Key Cases in Psychotherapy (Psychology Revivals)

Windy Dryden

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317648666
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychothérapie

Originally published in 1987, the purpose of this book was to show how therapists grappled with cases which challenged their ideas about the theory and practice of psychotherapy at the time, and how they revised these ideas as a result of encountering these cases. The contributors, leading therapists from Britain and the United States, discuss a range of issues – personal, conceptual and technical – that will be of interest to all those engaged in psychotherapeutic work. As such, the book is aimed at those working in psychotherapy counselling, clinical psychology and psychiatry, and at students of these disciplines. It will also have relevance for those with a scholarly interest in developments in the theory and practice of psychotherapy.

1

Key Cases in Psychotherapy: An Introduction

Windy Dryden

In this book a number of noted practitioners write about cases that have led them to revise their thinking about psychotherapy and/or to change some aspect of their clinical practice. The idea for the book emerged as I was completing a previous book entitled Therapists’ dilemmas (Dryden, 1985). In that book, well-known therapists discussed dilemmas of therapeutic work and often pointed to specific cases that provoked conflict and precipitated change in their thinking about therapy and how they practised it. I wondered, at that time, whether there existed any books that had as their central theme therapists discussing ‘key’ cases, which are here defined as ‘those cases which led therapists to experience a significant degree of conflict but out of which emerged important new developments in their theorising about psychotherapy and/or their practice of it’.

Although numerous casebooks have been published, some even describing so-called ‘great cases’ (e.g. Wedding and Corsini, 1979), none of these dealt with such ‘key’ cases (as defined above) in a systematic manner, with contributors being asked to address similar issues outlined in a common chapter structure.

At the time I was having these thoughts, I received a preprint of a research study which, among other things, considered the use that American psychotherapists make of different sources of information on therapy (Morrow-Bradley and Elliott, 1986). It was found that 48 per cent of the total sample of almost 300 therapists rated ‘ongoing experience with clients’ as their most important source of information about psychotherapy. This finding reinforced my belief that a book on ‘key’ cases would be timely, particularly when compared with the other sources given ‘top billing’ by smaller proportions of the total research sample:

— ‘theoretical/practical books/articles’: rated as most important by 10 per cent
— ‘through experience of being a client’: rated as most important by 8 per cent
— ‘supervision/consultation with others’: rated as most important by 7 per cent

Given these findings, I decided to put together a book that attempts to show how noted therapists have learned from their ongoing experience with clients. I believe that this book is timely precisely because we know very little about this aspect of therapists’ learning. Obviously, more research needs to be done on this subject, but if we can generalise from another finding obtained by Morrow-Bradley and Elliott (1986), only 4 per cent of psychotherapists will rate such research as their most important source of learning about psychotherapy, whereas 10 per cent will view a book like this as such.

In the present book, contributors could choose to present either a single ‘key’ case or, if they deemed it more relevant, a series of cases. This latter option was chosen by several writers, particularly those who wished to discuss more than one important shift in their theorising and/or practice (e.g. Albert Ellis and Arnold Lazarus).

I asked all contributors to adhere to a common chapter structure in writing their chapters. I did this (a) to have them all deal with issues that several colleagues wished to see addressed in a book of this nature, and (b) to help readers to make meaningful comparisons among the chapters. Contributors were asked to write on four themes:

(a)  Prior theory and practice. First, contributors were asked to describe their ideas on therapy and the mode of practice that characterises their work before the ‘key’ case(s), particularly emphasising elements of theory and practice that were later revised.

(b)  Description of the ‘key’ case(s). Then, contributors were asked to give a full description of the case(s) as it (they) unfolded over time. They were particularly asked to highlight the conflicts that they experienced during the case(s) and what steps (if any) they took to resolve these conflicts.

(c)  Emergent new developments. Next, contributors were asked to describe fully the new developments in theory and/or practice that emerged from the case(s) and to outline the subsequent impact that these developments had on their professional life.

(d)  Implications for other therapists. Finally, contributors were asked to discuss how the learning which they derived from the case(s) described could benefit other practitioners.

I shall discuss each chapter in greater detail in Chapter 12, but a few orienting remarks are in order at this point. The reader will note that contributors differ concerning the type of learning that is discussed in their chapters. Several contributors highlight the personal learning that they derived from their ‘key’ case(s) (Aveline, Thorne) or, in one instance, before the case (Morrison), and show how such learning influenced their conceptual thinking about therapy and their mode of practising therapy. Other contributors focus directly on the conceptual learning that they derived from the case(s). Thus, Butt and Bannister describe the gradual but radical shift in conceptual thinking that Butt experienced, as does Wessler who traces his change over a period of a decade; Ellis describes shifts in his ideas about the nature and determinants of psychological disturbance; Prochaska discusses revisions in his views about therapeutic change; Wile shows how his theory was paradoxically strengthened by his case; and Rowan’s case demonstrates how he resolved a conflict raised by the possibility of making a particular intervention by making a distinction between ‘therapy’ and ‘therapeutic’. Whereas all the contributors who made conceptual revisions show how these led to developments in their practice, only Wessler and, to some extent, Wile discuss the impact of these revisions on their personal experience. The remaining chapter, that of Lazarus, has a more technical focus. Lazarus’s concern with ‘what works’ led him to broaden the scope of his therapeutic approach and thence to make certain modifications in his thinking about therapy.

Only two contributors (Prochaska and, to a lesser extent, Morrison) discuss the role that their own research played in the learning process. It is noteworthy in this regard that Morrow-Bradley and Elliott (1986) found that only 3 per cent of their sample rated ‘doing psychotherapy research’ as the most useful source of learning about psychotherapy.

In summary, whereas all contributors discuss conceptual and practical changes as instructed, only half of them discuss personal issues or point to personal implications of the case(s). The reader should note, however, that the contributors were not specifically asked to address themselves to personal material.

The reader will note that there are no female contributors in the book. Before I am wrongly accused of being a sexist editor, it should be understood that invitations to contribute to the book were issued to more than a dozen women. Only one accepted, but was unable to complete her chapter.

Sadly, Don Bannister died shortly after completing his chapter with Trevor Butt and I dedicate this book to his memory.

REFERENCES

Dryden, W. (1985). Therapists’ dilemmas. London: Harper & Row

Morrow-Bradley, C. and Elliott, R. (1986). Utilization of psychotherapy research by practising psychotherapists. American Psychologist, 41, (2), 188–97

Wedding, D. and Corsini, R.J. (1979). Great cases in psychotherapy. Itasca, IL: Peacock

2

A Psychotherapist at the Crossroads: A Personal and Professional Turning Point

James K. Morrison

Exactly how a psychotherapist has evolved the theory and clinical techniques used in practice remains a mystery in most cases. It is unfortunate that so few psychotherapists take the time and effort to delineate this gradual unfolding process, because there is much to be gained by tracing one’s theoretical and practical approach from early training to present practice.

One way to approach this process is to think in terms of the event or clinical case that most affected one’s theory and practice. Is there one client with whom the clinical transactions led to a change of direction in the clinician; a change carried over into practice thereafter? Such questions, posed by the editor of this volume, have led to this chapter, which is a description of how I evolved as a psychotherapist due to the influence of a key case. After first outlining my clinical approach at the conclusion of my professional training, I will then proceed to discuss the two crucial experiences, one personal and one professional, which became the crucible for change in my development as a psychotherapist.

PRIOR THEORY AND PRACTICE

My theoretical position at the conclusion of my training (graduate course, clinical internship), and for the first few months of my first clinical position with a community mental health centre, is best described as that of cognitive-learning theory. In an article written during my internship and published two years later (Morrison, 1974), I outlined and referenced this approach (e.g. Harris, Johnston, Kelley and Wolf, 1964; Hawkins, Peterson, Schweid and Bijou, 1966; and especially Kanfer and Phillips, 1970 and Kanfer and Saslow, 1965).

At that time the importance of cognitive factors in behaviourism was not as clearly recognised as it is today. An emphasis was placed on what was happening in the present, rather than what had happened in the past. The clinical techniques that I was taught included behavioural analysis, assertive training, thought stopping, anxiety management training, treatment contracts, systematic desensitisation, modelling, and aversive conditioning. Mackay (1984) provides an excellent summary of most of these techniques. Psychoanalytic theory and techniques were openly ridiculed by the professors; Gestalt therapy and rational-emotive therapy were largely ignored. A few professors underlined the utility of client-centred therapy (Rogers, 1951), but most of the faculty tended to encourage graduate students to move in the direction of behaviourism. However, some limited eclecticism was not totally discouraged.

During my clinical internship, I soon discovered the unsuitability of the behavioural approach to my personality. I had always been an impatient person and found that the repetitive work of behavioural analysis and technique application (e.g. systematic desensitisation) was a tedious and too often boring process. Although I would readily admit the process was effective enough, especially with clients with phobias and other anxiety disorders, it seemed to take a longer amount of time than I thought was reasonable. Too often I found clients unwilling to do their homework assignments (e.g. practising relaxation techniques). Although I felt that behavioural approaches were superior to psychoanalysis in their efficient use of time, I was still searching for methods that were for me more interesting than behavioural ones, and ones that were more efficient as well.

My dissatisfacation with the results of behavioural techniques with the commonly reported problems of depression was another reason for my search for new methods. I found that even though behavioural methods were appropriate to reduce certain symptoms of depression, all too often the overall depression remained.

To sum up, I wanted to get more deeply into a client’s psyche without practising psychoanalysis which, at the time, was not a short-term methodology. Only a short-term insight-oriented, emotionally involving (for the client) process would seem to satisfy my personal needs at the time.

Perhaps it is a more personal reason which actually was the driving force behind my gradual rejection of the behavioural approach. Thus, because behavioural theory was not personally helpful in explaining the cognitive side of my neurotic conflict (to be explained later), such a theory was not to my liking. To explain my past, with all the emotional underpinnings, in terms of reinforcement contingencies seemed too arid and unreal to satisfy my curiosity.

It should also be mentioned that although clinical supervisors seemed happy enough with my work, I was not. They seemed patient with my progress. Again, I was not. So, gradually, I became a therapist in search of a different theoretical and operational approach. I was quickly approaching a crossroads in my professional career, a point where my neurotic conflict would trigger some personal insights which would enable me to try a new approach with a certain client. Both of these events would be key in my evolution as a psychotherapist.

DESCRIPTION OF THE KEY EVENTS

The personal experience

Despite my dissatisfaction with both the theoretical and practical aspects of my work, I had at the time made no decision to change these until faced with what I have called a ‘peak experience’ (Maslow, 1976) — an event which turned out to be unusually enlightening and therapeutic for me and which later led to drastic changes in my clinical work with clients. I was not able to change my work until then because I had not yet found a better alternative.

A few months after my internship, and while I was working full time as a community psychologist and completing my doctoral dissertation, I read Arthur Janov’s (1970) The primal scream. This book, one with which I violently disagreed concerning the author’s theory and techniques, offered a number of case studies which must have raised my anxiety level. These case histories, with their emphasis on early traumatic experiences, began to stir up in me unconscious memories of certain childhood events. However, before I went to sleep that night, I was only minimally aware of the anxiety the book was evoking.

At 2.30 a.m. I suddenly awoke with a vivid image and a powerful feeling. After I became a little more conscious I began to experience an eruption of tremendous anger associated with the image. The image was that of my mother, standing in the cellar of our house, with a knife in her right hand and a crazed, desperate and depressed look in her eyes. Right then and there an incredible anger burst forth and I found myself shouting out loud over and over to my father: ‘You son of a bitch!’ It was only then, at the age of 32, that I realised that for 27 years I had been blaming my father for driving my mother close to a nervous breakdown. Now I began to understand for the first time why I had rebelled against my father most of my life and why I had made most of the major life decisions I had. It seemed as if in five minutes I understood, for the first time, my family’s dynamics, why I was attracted to women I needed to save or heal, and why I thus chose the two professions (the ministry and psychology) I had. I also experienced a rush of childhood memories, most of which I had forgotten or repressed, which confirmed my conclusions.

My anger quickly subsided and suddenly I began to see my father’s perspective for the first time. I never experienced real anger at my father again after this. I also seemed to lose most of my need to save depressed females, a need which I feel made me a less effective therapist with women clients. Before this experience, all too often in trying to ‘save’ these women clients I was apparently so emotionally involved in the process that such clients were misled into believing that I was in love with them. Then, as I realised that they began to fantasise a different relationship with me, I began to be stiff and cold with them to discourage this. My behaviour then provoked anger and, at times, termination from therapy....

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Copyright Page
• Dedication
• Table of Contents
• List of Contributors
• 1 Key Cases in Psychotherapy: An Introduction
• 2 A Psychotherapist at the Crossroads: A Personal and Professional Turning Point
• 3 The Process of Being Known and the Initiation of Change
• 4 Beyond the Core Conditions
• 5 An Even More Offensive Theory
• 6 Siding with the Client
• 7 Better the Devil You Know
• 8 On the Origin and Development of Rational-Emotive Therapy
• 9 Listening to Oneself: Cognitive Appraisal Therapy
• 10 When More is Better
• 11 From Prescription to Integration
• 12 Key Cases in Psychotherapy: Concluding Issues
• Index