DRAFT April 17th 2020
The three principal schools of psychotherapy came about at nearly the same time. In 1900 Sigmund Freud published his classic Interpretation of Dreams that launched the Psychodynamic School. This school argued that human beings were principally driven by sexual and aggressive drives, what he called Drive Theory. Jacob Moreno profoundly disagreed and by 1908 was arguing for a Humanistic approach that respected the power and the ability of the person to change and to do their own healing. He was the first person to apply group psychotherapy with children based on existential principles, meaning principles informed by the here and now, what is happening today and what we can change today. Both Freud and Moreno were contradicted by Pavlov who since 1902 had insisted that human beings were at the mercy of external stimuli and could be conditioned, like his famous dogs, to behave as if they had no freewill. (For a more detailed explanation see The Handbook of Psychotherapy (1994) by Petruska Clarkson and Michael Pokorny, pps. 18 to 24.)
So, within the space of a single decade, three substantial but mostly contradictory explanations of human behaviour were taking form that would compete for worldwide acceptance and validation over the next hundred years. Practitioners would train and then practice according to the school they subscribed to. Patients with exactly the same presenting problems could be diagnosed and then treated in three completely different and possibly contradicting ways.
However, a Fourth School has emerged in the last decade or so by psychotherapists taking from the other three what they have found worked well and so made sense. This school is informally known as the integrative or pluralistic psychotherapy movement. I sometimes explain when I am teaching that the circle of theories I draw on the whiteboard is like an artist’s palette of colours that I dip into, sometime mix, according to the situation I am working in. Over the years I have refined the amount of colours I need, the essential ones. These are the one I teach and this chapter will deal with humanistic theories, the ones that mostly concern feelings.
Abraham Maslow is usually credited with founding the Humanistic School, although he really built on the work of Moreno. Maslow profoundly disagreed with Freud’s rather negative view of humans, hardly living, mostly just struggling to survive by repressing their primitive, anti-social urges. He also disagreed with John B.Watson, a key proponent of the Cognitive Behaviour school, who took the position that “the behaviour of man and the behaviour of animals must be considered on the same plane”.
Maslow did credit Freud for the work he had done understanding people who were ill, but he decided to concentrate on people who had lived very successful lives and had contributed to society. In the process he created his Hierarchy of Needs, which explains how people need to have their needs met, in a rising order of priority, in order to self-actualise, to become the person they were born to become. Foster carers readily see how they meet the basic needs of the children they care for, such as food, shelter, clothes; then security, and self esteem needs. And I think that this is where many carers can unfortunately stop, as this is where their needs may have stopped being met. How can they give what they don’t have? Perhaps they unconsciously foster in order to get love and a sense of meaning in their lives. This is not a bad thing in itself but once recognised it should lead the carer to their own therapy. They could then return to the task with renewed energy and effectiveness.
One question I often ask children and young people in care is whether they understand why they are in care. A surprising many don’t fully or clearly. They may be having their basic needs met, but how can they relax and feel secure if it feels temporary or could change the next time an official person turns up? How can they feel secure if they are having to attend family access against their wishes, where they may be told that they will be coming home soon? What Maslow tells us is that we cannot jump an unmet step on the hierarchy to a higher need, but are doomed to remain on that step until it is met. Might it make sense to check in with Maslow’s Hierarchy at every child in care review?
Another key theorist from the humanistic school is Elizabeth Kubler Ross, whose Quadrant theory is simpler but still chimes neatly with Maslow’s Hierarchy of Needs. Imagine drawing a circle and dividing it into four equal quadrants. Assuming that the average happy child life starts in the top right hand quadrant, who has all his or her physical needs met, will then move into the emotional quadrant. All things going well, at the age of about four or five, the child will go to school and will need to activate the Left brain in order to process all this new information and experiences in this, the intellectual quadrant. Come secondary or high school, the child will move into the final quadrant, the philosophical one, begin to wonder what life is all about and where he or she fits in this world. Towards the end of life, we all probably end up back in the first quadrant again, dependent and needing to have our physical needs met once again.
When I share this theory with foster carers, many recognise that some of the older children in their care are still stuck in the physical quadrant, preoccupied with food and perhaps stealing and hoarding food. They often see this as a problem to solve. I see it as an opportunity to address deficits in the child’s earliest years, maybe by offering the child a therapeutic adaptation to that need, a special snack or drink when they come home from school, at bedtime or at a time of their choosing.
Sadly, children will also be described as ‘needy’ and ‘clingy’, as if they should have moved on from this ‘baby’ stage long also. Better to accept that where everyone is now is where they need to be. Otherwise we cannot see their needs and so offer the comfort and closeness that was missed out on. One option to address deficits is Special Time, offered to the child like so:
How about we put aside an hour every week, just for you and me. I will turn off my phone and tell everyone else else I am very busy. Then you decide what we do in that time. You can be in charge of that. But we have to stop after an hour. What do you say?
I have yet to hear of a child or young person being offered this adaptation and saying no to it. Maslow stressed that humans are intrinsically good, have huge potential but also have needs, like a car needs fuel. Expecting a child to be happy and well behaved at school in the intellectual quadrant is futile when it has unmet needs left over from the emotional quadrant, and maybe even from the physical quadrant.
The second Kubler Ross theory I find essential is her famous Stages of Grief theory. She developed this while working with people who were dying. She observed that they seemed to approach the certainty of death in very similar ways. and to go through similar stages. These stages are also similar in the event of any great loss, marriage breakdown, redundancy. Children must experience great bereavement on being separated from their families, whether it was seen by other as a good thing or not.
Kubler Ross, towards the end of her own life, regretted that her 5 stages were taken too literally, that you did one, then the next. This can be used against grieving people, come on, you’ve done that one, move on to the next! I also use my own version of the stages that may not be kosher but they work for me.
Certainly, however, at the beginning of the grief process there is almost always disbelief, this can’t be happening!, denial. In the case of tragic news, denial is a healthy defence mechanism that protects the fragile psyche from breakdown, giving it some time to adjust and absorb the new reality.
Then usually comes anger that this is happening, and how unfair it is. The anger must be directed somewhere, often unfairly. Could Melanie still be stuck in this angry phase, striking out when her deep sadness and loss is restimulated? She may only acknowledge this and eventually move on if she is lovingly asked why she is so angry, or at least allowed to be angry. Coming back furious from school might be an excellent opportunity to help her with her leftover grief.
Some bereaved people may become unreasonably guilty about the loss, blaming themselves. Friends and relations will usually want to help them to feel less guilty and try to make them feel better. But Kubler Ross proposed that grieving is a natural process and that the grieving person should simply be lovingly supported to move through the process at their own time and pace.
Some people bargain, if this doesn’t happen, I will never smoke or drink again. Kubler Ross found this stage very common among patients facing their own deaths and wanting to avoid it any way possible.
I believe that once the affected person has eventually moved on from being angry or guilty, or both, they can then begin the real work of the process which is to actually grieve, meaning to cry, be upset, feel the terrible gut-wrenching pain of the loss. Some people might stay in anger and guilt as a way of avoiding this stage. Children in care may need to stay in those early unproductive stages because they have no people to support them through this ordeal. Sadly, while we all want the cure, few people can tolerate the messy healing process which can snotty, rude, tearful, angry. I don’t think it makes sense to call this stage Depression as it can be very active, volatile, churning and bewildering.
But eventually we get to the bottom, with a gentle, reassuring bump and realise that it doesn’t go any deeper or get any worse. And then we begin to float back to the surface and begin the last stage, which is readjusting to life without who or what we lost, re-locating that person within us, close to our heart. Kubler Ross liked to say that all terrible loss and bereavement brings to each of us an unexpected gift if we survive the pain. Many people claim they are left with a strong sense of strength from having come through in good shape and that makes living the rest of their lives easier and more satisfying.
Sadly, many children, perhaps like Melanie, never get to get on with the rest of their lives. Kubler Ross believed that unless we attend to our own unfinished grief work, as she called it, we will remain frightened of grief and useless to those who need to grieve. Her profound point, however, was that people don’t really need help to grieve properly. The process is natural and inevitable as long as it is not interfered with or shut down. It only needs to be trusted, and nature allowed to do its work.
What the effective psychotherapist most wants the hurt and damaged client to do in a session is to discharge the hurt, by crying, being angry, talking rapidly but without repetition, being red in the face, upset, snotty and often messy. We know that being rational and in the head all the time is going nowhere, and is probably avoiding getting to the pain. We qualified as psychotherapists by going through years of this grieving process ourselves. We looked good in training when our fellow student ‘clients’ cried, and when we cried. It showed we were self-actualising, becoming our real selves and letting go unhelpful defences.
But the average loving carer can often mistake the crying, angry person in their care as being in pain and will intuitively want to stop that pain and make them happy. The elderly person in the care home, crying because her son can’t visit, is likely to be cheered up, have a nice cup of tea, he’ll be here next time, watch a bit of telly, distracted from from the grief rather than be allowed to grieve, and heal.
It may also be that the sensible and intuitive reaction to Melanie’s angry outburst could be to try and calm her down. But maybe also because it is frightening and upsetting for us, rather than good for her. The counter-intuitive and therapeutic response (after you take a deep breath) could be to accept that sadly this is where Melanie is now, perhaps even stuck in the angry stage of her grieving process. You would then simply neither interfere, or intervene, but instead allow her to be angry. If anger is allowed to be expressed in a safe way, what inevitably follows are tears and healing.
To see and hear Kubler Ross explaining the quadrant, click this link.
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