Current Psychotherapies, 8e

current psychotherapies

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current psychotherapies eighth edition

Editors

Raymond J. Corsini Danny Wedding With the assistance of Frank Dumont

Australia • Brazil • Canada • Mexico • Singapore • Spain United Kingdom • United States

Current Psychotherapies, Eighth Edition Edited by Raymond J. Corsini and Danny Wedding, with the assistance of Frank Dumont Senior Acquisitions Editor: Marquita Flemming Assistant Editor: Samantha Shook Editorial Assistant: Meaghan Banks Technology Project Manager: Julie Aguilar Marketing Manager: Meghan McCullough Marketing Communications Manager: Shemika Britt Project Manager, Editorial Production: Christy Krueger Creative Director: Rob Hugel Art Director: Vernon Boes Print Buyer: Judy Inouye Permissions Editor: Roberta Broyer

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Overview

Integrative

Contemplative

Family

Multimodal

Gestalt

Existential

Cognitive

Behavior

Rational Emotive

Client-Centered

Analytical

Adlerian

Psychoanalysis

outline of book

Page 15 63 107 141 187 223 263 295 328 368 402 437 481

Basic Concepts

16 63 107 142 188 224 263 296 329 369 402 437 482

Other Systems

19 66 109 146 190 228 265 297 331 372 407 440 484

History

22 71 111 148 191 230 267 299 334 374 408 444 485

Precursors

22 71 111 148 191 230 267 299 334 374 408 444 485

Beginnings

22 72 112 149 192 231 267 300 335 375 409 444 486

Current Status

26 73 113 150 193 232 268 303 336 376 410 446 487

Personality

29 74 114 151 195 233 270 305 337 377 414 447 489

Theory of Personality

29 74 114 151 195 233 270 305 337 377 414 448 489

Variety of Concepts

33 77 117 154 198 235 271 305 340 380 415 453 489

Psychotherapy

36 78 120 156 200 237 275 307 345 381 417 455 490

Theory of Psychotherapy

36 78 120 156 200 237 275 307 345 381 417 455 490

Process of Psychotherapy

40 80 122 159 202 239 278 308 348 382 419 458 494

Mechanisms of Psychotherapy 44 85 123 160 208 244 280 311 350 387 424 460 497 Applications

48 88 126 162 210 246 281 316 352 388 425 462 498

Problems

48 88 126 162 210 246 281 316 352 388 425 462 498

Evidence

50 89 126 166 211 251 281 316 352 389 426 466 499

Treatment

53 90 128 172 211 253 284 318 358 391 428 469 502

Case Example

56 94 132 174 217 255 287 319 361 392 430 473 502

Summary

58 99 136 180 219 257 290 322 363 396 432 475 508

Annotated Bibliography

59 101 137 181 220 258 291 323 364 397 433 477 508

Case Readings

60 101 138 182 221 259 292 323 365 398 433 477 509

References

60 102 139 182 221 259 292 323 365 398 434 478 510

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contents CONTRIBUTORS

XI

ACKNOWLEDGMENTS PREFACE

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XV

INTRODUCTION

/ Raymond J. Corsini

1

Counseling and Psychotherapy 2 Patient or Client? 3 An Unusual Example of Psychotherapy 4 Comparisons of Theories 5 Modes of Psychotherapy 6 Mechanisms of Psychotherapy 8 The Current Situation in Psychotherapy 9 Correction of a Historical Error 11 Psychotherapy and Psychotherapist 13 References 13

2

PSYCHOANALYSIS / Ellen

and Jacob A. Arlow

Overview 15 History 22 Personality 29 Psychotherapy 36 Applications 48 Case Example 56 Summary 58 Annotated Bibliography Case Readings 60 References 60

3

B. Luborsky, Maureen O’Reilly-Landry,

15

59

ADLERIAN PSYCHOTHERAPY / Harold

Michael P. Maniacci

H. Mosak and

63

Overview 63 History 71 Personality 74 Psychotherapy 78 Applications 88 Case Example 94 Summary 99 Annotated Bibliography Case Readings 101 References 102

101

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contents

4

ANALYTICAL PSYCHOTHERAPY / Claire

Overview 107 History 111 Personality 114 Psychotherapy 120 Applications 126 Case Example 132 Summary 136 Annotated Bibliography Case Readings 138 References 139

5

Douglas

107

137

CLIENT-CENTERED THERAPY / Nathaniel J. Raskin, Carl R. Rogers, and Marjorie C. Witty 141

Overview 141 History 148 Personality 151 Psychotherapy 156 Applications 162 Case Example 174 Summary 180 Annotated Bibliography Case Readings 182 References 182

181

6 rational emotive behavior therapy / Albert Ellis Overview 187 History 191 Personality 195 Psychotherapy 200 Applications 210 Case Example 217 Summary 219 Annotated Bibliography Case Readings 221 References 221

220

7 behavior therapy / G. Terence Wilson Overview 223 History 230 Personality 233 Psychotherapy 237 Applications 246 Case Example 255 Summary 257 Annotated Bibliography Case Readings 259 References 259

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223

258

8 cognitive therapy / Aaron T. Beck and Marjorie E. Weishaar Overview 263 History 267

263

contents Personality 270 Psychotherapy 275 Applications 281 Case Example 287 Summary 290 Annotated Bibliography Case Readings 292 References 292

291

9 existential psychotherapy / Ed Mendelowitz and Kirk Schneider Overview 295 History 299 Personality 305 Psychotherapy 307 Applications 316 Case Example 319 Summary 322 Annotated Bibliography Case Readings 323 References 324

323

10 gestalt therapy / Gary Yontef and Lynne Jacobs Overview 328 History 334 Personality 337 Psychotherapy 345 Applications 352 Case Example 361 Summary 363 Annotated Bibliography Case Readings 365 References 365

364

11 multimodal therapy / Arnold A. Lazarus Overview 368 History 374 Personality 377 Psychotherapy 381 Applications 388 Case Example 392 Summary 396 Annotated Bibliography Case Readings 398 References 398

328

368

397

12 family therapy / Irene Goldenberg and Herbert Goldenberg Overview 402 History 408 Personality 414 Psychotherapy 417 Applications 425

402

295

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contents Case Example 430 Summary 432 Annotated Bibliography Case Readings 433 References 434

433

13 contemplative psychotherapies / Roger Walsh Overview 437 History 444 Personality 447 Psychotherapy 455 Applications 462 Case Example 473 Summary 475 Annotated Bibliography Case Readings 477 References 478

437

477

14 integrative psychotherapies / John C. Norcross and Larry E. Beutler 481 Overview 481 History 485 Personality 489 Psychotherapy 490 Applications 498 Case Example 502 Summary 508 Annotated Bibliography and Web Resources Case Readings 509 References 510

508

15 contemporary challenges and controversies / Kenneth S. Pope and Danny Wedding 512 The Mental Health Workforce 513 Physicians, Medications, and Psychotherapy 514 Empirically Supported Therapies 516 Phones, Computers, and the Internet 519 Therapists’ Sexual Involvement with Patients, Nonsexual Physical Touch, and Sexual Feelings 523 Nonsexual Multiple Relationships and Boundary Issues 526 Accessibility and People with Disabilities 532 Cultures 533 References 537 GLOSSARY NAME INDEX

541 552

SUBJECT INDEX

561

contributors Jacob Arlow, MD Deceased Aaron T. Beck, MD University Professor of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania Larry E. Beutler, PhD William McInnes Distinguished Professor of Psychology Director, National Center for the Psychology of Terrorism Pacific Graduate School of Psychology, Palo Alto, California Raymond J. Corsini, PhD Affiliate, Graduate Faculty, University of Hawaii, Honolulu, Hawaii Claire Douglas, PhD Independent Practice, C. G. Jung Institute of Los Angeles Training and Supervisory Analyst, Malibu, California

Ellen Luborsky, PhD Independent Practice, New York, New York Michael P. Maniacci, PhD Clinical Psychologist and Consultant in Independent Practice, Chicago, Illinois Ed Mendelowitz, PhD Independent Practice, Boston, Massachusetts Harold H. Mosak, PhD Distinguished Service Professor of Clinical Psychology, Adler School of Professional Psychology, Chicago, Illinois John Norcross, PhD Professor of Psychology & Distinguished University Fellow, University of Scranton, Scranton, Pennsylvania Maureen O’Reilly-Landry Independent Practice, New York, New York

Albert Ellis, PhD President Emeritus, Albert Ellis Institute, New York, New York

Ken Pope, PhD Independent Practice, Norwalk, Connecticut

Herbert Goldenberg, PhD Emeritus Professor, California State University, Los Angeles, California

Nathaniel J. Raskin, PhD Emeritus Professor of Psychiatry and Behavioral Sciences, Northwestern University Medical School, Chicago, Illinois

Irene Goldenberg, EdD Professor of Psychiatry, University of California–Los Angeles, Los Angeles, California Lynne Jacobs, PhD Independent Practice, Gestalt Therapy Institute of the Pacific, Los Angeles, California Arnold A. Lazarus, PhD Distinguished Professor Emeritus, Graduate School of Applied and Professional Psychology, Rutgers University, Piscataway, Executive Director, The Lazarus Institute, Skillman, New Jersey

Carl Rogers, PhD Deceased Kirk J. Schneider, PhD Adjunct Faculty, Saybrook Graduate School, Vice President, The ExistentialHumanistic Institute, San Francisco, California Roger Walsh, MD, PhD Professor of Psychiatry, Philosophy, and Anthropology, Adjunct Professor of Religion, University of California-Irvine, Irvine, California

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contributors Danny Wedding, PhD MPH Professor of Psychiatry and Director, Missouri Institute of Mental Health, St. Louis, Missouri

Marge Witty, PhD Professor of Clinical Psychology, Illinois School of Professional Psychology, Argosy University, Chicago, Illinois

Marjorie Weishaar, PhD Clinical Professor of Psychiatry, Brown Medical School, Providence, Rhode Island

Gary Yontef, PhD Independent Practice, Gestalt Therapy Institute of the Pacific, Santa Monica, California

G. Terence Wilson, PhD Oscar K. Buros Professor of Psychology, Rutgers University, Piscataway, New Jersey

acknowledgments Every text is shaped and refined by the comments of those readers who take time to provide feedback about its content, value, and form. This book is no different, and we have benefited from the suggestions of literally hundreds of our students, colleagues, and friends. We have been particularly vigilant about getting feedback from those professors who use Current Psychotherapies as a text, and their comments help shape each new edition. The following individuals were especially helpful in preparing the eighth edition, and we genuinely appreciate their contributions: Dan Abrahamson, Bernard Beitman, Adam Blatner, James Bray, Jaine Darwin, Jerry Davison, Pat DeLeon, Vicki Eichhorn, Ken Freedland, Kelly Gregory, James Hennessy, Zhang Jinying, Lockie Johnson, Amy Kamp, Kim Kirkland, Judy Kuriansky, Marsha Linehan, Al Mahrer, Anthony Marsella, Lisa Marty, Marilyn Metzl, Jill Meyer, Richard Nelson-Jones, Kathryn Norsworthy, Chris Pearce, Gayle Riesser, Anne Schutzenberger, Sara Serot, Sombat Tapanya, Paul Wong, Xumei Wong, and Bob Woody. My colleagues at the American University of the Caribbean (where I was a visiting professor while editing the final draft of this book) provided release time and technical support, and I especially appreciate the assistance of Wayne Gregory and Jason Smith. In addition, Dr. Frank Dumont, an erudite colleague from McGill University, provided invaluable assistance with this edition—as he did with the previous edition—and we are grateful for his friendship, commitment, sharp editing, and impressive knowledge of psychotherapy and the history of psychology.

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preface The eighth edition of Current Psychotherapies reflects our commitment to maintaining the currency alluded to in the book’s title, and the text in its entirety provides a comprehensive overview of the state of the art of psychotherapy. New chapters on Integrative Psychotherapies and Contemplative Psychotherapies have been added. To make room for the new chapters, previous chapters on Experiential Psychotherapy and Psychodrama have been removed; however, both of these chapters have been updated and are available on the course website. An earlier important but now dated chapter on Existential Psychotherapy, written by Rollo May and Irv Yalom, can be viewed at this same site. In addition, anyone interested can watch an interview of Dr. Raymond J. Corsini at this site by simply clicking on “Corsini videos.” The chapters on Psychoanalysis, Client-Centered Therapy, and Existential Psychotherapy have been largely or totally rewritten. New authors have been added for the chapters on Adlerian Psychotherapy and Contemporary Challenges and Controversies, and both of these chapters have been expanded. The other chapters have been revised to include up-to-date references and the most current psychotherapy research data available. In addition, each chapter describing a particular approach to psychotherapy now examines the evidence base supporting that particular theory, and I have asked each contributor to share his or her ideas about the current controversy regarding the importance— and limitations—of evidence-based practice. In a preface to an earlier edition, Raymond J. Corsini described six features of Current Psychotherapies that have helped ensure the book’s utility and popularity. These same principles guided the development of the eighth edition. 1. The chapters in this book describe the most important systems in the current practice of psychotherapy. Because psychotherapy is constantly evolving, deciding what to put into new editions and what to take out demands a great deal of research. The opinions of professors were central in determining the changes we have made. Before each new edition, professors who have taught from the book at least two years are asked what they would want in the next edition and what they no longer want in the current one. Their diverse opinions helped us decide what changes to make. 2. The most competent available authors are recruited. Newly established systems are described by their founders; older systems are covered by those best qualified to describe them. 3. This book is highly disciplined. Each author follows an outline in which the various sections are limited in length and structure. The purpose of this feature is to make it as convenient as possible to compare the systems by reading the book “horizontally” (from section to section across the various systems), as well as in the usual “vertical” manner (from chapter to chapter). The major sections of each chapter include an overview of the system being described, its history, a discussion of the theory of personality that shaped the therapy, a detailed discussion of how psychotherapy using the system is actually practiced, and an explanation of the various applications of the approach being described. In addition, each of the therapies described is accompanied by a case study that illustrates the techniques and methods associated with the therapy. Students interested in more detailed case examples can read this book’s companion volume, Case Studies in Psychotherapy

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preface (Wedding & Corsini, 2008). Those students who want to understand psychotherapy in depth will benefit from reading both Current Psychotherapies and Case Studies in Psychotherapy. 4. Current Psychotherapies is carefully edited. Every section is examined to make certain that its contents are appropriate and clear. In the long history of this text, only one chapter was ever accepted in its first draft. Some chapters have been returned to their original authors as many as four times before finally being accepted. 5. Chapters are as concise as they can possibly be and still cover the systems completely. We have received consistent feedback that the chapters in Current Psychotherapies need to be clear, succinct, and direct. We have taken this feedback seriously, and every sentence in each new edition is carefully edited to ensure that the information provided is not redundant or superfluous. 6. The Glossary for each new edition is updated and expanded. A good way for students to begin any chapter would be to read the relevant entries in the Glossary, thereby generating a mind-set that will facilitate understanding the various systems. Personality theorists tend to invent new words when no existing word suffices. This clarifies their ideas, but it also makes understanding their chapter more difficult. A careful study of the Glossary will reward the reader. Ray Corsini and I don’t always agree about what to keep and what to omit for each new edition of this book. However, we have maintained a cordial, amicable, and productive relationship over three decades of collaboration by alternating primary responsibility for each new edition. Ray is the editor responsible for all odd-numbered editions, and I am responsible for each edition with an even number. It’s now my turn, and I take full responsibility for any errors of judgment that may have occurred. Danny Wedding [email protected]

1

introduction Raymond J. Corsini

Psychotherapy cannot be defined with any precision. A definition might go as follows: Psychotherapy is a formal process of interaction between two parties, each party usually consisting of one person but with the possibility that there may be two or more people in each party, for the purpose of amelioration of distress in one of the two parties relative to any or all of the following areas of disability or malfunction: cognitive functions (disorders of thinking), affective functions (suffering or emotional discomforts), or behavioral functions (inadequacy of behavior). The therapist who takes part in this interaction has some theory of personality’s origins, development, maintenance, and change, applies some method of treatment logically related to the theory, and has professional and legal approval to act as a therapist. This definition may seem rather comprehensive. Nevertheless, some modes of therapy will not fit it. Would the system of psychotherapy that Sigmund Freud underwent—about which Karen Horney (1942) wrote a book, and which Theodore Reik (1948) claimed to be the best of all therapies—fit this definition? The system is self-therapy. In self-therapy there is only one party; there is no formal process, and no professional or legal approval is involved, yet it certainly is therapy. If we examine various theories and procedures in psychotherapy, we find a bewildering set of ideas and behaviors. There have been systems of therapy that had no therapist (Schmidhoffer, 1952); systems in which the therapist says and does nothing (Bion, 1948); systems in which patients are asked to scream or to strike out (Bach & Goldberg, 1975; Janov, 1970); methods in which the therapist makes fun of the patient, treating him or her

1

2 raymond j. corsini with apparent disrespect (Farrelly & Brasma, 1974), and methods in which the patient or client is treated with utmost respect (Losoncy, 1981); methods in which patients are treated as children (Painter & Vernon, 1981); methods that stress religion (Lair & Lair, 1973; van Kaam, 1976); and methods that are conglomerates of a wide variety of procedures (Gazda, 2001; Shostrom & Montgomery, 1978). What one authority considers psychotherapy may be completely different from how other authorities see the process. Counseling and psychotherapy are the same qualitatively; they differ only quantitatively. There is nothing that a psychotherapist does that a counselor does not do. No definition can be made that will include all psychotherapies and exclude all counseling methods. Various attempts to separate the psychotherapies and exclude all counseling methods have failed. The concept that psychotherapy goes into depth, whereas counseling does not, is discredited by procedures such as behavior modification that operate at the level of symptom removal (Wolpe, 1958). Behavior modifiers could hardly be called counselors, because they do not counsel. Also, when we encounter a term such as nondirective counseling, we recognize it as a semantic absurdity.

COUNSELING AND PSYCHOTHERAPY The terms counseling and psychotherapy probably seem interchangeable to many people, but they tend to have different meanings for people in the helping professions. Generally, counseling is understood by helping professionals to be a relatively short process, often occurring in one session and rarely comprising more than five sessions, whereas psychotherapy usually runs for many sessions and can even continue for years. Counseling is usually seen as problem-oriented, psychotherapy as person-oriented. The actual processes that occur in counseling and psychotherapy are identical, but they differ in the time spent. Essentially, counseling stresses the giving of information, advice, and orders by someone considered to be an expert in a particular area of human behavior, whereas psychotherapy is a process of helping people discover why they think, feel, and act in unsatisfactory ways. A counselor is primarily a teacher; a psychotherapist is essentially a detective. A simple example will help illustrate the difference between counseling and psychotherapy. Say that a married couple comes to a professional helper (a psychiatrist, psychologist, social worker, nurse practitioner, or the like) for help in their marriage. The helper puts on her counseling hat, listens as they tell their stories, asks questions, and finally gives information, advice, and “orders” (that is, she may insist that the couple must follow her suggestions if they are to achieve their goals). After all, if they came to her for counseling, they must be prepared to make suggested changes. Let us assume the counselor gives the couple the following information: Many marriages are unhappy because of little things, but if a couple can communicate their dissatisfactions to each other and agree by means of a mutual contract to change their behavior, the marriage may change from being unhappy to being happy. She then advises them to establish a new contract within their marriage. Let us assume the couple agrees to establish a mutual contract. The husband states that he wants his wife to stop smoking, and the wife wants her husband to put away his clothes and belongings rather than scattering them all over the house (two common complaints in marriages). Consequently, the counselor helps the couple establish a contract relative to the wife’s smoking and the husband’s sloppiness in the house. It may be that in the coming weeks, both partners live up to their agreements and that thereby marital harmony is established. The counseling has been successful. Now let us assume a different scenario. The couple returns to report that they are still unhappy. The wife has stopped smoking, but the husband is still leaving his possessions all

introduction

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over the house. As the result of further discussions, the helper suggests that the husband may need psychotherapy to try to discover why, even though he has agreed to stop this behavior, he continues it. Say that the husband accepts the suggestion and decides to have psychotherapy. The professional now puts on her psychotherapy hat. From now on, she no longer views herself as an expert on marriage who can give information, advice, and orders but instead sees herself as a facilitator, helping the husband to understand himself in general, and specifically helping him discover why he was not able to keep to his agreement to be neat in the house. At this point, the helper may act in any of a variety of unusual ways. For example, if she is a follower of Carl Rogers, she will not ask or answer questions, and she will be unwilling to give advice or suggestions. In this book we discuss a dozen ways of thinking and acting in therapy. The helper may have her own eclectic theory, and her methods of operating may be quite diverse. Let us say that the therapy is successful, that the reason for the husband’s resistance is uncovered, and that a favorable change in his behavior then occurs and the marriage is happy. Successful therapy may result, regardless of which theory and which method were applied. But what is important to recognize here is that in acting as a psychotherapist, the helper did not presume to be an expert on marriage but, rather, served as a kind of detective relative to the husband’s inability or unwillingness to conform to his own agreement. The helper as the therapist was a partner or collaborator with the husband to achieve a new state of being. Consequently, counselors are usually people who have considerable knowledge and expertise in specific areas of behavior. There are marriage and family counselors, educational and vocational counselors, counselors for people who abuse substances such as alcohol, and counselors for people who are handicapped in particular ways or have special problems such as chronic or contagious illnesses. Counselors depend on their specialized knowledge and their common sense. On the other hand, psychotherapists are generalists who tend to hold any of a variety of unusual theories or combinations of theories and who may use one or more procedures to try to achieve desired results.

PATIENT OR CLIENT? In the first four editions of this book, in the chapter on Adlerian psychotherapy, Dr. Harold Mosak used the term patient; in the fifth edition he changed this term to client. Some of our authors use one or the other of the two terms, and some use both. Psychotherapists who have a medical orientation or background tend to see those they work with as patients, whereas those who have other orientations tend to see them as clients. Thus it is possible for two therapists to see the same person at the same time in multiple therapy, with one therapist viewing that person as a patient and the other regarding that same person as a client. Neither term is really satisfactory. Patient implies illness, and client implies a business relationship. Someday, someone may coin a term that more exactly describes the role of the person who is undergoing psychotherapy. Meanwhile, in this book, each author uses whatever term he or she feels most comfortable with. All modes of trying to help people improve themselves via symbolic methods can be called psychotherapy, just as all methods to help improve psychological functioning through medications, surgery, electric shock, and other somatic procedures may be called psychiatry. Consequently, the interview, role-playing, projective, and other techniques that we discuss in this book can be considered procedures in counseling or psychotherapy, but it is best, in my judgment, to call them all processes of psychotherapy.

4 raymond j. corsini Let me illustrate by drawing on my own career preparation and “dropping a few names.” When Carl Rogers repeats what you have said, using his own terminology (as he did with me when I was in therapy with him), this is psychotherapy; when Rudolf Dreikurs, an Adlerian, points out basic life-style errors (as he did for me when I was in therapy with him), this is psychotherapy; when Albert Ellis contradicts my point of view (as he often has with me), this is psychotherapy; and when J. L. Moreno has people play different roles in front of a group (as I did when working with him), this is psychotherapy. A number of years ago, in Paris, I met with a French colleague, Dr. Anne Schutzenberger, and during the course of our conversation I mentioned psychotherapy. “Ah,” she said, “Psychothérapie comme ça—ou comme ça?” (Psychotherapy like that—or like that?) At the first ça she put the palms of her hands about an inch apart, and at the second ça she moved her hands out as far as she could, with the palms still facing each other. She was asking me whether I had a narrow conception of psychotherapy or a wide one. We can do the same thing with the hands vertically and ask about the depth of psychotherapy. Essentially, depth is a function of time spent in therapy rather than a matter of technique, and two people with the same theory and technique will vary with respect to depth, depending primarily on the time spent with the client. (I myself call the subjects of psychotherapy clients if I see them in a private office and patients if they are in a hospital or institution.)

AN UNUSUAL EXAMPLE OF PSYCHOTHERAPY About 50 years ago, when I was working as a psychologist at Auburn Prison in New York, I participated in what I believe was the most successful and elegant psychotherapy I have ever done. One day an inmate, who had made an appointment, came into my office. He was a fairly attractive man in his early 30s. I pointed to a chair, he sat down, and I waited to find out what he wanted. The conversation went something like this (P = Prisoner; C = Corsini): P: C: P: C: P:

I am leaving on parole Thursday. Yes? I did not want to leave until I thanked you for what you had done for me. What was that? When I left your office about two years ago, I felt like I was walking on air. When I went into the prison yard, everything looked different, even the air smelled different. I was a new person. Instead of going over to the group I usually hung out with—they were a bunch of thieves—I went over to another group of square Johns [prison jargon for noncriminal types]. I changed from a cushy job in the kitchen to the machine shop, where I could learn a trade. I started going to the prison high school and I now have a high school diploma. I took a correspondence course in drafting and I have a drafting job when I leave Thursday. I started back to church even though I had given up my religion many years ago. I started writing to my family and they have come up to see me and they remember you in their prayers. I now have hope. I know who and what I am. I know I will succeed in life. I plan to go to college. You have freed me. I used to think you bug doctors [prison slang for psychologists and psychiatrists] were for the birds, but now I know better. Thanks for changing my life.

I listened to this tale in wonderment, because to the best of my knowledge I had never spoken with him. I looked at his folder and the only notation there was that I had given him an IQ test about two years before. “Are you sure it was me?” I finally said. “I am not a psychotherapist, and I have no memory of ever having spoken to you. What you are reporting is the sort of personality and behavior change that takes many years to accomplish—and I certainly haven’t done anything of the kind.”

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“It was you, all right,” he replied with great conviction, “and I will never forget what you said to me. It changed my life.” “What was that?” I asked. “You told me I had a high IQ,” he replied. With one sentence of five words I had (inadvertently) changed this person’s life. Let us try to understand this event. If you are clever enough to understand why this man changed so drastically as a result of hearing these five words “You have a high IQ,” my guess is that you have the capacity to be a good therapist. I asked him why this sentence about his IQ had such a profound effect, and I learned that up to the time that he heard these five words, he had always thought of himself as “stupid” and “crazy”—terms that had been applied to him many times by his family, teachers, and friends. In school, he had always received poor grades, which confirmed his belief in his mental subnormality. His friends did not approve of the way he thought and called him crazy. And so he was convinced that he was both an ament (low intelligence) and a dement (insane). But when I said, “You have a high IQ,” he had an “aha!” experience that explained everything. In a flash, he understood why he could solve crossword puzzles better than any of his friends. He now knew why he read long novels rather than comic books, why he preferred to play chess rather than checkers, why he liked symphonies as well as jazz. With great and sudden intensity he realized through my five words that he was really normal and bright and not crazy or stupid. He had experienced an abreaction that ordinarily would take months. No wonder he had felt as if he were walking on air when he left my office two years before! His interpretation of my five words generated a complete change of self-concept— and consequently a change in both his behavior and his feelings about himself and others. In short, I had performed psychotherapy in a completely innocent and informal way. Even though what happened in no way matches the definition given earlier—that is, even though there was no agreement between us, no theory, and no intention of changing him—the five-word comment had a most pronounced effect, and so it was psychotherapy. Conversely, I have had two clients who, after more than 10 years of psychotherapy, made little progress as far as I could tell.

COMPARISONS OF THEORIES Karl Popper (1968), the philosopher of science who wrote Conjectures and Refutations, makes the astute observation that Marxists, Freudians, and Adlerians are all able to find evidence of the validity of their theories in any aspect of human behavior: During the summer of 1919 . . . I began to feel more and more dissatisfied with these theories . . . and I began to feel dubious about their claim to scientific status. . . . Why are they so different from Newton’s theory and especially from the theory of relativity? . . . It was not my doubting the truth of these theories which bothered me. . . . [W]hat worried me was . . . that these . . . theories, though posing as sciences, had in fact more in common with primitive myths than with science: that they resembled astrology more than astronomy. (p. 34) Popper goes on to say that he at the time had no reason to believe that Einstein’s theory was correct, but Eddington’s observation that light did not travel in a straight line but was bent by the sun due to gravitational attraction gave proof of the incorrectness of previous theories (such as Newton’s) and so established Einstein’s theory as superior to Newton’s theory. Popper concluded that (1) it is easy to find confirmation of the validity of theories, (2) confirmation should be considered only if it results from a risky prediction, (3) the more a theory “forbids,” the better it is, (4) a theory that is not possibly refutable

6 raymond j. corsini is a poor theory, (5) genuine tests of theories are attempts to refute them, and (6) the only good evidence is negative evidence—in other words, an unsuccessful attempt to refute a particular theory. Unfortunately, if we accept Popper’s contention that the scientific status of any theory rests on its potential for falsification, no theory of psychotherapy qualifies as scientific.

MODES OF PSYCHOTHERAPY All psychotherapies are methods of learning. All psychotherapies are intended to change people: to make them think differently (cognition), to make them feel differently (affection), and to make them act differently (behavior). Psychotherapy is learning. It may be learning something new or relearning something one has forgotten; it may be learning how to learn, or it may be unlearning; paradoxically, it may even be learning what one already knows.

Cognition There are two general ways we learn: directly by experience, and indirectly by symbols. Consider a simple example: A child about 3 years old sees the toast shooting up from a toaster and goes to touch the shiny gadget. The child has no idea that the toaster is hot. Now, how can the child learn that a toaster can be hot and can hurt? One way would be for the child to touch the toaster, thus learning by direct experience. Another way is by symbols (words)—that is by being told, “When we use the toaster, it gets hot, and if you touch it you will be burned.” In both cases, the child learns—in one case, actively (through experience) and in another case, passively (through information). Some therapists tend to use “active” methods, and their clients essentially learn on their own, whereas some therapists tend to make their clients passive learners. Two strongly contrasting learning styles are represented by the methodologies of Carl Rogers and Albert Ellis. In psychoanalysis, both modes occur. For example, while free associating, the patient may be said to be learning actively. Let us show this by a hypothetical example: Patient: “I really think my mother liked my brother more than she liked me. I can’t understand why. I tried so hard to win her affection, but somehow I never was able to make her really like me. But recently when I spoke about this with my brother, he told me he always thought that I was Mother’s favorite. How could this be? Could I have misinterpreted my mother? He thought I was the favorite and I thought he was. Who was? Maybe no one? Maybe Mamma liked us both equally, or as equally as possible. How did we come to have opposite conclusions? I think we are just both pessimists, that’s what it is! I am sure of it, both of us misinterpreted Mother.” This is an example of someone talking to himself, conducting a self-analysis, engaged in active learning. An actual example of passive learning follows: Client: I had the funniest dream. I was being chased by a rooster, and I was running for my life, and I knew that if I got to Lokonner Bay, I would be safe. Therapist: How do you spell that? C: I don’t know. It is pronounced LOKONNER BAY. T: And you don’t know any such place? C: No. T: Can you figure out what Lokonner means? C: I have been thinking all day about it. It makes no sense to me.

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T: Should I tell you what I think it means? C: Please. I have absolutely no idea. T: Well, dreams are all symbols. The rooster that is chasing you is a symbol of the male sexual organ, the “cock,” so you are running away from sex. But you believe you will be safe if you can get to Lokonner Bay. C: But what does Lokonner Bay mean? I have never heard of such a place. T: Lokonner is probably a contraction for “Love, honor, and obey.” What you are saying in your dream is this: Some man is pressuring you to have sex and you want him to marry you. You are afraid to have sex, but if you can get him to marry you (love, honor, and obey), you will be safe. These examples illustrate two general ways of learning in psychotherapy: actively through self-analysis and passively through being helped to understand the meaning of a dream.

Behavior Learning can also occur through action. For example, during World War I, Ernst Simmel was a German army psychiatrist concerned with curing German soldiers who were suffering from what was then called shell shock (Simmel, 1949). Believing that their condition was caused by repressed hatred of their officers, he gave these men bayoneted rifles and had them attack straw-filled dummies dressed as German officers. The modality of treatment was physical action. Some theorists believe that plain physical exercise is psychotherapeutic. Action is used in a number of psychotherapies. One argument for body therapies is the assertion that there is no mind. If we can affect the body, that is all that is needed: the body learns, the body is real, all else is an illusion. A contrary argument for body therapies is that the mind does exist, that conditions of the body affect the mind, and that if we work from the outside in, by changing the body we can change the mind. An example might be plastic surgery. Changing someone’s looks can affect how that person views himself or herself. Other examples of physical behavior as psychotherapy include complex physical activities, such as role playing, and doing therapeutic “homework”—that is, doing under direction things that one would not ordinarily do, such as asking for a date or looking for a job. As in the case of cognitive therapies, behavioral work in therapy can range from active to passive. In examining the various systems in this book, the reader may want to consider how much physical behavior is called for in the particular therapy.

Affection A third modality in psychotherapy is affection, known more popularly as emotions or feelings. The therapist who believes that this modality will be most effective with a particular client or patient may do things to stir up the person: to raise the individual’s emotional state through attempts to make him or her fearful, anxious, angry, hopeful, and so on. We cannot really work directly with the emotions and must reach them indirectly through the intellect or the body. Emotions are an important part of human psychology. However, we cannot manipulate emotions in the way we can manipulate thinking or behaving. Some systems of psychotherapy are intended to reduce or negate emotions, which are believed by these therapists to undermine the therapeutic process. Adlerian psychotherapy, for example, is essentially a cognitive therapy, and Adlerians usually see emotions as sabotaging efforts in the therapeutic process. However, in psychodrama (for example), both the words that the therapist will employ and the behavior directed toward the subject by the other actors are intended to generate strong emotions.

8 raymond j. corsini Some people see emotions as epiphenomena accompanying but not affecting therapeutic change, others see emotions as powerful agents leading to change, and still others see emotions as evidence of change. The whole issue of the relationship of emotions to psychotherapy is unsettled. The reader would do well to note and consider the place of emotions in the various systems described. All therapies are essentially combinations of all three of these modalities. Although some therapies are rather “pure” in that they attempt to deal only with the body, the intellect, or the emotions, elements of each apply in most cases. Thus, for example, in rational emotive behavior therapy, even though rational thinking is utilized for the most part in dealing with the patient, the therapist may give the client direct orders to do certain things (homework). And in cognitive therapy, emotionally upsetting situations are sure to develop. A therapist may think that improvement is a function of one element, but the curative process may actually be something else. It may not be the message per se that generates a change but, rather, the way the client interprets it. Were exactly the same treatment to be administered by a robot, it might not have any beneficial psychological effect. Change may well result from the interpretation, “Someone cares for me enough to do this to me.” One final common pathway for all therapies is a new way of seeing life, a reevaluation of self and others. If so, then all therapies are essentially cognitive. Still another way of considering psychotherapy is to see it as a process of “selling”—of trying to help a person to accept a new view of self and of others. From this perspective, the psychotherapist is a persuader or a facilitator attempting to change opinions. A clear-cut example of persuasion would be attempting to do psychotherapy with someone with a fixed paranoid delusion. A more common example is dealing with a person with incapacitating feelings of inferiority by trying to “sell him” on the notion that he is really OK. Another common example would be dealing with someone who harbors mistaken ideas about marriage or parenting. In all these cases, the therapist is, in a real sense, a salesperson attempting to sell new ideas, new concepts, and new behaviors.

MECHANISMS OF PSYCHOTHERAPY One of the most exciting meetings I ever attended included a major presentation by Carl Rogers on the necessary and sufficient conditions for psychotherapy. It was a most logical and impressive speech, and it deeply affected me. However, the next speaker was Albert Ellis, who had been asked to comment on Rogers’s paper. Ellis stated that in 25 years of clinical experience he had had many successful cases, but none of Rogers’s criteria seemed to him to be either necessary or sufficient. There was not then, and there is not now, any consensus about what constitutes the basis for change in psychotherapy. Each contributor to this volume uses a section titled Mechanisms of Psychotherapy to discuss what makes psychotherapy work. However, I have my own ideas that I would like to share with readers at this point. Some 50 years ago, with a psychiatrist colleague, Dr. Bina Rosenberg, I searched through more than 300 articles to identify the critical elements necessary for changing people (Corsini & Rosenberg, 1955). We found 220 statements such as “People change when they think that others believe in them” and “The realization that they are not alone makes the difference.” We eliminated redundant items, performed a “clinical factor analysis,” and identified nine factors.

Cognitive Factors Universalization. Clients improve when they realize that they are not alone, that others have similar problems, and that human suffering is universal.

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Insight. Growth occurs as clients increasingly come to understand themselves and others and gain different perspectives on their own motives and behaviors. Modeling. People benefit from watching other people. A client may model himself or herself on the therapist.

Affective Factors Acceptance. This factor reflects the sense of getting unconditional positive regard, especially from the therapist. Altruism. Change can result from the recognition that one is the recipient of the love and care of the therapist or other members of the group or from the sense of providing love and care to others and the feeling that one is helping others. Transference. This factor identifies the emotional bond that forms between the therapist and the client or between clients in a group setting.

Behavioral Factors Reality testing. Change becomes possible when clients experiment with new behaviors in the safety of the therapy hour, receiving support and feedback from the therapist and other group members. Ventilation. This factor encompasses those statements attesting to the value of “blowing off steam” through shouting, crying, or displaying anger in a context in which one can still feel accepted. Interaction. Clients improve when they are able to openly admit to the group that there is something wrong with themselves or their behavior. I believe these nine factors are the basic mechanisms of therapeutic change. Close examination of this model reveals that the cognitive factors imply “Know yourself,” the affective factors tell us “Love your neighbor,” and the behavioral factors essentially suggest “Do good works.” Perhaps there is nothing new under the sun, for this is what philosophers have told us for millennia: Know thyself, love thy neighbor, and do good works.

THE CURRENT SITUATION IN PSYCHOTHERAPY Corsini (2001) listed 250 different systems of psychotherapy, but currently there are probably more than 400 such systems. Just as there are some religions that are well known and widely accepted, some psychotherapies are well known and widely accepted. And just as there are religions viewed as unorthodox and absurd, there are systems of psychotherapy that exist on the fringe of traditional approaches. I was originally trained as a Rogerian therapist (I believe it is probably the best way for a would-be therapist to start training—and, for some people, the best way to remain). After 10 years of experience with this mode of therapy, I applied for a job at a prestigious institute, and while being interviewed, I was asked how I dealt with the problem of transference. I think I could not have shocked my learned colleagues more had I slapped them on the face when I replied, “To the best of my knowledge, none of my clients ever formed a transference relationship with me.” They held their mouths open, staring first at me and then at each other, unable to believe what they had heard me say. For this particular group, transference was a necessary factor in psychotherapy, and for someone who claimed to be a psychotherapist to deny transference was unthinkable.

10 r a y m o n d j . c o r s i n i In psychotherapy, ideological enclaves are found. Some enclaves consist of people who believe that they have the right, the final, the complete, and the only answer—and that all other systems are incomplete, tentative, weak, or simply mistaken. People within these enclaves (which are known as schools of therapy) tend to communicate mostly with people they meet at conventions. They read each other’s writings, and they tend over time to develop specialized vocabularies. They reinforce one another by recounting their successes with the former clients of therapists of different persuasions, “proving” to one another the superiority of their way of thinking and acting. As time goes on, within any particular method of psychotherapy, alternative positions tend to develop, schismatic groups begin to form, and then these groups either are expelled from the original enclave or take off on their own. This has happened many times in the case of people originally trained as Freudian psychoanalysts. I believe this situation is changing and these ideological boundaries are becoming more permeable. As Garfield and Bergin put it, “A decisive shift in opinion has quietly occurred; and it has created an irreversible change in professional attitudes about psychotherapy and behavior change. The new view is that the long-term dominance of the major theories is over and that an eclectic position has taken precedence” (1994, p. 7). I would go even further and state that all good therapists adopt an eclectic stance. This does not mean that they do not follow a particular theory or use specific methods associated with particular approaches to therapy; it does mean that technique and method are always secondary to the clinician’s sense of what is the right thing to do with a given client at a given moment in time, irrespective of theory. Put more simply, psychotherapy remains an art. Thus, if formal eclecticism is on the rise, it is all to the good: It shows the maturing of psychotherapy. Why then, a book such as this? In order to be effectively eclectic, one needs to know as many different theories and systems as possible, from which one can develop a personal theory, a personal system, and an integrated approach. Initially, the neophyte therapist is best served by operating as strictly as possible within the limits of a given system, with close supervision by a skilled practitioner of that system. Later, with experience, one can begin to develop one’s own individual style of therapy.

The Whohowwhom Factor I have come to believe that what counts in psychotherapy is who does it and how and to whom it is done: the whohowwhom factor. This belief developed from my experiences in a small group practice in which all the therapists had the same basic theoretical and operational concepts. We consulted on each other’s cases, worked together in co-therapy, met weekly to discuss cases we were handling, and came to know each other quite well over the 6-year period that I was with this group of Adlerians. However, although we all shared the same theoretical position and generally operated in the same manner, any new clients who came to our clinic were likely to get different kinds of therapy as a consequence of the whohowwhom factor. One therapist liked to tell stories to make various points. Another liked to ask Socratic questions. Still another would frequently interrupt to demonstrate errors in the client’s thinking and behavior. One played the role of the loving father; another was quite sarcastic. Some were friendly; others were distant. Some saw clients as equals; others saw clients as students who needed to be taught more effective ways to operate. So even in this particular group, with a shared theory and methodology, there were wide variations in therapy practice and style. The senior therapist, who had trained the others, was in a good position to decide which new client was to go to which therapist. For example, he tended to assign me difficult adult clients but no adolescents. Sometimes the how variable will be of less importance than the match between who and whom, because differences in actual technique may be relatively small for some

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systems. However, at times an apparently circumscribed method, such as the personcentered approach, may achieve superior results for some people when other, more complex methods will fail. I am reminded of the fable of the cat and the fox. The fox bragged that he had many ways of escaping from dogs. The cat admitted she had only one: to climb a tree. Then both the cat and the fox were chased by dogs. The cat scampered up the tree and remained there until the dogs went away. The fox used all his tricks but eventually was caught. Indeed something simple is often superior to something complicated, and even in psychotherapy, less can be more.

Research Many people in the recent history of psychotherapy have wondered about the effectiveness of counseling and psychotherapy. At one time, Dr. Wedding wanted to include a section in every chapter of this book examining relevant research findings for each system, but practically every contributor was against the idea. Nonetheless, the sentiment expressed by Strupp and Bergin (1969, p. 20) is still very much on people’s minds: The problem of psychotherapy research in its most general terms should be reformulated as a standard scientific question: What specific therapeutic interventions produce specific changes in specific patients under specific conditions? Perhaps the best and most complete answer to the issue of such research was given by C. H. Patterson (1987, p. 247): Before this model (relative to research) could be implemented we would need (1) a taxonomy of client problems or psychological disorders . . . ; (2) a taxonomy of client personalities; (3) a taxonomy of therapeutic techniques . . . ; (4) a taxonomy of therapists; and (5) a taxonomy of circumstances. . . . If we did have such systems of classification, the practical problems would be insurmountable. Assuming five classes of variables, each with ten classifications, . . . a research design would require 10 × 10 × 10 × 10 × 10 or 100,000 cells. . . . So, I conclude we don’t need complex multivariate analyses and should abandon any attempt to do the crucial, perfect study of psychotherapy. It simply is not possible. It is difficult for me or anyone else brought up with nomothetic approaches, and imbued with Edward Lee Thorndike’s concept that anything that exists can be measured, to accept this pessimistic point of view, but I contend that Patterson, who has studied this issue intensively and written widely on the problems of research in counseling and psychotherapy, is essentially correct. Psychotherapy is an art based on science, and as is true for any art, there can be no simple measures of so complex an activity.

CORRECTION OF A HISTORICAL ERROR In many historical accounts found in textbooks, an essentially incorrect view of the early years of psychotherapy is recounted. The story given generally goes as follows: In the beginning, Sigmund Freud started a brand new system of psychotherapy called psychoanalysis. A number of other people learned about it and became his students. In later years, for a variety of reasons, they decided to separate from him and went on to start their own systems of thought. In reality, numerous people preceded Freud, doing psychotherapy in a variety of ways. We may start with the Swiss physician Paul Dubois (1848–1918), one of the first psychotherapists in the modern sense of the term, because his method of treating psychotics was to talk with them in a reasonable manner. Still another person to be considered is

12 r a y m o n d j . c o r s i n i Pierre Janet (1859–1947), who is referred to by Ellenberger as “the first person to found a new system of dynamic psychiatry aimed at replacing those of the nineteenth century” (1970, p. 331). Janet, at about the time that Sigmund Freud began his work, was the best known and most respected psychotherapist of his time. There was a great deal of interest and activity in psychotherapy prior to Freud, and there were already the conflicts, schisms, claims, and jealousies that are also to be found later. The whole history of psychotherapy is replete with personality clashes and other signs of struggles for superiority. In 1902, Sigmund Freud invited several colleagues to meet with him to discuss personality theory. The group was later to be called the Wednesday Psychological Society. Some of the members were independent thinkers, each with his own position; Freud, the oldest, the best known, and the most published, was the host. It is important to understand that some members of this group were psycho-analysts and not psychoanalysts. Hyphenated, this word meant that these people were interested in the analysis of the psyche; spelled as one word it meant that they were followers of Sigmund Freud. Three members of this Wednesday night group are the subjects of the next three chapters: Sigmund Freud, Alfred Adler, and Carl Jung. From the beginning, these three moved in quite different directions. Freud was a mechanistic, deterministic thinker who developed a system of psychology with essentially biological/hydraulic elements: a system of stresses and strains, conflicts and tensions, with a dynamic interaction between biological instinctive drives and social demands. Adler was essentially a common-sense thinker with a shrewd understanding of people’s motivations. Jung was an internalized person, mystical, religious, and creative. Freud was the ideal German scientist, a keen student of minutiae, a pedant; Adler was a man of the people, socially oriented and concerned; Jung was an introverted, distant but friendly person. Their theories of personality and their psychotherapeutic systems can be seen as direct extensions of their manifest personalities. Since the deaths of Freud in 1939, Adler in 1937, and Jung in 1961, the theories of the latter two have remained more or less constant. The theory of Freud has evolved into a number of distinct approaches, some quite different from Freud’s original thinking. There are now a variety of psychoanalytic groups with varying orientations. To draw a religious analogy, psychoanalysis may be likened to Christianity; in both, various groups use the same ultimate authority (in one case, the Bible; in the other, Freud’s papers) but have different interpretations of these basic writings. During the period from 1910 to about 1939, these big three dominated psychotherapy in Europe and the United States. However, a number of other points of view existed at that time, most of which either have disappeared or have been incorporated into eclectic thinking, including the theories of such people as Pierre Janet, Jules Déjèrine, Trigant Burrow, Alfred Korzybski, Otto Rank, and Wilhelm Reich. However, a number of theories and methodologies considered to be deviations from pure Freudian psychoanalysis, such as the therapies of Harry Stack Sullivan, Karen Horney, and Theodore Reik, are still very much alive. Since 1940, when Carl Rogers delivered his historic Psi Chi paper in Minnesota, a considerable number of alternative systems of psychotherapy have come into being. It is difficult to pinpoint their beginnings because there is generally a considerable lapse of time between when a system starts and when publications about it first appear. But it might not be too far off to say that from about 1900 to 1939 there were three major points of view and about a dozen minor ones in psychotherapy and that during the next 60 years there were a dozen major points of view (including the original three) and perhaps two dozen others of consequence. This situation leads to the speculation that as time goes on, there may continue to be an expanding universe of major and minor systems of psychotherapy. If psychotherapy is

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essentially a matter of philosophy, then ultimately there will be multiple systems; if it is essentially a matter of science, then ultimately there will be one eclectic system.

PSYCHOTHERAPY AND PSYCHOTHERAPIST There appears to be a concordance between the personality of a psychotherapy innovator and the system he or she has developed. In an article titled “Freud, Rogers and Moreno” (Corsini, 1956), I compared the manifest personalities of these three men and their systems of psychotherapy. I never met Freud, but there is a good deal of biographical information about him, and there seems to be no question that his personality and his method of psychoanalysis were congruent. Freud was a rather shy person, uncomfortable with people, a pedantic, bookish type, an intellectual. His methodology—having people lie down, with him sitting behind them and out of sight while he listened intently to what they said—fits exactly his manifest personality. The system and the man seem identical. I got to know Carl Rogers quite well. As a graduate student at the University of Chicago (1953–55), I was in contact with him both as a client and as a student. In later years I met him on many occasions socially and at professional meetings. Rogers, whether in his social life, as a teacher, or as a therapist, was exactly the same. He and his system were identical. I also got to know J. L. Moreno, the founder of psychodrama. I listened to him lecture many times, I was often on the psychodrama stage with him, and we had a social relationship. There was no question at all about the congruence of Moreno’s unique personality and his methodology. Again, the system and the man were identical. What is the implication of these similarities for the reader? I believe that if one is to go into the fields of counseling and psychotherapy, then the best theory and methodology to use must be one’s own. The reader will not be either successful or happy using a method not suited to her or his own personality. Truly successful therapists adopt or develop a theory and methodology congruent with their own personality. (See Corsini, 1991, and Dumont & Corsini, 2000, for examples.) In reading these accounts, in addition to attempting to determine which school of psychotherapy seems most sensible, the reader should also attempt to find one that fits his or her philosophy of life, one whose theoretical underpinnings seem most valid, and one with a method of operation that appears most appealing in use. A final value of this book lies in the greater self-understanding that may be gained by close reading. This book about psychotherapies may be psychotherapeutic for the reader. Close reading vertically (chapter by chapter) and then horizontally (section by section) may well lead to personal growth as well as to better understanding of current psychotherapies.

REFERENCES Bion, J. (Ed.). (1948). Therapeutic social clubs. London: Lewis.

Corsini, R. J., & Rosenberg, B. (1955). Mechanisms of group psychotherapy. Journal of Abnormal and Social Psychology, 51, 406–411.

Corsini, R. J. (1956). Freud, Rogers and Moreno. Group Psychotherapy, 9, 274 –281.

Dumont, F., & Corsini, R. J. (2000). Six therapists and one client. New York: Springer.

Corsini, R. J. (1968). Counseling and psychotherapy. In E. F. Borgotta & W. W. Lambert (Eds.), Handbook of personality theory and research. Chicago: Rand McNally.

Ellenberger, H. (1970). The discovery of the unconscious. New York: Basic Books.

Bach, G. R., & Goldberg, H. (1975). Creative aggression. Garden City, NY: Doubleday.

Corsini, R. J. (1991). Five therapists and one client. Itasca, IL: F. E. Peacock. Corsini, R. J. (Ed.). (2001). Handbook of innovative therapy (2nd ed.). New York: Wiley.

Farrelly, F., & Brasma, J. (1974). Provocative therapy. Cupertino, CA: Meta. Garfield, S. L., & Bergin, A. E. (1994). Introduction and historical overview. In A. E. Bergin & S. L. Garfield, Handbook of psychotherapy and behavior change. New York: Wiley.

14 r a y m o n d j . c o r s i n i Gazda, G. M. (2001). Life skills training. In R. J. Corsini (Ed.), Handbook of innovative therapy (pp. 354–359). New York: Wiley. Horney, K. (1942). Self-analysis. New York: Norton. Janov, A. (1970). The primal scream. New York: Vintage Books. Lair, J., & Lair, J. C. (1973). Hey, God, what should I do now? New York: Doubleday.

Reik, T. (1948). Listening with the third ear. New York: Farrar and Strauss. Schmidhoffer, E. (1952). Mechanical group therapy. Science, 115, 120–123. Shostrom, E. L., & Montgomery, D. (1978). Healing love. Nashville: Abington.

Losoncy, L. (1981). Encouragement therapy. Englewood Cliffs, NJ: Prentice-Hall.

Simmel, E. (1949). War neuroses. In S. Lorand (Ed.), Psychoanalysis today (pp. 227–248). New York: International Universities Press.

Painter, G., & Vernon, S. (1981). Primary relationship therapy. In R. J. Corsini (Ed.), Handbook of innovative psychotherapies. New York: Wiley.

Strupp, H. H., & Bergin, A. E. (1969). Some empirical and conceptual bases for coordinated research in psychotherapy. International Journal of Psychiatry, 1, 18–90.

Patterson, C. H. (1987). Comments. Person-Centered Review, 1, 246–248.

van Kaam, A. (1976). The dynamics of spiritual self-direction. Denville, NY: Dimension Books.

Popper, K. R. (1968). Conjectures and refutations. Oxford: Oxford University Press.

Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press.

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psychoanalysis Ellen B. Luborsky, Maureen O’Reilly-Landry, and Jacob A. Arlow

OVERVIEW “It doesn’t add up.” How could a seemingly nice person abuse a child? Why would someone not show up at her own wedding, one she’d planned for a year? How could a child from a great neighborhood with fine schools and an intact family never develop any ambition? The next time you wonder, give credit where credit is due. Over one hundred years ago, Sigmund Freud pronounced that the surface, or manifest, level of life is but the topsoil of mental activity. Much of it happens at an unconscious level. Symptoms and problem behavior begin to make sense when the deeper levels are understood. Psychoanalysis, a system of treatment as well as a way to understand human behavior, has given rise to discoveries and controversies that are actively with us today. It has seeped into the language (“Was that a Freudian slip?”) and made an impact on our thinking. Consider your reaction to the questions raised at the beginning of the chapter. Did you wonder whether the abuser had himself been abused? (Repetition of an early experience not consciously remembered.) Did you suspect that the woman who never showed up at her wedding had mixed feelings she couldn’t face? (Inner conflict, with warded off emotional experience.) Did you think that the student without ambition had more issues than meet the eye? (The surface story functioning as a cover for, or defense against, inner emotional experience.) Psychoanalytic thinking has evolved over the last century, so that classical and modern psychoanalytic approaches now coexist. It has spawned different forms of psychotherapy, with psychodynamic psychotherapy being its most direct descendant. According to

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16 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w Rangell (1963), most of the widely practiced forms of psychotherapy are based on some element of psychoanalytic theory or technique. Psychoanalysis has affected fields that range from child development to philosophy to feminist theory. It has inspired thinkers and therapists who disagree with Freud’s premises to come up with methods of their own. Whether because it is rejected, adapted, or accepted, Freud’s legacy is still with us. The purpose of this chapter is to better understand psychoanalysis, particularly those concepts that have had staying power. Freud’s own concepts evolved over the course of his lifetime, and they continue to do so. Controversy and change have accompanied psychoanalysis since it began. The tests of time and of research have highlighted some ideas and discredited others. Both the clinical and the empirical evidence for the usefulness of psychoanalytic thinking will be explored. The goals of this chapter are • • • • • • •

To present the central psychoanalytic concepts To examine the ways in which those concepts have evolved To demystify the language and principles of psychoanalysis To look at the treatment methods that have emerged from a psychoanalytic perspective To consider different applications of psychodynamic ideas To examine research evidence for psychoanalytically oriented treatment To give examples of how psychodynamic ideas can be used in psychotherapy

Basic Concepts You have been trained to find an anatomical basis for the functions of the organism and their disorders, to explain them chemically and view them biologically. But no portion of your interest has been directed to the psychical life, in which, after all, the achievement of this marvelously complex organism reaches its peak. (Freud, 1916, p. 20) Psychoanalysis seeks to understand human behavior through an investigation of inner experience, and to treat psychological problems through a clinical application of that understanding. Consequently, the central tenets include both theoretical concepts and clinical methods.

Basic Theoretical Concepts The Unconscious The division of the psychical into what is conscious and what is unconscious is the fundamental premise of psychoanalysis. (Freud, 1923, p. 15) The unconscious consists of states of mind that are outside awareness. They include both emotional and cognitive processes, along with forms of memory that affect the patient’s reactions and behavior. Although the concept of the unconscious mind predates psychoanalysis, Freud’s unique contribution was to discover how the concept could be used to understand and inform the treatment of psychological problems. The scientific status of the unconscious has been in question since the concept was proposed. Recent discoveries of neuroscience offer some support for the influence of mental processes that are outside conscious awareness.

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Psychodynamics Our purpose is not merely to describe and classify the phenomena, but to conceive of them as brought about by the play of forces in the mind. . . . We are endeavoring to attain a dynamic concept of mental phenomena. (Freud, 1952, p .60) Psychodynamics is the “play [that is, the interplay] of forces of the mind.” The concept of inner conflict is a prime example of psychodynamics at work. The term inner or intrapsychic conflict refers to conflict between parts of the self that hold opposing perceptions or emotions, one or more of which is out of awareness. This may result either in problematic behavior or in symptoms. For example, a patient may express the conviction that he loves his wife and would never do anything to hurt her, while having affairs outside of the marriage. He may be acting out feelings that conflict with his consciously held beliefs. Or a patient may get a headache whenever Monday comes. The symptom may express a conflict between the part of her that knows she must go back to work and the part that dreads doing so. Symptoms in psychodynamic theory are often seen as an expression of inner conflict. Whereas in the medical or diagnostic model a symptom is a sign of a disorder, here a symptom is a clue, expressed through the language of behavior, to the patient’s core conflicts. Decoding its meaning in the course of treatment allows the feelings once expressed through the symptom to be expressed in less harmful ways. The symptom-context method is a clinical-research method that aids in that process.

Psychodynamic Psychotherapy. Psychotherapies that follow in a psychoanalytic tradition are referred to as psychodynamic treatments. They retain the central dynamic principles of psychoanalysis but do not make use of the metapsychology, or formal theories of the structure of the mind. Even Freud came to the conclusion that metapsychological hypotheses are “not the bottom, but the top of the whole structure [of science] and they can be replaced and discarded without damaging it” (Freud, 1915b, p. 77). Dynamic psychotherapy evolved from psychoanalysis to fill the need for a form of treatment that was not so lengthy and involved. Whereas psychoanalysis is typically conducted three to five times a week, with the patient lying down, dynamic psychotherapy usually takes place once or twice a week, with the patient sitting up. Supportive-expressive (SE) psychotherapy is a current form of dynamic treatment that incorporates clinicalresearch methods. Defenses The term “defense”. . . is the earliest representative of the dynamic standpoint in psychoanalytic theory. (Freud, A., 1966, p. 42) Defense mechanisms are automatic forms of response to situations that arouse unconscious fears or the anticipation of “psychic danger.” Examples of common defenses include avoidance and denial. These both function as “ways around” situations that bring up thoughts or emotions that the patient cannot tolerate. In the short term, such defense mechanisms may benefit functioning by making potentially overwhelming feelings manageable. However, they can cause problems in real life if they tend to obscure or distort reality. For example, a student who spends all of her time online instead of studying for exams may be using the defense of avoidance to counteract the intense anxiety she would feel if she opened up the semester’s untouched work. Other defenses will be discussed in the next sections of this chapter.

Transference. Transference, Freud’s cornerstone concept, refers to the transfer of feelings originally experienced in an early relationship to other important people in a

18 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w person’s present environment. They form a pattern that affects the patient’s attitudes toward new people and situations, shaping the present through a “template” from the past. Each individual, through the combined operation of his innate disposition and the influences brought to bear on him during his early years, has acquired a specific method of his own in the conduct of his erotic life. This produces a stereotype plate [or template], or several such, which is constantly repeated . . . in the course of a person’s life. (Freud, 1912, pp. 99–100) In psychoanalysis, the analysis of the transference is fundamental to the treatment. The patient’s transference to the analyst enables them both to see its operating force and to work on separating reality from memories and expectations. The transference contains patterns from the past that may be remembered through actions or through repetition of the past, rather than through recollection; “. . . the patient does not say that he remembers that he used to be defiant and critical toward his parents’ authority; instead he behaves that way to the doctor” (Freud, 1914, p. 150). Transference has been investigated through clinical research on the Core Conflictual Relationship Theme (CCRT) method. This research, which both clarifies and validates the concept, will be explored later in this chapter. Countertransference refers to the therapist’s reactions to the patient. As the counterpart to the transference, it refers to the therapist’s reactions to a patient that may be linked to personal issues the therapist needs to resolve. Countertransference has been used recently to evaluate whether the therapist’s reactions may be responses to the patient’s emotions or to nonverbal communications from the patient.

Basic Clinical Concepts Free Association. “Say what comes to mind” is a typical beginning to any psychoanalytic treatment. Unlike other forms of treatment, psychoanalysis invites all thoughts, dreams, daydreams, and fantasies into the treatment. Psychoanalysts believe that the expression of unedited thoughts will bring richer material about the inner workings of the mind. The less edited the material, the more likely that it will contain clues to parts of the self that may previously have been expressed through symptoms. Free association also gives the patient a chance to hear himself. Therapeutic Listening. Freud recommended maintaining a state of “evenly hovering attention” to what the patient says. That means that the analyst does not seize on one topic or another but, rather, listens to all the levels of the communication at once. That includes what the patient is literally saying, what kinds of emotions she conveys, and the analyst’s reactions while listening. This form of listening is at the foundation of the analytic method, since it allows a full hearing of the patient. A second kind of therapeutic listening occurs when the analyst develops a sense of the patient’s patterns—those that may form the transference as well as those that link symptoms with their meanings. Therapeutic Responding. Interpretation is the fundamental form of responding in traditional psychoanalysis. It involves sharing an understanding of a central theme of the patient, often a facet of the transference. Interpretations are intended to help a patient come to terms with conflicts that may have been driving his behavior or symptoms, offered when the analyst senses that the patient is ready to grapple with them. The interpretation of dreams has a special place in psychoanalytic treatment. “The interpretation of dreams is the royal road to a knowledge of the unconscious activities of the mind” (Freud, 1900, p. 608). Freud believed that the manifest content, or surface

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story, of dreams could be decoded to reach the deeper, latent content. Ways to understand the language of the dream will be explored in the next section. Empathy as a form of therapeutic responding has received increasing attention since the second half of the twentieth century. Empathic responding means attuning to the patient’s feeling states and conveying a sense of emotional understanding. Research now links the therapist’s empathy with the outcome of the treatment.

The Therapeutic Alliance. The therapeutic or working alliance is the partnership between the patient and therapist forged around working together in the treatment. Greenson (1967) clarified the difference between the working alliance and the transference and emphasized the importance of the alliance to the treatment. Current research confirms that a positive helping alliance is one of the factors that is consistently associated with a good outcome in psychotherapy.

Other Systems Psychoanalysis serves as both the grandfather and the current relative to many forms of psychotherapeutic practice. Some other systems and theorists (notably Jung and Adler) branched off from psychoanalysis during Freud’s lifetime. Others began as later adaptations and either remained under the “analytic umbrella,” as did dynamic psychotherapy, or highlighted an essential difference, as did Carl Rogers. A number of distinct, but still essentially psychoanalytic, theories have emerged since Freud’s time. These include classical psychoanalysis, ego psychology, interpersonal psychoanalysis, object relations and other relational perspectives, and self-psychology. Although psychoanalysis as a system of thought comprises many theories, three basic ideas are common to all and provide a framework for comparison with other systems of psychology: the role of the unconscious, the phenomenon of transference, and the relevance of past experiences to present personality and symptoms.

The Unconscious Mind The first central concept that distinguishes psychoanalysis from many other systems of psychology is a belief in the importance of the unconscious in understanding the human psyche. Other systems of psychology that acknowledge the significance of the human unconscious are, understandably, those developed by theorists who studied directly with Freud. Most notable among these is Carl Jung. Jung retained Freud’s belief in the unconscious but saw it as consisting of two important aspects. In addition to the type of personal unconscious that Freud described, Jungian analysts believe in a collective unconscious. The collective unconscious is made up of archetypal images, or symbolic representations of universal themes of human existence that are present in all cultures, as opposed to the more personal Freudian unconscious. Similar to psychoanalysis, neurosis in Jungian analysis results when one is excessively cut off from the contents of the unconscious and the meaning of the archetypes, which can be understood through various methods, including dream analysis. Jung brought in aspects of mysticism and spirituality that were rejected or ignored by earlier psychoanalysts but which are now beginning to receive attention from modern psychoanalysts, particularly those with an interest in meditation and Eastern religions. Adler, another of Freud’s students, departed from the belief in the unconscious as part of an intrapsychic system based on repression of drives, but he continued to believe that people know more about themselves than they actually understand The Existentialists are also concerned with the unconscious. Like psychoanalysts, they believe that people experience internal unconscious conflicts and that these are excluded

20 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w from conscious awareness but still exert an influence on behavior, thoughts, and feelings. For them, it is anxiety about basic existential fears such as death, isolation, and meaninglessness that is being defended against. Gestalt therapy was also an outgrowth of psychoanalysis but departed from it in radical ways, not only in eschewing much of its basic theory, but also by developing very structured and active therapeutic techniques. Despite these substantial differences, Fritz Perls held on to a belief in the therapeutic value of bringing what is unconscious into consciousness. Similarly, Moreno’s Psychodrama, by enacting problematic interpersonal situations, helps a patient get in touch with and express feelings she may not have realized she had. Alvin Mahrer’s experiential psychotherapy also differs from psychoanalysis in a wide variety of ways. Mahrer regards unconscious material as unique to each individual and believes it represents one of many aspects of a deeper potential for experiencing life. Finally, certain schools of family therapy deal with the ways in which members unconsciously play out particular roles in relation to each other. The “depth psychologies,” those that acknowledge that deeper underlying processes and experiences have significant effects on human behavior, contrast sharply with behavioral and cognitive approaches. Such therapies, which include behavior therapy, rational emotive behavior therapy (REBT), cognitive and cognitive-behavior therapy (CBT), and multimodal therapy, are all rooted in learning theory. In these systems, the undesired symptom, behavior, or thought is understood as having been learned and reinforced by environmental events. These models do not look for meaning beyond observed behavior or conscious experience, and behavioral observation and self-report are their primary methods of assessment. Some therapies derived from these models have demonstrated effectiveness in treating problems such as phobias and other well-defined anxiety disorders, as well as certain symptoms of major depression. Thus, they have made a valuable contribution to the alleviation of psychological suffering. However, many difficulties for which adults seek psychotherapy are not so readily delineated and categorized. A woman may seek psychological treatment, for example, because she is unable to maintain a close and satisfying relationship, or because she experiences a sense of malaise for which she has no explanation. Further, even with well-defined symptoms, when “treatment-resistant” cases occur, these systems offer no conceptual tools for looking beyond the observable to understand what might have gone wrong.

The Transference A second idea common to psychoanalytic therapies is the transference. Freud was the first to recognize the therapeutic value of transference phenomena, in which the patient comes to experience others, the analyst in particular, in ways that are colored by his early experiences with important people in his life. Countertransference, or the response of the analyst to the patient and his transference, is also utilized in various ways in psychoanalysis. Most contemporary psychoanalysts regard countertransference as useful clinical information about the patient, including the types of feelings he might evoke in others. Attention to transference and countertransference reflects interest both in the unconscious and in the importance of childhood experiences and early relationships. Jungian analysts and contemporary psychoanalysts work actively with the transference and countertransference, reflecting a move within both orientations toward recognizing the mutual influence between patient and therapist. In Psychodrama, transference is viewed as a real part of one’s experience and is dealt with very directly. In psychodrama therapy, when a client develops a transference reaction in the course of role playing with the therapist, a substitute therapist is called in so the client can role-play, with the new therapist, this problematic situation involving the original therapist.

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Gestalt, Adlerian, and Client-centered (Rogerian) therapists have less confidence in the therapeutic value of transference. They place greater value on actively cultivating a positive relationship with the client by maintaining a stance that is visibly empathic, supportive and non-judgmental and attempting to bypass any negative transference phenomena. Being empathic and non-judgmental are also highly valued by psychoanalysts, but they remain open to the expression of both positive and negative feelings about the therapist and attempt to understand and interpret either. They believe that understanding these feelings is important if deep and lasting therapeutic change is to occur. In REBT, the therapist attempts to eradicate transference phenomena at the outset by demonstrating that the client’s feelings are based on irrational, maladaptive wishes. Behaviorally and cognitively oriented therapists attempt to enhance the working alliance, but transference is not part of their theories. Their more active stance, in which homework assignments are routinely given and explicit instructions are provided about how to change thoughts and behavior, establishes the therapist as an authority figure, a role that is utilized to encourage compliance.

The Role of Childhood Experiences A third characteristic shared by psychoanalytically oriented clinicians is a belief that childhood experiences influence personality development, current relationships, and emotional vulnerabilities. Many contemporary psychoanalysts incorporate research findings demonstrating the long-term impact of the quality of a child’s early attachment, childhood trauma, early experiences of loss, and other related areas into their thinking about personality development. Any system for which transference is an important concept is necessarily one that recognizes this past-present relationship. Jungian analysts work actively with transference material and are similar to psychoanalysts in their view that aspects of early formative relationships affect the analytic relationship, affording the patient an opportunity to work through these feelings and move beyond their negative impact. Although Ellis does not use the term transference, he acknowledges that transferential thoughts and feelings toward the therapist might arise but regards them as little more than irrational beliefs. Rather than examine and attempt to understand them, he points out their unrealistic nature and applies his very systematic REBT procedure with the intention of eradicating them. In psychodrama, early past experiences are thought to have an impact on one’s current situation, and these are explicitly role-played in an effort to rework and replace the psychologically harmful experiences with more positive ones. Rogerians and existentialists are concerned with the therapeutic relationship, but past experiences do not figure prominently in their thinking. For systems greatly influenced by learning theory, such as cognitive, behavioral, and cognitive-behavioral therapies, as well as multimodal therapy, the past is significant only in terms of the direct antecedents to the dysfunctional behavior. This major difference from the analytic perspectives may limit the types of psychological problems that the systems that rely on learning theory are able to address.

Common Factors Various approaches to psychotherapy differ in what they see as fundamental to the process. Dynamic psychotherapies differ from behavioral forms of treatment in their understanding of the origins of psychological problems, as well as in aspects of technique. Although the differences among forms of therapy are frequently highlighted in writings about treatment, they also share important fundamentals. Establishing a working alliance is important in all forms of treatment, whether it is made explicit, as in psychodynamic

22 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w theory, or not. So is the frame, or structure, of the treatment and the establishment of treatment goals. The role of common factors will be further explored in the Evidence section of this chapter.

HISTORY Precursors Psychoanalysis, as originated by Sigmund Freud (1856–1939), represented an integration of the major European intellectual movements of his time. This was a period of unprecedented advance in the physical and biological sciences. The crucial issue of the day was Darwin’s theory of evolution. Originally, Freud had intended to pursue a career as a biological research scientist, and in keeping with this goal, he became affiliated with the Physiological Institute in Vienna, headed by Ernst Brücke. Brücke was a follower of Helmholtz and was part of the group of biologists who attempted to explain biological phenomena solely in terms of physics and chemistry. It is not surprising, therefore, that models borrowed from physics and chemistry, as well as the theory of evolution, recur regularly throughout Freud’s writings, particularly in his early psychological works. Freud came to psychoanalysis by way of neurology. During his formative years, great strides were being made in neurophysiology and neuropathology. This was also the time when psychology separated from philosophy and began to emerge as an independent science. Freud was interested in both fields. He knew the works of the “association” school of psychologists (Herbart, von Humboldt, and Wundt), and he had been impressed by the way Gustav Fechner applied concepts of physics to problems of psychological research. In the mid-nineteenth century, there was great interest in states of split consciousness. The French neuropsychiatrists had taken the lead in studying conditions such as somnambulism, multiple personalities, fugue states, and hysteria. Hypnotism was one of the principal methods used in studying these conditions. The use of the couch, with the patient lying down, began with the practice of hypnosis. The leading figures in this field of investigation were Jean Martin Charcot, Pierre Janet, Hippolyte Bernheim, and Ambrose August Liebault. Freud worked with several of them and was particularly influenced by Charcot.

Beginnings Freud made frequent revisions in his theories and practice as new and challenging findings came to his attention. In the section that follows, special emphasis will be placed on the links between Freud’s clinical findings and the consequent reformulations of his theories. These writings serve as nodal points in the history of the evolution of his theories: Studies on Hysteria, The Interpretation of Dreams, Three Essays on Sexuality, On Narcissism, the metapsychology papers, Beyond the Pleasure Principle (the Dual Instinct Theory), and The Ego and the Id (the Structural Theory).

Studies on Hysteria (1895) The early history of psychoanalysis begins with hypnotism. Josef Breuer, a prominent Viennese physician, told Freud of his experience using hypnosis. When he placed the patient in a hypnotic trance and encouraged her to relate what was oppressing her mind at the moment, she would frequently tell of some highly emotional event in her life. While awake, the patient was completely unaware of the “traumatic” event or of its connection with her disability, but after relating it under hypnosis, the patient was cured of her disability. The report made a deep impression on Freud, and it was partly in pursuit of the

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therapeutic potential of hypnosis that he undertook studies first with Charcot in Paris and later with Bernheim and Liebault at Nancy, France. When Freud returned to Vienna, he used Breuer’s procedures on other patients and was able to confirm the validity of Breuer’s findings. The two then established a working relationship that culminated in Studies on Hysteria. Freud and Breuer noted that recalling the traumatic event alone was not sufficient to effect a cure. The discharge of the appropriate amount of emotion was also necessary. Anna O., a patient whom Breuer cured in this way, referred to the treatment as “the talking cure.” The task of treatment, they concluded, was to achieve catharsis of the undischarged affect connected with the painful traumatic experience. The concept of a repressed trauma was fundamental in Freud’s conceptualization of hysteria, which led him, in an aphoristic way, to say that hysterics suffer mainly from reminiscences. Breuer and Freud differed on how the painful memories in hysteria had been rendered unconscious. Breuer’s explanation was a “physiological” one, in keeping with theories of psychoneuroses current at that time. In contrast, Freud favored a psychological theory. The traumatic events were forgotten or excluded from consciousness precisely because the individual sought to defend herself from the painful emotions that accompany recollection of repressed memories. That the mind tends to pursue pleasure and avoid pain became one of the basic principles of Freud’s subsequent psychological theory. Breuer refused to continue this line of research, but Freud continued to work independently. Meanwhile, Freud learned from his clinical experience that not all patients could be hypnotized and that many others did not seem to go into a trance deep enough to produce significant results. He began using suggestion, by placing his hand on the patients’ foreheads and insisting that they attempt to recall the repressed traumatic event. This method was linked to an experiment he had witnessed while working with Bernheim. In his Autobiographical Study (1925, p. 8), Freud described the incident: When the subject awoke from the state of somnambulism, he seemed to have lost all memory of what had happened while he was in that state, but Bernheim maintained that the memory was present all the same; and if he insisted upon the subject remembering, if he asseverated that the subject knew it all and had only to say it, and if at the same time he laid his hand on the subject’s forehead, then the forgotten memories began to return, hesitatingly at first, but eventually in a flood and with complete clarity. Accordingly, Freud abandoned hypnosis in favor of a new technique of forced associations. However, Elisabeth von R, the first patient whom Freud treated by “waking suggestion,” apparently rebuked Freud for interrupting her flow of thoughts. Freud took her response seriously, and the method of “free association” began to emerge.

Clinical Experience and Evolving Technique. The responses of Freud’s patients to his procedures made for modification in his technique as well as in his thinking. Not only did he attend to Elisabeth von R’s response to his “forced” questions, but he also began to notice that she actively refused certain questions. This observation prompted his thinking about resistance, or a force of “not wanting to know” in the patient. That furthered his emerging use of free association, where the task was to bring the resistances to the fore, rather than trying to circumvent them. This technical innovation coincided with another interest that pervaded Freud’s thought at the time. He had found that two elements were characteristic of the forgotten traumatic events to which he had been able to trace the hysterical symptoms. In the first place, the incidents invariably proved to be sexual in nature. Second, in searching for the pathogenic situations in which the repression of sexuality had set in, Freud was carried further and further back into the patient’s life, reaching ultimately into the earliest years

24 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w of childhood. Freud first concluded that the patients he observed had all been seduced by an older person. In his further investigation, Freud realized that this was not always true, and he began to develop his theory of childhood sexuality, eventually coming to believe in the importance of childhood fantasies about sexuality. Following the same principle of learning from patients, dynamic therapists who work with the survivors of childhood sexual abuse have reopened the topic of abuse and its aftermath in patients’ lives (Davies & Frawley, 1994). Thus, in the century that has followed Freud, attention has returned to actual abuse, along with the possibilities of complex, interwoven symbolic material.

The Interpretation of Dreams (1900) The second phase of Freud’s discoveries concerned a solution to the riddle of the dream. Dreams and symptoms, Freud came to realize, had a similar structure. He saw both as products of a compromise between two sets of conflicting forces in the mind—between unconscious wishes and the repressive activity of the rest of the mind. In effecting this compromise, an inner censor disguised and distorted the representation of the unconscious wishes. This process makes dreams and symptoms seem unintelligible, but Freud’s descriptions of the mechanisms of representation in the dream gave way to understand dreams and their symbols. The Interpretation of Dreams was the place where Freud first described the Oedipus complex, an unconscious sexual desire in a child, especially a male child, for the parent of the opposite sex, usually accompanied by hostility to the parent of the same sex, as well as guilt over this wish to vanquish that parent. The development of that theory coincided with Freud’s own self analysis. Although the Oedipus complex continues to have an important place in classical psychoanalytic theory, more recent approaches that emphasize early attachment rather than childhood sexuality do not give it the same credence.

The Structure of Mind. In the concluding chapter of The Interpretation of Dreams, Freud attempted to elaborate a theory of the human mind that would encompass dreaming, psychopathology, and normal functioning. The central principle of this theory is that mental life represents a fundamental conflict between the conscious and unconscious parts of the mind. The unconscious parts of the mind contain the biological, instinctual sexual drives, impulsively pressing for discharge. Opposed to these elements are forces that are either conscious or readily available to consciousness, functioning at a logical, realistic, and adaptive level. Because the fundamental principle of this conceptualization of mental functioning concerned the depth or “layer” of an idea in relation to consciousness, this theory was called the topographic theory. According to this theory, the mind could be divided into three systems: consciousness, resulting from perception of outer stimuli as well as inner mental functioning; the preconscious, consisting of those mental contents accessible to awareness once attention is directed toward them; and finally the unconscious, comprising the primitive, instinctual wishes. The concepts developed in The Interpretation of Dreams—unconscious conflict, infantile sexuality, and the Oedipus complex—enabled Freud to attain new insights into the psychology of religion, art, character formation, mythology, and literature. These ideas were published in The Psychopathology of Everyday Life (1901), Jokes and Their Relationship to the Unconscious (1905a), Three Essays on Sexuality (1905b), and Totem and Taboo (1913). Libido Theory. Freud conceived of mental activity as representative of two sets of drives: Libidinal drives seek gratification and are ultimately related to preservation of the

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species; these are opposed by the ego drive, which seeks to preserve the existence of the individual by curbing the biological drives, when necessary. The term libido refers to sexual energies, although they have different meanings and manifestations at different ages. Freud proposed a developmental sequence of the libidinal drives. The oral phase extends from birth to about the middle of the second year. One of the earliest analysts, Karl Abraham (1924), observed that people whose oral needs were excessively frustrated turned out to be pessimists, whereas those whose oral desires had been gratified tended to be more optimistic. The oral phase is followed by the anal phase. A child may react to frustrations during that phase by becoming stubborn or contrary. Through reaction formation the child may overcome the impulse to soil by becoming meticulously clean, excessively punctual, and quite parsimonious in handling possessions. Somewhat later (ages 3 1/2 to 6), the child enters the phallic phase. In this stage, children become curious about sexual differences and the origin of life, and they may fashion their own answers to these important questions. They enjoy a sense of power and can idealize others. By this time, complex fantasies, including Oedipal fantasies, have begun to form in the mind of the child. Today’s child may still come home from nursery school saying he wants to marry his teacher. Freud’s theories have allowed the culture to be relaxed about such statements, and the vast differences in the meaning of such feelings to a child and to an adult are better understood. These early psychosexual phases are followed by a period of latency, from the age of 6 to the onset of puberty. Then, under the influence of the biological changes of puberty, a period of turbulence and readjustment sets in, and when development is healthy, this period culminates in the achievement of adequate mastery over drives, leading to adaptation, sexual and moral identity, and attachment to significant others.

On Narcissism (1914) The next phase in the development of Freud’s concepts focused on his investigation into the psychology of the psychoses, group formation, and love—for one’s self, one’s children, and significant others. He found that some individuals led lives dominated by the pursuit of self-esteem and grandiosity. These same factors seemed to operate in the relationship of an individual to the person with whom he or she was in love. The beloved was aggrandized and endowed with superlative qualities, and separation from the beloved was seen as a catastrophic blow to self-esteem. These observations on narcissism remain relevant to more recent attention to the narcissistic personality disorder.

The Ego and the Id (1923) Having recognized that in the course of psychic conflict, conscience may operate at conscious and/or unconscious levels, and that even the methods by which the mind protects itself from anxiety may be unconscious, Freud reformulated his theory in terms of a structural organization of the mind. Mental functions were grouped according to the role they played in conflict. Freud named the three major subdivisions the ego, the id, and the superego. The ego orients the individual toward the external world and serves as a mediator between one’s external and internal worlds. The id represents the organization of the instinctual pressures on the mind, basically the sexual and aggressive impulses. The superego is a split-off portion of the ego, a residue of the early history of the individual’s moral training and a precipitate of the most important childhood identifications and ideal aspirations. Under ordinary circumstances, there is no sharp demarcation among these three major components of the mind. Intrapsychic conflict, however, highlights the differences and demarcations between them.

26 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w One of the major functions of the ego is to protect the mind from internal dangers and from the threat of a breakthrough into consciousness of unacceptable conflict-laden impulses. The difference between mental health and mental illness depends on how well the ego can succeed in this responsibility. In his monograph Inhibitions, Symptoms and Anxiety (1926), Freud pointed out that the key to the problem is the appearance of anxiety, perhaps the most common symptom of neurosis. Anxiety serves as a warning signal, alerting the ego to the danger of overwhelming anxiety or panic that may supervene if a repressed, unconscious wish emerges into consciousness. Once warned, the ego may utilize any of a wide array of defenses. This new view had far-reaching implications for both the theory and the practice of psychoanalysis.

Beyond Freud Psychoanalysis has gone through many changes since Freud. The earlier defections by Adler and Jung have already been noted, but a serious split began within psychoanalysis even during Freud’s lifetime. This grew out of the teaching and the influence of Melanie Klein in London, which eventually spawned what is know as the British school of psychoanalysis. Klein emphasized the importance of primitive fantasies of loss (the depressive position) and persecution (the paranoid position) in the pathogenesis of mental illness. Melanie Klein’s influence is preeminent in England, many parts of Europe, and South America. When Nazi persecution forced many of the outstanding European analysts to migrate to this country, the United States became, for a time, the world center of psychoanalysis. The leading figures in this movement were Heinz Hartmann, Ernest Kris, and Rudolph Loewenstein. These three collaborators tried to establish psychoanalysis as a general psychology. They did so by extending Hartmann’s concepts of the adaptive function of the ego (Hartmann, 1939) and clarifying fundamental working hypotheses concerning the development of the psyche (Hartmann & Kris, 1945). Hartmann, in particular, emphasized the role of the transformation of the basic instinctual drives in a set of metapsychological propositions that have been largely abandoned in recent years. Closely related to the work of Hartmann, Kris, and Loewenstein were the efforts of Anna Freud, derived from studies of long-term child development. Her book The Ego and the Mechanisms of Defense became a classic. For a while, issues concerning the development of the sense of self and personal identity were most prominent in the psychoanalytic literature. These were the focal point of works by D. W. Winnicott and John Bowlby in England and Edith Jacobson and Margaret Mahler in the United States. All of these studies underlined the importance of the child’s early attachment to the mother and the emergence of the self as an independent entity. Whereas Mahler emphasized the emergence of a sense of self through a process of separation and individuation, Winnicott emphasized the continuing influence of the psychological experience of the young child, where representations of the external world take the form of transitional phenomena. Winnicott’s concept of the transitional object can be seen to this day, whenever a child carries around a teddy bear or baby blanket. These objects serve as concrete ways for the child to maintain a connection between herself and her attachments.

Current Status Most people associate psychoanalysis with classical Freudian theory and techniques, without realizing how much the field has changed. As a result, psychoanalysis and psychodynamic therapies have been criticized for being irrelevant to today’s culture, for being appropriate only to an elite group of highly educated patients, and for not being

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based on empirical findings. This view, however, is inaccurate. Psychoanalysis is a continually evolving field that has been revised and altered by psychoanalytic theorists and clinicians ever since its origin. This evolution began with Freud himself, who often rethought and substantially revised his own ideas.

Changing Clinical Concepts In the century that has passed since Freud, psychoanalysts have developed different branches of psychoanalysis, including ego psychology, interpersonal theory, self-psychology, and various relational theories. In fact, there are so many differing theories that Wallerstein (1988) spoke of the need to recognize many psychoanalyses instead of just one. Perhaps the most significant differences within the field today concern the nature of the analyst’s view of the treatment situation. The issue is often drawn in terms of whether psychoanalysis is a one-person or a two-person psychology. A “one-person” psychology focuses exclusively on the mental reactions of the patient, whereas a “two-person” psychology considers the treatment as emerging from the interaction between two individuals. The relational viewpoint takes the “two-person” perspective and emphasizes the mutuality within the therapeutic relationship (Aron, 1996). A related issue is the question of the “blank screen.” In classical analytic theory, the analyst was thought of as a “blank screen” onto which the patient might project his transference. In order to facilitate this process, the patient lies on the couch with the analyst behind her, out of sight. However, current thinkers have pointed out that “the blank screen is not blank.” In other words, patients have reactions to an analyst who says very little and is out of sight, just as they have reactions to one who is visible and interactive. The Interpersonal school of psychoanalysis, which began with Harry Stack Sullivan, introduced a view of the analyst as an active participant, as well as observer, in the therapeutic relationship. Sullivan believed that an individual cannot be meaningfully understood outside of her interpersonal and social context. He described a process of selective inattention, a variation on the concept of the unconscious, in which a person will actively exclude from awareness certain anxiety-producing aspects of her interpersonal experiences (Sullivan, 1953). Because she is missing this information, she may construct a distorted view of the world. He advocated conducting a detailed inquiry of troubled relationships in order to bring to light those aspects of which the patient has been unaware. For interpersonalists the patient’s feelings about the therapist may be reactions to the analyst’s actual behavior and not merely manifestations of transference (Sullivan, 1954). A contemporary interpersonal analyst will attempt to be aware of the ways in which he may be contributing to the patient’s view of him. But he will also try to notice his own experience during the session, attempting to recognize when he has been “transformed” by reacting to some aspect of the patient. Exploration of the therapist’s reactions may then shed light on the nature of the patient’s relationships in the rest of her life (Levenson, 1972). The analyst’s own experience of the patient now becomes an invaluable source of clinical information. This emphasis on the patient’s real interaction with the analyst was a radical departure from the less involved stance of the classical analyst. It has led some analysts to let the patient sit up and look at them and to take a more interactive role in the treatment. The interpersonal view has strongly influenced many relational perspectives.

Psychodynamic Psychotherapy Psychodynamic psychotherapy is the most commonly practiced form of psychoanalytic treatment. It is less intensive than psychoanalysis, and sessions are held one or two times each week; the patient is sitting up and facing the therapist. Training in psychodynamic therapy is offered in many psychology, psychiatry, and social work programs and can be

28 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w conducted without formal advanced training at a psychoanalytic institute. Modifications in technique have enabled psychoanalytic concepts to be applied to new populations and settings. In supportive-expressive (SE) psychotherapy, the balance of supportive and expressive elements is calibrated to meet the needs of the patient. The level of psychological health or sickness of the patient is among the factors that help the therapist determine the appropriate balance of the treatment.

Incorporating Research and New Ideas In recent years, psychoanalysts have incorporated ideas from other fields. Empirical findings from research literature in sexual trauma (Alpert, 1995), cognitive psychology (Bucci, 1997), mother-infant interactions (Beebe & Lachmann, 2002), attachment (Lyons-Ruth, 2003) and other areas have been integrated into psychoanalytic thinking. Ideas from feminist theory (Benjamin, 1988) have also informed and enriched the field of psychoanalysis. Nobel laureate Eric Kandel (2005) has examined psychoanalytic concepts through the lens of neuroscience, and Schore (2003) has brought together developmental, psychological, and neurological research findings to significantly advance this new field of neuropsychoanalysis. Schore suggests that much of what occurs in psychotherapy is a function of right-brain, or non-verbal and non-linear activity, which clearly suggests that the value of the talking cure goes beyond the actual talking itself. Finally, despite frequently voiced perceptions to the contrary, research on psychodynamic therapies and psychoanalytic concepts is actively pursued, with positive results. That research will be reviewed in the Evidence section of this chapter.

Psychodynamic Diagnostic Manual In 2006, the first Psychodynamic Diagnostic Manual (PDM) was published. The PDM is a psychodynamic alternative to the Diagnostic and Statistical Manual (DSM), which is currently used for making psychiatric diagnoses (American Psychiatric Association, 2000). The DSM was conceived as a means for researchers and clinicians to have a common language for communicating about psychiatric disorders. It lists observable symptoms and characteristics for each diagnostic category but provides no conceptual framework for organizing the information. In contrast, the PDM is based on a psychodynamic model of human functioning and integrates up-to-date information from the empirical literature on cognitive psychology, trauma, and attachment. For example, psychoanalytic research has revealed two distinct types of depression; one results from an overly self-critical personality, while the other stems from fears of abandonment and loss (Blatt, 2005). Whereas the DSM emphasizes what is observable, the PDM describes the subjective experience of people who exhibit particular symptoms. For example, the subjective experience of anxiety is different for one who is neurotic (“I can’t stand the fear. I need comfort”), one who is borderline (“My sense of self was hollow, like I didn’t have a self”), and one who is psychotic (“They have been blowing poison gas through the keyhole. It’s destroying me and obliterating my thoughts”). The PDM represents an extremely significant effort to provide a conceptual framework that meaningfully organizes what is known about the complexity of human psychological functioning.

Psychoanalytic Training When psychoanalytic training began in this country, it was offered exclusively to physicians, but this is no longer the case. Today, admission to most psychoanalytic institutes

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requires that one first earn a Ph.D. or Psy.D. in clinical psychology or successfully complete a psychiatry residency. Institutes vary in their admission policies for clinical practitioners in social work. Whereas advanced training to be a psychoanalyst is extensive, training in psychoanalytic or psychodynamic psychotherapy is part of many graduate programs in psychology, psychiatry, or social work. Psychoanalytic training generally consists of at least four years of course work, accompanied by closely supervised treatment of psychoanalytic patients who are in treatment at least three (and most often four to five) times per week for several years. A candidate is also required to undergo a personal analysis conducted by a senior psychoanalyst. This is an important part of the training; it provides an opportunity for candidates to learn firsthand what being an analytic patient, or analysand, is like and to observe a senior psychoanalyst at work. Even more important, a practicing psychoanalyst needs to know himself or herself well, since the work is deeply personal, and one’s own emotional vulnerabilities and conflicts must be confronted and worked through if one is to be truly helpful to one’s patients. For these reasons, some graduate programs recommend that students enter a personal psychoanalysis or psychoanalytically oriented therapy themselves.

Psychoanalytic Organizations Much has changed in the organizational structure of psychoanalysis in recent years. The American Psychoanalytic Association (APsaA), founded in 1911, remains the largest of psychoanalytic societies in the United States, with 42 affiliate societies and 29 professional training programs. APsaA is part of the International Psychoanalytical Association, the largest worldwide psychoanalytic organization. The American Psychological Association’s Division of Psychoanalysis lists 92 psychoanalytic training programs. Whereas many institutes have evolved from a Freudian framework, others, such as the William Alanson White Institute, have an interpersonal/relational orientation. The New York University Postdoctoral Program houses a range of theoretical orientations and encourages an exchange of ideas between them. Both the American Psychological Association (Division 39, Psychoanalysis) and the American Academy of Psychoanalysis are good resources for further information.

Psychoanalytic Journals Because so many theoretical orientations and professional disciplines now represent psychoanalysis, there are simply too many psychoanalytic journals to list them here. They include The International Journal of Psychoanalysis, American Journal of Psychoanalysis, Contemporary Psychoanalysis (interpersonal), Psychoanalytic Dialogues (relational), and The International Journal of Psychoanalytic Self Psychology, to name a few of the more popular ones reflecting the range of orientations. There are also journals on specific topics, such as Gender and Psychoanalysis.

PERSONALITY Theory of Personality Personality evolves out of the interaction between biological factors and the vicissitudes of experience. That interaction is influenced not only by the nature of the life events but also by the ways those experiences are absorbed and handled. Likewise, overall mood and attitudes toward life are affected by early experiences. “Basic mood” begins to develop during the first year of life, and “confident expectancy” is a mood state that can emerge after a happy first year in which the baby’s needs are met.

30 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w Problems in early life may become embedded in personality through fixation or regression, hidden through defense mechanisms, or embodied through enactment. In fixation, aspects of the child’s personality get stuck at the developmental moment in which a traumatic event or unresolved conflict occurred. For example, a young adult never leaves home, in spite of pressures from those around him to move out and move on. His parents were “always gone” when he was a child, leaving him with an array of nannies, and he became fixated on the home as a form of family connection. In regression, the child reverts to earlier forms of behavior in response to stress. Many parents are familiar with this phenomenon, since the birth of a baby typically causes the older sibling to regress. This is usually a temporary event, but in some cases a regression has more lasting effects. Enactment is a form of “action memory,” in which memories of sequences of troublesome experience are replayed in action. A common example comes when parents find themselves disciplining a child in just the way their parents did, even though they thought they would do it differently.

Defense Mechanisms Psychological defense mechanisms play a pivotal role in the structure of personality. The concept of a psychological defense had its beginning in Freud’s writings, but it was his daughter Anna Freud who developed the concept. Whereas Freud paid a good deal of attention to the conflict between id and superego, Anna Freud brought the ego to the fore, delineating specific ego defenses and their important role in the development of the psyche. She observed in her clinical work with adults and children that there are specific types of defenses and that people tend to use them with some consistency. For example, one person might utilize her thinking ability to keep threatening feelings at bay by speaking about them in emotionally detached and abstract terms (intellectualization), whereas another might express unacceptable desires symbolically through a bodily symptom (conversion or somatization). In many people, defenses are activated by stress, but they may have a full range of other ways of responding. Other people have what Wilhelm Reich (1949) called character armor, in which their defenses pervade how they act and respond. Even positive traits can serve as defenses. Anna Freud gives the example of a matchmaker who used altruism as a defense. All her energies went into other people’s love lives, but she avoided experiencing her own needs and did not have a personal life of her own. The ego psychologists, following Anna Freud’s focus on the ego’s defenses, shifted the focus to the ways people adapt to reality and showed how defensive style shapes their experience of themselves, others, and the world in general. For example, those with more histrionic personality styles tend to be impressionistic and intuitive, whereas those who are more obsessional are likely to be focused, goal-oriented, and conscientious (Shapiro, 1965). Otto Kernberg (1975) investigated the character structure of patients in the “borderline” spectrum, so called because it was first considered as the area between neurosis and psychosis. Borderline patients tend to use certain pathological defense mechanisms. The most common are projection (projecting one’s own feelings onto another person) and splitting (seeing some people as all good and others as all bad, or alternately idealizing and devaluing the same person). Lyons-Ruth (2003) has shown how this type of personality structure may develop through certain forms of interaction between mothers and young children. The types of defenses a person employs have implications for later mental and physical health. Vaillant (1977, 2002) conducted a large longitudinal study, in which he followed Harvard students from graduation until old age. He showed that the use of more mature defenses, such as sublimation (channeling one’s impulses into positive, culturally desirable activities) and humor, as opposed to those that are less mature and pathological, such as projection, is highly predictive of both physical and mental health later in life.

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Knowledge of the defensive and personality style of patients has useful clinical implications, as well. McWilliams (1994) has formulated very useful ways of assessing and treating people seeking psychoanalytic psychotherapy, based on their personality style and structure. For treating post-traumatic stress disorder and other stress-related problems, Horowitz (2001) delineated different treatment approaches found to be most effective, based on the particular defensive style.

Culture and Development Erik Erikson, one of Freud’s students, drew on his background in developmental psychology and anthropology, expanding Freud’s theory of psychosexual development to include the effects of culture and society on psychological growth. Erikson (1968) postulated eight stages of psychosocial development from infancy to old age, in contrast to Freud’s five stages of psychosexual development, which ended with childhood. Each of Erikson’s stages was based on a specific psychosocial conflict or crisis. The resolution of each crisis is associated with a particular psychosocial outcome that shapes the way the individual relates to other people and to society. Erikson wrote a great deal about the ways in which our sense of identity develops throughout the life cycle, and he is best known for his formulation of the “identity crisis” of adolescence (Erikson, 1950). The period from 12 to 18 years (characterized in terms of the tension between identity and role confusion) is one in which an adolescent struggles to figure out who he is as a person in relation to his family, peers, and society. He then brings this sense of himself, however secure or confused, to his efforts to establish healthy and satisfying love relationships, which is the challenge of the next stage, in which the major psychosocial issue to be confronted is that of intimacy versus isolation. Freud also believed that culture plays an important role in personality development, and for him, the superego is an internalization of the moral codes of family and society. However, Erikson believed that society’s impact extends beyond its moral authority, and he placed great importance on the continual interaction between the person, culture, and family.

Early Relationships Margaret Mahler saw the first three years of life as an unfolding process of separationindividuation (Mahler, Pine, & Bergman, 1975). She believed that the mother-infant relationship began with a state of oneness that she termed symbiosis. From there, the child gradually separates and forms her own sense of identity. In order to do so, she internalizes the relationship with the mother, giving her the ability to experience a feeling of connection with her mother as she develops her own autonomy. Disturbances in the process give rise to lasting conflicts, with anxiety around separation and problems in establishing a secure identity. Mahler’s concept of symbiosis has been disproved by child development research, but the idea that the child internalizes the relationship with the mother is consistent with attachment theory on “inner working models” of relationships (Bowlby, 1988). Over time, many psychoanalysts have moved toward orientations that place greater emphasis on the social and relational aspects of psychological functioning. Freud initially hypothesized that people are motivated by a quest for pleasure and gratification of certain basic drives, such that specific people become significant to a child because they satisfy his basic biological needs. A mother becomes important to a baby because she feeds him when he is hungry and thus becomes associated with the child’s own gratification and pleasure. From the relational perspective, on the other hand, the primary motivation is the desire to be in a relationship with another person (Greenberg & Mitchell, 1983).

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Object Relations Fairbairn (1954) and others developed an idea that has come to be known as object relations theory. (He used the word object to mean a person who has great emotional significance to the child, having retained the term from Freud’s earlier descriptions of caregiving adults as being “the objects of the drives,” or those toward whom the drives are directed.) Fairbairn worked with abused children and observed that they remained extremely attached to parents who had severely abused them, suggesting they were looking to their parents for more than mere pleasure through need gratification. What is more, these children later sought out relationships characterized by the same abusive pattern as the earlier relationship. Object relations theory concludes that human emotional life and relationships center around the unconscious mental images we hold of our earliest and most intense relationships, or internalized object representations. In order to avoid the terror of loss and abandonment, a child (or adult) will do whatever she can to maintain her connection to her early love objects. She might do so by seeking out others to whom she can relate in ways that match her internalized images of those who comprised her early emotional life; in this way, she recaptures the soothing feeling of connectedness. Object relations theory has helped psychoanalysts to understand better why people find themselves in relationships that appear to be maladaptive and self-destructive. It has been applied to a wide range of populations and situations and has provided particular insights into more serious and therapeutically challenging types of disturbances, such as borderline and narcissistic personalities (Kernberg, 1975). It has also led to a variety of other relational perspectives (Mitchell, 1988). Numerous other psychoanalysts further elaborated on the early mother-infant relationship as it relates to personality development. One of these was Donald Winnicott (1965), who trained as a pediatrician before becoming a psychoanalyst. Winnicott (1965) believed that healthy emotional development requires a good-enough mother who provides a holding environment for her child with her consistent, loving presence. From this experience, the baby emerges with a sense of security and the ability to soothe herself during periods of stress and anxiety.

Self-psychology Heinz Kohut (1971) took a new look at a group of narcissistic patients for whom other formulations did not appear to apply. His was interested in those who presented with a chronic state of emptiness, a lack of inner vitality, and an unstable sense of themselves and their self-worth, which was frequently masked by a more grandiose or expansive presentation. Kohut observed that these patients often reported a lack of “mirroring” experiences in their childhoods, such that they failed to receive support and admiration for what Kohut regarded as “healthy narcissism.” Young children frequently demand attention from adults by showing off and exaggerating their own power and abilities. A very young child might run around shouting, “Look at me, I’m the fastest runner in the world!” The parents of Kohut’s patients, rather than mirroring the child’s joy, typically responded with a lack of warmth and often with criticism or ridicule. Many of his patients also lacked an adult figure to safely idealize, something Kohut regarded as crucial to healthy development. In this self-psychological model, narcissistic disturbances result from environmental deficiencies rather than biological drives or psychological conflict. Kohut found that psychoanalytic interpretations did not help narcissistic patients. Instead, he proposed offering empathy, mirroring, and support for positive self-esteem. In a well-known case of “Mr. Z,” he used his empathic approach to reanalyze a patient who had not done well with traditional analytic techniques (Kohut, 1979).

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Attachment and Personality Development Psychodynamic theory and attachment theory have arrived at congruent views of personality development. Both regard early relationships as formative in the development of the child’s emotional well-being and sense of self, and decades of attachment research supports this (Bowlby, 1969, 1988; Main, Kaplan, & Cassidy, 1985). Psychoanalysts are increasingly integrating these findings into their thinking. Lyons-Ruth (1991), for example, has proposed that Margaret Mahler’s concept of separation-individuation be renamed “attachment-individuation.” She points out that the child first develops an attachment to the parent and then individuates internalizing this relationship. Fonagy et al. (2002) has demonstrated that the ability to mentalize, or mentally represent internal psychological states, develops from a secure early attachment relationship and is related to the later ability to regulate emotions and calm oneself during times of stress and anxiety. The intersection between attachment research and psychodynamic concepts continues to offer the potential for fresh thinking and discoveries.

Variety of Concepts Defense Mechanisms Freud first described defenses as the ego’s struggle against painful or unendurable ideas or affects (Freud, 1894). He later shifted to using the word repression for that purpose, but the concept of defense returned in his later writings, and it has had staying power in the practice of psychodynamic forms of treatment. Repression came to refer to the process of removing a painful memory or feeling from consciousness, whereas defenses came to mean the varied ways in which the ego keeps itself protected from painful thoughts and feelings, especially those experienced as dangerous. The danger often has less to do with active danger in the current world and more to do with a sense of “felt danger.” The “felt danger” may have its origins in early, sometimes traumatic experience. For example, a child who was adopted from a Russian orphanage at two years of age reacts to new people with ease. But he wriggles away from his adoptive mother. He has developed a defense that is easy to decode, since we know its history. He seems on the surface as if he is at ease with adults, but he defends against getting close, since he knows too well that people leave. Without such an obvious trail of documented history, patients discover their own “trail” in treatment, as a way to begin to undo early defenses. The analysis of defense starts with noticing the defenses in operation. After becoming aware of their function, the patient can gradually look at the once intolerable content behind them. The therapist needs to respect that the content behind the “fence” of the defense may be difficult to tolerate and may even be part of a trail of memories to what was once a very painful experience. Here are some examples of prominent defenses: In projection, the patient attributes unacceptable impulses or feelings of his own to another person (or agency). Angry, controlling, sexual, or jealous feelings are frequently projected onto others. Projection is the major mechanism of paranoia. Obsessional thinking and compulsive rituals are defenses against unacceptable thoughts or unbearable feelings. Rather than allowing the individual to feel worried about the potential consequence of an aggressive thought, or overwhelmed by an anxiety-provoking one, obsessional thinking shifts the focus to small details that can be cognitively controlled. Compulsive rituals have a similar function, reducing anxiety through behavior. Denial is the refusal to accept external reality when it is too threatening, and may involve “the reversal of real facts into their opposites” (A. Freud, 1966, p. 93). Young children exhibit harmless denial when they use the “magical thinking” of childhood, but it becomes a serious problem if this defense mechanism survives beyond childhood. It is

34 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w frequently associated with alcohol or drug dependence, where acknowledging the related problems would mean facing the addiction. Avoidance is a much more common mechanism than denial. It involves withdrawing from the experience of “psychic pain” or anxiety. However, in doing so, the patient also avoids the entire situation that caused the perception of emotional pain.

Primary and Secondary Process Thinking Primary process thinking is nonlogical thinking. It is the language of the dream, of creative processes, and of the unconscious. The connections between thoughts have to do with images, memories, and emotion, rather than rational thinking. Secondary process thinking is logical, verbal thinking. These modes of thinking have been linked to the different modes of processing of the left and right hemispheres of the brain (Erdelyi, 1985).

Dream Interpretation Freud considered the dream to be “the royal road to the unconscious” and The Interpretation of Dreams to be his greatest achievement. He believed that to understand his theory of dreams is to understand psychoanalysis. Following the method Freud developed to interpret dreams, the dreamer holds the key to its meanings. Unlike Jungian analysis, psychoanalytic dream interpretation does not tend to attach preset meanings to dream symbols. Instead, the dreamer’s associations, or thoughts about each dream image, serve as clues to understanding the dream. When the dreamer comes up with associations to the dream elements, they offer links between the dream image and its meaning to the dreamer. The manifest content of the dream is the overt dream story, and the latent content consists of its underlying meanings. Day residue, or images that come from events of the day, may make their way into the dream. The interpretation of the dream emerges by listening to the dream and the dreamer’s associations to elements of it, while seeking the deep thematic links between them. Understanding the language of the dream gives the analyst the ability to make sense out of what might sound like nonsense to others. Although some aspects of Freud’s thoughts on dreaming (such as the idea that the dream is the guardian of sleep) have not withstood the test of science, his insights into the language of the dream still open doors to the “royal road.” The language of the dream consists of the use of nonlogical forms of expression, including condensation, [personal] symbolism, allusions, and displacement. Here is an example of some of these mechanisms at work in a dream: DREAM: “I dreamt about a flower. I was the flower and I was the picker.” BACKGROUND: The patient, a young woman of 20, had recently had an abortion. Her first thought about the flower was that it was a daisy. Her association to a daisy was “he loves me, he loves me not,” which made her think of her boyfriend (an allusion), who would not commit to their relationship. Then she thought of picking off the petals. This was a symbolic reference to the abortion, as “taking off” the flower. When asked for her association to picking the flower, her eyes became misty with tears. The dream condensed her feelings and thoughts about the abortion into one moving image. Freud believed that these mechanisms disguised hidden wishes and that interpreting the dream reversed the censorship created through these forms of disguise. Psychodynamic therapists now are likely to consider the dream as a symbolic representation of whatever is essential to the patient, in dream language. Whether the dream is considered as a product of censorship or as a different form of processing during sleep, understanding the language of dreams can still take the dreamer down the royal road to personal discovery.

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Clinical-Research Concepts Psychotherapy researchers have developed methods that allow for the study of psychotherapy process and outcome. The methods highlighted here have both clinical and research uses. Their clinical use is as procedures in the practice of supportive-expressive (SE) psychotherapy. They may also be used in other forms of treatment.

The Core Conflictual Relationship Theme Method (CCRT). The CCRT is a method to examine the inner workings of the patient’s relationship patterns. It serves as an operational version of the transference (Luborsky & Luborsky, 2006). The therapist listens for repeating patterns in the stories the patient tells about encounters with others (“relationship episodes”), including responses to the therapist. The pattern is termed conflictual because the responses are most often at odds with what the patient really wants for himself. Each CCRT pattern is composed of these three elements: 1. 2.

The wish (W), either stated or implied The response of others, either real or anticipated (RO)

3.

The response of self (RS)

Common wishes include the wishes to be loved, to be respected, and to be accepted. Here are some examples of CCRT material as it appears in session:

CCRT Example 1 P: I am getting behind in my work. It’s driving me crazy. Every time she passes by my desk it gets so dragged out that I have no time to myself. If this keeps up, my manager is going to get wind of it. W: (Implied) To be respected RO: Takes over; doesn’t consider patient’s needs RS: Feels trapped

CCRT Example 2 P: (Stares blankly for a few minutes, and then speaks) Nothing much to say (in a monotone). Rob is in L.A., and there is no point calling. He is much too busy meeting this one and that one to want to talk. W: (Implied) To be cared for RO: (Anticipated) Indifference, not caring RS: Give up, get depressed The CCRT is not decoded by one example alone. It comprises repeating episodes that bring the conflictual theme to light. The wish (W), response of other (RO), and response of self (RS) can be thought of as three strands of a rope that have become intertwined. The first task of the CCRT method is to notice the strands at work. That starts the action of the second aspect of the method, which involves disentangling the strands so that new forms of responses can begin. In fact, research suggests that is just what happens in successful SE psychotherapy. The patient’s wishes remain the same, but the responses of others and self show some change (Luborsky & Crits-Christoph, 1998). In other words, the patient still wants what he wants for himself, but he no longer has such negative expectations of others or so many self-defeating responses from himself.

The Symptom-Context Method. The Symptom-Context method offers a way to decode the meanings of symptoms that can be used both in clinical and research situations.

36 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w Instead of considering the symptom as having a life of its own, this method provides a way to examine why the symptom emerges. Just as clinicians look for the “triggers” for depression or problems of abrupt onset, the Symptom-Context method looks at the “material” surrounding the symptom—that is, the emotional and verbal responses of the patient. When this approach is used as a research method, the researcher blocks off the segment of the session before and after the appearance of the symptom (its nodal point). That segment is compared to other, nonsymptom segments of the same length (its control nodal point). In treatment, the Symptom-Context method gives the patient and therapist a way to make sense out of what was once a mysterious, disturbing event. Its power begins to diminish once the context gives clues to its meaning. This is particularly useful for patients with anxiety disorders, PTSD, or stress-related physical symptoms.

An Example of the Symptom-Context Method P: In the car coming over here, I started getting a headache. . . . I think it was because of what we’ve been talking about. You know, him. . . . And my sister wants me to drive her all the way to Staten Island to visit him. Context: The patient has been talking about her father, who singled her out for berating during her childhood. She has been working on the issue in therapy long enough to suspect that the headache is a manifestation of the conflict in her head, between the pressure to see her father, and her anger against him.

The Helping Alliance Methods. The Helping Alliance is the partnership between the patient and the therapist around the work of the treatment. In clinical writings, it has been referred to as the therapeutic, or working, alliance. The Helping Alliance methods include scales and questionnaires designed to be used in research to track the state of the Helping Alliance. Two kinds of Helping Alliance were found through factor analysis of clinical research material. The first kind, called Helping Alliance 1, is an alliance in which the patient feels that the therapist is there to help her. In other words, she feels that the therapist is doing his job and is on her side. The second kind, Helping Alliance 2, is an alliance in which the patient feels like a partner in the therapy process. He sees working together as a way to move his recovery forward. Both forms of alliance are linked with a successful treatment outcome in psychotherapy research. In SE psychotherapy, two different therapeutic tools are important in the development of the Helping Alliance. The first is the therapist’s empathy for the patient’s experience. Research shows that a strong Helping Alliance early in the treatment is linked to the therapist’s empathy, both of which are predictors of a good outcome for the therapy. The second is the process of examining problems that occur within the treatment, acknowledging anything that the therapist may have done that has bothered the patient, and setting about to clarify the problem. That is referred to as rupture and repair, a process that initial research suggests is beneficial to the treatment (Safrin et al., 2001).

PSYCHOTHERAPY Theory of Psychotherapy As a form of therapy, psychoanalysis brings the “whole person” to the couch, including his problems, stresses, memories, dreams, fantasies, and feelings, in order to discover the inner sources of his problems. The psychoanalytic process begins as the patient opens up, so that previously unknown parts of the self can be owned and recognized.

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During the patient’s free associations, the analyst starts to hear patterns in the midst of the stories the patient tells and begins to pick up the emotional “hot spots” in the patient’s life. At the same time, the patient may begin to convey his difficulties through the ways he reacts to the analyst. The convergence of these streams of information forms the basis of the transference. This gives the analyst and patient a chance to work on repeating patterns while they are active in the treatment. The analyst also listens for sources of inner conflict that may be linked to symptoms or life problems. Change comes through the process of reworking old patterns so that the patient can become freer to respond in new ways. The therapeutic relationship itself is the other central change agent. Greenson (1967) and Zetzel (1970) pointed out how an alliance between therapist and patient is beneficial to the treatment. Whereas in psychoanalysis the treatment relationship develops through the intensity of the treatment, in psychodynamic psychotherapy a strong working alliance is actively encouraged. Current psychoanalytic thinking emphasizes the importance of the emotional communication between patient and therapist as a way to gain information and create connection.

Change in Psychodynamic Psychotherapy What makes for change in dynamic psychotherapy? The theories about what matters in treatment have their origins in the central principles of psychoanalysis. Change is seen as a gradual process of (1) opening up to self-discovery, (2) discovering patterns of relating and perceiving that stand in the way of current functioning, (3) finding ways to disentangle the influences of the past from the present, and (4) finding new ways to cope. The first (1) objective is achieved through free association on the part of the patient and the “evenly hovering” attention of the analyst. The next (2) objective refers to the analysis of the transference or, in SE psychotherapy, the examination of the CCRT. The third (3) objective involves the gradual discovery of the sources of pain, through memories and through the unwelcome reminders that may come via symptoms and behavior in relationships. The final phase (4) is achieved by working through the changes from the preceding steps and developing an increasing ability to use the working alliance with the therapist as a backdrop for a new sense of emotional competence.

Psychoanalysis and Psychodynamic Treatment Although psychoanalysis is the subject of a vast amount of writing, psychodynamic treatment is more frequently used in practice. Psychodynamic treatment began in order to shorten and simplify the lengthy process of psychoanalysis. It remains popular for the same practical reasons. Supportive-expressive (SE) psychotherapy was developed in order to add clarity to the clinical process. It works from central dynamic principles and includes the use of clinical-research methods in the treatment. Gains in psychoanalysis and in dynamic psychotherapy derive from two sources: the therapeutic relationship and the exploration of the patient’s problems. In supportiveexpressive (SE) psychotherapy, the relationship and the structure of the treatment serve as the basis for the supportive aspect of the treatment. Exploration of the patient’s problems, using the CCRT and the Symptom-Context methods as tools, constitutes the expressive aspect. Table 2.1 illustrates the ways in which the psychoanalytic principles emerge in treatment. The term psychodynamic psychotherapies here refers to both psychoanalysis and dynamic psychotherapy, since both make use of the same fundamentals in their treatments.

The Purpose of the Psychoanalytic Method Why make the unconscious conscious? Why talk about the past? The psychoanalytic stereotype is that of patients spending dozens of years of talking to the ceiling and getting nowhere. Aimless analysis may sometimes occur, but that is not the intent of the method,

38 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w table 2.1

Application of Psychoanalytic Principles to Treatment

Psychoanalytic Principle

Psychodynamic Psychotherapies

SE Psychotherapy

Allow a positive regard for the analyst as a base for the treatment Understand the transference Unconscious conflict results in symptoms

Develop a working alliance

Apply Helping Alliance methods

Analyze the transference Explore conflicts that may be connected to symptoms

Apply CCRT methods. Apply Symptom-Context method

nor is it likely in a well-conducted treatment. Let’s look at the theoretical reasons for the psychoanalytic method. (The psychodynamic and clinical-research methods applicable to each of these points are given in parentheses.) 1. To uncover the inner problems that had been disguised as symptoms. Just as replacing a garden hose does not solve a problem in water quality, in psychodynamic psychotherapies, the goal is to resolve the problem at its source. In order to understand the meanings expressed in the symptom, the treatment allows in all kinds of material that might at first appear to be random and unrelated. The thematic and emotional links become apparent only after enough “emotional data” have been collected. An “emotional understanding” of the meaning and function of the symptom should prevent symptom substitution, in which a different symptom emerges that expresses the same inner problem, and should help reduce the likelihood that the same symptom will continue to recur. {Expressive work; Symptom-Context method} 2. To become integrated. In intrapsychic, or internal, conflict, the parts of the self are at odds with each other. For example, one part may hold the belief in high achievement, while the other part may feel burdened and resentful of work. In conflict, one part sabotages the other, as in the student who never makes it to class. In “working through the conflict” the student may come to know the part of himself that feels resentful and may give that part a chance to speak in session, rather than through behavior. The next task is to find solutions in life that work for both parts of the self. That may take the form of no longer holding on to old feelings that carried pain or frustration, so that what once was at impasse becomes possible. Or it might take the form of a different kind of adaptation, as in the student who decides to spend a semester in Alaska instead of in class. {Free association; working through; CCRT} 3. To uncover the sources of past pain that may be embedded in the present, causing ripples, or at times whirlpools, of the past in the present. Perhaps the most powerful reason to take the time to consider what may lie behind symptoms and problems in living is the power of the past to find its way into the present. Selma Fraiberg (1987) tells poignant stories of her work with mothers who had been neglected or abused themselves as children. Their own babies began life in a form of repetition of that neglect, because the mothers could not respond to their babies’ cries. Through her work with the mothers and their memories, Fraiberg and her colleagues helped two generations at once, separating the past from the present by first allowing past pain to be understood and then focusing on the present, new baby. An excerpt from one of these cases, “Ghosts in the Nursery,” is included in Case Studies in Psychotherapy, the companion book to this text. {Early memories; therapist’s empathy; Symptom-Context method} 4. To discover what stands in the way of taking appropriate actions for the self. Even the best plans sometimes go nowhere because other forces within the patient stand in her way. For example, a patient spent several sessions outlining her plan to apply to business school and then develop her own business. But she then canceled her next session and did not return the therapist’s phone calls. When she finally showed up, weeks later, she

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and the therapist discovered that she had expected the therapist to hold her to a plan she was not ready to follow. In fact, the people who would have been behind her plan were not even there. They were her parents as she remembered them from childhood, always planning for her, especially her mother. The therapeutic work needed to back up, and take a look at the transference, so that the patient could become free to make her own choices. The CCRT offered them a way to examine the anticipated responses of others (RO) as well as her own response (RS). {Transference; CCRT} The sources of change in dynamic treatment are summarized in Table 2.2.

The Purpose of Free Association The reason for encouraging free association, rather than structuring the treatment around specific problems, is that neither the patient nor the therapist knows where the keys to the patient’s problems will come from until they find them. That is because powerful aspects of the patient’s inner life have been operating without his full awareness. As he gradually allows more of himself to be known, both to himself and to the therapist, the patient can begin to take charge of a “fuller self.” New potential emerges once he gets in touch with sources of conflict that were previously operating in the language of symptoms. “Free speech” is the first step.

Example A patient who has just turned 30 finds that he loses interest in every woman he dates after 3 months. He tried “holding his nose” and staying, but that did not change his feelings. His current girlfriend suggested therapy.

table 2.2

Sources of Change in Dynamic Treatment Clinical-Research Goal Method

Theoretical Principle

Treatment Process

Unconscious conflict causes symptoms or problems in living

Pt: free associaUncover inner tion sources of conflict; pt gives voice T: open listening to parts of the self

Transference causes problems in current relationships

Uncover the workings of the transference

Early problems resurface in later functioning

Examine the transformation of past problems into new forms

The therapeutic relationship serves as the foundation of treatment

Helping Alliance Build a treatForge a treatment Empathy, along relationship that with examination methods; rupture ment alliance that gives the and repair of problems as builds trust patient a sense they occur that someone is “there for him”

Clinical Method

CCRT (for conflict) SymptomContext method (for symptom’s meaning)

Decode symptom; find new resolution to inner conflict

Attend to the transference to the analyst and others

CCRT method

Disentangle old expectancies from current attitudes

Listen for early memories and notice ways current stresses may trigger them

SymptomContext method (for the role of stresses in triggering old issues)

Give a new ear to old pain so that it no longer causes acute stress; disentangle the past and the present

40 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w P: So, tell me what is wrong with me. I mean, could it be that I just haven’t met the drop-dead gorgeous girl who deserves me? Just kidding. Mia says I’m scared of rejection. I don’t know about that. The patient is backing into his own feelings by talking about his girlfriend’s ideas first. The therapist is listening, her first job in the treatment. She knows better than to jump in too quickly with any answer to the patient’s problems. Instead, she is interested in beginning a process where the patient gets in touch with himself. Her two tasks, developing a Helping Alliance and starting the exploratory work, are beginning together.

Psychoanalytic Variations Although the fundamentals of the theory of psychotherapy are shared by most therapists working in a psychodynamic tradition, the emphasis on one element or another varies considerably. For example, classical psychoanalysts focus most on the exploratory work, with the analysis of the transference as the crux of the work. Self-psychologists focus on the nature of the therapeutic relationship, using empathy, rather than understanding, as a prime tool. Relational analysts focus on what gets conveyed through the relationship forged between patient and analyst. The diversity in viewpoints makes a refreshing change from the early days of psychoanalysis (Orfanos, 2006). However, underneath the differences, a common set of principles continues to operate. In addition to the fundamentals mentioned above, there is the importance of individual differences and the view of the treatment as an opportunity to help the patient rediscover himself. The patient’s unique story is the topic of the treatment, with its previously hidden parts as sources of both pain and potential. The dynamics to understand are not a theory to fit to the patient. Instead, they are principles that can guide the therapist’s ways of understanding the patient, once enough clinical material has emerged.

Process of Psychotherapy Psychoanalytically oriented psychotherapy is an unfolding interpersonal process aimed at both discovery and recovery. It is shaped by the personality and problems of the patient, the nature of the therapeutic relationship, and the pathway discovered by patient and therapist as most fitting for the patient. It moves through a series of stages that do not have a time line, except in time-limited versions of dynamic treatment. Instead, the stages are paced by the process and progress of the treatment.

Phases of Dynamic Psychotherapy Just like a book, the phases of dynamic psychotherapy can be divided in three: the beginning, or opening phase; the middle, which consists of the major work of the treatment, including working through the basic themes; and the end, commonly called the termination phase. Whereas the beginning and the end are defined by their place in the treatment, the middle phase is defined more by the nature of the processes and progress that take place. Consequently, the opening and termination phases will be discussed here as such, and the work of the treatment will be described in terms of the elements that go into the treatment.

The Opening Phase. The opening phase begins before the door opens. What made the patient decide to come into treatment at this time? How hard was it to make the decision? Has she ever been in treatment before? How “bad off” is she? Are there symptoms that might be dangerous to her well-being? Does she have clear goals, or is she “here because she’s here”? The therapist will be interested in all of these questions, but he will

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not want to bombard the patient with them. He will want to set a tone and a pace that allow the patient to begin to get comfortable being in therapy and telling her story. Psychoanalysis and dynamic psychotherapy differ in certain respects during the first phase. A notable difference is that analysts typically wait for the patient to tell her story, rather than asking many questions. Whether or not questions are explicitly posed, the therapist will want to understand •

Why the patient is seeking treatment at this time

• •

What kinds of triggers to the current problems seem to be present How troubled the patient appears to be (psychological health-sickness)

The therapist takes cues from the patient right from the start. Thus some patients will be able to talk over their reasons for coming into treatment in an organized way, whereas others convey their reasons by their level of distress and difficulty talking. The therapy begins where the patient is. The introductory phase typically lasts for several sessions. Some therapists use the first three sessions to get an initial sense of the patient and her problems and to go over treatment goals together. Others begin without a formal procedure, trusting that the process will unfold organically. In SE psychotherapy, some form of evaluation, however informal, takes place during the first several sessions. The therapist seeks to get a sense of the patient’s psychological well-being in order to consider what form of treatment will be in her best interest. Related decisions include the frequency of the treatment, as well as the balance of supportive and expressive elements. If the initial assessment raises concerns about psychotic process or severe depression, it is best if the therapist refers the patient for a psychiatric evaluation. Psychological testing may be used to better understand a patient’s cognitive and psychological problems. The practical arrangements of the treatment need to be made during the introductory phase. Those include establishing the frequency of the sessions, agreeing on the fee, and communicating any policies the therapist has regarding missed or canceled appointments. In psychoanalysis, particularly classical analysis, the patient moves from sitting up to lying on the couch either after a few sessions or when she is ready. In dynamic psychotherapy, the patient remains sitting up, facing the therapist. Psychoanalysis typically takes place three to five times a week, whereas psychotherapy sessions typically occur either once or twice a week. This reflects a difference in the process between the two forms of treatment. In psychoanalysis, the patient goes through what has been called a transference neurosis. That is, she replays her core relationship problems in the analysis, and they are resolved by working through their action in the treatment. Frequent sessions intensify that process. In dynamic psychotherapy, work on the transference also takes place, but it is less likely to be replayed in the same way. The CCRT offers a tool for uncovering its action in SE psychotherapy. The Helping Alliance begins in the opening phase, through the partnership forged between patient and therapist around beginning the treatment. An early positive Helping Alliance correlates with positive results in treatment, according to psychotherapy research studies. This does not mean that a therapy is doomed if the patient starts with mistrust and misgivings, but it does mean that forging a good connection is an auspicious start.

The Elements of the Treatment The two central elements of the treatment are the therapeutic relationship and the exploration of the patient’s problems. The balance of these two elements varies by the form of dynamic treatment being practiced and, more important, by the needs of the patient. In SE psychotherapy, the amount of supportiveness and the amount of expressiveness are

42 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w tailored to the needs and pathology of the patient. In other words, a patient who is more psychologically fragile will need more support from the therapist than one who functions well in daily life. Some patients respond more to the empathy and the feeling of connection; others respond more to the quest for self-discovery that happens through expressive work. The guide to the right balance of these elements is the patient.

The Supportive Relationship. In SE psychotherapy, the supportive relationship includes all elements of the therapeutic relationship that offer sources of human connection and structural support to the patient. These elements include the Helping Alliance, the therapist’s empathy, the structure of the treatment contract, and attention to the realities of the patient’s life. Although many people think of “support” as a lesser element, something either to avoid or to fall back on when nothing else works, empirical studies link support with a positive outcome of the treatment (Orlinsky, Grawe, & Parks, 1994). In all dynamic treatments, the therapeutic relationship is considered a source of the therapeutic action. The therapist’s empathy sets the stage for connection. “One begins to empathize with the patient as soon as one goes to open the door, even before seeing him” (Greenson, 1978, p. 158). Empathy connects the therapist and patient to a level of the patient’s experience that may not be expressed in words. Since patients often come to therapy when they find themselves in the midst of different kinds of negative emotion, it is encouraging for them to find that the therapist can get the “feel” of their lives. Example P sits in her chair in a way that makes her look as if the chair is her skin. She is not moving. The therapist sits very still, finding that she has quieted herself to be in tune with the patient’s slow rhythm. Time passes. The therapist watches the patient’s face. P: Tomorrow is another day. T: (Nods) P: You don’t know what it’s like to get up in the morning, look around the room, and see . . . (She begins to get teary.) T: (Hands her the tissues.) P: Thanks. T: (Nods) The patient is trying to come to terms with the end of her marriage. There are no words the therapist can offer her right now that are as useful as her presence. The patient needs someone to be with her feelings.

The Expressive Work The expressive work is a gradual process of making sense of the patient’s problems, in the context of the whole person. Before forming any hypotheses about the problems, the therapist needs to deepen her sense of the patient by tuning her ear to listen for all the levels of communication that take place. Freud called this “evenly hovering attention”; instead of preselecting what matters, the therapist listens to everything the patient brings. Luborsky and Luborsky (2006) refer to this process as open listening, and Rubin (1996) likens this form of listening to Buddhist meditation, in which the focus is not the content but a state of being. Meanwhile, the patient is asked to “say what comes to mind,” a suggestion that different patients use in a different ways. Some want to begin at the beginning and start with their memories and earlier problems. Some begin with today—with whatever events and thoughts come to mind. Some stay problem focused and select those situations that cause

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stress. In that way the treatment belongs to the patient, and he is shaping it as his own by the nature of the concerns he brings. It is not only what the patient says that helps the therapist develop an understanding of the patient, but also how he conveys himself. That includes his tone of voice, affect (emotional tone), and behavior. Many current analysts consider their countertransference reactions as possible sources of information as well.

Example P: (In a bland voice.) So I went to Washington, spent the day collecting the data that I needed, and made the train back that night. T: (T is silently wondering why this patient bores him. There is nothing wrong with what he is saying. Most patients give an account of the details of their daily life. He has been coming to treatment for three months, so he must be getting something out of it.) P: Marjorie was there . . . (He falls silent.) T: (Marjorie . . . She was the one who broke up with him last year. Maybe she is key to live feelings.) What was it like to see her again? P: You remembered. T: A surprise? P: Yes. People don’t. T: That must bother you. P: Not really. I’m used to it. T: How did you get so used to it? P: (Winces, the first show of real affect the therapist has seen in a long time.) T: (No longer feeling bored, and suspecting that his reaction is related to the patient’s CCRT pattern.) There may be good reasons why you got used to it. It would be rather frustrating to keep expecting people to remember what you have to say, if they never do. P: I’d say so. (His body posture relaxes ever so slightly.) T: (The therapist is glad to have found a way to understand the patient’s bland way of presenting himself. He did not want to mention it directly, feeling fairly certain that the patient would be insulted if he did. He realizes that his own worry about being rude had stopped him from looking more closely at the issue. He then begins to consider the patient’s CCRT pattern.) The therapist’s countertransference response had let him know that something active had been missing. He took advantage of an opening in the patient’s discourse to get to a “live issue.” That allowed him to consider the patient’s CCRT. In this case it would be W: (Wish) [implied and deeply buried] To be recognized, remembered RO: (Response of others) [anticipated] Not recognized, not remembered RS: (Response of self) No emotional reaction, no affect The therapist could also consider the patient’s bland presentation as a defense against affect. The defense against the pain he would feel if he let in the disappointing response of others had become a defense against all feeling.

Deepening the Exploration The expressive work deepens through the gradual emergence of patterns in the patient’s problems. That includes patterns in relationships and in handling stresses and emotions. Unlike symptom-focused treatments, dynamic treatments start with the premise that any

44 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w information can be useful in that process of discovery. Just as in mining for gold in a muddy stream, you don’t know where the nuggets are until you find them. In the middle phase of treatment, the patient and therapist gain a deeper understanding of what forces make for problems in the patient’s life. That takes place by an examination of problems in relationships, through the understanding of the transference or CCRT pattern. The patient’s emotions begin to make sense as their connections to her past and present life become clear. The emergence of symptoms takes on new meaning once the links to the patient’s inner conflicts are understood. The Symptom-Context method can help in that process. By the later phase of the exploratory work, the patient has gained understanding of the past patterns in her life and is no longer experiencing inner conflict that stops her from functioning. She may continue to work through the remaining ways in which old patterns may surface, as she gets ready to figure out new ways to cope. With some patients that happens as a natural outgrowth of the process of the therapy. Others make active efforts to develop new coping strategies, now that their energies are no longer tied up in past patterns and conflicts. In this phase of the work, the patient may notice herself “freed up” in situations that used to be impossible for her to handle.

The Termination Phase The end of the treatment comes when it comes. The best ending is an ending of the need for treatment, when the patient is engaged with her life in ways that feel positive, without the initial symptoms and turmoil that brought her to treatment in the first place. She should also have mastery of her core themes, so that she no longer falls back into the same problems once she has finished treatment. She should have developed new ways to cope, so that she feels that she can handle her life. In reality, people “get off the train” of treatment at different points. Some end due to symptom relief, some end due to difficulties in the treatment, and some stay until they reach a more definite end of the journey. Of course, there is really no such thing as being finished, if “finished” means having no problems and having complete confidence, but an end to a psychoanalytically based treatment should mean that the patient knows herself better, accepts herself and her feelings, and is not frightened of what she will find or feel if she really tunes into herself. She should instead be in a place, psychically, where the old demons have been tamed and no longer “spook” her in the present, and she is ready to move on. Termination is not as simple as setting a date to conclude treatment. It is a process instead, and considerable feeling comes up in ending therapy. Patients have typically become attached to their analysts, and there are many feelings about letting that person go. Old conflicts and symptoms may resurface as an expression of anxiety about stopping. However, these experiences should be brief and the patient should be able to get them back under control if she is really ready to end. It is important during this phase to explore any fantasies the patient has about how things will be after the analysis is over. That gives the patient and analyst a chance to share the patient’s hopes and fears, as well as to give the patient greater confidence going forward. An “open door” policy is often useful as an ending stance. That means the therapy is a place the patient can return to if she ever has the need. In the meantime (which could be forever), she takes it with her.

Mechanisms of Psychotherapy If someone listened through the walls to a psychodynamic treatment session, he would not be hearing “mechanisms.” Instead, he would hear someone talking about his life, telling anecdotes, memories, feelings, and fears. He would hear the therapist’s responses to those concerns—sometimes to the content, sometimes to the feelings, often to both.

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But those exchanges contain the treatment mechanisms, since the essential mechanism of psychotherapy is an interpersonal process. The two central elements of the treatment, the therapeutic relationship and the exploratory work, both contribute to their workings.

The Therapeutic Relationship The Helping Alliance is pivotal to the therapeutic relationship. It is the partnership between therapist and patient around the work of the treatment. Some patients experience that alliance as going to a therapist who gives them help (Helping Alliance 1), whereas others experience it more as a partnership between patient and therapist (Helping Alliance 2). Research links both forms with a good outcome for the treatment, provided it is a positive alliance, or one that the patient feels offers help. The Helping Alliance can be enhanced by the therapist’s efforts to keep the channels of communication clear. This means actively listening to the patient so that she feels the therapist is a partner in sharing her real concerns. It also means noticing if problems occur in the alliance and seeking to address them. A process of rupture and repair can benefit the alliance if misunderstandings or negative reactions have occurred. This process consists of talking over what may have been problematic for the patient, acknowledging any real difficulties that arose, and accepting the patient’s feelings about whatever went wrong. Being able to look at a mishap without brushing it away or overreacting can serve as a useful experience for the patient. Safran and Muran (1996) found it actually to be beneficial to the treatment outcome, especially for patients with negative expectations of relationships.

Example P: (P cancelled the last session. She arrives at this one just on time, and sits down.) So. T: (Waits. She notes that the patient is focused on the arm of the chair and looks annoyed.) P: Nothing much to report. Work is busy. What else is new? A lot has happened, I guess. T: (Wondering why she is so evasive, and whether something might be bothering her about the therapy. Since she canceled the last session, there could be a reason for both.) You haven’t been here in a few weeks, is that right? P: (Shrugs) T: So I imagine a lot has happened that you haven’t talked about here. P: As if that matters T: I get the feeling I am pretty useless in your life right now. P: (Shrugs again) T: But I do remember just a few weeks ago you talking about some really important things. I wonder what happened in between? I must have done something, or said something, that made it feel different here. P: Done something. T: OK, what did I do? It turned out that what the therapist did was to take a phone call during the patient’s session, something she ordinarily never does, but she had been worried about her own child, who was home sick. The therapist acknowledged that she had taken the call. She wondered if that felt to the patient like she was no longer interested in her. After hearing the patient’s feelings, the therapist apologized for causing the patient to feel that she wasn’t interested in her: “The last place you need to feel that is here.” After several sessions of work on this rupture, repair began. The incident ended up helping the treatment, because the patient said that she had figured she would have quit therapy until the therapist admitted

46 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w her mistake. It also led them to work on the patient’s transference expectations, through CCRT work on her negative expectations of others and her own defensive responses. And it led the therapist to reflect on the narrow bridge between her personal and professional lives. As we noted earlier, the therapist’s empathy is another crucial aspect of the therapeutic relationship. Understanding the affect states that the patient goes through makes the partnership deeper. “Most experienced psychoanalysts will agree that in order to do effective psychotherapy, knowledge of psychoanalytic theory and an intellectual understanding of the patient are not sufficient. In order to help, one has to know a patient differently— emotionally” (Greenson, 1978, p. 147).

The Exploratory Work The exploratory, or expressive, work of the treatment is made up of the human process of dialogue in a protected place. It is protected from intrusions by the “saving of the hour” for the patient. It is protected from the ears of others by the practice of confidentiality. And it is protected from having any agenda other than the patient’s well-being by the nature of the therapeutic contract. The patient’s part of the process in the expressive work is to “say what comes to mind.” The therapist’s part is a sequence of listening and responding, which gradually yields an understanding of the sources of the patient’s problems. In psychoanalysis, the analyst’s interpretations of the transference are pivotal.

Transference and the CCRT The transference is the cornerstone concept of psychoanalysis. It reflects the deep patterning of old experiences in relationships as they emerge in current life. Just as if someone had made footprints in the woods and started looking for a path in the dark, people find themselves retracing their patterns of relating and responding without realizing it. It is not so easy to illuminate an unfamiliar path and walk a new way. Old paths wind through the shadows of habit and history. The analysis of the transference provides the lantern. Even though volumes have been written about the transference and its role in psychoanalysis, its inner workings may still seem mysterious. The Core Conflictual Relationship Theme method (CCRT) demystifies the concept by describing the different elements of the process. Each CCRT pattern is made up of repeated episodes, consisting of the patient’s wishes (W), responses from others, either real or anticipated (RO), and responses from the self (RS). People tend to have either one or several central patterns, just as Freud described when he first came up with the concept of the transference. In fact, Luborsky and CritsChristoph (1998) found that the CCRT corresponded to the central defining characteristics that Freud gave for the transference pattern. Thus the CCRT is an operational version of the transference. In understanding the patient’s CCRT, the therapist looks for the “convergence of spheres.” That term refers to the commonality in the CCRT themes in each of three fundamental areas of the patient’s life: his current relationships, his past relationships, and the therapeutic relationship. Both the current and the past relationships are central relationships, typically with family members from the past and either family members or others who are close to the patient in the present. As the patient and therapist notice the ways in which this pattern intrudes into the present, they become able to begin changing its impact. In clinical practice, it is important not to overload the patient with interpretations. For this reason, the therapist usually brings up one sphere at a time, an area related to the topic the patient has been talking about. As the treatment progresses, the patient may be ready to notice links between the spheres, once the pattern has become evident.

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Example P: I wished I could have walked out of the meeting, but I was stuck. You know how bad it would have looked if I had gotten out of my chair and knocked it over? (Laughs) Anyway, I was good and I sat there till I saw someone else move his chair. The only problem is how am I going to stand this job, with all of their meetings? T: How are you going to stand that stuck, trapped feeling? P: Exactly. Oh, now that you say that, I remember I felt that way in the last job. When is it going to be over? T: When will there be a job that isn’t a trap? P: Will you find me one? (Laughs) T: Let’s take a look at what makes you feel trapped. Maybe we can figure it out that way. In this sequence, the patient is actively aware of his feeling state and realizes that there is some pattern to it. The therapist picks up the patient’s signs of readiness to look at this pattern in the context of the job sphere, since that is the patient’s current focus. In supervision, his supervisor points out that the patient could develop those same feelings about the therapy. After all, he is stuck in a room, sitting in a chair, having a meeting. The therapist decides to remember that possibility and to keep his ears open to see if that theme becomes active in the treatment.

Symptoms and the Symptom-Context Method When a symptom appears in the course of the treatment, it gives the patient and therapist an opportunity to investigate its meaning. By taking a look at its context, they can begin to decode the symptom and find out what is making it erupt. The symptom can be thought of as a language for forces that are out of the patient’s awareness, often an inner conflict. The context gives hints to what it might mean. The context includes not only the events in the patient’s life but also his feelings about them. In a therapy session, the material the patient has just been talking about is the immediate context. This method has a number of clinical uses. In instances of “momentary forgetting,” in which the patient suddenly forgets what he is talking about, paying attention to the context helps the patient and therapist discover whether there was something emotionally disruptive that could have prompted the lapse of memory. A different kind of clinical use comes into play with patients whose symptoms are intrusive and frightening, as in anxiety disorders and post-traumatic stress disorder. Understanding the meaning of the symptom makes it less frightening, and the translation into words can begin to shift its form.

Example P: It’s happening again. . . . My throat feels like it’s closing up. (The patient had just been talking about early sexual abuse.) T: What do you think about that? P: (In a rasping voice) What he did to me. (Referring to a form of sexual abuse that involved her throat.) I can’t talk. This patient has been in treatment long enough that she can readily use the Symptom-Context method to understand her symptoms. She reached that point through the gradual discovery that situations that triggered feelings or memories of the abuse also caused bodily symptoms.

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Transformation The goal of the expressive work is a kind of personal transformation. By gaining an understanding of parts of the self that were previously at odds or out of awareness, the patient can work out new ways of handling her needs and her feelings. This is a gradual process. As the patient gains self-understanding, she becomes more aware of the ways she has “been in her own way.” She can begin to shift her expectations toward more positive ones and can find ways to go toward what she really wants, instead of defending herself against her fears. The maladaptive defense mechanisms that were operating before become less powerful. As described earlier in this chapter, research on the CCRT suggests this is the course of events in successful treatment. Patients keep wishing for the same things they always wanted for themselves, but their negative patterns of responses from others and self undergo change.

APPLICATIONS Problems Psychoanalysis functions both as a form of psychotherapy and as a conceptual system to understand how people function psychologically. As a form of treatment, psychoanalytic therapies are particularly well suited for the many patients who have what Sullivan termed “problems in living,” which include difficulties with work and love. Often, people present with generalized patterns of behavior that interfere with their conscious goals for happiness and success. Such difficulties are usually complex and lack an obvious cause, and a psychoanalytic approach helps discern the causes, often by tracing them to an unconscious conflict or relational pattern. A man, for example, might repeatedly fall in love with and marry the same kind of woman, although he knows from previous experience that these relationships will end disastrously. Or perhaps a woman unconsciously arranges her life so that any success at work will be followed by an even greater failure.

Stress and Distress People with various symptoms of stress or distress, including depression, anxiety, or hypomania, are also well suited for a dynamic approach. A dynamic therapist attempts to understand a symptom in the context of the whole person. She takes into account biological and personality predispositions, past history, current circumstances, and unconscious and cultural meaning. A woman suffering from post-partum depression, for example, may have a genetic vulnerability, hormonal fluctuations, and stress and sleep deprivation, all of which contribute to a biological susceptibility to depression. A psychodynamic therapist would help her to explore the personal meaning of having her own baby to care for, looking at both her past and her present circumstances. Through this process, she may recognize the unconscious anxiety she has about her own unmet wish to be nurtured, which had been interfering with her ability to make an emotional connection with her baby. Once she has worked these feelings through, she will be able to form a positive bond with her child and to have more children without becoming depressed. Psychoanalytic treatments are beneficial for those who would like to gain a deeper understanding of their problems. Those in the mental health professions often wish for a high level of insight and self-knowledge, in order to be better able to help others with their difficulties. Because it can get at issues that are unconscious, psychoanalysis can also be quite helpful to people who feel generally troubled but do not know why.

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Personality Disorders Psychoanalytic treatment is probably the treatment of choice for personality problems and disorders. This is because psychoanalysts have developed sound theories and techniques to understand and treat them, whereas many other schools of psychotherapy have not. Such disorders are difficult to treat because, as the name suggests, they involve problems that pervade the patient’s personality, rather than a specific symptom or condition. Personality disorders call for intensive, long-term treatment to address these issues at a deep level, including work on the patient’s defenses and underlying feelings.

Range of Applications As a system for thinking about people and their problems, a psychodynamic model has a wide range of applications. Understanding the patient’s personality structure helps the therapist decide which types of therapeutic interventions are likely to be most effective. The Psychodynamic Diagnostic Manual (PDM) (2006), a psychodynamically based system of classification of psychological difficulties, can be used in that process. Projective psychological tests can sometimes provide information about personality structure, areas of potential conflict, or the presence of a thought disorder. In supportive-expressive (SE) psychotherapy, the therapist balances two basic elements of the treatment, the supportive relationship and the expressive work, in order to meet the needs of the patient. In that way the therapist is able to tailor the treatment to the level of the patient’s pathology. Psychoanalysis is now useful for many who might have at one time been deemed untreatable or “unanalyzable.” Variations of psychoanalysis are currently being used to understand and effect change with a much wider spectrum of people and situations than ever before. Object relations theory, in particular, has widened enormously the scope of treatable conditions, making psychoanalysis useful for many more people and situations. Kernberg (1975), for example, has established an object relations approach to working with patients with personality disorders in the narcissistic and borderline spectrum. Psychoanalytic formulations have been used to elucidate the dynamics of life in the inner city and their effect on psychological treatment (Altman, 1995). A relational approach has been found to be especially useful for people suffering from the long-term effects of chronic relational trauma, such as physical, emotional, or sexual abuse (Davies & Frawley, 1994). Other psychodynamic approaches to therapy have also been used to address the particular issues of gay men and lesbians (Drescher, D’Ercole, & Schoenberg, 2003).

Child and Family Treatment Problems with a family can be addressed in various ways using a psychodynamic approach. A psychoanalytic perspective informs certain schools of family therapy, such as object relations couples therapy (Scharff & Scharff, 1997) and has been utilized in an integrative way by combining individual and family/couples approaches (Gerson, 1996; Wachtel & Wachtel, 1986). When couples or families work to discover the sources of their problems together, they often find that some of those problems have come about as a result of their own personal histories, conflicts, and vulnerabilities. Understanding those patterns together provides an opportunity to shift the present interactions away from the past paradigms. Play therapy is an application of dynamic concepts for children, based on Melanie Klein’s concept that play is for children what free association is for adults. Such therapy gives the patient an uncensored opportunity to play out issues and express feelings in a way that causes no harm. Symbolic play allows children to express themes that might feel

50 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w threatening in words. Parents can be thrown out the window, children can take over the house, animals can fight battles, and no one really gets hurt. Working with parents to help them with their relationships with their children can involve the application of dynamic theory. Either with the parents alone or with the parents and child together, the therapist can help separate the current parenting relationship from those in the parents’ past. The work of Selma Fraiberg, excerpted in the Case Studies in Psychotherapy volume, gives an unparalleled example of that kind of work.

Combinations of Treatments Like other forms of psychotherapy, dynamic therapies may be combined with the use of medication for symptoms that are too severe to respond to psychotherapy alone. That is often the case in a major depression or other major mood disorder. Medication does not replace psychotherapy, and the two together are often more effective than either one alone. Understanding the meaning of symptoms and the psychological function they might serve is still an important task. Some dynamically oriented therapists combine tools such as relaxation and breathing techniques for addressing the immediate symptoms and the Symptom-Context method for understanding their meaning.

Evidence People often think of psychoanalysis as a “dinosaur” among psychotherapeutic treatments, with a few stray fossils around and no science that could bring it back to life. That happens to be untrue. Not only is psychoanalysis actively practiced in a variety of forms, but there has been ongoing psychodynamic research for decades. Research supports the efficacy of dynamic treatment and specifically supports the workings of its cornerstone principles. Although clinical research does not suggest that dynamic treatment yields more consistent success than other forms of psychotherapy, it does confirm its effectiveness, and studies of its working mechanisms confirm its most fundamental methods.

Psychotherapy Research Psychotherapy research often focuses on which form of therapy has the best outcomes, compared to other forms. Researchers who have an allegiance to one particular form of treatment often obtain results that support their favored approach. However, when psychotherapy studies are combined into meta-analyses, the results are different. Large-scale meta-analyses that aggregate data come up with two findings. The first, often ignored, may be more important than the second. The first finding is that psychotherapy works. Two thirds to three quarters of patients in psychotherapy get better, a very high rate of success (Lambert & Bergin, 1994). The finding that good “talk therapy” helps the majority of patients is often overlooked in the wake of all the attention given to psychotropic medication. Supportiveexpressive, or dynamic, psychotherapy is one of the forms of therapy that attain this level of success. The second finding is that no one form of therapy consistently outperforms the others. Differences that are too small to be statistically significant are the norm, especially when the studies are corrected for the effects of the researchers’ allegiance (Luborsky et al., 1999). This has been called the “Dodo bird finding” after a story in Alice and Wonderland. In that story, the Dodo bird gives prizes to everyone who participated in a race, declaring that “everyone has won, and all shall have prizes.” Why is it that everyone gets a prize, when each runner really thinks he should be the winner? The most likely reason is that well-performed psychotherapies share some

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fundamental factors. Prominent among them is the Helping Alliance. Dynamic psychotherapies highlight the importance of the alliance between patient and therapist, and other treatments rely on the partnership between client and therapist, even if it is not described as an aspect of technique. Whether explicit or implicit, the Helping Alliance is key in moving the treatment forward. Research also reveals that the therapist’s empathy is also linked with positive treatment outcomes. Empathy is another aspect of psychodynamic technique that may be present in other forms of treatment, whether explicitly or not. Other shared characteristics include the structure and frame of the treatment and an explanatory system that the patient gradually masters. That does not mean there are no meaningful differences between forms of treatment. There are important differences, as you will see as you read the chapters of this book. However, meta-analyses suggest that the differences do not overpower the effect of psychotherapy itself. The Dodo bird’s prize goes to those general (“g”) factors that all good treatments share.

Evidence-based Practice In order to gather clearer evidence on the effectiveness of different treatments, researchers have begun to establish empirically supported therapies (ESTs). By establishing precise guidelines for the treatment and for the type of disorder being treated, researchers intend to bring more objectivity to the studies comparing psychotherapies. However, pitfalls arise in relating the results of this approach to real life. Most ESTs are brief treatments, using specified techniques for specific disorders, with subjects whose problems fit with the criteria for that disorder alone. This makes for a clean research design, but in real life, people frequently have commingled problems, and those people are not eligible for the studies (Westen, Novotny, & Thompson-Brenner, 2004). The other real-life difference comes from the way psychotherapies are practiced. Whereas in studies of ESTs, the treatments follow “pure culture” methods, in reality good therapists adapt their treatment to the individual patient. In supportive-expressive therapy, that adjustment takes the form of balancing the supportive and expressive elements in accordance with the needs of the patient. Thompson-Brenner and Westen (described in Westen et al., 2004) found that therapists of different orientations tended to alter the degree of their activity in session, depending on the needs of the patient. Dynamic therapists reported using more structuring techniques (techniques associated with CBT) when dealing with emotionally constricted patients. And CBT therapists reported using interventions that explored relationship patterns (techniques associated with dynamic therapists) with emotionally deregulated clients. This means that in real life, the differences between forms of treatment are not always as clean as the differences suggested by EST research.

Effective Psychotherapy Seligman (1995) considered the question of the real-world effects of psychotherapy in a simple way. He polled actual patients for their impressions on a variety of factors. One of these factors was length of treatment. The patients said they found longer treatments more effective than brief ones. This type of research is not the whole answer either, as Seligman would be quick to agree. However, this approach provides another way to look at psychotherapy using research that is relevant and meaningful. Dynamic psychotherapies aim to treat the whole person and the patterns of his problems. When specific symptoms alone are studied, the important forces in dynamic treatment may be overlooked. Dynamic concepts and methods are supported by research evidence, which has been found through different kinds of studies.

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Evidence for Psychodynamic Concepts and Methods The Transference. Evidence on the key psychoanalytic concept, the transference, has accumulated through research on the Core Conflictual Relationship Theme (CCRT) method (Luborsky & Crits-Christoph, 1998; Luborsky & Luborsky, 2006). The CCRT is an operational version of the transference that allows it to be studied in research on the process of psychotherapy. Here are some of the findings: •

The same CCRT pattern can be found in patients’ narratives about different people.

• •

There is a parallel between the CCRT pattern with the therapist and with others. Interpretations of the CCRT are beneficial to the treatment when they clarify the habitual responses of self (RS) and other (RO).

The Unconscious Mind. Research in neuroscience has given the concept of unconscious processes scientific support through the study of implicit and explicit memory. The term explicit memory refers to the conscious retrieval of information, whereas implicit memory refers to memory that does not come to mind but is demonstrated through behavior (Westen, 1999). Implicit memory would be the kind of memory linked to transference patterns that are demonstrated through behavior in new relationships. Another form of memory, associative memory, links a network of things by their similarities. That process is akin to one tracked in dynamic inquiry into unconscious meanings, such as when the therapist follows the train of thought by its nonlogical, emotional links. Schore has studied the role of early relationships in early brain development. He notes that the processing of emotional understanding of the right hemisphere precedes verbal understanding. Schore hypothesizes that “the implicit self-system of the right brain that evolves in preverbal stages of development represents the biological substrate of the dynamic unconscious” (Schore, 2005, pp. 830–831). Finding Meaning in Symptoms. The meanings of a symptom can be found through the Symptom-Context method, which tracks the connection of a symptom to its context (Luborsky, 1996; Luborsky & Luborsky, 2006). The researcher compares samples of material from psychotherapy that contain a psychological symptom with samples of material that do not. This method has yielded three notable findings: • • •

The symptom emerges after a state of helplessness. Feelings of hopelessness, lack of control, and helplessness are linked to symptoms. The context for a symptom is significantly different from the context for a nonsymptom.

The Role of the Past in the Present. The belief that past relationship problems persist into the present is basic to psychoanalysis. Attachment research on the intergenerational transmission of attachment patterns (Main, Kaplan, & Cassidy, 1985) validates that hypothesis. Attachment researchers have also validated Bowlby’s concept that “inner working models” of relationships develop through attachment experience and affect the child’s sense of security and functioning in relationships.

Sprinters and Runners What would happen if someone decided to discover which were better, sprinters or longdistance runners? One of each type might be stopped after a quarter of a mile and tested for their heart rate and how rapidly they covered the distance. Would the winner really

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be the winner, or simply the one who best fit the research design? In order to study the effectiveness of psychotherapy, it is worth keeping in mind both the complexity of real people and their problems and the natural differences among forms of treatment. The performance of psychodynamic therapies, like that of the long-distance runner, may be best measured over time. Research suggests that symptom relief may be achieved through several “wellperforming” therapies. But psychoanalysis was never about symptom relief alone. Patients go into all forms of treatment because of symptoms that are troubling them, and they should get relief from those symptoms. But dynamic psychotherapies offer something else as well: a changed sense of self that is no longer stuck in old patterns.

Treatment Freud compared writing about psychoanalysis to explaining the game of chess. It is easy to formulate the rules of the game, to describe the opening phases, and to discuss what has to be done to bring a chess game to a close. But what happens in between is subject to infinite variation. The same is true of psychoanalysis. Since every patient (and every therapist) is different, no two treatments are alike. Even so, dynamic treatments have inherent operating principles and treatment techniques that are not immediately visible but are nevertheless at work. The following case fragment illustrates how they intermingle.

Example P: I have something I have been meaning to bring up . . . Night . . . (Pt’s voice is soft, and the therapist listens closely. After several minutes the patient starts again.) Katie made the soccer team. (Her voice is bright now.) Which is great, except for all the driving. The amount of miles I have put on that car . . . T: (T is wondering, what happened to what she had been meaning to bring up? It seemed that the patient had abruptly shifted gears. She notices the pun in her thinking and decides to ask about exactly that.) You know, I am still wondering about what you started the session with. It seemed like you shifted gears, just like the car. P: (Smiles) I have an automatic. But you’re right. So what was I avoiding? (The patient has been in treatment long enough to know that avoiding has reasons.) Well, you’re going to think, “She’s a fat pig” if I tell you. T: If I’m going to think that you’re a fat pig, I can see why you stopped talking. P: Well, maybe you won’t, but I do. . . . OK, here’s the thing. Jon (her husband) goes to bed early. He goes upstairs at 9:00, because he’s up at 5 to catch the train. And there I am. I just got the kids to bed, with the whole night in front of me. I keep telling you I want time to myself, but there it is, and what do I do? T: What do you do? P: Nothing. Clean the kitchen counters. Leave the TV low, so I don’t bother anyone. OK here it is. Eat. (Patient looks embarrassed.) I ate an entire package of Oreos last night. The whole package so I could throw the wrapping away and no one would know the difference. T: That must have been hard to talk about. P: Not as bad as I thought. T: And you must be wondering what I think. P: Well I really don’t think you would judge me, but . . . I mean, who wouldn’t? Why would anyone do something so stupid? I mean, I am trying to lose weight. Good reason not to eat that garbage. I should work on my writing if I ever want to get anything published. Good reason not to waste my time. I have no time to

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T: P: T: P: T: P:

T: P: T: P: T: P: T: P: T: P:

myself during the day and finally the kids are in bed and Jon’s up there too. You’d think I’d be happy about it. It sounds like you are really mad at yourself. I am. And that you figure I would judge you too. It’s hard to get to the “why’s” if you and I are both sitting in judgment, but I bet there are feelings hidden under there. (Nods) Lonely. (With empathy) Lonely. (Looks at T, and then back out the window.) Even though the house is full, it’s empty. . . . Yeah, OK, I’m trying to fill it up, but you can’t fill it with Oreos. (Looks at T, and they both smile.) . . . Is my time up? Actually, we have 10 minutes left. Oh, that’s so strange. I was sure it was over. Well, I wonder if there was something about what we just talked over that made you feel like I’d be ready to get rid of you. You mean, having feelings? Having feelings like . . . Lonely, mad that I get left with everything. And get left? Yeah, that. (Her eyes start to tear.) When I married Jon I thought I was done with that. He is solid. But he goes to bed and leaves you, and gets up early and does it all over again. (Nods) And now are we out of time?

This session gave the patient some relief. She told the therapist that she finally began writing again. But a month later the Oreos have returned. P: I started doing it again—eating. I was doing better with it, and then this last week, I got back in my old habit, you know, the night thing. T: I wonder if anything went on this week that might have been difficult? P: No. Good things actually. Katie got into a summer program we wanted her to do. Jon got offered a promotion at work. Got to buy some champagne. T: And your life? P: Yeah, that is my life. Me and my Oreos. (Looks the therapist in the eye.) You know when I was a kid, it was the same thing. When I came home from school, no one was there, but there was always food. T: What did you have to eat then? P: There’d always be something. Look in the refrigerator, look in the cupboard. Something. But I wished we’d have something really good. T: Like Oreos, by any chance? P: Now I’m throwing them away. My friend Andrea had all that junk in her lunch, and I wished I could have it too. In this sequence the symptom is multidetermined. As the session unfolds, more links between the patient’s feelings, present and past, and the symptom come to light. That kind of layering is itself a psychoanalytic principle. As more layers of related feelings collect, they add to the pull of the symptom. The next thing to notice is the sequence of the session. The patient’s emotional themes link her most spontaneous comments together. For example, just after she reveals emotionally laden material, she figures the session will be over. The sense that the session will be over comes from an inner theme, not from a realistic sense of time. Talking about her feeling of being left triggered the fear that she would be left by the therapist (by ending the session). Her response in this case was to become anxious. In the home sequences that she reports, she covers over the feeling by eating.

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The therapist is quick to note evasions in the patient’s process. They could be thought of as a form of defense. Since the patient and therapist have worked with each other for 9 months, they have an easy rapport. The patient has also already learned through previous examples that she may be avoiding things with which she doesn’t feel comfortable. The patient and therapist functioned as partners in this exchange, discovering what is really behind changing the subject. Their Helping Alliance helped the patient trust the therapist when dealing with a topic that was embarrassing to reveal. So did the therapist’s analysis of the defense. When she made a joke about the car changing gears, she was also pointing out the patient’s method of defense against difficult feelings. When she commented that “no wonder” the patient wouldn’t talk about eating if the therapist would think she was a “fat pig,” she was pointing out one of the functions of the defense. A CCRT pattern is suggested, through the convergence of the responses described from her childhood, in the present with her husband, and with the therapist. The possible CCRT pattern looks like this: W: (Implied) To be close RO: Leaves, does not stay close RS: Eats, fills the space with a substitute; avoids feeling (in the early part of the session, she tends to avoid feelings, whereas later she becomes anxious instead. This is actually a sign of improvement since the anxiety is really underneath the avoidance and use of food). The Symptom-Context method is at work when the patient and therapist examine the context for overeating. It gives them clues to the patient’s feeling state. Another technique that the therapist follows is responding to the patient’s affect. She slows down the dialogue and makes time for empathy with the patient’s feeling state. The potential for change is suggested by the patient’s positive response to the session and in her greater ease in moving into the material the second time. More work will be needed in order to better understand the patient’s feelings and their history. But what we have here is simply a fragment of a treatment, and it represents a good start.

The Psychoanalytic Situation Shame, fear, pride, political correctness, social conformity—these are among the forces that stand in the way of the patient acknowledging her own truth. The psychoanalytic situation, in which nothing is the wrong thing to say, gradually undoes those layers of inhibition. “The special conditions of the psychoanalytic situation are designed to promote the optimal unfolding of the patient’s unconscious subjective life” (Rubin, 1996, p. 24). As the analyst listens to all the layers of the patient’s experience, the patient begins to do the same. Logic, consistency, and the other person’s approval are not the goals of psychoanalytic discourse. It has its own logic, where the heart and the unconscious mind intermingle with the waking, rational self. As the patient comes to accept the varied parts of herself, a greater flexibility emerges. As the transference is worked through, the patient may find that he can relate to others in new ways. The transference can be understood as a form of memory in which repetition in action replaces recollection of events. Once memory’s voice is heard, its power to keep a patient repeating the same pathways weakens. Analysis of the transference helps the patient distinguish fantasy from reality, past from present. Analysis of transference helps the patient understand how he may have misperceived or misinterpreted. In place of the automatic ways in which he responded before, the patient becomes able to evaluate impulses and anxieties, rather than either acting on them or covering them over. Ironically, after making room in his consciousness for the illogical and irrational parts of the self, the patient is ready to make decisions on a more mature and realistic level.

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CASE EXAMPLE This case example illustrates the application of a classical psychoanalytic approach to a pivotal session in the treatment. The same session would be handled somewhat differently by therapists representing other psychoanalytic perspectives. In order to clarify some of the differences, the case description will be followed by the view of a relational analyst and the view informed by the use of the CCRT.

A Psychoanalytic Session The patient was a middle-aged businessman whose marriage had been marked by repeated strife and quarrels. His sexual potency had been tenuous. At times he suffered from premature ejaculation. At the beginning of one session, he began to complain about having to return to treatment after a long holiday weekend. He said, “I’m not so sure I’m glad to be back in treatment even though I didn’t enjoy my visit to my parents. I feel I just have to be free.” He then continued with a description of his visit home, which he said had been depressing. His mother was bossy, aggressive, manipulative, as always. He felt sorry for his father. At least in the summertime, the father could retreat to the garden and work with the flowers, but the mother watched over him like a hawk. “She has such a sharp tongue and a cruel mouth. Each time I see my father he seems to be getting smaller and smaller; pretty soon he will disappear and there will be nothing left of him. She does that to people. I always feel that she is hovering over me ready to swoop down on me. She has me intimidated just like my wife.” The patient continued, “I was furious this morning. When I came to get my car, I found that someone had parked in a way that hemmed it in. It took a long time and lots of work to get my car out. I was very anxious, and perspiration was pouring down the back of my neck. “I feel restrained by the city. I need the open fresh air; I have to stretch my legs. I’m sorry I gave up the house I had in the country. I have to get away from this city. I really can’t afford to buy another house now, but at least I’ll feel better if I look for one. “If only business were better, I could maneuver more easily. I hate the feeling of being stuck in an office from 9 until 5. My friend Bob had the right idea—he arranged for early retirement. Now he’s free to come and go as he pleases. He travels, he has no boss, no board of directors to answer to. I love my work but it imposes too many restrictions on me. I can’t help it, I’m ambitious. What can I do?” At this point, the therapist called to the patient’s attention the fact that throughout the material, in many different ways, the patient was describing how he feared confinement, that he had a sense of being trapped. The patient responded, “I do get symptoms of claustrophobia from time to time. They’re mild, just a slight anxiety. I begin to feel perspiration at the back of my neck. It happens when the elevator stops between floors or when a train gets stuck between stations. I begin to worry about how I’ll get out.” The fact that he suffered from claustrophobia was a new finding in the analysis. The analyst noted to himself that the patient felt claustrophobic about the analysis. The conditions of the analytic situation imposed by the analyst were experienced by the patient as confining. In addition, the analyst noted, again to himself, these ideas were coupled with the idea of being threatened and controlled by his mother. The patient continued, “You know, I have the same feeling about starting an affair with Mrs. X. She wants to and I guess I want to also. Getting involved is easy. It’s getting uninvolved that concerns me. How do you get out of an affair once you’re in it?” In this material, the patient associates being trapped in a confined space with being trapped in the analysis and with being trapped in an affair with a woman.

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The patient continued, “I’m really chicken. It’s a wonder I was ever able to have relations at all or get married. No wonder I didn’t have intercourse until I was in my twenties. My mother was always after me, ‘Be careful about getting involved with girls; they’ll get you in trouble. They’ll be after you for your money. If you have sex with them, you can pick up a disease. Be careful when you go to public toilets; you can get an infection,’ et cetera. She made it all sound dangerous. You can get hurt from this; you can get hurt from that. It reminds me of the time I saw two dogs having intercourse. They were stuck together and couldn’t separate—the male dog was yelping and screaming in pain. I don’t even know how old I was then, maybe 5 or 6 or perhaps 7, but I was definitely a child and I was frightened.” At this point, the analyst suggests that the patient’s fear of being trapped in an enclosed space is the conscious derivative of an unconscious fantasy in which he imagines that if he enters the woman’s body with his penis, it will get stuck; he will not be able to extricate it; he may lose it. The criteria he used in making this interpretation are the sequential arrangement of the material, the repetition of the same or analogous themes, and the convergence of the different elements into one common hypothesis that encompasses the data—namely, an unconscious fantasy of danger to the penis once it enters a woman’s body. The goal of this interpretation is to move toward what must have been an unconscious fantasy of childhood, that of having relations with his mother, and a concomitant fear, growing out of the threatening nature of her personality, that in any attempt to enter her she would swoop down upon him. In this case, there was a threat of danger associated with these wishes—namely, a fantasy that within the woman’s body there lurked a representation of the rival father who would destroy the little boy or his penis as it entered the enclosure of the mother’s body. As the therapist helped him become aware of the persistent effects of these unconscious childhood conflicts, the patient would gain some insight into the causes of his impotence and his stormy relations with women, particularly his wife, as well as his inhibited personal and professional interactions with men. To this patient, having to keep a definite set of appointments with the analyst, having his car hemmed in between two other cars, being responsible to authorities, and getting stuck in elevators or in trains were all experienced as dangerous situations that evoked anxiety. Consciously, he experienced restrictions by rules and confinement within certain spaces. Unconsciously, he was thinking in terms of experiencing his penis inextricably trapped inside a woman’s body. This is the essence of the neurotic process: persistent unconscious fantasies of childhood impose a mental set that results in selective and idiosyncratic interpretations of events.

Drive Theory versus Relational Theory The analyst in this case (Jacob Arlow) looks through the lens of drive theory. He sees the patient’s problems as having originated in the psychosexual anxieties of Oedipal conflict. The patient’s repressed sexual and aggressive impulses are behind his symptoms. Rather than succumb to these urges, he develops a symptom, claustrophobia, to represent the conflict symbolically, enabling him to simultaneously repress and express the impulse. This analyst sees his role as an objective observer who interprets the patient’s experience in order to make conscious what had previously been unconscious. In so doing, he works within a “one-person model,” offering insights that give the patient a deep-level understanding of his problems. A relational analyst would see the same material as an intersection of reality with long-standing relational patterns. She would be more likely to focus her responses on the ways the relationship patterns were activated in the present, by spending time on the patient’s feelings about the treatment. For example, when the patient talked about not wanting to come back to analysis after the weekend, she would have inquired about those

58 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w feelings, “shining a flashlight” on what the patient was experiencing with her. She would have had an interest in the patient’s early relationships as memories to explore, using them to understand the patient’s past and current feelings, rather than interpreting them in accordance with Oedipal theory. She would have tried to “get a feel” for the patient’s early world by empathizing with what was frustrating in his early experiences. She would be working from a two-person model, in which she is participant as well as observer. Her focus would be on the patient’s relationships, past and present.

Looking through the Lens of the CCRT In looking at the session through the lens of the CCRT, the convergence of spheres becomes apparent. The patient describes the same themes in his relationship with his mother, his work, the analyst, and his wife. That convergence makes it a good time for the patient and analyst to look at the pattern. The fact that the theme is reflected in the session itself means that the patient’s feelings about the analyst need to be further explored. Considering the session in that way makes it seem to be a pivotal session, just as it did to the treating analyst. However, what seems pivotal is the convergence of the CCRT pattern, not the Oedipal material. The CCRT pattern conveyed by this patient would be W: (Implied) To be free, independent RO: Controlling; trapping RS: Get angry; get anxious; get impotent The patient’s perception of the mother as controlling seems like an important driving force in his conflictual pattern. The patient’s symptoms, impotence and claustrophobia, both seem to be expressions of the CCRT pattern. The patient’s impotence appears to be linked to his perception of (female) others as controlling, and while his own response is to feel angry and trapped. The patient’s claustrophobia also seems symbolically related to his CCRT pattern, since the symptom involves the fear of being trapped. The SymptomContext method could be used to determine the context of that symptom, including feelings, thoughts, and events that precede it. We noted, when we traced themes in this psychoanalytic session, that for this patient, having to keep a definite set of appointments with the analyst, having his car hemmed in between two other cars, being responsible to authorities, and getting stuck in elevators or in trains were all experienced as dangerous situations that evoked anxiety. Whether seen through the lens of classical or relational analysis, or through the CCRT, the pattern in the transference is key in the process. The differing techniques use different language and approaches to help the patient come to terms with its impact.

SUMMARY Psychoanalysis began as a way to explain and treat human behavior that did not follow the laws of logic. What made people remain in states of psychic pain, with physical symptoms that had no apparent cause? From his early use of hypnotic techniques with patients who were then called hysterics, Freud began to develop a way to treat the conditions of psychic distress. Both his theories and technique evolved along with his clinical experience. As he discovered that psychological cures were often not as simple as recovering memories and regaining health, he noticed resistances within his patients that he began to explore. Theories of defense and of inner conflict as a source of symptoms evolved from there. He postulated an unconscious mind as the keeper of early patterns of relating, otherwise known as the transference.

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Since Freud, psychoanalytic ideas and forms of treatment have continued to evolve in different ways. In the century since his early discoveries, they have been alternately challenged, followed, rejected, and expanded. The classical psychoanalytic tradition has stayed the closest to Freud’s original ideas, whereas other theorists and practitioners have made changes in focus and technique. These include the ego psychologists, selfpsychologists, the object relations school, and the current interpersonal and relational analysts. Psychoanalytic concepts have been evaluated through clinical research, through methods that give operational status to their inner workings, notably the CCRT and the Symptom-Context method. Psychodynamic treatments make use of two basic elements of cure: the therapeutic relationship and exploratory work. Varied forms of treatment have evolved from the psychoanalytic core. They include both forms of psychoanalysis and dynamic psychotherapy, including supportive-expressive (SE) psychotherapy, which expands the range of patients who can be treated through a dynamic approach. Pivotal to all the forms of treatment are the fundamental psychodynamic beliefs in the power of old patterns of relationships to “trip the system” of current relationships, and the power of unconscious aspects of the self to appear in the form of symptoms. One of Freud’s seminal contributions to the history of psychology was his insight that there is more to us as human beings than what is on the surface, and that we can hide things about ourselves, even from ourselves. That is as true today as it was a century ago. Psychodynamic treatment continues to offer a way for patients to make sense of their own behavior and develop a clearer personal path. Psychoanalytic thinking continues to evolve by engaging in new ideas and clinical research. But perhaps most important of all, it is enriched by the source that sparked its origins: the patient.

ANNOTATED BIBLIOGRAPHY The following books are recommended for those who want to learn more about psychoanalysis as theory and practice: Freud, A. (1966). The ego and the mechanisms of defense. The writings of Anna Freud (Vol. 2). New York: International Universities Press. [Originally published in 1936.] Anna Freud has one of the finest and clearest writing styles in psychoanalysis. The Ego and the Mechanisms of Defense is an established classic for its lucidity in portraying the theoretical implications of the structural theory and its application to problems of technique. In a relatively small volume, the author offers a definitive presentation of the psychoanalytic concept of conflict, the functioning of the anxiety signal, and the many ways in which the ego attempts to establish defenses. The sections on the origin of the superego, identity, and the transformations in adolescence present a clear picture of how the child becomes an adult. Freud, S. (1915–1917). Introductory lectures on psychoanalysis. London: Hogarth Press. These lectures make up Volumes 15 and 16 of The Complete Psychological Works of Sigmund Freud. The books are based on a set of lectures Freud gave at the University of Vienna. His lectures are a model of lucidity, clarity, and organization. Introducing a new and complicated field of knowledge, Freud develops his thesis step by step, beginning with simple, acceptable, common-sense concepts, and advancing his argument consistently until the new and startling ideas that he was to place before his audience seemed like the

inevitable and logical consequences of each individual’s own reflection. Introductory Lectures on Psychoanalysis offers the easiest and most direct approach to the understanding of psychoanalysis. Greenberg, J. R. & Mitchell, S. A. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press. This landmark book contrasts drive theory and the relational model, in terms of theory and history. The latter paradigm follows from the British object relations theorists who believe that an innate need to maintain relationships is what motivates human behavior and that early relational patterns remain active throughout life. Greenson, R. (1967). The technique and practice of psychoanalysis. New York: International Universities Press. This book offers a clearly written introduction to psychoanalytic theory and technique. The psychoanalytic essentials of free association, the transference, and resistance are explained, as is the working alliance. The author gives clinical examples that demonstrate the psychoanalytic method and describes the “skills required of a psychoanalyst.” Greenson has a rare capacity to make complex concepts clear. Luborsky, L. & Luborsky, E. (2006). Research and psychotherapy: The vital link. Lanham, MD: Jason Aronson. This book has three functions. It brings clinical experience and research together in one volume, showing how the two

60 e l l e n b . l u b o r s k y , m a u r e e n o ’ r e i l l y - l a n d r y , a n d j a c o b a . a r l o w can enrich each other. It introduces Luborsky’s innovative methods, which can be used both in the practice of psychotherapy and as research tools. Finally, it offers a clear, stepwise introduction to the practice of supportiveexpressive (SE) psychotherapy, a form of psychodynamic therapy.

McWilliams, N. (2005). Psychoanalytic psychotherapy: A practitioner’s guide. New York: Guilford. The third of a trilogy, this volume builds on McWilliams’s previous books on psychoanalytic diagnosis and case formulations. She discusses in a sophisticated but accessible way the essential aspects of psychodynamic therapy.

CASE READINGS Arlow, J. A. (1976). Communication and character: A clinical study of a man raised by deaf-mute parents. Psychoanalytic Study of the Child, 31, 139–163. The adaptive capacities of the individual, even under difficult environmental circumstances, are illustrated in this well-documented case of a person raised by deaf-mute parents. In many respects, overcoming real hardships and conquering shame contributed to the character development of this person. Fraiberg, S. (1987). Ghosts in the nursery: A psychoanalytic approach to problems with impaired infant-mother relationships. In L. Fraiberg (Ed.), Selected Writings of Selma Fraiberg (pp. 100–136). Columbus, OH: Ohio State University Press. [Reprinted in D. Wedding and R. J. Corsini (Eds.). (2008). Case studies in psychotherapy (5th Ed.). Belmont, CA: Brooks/Cole–Thomson Learning.] Selma Fraiberg takes the psychoanalytic concept of the role of the past in the present into the lives of neglected infants. The mothers in these case studies could not respond to their babies until Fraiberg and her colleagues responded to the mothers’ previously forgotten memories of being neglected themselves. That opened up the potential for the mothers to hear their own real babies. Fraiberg offers a moving account of the ways two generations can be helped at once. Freud, S. (1963). The rat man. In S. Freud, Three case histories. New York: Crowell-Collier.

Freud outlined the role of the primary process, magical thinking, ambivalence, and anal fixation in the structure of an obsessive-compulsive neurosis. Although in his later writings Freud expanded his clinical theory and metapsychology, this case report is a prime example of how Freud used clinical observation to develop his ideas and shed light on previously obscure problems. Lindner, R. (1987). The fifty minute hour: A collection of true psychoanalytic tales. New York: Dell. Robert Lindner’s collection of authentic tales of psychoanalysis demonstrates his expertise in the subject, along with his willingness to stretch the “rules” of psychoanalysis in order to fully understand his patients, meet them where they are emotionally, and lead them toward health. Rather than textbook cases, these are stories about unique individuals and their journeys in psychoanalysis with an insightful, creative guide. Winnicott, D. W. (1972). Fragment of an analysis. In P. L. Giovacchini, Tactics and technique in psychoanalytic therapy (pp. 455–493). New York: Science House. Winnicott’s approach to psychoanalytic theory and practice represented an important turning point in psychoanalysis. This case report illustrates his special approach, which emphasizes the influence of interpersonal interactions and feelings. Winnicott’s technical precepts have had a strong and lasting effect on psychoanalytic practice.

The case of the “rat man” was a landmark in Freud’s developing theory of psychoanalysis. In precise, clinical reporting,

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Arlow, J. A. (1969). Unconscious fantasy and disturbances of conscious experience. Psychoanalytic Quarterly, 38, 28. Arlow, J. A., & Brenner, C. (1988). The future of psychoanalysis. Psychoanalytic Quarterly, 57, 1–14. Aron, L. (1996). A meeting of minds: Mutuality in psychoanalysis. Hillsdale, NJ: Analytic Press. Beebe, B., & Lachmann, F. (2002). Infant research and adult treatment: Co-constructing interactions. Hillsdale, NJ: Analytic Press. Benjamin, J. (1988). The bonds of love: Psychoanalysis, feminism, and the problem of domination. New York: Pantheon. Berenfeld, S. (1944). Freud’s earliest theories and the school of Helmholtz. Psychoanalytic Quarterly 13, 341–362. Beres, D., & Arlow, J. A. (1974). Fantasy and identification in empathy. Psychoanalytic Quarterly, 43, 4–25.

psychoanalysis Blatt, S. J. (2005). Experience of depression: Theoretical, clinical, and research perspectives. Washington, DC: American Psychological Association. Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York: Basic Books. Bowlby, J. (1988). A secure base: Clinical applications of attachment theory. London: Routledge. Brenner, C. (1982). The mind in conflict. New York: International Universities Press. Breuer, J., & Freud, S. (1895). Studies on hysteria. Standard edition of the complete psychological works of Freud, Vol. 2. London: Hogarth Press. Bucci, W. (1997) Psychoanalysis and cognitive science: A multiple code theory. New York: Guilford Press. Davies, J., & Frawley, M. (1994) Treating the adult survivor of childhood sexual abuse: A psychoanalytic perspective. New York: Basic Books. Drescher, J., D’Ercole, A. & Schoenberg. (2003). Psychotherapy with gay men and lesbians: Contemporary dynamic approaches. New York: Haworth Press. Ellis, A. (1994). Reason and emotion in psychotherapy, revised. Secaucus, NJ: Citadel. Erdelyi, M. (1985) Psychoanalysis: Freud’s cognitive psychology. New York: W.H. Freeman. Erikson, E. (1950). Childhood and society (2nd Ed.). New York: Norton. Erikson, E. (1968). Identity, youth and crisis. New York: Norton. Fairbairn, W. R. D. (1954). An object relations theory of the personality. New York: Basic Books. Fenichel, O. (1945). The psychoanalytic theory of neurosis. New York: Norton. Fonagy, P., Gergely, G., Jurist, E. L & Target, M. (2002). Affect regulation, mentalization and the development of the self. New York: Other Press. Fraiberg, S. (1987) Ghosts in the nursery: A psychoanalytic approach to problems with impaired infant-mother relationships. In L. Fraiberg (Ed.), Selected Writings of Selma Fraiberg (pp. 100–136). Columbus, OH: Ohio State University Press. Freud, A. (1966). The ego and the mechanisms of defense. New York: International Universities Press. Freud, S.1 (1894). The neuropsychoses of defense. (Standard Edition, Vol. 3.) Freud, S. (1895). Studies on hysteria. (Standard Edition, Vol. 2.) Freud, S. (1900). The interpretation of dreams. (Standard Edition, Vol. 4.) Freud, S. (1901). The psychopathology of everyday life. (Standard Edition, Vol. 6.) Freud, S. (1905a). Jokes and their relationship to the unconscious (Standard Edition, Vol. 8.) Freud, S. (1905b). Three essays on sexuality. (Standard Edition, Vol. 7.) Freud, S. (1911). Formulations regarding the two principles of mental functioning. (Standard Edition, Vol. 12.) 1

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Freud, S. (1913). Totem and taboo. (Standard Edition, Vol. 13.) Freud, S. (1914). On narcissism: An introduction. (Standard Edition, Vol. 14.) Freud, S. (1915a). Repression. (Standard Edition, Vol. 14.) Freud, S. (1915b). The unconscious. (Standard Edition, Vol. 14.) Freud, S. (1916). Introductory lectures on psychoanalysis. London: Hogarth Press. Freud, S. (1923). The ego and the id. (Standard Edition, Vol. 19.) Freud, S. (1925). An autobiographical study. (Standard Edition, Vol. 20.) Freud, S. (1926). Inhibitions, symptoms and anxiety. (Standard Edition, Vol. 20.) Freud, S. (1952). A general introduction to psychoanalysis. New York: Garden City. Fromm, E. (1955). The sane society. New York: Holt, Rinehart and Winston. Fromm-Reichmann, F. (1950). Principles of intensive psychotherapy. Chicago: University of Chicago Press. Gerson, M. J. (1996). The embedded self: A psychoanalytic guide to family therapy. Hillside, NJ: Analytic Press. Gill, M. N. (1987). The analyst as participant. Psychoanalytic Inquiry, 7, 249. Goldberg, A. (1998). Self-psychology since Kohut. Psychoanalytic Quarterly, 67, 240–255. Greenacre, P. (1956). Re-evaluation of the process of working through. International Journal of Psychoanalysis, 37, 439–444. Greenberg, J. R., & Mitchell, S. A. (1983). Object relations in psychoanalytic theory. Cambridge: Harvard University Press. Greenson, R. (1967). The technique and practice of psychoanalysis. New York: International Universities Press. Greenson, R. (1978). Explorations in psychoanalysis. New York: International Universities Press. Hartmann, H. (1939). Ego psychology and the problem of adaptation. New York: International Universities Press. Hartmann, H., & Kris, E. (1945). The genetic approach in psychoanalysis. The Psychoanalytic Study of the Child, 1, 11–20. New York: International Universities Press. Hartmann, H., Kris, E., & Loewenstein, R. N. (1946). Comments on the formation of psychic structure. The Psychoanalytic Study of the Child, 2, 11–38. Horney, K. (1940). New ways in psychoanalysis. New York: Norton. Horowitz, M. J. (2001). Stress response syndromes: Personality styles and interventions. Northvale, NJ: Jason Aronson. Jacobs, T. J. (1991). The use of the self. Countertransference in the analytic situation. Madison, CT: International Universities Press. Jones, E. (1953). The life and work of Sigmund Freud. New York: Basic Books. Jung, C. (1909). The psychology of dementia praecox. New York: Nervous and Mental Disease Publishing Co. Kandel, E. R. (2005). Psychiatry, psychoanalysis, and the biology of mind. Washington, DC: American Psychiatric Publishing, Inc. Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. Northvale, NJ: Jason Aronson.

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adlerian psychotherapy Harold H. Mosak and Michael Maniacci

OVERVIEW Adlerian psychology, developed by Alfred Adler (who referred to it as Individual Psychology), views the person holistically as a creative, responsible, “becoming” individual moving toward fictional goals within his or her phenomenal field. It holds that one’s life-style is sometimes self-defeating because of inferiority feelings. The individual with “psychopathology” is discouraged rather than sick, and the therapeutic task is to encourage the person to activate his or her social interest and to develop a new life-style through relationship, analysis, and action methods.

Basic Concepts Adlerian psychology is predicated upon assumptions that differ in significant ways from the Freudian “womb” from which it emerged. Adler throughout his lifetime credited Freud with primacy in the development of a dynamic psychology. He consistently gave credit to Freud for explicating the purposefulness of symptoms and for discovering that dreams were meaningful. The influence of early childhood experiences in personality development constitutes still another point of agreement. Freud emphasized the role of psychosexual development and the Oedipus complex, and Adler focused on the effects of children’s perceptions of their family constellation and on their struggle to find a place of significance within it.

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64 h a r o l d h . m o s a k a n d m i c h a e l m a n i a c c i Adlerian basic assumptions can be expressed as follows: 1. All behavior occurs in a social context. Humans are born into an environment with which they must engage in reciprocal relations. The oft-quoted statement by the gestalt psychologist Kurt Lewin that “behavior is a function of person and environment” is a striking parallel to Adler’s contention that people cannot be studied in isolation. 2. Individual Psychology is an interpersonal psychology. How individuals interact with the others sharing “this crust of earth” (Adler, 1931/1958, p. 6)1 is paramount. Transcending interpersonal transactions is the development of the feeling of being a part of a larger social whole that Adler (1964b) incorporated under the heading of Gemeinschaftsgefühl, or social interest. 3. Adlerian psychology rejects reductionism in favor of holism. The Adlerian demotes part-functions from the central investigative focus in favor of studying the whole person and how he or she moves through life. This renders the polarities of conscious and unconscious, mind and body, approach and avoidance, and ambivalence and conflict meaningless except as subjective experiences of the whole person. That is, people behave as if the conscious mind moves in one direction while the unconscious mind moves in another. From the external observer’s viewpoint, all part-functions are subordinate functions of the individual’s goals and style of life. 4. Conscious and unconscious are both in the service of the individual, who uses them to further personal goals. Adler (1963a) treats unconscious as an adjective rather than as a noun. That which is unconscious is the nonunderstood. Like Otto Rank, Adler felt that humans know more than they understand. Conflict, defined as intrapersonal by others, is defined as a “one step forward and one step backward movement,” the net effect being to maintain the individual at a point “dead center.” Although people experience themselves in the throes of a conflict, unable to move, in reality they create these antagonistic feelings, ideas, and values because they are unwilling to move in the direction of solving their problems (Mosak & LaFevre, 1976). 5. Understanding the individual requires understanding his or her cognitive organization and life-style. The latter concept refers to the convictions individuals develop early in life to help them organize experience, to understand it, to predict it, and to control it. Convictions are conclusions derived from the individual’s apperceptions, and they constitute a biased mode of apperception. Consequently, a life-style is neither right nor wrong, normal nor abnormal, but merely the “spectacles” through which people view themselves in relation to the way in which they perceive life. Subjectivity rather than so-called objective evaluation becomes the major tool for understanding the person. As Adler wrote, “We must be able to see with his eyes and listen with his ears” (1931/1958, p. 72). 6. Behavior may change throughout a person’s life span in accordance with both the immediate demands of the situation and the long-range goals inherent in the life-style. The life-style remains relatively constant through life unless the convictions change through the mediation of psychotherapy. Although the definition of psychotherapy customarily refers to what transpires within a consulting room, a broader view of psychotherapy would include the fact that life in itself may often be psychotherapeutic. 7. According to the Adlerian conception, people are not pushed by causes; that is, they are not determined by heredity and environment. “Both are giving only the frame and the influences which are answered by the individual in regard to the styled creative power” (Ansbacher & Ansbacher, 1956). People move toward self-selected goals that they feel will give them a place in the world, will provide them with security, and will preserve their 1

“1931/1958” indicates that the original date of publication was 1931 but that the page number refers to the reprint published in 1958.

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self-esteem. Life is a dynamic striving. “The life of the human soul is not a ‘being’ but a ‘becoming’” (Adler, 1963a, p. ix). 8. The central striving of human beings has been variously described as completion (Adler, 1931), perfection (Adler, 1964a), superiority (Adler, 1926), self-realization (Horney, 1951), self-actualization (Goldstein, 1939), competence (White, 1957), and mastery (Adler, 1926). Adler distinguishes among such strivings in terms of the direction a striving takes. If strivings are solely for the individual’s greater glory, he considers them socially useless and, in extreme conditions, characteristic of mental problems. On the other hand, if the strivings are for the purpose of overcoming life’s problems, the individual is engaged in striving for self-realization, in contributing to humanity, and in making the world a better place to live. 9. Moving through life, the individual is confronted with alternatives. Because Adlerians are either nondeterminists or soft determinists, the conceptualization of humans as creative, choosing, self-determined decision makers permits them to choose the goals they want to pursue. Individuals may select socially useful goals or they may devote themselves to the useless side of life. They may choose to be task-oriented or they may, as does the neurotic, concern themselves with their own superiority. 10. The freedom to choose (McArthur, 1958) introduces the concepts of value and meaning into psychology. These were unpopular concepts at the time (1931) that Adler wrote What Life Should Mean to You. The greatest value for the Adlerian is Gemeinschaftsgefühl, or social interest (Ansbacher, 1968). Although Adler contends that it is an innate feature of human beings, at least as potential, acceptance of this criterion is not absolutely necessary. Mosak (1991) defines social interest as a construct rather than as an innate disposition. People possess the capacity for coexisting and interrelating with others. Indeed, the “iron logic of social living” (Adler, 1959) demands that we do so. Even in severe psychopathology, total extinction of social interest does not occur. Even people who are psychotic retain some commonality with “normal” people. As Rabbi Akiva noted two millennia ago, “The greatest principle of living is to love one’s neighbor as oneself.” If we regard ourselves as fellow human beings with fellow feeling, we are socially contributive people interested in the common welfare and, by Adler’s pragmatic definition of normality, mentally healthy (Dreikurs, 1969; Shoben, 1957). If my feeling derives from my observation and conviction that life and people are hostile and I am inferior, I may divorce myself from the direct solution of life’s problems and strive for personal superiority through overcompensation, wearing a mask, withdrawal, attempting only safe tasks where the outcome promises to be successful, and other devices for protecting my self-esteem. Adler said the neurotic in terms of movement displayed a “hesitating attitude” toward life (1964a). Also, the neurotic was described as a “yes-but” personality (Adler, 1934); at still other times, the neurotic was described as an “if only” personality (Adler, 1964a): “If only I didn’t have these symptoms, I’d . . .” The latter provided the rationale for “The Question,” a device Adler used for differential diagnosis as well as for understanding the individual’s task avoidance. 11. Because Adlerians are concerned with process, little diagnosis is done in terms of nomenclature. Differential diagnosis between functional and organic disorder does often present a problem. Because all behavior is purposeful, a psychogenic symptom will have a psychological or social purpose, and an organic symptom will have a somatic purpose. An Adlerian would ask “The Question” (Adler, 1964a; Dreikurs, 1958, 1962) “If I had a magic wand or a magic pill that would eliminate your symptom immediately, what would be different in your life?” If the patient answers, “I’d go out more often socially” or “I’d write my book,” the symptom would most likely be psychogenic. If the patient responds, “I wouldn’t have this excruciating pain,” the symptom would most likely be organic. 12. Life presents challenges in the form of life tasks. Adler named three of these explicitly but referred to two others without specifically naming them (Dreikurs & Mosak, 1966).

66 h a r o l d h . m o s a k a n d m i c h a e l m a n i a c c i The original three tasks were those of society, work, and sex. The first has already been alluded to. Because no person can claim self-sufficiency, we are all interdependent. Not only do we need social recognition, but each of us also is dependent on the labor of other people, and they, in turn, are dependent on our contribution. Work thus becomes essential for human survival. The cooperative individual assumes this role willingly. In the sexual realm, because two different sexes exist, we must also learn how to relate to that fact. We must define our sex roles, partly on the basis of cultural definitions and stereotypes, and train ourselves to relate to the other, not the opposite, sex. Other people, of either sex, do not represent the enemy. They are our fellows, with whom we must learn to cooperate. Fourth (Dreikurs & Mosak, 1967) and fifth tasks (Mosak & Dreikurs, 1967) have been described. Although Adler alluded to the spiritual, he never specifically named it (Jahn & Adler, 1964). But each of us must deal with the problem of defining the nature of the universe, the existence and nature of God, and how to relate to these concepts. Finally, we must address the task of coping with ourselves. William James (1890) made the distinction between the self as subject and the self as object, and it is as imperative, for the sake of mental health, that good relations exist between the “I” and the “me” as between the “I” and other people. In this task we must also deal, subjectively and reductionistically on the part of the person, with the “good me” and the “bad me.” 13. Because life constantly poses challenges, living demands courage (Neuer, 1936). Courage is not an ability one either possesses or lacks. Nor is courage synonymous with bravery, such as falling on a grenade to save one’s buddies from injury or death. Courage is the willingness to engage in risk-taking behavior either when one does not know the consequences or when the consequences might be adverse. We are all capable of courageous behavior, provided that we are willing to engage in it. Our willingness will depend on many variables, internal and external, such as our life-style convictions, our degree of social interest, the extent of risk as we appraise it, and whether we are task-oriented or prestige-oriented. Given that life offers few guarantees, all living requires risk taking. It would require very little courage to live if we were perfect, omniscient, or omnipotent. The question we must each answer is whether we have the courage to live despite the knowledge of our imperfections (Lazarsfeld, 1966). 14. Life has no intrinsic meaning. We give meaning to life, each of us in our own fashion. We declare it to be meaningful, meaningless, an absurdity, a prison sentence (cf., the adolescent’s justification for doing as he pleases—“I didn’t ask to be born”), a vale of tears, a preparation for the next world, and so on. Dreikurs (1957, 1971) maintained that the meaning of life resided in doing for others and in contributing to social life and social change. Viktor Frankl (1963) believed the meaning of life lay in love. The meaning we attribute to life will “determine” our behavior. We will behave as if life were really in accord with our perceptions, and therefore, certain meanings will have greater practical utility than others. Optimists will live an optimistic life, take chances, and not be discouraged by failure and adversity. They will be able to distinguish between failing and being a failure. Pessimists will refuse to be engaged with life, refuse to try, sabotage their efforts if they do make an attempt, and, through their methods of operation, endeavor to confirm their preexisting pessimistic anticipations (Krausz, 1935).

Other Systems Students often have asked, “Do you Adlerians believe in sex too?” The question is not always asked facetiously. Freud accorded sex the status of the master motive in behavior. Adler merely categorized sex as one of several tasks the individual is required to solve. Freud employed esoteric jargon, and Adler favored common-sense language. One story has

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it that a psychiatrist took Adler to task after a lecture, denigrating his approach with the criticism “You’re only talking common sense,” to which Adler replied, “I wish more psychiatrists did.” Table 3.1 lists other differences between the theories of Freud and Adler. A more extended comparison of Freud’s and Adler’s concepts of humankind may be found in articles by Carlson, Watts, & Maniacci (2006), H. W. von Sassen (1967), and Otto Hinrichsen (1913).

Adler and the Neo-Freudians Adler once proclaimed that he was more concerned that his theories survive than that people remember to associate his theories with his name. His wish apparently was granted. In discussing Adler’s influence on contemporary psychological theory and practice, Henri Ellenberger commented, “It would not be easy to find another author from which so much has been borrowed from all sides without acknowledgment than Adler” (1970, p. 645). However, many neo-Freudians have credited Adler with contributing to and influencing their work. In her last book, Karen Horney wrote of “neurotic ambition,” “the need for perfection,” and “the category of power.” “All drives for glory,” she wrote, “have in common the reaching out for greater knowledge, wisdom, virtue or powers than are given to human beings; they all aim at the absolute, the unlimited, the infinite” (1951, pp. 34–35). Those familiar with Adler’s writings on the neurotic’s perfectionistic, godlike striving will immediately be struck by the similarity in viewpoint. Horney (1951) rejected Freud’s pessimism, “his disbelief in human goodness and human growth,” in favor of the Adlerian view that a person could grow and could “become a decent human being.” Others have also remarked on the resemblance between the theories of Horney and Adler; the reviewer of one Horney book wrote that Karen Horney had just written a new book by Alfred Adler (Farau, 1953). Erich Fromm also expresses views similar to those of Adler. According to Fromm, people make choices. The attitude of the mother in child rearing is of paramount importance. Life fosters feelings of powerlessness and anxiety. Patrick Mullahy (1955) indicates that The only adequate solution, according to Fromm, is a relationship with man and nature, chiefly by love and productive work, which strengthens the total personality, sustains the person in his sense of uniqueness, and at the same time gives him a feeling of belonging, a sense of unity and common destiny with mankind. (pp. 251–252) Although Harry Stack Sullivan places greater emphasis on developmental child psychology than does Adler, Sullivan’s “person” moves through life in much the same manner as Adler’s. Thus, Sullivan (1954) speaks of the “security operations” of the individual, a direct translation of Adler’s and Lene Credner’s (1930) Sicherungen. His “good me” and “bad me” dichotomy is, in expression if not in manner of development, essentially the same as that described by Adlerians. So many similarities between Adler and the neo-Freudians have been noted that Gardner Murphy concluded, “If this way of reasoning is correct, neurosis should be the general characteristic of man under industrialism, a point suspected by many Freudians and, in particular, by that branch of the Freudian school (Horney and her associates) that has learned most from Adler” (1947, p. 569). A summary of such resemblances appears in Heinz and Rowena Ansbacher’s Individual Psychology of Alfred Adler (1956), as well as in an article by Walter James (1947). Fritz Wittels (1939) has proposed that the neoFreudians should more properly be called “neo-Adlerians