The case surrounds Carlos, a man in his late 30s with a growing tumor that will not respond to radiation or chemotherapy. Carlos has been fighting this cancer for about a decade, but it is now to the point in which medical science can do no more for him. Carlos was referred to therapy by his oncologist, and responded somewhat to individual therapy but became combative and confrontational in group therapy. Carlos is a classic narcissist and misogynist. He has few friends, is estranged from his children, and is, at best cynical and sarcastic. However, through individual therapy, Carlos was able to come to some conclusions about the walls he built around himself, and the tremendous insecurity he harbored; typically using sex and sarcasm to cover up his need to belong. He eventually revealed that he had come up with two insights about himself and his relationship to the world: 1) everyone has a heart and should be treated with respect and kindness; and, 2) I am not my shoes -- or one's work, clothing, and outward appearance are only partially indicative of our psychological makeup (Yalom, pp. 73-92). Using four systems of psychotherapy, we will use Carlos' case as a basis for understanding different approaches to psychotherapy.
Yalom is existential in his approach to Carlos. He is initially not fond of Carlos, but finds over time that there are issues that can be overcome -- Carlos' counter transference and isolation from emotional intimacy. Yalom uses this approach to convince Carlos that it is Carlos' own perceptions of the world, and resultant actions that cause people to react negatively towards him. Unless Carlos opens up to the world, the world will never open up to Carlos. Yalom is ultimately successful with Carlos because he uses a rather clever role reversal technique that asks Carlos to put himself into another's shoes to decide how to best deal with many of Carlos' insecurities. This is particularly powerful when Yalom asks Carlos if he is ready to die without first making peace with himself, his children, and the universe.
Freud's approach to psychoanalytical theory did not evolve in a vacuum; but was built upon years of observation and past research. Freud's approach focuses on the overwhelming influence of the subconscious (fears, desires, thoughts, etc.) that become part of the conscious mind and behavior. Many of these issues developed for a number of reasons during infancy and childhood, and are wrapped up in the development of certain psychosis that expresses itself in adolescence and adulthood. Freud believed there were three components of one's personality, an id, an ego, and a super ego. The id focuses on the emotional, and often irrational, segement of the mind. At birth a baby's mind is "a bundle of id." It contains all the basic needs and feelings. It is the source for libido and it has only one rule, the "pleasure principle." The ego functions with the rational part of the mind. It realizes the need for compromise and negotiates between the Id and the Superego. The Ego's job is to get the Id's pleasures but to be reasonable and bear the long-term consequences in mind. The Ego denies both instant gratification and pious delaying of gratification. The Super Ego functions with the moral part of the mind. It stores and enforces rules. Its power to enforce rules comes from its ability to create anxiety (Corsini and Wedding, 2011, pp. 57-8).
Using a Freudian model for Carl leaves one with some very perplexing possibilities. The first, and most obvious, of course, is the parallel to his conscious and unconscious personality and inner needs. Carlos is obsessed with sex because he relatively incapable of emotional intimacy and fears rejection. To overcome this, he establishes a confrontational wall between himself and the world, reverting to sexual pleasure to seek his own validation. The idea of using psychotherapy is to bring Carlos as a "whole person" -- including problems, stresses, fantasies, and feelings in order to discover and treat the overlying problems he manifests. Further, the Freudian approach guides the therapist when dealing with Carlos' denial about his illness -- focusing it on an acceptance rather than a continual defensive posture. Finally, Freudian theory helps the therapist consider Carlos' unconscious needs through dreams and a greater attention to his unconscious processes (Corsini, pp. 58-9).
Carl Rogers, American psychologist and founder on the humanistic (client-centered) approach to therapy believed that all individuals were unique and continued to evolve in a continually changing environment where behavior is goal directed to satisfy the concept of self. For Rogers, Carlos is continually evolving as the center of a world in which external and internal experiences constantly change. Using Rogerian therapy, the goal is to move Carlos to his full potential, regardless of the time he has left -- to be a positive force, exhibit helpful qualities towards others that he rarely did, and to form a new self-image that is less likely to be negative (Corsini, 164-5).
To become this functioning person, Rogerian therapy moves away from defensiveness and encourages openness and frank honesty; to live each moment fully without overly worrying about the future. It is the job of the therapist to provide unconditional positive regard and empathy to the patient, and through that experience, patients like Carlos will come to understand alternatives to the fight or flight syndrome. By effectively communicating the positive and optimist attitudes with the client, over time, the client will come to see that there is little purpose for negativity and hostility. Therefore, the push in Carlos' case is to accept him so that he will accept others and learn to empathize just as the therapist empathizes with him. As opposed to the countertransference Carlos exhibits, particularly when stressed, Rogerian theory helps the therapist channel a different motivational output for uncomfortable situations. Further, the respect that the therapist shows to Carlos must be vigorous so that Carlos will come to understand that respect breeds respect -- the question is not Carlos' sexual needs, nor his judgmental nature -- it is how to lower his own boundaries of insecurity and open up to other people. The unconditional positive regard for the patient is successful, even with difficult and combative patients like Carlos. The Rogerian approach allows the therapist to help Carlos confront his illness and eventual demise with a more positive frame of mind. The idea, of course, is to "walk the talk" by modeling positive behaviors, unconditional respect, and thus allowing a safe environment for the patient to also express positive behaviors (Corsini, 164-6).
REBT (or rational emotive behavior therapy) theory holds that neurotic dysfunction occurs when individuals demand that their wishes be satisfied. If these individuals succeed, then the universe will be better for them, and their interaction with others will be more positive. When people like Carlos overly demand, they often get into emotional trouble, and are thus unable to actualize. Over time, this becomes a gradual spiral downward into negativity and depression. The goal of the therapist is to focus on resolving these emotional and behavior needs and helping the patient understand that needs and wants are different and dependent upon situations (Corsini, pp.212-13).
In the case of Carlos, using REBT would focus on his inflexibility and adversarialness -- and to help him see that these patters did not solve his interaction issues with others, nor do they bring him pleasure or satisfaction in the long run. The therapist would also help Carlos with his self-sabotaging and pessimistic behavior -- Carlos does not feel trust from others, so covers up that anxiety by not trusting as well, keeping walls up that become self-destructive. However, insight alone rarely is enough to elicit a firm and long-term behavioral solution (Corsini, pp. 213-15).
This issue is the Ellis REBT Insight Number 3, which holds that individuals will rarely get better and stay better because they still hold onto self-sabotaging thoughts and must be continually and aggressively mindful that it takes persistent work to modify one's core belief system. When Carlos says, "I don't give a shit… about the people in the group. They're not real people. I am never going to associate with losers like that… I don't want to get closer to them," he is actually talking more about his own fears. (Yalom, p. 70). According to REBT, replacing the previous absolutes with more flexible preferences, actively changing unhealthy and negative feelings to positive, and continually acting against dysfunctional fears and compulsions may well take years of assisted therapy, but is a necessary first step to confront the hostility and learn some techniques to improve his public empathy. For Carlos, the therapist must ensure that there is momentum forward, but is constantly vigilant regarding previous negative or self-sabotaging behaviors. When Yalom asks Carlos, "If you had a daughter…" the hostility and insensitive nature of Carlos' comments become personalized, but in a less combative manner. In this way, Carlos sees that many of his thoughts are irrational…