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The psychological management of individuals with speech and hearing problems
J. Communication
Dis. 1 (1967) 75-84 o North-Holland
Publ. Co., Amsterdam
THE PSYCHOLOGICAL MANAGEMENT OF INDIVIDUALS WITH SPEECH AND HEARING PROBLEMS LEWIS R. WOLBERG Postgraduate Center for Mental Health, New York City
Part II / Conclusions In general, the discussion groups at the conference concerned themselves with the varying roles of the speech therapist as a psychotherapist, as a speech trainer, as a group worker, as a group therapist, and as an educator to the patient‘ and parents of children with speech problems. An area of large concern was the training program itself. What are the constituents of a good training program? Who should participate in the training program? It was generally agreed that the staffing of the program be by professionals who have knowledge both about speech problems and psychotherapy. It was then agreed that training, more or less, should be in terms of a psychodynamic orientation and should be conducted on different levels, on masters, docto-lo ,rld =- supervisory levels. Additional training was also believed to be essential for speech therapists in practice, and two goups believed that there should be a workshop for seasoned professionals. Then the discussions concerned themselves with how one should practically go about getting the program off the ground. Ht was suggested that perhaps a summer workshop be organized that would deal specifically with the content of the program, and with the development of the tactics that would need to be employed in implementing it. More didactic problems came up, such as the question as to the communication difficulties between the professionals, the clarification of their roles and functions. How does the speech therapist differentiate himself from the psychotherapist? And how should the two begin to work together? What kind of language do they use that is similar and different? How do they interrelate? There was talk about the relation of the Postgraduate Center to the training program of universities and educational centers that deal principally with speech pro&m. This brought up the idea that perhaps the Center could pa&ipate not only in the training, but also in therapy, for example working actively with groups of parents of children who had speech problems. 75
76
LEwlS R. WOLBERG
The specific nature of training was brought up for discussion. What constitutes the best kind of training? The concensus was that a balanced composition of lectures, demonstratL)ns, supervised practice, group experience, screening procedures, observation t y speech therapists or psychotherapists in action was ideal. General plans about how this could be practically implemented were formulated. An important item repeatedly brought up was referral procedures: who to refer, how to refer, where to refer. In the organization of a training program referral would hi’ve to be considered quite pointedly, since this was a mos’r: important function of the speech therapist. He had to be skilled in processes of referral, and he had to know something about diagnosis. A question that constdntly arose was: ‘How does the psychtitherapist conceive of his role in contrast to the role of other persons who are doing work along the same lines, and yet are not psychotherapists.’ It would be expedient to try to differentiate psychotherapy from work that is psychotherapeutic. The chart in ‘Helping, Counseling and Psychotherapeutic Relationships’ applies itself to this question (Table 1). An aspect that concerns speech therapists is whether they are ‘helpers’, ‘counselors’ or psychotherapists. Role confusion is a common thing in our field. Are we, when we see patients, ‘helping’, ‘counseiing’ or doing psychotherapy? In a training program, would speech therapists be trained as psychotherapists? What constitutes the true difference bet ;tleen helping, counseling and psychotherapy? We heave opinions about these problems, but there are no definitive, authoritative answers. ‘Yet it is important for our present needs to attempt to isolate what the speech therapist does from . what the psychotherapist does. In the field of psychotherapy there are many variant points of view which may be subsumed under three majo, piositions. These are first the ‘relationship position’, second the ‘reward-punishment position’, and third, the ‘cognitive restructuring position’. The cluster of psychotherapies that are organized around the relationship positior! contend that what is fundamental in psychotherapy is the association that develops between patient and therapist. Given the proper kind of human relatiDr,sbip, self-actualizing tendencies will be released. What helps are not the tactical maneuver:. but the proper interactional climate which releases spontaneous forces of health and growth. Irrespective of the kind of problem, a fruitful liaison between patient and therapist will provide the essential base for cure. A number of schools, including clientcentered, phenomenological and some neo-freudian groups subscribe tlo this idea. A second large division of psychotherapists, namely the behavior thera-
I
Immediate present Support ; reassurance ; emotional catharsis ; placebo influence ; group dynamics Positive transference encouraged and utilized
Avoided
Temporal focus Technical processes
Transference
Counter transference
neurosis
Positive feelings utilized : negative feelings controlled
Immediate present Guidance; clarificatioil; suggestion; environmental manipulation ; use cf community resources Positive transference encouraged and utilized; negative transference discouraged Avoided
Conscious processes
Psychic urena
Positive feelings utilized to promote supportive process
Conscious processes
Manifest complaints and interpersonal problems
Inter view focus
Transference
Correction of situational problem; rectification of deviant behavior; expansion of personal abilities and skills; restoration of defenses; prevention of emotional breakdown Situational problems; conlicts; attitudes
Symptom relief
Objectives
Ke:ping situation
relationships
Counseling Supportive psychotherapy
Helping, counseling and psychotherapeutic
TABLE
In psychoanalysis purposefully promoted to release repression and to dete;t sources of i.nner conflict; otherwise avoided Constantly examined, analyzed and resolved
Underlying roots of complaints and conflicls ; r!efcnses, coping n, -chanisms, fantasies, symbolisms Conscious, preconscious and, in psychoanalysis, unco,lscious processes In-mediate present and historical past Inculcation >f insight, pattern reinforcement snd extinction, and, in psychoanalysis, dreams and free association Positive and negative transference interpreted
Alteration of defenses; Wiioation of interpersonal agd social adjustment; personality growth and deveiopment
-V--X I.__P Psychotherapy (re-educative and reconstructive goals)
LEWIS R. WOLBERG
pists, are dedicated to the ‘reward-punishment position’. This contends that neurotic behavior is learned behavior, and that anxiety is a secondary manifestation to be neutralized by the same processes through which it is learned. What is important in therapy, therefore, is the selective reinforcement of healthy responses and the unreinforcement of unhealthy reactions. Determine what is constructive for the person, and reward him for behavior that conforms with a good adaptation. Neither relationship nor insight are vital in getting well. What is crucial are procedures like operant conditioning that will eventuGly repair the damage to the personality. The third large grouping of thej*apies are organized around the ‘cognitive restructuring position’ which considers change impermanent without alteration of the intrapsychic processes. Symptom removing maneuvers, such as are involved in reconditioning manipulations are branded as superficial and temporary, What is essential is true reorganization of the constituent components of personality. Several means of accomplishing this have been proposed. First, there are some who believe that cognitive change may be brought about by imposing cn the patient a new ideological outlook. Through directive or non-directive means attempts are mad; to shape wholesome values. The philosophically oriented therapies are in this category. Second, there are therapists, such as the neo-freudian psychoanalysts, who contend that what must be examined is the relationship between the individual and his social environment. It is essential to bring the patient to an awareness of what he is doing in his interpersonal operations, the kinds of defenses he employs, and how these disorganize his adjustment. Awareness of his interpersonal distortions enables the individual to experiment with a new relationship, principally with the therapist. The therapeutic encounter then becomes a corrective emotional experience. Third, there are other therapists, namely Freudian psychoanalysts, who believe that cognitive restructuring best occurs when the learning experience is acted out in the transference situation. By manipulating the relationship and circumscribing communication, important conditionings in the past, which are now unconscious, will repcat themselves in the therapeutic situation with little; regard to their present appropriateness. The working-through of the distortions of early experience (inffantile neurosis) within the treatment setting itself (transference neurosis) is believed to produce widespread changes in the intrapsychic apparatus. Although therapists take different positions in psychotherapy and restrict their focus to a lim’ited group of vectors, we can, if we peer beyond the immediate techniques, discern a remarkable unity in operative processes. For instance, we find that in every relationship there is a selective reinforcement of positive responses. The fact that therapists take the ‘relationship
MANAGEMENT
OF SPEECH AND HEARING
PROBLEMS
79
position’, purposefully communicating ‘care’, understanding and empathy-, does not man that they act the same toward behavior that is destrvlctive as opposed to conWictive. Responses will be qualitatively different; and this will tend to reinforce certain kinds of behavior. Moreover, within the ‘client-centered’ relationship, transference is bound to develop. The perception by the patient of a new kind of authority as ve:sted in the therapist will tend to restructure attitudes toward punitive and irrutional authority. Therapists taking the ‘reward-punishment PO&ion’ (many forms of speech therapy are organized around conditioning procedures) minimize the importance of the relationship and of insight. But when one examines what goes on in treatment one finds that change is taking place within the context of a human relationship, and that the conditioning techniques are being influenced by auxiliary processes that automaticahy precipitate out in any relationship. If the therapist is not an empathic, understanding and giving person, conditioning procedures may prove to be of little avail. Elements in the ‘relationship position’ seem also to apply to the ‘rewardpunishment position’. Furthermore, comparing the new with the old authority, and testing the former in various ways (defying, resisting, being seductive in transference, etc.) will, if a strong difference is perceived in the responses of the therapist as compared with early authorities, alter aspects of the intrapsychic process itself. Reconstructive changes may then occur in the severity of the conscience and in the self-image. Inherent then in the rewardpunishment position are processes of insight even though these are not recognized as such. 111the ‘cognitive restructuring position’, that is the insight therapies, even the passive, anonymous, non-interfering activities of the classical psychoanalylst, will incorporate *relationship’ and ‘reward-punishment’ processes. The psychoanalyst who is not a giving or empathic person, irrespective of how passive he may act, will find his techniques impaled on the sword of his unresponsiveness. The patient will rapidly perceive from nonverbal cues the kind of a person with whom he is dealing, whether he is understanding and sympathetic, or cold and unconcerned. Moreover the analyst, whether he is aware of it or not, will reward certain responses from the patient and discourage others. For instance, whenever the patient deals with material that reproduces the convictions, theories and biases of the an:Jyst, the tatter will acknowledge these in a condoning way. On the other harld resistznces to such material are dealt with firmly in a climate of relative dis,;approv&. Et is perhaps for this reason that, no matter to what school the analyst &longs, his patient will bring up data in his analytic sessicns that seem to substantiate the premises of the analyst. Often both thewaist anq;lpatient are unaware of the influencing process that is going on. What
LEWIS R. WOLBERG
is being influenced may, of course, be valid. Nevertheless, invalid concepts too may gain sanction. What holds true for psychotherapists applies to speech therapists, who after all function in the medium of relationships with their clients or patients. Operative will be the enactment of certain roles and the execution of what therapists in the ‘relationship situation’ say is important. Speech therapists will also be involved in giving out rewards in the f’orm of approval for certain positive speech and behavioral responses. They will then do what the ‘reward-purGshment’ therapists say is significant. And in the course of themrcon:act with clients, transference is bound to appear. Speech therapists will most likely, in the minds of their patients, act as authorities who do not reproduce the punitive experiences of past authorities. A corrective lemotional exlperience will therefore be provided leading to changes the ‘cognitive restructuring’ therapists consider to be crucial. This does not mean the speech therapist is doing psychotherapy. Differentiated in the chart on ‘Helping, Counseling and Psychotherapy’ are processes, objectives and tactical maneuvers. A ‘helping situation’ can be in relationship to any non-professional person, friend, politician, even bartender. Incidentally there are probablUy more bartenders operating in the role of therapists than there are trained psychotherapists. The counselor is generally a trained professional person, for example social worker, lawyer, minister, teacher, psychologist or speech therapist. The psychotherapist is a psychiatrist, clinical psychologist or psychiatric social worker who has gone through a structured postgraduate course of training in psychotherapy or psychoanalysis. What are the goals in helping, counseling and psychotherapy? Do they differ? In the helping and counseling situations a prime objective is relief from symptoms. But in addition to symptom relief efforts are generally made to straighten out a situational difficulty, or t-o rectify certain aspects of deviant behavior, for instance speech problems. Other objectives include expansion of personal abilities and skills, and restoring of habitual defenses. These aims are somewhat different from those in psychotherapy in which a direct attempt is made to alter defenses and to facilitate new modes of interpersonal and social adjustmeAnt. The goal is not only restoration of homeostasis, but a concerted effort to promote personality growth and developizozt. In the helping and counseling situations the latter goals may sometimes spontaneously be reached, that is, not only will a person attain homeostasis, but he may, in the course of feeling an.d behaving better, develop some poterltialities that will approach, at least partially, reconstrucgive objectives. However the ‘helping agency’, or counselor, or ‘supportive therapist’, does not deliberately try to bring about reconstructive changes.
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OF SPEECH AND HEARING
PROBLEMS
81
If changes occur, they are in serendipity, a consequence of what is going on. We come next to the interview focus. What is the focus when a person relates himself to a non-professional helping agency? Usually this is on manifest complaints and interpersonal problems. The focus in counseling concern itself with situational problems, conflicts and attitudes. In psychotherapy it is the underlying roots of the existing complaints and conflicts, the defenses, coping mechanisms, fantasies a.ad symbolisms. The counselor does not involve himself with fantasies, symbolisms and defenses. He deals more with manifest complaints and attitudes. The psychic arena of the helping agency and counselor is the zone of consciousness, while the psychotherapist works with the conscious and preconscious, and, in psychoanalysis, the unconscious. The speech therapist thus will not ordinarily involve himself with unconscious material. He will have enough difficulty managing immediately tangible problems without delving into zones for which he is untrained. Assuming he has had training in psychoanalysis, experience does not credit superiority to treating the speech symptom on a depth as compared to a more topical level. This does not mean that the unconscious will not display itself as the speech therapist applies himself to the problems of his patient. Nor does it mean that the speech therapist will not do better work if he is analytically trained. Transference, countertransference, and tendencies toward actingout will always filter into a relationship, and the proper handling of these will be helpful even where the goal is merely to improve speech and not to reconstruct personality. But if the speech therapist is a perceptive person who does not defend too much against acknowledging his own difficulties to himself, and if he is not too hostile or detached, he can do excellent work even though he has not exposed himself to extensive personal analysis and training. When we consider the time dimension with which we are dealing, we find that the temporal focus in the helping and counseling situations is on the immediate present, while in psychotherapy it is on the immediate present and historical past. The speech therapist will, more 02 less, concern himself with what is going on in the present, which will, of course, embody some aspects of the past. The technical processes involved in helping are supportive and reasIsuring, and they take advantage of the auxiliary agencies of emotional catharsis, placebo, group dynamics, suggestion and use of the idealized projected relationship. These healing forces emerge and are taken advantage of in counseling and psychotherapy. In addition to helping, supportive and reassuring tactics, other operations are implemented. For instance, in counseling there is guidance, clarification, suggestion, environmental manipulation,
82
r
LEWIS R. VVOLBERG
and the concerted use of community resources. The speech therapist, 3s Dr. aloodstein has pointed out, utilizes some of these modalities, which essentially derived from casework, have proven to be of value in he&ng people in trouble. A good training program must COnSeqUently involve an understanding of casework techniques. In most forms of psychotherapy an effort is ma& to employ insight as a means of helping the patient to reorganize his &hay&x through focused interviewing, and, in psychoanalysis, &ougb dreams and free association. In some forms of psychotherapy insight. is in&i& in favor of conditioning strategies that lead to pattern reilgorcement and extinction, for instance as in the behaviori therapies. The speech therapist generally emplolys conditioning procedures, and thus, in his attempts to reinforce positive speech responses, he enters into the psychotherapeutic fiefci. While he strit,es to bring his client to some understanding of his interactional patterns, he does not attempt to delve into unconscious con&t or ‘depth insight.4s’.This does not preclude his working out with the client, in language the client can understand, a rationale for his speech retraining. What about transference? In the helping situation, the relationship is geared toward positive feelings, any negative reactions being dealt with by clarification and reassurance. Zn counseling, the positive transference is also cucouraged and utilized, a,rd, whenever negative transference begins to emerge, it is immediately handled by interpretation. This is something the speech therapist has to do constantly. Whenever the client gets hostile to him, or begins to develop feelings that are not reality-orierrted, he must step in and, as rapidly as possible, restore the relationshi? to a working level. In psychotherapy there are differences in how trahsferential inter;‘ictions are handled. Both positive and negative transference are nurtured, analyzed and interpreted. Attempts are made to comprehend them in terms of their deeper meanings, and in the context of the person’s historical past. The speech therapist will not generally delve into or handle transference on this level. Countertransference must also be managed in “helping’, counseling and psychotherapy= In the helping situation, perhaps without the helper acknowledging or realizing it, pa&iv e feelings will develop in him that he will utilize to promote the supportive process. In the counseling situation, posithe feelings w~U also be employed in this way. On the. ether hand, negative feelings in both helping and counseling are neutr,qliy.erl and controlled. obviously, in view of his training, the counselor shoul,d have more underS&anding into *he nature and manifestations of hit, teg;ative feelings than *he average helping agency, althougl. in practice this 6~5 no* always prove *o be *he USC In the psychotherapeutic situation, c ountertransference is
MANAGEMENT OF SPEECH AND HEARING PROBLEMS
83
constantly examined by the therapist in order to gain clues from the way he is personally reacting to defenses and operations of the patient. This examination wiil also help the therapist resolve my antitherapeutic projections, The therapist IINM particularly be on the alert not to get himself enveloped h the patient’s transferential designs. These transactions have, where the therapist is properly trained, a great therapeutic potential and hence are encouraged as in psychoanalytic treatment. The speech therapist will have neither the training nor the time to foster and explore these dimensions. It will be seen that the function of the speech therapist is compkxnentary to that of the psychotherapist. The fact that the speech therapist gets training in speech therapy does not make him a psychotherapist. He will act psychotherapeutically and the patient will respond to him in a psychotherapeutilc way, but he will not be duplicating the psychotherapist’s role. The dir: de speech o!:t- ;a?e may however be the same even though the process, goals and many 4 he methods are different. The speech therapist is concerned with nit .Vr‘j:ng speech patterns, the psychotherapist with altering the general personality structure. To say the one is superior to the other is arbitrary. We are dealing with affiliated approaches, both of which are worthwhile. This afternoon we have explored areas of interaction between speech therapy and psychotherapy from which both the psychotherapist and the speech therapist can benefit. As psychotherapists, we can learn a great. deal from what you are doing that will expand our own clinical awareness. In dealing with speech problems, the psychotherapist often finds his techniques limited and ineffectual. On the other hand, reinforcement of certain positive communicative patterns, which is the specialized skill of the speech therapist, may be remarkably effective, The activities of the speech therapist can complement the operations of the psychotherapist. By a working together, there can be a blending of functions, and an expansion of the usefulness af both professions. The speech therapist, for excnmple, may focus on thz speech difficulty per se, and refer the patient to a psychotherapist where general personality difficulties need urgent attention. I have the feeling - and this is only a hunch - that a speech therapist who is well trained can handle a good bulk af the cases that come to him without ever needing to refer them to a psychotherapist. There will be patients, however, whom he will be unable to reach, as weI1 trained as he may be, or as thoroughly endowed as he is with positive characteristics and qualities. These are the patients who are so completely embedded in their misery, whose speech problems are so deep and structuralized in personality distortions, that the communicative complaint is only a tiny surf& facet of a much more disruptive piocessa same severely ill patients may, of course, be helped remarkably bY dis-
84
_
LEWIS R. WOLBERG
locating one aspect of their neurotic equation. This is what occasionally happens when one deals with a disabling symptom. If one corrects the symptom, changes may register themselves in the total personality structure. Overcor&g a speech handicap will enable thz victim to feel better about himself, He will relate more productively with people. His work capacity and economic potential can change for the better. However where the psychopatho!ogy is too extensive this may not happen. It is this type of patient who will require referral to a psych*Jtherapist for intensive treatment. In my opinion, these constitute only a small fraction of the cases that come to the speech therapist. i I want to tGsnk the recorders, the leaders of the groups, and Dr. Bloodstein fo+ participating with us in what has been a most rewarding experience. I hope that we eventually r&laybe able to work together on a program that should prove to be mutually beneficial and that can bring our skills to bear on what constitutes one of the most disabling symptom complexes in our contemporary society.
Dis. 1 (1967) 75-84 o North-Holland
Publ. Co., Amsterdam
THE PSYCHOLOGICAL MANAGEMENT OF INDIVIDUALS WITH SPEECH AND HEARING PROBLEMS LEWIS R. WOLBERG Postgraduate Center for Mental Health, New York City
Part II / Conclusions In general, the discussion groups at the conference concerned themselves with the varying roles of the speech therapist as a psychotherapist, as a speech trainer, as a group worker, as a group therapist, and as an educator to the patient‘ and parents of children with speech problems. An area of large concern was the training program itself. What are the constituents of a good training program? Who should participate in the training program? It was generally agreed that the staffing of the program be by professionals who have knowledge both about speech problems and psychotherapy. It was then agreed that training, more or less, should be in terms of a psychodynamic orientation and should be conducted on different levels, on masters, docto-lo ,rld =- supervisory levels. Additional training was also believed to be essential for speech therapists in practice, and two goups believed that there should be a workshop for seasoned professionals. Then the discussions concerned themselves with how one should practically go about getting the program off the ground. Ht was suggested that perhaps a summer workshop be organized that would deal specifically with the content of the program, and with the development of the tactics that would need to be employed in implementing it. More didactic problems came up, such as the question as to the communication difficulties between the professionals, the clarification of their roles and functions. How does the speech therapist differentiate himself from the psychotherapist? And how should the two begin to work together? What kind of language do they use that is similar and different? How do they interrelate? There was talk about the relation of the Postgraduate Center to the training program of universities and educational centers that deal principally with speech pro&m. This brought up the idea that perhaps the Center could pa&ipate not only in the training, but also in therapy, for example working actively with groups of parents of children who had speech problems. 75
76
LEwlS R. WOLBERG
The specific nature of training was brought up for discussion. What constitutes the best kind of training? The concensus was that a balanced composition of lectures, demonstratL)ns, supervised practice, group experience, screening procedures, observation t y speech therapists or psychotherapists in action was ideal. General plans about how this could be practically implemented were formulated. An important item repeatedly brought up was referral procedures: who to refer, how to refer, where to refer. In the organization of a training program referral would hi’ve to be considered quite pointedly, since this was a mos’r: important function of the speech therapist. He had to be skilled in processes of referral, and he had to know something about diagnosis. A question that constdntly arose was: ‘How does the psychtitherapist conceive of his role in contrast to the role of other persons who are doing work along the same lines, and yet are not psychotherapists.’ It would be expedient to try to differentiate psychotherapy from work that is psychotherapeutic. The chart in ‘Helping, Counseling and Psychotherapeutic Relationships’ applies itself to this question (Table 1). An aspect that concerns speech therapists is whether they are ‘helpers’, ‘counselors’ or psychotherapists. Role confusion is a common thing in our field. Are we, when we see patients, ‘helping’, ‘counseiing’ or doing psychotherapy? In a training program, would speech therapists be trained as psychotherapists? What constitutes the true difference bet ;tleen helping, counseling and psychotherapy? We heave opinions about these problems, but there are no definitive, authoritative answers. ‘Yet it is important for our present needs to attempt to isolate what the speech therapist does from . what the psychotherapist does. In the field of psychotherapy there are many variant points of view which may be subsumed under three majo, piositions. These are first the ‘relationship position’, second the ‘reward-punishment position’, and third, the ‘cognitive restructuring position’. The cluster of psychotherapies that are organized around the relationship positior! contend that what is fundamental in psychotherapy is the association that develops between patient and therapist. Given the proper kind of human relatiDr,sbip, self-actualizing tendencies will be released. What helps are not the tactical maneuver:. but the proper interactional climate which releases spontaneous forces of health and growth. Irrespective of the kind of problem, a fruitful liaison between patient and therapist will provide the essential base for cure. A number of schools, including clientcentered, phenomenological and some neo-freudian groups subscribe tlo this idea. A second large division of psychotherapists, namely the behavior thera-
I
Immediate present Support ; reassurance ; emotional catharsis ; placebo influence ; group dynamics Positive transference encouraged and utilized
Avoided
Temporal focus Technical processes
Transference
Counter transference
neurosis
Positive feelings utilized : negative feelings controlled
Immediate present Guidance; clarificatioil; suggestion; environmental manipulation ; use cf community resources Positive transference encouraged and utilized; negative transference discouraged Avoided
Conscious processes
Psychic urena
Positive feelings utilized to promote supportive process
Conscious processes
Manifest complaints and interpersonal problems
Inter view focus
Transference
Correction of situational problem; rectification of deviant behavior; expansion of personal abilities and skills; restoration of defenses; prevention of emotional breakdown Situational problems; conlicts; attitudes
Symptom relief
Objectives
Ke:ping situation
relationships
Counseling Supportive psychotherapy
Helping, counseling and psychotherapeutic
TABLE
In psychoanalysis purposefully promoted to release repression and to dete;t sources of i.nner conflict; otherwise avoided Constantly examined, analyzed and resolved
Underlying roots of complaints and conflicls ; r!efcnses, coping n, -chanisms, fantasies, symbolisms Conscious, preconscious and, in psychoanalysis, unco,lscious processes In-mediate present and historical past Inculcation >f insight, pattern reinforcement snd extinction, and, in psychoanalysis, dreams and free association Positive and negative transference interpreted
Alteration of defenses; Wiioation of interpersonal agd social adjustment; personality growth and deveiopment
-V--X I.__P Psychotherapy (re-educative and reconstructive goals)
LEWIS R. WOLBERG
pists, are dedicated to the ‘reward-punishment position’. This contends that neurotic behavior is learned behavior, and that anxiety is a secondary manifestation to be neutralized by the same processes through which it is learned. What is important in therapy, therefore, is the selective reinforcement of healthy responses and the unreinforcement of unhealthy reactions. Determine what is constructive for the person, and reward him for behavior that conforms with a good adaptation. Neither relationship nor insight are vital in getting well. What is crucial are procedures like operant conditioning that will eventuGly repair the damage to the personality. The third large grouping of thej*apies are organized around the ‘cognitive restructuring position’ which considers change impermanent without alteration of the intrapsychic processes. Symptom removing maneuvers, such as are involved in reconditioning manipulations are branded as superficial and temporary, What is essential is true reorganization of the constituent components of personality. Several means of accomplishing this have been proposed. First, there are some who believe that cognitive change may be brought about by imposing cn the patient a new ideological outlook. Through directive or non-directive means attempts are mad; to shape wholesome values. The philosophically oriented therapies are in this category. Second, there are therapists, such as the neo-freudian psychoanalysts, who contend that what must be examined is the relationship between the individual and his social environment. It is essential to bring the patient to an awareness of what he is doing in his interpersonal operations, the kinds of defenses he employs, and how these disorganize his adjustment. Awareness of his interpersonal distortions enables the individual to experiment with a new relationship, principally with the therapist. The therapeutic encounter then becomes a corrective emotional experience. Third, there are other therapists, namely Freudian psychoanalysts, who believe that cognitive restructuring best occurs when the learning experience is acted out in the transference situation. By manipulating the relationship and circumscribing communication, important conditionings in the past, which are now unconscious, will repcat themselves in the therapeutic situation with little; regard to their present appropriateness. The working-through of the distortions of early experience (inffantile neurosis) within the treatment setting itself (transference neurosis) is believed to produce widespread changes in the intrapsychic apparatus. Although therapists take different positions in psychotherapy and restrict their focus to a lim’ited group of vectors, we can, if we peer beyond the immediate techniques, discern a remarkable unity in operative processes. For instance, we find that in every relationship there is a selective reinforcement of positive responses. The fact that therapists take the ‘relationship
MANAGEMENT
OF SPEECH AND HEARING
PROBLEMS
79
position’, purposefully communicating ‘care’, understanding and empathy-, does not man that they act the same toward behavior that is destrvlctive as opposed to conWictive. Responses will be qualitatively different; and this will tend to reinforce certain kinds of behavior. Moreover, within the ‘client-centered’ relationship, transference is bound to develop. The perception by the patient of a new kind of authority as ve:sted in the therapist will tend to restructure attitudes toward punitive and irrutional authority. Therapists taking the ‘reward-punishment PO&ion’ (many forms of speech therapy are organized around conditioning procedures) minimize the importance of the relationship and of insight. But when one examines what goes on in treatment one finds that change is taking place within the context of a human relationship, and that the conditioning techniques are being influenced by auxiliary processes that automaticahy precipitate out in any relationship. If the therapist is not an empathic, understanding and giving person, conditioning procedures may prove to be of little avail. Elements in the ‘relationship position’ seem also to apply to the ‘rewardpunishment position’. Furthermore, comparing the new with the old authority, and testing the former in various ways (defying, resisting, being seductive in transference, etc.) will, if a strong difference is perceived in the responses of the therapist as compared with early authorities, alter aspects of the intrapsychic process itself. Reconstructive changes may then occur in the severity of the conscience and in the self-image. Inherent then in the rewardpunishment position are processes of insight even though these are not recognized as such. 111the ‘cognitive restructuring position’, that is the insight therapies, even the passive, anonymous, non-interfering activities of the classical psychoanalylst, will incorporate *relationship’ and ‘reward-punishment’ processes. The psychoanalyst who is not a giving or empathic person, irrespective of how passive he may act, will find his techniques impaled on the sword of his unresponsiveness. The patient will rapidly perceive from nonverbal cues the kind of a person with whom he is dealing, whether he is understanding and sympathetic, or cold and unconcerned. Moreover the analyst, whether he is aware of it or not, will reward certain responses from the patient and discourage others. For instance, whenever the patient deals with material that reproduces the convictions, theories and biases of the an:Jyst, the tatter will acknowledge these in a condoning way. On the other harld resistznces to such material are dealt with firmly in a climate of relative dis,;approv&. Et is perhaps for this reason that, no matter to what school the analyst &longs, his patient will bring up data in his analytic sessicns that seem to substantiate the premises of the analyst. Often both thewaist anq;lpatient are unaware of the influencing process that is going on. What
LEWIS R. WOLBERG
is being influenced may, of course, be valid. Nevertheless, invalid concepts too may gain sanction. What holds true for psychotherapists applies to speech therapists, who after all function in the medium of relationships with their clients or patients. Operative will be the enactment of certain roles and the execution of what therapists in the ‘relationship situation’ say is important. Speech therapists will also be involved in giving out rewards in the f’orm of approval for certain positive speech and behavioral responses. They will then do what the ‘reward-purGshment’ therapists say is significant. And in the course of themrcon:act with clients, transference is bound to appear. Speech therapists will most likely, in the minds of their patients, act as authorities who do not reproduce the punitive experiences of past authorities. A corrective lemotional exlperience will therefore be provided leading to changes the ‘cognitive restructuring’ therapists consider to be crucial. This does not mean the speech therapist is doing psychotherapy. Differentiated in the chart on ‘Helping, Counseling and Psychotherapy’ are processes, objectives and tactical maneuvers. A ‘helping situation’ can be in relationship to any non-professional person, friend, politician, even bartender. Incidentally there are probablUy more bartenders operating in the role of therapists than there are trained psychotherapists. The counselor is generally a trained professional person, for example social worker, lawyer, minister, teacher, psychologist or speech therapist. The psychotherapist is a psychiatrist, clinical psychologist or psychiatric social worker who has gone through a structured postgraduate course of training in psychotherapy or psychoanalysis. What are the goals in helping, counseling and psychotherapy? Do they differ? In the helping and counseling situations a prime objective is relief from symptoms. But in addition to symptom relief efforts are generally made to straighten out a situational difficulty, or t-o rectify certain aspects of deviant behavior, for instance speech problems. Other objectives include expansion of personal abilities and skills, and restoring of habitual defenses. These aims are somewhat different from those in psychotherapy in which a direct attempt is made to alter defenses and to facilitate new modes of interpersonal and social adjustmeAnt. The goal is not only restoration of homeostasis, but a concerted effort to promote personality growth and developizozt. In the helping and counseling situations the latter goals may sometimes spontaneously be reached, that is, not only will a person attain homeostasis, but he may, in the course of feeling an.d behaving better, develop some poterltialities that will approach, at least partially, reconstrucgive objectives. However the ‘helping agency’, or counselor, or ‘supportive therapist’, does not deliberately try to bring about reconstructive changes.
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If changes occur, they are in serendipity, a consequence of what is going on. We come next to the interview focus. What is the focus when a person relates himself to a non-professional helping agency? Usually this is on manifest complaints and interpersonal problems. The focus in counseling concern itself with situational problems, conflicts and attitudes. In psychotherapy it is the underlying roots of the existing complaints and conflicts, the defenses, coping mechanisms, fantasies a.ad symbolisms. The counselor does not involve himself with fantasies, symbolisms and defenses. He deals more with manifest complaints and attitudes. The psychic arena of the helping agency and counselor is the zone of consciousness, while the psychotherapist works with the conscious and preconscious, and, in psychoanalysis, the unconscious. The speech therapist thus will not ordinarily involve himself with unconscious material. He will have enough difficulty managing immediately tangible problems without delving into zones for which he is untrained. Assuming he has had training in psychoanalysis, experience does not credit superiority to treating the speech symptom on a depth as compared to a more topical level. This does not mean that the unconscious will not display itself as the speech therapist applies himself to the problems of his patient. Nor does it mean that the speech therapist will not do better work if he is analytically trained. Transference, countertransference, and tendencies toward actingout will always filter into a relationship, and the proper handling of these will be helpful even where the goal is merely to improve speech and not to reconstruct personality. But if the speech therapist is a perceptive person who does not defend too much against acknowledging his own difficulties to himself, and if he is not too hostile or detached, he can do excellent work even though he has not exposed himself to extensive personal analysis and training. When we consider the time dimension with which we are dealing, we find that the temporal focus in the helping and counseling situations is on the immediate present, while in psychotherapy it is on the immediate present and historical past. The speech therapist will, more 02 less, concern himself with what is going on in the present, which will, of course, embody some aspects of the past. The technical processes involved in helping are supportive and reasIsuring, and they take advantage of the auxiliary agencies of emotional catharsis, placebo, group dynamics, suggestion and use of the idealized projected relationship. These healing forces emerge and are taken advantage of in counseling and psychotherapy. In addition to helping, supportive and reassuring tactics, other operations are implemented. For instance, in counseling there is guidance, clarification, suggestion, environmental manipulation,
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and the concerted use of community resources. The speech therapist, 3s Dr. aloodstein has pointed out, utilizes some of these modalities, which essentially derived from casework, have proven to be of value in he&ng people in trouble. A good training program must COnSeqUently involve an understanding of casework techniques. In most forms of psychotherapy an effort is ma& to employ insight as a means of helping the patient to reorganize his &hay&x through focused interviewing, and, in psychoanalysis, &ougb dreams and free association. In some forms of psychotherapy insight. is in&i& in favor of conditioning strategies that lead to pattern reilgorcement and extinction, for instance as in the behaviori therapies. The speech therapist generally emplolys conditioning procedures, and thus, in his attempts to reinforce positive speech responses, he enters into the psychotherapeutic fiefci. While he strit,es to bring his client to some understanding of his interactional patterns, he does not attempt to delve into unconscious con&t or ‘depth insight.4s’.This does not preclude his working out with the client, in language the client can understand, a rationale for his speech retraining. What about transference? In the helping situation, the relationship is geared toward positive feelings, any negative reactions being dealt with by clarification and reassurance. Zn counseling, the positive transference is also cucouraged and utilized, a,rd, whenever negative transference begins to emerge, it is immediately handled by interpretation. This is something the speech therapist has to do constantly. Whenever the client gets hostile to him, or begins to develop feelings that are not reality-orierrted, he must step in and, as rapidly as possible, restore the relationshi? to a working level. In psychotherapy there are differences in how trahsferential inter;‘ictions are handled. Both positive and negative transference are nurtured, analyzed and interpreted. Attempts are made to comprehend them in terms of their deeper meanings, and in the context of the person’s historical past. The speech therapist will not generally delve into or handle transference on this level. Countertransference must also be managed in “helping’, counseling and psychotherapy= In the helping situation, perhaps without the helper acknowledging or realizing it, pa&iv e feelings will develop in him that he will utilize to promote the supportive process. In the counseling situation, posithe feelings w~U also be employed in this way. On the. ether hand, negative feelings in both helping and counseling are neutr,qliy.erl and controlled. obviously, in view of his training, the counselor shoul,d have more underS&anding into *he nature and manifestations of hit, teg;ative feelings than *he average helping agency, althougl. in practice this 6~5 no* always prove *o be *he USC In the psychotherapeutic situation, c ountertransference is
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constantly examined by the therapist in order to gain clues from the way he is personally reacting to defenses and operations of the patient. This examination wiil also help the therapist resolve my antitherapeutic projections, The therapist IINM particularly be on the alert not to get himself enveloped h the patient’s transferential designs. These transactions have, where the therapist is properly trained, a great therapeutic potential and hence are encouraged as in psychoanalytic treatment. The speech therapist will have neither the training nor the time to foster and explore these dimensions. It will be seen that the function of the speech therapist is compkxnentary to that of the psychotherapist. The fact that the speech therapist gets training in speech therapy does not make him a psychotherapist. He will act psychotherapeutically and the patient will respond to him in a psychotherapeutilc way, but he will not be duplicating the psychotherapist’s role. The dir: de speech o!:t- ;a?e may however be the same even though the process, goals and many 4 he methods are different. The speech therapist is concerned with nit .Vr‘j:ng speech patterns, the psychotherapist with altering the general personality structure. To say the one is superior to the other is arbitrary. We are dealing with affiliated approaches, both of which are worthwhile. This afternoon we have explored areas of interaction between speech therapy and psychotherapy from which both the psychotherapist and the speech therapist can benefit. As psychotherapists, we can learn a great. deal from what you are doing that will expand our own clinical awareness. In dealing with speech problems, the psychotherapist often finds his techniques limited and ineffectual. On the other hand, reinforcement of certain positive communicative patterns, which is the specialized skill of the speech therapist, may be remarkably effective, The activities of the speech therapist can complement the operations of the psychotherapist. By a working together, there can be a blending of functions, and an expansion of the usefulness af both professions. The speech therapist, for excnmple, may focus on thz speech difficulty per se, and refer the patient to a psychotherapist where general personality difficulties need urgent attention. I have the feeling - and this is only a hunch - that a speech therapist who is well trained can handle a good bulk af the cases that come to him without ever needing to refer them to a psychotherapist. There will be patients, however, whom he will be unable to reach, as weI1 trained as he may be, or as thoroughly endowed as he is with positive characteristics and qualities. These are the patients who are so completely embedded in their misery, whose speech problems are so deep and structuralized in personality distortions, that the communicative complaint is only a tiny surf& facet of a much more disruptive piocessa same severely ill patients may, of course, be helped remarkably bY dis-
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locating one aspect of their neurotic equation. This is what occasionally happens when one deals with a disabling symptom. If one corrects the symptom, changes may register themselves in the total personality structure. Overcor&g a speech handicap will enable thz victim to feel better about himself, He will relate more productively with people. His work capacity and economic potential can change for the better. However where the psychopatho!ogy is too extensive this may not happen. It is this type of patient who will require referral to a psych*Jtherapist for intensive treatment. In my opinion, these constitute only a small fraction of the cases that come to the speech therapist. i I want to tGsnk the recorders, the leaders of the groups, and Dr. Bloodstein fo+ participating with us in what has been a most rewarding experience. I hope that we eventually r&laybe able to work together on a program that should prove to be mutually beneficial and that can bring our skills to bear on what constitutes one of the most disabling symptom complexes in our contemporary society.