Gerhard Lenz

med@praxis-lenz.at

The concept of man in psychotherapy can be understood as assumptions about man, which provide foundations for psychotherapeutic theories and psychotherapeutic action. The different psychotherapeutic orientations are based on different views of man, whereby different aspects of reality are illuminated in each case, among other things, in the field of tension between the inner world versus the outer world and nature versus culture. However, these often divergent perspectives serve the common concern for successful patient change in the therapy process (general overview in Kriz 2015).

Wampold (2001) contrasts the medical metamodel with the contextual metamodel in his great psychotherapy debate. In the medical model, in the extreme form, after researching the causes of problems or disorders, it goes to recommending specific strategies for change, which are administered analogously to a drug (e.g., in the context of following therapy manuals, where the person of the therapist appears interchangeable with verified competence or manual fidelity). In contrast, the hypotheses of the contextual model assume three mechanisms of action for change: Genuine Relationship, Expectation, and Treatment Delivery. The contextual model postulates that the genuine relationship can be therapeutic. Expectancies also operate in psychotherapy in a variety of ways (beginning psychotherapy, the importance of conveying hope in initial therapy sessions, school-specific explanatory systems for disorders,….). In treatment delivery, the contextual metamodel does not assume specific deficits that are cured by specific strategies, but that the specific components of all therapies cause the patient to do something generally curative (e.g., increased physical activity, increased social interactions, change in cognitions, reduction in avoidance behaviors,…..).

The conception of man of behavior therapy is based on the findings of natural and social sciences such as psychology, biology, medicine, sociology and includes especially the findings of developmental psychology, neurobiology and psychiatry about health and illness and the importance of relationships for healthy and pathological development. For overviews, see Egger 2015, Parfy & Lenz 2018 , Parfy et al 2016, Petzold 2015, and Wagner 2021.

Original simple models were based primarily on learning theories (triggers and consequences of observable behavior) with implications for the treatment of anxiety disorders (classical and operant learning theories). Subsequently, dysfunctional thinking patterns were described on the basis of depression treatment and cognitive theories were developed (cognitive turn). In the further development especially of personality disorders with schema therapy, the therapy relationship as a therapeutic agent and the non-conscious parts in early maladaptive schemas and in modes are particularly emphasized. Whereas emotions were originally regarded only as evaluations of physiological excitations, the emotional turn described the importance and independence of emotions. Behavior in the sense of modern behavior therapy always means the interaction of physical symptoms, thoughts, feelings and observable behavior and this in relation to the environment or relationship to others.

Important neurobiological foundations for our physical and psychological development. Neuroscience assumes that the development of the psyche and personality is closely related to the development of the brain. This process is determined by various factors, namely genes and epigenetic regulatory mechanisms, prenatal influences of the mother’s brain and body on the brain of the fetus , postnatal experiences and finally further socialization processes and individual experiences. Knowledge of excitation and information processing between nerve cells (communication via electrical impulses and via chemical messengers) is of fundamental importance for understanding the brain. Chemical messengers such as GABA, glycine, glutamate, serotonin, dopamine, adrenaline and noradrenaline, as well as neurohormones such as oxytocin and cortisol and the so-called brain drugs such as opioids and cannabinoids determine our mental events. Roth (2021) distinguishes the following basic psychoneural systems that develop in interaction between investment and environmental influences: stress processing, self-soothing, evaluation and motivation , attachment and empathy , impulse inhibition , sense of reality , and risk perception . According to Roth (2021), these six basic psychoneural systems determine the individual temperament and personality of a person. Further overviews of neurobiological principles can be found, for example, in Siegel 2010 and Strüber 2021.

Basic needs, motives, and conflicts : Grawe (2004) describes four basic human needs in his consistency-theoretic model of psychological functioning: The need for attachment to primary caregivers, for pleasure and displeasure avoidance, the need for orientation and control, , the need for self-esteem enhancement. Values, plans and goals can be derived from these basic needs, which then determine our actions. Violation of basic needs can result in harm to health or well-being. However, thinking, feeling and acting do not only take place on the level of consciousness; unconscious motives that developed at an early stage also play an essential role: Within different motives, unconscious conflicts may arise, or conflicts may arise between unconscious motives and conscious goals, with the consequence that people do not experience satisfaction when pursuing and achieving a conscious goal.

The importance of interpersonal relationships :

How we develop socially and emotionally depends to an important extent on our early attachments. Both genes and early experiences in the womb and after birth influence how a child responds to its environment. Epigenetic changes during pregnancy also influence the development of neuronal networks and thus, among other things, how the child’s stress system develops in the long term.

Much evidence suggests that early experiences with the environment-particularly the quality of relationships with close caregivers-condition individual differences in endocrine and neural stress responses that then persist into adulthood. They influence how quickly a child later becomes upset or calms down again and how well he or she handles stressful situations. A loving attachment figure who comforts, hugs, supports, and names the infant’s diffuse discomfort can strengthen neural networks for emotion regulation. This is also reflected on a chemical level: The neurotransmitter oxytocin dampens the activity of the amygdalae and inhibits the release of stress hormones. Bowlby (1975) described different attachment styles for the further course, the secure, the avoidant, the ambivalent, and the disorganized attachment styles. For the most part, neurobiological correspondences have already been demonstrated for these different attachment styles (Kapfhammer 2022). Once established, attachment styles have a high stability for the further life, although corrective new experiences – e.g. through a complementary relationship design – can make changes possible.

Function and use of the therapeutic relationship :

The therapeutic relationship is important on the one hand as a working alliance (alliance), on the other hand also as a therapeutic instrument. The working alliance is a necessary prerequisite for the patient’s readiness for treatment and the possibility of applying specific therapeutic techniques…. However, the therapeutic relationship can also be seen as an instrument that has a direct therapeutic effect in the sense of a corrective emotional re-experience. Caspar (2007) speaks here of the complementary relationship design, Young (2008) of the concept of limited parenting (“limited reparenting”), in CBASP (McCullough 2000) reference is made to the perception of the difference between therapist behavior and the previous behavior of formative attachment figures. In the therapeutic relationship, schemas are often activated , which can then be recognized and worked on. The patient’s behavior can trigger countertransference feelings in the therapist that are similar to those that the patient also triggers in other people. Here, appropriate feedback from the therapist can be helpful in processing this behavior.

The following core assumptions of behavior therapy approaches are, of course, each very reductionist in their own right, but are usually used together in modern behavior therapy with different emphases.

Man as an object of external conditions (classical theories of learning). :

Theories of learning: The study of learning processes provided the initial impetus for the development of behavior therapy, and the knowledge that emerged remains important to our understanding of human beings. Recognizing connections is an important goal of our learning and has directly served our own survival throughout human history.

One can distinguish three forms of learning: once. that a certain consequence can occur with certain stimuli to be perceived. This principle is followed by classical conditioning, which states that stimuli that are neutral in themselves acquire a signal function through temporal and spatial coupling with important events and can trigger a certain behavior.

The second form of recognizing and learning connections concerns the consequences that follow certain behaviors. This “operant conditioning” states that spontaneously exhibited behavior is influenced in its probability of occurrence based on subsequent conditions. The third form of recognizing connections, “model learning,” describes that people can learn from other people through observation. It must also be critically noted that in model learning we do not only adopt 1:1 but also bring in our own shares, according to the motto that a good student surpasses his master (constructivist approaches to learning).

These simple learning principles are of high survival value in human history, but inner influencing factors such as thoughts and feelings also play an important role in our behavior, and these influencing factors can also turn learning principles into the opposite, such as in the case of a political dissident who, despite the expected negative consequences, shows a certain behavior to be important and in accordance with his or her own principles and attitudes.

Through these learning processes, inner-psychic structures are built up, which have found their way into behavior therapy as “schemata” and draw on existing experiences to orient current behavior.

Man as a rational, action-oriented being (cognitive theories):

In this approach, the human being is seen as a rational subject capable of reflection and action. From the cognitive behavioral therapy, the cognitive therapy according to Beck, the rational-emotive therapy according to Ellis, the self-verbalization approach of Meichenbaum and the self-management approach of Kanfer play an important role. The cognitive model states that people’s feelings and behavior are influenced by their perception of events. It is not the situation itself that influences a person’s feelings, but the way the person interprets it. Depending on the mental interpretation of the situation, very different feelings and subsequent behavior can arise. We work on the so-called “hot” thoughts, which are those cognitions that are accompanied by particularly intense emotions. In the cognitive approach, three levels of thoughts are distinguished: On the surface are the automatic thoughts, which are suddenly occurring thoughts, words, memories or ideas. At a middle level are the conditional assumptions; these are beliefs that guide and direct our lives about various situations (should-assertions and if-then sentences). At a lowest level are the basic assumptions (schemas).These schemas are of fundamental importance in patients with personality disorders. The individual interaction of triggering conditions, thoughts, feelings, physical factors as well as reactions and behavior is captured in the case conception. The goal of therapeutic approaches here is to support the patient in acquiring an increased capacity for self-control.

Feelings and thoughts, schemesThe emotional processing system, which developed early in life history, is roughly oriented to sensations of pleasure and displeasure and reacts very quickly, e.g., to possible dangers. In contrast, thinking is experienced as an actively directed activity, which, however, proceeds relatively slowly. Feelings and thoughts are in constant interaction and can also get into a discrepancy with each other up to dissociation or disintegration of the experienced, which protects against psychological overload especially in traumatizing experiences. The basic feelings such as fear, grief, anger and joy have on the one hand orienting functions inwardly (fear: distance and protection, grief: detachment from bonds, anger: drawing boundaries, joy: rapprochement and creation of new bonds) and on the other hand direct the organism to certain behaviors which are connected with communicative signals outwardly (gestures, facial expressions, language, behavior).These basic feelings are based on genetically prepared biological processes which, however, are expanded and differentiated in the course of development. In the context of positive or negative life-historical experiences, embodied organizational units emerge through neuronal networks, which orient the organism in a specific way towards the environment . These organizational units can be referred to as schemas. Young (2008) described five dysfunctional schema domains (detachment and rejection, impairment in autonomy and achievement, other-centeredness, hyper-vigilance and inhibition, and impairment in coping with limitations) that would result from a lack of satisfaction of basic needs in childhood (attachment, orientation and control, pleasure gain and displeasure avoidance, self-esteem enhancement). Schemas are activated (“triggered”) by certain trigger stimuli and lead to structuring the present situation according to the pattern of past experiences and also to setting certain expectations for the future. A central active process in therapy is the repeated activation of affects that were previously experienced as unmanageable, with simultaneous cognitive processing.

Implicit memory and mental disorders (The “unconscious” in behavior therapy):

Explicit memory concerns conscious memories of experiences, events, or of people Implicit memory functions automatically and unconsciously, such as in skiing or habitual actions or immediately arising affects. The largely automated assimilation of complex experiences – so-called implicit learning, which takes place below the threshold of consciousness – provided a knowledge base that allowed rapid responses. The functions and structures belonging to implicit memory already exist in infancy, whereas explicit memory does not mature until the second to fourth year of life. There is evidence that early attachment experiences are internalized and stored as part of implicit memory. (Schneider 2021). Grawe (1998) describes motivational schemas as part of implicit memory that serve to achieve (approach schemas) or protect (avoidance schemas) basic needs. Functional characteristics of dysfunctional schemas in Young’s schema therapy show a high correspondence with the characteristics of implicit memory (automatic and rapid activation, strong filtering of perception, poor controllability, and the feeling of compellingly having to act this way). In psychotherapy, it is thus important to interrupt and inhibit long-burrowed implicit memory traces and, in parallel, to facilitate corrective new experiences and build new behavior (Schneider 2021). Benecke (2016) points out important differences and similarities between behavioral and psychodynamic therapies in this area.

Concepts of the therapeutic relationship with transference and countertransference processes and dealing with resistance are increasingly established in modern behavior therapy: for example, in CBASP (McCullough 2000) there is the technique of disciplined personal engagement and the transference hypothesis, in schema therapy there is the concept of maladaptive coping mechanisms, schema modes, and dysfunctional schemas, in trauma therapy there is the shifting of stressful experiences that cannot be consciously processed into implicit memory. In implicit memory processes, the contents are not immediately remembered and can only be accessed through associative bridges related to the original experience. For example, in the grand schema exercise, starting from a present problematic situation, by focusing on the emotions via association bridges, a transition is made to similar emotions in childhood with relevant reference persons, and the child’s basic needs, which were not sufficiently fulfilled at that time, are worked on. The associated coping strategies are then carried over into the current situation.

For behavior therapy, therefore, not only the rational conception of man applies as Kämmerer (2020) formulates it quite critically: ” the idea of man who acts rationally and purposefully, develops motivation to achieve goals, and finally realizes the goals by acquiring appropriate means to achieve them and by checking them in a process-accompanying manner in a changing inner and outer world”. The irrational, unconscious and intuitive of the human being would thus be blanked out here. “With today’s variety of methods in behavior therapy, the impression inevitably arises that this rational view of human beings in behavior therapy has had its day. Otherwise, the triumph of mindfulness-based and schema-oriented therapy models is not conceivable” (Kämmerer 2020).

From personality typologies to “structural levels”: a view to the future?: Previous personality typologies are described in the categorically delineated personality disorders in DSM-IV and ICD-10. Beck (1993) describes the cognitive profiles typical of each personality disorder. According to Young (2008), dysfunctional schemas are the basis of personality disorders and the behaviors described in the diagnostic criteria are primarily reactions to these schemas. In the DSM-5 (APA 2015) and in the ICD-11 (Herpertz 2018), aspects of the OPD (Operationalized Psychodynamic Diagnostic, Working Group OPD 2006) with its structural axis have now found their way into the diagnosis of personality disorders. For example, Criterion A for personality disorders in the DSM-5 distinguishes different levels of personality functioning in relation to the self and to interpersonal relationships. Similarly, in ICD-11, such different levels of functioning are the basis for the classification of personality disorders according to severity into mild, moderate, and severe. The future will show what consequences this will have for research and therapy in behavior therapy.

Literature:

American Psychiatric Association (2015): DSM-5. Göttingen, Hogrefe

OPD Working Group (2006): Operationalized Psychodynamic Diagnostics. Berne,Huber

Beck A.T. (1993): Cognitive therapy of personality disorders; Weinheim PVU.

Benecke C. (2016): Psychodynamic therapies and behavior therapy in comparison; Göttingen, Vandenhoeck & Ruprecht.

Bowlby J.(1975): Attachment; Frankfurt,Fischer

Caspar F. (2007): Understanding relationships and problems; an introduction to psychotherapeutic plan analysis. Bern, Huber

Egger J.W. (2015): Menschenbildannahmen in der verhaltenstheoretischen Psychotherapie. In : H.Petzold (Ed.): Menschenbilder in der Psychotherapie, pp. 447-480; Bielefeld, Aisthesis-Verlag.

Grawe K.(1998): Psychological therapy. Göttingen, Hogrefe

Grawe K. (2004): Neuropsychotherapy. Göttingen, Hogrefe

Herpertz S. (2018): New ways of classifying personality disorders in ICD-11. Fortschr Neurol Psychiatr 86(03):150-155.

Kämmerer A. (2020): Reflecting on psychotherapy; In M.Rufer, C.Flückiger (Eds.): Essentials der Psychotherapie; pp. 47-48; Bern, Hogrefe.

Kapfhammer H.P. (2022): Psychobiology of attachment and trauma-Part 2: secure, insecure, and disorganized attachment. Jatros Neurology & Psychiatry 1: 36-42

Kriz J (2015): Human images in psychotherapy-a cross-school perspective on fundamental aspects of psychotherapeutic discourses. In: H.Petzold (ed.) (2015): Menschenbilder in der Psychotherapie, pp. 133-155; Bielefeld, Aisthesis-Verlag.

McCullough J.P.(2000): Psychotherapy of chronic depression (Cognitive Behavioral Analysis System of Psychotherapy-CBASP); Munich, Urban&Fischer.

Parfy E, Schuch B, Lenz G (2016): Behavior Therapy

Parfy E, Lenz G (2018): Human image. In :J.Margraf, S.Schneider (Eds.): Lehrbuch der Verhaltenstherapie, Vol. 1 ,pp. 51-67; Berlin, Springer.

Roth G.(2019): Why it is so difficult to change oneself and others; Stuttgart, Klett-Cotta.

Schneider R (2021): Conditions of mental disorders from a neuroscientific perspective; In S.Fliegel et al (Eds.): Behavior Therapy, pp. 453-475; Tübingen, DGVT-Verlag.

Siegel D.J.(2010): how we become who we are: neurobiological foundations of subjective experience & human development in relationships; Paderborn, Junfermann.

Strüber N (2021): how I became what I am; Brain & Mind 2, 31-37.

Wagner R.F. (2021): Anthropological core assumptions of different psychotherapeutic approaches; In S.Fliegel et al (Eds.): Behavior Therapy; pp. 41-48; Tübingen, DGVT-Verlag.

Wampold B.E., Imel Z.E., Flückiger C (2018): The psychotherapy debate; Bern, Hogrefe.

Young J.E., Klosko J.S. & Weishaar M.E. (2008): Schema therapy . Paderborn, Junfermann