Specialized Techniques in Individual Psychotherapy PDF

SPECIALIZED
TECHNIQUES IN
INDIVIDUAL PSYCHOTHERAPY
Edited by
TOKSOZ B. KARASU, M.D.

LEOPOLD BELLAK, M.D.
Copyright © 1980 by Toksoz B. Karasu and Leopold Bellak
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Table of Contents
Introduction
1. Psychotherapies: An Overview
Toksoz B. Karasu, M.D.
2. General Principles of Psychotherapy

3. Brief and Emergency Psychotherapy
Leopold Bellak, M.D.
4. Enabling Conditions for the Ambulatory Psychotherapy of Acute Schizophrenics

5. Psychotherapy with Borderline Patients: An Overview

Otto F. Kernberg, M.D.
6. The Treatment of Established Pathological Mourners

Vamik D. Volkan, M.D.
Daniel Josephthal, M.D.
7. The Psychotherapy of the Depressed Patient

Myer Mendelson, M.D.
8. Brief Psychotherapy of Stress Response Syndromes1

Mardi J. Horowitz, M.D.
Nancy B. Kaltreider, M.D.
9. Psychotherapy with the Obsessive Personality

Leon Salzman, M.D.
10. Psychotherapy in Sexual Dysfunctions

Jon K. Meyer, M.D.
11. Psychotherapy of Ambulatory Patients with Severe Anxiety

Stanley Lesse, M.D., Med. Sc.D.
12. Psychotherapy with Violent Patients

Robert Weinstock, M.D.
13. Psychotherapy with Physically Ill Patients

14. Psychotherapy with Dying Patients
Arthur M. Schwartz, M.D.

15. The Behavioral Psychotherapy of Anorexia Nervosa

Michel Hersen, Ph.D.
Thomas Detre, M.D.
16. Psychotherapy with Suicidal Patients

Edwin S. Shneidman, Ph.D.
17. Psychotherapy with the Elderly
Ralph J. Kahana, M.D.
18. Psychotherapy with Bilingual Patients

Victor Bernal y del Rio, M.D.
19. Racial Issues in Psychotherapy

Hugh F. Butts, M.D.
20. Psychotherapy with Alcoholics
Sheldon Zimberg, M.D.
21. Hypnotherapy Combined with Psychotherapy

James R. Hodge, M.D.
22. Group Therapy Combined with Individual Psychotherapy

Saul Scheidlinger, Ph.D.
Kenneth Porter, M.D.
23. Family and Marital Therapy Combined with Individual Psychotherapy
Stephen Fleck, M.D.
24. Behavioral Techniques in Conjunction with Individual Psychoanalytic Therapy

Allan Cooper, Ph.D.
25. Combined Psychotherapy and Pharmacotherapy

Gerald J. Sarwer-Foner, M.D.
Contributors
LEOPOLD BELLAK, M.D.
Clinical Professor of Psychiatry, Albert Einstein College of Medicine; Clinical
Professor of Psychology, New York University.
VICTOR BERNAL Y DEL RIO, M.D.

Executive Director, The Puerto Rico Institute of Psychiatry, San Juan.
HUGH F. BUTTS, M.D.

Director, Bronx Psychiatric Center; Professor of Psychiatry, Albert Einstein
College of Medicine; Supervisor and Training Analyst, Post Graduate Center for
Mental Health; Collaborating Psychoanalyst, The Columbia Psychoanalytic
Center; Lecturer, Department of Psychiatry, Columbia University, College of
Physicians and Surgeons.
ALLAN COOPER, Ph.D.

Assistant Clinical Professor of Psychiatry, Albert Einstein College of Medicine;
Training and Supervising Analyst, William Alanson White Psychoanalytic
Institute.
THOMAS DETRE, M.D.

Professor of Psychiatry, University of Pittsburgh School of Medicine.
STEPHEN FLECK, M.D.

Professor of Psychiatry and Public Health, Yale University School of Medicine.
MICHEL HERSEN, Ph.D.

Professor of Psychiatry, University of Pittsburgh School of Medicine.
JAMES R. HODGE, M.D.

Adjunct Professor of Psychology, University of Akron, Ohio; Council of Scientific
Advisors, International Graduate School of Behavioral Sciences of Florida
Institute of Technology.
MARDI J. HOROWITZ, M.D.

Professor of Psychiatry, University of California Medical School, San Francisco.
DANIEL JOSEPHTHAL, M.D.

Clinical Associate Professor of Psychiatry, University of Virginia Medical Center,
Charlottesville.
RALPH J. KAHANA, M.D.

President, Boston Society for Gerontologic Psychiatry; Assistant Clinical
Professor of Psychiatry, Harvard Medical School; Associate Psychiatrist, Beth
www.freepsychotherapybooks.org 6
Israel Hospital, Boston.
NANCY B. KALTREIDER, M.D.

Associate Director, Psychotherapy Evaluation and Study Center, University of
California Medical School, San Francisco.
TOKSOZ B. KARASU, M.D.

Director, Department of Psychiatry, Bronx Municipal Hospital Center; Associate
Professor of Psychiatry and Vice Chairman, Department of Psychiatry, Albert
Einstein College of Medicine.
OTTO F. KERNBERG, M.D.

Medical Director, The New York Hospital—Cornell Medical Center, Westchester
Division; Professor of Psychiatry, Cornell University Medical College; Training
and Supervising Analyst, Columbia University Center for Psychoanalytic
Training and Research.
STANLEY LESSE, M.D., Med. Sc.D.

Editor-in-Chief, American Journal of Psychotherapy
MYER MENDELSON, M.D.

Professor of Clinical Psychiatry, University of Pennsylvania School of Medicine;
Senior Attending Psychiatrist, The Institute of the Pennsylvania Hospital,
Philadelphia.
JON K. MEYER, M.D.

Associate Professor of Psychiatry, Director, Sexual Behaviors Consultation Unit,
The Johns Hopkins Medical Institutions, Baltimore.
KENNETH PORTER, M.D.
Director, Group and Family Therapy, St. Luke’s Hospital Center; Instructor in Clinical
Psychiatry, Columbia University Faculty of Medicine, New York.
LEON SALZMAN, M.D.

Clinical Professor of Psychiatry, Georgetown University School of Medicine.
GERALD J. SARWER-FONER, M.D.

Professor and Chairman, Department of Psychiatry, University of Ottawa School
of Medicine Faculty of Health Sciences, Ottawa.
SAUL SCHEIDLINGER, Ph.D.

Professor of Psychiatry, Albert Einstein College of Medicine; Editor,
International Journal of Group Psychotherapy.
ARTHUR M. SCHWARTZ, M.D.

Associate Attending Psychiatrist, Montefiore Hospital and Medical Center.
EDWIN S. SHNEIDMAN, Ph.D.
Professor of Thanatology, University of California at Los Angeles.
VAMIK D. VOLKAN, M.D.

Medical Director, Blue Ridge Hospital, University of Virginia; Professor of
Psychiatry, University of Virginia School of Medicine, Charlottesville.
ROBERT WEINSTOCK, M.D.

Assistant Attending Psychiatrist, McLean Hospital; Clinical Instructor in
Psychiatry, Harvard Medical School; Deputy Medical Director and Director of
Treatment, McLean Hospital Program at Bridgewater State Hospital.
SHELDON ZIMBERG, M.D.

Associate Professor of Psychiatry, Mount Sinai School of Medicine, New York.
Introduction
Psychotherapy is a process of interaction between a
therapist and a patient. The interaction must be guided by the
therapist, as part of the fulfillment of the therapeutic contract and
his role as a responsible professional. Karasu has recently devised

a system of categorizing the complexities of psychotherapeutic
endeavors (see Chapter 1).
To qualify as a scientific endeavor, psychotherapy must be
predicated upon clearly formulated hypotheses, which must, at

least in principle, be verifiable or disprovable, as any scientific
hypothesis should be. The principle of verifiability is even more
important than demonstrated verification. Psychotherapy does

not stand alone among therapeutic modalities in its need for more
research. That, however, should not keep us from continuously
striving for operational definitions and verifications of
psychotherapeutic propositions.
Psychotherapy is an applied science. To be sound, its
propositions must be clearly derived from more general ones of a

theory of psychopathology which, in turn, must be derived from a
general theory of the psychology of personality (1). There are
many theories of psychotherapy, though the clarity of the
relationship between a theory of psychopathology and a theory of
personality often leaves much to be desired. Moreover, few of the
underlying theories of personality attempt to explain the broad
spectrum of human behavior. Except for psychoanalysis, it is hard
to think of any theory that ever tried to explain, however

dubiously, wit, humor and comedy in relation to the rest of
human behavior. Aesthetics, on the other hand, was especially
addressed by Gestalt psychology, as well as by psychoanalysis,

albeit rather reductionistically. And yet, to treat an artist, it may
be quite important to have a general theory of personality and
psychopathology to understand the patient and formulate

psychotherapeutic interventions.
With respect to this interrelationship of theory of

personality, psychopathology and psychotherapy, the field of
psychological therapeutics is not different from the rest of

medical therapeutics. We expect medical students to learn about
physics, chemistry, general biology, anatomy and physiology
before we expose them to pathology, and eventually let them
practice therapeutics based on the understanding of these

underpinnings.
Lest anyone be concerned about this seemingly radically
medical model, let us hasten to say that a good medical school
program must teach its students to see patients in terms of their

social environment in the broadest sense and in terms of
epidemiology and public health in a narrower sense. Even more
specifically, Selye's field theory provides an interactional model of
organisms that could keep any social psychologist, sociologist or

ecologist quite happy.
To the extent to which psychotherapy involves symbolic
operations the surgical model is especially serviceable. Before

engaging in surgical intervention, a careful diagnosis must be
made in terms of anatomical structure and physiological
processes. A thorough workup of the bio chemical status is

essential and the provision of optimal preoperative enabling
conditions, in terms of hematology, cardiac status, etc., is
essential.
Part of the need for specificity in the psychotherapeutic
operation must be a similarly careful diagnostic workup in terms

of psychodynamics, structure, and the external milieu as well as
the internal somatic ones. There should also be a careful
assessment of psychological liabilities and assets, possibly in term
of ego function (3), and a clear formulation of the therapeutic goal

and the steps necessary to reach it. For this purpose, a specific
formulation for each patient of the areas of intervention, methods
of intervention, and the sequence of areas and methods of

intervention is necessary (1, 2, 4).
A word about therapeutic success may not be amiss here.
Strupp and Hadley (5) have made clear that there are at least
three facets of success: the subjective feelings of the patient, the
assessment by society and, finally, success in terms of the
technical expectations of the therapist. Many a patient might feel
greatly improved, at least temporarily, if he has, for instance,

succeeded in changing some of his ego-alien symptoms, such as
shyness or excessive conscientiousness, into ego-syntonic
brashness and self-centeredness, with the help of some of the

current fads in quick cures, such as “taking care of number one’’
and cathartic self-expression. Society might take a different view
of such a “cure.”
Therapeutic success in terms of theoretical expectations is, in

turn, hardest to fulfill by psychoanalytic criteria. While the patient
might be feeling happy about being symptom-free, with both his

family and society sharing in this appraisal, a psychoanalyst
might consider his improvement merely the result of flight into
health or of a positive transference, the stability of which he

doubts. Or he might consider symptomatic improvement only a
small part of the desirable change which he sees as a structural
and dynamic one that would enable the patient—in the time
honored phrase—to function better in work, love and play.
So far, all that has been said holds true for general
psychotherapeutic propositions. Like the rest of the field of
medicine, psychotherapy has had to develop many subspecialties.
In the field of psychotherapy, a broad basic understanding of
human behavior is essential, and the more clinical psychology,
sociology and anthropology, ethology, philosophy and linguistics
it includes, aside from medicine, so much the better.
Such is the complexity of human behavior, however, that

there are many precise things to be aware of and many highly
individualized techniques to be mastered in order to work

successfully with infants, children and adults. Even restricting
oneself to the psychotherapy of adults, efficiency and success are
based on very precise knowledge of unique problems. Moreover,

it does seem as if our world has become increasingly complex.
The number of special problems seems to have multiplied,
bringing along with it the need for more specialized knowledge

and management.
The quest for health and happiness has burgeoned

dramatically since World War II, particularly in the American
culture. Affluence has stirred the desire for orthodontia as much
as for orthopsychiatry—the desire to grow up “straight”
emotionally. The post world war period changed value systems

radically, with a resultant change in character structure and
symptomatology, and a pressing need for different and
specialized psychotherapeutic techniques. Along with sexual

freedom came awareness of sexual problems, the quest for
greater sexual fulfillment, and a market for various and sundry

sex therapies. Along with equal rights for women came a changing
job market, a shift in traditional marital roles, a quest for greater
marital bliss, an increase in the divorce rate, and the extensive
development of marital therapy.
The “culture of plenty” provided fertile ground for the

narcissistic revolution. This led to an explosion of character
disorders and borderline conditions, and the need for special

forms of therapy. Traditional psychoanalysis has to broaden its
scope. Superego structure as well as ego structure became looser,
and feelings of emptiness became the most frequently voiced

psychiatric complaint. The myriad attempts at self-cure consisted
too often of trips into the drug culture, with its many psychiatric
complications and the need for special treatment designs. A

parallel development was a tremendous increase in the
population over age 65, having passed the 20 million mark at
present. Psychiatric care of the elderly became another special

field. The Community Mental Health Act (which created
Community Mental Health Clinics) and the greater concern with

emotional health had much to do with the development of brief
and emergency psychotherapy and of group modalities.
Consumerism and the entry of third party payment were
some of the forces responsible for the heightened concern with

accountability. Concepts such as “goal directed psychotherapy”
and “target symptoms” have become popular, as have peer review

and PSRO. Some of these developments, to be sure, have bordered
on the ridiculous. One major effort to study the effectiveness of
psychotherapy was undertaken by a nationally prominent
research organization, which attempted to introduce methods of

cost accounting to the evaluation of psychotherapy. Failing
entirely to arrive at some measures of quality control, it was
simply reduced to measuring the “delivery” of psychotherapeutic

services by the number of patients seen per therapist, with no
measure of quality at all.
Thus, one has to guard against excesses in the development

of psychotherapy, as in all forms of endeavor. The need for instant
gratification in our culture has found its counterpart in instant
therapies, such as primal scream, EST, Scientology and others,

and they are probably as valuable as all other attempts at miracle
cures.
On the other hand, if social and economic developments and

the complexities of our culture force us to develop better, more
specific, and more successful psychotherapies, this is only to be
welcomed. The more specific and better conceptualized the

hypotheses concerning a given form of psychopathology and its
treatment, the more effective a therapy it is likely to be. The
present volume is dedicated to that proposition. We have asked a

large number of psychotherapists with particular knowledge and
experience to write about the specific problems and special

techniques necessary for the treatment of patients with unique
kinds of problems.
We hope that the accumulated expertise of so many
distinguished contributors will make this an outstandingly

valuable volume.
REFERENCES
Bellak, L. Once over: What is psychotherapy? J. of Nerv. Ment. Dis., 1977, 165:295-299.
Bellak, L. Kombinierte Psycho- und Pharmakotherapie unter besonderer Berück-

sichtigung von Kurz—und Notfalltherapie. Psychiatria Clinica, 1977, 10:102-113.
Bellak, L., Hurvich, M., and Gediman, H. K. Ego Functions in Schizophrenics, Neurotics, and
Normals. New York: John Wiley & Sons, 1973.
Bellak, L. and Small, L. Emergency Psychotherapy and Brief Psychotherapy. Revised

edition. New York: Grune & Stratton, 1978.
Strupp, H. H. and Hadley, S. W. A tripartite model of mental health and therapeutic

outcomes. American Psychologist, March 1977, 187-196.
1
Psychotherapies: An Overview1
The emergence of numerous competing systems of

psychotherapy during the last few decades has been cited as one
of the principal problem areas in the field (1). In 1975 Parloff

polled more than 140 presumable forms of currently practiced
psychotherapy (2). Although London described this confusing

proliferation as a reflection of changing times in answer to
pervasive repression, anxiety, and/or boredom of man (3), the
specific ways in which each new modality may or may not differ
from its predecessors are far from clear. For the most part,
dogmatic partisan claims of the superiority of each successive
system continue to persist in spite of increasing evidence that

such separatist claims may be largely unfounded (4, 5).
In attempts to comprehend the therapeutic influence in the
total range of psychological treatments that have made their

appearance at various points in the course of time, many authors
have focused on the nonspecific or uncommon elements that all
psychotherapies are presumed to share (4, 6-19). The following
features have been repeatedly cited as basic to all
psychotherapies: an emotionally charged, confiding relationship;

a therapeutic rationale (myth) that is accepted by patient and
therapist; the provision of new information, which may be
transmitted by precept, example, and/or self-discovery; the

strengthening of the patient’s expectation of help; the provision of
success experiences; and the facilitation of the arousal of one’s
emotions (9).
Alternatively, Wittkower and Warnes pointed out that “while

such universal features undoubtedly exist, it seems absurd to
minimize differences in psychotherapy” (19). The originators and
strong proponents of individual systems of psychotherapy who

felt the need to differentiate and/or dissociate themselves from
their predecessors and peers to justify their efforts might share
this view (20-23). In addition, comparative conceptual studies of

various forms of psychotherapy typically cite striking contrasts
among various therapies (24-33). More recently, experimental
studies of different schools have lent some scientific support to
the separatist stance. Exemplary of such findings are the

systematic studies of analytically oriented psychotherapy versus
behavior therapy supporting the view that these are, in total,
highly contrasting styles of treatment (34, 35). Moreover, the

treatment procedures created, developed, and chosen in one
society or within the context of a particular belief system may not
be transposable to another. This is especially evident in attempts
at cross-cultural psychotherapy (19, 36).
The current state of the art attests to the lack of clarity and
lack of resolution of the specificity versus common elements

controversy in explaining what is the quintessence of the
therapeutic cure. This conflicting state of affairs is further

compounded by those comparative studies of various
psychotherapies which suggest that one’s espoused theoretical
orientation regarding the nature of the healing process may not

always be synchronous with one's actual practices (37-39). For
example, a comparison study of Freudian, Kleinian, Jungian, and
Gestaltist therapists found that descriptive ratings of the different

approaches in action did not differentiate the respective schools
of thought as well as the investigators (and, no doubt, the

proponents themselves) would have expected (39).
As treatments useful in one area of human disturbance are
found to be less valuable in another (5, 40), efforts are made to

arrive at better criteria for selecting patients for particular forms
of therapy and for modifying existing forms. Here the stated task
for the future is to achieve greater specificity concerning the

effects of particular kinds of interventions (13). Thus the
tantalizing need for increased examination and clarification of the
therapeutic process continues.
Doubtless there are many ways to slice the therapeutic pie.

In early attempts to schematize the many psychotherapeutic
methods and techniques throughout history, Menninger (41) and
Bromberg (42) ultimately subsumed the various forms under two
dichotomous heads: those which they thought used a principle of
suppression in their treatment approach versus those which

represented the use of a principle of expression.
Beginning where Menninger and Bromberg left off, Harper’s
descriptive overview of 36 established Freudian and post-

Freudian psychotherapeutic schools, or systems of
psychotherapy, attempted to divide the various approaches into
two overriding categories: those which reflected emotionally

oriented or affective forms of treatment versus those which
Harper considered essentially intellectually oriented or cognitive
(28). On a more philosophical plane, Rychlak addressed the

possible implications of ideology for methodology and assessed
psychotherapies on the basis of whether they represented
therapeutic models that were essentially Lockean (mechanistic)

or Kantian (humanistic) (43). Rychlak also conceptualized
psychotherapies according to a comparison of their respective
motives: those with a scholarly motive, which are primarily

concerned with unraveling the depths of man’s nature; those with
an ethical motive, which concern themselves primarily with
man’s self and his values; and those with a curative motive, which
directly aim at scientifically derived cure (44). Offenkrantz and
Tobin’s configuration is more implicit. They suggested that all

learning (including psychotherapeutic learning) occurs in three
modes: by identification, by conditioning, and by insight (45).
Thus one might assume to unite the various psychotherapies on

the basis of their primary modes of therapeutic learning or the
major ways in which they presume to effect change in or cure of

the patient.
With the preceding topographies in mind, I shall organize the

morass of systems practiced today according to a troika of basic
themes around which each school may be said to broadly, but

distinctively, pivot. These, representing a composite of
dimensions, are referred to as dynamic, behavioral, and
experiential (see Table 1). Although these rubrics per se are not
completely new (2, 46), to my knowledge no study has attempted
to portray schematically their respective features in relation to

the increasing array of modalities being practiced today. A
number of contrasting dimensions constitute or reside behind
these three themes (see Table 2). Each theme represents
something of a unity, that is, one’s conceptual framework or belief

system regarding the nature of man and his ills will have a
bearing on one’s concept of therapeutic modes or curative
processes and the nature of the therapeutic relationship between

patient and therapist and, ultimately, on one’s methods or
techniques of treatment.
Table 1
epresentative
Examples of Three Therapeutic Themes in the Psychotherapies and
nswanger
Their Variations*
hitaker
endlin
ogers
wen
ankl
nov
atts
the
orr
rls
tial
ss
olf
* Although some of the more recent psychotherapies may combine individual and group
techniques, this organization of psychotherapeutic systems focuses on
modalities that are essentially dyadic in nature. It therefore does not include
family, group, or milieu therapies per se, nor such adjunct therapies as art,
music, and dance.
Table 2
Summary of Thematic Dimensions of Three Kinds of Psychotherapy
Theme Dynamic Behavioral Experiential
Prime Sexual repression Anxiety Alienation

concern
Concept of Instinctual conflicts: Learned habits: Existential despair:

pathology early libidinal drives excess or deficit human loss of
and wishes that behaviors that have possibilities,
remain out of been fragmentation of self,
awareness, i.e., environmentally lack of congruence with
unconscious reinforced one’s experiences
Concept of Resolution of Symptom removal: Actualization of potential:

health underlying conflicts: absence of specific self-growth, authenticity,
victory of ego over id, symptom and/or and spontaneity
i.e., ego strength reduction of anxiety
Mode of Depth insight: Direct learning: Immediate experiencing:

change understanding of the behaving in the sensing or feeling in the
early past, i.e., current present, i.e., immediate moment, i.e.,
intellectual-emotional action or spontaneous expression
knowledge performance of experience
Time Historical: subjective Nonhistorical: Ahistorical:

approach past objective present phenomenological
and focus moment
Type of Long-term and Short-term and not Short-term and intense

treatment intense intense
Therapist’s To comprehend To program, reward, To interact in a mutually

task unconscious mental inhibit, or shape accepting atmosphere
content and its specific behavioral for arousal of self-
historical and hidden responses to expression (from somatic
meanings anxiety-producing to spiritual)
stimuli
Primary Interpretation: free Conditioning: Encounter: shared

tools association, analysis systematic dialogue, experiments or
techniques of transference, desensitization, games, dramatization or
resistance, slips, and positive and playing out of feelings
dreams negative
reinforcements,
shaping
Treatment Medical: doctor- Educational: Existential: human peer-

model patient or parent- teacher-student or human peer or adult-
infant (authoritarian), parent-child adult (egalitarian), i.e.,
i.e., therapeutic (authoritarian), i.e., human alliance
alliance learning alliance
Nature of Transferential and Real but secondary Real and primary for
relationship primary for cure: for cure: no cure: real relationship
to cure unreal relationship relationship
Therapist’s Interpreter-reflector: Shaper-adviser: Interactor-acceptor:

role and indirect, direct, problem- mutually permissive or
stance dispassionate, or solving, or practical gratifying
frustrating
The Dynamic Theme
The Nature of Man and His Ills
The dynamic point of view, as originally conceived in the

context of physics, subscribes to the idea that all mental
phenomena are the result of an interaction of forces (47). It

pertains to an appreciation of the complexity of man as reactor to
or victim of turbulent intrapsychic forces from which he
continually struggles to be set free. Freud described the major

force of this struggle in the origin of the neuroses of man
according to the theory of instinctual conflict: “From the very first
we have said that human beings fall ill of a conflict between the
claims of instinctual life and the resistance which arises within
them against it’’ (48, p. 57). More specifically, Freud considered
the etiology of the neuroses of man to be decidedly sexual in
nature: “No neurosis is possible with a normal vita sexualis” (49,

p. 276). In the orthodox dynamic tradition man is portrayed as
fraught with inner and unknown urgings and contradictions,

subject to and resisting against a reservoir of impulses largely
inaccessible to his conscious self.
The psychoanalytic perspective typically incorporates five

fundamental principles, i.e., dynamic, economic, structural,
developmental, and adaptive (50). Taken together, these
principles offer an analytic legacy that includes the following
allegiances: 1) a primary concern with the vicissitudes of man’s
instinctual impulses, their expression and transformation, and,
more crucially, their repression, by which is meant the pervasive

avoidance of painful feelings or experiences by keeping
unpleasant thoughts, wishes, and affect from awareness; 2) the
belief that such repression is of an essentially sexual nature and

that the roots of disturbance reside in faulty libidinal or
psychosexual development; 3) the idea that faulty psychosexual
development has its origins in early past and childhood conflicts

or traumata, especially those concerning a parental oedipal
configuration as manifested in the classic desire for one’s
opposite-sexed parent; 4) the belief in the resilience, persistence,

and inaccessibility of oedipal yearnings (i.e., these underlying
conflicts remain alive and ever active but out of awareness or
unconscious; man’s consciousness describes the exceptional

rather than the standard state of affairs); 5) the idea that we are
dealing essentially with the psychic struggle and torments of
biological man’s innate impulses or instincts (id), their

derivatives, and the primarily defensive mediation with external
reality (ego) in light of one’s moral precepts or standards
(superego) ; and, finally, 6) an adherence to a concept of psychic

determinism or causality according to which mental phenomena
as well as behaviors are decidedly not chance occurrences but
meaningfully related to events that preceded them and, unless

made conscious, unwittingly subject to repetition.
Therapeutic Change or Curative Processes
In accordance with these tenets, for the dynamic therapist

the ultimate task in its most parsimonious and famous form is to
make conscious the unconscious. This means that it is the ongoing

therapeutic charge of the therapist who subscribes to the
dynamic view to facilitate the emergence and comprehension of
unconscious and largely libidinal content. That is, the dynamic

therapist seeks to undo the essentially sexual repression of the
patient and to overcome the patient’s natural resistances to this
endeavor. The dynamic therapist attempts to accomplish this by

means of a slow and scrupulous unraveling of the largely
historical meanings of mental events and the devious ways in
which they may serve to ward off the underlying conflicts through
defensive camouflage. Understandably, the dynamic goal is
thereby a long-range one, perhaps even interminable. At best this
concept of cure means opting for total personality reorganization

in the final resolution of neurotic conflicts. The most crucial
manifestation of this is the resolution of the oedipal conflict,
which is traditionally regarded as requisite for a healthy

personality. This ultimate integration of personality would
translate itself into final mastery of ego over id impulses or, as
classically stated, where id was, there ego shall be.
Greenson defined the therapeutic process as “an interrelated
series of psychic events within the patient, a continuity of psychic
forces which have a remedial aim or effect” (51, p. 7). The
dynamic psychotherapeutic systems have consecutively

considered as their hallmarks of change the processes of catharsis
(following abreaction) and insight. Harper broadly defined insight

as “the process by which the meaning, significance, pattern, or use
of an experience becomes clear—or the understanding which
results from this process” (28, p. 163). He defined catharsis as

“the release of tension and anxiety by recounting and/or acting
out past experiences” (28, p. 158; author’s italics).
Although both processes have been considered in the
psychodynamic tradition, it may be noted that Freud never used

the term “insight” per se. The therapeutic process transferred its
emphasis from the primary importance of abreaction (catharsis)

to the removal of amnesia and the recovery of repressed
memories. Following this shift, Greenson pointed out, “catharsis
[is] no longer the ultimate aim of therapy” (51, p. 13). In its stead,
the process of insight has been extensively singled out not only to
refer to a phenomenon specially applicable to the psychodynamic
therapies in contrast to other therapies (51-53) but also as the
patient’s ultimate aspiration.
According to Hutchinson, there are four successive stages in
attaining therapeutic insight: 1) a stage of preparation, which is

characterized by frustration, anxiety, a feeling of ineptness, and
despair and may be followed by much trial-and-error activity
relevant to the solution of a certain problem and the falling into
habitual patterns or ways of thinking, foreseeing no apparent
solution to the problem; 2) a stage of incubation or renunciation

in which one desires to hide or escape from the problem and one
is resistant or unmotivated in therapeutic or insightful efforts; 3)
a stage of aspiration or illumination in which the whole problem

becomes illuminated and a solution or solutions suggest
themselves (often there is a flood of vivid ideas and a sense of
finality accompanied by a conviction in the truth of the insight);

and 4) a stage of elaboration and evaluation in which the validity
of the insight is checked against external reality (54).
Although the third stage tends to be most frequently

identified with the idea of insight (suggesting an essentially
eureka phenomenon), Ludwig pointed out that
during the typical course of psychotherapy, it is much more common for

the patient to experience insight in a… drawn out emotionally attenuated
form. The sudden tidal wave of illumination or enlightenment is rare
compared to the numerous small ripples of insights which are
experienced and intellectually assimilated over a long period of time.
Moreover, the therapeutic insights tend to be circumscribed and specific
to certain problem areas that the profound and general eureka
experiences, such as those described to occur during religious
conversion or revelation in which the “whole truth” suddenly is revealed
(55, p. 315).
In terms of the therapeutic value of the process of insight,

Ludwig noted that “there is no necessary relationship between
the truth or falseness of insight and therapeutic results” (55, p.
313). In addition, since intellectual insight alone is felt to be of
minimal value, attempts have been made to distinguish between
intellectual and emotional insight. However, it is difficult to
validate such a distinction (56).
In brief, Ludwig hypothesized that insight is therapeutic

when it meets all of the following specifications: 1) consistency,
that is, the deductions based on the original insight are stable and
logically sound regardless of the truth or falsity of the particular

content of the insight; 2) continuity, that is, insights must take
place within some existing theoretical framework or stream of
tradition in which the insight can be tested; 3) personal

consequences, that is, the insight must be judged by the fruit it
bears in terms of the ultimate use to which the insight is put; and
4) social consequences, that is, the acquisition of insight should

allow the person to interact with others in a more honest and
meaningful manner (55).
Although analysts have confidence in the role of insight as a

therapeutic agent, doubt has been cast on the “insight leads to
change” dictum. Schonbar, for example, has observed that “not all
change is attributable to insight” and “not all insight leads to

change” (57). However, the fact that insight, even as an ultimate
change agent, does not occur in isolation is more important for
consideration of the analytic therapies. Intricately embedded in
the psychodynamic curative process is the critical role of the
therapeutic relationship, expressly manifested in the
phenomenon of the transference relationship.
The Nature of the Therapeutic Relationship
In 1970 Strupp noted, “There can be no doubt that the

patient’s relationship to the therapist… embodies one of the most
powerful forces in the therapeutic enterprise.…
Psychotherapeutic changes always occur in the context of an

interpersonal relationship, and are to some extent inextricable
from it” (13, pp. 396, 400). The specific therapeutic agent,
according to Rosen, seems to be the “complex, emotionally-

charged parent-child kind of relationship between the
psychiatrist and the individual whom lie is treating” (58, p. 126).
In terms of the special nature of that therapeutic relationship, it

should be pointed out that deliberate systematic attention to the
vicissitudes of the special relationship between therapist and
patient is crucial to the conduct of the psychoanalytic
psychotherapies. It constitutes both the subject and the object of

analysis.
Historically, two roles or stances for the therapist have been
described in portraying the psychodynamic psychotherapies: the
primary stance with regard to the making of the transference

relationship and, more recently, the secondary stance with regard
to the making of a working or therapeutic alliance. Despite

increasing acceptance of the latter into the therapeutic situation,
these represent dual postures, which Greenson explicitly depicted
as antithetical to each other, both in their essential purposes and
in the actual requirements they make of the therapist (51).
The primary stance reflects Freud’s original

recommendations 1) that the analyst be like a mirror to the
patient, reflecting only what is reflected to him/her by the patient
and not bringing his/her own feelings (attitudes, values, personal

life) into play (59) and 2) that the analyst follow a posture of
privation or rule of abstinence, that is, technical motives must
unite with ethical ones in preventing the therapist from offering

the patient the “love” that the patient will necessarily come to
crave (59, pp. 157-171).
These dictums have been taken to mean that two basic

requirements are traditionally made of the analyst if he/she is to
best accomplish the therapeutic task: 1) he/she must continue to

judiciously frustrate and avoid gratifying the wishes of the
patient; and 2) he/she must remain relatively removed and
anonymous, a deliberately dispassionate observer and reflector of
the patient’s feelings. The therapeutic relationship is

asymmetrical. Henry and associates described the relationship as
follows:
Only the patient is supposed to reveal the intimate details of his life. The
psychotherapist is not only free to determine what he will reveal and
conceal about himself, but also to choose how to react to what the
patient is saying, if indeed he decides to respond at all. The relationship
is also asymmetrical in that only the therapist is supposed to interpret
and impute meaning to what the patient is saying and only the therapist
can evaluate the degree to which therapeutic objectives are being
achieved in the relationship (60, p. 218).
Conversely, within the same framework, the more recent

concept of a working or therapeutic alliance reflects an
alternatively nonregressive, rational relationship between patient

and therapist. Although still in the service of analyzing
transference and resistances, according to Chessick it means “that
the therapist aims at forming a real and mature alliance with the
conscious adult ego of the patient and encourages him to be a

scientific partner in the exploration of his difficulties” (53). The
real object need of the patient, deliberately frustrated by the
transference relationship, is satisfied by the therapeutic alliance.
Techniques and Methods
Bellis’ statement that “no technique is therapeutic in itself.…

Every clinician must understand and calibrate his own
instruments” (61) bears repeating in a discussion of the
techniques of dynamic psychotherapy.
The major instruments of the prototypic dynamic approach

are primarily verbal in nature. They rest in part on the proverbial
talking cure and may be regarded as free association on the part
of the patient and analysis of transference reactions and

resistances on the part of the therapist. Analysis, the task of the
therapist, is facilitated by four specific procedures: confrontation,

clarification, interpretation, and working-through. It is the third
of these, interpretation, that, according to Greenson, is regarded
as the “ultimate and decisive instrument” (51).
With regard to the input of the patient, the technique of free
association early reflected the major vehicle for the

communication of uncensored content from patient to therapist.
It has constituted the primary procedure for eliciting the raw
material on which the analysis ultimately rests. This includes the

eliciting of dreams, which Freud regarded as “the royal road to a
knowledge of the unconscious activities of the mind” (62, p. 608).
Methodically, the attempt to solicit free associations and dreams

from the patient accounts for the most notorious material
ingredient of the analytic method in classical analysis—the couch.
Having the patient in a supine position out of direct view of the

therapist and without extrinsic environmental intrusions is
meant to create conditions of relative sensory deprivation that in
turn serve to maximize the evocation of repressed memories.
With regard to the therapist’s task and response to the verbal

material elicited from the patient, the crux of the psychoanalytic
method remains the analysis of transference, which comprises

the major instrument of analysis as well as its major obstacle. The
deliberate elucidation of transference reactions results in
inevitable resistances to this endeavor, which must also be
overcome as part of the treatment. Methodologically, the
reflective, ambiguous stance of the therapist in concert with the
high frequency and regularity of contacts between patient and
therapist are meant to encourage the regressive transference
process and the intensity of feelings in the treatment situation.
Despite the endowment of the value of interpretation, the

therapeutic path must be carefully paved in order for it to have its
most beneficial effects. In this regard, the role of the techniques of

confrontation, clarification, and working-through have been
noted. Confrontation refers to having the patient discern or face
the particular mental event to be investigated: clarification refers

to placing the same event in sharp focus, separating important
aspects from insignificant ones (both of these processes prepare
for the actual interpretation); interpretation then goes beyond

the manifest material by assigning an underlying meaning or
cause to the event or phenomenon in question; finally, working-
through refers to the repetitive, progressive, and elaborate

explorations of the interpretations and resistances to them until
the presented material has become fully integrated into the

patient’s understanding. This is perhaps the most time-
consuming aspect of dynamic psychotherapy. Although the major
thrust of treatment occurs within the therapist’s office, working-

through necessarily includes the tacit work done by the patient
outside of the therapeutic hour.
In terms of comparisons with other forms of treatment and

their reputed curing powers, certain techniques or procedures
are considered to be expressly anti-analytic, i.e., to block or lessen
one’s understanding or insight rather than facilitating it.
Foremost in this regard are (perhaps ironically) abreaction,
which may still be used but is not felt to directly bring insight;
direct suggestion or advice, which is only useful to the extent that
it is openly acknowledged and analyzed within the therapy
setting; manipulation, allowable only to the extent that it can be
brought into the analytic arena and does not occur without the
ultimate knowledge of the patient; and the deliberate or
conscious assumption of roles or attitudes that create an
unanalyzable situation by their very nature.
Variations on the Dynamic Theme
The prototypic embodiment of the psychodynamic theme is,

of course, classical psychoanalysis. The variations on the dynamic
theme reflect overt and covert modifications of theoretical
conceptualizations as well as methodological and technical
applications in practice. These include attempts to partially or
completely transcend the biological focus of Freud with more
interpersonal, social, ethical, and cultural considerations (e.g.,
Adler, Horney, Sullivan, Fromm, Fromm-Reichmann, Meyer, and
Masserman); to extend or enhance the ego with earlier or more
adaptive endowments (e.g., Federn and Klein); to enlarge man’s
temporality with a time focus on his primordial past (e.g., Jung),
his present, and/or his future (e.g., Adler, Stekel, Rank, and Rado);
to expand treatment procedures by altering the range and goals
of treatment (e.g., Rank, Alexander, Deutsch, and Karpman); to
develop guidelines for his short-term psychotherapy with
anxiety-provoking techniques (e.g., Sifneos) and even brief
treatment of serious illness within the context of a single
interview (e.g., Malan) (63-67); to revise the role of the therapist’s
personality and relationship to the patient by making the
therapist a more direct, flexible, and/or active participant (e.g.,
Adler, Sullivan, Rank, Alexander, Stekel, Ferenczi, and Rosen);
and, at perhaps the opposing end of the analytic spectrum, to
restore the psychophysical balance of man by focusing equally on
the physical half of the psychophysical split (e.g., Rado and
Masserman) and/or substituting an approach to therapeutic cure
from the somatic side by trading the traditional change mode of
insight for a reversal back to the earlier catharsis by means of the
bodily release of conflictual tensions (e.g., Reich).
The Behavioral Theme
The behavioral theme presumes that all behavior, both

normal and abnormal, is a product of what man has learned or
not learned. Neuroses or neurotic symptoms are construed as
simple learned habits, involuntarily acquired, repeated,
reinforced responses to specific stimuli in the environment.
Indeed, Eysenck said, “there is no neurosis underlying the
symptom, but merely the symptom itself’’ (68). Conversely, since

external behaviors constitute the essence of the therapeutic
problem, the therapeutic cure is simple: “Get rid of the symptom

and you base eliminated the neurosis” (68).
Behavioral psychotherapy is an outgrowth of animal

laboratory experiments on classically conditioned responses in
which animals were observed to have habits that were like

human phobias. Traditionally, behavioral psychotherapy also
presumes that human neuroses have the same basic vicissitudes
as those of the animal, in which anxiety (equated with fear) is

regarded as its central manifestation (69).
Thus behavioral man is reducible to stimulus-response
connections that can be isolated and altered in a piecemeal

manner by reinserting new associations. Viewed in this way,
behavioral man is infinitely manipulable and therefore

controllable by external events in the environment.
The prototype of orthodox behavior therapy is exemplified in

Wolpe’s reciprocal inhibition therapy, which is based on a
classical conditioning paradigm.2 Wolpe’s main thesis is that
neurotic symptoms are all essentially phobias based on the

adverse learning of unrealistic fears. In behavioral theory this
means that anxiety has been conditioned during highly disturbing
or traumatic experiences. Wolpe would regard a complex
symptom like neurotic passivity as a learned fear of rejection or
disapproval reflecting one form of a phobic or anxious reaction to
others.
Therapeutic or Change Processes
For the behaviorist all problems are construed as

pedagogical in nature and therefore alterable only through direct
teaching and learning of new behavioral associations, i.e.,
stimulus-response connections. The patient must be taught new
alternatives that must be repeated and practiced within as well as
outside of the therapy situation. These alternative modes of

functioning do not occur simply as a concomitant of cognitive or
emotional understanding of one’s problems; the patient must

rehearse the new alternatives directly. Thus, in direct contrast to
the psychodynamic schools, the behavioral approaches, according
to Cautela, tend to sustain the view that insight is not only

unnecessary but usually hinders the treatment for deviant
behavior (70). Wolpe’s principle of reciprocal inhibition implies

the rejection of catharsis as well. Wolpe sees abreaction (the
symbolic re-evocation of a fearful past experience) as a special
case in point, asserting that no permanent effects are achieved if

unrelieved terror is the only emotional factor involved and is not
counterposed by relaxation responses.
One implication of this view of the mode of therapeutic

change is that change can presumably occur within a short period
of time. In contrast to the dynamic theme, Eysenck stated that “all
treatment of neurotic disorders is concerned with habits existing
in the present; their historical development is largely irrelevant”

(68). Moreover, Cautela stated, “In fact, it is possible to have a
situation in which symptoms have been removed with no
knowledge at all of the etiology” (70).
Although all behaviorists may be viewed as seeking change

through direct conditioning, shaping, or training, Wolpe, in
accordance with his classical conditioning paradigm, sees all

therapeutic learning or change (not just behavior therapy) as
occurring within the reciprocal inhibition framework per se. All
therapies necessarily incorporate the substitution of relaxation

for anxiety in the reduction or elimination of symptoms. However,
more critically, the difference between behavior therapy and
other therapeutic situations is that in the latter,

counterconditioning of relaxation over anxiety occurs fortuitously
or unsystematically, whereas in behavior therapy this process is

overt, systematic, and under the direct control of the therapist.
The nature of the therapeutic relationship between therapist

and patient in the behavioral therapies is, according to Hollander,
an essentially “educative, teacher-pupil relationship” (71). In

contrast to the psychodynamic transferential relationship but
comparable to the working or therapeutic alliance in certain
respects, the behavioral relationship may be portrayed as a
deliberately structured learning alliance, in which, at its best,
attention is drawn to the more current and presumably

constructive aspects of the patient's personality in collaborating
on the course of therapy.
Krasner depicted the behavior therapist as a learning

technician or “social reinforcement machine” (72). Although this
rubric may apply to all therapies to greater or lesser degrees,
usually the behavioral therapist openly regards himself/herself as

an instrument of direct behavioral influence or control, one who
directly and systematically manipulates, shapes, and/or inserts
his/her own values in the therapeutic encounter In a comparable

context, the therapist shapes his/her own behavior so as to be a
social reinforcer for the patient. If the therapy does not proceed
smoothly and effectively, the behavior therapist revises the

behavioral plan or schedule to better fit the patient to treatment
(71).
Behavior therapy deliberately does not dwell on the

therapist-patient relationship; at most, it does so secondarily, that
is, according to APA’s Task Force on Behavior Therapy, “only to
the extent that this is seen to be important in securing the

patient’s cooperation with the therapist’s treatment plan” (73, p.
27).
The behavior therapist’s use of warmth, acceptance, and any
other relationship skills is common but relegated to the realm of
secondary “relationship skills” that are not crucial therapeutic
requirements for desired change to occur in the patient (71).
In Ehrenwald’s words, the behavioral schools of

psychotherapy actively relinquish “the methods of the couch” and
replace them with “the methods of the classroom and the pulpit”
(7). The behavior therapist has at his/her disposal a large variety
of conditioning, training, and other directive techniques. This
repertoire may include any or all of the following: the more

classical conditioning techniques of systematic desensitization
combined with deep muscle relaxation, implosion, or

assertiveness training; the operant techniques of positive or
negative reinforcement; aversiveness training; shaping or
modeling; and/or the more flexible directive techniques

pertaining to the direct transmission of advice, guidance,
persuasion, and exhortation. The latter methods more typically

reflect the means by which behavior modification has been
extended recently to the teaching or conditioning of cognitive
behaviors or attitudes underlying specific behaviors, methods of

philosophical indoctrination, or cognitive programming.
More generally, the behaviorist initially sets out to identify
the patient’s specific target behaviors or responses that need to

be modified. These, in conjunction with the stimuli or
environmental situations that give rise to the specific behaviors,
constitute a behavioral formulation that may be regarded as the
behaviorist’s counterpart of psychodynamic formulation. The

behavioral formulation is used for the purpose of setting specific
treatment goals, which are usually made explicit to the patient at
the outset. The initial interview typically aims to specify what

situations or factors contribute to the maintenance of the
particular responses in question and on what occasions those
responses are most likely elicited. On this basis the behavioral

conditioning program can then begin.
Wolpe’s classical reciprocal inhibition therapy, which has as
its direct aim the reduction or inhibition of anxiety responses

through the substitution of relaxation responses for anxiety,
typically uses two basic techniques for the purpose of juxtaposing
relaxation with anxiety. The first technique is progressive deep

muscle relaxation training and the second is systematic
desensitization of anxiety through imagination. The patient is

instructed to relax and then tense up for intervals of 10-15
seconds each; the patient repeats this maneuver using various
different muscle groups or parts of the body followed by

breathing exercises. Then, after discussing with the patient which
real-life situations arouse the phobic symptoms, the therapist
incorporates each scene into an anxiety list or anxiety hierarchy;

this list constitutes the basic therapeutic tool. (Each scene or
situation is arranged hierarchically on the basis of level of anxiety
generated in the patient, with a ranking system of 1-10). Starting
with the weakest elicitor of anxiety in the hierarchy, the therapist

asks the patient to imagine the anxious circumstance for a few
minutes and then instructs the patient to concentrate on relaxing;

this process is repeated until the patient can imagine the scene
without feeling any anxiety. The therapist ascends the anxiety list
item by item in the same manner. When this process is finished,

the real-life situation that has created the phobia has lost its
capacity to elicit anxiety.
A more recent variation of this approach is, ironically, a
direct reversal of this procedure. The therapist starts not with the
bottom but with the top of the anxiety continuum; the patient is
flooded with the strongest anxiety-eliciting stimulus situation of

his/her imagination and keeps this in mind until the anxiety
dissipates. Then, with successive repetitions of the same scene,
the patient's anxiety progressively lessens until he/she is immune
to anxiety in that situation. This basic technique is referred to as

implosion (Stampfl’s implosive therapy).
A cognitive variation of this approach is the technique of

thought- stopping. In this variation the patient puts into words
the anxiety-producing situations instead of merely imagining
them. As the patient speaks about himself/herself in these

situations the therapist suddenly interrupts the train of anxious
verbalizations by shouting “Stop!” This procedure is repeated on
successive occasions until the patient validates the fact that this
overt suppression has indeed served to reduce the frequency of
the anxiety-loaded thoughts. Ellis’ rational therapy represents an

elaboration of this cognitive approach on a larger and more
varied scale.
The behavioral counterpart of the psychodynamic procedure

of working-through is behavioral rehearsal within the confines of
therapy as well as assignments to be worked on outside of
therapy; these are important parts of the total behavioral

treatment. For example, the patient might be directly trained in
certain social skills that may first be role-played or rehearsed
within the course of therapy as well as explicitly instructed, tested

out in outside real-life situations, and reviewed in subsequent
sessions.
A special instance of this method is assertiveness training, a

technique of instruction and practice of interpersonal behaviors
involving the relatively direct expression of one’s positive and
negative responses to others. Wolpe claimed that assertive

responses constitute a major class of behaviors that could be used
as an alternative to relaxation responses in the function of
reciprocally inhibiting anxiety. Assertive training by means of

behavior rehearsal, whether or not it is used as a technique for
expressly countering anxiety, has been incorporated into a variety

of schools that use the methods of the behavioral laboratory.
Variations on the Behavioral Theme
Three broad types of behavior therapies or behavior

modification are considered under the umbrella of the behavioral
theme (74): one, based on the early classical Pavlovian paradigm,

primarily uses systematic desensitization or extinction of anxiety
techniques (e.g., Wolpe’s reciprocal inhibition therapy); a second
type, based on an operant Skinnerian paradigm, uses direct

reinforcement by means of reward/punishment procedures (e.g.,
Allyon and Azrin’s token economy); and a third type, based on a
human social learning paradigm, is contingent on direct modeling

or shaping procedures (e.g., Bandura’s modeling therapy). The
latter type of therapy extends to a variety of new systems of
directive psychotherapy that expressly aim at attitudinal or

philosophical restructuring, using methods of the behaviorist’s
laboratory. Such so-called integrity therapies, although they share
the fundamental learning or problem-solving stance, are usually

more actively advisory and/or exhortative in their therapeutic
techniques (e.g., Ellis’ rational therapy, Glasser’s reality therapy,
and Sahakian’s philosophic psychotherapy).
Another way of viewing the scope of these behavioral
variations is through the evolution of their targets of change from

external to internal alterations in man’s learnings. The earlier
behavior therapeutic systems addressed overt behaviors and
fears (e.g., Wolpe); the more recent systems are directed to more
covert values and beliefs (e.g., Ellis). The most recent approaches
venture into the reaches of the most inaccessible and involuntary

mental and physiological states and responses, such as heart rate,
blood pressure, and brain waves (e.g., biofeedback).
The Experiential Theme
In terms of therapeutic ideology, a major source of

divergence and disagreement for the founders of schools of
psychotherapy since Freud has been their inability to reconcile
what they regard as a largely deterministic or defeatist image of

man. This includes the renunciation of a dynamic
conceptualization of man as a predominantly passive or
instinctually regressive recipient of his conflictual drives,

subservient to the less conscious aspects of himself. The
experientialists criticize classical psychotherapy’s
overcommitment to the canons of science and its concurrent
underplaying of man's ethical dimension, that is, his will, choices,

and moral relation to others. Through psychotherapeutic
practices and overemphasis on technique, man becomes
impersonalized, compartmentalized, calculated, managed, and/or

analyzed and thereby diminished instead of truly experienced by
others or himself (20, 26, 53, 75).
Haigh, an experientialist, has criticized the behavioral
conceptualization as follows:
The therapeutic process [is] essentially concerned with the experiential

anguish of isolation and alienation. These experiences of isolation,
encapsulation, alienation derive from social programming.… The central
problem cannot be understood exclusively at the level of overt behavior,
[but] must be understood as involving incongruence between overt
behavior and inner experience. Reinforcement learning theory is
inadequate for translating this central problem because it doesn’t
include concepts representing human experience. The behavioral
therapy techniques associated with reinforcement learning theory are
potentially harmful because they involve the very same programming
approach which induced these neurotic problems in the first place (76).
The experiential conceptualization represents an

increasingly emerging exaltation of man in order to counter
alienation, that is, the fostering of the fullest exploration of the

unique and universal nature of man’s self. It is expressly devoted
to the self-transcendent quality of human experience. In Frankl’s
words, “Man is basically striving to find and fulfill meaning and

purpose in life” (77, p. 252).
This reaching out involves a transpersonal as well as
intrapersonal dimension. According to Arendsen-Hein, the

intrapersonal refers to an “ego-centered level… where the main
concern is the discovery of one’s individuality, of one’s emotional
states and their representation in the physical body”; the

transpersonal, on the other hand, is “spiritually oriented towards
ultimate reality,… unity on the human, universal, or cosmic plane
... in which [the person] experiences a transcendence of his ego
boundaries into a universal consciousness” (78).
The experientialist tends to view man as an inherently active,
striving, self-affirming, and self-potentiating entity with almost
limitless capacity for positive growth, and the experiential

therapies typically opt for growth and not mere healing of illness.
Their therapeutic goal is attaining maximal awareness or a higher
state of consciousness, in which, according to May and associates,

“to be aware of one’s world means at the same time to be
designing it” (20, p. 60). Experientialists therefore direct
themselves to such expansive dimensions as self-determination,
creativity, and authenticity and make use of a potpourri of
methodologies that aspire to an ultimate integration of the mind,

body, and more recently, soul of fragmented man.
The experiential stance historically reflects the incorporation
of the basic philosophy of the European existentialist, with
his/her concern for the essential issues of man’s being or

becoming; the methodology of the phenomenologist, who
attempts to address data as given in order to tap their meaning
and to examine patients on their own terms without recourse to

preconceived theoretical formulations of a causal or diagnostic
nature; and, now more than ever, the religious teachings and
techniques of the Eastern mystic, who presumes to bridge the

mind-body split in seeking man’s spiritual center. All, according to
May and associates, focus on “man’s most immediate experience…
[i.e.,] that to fully know what we are doing, to feel it, to experience
it all through our being, is much more important than to know
why. For they hold, if we fully know the what, the why will come
along by itself” (20, p. 83).
Pathology is regarded as the reduced expression of one’s

potential, the result of blocking and the loss of congruence with or
repressing of one’s internal self-experience. Both the

psychodynamic and the experiential (essentially existential)
themes depict the neurotic personality as suffering from
repression and fragmentation. The dynamic view postulates

repression of instinctual drives, especially sexual ones, while the
experiential view construes repression as an ontological
phenomenon, “the loss of a sense of being, together with the

truncation of awareness and the locking up of potentialities which
are the manifestation of this being” (20, p. 86).
Neurosis is a fundamental universal despair resulting from

the individual’s estrangement from himself and Iris society (or
world). Comparably, anxiety, in marked contrast with the

behavioral equation of anxiety with specific circumscribed fears,
refers to “the anxiety of man facing the limits of his existence with
the fullest implications… death, nothingness” (20, p. 118). Such

anxiety manifests itself at every moment as man stands against
the reaches of his own possibilities. Moreover, the origin of guilt
accrues from the forfeiting of one’s potential, for which the

person alone is responsible.
In Maslow’s words, pathology is “human diminution”
(instead of neurosis), “the loss or not-yet-actualization of human
capacities and possibilities” (79, p. 124). Thus health and illness,
including all of the standard psychiatric categories, reside on a
continuum—the differential between what one construes himself

to be versus what one can become. The overall ideal or ultimate
state of health refers to man as maximally conscious and real at
every moment, to wit, according to Denes-Radomisli, man as

“vital, immediate, spontaneous, authentic, and active” (80, p. 104).
Therapeutic or Change Processes
The experiential schools of psychotherapy trade intellectual

cognition and insight for emotion and experience, forsaking the
there-and-then of the distant past for the here-and-now of the

immediate present.
Experiencing is a process of feeling rather than knowing or
verbalizing; occurs in the immediate present; is private and

unobservable but can be directly referred to by an individual as a
felt datum in his own phenomenal field; acts as a guide to
conceptualization; is implicitly meaningful, although it may not

become explicitly so until later; and is a preconceptual organismic
process. The many implicit meanings of a moment’s experiencing

are regarded not as already conceptual and then repressed;
rather, they are considered in the awareness but as yet
undifferentiated. In total, according to Gendlin, “therapeutic

change occurs as a result of a process [of experiencing] in which
implicit meanings are in awareness, and are intensely felt, directly
referred to, and changed, without ever being put into words” (81,
p. 239).
Therapeutic change through experiencing usually occurs by

means of a real or congruent interpersonal relationship between
the patient and therapist. In the latter regard, May and associates
said,
Beyond all considerations of unconscious determinism—which are true

in their partial context—the only thing that will grasp the patient, and in
the long run make it possible [for him/her] to change, is to experience
fully and deeply that [he/she] is doing precisely this to a real person ... in
this real moment (20, p. 83).
One variation of this thesis, especially applicable to Rogers’

client- centered therapy, reflects the underlying positive belief
that every organism has an inborn tendency to develop its
optimal capacities as long as it is placed in an optimal
environment. Thus, according to Hoehn-Saric, the patient is

offered “an optimistic self-image; he understands that he is
basically good and full of potentials.… Therefore, the therapist
does not need to challenge or shape the patient, he has only to

provide the warm and understanding milieu which will enable
the patient to unfold his latent potentials” (82, p. 261).
Unlike transference, which is dependent on the revival of a
former interpersonal relationship, experiential encounter works
“through the very fact of its novelty.” Through encounter the
therapist serves as a catalyst in whose presence the patient comes
to realize his own latent and best abilities for shaping his own self
(20).
Although methods may vary, the real here-and-now

therapeutic dialogue or mutual encounter between therapist and
patient is the sine qua non of many of the experiential schools. It
is, according to Ford and Urban, “an emotionally-arousing human

relationship in which each person tries to communicate honestly
with the other both verbally and nonverbally” (26, p. 470).
Rogers described the flavor of the therapeutic encounter as
follows:
I let myself go into the immediacy of the relationship where it is my total

organism which takes over and is sensitive to the relationship, not
simply my consciousness. I am not consciously responding in a planful or
analytic way, but simply in an unreflective way to the other individual,
my reaction being based (but not consciously) on my total organismic
sensitivity to this other person. I live the relationship on this basis (83,
pp. 267-268).
These approaches to psychotherapy ideologically aspire to

an egalitarian treatment model. The human alliance is not of
physician to patient or teacher to student but of human being to
human being. May and associates presented the following

rationale: “The therapist is assumedly an expert; but, if he is not
first of all a human being, his expertness will be irrelevant and

quite possibly harmful” (20, p. 82). Rogers stated that if the
patient is viewed as an object the patient will tend to become an
object (83). Therefore, the therapist says, “I enter the relationship

not as a scientist, not as a physician who can accurately diagnose
and cure, but as a person, entering into a personal relationship”
(83, p. 267). Naturally, what one construes to fall within the

domain of personal or real in a therapeutic relationship is open to
interpretation.
In sum, although Seguin pointed out that the quality of the
healer-patient relationship (and the form of therapeutic love or

eros that is transmitted) is “different from the one between father
and son, teacher and pupil, friends, and, of course, lovers” (84),
the experiential theme rejects the paradigm of the parent-child

relationship of the dynamic theme and the teacher-student
paradigm of the behavioral theme and opts for something closer
to the latter conceptualization (i.e., friends and lovers) in its

paradigm of the therapeutic relationship.
There is an assortment of schools of psychotherapy within
the experiential theme that recoils at the idea of therapeutic
technology. These schools, which are predominantly existential,

renounce technique as part of their philosophy of understanding
human existence. They feel that the chief block in the
understanding of man in Western cultures has been an

overemphasis on technique and a concomitant tendency to
believe that understanding is a function of or related to technique.
Rather, according to May and associates, they feel that “what
distinguishes [forms of] existential therapy is not what the

therapist would specifically do,… but rather the context of his
therapy” (20, p. 77). That is, according to Chessick, it is “not so
much what the therapist says [or does] as what he is” (58, p. 243).
Indeed, in this regard the existential schools of psychotherapy
have been criticized for their vagueness regarding technical
matters in the conduct of psychotherapy. Ford and Urban’s

analysis of their approach concluded that ‘‘they have developed a
new way of thinking about patients, but it does not lead them to
do anything different in treatment” (26, p. 469).
Less harshly, the experiential schools aspire to flexibility or

innovation in their actual methods as long as these methods are
useful in the therapist’s attempt to experience and share as far as

possible the being of the patient. Here the aim or rationale of all
techniques would be to enter the phenomenological world of the

patient. In direct contrast to the view of the dynamic therapist,
the experiential therapist does not concern himself/herself with
the patient’s past, the matter of diagnosis, the aspiration of

insight, the issue of interpretation, or the subtle vicissitudes of
transference and countertransference. Unlike the behavioral
therapist, the experiential therapist expressly does not set goals

for the patient and does not direct, confront, or otherwise impose
his/her personality on the patient with directives in the form of
behavioral instructions or problem-solving preferences.
Techniques that involve placing the therapist’s judgments or

values above those of the patient are considered anathema to the
requirements of unconditional acceptance of the patient and

placing the locus of control within the patient. It may also be
noted here that Rogerian methods as well as others within the
more classically existential framework retain a methodological

framework of essentially verbal interchange between therapist
and patient.
Although they share the same basic faith in the therapeutic
encounter and the emphasis on feelings, other schools under the

experiential umbrella are often antiverbal in approach. Such
schools (e.g., Gestalt therapy), view overintellectualization as part

of the patient’s problem, i.e., a manifestation of defense against
experiencing or feeling, and discourage it as part of the
therapeutic endeavor. These therapies attempt to accentuate
activity over reflection, emphasize doing rather than saying, or, at

the minimum, aim to combine action with introspection. The goal
of experiencing oneself includes developing the patient’s
awareness of bodily sensations, postures, tensions, and

movements, with an emphasis on somatic processes. Awareness
of oneself as manifested in one’s body can be a highly mobilizing

influence. The main thrust of therapy is therefore to actively
arouse, agitate, or excite the patient’s experience of
himself/herself, not simply let it happen.
Among the techniques for expressing one's self-experience in
such schools is the combination of direct confrontation with
dramatization, i.e., role-playing and the living out of fantasy in the
therapeutic situation. This means that under the direction (and
often the creation) of the therapist the patient is encouraged to
play out parts of himself/herself, including physical parts, by
inventing dialogues between them. Performing fantasies and
dreams is typical and considered preferable to their mere verbal
expression, interpretation, and cognitive comprehension. In
variations of the somatic stance, body and sensory awareness
may be fostered through methods of direct release of physical
tension and even manipulations of the body to expel and/or
intensify feeling.
In yet other attempts to unify mind, body, and more

especially, spirit, the immediate experience of oneself by focusing
on one’s spiritual dimension is sought. This is most often
accomplished through the primary technique of meditation. The
ultimate state of profound rest serves to transcend the world of
the individual ego in that it is a higher reality or state of
consciousness that the individual ego subserves. Major methods
of will training and attention focused on a special word-sound or
mantra, for example, serve to create an egoless or
nonegocentered transcendent state.
Variations of the Experiential Theme
The therapeutic systems that have evolved under the

experiential theme represent various approaches, each propelled
by the immediate moment and geared toward the ultimate unity

of man. These include the following: 1) a philosophic type, which
reflects existential tenets as a basis for the conduct of
psychotherapy and pivots on the here-and-now mutual dialogue

or encounter while retaining essentially verbal techniques (e.g.,
Rogers’ client-centered therapy and Frankl’s logotherapy); 2) a
somatic type, which reflects a subscription of nonverbal methods
and aspiration to an integration of self by means of focusing
attention on subjective body stimuli and sensory responses (e.g.,

Perls’ Gestalt therapy) and/or physical-motor modes of intense
abreaction and emotional flooding in which the emphasis is on
the bodily arousal and release of feeling (e.g., Lowen’s

bioenergetic analyses and Janov’s primal scream therapy); and,
finally, 3) a spiritual type, which emphasizes the final affirmation
of self as a transcendental or transpersonal experience, extending
man’s experience of himself to higher cosmic levels of

consciousness that ultimately aim to unify him with the universe.
This is primarily accomplished by means of the renunciation of
the individual ego in the establishment of an egoless state by

meditation (i.e., relaxation plus focused attention), in which one
reaches a state of profound rest (e.g., Transcendental Meditation),
a spiritual synthesis that may be amplified by various techniques

of self-discipline and will-training and practice of disidentification
(e.g., Assagioli’s psychosynthesis).
Conclusions
Individual names given to different schools of psychotherapy

often attempt to capture, if not exalt, their uniqueness; at the
same time, the very names may serve to mask their derivations
and the similarities they share with other systems. The schema
presented here subsumes a large array of therapeutic schools that
have proliferated under three broad themes since Freud. Each

major theme as depicted here in its prototypic or pure form has a
unity of its own; each dimension is broadly congruent with the
others in its domain and is overtly antithetical to those

dimensions described in the other two themes. However, in
reality these are rarely categorical distinctions. Therapeutic
boundaries in actual practice can and do overlap.
The systematic approach presented in this paper allows us to

consider the dimensions of greatest departure as well as
convergence in the ever- expanding field of the psychotherapies.

In so doing, it is hoped that psychotherapeutic schools and their
therapeutic processes will be more closely and critically explored.
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Notes
1 Reprinted by permission from The American Journal of Psychiatry, Vol. 134, pp. 851-
863, 1977. Copyright 1977 American Psychiatric Association.
2 The terms “classical” versus “operant” conditioning procedures refer essentially to the
respective sequence in the application of the stimulus. In classical conditioning
the stimulus precedes and in operant conditioning the stimulus follows the
behavioral response to be changed.
2
General Principles of Psychotherapy

The therapist’s ultimate commitment to the welfare of his patient
governs and directs his therapeutic interventions toward what he
understands to be ultimately in the patient’s best interests. This
principle implies that the therapist always uses his best therapeutic
skills to promote and accomplish for his patient the most effective course
of treatment (2, p. 364).
Definition and Scope
Broadly, psychotherapy can be described as a mutual

therapist-patient endeavor to investigate and understand the
nature of the latter’s mental distress for the purpose of providing
relief from his suffering. The suffering may take the form of
attitudes, feelings, behaviors or symptoms that are causing
difficulties; the major purpose of psychotherapy is to produce
changes in the person which will enable him to maintain a more

stable and less painful adaptation to himself and the world
around him. Although psychotherapy mainly focuses on the

source and manifestations of the patient’s difficulties,
maladaptations or psychopathology, it need not restrict itself to
the healing of the psychological illness per se; rather, it may
simultaneously aim for the individual’s growth, that is, the
attainment of his maximum mental health or best human

potential.
It should be pointed out that numerous forms of

psychotherapy are being practiced today, with different and often
conflicting conceptualizations about the fundamental nature of

man and his mental ills, therapeutic processes or change agents,
the requirements of the doctor/patient relationship, and the
primary techniques and methods that are utilized. Often, each

tends to exclusively emphasize either dynamic or behavioral or
experiential aspects of treatment (1, Chapter 1). Other more
common dichotomies include insight versus supportive therapies;

the treatment of psychotic versus neurotic patients, inpatients
versus outpatients, etc. However, in reality, these approaches are
rarely categorical distinctions. Therapeutic boundaries in actual

practice can and do overlap. Thus, if these aspects of the
psychotherapies were integrated, the common ground of
psychotherapy would currently refer to the treatment of mental
and emotional disorders based primarily on verbal (and

nonverbal) communication (2) within the context of a special
therapeutic relationship be tween two persons, wherein the one
seeking help is the recipient of affective experiences (catharsis,

abreaction, etc.), behavioral regulations (ad vice, control, etc.),
and cognitive mastery (insight, explanations, etc.) in relation to
his presenting and/or underlying problems (3).
More specifically, psychotherapy as defined above
represents a theoretical midpoint of psychological treatment
within a large and varied continuum of clinical approaches and

techniques. While the focus is on general principles, the actual
practice of psychotherapy is further delineated by descriptions of
two hypothetical endpoints of psychotherapeutic treatment—

intrapsychic conflict resolution within the context of a fantasized
and frustrating transference relationship; and adaptation to
current reality within the context of a real and gratifying
therapeutic alliance. (Approaches emphasizing each goal will be
elaborated upon in the last section of the paper.)
Theory of Mental Functioning
Basic psychotherapeutic theories have as their working
concepts the dynamic, genetic, structural, economic,

developmental and adaptive nature of mental functioning. In
brief, man’s affects, thoughts and behavior reflect the expression
and transformation of his innate instincts, and more crucially,

their repression, as well as the ways in which man defends
himself (and adapts) in the face of his moral standards and the
demands of external reality. Not only is man a product of inner

conflicts—that is, both subject to and resisting against a reservoir
of impulses largely inaccessible to his conscious self—but he is
also a product of his environment, his learned or unlearned

behaviors, values and beliefs which he has acquired through
identifications, conditioning and training. Beyond these
unconscious determinants and internal and external alterations

through learning, man strives not only for stability, but for self-
determination, growth, and authenticity; at the same time, he

seeks to find some meaning and purpose in life.
There are no procrustean therapeutic beds in which the

patient should be fitted. The therapist must formulate an
independent therapeutic rationale and working hypothesis for

each patient undertaking psychotherapy.
Diagnosis and Assessment
Psychotherapy is applicable to a large and complex range of
emotional disorders, including a variety of situational crises,

personality disorders, neuroses, reconstituted psychoses,
psychoses, and chronic mild organic condition. The categories in
most current use are described in DSM III.
However, in establishing the therapeutic assessment and
plan, a good clinician should avoid the simple attachment of one
of the above diagnoses to the patient, since this often prematurely

relegates him to a fixed position within that diagnostic label and
may produce closure on how the patient is subsequently viewed
and treated. Not only do few patients really fit DSM categories,
but often this expedient but clinically limited method of assessing
illness offers little of practical psychotherapeutic value.
Psychotherapy-oriented diagnosis and assessment in a more
constructive sense attempt to emphatically portray the patient
and his inner world, his strengths as well as weaknesses, his
capacities for health as well as illness. Throughout the therapeutic

process, therefore, the therapist reexplores and refines his
diagnosis by carefully observing the patient’s interactions, his
relationship to himself and others, his adaptability and

accessibility for particular therapeutic interventions.
Psychotherapeutic Objectives
Psychotherapy can have any or all of the following goals: 1)

relief of immediate crisis, 2) reduction or removal of
symptomatology, 3) strengthening of defenses and integrative
capacities, 4) resolution or rearrangement of underlying conflicts,

and 5) modification of personality organization towards an
adaptive and mature functioning.
Based upon the therapist’s ongoing assessment of the
particular patient, objectives may be modest, restricted, narrowly

focused short-term goals, such as reduction of specific
symptomatology, brief problem-solving, crisis intervention, or
achievement of limited insight into a well-circumscribed area of

conflict, or longer-term objectives such as a reduction in the
intensity of conflict, rearrangement of defensive structures,

resolution of therapeutic dependence, and modification, or, at
times, even resolution, of basic and unconscious conflicts. In some
cases, where the immediate need is to sustain the patient during a
particular crisis or period of stress, the major aim may be to
provide a supportive relationship. Supportive efforts can be of

brief duration or may extend over a long period, particularly with
patients whose capacity for therapeutic work and for adequate
functioning without a sustained therapeutic relationship is

limited.
Of course, goals set at the beginning of therapy may be—and,
indeed, must be—modified or replaced by new ones as therapy

progresses. In most instances, the patient should participate in
the setting of goals. Both therapist and patient should be aware
that the aims of treatment are subject to change throughout its

course, and that either overestimating or underestimating the
goals of treatment at any one time is not irrevocable. Overrating
the patient’s capacities may place undue pressure on him during

treatment; on the other hand, settling for modified objectives may
result in difficulties for the patient later on and necessitate

additional therapeutic work at that time.
The Psychotherapeutic Relationship
Psychotherapeutic change invariably occurs within the

context of an interpersonal relationship between the patient and
therapist. In fact, some approaches focus almost exclusively on

the therapeutic relationship (i.e., it is the subject and object of
analysis); others focus primarily on the patient’s life situation and
only secondarily on the therapeutic relationship per se. Three
significant aspects of the therapeutic relationship in
psychotherapy are: 1) real-object relationship, 2) therapeutic

alliance, and 3) transference relationship.
Real-Object Relationship
The calm, interested, helpful and empathic attitudes of the

therapist are essential for providing a warm and understanding
milieu which will enable the patient to undertake the tasks of
treatment. This milieu also serves to maintain the patient's

contact with objects and with reality, constituting the real-object
relationship.
The primary task of the therapist here is the establishment of
trust. In his initial contact, the therapist offers to fill the needs of
the patient through the possibility of being understood and
begins to develop a mutual interaction and rapport that will allow
the patient to view him as a constant, reliable, and predictable
person. The therapist also supplies to the patient certain moral

standards and values. These are not usually expressed directly;
rather, they are implicit in the character and behavior of the
therapist—that is, it is “not so much what the therapist says or

does as what he is” (4, p. 243). The therapist is a model for
identification by the patient, while providing the necessary

gratification from a real object during the therapeutic encounter.
Therapeutic Alliance
Any successful therapeutic venture requires the close

working together of two minds—the therapeutic alliance. This
essentially involves the conscious, rational, and non-regressive

aspects of the relationship between patient and therapist. It
means “that the therapist aims at forming a real and mature
alliance with the conscious adult ego of the patient and

encourages him to be a scientific partner in the exploration of his
difficulties” (4, p. 72). The therapeutic alliance is based on the
mutual explicit or implicit agreement to work together according

to the requirements of the therapeutic situation.
This therapeutic alliance is an essential part of the
therapeutic process. One of the major tasks of the therapist is to

foster its development and to indicate to the patient that it is
necessary for the psychotherapeutic work of observation,

evaluation, judgment, reasoning, and reality-testing in relation to
the material revealed in the sessions.
For the maximal development of this working relationship,
both therapist and patient must be capable of controlled ego-

splitting in the service of the treatment (5). That is, there are
times when the real-object relationship between the patient and
therapist would interfere with the therapeutic alliance; there is

need to oscillate between the two. To accomplish both tasks, the
therapist must judiciously set up a barrier against the patient’s
need to revert to the real-object relationship because he wishes to
remain gratified by the therapist. The matter is further
complicated because certain aspects of the working relationship

are real. The patient learns real things about the therapist both in
and out of the office, and the therapist behaves in a real and
human way toward the patient (6). Therefore, the reality of

certain aspects of the treatment relationship, as well as its place
in the formation and maintenance of the therapeutic alliance,
must be understood by both partners, If both the real-object

relationship and the therapeutic alliance are properly handled by
the therapist, they can constitute useful and complementary parts
of the treatment situation.
The Transference Relationship
How well the therapeutic alliance has been established

determines in large measure the therapist’s use of transference as
a therapeutic tool The real object need of the patient, satisfied by

the former relationships, is deliberately frustrated by the
transference relationship. The deprivations produced by
interpretations of transference result in loss of gratification and

comfort from an infantile object relationship. The patient is
confronted with the pain of his warded-off affects and conflicts
and is required to think and begin to deal with these.
Only under certain circumstances should the therapist focus

upon and encourage transference feelings: when he feels that
such regression will not impair the patient’s reality-testing, i.e.,
his capacity to distinguish reality from fantasy; when the
therapeutic alliance is sufficiently established to withstand the

frustration entailed in confronting the transference resistance;
and, finally, when the therapist’s time commitment allows him to
assist the patient in working through and resolving the

transference dependency.
In summary, the real-object relationship, the therapeutic
alliance and the transference relationship between patient and

therapist must be carefully balanced at all times as an essential
part of treatment.
Psychotherapeutic Techniques
No technique is therapeutic in itself. The choice of a

particular therapeutic approach for a specific human disturbance
at a particular time is crucial. Each technical step must have a
conceptual rationale adapted to the specific patient, and the
therapist must leave room for flexibility from his own

hypothetical standard. In short, a good clinician must be able to
calibrate the use and timing of his therapeutic instruments.
The therapist’s capacity to listen attentively and

empathically is indispensable. He listens not only to the patient’s
manifest content, but also to the latent, unconscious meanings.

Observation of the patient, with sensitivity to what he means as
well as to what he says, provides the foundation for therapeutic
endeavor. Upon initial evaluation, the therapist must indicate
clearly to the patient what his needs for treatment are and clarify
proposed purposes and limitations of that particular form of

treatment. This should include a statement about what is
expected of both parties—their respective roles and relationship
—in order to define as explicitly as possible the nature of

treatment. The establishment of regularly scheduled
appointments is a necessary, albeit obvious, requirement. The
frequency with which a patient is seen will depend upon his

specific needs (e.g., the nature of his psychopathology, capacity to
maintain the therapeutic relationship, etc.), the nature of his
particular treatment, and goals considered.
Once treatment is initiated, it is necessary for the therapist to

encourage the patient to verbalize his thoughts and feelings
despite inherent difficulties in doing so. For this purpose, the

therapist at times may need to be fairly active—by asking
questions, guiding the patient to focus on certain material, and
responding calmly as the patient finds ways of expressing his

thoughts and feelings. Here, the issue of whether and when a
patient should sit facing the therapist or lie down on a couch may
arise. This decision must be based upon consideration of what
will be most facilitating to the particular patient. While some
patients find it easier to verbalize emotional material when they

are not facing the therapist, the couch may be threatening to
other patients. In either event, the potential for regression of the
patient must be carefully assessed.
Therapeutic techniques are naturally dependent upon, and

inextricable from, the therapeutic relationship. (See section on
The Psychotherapeutic Relationship.) The therapist should

continually reinforce the therapeutic alliance between himself
and the patient, while gauging how much regression the patient
can tolerate at any one time. Essentially, the development of

excessive transference reactions should be prevented. In this
regard, some important and necessary defenses should be left
undisturbed, and others supported and strengthened. When to

stabilize the patient’s defenses and when to confront them; when
to frustrate the patient and when to gratify him; and when to

focus on real events and relationships and when to encourage
transferential manifestations—these are inevitable questions to
be asked by every therapist throughout the course of treatment.
The therapist has a variety of potential techniques at his

disposal, whose purposes may be explanatory, cathartic, or
directly educative. Interpretation (of transference, resistance,

repressed conflicts) is often considered to be the major
psychodynamic tool. The therapeutic path must be carefully
paved by a series of steps in order for interpretations to have

their most elucidating effects. In this regard, the roles of
confrontation and clarification are critical. Confrontation refers to
requiring the patient to discern or face the particular mental
event to be investigated; clarification refers to placing the same
event in sharp focus, separating important aspects from

insignificant ones. Interpretation then goes beyond manifest
material by assigning an underlying meaning or cause to the
event or phenomenon in question. In offering interpretations, the

therapist must pay careful attention to the way they are
presented, including the actual wording, the timing, the sequence
and the dosage.
Interpretations should deal with the psychological realities

of the patient, that is, his specific individual experiences in
relation to a conflict. They should go from manifest or current

connections to progressively more latent material—from what is
accessible or partially accessible to what is unknown. The patient
should be relatively removed from an anxiety-provoking

emotional experience before an attempt at interpretation. A
premature interpretation may backfire, in that it may increase the

patient’s resistance to insight rather than further it. Finally, the
interpretation should be reintroduced at various junctures
throughout the therapy; it may be that only after several doses

can an interpretation become integrated completely into the
patient’s understanding.
The therapist may also wish at times to use techniques which

can be considered essentially non-interpretive, that is, which may
serve to block or lessen insight rather than facilitate it. Foremost
in this regard are: abreaction, which may still be used but is not
felt to bring insight directly; direct suggestion or advice, which is

only useful to the extent that it is openly acknowledged and
analyzed within the therapy setting; manipulation, allowable only
to the extent that it can be brought into the explorative arena and
does not occur without the ultimate knowledge of the patient; and
the deliberate or conscious assumption of roles or attitudes that
create an unanalyzable situation by their very nature.
In addition, some patients (or all patients at some time) may

need to be directly instructed in matters pertaining to their life
outside of therapy, e.g., the nature of certain reality events and

relationships—at work, at school, at home. Such educative
interventions may interfere with access to depth material, but
they contribute to the patient’s defenses and enlarge the scope of

his ego.
Descriptions of Two Psychotherapeutic Parameters
Emphasis on Transference and Intrapsychic Conflict
This hypothetical end of the psychotherapy pendulum aims

at major changes in the patient's adaptive functioning and
personality organization and relatively firm resolution of

intrapsychic conflicts. Applicability of such an approach is felt to
require some degree of the following characteristics: the capacity
for therapeutic alliance—that is, a reasonably well-integrated ego
and some ability to relate effectively; sufficient resourcefulness
for effective therapeutic work; the capacity to sustain therapeutic

regression and to master the resulting anxiety; the capacity to
maintain the distinction between fantasy and reality; and the
capacity to form a transference (2).
This form of exploratory or depth psychotherapy can play an

effective role in treating a large range of psychopathology,
although the patients best suited to this approach are those

suffering from neurotic conflicts and symptom complexes,
reactive conditions, and the whole realm of non-psychotic
character disorders. It is also the treatment of choice for patients

with borderline personalities, but the management of these
patients’ regressive episodes may require occasional
modifications of this approach.
The patient is seen at least twice a week, preferably more, for

50 minutes each time, in the therapist’s office. Typically, it is an
environment with minimal extrinsic intrusions in order to create

conditions of relative sensory deprivation. This serves to
maximize the evocation of repressed memories, free association,
uncensored content of the patient’s life material, dreams, etc. The

crux of this method is the analysis of transference, which
comprises the major instrument of the psychotherapeutic

treatment as well as its major obstacle.
The therapist maintains the development of transference by
judiciously frustrating the patient and avoiding gratifying his
wishes, and by remaining relatively removed and anonymous. His

basic therapeutic stance is as a deliberately dispassionate
observer and reflector of the patient’s feelings. The
encouragement of transference reactions results in inevitable

resistances to this endeavor, which must also be overcome (e.g.,
interpreted) as part of the treatment. This frustrating stance, in
conjunction with the high frequency and regularity of contacts
between patient and therapist, encourages an essentially
regressive process and tends to increase the intensity of feelings

within the treatment situation. In contrast to psychoanalysis,
however, a full-blown transference neurosis should be prevented
from developing; interpreting the transference as resistance is

attempted only partially and in strictest accordance with the
needs and capacities of the patient; further, the therapist does not
attempt to completely resolve the original conflict.
The ultimate goal of therapy is, of course, working-through,

which refers to the repetitive, progressive, and elaborate
explorations and testing out of the interpretations and resistances
to them until the presented material has become fully integrated

into the patient’s understanding. This is perhaps the most time-
consuming aspect of dynamic psychotherapy. Although the major
portion of such therapeutic work occurs within the therapist’s

office, working-through necessarily includes the tacit work done
by the patient outside of the therapeutic hour.
Emphasis on Therapeutic Alliance and Adaptation to Current

Reality
Patients who require such an approach are those whose ego

impairment is considerable, whose basic conflicts are of the more
primitive and narcissistic types, and who are highly unlikely to
tolerate further regression. The patients who fall into this group
may be psychotic, especially those in remission, borderline cases,
or patients with severe characterological problems, whose
potential for decompensation is high. Treatment aims at the

reconstitution and stabilization of the patient s functioning. This
process may require short-term involvement or a relationship
extending over a considerable period of time.
The therapeutic posture of the therapist essentially is

dispassionate, but must be relatively active. He offers himself in a
firmly but gently authoritative way to be a protective, supportive,
and real object to the patient. He is generally accepting of the
patient’s dependency rather than trying to explore or change it.

Thus, the nature of the therapeutic relationship differs in
emphasis from the model which focused upon the transference
relationship, in which the therapist serves primarily as a

surrogate ego, a constant object that the patient can rely on.
Throughout the therapy, the focus is upon the establishment and
maintenance of rapport and a good therapeutic alliance.
Since conflicts over the patient’s attachment to the therapist
may develop, the intensity of therapeutic involvement can be
minimized by limiting the frequency and duration of

psychotherapy visits. In addition, minimal interpretation of
intrapsychic conflict is attempted, and non-analytic efforts are
made to influence the patient directly through advice,

encouragement, reassurance, direct suggestion, inspiration and
active persuasion.
This stabilizing type of treatment aims to support the

patient’s defenses and provide controls for his overwhelming
anxiety or destructive impulses. The least amount of frustration

and deprivation is imposed upon the patient, especially in terms
of not having to relinquish the therapist as a source of real object
gratification. In attempting to supply stability, the therapist seeks
to mobilize the patient’s presently available adaptive resources

and strengths. One approach is an examination of stressful
aspects of the patient’s environment, whereby he may then be
advised as to how to lessen these stresses or increase his capacity

to cope. The therapist may also supply stability by providing ego
support. This can be accomplished by guiding the patient in
differentiating reality from his inner distortions, validating, where

possible, the correctness of the patient’s perceptions and
thinking. In addition, the therapist may allow the patient to use
temporary displacements (transferential, projective or

introjective) (7). Education and information also strengthen the
patient’s ego by enlarging its scope.
In such therapy, the therapist may wish to use
extrapsychotherapeutic means. He should consider medication

and/or hospitalization to temporarily help the patient to control
his behavior, or to remove him from excessive stimulation which

may be contributing to a crisis reaction or stress and causing the
patient to decompensate. The therapist may also utilize family
and group approaches as adjunctive therapeutic measures. The

inclusion of the family can serve to reduce the stresses on
significant persons in the patient’s living situation, allowing them
to collectively participate in the establishment of a less conflict-

ridden environment.
With a supportive group approach, concrete efforts can be
made to reduce disturbances in interpersonal relationships by

providing information and direction with regard to everyday
problems of living. The multiplicity of transference opportunities

may be beneficial for the patient to test out more effective ways of
relating to others; he may also be directly trained in certain social
skills which can be rehearsed within the course of therapy, as

well as tested in outside real-life situations, and then reviewed in
subsequent sessions.
Finally, it is certainly possible in working with these patients

to tap intrapsychic conflicts and transference, as long as the
individual’s abilities and limitations are kept clearly in mind.
In conclusion, the prior section has elaborated upon two
hypothetical ends of a psychotherapeutic spectrum. These
alternate modes of intervention are by no means antithetical. In

actual practice these emphases should overlap and, in the best of
all possible therapeutic worlds, complement one another.
REFERENCES
1. Karasu, T. B. Psychotherapies: An overview. Amer. J. Psychiat., 1977, Vol. 131, No. 8.
2. Meissner, W. and Nicholi, Jr., A. The psychotherapies: Individual, family, and group. In:
Harvard Guide to Modern Psychiatry. Cambridge: Harvard University Press, 1978.
3. Karasu, T. B. Applied science of psychotherapy, visiting lecturer, grand rounds.

Ottawa University School of Medicine, Department of Psychiatry, November 23,
1977.
4. Chessick, R. The Technique and Practice of Intensive Psychotherapy. New York: Jason
Aronson, 1974.
5. Gill, M. M. Psychoanalysis and exploratory psychotherapy. J. Amer. Psychoanal. Assoc.,

1954, 2:771-797.
6. Glover, E. The Technique of Psychoanalysis. New York: International Universities

Press, 1955.
7. Tarachow, S. and Stein, A. Psychoanalytic psychotherapy. In: B. Wolman (ed),

Psychoanalytic Techniques. New York: Basic Books, 1967.
3
Brief and Emergency Psychotherapy1
Some Basic Propositions
Psychotherapy is basically a simple process of learning,

unlearning, and relearning, based upon 1) a sound theory of the
psychology of personality, 2) a set of hypotheses concerned with
the development of psychopathology, and 3) an interrelated

series of propositions concerned with optimal restructuring.
Using a general theory of psychology and a general theory of

psychopathology, the therapist attempts to help the patient to
restructure his past apperceptions from maladaptive ones to

more adaptive ones (1).
For psychoanalysts, the guiding propositions in trying to
understand a contemporary personality and its adaptive

problems center on the attempt to establish continuity between
childhood and adulthood, between waking and sleeping thought,

and between normal life and pathology. The entire attempt to
understand a personality and the problems in its functioning is
predicated upon establishing these continuities, finding common
denominators in the acquisition of apperceptive distortions, and

helping the patient attain better configurations.
Now, all this sounds basically simple and, indeed, it is a

simple process. Complications arise from the fact that the adult
patient, especially, has had years of accumulation of apperceptive

distortions. These apperceptive distortions interact with each
other so that they form configurations which are a Gestalt, a new
configuration which needs to be analyzed, i.e., broken down into

its previous components. Furthermore, aside from the basic
complexity of the personality, the burdens of psychotherapy lie in
the fact that much of pathological learning has started early, has
been often repeated, and has some primary as well as secondary
gains for the patient, which he may be reluctant to give up.
Therefore, psychoanalysis and psychotherapy are usually of
necessity drawn-out, long-lasting procedures of many years’
duration. The many cults and faddish quick-help methods, such as

scientology, dienetics, EST, primal scream, or a variety of
encounter groups, are unlikely to bring about fundamental
changes. The learning and relearning they provide usually rely on

the immediate effects of catharsis and on a kind of “permission”
to ease the superego and permit narcissistic behavior and, to

some extent, acting-out. These “therapies” provide, at best, some
short-lived relief.
It is understandable, therefore, that for a long time brief
psychotherapy, in general, was held in low esteem, especially by
psychoanalysts and other dynamically trained therapists. The

theoreticians cried of reductionism, and the practitioners thought
of it as merely supportive, or as comparable to providing
emotional band-aids.
Brief psychoanalytically conceived psychotherapy, however,
has genuine merit. It can, indeed, bring about some dynamic and
structural changes, often in as few as five or six sessions. To do
this, it has to be extremely carefully conceptualized and all
interventions have to be carefully planned for optimal effect. Brief

therapy can be effective because it is predicated upon very close
conceptualization of what ails the patient. The idea is to
understand everything, if possible, and then to do only the very
little bit that will make a difference. A very old story which
demonstrates this point: A general’s car broke down and army
mechanics were called to fix it. When they were unable to repair
the car, they turned for help to an old village smith. The smith
took a look at the car, rattled it a little and then banged it sharply.
Immediately, the car started up. The general asked, “What do I
owe you?” The village smith replied, “A hundred bucks.” “A

hundred bucks for one bang?” said the general. “No,” replied the
smith, “One buck for the bang, ninety-nine for knowing where to
bang.” That’s the way I see brief and emergency psychotherapy.

As a modality, I see brief therapy relating to traditional long-term
therapy the way a short story relates to a novel!
The process of brief therapy is aided by the fact that most
major psychopathological conditions can be understood in terms

of a basic set of hypotheses, as I point out below. What varies in
the individual patient’s psychopathology is the relative

importance and role that one or another factor plays, for instance,
in a depression. This determines the rank order of therapeutic
attention paid to each variable. This conception is not asking

more of the psychotherapeutic operation than one would of any
medical or surgical intervention. One can expect that a surgeon
approaching potential gall bladder surgery has a good grasp of

the general propositions involved in the anatomy, physiology and
pathology of the gall bladder and its surrounding structures, and

has a notion about the sequence of his interventions; he will
modify the operation only as the individual circumstances
demand.
Similarly, I expect that a psychotherapist dealing with

depression is aware of the fact that six, seven or eight factors may
play a dominant role: 1) problems of self-esteem; 2) aggression in

the presence of 3) a severe superego manifesting itself mostly as
intra-aggression; 4) a feeling of loss —of love, of a love object, or
part of oneself; 5) a feeling of disappointment, which Edith

Jacobson (3) has also related to a feeling of having been deceived;
6) instead of the narrower concept of orality, I like to speak of
stimulus hunger and the fact that the depressed personality tends
to be more dependent on positive input than other people;2 7) the
depressed personality, in a broader sense, is more dependent
specifically on narcissistic nutrients; 8) the outstanding defense

mechanism in depression is usually denial.
Though these are the main factors in all depressions, they
play a varying role in each depression. For instance, sometimes

problems of self-esteem may play the primary role, and insult to
the self-esteem is the primary factor in precipitating the current
depression. In other cases, a feeling of disappointment or

deception may have triggered aggression which, in the presence
of the severe superego, leads to intra-aggression and not only
depression but potential suicide.
In the brief psychotherapy of depression, it is important to

listen for the presence and role of these factors in the individual
patient, and to see the historical common denominators between

the precipitating situation and historical circumstances. By
vigorously working through the relevant factors with the
appropriate methods of intervention and sequence of methods of

intervention, depression, in my experience, lends itself very well
to brief psychotherapy most of the time.
As they do for depression, certain general propositions hold
true for the victim of any violence, be it mugging, rape or a violent

accident. A history of past experiences with violence will be
crucial or, more broadly, the specific personality structure will be
crucial. The new event will, to a large extent, be interpreted in
terms of the preexisting experience and personality structure.
Someone who already has a great fear of passivity will respond

differently from someone who has little. The particular
experience that brings the patient to us has to be brought into
relation to earlier insults to his or her integrity, such as violence

inflicted by older siblings, a parent, or others. The specific
features of the assault have to be brought into relation to specific
preexisting personality problems, be they fears of castration, a

problem of poorly defined self-boundaries, or other factors.
Presumably, the impact of the contemporary crisis has its
particular effect in terms of those preexisting problems and

produces in the patient a feeling of depersonalization, guilt or
panic, depending on the circumstances.
Therefore, in all instances, treatment consists of helping the

patient understand his symptomatology as an attempt to adapt to
his contemporary problem in terms of the past. This is often a
maladaptive anachronism, and we offer the patient better

problem-solving. It is, indeed, possible that the patient will
acquire new strength, and reconstitute with a better capacity for
tolerating certain stresses than he or she had prior to his
particular emergency. In a broader sense, one could say that the
brief psychotherapy permits a working-through of an old

problem and leads potentially to a better form of dealing with it
than existed premorbidly. In that sense, brief psychotherapy can
not only be effective for an existing problem, but may also lead to
truly better general integration. Elsewhere, we have described a
great number of problems and conditions which can be clearly

conceptualized and the treatment of which can then follow a
broad outline (2). This should not lead one to adhere to a rigid
program as if it were a train schedule. It should be considered as a

perspective with which to approach a patient and his problems
heuristically. One must remain flexible for finding the best
possible fit or be ready for a complete change of hypothesis

should circumstances call for it. In that way, the psychotherapist
is not in a different situation than the microbiologist who looks
through the microscope with a certain knowledge of cell structure

and certain expectations which help him see what is there.
Without having such a preconceived notion of what to look for
under the microscope, however, one would hardly be able to see
anything.
Based on such conceptions, I believe it is possible to listen
carefully to a detailed history in the first session, to formulate a
general treatment plan in terms of the general dynamics and

structure of the condition, and to make an individual plan for the
areas of intervention and methods of intervention suitable for the

particular patient. By areas of intervention I mean: in a
depression, I may choose to address myself in one patient to the
loss of self-esteem and only after that to his aggression, intra-
aggression and severe superego. In another patient, I may
primarily address myself to his severe superego and the intra-

aggression, and turn only later to orality and the feeling of
deception and other factors. The method of intervention may be

interpreting or any others on the list further below.
Methods of Intervention
1) Interpretation—While this is the classical method of
intervention in dynamic psychotherapy, it is by no means the only

one.
2) Catharsis certainly has its role to play even if it plays an

exaggerated one in such faddist therapies as primal scream and
others. The mistake is simply to believe that catharsis alone will

have a therapeutic effect, when the fact is that it is one form of
intervention which, by itself, is probably never enough.
3) Mediate Catharsis is a term which I like to use when I

express emotionally charged propositions for the patient. For
instance, with a depressed patient with a severe superego and a
good deal of aggression, I may say, “Certainly if the foreman had

done that to me, I would have kicked him.” In this instance, I am
expressing sentiments for the patient which might be too strong
for his sensitive superego but, by virtue of my saying them, I take

the superego responsibility for them. I hope that I also convey to
the patient that if an authority such as I, the therapist, can permit
himself such an aggressive thought, that it may not be so
unacceptable. Identification and introjection of the therapist as a
more benign part of the superego then play an important role in
this part of the therapeutic process. Other forms of indirect or

mediate catharsis: “Of course, a conscientious person like yourself
would not permit himself to think so, let alone to do it, but
somebody else might certainly feel like killing the son-of-a-bitch.”

By this statement, I give the patient a double message: 1) I
reassure him that he would never lose such control and that, as a
matter of fact, he is a person of strict conscience and 2) I convey

the idea that in this instance, such aggressive sentiments are not
inappropriate.
4) Reality Testing is the more necessary the more disturbed a

patient is, and the greater the need for the therapist to play the
role of an auxiliary reality tester, interpreting the patient’s
distortions of reality, and functioning as an auxiliary ego for him.
5) Drive Repression may play a role if we have a patient who

feels that he ought to be able to do as the Jones’ do, i.e., with
regard to promiscuity, but has reacted with a panic in such a

situation. I will flatly say—for instance, to an adolescent girl who
feels she has to engage in a certain amount of promiscuity in
order to have social standing in her high school—that she simply
should not. I will then help her to accept that she does not have to
be promiscuous in order to be accepted by her peers. By this
means, I hope to actually take a burden off her mind—or, at least,
to arrange for a pause in which she can reconstitute.
By selective inattention, one may sometimes discourage

some forms of behavior and encourage others, in effect bringing
about selective repression in the patient. It must be kept in mind,
however, that repression has a normal role to play in daily

functioning and that insufficient repression is, of course, as least
as much a problem as is excessive repression.
6) Sensitization to Signals is concerned with making the

patient aware that certain behavior on his part, be it acting out or
panic, occurs when there is a specific dynamic constellation. It

may not involve anything more sophisticated than pointing out to
a patient that she always has a flare-up with her husband in the
two or three days preceding her period.
7) Education might involve acquainting the patient with the

facts about sodium retention and irritability and advising her to
reduce her salt intake, etc. I might possibly prescribe a mild

sedative for the two or three premenstrual days to help avoid a
serious marital conflict.
8) Intellectualization plays a greater role in brief therapy

than in traditional longer term therapies. At times, I use it to
increase the therapeutic alliance. At other times, it is useful—for
instance, with a very panicky patient—to give him at least the
feeling of intellectually understanding his symptom—and with
this, at least some control over what otherwise seems to him

totally disruptive and ego-alien behavior.
9) Support in terms of the therapist’s accepting certain

feelings expressed by the patient, be they aggression, sexuality or
greed, makes it easier for him to bear anxiety. Making reassuring

statements has its role to play at certain times in therapy, but it
can never be all that is called for, if one expects to provide
something more than just ad hoc help.
10) Conjoint Sessions and Family Network Therapy are special

techniques which I cannot go into here, except to say that I use
them in connection with brief therapy in a very specific way. I try
to conceptualize very clearly what I want to accomplish in a joint

session, and then arrange for it to accomplish circumscribed
goals. In other words, it becomes one of the overall planned forms
of intervention, if the joint session seems to be the most
economical and most appropriate method, and I feel that it is

likely to lead to the best learning or unlearning experience for the
patient.
11) Psychoactive Drugs. See Enabling Conditions
The Therapeutic Process and the Therapeutic Relationship
Since I see all psychotherapy as a form of unlearning,
learning, and relearning, by insight, conditioning, and
identification-internalization, it is part of my conception of the

therapeutic relationship that it should provide and create optimal
circumstances for unlearning, learning, and relearning. This
methodology, of course, affects the therapeutic relationship as

defined within the terms of the 1)
transference/countertransference relationship, 2) the therapeutic
alliance, and 3) the therapeutic contract. I would like to discuss

these propositions within the framework of brief psychotherapy
as a chronological process.
The First Session
In the first session, I expect a great deal of work to be

accomplished. Of this, the establishment of the three aspects of
the therapeutic relationship is but one of the tasks.
1) Transference/countertransference relationship
To be sure, in the broad meaning of the term transference
relationship, the patient already comes programmed with certain

apperceptive distortions derived from the past, which he ascribes
to the as yet unknown therapist, e.g., by dreaming the preceding
night of going to the dentist. Certainly, more personal

transference/countertransference relations form as soon as the
patient and therapist meet in the waiting room.
As an integral part of establishing a relationship in the first
session, 1 expect to hear from the patient as complete a history as
possible, an exhaustive account of the patient’s current problems,

their onset and the life situation in which they arose. I consider
the history-taking reasonably complete only if I can see the
person now sitting opposite me at various stages of his

development in the concrete settings of the places he lived in and
their general cultural, ethnic and geographic aspects, and can
reasonably well relate his current chief complaint and the
dynamic situation surrounding its onset in terms of this past
history. In inquiring about precipitating events, I also ask

specifically why the patient happens to be here today. I include in
my questions almost routinely one concerning any dream the
patient might have had the night before the appointment, thus
hoping to get an idea of the preformed transference expectations.
In the course of the history-taking, a significant interpersonal
relationship is established, including positive or negative
countertransference features—more or less of a rescue fantasy on

my part, including cognitive closure and possible critical feelings.
For the patient, the intensive interest in his history is often a form
of narcissistic gratification. It conveys the genuine interest of the

interviewer and thus contributes to the establishment of a
positive transference.
At the end of the first session, I review the salient features of
the history and the complaint or problem which brought the
patient into therapy. I try to point out some common
denominators that one can easily perceive between the history

and the current problem, and the relationship of these factors to
me as therapist as expressed by the patient.
I consider it important to give the patient at least an

intellectual understanding of what his problem might be, thus
decreasing his feeling of helplessness and giving him the feeling
that whatever ails him can at least be understood and that I can
understand it. This further contributes to the development of an
interpersonal relationship between the patient and myself.
In order to get a meaningful history, I am not inactive in

eliciting it; I let the patient talk only as long as I feel the
information is immediately relevant and then redirect the

interview. It is part of my hypothesis concerning very close
conceptualization that I formulate some general notion of what
the dynamics and structure might be like and attempt to follow
up these heuristic hunches. I remain, I hope, flexible for altering

my notions as other data come in.
With the careful history-taking and my review of the salient

features, I create an atmosphere of compassionate empathy. This
has luckily remained entirely genuine because of my seeing life

somewhat in terms of a Greek drama, all of us being, to some
extent, helpless victims of circumstances to which we adapt in
various ways. I perceive my job as helping the patient to achieve a
little better adaptation than he had achieved before.
I also create some feeling of hope predicated upon my
understanding of the patient’s problems, mixing it with realistic

limitations as formulated in the statements concerning the
therapeutic alliance and the therapeutic contract.
To be sure, part of the therapeutic relationship involves

appropriate identification of positive and negative transference, as
in psychoanalysis or analytic psychotherapy, but this must be

adapted to the needs of brief therapy: This is, in essence, a matter
of style, where clear and often concrete formulation plays an
especially important role.
2) The therapeutic alliance
I introduce the therapeutic alliance with a specific formula:

“The rational and intelligent part of you needs to sit together with
the irrational unconscious part of you that causes you problems." I
may briefly explain the nature of the therapeutic process as I see

it, in the first or second session, to increase this alliance. I briefly
convey some basic ideas: The first idea is that we can understand
behavior if we understand that there is continuity between

childhood and adulthood, between waking and sleeping thought,
and between normal and pathological behavior. I illustrate this
fact with an example or two from the patient’s account. Dreams,
of course, are especially valuable for this purpose because they
show the relationship between the day residue, the dream, and
past history, and possibly something about the transference
relationship.
My second main explanation of the therapeutic process
involves an account of the acquisition of dynamics and structure

via apperception and apperceptive distortions and role
identification. I will compare the experiential process to the
laying down of thousands and thousands of transparencies, e.g., of

mother feeding, of mother cleaning, of mother punishing, fused
with pictures of other significant people in the patient’s life, and
suggest that his contemporary apperception of various figures is

structured to a greater or lesser degree by the Gestalten acquired
in the past.
I may at times use a Thematic Apperception Test (TAT)
picture and strive to demonstrate this phenomenon, especially
since I tend to use the TATs sometimes as a device for aiding

communication, interpretation and insight in the process of brief
psychotherapy; this is likely to happen in the second session or
the third session. The procedure is, of course, that I ask the
patient to tell me a story about what is going on in the TAT
picture, what led up to it and what the outcome will be; then I
point out common denominators in his responses, highly specific
features of his story as compared to some others that I can relate,
or some specific features, such as his not seeing the gun or the
pregnancy, etc.
I explain to the patient that the success of the therapy

depends to a large extent on the ability of part of him to work in
alliance with me. So as not to make patients feel overburdened, I
may add that their main job is just to talk and that it is mostly my
job to lead the way or to facilitate the rest of the process of
understanding. Many people are, of course, not accustomed to the
dissociative process that is involved in good analytic reporting

and giving what I call an “internal travelogue.” I frequently convey
the idea by relating the story of a delinquent who was being
prepared by a social worker for a consultation with me. When she

asked him if he knew what a psychiatrist was, he said, “Yeah,
that’s the guy who makes you squeal on yourself.” I explain to
patients that what is expected is that they squeal on themselves—

in a sense, tell things that they observe about themselves. If this is
difficult, I have them give a concrete account of their day and then
ask them what they thought at different points. I speak of starting
with an “external travelogue” and turn next to an “internal
travelogue.” I also have a standard set of questions that help

patients report and contribute their part to the therapeutic
alliance. I may inquire as to what they were thinking while
engaged in any number of semi-automatic tasks such as driving,

shaving, or putting on make-up. I may ask patients what the last
thought was that they had before falling asleep, and what they
first thought of upon waking up.
In this respect, I hold myself responsible for facilitating the
therapeutic process, which does not necessarily mean only making

it go. To the contrary, I consider regulating the flow of the
interview one of my crucial tasks, analogous to giving gas and

putting on the brakes when driving a car. Selective inattention to
some material, dilution by a little more general talking, or, on the
other hand, silence and interpretation of defenses, are some of the

main instruments I can employ to control the therapeutic process
as my part of the therapeutic alliance.
3) The therapeutic contract
During the first session, in addition to taking an extensive

history and establishing the basics of the transference
relationship and the therapeutic alliance, the therapist begins the

formulation of the therapeutic contract. As in so many other
respects, the therapeutic contract in brief psychotherapy is much
more clear-cut and specifically stated than it is in longer forms of
psychotherapy. I explain to the patients that I hope that we will be

able to deal with their problems in five sessions, each of them
lasting approximately 50 minutes, and that I shall want to hear
from them about a month after the fifth session, by telephone,

letter or in person, telling me how they are faring. I add that I
have reason to believe that five sessions may well be sufficient
and successful, but if it should turn out that they are not enough,
it will be part of my responsibility to see that the patient gets
whatever further therapy is necessary either by myself, or, if that
is impossible, by somebody else. I add to this that if I need to
transfer the patient to someone else, that second person will be

seeing the patient through therapy and that I will personally
introduce the patient to the therapist and, with his permission, sit
in on the first session, and, incidentally, give a brief account to the

other therapist in the patient’s presence. Of course, I also mention
that if there should be a real reason for contacting me before the
month is up following the fifth session, then the patient should by

all means do so. However, in order to interfere with the secondary
gain of continued transference feelings and dependence, I add here
that it is best to give the treatment process a chance; I quite

genuinely believe that often the treatment process opens up some
painful areas which are only partially healed by the time the
actual therapy stops. I convey to the patient that it is best to
permit the therapeutic process to come to its own conclusion

spontaneously and that it is best for the patient to try to give the
treatment results a chance to solidify rather than for him to call
me the first time anything disturbing is experienced, possibly just

because he feels abandoned. I thus try to convey—as part of the
contract—that I will continue to be interested and do whatever is
necessary, while I try at the same time to create a situation in
which the patient feels motivated to attempt to achieve optimal
results in the five sessions—in essence, by my conveying the idea
that the good patient gives up secondary gains and passivity.
Clearly, this is a situation which behavior therapists would
consider, appropriately, a matter of reward for giving up some

secondary gains.
In essence, this covers the establishment of the three aspects

of the therapeutic process in the first session of therapy.
Second Session
In the second session we explore further, get better closure
and reexamine the basis for choosing areas and methods of

intervention (2).
I attempt to strengthen the positive therapeutic relationship
—both transference and alliance—and interpret negative

transferences, watching for disappointment and negative
transference in myself as well as for excessive zeal. If possible, I
ask the patient at the beginning of the second session what he

thought about after he left the first session. I often refer to the
‘‘esprit d’ escalier”: As one walks down the stairs, one thinks of
things that one might have said and of things one might have
replied.
Furthermore, as a matter of routine, I ask the patient what he

dreamt the night after the first appointment and what he dreamt
the previous night, and I especially look for clues concerning the
therapeutic relationship. I get a high yield of dreams because even
after the patient tells me he didn’t have one, I ask whether he at

least recalls some feeling, or some word or picture, and
thereupon the patient will very often report an entire dream.
Aside from other therapeutic operations, I attempt to modify
the superego, the ego ideal and introject by lending myself as

modifier. I may tell anecdotes about myself or offer opinions,
contrary to the most customary procedure in psychoanalysis or
prolonged psychotherapy. I use vivid concrete stories to convey

certain ideas with colorful imagery, best delivered in an
understated way. For example, to attempt to make some
narcissistic behavior ego-alien, I might tell the story of Rothschild

and a poor bum who told him the heartbreaking story of his life.
As tears roll down Rothschild’s cheeks and he finally reaches for
the bell to summon the butler, the poor bum’s hopes soar. When
the butler appears, Rothschild turns to him and says, “Throw the
bum out; he’s breaking my heart.” Or I may illustrate self-harming
behavior by telling the story of the guy who stands in front of his
burning house laughing uproariously. His neighbor comes over

and says, “Hey, Joe, are you crazy? Your house is burning. How
come you’re laughing?” He says, “Oh, that’s okay, the bed bugs are
finally getting it!”
I consider it part of the technique of brief psychotherapy to

have a suitable style likely to facilitate optimal learning.
Third and Fourth Sessions
In the third and fourth sessions, more of the same

methodology continues. From the third session on I start
referring to the impending separation by mentioning to the

patient that there will be only two more sessions. I often predict
—in order to be wrong—that in response to this expected
separation the patient might even feel worse next time and that
this might be due to a fear of separation and a fear of
abandonment. Again, I will try to make this acceptable by talking
about the fact that so many people call a doctor late at night,
though they had some complaint most of the day, because
suddenly they become afraid that next morning might be too late
or that they may not be able to get hold of the doctor.
Fifth Session
In the fifth session, I review with the patient what we have
learned, and address myself to loose ends. Very often we learn of
some new aspects, despite all attempts to conceptualize in

advance. All work, however, is especially directed towards
aspects of the therapeutic alliance and the transference and
towards the reaffirmation of the contract as stated before.
I aim to terminate with a positive relationship. As mentioned
earlier, I also ask the patient to get in touch with me a month later
and let me know how he is faring. This is accompanied by the
statement that, of course, if the patient should have difficulties
before that time, he should by all means contact me. At the same
time, however, I caution the patient that the wish not to be

abandoned may make one call more readily than may be
necessary. There is some benefit in trying to go it alone rather
than be dependent. The patient is again reassured that if it turns

out that further therapy is necessary, it will be carried on either
by myself or by someone else, whom I will introduce to the
patient.
Enabling Conditions
At times, one may have to provide enabling conditions within

which the psychotherapeutic relationship can take place.
Psychotropic drugs may play a chief role in this. I have previously

written (2) of the various roles drugs may play for clinical
reasons, for metapsychological considerations, and, at times, for
physiological reasons. By clinical reasons, I mean that if a patient
is so crippled by agoraphobia that he cannot come to my office

when no one is available to come with him, I am likely to
prescribe enough medication to decrease the anxiety so that the
patient can at least come to the session without a companion.

Among the metapsychological reasons, I consider the prescription
of chlorpromazine if I feel that impulse control needs to be
improved in order to enable one to perform the
psychotherapeutic intervention. This holds true for some
psychotics. With them, at times, environmental intervention in the
life situation is necessary: If the patient’s sole contact with reality

is via a TV set and that TV set breaks down, I consider it essential
to see to it that his TV set is fixed promptly.
Returning to drugs specifically: I like to think of them as

enabling conditions for psychotherapy, very similar to the role
anesthesia plays for the surgeon. Sometimes they make
interventions bearable and create the field within which one can
intervene psychotherapeutically. One may stop the drugs as soon
as they are not necessary to carry on the psychodynamic
intervention.
Naturally, the role of drug giving has to be considered

dynamically and especially in terms of the transference role, but
generally they play a role in regulating the therapeutic process in

psychotherapy and psychoanalysis. For psychotics, this has been
described best by Ostow (5).
Some Administrative Aspects of Brief Therapy
I believe brief therapy to be useful in all settings—in private

practice as well as in clinics and social agencies. A measure of
improvement can be produced in acute conditions of all kinds,
even chronic psychosis. Naturally, longer therapies are indicated

for complex restructuring of personalities.
In public clinics, Leighton’s admonition, “Action on behalf of
one must be within the framework of calculations for the many”
(4, p. 110), is very appropriate. I cannot accept the fact that many
clinics and agencies have a year-long waiting list because only a
few patients are seen in long-term therapy. Upon inspection, this
therapy often turns out to be of poor quality because of

insufficient conceptualization of the process or simply lack of
therapeutic skill.
I urge the adoption of brief psychotherapy as the intake

procedure of choice. If used properly, this method avoids waiting
lists with their ensuing chronicity of pathology, and leaves

enough time for well-thought-out longer therapies when they are
indicated.
With regard to the indications for brief therapy: Instead of
selecting patients or diagnostic categories, I rather select the

treatment goals. In that framework, brief therapy can be useful for
virtually any patient for primary, secondary and tertiary
prevention. In the latter instance, for example, I have found it very

useful in the treatment of acute exacerbations of chronic
psychotics. In such cases, it may make the difference between
someone needing to be hospitalized, or being able to remain in

the community.
Brief Therapy as the Intake Method of Choice
There are at least two basic forms of intake for brief therapy
as the method of choice:
1) A Clinic Director sees all patients at intake, and then turns

them over to a staff member who is both available and
particularly likely to do well with a given patient.
2) Whichever staff member is free takes the next patient and

continues therapy.
Both methods have advantages and disadvantages. In the

first method, one advantage is that the presumably most
experienced person does the initial assessing. Also, if the
therapist chosen for the patient should become ill, go on vacation

or leave the position, the chief (director) can serve automatically
as auxiliary therapist to see the patient through, having already
met the patient and formed some relationship.
The disadvantage of this method is, of course, the
discontinuity: The first relationship is formed with the clinic head
and then another one with the actual therapist. To minimize the
problem of the transfer, I suggest that, at the end of the intake, the
director actually call in the person he has in mind to see the
patient through and, in the presence of the patient, run through

the salient features of the chief complaint, history, and whatever
understanding of the problem has been arrived at. At the end of
his presentation, the therapist would then ask some questions of

the patient and the clinic director. Thus, a dialogue is started
between patient and therapist, which ends with the setting of a
date for the next session.
The second method, where whoever does the intake sees the
patient through, has the advantage of direct continuity. Whatever

supervision is indicated can be obtained in the usual way, by
reviewing the case with a senior at any given time.
The disadvantage to this method is that there is no selection

process concerning the most suitable therapist for a given patient.
No one else is directly familiar with the patient in case the actual
therapist is not available. Above all, there may be an

administrative as well as a technical disadvantage: Many clinics
are organized with one M.D. as the bead, most of the other
therapists being psychologists or social workers. If the patient is

not first screened by the M.D. in charge, there may be a greater
chance of overlooking a medical condition which might play a
primary or secondary role in the patient’s complaints. In many
instances, medical screening may also be a legal requirement.

Furthermore, if the medical director has at least brief intake
acquaintance with the patient, he has a sounder basis for
prescribing psychotropic medication if it is called for later on,

rather than if he does so only on the basis of secondhand
information.
One rationale for brief therapy, which I see as five-session
therapy (with a sixth session as a follow-up a month later) is the
fact that statistics from outpatient clinics suggest that most
patients break off treatment after five sessions. Generally, people
are not attuned to the idea of long- range psychotherapy. Among
other things, they are accustomed to the medical model of usually

rather prompt and brief treatment. In view of this fact, it is better
to tailor-make therapy for the number of sessions the majority of
patients are actually likely to appear, rather than to plan long-

range therapy, which is too frequently prematurely interrupted.
Another basis for such time-limited therapy is the fact that
this temporal goal setting, as part of the contract, seems to work

well. It increases motivation, forces the therapist to conceptualize
clearly, and avoids the secondary gain of passivity and
dependence. Also, brief therapy can be offered to many more

patients than can long-term therapy, and it can be made available
very promptly, without the long waiting lists which cause
pernicious chronicity. Moreover, it may indeed free therapy time

for that percentage of patients who turn out to need longer
therapy and are both willing and able to engage in it.
Conclusions
Brief psychotherapy (when used in emergencies it becomes

emergency therapy) is a form of therapy with a status of its own.
When it is predicated upon a comprehensive theory of

personality, psychopathology and therapy such as psychoanalysis,
it can be effective for unlearning and relearning because of the
careful conceptualization of the dynamics and the process of
therapy itself. The aim is to understand “everything” and to select
carefully the few interventions which are likely to be crucially

effective. The therapeutic relationship, carefully defined, and
planfully utilized, plays an important role. Brief therapy is
probably the intake method of choice, at least for clinics. It offers

reasonable help to the largest number of those in need.
REFERENCES
1. Bellak, L. Once over: What is psychotherapy? Journal of Nervous and Mental Disease,
1977, 165:295-299.
2. Bellak, L. and Small, L. Emergency Psychotherapy and Brief Psychotherapy. New York:
Grune & Stratton, 1965.
3. Jacobsen, E. Depression: Comparative Studies of Normal, Neurotic and Psychotic

Conditions. New York: International Universities Press, 1971.
4. Leighton, A. H. An Introduction to Social Psychiatry. Springfield, Ill.: Charles C Thomas,

1960, p. 110.
5. Ostow, M. Drugs in Psychoanalysis and Psychotherapy. New York: Basic Books, 1962.
Notes
1 The author is greatly indebted to Helen Siegel, M.A., for her editorial assistance.
2 In speaking of the depressed personality, I have compared it often to the poikylotherm

in distinction to the homoiotherm. In the latter, there is something like an
emotional thermostat built into the psychic structure in the form of positive
introjects which provide a certain measure of love and self-approval, almost
independent of external circumstances. This is similar to the warm-blooded
animal which maintains its body temperature to a considerable extent even if
the temperature outside is higher or lower, in distinction to the cold-blooded or
poikylotherm.
APPENDIX:
SAMPLE INTERVIEW
Following is a transcript of an initial interview, which may
serve to illustrate some of my basic principles and methods. The

interviewee is a 30-year-old Vietnam veteran amputee who was
interviewed before an audience of 400 people, as part of a
seminar on brief therapy. These circumstances limited some

avenues of inquiry. All possible identifying characteristics have
been deleted and the interview was videotaped with the patient’s
permission.
Dr. Bellak: Would you be kind enough and tell me what brought you here in the first
place?
Patient: My marriage… Me and my wife separated due to problems of mine where I

became passive to the point where if she wanted to do something, I just
agreed with her to avoid arguments. When I was in Vietnam I had got
blown up by a mine. And I did a lot of things in Vietnam that I don't really
like myself for. And I’ve just become a mental pacifist because I'm afraid
that if I do get mad, of what I would do, because in Vietnam I had killed at
times due to various strenuous circumstances behind it, like having
several of my comrades blown away. Being put in a position where I had
killed…had done things that fell between being justifiable just to stay alive
and what is not. And I got to a point where I developed a resistance in
myself to the point where I would not love, would not hate. And it just got
to…got to the point where I just could not live in that atmosphere. I had to
let out some of the hate or some of the fear. Because I held myself to a
point where I did not love. You can’t love without hating.
Dr. Bellak: OK. That gives me a bit of an idea. It’s my job to ask you questions and try to
understand as much as possible. Under the circumstances, if there is
something that you don’t want to go into, that’s your privilege.
All right, you gave me a bit of a general background. Exactly when did you
come here. Do you remember the date?
Patient: December 10.
Dr. Bellak: December 10. What was the final push that got you here?
Patient: The final push was that I had been separated from my wife since July before I
came here, and from July to December my nerves had gotten to the point
where I drank quite a bit. And I’d be sitting at the bar and my hands would
be shaking to the point where I couldn’t control them. I’d crush a glass just
trying to hold them steady. My nerves ... I was afraid of violence. I was
having blackouts. My nerves were catching up with me.
Dr. Bellak: And what would you say made you that nervous? Between July and
December especially?
Patient: Not knowing whether I could live with me.
Dr. Bellak: That’s too fancy.
Patient: I was trying to make myself not love or hate. Totally blocked it all out. I got to a
point where I had no emotions. Didn’t feel.
Dr. Bellak: Where did you live at the time?
Patient: I had an apartment in Wallingford.
Dr. Bellak: Did you live by yourself?
Patient: I lived by myself.
Dr. Bellak: Still, there must have been something extra. Something that make you come
in here one day in December, after being upset all that while.
Patient: My wife had come in here before and basically she talked me into coming, with
the idea that they could give me some better answers.
Dr. Bellak: But was there something extra special that made you come in December
and not in July?
Patient: I had got to the point where I had left…when I felt that I could finance it
myself… Then by December, I had found out that I could not rationalize
some of the things I did by myself. When I was married, I had made myself
think that they were rational.
Dr. Bellak: Like?
Patient: Dealing with Nam. I was in several positions where we’d been hit. I worked on
what we called hunter-killer teams in Vietnam. You went out with one
other man. I went on five missions. Two missions I came back by myself.
Lost two men…friends of mine.
Dr. Bellak: So that was still really on your mind.
Patient: This was why I felt ... I had gotten to the point where I was afraid to love
anybody, for the fear of losing them. In Nam, we got attached to each other
very quick. All the guys I worked with. All the guys that worked with me. I
knew things about them that I didn’t know about my own brother, and
they knew things about me. And after losing so many people, I just refused
to get close to anybody… afraid to be close for fear of losing them.
Dr. Bellak: OK. Did you live all by yourself or did you see friends? From the time you
and your wife separated. ...
Patient: Matter of fact, from the time I was strictly by myself. For the first three or four
months.
Dr. Bellak: When did you actually come back from Vietnam?
Patient: I’ve been back a few years…from 1971.
Dr. Bellak: 1971. And the difficulties with your wife developed then?
Patient: I wasn’t married at the time.
Dr. Bellak: Oh, I see.
Patient: I was from New Year’s Eve till June 28th in the hospital. Just getting back
together… about six months…had one leg cut off…that a mine blew off.…I
basically got back or got home and my wife and parents had already sort
of set up the wedding arrangements. I didn’t know about it.
Dr. Bellak: But you knew the girl, I hope.
Patient: Yeah, I knew the girl. (Laughs)
Dr. Bellak: OK. (Laughs) I was thinking of some Japanese friends of mine where the
mother selects the girl.
Patient: I went from 210 pounds down to 105 pounds, during a period of being in the
hospital.
Dr. Bellak: In the hospital?
Patient: And there wasn’t too much arguing. I didn’t really want to fight or argue with
anybody anymore. And I still basically stayed that way.
Dr. Bellak: They arranged it and you accepted it? Is that what you’re telling me?
Patient: Yeah, we were good friends and we knew each other and had dated. Well,
really only about a month before I went into the Army, but I would have
postponed it awhile. Two or three months.
Dr. Bellak: Do I hear between the lines that if you had not been in your particular
shape that you might not have agreed to the marriage?
Patient: More than likely, because when I was in the hospital I didn’t even ask about it
and they were talking about it then. They waited a year…she waited ... we
waited ... to give me time to adjust to life and its problems.
Dr. Bellak: OK, so you agreed to go along with it, though. But what were your
misgivings? What were your doubts?
Patient: Well, much of my life I had been very athletic. I ran track the first year I was in
the Army. I had run cross-country. I didn’t know if I could accept not
running, not being able to go out and play. Basically, the thought of work ...
I could probably work as well as anybody, but I didn’t know if I could do
the other things in my life that always seemed to be so important to me.
Dr. Bellak: How did that affect the matter of whether you would or would not get
married?
Patient: I basically didn’t know if I wanted anybody else to support me that way and I
wasn’t sure that I even wanted to be that way.
Dr. Bellak: And then how did the marriage go?
Patient: Well, basically until the day I left, my wife felt that we had a great marriage. I
usually agreed to whatever she wanted to do. I really didn’t want to argue
for fear of being mad because I was afraid of what I might do if I got mad. I
just gave in and let her have her way. But it eventually just got to the point
where I started hating myself even more because I gave in to things that I
really didn’t want to do, really didn’t like.
Dr. Bellak: Could you give me some examples?
Patient: Well, like she was Catholic and I was Baptist. She never insisted that I go to
Church, but she always wanted me to and I, basically, the times I did go…
not really, I guess you’d say, under duress…but I really didn’t want to go.…
But I got tired of saying no.
Dr. Bellak: Other things? How about the conflict between you two?
Patient: Well, basically, I liked to horseback ride and I liked athletic things. I still do. I
like to water-ski and boat ride and every time I tried to get something that
we could do together, she was always afraid of it. Like just horses. I
bought two horses and she rode it about a hundred yards and stopped and
she got thrown off it and she never would get back on it. It aggravated me
that she would not try to do the things that we could do together. I just got
to the point where I thought about what I wanted to do and just did it by
myself.
Dr. Bellak: And towards the end, in July, what was the main point of the differences?
Patient: I had…we had drawn up blueprints for a house we were building and every
time I would get through with them, she decided that she wanted to
change things a little and we sent them back to the drawing board five
times. And I started to agree with her, just not to argue and basically it
wasn’t the way I would have liked. I know about houses because I used to
build them.
Dr. Bellak: Is that your field? What do you do?
Patient: A carpenter. I build furniture.
Dr. Bellak: That’s what you still do?
Patient: As a hobby. I’m basically military retired.
Dr. Bellak: OK, what would you say ails you most right now?
Patient: (Long pause) Now I can never get to the point where I like me.
Dr. Bellak: OK, let’s look into that. What is it, if you had to make a list, that makes you
dislike yourself the most especially?
Patient: I’m very closed . . . I’ve just gotten passive. (Starts to cry) You know, that’s not
my way normally. Normally I speak out, right? I’m very straightforward.
Dr. Bellak: So you dislike yourself for that. Having given in.
Patient: It got to the point where I didn’t like me for giving in all the time.
Dr. Bellak: OK, what else? Is that what still bothers you? Do you think about it?
Patient: Yeah.
Dr. Bellak: Today?
Patient: Yeah.
Dr. Bellak: Yesterday?
Patient: Yeah…Well, we didn’t talk yesterday.
Dr. Bellak: Are you and your wife still on talking terms?
Patient: We’re still on talking terms. I keep my kids on the weekend.
Dr. Bellak: But what of the things that you dislike about yourself kept running through
your mind?
Patient: I guess part of it is the fear of me. Not being able to control me.
Dr. Bellak: And then what would you do?
Patient: Rather than be around people where I would be put into a position where I
would be afraid that I would…I’d rather be by myself.
Dr. Bellak: I can understand that. But—and I know this is painful for you—but could
you try and spell out specifically what you are afraid of? Of doing?
Patient: Disintegrating. Just accidentally becoming mad.
Dr. Bellak: And then what would you do?
Patient: Killing somebody out of instinct rather than ...
Dr. Bellak: How? How?
Patient: With my hands.
Dr. Bellak: How?
Patient: There are several methods that the Army taught us.
Dr. Bellak: Which ones did you think of using?
Patient: There are certain areas. Like the person’s Adam’s apple. Taking your two
hands and breaking off the windpipe. And several methods of crushing a
man's ribcage and breaking his back. Hands over his neck, pull back. I had
caught myself twice going for a man’s throat when I had got angry.
Dr. Bellak: We want to understand. Could you be a little more graphic?
Patient: OK, the first time I was in a bar. Somebody else had come in (sighs) ... he was a
homosexual and made a proposition to me. And I got mad. If there weren’t
two guys in there that were friends of mine, and stopped me, I would have
killed him.
Dr. Bellak: How, in this case?
Patient: Well, I had grabbed him by his throat and had him up against the wall. I had
my hands around his throat (voice cracks), and I was trying to.…And the
other one. I had come into the bar and a man and another woman there
were arguing and I just went for him. I tried to kill him. I had him by the
inside of his throat rather than the outside…and this scared me to the
point where I refused to get mad. That happened in the first year after
coming back from the hospital. I got to the point where I just did not go
out and socialize with people at all. I just basically stayed home.
Dr. Bellak: And has it become better now?
Patient: I have more control now. Of my feelings. I can take and block everything out.
But also by blocking out, it leaves me in a situation where I have to fight
myself.
Dr. Bellak: Well, you described that very clearly—that empty feeling that is left after
you have tried to push away both love and hate. You made that very clear.
Do you have friends at this point?
Patient: I have about four people that I trust enough to call a friend.
Dr. Bellak: Guys?
Patient: Three are male, one's a female.
Dr. Bellak: What did you dream last night?
Patient: I don’t remember if I had a dream. I only dreamed twice since I came back
from Vietnam.
Dr. Bellak: Do you want to tell me those? Anytime that you feel too uncomfortable…
Patient: One was four years ago when me and my wife separated for awhile. I guess it
was the day after I had taken her back to Pittsburgh and left her with her
parents. I took the train back. That night…when I was in Nam I had gotten
hit several times while I was sleeping and I had gotten into the habit of
sleeping with a gun.
Dr. Bellak: By “hit” you mean attacked?
Patient: Yeah, while we were asleep. And I started dreaming about the day I was hit in
Vietnam. For some reason, something made a noise in the house and I
rolled out of bed and fired six times, blew six holes.
Dr. Bellak: In the dream?
Patient: No, really. And that was what scared me. I had rolled out of the bed. We were
sleeping on cots in Vietnam and I always had an M16 there and here I had
a .38 and when we got hit, I would roll out of the bed and start shooting.
Before I really realized I was not still in Vietnam, I had rolled out of the
bed and fired the gun six times till I flicked the trigger. And I blew six
holes in the side door of my house. Luckily there was nobody there.
Dr. Bellak: OK, that was the night after you left your wife off with her parents in
Pittsburgh.
Patient: Four years ago.
Dr. Bellak: And any others?
Patient: I had one while I was still in the hospital. Well, I had several of them that
reoccurred as the same dream. It was the day we were hit, going through
the minefield. The day I was hit I had 20 men on patrol ... 20 men…seven
of them were killed… and 12 of us came back amputees. Mutilated. One
leg…both legs…both legs and arms. And the dream was about the same
thing. About all the pain.
Dr. Bellak: Do you recall any dreams from your childhood?
Patient: When I was real young—about being attacked by a big gorilla. A bunch of
gorillas.
Dr. Bellak: Gorillas?
Patient: Being attacked by a bunch of gorillas. I think I had a habit of watching a lot of
Tarzan movies. That dream really stuck with me.
Dr. Bellak: OK, that tells me a little bit. You certainly have had a rough time. I just know
a little bit about it. I'm still a consultant to West Point and I was during
Vietnam so I saw quite a few people coming back and during World War
II, I just had enough of a taste of it myself to know what you’re talking
about. Nothing quite that drastic.
Would you be kind enough and give me a very brief capsule of your life
history?
Patient: I was born in 1948. I’m 30 years old. I lived in Philadelphia about until the
time that I got drafted in the service.
Dr. Bellak: Your family?
Patient: I have an older brother, and an older sister, and a younger sister.
Dr. Bellak: How much older is your brother?
Patient: My brother is two years older than I am. My sister is six years older than I am,
and my younger sister is six years younger than I am.
Dr. Bellak: And your parents? What kind of people are your parents?
Patient: They’re basically, from anybody else’s standpoint of view, very pleasant,
easygoing people. Which my father is in reality. My mother likes to put on
one face for everyone else and she really likes to bitch a lot.
Dr. Bellak: And what was her relation to you?
Patient: At times we had, or I had…problems growing up, where I had gotten into
trouble doing certain things in school.
Dr. Bellak: Two terms that I don’t understand. Problems growing up and getting into
difficulties in school. What does that mean?
Patient: In school, I had always been passive, but twice I had gotten into trouble for
fights.
Dr. Bellak: Passive meaning what?
Patient: Easygoing. I didn't like to fight, didn’t want to fight. Didn’t want to argue.
Didn’t want to be a bully. Didn’t—I tried to get along with people.
Dr. Bellak: I’ll remind you of that later, OK? But twice you got into fights?
Patient: And both times I felt that I was basically justified and then I was expelled from
school.
Dr. Bellak: Did you hurt the guys?
Patient: Not so that they had to go to the hospital. Just two black eyes, that’s all.
Dr. Bellak: OK (Laughs). What was the worst thing your mother ever did to you?
Patient: That fight—that time I felt I was justified in getting into that fight, when I got
home my father agreed with me, but yet my mother gave me a whipping
for it.
Dr. Bellak: How did she whip you?
Patient: With a belt.
Dr. Bellak: How old were you at the time?
Patient: The first time probably 13. The second time about 15.
Dr. Bellak: You were a pretty big guy.
Patient: Basically, it wasn’t that she could hurt me by the whipping. Just so that she
could hurt me inside. I leaned on her chair for her to do it. She didn't…
Dr. Bellak: She didn’t what?
Patient: She didn’t just whip me standing there. I basically ...
Dr. Bellak: So you sort of agreed to it.
Patient: Yeah…
Dr. Bellak: Was it with your pants? You wore your pants?
Patient: Without my pants.
Dr. Bellak: If you would describe—if you would apply three descriptive words to your
father, what would you pick?
Patient: (Silence)
Dr. Bellak: The first ones that come to your mind. Don’t make it too hard.
Patient: Passive, in terms of my mother. In comparison. Strong. Outgoing in terms of

everybody else.
Dr. Bellak: What does he do?
Patient: He’s retired now.
Dr. Bellak: What did he do?
Patient: We had a grocery store in Pittsburgh. Then when we moved to Philly, he and
my brother opened a construction company, which I worked with.
Dr. Bellak: And your mother? If you would describe her? You already said she was
bitchy. What else?
Patient: Two-faced. She was one way outside to everybody else and another way
inside. Incredible! She expected everyone to live one way and she wanted
to live another way.
Dr. Bellak: You got through high school?
Patient: Yes.
Dr. Bellak: And then what did you do between that and the Army?
Patient: The time between high school and the time I was drafted…Well, I left home
about six months before I graduated high school. The reason I left was
that I had a fight with my father and he slapped me. That was the first time
that he had beaten me up in five or six years. And I left because I was
afraid that I was going to hit him back. I wanted to hit him back…but I
loved him. (Starts to cry) I loved him but I wanted to hit him. That’s the
reason I left.
Dr. Bellak: Why did he hit you?
Patient: We had that grocery store down there. We worked there together in the
mornings. He had this habit of thinking that people were supermen. He’d
tell you ten things that he wanted you to do, come back in five minutes,
and think of two more things for you to do.
Dr. Bellak: I get the picture.
Patient: I think I was about 17. One day in the store I just finally told him that I couldn't
take it anymore, that I only had two hands and not four hands. And that’s
the first time I think I ever talked back to him. And he slapped me.
Dr. Bellak: So that was a good time to get into the Army?
Patient: I worked for a year and a half for an oil company, after high school and then I
got drafted.
Dr. Bellak: Let’s just think over some of the things that you’ve been saying.
Patient: Well, basically, what I didn’t like about the way I was living was that I had
gotten totally passive.
Dr. Bellak: If I can interrupt, if I may, I really didn’t ask you enough about your wife.
Would you just give me a very brief capsule. What kind of a woman is she?
Patient: My wife is 28, attractive. She has a different notion of what love is.
Dr. Bellak: What’s her background? Let’s stick to simple things.
Patients: Her background? After she got out of high school, she worked in a bank.
Dr. Bellak: What kind of family?
Patient: Her father is German, mother is Italian. And a lot of our problems stem from
them because they never showed any love of any kind to her. They totally
refuse—they ignore that sex exists. According to them, they don't know
how kids are born, they just hatched them. She did not understand that.
Her parents would never kiss in public or kiss openly or show any
affection of any kind. Totally closed, cold, no feeling.
Dr. Bellak: If you were to describe how her parents are different from each other, what
would you say?
Patient: Her father basically dominating, overbearing. Very tight with money. To the
point where I know there were times when I have seen her younger
brothers and sisters ask him for money, like a quarter to get a coke or
something, he would never let anybody see what he had, he’d turn around
and hide it and just take out a quarter.
Dr. Bellak: And her mother?
Patient: Her mother is like the father, basically.
Dr. Bellak: And your wife? If you could describe her briefly?
Patient: When we first got married, she was not basically aggressive. She was not
aggressive in any way. She was afraid of any kind of sex. She really didn’t
know how to show affection. Just blocks it away.
Dr. Bellak: And did sex remain a problem?
Patient: Yes.
Dr. Bellak: Ordinarily, I would go into it, but I don’t think we need to under the
circumstances.
But, now that you’ve rounded that out, did you mention children?
Patient: Yes, I have two girls.
Dr. Bellak: How old?
Patient: Five and almost two.
Dr. Bellak: How do you get along?
Patient: (Sighs) Both girls and me get along very well. I keep them every weekend—
Friday and Saturday.
Dr. Bellak: OK, let's go back to what you think we might have learned from what you
have told me so far. After all, my job is, among other things, to be of help
you.
Patient: (Silence).
Dr. Bellak: Well, let me make it a little bit easier. After all, I have a bit more
perspective. It's easier for someone standing away. Also, I’m supposed to
know something about it. Let’s see if we can agree on some things. Look,
what you complain about most and what brought you here is a fear that
your anger might get out of hand and that you might do violence. And you
have some very good reasons for it. Vietnam was a terrible experience. A
couple of times it almost got out of hand and you had some very
disturbing dreams, one of being hit and another in which you actually shot
your .38.
Patient: Yeah, and in the other dream—well they were the same dream but it was
when I was in the hospital.
Dr. Bellak: OK. Now, well curiously enough, when you told me your earlier history,
particularly with school, you started off by saying that most of the time
you were passive. Then a couple of times you beat up guys pretty badly.
Your whole concern now, and about the marriage, was that you were
being too passive. Feeling a great deal of anger, and the more you sat on it
because you were afraid that it might get out of hand, the more you felt
relief. As a kid, you had dreams of a gorilla going after you. And it scared
you.
Patient: Yeah, terribly!
Dr. Bellak: In a way, I see a little similarity between that anxiety dream of somebody
big, like a gorilla, doing you violence and the dreams of being hit, being
attacked.
Patient: Basically, they’re both about being attacked.
Dr. Bellak: That’s right.
Patient: They’re both forms of being attacked. One by an animal and the other by a
man.
Dr. Bellak: Yes. Whom did the gorilla look like, incidentally, in the dream? The first
thing that comes to your mind.
Patient: A big ape.
Dr. Bellak: Is it anybody you know?
Patient: No.
Dr. Bellak: All right. (Laughs).
Patient: Just looked like a big furry gorilla.
Dr. Bellak: So there is a certain continuity. While Vietnam undoubtedly made things
worse…
Patient: The fear of being attacked. The thought of it.
Dr. Bellak: And also, the whole axis turns around aggression, passivity. In school, you
say that you were passive most of the time, which is a curious way of
putting it. Not everybody would put it that way. And that continues
through your marriage, the closest relationship you have. You started out
by saying, if I remember correctly, that when your parents arranged it,
you were passive about it and agreed to the arrangement. When you
described your wife, you said that she was not aggressive. That seems to
be very much on your mind. You mentioned that she was not aggressive
and then that she got to be and bugged you with the constant changes
about the blueprints and different things. But at any rate, the point I want
to make is that to be aggressive or to be passive seems to be a thread that
runs through your mind very readily. It’s practically the main axis. Now,
then, what did you tell me about your parents that might have a bearing
on that?
Patients: Only that my father was passive with my mother.
Dr. Bellak: What effect might that have had on you? On your personality?
Patient: It made me where I almost did the same thing with my wife. Like the way my
parents continuously argued.
Dr. Bellak: If I put it in my vulgar way, I would say that you might have said to yourself
as a kid. “I'll be goddamed if I’m going to be a patsy to a woman the way
my father has been.” Is that right?
Patient: And I wound up doing the same thing. Either that, or I let myself get to the
point of doing the same thing.
Dr. Bellak: Either that, or at least it felt that way to you.
Patient: Right.
Dr. Bellak: What conclusions would you draw?
Patient: That I'm afraid of being like my father. Afraid of being pushed.
Dr. Bellak: OK, could I push that just a bit? That you're afraid of being passive. One of
the guys who got to you particularly was a homosexual in the bar.
Patient: Yeah. But I was only 21 at the time. I had never had relations with another
man. Never wanted to. Never.…
Dr. Bellak: So, if I may stretch things a little by implication—the idea that he would
think that you would be in any way interested in something not masculine
got you sore. That’s the point I want to make for right now. And how do
you think we could fit in that other time that you nearly got at the guy’s
Adam’s apple?
Patient: That was over a man striking a woman. I was brought up never to do that.
Dr. Bellak: Well, aside from the fact that . . . psychologically, what do you think it might
be? Look, you saw somebody attacked. When you and I see a car accident
on the highway, what do we do?
Patient: Stop and see if we can help.
Dr. Bellak: But if there is already an ambulance and a cop car there, what do we do
anyhow?
Patient: Stop and see if anybody was hurt.
Dr. Bellak: Yes, but usually everyone slows down a bit because you feel that “Gee, this
could happen to me. Maybe I shouldn’t drive so fast.” One identifies, as we
psychiatrists say, with the other person. Could there have been something
in that, when you saw the guy hit the woman?
Patient: Other than the actual fact?
Dr. Bellak: Well, I could be wrong, but what I wonder about in such a case, if one
doesn’t identify with the underdog. You don’t want to see her hit, because
you feel, “Damn, I don’t want to be hit.”
Patient: I don’t want to be hurt, but I don’t want to hurt anyone either.
Dr. Bellak: OK, let’s see if we can agree on a couple of things. One is that Vietnam was a
terrible experience. It might do all sorts of things to anybody’s…
Patient: (interrupts) People have to do a lot of things that they shouldn’t have to do.
Dr. Bellak: I know, but this might just have made more of an impression on your
personality because you had already been concerned with a fear of being
attacked, as witnessed in the dreams about the gorilla, a recurrent dream
in your childhood. You felt that you had to stand up against your mother,
about whom you had understandably mixed feelings. Mixed feelings. You
bent over the chair and let her whip you, but at the same time you must
have been full of a hell of a rage.
Patient: Anger, because I didn’t understand why. I felt that I was justified in what I did.
Dr. Bellak: Well, among other things ... So that you came with that pattern. Vietnam
made it worse. Then you had the feeling that you let yourself be shoved
into a marriage. You started out with a bit of a grudge and misgivings that
you had let yourself be shoved. And then, very promptly, saw yourself in a
situation and a relationship that seemed too much like the one you saw
between your father and mother.
What does it add up to? If you and I would just change chairs mentally and
you were the psychiatrist, what would you think of all the things you have
heard today?
Patient: As far as the marriage?
Dr. Bellak: No, as far as understanding what is going on with you.
Patient: What’s going on with me?
Dr. Bellak: Yes, and what we might do about it.
Patient: (Silence)
Dr. Bellak: Well, in view of the fact that we see that some of the same problems that
trouble you now and troubled you in your marriage existed in some form
in your youth, in your earlier life, what do you think you and your
therapist might work on?
Patient: Getting me to the point that I can, basically, release enough of myself to feel.
Dr. Bellak: How do you propose to do that?
Patient: The only way I can do it is to learn not to be afraid of reaching out and of being
hurt.
Dr. Bellak: Is there another way? Obviously, what ails you now has its origins in
childhood. Getting to understand the fact that many of the things that
happened to you as a kid make Vietnam much more difficult for you to
absorb and digest and to deal with now—and they still have an effect on
you today, the things that happened to you as a child. The better you can
understand to a certain extent how you either overemphasize or even
distort some of the things that happen to you now because you were
already primed in childhood— the gorillas and all that—the less you are
going to feel that rage. I think that rage has been there since childhood,
and got an extra shove from all the things in Vietnam. I don’t know if you
could have married any woman…
Patient: At that point.
Dr. Bellak: At any time, and not come with the same set of expectations. “I better watch
out that she is not a battle-axe who shoves me around.” Because that is
what you were accustomed to. So, the more you work on that, on
understanding your current feelings in terms of your early past, with
Vietnam just thrown in psychologically for good measure, the better able
you will be to handle the tensions that you have, which just seem to be all
along a matter of passivity, aggression—really, apparently, the axis
around which your life revolves. Some people have that problem even
without Vietnam if one has had that childhood. That’s one thing. The more
you can go into that, the better.
Would you like to hear my guess about who the gorilla was in the dream? I
bet you can make a pretty good guess. Can you tell me? The first person
who comes to your mind.
Patient: My mother.
Dr. Bellak: Oh, sure. And I bet if we could go into the dream in enough detail, we could
find things that would identify her. And I think that she is even sometimes
identified in your mind with some of the Vietnamese.3 Well, it gets a bit
complex. But those are some of the things that you two can continue to go
into. Meanwhile, I’m sure you use whatever athletics you can to get rid of
some of the tension. I think that’s a very good short range measure. Like
punching a bag.
You’re right-handed, I take it.
Patient: Yes.
Dr. Bellak: Never were left-handed?4
Patient: No.
Dr. Bellak: Well, I think that’s probably as much as we can go into now I feel, having
seen problems similar to yours before, that there is a good deal of hope
that the two of you—you and your therapist—can really work this out.
You know, there’s not anyone so tough that he doesn’t have some
passivity. I don’t care how tough the guy is.
Patient: Basically, I’m not afraid of being passive. The problem is that usually I get too
passive.
Dr. Bellak: Well, in part I guess you had to because with your mother…and then that
made you feel like nothing and you had to get really angry. So, if you two
can work it out so that you neither feel too passive nor the need to feel too
aggressive, I think that things should work out very well.
Thank you very much again. I really appreciate that you were willing to
discuss things.
Patient: Thank you very much.
REFERENCE
1. Bellak, L. Adult psychiatric states with MBD and their ego function assessment. In L.
Bellak (Ed.), Psychiatric Aspects of Minimal Drain Dysfunction in Adults. New
York: Grune & Stratton, 1979.
Notes
3 The ideal concise interpretation I should have made here is: “I think all you did was to
replace the gorillas with guerillas."
4 This was just a brief notion that the patient’s problems with impulse control might be
related to any aspect of minimal brain dysfunction. I discuss this more fully in
another book (1).
4
Enabling Conditions for the Ambulatory

Psychotherapy of Acute Schizophrenics1
The psychotherapy of acutely disturbed schizophrenics can

be one of the most rewarding of therapeutic experiences. It is
frequently possible to effect a dramatic loss of symptoms and

general improvement of the acute manifestations of the disorder
rather promptly. It often enough holds true that after the acute
phase has been successfully dealt with, there remain the
characterological features which are of complex nature and that
often require prolonged and patient treatment. The present

discussion, however, addresses itself only to the circumstances
necessary for the treatment of the acute phase of a schizophrenic
episode.
Certainly, the first question that must arise in the treatment

of an acutely disturbed psychotic on an ambulatory basis, in the
private office, social agency, or a clinic, must be whether a patient

is suitable for this type of treatment.
Therefore, I want to address myself to the necessary
conditions, the conditions that enable one to perform ambulatory
psychotherapy with acute schizophrenics. If the enabling

conditions outlined cannot be met, ambulatory psychotherapy
may not be advisable, and an alternate mode of treatment may be
indicated.
1) A Reasonably Cooperative, Non-assaultive Patient
One of the most obvious enabling conditions is that one has

to have a reasonably cooperative, non-assaultive patient. By
reasonably cooperative, I mean that he at least comes to the

session or is willing to be brought by a third party. However, it
may be possible to start psychotherapy with a patient who is
unwilling to come to therapy. Sometimes it is necessary to visit

the patient in his own home, at least to initiate therapy. When this
is not possible or feasible, an effective means of getting an
unwilling patient to the office is to instruct a family member to
ask the patient to accompany him to see the psychotherapist for

his—the relative’s—own sake. It is usually true enough that the
relative is deeply concerned and upset, and is being sincere when
he tells the patient that he wants some help for dealing with some
of his own problems. Often the patient is then willing to come
along as a mute companion. The initial exchanges are all between

the therapist and the patient’s relative. It must be part of the
therapist’s skill to eventually engage the patient until he or she
slowly becomes the main interactor and ultimately the sole one.
One other possibility of engaging a patient in treatment, if the
above procedure is ineffectual, is to engage in mediate

interpretations. If a patient refuses to come by himself or even
with a companion, as described above, it may be possible to learn

enough about the psychodynamics of the patient from the relative
to suggest statements or interpretations which the relative can
then relay back to the patient. If, in turn, the relative reports back
to the therapist, he can be used to mediate the therapy in such a
way that the patient might be affected beneficially enough to a
point where lie is willing to come for treatment with the relative
as companion. Then the therapist can proceed as above.
The fact that many schizophrenics may start out mute or
barely communicative is no contraindication to therapy. Even

potential assaultiveness need not be a contraindication, provided
one sets up certain conditions which I will discuss later, with

regard to certain precautions and the possible concomitant use of
drugs. Of course, I include patients in ambulatory psychotherapy
who are often actively deluded and hallucinated. Most of us are

aware of the fact that in many patients extensive delusions and
hallucinations need not necessarily interfere in seemingly normal
social behavior. There is many a patient who thinks he is Jesus

Christ or believes he can understand what the birds are saying,
but nevertheless may continue to hold a skilled job and arrive
punctually for each of his appointments. Although some patients
may not be well enough to come on their own by car or bus, they
may still profit from ambulatory psychotherapy, if someone

brings them to the therapist’s office.
The premise is that, whenever possible, it is better to avoid
hospitalization, provided the patient is not actively homicidal or

suicidal or so disturbed as to do harm inadvertently. The fact is
that very little competent psychotherapy is offered in any
hospital. In university-affiliated institutions, residents are usually

the ones directly treating the patient, even though under
supervision. Though they may be competent, the fact is they are
still at an early stage of their training. In private institutions, there

are usually not enough psychotherapists available, or else the
therapists available are of questionable competence. The cost of
hospitalization often approaches $100,000 a year. In addition,

regression and secondary gain from being cared for (“nursed”)
produce other problems. Very frequently, the patient’s reentry

into the community, if it is not extremely skillfully handled, starts
a new flare-up.
2) One Stable Relationship in the Patient’s Life
Less obvious and less generally considered is the almost
absolute need for at least one stable relationship in the patient’s

life situation—at least one person, such as parent, spouse, child,
close friend—anybody whom one might turn to if the
circumstances should warrant it. The therapist must be able to
talk to somebody who is willing to keep an eye on the patient at
home, because of concerns about suicide, or other potentially

harmful situations; someone who can take a helpful role if the
patient should require hospitalization, or can otherwise serve as a
constructive influence in the patient's life. Without at least a

single stable person close to the patient, I have found through
bitter experience that one may be left with almost impossible
situations, more responsibility than one can reasonably handle,

and with less safety than is essential for the treatment situation.
3) A Close Relationship with a Nearby Hospital
The third enabling condition for anybody who wants to treat

rather acutely disturbed psychotics is that one have a close
relationship with a nearby hospital, including a general hospital
willing to take psychiatric patients. It is essential in treating acute
psychotics that one be willing to take reasonable risks. Those

reasonable risks include the possibility that some patients will
become more disturbed in the course of treatment, either for
adventitious reasons or for reasons intrinsic to the treatment.
The therapist can engage in psychotherapy with acutely

disturbed people only if he feels safe enough. He needs an
arrangement which permits almost instant hospitalization of the

patient, should the need arise. At times, even only two or three
days of hospitalization can make a crucial difference. This
provision certainly helps to give one more therapeutic freedom
with less anxiety for patient and therapist. The hospital provides
some immediate protection for the patient and gives the therapist
freedom to engage in interventions which might possibly be
upsetting to the patient.
Though therapeutic freedom sometimes has to include

interventions which might prove unnerving to the patient, I do
not believe in inducing regressions intentionally: I am not certain
that therapeutically induced regressions and dissociations may

not lay the foundation for easier regression and dissociation at
other times, and therefore do not consider them a desirable
therapeutic modality.
However, I do believe in such active steps as cathartic
interpretations, i.e. interpreting unconscious material directly a la

John Rosen (3), without waiting until it becomes preconscious, as
is more customary in the treatment of less disturbed people.
Aside from the importance of having easy access to a

hospital, it is extremely desirable that it be a hospital setting in
which one can continue to see and treat one’s own patient while
he is there. This type of situation is often difficult to attain

because teaching hospitals always insist on having only their
residents and staff treat patients. In view of this fact, proprietary

hospitals, which may be otherwise less desirable, are to be
preferred. While the patient is hospitalized for an acute disorder,
actively deluded and hallucinated, one can make crucial
interventions which will speed up the therapeutic process greatly.
Of course, it is also essential that the patient has a sense of not
being deserted, so it is extremely beneficial when there is

continuity of contact. Therefore, anyone who wants to engage
frequently in the treatment of acutely disturbed psychotics has to
cultivate a close relationship with a hospital that will permit him

quick hospitalization and continued care of his own patient, both
psychotherapeutically as well as psychopharmacologically.
Another aspect which may be even more difficult than the

first two with regard to hospitalization is that it must be possible
to get one’s patients released from the hospital as promptly as
possible. Ordinarily, administrative procedures may make it

difficult to remove a patient from the hospital speedily. Yet, those
patients who are suitable for ambulatory psychotherapy could
especially easily be harmed by excessively long hospitalization

which induces passivity and secondary gains from the hot-house
conditions of support and external controls.
4) A Family Network
This point is really an elaboration of the second one, namely

the requirement that there be at least one person whom the
therapist car. address himself to, who will take some
responsibility for the patient. If there is a whole family network

available, this may play a crucial and beneficial role. Family
network therapy has a definite and well-known place in
treatment. Especially if inter-family pathology plays a marked
role, it is essential to draw other family members into the

therapeutic situation. This may be accomplished in different
ways. Indeed, one may choose to engage in either conjoint
therapy with one other family member, or in family therapy per

se. Under certain circumstances, the original therapist may wish
to work with the entire family himself. In other instances, it may
be more suitable to have other family members, or even the

entire family, seen by another psychiatrist or social worker or
psychologist. The two therapists must have the privilege of
conferring with each other, so as to work as a team, even if not

necessarily under the same roof.
5) An Auxiliary Therapist
The above point brings me to one of the less well-known and
less practiced techniques, and that is the desirability of utilizing

an auxiliary therapist, i.e. having two therapists treating the same
patient simultaneously. The auxiliary therapist may be drawn in
only during particularly stormy episodes. These may be due to an

especially acute transference psychosis, or at times to a particular
countertransference problem on die part of the therapist. Then
the role of the auxiliary therapist is to deal specifically with the
transference psychotic phenomenon which may be too difficult
for the patient, and maybe for the primary therapist, to handle
directly. Meanwhile, the primary therapist continues to work on
the problems that produced the acute transference psychosis.
Dyadic psychotherapy, especially in an office, can be a very

lonely type of endeavor, fraught with all sorts of emotions,
including anxiety for both therapist and patient. Therefore, it is

often very useful to have, as a routine proviso, an auxiliary
therapist who can dilute the transference and
countertransference, if necessary. If one routinely works with

acutely disturbed psychotics, it is often useful to introduce an
auxiliary therapist early in the relationship, explaining to the
patient that this colleague will be available should the primary

therapist catch a cold, go on vacation, or otherwise be
unavailable. Such availability, of course, is crucially important

with the most highly disturbed people. This kind of arrangement
is made more easily in a clinic or social agency than in private
practice, but it is not impossible in the latter.
6) Awareness of Family and Community Resources
Especially for psychiatrists in private practice, it is important

to be aware of all possible resources in a patient’s life (relatives,
friends, etc.) and in the community. Social workers and

psychologists are more likely to be aware of these social support
systems, such as social agencies, rehabilitation facilities, halfway
houses, recreational facilities, and eventually vocational
rehabilitation. It is important to make use of these facilities
during treatment and certainly towards the end of treatment,
when the patient needs a setting in which he can continue his
improvement and recovery.
7) Hot-lines and Emergency Centers
A variation on the theme of having access to an auxiliary
therapist is the need to have easy access to hot-lines and

emergency centers. Most communities, at this point, do have such
services available, as part of their community facilities. These
emergency services are usually listed on the inside cover of the

phone book and, when they are properly administered, are
accessible 24 hours a day. The telephone contact should be
backed up by an available psychiatric emergency center in a clinic

or social agency and, if possible, a mobile team which can visit a
patient in his home and, in an extreme situation, commit and
hospitalize him.
8) Do Not Be a Hero
I consider it extremely important to have easy access to an

alarm system, in case a patient should become acutely disturbed
and possibly dangerous. The ability to treat acutely disturbed

people depends as much on the relative security of the setting
within which therapy takes place, as on the therapist’s capacity to
tolerate feelings of anxiety and discomfort. Under any

circumstances, it is essential not to be inappropriately heroic. The
therapist should never allow situations to exist which are unduly
dangerous in terms of his own safety. An anxious therapist can
certainly not function effectively. An unsecured setting also

makes the patient uneasy, because he may well fear his own
possible loss of impulse control. Especially in large and active
emergency treatment centers, it is best to have security personnel

available. In settings which are less likely to have extremely
disturbed patients, it is advantageous to have an office which is
not located in too isolated a setting. It may be helpful to leave the

door slightly ajar, provided that reasonable privacy is still
retained. Again, such a provision is often also of benefit to the
patient, who feels less frightened of the therapist and of his own
impulses, when he perceives the situation as relatively secure.
9) Housing Situations
This point deals with a very difficult problem—the suitability
of the patient’s housing situation: namely, where the patient lives

and where he or she should live for optimal improvement. The
family setting is often extremely unhealthy and it may be almost
impossible to do constructive therapeutic work in two or three

hours a week if the remainder of the time there are forces within
the family setting which are regressive and pathogenic. Therefore,
it is often essential, and certainly a major enabling condition, that
if his present living situation is unsuitable then the patient must
be moved to another setting. At first glance, this often appears to
be impossible. I strongly suggest a very careful survey of all his
relatives, friends and community resources, in an attempt to find

a place for the patient to live and to sleep other than with his
immediate family, if they are acutely pathogenic. If there are no

appropriate relatives or friends, then foster homes or even half-
way houses may be preferable, even though these facilities are
often deleterious in their own way.
I cannot stress strongly enough the importance of proper

living situation for the patient, in order not to have the
therapeutic process be more difficult than is necessary, or even to
be ineffective. I have found this factor, namely a healthy setting, to

be so important, that if a patient of mine had a suitable family
member living in another state, I was in favor of the patient

moving to that other state, living with that family, and continuing
with another therapist rather than myself.
10) Drugs
Finally, the use of drugs has to be mentioned as one very

important enabling condition for engaging in psychotherapy with
acutely disturbed psychotic patients. My favorite analogy of the
role of medication in psychotherapy is that a drug plays the same

role in facilitating the psychotherapeutic operation as an
anesthetic does for a surgical intervention. It enables the doctor
to engage in the often painful but necessary interventions, and
still have a cooperative patient. Before general anesthetics were
available, it was not only excessively traumatic, but often fatal, to
perform an abdominal operation without properly relaxed
musculature. A similar situation holds true for some

psychotherapeutic interventions. Interpretations may be
extremely painful and distressing for a patient—indeed, more
than he can bear. This may provoke an episode of violence to

himself or others, and lead to a more acute psychotic state. In
other instances, without the benefit of psychotropic medication,
the patient may be generally too anxious, too withdrawn, or too

depressed to be either willing or able to communicate. Some
patients may be terrified of approaching particular subject
matters, material which it is crucial to air and analyze. In such

instances, drugs can be used to decrease “approach anxiety” or, as
in the case of antidepressants, provide the patient with the
“energy” to relate.
Caution must be observed not to medicate a patient to a
point where most ego functions are interfered with and reality
testing and the sense of self have been unduly affected by the
psychotropic drug (1). It is undesirable to have a patient who
feels foggy or “spaced-out”—so lethargic as not to have any

motivation for psychotherapeutic work. But it is, in fact, possible
to choose one’s drugs in such a way that some ego functions are
improved, thereby facilitating the therapeutic process.

Improvement of impulse control, e.g. of aggression, may be
accomplished with lithium or phenothiazines. The latter may also
improve thought processes, helping the patient to think logically
and reason deductively—skills basic to his understanding

therapeutic interpretations.
Summary
Before initiating therapy with acutely disturbed

schizophrenics (and other psychotics), it is not only necessary to
make a diagnosis in the narrow sense of the word, but also
extremely important to evaluate all assets and liabilities in the

patient’s life situation. All difficulties which are likely to emerge in
the process of treatment should be carefully assessed and
planned for (2). Such accurate assessment and treatment design
can serve to eliminate a great deal of trouble, waste and even
tragedy.
However, if at least the minimal enabling conditions outlined
above are met, the ambulatory treatment of acutely disturbed

schizophrenics and other psychotics may be a truly rewarding
experience for both patient and therapist. In most instances, after
the acute condition has been dealt with, it is desirable to engage
in extensive psychoanalytic psychotherapy in order to deal with

the patient’s subtle structural, dynamic and characterological
problems.
REFERENCES
1. Bellak, L., Hurvich, M., and Gediman, H. Ego Functions in Schizophrenics, Neurotics,
and Normals. A Systematic Study of Conceptual, Diagnostic, and Therapeutic
Aspects. New York: John Wiley & Sons, 1973.
2. Bellak, L. and Meyers, B. Ego function assessment and analysability. The International
Review of Psycho-Analysis, 1975, 2:413-427.
3. Rosen, J. Direct Psychoanalytic Psychiatry. New York: Grune & Stratton, 1962.
Note
1 The author is greatly indebted to Helen Siegel, M.A. for her editorial assistance.
5
Psychotherapy with Borderline Patients:

An Overview
Otto F. Kernberg, M.D.
Review of the Literature
The main question raised in the literature on intensive
psychotherapy with borderline conditions is whether borderline

patients can be treated by psychoanalysis or whether they
require some form of psychotherapy. Intimately linked with this
question is the delimitation of what is psychoanalysis and what is
not.
Gill (13, 14) has clarified this issue in delimiting classical

psychoanalysis from analytically oriented psychotherapies. He
states that psychoanalysis, in a strict sense, involves consistent
adherence by the analyst to a position of technical neutrality (and

neutrality, he rightly states, does not mean mechanical rigidity of
behavior with suppression of any spontaneous responses). He
believes that psychoanalysis requires the development of a
regressive transference neurosis and that the transference must
be resolved by techniques of interpretation alone. In contrast, Gill
further states, analytically oriented psychotherapies imply less

strict adherence to neutrality; they imply recognition of
transference phenomena and of transference resistance, but they
use varying degrees of interpretation of these phenomena

without permitting the development of a transference neurosis,
and they do not imply resolution of the transference on the basis
of interpretation alone.
Eissler (8) has further clarified this issue in his discussion of

the “parameters of technique,” which imply modifications of the
analytic method usually necessary in patients with severe ego
distortions. He suggests that the treatment still remains

psychoanalysis if such parameters are introduced only when
indispensable, not transgressing any unavoidable minimum, and
when they are used only under circumstances which permit their
self-elimination, their resolution through interpretation before
termination of the analysis itself. Additional clarifications of the
differences between psychoanalysis and other related
psychotherapies can be found in papers by Stone (69), Bibring

(3), Wallerstein and Robbins (78), and Wallerstein (75,77).
From the viewpoint of Gill’s delimitation of psychoanalysis,
authors dealing with the problem of the treatment of borderline

conditions may be placed on a continuum ranging from those who
recommend psychoanalysis, to those who believe that
psychotherapy rather than psychoanalysis, and especially a
supportive form of psychotherapy, is the treatment of choice.
Somewhere in the middle of this continuum there are those who

believe that some patients presenting borderline personality
organization may still be analyzed while others would require
expressive psychoanalytic psychotherapy; also there are those

who do not sharply differentiate between psychoanalysis and
psychoanalytic psychotherapy.
The early references in the literature to the therapeutic

problems with borderline patients were predominantly on the
side of recommending modified psychotherapy with supportive
implications, in contrast to classical psychoanalysis. Stern (67,

68) recommends an expressive approach, with the constant focus
on the transference rather than on historical material, and with
constant efforts to reduce the clinging, childlike dependency of

these patients on the analyst. He feels that these patients need a
new and realistic relationship, in contrast to the traumatic ones of

their childhood; he believes that such patients can only gradually
develop a capacity to establish a transference neurosis similar to
that of the usual analytic patient. Schmideberg (63) recommends

an approach probably best designated as psychoanalytic
psychotherapy.
Knight’s (39, 40) important contributions to the

psychotherapeutic strategy with borderline cases lean definitely
in the direction of the purely supportive approach, on one
extreme of the continuum. He stresses the importance of
strengthening the ego of these patients, and of respecting their

neurotic defenses; he considers “deep interpretations dangerous
because of the regressive pull that such interpretations have, and
because the weak ego of these patients makes it hard enough for
them to keep functioning on a secondary process level. He
stresses the importance of structure, both within the
psychotherapeutic setting and in the utilization of the hospital

and day hospital, as part of the total treatment program for such
patients.
At the other end of the spectrum are a number of analysts

influenced to varying degrees by the so-called British school of
psychoanalysis. These analysts believe that classical
psychoanalytic treatment can indeed be attempted with many, if

not all, borderline patients. Some of their contributions have been
of crucial importance to the better understanding of the defensive

organization, and the particular resistances characteristic of
patients with borderline personality organization. Despite my
disagreement with their assumption about the possibility of

treating most borderline patients with psychoanalysis and with
many of their theoretical assumptions in general, I believe that
the findings of these analysts permit modifications of

psychoanalytic psychotherapies specifically adapted to the
transference complications of borderline patients. I am referring
here especially to the work of Bion (4, 5, 6), Khan (37), Little (42,
43, 44), Rosenfeld (60, 61, 62), Segal (65), and Winnicott (79, 81).
In this country, Boyer and Giovacchini (7) also recommend a

nonmodified psychoanalytic approach to schizophrenic and
characterological disorders. Although Giovacchini, in chapters

dedicated to character disorders, does not refer specifically to
borderline conditions (in contrast to severe character pathology
in general), his observations focus on the technical problems

posed by what I think most authors would consider patients with
borderline conditions.
Somewhere toward the middle of the spectrum are the
approaches recommended by Stone (70) and Eissler (8). Stone

feels that borderline patients may need preparatory
psychotherapy, but that at least some of these patients may be

treated with classical psychoanalysis either from the beginning of
treatment or after some time to build up a working relationship

with the therapist. Stone also agrees with Eissler that analysis can
be attempted at later stages of treatment with such patients only
if the previous psychotherapy has not created transference

distortions of such magnitude that the parameters of technique
involved cannot be resolved through interpretation. In following
Eissler’s and Stone's approaches, various authors in this country

have recommended a modified psychoanalytic procedure or
expressive psychotherapeutic approach to borderline patients
that has influenced and is related to my own treatment
recommendations that are outlined below.
Frosch (10, 11) has spelled out the clinical approach to

borderline patients within a modified psychoanalytic procedure,
and summarized his overall strategy of treatment with these
patients. Greenson (17, 18, 19) proposes a similar approach,

illustrating his modified psychoanalytic technique with clinical
cases. Both Frosch and Greenson stress the importance of
clarifying the patient’s perceptions in the hours, and his attitude

toward the therapist’s interventions. Their approach (with which
I basically agree) implies a neutral technical position of the
therapist, and only a minimum deviation from such a position of

neutrality as might be necessary.
In contrast, other psychoanalytically derived

psychotherapeutic approaches to borderline conditions involve
more modifications of technique. Thus, Masterson (49, 50, 51)
designs a special psychotherapy as specifically geared to the
resolution of the “abandonment depression” and the correction

and repair of the ego defects that accompany the narcissistic oral
fixation of these patients by encouraging growth through the
stages of separation-individuation to autonomy. He proposes that

psychotherapy with borderline patients start out as supportive
psychotherapy and that intensive reconstructive

psychoanalytically oriented psychotherapy is usually an
expansion and outgrowth of supportive psychotherapy. He
stresses the importance of the analysis of primitive transferences,
and has expanded on the description of two mutually split off part
object relations units (the rewarding or libidinal part object
relations unit and the withdrawing or aggressive part object
relations unit) thus combining an object relations viewpoint with

a developmental model based upon the work of Margaret Mahler.
Rinsley (57) and Furer (12) are other authors among a
growing group of psychoanalytically oriented therapists who are

combining an ego psychological object relations theory with a
developmental model stemming from Mahler’s work (45, 46, 47,
48). Giovacchini (15), Bergeret (2), Green (16), Searles (64), and
Volkan (74) have also been applying object relations theory
derived models, and Searles, particularly has focused on the
understanding of the characteristics of transference and

countertransference developments in the treatment of borderline
and psychotic patients. Comprehensive overviews of some of

these approaches can be found in Hartocollis (21) and
Masterson’s (51) recent book.
While the American authors just mentioned base their
approach on an essentially ego psychological model that

incorporates recent developmental findings and ego
psychological object relations theories, the British school of

psychoanalysis (that was originally identified with certain object
relations theories) has continued to influence the technical
approaches to borderline patients. Little’s work (42, 43, 44)
focuses mostly on technique. Although she assumes that the

patients she describes are mostly borderline conditions, her
implication that her patients presented a lack of differentiation
between self and object, and her technical proposals for helping
them develop a sense of uniqueness and separateness, seem to
focus on the pathology of the early differentiation subphase of
separation-individuation. Her views are somewhat related to

those of Winnicott, but her patients seem to be more regressed
than those described by him.
Winnicott (80) stresses the need to permit the patient to

develop his “true self” by avoiding an “impingement” upon him at
certain stages of therapeutic regression. Winnicott has described
the optimal attitude of the therapist under these conditions as a

“holding” object, a function akin to basic mothering for patients
for whom, for whatever reason, normal mothering was lacking. At

such moments, Winnicott suggests, a silent regression takes place
to what amounts to a primitive form of dependency on the analyst
experienced as a “holding mother.” At such times, the analyst’s

intuitive, empathically understanding presence may be sufficient,
in contrast to the disturbing, intrusively experienced effects of
verbal interpretation.
This conception is related to Bion’s theory that mother’s
intuitive daydreaming (or “reverie,” in Bion’s terms) permits her
to incorporate the projected, dispersed, fragmented primitive
experiences of the baby at points of frustration, and to integrate

them by means of her intuitive understanding of the total
predicament of the baby at that point. Mother’s intuition, Bion
says, thus acts as a “container” which organizes the projected

“content.” Similarly, Bion goes on, the dispersed, distorted,
pathological elements of the regressed patient’s experience are
projected onto the analyst in order to use him as a “container,” an

organizer, one might say, of that which the patient cannot tolerate
experiencing in himself.
In short, both Winnicott and Bion stress that it is very

important for the therapist working with borderline patients to
be able to integrate both cognitive and emotional aspects in his
understanding of the therapeutic situation, and while Bion

focuses on the cognitive (“containing”) in contrast to Winnicott’s
emphasis on the emotional (“holding”), these seem closely related

aspects of the analyst’s attitude.
In recent years, there has been a gradual shift away from the
recommendation that borderline patients should be treated with
supportive psychotherapy, and Zetzel (83) and Grinker (20) seem

to be the last proponents of the purely supportive approach to the
psychotherapy of borderline conditions that was so predominant

twenty years ago. Zetzel recommends regular but limited contact
(very seldom more than once a week) with these patients in order
to decrease the intensity of transference and countertransference
manifestations, and a stress on reality issues and structuralization

of treatment hours, all of which constitute jointly an essentially
supportive approach. Zetzel acknowledges that, with that
approach, it may be necessary for many borderline patients that

the therapist remain at least potentially available over an
indefinitely extended period. The implication is that this
supportive approach, while effective in permitting the patient to

adjust better to reality, may contribute to an interminable
psychotherapeutic relationship. Zetzel and Grinker share the fear
expressed in earlier literature regarding the presumed “frailty” of

the defensive system, personality organization, and transferences
of borderline conditions. Implicitly, this fear is also reflected in
various psychoanalytically based but operationally manipulative

approaches, such as those of Marie Nelson (53) and Arlene
Wolberg (82).
In summary, a majority of clinicians who have worked

intensively with borderline patients have been shifting in recent
years from a supportive approach inspired by Knight’s earlier

work to modified psychoanalytic techniques or psychoanalytic
psychotherapy for most patients, while: still considering the
possibility that some patients may be treated by nonmodified

psychoanalysis from the beginning of treatment and others with a
modified psychoanalytic procedure which might gradually evolve
into a standard psychoanalytic situation at advanced stages of
treatment (11, 19, 26, 70).
My own work in this area fits clearly within this overall

approach (28, 30, 32, 33, 35). I think that, while some borderline
patients may respond to a nonmodified psychoanalytic approach,

the vast majority respond best to a modified psychoanalytic
procedure or psychoanalytic psychotherapy which I shall
describe in detail below. I believe that for some borderline

patients a psychoanalytic approach—standard or modified— is
contraindicated, and that these patients do require a supportive
psychotherapy (that is, an approach based upon a psychoanalytic

model for psychotherapy relying mostly on the supportive
techniques outlined by Bibring (3); Gill (14); and Zetzel (83). I

also think that psychoanalysis and psychotherapy should be most
carefully differentiated, and I follow Gill (14) in this regard.
In addition, I think that much of what appears as “ego

weakness,” in the sense of a defect of these patients, turns out,
under a psychoanalytically based exploration, to reflect
conflictually determined issues. Obviously, this conviction

underlies my stress on the value of an interpretive, in contrast to
a supportive, approach with borderline patients. A major source
for this conviction stems from the psychotherapy research project

of The Menninger Foundation (36), which revealed, contrary to
our initial expectations, that borderline patients did much better
with an interpretive or expressive approach, and much more
poorly with a purely supportive one.
Outline of Psychoanalytic Psychotherapy With Borderline

Patients
If psychoanalysis is defined by 1) a position of technical

neutrality, 2) the predominant use of interpretation as a major
psychotherapeutic tool, and 3) the systematic analysis of the
transference, psychoanalytic psychotherapies may be defined in

terms of changes or modification in any or all of the three
technical paradigms. In fact, I think the definition of a spectrum of
psychoanalytic psychotherapies, ranging from psychoanalysis, on

the one extreme, to supportive psychotherapies, on the other, is
possible in terms of these three basic paradigms.
Within an ego-psychological approach, psychoanalytic
psychotherapy may be defined as a psychoanalytically based or
oriented treatment that does not attempt, as its goal, a systematic
resolution of unconscious conflicts and, therefore, of all

impulse/defense configurations and the respective resistances;
rather, it attempts a partial resolution of some, and a
reinforcement of other resistances, with a subsequent, partial

integration of previously repressed impulses into the adult ego.
As a result, a partial increase of ego strength and flexibility may
take place, which then permits a more effective repression of

residual, dynamically unconscious impulses, and a modified
impulse/defense configuration (that increases the adaptive—in
contrast to maladaptive—aspects of character formation) . This
definition differentiates psychoanalysis from psychoanalytic

psychotherapy, both in the goals and in the underlying theory of
change reflected in these differential goals.
Regarding the techniques employed in psychoanalytic

psychotherapy geared to the achievement of those goals, and the
differences between such techniques and those of psychoanalysis
proper, the ego-psychological approach defines two major

modalities of treatment based upon the psychoanalytic
framework: 1) exploratory, insight, uncovering, or, simply,
expressive psychoanalytic psychotherapy, and 2) suppressive or

supportive psychotherapy.
Expressive psychotherapy is characterized by the utilization

of clarification and interpretation as major tools, and, in this
context, also abreaction. Partial aspects of the transference are
interpreted, and the therapist actively selects such transferences
to be interpreted in the light of the particular goals of treatment,

the predominant transference resistances, and the patient’s
external reality. Technical neutrality is usually maintained, but a
systematic analysis of all transference paradigms or a systematic

resolution of the transference neurosis by interpretation alone is
definitely not attempted.
Supportive psychotherapy is characterized by partial use of
clarification and abreaction and the predominance of the use of
technical tools of suggestion and manipulation. Bibring (3)
defined these techniques and illustrated their technical
utilization. Insofar as supportive psychotherapy still implies an

acute awareness and monitoring of the transference on the part
of the psychotherapist, and a careful consideration of
transference resistances as part of his overall technique in dealing

with characterological problems and their connections with the
patient’s life difficulties, this is still a psychoanalytic
psychotherapy in a broad sense. By definition, however,

transference is not interpreted in purely supportive
psychotherapy, and the utilization of technical tools such as
suggestion and manipulation implicitly eliminates technical

neutrality.
The major problem with this psychoanalytic theory and
technique of psychoanalytic psychotherapy has been the

contradiction between the theoretical model from which it stems
and the structural intrapsychic organization of many patients
with whom it has been used. The theoretical model underlying

this approach holds remarkably well for patients with good ego
strength. In contrast, however, the application of this
psychoanalytic psychotherapy model to patients with severe
psychopathologies— particularly the borderline conditions—has
led to puzzling and contradictory findings.
First, these patients present a constellation of primitive
defensive mechanisms centering around dissociation of
contradictory ego states rather than on repression. Second, the

transferences of these patients have peculiarities that are very
different from the more usual transference developments in
better functioning patients. Third, and most importantly, their

primitive impulses are not unconscious but mutually dissociated
in consciousness. In this connection, the evaluation of defense-
impulse constellations often does not permit a clarification of
what agency within the tripartite structure (ego, superego, and
id) is motivating and activating a defense against what impulse

within what other agency. In other words, the transference seems
to reflect contradictory ego states that incorporate contradictory,
primitive internalized object relations within an overall psychic

matrix that does not present a clear differentiation of ego,
superego, and id.
This leads to an additional, specialized psychoanalytic
approach that attempts to deal with the phenomena just

described, namely, psychoanalytic object relations theory.
Within an object relations framework, intrapsychic conflicts
are conceptualized as always involving self- and object

representations, or, rather, as conflicts between certain units of
self- and object representations under the impact of a determined
drive derivative (clinically, a certain affect disposition) and other,
contradictory or opposite units of self- and object representations
under the impact of their respective affect dispositions.
Unconscious intrapsychic conflicts are never simply conflicts

between impulse and defense, but, rather, the drive derivative is
represented by a certain primitive object relation (a certain unit
of self- and object representation) , and the defense, as well, is

reflected by a certain internalized object relation. Thus, all
character defenses really reflect the activation of a defensive
constellation of self- and object representations directed against

an opposite and dreaded, repressed self-object constellation. For
example, in obsessive, characterological submissiveness, a
chronically submissive self-image in relating to a powerful and

protective oedipal parental image may defend the patient against
the repressed, violent rebellious self relating to a sadistic and
controlling parental image. Thus, clinically, both character

defenses and repressed impulses involve mutually opposed
internal object relations.
From the viewpoint of object relations theory, the

consolidation of the overall intrapsychic structures (ego,
superego, and id) results in an integration of internalized object

relations that obscures the constituent self representation-object
representation-affect units within the overall structural
properties of the tripartite system (33) ; the psychopathology of

the symptomatic neuroses and less severe character neuroses is
produced by intersystemic conflicts between such integrated ego,
superego and id systems. In contrast, in the psychopathology of
borderline personality organization, such an integration of the

major intrapsychic agencies is not achieved, and conflicts are,
therefore, largely or mostly intrasystemic (within an

undifferentiated ego-id matrix). In severe psychopathologies—
particularly the borderline conditions—early, primitive units of
internalized object relations are directly manifest in the

transference, in the context of mutually conflictual drive
derivatives reflected in contradictory ego states.
In these cases, the predominance of a constellation of early
defense mechanisms centering around primitive dissociation or

splitting immediately activates, in the transference, mutually
contradictory, primitive but conscious intrapsychic conflicts (30).

What appears on the surface as inappropriate, primitive, chaotic
character traits and interpersonal interactions, impulsive
behavior and affect storms actually reflect the fantastic, early
object relations derived structures that are the building blocks of

the later tripartite system. These object relations determine the
characteristics of primitive transferences, that is, of highly
fantastic, unreal precipitates of early object relations that do not

reflect directly the real object relations of infancy and childhood,
and that have to be interpreted integratively until, by

reconstitution of total—in contrast to partial or split—object
relations, the more real aspects of the developmental history
emerge (31). In the treatment, structural integration through
interpretation precedes genetic reconstructions.
Let me now spell out a proposal for an integration of ego
psychological and object relations theory derived

conceptualizations geared to outlining a theory of psychoanalytic
psychotherapy for borderline conditions.
Because primitive transferences are immediately available,

predominate as resistances, and, in fact, determine the severity of
intrapsychic and interpersonal disturbances, they can and need to
be focused upon immediately, starting out from their

interpretation only in the “here and now,” and leading into
genetic reconstructions only at late stages of the treatment (when
primitive transferences determined by part object relations have

been transformed into advanced transferences or total object
relations, thus approaching the more realistic experiences of

childhood that lend themselves to genetic reconstruction).
Interpretation of the transference requires that the therapist

maintain a position of technical neutrality for the reason that
there can be no interpretation of primitive transferences without
a firm, consistent, stable maintenance of reality boundaries in the

therapeutic situation, and without an active caution on the part of
the therapist not to be “sucked into” the reactivation of
pathological primitive object relations by the patient. Insofar as

both transference interpretation and a position of technical
neutrality require the use of clarification and interpretation and
contraindicate the use of suggestive and manipulative techniques,
clarification and interpretation are maintained as principal
techniques.
However, in contrast to psychoanalysis proper, transference

interpretation is not systematic. Because there is a need to focus
on the severity of acting-out and on the disturbances in the

patient’s external reality (that may threaten the continuity of the
treatment as well as the patient’s psychosocial survival) and, also,
because, as part of the acting-out of primitive transferences, the

treatment easily comes to replace life, transference interpretation
now has to be codetermined by: 1) the predominant transference
paradigm, 2) the prevailing conflicts in immediate reality, and 3)

the overall specific goals of treatment.
In addition, technical neutrality is limited by the need to

establish parameters of technique, including, in certain cases, the
structuring of the patient’s external life and the establishment of a
teamwork approach with patients who can not function
autonomously during long stretches of their psychotherapy.

Technical neutrality, therefore, is a theoretical baseline from
which deviations occur again and again, to be reduced— again
and again—by interpretation. One crucial aspect of

psychoanalytic psychotherapy with patients presenting severe
psychopathology is the systematic interpretation of defenses. In

contrast to expressive psychotherapies in better functioning
patients—where certain defenses are selectively interpreted
while others are not touched—the systematic interpretation of
defenses in severe psychopathology is crucial to improve ego

functioning and to permit the transformation and resolution of
primitive transferences.
Therefore, the similarity between expressive psychoanalytic

psychotherapy and psychoanalysis is greater in the case of severe
psychopathology than in the case of patients with milder
psychological illness. One might say that, in psychoanalytic

psychotherapy of borderline conditions, the tactical approach to
each session may be almost indistinguishable from
psychoanalysis proper, and that only from a long-term, strategic

viewpoint do the differences between psychoanalysis proper and
psychoanalytic psychotherapy emerge. By the same token, the
cleavage between expressive psychotherapy and supportive

psychotherapy is sharp and definite in the case of patients with
borderline conditions, while it is more gradual and blurred in

cases with less severe illness. In other words, it is not possible to
bring about significant personality modifications by means of
psychoanalytic psychotherapy in patients with severe

psychopathology without exploration and resolution of primitive
transferences, and this requires a purely expressive, meticulously
analytic approach, although not psychoanalysis proper.
Manipulative or suggestive techniques destroy technical
neutrality and interfere with the possibility of analyzing primitive
transferences and resistances. Such analysis is the most
important ego strengthening aspect of the psychoanalytic

psychotherapy of borderline patients. Technical neutrality means
equidistance from the forces codetermining the patient’s
intrapsychic conflicts, and not lack of warmth or empathy with

him. One still hears comments implying that borderline patients
need, first of all, empathic understanding rather than a precise
theory and cognitively sharpened interpretations based on such a

theory. All psychotherapy requires as a base line the therapist’s
capacity for authentic human warmth and empathy; these
qualities are preconditions for any appropriate

psychotherapeutic work.
Empathy, however, is not only the intuitive, emotional
awareness in the therapist of the patient’s central emotional

experience at a certain point, but must also include the therapist’s
capacity to empathize with that which the patient can not tolerate
within himself; therefore, therapeutic empathy transcends the
empathy involved in ordinary human interactions, and includes
the therapist’s integration, on a cognitive and emotional level, of

what is actively dissociated or split in borderline patients.
In addition, when serious distortions in the patient’s reality
testing in the psychotherapeutic hours evolve as part of the

activation of primitive transferences and primitive defensive
operations (particularly that of projective identification), it may
be crucial for the therapist to start out his interpretive efforts by
clarifying the reality of the therapeutic situation. Such initial

interventions often require a great deal of active work on the part
of the therapist, a direct dealing with what the reality is in the
sessions or in the patient’s external life, that may be

misunderstood as a technically supportive, suggestive, or
manipulative intervention.
Strategy and Tactics of Transference Interpretation
Perhaps the most striking characteristic of the transference

manifestations of patients with borderline personality
organization is the premature activation in the transference of
very early conflict-laden object relationships in the context of ego

states that are dissociated from each other. It is as if each of these
ego states represents a full-fledged transference paradigm, a
highly developed, regressive transference reaction within which a
specific internalized object relationship is activated in the

transference. This is in contrast to the more gradual unfolding of
internalized object relationships as regression occurs in the
typical neurotic patient.
The conflicts that typically emerge in connection with the
reactivation of these early internalized object relations may be

characterized as a particular pathological condensation of
pregenital and genital aims under the overriding influence of
pregenital aggression. Excessive pregenital, and especially oral,
aggression tends to be projected and determines the paranoid
distortion of the early parental images, particularly those of the

mother. Through projection of predominantly oral-sadistic and
also anal-sadistic impulses, the mother is seen as potentially
dangerous, and hatred of the mother extends to a hatred of both

parents when later they are experienced as a “united group” by
the child. A “contamination” of the father image by aggression
primarily projected onto mother and lack of differentiation

between mother and father tend to produce a combined,
dangerous father-mother image and a later conceptualization of
all sexual relationships as dangerous and infiltrated by

aggression. Concurrently, in an effort to escape from oral rage and
fears, a “flight” into genital strivings occurs; this flight often
miscarries because of the intensity of the pregenital aggression

which contaminates the genital strivings (23).
The transference manifestations of patients with borderline

personality organization may at first appear completely chaotic.
Gradually, however, repetitive patterns emerge, reflecting
primitive self-representations and related object-representations

under the influence of the conflicts mentioned above, and appear
in the treatment of predominantly negative transference
paradigms. The defensive operations characteristic of borderline

patients (splitting, projective identification, denial, primitive
idealization, omnipotence) become the vehicle of the transference
resistances. The fact that these defensive operations have, in
themselves, ego-weakening effects is suggested as a crucial factor

in the severe regression that soon complicates the premature
transference developments.
Once a borderline patient embarks on treatment, the crucial

decompensating force is the patient’s increased effort to defend
himself against the emergence of the threatening primitive,
especially negative, transference reactions by intensified

utilization of the very defensive operations which have
contributed to ego weakness in the first place. One main “culprit”
in this regard is probably the mechanism of projective

identification, described by Melanie Klein (38) and others,
namely, Heimann (24), Money-Kyrle (52), Rosenfeld (59), and

Segal (65). Projective identification is a primitive form of
projection, mainly called upon to externalize aggressive self- and
object-images; empathy is maintained with real objects onto
which the projection has occurred, and is linked with an effort to

control the object now feared because of this projection
In the transference this is typically manifest as intense

distrust and fear of the therapist, who is experienced as attacking
the patient, while the patient himself feels empathy with that
projected intense aggression and tries to control the therapist in a

sadistic, overpowering way. The patient may be partially aware of
his own hostility but feel that he is simply responding to the
therapist’s aggression, and that he is justified in being angry and
aggressive. It is as if the patient’s life depended on his keeping the
therapist under control. The patient’s aggressive behavior, at the

same time, tends to provoke from the therapist counteraggressive
feelings and attitudes. It is as if the patient were pushing the
aggressive part of his self onto the therapist and as if the

countertransference represented the emergence of this part of
the patient from within the therapist (52, 55).
It has to be stressed that what is projected in a very

inefficient and self-defeating way is not pure aggression, but a
self-representation or an object-representation linked with that
drive derivative. Primitive self- and primitive object-

representations are actually linked together as basic units of
primitive object relationships (27), and what appears
characteristic of borderline patients is that there is a rapid

oscillation between moments of projection of a self-
representation while the patient remains identified with the

corresponding object-representation, and other moments in
which it is the object-representation that is projected while the
patient identifies with the corresponding self-representation. For

example, a primitive, sadistic mother image may be projected
onto the therapist while the patient experiences himself as the
frightened, attacked, panic-stricken little child; moments later, the

patient may experience himself as the stern, prohibitive,
moralistic (and extremely sadistic) primitive mother image, while
the therapist is seen as the guilty, defensive, frightened but
rebellious little child. This situation is also an example of

“complementary identification” (55).
The danger in this situation is that under the influence of the
expression of intense aggression by the patient, the reality

aspects of the transference-countertransference situation may be
such that it comes dangerously close to reconstituting the
originally projected interaction between internalized self- and

object-images. Under these circumstances, vicious circles may be
created in which the patient projects his aggression onto the
therapist and reintrojects a severely distorted image of the

therapist under the influence of the projected aggressive drive
derivatives, thus perpetuating the pathological early object

relationship. Heimann (24) has illustrated these vicious circles of
projective identification and distorted reintrojection of the
therapist in discussing paranoid defenses. Strachey (71) has
referred to the general issue of normal and pathological

introjection of the analyst as an essential aspect of the effect of
interpretation, especially in regard to modifying the superego.
Rapidly alternating projection of self-images and object-

images representing early pathological internalized object
relationships produces a confusion of what is inside and outside

in the patient’s experience of his interactions with the therapist. It
is as if the patient maintained a sense of being different from the
therapist at all times, but concurrently he and the therapist were
interchanging their personalities. This is a frightening experience
which reflects a breakdown of ego boundaries in that interaction,

and as a consequence there is a loss of reality-testing in the
transference. It is this loss of reality-testing in the transference
which most powerfully interferes with the patient’s capacity to

distinguish fantasy from reality, and past from present in the
transference, and also interferes with his capacity to distinguish
his projected transference objects from the therapist as a real

person. Under such circumstances, the possibility that a mutative
interpretation will be effective is seriously threatened. Clinically,
this appears as the patient experiencing something such as “Yes,

you are right in thinking that I see you as I saw my mother, and
that is because she and you are really identical.” It is at this point
that what has been referred to as a “transference psychosis” is

reached.
“Transference psychosis” is a term which should be reserved

for the loss of reality-testing and the appearance of delusional
material within the transference that does not affect very
noticeably the patient’s functioning outside the treatment setting.

Hospitalization may sometimes be necessary for such patients,
and at times it is quite difficult to separate a transference-limited
psychotic reaction from a broader one. Nevertheless, in many

borderline patients this delimitation is quite easy, and it is often
possible to resolve the transference psychosis within the
psychotherapy (25, 41, 56, 58, and 76). Control of transference
acting out within the therapeutic relationship becomes of central

importance.
The acting out of the transference within the therapeutic
relationship becomes the main resistance to further change in

these patients, and parameters of technique required to control
the acting out should be introduced in the treatment situation.
There is a danger of entering the vicious circle of projection and

reintrojection of sadistic self- and object-images of the patient as
the therapist introduces parameters of technique. He may appear
to the patient as prohibitive and sadistic. This danger can be

counteracted if the therapist begins by interpreting the
transference situation, then introduces structuring parameters of

techniques as needed, and finally interprets the transference
situation again without abandoning the parameters. Some aspects
of this technique have been illustrated in a different context by
Sharpe (66), who demonstrates how to deal with acute episodes

of anxiety.
Because the acting out of the transference within the

therapeutic relationship itself appears to be such a meaningful
reproduction of past conflicts, fantasies, defensive operations, and
internalized object relationships of the patients, one is tempted to

interpret the repetitive acting out as evidence for a working
through of these conflicts. The repetition compulsion expressed
through transference acting out cannot be considered working
through as long as the transference relationship provides these
patients with instinctual gratification of their pathological,

especially their aggressive, needs. Some of these patients obtain
much more gratification of their pathological instinctual needs in
the transference than would ever be possible in extratherapeutic

interactions. The patient’s acting out at the regressed level
overruns the therapist’s effort to maintain a climate of abstinence.
The question of insight in borderline patients deserves

discussion. Unfortunately, one frequently finds that what at first
looks like insight into deep layers of the mind and into
unconscious dynamics on the part of some borderline patients is

actually an expression of the ready availability of primary process
functioning as part of the general regression of ego structures.
Insight which comes without any effort, is not accompanied by

any change in the patient’s intrapsychic equilibrium, and, above
all, is not accompanied by any concern on the patient’s part for

the pathological aspects of his behavior or experience, is
questionable insight. Authentic insight is a combination of the
intellectual and emotional understanding of deeper sources of

one’s psychic experience, accompanied by concern for and an
urge to change the pathological aspects of that experience.
The following general principles summarize what has been

said in this section.
1. The predominantly negative transference of these patients
should be systematically elaborated only in the here
and now, without attempting to achieve full genetic
reconstructions. The reason is that lack of
differentiation of the self concept and lack of
differentiation and individualization of objects
interfere with the ability of these patients to
differentiate present and past object relationships,
resulting in their confusing transference and reality,
and failing to differentiate the analyst from the
transference object. Full genetic reconstructions,
therefore, have to await advanced stages of the
treatment.
2. The typical defensive constellations of these patients

should be interpreted as they enter the transference;
the implication is that the interpretation of the
predominant, primitive defensive operations
characteristic of borderline personality organization
strengthens the patient’s ego and brings about
structural intrapsychic change which contributes to
resolving this organization.
3. Limits should be set in order to block acting out of the

transference, with as much structuring of the patient’s
life outside the hours as necessary to protect the
neutrality of the therapist. The implications are that,
although interventions in the patient’s external life may
sometimes be needed, the technical neutrality of the
therapist is essential for the treatment; moreover, it is
important to avoid allowing the therapeutic
relationship, with its gratifying and sheltered nature, to
replace ordinary life, lest primitive pathological needs
be gratified in the acting out of the transference during
and outside the hours.
4. The less primitively determined, modulated aspects of the

positive transference should not be interpreted. This
fosters the gradual development of the therapeutic
alliance; however, the primitive idealizations that
reflect the splitting of “all good” from “all bad” object
relations need to be interpreted systematically as part
of the effort to work through these primitive defenses.
5. Interpretations should be formulated so that the patient’s

distortions of the therapist’s interventions and of
present reality (especially of the patient’s perceptions
in the hour) can be systematically clarified: one
implication is that the patient’s magical utilization of
the therapist’s interpretations needs to be interpreted.
6. The highly distorted transference (at times, of an almost

psychotic nature), reflecting fantastic internal object
relations related to early ego disturbances, should be
worked through first, in order to reach, later, the
transferences related to actual childhood experiences.
All transferences, of course, recapitulate childhood
fantasies, actual experiences, and defensive formations
against them, and it is often difficult to sort out
fantasies from reality. However, the extreme nature of
the fantasied relationships reflecting very early object
relations gives the transference of borderline patients
special characteristics, our next issue.
The Transformation of Primitive into Advanced or

Neurotic Transferences
The ordinary transference neurosis is characterized by the
activation of the patient’s infantile self, or aspects of that infantile
self linked to or integrated with his infantile self in general, while

the patient reenacts emotional conflicts of this infantile self with
parental objects that are, in turn, integrated and reflect the
parental figures as experienced in infancy and childhood. In

contrast, the nonintegrated self- and object-representations of
borderline patients are activated in the transference in ways that
do not permit the reconstruction of infantile conflicts with the

parental objects as perceived in reality, and rather, the
transference reflects a multitude of internal object relations of
dissociated or split- off self aspects with dissociated or split-off

object-representations of a highly fantastic and distorted nature.
The basic cause of these developments in borderline patients

is their failure to integrate the libidinally determined and the
aggressively determined self- and object-representations (27, 29

and 36). Such a lack of integration derives from the pathological
predominance of aggressively determined self- and object-
representations and a related failure to establish a sufficiently
strong ego core around the (originally nondifferentiated) good

self- and object-representations. However, in contrast to the
psychoses, in which self images have not been differentiated from
object images, in borderline patients there has been at least

sufficient differentiation between self- and object-representations
for the establishment of firm ego boundaries. The problem with
borderline patients is that the intensity of aggressively
determined self- and object-representations, and of defensively
idealized, all good self- and object-representations makes

integration impossible. Because of the implicit threat to the good
object relations, bringing together extremely opposite loving and

hateful images of the self and of significant others would trigger
unbearable anxiety and guilt; therefore, there is an active
defensive separation of such contradictory self and object images:

in other words, primitive dissociation or splitting becomes a
major defensive operation.
The overall strategic aim in working through the
transference developments of borderline patients is to resolve

these primitive dissociations of the self and of internalized
objects, and thus to transform primitive transferences—that is,

the primitive level of internalized object relations activated in the
transference—into the transference reactions of the higher level
or integrated, more realistic type of internalized object relations
related to real childhood experiences. Obviously, this requires

intensive, long-term treatment along the lines I have suggested
(31), usually not less than three sessions a week over years of
treatment. The strategy of interpretation of the transference of

borderline patients may be outlined into three consecutive steps.
These three steps represent, in essence, the sequence involved in

the working through of primitive transference developments in
patients with borderline personality organization.
The first step consists in the psychotherapist’s efforts to
reconstruct, on the basis of his gradual understanding of what is
emotionally predominant in the chaotic, meaningless, empty,

distorted or suppressed material, the nature of the primitive or
part-object relation that has become activated in the transference.
He needs to evaluate what, at any point, in the contradictory bits

of verbal and behavioral communication, in the confused and
confusing thoughts and feelings and expressions of the patient, is
of predominant emotional relevance in the patient’s present
relation with him, and how this predominant material can be
understood in the context of the patient’s total communications.

In other words, the therapist, by means of his interpretive efforts,
transforms the prevalent meaninglessness or futility in the
transference—what literally amounts to a dehumanization of the

therapeutic relationship—into an emotionally significant,
although highly distorted, fantastic transference relationship.
As a second step, the therapist must evaluate this
crystallizing predominant object relation in the transference in

terms of the self image and the object image involved, and clarify
the affect of the corresponding interaction of self and object. The
therapist may represent one aspect of the patient’s dissociated

self and/or one aspect of the primitive object representation; and
patient and therapist may interchange their enactment of,
respectively, self or object image. These aspects of the self and of

object representations need to be interpreted and the respective
internal object relationship clarified in the transference.
As a third step, this particular “part-object” relation activated

in the transference has to be integrated with other “part-object”
relations reflecting other, related and opposite, defensively
dissociated “part-object” relations until the patient’s real self and
his internal conception of objects can be integrated and
consolidated.
Integration of self and objects, and thus of the entire world of

internalized object relations, is a major strategic aim in the
treatment of patients with borderline personality organization.
Integration of affects with their related, fantasied or real, human
relation involving the patient and the significant object is another
aspect of this work. The patient’s affect dispositions reflect the
libidinal or aggressive investment of certain internalized object
relations, and the integration of split-off, fragmented affect states
is a corollary of the integration of split-off, fragmented
internalized object relations. When such a resolution of primitive
transferences has occurred, the integrative affect dispositions
that now emerge reflect more coherent and differentiated drive
derivatives. The integrative object images now reflect more
realistic parental images as perceived in early childhood.
Arrangements and Difficulties in the Early Stages of Treatment
A major question in the early stages of treatment is to what
extent an external structure is necessary to protect the patient
and the treatment situation from premature, violent acting out

that may threaten the patient’s life or other people's lives or
threaten the continuation of the treatment. When the treatment
starts out right after a recent or still active psychotic episode

(which borderline patients may experience under excessive
emotional turmoil—under the effect of drugs, alcohol, or in the
course of a transference psychosis), there may be indication for a
few days to a few weeks of hospital treatment, with a well-
structured hospital milieu program and clarification of the

immediate reality and a combination of an understanding and
clarifying and yet limit-setting milieu approach. A generally
chaotic life situation, particularly when complicated by the

patient’s difficulty in providing meaningful information about his
life to the psychotherapist, may represent another indication for
short-term hospitalization. Severe suicidal threats or attempts, a
deteriorating social situation, or severe acting out with

involvements with the law, are all typical examples of situations
which threaten .lie patient’s life or the continuation of treatment.
Under such circumstances, short-term hospitalization may be

necessary, simultaneously with the beginning or continuation of
intensive psychotherapeutic treatment along the lines mentioned
before.
The most important objective regarding the degree of
structuring required is to set up an overall treatment
arrangement which permits the psychotherapist to remain in a

position of technical neutrality, that is, equidistant from external
reality, the patient’s superego, his instinctual needs, and his acting
(in contrast to observing) ego (9). This objective can sometimes
be achieved with less than full hospitalization, by means of the
utilization of part-hospitalization arrangements, foster home

placement, the intervention of a social worker within the patient's
environment, etc. There are borderline patients who do not have
a sufficient degree of observing ego for intensive, outpatient

psychoanalytic psychotherapy; for example, many borderline
patients with extremely low motivation for treatment, severe lack
of anxiety tolerance and of impulse control, and very poor object

relationships may require a long-term environmental structuring
of their lives in order to make an expressive psychotherapeutic
approach possible. Such long-term structuralization of their life
may be provided by many months of hospitalization or a part-

hospitalization environment, or by extra-mural social services
which provide the necessary limit-setting in the patient's life or
support of his family for this purpose. Severe, chronic acting out,
suicidal or general self-destructive trends which the patient
cannot control, and some types of negative therapeutic reaction,
may require such a long-term external structuralization.
Many borderline patients are able, without external
structuring of their lives, to participate actively in setting limits to
certain types of acting out which threaten their treatment or their
safety. At times the psychotherapist has to spell out certain

conditions which the patient must meet in order for outpatient
psychoanalytic psychotherapy to proceed. The setting up of such

conditions for treatment represents, of course, an abandonment
of the position of technical neutrality on the part of the
psychotherapist, and the setting up of parameters of technique.

Such parameters of technique need to be kept at a minimum.
If a patient has a history of frequent suicidal attempts, or of
utilizing threats of suicide to control his environment (including
the psychotherapist), this situation needs to be discussed fully

with him. The patient must either be able to assume full control
over any active expression of his suicidal tendencies (in contrast

to the freedom of verbally expressing his wishes and impulses in
the treatment hours), or he must be willing to ask for external
protection (in the form of hospitalization or part-hospitalization)
if he feels he cannot control such suicidal impulses. In other

words, several brief hospitalizations arranged by the patient
himself, by his family or a social worker may provide an
additional, external structure needed to maintain the treatment

situation; this is preferable to the therapist changing his
technique in the direction of relinquishing a primarily

interpretive approach in the context of technical neutrality.
In contrast, many other potentially self-destructive
symptoms may be left untouched for a long period of time, if they
do not threaten the patient’s life or treatment. For example, it
may take years before a borderline patient with severe obesity

may be able to control his obesity effectively; general failure in
school or at work and interpersonal difficulties of all kinds may
express the patient’s psychopathology and a long time may elapse

before they can be brought into the focus of the treatment.
When the patient consciously withholds information, or
when he lies, the psychotherapist’s first priority has to be to

interpret fully and reduce this suppression of information by
interpretive—in contrast to educational—means. This may take
weeks or months, particularly in cases with antisocial features.

However long it may take, full resolution of the reality and
transferential implications of the patient’s lying takes precedence
over all other material, except life-threatening acting out.

However, because lying interferes with the psychotherapeutic
approach toward all other problems including acting out, it may

be preferable, if the patient who habitually lies also shows
evidence of life-threatening or other treatment-threatening acting
out, to start his treatment with sufficient structuring in his life,

such as long-term hospitalization. Patients who lie habitually,
and, therefore, give evidence of serious superego deterioration,
tend to project their own attitude regarding moral values onto the
psychotherapist as well, and to conceive of him as being dishonest
and corrupt. The interpretive approach to the transference
functions of lying includes, therefore, focusing on the patient’s
projection of his own dishonesty onto the therapist, and on the

transferential implications in the “here and now’’ of this
development.
In some borderline paranoid patients conscious withholding

of material is acknowledged by the patient as part of the
expression of paranoid fantasies about the therapist; for example,
one patient refused to give his real name over a period of several
weeks. Whenever manifest paranoid ideation becomes
predominant in the early hours of treatment, it is important for
the therapist to evaluate carefully whether the patient is, indeed,

a borderline patient, or whether the patient suffers from a
paranoid psychosis. Since a psychotic paranoid patient might

present serious aggressive acting out when transference
psychosis develops, it is extremely important for the therapist to
carry out an early, careful differential diagnosis, and not to
initiate an intensive psychotherapeutic treatment without a clear

understanding of all the implications of treating a psychotic
patient. At times, when this diagnostic question cannot be
clarified in the early treatment hours of a borderline paranoid

patient, it may be preferable to start the psychotherapy with a
concomitant period of brief hospitalization geared to evaluate the

situation further. The long-range benefits of an early, brief
hospitalization compensate for the increase of anxiety and
transference distortions and other complications in these
patients’ daily life related to an early, brief hospitalization. In any
case, it is important that the psychotherapist not permit the

patient to control the treatment situation in a pathological way, as
this would affect not only the psychotherapist’s technical

neutrality, but his very availability, on a simple human level, to
the patient. Sometimes it is preferable not to treat a patient at all
rather than to treat him under impossible conditions.
In the case of borderline patients whose treatment is carried

out, either initially or during later phases of the treatment, in
combination with hospitalization, it is important for the
psychotherapist to keep in close relationship with the leader of

the hospital management team. This raises such issues as
confidentiality, danger of splitting of the transference, and general

coordination of hospital treatment and psychotherapeutic work.
In my experience, I have found it helpful for the
psychotherapist to receive routinely full information regarding

the patient’s interactions in the hospital, and for the patient to be
told about this. Thus, the psychotherapist can share significant
information regarding the patient’s interactions in the hospital

with the patient himself and integrate it into his analysis of the
transference. At the same time, the psychotherapist should inform
the patient that he will keep confidential all information given

him by the patient, except for specific issues which the therapist
might wish to explore with the hospital team. But, before doing
so, he would ask the patient specifically for authorization. In other
words, general confidentiality should be maintained unless
specific authorization is given by the patient for the

psychotherapist to share certain information with the hospital
team. Finally, I explicitly inform patients that I would not feel
bound by confidentiality under circumstances which would

involve threats to the patient’s or other people’s lives; again,
under these circumstances, I would first share with the patient
the nature of the information I feel needs to be talked over with

the hospital treatment team.
The general implication of this approach is that if
hospitalization is needed and carried out during

psychotherapeutic treatment, the total treatment should be
integrated; in practice, this should help reduce or prevent
splitting operations by which part of the transference is

expressed to the hospital treatment team. In the case of
outpatients where social complications, for example, pressures

from the family, are expressed in the form of efforts of relatives or
other persons related to the patient to establish direct contact
with the psychotherapist, a social agency, or a psychiatric social

worker might be asked to provide a structure which keeps the
psychotherapist separate from the patient’s external social
environment, while still containing the overall treatment

situation that has evolved. Again, under these circumstances the
psychotherapist should maintain an open communication with
the social worker who is seeing the family, but any information
that the psychotherapist is planning to share with the social

worker must be discussed with the patient.
Therapeutic Stalemates in Advanced Stages of the

Treatment
Many borderline patients do not change significantly over

years of treatment, despite the efforts of skilled therapists of
various orientations. What follows are some general
considerations regarding the issues frequently involved in lack of

change in the treatment situation and some general requirements
for the therapist which have seemed helpful to me in facilitating
significant change in some of the more difficult cases.
The problem merges with that of the development of severe

negative therapeutic reactions in the treatment of borderline
cases. In fact, negative therapeutic reactions are a major cause of
lack of significant change. However, in order to avoid an excessive
broadening of the term negative therapeutic reaction, I think it

preferable to discuss these issues in terms of lack of significant
change.
I would restrict the meaning of negative therapeutic reaction
to the worsening of the patient’s condition, particularly as

reflected in the transference, at times when he is consciously or
unconsciously perceiving the therapist as a good object who is
attempting to provide him with significant help. Such negative
therapeutic reactions derive from 1) an unconscious sense of guilt
(as in masochistic character structures); 2) the need to destroy
what is received from the therapist because of unconscious envy

of him (as is typical in narcissistic personalities); and 3) the need
to destroy the therapist as a good object because of the patient’s
unconscious identification with a primitive, sadistic object which

requires submission and suffering as a minimal precondition for
maintaining any significant object relation (as in some borderline
and many schizophrenic patients who severely confuse love and

sadism (30)). My findings seem consonant with those of other
recent contributions to the psychoanalytic study of negative
therapeutic reaction (1, 54, 60, 61, 62, 73).
I would like to focus on some common features of chronic

stalemates in treatment. The situations most frequently met with
are: 1) Unchanged grandiosity in severe narcissistic structures.

Dehumanization of the treatment situation, amounting to a
complete denial of any emotional reality in the transference, may
appear even in narcissistic patients who seem to be functioning at

a nonborderline level. 2) Severe masochistic acting out, related to
the submission to and triumphant identification with a relentless,
sadistic superego formation. 3) The even more primitive
identification with a sadistic, mad object which provides love only
under the aegis of suffering and hatred. Any satisfactory relation

is thus equivalent to killing—and being killed by—the needed
parental image, and, therefore, losing it, while the triumph over
all those who do not suffer from such a horrible human destiny is
the only protection from a sense of total psychic disaster.
4) The need, derived from all these situations, to neutralize
or defeat the therapist’s efforts may evolve into a malignant

vicious circle. As the therapist persists in helping the patient in
the face of obvious lack of response or even worsening of the
patient’s condition, the patient’s envy and resentment of the

therapist’s commitment and dedication may reinforce the need to
escape from what would otherwise be unbearable guilt.
In the middle of chronic therapeutic stalemate, patients may
formulate quite directly the angry, revengeful request that the

therapist compensate them for their past suffering by dedicating
his life totally to them. But, regardless of the extent to which the
therapist might go out of his way to accommodate the patient’s
desires, eventually the following issues tend to become

prominent. First, the patient may destroy time in the sense of
losing his perspective on time; that is, he focuses on each session
as if time had come to a halt in between the sessions, and, in a

deeper sense, as if both patient and therapist would live forever.
Second, this destruction of time may be accompanied by a

specific neglect and rejection of what otherwise would have to be
perceived as manifestations of the therapist’s concern for and
dedication to the patient. It is as if the patient’s suspiciousness
and destructive disqualification of the therapist were geared to
destroying love with cruelty, while projecting this cruelty on to
the therapist. Relentless accusations implying that the therapist
does not love the patient enough are the most frequent, but not
the most severe, manifestation of this tendency. Uncannily, at
times when the therapist may in fact be internally exhausted and
withdraw passively from active attempts to work with the

patient, the patient’s accusations may decrease, and an eerie
unconscious collusion fostering paralysis and emptiness in the
psychotherapeutic situation ensues.
Third, the patient may attempt to convince the therapist that

the patient is really not human, that ordinary psychological
understanding and empathy have no place in this situation, and

the therapist may be induced to replace his concrete
understanding of the dynamics of the transference by more
general formulations of ego arrests, lack of capacity for emotional

understanding, cognitive deficits, and the like.
In short, something very active in the patient attempts to
destroy time, love and concern, honesty, and cognitive

understanding. I think that under these circumstances the
therapist is facing the activation of the deepest levels of human
aggression—sometimes hopelessly so. However, it is sometimes
possible to resolve these severe treatment stalemates with an
essentially analytic approach, and it seems to me that some of the
therapist’s general characteristics and attitudes now become
crucial. I shall attempt to spell out these attitudes.
First of all, it is helpful to combine an attitude of patience

over an extended period of time with an attitude of impatience, of
not accepting passively the destruction of concrete
psychotherapeutic work in each hour. This approach is in

contrast to a gradual giving up reflected in a passive wait-and-see
attitude in each hour, while the therapist actually becomes more
and more impatient and discouraged as time passes; he may even

reach a sudden explosion point. The implication is that the acting
out of severe aggression needs to be actively countered by the
therapist. Activity does not mean abandoning the position of

technical neutrality, a point I have explored in detail before.
It hardly needs to be stressed that the therapist should

intervene only when he is not under the sway of negative, hostile
affects toward the patient. Such aggression toward the patient
may be a normal reaction under such extreme circumstances, but
it usually becomes condensed with whatever potential for

aggressive countertransference reactions exist in the therapist,
and the therapist must contain this reaction in terms of utilizing it
for his understanding rather than transforming it into action.
A second major attitude of the therapist that might be helpful

under conditions of therapeutic stalemate is to focus sharply on
the patient’s omnipotent destruction of time. The therapist needs
to remind the patient of the lack of progress in treatment, to bring
into focus again and again the overall treatment goals established
at the initiation of treatment, and how the patient appears to
neglect such goals completely while assuming an attitude that the

treatment should and could go on forever. In this connection, the
establishment of realistic treatment goals and their
differentiation from the patient’s life goals, as stressed by E. Ticho

(72), become crucial.
The focus on the broad goals of the treatment needs to be
complemented by a sharp focus on the patient’s immediate

reality. Usually, under conditions of extreme, prolonged
stalemate, the patient also neglects his immediate reality
situation and reveals what at times amounts to an almost

conscious sense of triumph in defeating his own efforts; a triumph
over the therapist, whose impotence is reconfirmed every day as
impossible situations develop and disaster is courted. It is

essential that the therapist interpret the unconscious (and
sometimes conscious) rage at him expressed in the patient’s
playing Russian roulette in his daily life.
The patient will, in the process, have to reassume

responsibility for his immediate life situation as well as for his
long-range plans. This is a responsibility that I think we expect
any patient who undergoes psychoanalytic psychotherapy on an
outpatient basis to be able to assume, and it constitutes the reality
baseline against which transference acting out can be evaluated
and interpreted. In other words, acting out may take the form of
burning all bridges with the present external life and with the
future, with the implicit expectation that the therapist will
assume full responsibility for these; this must be interpreted
consistently.
Countertransference
I have suggested elsewhere (30) that one can describe a

continuum of countertransference reactions ranging from those
related to the symptomatic neuroses at one extreme, to psychotic

reactions at the other, a continuum in which the different reality
and transference components of both patient and therapist vary
in a significant way. When dealing with borderline or severely

regressed patients, as contrasted to those presenting
symptomatic neuroses and less severe character disorders, the
therapist tends to experience, rather soon in the treatment,
intensive emotional reactions having more to do with the

patient’s premature, intense and chaotic transference and with
the therapist’s capacity to withstand psychological stress and
anxiety, than with any specific problem of the therapist's past.

Thus, countertransference becomes an important diagnostic tool,
giving information on the degree of regression in the patient, his
predominant emotional position vis-à-vis the therapist, and the
changes occurring in this position. The more intense and
premature the therapist’s emotional reaction to the patient, the
more threatening it becomes to the therapist’s technical

neutrality, and the more it has a quickly changing, fluctuating, and
chaotic nature—the more we can think the therapist is in the

presence of severe regression in the patient.
The therapist normally responds to the patient’s material

with some affective reaction, which under optimal conditions, is
subdued and minor, and has a “signal” quality rather than

reflecting an intense emotional activation. At points of heightened
transference reactions, or when countertransference reactions
complicate the picture, the emotional intensity of the therapist’s

reaction increases and may interfere with his overall immediate
understanding of, or internal freedom of reaction to, the patient’s

material. With borderline patient’s not only is the intensity of the
therapist’s emotional reaction higher after relatively brief periods
of treatment, it is also more fluctuating, and, at times, potentially
chaotic. Obviously, rather than reacting to the patient under the

sway of these affective reactions, the therapist has to be able to
tolerate them and utilize them for his own understanding. Insofar
as what the patient is reactivating in the transference and the

analyst is perceiving in his affective response to it is not only a
primitive affect, but a primitive object relation connected with an

affect (that is, the therapist perceives a primitive self-image
relating to a primitive object-image in the context of the
particular activated affect) the therapist’s diagnosis of his own
emotional reaction implies the diagnosis of the patient’s—often
dissociated—primitive object relations in the transference.
Nowadays, the term countertransference is often used to

refer to the therapist’s total emotional reaction to the patient. For
the most part, however, particularly for those with an ego-

psychological approach, the term is still reserved to apply to the
therapist’s specific unconscious transference reactions to the
patient. In other words, this latter, restricted definition of

countertransference focuses on its pathological implications,
while the former, broader one focuses on the intimate
relationship between the general affective responses of the

therapist with his specific countertransference potential.
From the viewpoint of treatment of borderline patients it is
an advantage to consider the total emotional reaction of the

therapist as a continuum of affective responses from mild,
realistic “signal” affects to intense emotional reactions which may

temporarily interfere with the therapist’s neutrality, and which
constitute a compromise formation determined by the
transference and specific countertransference reactions. In any

case, the therapist needs to be free to utilize this material both for
resolving analytically his own excessive reactions to the patient,
and for diagnosing primitive object relations activated in the

transference.
One important force active in neutralizing and overcoming
the effect of aggression and self-aggression in the
countertransference is the capacity of the therapist to experience
concern. Concern in this context involves awareness of the
serious nature of destructive and self-destructive impulses in the

patient, the potential development of such impulses in the
analyst, and the awareness by the therapist of the limitation
necessarily inherent in his therapeutic efforts with his patient.

Concern also involves the authentic wish and a need to help the
patient in spite of his transitory “badness.” On a more abstract
level, one might say that concern involves the recognition of the
seriousness of destructiveness and self- destructiveness of human
beings in general and the hope, but not the certainty, that the fight
against these tendencies may be successful in individual cases.
Realistic treatment goals involve the acceptance not only of

unresolved shortcomings but of the unavoidability of aggression
in ordinary life. The therapist’s tolerance of his own aggression

and that of the people he loves may make it easier for him to
interpret the patient’s aggression without being sucked into the
patient’s conviction that his aggression is dangerous because it

will inevitably destroy love, concern, meaning, and creativity.
Therefore, the therapist’s thoroughly understood awareness of
the aggressive components of all love relations, of the essentially
ambivalent quality of human interactions, may be a helpful asset
in the treatment of extremely difficult cases.
The fact that the therapist can accept truths about himself
and his own life may permit him to express in his behavior the
conviction that the patient might also be able to accept truths

about himself and his own life. Such uncompromising honesty in
facing the most turbulent and painful of life’s prospects may
become part of very concrete interventions with patients having

long-term stalemates in the treatment. The confidence that the
patient can take and accept the truth about himself expresses at
the same time a confidence in the patient’s potential resources.
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6
The Treatment of Established

Pathological Mourners
Vamik D. Volkan, M.D.

Daniel Josephthal, M.D.
There is much in the psychiatric literature about the

similarities and differences between uncomplicated grief and the
reactive depression that follows the death of someone close and

important to the mourner. Freud (12) showed long ago how both
“mourning and melancholia” may be initiated by such a loss, and
how both include painful dejection, a loss of interest in the world
outside the self, a decrease in the capacity to love, and the

inhibition of any activity not connected with thoughts of the dead.
What distinguishes mourning from neurotic depression is the

disturbance in self-regard that appears in the latter state. In
uncomplicated grief the mourner can loosen his ties to the
representation of the dead through the work of mourning, or can

form the kind of loving identification with it that promotes his
growth. In depression, however, the mourner experiences
disruptive identification with it, and the ambivalent relationship
he had had with the one now dead becomes an internal process;
the yearning to keep the representation and at the same time to
destroy it is felt as an issue of one’s own—a struggle between
cherishing and doing away with one’s self.
Further accounts of the complications of grief appear in the

literature. For example, the initial absence of a grief reaction is
mentioned by Deutsch (7), and the chronicity of what are

generally thought of as "normal” grief manifestations by Wahl
(48). However, differentiation between varieties of complicated
grief and depression over loss by death is not always made, and
these diagnostic terms are commonly used interchangeably. The
study of adult mourners carried out at the University of Virginia
has demonstrated the existence of a type of established

pathological grief with a clinical picture and underlying
psychodynamics which are unique, persistent, and different from
those of either a normal but protracted grief reaction or a

neurotic depression. It is, in fact, a common psychiatric problem.
After the death of someone greatly valued, the grief-stricken
relative or friend goes through consecutive phases of mourning.

One might anticipate that when the process develops
complications these might include fixation in any one of these
phases, but clinical research shows that fixation usually occurs at
one specific phase—that in which the mourner is in a limbo of
uncertainty about the death and yearns to bring the dead to life.
The situation is complex inasmuch as along with the longing to
restore the dead is a dread of ever seeing him again. These
conflicting emotions result in the picture of established

pathological grief with its characteristic underlying
psychodynamic processes. Once diagnosed, this condition may be
successfully treated by a method of brief psychotherapy called re-

grief work (39, 41, 46, 47).
The Phases of Grieving
The psychological phenomenon involved in the process of
grieving over the loss of someone who had been important to

one’s self is one, the course of which can be represented
graphically as though it were the course of a physiologic process
seen longitudinally. Indeed, Engel (8), in asking whether or not

grief might lie called a disease, suggested that it resembled the
working-through of a healing wound. Just as a wound can become
infected or form keloids, so can the course of grieving become
complicated.
It begins when someone is lost, or when his loss is seen as
imminent. This external event affects the internal milieu of the
mourner, triggering a psychological process. Freud (12) described

how this process runs its course over an interval of time. As the
work of mourning goes on, memories and expectations connected

with the one who died are brought to the mourner’s mind one by
one. When they are hypercathected and examined, it becomes
possible to detach the libido that had been invested in the
deceased, and when the mourning is completed the mourner’s
ego becomes “free and uninhibited again.” However, a closer look

suggests that the end of the grieving process is not so easy to
identify, since the internal image of the lost one remains with us
to a certain extent all our lives—and may sometimes be

externalized with a degree of communication with that person
continuing. When one is asked to recall a dead relative, for
example, his image is usually readily available to the mind’s eye;

what is more important is that such an image may impress itself
on the mourner in moments of need without conscious recall. For
example, a woman who has completed the healing of the wound

caused by her father’s death may find herself preoccupied with
his image at the approach of her wedding day, as she longs for his
approval of this important step in her life. Nonetheless, the

grieving process does terminate for all practical purposes when
the image of the dead person is not required in any absolute and
exaggerated way to maintain the mourner’s internal equilibrium,

although it may from time to time be reactivated, as in
anniversary reactions (29, 30). The healed wound is, as it were, at
least covered over by scar tissue, but it never altogether

disappears; the feelings about an internal relationship to the one
who is lost continue.
Once initiated, the phases through which mourning over the

death of someone important proceeds are recognizable. Although
these have been described somewhat differently by different
writers, it is clear that they were all observing similar

manifestations. Engel (9) divided grieving into three stages: a)
shock and disbelief; b) a growing awareness of the loss; and c)

restitution, the work of mourning. Schuster (31) focused further
on the stage of shock and disbelief, Bowlby (1) also identified
three phases of grieving, although he and Parkes (5) later worked

out a schema with four. They describe the first phase as a brief
phase of numbness that may last from a few hours to a week and
be interrupted by outbursts of extremely intense anger and

distress. The second phase is one “of learning and searching for
the lost figure” that lasts for some months, even years. The third
phase is one of disorganization and despair; and the fourth, one in

which reorganization appears. Pollock (28, 31) made a special
contribution to the psychoanalytic understanding of this
reorganization (adaptation) when he went beyond Freud’s
original notion of the transformation into ego loss that occurs

with the loss of a loved object—or even of an ideal—by showing
that the ego uses the adaptational process of mourning for its
own healing. “Mourning processing, like working through, is

internal work to restore psychic balance (32, p. 16). Using the
term mourning in a broad sense to include reaction to losses
other than those occasioned by death, he holds that to be able to

mourn is to be able to change. People also mourn their own
impending death; people aware of having incurable cancer, for
example, go through similar phases if time allows and they are
psychologically capable (17).
This paper refers only to the mourning of adults, its

complications and therapeutic management. Psychoanalysts
debate the possibility that infants or small children faced with

loss grieve in the manner of the adult. In his review of children’s
reactions to the death of someone important to them, Nagera (23)
concludes that such losses interface with development. Our own

experience suggests that Wolfenstein (50) was accurate in saying
that adolescence constitutes a necessary precondition of the
ability to mourn. A painful and gradual decathexis of the living

parents is accomplished in adolescence and serves as a model for
the adult type of grieving.
As noted, our clinical research (39, 40, 42, 43, 44, 45), which
was conducted with a hundred patients during eight years,

confirmed our belief that the fixation typical of established
pathological mourning occurs mainly in the phase Bowlby and
Parkes (5) describe as one of “the yearning to recover the dead’’

and, to use a term of Kubler-Ross (17), to “bargain” for his return.
When such yearning is crystallized, it is inevitably accompanied
by dread of such a return. Manifestations of earlier grief stages—

denial, numbness, or angry outbursts—may appear also, as well
as occasional periods of disorganization usually more typical of a
later phase. If the fixation we describe is extended we are,
however, justified in diagnosing “established pathological grief.”
The Clinical Picture of Established Pathological Grief
Although the pathological mourner has intellectual
appreciation of the historical fact of the death, he clings to chronic

hope that the lost will return, even after the six months or a year
that usually disabuses the normal mourner of any such notion.
The pathological mourner’s dread of such an eventuality is as

strong as his hope. This situation can persist over time without
alteration, or the picture may be overlaid by others.
Wistful longing is not abnormal; Parkes (25), for instance,
speaks of how a widow yearning for her dead husband may

imagine hearing his footfall at coming-home time for a year after
his loss, and even “hallucinate” his appearance. In the established
pathological mourner, however, longing becomes such a strong
preoccupation that it dominates his daily life and keeps him
ongoingly involved in the conflict produced by the ambivalence of
deciding whether to bring the dead person back or to kill him, i.e.
expunge him from consideration. Many pathological mourners
become interested in reincarnation (40), the sophisticated
sublimating this interest in a related hobby or scientific

hypothesis. Some compulsively read obituary notices, betraying
not only anxiety over their own death but trying to deny the one
they mourn by finding no current mention of his death, while at
the same time recalling how such mention as it appeared earlier
had the finality of “killing” the lost one. This kind of
preoccupation can become extremely morbid, as in the case of
one patient who changed his dead wife’s burial place three times
in as many years, one move taking her coffin some distance away
and another bringing her “nearer home.” When he came to our
attention he was planning a fourth move. His preoccupation with

his dead wife’s image was ambivalent, clearly reflecting the
painful struggle that this religious man had had being faithful to
his marriage vows over the many years in which she had been a
suffering invalid. He had longed for liberation from her tragic
situation, and after her death he went through cycles of trying to
draw her close to him and then to put her away.
Some established pathological mourners think they

recognize their lost one in someone they see alive. A son
pathologically mourning a father dead for years may be struck by

a resemblance perceived in some stranger passing by, and rush
forward to peer at him over and over to see if this can indeed be
his parent. This act represents an effort to return the dead to life;
when the illusion is recognized as such it serves the wish to “kill”
him. The mourner may make daily reference to death, tombs, and
graveyards in ritual ways that obviate painful affect, but it is
unusual for such a mourner actually to visit the grave. For
example, a 20-year-old college student still, a year-and-a-half

later, mourning the sudden death of a grandfather she described
as “the most important person in my life” was surprised when she
was asked if she had ever gone to his graveside. Like most people
with established pathological mourning, she was quick to find an

excuse. She doubted that she could find it in a cemetery as “big” as
the one in her small town. Her preoccupation with her

grandfather was nonetheless evident in her daydreams about him
and her search for him in an affair with a married man 30 years
her senior.
The therapist of such a patient gets the impression that the

one being mourned is in a sense alive as far as the patient is
concerned and still exerts his influence. The patient uses the
present tense, stating confidently, “My father likes to go to the

movies.” One patient joked nervously during our first interviews,
cautioning that, “You can’t talk much against dead people because
if you knock them down they come back.” Certain typical dreams
can be expected. They have been classified (40, 41) as:
1) “Frozen” dreams, to use a term many patients use

themselves to describe tableaux without motion. One
tableau may follow another as though the dreamer
were watching the projection of a slide series. One
patient used the analogy of watching slices of bread fall
out of a package. The patient’s associations to each
tableau indicate a connection with his complicated
mourning and his fixation in the grieving process as
though the process had congealed in its course.
2) Dreams in which the dead person is seen alive but engaged

in a struggle between life and death. He may be lying in
a hospital bed or under the rubble of a collapsed
building, or sitting in a burning vehicle. The dreamer
tries to save him—or to finish him off. Interestingly,
both persons in the dream are usually undisguised. The
situation’s outcome remains indeterminate because the
patient invariably awakens before it is resolved.
3) Dreams of the dead body in which something indicates that

death is only an illusion. The body seen in its casket
may be sweating, or one long buried may show no sign
of decay. Such dreams are not unusual among normal
mourners during the months immediately after the
death, but these dreams either cease or the appearance
of the body begins to change. However, the mourner in
pathological grief will dream of the undecayed body
many years after death.
Several investigators (28, 41) have spoken of the reporting of
dream series appropriately parallel to phases of uncomplicated

grief in persons either completing their grief work without
incident or beginning to re-grieve in normal fashion as the
therapy for pathological grief starts taking effect. For example,

what is first reported is a view of grass-covered earth in which, in
the following dream, there is a grave-like excavation. The next
dream will include the half-alive body of the lost one lying nearby;
the dreamer may next see himself pushing it into the grave. In the
final dream of the series, the manifest content of which has been
the dreamer’s progress toward resolution of his grief, a grave,
smoothed over and covered with grass, appears. The established
pathological mourner is usually ready enough to disclose to the

therapist, when asked about his dream life, the appearance of the
kinds of dreams we cite as characteristic of this pathological state.
These dreams are usually repeating dreams, and information
about them is diagnostically helpful.
The person with established pathological grief can keep in

touch with the image of the dead, over which he maintains
absolute control. He is able to establish contact with the dead by

forming a presence (introject) of the dead person within himself
that is perceived, by the patient, as having definite boundaries
separating it from the mourner. Most patients, when questioned

about it, can give good descriptions of this phenomenon. Volkan
(41, 42) and Volkan, Cillufo and Sarvay (46) tell of patients who,
during the time of their treatment, would ask the inner presence
to get out of their bodies and leave them alone. It is also not
unusual for the person with established pathological grief to hold
“inner conversations” with the image of the deceased that dwells

within him. One patient would hold conversations with his dead
brother while driving in his car, and ask business advice from
him, feeling that the brother was somehow living within his own
breast.
Another sort of contact with the dead, again one under the
mourner’s absolute control, is maintained by the use of some

object contaminated with certain elements, some of which came
from the dead while others come from the mourner himself.
These have been named “linking objects” (43, 44, 45). They differ
from the ordinary keepsake since the mourner invests them with
magic capable of linking him with the one he has lost. Typically,
he keeps his linking object locked away or located in some place

where he can be in touch with it in a way that is consciously or
unconsciously ritualized. One patient, still mourning the death of
a son from an automobile accident many years earlier, kept his

son’s shoes, polished except where they were blood-stained, in
his own clothes closet. There he could see them daily as he
removed and put away his own garments, while all the time never
touching them. When he went into full-blown pathological grief
after the passage of many years, and was sent by his family
physician for consultation, he wore the shoes to the first

interview. He was greatly surprised and anxious when the
therapist asked if he had kept any special object or objects that
had belonged to his dead son, and only then realized what shoes
he was wearing.
A great variety of objects may become linking objects. The

mourner chooses such an object from among a) something once
used routinely by the dead, perhaps something worn on the
person, like a watch; b) something the dead person had employed

to extend his senses, like a camera (an extension of seeing); c) a
symbolic or realistic representation of the dead person, the
simplest example of which is, of course, a photograph; or d)

something at hand when the mourner first learned of the death or
when he viewed the body. We have also known patients to cling
to something less tangible, such as an elaborate fantasy. For
example, the mourner might entertain a certain thought during

the burial ceremony and regularly reactivate it to keep controlled
contact with the image of the dead.
The Psychodynamics of Established Pathological Grief
Three major intrapsychic processes underlie the clinical

picture described here: splitting, internalization, and
externalization. One must identify and understand the defensive

use of these mechanisms in order to make definitive diagnosis.
Splitting
The adult patient with established pathological grief uses the

mechanism of splitting extensively. The term splitting refers here
not to the “primitive splitting” currently used widely in relation to
borderline personality organization—that persistent separation

of “all good” self- and object-representations from those seen as
“all bad.” Here we see splitting on a higher, neurotic level, as a
splitting of the ego functions to protect the individual from any

global break with reality. Thus the ego's denial of the death can
coexist with the ego’s knowledge that the death has, in fact,
occurred. The pathological mourner's splitting of ego function is

selective and concerned only with the issues of the death in
question. Freud (13, 14) spoke of this type of splitting in
connection with both grief and fetishism. The fetishist does not
experience a global break with reality either; he understands that
women do not have penises but behaves as though they did.
Similarly, the established pathological mourner acknowledges the

death but behaves as though it had not occurred. One particular
function of his ego has become inconsistent with the rest. He is
usually able to identify the point at which splitting began, as when

he recalls gazing at the corpse in full knowledge that it was a dead
body, and convincing himself that he saw perspiration appearing
on its brow as an evidence that life continued in it. Such a notion

is not outside the experience of the normal mourner, but he soon
sets it aside, whereas it remains a powerful question in the mind
of the pathological mourner, militating against the

separation/castration anxiety triggered by the death. Two other
cogent psychological processes inherent in this condition—
internalization and externalization—foster the illusion of

continuing contact with the dead and thus support the
mechanism of splitting in its defense against anxiety. All three of
these mechanisms contribute to the patient’s continuing existence

in a limbo of uncertainty.
Internalization
Such processes—including introjection and identification—

which are involved in both grief and reactive depression, have
been known since the original publication of the works of
Abraham (1) and Freud (12). When his search for the lost one
forces the mourner to test the reality of his disappearance, he
uses hundreds of memories to bind him to the one he mourns,

and becomes so preoccupied with doing so that he loses interest
in the world around him. This painful longing must be worked

through piecemeal. Tensions are discharged through weeping, for
example. He regresses and resorts to "taking in” the deceased by
introjection. Thus, the dead person’s representation within the

mourner’s self becomes hypertrophied and is seen as an introject.
As noted earlier, the introject may be perceived by the patient as
an inner presence. Although the patient may describe this

psychological phenomenon in such a realistic way as to call it “a
foreign body in my bosom,” it should be remembered that, in
actuality, introjects are only code symbols of complicated

affective-dynamic psychological processes. Fenichel (11) states
that “introjections [introjects] act as a buffer by helping to
preserve the relationship with the object while the gradual
process of relinquishing it is going on.” Our work with established

pathological mourners indicates that the gradual process of
relinquishing an introject fails to take place. Thus the introject’s
continued presence does not lead either to disruptive

identification, as in reactive depression, or rewarding
identification (19) for the enrichment of the patient’s psychic
system. He is obliged to retain it and, like the introjects of early

life representations in psychotic patients, it never evolves further
but remains chronically cathected and is continually a party in the
yearning/dreading transactions of the patient.
Externalization
The child’s transitional object (49), perhaps a teddy bear or a
"security blanket,” is vitally important to him. Its main function,

one universally present, is to cause the infant to develop in
response to the ministrations of the “good enough” mother. In it
he has created his first “not-me” possession, which falls short

nevertheless of being totally “not-me” since it links not-me with
mother-me (15). The transitional object provides a bridge over
the psychological chasm that opens when the mother and child
are apart; the child may need it if he is to sleep, for example. Some
children who experience defective child/mother interaction may
have such extreme anxiety when separated from the mother that
they concentrate unduly on this object and use it in bizarre ways.
At this this level such objects are called childhood fetishes (37),
psychotic fetishes (21), or instant mothers (36). Since the main
function of these inanimate objects is to deal with separation

anxiety, it is not surprising that the adult suffering a separation, to
which he has responded with established pathological grief, may
reactivate in his regression this archaic way of dealing with this

stress. This would create in a linking object a locus for the
meeting of part of his self-representation with the representation

of the dead. Thus an externalization—a projection of self- and
object-images—is crystallized (43, 45).
Jaffe’s (16) emphasis on the dual role played by projection in
object relations, and the ambivalence it facilitates, can be applied
here. He wrote: “On the one hand of the continuum, the

annihilation of the object is predominant, while on the other, the
identification with and preservation of the object is paramount”
(pp. 674-675).
The linking object is completely under the patient’s control;
he has the unconscious illusion that it makes it possible for him to

kill the dead person or bring him back to life. It is contaminated
with intense emotion, i.e., the urge to kill, and is nothing that can
simply be put to use in the manner of a keepsake. It must be

hidden away and perhaps even locked away, or have a ritual for
relating to it. For example, one patient had a picture of his father
as linking object and developed a ritual concerning it that
persisted for many years until he had treatment. He could manage

to remain in a room alone with it until, when lost in
contemplating the picture, it seemed to him that his father began
to move toward him out of the frame. Then he would be so

overwhelmed by anxiety that he would rush from the room. He
had a strong desire to know at all times where his linking object
was. Many mourners are satisfied to keep theirs in a distant place,

provided that it is safe and accessible. Another patient used the
clothing of his dead brother as a linking object; he kept the
garments locked away, but worried constantly that he would

grow to “fit” them.
One young woman’s psychotherapist committed suicide
while she was in the middle of a transference neurosis. When she
learned that he had been cremated and his ashes had been placed
in an urn, she bought an urn-like vase which she established on
the mantel in her living room, depositing her last appointment
slip in it as a linking object. Although knowledge of its presence in

the vase was necessary to her, she would neither look at it nor
throw it away.
No patient we studied reactivated a transitional object in the

form of the transitional object or childhood fetish used in his
childhood, but patients did employ the same dynamic processes

that foster in the infant his illusion of power over the
environment. Put into the external world, the linking object also
helps the patient externalize the work of mourning and helps him
put the work aside for future attention which he keeps on

postponing because of the pain it would cause.
Differential Diagnosis
There is no dearth of observation in psychiatric literature

that recognizable mental illness, such as the different neuroses,
psychoses, antisocial behavior patterns, psychosomatic

conditions, etc., is precipitated by a loss by death (6, 10, 18, 20,
22, 24, 26, 27, 33, 38). In such conditions, while death and loss are
precipitating events, these are distinctly different from

established pathological grief, the latter state being, as we have
stressed, unique in a number of ways. It should be differentiated
with care from depression, fetishism, and psychosis.
Depression
Internalization processes are common to both depression

and established pathological grief, but in the latter, the introject of
the dead does not bring about identification. Thus, the introject
does not blend into the patient’s self-representation, but it is
something lie reacts to as an internal presence that has its own
discrete boundaries. The mourner’s tie to the introject does not

loosen. In a reactive depression, however, introjection of the lost
object leads to identification so that the mourner is the
battleground on which the conflicts, formerly so lively between

the patient and the one now dead, continue to be played out.
Thus, we see the pathological guilt, and the self-reproachful and
self-degrading features of the depression. We agree with Pollock
(28) and Smith (35) that in depression, identification tends to be

nearly total, with little difference being made between
characteristics of the mourner and aspects of the dead he takes in.
As Freud (12) indicated: “…if the love for the object—a love which
cannot be given up— takes refuge in narcissistic identification,
then the hate comes into operation on this substitute object,
abusing it, debasing it, making it suffer and deriving sadistic
satisfaction from its suffering” (p. 251). To be sure, there are grey
areas between pathological grief and a depression that follows a
death. One suffering from depression (total identification with the
representation of the dead) after a death may, in fact, go into

typical established pathological grief with an ambivalently related
introject before he is able to respond appropriately to his loss. We

have seen situations in which it was hard to determine whether
the patient had an introject or identified totally with the dead;
since the mourner’s behavior resembled on the surface that

known to have been characteristic of the deceased, careful
scrutiny was required. In any case, the patient who can easily
fluctuate psychodynamically between reactive depression and

established pathological grief may be a suitable candidate for re-
grief therapy. The fusion with the image of the deceased that is
exhibited by the person in established pathological grief, and

which comes and goes, contains manifestations of identification.
However, the identification of the reactive depressive is usually
different inasmuch as it follows the establishment of an introject
before turning into something more clearly identification per se.
The pathological mourner may experience feelings of guilt,
but with him such feelings are transient, since he maintains the
unconscious illusion that he can bring the dead to life again (as
well as kill him) if he chooses. Intense guilt is the earmark of
depression, which is characterized also by the dominant ego

feeling of helplessness (3). In established pathological grief there
is chronic hope—and dread (40, 42).
Fetishism
High-level splitting occurs in both fetishism and established

pathological grief, as does the use of certain objects in magical
ways. The differences that distinguish the fetish, the linking
object, and the transitional object are described elsewhere in
some detail (43, 45). The linking object provides a means for
external maintenance of object relationships with the dead. The
ambivalence of the wish to annihilate the deceased and to keep
him alive is condensed in it so that the painful work of mourning
has an external reference and is thus not resolved. The linking
object thus deals with separation anxiety, but the classical fetish
used by adults serves primarily to deal with castration anxiety
and only secondarily with separation anxiety. The literature (2)
reports the development of fetishistic behavior in a classical
sense after a loss by death, and in this circumstance a grey area
between fetish and linking object is evident. If the therapist takes
his patient's history with great care and is watchful for any
historical loss that might have initiated the appearance of the
clinical picture, he is usually able to find clues to the nature of the
magical object being used by his patient. One of our patients
discovered a pair of women’s shoes in the desk of his father after
his death, and kept them—primarily fetishistic objects for his
father—for his own linking objects.
Psychosis
As noted, a break with reality does in one sense occur in

established pathological grief through the use of high-level
splitting, but it falls far short of being global, as it would be in a

full-blown psychosis. For example, we would not over-diagnose
as psychotic a widow who tells of hearing her dead husband's
footsteps. If she is suffering from established pathological

mourning her experience indicates no more than what might be
called “mini-psychosis,” since it is focused and reversible by the
patient’s own capacity for reality-testing.
The Suitability of Patients for Re-grief Therapy
There are a number of reasons why an adult may be caught

up in established pathological grief. He may not have been
prepared for a sudden death, for example, and fall victim to
something like traumatic neurosis when a sudden death does

occur. His situation may in this case be seen as one of established
pathological grief that is a variation of traumatic neurosis, the
most suitable variety of pathological grief for re-grief therapy. Or

the mourner may have unfinished business with the one who
died, and be unconsciously trying to keep him alive for this
reason, while at the same time feeling anger toward the dead
person that makes him want to “kill” him. Such unfinished
business would include uncompleted intrapsychic processes. An
example is provided by a young man whose father had died

suddenly while the son was courting the girl who was to become
his wife. During the boy’s puberty his father, a physician, had had
some reason to be concerned about his son’s genital development

and shared these misgivings about what a failure to develop
properly might mean to the boy’s manhood. So the son, who had a
need to prove his virility to his father, accordingly impregnated
his fiancée soon after the father died. He had to keep his father’s
image alive to convey this triumph to him (41).
It is significant whether the death being mourned came

about from natural causes or involved violence, as in suicide,
accident, or homicide. Violence, unconsciously connected with the
mourner’s aggressive feelings, fosters guilt that can preclude the

expression of natural anger and aggressive reactions. This
situation may involve the patient’s fixation in established

pathological mourning, so that he can avoid feeling aggression
and guilt. Such fixation may in some cases be accomplished in the
service of so-called secondary gain. When a death brings about
such changes in the real world as the blow of losing the family
home or having to face a sudden loss of income because of the
wage-earner’s death, the mourner is more apt to keep the dead
one alive and struggle with the wish to ‘‘kill” him in order to
complete the natural process of grieving.
Any loss, including the death itself, deals a narcissistic blow

to the psyche of the one left behind. If the mourner has
narcissistic character pathology, brief psychotherapy is unlikely
to change this, however closely the clinical picture following the
death may resemble that of established pathological grief. He may
seem to go through re-grief therapy readily enough but still

become symptomatic very easily whenever his narcissistic
character organization is threatened. Such patients, while
seemingly trying to deal with the lost object, are actually trying to
deal, whether in hidden or open ways, with the narcissistic blow
itself. For such people to become able to grieve genuinely usually
requires more than re-grief therapy by itself can provide. We do

not advise taking into re-grief therapy the patient with
narcissistic personality organization.
The therapist should ascertain if the individual with the

clinical picture indicative of established pathological grief has
severe problems that stem from separation/individuation, and
has extensively used such primitive defenses as internalization

and externalization prior to the death he mourns. If he has low-
level psychic organization—that is, if he has moderate-to-severe

pathology in his internalized object relations—it is doubtful that
he will benefit from “re-griefing.” The most suitable patients are
those with intact ego functions in all respects other than higher-
level splitting, and who are psychologically-minded, motivated,
and thus capable of forming a therapeutic alliance. Since “re-
griefing” is a process leading to an inner structural change, it is

not surprising that candidates suitable for it are those who would
be suitable for classical psychoanalysis proper.
It has been demonstrated (46) that the Minnesota
Multiphasic Personality Inventory is not only an effective self-
rating measurement of change occurring during re-grief therapy,

but a promising instrument for the selection of patients for this
kind of treatment. It pointed to an underlying personality trait of
hysteria and dependence in those patients who received great

benefit from re-grief therapy with us. A pilot study suggested that
established pathological mourners tended to have an elevation of
scales 1, 2, 3, 7 and 8, and, to a lesser extent, of scales 4 and 6 also.
Peaks came generally in scales 2 and 7. The data of the pilot study
suggest that elevation of scales 2 and 7 to a point in excess of the

showing on scale 8 is predictive of maximum benefit from “re-
griefing.”
A Description of Re-grief Therapy
Once the patient has been seen in a diagnostic interview and

found suitable for re-grief therapy, he is told that his
psychological condition is due to Ills inability to complete the

grieving process, which a brief course of therapy will help him to
complete. One of the therapist’s first tasks will be to develop a
formulation as to the cause of his patient’s being “frozen” in the

course of his grieving. This requirement makes it necessary for
him to have had adequate experience in psychodynamically
oriented therapies, and to have developed a high degree of

competence in formulating unconscious mental processes. If the
patient is capable of really “hearing” at the outset what his
reasons are for failing to complete the normal process of

mourning, they can be shared with him; otherwise, the therapist
may keep his formulation to himself for later use in

interpretations when the patient is ready to hear them.
Since the established pathological mourner is in a state of

chronic hope that the dead wall return—and simultaneously
wants to “kill” him in order to complete grieving—he is

preoccupied with psychological contact with the introject. During
the initial phase of re-grief therapy, after carefully taking a
history, we help the patient to distinguish between what is his

and what belongs to the representation of the one he has lost,
using what have been called (47) demarcation exercises.

Demarcating the introject, so to speak, will enable the therapist to
help his patient see what he has taken in and thus what he feels
about the introject, and which of its aspects he wants to retain in
non-disruptive identification and which he wants to reject. It is

important here to note again that although the patient employs
the kind of physical terms we use in referring to his introject, it is,
in actuality, an affective-dynamic process. The therapist of such

patients should have sufficient experience to keep from engaging
in intellectual gymnastics instead of bona fide therapy when he

attempts the analytic formulations involved here. The manifest
content of the patient's dreams may demonstrate to him how his
grieving has been "frozen.”
In the initial phase of demarcation, which lasts for several
weeks, the therapist does not encourage an outpouring of intense
emotions, but helps his patient into a state of preparedness for

such an outpouring. If the patient senses emotion building up in
himself and feels frustrated at being unable to allow himself yet to
feel its full impact, the therapist may say, “What is your hurry? We
are still trying to learn all about the circumstances of the death
and the reasons why you cannot grieve. When the time comes you
may allow yourself to grieve.”
Following the demarcation exercises and exploration of the
reasons why the patient was fixated and unable to work out his
grief, the therapist will focus on the linking object. When the
linking object is being dealt with, the therapist will make a
formulation about its choice from among many possibilities.
Meanings condensed in a linking object are discussed elsewhere

(43, 45). Because it has physical existence with properties that
reach the senses, it has greater impact as “magical” than the
introject has. Once the patient grasps how he has been using it to
maintain absolutely controlled contact with the image of the dead,
as well as to postpone grieving and keep it frozen, he will use it to
begin his “re-grieving,” and this move will increase his dread. He
is asked to bring the linking object to a therapy session, where it
is at first avoided. With the patient's permission the therapist may
lock it away somewhere in the therapy room, saying that its

magical properties exist only in the patient’s perception of it.
Finally, introduced into therapy, it is placed between patient and
therapist long enough for the patient to feel its spell. He is then
asked to touch it and explain anything that comes to him from it.
We are constantly surprised at what intense emotion is congealed

in it, and caution others about this; such emotion serves to unlock
the psychological processes contained until now in the linking
object itself. Emotional storms so generated may continue for

weeks; at first diffuse, they become differentiated, and the
therapist, with his patient, can then identify anger, guilt, sadness,
and so on. The linking object will then at last lose its power,
whether the patient chooses to discard it altogether or not.
A graft of secondary process thought is needed to help heal
the wound that this experience has torn open. During the weeks
that follow, patient and therapist go over in piecemeal fashion
memories of how news of the death came; recognition of when
splitting began; the funeral; the attempts to keep the dead alive,
etc. Although this review may make the patient highly emotional
at some point, he can now observe what is happening to him, and
disorganization no longer frightens him. Many patients
spontaneously plan some kind of memorial ritual. For example,

one went, without advice from us, to the synagogue from which
his father had been buried and to the grave in which he lay
making a photographic record of it all. Many patients consult their
priests, ministers, or rabbis for religious consolation as they begin
to accept the death toward the conclusion of re-griefing. With
suitable patients, we were successful in using, toward the end of
their therapy, the manifest content of their serial dreams to

indicate where they were in their re-griefing (41). Patients then
have a sense of the introject’s leaving them in peace, and they are
often able to visit the grave to say “goodbye.” They feel free, even
excited with the lifting of their burden, and begin to look for new
objects of their love. Re-griefing is over. Our experience has been

that it can be completed in about four months, with sessions
occurring at least three times a week.
Transference: Therapeutic Efficacy
In re-grief therapy the transference relationship becomes the

vehicle whereby insight into ambivalence and the conflict
between longing and dread may be gained, and resolution

effected. A truly supportive approach is required, as in all other
therapies whether psychoanalytic or not. The therapist must

convey his non-exploitative desire to heal, and encourage his
patient to express himself directly without any fear of hostile,
punitive, engulfing, or abandoning responses. The therapist

should actively, directly, and instructively oppose any initial
shame or excessive control with which the patient may conceal
the complications of his grief, and encourage his head-on

exploration of feelings and fantasies about the person he has lost
and the internal and external relationship he has with him.
Through his activity the therapist offers himself as a new object
for the patient’s consideration, aiming, as in psychoanalytic
therapy, to develop a therapeutic alliance without encouraging an

infantile transference neurosis. Transference—but not
transference neurosis—is inevitable, and may be therapeutic by

providing close and intimate contact within the therapeutic
setting as conflicts are understood. At times the patient may
relate to his therapist as he had related to the one he mourns, and

thus make it possible to work through in a focal way the conflicts
he had had with him. The fresh grief caused by separation as
therapy terminates can be put to appropriate use.
Although re-grief therapy is brief, lasting for some months

rather than for years, it is intense, intimate, and certainly not
superficial. It can be likened to a “mini-focal analysis” since it

leads to the activating of certain areas of intrapsychic process,
however focalized, and effects intrapsychic change in areas under
treatment by means of “working-through.” Thus, it is not
recommended for therapists inexperienced in listening to the

flow of unconscious process. It requires adherence to a
therapeutic position and expert handling of transference and
countertransference.
A Case Report
A 30-year-old, well-respected, and highly competent female

lawyer sought treatment from one of us (Josephthal) for the
trouble she was having in resolving her grief reaction to her
husband’s death in an airplane accident six months earlier.
Although she showed some manifestations of what could be
understood as prolonged “normal grief,” her case history revealed

a basic picture of established pathological grief with typical
psychodynamics underlying it. She continued unable to control
the tears and weeping that came whenever she thought of him,
and she was ashamed over so losing her self-control and
dismayed that the situation seemed not to improve as time went
on. Her tears were accompanied by sad and poignant longing for
her husband and for her own death to come in order that they
might be together again. She reported being especially upset on
the tenth and twelfth of each month; she had had to identify the
body on the tenth day of the month in which he died, and to make
arrangements for the cremation two days after.
Her history indicated no significant psychological,

developmental trauma, nor deprivation, overindulgence, or
difficulties with object relations. She grew up in a farm family in

which self-reliance was a virtue, and she rejected any sign of
dependency within herself. Her social, educational, sexual, and
vocational development progressed smoothly, and when she was

24 she married a dynamic, successful, and glamorous lawyer who
was also a real-estate investor, and she spoke of having had a full
and exciting life with him. The couple traveled extensively and
had many friends. She felt that her relationship to her husband,
which was deep, rich, and intimate, had only one flaw—his
engagement in several transient extramarital affairs while on
business trips. Although she tried to condone this as unimportant

in the contemporary climate of openness and enlightenment, and
felt that he did not, in fact, have any real emotional involvement
with the women in question, she was inwardly upset and felt that
her husband had shown less than total commitment to their
marriage. She tried to feel accepting and liberated, and not to be

controlling, but, however she questioned her objections
intellectually, emotionally she continued to resent his affairs. This
was an unresolved issue at the time of his death, but otherwise

she felt hers had been a very happy marriage. The couple had
chosen to delay having children, but the patient was making plans
for a child when her husband lost his life in the crash of a private
plane while on a business trip abroad.
In the first few sessions she recounted her experiences
immediately after being notified of her husband's death. She had
felt shock and disbelief at first, and continued to hope against

hope that the news was in error until she identified the body two
days after the accident in the country where the plane had
crashed. The identification had been very traumatic for her; she
saw to her horror that his face had suffered severe mutilation.
Part of his jaw was gone, and the tissue that remained was
bloated and discolored. His mutilated face kept appearing in her
mind’s eye in what she called a “flash,” but it was interesting to
hear that as time went on it began to return to its normal
appearance without volition on her part; the missing area was
filling in, and the swelling was subsiding. Such gradual fading of
horror was reminiscent of what happens in the recurring dreams
of traumatic neurosis.
The patient kept her husband’s ashes in her bedroom in a

wooden box. Although she had made plans to dispose of them in
several places meaningful in terms of their shared experiences,
she found that she kept procrastinating. She had never been able
to open the box and examine the ashes, but she could not dispose
of them. When she happened to see the Tutankhamen exhibit
which was touring the country, she had what she described as a
“weird experience.” In reading the dates of the excavation of the
Tutankhamen tomb and doing some mathematical calculations

concerning her husband’s birthdate, his age at death, his age at
the excavation dates, etc., she had a sudden flash of insight that
momentarily persuaded her that her husband had been the King’s
reincarnation. She quickly saw the absurdity of this and

understood that it indicated a wish that her husband could return
through reincarnation. This insight was replaced by a search for
meaning. Being of a philosophical turn of mind and well-read in

Eastern philosophy, she began trying to understand what lessons
or meaning her husband’s death would reveal to her.
She came weekly for therapy, except for one week during
which the box of her husband’s ashes was in the therapist’s office,
where she opened it in his presence; then she came on four
consecutive days. She began treatment with a well-developed
capacity for the alliance and unusual insight and psychological-

mindedness, and she seemed at each session to bring in fresh and
absorbing material, showing deep and appropriate affect. She had
shared her grief response with no one and seemed eager to

unburden herself and to work on some of her difficulties. She very
quickly began to work through her problems while the therapist
encouraged her and acted as an auxiliary superego to help her

overcome her initial resistance based on shame and fear over
being what she thought of as weak, dependent, and vulnerable.
After the first few visits she had fewer episodes of crying; now
they seemed to occur chiefly during her sessions in therapy.
Shortly after beginning treatment she took a previously arranged
trip which included a plane flight. This was preceded by a dream:
Five pterodactyls fly over my property. I hide. One of them seems to have
a man's body. He swoops down and carries me off. It felt pleasant.
Her immediate associations were that there had been five

people in the plane crash, that the pterodactyl was her husband,
and that this was a dream of reunion. The therapist offered that
her husband has mastered what killed him by being able to fly,
and she immediately added “and thus be immortal.” She then
reported a recurring thought, a quotation from T. S. Eliot’s
Quartos: “After all our searchings we return to the same place and
see it for the first time.”
She then suggested—as the therapist had been about to do—
that it might be therapeutic to open the box of ashes in the
therapist’s office. Her wish for reunion, seen in the dream, along
with the attendant dread, was experienced and worked through
in the following way. She brought the box to her therapist’s office
and left it there in his safekeeping while together they explored

all her fantasies about it. These included what she called her
“terrible imaginings”; she had not opened the box because she
was afraid she would be impelled to smear the ashes over her
face and hug herself if she did so. Although clearly pointing to
images of merger, the opening of the box also meant the final
separation from her fantasied reunion, and thus an act of “killing”
her husband.
On the day she opened the box she was dressed completely
in black without realizing the meaning of this, and wore a

necklace of seashells. When she opened the box, trembling and
with great trepidation, she gasped at unexpectedly seeing chips of
bone. She likened these to seashells—she and her husband had

enjoyed sailing and spent considerable time at the seashore. She
sifted through the ashes in an almost caressing manner, then
unconsciously patted the side of her jaw. When this gesture was
called to her attention, she immediately realized that she was
trying to “fix him.” She then relaxed and examined the ashes with
a more detached interest. After that session she took the ashes
home with her and went on to dispose of most of them, keeping
some in the box. She would occasionally pat it as she walked out
of the room, and engage in fond reminiscence as she did so. The
box of ashes continued to be a linking object, but further
exploration disclosed that it no longer evoked anxiety and dread,

but held a new meaning. At first she said, “I’d rather keep it and
not think about it.” She explained that if she thought about it she
was afraid that she “would think angry thoughts and lose the fond
memories.” She also thought, “I’m keeping him in the box,” and
this came to mean that she was holding him as she had been
unable to do completely when he was alive. She was somewhat

ashamed to realize that she was acting this fantasy out, but her
shame gave way to greater interest in her motivation. She began
to work with more integration on the ambivalence she felt, trying

to sort out and reconcile the anger she had been denying and the
affectionate feelings that had contained an over-idealization of
her husband. At this point, “further unfinished business” came up
when she described in greater detail her experience of mourning

the death of her father when she had been in her early twenties.
He had died of metastatic cancer and until the end so used denial
that she had been unable to discuss his impending death with
him. Any approach to the subject disturbed him and with tears in
her eyes she would begin talking of something more hopeful. She
felt that she had never had “the chance to say goodbye,” and she
realized that this had been true also with her husband.
After six months, reference was made to terminating her
treatment. She was reluctant to terminate, recognizing
spontaneously that this would involve yet another separation and

experience of grief that she would have to resolve. She recognized
also that the positive feelings and the closeness and intimacy that
she had invested in her treatment had served at some level as a
replacement for the loss of closeness and sharing with her
husband. She reported what she called a termination dream. In

this she was a schoolgirl painting with great care and in
considerable detail the portrait of a girl. She was unable to finish
the portrait in the time allotted because when she applied the
brush to one eye and one side of the mouth no color resulted
although the rest of the face had been colored without difficulty.
She thought, “Oh well, I can always come back and finish it later;
besides, what I’ve done is beautiful.” She saw the incomplete eye
as evidence that there was more to see about herself, and the
incomplete mouth as testimony that there was more to say.
The therapist offered the interpretation that the lack of color

around the eye represented her tears, and wondered about the
incomplete mouth as representing her husband's jaw. This made
her tearful and she said, “I thought I had gotten over identifying
with him.” She went on to describe her feeling that a piece of her
had died with him. Delineating a small square space with her
hands, she spoke of “this space in me where he resides.” However,
there was now a boundary around her and the dream, and the
dream face, although a fusion of herself with her husband, was
also separate from her, the dreamer. The suggestion in the dream
that she could “finish the portrait later” represented her thinking
that she might like to be analyzed at some future time since some
characterological issues—some obsessional and superego

features, and her concerns about dependency—had come into
discussion. Agreement had been reached that analysis might
await fuller resolution of her grief. The feeling that the rest of the
painting was beautiful had to do, she surmised, with her feeling of
being otherwise fairly hopeful and optimistic about herself and
her life. Thus a termination date was planned for a short time
after the first anniversary of her husband’s death.
During the termination period she presented what she called
a “healing dream.” It was introduced in association with her

mention of a man she had been seeing toward whom she now felt
it possible that she might come to respond deeply; she had until
then been judging men as, first, not her husband, and then, not
like him.
I was running in a marathon, a peculiar kind with a lot of obstacles, over

a gorge. It was 26.2 miles. My husband was there encouraging me. In the
first part of the dream it was as if I were running in a slow motion. I
thought I’d never do it. It got dark. I didn’t want to stop but I was afraid
I'd trip in the dark. My husband went into a store, bought me a flashlight,
and gave it to me. I was able to run easily. The next morning I had
finished the race. Getting the light was a great relief. At the finish, where I
placed or what my time was didn’t matter—it was a notable finish.
She immediately connected this dream with her experience in

therapy and the past year of dealing with her husband’s death—
how hard it had been, how slow and painful. In association to
getting the light she felt that her husband’s death had made her
aware of troubles previously warded off, and that the therapist

had given her the light of the therapeutic process to guide her
way. She began that session with a radiant: smile which reflected
her relief and well-being—her delight at finishing the race after

dreaming heretofore of incompleteness. She had not finished
grieving, but the obstacles and complications of her grief were
gone. The obstacle of the gorge or chasm with an unfathomable

black bottom represented her wish for union with her husband in
death. She had gotten over that obstacle, hand over hand, in
therapy. The finish of the race, which came in the morning in the
dream, transformed mourning into morning; she associated to this
by saying that she had once again begun to enjoy the morning
sunrise on her way to work. She wept as she said that although
she had been eager to tell her therapist this dream, it also made
her very sad because it was so evident that she was ready to leave
him. He had appeared as her husband in the dream as she lived
again through the loss of her husband with him. She felt that if she
could set a date for terminating therapy she could prepare herself
for losing the therapist, and feel some control over the loss as she
had been unable to do when she lost her husband so
unexpectedly. She was wearing a black dress, but a white blouse
and grey jacket with it, and she commented that she realized after
dressing so that she had finally become able to blend white and
black.
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7
The Psychotherapy of the Depressed

Patient
Myer Mendelson, M.D.
Conceptual Aspects
Anyone engaged in the psychotherapy of the depressed
patient must not overlook the ambiguities inherent in the term

“depression.” It has become increasingly clear that this term has
been used to refer to a transient mood, to a symptom found in a
number of clinical states and to any one of a variety of affective
illnesses. Writers on depression often confusingly fail to

distinguish between these various uses of the word.
Consequently, it is often difficult to know which usage of the term

depression their writing has reference to.
One of the most experienced and sophisticated of

psychoanalytic writers on depression, Edith Jacobson (1),
expresses herself solidly in favor of distinguishing clearly
between depressive moods and depressive illness. She is very
critical of any tendency to neglect differential diagnostic criteria.
She impatiently points out the futility, for example, of doing
research on “endogenous types of depression with a group of

patients consisting of neurotic, manic-depressive and
schizophrenic patients” (p. 170). This kind of research, she
emphasizes, “cannot yield scientifically correct, acceptable

results.” She is critical of writers who fail to make these
distinctions. Clearly separating psychodynamic and diagnostic
considerations, she disagrees with those who, like Beres (2),

restrict the diagnosis of depression to those conditions which are
characterized by guilt.
She also stands out for her insistence on differential
diagnosis within the group of depressive illnesses. Jacobson

points to what she regards as quite distinct differences between
neurotic and psychotic depressions She views this distinction as
based on “constitutional neuro-physiological processes’’ (1, p.

183). She describes how differently the psychotic depressive
experiences his depression compared with the neurotic
depressive. She notes “an impoverishment of the ego”
characterized by “feelings of blankness and detachment, inner

weariness and apathy, a mental and physical inability to enjoy life
and love, sexual impotence (or frigidity) and feelings of deep
inferiority, inadequacy and general withdrawnness'’ (1, pp. 171-

172). She refers not only to symptoms such as insomnia, anorexia,
amenorrhea, weight loss and other “vegetative” symptoms, but
also to the psychosomatic features in the retardation which affect
the way that cyclothymics experience their inhibitions, a
subjective experience quite different from that of neurotic

depressives. Such patients may be unaware of depressed spirits
or a depressed mood and may complain primarily about their

fatigue and exhaustion. “They may compare the slowing up to a
fog settling down in their brain, to a veil drawn over their
thinking: to insurmountable walls blocking their feelings, their

thinking and their actions” (1, p. 174).
I have referred to her description of the typical subjective
experiences in a cyclothymic depression because I believe this is
the best such description in the psychoanalytic literature on

depression. It is a testimonial to her clinical as well as to her
conceptual perspicacity. It corresponds in every detail to what I

have observed myself in such patients. And I agree that these
experiences are very different from those of the neurotic
depressive, although I would label the difference between
neurotic and other affective illnesses differently (3, Chapter 1).
Treatment in psychiatry, as well as in medicine generally, is
based on some theory of etiology. Insofar as the psychotherapy of

the depressed patient is concerned, it is based on an
understanding of the particular patient. Before going on to the
specifics of psychotherapy, it is, therefore, necessary to make

explicit the underlying theoretical structure on which the
treatment is based.
As we know, Freud (4) in “Mourning and Melancholia”
pointed out that his melancholic patients’ self-castigations were
not, if one listened carefully, complaints, but rather accusations

and could be best understood as accusations leveled not actually
at the patient himself but rather at a disappointing love object at
whose hands the patient had experienced a rejection. In other

words, Freud discerned that the patient’s hostility, engendered by
the loss or injury that he had suffered, found itself directed by a
circuitous route at the patient himself rather than at the
appropriate target for his aggression, the rejecting love object.
It was this finding that, later, in the hands of inexperienced

therapists, became transformed into a universal formula for the
treatment of all depressed patients. In light of this, it is instructive
to note Freud’s description of the condition that he was
discussing:
The distinguishing mental features of melancholia are a profoundly

painful dejection, cessation of interest in the outside world, loss of the
capacity to love, inhibition of all activity, and a lowering of the self-
regarding feelings to a degree that finds utterance in self- reproaches
and self-revilings, and culminates in a delusional expectation of
punishment (p. 244).
This is clearly the description of a psychotic depression, a fact

which should obviously make one very cautious about applying
the findings in “Mourning and Melancholia’’ too widely. And, in

fact, Freud explicitly announced that “any claim to general
validity for our conclusions shall be foregone at the outset” (p.
243).
Abraham (5) directed attention to what he considered to be
constitutional factors predisposing to melancholia. From his
observations of symptoms, fantasies and perversions centering

around the mouth, he drew the conclusion that melancholics had
a constitutionally determined over-accentuation of oral eroticism
which predisposed to fixations at the oral level of psychosexual

development. This fixation, he believed, led, as a consequence, to
excessive needs and subsequently frequent frustrations
associated with acts of eating, drinking, kissing and sucking.
He believed that the increased frequency and intensity of
such frustrations made the potential melancholics more

vulnerable to disappointments in their relations to their love
objects and hence more prone to melancholia. He drew attention,
in melancholics, to the frequency of repeated disappointments in
parental affection (presumably related to these patients’ intensely

great oral needs) and their consequent vulnerability to
deprivation and disappointment. He believed that the melancholic
becomes ill when he experiences a repetition of these early

disappointments.
Rado (6) in 1926 translated these concepts into
psychological rather than semi-visceral language. He visualized

the depressive as comparable to a small child whose self-esteem
is dependent on external affection, appreciation, approval and
love. He conceptualized the melancholic’s vulnerability in terms
of his “intensely strong craving for narcissistic gratification” and
of his extreme “narcissistic intolerance.” As he viewed it, the
depressive derives his self-esteem not from his accomplishments

and effectiveness but from external sources, a characteristic
which constitutes his vulnerability.
He elaborated both on Freud’s concept that melancholia

occurs after the loss of a love object and on Abraham’s emphasis
on oral eroticism and the dangers of disappointments in the life of
the depressive. He viewed the melancholic’s self-derogation as “a

great despairing cry for love,” a manipulative device
unconsciously designed to win back the love that was lost and to
undo the disappointment. Rado, thus, in partial contrast to

Abraham, viewed the melancholic’s vulnerability more purely in
psychological terms. He cast his formulation in the framework of
external narcissistic supplies to emphasize the precarious self-

esteem of the potentially depressed patient who is so dependent
on these external supplies.
In 1936 Gero (7), with a more sophisticated grasp of the

importance of object relations, expanded the concept of “orality”
in a manner that represents the sense in which the term is
currently understood—namely, as having to do not only with the

sensual gratification of the mucous membrane of the mouth and
alimentary canal but also with the emotional satisfactions

inherent in the whole mother-child relationship. “The essentially
oral pleasure is only one factor in the experience satisfying the
infant’s need for warmth, touch, love and care” (p. 457). Thus
“orality” took on the current symbolic associations of this term,

referring to the yearning for “shelter and love and for the warmth
of the mother’s protecting body,” along with the more literal
meaning that refers to the libidinal stimulation of the oral zone. It

was in this widened sense of the need for dependency,
gratification, love, and warmth that Gero agreed with Abraham
and Rado in declaring that “oral erotism is the favorite fixation

point in the depressive.”
Other writers (e.g. 8) began to question the universality of
Freud's formulation. They argued that not all depressions were

similar to the ones that he had studied. Furthermore, they
explained the process that Freud had observed in different ways.
Fenichel (9), for example, pointed out that in depression, two

distinct intrapsychic processes occurred, an “instinctual
regression and a regression in the sphere of the ego.” By

“instinctual” regression, he referred, of course, to regression to
the oral phase of psychosexual development which Freud,
Abraham, Rado, and Gero had successively elaborated. He felt that

this form of regression was common to both neurotic and
psychotic depressions. But he considered that in a psychotic
depression or “melancholia,” there was, in addition, a regression

in the sphere of the ego. As a result of this, the individual could
not distinguish himself from the love-object. This led to the
substitution of self-vilification for reproaches more appropriately
directed at the disappointing love-object. He visualized this as

regression to a stage of ego development before there was an
awareness of objects as distinct from the self. Thus, accepting

Freud’s disclaimer to general validity for his formulation, he
revised Freud’s theory as indicated and restricted his revised
version of Freud’s formula to psychotic depression.
Furthermore, Fenichel stressed the role of self-esteem in

depression by defining a depressive as a “person who is fixated
on the state where his self-esteem is regulated by external
supplies” (p. 387). He went so far as to state that the precipitating

factors in depression “represent either a loss of self-esteem or a
loss of supplies which the patient had hoped would secure or

even enhance his self-esteem” (p. 390). Among these experiences
he listed failures, monetary losses, remorse, a drop in prestige, or
the loss by rejection or death of a love partner.
Bibring (10) and Jacobson (1, 11), in somewhat different

ways, contributed valuable insights to the understanding of
depression. The importance of self-esteem in depression had

been particularly stressed by Rado and Fenichel. What Bibring
and Jacobson did was to delineate the variety of determinants of
self-esteem. In the views of previous writers, the loss of self-

esteem in depression was related to the deprivation of oral
supplies.
Bibring fully acknowledged the marked frequency of
depressions related to the frustration of the “need to get affection,
to be loved; to be taken care of, to get ‘supplies’ or by the opposite

need to be independent, self-supporting.” However, what
represented a quite original contribution was Bibring’s thesis that
many patients experienced their loss of self-esteem because of

the frustration of aspirations other than those associated with the
oral level. In other words, he indicated that depressions could be
precipitated by frustrations associated with either the anal or the
phallic levels of development.
When frustration is associated with anal development,

aspirations consist of “the wish to be good, not to be resentful,
hostile, defiant, but to be loving, not to be dirty, but to be clean,
etc.” (p. 38). The failure to attain these goals could precipitate
depressions colored by feelings of being too weak and helpless to

control one’s impulses or by guilt about this lack of control.
Depression related to frustrated phallic aspirations such as “the
wish to be strong superior, great, secure, not to be weak and

insecure” (p. 24), might be characterized by feelings of
inadequacy, inferiority and ineffectiveness.
He was aware that the three modes of being depressed often

overlapped. However, he maintained that most depressions
represented a loss of self-esteem characterized chiefly by feelings
of helplessness associated with one or another of the levels of
psychosexual development. Clinically, these depressions were
characterized respectively by feelings of dependency, loneliness
and the need for love, or by feelings of guilt and unworthiness or

by feelings of inadequacy and ineffectiveness.
Edith Jacobson (1, 11, 12) considered the subject of
depression from the perspective of Hartmann's (13) important

contributions to ego psychology. Hartmann had introduced a
number of useful refinements in psychoanalytic thinking and
terminology. He had, for example, made a distinction between the

terms “self” and “ego.” As he saw it, the “self” refers to one’s own
person as distinguished from others. The “ego,” on the other hand,
refers to a structure of the psychic apparatus which rep resents

an integrated organization of psychic functions referred to as “ego
functions.” He did not think of the ego, as there is undoubtedly a
tendency to do, as a reified part of the brain or as a homunculus

directing operations.
He also adopted the terms self-representation or self-image
by which he meant the endopsychic representations of our bodily

and mental self. In addition, he introduced the analogous
concepts of “object-representations” or “object-images” to stand
for the endopsychic representations of person- or thing-objects.
Jacobson adopted and expanded this terminology. She, too,

along with Rado, Fenichel, Bibring, and others, found that lowered
self-esteem represented the core of depression. She, therefore,
explored the determinants of this self-esteem that were of such
central importance in depression and the multiplicity of
depressive states that derived from these different determinants.
She conceptualized one’s self-image as not being at first a

firm unit but as representing a series of ever-changing transient
self-representations derived from the infant’s early fluctuating
perceptions of himself and of those objects, or part-objects, such

as the breast, to which he is exposed. Under optimal
circumstances, the self-image gradually becomes integrated into a
relatively enduring, consistent endopsychic representation of his

self and becomes clearly distinguishable from the internal
representations of objects.
In other words, the child begins to acquire a clear sense of
his identity and becomes able to distinguish himself from other

people. Furthermore, under ideal developmental circumstances,
his self-image becomes optimally libidinally cathected. In the

context of loving parents and of tolerable frustrations adequately
managed, he develops a high level of self-esteem and self-
confidence and a lesser likelihood of developing a depression.
When the desirable outcome described above does not occur,

the child is burdened with a poorly integrated, aggressively
cathected, and inadequately differentiated self-image. Expressed
clinically, he is destined to experience problems of identity (“Who
am I?”) and of low self-esteem (with a predisposition to
depression) or difficulties in distinguishing himself from others
with possible psychotic troubles of a depressive, paranoid, or
schizophrenic type, depending on the vicissitudes of his
development.
In addition to this pathological development of the self-image

(which essentially represents the reflected appraisal of the
patient by his earliest love-objects), Jacobson also examines other

determinants of self-esteem. His actual talents, capacity, and
achievements also inevitably affect an individual’s estimation of
himself. Problems in this area may give rise to depressions

characterized by feelings of inadequacy and ineffectiveness.
Another determinant of self-esteem is the character of the

superego that the individual has developed. If developmental
circumstances have endowed the person with a harshly critical

superego retaining the unmodulated, exaggerated, fantasy-related
version of parental expectations associated with the early years of

childhood, then his self-esteem is proportionately vulnerable and
his predisposition to depression increased. The type of
depression resulting from such a superego may be characterized

by feelings of guilt and “badness.”
Jacobson also considers the ego-ideal an important

determinant of self-esteem, since, of course, the more grandiose
and unrealistic the individual's expectations of himself are, the
more likely it is that his performance will not match this ego-ideal
and the more probable it is that he will suffer a loss of self-
esteem, with resultant depression. Depending on the specific
characteristics of this ego-ideal and of the patient’s expectations
of himself, the depression may be characterized by feelings of

inadequacy and inferiority or by feelings of guilt and weakness.
Thus, Jacobson makes room in her conceptual framework for
a great variety of depressive reactions and does so primarily in

the language of ego psychology, rather than in the more simplistic
terminology of Bibring, who, while speaking of depression as an
ego phenomenon, nevertheless used psychosexual fixation points

as his major explanatory device.
But what of Freud’s formulation of the regressive

identification in melancholia? Jacobson conceives of regressive
identification as occurring when the boundaries between the self-

image and the object-representation dissolve away and result in a
fusion of self-and object-images. The target of the patient’s

hostility—the disappointing object-representation —thus
becomes indistinguishable from the self-image; hence self-
reproaches and self-vilification occur. But this kind of dissolution

of boundaries between self- and object-representations is by
definition a psychotic process. Therefore, the depression resulting
from this is, by definition, a psychotic depression, as indeed was
the case in the melancholia that Freud described but which by a
strange fate mistakenly became the model for all depressive
illness.
To remind ourselves of why we have reviewed the
psychoanalytic concepts of depression, I must point out again that

the treatment of depressed patients is necessarily based on some
theoretical model of the psychodynamics of depression. However,
as we have become aware, the term depression covers a variety of

affective states which differ not only overtly, but also subjectively.
Many of the previous formulations of depression and of the
depressive character structure are simply not comprehensive

enough to do justice to the variety of clinical types. Depressed
patients are to be found not only among those who are
excessively dependent for self-esteem on external narcissistic

supplies, or only among rigid over-conscientious perfectionists
who expect the impossible of themselves; the spectrum is not
nearly so narrow.
This relative multiplicity of depressed states—associated in

some instances perhaps with private biases on the parts of the
authors describing these states—has led to a variety of

psychodynamic formulations and conceptualizations of the
depressive illnesses, each with partial application. For different
writers, depression has not only different components but also

different purposes. For one author it is, in essence, emptiness and
loneliness; for another it is rage and guilt. For one observer it is a

passive consequence of having sustained a loss in self-esteem; for
another it is an active, though distorted, attempt to undo this loss.
A more widespread awareness of the complexity and variety
of the depressive reactions will perhaps give rise to less dogmatic

and more sophisticated theoretical models.
Of course, how one regards the genetic, constitutional or

physiological aspects of the depressive illnesses also affects one’s
view of the treatment of these conditions.
Although writer after writer has attempted to explain the

etiology and mechanisms of depression in psychological terms,
there has been evident a lingering feeling of discomfort and an
underlying but varying degree of awareness that there was more

to the depressive reaction than could be explained by
environmental and experiential factors. Kraepelin (14) regarded
depression in its various manifestations as essentially a

constitutional disease process. Meyer (15) pointed out the
therapeutic uselessness of such a focus and determinedly turned
toward an examination of the potentially treatable factors in the

reaction. Freud did not exclude the possibility that some types of
melancholia were constitutional, while proclaiming his field of
interest to be the psychologically understandable features of the

condition. Yet, even in types of melancholia which he considered
essentially psychogenic, he felt that some symptoms, such as

diurnal variation, were basically somatic in nature. Abraham, in
his effort to understand the choice of neurosis, postulated that in
depressives there was an inherited constitutional increased oral
eroticism, a heightened capacity of the mucosa of the mouth to
experience pleasure with an accompanying increased need and a
consequent greater possibility of frustration of this need. Gero

broadened the meaning of the term “orality” to include all
manifestations of the need for dependency, love and warmth,
with the implication that in depressives a heightened

constitutional need of this kind stood in greater danger of
frustration. Melanie Klein postulated a constitutionally
strengthened oral sadism as a possible factor in the most serious

deficiencies of development and in psychic illnesses.
Jacobson (1), with her interest in the ego psychological
aspect of depression, considers the question of predisposition in a

somewhat different light. First of all she clearly distinguishes
neurotic from psychotic depression and feels that the latter
represents not only a mental but an unknown psychosomatic

process. She believes that psychotic patients are predisposed to
total regressive processes by an arrested defective ego and
superego development, the result of their inherited constitution

and their infantile history.
Jacobson (1) contends that a psychodynamic approach to the

understanding of depressive psychosis is insufficient. She takes
issue with writers such as Bibring who reduce the diagnostic lines
between the various types of depression to matters of “content.”
She argues for a qualitative rather than a quantitative difference
between psychotic and neurotic depressions. She calls for what
Bellak (16) refers to as a “multiple-factor…psychosomatic” (p. 5)

approach to the affective disorders. Insofar as such an approach
deals with the psychological aspects of neurotic or psychotic
depression, however, she takes it for granted that it will use

psychoanalytic theory.
This brief survey of the gradual evolution of the
psychodynamic: understanding of depression has been necessary

in order to explain and to emphasize the undesirability of a too
simplistic view of depressive dynamics. As was mentioned above,
Freud’s insightful observation of the presence of aggressive

components in melancholia has given rise to a tendency to treat
all depressives as if their conflicts were identical with those of the
psychotic melancholics whom Freud had studied. Too often, even

before the psychodynamic issues in a particular depressed
patient have been identified, treatment is focused on making the

patient aware of hostile feelings and on encouraging him to
express these feelings.
As we have seen, the pathognomonic introjection that Freud
described represents essentially a psychotic failure to maintain

the boundaries of the self-representation rather than a typically
depressive mechanism. It is the fusion of self-images and object-

images that causes the melancholic to berate himself in terms that
are more appropriate to the disappointing object.
Neurotic depressives do not undergo this psychotic
regressive process. They do not confuse themselves with the

object. And although the self-image may, in psychoanalytic terms,
be aggressively cathected by the superego, the “aggression” here
refers to instinctual energy, an entity belonging more in the realm

of metapsychological conceptualizations than in the world of
hostile feelings.
Nor is it universally agreed among psychoanalytic authorities

that aggression, even in the form of tension between the superego
and the self-image, plays a universal role in depression. Some

analysts (e.g. 10) see depression entirely as an ego phenomenon,
not involving aggressive cathexes at all. However, even analytic
writers who do not question the role of aggression and the

superego in depression visualize some types of depression as
resulting from a defect in ego development secondary to early
disturbed parental interactions. This ego defect results in a self-
image inadequately endowed with libidinal cathexis. It results in

an individual who chronically feels empty, lonely, and yearning
for affection and closeness. Oversimplified, his problem is not that
he is inadequately expressing his hatred of others; his problem is

that he feels starved for love, closeness, and self-respect.
Even in those patients where seemingly unavoidable
resentful and hostile feelings are not being expressed, it is often a
therapeutic error to focus on these feelings too early. Frequently,
the patient’s inability to express or experience these feelings
stems from his own sense of unworthiness. It requires a certain
amount of self-respect before one can feel resentment at an

injury. Before one can experience and express hostility, one’s self-
esteem must be restored.
Furthermore, not all endogenous depressives are

characterized by guilt and by self-castigations. As Jacobson (1)
has perceptively noted, they may experience their condition as an
illness which robs them of the capacity to function rather than as

a state of unworthiness. The balance of psychological and
biological elements varies enormously from patient to patient.
Given all this, how does the literature—that is the most
sophisticated literature—view the psychotherapy of non-neurotic

depression? We found that the views expressed ranged across the
spectrum from a determined optimism to a discouraged

pessimism. In the early literature, Abraham set the tone with his
resolute declaration (17) that psychoanalysis was the “only
rational therapy to apply to the manic-depressive psychosis” (p.

154). Of the six patients in his series, two had already completed
their analyses. One of these analyses had taken what seems now
to have been the unusually short period of six months. Abraham
acknowledged that “it is usually extraordinarily difficult to
establish a transference in these patients who have turned away
from all the world in their depression” (p. 153) and he advised
that treatment should be begun during the free intervals between
their attacks because he did not feel that analysis could be carried
on with severely inhibited depressed patients.
In 1945 Fenichel (9) summarized the current views on the
therapeutic analysis of manic-depressive conditions. He cited

three special types of difficulties which must be overcome in the
treatment of these patients. The first was the oral fixation, “the
remoteness of crucial infantile experiences which the analysis

must uncover” (p. 413). The second was the looseness and the
ambivalence of the transference. And the third was the
inaccessibility of the severely depressed patient. He

recommended the free interval as the period of choice for
treatment but drew attention to the observation which had also
been made by Abraham and other workers that even inaccessible

patients who do not appear to be in contact with the world are
grateful and may sometimes derive benefit from a patient

listener. Fenichel’s tempered optimism about the treatment of
manic-depressives is revealed in his remark that “even if the
analysis fails, the patient is temporarily relieved through the

opportunity of unburdening himself by talking” (p. 414). He was
much more sanguine about the treatment of neurotic depressives.
He felt that they needed no special techniques and presented no

problems not found in other neurotic conditions.
Lampl-de Groot (18) felt that a deeply melancholic patient
was not amenable to analytic therapy, while Kohut (19) feels that
manic-depressive psychosis is not analyzable because of its very

considerable psychosomatic component.
Jacobson (1), in her consideration of the efficacy of

psychoanalysis and psychoanalytically oriented psychotherapy in
the treatment of depressive illness, reveals a wary, discriminating
optimism. She considers that treatment is least successful in

chronic depressions and in patients who had had depressive
episodes and suicidal ideas as far back as childhood. She feels that
prognosis is best in patients with hypomanic and compulsive

characteristics in their premorbid states, which seems to mean in
patients who are most effective in the interpersonal and
vocational spheres of their fives. She adheres firmly to the
usefulness of making diagnostic distinctions between neurotic

depressives and patients with endogenous or psychotic
depressions. She notes that treatment goes best in the healthy
intervals between depressive episodes but acknowledges that

patients are least likely to come for treatment then. She
acknowledges that it is often not possible to carry analyses with
depressed patients to the point “where their pre-oedipal fantasies

and impulses are produced and interpreted” (1, p. 300). Despite
all this, Jacobson advocates the use of psychoanalysis or
psychoanalytically oriented treatment for depressed patients.
Technical Aspects
Before the patient is accepted for treatment, a therapist’s

first encounters with a patient usually consist of a period of
evaluation, brief or extended. This introductory period should be

used not only to identify the dynamic issues that the patient may
manifest but also to assess the degree of biological contribution to
the depression. The higher the incidence of endogenous or

physiological features (e.g., early morning awakening, diurnal
variation of symptoms, impairment of concentration, loss of
interest, appetite and libido, psychomotor retardation or

agitation), the more likely it is that the patient will require
antidepressant medications in addition to psychotherapy. The
differential usefulness of antidepressants and psychotherapy in

such instances is beyond the scope of this chapter and, indeed, is
a subject that has not yet been adequately studied.
The therapist must estimate the depth and severity of the

depression and the danger of suicide. If there is evidence of a
serious suicidal risk, the patient should be hospitalized.
The criteria for the likelihood of a suicidal attempt include

the depth of the mood disorder, feelings of hopelessness, and the
presence and quality of suicidal thoughts, fantasies, or plans. A

criterion that has more to do with the personality structure and
the ego functions of the patient than the depression itself has to
do with the patient’s history of impulsivity or with the degree of
control he has over his impulses.
The lifelong, empty, lonely kind of depressed patient may at

some point decide that, unless something can be done to make his
life seem worthwhile, he will commit suicide. Here the clinician is

faced with the management not of a depressive episode but of a
long, enduring, lonely or depressed state. A brief period of
hospitalization will not abolish the danger of suicide. Unless the

inner emptiness and desolation are relieved, the patient may at
any point decide that he has had enough distress. And it is
impractical to hospitalize a patient like this for the rest of his life.
An empathic, understanding and nonexhortatory attitude on
the part of the therapist is a prerequisite in the treatment of

depression. Needless to say, the clinician should avoid
admonishing or advising the patient to cheer up, to try harder, to

stop complaining, or to cease being so absorbed with himself. The
probabilities are good that the patient’s relatives and friends have
been very generous with advice of this type, often to the patient’s
despair.
The clinician who treats depressives must be able to tolerate

the intense dependency needs of many of these patients and the
often monotonously recurring complaints. He must be sensitive to
certain reactions in himself that may interfere with an effective
therapeutic relationship. The patient’s incessant complaining may
eventually irritate or anger the therapist. If the patient does not
seem to be improving, it may threaten his sense of effectiveness.
It may then produce a defensive avoidance reaction on his part or
perhaps an attitude of antagonism or blame, as if it were the
patient’s fault that he was not getting well despite all that the
therapist was doing.
Jacobson (1) emphasizes the danger of seeming to offer these
patients “seductive promises too great to be fulfilled” (1, p. 298).

To avoid this she advises that early in treatment, in connection
with interpretations regarding the illusory nature of the patients’
expectations, one should utter warning about the future. She

advocates deviations from the classical technique. For example,
she advises only three or four sessions per week, because she
believes that this tends to reduce rather than increase the

ambivalence of these patients. She has noted that daily sessions
are interpreted by them either as unspoken and really
unfulfillable promises or as intolerable obligations which must be

masochistically submitted to. However, she acknowledges that
more frequent or longer sessions may sometimes be necessary
with very deeply depressed patients. Further, she notes that

during periods of deep depression, the therapist may serve
merely as a patient listener, providing the patient maybe for
weeks or months “no more than support from a durable
transference which may carry them through the depression” (1, p.
299).
One of the analyst’s or therapist’s difficult tasks is to adjust
his responses and remarks to the patient’s psychological rhythm.
This is essentially an exercise in subtle empathy. “There must be a

continuous, subtle, empathic tie between the analyst and his
depressive patients; we must be very careful not to let empty
silences grow or not to talk too long, too rapidly and too
emphatically; that is, never to give too much or too little. …What
those patients need is a… sufficient amount of spontaneity and
flexible adjustment to their mood level, of warm understanding
and especially of unwavering respect; attitudes which must not
be confused with over-kindness, sympathy, reassurance, etc.” (1,

p. 280). Jacobson remarks that analysts who tend to be detached
in temperament seem to have greater difficulty in treating these
patients.
Jacobson takes up the matter of the apparently almost

inevitable occasional spontaneous flash of anger on the part of the
therapist. She believes that this is a most precarious event since it
is, in a sense, a response to the patient’s demandingness, for not

only does he demand love and affection but, at times, he
unconsciously demands a show of power from the analyst. As she
observed, when the patient finds that the analyst is no longer able
to live up to his expectations of love, he may, in his fear of the
complete loss of his object, regress a step further. “The patient
may now attempt to hold on at least to the reanimated image of

an omnipotent, not loving, but primitive sadistic object” (1, p.
239). He may try to bring down upon himself a show of strictness,
anger and punishment. She feels that the patient prefers an angry
therapist to a nonparticipating one, a punitive object to no object.
This explosion of anger sometimes serves to carry the patient

over a dangerous depressive stage, but, in view of the
provocativeness of these patients, she advocates “the most careful
self-scrutiny and self-control in the analyst” (1, p. 300).
The first phase of treatment, as Jacobson outlined it, may be

marked by the establishment of prompt, intense rapport with the
therapist, reflected in idealized fantasies about him and in
marked enthusiasm for the treatment. Improvement may follow

rapidly. But it is a deceptive improvement which depends on the
unrealistic magical quality of the transference feelings and on the

“exaggerated idealization and obstinate denial of possible or
visible shortcomings of the analyst” (1, p. 288). No real change
occurs in the patient but his mood is one of hope and optimism.
Success seems certain to him, though perhaps not until a time

long in the future.
This phase may then be followed by a period of growing

disappointment, which is marked by sporadic doubts about the
excellence, wisdom and kindness of the therapist, followed by
immediate efforts to transform him again into the loving,

idealized image of the patient’s former fantasies. Feelings of
hopelessness and self-doubt increase. Manifestations of
ambivalence become more marked and may be displaced for a
time to a third person, perhaps the spouse. Typically, a long
period follows in which the patient becomes more and more

involved in therapy and withdraws dangerously from other
interpersonal relationships. Dependent, masochistic attitudes
now characterize the transference, accompanied by demands for

self-sacrificing devotion. The transference becomes more
ambivalent and the patient, with his attempts to arouse guilt in
the therapist for his alleged mistreatment of him, becomes more

exhaustingly provocative.
Such a phase may be followed by a deepening of the
depression, in which the patient may totally abandon the “bad”

object and enter a stage of pathological introjective defenses and
narcissistic withdrawal, i.e., his restitutive maneuvers may now
be enacted entirely in the psychic plane. The danger of

discontinuation of therapy in this phase is great.
Despite the unanswered questions that she freely raises,
Jacobson is able to report some considerable success with these

trying and difficult patients. She emphasizes the importance of a
slow and careful analysis of their transference conflicts, their ego
distortions and their superego defects.
A number of other helpful papers on the treatment of

depression have recently appeared (e.g., 20, 21, 22). It is
interesting that many topics which so exclusively preoccupied
previous writers on depression—such as the depressive’s self-
reproaches, his hostile introjection of the abandoned object, the
freeing of his hostility in treatment—now, in the broader
perspective of the recent workers, find their place as mere phases

in the interpersonal and transference conflicts of these very
difficult patients.
Beck (23, 24) has introduced one major new note in the
treatment of depressive illness, a technique which he refers to as
the cognitive therapy of depression. In brief, his view is that the
patient’s depression is activated either by the effect of specific

stresses or by the overwhelming accumulation of nonspecific
stresses on his idiosyncratic cognitive patterns. When activated,
these tend to dominate the patient’s thinking and produce

depressive affective and motivational phenomena.
He believes that cognitive psychotherapy may help the
patient symptomatically during the depression by helping him

gain objectivity and some control over his automatic pattern.
When the patient is not depressed, the treatment is directed
toward modifying his idiosyncratic patterns in order to reduce his

vulnerability to future depression.
In this insight therapy, an important step is to identify the

major maladaptive patterns through a study of the patient’s life
history. It is usually possible to demonstrate to him that he does
not overreact indiscriminately to all situations but that he
responds selectively to certain events and experiences. The
therapist attempts to help the patient understand these
overreactions as the consequences of early-life experiences which
produced idiosyncratic sensitivities to certain kinds of stress.

Thus the patient is enabled to understand his disturbances in
terms of specific problems, rather than as an amorphous
collection of symptoms. This in itself gives the patient a beginning

sense of mastery over his problems. He may, for example,
understand his reaction to an unusual slight by his spouse or by
an employer as a stereotyped response dating back to an early

feeling of being slighted or perhaps of not receiving preferential
treatment.
Many of the techniques that Beck identifies and labels are

part of our daily therapeutic work which we do not ordinarily
label or identify with technical terms. But technical language of
this kind does brings into clear awareness the nature of the
therapeutic work that one does. To name, as even primitives
know, is to acquire power over what is named.
One criticism that might be made of cognitive therapy is that

there seems to be a special emphasis on cognitions having to do
with success, failure or guilt. Cognitions having to do with
loneliness, emptiness, and loss—not so much distortions as
perceptions of painful states—would seem to lend themselves
less well to cognitive techniques, except in those instances where
negative self-concepts are largely responsible for the patient’s
inhibitions or lack of self-confidence in establishing satisfying
relationships.
However, Beck (23, p. 319; 24, p. 130) acknowledges that the

major usefulness of cognitive therapy during a depression is with
those reactively depressed neurotic patients who are not severely

ill, whose depressions are precipitated by identifiable events and
who do not have the characteristics of endogenous depressions.
“The depressed patient who is amenable to cognitive

psychotherapy generally shows wide fluctuations during the
course of a day and also from day to day. These fluctuations,
moreover, are related to specific environmental events; positive

experiences diminish and negative experiences increase the
degree of depression” (23, p. 379, 24, p. 130). This seems to be
the description of a neurotic depression rather than an

endogenous depressive illness. Despite these reservations,
however, it would appear that Beck considers cognitive insight

therapy in the post-depressive period to be not limited in its
usefulness by these diagnostic and phenomenological
characteristics.
There is, as we have seen, widespread agreement that

depression is essentially an affective state characterized by a loss
of esteem. The therapeutic task, therefore, is to examine the

circumstances of this loss and of the factors that predispose the
patient to it. The goal of treatment is not only the alleviation or
resolution of the depressive symptoms but also the development
of the kind of insight that will give the patient greater immunity
to subsequent recurrences and that will permit a more successful
adaptation to life.
Therapy involves one or more of the following tasks.
1. Where the patient is empty and lonely, the therapeutic task

may be to uncover the factors that prevent the patient
from achieving the kind of object relationships that are
necessary for adequate self-esteem. This may lead into
the following areas: helping the patient identify his
needs, for not every person is consciously aware of his
interpersonal and affectional needs; examining
defensive maneuvers that tend to isolate the patient;
identifying self-defeating patterns of relating to
members of the opposite sex. To achieve these goals
often requires a long period of intensive therapy,
especially if the patient has evolved complex or
stubborn defenses or personality patterns that
interfere with the gratification of his needs.
2. Where the problem is one of guilt, the therapeutic task may

involve the modification of an unrealistically harsh
conscience, that is, of a superego retaining much of its
early unmodulated punitiveness, somehow
insufficiently affected by the usually softening influence
of the developmental process. Although guilt is
probably more characteristic of psychotic depressions,
it is by no means unusual in the neurotic depressive
reaction.
3. Where the patient’s reduced self-esteem is a consequence
of an unrealistic feeling of inadequacy, the therapeutic
goal, whether accomplished by cognitive or other
modes of treatment, will be to help the patient acquire
a more realistic perspective on his abilities and talents.
This usually includes the modification of an unrealistic
ego-ideal in the direction of a more reasonable level of
aspiration.
REFERENCES
1. Jacobson, E. Depression. New York: International Universities Press, 1971.
2. Beres, D. Superego and depression. In: R. M. Loewenstein, L. M. Newman, M. Schur,

and A. J. Solnit (Eds.), Psychoanalysis—A General Psychology. New York:
International Universities Press, 1966, pp. 479-498.
3. Mendelson, M. Psychoanalytic Concepts of Depression, 2nd ed. Flushing, New York:

Spectrum, 1974.
3. Freud, S. Mourning and Melancholia. Standard Edition. London: Hogarth Press, 1957,
14:237-260, 1917.
4. Abraham, K. (1924). A short study of the development of the libido. In: Selected
Papers on Psycho-Analysis. London: Hogarth Press and the Institute of Psycho-
Analysis, 1927, pp. 418-501.
5. Rado, S. The problem of melancholia. Int. J. Psycho-Anal., 1928, 9:420-438.
6. Gero, G. The construction of depression. Int. J. Psycho-Anal, 1936, 17:423-461.
8. Deutsch, H. Psychoanalysis and the Neuroses. London: Hogarth Press, and the Institute
of Psycho-Analysis, 1932.
9. Fenichel, O. The Psychoanalytic Theory of Neurosis. New York: Norton, 1945.
10. Bibring E. The mechanism of depression. In: P. Greenacre (Ed.), Affective Disorders.
11. Jacobson, E. Contribution to the metapsychology of cyclothymic depression. In: P.

Greenacre (Ed.), Affective Disorders. New York: International Universities Press,
1953.
12. Jacobson, E. The Self and the Object World. New York: International Universities
Press, 1964.
13. Hartmann, H. Ego Psychology and the Problem of Adaptation. New York:
14. Kraepelin, E. Clinical Psychiatry. New York: Macmillan, 1902.
15. Meyer, A. The problems of mental reaction types. In: The Collected Papers of Adolf
Meyer, II. Baltimore: The Johns Hopkins Press, 1951.
16. Bellak, L. Manic-Depressive Psychosis and Allied Conditions. New York: Grune &
Stratton, 1952.
17. Abraham, K. Notes on the psycho-analytic investigation and treatment of manic-

depressive insanity and allied conditions. In: Selected Papers on Psycho-Analysis.
London: Hogarth Press and The Institute of Psycho-Analysis, 1927, pp. 137-156.
18. Lampl-de Groot, J. Depression and aggression. In: Rudolph M. Loewenstein (Ed.),
Drives, Affects, Behavior. New York: International Universities Press, 1953.
19. Kohut, H. The Analysis of the Self. New York: International Universities Press, 1971.
20. Gibson, R. W. Psychotherapy of manic-depressive states. Psychiat. Res. Rep. Amer.

Psychiat. Assoc., 1963, 17:91-102.
21. Levin, S. Some suggestions for treating the depressed patient. Psychoanal. Quart.,
1965, 34:37-65.
22. Lorand, S. Adolescent depression. Int. J. Psycho-Anal., 1967, 48:53-60.
23. Beck, A. T. Depression: Clinical, Experimental and Theoretical Aspects. New York: Paul
B. Hoeber, 1967.
24. Beck, A. T. The Diagnosis and Management of Depression. Philadelphia: University of

Pennsylvania Press, 1973.
8
Brief Psychotherapy of Stress Response

Syndromes1
Mardi J. Horowitz, M.D.

Nancy B. Kaltreider, M.D.
Stress response syndromes are neurotic reactions to serious
life events such as loss or injury. The signs and symptoms include
episodes characterized by intrusive ideas, feelings or behavior, as
well as episodes which include periods or ideational denial,
emotional numbing, and behavioral constriction (5). Preexisting

sets of meaning, conflicts, and develop mental problems are
invariably incorporated into how a person responds to the life

event in question. When indicated by the severity or persistence
of the reaction, brief psychotherapy can provide both symptom

relief and restoration of ongoing personal development. We plan
to present here the goals of such brief therapy and several aspects
of the related technique.
Stress Response Syndromes
The word “stress” has connotations ranging from the
aggravations of everyday life to the physiologic response states
produced by acute and chronic trauma. Here, we discuss stress

response syndromes as personal reactions when a sudden,
serious life event triggers internal responses with characteristic
symptomatic patterns. All persons would be expected to have

some reaction to a disruptive event, such as the death of a loved
one or a personal injury. Here we focus on responses that,
because of intensity or special qualities, reach a level of painful

neurotic symptomatology, that interfere with the integration of
the event into the life schemata and thus lead the person to seek
help. For several years, we have been evaluating and treating

such patients in a special outpatient clinic at Langley Porter
Institute, University of California at San Francisco. Our
experience, theoretically drawing on the work of others (1, 9, 11,

12, 13) has led to formulation of a specific therapeutic strategy
based on a pattern of phases and modified by individual character

style.
Phases of Response
As reviewed elsewhere (5), a sudden, serious life event may
evoke a predictable pattern of response. The affected person may

react with an outcry, such as “Oh no, no. It can’t be true,” or
appear stunned and unable to take in the meanings of the loss.
Especially in situations where the person has sustained a physical

injury and must get help, or has to carry out functions such as
planning for a funeral, there is often a phase of effective, well-
controlled behavior. Over time, the multiple painful meanings of

the event and its disruption of the patient’s homeostasis leads to
other, less well controlled states of mind.
Particularly prominent is a state of mind characterized by

intrusive symptomatology: unbidden thoughts, images,
nightmares, pangs of emotion and compulsive behavior. The
attempt to deflect such experiences may lead to avoidant

symptoms such as conscious warding off of thoughts about the
event, isolation of affect, overactivity and overt denial of the
meaning and consequences of the loss. Eventually, the

implications of the event are worked through, leading to relative
completion of the stress response. This rough delineation of

phases, with normal and pathological variations, is found in
Figure 1. The typical signs and symptoms of the denial and
intrusion phases are found in Table 1 and Table 2.
Figure 1
Stress Response States and Pathological Intensification
Table 1
Denial Phase
PERCEPTION and ATTENTION Daze
Selective inattention
Inability to appreciate significance of stimuli
CONSCIOUSNESS Amnesia (complete or partial)

Non-experience
IDEATIONAL PROCESSING Disavowal of meanings of stimuli

Loss of reality appropriateness
Constriction of associational width
Inflexibility of organization of thought
Fantasies to counteract reality
EMOTIONAL Numbness
SOMATIC Tension-inhibition type symptoms
ACTIONS Frantic overactivity to withdrawal
Table 2
Intrusiveness Phase
PERCEPTION and Hypervigilance, startle reactions
ATTENTION Sleep and dream disturbance
CONSCIOUSNESS Intrusive-repetitive thoughts and behaviors (illusions, pseudo-

hallucinations, nightmares, ruminations and repetitions)
IDEATIONAL Overgeneralization
PROCESSING Inability to concentrate on other topics, preoccupation Confusion
and disorganization
EMOTIONAL Emotional attacks or “pangs”
SOMATIC Symptomatic sequelae of chronic fight or flight readiness (or of

exhaustion)
ACTIONS Search for lost persons and situations, compulsive repetitions
Pathological Response
The pathological stress response syndrome is one that is

prolonged, blocked, or exceeds a tolerable intensity. In other
words, pathology is usually not the result of some qualitatively

different response, but rather of responses that are of such
magnitude that the person requires help, or they are responses
that do not progress towards adaptive completion over an

extended time. At this point, referral of the patient for
psychotherapy is indicated.
A case vignette will be used as an example of a stress
response syndrome.
The patient was a 21-year-old female Italian-American college student

referred to the Stress Clinic from a local general hospital. Twelve days
previously, she and her finance were shot by her father, who
disapproved of their relationship. Before losing consciousness, the
patient recalled watching her fiancé fall to the ground and remembered
seeing her father shoot himself. She awoke in the hospital and was told
that both her fiancé and her father were dead. She had had surgery for a
bullet imbedded in her skull with no impairment remaining other than
recurrent headaches and dizziness. She reacted with disbelief, felt
“numb,” and spent most of the next several days ignoring the event and
focusing on physical sequelae from the shooting. Three days prior to
discharge, she began having recurrent, unbidden images of the shooting
and her life with her fiancé. She also experienced anxiety attacks, crying
spells, difficulty falling asleep, and night terrors. These continued until
the day after discharge, when she came to the Stress Clinic.
The patient was raised by her mother, whom she describes as

hardworking but critical and sometimes emotionally distant. She had no
siblings. Her father left the family when she was a few weeks old. The
patient always believed he left because she wasn't born a male, an idea
reinforced by her mother. She did not see her father until she was in high
school, when he made a visit to her home city. She was immediately
disappointed, describing him as “seedy-looking, crude, and macho.”
Although he sent her money and gifts and tried to visit her over the next
few years, she managed to avoid him. After several months without
communication, the father suddenly reappeared on the day of the
shooting. The patient felt that he had learned about her and her
relationship with her fiancé through “cronies” sent out to spy on her.
The patient met her fiancé during their first year in college. He was a pre-
med student, and she described him as extremely bright, well-liked, kind,
and understanding. His intellectual interests motivated her to do better
in school; in time, his influence awakened her interest in medicine. The
patient described their relationship as unique in her life, in that she had
not generally attracted many men since she was always a “tomboy” and
preferred to dress “like a boy.” Her only other serious boyfriend was
someone she had dated for a few months in high school until he left her
for another girl (8).
The pattern of treatment of this case will be examined in
mote detail later on.
Treatment of Stress Response Syndromes
Goals
If we see the goal of brief therapy as working through a

recent serious life event and all its related personal issues to a
point of completion, then we can state three goals for therapy that
are orienting ideals rather than generally achieved aims.
1. Despite the fact that a person may have experienced a loss

or an injury, an ideal goal would allow him to retain a
sense of his competence and self-worth. In doing so he
would have to accept whatever unalterable limitations
were placed on his life plans. This should be done
without loss of hope or a sense of meaning in his life.
2. The person should continue realistic and adaptive action.

This would include maintenance of available
relationships and development of new, adaptively
useful ones.
3. In terms of long-range experience and behavior, an ideal

goal for completion of working-through reactions to a
serious life event would be the use of that opportunity,
even with its inevitable losses, for some type of growth.
The Pattern of Treatment
After a serious life event, persons usually reconsider the

meanings and plans for response to that event in a manner that is
systematic, step by step, and dosed. When emotional responses

become excessive, or threaten flooding, the person initiates
control operations. The intrinsic property of recollection of the
unfinished processing of sets of meanings will tend to counteract

these controls. When the person cannot handle both the
repetition compulsion (3) and the defensive counters (2), he

seeks help. The therapist, after establishing a working alliance,
assists the person in working through his natural responses to the

event and the overall situation. In addition, efforts may be
directed at modification of preexisting conflicts, developmental
difficulties, and defensive styles that made the person unusually

vulnerable to traumatization by this particular experience.
Therapy is dependent, in part, on establishing a safe
relationship. Once this is done, work within the therapy alters the
status of the patient’s controls. With a safe relationship and

gradual modification of controls, the patient can then proceed to
reappraise the serious life event, as well as the meaning
associated with it, and make the necessary revisions of his inner
models of himself and the world. As reappraisal and revision take
place, the person is in a position to make new decisions and to

engage in adaptive actions. He can practice the altered models
until they gradually become automatic. Overlapping with these
processes is the necessity of working through reactions to the

approaching loss of the therapist and the therapy.
As the person is able to accommodate to new levels of
awareness, this process repeats itself. When he can relate in a still

more mutual and intimate manner, he can examine himself more
deeply, and controls can be modified further. Additional work of
this sort may modify aspects of character structure.
Within the time limits of a brief psychotherapy, the therapist

works to establish conditions which will be helpful to the
processing of the painful event. There is an early testing by the

patient both of the safety of the relationship and the therapist’s
ability to help him cope with symptoms. Most commonly, patients
will seek help for intrusive symptoms. These symptoms can seem
less overwhelming when the therapist provides support, suggests
some immediate structuring of time and events, prescribes
medication if anxiety or insomnia is too disruptive, and gives
“permission” for the patient to work his feelings through one step
at a time rather than as quickly as possible.
Patients who are more handicapped by their avoidance
symptoms can be helped by encouragement from the therapist to
recollect the stress event with associations and abreactions, while

working towards changing attitudes that made the controls
necessary.
Frequently, symptoms subside rapidly with the

establishment of a good working alliance. Then therapy can focus
on the relationship of the stress event to the patient’s various self-

concepts.
Introduction of the plans for termination several sessions

before the final one leads to a reexperience of loss, often with a
return of symptomatology. But this time loss can be faced

gradually, actively rather than passively, and in a communicative,
helping relationship. Specific interpretations of the link of the
termination experience to the stress event are made and the final
hours center on this theme. At termination, the patient will
usually still have symptoms due, in part, to the time needed to
process a major loss and to anxiety about the loss of the

relationship with the therapist. Follow-up evaluations suggest to
us that the therapy serves as a catalyst for both symptomatic and
structural change over the ensuing year or more. This very global
and generalized overview is diagrammed in Figure 2, for a modal
12-hour therapy.
Figure 2
rence reactions
ted, when seen
ndicated, and
r configurations
www.freepsychotherapybooks.org
king-through
and termination
Examples of Timing in Brief Psychotherapy
291
Illustration of Treatment Course
The pattern of treatment in the case previously presented

can new be considered, followed by a closer look at selected
facets of the treatment process. The patient previously described

was seen for 21 sessions over a period of about four months. No
time limit was set at treatment onset, although there was a clear
intent to complete a brief therapy. During the first three sessions,

her symptoms gradually decreased as she regained control over
her actions and thoughts. Following this, she avoided discussing
the stress event. She also avoided encounter with angry feelings
toward her father and any sense of loss of her fiancé. Instead, she
focused on minor physical sequelae from her injuries and spoke
idealistically of her fiancé as if he were still alive.
Although she began reexperiencing anxiety, anger, and

intrusiveness just prior to and during her therapist’s two-week
vacation, which occurred one month after she began treatment,

these symptoms disappeared on his return. The patient spent
much of the next two sessions discussing her plans to return to
school in another city. The night before she was to leave (two
months after the stress event), she dramatically called her
therapist at home, saying she was fearful and anxious about
returning to the place where she and her fiancé had spent so
many happy months. She admitted that part of her motive in

leaving was to prove to herself she could “hack it.” She calmed
down as she spoke to her therapist and reaffirmed her intent to
leave. One week later, she again called her therapist and stated
she was experiencing anxiety and intrusive thoughts of her fiancé,

and had decided to return to continue therapy.
Over the next month and a half, the patient first denied and
then began dealing with feelings of anger and self-blame over the
death of her fiancé. She began making connections between the
two separations from her therapist, the permanent loss of her
father and fiancé as a result of the shooting, and the emotions that
resulted from “causing” her father to leave the family when she
was an infant. She discussed her feelings and viewed her fiancé’s
death in terms of its realistic meaning. She expressed a desire to

date other men, discussed feelings of guilt at being unfaithful to
the memory of her fiancé and expressed warm feelings for her
therapist.
During the patient’s intrusive stages, the therapist was

supportive and encouraged her to reduce external demands. For
example, she was encouraged to delay enrolling in school because

it might activate painful memories. An anti-anxiety agent was
prescribed when needed for occasional symptomatic relief. The
therapist often tried to help her organise her thoughts. Once,

when she felt she was “going crazy” because of intrusive thoughts,
the therapist helped her put these thoughts into perspective by

relating them to the severity of the stress event and to the
universality of this type of response to stress. During the
avoidance stages, when the patient eluded discussion of the
importance of the stress event, the therapist focused on the event

and encouraged her to be aware of her emotions and make
associations to past conflicts. It was sometimes necessary to
interpret her use of denial and relate it to its defensive purposes.
The patient had several dynamic conflicts triggered by the

stress event. She had a long history of losses related to men,
beginning with her father’s abandonment and continuing with her

difficulty in maintaining relationships with boyfriends. She
blamed herself for her father’s desertion and felt both angry and
guilty at his leaving. The stress event caused her to lose the two
significant men in her life, thus reactivating the theme of loss and
its attendant unresolved conflicts. This theme was again
demonstrated in the transference during the two separations

from her therapist, and was reviewed for reality-fantasy
comparison in that context.
In addition to these object loss issues, the bodily injury she

suffered in the shooting also activated old themes. Her tomboyish
dress and manner represented a reaction to the anxiety and
insecurity she felt at being born a female. She had always been
concerned with her body image. As a result of the stress event,
she not only had real physical sequelae, but, after her hair was
shaved off for skull surgery, she was often mistaken for a male.
These old areas of conflict were explored during the course of
therapy in relation to themes associated with the recent stress
events.
The final two sessions were devoted to issues of termination.

The patient exhibited some transient anxiety at leaving her
therapist but was able to admit she was feeling much better and
was “ready to go” (8).
Relationship Issues
If we think of a person as coming in after a loss: to the self (as
in surgical removal of an organ); of another person (as in the

response to the death of a loved one); or after a work situation (as
in being fired), then it is obvious that he will test the therapist to
see if the therapist will deplete, leave, or insult him. He

consciously (and/or unconsciously) will also want to see not only
if the therapist is competent to help, but if the therapist will go
beyond helping him with this problem to personally replace that
which has been lost.
We see the therapeutic alliance as a pathway, with other

potential relationships falling to either side. On one side lies the
social relationship used as a deflection from work; on the other

side of the pathway lies the potential for various transference
relationships.
Instead of beginning to communicate the kinds of ideas and
feelings that he has been avoiding on his own, the patient may
attempt to engage the therapist in ordinary levels of social

discourse. He may do this by telling his story, by maintaining a
kind of bantering manner, or by trying to find out details about
the therapist’s personal life and experience with similar life

events.
When there is stress response syndrome where the person

wears the badge of a recent serious loss, he may tend to do the
social things naturally done at those times, such as requesting
sympathy and advice on how to manage. To some extent, these

requests are realistic, but they also may be tests to see if the
therapist expects the relationship to go beyond ordinary social
interchange. As the patient tests to see if he is going to be
expected to deepen the relationship to the level of the therapeutic

alliance, he is also alert and is testing to see if the therapist will do
more than this.
In the mind of each person there are certain role

relationships that contain feared self-images. The loss implied by
most serious life events tends to reduce the stability of more
developmentally advanced or compensatory self-images. He now

may feel weak, bad, or worthless. Even though his goal is
recompensation of a competent self-image, he will sometimes test
to see if it is possible that the therapeutic alliance may, in a sense,
go too far for him. That is, he may be concerned about reaching
some excessive degree of exposure that would be threatening to
him. The patient may fear falling in love or being enthralled with
the therapist, becoming too needy, or becoming dependent upon
exhibiting himself for the therapist. The patient may also fear, as
he begins to establish a real attachment to the therapist, that the

therapist might then desert him, scorn him, or use him.
In other words, even in a brief therapy focused on the
patient's recent serious life event, there are all the various tests
and trials that establish the network of communication in a long-
term therapy. If the therapeutic alliance is like a pathway, then
the patient and therapist can step to either side of the path.
Stepping to one side would preserve an excessively social
relationship and not deepen it to the usually open communication
of a therapeutic alliance; stepping to the other side would

intensify transference reactions.
Formation of a therapeutic alliance does not mean that
transference reactions will not develop, nor does it mean that the
patient and the therapist may not at times engage in social
interchange. It does mean that there is a relatively secure and
agreed upon model of the roles of each person and the ground
rules they will follow. When a transference reaction occurs, it can
be examined in contrast to this therapeutic alliance. The image

that the patient has of the therapist in the transference can be
contrasted with the image that the patient has of the therapist as
his therapeutic ally. His self-image within the transference can be
contrasted with his self-image in the working relationship. These

contrasts and challenges allow the patient to revise or
subordinate the self-images and role relationships that have been
projected into the transference reaction.
As the therapy progresses, even if it is very brief, the safe

relationship is deepened because both parties, but particularly
the patient, learn that risks can be taken and result in good
outcomes. The patient may work out new levels of awareness,
especially about primitive self-images and role relationships
activated in response to the life event. Through the therapeutic

communication, he may learn new ways of thinking through
immediate problems. He may learn these skills, not only directly
by insight, but also by identification with the therapist. As in other

therapies, the brief treatment of stress response syndromes often
produces a period in therapy in which the patient reverses roles.

After initial relief he tends to make the therapist feel helpless, just
as he has been made to feel helpless by the stressful event. He
then watches very carefully to see how the therapist handles

helplessness. He copies the therapist’s coping maneuvers. If the
therapist appears intact he may then allow himself to experience
the feelings he has warded off. For example, he may tell about the
loss of a loved one in such a moving manner that the therapist
feels sad. He watches this very carefully, and if the therapist can
feel sad and can tolerate feeling sad, then the patient may allow
himself to feel sad and to begin a mourning process.
Information Processing Issues
Let us assume now that the therapeutic alliance is

established and within that safe relationship there is work on
modifying the status of the patient’s controls. Once again, talking
particularly about stress response syndromes, one notices two

common variations from the ideal path of naturally working
through reactions to a serious life event. One is that the person is
in a state of relative failure of controls; he feels and acts flooded

and overwhelmed by ideas and emotions related to the stress
event. The other is that he cannot permit contemplation of the
event and its personal implications.
When the person experiences relative failures of control, the
activities of the therapist are geared toward helping him to regain

a sense of his ability to be self-regulating. This is done through the
everyday methods of psychotherapy: by helping the patient to

focus attention, by asking questions or repeating comments, and
by clarifying statements. Most importantly, it is helped by
reconstructive interpretations—interpretations that help the

patient to order facts in a sequence of time (7), to make
appropriate linkages, and to separate reality from fantasy in
order to reduce the threats of reality by reducing the adherence
to fantasy expectations. Even when a person is frightened by his
own impending death, as when he has a serious and fatal illness,
he can often courageously cope with the reality of this, if he is
helped to dissociate the real loss, real sadness, and real tragedy
from imagined, fearsome consequences such as being entombed
while alive, being helpless and deserted by people, and endlessly
falling away from life with continued panic-stricken

consciousness.
One aspect of working-through a serious life event is review
of the various self-images and role relationships that are

associated with it. Because of the emotional pain aroused by this
review, most patients will have interrupted some aspects of it. In
therapy the controls used in that interruption are set aside in a

sequential manner. Most of this is done automatically by the
patient himself, once he has established a safe relationship with
the therapist. When there is reluctance to do so, the therapist,

using the repertoire of customary psychotherapeutic
interventions, may alter the defensive deployment by

interpreting defenses and the reasons for them, by increasing
attention to warded-off material through interpretation and
labeling, or by simply creating evocative situations into which the

patient will bring the ideas and feelings that have been avoided.
The goal is to allow the patient to reappraise and revise his
inner thoughts so that models of the world now accord with new
realities. This may be reached by establishment of a safe
relationship or by additional interventions to alter the status of
the patient’s control.
As he examines warded off ideas, the patient may find, even

after a serious life event where he has sustained a loss, that he is
not as vulnerable or as incapable of coping with this event as he
had thought. He may also become aware of other real available

resources.
Every life event will set in motion a process of analysis of the

changes caused by that event, as the mind seeks to maintain a
reasonably accurate inner model of the external reality. Therapy
will deal with the themes or constellations of meaning that the

person cannot process on his own. Certain themes are relatively
universal, as indicated in Table 3. The person will examine many
of these themes independently and without difficulty. One or

another theme, however, will either be accompanied by flooding
of emotions, be warded off by pathological defensive maneuvers,
or a combination of both. These themes will be a primary focus in
therapy.
Table 3
Common Concerns After Stressful Life Events
Fear of repetition.
Fear of merger with victims.
Shame and rage over vulnerability.
Rage at the source.
Rage at those exempted.
Fear of loss of control of aggressive impulses.
Guilt or shame over aggressive impulses.
Guilt or shame over surviving.
Sadness over losses.
Realignment of the Therapeutic Focus
The patient will have presented a problem state as a chief

complaint or motivation for seeking help. The first focus or
agreement between patient and therapist will be to help

attenuate this state, or avoid reentry into it. This state will be seen
in relation to other states of experience and behavior. A broader
analysis of the situation, with the patient, will include

examination of the reasons for entry into problem states, as well
as other even more threatening states that are warded off. A more
detailed analysis of this issue, with a verbatim account of a brief
therapy of a stress response syndrome is available in the

literature (5).
As this process occurs, there is modification of the focus
agreed upon by patient and therapist. At first the focus is a

problem state, such as intrusive ideas and pangs of emotion
which exceed tolerable limits. As these symptoms are resolved,
the focus is on when and why the person enters such painful
states. This revised focus often has to do with particular self-
images and inner models of role relationships. If the focus is not

modified, then the patient tends to move towards termination or
avoidance of treatment when he achieves enough control to enter
a relatively stable denial phase. We see separation from

treatment at this time as an error because the patient has not
worked through some of the most difficult issues of his response,
and may not do so on his own.
A clinical example may illustrate this point.
The patient was a young woman in her mid-twenties. She sought help
because of feelings of confusion, intense sadness, and loss of initiative six
weeks after the unexpected death of her father. Her first aim was to
regain a sense of self-control. This was accomplished within a few
sessions, because she found a substitute for the idealized, positive
relationship with her father in the relationship with the therapist, and
experienced a realistic hope that she could understand and master her
changed life circumstances.
As she regained control and could feel pangs of sadness without entering
flooded, overwhelmed, or dazed states, she began to wonder what she
might accomplish in the therapy and if therapy was worthwhile. The
focus gradually shifted from recounting the story of his death, her
responses, and the previous relationship with the father to
understanding what her current inner relationship to her father was and
how her view of that relationship affected her shifts among a variety of
self-images. The focus of therapy became her vulnerability to entering
states governed by defective, weak, and evil self- images.
Her defective self-images related to feelings that her father had scorned
her in recent years because she had not lived up to the ideals that he
valued both in himself and in her during an earlier, formative time. He
died before she could accomplish her goal of reestablishing a mutual
relationship of admiration and respect by convincing him that her
modified career line could lead to its own worthwhile accomplishments.
This image of herself as defective was matched by a complementary
image of him as scornful of her. Reacting to that interpretation of the
relationship, she felt ashamed of herself and angry at him for not
confirming her as worthwhile. In this role relationship model, she held
him to be strong, even omnipotent, and in a magical way saw his death as
his deliberate desertion of her. These ideas had been warded off because
of the intense humiliation and rage that would occur if they were clearly
represented. But contemplation of such ideas, in the therapeutic alliance,
also allowed her to review and reappraise them, revising her view of
herself and of him.
Every person has multiple self-images and role relationship models. In

this patient, an additional important self-image of herself was as a
person too weak to tolerate the loss of a strong father. As is common, no
life event occurs in isolation from other life changes, but is almost
invariably part of a cluster or domino effect. As she returned from the
funeral for her father, she turned to her lover for consolation and
sympathy. She had, however, selected a lover who, like her father, was
superior, cool and remote. When she needed care and attention he was
unable to comfort her, and they separated. Establishment of a
therapeutic alliance provided needed support, but termination
threatened her once again. In the mid-phase of therapy, it was also
necessary to focus on these weak self-images in order to test them
against reality and her other self-images as competent and capable of
independence.
In addition, a focus was also established on her self-image as an evil,

destructive person. It was her belief that persons of sound mind and
psychological well-being did not fall physically ill. Her father had died
suddenly of a cerebrovascular accident and was thought to be in perfect
health until that time. Before his death she had indicated to her father
that he was too cold and remote, and had detached himself from a
relationship with her that ought to be warm and loving. She now felt as if
she had caused him emotional conflicts that had contributed to his
hopelessness, guilt, and self-punishment, as well as to his somatic
reactions. Her anger with him for deserting her before his death was
activated by rage responses at his deserting her by dying. Recognition of
incipient hostile thoughts tended to bring forward her evil, destructive
self-images. Confrontation with this theme allowed separation of reality
from fantasy, reduced guilt, and enabled her to complete this aspect of
reviewing implications of the death.
To recapitulate, early in therapy this patient rapidly established a

therapeutic alliance, focused on relieving her of the acute distress of the
intrusive phase of a stress response syndrome. This alliance led to rapid
attenuation of the problem states. With symptom reduction, the focus
shifted to the agreed upon aim of working through various aspects of her
relationship with her father. In addition to the primary meanings around
grief, that is, the loss of continued relationship with her father and hope
for working further changes in it, she had to work through several
additional themes: herself as scorned by her father, herself as too weak
to survive without her father, and herself as evil and partly responsible
for his death.
These important self-images, present before the death, were worked

with during the mid-phase of therapy. They were related not only to her
father, but to other past figures (mother and siblings), current social
relationships, and transference themes. As she developed controlled
ability to recognize and work with these themes, the focus shifted from
past and current versions of these constellations to future issues. Were
she to continue with these self-images and views of role relationships,
she might either reject men altogether or continue with a neurotic
repetition of efforts to regain her father and convert him into the ideal
figure she remembered from early adolescence. This prospective work
also included examination of her reaction to separation from the
therapist and how she would in the future interpret that relationship.
The focus in the therapy shifted from her responses to the death, to four
major themes connected associatively to the loss. One theme was the
mourning itself: herself as bereaved and her father now as lost except to
her memory. Exploration of this theme could not be completed in a brief
therapy. The issue in therapy was to normalize the grief process so that
she could continue on her own, feeling dejected and sad, but not
uncontrollably overwhelmed by the process.
Another theme focused on her self-image as being too weak without the
inner model of her strong father to sustain her. Active confrontation with
this fantasy was enough to restabilize competent self-images which
allowed her to enter and continue mourning.
A third problem image was herself as worthless and defective, in relation

to scornful men. She held this preexistent self-image in check by having
relationships with older, “superior” men. Their admiration for her was
held as an effective but brittle rebuttal to the other premise she held that
she was as worthless to them as she had been to her father. This was a
core neurotic theme examined in the therapy and related to her future
prospects. It was not worked through in the brief therapy. There was,
however, the possibility that once she recognized the issue, she might be
able to work it through herself in the course of her later life experiences,
with resulting structural personality change.
A fourth self-image was herself as evil because she had experienced

anger with her father and the associated premise that anger harms
others physically. Once this idea was encountered with clear
consciousness, it could be dissociated from magical thinking and lo:-e its
power to make her feel guilty.
Working with Control Operations
Every person has his own style for controlling the flow of
ideas in order to avoid entry into painful states. The shifts in focus
just discussed in the case evolved gradually because the person
had warded off threatening ideas about herself as guilty for the
death, as too weak to cope with it, and as too defective to have a
future. Once she contemplated these ideas in the therapeutic
alliance, which strengthened and stabilized her competent self-
image, she could tolerate and deal with them. But en route to this
position, various controls interrupted her associative processes.
Each person will exert different control patterns. While all

persons may inhibit some ideas and feelings, switch between
reversed ideas and feelings, or slide around the interpretation of

an important idea or feeling, each person may favor certain
avoidances and certain ways of representing ideas and feelings.
Even in a focal therapy aimed at working through ideas and

feelings responsive to a serious life event, the technique of the
therapist should be sensitively geared to these habitual modes. It
is beyond the scope of the present communication to go into

detail on varied approaches to the facilitation of information
processing. However, three tables (Tables 4, 5, and 6) summarize
some of these issues. Relevant discussions may be found

elsewhere (4, 5, 6).
Table 4
Some “Defects” of the Hysterical Style and Their Counteractants in
Therapy
Function Style as “Defect" Therapeutic
Counter
Perception Global or selective inattention Ask for details
Representation Impressionistic rather than accurate "Abreaction”

and
reconstruction
Translation of images Limited Encourage

and enactions to talk
words Provide verbal
labels
Associations Limited by inhibitions Encourage

Misinterpretations based on schematic production
stereotypes, deflected from reality to wishes Repetition
and fears Clarification
Problem solving Short circuit to rapid but often erroneous Keep subject
conclusions open
Avoidance of topic when emotions are Interpretations
unbearable Support
Table 5
Some “Defects” of Obsessional Style and Their Counteractants in
Therapy
Function Style as “Defect" Therapeutic Counter
Perception Detailed and factual Ask for overall impressions and

statements about emotional
experiences
Representation Isolation of ideas from emotions Link emotional meanings to

ideational meanings
Translation of Misses emotional meaning in a Focus attention on images and

images to rapid transition to partial word felt reactions to them
words meanings
Associations Shifts sets of meanings back and Holding operations

forth Interpretation of defense and of
warded-off meanings
Problem Endless rumination without Interpretation of reasons for

solving reaching decisions warding off clear decisions
Table 6
Some “Defects” of Narcissistic Style and Their Counteractants in
Therapy
Function Style as “Defect" Therapeutic Counter
Perception Focused on praise and Avoid being provoked into either praising
blame or blaming
Denial of “wounding” Tactful timing and wording to counteract
information denials
Representation Dislocates attributes as Clarify who is who in terms of acts,

to whether of the self or motives, beliefs, and sensations
another person
Translation of Slides meanings Consistently define meanings, encourage

images into decisions as to most relevant meanings
words or weightings
Associations Overbalanced in terms Hold to other meanings; cautious

of finding routes to self deflation of grandiose meanings
enhancement
Problem Distortion of reality to Point out corruptions (tactfully),

solving maintain self esteem, encourage and reward reality fidelity
obtain illusory Support of self esteem during period of
gratifications, forgive surrender or illusory gratification (real
selves too easily interest of therapist and identification with
therapist as non-corrupt person help)
Help develop appropriate sense of
responsibility
Find out and discourage unrealistic
gratification from therapy
Termination
Overlapping with these processes is the recognition by both
patient and therapist, especially if a time limit is used, that they

must work through detachment from each other. In our work, we
now generally set a time limit of 12 sessions; the patient and
therapist then know how to pace topics and can relate themes of
termination to themes of loss involved in the prior stress event.
For example, the approach of an agreed upon endpoint of therapy

may be misinterpreted by the patient as a rejection because he is
unworthy, as a separation that he is too weak to tolerate, or as a
retaliation for his hostile ideas and feelings. Interpretations of
transference reactions involved in such views can be related to

reactions to the life event and configurations of the
developmental past. In this linking work the focus on the stressful

event is not lost, but intensified by meaningful linkages to
recurrent patterns of self- image and role relationship. These
patterns, especially during a termination period, can be examined

from different points of view, from the ‘‘here and now” of therapy,
the “there and now” outside of the therapy, and the “there and
then” of the past as reviewed “here and now” in the therapy.
Towards What End?
While there has been general clinical agreement on the gains
of working through a focal problem, there has not been

agreement on the types of change in character structure that are
possible through brief therapy. Some say that radical changes can
be made in psychic structure as a result of processes initiated
although not completed in brief therapy (10, 11). Others believe
such changes in personality structure can only take place in the

context of extended psychotherapy or analysis.
In our own treatment of stress response syndromes, we have

not yet accumulated sufficient research data to say, on the basis of
evaluations, what structural changes generally are possible. We

have, however, seen some instances where some personality
changes have been set in motion and then accomplished by the
patient through life development in the ensuing year or two. We
speculate here on some reasons for these observations.
In the previous discussion, we briefly described a process

concerned with completing the reaction to a serious life event.
This involved working through not only the meanings of the event
itself, but its implications for one’s relationships, self-images, and

behavior in the world. Such work entailed not only reappraisal of
the event and reappraisal of the self, but revision of core inner
models of self, role relationships and future plans. During this

process the person decides to make revisions, plans different
types of actions and attitudes, and finally practices new attitudes
until new models become as automatic as previous models. This

practice continues after termination.
In the course of this work, the patient studies his own

responses, not only to this event, but to a series of related life
events in the past. Thus, the patient is learning something from
the therapy that goes beyond the focal working-through of the
specific event. When he is following the more directive

interventions of the therapist, he is learning new skills such as the
ability to use reflective awareness to think in new ways. When he
is following the interpretive line suggested by the therapist, he is

learning how to be insightful and how to modify habitual
avoidances that usually operate preconsciously or unconsciously.
Patients sometimes become aware, in the course of these
brief therapies, of a particular style they have of not thinking
about events, and they are able to deliberately alter that situation.
It may be possible for them, by continued work on their own after
the therapy, to live out changes that may gradually be

incremental in altering habitual controls.
When a person experiences the impact of a serious life event,
such as a loss or injury, there is threat of undermining his most

advanced, adaptive role relationships. There may be regression to
earlier role relationships or the meaning of the event itself may
tend to create some new role relationship, perhaps with

unattractive, dangerous or undesirable characteristics. The
person may then enter a series of painful, strongly affective states
based on the altered self-images and the changed role

relationship. As a consequence of therapeutic facilitation of
normal processes, the disturbing role relationships or self-images
can once again be subordinated to more adaptive, mature self-

images and role relationships. Intensive work in a brief therapy
model may both alter the symptomatic response to a stressful life
event and facilitate further progress along developmental lines.
REFERENCES
1. Caplan, G. Approach to Community Mental Health. New York: Grune 8: Stratton, 1961.
2. Freud, A. The Ego and the Mechanisms of Defense. London: Hogarth Press, 1920, p. 7-
64.
3. Freud, S. Beyond the Pleasure Principle. Standard Edition, Vol. 18. London: Hogarth
Press, 1920, pp. 7-64.
4. Horowitz, M. J. Sliding meanings: A defense against threat in narcissistic personalities.
Int. J. Psychoanal. Psychother., 4:167-180. New York: Aronson, 1975.
5. Horowitz, M. J. Stress Response Syndromes. New York: Aronson, 1976.
6. Horowitz, M. J. Structure and the processes of change. In: M. J. Horowitz (Ed.),

Hysterical Personality. New York: Aronson, 1977.
7. Jacobson, G. E. “The Crisis Interview” presented at symposium on “Comparative

Psychotherapies,” University of Southern California School of Medicine,
Department of Psychiatry, Division of Continuing Education. San Diego, Ca.: June
1974, 24-28.
8. Kanas, N., Kaltreider, N. B., and Horowitz, M. J. Response to catastrophe: A case study.
Dis. Nerv. Syst., 1977, 37:99-112.
9. Lindemann, E. Symptomatology and management of acute grief. Amer. J. Psychiat.,

1944, 101:141-148.
10. Malan, D. A Study of Brief Psychotherapy. London: Tavistock, 1963.
11. Malan, D. Frontier of Brief Psychotherapy. New York: Plenum, 1976.
12. Mann, J. Time Limited Psychotherapy. Cambridge, Mass.: Harvard University Press,
1973.
13. Sifneos, P. F.. Short Term Psychotherapy and Emotional Crisis. Cambridge, Mass.:
Harvard University Press, 1972.
Note
1. Research on which this article is based was supported by a Clinical Research Center
grant from the National Institute of Mental Health (MH 30899 01) to the Center
for the Study of Neuroses of the Langley Porter Institute, University of California,
San Francisco. Staff and faculty members of the center include: Seymour
Boorstein, Dennis Farrell, Eric Gann, Michael Hoyt, Nick Kanas, George Kaplan,
Janice Krupnick, Richard Lieberman, Norman Mages, Charles Marmar, Alan
Skolnikoff, John Starkweather, Robert Wallerstein, and Nancy Wilner, who also
edited this manuscript. Their contribution to these ideas is gratefully
acknowledged. Additional research grant support was given by the Fund for
Psychoanalytic Research of the American Psychoanalytic Association, the
Chapman Research Fund and the general fund of UCSF for bio-medical research
(BRSG-05755).
9
Psychotherapy with the Obsessive

Personality
Leon Salzman, M.D.
Psychodynamic Conception of Obsessive Disorders
The therapy of the obsessional states must bear some
relationship to the psychodynamic concepts that underlie the

etiology of these obsessive disorders. If one views the problem as
a process of holding in check sexual or aggressive impulses, we
can hypothesize that the patient is overwhelmed by angry, hostile
or sexually exploitative feelings that, if unrestrained, would

seriously endanger his existence. Our therapy would, therefore,
be directed at helping the patient recognize that, in fact, he has

such feelings that he is managing to control by displaced
obsessional or compulsive symptoms which impair his
functioning.
This notion would encourage the therapist to see the

patient’s behaviors, overt or subtle, conscious or unconscious,
manifest or latent, as distortions, displacements, reaction
formations, and the like, of hostile, aggressive or sexual feelings
and interpret such feelings in this light. The focus would be on the
patient's hostility and even his tender feelings would be viewed
as defenses against his hostility. The content of his rituals,
doubting, procrastinating, indecisiveness and perfectionistic

arises would be visualized by the therapist and translated to the
patient as evidence of his hostile designs and intentions towards
the significant individuals in his life. The psychotherapeutic

process would focus on exposing, interpreting and reviewing
these activities to emphasize the hostilities and ultimately relate
them to the original libidinal source in the anal psychosexual

period of development. The expectation would be that after
sufficient exposure of these regressed tendencies through a
transference relationship the behavior would be abandoned as

unnecessary.
This was the initial conception of these disorders. Freud saw

the symptom as a device for dealing with unacceptable hostile or
sexual impulses by using displacement, condensation, and
symbolization as defenses against them. The symptom, he

thought, was a compromise of “doing” the forbidden wish and at
the same time “undoing” it. However, not only sexual or hostile
impulses need to be controlled, but also the tender, friendly, or

stupid and unworthy thoughts and feelings. In my view, the
obsessive-compulsive dynamism is a device for preventing any
feeling or thought that might produce shame, loss of pride or status,
or a feeling of weakness or deficiency—whether such feelings are
hostile, sexual, or otherwise. I see the obsessional maneuver as an

adaptive technique to protect the person from the exposure of
any thought or feeling that will endanger his physical or

psychological existence. This extends Freud's views and does not
require the postulate of an instinct theory or libido theory.
Psychotherapy
A rational psychotherapy must include an understanding of

the pervasive and persistent tendency to resist change in order to
preserve the relative stability of the anxiety-reducing defensive
structure. It is also necessary to have a knowledge of techniques
of therapy which aid the process of illumination, insight and
behavior alterations. Awareness of both the neurotic structure

and the overpowering need of the obsessive individual to
maintain it intact is crucial in the treatment of the obsessional

states. Every tactic, gambit, maneuver, interpretation and clinical
intervention must take into account the extraordinary capacity of
the obsessional to evade, distract, obfuscate and displace in order

to avoid confrontation and change. Tactics which reinforce or
encourage those defenses must be avoided by the therapist who,
more often than not, has many obsessional characteristics

himself.
The essence of the obsessional defenses is antithetical and

opposed to the essential requirements of the therapeutic process
and militates against the exposure and discovery of the patient's
deficits and deficiencies. The obsessional often views therapy as a
challenge to his omniscience and omnipotence and steadfastly

rejects any new awareness which would require him to admit to
himself and others that there are matters about which he is
unaware. Since he feels he must know it all, he frequently rejects

an observation as invalid—only to present it later as his own
discovery. The therapist’s early tolerance of this tactic must give
way to a later confrontation after a positive relationship has been

established. This may be long in developing, since the
requirements of trust and commitment needed to bind a
therapeutic relationship are precisely what the patient fears and

tries to avoid.
The overriding need to control one's inner and outer world
requires orderly, manageable and guaranteed living. The adaptive

devices, such as the ritual, the maintenance of doubts and the
unwillingness to commit oneself, along with the attempts of

omniscience, omnipotence and striving for perfection and
superhuman performance, are all attempts to control one’s safety,
security and survival. This permits the obsessional to have an

illusory feeling of being safe, secure and in control. Being in
control means guaranteed certainty and an absolutely secure
stance, which interferes with the growth of enough trust for a

minimal commitment to therapy. The barrier to trust may never
be overcome, regardless of the ostensible cooperative behavior
and the willingness to be a patient in an interminable program.
No wonder the treatment is long, uncertain and tediously

unrewarding for both parties! The obsessional spends many
therapy hours in distracting avoidances and contentious

disagreements while he is intellectually astute and cognitively
capable of clearer analysis. Affectively, however, he is totally
unengaged until well into therapy.
To be absolutely safe and certain, it is necessary to know

everything in order to predict the future and prepare for every
eventuality. The obsessional needs to know everything and
emphasizes intellectual attainments above all else. To maintain

the fiction of perfection he must never make an error or admit
any deficiency. It requires that he never risk, being wrong by

taking sides, making definite decisions or committing himself to a
point of view or course of action, in case it turns out to be the
wrong one. This, in turn, produces the classical behavior of the
indecisive obsessional, who tries to avoid definitive actions of any

kind lest he be wrong.
How do we deal with the indecision, and the unwillingness to

make a commitment or express a point of view? We must
encourage the patient to take the risk of being unsure and even
making an error. He must see that this does not imply danger and
total rejection. He must try to experience the reality of being
human and uncertain. The therapeutic task, therefore, is to
encourage action anti decision even when all the facts are
unavailable and the issue is in doubt. The therapist must also risk
being criticized if the decision he encourages is not the best. This

applies to only minor decisions and not to the major ones like
marriage, change of job or the like. In cases such as those, the
therapist must be very clear and cautious in not providing the

patient with the rationalization for his decision and not allowing
him to put the responsibility for failure on to the therapist. The
patient must be encouraged to take a stand, but the therapist

must be the neutral agitator who pushes for a solution without
taking sides. In fact, decisions and closures are so difficult for the
obsessional that he/she generally makes them by default rather

than by committed intention. In any situation the therapist must
not take the responsibility for being the decision maker.
The tendency towards procrastination is intimately related

to the tendency to doubt as a way of guaranteeing one’s
omniscience when life forces a decision or a choice. It is the

pervasive doubt that produces some of the most bizarre
obsessive symptoms, such as trying a door dozens of times to
make certain it is, indeed, locked. No sooner has the action been
taken than the individual becomes uncertain that he has carried it
out. It is also the doubting that produces the “yes-no” response
we call ambivalence. One must entertain both feelings or support

both sides of every issue in order to come out correct and in
control of the situation. The ambivalent attitude in the
obsessional is this aspect of playing both sides and promoting an
ambiguity and uncertainty which allow him to maintain doubts

and to avoid positive feelings and attitudes.
The rituals, whether they relate to hand-washing, checking
the lights or door, keeping books in order, etc., are attempts to

achieve certainty and control by magical gestures. At the same
time, they shift the focus of the patient’s interest onto issues not
directly related to the main concern. The ritual activity becomes

so pervasive and time-consuming that the original reason for
engaging in this activity is forgotten.
Attempting to understand the precise meaning of the ritual
may be an interesting intellectual exercise, but in general it will

not advance the therapeutic process to any appreciable extent.
The same problems which stem from investigating the origin of

the doubting also apply in the instance of rituals. Further, while
the symbolic meaning of the ritual can often be inferred from the
various elements in it, an intellectual elucidation of the symbolic
acts seldom, if ever, alters the ritual. The classical hand-washing
ritual, for example, can be correctly interpreted as an attempt to

guarantee safety and survival by eliminating dangerous germs or
sexual contamination or wash away guilt. It could also be a device
for keeping the person preoccupied and thereby prevent him

from getting on with his living. The particular ritual employed
may be entirely accidental or coincidental and may have
significance only in terms of the setting in which a severe anxiety
attack may have occurred. Since the real roots of the ritual lie in
deep-seated feelings of uncertainty about one’s safety and

security, the proper interpretation of its meaning usually does not
influence its continuation. The understanding of the purpose of
the ritual may be easily and readily accepted by the patient, while
at other times the ritual may be so autistic and complicated that
its elucidation is impossible.
Generally, the search for the origin of the ritual is not worth
the time spent, since one way of evading the therapeutic
relationship is for the patient to become preoccupied with
descriptions and detailed explanations of the ritual. The presence

of many rituals in a patient is some indication of the severity of
the obsessional illness and generally implies a poor prognosis,
while a paucity of rituals suggests a less severe personality

disorder. In either case, the fate of the ritual is tied to the overall
treatment progress, and the patient must be so informed from the

beginning.
The ritual will be abandoned when the patient’s need for

magic and ultimate control of himself and the universe is
lessened. If the ritual is particularly incapacitating, the therapist

might try to attack it directly and either eliminate it or alter it. In
doing this, however, it must be clear that the basis for the
development of the ritual has been unchanged even though its
presence may have been eliminated.
Communication
The obsessional’s need for perfection, which colors his

communication, is especially complicated and difficult in a
treatment situation, since verbal productions are an integral part
of the process. In his effort to be precise and clear, the obsessional

introduces more and more qualifications in his presentation to be
certain the matter is presented in its fullest and most complete
form. This adds confusion to the process and, instead of clarifying,

tends only to cloud the issues. While it may appear that the
patient is deliberately trying to confine the therapist, the
therapist must understand that the patient is trying to be more

precise and avoid making errors; he is not trying to sabotage the
treatment. The tendency to be distracted and to move off in
tangents keeps the patient from getting to the point of his
communication and makes exchanges with him seem like a never-

ending succession of waves, with each idea setting off a multitude
of ripples. Because of the obsessional’s tendency to ramble and be
distracted, the free association process often serves to defeat its

purpose and may involve the therapy in endless trivia and
irrelevancies. The therapist must be active and energetic to
prevent this development by attempting to interrupt the
irrelevancies and focus on the relevant whenever it is apparent to
him.
The therapist must always be aware of the limits of his
patient’s capacities to tolerate certain interpretations or
observations; he must stop short lest he increase the defenses

which ordinarily protect the patient against anxiety. Anxiety will
limit the patient’s capacities to observe and acknowledge the
therapist’s interpretations. When interpretations are seen as

criticisms or as deflating to the patient’s esteem, the patient will
react with even more elaborate defenses. On the other hand, the
therapist’s observations must not be too bland or they may be
easily overlooked.
Activity
Activity on the part of the therapist is absolutely essential
from the beginning of the therapy to the end. Even a meagre

understanding of the dynamics of the obsessional state requires
that the therapist not permit the techniques which defeat
communication to continue for too long a time—although the
therapist’s activities must never be so intense as to overwhelm

the patient or make him feel that the therapy is being dominated
by the therapist. Free association, as well as the tendency to
endless detail and circumstantiality in the obsessive accounts,

must be controlled by the therapist. Therapist passivity can only
lead to interminable analyses in an atmosphere that becomes

more clouded and confused, which is often the reason for the
long, fruitless analyses, which characterized an early stage in the
development of the methodology of psychoanalytic treatment of
the obsessional.
How do we determine what is relevant and what is irrelevant

in the clarification of an obsessional problem? The notion that
“everything is relevant’’ in a deterministic view of the mind often
leads to endless and interminable inquiries which reinforce the
obsessional pattern, while discouraging certain communications
may imperil the unfolding of significant and illuminating details.
Clinical judgment, based on the growing knowledge of the
etiology and maintenance of an obsessional neurosis, permits us
to make such decisions with reasonable expectation of success.
One must determine, from the abundance of issues

presented, those details and matters which should be dealt with
at once and those which can be left for a biter date. What is
selected depends on many factors, such as the therapist’s
theoretical orientation, the nature of the main theme currently
being explored, the possibility of a potentially enlightening
recollection being introduced, or the contradictions or
substantiation of earlier material. Of all the possible determinants
I would suggest that the most cogent issue is the therapist’s
treatment plan and the direction he is currently pursuing. lie
should pick the lead that is generally moving towards the goal.
Emotions
Difficulty in controlling one’s feelings and emotions, which is
ontogenetically more primitive than intellectual capacity, leads
to the tendency to avoid, isolate and displace emotional
responses. In addition, feelings may involve or commit one to a
person or an idea. The need to control emotions prevents a
commitment to the process of therapy, to a person, or to the
therapist.
The obsessional exhibits great skill in avoiding any

involvement with the therapist, although he may talk extensively
about involvement and the problems of transference and
countertransference. He will even talk about feelings and
emotions. However, it will be a succession of words drawn from
an intellectual comprehension of the issues involved, devoid of
any real emotional response. It is, therefore, necessary to focus on
real feelings and to limit, as much as possible, such intellectual
discussions. Obviously, they cannot be avoided entirely, but they
can and should be minimized and, whenever possible, the
expression of feelings be encouraged with questions such as
“How do you feel about that?” or “You must have been annoyed
(pleased, etc.).”
Recent Events
Much of the therapeutic process comes from the examination

of events that can be explored in the immediacy of the therapeutic
hours, especially in the transference relationship. While this is
true in any psychotherapeutic situation, whatever the disorder or
personality style, it is crucial in the treatment of the obsessional,
whose recollections are pervaded with doubts that limit

conviction about the interpretations growing out of earlier
reconstructions. The endless bickering, qualifying and
uncertainty about past events make it much more convincing

when the patient can see his distortions or other defensive
activity under circumstances where doubts cannot be introduced
or used to defeat insight. The most effective technique is the

examination of recent events, here-and-now events, which allow
for the least distortions. Even under these circumstances there
are many complications. It is difficult to avoid getting involved in

a “flypaper relationship” or a tug-of-war with the patient, who
reacts to what he experiences as control and attempts to put
down the therapist and minimize the value of the exploration.
Our desire to explore the emotions is also aided by the tactic
of focusing on recent events. The patient can readily discuss the

frustrations, disappointments and despairs of previous years.
They are behind him and are open to explanations and
justifications of many kinds. Past feelings can be described and

experienced calmly, judiciously and intellectually, so that the
value of their assessment in the therapeutic process is sharply
reduced. However, present hostilities and frustrations,

particularly as they involve ongoing relationships, are much more
difficult to admit. For the patient they represent failures or
deficiencies and expose too much of his feeling.
Sharing his feelings of distrust, dislike or liking for the
therapist is very difficult, even though he attends to the formal

requirements of the therapeutic contact. Anger is much more
easily expressed because it is more actively encouraged and

presumed to be therapeutic.
The obsessional is often visualized as having stored up

hostilities, and the critical element in the resolution of the
disorder is the expression of these aggressive feelings. The

overriding tendency towards control blankets both tender and
hostile feelings; consequently, the obsessional appears to be calm
and controlled. However, his hostile feelings are more available to

him than his tender feelings; they are invariably expressed in
subtle, covert, but unmistakable ways in detracting, derogating,

sniping, petty oversights and the like. Direct expressions are
avoided but the presence of hostility is apparent to the patient

and to others. The tender impulses and affectionate reactions,
which are viewed as threatening and dangerous, are securely
bound down and rarely exposed overtly or covertly, even in the

subtleties of his behavior. The obsessional must learn to identify
these feelings and be encouraged to express them. I believe the
control over these tender and loving feelings constitutes the

essence of the obsessional defenses. It is the failure to express
these feelings, rather than his hostile behavior, that initiates
retaliatory behavior from others, which in turn stirs up the
obsessional’s wrath and hostile rejoinders.
The emphasis on the “here and now” by many post-Freudian

theorists finds its greatest reward in the treatment of obsessional
disorders. The more recent conceptions of mental illness do not
focus exclusively on the genesis of these disorders as libidinal

deformations, nor do they conceive of the beginnings in relation
to any specific trauma. The developments are seen as occurring in
an atmosphere in which repeated experiences produce effects on

the person in obvious or subtle ways. Therefore, discovering the
actual origin or beginning of a symptom or personality
characteristic seems of less value than a general recognition of

the milieu or atmosphere of the household, or the general
attitudes of the parents.
In the adult years, one deals with a problem, the origin of

which is only a single element in its continuation; the persistence
of the faulty pattern is related to the process of conditioning and
habit. Therapy must unravel the detailed and widespread

defensive techniques which develop and penetrate into every
aspect of the obsessional’s life, as well as search for the origins of
the symptoms. This requires a knowledge of the patient's present

living, in order that the therapist may see the subtleties and
intricacies of his defensive processes. This is a most difficult task

and comprises the bulk of the work in the therapeutic process. To
achieve this the therapist must be prepared for a long and
arduous job of repeating the same observations and
interpretations frequently before they are truly recognized by the

patient. It requires patience and understanding of the tenacious
and persistent nature of the obsessional process.
Grandiosity
To deal with his feelings of powerlessness, and his

assumption of omnipotence, the obsessional often develops
attitudes which get expressed as belittling and condescending

feelings towards others, as well as toward the therapist. The
patient remains distant but proper in fulfilling his role. Secretly
he feels superior and contemptuous of the therapist and feels he

is “on” to all that is happening. He catalogues all the therapist’s
deficiencies, storing them up for use at a proper time. In this way
he maintains a secret ammunition cache and an advantage over
the therapist. The therapist therefore cannot take for granted that
the patient, even though he appears to be pursuing the
therapeutic process is, in fact, doing so. He may simply be doing
the right thing. It is a long time before such patients can

experience and express their doubts and concerns about the
process. Their omniscient needs do not allow the recognition of
deficiencies and, therefore, they resist interpretations which
require them to admit they were ignorant about many things,
especially interpersonal relationships.
In order for the patient to accept new insights, he must be
encouraged to see how it will benefit him instead of visualizing
the disasters that will confront him when he feels helpless and is
not in total control of everything. This problem becomes acute
when the patient is called upon to try out new insights in his
living, and his needs for certainty and guarantees deter him from
attempting new and untried pathways or solutions. Since the
patient will report difficulties and failures in his attempts at
change, this tendency must be clarified to avoid becoming
entrenched in his neurotic, circumscribed existence which is
experienced as safe because it is familiar.
The obsessional’s grandiosity leads him to expect magical

leaps and massive advances in therapy. He is impatient with small
gains and expects every meaningful interpretation to be followed
by great advances or total cure. There is often a profound

disappointment when an illuminating exchange is followed by a
repetition of the old pattern. When this happens, the patient
criticizes the therapist and the psychotherapeutic theory as well

as himself because he feels that he has failed to live up to his own
grandiose expectations. As he can accept only total and complete
restoration of his grandiose self through therapy, he cannot abide

the slow, gradual process of learning and changing. This leads him
to the frequent charge that the therapy is doing no good
—“Nothing has changed; it’s been a waste of time and money.’’
The therapist must avoid trying to justify his work or
blaming events on the patient’s lack of cooperation. When
progress is slow or absent, the therapist should not put the blame
on the patient’s resistance or resort to the concept of the negative
therapeutic response. While many factors may be at work in the
negative therapeutic reaction, it is clear that many therapeutic

impasses or failures are also caused by the therapist’s inadequate
handling of the obsessional defense. This the therapist must face
and take responsibility for. Therefore, failure cannot be said to be
the fault of either the patient or therapist exclusively.
It should be clear that understanding of undue expectation, a

need for magical solutions, and feelings of despair and
disappointment when immediate success is not forthcoming is of
particular significance in the treatment of obsessionals.
Change
The process of therapy involves a tedious examination and

exposure of a patient’s patterns of behavior which he
compulsively maintains and reluctantly alters. The therapist’s
task is to review and strengthen the patient's awareness of these

patterns and assist him in overcoming his doubts about the
validity of the view that they play a destructive role in his life.
Before any moves can be made to change one’s behavior, the

individual must have a strong conviction about the need to
change and a trust in the understanding derived in collaboration
with the therapist. This is especially true with the obsessional
who clings rigidly and tenaciously to his behavioral pattern and to
his rationalizations and explanations for his behavior. The

strength of his defenses demands strict, rigid, compulsive
adherence, since the dangers which would unfold if he were to
stop defending against anxiety would be severe and dramatic. The

obsessional’s stickiness, persistent intellectual defiance and
resistance to seeing his behavior in alternative ways are intense
and stubborn. His views and attitudes are firmly embedded and
defended by barricades that must be slowly eroded piece by
piece. This requires patience, tolerance and the ability to sustain a
continual interest in the face of boring, repetitive behavior which

seems to continue in spite of clarification and agreement about its
destructive, negative quality. In fact, this is precisely the nature of
the compulsive symptom, which is repeated with no alteration

and no deviation in spite of the knowledge of its lack of validity.
Consequently, a large part of the therapeutic process is

concerned with a review and reexamination of issues that are
dealt with over and over again. The therapeutic skill lies in the
therapist’s ability to see the same issues in a new light, adding an

additional piece of insight and reviving an additional recollection
to strengthen and fortify the patient’s conviction about the
understanding so that it becomes such an intrinsic part of himself

that he finally sees it as if he discovered it all alone. Familiar
neurotic tendencies must be explored from the fresh perspective
of different events, which include new pieces of data and
additional insights. This also relieves the monotonous refrain of

the patient, who says, “We went through that already,” and the
deadly dullness for the therapist, who must become reconciled to

the awareness that a single clarification is rarely followed by a
change in behavior. Working-through must be seen as a necessary
ingredient in the process of change in providing conviction and

trust to risk a new and untried approach that previously was
considered dangerous by the patient. This is crucial to the
resolution of an obsessional disorder.
Not every obsessional patient presents all of the obsessional

characteristics. Some are more prominent than others. Some
relate to the need to be in major control by bringing in lists or

agendas to the session. Others will have to do with the presence
of severe rituals or phobias that occupy the forefront of the
communication process. Others are hampered mostly by their
grandiosity and contempt for others and still others are

overwhelmed by their need for guarantees and certainties that
prevent them from taking any risks or accepting any new
interpretations.
The particular elements which are most prominent in the
patient being treated determine the general principles that need

to be applied in each instance. Where intellectual discussions
seem to be preeminent, the therapist must permit himself to be
somewhat spontaneous in expressing some of his own feelings
and perhaps encouraging the expression of feelings from his
patient by allowing and fostering the communication of his

doubts and certainties. Spontaneous behavior is so difficult for
the obsessional that the therapist can encourage this by getting
more involved with the patient, taking some risks in exposing

some of his own weaknesses so that he can allow the patient to
recognize that human fallibility is not a cause for total rejection
by others. In this connection it is important for the therapist to be

aware of how he is being controlled or manipulated by the
obsessional's tactics. The inevitability of being drawn in and being
unable to find one’s way after being caught in the sticky mesh of
obsessional communication need not be viewed as a failure or a
weakness of a therapist’s technical skill. A review of such
entrapments by the therapist can be illuminating as an example of

the enormous difficulties in seeing one’s way into the process so
that one can avoid being caught by the obsessional’s tactics.
Each occasion in the development of the interaction with the

therapist needs to be seen in the light of the obsessional
mechanisms and the therapist’s tendencies to be fallible. This

allows the process of therapy to be one which is not autocratically
determined by the expert and his helpless patient, but rather by
two people attempting to explore an issue together in which one

has skills the other does not.
Indecision
The indecision of the obsessional is closely related to his

morbid doubts. As he requires certainty in every choice he must
make and is unwilling to take any risks, it is understandable that

he puts off making a decision until he can feel absolutely sure.
It is indecision which keeps the obsessive from coming into
therapy early. Once in, however, he may remain endlessly and be
unable to leave unless an adequate handling of the therapeutic

situation forces a change. He must be very careful, since he
presumes that every decision will tie him down permanently,

with no way out. This accounts for his tentative acceptance of the
exchanges in the therapeutic process; nothing is seen or
experienced with any degree of closure, but remains open to

alteration or reversal. Therefore, interpretations are rarely
accepted with conviction or full agreement, but with a qualifying,

uncertain uneasiness. The usual instructions to forego any
decision during therapy and to postpone living until more valid
decisions can be made play directly into his neurotic pattern.

Many obsessionals who should benefit greatly from the
psychotherapeutic process find a haven for their neurosis and a
reinforcement of their defenses because of inadequate or inept

therapeutic handling in this regard. The obsessional prefers to
take no action. Thus, psychotherapy, under certain conditions,
can become an ideal culture for the enhancement of obsessional
doubts and indecisions.
It is only in recent years that psychoanalysts have begun to
recognize that the routine therapeutic techniques are not suitable

for all types of character structures and sometimes need to be
adjusted to the particular characteristics of the personality

involved. The obsessional should be encouraged to arrive at
conclusions and to make decisions which are the product of a
reasonable and adequate exploration of the relevant; factors. The

technique for dealing with the patient’s indecisiveness involves
the need to clarify his quest for absolutes and certainties.
Use of Dreams
The analysis of dreams in the therapy of the obsessional

must take into account the tendencies to evade and obfuscate the
therapeutic process, since such patients tend to either comply or
resist suggestions. If the therapist puts undue emphasis on

dreams or displays any special interest in them, he may be
flooded with dream material, or else get no dreams at all.
There are no particular characteristics of the obsessional’s

dreams. They reflect the life problems and the emotional
relationships of the patient with the therapist, friends, etc., as all

dreams do. The patient also utilizes the particular techniques of
defense in the dreams which are characteristic of his patient’s
waking life. As so much of the obsessional’s life is preoccupied
with problems of control, it is not surprising to find that much of
the dream material concerns itself with control.
The dream content should be examined in terms of the “here
and now,” as it sheds light on the current living of the patient, and
can be very illuminating with regard to sources and
unacknowledged feelings and attitudes. The tendency to get
deeply involved in understanding all the associations and every

bit of detail can become a trap for the therapist. It can turn into an
obsessional investigation in which the ultimate effect is to
become distracted from the main pursuit. The dreams must be

treated as simple data and dealt with in the same way as other
productions of the patient.
Termination
When the patient comes to therapy, his goal is to achieve a
state of anxiety-free living while retaining the same collection of

personality traits that he had originally. During the course of
therapy the patient must recognize the extreme nature of his
demands and accept some limitations of his expectations. It is

hoped that he will be able to achieve some balance and
compromise; instead of having to be a superhuman, he will be

able to function as a fallible human being. This simplified picture
of the therapeutic goal of treatment of the obsessional provides
some clues as to guidelines in determining a termination date.
What are the criteria for assessing termination? First, there
must be a recognition that termination must be done gradually
and experimentally, and rarely in an absolute way. To begin with,

the number of interview hours can be cut down, or the frequency
reduced over a reasonable period of time. Experimental
reductions in therapy hours can begin when the patient becomes

comfortable enough to accept some reverses in his living which
heretofore stimulated panic or severe anxiety. There should also
be a reduction of tension in many areas of his living, coupled with
a greater emotional involvement in all his relationships. Another
criterion is evidence of reduction in ritualistic behavior; also,

many of the obsessions which plagued the patient when he came
to treatment should have become less tenacious or no longer
occur. There should be an increased capacity to enjoy life without

having to fulfill certain demands all the time. But even these
criteria should be flexible. The therapist must not get trapped into
postponing or abandoning his plans to terminate because the
patient gets a renewed anxiety attack when termination is under

consideration. It must be clearly understood by both patient and
therapist that anxiety attacks will occur throughout the life of the
patient and that therapy is not a permanent guarantee against

disturbed living.
The therapy of the obsessional involves illuminating and
exposing the patient’s extreme feelings of insecurity and

uncertainty—which he tries to handle through the complicated
patterns of defense already described in detail. As he comes to
understand his neurotic structure as a defense against

recognizing these weaknesses, he can then begin to build a new
security system. At therapy’s inception, the obsessional defense

cannot be abandoned because the individual is afraid of the
consequences. As his esteem grows and the awareness of his
strength increases, he can slowly risk abandoning such patterns

and be freed to function on a more productive level. The goal is to
move from superhuman expectations to human productiveness—
which can reach whatever limits the individual is capable of.

'When he recovers, his ambitions will no longer be sparked by his
neurosis; rather, his achievements will be limited only by his
capacities. The impossible goals which left him disappointed will

be abandoned. An awareness of his valid capacities to produce
may actually stimulate greater activity. In essence, the
obsessional must learn that in abandoning rigid, inflexible
patterns of behavior designed to control and protect himself, he

can actually feel more secure and more capable—and be more
productive as well.
10
Psychotherapy in Sexual Dysfunctions
Jon K. Meyer, M.D.
Although sex and sexuality are often used synonymously,

there are differences in what the words connote. Sex in its
abruptness conveys a sense of mechanical acts. There is little
subtlety about the word. Sexuality, on the other hand, conveys a

sense of progression from sensual awakening to intimacy. Sex
connotes what the genitals do; sexuality connotes integrated and
highly personal responses including, but by no means limited to,

genital involvement (11).
Sexual dissatisfactions are virtually universal among
individuals who seek psychotherapy. Hesitation, fright,

repugnance, anger, withdrawal, or disappointment infect sexual
participation whether or not there is an accompanying incapacity
in performance. In fact, the more substantial the ego strengths

and the more compensated the neurosis or character disorder,
the more likely there are to be failures of satisfaction or
impairment of sexual creativity rather than loss of function. What

varies is the prominence of sexual complaints, either in
consultation or in treatment. Sexual complaints may serve as the
principal motivation for treatment, or may be mentioned only in

passing. In an analogous way, sexual issues may emerge in
treatment as the major arena of conflict and resistance, or may be
of little importance.
When the sexual problem is the primary complaint,

consultation reveals that sex has replaced sexuality. The sexual
efforts are not over-stimulating, unusual, or shocking, but
stagnant and unimaginative. Manipulation of orifices has replaced

passionate caress. There is fear of giving fantasy its play and
intolerance of the tension and controlled aggression in sexual
hunger. The sex acts have a concreteness, an anatomical

preoccupation, a paucity of fantasy, and a denial of intense
emotion, all of which exclude sensuality and intimacy and stultify
passion.
In listening to the patient’s history and associations, the
spouse often fails to emerge three-dimensionally. There seems to

be little in the way of shared elements of experience which allows
identification and empathic sharing of eroticism. Romantic
gestures have become stereotyped and, rather than being enjoyed

in themselves, provide the merest pretext for coitus.
The inhibited, mechanical quality of the sexuality, however,
does not indicate that the person is without feeling or insight. His
sexual inhibitions and fears may seem quite unreasonable, but he
is at a loss to be rid of them.
The usual patient with a primary sexual complaint is a young

or middle-aged adult who is married or wishes to be.
Occasionally, such a relationship is longed for, but feared. There is

a sense that it is desirable and possible to have a relationship with
another person—usually, though not necessarily, of the opposite
sex. In other words, there is a hunger for intimacy, as well as

sexual release, and the sense that another person would
complement rather than complicate life. Thoughts about children
generate mixed feelings. Although there is a concern that children

would be an economic stress and a psychological burden,
underneath there is the capacity to feel that a child is also a
blessing. The patient can perceive, however dimly, that as a child

himself he was welcomed and loved at least to the limits of his
parents’ capacities. Sufficient emotional sustenance was available
to him that he can conceive of sharing warmth with a new

generation of children.
Clearly, such a patient deserves an opportunity to unfetter
his sexuality, and his life, through psychotherapy. The patient’s

sexuality is our central interest because it is an integral
component of his personal and biological enjoyment. His
sexuality, however, cannot be viewed or worked with in isolation
from the remainder of his personality. Although the sexually
handicapped individual may in certain ways be unique in the
construction of his illness and in his requirements for
psychotherapy, universal issues of individual development,
symptom construction and treatment cannot be avoided.
Psychotherapy
I have not met a psychiatrist, or practitioner from related

psychological or humanistic fields, who did not claim to do
psychotherapy. Yet, clearly, what is done and how it is

conceptualized vary immensely. While this observation is
inescapable in general, it is pointedly apt among those whose
special interests are in the treatment of sexual disorders. In this

subspecialty methods range from the most abstinent to the most
intemperate.
I believe psychotherapy is defined by psychoanalysis by

virtue of the elegant simplicity of its assumptions, methods, and
observations, and its extended, intensive patient contact. The
basic assumption of analysis is that what goes on inside the head,
rather than what happens in the surroundings, is most germane

to treatment. The patient’s rules of thought —governing linkages
of feeling, recollection, and anticipation—determine his strengths
and pathology and provide the pathway to his recovery.
Fundamental psychoanalytic methodology consists of
inviting verbal expression of thoughts and feelings, and then

doing as little to impede and as much as possible to expedite the
process without directing it. There is a repeatedly confirmed
observation that, given a chance, the patient will do his best to
manifest his difficulties in living form in treatment, and in the
process hear, feel, and rework his conflicts. Frequent contact

paves the way for the trust and security that bring guarded
thoughts and feelings into the open and for the intense
relationship that brings conflicts to life. For those patients,

however, who would find the analytic combination of intensity
with abstinence disorganizing, dynamic psychotherapy (the
psychoanalytic derivative with the same fundamental

assumptions) is the treatment of choice.
Other psychotherapies, in one way or another, most often
constitute a retreat from the patient and from what is intrinsically

emotional in his difficulties. Other methodologies, including those
clinical efforts lumped together as “sex therapy,” largely utilize
counseling (i.e., giving advice or direction), direct education, or

manipulation through suggestion. The difference between
counseling or educative approaches and dynamic methods is, for
example, that rather than giving counsel, we would be interested

in what counsel the patient might give himself (and in what way
he might be suspicious of it or reluctant to use it).
Sex therapy is the creation of Masters and Johnson, growing

out of their laboratory observations (7) and their treatment
procedures (8), although in recent years they have appeared
unhappy about some extensions and applications of their work.
Central to sex therapy is the notion of the uniqueness of sexual
problems and their treatment, about which I have previously

expressed my reservations (10). Sexual problems differ from
other forms of psychiatric difficulty in terms of the manifest
symptom, but there are very few differences in the makeup of the
illness. To illustrate what I mean, impotence and agoraphobia are
clearly different symptoms (and the dynamics behind such
symptom choices are important), but there is the distinct

possibility that unresolved castration anxiety lies behind both.
The phobic state in one case shows up as a fear of leaving the
house and in the other as a fear of entering the female genital. The
critical factor in the two situations is not the difference in the
symptoms, but whether the fear stems from castration anxiety or
a more primitive separation anxiety, since the focus of

interpretation and concern would be different in the two
instances.
Efforts have been made to explain the phenomenal success

claimed for sex therapy, but my impression is that such efforts are
unnecessary. Recent series (5, 12) have not substantiated the

results published by Masters and Johnson (8) and claimed by
others (4). Time seems to have passed by sex therapy. The loss of
popularity is related in part to the failure to replicate success

rates and in part to the well-known phenomenon of therapeutic
erosion once initial enthusiasm is exhausted. An additional factor
among some sex therapy teams is that clinical success seems to
vary directly (factors of patient selection and prognosis being

equal) with the latent sexual excitement between the co-
therapists. Mutual erotic interest investing the co-therapists’

work seems to establish a libidinal field which temporarily fans
patients’ ardor. Once the work becomes routine and the co-
therapists’ interest in one another de-sexualized, success rates

drop off (3).
If there has been a major benefit to the use of sex therapy it
has been, almost paradoxically, in the education of the patients to
the authentic nature of their difficulties. After a couple has been

treated with the Masters and Johnson techniques, one partner or
both may recognize for the first time the presence of internal
resistances to working through a problem initially seen as
educational and mechanical. In this sense, the techniques of sex
therapy may occasionally be used as an introduction to treatment
proper.
Sexual Development and Symptom Choice
In the last decade, simplified assumptions about etiology and

symptom maintenance have marked much of the psychiatric
writing on sexuality. Some serious authors have justified this
simplification on the grounds of data reduction, a commonly

employed and useful scientific procedure.
Data reduction, however, is more applicable in systems that
operate through mechanical, although not necessarily simple,
rules. Biochemical and biomechanical systems, unlike the patient

and his fellow human beings, do not defensively disguise,
rationalize, deny, forget, negate, reverse or substitute objects or
interactions. No matter how complex and marvelous the

chemistry of substrate and enzyme, whimsy or perversity is not
part of it. When systems follow cut and dried rules, no matter
how complex, data reduction is a reasonable goal. When the
system is not only as intricate as the human mind but also
motivated and capable of synthetic functions, data reduction can

become reductionism. Presently, one of the clearest examples of
reductionism in the field of human sexuality is the assertion that
“homosexuality is like left-handedness,” in other words, purely a

biological variant (11).
Sexuality is not simply biology. In addition to physical
processes leading to arousal, tumescence, and release, sexuality
involves the capacity to trust and feel trustworthy, to merge and

separate without intolerable anxiety, and to experience the sexual
partner as a consort rather than an incestuous parental
substitute. Sexuality, physically and subjectively, flows so

smoothly when properly integrated that it seems almost natural,
yet it is the product of a long, complicated, and difficult
developmental sequence.
Although there are elements that are singularly sexual in
development, sexuality does not ripen in isolation from other
aspects of the personality. Sexual gratification is a single aspect of

a broader capacity to feel good about others and to get
satisfactions from them. Sexual disorders may present
monosymptomatically, but are always strongly and pervasively

attached to hidden neurotic conflicts and character defenses. A
sexual problem in this light is simply one manifestation, although
an important one, of a more complex disorder.
The patient's sexual symptom is a creative, though
uncomfortable, synthesis of early experiences, childhood

fantasies, and biological needs. Except in incestuous households,
sexual performance ordinarily is limited in childhood to
masturbation and eroticized peer-level play. Nonetheless, the
roots of intimacy, fantasy, and sensuality are put down in infancy.

The roots of emotions and behaviors are like the halting and
stumbling first steps in learning how to walk that establish the
base for future locomotion, no matter how skillful and

sophisticated it may become. Similarly, halting and stumbling
early formative experiences with intimacy and sensuality are the
germs of later capacities for friendship, intimacy, sexual relations,

procreation, and childrearing.
In sexuality, as in other essential components of the
personality, there are developmental lines which may be traced
through a convergent sequence from infantile emotional
dependence to mature sexual and work relationships. In this
progression there is an interplay among psyche, constitution,

predisposition, and environment to achieve, in the healthy
situation, more and more satisfactory levels of mastery and
integration. Personality maturation, as distinct from the simple

accumulation of years, is dependent upon a “good enough”
experience at one stage to allow, seriatim, personality
consolidation at succeeding levels. Interference with the normal

sequence is usually brought about by a combination of
unfortunate relationships, untoward coincidence, constitutional
predispositions, and the seductiveness or fearfulness of fantasy.
Sexual development involves the drives, object relations, the

psychic structures, and aspects of the self. Although it is known
that all these personality components participate in sexual

growth, I don't believe the interrelationships and contributions of
these factors have been well worked out and so it is only possible
to outline a few points.
In the first few months of life, during autistic and symbiotic

phases, the essential substrate for psychological development is
an empathic and stable relationship between mother and child,

which helps the infant deal with his poorly controlled tensions.
An empathic mother-infant relationship serves as the feeling

basis for comfortable and trusting intimacy in later childhood and
in adulthood. From this relationship comes the basic sense that
biological needs and tensions are acceptable and appropriate and
will call forth an intuitively sensitive response. Without this basic

sense, all intimacy suffers, including sexual intimacy.
Sexuality trapped at this oral level is marred by an insatiable
emptiness which gives rise to perpetual efforts to extract

sustenance from other people. The hopeless inadequacy of any
response from others leads to efforts to exact revenge. Emptiness,
envy, and destructive rage are the uncomfortable bedfellows of

sexual expression.
At five months, or somewhat later, the child normally

hatches from the symbiotic shell, slowly at first and then with
gathering speed independently moving away and dependently
returning to mother in the process of establishing against her grid

the capacity to relate as a separate and individual person (6). The
child in difficulty at this stage will often manifest night terrors,
chronic nightmares, phobias, fear of the dark, fear of being left
alone, or a need for the touch of clothes, jewelry, and other items
associated with mother. Relative failure at this stage causes
separation to be experienced as abandonment and closeness to be
feared as engulfment.
The father is important in the separation-individuation

process, fostering the inquisitiveness and exploration that leads
to separation and differentiation. He is a familiar and caring
person, but outside of mother’s immediate orbit. Where father is
absent, uncaring, effeminate, devalued, or dominated by mother,
he is also unable to help his sons dis- identify from mother or his
daughters shift object choice. Feminine identification or failure to

shift object choice has a variety of pathological manifestations in
sexual life.
In the pre-oedipal, separation-individuation phase, the drives

are strongly tainted with oral and anal components and butt
against a severe, primitive superego. The drives, along with self-
and object-images, are split into aggressive and libidinal clusters.

Internalized objects and identifications are primitive. Sexuality
arrested at this level is characterized by perverse trends, being
particularly infiltrated with sadomasochism. Coincidentally, there

is exquisite sensitivity to engulfment or abandonment with an
uneasy oscillation in the degree of intimate contact permitted. In
an effort to cope, devices such as fetishes, which are

simultaneously bridging and distancing part objects, may be
adopted and incorporated into sexuality.
A pre-oedipal appreciation of anatomic, behavioral, and

biological differences between males and females leads to a
gender identity—a basic sense of maleness or femaleness. I
believe that the psychological basis of reproduction—the concept
of oneself as an individual who can ultimately bring forth children
—is laid down at the same time as gender identity formation.
Disorders of gender are associated with aberrations in the
psychological fabric of maternity or paternity, with problems of
abandonment and engulfment, with primitive internalized

objects, and with severe splitting of self and object images along
libidinal and aggressive lines. Developmentally, the gender
identity disorders are closely linked with the perversions, but are
intermediate between the perversions and the psychoses.
The incorporation of significant pre-oedipal psychopathology
into a sexual dysfunction has effects in two directions. First, there

may be severe impairment of sexuality to the point of lost
function, or, second, in the effort to preserve sexual expression,
sexuality may be modified by perversion or defensive

externalization. In the more usual dysfunctions (e.g., premature
ejaculation, impotence, and dyspareunia), dominance of pre-
oedipal factors may lead to virtual loss of sexual performance.

Pre-oedipal fixation, of course, is often evident in the perversions
and the homosexual variants. Perhaps the most impressive

defensive externalization I have seen was in a young man who
requested sex reassignment. He showed the usual gender
dysphoric detachment from his penis and, in fact, wanted it

surgically removed. Nonetheless, he was sexually active with
remarkable staying power and potency. He took pride in the
admiration this elicited from his casual partners although he

derived no pleasure and scarcely any physical sensation from the
act itself. His penis was psychologically an external instrument.
Although psychotherapy was strongly recommended, he did not
allow through and, sadly, committed suicide a year or two

following consultation.
The separation-individuation phase closes with the sufficient
internalization and integration of the mother’s caretaking and

loving functions that the child can separate periodically without
feeling abandoned or regressing in function. Following on its
heels is the oedipal phase, during which relationships with

parents become highly sexualized, complicated, and triangular. In
the positive oedipal constellation girls become coquettish toward
their fathers and irascible toward mother while boys are

demonstrative, beguiling, or compelling toward their mothers
and openly resentful or belligerent toward their fathers. Side by

side with the positive oedipus is the negative with an attraction
toward the parent of the same sex. An amalgam of positive and
negative oedipal longings and identifications makes up the
ultimate sexual identification and object preference. Although

negative oedipal identifications and object choices predominate
in homosexuality, there are opposite sex identifications and
longings for intimacy with the same sex even in the most
heterosexual individual.
Negotiation of the oedipal stage is a landmark for integrated,

individualized sexuality. If all goes well there is an integration of
bodily representations, sexual object choice, and masculine and
feminine identifications. Sexuality is thoroughly woven into drive
structure, identifications, ego ideal, superego, and self. Because of
this integration, conflict cannot be defended against in any realm

of the personality without compromising sexual interests.
Unsatisfactory' resolution of the childhood neurosis always
compromises sexuality but most often in the direction of

dissatisfactions without loss of function.
Latency is classically a time of relative quiet following
oedipal storms, but I have never been impressed that boys or girls
(particularly boys) were especially latent. They are simply less
obvious about their sexual interests than oedipal youngsters or
adolescents. Latency boys and girls don’t like each other very
much and frequently show their contempt. Contemptuous
disinterest comes about, in part, as a result of the relative
inadequacy of peers in comparison with the original parental

object choices. Not only is the little boy licking his wounds after
being rejected by his mother or muscled-out by his father, but he

is upset about the inadequacy of the little girls to whom he must
turn. The antagonism between boys and girls grows out of
castration anxiety and penis envy to be sure, but is also designed

to demonstrate how second best they feel each other to be. This
process is reversed in adolescence with defiant overvaluation of
peers, but the reversal is still part of the process of giving up

parental objects. The more conflicted the attachment to parental
objects, the more second best non-parental objects seem. In some
adult couples there is a continuing, nagging, bitterness at the age-
appropriate partner which seems very much related to latency-

age disappointments.
Latency comes to a stormy end with a surge of biological and
psychological development. Changes in physical, coital, and

reproductive capacities are new factors to contend with. Any and
all areas of conflict are worked through again at a more
sophisticated level. Behavioral disorders, antisocial activity,

psychosis, depression, homosexual experimentation, or
perversion may emerge as signs of long-standing difficulty. In the
happy situation, personality consolidation in later adolescence

serves as a basis for intimacy. Where the outcome is less
fortunate, problems that were acute and flagrant in early

adolescence often show signs of settling into a more chronic and
crippling form.
The early phase of psychosexual maturity is marked by

intimacy and marriage, the prospect of children, and beginning
life’s work. Later the psychological potential for procreation laid
down at the time of gender identity formation finds expression in

parenthood and another developmental stage is entered. With
conception, gestation, delivery, and child-rearing, the adult’s own
developmental milestones are reworked in identification with his

child and with his parents. Conflicts in the new father or mother
may show up as symptoms and distress in the offspring.
Alternatively, residual parental conflicts may be catalyzed into
symptoms by an offspring’s entry into a particular developmental
stage. A striking example of this phenomenon from the gender

dysphorics, in whom almost everything stands out in bold relief,
occurs among a group of men with more or less transvestite
histories (9), who precipitously applied for sex reassignment

when their sons reached the ages of three to five. Their headlong
flight into sex reassignment represented a concrete expression of
negative oedipal wishes (in addition to developmentally more

primitive wishes for fusion with mother) precipitated by an
oedipally-conflicted son. The correspondence between the child's
oedipal flowering and the father’s anxious quest for sex

reassignment indicated a peculiar identification with the child
and a special sensitivity to phallic and castration issues (15).
I have outlined some developmental issues related to clinical

sexual dysfunctions. My purpose has been to emphasize the
sexual symptom in a developmental context as a guide to

meaningful diagnosis, prognosis, and treatment selection. The
presenting symptom is a guide to treatment only when it is
understood as being that outgrowth of a developmental sequence

which is the most acceptable synthesis of unresolved conflicts. In
sexual disorders as in other psychiatric problems treatment
selection and prognosis turn on a determination of ego strength,

patterns of defense, superego characteristics, level of drive
maturation and the accomplishment of milestones in object
relations.
In the clinical setting the commonest sexual symptoms are
impotence in the male, anorgasmia in the female, and withdrawal

from sexual activity on the part of either sex. Less common,
although still prevalent, are premature ejaculation in the male

and dyspareunia in the female. The perversions, homosexuality,
and the gender identity disorders are of lesser frequency.
Ejaculatory incompetence, the sexual anhedonias, and the sexual

anesthesias are rare.
Certain sexual symptoms cluster preferentially with

particular psychopathological states. For example, the full
syndrome of the adult gender identity disorders is associated

with pre-oedipal pathology showing up as severe borderline
character problems. Similarly, the perversions show some

borderline features, although the borderline pathology may be of
a relatively mild degree in the well organized perversion.

Ejaculatory incompetence is not a perversion, but it is a closely
allied condition. Sado-masochistic practices, often of a severe
degree, are a regular finding in individuals with retarded

ejaculation and, not uncommonly, erection or intravaginal
ejaculation requires antecedent sadistic activity.
The probable symptoms of a neurotic patient with a sexual

disorder cannot be predicted with certainty. However, as I have
mentioned previously, sexual dissatisfaction without loss of
function is more likely to be found in neurotic individuals
functioning at an oedipal level. On the other hand, dissatisfaction
accompanied by frank loss of function or obligatory modification
of practice is more likely to be found in borderline individuals

functioning at a preoedipal level. Sexual dysfunction, of course,
may serve as the visible peak of a psychosis and unwary pursuit
of the sexual symptom may precipitate personality fragmentation.
The neurotic choice of a sexual symptom presents intriguing

problems. In my experience the sexual dissatisfaction or
dysfunction serves at one time or another each of the following

secondary functions: As a means of avoiding sexuality and as a
means of having at least some sex; as a means of avoiding
intimacy and as a means of providing at least some intimacy; as a

means of sustaining and as a means of breaking up a relationship;
and as a motivation for treatment and as the most substantial
resistance to it. The primary function of the sexual symptom

varies in its specifics from patient to patient although there is no
reason to doubt that it serves as a compromise formation
expressing the drive in limited fashion while incorporating

superego sanctions and keeping the true aim or object of the
drive out of awareness.
The Consultation Interview
Consultation interviews are conducted with the outline of
sexual development in mind. Since assessment takes time, I
ordinarily schedule three evaluation sessions. This provides the
opportunity to take a thorough history, during which I take pains
to notice the linkages between history and symptom and observe

the patient’s capacity to hear and work with his own material.
I begin by inquiring after the patient’s life and what he can
tell me about it, expressing a hope that in the process he will tell
me the details of his symptomatology. If the patient is inclined to
be silent or vague, I may ask what he has noticed about the onset
of his difficulties, its timing, the events associated with

exacerbations or remissions, his best sexual experience, his worst,
his fantasies, his theories of causation, and so forth. In terms of
his life, I may ask him to tell me about his family, his hometown,
his wife, etc. Although I may inquire about aspects of the patient’s
life, my inquiries are carefully framed as questions and not as
veiled conclusions.
Inquiring after what the patient has noticed or can recall

serves a number of purposes. It keeps descriptions in the
patient’s frame of reference and avoids hasty, often erroneous

assumptions about the nature of his illness. Secondly, steadfast
interest in the patient’s observations assesses his curiosity about
himself and powers of observations, both of which serve as

measures of the capacity for self-explorative psychotherapy.
Finally, in outlining his observations in detail the patient

inevitably makes associations to developmentally significant
events or people. The timing of the associations (i.e., their
appearance in sequence with specific details of history or
symptomatology) establishes presumptive links between history,

symptom, and development. As associative points of contact
between symptom and genetic history, such material serves to
open the door to the meaningful parts of the developmental

history.
A difficulty that inexperienced clinicians have with the
developmental history is that they tend to administer it in the

same way to every patient, almost as a standard interview. While
the facts may be obtained in this manner, they are most often
meaningless both to the psychiatrist and to the patient because

they are not tied in to the patient’s memories, affects, or
associative linkages. Proceeding in the way I have suggested will
uncover the same facts but the facts will come alive.
Extended, apparently unstructured history taking will also

give the patient an opportunity to reveal his defensive operations.
These essential ingredients of prognosis may show themselves in

terms of what is missing from the history, as elements of
character, and as reactions to the evaluator’s questions or silence.
It goes almost without saying that primitive defenses like denial,

projection, and splitting portend a difficult therapeutic time,
whereas repression, reaction formation, and dissociations are

likely to be less formidable (although never easy to work
through).
Two insights are prerequisites to restoration of sexual
enjoyment and function through psychotherapy: The first is a

sense that internal blocks preclude emotional freedom and the
second is a hope that things really could be better. For the patient
to work on his symptoms usefully, it is critical for him to feel that

the sexual inhibitions come from within, however much he may
overtly blame his sexual partner or external circumstance.
Treatment has little to offer the patient who believes that sexual
gratification will be accomplished by changing partners or
altering circumstances, or for the patient who has no hope that
things could ever be different. For example, although

homosexuality is a developmental aberration, the homosexual
may be comfortable in his deviancy and be without motivation for
treatment. On the other hand, the homosexual may feel hopeless

about ever being different even though the inversion’s central
generative disappointments and conflicts are intuitively grasped.

In the one case, there is no motivation for treatment and, in the
other, no hope for it.
Once assessment is complete, the decision regarding
treatment may be made. Where interest is in remodeling and not

renovation, the patient may best be aided by counseling or
support. Where there is both the interest in and capacity for

personal restoration, analysis or dynamic psychotherapy may be
recommended.
Treatment
A multiplicity of difficulties may be reflected in sexual
dysfunction. Sexuality is plastic and multifaceted, lending itself to

the expression of conflicts, fantasies, and aggressive and libidinal
drives in subtle and highly personal variations. Sexuality involves
objects and their representations in fantasy, allowing the

reenactment of unresolved attachments. Sexuality, unlike
breathing or eating, is not essential for life itself and may be given
up entirely, thereby serving as a vault for intolerable anxieties.
Sexuality is historically at the center of psychoanalytic

theory. With the exception of the perversions, however,
therapeutic specifics are scarce in the literature despite the
ubiquity of sexual inhibitions and dissatisfactions. I believe the
reason for the relative absence is that in any analysis sexual
conflicts are always present and are dealt with as a matter of
course. In other words, sexual problems are so universally dealt

with that their very commonness has excluded them from
attention. Since the early days of analysis they have attracted little
technical commentary. In the following pages I will try to focus on

a few issues which, if not unique to sexual difficulties, are more
common or exaggerated in such conditions.
Although the general structure of analysis and dynamic
psychotherapy is well known, I will outline some aspects that I
believe are important. I establish from the beginning the fact that
treatment will be open-ended, continuing until the patient is
satisfied. Artificial time constraints, which are sometimes

employed in sex therapy, focus the work but allow resistance to
hold out long enough to cover embarrassing or conflictual
material. I ask the patient to report recollections, thoughts,

fantasies, bodily feelings, and affects as they come to mind even
though the material may seem embarrassing, trivial, offensive, or
in violation of some external confidence. It is my aim to aid in this

self exploration through open-ended questions about the material
at hand and through interpretation of roadblocks to free
association and communication. I take special responsibility for

maintaining the structure of the treatment situation. I am reliably
present and punctual and free from telephones and

administrative matters during sessions. I maintain an unwavering
respect for the patient which I view as an integral component of

the structure. Such respect is easy to sustain. The patient’s sexual
difficulties are a source of embarrassment, they are of immediate
interest to him; treatment is a frightening experience, and a high

degree of hope is riding on the outcome. He is also an
extraordinary person. Rather than simply living with his
problems or demanding to have them accommodated, he has set
out on a course of self-exploration designed to remedy them.
Respect for the patient, regard for the structure of the
psychotherapeutic situation, free association, interpretation of
resistance, and abstinence from immediate gratification pave the

way for the analyzable transference. (Transference will come in
any event, but will not be analyzable unless the preconditions of

analytic structure are met.) Transference brings conflicts and
fantasies into the immediacy of the therapeutic relationship,
allowing dynamically important affects, object relations, and

defenses to be replicated and observed in a current time frame.
The transference makes vivid both unsatisfied claims for love and
sexual release and prohibited aggressive feelings (13).

Transference comes in behavioral as well as in verbal form,
showing up in repetitive behavior in the treatment hour and
outside. The greater the resistance to remembering and

reporting, the more likely the transference is to take the form of
repetitive behavior.
Transference operates Janus-like, in two directions, not only
as a means to understanding and moderation of psychopathology

but also as a stubborn resistance to successful outcome. The
phenomenon of transference, however, fundamentally provides
an opportunity for real work since a neurotic construction cannot

be dismantled purely in retrospect or, as Freud (1) put it, “in
absentia.” Demands for transference gratification are given up

only grudgingly, after considerable effort to make the
transference wishes come true. The end point of treatment, of
course, is not freedom from all transference, but rather
replacement of primitive, conflicted transferences with direct and
satisfying eroticism and mature sublimations.
It is not unusual for the patient to fall in love as part of the

transference, although “falling in love” is an inadequate and trite
description of a powerful and complex phenomenon. As Freud (2)

pointed out, falling in love is induced by the treatment situation
rather than the charms of the psychiatrist, and its effects are in
the service of resistance. Love seems to blossom just when the

most difficult and painful material begins to emerge. Having a
reputation as a “sex doctor” sometimes lends the erotic
transference a more overt and concrete coloration. The demands

may be for concrete and immediate alleviation of the sexual
frustration. This tendency is more likely in borderline patients

where the therapeutic alliance is tenuous and an observing ego
difficult to sustain. In such patients the analytic or
psychotherapeutic situation is often interpreted as an
opportunity to achieve real satisfaction of transference longings,

including sexual satisfactions. The assumption is that their
difficult sexual situation could be corrected by accepting them as
pupils or partners rather than as patients. The difficulties

encountered are illustrated by a patient who, upon entering
treatment, separated from her husband and made it clear that I

was to function as her emotional support, companion, and
regulator of her daily life. There were constant disappointed and
vituperative attacks because I was insufficiently gallant and
accommodating. The wish for immediate symptom relief is
common among sexual patients. Other patients may have similar

inclinations, but the tendency is more pronounced with sexual
dysfunctions because of the publicity given rapid treatment. I deal

with this unfounded hope for speedy cure by acknowledging the
wish while pointing out the value of symptoms as markers of
difficult areas. I assure the patient that he is always free to work

on his problem by bringing up sexual associations.
It should go without saying that the patient is not taken up
on his or her offer of love. However, since among sex therapists
there are those who misunderstand the transference and

prescribe their sexual attentions as medicine for the patient's
frustrations, it may be necessary to make the point explicitly.

Sexual intimacy with patients completely derails treatment.
Treatment inevitably terminates without completion, although
often not rapidly enough to prevent a great deal of wasted time,
money, and therapeutic opportunity. The patient may at first feel

elated at the attention or triumphant at toppling the psychiatrist
from his pedestal. In the final analysis, however, he feels
betrayed. Transference love must be allowed to flourish, but for

purposes of understanding and resolution. The analysis of the
detailed characteristics of being in love brings to light the

infantile and conflicted roots of the patient’s symptoms.
Issues of the structure of the treatment situations and the
manifestation of transference are as important in the treatment of
sexual problems as in other conditions. Issues specifically related
to the treatment of sexual disorders, however, can best be

approached by grouping the patients according to the overall
severity of their psychopathology. Although schizophrenic
patients may have severe sexual pathology, it is often not

sufficiently organized to deserve consideration as a syndrome.
Not infrequently, the sexual symptom serves as a shaky bolster
against decompensation and it is ill-advised to remove it. Among

severely borderline, less severely borderline, and neurotic
patients (including those with neurotic characters), organized
sexual symptoms may be dealt with profitably for the patient.
The two more common organized sexual syndromes among

patients with severe borderline pathology are the perversions
and the gender identity disorders (gender dysphoria syndromes;

“transsexualism”). There is considerable pessimism about
psychotherapy in the gender dysphoria syndromes. In part,

pessimism is warranted because of the severity of the disorder,
but it derives, in part, from an assumption that the gender
reversal is non-conflictual. If there were unconflicted core gender

reversal, pessimism would be doubly justified. It is axiomatic in
psychiatry that conflict heralds therapeutic opportunity; without
conflict there is no energy driving the therapeutic process. In the

cases I have seen, however, the apparent non-conflictual core
gender reversal turns out to be a symptomatic compromise
formation that is superficially ego syntonic as in the perversions.
Some patients readily respond to the suggestion for exploratory

work so long as their major symptom, the gender dysphoria, is
not attacked head-on. The treatment of these patients is similar to

that of other severe borderline characters and requires the back-
up of ready hospitalization. Since such psychotherapy is in the
patient's own best interest, it should be a routine part of any

evaluation for sex reassignment.
I proceed in a similar manner for the gender identity
disorders and for the perversions which have severe borderline
personality disturbances. In both clinical situations, head-on

tackling of the perverse conviction only increases the patient’s
counter-resistance immeasurably. It is useless for this reason to

make giving up the perverse practices or the search for sex
reassignment the condition for treatment. The patient cannot
comply since the symptom protects against ego dissolution.
I set the task of treatment as the patient’s reporting his

thoughts, feelings, and observations as they come to mind.
Although this is standard analytic technique these patients are

seldom, if ever, put in analysis proper since they cannot tolerate
the regression it fosters. Whenever possible I arrange for twice-
weekly sessions. I keep the patient sitting up and make myself

more available as a “real person.” What this means is that I am
more encouraging, more sympathetic regarding the difficulty of
putting thoughts and feelings into words, more obvious in my
concern about the serious problems in the patient's relationships
with himself and others, and more available by phone and for
special sessions than I ordinarily would be within the constraints
of psychoanalytic abstinence.
I never deviate, however, from the fundamental position that

the task of treatment is for the patient to understand himself
through expressing and hearing his thoughts, feelings,
recollections, and fantasies as they come to mind. This is the only

procedure that will put the patient into contact with the
desperate conflicts and all but overwhelming affects which have
led him to embrace severe and crippling symptomatology as a

preferable alternative. It is difficult to keep in mind that the
patient's self-exploration is the essential task in treatment since
the patient will resist coming face-to-face with his feelings. He

will resist by attempting to have you guess (from the patient’s
point of view “explain”) his thoughts and feelings, to have you

endorse his perversion or quest for sex reassignment, or to have
you take a stand against his practices. In a variety of ways he will
attempt to make his manifest symptoms a battleground in order

to completely eclipse the true work of treatment. Needless to say,
when the patient’s symptom may involve castration and
penectomy (as in gender dysphoria) or other severe risk (as in

eroticized hanging), it is difficult to resist the battle. It may be
necessary to hospitalize the patient to protect his life and physical
integrity; on the other hand, it is useless and counterproductive to
decry the symptom. The situation is best handled by taking those

steps which are necessary to protect the patient while at the same
time being interested in the timing of the symptomatic eruption

and the thoughts and feelings which accompanied it. Almost
without exception, the eruption of the symptomatology will be
due to unendurable tension unconsciously related to a loss, a

separation, or envious rage at some perceived slight in the
therapeutic or other meaningful relationships.
Interpretations of the transference are almost always
directed toward loss, emptiness, feelings of personality

dissolution, and rage rather than toward the developmentally
more advanced concerns of castration anxiety, penis envy,

homosexual attraction, or guilt. It is only toward the end of
prolonged treatment that such higher order developmental issues
may be the dynamics that are truly operative and therefore
appropriately interpreted. In fact, as therapy proceeds and the

relationship intensifies the transference may become psychotic in
its intensity. Under these circumstances, I maintain a low
threshold for hospitalization, particularly around times of

separation.
The outcome of treatment with severe perversions and

gender identity disorders may well not be the highest level of
psychological integration. It is not uncommon for the severely
crippling perversion which threatens life or physical integrity to
be replaced by a more stable and less destructive paraphilia. For
example, a stable homosexual state or transvestite depressive

picture may be the outcome of treatment of the gender
dysphorias.
Analysis and psychodynamic treatment of borderline

patients is often many years in duration since the slow accrual of
ego strengths through contact, analysis of crippling defenses,
structure building, and partial replacement of highly pathological

internalized parental objects is required to transform concrete
demands for satisfaction into a transference neurosis which may
be analyzed in collaboration with an observing ego. Neurotic

patients, for whom the difficulties with separation and oral
fixation are not so severe, tend to move more rapidly toward an
analyzable transference. In either case my experience is that the

transference neuroses of patients with sexual disorders contain
exaggerations of certain familiar elements.
In women with prominent sexual dysfunctions, feelings of

genital inferiority, penis envy, and penis-breast-feces-baby
equivalencies are marked. This is associated with a singular
competitiveness between mother and daughter. These mothers

have pushed precociously mature attitudes toward anatomy and
reproduction, while at the same time making it clear that

independence or separation, let alone competition, was
intolerable. The father deepens the conflict and the regressive
pull by encouraging a little-girl sexuality while being clearly
unable to handle his wife. The patient as a little girl was in a

situation in which her father could not provide a frame of
reference sufficiently independent from mother to help effect
optimum separation. He stimulated her but: could not establish

limits on her infantile sexuality or help in her establishment of
age-appropriate outlets and sublimations. Because of father’s
relative impotence, fantasies of mother’s potency are extravagant,

as are the fantasied consequences of competition with her.
Fantasies of having been castrated or denied a penis by mother—
who greedily appropriated all good things to herself (father,

penis, breasts, and babies)—are unusually strong, the rivalry
intense, and the guilt and anticipated punishment
correspondingly severe. All drives are put under strong

interdiction. Issues of control—including control of impulses,
people, part objects, and events—reach proportions where the
patient is frantic to avoid an unguarded moment which might let

a dangerous impulse escape. In the nature of the symptom, of
course, efforts at control provide ample opportunity for the
unconscious expression of rivalry, sadism, and rage.
Such women are anorgasmic for many reasons. They have
not effected a complete separation from mother, nor are they

completely identified as female. Their orientation remains
strongly bisexual. Although the desire for sexual fulfillment is
strong, their objects remain confused. Furthermore, men and
sexual congress with them is a prerogative of mother so that

sexual desire becomes contaminated with intense rivalry and
guilt. Constant wariness against an unguarded thought or act

virtually eliminates the possibility of being swept away to
orgasm.
Transference and the transference resistance revive and
intensify the conflicts and defenses in the relationship with the

internalized mother. Separation and control are the early issues
in treatment and only later does frank penis envy emerge along
with the paternal transference.
Among men who are sexually dysfunctional, the fabric of

their disability is woven out of an impressive degree of feminine
identification. In borderline men, an aspect of incomplete

separation-individuation includes a partial failure to dis-identify
after having formed the primary maternal identification. Neurotic

men have resolved their primary identification with mother, but
form a secondary identification with the frustrator. Their mothers
are cold, withdrawn, and often chronically depressed. Although

there is no question these women love their sons, the watchword
is responsible rather than empathic parenthood. There is very
little spontaneity or joy in these families and the people within

the household may lead rather isolated lives despite the spatial
contiguity of their existences. These mothers have an unresolved
attachment to their own mothers which has left them with
conflicts surrounding femininity and maternity. Their masculine
strivings are reflected in their marriage to a man with strong

maternal leanings and often more than the usual feminine
identifications. Through his failure to provide a strong male
object for identification and through the example of his rather

feminine attachment to his wife, the father fosters feminine
identification in his son.
The boys who grow up to be neurotic men with sexual

problems are not usually effeminate or sissified to outward
appearance. However, during the oedipal childhood neurosis the
more than usual feminine identification materially intensifies

castration anxiety. The fantasies of castration are all the more
fearful because in some ways the boy must struggle with a
longing to yield up his penis in order to express his feminine

identifications.
As adults these men are usually premature ejaculators or
impotent. The characteristics of their sexual lives most

maddening to their partners, however, are the hesitation and
passivity in their sexual approach. Their apparent timidity is not
simply due to lack of confidence as a product of the erectile or

ejaculatory dysfunction. The passivity continues even if the
primary sexual symptom is relieved. The primary sexual

symptom and the passivity independently serve multiple
functions including to express feminine identification, to
camouflage intrusive phallic strivings, to withhold satisfaction
from the maternally-identified sexual partner, and to allay

castration anxiety.
The transference usually develops with the patient being
passive, dependent, and little-boy charming in an attempt to elicit

encouragement, approval, and care. It is only later that the
resentment, phallic strivings, and conflict around such strivings
come into play.
I do not mean to suggest that either the dynamics or the
transference of patients with sexual disorders is predictable. I do

feel, however, that in women with sexual disorders issues of
control, genital inferiority, and penis envy are especially
prominent and in men with sexual disorders feminine

identification is particularly problematic.
However the transference may be manifest, just as in the
treatment of any other neurosis or character disorder the

transference neurosis is resolved by small increments through
mutative interpretations timed to coincide with the emergence of
emotionally laden material which is tinged with archaic fantasy

and directed toward the therapist as a transference object (14).
If the patient is appropriately selected for analysis,

interpretations are likely to be directed toward castration
anxiety, penis envy, perverse fantasies, forbidden sexual
impulses, and other areas which, in whatever derivative form, are

related to issues of sexuality. I always keep in mind the
uselessness of en bloc interpretation. It does no good to suggest to
a female patient that her difficulties are related to “penis envy.”

Instead, following the policy of small increments, it is fruitful to
observe that her fantasies suggest uncertainty about whether her
lover’s penis is attached to her or separate from her. If it is there,

the patient should be allowed to discover penis envy on her own.
A similar sense of discretion and tact about the patient's anxieties
should accompany the interpretation of homosexual interest,

feminine or masculine identifications, and the other anxiety
provoking material.
REFERENCES
1. Freud, S. (1912). The dynamics of the transference. In: J. Strachey (Ed.), Standard
Edition of the Complete Psychological Works of Sigmund Freud, Vol. 12. London:
Hogarth Press, 1958, pp. 99-108.
2. Freud, S. (1915). Observations on transference-love. In: J. Strachey (Ed.), Standard

Edition of the Complete Psychological Works of Sigmund Freud, Vol. 12. London:
3. Halle, E. Personal communication with Mrs. Halle has suggested these observations,
1978.
4. Kaplan, E. The New Sex Therapy. New York: Brunner/Mazel, 1974.
5. Levay, A. N. and Kagle, A. A study of treatment needs following sex therapy. Amer. J.
Psychiat., 1977, 134 (9):970-973.
6. Mahler, M. On Human Symbiosis and the Vicissitudes of Individuation, Vol. 1. New York:
7. Masters, W. and Johnson, V. Human Sexual Response. Boston: Little, Brown, 1966.
8. Masters, W. and Johnson, V. Human Sexual Inadequacy. Boston: Little, Brown, 1970.
9. Meyer, J. K. Clinical variants among applicants for sex reassignment. Archives of Sexual
Behavior, 1974, 3:527-558.
10. Meyer, J. K. Training and accreditation for the treatment of sexual disorders. Amer. J.
Psychiat., 1976, 133:389-394.
11. Meyer, J. K. Sexual dysfunction. In: A. Freeman, R. Sack and P. Berger (Eds.),
Psychiatry for the Primary Care Physician. Baltimore: Williams & Wilkins, 1979,
pp. 381-399.
12. Meyer, J. K., Schmidt, C. W., Jr., Lucas, M. J., and Smith, E. Short-term treatment of
sexual problems: Interim report. Amer. J. Psychiat., 1975, 132:172-176.
13. Novey, S. The Second Look: The Reconstruction of Personal History in Psychiatry and
Psychoanalysis. Baltimore: Johns Hopkins University Press, 1968.
14. Strachey, J. The nature of the therapeutic action of psycho-analysis. Int. J.

Psychoanal., 1934, 15:127-159.
15. Wise, T. Personal communication with Dr. Wise has led to the development of these
ideas, 1978.
11
Psychotherapy of Ambulatory Patients

with Severe Anxiety
Stanley Lesse, M.D., Med. Sc.D.
Psychiatrists who treat ambulatory patients with severe
anxiety reactions must have immediate, intermediate and long-
range goals. Different therapeutic procedures may be more or less

effective with regard to the attainment of one or another of these
aims. Depending on the therapist’s personality and earlier
training, a broad spectrum of treatment modalities may be

brought into play. Some psychiatrists who are purely organicists
in their orientation will automatically administer tranquilizing

drugs or electroshock therapy, and these treatment procedures
will be the sum and substance of their planned therapy.
Other psychiatrists and psychologists will only employ
purely psychotherapeutic techniques in the management of

severely anxious patients whether the prime nosologic problem is
psychoneurosis, schizophrenia, or sociopathy. These polarized
therapeutic conceptualizations of the treatment of patients

manifesting severe anxiety are anachronistic at our current level
of psychiatric development (1). In my experience,
psychoanalytically oriented psychotherapy, combined with

properly chosen and administered tranquilizing drugs, is the
optimum therapeutic technique for the effective management of
the vast majority of patients in whom severe or even massive

anxiety is a prominent clinical feature.
I will present a step-by-step description of the technical

intricacies involved in the use of tranquilizers in combination
with psychoanalytically oriented psychotherapy. It is a digest of

more than 20 years of experimentation and experience with this
treatment procedure in the management of many hundreds of
severely anxious patients who had a broad spectrum of

psychiatric illnesses (2, 3).
The combined tranquilizer-psychotherapy procedure is a

complicated method from a theoretic basis, because it involves
the compounding of biodynamic, psychodynamic, and
sociodynamic elements into a single unified treatment approach.

At present, few psychiatrists use combined therapy in a planned,
intended fashion. Dynamically oriented psychotherapy has not
been purposefully combined with psychopharmacologic therapy,

owing mainly to the lack of broad training that is necessary if one
is to employ this technique. Psychiatrists, in order to utilize this

combined procedure effectively, must have extensive experience
with the organic therapies and with dynamically oriented
psychotherapy, particularly brief analytically oriented
psychotherapy. Unfortunately, most psychiatrists adhere either to
the organic treatments or to the psychotherapies and use

combined therapy only unintentionally.
Combined Therapy in a Patient with Marked Anxiety
The combined process can be introduced at any of three
phases of the therapeutic procedure, namely, at the inception of

therapy, during the course of treatment, or as maintenance
therapy.
At the Inception of Treatment
Combined therapy logically should be instituted at the

beginning of the therapeutic procedure in patients who are too
overtly anxious to be amenable to psychotherapy alone or on an

ambulatory basis. It is especially effective if the motor component
of anxiety is extremely marked. At this phase of treatment, the
therapist is primarily interested in short-term goals related to the

amelioration or blunting of the initial level of anxiety and the
symptoms and signs that are the secondary defenses against this
anxiety.
Prior to the advent of the tranquilizers, when

psychotherapeutic techniques were employed alone, weeks or
months were often spent in ameliorating the level of anxiety to
the point at which the patient had sufficient ego strength to
cooperate effectively in a dynamically oriented psychotherapeutic
relationship. In a great many instances, the early administration
of tranquilizing drugs greatly shortens the period of anxiety

decompression and thereby enables the patient to cooperate
effectively and meaningfully more quickly. Since the advent of the
combined technique, many patients who formerly would have

required hospitalization can be managed on an ambulatory basis.
The proper use of the combined technique prevents the necessity
for hospitalizing many severely anxious schizophrenic patients

and some patients with agitated depressions, who otherwise
would have been exposed to the psychic trauma and economic
drain that are often associated with institutionalization.
Combined therapy is particularly effective among those

severely anxious patients who are commonly diagnosed as having
schizophrenia, pseudoneurotic type (2). I would go further and

state that, from my point of view, the combined therapy technique
is the treatment of choice for most pseudo-neurotic
schizophrenics who overtly manifest a marked degree of anxiety.

I have also found that many severely decompensated
schizophrenic patients, whose illnesses were previously
considered incompatible with ambulatory psychotherapy, often
become suitable candidates for analytically oriented therapy
when it is combined with tranquilizing drugs, particularly those

of the phenothiazine group.
Combined therapy is a necessity in the management of many
very anxious patients who have organic mental reactions. Prior to
the advent of the tranquilizing drugs, outpatient electroshock

therapy or hospitalization was mandatory for a very large group
of these individuals. At the present time, a high percentage of
those anxious patients with organic mental illnesses, particularly

those that fluctuate in appearance and intensity, can be managed
very effectively by a combination of tranquilizing drugs and
supportive psychotherapy.
Though combined therapy has its most dramatic effects in
the outpatient treatment of anxious psychotic patients, it is also

indicated at the very inception of treatment with some extremely
anxious psychoneurotic patients. Weeks and even months of
painful anxiety that severely limits the benefits of all
psychotherapeutic efforts may be greatly shortened if combined

therapy is diligently employed.
The combined therapy approach is also indicated at the
inception of treatment with very anxious, acting-out adolescents

and some hyperactive children, where the acting-out or
hyperactivity is a secondary defense mechanism against a marked
increase in the degree of anxiety.
During the Course of Treatment
The tranquilizing drugs also may serve a purpose when
introduced during the course of analytically oriented
psychotherapy or even during the course of intensive,
reconstructive, psychoanalytic psychotherapy. They should be
considered when the level of anxiety escalates sharply or

persistently secondary to an increase in environmental stress or
psychotherapeutic events. The judicious introduction of the
tranquilizers may often literally save psychotherapy. This is

particularly so in the ambulatory management of anxious
schizophrenic patients.
The insights unveiled during the course of dynamically

oriented psychotherapy may precipitate a marked or even
massive elevation in the intensity of anxiety in some neurotic
patients, and most particularly in a large group of schizophrenic

patients, no matter how diligent and careful the therapist may be.
This marked increase in anxiety may be attended by the
appearance of a strong negative transference and a decrease in

effective free association. The tranquilizing drugs, when properly
utilized, by rapidly reducing the level of anxiety not only may
ameliorate the secondary signs and symptoms associated with

the increased level of anxiety, but also may ameliorate the
destructive effects of a strong negative transference and permit
more significant free association.
As Maintenance Therapy
Many patients require intermittent psychiatric treatment
throughout their lives. This is particularly true with schizophrenic
patients. To a lesser degree it pertains also to a segment of the
population of neurotic patients who have been chronically ill and

to some with recurrent depressions.
An experienced therapist learns to recognize and appreciate
which patients require scheduled visits and which patients may

be permitted to use their judgment as to when they should seek
help. As I have noted before, it is imperative that patients be
taught to recognize the earliest evidences of mounting anxiety

and the threshold beyond which they should return for further
treatment.
The nature of maintenance therapy will differ depending on

the patient, the therapist, and the environment. Some patients are
unable to function successfully vocationally, socially, or sexually

without maintenance drug therapy even in the face of routine,
everyday responsibilities. Usually the required dose of a
tranquilizer for maintenance purposes is far less than the amount
needed to ameliorate the original anxiety. Indeed, a less potent

tranquilizer than that originally required, one that may also have
less severe side effects, may be sufficient during the maintenance
period.
There are literally tens of thousands of patients who are on a

continuous program of tranquilizing drugs. Very often, when they
evidence psychic decompensation, the problem may be met by a
simple increase in the dose of the prescribed drug. On occasions it
may be necessary to change the drug with a different biochemical
agent being substituted. The psychotherapeutic techniques
utilized in combination with the drugs will differ depending on

the intensity and rate of increase in the level of anxiety and the
patient’s immediate response to the tranquilizers (4, 5). If the
level of anxiety is readily controllable, an analytically oriented

psychotherapeutic approach, in which reeducation is continued,
is feasible. If the level of anxiety is very pronounced, a return to a
supportive psychotherapeutic approach will be necessary.
Certainly not all patients require maintenance drug therapy

but instead can be managed with various types of
psychotherapeutic techniques alone, the visits being scheduled

periodically or as required by evidences of psychic
decompensation. Usually, maintenance psychotherapy merely
reinforces previously learned processes. Less frequently, the

widely spaced maintenance visits may further the learning
process by bringing to light insights that advance psychic
maturation.
If the presenting level of anxiety is severe or if the rate of

increase is pronounced, the therapeutic process will become
more supportive until the overt manifestations of anxiety are
significantly reduced. Very commonly it is advisable to
supplement the psychotherapeutic regime by the addition of a
tranquilizer, depending once again on the degree of manifest
anxiety and the rate of acceleration in the degree of anxiety. If the
level of anxiety is not marked, small amounts of the original drug

or even a less potent tranquilizer usually are sufficient to block or
ameliorate the presenting symptoms and signs. In any case, when
employing am drug, one must use the appropriate preparation in

sufficient amounts.
Selecting the Proper Tranquilizer
My rules for the selection of a particular type of preparation
are very simple. Wherever there is clear-cut evidence of marked

or extreme, overt anxiety, usually accompanied by one or more
secondary symptoms or signs, I select a neuroleptic, usually a
phenothiazine preparation. If the patient has a history of an

inadequate response or a sensitivity to drugs of the phenothiazine
group, then one of the butyrophenones or thioxanthenes may be
chosen. In patients in whom anxiety is obviously very pronounced
I find that chlorpromazine, the first of the phenothiazines to be

introduced, is still the most reliable and effective preparation. The
initial soporific side effect commonly associated with
chlorpromazine may be beneficial.
Where the level of anxiety is moderate, and the patient has
not responded to psychotherapeutic procedures alone, drugs

such as Librium (chlordiazepoxide) or Valium (diazepam) may be
utilized.
If neurotic patients are extremely anxious, the so-called minor
tranquilizers are of relatively little benefit and the major
tranquilizers usually must be employed (1). Conversely, there are

ambulatory schizophrenic patients, seen in private or clinic
practice, who will respond to chlordiazepoxide or diazepam if the
degree of manifest anxiety is not severe.
Analytically Oriented Psychotherapy in Combination with

Tranquilizers
Initial Phase
This combined technique is optimally suited to patients

whose illnesses are characterized by marked or extreme overt
anxiety, together with various secondary symptoms and signs.

Indeed, it is the preferred technique for such patients. The
primary purpose during the initial phase of treatment is to
ameliorate the severe pathologic level of anxiety, this decrease

being accompanied by a blunting or removal of the secondary
clinical manifestations.
When this is accomplished, the therapist should not be

deluded that he has caused a grand metamorphosis that will
stand the ravages of time and stress. All that has been
accomplished is the lessening of the patient’s psychic pain, as
evidenced by marked anxiety, and of those symptoms that are
secondary defense mechanisms against this anxiety.
The initial process of the combined therapeutic procedure
usually lasts from one to three weeks. It is rare for this phase to
be of longer duration. The psychotherapeutic aspect is strongly

supportive and is conducted in a face-to-face setting. Under no
circumstances should the patient be placed on a couch at this
point, for it is imperative that the therapist be sharply aware of all

clinical changes, whether the information is transmitted to him by
visual, auditory, or tactile means.
The recording of the anamnesis is an intimate part of the

technique of anxiety reduction. The therapist should take great
pains to reassure the patient as to a positive outcome. During the

initial interview, the therapist must obtain a detailed qualitative
and quantitative analysis of the anxiety that is present, together
with a sharp awareness of the sequence of appearance of the
secondary defense mechanisms. He must also evaluate as clearly

as possible the sources of stress, both chronic and acute. In
addition to being aware of the initial value or level of anxiety, the
therapist must know prior to the institution of therapy whether

the level of anxiety is increasing, has already plateaued, or is
decreasing. The therapist may require a number of visits before
he can accurately ascertain the direction and rate of change in the

quantitative degree of anxiety. The therapist should be aware also
as to whether the anxiety and secondary symptom formation are
in a psychotic or neurotic framework. (Though this determination

cannot be made in some instances during the initial interview, a
tentative evaluation is a great aid.)
The patients should be seen two to three times during the
first week of combined therapy. This permits the therapist to

adjust the dosage of medication, obtain further history, and
continue the supportive psychotherapy begun during the initial

interview.
In very anxious patients the tranquilizers are prescribed at

the time of the initial interview. The psychiatrist should have a
thorough knowledge of the drug that he is employing, both from a

therapeutic standpoint, and with regard to possible side effects.
He must be confident in his handling of the medication. It is also
imperative that he be experienced in the technique of brief

analytically oriented psychotherapy. He should understand the
capacities, as well as the limitations, of both the organic and

psychotherapeutic aspects of the procedure. The therapist should
also understand the benefits and limitations of hospitalization, for

with many of these patients, should their ailments worsen instead
of improving, emergency hospitalization may be necessary.
Finally, the therapist should be cognizant of the benefits of

ambulatory electroshock therapy, for some of the psychotic
patients who continue to regress or show no significant
improvement may be excellent candidates for electroshock

therapy as far as the amelioration of the initial levels of anxiety
and secondary symptoms and signs is concerned.
Before the therapist prescribes a drug, its nature and
purpose, especially its potential positive benefits, should be
described to the patient in general terms. The mechanism by

means of which the combined technique operates can best be
described to the patient in terms of anxiety reduction, with
symptomatic relief being secondary to this amelioration. Many

patients come expecting medication. Indeed, many may request
one particular “magic pill.” Environment may exert a negative
effect on the patient. Some patients come with great antipathy to
drug therapy or psychotherapy or to a particular type of drug
therapy or a particular type of psychotherapy. This is especially

true if they have had any prior treatment. Such a situation may
complicate the initial therapeutic situation to varying degrees.
The most common potential side effects that many occur
secondary to a particular drug should be presented simply and

honestly. The descriptions must take into account the patient’s
preconceived conceptualizations, correct or incorrect. Every
therapist should be prepared for possible difficulties arising in

anxious patients who have hypochondriacal manifestations as
part of their secondary defense mechanisms, should side effects
occur. Finally, one should be aware of difficulties that may arise

among severely anxious schizophrenic patients, particularly
among those in whom there are evidences that a decrease in the
level of consciousness may be followed by difficulties in reality

contact. Some very anxious patients who have organic mental
deficits also are prone to pose problems should the tranquilizers
have a potent soporific side effect. Finally, patients with a very

pronounced obsessive-compulsive matrix may pose a problem in
the very initial phase of therapy as a manifestation of their fear of

losing control secondary to the use of any drug.
One of the primary aims during the initial phase of treatment

is to foster a very strong, positive transference reaction (2). The
accomplishment of this aim is rendered relatively easy if the

therapist’s and patient’s initial goals are in harmony and the
prime basis for concomitancy at this point is an expectation of
rapid amelioration of the presenting symptoms and signs. If the

initial aims are divergent, therapy will be star-crossed from the
very beginning. Unfortunately, a negative transference reaction is

likely to occur if the therapist states, in effect, that “the main
purpose of treatment is reeducation and this will take a long, long
time.’’ The severely anxious patient’s prime desire at this point is
symptomatic relief, and he should be approached overtly with the

general idea that, “I will relieve you of your pain.”
By the use of this combined tranquilizer-psychotherapeutic

approach, a working relationship between doctor and patient that
would have taken months to establish with psychotherapy alone
may be accomplished in a matter of weeks. Many patients react to

the rapid relief of painful anxiety with unquestioning gratitude
and a desire, indeed an eagerness, to relate to the psychiatrist.
This is quickly established and enhances the strong positive
transference. It occurs at times as part of the magical expectancy,
with the therapist being viewed as an all-powerful father who is

infallible in the patient’s judgment.
I cannot stress too forcefully that the initial phase of the
combined technique produces rapid clinical changes that are

ever-changing and that have a momentum far greater than that
seen when psychotherapy is used alone. This puts greater
demands on the therapist. Indeed, some therapists are poorly

equipped psychologically to effectively handle this type of
procedure.
During every visit, by direct questioning and careful

observation, the degree of the patient’s anxiety, the nature and
status of the secondary symptoms, the vocational, social, and

sexual behavior, and the dream material are reviewed in detail.
Close contact is made, where possible, with the patient’s family
and friends. I appreciate the fact that relatives and friends may be
poor informants, but the nature of the information to be gathered

is simple and can be readily correlated with the data obtained
from questioning and observing the patient.
In view of the rapid change in the patient’s clinical status, the
therapist may be prone to overestimate the patient’s capacities

for vocational and social adaptation. However, I must emphasize
that at this point the improvement is primarily symptomatic in
nature, with the patient having little or no understanding of the
nature or origins of his problems. It is safer to be conservative in
the estimation of a patient’s ego capacities At this point in
treatment, overoptimism could result in anxiety to the point of

panic if the patient is exposed prematurely to excessive
vocational or social stress.
The rate of change that occurs as a result of the combined

technique can be controlled. This pacemaker can take several
forms. First, the dosage of the tranquilizer can be varied. A rapid
buildup is often necessary during the first week with changes

being made daily or every few days until the intensity of anxiety
is very definitely ameliorated. After the level of anxiety is
decreased, the total daily dosage of medication may be lessened.

The total daily dosage has to be titrated against the degree of
overt anxiety.
From a psychotherapeutic standpoint, the level of anxiety

can be affected by the relative control or encouragement of the
process of patient catharsis. In some patients, a free outpouring of
affect-laden material may be an effective tool leading to anxiety

decompression. However, at times it can cause a negative
feedback reaction and actually increase the level of anxiety,
leading to a new pananxiety state. In such instances the therapist
may aid anxiety amelioration by limiting the nature and rate of
catharsis. Systematic autorelaxation exercises, vigorous physical
outlets, and occupational diversions are good temporary channels
that may serve as braking mechanisms. It should be understood
that this process is very fluid and depends entirely upon the rate
and direction of the patient’s clinical change. The rate of clinical
change can also be affected by controlling the patient’s activities
relevant to work, socialization, and sexual relationships.
It can be affected to a lesser degree by interpretations. At this

phase of treatment, interpretations should be made sparingly.
The therapist must be careful not to precipitate insights that the

patient is emotionally incapable of handling. Interpretations,
when they are given, should deal with the here and now. When
they involve situations from the patient’s past they should be

pertinently related to the patient’s current behavior or life
situation. Poorly timed and poorly conceived interpretations may
precipitate a massive panic reaction.
The reporting of dreams is encouraged even in the initial

phase of therapy. As the level of anxiety is rapidly decreased,
there is a greater awareness of dream material. The therapist

should be cautious and not overwhelmed by this seeming deluge
of dream recall. Once again, at this point he should refrain from
making profound interpretations that the patient may not be able

to tolerate. At this phase of treatment dreams should be viewed
primarily as a source of psychodynamic information and

secondarily as a means of anxiety decompression. Interpretations,
when deemed pertinent, should be related to the current scene
and should be gauged according to the patient’s capacities to
tolerate an awareness of the latent content.
Dangers Associated with the Initial Phase
Many complications can occur during the initial phase of
treatment. Most can be anticipated and avoided. Others can

readily be corrected.
Excessive Tranquilizing. At times the dosage of the

tranquilizers may be increased too rapidly or, as the overt level of
anxiety is decreased, the drug level may be kept at levels more

appropriate for the period when the overt level of anxiety was
much greater. It is imperative that the dose of medication be
optimally titrated according to the intensity of manifest anxiety.

This titration should proceed gradually, never precipitously.
One must be particularly cautious in the reduction of drug

dosage in schizophrenic patients, for at times an excessively rapid
decrease in medication may precipitate a panic episode. On the
other hand, overtranquilizing may cause a paradoxic, massive

pananxiety state in schizophrenic patients if the soporific side
effects of the drug lead to difficulties in reality control. On

occasions this may be relieved by the addition of small amounts
of amphetamine.
Excessive tranquilizing also may produce a degree of
placidity and passivity that will block further effective treatment.
The overly rapid amelioration of anxiety may lead some patients

to minimize the severity of their illnesses. Indeed, in some, one
can observe the unfolding of a complete scheme of denial or
illness. Some will run from treatment. Others may remain purely
to receive the medications. It was interesting that these patients
are afraid, in many instances, to have other physicians take over
the administration of drugs. This is an example of what I have
called drug transference, in which the therapist becomes merely
the purveyor of a “magic elixir” (6).
Insufficient Dosage of Tranquilizer. The danger of an

insufficient dosage is self-evident. If the therapist utilizes the
information that can be accumulated from an awareness of the
basic mechanisms of anxiety reduction (4), he should have little

difficulty in administering the amount of drug necessary for the
amelioration of a certain quantum of anxiety. I repeat that the
therapist must know his drug, its benefits and its limitations.
Side Effects of Medication. All drugs that have any potency
may have adverse side effects. Fortunately, most that occur as a
result of the administration of tranquilizers are mild and

transient. The patients should be forewarned to minimize the
anxiety that is associated with the appearance of side effects.
As side effects appear the therapist should interpret them
clearly to the patient so that they are not falsely conceived by tire
patient as being an integral part of his illness. This is particularly
important in patients who have hypochondriacal defense
mechanisms. It is also important in patients who have an

obsessive-compulsive personality matrix, for they may conceive
that side effects are a further indication of their lack of control.
Paranoid schizophrenics may interpret side effects as evidence of

the therapist’s malevolence toward them.
Excessive Positive Transference. In some instances the
patients develop a degree of dependency that renders them

affectively almost inert. In general, this is not a problem during
the initial phase of treatment; it usually becomes a major concern
during the second, or psychoanalytically oriented phase of

treatment. Quite often this difficulty may be associated with
overmedication and can be corrected by a reduction in the daily
dose of tranquilizer.
Drug Transference. As mentioned earlier, drug transference

pertains to situations in which patients will remain in therapy
with a given psychiatrist because they associate him with the

administration of a successful drug and are afraid that the same
drug will not be so effective if administered by a different
physician (6). In these instances, the therapist becomes merely
the purveyor of a pill. At times drug transference may be confused
by the therapist as representing a true, strong, positive
transference. When such misinterpretations are marked, owing to
the therapist’s own emotional needs, effective treatment is bound
to collapse. With the use of drugs, as with all types of treatment,

accurate observations, undiluted by exaggeration due to
immodesty and neurotic wishful thinking, are necessary for
optimum benefits.
Premature or Excessive Environmental Commitments. The

rapid amelioration of the initial level of anxiety and secondary
symptoms and signs is interpreted by most patients as a sign of a

“return to health.” When this occurs, almost all patients, if left to
their own design, immediately will attempt to resume full
vocational and social activities. Indeed, many will strive to make

up for lost time. They will try to compensate for that period of
time in which their psychic difficulties limited effective activity.
I cannot emphasize too urgently that, following the initial

symptomatic improvement secondary to drug therapy, premature
resumption of routine responsibilities may lead to a massive
psychic collapse. It is one of the main tasks of the psychotherapist,

at this phase of treatment, to guide the patient’s vocational and
social performance with a firm hand until the patient
demonstrates firm evidence of increased ego capacities. The

failure on the part of psychiatrists to follow these suggestions is
one of the commonest causes of failure in drug treatment.
Family Interference. The rapid amelioration of the presenting
symptoms and signs is considered to be synonymous with a cure
in the minds of most relatives and friends of patients, and they
often become a negative influence with regard to the patient’s
remaining in therapy.
To a degree this can be forestalled by predicting for the

patient and family at the first visit that symptoms and signs will
probably disappear very quickly but that any cessation of

treatment at that point would be fraught with danger. This
admonition may now be repeated, if unintentionally malevolent
advice from the family threatens to interfere with further

treatment. Both the family and the patient should be warned in no
uncertain terms of the dangers of premature termination of
treatment.
Psychoanalytically Oriented Phase
There is no sharp demarcation between the initial and

secondary, or psychoanalytically oriented, phase of treatment.
Rather, the change takes place gradually, with the
psychotherapeutic process becoming less and less supportive.

The change usually begins from one to three weeks after the
onset of treatment, after there has been definite evidence of a

marked decrease in the quantitative degree of anxiety and a
significant amelioration of secondary symptoms and signs. In
some instances the secondary symptoms and signs may be

completely gone. In other patients, one or even two of the
symptoms may be present but only intermittently and without
their pretherapeutic level of affect.
Aberrations such as delusions, illusions, and hallucinations

should be ameliorated completely before the analytically oriented
phase of the treatment begins.
The primary aims of the psychoanalytically oriented phase of

treatment are 1) reinforcement of anxiety decompression begun
in the initial phase of treatment and 2) reeducation with the aim

of increasing the patient’s psychosocial maturation.
As treatment progresses, the first goal becomes less and less
important as the second goal becomes increasingly realized. I

would like to reaffirm that at the onset of this second phase of
treatment the patient has little or no insight as to the sources or
psychodynamics of his difficulties. Improvement, thus far, has

resulted from the tranquilizer, the supportive psychotherapy, and
various placebo effects.
This is a dangerous point for a therapist to become

overwhelmingly enthusiastic and undercautious, particularly if he
becomes enamored with his own magical powers. Poor judgment,

in this regard, may lead to a precipitous collapse of all that has
been attained. At this point, die patient still has relatively fragile
ego capacities.
The psychotherapeutic support that characterized the initial
phase of therapy can be gradually relaxed when there is adequate
indication of increasing ego strength. This is measured to a great
extent by the degree of overt anxiety and the patient’s vocational,
social, and sexual adaptation. Therapy remains ego supportive in
nature but to a gradually lessening extent. Free association is

encouraged but in a guided fashion.
The clinging positive transference relationship is given active

attention. As noted before, if it continues in an undiluted form,
therapy will become paralyzed. The positive transference is

actively interpreted and dissipated, for its existence is a constant
threat to the effective continuation of the psychoanalytically
oriented phase of treatment. Its presence is a residue of magical

expectations and is antithetical to any psychotherapy that has
emotional maturation as a goal.
As mentioned before, in the presence of a very strong
positive transference reaction there is often a marked inhibition

of any negative or hostile responses. I do not mean that repressed
hostility is completely inhibited. To the contrary, marked anxiety
has a hostility-inhibiting effect in many patients, and during the

initial phase of therapy, as the level of anxiety is rapidly reduced,
anger directed toward persons other than the therapist may come
forth.
The decompression of anxiety during the initial phase of

treatment is often followed by a free flow of repressed hostility,
but this hostility is rarely directed toward the therapist in the
form of a strong negative transference reaction. This situation
poses a therapeutic problem in a number of instances if it persists
in the psychoanalytically oriented phase of treatment.

Manifestations of negative transference, when kept within
reasonable bounds, afford an excellent means for the controlled
discharge of hostility and at that same time serve as a valuable

medium by means of which the patient obtains significant
insights.
As the excessively positive transference is reduced in

intensity, the therapist usually can expect the appearance of a
negative reaction. However, it will usually not be so intense as it
might have been if a tranquilizer had not been used in the initial
phase of treatment. This poses an active task for the
psychotherapist to guide the release of hostility in such a manner
as to benefit the patient, while at the same time avoiding an

indiscriminate and inappropriate outburst of rage against family
and friends. I have noted only a few instances, in my studies, in
which the released hostility could not be managed by diligent

guidance even with schizophrenic patients.
Communication Zone
The term communication zone refers to a quantitative degree
of anxiety in which the patient appears to communicate most

freely (6). In some patients the range appears rather broad,
whereas in other patients, it is relatively narrow.
Psychotherapists, beginning with the classical psychoanalysts,
correctly warned that, if the patient’s level of anxiety is depressed

to too great a degree, the patient will not communicate efficiently.
Relatively few psychotherapists have drawn attention to the fact
that when patients are extremely anxious there is also relatively

little effective communication.
Though the pattern is highly individualized, in many
instances I find that there is a certain threshold of anxiety below

which the patient will communicate with greater freedom. The
rate of change in the quantitative degree of anxiety also appears
to affect communication. The level of communication is greatly

enhanced as an excessive level of anxiety is decreased and is less
evident as anxiety establishes a plateau effect. Similarly, as the
quantitative degree of anxiety is increased in patients who

present a flat affect, a zone of anxiety will appear characterized by
relatively free communication that may disappear if an

excessively high level of anxiety is attained. I repeat, once again,
that this is a highly individualized process that requires greater
study.
With regard to interpretations made by the psychotherapist

during the combined therapy technique, the same general rules
pertain as in any other brief psychoanalytically oriented

procedure. It should be remembered, once again, that the process
of change is much more rapid here than in the usual
psychotherapeutic process. The therapist must be very cautious
lest he permit the development of a free-floating pananxiety state

secondary to interpretations that the patient is unable to accept at
a particular state of emotional maturation. As in dream
interpretation, the interpretation of other material should focus

on the here and now, with past events and associations being
related as much as possible to current processes. At all times,
evidence of increasing anxiety should be probed.
Vocational and social adaptation, with pride and pleasure in

relationship to past and present relationships, is stressed, with
primary emphasis on current processes. The necessity to function

within one’s current psychic capacities is prominently
emphasized throughout this analytically oriented phase of
treatment. The patient is conditioned, so to speak, to an

awareness of the earliest evidences of increased anxiety
secondary to any type of environmental stress. As the patient

attains a more mature level of awareness, he learns to anticipate
situations more positively. Usually, at this point, the amount of
anxiety precipitated by a particular situation is relatively slight.

The final attainment of maturity with regard to a particular
situation is attained when the patient is automatically able to
manage a situation without significant anxiety.
If the tranquilizing drugs are introduced during the
psychoanalytically oriented phase of treatment for the first time,
or if they are reintroduced after having been discontinued, the
degree of the positive transference that occurs is not so profound

as noted when drugs are introduced in the initial stage of the
combined therapy program. Similarly, in such instances it is rare
for a strong drug transference to occur. The patients in this

situation usually maintain a realistic attitude toward the
medications, and they merely credit the therapist with good
judgment for having employed the tranquilizers.
REFERENCES
1. Lesse, S. Drugs in the treatment of neurotic anxiety and tension. In: P. Solomon (Ed.),
Clinical Studies in Psychiatric Drugs. New York: Grune & Stratton, 1960, pp. 221-
224.
2. Lesse, S. Psychotherapy and ataraxics. Amer. J. Psychother., 1956, 10:448.
3. Lesse, S. Combined use of psychotherapy with ataractic drugs. Dis. Nerv. Syst., 1957,
18:334.
4. Lesse, S. Psychodynamic relationships between the degree of anxiety and other

clinical symptoms. J. Nerv. Ment. Dis., 1958, 127:124.
5. Lesse, S. Anxiety—Its Components, Development and 'Treatment. New York: Grune &
Stratton, 1970.
6. Lesse, S. Psychotherapy in combination with ataractic drugs—A six-year study with

350 patients. Amer. J. Psychother.. 1960, 14:491.
12
Psychotherapy with Violent Patients
Robert Weinstock, M.D.
Psychotherapy with violent patients can best be regarded as

psychotherapy with patients having a variety of diagnoses who
present with the symptom of violence. One definition of a violent
patient is an individual who is physically assaultive toward other

people or things (1). Except for the fact that the symptom can be
so frightening and potentially dangerous, it is not really that
different in kind from other symptoms, such as suicidal behavior.

A suicide attempt, violence directed against the sell, can also
occur in a variety of different conditions. However, since violent

patients present special problems, institutions often set
themselves up in ways in which they are unable to deal with such

patients. They are passed from institution to institution until
often they end up in a punitively oriented criminal justice system,
which can exacerbate the person’s problem. Alternatively, the

patient can find himself in an open community hospital setting
which has no locked facility or capacity to deal with violent
patients. Staff become frightened and can try to extrude the
patient and put him into the criminal justice system.
I believe that the only constructive solution is to approach

the problem as a multifaceted one. First, a unit capable of dealing
with the violent patient in a manner such that both staff and
patient can feel secure that no harm will come to anyone is
needed. Second, one must evaluate what the immediate cause of
the violent behavior is with a particular patient. Third, the

underlying psychiatric problem must be diagnosed and treated
according to standard techniques. Fourth, the reactions of the
staff towards the patient must be handled in a way which will

enable the patient to be treated in a rational manner. Last, a
follow-up plan must be instituted which will help prevent future
instances of the problem.
Because of the potential severity of the danger in dealing

with such patients and because of the complex reactions of staff
and society towards them, it is impossible to discuss treatment

without also examining some of the ethical issues involved.
Violent patients are seen both in mental health and criminal
justice systems. They probably produce stronger feelings, usually

of a negative kind, than any other patient group. Where a
particular patient is seen may depend on the seriousness of his
violence, his socioeconomic status, the prevailing views of the
community and social era, facilities available and many purely
fortuitous factors. The violence can range from throwing
something against a wall, to assaulting someone, to murder. It can
be a result of many different causes, such as paranoid
schizophrenia, homosexual panic, temporal lobe epilepsy,

alcoholism, explosive and impulsive personalities, depression,
pseudopsychopathic schizophrenia, narcissistic injury, a
reflection of staff conflict, and organized criminal behavior. Each

of these causes needs to be treated differently.
We also have to cope with our own tendencies to stereotype
and scapegoat. Undue therapeutic pessimism can result from

fears of such patients and disappointments or failure of previous
unrealistic optimism. In recent years we have seen a paradoxical
incarceration of violent patients in correctional facilities because

mental health districts have often not even had one locked facility.
Instead, a unit where one can safely examine and evaluate such
patients, with adequate well-trained support staff, is required to

come up with rational nonpunitive therapeutic plans on an
individual basis. One should have a secure facility and a

nonvindictive staff. Unfortunately, such a combination is all too
rat e in our current mental health-criminal justice system.
Special Factors in Treatment of Violent Patients
Halleck (2) has discussed some of the ethical problems in
treating violent patients. When the patient is seen in an

institution, the psychiatrist must decide to what degree he should
follow the goals of the treated subject or those of the treating
agency. Treatment goals can range all the way from controlling
behavior, with total disregard for the psychological state of the
offender, such as prolonged restraint, seclusion, or incarceration,

to the more desirable development of internalized controls
accompanied by greater personal comfort and awareness.
Alternatively, one could aim towards development of internalized

controls, without external restraint, with no regard whether the
person became more withdrawn, nonproductive, passive or even
mentally ill. Hopefully, treating personnel will show respect for

individual rights and values and not be hypocritical and call
anything, even punishment, treatment. It is important to be
honest to patients and realize that when an institutional

psychiatrist acts for the good of the institution he is not
necessarily acting in the patient’s interest. Often, preventing a
patient from doing harm is in the patient’s long-term interest also,

but there are times when an institutional psychiatrist’s loyalties
conflict and he must be honest to the patient about the conflict
and to what use a potential report will be made. Reasonable risk-

taking, which will allow the patient whatever responsibility he
can handle, is necessary. An appropriate balance between
security and ego-strengthening activities must be found.
Violent patients additionally present problems because of
society’s needs to have a scapegoat for its problems. Ryan (3) has
stated the important symbolic role of prisoners is that they
symbolize crime that has been contained and this makes the
citizens feel safe. Menninger (4) has described the cops-catch-
robbers ritual as a morality play which is not totally without

redeeming social value, but with scapegoats necessary for the
spectacle. According to Menninger (5), as long as the spirit of

vengeance and a punitive attitude persists, and as long as we seek
to inflict retaliatory pain, we will neither be able to assess
appropriate and effective penalties nor make headway in the

attempt to control crime.
Most murders are committed as isolated acts by people
closely acquainted with the victim. Mass murderers, the ones who
stir up the most hatred and fear, and the least sympathy, are,
according to Lunde (6) almost always insane. Contrary to the
view that the United States goes too easy on murderers with
insanity pleas, Lunde reports that the United States has insanity
verdicts in only 2% of the cases, compared with 25% in England.
Unfortunately, scapegoating is an issue from which even

mental health professionals are not immune, particularly when
people are overburdened. A sort of projective identification with
the violent patient can occur. The therapist can project his own
violent impulses into the patient, and see the patient as much
more dangerous than he really is. Kernberg (7) describes some of
the problems a therapist struggling with his own aggressive

impulses can have, where he can project the impulse into the
patient whom he then sees as the bad dangerous side of himself.
Violent patients can bring up extreme reactions in the therapist.
One must guard against either being excessively punitive or
alternatively masochistically submissive to the patient’s control

efforts, while excessively denying the real dangerousness of a
patient. Moreover, the openness of aggressivity, sexuality, and
dependency in such patients can lead to countertransference

problems for the therapist (2, p. 330).
Involuntary commitment of such patients raises questions of
dangerousness. Stone (8) has criticized the criteria of

dangerousness for civil commitment because of the impossibility
of accurately predicting it. Even Kozol’s study (9), which
succeeded to some degree in predicting dangerousness, had

61.3% false positives. The Baxstrom decision (10), which released
a large number of so-called dangerous people from maximum
security prison hospital in New York into the community, showed

that there had been a severe overprediction of violence. The
overwhelming majority of the released prisoners were, in reality,

not dangerous. This natural experiment shows that psychiatrists
can be overconservative in their judgments. There can be
problems with so-called indeterminate sentences where a

psychiatrist must guarantee that a patient will not be dangerous
in order to discharge him. I believe a better model is one in which
there are yearly reviews of any long-term commitments and

where a judge makes a final decision rather than putting the full
burden for retention or release on the psychiatrist. The public
seems better able to accept a court making a mistake than a
psychiatrist making a mistake. Recidivism is acceptable from

prison, but psychiatrists are often under pressure to be infallible.
Monahan (11) makes the point, though, that the difficulty
with most predictions of dangerousness is that the context of

prediction is a locked facility, while the context of validation is the
community. In an emergency room setting, the context of
prediction and validation is almost the same; the patient has been
living in the community, and will likely be returning there. The
time interval between prediction and validation is short, so one
should be able to do a much better job at this sort of prediction.

Skodol and Karasu (12) found in a study of emergency room
patients, however, that most acts of violence are spontaneously

occurring and unpredictable. They did find, though, that a
statement of intent to do harm and a family member being the
target both indicate serious situations. I believe that there can be
some meaningful assessment of imminent dangerousness (2) and

that, Szasz notwithstanding (13), such patients should be
hospitalized even involuntarily.
The problem is not, in my opinion, so different from the

suicidal patient (14), where one can monitor and assess his
suicide potential even if one does overpredict it. More serious

ethical problems arise because, while almost no one would
seriously argue for hospitalizing or incarcerating a suicidal
patient for years or even life because he might regress and
become suicidal again, one does hear such proposals for
potentially violent patients. It is very difficult to disentangle

feelings about a patient and values of a particular psychiatrist
from any long-term assessment of a patient's dangerousness.
However, it is unrealistic to think that the criminal justice system

always handles these situations reasonably, or that psychiatrists
could even agree about the treatability of such patients, should
treatability become the prime criterion as some have proposed. I

believe reasonable assessments of imminent danger to others can
be made, as well as danger to oneself. Longer-term assessments
of potential danger are possible but much more questionable.
It is also important to be aware of the social factors that

contribute to law-breaking. Law-breaking (2, p. 322) can have
many different meanings. Undoubtedly, not every law is correct

and moral. Certainly, there are differences between the
professional criminal, civil rights demonstrators, American

Revolutionary leaders and a poverty-stricken adolescent who
steals. Some of the abuses of Soviet psychiatry stem from
psychiatrists’ being willing to see all law-breakers as mentally ill.

Obviously, the treatment of violent patients can be fraught with
many political implications. Psychiatrists must watch not to
become an agent for political and social repression.
Kernberg (7, p. 115), in assessing the meaning of antisocial
behavior, suggests assessing whether the behavior is antisocial
from the viewpoint of a conventional social prejudice, reflects a
normal adaptation to a pathological environment, is an

adjustment reaction of adolescence, is reflective of other
character pathology such as a narcissistic or infantile personality,
or is reflective of an antisocial personality proper. He feds factors

other than pure antisocial personality improve the prognosis.
The diagnosis of antisocial personality itself can often
obscure more than it enlightens. Many workers have been

impressed by the similarities of so-called antisocial personalities
to psychotic patients. Schizoid elements, such as poor
interpersonal relationships, are a part of most diagnostic criteria

for the diagnosis. Lewis and Balla (15) feel it may be a forme
fruste of a psychotic disorder. Cleckley (16) believes the central
disorder may not only be similar in degree to schizophrenia but

more similar in quality that is generally realized. Menninger (5,
pp. 178-180) believes many individuals perform criminal acts in

order not to go crazy. Violence and crime may be attempts to
escape from madness, and mental illness may be a flight from
violence. Murder can be used to avert suicide or can even be a

form of suicide attempt.
Lewis and Balla (15, p. 39) suggest that many of the
symptoms used to define sociopathy, such as poor school

performance, discipline problems, cruelty to animals, fire-setting,
and multiple delinquent acts, are found in children with many
types of psychiatric disorders. Guze (17) diagnoses antisocial
personality, if in addition to a criminal record the person has two

of the following five in their history: excessive fighting, school
delinquency, poor job record, a period of wanderlust, and running
away from home. It is not clear that the list says much more than
the lay judgment of a prior criminal record, the first of the
criteria, and a long-term history of behavior problems. The
danger of such diagnoses is that they may lead to premature

closure attempts to find underlying psychopathology and lend
themselves to hidden moral judgments disguised as medical
science. As Lewis and Balla (15, pp. 41-42) indicate, DSM II uses
terms like selfish, callous, irresponsible, and impulsive to describe
antisocial personalities, giving an indication of the feelings of the
psychiatrist towards a patient whom he gives such a diagnosis.
These issues are not academic matters; a diagnosis for a
patient involved with the legal system can have profound

consequences for the patient. In some states it can make the
difference between six months in a psychiatric hospital and a life
sentence in a maximum security prison. The American Law

Institute (118) criteria for criminal responsibility exclude
conditions manifested solely by repeated criminal or otherwise
antisocial conduct, although this exclusion, if applied

meaningfully instead of being equivalent to a personality disorder
as it has been defined by case law, would apply more properly to
dyssocial behavior, such as organized crime, rather than to
antisocial personalities or personality disorders, to whom the

exclusion is generally applied. Appropriate diagnoses of
underlying psychopathology can lead to proper treatment, both

psychopharmacologically and psychotherapeutically. It is
important, though, that mental illness not be used as an excuse
for indefinite incarceration.
Kernberg (7, p. 13) states that all antisocial personality

structures he examined present a typical borderline personality
organization. Borderline patients (7, p. 24) seldom give evidence
of formal thought disorder in clinical mental status examinations,

but on projective testing with unstructured stimuli, primary
process thinking shows itself with primitive fantasies, peculiar

verbalizations and a deficient capacity to adapt to the formal
givens of the test material. These indications show the patient’s
tendencies to become psychotic for brief intervals and implicate
that he could have been psychotic at the time of a crime. It is rare,

however, that projective tests are given in forensic evaluations
and rarer still that the patient has either the trust or the time to
reveal his psychosis to an examining psychiatrist in an unfriendly

setting. The diagnosis of borderline personality at least calls
attention to the potential for psychosis though this possibility

must be stressed since DSM III lists borderline personality as a
personality disorder potentially obscuring a patient’s propensity
to have brief psychotic episodes. In contrast, antisocial
personality, in most people’s minds, implies the absence of
psychosis, certainly a matter with potentially grave implications

for a patient.
Guttmacher (19) coined the term “pseudopsychopathic
schizophrenia,” a condition which in my experience occurs

frequently. Lewis and Balla (15) have called attention to the
presence of all types of psychopathology in people with antisocial
behavior. My own experience in a maximum security hospital

setting in the corrections system confirms these observations by
showing numerous instances of frank psychosis in people whom
correctional staff saw as merely antisocial. Psychosis and violent

or even antisocial behavior are by no means mutually exclusive
and are, not uncommonly, coexistent.
It is important to realize that antisocial behavior, as well as

violence, can be found in people with all types of psychiatric
disorders, and can have diverse etiologies. The danger of

antisocial personality as a diagnosis, however, is that it can
foreclose all further attempts to look for underlying
psychopathology which can be treated by standard procedures.

Too often the diagnosis of antisocial personality leads to
therapeutic nihilism and nontreatment in a prison facility, or to
discharge of dangerously mentally ill people into the community.

At least in some places, a diagnosis of mental illness can lead to
appropriate treatment.
As I have indicated earlier, the best approach to violent
patients is, first, to contain the violent behavior, then to
accurately diagnose the cause of the behavior, next to determine

the extent of underlying psychopathology, and finally, to institute
appropriate treatment procedures. It is important to remember
that violence can be a symptom of many different conditions and

that lesser forms of violent behavior may even be appropriate
responses to certain situations. One must also remember that the
violent patient is a person and be careful not to use him as a
projection of our own unwanted impulses or our own
stereotypes. One must examine the patient in a setting where

both start and patient can feel secure, and institute appropriate
treatment procedures for whatever underlying psychopathology
the patient is found to have.
The initial problem one may need to confront is how to

contain the violent behavior. This containment may entail
restraint and appropriate pharmacotherapy. Redl (20), writing
about children, says patients can exhibit fits of rage which remind
us of total abandon and constitute a real state of emergency. The
situation can also occur with violent adult patients. One may have
to hold the patient physically, remove him from the scene of

danger and involvement, and prevent the patient from doing
physical damage to others or himself. Since psychiatrists are
ordinarily not skilled at handling physical violence, it is necessary

to have members of the start who are able to subdue the patient
sufficiently without becoming overly punitive. Redl and Wineman
(20, pp. 211-212) describe the ideal approach as one in which no

more counterforce is used than is necessary to achieve the goal of
restraint. Ideally, the therapist should remain calm, friendly, and

affectionate, neither threatening nor blaming the patient. Patients
in a fit of rage can sometimes be totally irrational, and a show of
force can often be reassuring. It can be a face-saving device for a

patient, allowing him to feel that it is not shameful to stop fighting
in the presence of an opposing army. It is important to realize that
the underlying theme in the lives of such patients is helplessness,

which leads to feelings of inadequacy and terror (1, p. 14). It is
crucial to approach patients in ways which are reassuring and do
not increase the panic.
Lion (1, pp. 3-4) writes that the psychiatrist must be

comfortable with a violent patient in order to convey a sense of
security. Often, the presence of ancillary personnel can help
lessen the physician’s own anxieties and later allow him to work
better individually with the patient. The patient’s underlying fears
of loss of control can be accentuated by panic like states in
personnel. Most violent patients are afraid of their impulses and

want controls furnished so that they will not hurt or kill. After the
patient is subdued, he may be put in restraints, and may be given

barbiturates such as sodium amobarbital intramuscularly or
intravenously, benzodiazepines such as diazepam administered
slowly intravenously, phenothiazines, or other antipsychotics
(21). Haloperidol, intramuscularly, is especially useful and has
less of a hypotensive effect than chlorpromazine. On a longer-

term basis, one should prescribe medications, but not
overmedicate with the idea that large dose will help a dangerous
patient. Sometimes paranoid patients can be made worse by
drowsy side effects which feel like a loss of control. Antipsychotic
medications with frequent side effects of sexual inhibition, such

as thioridazine, should probably be avoided in patients with
conflicts about their sexual identity.
It is also crucial to accurately assess the patient
diagnostically. The patient should be tested neurologically and an

EEG performed to rule out temporal lobe epilepsy (22, 23). In
addition, it is important to evaluate for the episodic dyscontrol

syndrome (24). One must try to understand what social situation
triggered the violent behavior to attempt to make certain the
patient does not return into exactly the same situation which
initially set off the behavior. Family intervention may be essential

in this process.
It is useful to further determine whether the violent person

has been what Lion (1, pp. 29-30) describes as an obsessive
compulsive and schizoid individual who doesn’t ordinarily
express anger, and who one day loses control in a fleeting violent
psychotic episode. Alternatively, the person can be an individual
with labile mood swings who is immature, explosive with low'
tolerance for stress, and impulsive with poor judgment. Megargee
(25) has referred to overcontrolled and undercontrolled patterns
of aggression.
The underlying psychopathology must be assessed. One

should ascertain whether there is an underlying situational
disorder, which psychosocial interventions in the community can

affect; whether the violence is due to a schizophrenic episode,
which antipsychotic medications can alleviate; whether a
psychotic affective disorder is the problem, which appropriate

medications can help and control; whether the problem is
alcoholism, and an alcoholic abstinence program like Alcoholics
Anonymous is indicated; or whether drug use, such as

amphetamine use, is the problem and appropriate treatment
needed. Lithium has been found helpful in emotionally unstable
patients who have problems with frustration and who are

impulsively violent. Anticonvulsants can be helpful in people with
seizure disorders. Additionally, the problem can be a long-

standing characterological one which would require long-term
treatment in facilities that are unfortunately rarely available to
lower socioeconomic level patients. Also of use is the assessment

of the person’s childhood, since child abuse and the triad of
enuresis, fire-setting, and cruelty to animals have been associated
with violent behavior (26).
Havens (27) has described an interpersonal technique of
displacement and resultant reduction of projection, which can be
helpful in the acute management of such patients, especially when
the patient is either building up to a violent outburst or is

recovering from one. “Counterprojection” is a technique used to
displace aggression towards other people and, at the same time,
have the therapist on the side of the patient. During the acute
phase one should not talk of introjection and projection. So-called
reality interventions may often just lead to the therapist’s being
included in the patient's projection and the patient’s becoming

violent toward the therapist. Such clarifications can be offered
later on if needed. During the phase where the patient is building
up his projections, the therapist must do everything he can to

separate himself from the patient’s projections. Moralistic
statements at such times can be dangerous as well as
untherapeutic. Some reality-testing about the doctor can

sometimes be useful. If the doctor has reason to believe that the
patient is favorably disposed toward the medical profession, he
might emphasize that he is a doctor and there to help.

Pinderhughes (28) has stated that violence toward another can’t
occur in a moment of introjective relationship, while the victim is
seen as an acknowledged and valued part of the self. Violence can

occur only in moments of projective relationship against a
renounced part of the self, which in the moment of violence is
perceived as evil. The victim is seen as deserving and needing the

violent act to bring about justice. This dynamic operates both in
individual violence and in group violence, where there are shared
projections.
In counterprojection, one might speak negatively about the

introject, thereby giving the patient permission to do likewise.
Since speaking too negatively about introjects can terrify some

schizophrenics, one might have to use ambiguous and double
remarks like “Mother wasn’t an unmitigated blessing.” By
expressing such feelings, the therapist helps the patient to bear

what he cannot bear alone and has previously had to project
because he could not take responsibility for it. As the therapist
takes over the feeling, the patient can give up the feelings he
really didn’t want anyway—which was why he projected them in
the first place. In dangerously conflictual situations, ambiguous
and double statements can help. Double statements explore the
other side; for example, the therapist might say, “She is a pain but
she has, I suppose, a good side.” By techniques of successive
approximations, the truth eventually comes out. The use of the
counterprojection technique can sometimes be difficult; other

people can become upset if they feel the doctor is taking the
patient's side against them. This situation can be especially
difficult when the other people are police or correction officials,

or even other hospital officials. In my experience, one sometimes
has to direct counterprojective devices toward other staff when
referring to violent patients, such as exaggerating how dangerous

or difficult a patient may be.
Another frequent error in dealing with violent patients is
premature confrontation motivated out of the therapist’s own
hostilities. The borderline patient’s narcissism may be the

healthiest part of him. Buie and Adler (29) describe the fear of
abandonment and aloneness of the borderline. It can feel like
annihilation, and lead to destructive rage in a desperate effort to

obtain the needed person permanently. The patient may not be
experiencing the neurotic narcissistic entitlement described by
Murray (30), but more of what Buie describes as an entitlement
to survive. An overlay of megalomania may help the patient keep
from facing the painful belief that he is devoid of all significance.

The struggle can be perceived as a life or death matter.
Confrontation may be used by the therapist to express his own
fury and resentment (31). It can be disastrous to ask a patient to

prematurely give up narcissistic demands when that patient is
struggling with an entitlement to survive.
Countertransference problems (used in the total sense
defined by Kernberg (7) as conscious and unconscious reactions

to the patient’s reality as well as his transference) can be difficult
when treating such patients. The therapist, according to Adler
(31, p. 157), may have to deal with a sense of helplessness and

hopelessness in a patient who seems to remain unresponsive for
long periods. Glover (32) writes that the therapist must handle
repeated disappointments and assaults on his most cherished

possession, his capacity to heal. The psychopathic patient begins
treatment in a state of negative transference and tests the
therapist with a series of relapses or crises, repeating his lifelong

tendency to exploit, hurt, and disappoint people. Unfortunately,
too often therapists give up on patients at such junctures,

confirming the patient’s view of the world. In order to withstand,
in any long-term work with such patients, the pain and suffering
psychopathic patients can cause the therapist, he must basically

like the patient, and accept the patient as he is, much as Day and
Semrad (33) have described with schizophrenics. He should also
be hopeful, but realistic, and aware of the patient’s tendencies to

appear much more healthy and motivated than is real in an “as-if”
manner. Both therapist and patient can sometimes avoid facing
the real problems and can engage in a shared denial. The patient
can put on a charming facade to appease the therapist, and can
then suddenly regress and disappoint him in order to keep what
he believes will be an inevitable rejection under his control.
Sometimes interpretations of such maneuvers, particularly when

they have been previously predicted by the therapist to the
patient, can be helpful.
Lion (1, p. 62) warns of the importance of monitoring the

transference since negative feelings about the therapist can be
converted into destructive behavior outside of sessions. With

potentially violent patients, neglect of negative transference
feelings can be disastrous. If the patient is allowed to get too close
too soon and then the therapist becomes frightened of the patient,
this can lead to an accentuation of the patient’s panic and
potential violence towards the therapist. Usually, however, in an

inpatient setting the transference will be diffused, and in an
outpatient setting the patient’s avoidance defenses will lead to the

patient’s taking off rather than seriously hurting the therapist. It
can be helpful for a therapist to tell a patient when the patient’s
behavior frightens him, so that the patient doesn’t misinterpret

and, by means of projective identification, see the therapist as
frightening and attack him. Therapists can at times also
experience what Kernberg (7, p. 59) describes as complementary

identification, where the therapist is identified with the
transference objects of the patient. The therapist experiences the
feeling the patient is putting into his transference object, and the
patient experiences the feeling he had in the past with that
particular parental image. Commonly, the therapist can feel angry
at the patient and the patient wary and suspicious of the
therapist.
On occasion, work with such patients can lead to an
additional potential problem described by Kernberg (7, p. 62),
whereby the therapist has unrealistic ideas of being able to help a

patient in spite of all reality factors and approaches the patient
with total dedication. Unfortunately, the unrealistic views of the

therapist can break down in a sudden way and lead to an abrupt
termination of treatment. MacVicar (34) writes about a not
uncommon problem of masochistic submission by a staff
member, with attempts to gratify every whim of a patient to avoid
an explosion. It can be a problem to overly submit to a patient,

and it can deprive a patient of an opportunity to learn how to
handle small amounts of unpleasant affect, with resulting

strengthening of the patient’s ego. Interpretations to the patient
can be helpful at such junctures. Either overpunitiveness or
oversubmission can be counterproductive. Timing is also

important, since underlying character pathology should not be
confronted too soon.
Helplessness (1, p. 15) is an important underlying dynamic
with violent patients, and should be kept in mind in determining

how to approach them. They have reaction formations against
helplessness and dependency. They pretend to be tough and

independent to cope with helplessness, and are threatened by any
insults to their masculinity or potency. Menninger (5, p. 183)
describes bravado crimes done with brutality and ruthlessness
which seek to prove to the doer that he is no weakling but a tough

man who fears nothing. Nazi storm troopers were often mere
boys trained to stifle all tender emotions and behave heartlessly
brutal and ruthless. Halleck (2, p. 317) says that men who have
serious doubts about their masculinity and a need to constantly
reassure themselves and others are more prone to violent

behavior. People driven to prove their masculinity can ignore the
consequences of their actions.
Homosexual panic can lead to violence. Ovesey (35) has
referred to pseudohomosexual concerns, motivated by strivings
for dependency and power, which can develop in men not

meeting societal standards for masculine performance. The man
tries to dissipate his weakness in compensatory fashion through
competition about anything and everything and a show of

strength (35, pp. 56-58). He exaggerates so-called masculine
traits with care to look manly, be overaggressive (with a
hypersensitivity to any slight that connotes feminine behavior),
the power motivation being predominant (35, p. 111). He tries to
have men submit to him, sometimes sexually, and denies his own
dependency at the expense of the weaker man whom he makes
into a woman. It is a fragile adaptation; the homosexual act is ego-
alien and is often felt to be a confession of masculine failure.
Sometimes, a male patient who becomes afraid of

dependency feelings on a male therapist will become afraid that
he is a homosexual, and can become violent in a homosexual
panic. It can help to discuss the patient’s fears of and wishes for
dependency and define the issue as fear of closeness and fusion,
with feared annihilation of the self. It often can relieve the patient
to see the conflict as a pseudohomosexual one, rather than a

homosexual one which can imply to a patient loss of his identity
as a man, with resulting destruction as an individual. Other times,
desires for dependency in and of themselves can make a patient

believe he is not a man and lead to his becoming aggressively
violent in a panic-like attempt to prove to himself that he is a man
and that he is not afraid. He can project his feelings onto a

therapist and can become violent if the therapist does, in fact,
become afraid and not explain to the patient that it is the patient’s
threatening behavior that is making the therapist uneasy. Woods
(36) has described instances of pseudohomosexual panic leading
to violence. Sometimes a patient needs to be able to discuss

homosexual feelings with a therapist in order to feel comfortable
enough with them not to project them onto the therapist. It can be
an error for the therapist to avoid discussing the issue with a

patient at such times. When hypermasculine behavior is exhibited
in relation to women, the patient becomes a Don Juan. He has a
need to “score” with women to prove his masculinity, often in a

compulsive and, on occasion, desperate manner. Sometimes sex
and aggression can become fused or, in instances of rape, sex can
be used in the service of aggression (37).
Patients with an underlying dynamic of helplessness and a

need for hypermasculine behavior often seem to be the male
counterparts of the female hysteric, and might appropriately be
called male hysterics as described by Blacker and Tupin (50).

They exhibit masculine sexual behavior in contrast to the
feminine sexual behavior of women hysterics. In addition, the aim

is often not really sexual, in spite of the overt behavior; their
behavior is an exaggeration of the culturally defined male
stereotype, often accompanied by sexual anxieties and
inhibitions. The patient can function at a relatively high
narcissistic level or at a low borderline level. Similar to the so-

called good hysteric of Zetzel (38), such a patient can use
masculine behavior as part of proving his entitlement to survive,

proving his adequacy as an individual, or even satisfying
dependency needs at the hands of nurturant women or men.
Alternatively, he can struggle in a reaction formation way against

all feelings of dependency or passivity.
Guze (17, p. 97) finds an interesting association between
sociopathy and hysteria, giving added credence to the suggestion
that some sociopaths may be the male equivalent of the primitive

borderline hysteric, each using exaggerations of the culturally
defined sexual stereotypes. Guze, in studying female felons, found

sociopathy or hysteria in 80 percent of them, suggesting a
possible relationship between the two disorders. Hysteria and
sociopathy are the two psychiatric disorders he found to be most
often associated with classical conversion symptoms. It is

possible that the two disorders are related, but hysteria tends to
manifest itself most often in women and sociopathy manifests
itself most often in men. Women’s liberation, perhaps, may lead to

more sociopathic behavior previously reserved for males. Women
with behavior problems frequently show signs of sexual

promiscuity and running away from home (2, p. 138). However, it
is possible that they will now turn to more violent behavior.
Women hysterics, according to Chodoff and Lyons (39), can use
exaggerated femininity and passivity in a controlling way; men
tend to be more directly aggressive. It is important to realize that

the hypermasculine behavior of what has been labeled male
hysterics, or what Oversey calls pseudohomosexual anxiety,

covers over feelings of helplessness. A challenge to the patient by
a staff member who also needs to prove his masculinity can
precipitate violent behavior.
Yochelson and Samenow (40) use a reality-moralistic

approach which can, I believe, be helpful for those patients who
need a male authority figure for identification. However, I believe
the approach only can work with significant numbers of patients

in an atmosphere of warmth, and that Yochelson and Samenow
(41) are too pessimistic about more standard approaches. I

believe their approach is not immune from being vulnerable to
the possibility they fear of patients’ giving the therapist merely
what he wants to hear. Yochelson, in my opinion, is too ready to
confirm the patient’s own already low opinion of himself, which

society also already has confirmed.
The patient may initially feel understood if the therapist

believes he is bad. However, I believe it is more effective not to
confirm the patient’s notion but merely to convey to the patient
that the therapist understands that the patient himself believes he

is bad but that the opinion is not necessarily correct. I believe
Yochelson’s approach leads to overly rigid bad-good dichotomies
and, even when successful, can lead to patients’ becoming narrow,
conventional people who lead lives almost the opposite of the
chaotic ones they led before. Too often people feel that an overly
hard, tough, authoritarian approach is needed for such patients,
who at least on the surface present a tough, hard exterior. It can
be important to realize the patient’s underlying insecurity; often,

a non-threatening, sympathetic, though aware and incorruptible,
approach can be much more effective.
Secondary gain issues can be prominent in the treatment of

patients with a more sociopathic picture. Some patients have
advantages to be gained by feigning mental illness; however, at
least an equal number will probably try to conceal mental illness,

even from themselves, because it is more acceptable in their
subculture to be considered criminal rather than crazy. It can be
difficult, at times, to establish a real therapeutic alliance, and the

therapist can often be “taken in” and believe a more meaningful
alliance has been established than is really the case. Patients may
be more mistrustful than is at first evident, and participate in
therapy in more of an “as-if” manner. A therapeutic alliance can
often eventually be established around issues of concern to the

patient himself, such as his self-defeating behavior or his
loneliness. The alliance is fragile and tested on many occasions.
However, ambivalent motivation occurs with many types of

patients. Some patients even need to be “forced” into therapy,
such as by a probation condition, in order to “save face.” The
danger with the treatment of more sociopathic patients is that a
naive therapist can be led to falsely believe he has “cured” the

patient, and react in an overly rejecting, punitive manner, when
he discovers he has been deceived. Disappointments such as

these lead, in my opinion, to many therapists’ becoming
disillusioned and giving up on working with such patients
incorrectly at crucial junctures. The therapist must set realistic

goals for his work and expect regressions and disappointments.
Longer-term intensive treatment, in my opinion, though
rarely available, can help a number of violent patients with
characterological disorders. However, one needs a setting which

can cope with the patient’s behavior and regressions, and the
patient needs at least the potential for both a locked setting and
more independence when he can handle it. The setting can be a
locked hospital setting, or a therapeutically oriented correctional
setting with a nonpunitive atmosphere (a rarity). Motivation is
important, and therapy is most necessary and useful when the

patient is aware of how unreasonable his behavior is and wishes
to do something about it (2). Many patients also need things like
vocational rehabilitation, and group therapy can be of value.
The psychotherapy study of the Menninger Foundation (42)
indicated intensive psychotherapy, combined with

hospitalization, to be useful for borderline patients. Therapists
who worked on undoing the manifest and latent negative
transferences were the most successful. This study contrasts with
many prevailing views regarding treatment of borderlines, and
notions about their untreatability. Kernberg (7) sees a continuum

between the narcissistic personality and antisocial personality,
which he sees as an extreme form of pathological narcissism with
absence of an integrated superego.
Treatment of such patients requires consideration of other

dynamics which are sometimes present and can require
intervention. Johnson and Szurek (43) have described superego

lacunae in antisocial patients, who act out their parents’
unconscious conflicts. Family intervention may be required in
such cases. Also, as stated earlier, it is important to interpret

projective identification when it occurs, whereby the bad part of
the self is projected into another person with lack of self-object
differentiation. The patient continues to experience the impulse

as well as the fear of it and this dynamic can sometimes lead to
violence (7).
Treatment of narcissistic personalities requires

consideration of the idealizing and mirror transferences,
described by Kohut (44), which narcissistic patients develop
about their therapists. Therapists can find such transferences

difficult to accept and reject them by prematurely given, though
correct, genetic or dynamic interpretations. The therapist may

experience embarrassment, self-consciousness, and shame at the
narcissistic tensions generated by his own repressed fantasies of
his grandiose self being stimulated by the patient’s idealization.
Accepting the admiration would be a more correct response when

an idealizing transference starts to germinate. In the mirror
transference, the patient wants the therapist to reflect, echo,
approve, and admire his exhibitionism and greatness. For a long

time, the therapist should encourage the patient to reveal his
grandiosity; it would be a mistake to prematurely emphasise the
irrationality of the grandiose fantasies or stress that it is

realistically necessary to curb his exhibitionistic demands. The
therapist must accept a limited role. In settings which allow for
long-term treatment of patients with characterological disorders,

or even in brief, limited insight therapy, issues of narcissism and
techniques for treating borderline personalities become
especially relevant.
It is useful to realize the importance of narcissism and its
connection with aggression. Rochlin (45) says that aggression

always issues as a reaction to threatened or actually damaged
narcissism. Narcissism, moreover, is in double jeopardy; when
threatened it becomes intensified and more brittle. We deal with

aggressiveness easiest (45, p. 164) when we are, or believe we
are, the victim of another’s hostility. Aggression, and
identification with the aggressor (45, p. 213), can enhance self-

esteem and fend off fears and uncertainty. Social and other factors
influence the development of narcissistic personalities. Upper-
class narcissistic personalities can become businessmen and
political leaders; lower-class narcissistic people may feel that

their only resort is antisocial behavior.
Rochlin (45, p. 157) suggests that the value we accord
another person acts as the most effective deterrent to violence. I

have seen (46) several examples of Capgras’ syndrome, where
patients insist that an important figure has been replaced by an
impostor, as a delusional way of coping with unacceptable

hostility and as an excuse for violent action. The patient seems to
need to deny that the individual is a valued other person in order
to cope with his hostility; however, this denial unfortunately can

enable the person to become violent towards an individual he
would otherwise not harm.
I believe, like Halleck (2, pp. 324-327), that one should not be
moralistic but should approach the patient in a manner that
suggests that the patient’s behavior is not bringing the patient

what he is looking for and can lead to even more discomfort. Since
this behavior can result in loss of liberty, one should suggest that
there are better ways for the patient to achieve his own goals.
Insight can lead to the discovery of alternative adaptations which
can be chosen by a patient. It is also relevant to look for instances
of what Alexander (47) called the neurotic character, describing a

person who commits crimes in order to be punished for things
about which he feels unconsciously guilty. Halleck (2) describes a
close linkage of masochism and paranoia, with the criminal
denying that he brought his difficulties on himself and projecting
all his problems to the outside. The sociopath has conflicts with
dependency and searches for a painless freedom from object
relations—an ideal which is never achieved. He says he doesn’t
need people, in a way to ensure a return to dependency.

Moreover, it is important to work with whatever elements of a
positive transference exist, as Aichhorn (48) did in his work with
delinquent youth.
Conclusions
I have suggested that violent behavior is a symptom. It is

important to keep one’s countertransference feelings under
control; violent patients, probably more than any others, lead to

all types of countertransference difficulties usually related to the
therapist’s difficulties with his own hostility towards the patient.
Mental health people should try not to engage in scapegoating but
realize that violent patients are people who have problems with
violent behavior. They are not inherently different from other
patients or members of a different species.
It is important to contain the violence on an emergency basis

and then try to assess its causes. Certain types of problems, such
as situational difficulties, acute psychosis, or unresolved hospital

staff conflicts, such as described by Stanton and Schwartz (49),
lend themselves to emergency, crisis-oriented interventions.
Antipsychotic medications can have dramatic results, if the
violence is a result of a psychosis. Assessment and treatment
must be done in settings where both patient and therapist can

feel realistically safe and dangerous acting-out by the patient can
be prevented. Attempts should be made not to become confused
with the patient’s projections. Structure and limit-setting are

necessary.
A further assessment of the patient’s characterological
difficulties should be made and treatment instituted if suitable

facilities exist. Otherwise, one is often forced to settle for
incarceration or release of the patient to the streets. Issues
regarding commitment of dangerous patients can produce

problems and must be considered. Motivation of patients is an
important factor for successful psychotherapeutic endeavors.
Many patients with characterological difficulties will probably be

found on careful examination to have borderline personality
organizations and/or narcissistic personalities and should be

treated appropriately. Issues relating to object splitting and
trouble integrating good and bad introjects are encountered.
Depending on the nature of the patient’s problem and the
severity of the pathology, the patients can be difficult or relatively

routine to treat. I believe it is important, however, that mental
health personnel not shun their responsibilities and neglect

treating such patients. Such neglect leads to violent behavior in
the streets and paradoxical incarceration of such patients in
prisons. The majority of violent patients are treatable by one of
the approaches I have described and it is important that neglect

of the problem not be rationalized by the myth of their
untreatabiliiy. While it is true that some patients have been so
badly scarred and are so suspicious, mistrustful and unmotivated

that they may be untreatable, the majority are, in my opinion,
treatable by appropriate personnel in appropriate settings. It is
essential that facilities be available where therapists and patients

can feel secure. Therapists, moreover, must be aware of and
constantly examine the complex ethical problems which the
treatment of such patients represents and try to not let their own
moral values or their own political beliefs overly influence
treatment decisions made for patients. Patients should not be
forced to adopt the therapist’s life style in the name of treatment.

We can also be overconcerned with a patient’s rights instead of
treating him, and the result can sometimes lead to his being
incarcerated in an antitherapeutic prison paradoxically.
It is also crucial to remember that emergency crisis
intervention approaches may be all that is needed for many

violent patients, but such patients should not be prematurely
discharged, without any psycho-social intervention, right back
into the problematical or crisis situation which originally led to

the violent behavior. It is ironic that large amounts of money are
often spent to keep someone incarcerated in prison, but sufficient
funds and personnel are often not available to treat someone less
expensively for shorter periods of time in mental health facilities.

Some judges are reluctant to send clearly mentally ill violent
patients to treatment facilities because they do not have

confidence that mental health personnel will keep the patient
hospitalized for adequate periods of time or follow him
persistently in the community. Instead, such patients can be sent

to expensive, often antitherapeutic, penal facilities which
encourage regression, dependency, and stifle any constructive,
ego-developing efforts by their inmates. Prisons generally have

inadequate follow-up resources with poor recidivism rates.
Hopefully, psychiatrists will continue to be actively involved in
the treatment of violent patients and will keep in mind

specialized techniques such as the ones I have described.
Moreover, serious attempts should be made to organize
treatment programs in an individualized manner and not require
that patients have the right psychopathology to fit in with

someone’s idea of what a program should be. Careful attention to
some of the techniques I have discussed will help in treating
patients who have already become violent or who have a great

potential for becoming violent.
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and Wilkins Company, 1975, p. 1541.
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Growth. New York: International Universities Press, 1970, pp. 229-245.
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conversion. Amer. J. Psychiat., 1958, 114:734-740.
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Aronson, 1977.
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Aronson, 1976.
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135:855.
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1977, pp. 122-123.
13
Psychotherapy with Physically Ill

Patients
Conceptual and Clinical Foundations
Psychotherapy with patients who are afflicted with so-called
psychosomatic disease is one of the most challenging areas in our

profession. Not only the knowledge and the technique of the
therapist, but also his personal resources, face the greatest test in
dealing with these patients. “Psychosomatherapists” have limited
theoretical concepts and frames of reference in dealing with these

patients, in comparison to those available in the treatment of
neurotics, character disorders or borderline patients, and even

psychotics. Craddock (1) has noted how the therapist’s limited
knowledge and experience make work with somatic patients
discouraging.
The most striking influence in the field of psychotherapy

with psychosomatic patients has undoubtedly been the
application of psychoanalytic al principles to the study of the so-
called “holy seven”—bronchial asthma, dermatitis, hypertension,
thyrotoxicosis, peptic ulcer, rheumatoid arthritis, and ulcerative

colitis. While Dunbar (2) investigated the correlation between
particular personality dimensions and different diseases,
Alexander (3, 4) examined the relationship of specific

intrapsychic conflicts to specific psychosomatic disorders. These
types of theoretical models still constitute the core of working
hypotheses for practitioners who are engaged in the treatment of

such patients. Later work of Wolff (5, 6), Rahe (7, 8, 9) and others
has addressed itself to social and environmental crises in the lives
of patients, thereby initiating an era of stress-oriented, short-term

approaches and the extension beyond orthodox psychosomatic
disorders to encompass the recently renamed
“psychophysiological” reactions (10), as well as diseases such as

myocardial infarction, migraine headaches, anorexia nervosa, etc.
The conceptual foundations and application of

psychoanalytic theory and psychodynamic principles to the
treatment of psychosomatic disorders are well reflected in the
case studies of Sperling (11, 12), Jessner (13), and Castelnuovo-

Tedesco (14, 15). The basic psychodynamic thesis of Sperling, for
example, is based on her work with children who have severe
psychosomatic disorders, especially ulcerative colitis and

bronchial asthma. She has concluded that “every case of
psychosomatic disorder has its origin in the mother-child relation
of dependency.’’ That is, “no matter how independent and self-
sufficient a patient’s life may appear to be, we find on closer
inspection in every psychosomatic case…that the patient lives in

an emotional symbiosis with one object in his environment, who
does not have to be the actual mother but who somehow, in the
patient’s unconscious, serves the dynamic function of a mother
figure. The psychosomatic patient cannot consciously tolerate his
pregenital impulses ... he, therefore, denies them completely and

they are converted into somatic symptoms and in this way
gratified’’ (11, p. 286). Castelnuovo-Tedesco (14, 15), who
worked with adult patients, has emphasized the roles of

fantasized or real alterations (i.e., real or threatened separation,
coercion or intrusiveness in significant object relationships of the
patient) which play a major part in the exacerbation of illness.
Although some success with psychoanalytic techniques has

been reported by individual therapists, research findings have
been nonconfirmatory (16, 17, 18). The application of analytical
approaches in the therapy of psychosomatic disorders has not

synchronized with the wide acceptance of its theory. Thus, few
therapists still continue to treat these patients in a traditional
psychoanalytical manner. Their reluctance is compounded by the

general opinion of the public and the resistance of referring
physicians, whose view of psychotherapy for psychosomatic

patients has been less than favorable (19).
Moreover, not much support has come from within the
profession itself. Sperling (11) stressed the uneconomic aspect of
therapy with these patients. Sifneos (20) suggested that some
patients actually get worse from the psychodynamic process, and

that, for the majority of patients with psychosomatic disorders,
dynamic psychotherapy is contraindicated.
Similar statements could be made about any group of

patients. Certainly, analysis of neurotic patients is no less
uneconomic, and one may comfortably state that, for the majority
of the patient population at large, an analytical approach would

be contraindicated. One should not forget, however, the heuristic
value of working with these individuals, as well as the
contribution that psychotherapy could make to the health of such

individuals who are suffering from intractable chronic illnesses,
no matter how few they are and how expensive it might be.
The above attitudes certainly have not encouraged

psychosomatherapists to continue the arduous task of working
with these patients. Most psychiatrists in the field have therefore
confined their work to consultation-liaison services and brief

intervention approaches. Alexander’s (21) “platonic ideal” of
teamwork between the psychiatrist, the medical specialist and
others on the wards is not necessarily an unachievable goal. In

fact, relative success has been gained in such collaborative efforts
on liaison services. Rather, a major difficulty is the lack of

accepted theory and a working hypothesis that one is relatively
sure about and can share with others. The latter, I believe, is the
main source of therapist countertransference in working with
these patients, as discussed in the writings of Fain and Marty (22)

and Wolff (19).
Nonetheless, research work in this area has continued to
explore the efficacy of psychotherapy. Lazarus and Hagens (23)

have utilized brief psychotherapy in their attempt to decrease
postoperative delirium in cardiotomy patients. Layne and
Yudofsky (24) have reported positive results with even single

interviews, and Surman et al. (25) have replicated these favorable
findings. These brief approaches utilized supportive as well as
educational techniques, including rectifying possible

misconceptions about forthcoming procedures, teaching patients
a simple autohypnotic technique, etc.
The aim of this chapter, however, is to delineate some of the

specific practices of long-term individual psychotherapy with
patients who have a medical illness, addressing psychological
components in initiation, maintenance, or etiology of the disease.
It may be hypothesized that all medical diseases have
psychological components. The earlier theories, that there are

specific factors in the psychological makeup of the patients which
make them susceptible to certain somatic diseases, have not been

confirmed by research findings. But controversy on the matter is
still quite alive, as exemplified in theories of the dependency
struggle of ulcer patients, or the hard-driven personalities of
patients with cardiac disorders. Others have focused their
attention upon more generalized factors, such as the patients’
cognitive organization, defense mechanisms, and attitudes, e.g.,

inability to verbalize emotions, denial of psychic conflicts, and a
major manifestation—profound resistance to therapy. Reckless
and Fauntleroy (26) viewed such denial as an archaic defense

against feelings of anxiety, and emphasized the difficulty of these
patients in expressing emotions, especially their aggressive
feelings against others. O’Connor (27) pointed out the

psychosomatic patient's need to have his physical symptoms for
the very purpose of warding off psychological insights. Wolff (19),
in fact, believes that somatic disorders often develop because

emotional conflicts and impulses are not allowed direct
expression. In addition, most somatically distressed patients are

usually unaware of their being under stress (28). Thus, they will
consciously deny the psychological contributions to their illnesses

with a facade of emotional strength, regarding the show of
emotional problems as signs of weakness, or as synonymous with
malingering (29). Others have focused on the fundamental

character problems of patients with psychosomatic disorders. A
so-called “psychosomatic character pattern’’ has been formulated
with the following manifestations: lack of libidinal affect,
impoverished use of language, operational thinking, inability to
regress, and lack of neurotic behavior (30). Sifneos (31) observed
these patients’ poverty of fantasy life, constriction of emotional
functioning, inability to find appropriate words to verbalize
feelings, and absence of ability and motivation for self-

examination, which occurred within the therapeutic situation. He
termed this composite of characteristics, “alexithymic.’’
McDougall (28) recognized a "psychological hardiness’’ in these

patients, a need to refuse to reveal or give in to their dependency,
disappointment, anger or despair. Castelnuovo-Tedesco (14)
spoke of the ulcerative colitis patient’s aloofness, detachment, and
contentious demandingness, which tends to come to the fore in
the analytic situation. Reckless and Fauntleroy (26) described this

overall posture of psychosomatic patients in treatment as “a
negative attitudinal set.”
Nevertheless, these hypotheses and observations have not
been sufficiently translated into the language of practice so that

they might be applied to the actual treatment of patients. In
describing this, I will focus my discussion on the treatment of
patients with peptic ulcer or myocardial infarction, with whom I

have had the most contact, although I believe that the following
generalized principles are clinically applicable to most
somatically disturbed patients.
The Treatment Process
Treatment of illnesses like acute ulcers and myocardial

infarctions in an inpatient hospital setting relies upon the
therapeutic benefits of a great deal of physical and psychological
rest and, to a great extent, the actual removal of the patient from
his life situation and its stresses. The role of the psychiatrist at
this time is usually limited to identifying the sources of stress in
the life of the patient. Most patients may not volunteer such
material for discussion with the therapist. In general, the

therapist’s support and availability are needed, but only tolerated
by the patient, his family and physicians. Unfortunately, after
treatment of the acute phase of their illness, patients are usually

discharged to the same situation from which they came. But these
illnesses are usually chronic, and stresses in the life of an
individual everlasting. It would be unwise for the therapist to

promote the fantasy of a nonstressful existence; however, if the
therapist’s relationship with the patient can be established, the
therapist may temper the situation by neither indulging nor

totally denying the stress. These efforts by the therapist,
unfortunately, are often of little avail, since a large proportion of
patients tend to drop out at this early stage of treatment.
In a moderately longer-term treatment, where a manageable
stress situation can be maintained, the therapist may attempt to

make the patient aware of some of his unconscious needs and
defenses, and try to modify his coping mechanisms to life
stresses. Here, lack of success in simple reduction of stresses, or

rejection by the patient of suggestions of alternative coping
mechanisms, may lead to the therapist’s becoming discouraged.
In such instances, the therapist may revert back to the typical
analytical model with which he is most comfortable.
The psychodynamic working theory for long-term treatment

of somatic patients is based on certain assumptions: a) that
unconscious impulses are manifesting themselves in pathology of

the organs; b) that affective experience is inhibited or repressed
and/or somatically manifested; and c) that developmental stages
of the individual are arrested and have never reached their

symbolic, verbal, expressive stage. Regardless of the validity of
these theoretical formulations, such generalizations are of little
practical use as such. Moreover, they may actually interfere with

the clinician’s careful evaluation of the patient, since they provide
ready-made explanations. Such categorical approaches only help

to comfort the therapist. Therefore, firstly, the psychotherapist
treating psychosomatic illnesses should get away from any
generalized formula that may be applicable to all diseases or
patients; rather, he needs to explore with the individual patient

the role of his symptoms in his life, their conscious and
unconscious meanings, and whether there are stresses that
initiate them, or conflicts that maintain the patient’s disease.

Individual patterns of somatization, the patient’s coping
mechanisms and defense structures, instinctual patterns, and his

total character organization require careful individual attention
prior to assessing the specific patient’s suitability for
psychotherapy. Criteria used to assess the suitability for
psychotherapy of neurotic patients and those with character
disorders are quite applicable to medically ill patients, that is,

ability to establish an interpersonal relationship, insightfulness,
psychological mindedness, ability to sustain motivation, etc. Yet,

the relative lack of these desirable qualities should not deter the
therapist from attempting to treat the patient because it may
mean altering his approach. Practitioners modify their

approaches all the time to accommodate psychotic populations,
less intelligent patients, severe borderlines, etc.
At the end of the initial evaluation of the person, the patient
and therapist should share a sense that either the patient’s

medical illness is reactive to external stresses, or is the result of
his failing coping mechanisms (with or without primary or

secondary gains associated with illness). It is then possible to
formulate a treatment approach that can be acceptable to both
parties. Such a negotiation is quite an important aspect of
working with somatic patients.
On the other hand, if the therapist does not find external
stresses or failure of coping mechanisms, but identifies certain

characterological structures of the patient as either causing or
participating in the initiation or maintenance of the illness, he
may still attempt to do psychotherapy, recognizing that such

assumptions are only inferential. Whether the primary goal of
psychotherapy is addressed to the maturation of the individual or
a resolution of psychodynamic conflicts, it must be understood
that the therapist may state only that the patient’s illness be
secondarily helped by such a process. It is important that the

patient agree to a working relationship on this basis at the
beginning; otherwise, the question of “what has all this got to do
with my illness?’’ will become a major obstacle in therapy, and the

patient will drop out of treatment sooner or later.
The difficulty of keeping these patients in treatment is well-
known. This might be due partly to factors relating to the patient

per se, such as defensiveness and the characterological aspects
discussed earlier, but it is also a result of the psychiatrist’s
inability to present convincing evidence to the patient that he

might be of help. This is partly related to the fact that we are not
ourselves convinced about the nature of these diseases and their
psychological treatment, and we certainly do not have enough

experience or confidence. There is a lack of a consistent body of
knowledge in the field, especially in the application of

psychotherapy and its techniques in the treatment of these
patients. Therefore, the therapist is very much without adequate
tools. Unfortunately, most training programs fail to provide

experience in the treatment of psychosomatic illnesses. This,
compounded with insecurities from limited knowledge in the
field itself, creates an unfavorable condition from the beginning.

These uncertainties are consciously and unconsciously conveyed
to the patient in the earlier stages of treatment, possibly resulting
in disruption of the therapeutic relationship. This is not to say
that the therapist ought not have scientific skepticism about what
he does and its effects in clinical practice, but the balance has to
favor the basic premise of the importance of the therapist’s

confidence in his work. That is, he must be relatively sure of his
theoretical frame of reference, his goals to be accomplished, their
feasibility, as well as how he will go about performing his

therapeutic tasks, i.e., his techniques.
Unfortunately, psychosomatherapists are handicapped in all
of these areas. Moreover, medically ill patients constantly
challenge the therapist, his knowledge, the relevancy of the

psychological material to their illnesses, etc. Since the therapist is
under such attack when working, these patients typically pose a

threat to his self-esteem and self-confidence, and tax his patience.
Very few therapists are willing or able to survive such an
experience. The typical neurotic patient may confront the
therapist similarly, but usually responds favorably when the

therapist makes explicit the patient’s implicit doubts and
questions about his ability. Also, he is more accepting of the
therapist when he interprets the negative transference. But

generally such approaches have not proven to be successful in
dealing with psychosomatic patients. Rather, the clarification or

interpretation of the patient’s doubt of the psychotherapist and
psychotherapy in the treatment of his illness tends to lead to
confirmation of the patient’s doubt; most attempts at the
searching into the negative transference only serve to exacerbate
the situation by precipitating termination.
In practice, a reasonable therapist would suggest at this stage

that he is not sure that the patient’s medical illness would be
ameliorated by psychotherapy. But there are probably certain

problems in the individual’s life, which may be identified during
the sessions, which he would be glad to work on with the patient
in the hope that somatic symptoms of the patient might benefit

from such treatment. However, most patients are not likely to be
favorably disposed to such a proposal and will demand either a
greater promise or a more concrete statement from the therapist

that symptoms will be helped by psychotherapy. That is usually
the end of the relationship. A therapist who overpromises with

the hope of keeping the patient in treatment will suffer through
each session again and again answering the same questions, but
will end up with the patient terminating anyway.
Case Illustrations
A typical case demonstrates some of the difficulties
confronting the therapist in the initial interview: A 49-year-old

male patient, owner of a large manufacturing company, was
referred to me after having his first myocardial infarction. His
physician was familiar with the studies of type A personality and

felt that his patient belonged to this category and might benefit
from psychotherapy.
The patient was a largely built man, weighed about 300
pounds and was 5 feet, 9 inches tall. He was well-dressed, self-
confident, aggressive and verbal. He had been married for 20

years to his high school sweetheart and had two children, ages 18
and 16. Both girls were doing well in school and their social lives.
His wife was a maternal, somewhat demanding woman, but

dedicated and loyal to him. The family situation was relatively
stable. The patient was the youngest of three children, with a
sister five years older and a brother 14 years older than himself.
His father died when he was 15 years old and left a large business
to his brother, himself and his brother-in-law. His mother was

living in a nursing home. His older brother had taken charge of
the operation of the business since the death of the father, but the
patient himself was quite active and successful, especially in a

special part of the business. He smoked one pack of cigarettes a
day, drank two to three cocktails every night, was sexually active
with his wife at least three times a week, and also was seeing
other women, mostly call girls, at least once a week while

entertaining his out-of-town customers. The patient had no
history of other medical illnesses or psychiatric problems. He was
put on a diet and anticoagulants by his medical doctor, but he was

not complying with these orders.
In his relationship with me, he reluctantly gave responses to
my questions in trying to explore his psychological world. He

looked annoyed and asked what all this had to do with his heart
problems. I told him I did not know, but perhaps he felt there
were areas in his life about which he felt distressed. He said that
he would like to smoke less and eat less, and asked whether I
could hypnotize him for that purpose. He was clearly interested in

a quick and effortless result. I told him that I agreed that smoking
and eating were certainly important areas for him to modify, that
hypnosis might be one of the possibilities to explore in getting

help, and asked if that was the only area he considered
problematic. He said that there was nothing else that might be
helped by a psychiatrist. It was clear that the communication

between me and the patient was leading towards a typical ending.
I decided to tap some of the other areas mentioned at the risk of
further alienating the patient. I asked him whether he was

conflicted about sleeping with other women. He said, “No,” that
this had been his pattern throughout his marriage and had never
interfered with his life. In relation to business, he said it was all
okay—he was making a lot of money, though his brother

sometimes was too domineering, but he had learned to bear with
him.
As far as his medical illness (myocardial infarction), he said,

“I guess I could have died,” recognizing some degree of fear, but
bragged about his flirting with the nurse the second day of his
admission to the hospital. I asked him whether that was his way
of dealing with his fears. His answer was “No, I always like
women.” About dying, he said that one day he will die, but he
cannot stop and worry about it, and that he is determined to
enjoy his life. He had no other interest in matters such as art,

music, etc., although he had finished college. He said that he did
not fantasize, that his dreams were very realistic. He did say he
had some preoccupations, but when I asked whether he could tell
me about them he replied, “You would be bored with what’s on
my mind.” When I persisted he responded by saying that his mind

was blank at the moment.
I asked him why he agreed to come to see me even though he
felt that psychologically there was nothing wrong with him. He
said that he came because his physician insisted. He

apologetically added that he didn’t want to insult me, but thought
he was wasting his time and money with me. There was a long
silence while I was thinking that he might be right. We looked into
each other’s eyes, searching for a graceful way of terminating the
session. I asked him what he was thinking while looking at me. He
said that he was wondering whether it would be difficult to find a

cab at 5:00 p.m. in this neighborhood. Our time was up for the
day. When I then told him that we should set up another
appointment for the next week, he looked rather surprised.
This case illustrates how my attempts to find an area of
intrapsychic conflict were responded to with denial, even though

his resentful relationship with the brother, his sexual acting out,
and his concern about dying were rather easy to identify.
Although he did so reluctantly, he responded to the questions
enough for me to formulate some understanding of the patient.
However, he was completely unaware of the pathological aspect

of his own behavior. In contrast to psychopathic persons who
would likely make some attempt to justify or rationalize their
behavior or manipulatively may express some pseudo-guilt, my

patient was quite comfortable with himself, and only annoyed by
my search for an ego-alien aspect of his behaviors, feelings or
tendencies towards acting out. His feelings toward his dominating

brother were kept out of his consciousness, and my attempts to
unearth them created further solidification of his defensive
attitude; this was the beginning of his disengagement with me

during the interview. His “operational thinking’’ (30) was almost
caricatured in his wondering whether, “he would find a cab at
that hour,” at a moment of search for insight, feelings or

comments about our interaction. Of course, at the end one could
have terminated the session without further appointment. But I
have learned with these patients not to take the no for an answer.
Yet the therapist who takes such a risk must be ready to deal with
sarcasm, further questioning, or outright rejection.
This patient illustrates several initial difficulties in working

with these patients—reluctance to become engaged with the
therapist; lack of suitable material for psychological work; lack of

motivation or incentive for the therapy; lack of introspectiveness;
apparent absence of ego-alien psychological symptoms; absence
of seeds for transference; pensée opératoire par excellence;
affective distancing; strong denial and other pathological

defenses; and frustrating, challenging and other non-accepting
postures towards the therapist. But one should not be

discouraged by this conglomerate of negative factors because
these are related parts of the overall defensive structure of the
patient, and potentially amenable to therapy. These can become

workable patients.
A negative attitude or set as initial resistance to becoming
engaged with the therapist is typical of many patients with
psychosomatic disorders. Basically, they are loners who will

maintain their self-image and the relative stability of their
psychological order, internally, by using a great deal of denial, and

externally, by constantly reshaping their environment to secure
their stability. Any threats directed towards these external factors
may create disorganization for the patient, whose defense
mechanism of denial may no longer be successfully operative. In

some patients, the somatic symptoms are manifestations of this
particular stage of failure of coping mechanism, the latter
precariously kept in balance between the denial and the private

order of the external world. Here, these patients’ reluctance to
engage with the therapist is a resistance to a real, as well as to a

transferential, relationship. I call this avoidance the “resistance to
transference” because, in contrast to psychotic patients, these
patients’ potential for transference does exist. Therefore, the first
task of the therapist is to keep the patient in treatment, which is
an inherently difficult task. One cannot expect a typical positive

attitude from these patients, as compared to those who are
experiencing psychic pain, because of their lack of ego-alien

symptoms such as depression, anxiety, etc. As such, there are no
given incentives to keep the patient in treatment, nor enough
motivation generated during the interview to maintain the

patient’s initial interest in treatment (which is usually meager to
begin with).
In this regard, I have found certain similarities between
somatic patients and adolescents, who are also somewhat

reluctant to talk about their psychological problems at the initial
stage of treatment. In the latter instances, the therapist has to

engage the adolescent actively in the discussion of a subject that
is to his interest, i.e. football, jazz, etc. With the patients who have
somatic disorders, a common initial ground for patient and
therapist is the patient’s daily life, which is his major

preoccupation even though he may be reluctant to talk about it.
Therefore, in order to engage the somatic patient in a
relationship, the therapist has to, at times, learn a great deal

about the person’s business life or other daily life, almost as much
as about the childhood and interpersonal relationships of the

patient. What may appear to be a trivial matter that preoccupies
the patient’s mind and a seemingly unimportant detail to the
therapist in his attempt to understand the patient may lead to a
great deal of information, if the therapist is willing to listen with
patience. Interpersonal and work behaviors are always worth

exploring because they may give clues to the psychological
makeup of the individual as well as his conflicts.
The psychosomatherapist should not make any attempt to

replicate traditional psychotherapy by keeping silent and
encouraging development of the classical transference. If he is
successful at all in his attempts, he will only create a negative

transference, which will not be undone by interpretations, and
the patient will end up dropping out of therapy. The fact that the
patient is not forming transferences is a manifestation of his

object relations in life. Patients that I have treated never had a
good object relationship in their lives. Most of the objects in the

past have been extremely ambivalently incorporated; therefore,
every effort is being made by these patients against the
development of transference.
Another feature, lack of affective experiencing, which is

commonly mentioned in the literature, is related either to the
overpowering aspect of the affect, which is usually negative, or to

the fact that the affect is associated with certain somatic
experiences and therefore to be avoided. The therapist should not
insist upon inquiring into the absence of affects or keep prodding

the patient, “tell me how you feel”; rather, he should understand
the defensive purpose of the affective block as one of the
characteristics of these personalities.
Even during the initial interviews, there are usually longer
silences than psychotherapists are accustomed to. This is related

to a particular inability of the patient to engage in free
associations, verbalization of his feelings, spontaneity, etc. This is
consistent with the findings of Marty, M'Uzan and David (30), in

their studies of psychosomatic patients. They observed a type of
inertia which threatened to bring discussion to an end; the
investigator had to make vigorous efforts to stimulate associative

material concerning the patient’s relationships, life experience
and illness; also, significant or painful events were absent unless
directly solicited. In such instances, therapists should not stay

silent as they might in typical psychotherapeutic situations with
neurotic patients.
Mushatt’s (32) work with ulcerative colitis patients confirms

that these patients cannot tolerate therapists’ silences. Therefore,
therapists should be as encouraging as possible and actively try to
engage the patient to speak. Sifneos (20) also noted that

psychosomatic patients find little to talk about. In fact, most of
these patients will respond by saying “nothing” to the question,
“What are you thinking?” On further inspection, they usually are

thinking about minor matters and details in their lives, and are
embarrassed to mention them unless the therapist insists and

also reassures them that such realities are important to talk
about.
Since material that is necessary for psychotherapy is so
difficult to elicit, one is often tempted to talk to the patient about

his defensive posture and his avoidance of the therapeutic
situation. Again, such an approach generally proves to be rather
useless and even further alienates the patient. As a result, the

countertransference of the therapist to these patients is a very
significant matter to consider; it commonly manifests itself in
annoyance, boredom, or belittling statements of an aggressive

nature, either in the guise of attacking their defenses or of
interpreting the affective distance, which further eliminate the
potential for a therapeutic alliance. Since the traditional

therapeutic frame of reference is not operative, the typical
therapist tends to become defensive. Feelings of impotence,
rejection, self-doubt, and defeat emerge. Such unsettling

conditions in the therapist are not conducive to creating any
confidence in the patient; therefore, the vicious cycle will

continue, with a typical statement on the part of the therapist that
the patient is not motivated or suitable for psychotherapy. Fain
and Marty (22) have pointed out the countertransferential lack of

interest that develops from the patient’s character and constitutes
a chronic narcissistic blow to the therapist’s interpretive powers
because the patient appears impervious to his special skills. The

truth is that the patient has come to at least explore the
possibilities, but the working hypothesis of the therapist may not
be suitable for that particular patient.
Four years later, the patient I discussed earlier in a case
study is still with me. Recently we are in the process of discussing

termination of therapy. He does not have any symptoms of MI,
has lost 100 pounds over the past two years, stopped smoking
and acting out, is complying with his medical doctor’s food and
activities regimen, has taken up a hobby of his father
(photography) upon my suggestion, and has become a more

active partner in the business. There are many relatively
unresolved issues related to his character structure, such as his
fear of aggression and his strong dependency needs, but he

acknowledges them with a sense of humor, expressing his
disappointment that he has to lose childhood forever. In

summary, I do not want to overestimate what has been
accomplished. The patient’s characterological problems by and
large remain unchanged or mildly modified. But he has gained a
perspective over his life and his problems, has learned to think
psychologically, and has begun to enjoy himself and to laugh at
times at his “craziness.” He has explored the other simple
pleasures of life, and stopped the sexual acting cut which was
guilt provoking (though previously denied). He has become less
anxious and made contingency plans in case of death; a

reasonable fear of death has begun to emerge. Whether these
changes have contributed to his not having any signs of MI, I
cannot answer. But if he does have one in the future, I know he
will be able to cope with it.
Treatment Recommendations
In considering the totality of treatment, there are many

stages of the relationship between the psychiatrist and the
patient. Initially, the therapist may have to be involved with the

physician, the family of the patient, and the other staff involved in
his care. During this stage, the psychiatrist’s main locus is
diagnosis and management. He will continue to explore the

psychological makeup of the patient, but basically treatment is
limited to recommendation of medication, changes in the
environment, and facilitating the communication between the
parties involved. This first phase is applicable not only to
psychosomatic disorders, but to all medical illnesses. The

therapist is basically a supportive person who is available to deal
with the stresses in the person’s life, family, job, etc. He may
explore the patient’s psychological contribution to his illness as
well as his psychological reaction to it, i.e., fears of dying,
shattering of omnipotence, guilt, frustration, and issues such as

money, confinement, etc. The therapist may provide an
alternative to the patient’s pathological and nonadaptive
defenses.
In a chronic phase, the therapist may repeat the issues of the

acute phase in a modified way, especially if it is his first contact
with the patient. Otherwise, the therapist’s role would be one of
focusing more on establishment of the working alliance with the
patient and engaging with him in the areas where mutual work
could be done. Chronic patients are more reluctant than acute

ones in establishing a relationship with the psychiatrist. Initially,
a session once a week is the best frequency that a patient can
tolerate. This allows the patient to be distant enough not to force

premature intimacy, but also it will provide sufficient continuity
of contact with the therapist. Towards the resolution of the
dependency phase, one may increase the sessions to more than

once a week. This stage usually corresponds to development of
freer associations and the presence of dream material and is,
therefore, appropriate in its intensity.
During the initial phase of the treatment, then, the therapist

must:
1. take an active role during the sessions in creating an

atmosphere of easier interchange;
2. receive initial trust of the patient by a display of acceptance

and knowledge of his medical illness;
3. create a working alliance by taking an interest and learning

about the daily life of the individual, and tolerating his
operational thinking while gradually educating him to
psychological introspection;
4. recognize and tolerate the patient’s major defenses, which

are: splitting, avoidance, manipulating, distancing; and
5. resist the temptation for premature interpretations.
After a successful first phase of therapy, the patient may
begin to recognize the therapist as a teacher, ally, supporter, etc.
The second phase may be described as the “phase of

experiencing.’’ This is the time when the patient develops
dependency on the therapist. He will begin to open up about his
well-kept secrets in his daily life, testing the acceptance of the

therapist, and also making an attempt to deal with the guilts and
fears associated with it. Even at this stage, psychological elements
of early childhood are rarely present, and the focus of therapy is
basically here-and-now. Any attempt on the part of the therapist
to interpret increasing dependency is ill-advised, because it

usually leads to denial of it by the patient, and very commonly, to
a reexperiencing of the somatic symptoms. Stevens (33) noted
that the transference interpretations in therapy mobilize

enormous anxiety in these patients. Most patients mistakenly
view the therapist’s comments about their dependency as a threat
of termination. Such fear will not dissipate with interpretation or
reassurance, which the patient may perceive as confirmation of

his dependency, a weak position that he has defended against all
his life. The rate of dropouts among these patients is probably
higher during this phase than at any other time, except the initial
phase of treatment. The therapist is usually blamed for having
aggravated the patient’s condition. However, in a well-managed
second stage, the patient should be able to experience the first

positive feelings towards the therapist—affection, dependence,
protective friendliness, etc. These feelings usually do not create
any somatic symptoms, much to the amazement of the patient,
who had withheld all these feelings for a lifetime. With the
pleasure of these new sensations, the patient may indulge himself
by going into a positive expressive stage, not only with the
therapist, but also with some members of the family and friends
alike. The therapist should allow this somewhat superficial stage
of experiencing positive feelings to go on for a long time. Of
course, one cannot necessarily avoid the unpleasantness in a
person’s life, but experiencing negative feelings should not be
encouraged during the therapy sessions. Rage, anger and similar

affects should not be explored prior to establishing some somatic
comfort along with positive feelings.
Affect has been said to be non-existent in the patient, that is,
the patient usually makes every effort not to experience the

feelings associated with unpleasant bodily sensations. In the past,
headaches, stomach acid, pain in the chest, etc. are experienced
with feelings such as anger, anxiety, fear, and later on generalized

to include the positive feelings as well, i.e. warmth, intimacy, love,
affection, dependency, yearnings. All affect is to be avoided if one
wants to stay somatically well. Therefore, for the patient to

express his positive feelings without experiencing bodily
discomfort is an important step in the treatment.
The earlier objects of the patient are commonly remembered
as undependable. Therefore, the therapist should avoid any
behavior, i.e., cancellations, lateness, in order to prevent
development of negative feelings during the initial phase of the

treatment. During this time, the initial doctor/patient relationship
will gradually shift towards more of a friend/friend relationship.
Later on, a teacher/student type of relationship may begin to

develop. The typical analytical therapist/patient relationship,
which has been likened to a father/child relationship, may
eventually be established, approximately six to twelve months

after the onset of treatment. Only when a reliable dependency
relationship has been established will some early material start to
emerge. At such time, the affect that is experienced may be

positive or negative; at this point the therapist has to monitor the
somatic symptoms before he can encourage further regression,
freer associations, or the reporting of dream material. The

conduct of treatment during this phase is no different from the
traditional approach, that is, insight-oriented dynamic
psychotherapy. At the same time, the patient may be encouraged

to do certain homework in the form of behavioral exercises, i.e.,
controlled aggression and assertion, sexual intimacy, and the
expression of dependency needs to other individuals.
Conclusion
The following guidelines are recommended in the treatment

of physically ill patients:
1. First and foremost, the therapist has to create a climate of
therapeutic acceptance, warmth, understanding, and
empathy in the therapeutic situation, as well as provide
all the other nonspecific conditions for a supportive
environment. Specific techniques have to be flexible
enough to accommodate a range of psychosomatic
concepts, such as the psychogenesis of the illness, one’s
psychological contribution or psychological reaction to
life stress and illness, maintenance of the disease and
symptoms and/or specific psychological predisposition
to them, psychodynamic configurations and character
structures related to particular somatic disorders, etc.
In some instances, none of these elements may be
represented; in others, one or more of these
possibilities may exist. Therefore, a highly
individualized approach to each patient, with specific
assessment of his respective psychological picture, is
important prior to initiating or formulating the
therapeutic plan.
2. A thorough medical and psychological history should be

taken on intake. This requires that the therapist must
be familiar not only with the disease in question, but
with its medical treatment.
3. At the beginning, the therapist should address himself to

the patient’s understanding of the psychiatric referral
itself, about which there are fears and concerns as well
as expectations. Most patients do show up for the first
interview to pass the test of sanity, but not necessarily
to be helped by a psychiatrist. Halsted and Weinberg
(34), for example, had observed that the ulcer patient
would ultimately agree to psychiatric investigation not
because of a recognition of his own needs, but because
he was convinced he was doing it for someone else. It is
important to recognize this phenomenon at an early
session, which has an educational value for the patient
as well as helping to create positive relations with the
therapist.
4. Therapeutic intervention should be carefully paced.

Initially, the patient should not be seen more than once
or twice a week because any more intensive
involvement can generate excessive anxiety and
exacerbation of symptoms. At this time, he should be
able to discuss the questions of the patient with regard
to his illness without competing with the internist. This
interaction will serve to increase the confidence of the
patient in the therapist, and will also serve an educative
function of clarifying those questions of the patient that
the internist may not have answered. For example,
Bilodeau and Hackett’s (35) study of cardiac patients in
group therapy revealed several questions and concerns
of their patients, including issues of diminished libido
and fear of death during intercourse; yet, no group
member had discussed these concerns with his medical
doctor, and none of the internists ventured to bring up
these subjects with their patients. The patient’s
misconceptions and misunderstandings about his
illness need to be corrected first as a way of dealing
with his anxieties, fears, and concerns about himself.
Such discussions usually include the vulnerability and
mortality of the patient, his or her fear of dying, issues
of separation, etc. On one level, medical illness and its
medical treatment are discussed, and on the other,
psychological parameters of the illness are explored.
5. In terms of therapeutic technique and its timing, the
therapist has to engage the patient initially in reality
issues, which may be trivial daily affairs, in order to
establish a common ground between patient and
therapist. It must be emphasized that, as Sperling (11)
has pointed out, interpretation of maladaptive defenses
in psychosomatic patients at an early stage of the
treatment may aggravate the patient’s somatic
condition. It is common, too, that the patient’s
psychological condition may also deteriorate. However,
precipitation of a psychotic breakdown, however
feared by therapists, has been reported as unlikely in
actual practice (19).
6. In general, the therapist should recognize that it is not his

role to treat medical illness, but that he must be
concerned with identifying psychosocial contributors
in patients’ lives to their illness. He must help patients
to recognize their adaptive and nonadaptive responses
to their medical illness and help them to modify their
responses where necessary, identify secondary gains
associated with the illness in order to prevent
maintenance of the symptoms, and anticipate and
prevent psychological conflicts which might exacerbate
somatic symptomatology.
7. Finally, although I suggest that the therapist establish an

authentic object relationship with the patient and try to
closely monitor the patient in experiencing affect
within the therapeutic context, he must at the same
time be flexible enough to utilize all potential
therapeutic agents which might be suitable to his
patient. In this way he will be able to establish an
approach that might be not only therapeutic as
conceptualized by the therapist, but also acceptable to
his patient.
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14
Psychotherapy with Dying Patients1
Arthur M. Schwartz, M.D.

Edith Weigert said, “The exclusion of death deprives life of its
meaning, the personality of its wholeness and human relations of

the depth of mutuality” (1, p. 192). Death is an existential fact, and
it is more than likely the model for all human feelings of
abandonment and separation. Is it, then, so difficult to understand

why one should not feel anxious when faced with leaving the life
he finds so rewarding and enriching? What we have in mind is the

shared denial of death, in both the patient and the
psychotherapist, and that the current thinking is overwhelming

on the passionate, pleasurable, and sexual aspects of the human
experience. After all, if we actually believe in the reality-principle,
death is, or should be, as much a part of our discussions as life,

else we deny something vital to our patients and, of course, to
ourselves. If we are going to be able to offer a therapy for the

dying person, then the psychotherapist must examine his own
attitudes towards his very own death. It is the
countertransference aspects that must first be understood. It has
been our impression that psychotherapists are especially
reluctant to face up to death in their personal lives and in their
professional fields. For the most, the psychotherapist relegates

matters of dying to other specialties or paramedical professions.
It is only within the last decade that the psycho therapist has
allowed himself some closeness with the dying person.
All professions, and especially the health sciences, have a

very necessary mythology which helps and allows one to get on
with more disagreeable portions of the work. It may be that the

others, particularly theology, have a better myth. For the
clergyman, his myth does not see death as necessarily an end. For
the psychotherapist, this is not true. For him dead is dead and
irrevocable, and consequently we can anticipate some of his
resistances in dealing with a dying person. The selection of the
material that the patient brings to the “talking-treatment” is not

always as random as we would have ourselves imagine. There
exists a “patient empathy” whereby the patient tells us what he
thinks we would like to hear. And, if his input senses our

reluctance to deal with death, then it is very likely that we will not
hear about his fears of death. There exists a discomfort in both
parties in talking about death and, in a sense, that is the way it
should be. It is no easy matter to tell a patient of his fatal illness,
and even more difficult to tell of his coming death. We know that
there are physicians for whom this represents no problem. Inured
to death and untouched by it, they, of course, are no help for the
suffering of the dying person. They might, conceivably, give rise to

more suffering, psychosis or stimulation for a massive self-
destructive act.
In the past, it was felt that one must not talk with patients
about anything that might disturb or excite them; they had to be
treated like children. Phrases like, “be brave and everything will
be all right,” were most commonplace. While we would not deny

that in many instances this “suggestion”—a popular albeit
frequently misunderstood word—had a magical feeling and did
prove helpful, we must admit that the results were, at best,

temporary and short-lived, requiring frequent reassurance. In
this “psychotherapy,” there are also elements of the confessional

which tended to hide rather than reveal. While these methods
restrict the function of secondary process reasoning and obtain
their cure by attaching primary process thinking, there remain
some individuals for whom this could be thought of as the method

of choice. This is, and should be, an assessment that the
psychotherapist would be making during the early phases of his
relationship with the dying person.
The gratification for the psychotherapist in his work with
patients is seeing and taking part in the resolution of intrapsychic

conflict, reducing anxiety and consequently freeing energy for
additional libidinal cathexis. There is no doubt of the gratification
when we are dealing with a young person who comes to
treatment in good physical health, who brings as his chief
complaint a desire to establish more loving relationships and in

whose growth and maturity we can play a part. But, what are the
gratifications for the therapist when the patient’s life ends in
death? For the therapist, the rewards, in part, can be in terms of

trying to bring about a “euthanasia” (2, 3), which literally means
the art of dying easily and without pain.
There would be little difficulty if the pain were restricted

only to the physical. However, the mental anguish and fear of
death, menaces from a punitive superego, are what we have to
deal with. Also, as stated earlier, the pitfalls of the manifold

countertransference feelings present difficulties. When faced with
a hopelessly ill, dying person, the therapist is struggling with
many conflicts. For example, is it really harder to die or witness

death? The question has a justification when the relationship with
the dying person has a closeness. Likewise, there exists a strong

sense of embarrassment as one attempts to talk with
encouragement when the future is death. Especially at those
times when the patient’s denial becomes so massive that it goes

beyond that of the therapist, and is consequently so unrealistic
that the therapist feels removed from reality, a failure of the
treatment could be a possibility. At those moments, if the

therapist chooses to remain silent, his silence could be
understood as accepting the patient’s denial as truth. Still another
opportunity for failure exists if the therapist permits himself to
become part of the real family-situation with all the feelings of

guilt and hostility, as if he were really a family member.
More specifically, when working with the dying person,
affective empathy is the most effective—where it is understood

that there exists an honesty, with very direct communications and
without any semblance of value judgments. There must also be
present an acceptance, without reservation, of the other person’s

life story, at least for transitory moments. The empathizer must
be able to allow himself to share in the reliving and living through
of the dying person's experiences. From this, the dying person

gains a sense of this experience and becomes aware of a fusion,
which is brief but certainly realized. There seems to be much

more difficulty for an observer to be aware of this state in the
usual therapeutic situation; at times, however, the dying person’s
response will make the affective empathy known.
In our personal experience of treatments with dying persons,

there have been moments when the patient reversed the roles
and became the comforter or caregiver. The fusion permitted and

allowed identification and empathy with the therapist, thereby
diminishing the sense of extreme loss for both. It is this state of
feeling which removes the aloneness for all of us. The aversion to
empathize with the dying person, to feel his helplessness and
terror, can be most uncomfortable with our own built-in needs to
avoid pain and anxiety. This affective empathy senses the
person’s real needs rather than waits until it is expressed in
uncompromising terms. It is not just emotional closeness or

identification with its narcissistic implications and possible
failure of any real support but, rather, allowing oneself to enter
into another’s life experience fully and without reservation.
The affect of empathy does not mean to imply a mutual

suffering along with the person. Olden (4) remarked that it is the
interplay between mother and child with mutual sensitivity to the

other’s feelings that should be regarded as the starting point of
empathy. She also stated that the mother needs satisfaction from
the infant in order to accomplish the transition from physical

gratification to mature empathy. She feels it may begin with the
infant's searching of his mother’s face. Beres (5) separated the
process of identification from empathy. The feeling of

identification is transitory and implies a temporary fusion with
the object. Beres and Arlow (6) stated that empathy is not merely
feeling with the patient or the object, but about him. Frequently,
in the caring for and about the dying person, a bodily contact, i.e.,
holding or touching an arm or hand, will be meaningful and

supportive.
The quality of empathy is the most significant affect a
therapist can bring to the treatment of the dying person. It is a

quality that requires a substantial degree of ego development,
namely, memory, thinking, and good conceptualization; it is
likewise much enhanced with age and experience. Greenson (7)
also separates identification from empathy by virtue of its

permanence and unconsciousness. It is meaningful in the therapy
with the dying person because its aim, as in childhood, is to
overcome anxiety, guilt, and object loss. Our ubiquitous conscious

fears of death are felt in the everyday life as fears of helplessness,
injury or abandonment which, in turn, have their origins in the
infantile anxiety due to separation from the protecting mother

and in situations where the (go feels powerless. In this state of
consciousness with which we are confronted in the interaction
with the dying person, it will be the degree of affective empathy

which will aid in removing the terror of death, and still permit us,
as therapists, to maintain our individuality and perspective. At the
conclusion of Greenson’s paper, he suggests that “people with a

tendency to depression make the best empathizers” (p. 422).
The problems of bringing the necessary degree of empathy to

the treatment of the dying person are manifold: firstly, because
we seem to live our lives deliberately ignoring the anticipation of
our own death as well as the deaths of those we love; additionally,

the confrontation with the dying person forces us to deny the
truth of death to the point of aversion. Painters’ and writers’
works frequently confront us with the dirty, ugly realities of our

existence, perhaps saving great energies which we often expend
in avoiding and facing death. In his “Thoughts for the Times on
War and Death,” Freud (8) stated it thus: “Si vis vitam, para
mortem”—“if you would endure life, be prepared for death” (p.

317).
We would like to report the treatment of two persons who
came to "thanato-therapy” via two different routes.
Case 1
The first patient, a 26-year-old, moderately attractive, bright,

keen, and mistrusting woman, developed a fatal illness during the
course of analysis. When entering treatment, she was married

and sought help because of difficulties within the marriage and
obsessive thoughts of death and illness with accompanying
anxiety. Also, she had an honest desire to spare her one-and-a-

half-year-old adopted son her neurotic problems and conflicts.
She had felt that her problems were destructive to herself and the
family.
Following the summer vacation, she returned to analysis and
reported that she had been able to enjoy being with her son and
husband on brief holidays at beach resorts and on short trips.

However, in keeping with her basic character structure, which
was predominantly masochistic, she had sought out a situation
during the vacation that would make for guilt and anxiety by
entering into an extramarital affair. The material following her
return was occupied with efforts to understand the meaning of
the acting out. It was during this time that she began to complain
of intermenstrual bleeding with painful gums and teeth, all of
which she viewed as punishment for her indiscretions.
She had consultations with a dentist and her gynecologist;

her dentist encouraged her to have more extensive blood
examinations. At this point, she contacted her uncle, a physician,
who had functioned as the family doctor through most of the

early years. Following a preliminary examination, he phoned the
therapist without knowledge of the patient, informing him that
everything pointed to acute myelogenous leukemia. He did not

comply with the therapist’s demand to discontinue the telephone
conversation, stating that the emotional shock—a feeling shared
by the therapist—made him incapable of providing any further

help He implored the therapist to take over and make any
arrangements that he felt necessary.
The therapist informed the patient of the uncle’s phone call,

but did not disclose the exact nature of the findings other than to
say that the uncle would like the therapist to suggest an internist.
The patient was most willing to accept the recommendation of the

internist who suggested hospitalization for a more complete
examination. While hospitalized, she phoned the therapist’s office
asking if he would be coming to the hospital, since she knew that
it was the hospital where the therapist taught psychiatric
residents. Her phone call was regarded as a request and the
therapist visited her.
There was a quietness about her mood; she was seemingly
satisfied with the diagnosis which was said to be infectious

mononucleosis. She was free from anxiety and did not appear
depressed. There was a distinct sense of well-being about her
affect. She was free of symptoms and it was the feeling of the
therapist that the illness represented the fulfillment of some
unconscious childhood wishes that had the effect of appeasing an
underlying harsh and critical conscience, thus causing the

neurosis seemingly to vanish.
After this visit, the therapist was button-holed by various

family members—the physician-uncle, mother, and husband. The
father was present, but chose to remain out of the conversation.
The mother and uncle immediately raised the issue of the

diagnosis, and both agreed that, at all costs, the truth would be
kept from the patient. The husband was not as firm that this
should be the course of action, as he would be the one with the
patient most often, and having to fend off her ever-present

suspicions would be nothing less than formidable. The family,
following the patterns of her early childhood, exerted great
pressure that the truth be hidden.
Bowing reluctantly to family pressure, the therapist agreed

to continue in the deception for the time being. However, he
insisted on reserving the right to disclose the nature of her illness
to the patient, should he feel that this would alleviate her anxiety,
guilt, and despair, when assured at the same time that she would
never be abandoned, but rather that the therapist would try to
share her experience. He explained to the family that the denial

would foster mistrust and the feeling of being set apart, both of
which should be avoided if the patient were to have any real
opportunity for an “easy death.”
The patient returned to the “analysis,” where no changes

were suggested in the way treatment was to be conducted. The
manifest content of her first dream had themes of punishment

and death. For the most part, the time that followed was filled
with similar material. She would talk about death, diagnosis,
punishment and guilt. At no time did she directly question the

diagnosis of her illness. The game of hiding the reality and
reinforcing the denial continued. She wondered how one goes
about explaining death to a child and said that her own mother
always shielded her from the realistic details of death. Then she
added, “When you die, you are put out of the house and separated
from the family.” The therapist’s formulation, in part, was that it

was this separation anxiety with which she had struggled most of
her life. She developed an interest in, and fascination with,
perpetual motion machines and would fantasize about inventing
one.
About two weeks before her death, she decided to write her
will, mentioning that she had somewhat less money than when
she first married. Four days before her death, she called, saying
that she felt too weak to keep her appointment. She had fever, a
sore throat and a cough, and asked directly what she should do.
The recommendation was that she call her internist and follow
his advice. She was hospitalized, but it could not be certain

whether this episode represented an upper respiratory infection
or perhaps the terminal part of her illness. The following day she
called the therapist from the hospital, saying that she did not
want to see him, and if he had made plans to visit, it would not be
necessary. He was quite aware of her rage, her disappointment
with him and his magic. She was experiencing the most intense
despair and helplessness, so the therapist decided to visit in spite
of her conscious contrary verbalizations. He was cognizant that
his insistence on the visit could confirm the seriousness of the

illness and give additional proof that he would never abandon
her. His formulation and attitude would be reality testing
dependent on the assessment of her ego strengths with preserved

hope and magical thinking.
The laboratory reports were very unfavorable, disclosing an

overwhelming process. Upon first seeing her, there was little
doubt in the therapist’s mind that she was nearing the end of her
life. She was outspoken towards him with her rage, wished for
enough strength to toss the water pitcher at him, and advised him
that he was lucky she was so weak. But, the ambivalence quickly
revealed itself when she thanked him for coming to see her and
for sensing that this was really what she wanted. After a while,
her father came into the room. She introduced the therapist,
asking her father to leave and return later. The remainder of the
visit concerned the new medication, her fever, and the weakness
she felt. As the therapist was leaving, she repeated that it would
not be necessary for him to return the next day, since it was
Saturday and should be spent with his family. He said he would
return, because he felt she needed him more
Departing from the hospital, the therapist reviewed the hour
just spent in the hope of gleaning what, perhaps, was uppermost

in her unconscious. The intuitive response was that she felt he
was failing her in the moments of her greatest need. In reality, she
felt his performance was very similar to all others in her past and
present life. He was making a pretense, keeping secret the truth
and not acknowledging that she was dying. He was, for all
purposes, allowing her to die alone (9), without comfort, without

expression of his grief or compassion, merely continuing a hoax,
the nature of which had long since been known to her.
For the following visit, the therapist formulated a tentative

plan: to listen, wait for the appropriate moment and disclose the
nature of the illness. His hope was to allay or appease the conflict
of ambivalence by giving her the feeling that somehow that part
of him was dying with her. In his paper, “Dying Together,” Ernest
Jones (10) pointed to this fantasy and noted that it also contained
the wish to be impregnated by, or fused with, the partner. The
previous material gave strong evidence for this feeling. At one

point during the past months, her desire to adopt another child
was so strong that she brought her husband to the office
specifically to discuss this possibility. In this psychotherapy, the

therapist would be accepting her on one level as a mature woman,
giving her the feeling of intense sublimated love or, better called,
fondness, and at another level accepting her as a helpless child,

but being truthful and refusing to be caught up in the
performance of her past family experience.
The next morning the clinical state was somewhat improved,

giving hope that a remission might possibly be in the offing. Of
course, the therapist’s own ambivalence was revived. If this were
to be true remission, perhaps the course now would be to

withhold the facts and continue the game of making strong the
ever-present archaic belief of her own immortality. His decision

had to be guided by the expression of her overt anxiety and what
he felt she was asking to know. Her greeting was friendlier than
the previous day, and she reiterated that this visit was
undoubtedly inconveniencing him additionally as, for the most
part, she did not feel it was necessary. Her denial was still active
and her testing the transference was manifest. She was anxious,
tearful and mildly agitated. At the moment the hematologist was
preparing to leave the room, and upon his leaving, she expressed
relief that the “clown” was gone. She could no longer stand his
silly jokes and the talk about infectious mononucleosis; certainly

now, she was more aware than at any other time of her
impending death.
The therapist sat at her bedside and she continued to talk.

She was clear and lucid, giving no evidence of any alteration in
her state of consciousness. She spoke about the illness—her
doubts about the diagnosis, the trouble she was putting the family
through. She was bothered by the loneliness her young son must
be feeling; just talking with him by telephone must have helped
some. “Why is it taking me so long to get well? Why don’t they tell
me the truth?”
The therapist reminded her that in all the previous months
she never once asked him the diagnosis. She continued to talk,
generally performing like a person without the benefit of hearing.
After a silence, she turned toward him and asked, “What do I

have?” With knowing hesitation, he told her. For the first time in
many days, she sat up in bed, reached for his arm, held it tightly,
and rested backwards on the pillow. She looked for his hand and
clasped it in hers. Speaking softly, haltingly, and with a
seriousness of which more would be heard, she asked, “What will
I do now?” He replied that they would continue as they had

during the past months and that he would give all possible help.
She admitted that she had suspected this for a long time, but
would never ask him, knowing that he, of all people, would tell
her the truth. She remarked that she felt strange and that things
appeared unreal to her. She thought and spoke of suicide but felt
that there is a difference to a child as to how a parent dies, and
she would not leave her son with this other burden.
She began crying, and the intensity of her emotional

response brought tears to the therapist’s eyes. His first impulse
was to attempt to conceal this from her. Would his crying forfeit
the omnipotent role she so heavily demanded? His own feelings of

compassion and sorrow were uppermost. No one else previously
had permitted himself the freedom of crying with her, and his
behavior might give additional strength to the formulation that he

was empathic with her feelings and that perhaps he, too, was
“dying.” For the most part, others were bent on playing the game
of denial without truly acknowledging her illness. She said, “I’m

feeling a little better now. I think it took a lot of guts for you to tell
me. Aren’t you afraid that I might go crazy? Maybe I’ll have a
delayed reaction?” The therapist was beginning to feel reassured
and his own doubts were assuaged. There was the feeling of a
shift in their roles, with her identifying herself as the therapist.

Realistically, it was a “gift situation,” giving her part of his life—
like “dying together.” Her unconsciously incorporating the
therapist thereby insured the mutual death. This fantasy of

mutual death has been called “Liebestod Fantasies” by J. C. Flugel
(12) and is further documented and elaborated on in a recent
paper by Bernard Brodsky (11).
She spoke about her pregnancy that had occurred during the
second year of treatment and, in spite of the fact that it had ended
in a spontaneous abortion, she said, “I was happy to know that I
could at least almost have a baby.” Soon after, her husband

arrived. She promptly in formed him that there was no longer any
need for pretense. It appeared that this knowledge of her illness
made her unique and imparted a feeling of strength. Her affect

became more elated and she phoned the hematologist, informing
him that he, too, could stop playing the hoax She asked for a drink
of liquor—this had been restricted during the past, four months—

quickly assuring the therapist that it was not to be dead drunk,
because she loved life too much, but merely to feel somewhat
mellow. At her invitation, the therapist joined her and her
husband with a drink. Leaving her with her husband, the
therapist mentioned that he would return later that day. She
replied that she would be looking forward to the visit, and to

talking more. This last verbalization gave dramatic proof that in
some way her ambivalence had gained some resolution.
The therapist’s second visit that same day was shorter, and
for most of it her husband was present. She was quite eager to
relate her fantasies, especially about the future. She had a great
interest in travel and wanted to go to far-off lands, but only by
airplane. Her husband, who owned a small plane, joined in by
saying that he would fly all of us to Europe. It appeared that he,
too, had entered the fantasy of “dying together,” since his plane
had a very limited range and would carry all of us to a watery

grave. In this fantasy, the therapist was to be her personal
physician, again giving affirmation, I felt, of the theme of “dying
together.” Before leaving, he suggested that arrangements could

be made to bring an extra bed in the room so that the husband,
who was most eager to be of honest help, might spend the night at
her bedside. Their marriage had been estranged and his guilts
were being rather strongly felt. Her final words to the therapist,
when leaving, were, “I want to see you for many more hours, and I
hope you make lots of money from us.”
The therapist visited the following morning to find the

patient unconscious, breathing in a labored manner, and
moribund. Her husband related the events of the evening leading

to the coma. She began to feel anxious, and became talkative,
having concern about the enlarged nodes in her neck. The

resident physician was called and ordered a mild sedative for the
night. Shortly thereafter, quietly and without a struggle, she
lapsed into a deep coma. Most fitting, and quite appropriate at

this point, are the words of Lewin (13): “In the desired sleep state
related to ecstasy, we meet the quality of immortality, the
unending heavenly bliss…union with the immortal superego

forms a prominent feature and the sense of immortality is a
function of the fusion”—as he emphasizes, “the good death with
the good sleep” (pp. 1551-1552). She fulfilled a long sought goal.
There was some harmony, some lessening of fear and trepidation,

with little mention of resentment about her coming death.
At various moments since her death, the therapist’s
speculations concerning the specific event itself, and the time it

occurred have been most provocative. One cannot help but feel
that what we call the human person represents a tremendous
interaction of many various and diversified psychobiological

forces, and that when we refer to the realities of life giving the
appearance of being the only dynamic forces, perhaps we might
be putting aside the totality of the human organism. It is

suggested that her death, this most decisive event, final and
ultimate, may very well have come by her own choice. Without
anxiety or despair, she saw her death as a solution to her problem
rather than as a source of conflict.
Case 2
The second case presents some different problems related to

the psychotherapy with the dying person. This patient made a
request to the internist for psychiatric assistance after she had

been told of the discovery of an abdominal malignancy. The
discovery of two metastic lesions in her lungs was not revealed to
her. The therapist visited her in the hospital six days following
her surgery, and the remainder of his visits occurred within the
hospital. They met for a total of ten sessions during a three-week
period. As the course of illness came closer to her death, the visits
were more frequent. Several unexpected and unannounced visits
were made at what might be thought of as “odd” times, for which

she expressed great pleasure. Their first meeting had been seven
years earlier at the funeral of her older son whom the therapist
had seen for five months of psychotherapy before his sudden and,
in a sense, unexpected death. The son had had a session with the
therapist at the office two days before he suffered a massive
intracerebral hemorrhage.
Though at the first meeting with the mother in the hospital,

neither she nor the therapist recognized each other, the
transference had a “ready made” component, as did the

therapist’s feelings about this patient. Her son had been a talented
and distinguished scholar with an international reputation, about
whose early life the therapist was very curious. To have the
opportunity to meet his mother was an added dimension for the
therapist.
At the time of the first session, the room was bright and
cheerful, with full sunshine streaming through the blinds. The
patient was out of bed, standing in front of the wall mirror,
grooming herself with care. She looked her age of 77, but
certainly not like a woman who was preparing for her death. After
the introduction, there was little necessity for him to ask

questions. She mentioned how much she had enjoyed the changes
in her son during his visits with the therapist, and hoped the same
could be done for her. “I know that I have a malignancy and that I
probably will die from it,” she said, touching the area of her
wound as she talked. She added, “I have made out a ‘living-will’
(4), so please see that the other doctors do not use any heroic
measures.” He said that he understood these feelings and would

try to see that her wishes were respected.
After this prologue—this contract between them—she
launched into a list of complaints about the nursing staff and

some physicians. Getting enough medication for her pain and for
sleeping was uppermost in her mind. She felt that medication for
pain should be given before the pain returned—“it makes it more

difficult, and then I have to wait almost 45 minutes before there’s
help.” She was unhappy about the fact that the staff did not reveal
to her the names of the various medications as well as her

temperature. This woman had been a scientist, working at a full-
time job until before the surgery, and had been independent since
her husband’s death two years previously. It was difficult for her
to accept a position of passivity in merely being a patient. She
spoke quite openly about her death, but found it most difficult
really to accept the idea. She did not express any feelings of “why
me?” or any significant anger other than the complaints about
staff. She wanted to have more talks with the therapist and hoped
he could help her arrange her life.
The therapist was taken by this woman, and there was no
difficulty in his mind about his full commitment for the remainder
of her life. He completely enjoyed her stories about her early

education in a small Central European town and her later
university studies. When she spoke in scientific jargon about her
field of interest, there was complete seduction. She was a most

extraordinary and unforgettable person, and now he also had
some additional documentation for her son’s character.
Tentatively, he felt that the current evidence led toward thinking
of her coming death as a most peaceful, if not a happy one.
During the next visit, it appeared that much had changed. She
was more disturbed about the staff and blamed the breakdown in
her wound on faulty technique. The wound drainage became the
reality which did not allow adequate denial to take place, as did
the continued pain. The therapist felt that she “knew” more of her
was dying, but did not really understand that she would be dead.
It was made clear that he would improve the arrangements for
the medication, both for pain and sleeping. The nursing staff was
instructed to tell her the names of all drugs, to give her some
sense of control. This was done, of course, with the realization
that this desire to know might represent some feeling that the
staff was being less than honest. She was encouraged to feel that
the therapist’s position was to be utilized for her welfare.
The draining wound prevented the denial and the symbolic
displacement from incurable illness to curable. The focus on the
wound was an expression of the symbolic fear of death for her.
Her trusted “friend,” her body, was beginning to fail and desert
her; she was feeling “attacked” and becoming somewhat more
angry and depressed. Nine days following the first visit, she was
eating less, and she was beginning to permit some assistance

from the therapist at mealtime (some visits were especially made
to coincide with meals).
The 47th birthday of her deceased son was close at hand. She
spoke again about his untimely death, and also about her
mother’s grave remaining unmarked. She made a request that her
mother's name be inscribed along with her own on the new

tombstone. Here the therapist felt that the material revealed
some sense of guilt towards her mother and that the knowledge
of her impending death was an atonement for same; likewise,

there was the theme of “dying together” (16) and fusion. In other
words, freedom from guilt is derived from the conscious

recognition of death. During this visit, she spoke somewhat about
the difficulty of being alone at night. The therapist’s next visit,
unscheduled, was on a Sunday morning, and she questioned the

reason for his coming to see her unannounced. He responded that
on Friday he had sensed a feeling that she was fearful of being left
alone. Then she said, “I’m pleased to have a chance to talk more
with you.”
Four days before her death, she requested that her phone be
turned off; she no longer had the patience to speak, even with old
friends. This was the first striking evidence of a desire for the
beginning of cutting her ties and decathecting old subjects. The
odor from the wound was a continuous concern and source of
much displeasure. She was embarrassed, and said that her death
would be easier if she did not have that added burden. She
requested that the therapist prescribe a tranquilizer for her
anxiety, and mentioned her regret that she had not brought her
own medication. He agreed to order the additional medication.
On the same day, her younger son came from another city
and, during his visit, told her that, when discharged from the
hospital, she would come and live at his home. She spoke of dying
in this other city. Then, by administrative decision, and
unbeknown to the therapist, she was transferred to another part

of the hospital. Briefly, she was moved from an acute active
service to the more chronic part of the hospital where beds are
also utilized for convalescence. From this point on, her course
was rapidly downhill. The therapist sensed and felt that she
regarded the move as a signal that staff had despaired of her
recovery. She stopped eating completely, talked little and left her
bed only for bathroom needs. The nights, with darkness and the
quietness about the hospital, became more frightening. She
accepted fluids from the therapist in the form of ice water and tea.
Visiting with her about 12 hours before her death, he found
her silent, lying in bed staring straight ahead, but not actually
acknowledging his presence. The silence was complete without

any verbal response even to colloquial questions. She did not
appear to be in any severe pain; her face was not tense, but she
was perspiring. After about half an hour, when asked whether she
might wish him to leave, she shook her head negatively. He
remained longer, but they never spoke again. Some relatives who
came received the same silence; her only responses were
displayed by head-nodding. The silence possibly was part of an
acceptance and her way of saying, “Nothing more need be said.”

She died the following morning.
In this psychotherapy, there was no conspiracy which would
have tended to isolate the patient. None of her questions were
ever considered irrelevant and all were answered in a very direct

manner. However, she was never told directly that she was dying,
nor was she told about the metastases. The therapist felt honest
with her, despite his withholding some of the truth. They talked
about death often and she was aware of her diagnosis. In their
first visit, she informed him that she was in fact dying—it was
after she knew the diagnosis that she requested his visit. In
addition, there existed this “ready-made” transference as the
person who had treated her son before his death, and the
transference had the appearance that the therapist was the bridge
for her to the dead son and mother. But even this “reconciliation”
was not sufficient to make her death positively a happy one. The
transfer to the more chronic division of the hospital seemed to

hasten the course of her death. Her ego must have felt that the
“game” was up. There was no way out except through a flight into
“psychosis,” manifesting itself in withdrawal, feelings of unreality,
negativism, and becoming completely mute. When the body was
threatened—and with this patient the constant draining wound

was felt as a continuous threat—there was the gradual
withdrawal from objects and great intensification of her feeling of
narcissistic injury. This aggression against her was felt, perhaps,

as a punishment. Early in the treatment she fought back and
directed complaints against the staff. During the last few days the
therapist speculated that there existed some, perhaps

masochistic, albeit pleasurable, suffering. All visiting relatives
were made to feel guilty and helpless by her negativism. The guilt
was especially strong with her former daughter-in-law, who was
a constant and devoted visitor at her bedside, and who found it

difficult to accept the patient’s behavior in spite of the therapist's
explanations.
The dynamics in this case, indeed, are complicated further

with the time of her dead son’s birthday and her wish that her
mother’s name be inscribed on her tombstone. We are all quite

familiar with the anxiety that many women suffer before
parturition, and how this often becomes fear of death. While there
is no actual strong data to support the speculation that the
thought of being in childbirth was active within her (i.e.,
abdominal mass), it remains a thought for consideration. Also,

perhaps, the wish for reunion with her mother might have been
another possibility—the headlines of the material were present.

Additional support for these speculations centers on the meaning
of the mass growing within her. Candidly, the therapist could not
say that her death was a complete euthanasia (2) in spite of his
original feelings following the first meeting. Perhaps the death
might have been happier, if the transfer had not occurred, but that
will remain her secret. However, the case does show the
investment of time and torment that the physician who commits
himself to the treatment of the dying person must be prepared to
make. In such instances, he must sustain some sense of medical

failure and, not least of all, at times a poor psychological death. No
matter the degree of honesty, each person has his death in his
appropriate setting, based on the concept that all of us will have
our own private style of dying, an outgrowth of our previous life

cycle.
An Approach to Helping a Dying Person
The material presented from the history and course of
treatment of these two particular dying people can be helpful in

delineating various essential psychotherapeutic tools which could
be comforting for the dying person. However, in both these
situations there was a “ready-made” transference, an advantage
that does not exist in all instances. In the first case, the fatal
illness became part of an ongoing treatment. With the second

case, it was clear at the first session that the therapist was to be
the bridge between her dead son and her death (2). In numerous
situations of consultation the goals, of necessity, will have
imposed limitations, and the time needed does not exist. Often,
the assessment must be quite rapid and, hopefully, gets to the

heart of the matter. Consequently, the considerations should be 1)
to help the patient; 2) to give assistance to the staff, including
paramedical helpers; 3) to provide time to be spent with the

family. In dealing with these categories, the matter of the
individual and collective grief must be realized and treated. Most
usually, this involves management of their guilt and feelings of

helplessness referable to themselves and towards the dying
person as well. The referring physician, with his sense of medical
failure and damage to his narcissism, cannot be forgotten or
neglected.
The therapist who decides to involve himself in the
treatment of a dying person must commit himself 1) to utilize all
his efforts in behalf of the patient's welfare. The patient must

understand this clearly, and also know that the therapist will be a
constant, available, and reliable figure for the patient. The

psychodynamic evidence is that the fear of abandonment
occupies a central position in the mind of the dying person. The
therapist should have knowledge of the various pharmacological
agents that can allay anxiety, counter depression and, at times,
handle more malignant symptoms, namely paranoid thinking.

Superficial optimism is usually opposed, since it can encourage
suspicion and mistrust. However, in certain instances of persons

with character traits of being chronic optimists, the denial should
not be challenged; it should be viewed as homeostatic and as ego-
syntonic for maintaining self-esteem; 2) to try to respond

appropriately to the patient’s needs by listening carefully to the
complaints and the words used to express them. It is especially
important to watch for displacements of the symbolic

representation of the fear of death, namely, “the room is dark,
please open the blinds,”…“the room is stuffy.” Making minor, or
seemingly minor, physical changes often has a remarkable way of

making the patient more comfortable, reducing anxiety and lifting
depression; 3) to be fully prepared to accept his own
countertransference, as doubts, guilts and damage to his
narcissism are encountered. He must be fully prepared to have

his own death wishes from earlier years reactivated and, of
course, to be reminded constantly of his own death and mortality.
From this, it remains an easy step to see why we have left in

the past and continue now to leave the dying person alone. We
know that the pain of death is made more intense, if the journey is
embarked upon alone. Without a partner, the fear quickly
escalates to panic and dread. Here, then, is the role for the
therapist—an empathy—an affective one which provides a fusion
with the patient’s unconscious and transmits the feeling that a
part of the therapist will die with that person. Superficial

optimism which is so removed from the reality can oppose this
fusion and empathy.
The ability to transmit this feeling quite naturally

transgresses individual capacities in therapists and is not
accessible to all. The therapist must be aware that his own
defenses cannot be rigidly adhered to, since they tend only to

widen the gap in communication between himself and the patient.
The treatment must permit a guilt-free regression in the patient;
this will go a long way to preclude object-loss.
It is not too difficult to know and realize a “bad” death, but to

be able to sort out a “good” death presents more difficulty. The
therapist must work for relief of pain, and counter the arguments
of “addiction” as often, reflecting, in part, some of the staff's
inability to give up control, even though they require that the

patient do so. It may also express their denial and false hope or, at
best, indicate an example of awkward thinking. Above all, the
therapist must understand that this personal presence remains all

that is available against the fear of abandonment (15)—the
journey to death remains an illusion that must have some allies.
The struggle and torment for the therapist with the dying person
is always the battle of David and Goliath, but we must recognize
beforehand that Goliath, in all instances, will be the winner.
REFERENCES
1. Weigert, E. The nature of sympathy in the art of psychotherapy. Psychiatry, 1961,

24:187.
2. Deutsch, F. Euthanasia: A clinical study. Psychoanal. Quart., 1930, 5:347-368.
3. Eissler, K. R. The Psychiatrist and the Dying Patient. New York: International
4. Olden, C. On adult empathy with children. In: The Psychoanalytic Study of the Child.
Vol. 8, New York: International Universities Press, 1953, pp. 111-126.
5. Beres, D. The role of empathy in psychotherapy and psychoanalysis. J. Hillside Hosp.,

1968, 17:362.
6. Beres, D. and Arlow, J. Fantasy and identification in empathy. Psychoanal. Quart.,

1974, 43:26.
7. Greenson, R. Empathy and its vicissitudes. Int. J. Psychoanal., 1960, 41:418.
8. Freud, S. Thoughts for the times on war and death. In: J. Strachey (Ed.), Collected
Papers, Vol. 4. London: Hogarth Press, 1925, pp. 288-319.
9. Saunders, C. The moment of truth. In: L. Pearson (Ed ), Death and Dying. Cleveland:
Press of Case Western Reserve University, 1969, pp. 49-78.
10. Jones, E. Dying together. In: E. Jones (Ed.), Essays in Applied Psychoanalysis. London:
11. Brodsky, B. Liebestod fantasies in a patient faced with an illness. Int. J. Psychoanal.,
1959, 40:13.
12. Flugel, J. C. Death instinct homeostasis and allied concept. Int. J. Psychoanal Suppl.,
1953, 34:43.
13. Lewin, B. D. Psychoanalysis of Elation. London: Hogarth, 1950.
14. Hendin, D. Death: A Fact of Life. New York: W. W. Norton, 1973.
15. Kübler-Ross. E. On Death and Dying. London: The Macmillan Publishing Co. 1969.
Note
1. This is a modified version of the paper that was published in the American Journal of
Psychotherapy, Volume XXXI, No. 1, pp. 19-35, January, 1977.
15
The Behavioral Psychotherapy of

Anorexia Nervosa
Michel Hersen, Ph.D.

Thomas Detre, M.D.
Preamble
The label of anorexia nervosa is misleading on two accounts:
1) anorexia—far from being anorectic, these patients are starved

and periodically engorge themselves; 2) nervosa—this implies
that the ailment is psychological in origin, but apart from change
in dietary habits consistent with the patient’s belief system that

she is too fat, the majority of the cases exhibit no changes in mood
or cognition typically found in psychiatric disorders. The situation
is not unlike the one found in transsexuals, who are convinced

that their “soul” has been mistakenly placed in a body shell
displaying sexual characteristics that are inconsistent with their
internal convictions about their sexual assignment. Both have, as

has been pointed out, an obsessoid personality structure.
Although the biological symptoms and signs thus far
reported in anorexia nervosa also are scarce, inconsistent, and
mostly secondary to weight loss, it is by now generally recognized

that a significant percentage of patients becomes amenorrheic
before developing symptoms of anorexia. Minimally, this finding
should suggest that at least one subgroup of patients suffers from

some sort of disorder involving neuroendocrine regulation.
Irrespective of the etiology, all evidence points to the

effectiveness of psychological rather than biological treatment,
though the latter has been used as co-adjuvant in the

management of patients. It also is reasonably clear, but by no
means surprising, that the success or failure of treatment
depends largely on the consistency of the family environment,

given that the majority of patients are preadolescent or
adolescent and thereby still dependent on the parents or parent-
substitutes when first brought to medical attention.
The major difficulties encountered in the management of
anorexia nervosa, however, have less to do with the failure on the

part of the parents to acknowledge their child's need for
treatment than with the failure of mental health professionals to
recognize a fatal error in their own reasoning: namely, that the

success of psychological therapies per se does not prove that the
disorder should be regarded as a psychiatric disorder. Yet, the

view that anorexia nervosa is a “mental disorder” and the
insistence that patient and family endorse and enthusiastically
participate with the staff in a “fishing expedition” aimed to
uncover some sort of psychological problem (or at least come to
an agreement about one), even when the evidence is

unconvincing, do turn family members off, and rightly so. The
collaboration between treatment staff, the patient, and the family
should be based on an honest understanding of what we know

and do not know about this disorder. Accordingly, and given the
considerable short- and long-term risks, it is perfectly
appropriate to present the need for psychological management

convincingly. On the other hand, the fact that psychological
treatment seems effective is insufficient reason for persuading
the patient and the family that the psychiatric disorder exists, or
worse yet, that in some mysterious manner it has been produced
by them. Indeed, statistically just the opposite is true. In those
instances where symptoms and signs of an affective, obsessive, or

schizophrenic disorder are observable, the chances are very high
that patients suffer from a secondary rather than a primary or
idiopathic type of anorexia nervosa.
General Psychotherapeutic Considerations
When we speak of anorexia nervosa, the generic label not

only is misleading, as already noted in our Preamble, but it
subsumes a wide variety of specific signs and symptoms in any
given individual so afflicted. Recent comprehensive reviews of the
literature by Van Buskirk (1) and Bemis (2) clearly suggest,
however, that individuals who eventually receive the diagnosis of
anorexia nervosa do not necessarily share all of the same signs

and symptoms. For example, although many anorectics have lost
at least 25% of their “normal'' body weight, all do not typically

induce vomiting as a means to maintain diminished weight. Some
anorectics exhibit certain characterological difficulties such as a
“passive-aggressive” life-style, but that does not hold true for

many others who are quite obsessive in their orientation. While in
some cases there may be an alternation of anorexia and periods of
bulimia, in still others, particularly when the disorder remains

untreated for many years, anorexia predominates, leading to a
dramatic linear reduction in weight.
Given that specific symptomatology does vary considerably

across patients labeled anorexia nervosa, there can be no uniform
psychotherapeutic approach that will deal effectively, at one time,
with all the manifestations of the disorder. Indeed, a very careful
diagnostic appraisal of each aspect of the disorder is warranted.

Then, for each aspect of the disorder so identified, the
appropriate treatment strategy must be specifically tailored (3).
In light of the specificity of treatment required and in

consideration of the unique problems posed by each of the
individual symptoms subsumed under anorexia nervosa, we

submit that, for the most part, the behavior therapy approach
should prove parsimonious and expedient (4, 5).
Although the behavioral approach for treating anorexia
nervosa has received some sharp criticism by Bruch (6), as
astutely pointed out by Wolpe (7), failures of behavioral

treatment can easily be traced to an incomplete behavioral
assessment and attention to only one facet of the disorder (e.g.,
attention to weight gain but no attempt to deal with the “weight”

phobia leading to the original weight loss). Thus, in the
succeeding sections, we will outline specific treatment strategies
that may be applied to each of the identified facets of the disorder.
Undoubtedly, future research should confirm that a multifaceted
approach to treatment will prove superior to the more naive

behavioral treatment approach that only deals with one facet (i.e.,
weight gain) or the nonspecific psychotherapy that is not at all
tailored to the patient’s unique presenting problems. Even more

important, we will argue that for maintaining gains initially
accrued during inpatient treatment, programmed booster therapy
sessions over a period of many years will probably be required.
Weight Loss
Treatment of the weight loss, which at times may be of life-
threatening proportions, is best accomplished in a well-controlled

environment such as the inpatient psychiatric ward. Although
when medical complications arise (e.g., viral infection), forced
feeding via a naso-gastric tube may become a necessity, under

ordinary circumstances a less invasive procedure for inducing
weight gain is recommended.
Experience in a wide variety of centers over the last decade
indicates that the use of operant conditioning procedures is the

behavioral treatment of choice for obtaining “rapid weight
restoration at times of nutritional crisis” (8, p. 171). In essence, a

somewhat one-sided contract is drawn up between the treating
agent and the patient, stating that the patient will be given access
to reinforcers (e.g., physical activity, television, reading material,

other privileges) contingent on a specific weight gain in a
designated time period. For example, Halmi, Powers, and
Cunningham (9) maintained patients in relative isolation unless

they gained 0.5 kg per five-day period. Naturally, the specific
weight gain required per time period should be realistic and

determined by the extent of the weight loss. Also, to maximize the
efficacy of the behavioral contingency, it is of paramount
importance that the patient be given access to her (only 15% of
reported cases are males) favorite reinforcers. Moreover, Agras,

Barlow, Chapin et al. (10) found that informational feedback
about caloric intake and weight gain given to the patient as well
as presenting her with four high caloric meals (1500 calories

each) per day further promoted rapid weight gain.
To summarize, the patient should be restricted to her room,

privileges are to be given contingently on increased caloric intake
and weight gain, informational feedback about caloric
consumption and weight gain are to be provided, and large as
opposed to small meals are to be presented to the patient at least
four times a day. No comments should be made to the patient

prior to or while eating. That is, the therapist need not engage in a
prolongation of the verbal struggle with the patient. In addition,
the patient should be weighed daily under standardized

conditions (i.e., after urinating, in hospital gown only, at precisely
the same time each day). It is widely known that anorectics
attempt to falsify their weight and, of consequence, need to be

carefully examined for foreign objects in or on their bodies and
garments when being weighed.
Although making privileges strictly contingent on weight

gain first requires the withdrawal of non-contingent
reinforcement and has been described by some as coercive and
furthering the “power struggle” with the patient (6), it is no more

coercive and certainly less invasive than forced feeding by tube.
Also, considering that weight loss in anorexia nervosa has led to

eventual death in up to 15% of documented cases, the polemical
nature of such an argument is nonsensical. Indeed, the first order
of business in treating the anorexia nervosa patient is to restore

her weight to a level that is reasonable and medically safe.
Attitudes Toward Food and Weight
We fully agree with Bruch’s (6) contention that the concern

with weight gain alone in anorexia nervosa constitutes only a
partial and surface treatment of the problem. A very careful
interview of the anorectic patient clearly reveals that she
invariably has a most negative attitude about gaining weight,

which often has an historical antecedent (i.e., at one point she
actually may have been overweight). However, what also
becomes readily apparent is that her current perception of how

she looks and what she weighs is highly inaccurate. Thus, even
though in reality rather thin (at times emaciated), the patient
continues to think of herself as if she were still “fat.” Therefore,

one might conceptualize the problem as a cognitive distortion
with a resultant phobia for gaining weight.
Several single case reports have appeared in the literature

illustrating the use of systematic desensitization in the treatment
of anorexia nervosa (11-13). In these case studies the patients
were treated as if they were suffering from a “weight” phobia.

Generally, following training in deep muscle relaxation, separate
hierarchies involving consumption of food and gaining weight

were constructed. Then, in standard fashion, systematic
desensitization treatment proceeded until all items in the two
hierarchies were successfully completed under conditions of

minimal anxiety. Of the cases reported, follow-ups were brief with
the exception of the patient treated by Ollendick (13). But,
although Ollendick’s (13) patient has a five-year follow-up and

the controlling effects of systematic desensitization on weight
gain are documented, additional strategies (e.g., cognitive
restructuring) were required to reinstate weight gain and
maintain the patient’s improvement during follow-up.
Thus, while systematic desensitization or some form of

cognitive behavior therapy appears to make sense in dealing with
the anorectic’s faulty cognitions and perceptions, it would be

essential to obtain empirical documentation of the long-range
effects in a large number of cases. Nonetheless, irrespective of the
therapist’s specific choice of technique at this point, a direct

intervention aimed at modifying the patient’s cognitive distortion
about her body image should complement the operant approach
directed to increasing weight. In practice, application of

systematic desensitization could be accomplished concurrently
with contingency management after some of the patient’s weight

has been restored
Bulimia
Surprisingly, little attention has been accorded to the direct

treatment of episodes of bulimia even though it is well
documented that many anorectics (contradicting their diagnostic
label) periodically engorge themselves with fattening foods

during the course of binges. Some of these binges may last for
several hours or days at a time and are usually followed by the
patient’s feeling of disgust or remorse, leading to self-induced

vomiting. When interviewed about their binge behavior,
anorectics describe the antecedent as an irresistible impulse
(associated with high levels of anxiety) which must be fulfilled.
Once eating behavior has actually begun, the patient feels totally
helpless, cannot stop, and continues consumption well past the

state of normal satiation, even though the act of eating at that
point no longer is enjoyable. Often it is reported that various food
cues in the environment trigger off the entire chain of behaviors:

impulse—bulimia—remorse—self-induced vomiting.
Although bulimia in anorexia nervosa may subside after lost
weight has been regained and “normal” eating patterns have been
established, it is quite possible that extinction of the phenomenon
may not automatically take place. This being the case, it also is
conceivable that with the appropriate stimulus conditions bulimia

may recur, thereby leading to a return of self-induced vomiting
after appropriate food consumption has taken place, once again
eliciting the dramatic weight loss that brought the anorexia

nervosa patient to our attention in the first place.
Considering the phenomenon of bulimia as anxiety-based
and the resulting chain of events as anxiety-reducing, we recently

have dealt with bulimia using anxiety-reducing techniques of
flooding and response-prevention (14). In a few cases of anorexia
nervosa, where bulimia was a prominent feature, we have placed

the patient in a laboratory situation surrounded by her favorite
foods (e.g., candy bars, cakes, chocolates, etc.). Upon presentation

of food cues the patient appears physiologically aroused
(increased heart and pulse rate). She is instructed to take a few
bites of food and then told to stop eating. At that point
physiological arousal is further enhanced (confirmed by the

patient’s self-reports of heightened anxiety). The patient is then
maintained in this environment (with the salient food cues),
prevented from binge eating, and also prevented from inducing

vomiting after “normal” food consumption. Such flooding and
response prevention are continued (2-4 hours at a time) until
physiological responses return to normal resting levels and the

patient reports no further impulse to engage in binge eating. After
several sessions of combined flooding and response prevention, a
“temptation” test is given the patient to assess the effects of

treatment. In spite of a few successes employing this strategy,
obviously further confirmation would be needed to determine
whether generalization of treatment gains extend to the patient’s

natural environment.
Family Therapy
Although it is most tempting to speculate what role the

family has in producing anorexia nervosa, any such speculation
must take into account that such patients, apart from bizarre food
habits and eating patterns, appear psychologically quite well. The
contrast between the patient’s peculiar views on food intake and
her otherwise “normal” behavior also is the reason why referral
to treatment occurs usually late in the course of the disorder,
when the patient is already emaciated and the family is no longer
able to cope with the situation. It should come as no surprise that

by the time the patient comes to medical attention, the power
struggle which almost inevitably ensues when family members

attempt (albeit ineffectively) to deal with the patient’s attitude
causes considerable dissension as well as inconsistencies which
inadvertently reinforce the patient’s weight loss and bizarre

eating habits. Indeed, the situation parallels that of the family’s
reaction to severe obsessive-compulsive ritualistic actions and
his/her increasing demand for family participation. Thus, even

though we find the etiologic role assigned to the family by some
theoreticians unconvincing, we agree that a comprehensive
approach to treating anorexia nervosa must include family

therapy (15). Our preference for family therapy is one that is
educative, non-punitive, and focused on the presenting problems
unless, of course, there is evidence of conflicts unrelated to the
patient’s eating problems. Since the relief which hospitalization

provides to the immediate family tends to be very temporary, we
believe the anorectic’s inpatient stay presents an excellent
opportunity to teach the family how to manage her when she

returns to the home setting. In essence, the goal is to teach family
members those strategies that were successful in dealing with the
patient while she was hospitalized. Formal behavioral contracts

(specifying behavior, privileges, and punishments) are helpful, as
are treatment sessions done in a semi-naturalistic fashion during
the course of meals in the hospital (15). It is. in our experience,
always preferable to reinforce the patient’s positive behavior
while ignoring her negative initiatives. However, as with most

aspects of the contemporary treatment of anorexia nervosa,
confirmation of the successes reported will have to await the
outcome of well-controlled clinical trials.
Long-Term Maintenance
We already have potent psychotherapeutic techniques in our

armamentarium to improve the condition of anorectics during the
course of their hospital stay. The often dramatic gains achieved
during the inpatient phase of treatment, however, are misleading,

for it is clear that in the absence of maintenance therapy following
discharge, long-term results will be disappointing (6, 7, 13, 16).
While the multi-faceted approach to anorexia nervosa suggested

by us should facilitate long-term maintenance, it is very difficult
to predict what stresses the anorectic and her family may
encounter that would lead to the recrudescence of the disorder

even after a prolonged and well-organized aftercare program.
Given the chronicity and acute exacerbations, there is every
reason to believe that psychiatric care should continue regardless

as to how successful inpatient therapy has been. Looking at the
natural history of anorexia nervosa and consistent with the
medical model of treatment for chronic disorders, it would seem

logical to recommend long-term maintenance treatment for at
least five years.
Thus, the follow-up care of such patients should not be
confined to the periodic reassessment of the situation, but consist

of an active booster treatment program in which individual and
family therapies are scheduled at regular intervals, minimally six
to twelve times per year. Furthermore, since relapses with severe

weight loss are common and since, in our experience, neither the
patient nor the family show less reluctance than the first time
around to consider hospitalization, it is always advisable to spell

out under what conditions the clinician is willing to assume
responsibility for continuing care as well as to explain the rules
which will prompt the clinician to recommend rehospitalization.

Although some clinicians are willing to treat such individuals as
outpatients even in the face of severe and progressive weight loss,
it is our practice to insist on readmitting the patient whenever

there is 15% weight loss, using weight at discharge as a baseline.
Should the patient (or family) refuse readmission, the alternative

of transferring the patient into another clinician’s care should be
offered.
Conclusion
In conclusion, we view anorexia nervosa as a disorder of
uncertain etiology which responds to psychological treatments.

Because of the diversity of symptoms, not all of which may be
prominent or even present in a particular case, rather than
recommending a single form of therapy, a highly individualized
treatment program using techniques of behavior therapy is
indicated. Given that the majority of such patients are

preadolescents or adolescents and still dependent on the parents
or parent-substitutes, we consider family therapy essential both
in the immediate and long-term management of patients. Our

approach calls for family therapy that is educative rather than
punitive and teaches the family how to manage the patient when
she returns to the home setting. Since anorexia nervosa is a

chronic disorder with periodic exacerbations, we consider it
essential to provide maintenance therapy for at least five years
consisting of an active booster treatment program administered

at regularly scheduled intervals.
REFERENCES
1. Van Buskirk, S. W. A two-phase perspective in the treatment of anorexia nervosa.

Psychol. Bull., 1977, 84:529-538.
2. Bemis, K. M. Current approaches to the etiology and treatment of anorexia nervosa.

Psychol. Bull., 1978, 85:593-617.
3. Hersen, M. and Bellack, A. S. Behavioral Assessment: A Practical Handbook. New York:

Pergamon Press, 1976.
4. Stunkard, A. J. New therapies for the eating disorders: Behavior modification of

obesity and anorexia nervosa. Arch. Gen. Psychiat., 1972, 26:391-398.
5. Kellerman, J. Anorexia nervosa: The efficacy of behavior therapy. J. Behav. Ther. & Exp.
Psychiat., 1977, 8:387-390.
6. Bruch, H. Perils of behavior modification in treatment of anorexia nervosa. JAMA.,

1974, 230:1419-1422.
7. Wolpe, J. Behavior therapy in anorexia nervosa. JAMA., 1975, 133:317-318.
8. Bhanji, S. and Thompson, J. Operant conditioning in the treatment of anorexia
nervosa: A review and retrospective study of 11 cases. Brit. J. Psychiat., 1974,
124:166-172.
9. Halmi, K. A., Powers, P., and Cunningham, S. Treatment of anorexia nervosa with
behavior modification: Effectiveness of formula feeding and isolation. Arch. Gen.
Psychiat., 1975, 32:93-96.
10. Agras, W. S., Barlow, D. H., Chapin, H. N., et al. Behavior modification of anorexia
nervosa. Arch. Gen. Psychiat., 1974, 30:279-286.
11. Hallsten, E. A. Adolescent anorexia nervosa treated by desensitization. Behav. Res. &
Ther., 1965, 3:87-91.
12. Schnurer, A. T„ Rubin, R. R., and Roy, A. Systematic desensitization of anorexia

nervosa seen as a weight phobia. J. Behav. Ther. & Exp. Psychiat., 1973, 4:149
153.
13. Ollendick, T. H. Behavioral treatment of anorexia nervosa: A five-year study. Behav.

Mod. 1979, 3:124-135.
14. Marks, I. M. Behavioral treatments of phobic and obsessive-compulsive disorders A

critical appraisal. In: M. Hersen, R. M. Eisler, and P. M. Miller (Eds.), Progress in
Behavior Modification, Vol. 1. New York: Academic Press, 1975, pp. 65-158.
15. Liebman, R., Minuchin, S., and Baker, L. An integrated treatment program for
anorexia nervosa. Amer. J. Psychiat., 1974, 131:432-436.
16. Erwin, W. J. A 16-year follow-up of a case of severe anorexia nervosa. J. Behav. Ther.
& Exp. Psychiat., 1977, 8:157-160.
16
Psychotherapy with Suicidal Patients
Edwin S. Shneidman, Ph.D.
It seems logical that before we consider what the

psychotherapy of a suicidal person ought to be that we have some
common understanding of the suicidal state itself. Of course,
everybody agrees that suicide is an enormously complicated

term, encompassing a wide variety (and different ranges) of
dysphoria, disturbance, self-abnegation, resignation, terror-cum-
pain—to mention but a few inner states that are involved. But
perhaps nowhere is there as insightful a description of suicide in
as few words as that found in the opening paragraph of Melville's

Moby-Dick: "a damp and drizzly November in my soul.” For that is
what, metaphorically, most suicide is: a dreary and dismal wintry

gale within the mind, where the vital issue that is being debated is
whether to try to stay afloat in a stormy life or willfully to go
under to nothingness.
Suicide is the human act of self-inflicted, self-intended
cessation (i.e., the permanent stopping of consciousness). It is

best understood as a bio-socio-psychologico-existential state of
malaise. It is obviously not a disease and just as obviously a
number of kinds of trained individuals other than physicians can

help individuals who are in a suicidal state.
If we are to escape many of the current somewhat simplistic

notions of suicide (especially those which totally equate a disease
called suicide with a disease called depression), then we need to

explicate what the suicidal state of mind is like. Our key source in
this can be the ordinary dictionary—eschewing any
nomenclature of technical and, especially, technically diagnostic

terms. In the dictionary there are words, e.g., angered, anguished,
cornered, dependent, frustrated, guilty, helpless, hopeless, hostile,
rageful, shamed, that will help us in our understanding. For us, in

this chapter, two less common (but ordinary) dictionary words
—perturbation and lethality—will be the keystone words of our
understanding.
Perturbation refers to how upset (disturbed, agitated, sane-
insane, discomposed) the individual is—rated, let’s say, on a 1 to

9 scale. Lethality refers to how lethal the individual is, i.e., how
likely it is that he will take his own life—also rated on a 1 to 9
scale.
At the outset, I need to indicate what kinds of suicidal states I

am talking about in order to indicate what kinds of psychotherapy
are appropriate for them. We can arbitrarily divide the
seriousness (or risk, or lethality, or suicidality) of all suicidal
efforts (actions, deeds, events, episodes)—whether verbalizations
(ordinarily called threats) or behaviors (ordinarily called
attempts)—into three rough commonsense groupings: low,
medium and high. In this chapter, I shall focus on the suicidal

events or deeds of high lethality, where the danger of self-inflicted
death is realistically large and imminent; what one might
ordinarily call high suicide risks. Of course, a suicide act (deed,

occurrence, event, threat, attempt) of whatever lethality is always
a genuine psychiatric situation and should be treated without any
iatrogenic elements. Thus, in the treatment of the suicidal person

there is almost never any place for the therapist’s hostility, anger,
sardonic attitudes, daring the patient, or pseudo-democratic
indifference.
By focusing solely on the psychotherapeutic approaches to

high suicide risks, it should be obvious at the beginning that this
chapter is a moiety—omitting entirely (and advertently) the

lively areas of treatment suicidal individuals receive by means of
chemical, electrical or institutional modalities.
Theoretically, the treatment of an acutely highly suicidal

person is quite simple: It consists, almost by definition, of
lowering his lethality level; in practice, this is usually done by
decreasing or mollifying his level of perturbation. In short, we
defuse the situation (like getting the gun), we create activity of
support and care around the person, and we make that person’s
temporarily unbearable life just enough better so that he or she
can stop to think and reconsider. The way to decrease lethality is
by dramatically decreasing the felt perturbation.
Working intensively with a highly suicidal person—someone

who might be assessed as 7, 8 or 9 on a 1 to 9 scale of lethality—
as distinguished from someone of moderate or low lethality, is

different from almost any other human encounter, with the
possible exception of that of working intensively with a dying
person—but that is another story. Psychotherapy with an

intensely suicidal person is a special task; it demands a different
kind of involvement. The goal is different—not that of increasing
comfort, which is the goal of most ordinary psychotherapy, but

the more primitive goal of simply keeping the person alive. The
rules are therefore different, and it follows (or rather precedes)
that the theoretical rationale is different.
At this juncture, I wish to make a distinction among four

psychologically different kinds of human encounters:
conversation (or “ordinary talk”); an hierarchical exchange;

psychotherapy or a “professional exchange”; and, finally, clinical
suicidology or working psychologically with a highly lethal
person.
In ordinary talk or conversation, the focus is on the surface

content (concrete events, specific dates, culinary details); on what
is actually being said; on the obviously stated meanings; on the
ordinary interesting (or uninteresting) details of life. Further, the
social role between the two speakers is one in which the two
participants are essentially equal. Each participant has the social
right to ask the other the same questions which he or she has
been asked by the other. The best example of ordinary talk is two
friends conversing with one another.
In a hierarchical verbal exchange the two participants are

socially, and hence psychologically, unequal. This difference may
be imposed by the situation, such as the exchange between a
military officer and an enlisted person, or it may be agreed to by

the two involved parties, such as between a physician and a
patient. In either instance, the two are not psychologically equal.
For example, an officer or a physician can ask an enlisted person

or a patient, respectively, certain personal questions to which a
rational response is expected, that the person of “lower status”
could not ask the other person in return without appearing

impertinent or aberrant. Yet most of the talk is still on the surface,
concerning the real details of everyday life.
In a professional psychotherapeutic exchange the focus is on

feelings, emotional content and unconscious meanings, rather
than on what is apparently being said. The emphasis is on the
latent (between-the-lines) significance of what is being said more
than on the manifest and obvious content; on the unconscious
meanings, including double-entendres, puns, and slips-of-the-
tongue; on themes that run as common threads through the
content, rather than on the concrete details for their own sake.
Perhaps the most distinguishing aspect of the professional

exchange (as opposed to ordinary talk) is the occurrence of
transference, wherein the patient projects onto the therapist
certain deep expectations and feelings. These transference

reactions often stem from the patient's childhood and reflect
neurotic patterns of reaction (of love, hate, dependency,
suspicion, etc.) to whatever the therapist may or may not be

doing. The therapist is often invested by the patient with almost
magical healing powers, which, in fact, can serve as a self-fulfilling
prophecy and thus help the interaction become therapeutic for

the patient. In this paragraph, the use of the words therapist and
patient already implies that, of the two parties, one has tacitly
agreed to seek assistance and the other has agreed to try to give
it. The roles of the two participants, unlike those in a
conversation, are, in this respect, not co-equal. A therapist and a
patient could not simply exchange roles.
In working as a clinical suicidologist with an individual who
is highly suicidal, the focus is again different. In this situation, the

attention is primarily on the lethality. Most importantly, what
differentiates this modality of therapy from any other
psychotherapy is the handling of the transference feelings.

Specifically, the transference (from the patient to the therapist)
and the countertransference (from the therapist to the patient)—
especially those positive feelings of affection and concern—can
legitimately be much more intense and more deep than would be

seemly or appropriate (or even ethical) in ordinary
psychotherapy where time is assumed to be endless and where it

is taken for granted that the patient will continue functioning in
life.
Working with a highly suicidal person demands a different
kind of involvement. There may be as important a conceptual

difference between ordinary psychotherapy (with individuals
where dying or living is not the issue) and psychotherapy with
acutely suicidal persons as there is between ordinary

psychotherapy and ordinary talk.
The main point of working with a lethally-oriented person—
in the give-and-take of talk, the advice, the interpretations, the

listening—is to increase that individual's psychological sense of
possible choices and sense of being emotionally supported.

Relatives, friends and colleagues should, after they are assessed
to be on the life-side of the individual’s ambivalence, be closely
involved in the total treatment process. Suicide prevention is not

best done as a solo practice. A combination of consultation,
ancillary therapists and the use of all the interpersonal and
community resources that one can involve is, in general, the best
way of proceeding.
Recall that we are talking about psychotherapy with the
highly suicidal persons—not one of low or even medium lethality.
With this in mind—and keeping in mind also the four
psychological components of the suicidal state of mind
(heightened inimicality, elevated perturbation, conspicuous

constriction of intellectual focus, and the idea of cessation as a
solution)—then a relatively simple formula for treatment can be
stated. That formulation concentrates on two of the four

psychological components, specifically on the constriction and the
perturbation. Simply put, the way to save a highly suicidal person
is to decrease the constriction, that is, to widen the range of

possible thoughts and fantasies (from the dichotomous two—
either one specific outcome or death—to at least three or more
possibilities for admittedly less-than-perfect solution), and, most

importantly—without which the attempt to broaden the
constriction will not work—to decrease the individual’s

perturbation.
How does a psychotherapist decrease the elevated

perturbation of a highly suicidal person? Answer: by doing
anything and almost everything possible to cater to the infantile

idiosyncrasies, the dependency needs, the sense of pressure and
futility, the feelings of hopelessness and helplessness that the
individual is experiencing. In order to help a highly lethal person,
one should involve others; create activity around the person; do
what he or she wants done—and, if that cannot be accomplished,

at least move in the direction of the desired goals to some
substitute goals that approximate those which have been lost.
Remember that life—and remind the patient of this fact (in a

kindly but oracular way)—is often the choice among lousy
alternatives. The key to functioning, to wisdom and to life itself is

often to choose the least lousy alternative that is practicably
attainable.
Taken down to its bare roots, the principle is: To decrease
lethality one puts a hook on perturbation and, doing what needs

to be done, pulls the level of perturbation down—and with that
action brings down the active level of lethality. Then, when the
person is no longer highly suicidal—then the usual methods of

psychotherapy (which are not the subject for this chapter) can be
usefully employed.
As to how to help a suicidal individual, it is best to look upon

any suicidal act, whatever its lethality, as an effort by an
individual to stop unbearable anguish or intolerable pain by

“doing something.” Knowing this usually guides us as to what the
treatment should be. In the same sense, the way to save a
person’s life is also to “do something.” Those “somethings”

include putting that information (that the person is in trouble
with himself) into the stream of communication, letting others
know about it, breaking what could be a fatal secret, talking to the
person, talking to others, preferring help, getting loved ones
interested and responsive, creating action around the person,
showing response, indicating concern, and, if possible, offering
love.
I conclude with an example—actually a composite of several

actual highly suicidal persons I have known.
Case Study
A young woman in her 20s, a nurse at the hospital where I

worked, asked me pleadingly if I would see her teenage sister
whom she considered to be highly suicidal. The attractive,

younger woman—agitated and tearful but coherent—told me (in
the privacy of my office) that she was single, pregnant and
determined to kill herself. She showed me a small automatic

pistol she had in her purse. Her being pregnant was such a mortal
shame to her, combined with strong feelings of rage and guilt, that
she simply could not “bear to live” (or live to bear?). Suicide was
the only alternative, and shooting herself was the only way to do
it. Either she had to be unpregnant (the way she was before she
conceived) or she had to be dead.
I did several things. For one, I took out a sheet of paper and—
to begin to “widen her blinders”—said something like, “Now, let’s
see: You could have an abortion here locally.” ("I couldn’t do

that.”) It is precisely the “can'ts” and the “won’ts” and “have tos”
and “nevers” and “always” and “onlys” that are to be negotiated in

psychotherapy. “You could go away and have an abortion.” (“I
couldn’t do that.”) “You could bring the baby to term and keep the
baby.” (“I couldn’t do that.”) “You could have the baby and adopt
it out.” (“I couldn’t do that.”) “We could get in touch with the
young man involved.” (“I couldn’t do that.”) “We could involve the
help of your parents.” (“I couldn’t do that.”) and “You can always
commit suicide, but there is obviously no need to do that today.”
(No response.) “Now first, let me take that gun, and then let’s look
at this list and rank them in order and see what their advantages,
disadvantages and implications are, remembering that none of
them may be perfect.”
The very making of this list, my fairly calm and nonhortatory

and nonjudgmental approach already had a calming influence on
her. Within 15 minutes her lethality had begun to deescalate. She

actually rank-ordered the list, commenting negatively on each
item, but what was of critical importance was that suicide, which I
included in the total realistic list, was now ranked third—no

longer first or second.
She decided that she would, reluctantly, want to talk to the
father of her child. Not only had they never discussed the “issue,”
but he did not even know about it. But there was a formidable
obstacle: He lived in another city, almost across the country and
that involved (what seemed to be a big item in the patient's mind)
a long distance call. It was a matter of literally seconds to
ascertain the area code from the long distance operator, to obtain
his telephone number from information, and then—obviously
with some trepidation and keen ambivalence for her—to dial his
number (at university expense), with the support of my presence

to speak to him directly.
The point is not how the issue was practically resolved,
without an excessive number of deep or shallow interpretations

as to why she permitted herself to become pregnant and other
aspects of her relationships with men, etc. What is important is
that it was possible to achieve the assignment of that day: to

lower her lethality.
In general, any suicidal state is characterized by its transient

quality, its pervasive ambivalence, and its dyadic nature.
Psychiatrists and other health professionals are well advised to
minimize, if not totally to disregard, those probably well-

intentioned but shrill writings in this field which naively speak of
an individual’s “right to commit suicide”—a right which, in
actuality, cannot be denied—as though the suicidal person were a
chronic univalently self-destructive hermit.
A number of special features in the management of a highly
lethal patient can be mentioned. Some of these special therapeutic

stratagems or orientations with a highly lethal patient attend to
or reflect the transient, ambivalent and dyadic aspects of almost

all suicidal acts.
1. A continuous, preferably daily, monitoring of the patient’s
lethality rating.
2. An active out-reach; being willing to deal with some of the

reality problems of the patient openly, where
advisable; giving direction (sans exhortation) to the
patient; actively taking the side of life. It relates to
befriending and caring.
3. Use of community resources including employment,

Veterans Administration (when applicable), social
agencies, and psychiatric social work assistance.
4. Consultation. There is almost no instance in a psychiatrist’s

professional life when consultation with a peer is as
important as when he is dealing with a highly suicidal
patient. The items to be discussed might include the
therapist’s treatment of the case; his own feelings of
frustration, helplessness or even anger; his
countertransference reactions generally; the
advisability of hospitalization for the patient, etc.
5. Hospitalization. Hospitalization is always a complicating

event in the treatment of a suicidal patient but it should
not, on those grounds, be eschewed. Obviously, the
quality of care—from doctors, nurses and attendants—
is crucial. Stoller (1), discussing one of his complex
long-range cases, says: “. . . there were several other
factors without which the therapy might not have
succeeded. First, the hospital. The patient’s life could
not have been saved if a hospital had not been
immediately available and a few of the personnel
familiar with me and the patient. (Italics added).
6. Transference. As in almost no other situation and at almost
no other time, the successful treatment of a highly
suicidal person depends heavily on the transference.
The therapist can be active, show his personal concern,
increase the frequency of the sessions, invoke the
"magic” of the unique therapist-patient relationship, be
less of a tabula rasa, give “transfusions” of (realistic)
hope and succorance. In a figurative sense, I believe
that Eros can work wonders against Thanatos.
7. The involvement of significant others. Suicide is most often

a highly charged dyadic crisis. It follows from this that
the therapist, unlike his usual practice of dealing almost
exclusively with his patient (and even fending off the
spouse, the lover, parents, grown children), should
consider the advisability of working directly with the
significant other. For example, if the individual is male
and married, it is important to meet his wife. The
therapist must assess whether, in fact, she is
suicidogenic; whether they ought to be separated;
whether there are misunderstandings which the
therapist can help resolve; or whether she is insightful
and concerned and can be used by the therapist as his
ally and co-therapist. The same is true for homosexual
lovers, for patient and parent, etc. It is not suggested
that the significant other be seen as often as the patient
is seen, but that other real people in the suicidal
patient’s life be directly involved and, at the minimum,
their role as hinderer or helper in the treatment
process be assessed.
8. Careful modification of the usual canons of confidentiality.

Admittedly, this is a touchy and complicated point, but
the therapist should not ally himself with death.
Statements given during the therapy session relating to
the patient’s overt suicidal (or homicidal) plans
obviously cannot be treated as a “secret” between two
collusive partners. In the previous example of the
patient who opened her purse and showed me a small
automatic pistol with which she said she was going,
that day, to kill herself, two obvious interpretations
would be that she obviously wanted me to take the
weapon from her, or that she was threatening me In
any event, I told her that she could not leave my office
with the gun and insisted that she hand her purse to
me. She countered by saying that I had abrogated the
basic rule of therapy, namely that she could tell me
anything. I pointed out that “anything” did not mean
committing suicide and that she must know that I could
not be a partner in that kind of enterprise. For a
moment she seemed angered and then relieved; she
gave me the gun. The rule is to “defuse” the potentially
lethal situation. To have left her with a loaded gun
would also leave her with a latent message.
9. Limitation of one’s own practice to a very few highly lethal

patients. It is possible to see a fairly large number of
moderate and low-rated lethal patients in one’s patient
load, but one or two highly lethal patients seem to be
the superhuman limit for most therapists at any given
time. Such patients demand a great deal of investment
of psychic energy and one must beware of spreading
oneself loo thin in his or her own professional life.
Working with highly suicidal persons borrows from the goals

of crisis intervention: not to take on and ameliorate the
individual’s entire personality structure and to cure all the
neuroses, but simply to keep him or her alive. That is the sine qua
non without which all the other expert psychotherapists
represented in this volume could not function.
REFERENCE
1. Stoller, R. J. Splitting. New York: Quadrangle Books, 1973.
BIBLIOGRAPHY
Below I have listed a half-dozen references of my own.
Shneidman, E. S. Lethality and perturbation as precursors of suicide in a gifted group.

Life-Threatening Behavior, 1971, 1:23-45.
Shneidman, E. S. Suicide. In: Encyclopaedia Britannica, 1973 edition, Vol. 21, 383 et seq
to 385.
Shneidman, E. S. Suicide notes reconsidered. Psychiatry, 1973, 36:379-394.
Shneidman, E. S. Psychiatric emergencies: Suicide. In: A. M. Freedman, H. I. Kaplan, and

B. J. Sadock (Eds.), Comprehensive Textbook of Psychiatry, Second Edition.
Baltimore: Williams & Wilkins, 1975. Vol. II, Chap. 29, pp. 1774-1784.
Shneidman, E. S. (Ed.). Suicidology: Contemporary Developments. New York: Grune &

Stratton, 1975.
Shneidman, E. S. Some aspects of psychotherapy with dying persons. In: C. A. Garfield

(Ed.), Psychosocial Aspects of Terminal Patient Care. New York: McGraw-Hill
Book Co., 1978.
17
Psychotherapy with the Elderly
Ralph J. Kahana, M.D.
What is special about psychotherapeutic work with older

people? When we try to answer this question we may err in two
opposite ways: by equating aging with extreme, debilitated or
senile old age, thus accentuating the differences from earlier

years, but taking a narrow, pessimistic view of the nature and
value of therapy; or by overemphasizing the psychological
similarities between older and younger adults and, in effect,

denying and failing to take into account the impact of aging. These
common errors have a history.
Until recently, interest in the mental and emotional problems

of later life centered almost exclusively upon the most disabled
segment of older people, the confused, demented, psychotic,
institutionalized, physically ill or dying. Excluded was the larger,

more vigorous segment of aging persons. Contributions to
geriatric psychotherapy tended to be limited to approaches to the
special problems of the disabled minority of elders, and they were

often put forth as if they applied generally to the entire
population of older people. On the other hand, dynamic
psychotherapy, growing out of psychoanalysis, found its

application and sources of knowledge first among young adults
and then among children and adolescents. As interest extended to
encompass the later years it was logical to stress continuities in

psychological development over the entire life span. Early
psychoanalytic discoveries pointed to the lasting importance of
formative experiences in infancy and childhood. The excitement

of these findings led to overvaluation of the idea that personality
is established in all its essentials during childhood, so that later
development merely repeats and reworks these foundations. It

followed that the inner life of older people was only the
continuation of post-adolescent existence without essential
differences in normal personality or psychopathology except for

organic brain diseases. The unique qualities of older persons and
the special experiences and problems of later life were neglected.
Difficulties in Applying Psychotherapy with Other People
Although today psychoanalytic psychotherapy is an
established method for younger adults and even children and

adolescents, when we try to apply it to aging or elderly patients
we encounter special difficulties in defining when a person is
“old,” in approaching the topic objectively, in gauging whether

patients are flexible enough to benefit from treatment, and in
making useful generalizations.
While psychological aging, like physical aging, is correlated
with adaptability, it defies simple definition. Although related to
chronological age, senescence of body and brain, and

accumulation of experience, aging cannot be equated with any of
these. An 80-year-old, despite physical infirmities, may be more
responsive, adaptive and forward-looking than a healthy 50-year-

old. The only clearly established age-related change in the
functioning of the central nervous system in the healthy older
person is a slowing down of perceptual processes, with
prolongation of the time spent in recovery between mental or
physical actions that call for accurate perception and adjustment

to changing stimuli; this decline is not uniform or specifically
predictable. Some people are wise and experienced when quite
young, while others remain relatively naive and simple through

their late years. The complexity and ambiguity in defining “old”
facilitate the errors of denying aging or equating it with senility.
This may impede diagnosis of manifestations of illness which vary
with age, or lead to misunderstanding of the motives, values and

adaptive tasks of the older patient or to setting of too ambitious
or too limited therapeutic goals.
A vigorous woman of 79, still able to run her own business,

was observed to distinguish herself from her contemporaries and
even somewhat younger friends who showed diminished energy,
dwelled upon their physical illnesses and complaints, or

displayed an accentuation of characterological stinginess, as if
they were the old people. Thus, she agreed implicitly with those
who define old age as physical infirmity and she had a pejorative
attitude toward old age.
Disparagement and denial of aging are prevalent in our
youth-oriented culture where youthful appearance, activity and

achievement are overvalued. When aging is recognized, it may be
pictured as unduly bleak, or it may be caricatured or treated with
patronizing praise. Psychotherapists may unconsciously reflect

gerontophobia and prejudice against older people through
stereotyped attitudes in which the aging are regarded a priori as
burdensome, demented, psychologically rigid or untreatable (1).

A number of common circumstances, especially with the
debilitated older group, play a part in evoking and rationalizing

these attitudes and in inducing countertransferences. Older
patients frequently show increased needs for encouragement,
appreciation, and even admiration. They express depressive
helplessness, or demand advice, assistance and magical help, thus

placing particular strain upon their therapists. Unpleasant
regressive character manifestations may appear or intensify in
later life. Often, attention must be paid to the needs and

sometimes interfering behavior of family members. There may be
difficulties in communication, as with patients who show the

early indications of organic brain disease. Younger therapists may
have insufficient empathy with the perspective, physical
limitations and traumatic experiences of older persons. They
must draw upon whatever analogous personal events are
available to them, such as periods of intensified physical and

mental change and development, illnesses, family crises, raising
their own children and, especially, dealing with their own aging
parents.
Regarding psychoanalysis, the most intensive form of

psychological treatment, analysts, following Freud (2, 3, 4), have
been reluctant to treat persons over 45 by classical

psychoanalysis. Even though his own later discoveries regarding
narcissism and the structural point of view (id, ego and superego)
increased the scope and the effectiveness of analysis, and despite

the cautiously optimistic findings of other pioneering analysts,
Freud apparently never revised his early opinion that by age 50

the mental processes are too rigid for favorable treatment results.
As we know, Freud himself made major revisions and additions to
his theories when he was near 70 and continued his scientific
contributions into his 80’s. His view may have impeded study of
the psychodynamics of aging and application of dynamic
psychotherapy in older people. Today many psychotherapists
would agree with Berezin (5) that rigidity and flexibility are not
functions of age but rather of personality structure throughout
life. The impact of Freud’s pessimism was mitigated by the initial

successes of other analysts, such as Abraham (6) and Jelliffe (7). It
was their point of view that chronological age did not of necessity
involve deterioration of those intellectual and emotional
capacities required for analysis, and hence some older persons
could successfully undergo orthodox treatment. Kaufman (8)

applied psychoanalytic principles in the treatment of two
hospitalized patients with psychotic depressions, aged 56 and 60,

achieving significant improvement. More recently, Hanna Segal
(9) reported the 18-month treatment of a man in his late 70's
with a chronic psychotic state of depression, paranoia and

hypochondriasis, unresponsive to electroconvulsive therapy; and
Anne-Marie Sandler (10) described the analysis of a man with
narcissistic oversensitivity, treated between the ages of 58 and

65. These latter cases attest further to the possibilities for
analysis, but also to the difficulties and limitations.
In a useful review of the literature on psychotherapy with

geriatric patients, Rechtschallen (11) evaluated psychoanalytic
studies as well as some other contributions ranging from
idiosyncratic efforts of talented therapists through Jungian,
Meyerian, general psychiatric and social casework approaches. He

noted that psychotherapy with the aged had a slow, pessimistic
beginning followed by a wave of optimism and then a more
considered attitude. Although almost 20 years have passed, the

papers reviewed have much to offer that is useful today.
Starting in the 1940s, Grotjahn, Alexander, G. Lawton, J.

Weinberg, G. J. Wayne, M. H. Hollender, and Meerloo used
modified analytic approaches which stressed support and the
active participation of the therapist. For example, Wayne (12, 13)
suggested that the treatment begin with the elicitation of enough
historical material to permit a psychodynamic formulation and an

understanding of transference; that limited goals be set; and that
a focus be kept upon a current problem that the patient
consciously recognizes. He also made the following points: The

patient should be given a readily perceivable part in solving his
own problems; without deliberately avoiding material, no
attempt should be made to rekindle old conflicts; the therapist

should be active in providing guidance, reassurance and
environmental manipulation; some educational techniques may
be used, such as discussions of the cultural attitudes toward the

elderly; scheduling should be flexible, with an effort to
progressively decrease the number of weekly sessions; therapy
need not be finally terminated; and tranquility, the goal of old age
living, can be accepted and expressed tacitly in the therapeutic
atmosphere. One may raise all sorts of questions, not easily
resolved, about this advice: What is the nature of transferences in

older people? Who or what limits the goals and how is this done?
What is “activity” on the therapist’s part? Is there a unitary “goal”
of old age living? Yet, from a sufficiently broad and general

standpoint, these and similar technical recommendations seem
clear and sensible enough. But to which patient s and in which
conditions do they apply?
It is difficult to make accurate generalizations about older
persons as a group, since they present the greatest diversity and
individuality in life experiences, personality styles and current

circumstances. In order to help clarify the aims and technical
approaches in psychotherapy of older people, and at risk of

making another procrustean overgeneralization, the distinction
will be made between those past middle life who ate aging and
the smaller group of debilitated aged. There are, of course, many

gradations and various combinations between these polarized
extremes. Those in the group of the aging are experiencing:
physical changes in appearance, attractiveness, strength, agility

and reaction time; physical illnesses which are manageable rather
than critical; some fluctuation and recession of instinctual drives;
conflict over and reassessment of the balance between ideal

aspirations and actual achievement, whether in personal
development, social relationships, community activities, work or
creative efforts; the prospect of retirement from work; awareness
of limitation of time and of the eventual reality of dying; the

deaths of people who are significant to them; and changes in their
relationships with spouses, children, friends and co-workers.
An intermediate group of people experience states of crisis

stemming from severe physical and mental illnesses, losses by
death, divorce or radical change in personal relationships, or

failures in their work.
The debilitated aged show in varying combinations and
degrees: the limiting and burdening effects of chronic, multiple or
dangerous illnesses, with diminished functional reserves of organ
systems; manifestations of brain damage; constriction of

activities; inability to maintain themselves without considerable
assistance from their families, community resources or
institutional facilities; a dominance of pregenital drives; and the

depletion of stimulation, affection and satisfaction, the recurrence
of grief reactions, and the strengthening of defenses against
painful affects resulting from repeated, cumulative losses of

significant people.
If we distinguish these groups, we can see that much of the
literature on psychotherapy with older people appears directed

to the debilitated group. This is explicit in Alvin Goldfarb’s (14)
special application of psychoanalytic thinking in brief therapy for
the very old, mainly braindamaged, residents of a home for the

aged. His major point of departure was the overdependence of the
aged, which he attributed to somatic changes, intellectual

impairment, and socioeconomic and personal losses. Instead of
responding as previous writers had with discouragement or
promoting acceptance of dependency and providing dependent

gratification, he attempted to utilize the patient’s misperception
of the therapist as a powerful parental authority. This illusion
enables gratification of needs for affection, respect, protection

and punishment. Patients were seen for five to 15 minutes weekly
or less frequently. With those who have never been able to accept
a dependent position he attempted, e.g. by granting small
concessions, to create the feeling of having triumphed and gained

control over the “parent”/therapist.
The kind of behavior that Goldfarb refers to was seen in a
married woman in her mid 70’s with an agitated depression,

hypochondriasis and a definite degree of loss of recent memory.
She came to the psychiatrist’s office accompanied by family
members, usually by her husband and one or more children.

Initially fearful of the interviews and urgently requesting relief,
she cast her younger therapist in the role of a savior or at least a
superior court judge. He demurred and cautioned her

overvaluation but could not entirely escape this omnipotent role.
In a later session, when she felt better, she clasped him in her
arms, said that she loved him—teasing that he mustn't tell his
wife—and at the end of the session gave him a kiss. He was, of
course, pleased with her improvement and he accepted her
positive expression as he might from any affectionate older

relative.
The Aims and Techniques of Individual Psychotherapy
The purpose of any treatment is, of course, to relieve

suffering, to allow normal functioning and, if possible, to “cure”
and prevent difficulties. With these goals in mind, in

psychotherapy we may place emphasis upon one of three
intermediate treatment aims or strategies. We may try to bring
about structural change, a further development and integration of
drive derivatives, ego and superego functions, the self and other
components of the personality. Alternatively, we seek to reinstate

the best level of functioning that the patient has ever attained. Or
we direct our attention primarily to assisting the patient’s
responsive and caretaking environment, usually the family. As

shown by Grete and Edward Bibring (15, 16), our techniques for
accomplishing these aims include the promoting of insight,
adaptive intervention (manipulation), and basic supportive

methods. Insight occurs at two levels. The form employed most
often is clarification, the giving of understanding of what is
preconscious, that is, “fit to be conscious” but outside of

immediate attention and comprehension. The other form of
insight involves bringing to consciousness well-defended
unconscious mental contents. The possibility of achieving insight

depends upon the patient’s tolerating an optimum intensity of
conscious exposure to distressing conflicts that were
preconscious or unconscious.
Gradual increase in self awareness was observed in a woman
treated in her late 50’s and early 60’s for depression precipitated
by grief at the death of her aged mother (17). Mrs. A’s depression
was marked by sadness, psychomotor retardation, and excessive
concern with the distress that her condition produced in her

family members. When most depressed, she repeatedly asked for
reassurance and wanted change to occur without her
understanding anything. When depression lifted, persistent
clarification of her covered-over feelings sometimes led to

appropriate weeping and the recall of events and emotions,
particularly during the period of her mother’s terminal illness.

Her mother had died of a slow-growing gastrointestinal tumor
after a two-and-one-half-year terminal illness in which she had
little pain, but weakened, lost weight, and went through several
crises. She lived by herself in a city 400 miles away, and although
a married son lived in the same town, it was the patient, her only
daughter, who assumed the burden of looking after her. Mrs. A,

who had not been away from her husband for more than a day in
over 30 years, spent long periods with her mother and observed
her deterioration. When she returned home she constantly

expected a telephone call announcing a further crisis. When the
question of palliative surgery came up, she felt that the decision
was placed in her lap even though another brother, living 2000
miles away from her, was a physician.
It became apparent that her mother had been phobic,
overdependent and self-sacrificing. Moreover, the patient herself
had struggled since childhood against similar fears, dependent

feelings and masochistic tendencies. She spoke of having been
somewhat depressed for many years. She dated this to the time
when one of her children developed a school phobia, reactivating
conflictual, repressed memories of her own struggle with her
phobic mother who had tried to keep her at home. Psychotherapy,
assisted by antidepressant medication, was usually scheduled at
weekly intervals and was intermittent. The patient came when

distressed and at times, later on, when she wanted to work on her
problems. Movement in therapy proceeded as follows.
She recalled more of the events preceding her mother’s

death, particularly the deaths of two other close relatives, one by
suicide. Also, two of the patient’s grown children had experienced
significant emotional crises then. Her awareness of the

precipitating causes of recurrent depressive episodes increased.
These causes included experiences which reminded her of her
mother, anniversaries, the prospect of vacations and other

separations, the deaths of relatives and acquaintances, and,
increasingly, her children’s problems and her husband’s

approaching retirement. Clearly, she had difficulty in achieving
objectivity based on sufficient psychological differentiation from
her children. She recognized that she was oversensitive,
particularly to boastful and overbearing attitudes of others. This

became focused upon important family members. Eventually she
experienced strong resentment of the humble and sacrificing role
assumed by her husband and, she felt, forced upon her as well in
relation to his family. As she expressed these feelings, over a
period of time, she gained courage and became purposefully and

appropriately more assertive in these family relationships. She
received added support from one of her children who
coincidentally had also started therapy. Her husband made an
effort to be more understanding and she became more perceptive
of his depressive symptoms. Her intermittent depressions were

painful, but her affective expressions were freer. When well, she
felt better than she had in years, her imaginative community

activities blossomed, and she renewed old friendships. Her
transference was generally positive and her husband was the one
who expressed displeasure, at times quite strongly, with the long,

slow course of treatment.
In this case a childhood neurosis, phobic and depressive, was
covered over by reaction formations, though at the price of
overdependence and masochistic attitudes. Her defenses broke

down under the impact of problems of aging, i.e., her mother’s
death, the independence of her children, and her husband’s

retirement. A new equilibrium had to be found based upon better
resolution of her early conflicts. Prevention of the recurrence of
depression was one of the treatment goals.
Where insight plays a major role in achieving structural

improvement, therapeutic manipulation or adaptive intervention
(15, 16) is the technical principle most useful in reinstatement of

optimum functioning within the existing personality structure.
Particularly suitable for brief therapy of psychological
emergencies and crises and for medical psychotherapy, it utilizes

the patient’s defenses and adaptive methods, enabling him to find
and follow ways in which he can function more satisfactorily and
gain increasing security without having to go through a major
psychological reorganization. Goldfarb’s approach, noted above,
can be characterized as a form of adaptive intervention.
In the case of Mr. B, a 60-year-old, single man seen in a

surgical ward consultation, we can see how both his character
type and his age characteristics were taken into account in a

therapeutic intervention (18). He was referred for psychiatric
evaluation because he repeatedly postponed necessary surgical
treatment. Almost seven months before, on a private surgical

service, he had been operated for gallstones which obstructed his
bile duct. The complication of acute pancreatitis necessitated
drainage of an abdominal abscess. Because of his financial

situation in the face of his long illness, the patient was transferred
to the ward service. Subsequently, a third operation for revision
of the sinus was performed. Although it appeared that a fourth

procedure to assist drainage would shorten his hospital stay, he
had become anxious and talked of signing out of the hospital. The
patient had discussed this important decision with his sister who
lived in another city. Greatly concerned, she had contacted his
private surgeon and also the chief of surgery. This added to the
house doctors’ determination to treat him very successfully; the
difficulties which they encountered then led to feelings of
frustration and to definite tension between them and their

patient.
When interviewed, Mr. B was friendly and polite, had a very
neat appearance, and showed great consideration of others on the
ward. He knew that he was upset and thought that the

psychiatrist might help him to feel better. As he spoke of his grave
fears about the proposed operation and then described his life
and work, a picture of him emerged as a steady, reliable,

responsible, planful, conscientious person, who approached
decisions gradually. He had run his own business for many years
with great resiliency in the face of setbacks, and had then taken
over direction of a section of a larger enterprise, strongly
identifying himself with the management. His positive

appreciation of his former private surgeon contrasted with his
feeling that the younger ward physicians were inconsiderate and
“walked away’’ from him at rounds. The psychiatric discussion

and formulation centered upon the patient’s compulsive
personality structure and his seniority.
It was emphasized to the surgical staff that Mr. B felt
disappointed and anxious because of the stress of his prolonged

illness and reacted to pressure with indecisiveness and obstinacy,
characteristic for the compulsive personality under stress.
Accordingly, it was important to approach him in such a way as to

permit him to use his careful, planful method of proceeding in
order to deal with his anxieties adequately. He should not be
pushed but rather be allowed further time to make up his mind

about the operation. His questions were to be answered carefully,
thoroughly, as often as necessary, and as unhurriedly as possible.
With regard to his seniority and self-esteem, it was apparent that

his transfer to the ward service had deprived him of the direct
care of his private surgeon and he had found it difficult to

establish a close relationship with the ward “management” in his
accustomed manner. To correct this, it was to be suggested to the
patient that if he felt anyone avoided answering his questions he

did not have to accept this as final. In such circumstances he could
make an appointment with the doctor to see him at a convenient
time, e.g., after the rounds were completed. The doctors would try
to establish clearly that the patient took an appropriate amount of
responsibility in accepting or rejecting surgical
recommendations.
As it turned out, following discussion along these lines

between the consultant, the surgeons, the patient and his sister,
Mr. B decided to permit the operation. Afterwards, he expressed
appreciation of the talks with the psychiatrist and the surgeons

because they had shown him how he could be strong. He was now
functioning as an active, self-disciplined, effective compulsive
type of personality, utilizing his rational and systematic abilities.

The only clear elements of clarification and support (directed to
his self-esteem) were expressed in acknowledging to him that his

present anxiety at the prospect of a relatively minor surgical
procedure could be understood in light of the strain and
discomfort of the long illness (which he had actually borne in a
good spirit).
The method of basic support is sometimes denigrated as
being limited to a kind of unskilled, mindless handholding,

demeaning to both holder and holdee—as if it required little
therapeutic judgment, and as if one could not have a legitimate

need to have one's hand held. In the hope of countering this
prejudice, my illustration of this technique concerns a highly
intelligent and insightful university professor with a national

reputation in his field. He had been married for many years and
was pleased with the way his children had turned out.
At 65, Professor C was facing the pressure of imposed partial
retirement, with loss of the security of tenure, the recent

appearance of symptoms suspected to be heart disease, and his
wife’s anxiety in response to these developments. He questioned

whether her current anxieties and some related tensions between
them were at least partly his fault. Both he and his wife had
benefitted from psychotherapy directed toward structural change
in the past, before middle age. Interestingly, he had recently
discontinued psychotherapy after a brief trial, because he felt his

former therapist had been too talkative and too supportive, that
is, too directive. He was concerned that his cardiologist tended to
see the diagnostic possibilities and treatment indications in an all

or nothing fashion. His impressions were accurate but also
reflected his personal needs and sensitivities. He understood that
these feelings were related to his experience with his parents. His
father had set an example of effective, professional, hard work,
had encouraged his talent, had given him reams of advice and
pressured him to be outstanding, was very stern, and had
episodes of rage. The patient had identified strongly with his
father’s ways and values but reacted to his pressure at times by

becoming stubbornly overcautious. His relationship with his
mother had been very close and loving, and he took care of her in
her late years until her death. This attitude of responsibility was
continued with his young and admiring wife.
Although he did not specify how he thought psychotherapy
could help, it was clear that advice was the last thing he needed.
He utilized the sessions to air his concerns and get his bearings.
One of the leading issues was the challenge to his self-esteem
posed by the threats of illness (he had been quite athletic) and
financial insecurity. He had strong feelings about the
administrative opposition he encountered at the university where

he believed that his contribution, which represented a special
tradition of teaching in his discipline, was not well recognized.
Here his insight and mature strength of personality proved useful.

He said that he had recognized long ago that he was not the most
celebrated living individual in his field. He was aware that when
the urge to become famous was compelling he tended to

overwork and to criticize himself. This awareness helped him to
ease up and to regain his objectivity. In relatively few sessions he
outlined his problems, expressed many feelings, remastered his
revived conflicts, and then dealt with the realistic pressure that
he faced. The therapist responded by indicating his
understanding and trying to understand more, and by

acknowledging the patient’s expressions of feelings, attempted
solutions, and frustrations and gains. These were supportive
elements, gaining their effectiveness largely from a maternal

transference. The therapist responded explicitly to Professor C’s
competence and experience, evident not only in his professional
activities but in many of the ways in which he managed his life.

This was an adaptive intervention. The therapist clarified issues
which seemed most important, such as those bearing on the
patient’s self-esteem. Finally, the therapist accepted certain

limitations of their therapeutic effort, for example, when his
tension with his wife required joint sessions which were
undertaken with his wife’s therapist. It is significant that, despite
persisting conflicts, the patient saw himself appropriately within

his age group with regard to issues of achievement and prestige.
He told a charming anecdote in which one distinguished man
reminds another that, unlike younger people, the latter no longer

has to struggle to establish his position in the world.
A Comparison of Aging and Debilitated Patients
Among 16 patients treated in my practice, 11 women and
five men ranging in age from late middle life to mid 70’s, half were
in the aging group, three intermediate, and five in the debilitated
aged category. None was permanently institutionalized in

hospitals, nursing homes or special residences. Almost all
suffered some form of depression. In the aging group depression

ranged from reactive (neurotic) to psychotic and paranoid. The
intermediate group included one psychotic, paranoid depression
and one of moderate severity, between neurosis and psychosis.

All five of the debilitated patients had depressions, in two cases
associated with senile brain disease. Three of these were anaclitic
depressions associated with depletion of functions and

satisfactions, while one was an agitated depression and another a
deepening of chronic depression. With regard to diagnoses other
than depression, two patients in the aging group had states of

tension, another proved to have normal grief and a fourth was
phobic. One of the patients in the intermediate category
presented the surgical management problem cited above.
The precipitating causes of these problems were mainly

personal losses and physical disorders. The aging patients were
reacting to losses of mother, husband or brother, to physical or
mental illness of a close relative, or to retirement from work. In

the intermediate group two had physical illnesses and one was
widowed. Brain damage and physical aging were the leading

precipitants among the debilitated, followed by illness of a close
relative, death of a spouse or retirement from work. A range of
personality types was found in all groups, but in this small series
the only hysterical types were among the aging, while the
debilitated showed more oral behavior.
In keeping with the findings of others, structural change as

the principal therapeutic aim was found only in the aging group.
The aim of reinstatement of optimum functioning was important

in all three groups and was the only aim in the intermediate or
crisis sample. Offering basic support was a major aim in the
treatment of the debilitated, but it was also employed

significantly with the aging. Assistance to and through the family
was a treatment aim in most of the debilitated patients.
Prevention of future suffering, maladaptation or breakdown was

a principal consideration in the aging and intermediate groups in
relation to widowhood, preparation for retirement, the regression

promoting threat of physical illness, and changes in a marital
relationship. Regarding duration of treatment, there was no clear
pattern among the three categories, whether brief (under three
months), average (up to three years) or long-term (over three

years). I was surprised to find that half of my aging patients were
in the brief category and that most of the patients in the
debilitated group were seen for an average length of time. In the

aging group, one of my long-term patients had subsequent
unterminated maintenance therapy at monthly intervals, while

one of the intermediate category patients was treated for an
average duration and then seen in follow-up twice a year until her
death 15 years later.
To recapitulate and highlight these observations according to
each group, psychotherapy of the aging was aimed at structural
change, restitution of personality functioning or basic support.

These patients had neurotic or psychotic depressions, other
neuroses or adjustment reactions, often precipitated by personal
losses or retirement. They represented a full range of personality

types. Prevention of future disturbance was an important
consideration. In the intermediate group, the aim of treatment
was restitution of optimum functioning. Illnesses were of crisis
proportions in reaction to physical diseases or personal losses,
and prevention was a common goal. The debilitated aged

responded to measures of basic support for treatment of anaclitic
depressions set off by brain damage, physical aging or multiple
personal losses. They often showed oral personality traits. Their

families had a significant role in their treatment.
The Management of Crises
Zinberg (19) observed how frequently a psychiatric referral

of an older patient involved an emergency. Psychiatric
emergencies at any age may require considerable involvement
with members of the patient’s family, time spent in telephoning,

and pressures for immediate help, with insight taking second
place to dealing with problems of the moment. The number of
emergencies one sees in practice is, naturally, a function of where

and how one practices. However, it is my impression that these
circumstances often prevail with older people and especially with
the debilitated aged.
The fundamental therapeutic injunctions to safeguard life

and functioning, and to do no harm, as they are followed in
geriatric psychiatry, have certain implications which are

highlighted in crisis situations. On the one hand, emergencies,
whether of confusion, anxious agitation, incipient or acute
psychosis, or suicidal despair, call for rapid, concentrated

intervention. At the same time, the limited adaptability, poor
tolerance of painful affects, and potential for ego regression
shown by elderly, and especially by debilitated patients, dictate

that we intervene in ways that are the least disruptive of the
individual's familiar life-style. The threat of suicide requires, of

course, stringent protective measures—we are reminded of the
high incidence of completed suicide in older men. States of
confusion call for thorough medical investigation, often in the
hospital. Acute psychoses may only be manageable in an

institution. Otherwise, if possible, we try to keep the patient at
home and treat him or her in the office. We help mobilize the
support of close relatives whom the patient trusts, and we

communicate and present ourselves in ways that are familiar and
understandable to the patient.
A 75-year-old woman who became confused after an

operation for cataracts was managed entirely by restructuring
her environment. It was her first hospitalization, and separation
from her home and family played a major role in her
postoperative reaction. The surgeon had gained her cooperation

by a preparatory discussion of the procedure, and he prevented
more serious delirium by avoiding any blindfolding. When she
became frightened and noisy she was moved to a private room

away from gravely ill patients. A small night light and side rails on
her bed were provided. Restraints were not used. Her daughters
took turns staying with her during the day and sleeping
overnight, while other visitors were restricted. The patient had
been a mildly anxious, slightly overdevoted mother and now her
children, in turn, found it easy to be protective, even a little

overprotective, toward her. Under this regime she calmed down,
believing that she was in her eldest daughter’s home. She was
discharged with a clearing sensorium after the minimum of

hospitalization.
The principle of keeping interventions to a necessary

minimum has its parallel at the physiological level where
medications for anxiety and mood disorders are prescribed
cautiously, in small initial doses, while we monitor carefully for

any side effects to which these older patients may be sensitive.
Psychotherapy, resting upon the patient’s consent and
collaboration, is the least interfering form of treatment. The use of

psychotherapy is almost indispensable, even when the principal
treatment is medication or electroconvulsive therapy. At a
minimum, it constitutes the basic support necessary to have
patients accept and continue with other methods. When

communication with the patient is severely limited due to brain
disorder or psychosis, then psychologically correct measures of

environmental support are necessary, as we saw in the preceding
example.
The combination of drug treatment and psychotherapy is
often employed in the management of emergencies. A 65-year-old

woman with an intense, worsening depression had the kind of
symptoms that often respond to medication. She suffered from
insomnia, tenseness and lack of enjoyment, was slowed down in

speech and action, and felt ashamed of her condition. These
complaints had begun a year before and had become more severe.
Despite all this she was well-groomed and attractive in
appearance. She lacked insight into any predisposing or
precipitating causes of her depression. For example, she did not
connect it with the death of her mother three years before.

Mother, she said, was a nice person, who died in her old age after
an illness of a few days, and “I got over my grief.” Referral came
through a former therapist of her oldest son, and this son

accompanied her on the first two visits. Her husband, in his late
70's and retired from work, came in with her each time. She had
had a thorough medical workup and had taken on prescription a
number of standard antidepressants and tranquilizers. Despite
the apparently correct indications for these medications, they had
not brought relief. The patient was seen six times in all, twice in
the first week, then at two-week and finally one month intervals,
with a telephone follow-up.
In the interviews she quickly expressed an intense
preoccupation with an elderly woman relative. They had had a

misunderstanding dating back several years over a wedding gift
given by the patient to this relative’s grandson. The patient had
meant to send a check but had accidentally mailed an empty

envelope, and had then corrected this error. The relative’s
response, as the patient saw it, was to avoid attending the funeral
of the patient’s mother. Also, she had not sent gifts when the
patient’s grandchildren were born. The patient felt terribly guilty
that she had, in turn, reacted by avoiding a baby shower for this
relative’s great grandson. Subsequent efforts by the patient at
reconciliation had been rebuffed. Moreover, this woman’s
daughter, in her 40's and recently widowed, had also refused to
see her. The patient could not answer why this troubled
relationship was having such a drastic, lasting impact upon her.
She had grown up in a strictly regulated home as part of a

small, stable ethnic community. She believed that, of all her
siblings, she had been closest to her mother. Her marriage at 17
was arranged by a matchmaker. For the next 15 years her

mother-in-law had lived out her life with her. The patient’s
existence had centered around raising her sons, visits with
nearby relatives, attending a women’s group of her church, and
enjoying some handicrafts. Her mother, in the same city, was very
demanding of attention by her children. The patient remarked

that she has tried not to be this way with her children. However, it
is lonely without a daughter. Her oldest son’s wife is rather
independent and the patient has to telephone before she goes

over.
At 15, when her mother became ill and unable to work
outside the home, the patient left school to take a job in a factory
where she contracted a severe case of skin disorder, an eczema
that involved her hands and was believed due to contact with an
industrial chemical. After her last son was born, she had two
miscarriages and then, following her doctor’s recommendation,
had tubal ligations. This had saddened her; she wondered if one
of the miscarriages had been a daughter. Completing the relevant

medical history, at 38 she had had a previous depression but
snapped out of it after two shock treatments. It was not clear

whether this was related to the loss of pregnancies and the
sterilization.
At the end of the first hour the therapist prescribed
antidepressant and sleep medication, employing drugs that had

been given her before. Five days later she reported feeling calmer
and sleeping well except for one night. She continued to speak
about her elderly relative, and it was learned that this woman
carried grudges and had avoided other funerals of family
members. The patient's son provided additional information
tending to confirm the therapist’s hunch that this elderly woman

relative was seriously ill physically and probably had a severe
personality disorder; both she and her daughter wanted the
patient to stay away. The therapist recommended strongly to the

patient that she stop pursuing a reconciliation, suggesting that
she had done all the proper things and that this was a kind of
misunderstanding which could not be resolved in a reasonable

fashion at this time. In the absence of side effects, the dosage of
medication was increased.
A week later she was more alert and cheerful. She read some
notes that she had made regarding her attempts to make up with
her relative. The therapist reinforced his recommendation that
she put aside this effort. On her fourth visit, two weeks later, she
reported herself as back to normal. She complained that her
husband doesn't go out of the house very much, implying that this
limited her own mobility. The therapist suggested that she may
need more outside activities and contact with friends, particularly
women. He spoke with her about the death of her mother, putting
forward the suggestion that she had reacted as most people do
with feelings of loss, need, disappointment and even anger, and
with an attempt at symbolic replacement of her mother. He said

that he thought this was behind the pressure of her efforts to
reconcile with the older woman relative. She listened but did not
confirm or deny this.
A month later she had maintained her gains, and she
described having had an enjoyable Christmas celebration. During

the previous hour she had inquired about the therapist’s name
and its origins. Now, in a friendly way, she asked whether he had
enjoyed the Jewish celebration of Hanukkah. The pressure to see
her relative had abated. It was agreed to meet again in a month
and then, if she had maintained her improvement, to terminate

therapy and discontinue the medication.
At the final meeting she was looking and feeling well. The
therapist complimented her on her appearance. She reported
memories of her mother which had come back, accompanied by

tears, during the Christmas and New Year holidays. Then she told
more about the stresses which she had experienced in the

preceding years. Two of her sons had divorced nine or ten years
before. She had had good relations with these daughters-in-law

and still kept in touch with one and with a grandson. However,
she had lost touch completely with the other daughter-in-law and
with a granddaughter.
In her late 40's she had taken a factory job and had held it
until three or four years ago, when she gave it up with the plan of
enjoying traveling with her husband. Then mother died and her
husband became “too old” and sedentary for this recreation. Now
he is “her job” but she feels lonely. She was encouraged again to
resume outside activities. The dosage of her medication was
reduced and a date set to discontinue it. A week later she
telephoned and said that she would like to stop all medication. It
was agreed that she should. She was most appreciative of the help
that she had received.
In this case, rapid intervention using psychotherapy and
medication relieved an incipient crisis of worsening depression. It

was essential to understand that the dynamic basis of her
reaction was an unresolved grief reaction with attempted
restitution of her loss through a current relationship. The

relationship with her elderly relative was burdened with
displaced ambivalent feelings, and was doubly unsuitable because
of the relative’s own personality disorder. The support for

undertaking therapy given by the patient’s son and the
information that he supplied were essential. Suggestion, guidance,
manipulation, and some clarification were utilized in the

psychotherapy. The patient’s son reinforced her belief in the
expert power of the therapist, a basis of suggestion. Intervention
to help her calm down and distance the relationship with her
relative may be considered a form of guidance. The therapist
approached her severe superego reaction manipulatively by
giving her credit for her good intentions toward her relative. The
patient’s experience of grief during therapy tended to confirm the
dynamic formulation and indicated some response to

clarification. Previously medication alone had not been sufficient,
but together with this psychotherapeutic approach it became
effective.
Various Dimensions of Psychotherapy with the Aging and

Elderly
In recent years a number of reviews and detailed reports of
psychotherapy with older persons have enriched our

understanding of the process and its applications.
M. P. Lawton (20) notes some frequent characteristics of

older patients that may signal the desirability of particular
approaches to therapy. Older people tend to be relatively low in
educational attainment as compared with younger ones,
unfamiliar with psychological concepts, resistant to the idea of
psychological assistance, and rejecting of moral liberalism. This

suggests that the therapist must be careful in his choice of words,
cautious in inviting older patients to explore tabooed feelings, and
not too ready to assume that psychological explanations will be
comprehensible. It may be better not to generalize too abstractly

or to rely upon analogies and metaphors. Poorly structured
interviews and the use of ambiguity may elicit anxiety and
overcautiousness. Support may be necessary to maximize the

older patient's ability to pursue problem solutions in his own
way. The pace of therapy will often be slower than with younger
persons. The therapist must tread between acknowledgment of

the patient’s limitations and succumbing to overgeneralized,
ageistic devaluation of his patient. It appears that Lawton’s
observations are especially applicable to the debilitated aged.
Berezin and Fern (21) described a 70-year-old woman with a

hysterical character disorder who was admitted to a mental
hospital because of increasing alcoholism. She was seen initially
because she had become a management problem. Psychotherapy

twice weekly for 15 months enabled her to partially work through
some early, persistent conflicts, so that she could function in less
regressive ways and eventually make a satisfactory adjustment in

a nursing home. During psychotherapy the availability of
conflictual material, in the form of early memories and fantasies
with their corresponding affects, was striking. As the discussants

of this paper note, therapy enabled her to accept her age, i.e., that
she was no longer adolescent. There is an interesting discussion
of the use of transference in psychotherapy of older persons.
A beautifully written depiction of an eight-month treatment

of a 66-year-old woman with a hysterical neurosis by Gitelson
(22) highlights her transference reactions and the therapist’s

responses.
Hauser (23) details the treatment of a 78-year-old woman,

utilizing psychotherapy and ECT. She had her first paranoid
depression at age 59. Among important issues in her life and

therapy were her fear of being abandoned and left helpless, her
overdependence and the need to be in control of personal
relationships, her suppressed anger, a strongly sexualized
transference, and her enormous effort to deny aging.
Zarsky and Blau (24) describe the response to two brief
periods of therapy of a woman with a lifelong narcissistic

character neurosis, reacting to the death of her favorite son.
During periods of regression she showed clinging dependence,
insatiable overentitlement, and endless rage and blamefulness.

When functioning better, she was dominating, bright, charming
and entertaining, with a capacity for making and losing friends.
Treatment was at ages 60 and 70 with a five-year follow-up. The

paper and discussions consider the psychotherapeutic measures
that helped reverse the process of regression. Differential
diagnosis and therapeutic aspects are taken up.
Ronch and Maizler (25) agree that insight-oriented,

dynamically based individual psychotherapy is an effective
treatment modality with the institutionalized elderly. A crucial

area in such psychotherapy is the heightened resurgence of
dependency conflicts because of the institutionalization itself. One
must deal with increased manifestations of ambivalence and

anger toward the staff, and the correlated fear of abandonment.
The treatment of a paranoid, suicidal depression in a man with
Alzheimer’s disease is cited. After about a year the patient moved
from a protected psychiatric facility up to the second highest level
of self-care of eleven levels of progressive care in the institution.
The technique of reality orientation was also used to solidify his
gains in judgment, memory, intellect and orientation. Another
example is of a 69-year-old woman with overdemanding

behavior, depression, pain and anxiety following a spinal
operation. She perceived therapy as a magical rescue.
Environmental measures, adaptive intervention and clarification

met with considerable success.
Hasenbush (26) reported the successful brief therapy of a
retired elderly man with intractable pain, depression, and drug

and alcohol dependence. I think of this case as belonging to a
category of patients who seem impossible to treat, but turn out,
unexpectedly, to have some capacity for improvement. In some

instances their psychopathology appears longstanding and deeply
fixed. I have seen such patients whose chronic anaclitic
depressions have worsened, increasing their suffering and

distressing their families or others in their environment.
Supportive psychotherapy and medication gave enough relief to

make their condition tolerable. In other cases, life circumstances
are the principal burdening and limiting factors. A woman in this
group, with a reactive depression stemming from taking care of

her husband who had Alzheimer’s disease, was able to find some
relief by ventilating her feelings of frustration. A man attached to
his wife, despite her refusal of sexual intercourse, was able to

manage by returning to a previous extramarital relationship. Dr.
Hasenbush’s patient seemed to belong to the first group with
serious psychopathology. This 72-year-old man with lifelong
character problems had retired from work seven years

previously. Since then, he had suffered severe burning pain in a
foot for six years, had not improved with two peripheral nerve
operations, spinal blocks and 30 electric shock treatments, and
had withdrawn to a bed and chair existence, depending upon
increasing amounts of codeine, tranquilizers and alcohol. Despite

all of this, there were some hopeful indications. The
interdependence of needs and the matching of personality styles
between the patient and his wife could be approached in

concurrent therapy of both. Treatment in later life was facilitated
by the psychoanalysis of each partner approximately 30 years
before, even though the results of analysis had been limited.
Hypochondriasis is one of the typical disturbing symptoms of

older people, and in its most common form reflects neurosis or
borderline disorder rather than psychosis. It is often resistant to
treatment. Busse and Pfeiffer (27) outline an approach to the

treatment of this symptom by the family doctor or internist. They
point out the limitations and drawbacks of giving the patient a full
medical explanation or an organic diagnosis, of offering a

psychiatric formulation of his condition, or of doing surgical
procedures. Effective techniques include listening, respecting

defenses, and conveying recognition that the patient is indeed
sick and the assurance that he will be cared for. The use of
medication, handling of relatives, and the conduct and spacing of
interviews are discussed.
Da Silva (28) describes the treatment of a man with manic-
depressive illness, seen in a state hospital between the ages of 81

and 84. The paper, which should be read together with the
discussions that follow it, gives a moving and impressive picture

of the patient’s deep, longstanding loneliness, the correlation of
his life history with his personality and psychopathology in old
age, the ways in which he related himself to his therapist, and the
strong feelings he evoked in his therapist. His images and
concepts of death are of particular interest. Treatment moved
from a phase in which he denied his oncoming death to one in

which he gave up the denial, reviewed and examined his life, and
in effect prepared for dying. Psychotherapy appears as a means of

prolonging and enriching life.
Myerson (29) discusses two cases of psychotherapeutic
management of terminal illness, one involving an 85-year-old

woman (30). He concentrates upon the personal hazards for the
therapist of intense involvement with a dying person. He
observes that we have come to believe that, in general, the dying

patient is better off if he has the opportunity to talk about his
impending death, and can be supported by the caring presence of
people who respect his dignity. In dynamic psychotherapy, the

patient’s desire for explicit reciprocation of transference love felt
for the therapist cannot be gratified. The borderline patient has
poor tolerance for this frustration. Intense therapeutic
relationships with dying patients run the risk of creating a
borderline situation. It is often not possible to analyze and work

out the patient’s transference feelings under these circumstances.
The therapist senses that the patient wants more from him than
he can provide. This is the level of distress that is peculiar to

professionals. We are forced to frustrate people who have needs
that cannot be met, and we feel guilty—in part because we
recognize that we have implicitly promised that we would give

what is desired of us.
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Educ., 1959, 34:1003-1009.
19. Zinberg, N. E. Special problems of gerontologic psychiatry. In: M. A. Berezin and S. H.

Cath (Eds.), Geriatric Psychiatry: Grief, Loss and Emotional Disorders in the Aging
Process. New York: International Universities Press, Inc., 1965, pp. 147-159.
20. Lawton, M. P. Geropsychological knowledge as a background for psychotherapy with

older people. ]. Geriat. Psychiat., 1976, 9:221-233.
21. Berezin, M. A. and Fern, D. J. Persistence of early emotional problems in a 70-year-

old woman. J. Geriat. Psychiat., 1967, 1:45-60.
22. Gitelson, M. A transference reaction in a 66-year-old woman. In: M. A. Berezin and S.

H. Cath (Eds.), Geriatric Psychiatry: Grief, Loss, and Emotional Disorders in the
Aging Process. New York: International Universities Press, Inc., 1965, pp. 160-
186.
23. Hauser, S. T. The psychotherapy of a depressed aged woman. J. Geriat. Psychiat.,

1968, 2:62-87.
24. Zarsky, E. L. and Blau, D. The understanding and management of narcissistic
regression and dependency in an elderly woman observed over an extended
period of time. J. Geriat. Psychiat., 1970, 3:160-176.
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aged. Amer. J. Orthopsychiat., 1977, 47:275-283.
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Brown and Co., 1969, pp. 202-209.
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Psychiat., 1975, 8:127-135.
18
Psychotherapy with Bilingual Patients
Victor Bernal y del Rio, M.D.

Let us go down, and there confuse their language so that they will not
understand one another’s speech. For this reason the tower was called
Babel, because there the Lord confused the speech of all the earth.
Genesis 11:7-9
I shall be sharing with you experiences with patients of

multiple cultural backgrounds and of different languages whom I
have encountered in more than 25 years of psychotherapeutic
practice in Puerto Rico. Although the English-speaking population

in Puerto Rico is small, 30% of my patients are English-speaking
and 50% of the 70% who are Hispanic or of other origins have, at
one time or another, lived in an English-speaking culture. All of
my patients are bilingual to some degree.
Bilinguality in psychotherapeutic practice is not new. Freud

recognized bilinguality and sometimes multilinguality in the
analytic situation. What is unique, however, is that my patients
live in a bilingual society that has a continuous bilingual input: in

the streets, over the radio, in the newspapers, etc. Most of my
patients are able to start treatment with equal facility in one
language or in another.
The birth of language is the dawn of humanity. We are born

into a world of sounds. The sound changes to language, the
language to communication. If psychotherapy is defined as the

intent of changing behavior, feelings, and emotions by
psychological means, language is the core of that transference. In
the General Introduction to Psycho-Analysis, Freud states that: . . in
psychotherapy nothing happens but an exchange of words
between the patient and the physician. The patient talks, tells of
his past experiences and presents impressions, complaints, and
expresses his wishes and his emotions. The physician listens,
attempts to direct the patient’s thought processes, reminds him,

forces his attention in certain directions, gives him explanations
and observes the reactions of understanding or denial thus

evoked” (11, p. 61).
Thus, Freud establishes that psychotherapy is structured on

verbal intercommunication. It is through language that the
patient reveals himself to the physician who, in turn, exerts his
therapeutic influence upon the patient by the same media. The

work of Felix Deutsch on analytic posturology (6), of Sullivan on
body language (24), of Jackson, Bateson and Haley on nonverbal

communication, and of Weakland on double bind (2) has added
significant dimensions to the understanding of communication.
Yet, in the final analysis, the psychotherapist and the patient rely
on the security of the spoken word.
The security of the verbal arena is not without complexity.

Words have both an intellectual and emotional meaning: Few
words are devoid of any emotional meaning. The individual’s
history of the acquisition of a word gives the matrix for the

emotional response that is evoked by its use. Words may actually
be repressed as concepts disassociated from their meaning.
Differences in the patient’s emotional reaction to the

recollection of even the most hypercathected objects or events in
the environment are revealed by either his use of semi-

technical/transitional terms that he has newly acquired or by his
use of words that he had early in life—with their personal or
family oriented particularities. It is within the realms of sexual,

micturative, and evacuative behavior that such highly cathected
words appear. At all stages of development the spoken word is
cathected differently depending on whether it is said or heard,
read or written.
I was treating a professional of Spanish parentage. He was
raised in a Spanish-speaking country but had lived in the United

States for a few years. He kept talking about axilas or arm pits,
and gave recollections of an extremely personal nature regarding

his early interest in this part of the human anatomy. He related it
to a symptom of anxiety that he experienced while riding in the
subway where women stood with their arms on the railing
exposing their axilas. He went into early recollections of smell,
meaning of hair, etc., and seemed to exhaust the possibilities of
exploration without any change in his anxiety. After what

appeared an exhaustion of the theme, it became apparent that he
was always using the technical term axila (arm pit), undoubtedly
of later acquisition. I asked him if he knew any other word for

axila; his brusque answer was that there was no other word in
Spanish for arm pit. He left it at that. Upon insistence, he reacted
with bitter, half concealed rage. I finally asked him if he ever knew
the word sobaco which is axila in autochthonous Spanish. He was
silent for a moment, recognized the word, then continued to talk
at length about the same recollection that he had brought to

previous sessions, now accompanied by body motion and voice
fluctuation. The recognition of a personal word and the continual

discussion allowed him, in time, to subdue his anxieties in regards
to the subway.
I also had a female patient who would use exactly the same
word fundillo, which in Spanish is a jovial term for the buttocks,

interchangeably for female genitalia and anal region. I became
aware of this double meaning and its ensuing confusion. She
finally recognized that she had never established the word
distinction for these parts of the anatomy and further claimed
that in her household, even as a child, this “confusion” was

familiar. This patient suffered from severe menstrual pains and
very severe constipation. After word clarification and therapy,
both problems disappeared. With these examples in mind, and

the complexity of language nuances, you may wonder how I dared
to treat patients in languages which were not mine from the

cradle. I was not particularly brave, but was sustained by the
knowledge that more than 90% of the psychotherapeutic work
done in this country from the thirties to the fifties was practiced
in very similar circumstances and with the thickest of mid-
European accents. This interest in linguistic studies had a glorious
start, yet faded rapidly from the psychiatric literature, as pointed

out by Spitz, Rosen, Ekstein, and others.
Freud's linguistic observations were recorded in “The
Psychopathology of Everyday Life” (12). He illustrated mistakes,

slips of the tongue and pen, memory lapses, etc. His examples
were primarily from slips in a foreign language, as the cases of
“Signorelli” or the quotes from Latin verse, etc. He generated the
idea that slips of the tongue occurred more in a foreign language.

He analyzed many foreign patients, was extremely interested in
the translation of his own work, and personally supervised some
of his own translations. With such an auspicious start, it is strange

indeed that the psychotherapeutic literature is particularly
undeveloped in comparative linguistic studies.
After 25 years of experience, I can assess that the therapist

practicing in a foreign language can produce very rapid
transferential cures which are seldom seen when dealing with the
native tongue. After all, God does speak in a foreign tongue.
Patients of different cultures and languages are difficult to

categorize under sweeping generalities. Yet, residents treating
exclusively Spanish-speaking patients on a face-to-face
psychotherapeutic situation do not report occurrences of silence.

On the other hand, in many classical books, the generality that
silences are more frequent in Latin people is expressed. This can
be seriously questioned. By analogy, if Latins are loquacious at a

social level, they should be garrulous in therapy. Silences,
although not frequent in psychotherapy, are very frequent in
psychoanalysis and maintain a very profound type of resistance

in the Spanish-speaking population. Silences are prolonged and
resistive to interpretation or intervention.
Language, on the whole, can be seen as the principal

characteristic of the ego in its performance of communication.
When the ego cannot perform well in the role of communication,

anxiety results. We have cases of neurotic depression,
compensatory overreaction and transitional paranoid reactions,
mostly from wives of English-speaking executives who ate

catapulted both geographically and hierarchically from the
mainland into a Spanish-speaking situation. The psychodynamics
of such a situation is very complicated indeed and could include

competition with their husbands, anger reactions, etc., but the
sudden language change is an added stress in the appearance of
the pathology. Strangely enough, complaints are not voiced along
the lines of language difficulties. Instead, many complaints reveal

an intolerance towards differences of non-human physical
surroundings. These complaints do not pertain to the man-made

physical environment which would, indeed, be pertinent
(breakdown of appliances, lack of adequate services, etc.). Rather,
most complaints are noncontrollable areas such as rain, heat,

light and lack of non-inhabited spaces.
Some people come into the country with a rationalization
regarding the acquisition of the new language. These people keep
alive the fantasy of eventually becoming very knowledgeable and

efficient in the new language and its literature. Yet, they stress the
differences in pronunciation and the usual use of localisms. Their

fantasy is that some day they will learn “pure” Castilian, like
Oxford English—it is as if a Spaniard going to Minnesota would
decide not to learn English until he could go to Oxford, or at least
to Boston.
Another example of ego conflict with language difficulties
was a patient referred to me from the mainland, who presented,

during a short period of treatment, particular language
characteristics and ego confrontations. He was a tall, good-
looking, amiable, 37-year-old, single, engineer, born and raised in

Berlin. He had served in the German Army during World War II,
after which he had migrated to the United States, where he had
learned English and worked for two years. He had then been
transferred by his company to Puerto Rico, and given the
customary raise in salary. Although he was unhappy about the

transfer, he accepted it because of the raise.
He had been seeing a psychiatrist on the East Coast, who had
referred him to us because of insomnia, anxiety, and indecision

regarding getting married. The patient started his treatment
completely in English, four times a week. After a short period, he
abandoned the island in a state of panic and returned to the

United States. Later, when I looked over the protocol, I found two
striking things: 1) His regressive behavior at the beginning of
treatment was greater than any I have seen in such cases; 2) He

immediately started dreaming in German exclusively, his dreams
dealing with his previous experience in the German Army. There
was no direct day residue, to speak of, detectable in the dreams.
It seems that having only recently carried through such a

formidable job of adaptation into the English culture and
language, the capacity of his ego was depleted for further

adaptive compensation. Upon being faced too rapidly with a
second new situation, in both language and culture, he suffered
deep regression at a clinical level, and defensively went back to

his original familiar grounds every night in his dreams, in an
attempt to ease his tensions.
Language preference in psychotherapy is a commanding
phenomenon. Many factors influence the acquisition of a foreign
language. Studies have been made on preferences of second
generation émigrés, identification difficulties, and tendencies to
protest the parental figures. Many Puerto Ricans, by reasons of

their multiple geographical and cultural upbringings, come very
close to bilinguality—a perfect command of both languages.
In Puerto Rican émigrés, rarely does language identification

become so clearly and completely categorized as in this case
quoted by Greenson, “I would like to cite some material from the
analysis of a young woman who developed a great aversion to

speaking her mother tongue, German. She described her
predicament as follows: ‘In German, I am a scared dirty child; in
English I am a nervous, refined woman.’ As long as she spoke

English, her picture of herself was the English-speaking refined
lady. The moment she spoke German, her self-image changed, and
she became a ‘scared dirty child.’ The English identity was a

screen against the German identity. It served the purpose of
maintaining in repression the painful German self-image, as well
as offering an opportunity to exhibit a more pleasing aspect of the

self” (14, p. 247).
Puerto Rican émigrés, especially the teenagers, go through

intense language shifts. In general, I can say that most teenagers,
as partial émigrés, would accept only a therapist who was fluent
in both languages. The preference shifts at different stages in the
therapy. Sometimes it is by deference to the therapist that a
language is chosen. In only two cases of prolonged treatment have
I seen a definite sequence which sharply demonstrates an analogy

with their genetic development. Both cases were females in their
late twenties, with social and sexual maladjustments, who had
been transplanted to the mainland at around the age of 4½ years.

Both had been raised on the mainland up to age 25, and had
experienced sharp increases in their socioeconomic position.
Both returned to the island from highly paid jobs. Both started
consultation and undertook the initial phase of analysis in
Spanish, with occasional shifts into English. In both cases, at
about the fourth month, they shifted to English completely,

remaining thereafter in that language, with very few mixtures. By
the end of the third year, they both used English and Spanish
interchangeably, and then made a final definite reintegration to

the Spanish language.
Language tendencies are selected by patients. Some express

their thoughts in what can be called a ‘‘progressive insecurity.”
Example: "It was Monday, no, Tuesday, no, Wednesday,” or: “A
hundred, two hundred and fifty, three hundred.…” This is in

contrast to the patient who will express the same idea in a
decreasing type of dialogue. “It was the 23rd, no, the 22nd, no, the
21st.…” Whether this gives some inkling into the emotional

matrix “progressive or depressed” as characterological aspects
should be the subject of further studies.
During a chance encounter, a friend reporting failure in his
attempt to establish telephone communication could verbalize
this in many different ways, as follows:

I called your house… and there was no answer.
they did not answer.
there was nobody in.
you did not answer.
the telephone did not answer.
the phone seemed to be out of order.
The choice seems to depend on the emotional state involved in

the selection.
Strange and complex language usages were revealed by a
patient who did not exhibit neologism proper, but who showed
new logistics in language usages and word meanings. On a
consultation at a V.A. facility, I saw a 22-year-old, single Korean

War veteran with a diagnosis of paranoid schizophrenia. This
patient’s education was up to the second year of public high

school in Puerto Rico; he was exposed to very little teaching of
English which was followed by a two-year period in the Army,
mostly in a Spanish-speaking milieu. Among his many complaints,

he mentioned a “pressure on the right side of his head.” He had a
history of having painted his room totally black where he
secluded himself for long periods. He stated that all his troubles
were due to the fact that both his father and his brother, who
were truck drivers, had their trucks painted red. Now, every time
they drove their trucks, he could detect it from afar, which
produced feelings of unpleasantness and discomfort. He claimed
that if his father and brother would paint their trucks another
color, preferably blue, his feelings of unpleasantness would

subside. Not knowing really how to proceed, I asked him, I think
by intuition, why was it that the right side of his head bothered
him (right in Spanish is derecho). Immediately he answered,

without hesitancy, that right (derecho) was made out of der and
echo—that der was really the letters rearranged to spell RED,
which was the color of the trucks. At his command was rapidity of
both translation, word division, and letter rearrangement,
meaning link of the phoneme from one language to another in the
middle of a psychotic state. The opposite phenomenon of

retranslation of visual stimuli into reconstructed words also
occurred.
A Latin female patient1 in the third year of her treatment
revealed a dream. She was married to an English-speaking

European and had previously been in treatment for two years in
the United States during which she spoke English. The dream
was: “I am standing on a balcony in a house by the seashore. The
sea has receded, leaving a big empty beach. As I was preparing to
investigate this dream, she exposed a linguistic association that

made the meaning of the dream very plain. She said—‘‘sea gone”
(marido), marido means husband in Spanish. Her husband and
her former therapist were both English-speaking, thus the dream
in English would be nearly impossible for them to understand.
Translated into Spanish, the clarity of the word play is

transparent. Her present therapist is Spanish-speaking and, thus,
she makes this direct gift of establishing understanding that

would be foreign to her former therapist and to her husband. Her
father was also Spanish-speaking. Her English world is gone and
is being substituted by a Spanish-speaking world.
“Sound language” in the sense of awareness of grammar and

syntax is more evident to the child than to the adult. Sometimes,
apparently, the foreign word acquires sound meanings which are
more feasibly explored in the bilingual situation. Children can

imitate foreign utterances more readily than adults. This
represents more “sound meanings” than actual meanings. A four-

year-old English-speaking girl living in Puerto Rico in a bilingual
household was asked what name she wanted to give her newly
acquired puppy. She answered rapidly, “Jayuya," which sounds
like “hau hau” in Spanish, or the English equivalent of “bow-wow.”

This is the name of a small town in the interior part of the island,
which in all probability this little girl may have heard mentioned a
couple of times. It seems to be evident that she was struck by the

sound of a barking dog, which is present in the word Jayuya.
While treating patients in different languages and adjusting

my ear from one language to another at least four or five times a
day, I became aware of an impossibility. I was unable to follow if
the patient shifted suddenly from one language to another in a
word or perhaps a phrase. This is not prominent when “tuned in
free floating awareness,” “listening with the third ear,” or as

Sullivan states, “deep in selective inattention” (24, p. 12). The
sudden shift left me completely unaware of the meaning of the
word or phrase. Usually I could not remember the word or phrase

even though it was a completely familiar term. The sound was
completely alien as if I had never encountered it before. After a
number of observations of this sort, and certain tribulations

regarding my own countertransference in these particular
situations, I received personal communication from another
therapist in town which corroborated my observations. At the

time, I also wondered whether I was subjected to special
pronunciations on the part of the patient which would have made
it difficult to detect the meaning of the pronounced word. This

was not the case at all; such “language unawareness” happens
even when treating completely bilingual patients whose
pronunciations are perfect in both languages. This phenomenon

appears whether the word is a name, title, a familiar phrase, or
even a verse. The key to the matter is the fact that verbalization is
the message from the preconscious into the conscious and such
processes happen within the framework of grammar, syntax, etc.,
which is particular to each language. Pick states, “grammar and
syntax are not something added to the words chosen, but a matrix
into which the words are embedded.” It follows that one is, so to
speak, tuned in to a certain grammar and syntax; the falling of a
communication from a foreign language into such a matrix would
be lost to understanding. “Deverbalization precedes

verbalization,” as stated by Rosen (21, p. 471). The same thing
happens in the patient when faced with the task of free
association: “the patient regresses to earlier stages of

communication.” The therapist on his own, when faced with the
task of listening with his “third ear,” regresses also and his
deverbalization processes happen in a subconscious state of
mind. If we see a patient or meet a person who by physical
characteristics we expect to speak in one language and who does

the opposite of what we expect, we suffer a similar sense of
disorientation. I want to point out that the same feeling of loss
does not happen in social conversations when our interlocutor

shifts suddenly to a different language. Somehow the selective
“third ear” never emerges in the nonprofessional situation and
thus this particular idiosyncrasy never occurs.
The matrix of continual verbalization is characteristic of

mothers taking care of infants in a Spanish-speaking culture. They
accompany their child-rearing practices with a continuous
verbalization during the process of food preparation, diaper

changing, etc. This is in contrast with the historical case quoted by
Edelheit, “Salimbene, in his twelfth-century chronicles. He
describes a linguistic experiment that has been made by the

Emperor Frederick III: ... he wanted to find out what kind of
speech and what manner of speech children would have when
they grew up, if they spoke to no one beforehand. So he bade

foster mothers and nurses to suckle their children, to bathe and
wash them, but in no way to prattle with them or to speak to

them, for he wanted to learn whether they would speak the
Hebrew language, which was the oldest, or Greek, or Latin, or
Arabic, or perhaps the language of their parents, of whom they

had been born. But he labored in vain, because the children all
died. For they could not live without the petting and the joyful
faces and loving words of their foster mothers” (7, p. 409).

Continual verbalization is also necessary in taking care of
catatonic regressed mute negativistic patients. If the nurse or
attendant keeps communicating during the minutiae of their

activities around the patient, it is an observed fact that the
patient’s response is better.
The child, not only imitates the mother's tongue, gestures,
etc., in the prestages of language, whether in the first stage of

echolalic repetition or in the second stage of naming, really
communicating conceptual language. He also imitates all the
other noises in the house, animals, cars, wind, seashore, etc. With
the advent of popularity of radio, TV, phonographs, and tapes,
sometimes on during the whole day and part of the night, children
of today are subjected to a barrage of noises that at some level
constitute an example of overstimulation or “emotional overload,”
according to Spitz.
Dream phenomena, whether in one language or another,
have, in my experience, not presented themselves readily to
cultural distinctions. Their composition of elaboration, symbol

formation, and the aspects of the day residue are similar. I have
been unable to assess the much valued and expressed idea of
dreaming in Spanish, dreaming in English, or dreaming in

German. Except for a few exceptions, verbal utterances are
usually indistinguishable and confused. When thoroughly
explored, the patient is seldom sure about the language of
utterances, thus pointing out the power of secondary elaboration
and to the presence of perhaps some functions of the

consciousness mind which seems to be very resistant to any
influence by the subconscious. As I expect some arguments on
this observation, I want to make it clear that if I were to quote

dreams from my protocols, I do not see how anybody could
appoint them to English or Spanish patients except by guessing.
There is, in my experience, examples that show a difference
in the culture but because of the lack of statistical value I am

hesitant to communicate them. I do so only in the hope that it will
stir some discussions and observations from other sources. In a
few instances, some Spanish-speaking patients discussed what I

call “mini-dreams,” which were uttered in the shortest way
possible. There does not seem to be a counterpart in English. The
smallest meaningful word, almost a phoneme, constituted a whole

dream. I am purposely avoiding the word condensed as there is a
question in my own mind as to whether these particular dreams
are the product of hypercondensation. Do these dreams pertain to

the interminable as far as dream exploration and analysis are
concerned or do they represent a special direct utterance from

the unconscious with very little elaboration or dreamwork? These
“mini-dreams,” or psychotherapeutic snapshots, usually were
revealed in the second year of treatment. Dreams such as a name,

a word, a neologism, were reported as "night,” or “raining.” The
best example was a patient in his second year of treatment who
had a dream of “ants.” He was, by then, well oriented in reporting

dreams, developing associations, and analyzing them. In his
particular dream he could say very little—just “ants.” He did not
know whether he had seen or felt the ants. As an association, he

said, “crablice.” He then proceeded to talk at length of the
significance of this in his sexual development. This same patient
had had another dream with an “ear” which I again consider
within the range of a “mini-dream.” Mini-dreams have also been

in sequence repeated with a change in only one word. A patient in
his second year of treatment had, within a span of two weeks,
dreamt of the following sequence: first dream, “I was walking

with an erect penis”; second dream, “I was walking with an
‘inspoon’ (ponzoña)”; third dream, “I was walking with a small
knife.”
I come at last to perhaps one of my most controversial
statements. It has been my experience that bilingual patients,
though not particularly loquacious, do present a great avoidance
of the expression of verbal aggression in the therapeutic situation.

Direct verbal expressions of anger are practically nonexistent.
Even the raising of the voice is rare. The panting, raving patient is
an infrequent occurrence. Patients are usually extremely polite.
Even indirect verbal expressions of anger, long tirades against
psychiatry, commentaries on adverse publicity, etc., are unusual.

The use of foul language, even when encouraged, proves a
formidable barricade. Quoting disparaging remarks about the
therapist is done with extreme hesitancy. Nevertheless, indirect

expressions of anger are evident: wanting more time, delaying
payment of bills, accidentally throwing ashes on the rug,
stumbling on chairs, banging doors when leaving, etc., are indeed

to be found. What is worthy of consideration is that, upon very
careful evaluation, it is evident that English-speaking Anglo-Saxon
patients who have lived in the local milieu for some time acquire
similar characteristics.
Rothenberg (22), Fernandez Marina, Mehlman, Ramirez de
Arellano, et al„ (10), Maldonado Sierra and Trent (19), have
commented on aggression in Puerto Ricans, hyperkinetic-like

seizures, musculoskeletal expression of anger, rage, etc.—the so-
called Puerto Rican syndrome. It seems to me that these

superficial differences in dealing with aggression (I consider them
“self” characteristics rather than ego characteristics) can be
better explained by the smallness of the local geographical
situation and population characteristics, the immediacy of the
relationships (by familiar groups) and the inevitability of

neighbors. A verbal insult could realistically establish an eventual
vendetta. It is easy to insult a neighbor whom you do not see often

or will never encounter again. But to do that with somebody
whom you are sure you are going to meet twice a day, 365 times a
year, is different. This would lead to tremendous amounts of pent

up rage and could only be released by the musculoskeletal
expression, always of a psychotic-like flavor.
Rosen states that, “the prestages of language are seen as a
development of a systems of signals between parent and infant,”

and later, “in the gestural system, the development of forefinger
pointing is said to be a milestone in human evolution” (21, p.

479). It would seem to follow then that the increase of gestural
language or its reappearance in psychotherapy could be either a
sign of regression and a deeply embedded type of defense or an
actual part of the self. The perseverance of sign language, gesture

language, pointing, etc., could be interpreted as a lack in
command of exclusively verbal communication. We know that
verbal communication is always accompanied by certain aspects

of gesture language, modulation, pitch, accent, etc., which form
the core of the communicative process. Again, patients submitted

to the bilingual situation, but more frequently Spanish-speaking
patients, have a tendency to keep their hands occupied during the
therapeutic session with toothpicks, lighters, pieces of paper,
bags, etc., which are kept in their hands, caressed, played with,
etc. This method of keeping their hands occupied makes gesturing

difficult and complicated to assess. The patient submitted to the
bilingual situation has a tendency not to express verbal hostility

easily. He tends to be too courteous or correct. Keeping his hands
occupied assures him that even in extreme bouts of anger, the
hands will never be used for the expression of anger.
Patient behavior in Puerto Rico is markedly distinctive. The

tendency of patients to use language proper as a resistance—
almost as a weapon—is evident. Some resistances are of content,
and others are of form. By the latter, I mean that patients tend to
talk in the plural or in the present tense when recollecting, or
they use crutch words like “then” and “and” to start every
sentence with a phrase such as “I am thinking,” or “it comes to my
mind,” etc. These resistances are sometimes impervious to
exploration or interpretation. In a few cases, this resistance is
maintained through the entire process of treatment. This occurs

in English and Spanish speaking patients under treatment who
are intensely subjected to a barrage of bilingual stimulation of
radio, TV, newspapers, billboards, directions. Then, the question

arises, if their mother tongue is continually subjected to the
continuous attack by the bilingual milieu, could defensive

maneuvers be raised inadvertently in the native tongue, which
appear as resistances of form in the psychotherapeutic process? I
am particularly impressed by the imperviousness, the duration
and the almost complete opaqueness to interpretation of these
real strongholds of defense.
Patients tend to use incognitos such as “my friend”

persistently. Proper names are rarely use. Without consistent
insistence by the therapist, identification of places, persons, and

sources of opinions are rarely given. Patients express themselves
in such terms as: “people say,” “one does,” “we do,” “we want,”
“we think,” “I am thinking,” “I think,” or “what comes to my mind.”

These phrases are repeated cacophonically by patients for
months as an introduction to every paragraph. The usage of the
past tense, “I was thinking” or “I thought,” precedes the

appearance of the “I think.” Starting sentences with prepositions
is a type of verbal defense of great consistency. Patients also use

“I don’t remember” as a form of defense. Ironically, “I don’t
remember” is a formidable denial of recollections and yet it is
expressed as if it were a positive attempt at recollection. Patients
also tend to start a paragraph with “for example”— examples are

not the product of free association.
I find, in borderline Spanish-speaking cases and in

narcissistic personalities, the presence of a type of verbal
resistance that is extremely difficult to overcome. The patient will
repeat in an echolalic form every intervention of the therapist

before responding to it. I am talking specifically of material
presented to stimulate association. Before the patient gives any
association to the stimulus, he repeats it, usually slowly—
whether it is a word, a phrase, part of a dream, or part of a
sentence. The therapist must be aware that this is a resistance

that can be interpreted as a very positive identification with the
therapist. When encountered at the beginning of treatment, it
seems a manifestation of a budding positive transference. It

seems like an expression of interest, eagerness, and
responsiveness. Yet it is a resistance and becomes even more
evident when dealing with dream material or even when the

therapist’s intervention is a repetition of the last word or phrase
of the patient. In some cases, the resistance is totally impervious
to interpretation and demonstration. I have not seen it in neurotic

patients in therapy except at the very beginning. We can theorize
that this resistance is a demonstration of an ego defect. The word
pronounced by the therapist cannot be received or accepted as a

representation of an object or even as a transitional object to
respond to. As long as it remains “in the voice of the therapist,” it
is a strange object to which the ego cannot respond. As the patient

pronounces it with his own voice, he makes it his own by placing
it in his mouth. The word or phrase as a representation of an
object becomes part of the patient’s ego or is at least positively

cathected. It becomes less menacing and thus his own thoughts
and words can come forth and be linked to the ego sound, ego
word, and ego phrase. I have seen this happen in some neurotic
patients on the couch but it disappears when pointed out and
interpreted.
In borderline patients this resistance to words of the

therapist is impervious and I have seen it persist in patients who
have been in treatment for two to three years. In general, verbal
resistances, even when carefully pointed out and analyzed,

reappear in the course of the treatment. They become good
means of judging the awareness of the transference situation or
the stage of the therapeutic alliance.
Sharing experiences is to start the dialogue. I consider

dialogue to be both a “hope” and an “end.” Purposely then, our
dialogue has its beginning.
REFERENCES
1. Appelbaum, S. A. Evocativeness. J. Amer. Psychoanal. Assoc., July 1966, 14:3.
2. Bateson, G., Jackson, D. D., et al. A note on the double bind. Family Process, 1962,
2:154-164.
3. Bateson, G., Jackson, D. D., Haley, J., and Weakland, J. Toward a theory of
schizophrenia. Behavioral Science, 1956, 1:251-264.
4. Bernal y del Rio, V. On psychotherapy. Puerto Rico Med. Assoc. Bull., November 1968,
60:11.
5. Deutsch, F. Thus speaks the body. Acta Medica Orientalia, March-April 1951, 10 3-4.
6. Deutsch, F. Analytic posturology. Psychoanal. Quart., April 1952, 21:2.
7. Edelheit, H. Speech and psychic structure: The vocal auditory organization of the ego.
J. Amer. Psychoanal. Assoc., April 1969, 17 (2):381-412.
8. Ekstein, R. Historical notes concerning psychoanalysis and early language

development. J. Amer. Psychoanal. Assoc., 1965, 13 (4):707-729.
9. Fernandez Marina, R. The Puerto Rican syndrome: Its dynamics and cultural
determinants. Journal for the Study of Interpersonal Processes, February 1961,
24:1.
10. Fernandez Marina, R„ et al. Psychiatry. U.S. Armed Forces Med. J. 1767-1955, 1961,
22-79.
11. Freud, S. Introducción al Psicoanalisis, Vol. II, Chap. 2. Madrid: Editorial Biblioteca
Nueva, 1948a.
12. Freud, S. Psicopathologia de la Vida Cotidiana, Obras Completas, Vol. I. Madrid:

Editorial Biblioteca Nueva, 1948b, pp. 635-756.
13. Froeschels, E. Grammar, a basic function of language speech. Amer. J. Psychother.,

January 1955, 9 (1).
14. Greenson, R. R. On screen defenses, screen hunger and screen identity. J. Amer.
Psychoanal. Assoc., 1958, 5 (2):242-261.
15. Jackson, D. D. Psychoanalytic education in the communication processes. Science and

Psychoanalysis, Vol. V. Grune & Stratton, Inc., 1962.
16. Kohut, H. Clinical and theoretical aspects of resistance. (Scientific Proceedings Panel
Report Midwinter Meeting 1956). J. Amer. Psychoanal. Assoc., 1957, 5(3): pp.
548-555.
17. Langer, S. K. The phenomenon of language. In: I. J. Lee (Ed.), The Language of
Language and Folly. New York: Harper & Bros., 1949.
18. Lee, L. Language Habits in Human Affairs. New York: Harper & Bros., 1941.
19. Maldonado Sierra, E. D. and Trent, R. D. Amer. J. of Psychiat., 1960, 117-241.
20. Ramirez de Arellano, R. et al. Attack, hyperkenetic type: The so-called Puerto Rican
syndrome and its medical psychological and social implications. San Juan, Puerto
Rico Veterans Administration Report, 1956.
21. Rosen, V. H. Disorders of communication in psychoanalysis. J. of Amer. Psychoanal.

Assoc., 1967, 15 (3):467-490.
22. Rothenberg, A. Puerto Rico and aggression. Amer. J. Psychiat., April 1964, 120(10).
23. Spitz, R. A. The derailment of dialogue: Stimulus overload, action cycles, and the
completion gradient. J. Amer. Psychoanal. Assoc., 1964, 12(4): 752-775.
24. Sullivan, H. Stack. The Psychiatric Interview. New York: W. W. Norton & Co., Inc.,
1954.
Note
1 Due to the limited geographical reality in Puerto Rico if you disqualify for treatment
every person that you have met or that knows about you, your practice would
become nonexistent. Therefore, because of this reality factor and possible
feedback, great liberties have been taken with the rearrangment of personal
data. On the other hand the geographical limitation and social inevitability
provide us with a built-in follow-up system which proves a deterrent in self-
aggrandizement and provides humble and cautious evaluation of therapeutic
results.
19
Racial Issues in Psychotherapy
Hugh F. Butts, M.D.
The appeal that psychotherapy and racism hold for me

emanates from the confluence of several parameters:
psychoanalysis, anthropology, sociology, politics, history,
literature, mythology, economics, and racism.
As one attempts to tease out, examine and synthesize our

treatment approaches to the interracial therapeutic situation, all
of these parameters must be considered. Some of the frustrations

experienced by those who have attempted to shed light on the
topic may relate to the difficulty in assessing and weighting the
several parameters, as well as a tendency to resort to

oversimplistic theoretical formulations. Only by adopting a
“multifactorial open systems approach” with respect to the
subject of interracial psychotherapy, may we emerge in some

rational, systematic manner with a holistic, meaningful and
applicable theory. With this approach in mind, I would like to
briefly summarize some of what we currently know by reviewing

some of the literature, then explicate some of the lacunae in our
knowledge, and highlight some future directions.
The majority of the works on interracial analyses have
appeared within the past three decades. Early formulations

during the fifties, such as those by Bernard (1), Kardiner and
Ovesey (2), and Kennedy (3), described both the problematic
nature of such treatments and the nature of the resistances

encountered. Some practitioners such as Oberndorf (4) expressed
cynicism concerning the feasibility of the black-white treatment
encounter. White behavioral scientists contributed the majority of

the articles during the fifties. The formulations and writings of
black practitioners emerged during the sixties and seventies. This
fact may be significant for several reasons:
1. A significant increase began to take place in the numbers of

black behavioral scientists during the fifties and sixties.
2. A significant increase began to take place in the numbers of

black and other minority patients seeking help for
psychological problems during the same period.
3. This was the tumultuous period of the civil rights and black
power movements, both having profound effects upon
all of our institutions, as well as upon the conduct of
psychotherapy.
4. Socioeconomic and interpersonal factors and societal

stresses impacted upon blacks in such a manner as to
necessitate increased seeking of professional help.
Black professionals initially began writing not about interracial
psychotherapy but about the psychological effects of
institutionalized and individualized racism. Examples are:

Pinderhughes’ “Understanding Black Power: Processes and
Proposals,” Comer’s “White Racism: Its Root, Form and Function,”
in addition to papers by Palmer (7), Butts (8), Harrison (9), and

many others, such as Canon, Davis, Elam, Pierce, Poussaint,
Spurlock, Tompkins, Wilkinson, Youngue and Calhoun (10).
One of the landmarks in terms of papers on interracial

analysis was the Schachter and Butts work, “Transference and
Countertransference in Interracial Analyses.” It marked one of the

first collaborative efforts between a black psychoanalyst and a
white psychoanalyst, in an effort to come to grips with the salient
issues in such treatments and to define some of the therapeutic
issues. One aspect worthy of emphasis in this paper, that has been
overlooked in many others, is the emphasis on
countertransference issues that played a prominent role in these
analytic situations. Both authors, with absolute professionalism

and candor, admitted to their countertransference "problems”
with contra-racial patients. In a sense, the black analyst was
describing his pro-white, anti-black paranoia, as was the white

analyst. In addition, both analysts made serious efforts to resolve
these difficulties. Many of the papers on interracial analyses and
therapies have been from the vantage point of the white therapist
describing “Problems Posed in the Analysis of Negro Patients” (3),
whereas, papers by black therapists have focused on the
unconscious racism (and its therapeutic vicissitudes) extant in

white analysands, as well as emphasizing the manner in which
the therapist’s blackness often served to catalyze the treatment

situation. Both approaches are extreme, and serve to reinforce the
unconscious attitudes, myths, and racist notions that make the
working-through process more difficult than it might be

otherwise. Pinderhughes (11) has made a very salient
observation:
All individuals who highly value their groups encourage restriction or

repression of those body parts, body products, and thoughts, feelings,
and behavior that threaten, disrupt, or heighten conflicts in the group.
Activity with the head is encouraged in the social relationship with one’s
group members while perineal activity is discouraged in the social
context of one’s group. "Racism” beginning pragmatically in the behavior
of group members with fellow group members inadvertently produces
racism within the mental functions of each individual as certain exciting,
disruptive, “dark,” “evil,” threatening components are segregated. This
internal “racism” is then externalized and projected into the behavior of
each individual.
. . . Each individual can resolve the ambivalence about the goodness or

badness of one object by relating to two objects. One of these objects can
be perceived as good, and one as bad, one can be loved and the other
hated (p. 8).
In describing the group-related paranoias (of which racism is
a subgroup), Pinderhughes regards as ubiquitous the tendency

toward aggrandizing one’s group and of projecting to other
groups unacceptable, “dark,” and "evil” characteristics. He
concludes on a somewhat pessimistic or equivocal note:
It seems quite likely that failure to recognize the primitive origins and
dynamics of racism may lead to faulty, inadequate, or oversimplified
diagnosis and treatment…ambivalence and the use of paranoid
mechanisms in its resolution may be as ubiquitous as conflict is among
and within humans. As with conflict emphasis upon management of
paranoia may be more realistic than attempts to eradicate it. Some
racism is a group-related paranoia having to do with exclusive groups, it
may be eliminated by converting exclusive groups into inclusive ones (p.
8).
The white analyst-black patient, and black analyst-white

patient represent pairings that exemplify many of the dynamics
cited, as one observes and charts the vicissitudes of transference-
countertransference during the progress of treatment.
We have no reason to expect that the conflicts, ambivalences,

paranoid defenses, self-denigrations, and aggrandizements that
occur in black- white extra-analytic or social encounters would
not also be present in the professional treatment situation.
The white patient with the black analyst will often project his
unacceptable “bad,” “evil’’ self onto the analyst, whom he will then
depict in his dreams as a threatening, malevolent, “father-devil”

type. The black analyst may at times (12, p. 806), because of his
unconscious need for acceptance into the “exclusive group,”
respond to references in accord with this need, and thereby miss

the opportunity to interpret his patient’s behavior. Sensitivity to
racial epithets uttered by a white patient, may also indicate an
unconscious wish for inclusion into the group. The black patient
with the white analyst will often use race in the service of
resistance. This often betokens a lack of trust, implicit in which is
a conviction that his blackness is a barrier to admission to the
white exclusive group. The white analyst in this duo will often
react as did Schachter with an overdetermined response to
apparent threats and menacing descriptions of former behavior
by her analysand. This may have indicated her unconscious

acceptance of the myths regarding the aggressive and threatening
stereotype of blacks.
If black and white individuals are participating members of

the exclusiveness of one and the concurrent rejection of the other,
groups and institutions function similarly. “Some persons we
understand by taking them in or by taking in what they offer

while we understand others by dumping upon them things we do
not want within ourselves with the claim that what we renounce
belongs to them, and not to us (5, p. 11). Wherever a white and

black experience conflict in “white racist” structure, the white is
understood by projection and is presumed to be wrong and
unacceptable. Several recommendations are appropriate at this

point:
1. Any significant understanding and working-through of the

interracial analytic situation must be based on a precise
definition as to the manner in which both parties utilize
projective as well as introjective mechanisms as means
of dealing with unacceptable impulses (projective), or
by “taking in” their virtues and aggrandizing them
(introjection).
2. Any significant understanding of the working-through

involving blacks and whites in group situations should
require the same process as in the first point.
3. Both the above points are difficult to attain unless there is

adequate black and other minority representation
among the candidates and supervising/training staffs
of our analytic institutes and other training institutions.
This is not merely a plea for psychoanalytic affirmative
action, but represents an approach aimed at the
elimination of the elitism of psychoanalysis and
psychotherapy and a reduction of the group-related
paranoia that has severely crippled the analytic
movement.
Many of the interracial transference and countertransference
manifestations we observe may be artifacts related to the

practical nonexistence of black training analysts, and the
miniscule numbers of blacks involved in analytic training. In the
survey reported on by Harrison and Butts (13), the same 50% of

white psychiatrists who did not refer to black psychiatrists
reported having few or no black friends.
Black and While Characterization in Literature
Melville, Mark Twain, Fenimore Cooper, as well as

contemporary white and black literary figures, have shed a great
deal of enlightenment on the issues of whiteness and blackness as
reflected in their literary characters. Melville, in his chapter
entitled “On the Whiteness of the Whale” (Moby Dick), attempts to
dissipate the myth equating whiteness with purity and blackness
with evil:
This elusive quality it is, which causes the thought of whiteness when
divorced from more kindly associations and coupled with any object
terrible in itself, to heighten that terror to the furthest bounds. Witness
the white bear of the poles, the white shark (requin) of the tropics: what
but their smooth, flaky whiteness makes them the transcendent horrors
they are?” . . . “and though in other mortal sympathies and symbolizings,
this same hue (whiteness) is made the emblem of many touching noble
things—the innocence of brides, the benignity of age; though among the
Red men of America the giving of the white belt of wampum was the
deepest pledge of honor; though, in many climes, whiteness typifies the
majesty of justice in the ermine of the Judge, and contributes to the daily
state of kings and queens drawn by milk-white steeds; though even in
the higher mysteries of the most august religions it has been made the
symbol of the divine spotlessness and power; by the Persian fire
worshippers, the white forked flame being held by the holiest on the
altar; and in the Greek mythologies, Great Jove himself being made
incarnate in a snow-white bull…yet for all these accumulated
associations, with whatever is sweet, honorable, and sublime, there yet
lurks an elusive something in the innermost idea of this hue, which
strikes more of panic to the soul than that redness which affrights in
blood (14).
James Fenimore Cooper in The Last of the Mohicans
described the red-white relationship. “The Indian represents to

Cooper whatever in the American psyche has been starved to
death, whatever genteel Anglo-Saxondom has most ferociously
repressed, whatever he himself has stifled to be worthy of his

wife and daughters.” “Cora and Alice (the heroines) the
passionate brunette and sinless blonde, made once and for all the
pattern of female dark and light that is to become the standard

form in which American writers project their ambivalence toward
women” (15, p. 190).
Writers and literary critics have been aware for many years
of the unconscious significance of blackness and whiteness. Huck

Finn’s relationship with Nigger Jim contains transferential
overtones. “It is an impossible society which they constitute, the
outcast boy and the Negro, who even for Huck, does not really
exist as a person: a society in which momentarily, the irreparable

breach between black and white seems healed by love…and
through it all, Jim plays the role of Uncle Tom, enduring
everything, suffering everything, forgiving everything. ... It is the

southerner’s dream, the American dream of guilt remitted by the
abused Negro, who, like the abused mother, opens his arms
crying, ‘Lawsy, I’s mighty glad to git you back agin honey’ ” (15, p.
20).
Melville, Twain, Poe, Cooper, Hawthorne and others were
utilizing fiction in order to demonstrate the American national

character responses (conscious and unconscious) to blackness
and whiteness. The black-white duo occurs frequently in
American fiction, and is frequently utilized to represent the

redemptive love of man for man.
There is no more precise explication of aspects of the
American experience and of the American national character than

that furnished us by Melville in Moby Dick. In what is probably the
greatest love story in American fiction (15), Herman Melville
describes a number of relationships in which the redemptive love

of man for man is represented. One of the several romantic duos
in Moby Dick is Ahab and Pip, the black cabin boy. Pip, abandoned
at sea, is blatantly psychotic when finally rescued. “He saw God’s
foot upon the treadle of the loom, and spoke out: and therefore
his shipmates called him mad. So man’s insanity is heaven’s
sense; and wandering from all mortal reason, man comes at last
to that celestial thought, which, to reason, is absurd and frantic;
and weal or woe, feels then uncompromised.” Pip’s “insanity” has
resulted from abandonment, and his consequent sense of

isolation. Ahab adopts Pip, with whom he shares his cabin. Dr.
Jose Barchilon (16, pp. 22-23) states, “Ahab understands the
depth and wisdom of Pip’s craziness, identifies with him, and

takes him to his cabin as a son. Not in an attempt to make amends
for the harm done to Pip…but to find company in his misery,
because Ahab knows that he and Pip are different sides of the
same crazed coin. He also knew that, were he to like and grow too
tender towards Pip, it would soften his hatred and make him give
up his pursuit of white hooded phantoms.” Ahab is in a sense

doing that for Pip which was never done for him (he had been
“doubly-orphaned” by 12 months of age). “This is his attempt at
restitution, at recapturing by projective identification, the parents

he didn’t really have.
Thus, Melville, nearly 128 years ago, comprehended the

genesis of psychotic decompensation, the therapeutic
effectiveness of relatedness to another human, the nature of
projective identification, the nature of the type of developmental

arrest that follows parental loss, the nature of primary process
thinking, and the unconscious meanings of blackness and
whiteness.
A major and recurring psychological pattern of the
“American national character” has been well stated by the literary

critic Leslie Fiedler: “To express this ‘blackness ten times black’
(original sin) and to live by it in a society in which, since the

decline of orthodox Puritanism, optimism has become the chief
effective religion” (19, p. xxii). This pattern is reflected in the
American literature, which is a literature of “darkness and the

grotesque in a land of light and affirmation” (19, p. xxii). The
major literary concerns from Cooper to Baldwin are with death,
incest, and homosexuality. The child’s world, in literature, is

asexual, terrible, and a world of fear and loneliness. The
companion of the lonely, frightened, “man-child” who ventures

forth into the unexplored world is “pagan and unashamed,” but
the companion is described as both a dream and nightmare
simultaneously. This literary, metaphoric companion
(Chingachgook, Nigger Jim, Babo, Pip) is concretized in the form

of the black American. One could at this point expatiate on the
psychodynamics of unconscious racism. The “pagan” companion
possessed of both material and demonic features permeates all of

American literature. Splitting of the imagery in this way attests to
and evokes ambivalent responses, in addition to allowing for or

facilitating projection of unacceptable feelings and thoughts
(“Racism-pro white, and anti-black paranoia”).
The colonial world is a world cut in two. The dividing line, the frontiers
are shown by barracks and police stations. In the colonies it is the
policeman and the soldier who are the official, instituted go-betweens,
the spokesmen of the settler and his rule of oppression. In the capitalist
societies the structure of moral reflexes handed down from father to son,
the exemplary honesty of workers who are given a medal after fifty years
of good and loyal service, and the affection which springs from
harmonious relations and good behavior—all these esthetic expressions
of respect for the established order serve to create around the exploited
person an atmosphere of submission and of inhibition which lightens the
task of policing considerably. In the capitalist countries a multitude of
moral teachers, counsellors and bewilderers separate the exploited from
those in power. . ..
This world divided into compartments, this world out in two is inhabited
by two different species. The originality of the colonial context is that
economic reality, inequality and the immense difference of ways of life
never come to mark the human realities. When you examine at close
quarters the colonial context, it is evident that what parcels out the
world is to begin with the fact of belonging to or not belonging to a given
race.…The cause is the consequence; you are rich because you are white,
you are white because you are rich (17, p. 32).
Case Studies
Having laid down some of the theoretical and literary

underpinnings for a better understanding of ethnicity and
psychotherapy, a few case examples may be helpful. Some of
these case are incorporated into papers already referred to. Other
cases will represent brief vignettes drawn from my clinical
practice.
Case #1: White Female Patient, Black Male Analyst
An attractive 32-year-old Jewish school teacher entered

biweekly psychotherapy after having three years of analysis with
a white analyst. She had sought help initially because of frigidity,

vocational dissatisfaction, depression, and anxiety. In the course
of that analysis, her vocational adaptation improved, her
depression disappeared, and her anxiety diminished. She
remained frigid, however, and unmarried. The major difficulty
remaining after the three-year analysis was her fear of giving up

the child’s role in relation to men.
She was born and reared in New York, the oldest of three
girls. Her father was a somewhat cynical, successful lawyer; her

mother was described as a cold, frigid, materialistic matron. The
patient was cared for by a succession of maids until the age of
eight. Between the ages of eight and 15, she was cared for by one
black maid with whom she established a warm and meaningful
relationship and to whom she turned for warmth and dependency
because of her mother's inaccessibility. In general, as a child, she

did not express anger openly, and her parents were constantly
critical of her inability to be openly affectionate. She and her
mother perpetually quarreled over her grooming and

deportment, with her father supporting her mother in these
disputes. She had no memories of the birth of her sister when she
was seven years old. Her reactions of rage at the time of her
second sister’s birth, when she was 10, were displaced onto her
other sister.
As a child she wanted to be a boy, and felt that menarche

made her "dirty.” She was always concerned about the value and
importance of money. She was a pudgy adolescent who read
voraciously, had few friends, and did not date. Throughout
adolescence, she felt that her parents were dissatisfied with her
physical appearance and her inadequate social adjustment.
After graduation from college, she attended and graduated

from law school. At the age of 20, she married precipitously. Her
dissatisfaction with her marital sexual adjustment caused her to

seek brief psychotherapy after she had been married for one year.
Two years later she obtained a divorce. Her vocational, social and
sexual behavior deteriorated; she became progressively more

depressed and sought therapy again at the psychoanalytic clinic.
Key among her dynamics, when she entered treatment with

me, was her perception of men as destructive because of her
projected rage. Rejection by the therapist was perceived by her as
safer than dependency upon him. Vocational success was viewed

as a renunciation of her femininity. Again, the most striking
feature of her life adjustment was her failure in virtually every
area of behavior: vocational, social, sexual, and family life. She felt
disliked and rejected by everyone, and her hostile, provocative

behavior tended to bring about rejection. The closer she
approached adult womanhood, the more frightened she became
of the consequences, namely a destructive sexual assault by a

man. She rejected her feminine feelings and became aware of and
anxious about sexual interest in women.
The analyst’s anticipation of the development of a strongly
erotic transference accompanied by intense anxiety was soon
borne out, but her initial gambit consisted of applauding the
therapist’s empathic ability with the statement, “Negroes have
guts.” She had wound up the previous three-year analysis as she

was beginning to express affection and to get closer to people.
There, the oedipal implications of being “number one” were
frightening, and she had created obstacles to block her awareness

of the positive-affectionate tie to her father.
The selection of a black analyst was multidetermined. In part
it reflected a need to select a person whom she regarded as being

the antithesis of her cold, distant father, thereby avoiding the
anxiety of the oedipal strivings for her father. The early parent-
child power disparity was also reflected in her choice, in that she
saw herself in association with an “underdog,” who she felt would
understand her disenfranchised position in the family. The
selection of a black analyst was motivated by a wish to utilize a

counterphobic defense to deal with her sexual anxieties. She was
overtly seductive, while expressing anxiety lest her sexual wishes
be realized. In one session she reported this dream: “I was at an

isolated house in the country with a man. Nobody was there, but
then a maid came down and motioned upstairs. I was frightened
to be there alone with him.”
She placed her hand over her pubic area as she related the
dream and associated to the isolation of the analytic situation. A
series of dreams followed in which she depicted herself as
deprived and losing in the oedipal struggle. For example: “A
doctor was getting ready for a skiing trip. He was on the porch
with his children and wife. She had dark hair.”
The therapist utilized the transference to demonstrate her
renunciation of her femininity lest she be damaged sexuality; her

ability to function independently without dependency on her
mother; and her ability to form a therapeutic relation not
predicated on the exchange of sexual favors or on her

parentifying the analyst. Her pain-dependent, self-defeating
behavior was interpreted repeatedly. The therapist’s genuine
interest in her welfare was questioned by her from the outset of

treatment; she identified him with her presumably indifferent,
unaffectionate mother.
The two years of treatment resulted in a modification of her

affective symptoms, and an increase in her self-esteem, with a
consequent diminution of her self-defeating behavior. She was
married six months after termination of her treatment.
Case #2: White Male Patient, Black Male Analyst
A 35-year-old, white, professional man of Jewish extraction,

who was referred by his cousin, a former patient of the analyst,
sought analysis because of his inability to get married. During
each of two engagements he had become progressively depressed
and anxious and in each instance had broken off the relationship.
A second complaint, premature ejaculation, had begun a year
before the patient sought help. Vocationally, he was insecure,
despite the fact that he worked in an executive capacity. He was

ingratiating with fellow employees and fearful that he might not
be able to control his anger in work situations.
His most vivid memories of early childhood dated back to

age six, with recollections of visits to his Jewish aunt and
grandmother in Harlem. He took pride in making the subway
trips alone, but recalled mixed feelings of anxiety and excitement.

The Harlem community of that period was racially integrated. His
anxiety was predicated upon his fear of physical attack, and his
excitement seemed rooted in sexual fantasies which utilized

racial stereotypes and myths.
An intense fear of losing his parents pervaded his childhood.
He was a good student and active in athletics, but frequently

needed his mother s intervention on his behalf during
altercations with other children. At home, his mother was a
severely critical, domineering, anxious woman, who subjugated

her husband and chided him for being weak, inadequate, and a
poor provider. She lamented her difficult lot in life and confided
the intimacies of her marital dissatisfaction to the patient. The
father was physically and emotionally inaccessible.
Castration anxiety increased at age 14 when his parents’
concern about the size of his penis led them to consult a
physician. He was embarrassed to shower with schoolmates for
fear that they would discover that his penis was small.
Adolescence brought sexual interest and exploration; he dated,

but was always inhibited and anxious. During this period he
shared his sister’s bedroom but recalls only one instance of
embarrassment, when she giggled on overhearing him

masturbate.
Concern about the size of his penis persisted into adulthood.
After completion of Army service and college, he worked in an

executive position, continuing to live with his parents. He
perceived phallic women as castrators, and used prematurity and
impotence to defend against castration. With men, his

nonassertiveness socially, sexually, and vocationally derived from
his need to control his rage.
Early dreams gave form to the negative transference of the

first six months and heightened one of the patient’s key problems:
The black man was presented as physically assaultive, drunk, and
debased, and the patient feared his analyst’s aggression and

sexual exploitation.
In his association he dwelt on the theme of the menacing

black, juxtaposing his sexual inadequacy, fear of women, and his
perception of women as castrating, humiliating creatures. Soon
after beginning the analysis he moved from his parents’ home,
magically utilizing the therapist’s strength as a buffer against his
mother. The move was accompanied by a great deal of anxiety,
represented in dreams as a fear of starving to death. He began to
date and to attempt sex, expressing his lack of assertiveness and

his dependency orientation in dreams such as the following: “I
was in my apartment with C; we were necking. I had her breasts
in my hand. There were many women around. They were

exposing their breasts. I was completely fascinated and felt
pressure.”
The therapist challenged his fragmented view of women and

its emotional counterpart, his affective isolation and his wish to
present himself as dead emotionally. His dreams and associations
were replete with his wish to be regarded as a helpless infant,

which was interpreted at that time as a defensive retreat to a
position of dependent safety designed to avoid castration. The
patient was then able to associate this with his difficulty in

separating from his mother to attend kindergarten.
Ten months after the beginning of the analysis, he
triumphantly reported that he was able to penetrate a woman

sexually despite intense anxiety and fear of impregnating her. He
plied the analyst with questions about contraception, in actually
seeking approval for his sexual accomplishments. The analyst’s
mild disbelief in the therapeutic significance of the patient’s
achievement in part reinforced the patient’s stereotyped
perception of the Negro as a virtual sexual superman, thus
widening the gulf between analyst and analysand.
Another source of difficulty during this period was the

analyst’s need to disclaim his therapeutic power to achieve such a
great effect with the patient. This problem was rooted in the
analyst’s insecurity about his effectiveness which was combined,

however, with a need to assert his greater power over the patient.
With continued attempts at intercourse, a pseudo-

homosexual theme emerged in a dream: “I was in bed with S. She
got on top of me. We were having intercourse. But it was not S’s
face. It was a man’s face. I was frightened.” He discussed the

anxiety in the dream, adding, “I’m afraid of women so a man is
safer. But why am I afraid of women? My mother is a woman.”
The second year of analysis was concerned with his efforts to

separate emotionally from his parents, to improve his sexual
adaptation, and to deal with his chronic anxiety. During this
period he maintained a relationship with one woman, advanced

vocationally, and began to see himself as having an existence
separate from that of his parents, with lessening anxiety about
their death. References to the therapist’s race were minimal,

although when the patient's fear of the therapist mounted, the
menacing black would reappear in his dream life: “A Negro

trooper strikes a white policeman in the stomach. The white man
beats him up.”
Increased separation from his family brought mounting
anxiety about his relationship with the analyst, and he
reconsidered his childhood visits to his aunt’s home in Harlem,

which were marked by a mixture of pleasurable excitement and
fear. The omission of his father’s role in the family, previously
justified by his father's absence at work during the patient’s

childhood, became a therapeutic focus, particularly since any
information about his father had been transmitted by his mother.
During the latter part of the second year of analysis, material
emerged indicating that his father had protected him against the
mother and against destructive women in general. His dreams

became less frighteningly destructive and he dreamed of father
and therapist in terms of helping figures. He was married in the
third year of analysis and terminated six months later. His

functioning had improved considerably in all areas.
Case #3: Black Male Patient, While Female Analyst
An unmarried man with one black parent and one white

parent entered analysis because of his inability to form a stable
relationship with a woman and increasing awareness of his
inability to face marriage. He was also troubled by difficulties at

work, particularly with a woman supervisor, which had
contributed to his recent loss of a job. He was unable to express

his feelings or to tolerate the expression of feelings by others, and
appeared passive, isolated, and dependent upon his mother.
Early childhood was spent in a white commercial
neighborhood in a northern city, living in the maternal
grandfather's home with his lightskinned mother and father.

During the depression, the family moved to Harlem. Thus, at six,
he believed that it was his dark color that necessitated the
family’s choice of home. At 12 to 13 years, he was the successful

vice-president of a gang because of his boxing skills, and two
years later he was caught in his first serious delinquency,
pilfering from the mail. After high school graduation, he got a
construction job and began passive homosexual activities in
toilets, apparently after his mother arranged for his girlfriend’s

abortion. On the job he suffered a minor injury, and during the
subsequent hospitalization he applied to and was accepted by a
large Negro college out of town.
Once there, he lived with an older woman off campus and

avoided both school contacts and fraternities, which were divided
on color lines. He associated only with men who were appreciably
darker than himself. After graduation, he returned to his mother

and sporadic employment until he was encouraged by a
supervisor to take up his work seriously. In his first year he was
successful and well liked and, after applying for analysis, finally
moved into his own apartment, distant from employment and
Harlem. He subsequently noted tenseness, frequent masturbation,
difficulty with his girlfriends, work, and his woman supervisor. He

had lost that job before his analysis had begun.
During the historical recounting in the opening phase of
treatment, the patient used Negro stereotypes to fend off the
analyst. For example, he described how he had been asleep at the

wheel during an accident in which a male friend had been killed
and a girl injured. He sought to impress the analyst that his
subsequent behavior toward the injured girl passenger involved

minimal guilt and maximal undependability. During this period of
treatment, he also acted-out by attempting intercourse with his
stepmother’s sister, related several incidents in which he
presumably had gotten girls pregnant, and recounted several
“rape attempts.” He was finally able to recognize his desire to

scare the analyst by exaggerating the material, “You won’t like me
as much ... do I want to be rejected and construct a situation?” At
the same time, he directly verbalized anxieties about rejection

related only to the building doormen and his feeling that he might
be stopped on entering the lobby.
Dreams of the possibility, as well as the dangers, of a real
concern for an attachment to a woman occurred shortly before he

verbally recognized the analyst’s pregnancy. Not only feelings of
loss, but also those of considerateness were mobilized for the first
time. When treatment resumed, he dreamed he was attempting in

vain to find his Spanish Class, which he identified with passing as
white. He felt that the analyst accepted the self-stereotyped
rejected part of himself that he characterized as Negro. He later

asked, “I wonder if my coming to treatment would tend to make
me feel equal to white.” He became increasingly involved with
color and in a dream indicated that Negro children and white

women, including his mother, could be assertive because they had
rights, while he, as an adult Negro man, had none.
He insisted that he was basically ill-equipped for life, that the

burdens of color and a poor cultural heritage increased his
vulnerability, and that the analyst's attitude that he could make it
only indicated how little she understood. At the same time, trust
and mutuality developed through a discussion of The Invisible
Man, which served as a vehicle for expression of his fears that the
analyst would be paternalistic in setting his fee. For the first time
he contemplated working in Harlem and enlarged upon the Negro
stereotype. “I’ve never worked around many colored people. I

have stereotyped ideas of what the people would be like… more
impulsive, physically impulsive, likely to hit out…I see whites as
having more controls over themselves.”
Near the end of the second year of analysis, he began an

affair with a blonde, white, woman co-worker, and during the
analyst’s second pregnancy he verbalized his feelings more

meaningfully, and began to use insight to control himself. “What
kind of woman do I want…someone like you. I’m not going to get
it while I’m doing all the taking.” The analyst demanded that he
recognize and not give in to his impulse to change all his
relationships with women into sexual affairs, despite his
increased awareness of anxiety and anger. He made an abortive
attempt to escape into marriage, then returned to examine his
feeling that he lacked the equipment to explore reality and his

stereotypes. Months of angry resistance followed, during which
he repeatedly enunciated his desire to get what he wanted as a
gift. Finally, however, he accepted the overtures of his white

employer, who became the first woman outside analysis with
whom he had a friendly, nonsexual relationship. This brought
color specifically back into the analysis, and after he invited her
out to dinner he dreamed that he was castrated and had his penis
in his hand.
At the beginning of the fourth year of his analysis he met the

young Negro professional woman whom he married two years
later. When he met this woman, she was, presumably, engaged to
a very light-skinned Negro man in a position of social importance,

and he both acted-out his oedipal anxieties and became aware of
them in the transference. The use of color as a barrier to sexual

impulses to mother was further explored since it included his
picture of father, the Negro, as neither gratifying mother nor able
to serve as a model for control of impulses, thereby exposing the

patient to his sexual desire for mother. At the same time, he felt
that he had to lose out to a light-skinned man and could win only
if he associated with darker people. “I get angry at all white

people and have to think a second time.” His attempt to exempt
the Jewish analyst because of similarity in minority status was
confronted by the distinction between mutual social problems as
well as his need to obliterate differences. As he grappled to

understand the nature of the sexual barrier between himself and
his therapist, and between himself and his mother, he repeatedly

came back to color. In a dream, the slow analytic train was held
up by white barriers, which represented the analyst, who would
cause the crash and hurt the driver. Furthermore, associations

were to the analyst's open and free attitude toward color in
comparison to his own feelings of prejudice against dark women.
His angry self-justification was: “You’ve had a better life than I. . . .

You can afford to be more liberal, freer of prejudice than I. How
can you understand what it is to be a Negro in America…a bitter
thought… it’s one thing to see something from the outside and
another to live within it.”
During the last year of treatment he reexamined why the
analyst was not afraid of his impulses or of him. “The only reason
I can think of your being scared is because of color; it’s the way I
separated myself from my mother. I associate all my failures with
color. My uncle drove a coal truck and was dirty and I identify him
with color.”
Setting his wedding date precipitated more anxiety, focused
now on fears of having a dark child. He was forced again to face

his prejudices and his feeling that his child would make him more
identifiable, as did his fiancée, who was approximately his color
and had a “pug” nose. At the same time, the realities of his life
made him more aware of his opportunities. The pleasures ahead
of him and guilt at leaving the analyst, as well as his parents,

behind became the final theme of the analysis.
Follow-up has shown that the patient has consolidated the
gains made in analysis. The opening up of his ambitions,

particularly in the beginning of the sixth year of analysis, has
expanded to active and successful work. He sees himself as a
leader in his profession and of his race. His marriage appears

stable and successful. Although he was momentarily upset at the
birth of a child lighter than either he or his wife, he recognized
and coped with these feelings, identified the child as his own, and
made plans for another.
Case #4: Black Male Patient, Black Male Analyst
Although accorded scant clinical attention, the therapeutic
situation in which both therapist and analysand are black
contains both positive as well as resistant features. A 28-year-old

black social worker sought professional help because of feelings
of professional and personal inadequacy, periods of depression
and anxiety, and marital discord. His past history, in brief, was
characterized by an ambitious drive to achieve and gain
recognition, combined with a self-defeating sense of inferiority

which, during childhood, had been reinforced by the negative
responses of his siblings, as well as by covert rejection by his
parents. He approached the therapeutic situation with an
optimism which was enhanced by his therapist’s blackness and
the unconscious, but later stated, impression that he would be

immediately understood and his difficulties would be resolved
without the need for his active participation in the therapeutic
process. In transferential form, he soon began to express feelings

of inadequacy and inferiority vis-à-vis the therapist and to
experience a rapid and malignant pseudo-homosexual anxiety
with respect to his therapist, based on his resort to myths and

stereotypes about the supermasculinity of black men. What began
as a quasi-alliance aimed at his personality reconstruction soon
evolved into marked resistance, panic and feelings of distrust

bordering on paranoid behavior. It was virtually impossible to
examine and resolve these conflicts, and the treatment was
terminated by mutual consent.
Maynard Calnek expresses the view that the black
therapist/black patient therapeutic situation, while promising

much, is threatened by difficulties because of the traditional
American racial climate. Calnek cites instances in which the
therapist’s denial of identification/overidentification leads to a

failure to appropriately assess the impact of class differences
and/or similarities. He concludes, “I have attempted to state that
because of the American racial situation there are some

difficulties involved but not necessarily total roadblocks to
working successfully with black clients. One of my major points is
that the black family and the black community, not the white
family and the white community, should be the reference points
for diagnosis and therapy with any black person’’ (18).
I made an earlier reference to the confluence of

psychoanalysis, literature, mythology, sociology, anthropology,
politics, economics, as important parameters in the interracial
therapeutic situation. While the foe as of this paper has been on
interracial psychotherapy, it would be a gross omission to make
no mention of unconscious racist manifestations in the white-
white therapeutic encounter.
Every black person has a “white mind” and a “black mind”

and every white person has a “white mind” and a “black mind.”
“The white mind constitutes the elements which are uniting and
not disruptive to one’s groups and are therefore socially
acceptable. The black mind constitutes those elements which are
disruptive to one’s groups and are therefore excluded from
society. Racism prevails in every personality since the white mind
is permitted free play in personality and behavior, whereas the
black mind is carefully censored and excluded from the
mainstream of social experience. Disruptive sexual, aggressive, or
other emotions, sudden loud noises, and exciting or annoying
body parts or body products are associated with the black mind
and must be repressed” (19).
Case #5: White Patient, White Male Analyst
Myers (20) is one of the few white behavioral scientists to
focus on the significance and utilization of blackness in the
dreams and other unconscious manifestations of white patients.

His formulation is consistent with those of Pinderhughes, Butts,
and others. “These ‘dirty’ wishes are initially represented in the
dream via the projection onto the black ‘mammy’ and then onto
the real mother. As the color defense was broken down in the
session, the feelings toward the father analyst emerged in more
undiluted form” (p. 10). In the patient under discussion, a 25-
year-old white man with obsessional doubts, the dream was
reported in a session in which he was discussing his fear of the

therapist’s anger because of a missed session. He then related the
following dream: “My father visited me with a black girl friend,
not my mother. He said he’d separated from mother because she

was seeing other men. I got upset but he seemed right in doing so.
I felt I should live with him but I cried and said, ‘I love mommy
more and I want to live with her,’ and he understood. Then my
mother walked in and there was a man in a wheelchair who was

having ideas of my mother naked and of having sex with her. I got
anxious then and awoke.”
Myers continues, “He associated to his sense of strangeness

at seeing his father with a black girl. She reminded him of an
attractive black patient of mine he had had sexual fantasies about
and who he felt interested me more than he did. He perceived his

competition with my black patient as paralleling his earlier
competition with his sisters for his mother’s love.”
Myers reports on another patient, a white woman in analysis
for anorexia nervosa. She dreamt frequently of swimming

through seas of black feces, struggling to reach some pure white
object. “In such dreams, the color black was seen as the
representation of her sexual and aggressive wishes, which she
had to keep hidden and under control, and the color white was
conceptualized as the asexual, nonaggressive exterior she wished

to present to the world, especially to her mother.”
In his summary, Myers states, “The emphasis in the paper is

placed on the defensive and resistance aspects these colors seem
to serve against the emergence of the affectual aspects of the

transference neurosis…wishful self-representations and idealized
object-representations utilizing the colors black and white are

seen in both inter- and intra-racial analyses . . (p. 17).
I have cited Myers’ references because I believe they have

limited applicability to the issue at hand. It is abundantly clear
that white patients make use of blackness with white therapists in

much the same way that white patients do with black therapists.
In my discussion of Myers’ paper at its presentation in 1975, I
debated what I regarded as a limited view of the issues. “Since,

however, both black and white patients have introjected both the
positive and negative black stereotypes, it is surprising that only
the negative transference or resistance aspect was evidenced in
Dr. Myers’ analyses. There were in my opinion several instances
in which the analytic data rather easily lent themselves to
interpreting blackness as being an expression of the positive
transference.
Terry Rodgers (21), a white psychoanalyst, reports on the

therapeutic vicissitudes, development of unconscious racism and
then overt rabid anti-black sentiments in a white analysand. The

treatment occurred in the South. The patient, a 43-year-old,
single, white man, sought analysis for a variety of neurasthenic
symptoms that had begun when his father died 12 years prior to
the analysis. His symptoms were, for the most part, obsessional,
and he tended to dichotomize everything as either good or bad,
clean or dirty, acceptable or unacceptable. Both his parents also

exemplified obsessional character traits. He was cared for by a
black nurse. Early in the course of therapy it became apparent
that “a common denominator running through all his obsessive

symptoms was a struggle with authority” (p. 240). An early dream
made reference to a “black cane,” and to the sexual freedom of
adolescents. The confluence of the two themes resided in his

unconscious view of blacks as sexually lascivious. As his defenses
began to yield to analytic uncovering, he made repeated
references to the integration-segregation issue, finally reporting
the following dream: “My mother is by me on the ground about to
be gored by a huge bull with black horns. I feel momentarily

paralyzed as in the other dream, but by an enormous act of will I
overcome it. Then with a feeling of almost unlimited strength I
leap at the bull and rip its horns off with my bare hands. I feel an
indescribable sense of triumph and exhilaration.”
There were obvious transferential references in the dream
(father/ a black cane, therapist’s black horn-rimmed glasses, and

the association between black horns and black people). He
terminated shortly thereafter and became intensely involved in
anti-black political activities. Rodgers summarizes: “Thus, by the

wholesale use of the defense mechanisms of projection and
identification with the aggressor, he protects himself against
eruption into awareness of (a) his unconscious homosexual

wishes, (b) his incestuous desires, and (c) his patricidal impulses
—and in so doing wards off a potential psychotic breakdown.

Instead of being the white female who will be attacked by the
Negro male (father, analyst) or the Negro male who commits the
unpardonable crime of sexual union with the white female
(mother), he becomes the powerful white male who protects the

white female from the fantasied lust and aggression of the Negro
male.”
Rodgers draws heavily upon Sterba (22) in his

psychodynamic formulation as to the significance and utilizations
of blackness by white patients:
. . . our negative feelings against God the Father have to be displaced onto
a substitute figure which is created for this purpose, and that is the devil.
Psychologically God and Satan were originally one and the same. The
myth of the fall of the angels betrays that originally the two belonged to
the same locality; Satan wears horns which are attributes of gods in
many other religions…Satan is therefore the substitute for God as the
object of our negative feelings, which derive from our original
ambivalence toward our father in childhood. The devil has one
significant feature in common with the Negro: Both are black. In the
unconscious of many people the two are identical, both being substitutes
for the father insofar as he is hated and feared (22).
Case #6: White Female Patient, Black Male Analyst
The transference/countertransference issues that have been

described have occurred in the context of the treatment of
patients who presented neurotic conflicts. The utilization of race

either in the service of resistance to treatment or as an expression
of the positive transference is rendered infinitely more

complicated in patients with integrative pathology or borderline
pathology. In such patients the pathology, transference and

countertransference constitute a rather tangled skein requiring
extreme sensitivity, careful timing, selectivity and skill, in those
instances in which patient and therapist differ racially. The

presentation of a patient illustrating the aforementioned issues is
extremely salient because both black and white therapists have
treated and will treat a significant number of borderline patients

and patients with integrative pathology.
In this case the patient, a 53-year-old Jewish woman, was

readmitted to a psychiatric hospital after having attempted to
cope as an outpatient for approximately a month. Her most

pronounced symptomatology on admission consisted of a fixed
delusion that ultrasonic rays were being transmitted into her
body, resulting in her physical discomfort and inability to remain
in her apartment. Her symptom had existed for several months,

but had become more intense just prior to admission. Other
problems elicited by the therapist early in the course of this
patient’s therapy consisted of (a) an incapacity for close, intimate

interpersonal relationships; (b) internal object splitting according
to the pleasurable or unpleasurable nature of the affect associated
with the object; (c) an inability to perceive others as separate

from herself, but a tendency to identify others in terms of
projected parts of herself; (d) cyclic alterations in thinking,
feeling, and behavior; (e) vacillation between an erotic-dependent

transference relationship and a hostile, vindictive, demanding one
with marked fear accompanying the former reaction and intense
guilt-fear accompanying the latter; (f) a tendency in the direction

of over-intellectualization; (g) a general weakening of ego
boundaries, reality testing and a lessened tendency to engage in
secondary process thinking.
Some aspects of her history will be described. She was born
and raised in New York City. Her parents were a merchant and a
homemaker. She was the last of three girls and recalls that her
father constantly stated he was disappointed that she was not a
boy. She regards herself as rejected and physically abused by her

parents and sisters Irene and Anna but actually received some
degree of support and solace from her mother. She characterized
herself as a brilliant but erratic student. Her rebelliousness
resulted in her dismissal from two high schools. She ran away
from home on several occasions during adolescence. At age 15
she ‘‘lost interest in school” and began playing the piano in night
clubs. The next ten years were a chaotic period with periodic
unemployment, periods of prostituting and use of opiates. She
married a fellow musician at age 26 and after seven years of

mental strife they separated. The next several years were
characterized by a series of ungratifying affairs, diminished use of
opiates, and gradual withdrawal from interpersonal contacts.

Contact with her family decreased and painful verbal altercations
occurred with each encounter.
Her withdrawal continued until her admission to the

hospital. Her diagnosis was “borderline personality” and she
exemplified the object-splitting, ambivalence, lability of affect and
other symptoms consonant with that disorder. She was, at times,
extremely hostile, and at other times quite seductive.
Approximately three months after admission she reported
several dreams. The first was as follows: “In a huge meeting hall
filled with people, a young woman was selling tickets. She was
busy. I didn’t like her face. It was ugly. I saw my sister smiling. It
was a Communist party function and she wanted me to join. I

pretended not to see her. She tried to make me notice her. I saw
my psychiatrist. He was young, white and handsome. I accused
him of plotting with her. He replied that he had nothing to do with
it. I begged him to keep her away. He put a black umbrella
between the two of us. I wanted him to take me home and fuck
me.”
Therapist interpreted patient's wish that he “protect” her
from her sister.
The patient then reported this dream: “A postman in
uniform. Fear. The middle of the night. He said he had come to

deliver something. He had a large package from Irene that
contained two puppies and three kittens. They were beautiful. I
was annoyed. The puppy peed on the floor. I began fondling them.
One pup should be a protector when it grows up. I was in the
street naked. A woman permitted me to wear her jacket. The
animals were starving. They were skinny and looked ugly. One
kitten died. One was Persian white. Another was black and white
(spotted). One cat grew vicious and clawed my arm, looked like a
rat. I tore it off my arm.”
She associated: “My sister was the cat that turned into a rat.
The three kittens were me and my two sisters. One puppy was
you (would protect me when it grew up). I wish you would see me
objectively. I’m disturbed by the staff on the 4-12 shift. The
vibrations are happening in my bed.”
Therapist interpreted her wish to separate from her sister
Irene and move toward therapist and the fact that this
represented a source of anxiety.
She began the next session by presenting me with a gift,
additional thoughts about the dream: “Coming in the middle of

the night. This boy on his shoulder (transference?). You were
being made a member of the family. I always wished for a brother.

I really wished for two brothers. I should have been a brother. My
father is fair, my mother is dark skinned (used to call her a
gypsy). Anna got mother's love. I didn’t get anybody’s love. I was
relieved to have the rat off my arm.” She had an altercation with
staff the night before.
She was obviously making several references to the
transference: “The black umbrella,” the two puppies, one of which

was dark, the “black and white” cat, the reference to her “dark
skinned” mother. The racial transference both facilitated and
served as a resistance to treatment. Her object splitting was
facilitated by references to blackness and its antithesis,

whiteness.
The following dream and its associations further exemplify
her unconscious utilization of blackness: “Anna and I were in a
secondhand bookshop. I pulled out a handsome volume and we

leafed through it. It seemed to have something to do with the
history of ancient warfare. We decided to steal the book at my
suggestions and as we approached the door the owner was
looking straight at us so I motioned for her to slip it to me; she did
so and we got out all right. Then outside it was dark, there was no
landscape and it was windy; we were alone (no people). As we
walked, I turned toward her and said (but not exactly in so many
words) that we must love and trust each other. An embrace was
attempted but not consummated, our bodies seemed to go awry.
Then I held her away from me a bit to study the expression on her
face, to see if she was in sympathy or crying. Instead, I observed
her puzzlement that the side of her face turned toward me was
black. I believed that this was a theatrical makeup and that the
other side was white; I wondered why she had put on the
makeup, then I wondered whether it really was her skin. At some
point earlier in the dream, on leaving the bookstore, we looked at

an illustration in the book and it depicted male exultation in
warfare. I wanted to learn why men took such fierce pride in

destruction. But I learned that the book was a sham; at the very
opening there was a reference to Kitty Carlisle and early days of

movie making with particular reference to her costume jewelry.”
She associated the secondhand bookstore to “things written

down,” “as opposed to intellectualized”; “warfare with my sister.”
The handsome volume may have represented her past
(anamnestic material). Stealing the book represented her taking
that which was not freely granted (love?). She equated the shop
owner with the therapist (= father). She was relieved to be out of

the store, “we seemed to move to an emotional plain” (although
barren and windswept). She compared the dark barren exterior
with the treatment room. Made efforts to be loving toward “I” but
to no avail. “She was cold.” “Is a sham.” She got all involved in the
Angela Davis case, pretending to be pro-black while acting

antisemitic. “Anna’s face was half-white, half-black.”
“I still wonder if there’s something secret going on between

the two of you. Like you’re in league with each other. Men want to
win all the time. Like you.” She equated the book to sessions and
referred back to the theme of trust in the last session. “If I trust
you, you will destroy me?”
The dream was an obvious transference dream in which her
sister was substituted for therapist and an effort made to

reconcile their warlike differences and substitute a more losing
relationship. The dream indicated a wish to be involved in

therapy, but a marked ambivalence and fear related to her
perception of therapist’s power-orientation. The theme was

optimistic, in that the dream represented therapeutic engagement
and a willingness to begin trusting her therapist.
Racism and Psychotherapy
Schachter and Butts (12) underscore the fact that:
1. Racial differences may have little or no effect on the course

of the analysis.
2. Racial differences may have catalytic effect upon the
analytic process, and lead to a more rapid unfolding of
core problems.
3. Stereotypes of race and color occasionally induce both

analyst and patient to delay the analytic process, either
by obscuring reality or by overestimating its
importance.
4. Subculturally acceptable pathology or acting-out may

evoke overreactions in the analyst while material
fitting racial stereotypes may be ignored.
5. Countertransference may coincide with stereotypes and

delay the analytic process.
In addition to underscoring the efficacy of interracial therapy

and emphasizing the issues (both transferential and
countertransferential as well as realistic) that catalyze or impede
the therapeutic process, one cannot ignore the fact that

unconscious racism and lack of awareness and sensitivity to the
black (and other minority) experiences are crucial factors in the
treatment accorded to blacks by whites.
Harrison and Butts (9) recommended that “one should tell

patients honestly that their racial stereotypes do not get them
doctors who are appropriate for them, and that stereotyped

thinking only leads to more psychological troubles, particularly
when it degrades or gives super-powers to someone based on

racial characteristics’’ (p. 281). If psychoanalysts and
psychotherapists are to advocate healthy and adaptive behavior
on the part of their clients, it would behoove the mental health
professionals to look to their own unconscious racism.
Based on this survey (9), destructive racial attitudes among
psychiatrists manifested themselves in the following ways:
1. A fear that the black psychiatrist would not be able to cope

with the racial attitudes of the patient, leading, in some
cases, to: (a) failure to make referrals at all; and (b)
failure to utilize the therapeutic effect of the positive
aspects of the syndrome of the “liberal white patient”
who is pleased with referral to a black psychiatrist.
2. Failure to refer patients because of overconcern that racist

attitudes from these patients will “humiliate” and
“hurt” the black psychiatrist.
3. Feelings that black psychiatrists are better able to treat

children, adolescents, hippies, and super-liberals,
which explicitly assumes a better communication
between black psychiatrists and these anti-
establishment patients. This unfortunately parallels in
psychiatry the national policy of lumping together
those groups that are seeking to change society as it is
today.
4. Feelings that the black psychiatrist is better able to treat

working-class patients, particularly black patients who
use color as a defense. Working black patients pay
lower fees. This has led to the misconception that
competency in this area is due to the color of the
psychiatrist rather than due to the talents of a skillful
professional. Further, lack of skill or failure to learn
techniques utilizable with this group of people was
then excused on the basis of lack of color. Because
there are so few black psychiatrists, these patients
receive minimal psychiatric services at best. This
exemplifies institutional racist practices.
5. Low-fee or free clinics without religious affiliations are

remarkably free of any consideration of race when
servicing clients. Only as fees increase, or in private
practice, does racial differentiation in the selection of a
therapist become an important issue. Fortunately,
these low-fee or free clinical experiences allow us to
see the irrelevance of race as an issue in a therapeutic
relationship.
6. There is overconcern for the preference for a black

therapist by the black patients which in reality can
never be met, and subsequently leads to no treatment
at all for many of these patients.
7. Some of the white psychiatrists expressed their own initial

reactions at being taught and interviewed by black
psychiatrists, i.e., anxiety around feelings that the black
psychiatrist was unable to teach or evaluate them. They
reported that their anxiety decreased and that they
were relieved to discover his competence.
8. White psychiatrists do not appear to accept the fact, or

point out explicitly to patients with racist attitudes, that
racial prejudice is a crippling symptom. They merely
ask, “Why the feeling?’’ When a person has to use
degradation of a group of people to maintain his own
self-esteem, he is sick in this area and should have
treatment around this issue, beginning with
identification of the symptom as indication of illness.
The failure to identify the symptom as evidence of
illness may result in diminished referrals of white
patients to black psychiatrists. The white psychiatrist
may often feel that this symptom is an impossible one
to treat, because of his failure to establish modifiability.
9. Both black and white psychiatrists report reactions of

white patients to black therapists. White psychiatrists
tend to report such reactions of white patients to black
therapists as “shocking,” “jolting,” “dismaying,”
“disorienting.” Black psychiatrists use words like
“surprise.” There seems to be evidence here then that
patients’ reactions to a black psychiatrist are perceived
as more intense by the white psychiatrist.
10. Defined explicitly as their own stereotypic thinking by the

white psychiatrists is that the black psychiatrists: (a)
“have a natural sense of rhythm”; (b) are tied up in
exploring and exploiting black/white situations; (c) are
trying to work out past problems and change them a
bit; and (d) are a little whiter than most blacks.
11. Only half of the psychiatrists polled have close black

friends. This lack of social opportunity for modifying
racial stereotypes contributes to the ineffectiveness of
white psychiatrists, not only with black patients, but in
the referral of white patients to black psychiatrists.
Black psychiatrists encompass the greater part of the
white culture, in contrast to white psychiatrists, who
make no efforts to move into the black world.
Harrison and Butts made the following recommendations:
1. One should tell patients honestly that their racial

stereotypes do not fit doctors who are appropriate for
the patient and that stereotypic thinking only leads to
more psychological troubles, particularly when it
degrades or gives super-powers to someone based on
racial characteristics. Patients with questions or
ambivalence about black psychiatrists need a definitive,
reassuring statement by the white psychiatrist, not just
an exploration of their feelings. Black psychiatrists are
much clearer about this with their patients than white
psychiatrists.
2. It is educational and ego-broadening to intimately know

people of other ethnic groups. All psychiatrists should
have this experience and get to know black people.
They will then be able to deal more effectively with
prejudice as a sickness in patients and society. A
broadening of professional and social relationship
increases the knowledge of others and self-knowledge.
Conclusions
In a multi-racial society such as ours, unconscious myths and
stereotypes are ubiquitous, are maintained by both minority and

majority members, and impact not only upon social relationships,
but upon the processes of psychotherapy and psychoanalysis.

There is no doubt that analysis or psychotherapy between blacks
and whites can be effective, but the therapists involved in these
treatments must be mindful of the resistances, catalytic effects of

racial differences, and, in addition, must be aware of the fact that
both black and white patients have incorporated the unconscious

notions extant throughout the society.
The author draws heavily upon literature for examples as to
the meanings and utilizations of blackness and whiteness. It is
somewhat disconcerting and perplexing that white therapists and
analysts have made so few references to “black thoughts” and
“black deeds” surfacing in their treatment of white patients. It is

also strange that only 4% of our nation's psychiatrists today
belong to minority groups, even though the admission rate of
non-whites to public mental hospitals is double what it is for

whites. Equally amazing, only 7% of the research awards made by
the National Institute of Mental Health are of major relevance to
minorities, despite the stresses of prejudice and racism they must

suffer. In addition, there are three black medical training analysts
in the United States. Rather than a bid for behavioral science
affirmative action, these statements are intended to put into a

more comprehensive context the clinical issues referred to
earlier.
This paper is an effort to examine pro-white, anti-black

paranoia as it evidences itself in every therapeutic situation. For
too long the focus has been on the white therapist/black patient
duo. The vistas of this presentation have expanded to include the

black therapist/white patient, black therapist/black patient, and
white therapist/white patient. In each pairing, with varying
degrees of intensity and frequency, references are made to
blackness, “black thought and feelings,” “black deeds.” The unique
background of each therapist and patient will undoubtedly

influence the timing, form, frequency and intensity of the
reference(s) to “blackness.” Transference and
countertransference manifestations that utilize blackness may

occur in therapeutic and analytic situations. Although the main
thrust of this paper has been a clinical one, since the focus is on
emphasizing certain clinical issues (unconscious racism) that
generally tend to be minimized or overlooked, one might, in
broad terms, regard aspects of this presentation as “political” in

nature (see Henry Stillman’s (24) definition of politics as the
science of how who gets what when and where). It would be
naive to discuss clinical issues in isolation from institutional

training practices, institutional racism and reality issues that have
an impact on the treatment and therapists that effect patients.
Pinderhughes (19) concludes:
The data on human beings from all sources overwhelmingly support the
conclusion that man is more paranoid than wise. This paranoia is not
accessible to reason, and attempts to alter it lead to confrontations and
often to violence. The paranoia is especially oppressive and deadly when
it has been frozen into culture and when it has molded institutions.
When enough influential men in important institutions decided to

humanize the structures over which they have power, then dissent,
revolt, and revolution cease, the leaders are embraced with appreciation
and affectionate bonds. However, there must be a sizeable number of
such leaders, enough to constitute a movement among influential men.
In essence, to eliminate racism, it would be necessary to develop a

rededication to democratic and humanitarian values, a shift from the
ethics of competition to those of sharing and a new order of priorities in
major institutions.
Factors like these determine, to a considerable degree, needs for

psychotherapy, the nature of it, and who receives it. Factors like these
determine the philosophies, the rationales, and the ethics with which
psychotherapy is practiced and must be considered relevant in any
discussion of racism and psychotherapy.
The author could not agree more wholeheartedly. In an

unpublished article (23), the author expresses a view comparable
to that of Pinderhughes. The American educational system is
criticized for its lack of humanism and for its emphasis on

technology. Such a value system lends itself to the type of
dehumanization exemplified by pro-white/anti- black paranoia.
Postlude
I sit on a man’s back, choking him and making him carry me, and yet
assure myself and others that I am very sorry for him and wish to lighten
his load by all possible means—except by getting off his back.
Leo Tolstoy
Both individuals are victims and both bear the emotional
scars of the slave-master relationship.
REFERENCES
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Assoc., 1953, 1:256-26.
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1951.
3. Kennedy, J. A. Problems posed in the analysis of Negro patients. Psychiatry, 1952,

15:313-327.
4. Oberndorf, C. P. Selectivity and option for psychotherapy. Amer. J. Psychiat.,

1954,110:754-758.
5. Pinderhughes, C. Understanding black power—processes and proposals. Amer. J.

Psychiat., 1969, 125-11.
6. Comer, J. White racism: Its root, form, and function. J. Amer. Psychoanal. Assoc., Dec.
1969, 126:6.
7. Palmer, Don. White training institutions. The Black Psychiatric Resident—The

Encounter (unpublished).
8. Butts, H. F. White racism: Its origins, institutions, and the implications for
professional mental health practice. Int. J. Psychiat., December 1969, 8(6).
9. Harrison, P. and Butts, H. F. White psychiatrist racism in referral practices to black

psychiatrists. J. National Med. Assoc., July 1970, 62(4).
10. Cannon, Davis, Elam, et al. Personal communication.
11. Pinderhughes, C. Discussion of white racism: Its origins, institutions, and the
implications for professional mental health practice. Int. J. Psychiat., December
1969, 8 (6).
12. Schachter, J. and Butts, H. F. Transference and countertransference in interracial

analyses. J. Amer. Psychoanal. Assoc., October 1968, 16(4).
13. Butts, H. F. Psychoanalysis and unconscious racism. J. of Contemp. Psychother., Spring

1971, 3 (2):67-81.
14. Melville, Herman. Moby Dick. New York: The Bobbs-Merrill Co., Inc., 1961, pp. 252-
264.
15. Fiedler, L. A. Love and Death in the American Novel. New York: Criterion Books. 1960,
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1977, unpublished.
17. Fanon, F. The Wretched of the Earth. New York: Grove Press, 1963, p. 32.
18. Calnek, M. Racial factors in the countertransference: The black therapist and the
black client Amer. J. Orthopsychiat., January 1970, 40(1).
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Racism and Mental Health. Contemporary Community Health Series. University
of Pittsburg Press, 1973.
20. Myers, W. A. The significance of the colors black and white in the dreams of black
and white patients. American Psychoanalytic Association meeting. December 20,
1975.
21. Rodgers, T. C. The evolution of an active anti-Negro racist. The Psychoanalytic Study
of Society, 1960, 1:237-247.
22. Sterba, R. Some psychological factors in Negro race hatred and in anti-Negro riots.
Psychoanalysis and the Social Sciences, Vol. 1. New York: International
Universities Press, 1947, pp. 411-427.
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1119.
24. Hellman, S. Partial primer for all Americans. 1944.
20
Psychotherapy with Alcoholics
Sheldon Zimberg, M.D.
Introduction
Psychiatry has in general not been very effective in treating

alcoholics. Most psychiatrists have little interest or experience in
this field. Since most psychiatric residencies at the present time

do not offer clinical training in the addictive disorders,
psychiatrists are ill equipped to diagnose and treat alcoholism.
Therefore, with a few exceptions, psychiatry has left the field of
alcoholism largely to Alcoholics Anonymous, a few interested

internists and general practitioners, and paraprofessional
alcoholism counselors. However, psychiatry with its

understanding of psychodynamics and the sociopsychological
factors relating to human behavior can make important
contributions to this field.
It is generally accepted that psychological factors alone are

not sufficient to produce alcoholism in an individual.
Sociocultural and physiological factors (possibly of genetic origin)
along with psychological mechanisms are the necessary and
sufficient contributors that produce the clinical state of

alcoholism. Flow these factors interrelate to produce alcoholism
in a particular individual is unknown. In some individuals one of
the three factors may predominate. However, alcoholism shares

with many other mental health related disorders a lack of
etiological knowledge along with some fairly effective treatment
approaches.
This chapter will present a psychiatrist’s understanding of

sociopsychological factors relating to alcoholism and the
approaches for successful psychotherapy of this condition in a
significant number of alcoholics. The experience and views

presented are based on the author’s work with many alcoholics in
urban ghetto alcoholism programs, in a suburban community
mental health center, and in private psychiatric practice. There

will also be a discussion of results obtained in the treatment of
alcoholics during a two-year period in the author’s private
psychiatric practice.
Psychodynamics of the Primary Alcoholic
There is considerable literature on psychoanalytic theories of
alcoholism. Much of this literature was reviewed by Blum (1).

Blum indicates that psychoanalytic concepts can be applied to the
psychodynamic understanding of alcoholism and that oral
fixation is the arrested stage of development for the primary
alcoholic. This fixation accounts for the infantile and dependent
characteristics noted in alcoholics, including excessive narcissism,
demanding behavior, passivity, and dependence. This fixation

occurred in the development of the primary alcoholic due to a
significant degree of deprivation during early childhood
development. Other types of alcoholics are described as being

fixated at the anal level or the phallic oedipal stage. There is
considerable evidence to support the view that alcoholics had
been exposed to rejection by one or both parents and that

dependency needs are among the major psychological factors that
contribute along with other etiologic factors to the development
of alcoholism (2, 3, 4, 5, 6).
The dependency needs of many of the alcoholics the author

has treated have been profoundly repressed and there was often
little evidence of overt passivity or dependent traits when the

patients were sober. Such dependent and passive traits were
apparent, however, when they were under the influence of

alcohol. Alcoholics who were sober in many cases had obsessive-
compulsive personality traits. They were often perfectionistic and
in need of maintaining control over their feelings and their lives,

and were often completely unaware of the most intense feelings,
particularly anger. Therefore, it is not appropriate to look for or
to characterize an “alcoholic personality.” The psychological

conflict that is discussed below forms a psychodynamic
constellation which is the key psychological factor in alcoholism
and is the core conflict that must be dealt with in therapy. This
psychodynamic constellation is a common problem among

alcoholics, but does not produce a common personality.
The psychodynamic conflict that the author found in the
alcoholics he has treated has been lack of self esteem, feelings of

worthlessness, and inadequacy. These feelings are denied and
repressed and lead to unconscious needs to be taken care of and
accepted (dependent needs). Since these dependent needs cannot

be met in reality to compensate for the profound feelings of
worthlessness, they lead to anxiety and compensatory needs for
control, power, and achievement. These excessive needs are often

doomed to failure, resulting in the use of alcohol which
tranquilizes the anxiety felt in the face of failure and, more

importantly, produces, pharmacologically, feelings of power,
omnipotence, invulnerability. When the alcoholic wakes up after a
drinking episode, he is full of guilt and despair because he hasn’t
achieved anything more than before he drank and his problems

remain. Thus, his feelings of worthlessness are intensified and the
conflict continues in a vicious circle fashion, often with a
progressive downward spiral.
McClelland et al. (7) conducted extensive research with male
alcoholics on the effects of alcohol on feelings and imagery. They

noted that alcohol produces “ego-enhancing” effects and thoughts
of power and strength. They hypothesized that “drinking serves
to increase power fantasies and that heavy liquor drinking
characterizes those whose personal power needs are strong and
whose level of inhibition is low.” They rejected the theory that

alcoholism is related to dependent needs since they were unable
to demonstrate increased fantasies regarding warmth and
dependency during drinking. Similar studies conducted among

women alcoholics by Wilsnack (8) suggest that alcohol enhances
feelings of womanliness.
The psychological mechanisms presented above are basically

not in conflict with McClelland's or Wilsnack’s theories, since the
male alcoholic can be viewed as striving for power and control
consciously and the woman alcoholic as striving for womanliness

as compensations for unconscious feelings of worthlessness, a
poor self image, and the need to be nurtured. Alcohol provides an
artificial feeling state of power and control in men and increased

feelings of womanliness in women that cannot be achieved in
reality for very long. The very act of producing such feeling states
at will feeds the alcoholic’s conscious grandiose self image. This
intense need for grandiosity can be called a reactive grandiosity.
McCord and McCord (9) conducted longitudinal studies of
families. Some of the boys in the families under study later

became alcoholics. They noted that alcoholics were often raised in
homes that could be characterized as conflict-ridden, and in

which there was an extremely erratic, unstable mother and a
rejecting, punitive father. They noted the alcoholics had evidence
of heightened dependency needs which were unacceptable and
had feelings of being victimized by society and compensatory

feelings of grandiosity. Feelings of fearlessness, self-sufficiency
and aggression that were noted in prealcoholic boys were felt to
be a facade erected in place of feelings of rejection and a

heightened desire for dependency.
The observation that the core psychodynamic problem in the
treatment of alcoholism is reactive grandiosity and a need to feel

omnipotent was discussed in Tiebout's paper describing the
psychological process by which an alcoholic becomes involved in
Alcoholics Anonymous (10). The conversion process was

described as occurring in four steps: 1) the need to hit bottom; 2)
the need to be humble; 3) the need to surrender; and 4) the need
for ego reduction. These steps were based on Tiebout’s

observation of an excessive amount of narcissism in the
alcoholic’s ego which gives rise to feelings of omnipotence. The

steps in the conversion process are necessary to produce a
reduction in this narcissism which perpetrates the self-
destructive drinking behavior and the coexisting denial of this

behavior. Tiebout did not indicate in this paper what happens to
the excessive narcissism of the alcoholic’s ego. Clearly, the
narcissism is sublimated toward the goal of A.A. to rescue other

alcoholics. Thus, the grandiosity becomes fulfilled and socially
useful in the rescuing of other alcoholics. A.A. members recognize
that their help of other alcoholics is a way that they keep
themselves sober. The first step in the 12 steps of A.A. is the

recognition of the alcoholic’s inability to control alcohol. With this
recognition, there is also the beginning of recognition of one’s

inability to control other aspects of one’s life. Thus, the
beginnings of humility appear in an alcoholic, with a crack
developing in the wall of denial built by the need for omnipotence

as the alcoholic becomes involved in A.A.
Therefore, the central problem in rehabilitating an alcoholic
is breaking through the reactive grandiosity that produces the
massive denial of profound feelings of inferiority and dependency

and perpetuates the pattern of self-destructive and family
destructive drinking. The alcoholic not only destroys himself but

his loved ones as well, without really perceiving his lack of control
of this behavior pattern. The typical response of an alcoholic
without insight into this behavior is, “I can stop drinking any time
I want to.” This occurs in spite of overwhelming evidence to the

contrary. This self-deception must be penetrated if rehabilitation
is to succeed.
Sociopsychological Factors Affecting Treatment
In addition to recognizing the psychodynamics of the
alcoholic in treatment, one must recognize the social

circumstances of the alcoholic. It is necessary to evaluate the
family and marital relationships that exist or existed in the past,
as well as the employment situation. In addition, information
should be obtained regarding the cultural attitudes toward
drinking and drunkenness that existed in the individual's family

while he was growing up and how he integrated these attitudes
into his present drinking behavior.
There must be a determination as to how the individual has

handled crises and stress, and whether he has been able to modify
or stop destructive drinking behavior spontaneously in the past,
and for how long. One must determine at what level the
individual is psychologically, socially, and developmentally and
how he reached these levels historically.
The social, family, and cultural contexts in which problem

drinking occurs are significant factors in determining what
treatment approaches can be most effective with the individual,

and to determine what influences can be brought to bear to
convince the alcoholic of his need for help. Coercion is often
necessary because of the massive denial and self- deception that
exist. Industrial alcoholism programs often use the implied threat

of losing one’s job unless the individual enters a treatment
program for his alcoholism. Such programs report relatively high
rates of success in rehabilitating their alcoholic employees. Such

coercion can be viewed as therapeutic leverage in which a small
degree of self-awareness is forced upon the alcoholic. Such

therapeutic leverage can be useful; however, it cannot in and of
itself produce recovery, which can occur only in the treatment
process which will be described below. Therefore, looking for
possible sources of therapeutic leverage should be a part of the

initial evaluation of an alcoholic.
All alcoholics are not the same, even though most share the
common psychodynamic conflict with dependency and the need

for compensatory power and control. Alcoholics exist in differing
age groups, socioeconomic circumstances, and cultural groups.
Approaches with the skid-row homeless alcoholic cannot be the

same as with the so-called “high-bottom” executive, or with the
individual living in poverty in an urban ghetto. The skid-row
homeless person is at the bottom of the barrel socially. He

reached this depth after a prolonged history of alcoholism and
has developed an adaptation, although a very tenuous one, to this
state. The social, physical, and psychological consequences of this

state require differing approaches aimed at physical, social, and
vocational rehabilitation requiring years to accomplish. The

executive who is still employed requires approaches dealing with
his drinking, education about alcoholism, and psychotherapy
and/or involvement in A.A., since social, vocational, and physical

deterioration have not progressed to a severe degree.
One must make a distinction among various populations of
alcoholics—for example, people living in poverty. In this case

drinking problems are often a reaction to the depression and
stress of poverty. Alcoholism treatment for this group is
necessary, but not sufficient to produce recovery. Socioeconomic
incentives are needed to provide a motivating force to remain

sober once sobriety has been produced through treatment (11).
It has been noted by several studies that different
subpopulations of alcoholics respond differentially to various

treatment modalities (12, 13, 14). Varying social and
psychological factors in the alcoholic subpopulation will affect
outcome. Therefore, programs that offer the widest range of

treatment alternatives will have the greatest success for mixed
populations, as well as those programs that provide the most
effective specific approaches to a relatively homogeneous

subpopulation.
The elderly alcoholic facing the stress of aging uses alcohol to

cope with these problems (15). Treatment in such cases can be
effective by dealing with the depression and social isolation of the
individual with socialization activities and antidepressant
medication best carried out in a setting serving the elderly.
Therefore, treatment approaches must be based on
knowledge of the sociocultural norms, attitudes and needs of the

patients under treatment. Sociocultural influences are often
major contributing factors in the etiology of alcoholism, and such

influences must be understood if the alcoholism is to be
successfully treated.
It should be noted that alcoholism does not occur as an all or
none phenomenon, but rather as a degree which will vary in
severity from time to time in the same individual. Table 1 shows a

scale (16) which approximately defines varying levels of severity
of alcohol abuse from no problem to the skid-row alcoholic at
level six. Improvement in treatment can be determined by

movement upward in this scale, although the goal of abstinence
with improvement in social functioning and greater awareness of
and insight into one’s behavior should be the end point of
rehabilitation.
Table 1
Alcohol Abuse Scale
Level Characteristics
1. None Drinks only on occasion, if at all.
2. Minimal Drinking is not conspicuous, occasional intoxications (up to 4 per

year). No social, family, occupational, health, or legal problems related
to drinking.
3. Mild Intoxication occurring up to once a month, although generally limited

to evening or weekends, and/or some impairment in social, family
relations, or occupational functioning related to drinking. No physical
or legal problems related to drinking.
4. Moderate Frequent intoxications, up to one or two times per week and/or

significant impairment in social, family or occupational functioning.
Some suggestive evidence of physical impairment related to drinking,
such as tremors, frequent accidents, epigastric distress, loss of
appetite at times. No history of delirium tremens, cirrhosis, nutritional
deficiency, hospitalizations or arrests related to drinking.
5. Severe Almost constantly drinking (practically every day). History of delirium

tremens, liver cirrhosis, chronic brain syndrome, neuritis, nutritional
deficiency, or severe disruption in social or family relations. Unable to
hold a steady job but able to maintain himself on public assistance.
One or more arrests related to drinking (drunk and disorderly).
6. Extreme All the characteristics of severe impairment plus homelessness and/or

inability to maintain himself on public assistance.
The Treatment Process
The treatment of the alcoholic is a long-term process.

Alcoholism is a chronic illness with a high potential for relapse. As
in other such chronic disorders, continuous care is required in

some cases for the duration of the individuals’ lives. Alcoholics
Anonymous is particularly well suited to provide this supportive

treatment for an indefinite duration. All an individual has to do is
to attend meetings and follow through with their “12 Step’’
procedures. However, professional intervention during the

beginning stages of treatment is necessary to provide
detoxification from alcohol and a thorough psychosocial
evaluation. The psychotherapeutic process described is best

suited for middle-class alcoholics who have family ties and a
reasonable amount of socioeconomic resources.
Directive counseling during the process of detoxification can
enhance the motivation of an alcoholic to continue the treatment

after detoxification has been completed. Detoxification from
alcohol can be accomplished in many cases on an ambulatory
basis (17) using diazepam (Valium) 5 mg. 3-4 times a day

progressively reduced over 1-2 weeks. Patients are seen in the
office 2-3 times per week during the detoxification, but not
maintained on Valium after detoxification. Patients who cannot be

detoxified on an ambulatory basis should be hospitalized.
Counseling or more intensive psychotherapeutic approaches
are often necessary after detoxification has been accomplished.
Acquainting the alcoholic with the physical effects of alcohol on

his body and the effects on his ability to perform his necessary
functions should be part of this effort. The use of disulfiram
(Antabuse) in maintenance doses of 250 mg. per day to produce a

deterrent effect in regard to drinking is also an effective
approach.
Several principles are important in the treatment of an

alcoholic individual. The first principle is that the drinking itself
must be terminated if therapy is to be at all effective in achieving

rehabilitation. A common mistake mental health professionals
make is viewing alcoholism as a symptom of underlying
psychopathology or personality disorder and attempting to treat
the underlying disorder. This approach to alcoholism

psychotherapy has resulted in many failures and a reluctance of
psychiatrists to treat alcoholics in spite of an occasional paper
describing some success with psychoanalytic psychotherapy of

alcoholism (18).
Psychological conflict does exist as indicated, but efforts
must first be directed to achieve sobriety for the patient through

detoxification and the maintenance of sobriety through intensive
directive psychotherapy, and the use of Antabuse. A patient who
is continuing to drink will not be responsive to counseling or
psychotherapeutic approaches and a power struggle often
develops between the therapist and the drinking patient.
The second principle in treating the alcoholic is the

understanding of the transference the alcoholic will often
establish with a therapist. This transference will be very intensive
and be characterized by a great amount of dependence coupled

with hostile, manipulating, and testing behavior. Thus, a great
deal of ambivalence will be noted in the transference relationship.
The alcoholic will be dependent, but at times act in a grandiose

way, believing he can control his drinking as well as his life when
the evidence is obviously to the contrary. Thus, massive denial is
utilized by alcoholics to avoid facing their problems and their

inability to handle alcohol. The therapist should encourage a
dependent relationship with the patient by the use of support,
acceptance, and directive counseling to permit the patient to

change his dependence on alcohol, which can be considered an
object relationship, to dependence on the therapist.
The third principle in the treatment of the alcoholic is

understanding the countertransference that may develop in a
therapist in response to the provocative behavior and drinking of
the patient as testing of his continued interest. Because of this

type of testing behavior, the treatment of an alcoholic can be felt
to be frustrating and unrewarding. However, the therapist must

recognize that he is not omnipotent in regard to the alcoholic’s
drinking. He cannot, nor can anyone, stop an alcoholic determined
to drink. A therapist can only provide the means to assist the
alcoholic in achieving sobriety and cannot force him for long into
refraining from drinking. Only the patient’s conscious efforts can
achieve this for himself. Recognizing this reality, the therapist
must impose limits on the behavior of the patient and conditions

under which treatment can continue. If the patient cannot meet
these conditions at a particular point in time, treatment should be
discontinued. The door, however, should be left open to renew

the efforts to achieve sobriety as the first step in the treatment
process.
The treatment of an alcoholic has been observed to progress

through several stages. Although the stages can be observed in
group therapy, they are more apparent in individual therapy. The
first stage involves the situation where the alcoholic “cannot

drink.” This situation exists when there is external pressure on
the patient to stop drinking, such as the threat of loss of job, or his
wife leaving, or deteriorating physical health. In a sense, the
alcoholic is forced to stop drinking, at least for a short time. Most
alcoholics are pushed into treatment because of such external

pressure. Attitudes toward drinking and the denial of drinking as
a serious problem have not changed. The alcoholic has stopped
drinking not because he sees it as necessary, but because

someone else does. Often during this stage after the alcoholic has
stopped drinking, he feels extremely confident about his newly
acquired sobriety and experiences a “glow” of euphoria. This
behavior is a reaction formation to his unconscious lack of control

over his drinking which is now experienced as a certainty of
control over his not drinking as well as control over the other
aspects of his life. This situation is by its nature very unstable
since there has been no significant change in his attitude about
drinking or an ego reduction as described by Tiebout (10). It can

easily lead to a return to drinking or can lead through
psychotherapy and/or further Alcoholics Anonymous
involvement to a second stage where the alcoholic "won’t drink.”

The use of Antabuse as an external control over the impulse to
drink is particularly valuable during the beginning stage of
treatment. All patients should be encouraged to attend A.A.

meetings as an adjunct to the psychotherapy. Not all patients will
be willing to attend, but those who do will learn a great deal about
alcoholism and obtain a considerable amount of hope and support
for their own recovery. Involving the spouse in conjoint therapy

and a referral to Al-Anon can also greatly enhance the therapeutic
process by changing destructive attitudes and behavior in the
spouse and tangibly demonstrating to the patient the spouse’s

active participation in the recovery effort.
The second stage is where the controls on the compulsion to

drink have become internalized and there is no longer a serious
conscious conflict about whether to drink or not. At this stage, the
individual’s attitude toward the necessity of drinking and the
deleterious consequences in resuming drinking are apparent. He
has experienced a considerable attitudinal change toward

drinking. The conflict about drinking is still present, but at an
unconscious level. Evidence of the continued existence of this

conflict is present in terms of fantasies of the patient and in
dreams. This stage is the level many Alcoholics Anonymous
members have achieved. It is a reasonably good stage of recovery

and is fairly stable, only occasionally leading to a “slip” after years
of sobriety. This stage requires at least six months to one year of
treatment and sobriety to achieve. A decision regarding the

stopping of Antabuse can be considered at this time because there
has been established a good set of internalized controls over the
impulse to drink.
During the first two stages of therapy, most of the defenses of

the alcoholic should not be analyzed but redirected, particularly
the grandiosity, through A.A. involvement. Patients who do not
attend A.A. but are able to achieve sobriety have the grandiosity
turned into an ego enhancing feeling of being able to control a
problem that was extremely difficult. A paper by Wallace (19)
discusses in detail how defenses of alcoholics can be redirected

rather than removed to facilitate the therapeutic process.
The third stage of recovery involves the situation where the

alcoholic “does not have to drink.” This stage can only be achieved
through insight into the individual’s personality problems and
conflicts and their resolution to a major degree. The habitual use
of alcohol at this stage can be understood as a way of dealing with
the individual’s conflicts and as a reaction to stress. With the

resolution of the conflicts, the individual can achieve more
adaptive ways of coping with problems, internal and external.
This stage can be achieved only through psychotherapy and self

understanding. It is a stable stage so long as the alcoholic refrains
from drinking. The ability to refrain from drinking is relatively
easy to maintain at this stage.
The fourth stage of recovery is a theoretical stage and

involves the situation where “I can return to social drinking.”
Probably a small percentage of alcoholics can achieve this stage

(20), but at our present level of knowledge, it is impossible to
predict which alcoholic this might be. All alcoholics believe during
the initial stages of recovery that they can return to controlled

drinking. Therefore, for all practical purposes abstinence should
be a necessary goal in the treatment of all alcoholics. Alcohol is

not necessary to life and it is quite possible to live and even be
happy without consuming alcohol. This fact should be part of the
attitudinal change an alcoholic experiences during the process of

recovery.
The termination of treatment with an alcoholic is a critical
point. If the treatment process has been successful, the alcoholic

will have established a dependent, trusting relationship with the
therapist and, therefore, termination will produce anxiety and the
possibility of return to drinking. This termination should be based
on mutual agreement between the therapist and patient, a

termination date in the future determined, and the final months
of therapy involved with the issue of termination.
Termination can occur at stage II or III since both are

relatively stable stages regarding control of drinking. A decision
has to be made, however, when a patient reaches stage II as to
whether further treatment to achieve insight into the

psychological conflict related to his drinking problem and,
therefore, moving to reach stage III are considered important to
the patient. As far as control of drinking is concerned, it is not

essential to reach stage III in treatment. Therefore, this option
should be left to the patient.
Regardless of whether the patient terminates in stage II or

III, the door to return to therapy at any time should be left open. A
patient who stops treatment after stage II may determine after a
while that not drinking is not enough to help him deal with his
feelings and conflicts and, therefore, might wish to return to
treatment to try to achieve insight into his personality conflicts. A
patient terminated after stage III may have a slip; therefore, a

return to treatment should be available. However, this slip should
not be viewed as a treatment failure, but as part of a

rehabilitation process that is not yet complete. Patients who slip
in stages II and III generally do not return to continuous
uncontrolled drinking because their awareness of their problem
and control mechanisms are such that controls can be quickly

reinstated. The slip can be analyzed as a psychological
maladaptation to conflict and anxiety or as a transference
reaction.
Report of an Outcome Study
The author analyzed data on 23 alcoholic patients treated in

individual psychotherapy during a two-year period in a private
psychiatric office setting where the methods described above

were utilized. The patients were seen in most cases on a once-a-
week basis. In some cases where marital problems were major
aspects of the patient’s difficulties, joint sessions were held

periodically. All patients received a physical examination and
laboratory studies from an internist.
The data obtained for this study came from a review of the
charts kept on the patients and follow-up telephone calls to

patients who were no longer in treatment.
The results of the study can be seen in Table 2. This table
indicates that 14 of the 23 patients treated (61%) were successes.

An outcome was considered successful when there was at least 1
year of abstinence from alcohol with functional improvement in

other aspects of their lives. Of the 14 patients who achieved a
successful outcome, 10 patients achieved a stage II level of
recovery (internalized controls over the impulse to drink) and 4
achieved a stage III level of recovery (conflict resolution).
Table 2
Characteristics of Treated Patients
Successes* Early** Drop-Outs Failures
14*** (61%) 5 (22%) 4 (17%)
A. Sex
Male 8 4 2
Female 6 1 2
B. Age
Average 43 38 41
Range 33-54 22-52 30-51
C. Religion
Catholic 3 1 1
Protestant 6 2 3
Jewish 4 1 0
Other 1 1 0
D. Marital Status
Married 7 3 1
Divorced 3 1 1
Single 3 1 1
Separated 0 0 1
Widowed 1 0 0
E. Employment
Employed 11 5 3
Student 1 0 0
Housewife 2 0 1
F. Social Class
Lower Middle 1 2 1
Middle 7 1 1
Upper Middle 6 2 2
G. Duration of Alcohol Abuse (Years)
Average 7 6 5
Range 3-17 2-12 2-10
H. Level of Alcohol Abuse
4 8 3 2
5 6 2 2
I. Use of Antabuse
Yes 13 2 4
No 1 3 0
Complications 2 0 0
J. Type of Detoxification
Hospital 3 0 1
Ambulatory 9 5 3
None 2 0 0
K. Use of Alcoholics Anonymous
Yes 10 2 1
No 4 3 3
L. Previous Treatment
None 6 3 2
Psychiatric 7 2 2
Alcoholism 1 0 0
* One year or more of abstinence with improvement in other aspects of their

lives.
**Six sessions or less.
***Stage II–10; Stage III–4.
In the study, 5 (22%) patients dropped out of therapy early
(6 sessions or less) and 4 (17%) were failures. If we consider the
outcome of the 18 patients who remained in therapy, 14 (78%)

had successful results.
There were 14 males and 9 females. The average age was 44
with a range of 22-54. The average duration of their alcoholism

was 8 years with a range of 2-17 years. The severity of their
alcoholism placed 13 of the patients at level 4 of the Alcohol
Abuse Scale (see Table 1) and 10 at level 5,
Additional demographic characteristics of this treatment

population indicated that 11 patients were married, 6 divorced or
separated, 5 single and 1 widowed; 5 were Catholic, 11

Protestant, 5 Jewish, 1 Moslem, and another with no religious
affiliation; all of the patients were middle-class individuals, with
19 employed, 1 student and 3 housewives.
History of the treatment population indicated that 11 had no
previous treatment for their alcoholism, 11 had previous

psychiatric treatment which was unsuccessful, and 1 had
previous alcoholism treatment which was unsuccessful.
When first seen for treatment, most of the patients required

detoxification from alcohol, with only 2 being sober on initial
contact. Of the 21 requiring detoxification, 17 (81%) were
successfully detoxified on an ambulatory basis; 4 (19%) required
in-hospital detoxification after failure of ambulatory
detoxification.
Regarding Alcoholics Anonymous attendance, 13
participated in A.A. and 10 did not. Among the 14 patients who

had successful outcomes, 10 used A.A. and 4 did not. Among the
patients who dropped out and those who failed in therapy, 3 used
A.A. and 6 did not. Although the numbers are too small to
determine statistical significance, it is suggested that attendance
at A.A. is associated with a successful outcome.
Antabuse was used with 19 of the 23 patients and with 13 of

the 14 patients who had successful outcomes. There were 2
patients who had complications from the use of Antabuse which
required its discontinuation. One patient developed a toxic

hepatitis and another developed an organic brain syndrome.
These conditions cleared up after the Antabuse was stopped.
Case Reports
Case 1
Patient is a 44-year-old married, Jewish lawyer. He had a 17-

year history of alcoholism with several hospitalizations, an
episode of delirium tremens about 10 years ago and several

attempts at alcoholism treatment including A.A. attendance,
Antabuse, group therapy with a psychiatrist who specialized in
alcoholism treatment, and most recently an internist who
specialized in alcoholism treatment.
In recent years his drinking pattern had changed from daily
drinking to abstinence of 1-2 months’ duration and then going on

binges of several days’ to a week’s duration. He came into
treatment at a point when he appeared to be losing control of his
periods of abstinence and his binges were becoming more

frequent. He always planned his drinking to occur at times when
it would least interfere with his work, but his more frequent
binges were beginning to affect his work performance and create

marital problems.
The patient was started in individual psychotherapy,

Antabuse, and referred to A.A. He refused to go to A.A., however.
During the beginning stages of treatment he would stop
taking Antabuse, wait a few days, and start a binge. This

continued for several months until he was told he couldn’t
continue in treatment if he continued to drink. He came to one
session drunk, at which time he was extremely depressed and full

of anger at his father.
Prior to this session, the patient had denied any feelings

about his father or, in fact, any disturbing feelings or thoughts of
any kind. A joint session with his wife after this session confirmed
his depression when he was drunk and his angry feelings at his
father. He realized for the first time that he drank not only
because he wanted to do so, but also as a way of coping with a

great deal of emotional conflict.
The author’s acceptance of him when he was drunk and the

beginning awareness of his having repressed a great deal of
feelings that were liberated by intoxication enabled him to accept

the need for sobriety. He took the Antabuse on a regular basis and
began attending A.A. meetings. He was able to identify with some
of the members for the first time. He went on to achieve

continuous sobriety.
The use of the dependent relationship he had established

with the author in the transference was threatened by the
possibility of discontinuing therapy and was enhanced by his

being accepted when he came to a session drunk. This represents
a breakthrough in the treatment. The transference was not
interpreted. He achieved a stage II recovery level because once
his drinking ceased, his defenses in relation to his underlying

conflicts were strongly reinstituted. He was able to achieve more
than a year of continuous sobriety.
Case 2
Patient is a 44-year-old divorced, Protestant man who was
the controller and treasurer of a financial corporation. He had a 4-

year history of alcoholism which had contributed to his recent
divorce.
He came to treatment just before his divorce was finalized

because his wife had indicated that his drinking was the major
reason for her leaving him. He was started on individual

psychotherapy, but at first refused to take Antabuse or attend
A.A., saying that he could stop drinking on his own. He was told
that if he had a drinking episode it would prove that he couldn’t

abstain without help and at that time Antabuse would be
necessary for his continued treatment. He agreed to this
suggestion.
After about 3 weeks of sobriety he began drinking heavily
again. He said he really wanted to drink socially and that he

wasn’t an alcoholic. When reminded of the agreement, he
reluctantly agreed to take Antabuse. He also went to an A.A.

meeting. He continued taking Antabuse for several months; at
that time he was told that he was going to lose his job because of
an economy move of his company. He became very upset and
would have begun drinking again except that he was still taking
the Antabuse. He realized that without the Antabuse he couldn’t

control his impulse to drink.
His problem with his loss of his job was worked through and
he began looking for another job. He had begun attending A.A.
meetings and found them helpful. After about 6 months of
therapy, he began to develop signs of organic mental impairment.
The Antabuse was discontinued and his organic mental
symptoms cleared up. He had changed his attitude significantly
about the need to drink and he was able to maintain his sobriety
when the Antabuse was discontinued.
He was referred to an organization called Parents Without

Partners to help him meet women since he had problems making
such social contacts. He met a woman whom he fell in love with

and after 6 months of seeing each other they became engaged.
He was given a year to find another job by his present

company. He had obtained some good prospects of another job
and after about 14 months of treatment, with 1 year of sobriety,
he was discharged from therapy.
Summary
The approach to psychotherapy of alcoholics that has been
presented in terms of stages of progression of treatment in

relation to varying levels of ability to control the impulse to drink
provides a framework that structures a complex and often
amorphous treatment process. It provides a goal-directed

approach to achievable levels of improvement. Complex
therapeutic decisions regarding involvement of the family in

treatment, starting or stopping of Antabuse, attendance at A.A.
meetings, use of uncovering techniques, discontinuation of
therapy, and others can be considered in relationship to these
fairly predictable stages in the recovery process. It is possible to
make predictions of outcome of therapeutic intervention or lack
of intervention based on knowledge of the stage of recovery the
patient has entered. Therefore, such an awareness can make the

complex psychotherapeutic process with alcoholics potentially
understandable and subject to a certain degree of predictability.
Data have been presented that analyzed the results of private

psychiatric office treatment of alcoholics according to the
approaches described in this chapter. A significant number of the
23 patients treated improved (61%). Patients who remained in

therapy beyond 6 visits had a 78% successful outcome. Such
results suggest that alcoholism can be successfully treated with
individual psychotherapy with the modified approaches

indicated.
Although group therapy had been considered the treatment
of choice by many specialists in alcoholism, the author’s

experience with individual therapy suggests that it can be quite
useful in the treatment of alcoholism. Individual therapy
facilitates a profound transference relationship which, if

effectively managed, can lead even very resistant alcoholics to
recovery.
REFERENCES
1. Blum, E. M. Psychoanalytic views of alcoholism: A review. Quart. J. Stud. Alc., 1966,

27:259-299.
2. Knight, R. P. The psychodynamics of chronic alcoholism. J. Nerv. Ment. Dis., 1937,
8:538-543.
3. McCord, W. and McCord, W. Origins of Alcoholism. Stanford: Stanford University Press,

1960.
4. Bacon, M. K., Barry, H., and Child, I. L. A cross-cultural study of drinking. II: Relation to
other features of culture. Quart. J. Stud. Alc., 1965 , 3:29-48.
5. Tahlka, V. The Alcoholic Personality. Helsinki: Finnish Foundation for Alcohol Studies,
1966.
6. Blane, H. T. The Personality of the Alcoholic: Guises of Dependency. New York: Harper &
Row, 1968.
7. McClelland, D. C., Davis, W. N., Kalin, R., et al. The Drinking Man. New York: Free Press,
1972.
8. Wilsnack, S. C. The impact of sex roles and women’s alcohol use and abuse. In: M.
Greenblatt and M. A. Schuckit (Eds.), Alcoholism Problems in Women end
Children. New York: Grune & Stratton, 1976.
9. McCord, W. and McCord, J. A longitudinal study of the personality of alcoholics. In: N.

J. Pittson and C. R. Snyder, (Eds.), Society Culture and Drinking Patterns. New
York: Wiley, 1962.
10. Tiebout, H. M. Alcoholics Anonymous—an experiment of nature. Quart. J. Stud. Alc.,

1961, 22:52-68.
11. Zimberg, S. Evaluation of alcoholism treatment in Harlem. Quart. J. Stud. Alc., 1974,
35:550-557.
12. Pattison, E. M., Coe, R., and Rhodes, R. J. Evaluation of alcoholism treatment: A
comparison of three facilities. Arch. Gen. Psychiat., 1969, 20:478-499.
13. Kissin, B., Platz, A„ and Su, W. H. Social and psychological factors in the treatment of
chronic alcoholism. J. Psychiat. Res., 1970, 8:13-27.
14. Mindlin, D. F. The characteristics of alcoholics as related to therapeutic outcome.

Quart. J. Stud. Alc., 1959, 20:604-619.
15. Zimberg, S. The elderly alcoholic. The Gerontologist, 1974, 14:221 -224.
16. Zimberg, S., Lipscomb, H., and Davis, E. B. Sociopsychiatric treatment of alcoholism
in an urban ghetto. Amer. J. Psychiat., 1971, 127:1670-1674.
17. Feldman, D. J., Pattison, E. M„ Sobell, L. C., et al. Outpatient alcohol detoxification:
Initial findings on 564 patients. Amer. J. Psychiat., 1975, 407-412.
18. Silber, A. An addendum to the technique of psychotherapy with alcoholics. J. Nerv.

Ment. Dis., 1970, 150:423-437.
19. Wallace, J. Tactical and strategic use of the preferred defense structure of the
recovering alcoholic. National Council on Alcoholism, 1976.
20. Pattison, E. M. Abstinence criteria: A critique of abstinence criteria in the treatment

of alcoholism. Int. J. Soc. Psych., 1968, 14:268-276.
21
Hypnotherapy Combined with

Psychotherapy
James R. Hodge, M.D.
Introduction
Hypnosis is a very powerful tool in psychotherapy, with a
wide range of application: from the superficial treatment of

volitional disorders, such as smoking and overeating, through the
treatment of specific symptoms, such as phobias; from
intermittent use in psychotherapy programs, to being the basic
treatment modality in psychotherapy; and finally to

hypnoanalysis. It has been used effectively with individuals, with
couples, and with groups.
Hypnosis is of least value in conditions in which there is a
brief attention span, such as the organic brain syndrome and the
acute psychotic episode, because attention is required for trance
induction. The effective use of hypnosis depends upon a positive
therapeutic relationship; failure to develop this relationship is the
primary contraindication to the use of hypnosis as well as the
primary reason for its failure.
The use of hypnosis in psychotherapy requires three

attributes in the therapist: experience in hypnosis and in
psychotherapy, imagination, and courage to try both accepted and
innovative techniques. Also, he should always practice within his

area of competence—that is, he should use hypnosis only for
conditions he would be willing and able to treat without the use
of hypnosis.
Inducing a hypnotic trance is the easiest part of hypnosis;

more important is the therapeutic use of the hypnotic trance
phenomena. The goal of this chapter is to demonstrate how a

basic knowledge of psychotherapy and of hypnotic trance
phenomena can be integrated into a total treatment program.
Fundamental Concepts of Hypnotherapy
When hypnosis is considered in the treatment program for
any condition, the therapist must first make an adequate

evaluation of the patient —his life history, his illness, and his
psychological state—and then develop at least the beginnings of a
positive doctor-patient relationship. The therapist should keep

several basic questions in mind:
1.. What is the therapeutic goal, regardless of hypnosis, and

why?
2. At what point in the process of the illness is therapeutic
intervention planned?
3. How can hypnosis help, that is, what are the strategies
and tactics available and appropriate for the treatment
of this specific patient?
To answer these questions appropriately, the therapist needs
a basic understanding and awareness of: 1) the natural history of
psychiatric illness in general and the history of the patient's

illness in particular, 2) the nature of psychotherapy and the
strategies available, and 3) the nature of hypnosis and the
strategies and tactics available.
Advantages of Hypnosis
If the therapist is to use hypnosis only in the treatment of

conditions which he would otherwise treat without hypnosis,
then what are the advantages of hypnosis? There are several:
1. The use of hypnosis can shorten the duration of therapy

without interfering with the permanence of results.
2. When used appropriately, it elicits the patient’s awareness

of his own participation in the treatment process.
3. Even more than the analysis of dreams and the process of

free association, hypnosis is truly "the royal road to the
unconscious”; it is certainly a more incisive and direct
road to the "relevant unconscious.” A hazard here is
that it is also a loyal road to the therapist’s unconscious,
and he must be constantly aware of the process of
countertransference.
4. Hypnosis is a powerful tranquilizing agent. It can directly
effect relief from some symptoms; it can lead to the
moderation of others, thus permitting their
investigation without undue anxiety and without
altering their dynamic meaning.
5. Hypnosis can facilitate the interpretation of symbolic

material.
6. Hypnosis can promote the affective and relevant

recollection of past events for connection with present
life experiences.
7. Hypnosis strengthens the doctor-patient relationship. As a

result, the patient is more willing to study himself in
greater depth, more able to do it at greater speed, and
less fearful of attempting new behaviors.
However, in spite of all these advantages, just because you
can use hypnosis does not mean that you should use it; if you can
do as well or better without it, you should do so.
The Nature of Hypnosis and the Hypnotic Relationship
Although no fully satisfactory theory of the nature of

hypnosis has been generally accepted, it is essential that the
therapist constantly bear in mind that the responsibility for the
trance and for what happens during the trance always rests with
the patient. The therapist does not actually "hypnotize”; instead,
he helps the patient to enter a trance. The primary role of the
therapist is that of a catalyst, a medium, a guide, a helper, a
protector, and someone who can suggest ideas and techniques
which the patient is not likely to think of by himself. Essentially,
the therapist is a person who can teach the patient how to use the
trance.
I assume that the reader has a basic familiarity with trance
induction techniques and I will not address this topic here. For
those wishing to study it in more detail; the books by Wolberg
(1), Chertok (2), Weitzenhoffer (3), and Brenman and Gill (4) are
recommended. Most important is that the therapist learn one or

two basic techniques which he can use effectively and which he
can modify as indicated by the patient’s needs. Current concepts
of trance induction and deepening are in terms of developing the

patient's “talent for hypnosis” or "trance capacity” so that he can
be taught to utilize the phenomena of hypnosis at all levels of
trance from the very light to the very deep. For many therapeutic
purposes the light trance is quite effective, and the therapist
should not be deterred by a patient’s apparent mediocre talent,
for this may be all that is required and it may be improved with
practice.
Basic Strategies of Psychotherapy
Though every therapist has his own concepts of the nature of
psychotherapy, I will briefly review the basic types of

psychotherapy in terms of strategies and tactics. Knowing and
selecting the strategies and tactics that are available are two of
the greatest skills in psychotherapy
Psychotherapy by Promoting Rational Understanding
In the use of this strategy, the primary goal is to promote an

understanding of the process of illness: “Now that you know the
reason for your symptom, you can decide for yourself whether to
keep it.” It is basically exploratory and explanatory: 1) to find “the

reason,” or at least an acceptable reason, for the illness; 2) to
make the irrational rational; and 3) to promote an understanding
and acceptance of the acceptable reason.
The strategy of analytically oriented insight psychotherapy is

the one in which the techniques of clarification, interpretation,
paradoxical intention, and utilization of transference are used
more than in any other.
Psychotherapy by the Direct Modification of Behavior
Here, the primary goal is the relief of symptoms and anxiety;
however, interpersonal relationships and problem-solving in
current life situations are also studied, and although an

understanding of the cause is not sought, it may develop. What is
being sought is that the patient develop a sense of personal

mastery of the symptom and of his life situation: “Now that you
are no longer afraid, you can do whatever you wish." The specific
tactics of this strategy involve: 1) the behavior therapies,
especially assertive training, systematic desensitization,
reciprocal inhibition, implosion (flooding) therapy, and aversive
conditioning; 2) education and instruction; 3) counseling and
exhortation; and 4) paradoxical intention.
Psychotherapy by the Release of Energy
Many symptoms and problems of life situations can be

relieved by the release of energy which has been dammed up,
blocked, suppressed, or repressed. The primary goal of this
strategy is the release of this energy: “Now that you have this out
of your system, understand it, and do not fear a recurrence, you

no longer need it.” This is most often accomplished by: 1)
ventilation; 2) abreaction; 3) connecting a feeling with an idea or

an event; 4) seeking the barrier to the release of energy and
removing it by promoting rational understanding; 5)
confrontation through one of the various types of group

psychotherapy.
Supportive Psychotherapy
In this strategy, it is acknowledged that no major changes are
necessary nor are they likely to occur. The basic goal, then, is to
help the patient live with his symptoms either by controlling,
modifying, or accepting them or by modifying his life-style: "You
are doing a good job. You see how situations like this can be
handled. Keep up the good work. Your next appointment will be
on. . . With transitory problems, such as grief or divorce, the goal
is to support the patient through the adjustment period. A
program of supportive therapy does not preclude the use of any

other therapeutic strategy which may be indicated by the specific
situation. The basic tactics in this strategy are support,
reassurance, encouragement, promotion of a good therapist-

patient relationship, "modeling" or the promotion of
identification with the therapist, and the use of medicines
appropriate to the condition.
Psychotherapy by the Direct Relief of Symptoms
In selecting this strategy, the therapist assumes that the
direct relief of symptoms may be all that is necessary: "Now that

your symptom is gone, is there anything else you would like?”
This strategy is most helpful in habit pattern disorders (enuresis,
tics, nailbiting) or volitional disorders (smoking, overeating,
alcoholism). It is acknowledged that direct symptom relief may be

followed by the release or substitution of another symptom; this
is not necessarily “bad” if the therapist is prepared to continue
treatment, possibly selecting another strategy.
The basic tactics in this strategy are those of instruction,

exhortation, "planning a program,” behavior therapy, direct or
indirect suggestions such as may be given with hypnosis, and the

use of appropriate medicines.
Psychotherapy by Paradoxical Intention
This particularly interesting strategy is sometimes used as a

tactic within other strategies. It takes advantage of the
paradoxical nature of human behavior; it stresses the need to

confront fears in order to overcome them. Having selected this
strategy, the therapist requires the patient not to avoid the
symptoms, but actually to confront them, create them, study

them, and become an expert on them. By using these tactics, the
patient can learn when the symptoms come, how he keeps them
going, and what makes them go away; seeking them out, he is no

longer embarrassed by them and comes to learn how irrational
they are: “Now that you can look at your symptoms without fear,
you can understand them better and see how your fear and
avoidance have perpetuated them. Now that you know that you
are in charge of them, you may either keep them or let them go.”
Basic Strategies of Hypnotherapy
There are three basic hypnotherapeutic strategies. These are
(1) the projective strategy, (2) the strategy of direct and indirect
suggestion, and (3) the strategy of behavior modification.
The Projective Strategy of Hypnotherapy
This strategy is similar to the use of projective psychological
tests in that the hypnotized subject is requested to project himself

into a situation different from that which exists in reality at the
moment. Doing this with hypnosis permits him to be
simultaneously both the observed and the observer. Some of the
numerous tactics within this strategy are given below:
TACTIC I: Time distortion. The subjective experience of time

can be changed in many ways. Among these are:
1.1 Age regression. The basic concept here is to connect the

past with the present in terms of memories, symptoms, and
affects by having the hypnotized patient regress to an earlier

period when an event occurred that is relevant to the current
problem. Some techniques are: 1) using the “affect bridge” (6)
from the present to the past by intensifying a present affect

through hypnotic suggestion and then having the patient go back
in time to a previous event where he experienced the same
feeling, and then relating the two events; 2) using the “symptom
bridge” from the present to the past over which the patient traces
his symptom to its beginning and to the circumstances
surrounding it; and 3) using the rational selection of a previous
event which is chosen to induce abreaction or to study the

circumstances around the event or to produce desensitization to
that event.
The purposes of age regression are several: 1) to explore the
patient’s past and to relate his past experiences to the present,

especially on an affective basis; 2) to release the patient’s
dammed up energies associated with past experiences and
present anxieties; and 3) to help the patient master the feelings of
helplessness associated with his past experiences.
1.2 Time compression and time expansion. The subjective
experience of the passage of time is changed by suggestion so that

time can be perceived as passing more rapidly, for example, when
the patient is in pain, or more slowly, as when the patient is
feeling well.
1.3 Age progression. In a sense, this involves forecasting the
future by getting the patient to perceive how he may appear or

behave at some future time.
TACTIC 2 The production of hallucinations or dreams. The
dreams of a hypnotized patient can be analyzed in the same way

that normally occurring dreams are analyzed in analytically
oriented psychotherapy, but with the added advantage that the
dream can be suggested to occur not only during normal sleep but
also during the therapy session. Dreams can even be projected as
hallucinations in which the patient can participate and then
analyze. Even more, hallucinations and dreams whose meanings

are not obvious can be reexperienced, or can be caused to recur
with the use of different symbols, until the meaning becomes
clear.
TACTIC 3. Hypnoanalysis. Hypnoanalysis is the procedure of
analytically oriented psychotherapy taking place while the patient
is in a hypnotic trance. Although this is rarely done in toto, during
any given session or series of sessions most of the analytic

therapy may occur while the patient is in a trance. This tactic is
particularly helpful when the patient cannot confront the
discussion of repressed material in the unhypnotized state but

can discuss it relatively easily while in a trance knowing that he
does not have to remember it upon awakening until he is ready to
do so.
TACTIC 4. Connecting affect and experience in the present.

This technique is especially helpful when the patient has physical
or psychosomatic problems and denies the presence or relevance
of his emotions. The symptom is intensified by suggestion, and

while he is experiencing this he is requested to develop some
affect of equal intensity which he will be able to recognize and
express both behaviorally and verbally. This is a powerful method

of producing insight.
TACTIC 5. The mini-vacation. The patient may briefly escape

an intolerable situation by going on a 10- or 15-minute vacation
to a place of his own choosing so that he may return refreshed.
Since the ability for only a light trance is required, this tactic is
most suitable for a person who has learned self-hypnosis and can
use it between sessions.
TACTIC 6. Behavior therapy. Here, all the basic behavior
therapy techniques can be accentuated and facilitated, especially
the technique of relaxation by hypnotic suggestion. Particularly
helpful is the method of psychodynamic desensitization in which
the patient is asked to take ‘‘one step beyond” his expressed fear
and to imagine what would happen if he were actually in the

anxiety evoking situation. He will almost always find some fear of
being out of control, and treatment of this fear is often of more
value than treatment of the expressed fear.
TACTIC 7. Ego state therapy. The patient is asked to identify

various aspects of his personality and to act out these states in the
session, much as is done in Transactional Analysis.
The Strategy of Direct and Indirect Suggestion
Because it has often been said that one of the reasons Freud
stopped using hypnosis was that his direct suggestions did not
work, it has become almost axiomatic that hypnotherapists
should not use direct suggestions to remove symptoms. As good

an axiom as this may be, there are exceptions. The direct
confrontation-challenge to the symptom is almost always bound
to fail unless 1) the doctor-patient relationship is such that the

patient can accept the suggestion and its results, and 2) a face-
saving way out can be left for both the patient and the symptom.
It is accepted that direct symptom removal may result in either
the liberation or the substitution of another symptom by the
patient for psychodynamic reasons, and that this is not

necessarily undesirable if the therapist is prepared to make use of
this experience in further treatment. Because of this
phenomenon, however, most suggestive therapies have now
turned from the simple directive, ‘‘Your pain (or other symptom)
will disappear now,” to indirect suggestions such as, “Here is a
way to handle your pain (symptom) until we can get rid of it
permanently,” or, “If you are ready now to start giving up your
symptom, here are some ways to do it.” Sometimes a direct
interpretation to the receptive patient will result in removal of
symptoms as in the case of the woman who had had a constant

headache for 26 years and who was told while hypnotized, "You
have been carrying a heavy burden,” and the symptom
disappeared. The direct suggestion is imposed upon the patient;

the indirect suggestion enlists the patient’s aid.
Indirect suggestion is almost always accompanied by a great
many direct suggestions; however, the indirect nature of these

suggestions for symptom relief should be emphasized. The
symptom is rarely attacked directly. Instead, some aspect of the

symptom is modified while it is permitted to continue
temporarily so that it may be studied analytically, removed
gradually by desensitization or other behavior therapy methods,

or allowed to die out by attrition. Self-hypnosis is a very effective
technique which patients can use with only a small amount of
training, but part of that training is learning not to attempt to

remove the symptom directly. It may take longer to teach this
than it takes to teach self-hypnosis itself. This hypnotherapeutic
strategy, one of the most versatile, effective, and frequently used,
involves what I like to call “emotional judo” in which the therapist

uses the patient’s momentum and problems for therapeutic
purposes. Some of the tactics within this strategy are:
TACTIC 1. Symptom substitution. This involves the planned

and purposeful replacement of one symptom with another. A
classical way of doing this is to move the symptom from one part
of the body to another, preferably within the same organ system;

e.g. if a person is having a muscular pain, it is desirable to
substitute some other form of muscular pain or muscular activity.
When this tactic is chosen, it is important for the therapist to

remember that it is the patient who substitutes the symptom, not
the therapist. The therapist only takes advantage of the patient’s

own abilities, and helps him to change the symptoms in a
controlled way for therapeutic purposes.
TACTIC 2. Hypnosis as a deterrent. Hypnosis can be used as a

deterrent to almost any kind of acting-out behavior, e.g. suicide.
When used as a direct confrontation-challenge to prevent such
behavior, it may actually compel the patient to respond to the

challenge. However, a suggestion such as, “You will not be able to
carry out a serious suicidal act without first discussing it with me
in my office very clearly,” serves to enlist the patient’s aid by

giving him a task to perform before he can carry out his suicide
attempt. It also gives the therapist a chance to work with the
patient and not be caught by surprise.
TACTIC 3. Promoting personal mastery. General ego
strengthening through promoting personal mastery is a valid,

effective, and often undefined tactic of therapy. Many neuroses,
especially the traumatic neurosis, are precipitated by the patient’s
having been caught by surprise as a helpless victim of

circumstances beyond his control; this feeling of helplessness also
often occurs as a characterological state. When this tactic is used,
the goal is to promote feelings of strength, competence, and

“copability.” Sometimes this can be accomplished by direct
suggestion, though more often it is promoted through the use of
projective techniques, such as age regression with abreaction, or

through the behavior therapy techniques. Another useful
technique here is to have the patient visualize himself the way he
was as a small helpless child (“Little Billy”) and then to have him
visualize himself with all the assets that he has as an adult ("Big
Bill”). Visualizing this contrast lessens the sense of helplessness

and increases the patient’s awareness that he is no longer the
helpless “Little Billy.”
During the process of trance induction, I repeatedly state to
the patient that as he enters and deepens the trance he will feel
progressively more "relaxed, comfortable, pleasant, strong, and
secure.” These sensations serve as a baseline experience of the

trance state, alleviate many unspoken fears, and cause the patient
to expect that the trance will always be a pleasant and secure
experience. As he proves through repeated experiences that this
is true, he develops confidence in his ability to use hypnosis. Thus,

he is better able to tolerate his symptoms and to confront them in
a therapeutic manner.
TACTIC 4. Direct and indirect control of symptoms. For the use

of this tactic the imagination of the therapist and his knowledge of
hypnosis are particularly valuable.
In the treatment of pain, for example, sometimes all that is

required for relief is for the hypnotized patient to be told that he
will have no pain or that the pain will be of a different nature, as

every dentist knows. Sometimes merely entering the trance will
bring relief. Sometimes more specific techniques are chosen. One
method is to give a psychological injection of novocaine to an

affected trigger area. Another is to teach the patient to develop a
glove anesthesia of one hand and to transfer that anesthesia to
any part of the body that is painful. Another method is to teach
the patient to take the pain from wherever it is into his hand and
then to drop it into the nearest wastebasket. Still another, more
physiological, method is to create a feeling of either heat or cold
in an inert object, or in the therapist’s hand, or in the patient’s

hand, and then to transfer that sensation to the affected area; this
is particularly helpful for muscular types of pain, as is applying a

psychological splint or brace.
Chronic and recurrent symptoms of many types can be
aborted or attenuated by these techniques, such as episodes of
anxiety or even of schizophrenia. The patient can be taught, for

example, to recognize the earliest symptoms of the illness and
then to use self-hypnosis with relaxation or taking a “mini-
vacation” until the precipitating event can be analyzed and the

problem brought under control.
TACTIC 5. Creating physiological changes. In the hypnotic

state, it is possible to create physiological changes which can be
used for diagnostic purposes, for a symptom bridge to connect
affect with symptoms, and for direct treatment purposes.

Biofeedback studies have demonstrated what practitioners of
hypnosis have known for many years, namely, that the autonomic
nervous system is not entirely beyond conscious control. It is well
known not only that sensations can be changed by hypnotic

suggestion, but that heart rate can be altered, blood pressure
changed, some bleeding controlled, and muscle spasm relieved.
Hypnotic suggestion has both produced and relieved asthma

attacks and has given temporary relief of bronchitis. It has been
successfully used as a diuretic (‘‘Each one of your body cells will
squeeze out the excess fluid”), has relieved menstrual cramps by

suggestions of relaxation and by hypnodiathermy, and has also
altered the duration but not the occurrence of menstrual periods.
Injections of “psychological cortisone” have been effective in

treating some skin conditions. A very simple and effective
suggestion is that the desired effects of any medicine, from a
tranquilizer to an antibiotic, will be doubled while the

undesirable effects will be halved.
The Behavior Modification Strategy of Hypnotherapy
The basic theory of behavior modification is that persistent

maladaptive anxiety responses to stress are the nucleus of most
neuroses, that anxiety is conditioned, and that it can be

deconditioned. Almost all forms of behavior modification involve:
(a) teaching the patient to relax even in the presence of stress; (b)
creating visual and other sensory images, either of pleasant or of

feared situations; and (c) presenting these images to the patient
in a systematic manner in his imagination before exposing him to
the anxiety-evoking situation in real life.
TACTIC 1. Intensification of behavior modification techniques.
For the patient with a talent for hypnosis, all of the techniques
described above can be facilitated and intensified, making
therapy more effective and often shorter. The effect of

hypnotically induced hallucinations, for example, is much more
profound and realistic to the patient than is the simple use of his
imagination in the unhypnotized state.
TACTIC 2. Biofeedback. Hypnosis is a natural and valuable

adjunct to instrumental biofeedback training in which the patient
is trained by a process of operant conditioning to achieve both
specific and generalized relaxation and to produce other bodily
changes. Further, the patient who can use hypnosis can bring
about the changes sought in biofeedback training much more
rapidly, regularly, and intensively than can other patients. Even

more, since the ultimate goal of biofeedback training is for the
patient to learn to produce the desired effects without the
instrument, which does no more than to feed back information to

the patient about how he is doing, hypnosis is of particular value
in that it is always available. Merely entering a light trance for
self-hypnosis can produce a recognizable state of general

relaxation, and self-suggestion about specific changes may then
be given if desired. Hypnosis, then, not only is an effective adjunct
to instrumental biofeedback training, but can be used by itself as

a form of subjective or non-instrumental biofeedback training.
TACTIC 3. IRD. The “IRD,” or the “internal regulatory device,”
is a specific supportive, ego-strengthening, and quasi-

instrumental biofeedback technique which has been found
particularly helpful for patients who have fluctuating or unstable
symptoms or anxieties. This concept occurred to me during the

treatment of a patient suffering from cyclical bipolar affective
disease before lithium became available. Searching for a method
to control her mood swings from mania to depression, I gave the
following suggestions: “I would like you to look into my right eye
while I put one finger on each side of your head. At the spot where
these two lines intersect you will soon feel a tingling sensation.
We are creating an internal regulatory device in your brain which
will work just like a thermostat. We can now put your euphoria
on a scale of 0 to +10 and your depression on a scale of 0 to –10
and we can set this thermostat so that it will start to function at
either +7 or –7 and your symptoms will not be able to go beyond
these levels.” As soon as we established that this technique was
effective, we were gradually able to reduce the number-settings of
what came to be called the “Psychestat” until the range of the
mood swings was essentially within normal limits, where they
have remained for many years. A refinement of this technique
developed following the exclamation of a patient: “I feel that there
is a part of you in my head!” Every experienced therapist is aware
that over a period of time the patient tends to introject various
aspects of the therapist; i.e. the patient gets to know the therapist
just as the therapist gets to know the patient. For appropriate
patients, then, this process can be utilized in a supportive way by
“lending” the patient a “part of the therapist” along with the
internal regulatory device. With this, the patient can then utilize
the therapist even though the therapist is not physically present.
Naturally, this technique should not be used early in therapy
because a good doctor-patient relationship must first be
established. When I use this technique, I specify that the situation
may continue to exist for a defined period of time such as a week
or a month, though it may be renewable as often as necessary.
The Combination of Psychotherapy Strategies with
Hypnotherapy Strategies
Hypnosis is used most effectively when it is used

systematically, taking into account 1) the natural history of
psychiatric illness, 2) how the patient’s illness fits into that
natural history, 3) the psychotherapy strategies available, and 4)
the hypnotherapy strategies available. Hypnosis and
psychotherapy are not the same thing. Hypnosis is merely a
method of facilitating the overall program as a part of the
treatment process. It may be used during most of every session,
during part of every session, intermittently during the course of
therapy, or regularly until a specific goal is accomplished. When
the therapist elects to use hypnosis, he should keep in mind what
he wants to accomplish, how he can accomplish it, and why
hypnosis will be of value. Just because he can use hypnosis does
not mean that he should use it.
The following rationale for using hypnotherapeutic

strategies assumes that there is a natural course of psychiatric
illness just as there is a natural history of physical illness and that
in this natural history certain identifiable factors are involved, viz.
a predisposing personality, a current conflict, an external
precipitating stress, the development of anxiety, a primary gain or
symptom-forming factor, the symptom complex itself, and a
secondary gain or symptom-fixing factor. It further assumes the
formulation of a total treatment program in which the therapeutic
goal and sites of intervention are selected on the basis of this
natural history. In choosing the site of intervention in accord with
this formulation, the therapist should consider 1) the purpose of

intervention at that site, 2) the psychotherapy strategies available
and applicable, and 3) the hypnotherapy strategies available and
appropriate. Further, the selection of the hypnotherapy strategies

always depends upon the preselection of the psychotherapy
strategies.
Predisposing Personality
The predisposing personality refers to all the genetic,

constitutional, developmental, educational, and experiential
factors which constitute the basic personality of the individual.
1. Purpose. The basic goal is to promote insight into the

nature of the personality and understanding of it by
demonstrating recurring patterns of behavior, the relationship
between the past and the present, and the process of repetition
compulsion or how present behavior is an extension of or a

repetition of past behavior which may or may not be appropriate
to the current life situation of the patient. Awareness of the self as
an individual in the process of development is stimulated, and the

patient becomes aware of the difference between himself as a
child and himself as an adult; he learns the difference between

"Little Billy” and "Big Bill." Unconscious memories and
experiences become conscious and are analyzed as part of the
developmental pattern so that the patient may develop more of a
free choice about what his further development will be.
Treatment designed to make changes in this area must be

considered as long-term therapy. However, information obtained
about the predisposing personality may be very useful in brief
therapy and in therapy focused in other areas of the process of

illness.
2. Psychotherapy strategies. The basic psychotherapy strategy

chosen for work in this area is that of promoting rational
understanding. During this process, psychotherapy by the release
of energy may occur spontaneously or by rational selection.

Sometimes, especially if a discrete symptom exists, behavior
modification techniques may precede the development of rational
understanding, for change may produce insight as frequently as

insight will produce change. This is particularly noticeable when a
strategy such as the use of paradoxical intention is introduced
early in the therapy process, for it enables the patient to focus on
exactly what he is doing, thinking, and feeling; it compels change

which produces insight which may be followed by a more
fundamental change.
3. Hypnotherapy strategies. When the psychotherapy strategy
of promoting rational understanding is selected, the projective

hypnotherapeutic techniques are most helpful, though any of the
methods of hypnotherapy may be used as the developing
situations might indicate. The therapist must be particularly
careful, however, of providing too much relief of anxiety through
direct suggestion, for otherwise this will increase the dependency
of the patient on the therapist and will interfere with the progress
of the analysis. It must be remembered that the goal of the
therapy is insight and understanding, and that to accomplish this
it may be necessary to confront anxiety or to liberate the anxiety

that is bound in the production of symptoms. The therapist must
be prepared to help the patient with this anxiety.
Current Conflict
Just before and at the time of onset of an illness, a person
almost invariably experiences a conflict in his life. This conflict is

continuous, troublesome, and disturbing the equilibrium of his
life; and it usually involves his feelings about himself, his
activities, or his relationship with some other significant person.
1. Purpose. The basic goal is to relate the presenting
symptom to the current problems of living, and clarification of
this relationship may be all that is necessary for the patient. This
may not be easy, however. It should be recalled that part of the
function of the symptom is to conceal these current problems, yet

it must also reveal them, especially when the symptom is
carefully analyzed. Here again, insight may precede change or
may follow it. For many patients a personality change is not

necessary, though the patient may obtain self-knowledge which
he can put to effective use if later episodes should develop. It is in
this area of intervention that most of the useful short-term
psychotherapy is done.
2. Psychotherapy strategies. The basic strategy here, also, is

that of promoting rational understanding. Intervention in depth is
not usually necessary, though it is often helpful to relate the new

insights to the predisposing personality and patterns of behavior.
3. Hypnotherapy strategies. When therapy by promoting

rational understanding is selected, the projective hypnotherapy
techniques are of most value, especially those involving age
regression using the affect bridge or the symptom bridge from the
present to the past. Hypnotherapeutic techniques of the direct
and indirect suggestion type may be necessary or helpful to give
support to the patient while the basic therapy is proceeding.
External Precipitating Stress
A person with an appropriate predisposing personality and
current conflict can be said to be waiting, even hoping, for
something to happen which will solve his problem; and this

"something” is often inaccurately called “the cause” of the illness
when it is only a triggering factor or a permissive event. It may be

a severe trauma or it may be an innocuous event which is seized
upon as the solution to the current conflict.
1. Purpose. The primary goal is to relieve the stress or its
sequelae whenever possible by the use of medicinal or
psychotherapeutic methods. It is necessary to demonstrate the

effect of the stress to the patient while relating the stress to the
ever-present current conflict and the predisposing personality by
promoting recall of the circumstances surrounding the external

precipitating event. Desensitization of the patient to the stress or
its memories is essential, as in a traumatic neurosis or a grief
reaction. If the external precipitating stress consists of a series of
minor stresses, relief of this input overload is important.
When early intervention is possible, therapy focused in this

area is most effective; and sometimes only a few sessions may be
necessary, especially when the external precipitating stress is
quickly related to the current conflict. When early intervention is
not possible, therapy may not be able to be limited to this area

and will therefore take longer.
2. Psychotherapy strategies. Any or all of the psychotherapy
strategies can be used during intervention at the level of the

external precipitating stress as long as the therapist follows the
basic principle that the patient must confront the stressful
situation and recognize its effects. Psychotherapy by promoting

rational understanding is effective in helping the patient to
understand how the stress developed and how it is related to the
current conflict and the predisposing personality. Psychotherapy
by the modification of behavior using systematic desensitization
and rehearsal techniques can be particularly helpful, especially as
the patient is taught to relax while he recalls and contemplates

the stressful situation. Aversive conditioning can sometimes be of
value here. Repeated ventilation and abreaction can be especially
helpful for releasing the dammed up energy and emotion

associated with the stress. The direct relief or alleviation of
symptoms through medicinal and/or psychotherapeutic methods,
when possible, can be very helpful and supportive to the patient

as he works through his problems, but it should not allow him to
avoid working on them. Paradoxical intention helps the patient to
confront the stressful situation, its memories, and its effects by

compelling him to think about it in minute detail.
3. Hypnotherapy strategies. Any of the hypnotherapy
techniques can be effective as long as they fit in with the

psychotherapy strategies already selected. The most appropriate
of the projective strategies are those of time distortion,

abreaction, and the production of dreams and hallucinations.
Hypnotherapy by direct and indirect suggestion is helpful when
used to control symptoms and to give psychological support as

the patient develops personal mastery of the situation and
strengthens his personality. Accentuation of the behavior
modification techniques by hypnotic suggestion will improve

their effectiveness.
The Development of Anxiety
Whenever a stressful situation occurs, anxiety accompanies

it or follows it. Anxiety is an essential ingredient in almost all
psychiatric symptoms; but even more than this, the basic anxiety
stimulates the personality defenses to attempt to control it, and
these defenses will characteristically create symptoms in this
attempt. The symptom, then, is an unsuccessful attempt of the

personality to control anxiety.
1. Purpose. The main goal is to encourage the patient to
become aware of and to confront the primary anxiety related to

the external precipitating stress, the current conflict, and the
predisposing personality. The patient is to learn that the anxiety
is either irrational, unnecessary, maladaptive, or simply not

currently helpful to him. He is to learn to handle both current and
future anxiety in a healthy, productive manner instead of in a

pathological manner.
This is another point at which early intervention in the

process of illness is not only helpful in relieving present
symptoms but also in preventing future ones. Short-term therapy

is often quite effective here.
2. Psychotherapy strategies. Any one or all of the

psychotherapy strategies can be used in treating the problem of
anxiety; but whatever strategy is chosen, the anxiety must first be
admitted and confronted, and the patient must learn that fear is
perfectly normal. When the strategy is to promote rational
understanding, the current anxiety should be related to both past
and future anxieties, for anxiety by its very nature is future-

oriented in terms that "this could happen to me again.” In this
sense, dynamic desensitization is particularly helpful as the
patient is asked to fantasize what would happen if he were in the

anxiety-evoking situation. The key question here is “What if . . . ?”
Promoting the release of energy will also be facilitated by
connecting the present with the past. If the anxiety is considered

maladaptive, it can be attacked directly by using one of the
behavior therapy approaches, such as systematic desensitization
or reciprocal inhibition. Supportive therapy, including the

appropriate use of psychiatric medicines, can demonstrate that
the anxiety can be relieved or modified so that it is not too intense

for the patient to confront. Confronting the anxiety by taking
charge of it, as taught by paradoxical intention, is effective in

relieving the anxiety and developing an understanding of it.
3. Hypnotherapy strategies. The choice of hypnotherapy

strategies depends upon the choice of psychotherapy strategies.
Projective techniques are particularly helpful, especially with
time distortion tactics such as age regression to recent and
remote past anxiety situations, time compression to demonstrate
a method of controlling anxiety and time progression to forecast

how the patient can become in the future. The release of energy is
promoted by age regression and abreaction. While this may be
unpleasant for the patient, it is also supportive in that it shows

that he can survive the anxiety and that it can be controlled.
Direct suggestions about controlling the degree and duration of

anxiety are supportive and promote mastery of the fear of
anxiety. Accentuation of behavior therapy techniques with
hypnosis aids the development of a sense of mastery, and the

installation of the “internal regulatory device” can be very
supportive.
Primary Gain or Symptom-Forming Factor
Anxiety, like pain, is an unpleasant sensation, and the patient
attempts to relieve it at all costs. The primary gain or symptom-
forming factor is the process by which the patient attempts to do

this; it is the process by which the defense mechanisms bind the
anxiety by attaching it to a symptom or by creating a symptom.
1. Purpose. The primary goal here is to help the patient see
and understand how symptom formation occurs and that it is not

necessary for him to develop or maintain symptoms. It is
important that he understand that he causes the symptoms
himself in order to escape a sense of intolerable anxiety, that he

"owns” them, and that he is not merely their victim. He should be
helped to understand how he has handled stress in the past,
continues to use the same techniques in the present, and can be
expected to continue this way in the future unless he understands
these processes better.
Treatment designed to make changes in this area must be
considered as long-term therapy; however, information obtained

about these processes may be very useful in briefer therapy and
in working in other treatment areas.
2. Psychotherapy strategies. Only one basic psychotherapy

strategy is appropriate here and that is the analytically-oriented
strategy of promoting rational understanding through studying

defenses, resistances, and transference. Gestalt methods and
paradoxical intention may be helpful adjunctive techniques.
3. Hypnotherapy strategies. When analytically-oriented

therapy is chosen, the most frequently indicated
hypnotherapeutic techniques are the projective ones, especially
the hypnotic analysis of natural dreams and the production of

hypnotic dreams for analysis, and age regression using the affect
bridge and the symptom bridge. Creating substitute symptoms by
direct suggestion and then analyzing them is, in effect, creating a

“parallel neurosis” much like that of a transference neurosis; and
analysis of the substitute symptom makes the original symptom
easier to analyze. Supportive suggestions should be given only

with care so as not to distort the processes which are being
analyzed. Observation and analysis of the patient’s behavior

during trance induction may be very enlightening, as may failure
to dehypnotize if it should occur.
The Symptom Complex
The symptom is almost invariably the patient’s presenting

complaint but it is important for the therapist to remember that
the symptom is really only a stage in the development of the

overall illness. It represents an unsuccessful attempt of the
psychological defense mechanisms to control the primary anxiety
and therefore involves elements of die primary anxiety as well as

elements of the secondary anxiety about the presence of the
symptom itself. The symptom, with its anxiety, represents a “cry
for help” and is a “ticket of admission” to therapy.
1. Purpose. The primary goal here is the relief of symptoms

while preventing their recurrence or replacement by other
symptoms. This is accomplished by 1) relating the symptom to

the basic anxiety, the cur rent conflict, and the predisposing
personality; 2) providing insight that the symptoms are not really

necessary, are unadaptive or maladaptive, and do not truly solve
the underlying problem; and 3) identifying the underlying
problem by “getting behind the symptoms.”
The symptom complex is the point at which all of the

patient’s problems come to a focus. It is a good place to intervene,
perhaps the best; but intervention here is usually only the
beginning of therapy. With tin; symptom as the focal point,

therapy may spread out to all aspects of the process of illness.
2. Psychotherapy strategies. Any of the therapeutic modalities
can bit used here, either alone, in combination, or in sequence.
The decisions must be made by the therapist according to his own

continuing evaluation of the patient’s needs, assets, liabilities, and
progress in treatment. The strategy of choice is psychotherapy by
promoting rational understanding; but this may be neither

necessary nor possible, depending on the nature of the problem
and the capacity of the patient for psyche-therapy. Sometimes all
that is necessary for a given patient is the relief of his presenting
symptom with or without some degree of insight, as exemplified
by the patient with a 26-year-old headache which was relieved in

two appointments with the simple interpretation that she had
been carrying a heavy burden. It is predictable that the mere
relief of such a prolonged symptom without taking a history and

providing insight through interpretation would have had little
lasting value, but the combination did.
3. Hypnotherapy strategies. When the psychotherapy
strategies of promoting rational understanding and/or of

promoting the release of energy have been chosen, any or all of
the hypnotherapeutic projective tactics are especially indicated.
Direct or indirect suggestion therapy may be effective either for

temporary symptom relief while the analysis is proceeding or for
long-term supportive therapy. The production of substitute
symptoms by hypnotic suggestion is analogous to the production

of substitute dreams, and they can be analyzed in the same way.
Behavior modification may be a primary hypnotherapy strategy
at this level of intervention, or it may be chosen as an adjunctive

technique for the other strategies.
Secondary Gain or Symptom-Fixing Factor
The secondary gain is what keeps the established illness, the

symptom complex, from going away like a self-limiting condition
such as the common cold. Since the primary anxiety is not totally
relieved by the creation of the symptom complex, the symptom
must continue because of the danger of releasing the primary
anxiety. Often, however, by the time the patient comes for

therapy, the primary anxiety has essentially been dissipated, and
the symptom continues almost as a habit or as a new life-style; it
has become ego-syntonic. Further, the patient may not only adapt
to the symptom itself, but may consciously or unconsciously learn
that there are secondary advantages to having it; and if this

occurs, he will hold on to it at all costs.
1. Purpose. The primary goal of treatment in this area is to

break up the continuing development of the process of illness and
to prevent the illness from becoming ego-syntonic. It can be very
difficult, but the patient should be helped to develop insight into

how he “uses” his illness as he has learned in the past to use other
situations, how he must remain ill to do so, how the cost to him is
high in terms of discomfort and dissatisfaction, and how there
may be different and better ways to accomplish what he really
wants to accomplish.
This is one of the most difficult areas to work in, partly
because of the confusion between secondary gain and

malingering, and partly because the patient has acquired a vested
interest in maintaining his symptom. It is also one of the most
important areas to work in, for therapy here, especially early in

the illness, is true preventive medicine in the best sense of the
word. It may prevent the need for rehabilitative therapy later.
This is one of the areas in which other special techniques such as

environmental manipulation and/or family therapy may be used
effectively. Intervention in this area may be either preventive or
therapeutic.
2. Psychotherapy strategies. Direct symptom relief, especially
when early intervention is possible, prevents the development of

secondary gain. After the secondary gain is entrenched, however,
a direct relief of symptoms may be almost impossible because
such relief could threaten the patient’s entire life-style. Any
psychotherapy strategy, however, can be effective if it modifies

the symptom, interferes with the development of the process of
illness, or disrupts the equilibrium of the established illness.
Environmental manipulation can be effective not only in

preventing the development of any secondary gains, but also in
eliminating their effectiveness and their desirability for the

patient. None of the psychotherapy strategies are likely to be
successful here, however, unless the therapist 1) can develop a
rational understanding of the nature of the process of illness and
the value of the secondary gains for his particular patient, and 2)
can impart this same understanding to the patient through the
strategy of promoting rational understanding, including analysis
of how the illness affects the patient’s environment and the other
people in it. This process almost always involves the laborious
procedure of identifying, analyzing, and interpreting the patient’s
conscious and unconscious resistance. It is in working in this area

that the therapist and the patient are most likely to become
adversaries, and thus both transference and countertransference
phenomena abound. These must be handled by the therapist,

whether or not they are interpreted.
3. Hypnotherapy strategies. When the psychotherapy strategy
of promoting rational understanding is employed, the projective

techniques directed toward cure, relief, and understanding of the
symptoms are of most value. A combination of age regression and

age progression can enable the patient to see himself as he was,
as he is, and as he would like to become. Hypnoanalysis can be
particularly helpful in that the patient, while in a trance, may be

able to discuss things which he would not be able to discuss
otherwise. Hypnotherapy using direct and indirect suggestions to
give some degree of control of discomfort, or to produce

substitute symptoms for analysis, can help to keep the patient
stable enough yet in a sufficient state of disequilibrium that he
will keep working on his problems and his “cure.” Ego state
therapy may assist the patient to become aware of the different

parts of his personality, some of which may be working for cure
while others are working to maintain the illness. The behavior

modification strategy, especially with the special tactics such as
biofeedback and the internal regulatory device, may alleviate the
symptoms and maintain the patient’s interest in treatment while

those persons in his environment who are influenced by his
symptoms are taking the opportunity to change their own
behaviors, thus having an indirect positive effect upon the patient.
Summary
Hypnosis has a wide range of application in the field of
psychotherapy, but it is only a part of the overall

psychotherapeutic program for any patient. It can be of value in
the treatment of almost any condition. Hypnosis is of most value

when it is used according to a rationale involving the concept of
intervention at various sites of the natural history of the illness.
Hypnotherapeutic strategies should be selected on the bases of 1)

the purpose of intervention, and 2) the psychotherapeutic
strategies already selected.
Examples of Hypnotherapeutic Intervention
Dream analysis (7). A woman had a recurring dream of being

in a closed room with thousands of spiders. While in a deep
trance, she was asked to repeat the dream. She did, but it
produced extreme anxiety. She was then asked to put distance
between herself and the dream by watching it on a hallucinated

television set. She noted that the spiders had features like those of
her mother. She then recalled a current conflict with her mother
and related this to childhood experiences with mother and father,

then to her relationship with her husband. Again repeating the
dream, she felt a desire to step on the spiders; she also visualized
my presence in the background, and as I came to the foreground

the spiders disappeared and she felt well. Interpretation is left to
the reader.
Control of symptoms and age progression (8). A young marine

had recurrent dissociative episodes in which his body was “taken
over” by his dead dog. The episodes were unpredictable, and
dangerous in that he would attempt to gouge out his eyes; so he

had to remain under observation in the hospital and to be
restrained during the attack. He was given the post-hypnotic

suggestions that he could not have an attack without also being in
a trance and that while having the experience he could not bring
his hands within two inches of his eyes. Communication was

established with “Brownie” by a Ouija board technique, and
"Brownie” could tell us when the next attack would occur. The
patient was released from the hospital with post-hypnotic

suggestions that at the scheduled time nothing could prevent him
from returning to the hospital and that he could not have the
attack without being in the psychiatric unit. The suggestions
protected the patient and permitted definitive therapy to proceed.
Hypnosis as a deterrent (9). A recurrently suicidal patient was

given the suggestion that she could not make a serious suicide
attempt without first discussing it with me in the office and that I

would see her as an emergency if necessary. She became suicidal,
called, and was seen. Her thought processes were severely
suicidal, and she revealed that she had a gun in her purse. She
readily entered a trance, revealed the nature of her current
conflict with her husband, was given a face-saving way out,
traded her gun to me for two sleeping pills, and returned the next
day for conjoint therapy with her husband.
Age regression and hallucination production. A middle-aged
man had severe pain and disability of his left arm as the result of
an industrial accident. Part of his treatment involved age
regression with abreaction of the incident. This was so anxiety-

inducing that we reproduced it on a hallucinated television set.
This was still too intense, so we speeded up the projection. When
he was able to tolerate this, we slowed it down and ultimately he

abreacted the episode repeatedly. In doing this he became aware
of his anger and resentment at the company and also of his sense
of being a cripple and losing his masculinity. This made the

significant difference in his overall treatment program.
Producing physiological change. The patient mentioned
previously had received many surgical forms of treatment,
including nerve blocks. During one episode of pain, I touched a
pencil to his neck and had him experience receiving a stellate
ganglion block. He developed a typical Horner’s syndrome, and

his pain was relieved.
The mini-vacation. A woman, experienced in the use of
hypnosis, reported that between sessions she had gone to the

dentist, requested no novocaine for the first time ever, and had
taken a vacation in the mountains while the dentist did his work.
After several sessions like this, the dentist remarked, “Your

hypnosis is the best thing that ever happened to me.”
Aborting a psychotic episode. A woman had had episodes of

schizophrenia requiring hospitalization and ECT about twice
yearly for five years. She learned to use hypnosis, to recognize her
earliest symptoms, and to call me when these occurred. If I could
not see her immediately in the office, I would have her enter a
trance by a prearranged signal and tell her to relax until I could
see her and to analyze her current life situation. The episodes
were aborted, became less frequent, and required less

intervention by me. Following an emergency hysterectomy, she
became catatonic at night. Using a telephone held to her ear by
the house physician, I gave her the prearranged signal. She
entered the trance, spoke calmly with me, accepted my
supportive suggestions, slept well that night, and had no residuals
the next day.
Hypnoanalysis involving secondary gain. A young woman was
making great progress with her claustrophobia, but had reached

an impasse. One day she entered a trance more deeply than ever
and said, “Doctor, I don’t want to remember this when I come out
of the trance. I need my symptom. Please don't take it away from

me.” She did not remember saying this and left me with the
difficult decision as to whether to attempt to continue her
treatment. Using my best judgment under the circumstances, I

arranged to gracefully terminate her treatment as “improved.”
REFERENCES AND RECOMMENDED READING
1. Wolberg, L. Medical Hypnosis, Vol. 1: The Principles of Hypnotherapy, Vol. II: The
Practice of Hypnotherapy. New York: Grune & Stratton, 1948.
2. Chertok, L. Hypnosis. New York: Pergamon Press, 1966.
3. Weitzenhoffer, A. M. General Techniques of Hypnotism. New York: Grune & Stratton,

1957.
4. Brenman, M. and Gill, M. Hypnotherapy: A Survey of the Literature. New York: Wiley,
1964.
5. Kroger, W. and Fezler, W. Hypnosis and Behavior Modification: Imagery Conditioning.

Philadelphia: J. B. Lippincott, 1976.
6. Watkins, T. The affect bridge: A hypnoanalytic technique. Int. J. Clin. Exper. Hyp., 1971,
19 (1): 21-27.
7. Hodge, J. An exploration of psychodynamics with hypnosis. Amer. J. Clin. Hyp., 1969,

12 (2): 91-94.
8. Hodge, J. The management of dissociative reactions with hypnosis. Int. J. Clin. Exper.
Hyp., 1959, 7(4):217-221
9. Hodge, J. Hypnosis as a deterrent to suicide. Amer. J. Clin. Hyp., 1972, 15(1): 20-24.
10. Hodge, J. Contractual aspects of hypnosis. Inter. J. Clin. Exper. Hyp., 1976, 14(4): 391-
399.
11. Frankel, F. H. Hypnosis: Trance as a Coping Mechanism. New York: Plenum Press,
1978.
APPENDIX
The Selection of Psychotherapy and Hypnotherapy
Site of Purpose Psychotherapy Hypnotherapy

Intervention in Strategies and Strategies and
Process of Tactics of Most Tactics of Most
Illness Value Value
Predisposing 1. Understand 1. Promoting Rational 1. Projective

Personality patterns Understanding
of behavior
2. Release of Energy
2. Relate past to
present 3. Direct Modification
of Behavior
3. Promote growth
and development
Current 1. Relate symptom 1. Promoting Rational 1. Projective

Conflict to current problems Understanding a. Age regression
of living
2. Direct and Indirect
2. Prevent Suggestion
secondary gain
3. Brief therapy
possible
External 1. Relieve stress 1. Promoting Rational 1. Projective

Precipitating Understanding a. Time distortion
Stress 2. Relate stress to b. Dreams and
current 2. Direct Modification Hallucinations
conflict and of Behavior
predisposing 2. Direct and Indirect
personality 3. Release of Energy Suggestion
3. Prevent 4. Direct Relief of 3. Behavior

secondary gain Symptoms Modification
4. Brief therapy 5. Supportive

possible Psychotherapy
6. Paradoxical
Intention
Development 1. Promote 1. Promoting Rational 1. Projective

of Anxiety awareness Understanding a. Time distortion
of anxiety and Age repression and
confront it 2. Direct Modification age progression
of Behavior
2. Relate to 2. Direct and Indirect
external 3. Supportive Therapy Suggestion
precipitating stress
and 4. Release of Energy 3. Behavior
current conflict Modification (with or
5. Paradoxical without IRD)
3. Brief therapy Intention
possible
6. Direct Relief of
Symptoms
Primary Gain or 1. Insight into 1. Promoting Rational 1. Projective

Symptom psychodynamics Understanding a. Dream analysis
Forming Factor b. Age regression
2. Long term 2. Paradoxical c. Symptom
therapy Intention substitution
3. May be useful in
short-term therapy
The Symptom 1. Relief of 1. Promote Rational 1. Projective

Complex symptoms Understanding a. Time distortion
2. Relate symptom 2. Direct Modification 2. Direct and Indirect

to of Behavior Suggestion
predisposing a. Production of
personality, 3. Release of Energy substitute symptoms
current conflict,
external 4. Supportive 3. Behavior
precipitating stress, Therapy Modification
and basic anxiety
5. Direct Relief of
3. Promote insight Symptoms
and understanding
of symptoms 6. Paradoxical
Intention
Secondary 1. Prevention 1. Promote Rational 1. Projective

Gain or Promote insight Understanding a. Time distortion
Symptom- and understanding Age regression and
Fixing Factor 2. Direct Modification progression
2. Therapeutic of Behavior Symptom substitution
Promote insight b. Hypnoanalysis
and understanding 3. Supportive c. Behavior Therapy
Promote Therapy d. Ego State Therapy
disequilibrium
4. Direct Relief (or 2. Direct and Indirect
alleviation) of Suggestion
Symptoms
3. Behavior
5. Paradoxical Modification
Intention
6.(Also, Family
Therapy and
Environmental
Manipulation)
22
Group Therapy Combined with

Individual Psychotherapy
Saul Scheidlinger, Ph.D.

Kenneth Porter, M.D.
In view of the confusing ways in which therapeutic group

approaches have been depicted in the mental health field, the
term group psychotherapy will be employed in this chapter in its

strictest sense, as connoting an intervention modality wherein a
specially trained professional practitioner “. . . utilizes the
interaction in a small, carefully planned group to effect ‘repair’ of
personality malfunctioning in individuals specifically selected for

this purpose. A clinical orientation, which includes a diagnostic
assessment of each group member’s problems, is part of this

picture. Furthermore, each patient is cognizant of the
psychotherapeutic purpose and accepts the group as a means to
obtain help in modifying his pathological mode of functioning”

(1).
The group psychotherapy field distinguishes between two
distinct patterns of utilizing group psychotherapy for a patient
who is concurrently receiving individual treatment. The first
pattern, employed with the greatest frequency, involves the

“combined” use of individual and group treatment by the same
therapist. The second, termed “conjoint” therapy, calls for the
cooperative utilization of the two treatment modalities for a given

patient by two different therapists. The respective technical
issues posed by these two similar, yet distinct approaches will be
delineated at a later point.
It must be stated here that while we share the belief of most

clinicians that both individual and group psychotherapy have
their respective places in the clinical realm and that there are
many specific circumstances where individual psychotherapy

alone is not enough for certain kinds of patients, this view is not
necessarily shared by others, in fact, as we will note in the review
of the literature, there are a number of authorities in the group

psychotherapy field, especially from the so-called “British School,”
who conversely advocate the exclusive use of group treatment for
most patients and who are principally opposed to simultaneous
dyadic interventions in any form. These latter group therapists

frequently view the introduction of individual sessions as a
dilution of the potent group transferences and as a resistance to
the group treatment medium.
While combined therapy has been also employed with

children and with adolescents, our chosen focus here will be on
the treatment of adults only.
It is noteworthy that well over 50 contributions dealing with
combined individual and group psychotherapy appeared during

the fifties and sixties. The virtual absence of more recent
publications on this subject is probably due to the fact that, like
group psychotherapy employed exclusively, these once new and

controversial modalities have by now become an accepted part of
the mental health scene.
Beginning with a 1949 paper by Wender and Stein (2) there
were a number of articles during the fifties by Fried (3), Sager (4),
Papanek (5) and Lipschutz (6) dealing with the general subject of
combined psychotherapy. The stress was on how the two
approaches can be afforded equal importance in an overall
treatment strategy or, in Wilder’s (7) case, how he utilized the
group sessions to facilitate his primary reliance on dyadic
psychoanalysis. The most recent comprehensive review of the

entire subject of combined therapy by Bieber (8) was published
in 1971.
There were many publications which depicted the use of

combined therapy for patients with specific diagnostic categories.
These range from an early paper by Baruch and Miller on the

treatment of allergic conditions (9), through the use of combined
therapy in inpatient settings by such writers as Klapman (10) and
Hill and Armitage (11), to a number of articles on the advantage
of such treatment for oral characters by Jackson and Grotjahn
(12), by Rosenbaum (13), and Tabachnick (14). Wolberg (15)

discussed the use of combined therapy for borderline patients,
while Glatzer (16) and Durkin (17), among many others,
emphasized the special value of such an approach for narcissistic

and other preoedipal character disorder. Some authors, among
them Graham (18) and Shecter (19), employed combined therapy
successfully with psychoneurotic patients.
As might be expected, the technical questions pertaining to

the differential uses of individual and group sessions raised by
Sager (20) and Spotnitz (21), as well as to transference and

resistance in these concurrently used modalities, evoked most
interest and controversy in the literature. Thus, Stein (22)
subjected the broader issue of transference in combined therapy

to special scrutiny, while Beukenkamp (23) depicted the ways in
which this approach could facilitate the resolution of transference
problems. Berger (24), among others, paid particular attention to

the subject of resistance.
Other technical issues such as the handling of confidentiality,

when and how to introduce the group medium, and
countertransference in combined individual and group treatment
were discussed by Aronson (25) and Sager (26). Some authors
such as Ormont (27) and Teicher (28) reviewed the relative
advantages of combined versus conjoint group psychotherapy.
As we mentioned earlier, some authorities in the group

therapy field view combined group therapy with disfavor,
advocating instead an exclusive emphasis on group therapy alone.
Wolf and Schwartz (29) for example, asserted that individual
therapy would interfere with the establishment and resolution of
the transference neurosis characteristic of what they termed
“Group Psychoanalysis.” Whitaker and Lieberman (30), Foulkes
and Anthony (31), and Ezriel (32) are also against the use of
combined therapy, claiming that the group medium is markedly
powerful in its own right and that individual interventions would
be counterproductive.
The Unique Potential of the Psychoanalytic Therapy

Group
When a clinician decides to add group therapy to the

individual treatment of his patients, he is likely to be influenced
by certain assumptions regarding the special therapeutic
ingredients inherent in the therapeutic group process. These have
been spelled out in much detail in the voluminous group therapy
literature and will accordingly be reviewed here in brief outline
only:
1. The Group as a Real Social Experience
The co-presence of a number of people fosters multiple

interpersonal relationships revealing to everyone’s full view each
individual’s coping and defensive patterns. As a group member’s

characteristic ways of relating emerge and evoke reactions from
others, the stage is thus set for nonverbal as well as verbal
interventions by other group members as well as the therapist.

This is especially advantageous for those patients who in their
massive employment of denial, projection, silences and
withdrawal are difficult to engage in the one-to-one setting.
2. Multiple Transferences
In addition to the above-noted largely conscious

interpersonal relationships, the unconscious group level is
characterized by transference manifestations to other members

and to the therapist, as well as to the group as an entity. These
transferences frequently assume the representations of siblings,
of parental figures, and of the family as a whole. The shifting
character of these “neurotic” transferences—coupled with the

emergence of more primitive, defensive transference
manifestations such as “splitting,” identifications and part-object
relationships—allow for significant diagnostic observations and

for appropriate therapeutic interventions both in the group and
in the individual sessions.
In this connection, the group psychotherapy literature is

replete with discussions of the regressive perceptions and
relationships which characterize the unconscious levels of group
processes. These primitive emotional themes are believed by
some writers such as Bion (33) to be of even greater “depth” than

those elicited in the dyadic psychoanalytic setting. Such fleeting
group manifestations pertaining to the reactivation of early
relationship patterns and especially of primitive perceptions of

the therapist, of the other members and of the group entity can be
subjected to a more planned and controlled scrutiny in the
context of combined therapy. Breen (34) provided a poignant

illustration of some of the differences in the unconscious object
relationship themes evoked by the group therapy and individual
analytic settings, respectively.
3. Opportunity for Reality Testing
In contrast to the relatively unstructured dyadic setting

which tends to promote only a regressive climate, the group, with
its accompanying reality component of an open circle and the co-

presence of a number of people, facilitates the testing of reality.
Imagined fears, hurts and retaliations. as well as transference
distortions, are thus subject to easier exploration and correction.
4. Support of Peers
While ego support offered in the context of individual
psychotherapy is likely to reinforce dependency on the therapist,

this is more readily avoided in the supportive climate of the
group. Here, the frequently disheartened and demoralized patient
is soon helped to realize that he is not alone nor necessarily the
worst off. Furthermore, vivid examples of change for the better on

the part of others promote hope for one's own improvement. The
group's code of acceptance and of honesty, which is consciously
fostered, tends to reduce irrational feelings of shame and guilt, to

correct biases and cultural misinformation. Being afforded the
role of helper to others enhances each patient’s self-esteem
besides serving as a motivation to take personal risks on the road

to newer behaviors.
Maximizing the Effects of Individual Therapy
The above-noted unique motivational factors for change and
growth inherent in the group setting tend to enhance the

effectiveness of the patient’s simultaneous one-to-one treatment.
In addition, other more experienced group members can serve as
role models in the acceptance of irrational feelings and anxiety, as
well as of the need for self-exploration, as a necessary ingredient

of therapy. Furthermore, confrontations and interpretations by
peers are often more readily accepted than those from the
authority figure. The motivational reinforcement of the group’s

commitment to work toward therapeutic progress also helps to
overcome resistances. While the earlier mentioned regressive
group transactions are likely to facilitate the expression of deeply
repressed ideations, the necessary lengthy, detailed and
individualized working-through of such material is usually not
possible in a group because the coexisting needs of so many

others interfere with this process. It is here, as noted by
Scheidlinger (35), where the individual sessions serve to

complement the group situation, allowing for the repetitive and
necessarily slow process of “working-through” to occur. The
patient’s observing ego is thus enabled to master the new insights

at its own pace, with due regard to the inevitable resistances
reinforced by early traumas.
Specific Indications for Combined Therapy
There is considerable agreement in the literature that

combined therapy, while potentially useful with most ambulatory
patients, is the treatment of choice for character disorders and

borderline personalities. The integrated use of the two modalities
lends itself especially well to working with primitive, pre-oedipal

transferences and related rigid character defenses which, as
noted by Kernberg (36), are frequently coupled with schizoid
behavior and deep fears of intimacy. (Some of these same

problems are encountered in severe psychoneuroses.)
As we mentioned earlier, the group’s aid in the evocation and

resolution of complex transferences and resistances is likely to
hasten the pace of individual treatment and its reconstructive

nature. This is especially true under prevailing conditions of
practice where financial limitations constrain many patients to a
less intensive schedule of individual therapy than is clinically
indicated. Under such circumstances, a single group session can
often be combined with even a single individual session to

marked advantage.
Following are some of the major therapeutic problems of
patients with character pathology, including “borderline”

conditions, which were found to be specially responsive to
combined individual and group treatment.
1. Difficult Transferences
The varied complexities in the resolution of primitive

transference themes encountered in pre-oedipal character
problems in the dyadic treatment context are well known and do
not require repetition. By introducing simultaneous group

treatment, the patient’s rigid narcissistic, paranoid, withdrawing
or dependent transference patterns become subject to the group’s
scrutiny and confrontation. The therapist may at first need to use
the individual sessions to support the patient in view of the

group’s undermining of his tenaciously defended perceptions.
Subsequently, the inevitable negative transference reactions to
other group members (siblings) are likely to be displaced onto

the therapist, where they belong. At the same time, the positive
transference ties to some of the group peers and the perception of

the group entity in a positive maternal vein can serve as support
on the painful road to the analysis of the patient’s distorted angry
perceptions of early objects in both the individual and group
encounters. Individual sessions can be used flexibly— at times to
offer ego support when the group’s confrontations promote too

much anxiety, at other times for analytic exploration and working
through. Group meetings as well are likely to serve varied
functions at different stages of treatment. These include

experiential frustrations or gratifications of transference wishes
and direct verbal expressions and confrontations of transference
feelings coupled with reality-testing and resolution.
2. Analysis of Rigid Character Defenses
We referred earlier to the unequalled value of the group
setting for portraying interpersonal behavior patterns and

defenses. In fact, group therapists have often noted with
amazement how different their patients appear in the group
when compared to their behavior in the dyadic sessions. Thus
when the new group member’s narcissistic defenses of

grandiosity, aloofness and arrogance persist over a period of time,
the other members are bound to confront and later undertake
concerted efforts to demand relevant self-scrutiny and

modification of the unacceptable conduct. Similarly, a cohesive
therapy group imbued with a spirit of self-examination coupled
with genuine emotional support when called for will not tolerate
persistent patterns of projection, denial, withdrawal, withholding
or intellectualization. The frequently painful sequelae of such
transactions are likely to involve the therapist in both the group
and individual sessions as supporter, confronter and interpreter,

as the situation may demand.
Clinical reports are unanimous about the special value of a
group setting as a way station for patients to work through

problems of relating to members of the opposite sex or of schizoid
withdrawal. Somehow, these issues are better lived out in at least
a microcosm of the real world—the group—rather than being

merely talked about in the individual session.
The Differential Uses of Individual and Group Sessions
During combined therapy, group sessions tend to be
generally used to elicit and resolve resistances and to promote

the expression of the earlier- noted deep affects and phantasies.
The individual sessions can then serve as the calmer “laboratory”
to analyze these therapeutic productions, especially of primitive

transference perceptions, in greater detail and
comprehensiveness. In either session, the stress may need
occasionally to be placed on the provision of ego support. As part
of the working through process, group meetings are more likely

to offer opportunities for experimenting with new behaviors
while the individual sessions would stress the integration of
deeper intrapsychic themes.
Needless to say, all therapists do not necessarily operate in
accordance with this scheme. The unique needs of different
patients, the variability in the character of therapy groups, and
the therapist-style may dictate different ways in which the two
media are harmonized to enhance the task of therapy.
Technical Issues in the Initiation and Scheduling of

Combined Therapy
It is almost universal practice among therapists employing

combined therapy to initiate treatment with a period of individual
psychoanalytic psychotherapy, and to add group therapy at a

later point. A common view is that group therapy may be
introduced once the patient has developed a strong working
alliance with the therapist and after a transference has been

clearly established and at least partially understood. If the patient
is introduced to group therapy too soon, transference patterns
may become confused or repressed and therapeutic progress
halted. In fact, some patients may flee treatment altogether
should they fail to be fully prepared for the group and feel that
they are being “thrown to the wolves” or abandoned.
Similarly, patients in individual treatment should probably

not be brought into a group until the acute problems that led to
the treatment have been at least partially resolved and the
patient’s self-esteem is sufficiently strong to withstand the
inevitable stresses entailed in group belonging.
In practice, there is considerable variation in the timing of
combined therapy, ranging from a wait of only a few weeks at one
extreme to a preceding stretch of several years of individual

psychotherapy, at the other.
Although the pattern of commencing treatment with

individual psychotherapy and later adding group therapy is the
most common approach, there is no reason why the reverse
procedure cannot be employed. Thus, some clinicians begin

combined therapy with exclusive group psychotherapy, and only
after a period of months or years do they add individual analytic
sessions. This scheme may be best suited to patients with

previous psychoanalytic experience, or to those who are
extremely frightened of their transference reactions in the
individual treatment setting.
As for the therapy groups in combined therapy, these may

consist of a mixture of patients, including some in exclusive group
therapy and others in combined or in conjoint therapy. While this
might seem to create formidable problems of transference

complexity and of rivalry reactions within the psychotherapy
group, most workers have actually found such an approach quite
workable. Given sufficient sensitivity and experience in the

employment of combined therapy on the part of the therapist, the
use of a flexible approach permits a truly rich variety of
therapeutic transactions.
As can be expected, raising the issue of joining a group with a
patient is likely to provoke a number of concerns. Most common
are feelings of rejection, narcissistic injury, separation anxiety

and sibling rivalry. These feelings invariably provide significant
themes for the ongoing treatment program.
Combined treatment is usually initiated either by adding a

group therapy session to the patient’s pre-existing schedule of
individual sessions or by substituting a group meeting for an

individual session. The decision is made on clinical grounds,
depending on the optimal intensity of individual psychotherapy
sessions and the availability of time and financial resources.

Naturally, the issues posed by the planning for combined therapy
will differ in the two circumstances and the therapist must be
prepared to deal with the relevant therapeutic material which is
bound to arise.
The most common pattern of combined therapy appears to
be one group therapy session per week combined with one or two
individual sessions. Fewer therapists employ a twice-weekly

group therapy schedule.
Whether it is feasible to combine a more intensive individual
psychoanalytic schedule of sessions with group therapy has been

extensively debated. Some writers maintain that the deep
regressive transference of a classical individual psychoanalysis is
incompatible with concurrent group therapy, while others believe
that a schedule of three, four, or even five times a week for
individual psychoanalytic sessions, including the use of the couch,
can go hand in hand with group therapy. These therapists report
that patients exhibit a variety of transference reactions in both

group and individual analytic sessions. Although the anonymity of
the clinician is obviously not preserved, the essential nature of
the analytic development and resolution of the transference is

believed not to be disturbed.
The most prevalent point of view at this time among
practitioners of combined therapy is that intensive, three to five

times weekly individual psychoanalytic sessions may be
combined with group therapy. While this probably alters the
nature of the transference relationship within the individual

analytic treatment, the total process of this type of combined
therapy is nevertheless considered as being compatible with the
overall reconstructive goals of the psychoanalytic treatment

process.
Confidentiality in Combined Therapy
The use of concurrent individual and group psychoanalytic
sessions offers the therapist a range of possibilities in exploiting

therapeutic material which exceeds what is possible through the
use of either therapeutic modality alone. To restrict the use of

themes which emerged in either modality to subsequent sessions
within the same modality only would deprive combined therapy
of some of its greatest potential. For example, individual sessions
may be utilized to permit the patient to discuss the defensive or
transference patterns of fellow group members. These

discussions may be a source of considerable insight for the
patient and often facilitate his deeper understanding of similar
aspects of his own psychopathology. Similarly, with the patient’s

permission, material from individual sessions may be
productively employed to further understanding of this topic
within the group transactions.
Considerations of clinical judgment and personal tact, are of

course critical in the flexible use of therapeutic data emanating
from combined therapy.
Combined Therapy and Conjoint Therapy
As we noted at the outset, “conjoint therapy” refers to

combined treatment in which group and individual therapy of a
patient are conducted by two different therapists. It is similar to
traditional, shared treatment in most respects, and offers most of

the same advantages.
The main issue which distinguishes combined from conjoint
therapy is the effect of such a divided treatment structure on the

working alliance and on transference. Conjoint therapy fosters
the development of multiple transferences and of transference-

splitting even more than the use of combined group and
individual therapy. Some clinicians have claimed that this allows
for clearer delineation, and hence for easier resolution, of some
patients’ transference patterns. Many others believe that the use
of two therapists unnecessarily confuses the picture and invites

complicated countertransference issues, plus the conscious and
unconscious manipulation of the treatment situation by the
patient to such a degree as to inhibit the successful resolution of

basic pathology. At this time, it is probably fair to say that both
treatment approaches appear to be effective, that their uses are
similar, and that a clear preference for one or the other is up to

the therapist. However, the fact that conjoint therapy is used with
much lesser frequency suggests some doubt among most
clinicians regarding its efficacy in deeper, reconstructive

psychotherapy. Further experimentation will reveal the specific
ways in which combined and conjoint therapy, respectively, have

their proper place in the therapeutic armamentarium according
to the varying needs of different patients, psychopathologies and

treatment situations.
Contraindications to Combined Therapy
There was a time when both group therapists and individual
psychotherapists were wary of combined therapy. Individual

therapists felt that the addition of group therapy to dyadic
treatment would dilute it to the point where the attainment of
analytic goals would be made more difficult, if not impossible.
As for clinicians who employ group therapy as the treatment
of choice for most patients, they feared that the addition of
individual sessions would drain off energy and material from the
group.
It is our belief that to date neither side in this dialogue has

been proven correct. We think that individual psychoanalytic
treatment can essentially proceed with the attainment of its goals
when group therapy sessions are added to the treatment regimen,

and that, if anything, the work of character reconstruction may
occur with greater alacrity and depth. Similarly, psychoanalytic
group therapy is most often enhanced by the addition of

individual sessions as patients are provided with the opportunity
to work through issues in greater genetic and intrapsychic depth.
The only two major clinical contraindications for combined
therapy appear to be:
A) Classical psychoneuroses, which probably are still best
treated with the technique of intensive individual psychoanalysis.
For these patients, the addition of group therapy is probably

unnecessary, since the latter s virtue is to facilitate the resolution
of the character problems and severe transference patterns which
are not characteristic of the neuroses.
B) Some borderline, psychotic and masochistic patients, whose
ego structure is such that they respond to the addition of group
therapy with enhanced anxiety, regressed behavior or depression
when exposed to the group’s psychological forces of regression
and contagion.
Clinical Examples
Case #1
Joe is a 32-year-old, public utility repairman from a poor

working-class background. He spends his free time as part of a
group of motorcycle riders who use a variety of non-addictive

drugs. He is bright, upwardly mobile and committed to
psychotherapy. His childhood was characterized by a severely
dominating mother and the almost total absence of a father. He is

overweight, fierce-looking, and filled with rage toward women,
coupled with a strong desire to overcome it. He was married for
five years to a woman whom he described as in many ways a

carbon copy of his mother. He said that he did not love her, but
nevertheless could not get himself to leave her and his five-year-
old daughter.
Joe began once-weekly individual psychotherapy and a year
later was invited to join a psychoanalytic therapy group led by the

same male therapist. At first, the therapeutic work in individual
sessions was largely supportive, aiming to help Joe deal more
competently with his wife and child as well as with a variety of
work-related practical conflicts. Joe related to the therapist in a
friendly and submissive fashion.
In the group, Joe was initially withdrawn and silent, and was
often depressed. His occasional talk consisted of sarcastic
comments to the women members and deferentially friendly

remarks to the males. He usually came dressed in his torn, greasy
work clothes.
Over a period of two years, the other group members, at first

gently then more firmly, confronted Joe with his tendency to
withdraw into depressions instead of dealing with his problems.

The defensive aspects of his “Macho” denial of dependency, of his
dress, appearance and aggressiveness, were repeatedly
emphasized.
In time, several significant changes were noted. In the group,

Joe began to talk spontaneously during every session, emerging
also as being concerned and involved with all group members. He
could now acknowledge pain, inadequacy, and vulnerability in

front of the others, including the women. In fact, he began to use
the group to practice new ways of relating to women as equals
whom he might care about. In addition, there were the beginnings

of a kind of transference rage toward women, as well as, for the
first time, towards his male group therapist.
At this point, the nature of Joe’s individual therapy sessions

gradually also underwent a change. Dreams began to appear and
the sessions became less reality-oriented and supportive and
more concerned with genetic and intrapsychic material. The heart
of this work settled for a time on homosexual fears and wishes
involving male friends, Joe’s father, and the therapist.
After three years of combined therapy, Joe was enabled to
separate from his wife, to lose a significant amount of weight, to

alter his style of dress, reduce his involvement with motorcycles
and drugs, and begin to date women for the first time in his adult
life.
This case illustrates the following points concerning
combined therapy: 1) The value of the group to reveal and resolve

character defenses; 2) the use of the group to explore and begin
to resolve patterns of transference rage; 3) the group’s
availability as a testing-ground for more adaptive behavior during

the working-through process; 4) the opportunity to focus in the
individual sessions on genuine reconstructive psychotherapy.
Case #2
Rose is a 28-year-old nurse who is married and has a nine-

month-old son. Rose’s mother is schizophrenic; one of her
psychotic episodes followed Rose’s birth. Her father beat the
patient when she was young. Rose was in individual

psychoanalytically-oriented psychotherapy for five years with a
female therapist whom she described as “very supportive and
maternal.” She felt that she had benefited greatly from this period
of treatment, but she and her therapist believed that a span of
analytic group therapy accompanying the individual work would
be helpful to work on issues related to her anger and need for

more self-assertion.
Rose entered a therapy group led by a male therapist. At first,

she was quiet and shy. She rarely spoke, even when she appeared
to be obviously upset. The group therapist suggested that she

experienced the entire group as her schizophrenic mother and
that she felt that if she asserted herself by asking for help, the
group would not be emotionally available to her, just as her own

mother had not been. Subsequently, with continued
encouragement from the others, she began to verbalize her
feelings, requests and needs to an ever greater extent.
Following this, the other members began to consider Rose’s

shyness, hesitancy, and soft voice as relating to difficulties with
self-assertion and anger. Her timidity and marked friendliness
were repeatedly interpreted as reaction-formations to underlying
feelings of anger. Soon, Rose began to oppose others in the group,

starting with the females but then going on to challenge also the
male members and the therapist. She reported a concurrent
increased ability to confront her husband when she felt he was

treating her unfairly. Recently, she gave birth to a girl and went
through the postpartum and infancy periods without significant

symptomatology. She is now making plans to return to part-time
work over the mild objections of her husband.
Needless to say, the two therapists communicated with each
other on occasion, with Rose's knowledge.
This case illustrates the following: 1) The conjoint use of

individual and group therapy sessions with differing therapists, in
which the individual sessions served a mixed supportive-

reconstructive function and the group sessions came to take on a
primarily reconstructive quality; 2) The resolution of
transference patterns in the group; 3) The use of group sessions

to reveal and resolve character defenses; 4) The opportunity
offered by the group to serve as an arena for the practice of new,
adaptive patterns of behavior.
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23
Family and Marital Therapy Combined

with Individual Psychotherapy
Stephen Fleck, M.D.1
Introduction
Family therapy, i.e. conjoint treatment of the family unit by

one or more therapists, is of quite recent origin. Although
Midelfort (1) treated families of schizophrenic patients some

forty years ago, this was an isolated experiment until some fifteen
years later, when studies of the family environment of

schizophrenic patients at several different centers rendered
treatment of these families a necessity. Seeing such troubled

families routinely over time could not be accomplished without
having a therapeutic impact (2-5).
Somewhat earlier Ackerman began treating families with

disturbed children as units instead of having different clinic staff
members see individual family members in the then traditional
pattern (6). Although marital counseling has a long history,

marital therapy along psychoanalytic concepts has been practiced
only for the past few decades (6, 7).
Before presentation of indications and techniques of family

therapy with or without simultaneous psychotherapy for one or
more individuals in the group, some principal differences of
families compared with other groups, and consequently

differences between family treatment and other psychotherapies,
must be understood.
Because the family as a human group and institution is

ubiquitous and a part of everybody’s experience, it has been
difficult to conceptualize and formulate what the essential nature,
characteristics and functions of this group are.
The family is the link between every individual and the

larger society. Therefore, physicians and psychiatrists must
consider this unit not only for therapeutic reasons, but also
because social and preventive medicine and psychiatry must
focus on the family as the relevant basic system (8-10).
Individual therapy, actually a dyadic system, is rooted in the

ancient doctor/patient relationship, with a long tradition of
confidential, private and privileged communication. Sigmund

Freud, clearly the central figure in the development of
psychotherapy, came to his discoveries as a physician by working
with individual patients, and decided to exploit this dyadic field

for investigation and therapeutic intervention centered on the
evolving relationship of the patient to his or her physician.
Although much of what he discovered was about familial

experiences, and early in his venture into psychoanalysis he
seemed to feel no compunction about having all sorts of contacts
with family members or friends and, in one instance, treating a

child by advising the father, he increasingly eschewed such
contacts (11, 12). Apparently he never sought to confirm his
findings or influence patients’ clinical course by meeting with

their families. Furthermore, despite his appreciation of the
complexities of the human mind and the over-determination of all
behaviors, he remained steeped in an essentially cause-and-

effect-philosophy characteristic of his era and reinforced by the
concurrent “single cause’’ discoveries in infectious disease
medicine.
Group therapy is also rooted in medical tradition in that an

inventive physician, Joseph H. Pratt, discovered that patients with
like diseases, e.g. tuberculosis, have sufficiently similar problems
to make it therapeutically effective to converse about these
problems in groups (13). Although group therapy has long since

been used primarily with psychiatric patients or even non-patient
groups, incorporating psychoanalytic principles and formulations,
it remains a technique for help-seeking persons who come to a

therapist to join with strangers in such a group for therapy (14,
15).
The family has existed as a group long before help is sought,
often help for one particular member, and the remainder of the
family may not consider themselves in need of help or therapy or

may even resist such involvement. Yet, as Richardson (16)
pointed out many years ago, treating a patient as if he or she had
no family is like treating an organ as if there were no body. In

other words, the existence of a sick family member affects the
entire group, has consequences for the entire group, and the
sickness may have roots in the previous behavior and functioning
of the family.
The Family as a System
A systems view obviates the phenomenological specification

of deviance or abnormality as such because it addresses
relationships and energy transformation within the system,

thereby specifying the nature and effectiveness of relevant
functions regardless of whether or not they will be found
abnormal, deficient or excessive. But considering only energy

transformation and making diagrams of relationships are
abstractions useful to mathematical systems analysts, but hardly
to a clinician. We propose, therefore, to examine this system, the

family—or other human organizations, according to five system
sectors or parameters which have clinical and managerial
relevance. These five are: Governance or leadership; Boundary

management; Affectivity or sentient forces; Communication; and
Task performance or system mission. The family is minimally a
two-generation system, with the children usually biologically

related, but can be multi-generational and include collateral
nuclear families in so-called extended family systems. We shall

confine our discussion mostly to the nuclear family consisting of
two generations, that is, one or two parents and a child or
children living as a unit.
Unlike other human systems, the family lives through an

extraneously given bio-psychosocial cycle which determines its
internal individual and collective needs and tasks, while serving
society by providing it with new adult members prepared to

participate in the life of the community. Implicit in society’s
expectation is that the family produce adults who will not only
participate in the community’s work, but also adhere to and
preserve its culture and values.
Marriage
The family begins as a sub-system—the marriage or marital

coalition, a relationship undertaken by two adults, by their choice
or by interfamilial arrangement, in which latter case the spouses

may still be quite young. These two people who join or are joined
for a lifetime must establish life as a dyad for their mutual
satisfactions and care and prepare themselves to function as

parents, that is, leaders in the family system if this is created.
Until they produce children or become parents through adoption
of a child, their marital task is to serve each other, establish
effective communication and a sense of belonging to each other in
special ways, thus creating at least an eidetic boundary as a

couple and a basically positive-feeling atmosphere toward each
other. These issues entail respect for personal divergences and a
willingness to reconcile negative feelings instead of one

demanding submission of the other or allowing conflicts to fester
and produce a significant rupture in the relationship, be that
overt or covert.
A special sub-system relationship of this couple with regard

to intimacy and sex must be preserved throughout the family’s
life cycle and, eventually, in Western societies must serve again

for them to live as a couple when children have left the nuclear
family system.
Among the important leadership functions in established

families are the role and task divisions parents work out for each
other, basic arrangements for rearing and guiding their children,
representing each other, i.e. the other parent, to children

positively but realistically, and serving as gender- and culture-
typical models for their offspring.
Marital Therapy
Indications for therapeutic intervention in the marital sub-

system derive from the foregoing outline of the nature and
function of marriage and parenthood. Regardless of what
indications there may be for individual psychotherapeutic
treatment of one spouse based on clear formulation and
understanding of an intrapsychic problem or mal-development

related to a complaint or complaints, such treatment should not
be recommended and undertaken without some consideration of
its effect upon the marital and family systems. Nor can we any
longer forego considering to what extent and in what way the
marital relationship or the entire family situation may have
contributed to the distress or may have ameliorated or delayed

symptomatic expression. Such delay may have occurred at the
expense of other system functions or because the marital or
family systems had achieved a relatively comfortable equilibrium

because of the disturbed and possibly disturbing behavior of one
member, be that parent or child (17, 18).
Because marriages are undertaken at a certain stage of

personality development and because further growth or change is
a personal and family life cycle necessity, it is as possible that
people will continue their personal development in a direction

that fosters greater closeness, mutual understanding and
empathy enhancing familial task sharing as it is that they grow
apart, becoming increasingly estranged with the likelihood that
whatever neurotic traits they brought into the marriage will
become increasingly fixed in their interaction and relationship,

resulting in disharmony, strife and defective leadership within
the family.
If one partner had a stake in the spouse’s immaturity or lack
of full personal independence, then that spouse’s development

must either not occur or if it occurs the marriage may no longer
be satisfactory to the other spouse. This is particularly cogent if

such development is furthered or brought about (as it should be)
by psychotherapy of the immature spouse. The therapist,
therefore, has a clinical responsibility in all instances to evaluate

whether the marital system can tolerate this change and, if not, at
least to see to it that the “more mature spouse” receives some
help in accepting the change, be that in individual treatment or

marital therapy. On the whole, if a discrepancy of this type is
ascertained in clinical investigation, it is preferable to undertake

marital therapy first and individual therapy subsequently, if at all.
This preference is based on the experience that one
relatively minor change in a human system can have

consequences of a much more incisive nature than a simple and
brief intervention would lead one to expect. The case of an elderly
diabetic patient living with his wife may illustrate this. He had
been in good metabolic control for quite a number of years,
although he had slowly lost his eyesight. Yet he had managed to
carry on his job as furnace supervisor with the help of special

glasses and lighting. Over a period of several months his diabetes
was repeatedly out of control, which led to some altercations with
the clinic staff, who had been very proud of this model patient.
Then he quit his job, although there had been no clear indication
of any significant change in his eyesight or basic physical

condition; he was therefore referred for psychiatric consultation
while hospitalized to regulate his diabetes. Upon examination, it
appeared that the reason for his diabetic discontrol was that his
wife had stopped preparing lunches for him as she had done for
many years. He claimed he had no explanation for the change, but
it meant that he had to either forego lunch and adjust his insulin
accordingly or eat lunch out, which he could not do very well
within the limits of his diet near or at his place of work. The wife
was then contacted, and she had little trouble explaining her
dissatisfaction and her refusal to prepare his lunches, which she
found a nuisance at best. She was suspicious, if not convinced,
that he was unfaithful because he had "claimed” that he had

become impotent. Even though this had not developed suddenly,
she was preoccupied in her own mind that he had some other
woman. After it was explained to her and subsequently to both of

them that impotence is a common symptom of long-standing
diabetes, both felt relieved, she reassured and he less guilty and
ashamed about this problem, and they could resume their

previous more cooperative equilibrium and he his job.
Marital therapy is indicated whenever clinical investigation

reveals significant disturbance in the system. It is not possible to
present an exhaustive list of such indications, but the following
should include the more common system problems.
In the course of family investigation or therapy the original
problem of a disturbed or disturbing child can often be traced to a

significant, if not primary, marital conflict or maladjustment. In
such instances, marital therapy may be instituted either in

addition to or instead of therapeutic work with the family. For
instance, in one family the initial contact between the family and
the mental health system occurred because of the elopement of a

teenage daughter, the older of two children in this family. In the
course of family work it became apparent that although
everybody in the family was suffering to some extent, the basic

problem resided in the parents’ marriage. Although the mother
had originally sought psychotherapeutic help on her own and had

worked effectively in this situation, it resulted in a deterioration
of the marital relationship in that the husband became more
withdrawn and depressed as his wife became less dependent and
more assertive. However, none of the family recognized this

consciously or overtly until work with the entire group was begun
following the elopement. The parents were then taken into
marital treatment, with considerable improvement and a

reasonable hope for eventual resolution of their difficulties and
the father’s depression.
In younger couples, especially before children have been

born, one of the common symptoms and problems is insufficient
emotional if not psychosocial emancipation from one or the other
spouse’s family of origin. In some instances, marriage is carried
on as if it were a continued courtship rather than the

establishment of a fully adult and therefore relatively
independent life situation (at least in Western societies) and the
opportunity, if not desire, to create a new generation. But

pregnancy and the birth of a child in and of themselves do not
automatically change motivation or capacity for parenthood, nor
necessarily influence a conflictual marital bond for the better.

Some marriages are undertaken to “regain” a family, one of the
spouses having been either rejected by his or her own family or
having lost them through death.
Any clinical investigation, therefore, must include

information about how spouses got together, what sort of
coalition they established for themselves, and how they decided

to reproduce, if indeed such a decision was ever made. Over half
first-ever pregnancies are conceived without clear intention to

assume parenthood, however this responsibility may be
perceived or understood. Such data have relevance to treatment
indications, as do data derived from observing interspousal and

familial interactions and transactions.
Incomplete emancipation of spouses from their respective
parents interferes not only with the marital relationship, but even
more with parenthood and family leadership. Moreover, guilt
over leaving a needy parent or unresolved mourning over a
deceased parent or even transmission of such unresolved guilt or
mourning across the generation boundary is a common source of
family difficulties and requires marital or family therapy with or
without individual treatment for the directly affected spouse (19,
20). Sexual difficulties are common and probably indicate marital
therapy more often than so-called sex therapy despite the current
vogue for the latter.
Couples in severe chronic conflict are often referred for

treatment by lawyers in an attempt to prevent, or ascertain the
necessity for, a divorce. In some states, such referrals for
counseling are mandated by law prior to the implementation of a
legal separation. Such referrals can constitute a treatment
indication, but more often they result from the effort of one
spouse to save or repair a relationship in which the other spouse
no longer has any investment and indeed may already have made
an emotional commitment to another prospective spouse.
If divorce occurs or is imminent in the context of an

established family, children will suffer and family treatment may
be indicated to minimize suffering and its consequences. Such
ameliorative and preventive treatments have been well presented
by J. Wallerstein et al. (21, 22).
Family Pathology
1. System deficiencies other than primarily marital ones,

which require treatment, almost always also reflect leadership
deficiencies. Such is the interdependency of system vectors and

functions.
2. Boundaries may be drawn either too rigidly and narrowly

or too loosely. The evolvement of ego boundaries for each child is
difficult to trace because it normally is a subtle, discrete and
essentially intrapsychic process. Yet interferences with this

normative development of the self-sense can be gross and the
resultant defects are well known to psychotherapists as
constituting indications for treatment. The severe boundary

defects seen in schizophrenic patients have been described in
detail by Lidz et al. (2, 8), Stierlin (23), Wynne et al. (24), and
others. Such patients often have experienced both intrusive
penetrations and impervious distance perpetrated by one or both

parents instead of consistent boundary contiguity. Certain
patients with severe psychosomatic problems may have
experienced similar boundary violations especially, on the part of

their mothers (25).
Violations of the generation boundary can produce or
prolong incestuous proclivities, fears and conflicts (26). These

pathological situations call for individual as well as family
therapy.
The family-community boundary can be mismanaged,
although this is usually not as devastating in itself to young
children’s personality formation as interferences with ego
boundary development.
Overly rigid family boundaries will interfere with children’s

experiences and relationship opportunities in the community.
School phobias are an early manifestation of such
mismanagement, often rooted in parental anxiety and deficient

separation mastery. At later stages, insufficiently permeable
boundaries are often found in families with disturbed adolescents
for whom increasing independence and emancipation then

becomes problematic, a common family treatment indication.
Unduly loose family-group boundaries interfere with both

personal and familial development. Children may feel uncared for
if not unwanted, and this latter sense may even be a realistic

appraisal of parental attitudes involved in such uncaring
boundary management, e.g. not telling and expecting children

when they are to return from playgrounds, visiting neighbors,
dates, etc. Such children become dependent on peers and
substitute parents in the neighborhood, if they are available, and

a sense of family unity and belonging is stunted. Although there is
an indication for family treatment for such families, lacking a
sense of unity they often are not available for conjoint treatment.
3. Aberrations in familial affects are probably involved in all
personal and family pathology. Even if primary, these also cannot
exist without some functional decrement in other system
parameters. Symptomatically, the outstanding example is
probably the scapegoated member described in detail first by
Ackerman (27). This occurrence constitutes a clear indication for

family treatment, especially because it has been frequently
observed that if the “scapegoat” is treated alone, or removed, the
family may scapegoat another member to re-establish the earlier

equilibrium (27). Other manifestations of affect disturbance and
family treatment indications are misuse of power to further
parental or sibling hostility, or the reverse: failure to set limits or

enforce any discipline. These may be two sides of the same hostile
coin.
4. Communication difficulties characterize all disturbed

families to some extent, and have been studied and analyzed
more than other system sectors (28, 29). Communication itself is
not usually presented as the problem or complaint, but it is very

important in clinical assessment and in arriving at treatment
indications. The nature of the aberrant communication may
reveal quite specific clues as to individual pathology, e.g. Wynne

and Singer’s family Rorschach method. In and of itself,
communicative disturbance in the family does not indicate what
form treatment should take, because that decision must be based
on considerations of all system functions. Yet a finding of
amorphous or fragmented communication styles, usually in

families with a schizophrenic member, requires family treatment
as it is not likely that the patient can be helped with his thought
disorder without some shift and improvement in the familial

communication style.
Communication in the broadest sense provides an essentially
cross-sectional view of the family, as it does in any therapeutic

situation, but may also reveal many clues about antecedent
events and problems, gleaned and inferable in family interviews.
There may be culture-deviant language, for instance, when
parents have persisted in and insisted on familial communication

in a foreign language. This need not be a problem; in fact, growing
up as a bilingual child can be advantageous, provided there is
tolerance for both languages. However, some immigrants

consciously or unconsciously resist integration into their new
environment and denigrate the language of the surrounding

community and also its values. In such families, children may be
handicapped because they may feel guilty and constrained with

regard to the language of their peers; indeed they may not easily
think and conceptualize in that language.
However, even without adhering to a foreign language,

parents’ thinking and verbal expression may be so disordered
that children do not, in fact cannot, acquire the syntax and the
symbolic meanings of the language of the outside world. Such
children not only are handicapped in formal learning, especially
when they are expected to move from concrete to abstract forms
of thinking, but will also be handicapped in interpersonal
relationships and will find themselves distant and estranged from
peers and other persons in their community. In reverse, if such
offspring do manage to identify with extra-familial figures, they

may be in serious conflicts with their own family and thus feel
extremely threatened by such disloyalty. This type of situation is
now known as a seedbed for schizophrenic disturbances. In

addition to verbal communication aberrations, there may also be
in such families a striking deviance between non-verbal and
verbal communication, as well as frequent use of doublebinding

(30).
There are families in which communication is extremely
sparse, although not particularly deviant. Their communication is

not practiced as a means of expressing feelings or sharing
feelings, and if children attempt expressiveness they may feel
thwarted by non-response or even negative responses. In

particular, in some families the expression of hostility or angry
feelings is suppressed or denied, creating an atmosphere of
pseudo-pleasantry and harmony. Such suppression and eventual

repression of anger and hostility are, of course, well known in
individual psychopathology as an important component of
depression—not only a communication impediment, but also an
affect disorder. Whether seen in one form or another, i.e. as
depression or communicative blockage, it is an important

indication for family therapy to break up such circularity of
depression in one member leading to inhibition and repression in
another or to destructive behavior in children. Children who have

grown up in such an atmosphere often are seen later clinically as
severely neurotic or so-called borderline patients who more

likely need individual therapy even though the family roots of
their difficulties may be striking. For example, a suicidal college
student drop-out could not discuss with either of her parents or

other family members the fatal metastatic illness of her father.
She had to be hospitalized and treated individually, as the family
could not be engaged as a unit, which would have been

preferable.
Another type of communication aberration usually seen in
families of sociopathic patients is the striking use of

communication as an instrument to influence others regardless of
truth or facts, and an absence of any expressive use of
communication. Although there may be an assertion of strong
feelings by such patients and their families, especially contrition

early in treatment contacts, it is probably a contrived expression
designed to influence others, e.g., the therapist. Such problems are
probably best dealt with in a combination of family treatment and

group treatment for the patient, possibly in a group-home for
patients of this type, although not infrequently by the time these

individuals come for treatment, often through court or police
referral, regular contact among the family has been broken. It has
also been our experience that such families often continue to aid
and abet the asocial behavior for homeostatic reasons, as already
discussed, resisting or interfering with therapy. Even treatment

appointments are “forgotten” or cancelled with barely an excuse.
Family Task Performance and Deficiencies
Family tasks are determined by the life cycle and therefore

must be assessed by obtaining historical data for the period of
family life prior to the initial contact with a clinician. Only the
present state of family functioning can be observed directly. Aside

from the task to establish a marital coalition and parenthood
readiness, already discussed at the beginning of this chapter, the
life-cycle-related task can be divided, albeit somewhat arbitrarily,
according to the phases outlined by Erikson (31). The first stage is
that of nurturance, which includes weaning and teaching infants

and young children body mastery. This is followed by the era of
enculturation, during which the child learns to speak and how to

behave in the family, as well as with peers in nursery school or
similar play experiences, play being the child’s work. The child
and family then enter a period of ordering their relationships,

passing through the oedipal phase in individual development
terms or from a systems view establishing equidistant and
comfortable relationships with both parents and with siblings, if

there are any.
With the beginning of school, children should be ready for

more significant peer relationships and friendships outside the
family, and also should participate in family life during the next
five years or so in increasingly reciprocal ways, assuming some
responsibilities or chores. This is also the period of maximal

harmony in the family, a period in which the family can move,
work and play as a unit, celebrate and mourn together, and
engage as a unit with other families with children of comparable

ages.
When children reach adolescence, family harmony is hardly
the order of the day. Looming ahead is the ultimate emancipation

of late adolescents or young adults from their families.
Adolescents initiate this eventual separation by challenging
family life and values, by testing and probing the limits of

parental leadership, while almost simultaneously also expecting,
even demanding, dependency gratification from the family.
As children leave the family, the parental generation

eventually returns to dyadic living in mid-life or later, and issues
of non-familial creativity and effectiveness for both parents
become important. They must also shift to accepting their

children as equals, and the latter must be ready to be equals in
their relationships with parents. Only thus can a sense of
familiness continue without undue conflict or interfering with the

formation of children’s own nuclear families.
As the life cycle continues and parents, likely grandparents
by then, begin to age and withdraw from productive life, infirmity
may also require a role reversal between parents and children,
the latter becoming the leaders and decision-makers even though
they may not actually live together.
Therapy indications can arise at all these stages, but must be

considered in the context of the total system and not only in
terms of a particular family task deficiency. Elderly people should
be helped to live as couples or even with one of their children’s

families for as long as this can be reconciled with caring for each
other and them without any significant handicap for anyone
concerned.
Treatment indications stem from performance defects of the
family or any sub-system. Probably the most common and

clearest recommendations to seek help, not necessarily in the
form of family treatment, often arise from outside the system.

General physicians, pediatricians, school staffs and recreation
workers, e.g. scout leaders, are all concerned with children’s

behaviors and performance—indirect or direct indices of family
system functioning. Lags in physical development,
underachievement in school, or conspicuous behavior on the

playground, all these can be manifestations of family disturbance
and often are that. R. Beavers (32) speaks of therapy as growth; in
general this is what therapy is about regardless of specific
technique or diagnosis. J. C. Whitehorn, many years ago, also
referred to people seeking or being referred for help from us as
“unfinished people” (33). As we examine and increasingly
understand family functioning and family failures and their
connection with and reflection in individual functioning and

failures and vice versa, treatment techniques and formats and
their combinations become less important than is our
competence to think in terms of systems. Typhoid fever can be

prevented by removing the agent from our environment and from
food and water, or by raising specific body defenses to interfere
with the agent’s invasion of and spread in tissues, or by

introducing chemicals into our bodies which neutralize or destroy
the agent. In other words, through knowledge and understanding
of the systems and subsystems involved in a problem, we can

determine which of several points of attack or intervention is the
most efficient, appropriate and applicable. Thus we can and
should explore with a single patient, or a family, or a group the

nature of pain and difficulties and consider ways and means of
relief and resolution. Often this step or process entails removal of
growth obstacles or barriers, or, in systems terms, converting

stagnating energy—homeostasis—to movement and change.
Initiating such change from stagnation to mobility can occur on a
cellular level, i.e. with drug treatment, in the personality system,

e.g. through some special relationship, identification with or
transference to a therapist or leader, or on an interpersonal plane.
Whichever is chosen for the first step, if change occurs in one

system there will be correlated or reactive changes in the others.
It must also be appreciated that observations and study in
one context, e.g. the traditional dyadic treatment system, may
obscure or hide other systems processes. The reverse is equally

possible—some significant intrapersonal malfunction may be
covered up or hidden in the family context.
For instance, the family of a young, single, art student who

became psychotic when her boyfriend of long standing involved
himself with another woman, on initial contact gave enough

information to constitute the genogram in Figure 1, confirmed
subsequently despite increasing resistance to any form of therapy
by all concerned. The patient initially convincingly denied any

significant family events or involvement in her difficulties. The
epithets are quotes from family members about each other.
Figure 1
One can glean from this diagram an ambitious mother, likely
in need of improving herself, and an effective transmission of
such values to two daughters, but not to the third (patient), who
breaks down when her “main support” leaves her. She had never
felt appreciated as her sisters were and thus felt unable to replace
the dying sister. In addition, the father felt very close to the
patient and overprotected her, trying to mend the rift with her
boyfriend.
A summary list of clinical judgments about the five major

family system components has been found useful in arriving at
treatment indications. However, establishing the need for
remedial measures in this way does not necessarily indicate what

form or combination of treatments may be most suitable in any
particular clinical situation. Assessments can be plotted along a
continuum ranging from good or optimal, to mixed, to abnormal

or deficient functioning, or for example from (1-Good) to (5-
Aberrant). The following tentative list has been and is being
tested in our center and its reliability among different clinicians

validated.
Leadership Boundaries Affectivity Communication Task/Goal
Performance
Parental Ego boundary Inter- Clarity as to form Nurturance

personalities development in parental and syntax and weaning
children intimacy
Marital coalition Generation Equivalence Responsiveness Separation

boundary of family mastery
triads
Parental role Family- Tolerance Verbal/non- Behavior

complementaries community for feelings verbal control and
permeability consistency guidance
Use of power Unit Expressivity Peer

(discipline) emotionality relationship
management
Abstract thinking Unit leisure
Crisis coping
Emancipation
Post-nuclear
family
adjustments
Techniques
We do not advocate a stereotype technique for family

treatment. There are some ground rules we believe to be sound,
but special technical maneuvers like “getting into the system’’
(34) or “reciprocal suggestions or tasks’’ (35), etc. are very

successful if carried out by sensitive, experienced masters of the
art, but are not necessarily so if attempted by others, even if there
is conviction as to the soundness of a particular intervention.
We would advocate that a leader/therapist meet with the
family, establish him- or herself as a helper and the person to set
boundaries and rules if necessary. The therapist should use the

first session or two to obtain a marital and family history, in
addition to allowing for some relatively unstructured family

interaction. The family should be invited to state the problem, and
agreement or disagreement on this statement should be
established. This may encompass much of the first session. The

therapist should avoid special or intensive involvement with any
one member, but in an initial interview should invite some
activity from each member (36).
After the initial sessions—perhaps up to four or five—the
therapist should put into writing his or her formulation of the

problem and how it is to be treated, not necessarily only through
family therapy. The recommendation should be communicated to

the family in language useful to them and with appropriate
proposals for subsequent sessions and schedules.
Unless two therapists intend to work together as a team
indefinitely and are willing to work at becoming a team, we

recommend against cotherapists. If there is a problem of data
overload with a very active family, especially for a beginning
therapist, it is preferable to have a non-participant observer

either in the room or behind a one-way mirror instead of
crowding a beginner by coupling him or her with an experienced
therapist who probably would and should dominate the
therapeutic interaction.
Hospitalization
Because of the system’s interdependence, the hospitalization
of any family member for whatever reasons constitutes a family

crisis requiring minimally sympathetic and supportive interaction
between family and hospital staff. If the hospitalization is for
psychiatric reasons, such a crisis is particularly severe because of
the probable prior efforts on the part of the family to contain the
problem within its midst. Furthermore, it is possible, if not likely,
that that containment served to maintain system equilibrium and
also that such homeostasis has been maintained by virtue of the

patient’s symptoms and maladaptive or aberrant behavior. In this
case, considerable resistance to hospitalization or to its
continuance may be encountered. Lastly, the hospitalization can

also represent the family’s need and effort to extrude the
identified patient either after or without prolonged efforts to
maintain him or her within the system (37).
Whichever of these contingencies may be particularly valid,

system upheaval is very likely at the time of hospitalization,
including a sense of conflict, guilt, shame and anger in the

individuals and in the group. A sense of failure may be
unavoidable under such circumstances as it is in any situation
where system dysfunction and discomfort cannot be corrected

from within the system; with that sense of failure, reactive and
defensive stances are likely to be manifest. In the case of
psychiatric illness, this most often is expressed in an effort to find

blame outside the system, or results in a magic belief in and
frantic search for some causative biological factor beyond human
control. Therefore, the family of any newly hospitalized
psychiatric patient deserves professional attention and help with
the immediate crisis by being informed as much as possible about

the nature of the hospital program, about the likely duration of
the institutional care, and about whatever therapeutic program is
planned for the patient and for the family respectively. Often
families and patients attempt to collude for a time in blaming the
hospitalization and hospital procedures for the patient’s

difficulties, instead of exploring with the therapist(s) antecedents
of the illness and the family’s functioning and history.
Further treatment indications essentially parallel those listed
for family treatment in general, but obviously with a hospitalized

patient, individual and other forms of treatment for the patient
are also indicated.
From the earliest possible time in the hospitalization, the
family should be helped with the admission crisis. A minimal

program for working with patients’ families should be arranged
to keep the family abreast of the patient’s development and his or

her clinical course, and to prepare and work with the family for
the eventual disposition and discharge of the patient. Even when

such plans can be formulated only tentatively, one of the major
decisions to be made early is whether it is envisioned, if not
planned, that the patient join the family to continue living with
them or whether the assessment of the family system and of the
patient’s age-appropriate needs will point to the patient’s living
apart from the family in the future. The reverse can, of course,
also be a necessary consideration, i.e. whether patients who have
attempted to live apart from their families of origin or
procreation should return to living with them, at least
temporarily if not permanently.
A common constellation is a breakdown in personal

functioning of a young adult at the time of expected emancipation
from his or her family of origin, either while facing this step or
after a relatively brief period of having attempted to implement it.

These considerations must also determine whether therapeutic
work planned with the family is to be done with the entire family
as a group, the patient included, or whether the parents or the

parents and siblings should be treated in sessions without the
patient. Often it is indicated that one proceed from one format to
another, but the ultimate aim is to enable the family to accept and
live with whatever disposition is considered optimal. Without
therapeutic work and some essential change in the family
equilibrium, for instance a rapprochement between the parents

so that one or the other parent can forego the close bind to a child
or delegating a particular role to this child as described in detail

by Stierlin (38, 39), pathogenic forces will continue and re-
hospitalization is likely to occur.
It is also important that the family not reestablish a similar
equilibrium without the hospitalized patient, thereby creating a

new “patient” in their midst. It is not an infrequent experience
that following hospitalization of one child and amelioration of the

immediate crisis, another child will develop symptoms.
Therefore, family therapy can have immediate preventive impact;
it should also have a more long-range, but possibly less obvious,
preventive result for the entire system.
Indications for more formal family treatment exist if there is

a clear assessment that it is not only the family stressed by the
mental illness of one member, but also the established type of

family system that contributes significantly to the development of
the illness. We can point out four types of such etiological
movement.
1) We have indicated in the foregoing section that the patient
may serve as a kind of messenger for family disturbance.

However, if this messenger “status” is not reached until the
particular family member becomes so disturbed that he or she
has to be hospitalized, there are obvious indications for individual

therapy as well as family treatment. Most likely in such families,
there is severe leadership aberration aside from other system
defects pointing to marital conflict or some unresolved
interpersonal or neurotic condition in one or both parents.
2) The identified patient may have served as a significant
homeostabilizing element in the system. This phenomenon seems

to occur in two ways (40):
a) One is in a family equilibrium where much concern and

attention and emotional force are directed toward and
attached to a problem-member, be it a delinquent child,
an ailing possibly hypochondriacal parent, or a child
with eating problems. As long as the overt problem
continues as a daily preoccupation and concern, other
more basic system deficits can be ignored, or indeed
may exist and smolder because the “noisy” problem
leaves no time or energy for more basic issues. Such a
family pattern is often seen in patients identified as
anorexia nervosa, and their treatment has been
described in detail by Minuchin and Selvini (34,41). In
such instances, family therapy is a must and often very
effective in addition to the possibly lifesaving treatment
of a hospitalized patient of this type. Even in less
pathological systems, homeostasis may be based on
infantilizing growing children so that just by virtue of
biopsychological development an impasse is reached
when one or the other child is expected and needs for
the sake of his or her personal growth to move
increasingly outside the family.
b) The other hidden homeostatic maintenance role we have

observed at a time of acute psychiatric illness or
deterioration in a chronic psychiatric condition
concerns families in which parents are contemplating
separation or dissolution of the marriage. The illness
then provides a focus for both parents; unless the basic
conflict between the parents is resolved in whatever
direction, the patient will retain a stake in remaining ill
so as to keep his or her parents together, or at least to
remain involved with both of them in significant ways.
This does not mean that the treatment goal must be in
the direction of maintaining the marriage as such, but
rather that the problems be treated as indicated
regardless of ultimate reconstitution or dissolution of
the system (42).
3) A related, but also different problem leading to
hospitalization arises when emancipation of a child from the
family is resisted by the system, also a common finding. In such

instances, there may have been relatively little psychiatric
disturbance in the clinical sense on the part of any individual, but
the system, especially in its boundary management, is overly rigid

and parents may be unable to face the prospect of living as a dyad
again. There may be more pathological themes, such as that a
child may have been used to avoid confrontations between the
spouses or between the parents and another child, or that one or
the other parent, or both of them, will permit emancipation only

in a constrained fashion—for instance, insisting on a career
choice which may be anathema to the particular child. The
hospitalization may, therefore, actually constitute for such a

patient a step toward emancipation and separation, albeit a very
circuitous and painful one. Again, this is a clear indication for
family therapy in addition to whatever individual treatment may
be indicated for the patient, but probably a family therapy plan

that soon will move to working with the family without the
hospitalized patient.
4) Lastly, there is extrusion of the patient by a family that

cannot accept or work out within its system a particular
member’s handicap, career choice, personality change, etc.
Extrusion can be perpetrated upon either parent, siblings or

children, and may have beneficial effects for the entire family, as
for instance in the case of the hospitalization of an alcoholic
parent with a stance that he or she will not be acceptable into the
system unless the drinking stops. It may indeed be realistic in that
the family system can function better with one parent than with a
severely disturbed and disturbing second parent. It is, of course,
well known that often only such a step inflicts sufficient pain on
an addictive person for him to accept treatment and

rehabilitation.
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Proceedings 4th Symposium of Psychotherapy of Schizophrenia, Amsterdam.
Excerpta Med., 1972, 56:166.
24. Wynne, L. C., Ryckolf, I., et al. Pseudo-mutuality in the family relations of
schizophrenics. Psychiatry, 1958, 21:205-220.
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Psychiat., 1962, 126:85-90.
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Incestuous and homosexual problems. In: J. H. Masserman (Ed.), Individual and
Familial Dynamics. New York: Grune & Stratton, 1959.
27. Ackerman, N. W. Treating the Troubled Family. New York: Basic Books, 1966.
28. Scheflen, A. Body Language and Social Order: Communication as Behavior Control.
New Jersey: Prentice-Hall, 1972.
29. Watzlawick, P., Beavin, J. H., and Jackson, D. D. Pragmatics of Human Communication.
New York: W. W. Norton & Co., Inc., 1967.
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Behav. Sci., 1956, 1:251-264.
31. Erikson, E. H. Childhood and Society. New York: W. W. Norton, 1950.
32. Beavers, W. R. Psychotherapy and Growth: A Family Systems Perspective. New York:
Brunner/Mazel, 1977.
33. Whitehorn, J. C. and Betz, B. Effective Psychotherapy With the Schizophrenic Patient.
New York: J. Aronson, Inc., 1975.
34. Minuchin, S. Families and Family Therapy. Cambridge, Massachusetts: Harvard

University Press, 1974.
35. Selvini, P., Boscoto, G., et al. Paradoxon und Gegenparadoxon. Stuttgart: Klett-Cotta,
1977.
36. Stierlin, H. Rücker-Embden, I., et al. Das erste Familien gespräch. Stuttgart: Klett-
Cotta, 1977.
37. Fleck, S., Cornelison, A., Norton, N„ and Lidz, T. Interaction between hospital staff
and families. Psychiatry, 1957, 20:343-350.
38. Stierlin, H. The adaptation of the “stronger" person's reality: Some aspects of the
symbolic relationship of the schizophrenic. Psychiatry, 1959, 22:143-152.
39. Boszormenyi-Nagy, I. Loyalty implications of the transference model in

psychotherapy. Arch. Gen. Psychiat., 1972, 27:373-380.
40. Jackson, D. D. The Question of Family Homeostasis. Psychiat. Quart., 1957, 31:79-90.
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Suppl., 1963, 169 (39): 1 -24.
Note
1. The editorial assistance of Ms. L. H. Fleck and Ms. K. Molloy is gratefully
acknowledged.
24
Behavioral Techniques in Conjunction

with Individual Psychoanalytic Therapy
Allan Cooper, Ph.D.
Psychoanalytic psychotherapy conducted by a competent
therapist and an apparently motivated patient sometimes
develops an impasse. Much time and thought have been devoted

in the literature to dealing with various forms of therapeutic
stalemates. Problems in the transference/ countertransference
relationship have been discussed; intrapsychic motivations to

remain under psychological distress have long been considered
part of such problems. In the treatment situation, the analytic

therapist and patient look for unconscious motivations that may
represent the resistance to change. After extensive exploration,

the therapeutic stalemate sometimes remains. The therapist may
have no alternative but to stop treatment, or do more of what he
has been doing.
When certain impasses present a stalemate in psychoanalytic
psychotherapy, the use of certain behavior therapy techniques

may be of help. What makes this suggestion startling and unusual
is that psychoanalytic theory and behavioristic theory appear to
have very different views about the nature or source of symptoms

and psychological difficulties. However, a therapist does not have
to resolve issues of theoretical difference in order to utilize these
procedures. The clinician has to see if a procedure will be of help

to his patient. For instance, a therapist may feel that an
antidepressant medication would be helpful during
psychoanalytic psychotherapy without subscribing to the notion

that all neuroses are biochemical in nature. If new procedures are
successful, the clinician may modify his theory and find a way to
reconceptualize the procedures so that they fit into his slightly

altered theoretical position.
There have been a few authors who have attempted to

integrate behavior therapy techniques with psychoanalytic
psychotherapy (1, 2, 3). For the most part, however,

psychoanalytic therapists have viewed behavioral approaches
with alarm, fear, or disbelief. For the most part, analytic
therapists are not acquainted with the procedures used in
behavior therapy. They often react to what they imagine the

procedures consist of and tend to regard these procedures as
authoritarian in nature. Wachtel has discussed this issue at
several points in his book (2) on the integration of psychoanalysis

and behavior therapy.
The number of techniques that can be included under the
rubric of behavior therapy is great. It is not possible to discuss all
these techniques in the present discussion. This discussion will
include only those techniques introduced by Wolpe, which

probably represent the major techniques used in outpatient
practice.
The techniques include desensitization, assertive training,

and sexual retraining. These procedures have in common a
gradual approach to a situation that produces anxiety. Be the
problem an actual phobia or a fear of direct expression to others,

the desired goal is approached in a series of incremental steps.
These steps have been discussed with the patient, and the patient
actively participates in bringing in material and evaluating how

much anxiety would be produced if the patient were actually in
the situation in question. The therapist also takes an active role in
inquiring about situations related to the problem in question.
When ten to twelve situations related to the problem have

been collected and rank-ordered for degree of difficulty, they are
presented to the patient. In the desensitization procedure, the

patient is taught muscle relaxation and trained to be able to enter
a state of extreme body relaxation. In this state the patient is
asked to visualize the scenes that were worked out earlier. Each
scene is presented a few times, with a rest period between
presentations. The scenes are presented in rank order, moving

from least anxiety-provoking up the scale until the most
frightening scene is finally visualized without anxiety. As each
scene is desensitized so that it no longer evokes anxiety, the
succeeding scene appears to be less frightening than it was before

the procedure was begun. Thus, when the fifth item is presented
for imagination, it does not evoke as much anxiety as it would
have if it had been presented at the beginning of procedure.

However, the imagined situation still does evoke some anxiety
until it is desensitized by being imagined several times in the
state of extreme body relaxation.
A typical hierarchy presented by Wolpe (4) contained the

following items in a claustrophobic series: the lowest item—
reading of miners trapped underground; a middle scene—on a

journey by train (the longer the journey, the more disturbing); the
highest anxiety scene— being stuck in an elevator (the longer the
time, the more disturbing). At the conclusion of the hierarchy in

imagination, the patient is expected to be able to confront the
actual situations without anxiety.
In the case of assertive training, situations are discussed in

the manner outlined above. The capacity of the situation to evoke
anxiety is discussed, and the situations are rank-ordered. In ease
of assertion it might be easier for the patient to express

annoyance to a waiter who brings the wrong order than to ask his
boss for a raise or a vacation. The types of situations that create

interpersonal anxiety will vary with each individual, as will the
order of difficulty different situations produce. The patient is then
asked to express himself in the actual situations, moving from
least to most anxiety-provoking. If the situations, despite their

being rank-ordered, still evoke too much anxiety for the patient to
express himself, desensitization of the situation in imagination
may be added as a prior step. After desensitization in imagination,

the patient may then be able to express himself successfully in the
actual situation.
In sexual retraining for a problem with impotence, the

patient would be asked to avoid attempting intercourse until less
anxiety-provoking sexual activities are accomplished without
anxiety. The order of activities might be: lying in bed naked with
the sexual partner; caressing in a pleasurable, non-erotic way;
erotic stimulation without intercourse; and, finally, intercourse.
As in the case of assertive training, sexual retraining may be

combined with desensitization.
The above descriptions of the procedures are necessarily
sketchy in this short a space. A more complete description of the

procedures, variations in techniques, and other behavior therapy
techniques can be obtained from the literature (5, 6).
It is the use of the procedures of systematic desensitization,
assertive training, and sexual retraining that will be discussed as

techniques that might loosen some of the stalemates that develop
in psychoanalytic psychotherapy.
One area of impasse is that in which specific troublesome
symptoms do not abate during the analytic inquiry. This may
cause continuous pain, anxiety, and/or embarrassment to the

patient. It may also interfere with the patient’s ability to talk
about anything other than his symptoms and their ramifications.
From an analytic perspective, the continuous discussion in

therapy of problems with symptoms can be viewed as a
resistance. However, if the resistance does not yield to
interpretation, confrontation, etc., the therapist and patient are
left in a painful stalemate. The introduction of behavior therapy
techniques may alleviate the symptoms and may allow the

psychoanalytic therapy to continue when the symptom is
alleviated. Contrary to the thinking of a few years ago, the
alleviation of symptoms does not necessarily reduce the patient’s

motivation for treatment, but may actually increase motivation
for further change. It should also be added that symptom
substitution has rarely been reported with treatment by
behavioral techniques.
A man came to therapy with a primary complaint of
impotence. He had been living with a woman for two years. He
was clear about the positive qualities of this woman, who was a
few years younger than he. She was bright, verbal, lively, exciting,
successful in her career, and very attractive. He had had a good
sexual relationship with her for over a year when the problem
with impotence began. He could not trace his reaction to any
difficulty in his interaction with his partner, nor could she identify
any interpersonal difficulty that precipitated the lack of sexual

response. Several other potential precipitants were explored in
the course of early interviews. The death of a close friend from a

lingering illness had occurred around the time of onset of the
impotence, but precise relationship in time was vague. Business
worries and successes had fluctuated during the past several

years. His developmental history indicated both deprivation and a
rather strict upbringing, with rather harsh punishments for minor
infractions of conduct. However, he was not aware of any

resentment, anger, or depression related to parental treatment in
the past or present. He was aware that he did not feel very close
to anyone in his family, but he remained on pleasant terms with

family members and tried to fulfill what he considered his
obligations to them.
During sessions he appeared to be cooperative and
motivated, but his thoughts did not range far afield from his
symptoms. After a few months of twice-a-week
psychoanalytically-oriented psychotherapy, I suggested a
behavioral approach to the problems of impotence in the form of

a graded approach to sexual intimacy. The patient and I discussed
the stages of intimacy that would lead finally to sexual

intercourse. They ranged from lying naked together, to non-erotic
but pleasurable caressing, to several levels of erotic intimacy, and,
finally, to intercourse. I explained that he should not shift stages
of sexual intimacy too rapidly, so that he could feel pleasure and
enjoyment without the anxiety of having to perform. He explained

the procedure to his friend, who was agreeable to following the
plan. Within a month he was able to have erections and to have

intercourse.
At first the patient and his girlfriend were delighted with the
change. However, the patient soon began to complain that,
although he could perform adequately, he did not enjoy it very

much. This led the patient to a more careful evaluation of his
relationship with his partner. He began to recognize a pattern in
which most ideas about what they should do came from her. He
began to be aware that he was both resentful at always pleasing
her and chagrined at himself for not having many desires about
what he, himself, would like to do. These issues led to further
investigation in therapy.
The point of this vignette is to indicate that the use of a

behavioral approach to a symptom is not incompatible with
analytic therapy and may facilitate the analytic process. In the
above instance, the alleviation of a disturbing symptom led to a

closer investigation of the patient’s character problems and how
these problems affected his relationships.
We cannot know how things would have worked out if I had

not employed the behavioral procedures. However, I am
indicating that if one’s clinical judgment suggests the use of other
techniques, behavior therapy techniques may be useful both in
alleviating a symptom and in facilitating analytic therapy.
Obviously, there is no guarantee that an attempt to alleviate
a symptom by behavioral techniques will be successful. In one

case of a married man with a problem of impotence alternating
with premature ejaculation, a program similar to the one outlined
above was suggested. In that case the patient reported that,

although his wife agreed to follow the procedure, she seemed to
do everything wrong. The procedure failed to alleviate the
symptom, and the analytic therapy continued. However, some

information about this patient’s capacity to cooperate with his
wife and others was obtained and questions about his ability to
accept help were raised for the analytic therapy. It did not appear
that much was gained in the way of symptom alleviation from the
procedure in this instance, but it did not appear that much was
lost in the process and some increased awareness of character

problems was obtained. Many analytic therapists who are not
familiar with behavioral procedures regard them as authoritarian,
controlling, and therefore dangerous and stifling of the patient’s

independence. However, anyone who has actually worked with
the more common behavioral techniques is aware that they are
quite benign and tend to be simply ineffective when they do not
succeed.
An obvious area of concern by therapists would be how the
introduction of behavioral techniques affects the therapeutic
relationship. If a therapist takes as his exclusive model a
psychoanalytic technique in which the therapist tries to remain

neutral and vague in order to facilitate the expression of phantasy
material in the transference, the introduction of any parameter is
obviously incompatible with the procedure.
If, however, one accepts the concepts of psychodynamics and

the transference, but is willing to interact with the patient, then
the introduction of behavioral techniques should not alter the

basic nature of inquiry into the relationship between the patient
and therapist.
During the introduction of behavioral techniques, the

therapist assumes a more active role of educator and expert. This
may be especially helpful where the patient has difficulty in the

process of working through certain issues of a long-standing
characterological nature. When analytic therapy is working well,
the patient recognizes and discusses patterns of interaction with
people. Often the patient will attempt to change certain patterns

to produce more effective and satisfying relationships. Much of
this work is done spontaneously by the patient and may only be
mentioned incidentally in the therapy sessions. For instance, a

man began to observe in greater detail how he held back at
meetings and in initial interactions with other professionals. He

began to realize that he automatically expected that, if he
appeared confident and competent, people would have excessive
and unrealistic expectations of him. His phantasies and dreams
indicated that not being able to fulfill these expectations would

lead to severe disappointment and anger from others. When
further inquiry in this area was pursued in succeeding months,
his own competitive feelings began to emerge. The analytic

inquiry and discussion led the patient to resonate within himself
to the therapy discussions. This led to dreams, phantasies, new
observations, recollections, and attempts at new behavior.

Although he had employed a variety of defenses over the years to
deal with his anxiety over angry, competitive feelings, he could
recall having the feelings, and in some cases acting on these

feelings, as a young boy. As he began to differentiate between
appropriate and inappropriate reactions within himself, he was
able to experiment with new behaviors on his own, with no

prompting from the therapist. The patient’s activity in his own
behalf was of obvious help in changing his patterns of interaction
with people and facilitated the working through.
With this type of patient no modification of technique seems
to be required.
One of the serious problems in analytic therapy arises when

the patient talks over and over about some pattern of interaction
with people but makes no attempts at changing these patterns.

Often the patient appears to search for new insights which will
lead to his understanding why he doesn’t change his behavior.
The therapist may continue to explore, inquire, and analyze. He
may continue to search for the meaning of the patient’s resistance

to change and hope that a more precise interpretation will lead to
a significant insight that will move the patient towards change.
However, as a number of therapists have observed, insight often

follows change rather than being the cause of change. The search
for understanding oneself is the important process of analytic
therapy. However, at times the search for understanding can be

put in the service of a subtle form of passivity in which the patient
secretly hopes that the therapist will provide the correct insight
that will magically change the patient. The patient hopes he can
be spared the anxiety and struggle that often accompany attempts
at change. The therapist’s attempts at further understanding and
interpretations may collude with the patient's passive

orientation. The patient may even derive some gratification from
the therapist’s attempts to help or may enjoy seeing the therapist
frustrated in his attempts to be helpful. In any event, the patient

may ultimately be left with the frustrations and anxieties inherent
in the types of interactions he has been unable to change. The
therapist may be forced to conclude that the patient’s resistances

were too powerful, that the patient really needed this type of
interaction, and that the patient had a powerful masochistic need
to remain the same.
However, it may be that therapists with psychoanalytic
orientation are at times oversold on the concept that the
unconscious processes control all change. They therefore make an

a priori assumption that attempts to achieve change by methods
that do not deal with the unconscious are doomed to failure.

However, this assumption does not agree with data that patients
present to us.
One patient who came for treatment of depression with
feelings of anxiety and sadness had on the occasion of the

outbreak of her symptoms also developed a phobia of heights. She
had on her own initiative developed a form of desensitization
technique in which she gradually moved herself to looking out

windows in her house at greater and greater heights. When she
came to feel comfortable at one height, she would move on to the

next. She continued this spontaneously developed procedure until
she was able to endure the various heights without anxiety.
A man who came to therapy with problems centering around

his difficulty in communicating and feeling close to a woman
reported that a few years before he came to therapy he had
developed a severe claustrophobic reaction. He was unable to sit

in any small confined area. He was unable to have dinner in a
restaurant because of the claustrophobic sensation of being
trapped, with ensuing waves of panic. However, when he told one

girlfriend about this problem, she suggested that they go to a
restaurant and assured him that if he felt anxious she would be
willing to leave immediately without finishing the meal. He
reported that this produced a sense of security within him, so that
when he went to the restaurant he did not feel the anxiety; the
claustrophobia abated and had not returned since.
One can certainly wonder about what factors produced the
change in this man; in fact, they were profitably explored in

therapy. However, the point I am focusing on is that important
change takes place without first making unconscious material
conscious. In fact, previously dissociated material may become

conscious as the patient begins to make changes, especially in his
interaction with others. Under ideal conditions, discussion with
the therapist may lead to pointing out of patterns that were not
previously noted in a focused way by the patient. This may stir
recollections of earlier patterns of interactions and clarification of
feelings. The patient may then, spontaneously and without urging

from the therapist, begin to behave and interact differently with
others, which will lead to the surfacing of other conflicts and

dissociated material. However, when this pattern does not occur
and when the patient does not put into action any of the insight
gained in therapy, the therapist may feel that his only recourse is
to try to provide more insight into the unconscious processes. At
some point of exasperation or frustration the therapist may ask,
“What would be so terrible if you told your mother… father…

child…that you didn’t feel like doing what they ask?”
The problem with this indirect urging of the patient to action
is that the therapist is forced to react to a situation that the
patient has spontaneously brought to the therapist’s attention. I

think it is especially true, where patients have difficulty in
asserting themselves and being direct and straightforward, that
what they discuss in therapy is only a fragment of the total

problem they have with assertion.
There are several problems that are often encountered by

people who have serious difficulty in learning to assert
themselves. They have often come from homes in which any form
of assertion was strongly discouraged. Their families often

equated assertion with aggression or hostility. The patients were
threatened with loss of love and with being viewed in a negative
way if they attempted to assert their feelings and opinions. If this
pattern were not modified through interactions with peers, a total

state of inhibition of assertion may have developed and been
maintained until the patient entered therapy. The patient has
become used to rationalizing his lack of assertion. In many, many

small incidents he will tell himself that it would be unimportant to
say what he felt, or that it might even be petty. There is nothing
wrong with the judgment as it is applied to any given incident.

However, if many incidents are observed, it could be seen that
there is a compulsive quality to the lack of assertion and that the
choice is not voluntary. The patient lacks the option to assert

himself. This freedom of choice becomes the goal of the
behavioral change. The goal should not be to make the patient an
assertive individual. To decide what kind of person the patient

should be is clearly a countertransference problem of the worst
order and does indicate an authoritarian orientation. The patient

who is used to rationalizing his lack of assertion will dismiss
incident after incident until a situation develops in which his lack
of assertion embarrasses him or causes him a severe problem,

such as not asking for a raise.
This type of patient raises the issue only on the rare
occasions in which an embarrassing situation has suddenly
developed. He does not have the resources to handle such an

extreme situation. He may continue to avoid assertions in the
milder everyday encounters and probably will have a blind spot

regarding these events. His self-image may be dependent on his
being a saint. His initial discussion of difficulty in assertion
probably will not be followed up spontaneously until a new
humiliating incident develops. As in most learning or relearning

situations, it is best to progress from the simple to the difficult.
However, life’s events, especially as observed by the patient with
selective inattention, do not present themselves in a way that is

orderly enough to be optimal for learning. Events may appear to
pop up in a willy-nilly fashion, and it is especially the more

difficult ones that capture the patient’s attention.
It can be helpful to the patient if the therapist takes a more
active behavioral approach with such a patient. In order to do
this, the therapist must actively explore situations in which
assertion is a possible response. He can use some stock situations

requiring assertion that have been compiled in the literature and
can use his imagination to raise questions about other situations.
He can then rank-order these situations with the patient. The

patient can then practice new behaviors in a way that is within his
grasp and is conducive to learning. This is not to say that various
problems and unexpected issues may not develop. They probably

will, and this is all to the good as it probably represents other
characterological issues that are related to the issue of assertion.
I am suggesting that it may be of more therapeutic benefit to

develop a detailed analysis of the patient's capacity to assert
himself with different people and in different situations than
simply to explore his phantasies about assertion. Especially when

the therapy is at an impasse, it would seem that the therapist
should not do more of the same thing when that procedure has
not yielded results. Furthermore, when a therapist addresses an
issue as potent as being able to be direct with other people
(strangers, friends, family), change in this area is bound to

resonate with the total personality and produce new material in
the patient’s observation of self and others, in his dream life, and
in his production of phantasies. This ripple effect, especially as it

has its effect on intrapsychic processes, has not been reported in
the literature because behavioral techniques are used primarily
by behavior therapists and the production of dreams and
phantasies is not used much in their work. It has been my

observation that, when behavioral techniques are added to the
analytic therapy, significant material develops in dreams and

phantasies which can be used at the therapist’s discretion for
further analytic work.
One of the few reports of the interaction between behavior
therapy techniques and psychoanalytic therapy is provided by

Weitzman (3). In a detailed and thoughtful examination of the
relationship between behavior therapy and psychoanalytic
psychotherapy, he reports the use of desensitization to be of help

in working with dreams. He states that when a patient reported a
dream in which he had sparse associations, the patient was asked

to use the muscle relaxation used in desensitization. The patient
was then instructed to imagine either the last image of the dream
or an image in the dream that seemed particularly disturbing. The
author reports that the procedure greatly enhanced the patient’s

capacity to produce further images, free associations, and
interpretations of their dreams.
Another example of the interaction between behavior

therapy techniques and psychoanalytic psychotherapy is
provided by Rhodes and Feather (1). They distinguish between

symptoms that yield directly to systematic desensitization and
those that are resistant to this procedure. These latter symptoms
are hypothesized to be related to an active current intrapsychic
conflict. The symptoms that yield easily are seen as once having
been related to intrapsychic conflict but currently not tied to

conflict. The symptom is seen as a vestige of the former conflict.
The symptoms that do not yield easily to systematic
desensitization are hypothesized to be related to a current

intrapsychic conflict. The authors describe using a form of
desensitization procedure, but the scenes that the patient is asked
to imagine are made up of phantasies based on the therapist’s

hypothesis of the underlying intrapsychic conflict. For instance, in
the case of a young man with a problem of transvestism, they
hypothesized underlying unconscious sadistic phantasies

towards women. They constructed phantasies to match their
hypothesis and asked the patient to imagine these scenes in the
desensitization procedure. They report rapid alleviation of the

symptom in 29 sessions; five months later in follow-up the
patient reported no further desire to dress in women’s clothing.
This report presents an interesting amalgam of

psychoanalytic and behavioral approaches in which
psychoanalytic hypotheses are brought in to help the behavioral

technique.
Having stated that use of behavioral techniques not only may
produce desired change in some behavior or symptom, but will

likely have strong reverberations in the rest of the personality, I
would like to return to the question of symptom substitution and
why it does not seem to occur when a symptom is alleviated by
behavioral techniques.
From the analytic perspective, one would have predicted

symptom substitution with the rapid alleviation by behavioral
procedures. Since the symptom is seen as a result of an

unconscious process, then the alleviation of the symptom leaves
the unconscious process intact and it would be anticipated that a
new symptom would take the place of the old. On empirical

grounds, one would have expected the substitution from early
observations of work in hypnosis. However, in early hypnotic
technique, direct suggestion using the authority of the therapist

and the passive obedience of the patient appear to have been the
key factors in symptom alleviation. In using behavioral
techniques, the active cooperation and participation of the patient

are required. He must not only agree to the procedure but must
actively help in developing hierarchies, bringing in relevant

material and discussing with the therapist his assessment of what
is being done. If at any point in the procedure the patient feels
that the procedure does not suit him, he can break off the process
directly or can sabotage the proceedings unconsciously. I suspect
that if the process of change is felt to be threatening, the patient
has enough latitude to interfere with the procedure so that

change does not take place; therefore, symptom substitution is
not an issue.
Viewing behavioral techniques from a psychoanalytic
perspective, there has probably been too much emphasis on the
older Id psychology. That is, where the unconscious motivations,

drives, and conflicts are seen as the powerful, important forces
and the primary focus of analytic attention. However, if one thinks
more about the newer Ego psychology, much of what is

accomplished could be viewed as a strengthening of the ego and
the providing of procedures that allow greater adaptation and
flexibility. Certainly, if one keeps focused on the patient's
relatedness to others, as opposed to a narrow focus on primitive
impulses, the learning situation provided by the behavioral

techniques will seem more compatible with analytic therapy.
Whenever there is change in one significant area of
personality, it is likely that the ripple effect will produce change
or the desire for change in other areas. A young woman was

afraid to ride in elevators. A new job required that she visit
different businesses, requiring that she ride in elevators, which
she was unable to do. She had previously been in psychotherapy,

which had helped her. Desensitization was considered the
technique of choice. She was taught muscle relaxation, and
different types of elevators were rank-ordered in terms of the

capacity to produce fear or terror. A large, open-grill elevator in a
metal shaft where she could both see and communicate with the
world outside the elevator was much less frightening than a

small, old, slow-moving elevator. A modern, quick-moving
elevator with a telephone that connected to the lobby was
somewhere between the other two in ability to produce fear.

About ten variations in elevators were developed. With her eyes
closed and under muscle relaxation, she visualized being in the

elevators. She imagined the least frightening elevator first and
moved to the next most frightening when the preceding
visualization ceased to produce anxiety. As this desensitization

procedure was completed, she was able to ride most elevators
without anxiety, or with minimal anxiety.
The sessions had not been devoted exclusively to the
desensitization procedure. We spoke about her relationships with

her husband, her family, her friends, business associates. We
spoke somewhat about her daydreams and I listened to her

dreams, making a few comments and observations. I had gotten
to know her during the desensitization sessions. As she became
more able to get around in elevators, she began to talk about her
difficulties in relating to others on her job. She explored these

relationships, as well as her relationship with her family. She
made connections between the familial patterns and her
relationships on the job. She began to sort out what she was
entitled to and what she was responsible for.
The alleviation of the symptom gave her motivation for

making further change. I think that, at the simplest level, it
indicated to her that change was possible. The alleviation of the
symptom gave her more energy to deal with other issues. The
alleviation of the symptom, I think, also changed her self image. I
think it made her feel much less like a frightened little girl and
allowed her to see herself as a young adult who was entitled to
share and interact in the world of other adults. As a result, she felt
more motivated and more entitled to work out her relationships

and to solidify her image of herself as a grownup.
It used to be said in analytic circles that the symptoms
provided the motivation for self-exploration and change. It was

feared that, if there were rapid symptom alleviation, the patient
would lose his motivation for analytic therapy. I supposed that
this might still be the case where the patient enters analytic
therapy, becomes frightened, makes a rapid but illusory recovery,
and leaves treatment. This type of flight into health is short-lived,
and the symptoms usually return. With the use of behavioral

techniques, the patient has not been frightened, but has been
cooperating with the therapist in working to alleviate the

symptom. Under the latter circumstances, when the system is
alleviated, the patient feels he has achieved something that is
positive for himself and may want to change other aspects of his
life. However, it is possible that with the alleviation of the
symptom the patient would feel that life is satisfactory and would
not want further treatment. I feel that the patient should be

entitled to leave with the option to return if life does not run as
smoothly as he anticipates. If the therapist decides how much and
what kind of change a person should make (albeit for humane
reasons based on psychoanalytic understanding of character

structure), the therapist will, nevertheless, begin to play
Pygmalion. The therapist has the obligation to state what further

change he feels might be indicated and to raise questions about
stopping if he feels it is unwise to do. However, to insist on
further change, exploration, and treatment is at best to play the

role of the parent in deciding what is best for the patient and
what type of person he should become. To take things a step
further, when the analytic therapy bogs down because the patient
becomes focused on a debilitating symptom, it may be an injustice
to the patient to avoid the use of new techniques on theoretical
grounds or on an aesthetic distaste for some other form of

treatment, such as the behavior techniques.
It is often possible for the therapist practicing analytic
therapy to refer the patient for behavioral techniques while
continuing the analytic therapy. A man was in analytic therapy

and had a severe elevator phobia. After two years of therapy, the
phobia had gotten slightly worse and the patient spent a great
deal of time talking about his problem of having to walk thirty

flights of stairs to work. In addition to this unwanted exercise, the
man lived in dread that someone would discover his fear. In

therapy he spent more and more time discussing strategies for
how to avoid elevators without anyone’s discovering his phobia.
The analytic therapy became bogged down in endless discussions
of his fear, his strategies to avoid detection, and his search for the
cause of the phobia. Both he and the therapist became

increasingly frustrated and annoyed with each other.
At this point in the treatment the therapist might think of
doing something to alleviate the fears. However, reasoning from

an analytic point of view, the therapist might have some serious
concerns. The increased focus on the troubling symptom could be
viewed as a resistance. As such, the resistance should be analyzed.

The therapist might fear that the addition of techniques to deal
with the symptom would alter the transference and
countertransference so that future analytic therapy would not be

possible. However, the therapist referred the patient for
behavioral treatment of the phobia. Desensitization of the phobia

was successful in alleviating the intensity of the symptom; while it
did not eliminate the fear entirely, the patient was able to ride the
elevator to work. The patient had continued the analytic therapy
while going to a second therapist for behavioral treatment. As

soon as the behavioral therapy was added, the patient was able to
talk to the analytic therapist about other things, feeling that the
behavioral therapist would be dealing with the symptom. When

the behavioral therapy was concluded, the patient continued to
work with the analytic therapist on other analytic issues.
Analytic therapists who feel that they might like to add

parameters when therapy is at an impasse often express concern
about what the addition of behavioral techniques will do to the
transference/countertransference.
If one is committed to remaining neutral and vague as a

technique in order to promote and not interfere with the
emergence of transference, then no parameter may be introduced
without violating the technique. If one is willing to introduce

modifications, then one does have to be alert to the effect on the
therapeutic relationship, which includes transference and
countertransference. However, if the therapist truly has respect

for the powerful force that transference has, then he will not fear
that the transference reaction will disappear because he takes a
more active role. His activity as an expert who can work in

cooperation with the patient in designing approaches to alleviate
symptoms or working on procedures that will facilitate the
learning of new interactions with others will undoubtedly

produce reactions in the patient. Some of these reactions will be
distortions based on the patient’s prior interpersonal

experiences. In working with these procedures, the patient could
feel anything from undue gratitude to resentment that he couldn't
do it himself. These reactions are worthy of further analysis in

treatment, as they would be if the new techniques were not
introduced. If transference is the powerful reaction we think it is,
it will manifest itself without the special technique of neutrality.

More active analytic techniques include working with
transference, and analysts who are active, confronting, and
spontaneous report a great deal of transference material
developing in their work with patients. If the therapeutic

atmosphere is open to hearing about these reactions, they will
occur and be stated.
In describing what the therapist does when he uses

behavioral techniques, there is a tendency to borrow the language
of the behaviorists. This can actually be misleading in that the
behavioral description is not only operational but includes

behavioristic concepts. In behavioristic language, one could say
that in desensitization the therapist, through discussion with the
patient, develops a series of stimulus situations dealing with

whatever the patient is anxious about. These stimuli are
presented in rank order, from least to most frightening, while the

patient is in a state of extreme relaxation. The presentation is
made by asking the patient to imagine the stimulus situations.
However, as in any complex activity, there are many things taking
place simultaneously. Each therapist is alert to those aspects that

his theory suggests are the important and crucial ones. If non-
behaviorists used some of the behavioral techniques, they might
be alert to the following phenomena: While imagining the

frightening scenes, the patient is in a state of muscle relaxation.
Does this effect a change in the character armor of the patient, as

discussed by Reik?
In working with a patient who has anxiety reactions or
multiple phobias, the therapist accepts that the patient has fears
without questioning underlying motivations, wishes, impulses
and the like. Is this a form of unconditional positive regard for the
patient, as described by Rogers? In desensitization, the patient is
asked to imagine a frightening scene that is judged to be at a level
that will produce minimal anxiety. He is then asked by the

therapist to relax. After relaxing, he is asked to face the next,
slightly more anxiety-provoking scene and then asked to relax
again. In this situation, is the therapist recreating the situation of

the good mother, who encourages the child to face an age-
appropriate level of anxiety with the reassurance that the child
can return to the mother and feel protected and relaxed? Is the
process of desensitization a way of correcting a developmental
flaw that psychoanalysts have discussed but have no direct way of
treating through analysis? The process of relaxation tends to

promote an increase in visual imagery. When patients are asked
to visualize a scene, they may visualize the scene for a time but
may also visualize other images, while stray thoughts and feelings
enter their awareness (3). I have had patients describe that,
although they could visualize the scene they were asked to, they
also had thoughts and images that they could not remember but
that were like images they had in dreams, or while falling asleep.
Are these stray thoughts and images free associations that are
connected to the fear, and are these associations also being

desensitized?
I raise these questions to indicate that there are many
phenomena taking place that might be worthy of study in their
own right. I do not raise these notions to refute the behavioral

theory that a special kind of learning, called conditioning, is
taking place. A theory is a model for understanding and
predicting. I am suggesting that when therapists of other

theoretical viewpoints use the behavioral techniques they may
refine their observations and thinking about their own theoretical
point of view.
At a practical level, the introduction of behavioral techniques
into analytic therapy may be of help to the patient’s problems and

may facilitate further therapy. The use of behavioral techniques in
analytic therapy may also broaden theoretical considerations.
REFERENCES
1. Rhodes, J. M. and Feather, B. W. The application of psychodynamics to behavior

therapy. Amer. J. Psychiat., 1974, 131:17-20.
2. Wachtel, P. L. Psychoanalysis and Behavior Therapy. New York: Basic Books, 1977.
3. Weitzman, B. Behavior therapy and psychotherapy. Psychol. Rev., 1967, 74:300-317.
4. Wolpe, J. The systematic desensitization treatment of neurosis. J. Nerv. Ment. Dis.,

1961, 132:189-203.
5. Wolpe, J. Psychotherapy by Reciprocal Inhibition. Stanford: Stanford University Press,

1958.
6. Lazarus, A. A. Multimodal Behavior Therapy. New York: Springer, 1976.
25
Combined Psychotherapy and

Pharmacotherapy
Gerald J. Sarwer-Foner, M.D.
In discussing combined psychotherapy and
psychopharmacology, several basic assumptions will be
summarized to lay the groundwork for a discussion of the

principles involved.
Psychotherapy and the Doctor-Patient Relationship
The assumption is that the patient is able to participate in

psychotherapy and is able to make significant efforts to help
himself master those of his problems which at the moment in

time are partially or totally unmastered, thus producing
symptoms. The patient has to have the attitude that he/she is to
work, as an active participant in the process, while the doctor is

helping him/her do this, using the therapeutic alliance that exists
between doctor and patient for this purpose. This
“psychotherapeutic doctor-patient relationship” differs from the
“classic doctor-patient relationship.” In the latter, the patient has
done his duty when he has presented his body and his problems
to the doctor for the physician's ministrations. The doctor in this

"classic” doctor-patient relationship does the work, the patient
being the passively-active recipient of the physician’s acts.
In combined psychotherapy and pharmacotherapy, it is a
basic assumption that the physician has a therapeutic alliance

with the patient for dealing with the patient’s problems. The
patient discusses with the physician the problems that come to
his or her mind. This is true for supportive or relationship

psychotherapy in which the doctor is steady, present, friendly but
objective, in relating to the patient, who develops a feeling of
being cared for and strengthened.
Target Symptom Approach to Pharmacotherapy
A medication is given to obtain the particular effects of the

medication (4, 7, 11, 12, 22, 24, 25). With both neuroleptics and
antidepressant drugs given in adequate dosage, the patients will

show the characteristic “clinical pharmacological profile of the
drug concerned” (15). This characteristic pharmacological effect
is not “specific” for the therapy of a particular psychiatric disease,

even though it reliably produces its typical pharmacological
action. This is a complicated way of saying that the characteristic

clinical pharmacological action of the drug does not necessarily
“cure” the psychiatric illness. This author has published studies
(1, 12-18, 20) indicating that the establishment of a neuroleptic
effect of an “antidepressant” effect influences different patients in
different ways, even though the same characteristic clinical
pharmacological profile of the drug is present. Some patients,

whose major symptoms are controlled or partially controlled by
the drug, can improve remarkably quickly. Some improve initially
and explore with their significant entourage whether they are

indeed better, since they feel better or are beginning to feel
better. If their entourage of significant individuals responds with,
“Yes, you have changed,” the patient continues to integrate his

defences in progression towards relative health (17). In some
patients, the typical clinical pharmacological profile of a drug may
not control symptoms or signs, which are to the patients the

significant landmarks proving that they are ill or out of their own
control. When this occurs, these patients remain essentially
clinically unimproved despite the presence of the

pharmacological action of the drug. Other patients begin to
improve when the drug controls significant symptoms, but if their
significant people signal that they are unchanged, or that they are
seen as inadequate, they rapidly relapse despite the continuing
effects of the drug.
Both Freyhan (2) and Sarwer-Foner (15) advocated a “Target

Symptom” approach to psychopharmacology in which the
physiological action of the drug given in adequate dosage is used

to control specific symptom complexes. For example, if one wants
to stop agitation, to control the amount of energy available to
striated muscle and the locomotive systems for aggressive, or
energetic display, to lower the blood pressure, make a patient feel

tired, sleepy, and make him feel held down and need to lie in bed,
then a straight-chain phenothiazine having all the above

mentioned actions would be used. If instead one wants a patient
to be ambulatory despite a neuroleptic dampening effect, i.e.
dopaminergic blockade, reducing capacity for muscular energetic

action and reducing the feeling of wishing to act while permitting
the patient to be up and about, then one of the piperazine
substituted phenothiazines would be used. Here the patient’s

energy is reduced, but there is less tendency to produce a
significant fall in blood pressure. The patient therefore finds it
easier to be up and around even though he feels chemically held

down, and under better control in terms of aggression and energy
use.
The patient reacts to the physiological effects of a drug, its
side effects, and the neuroleptically determined reactions such as

akathisia, dyskinetic reactions, parkinsonism, etc. with either
feelings of, “Yes, this is unpleasant, but it is good for me and I can
take it,” or “It is a hostile brutal attack on me, why are you doing
this—you’re like everyone else and I won’t let you do this to me.”
If he feels in the last described way, the patient can become more
disturbed. This latter often produces (in all varieties of patients,
not just schizophrenic patients) the psychodynamically
determined “paradoxical” drug reaction which we have
previously reported (13). We have elsewhere published the
psychodynamic principles governing this type of patient in

relationship to drugs and established criteria for selection and for
contraindications.
One must at this point introduce the problem of

countertransference (16). If the doctor does not like, or fears, the
patient (and many patients have excellent reality-testing
mechanisms in this sense), and does not wish to become involved

psychotherapeutically, he can give drugs as an “excellent” excuse
to keep distance between himself and the patient. We have seen
physicians trigger panic reactions in patients, not because of

anything necessarily specific in that patient, but because the
patient sensed all too well the deep rejection of himself by the
authoritarian treating figure. This rejection was implied precisely
when the physician gave the patient the drug in the first place;
therefore, the physiological effects of the drug were interpreted
by the patient as a rejecting, hostile, and threatening thing.
Dopaminergic Blockade
It is likely that dopaminergic blockade action by the
neuroleptic drugs affects the buildup of the impulse to act at a

motor level (9) in the central nervous system by lessening it, and
that this is useful in dampening down the energetic tendencies of
many schizophrenic patients. However, this is not specifically
curative of schizophrenia. It lessens the quantity of action-
oriented symptoms in schizophrenic patients, which can have a
beneficial effect, once the neuroleptic effect is established, on
secondary psychopathological constructs such as the capacity to

have hallucinations, delusions, and ideas of reference. The latter
actions are, however, secondary phenomena and are not seen in
all patients.
Combining Psychotherapy and Chemotherapy
If the above principles are understood, we can then turn to

the use of combined psychotherapy and chemotherapy in acute
schizophrenic reactions in the hands of the skilled psychiatrist

who understands both psychotherapy and pharmacotherapy. In
the supportive relationship with an acutely psychotic patient, the
doctor would have the basic therapeutic attitude that the patient
was potentially capable of pulling himself together and of taking
responsibility at some level for his potential improvement even
while grossly psychotic. The physician would explain the need for
neuroleptic medication after exploring this with the patient.

Neuroleptic medication could be given to an involuntary patient,
the action of the drug explained, and the patient encouraged to
use this action to collaborate with the physician and improve his
state.
The drug effect is subjectively perceived by the patient (8,

23). In the midst of an acute psychosis, if the patient sees the
doctor as someone with whom he could form a therapeutic
alliance, this sets the stage for the patient to begin to test out the
doctor’s reliability as a potentially trusted person even around
crisis intervention in the emergency room or receiving hospital.

In other words, this experience can be the beginning of a
“bonding” relationship between that patient and that particular
physician or other therapeutic staff who participate in helping the

patient in acute crisis. As the patient settles down, the fact
(because it is then a fact) that the doctor understands enough to
give the patient what is needed while encouraging the patient’s

active collaboration in getting well cements the beginning of the
doctor-patient supportive psychotherapeutic relationship.
The patient is then encouraged to discuss the problems in

this context, and the doctor does reality-testing psychotherapy
with the patient, while the drug is being given. The drug is given
with the patient understanding that it will be given for as long as

the patient needs it. The length of drug therapy is left as a variable
quantity of time, but with a definite implication that when the

patient can get along without the drug, the drug will be stopped.
By then the patient will have been taught how to use the drug,
either with the doctor’s help or alone, so that should the patient
need further help when things go out of the patient’s control, the
medicine is available, as well as the doctor’s relationship. This is
perhaps the trickiest part of the supportive combined

psychotherapeutic-pharmacotherapeutic relationship with
acutely psychotic patients. Many of these, once they recover,
“want no part of anything,” including the therapeutic relationship,
that reminds them of having been ill (19). The patient must,
therefore, be helped to understand the importance of being able
to deal with things themselves and handle medicine over a period

of time.
In the past, probably the majority of doctors felt that a

schizophrenic patient who had had an acute and serious
psychotic episode needed ongoing maintenance therapy (i.e.

without stop). This author never shared this view for all patients,
preferring the above-mentioned visualization for many treated in
a personalized therapeutic context. The late complications of

maintenance neuroleptic therapies, such as tardive or persistent
dyskinesia, have done much to bring the need for time-related

and time-controlled drug therapies into focus. As a result, many
who previously favored ongoing maintenance therapy have
adopted a more favorable consideration of a target symptom,
patient-physician, cooperation- oriented approach to the

chemotherapy, thus tending to introduce more and more of the
psychotherapeutic element. In this regard, some studies of
“sociotherapy” and pharmacotherapy (3, 6) have shown that the

more than two-year progress of patients on neuroleptics and
supportive relationship is better as to quality of life, work

performance, etc., than straight drug therapy, and this in a
straight, once-a-month social work contact.
Treatment of Schizophrenia
A potent neuroleptic, given in adequate dosage, will present

its characteristic pharmacological profile in the patient receiving
it. Regardless of what this profile is (and it will vary from drug to
drug), the neuroleptic drugs have a beneficial effect in
schizophrenia when the following conditions seem to be satisfied:
1. The physiological effects (pharmacologic profile) of a drug

permit control of a symptom or symptom complex.
2. This symptom complex must express for this particular

patient his inability to face himself and his most feared
impulses. Here I refer to those specific impulses which,
for this particular patient, represent the core of the
inner conflict that he cannot solve for himself without
regressing into his schizophrenic illness as his best
personal compromise.
3. The control of this symptom or symptom complex must

be interpreted by the patient as beneficial for him
rather than detrimental to him.
4. The patient considers this in terms of his total

constellation of impulses, his defences against them,
and his present reality situation. Therefore, the patient
who benefits from the characteristic pharmacological
profile of the neuroleptic medication does so because
he interprets the action of the drug in controlling
certain symptoms or symptom complexes as a “good”
thing for him rather than a “bad” thing for him. For the
majority of such patients, much of the efficacy of the
medication depends on these external variables which
help to give its pharmacological profile the value
judgment “good” or “bad.” Some of these include the
attitude of the doctors, nurses, and orderlies towards
both the particular drug and the patient's reaction to
receiving it. The unconscious, as well as the conscious,
visualization by the patient of what is appropriate to
the hospital setting (that is, what is sociologically
required of him when under the influence of a drug and
therefore is controlled in reference to the standards of
behavior in a specific hospital society) may play some
role here. Many external factors concerned with
interpersonal relations in psychotherapy are vital here.
5. When the above-mentioned symptom complex is

controlled by the drug, this lays the foundation for the
fundamental process of remitting from a regressed
state, that is to say, for ego growth, and the enlarging of
neurotic and normal defenses. It is to be emphasized
that the patient does not immediately return from a
regressed state.
It must be remembered that there are many different types

of schizophrenic patients, and there are many approaches to the
treatment of patients and to interpersonal dealings with such
patients. Not all of these patients need drugs, but in those who do
and get better, we feel that the modalities of the treatment are
those we are describing.
When a patient with a schizophrenic illness arrives in

hospital in an acute phase of his illness, he can be approached
from the point of view that you in the hospital are going to help
him overcome and master what he is most afraid of in himself and
fears in others as stimulating these impulses in him.
Those patients who do well on the drug do so because the

drug helps control symptoms expressing the patient’s attempts to
cope with problems such as intolerable aggression, perverse

sexuality, and feelings of total inadequacy producing tremendous
frustration, rage and anger. When the physiological effects of the
drug help the patient feel that what he most fears in himself has
been brought under better control, the stage is set for renewed
externalized flow of energy into renewed reality interest and
reality testing.
The patient may immediately or very quickly feel changed or
see himself as different under such circumstances. He then tests

whether this feeling of difference in him is real and, therefore,
perceivable by others and accepted by others, or is a transitory

thing. He does this by observing very closely the reactions toward
him of the hospital staff, as well as other significant figures in the

milieu or his family. These testing maneuvers are essentially
independent of any drug, but in some patients they come into
play through the beneficial action of the drug in controlling the

significant symptom complexes.
If the patient improves under these circumstances, he does

so because he feels changed as a result of being controlled. He has
been made better able to use his powers, for he now visualizes
himself as a less fearful and fearsome object. Because he is in
better control of himself or feels himself to be a more worthwhile
being than before, the world becomes a less fearful place whether
actually or potentially. The way in which others (doctors, family,
relatives, nurses, hospital staff) regard the patient, what they
expect of him, the enthusiasm for or rejection of certain
therapeutic agents, all may as a result play important roles here.
It is at this point that many patients, previously relatively
inaccessible to psychotherapy, become potentially accessible, for
they become ready to endow the external world with new
interest and to use their energies to deal with it.
When these attempts to reinvest energy (cathexis) on to

external objects receive sympathetic responses from his
entourage (that is to say, from the significant figures in his milieu,
be they doctor, hospital, nurses, or family group), ego
reintegration continues and the patient remits from his psychotic
episode. It is up to the physician to take full advantage of his
knowledge of transference, of the patient’s testing maneuvers, of
the patient’s conflicts, and of the patient’s reaction to neuroleptic
medication, and to interpret heavily on the side of better
interpersonal relations so as to help the patient use his new and
very cautiously used “outgoingness” to gain self-confidence. If this
is done, the patient responds well. If this situation continues for a
sufficiently long time, further ego integration takes place.
Poor Therapeutic Results
When the schizophrenic patient interprets the drug effect as

threatening, that is to say, as an assault or manipulative attempt
by the physician, or when he feels that it does not help control

what he most fears in himself despite the appearance of the
characteristic pharmacological effects, the patient either does not
get better or can even become worse (13). Sometimes, if the

patient initially improves, faulty relationships with his family and
significant adults may shatter his newly developing concept of
himself as different, and thus curb the externalized flow of
energy. Such rejections confirm his worthlessness and his fear of
his own impulses; the patient regresses, relapses, or does not get
well.
Thus, in schizophrenia the role of medication is to control
those “target symptoms” which express the patient’s inability to
tolerate those of his impulses which represent to him the essence

of his conflicts. If these are controlled, this makes the patient
more accessible to psychotherapy, more able to channelize
energy into externalized contacts and renewed interest in

external reality and interpersonal relations. It is at this point that
psychotherapy may become more meaningful, and that
psychotherapy may be of more direct benefit in the patient’s

reality testing maneuvers.
Psychotic Decompensation During Psychotherapy
When a patient in psychotherapy (i.e. without concomitant
drug therapy) begins to show signs of deterioration of his ego
defenses, the signs and symptoms of a threatened eruption of an
underlying psychosis can begin to appear. Increased anxiety,

restlessness, irritability, and frightening dreams appear.
Sometimes the first warning the physician has is the emergence of
an acute psychotic episode with florid schizoaffective or florid

paranoid symptomatology, with much affect and agitation. The
physician must ask himself which of the symptoms most
symbolizes for the patient his feared psychotic deterioration. For

example, if the patient cannot sleep and is having nightmares—
nightmares which represent the patient’s disintegrating mind—
the capacity to medicate adequately, to guarantee sleep in the

context of psychotherapeutic support, can prove to the patient
that the doctor understands the process, and is able to do
something about it. Generally, if this is done systematically

producing several good nights’ sleep and counteracting the
sleepless exhaustion that the nightmares have been producing,
the patient will often pull himself together and the threatened
psychotic deterioration will disappear. Meanwhile, the life crisis
that produced it can be fruitfully explored in the supportive
psychotherapeutic relationship.
This also holds true when one is doing uncovering
psychotherapy, and applies to the decompensating crises that can

be occasionally seen even during psychoanalysis (the most
intensive form of psychotherapy) of a patient. The
symptomatology and the downward progression in the patient’s
ego defenses indicate that interpretations and the therapeutic

relationship are at the moment not necessarily enough. This
happens rarely, but particularly with some borderline patients

during exploration of weaning and separation experiences (5, 21).
In these cases it is very important to medicate the patient
adequately, so that what is uncontrollable becomes more

controllable, while one continues the psychotherapeutic
uncovering or psychoanalytic relationship. Sometimes in
psychoanalysis it is necessary to sit the patient up during such a

crisis, but on many occasions it is possible to carry on with the
patient on the couch, provided that the patient is able to feel that
the physician can help him master that which becomes much
more dubious and more difficult without these interventions (1,
9). The important thing in the context of psychoanalysis is to
withdraw all the drug treatment as soon as the patient can master
the situation himself; thus, the use of drugs in this context is a

“parameter” to be introduced when needed but to be withdrawn
as quickly as possible and in full collaboration with the patient
when not needed.
In short, in all the above situations, the concept of a time-
limited intervention of a nonpsychotherapeutic kind, only when

needed—and only to strengthen the patient’s ego and ego
capacities—is the principle around which one uses
pharmacotherapy.
Anti-Depressant Drugs and Psychotherapy
Psychotropic medication includes the tricyclics, the

quadracyclics, and the MAO Inhibitors. These are active
psychotropic agents when given in adequate dosage. Again, they

produce a characteristic clinical pharmacological profile and,
again, this drug action is not specifically curative, but rather
helpful. We must remember that the vast majority of patients who

consult the physician with a depressive illness consult him for a
Reactive Neurotic Depression. These conditions are generally
time limited and most patients improve in more than thirty days
and within six months to a year, with the vast majority improving
in the first six months. Thus, there is an inherent time-related
improvement pattern. The majority of such patients are seeking

support and the recovery of significant object relationships
shattered through loss, i.e. losses which have shattered their
inner concept of self. This may be the loss of a job, the loss of a
loved one, the loss of a boyfriend, girlfriend, wife or husband, a
shattering emotional rejection such as a lack of promotion or
getting fired from a position which symbolically represented the

persona of the individual. It is the symbolic representation of this
event that affects the patient. The presence of unconscious hope in
the patient should be assessed. The patient who is unconsciously

hopeless and thus feels helpless and abandoned cannot really aim
his symptomatology at the physician with a demand for
resolution. The fact that a patient is able to form a therapeutic
relationship with a doctor and aims his symptomatology at the
physician for resolution, even though the patient looks helpless
and hopeless on the surface, is an indication of the presence of at

least unconscious hopefulness. Its presence and extent have to be
used psychotherapeutically.
The physician should maintain the capacity to be a steady,

realistically optimistic person, who helps the patient fight
through his difficulties in psychotherapy. The target symptom

principle is used here. One must remember that the
antidepressant medication may temporarily induce drowsiness
and have other side effects, but that the main therapeutic effect of
the antidepressants is to increase the patient’s inner drive
towards outgoingness and object relatedness. This takes three or
more weeks to become clinically manifest. In this regard, the
spontaneous improvement of many patients in more than thirty

days, mainly in neurotic but also in some other depressions as
well, must be remembered.
The major indication for the antidepressant drugs, in the

presence of a supportive psychotherapeutic attitude on the part
of the physician, is in the severe psychotic depressions, or
depressions with severe psychomotor retardation. This applies

equally to the young, the elderly, or the middle aged (i.e.
involutional melancholia, psychotic depressions, with marked
psychomotor retardation—the so-called endogenous
depressions). Many of these patients cannot relate well while
depressed. Here the antidepressants, given in adequate doses,
improve the patient’s capacity to reach outward and become

more outgoing in approximately 70% of such patients after at
least three weeks of treatment. Often the drugs must be
maintained for the length of the depressive episode, but the

patient becomes increasingly available for supportive
psychotherapy as the improvement increases.
One must remember these patients’ propensities to have

nothing to do with any part of treatment or anything that is linked
with the depressive psychotic episode of this magnitude—i.e.,
when they are well, they are in a statebound consciousness of

being well, and when they are ill, they are in a time-related
statebound consciousness of being ill (19). When one state is
present, the other state is absent. Thus, such patients avoid

therapeutic contacts of any kind with physicians and with
anything that reminds them of their illness when they are well.
One has to wait for the next episode, if there is one, before one
sees the patient again (19).
Antianxiety Agents
Antianxiety agents are not specifically discussed here. They
are, as a class, the most abused and overused of all medications.

In psychotherapy, mastery of problems is a primary goal; as this
is done, it is rare to need antianxiety agents for any length of time.
REFERENCES
1. Azima, H. and Sarwer-Foner, G. J. Psychoanalytic formulations of drugs in

pharmacotherapy. Rev. Canad. Biol., (June) 1961, 20:603.
2. Freyhan, F. Neuroleptic effect: Fact or fiction. In: G. J. Sarwer-Foner (Ed.), The

Dynamics of Psychiatric Drug Therapy. Springfield, Ill.: Charles C Thomas, 1960.
3. Goldberg, S. C., Schooler, N. R., Hogarty, G. E., and Roper M. Prediction of relapse in
schizophrenic outpatients treated by drug and sociotherapy. Arch. Gen. Psychiat.,
Feb. 1977, 34:171.
4. Gottschalf, L. A. Some problems in the use of psychoactive drugs, with or without

psychotherapy, in the treatment of non-personality disorders. In: D. H. Efron
(Ed.), Psychopharmacology. A Review of Process 1957-1967. Washington, D.C.:
Public Health Service Publication No. 1836, 1968, p. 225.
5. Harticollis, P. (Ed.). Borderline Personality Disorders: The Concept, the Syndrome, the
Patient. New York: International Universities Press, 1977.
6. Hogarty, G. E., Goldberg, S. C., Schooler, N. R. et al. Drug and sociotherapy in the
aftercare of schizophrenic patients II—Two year relapse rates. Arch. Gen.
Psychiat., 1974, 31:603.
7. Lesse, S. Psychotherapy and ataractics: Some observations on combined

psychotherapy and chlorpromazine therapy. Amer. J. Psychother., 1956, 10:448.
8. McChie, A. and Chapman, J. Disorders of attention and perception in early

schizophrenia. Br. J. Med. Psychol., 1961, 34:103.
9. Ostow, M. Drugs in Psychoanalysis and Psychotherapy. New York: Basic Books, 1962.
10. Sabshin, M. and Ramot, J. Pharmotherapeutic evaluation of the psychiatric setting.

Arch. Neurol., 1956, 75:362.
11. Shapiro, A. K. Etiological factors in placebo effect. J. Amer. Med. Assoc., 1964, 187:712.
12. Sarwer-Foner, G. J. and Ogle, W. Use of reserpine in open psychiatric settings. Canad.
M.A.J., 1955, 73L187.
13. Sarwer-Foner, G. J. and Ogle, W. Psychosis and enhanced anxiety produced by

reserpine and chlorpromazine. Canad. M.A.J., 1956, 74:526.
14. Sarwer-Foner, G. J. Psychoanalytic theories of activity-passivity conflicts, and the

continuum of ego defenses. Experimental verification with reserpine and
chlorpromazine. A.M. A. Arch. Neurol. & Psychiat., 1957, 78:413.
15. Sarwer-Foner, G. J. The Dynamics of Psychiatric Drug Therapy. Springfield, Ill.:
Charles C Thomas, 1960.
16. Sarwer-Foner, G. J. and Koranyi, E. K. Transference effects, the attitude of the

treating physician, and countertransference in the use of neuroleptic drugs. In:
G. J. Sarwer-Foner (Ed.), The Dynamics of Psychiatric Drug Therapy. Springfield,
Ill.: Charles C Thomas, 1960.
17. Sarwer-Foner, G. J. Some therapeutic aspects of the use of neuroleptic drugs in

schizophrenic, borderline states and in short-term psychotherapy of the
neurosis. In: G. J. Sarwer-Foner (Ed.), The Dynamics of Psychiatric Drug Therapy.
Springfield, Ill.: Thomas, 1960, pp. 517.
18. Sarwer-Foner, G. J. The role of neuroleptic medication in psychotherapeutic

interaction. Comprehen. Psychiat., 1960, 1:291-300.
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depressions. Canad. Psychiat. A. J. Suppl., 1966, 11:S221.
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relation to the psychodynamic actions of drugs. In: H. C. B. Denber (Ed.),
Psychopharmacological Treatment in Psychiatry. New York: Marcel Dekker, 1975.
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Psychoanalytic, psychotherapeutic and psychopharmacological considerations.
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doctor’s verbal attitude and clinical setting in the symptomatic response to
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psychotherapy. In: G. J. Sarwer-Foner (Ed.), The Dynamics of Psychiatric Drug
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Springfield, Ill.: Charles C Thomas, 1966.

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SPECIALIZED

TOKSOZ B. KARASU, M.D.

e-Book 2018 International Psychotherapy Institute

All Rights Reserved

This e-book contains material protected under International

Created in the United States of America

2. General Principles of Psychotherapy

3. Brief and Emergency Psychotherapy

Leopold Bellak, M.D.

4. Enabling Conditions for the Ambulatory Psychotherapy of Acute Schizophrenics

5. Psychotherapy with Borderline Patients: An Overview

6. The Treatment of Established Pathological Mourners

7. The Psychotherapy of the Depressed Patient

8. Brief Psychotherapy of Stress Response Syndromes1

9. Psychotherapy with the Obsessive Personality

10. Psychotherapy in Sexual Dysfunctions

11. Psychotherapy of Ambulatory Patients with Severe Anxiety

12. Psychotherapy with Violent Patients

13. Psychotherapy with Physically Ill Patients

14. Psychotherapy with Dying Patients

Arthur M. Schwartz, M.D.

15. The Behavioral Psychotherapy of Anorexia Nervosa

16. Psychotherapy with Suicidal Patients

17. Psychotherapy with the Elderly

Ralph J. Kahana, M.D.

18. Psychotherapy with Bilingual Patients

19. Racial Issues in Psychotherapy

20. Psychotherapy with Alcoholics

Sheldon Zimberg, M.D.

21. Hypnotherapy Combined with Psychotherapy

22. Group Therapy Combined with Individual Psychotherapy

23. Family and Marital Therapy Combined with Individual Psychotherapy

Stephen Fleck, M.D.

24. Behavioral Techniques in Conjunction with Individual Psychoanalytic Therapy

25. Combined Psychotherapy and Pharmacotherapy

VICTOR BERNAL Y DEL RIO, M.D.

HUGH F. BUTTS, M.D.

ALLAN COOPER, Ph.D.

THOMAS DETRE, M.D.

STEPHEN FLECK, M.D.

MICHEL HERSEN, Ph.D.

JAMES R. HODGE, M.D.

MARDI J. HOROWITZ, M.D.

DANIEL JOSEPHTHAL, M.D.

RALPH J. KAHANA, M.D.

NANCY B. KALTREIDER, M.D.

TOKSOZ B. KARASU, M.D.

OTTO F. KERNBERG, M.D.

STANLEY LESSE, M.D., Med. Sc.D.

MYER MENDELSON, M.D.

JON K. MEYER, M.D.

KENNETH PORTER, M.D.

LEON SALZMAN, M.D.

GERALD J. SARWER-FONER, M.D.

SAUL SCHEIDLINGER, Ph.D.

ARTHUR M. SCHWARTZ, M.D.

VAMIK D. VOLKAN, M.D.