FThis article is for use only of students enrolled in GPS 520: Advanced Social Psychology for purposes associated with this course and may not be retained or further disseminated.
Rabinowitz,
V. C., Zevon, M. A., & Karuza, J. (1988).
Psychotherapy as helping: An attributional analysis.
Psychotherapy
as helping: An attributional analysis.
Vita
c. Rabinowitz
Michael
A. Zevon
Jurgis
Karuza, Jr.
The
purpose of this chapter is to consider various psychotherapeutic systems as
helping interventions and to examine the role of the therapist's attributional
judgments on the process of therapy. Construing different psychotherapies as
special cases of the broad category of helping allows us to describe them in
terms of four basic helping models proposed by Brickman et al. (1982). We view
psychotherapeutic approaches as differing importantly in the therapist's
attributional judgments about the client's responsibility for the origin of his
or her problem as well as for the solution to it. The implicit or explicit
attributional assumptions of particular psychotherapies may cause each therapy
to be more or less appropriate in treating various psychological disorders. In
contrast to existing psychotherapies that rely on a single attributional
perspective throughout the course of treatment, we suggest that at times it may
be useful to shift perspectives in viewing the causes of and solutions to the
client's problems as therapy progresses.
PSYCHOTHERAPY
AS HELP
In
its early form, psychotherapy consisted primarily of a single therapeutic
approach employed in the treatment of a narrow range of specific and
debilitating disorders (Freud, 1912/1958). Since this beginning, however,
psychotherapy has evolved and expanded to encompass a vast number and diversity
of therapeutic systems. In their contemporary form, these systems address a wide
range of human problems, from specific behavioral disorders to the fostering of
optimal human development and growth. As a number of reviews have noted (Corsini,
1973; Goldstein & Simonson, 197 1; Urban & Ford, 197 1), the days of
psychotherapy qua psychotherapy are long past.
Despite
the multiplicity of modern day therapeutic approaches, it is important not to
overlook the fact that psychotherapy remains a helping process (Wills, 1982;
Wolman, 1976). As Weiner (1975) has stated, psychotherapy "is an
Interpersonal process in which one person communicates to another that he
understands him, respects him, and wants to be of help to him" (p. 3). From
within this framework, we view therapists as help givers who use their skills
and training to bring about improvement in their clients' functioning. Clients
are seen as recipients of help, individuals who experience and acknowledge, in
some sense, an inability to resolve a particular problem or set of problems. We
view this helping process as basic to psychotherapy, and see it operating across
the theoretical boundaries of particular psychotherapeutic systems.
It
is becoming apparent through recent empirical work, however, that the
psychotherapeutic process is determined and influenced by a wide variety of
factors. These elements range from nonspecific therapeutic ingredients
(Goldstein & Stein, 1976), such as the interpersonal relationship between
client and therapist (Fehrenbach & O'Leary, 1982; Schofield, 1964), to
specific factors, such as the mediating goals and procedures inherent in a
particular therapeutic orientation (Parloff, Waskow, & Wolfe, 1978).
Together, these components structure the therapeutic process and determine its
effectiveness. Given this multidimensional and multidetermined view of
psychotherapy, no simple model of the therapeutic process is readily apparent.
Contemporary
approaches to the analysis of the therapeutic process (e.g., Howard, Orlinsky,
& Perilstein, 1976) have attempted to deal with this complexity by
determining the relative contribution of various therapeutic components to the
process and outcome of therapy. Taking their lead, we will focus on the
therapists and how they translate the mediating goals and procedures of the
therapeutic school they embody. Specifically, we will propose an attributional
analysis of various therapeutic orientations and consider the attributional
foundation of the clinical decisions made by the therapist in psychotherapy.
JUDGMENTS
IN PSYCHOTHERAPY
Despite
the admitted complexity of psychotherapeutic processes, we will focus here on
the clinical decision-making basis from which the therapist makes critical
decisions about the client and structures the process and pace of therapy.
(Urban & Ford, 1971). On the basis of experience and training in
psychotherapeutic systems, the therapist makes, implicitly or explicitly,
decisions directed at issues such as whether to accept a client for therapy, the
etiology of the presenting complaint, the appropriate interventions, and the
criteria for judging the success of the treatment. The therapist must process
information about the client and his or her complaint; in other words, the
therapist must make a series of evaluations and judgments about the client.
A
complicating factor in this view of psychotherapy is the variation of the
therapist's role as dictated by the numerous schools of psychotherapy. For
example, Gestalt, ratio nal-e motive, and psychoanalytic therapies stress the
evaluative and interpretive role of the therapist. On the other hand, therapies
such as Rogers's client-centered approach stress a nondirective, evaluation-free
orientation. Indeed, client-centered practitioners pride themselves on their
nonjudgmental approach to therapy and would perhaps bridle at any intimation
that the therapist makes judgments concerning the client. It can be argued,
however, on both empirical and logical grounds, that therapists of all
persuasions do make judgments about clients and, further, that these judgments
either implicitly or explicitly play an important role in psychotherapy. Strupp
and colleagues (Strupp, 1978; Strupp & Wallach, 1973; Strupp & Williams,
1973) cogently make the point when they state that whatever the therapist's
background or level of training, he or she cannot escape the necessity of (1)
forming some notions or hypotheses about the patient's "problem" or
difficulty, and (2) deciding what needs to be done to bring about an improvement
in the patient's condition. In order to address this issue, a consideration of
"judgment" is in order.
Judgments
come in a variety of forms. On the one hand a judgment can involve an opinion
held about another and, as such, possesses an evaluative or critical component.
More pertinent to our analysis, however, is the sense of judgment that refers to
an assessment or appraisal that is nonevaluative and instrumental. Judgments of
this nature would seem to be endemic to psychotherapy, and, indeed, at the heart
of each school of psychotherapy is a theory that defines a particular view of
human nature. In attempting to explain behavior, each theory more or less
explicitly guides therapists in their attempts to understand clients and their
presenting problems. This guidance, in turn, sets up expectancies about clients'
potentials and their ability to control their behavior. Implicitly, the theory
serves as a prescriptive framework from which the therapist makes instrumental
judgments and attributions about the nature of the presenting complaint and how
to solve it.
While
the proper role of evaluative judgments in psychotherapy may be moot, we view it
as unrealistic to contend that instrumental judgments are not or should not be
made. While psychotherapies may differ in the form, overtness, and centrality of
these instrumental judgments, we view them as basic to the psychotherapeutic
process and guided by the theoretical orientation of the therapist.
ATTRIBUTIONAL
PROCESSES IN PSYCHOTHERAPEUTIC JUDGMENTS
With
the goal in mind of ameliorating the client's presenting complaint, the
therapist must make two instrumental judgments; he or she must determine the
nature of the presenting complaint and its solution. Using the analysis of
Brickman et al. (1982), these judgments may be seen as reflecting two strategic
concerns: who or what is to blame for the cause of the presenting complaint and
who or what is to have control over its solution. These concerns can best be
defined in terms of two distinct attributions about the client: (1) the extent
to which the client is responsible for the cause of the presenting complaint,
and (2) the extent to which the client is to be held responsible for the
solution to the presenting complaint.
Although
several researchers and theoreticians (e.g., Ross, Rodin, & Zimbardo, 1969;
Storms & McCauly, 1976; Wills, 1978) have applied attributional analysis to
clinical issues, they have, in the main, avoided the consideration of the
attributional dynamics that define and shape the mediating goals and procedures
of therapy. We view this, at least in part, as the result of an inadequate
mapping of the instrumental judgments that underlie psychotherapy as e as other
helping interventions, see Karuza, Zevon, Rabinowitz, & Brickman, 1982). As
Brickman et al. (1982) point out, traditional attributional analyses are
predicated on a view of individuals as generally objective scientists who seek
to determine the causes of events in order to achieve an accurate understanding
of the world. Therapists, however, may be less interested in objectively
defining causes of events than with acting on the presenting complaint.
Further,
traditional attributional analyses (e.g., Jones & Davis, 1965; Kelley, 1967;
Weiner et al., 1971) tend to emphasize how causality is assigned for past or
current events. What is typically overlooked is how attributions are made about
the cause and control of future behavior, an issue that is critical in setting
the goals and direction of therapy. Because of the orientation of existing
attributional theories and their language (e.g., internal or external locus of
control; stable or unstable, global or specific causes) they do not clearly
define the interrelationship of the strategic attributions about the client's
responsibility for the cause of the presenting complaint, a past-focused
attribution, and the client's responsibility for the solution of the presenting
complaint, a future-focused attribution.
In
the section that follows we will review the existing theoretical and empirical
clinical literature that shows the impact of the attributions about the cause of
and solution to the client's presenting complaint on the therapeutic enterprise.
ATTRIBUTIONS
ABOUT THE CLIENT'S RESPONSIBILITY
A
number of historical trends and ongoing debates in clinical psychology are
concerned with determining the most useful attributional perspective for
conceptualizing and understanding patients' presenting problems. In a historical
vein, the treatment advocated by, among others, Phillipe Pinel and William H.
Tuke proposed that mental patients be treated with kindness, understanding, and
the belief that they (given the required environmental support) possessed the
necessary capacity to effect change and experience a "cure." The
decline of moral treatment and the ascendence of medical forms of treatment
represented a shift in attributional perspective: The "cure" was now
the responsibility of the psychiatric expert, and the patient's responsibility
was reduced to a "passive, submissive, quiet, untroublesome waiting for the
discovery of a cure" (Ullman & Krasner, 1975, p. 138). In a related
vein, the essence of the behaviorists' challenge of psychoanalytic theory is to
a large extent the question of whether deviant behavior is caused by factors in
the person (an internal attributionthe psychoanalytic approach) or factors in
the environment (an external attribution-the behavioral approach). We contend
that therapists, as a result of their training and allegiance to a particular
theory of abnormal behavior and psychotherapy, operationalize these attributions
in terms of assigning responsibility for the causes of and solutions to the
patient's problems. In his discussion of the difficulties in understanding
abnormal behavior, Price (1972) states:
What passes for theory in the study of abnormal
behavior is often mixed with large doses of ideology. Whether this is a
beneficial effect is arguable. In any event, theory and ideology are often
mistaken for one another, and it is sometimes unclear whether the intent of a
particular viewpoint is descriptive or prescriptive (p. 5).
Past-focused
Attributions
Evidence
supporting our contention that therapists make attributions about the client's
responsibility for the cause of problems can be found in examinations of the
theoretical language of various psychotherapeutic schools. Therapeutic systems
such as rational-e motive therapy (Ellis, 1962) and client-centered therapy
(Rogers, 1951) adopt a view that stresses personal responsibility for one's
actions, while the behavioristic therapies focus on the environment and see the
causes of behavior as externally based. The psychoanalytic perspective has,
likewise, implicit views on the causes of and responsibility for the client's
difficulties. The major thrust of the psychoanalytic approach is a historical
analysis of the client in which his or her present dysfunction is seen as caused
by a past trauma. The salience of attributions for understanding psychological
disturbance is more directly addressed in recent formulations of the learned
hopelessness theory, formerly the learned helplessness theory, of depression,
which emphasizes an attributional analysis of the causes for negative life
events as key to understanding the dynamics of depression (Abramson, Metalsky,
& Alloy, Chapter 2, this volume; Abramson, Seligman, & Teasdale, 1978).
Increasingly, clinical researchers are recognizing the role of attributions in
the development and maintenance of psychological problems, as well as the
attributional aspects of psychotherapy (e.g., Harvey & Galvin, 1984; Leary
& Maddux, 1987).
Further support for the prevalence of
therapist-based attributions about client responsibility for the cause of
problems can be inferred from investigations that illustrate the personalistic
attributions made by observers for the causes of a client's problems (see Wills,
1978, for a review). An example is the study by Snyder, Shenkel, and Schmidt
(1976) in which subjects were instructed to adopt the perspective of a counselor
when listening to a therapy interview. Results showed that subjects under these
instructions made more personalistic attributions of the cause of the client's
problems as compared to subjects instructed to adopt the perspective of the
client and subjects in a control group given no instructions. This tendency is
echoed in Rosenhan's (1973) well-known study, which reported hospital
psychiatric staff as more likely to ascribe the behavior of patients to
personalistic, rather than situational, factors. As this discussion suggests,
attributions regarding the cause of, and responsibility for, the client's
problems are a component of all forms of psychotherapy.
Future-focused
Attributions
The
question of who should be responsible for solving the presenting complaint is an
often overlooked but central one in psychotherapy. Only by making judgments
about the client's future potentials, and the extent to which clients can be
seen as responsible agents in seeking solutions to their problems, can the
therapist rationally design and implement interventions.
Evidence for the salience of attributions of the
client's responsibility for the solution to the presenting problem can again be
found by examining the theory underlying the activity of the psychotherapist.
Each theory of psychotherapy proposes intervention styles or techniques that
involve a set of expectations about the client's role in, and potential for,
change. Client-centered therapy, for example, sees the client as the ultimately
responsible agent. The therapist's role as a change agent is minimized and
consists of developing a relationship with the client based on congruence,
positive regard, and empathic understanding (Rogers, 1959). Cognitively based
behavioral therapies also stress the responsibility of the client for achieving
a solution to the problem. The therapist's role is primarily that of a teacher
who instructs the client. The client, however, is responsible for the mastery
and employment of these techniques.
On the other hand, a number of therapeutic
approaches exist that see the client as having little or no responsibility for
the solution to the problem. Psychoanalysis is the premier example of a
psychotherapy where clients are assumed to have little future responsibility for
directly solving their problems. The psychoanalytic approach stresses the
unconscious motivation that underlies behavior, a motivation the unanalyzed
client can have little hope of controlling or even understanding directly. A
further example can be found by examining the approach of therapeutic groups
such as Alcoholics Anonymous. Within these therapeutic systems the client is
seen as having little individual control over his or her problem. The group, its
support system, and a spiritual force are held to be important regulators of
behavior and the ultimate "cause" for the future adjustment of the
client. Most pronounced, perhaps, is the orientation of pharmacological
treatments; their practitioners assume that behavioral change and future
effective functioning is largely beyond the ability of the individual. The
solution to the problem and the subsequent adjustment of the client result from
the administration of the external chemical intervention.
Considerable empirical evidence for the presence,
in therapy, of attributions about client responsibility solutions can be found
in the clinical literature, For example, Saltzman, Luetgert, Roth, Creaser, and
Howard (1976) had therapists and clients rate each other on a variety of
dimensions, including the perceived responsibility of the client and the
therapist for solving the client's problem. The therapists' assessment of the
degree of resolution of the presenting problem was found to be significantly
correlated with their perceptions of the clients' acceptance of responsibility.
In addition, clients' reported resolution of presenting problems was
significantly correlated with their perceptions of their own responsibility for
their behavior and with their therapists' perceptions of their responsibility.
The fact that judgments of client responsibility were made, and that they were
related to therapeutic outcome, shows the importance of considering attributions
of the client's future responsibility for the solution to the problem.
As our review suggests, the therapist's
attributions about responsibility for the cause of and solution to the client's
problems, whether explicit or implicit, combine to affect the entire course of
psychotherapy. First, these attributional judgments help define the presenting
problem and its scope and therefore allow the therapist to understand the nature
of the problem. Second, in assessing the cause of the problem and the potential
of the client, the therapist is able to judge when, how, and where to intervene
in order to ameliorate the problem. Finally, knowledge of the client's
potentials and his or her responsibility for the cause of the problem provides
the therapist with indications of where to look for improvement and furnishes
guidelines for gauging the effectiveness of therapy.
Ideally speaking, by applying our attributional
analysis to psychotherapy, a client can be viewed as having high or low
responsibility for the cause of the presenting problem and at the same time be
expected to have either high or low responsibility for the resolution of the
problem. Thus, by crossing the two attributional dimensions, four distinct
attributional combinations in psychotherapy can be derived.
ATTRIBUTIONS
OF RESPONSIBILITY AND FOUR MODELS OF HELPING
Both
theoretical (Brickman et al., 1982) and empirical (Rabinowitz, 1979)
investigations have argued that each of four attributional combinations defines
a particular approach to helping. The attributional combinations for presenting
problems are high causal responsibility-high solution responsibility, low causal
responsibility-high solution responsibility, low causal responsibility-low
solution responsibility, and high causal responsibility-low solution
responsibility. Each model embodies a specific helping ideology that in turn
determines: (1) the characterization of clients, (2) the essential agents of
change, and (3) the intervention strategy. Each of these models appears to be
internally consistent and incompatible with the others. The models are described
most fully in Brickman et al. (1982) and are summarized here in Table 7-1. We
will first briefly describe the general characteristics of each model.
MORAL
MODEL
Attributing
responsibility for both the cause and solution of the problem to potential
clients characterizes the moral model of treatment. At the beginning of the
century, treatment of alcoholics and mental patients was guided by this model.
These groups were generally viewed as responsible for their problems and for
getting better. When help is given under moral model assumptions, it is the kind
of help that motivates or reminds the person to accept responsibility.
|
TABLE 7.1: Consequences
of Attributions of Responsibility in Four Models of Helping and Coping |
||
|
Attributions to
self of responsibility for
problem |
Attributions to
self of responsibility
for solution |
|
|
HIGH |
HIGH (Moral model) |
Low (Enlightenment
model) |
|
Perception of self Actions expected
of self Others besides
self who must act Actions expected
of others Implicit view of
human nature Pathology |
Lazy Striving Peers Exhortation Strong Loneliness |
Guilty Submission Authorities Discipline Bad Fanaticism |
|
LOW |
(Compensatory
model) |
(Medical model) |
|
Perception of self Actions expected
of self Others besides
self who must act Actions expected
of others Implicit view of
human nature Pathology |
Deprived Assertion Subordinates Mobilization Good Alienation |
Ill Acceptance Experts Treatment Weak Dependency |
for
getting in and out of trouble and to take control of his or her life. Potential
clients are considered to be unaware that their own actions or perceptions are
at the heart of the problem, or stubborn in their refusal to relinquish these
self-defeating actions or perceptions. Helpers' interventions can best be
described as motivating or exhorting clients to change themselves.
The moral model is presently exemplified in the
vast array of popular "how to" books, newspaper advice columns, and
radio phone-in shows. Readers and listeners are generally shown how they have
caused or compounded their problems and what they can do to solve or improve the
problem. But the most dramatic illustration of the moral model of helping is the
formerly fashionable program of Erhard Seminars Training, or est (Brewer, 1975;
Frederick, 1974). The primary message to est participants is that they are
"deficient" for not having realized that they are totally responsible
for everything they ever have been or will be.
COMPENSATORY
MODEL
The compensatory model of helping does not
attribute responsibility to people for the cause of their problem, but expects
them, after help is delivered, to take responsibility for the solution to it.
The help is compensatory in the sense that it requires clients to take steps to
compensate for their problems. Unlike the moral model, these problems are not
seen as caused by the client. Thus, in the compensatory model, clients are seen
as deprived or victimized by circumstances beyond their control, yet fully
responsible for finding a solution. Helpers are expected to provide resources,
training and opportunities to the client, who is expected, in turn, to use them
to craft a solution to the problem. Because this kind of help is goal-directed
and targeted at specific deficits, it is fixed and temporary in duration.
Examples of help in this model abound in
community-action programs and government-sponsored aid to underprivileged
minorities. Among psychotherapies, cognitive-behavioral treatments that
incorporate such elements as self-observation, cognitive restructuring,
contingency contracting, and skills training, are based on this model.
MEDICAL
MODEL
The case in which recipients of help are not
responsible for either the cause of their problem or the solution to it has come
to be known as the medical model of treatment. Problems are viewed as disorders
and clients as ill and unable to find solutions. The essential agents of change
in this model are expert helpers, who are specially trained to solve a
particular set of problems. The intervention requires skilled individuals who
provide the needed treatment or service to clients who could not provide for
themselves. Help in hospitals is the most familiar embodiment of the medical
model.
There are now numerous biological treatments that
attempt to relieve psychological disorders by altering some aspect of
physiology, particularly the central nervous system. These include psychoactive
drugs, electroconvulsive therapy, and the most radical of all biological
treatments, psychosurgery.
ENLIGHTENMENT
MODEL
In
this model, clients are held responsible for the cause of their problem, but not
for the solution of their problem. The name is derived from the essential
feature of help given under this model: Clients must come to see themselves as
the source of their problems, but someone or something outside of themselves as
their salvation.
The agent of change in this model is a
"force" or authority, often found in a select community of fellow and
former sufferers. This group is uniquely suited to provide the critical
resources of discipline and understanding. Having or having had the same problem
as the client, the group members can sympathize with the client's distress. At
the same time, their own experience with the problem gives them the knowledge
and legitimacy to impose the strict rules regarded as necessary to contain and
manage the problem.
Because the solution to the problem lies outside
the individual, it can be maintained only so long as the relationship with the
group is maintained. Thus, the treatment is relatively permanent. Past
recipients of help in this model often maintain their ties to the community and
thus continue to receive help and reaffirm their commitment to improvement by
helping others with the same problem. With no help, individuals are seen as
likely to continue their troubled behavior.
Some peer support groups for problems like
alcoholism, drug addiction, and overeating are examples of enlightenment model
helping. In each case, only when participants put their trust and their futures
in the therapeutic community can the problem be managed.
UNIQUE
ADVANTAGES OF THE HELPING MODEL
These
moral, compensatory, medical, and enlightenment models of help represent
distinct orientations. While it is ostensibly true that any of the four
approaches could be applied to any pr senting problem, each of the mo dols
occupies a particular domain in which it is uniquely valid and instrumental. In
this section, the unique advantages associated with each del will be discussed.
There is probably no model in which greater overall
potency is attributed to clients than in the moral one. Within this framework,
clients are held responsible for their pasts and futures, successes and
failures. By attributing this potency to clients, therapists reflect a belief in
the client's capacity to improve, a belief which in itself may cause an
amelioration of the presenting complaint. The extensive literature on
self-fulfilling prophecy lends further credence to this premise (Rosenthal &
Jacobson, 1968). Research further suggests that when clients are induced to view
themselves as responsible causal agents, it is more likely that any improvement
they do exhibit will be attributed to internal rather than external forces, and
thereby be more enduring (Davison & Valins, 1969; Miller, Brickman, and
Bolen, 1975).
In a related vein, when clients see themselves as
both the source of and solution to their problems, they may avoid the tendency
to adopt a "sick role" with its attendant manifestations of dependency
and malingering. They may also be less likely to rely unduly on external excuses
and supports. As Brickman et al. (1982) have contended, holding individuals
responsible for solutions (and, often times unfairly, for the causes of problems
as well) may be the most effective way to motivate them to make positive changes
that they may not otherwise be inclined to make. If, as in the case of a rape
victim, a certain measure of personal responsibility is assigned, the victim may
be more disposed to install better locks on doors, travel with a companion at
night, or move out of a dangerous neighborhood than those victims who view
themselves as powerless to prevent future rapes. As Janoff-Bulman (1979)
indicated, a majority of women who present themselves for rape counseling do in
fact assign some responsibility to themselves for the rape, often for imprudent
or unwise behavior.
According to existential philosophers, accepting
full responsibility for one's acts affords an individual not only a personal
dignity, but also the opportunity to discover the deepest meaning of existence.
Viktor Frankl, an existentially oriented psychiatrist and founder of
logotherapy, has stated (1959):
Ultimately, man should not ask what the meaning of
his life is, but rather must recognize that it is he who is asked. In a word,
each man is questioned by life, and he can only answer to life by answering for
his own life; to life he can only respond by being responsible. Thus,
logotherapy sees in responsibleness the very essence of human existence. (p.
172)
The moral model orientation offers many advantages
to therapists as well as clients. If help is given, but is insufficient or
falls, the failure cannot be attributed to the therapy. Further, when help does
occur in this model, it tends to be offered at the discretion of the therapist,
to be limited in scope and duration, and to be symbolic rather than material.
The moral model is expected to achieve greatest results when applied to those
clients who already possess the resources, talent, support, and opportunities to
better themselves, but who require a new perspective on their problems or a
motivational boost.
COMPENSATORY
MODEL
No
model takes a more auspicious view of the client's blameworthiness or prospects
than the compensatory model. While clients are not seen as the sources of their
own problems, they are perceived as being able to effect necessary changes in
their lives. Implicit in this model is a particularly optimistic view of the
client's potential: If just given the skills, resources, or opportunities, the
client will be successful and self-reliant (Karuza, Zevon, Rabinowitz, &
Brickman, 1982).
The attributional pattern of the compensatory model
(along with the enlightenment model) asks something of both clients and
therapists, and involves the two in a mutually responsive relationship.
Therapists are requested to contribute some combination of time, resources, and
opportunities to deserving clients in a manner that unites the therapist's
feelings of competence with the fate of the clients. While the therapist is
active in this form of treatment, the duration of the therapy is expected to be
fixed and temporary, because it is the client's role to implement the solution.
Because this model appears to have so much to
recommend it, we would expect it to work well with a large variety of clients
who can play a significant role in their treatment and whose need is primarily
to acquire skills.
MEDICAL
MODEL
As with the compensatory model, the medical model
orientation does not hold clients responsible for the causes of their problem
and thus relieves them of the guilt and anxiety that come from wondering what
they have done to bring on their difficulties. Medical ideology specifies that
help is to be given to all, regardless of the circumstances surrounding the
illness or injury, the personal or social characteristics of the needy, or even
how effective the help is likely to be. But because in the medical model clients
are also not held responsible for the solutions to their problems, there is
probably no model in which clients are seen as more passive and helpless, and
more needy of indefinite amounts of help.
The passivity on the part of clients, which is a
natural consequence of this model's assumptions, can make it easier to treat
certain disorders. If the solution to a problem requires treatment aimed at
specific organs or processes rather than a, he "whole person," medical
model assumptions may be ideal. Passivity on the part of the patients also makes
it easier to treat large numbers of patients in a relatively short period of
time, and to treat patients in institutional settings. Thus, the medical model
may constitute a highly cost-effective type of treatment. The features that make
patients easier to treat are, of course, advantageous to helpers in this model.
ENLIGHTENMENT
MODEL
How can holding people responsible for problems
which they are deemed incapable of solving be advantageous? For one thing,
attributing responsibility to clients implies a view of them as effective and
willful, if misguided, actors, a view which, we have argued, has its merits. On
the other hand, denying clients responsibility for improvement encourages a
perception of them as really needing, if not deserving, help. Its historic
popularity and current appeal may derive from the fact that, unlike the
compensatory model, the assumptions of the enlightenment model call for
interventions that keep clients under tight social control.
For another, admitting one's guilt may initially be
quite painful, but may ultimately bring a tremendous relief as one relaxes one's
pretenses. In addition, the realization that one cannot overcome one's problems
by oneself may further reduce discomfort. Encouraging clients to relinquish
notions of being able to solve their problems while at the same time holding
them responsible for the causes of the problem discourages clients from adopting
a "sick role."
Perhaps the greatest advantage of this model lies
in the special relationship of the client to the therapeutic community. In no
other model is the investment of helpers in the success of the client so large.
Indeed, when recipients in this model succeed, it is as if the helper's own
solution (and way of life) is vindicated.
When solutions require discipline on the part of
recipients, the difficult question of who has the right to impose this
discipline must be addressed. When problems require empathy or understanding,
the question of who can best empathize with recipients is a delicate one.
Clearly, individuals who have overcome the problem seem uniquely suited to
provide both discipline and understanding. In this connection, two of the most
robust findings in the helping literature are that people who have close
personal relationships with others cope better with their problems than those
who do not (e.g., Lowenthal & Haven, 1968; Moos & Mitchell, 1982) and
that similar others provide troubled people with special validation and support
(cf. Gottlieb, 1983). Individuals who would be expected to profit most from the
enlightenment model assumptions are those whose solutions require sustained
discipline and continued support from concerned others.
THE
MODELS AND MODES OF PSYCHOTHERAPY: AN ATTRIBUTIONAL ANALYSIS
The models discussed are seen as relatively pure
and general types, strongly determined by specific attributional patterns. As
such, we would not expect them to be neatly embodied in any existing form of
psychotherapy. Nonetheless, as previously noted, in all modes of psychotherapy
implicit and explicit assumptions about the client's responsibility for the
causes and solution to the presenting problem are made. Further, these
attributions seem to underlie and justify the intervention strategy.
Although there are hundreds of different types of
psychotherapies, we can isolate a few dominant modes that illustrate each of the
four models. First, however' a few caveats are in order. The mapping of
psychotherapies onto models is bound to be somewhat imprecise because, in many
cases, attributions of responsibility must be inferred from the therapy's
theoretical framework. Further, many of the dominant modes of therapy have
significant variations. At the very least, each type of psychotherapy may be
interpreted differently by its advocates, and each therapist's unique style and
approach to therapy may further contribute to variations within modes. Despite
these reservations, we feel that an understanding of psychotherapies may be
enhanced by considering the underlying attributional assumptions they make. For
heuristic purposes, then, we will consider four ideologically distinct
therapeutic approaches: rational-emotive therapy, behavior modification,
psychoanalysis, and therapeutic communities.
RATIONAL-EMOTIVE
THERAPY AS A MORAL MODEL TREATMENT
Rational-emotive therapy (RET), like several
existential therapies, appears to be a clear embodiment of the moral model.
Ellis (1962, 1973) rejected the medically toned term "psychotherapy"
to describe his approach in favor of descriptors such as "emotional
education."
This form of therapy sees clients as stubbornly
fixed in their self-defeating perceptions. Their cognitive errors and irrational
thoughts are seen as needing "vigorous and persistent attacks" by the
therapist (Ellis, 1973). RET is usually conducted in face-to-face settings in as
"efficient and rapid-fire a manner as the client can tolerate" (Ellis,
1973).
As we would expect in the case of a moral model
treatment, the notion of responsibility is central to Ellis's perception of the
causes and solutions to psychological problems. Ellis lays the responsibility
for the client's problems squarely on the client's shoulders. He states that
"It follows that feelings of worthlessness do not stem from the attitudes
that an individual's parents take toward him, but from his one tendency to take
these attitudes too seriously, to internalize them, then perpetuate them through
the years" (Ellis, 1973, p. 34).
Ellis is just as clear on the locus of the solution
to people's problems as he is on their cause. He writes:
To argue a better solution to the problem of his
own worth, the individual had better see his own propensities to exaggerate the
significance of others' attitudes toward him, and see clearly that he can
vigorously question, challenge, change, and minimize these tendencies toward
distorted thinking about himself and others.
Because, in moral model fashion, clients are seen
as completely responsible for their problems, treatment is didactic, consisting
mainly of persuasion attempts and candid feedback on the client's attempts at
change.
BEHAVIOR
MODIFICATION AS A COMPENSATORY MODEL TREATMENT
We regard the recently developed self-control and
social and cognitive learning therapies as examples of compensatory model
treatments. The following is Just a sampling of the therapies that have been
called self-control or cognitive learning therapies (cf. Mahoney & Arnkoff,
1978): self-monitoring, the strategy of recording one's habits;
self-reinforcement, the self-presentation of rewards contingent on performance
of some desired response; thought stopping, the procedure designed to terminate
unwanted cognitions; and coping skills therapy, a combination of procedures such
as relaxation training, meditation, and preperformance rehearsal. The therapies
that come under this umbrella are varied in their underlying assumptions and
their intervention strategies. What they share, however, is the belief that
maladaptive behavior and cognitive processes, no matter how developed, can be
treated by teaching the clients skills and techniques for rearranging the
environmental contingencies that affect their behavior.
Unlike radical behaviorists, who adopt the view
that the individual is but a pawn of external influences (Skinner, 1972),
utterly incapable of influencing his or her own actions, let alone being
responsible for them, cognitively oriented behavior therapists generally
advocate a position of "reciprocal determinism." This is the notion
that people are, in fact, partially free because environmental contingencies are
partly of their own making (Bandura, 1977). But whether a behaviorist supports
the position of environmental determinism or of a reciprocal relationship
between environment and behavior, virtually all behavior therapy techniques look
to faulty environmental contingencies as the source of the problem.
Consistent with this attribution, solutions are believed to follow a
simple rearrangement of the contingencies. The role of the behavior modifier is
critical, but limited to that of a "diagnostician-educator" (Mahoney
& Arnkoff, 1978). He or she assesses the maladaptive cognitive processes and
teaches the client how to alter the cognitions, behaviors, and patterns of
affect that are troublesome. Once taught how to recognize and control
maladaptive thoughts and behaviors, however, the client is often expected not
only to monitor his or her own behavior and to compare monitored performance to
goals or standards, but also to self-reward or self-criticize (Kanter, 1970).
PSYCHOANALYSIS
AS A MEDICAL MODEL TREATMENT
Traditional psychoanalysis holds that individuals
are at the mercy of forces which they cannot identify or understand, let alone
control. Human nature, the fallibility of parents, and the rigid demands of
civilized society all combine to create neurotic patterns in the individual.
More specifically, neuroses are seen as forced upon individuals by the peculiar
circumstances of their lives; too much or too little gratification, frustration,
condemnation, and so forth. It is one purpose of psychoanalysis to relieve
patients of their guilt and responsibility for their past. Discussing
psychoanalysis, Dollard and Miller (1950) point out:
From the patient's standpoint, the novelty of the
therapeutic situation lies in its permissiveness. The therapist is understanding
and friendly. He is willing, so far as he can, to look at matters from the
patient's side and make the best case for the patient's view of things. (p. 243)
The therapist takes the view that what is past had
to happen. The patient understands this acceptance as forgiveness, which in a
sense, it is.... If the recital is followed by condemnation and punishment, we
would not expect the effect of the confession to be therapeutic. (pp. 245-246)
It has been noted that simply being accepted for
psychoanalytic treatment is so reassuring to clients that it is immediately
followed by a decrease in symptomatology.
The solutions to the client's problems, like the
causes, are seen as lying entirely outside the patient. Learning, or any real
change in personality, comes about only through psychoanalysis. Since the
dynamics of behavior lie hidden in the unconscious, the unanalyzed client cannot
possibly know the real truth about himself or herself, despite his or her best
efforts and those of significant others. In fact, the analyst generally takes
the position that the client cannot and should not discuss his or her problems
with anyone else, as that would weaken the transference. Talking freely with the
analyst is regarded as therapeutically sufficient. Because they do not
adequately understand their motives, new clients are warned that they should
not, at least in the short run, make any major decisions or changes in their
lives without consulting their analyst.
Psychoanalysis may be distinguished from other
psychotherapies primarily by the therapist's interpretations of the client's
statements, and on the presumed necessity for the therapist to uncover the
client's drives and motives. Of course, the asymmetrical relationship between
analyst and patient facilitates this general relinquishing of responsibility by
the client. In typical medical model fashion, the therapist is viewed as an
expert in an esoteric area poorly understood by the uninitiated. The behaviors
of the client are viewed as "symptoms" of an underlying disorder.
THERAPEUTIC
COMMUNITIES AS ENLIGHTENMENT MODEL TREATMENTS
As we noted earlier, we see many group therapeutic
treatments as examples of help based on enlightenment model grounds. Obviously,
this form of treatment appears to be much more narrow and focused than the other
examples reviewed in this section. However, the model on which these groups are
based can be and appears to have been applied to a variety of specific problems,
including drug addiction (e.g., Daytop Village besity (e.g., Overeaters
Anonymous), and compulsive gambling (e.g., Gamblers Anonymous), and to general
problems in living. Two central features of all of these treatments can be
identified: (1) the existence of a special community of former or current
sufferers as the agents of change, specifically of emotional support and
discipline, and (2) the client's acceptance of and strict adherence to
enlightenment model assumptions about the causes of and solutions to the
problem.
People who join group therapeutic treatments are
either predisposed or socialized to accept full responsibility for their
problem. Any confession by a newcomer that attempts to share the blame with
family or friends is roundly denounced. At the same time that clients are
required to acknowledge their responsibility for the problem, they are also
required to admit that the problem is beyond their ability to solve or control.
They are compelled to acknowledge that forces beyond their control determine
their futures-the power embodied in the community of repentent and reformed
peers. It is only with the help of the community that group members' desire to
drink (or overeat or gamble, and so forth) can be overcome. The closely knit
community, with its rituals of confessions and testimonials, serves to reinforce
the notions of accepting responsibility for the solution.
IMPLICATIONS
OF AN ATTRIBUTIONAL ANALYSIS OF PSYCHOTHERAPY
We have detailed an attributional analysis of the
decision-making component in psychotherapy. In doing so, we have proposed that
various psychotherapeutic schools and their intervention strategies are
describable in terms of their underlying attributional assumptions. In this
section we will consider some of the implications our attributional analysis has
for the psychotherapy.
Specific psychotherapies may be differentially efficient and effective
for certain subsets of clients and disorders. We would further maintain that as
an alternative to arguing for the supremacy of one psychotherapy over another,
closer attention should be paid to considering the attributional assumptions of
the therapeutic school and how they are translated into the activity of the
therapist.
While at this juncture it is tempting to offer a
series of prescriptions of which therapy would be optimally effective for
particular disorders, we feel we must resist at present. Several factors lead us
to this position. For one, several attempts have been made at offering
prescriptive frameworks (e.g. Goldstein & Stein, 1976). In general, a mixed
picture has emerged. This lack of clarity is due, in a large measure, to a
realization of the complexity of the therapeutic effort. As was pointed out
previously, a host of factors, ranging from client and therapist characteristics
to the mediating goals of a particular therapeutic system, interact to produce
the structure and pace of therapy. In this context, a therapy's attributional
assumptions may be only one factor, albeit a potentially important one, that
governs the efficacy of the therapeutic intervention.
A second difficulty in offering prescriptive statements is the possibility of slippage between the therapist's ideological orientation and his or her actual practice of therapy. The therapist's expectancies and approaches may not directly mirror the formal school he or she represents. In a real sense, the therapist's experiences and worldview may dilute and distort the "pure" orientation of the formal therapeutic system. Indeed, research by Fiedler (1950) and Strupp (1955; Strupp & Wallach, 1973; Strupp & Williams, 1973) has shown that the distinction among therapists of different schools blurs when one investigates therapists who have been practicing for an extended period. These therapist factors, such as their worldview or expectations about clients and the presenting complaints, may affect the attributional process and color the instrumental judgments guiding the therapy. Any attempts to offer a convincing prescriptive framework should consider these therapist factors in conjunction with the formal tenets of the psychotherapeutic system. While such a full-blown analysis is beyond the scope of this chapter, it is our hope that research that considers both the formal and informal attributional processes in therapy (especially on the consequences of having an accurate mapping of the client's responsibility for the cause of the presenting complaint and for its solution) can offer the basis for prescriptive statements about therapeutic effectiveness.
PROBLEMS
IN ADOPTING AN ADEQUATE ATTRIBUTIONAL PERSPECTIVE
One important issue in this research is an adequate
definition of a "proper attribution" of the client's responsibility.
Should the client's beliefs about causality, the results of diagnostic
instruments, or the therapist's understanding of the situation serve as the
criterion? Further, the existence of causal chaining (Brickman, Ryan, &
Wortman, 1975) may compound the questions of finding an adequate attributional
framework. As these authors point out, there is no logical reason why
attributions about the causes of events should stop at any one point. For
example, an internal cause for a disorder (a disposition or trait) may itself be
attributed to an external cause, (for example, the child-rearing practices of an
individual's family). In a certain sense, it may be a matter of personal
preference as to where to look for the causes of particular behaviors or how far
one is willing to go before the "true" cause is found. The assumptions
of the therapeutic school and the helping model it embodies may artificially
direct the search for the causes and solutions of the problem. In practice,
though, the stopping point in the causal chain may be operationally determined
as the intervention strategy based on the set of attributions that first lead to
a desirable change in the client. We see these questions, however, as empirical
in their scope. Research exploring the relationship of client, therapist, and
"objectively" based attributions to the effectiveness of the therapy
is needed. On a theoretical level, however, we can specify certain factors that
may cloud the true attributional picture.
First, the therapist's allegiance to a particular
psychotherapeutic model may bias attributions about the cause of the client's
presenting complaint and the solution for that complaint. Acting upon these
attributional assumptions, the therapist may incorrectly define the etiology of
the client's problem. The resulting interventions may be inappropriately related
to the problem and, in the worst possible case, work against the client.
A related and complicating factor is the inherent
complexity of causal analysis. Nisbett and Ross (1980) address this issue in the
context of human inference; their arguments, however, directly apply to the
activity of the psychotherapist. Particularly relevant is the principle of
misguided parsimony, otherwise known as the "hydraulic" model of
causation. Drawing upon Mill (1843/1974) and Kanouse (1972), the authors state:
The pronounced availability effects on causal
attribution would appear to depend on the individual's willingness to be content
when a single sufficient cause has been adduced and to forego exhaustive
searches for further, potentially influential antecedents. That is, by
manipulating the causal factors that the person will notice or ponder first, one
can manipulate the person's ultimately preferred explanation for the event in
question. (p. 128)
Our contention is that, in psychotherapy, the
causal factors that are perceived first will be those most congruent with the
attributional perspective of the therapist.
A further source of attributional bias in therapy
may be the tendency of therapists to view their clients in a negative light
(Wills, 1978). A number of studies have shown that therapists and professional
help givers view clients as less adjusted (Wills, 1978), less capable of
improvement (Batson, O'Quin, & Pych, 1982), and more in need of help as
contrasted with individuals not seeking treatment and with the perceptions of
the clients themselves. This negative bias may shape and direct the therapist's
attributional judgments and lead him or her to see the client as less
responsible both for the cause of the presenting complaint and for its solution.
In terms of the analysis presented above, this lack of responsibility for cause
and solution is characteristic of the medical model orientation. In other words,
the negativity bias may cause the therapeutic endeavor to regress toward this
medical model orientation, which views the client as sick and dependent on the
therapist for amelioration of the problem. This negativity bias is a
therapist-specific factor that operates independently of any formal theoretical
orientation.
Wills suggests several causes for this bias. Of
particular importance is the fact that the clinician's training and experiences
may lead to a selective focus on the weakness and deficiencies of clients. Large
caseloads and their resulting time pressures may force the therapist to
concentrate on the problematic aspects of the client's behavior "because
these are most immediately relevant for ameliorating the client's presenting
problem" (Wills, 1978, p. 987). Certain personal or social characteristics
of clients, such as advanced age, appear to elicit among professional helpers
and observers alike unfavorable assumptions about the clients' prospects for
solving their problems or controlling their futures (Karuza, Zevon, &
Rabinowitz, 1986; Zevon, Karuza, & Brickman, 1982). In addition, the
therapist's training may predispose him or her to identify negative or
unpleasant facts in the client's background as playing an important etiological
role (Meehl, 1973).
This negativity bias may be particularly
deleterious when one considers that it may work against psychotherapies that
reflect the moral, compensatory, or enlightenment models. The therapist may be
caught between the attributional assumptions reflected in the therapeutic
orientation and his or her personal attributional bias in regard to the client's
responsibility. The negative bias may become prepotent for the therapist and
result in the therapy drifting toward medical model attributional assumptions
and associated intervention strategies.
Also contributing toward this drift is a
corresponding therapist "burnout" effect. The initial image of the
client as a troubled and overwhelmed individual stands in contrast to the image
of the therapist as a responsible, competent expert. If the therapist were not
perceived in this way, the client would presumably not seek his or her help, and
the therapist would not inspire the confidence needed for a successful
therapeutic interaction (Frank 1973). At least relative to the clients, then,
therapists may initially view themselves as being in control of their lives,
responsible for their problems and solutions. With competence attributed to them
and deficits attributed to clients, they may also view themselves as responsible
for clients and the course of therapy.
However, all of the factors that make it difficult
for clients in psychotherapy to improve, including the simple intractability of
some problems, make it easy for therapists to change their perceptions of
themselves as well as their clients. When help is wholly or partly unsuccessful,
there is some evidence to suggest that therapists tend to minimize their own
responsibility for clients and heighten their sense of client's responsibility
for themselves (Maslach, 1978; Wills, 1978). The therapist who has devoted much
time and effort to an unsuccessful case may come to believe that the client is
at fault for the failure to help because he or she is stubborn, uncooperative,
irresponsible, or incorrigible. At the same time, the therapist may come to feel
frustrated and helpless for being ineffective (Maslach, 1978). In the end,
especially with unsuccessful cases, the attributional orientation of the
therapist is likely to be the reverse of what it was at the start of therapy.
Therapists may see clients as responsible for the causes of their problems and
their failure to improve. On the other hand, they may see themselves as not
responsible for their client's problems or for solving those problems.
PROCESS
REDEFINED
In the beginning, we viewed psychotherapy as a
problem-solving process in which the therapist's attributional judgments played
an important role in the dynamic process of defining the client's presenting
complaint, setting the goals of therapy, and crafting a solution for the
client's problem. In our considerations of the attributional bases of various
psychotherapeutic systems, much of this process view was absent. For the sake of
expediency, we intentionally adopted a static compartmentalized view of these
components of psychotherapy. We did so for two reasons: first, to isolate and
highlight the particular attributional orientation of each therapy, and, second,
to illustrate how the attributional orientation defines and is mirrored in the
actual intervention strategy of the therapist. In vivo, psychotherapy is an
ongoing process that ideally leads the client through a series of cognitive/
emotional changes. As therapy progresses, changes occur in the client-therapist
relationship, the client's self-disclosure (Jourard, 1964), self-perceptions,
self-examination, and behavior. For each psychotherapeutic school, the
attributional assumptions not only define the nature of the presenting
complaint, but offer the therapist a criterion, or definition of a fully
functioning, adjusted client. The thrust of the therapeutic endeavor is to lead
the client to this goal. In this traditional sense, the process of therapy is
theoretically canalized.
At this point, we would like to reconsider the
process notion in therapy from an admittedly speculative perspective. As the
therapy progresses and interventions are implemented, changes may occur in the
client's behavior and his or her verbal reports, changes that may be indicative
of a shift in the client's view of his or her responsibility for past, present,
and future actions. The ability and tendency of the therapist to recognize these
changes and reevaluate the client's responsibility for his or her actions may be
limited by the directional momentum of the therapy. As indicated above, the
therapist may adhere to a specific set of attributions about the client that are
dictated by the therapist's theoretical orientation. Thus, the therapist may
fail to recognize change in the client, incorrectly attribute causes for a
particular behavior of the client, distort the potentials of the client, or
continue with interventions that are ineffective or irrelevant. When clients do
not fit the attributional profile dictated by the therapeutic system, therapists
may label the client as uncooperative or incompetent, or the therapists may
start to feel that they are failing. This may set the stage for the negativity
bias in viewing clients or, in the long run, to therapist "burn-out."
Conversely, if the client is initially
"cooperative" and responds to the therapy early on with an alleviation
of symptoms, the therapist may be seduced into accepting the attributional
assumption of the therapy as an absolute. Thus, the therapist may set up
expectancies for the client that mirror the attributional ideology of the
therapeutic system, expectancies that may be unrealistically accepted and
embodied by the client. Further, the therapist, upon seeing the preliminary
success of the treatment, may be tempted to continue treating the client with
the same intervention strategy that brought about the initial change, even
though it is based on erroneous assumptions and is unlikely to be helpful in the
long run.
Erroneous attributions about the client's ability
to take responsibility for solving a problem may underlie some current
approaches to the treatment of alcoholism. A controversial issue in the
treatment of alcohol abuse is whether alcoholics can learn to control their
drinking so that they can drink in moderation. The prospect of being able to
"drink socially" is appealing to many alcoholics and attracts them to
treatment (Pomerleau, Pertschuk, Adkins, Brady, 1978). Several multimodal
cognitive-behavior therapies have been developed to promote controlled drinking
among alcoholics. These therapies embody the characteristically optimistic
compensatory model assumptions that once clients acquire the knowledge, skills,
and resources to control their drinking, they can become responsible
"social drinkers." To this end, clients receive education about the
effects of alcohol and how to discriminate their blood alcohol level, group
therapy, self-management skills, job-seeking and interpersonal skills training,
social drinking practice sessions and relaxation training. Despite reports of
short-term success with such programs, there is no evidence to suggest that they
have any long-term success (Armor, Polich, & Stambu, 1976; Foy, Nunn, &
Rychtarik, 1984) or that their orientation to alcoholism is valid over time.
In redefining the "process" in
psychotherapy, we are contending that therapy naturally affects the client's and
therapist's view of the client's responsibility. We propose that this fluidity
of attributional perspective may be adaptive, and offer it as an alternative to
the more intransient attributional stance associated with existing theories of
psychotherapy. Specifically, we see that each of the four attributional views of
the client may be valid at various steps in the course of therapy. As clients
change, the old set of attributions guiding the therapist's activities may no
longer be relevant, while new assumptions of the cause of the client's present
and future behavior may become valid. Instead of locking the client into a fixed
set of attributions, we are arguing that therapists should be flexible,
reevaluating clients periodically and implementing interventions that are in
keeping with the changes in the clients' perceived responsibility for their
behavior and in their newly developing potentials. In other words, we are
proposing a guided eclecticism in which the attributional orientations and
interventions of each therapeutic model are employed. As therapy progresses,
instead of approaching the client from a particular therapeutic vantage point, a
shifting perspective may better serve the goals of psychotherapy.
To illustrate this point, let us consider a
rational-emotive approach, which reflects the moral model of helping. A client,
when he or she first approaches the therapist, may indeed feel helpless and
dependent, more typical of someone who fits a medical model orientation. The
first task of the therapist, rather than preaching self-reliance, might be to
help organize the client's life, offering suggestions and directions on how to
take care of some of the pressing problems of the client (e.g., "Whom
should I see for a divorce?" or "How can I avoid confronting my
mother?"). As the client gets on firmer footing, the therapist may then
shift to a compensatory approach, training the client in skills needed to cope
with the demands of life (e.g., assertiveness training) and reinforcing the
client's sense of responsibility for his or her future. After these skills have
been acquired, the therapist may be better able to implement the
rational-emotive approach, that is, to encourage and motivate the client to take
control over his or her life.
An example of this can be found by considering the
"paradox of depression." According to Abramson and Sackeirn (1977),
depressed people blame themselves for their own unhappiness and that which they
inflict on others, yet feel helpless to do anything about the situation. From
the vantage point of the models, the paradox disappears. Feelings of
responsibility for problems and solutions, for pasts and futures, need not be
correlated. It seems entirely possible that people might feel responsible for
the origin of the problem, but not for the solution.
When people become stuck in this attributional set,
relief may come simply by moving them out of this set-to any of the others. If
it is recognized that a central problem with depression is precisely this
pattern of attributions, then helping might take the form of changing people's
attitudes about the origin or the solution to the Problem. The recent popularity
of cognitively oriented therapies such as Beck's (1976) for problems like
depression may indicate the virtues of
demanding more active and responsible behavior on the part of the client.
Increasingly, it is becoming clear that more than
half of all visits to physicians are for conditions with no known physical basis
(Cummings & Follette, 1976). Many of the complaints brought to medical
doctors are stress related illnesses or physical symptoms caused by
psychological problems. Doctors and patients who pursue biological explanations
for what are essentially emotional problems and look to a pill, a shot, or an
operation to cure the malady may be incorrectly applying the medical model to
the presenting problem. Mounting evidence suggests that simply inducing these
patients to discuss their problems and feelings and enter short- or long-term
psychotherapy can have lasting positive effects on their physical health
(Cummings & Follette, 1976; Jones & Vischi, 1979). One of the most
commonly offered explanations for this consistent finding is that the
psychotherapeutic and behavioral treatments make patients more active and
responsible participants in their own care. Again, it appears that guiding
clients to adopt a new orientation to long-standing problems can be quite
beneficial.
By following a more fluid or cyclic approach, the
advantages of each therapy can be used to build a more comprehensive and
effective therapeutic effort. At the same time, the problems associated with a
unidirectional attributional approach may be avoided. What we are proposing is
theoretical in nature, and perhaps anathema to theoretical purists. However, we
hope that a consideration of the attributional foundations of psychotherapy and
the dynamic changes in attributions inherent in therapy will stimulate research
in social and clinical psychology that, in the long run, will inform and improve
the therapeutic process.