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Freud thought that neuroses served a purpose for the patient. The ego uses abnormal thinking
and behavior as a means of protecting itself from impulses of the id and unconscious conflicts.
Behaviorists admit that mental disorders can have advantages. They can make it possible for
people to avoid unwanted responsibilities, to excuse failure, and to manipulate others. Therefore,
the willing patient may have a conflict. In order to be relieved of the pain and misery associated
with the disorder, the advantages gained from it must be sacrificed. Take the addict as an
example. The addiction causes problems, and even physical pain, yet the person may feel that life
would be unbearable without the addictive substance. In the case of anxiety disorders, the
conflict is not so clearly perceived by the patient, who would generally deny getting any rewards
(secondary gains) from holding on to the disorder.
Many disorders develop over a period of years, sometimes beginning in childhood. Patterns of
abnormal or maladaptive thoughts and behaviors become an integral part of the personality,
affecting the person’s view of reality and all his or her patterns of thought and behavior. Freud
believed that restructuring of the personality was a necessity in successful therapy. This idea was
that once the offending conflict or problem was identified, the person would need to rethink and
reconstruct other aspects of the self that developed, in order to accommodate the abnormal
patterns of thought and behavior. Most current therapies do not aim at reconstruction of the
personality, but perhaps they should be more mindful of the possibility that you cannot excise an
abnormality without affecting the personality structure from which it is removed.
Consider the example of a hypochondriac who has spent a good part of his life monitoring his
body and looking for pathology to explain every irregularity of function or unfamiliar twitch. His
illnesses have brought him sympathy and attention, and he has used his poor health to explain to
himself and others why he has not “climbed the ladder of success.” After his life is endangered
by an unnecessary surgery, he goes to a psychotherapist for help. The issue is, will he be able to
give up his hypochondria and its benefits? Can he change his perception to see himself as a
normal, healthy person living in a world in which illnesses and the danger of infection can play a
relatively minor role?
It is not easy for people to give up their maladaptive behavior, just as it is not easy for any of us
to break bad habits or improve aspects of our personalities. The therapist is in the position of
trying to teach old dogs new-or better-tricks.
Prefrontal Lobotomies
The doctor who developed the prefrontal lobotomy was given the Nobel Prize in Medicine. Ask
students if they have seen movies such as “One Flew Over the Cuckoo’s Nest” and what their
perception is of the procedure. Do they consider it barbaric, without any possible redeeming
value? If the answer to that question is “yes,” then you can play devil’s advocate by presenting
the following scenario.
Imagine that you are a doctor on staff in a mental hospital in the late 1940s. Your mental hospital,
constructed to hold 700 patients, now has over 1,300. Many of these are violent and need to be
tied to their beds or kept in locked cells. Antipsychotic drugs will not be invented for another five
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CHAPTER 16: THERAPIES FOR PERSONAL CHANGE
to ten years. Patients regularly attack one another, as well as the attendants. Other patients run
through the hallways, screaming and yelling. You have one patient who has been in the hospital
for 25 years and has essentially been kept in confinement. You hold no hope of recovery.
However, you know that there is a therapeutic technique that will take only a half-hour, and if
successful, will result in a significant decrease in episodes of violent behavior in this patient.
Again, if the procedure is successful, the patient will appear to be much happier and more
content with life. You also know that for most patients receiving this procedure there will be little
difference in measurable IQ. You know of no behavioral test that routinely shows any mental
deficit from the procedure. Would you, as this patient’s doctor, use this procedure?