The idea that behavior therapy can be integrated with psychotherapy to create a powerful treatment program for troubled patients is not a radical notion.1-3 For nearly 20 years, evidence has been accumulating that the two can work comfortably and effectively hand-in-hand. Psychodynamic treatment enables individuals to consolidate gains made by behavior therapy leading to greater understanding of the psychic forces associated with symptoms.4,5
More recently, it has been documented that behavioral treatment enhances the effects of psychotherapy. Borkovec et al6 reported that individuals with anxiety disorders given either a cognitive or nondirective psychotherapy along with progressive muscle relaxation showed substantial reductions in tension. Kutz, Borysenko, and Benson7 found that ten weeks of meditation was an effective complementary treatment for patients undergoing long-term psychotherapy.
Just how behavior therapy acts to enhance psychotherapy has not been widely discussed. One promising possibility, consistent with the experience of the author, is that behavior therapy has the potential to arouse spontaneous insights as well as affects associated with the target symptoms. In about 15% of the patients we have treated behaviorally for physical and emotional problems, ranging from migraines and Raynaud's phenomena to performance anxiety, we find evidence of behavior therapy aroused insights (BTAI). As these men and women became aware of the conflicts related to the formation of their symptoms, some degree of remission nearly always followed. When the psychodynamic material was then discussed in accompanying psychotherapy, the improvement in self-regulation of the symptoms was maintained. Unfortunately, not all of the patients were able or willing to work through these sudden recognitions and abandoned therapy. In most of the latter cases in which follow-up was possible, symptoms reappeared after a short time.
What is striking is that the patients were not aware of these connections during the diagnostic phase of treatment nor during previous psychodynamically oriented psychotherapy. What triggered the breakthrough of the repressed material appeared to be the behavior therapy itself.
We have witnessed three patterns of BTAI among our patients:
* spontaneous recognition of conflicts associated with the symptom while practicing behavior therapy by itself;
* rapidly growing awareness of events keyed to symptom formation while practicing behavior therapy, indirectly enhanced by discussion with the psychotherapist; and
* patients in ongoing psychotherapy whose spontaneous insights occurred only after beginning behavior therapy.
The first group is far more common in our experience. Malcolm is an example.
Malcolm was a single, socially isolated, 36-year-old scientific researcher. He sought biofeedback at the suggestion of his internist to relieve severe debilitating pain in his shoulders and neck. A thorough physical exam revealed nothing significant. A detailed history showed no obvious contributing psychological factors. He was referred for progressive muscle relaxation (PMR) and biofeedback. A follow-up meeting was scheduled one month later at which time he was largely symptomfree. He said that after two sessions of PMR he began to realize that his body tensed up in particular situations. Following these kinesthetic clues, Malcolm realized that although he liked science he did not enjoy it enough to spend the rest of his career working in a laboratory. Besides, the long hours severely constricted his social life. Eventually Malcolm decided to alter his career pathway from science research to applied science, which he thought he would like better and which might give him a chance to meet members of the opposite sex. At our last contact, three months after treatment began, he was still symptom-free. Shortly thereafter he left the university for a genetic engineering firm. Although Malcolm had not yet established a relationship with a woman, he had met two potential friends.
A striking aspect of Malcolm's improvement was that it was unassisted by psychotherapy. The behavioral treatment allowed him to recognize the problems and take direct action on his own.
The second group of patients rapidly became aware of conflicts keyed to their symptoms while practicing behavior therapy. This awareness was indirectly enhanced by discussions with the psychotherapist.
Rex8 came to see me in the Mental Health Clinic because he had severe inhibitions about speaking in class. He was a 34-year-old, first year student at the Harvard Business School. His professors based about 50% of the students' grades on classroom participation. Unless he could bring himself to speak in class, Rex was assured that he would fail.
In the past, Rex had undertaken psychotherapy on three occasions with considerable psychological relief, but the public speaking anxiety remained. A range of medications had been prescribed but with little success. When he tried to speak in class he perspired heavily, his heart pounded and his muscles tightened. Feeling that his body was betraying him, Rex remained silent.
The treatment involved teaching him systematic desensitization and behavioral monitoring. After learning how to relax in the classroom through the first technique, Rex was encouraged to observe opportunities to speak. When he felt he might say something relevant to the points under discussion, he was instructed to draw a circle in his notebook. Should he actually speak in class, he was told to draw a line through the circle.
Within a month of following this self-monitoring technique, Rex found himself able to speak in class and within three months he was essentially symptom-free and began to think that he might be one of the "stars" of his section. During this period I saw him every two or three weeks. In the second month, while he was recording opportunities to talk in class. Rex came to tell me that he was beginning to recognize that he had excessively high ambitions. This caused him to cast every classroom situation into heroic terms: it was a kind of academic superbowl in which he had to be a star. In previous psychotherapy Rex had learned that this had to do with trying to please a demanding father, but now he was not so sure. The previous day he had begun to see his father in another light - as a fragile, distant man whom he could never please. Rex began to wonder whether his excessive anxiety about performing in class was because he had thought that only through superstardom could he obtain the love of a father whom he had perceived as superdemanding. He could now see this as an objective that was not only inappropriate but unachievable.
This breakthrough of insight set the stage for another dozen sessions. Together we explored Rex's depression around his inability to please his father, his efforts to obtain love through high-level achievement, and the role of public speaking anxiety in continually recreating this whole struggle. Eventually Rex was able to take the first steps in understanding his father, forgiving him, becoming reconciled to the loss, and getting on with the business of living.
The last time 1 saw Rex, just before graduation, he said that he continued to feel a lot more relaxed. He was able to sit through his classes now without feeling the need to talk at every opportunity. He felt comfortable speaking when he chose to do so. He also asked me for the name of someone with whom he could continue exploring his feelings about his father.
The third group is comprised of patients for whom spontaneous insights are aroused when behavior therapy is added to psychotherapy.
Debbie was 29 when I first saw her, a junior faculty member in Romance languages. She was 5 feet, 3 inches tall, and weighed 210 pounds. She had been obese since she entered her teenage years. She had tried everything, including diets and psychotherapy, but with no results. She thought she had lost a ton of weight in her life but had been unable to maintain a reasonable level.
We agreed to meet weekly for psychotherapy, using a combination of behavioral therapies, including monitoring caloric intake, covert reinforcement, and hypnosis. Debbie lost about 50 pounds in 12 weeks. Then she began to gain weight again. Prior to her increase in weight, however, we noticed that she was increasingly restless, was having trouble sleeping, and was beginning to drink too much. By her standards, she was becoming sexually promiscuous. All of these were new feelings and actions.
In the next three months we stopped the behavior therapy and she gained weight again. The restlessness and acting out abated, however. As she approached her 30th birthday, Debbie said she would like to try again to lose weight. We added the same behavioral techniques as before to the ongoing psychotherapy. Again she began to lose weight. As Debbie approached 160 pounds, restlessness appeared, insomnia began, and sexual urges strengthened. She once more felt drawn to alcohol abuse. This time we paid very close attention to the symptoms, focusing on her distress, looking at what these feelings recalled for her. She found the process of exploring these symptoms extremely painful. During a three-month period in which we examined the restlessness and insomnia, she began to recognize that she was abusing alcohol as a way of blunting these feelings, much as she had used overeating in the past.
Then she recalled a repressed memory. When she was about 11 years old and physically precocious, her older brother began to regularly visit her bedroom to fondle her. Instead of being angry, Debbie felt guilty, concluding that her emerging sexual feelings must have provoked him. Eleven-year-old Debbie associated sexual desire with physical appearance.
Debbie recognized that she had been literally covering over her sexuality and lustful feelings with overeating. As she grew thinner and approached a particular weight threshold she experienced the same shameful lust that she had earlier felt. Her promiscuity was one manifestation of acting out some of these feelings. These understandings helped her lose another 15 pounds.
As often happens in a university setting, Debbie received an offer for a position at another school in the south, so we were unable to conclude our work. A year later, Debbie wrote to say that she was enjoying herself, holding her weight at about 150-still a little pudgy by her standards-and living with a man she thought she might eventually marry.
Support for the thesis that behavior therapy has the power to stimulate unanticipated thoughts and feelings can be found in these cases and also in accumulating evidence from clinical practice and the research lab. Other clinicians tell of patients whose insights are facilitated by behavior therapy. Many fall into One of the groups described above.
Our Group I patients, with BTAI, apparently unassisted by psychotherapy, are reminiscent of a case reported by Kuhlman.9 He tells of treating a married business school student who failed four exams in a row due to "test-taking anxiety." A careful history was taken, and nothing significant appeared to be causing the problem. During the process of constructing a desensitization hierarchy, the young man visualized a scene between himself and his wife prior to an imagined exam. Shortly after visualizing his spouse saying to him, "You'd better do well on this test or else," the patient began to see that a major reason why he was having trouble taking tests was that he felt that she was pressuring him to do well in school so that her parents with whom they lived would be pleased. A week later, the young man said that he had obtained a B in the last exam and was talking to his wife about their marital problems. He declined an offer to pursue the matter further with the therapist.
Group Il patients have also been described by others. Sedlack10 presents the history of a 42-year-old woman with severe Raynaud's disease. The woman worked with the author in learning to relax and to dilate her efferent peripheral blood vessels using a combination of electromyographic and thermal biofeedback to warm her hands. During this process she became aware of considerable repressed anger and guilt in relation to her spouse. After talking it over with her physician she was referred for psychotherapy to explore these feelings. At three-year follow-up she continued to be able to control her Raynaud's symptoms.
Finally, our Group IU patients, whose spontaneous insights were triggered by behavior therapy while in psychotherapy, have been reported by others. Perhaps the most compelling example was Lazarus'11 32-year-old male with numerous problems, including anxiety attacks, somatoform disorders, and overdependence upon his mother. He had a long history of unsuccessful treatment by therapists of various persuasions. During the course of a desensitization treatment the man was asked to imagine coping with anxiety prompted by being alone in a strange city. During this behavioral work the patient became highly anxious and broke down sobbing. There followed the recall of a vivid memory from his seventh year. As he was coming out of general anesthesia following a tonsillectomy, he heard his mother talking to someone about his frail and sickly make-up. "I hope he lives to see 21," he heard her say.
Lazarus used this spontaneous insight to help the man to recognize that he had internalized his mother's view of him and had become the fragile son his mother assumed him to be. This memory was a turning point in the therapy. Over the next two years, fears about his physical fragility, about death, and about traveling alone were explored in the context of his mother's attitude. During this period he also learned to apply a range of behavioral and cognitive techniques to control his anxieties and to get on with the business of living.
On a closely related track, researchers Heide and Borkovec12 documented the occurrence of anxiety reactions, rather than the emergence of insights, in over one third of volunteer subjects practicing relaxation training in their laboratory. Increased tension was experienced by 31% of the men and women receiving progressive muscular relaxation and by 54% of those undergoing meditational relaxation. These findings correspond to Borkovec's previous and subsequent reports of unintended effects of behavioral techniques.6,15"15 His reported incidence of paradoxically occurring tension does not seem notably high in light of the fact that his subjects were volunteers who experienced moderate to severe tension in a substantial part of their everyday lives. Since the setting was an experimental rather than a clinical one, the findings do not lend themselves to a direct comparison with our own. It is understandable that Heide and Borkovec refrained from making an in-depth clinical exploration of the reasons why their subjects experienced these reactions. They tended, however, to support a previously hypothesized fear of losing control.16 They also recommended that future studies of this phenomenon would be more meaningful if pursued in a clinical setting. In the meantime, the explanation for such effects remains an interesting question.
Equally intriguing are those patients who experienced what have been called "negative" effects when treated with behavior therapy. These effects have been the subject of spirited debate among mental health professionals. Until recently behavior therapists have argued that their treatments do not cause other distress or symptom substitution.11,1718 However, accumulating evidence from clinical practice indicates that a minority of individuals respond to behavior therapy with distressing physical and emotional symptoms, iacobsen and Edinger19 noted that two of their patients developed severe anxiety following progressive muscular relaxation. Others describe patients who exhibited signs of depression, depersonalization, obsessive thinking, or impulsive fantasies following relaxation or densensitization procedures.2,21
The finding of such symptoms would not surprise those practitioners who have cautioned against the "negative" or "deterioration" effects of behavior therapy.22,23 It is not yet clear whether or to what extent these side effects represent the "symptom substitution" that was predicted by the foes of behavior therapy, or whether they may be simply expressive of the variant ways in which patients react to the behavioral techniques per se.
It seems possible that for a substantial number of these patients, relaxation-induced anxiety and other so-called "negative effects" may signal the presence of buried conflicts and foreshadow a beginning awareness of them. The therapist who is skilled in both behavioral and psychodynamic modalities will have a sense of when to pursue these negative reactions in the search for underlying connections, and when to slow the pace or to elect an alternate treatment plan so as not to overwhelm the patient's defenses.
It may well be asked why we have given so much consideration to these behavior-therapy-aroused side affects. It is because they are seen to be on a track that converges with behavior-therapy-aroused insights rather than to be merely a parallel, analogous phenomenon. If this is true, it would appear that dynamic psychotherapy and behavior therapy may at times work in opposite but complementary directions - from symptom reduction to insight awareness and vice versa.
Why does behavior therapy arouse spontaneous insights and other effects in a minority of patients treated for symptom reduction? Why do repressed conflicts enter awareness in response to behavioral techniques when they did not emerge in previous psychotherapies, the very approaches that actively seek such latent material? Three explanations come to mind.
The first explanation is that the process of relaxation enables some patients to become unusually sensitive to neural messages from their musculature. These individuals, like Malcolm, feel they can "read" their bodily state and recognize those situations that trigger increased tensions. These insights, although superficial, were not accessible to the patients prior to learning relaxation strategies.
The second way of understanding the phenomenon of BTAI is that relaxation and other behavioral techniques may lower psychological defenses just enough to allow recollections and understandings to enter awareness from a dormant state. These new insights into old conflicts may liberate distressing affects of one kind or another - affects that were originally associated with those conflicts and which now become available for the psychodynamic part of the work.
The third reason has to do with the possible direct physiological effects upon the brain of relaxation, desensitization, and other forms of behavioral treatments. The literature reviewed by Kutz, Börysenko, and Benson7 provides evidence that meditation and relaxation techniques affect brain physiology and can influence both mood and thought patterns. They conclude, "Not only may specific moods and insights have specific neuroanatomical bases, but these moods and insights may also be achieved by intentional manipulation of underlying psychophysiology through specific mental practices such as meditation."
In the author's experience, spontaneous insight occurs in only a small number of behaviorally-treated cases. Reports from other clinicians are scattered and anecdotal. The research on relaxation-induced anxiety awaits confirmation by others. Yet, when one talks to one's colleagues practicing behavior therapy, one is struck by their lack of surprise when the subject of BTAI is introduced. It may be that clinicians applying behavioral treatment have been responding intuitively to this phenomenon for decades. Without formalizing their perceptions, they have proceeded to deal with the manifestations of BTAI in a pragmatic way, by working toward the reduction of symptoms while at the same time processing emerging insights. Through these activities they have consolidated a clinical basis upon which a conceptual understanding could later be built.
Perhaps those of us who aré interested in the integration of therapies in clinical practice can make more systematic use of BTAI to benefit our patients. Thus when carrying out symptom-focused treatment we should be on the lookout for unexpected cognitions and affects arising out of relaxation and other behavioral techniques. Following Messere suggestion,24 we might mount an effort to assist our patients in understanding these "irrational" thoughts and feelings when they occur. We should encourage them to see relationships between symptoms and past conflicts instead of viewing such symptoms as merely requiring relief.
The phenomenon of BTAI may also be of value for those conducting psychotherapy. Symptom-focused behavior therapy, if applied adjunctively or sequentially, has a high probability of reducing symptom severity by teaching self-regulation. It also may give the patient new opportunities to discover something of the psychodynamic origin of his emotional difficulties by working in a retrograde fashion, from symptom reduction to insight emergence.
In summary, the two approaches can be mutually reinforcing when used in an overall therapy program that integrates the techniques for which each approach has proven itself best suited.
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