My View Of Behavior

 Schools Of Thought

There are many ways of looking at humans---their behaviors, their thoughts, their feelings and their attitudes.  And there are many schools of thought about the best way to change people. Some psychotherapists focus almost exclusively on one way of explaining humans and they use primarily one approach to helping. They describe their approach to helping as either "dynamic" or psychoanalytic" or "behavioral" or "cognitive" or "Gestalt" or  "client-centered" or "rational-emotive" or . . . .   I could go on and on.  

There have been approximately  300 types of therapy since Freud sat his first patient down on a couch!  And more are being touted every day.  Each of these schools of thought claims to be "right" and each claims to have great success in helping people. Most of these therapists follow the teachings of some "founder"---usually an exceptionally bright and helpful therapist who then trained many other therapists in his or her new way of helping and wrote books and articles about it.

If you ask for help from someone who focuses on one "orientation," you are likely to get the same explanation for your problem no matter what your problem is.  You are also likely to get the same treatment, regardless of what your problem is or who you are. If you go to a psychoanalyst, you will be asked to say everything that comes into your mind and to report your dreams.  If you go to a rational-emotive therapist, you will be asked to challenge your own irrational thinking.  If you go to a biofeedback specialist, you will be treated with biofeedback techniques. If you go to a behaviorist, you will be guided in setting up your life so that you are rewarded for achieving your own goals.  If you go to an EMDR therapist, you will be instructed to follow their fingers back-and-forth, no matter what ails you.  The one-size-fits-all approach tends to force you into a particular mold, whether it fits you or not. Sometimes, by chance, it's a good fit and it helps; sometimes it's not and it doesn't.

Some of these "orientations" have the distinct flavor of being religious cults, complete with promises of salvation, a missionary zeal to spread the word and, usually, a charismatic leader.  A few of these "one-track" practitioners are out-and-out frauds, though most of them are licensed social workers, family counselors or legitimately credentialed doctors of psychology or psychiatry. But remember, history shows that many treatments, once thought to be valid by the professionals of that time, were later shown to be useless and sometimes harmful.  

Although I think it is wise for anyone seeking help to consult a licensed and credentialed person,  I do not think that  a license or degree guarantees against receiving "help" that is narrow-minded or based on superstition, nonsense and magical thinking.

My "Orientation"

Many therapists, like myself, do not stick exclusively to one orientation. I draw on the thinking of many different respected approaches to helping.  My approach to helping is called "eclectic".  I try to find the best explanation for your problem that really fits, and I try to use the best combination of interventions, no matter what "school of thought" they come from. I try to tailor my approach to fit you, rather than tailor you to fit my approach. Everyone is unique; what works for one person may not work for another. Every problem is different; what solves one problem may not solve another.

Emotional and behavioral problems are complicated. They're not caused by any one thing, but rather by a combination of things. There is no simple and single explanation or cure-all solution to any problem.  I will try to find "whatever works" for you, including many interventions that don't belong to any "school of therapy."

Since my own training was in "behavioral" and "cognitive behavioral" psychology, I tend to lean a bit more in those directions.  But I am not so simplistic to believe that simply rewarding desirable behaviors or trying to get you to change your thoughts is any kind of cure-all.  These are just two of many possible ways to help you.  

No Magic Cures

I am definitely an "empiricist."  This means I am more impressed by scientific evidence that shows that some approach works, and I'm not impressed by fads, case histories or impressive claims made by charismatic psychotherapists. I'm very skeptical of "healers" who claim to cure just about whatever ails you, with a whoosh of their hands or with "energy" or with some unexplained-bordering-on-magical force. Rest assured, if it sounds "too good to be true," it probably isn't true. You may find yourself attracted to magical cures, but in actuality, there is no magic. The field of psychology is, unfortunately, FULL of well-meaning, licensed therapists who fall for magical-sounding cures, go out of their way to get trained and "certified" in the latest "miracle treatment", and then offer it to desperate, trusting patients.

Caveat emptor! (Latin for: Let the buyer beware!)

If you're tempted to try something that sounds like magic, check it out first with the New York Area Skeptics and with the Committee For  Skeptical Inquiry (CSI). These are excellent sources of reliable information about claims that sound "too good to be true."  I was an active member of  the New York Area Skeptics for  many years and fully recommend CSI and their publication, The Skeptical Inquirer.

I'm also skeptical of therapists who claim to be able to cure you in just one or two sessions.  Problems with behaviors, feelings, thoughts and attitudes don't develop suddenly and they're not likely to disappear suddenly either.  It may take a while to feel better, and to act and think differently.

No Unending Therapy

How long should therapy take?  Definitely not one or two sessions.  But if you've made no progress in six months, then you might want to start looking elsewhere for help. I do not regard this as evidence of "resistance" on your part.  In fact, I will help you find someone else. I will even suggest that you find someone else if you're approaching the one-year mark with me.  I very much disapprove of psychotherapists who keep people in therapy for years and years without defining any concrete goals and without achieving any discernible change in behavior, attitudes or feelings. My function is to get you to the point where you don't need me!  

Exceptions:  Persons with serious, chronic mental illnesses will probably require continuous, ongoing help throughout their entire lives. By "serious, chronic mental illnesses," I mean such things as schizophrenia, other psychotic disorders, bipolar disorder, organic brain damage, certain personality disorders, autism and mental retardation. These are conditions which may have made it difficult or impossible for the person ever to live on his own, finish school or hold a job for any length of time. Often long-term residential treatment or living in a supervised apartment is necessary indefinitely in order for such persons to remain out of a psychiatric hospital.  

"Resistance"

You've decided there is something about your own behavior, feelings, thoughts or attitudes that is making you miserable. You want to change. You go for help.  You even pay your hard-earned money for that help. And then, very predictably, you do everything in your power to stay the same.

I say, "very predictably," because every therapist from Freud on down has experienced "resistance" in the people they try to help. Freud ran into it when his patients wouldn't tell everything that came into their mind, as they were asked to. They'd hold back, edit their thoughts, or claim that nothing was coming into their minds. He also ran into it when they came late, missed appointments or refused to pay their bills.  Behavior therapists run into resistance when their clients "forget" or are "too busy" to do their therapy "homework." Often they don't keep self-observation records as the behavior therapist has asked. Gestalt therapists run into it when their clients refuse to participate in the recommended activities or claim they "can't" do some of the simple things they are asked to do during the session. All kinds of therapists run into resistance when their clients chatter on about irrelevant things or the latest developments of the week, leaving no time during the hour to address the problem that the person came to therapy for in the first place, and no time to engage in any of the treatment procedures that the therapist may have planned.  Cancelling sessions, simply not showing up for appointments or disappearing for weeks at a time are also forms of resistance.

No matter what form the resistance takes, it amounts to driving with one psychological foot on the brake and the other on the accelerator. Net result: You don't get anywhere. All you get is frustrated.

Why would you do this?  Why would you continually get in your own way and guarantee that you will not reach goals that you yourself set? Freud thought it was because of unacceptable feelings that were bubbling to the surface, usually about sex or aggression.  (But then, he thought everything boiled down to sex or aggression.)  Other therapists have thought it has to do with anxiety about learning something about yourself that would not be flattering or acceptable---not necessarily about sex or aggression---but something unflattering or undesirable (selfishness, dishonesty, weakness, materialism, a traumatic memory, etc.). Behavioral therapists don't use the term, "resistance," but they know that  often unpleasant consequences might occur if you were to change in the way you say you want to change. And therapists of every "school" are aware that sometimes a person would lose something desirable if he were to change (e.g., attention, being special, welfare money, being right). All this can keep you from changing.

Usually, you don't think much about the unpleasant consequences of changing, that is, the "costs."  Usually, you don't talk about the advantages to staying the way you are. But just because you don't think or talk about these things doesn't mean they can't affect you.  In fact, they can stop your progress even more when you don't know they're there!

Before any lasting change can occur in your behavior, thoughts, feelings or attitudes, you must uncover the "pro's" of keeping your problem. (You already know the "con's." That's easy.) What are you getting out of it?  What would you lose if you were suddenly "cured"?  How might other people look at you and treat you if you changed?  What would be scary about being "cured"? What might you be like? 

At first, you will probably say, "There aren't any advantages to keeping my problem." And that's the first problem we have to resolve.

Are You "Resistant" Or Are You Just Not Yet Ready To Change?

You may be coming to therapy because someone else is  making you come (your spouse, your parent, the Courts). Or, you may be coming because you feel you just can't take it anymore and you've got do something! Your thoughts and feelings about changing yourself have a lot to do with whether therapy can help. (You know the old saying, "You can lead a horse to water, but you can't make him drink.") Most treatment programs and some individual therapists assume that you're ready to change when you come to therapy. Then, if you don't make progress, they (and you) get frustrated. But, maybe you're just not ready to change.

A very well-respected psychologist, named James Prochaska, found that people coming to therapy can be in different "stages of change" What stage of change describes you best?

                Pre-Contemplative Stage: "I'm fine. There's nothing I want to change about myself. Other people in my life are the ones
                who need to change. I don't need therapy. Therapy is bunk. Therapy is for crazy people. I'm only here because someone
                else is making me come." I don't even come to my appointments.

                Contemplative Stage: "Well, maybe there's something I could change about myself. I'll think about it. But I really can't do
                anything differently because [blah, blah, blah]." I usually come to my appointments, but either I argue a lot with my therapist,
                or I just don't get around to doing whatever my therapist recommends."

                Planning Stage: "Yes, there really are things I need to change about myself. I'm reading up on it. I'm looking around for answers.
                I'm not actually doing anything differently yet, but I can see myself taking some action in the near future." I come to my
                appointments faithfully, and I'm collaborating with my therapist in planning some "baby steps."

                Action Stage: "Okay, I'm ready to do things differently. I'll try anything, no matter how new or scary or inconvenient it is to me."
                I come to my appointments faithfully, and I jump in and do whatever my therapist and I agree to do.

Therapists who use Prochaska's approach (and I'm one of them) tailor their therapy, according to what stage you're in.  If you're not already in the "action stage," I will try to help you move from whatever stage you're in to the next stage.  (You have to be able to crawl before you can walk. You have to be able to walk before you can run.)

Medication?

If you ask a psychiatrist, you will probably be told that chemical imbalances in the brain cause emotional and behavioral problems.  If you ask a non-medical mental health professional, you might be told that emotional and behavioral problems cause the chemical imbalances in the brain.  In truth, it's a chicken-and-egg question for which no one really knows the answer. And it may very well be that the chain of causality goes around in a circle: Maybe they cause each other. Or maybe neither causes the other.  Maybe they are just different aspects of the same thing.

Medication can be useful for some, but not all, emotional problems.  For certain types of serious, chronic mental illnesses, medication is a necessity, and even then, sometimes it helps and sometimes it doesn't.  For other types of problems, medication doesn't do much good. Most research conducted by psychologists shows that, for many problems, people who take medication and receive psychotherapy fare better than those who only take medication or only receive psychotherapy.

I may recommend that you see a psychiatrist and be evaluated for medication. Then again, I may not. It depends on your particular situation.  (In a few severe cases, I have insisted that a patient get psychiatric medication, if he or she wanted to continue seeing me.)

If  you take psychotropic medication, I can show you how to evaluate whether and how well it's helping you. You can then share your own assessment with your psychiatrist.  I recommend that you give me written authorization to consult with your psychiatrist directly, so that we can  work together to help you better.  See Confidentiality.

I highly urge you to get your psychiatric medication through a board-certified psychiatrist, rather than from your family doctor or "primary care provider." Although any medical doctor is allowed to prescribe psychiatric medication, a psychiatrist specializes in this area and is, I believe, better-informed about the latest developments in this field. There is a shortage of psychiatrists in Hawaii (and in the entire United States), so you may have difficulty getting an appointment with one right away.  Keep trying!

You would also have to find a psychiatrist who accepts your medical insurance and who is open to working with a psychologist. Not all psychiatrists are willing to limit themselves to doing "only medication management." Many will insist that you drop your psychologist and receive both your psychiatric medication and your psychotherapy from them.

But don't despair! I keep a list of psychiatrists who are open to working with a psychologist.  And I try to keep informed about which medical insurance each one does and does not accept. Just ask me.

Nada Mangialetti, Ph.D.


DrNada@KapoleiCounseling.com

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