A BACKWARD LEAP INTO THE FUTURE
or Chutzpah's Laws
GERALD A. KLEE, M.D.
Professor of Psychiatry, Temple University School of Medicine
Reprinted from AMERICAN JOURNAL OF PSYCHOTHERAPY,
Vol. XXII, No.4, pages 674-683, October 1968
A BACKWARD LEAP INTO THE FUTURE
By Professor Timothy Malarkey, Director, Blarney Institute for Human Affairs
[1] Based on the Fifth Academic Lecture of the American Society for Scientific Psychotherapy by Professor Timothy Malarkey. Dr. Klee obtained a copy of the manuscript which he felt deserved wider attention.
[2] Supported by the Surplus Funds Disposal Branch of the Northern Health Institute
Philadelphia
,
Ladies and gentlemen. It is a great honor to have the privilege of addressing this distinguished audience. The topic for this paper is of far reaching significance in human affairs. I am referring to the field traditionally known as psychotherapy. As you will see, this name is no longer descriptive of what has come to be the corrective scientific manipulation of disturbed human behavior. We will retain use of the word "psychotherapy" a little longer, however, for literary and sentimental reasons. If nothing else, the term has historical significance, since it serves as a reminder of the mythopoetic origins of our field. We may look back with some nostalgia to the early gropings of the pioneers in psychotherapy, whose zeal was unfortunately not matched by adequate conceptualizations or scientific methodology. While their theorizing was obscure, their methods primitive, and their results unpredictable, they succeeded in keeping the spark alive until such time as the field was ready for genuine scientific development. We may even credit them with having laid a patchy groundwork, upon which later advances could be built. So much for the past. We may respect it, even honor it, but we must not allow ourselves to be trapped by it.
I will attempt to summarize certain aspects of the years of painst
As
you will see, the over-all pattern, or architecture, which was followed in the
course of our work, consisted of a series of analyses and syntheses, at ever
higher levels. We began with the raw material of psychotherapy in its pristine
form, m
A list of 130 characteristics would be hard to work with, therefore, through factor analysis, and other analytic techniques, we succeeded in condensing these 130 characteristics to 13, somewhat more generic, though not entirely discrete qualities. These were as follows: (1) Nurturance, (2) Warmth, (3) Integrity, (4) Stability, (5) Intuitiveness, (6) Communicativeness, (7) Responsivity, (8) Leadership, (9) Control, (10) Permissiveness, (11) Persistence, (12) Dependability, (13) Penetrance. Each of these therapist traits corresponded with reciprocal traits requiring modification in behaviorally disturbed patients. For example: Integrity corresponds with the reciprocal patient trait of Mistrust; and Penetrance corresponds with the reciprocal patient trait of Defensiveness, and so on. These therapist traits were identified by means of symbols in cuneiform script in order to avoid the confusion and ambiguity associated with purely verbal denotations. For the purpose of discussion, however, I will continue to employ the loose descriptive terms.
Having identified the therapist traits associated with effectiveness, the next task was to try to tease them apart, and test them separately for their effectiveness in therapy. The most natural way to do so would be to find therapists who rated unusually high for the individual trait under consideration, and relatively low on the others. Fortunately, we were able to do just this, since we had an unusually large therapist pool from which to draw.
I
will now present a few examples from this phase of our work. For the trait of
Nurturance, Dr. Lydia Dumpling was found to have ratings far beyond any other
therapist we had studied. None of her scores for the other traits exceeded the
mean for the total group. Thus, she was an ideal candidate for a study of the
effectiveness of the Nurturance trait in psychotherapy. The trait of Nurturance
is defined as one representing a tendency toward unqualified giving, usually in
an abstract rather than a literal sense. Dr. Dumpling, who overflowed with this
quality, chose to manifest it on both abstract and concrete levels in her
therapeutic work. Thus, she interspersed verbal interactions with frequent
feedings of the patient. The patient was asked to prepare a list of ten most
preferred dishes; prior to therapeutic sessions, the patient was fasted for a
period of 12 hours, and then one or another of these dishes, carefully prepared,
was fed directly to the patient by Dr. Dumpling herself.
* A variety of patient ratings was conducted prior to, during, and
following the six-week therapy period. By the end of the second week of therapy,
Dr. Dumpling's patients began to show dramatic psychological and physiological
effects, which could only be attributed to her therapeutic intervention.
Salivary and gastric secretions were found to increase markedly as Dr. Dumpling
approached the patient. Psychological factors also began to show definite and
persistent changes in a beneficial direction. As the experiment, or therapy,
progressed, patients began to show anticipatory increases in salivary and
gastric secretions within one hour prior to their appointment times with Dr.
Dumpling. Next, it was found that brief exposure to a tape recording of Dr.
Dumpling's spoken voice, or visual exposure of her picture, was sufficient to
produce similar effects. Soon afterward, it was found that further symbolic
generalization could be demonstrated, since the same physiologic changes could t
Marked improvements were found on a number of psychological measures in the patient group. In the foreground were improvements in ratings for emptiness, loneliness, and isolation. A radiation effect to other symptoms was also found, however, for this and later, for the other therapies. Thus, feelings of inadequacy, low self-esteem and depression also showed marked improvements. A number of other psychological measures showed lesser degrees of therapeutic change. Over-all, 90% of Dr. Dumpling's patient group showed significant degrees of improvement so that a mere 10% of patients proved refractory to this form of treatment. This compares very favorably with a 50% spontaneous improvement rate in untreated patients, and a 50% to 70% improvement rate when the results of effective and ineffective therapists are lumped together. Of those who improved, one-third were markedly improved, one-third moderately improved, and one-third were slightly improved. As Dr. Dumpling subsequently demonstrated, the results can be even better with more intensive treatment.
While Dr. Dumpling was producing these remarkable results with Nurturance therapy, another sample of patients was being treated by a warm therapist in the person of Dr. Hans Gemütlichs. Dr. Gemütlich was an irrepressibly warm and jolly therapist. His enthusiasm and affability could not be dampened by even the most sullen, depressed, or resistant patient. I will spare you the details of all the experimental and evaluative methodology which was conducted by the research group in conjunction with Dr Gemütlich's work. It was found that therapist warmth was also highly effective in producing therapeutic changes in patients. The results were strikingly similar to those for Nurturance therapy. Nearly all patients showed some degree of improvement, in most cases of a high degree. Improvements were found especially on scores for self-image, depression, hopelessness, loneliness, and unrelatedness.
A parallel study for the effect of Therapist Integrity was conducted by Dr. Fritz Wahrheit. While he did not have much else, Dr. Wahrheit, in his general demeanor, and in all of his dealings with patients, represented the ultimate in uprightness, probity, and sincerity. There can be no doubt that this was not wasted on his patients, since again, nearly all showed significant degrees of improvement. Most notable were the changes in scores for trust, and feelings of relatedness, first of all to Dr. Wahrheit, but also generalized to other people.
For each of these therapies, therapeutic improvement was most marked for target symptoms, but as I have mentioned, there was a radiation effect of varying degrees to other areas of symptomatology. Thus, it was found that each of the distinctive forms of therapy produced quantitatively identical and qualitatively similar therapeutic results. The qualitative differences, as already noted, were in the areas of target symptoms, associated with each of the specific therapies. The radiation effects, however, produced considerable overlap and similarity in results. In all cases there were behavioral changes corresponding to symptomatic improvement.
Each of the other traits was tested in similar fashion by therapists who rated highly for the trait under study. In nearly every case, the results were parallel to those that I have already described. There was one exception, however. The trait of therapist Penetrance as tested by Dr. Lucifer Needle, (although successful in piercing patients' defenses) was not found to produce significantly beneficial results. Indeed, when unaccompanied by warmth, or some other positive trait, it was found to be actually detrimental.
For every group of patients treated, there were two control groups. One of these received no treatment, while the other was treated by a therapist similar to his counterpart in every respect, except for the relative absence of the trait under study. Patients treated by this latter group of therapists had the worst outcomes of all, while outcomes for the no treatment group were intermediate. Subsequently, the entire study was replicated, using different groups of therapists and patients, and the results were found to be almost identical.
We found ourselves then, in the possession of extraordinary data with far reaching implications; but our work was far from finished. The logical next step was to link these positive traits in the treatment of individual patients. A plan was drawn up to treat a group of more seriously disturbed and difficult patients in series, each patient receiving two sessions of each type of therapy. Thus, an individual patient would experience Nurturance therapy, followed by Warmth therapy, then Integrity therapy, and so on. Although somewhat cumbersome the plan was certainly feasible. At this point, however, serendipity changed our approach entirely. We discovered in our midst a remarkable individual in the person of Dr. Sven Smorgasbord, who had recently joined our staff. Dr. Smorgasbord was found to possess all of the positive therapist traits, in high degree. This good fortune permitted us to replace the assembly line technique with a much simpler one. Dr. Smorgasbord agreed to treat a sample of 50 of our most difficult patients over a period of time. The results exceeded even our most hopeful predictions. Ninety-five per cent of the patients treated by Dr. Smorgasbord showed highly significant improvement on all measures. Moreover, these improvements persisted during a two-year follow-up period.
These
results were highly gratifying, to say the least. Not only was it possible to
produce therapeutic results far superior to anything previously known, but we
also had succeeded in identifying the factors which were responsible. The
guesswork was t
We were pleased, but not completely satisfied. We could afford to waste no time in resting upon our laurels. Up to this point we had depended upon born therapists. The vast, almost limitless, requirements for psychotherapy, which exist in society at large, could never be met by the handful of professional therapists available, and certainly not by the few among them who possessed natural therapeutic gifts. Further steps were necessary in order to ensure that our discoveries would be made available to mankind at large.
Dr. Chutzpah was the first to point out that there would never be enough professional therapists to satisfy the great public need and demand. It was inevitable then, that we should turn our attention, and our energy, to the training of lay persons for the great work which lay ahead. At first, we selected our students from mature college graduates who rated high for therapeutic traits as well as for intelligence and motivation, but very quickly we recognized that such qualifications were unnecessary. Soon we became quite satisfied with students who were high school graduates or less, and who in most respects, were fairly representative of the population at large. The chief requirement was the possession of one or more rudimentary therapeutic traits, which could be refined by training.
The training program also underwent rapid modifications as we proceeded. Initially, a lengthy series of didactic sessions, seminars, and supervised therapy was employed. This proved cumbersome, tedious, and time consuming, although its effectiveness was beyond dispute. These students eventually developed the ability to apply their therapeutic traits, and their therapeutic effectiveness compared favorably with that of our best professionals.
The need to shorten and streamline the training course led to the development of programmed instruction for our students, utilizing the very latest techniques in this field, plus a number of innovations of our own. The entire training course was telescoped into an intensive eight-week program. Once the programmed instruction was developed, the number of students was limited only by the amount of equipment which we could provide. For over a year we turned out Dumplings, Gemütlichs and so forth, by the hundreds. They were all absorbed by a variety of mental health facilities as rapidly as we could produce them.
We might well have remained content with this widely acclaimed achievement and
devoted our efforts thereafter to the continuation of the program which we had
so successfully developed. If we had done so we would have missed still greater
opportunities. Fortunately we did not. In a brilliant flash of insight, Dr.
Chutzpah saw a chance to cut out still another step in m
His reasoning was that, if we can provide programmed instruction for the training of therapists with such relative ease, why not skip a step by eliminating therapists entirely, and treating patients directly by the use of methods analogous to those employed in the training of therapists? This insight proved to be both timely and fruitful. Periodically, in the course of scientific development, a number of seemingly independent streams of investigation will suddenly coalesce to form a mighty river, which permanently alters the course of scientific and human development. This was just such a time.
A considerable amount of groundwork had to be laid in order to translate therapist behaviors into operational terms, and to tease out the many discrete factors which made them effective. Powerful statistical methods were brought to bear upon the data with which we had been working, and various therapist maneuvers became translatable into machine language. Advanced computers were programmed with the necessary information, and the teaching machines were hooked-up to them. The teaching machines themselves were developed to a point where they could provide a wide variety of visual, auditory, tactile, olfactory, and gustatory stimuli, containing the essential characteristics of those provided by human therapists. The machines were made to be responsive to patient behavior, and also, to provide powerful reinforcing and aversive stimuli to shape patient behavior.
Just as a therapist would, but with greater speed and precision, the machines
were made to diagnose, as well as treat patients. Patients hooked into the
assembly were presented with a variety of stimuli, to which they were required
to respond, and in many cases, to m
A male patient, who at first was strongly avoidant toward photographic images of nude females, was trained in a series of trials to seek this stimulus above all others. His subsequent behavior was disappointing, however, in that his responses outside the laboratory did not generalize to females, but instead, he developed a passion and a dependency on pictures of nude females. He was able to overcome the insomnia from which he had previously suffered, but only by means of keeping a photograph of a nude female underneath his pillow. This was regarded as only a partial therapeutic success. We were undaunted by such setbacks, and soon found ways of avoiding and correcting them. The aforementioned patient now sleeps without a pillow.
Since these crude early phases, we have advanced considerably. Our programs are more varied and responsive, and in particular, our methods of reinforcement and extinction of responses have been considerably improved. Rather than relying upon the crude reinforcement and extinction techniques utilized by human therapists and by our early programmed machines, we are now able to go directly to the centers for a pleasure and pain, within the brain itself. Careful stereotactic placement of minute electrodes within the brain permits the stimulation of highly specific centers for particular modalities of both pleasure and pain, and other states. In the hypothalamic region alone, we use six locations, stimulation of which produces sexual arousal, hunger, euphoria, fear, and so on. This of course, goes beyond mere pleasure and pain. Various sites in the midbrain, the limbic system, the cortex, and elsewhere, can be stimulated to evoke memories, percepts, and emotional states in various combinations. No more powerful techniques can be conceived for the evocation, reinforcement, or extinction of behavior. Permanent electrode implantations permit complete freedom of movement, and in the near future, will allow stimulation at a distance by means of radio signals.
In a short span of time, we have traversed a path leading through years of work in psychotherapy, beginning with the most crude and primitive techniques, upon which the field of psychotherapy long foundered, and leading up to the very latest of refined scientific developments. Today, we are witnesses to the blessings provided by the marriage of a host of modern scientific techniques, to produce highly refined and efficient methods designed for the betterment of the human condition. Behavioral science, mathematics, electronics, computer technology, and biomedical engineering, are working as one for the promotion of human welfare. Of course, all of these scientific contributions would have been valueless without the addition of the human ingredients of imagination, dedication, and persistence. Although we have made enormous strides, I am convinced that the future holds many surprises.
Such powerful techniques for the alteration and control of human behavior are not without their risks. Indeed, in the wrong hands their power for evil is equally as great as their power for good. By these methods, human personality and behavior can be shaped in almost any direction one might choose. For this reason, we must dedicate ourselves to the proposition that the control and direction of these techniques must always remain in the hands of professionals in the behavioral sciences. There can be no question that only we have the judgment, the wisdom, and the ethical standards to see that they are used for the good of man!
Before concluding, I must add a somewhat painful epilogue dealing with a series of betrayals and losses we experienced with our human therapists of earlier days. To our regret, we learned that only machines can be made to possess infallible predictability and integrity. Humans can be taught in the laboratory only to simulate integrity, but its true possession, as found in the honorable and loyal Dr. Chutzpah, is a rarity.
As I mentioned before, each of the therapies built around a specific trait met with considerable patient satisfaction.. Human nature being what it is, each of the therapists who had witnessed such extraordinary success with his or her own method of treatment soon began to claim pre-eminence for it. They began quarreling with us, and among themselves, and soon the divisions between them became irreconcilable. It was with great sadness that we saw them go out into the world in order to practice their own types of therapy exclusively. Before long, each attracted students and eventually developed rival schools, named after their founders. Since then, the world has witnessed the unseemly spectacle of acrimonious public debate among these schools, each claiming superiority and competing with the others, for students and for patients.
Dr. Lucifer Needle, whose efforts proved to be actually harmful to patients,
could not accept defeat so easily. He found substitutes for his lack of
therapeutic gifts in LSD and yoga. Before long, he was claiming transcendent
success for his methods. A ready group of followers existed for him among those
other therapists who lacked essential gifts. The entire band descended upon
The
noble Dr. Smorgasbord, loved by all, did not choose to follow his personal
ambitions, but joined a medical mission to the
Despite its superior results our advanced treatment system involving stereotactic brain electrodes has not gained the popularity we expected. After the loss of Smorgasbord the field was left to rival schools, each offering its own particular brand of salvation. The public's response has been interesting and instructive. After the initial confusion and skepticism, there was a rapid acceptance of these “schools” of therapy. Dumpling therapy quickly assumed the lead in public favor, and has never lost it. Least popular has been Wahrheit therapy. This is merely another illustration of the fact that most people prefer dumplings to truth.
Now that these lamentable facts are disposed of, we can look forward once again. Do not be disheartened by our occasional misfortunes, for the course of human progress is never easy. There are many false paths which may lead the unwary into the thickets. But follow the light of science, at times dim, at times blinding, and you will keep on the true path of progress! I am approaching the end of my career, but the work which I have described, though intermixed with sorrows, has been my fulfillment. When the time comes for me to lay down my tools, I shall leave content in the knowledge that others will carry on the good work.
* For Dr Dumpling’s patients who had a weight problem, our dietician prepared special, low caloric equivalents.
** Those unacquainted with this field will be interested in Malarkey's Law, which was formulated after extensive worldwide studies of the practices of psychotherapy. Malarkey's Law states that The duration of psychotherapy is inversely proportional to the supply of patients. A more precise mathematical statement is as follows: D = (Nt/Np)K where D = Duration of therapy; Nt = the Number of therapists Np = the Number of patients and K = a constant, which varies in proportion to the amount of money available to pay for treatment.
Corollary to this are Chutzpah’s Laws: Chutzpah’s Law number One states that The Effectiveness of Therapy is inversely proportional to its Duration.
E = (Np/D)K
In other words, brief therapy is most effective. This applies in situations where patients are overabundant.
When patients are in short supply, Law Number Two applies. The Effectiveness of Therapy is directly proportional to its Duration. E= (D/Np)K Long term therapy is most effective.
Thus, whatever is most expedient is also most effective.