to be made step by step until normal intercourse is achieved, usually from three to six weeks after the start of therapy. Although the principle is simple, the detailed tactics must always be adjusted to the individual case (see Wolpe 1958; Wolpe & Lazarus 1966).
Desensitization and muscle relaxation Relaxation, long a popular prescription for nervous disturbances, first achieved scientific respectability through the work of Edmund Jacobson (1938), who showed its autonomic effects to inhibit those effects characteristic of anxiety. Jacobson treated neurotic patients by giving them very extensive training in relaxation and then instructing them to relax at all times all muscles not in use (differential relaxation). A similar program promulgated by Schultz (Schultz & Luthe 1950) has been widely adopted in Europe. It would seem that when improvement occurs, it is because persistent relaxation provides the possibility of reciprocal inhibition of anxiety aroused by stimuli that appear in the course of daily life.
Systematic desensitization, one method of using deep muscle relaxation to decondition neurotic anxiety, is much more economical of time and effort and affords detailed control of the therapeutic process. Training in deep muscle relaxation occupies only part of each of about six sessions. The greater part of these sessions is devoted to the construction of anxiety hierarchies. If a particular patient is neurotically anxious about high places and about being rejected, situations relating to each of these areas are listed in descending order of intensity of anxiety reaction, each list constituting a hierarchy.
In the actual desensitization procedure, the patient is made to relax as deeply as possible, and then the least disturbing scene from one of his hierarchies is presented to his imagination for a few seconds. Presentations are repeated until he no longer has any disturbance, and the same procedure is followed all the way up the hierarchy. Almost invariably there is transfer of this effect when the patient is exposed to the real situation. In individuals who are not disturbed upon imagining situations that disturb them in reality, desensitization requires the exploitation of real stimuli, being then called “desensitization in vivo.”
Other modes of desensitization Other inhibitors of anxiety may also be employed therapeutically in a systematic way. An anxiety-inhibiting effect is produced by the emotions spontaneously aroused in some patients by the therapeutic situation itself (see below). In behavior therapy this has been mainly used for desensitization in vivo. For example, in cases of anxiety in social situations characterized by tremor of the hand while lifting a teacup, patient and therapist repeatedly raise first an empty glass and then a progressively fuller one, until all signs of shaking disappear at each stage; and later they repeat the sequence before an audience.
Lazarus and Abramovitz (1962) have reported the desensitization of children’s phobias by the use of what they call “emotive imagery.” The patient is made to expose himself in imagination to phobic stimuli of increasing intensity in contexts of pleasant emotional excitement.
Recently, use has been made of the observation that anxiety can be inhibited through cutaneous stimulation by nonaversive galvanic shocks. The mechanism of this effect may well turn out to depend on afferent collateral inhibition (Eccles 1957) as may also that of the technique of inhibiting anxiety through the arousal of a dominating motor response evoked by mild electric current (Wolpe 1954; 1958).
Avoidance conditioning Avoidance (aversive) conditioning is the application of the reciprocal-inhibition principle to the overcoming of responses other than anxiety. It is employed largely to treat obsessional behavior. The agents commonly used have been strong faradic stimulation of the forearm and drug-induced nausea, either of which must be administered in an appropriate time relation to the stimulus to which avoidance conditioning is desired. Avoidance conditioning has been effectively used in cases of obsessional thinking, compulsive acts, fetishism, and homosexuality. It has been least successful in homosexuality, which is often based on neurotic interpersonal anxiety and in such cases should be treated by deconditioning the anxiety (Stevenson ’ Wolpe 1960). Avoidance conditioning has also been applied with limited success in the treatment of addiction, especially alcoholism. [SeeLearning, article onavoidancelearning.]
Techniques based on the extinction mechanism—the breaking of habits through repeated performance of the relevant act without reinforcement—were introduced by Dunlap (1932) under the name “negative practice” and in recent years have again been employed occasionally in the treatment of such motor habits as tics. In the course of large numbers of forced evocations of the undesired movement, spontaneous evocations of it are progressively lessened.
Certain therapeutic measures have given the appearance of applying the extinction principle to the elimination of emotional reactions (e.g., Malleson 1959). The patient is exposed to anxiety-arousing stimuli, either in reality or in imagination, at the greatest possible strength. In some cases this leads to the decline and ultimate elimination of the anxiety response habit, but more often it does not. It is very doubtful that such improvement is really due to experimental extinction; and a form of inhibition has been suggested as the possible mechanism (Teplov et al. 1956). Both clinically and experimentally, the elicitation of a high-intensity anxiety response ordinarily tends to increase the habit strength of that response.
While the overcoming of unadaptive autonomic response habits is usually the central task of behavior thery, very frequently there is also a need to form adaptive motor habits. Such conditioning is often part and parcel of the measures employed to break down the anxiety habit, as, for example, in the case of assertive training. But motor habits often need to be changed even where anxiety is not involved. For instance, a man who has repeatedly spoiled courtships by over-eager behavior might be taught to “play it cool.” If the new behavior is successful, it naturally tends to replace the old. In enuresis nocturna, waking is conditioned to the imminence of urination, and this makes possible the subsequent conditioned inhibition of urination during sleep (Eysenck 1960, p. 377).
In recent years Skinnerian operant conditioning techniques have been used to remove and replace undesirable habits. Anorexia nervosa has been successfully treated by providing social rewards—such as the use of a radio or permission to receive company—contingent upon the patient’s eating, while withdrawing these rewards when the patient fails to eat (Bachrach et al. 1965). Several varie-ties of psychotic behavior have been treated on the same principle (e.g., Ayllon 1963), bringing about major and lasting changes in chronic schizophrenic patients, some of whom have been continuously hospitalized for decades.
The results of behavior therapy
The most distinctive feature of behavior therapy is that it enables the therapist to plan therapeutic strategy and control its details, in contrast to merely setting a framework for transactions with the patient and hoping that beneficial effects will emerge. The behavior therapist can specify the reactions to be overcome and the means to be employed in overcoming them, and he can often state the quantitative relations to be expected between defined therapeutic operations and amount of habit change (Wolpe 1963).
Two fairly extensive studies (Wolpe 1958; Lazarus 1963) have evaluated the results of behavior therapy in terms of R. P. Knight’s five criteria: symptomatic improvement, increased productiveness, improved adjustment and pleasure in sex, improved interpersonal relationships, and the ability to handle ordinary psychological conflicts and reasonable reality stresses (Knight 1941). From these reports it appears that over 80 per cent of unselected neurotic patients exposed to the available techniques either recover or improve markedly.
These results must be compared with the 60 per cent “cured” or “greatly improved” among the completely analyzed patients studied by the Central Fact-Finding Committee of the American Psychoanalytic Association. While the psychoanalyzed patients were treated an average of four times a week for three to four years—i.e., about seven hundred sessions—the average course of behavior therapy covers about thirty sessions (Wolpe ’ Lazarus 1966, p. 156).
A fairly constant number of neurotic patients (about 40 per cent) improve markedly with therapies other than behavior therapy. It is suggested that these nonspecific improvements are due to emotional responses in the therapeutic situation that reciprocally inhibit the anxiety responses evoked by verbal stimuli during interviews. Such nonspecific effects presumably also account for part of the favorable results of behavior therapy.
Depth of the effects of behavior therapy
It is sometimes stated as a criticism of behavior therapy that it does not attempt to deal with the “basic dynamic conflict” that is alleged to underlie neurosis. This would be an important objection if a neurosis really had such a conflict as its basis. But there are facts that are hard to reconcile with this idea. For example, a corollary of such an objection would claim that unless the dynamic conflict is resolved, relapse or symptom substitution will sooner or later occur. But a survey (Wolpe 1961) of the results of follow-up studies on neuroses successfully treated by a variety of methods not concerned with the “dynamic conflict” revealed only a p 1.6 per cent incidence of relapse or symptom substitution.
Weighing the evidence, it seems reasonably certain that neuroses can be considered to be nothing but habits and that therefore a therapy able to break these habits must be considered fundamental.
[See alsoLearning, articles onclassicalconditioning, instrumentallearning, reinforcement . Other relevant material may be found inAnxiety; Clinicalpsychology; Conflict, article onpsychological Aspects; Neurosis; Psychiatry; and in the biographies ofGuthrie; Hull; Pavlov; Thorndike; Watson.]
Ayllon T. 1963 Intensive Treatment of Psychotic Behaviour by Stimulus Satiation and Food Reinforcement. Behaviour Research and Therapy 1:53–61.
Bachrach, A. J.; Erwin, W.J.; and Mohr, J.P.1965 The Control of Eating Behavior in an Anorexic by Operant Conditioning Techniques. Pages 153–163 in Leonard P. Ullmann and L. Krasner (editors), Case Studies in Behavior Modification. New York: Holt.
Dunlap, Knight 1932 Habits. New York: Liveright. Eccles, John C. 1957 The Physiology of Nerve Cells. Baltimore: Johns Hopkins Press.
Eysenck, Hans J.(editor) 1960 Behaviour Therapy and the Neuroses: Readings in Modern Methods of Treatment Derived From Learning Theory. Oxford. Pergamon.
Eysenck, Hans J. 1964 Experiments in Behaviour Therapy. New York: Macmillan.
Guthrie, Edwin R.(1935) 1952 The Psychology of Learning. Rev. ed. New York: Harper.
Hull, Clark L. 1943 Principles of Behavior. New York: Appleton.
Jacobson, Edmund 1938 Progressive Relaxation. Univ. of Chicago Press.
Jones, Mary C.(1924) 1960 A Laboratory Study of Fear: The Case of Peter. Pages 45–51 in Hans J. Eysenck (editor), Behaviour Therapy and the Neuroses: Readings in Modern Methods of Treatment Derived From Learning Theory. Oxford: Pergamon.
Knight, R. P. 1941 Evaluation of the Results of Psychoanalytic Therapy. American Journal of Psychiatry 98:434–446.
Lazarus, Arnold A. 1963 The Results of Behaviour Therapy in 126 Cases of Severe Neuroses. Behaviour Research and Therapy 1: 69–79.
Lazarus, Arnold A.; and Abramovitz, Arnold 1962 The Use of “Emotive Imagery” in the Treatment of Children’s Phobias. Journal of Mental Science 108:191–195.
Malleson, Nicolas 1959 Panic and Phobia: A Possible Method of Treatment. Lancet , no.1:225–227.
Salter, Andrew (1949) 1961 Conditioned Reflex Therapy. 2d ed. New York: Capricorn Books. → A paper-back edition was published in 1961 by Putnam.
Schultz, Johannes H.; and Luthe, W.(1950) 1959 Autogenic Training. New York: Grune. → First published in German.
Skinner, B.F. 1938 The Behavior of Organisms. New York: Appleton.
Stevenson, Ian; and Wolpe, Joseph 1960 Recovery From Sexual Deviations Through Overcoming Non-sexual Neurotic Responses. American Journal of Psychiatry 116:737–742.
Teplov, Boris M. et al. (1956) 1964 Pavlov’s Typology: Recent Theoretical and Experimental Developments From the Laboratory of B. M. Teplov, Institute of Psychology, Moscow. Compiled, edited, and translated by J.A. Gray, with an editorial introduction by H.J. Eysenck. Pergamon. → First published in Russian.
Wolpe, Joseph 1952 Experimental Neuroses as Learned Behavior. British Journal of Psychology 43:243–268.
Wolpe, Joseph 1954 Reciprocal Inhibition as the Main Basis of Psychotherapeutic Effects. A.M.A. Archives of Neurology and Psychiatry 75:205–226.
Wolpe, Joseph 1958 Psychotherapy by Reciprocal Inhibition. Stanford Univ. Press.
Wolpe, Joseph 1961 The Prognosis in Unpsychoanalyzed Recovery From Neurosis. American Journal of Psychiatry 118:35–39.
Wolpe, Joseph 1963 Quantitative Relationships in the Systematic Desensitization of Phobias. American Journal of Psychiatry 119:1062–1068.
Wolpe, Joseph; and Lazarus, A.A. 1966 Behavior Therapy Techniques. Oxford: Pergamon.
Somatic treatment comprises all therapeutic procedures which are based primarily on physical means of influencing the human organism. The agents employed may be mechanical, electromagnetic, or chemical in nature, but they are all characterized by their potential to change the energy balance within the physiochemical system of cerebral dynamics. Defined negatively, somatic treatment of mental disorders may be said to be essentially independent of social and psychological factors, and it would be expected to be generally effective regardless of individual differences in personality structure, in personal interactions, and in transactional processes inherent in the treatment situation.
Organic and functional mental disorders. Mental disorders are traditionally divided into two categories—the organic and the functional. Organic mental disorders are characterized by the presence of demonstrable morphological or metabolic abnormalities, which are necessary factors for the establishment of their clinical and pathological diagnosis. Mental disorders for which physical cerebral pathology cannot be demonstrated are defined as functional in nature.
Since it is in the organic mental disorders that somatic pathology has been clearly established, it would appear plausible to expect here the best results of somatic treatments. However, the most significant progress with somatic therapies has so far been made by psychiatry in the field of functional mental disorders, just since the mid-1930s.
The most spectacular exception to this statement was the discovery of malaria treatment for general paresis of the insane, or dementia paralytica, an inflammatory brain disease caused by syphilis. The discoverer of this therapy, Wagner-Jauregg, received the Nobel Prize in 1927, thus becoming the first psychiatrist to be so honored. However, because of the discovery of penicillin as the specific cure for syphilis, general paresis is no longer a significant mental disorder in many parts of the world.
It remains a fact that the major breakthroughs in the somatic treatment of mental disorders have occurred only fairly recently and in the field of functional psychoses—namely in schizophrenia and in manic-depressive psychosis and other depressions. These therapeutic advances have been achieved through shock therapies and still more recently through pharmacotherapy.
Throughout the history of psychiatry there have been those who have predicted that some day scientists will discover the physical substrate of all mental disorders. At that time, the argument goes, we might be able to approach all psychiatric treatment with the same scientific detachment that characterizes a surgeon performing an appendectomy or a physician treating a case of pneumonia with modern antibiotics. This hope of finding some kind of “magic bullet” for every mental disorder is not likely ever to be fulfilled.
First of all, it is by no means certain that physical substrates or lesions will be discovered for every psychological disorder. Even more important, however, is the well-established fact that in the realm of behavior, physical and psychological factors are so closely interwoven that a mental disorder—which is essentially a disorder of behavioral manifestations—will seldom respond to somatic therapy alone, without any consideration of psychological and interpersonal factors, even if its primary cause is clearly a physical one.
Are somatic treatments cures? The action of few of the major successfully employed somatic therapies is clearly understood, and none of the therapies are specific cures. This is not surprising, since these treatment methods are most effective in the functional psychoses, and this class of mental disorders is characterized by the fact that no definite physical or psychological cause has consistently been established by the many investigators who have searched intensively for the final common physical path of these disorders for nearly a century. A truly curative treatment, however, can be undertaken only if the cause of an illness is known. Otherwise, even the most successful treatment of a disease—for instance, insulin therapy of diabetes mellitus—can only be symptomatic, supportive, or compensatory in nature.
A comprehensive approach
Psychiatry is fundamentally a pragmatic science. Its raison d’etre and essential goal are the improvement or cure of mentally disordered patients. While psychiatry has developed major theoretical frameworks of its own, e.g., psychoanalysis, and has assimilated others from behavioral sciences for its own use, e.g., learning theory, most of the major advances in psychiatric somatic therapy originated in empirical observations, and the underlying mechanisms through which these treatments became effective were usually inadequately or even erroneously understood.
The present methodological situation in the treatment of mental disorders is characterized by a highly dynamic state of flux. The two extreme positions of those who “believe” only in the psycho-dynamic approach to and resolution of the problems posed by mental disorders and regard a physical approach to mental disorders as methodo-logically naive and grossly inappropriate, and those who consider any other than a clearly somatic orientation and therapeutic approach to mental disorders as unscientific and doomed to failure, are no longer clearly defined. Today it is generally accepted that all psychodynamic processes depend on a neurophysiological substrate; consequently, psychoanalysts have in recent years shown much interest in neurophysiological research and the pharmacotherapeutic approach to mental disorders. On the other hand, even in their laboratory experiments, behavior researchers are now clearly acknowledging the important role of individual personality differences, nonquantifiable psychodynamic factors, and interpersonal transactions.
Therapeutic revolution in psychiatry
During the decade between 1950 and 1960 the therapeutic and administrative approach and the social attitudes toward the mentally ill underwent changes of such magnitude that one would be justified in speaking of a quiet revolution. In the United States there was a spectacular decrease of mental hospital populations. In the eight years between 1956 and 1964, i.e., since systematic drug therapy became widely established, there was a decrease of 54,000 patients instead of an anticipated increase of 82,000 patients confined in mental hospitals. One of the by-products of this decrease in mental illness and suffering is a probable saving of more than one billion dollars (“What Tranquilizers . . .” 1964).
Thousands of mental patients who only 15 years ago would have remained hospitalized for months, years, or often indefinitely, are now functioning in the community as the result of two new developments: (1) modern drug therapy for mental dis-orders for which there has been no precedent, and (2) a more progressive and tolerant attitude of mental hospital administrations coupled with increased social acceptance of the former mental patient. The second development is not entirely new, but in the past, if such liberal attitudes emerged they eventually disappeared because there were no effective physical treatments supporting them.
Historical treatment methods
During the more than two thousand years that elapsed between the time the somatic nature of mental disorders was first proclaimed by Alcmaeon and Hippocrates and the time it was reasserted by Wilhelm Griesinger at the beginning of the nineteenth century, medicine applied innumerable somatic treatment procedures and remedies, none of which survived because none was ever systematically explored and tested for its efficacy under controlled conditions (Zilboorg 1941; Haisch 1959; Kalinowsky & Hoch 1961). Bloodletting, purging, and induced vomiting were therapeutic mainstays in the treatment of mental disorders for many centuries. Physical threats, restraint, solitary confinement in the dark, whipping, periodic submersion under water, vio-lent spinning of the mental patient on specially constructed revolving chairs, were all frequently applied. Many of these procedures, particularly when applied to severely excited patients, resulted, of course, in rapid “symptomatic improvement,” because the patients fainted or became utterly exhausted and remained quiet for some time. Some of these uncritically employed treatment methods have sometimes been referred to as forerunners of modern shock therapies—for instance, the sudden pouring of ice water over the naked patient, burning of the scalp with scalding water, or the sudden plunging of the unsuspecting patient into a lake from a room with a trap-door device. however, the shock induced by these methods was primarily psychological. In contrast to this, modern somatic shock therapy is based on the induction of physiological shock.
A certain semantic confusion exists if no clear distinction is made between the biological and the experiential aspects of shock. The old treatments aimed at causing surprise and fear in the patient, while modern shock therapy tends to avoid conscious distress of the patient and aims at the production of a specific state of physiological stress.
Countless substances were prescribed as remedies for mental disorders, involving not only a great variety of the basic elements such as mercury, phosphorus, copper, iron, etc., but also chemical compounds—for instance, salts of silver, iodine, or lead. A host of organic chemical compounds was employed, most of which were derived from plants. In ancient times and during the Middle Ages the helleborus plant was thought to possess special powers for the treatment of mental illness.
Other treatments, which involved the drinking of the blood of a recently beheaded criminal or concoctions and distillates made from toads, snails, and salamanders, as well as the wearing of precious metals, crystals, and gems, were based on ideas and principles developed by magic and later elaborated on in the symbolic systems of alchemy.
Even in prehistoric times, surgical trepanations of the skull were performed, as a number of archeological findings prove. It is likely that the opening of the skull was not always undertaken because of increased intracranial pressure—the modern indication for such surgery—but more often to provide an escape for the evil spirits which were thought to possess the brain of an insane person.
Scientific rationale and evaluation
At first glance one might conclude that not much that is new has been added to the modern repertoire of somatic treatment methods in psychiatry, since basic patterns of shock therapy, chemotherapy, and even psychosurgery were traced out many centuries ago. However, it must be remembered that the number of possible physical treatment modalities at our disposal is limited and that the value of a therapeutic procedure does not lie in its incidental application but in the fact that its indication is based on a well-established rationale and that the results of the treatment have been assessed by scientific methods. Evidence of favorable results of any specific treatment procedure must be provided through objectively controlled and statistically evaluated clinical experiments. A rationale for psychiatric treatment was not seriously considered in scientific terms until the nineteenth century, and evaluation of treatment results based on controlled and statistically processed observations came into being only in the twentieth century.
The scientific groundwork for a successful therapeutic attack on mental disorders was laid at the turn of the twentieth century. This groundwork is founded on three major achievements: (1) the introduction of a clinically valid and useful classification of mental diseases by Kraepelin; (2) the discovery of the principles of a consistent and comprehensive psychodynamic theory by Freud; (3) the progress made by many researchers in bacteriology, cellular pathology, neurophysiology, and chemistry.
In the first decade of the twentieth century it was shown that the spirochete, which is the causative agent in syphilis, is present in the brains of patients with general paresis. Soon after the syphilitic etiology for this mental disorder became firmly established, August von Wassermann discovered a practical serological procedure which made it possible to prove objectively the presence or absence of syphilis. Until Wassermann’s test became available, many patients, particularly those afflicted with dementia due to the effects of chronic alcoholism on the brain, had been misdiagnosed as suffering from general paresis.
Malaria treatment—first breakthrough
In 1917 Wagner-Jauregg, at the University of Vienna, announced results of tests using deliberately induced malaria fever as a treatment for nine patients diagnosed as suffering from general paresis. Six of these patients improved greatly and three of them were cured. Until then, general paresis had been an incurable disease which invariably led to complete dementia and a miserable death. For thirty years Wagner-Jauregg had thought about this kind of treatment, ever since he had observed that the course of a psychosis was often favorably influenced by intercurrent infectious diseases. However, this general observation and even Wagner-Jauregg’s idea of imitating this “experiment of nature” and inoculating paretic patients with tertian malaria could not have assumed the status of a scientific procedure until he had, at his disposal, a reliable method—namely, Wassermann’s serological test—which enabled him to make an objective diagnosis and select a homogeneous sample of patients for his experiment. Had he tried the experiment twenty years earlier, he might have inadvertently chosen a group of patients whose diagnosis in 50 per cent of the cases was alcoholic dementia and only in the other 50 per cent, general paresis. Under those conditions, to draw valid conclusions about the efficacy of his malaria treatment in cases of general paresis he would have had to employ a much larger sample, and this would have proved difficult, since he was using an untried, somewhat hazardous procedure (Wagner-Jauregg 1946).
A variety of unsuccessful treatments
Around 1920 a group of clinicians conceived of focal infections in tonsils, teeth, and the intestines as the cause of many diseases, including the functional psychoses, and for a few years a great deal of un-necessary surgery was performed with the idea of removing the infectious foci. However, the theory was soon disproved, and this kind of surgical treatment was shown to be valueless or even harmful.
A number of other therapeutic efforts were aimed at duplicating the spectacular results of the malaria treatment of general paresis, and, in several places, particularly in Europe, fever was induced artificially through injections of sulfur, typhoid vaccine, or foreign protein in patients suffering from various functional psychoses. Other attempts in the same direction, namely, to produce a systemic irritation and thereby a general mobilization of biological defenses, consisted of producing large blisters on the skin through the use of vesicantia, of making sterile abscesses in the muscles through the injection of turpentine oil, and of creating an aseptic meningitis by means of horse-serum injections into the spinal canal. Although short-term improvements in psychotic states were often observed in response to some of the procedures, no lasting re-missions in the major psychoses could be achieved by any of them.
The advances made in endocrinology suggested the therapeutic use of various hormones. Again, this approach did not prove to be fruitful. Most frequently employed in these therapeutic trials were the male sex hormone, testosterone, and the female sex hormones, estrogen and progesterone. However, some promising results in this field were obtained with the hormone of the thyroid gland in the treatment of mental and emotional disorders secondary to hypothyroidism.
Castration was used in the nineteenth century and earlier because of the mistaken belief that such surgery on the genital organs would prove beneficial in certain psychiatric disorders, particularly those with hysterical manifestations. In modern times, castration of recidivist male sex offenders is a legal therapeutically employed procedure in some countries, particularly in Scandinavia. A recent review of results of this procedure in this particular group of psychiatric patients has shown that the treatment is often effective, but since it has so many drawbacks of a moral, psychological, and medical nature—not the least being its irreversibility—it is not likely to become a widely accepted procedure (Tappan 1951).
Pharmacotherapy and psychopharmacology
Around 1930 new interest was aroused in the use of various drugs in mental disorders. Loevenhart and others (1929) reported interesting experiments with injections of small doses of potassium cya-nate and with the inhalation of carbon dioxide in stuporous patients. Patients who had been mute and motionless for weeks would suddenly, under the influence of these drugs, begin to talk and move about. Within a short time, however, they would invariably relapse into their previous stuporous condition. These therapeutic procedures were hardly more than provocative laboratory experiments. Their mechanism of action was not well understood, and their therapeutic action could not be sustained.
New synthetic drugs which had become available at that time were given widespread application in psychiatric disorders. Benzedrine, one of the early representatives of the group of amphetamine compounds, produced marked stimulation of the central nervous system and had certain euphorizing effects (Myerson 1936). However, the early hopes that this drug might prove to be a specific agent counteracting depression were not fulfilled. Therapeutic experiments with photosensitization of depressed patients through the administration of hematoporphyrine, a hemoglobin derivative, seemed to give promising results at first but eventually proved to be disappointing. Amobarbital, a barbiturate, when given intravenously, was shown to produce the same tantalizing effect of relieving stupor states temporarily as did potassium cyanate injections and carbon dioxide inhalations.
Gjessing, in a series of beautifully designed and very carefully controlled experiments conducted at a Norwegian mental hospital, demonstrated that a certain type of schizophrenia, which he named “periodic catatonia,” was characterized by recurrent attacks of stupor or excitement and was associated with a defective regulation of nitrogen metabolism (Gjessing et al. 1958). Patients afflicted with it either accumulated or lost nitrogen beyond the normally permitted bio-logical limits, and at the critical points of change in the nitrogen balance of the body, psychotic episodes would occur. Gjessing showed that a small amount of thyroxin would enable these patients to maintain their nitrogen balance within normal limits and thus remain free from psychotic attacks. His brilliant work was greeted with great enthusiasm as another milestone on the road toward effective and scientifically grounded somatic treatment in psychiatry. Unfortunately, its practical importance is limited, since the mental disorder for which this treatment is indicated is comparatively rare.
Pellagra and phenylketonuria
Two more important therapies must be mentioned—both the outcome of systematic, scientific research. One has led to the almost complete disappearance of a mental disease that formerly was fairly frequent in certain parts of the world, while the other one has opened up exciting vistas for a practical therapeutic and preventive approach to mental deficiency.
In 1938 Elvehjem demonstrated that the so-called “black tongue”in dogs was a deficiency dis-ease caused by a lack of nicotinic acid, a component of the vitamin B complex, in the food (see Woolley et al. 1938). Soon afterward, the first cases of pellagra in humans, which seemed to be closely related to the black-tongue disease, were successfully treated with nicotinic acid. Pellagra is a disease which produces manifestations in the skin, intestines, and the brain. In the past, many patients suffering from pellagra psychosis could be found in mental hospitals in certain parts of the world—for instance, in the south of the United States, where nutritional conditions were particularly bad among the lower classes. Today one rarely sees a patient with psychosis due to pellagra, and in the few instances where such a diagnosis is made, the condition readily responds to treatment with nicotinic acid.
The modern antibiotic treatment of general paresis with penicillin—which has superseded Wagner-Jauregg’s original malaria treatment—and the supplementary vitamin therapy with nicotinic acid of pellagra psychosis are the only two truly curative treatments of mental disorders at our disposal today.
A recently developed treatment that has opened fresh possibilities for an attack on mental deficiency is really a preventive one. It consists of the reduction of a certain amino acid—phenylalanine—in the food intake of infants and young children in whom the diagnosis of phenylketonuria has been made. In 1934 Föiling showed that a certain small group of mental retardates was characterized by the excretion of an abnormal metabolite, namely, phenylpyruvic acid, in the urine. Later it was shown that these patients were afflicted with an “inborn error of metabolism,” and, lacking certain essential enzymes—in particular, phenylalanine hydroxylase—were unable to metabolize phenylala-nine, which is a component of normal food intake, to tyrosine. Because of this metabolic inadequacy, another metabolic product—phenylpyruvic acid—accumulates in their system. It seems that the increased blood level of phenylalanine is highly toxic for the developing brain. By carefully eliminating most phenylalanine from the food of a patient in whom the diagnosis has been made early enough—that is, before the toxic excess of phenylalanine can exercise its damaging influence on the developing brain, up until the fourth or fifth year of life—it is possible to prevent or at least reduce the intellectual damage inflicted upon individuals who carry this genetic error of metabolism [Ragsdale & Koch 1964; “Mental Deficiency...” 1961; seeMentalRetardation].
Disulfiram in alcoholism
When it was noted accidentally that people who had been exposed to a certain chemical (disulfiram) reacted during a period of several hours with considerable discomfort, flushing, nausea, palpitation, and vertigo to any amount of alcohol they consumed afterward, this substance was soon introduced into the therapeutic armamentarium of psychiatrists for treatment of alcoholism. The mechanism of disulfiram consists of the blocking of an enzyme which is essential for the metabolic breakdown of products of alcohol in the body. Accumulation of acetaldehyde in the body causes unpleasant toxic effects if any alcohol is taken while the enzyme action is blocked by disulfiram. This drug can serve as a self-imposed chemical restraint for the problem drinker. As long as he takes it, he knows he cannot drink alcohol without rapidly producing an alarming reaction. If the patient is motivated well enough to take his medication regularly, this treatment can be a valuable aid in the comprehensive treatment program required for the psychiatric management of alcoholics[seeDrinking AND Alcoholism.]
Psychotropic drugs and neuroleptic effects
The latest chapter of somatic therapy in psychiatric disorders began in the early 1950s with the introduction of a new class of drugs. These drugs are designated as psychotropic or psychoactive substances, because their principal action is manifested in the realm of human behavior and experience. A whole new scientific discipline has developed under the name of psychopharmacology. Its principal task is the study of psychoactive drugs [Lehmann 1963; seeDrugs.]
Although psychoactive drugs are as old as civilization—alcohol, caffeine, and opium fall into this category—the new type of psychoactive drugs, first systematically applied in 1951, was characterized by a particular quality which has been termed “neuroleptic” by the French psychiatrists Jean Delay and Pierre Deniker, who were pioneers in proving the value of pharmacotherapy in psychiatry. A neuroleptic drug is a substance which produces distinct neurological effects in addition to its psychotropic action. The neuroleptic action may manifest itself in various ways, but it appears most frequently in the form of extrapyramidal symptoms. Extrapyramidal symptoms may occur as drug-induced Parkinsonism, which is characterized by muscular rigidity, a masklike face, tremor, and a shuffling gait, or sometimes they may occur as severe muscular dystonia or akathisia—a term de-noting motor restlessness, which makes it impossible for the patient to sit or stand still.
Such a neuroleptic quality had never before been observed with any psychoactive drugs. In fact, there had been no experimental way of producing extrapyramidal symptoms consistently by pharmacological means. However, the neuroleptic action is only a side effect of the new drugs, whose principal action is their marked therapeutic effect on such psychotic symptoms as hallucinations, delusions, autistic thought-disorder, and psychotic stupor and withdrawal. For this reason, these drugs have often been referred to as antipsychotic or, more recently, as psychotostatic in their action. Up until a few years ago none of the clinically applied psychoactive drugs—mainly hypnotics, sedatives, and stimulants—had been effective in reducing specifically psychotic manifestations. In addition to their neuroleptic and their antipsychotic action some of the new drugs also possess an unusual sedative action which is characterized by their pronounced effect on psychomotor tension and agitation, without inducing any clouding of consciousness or impairment of cognitive processes. Until recently, clouding of consciousness and impairment of judgment had been almost synonymous with the notion of powerful sedation (Leh-mann 1961; 1966).
Although the name “tranquilizer” was given to these new drugs and became a popular label for them soon after they appeared on the clinical scene, when generally applied it may sometimes be a misnomer, since a number of the new drugs which possess neuroleptic and antipsychotic properties may not tranquilize, but, instead, exercise a mild stimulant action.
Rauwolfia and phenothiazine derivatives. The first two substances which were clinically employed and systematically studied in the treatment of acute manic and schizophrenic psychoses were the rauwolfia and the phenothiazine derivatives. Rauwolfia derivatives are related to the principal active ingredient of the plant R. serpentina, which was used for centuries in India for the treatment of mental disorders. However, it was given in doses which today we would consider inadequate. The phenothiazine derivatives, on the other hand, are synthetic products of a systematic search by pharmacologists for certain compounds with pronounced effects on the central nervous system. The first rauwolfia derivative studied extensively in psychiatric patients was reserpine, and the first phenothiazine derivative was chlorpromazine. In the few years since their introduction into psychiatry a tremendous number of clinical and experimental observations has been reported, and a great number of other rauwolfia and phenothiazine derivatives with similar properties have been developed by the pharmaceutical industry. It has become evident that for clinical purposes the phenothiazine derivatives present the advantages of being more reliable and producing fewer undesirable side effects than the rauwolfia derivatives. The latter, however, still play an important role as standard drugs for certain psychopharmacological experiments.
Evaluation of neuroleptics. Many of these new drugs have the particular tranquilizing effect which has been described above, and they do not, like most other sedatives, lead to addiction, even in predisposed individuals. All of the clinically applied neuroleptics counteract specific psychotic manifestations in acute mental breakdowns, and they were soon found to be effective therapeutic agents even in chronic psychotic states. A considerable number of regressed, chronic schizophrenics, some of whom had vegetated for ten or twenty years as hopeless human derelicts in the back wards of mental hospitals, responded to treatment with the new anti-psychotic drugs, although they had previously failed to show any favorable response to repeated courses of insulin-coma and electroconvulsive treatment.
The atmosphere of mental hospitals all over the world has changed rapidly since the new drugs were introduced, since treatment with phenothiazine derivatives often renders an acutely psychotic individual rational and cooperative within a matter of hours or days instead of weeks and months, as had been the rule prior to the drug era. As psychiatrists learned to employ the new tranquilizers it became possible to reduce violent and destructive behavior to a minimum. The construction of new hospitals has been profoundly influenced by these therapeutic developments in that facilities for seclusion and restraint are no longer considered to be essential features of every mental hospital.
Perhaps the most important function of the new drugs is their role in the maintenance treatment of psychotic patients in remission. It is now possible to maintain a psychotic patient who has been rendered symptom-free through the use of antipsychotic drugs indefinitely in this compensated, and for all practical purposes, recovered state, provided the patient is carefully observed and continues to take antipsychotic medication regularly and in adequate doses. There are as yet no objective methods to determine which patients may eventually be able to discontinue maintenance medication and which will have to remain on it indefinitely.
There are four therapeutic functions for neuroleptic drugs with antipsychotic or psychotostatic activity. The drugs may be used as: (1) symptomatic sedatives; (2) therapeutic agents in acute psychotic conditions; (3) therapeutic agents in chronic psychotic conditions; (4) maintenance agents in former psychotic patients in remission. Older somatic treatments had been known to provide sedation effectively (e.g., the barbiturates or scopolamine), and insulin-coma or electroconvulsive treatment was effective in acute psychotic conditions. However, there had been no therapeutic procedures which could promise any real hope for chronic schizophrenic patients, and there had never been any drug that could maintain former psychotic patients symptom-free.
At least 70 per cent of all patients suffering acute schizophrenic breakdowns respond favorably to modern pharmacotherapy. Pharmacotherapy is simpler and at least as effective as insulin-coma therapy and consequently has replaced the latter in most psychiatric clinics today. Drug treatment of functional psychoses is neither merely symptomatic nor capable of curing the mental disease. The function of such treatment has been characterized as compensatory in nature. In this respect it resembles such therapeutic procedures as insulin treatment for diabetes or anticonvulsant therapy for epilepsy: as long as the treatment is administered the patient’s symptoms will remain in abeyance. The drugs seem to counteract and neutralize the behavioral effects of a somatic substrate in psychotic conditions without, however, being able to eliminate this physical substrate.
Today many different phenothiazine derivatives are used in the treatment of psychotic conditions—in particular in the therapy of schizophrenia. One may easily become confused by the many generic names and the innumerable trade names under which these drugs appear on the international markets. Common to most of them is the phenothiazine nucleus; their differences depend on the chemical structure of the side chain attached to this nucleus. Carefully controlled observations have shown that the therapeutic effectiveness of the great majority of phenothiazine derivatives appears to be roughly equal. The derivatives differ, however, in the dose which is required to produce therapeutic effects and also in the side effects which accompany their administration. Recently, another chemical class with neuroleptic and antipsychotic properties is being studied intensively—the butyrophenones. There seems to be little doubt that equally or more effective new psychotostatic drugs will be developed in the future.
Other psychoactive drugs
While the mainstream of therapeutic activity has been going in the direction of treating psychotic manifestations, a number of new chemical substances with other interesting psychoactive properties have also been developed since 1955. These new drugs can be considered under three headings: (1) minor tranquilizers. (2) antidepressants, (3) psychotomimetics.
Minor tranquilizers. Minor tranquilizers are sedatives which do not possess antipsychotic properties. In other words, they can sedate a tense and excited patient but they cannot counteract such specific psychotic manifestations in the cognitive and perceptual field as delusions, thought disorder, and hallucinations. Drugs which do have antipsychotic effects—for instance, phenothiazine or butyrophenone derivatives—are sometimes referred to as major tranquilizers. While a considerable number of new minor tranquilizers have appeared on the market, there is, so far, no convincing evidence that these new substances have accomplished anything that is essentially different from the achievement of the older well-known sedatives.
Minor tranquilizers which are useful adjuncts to the treatment of anxiety and emotional tension are also characterized by the fact that they usually induce drowsiness and postural ataxia, exert an anticonvulsant action, and may lead to habituation and psychological addiction. In contrast, major tranquilizers do not induce postural ataxia, and only rarely do they induce persistent drowsiness. Major tranquilizers also tend to lower the brain’s convulsive threshold and they do not lead to habituation and addiction (Berger & Ludwig 1964).
Antidepressants. The early hopes that the new stimulants (such as the amphetamines), which had been introduced in the 1930s, would be useful in the treatment of severe depressive states were not fulfilled. A depressed person is frequently in a state of heightened arousal, and giving him stimulants might only increase his anxiety and agitation without affecting the fundamental symptom of all depression—namely, the depressive mood. To fill the gap that existed in the pharmacotherapy of mental disorders characterized by depression, another type of psychoactive substance was developed a few years after the discovery of the psychotostatic drugs (major tranquilizers)—the antidepressant drugs (Lehmann 1965). These may be divided into two major groups: (1) the mono-amine-oxidase inhibitors, (2) antidepressants with no mono-amineoxidase inhibiting activity—also referred to as tri-cyclic antidepressants.
Mono-amine-oxidase is an enzyme which degrades the so-called neurohormones, noradrenalin and serotonin. There is indirect clinical and experi-mental evidence that the distribution and balance of these neurohormones in the brain is significantly related to emotional states. It has been observed clinically that chemical substances which inhibit mono-amine-oxidase and thereby allow noradrenalin and serotonin to build up in the brain may successfully reduce the duration of a depression from several months or years to a period of three or four weeks.
While this observation has provided a pharmacological model in the systematic search for new antidepressant drugs, the mono-amine-oxidase inhibitor model certainly does not account in full for the physical substrate of depressive states, since a number of other substances with no enzyme inhibiting activity but a close chemical resemblance to the phenothiazines have proved to be equally effective in the treatment of severe depression. Our knowledge of the specific indications for each type of antidepressant—for instance, which should be prescribed for reactive depressions and which for endogenous, agitated, or retarded depressive states—is still incomplete.
Nevertheless, antidepressant drug therapy represents a considerable step forward in psychiatric treatment, and antidepressant drugs are effective in about 60 per cent of all depressive conditions. This reduces the number of patients who otherwise would have to be given electroconvulsive therapy. It takes from one to three weeks for antidepressant drugs to manifest their therapeutic action, and they are, therefore, slower acting than the antipsychotic drugs. Some, but not all, antidepressants have stimulating effects. The mono-amine-oxidase-inhibiting drugs tend to produce mild euphoria, while the tri-cyclic antidepressants that do not inhibit monoamine-oxidase merely eliminate depressive symptoms without inducing euphoria.
Like many other psychoactive drugs, antidepressants frequently produce side effects; the monoamine-oxidase inhibitors are particularly prone to do this. It is interesting to note that all effective antidepressants may potentiate psychotic symptoms—for instance, hallucinations and delusions—and may sometimes even induce a toxic psychotic state.
Recently, the distinction between antipsychotic and antidepressant drugs, which at first appeared to be quite clear-cut, has lost some of its sharpness. There are depressed patients, particularly the anxious depressed, who respond to major tranquilizers, and there are schizophrenic psychotics who respond favorably to antidepressants. Patients who respond in this different manner cannot yet be clearly distinguished in advance from the patients who show average response tendencies.
Psychotomimetics. Psychotomimetics are drugs which experimentally induce states of psychotic disintegration accompanied by thought-disorder and perceptual disturbances. Some representatives of this class of drugs have been known for a considerable time—for instance, marijuana, an ingredient of the hemp plant, and mescaline, the active component of the Mexican peyote cactus (Unger 1963). Other psychotomimetic substances have been developed more recently—for instance, lysergic acid diethylamide, a synthetic ergot compound, and psilocybin, which is derived from Mexican mushrooms. These strange substances have received a great deal of public attention in recent years and have stirred up considerable controversy.
Preliminary clinical trials with some of the psychotomimetics, or hallucinogens as they are some-times called, suggest that they may prove to be useful in the treatment of alcoholism and character disorders. However, these results will have to be confirmed, and a methodology for systematic therapy with these substances still needs to be developed.
In the meantime, these substances provide interesting tools for the experimental study of the psychotic process, since it is possible to induce “model psychoses” in volunteer subjects, who will, for a period of hours, undergo experiences which seem to be closely related to the experiential world of the schizophrenic. Unfortunately, these chemicals, which, like any powerful drug, carry a dangerous physical potential, have become a rallying issue of almost political importance for a small but vociferous group of intellectuals who claim the right to administer these drugs to themselves and to others according to their own, nonmedical judgment. It appears that under the influence of such substances, states of ecstatic exaltation can be fairly easily induced.
Viewed in an objective clinical and psychopharmacological perspective, the development, understanding, and administration of psychotomimetic drugs must be judged to be still in the experimental stages.
Prolonged sleep treatment
In 1922 Klaesi introduced prolonged sleep therapy into the therapeutic armamentarium of the psychiatrist (Klaesi 1922). This treatment method, which consisted of keeping patients asleep with the help of hypnotic drugs throughout most of the day for a period of several weeks, has held its place in the treatment of certain psychiatric conditions. Originally introduced for the treatment of schizophrenia, depressions, and manic states, it is now mostly given to patients suffering from long-standing psychoneuroses and psychosomatic conditions. It is particularly popular with psychiatrists in So-viet Russia, where Pavlov’s teachings determine the basic theoretical approach to psychiatry. In Pavlov’s conceptual framework, prolonged sleep is viewed as a form of protective inhibition that can successfully counteract the pathological excitation of the higher central nervous processes that manifest themselves as symptoms of pathological behavior. A variety of hypnotic and sedative drugs are used for sleep therapy. They are given at regular intervals either by mouth or by injection. This therapy does not produce any unpleasant experiences for the patient, but it requires careful, continuous nursing care in order to avoid circulatory collapse or other untoward effects in the patient, who has to be kept inactive for long periods of time. [SeeSsleep.]
The use of sleep-producing drugs in psychiatric patients may be variously determined according to the different theoretic orientations of the therapist. While the Russian psychiatrists think in terms of physiological protective inhibition, a psychiatrist from the West may be more interested in the psychodynamic aspects of sleep therapy—e.g., disinhibition, abreaction, or anaclitic dependency.
Another method of inducing therapeutic sleep makes use of a rather weak continuous electrical current that is passed through the brain and produces relaxation and sleep which may be sustained for several hours without eliciting pain, shock, or convulsions. As with drug-induced prolonged sleep, Russian psychiatrists invoke the concept of protective inhibition for this kind of electrically induced alteration of consciousness, and the therapeutic procedure is more widely employed in countries in the Russian sphere of influence than in Western countries. However, neither its technical application nor its therapeutic effects are as reliable as electroconvulsive treatments. Recent claims for success with electrically induced sleep are made mainly for neurotic states and for a variety of psychosomatic dis-orders (see Clapp & Loomis 1950; Giljarowskii et al. 1956; Wageneder & Hafner 1965).
A new era of somatic therapy in mental disorders began around 1935 with the discovery of two types of physiological shock therapy: (1) the hypoglycemic coma treatment, or insulin-shock therapy, developed by Sakel, a young German psychiatrist; and (2) the convulsive therapy, or pentylenetetrazol-shock treatment, developed by Meduna, a psychiatrist at the University of Budapest. Sakel started his experiments two years prior to Meduna’s (Kalinowsky & Hoch 1961; Sakel 1958; Meduna 1935).
The principle of insulin-shock treatment lies in the production of the deep coma that results from a severe lowering of the blood-sugar level following an injection of insulin. The brain depends for its metabolism mainly on carbohydrates. A reduction of the blood-sugar supply, therefore, lowers brain metabolism relatively more than that of any other organ. Sakel had been treating patients addicted to morphine with small doses of insulin as a relief measure during their withdrawal from the narcotic; he observed that sometimes they had inadvertently slipped into a deep coma and after having been aroused from it had appeared much improved. He was an imaginative man who, without much other justification, generalized from these specific observations to the bold hypothesis that schizophrenic patients would benefit from hypoglycemic coma therapy. He was also a courageous man, for, at that time, a coma produced by an overdose of insulin was still considered to be a dangerous complication. At any rate, in 1933 Sakel presented his first promising report with insulin-coma therapy in one hundred schizophrenic patients from the University Clinic of Vienna. His findings were soon confirmed in other European countries, and the treatment was rapidly adopted all over the world. It constituted the first effective major therapeutic advancement in the management of schizophrenia (Sakel 1958).
Insulin-coma therapy of schizophrenia is most effective in patients who have been sick for not more than six months to a year. After this time it rapidly loses its effectiveness. Patients have to be treated in specially equipped hospital units for several months. They receive an injection of insulin while in the fasting state early in the morning. Within one to two hours they fall asleep and eventually go into a deep coma from which, at the end of three or four hours, they are aroused by an injection of glucose into the blood stream or by the infusion of a sugar solution into the stomach. A recent refinement of technique consists in the administration of glucagon, a substance which rapidly mobilizes available carbohydrate stores in the body and, therefore, reduces the need for large amounts of sugar to be administered through intravenous injection or stomach tube. The amount of insulin required for each patient to induce coma differs considerably and might change from day to day. The medical and nursing staffs administering insulin-coma treatment have to be well trained and experienced. Usually not more than ten or twenty patients can be treated on any one day. All these factors make the treatment a rather expensive procedure which requires considerable vigilance on the part of the staff and is by no means entirely without risk. Nevertheless, in competent hands, insulin treatment produces 70 per cent to 75 per cent remissions in acute schizophrenia, and it was the favored treatment for this disease until the advent of pharmacotherapy.
Subcoma insulin treatment. A modification of insulin-coma therapy consists of the administration of smaller doses of insulin, which will produce a state of lowered blood-sugar level (hypoglycemia) without, however, bringing about a deep coma. The patients are rendered sleepy, and a state of deep relaxation is produced. At the termination of each treatment—which lasts from two to three hours with the patient lying quietly in a darkened room—the patient feels hungry but relaxed. A course of subcoma insulin treatment usually lasts for several weeks. Indications for this type of therapy are conditions of neurotic anxiety and increased tension. Patients often respond to the treatment with improved sleep, gain of weight, a feeling of increased well-being, and a reduced need for sedatives.
Drug-induced convulsive treatment
Insulin-produced hypoglycemia sometimes leads to convulsions. It had been observed that patients often appeared to improve more rapidly after they had had a convulsion. Meduna theorized that there existed a biological antagonism between epilepsy and schizophrenia because these two diseases do not often occur simultaneously in the same patients. He had transfused schizophrenic patients with the blood of an epileptic and vice versa, hoping to see an improvement in the patients treated in this manner. When he obtained no results, he conceived of the idea of producing epileptiform convulsions in schizophrenic patients by injecting them intramuscularly with camphor in oil. Later he used the synthetically produced drug pentylenetetrazol, instead. This drug is water soluble and can be injected into a vein. When this is done the patient experiences for a short time an agonizing state of apprehension and panic and then, within a minute or two, loses consciousness and has a typical epileptiform convulsion of the grand mal type. The treatment is given every other day until a series of 10 to 25 or more convulsions has been produced. With his first group of schizophrenics treated with pentylenetetrazol, Meduna could re-port almost 90 per cent remissions. However, a considerable number of patients relapsed within a few weeks, and the over-all results of pentylenetetrazol-convulsive treatment in schizophrenia were not quite as favorable as those obtained with insulin-coma therapy. Often the two treatments could be combined for best results (Meduna 1935).
It did not take long before it became evident that convulsive therapy was highly effective in depressive states—in fact, more so than in schizophrenia—and in the treatment of severe depression convulsive therapy still plays an important role.
Electroconvulsive treatment (ECT)
In 1938 Cerletti and Bini in Rome treated a patient with an improved modification of the convulsive treatment method, namely with convulsions produced through the application of an electrical current instead of the administration of convulsant drugs (Cerletti 1950). This method soon supplanted the pentylenetetrazol treatment, since it was simpler and, above all, did not produce the unpleasant subjective effects of the drug. A patient who receives electroshock therapy may remain comfortably in his own bed. Two electrodes are applied to the temples, and even if no anesthetic is given the patient never feels any pain, since the passage of the current—about 100 volts for 0.3-0.5 seconds—causes immediate loss of consciousness. After regaining consciousness the patient might remain rather confused for thirty minutes to an hour.
A depressed person usually begins to show definite improvement after the first four or five treatments, but additional treatments are required to prevent a relapse of depressive symptoms. Six to twelve treatments—administered over a period of two to four weeks—are the usual number for a course of ECT in acute depressions. If electroshock therapy is given to schizophrenic patients, twenty or more treatments are usually administered.
After three to five electrically induced convulsions, one observes a change in the patient’s electroencephalogram in the direction of a general slowing of the electrical brain rhythms. At about the same time the patient develops an acute amnestic syndrome. He shows impairment of recent memory, and after a large number of treatments—or also if treatments are given at closely spaced intervals, for instance, every day or several times a day—the patient might become greatly confused. Sometimes such confusion is deliberately induced in the course of “regressive” or “depatterning” shock therapy, in the hope that the complete shattering of the patient’s mental processes will be followed by a reconstitution and reintegration of his mental functioning but with a selective permanent destruction of the more recently acquired pathological manifestations [Cameron et al. 1962; seeElectroconvulsiveShock.]
Within two to four weeks after discontinuation of electroshock therapy, memory functions and electroencephalographic indices tend to return to their normal levels. Although the human organism is able to tolerate convulsions amazingly well at any age, in elderly persons there is some danger of either producing or triggering off permanent impairment of memory due to physical brain changes. The aged are, of course, already predis-posed to such organic brain damage. In younger persons there seems to be little or no danger of any permanent brain damage due to electroconvulsive treatment.
Several modifications of the standard treatment method have been proposed, mostly with the intention of reducing confusion and amnesia following ECT. One of the most promising is the uni-lateral application of the current, which seems to produce less memory impairment than the standard method (Cannicott 1962).
It has been demonstrated that the induction of paroxysmal seizure discharges in the brain is the essential factor in electroconvulsive therapy. All muscular, autonomic, and metabolic responses which can be observed during and after the convulsions seem to be secondary and carry little or no therapeutic value.
The violent muscular contractions which accompany the seizure discharges of the brain can easily lead to fractures of the vertebrae or of other bones in the trunk or the extremities, and for this reason electroconvulsive therapy today is almost always preceded by the administration of a muscle relaxant—either curare or one of its analogues, or more frequently, succinylcholine—which is injected into a vein together with a short-acting barbiturate to produce a superficial anesthesia as well as muscular relaxation. Immediately following these injections artificial respiration is established for a few minutes; the electrical shock is administered; and the convulsion ensues. However, sup-pressed by the muscle relaxant, the convulsion consists of hardly more than a flickering of the eyelids or a movement of the toes, although the electrical and physiological effects on the brain are not essentially altered.
Electroshock therapy, which should be referred to as electroconvulsive therapy (ECT), is today the most reliable treatment of severe depressive states. It produces favorable results in about 90 per cent of the cases, while treatment with anti-depressant drugs is effective only in about 60 per cent of depressive conditions. Electroconvulsive treatment is most successful in involutional melancholia, an endogenous depressive condition usually associated with agitation and occurring in patients of the involutional age, i.e., between forty and sixty years. Electroconvulsive treatment is less effective when marked anxiety or many hypochondriacal symptoms are associated with the depressive state.
While ECT is still the most reliable treatment for severe depressive states and is also often remarkably effective in states of acute psychotic excitement or schizophrenic disintegration, it should be clearly understood that this type of therapy does not seem to influence the long-term development of a psychopathological process. Various studies have shown that ECT does not prevent depressive or psychotic relapses; nor does it seem to reduce the number of such relapses or prolong the normal intervals in recurrent mental diseases. The main value of this dramatic therapy lies in the fact that it leads to a rapid disappearance or amelioration of depressive or psychotic symptoms and that it may reduce the duration of a severe depression from nine to twelve months to three to six weeks. Although most manic-depressive episodes terminate eventually in spontaneous recovery, the ever-present danger of suicide in depressed patients can be eliminated with ECT, and the value of saving a patient a great deal of unnecessary suffering and restoring him early to useful functioning in the community is, of course, sufficient justification for employing this kind of therapy whenever it is indicated as the most suitable therapeutic approach. If the mental disease is not of a periodic nature, as in manic-depressive psychosis, but tends to be chronic, as for instance, schizophrenia, then ECT is much more limited in its value, because although regular repeated maintenance treatment with ECT is possible, it is more hazardous and not as practical as the continuous suppression of psychotic symptoms with pharmacotherapy.
In 1936, almost simultaneously with the introduction of the shock therapies, another dramatic somatic therapy was introduced into psychiatry by the Portuguese neuropsychiatrist Antonio Egas Moniz—the surgical procedure of prefrontal lobotomy. Basing his work on accumulated data from neurophysiological and experimental psychological research, Moniz theorized that the frontal lobes were essentially related to the higher mental processes, which were necessary components of normal cerebral and behavioral functioning. In particular, certain processes of abstraction, inhibition, and time projection had been thought to find their representation in the frontal and prefrontal lobes. Moniz severed the connections between the frontal lobes and the thalamus through small cuts of the fiber tracks responsible for these connections. He showed that his operation was often followed by improvement, particularly in early schizophrenia but also in chronic states of depression or in obsessive-compulsive ruminations that had not yielded to any other treatment. [SeeNervousSystem, article on Structure AND FunctionOfTheBrain; Obsessive-CompulsiveDisorders.]
This operation is not followed by any deterioration of intellectual performance, but it leads to a marked reduction in the intensity of the person’s emotional involvement, imagination, and creative productivity. If an insufficient amount of brain substance is cut there will be no adequate relief of symptoms. If exactly the right amount of brain substance is destroyed, the therapeutic result might enable the patient to function better after the operation than he ever functioned before. If the surgeon destroys too much brain substance, the patient might develop into an apathetic slob or an irresponsible psychopath, being left either without ambition or without any consideration for others. Unfortunately, it is not possible to calculate precisely where and how much to cut. However, a great deal of progress has been made in perfecting this particular neurosurgical procedure, so that the probability of a good therapeutic response is heightened and the probability of personality deterioration is minimized.
Most of the results with this kind of therapy were collected in the United States prior to 1955 and particularly in Britain, where the interest in prefrontal lobotomies still persists and is probably higher than anywhere else. On the North American continent interest in psychosurgery has sharply declined since the introduction of modern drug therapy for mental disorders. There are probably two principal reasons for the disinclination of most American psychiatrists to submit their patients to a prefrontal lobotomy or to any other type of surgical interference with the brain: (1) Since neurons cannot regenerate, any artificially produced morphological changes in the brain—in particular any loss of substance—would be irreversible; (2) Several careful follow-up studies have brought out evidence that marked personality changes supervened eventually in almost all lobotomized patients, even if the therapeutic gain outweighed the personality deficit due to the operation (Greenblatt et al. 1950; Petrie 1952; Rylander 1939). One general consequence of a prefrontal lobotomy is a certain loss of subtleness and complexity in the patient’s personality; he usually loses some of his creative imagination; he dreams less; and his dreams tend to become much simpler in structure; and on the whole he becomes less sensitive. however, for intractable conditions of chronic depression or for chronic obsessive-compulsive psycho-neurosis which has been refractory to any other type of therapy, prefrontal lobotomy would still have to be seriously considered as a last resort, which, nevertheless, may often yield surprisingly good results.
Mechanisms of action
The rationale for a therapeutic procedure is easily understood if the etiological factors of the condition to be treated are known and if the treatment is specifically aimed at eliminating these etiological factors. This would apply to the modern penicillin treatment of general paresis, which kills the trepanoma pallidum and thus eliminates the causal factor of syphilis, which in turn is responsible for the psychosis. But the modus operandi of Wagner-Jauregg’s malaria treatment of general paresis was not so easily understood because it constituted an unspecific attack on the disease, and a number of theories have been proposed to explain its effect. It was thought, for instance, that the physical hyperthermia factor produced by malaria might kill the trepanoma pallidum, and it was also put forward that malaria therapy was effective because it mobilized general biological defenses in an unspecific manner, thus enabling the organism to deal successfully in its own way with the brain disease.
Many theories have been offered to explain the therapeutic action of insulin-coma treatment, ranging from a conception of reduced cerebral metabolism, which is equivalent to partial anoxia, to the idea that the artificially induced regression of the patient to an infantile level and the nursing care he is receiving during the coma treatment from doctor and nurse constitute a re-enactment of the patient’s infantile situation without the traumatic factors which supposedly prevailed originally in his infancy. Theories to explain the effects of electroconvulsive treatment also involve physical and psychodynamic concepts and range from neurophysiological, biochemical, and endocrino-logical hypotheses to the proposal that the induced amnesia is responsible for the “unlearning” of recently acquired pathological behavior patterns and also to the suggestion that the patient experiences symbolic death and resurrection under the magic influence of the doctor administering the treatment.
There is no generally accepted theory for the action of modern psychopharmacological agents. It has already been mentioned that the therapeutic action of one group of antidepressants, namely the mono-amine-oxidase inhibitors, has been explained on the basis of competitive affinity of the drug and hormones to essential receptor sites on an enzyme. The neuroleptic major tranquilizers seem to act on the brain’s reticular activating system, the diencephalon, and the extrapyramidal system and possibly produce their effects through an influence on synaptic transmission in the sub-cortical structures of the brain. Minor tranquilizers apparently affect more prominently the cerebral cortex and parts of the limbic system in the sub-cortical structures. The action of psychotomimetics still poses a very puzzling phenomenon: these drugs may lead to desynchronization and imbalance between the transmission of impulses through the primary sensory paths and their processing through the associative systems of the brain.
Treatment practices in clinical psychiatry
A general principle may be formulated, stating that somatic treatment is the primary therapeutic approach to the psychoses, with psychotherapy playing an auxiliary role, and that psychotherapy is the primary therapeutic approach to the psycho-neuroses, with somatic treatment serving as an adjutant (Kline & Lehmann 1962).
This would mean that the treatment of psychoses is less complex and demands less personal skill and experience from the therapist than the treatment of psychoneuroses. The recently developed pharmacotherapy of schizophrenia, manic states, and depressive conditions makes it now possible for a nonspecialist physician to treat a psychotic patient successfully outside a mental hospital. This is of particular significance for the organization of psychiatric services in underdeveloped countries, where the impossibility of constructing mental hospitals and finding enough well-trained specialists has prevented the build-up of such services until now. That modern pharmacotherapy can indeed provide the nucleus for a successful psychiatric service organization in a country where such services were nonexistent be-fore has been demonstrated in Haiti, where a well-functioning psychiatric clinic with preventive, therapeutic, and rehabilitative functions has recently been set up within a short time and at minimum expense of financial means and trained manpower. Such shortcuts have become possible only since rapidly effective and self-administered therapeutic agents that can also maintain the patient symptom-free following the acute treatment phase have been made available in the form of antipsychotic and antidepressant medication.
Ready availability, ease, and continuity of administration are the main advantages of drug treatment over insulin-coma and electroconvulsive therapy. Insulin-coma therapy, although still a valuable treatment for schizophrenic patients who do not respond to drug therapy, is no longer given at most psychiatric treatment centers because the necessary, specially equipped insulin-treatment units have been dissolved. Electroconvulsive treatment is simple to administer but also requires some special apparatus and technical skill on the part of the therapist; besides, it cannot be given continuously because of its cumulative effects on a patient’s memory. However, it is still widely used in the treatment of acute or chronic manic or schizophrenic psychoses, particularly when they do not respond to drug therapy. Prefrontal lobotomy—sometimes also referred to as leucotomy—is rarely performed today except in cases manifesting depressive or obsessive—compulsive symptoms which have failed to respond to any other treatment. Pharmacotherapy has in many instances replaced these older methods of somatic treatment.
Different national cultures seem to have shaped different therapeutic attitudes, and in certain countries preferences and dislikes for particular modes of treatment are clearly evident. In a very broad sense it may be stated that psychiatric orientation on the North American continent is characterized by a much heavier bias toward a psychodynamic—more specifically, Freudian psychoanalytic—approach to theory and practice than psychiatry in other parts of the world. European schools of psychiatry place more emphasis on genetic-constitutional and physicochemical factors in their speculation on the etiology of mental disorders as well as in their clinical approach to them.
In the Soviet Union, psychosurgery, in the form of prefrontal lobotomy, has been officially ruled out as a permissible treatment method. In Britain, on the other hand, there is still greater interest in this type of therapy than in most other countries. In German-speaking countries, where the influence of an existentialist orientation is fairly strong, electroconvulsive therapy seems to be disliked—possibly because of the radically disrupting effect such treatment has on the continuity of a patient’s orientation toward his problems and his experience of the world in which he lives. In countries where psychiatric services must be created de novo, the practical advantages and the comprehensive effectiveness of modern pharmacotherapy have made it the favorite choice of somatic treatment for mental disorders.
It should again be recalled that the undoubted effectiveness of modern somatic treatment applies only to psychotic disorders, in particular to those of functional origin. Physical methods, including drug therapy, are of very limited value for the therapeutic management of psychoneuroses and character disorders.
In accordance with modern concepts one may view mental disorders as the resultants of multi-factorial functions and forces. The complex factors interacting with each other may be categorized under the headings: (1) genetic factors—constitutional personality matrix, idiosyncratic and, within wide limits, independent of time; (2) situational factors—idiosyncratic and time-dependent; (3) physicochemical factors—general and independent of time.
Somatic treatment of mental disorders is aimed only at the physicochemical sector of the human behavioral complex. The indirect repercussions of physical treatment may, however, bring about a change of balance in the entire organism and thus result in therapeutic effects which seem to go far beyond simple physical changes.
Heinz E. Lehmann
[Other relevant material may be found in Depressive Disorders; Drugs; Electroconvulsive Shock; Nervous system, article on Structure AND Function Of The Brain; ="">Neurosis; Psychiatry; Psychosis; Schizophrenia.]
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The term “therapeutic community” designates a method of treatment which attempts to use a hospital's social environment as an integral part of the treatment approach. It belongs to the general approach often referred to as “milieu therapy.” As such, it is related to the field of social psychiatry, which attempts to incorporate sociocultural perspectives into psychiatry.
The first use of the term “therapeutic community” was by Thomas Main (1946) in his description of the experimental units developed during World War II in England for the treatment of various kinds of wartime psychological casualties. The felicitous phrase, mentioned almost casually in Main's report, was picked up and made into a self-conscious, organizing concept in the work of Max-well Jones (1952), with whose name the concept is generally associated.
Although the idea of the therapeutic community was forged in the exigencies of war, it was devel- oped to its fullest elaboration in its postwar applications. In essence, it represents a critique of prior psychiatric theories and practices in that it advocates radical changes in psychiatric hospitals to make them therapeutic rather than merely custo-dial or even psychologically damaging, and it is based on a new combination of ideas that have emerged from psychoanalysis and the social sciences. Accordingly, it is important to consider the complex of ideas associated with the term “therapeutic community” in the context of an appreciation of its precursors both in and out of psychiatry in Europe and America. There are two sets of pre-cursors: those against which the therapeutic community idea represented a protest and those from which it drew its own creative elements.
Characteristics of therapeutic communities
There have been numerous attempts to find a quintessential definition of the therapeutic community idea as it has evolved and been applied in various settings (e.g., Jones 1952; Jones & Rapo-port 1955; Rapoport et al. 1961; Research Conference . . . 1960; Schwartz et al. 1964). A number of key ideas are distinguishable that differentiate the therapeutic community approach from other forms of milieu therapy or administrative psychiatry. Some or all of the elements described below are employed in units designated as therapeutic communities. In any given setting, these elements may be part of a focal treatment method, they may be secondary elements with other methods more focally applied, or they may be a part of the general background or atmosphere against which various methods may be applied.
The holistic view
Conceptualizing the organization in system terms, according to a “holistic” view of the entire hospital or unit, is an integral part of most therapeutic community ventures. As the concept suggests, the hospital or unit is seen as a “community,” of more or less closed corporate character. The emphasis is on understanding how behavior is affected by and affects the over-all functioning of the hospital as a social system. This element of the therapeutic community idea is taken to contrast with the tendency of the old-fashioned mental hospital (with its associated theories emphasizing constitutional determination and therapeutic pessimism) to regard individual patients in depersonalized, asocial, atomistic terms. By conceptualizing the hospital as a special type of community in which the patient can be helped, therapeutic community practitioners seek, at the very least, to sustain a social definition of the nature of the patients' conditions and potentialities. They hold that this social definition is a prerequisite of therapeutic effectiveness. The new community in the hospital is seen as belatedly providing a “good” substitute for the earlier pathogenic environment in which the patients' socially unadaptive tendencies developed. Identification with the hospital community is seen as a steppingstone to identification with society at large.
In contrast with the restrictive environment of the old-fashioned mental hospital, which was prisonlike or even punitive in character, the therapeutic community allows patients to ex-press themselves relatively freely, even if this means the enactment of behavior that would be morally repugnant in ordinary settings. The degree to which this “acting out” can be tolerated is, of course, limited by several factors: the capacity of the institution to endure disruptive behavior, the exercise by the staff of their responsibilities for the care and protection of their patients, and the degree to which the expressive behavior may be taken to be in the interests of therapy. But some degree of permissiveness has become a hallmark of the therapeutic community.
Underlying the application of permissiveness is the theoretical viewpoint that psychiatric disorder is the manifestation of maladaptive responses to earlier situations which have formed a covert, often unconscious framework for the individual's contemporary behavior. Success in attempting to change the latter is seen as depending, to some extent, on uncovering the former. Permissive standards of patient role prescription thus create a deliberate, rather than a careless, set of ambiguities in the structuring of hospital role relationships. The hospital social structure can, in this context, be seen to act somewhat as a “social screen” onto which patients project their covert behavioral tendencies; these tendencies can then be subjected to group analysis. In addition, involvement of patients in one another's treatment responsibilities helps the staff to allow more permissiveness by providing a more diffuse base of social controls.
Increasing patient participation
In old-fashioned mental hospitals the patients were treated as objects, led passive lives removed from ordinary social activities, and had little or no voice in the conduct of the affairs of the institution in which they lived. In therapeutic communities, by contrast, patient participation is encouraged. This trend seems to have several components: “democratization,” which implies the increase of patient participation in policy decisions relating to the general administration of the organization (for example, by patient government); “egalitarianism,” which implies a reduction of status differentiation between staff and patients, with an emphasis on sharing of the facilities and resources of the institution (usually accompanied by the use of familiar terms of address, the forgoing of titles, uniforms, etc.); and “harnessing of patients for therapy” through attempts to use their intimate knowledge of one another, their communications, and insight potentials (for example, by the emphasis on group therapy sessions as a major treatment method).
Broadening the base of therapy
In the therapeutic community a broader range of activities, relationships, and qualities of the patient's environment are considered relevant to the course of his treatment. Conventional medical thinking has always defined treatment in terms of what the doctor does—giving an injection, applying electrical shock therapy, or even subjecting the patient to “analysis” in a therapeutic “hour.” Proponents of the therapeutic community, however, recognize that many experiences, relationships, and characteristics of the patient's life in the hospital can have a critical effect on his treatment. Activities previously thought of as purely diversionary or recreational have come to be seen as part of a program of treatment, and subordinate ranks of hospital personnel have be-come important links in the human communications network through which treatment is provided. Likewise, patient roles which had been seen as relatively unimportant or even troublesome, such as the leader of an informal patient clique, have become parts of the organizational and interactional process which therapeutic community practitioners seek to harness for therapy.
Another feature of therapeutic communities is their orientation toward patient rehabilitation, which is based on an optimistic view of therapeutic potentialities. Therapeutic communi-ties seek to reproduce within the hospital a microcosm of the ordinary world of the patient so as to enhance the possibilities for rehearsing social roles while still in the hospital. Thus there is an emphasis on training or retraining individuals to take social roles outside the hospital, not by forcing conformity to ordinary role requirements but, rather, by providing the opportunity for learning what kinds of problems interfere with the individual's capacity to perform acceptably in these roles.
This emphasis is seen in the development of “realistic” workshops in the hospital and in the tendency to confront patients continually with others' perceptions of their behavior.
This optimistic view of rehabilitation is reflected in what has come to be known as a “therapeutic atmosphere,” which to some extent consists of a series of new attitudes toward the patient and the hospital. These attitudes emphasize, for example, the positive elements in personality rather than the sick parts and thinking from the outset in terms of pathways back to a normal existence in the community rather than in terms of a long and hopeless removal in the artificial and impersonal life of the mental hospital. To some extent this “atmosphere” seems to have been made up of a set of attitudes held by the psychiatric leader: a sense of innovative change, high valuation of the work and people involved in it, optimism, and a feeling for the social significance of the therapeutic enterprise. There has been an impression by some observers (for example, see World Health Organization, Expert Committee on Mental Health 1953) that this charismatic quality of the leader contributes a major share to the success of therapeutic communities. To the extent that sophisticated practitioners of the therapeutic community approach have been aware of the importance of this sense of innovative change (akin to the “Hawthorne effect” in industry), they have sought to develop a continuing sense of challenge. They have looked to positive elements of the therapeutic community concept on which to build after many of the inequities of the old hospital system have given way to widespread reform.
History of the concept
Ingredients of the therapeutic community concept within psychiatry stem from the reformist stance taken over a century ago, when, in keeping with the trends emanating from the French Revolution, mental patients in country after country were brought under the benign aegis of medicine. Philippe Pinel in France, William Tuke in England, Vincenzo Chiarugi in Italy, Johann Reil in Germany, and Benjamin Rush in the United States were leaders among scores of hospital superintendents who attempted to redefine the ailments of mental patients. With the development of “moral treatment,” physicians sought to treat psychologically disturbed individuals with compassionate understanding and close attention to their personal needs, thoughts, and feelings.
The custodial system. The
“moral treatment” approach declined in the latter part of the nineteenth century, to be replaced by a custodial, incarcerative system accompanied by deep-seated attitudes of therapeutic pessimism. The reasons for the change included the influx into urban areas of individuals who had few if any ties and who were disturbed and disfranchised through their experiences with urbanization and industrialization. Hospitals were overloaded, their patients were not inte- grated into the local communities, and as costs mounted, the tendency was to remove them to the outskirts of major urban concentrations. Patients were held there with prisonlike restraints for their own and society's security. Concurrently, a theory of psychopathology developed which attributed the more serious mental disorders (which were thought to be on the increase) to brain lesions, the cure of which was yet to be discovered by medicine. The fact that the moral treatment proponents had not developed a theory of etiology and therapy to underpin their efforts left them without a rationale to support a concerted program of care in the face of the new influx of intractable patients and competing etiological theories. Their effectiveness was based on their norms of personal conduct as genteel members of the relatively small, intimate communities of their times.
Thus a combination of factors—ranging from fiscal to theoretical—led to the build-up of large custodial mental hospitals, which were stocked with chronically disturbed, neglected mental patients and ill-trained, pessimistic staffs. The therapeutic community approach found its immediate impetus in the reaction against this situation. The reformers were motivated in part by the ancient injunction Primum non nocere; as Florence Nightingale put it, “It may seem a strange principle to enumerate as the very first requirement in a hospital that it should do the sick no harm.” The forces of institutionalization and neglect, as much as the innate pathology of the individual patients, were increasingly seen as having played a part in bringing them to their predicament.
As compared with their predecessors, the new reformist movements were better equipped by modern theory and research methods to implement new approaches to mental patient care. The new theoretical orientation stressed the growth potentialities of the mentally ill. One of the fortunate by-products of the great depression was a new recognition that individuals could not entirely control the social forces affecting their lives. This recognition negated the view that casualties of the social process were constitutionally defective. World War II led to the mobilization of new talents and energies, accompanied by a revised sense of federal responsibility for the care of the nation's casualties. The changes have been so great in the period following World War II, particularly in the fields of social psychiatry, that they have been termed by such partisans as Moreno (1934) and Dreikurs (1955) the “third revolution” in psychiatry—the first having been that associated with the early reformers and the second with the psychoanalytic movement.
Of particular relevance to the therapeutic community approach were the efforts of August Aich-horn in Austria, Jacob Moreno and Harry Stack Sullivan in America, Ernst Simmel in Germany, and Wilfred Bion and others associated with the Tavistock Clinic and Institute in England. Aichhorn's work (1925) was influential in applying the psychoanalytic conception of permissiveness to the administration of an adolescent treatment institution. His work has been carried on and developed in the United States by such men as Bettelheim (1950) and Redl (Redl & Wineman 1952); Moreno stressed the importance of “psychodrama,” or the use of role playing for both diagnostic and therapeutic purposes. Harry Stack Sullivan's Interpersonal Theory of Psychiatry (1953) was a pioneering effort to revise psychoanalytic theory so that it would take sociocultural processes into account in therapy, and while he did not directly influence the early therapeutic community innovations, his work was important in the development of parallel efforts such as those of Rioch and Stanton (1959), Stanton and Schwartz (1954), and Artiss (1962) and in laying some of the groundwork for American acceptance of the therapeutic community idea. Ernst Simmel (1929) noted that the transference relationship, so vital to psychoanalytic therapy, could be developed in a hospital setting with reference to social roles and, therefore, be displaceable to some extent from one individual incumbent in the role to others. The Tavistock group, influenced particularly by Bion (1961), developed many of the notions of group dynamics that informed the efforts of Maxwell Jones and his colleagues with therapeutic community experiments.
A prior effort that resembled the therapeutic community method and provided ingredients for its subsequent development as a well-formulated approach was the “total push” method of Abraham Myerson (1939). This was an eclectic approach which optimistically sought to harness whatever resources and methods were at hand to reorient the staff's activity into a more holistic attack on the problems of psychiatric rehabilitation.
Ideology of the therapeutic community
It is interesting to consider the question of why such a movement, with its utopian emphasis on the healing power of the community, should have developed at this point in history. It may be conjectured that the movement to establish therapeutic communities is essentially a reaction against the anomic by-products of rapid social change attendant on increasing industrialization and urbanization. It represents an attempt to restore what Edward Sapir referred to as a “genuine culture,” at least within the limited and more manageable sphere of the mental hospital world. The fact that the segregated mental hospital system displayed a remarkable degree of cultural lag and at the same time was associated with an idealistic, science-minded group of professional practitioners, gave unusual leverage for rapid implementation of this program once the conditions were favorable. The wartime mobilization of effort seems to have galvanized the profession to action that was directed toward reducing the cultural lag. The scientific ingredients of the new method were at hand, and the ideological emphasis on the corrective power of the tight-knit, intensively interacting community seems to be explainable in terms of a reaction against the anomic effects of modern society.
Social science and the therapeutic community
Social science has affected the development of therapeutic communities both indirectly, through the interest of innovating psychiatrists in social science concepts such as “culture” and “social structure,” and directly, through the participation of social scientists in research on hospitals using this method of treatment.
The Rapoport study
Although there were several prior social science studies on mental hospitals of various kinds (see Belknap 1956; Dunham & Weinberg 1960; Rowland 1938; and Henry 1954 on the old-fashioned mental hospital; Stanton & Schwartz 1954 and Caudill 1958 on psychoanalytically oriented hospitals), the first social science study of a hospital styling itself a therapeutic community was the study by Robert N. Rapoport and his associates (1961) of the British unit under Maxwell Jones. The latter had advocated setting up such a unit, as a result of his wartime experiences with soldiers suffering from war neuroses and from the difficulties of returning to normal social life after such deprivations as prolonged prison camp internment. When the unit became established, it gained a wide reputation as the first fully developed therapeutic community.
In seeking to repeat their wartime successes with intensive resocialization methods, Jones and his staff developed a unit for the treatment of a variety of patients with problems of social maladjustment. They reported that their extension of the therapeutic community method was effective. Indeed, they advocated its application not only to the treatment of “psychopathic” personality disorders but also to the treatment of all sorts of behavioral adjustment problems, including those of imprisoned criminal offenders. Since the method was essentially one of harnessing the social processes of institutional community life, the collaboration of a social scientist was sought.
Rapoport and his colleagues, following Caudill (1958) in viewing the hospital as a form of small society, observed that the culture of this society emphasized four principal themes—permissiveness, democratization, communalism, and rehabilitation (through reality confrontation). Analysis of the program of activities and prescriptions for social roles in relation to these themes led to certain conclusions of a structural-functional nature. For example, one structural recommendation focused on the importance of incorporating into the formal ideology a conceptual distinction between “treatment” (measures aimed at improving the organization of the individual personality structure) and “rehabilitation” (measures aimed at improving the individual's adjustment to his social role relation-ships). This distinction was shown to be important in avoiding certain potential conflicts between overt and covert role prescriptions, among ideological themes in their spheres of possible contradiction, and between intrahospital and external norms for social behavior.
One of Rapoport's functional recommendations was that treatment should concentrate on the hitherto relatively unrecognized process of “oscillations” in the state of over-all organization and functioning of the system. It was pointed out that all social systems are subject to variations in their state of organization and that systems with the properties of the unit are subject to particularly great swings in the state of “collective disturbance”—due to their permissiveness, the properties of their patients, and their emphasis on maximizing intercommunication. The tendency in the unit, as among practitioners generally, was to view these swings toward states of great collective disturbance with alarm and to attempt to avoid them wherever possible. However, Rapoport found evidence to support the view that the oscillatory process could be therapeutically very useful if appropriately harnessed. In the stage of social reorganization following the critical turning point of maximum disorganization, patients were observed to involve themselves more meaningfully in the constructive social processes and thereby to learn modes of social adaptation which could serve them in their subsequent relationships. The technique of managing these processes in the interests of therapy was shown to involve an interest in and alertness to their special properties; thus the Rapoport study recommended an avoidance of such pitfalls as “collusive anxiety” (premature intervention and imposition of authoritative staff social controls) and “collusive denial” (lack of recognition of the state of disorganization and consequently the failure to intervene at the social-psychologically critical point).
In addition, an analysis was made of the “careers” of a cohort of patients, and several conclusions were drawn, principal among which were the following. There was a relationship between the patient's acceptance of unit culture (as measured by change in profile scores on the ideological themes) and his perceived improvement in the unit (as measured by the patient, by the physician, and by the nursing staff); moreover, acceptance of unit cultural norms (and thus manifestation of clinical improvement) was far less likely to occur among patients who left the unit in less than six months than among those who stayed at least six months. The persistence of improvement in social functioning in the community for a year following discharge was more likely to be seen among certain types of “improved” patients than among others. Married patients did better than unmarried, and patients whose dominant personality defenses did not involve aggressive behavior did well in the per-missive atmosphere of the unit. However, the fact that patients suffer setbacks in relationships outside the unit following discharge points up the importance of being alert to cultural discontinuities between treatment unit and community; in therapeutic communities the sense of contrast with the segregated mental hospitals may tend to obscure the contrast between such communities and their surrounding cultural context.
In conclusion, Rapoport and his colleagues listed 30 principles for the formation of therapeutic communities, attempting to formulate them in sufficiently flexible terms to make them adaptable to a wide range of therapeutic contexts (R. N. Rapo-port et al. 1961).
Holistic and segmental studies
In considering the place of the Rapoport study of the therapeutic community among social science studies of the mental hospital generally, a useful distinction might be made between holistic studies and segmental studies. The study by Belknap (1956) and some other earlier studies of the state mental hospital, as well as Goffman's study (1961), may be thought of as cases at the custodial extreme of the continuum (described by Greenblatt et al. 1955) which ranges from custodial to therapeutic care; the Rapoport study is a holistic analysis of a case at the therapeutic extreme. Brown and Wing (1962) pre-sent a study of three hospitals representing three points along the continuum and provide further evidence to support the contention that changes in the over-all organization of the hospital are reflected in changes in patients' behavior.
Segmental studies would be those which focus on part processes. Even the Stanton and Schwartz classic study, The Mental Hospital (1954), is essentially a collection of segmental analyses of part processes, most notable among which is the demonstration of a relationship between covert disagreement among staff members and clinical excitation of patients. Gilbert and Levinson (1956) are particularly concerned with the relationship between the espousal of a custodial ideology and certain personality types, notably the “authoritarian personality.”
The other form of segmental research is seen in the replication studies, such as that of Carstairs and Heron (1957), who studied a British mental hospital, using the same measures as Gilbert and Levinson (1956) and their colleagues; they found that in Britain, as in the United States, higher-status staff members are more likely than lower-status members to have a low “custodial ideology” score. Working with a greater cultural contrast, Stein and Getting (1964) found that the culturally prescribed role of the physician in Latin America countervails this tendency for liberalism to be easier for higher-status, relatively disengaged people. The role of the psyhiatrist in Latin America is still oriented to the more authoritarian norms of physician conduct (reminiscent of the earlier period in Europe and the United States), and therefore their scores on the “custodial ideology” measures were less differentiated from their lower-echelon staff members than was found to be true in England and America.
Another type of segmental study involves focal concentration on process. Many of the processes indicated in the earlier holistic studies (e.g., Caudill's “linked open systems,” or “transactions,” Rapoport's “oscillations,” and Stanton and Schwartz's “covert disagreements”) have become the focuses for subsequent studies seeking to replicate, refute, or extend their relevance into other contexts. Some segmental process studies seek further development of these earlier insights, particularly of the dynamics of inducing changes in hospital structures. For example, a study by Isabel Menzies (1960) seeks to elucidate a specific type of psychological barrier to the accomplishment of social changes. She concentrates her attention on the deep intrapersonal functions served by the conventional role prescriptions, such as those of the nursing role, and the built-in resistances of participants in the change process that work against their conscious wishes for change and modernization. Agnew and Hsu (1960-1961) approach the problem of understanding and overcoming resistances to change by using social structure as a point of departure; they suggest that the “democratization” theme of therapeutic communities may be most applicable to the phase of steady functioning following the institutionalization of the new system. In order to break through the rigidities of the older system, a measure of authoritative behavior may succeed where the democratic mode would be rejected.
Social science contributions of a more indirect kind can be seen in the clinical reports by psychiatrists on attempts to apply the therapeutic community idea to other contexts and in the course of so doing to evaluate and modify it to suit the circumstances (see Wilmer 1958; Scher 1958; Stainbrook 1955; Clark 1964). To some extent, the attention given to the therapeutic community idea in psychiatry has diminished as a con-sequence of the great development and immediate successes of new pharmacological treatments, even while the former was gaining general, if ancillary, acceptance. However, there is some reason to believe that interest in the therapeutic community dimensions of treatment will once again receive prominence as research reveals the limitations of a simplistic pharmacological approach (Klerman 1960).
Lessons of the therapeutic community
There are several ways in which the development of the therapeutic community emphasis in psychiatry may be seen as relevant to social science. Milieu therapists have provided opportunities for social scientists to observe the intimacies of an important form of institutional life that might other-wise have been inaccessible. Thus, the field of hospital studies and the entire field of comparative institutions have been enriched. Furthermore, the therapeutic community investigations have contributed to the already active trends in social science toward interdisciplinary collaboration. Epitomized in the work of Stan ton and Schwartz (with their demonstration of the connection between structured conflict in the environment and emotional upset in the individual) and of Caudill (with his conception of “linked open systems”), research in the milieu therapy-oriented hospital demands interdisciplinary approaches.
The subsequent work by Robert N. Rapoport and his colleagues (1961) in the more labile environment of an innovating, experimental therapeutic community provided opportunities to examine unusually fluid social systems. This research has fed into the general trend toward developing more processual modes of social science analysis and thus has become associated with numerous other approaches, such as general systems theories and the crisis theories. The experimental therapeutic communities were useful for such analyses because of their positive orientation toward flexibility and change and their relatively unstable functioning due to their tendency to de-emphasize authority hierarchies, to permit disruptive behavior by patients, and to encourage expressive communication. The resulting phenomenon, described in the mental hospital literature as “collective upsets,” tends to be particularly notable in the therapeutic community. The “oscillatory tendency,” as Rapo-port termed it, was observed to have a discernible periodicity, to be affected by specific organizational events, and thus to have properties in common with other systems, as described, for example, in cybernetics.
The oscillatory process was also observed to en-gender therapeutic potentials if properly harnessed, particularly in its phase of social reorganization. This interest in harnessing the energies that be-come available at critical turning points is shared by those social scientists who have been studying the process of critical role transitions (Rhona Rapo-port 1963). The importance of ritual at times of transition in primitive societies has long been recognized by sociologists and anthropologists, notably Arnold van Gennep. In the more complex situations of modern secular society, the mechanisms used to cope with these status transitions are of a more deliberate, rational kind, aiming at adaptation to changing situations as well as accommodating existing needs and expectations. The processes of oscillation within a complex organizational framework can, in this sense, be seen as resembling the pattern of alternation between periods of stable functioning and critical transition followed by reorganization that characterizes the life cycle.
From the viewpoint of the more analytic or fragmentary approaches, the quasi-experimental situation represented by the therapeutic community approach, particularly in its innovating stages, has been an attraction that has only begun to yield the kinds of results of which it is potentially capable.
As the therapeutic community concept has gained wider acceptance, the range of issues con-fronting social scientists in relation to research in this field has changed somewhat. There is still much to be desired by way of sheer evaluation of the effectiveness of the method; however, the types of research concern seem to be shifting. Rather Therapeutic Community than asking what the therapeutic community is and how well it works, the questions are being posed more in terms of what aspects of the approach are most relevant for what types of persons under what conditions, including conditions of concurrent use of other forms of therapy.
Furthermore, the possibility of the initial efficacy of the method as a novelty stimulus—akin to the medical “placebo effect” or the “Hawthorne effect” as recognized in industrial research—has relevance not only for evaluation of the method but also for the type of interest which it has for social scientists. Many of the early social scientists were interested in it as an innovating experiment with some of the characteristics of a utopian reformist movement. However, as the method has gained acceptance and has become to some extent routinized within the psychiatric profession, its appeal for social scientists has changed. The emphasis has shifted, to some extent, from the more macrosociological or holistic, anthropological type of approach to the more structured, quasi-experimental approaches that are more characteristic of the social psychologist. However, the holistic researcher still has scope for analyzing the range of problems associated with application of the concept in different subcultural and structural situations—in large state mental hospitals, prisons, delinquent groups, depressed slum neighborhoods, schools, and industrial work groups. The concept can also be applied to different national and cultural settings, and to functional processes related to the persistence of innovations.
In the context of these new and contrasting over-all situations, analyses will be fruitful on both the holistic level and on the level of part processes. Such issues as optimal size of the hospital unit, degree of social differentiation, type of authority structure, degree of interlinkage of subsystems, and flexibility versus fixity of value hierarchy can be tested in various contexts in relation to therapeutic effectiveness. The issues involved in doing systematic evaluative research in this field have hardly been broached and present a major challenge. On the side of implications for social theory, one can only note a great hiatus in work already done. Goffman's linking of the old-fashioned mental hospital to the larger class of “total institutions” (1961) is the most creative effort available in the hospital research field, but it relates not to therapeutic communities but, rather, to the polarity against which they are reactions.
Therapeutic communities of the future will prob-ably turn out to be far more differentiated and can therefore be expected to provide materials for understanding many kinds of dynamic processes. It would seem that their contribution to social science might be expected to lie in two spheres: first, the reciprocal relationship between personality and social structure, and second, the relationship between stability and structure on the one hand, and fluidity and change on the other, in the functioning of institutions designed to “process” a continuous flow of people while the organization maintains continuity and reliable functioning. These are challenges faced by social scientists in increasingly numerous fields of investigation, and the degree to which the therapeutic community will be a fruitful arena for investigation of these issues will depend on a complex of many factors other than the intrinsic interest which it presents.
Robert N. Rapoport
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