Therapy goes beyond the couch

The traditional patient-therapist dynamic has evolved.

No longer is it confined to the couch and the 55-minute session. Psychologists and other therapists now teach classes and workshops, expound before TV-studio audiences, write self-help books, create websites and are featured on countless DVDs, CDs and MP3s.

And as they share their trade secrets of personal change and discovery, they’ve become less like all-powerful healers and more like co-equal coaches and teachers. In doing so, they’re helping patients -- now often called “clients” -- help themselves.

In a survey of psychologists published in 2000, 82% said they recommended self-help groups to their psychotherapy patients; 85% recommended self-help books. Nearly half also “prescribed” movies that they believed would be therapeutically useful for patients.

The lead author of the survey, John C. Norcross, professor of psychology at the University of Scranton, says the trend toward behavioral self-help is driven by several factors. Self-help can be cheap and is often somewhat effective. Studies have shown that 12-step programs such as Alcoholics Anonymous can work for many people. And managed care has curbed people’s access to behavioral healthcare specialists.

Other people simply want more privacy than a traditional therapist-client relationship provides. And, too, it’s very American to want to go it alone.

For the last 20 years, psychologists Stuart W. Alpert and Naomi Lubin-Alpert have taught their approach to psychological treatment to laypeople who want to learn how to help themselves.

Many students have returned again and again to the once-a-week class and group discussion at the Hartford Family Institute in West Hartford, which was founded by the Alperts. They say they keep coming back because the Alperts’ approach, called body-centered Gestalt psychotherapy, has helped transform their work and personal lives.

Rabbi Donna Berman, 49, says traditional therapy has helped her from the neck up, but that the approach she is learning in the Human Relations Program at the institute is a whole-body approach.

“You’re doing it with a guide,” Berman says. “Somebody wise once said to me, ‘If you’re mountain-climbing and you’re stuck behind a rock, you really need somebody on the outside who can see the way out.’ ”

For those who prefer anonymity, there’s www.myselfhelp.com, a $15-a-month subscription website. It offers behavior-change exercises for people with such problems as depression, eating disorders and insomnia. The site is supposed to be used in conjunction with therapy, according to the website’s president, psychologist Richard Bedrosian of Northborough, Mass., but many subscribers are on their own and in settings where they feel they need privacy.

“We’ve had people join up for our services from the armed forces over in Iraq and Afghanistan,” he says.

The self-help trend perhaps goes back to Socrates with his trademark question-and-answer coaching program. But the more recent origins of the movement date from the late 19th century, with philosopher-psychologist William James and other colleagues dubbed the “functionalists,” who attempted to reshape the then-new science of psychology into a more helpful field, according to Robert Henning, associate professor of psychology at the University of Connecticut.

“William James took a very pragmatic view of how to take control over your life,” Henning says. James suggested, for example, that troubled people should manage their depression by becoming more physically and socially active.

This was certainly not the approach of Sigmund Freud, the father of psychotherapy, for whom a patient was just a patient. “He had much more of a treat-people-as-patients type of an approach,” Henning says. “And it was mostly up to the psychiatrist to diagnose and help someone recover.”

More recently, the success of 12-step groups and the emergence of cognitive behavioral therapy as a leading mode of psychotherapy have tipped the balance of power toward the patient. Cognitive behavioral therapy -- used especially for depression, anxiety and phobias -- emphasizes the identification and rewiring of one’s harmful self-images and behavior.

Psychologist Jean Cirillo of Massapequa, N.Y., says cognitive behavioral therapy typically involves the use of “homework” for clients between sessions -- both because it’s very much in the spirit of the therapy and because insurers typically limit the number of therapy sessions and therapists seek to maximize the effect of short-term therapy.

“Usually it involves having the patient run some play out there between sessions, if only to bring material to the next session,” Cirillo says. For example, she says, if she has a patient who is afraid of making a fool of himself, she might ask him to walk a banana on a string in public.

Cirillo, a 20-year veteran of psychotherapy, has seen the shift from therapist-goddess to therapist-facilitator more clearly than most. She has done hundreds of television and radio talk shows and was the staff psychologist for “The Jenny Jones Show.”

When she and her colleagues appear on TV, she says, they are “helping the masses who might not have access to a therapist” -- or who might not go even if they do have access. The University of Scranton’s Norcross estimates that three-quarters of Americans with mental-health or substance-abuse problems do not receive professional help.

But rugged individualism has its limits.

“As optimistic as I am about self-help, it’s a double-edged sword,” Norcross says. “It assumes that people can reliably diagnose their problem. For many people it’s an open question, and for many others it flatly cannot be done.”