The Psychotherapeutic Process. Proc. 10th Int. Congr. Psychother., Paris 1976 Psychother. Psychosom. 29: 13-18 (1978)
Psychotherapy Contemporary Trends in the United States
My appreciation for the honor of the invitation to present an account of ‘topical facts or theories with an emphasis on contemporary data’, as Dr. Benoit phrased it in his invitation, has been tempered by a sobering awareness of the magnitude of the task. Clinical and research activities in the field of psychotherapy are, if anything, more variegated and tumultuous than at the time of the Oslo meeting in 1973, so the account I am about to offer is of necessity incomplete and reflects my personal perspective. Let me begin with a definition of psychotherapy so that it will be clear what I am talking about. Psychotherapy is an emotionally charged, confiding relationship in which a qualified healer seeks to relieve a particular type of distress by systematic use of symbols - primarily, but not necessarily ex clusively, words. The kind of suffering which psychotherapy can ameliorate arises chiefly from distortions in the sufferer’s self-image and disturbed interactions with others important to him, and always includes demorali zation. Specific symptoms increase proneness to demoralization and are intensified by it, so all forms of psychotherapy seek to treat both. In so doing, psychotherapy often includes helping the patient to accept and endure some suffering as an inevitable aspect of life and to use it as an opportunity for personal maturation and growth. This may appear to be too broad a definition of psychotherapy, but I have been unable to circumscribe it in such a way as to include all established forms of psychotherapy while excluding a host of other types of psychologi cal healing, including therapies practiced in prisons and mental hospitals, activities of community mental health centers and the profusion of healing groups and cults aimed at fostering personal growth, inner peace and the like. In this presentation, therefore, while emphasizing the mainstream of psychotherapy, I shall inevitably have to consider these related forms of help. Considering first the established psychotherapies, the general picture has shown little change since our last meeting in 1973. All schools continue to
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 3:30:34 AM
Jerome D. Frank
14
flourish and none has yet announced its dissolution because it has become convinced that another obtains superior results. Nor has any approach been able to demonstrate that it is more successful than any other in alleviating most symptoms (3). An interesting development in behavior therapy, proclaimed with much fanfare, is the rediscovery of mental processes, under the term ‘cogni tive behavior therapy’. A group of behavior therapists is writing about belief systems, attention, self-instruction and the like. In escaping from the con ceptual straitjacket of Freud, behavior therapists had donned another one created by Pavlov and Skinner. Now at last they seem to be freeing themselves from these doctrinaire shackles as well. Whether this will help to close the rifts between behavior therapists and proponents of other schools remains to be seen. Another development is increasing emphasis on the interaction of bodily and mental states, as revealed by the increasing popularity of procedures aimed at promoting inner tranquility, improved access to one’s own feelings and personality integration through bodily manipulations - procedures that can be traced back to Jacobson’s progressive relaxation and autogenic train ing, but differing in that the therapist, instead of merely instructing the patient, lays hands on him. Currently popular versions are bioenergetics and Rolfe’s structural integration. Especially striking in recent years has been the upsurge of biofeedback training. The essence of this method is to train a person to control uncon scious bodily processes by making them visible or audible through appropriate instruments. By thus being linked to instrumentation, Indian Yoga has become acceptable to the West. Although biofeedback appears to be focussed entirely on the control of bodily processes, the means of achieving this involve the same ingredients as those of psychotherapy, namely a strong relationship with the therapist, a highly motivated patient, and a rationale in which both therapist and patient believe. Furthermore, many experts in biofeedback maintain that the main sources of clinical improvement are psychological in that they lie in the sense of mastery the patient gains from the discovery that he can control a bodily process which previously was inaccessible to him. This strong success ex perience leads him to tackle other problems in his life with renewed con fidence. I shall return presently to other developments in the field of mind-body interaction, but at this point wish to call attention to certain trends involving the relationship of psychotherapy to American society. Since the sufferings of our patients cannot be disentangled from social stresses, psychotherapy cannot isolate itself from social expectations and values. One example is the
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 3:30:34 AM
Frank
15
potential effect on psychotherapy of the American value that health care, including mental health care, is a right, not a privilege, and therefore should be available to all who need it. This has resulted in increasing pressure to ward the enactment of national health insurance, and in the meanwhile private insurance companies are beginning to pay for psychotherapy. As a result, psychotherapy is under pressure to become more cost-effective - that is, briefer and less expensive. This has been salutary in some respects but potentially damaging in others. Insurance coverage has made psychotherapy available to a larger proportion of the population, and holding therapists to accountability for their performance should in time lead to stricter stand ards and less wastefulness. On the other hand, as we know, many of the ills which are helped by psychotherapy cannot be clearly defined nor can pro gress be stated in terms of so much gain for so many dollars, so pressures in the direction of accountability may discourage use of the more open-ended, long-term psychotherapies. Economic considerations have also led to questions about the justifi cation for costly, long-term training programs producing high-priced therapists, when more briefly trained, less expensive ones might do just as well. This has contributed to the proliferation of training programs for paraand sub-professionals, many financed with public funds. The burning question now becomes whether these newcomers will squeeze professionals out of the field of psychotherapy, especially psychiatrists, whose services are the most costly. While this concern has plausibility, the fact is that there is no evidence of slackening of the demands for psychotherapy by psychiatrists. Another social trend which is markedly influencing American psycho therapy may be termed ‘mental health imperialism’, expressed in the title of a brochure of a community mental health center: ‘Mental Health Affects Everyone.’ The implication is that psychological distress and disorganized or criminal behavior of the socially or economically oppressed are forms of mental illness amenable to psychotherapy; therefore psychotherapy should be offered to prisoners and slum dwellers, who do not see themselves as patients. The impetus for offering psychotherapy to them comes from the providers, not the consumers. A major manifestation of mental health imperialism has been the creation of community mental health centers. Promoted by mental health professionals, these centers have been established by legislation and support ed by public funds. They are charged with a twofold mission: treatment and prevention, the latter to be achieved through promotion of the mental health of the community. This implies shifting the primary focus from the distressed individual to the living conditions which put him under stress, which opened a Pandora’s box for all concerned. Professional staffs found
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 3:30:34 AM
Contemporary Trends in the United States
16
themselves expected to function in roles for which they were not trained, such as mental health educators and consultants to teachers, police, welfare workers and the like. The statutory requirement of community participation led to endless power struggles between the centers and members of the community they serve, with the communities pressing for more action toward social reform than the professionals found comfortable. This also has raised questions as to how far a public-supported agency dare go in attacking the institutions on which it depends for support. Although the community mental health centers have had some success in offering services that keep ex-hospitalized patients out of hospitals, as well as programs for alcoholics and drug addicts, they have not lived up to ex pectations, primarily because too much was expected of them in the first place. Growing public disillusionment coupled with retrenchment in public spending for all aspects of mental health make the future of these centers uncertain. The trend in this realm, in short, has been a spurt forward follow ed by retrenchment to levels that are as yet undetermined. In contrast to the retreat of community psychiatry, unconventional group activities aimed at enriching life or combatting existential despair, and arising in response to consumer demand, continue to flourish. Personal growth centers offering a variety of consciousness-raising and emotionally stirring experiences may perhaps have declined somewhat in popularity, but secular and religious cults that meet some of the same psychological needs are attracting literally millions of devotees. Examples are Scientology, Transcendental Meditation, Arica Mind Control, Hare-Krishna and the relative newcomers ‘Est’ and the Unification Church of the Korean evangelist Sun Myung Moon. Their astonishing popularity is, I believe, a manifestation of the continuing decay of traditional religions and other institutions for relieving individual guilt and providing a sense of personal security and of meaning to life. The justification for including these cults in a review of psychotherapy in the United States is, first of all, that they attract the same people, namely those who are demoralized - the lonely, the desperate and the confused except that in this case they do not have symptoms which would lead them and others to label them as psychiatric patients. Many of their adherents, however, are or have been in psychotherapy. Furthermore, they possess all the features of conventional psychotherapies in exaggerated form, including an intense, emotionally charged, confiding relationship with a leader and a group, and procedures based on a rationale which they all share. These inspire the hopes and raise the self-esteem of their adherents. Nor are their procedures as far from those of many conventional psychotherapies as might appear at first. Thus, entrance into altered states of consciousness is an
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 3:30:34 AM
Frank
17
aspect of relaxation therapies, autogenic training, even hypnosis and the reverie of psychoanalysis. In contrast to the practice of psychotherapy, which seems, if anything, more chaotic than when last we met, research has been making steady progress. A major step has been the greater use of experienced therapists rather than young graduate students of psychology or psychiatric residents. New mathematical techniques made possible by computers enable the ana lysis of many variables simultaneously. This has been accompanied by continued improvements in scales for measuring both process and outcome in individual and group therapies, in terms which permit them to be related to each other. Two outstanding examples of studies of psychotherapy illus trating these points are a study of large numbers of encounter groups conducted by experienced leaders of different schools (2) and a comparison of interview and behavior therapy conducted by recognized experts with psychiatric outpatients (4). Both confirm that qualities of the patient and therapist contribute more to therapeutic outcome than the specific proce dures used. A third example is a comparison of the interaction of anti depressants and psychotherapy in the treatment of neurotic depressions which found that medication was responsible for symptomatic improvement but not improvement in social skills, which was produced by psychotherapy (5). The therapeutic functions of meditation have been illuminated by demonstration that the changes in blood pressure, blood chemistry and the like produced by meditation can all be duplicated by simple relaxation exer cises (1). This has served not only to de-mystify meditation but has opened new fields for study. Closely related is the research on biofeedback which I have mentioned earlier. Equally encouraging are rapid advances in elucidating interactions be tween bodily and mental processes in organic diseases, which foreshadow an increasing role for psychotherapy in the treatment of these conditions. One example, which illustrates the new discoveries made possible by improved methods for determining blood levels of circulating hormones, is the finding that retardation of growth and maturation of children reared in emotionally traumatic homes is related to suppression of their pituitary growth hormones. When removed to nonthreatening environments, growth immediately resumes (6). Let me in conclusion summarize this inevitably personal view of con temporary American psychotherapy. Despite attacks, the vitality of psycho therapy is undiminished. The mainstream has continued much as before with perhaps a trend towards more flexibility and a greater rapprochement be tween different treatment philosophies. Striking in this regard is the emer
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 3:30:34 AM
Contemporary Trends in the United States
Frank
18
gence of cognitive behavior therapy, which directly links behavior therapies with the earlier insight-oriented forms. As to psychotherapeutic activities in a broad sense, the chastening ex perience with community mental health centers has made psychotherapists more modest in offering psychotherapy as a means of alleviating distress and discouraging antisocial behavior in oppressed segments of society, or of promoting social reforms. These centers will, I believe, continue to play an important part in the treatment of the ambulatory mentally ill as well as alcoholics and addicts. At the other end of the spectrum, secular and religious cults incorporating psychotherapeutic principles are still growing vigorously. Their ultimate level will depend on whether the United States can revitalize its institutions and develop shared values and purposes that will rekindle a sense of mutual trust, confidence and group solidarity. The most encouraging recent developments in research have been the emergence of findings elucidating the processes and outcomes of certain psychotherapies, the interaction of mental and bodily processes in medi tation and biofeedback, and the relationship of mental states to bodily diseases. These developments presage not only an expanded role for psycho therapy, but its emergence from a tumultuous adolescence to a more sober but, one may hope, a more effective maturity. References
2 3
4 5
6
Benson, H B e a r y , J.F., and Carol, M.P.: Meditation and the relaxation response; in Dean Psychiatry and mysticism, pp. 207-222 (Nelson-Hall, Chicago 1975). Liebennan, M.A.; Yalotn, I.D., and Miles, M.B.: Encounter groups. First facts (Basic Books, New York 1973). Luborsky, L.; Singer, B., andLuborsky, L.: Comparative studies of psychotherapies. Is it true that ‘everybody has won and all must have prizes’?; in Spitzer and Klein Evaluation of psychological therapies. Psychotherapies, behavior therapies, drug therapies, and their interactions, pp. 3-22 (Johns Hopkins University Press. Balti more 1976). Sloane, R.B.; Staples, F.R.; Cristol, A.H.; Yorkston, N.J., and Whipple, K.: Psycho therapy versus behavior therapy (Harvard University Press, Cambridge 1975). Weisstnan, M .M .; Klerman, G.L.; Prusoff, B.A.; Hanson, B., and Paykel, E.S.: The efficacy of psychotherapy in depression. Symptom remission and response to treat ment; in Spitzer and Klein Evaluation of psychological therapies. Psychotherapies, behavior therapies, drug therapies, and their interactions, pp. 165-177 (Johns Hopkins University Press, Baltimore 1976). Wolff, G. and Money, J.: Relationship between sleep and growth in patients with reversible somatotropin deficiency. Psychol. Med. 3: 18-27 (1973).
J.D. Frank, The Henry Phipps Psychiatric Clinic, Johns Hopkins Hospital, 601 N. Briadway, Baltimore, MD 21205 (USA)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 3:30:34 AM
1
Psychotherapy Contemporary Trends in the United States
My appreciation for the honor of the invitation to present an account of ‘topical facts or theories with an emphasis on contemporary data’, as Dr. Benoit phrased it in his invitation, has been tempered by a sobering awareness of the magnitude of the task. Clinical and research activities in the field of psychotherapy are, if anything, more variegated and tumultuous than at the time of the Oslo meeting in 1973, so the account I am about to offer is of necessity incomplete and reflects my personal perspective. Let me begin with a definition of psychotherapy so that it will be clear what I am talking about. Psychotherapy is an emotionally charged, confiding relationship in which a qualified healer seeks to relieve a particular type of distress by systematic use of symbols - primarily, but not necessarily ex clusively, words. The kind of suffering which psychotherapy can ameliorate arises chiefly from distortions in the sufferer’s self-image and disturbed interactions with others important to him, and always includes demorali zation. Specific symptoms increase proneness to demoralization and are intensified by it, so all forms of psychotherapy seek to treat both. In so doing, psychotherapy often includes helping the patient to accept and endure some suffering as an inevitable aspect of life and to use it as an opportunity for personal maturation and growth. This may appear to be too broad a definition of psychotherapy, but I have been unable to circumscribe it in such a way as to include all established forms of psychotherapy while excluding a host of other types of psychologi cal healing, including therapies practiced in prisons and mental hospitals, activities of community mental health centers and the profusion of healing groups and cults aimed at fostering personal growth, inner peace and the like. In this presentation, therefore, while emphasizing the mainstream of psychotherapy, I shall inevitably have to consider these related forms of help. Considering first the established psychotherapies, the general picture has shown little change since our last meeting in 1973. All schools continue to
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 3:30:34 AM
Jerome D. Frank
14
flourish and none has yet announced its dissolution because it has become convinced that another obtains superior results. Nor has any approach been able to demonstrate that it is more successful than any other in alleviating most symptoms (3). An interesting development in behavior therapy, proclaimed with much fanfare, is the rediscovery of mental processes, under the term ‘cogni tive behavior therapy’. A group of behavior therapists is writing about belief systems, attention, self-instruction and the like. In escaping from the con ceptual straitjacket of Freud, behavior therapists had donned another one created by Pavlov and Skinner. Now at last they seem to be freeing themselves from these doctrinaire shackles as well. Whether this will help to close the rifts between behavior therapists and proponents of other schools remains to be seen. Another development is increasing emphasis on the interaction of bodily and mental states, as revealed by the increasing popularity of procedures aimed at promoting inner tranquility, improved access to one’s own feelings and personality integration through bodily manipulations - procedures that can be traced back to Jacobson’s progressive relaxation and autogenic train ing, but differing in that the therapist, instead of merely instructing the patient, lays hands on him. Currently popular versions are bioenergetics and Rolfe’s structural integration. Especially striking in recent years has been the upsurge of biofeedback training. The essence of this method is to train a person to control uncon scious bodily processes by making them visible or audible through appropriate instruments. By thus being linked to instrumentation, Indian Yoga has become acceptable to the West. Although biofeedback appears to be focussed entirely on the control of bodily processes, the means of achieving this involve the same ingredients as those of psychotherapy, namely a strong relationship with the therapist, a highly motivated patient, and a rationale in which both therapist and patient believe. Furthermore, many experts in biofeedback maintain that the main sources of clinical improvement are psychological in that they lie in the sense of mastery the patient gains from the discovery that he can control a bodily process which previously was inaccessible to him. This strong success ex perience leads him to tackle other problems in his life with renewed con fidence. I shall return presently to other developments in the field of mind-body interaction, but at this point wish to call attention to certain trends involving the relationship of psychotherapy to American society. Since the sufferings of our patients cannot be disentangled from social stresses, psychotherapy cannot isolate itself from social expectations and values. One example is the
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 3:30:34 AM
Frank
15
potential effect on psychotherapy of the American value that health care, including mental health care, is a right, not a privilege, and therefore should be available to all who need it. This has resulted in increasing pressure to ward the enactment of national health insurance, and in the meanwhile private insurance companies are beginning to pay for psychotherapy. As a result, psychotherapy is under pressure to become more cost-effective - that is, briefer and less expensive. This has been salutary in some respects but potentially damaging in others. Insurance coverage has made psychotherapy available to a larger proportion of the population, and holding therapists to accountability for their performance should in time lead to stricter stand ards and less wastefulness. On the other hand, as we know, many of the ills which are helped by psychotherapy cannot be clearly defined nor can pro gress be stated in terms of so much gain for so many dollars, so pressures in the direction of accountability may discourage use of the more open-ended, long-term psychotherapies. Economic considerations have also led to questions about the justifi cation for costly, long-term training programs producing high-priced therapists, when more briefly trained, less expensive ones might do just as well. This has contributed to the proliferation of training programs for paraand sub-professionals, many financed with public funds. The burning question now becomes whether these newcomers will squeeze professionals out of the field of psychotherapy, especially psychiatrists, whose services are the most costly. While this concern has plausibility, the fact is that there is no evidence of slackening of the demands for psychotherapy by psychiatrists. Another social trend which is markedly influencing American psycho therapy may be termed ‘mental health imperialism’, expressed in the title of a brochure of a community mental health center: ‘Mental Health Affects Everyone.’ The implication is that psychological distress and disorganized or criminal behavior of the socially or economically oppressed are forms of mental illness amenable to psychotherapy; therefore psychotherapy should be offered to prisoners and slum dwellers, who do not see themselves as patients. The impetus for offering psychotherapy to them comes from the providers, not the consumers. A major manifestation of mental health imperialism has been the creation of community mental health centers. Promoted by mental health professionals, these centers have been established by legislation and support ed by public funds. They are charged with a twofold mission: treatment and prevention, the latter to be achieved through promotion of the mental health of the community. This implies shifting the primary focus from the distressed individual to the living conditions which put him under stress, which opened a Pandora’s box for all concerned. Professional staffs found
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 3:30:34 AM
Contemporary Trends in the United States
16
themselves expected to function in roles for which they were not trained, such as mental health educators and consultants to teachers, police, welfare workers and the like. The statutory requirement of community participation led to endless power struggles between the centers and members of the community they serve, with the communities pressing for more action toward social reform than the professionals found comfortable. This also has raised questions as to how far a public-supported agency dare go in attacking the institutions on which it depends for support. Although the community mental health centers have had some success in offering services that keep ex-hospitalized patients out of hospitals, as well as programs for alcoholics and drug addicts, they have not lived up to ex pectations, primarily because too much was expected of them in the first place. Growing public disillusionment coupled with retrenchment in public spending for all aspects of mental health make the future of these centers uncertain. The trend in this realm, in short, has been a spurt forward follow ed by retrenchment to levels that are as yet undetermined. In contrast to the retreat of community psychiatry, unconventional group activities aimed at enriching life or combatting existential despair, and arising in response to consumer demand, continue to flourish. Personal growth centers offering a variety of consciousness-raising and emotionally stirring experiences may perhaps have declined somewhat in popularity, but secular and religious cults that meet some of the same psychological needs are attracting literally millions of devotees. Examples are Scientology, Transcendental Meditation, Arica Mind Control, Hare-Krishna and the relative newcomers ‘Est’ and the Unification Church of the Korean evangelist Sun Myung Moon. Their astonishing popularity is, I believe, a manifestation of the continuing decay of traditional religions and other institutions for relieving individual guilt and providing a sense of personal security and of meaning to life. The justification for including these cults in a review of psychotherapy in the United States is, first of all, that they attract the same people, namely those who are demoralized - the lonely, the desperate and the confused except that in this case they do not have symptoms which would lead them and others to label them as psychiatric patients. Many of their adherents, however, are or have been in psychotherapy. Furthermore, they possess all the features of conventional psychotherapies in exaggerated form, including an intense, emotionally charged, confiding relationship with a leader and a group, and procedures based on a rationale which they all share. These inspire the hopes and raise the self-esteem of their adherents. Nor are their procedures as far from those of many conventional psychotherapies as might appear at first. Thus, entrance into altered states of consciousness is an
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 3:30:34 AM
Frank
17
aspect of relaxation therapies, autogenic training, even hypnosis and the reverie of psychoanalysis. In contrast to the practice of psychotherapy, which seems, if anything, more chaotic than when last we met, research has been making steady progress. A major step has been the greater use of experienced therapists rather than young graduate students of psychology or psychiatric residents. New mathematical techniques made possible by computers enable the ana lysis of many variables simultaneously. This has been accompanied by continued improvements in scales for measuring both process and outcome in individual and group therapies, in terms which permit them to be related to each other. Two outstanding examples of studies of psychotherapy illus trating these points are a study of large numbers of encounter groups conducted by experienced leaders of different schools (2) and a comparison of interview and behavior therapy conducted by recognized experts with psychiatric outpatients (4). Both confirm that qualities of the patient and therapist contribute more to therapeutic outcome than the specific proce dures used. A third example is a comparison of the interaction of anti depressants and psychotherapy in the treatment of neurotic depressions which found that medication was responsible for symptomatic improvement but not improvement in social skills, which was produced by psychotherapy (5). The therapeutic functions of meditation have been illuminated by demonstration that the changes in blood pressure, blood chemistry and the like produced by meditation can all be duplicated by simple relaxation exer cises (1). This has served not only to de-mystify meditation but has opened new fields for study. Closely related is the research on biofeedback which I have mentioned earlier. Equally encouraging are rapid advances in elucidating interactions be tween bodily and mental processes in organic diseases, which foreshadow an increasing role for psychotherapy in the treatment of these conditions. One example, which illustrates the new discoveries made possible by improved methods for determining blood levels of circulating hormones, is the finding that retardation of growth and maturation of children reared in emotionally traumatic homes is related to suppression of their pituitary growth hormones. When removed to nonthreatening environments, growth immediately resumes (6). Let me in conclusion summarize this inevitably personal view of con temporary American psychotherapy. Despite attacks, the vitality of psycho therapy is undiminished. The mainstream has continued much as before with perhaps a trend towards more flexibility and a greater rapprochement be tween different treatment philosophies. Striking in this regard is the emer
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 3:30:34 AM
Contemporary Trends in the United States
Frank
18
gence of cognitive behavior therapy, which directly links behavior therapies with the earlier insight-oriented forms. As to psychotherapeutic activities in a broad sense, the chastening ex perience with community mental health centers has made psychotherapists more modest in offering psychotherapy as a means of alleviating distress and discouraging antisocial behavior in oppressed segments of society, or of promoting social reforms. These centers will, I believe, continue to play an important part in the treatment of the ambulatory mentally ill as well as alcoholics and addicts. At the other end of the spectrum, secular and religious cults incorporating psychotherapeutic principles are still growing vigorously. Their ultimate level will depend on whether the United States can revitalize its institutions and develop shared values and purposes that will rekindle a sense of mutual trust, confidence and group solidarity. The most encouraging recent developments in research have been the emergence of findings elucidating the processes and outcomes of certain psychotherapies, the interaction of mental and bodily processes in medi tation and biofeedback, and the relationship of mental states to bodily diseases. These developments presage not only an expanded role for psycho therapy, but its emergence from a tumultuous adolescence to a more sober but, one may hope, a more effective maturity. References
2 3
4 5
6
Benson, H B e a r y , J.F., and Carol, M.P.: Meditation and the relaxation response; in Dean Psychiatry and mysticism, pp. 207-222 (Nelson-Hall, Chicago 1975). Liebennan, M.A.; Yalotn, I.D., and Miles, M.B.: Encounter groups. First facts (Basic Books, New York 1973). Luborsky, L.; Singer, B., andLuborsky, L.: Comparative studies of psychotherapies. Is it true that ‘everybody has won and all must have prizes’?; in Spitzer and Klein Evaluation of psychological therapies. Psychotherapies, behavior therapies, drug therapies, and their interactions, pp. 3-22 (Johns Hopkins University Press. Balti more 1976). Sloane, R.B.; Staples, F.R.; Cristol, A.H.; Yorkston, N.J., and Whipple, K.: Psycho therapy versus behavior therapy (Harvard University Press, Cambridge 1975). Weisstnan, M .M .; Klerman, G.L.; Prusoff, B.A.; Hanson, B., and Paykel, E.S.: The efficacy of psychotherapy in depression. Symptom remission and response to treat ment; in Spitzer and Klein Evaluation of psychological therapies. Psychotherapies, behavior therapies, drug therapies, and their interactions, pp. 165-177 (Johns Hopkins University Press, Baltimore 1976). Wolff, G. and Money, J.: Relationship between sleep and growth in patients with reversible somatotropin deficiency. Psychol. Med. 3: 18-27 (1973).
J.D. Frank, The Henry Phipps Psychiatric Clinic, Johns Hopkins Hospital, 601 N. Briadway, Baltimore, MD 21205 (USA)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 3:30:34 AM
1
