Finding Your Own Therapeutic Style

 Albert Ellis and Carl Rogers

By: THEODORE MILLON and

      Seth Grossman

      Carrie Millon

      Sarah Meagher

      Rowena Ramnath

Although Albert Ellis was originally trained as a psychoanalyst, he is an important figure in the history of the cognitive therapy movement. His transformation is striking, as it represents a philosophical shift from that which is deep and mysterious in human nature, namely the unconscious, to that which is more or less obvious, the rational process and errors of reasoning.

The movement Ellis founded is called rational-emotive therapy. According to Ellis, logical reasoning is the foundation of mental health. Psychopathology is the product of illogical inferences and other irrational beliefs.

From this, it follows that mental unhappiness, ineffectuality, and other disturbances can be eliminated when people learn how to maximize rational thinking. Correct your reasoning, and your emotions will follow.

The task of the therapist, then, is to identify errors in the reasoning process, showing patients that their difficulties result largely from distorted perceptions and erroneous beliefs. Not surprisingly, then, rational-emotive therapy tends to be more confrontive than supportive: The patient is doing something wrong, and this must be identified and exterminated. Patients’ mistakes are their disease.

Like other cognitive theorists, Ellis’s thinking does not generate a series of personality constructs, but instead addresses cognitive processes as they cut across most mental disorders.

Carl Rogers, perhaps the single most influential theorist on therapy from the 1960s through the 1970s, is opposite Ellis, both philosophically and in bedside manner. Whereas Ellis is confrontive and highly directive (you must show patients their errors), Rogers impressed patients as a kind grandfather, always listening and reflecting their own emotions as a gentle commentary, intended to make them feel understood rather than thrusting their mistakes into awareness.

According to Rogers, each person is innately right; that is, individuals possess their own innate sense of what is required for their own growth as a unique person. Healing emerges from the quality and character of the therapeutic relationship.

Rogers’ movement, therefore, became known as client-centered therapy. Growth could be facilitated through certain therapist attitudes, notably genuineness and authenticity. Rather than learn complicated techniques founded in some abstract theoretical model, therapists should “be themselves,” expressing their thoughts and feelings in a constructive way that honors the person, but without pretension or the cloak of professional authority.

For Rogers, “unconditional positive regard” was the key. Clients should be respected as beings of intrinsic worth and dignity, no matter how unappealing and destructive their behaviors might be.

However, Rogers also emphasized that clients must assume full responsibility for their own growth.

Through accurate empathy and positive regard, the therapist lays the foundation. Only the client can follow through.

References

Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

Read Also

Are We Just a “Tabula Rasa”?

Marsha Linehan and Dialectical Behavior Therapy
The cognitive-behavioral approach
Positive Psychology
The Psychodynamic Approach
The Humanistic Approach
The Family Systems Approach

Are We Just a “Tabula Rasa”?

Whatever Happened to Behaviorism?

By: THEODORE MILLON and

      Seth Grossman

      Carrie Millon

      Sarah Meagher

      Rowena Ramnath

The duality between empiricism and rationalism has a long history in philosophy and psychology.

Empiricism is most often identified with the English philosophers John Locke and David Hume. Locke emphasized the role of direct experience in knowledge, believing that knowledge must be built up from collections of sensations. Locke’s position became known as associationism. Here, learning is seen as occurring through a small collection of processes that associate one sensation with another.

Empiricism found a counterpoint in the rationalism of continental philosophers, notably the Dutch philosopher Spinoza, the French philosopher Descartes, and the German philosopher Leibniz. In contrast, the empiricists held that innate ideas could not exist. Locke, for example, maintained that the mind was a tabula rasa, or blank slate, on which experience writes. Eventually, however, the elements of learning were recast in the language of stimulus and response.

The foundations of behaviorism are perhaps more associated with J. B. Watson than with any other psychologist, though Watson was preceded by other important figures in the history of learning theory, notably Thorndike and Pavlov. Although a variety of learning theories eventually developed, behaviorism as a formal dogma is most associated with the views of B. F. Skinner.

According to Skinner’s strict behaviorism, it is unnecessary to posit the existence of unobservable emotional states or cognitive expectancies to account for behavior and its pathologies. Hypothetical inner states are discarded and explanations are formulated solely in terms of external sources of stimulation and reinforcement. Thus, all disorders become the simple product of environmentally based reinforcing experiences. These shape the behavioral repertoire of the individual, and differences between adaptive and maladaptive behaviors can be traced entirely to differences in the reinforcement patterns to which individuals are exposed. Inner states, such as traits or schemata, are considered throwbacks to primitive animism. Instead, the understanding of a behavior can be complete only when the contextual factors in which the event is embedded are illuminated.

The logic is relatively simple: If there are no innate ideas, sensation or stimuli are by definition all that exist. Because sensation originates in the environment, the environment must ultimately control all behavior, however complex. The mind becomes an empty vessel, or tabula rasa, that contains only what the environment puts there.

All behavior is said to be under stimulus control. For this reason, the relationship between personality and behaviorism has been mainly antagonistic, and understandably so, because behavioral psychology exclusively focuses on observable surface behavior rather than on inferred entities, such as personality traits, cognitive schemata, instinctual drives, or interpersonal dispositions, all essential units in the study of personality.

By the mid-1980s, a number of crucial reinterpretations of traditional assessment had been made that allowed clinically applied behavioral approaches to become successively broader and more moderate. Most notably, the diagnoses of Axis I, regarded in psychiatry as substantive disease entities, were reinterpreted with the behavioral paradigm as inductive summaries, labels that bind together a body of observations for the purpose of clinical communication.

For example, whereas depression refers to a genuine pathology in the person for a traditional clinician, a behavioral clinician sees only its operational criteria and their label, not a disease. As a result, behavioral assessment and traditional assessment could thus speak the same tongue, while retaining their respective identities and distinctions. This allowed behavioral therapists to rationalize their use of diagnostic concepts without being untrue to their behavioral core.

Likewise, as the cognitive revolution got underway in earnest in the late 1960s and early 1970s, behavioral psychologists began seeking ways to generalize their own perspective to bring cognition under the behavioral umbrella. In time, cognitive activity was reinterpreted as covert behavior. Finally, the organism itself began to be seen a source of reinforcement and punishment, with affective mechanisms being viewed as the means through which reinforcement occurs.

Contemporary behavioral assessment, then, is no longer focused merely on surface behavior. Instead, behavioral assessment is now seen as involving three “response systems,” namely, the verbal-cognitive mode, the affective-physiological mode, and the overt-motor response system, a scheme originated by Lang (1968).

However, behavioral theorists have gone far toward rediscovering personality. The relationship among responses across the three response systems, for example, has been extensively studied (see Voeltz & Evans, 1982, for a review). Behavioral psychologists now talk about the organization of behavior, an idea that draws on the conception that the individual person is more than a sum of parts, even where those parts are only behavioral units.

An especially seminal thinker, Staats (1986) has developed a more systematic approach to personality that broadens the behavioral tradition. In what he terms “paradigmatic behaviorism,” Staats has sought a “third-generation behaviorism” that adds a developmental dimension, arguing that the learning of “basic behavioral repertoires” begins at birth and proceeds hierarchically, with each new repertoire providing the foundation for successively more complex forms of learning. Thus, some repertoires must be learned before others. For example, both fine motor movements and the alphabet must be learned before cursive writing can develop. Staats holds that repertoires are learned in the language-cognitive, emotional-motivational, and sensorimotor response systems, and these systems are interdependent and only pedagogically distinct.

Personality thus becomes the total complex hierarchical structure of repertoires and reflects the individual’s unique learning history. Different repertoires mediate different responses, so individual differences simply reflect different learning histories. Thus, the concept of a behavioral repertoire is simultaneously both overt and idiographic, making it acceptable from both behavioral and personality perspectives and capable of spanning both normality and abnormality.

References

Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

Read Also

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The cognitive-behavioral approach
Marsha Linehan and Dialectical Behavior Therapy
Positive Psychology
The Psychodynamic Approach
The Humanistic Approach
The Family Systems Approach

Dependent Personality and Partner Illness

Separation Anxiety and Dependent Personality

By: THEODORE MILLON and

      Seth Grossman

      Carrie Millon

      Sarah Meagher

      Rowena Ramnath

The connection among aging, depression, and dependency is a burgeoning frontier of research.

The quality of life for many aging dependent personalities is complicated by the health status of the partner they have always relied on, in many cases for most of their life.

Dependents seek out those who are willing to face a cruel and uncertain world and make major life decisions for them. Their chosen protector, usually a spouse but sometimes a mother or father, provides structure and resources intended to shelter dependents from responsibility. Dependents are just along for the ride, so to speak. And that’s exactly how they prefer it.

What’s a dependent to do, however, when the all-powerful protector begins to succumb to the effects of aging?

Because age and stability usually go together, it is not uncommon for the protector to already be many years older. Eventually, the protector may require steady in-home care or even begin to develop a dementing illness, such as Alzheimer’s, eliminating his or her role as chief decision maker.

Because many families cannot afford round-the-clock nursing care, the burden often shifts to the dependent personality. A role-reversal may occur in which dependents are required to assume control of the family and take charge of financial and legal responsibilities. They may also be required to administer medications on a schedule, watch over the activities of the ailing partner, coordinate their partner’s day, or perform a series of medical chores in a routine program. As the illness worsens, dependents must take control of two lives, whereas previously, they sought to forfeit control of their own.

In a study examining the relationship between personality and caregiving, Alzheimer’s caregivers who were distressed were found to be six times more likely to possess dependent traits (J. T. Olin, Schneider, & Kaser-Boyd, 1996).

As the population of the United States continues to age, individuals with dependent traits can be expected to complicate an already troublesome crisis in health care.

References:

Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

Read Also:

Do men and women differ in their willingness to admit dependent feelings, attitudes, and behaviors?

Separation Anxiety and Dependent Personality
Dependent Personality Disorder, Case vignette (1)
Dependent Personality Disorder, Case vignette (2)
HIV and Personality Disorders
Psychology of Aging
Conceptual and methodological perspectives in Psychology of Aging

Other Conditions That May Be a Focus of Clinical Attention
Assessment Factors with Older Adults

Separation Anxiety and Dependent Personality

A number of personality disorders have parallel diagnoses in children.

By: THEODORE MILLON and

      Seth Grossman

      Carrie Millon

      Sarah Meagher

      Rowena Ramnath

Separation anxiety disorder, first introduced in DSM-III (1980) and elaborated in DSM-IV (1994), provides a diagnostic label for children who experience intense anxiety upon separation from home or from important attachment figures.

When separated from caretakers, many children become frightened, requiring frequent reassurance that they will eventually be reunited. Separation may lead to fearful fantasies that the caretaker or the child will suffer a horrible accident or illness and never return. Younger children may fear becoming lost, after which they never find their way home or see their parents again. In more extreme cases, they have nightmares, rarely leave their parents’ side, and may not be able to be left alone in a room without one parent present. Many of these children cannot stay overnight with a friend; they resist going to school or even being left with relatives.

Although separation anxiety reflects a pathology of attachment, theorists nevertheless distinguish between attachment and dependence (Ainsworth, 1969, 1972; Bowlby, 1973; Sears, 1972).

Attachment is generally regarded positively and refers to an exclusive relationship in which the individual seeks proximity to another individual who is usually stronger or wiser. This proximity increases feelings of security in the individual.

Dependency, on the other hand, refers to generalized behaviors that are not directed at any specific individual but designed to elicit assistance, guidance, or approval (Hirschfeld et al., 1977).

Current conceptualizations of dependent personality disorder appear to include components of both attachment and dependency. The sixth diagnostic criterion states, “Feels uncomfortable or helpless when alone”; the seventh, “urgently seeks another relationship . . . when a close relationship ends”; the eighth, “is unrealistically preoccupied with fears of being alone to take care of self.”

Livesley, Schroeder, and Jackson (1990) obtained two factors when studying the dependent personality criterion of the DSM-III-R. One had as its central feature lack of confidence or assurance about themselves and their abilities. People who scored high on this factor were probably “impressionable, dependent on advice and guidance from others, and prone to establish submissive relationships” (p. 138). The second factor was descriptive of insecure attachment and related to persons who are “unable to function independently, and that require the presence of attachment figures to feel secure” (p. 138).

Accordingly, persons could presumably be diagnosed as dependent personalities in two different ways, either suffering the effects of insecure attachment or lacking confidence and assurance in themselves. This duality may help explain the results of some research that shows that many adult patients who can be diagnosed as suffering from separation anxiety disorder do not suffer from dependent personality disorder (Manicavasagar, Silove, & Curtis, 1997). For example, some might have a secure attachment but no self-confidence. Others may have developed a level of self-confidence but nevertheless experience an insecure attachment. These are the individuals who are likely to have had separation anxiety concerns as children.

References

Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

Read Also

Do men and women differ in their willingness to admit dependent feelings, attitudes, and behaviors?
Dependent Personality and Partner Illness
Dependent Personality Disorder, Case vignette (1)
Dependent Personality Disorder, Case vignette (2)
Overanxious Disorder in Children
Once a Criminal, Always a Criminal?
Are Dysthymia and Depressive Personality Synonymous?
Taijin Kyoufu and Avoidant Personality Disorder
Assessment Factors Related to Children

Do men and women differ in their willingness to admit dependent feelings, attitudes, and behaviors?

Gender Differences in Dependency

  

By: THEODORE MILLON and

      Seth Grossman

      Carrie Millon

      Sarah Meagher

      Rowena Ramnath

Studies using self-report measures have found significantly higher levels of dependency in women than in men. Similar results have been obtained using school-age children rather than adults and using subjects from other cultures.

Because self-reports measure what is accessible to conscious awareness, Bornstein (1993) asked whether the difference between males and females would be found when using projective tests intended to tap motives outside conscious awareness, in the realm of the unconscious, not available for self-report.

Similar levels of dependency were found for men and women. Bornstein concluded: “Women report higher levels of dependency than do men on self-report measures, but men and women obtain comparable dependency scores on projective measure” (1993, p. 47). Women are thus more willing to admit dependency; men are just as dependent but unwilling to admit it.

In fact, there is a consistent relationship between the face validity of the measure used and the extent to which gender differences are found when assessing dependency. As face validity increases, so does the magnitude of the gender differences found when using that measure (Bornstein, Rossner, Hill, & Stepanian, 1994). Because face validity is largely a function of how easy it is to figure out what a test assesses (the item, “I feel helpless without someone to protect me,” is face valid for dependency), such differences between men and women can only be a function of self-presentation and social desirability. As it becomes easier to figure out that a test measures dependency, men refuse to admit their dependency needs.

Traditionally, men have been socialized to express dependency indirectly, whereas women express dependency in a more direct and overt manner (Maccoby & Jacklin, 1974; Mischel, 1970).

Future studies of the dependent personality must take into account the potential masking effects of self-presentation and social desirability. Valid assessment of a personality trait so closely linked to sex-role orientation argues for an unobtrusive approach to assessment, at least where males are concerned.

References

Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

Read Also

Dependent Personality Disorder, Case vignette (1)
Dependent Personality Disorder, Case vignette (2)

Separation Anxiety and Dependent Personality

Dependent Personality and Partner Illness

Gender Bias in the Diagnosis of Personality Disorders
Developing drug policy: gender matters
Why No Wandering Penis?
Rarely Is a Woman Wicked . . .!!??

Overanxious Disorder in Children

Pathways to Adult Personality Patterns

By: THEODORE MILLON and

      Seth Grossman

      Carrie Millon

      Sarah Meagher

      Rowena Ramnath

Developmental psychopathology is one of the most rapidly evolving areas in diagnostic knowledge. Accordingly, a variety of childhood disorders included in the DSM-III, published in 1980, are no longer listed in the DSM-IV, published in 1994.

One of these, overanxious disorder in children, includes features related to the compulsive personality. According to the DSM-III, such children often seem “hyper-mature with their precocious concerns.” They take on responsibilities or attitudes that go far beyond their developmental level.

Also noted were traits such as perfectionistic tendency, obsessional self-doubt, excessive conformity, excessive approval-seeking, over-concern about competence, a preoccupation with the appropriateness of their behavior, excessive need for reassurance, somatic complaints, and marked feelings of tension or an inability to relax.

Overly trained and disciplined youngsters have little opportunity to shape their own destinies. Such children learn to control their feelings and focus their thoughts on becoming a model of parental orderliness and propriety. Although adults may be comforted by their good manners, many are uptight and agitated. Some will act out later in life when parental disapproval and discipline are no longer a force in their lives.

References

Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

Read Also

Compulsive Personality Disorder, Case vignette (1)
Compulsive Personality Disorder, Case vignette (2)
Compulsive Personality Disorder, Case vignette (3)
Cross-Cultural Dissonance
Once a Criminal, Always a Criminal?
Magical thinking – Reality or illusion?
Separation Anxiety and Dependent Personality
Assessment Factors Related to Children

Taijin Kyoufu and Avoidant Personality Disorder

By: THEODORE MILLON and

      Seth Grossman

      Carrie Millon

      Sarah Meagher

      Rowena Ramnath

Taijin kyoufu, literally “interpersonal fear,” is a syndrome characterized by interpersonal sensitivity and fear and avoidance of interpersonal situations (Ono et al., 1996, p. 172).

Presumably, its origins lie in the belief that blushing, eye contact, ugliness, and body odor are noticeable and troubling to others. Apparently common in Japan, the disorder is recognized as a culture-bound syndrome in the DSM-IV (APA, 1994) that resembles social phobia. Ono and his associates (1996), however, argue that taijin kyoufu is really more closely related to the avoidant personality.

In collectivist societies, such as Japan, the self is defined externally through its relationships with others. The self is, therefore, subordinated to the concerns of the group. In individualistic societies, such as the United States, the self is more an internal construct regarded as the individual’s exclusive identity. Because Japanese and American concepts of the self are so radically different, it is logical that the same disorder should be manifested in different ways in each culture.

In individualistic societies, the avoidant personality fears criticism from others, negative evaluation, and rejection. This is followed by what Okonogi (1996) calls a Western-style type of shame: “One is concerned that one is not behaving as expected according to one’s own ego ideal” (p. 175); that is, “I have failed to live up to my own standards.”

In a collectivist society, however, the avoidant personality is more likely to be manifest as a fear of offending others with one’s behavior, with the discomfort that one’s own characteristics may be causing to others. Logically then, taijin kyoufu subjects tend to be more concerned with their appearance and the impact that it may have on others.

Such cultural distinctions make another prediction as well. You would expect that social phobia, being more concerned with embarrassment to self, would be more prevalent in individualistic societies such as the United States and that avoidant personality disorder, taijin kyoufu, would have a higher prevalence rate in collectivist societies such as Japan.

Although there are no studies of differential prevalence rates between these two countries, Ono and his colleagues (1996) offer data showing that the avoidant personality was the most frequently diagnosed personality in their study. More research is required on prevalence rates of personality disorders in different cultures.

References

Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

Read Also

Avoidant Personality Disorder, Case vignette (1) 
Avoidant Personality Disorder, Case vignette (2)
Defining Mental Illness
The cultural Framework for health
What we know about culture and health?

How Do Culture and Personality Interact?
Are Dysthymia and Depressive Personality Synonymous?
Separation Anxiety and Dependent Personality

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