This is the second in a series of articles about contemporary mental health and psychotheraputic treatment, following an article focusing on meaning and society in mental illness.
Different models of psychotherapy not only offer distinct understandings of pathology and ‘ways of intervening’, but suggest wildly varying pictures of health or recovery. The integrative psychotherapist needs to evolve an approach that selectively combines often mutually incompatible seeming therapies, into a coherent, client directed treatment.
Choice Theory / Reality Therapy, takes a needs based approach, positing five basic needs which are individually variant (love & belonging, freedom, fun, power and survival). The idea of needs, whether viewed as libidinous impulses or aspects of personality, is valuable. However, Glasser’s specific taxonomy of needs seems arbitrary and ethnocentric. For Glasser, all fun and creativity is based on learning, while sex is not a need on its own, but rather serves a variety of other needs. This is starkly at odds with an evolutionarily perspective – situating our universal dimensions of personality and behaviour in the context of their utility in our environment of evolutionary adaptedness.
In keeping with Jungs idea of enantiodromia, Glasser’s needs could be refined by adding another dimension, perhaps entitled ‘avoidances’. Since it seems evident motivation is as much about the avoidance of unwanted / intolerable situations, states etc, as desire. Avoidances might be perceived as neurotic, however resolving or satisficing (SIC) them could be an important element of lifelong happiness. For example – jogging in the morning might help to fulfil my freedom need, however if my experience each afternoon is to suffer under the caprices of a tyrannical boss, my need-avoidance of domination may be a larger contribution to the happiness of my day.
Glasser also emphasises that all needs are met through present relationships – and here he has something to offer psychoanalysis. Fixating on past relationships and their discussion in the present can blind us to the value of real and potential relationships, in providing a healthy emotional environment and support for life challenges. While people certainly re-enact toxic (as well as positive) patterns of relating, whether in the psychotherapeutic encounter or with friends, partners and families; present relationships offer the field of current functioning, and can act to sustain or alleviate trauma, to heal and to wound afresh.
Psychoanalysis traditionally offered the catharsis of past trauma, and the development of insight as the ultimate routes to healing. Insight, combined with ‘corrective recapitulation‘ in the safety of the therapeutic encounter, allowed a ‘reverie’ to contain the clients suffering, and transform it into something which could be re-introjected – split off aspects of self becoming defrosted, feelings long disowned being assumed into the emotional vocabulary. While we need to be wary of re-traumatisation of clients; and equally of the construction of artificial memories previously ‘repressed’; the value of catharsis should not be understated. Simply being heard (and accepted through congruent empathic unconditional positive regard of Person Centred therapy) is a healing experience, which allows the self to obtain a measure of secure reality – which may have been absent developmentally. This is emphasised in contemporary object relations approaches, which focus on ‘reparenting’ (essentially healing attachment difficulties), through corrective emotional experiences in the ‘containment’ of the psychotherapeutic encounter. Through the therapeutic relationship the analyst provides the appropriate tolerance and nuanced emotional response lacking in the client’s developmental history. They ‘fail gradually’, allowing the client to assume responsibility and self direction.
Psychodynamic processes like projection, can provide more insight into a range of expressions of suffering than many current (and proposed) DSM criteria of syndromal mental illness. In the mental universe ‘symptoms’ are less important in their specificity than in their utility, their function in expressing or providing relief from intolerable pain. Allowing meaning into the understanding of illness, not only provides for a more hopeful outcome, and motivates a more genuine listening to client issues, but also more accurately reflects the experience of clients – that mental illness is frequently potentiated by trauma, in both its timing and mode of expression.
However, risk factors like neurological insults, developmental disorders and neurocognitive impairment contribute to vulnerability to mental illness; interfacing with resilience factors (like family health, access to educational resources etc) that ameliorate or even prevent mental illness. The support and resources a client receives outside of the therapy room (and the skills needed to acquire them), may in fact be much more important than the psychodynamic processes at work in their individual distress. Communications skills, social support and practical resources can provide the bulwark against illness that clients need.
Teaching clients how to acquire such resources, whether through CBT, or life skills training, can be a valuable aspect of psychotherapy: Although this very much conflicts with the Winnicotian idea that therapists must never ‘model health’ for the client, and need to move past being a ‘need fulfilling object’ – to avoid transference dependency. This kind of agentic approach has emerged as important in my own life, since my diagnosis with severe central and obstructive sleep apnea, a condition which leads to hypoxia, tiredness and dysphoria along with memory difficulties and other health risks. Treating my sleep apnea has enabled me to greatly increase my productivity, consistency, sense of competence and general mood. All of which might have been seen, by psychoanalysts and cognitive therapists alike, as related to motivation, disorder or personality type.
New research has called into question the famous ‘marshmallow test’, which demonstrated that children with better ability to resist the allure of immediate rewards went on to greater success in adulthood. It seems now that what the test was measuring was not simply an innate reward circuit, malfunctioning in some, but rather the predictability of the childhood environment. Kids raised in chaotic circumstances could not realistically expect to be rewarded for forbearance. This is important, because the kind of resilience demonstrated by patient kids can be taught. Teaching such ‘soft’ and ‘metacognitive’ skills, can be enormously beneficial in ameliorating the gap between healthy and dysfunctional family of origin. Similarly, providing clients with the tools to develop relationships that will support and encourage them, can be extremely productive.
The role of meaning is also important in lifelong emotional health. Meaning making has been examined by Viktor Frankl in his ‘logotherapy’, while modern research into Positive Psychology, statistically examines what makes people happy in general. Logotherapy posits that we can derive meaning a number of ways: through creative work or deed, through experience or encounter, or through our attitude to unavoidable suffering. For Frankl (a holocaust survivor), the existential vacuum accounts for much despair, addiction and power seeking. Individual meaning needs an individual process, and cannot be imposed.
Helping clients to find and develop the meaningful aspects of their lives and work, could be an important element of enabling them to find happiness.
Factors like community participation, ‘spirituality’, norms, values, education, creativity / self expression and continuing personal development – the top of Abraham Maslow’s hierarchy of needs – are elements of meaning making. Meaning making likely changes with life stage too, taking into account Erik Erikson’s conception of a variety of lifelong developmental stages. Although Erikson’s stages and stage crisis’s are somewhat arbitrary and culture bound; they can point us towards a far more helpful developmental model than the folk psychology concept of ‘maturity’ / degeneration.
Finally, psychological research indicates an enormously important role for the physiological and physical environment in emotional health. We are embodied creatures, our affect linked to what neuroscientist Antonio Domasio calls ‘somatic markers’, conditioned bodily responses / brain circuits, that mediate emotion (and, in the case of mirror neurons, empathy). Thus light, exercise, diet, and environmental stressors (like sitting down all day at work), can be important determinants of maintaining mood stability – particularly in those subject to mood dysfunction.
I’d go further than this, and suggest that the design and history of our buildings and neighbourhoods, can have an enormous impact on wellbeing; be it in reminding us of the hopelessness of our situation, or elevating us to new levels of self belief and trust.
As important to psychological health as the physical environment, is the family system. The stability, warmth and encouragement of the family in childhood; and the health and support provided by a client’s current friends, family and partner, are vital elements in determining well being. Similarly, a client’s current position within a dysfunctional family system may force them into the role of the ‘identified patient’, or may reinforce their predispositions toward unhealthy behaviours and addictions. Our place in the social strata is also an important determinant of stress, and a variety of life outcomes, and societies with a low ‘power distance’, have been found to be more happy and helpful.
In summary – not only the client’s traumatic history / object relations, but also their broader family and social system, their physiology and physical environment, their innate needs and learned avoidances, their resilience factors, and the meaning they find in their lives, may all be as or more important as the therapeutic relationship in a client’s happiness and overall life satisfaction. Perhaps there is a role for assessments of wellbeing (much broader than that offered by clinical psychological global assessment of functioning), prior to beginning therapy, and before ending it. A way of learning, with and from the client, how best to help them become happier, more fulfilled people.