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Systems of Psychotherapy

A Transtheoretical Analysis

Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
Systems of Psychotherapy
A Transtheoretical Analysis
EIGHTH EDITION

JAMES O. PROCHASKA
University of Rhode Island

JOHN C. NORCROSS
University of Scranton

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A Transtheoretical Analysis,
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To Jan and Nancy

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Brief Contents

1 Defining and Comparing the Psychotherapies 1

2 Psychoanalytic Therapies 20
3 Psychodynamic Therapies 51

4 Existential Therapies 83

5 Person-Centered Therapies 113

6 Experiential Therapies 142


7 Interpersonal Therapies 173

8 Exposure Therapies 194

9 Behavior Therapies 217

10 Cognitive Therapies 261

11 Third-Wave Therapies 298


12 Systemic Therapies 316

13 Gender-Sensitive Therapies 353

14 Multicultural Therapies 375

15 Constructivist Therapies 405

16 Integrative Therapies 425


17 Comparative Conclusions 453

18 The Future of Psychotherapy 482

Appendix An Alternative Table of Contents 499


References 503
Name Index 538
Subject Index 546
Credits 557

vii

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Detailed Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii CHAPTER 3


About the Authors . .. . . . . . . . . . . . . . . . . . . . . . . . . .xvii Psychodynamic Therapies . . . . . . . . . . . . . . . . . . . . . 51
A Sketch of Freud’s Descendants 52
CHAPTER 1 A Sketch of Alfred Adler 53
Defining and Comparing the Psychotherapies . . . 1 Theory of Personality 54
Defining Psychotherapy 2 Theory of Psychopathology 56
The Value of Theory 4 Therapeutic Processes 57
Therapeutic Commonalities 4 Therapeutic Content 60
Processes of Change 8 Therapeutic Relationship 63
Initial Integration of Processes of Change 14 Practicalities of Adlerian Therapy 64
Therapeutic Content 15 Ego Psychology 65
The Case of Mrs. C 17 Object Relations 66
Key Terms 19 Supportive Therapy 70
Recommended Readings 19 Brief Psychodynamic Therapy 70
Recommended Websites 19 Effectiveness of Psychodynamic Therapies 72
Criticisms of Psychodynamic Therapies 76
CHAPTER 2 An Adlerian Analysis of Mrs. C 78
Psychoanalytic Therapies . .. . . . . . . . . . . . . . . . . . . . 20
Future Directions 79
A Sketch of Sigmund Freud 21
Key Terms 81
Theory of Personality 22
Recommended Readings 81
Theory of Psychopathology 27
Recommended Websites 82
Therapeutic Processes 29
Therapeutic Content 32 CHAPTER 4
Therapeutic Relationship 36 Existential Therapies . . . . . . . . . . . . . . . . . . . . . . . . . 83
Practicalities of Psychoanalysis 37 A Sketch of Early Existential Therapists 84
Major Alternatives: Psychoanalytic Psychotherapy and Theory of Personality 86
Relational Psychoanalysis 38 Theory of Psychopathology 89
Effectiveness of Psychoanalysis 41 Therapeutic Processes 92
Criticisms of Psychoanalysis 43 Therapeutic Content 95
A Psychoanalytic Analysis of Mrs. C 46 Therapeutic Relationship 100
Future Directions 48 Practicalities of Existential Therapy 101
Key Terms 49 Major Alternatives: Existential-Humanistic, Logotherapy,
Recommended Readings 50 Reality Therapy 102
Recommended Websites 50 Effectiveness of Existential Therapy 106

ix

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x Detailed Contents

Criticisms of Existential Therapy 107 CHAPTER 7


An Existential Analysis of Mrs. C 109 Interpersonal Therapies . .. . . . . . . . . . . . . . . . . . . . .173
Future Directions 111 The Heritage of Interpersonal Therapies 174
Key Terms 112 A Sketch of IPT Founders 175
Recommended Readings 112 Theory of Personality 175
Recommended Websites 112 Theory of Psychopathology 175
Therapeutic Processes 177
CHAPTER 5
Therapeutic Content 179
Person-Centered Therapies . . . . . . . . . . . . . . . . . . . .113
Therapeutic Relationship 181
A Sketch of Carl Rogers 114
Practicalities of IPT 181
Theory of Personality 115
A Major Alternative: Transactional Analysis 182
Theory of Psychopathology 117
Effectiveness of Interpersonal Therapies 187
Therapeutic Relationship 119
Criticisms of Interpersonal Therapies 189
Therapeutic Processes 120
An Interpersonal Analysis of Mr. and Mrs. C 191
Therapeutic Content 124
Future Directions 192
Practicalities of Person-Centered Therapy 127
Key Terms 193
A Major Alternative and Extension: Motivational
Recommended Readings 193
Interviewing 128
Recommended Websites 193
Effectiveness of Person-Centered Therapies 132
Criticisms of Person-Centered Therapies 135
CHAPTER 8
A Person-Centered Analysis of Mrs. C 138
Exposure Therapies . . . . . . . . . . . . . . . . . . . . . . . . . .194
Future Directions 139
A Note on Exposure Therapies 195
Key Terms 140
Implosive Therapy 195
Recommended Readings 140
Prolonged Exposure 197
Recommended Websites 141
EMDR 205
CHAPTER 6 Criticisms of Exposure Therapies 211
Experiential Therapies . . . . . . . . . . . . . . . . . . . . . . . .142 Exposure Therapy with Mrs. C 213
A Sketch of Fritz Perls 143 Future Directions 215
Theory of Personality 144 Key Terms 215
Theory of Psychopathology 146 Recommended Readings 215
Therapeutic Processes 148 Recommended Websites 216
Therapeutic Content 154
Therapeutic Relationship 159 CHAPTER 9
Practicalities of Gestalt Therapy 160 Behavior Therapies . .. . . . . . . . . . . . . . . . . . . . . . . . .217
Experiential Therapies 161 A Sketch of Behavior Therapy 218
Emotion-Focused Therapy 162 Counterconditioning 220
Effectiveness of Experiential Therapies 164 Contingency Management 228
Criticisms of Experiential Therapies 166 Cognitive-Behavior Modification 236
A Gestalt Analysis of Mrs. C 168 Therapeutic Relationship 241
Future Directions 170 Practicalities of Behavior Therapy 242
Key Terms 171 Effectiveness of Behavior Therapy 244
Recommended Readings 171 Criticisms of Behavior Therapy 254
Recommended Websites 172 A Behavioral Analysis of Mrs. C 256

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Detailed Contents xi

Future Directions 258 Key Terms 314


Key Terms 258 Recommended Readings 314
Recommended Readings 259 Recommended Websites 315
Recommended Websites 260
CHAPTER 12
Systemic Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . .316
CHAPTER 10
The Context of Systemic Therapies 317
Cognitive Therapies . . . . . . . . . . . . . . . . . . . . . . . . . .261
Communication/Strategic Therapy 319
A Sketch of Albert Ellis 262
Structural Therapy 327
REBT Theory of Personality 263
Bowen Family Systems Therapy 333
REBT Theory of Psychopathology 265
Evidence-Based Family Therapies 338
REBT Therapeutic Processes 267
Effectiveness of Systemic Therapies 340
REBT Therapeutic Content 271
Criticisms of Systemic Therapies 345
REBT Therapeutic Relationship 275
A Systemic Analysis of the C Family 348
A Sketch of Aaron Beck 276
Future Directions 350
Cognitive Theory of Psychopathology 277
Key Terms 351
Cognitive Therapeutic Processes 278
Recommended Readings 351
Cognitive Therapeutic Relationship 281
Recommended Websites 352
Practicalities of Cognitive Therapies 282
Effectiveness of Cognitive Therapies 283
CHAPTER 13
Criticisms of Cognitive Therapies 290 Gender-Sensitive Therapies . .. . . . . . . . . . . . . . . . . .353
A Cognitive Analysis of Mrs. C 293 A Sketch of Sociopolitical Forces 353
Future Directions 294 Theory of Personality 354
Key Terms 296 Theory of Psychopathology 355
Recommended Readings 296 Therapeutic Processes 359
Recommended Websites 297 Therapeutic Content 362
Therapeutic Relationship 365
CHAPTER 11 Practicalities of Gender-Sensitive Therapies 366
Third-Wave Therapies . . . . . . . . . . . . . . . . . . . . . . . .298 Male-Sensitive Psychotherapy 367
A Sketch of Steven Hayes 299 Effectiveness of Gender-Sensitive Therapies 369
ACT Theory of Psychopathology 300 Criticisms of Gender-Sensitive Therapies 370
ACT Therapeutic Processes 300 A Feminist Analysis with Mrs. C 371
ACT Therapeutic Relationship 302 Future Directions 372
A Sketch of Marsha Linehan 302 Key Terms 373
DBT Theory of Psychopathology 303 Recommended Readings 373
DBT Therapeutic Processes 303 Recommended Websites 374
DBT Therapeutic Relationship 305
Mindfulness Therapies 305 CHAPTER 14
Practicalities of Third-Wave Therapies 307 Multicultural Therapies . . . . . . . . . . . . . . . . . . . . . . .375
Effectiveness of Third-Wave Therapies 308 A Sketch of Multicultural Pioneers 376
Criticisms of Third-Wave Therapies 310 Theory of Personality 379
A Third-Wave Analysis of Mrs. C 312 Theory of Psychopathology 381
Future Directions 313 Therapeutic Processes 384

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xii Detailed Contents

Therapeutic Content 388 Key Terms 451


Therapeutic Relationship 390 Recommended Readings 452
Practicalities of Multicultural Therapies 392 Recommended Websites 452
Psychotherapy with LGBT Clients 394
CHAPTER 17
Effectiveness of Multicultural Therapies 397
Comparative Conclusions . . . . . . . . . . . . . . . . . . . . .453
Criticisms of Multicultural Therapies 398
Developmental Perspectives 454
A Multicultural Analysis of Mrs. C 400
The Transtheoretical Model 456
Future Directions 402
Processes of Change 457
Key Terms 403
Stages of Change 459
Recommended Readings 403
Integration of Stages and Processes 465
Recommended Websites 404
Levels of Change 467
Putting It All Together 469
CHAPTER 15
Constructivist Therapies . . . . . . . . . . . . . . . . . . . . . .405 The Transtheoretical Relationship 472
A Sketch of the Construction of Therapies 406 Effectiveness of Transtheoretical Therapy 472
Solution-Focused Therapy 407 Criticisms of Transtheoretical Therapy 475
Narrative Therapy 412 A Transtheoretical Analysis of Mrs. C 476

Effectiveness of Constructivist Therapies 416 Key Terms 480

Criticisms of Constructivist Therapies 418 Recommended Readings 480

A Narrative Analysis by Mrs. C 421 Recommended Websites 481

Future Directions 422


CHAPTER 18
Key Terms 423 The Future of Psychotherapy . . . . . . . . . . . . . . . . . .482
Recommended Readings 423 A Delphi Poll 482
Recommended Websites 424 Twelve Emerging Directions 485
In Closing 497
CHAPTER 16
Key Terms 497
Integrative Therapies . . . . . . . . . . . . . . . . . . . . . . . . .425
Recommended Readings 497
A Sketch of Integrative Motives 426
Recommended Websites 498
Common Factors 428
Technical Eclecticism or Theoretical Integration? 431 Appendix An Alternative Table of Contents . .. . . .499
Integrative Psychodynamic-Behavior Therapy 433 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .503
Multimodal Therapy 439 Name Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .538
Criticisms of Integrative Therapies 447 Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .546
A Multimodal Analysis of Mrs. C 449
Credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .557
Future Directions 450

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Preface

Welcome to the eighth edition of Systems of counseling, social work, psychiatry, nursing,
Psychotherapy: A Transtheoretical Analysis. Our human relations, and other students. Our volume
abiding hope is that our book will inform and is intended, secondarily, for psychotherapists of all
excite you. Inform you about valuable psychother- professions and persuasions seeking a comparative
apy theories and excite you to conduct powerful overview of the burgeoning field of psychotherapy.
psychotherapy for the enrichment of fellow We have been immensely gratified by the feedback
humans. from readers who have used this text in preparing
Our book provides a systematic, comprehen- for comprehensive exams, licensure tests, and
sive, and balanced survey of the leading systems of board certification as well as from those who
psychotherapy. It is designed, however, to be more have found it instrumental in acquiring a more
than just a survey, as we strive toward a synthesis integrative perspective.
both within each psychotherapy system and across
the various systems. Within a particular system of Our Objectives
therapy, this book follows the integrative steps The contents and goals of this eighth edition
that flow from the system’s theory of personality embody our objectives as psychotherapy practi-
to its theory of psychopathology and culminates in tioners, teachers, researchers, and theorists. As
its therapeutic process and therapy relationship. practitioners, we appreciate the vitality and mean-
Across the various systems of therapy, our book ing of different clinical approaches. We attempt to
offers an integrative framework that highlights the communicate the excitement and depth of these
many similarities of therapy systems without blur- psychotherapy systems. Accordingly, we avoid
ring their essential differences. The comparative simple descriptions of the systems as detached
analysis clearly demonstrates how much psycho- observers in favor of immersing ourselves in
therapy systems agree on the processes producing each system as advocates.
change while disagreeing on the content that As practitioners, we are convinced that any
needs to be changed. treatise on such a vital field as psychotherapy
Systems of Psychotherapy: A Transtheoretical must come alive to do the subject matter justice.
Analysis is intended, primarily, for advanced To this end, we have included a wealth of case illus-
undergraduate and graduate students enrolled in trations drawn from our combined 75 years of clin-
introductory courses in psychotherapy and ical practice. (When one of us is speaking from our
counseling. This course is commonly titled Sys- own experience, we will identify ourselves by our
tems of Psychotherapy, Theories of Counseling, initials—JOP for James O. Prochaska and JCN for
Psychological Interventions, or Introduction to John C. Norcross.) We demonstrate how the
Counseling and is offered to psychology, same complicated psychotherapy case—Mrs. C—is

xiii

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xiv Preface

formulated and treated by each system of psycho- outcome studies and meta-analytic reviews that
therapy. This and all of the case examples counter- have evaluated the effectiveness of each therapy
balance the theoretical considerations; in this way, system.
theories become pragmatic and consequential— Research and practice have further taught us
relevant to what transpires in the therapeutic that each psychotherapy system has its respective
hour. The details of individual clients have been limitations and contraindications. For this reason,
altered, of course, to preserve their privacy and we offer cogent criticisms of each approach from
anonymity. the vantage points of cognitive-behavioral, psy-
As psychotherapy teachers, we recognize the choanalytic, humanistic, cultural, and integrative
complexity and diversity of the leading theories of perspectives. The net effect is a balanced coverage
psychotherapy. This book endeavors to present the combining sympathetic presentation and critical
essential concepts clearly and concisely but without analysis.
resorting to oversimplification. Our students occa- As psychotherapy theorists, we do not endorse
sionally complain that theorists seem to have a the endless proliferation of psychotherapy sys-
knack for making things more complicated than tems, each purportedly unique and superior
they really are. We hope that as you move through despite the absence of research evidence. What
these pages you will gain a deeper appreciation for our amorphous discipline does need is a concerted
the complexity of the human condition or, at least, effort to pull together the essentials operating in
the complexity of the minds of those attempting to effective therapies and to discard those features
articulate the human condition. unrelated to effective practice. From our com-
Our decades of teaching and supervising psy- parative analysis of the major systems of therapy,
chotherapy have also taught us that students we hope to move toward a higher integration
desire an overarching structure to guide the acqui- that will yield a transtheoretical approach to
sition, analysis, and comparison of information. psychotherapy.
Unlike edited psychotherapy texts with varying And from comparative analysis and research,
writing styles and chapter content, we use a we hope to contribute to an inclusive, evidence-
consistent structure and voice throughout the based psychotherapy in which treatment methods
book. Instead of illustrating one approach with and therapy relationships—derived from these
Ms. Apple and another approach with Mr. major systems of therapy—will be tailored to the
Orange, we systematically present a detailed treat- needs of the individual client. In this way, we
ment of Mrs. C for each and every approach. believe, the effectiveness and applicability of psy-
As psychotherapy researchers, the evidence chotherapy will be enhanced.
has taught us that psychotherapy has enormous
potential for impacting patients in a positive Changes in the Eighth Edition
(and occasionally a negative) manner. In this Innovations appear and vanish with bewildering
view, therapy is more analogous to penicillin rapidity on the psychotherapeutic scene. One
than to aspirin. With psychotherapy expected to year’s treatment fad—say, neurolinguistic
produce strong rather than weak effects, we programming—fades into oblivion in just a few
should be able to demonstrate the effectiveness years. The volatile nature of the psychotherapy
of psychotherapy even in the face of error caused discipline requires regular updates in order for
by measurement and methodological problems. practitioners and students to stay abreast of
We thus include a summary of controlled developments.

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Preface xv

The evolution of this book closely reflects the and briefly surveys another 31, thus affording a
changing landscape of psychotherapy. The first broader scope than is available in most textbooks.
edition in 1979 was relatively brief and only hinted Guiding all these modifications has been the
at the possibility of integration. The second edition unwavering goal of our book: to provide a com-
added sections on object relations, cognitive, and prehensive, rigorous, and balanced survey of the
systems therapies. The third edition brought new major theories of psychotherapy. Expanding the
chapters on gender-sensitive therapies and inte- breadth of Systems of Psychotherapy has been
grative treatments, as well as John C. Norcross as accomplished only within the context of a com-
a coauthor. The fourth edition featured a new parative analysis that seeks to explicate both the
chapter on constructivist therapies and the addi- fundamental similarities and the useful differences
tion of material on motivational interviewing, among the therapy schools.
EMDR, and psychotherapy for men. The fifth edi-
tion brought more material on experiential thera-
pies and on interpersonal psychotherapy (IPT). Student and Instructor Friendly
The sixth edition provided a separate chapter on The 30-plus years since the first edition of this
multicultural therapies (formerly combined with book have repeatedly taught us to keep our eye
gender-sensitive therapies), and the seventh edi- on the ball: student learning. On the basis of feed-
tion featured new sections on dialectical behavior back from readers and our students, we have
therapy and relational psychoanalysis. introduced aids to enhance student learning.
This eighth edition, in turn, brings a host of These include:
changes that reflect trends in the field. Among • a list of key terms at the end of each chapter to
these are: serve as a study and review guide
• a new chapter on third-wave therapies, • a series of recommended readings and web-
including acceptance and mindfulness sites at the end of each chapter
approaches (Chapter 11) • a student companion website at cengagebrain.
• a reorganization of the chapter on experiential com, which includes mini-chapters on trans-
therapies (Chapter 6) to focus equally on actional analysis and implosive therapy, as
Gestalt and emotion-focused therapy well as elements to help with review and
• a new section on the emerging evidence-based mastery of the textbook material.
family therapies (Chapter 12) • a set of PowerPoint slides for each chapter
• more attention to attachment-based therapies (coordinated by Rory A. Pfund, Krystle L.
in both the psychodynamic and experiential Evans, and John C. Norcross, all at the Uni-
chapters versity of Scranton)
• enlarged consideration of the transtheoretical • an expanded Test Bank and Instructor’s
model (Chapter 17) Resource Manual coauthored by two excep-
• updated reviews of meta-analyses and con- tional teachers, Drs. Linda Campbell (Uni-
trolled outcome studies conducted on each versity of Georgia) and Anthony Giuliano
psychotherapy system (Harvard Medical School). Available to
• continued efforts to make the book student qualified adopters, the manual lists filmed
friendly throughout (see the following section) therapy demonstrations of the psychotherapy
systems featured in the text, more than
With these additions, the text now thoroughly 400 activity/discussion ideas, and additional
analyzes the 16 leading systems of psychotherapy case illustrations for use in class or on

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xvi Preface

examinations. The manual also presents Barbara Beaver, University of Wisconsin–


2,000+ original exam items. Whitewater
• an alternative table of contents as an appendix We are amused and strangely satisfied that
for those who wish to focus on the change reviewers occasionally find our book to be slanted
processes cutting across theories, rather than toward a particular theoretical orientation—but
the psychotherapy theories themselves then they cannot agree on which orientation that
• a Theories in Action video, developed by Ed is! One reviewer surmised that we disliked psycho-
Neukrug (Old Dominion University), that analysis, whereas another thought we carried a
presents short clips illustrating the systems of psychoanalytic vision throughout the book. We
psychotherapy in action. Available to qualified take such conflicting observations as evidence
adopters. that we are striking a theoretical balance.
Three groups of individuals deserve specific
Acknowledgments mention for their support over the years. First, we
Our endeavors in completing previous editions are grateful to the National Institutes of Health, the
and in preparing this edition have been aided University of Rhode Island, and the University of
immeasurably by colleagues and family members. Scranton for their financial support of our research.
In particular, special appreciation is extended Second, we are indebted to our clients, who con-
to our good friends and close collaborators, tinue to be our ultimate teachers of psychotherapy.
Dr. Carlo DiClemente and Dr. Wayne Velicer, And third, we are appreciative of the good people
for their continuing development of the trans- at Brooks/Cole and Cengage Learning for seeing
theoretical approach. We thank Allison Smith this new edition of Systems of Psychotherapy: A
for her contributions to the chapter on multicul- Transtheoretical Analysis to fruition.
tural therapies (Chapter 14) in previous editions. Finally, we express our deepest appreciation to
We are indebted to Rory Pfund and Donna Rupp our spouses (Jan; Nancy) and to our children
for their tireless efforts in word processing the (Jason and Jodi; Rebecca and Jonathon), who
manuscript and in securing original sources. were willing to sacrifice for the sake of our schol-
We are also grateful to the following reviewers arship and who were available for support when
of the eighth edition: we emerged from solitude. Their caring has freed
us to contribute to the education of those who
Sheli Bernstein-Goff, West Liberty University might one day use the powers of psychotherapy
David Carter, University of Nebraska to make this a better world.
Omaha
Melody Bacon, Argosy University James O. Prochaska
Mark Aoyagi, University of Denver John C. Norcross

Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
About the Authors

James O. Prochaska, PhD, earned his baccalau-


reate, master’s, and doctorate in clinical psychology
from Wayne State University and fulfilled his
internship at the Lafayette Clinic in Detroit. At
present, he is Professor of Psychology and Director
of the Cancer Prevention Research Consortium at
the University of Rhode Island. Dr. Prochaska has
over 45 years of psychotherapy experience in a vari-
ety of settings and has been a consultant to a host of
clinical and research organizations. He has been the
principal investigator on grants from the National
Institutes of Health totaling over $90 million and
has been recognized by the Association of Psycho-
logical Science as one of the most cited authors in psychology. His 50 book
chapters and over 300 scholarly articles focus on self-change, health promo-
tion, well-being, and psychotherapy from a transtheoretical perspective, the
subject of both his professional book, The Transtheoretical Approach (with
Carlo DiClemente), and his popular book, Changing for Good (with John C.
Norcross and Carlo DiClemente). An accomplished speaker, he has offered
workshops and keynote addresses throughout the world and served on vari-
ous task forces for the National Cancer Institute, National Institute of Mental
Health, National Institute of Drug Abuse, and American Cancer Society.
Among his numerous awards are the Rosalie Weiss Award from the
American Psychological Association (APA), Innovators Award from the
Robert Wood Johnson Foundation, SOPHE Honorary Fellow Award from
the Society for Public Health Education, Beckham Award for Excellence in
Education and Inspirational Leadership from Columbia University, and the
Fries Health Education Award from the Society for Public Health Education;
he is the first psychologist to win a Medal of Honor for Clinical Research
from the American Cancer Society. Jim makes his home in southern Rhode
Island with his wife, Jan. They have two married children and five grand-
children living in California.

xvii

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xviii About the Authors

John C. Norcross, PhD, ABPP, received his


baccalaureate from Rutgers University, earned his
master’s and doctorate in clinical psychology from
the University of Rhode Island, and completed his
internship at the Brown University School of Medi-
cine. He is Distinguished Professor of Psychology at
the University of Scranton, Adjunct Professor of
Psychiatry at SUNY Upstate Medical University,
and a board-certified clinical psychologist in part-
time independent practice. Author of more than
300 scholarly publications, Dr. Norcross has cowrit-
ten or edited 20 books, the most recent being
Psychotherapy Relationships That Work, Self-Help That Works, Leaving It at
the Office: Psychotherapist Self-Care, Psychologists’ Desk Reference, Handbook of
Psychotherapy Integration, and multiple editions of the Insider’s Guide to
Graduate Programs in Clinical and Counseling Psychology. He has also authored
two self-help books, most recently Changeology: 5 Steps to Realizing Your
Resolutions and Goals. He has served as president of the APA Division of
Psychotherapy, president of the Society of Clinical Psychology, and Council
Representative of the APA. He has also served on the editorial board of a
dozen journals and was the editor of the Journal of Clinical Psychology: In Session
for a decade. He is a diplomate in clinical psychology of the American Board of
Professional Psychology. Dr. Norcross has delivered workshops and lectures in
30 countries. He has received numerous awards for his teaching and research,
such as APA’s Distinguished Contributions to Education & Training Award,
Pennsylvania Professor of the Year from the Carnegie Foundation, the Rosalee
Weiss Award from the American Psychological Foundation, and election to the
National Academies of Practice. John lives, works, and plays in northeastern
Pennsylvania with his wife, two grown children, and two new grandkids.

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CHAPTER 1
Defining and
Comparing the
Psychotherapies
An Integrative Framework

The field of psychotherapy has been fragmented ourselves using the new ideas and methods in
by future shock and staggered by over-choice. practice while reading the book. But when we
We have witnessed the hyperinflation of brand- turn to an advocate of a radically different
name therapies during the past 50 years. In approach, the confusion returns. Listening to
1959, Harper identified 36 distinct systems of proponents compare therapies does little for our
psychotherapy; by 1976, Parloff discovered more confusion, except to confirm the rule that those
than 130 therapies in the therapeutic marketplace who cannot agree on basic assumptions are often
or, perhaps more appropriately, the “jungle place.” reduced to calling each other names.
Recent estimates now put the number at over 500 We believe that fragmentation and confusion
and growing (Pearsall, 2011). in psychotherapy can best be reduced by a
The proliferation of therapies has been comparative analysis of psychotherapy systems
accompanied by an avalanche of rival claims: Each that highlights the many similarities across
system advertises itself as differentially effective and systems without blurring their essential difference.
uniquely applicable. Developers of new systems A comparative analysis requires a firm
usually claim 80% to 100% success, despite the understanding of each of the individual systems of
absence of controlled outcome research. A healthy therapy to be compared. In discussing each system,
diversity has deteriorated into an unhealthy chaos. we first present a brief clinical example and introduce
Students, practitioners, and patients are confronted the developer(s) of the system. We trace the system’s
with confusion, fragmentation, and discontent. With theory of personality as it leads to its theory of
so many therapy systems claiming success, which psychopathology and culminates in its therapeutic
theories should be studied, taught, or bought? processes, therapeutic content, and therapy
A book by a proponent of a particular therapy relationship. We then feature the practicalities
system can be quite persuasive. We may even find of the psychotherapy. Following a summary of

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2 Chapter 1

controlled research on the effectiveness of that our integrative model assumes that a limited number
system, we review central criticisms of that of processes of change underlie contemporary systems
psychotherapy from diverse perspectives. Each of psychotherapy. The model further demonstrates
chapter concludes with an analysis of the same how the content of therapy can be reduced to four
patient (Mrs. C) and a consideration of future different levels of personal functioning.
directions. Psychotherapy systems are compared on the
In outline form, our examination of each particular process, or combination of processes,
psychotherapy system follows this format: used to produce change. The systems are also
compared on how they conceptualize the most
• A clinical example
common problems that occur at each level of
• A sketch of the founder
personal functioning, such as low self-esteem, lack
• Theory of personality
of intimacy, and impulse dyscontrol. Because
• Theory of psychopathology
clinicians are concerned primarily with the real
• Therapeutic processes
problems of real people, we do not limit our
• Therapeutic content
comparative analysis merely to concepts and data.
• Therapeutic relationship
Our analysis also includes a comparison of how
• Practicalities of the therapy
each major system conceptualizes and treats the
• Effectiveness of the therapy
same complex client (Mrs. C).
• Criticisms of the therapy
We have limited our comparative analysis to 15
• Analysis of Mrs. C
major systems of therapy. Systems have been omitted
• Future directions
because they seem to be dying a natural death and are
• Key terms
best left undisturbed, because they are so poorly
• Recommended readings
developed that they have no identifiable theories of
• Recommended websites
personality or psychopathology, or because they are
In comparing systems, we will use an integrative primarily variations on themes already considered in
model to demonstrate their similarities and the book. The final criterion for exclusion is
differences. An integrative model was selected in empirical: No therapy system was excluded if at
part because of its spirit of rapprochement, seeking least 1% of American mental health professionals
what is useful and cordial in each therapy system endorsed it as their primary theoretical orientation.
rather than looking for what is most easily criticized. Table 1.1 summarizes the self-identified theories of
Integration also represents the mainstream of clinical psychologists, counseling psychologists,
contemporary psychotherapy: Research consistently social workers, and counselors.
demonstrates that integration is the most popular
orientation of mental health professionals (Norcross,
2005). Defining Psychotherapy
Lacking in most integrative endeavors is a A useful opening move in a psychotherapy textbook
comprehensive model for thinking and working would be to define psychotherapy—the subject mat-
across systems. Later in this chapter, we present an ter itself. However, no single definition of psycho-
integrative model that is sophisticated enough to do therapy has won universal acceptance. Depending
justice to the complexities of psychotherapy, yet on one’s theoretical orientation, psychotherapy can
simple enough to reduce confusion in the field. be conceptualized as interpersonal persuasion,
Rather than having to work with 500-plus theories, health care, psychosocial education, professionally

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Defining and Comparing the Psychotherapies 3

Table 1.1 Theoretical Orientations of Psychotherapists in the United States


CLINICA L COUNSELING SOC IAL
O RI EN T A T ION P SY C H OL O GI ST S PSYCHOLOGISTS W ORK ER S CO UN S E L OR S
Behavioral 15% 5% 11% 8%
Cognitive 31% 19% 19% 29%
Constructivist 1% 1% 2% 2%
Eclectic/Integrative 22% 34% 26% 23%
Existential/Humanistic 1% 5% 4% 5%
Gestalt/Experiential 1% 2% 1% 2%
Interpersonal 4% 4% 3% 3%
Multicultural 1% – 1% 1%
Psychoanalytic 3% 1% 5% 2%
Psychodynamic 15% 10% 9% 5%
Rogerian/Person-Centered 2% 3% 1% 10%
Systems 2% 5% 14% 7%
Other 2% 9% 4% 3%
SOURCES: Bechtoldt et al., 2001; Bike, Norcross, & Schatz, 2009; Goodyear et al., 2008; Norcross & Karpiak, 2012.

coached self-change, behavioral technology, a form psychotherapist have not been delineated. We
of reparenting, the purchase of friendship, or a con- recognize multiple processes of change and the
temporary variant of shamanism, among others. It multidimensional nature of change; no attempt
may be easier to practice psychotherapy than to is made here to delimit the methods or content
explain or define it (London, 1986). of therapeutic change. The requirement that the
Our working definition of psychotherapy is as methods be “derived from established psycholog-
follows (Norcross, 1990): ical principles” is sufficiently broad to permit
clinical and/or research validation.
Psychotherapy is the informed and intentional
Our definition also explicitly mentions both
application of clinical methods and interper-
“clinical methods and interpersonal stances.” In
sonal stances derived from established psycholog-
some therapy systems, the active change mechanism
ical principles for the purpose of assisting people
has been construed as a treatment method; in other
to modify their behaviors, cognitions, emotions,
systems, the therapy relationship has been regarded
and/or other personal characteristics in direc-
as the primary source of change. Here, the interper-
tions that the participants deem desirable.
sonal stances and experiences of the therapist are
This admittedly broad definition is nonethe- placed on an equal footing with methods.
less a reasonably balanced one and a relatively Finally, we firmly believe that any activity
neutral one in terms of theory and method. We defined as psychotherapy should be conducted
have, for example, not specified the number or only for the “purpose of assisting people” toward
composition of the participants, as different mutually agreed-upon goals. Otherwise—though
theories and clients call for different formats. it may be labeled psychotherapy—it becomes a
Similarly, the training and qualifications of the subtle form of coercion or punishment.

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4 Chapter 1

The Value of Theory the clinical phenomena, delimits the amount of rel-
evant information, organizes that information, and
The term theory possesses multiple meanings. In
integrates it all into a coherent body of knowledge
popular usage, theory is contrasted with practice,
that prioritizes our conceptualization and directs
empiricism, or certainty. In scientific circles, theory
our treatment.
is generally defined as a set of statements used to
The model of humanity embedded within a
explain the data in a given area (Marx & Goodson,
psychotherapy theory is not merely a philosophi-
1976). In psychotherapy, a theory (or system) is a
cal issue for purists. It affects which human capac-
consistent perspective on human behavior, psycho-
ities will be studied and cultivated, and which will
pathology, and the mechanisms of therapeutic
be ignored and underdeveloped. Treatments in-
change. These appear to be the necessary, but perhaps
evitably follow from the clinician’s underlying
not sufficient, features of a psychotherapy theory.
conception of pathology, health, reality, and the
Explanations of personality and human development
therapeutic process (Kazdin, 1984). Systems of
are frequently included, but, as we shall see in the
therapy embody different visions of life, which
behavioral, constructivist, and integrative therapies,
imply different possibilities of human existence
are not characteristic of all theories.
(Messer & Winokur, 1980).
When colleagues learn that we are revising our
In this regard, we want to dispute the miscon-
textbook on psychotherapy theories, they occasion-
ception that psychotherapists aligning themselves
ally question the usefulness of theories. Why not,
with a particular theory are unwilling to adapt
they ask, simply produce a text on the actual prac-
their practices to the demands of the situation
tice or accumulated facts of psychotherapy? Our
and the patient. A voluntary decision to label one-
response takes many forms, depending on our
self an adherent of a specific theory does not con-
mood at the time, but goes something like this.
stitute a lifetime commitment of strict adherence or
One fruitful way to learn about psychotherapy is
dogmatic reverence (Norcross, 1985). Good clini-
to learn what the best minds have had to say
cians are flexible, and good theories are widely
about it and to compare what they say. Further,
applicable. Thus, we see theories being adapted
“absolute truth” will probably never be attained in
for use in a variety of contexts and clinicians bor-
psychotherapy, despite impressive advances in our
rowing heavily from divergent theories. A prefer-
knowledge and despite a large body of research.
ence for one orientation does not preclude the use
Instead, theory will always be with us to provide
of concepts or methods from another. Put another
tentative approximations of “the truth.”
way, the primary problem is not with narrow-gauge
Without a guiding theory or system of psycho-
therapists, but with therapists who impose that
therapy, clinicians would be vulnerable, direction-
narrowness onto their patients (Stricker, 1988).
less creatures bombarded with literally hundreds of
impressions and pieces of information in a single
session. Is it more important to ask about early Therapeutic Commonalities
memories, parent relationships, life’s meaning, Despite theoretical differences, there is a central and
disturbing emotions, environmental reinforcers, recognizable core of psychotherapy. This core distin-
recent cognitions, sexual conflicts, or something guishes it from other activities—such as banking,
else in the first interview? At any given time, should farming, or physical therapy—and glues together
we empathize, direct, teach, model, support, ques- variations of psychotherapy. This core is composed
tion, restructure, interpret, or remain silent in a of nonspecific or common factors shared by all
therapy session? A psychotherapy theory describes forms of psychotherapy and not specific to any

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Defining and Comparing the Psychotherapies 5

one. More often than not, these therapeutic determine convergence among proposed thera-
commonalities are not highlighted by theories as of peutic commonalities. A total of 89 commonalities
central importance, but the research suggests exactly were proposed. The analysis revealed the most
the opposite (Weinberger, 1995). consensual commonalities were clients’ positive
Mental health professionals have long observed expectations and a facilitative relationship. In
that disparate forms of psychotherapy share com- what follows, we review the therapeutic common-
mon elements or core features. As early as 1936, alities of positive expectations, the therapeutic
Rosenzweig, noting that all forms of psychotherapy relationship, the Hawthorne effect, and related
have cures to their credit, invoked the famous Dodo factors.
bird verdict from Alice in Wonderland, “Everybody
has won and all must have prizes,” to characterize Positive Expectations
psychotherapy outcomes. He then proposed, as a Expectation is one of the most widely debated and
possible explanation for roughly equivalent out- heavily investigated of the common (or non-
comes, a number of therapeutic common factors, specific) variables. This commonality has been
including psychological interpretation, catharsis, described as the “edifice complex”—the patient’s
and the therapist’s personality. In 1940, a meeting faith in the institution itself, the door at the end of
of prominent psychotherapists was held to as- the pilgrimage, the confidence in the therapist and
certain areas of agreement among psychotherapy the treatment (Torrey, 1972).
systems. The participants concurred that support, A computer search yields more than 500 stud-
interpretation, insight, behavior change, a good ies that have been conducted on patients’ expec-
relationship, and certain therapist characteristics tations of psychotherapy. The hypothesis of most
were common features of successful psychotherapy of these studies is that the treatment is enhanced
(Watson, 1940). by the extent to which clients expect the treat-
If indeed the multitude of psychotherapy sys- ment to be effective. Some critics hold that psy-
tems can all legitimately claim some success, then chotherapy is nothing but a process of influence
perhaps they are not as diverse as they appear on in which we induce an expectation in our clients
the surface. They probably share certain core fea- that our treatment will cure them, and that any
tures that may be the “curative” elements—those resulting improvement is a function of the
responsible for therapeutic success. To the extent client’s expecting to improve. Surely many thera-
that clinicians of different theories arrive at a com- pists wish on difficult days that the process were
mon set of strategies, it is likely that what emerges so simple!
will consist of robust phenomena, as they have The research evidence demonstrates that cli-
managed to survive the distortions imposed by ent expectations definitely contribute to therapy
the different theoretical biases (Goldfried, 1980). success, but is divided on how much (Clarkin &
But, as one might expect, the common factors Levy, 2004; Constantino et al., 2011). Of the stud-
posited to date have been numerous and varied. Dif- ies reporting expectation effects, most demon-
ferent authors focus on different domains or levels of strate that a high, positive expectation adds to
psychosocial treatment; as a result, diverse concep- the effectiveness of treatments. Up to one third
tualizations of these commonalities have emerged. of successful psychotherapy outcomes may be
Our consideration of common factors will be attributable to both the healer and the patient
guided by the results of a study (Grencavage & believing strongly in the effectiveness of the treat-
Norcross, 1990) that reviewed 50 publications to ment (Roberts et al., 1993).

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6 Chapter 1

But psychotherapy can by no means be reduced This most robust of common factors has con-
to expectation effects alone. A sophisticated analysis sistently emerged as one of the major determi-
of multiple outcome studies found that psychother- nants of psychotherapy success. Across various
apy was more effective than common factors condi- types of psychotherapy, at least 12% of psycho-
tions, which in turn were more effective than no therapy outcome—why patients improve in
treatment at all (Barber et al., 1988). The ranking for psychotherapy—is due to the therapeutic relation-
therapeutic success is psychotherapy, placebo, and ship (Norcross, 2011). To summarize the conclu-
control (do nothing or wait), respectively. In fact, psy- sions of an exhaustive review of the psychotherapy
chotherapy is nearly twice as effective as “nonspecific” outcome literature (Bergin & Lambert, 1978): The
or placebo treatments, which seek to induce positive largest variation in therapy outcome is accounted
expectations in clients (Grissom, 1996). for by pre-existing client factors, such as expecta-
On the basis of the research, then, we will tions for change and severity of the disorder. The
assume that expectation is an active ingredient in therapeutic relationship accounted for the second
all systems of therapy. Rather than being the central largest proportion of change, with the particular
process of change, however, a positive expectation treatment method coming in third.
is conceptualized as a critical precondition for ther- Still, the relative importance of the therapeutic
apy to continue. Most patients would not partici- relationship remains controversial. At one end of
pate in a process that costs them dearly in time, the continuum, some psychotherapy systems, such
money, and energy if they did not expect the pro- as the radical behavior therapies, view the rela-
cess to help them. For clients to cooperate in being tionship between client1 and therapist as exerting
desensitized, hypnotized, or analyzed, it seems rea- little importance; the client change in therapy
sonable that most of them would need to expect could just as readily occur with only an interactive
some return on their investment. It is also our computer program, without the therapist’s pres-
working assumption that therapists consciously ence. For these therapy systems, a human clinician
strive to cultivate hope and enhance positive expec- is included for practical reasons only, because our
tancies. Psychotherapy research need not demon- technology in programming therapeutic processes
strate that treatment operates free from such is not developed fully enough to allow the thera-
nonspecific or common factors. Rather, the task is pist to be absent.
to demonstrate that specific treatments considered Toward the middle of the continuum, some
to carry the burden of client change go beyond the therapy schools, such as cognitive therapies, view
results that can be obtained by credibility alone. the relationship between clinician and client as
one of the preconditions necessary for therapy to
Therapeutic Relationship proceed. From this point of view, the client must
Psychotherapy is at root an interpersonal relation- trust and collaborate with the therapist before being
ship. The single greatest area of convergence able to participate in the process of change.
among psychotherapists, in their nominations of At the other end of the continuum, Rogers’s
common factors (Grencavage & Norcross, 1990) person-centered therapy sees the relationship as the
and in their treatment recommendations (Norcross essential process that produces change. Because Carl
et al., 1990), is the development of a strong thera- Rogers (1957) has been most articulate in describing
peutic alliance. what he believes are the necessary conditions for a

1
We will employ the terms client and patient interchangeably throughout this textbook because neither satisfactorily describes the therapy
relationship and because we wish to remain theoretically neutral on this quarrelsome point.

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Defining and Comparing the Psychotherapies 7

therapeutic relationship, let us briefly outline his cri- attention. Usually such improvement is assumed to
teria so that we can use these for comparing systems be due to increases in morale, novelty, and esteem
on the nature of the therapeutic relationship. that people experience from having others attend to
them—a phenomenon that has come to be known as
1. The therapist must relate in a genuine manner.
the Hawthorne effect.
2. The therapist must relate with unconditional
One commonality among all psychosocial
positive regard.
treatments is that the therapist pays special atten-
3. The therapist must relate with accurate
tion to the client. Consequently, attention has
empathy.
been assumed to be one of the common factors
These—and only these—conditions are necessary that impact the results of therapy. Anyone who
and sufficient for positive outcome, according to has been in psychotherapy can appreciate the grat-
Rogers. ification that comes from having a competent pro-
Then there are those psychotherapy systems, fessional’s undivided attention for an hour. This
such as psychoanalysis, that see the relationship special attention may indeed affect the course of
between therapist and patient primarily as the source therapy—including those occasional cases in
of content to be examined in therapy. In this view, which patients do not improve because they do
the relationship is important because it brings the not want to surrender such special attention.
content of therapy (the patient’s interpersonal Researchers have frequently found that attention
behavior) right into the consulting room. The con- does indeed lead to improvement, regardless of
tent that needs to be changed is thus able to occur whether the attention is followed by any other thera-
during therapy, rather than the person focusing on peutic processes. In a classic study (Paul, 1967), 50%
issues that occur outside of the consulting room. of public-speaking phobics demonstrated marked
In light of these various emphases on the role improvement in their symptoms by virtue of
of the therapeutic relationship, it will be necessary receiving an attention placebo intended to control
to determine for each therapy system whether the for nonspecific variables such as attention. (In psy-
relationship is conceived as (1) a precondition for chotherapy studies, an attention placebo control
change, (2) a process of change, and/or (3) a con- group receives a “treatment” that mimics the amount
tent to be changed. Moreover, in each chapter that of time and attention received by the treatment group
follows, we will consider the relative contribution but that does not have a specific or intended effect.)
of the therapeutic relationship to treatment suc- Years of research demonstrate that attention can be a
cess, as well as the therapist behaviors designed powerful common factor in therapy.
to facilitate that relationship. To conclude that any particular psychother-
apy is more effective than an attention placebo,
Hawthorne Effect it is necessary that research include controls for
Psychologists have known for years that many peo- attention effects or simply the passage of time. It
ple can improve in such behaviors as work output is not enough to demonstrate a particular therapy
solely as a result of having special attention paid is better than no treatment, because the improve-
to them. In the classic Hawthorne studies (Roethlis- ment from that particular therapy may be due
berger & Dickson, 1939) on the effects of improved entirely to the attention given to the patients.
lighting on productivity in a factory, it was discov- Several research designs are available to mea-
ered that participants increased their output by sim- sure or control for the effects of attention in psy-
ply being observed in a study and receiving extra chotherapy. The most popular design is to use

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8 Chapter 1

placebo groups, as in Paul’s study, in which control therapeutic ritual. Other consensual commonalities
participants were given as much attention as clients include an inspiring and socially sanctioned thera-
in therapy but did not participate in processes pist; opportunity for catharsis; acquisition and
designed to produce change. An alternative design practice of new behaviors; exploration of the
is to compare the effectiveness of one treatment with “inner world” of the patient; suggestion; and inter-
that of another, such as psychoanalytic therapy with personal learning (Grencavage & Norcross, 1990).
cognitive therapy. If one therapeutic approach does Many observers now conclude that features shared
better than the other, we can conclude that the by all therapies account for an appreciable amount
differential improvement is due to more than just of observed improvement in clients.
attention, because the less effective treatment So powerful are these therapeutic commonalities
included—and therefore controlled for—the effects for some clinicians that explicitly common factors
of attention. However, we do not know whether the therapies have been proposed. Sol Garfield (1980,
less effective therapy is anything other than a pla- 1992), to take one prominent example, finds the
cebo effect, even if it leads to greater improvement mechanisms of change in virtually all approaches to
than no treatment. Finally, in such comparative be rooted in the therapeutic relationship, emotional
studies, if both therapies lead to significant improve- release, explanation and interpretation, reinforce-
ment, but neither therapy does better than the other, ment, desensitization, confronting a problem, and
we cannot conclude that the therapies are anything skill training. We shall return to common factors
more than Hawthorne effects, unless an attention approaches in Chapter 16 (Integrative Therapies).
placebo control has also been included in the
Specific Factors
study. To be considered a controlled evaluation of
At the same time, common factors theorists rec-
a psychotherapy’s efficacy, studies must include
ognize the value of unique—or specific—factors in
controls for the Hawthorne effect and related
disparate psychotherapies. A psychotherapist can-
factors.
not practice nonspecifically; specific techniques
Other Commonalities and relationships fill the treatment hour. Indeed,
In his classic Persuasion and Healing, Jerome research has demonstrated the differential effec-
Frank (1961; Frank & Frank, 1991) posited that tiveness of a few therapies with specific disorders,
all psychotherapeutic methods are elaborations such as exposure therapy for obsessive-compulsive
and variations of age-old procedures of psycholog- disorder, parent management training for conduct
ical healing. The features that distinguish psy- problems, and systemic therapy for couples con-
chotherapies from each other, however, receive flict. As a discipline, psychotherapy will advance
special emphasis in the pluralistic, competitive by integrating the power of common factors with
American society. Because the prestige and finan- the pragmatics of specific factors. We now turn to
cial security of psychotherapists hinge on their the processes of change—the relatively specific or
being able to show that their particular system is unique contributions of a therapy system.
more successful than that of their rivals, little glory
has traditionally been accorded to the identifica-
tion of shared or common components. Processes of Change
Frank argues that therapeutic change is pre- There exists, as we said earlier in this chapter, an
dominantly a function of common factors: an emo- expanding morass of psychotherapy theories and
tionally charged, confiding relationship; a healing an endless proliferation of specific techniques.
setting; a rationale or conceptual scheme; and a Consider the relatively simple case of smoking

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Defining and Comparing the Psychotherapies 9

cessation: In one of our early studies, we identified thoughts, behaviors, or relationships related to a
more than 50 formal treatments employed by health particular problem or more general patterns of
professionals and 130 different techniques used by living. In fewer words, processes are how people
successful self-changers to stop smoking. Is there no change, within psychotherapy and between
smaller and more intelligible framework by which to therapy sessions. These processes were derived
examine and compare the psychotherapies? theoretically from a comparative analysis of the
The transtheoretical—across theories—model leading systems of psychotherapy (Prochaska,
reduces the therapeutic morass to a manageable 1979). In the following sections, we introduce
number of processes of change. There are literally these processes of change.
hundreds of global theories of psychotherapy, and
we will probably never reach common ground in
Consciousness Raising
the theoretical or philosophical realm. There are
thousands of specific techniques in psychotherapy, Traditionally, increasing an individual’s conscious-
and we will rarely agree on the specific, moment- ness has been one of the prime processes of change
to-moment methods to use. By contrast, the in psychotherapy. Consciousness raising sounds so
processes of change represent a middle level of contemporary, yet therapists from a variety of per-
abstraction between global theories (such as psy- suasions have been working for decades to increase
choanalysis, cognitive, and humanistic) and specific the consciousness of clients. Beginning with Freud’s
techniques (such as dream analysis, progressive objective “to make the unconscious conscious,” all
muscle relaxation, and family sculpting). Table 1.2 so-called insight psychotherapies begin by working
illustrates this intermediate level of abstraction to raise the individual’s level of awareness. It is
represented by the processes of change. fitting that the insight or awareness therapies
It is at this intermediate level of analysis— work with consciousness, which is frequently
processes or principles of change—that meaningful viewed as a human characteristic that emerged
points of convergence and contention may be with the evolution of language.
found among psychotherapy systems. It is also at With language and consciousness, humans do
this intermediate level that expert psychotherapists not need to respond reflexively to every stimulus.
typically formulate their treatment plans—not in For example, the mechanical energy from a hand
terms of global theories or specific techniques but hitting against our back does not cause us to react
as change processes for their clients. with movement. Instead, we respond thoughtfully
Processes of change are the covert and overt to the information contained in that touch, such as
activities that people use to alter emotions, whether the hand touching us is a friend patting us
on the back, a robber grabbing us, or a partner hitting
us. In order to respond effectively, we must process
Table 1.2 Levels of Abstraction information to guide us in making a response appro-
L E V E L AB S T R A C T I O N EXAMPLES priate to the situation. Consciousness-raising thera-
pies attempt to increase the information available to
High Global theories Psychodynamic,
Gestalt, behavioral individuals so they can make the most effective
Medium Change processes Consciousness raising, responses to life.
counterconditioning For each of the change processes, the psy-
Low Clinical techniques Interpretation, chotherapist’s focus can be on producing change
two-chair technique, either at the level of the individual’s experience or
self-monitoring
at the level of the individual’s environment. When

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10 Chapter 1

the information given a client concerns the indi- friend’s name, my wife laughed and said that she
vidual’s own actions and experiences, we call that knew I always thought that, but she wasn’t attracted
feedback. An example of the feedback process to him. She also said that she was now sure that his
occurred in the case of a stern and proper wife was on my list. My next two guesses were also
middle-aged woman who was unaware of just wrong, but my wife was quickly able to guess that I
how angry she appeared to others. She could not found their wives attractive. I was amazed to realize
connect her children’s avoidance of her or her how much I had been projecting over the years and
recent rash of automobile accidents with rage, how my projection kept me from being aware of the
because she kept insisting that she was not qualities in men that my wife found appealing.
angry. After viewing videotapes of herself interact- How can our awareness of such information
ing with members of a psychotherapy group, how- lead to behavior change? Think of our conscious-
ever, she was stunned. All she could say was, “My ness as a beam of light. The information unavailable
God, how angry I seem to be!”2 to us is like a darkness in which we can be lost, held
When the information given a client concerns back, or directed without knowing the source of the
environmental events, we call this education. An influence. In the darkness, we are blind; we do not
example of therapeutic movement due to educa- possess sufficient sight or light to guide us effectively
tion occurred in the case of an aging man who was in our lives. For example, without being aware of
distressed over the fact that his time to attain erec- how aging normally affects sexual response, an
tions and reach orgasms had increased noticeably aging man (or woman) would not know whether
over the past few years. He was very relieved when the best direction would be to admit he (or she)
he learned that such a delay was quite normal in was over the hill and give up on sex, to eat two
older men. raw oysters a day as an aphrodisiac, to take Viagra,
Defenses ward off threatening information or to enjoy his or her present behavior without liv-
about ourselves in response to education and feed- ing up to some media stereotype of sexuality.
back. These defense mechanisms are like blinders As we will see, many psychotherapy systems
or the “rose-colored glasses” that some people use agree that people can change as a result of raised
to selectively attend only to positive information consciousness—increasing experiential or environ-
about themselves and to ignore negative input. mental information previously unavailable to them.
Cognitive blinders prevent individuals from The disagreement among these consciousness-
increasing their consciousness without feedback raising psychotherapies lies in which concrete
or education from an outside party. techniques are most effective in doing so.
For example, my (JOP’s) wife, who is also a psy-
chotherapist, confronted me with the following Catharsis
information that made me aware of blinders I was Catharsis has one of the longest traditions as a
wearing: We were trying to anticipate who would be process of change and refers to the therapeutic
on each other’s list of sexually attractive individuals. release of pent-up feelings and emotions. The
I was absolutely sure that my first three guesses ancient Greeks believed that expressing emotions
would be high on my wife’s list. When I said a was a superb mechanism of providing personal

2
In the case of this woman, as with so many clients, we cannot demonstrate that the way we conceptualize the person’s problems is, in fact,
the way things really are. We cannot, for example, demonstrate in an empirical manner that this woman’s problems were due to angry feel-
ings that were outside of her awareness. Nevertheless, it is still useful in psychotherapy to make provisional assumptions about the origins of
a client’s problems. As case illustrations are presented throughout this book, they will be described in the manner that we found most helpful
for the purposes of treatment, without assuming some ultimate validity of the clinical interpretations.

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Defining and Comparing the Psychotherapies 11

relief and behavioral improvement. Human suffer- rage toward her mother for always being on her
ing was, quite literally, let out and let go. back. She soon let herself express her intense
Historically, catharsis used a hydraulic model anger by tearing her blouse to shreds. By the time
of emotions, in which unacceptable emotions— her partner arrived home, she felt quite relieved,
such as anger, guilt, or anxiety—are blocked although her partner, looking at the destroyed
from direct expression. The damming off of such blouse, wondered aloud whether she had flipped.
emotions results in pressure from affects (or emo- The belief that cathartic reactions can be
tions) seeking some form of release, however indi- evoked by observing emotional scenes in the envi-
rect, as when anger is expressed somatically ronment dates back at least to Aristotle’s writings
through headaches. If emotions can be released on theater and music. In honor of this tradition, we
more directly in psychotherapy, then their reser- will call this source of catharsis dramatic relief.
voir of energy is discharged, and the person is A patient suffering from headaches, insomnia,
freed from a source of symptoms. and other symptoms of depression found himself
In a different analogy, the patient with weeping heavily during Ingmar Bergman’s movie
blocked emotions is seen as emotionally consti- Scenes from a Marriage. He began to experience
pated. What these patients need to release psycho- how disappointed he was in himself for having
logical suffering is a good, emotional bowel traded a satisfying marriage for security. His
movement. In this analogy, psychotherapy serves depression began to lift because of the inspiration
as a psychological enema that allows patients to he felt from Bergman to leave his hopelessly devi-
purge their emotional blockage. The therapeutic talized marriage.
process is aimed at helping patients break through
their emotional blocks. By expressing the dark side Choosing
of themselves in the presence of another, the indi- The power of choice in producing behavior change
viduals can better accept such emotions as natural has been in the background of many psychotherapy
phenomena that need not be so severely con- systems. The concept of choosing has lacked
trolled in the future. respectability in the highly deterministic worldview
Most often, this therapeutic process has been of most scientists. Many clinicians have not wanted
at the level of individual experience, in which the to provide ammunition for their critics’ accusations
cathartic reactions come directly from within the of tender-mindedness by openly discussing free-
person. We shall call this form of catharsis correc- dom and choice. Consequently, we will see that
tive emotional experiences. As the term suggests, many therapy systems implicitly assume that cli-
an intense emotional experience produces a psy- ents will choose to change as a result of psycholog-
chological correction. ical treatment but do not articulate the means by
A fellow clinician related a cathartic experience which clients come to use the process of choosing.
several years ago when she was fighting off a bout With so little open consideration of choosing
of depression. She was struggling to get in touch as a change process (with the exception of existen-
with the source of her depression, so she took a tial and experiential therapists), it is predictably
mental health day off from work. Alone at home, difficult to suggest what choice is a function of.
she put on music and started to express her feelings Some theorists argue choice is irreducible, because
in a free form of dance that she could perform only to reduce choice to other events is to advance the
when no one else was present. After some very paradox that such events determine our choices.
releasing movements, she experienced childhood Human action is seen as freely chosen, and to say

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12 Chapter 1

that anything else determines our choice is to An example of so-called existential anxiety was
show bad faith in ourselves as free beings. Few seen in a college student who consulted me about
clinicians, however, accept such a radical view of the panic attacks she was experiencing since she
freedom for their clients; they usually believe that informed her parents of her unplanned pregnancy.
many conditions limit choice. They insisted that she get an abortion, but she and
From a behavioral perspective, choice would her husband wanted to have the baby. They were
be a partial function of the number of alternative both students, and entirely dependent on her
responses available to an individual. If only one wealthy parents for financial support. Her parents
response is available, there is no choice. From a had informed her that the consequence of having a
humanistic perspective, the number of available baby at this time would be disinheritance, because
responses can radically increase if we become they believed she would not finish college once she
more conscious of alternatives that we have not had a baby. In 21 years she had never openly dif-
previously considered. For a variety of psychother- fered with her parents, and although she was con-
apy systems, then, an increase in choice is thought trolled by them, she had always felt protected by
to result from an increase in consciousness. them as well. Now, after just a few psychotherapy
The freedom to choose has traditionally been sessions, she became more aware that her panic
construed as a uniquely human behavior made pos- attacks reflected her need to choose. Her basic
sible by the acquisition of consciousness that accom- choice was not whether she was going to sacrifice
panies the development of language. Responsibility her fetus to her family’s fortune, but whether she
is the burden that accompanies the awareness that was going to continue to sacrifice herself.
we are the ones able to respond, to speak for our- At an experiential level, then, choosing
selves. Insofar that choice and responsibility are pos- involves the individual becoming aware of new
sible through language and consciousness, it seems alternatives, including the deliberate creation of
only natural that the therapeutic process of choosing new alternatives for living. This process also
is a verbal or awareness process. involves experiencing the anxiety inherent in
The easiest choices follow from accurate infor- being responsible for which alternative is followed.
mation processing that entails an awareness of the We will call this experiential level of choosing a
consequences of particular alternatives. If a men- move toward self-liberation.
opausal woman were informed, for example, that When changes in the environment make more
hormone replacement therapy (HRT) eventually alternatives available to individuals, such as more
caused cancer in all women, then her best alterna- jobs being open to gays and lesbians, we will call
tive would be to follow the information she has this a move toward social liberation. Psy-
just processed. With HRT, however, as with so chotherapists working for such social changes
many life decisions, we are not aware of all the are usually called advocates.
consequences of choice, and the consequences
are rarely absolute. In these situations, there are Conditional Stimuli
no definitive external guidelines, and we are con- At the opposite extreme from changing through
fronted with the possibility of choosing an alter- choosing is changing by modifying the conditional
native that might be a serious mistake. Then our stimuli that control our responses. Alterations in
ability to choose is more clearly a function of our conditional stimuli are necessitated when the indi-
ability to accept the anxiety inherent in accepting vidual’s behavior is elicited by classical (Pavlovian)
responsibility for our future. conditioning. When troublesome responses are

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Defining and Comparing the Psychotherapies 13

conditioned, then being conscious of the stimuli will the treatment of choice. Before the treatment was
not produce change, nor can conditioning be over- under way, however, the student traded in his car
come just by choosing to change. We need, literally, for a van. Because his anxiety response did not
to change the environment or the behavior. generalize to his van, he solved his problem through
Again, either we can modify the way indivi- his own stimulus control procedure. Eliminating or
duals behave in response to particular stimuli, or avoiding environmental cues that provoke problem
we can modify the environment to minimize the behaviors is the core of stimulus control.
probability of the stimuli occurring. Changing our
behavior to the stimuli is known as countercon- Contingency Control
ditioning, whereas changing the environment Axiomatic for many behavior therapists is that
involves stimulus control. behavior is controlled by its consequences. As
Counterconditioning was used in the treatment most of us have learned, if a response is rein-
of a woman with a penetration phobia who forced, then the probability of that response is
responded to intercourse with involuntary muscle increased. If, on the other hand, a punishment
spasms. This condition, known as vaginismus, pre- follows a particular response, then we are less
vented penetration. She did not want to modify her likely to emit that response. As B. F. Skinner dem-
environment, but rather to change her response to onstrated, changing the contingencies governing
her partner. As in most counterconditioning cases, our behavior frequently leads to changed behavior.
the procedure involved a gradual approach to the The extent to which a particular reinforcer or
conditioned stimulus of intercourse while learning punisher controls behavior is a function of many
an incompatible response. She learned relaxation, variables, including the immediacy, saliency, and
which was incompatible with the undesired response schedule of the consequences. From humanistic
of anxiety and muscle spasms that had previously and cognitive-behavioral points of view, the indi-
been elicited by intercourse. Counterconditioning is vidual’s valuing of particular consequences is also
learning to do the healthy opposite—relaxation important in contingency control.
instead of anxiety, assertion instead of passivity, If behavior changes are made by modifying
exposure instead of avoidance, for example. the contingencies in the environment, we call
Stimulus control entails restructuring the this contingency management. Desirable, healthy
environment to reduce the probability that a behaviors are followed by reinforcement; in select
particular conditional stimulus will occur. A cases, undesirable, pathological behaviors are fol-
high-strung college student suffered from a host lowed by punishment.
of anxiety symptoms, including considerable For example, a graduate student with a bashful
distress when driving his car. Whenever the car bladder wanted to increase his ability to use public
began to shake in the slightest, the student restrooms; he also wanted more money to improve
would also begin to shake. He attributed this his style of living. Therefore, he made a contin-
particular problem to a frightening episode earlier gency contract with me (JOP) that earned him
in the year, when the universal joint on his car two dollars for each time during the week he uri-
broke with a startling noise. Not once but three nated in a public restroom. I am pleased to say that
times it broke before a mechanic discovered that I lost money on that case.
the real cause was a bent drive shaft. Because the Seldom have behavior therapists considered the
problem appeared to be a function of condition- alternative, but there are effective means to modify
ing, a counterconditioning approach was deemed our behavior without changing the consequences

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14 Chapter 1

themselves. Modifying our internal responses to existential, and humanistic traditions. These
external consequences without changing those con- psychotherapy systems focus primarily on the sub-
sequences will be called reevaluation. jective aspects of the individual—the processes
A very shy man continued to desire a relation- occurring within the skin of the human. This
ship with a woman but avoided asking anyone out perspective on the individual finds greater potential
because of his anticipation that he would be for inner-directed changes that can counteract some
rejected. After several intensive discussions in psy- of the external pressures from the environment.
chotherapy, he began to accept that when a woman The processes of conditional stimuli and con-
turns down a date, it is a statement about her and tingency control represent the core of action ther-
not about him. We do not know whether she is apies, including those in the behavioral, cognitive,
waiting for someone else to ask her out, whether and systemic traditions. These psychotherapy sys-
she doesn’t like mustaches, whether she is in a com- tems focus primarily on the external and environ-
mitted relationship, or whether she doesn’t know mental forces that set limits on the individual’s
him well enough—we simply don’t know what her potential for inner-directed change. These pro-
saying no says about him. After reevaluating how he cesses are what the existentialists would call the
would interpret being turned down for a date, more objective level of the person.
the fellow began asking out women, even though Our integrative, transtheoretical model sug-
he was rejected on his first request for a date. The gests that to focus only on the awareness processes
external consequences of his behavior were the of consciousness, catharsis, and choice is to act as
same, but he reevaluated their personal meaning. if inner-directedness is the whole picture and to
ignore the genuine limits the environment places
on individual change. On the other hand, the
Initial Integration of action emphasis on the more objective, environ-
Processes of Change mental processes selectively ignores our potential
A summary of these processes of change is pre- for inner, subjective change.
sented in Table 1.3. The processes of consciousness An integrative model posits that a synthesis of
raising, catharsis, and choosing represent the heart both awareness and action processes provides
of the listed traditional insight or awareness more balanced and effective psychotherapy that
psychotherapies, including the psychoanalytic, moves along the continuous dimensions of inner

Table 1.3 Change Processes at Experiential and Environmental Levels


A W A R E N E S S O R I N SI G HT T H E R A P I E S A C T IO N O R B E H A V IO R A L T HE R A P I ES
Consciousness raising Conditional stimuli
Experiential level: feedback Experiential level: counterconditioning
Environmental level: education Environmental level: stimulus control
Catharsis Contingency control
Experiential level: corrective emotional experiences Experiential level: reevaluation
Environmental level: dramatic relief Environmental level: contingency management
Choosing
Experiential level: self-liberation
Environmental level: social liberation

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Defining and Comparing the Psychotherapies 15

to outer control, subjective to objective function- formal content (Held, 1991). Other systems, such
ing, and self-initiated to environmental-induced as Adlerian, existential, and culture-sensitive thera-
changes. Integrating the change processes afford pies, which adopt change processes from other
a more complete picture of humans by accepting therapy systems, primarily address the content of
our potential for inner change while recognizing therapy. Many systems of therapy differ primarily
the limits that environments and contingencies in their content, while agreeing on the change
place on such change. In Chapter 17, we will sum- processes.
marize the research evidence for these processes of Put differently, theories of personality and
change and our transtheoretical model. psychopathology tell us what needs to be changed;
Before leaving the processes of change, we theories of process tell us how change occurs.
would offer two additional comments about them. Because psychotherapy systems espouse many
First, please do not confuse the change processes more differences regarding the content of therapy,
with components of specific therapy systems. Con- it is more difficult to bring order and integration to
sciousness raising, contingency control, and the this fragmented field. A refreshing guide is Maddi’s
other processes are not methods suggested by (1996) comparative model for personality theories.
specific theories. Rather, they are generic change We have adapted parts of Maddi’s model in syn-
strategies that cut across many theories. Second, thesizing and prioritizing the vast array of
the names of many of the change processes are content—the what—in psychotherapy.
probably new to you. But rest assured that you Most systems of therapy assume a conflict view
will become familiar and comfortable with them of personality and psychopathology. Some conflict-
as you move through the remainder of the book. oriented systems believe psychopathology results
from conflicts within the individual. For these, we
shall use the term intrapersonal conflicts, indicating
Therapeutic Content that the conflicts are competing forces within the
The processes of change are the distinctive contri- person, such as a conflict between desires to be inde-
butions of a system of psychotherapy. The content pendent and fears of leaving home. Other therapy
to be changed in a particular therapy system is systems focus on interpersonal conflicts, such as
largely a carryover from that system’s theory of chronic disagreements between a woman who likes
personality and psychopathology. Many books pur- to save money and a man who likes to spend money.
portedly focusing on psychotherapy frequently Another group of therapies focuses primarily on the
confuse content and process. They wind up exam- conflicts that occur between an individual and soci-
ining the content of therapy, with little explanation ety. We shall call these individuo-social conflicts; an
about the change processes. As a consequence, they example is the tension of an individual who wants to
are actually books on theories of personality rather live an openly gay life but is afraid of the ostracism
than theories of psychotherapy. that may result from society’s bias against homosex-
The distinction between process and content in uality. Finally, an increasing number of therapies are
psychotherapy is fundamental. As we shall see, psy- concerned with helping individuals go beyond con-
chotherapy systems without theories of personality flict to attain fulfillment.
are primarily process theories and have few prede- In our integrative model, we assume that
termined concepts about the content of therapy. patients’ dysfunctions emanate from conflicts at
Behavioral, integrative, systemic, and solution- different levels of personality functioning. Some
focused theories attempt to capitalize on the unique patients express intrapersonal conflicts, others evi-
aspects of each case by restricting the imposition of dence interpersonal conflicts, and still others are

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16 Chapter 1

in conflict with society. Some clients have resolved and relationship disorders—are most profitably
their principal conflicts and turn to psychotherapy conceptualized as intra- or interpersonal conflicts.
with questions as to how they can best create a Thus, we expect disagreement over our assign-
more fulfilling existence. ment of problems to a particular level of person-
Because different patients are troubled at dif- ality functioning.
ferent levels of functioning, we will compare the Any viable theory of personality can reduce all
psychotherapy systems in terms of how each psychopathology to a single level of functioning that
conceptualizes and treats typical problems at each the theory assumes to be critical. For example, an
level of conflict. At the intrapersonal level, we will intrapersonal theory can marshal a convincing case
examine how each therapy system addresses con- that sexual disorders are primarily due to conflicts
flicts over anxiety and defenses, self-esteem, and per- within individuals, such as conflicts between sexual
sonal responsibility. At the interpersonal level, we desires and performance anxieties. By contrast, an
will consider problems with intimacy and sexuality, individuo-social theory could summon a coherent
communication, hostility, and interpersonal control. argument that sexual disorders are primarily due
At the individuo-social level, we will compare their to the inevitable tensions between an individual’s
perspectives on adjustment versus transcendence sexual desires and society’s sexual prohibitions.
and impulse control. At the level of transcending Our integrative assumption is that a comparative
conflicts to fulfillment, we will examine the ultimate analysis of psychotherapies will demonstrate that
questions of meaning in life and the ideal person that particular systems have been especially effective in
would emerge from successful psychotherapy. conceptualizing and treating problems related to
Table 1.4 summarizes the therapeutic content their level of personality theory.
occurring at different levels of personality. In comparing psychotherapy systems, we will
Honest differences abound over whether discover that a theory’s level of personality will largely
particular problems—such as addictive, mood, dictate the number of people in the consulting room
and the focus of the therapeutic transaction. If a
theory focuses on intrapersonal functioning, then
Table 1.4 Therapeutic Content at Different
Levels of Personality
the therapy is much more likely to work solely with
the individual, because the basic problem is assumed
to lie within the individual. If, by contrast, a theory
1. Intrapersonal conflicts
concentrates on interpersonal functioning, then it
a. Anxieties and defenses
b. Self-esteem problems is more likely to involve two or more persons in
c. Personal responsibility conflict, such as a couple or family members.
2. Interpersonal conflicts Psychotherapies focusing on individuo-social
a. Intimacy and sexuality conflicts will work to change the client, if the thera-
b. Communication pist’s values are on the side of mainstream society.
c. Hostility
For example, in working with a pedophile who
d. Control of others
3. Individuo-social conflicts experiences no inner conflict over having sexual
a. Adjustment versus transcendence relations with children, a therapist will try to change
b. Impulse control the client, in that the therapist’s values converge
4. Beyond conflict to fulfillment with society’s values that this sexual behavior is
a. Meaning in life unacceptable. However, if the therapist’s values are
b. The ideal person
on the side of the individual in a particular conflict,

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Defining and Comparing the Psychotherapies 17

such as a Hispanic/Latino wanting to freely express then, we will examine which level of personality
his ethnicity in a White-dominated workplace, then functioning is emphasized and whether such an
a therapist is far more likely to work for the client emphasis leads to working primarily with an indi-
and to support movements that are transforming vidual, with two or more people together, or with
society. In comparing psychotherapy systems, groups seeking to alter society.

The Case of Mrs. C


Psychotherapy systems are not merely static George was, understandably, becoming
combinations of change processes, theoretical increasingly impatient with many of his wife’s
contents, and research studies. The systems are, related symptoms. She would not let anyone
first and foremost, concerned with serious disor- wear a pair of underwear more than once and
ders afflicting real people. In comparing systems, often wouldn’t even let these underwear be
it is essential to picture how the psychotherapies washed. There were piles of dirty underwear in
conceptualize and treat the presenting problems each corner of the house. When we asked her
of an actual client. The client selected for compar- husband to gather up the underwear for the laun-
ative purposes is Mrs. C. dry, we asked him to count them, but he quit
Mrs. C is a 47-year-old mother of six children: counting after the thousandth pair. He was
Arlene, 17; Barry, 15; Charles, 13; Debra, 11; Ellen, depressed to realize that he had more than
9; and Frederick, 7. Without reading further, an $1,000 invested in once-worn underwear.
astute observer might be able to discern Mrs. Other objects were scattered around the house,
C’s personality configuration. The orderliness of because a fork or a can of food dropped on the
children named alphabetically and of childbirths floor could not be retrieved in Mrs. C’s presence.
every 2 years are consistent with obsessive- She felt it was contaminated. Mrs. C had been
compulsive disorder (OCD). doing no housework—no cooking, cleaning, or
For the past 10 years, Mrs. C has been plagued washing—for years. One of her children described
by compulsive washing. Her baseline charts, in the house as a “state dump,” and my (JOP) visit to
which she recorded her behavior each day before the home confirmed this impression.
treatment began, indicated that she washed her Mrs. C did work part-time. What would be a
hands 25 to 30 times a day, 5 to 10 minutes at likely job for her? Something to do with washing,
a time. Her daily morning shower lasted about of course. In fact, she was a dental technician,
2 hours with rituals involving each part of her which involved washing and sterilizing all of the
body, beginning with her rectum. If she lost track dentist’s equipment.
of where she was in her ritual, then she would As if these were not sufficient concerns, Mrs. C
have to start all over. A couple of times this had had become very unappealing in appearance. She
resulted in her husband, George, going off to had not purchased a dress in 7 years, and her clothes
work while his wife was in the shower only to were becoming ragged. Never in her life had she
return 8 hours later to find her still involved in the been to a beautician and now she seldom combed
lengthy ritual. her own hair. Her incessant washing of her body
To avoid lengthy showers, George had begun and hair led to a presentation somewhere between
helping his wife keep track of her ritual, so that at a prune and a boiled lobster with the frizzies.
times she would yell out, “Which arm, George?” Mrs. C’s washing ritual also entailed walking
and he would yell back, “Left arm, Martha.” His around the house nude from the waist up as she
participation in the shower ritual required George went from her bedroom bath to the downstairs
to rise at 5:00 A.M. in order to have his wife out of bath to complete her washing. This was especially
the shower before he left for work at 7:00 A.M. upsetting to Mr. C because of the embarrassment
After 2 years of this schedule, George was ready to it was producing in their teenage sons. The
explode. children were also upset by Mrs. C’s frequently
(continued)

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18 Chapter 1

nagging them to wash their hands and change strain. During the first 13 years of their marriage,
their underwear, and she would not allow them Mrs. C had demonstrated some of her obsessive-
to entertain friends in the house. compulsive traits, but never to such a degree that
Consistent with OCD features, Mrs. C was a Mr. C considered them a problem. Mr. C and the
hoarder: she had two closets filled with hundreds older children recalled many happy times with Mrs.
of towels and sheets, dozens of unused earrings, C, and they seemed to have kept alive the warmth
and her entire wardrobe from the past 20 years. and love that they had once shared with this now
She did not consider this hoarding a problem preoccupied person.
because it was a family characteristic, which she Mrs. C hailed from a strict, authoritarian, and sex-
believed she inherited from her mother and from ually repressed Catholic family. She was the middle
her mother’s mother. of three girls, all of whom were dominated by a
Mrs. C also suffered from a sexual arousal disor- father who was 6 feet, 4 inches tall and weighed
der; in common parlance, she was “frigid.” She said 250 pounds. When Mrs. C was a teenager, her father
she had never been sexually excited in her life, but would wait up for her after dates to question her
at least for the first 13 years of her marriage she was about what she had done; he once went so far as to
willing to engage in sexual relations to satisfy her follow her on a date. He tolerated absolutely no
husband. However, in the past 2 years they had expression of anger, especially toward himself, and
had intercourse just twice, because sex had become when she would try to explain her point of view
increasingly unpleasant for her. politely, he would often tell her to shut up. Mrs. C’s
To complete the list, Mrs. C was currently clini- mother was a cold, compulsive woman who repeat-
cally depressed. She had made a suicide gesture edly regaled her daughters about her disgust with
by swallowing a bottle of aspirin because she had sex. She also frequently warned her daughters
an inkling that her psychotherapist was giving up on about diseases and the importance of cleanliness.
her and her husband was probably going to commit In developing a psychotherapy plan for Mrs. C,
her to a psychiatric hospital. one of the differential diagnostic questions was
Mrs. C’s compulsive rituals revolved around an whether Mrs. C was plagued with a severe
obsession with pinworms. Her oldest daughter had obsessive-compulsive disorder or whether her
come home with pinworms 10 years earlier during a symptoms were masking a latent schizophrenic
severe flu epidemic. Mrs. C had to care for a sick process. A full battery of psychological testing
family while pregnant, sick with the flu herself, and was completed, and the test results were consis-
caring for a demanding 1-year-old child. Her physi- tent with those from previous evaluations that
cian told her that to avoid having the pinworms had found no evidence of a thought disorder or
spread throughout the family, Mrs. C would have other signs of psychotic processes.
to be extremely careful about the children’s under- Mrs. C had previously undergone a total of 6
wear, clothes, and sheets and that she should boil years of mental health treatment, and throughout
all of these articles to kill any pinworm eggs. Mr. C this time the clinicians had always considered her
confirmed that both she and her husband were problems to be severely neurotic in nature.
rather anxious about a pinworm epidemic in the The only time schizophrenia was offered as a
home and were both preoccupied with cleanliness diagnosis was after some extensive individual
during this time. However, Mrs. C’s preoccupation psychotherapy failed to lead to any improvement.
with cleanliness and pinworms continued even The consensus in our clinic was that Mrs. C was
after it had been confirmed that her daughter’s demonstrating a severe OCD that was going to be
pinworms were gone. extremely difficult to treat.
The C couple acknowledged a relatively good At the end of the following chapters, we will
marriage before the pinworm episode. They had see how each of the psychotherapy systems
both wanted a sizable family, and Mr. C’s income as might explain Mrs. C’s problems and how their
a business executive had allowed them to afford a treatment might help her to overcome these
large family and comfortable home without financial devastating preoccupations.

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Defining and Comparing the Psychotherapies 19

Key Terms Zeig, J. K., & Munion, W. M. (Eds.). (1990). What


is psychotherapy? Contemporary perspectives.
action therapies expectation
San Francisco: Jossey-Bass.
awareness (insight) feedback
JOURNALS: American Journal of Orthopsychiatry;
therapies Hawthorne effect
American Journal of Psychiatry; American Journal
catharsis integration
of Psychotherapy; Archives of General Psychiatry;
choosing placebo
Brief Treatment and Crisis Intervention; British
common (nonspecific) processes of change
Journal of Psychotherapy; Clinical Case Studies;
factors psychotherapy
Clinical Psychology and Psychotherapy; Clinical
consciousness raising reevaluation
Social Work Journal; Counselling and Psychotherapy
contingency self-liberation
Research; International Journal for the Advance-
management social liberation
ment of Counseling; Journal of Child and Adolescent
corrective emotional specific factors
Psychotherapy; Journal of Clinical Psychology: In
experiences stimulus control
Session; Journal of College Student Psychotherapy;
counterconditioning theory
Journal of Consulting and Clinical Psychology;
dramatic relief therapeutic content
Journal of Contemporary Psychotherapy; Journal of
education transtheoretical
Counseling and Development; Journal of Counseling
Psychology; Journal of Infant, Child, and Adolescent
Recommended Readings Psychotherapy; Journal of Mental Health Counsel-
Castonguay, L. G., & Beutler, L. E. (Eds.). (2006). ing; Pragmatic Case Studies in Psychotherapy;
Principles of therapeutic change that work. New Journal of Psychosocial Nursing and Mental Health
York: Oxford University Press. Services; Journal of Psychotherapy in Independent
Frank, J. D., & Frank, J. (1991). Persuasion and Practice; Psychotherapy; Psychotherapy and Psy-
healing (3rd ed.). Baltimore: Johns Hopkins chosomatics; Psychotherapy Networker; Psychother-
University Press. apy Patient; Psychotherapy Research; The Scientific
Lambert, M. J. (Ed.). (2013). Handbook of psycho- Review of Mental Health Practice; Voices: The Art
therapy and behavior change (6th ed.). New and Science of Psychotherapy.
York: Wiley.
Nathan, P. E., & Gorman, J. M. (Eds.). (2007). Treat-
Recommended Websites
ments that work (3rd ed.). New York: Oxford American Association for Marriage and Family
University Press. Therapy:
Norcross, J. C. (Ed.). (2011). Psychotherapy www.aamft.org
relationships that work (2nd ed.). New York: American Counseling Association:
Oxford University Press. www.counseling.org
Norcross, J. C., VandenBos, G. R., & Freedheim, American Psychiatric Association:
D. K. (Eds.). (2010). History of psychotherapy: www.psych.org/
Continuity and change (2nd ed.). Washington, American Psychiatric Nurses Association:
DC: American Psychological Association. www.apna.org/
Maddi, S. R. (1996). Personality theories: A com- American Psychological Association:
parative analysis (6th ed.). Pacific Grove, CA: www.apa.org/
Brooks/Cole. National Association of Social Workers:
Prochaska, J. O., Norcross, J. C., & DiClemente, www.naswdc.org/
C. C. (1995). Changing for good. New York: Society for Psychotherapy Research:
Avon. www.psychotherapyresearch.org/

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CHAPTER 2
Psychoanalytic
Therapies

National Library of Medicine


Sigmund Freud

Karen was to be terminated from her nursing father had a heart attack and had to be rushed to
program if her problems were not resolved. She the hospital. For a while it looked as though her
had always been a competent student who father was going to pull through, and Karen
seemed to get along well with peers and patients. began enjoying her daily visits to see him. During
Now, since beginning her rotation on 3 South, a one of these visits, her father clutched his chest in
surgical ward, she was plagued by headaches and obvious pain and told Karen to get a nurse. She
dizzy spells. remembered how helpless she felt when she could
Of more serious consequence were the two not find a nurse, though she did not recall why this
medical errors she had made when dispensing was so difficult. Her search seemed endless, and
medications to patients. She realized that these when she finally found a nurse, her father was
errors could have proved fatal and was as dead.
concerned as her nursing faculty that she I don’t know why, but I asked Karen the name
understand why such problems had begun in this of the ward on which her father had died. She
final year of her education. Karen knew she had paused and thought, and then to our surprise, she
many negative feelings toward the head nurse on blurted out, “3 South.” She cried heavily as she
3 South, but she did not believe these feelings could expressed how confused she was and how angry
account for her current dilemma. she felt toward the nurses on that ward for not
After a few weeks of psychotherapy, I (JOP) being more available, although she thought they
realized that one of Karen’s important conflicts had been involved with another emergency. After
revolved around the death of her father when she weeping, shaking, and expressing her rage, Karen
was 12 years old. Karen had just gone to live with felt calm and relaxed for the first time in months.
her father after being with her mother for 7 years. My psychoanalytic supervisor said her symptoms
She remembered how upset she was when her would disappear, and sure enough they did. He

20

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Chapter 2 Psychoanalytic Therapies 21

knew we would have to go much deeper into what work and commitment would result in recogni-
earlier conflicts this adolescent experience tion and financial success. He had never intended
represented, but for now, Karen’s problems in the to practice medicine, but he found the rewards of
nursing program were relieved. research to be quite restricted and the opportu-
nities for academic advancement for a Jew to be
A Sketch of Sigmund Freud limited. Finally, after marrying at age 30, he began
Early in his career, Sigmund Freud (1856–1939) to develop a rewarding private practice. Yet Freud
was quite impressed by the way some of his was willing to risk his hard-earned financial suc-
patients seemed to recover following cathartic cess to communicate to his colleagues what his
recollections of an early trauma. But he soon dis- work with patients had convinced him of: The
covered that more profound, lasting changes basis of neurosis was sexual conflict—or, more
required changes in his own approach. Over specifically, the conflict between the id’s instinc-
time, he switched from hypnosis, to catharsis, tive desires and society’s retribution for the direct
and finally to a dynamic analysis that radically expression of those desires.
increased not only the consciousness of his clients Freud’s profound insights were met with pro-
but also the consciousness of his culture. fessional insults, and his private practice rapidly
Freud’s genius has been admired by many, but declined. For months he received no new referrals.
he complained throughout his life about not hav- For years he had to rely on his inner courage to
ing been given a bigger brain (Jones, 1955). Freud continue his lonely intellectual pursuits without a
himself believed that his outstanding attribute was colleague to share his insights. During this same
his courage. Certainly it took tremendous daring period of the 1890s, he began his painful self-
and inquisitiveness to descend into the uncharted analysis, in part to overcome some neurotic symp-
depths of humanity and then to declare to a strict toms and in part to serve as his own subject in his
Victorian culture what he had discovered. Freud studies of the unconscious. Surprisingly, Freud
once observed that scientific inquisitiveness is a was not particularly discouraged by his profes-
derivative of the child’s sexual curiosity, the subli- sional isolation. He was able to interpret the oppo-
mation of anxiety-laden questions of “Where do I sition he met as part of the natural resistance to
come from?” and “What did my parents do to taboo ideas.
produce me?” These questions exercised a partic- Finally, in the early 1900s, Freud’s risky work
ular fascination for Freud and later assumed a began to be recognized by scholars, such as the
central position in his theory of personality dying William James, as the system that would
because of his own intricate family constellation. shape 20th-century psychology. Shape it he did,
His mother was half his father’s age, his two along with the incredibly brilliant group of col-
half-brothers were as old as his mother, and he leagues who joined the Vienna Psychoanalytic
had a nephew older than he (Gay, 1990). He was Society. Most of these colleagues contributed to
the prized “golden child” born into a lower-class the development of psychoanalysis, although Freud
Jewish family. insisted that as the founder he alone had the
For years he struggled for success. From his right to decide what should be called psychoanal-
entry in 1873 into the University of Vienna at age ysis. This led some of the best minds, including
17, to his work as a research scholar in an institute Alfred Adler and Carl Jung, to leave the Psycho-
of physiology, to earning his MD in 1891 and his analytic Society to develop their own systems.
residency in neurology, he expected that his hard Freud’s insistence may also have set a precedent

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22 Chapter 2

for a dogmatism that relied more on authority • The structural, which revolves around the
than on evidence in revising psychotherapy theo- persistent functional units of the id, ego, and
ries. Freud himself, however, continued through- superego
out his lifetime to be critical of his own theories • The adaptive, implied by Freud and developed
and would painfully discard selected ideas if expe- by Hartmann (1958), which involves the
rience contradicted them. inborn preparedness of the individual to inter-
Success did not diminish Freud’s commitment act with an evolving series of environments
to his scholarly work or to his patients. He worked
We will focus primarily on his dynamic, genetic,
an 18-hour day that began with patients from 8:00
and structural perspectives because these are most
A.M. until 1:00 P.M., a break for lunch and a walk
directly related to his theories of psychopathology
with his family, patients again from 3:00 P.M.
and psychotherapy.
until 9:00 or 10:00 P.M., dinner and a walk with
From all these perspectives, psychoanalysis is a
his wife, followed by correspondence and books
conflict model leading to compromise formation.
until 1:00 or 2:00 A.M. His dedication to his
The mind is embroiled in constant conflict between
work was remarkable, although it is also striking
conscious and unconscious forces, between what the
that this man, dedicated to understanding sex and
individual immediately desires and what the society
its vicissitudes, left little time or energy for his
deems acceptable. In the end, mature human behav-
own sexuality.
ior represents a compromise between these warring
Having emigrated from Vienna to London
factions. The id will demand instant gratification of
before World War II, Freud continued to work
food, sex, bodily relief, and adoration, but the super-
despite suffering from the ravages of bone cancer.
ego will deny these earthly and immediate pleasures.
At age 85 he died of probable physician-assisted
So we invariably compromise—we wait until the
suicide (Gay, 1988), leaving the most comprehen-
acceptable time and place to eat, defecate, have
sive theory of personality, psychopathology, and
sex, and secure undivided attention. We mentally
psychotherapy ever developed.
compromise all day long.
Freud believed that the basic dynamic forces
Theory of Personality motivating personality were Eros (life and sex) and
Thanatos (death and aggression). These comple-
Freud’s theory of personality was as complex as he
mentary forces are instincts that possess a somatic
was. He viewed personality from six different
basis but are expressed in fantasies, desires, feelings,
perspectives:
thoughts, and most directly, actions. The individual
• The topographic, which involves conscious constantly desires immediate gratification of sexual
versus unconscious modes of functioning and aggressive impulses. The demand for immediate
• The dynamic, which entails the interaction gratification leads to inevitable conflicts with social
and conflict among psychic forces rules that insist on some control over sex and
• The genetic, which concerns the origin and aggression if social institutions, including families,
development of psychic phenomena through are to remain stable and orderly. The individual is
the oral, anal, phallic, latency, and genital forced to develop defense mechanisms or inner
stages controls that restrain sexual and aggressive impulses
• The economic, which involves the distribu- from being expressed in uncontrollable outbursts.
tion, transformation, and expenditure of psy- Without these defenses, civilization would be
chological energy reduced to a jungle of raping, ravaging beasts.

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Chapter 2 Psychoanalytic Therapies 23

Defense mechanisms keep individuals from defense mechanisms too restrictive, that neurotic
becoming conscious of basic inner desires to symptoms begin to emerge.
rape and ravage. The assumption here is that if Although all personalities revolve around
individuals are unaware of such desires, they can- unconscious conflicts, people differ in the particu-
not act on them, at least not directly. The defenses lar impulses, anxieties, and defenses in conflict.
serve to keep the individual out of danger of pun- The differences depend on the particular stage of
ishment for breaking social rules. Defenses also life at which an individual’s conflicts occur. For
keep us from experiencing the anxiety and guilt Freud, the stages of life are determined primarily
that would be elicited by desires to break parental by the unfolding of sexuality in the oral, anal,
and social rules. For defenses to work, the person phallic, and genital stages, as summarized in
must remain unconscious of the very mechanisms Table 2.1. Differences in experiences during each
being used to keep sexual and aggressive impulses of these stages are critical in determining the
from coming into awareness. Otherwise, the indi- prominent traits and personalities that ensue.
vidual is faced with a dilemma akin to keeping a
secret from a 3-year-old child who knows you Oral Stage
have a secret—the constant badgering to know During the first 18 months of life, the infant’s sex-
what is being hidden can be overwhelming. ual desires are centered in the oral region. The
The core of the Freudian personality is the child’s greatest pleasure is to suck on a satisfying
unconscious conflict among sexual and aggressive object, such as a breast. The instinctual urges are to
impulses, societal rules aimed at controlling those passively receive oral gratification during the oral-
impulses, and the individual’s defense mechan- incorporative phase and to more actively take in
isms controlling the impulses in such a way as to oral pleasure during the oral-aggressive phase.
keep guilt and anxiety to a minimum while allow- Sucking on breasts or bottles, putting toys, fingers,
ing some safe, indirect gratification (Maddi, 1996). or toes in the mouth, and even babbling are repre-
The difference between a normal personality and a sentative actions a child takes to receive oral grati-
neurotic one, of course, is simply a matter of fication. As adults, we can appreciate oral sexuality
degree. It is when the unconscious conflicts through kissing, fellatio, cunnilingus, or oral cares-
become too intense, too painful, and the resultant sing of breasts and other parts of the body.

Table 2.1 Summary of Freudian Psychosexual Stages


L I B ID I N A L L IB I D I NA L
STAGE AG E ZONE OBJECT DEVELOPMENTAL CHALLENGES
Oral Birth to 1 Mouth, Mother’s breast, Passive incorporation of all good through mouth;
thumb own body autoerotic sensuality
Anal 2–3 Anus, bowels Own body Active self-soothing and self-mastery; passive
submission
Phallic 3–6 Genitals Mother for boy Oedipus and electra conflicts; identification with
Father for girl same-sex parent; ambivalence of love relationships
Latency 6–11 None Largely Repression of pregenital forms of libido; learning
repressed shame and disgust for inappropriate love objects
Genital 12+ Genital Sexual partner Sexual intimacy and reproduction
primacy
SOURCE: Table content courtesy of Dr. Robert N. Sollod.

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24 Chapter 2

The infant’s oral sexual needs are intense and Fixation due to either deprivation or overgra-
urgent, but the child is dependent on parental fig- tification leads to the development of an oral per-
ures to provide the breasts or bottles necessary for sonality that includes the following bipolar traits:
adequate oral gratification. How the parents pessimism/optimism, suspiciousness/gullibility,
respond to such urgent needs can have a marked self-belittlement/ cockiness, passivity/manipula-
influence on the child’s personality. Parents who tiveness, and envy/admiration (Abraham, 1927;
are either too depriving or too indulgent can make Glover, 1925).
it difficult for a child to mature from the oral Besides these traits, fixation at the oral stage
stage to later stages of personality development. brings a tendency to rely on more primitive
With deprivation, the child can remain fixated defenses when threatened or frustrated. Denial
at the oral stage: Energies are directed primarily derives from having to finally close one’s eyes and
toward finding the oral gratification that was in go to sleep as a way of shutting out the unmet oral
short supply during childhood. Deprivation likely needs. On a cognitive level, this defense involves
leads to pessimism; the mental set from the start is closing off one’s attention to threatening aspects
that one’s needs will not be met. Suspiciousness of the world or self. Projection has a bodily basis
comes from a feeling that if parents cannot be in the infant’s spitting up anything bad that is taken
trusted, there are few whom one can trust. Self- in and making the bad things part of the environ-
belittlement derives from an image of having been ment. Cognitively, projection involves perceiving in
awful, if one’s folks could not care less. Passivity the environment those aspects of oneself that are
follows from the repeated conclusion that no mat- bad or threatening. Incorporation on a bodily level
ter how hard one kicks or cries, parents will not includes taking in food and liquids and making
care. Envy is an inner craving to have the traits these objects an actual part of oneself. Cognitively,
that would make one lovable enough for people to this defense involves making images of others part
provide special care. of one’s own image.
With overindulgence, the child can also The well-defended oral personality is not con-
become fixated at the oral stage but energies are sidered pathological but rather an immature person,
directed toward trying to repeat and maintain the like all of the pregenital personalities we shall dis-
gratifying conditions. Overindulgence typically cuss. There certainly are many people who are overly
leads to preverbal images of the world and oneself optimistic, gullible, and cocky without considering
that result in traits on the right side of each pair. themselves or being considered by others as patho-
Optimism comes from an image that things have logical. Likewise, there are many people who believe
always been great, so there is no reason to expect it is wise to be suspicious, expect too little from this
that they will not continue to be so. Gullibility world, and perceive selfishness in others. These
derives from the experience of finding early in people are also rarely judged to be pathological.
life that whatever one received from people was
good, so why not swallow whatever people say Anal Stage
now. Cockiness ensues from having been some- In a society that assigned functions of the anus to
thing super for parents to dote on. Manipulative- the outhouse and gagged at the sight or smell of
ness relates to the mental set that comes from the products of the anus, it must have been ghastly
getting parents to do whatever one wants. Finally, to think that a physician like Freud believed that
admiration results from feelings that other people this dirty area could be the most intense source
are as good as oneself and one’s parents. of pleasure for children between the ages of

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Chapter 2 Psychoanalytic Therapies 25

18 months and 3 years. Even in our ultraclean anal personality dominated by holding-on tenden-
society, many people still find it difficult to imag- cies. The child was frequently forced to let go when
ine that their anuses can be a source of sensuous the child didn’t want to let go. Then when the child
satisfaction. In the privacy of their own bath- did let go, what did the parents do with the gift to
rooms, however, many people admit to themselves them? Just flushed it down the toilet. Now such indi-
that the releasing of the anus can be the “pause viduals react as if they will be damned before they
that refreshes.” As one of our constipated patients again let go against their will. So these personalities
said, it is his most pleasurable time of the week. hold tightly to money (stinginess), their feelings
Children in the anal stage are apt to learn that (constrictedness), and their own way (stubborn-
urges to play with the anus or its products bring ness). Again, a well-defended anal character is con-
them into conflict with society’s rules of cleanliness. sidered immature, not pathological; anal people
Even the pleasure of letting go of the anus must typically take pride in their neatness and punctuality
come under the parental rules for bowel control. and even may be admired by others for these traits.
Before toilet training, the child was free to release Overindulgent parents who are lackadaisical
the sphincter muscles immediately as soon as about toilet training more likely encourage a child
tension built up in the anus. But now society, as to just let go whenever any pressure is felt. This
represented by the parents, demands that the child route to an anal personality results in people who
control the inherent desire for immediate tension easily let go of money (wasteful), let go of feelings
reduction. In Erikson’s (1950) terms, the child must (explosiveness), and let go of their wills (acquies-
now learn to hold on and then to let go. Not only cent). Lack of concern with such a basic social rule
that, but the child must also learn the proper tim- as proper toilet training is assumed to encourage a
ing of holding on and letting go. If the child lets go child to be generally messy, dirty, tardy, and vague.
when it is time to hold on—trouble; and if the child For Freud, conflicts during the anal stage
holds on when it is time to let go—more trouble! resulted in the development of particular defenses.
The anal stage involves all kinds of power Reaction formation, or behaving the opposite of
struggles, not solely those associated with toilet what one truly desires, develops first as a reaction
training. What to eat, when to sleep, how to to being very clean and neat, as the parents
dress, whom to kiss—all of these struggles during demand, rather than expressing anal desires to be
the “terrible twos” represent the child’s efforts to messy. Undoing, or atoning for unacceptable
negotiate societal and parental rules and to assert desires or actions, occurs when the child learns
themselves. The child is most likely to become that it is safer to say, “I’m sorry I let go in my
conflicted and fixated at the anal stage if the care- pants,” rather than saying, “I like the warm feeling
takers again are either too demanding or overin- of poo in my pants.” Isolation, or not experiencing
dulgent. The bipolar traits that develop from anal the feelings that would go with the thoughts,
fixation are stinginess/overgenerosity, constricted- emerges in part when the child has to think about
ness/expansiveness, stubbornness/acquiescence, an anal function as a mechanical act rather than an
orderliness/messiness, punctuality/tardiness, pre- instinctual experience. Intellectualization, or the
cision/vagueness (Fenichel, 1945; Freud, 1925). process of neutralizing affect-laden experiences by
Freud was concerned with overdemanding or talking in intellectual or logical terms, is partly
overcontrolling parents who forced toilet training related to such experiences as talking about the
too quickly or too harshly. The individual receiving regularity of bowel movement as being soothing
this caretaking style was more likely to develop an to one’s gastrointestinal system.

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26 Chapter 2

Phallic Stage them because they lacked a penis, rather than vice
The name of this stage, which refers specifically to versa, has always been a mystery. For example, a
male genitalia, reflects Freud’s problem of theoriz- non-Freudian colleague tells the story of his
ing too much about men and then overgeneralizing 5-year-old daughter’s discovery of her 3-year-old
to women. For both, the sexual desires during the brother’s penis. Rather than envying his penis, she
phallic stage are thought to be focused on the gen- went yelling, “Mama, Mama, Andy’s ’gina fell out.”
italia. From ages 3 to 6, both sexes are fascinated by Nevertheless, and in spite of understandable
their own genitalia and increase their frequency of protest by enlightened women, many classical psy-
masturbation. They are also very interested in the choanalysts still assume that girls initially envy
opposite sex and engage in games of “doctor and penises, that they become enraged toward the
patient” in which they examine each other to satisfy mother, and that they turn their desires to the father
their sexual curiosity. in part to be able to at least share his phallus.
The conflict for youngsters is not with their Again, the critical issue is how the parents
genital desires, because theoretically they and respond to the genital desires of their children.
other kids could satisfy these desires. The conflict Both overindulgence and overrejection can
is over the object of their sexual desires, which in produce fixations at the phallic stage, resulting in
this stage is the parent of the opposite sex. formation of the following bipolar traits:
The boy’s desire for his mother is explained as vanity/self-hatred, pride/humility, stylishness/
a natural outgrowth of the mother’s serving as the plainness, flirtatiousness/shyness, gregariousness/
major source of gratification for his previous needs, isolation, brashness/bashfulness.
especially the need for sucking. Therefore, the son Overrejection, in which parents give their
will naturally direct his genital sexual desires ini- opposite-sex children little affection, few hugs or
tially toward his mother and would expect her to kisses, and no appreciation of their attractiveness,
gratify him. The oedipal conflict, of course, is that is likely to lead to the following self-image: “I must
the father already has the rights and privileges of be hateful if my parent wouldn’t even hug or kiss
enjoying the mother. The son’s fear is that the me. Why flirt, dress stylishly, be outgoing or brash,
father might punish his rival by removing the or take pride in myself if the opposite sex is sure to
source of the problem—the son’s penis. This find me undesirable?” On the other hand, people
castration anxiety eventually causes the son to who had overindulgent parents, whether seductive
repress his desire for his mother, repress his hostile or actually incestuous, can more readily develop
rivalry toward his father, and identify with his feelings of vanity. They feel they must be really
father’s rules, in the hope that if he acts as his father something if daddy preferred them over mommy,
would have him act, he can avoid castration. or vice versa. The flirting, stylishness, pride, and
Why a girl ends up desiring her father rather brashness would all be based on maintaining an
than her mother is more difficult to explain, given image as the most desirable person in the world.
that the mother is presumed to be the main source Conflicts over sexual desires toward a parent
of instinctual gratification for daughters as well as are not solely due to how the parent reacts, how-
sons. Freud asserted that girls become hostile ever. The child must also defend against society’s
toward their mothers when they discover that basic incest taboo. These conflicts lead to repression
their mothers cheated them by not giving them a as the major defense against incestuous desires.
penis. Why Freud assumed that females would By becoming unaware even of fantasies about
conclude that there was something wrong with one’s opposite-sex parent, the youngster feels safe

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Chapter 2 Psychoanalytic Therapies 27

from incest and the consequent castration or Theory of Psychopathology


taboos that would accompany it. However, as with
Because all personalities contain some immaturity
all conflicted desires, the impulse is omnipresent
due to inevitable conflicts and fixations at pregen-
and can be kept at bay only by unconscious
ital stages, all of us are vulnerable to regressing
defenses.
into psychopathology. We are more vulnerable if
our conflicts and fixations occurred earlier in life,
Latency Stage
because we would be dependent on more imma-
In classical psychoanalytic theory, this stage ture defenses for dealing with anxiety. In addition,
involved no new unfolding of sexuality, but rather the more intense our pregenital conflicts are, the
was a stage in which the pregenital desires were more vulnerable we are, as more of our energy
largely repressed. Freud associated no new person- is bound up in defending against pregenital
ality development with the latency stage, believing impulses, and less energy is available for coping
that all pregenital personality formation had been with adult stresses. Well-defended oral, anal, phal-
completed by age 6. Latency was seen primarily as a lic, or mixed personalities may never break down
lull between the conflicted, pregenital time and the unless exposed to horrendous stress, which would
storm that was to reemerge with adolescence—the then lead to symptom formation and intensifica-
beginning of the genital stage. tion of immature defense mechanisms.
In more recent psychoanalytic formulations, Stressful events—such as the death of a loved
latency is a time for ego development and learning one, an offer of an affair, or a medical illness—
the social rules of being a citizen. These gains enable stimulate the impulse that individuals have been
the child to psychologically enter adolescence and to controlling all their lives. They react on an uncon-
navigate the genital stage when it hits. scious level to this current event as if it were a
repetition of a childhood experience, such as rejec-
Genital Stage tion by a parent or a desire for taboo sex. Their
In the genital stage, the libido reemerges—this infantile reactions lead to panic that their impulses
time in the genitals. Having largely completed may get out of control and that the punishment
the challenges of the phallic and latency stages, they have dreaded all their lives, such as separa-
the adolescent must now find appropriate objects tion or castration, will occur. These individuals
for sex (love) and aggression (work). feel that they are “falling apart”—their very per-
In Freudian theory, an individual does not sonality is threatened with disintegration. Like
progress to the genital stage without at least some children, they are terrified that their adult person-
conflict between instinctual desires and social ality will break down and that they will become
restraints. Some individuals will be fixated at the dominated by infantile instincts. These individuals
oral, anal, or phallic stage and will demonstrate reexperience at an unconscious level the same
the related personality type. Others will experience infantile conflicts that caused their personality
conflicts at each of the stages and will demonstrate a development and now threaten to cause their per-
mixed personality that combines traits and defenses sonality disintegration.
of each stage. But no one becomes a fully mature, In the face of such threats, the person is highly
genital character without undergoing a successful motivated to spend whatever energy is necessary
psychoanalysis. Because such a personality is the to keep impulses from coming into consciousness.
ideal goal of analysis, we will delay discussion of it This may translate into an exacerbation of previ-
until the section on this theory’s ideal individual. ous defenses to the point which they become

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28 Chapter 2

pathological. For example, a married woman who 3 South as if she were 12 years old. If her response
has been offered an affair and has an intense to 3 South was primarily on a conscious level, then
desire for taboo sex may rely more heavily on she could indeed have made such logical distinc-
repressing such desires. Soon she is entirely tions based on her conscious, secondary process.
fatigued and may show other symptoms of fatigue But unconscious responses like Karen’s follow
and depression, but at least she does not have the primary-process thinking, which is alogical.
energy to act on an affair even if she wanted to. Logical thinking includes reasoning from the
Although she constantly complains about her subjects of sentences, as in: (1) All men are mor-
fatigue, for her it is better to be tired than to be tals; (2) Socrates was a man; therefore, (3) Socrates
in terror of acting out her infantile desires. A was mortal. In primary process, reasoning fre-
woman who did not have such intense fixations quently follows the predicates of statements, so
and conflicts over taboo sex might simply decline that we think: (1) The Virgin Mary was a virgin;
the offer or might accept if she thought it was (2) I am a virgin; therefore, (3) I am the Virgin
worth the risks. Mary. Or in Karen’s case: (1) The ward where they
When a person overreacts to life’s events to let my father die was 3 South; (2) the ward where I
such an extent that symptoms develop, Freudians am now is 3 South; therefore, (3) this 3 South is
believe the symptoms are defending against unac- where they let my father die.
ceptable impulses and childish anxieties. In many When Karen responds on an unconscious
cases, the symptoms also serve as indirect expres- level, she does not systematically proceed through
sions of the person’s unacceptable wish. An exam- any reasoning process; rather, her primary-process
ple: Karen’s symptoms of headaches, dizziness, reaction is automatically alogical. Primary-process
and medical errors diverted her attention from responding is also atemporal, with no differentia-
emerging rage toward the nurses on 3 South and tion among past, present, and future. Therefore,
the accompanying anxiety. Her medical errors on an unconscious level, Karen’s response makes
also provided some expression of her hostile no distinction between the 3 South of 10 years ago
wishes without her being conscious that she was and the 3 South of now. On an unconscious level,
even angry, to say nothing of being threatened by all is now, and so the same impulses and anxieties
internal rage. are elicited that were present 10 years ago.
When symptoms serve both as defenses Another characteristic of primary-process
against unacceptable impulses and as indirect thinking is displacement, which involves placing
expressions of these wishes, then the symptoms the energies from highly charged emotional ideas
are doubly resistant to change. Other benefits onto more neutral ideas. In this case, Karen dis-
from symptoms, such as special attention from placed the intense anger she felt toward her father
loved ones or doctors, are secondary gains and for leaving onto her image of the more neutral
make symptoms even more resistant to change. people responsible for 3 South. Primary-process
But why does a person like Karen overreact thinking is also symbolic, which means pars pro
in the first place to an event like being assigned toto, that any part of an event represents the total
to 3 South? Why did she respond to the current event; thus, the name 3 South became a symbol
3 South as if she were 12 years old again? Why for the many feelings stirred up over the death of
didn’t she just make the logical discrimination Karen’s father.
between an old 3 South and the current 3 South? Finally, primary-process experiencing includes
Obviously, Karen was unaware of responding to both manifest and latent content: The content that

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Chapter 2 Psychoanalytic Therapies 29

is conscious, or manifest, is only a minor portion of Statistical Manual of Mental Disorders (DSM).
the hidden, or latent, meaning of events. Karen was Starting with childhood development and acknowl-
thus originally aware of only the manifest event of edging unconscious motivation, psychoanalytic
becoming upset on her new ward; she was not even diagnosis provides a richer, multidimensional por-
aware of the latent significance of the name 3 South trait of personality style, mental functioning, and
until it was uncovered in psychotherapy. relational capacities. Five psychoanalytic organiza-
With this understanding of primary-process tions collaborated to publish the Psychodynamic
responding, we can more fully appreciate why Diagnostic Manual (PDM) to complement the
Karen’s unconscious response to being placed on DSM. In this way, psychoanalysis and the PDM
the present 3 South appeared to be irrational, or provide a comprehensive profile of an individual’s
alogical. We can also appreciate why she was mental life. If the essence of psychopathology lies at
reacting like an angry child and why her response an unconscious level and if the person has no
involved much more energy and meaning than awareness of the psychological significance of pre-
could be understood from a relatively neutral sit- cipitating events, the impulses being elicited, the
uation like the name of the ward, 3 South. anxieties threatening panic, and the defensive yet
If we went even deeper into the latent meaning gratifying nature of symptoms, then how can indi-
of this event for Karen, we would probably find viduals be helped to overcome their disorders?
that her experience at age 12 represented her origi-
nal loss of her father (through divorce) when she
was 5. The rage that threatened to break out toward Therapeutic Processes
the nurses on 3 South may have been in part dis- For Freud, only one therapeutic process could suc-
placed from her original rage toward her mother, ceed in making the unconscious conscious. Before
whom Karen imagined caused her father to leave at we can respond to environmental events in a more
an age when she so desired him. Working on 3 realistic manner, we must first be conscious of
South may also have threatened to bring to aware- how our pathological responses to the environ-
ness feelings of sexual desire for her father mixed ment derive from our unconscious, primary-
with hostility for his leaving when she needed him process associations. To remove symptoms, we
so. Even the fantasy that she might wish his death must become conscious of our resistance to letting
could damage Karen’s image of herself as the caring go of those symptoms because they both defend
daughter who would have saved her father if she against and give partial release to unacceptable
had been a nurse 10 years before. To protect her impulses. We must gradually recognize that our
image of herself, to protect herself from acting out impulses are not as dangerous as we thought as
dangerous impulses, and to protect herself from all children and that we can use more constructive
the anxiety and guilt such impulses would elicit defenses to keep our impulses in control, in part
could be the reasons for her symptoms as defenses by allowing more mature expressions of our
of last resort. instincts. Finally, to prevent future relapses, we
In this sense, as William Faulkner wrote, “The must use our conscious processes to release our
past is never dead. It’s not even past.” The unconscious pregenital fixations so that we can continue to
remains alive and present in our primary processes, develop to mature, genital levels of functioning.
apt to be reactivated at any time in our lives. Such radical increases in consciousness require
Psychoanalytic theory offers a diagnostic alter- considerable work on the part of both patient and
native to the static, symptom-based Diagnostic and analyst.

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30 Chapter 2

Consciousness Raising schizoid, or borderline personalities are consid-


The Patient’s Work ered poor risks for classic psychoanalysis.
The work of free association sounds simple If psychoanalysis does proceed, the therapist
enough—to freely say whatever comes to mind, uses four procedures—confrontation, clarification,
no matter how trivial or repulsive. If patients interpretation, and working through—in analyz-
could let their minds go and associate without ing the patient’s resistance to free associating and
defending, then their associations would be domi- the transference that emerges as the patient
nated by instincts. Because the instincts are the regresses and expresses instinctual desires toward
source of all energy and therefore the strongest the analyst (Bibring, 1954; Greenson, 1967).
forces in the individual, and because the instincts Confrontation and Clarification
are always pressing to emerge into consciousness,
The first two are fundamentally feedback proce-
patients would immediately associate to thoughts,
dures. In analytic confrontation, the therapist
feelings, fantasies, and wishes that express instincts.
makes sure patients are aware of the particular
However, free association is anything but easy
actions or experiences being analyzed. For
or simple. Our earliest lessons in life were that such
example, in confronting a particular transfer-
direct, uncontrolled expressions of instincts are
ence, the analyst might give the patient the
dangerous. Humans also learned at the time symp-
following feedback: “You seem to be feeling
toms developed that a loosening of defenses can be
angry toward me,” or “You seem to have sexual
terrifying and can lead to pathology. Now, just
feelings toward me.”
because the psychoanalyst has asked the patient
Clarification, which frequently blends with
to lie on the couch and say everything that comes
confrontation, is sharper and more-detailed feed-
to mind does not mean that the patient can do so
back regarding the particular phenomenon that
without considerable resistance or defensiveness.
the patient is experiencing. Greenson (1967,
To help the patient work in the face of poten-
p. 304) gives an example of how, after confronting
tial terror and resulting defensiveness, the analyst
a patient with his hatred for the analyst, he
must form a working alliance with the part of the
helped the patient clarify the exact details of his
patient’s ego that wants relief from suffering and is
hatred:
rational enough to believe that the analyst’s direc-
tions can bring such relief. Through this alliance, He would like to beat me to a pulp, literally grind
patients also become willing to recall in detail me up and mash me into a jelly-like mass of
dreams and childhood memories, even though bloody, slimy goo. Then he’d eat me up in one big
such material brings them closer to threatening “slurp” like the god damned oatmeal his mother
impulses. made him eat as a kid. Then he’d shit me out as a
foul-smelling poisonous shit. And when I asked
The Therapist’s Work
him, “And what would you do with this foul-
The therapist’s work begins with evaluating the smelling shit?” he replied, “I’d grind you into the
patient to determine whether he or she is indeed dirt so you could join my dear dead mother!”
a suitable candidate for psychoanalysis. As Green-
son (1967, p. 34) succinctly puts it, “People who Interpretation
do not dare regress from reality and those who Confronting and clarifying a patient’s experiences
cannot return readily to reality are poor risks for prepare patients (or analysands) for the most
psychoanalysis.” This generally means that important analytic procedure: interpretation.
patients diagnosed as schizophrenic, bipolar, Greenson (1967, p. 39) defines interpretation in

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Chapter 2 Psychoanalytic Therapies 31

such a way as to make it almost synonymous with that improvement in psychoanalysis is expected to
analysis itself: be a slow, gradual process. First, the analyst and the
To interpret means to make an unconscious phe- patient must interpret the repeated resistance the
nomenon conscious. More precisely, it means to client throws up against becoming conscious of
make conscious the unconscious meaning, threatening forces from within. The client misses
source, history, mode, or course of a given appointments, comes late, recovers dramatically
psychic event. The analyst uses his own uncon- and wants to leave therapy, wants to leave because
scious, his empathy and intuition as well as his of not recovering, represses dreams, and does a
theoretical knowledge for arriving at an inter- million other things to shore up defenses. Then,
pretation. By interpreting we go beyond what as blind resistance is gradually reduced through
is readily observable and we assign meaning insightful interpretations, the client begins to
and causality to a psychological phenomenon. release hidden instincts toward the therapist.
The patient satisfies frustrated sexual and
Because interpretation goes beyond the experience
aggressive impulses by displacing them onto the
of the patient, it is more than feedback to the patient.
analyst, and gradually a neurotic transference
The meaning and causality assigned to psychological
develops in which the patient relives all of the sig-
phenomena are determined, at least in part, by psy-
nificant human relationships from childhood. For
choanalytic theory. Therefore, the information
weeks or months, the therapist may be experienced
patients are given regarding the meaning and causal-
as the nongiving, miserly mother who does not care
ity of their responses is partly an education on how
about the patient; then the analyst is the lecherous
psychoanalysis makes sense of people and their pro-
father who wants to seduce the patient; or the
blems. This is not to say that interpretations are
wonderful, wise parent who can do no wrong; or
given in theoretical terms. They certainly are person-
the stupid fool who is always wrong. Transference
alized for the individual, and in that respect are feed-
reactions serve as intense resistances: Why mature
back. Nevertheless, through interpretations patients
further when you feel so good beating on your
are taught to view their conscious experiences as
therapist or feel so safe with such a wise, caring
caused by unconscious processes, their adult behav-
parent? Painfully, through repeated interpretations,
ior as determined by childhood experiences, their
the patient must realize that these intense feelings
analysts as if they were parents or other significant
and impulses come from within and represent the
figures from the past, and so on.
patient’s pregenital conflicts, not realistic feelings
Psychoanalytic therapists assume that patients
elicited by the relatively blank-screen analyst.
accept such teachings because the interpretations
hold true for the patient. After all, it is the patient’s Working Through
response that verifies an interpretation. If patients The slow, gradual process of working again and
gain insight—that is, if they have a cognitive and again with the insights that have come from inter-
affective awakening about aspects of themselves pretations of resistance and transference is called
that were previously hidden—then analysts have working through. In this last and longest step of
some evidence for the validity of their interpreta- psychotherapy, patients are acutely conscious of
tions. The most critical response for verifying inter- their many defensive maneuvers, including symp-
pretations is whether the interpretations eventually toms. They are undeniably aware of the impulses
lead to a change for the better in the patient. they have tried to defend against and the many
The problem with patient improvement as the ways in which they are still behaviorally expressed.
criterion for the verification of interpretations is They realize that they need not fear their impulses

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32 Chapter 2

to the degree they once did as children, because in with stimulation. Primal anxiety is the bodily
transference relationships they expressed impulses basis for panic, which is the adult threat of being
in intense words and were not castrated, rejected, overwhelmed with instinctual stimulation. Moral
or overwhelmed. Gradually the person becomes anxiety, or guilt, is the threat that comes with
aware that there are indeed new and more mature breaking internalized rules.
ways of controlling instincts that allow some grat- In psychotherapy, anxiety may drive a person
ification without guilt or anxiety. Gradually the to seek relief because of its aversive properties.
patient channels impulses through these new con- Once in therapy, however, an analyst must be
trols and gives up immature defenses and symp- careful not to uncover impulses too quickly lest
toms. The use of new defenses and the radical the person panic and either flee therapy or feel
increase in consciousness are seen by Freudians psychotically overwhelmed. Anxiety is one of the
as structural changes in personality, in which central reasons therapy moves slowly—partly
energies once bound up in pregenital conflicts because anxiety signals the person to shore up
are now available to the more mature ego of the resistance when dangerous associations are
individual. being approached, and partly because analysts
feel that immature egos cannot hold up under
Other Processes high anxiety.
Most psychoanalysts accept that corrective emo- Defenses or resistance, as defenses are called
tional experiences can lead to temporary relief of when they occur in psychotherapy, are half of the
symptoms, especially for traumatic neuroses. content of psychoanalysis. Almost any behavior in
Catharsis, however, even if used by an analyst, is therapy can serve defensive functions—talking too
not considered part of the psychoanalytic process. fast or too slowly, too much or too little, feeling
There is only one fundamental change process in good toward the therapist or feeling hostile, focus-
analysis, and that is to increase consciousness; all ing on details or avoiding details. So the analyst is
the steps in analysis are part of that process. never without material. It is just a matter of which
defenses are most likely to be acknowledged by the
client as resistance, such as missing appointments
Therapeutic Content
or not recalling dreams. The analytic goal is not to
Intrapersonal Conflicts
remove defenses, but rather to replace immature
Psychoanalysis obviously focuses on intrapersonal and distorting defenses with more mature, realis-
conflicts in therapy. The patient’s inner conflicts tic, and gratifying defenses.
among impulses, anxiety, and defenses represent
the central concern. Problems may be acted out at Self-Esteem
an interpersonal level, but the understanding and Self-esteem has not been a major content area for
resolution of such problems are achieved only psychoanalysis. It seems to be taken for granted
through an analysis of each person’s intrapsychic that patients will experience conflict over self-
conflicts. esteem. Some will hold unrealistically low self-
esteem—deprived oral characters who engage in
Anxieties and Defenses continual self-belittlement or rejected phallic char-
We have already discussed anxiety due to threats acters who feel ugly and undesirable, to name but
of separation and castration. The Freudians also two. Other patients will hold unrealistically high
postulate primal anxiety, which is due to the self-esteem, such as overindulged oral characters
assumed birth trauma of being overwhelmed who are cocky or overindulged phallic characters

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Chapter 2 Psychoanalytic Therapies 33

who are vain and brash. Pregenital personalities Interpersonal Conflicts


cannot feel fundamentally good about themselves Intimacy and Sexuality
as long as they are dominated by infantile desires Intimacy, the authentic revealing and sharing
to be selfishly taken care of, hostilely controlling, or between people, is fundamentally impossible for
seductively narcissistic. an immature personality. The problem of inti-
Lack of genuine self-esteem results from person- macy is basically a transference problem. The pre-
ality problems, rather than causing such problems. genital personality cannot relate to another person
As such, analysts do not treat esteem problems as the other person really is, but distorts the other
directly. Acceptance of infantile characteristics may according to childhood images of what people are
bring temporary relief, but what the pregenital like. In Piaget’s terms, the person’s earliest inter-
personality really needs is a personality transplant. personal experiences with parents result in inter-
The best that can be done is to help patients con- nalized schemas that are primitive concepts of
sciously restructure their personalities into a more what people are like. Any new experience of a
genital level of functioning. Only then can indivi- person is assimilated into this schema through
duals experience a stable sense of self-esteem. selective attention to that person’s actions.
Whereas Piaget (1952) suggests children’s sche-
Responsibility mas of people change to accommodate new experi-
In a deterministic system such as psychoanalysis, ences, the Freudian concept of fixation suggests
how can we talk about individual responsibility? In that pregenital personalities do not evolve in their
practice, the analyst expects the patient to be respon- schemas of people. Rather, immature individuals
sible for the bill, to keep appointments three to five distort their perceptions of other people to fit inter-
times a week, and to free associate. But theoretically, nalized images. For example, a repeatedly abused
there is no freedom and no choice in psychoanalysis child views people as untrustworthy and rejecting.
and, therefore, no responsibility. How can we hold a That child becomes an adult who attends to the
person responsible for any action, whether it be slightest reason for mistrust and the smallest sign
murder, rape, or just not paying a bill, if all patho- of rejection as evidence that a new, potential inti-
logical behavior is determined by unconscious con- mate is the same as the abusers in childhood.
flicts and pregenital fixations? This difficulty in A thorough psychoanalysis is the premier
holding an individual responsible for his or her method to mature to a level which people can
actions is one of the reasons why Mowrer (1961) perceive each other with the freshness and unique-
said that Freud freed us from a generation of ness each deserves. It is only by being fully aware
neurotics and gave us a generation of psychopaths. of how we have distorted our relationships in the
Freud was a determinist, yet his theory is a past that we can avoid destructive distortion in the
psychology of freedom (Gay, 1990). His psychic present.
determinism held that just as there is no event Sexual relationships for immature people also
in the physical universe without its cause, so reflect transference relationships. Two immature
there is no mental event or mental state without people can only engage in object relationships in
its cause. Nothing is chance in the psychological which the other is seen as perhaps finally being
world. Yet psychoanalysis is ultimately designed to the one who will satisfy ungratified pregenital
make us more aware of our repressed conflicts and instincts. So the oral character may relate sexually
mental defenses, and thereby free us from the with a clingy and demanding manner that
tyranny of the unconscious. smothers a spouse. The anal personality may relate

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34 Chapter 2

sexually in a very routinized manner, such as every With paranoid personalities barely controlling their
Wednesday night when the 11:00 television news is rage, defenses must be strengthened through support-
over rather than when sex is spontaneously desired. ive therapy or medication rather than uncovered by
The phallic character may relate as the teasing, analysis. With overcontrolled neurotics, the best we
seductive person who promises so much in bed can expect is to rechannel hostility into more socially
but has so little to give. The ability to relate to acceptable outlets such as competition, assertiveness,
another as a mature, heterosexual partner results or hunting. Otherwise, we will all be hunters and
only after a satisfying working through of one’s the hunted.
pregenital fixations. Otherwise we are reduced to
Control
two objects bumping in the night.
Struggles over interpersonal control are frequently
Communication struggles over whose defenses will dominate the
Most interpersonal communication between two relationship. The more rigid the defenses, the
immature people is interlocking monologue, not a more likely it is that individuals will insist on
genuine dialogue. Immature personalities are others conforming to their view of the world and
locked into their egocentric worlds, in which others their ways of acting. The person who repeatedly
are only objects for their gratification. They do not projects hostility onto the world, for instance, is
respond to what the other says, but rather to their likely to put considerable pressure on others to see
own selfish desires. They do not talk to each other, the world as a hostile place. Conversely, if a
but rather speak to their internal images of what person defends with repressive, rose-colored
the other is supposed to be. The messages they send glasses, then interactions will be focused on only
have a manifest content that is also directed at hid- the cheery aspects of the world. If two people with
ing what the person really wants to say. If it takes incompatible defenses try to interact, there will be
an analyst years of “listening with the third ear” conflict. An insignificant matter, such as deciding
(Reik, 1948) to interpret what the person truly which movie to see, can turn into a heated battle
means, how can a spouse with two blocked ears for control when it involves a spouse with rose-
be expected to hear? From a classical Freudian colored glasses who wants to see a light comedy
viewpoint, attempts at couples therapy between and a hostility-projecting spouse who wants to see
two immature personalities will only produce a war flick.
absurd dialogue best left to modern playwrights. Individuals also expect to control relation-
ships when they experience the other person as
Hostility nothing more than an object that exists to gratify
The violence in our society, according to Freudians, their infantile desires. Each pregenital type of per-
reflects the hostility inherent in humans. Just as the sonality has its unique style of controlling others:
work of ethnologists such as Tinbergen (1951) and Oral characters control by clinging, anal charac-
Lorenz (1963) suggested that animals instinctively ters control through sheer stubbornness, and phal-
release aggression, the work of Freud suggested that lic characters control through seductiveness. The
the human animal possesses aggressive instincts to most intensely controlling people seem to be anal
strike out and destroy. But humans also desire to personalities who have come from overcontrolling
live in civilized societies, and the stability of social families. They feel they were once forced to give in
organizations—relationships, families, and commu- on the toilet and thereby lost control over their
nities, to name a few—is continually threatened by bodies. Now they act as if they are determined
the hostile outbursts of poorly defended personalities. never to give in again.

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Chapter 2 Psychoanalytic Therapies 35

An anal-restrictive woman was raised by a cultures did not need to be as oppressive about
governess who seemed to enjoy giving her cold- childhood sexuality as was his Victorian age; in
water enemas to force her to let go when she was fact, Freud, more than any other individual, was
2 years old. She married a man who was toilet responsible for our modern sexual revolution.
trained at 10 months of age. He was complaining Nevertheless, Freud accepted the idea that culture
that his wife could never let go and enjoy their must be repressive to some degree. Being the civi-
sexual relationship. She went along with his lized individual that he was, he threw his weight
demands for sex but seemed unable to let go to behind civilization and was willing to treat its
have an orgasm. The trauma that brought them discontents.
into psychotherapy followed the wife’s decision Some radical post-Freudians argue that indi-
to solve her problem. She read Masters and viduals need not be repressed. All of the destruc-
Johnson’s sex therapy book and reserved a hotel tive expressions of the death instinct, such as
room in New York so they could have a sexual violence, materialism, and pollution, result from
holiday. Once in New York, she became very repeated frustration of the life instinct. If we
aroused as she approached her husband, but he adopt more childlike, spontaneous lifestyles, in
was now unable to get an erection. He was so which we give free expression to playing in bed
determined to control their sexual relationship and in fields, then we would not be frustrated
that he shut off his penis to spite his wife. and so aggressive. Those who assume a radical
In treatment, the analyst must be keenly aware Freudian view usually accept sexuality as an
of how a patient is trying to control. The analyst instinct but see aggression as the product of the
will recognize when controlling behavior is serv- repression of our desires for spontaneous sexual-
ing defensive purposes of resistance or gratifying ity. Radical Freudians generally believe that indi-
purposes of transference. The analyst must con- viduals should be encouraged to transcend their
front and clarify the patient’s attempts to control particular cultures and find fulfillment by follow-
and then interpret the meaning and causality ing their own unique paths in the face of possible
of controlling maneuvers. The analyst’s most social ostracism. But Freud himself, as radical as
effective method of countercontrol is silence: No he was in many ways, was convinced that even the
matter what response the patient insists on, the most conscious individuals must compromise
analyst can respond with silence. It is like trying with the culture in which they live and leave fan-
to fight with a partner who clams up—it can be tasies of transcendence to the angels.
terribly frustrating because the quiet one remains
Impulse Control
in control.
Freud was convinced that human sexual and
aggressive impulses must be controlled. We are
Individuo-Social Conflicts animals covered with a thin veneer of civilization.
Adjustment versus Transcendence For psychotherapists to encourage the removal of
Freud (1930) believed there was a fundamental that veneer is ultimately to encourage raping and
and unresolvable conflict between an organized rioting in the streets. Some believe that Freud
society’s need for rules, on the one hand, and an himself contributed to removing this thin veneer.
individual’s desires for immediate, selfish gratifi- They see sexuality and aggression as out of control
cation, on the other. This represents, in a nutshell, in our post-Freudian society. Dependency on
the superego versus the id, the reality principle drugs, alcohol, and food is rampant; violence
versus the pleasure principle. Freud argued that seems to dominate the streets. Freud, however,

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36 Chapter 2

was one of the earliest to recognize it is much loves sex without the urgent dependency of the oral
easier for therapists to loosen the controls of neu- character, is fully potent in work without the com-
rotics than to produce controls for impulse-ridden pulsivity of the anal character, and is satisfied with
personalities. He did not preach removal of the self without the vanity of the phallic character. This
thin veneer of controls; instead, he believed that ideal individual is altruistic and generous without
the best hope for individuals and society was to the saintliness of the anal character, and is fully
replace the rigid but shaky infantile veneer with a socialized and adjusted without immeasurable suf-
more mature set of controls. fering from civilization (Maddi, 1996).

Beyond Conflict to Fulfillment


Therapeutic Relationship
Meaning in Life
There are two parts of the patient–analyst rela-
Freud once said that, “The intention that Man
tionship, and they serve two different functions
should be happy is not in the plan of Creation.”
in treatment. The working alliance is based on
He believed we could not go beyond conflict, but
the relatively nonneurotic, rational, realistic atti-
he did suggest that we could find meaning in life in
tudes of the patient toward the analyst. This alli-
the midst of conflict. Meaning is found in love and
ance is a precondition for successful analysis,
work (lieben und arbeiten). Work is one of society’s
because the rational attitudes allow the patient to
best channels for sublimating our instincts; Freud
trust and cooperate with the analyst even in the
himself could sublimate his sexual curiosity into
face of negative transference reactions.
his work of analyzing his patients’ sexual desires.
Transference, by contrast, represents the
Sublimation is a mature ego defense that allows
patient’s neurotic, unrealistic, and antiquated feel-
us to channel the id’s energy into more acceptable
ings toward the analyst. In transference reactions,
substitute activities: Oral sucking can become cigar
the patient experiences feelings toward the analyst
smoking, anal expression can become abstract art,
that do not befit the analyst but actually apply to
and so on.
significant people in the patient’s childhood. Feel-
Freud’s embrace of the value of work came
ings and defenses pertaining to people in the past
mainly from his total involvement in his own
are displaced onto the analyst. These transference
work. His voluminous productivity could come
reactions represent the conflicts between impulses
only from a person with a passion for work. A
and defenses that are the core of the person’s pre-
clearer source of meaning is love—the atmosphere
genital personality.
that allows two people to come together, the most
Repeating these impulses and defenses in rela-
civilized expression of sexuality, and therefore the
tion to the analyst provides the content of psycho-
safest and most satisfying. Obsessive ruminating
pathology for analysis. The person does not
about meaning in life can come only from some-
simply talk about past conflicts, but relives them
one too immature to love and to work.
in the current relationship with the analyst. Rela-
Ideal Individual tionship expectations from there and then are
The ideal individual for Freud, and the ultimate goal reenacted in the here and now of the consulting
of psychoanalysis, is a person who has analyzed room. Manifesting transference reactions is not a
pregenital fixations and conflicts sufficiently to curative process per se, because the essence of the
attain, and maintain, genital functioning. The geni- transference is unconscious. Patients know they
tal personality is the ideal. The genital personality are having intense reactions toward the analyst

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Chapter 2 Psychoanalytic Therapies 37

but are unaware of the true meaning of their reac- Analysts must be aware of their own
tions. It is the analysis, or making conscious the unconscious processes, as another source of
unconscious content of the transference reactions, accurate interpretations and as a guard against
that is the therapeutic process. reacting toward their patients on the basis of
The analyst’s own reaction to the patient con- countertransference—the analysts’ desires to
stitutes a delicate balance between being warm and make clients objects of gratification of their own
human enough to allow a working alliance to infantile impulses. For example, the analyst must be
develop, yet neutral and depriving enough to stim- able to analyze hostile withholding of warmth or sup-
ulate the patient’s transference reactions. The port because a patient reminds the analyst of an
stereotype has emerged that an analyst is just a annoying sibling. Likewise, an analyst must be able
blank screen and therefore cool and aloof. Even to recognize that giving too much of oneself to a client
such an orthodox analyst as Fenichel (1941), how- may represent encouragement to the patient to act
ever, has written that above all the analyst should be out sexual desires with the analyst. In short, the ana-
human. Fenichel was appalled at how many of his lyst must be healthy enough to discriminate what is
patients were surprised by his own naturalness in coming from the patient and what the analyst is
therapy. In order for the patient to trust the analyst encouraging, because a patient in the midst of trans-
and believe the analyst cares, the analyst must ference reactions cannot be expected to make such
communicate some warmth and genuine concern. crucial discriminations.
Freudians disagree with Carl Rogers’s (1957)
assumption that it is therapeutic to be genuine
throughout therapy. If analysts become too real, Practicalities of Psychoanalysis
they will interfere with the analysand’s need to In order for psychoanalysts to accurately analyze
transfer reactions onto them from people in his or their own countertransference reactions, they must
her past. Patients can transform a blank screen into be psychoanalyzed by a training analyst and must
almost any object they desire, but it would take have graduated from a psychoanalytic institute—a
a psychotic transference to distort a three- process that takes 4 to 6 years, depending on how
dimensional therapist into an object from the past. much time is spent per week at the institute. Early
Although psychoanalysts agree with Rogers on, most analysts in the United States were psychia-
that it is best to adopt a nonjudgmental attitude trists, because it was very difficult for nonphysicians
toward a patient’s productions to allow for a freer to be admitted to analytic institutes—even though
flow of associations, they do not respond with Freud supported the practice of lay analysis, which
unconditional positive regard. Frequently, neutral is analysis by a nonphysician. In the past three
responses such as silence are more likely to stim- decades, however, nonmedical mental health profes-
ulate transference reactions, and thus an analyst’s sionals have been routinely accepted into formal
reactions to the patient’s productions are best psychoanalytic training.
described as unconditional neutral regard. “But where and how is the poor wretch to
Analysts would agree with Rogers that accu- acquire the ideal qualifications which he will
rate empathy is an important part of therapy. need in this profession? The answer is in an anal-
Empathy is a prime source of useful interpreta- ysis of himself, with which his preparation for his
tions, after all. Psychoanalysts also agree that an future activity begins.” So asked and answered
analyst must be healthier or, in Rogers’s terms, Freud (1937/1964, p. 246) in enjoining psychoana-
more congruent than patients. lysts to complete personal analysis themselves.

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38 Chapter 2

Research has indeed found that 99% of psycho- Major Alternatives:


analysts and approximately 90% of psychoanalytic
Psychoanalytic Psychotherapy
psychotherapists have undergone personal therapy
themselves and that their therapy experiences are and Relational Psychoanalysis
typically lengthier than psychotherapists of other Variations in the standard operating procedures of
persuasions, averaging 400 to 500 hours (Norcross psychoanalysis have occurred throughout its his-
& Guy, 2005). tory. At times, the innovations resulted in rejec-
Although classical analysts prefer seeing tion of the unorthodox analyst by more classical
patients four or five times per week, treatment colleagues, and the innovator has gone on to
can still be considered psychoanalysis if it occurs establish a new system of psychotherapy. A case
at least three times a week. Psychoanalysis in point is Carl Jung and his subsequent deve-
currently costs between $120 and $200 per lopment of analytical psychology (considered in
50-minute session, with the cost varying according Chapter 3). At other times, variations in orthodox
to the city and the reputation of the analyst. analysis have been seen as a practical necessity,
Theoretically, analysis has been considered inter- because particular patients lacked the ego or finan-
minable, in that there is always more in the cial resources to undergo the stress of long-term,
unconscious that could be made conscious, but intensive analysis. Cases in point are the deve-
the actual work with an analyst is completed in lopment of psychoanalytic psychotherapy and
an average of 3 to 5 years. relational psychoanalysis.
In orthodox analysis, patients agree, if possi- In practice, most contemporary followers of
ble, not to make any major changes—such as mar- Freud lean more heavily on psychoanalytic
riage or relocation—while in analysis. Above all, psychotherapy than on classical psychoanalysis.
they should make no important decisions without Furthermore, many psychotherapists consider
thoroughly analyzing them. At times, patients are themselves Freudians although they have been
asked to give up psychotropic medications and trained in settings other than psychoanalytic
chemicals such as alcohol or tobacco. institutes—including social work, clinical psychol-
The psychoanalysis itself involves the patient ogy, and counseling training programs.
(or analysand) and the analyst interacting alone in Anna Freud (1895–1982), Sigmund’s youngest
a private office. The patient lies on a couch with child, devoted nearly 60 years to adapting psycho-
the analyst sitting in a chair at the head of the analysis to children and adolescents. Her work
couch. The patient does most of the talking; the tried to address the unfinished problems
analyst is frequently silent for long periods of time bequeathed by her father. She enlarged the bound-
when the patient is working well alone. Patients aries of psychoanalysis with direct considerations
are subtly encouraged to associate primarily to of ego functioning without abandoning the bed-
their past, their dreams, or their feelings toward rock of psychoanalytic instinct theory. Indeed,
the analyst. The analyst keeps self-disclosures to a Anna is rightfully known as one of the “mothers”
minimum and never socializes with patients. of ego psychology (which is also considered in
Needless to say, the analyst becomes a central fig- Chapter 3). Anna systematized and expanded
ure in the patient’s life, and during the neurotic our understanding of defense mechanisms. Her
transference, the analyst is the central figure. Fol- classic monograph (1936), The Ego and the
lowing termination, the analyst remains one of the Mechanisms of Defense, legitimized interest in
most significant persons in the patient’s memory. both the ego and defenses (Monte, 1991).

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Chapter 2 Psychoanalytic Therapies 39

Establishing more flexible forms of psychoan- included when appropriate. Therapeutic advice
alytic therapy as truly acceptable alternatives and suggestions will be included along with
within psychoanalysis has usually been credited dynamic interpretations.
to Franz Alexander (1891–1963) and his collea- Because daily sessions tend to encourage
gues at the Chicago Institute of Psychoanalysis. excessive dependency, psychotherapy sessions are
Alexander and French (1946) argued that ortho- usually spaced over time. Daily sessions can also
dox analysis had been developed by Freud to serve lead to a sense of routine in which the client fails
as a scientific means of gathering knowledge about to work as intensely as possible because tomor-
neuroses, as well as a means for treating neuroses. row’s session is always available. As a rule, ses-
Once the fundamental explanations for the devel- sions are usually more frequent at the beginning
opment of personality and psychopathology had of therapy to allow an intense emotional relation-
been established, however, there was no justifica- ship to develop between client and therapist, and
tion to proceed with all patients as if each analyst then sessions are spaced out according to what
was rediscovering the oedipal complex. With a seems optimal for the individual client. After ther-
thorough understanding of the psychoanalytic apy has progressed, it is usually desirable for the
principles of psychopathology, therapists could therapist to interrupt treatment to give clients a
begin to design a form of psychoanalytic therapy chance to test their new gains and to see how
that fit the particular patient’s needs, rather than well they can function without therapy. These
trying to fit the patient to standard analysis. interruptions also pave the way for more success-
Some patients do indeed require classical ful termination.
analysis—namely, those with chronic neuroses Transference is an inevitable part of any psy-
and character disorders. But these patients are in choanalytic therapy, although the nature of the
the minority. Much more common are the milder transference relationships can be controlled. A
chronic cases and the acute neurotic reactions full-blown transference neurosis is usually what
resulting from a breakdown in ego defenses due accounts for the length of standard analysis, so
to situational stresses. Clients with milder and briefer psychoanalytic therapy will frequently dis-
acute disorders can be successfully treated in a courage a transference neurosis from developing.
much more economical manner than previously A negative transference can also complicate and
thought. Alexander and French (1946) reported extend therapy, and so may be discouraged with
600 such patients who were treated with psycho- particular clients. When the transference relation-
analytic therapy that lasted anywhere from 1 to 65 ship is controlled and directed, and when the
sessions. The therapeutic improvements they therapist relies on a positive transference to help
reported with their abbreviated therapy were pre- influence clients, therapy can usually proceed
viously believed to be achievable only through more rapidly. A client with a positive father trans-
long-term, standard psychoanalysis. ference toward the therapist, for example, is much
Following the principle of flexibility, psycho- more likely to accept the therapist’s suggestions to
analytic therapy becomes highly individualized. leave a destructive marriage or change to a more
The couch may be used, or therapy may proceed constructive job than would a client involved in a
face-to-face. Direct conversations may be substi- negative transference.
tuted for free association. A transference neurosis The nature of the transference can be con-
may be allowed to develop, or it may be avoided. trolled through the proper use of interpretations.
Drugs and environmental manipulations will be If it has been decided that a transference neurosis

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40 Chapter 2

is unnecessary or perhaps even damaging, the a flexible attitude toward therapy does not see
interpretations will be restricted to the present sit- the process as an either/or issue. Psychoanalytic
uation, because interpretation of infantile conflicts psychotherapy at its best should involve corrective
encourages regression and dependency. Regres- emotional experiences integrated into conscious
sion to early stages of functioning can also be ego functioning through intellectual insights into
interpreted as a means of avoiding dealing with the history of troubled emotions.
present conflicts. Attention to disturbing events In recent years, psychoanalysis has undergone
in the past would be used only to illuminate the a paradigm shift from drive reduction to the rela-
motives for irrational reactions in the present. tional model. Relational psychoanalysis posits
The psychoanalytic psychotherapist can also that the therapist is unavoidably embedded in
control the transference by behaving less of a the relational field of the treatment; the pulls
blank screen and more the type of person that and feelings of the therapist are regarded as
clients expect to find when they seek assistance related to the patient’s dynamics and as providing
for behavioral disorders. When the therapist is potentially useful information (Mitchell, 1988,
more real and empathic, neurotic transference 1993). Instead of transference being assigned
reactions will be more clearly seen as inappropri- entirely to the patient, relational psychoanalysts
ate to the present situation and will be less likely regard it as an interactive process between patient
to develop. Countertransference reactions in the and therapist. Instead of assiduously avoiding
therapist can also help foster a stronger therapeu- countertransference, interpersonal psychoanalysts
tic alliance. Such reactions in the therapist need accept it as an invaluable source of information
not be analyzed away; rather, the therapist must about the patient’s character and difficulties in liv-
consciously decide which reactions will be helpful ing. Stephen Mitchell (1988, p. 293) captures this
to therapy and must express those reactions. If a idea in a passage from his book, Relational Con-
client had a very rejecting father, for example, cepts in Psychoanalysis:
then remaining a blank screen may engender a
Unless the analyst affectively enters the patient’s
negative transference, whereas expressing more
relational matrix or, rather, discovers himself
accepting attitudes could foster a more therapeutic
within it—unless the analyst is in some sense
relationship.
charmed by the patient’s entreaties, shaped by
The development of a safe and trusting thera-
the patient’s projections, antagonized and frus-
peutic relationship determines whether clients can
trated by the patient’s defenses—the patient is
express the troubling feelings that have been
never fully engaged and a certain depth within
blocked off because of early conflicts with parents.
the analytic experience is lost.
The expression of previously defended feelings,
such as anger, erotic desires, and dependency, is This relational or intersubjective evolution in
what leads to therapeutic success. A corrective psychoanalysis functionally means that it has
emotional experience occurs when patients reex- progressed from a one-person psychology to a two-
perience the old, unsettled conflict but with a new, person psychology (Chessick, 2000). The therapist is
healthier ending within the therapeutic relation- always as much a participant in the interaction as the
ship. Corrective emotional experiencing, then, is patient.
a more critical process than the consciousness Relational psychoanalysis focuses upon desires,
raising stressed in orthodox analysis. Of course, not sexual and aggressive drives. A major desire is

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Chapter 2 Psychoanalytic Therapies 41

for close, satisfying relationships. The correspond- distortions involved in analyzing its own effective-
ing theory of mind is not Freud’s structural per- ness. Freud viewed experimental support of
spective of id, ego, and superego, but rather a psychoanalytic propositions and treatments
mind socially constructed from interactions with as unnecessary. In a letter to early researcher
others and the external world. Both the important Saul Rosenzweig, he wrote that psychoanalytic
content and the curative method of relational assertions were “independent of experimental
psychoanalysis are human relationships. verification.” For its first 90 years, the effectiveness
The relational model of psychoanalysis of psychoanalysis was supported almost entirely
assumes that both insight and corrective emo- by case studies and clinical surveys reported by
tional experiences are necessary to produce deep enthusiastic analysts. Such case studies and clini-
and enduring change. Thus, the relational analyst cal surveys are the empirical starting point for all
has an expanded repertoire of change processes at psychotherapy systems, but they are too biased
his or her disposal: interpretation remaining one, and uncontrolled to scientifically establish the effi-
but complemented by the power of the novel cacy of any system (Meltzoff & Kornreich, 1970).
interaction within the therapy relationship (Gold & One of the earliest and best-known psychoan-
Stricker, 2001). alytic survey studies is that of Knight (1941), who
The locus of change for Freud was inside the surveyed dispositions of patients who stayed in
patient’s head; for relational psychoanalysts, the psychoanalysis for at least 6 months. The data
locus is between people. The analyst’s role is involved the analysts’ judgments of whether
thus transformed from lofty, cerebral detachment patients were “apparently cured,” much improved,
to concerned, active involvement. The importance improved, unchanged, or worse when analysis was
assigned in classical psychoanalysis to abstinence, terminated. This survey study had the advantage of
neutrality, and anonymity gives way in relational being cross-cultural, in that it included data on
psychoanalysis to responsiveness, reciprocity, and patients seen at psychoanalytic institutes in Berlin,
mutuality. The relational analyst creates a differ- London, Topeka, and Chicago. Dividing patients by
ent emotional presence to get the patient to hear diagnostic category, Knight reported the results
and experience him or her in a different way. In shown in Table 2.2. Across patient diagnoses,
this engaging manner, the patient undergoes a approximately half of the patients completing clas-
corrective emotional experience and learns new sical psychoanalysis were apparently cured or much
skills within the context of an empathic relation- improved.
ship. (We will have much more to say about the Subsequent surveys on the outcomes of psy-
relational trends in psychoanalysis in our coverage choanalysis show similarly positive results (e.g.,
of psychodynamic therapies in Chapter 3.) Bachrach et al., 1991; Fonagy & Target, 1996;
Freedman et al., 1999). Improvement rates are
typically reported by analysts to be 60% and bet-
Effectiveness of ter, depending on how improvement is measured
Psychoanalysis (Galatzer et al., 2000). Naturalistic effectiveness
Although psychoanalysis has concerned itself with studies of psychoanalysis, too, show positive
the distortions emanating from transference for effects (e.g., Blomberg et al., 2001). However, vir-
more than 110 years, it has not been nearly as tually all of that research entails retrospective,
concerned about scientifically controlling for the uncontrolled studies in naturalistic settings in

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42 Chapter 2

Table 2.2 Early Survey Results on the Effectiveness of Psychoanalysis by Patient Diagnosis
N U MB E R O F CURED OR MUCH NO CHANGE
DIAG NOSTIC CA TEG OR Y PATIENTS I MP RO V E D O R WO RS E
Neuroses 534 63% 37%
Sexual disorders 47 49% 51%
Character disorders 111 57% 43%
Organ neurosis and organic conditions (e.g., colitis, 55 78% 22%
ulcers)
Psychoses 151 25% 75%
Special symptoms (e.g., migraine, epilepsy, alcoholism, 54 30% 70%
stammering)
SOURCE: Data from Knight (1941).

which the treatment was not standardized with psychoanalysis is “the only significant branch of
respect to duration, technique, and so on. Such human knowledge and therapy that refuses to
research is subject to considerable criticism, such conform to the demand of Western civilization
as therapists not actually practicing the prescribed for some kind of systematic demonstration of its
method, but it is a starting point for controlled contentions.” Thus, the effectiveness of classical
experiments. and relational psychoanalysis has not been ade-
At the same time, the goals of psychoanalysis quately tested.
are not particularly amenable to quantification.
How does one measure more joy in life or opera- Psychoanalytic Psychotherapy
tionalize the capacity for love and work? Can Fortunately, several controlled outcome studies
resolved transference neuroses be gauged by a have been conducted on long-term psychoanalytic
self-report checklist? Psychoanalysis is more ambi- psychotherapy. Let us consider them, starting with
tious than other therapies in that it hopes to impact a classic study.
fundamental personality organization—enduring The Menninger Foundation’s Psychotherapy
structural change. Its treatment objectives are not Research Project began in 1959 and lasted nearly
easily specified in measurable, symptom-based out- 20 years. The study involved 42 adult outpatients
comes. Many psychoanalysts believe that the and inpatients seen in psychoanalysis or psycho-
extensive research via clinical surveys and natural analytic psychotherapy. Psychoanalysis lasted
effectiveness studies is sufficiently scientific and an average of 835 hours; psychotherapy lasted an
sensitive to document the multifaceted success of average of 289 hours. The majority of patients
psychoanalysis. improved on the Health-Sickness Rating scale,
Unfortunately, there are not any randomized but there was no difference in improvement
clinical trials conducted on classical psychoanaly- between those in psychoanalysis and those in psy-
sis or relational psychoanalysis, to our knowledge. choanalytic psychotherapy (Kernberg, 1973).
Merton Gill (1994, p. 157), himself a passionate Direct comparisons between the two treatments
analyst, lamented before his death that are difficult to make because patients were not

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Chapter 2 Psychoanalytic Therapies 43

randomly assigned but differed systematically therapy is not directly compared to alternative
between the two groups. Further limiting the con- (including briefer) treatments. A more rigorous
clusions on the efficacy of the two therapies was meta-analysis of 11 controlled studies on the effec-
the absence of both a placebo therapy group and a tiveness of long-term psychoanalytic psychother-
no-treatment group. apy found the evidence to be limited and
In Forty-Two Lives in Treatment, Wallerstein conflicting (Smit et al., 2012). The recovery rate
(1986) extensively chronicles, over a 30-year span, from various mental disorders was the same for
the treatment careers and subsequent life changes long-term psychoanalytic therapies as for various
of the patients seen in the Menninger project. control treatments, including treatments as usual.
Paralleling earlier reports, Wallerstein drew the fol- That is, in controlled studies, psychoanalytic
lowing overarching conclusions from this extensive psychotherapy did not significantly outperform
study: The traditional distinction between “struc- the control conditions.
tural change” and “behavioral change” is highly In sum, there are multiple clinical surveys of
suspect; intrapsychic conflict resolution is not psychoanalysts about the benefits of their craft
always a necessary condition for change; the sup- and several naturalistic effectiveness studies of
portive psychoanalytic therapy produced greater psychoanalysis, but no controlled outcome
than expected success; and classical psychoanalysis research attesting to its absolute or relative effec-
produced less than expected success. The treatment tiveness. We can state with reasonable confidence
results of psychoanalysis and psychoanalytic ther- that psychoanalysis is superior to no treatment at
apy in this study, as in others (Sandell et al., 2000), all, but we cannot safely conclude that psycho-
tend to converge rather than diverge in outcome. analysis has proved itself more effective than a
Enough studies on psychoanalytic psychother- credible placebo therapy.
apy have appeared in recent years to enable a The conclusions from the growing research
meta-analysis, a systematic evaluation of the base on long-term psychoanalytic therapy remain
results of several independent studies. One such decidedly conflicted. On the one hand, most of its
meta-analysis located 27 studies of long-term psy- patients do indeed profit from the beginning to
choanalytic therapy, involving more than 5,000 the end of treatment. What’s more, the evidence
patients and averaging 150 sessions (de Maat et al., suggests that the outcomes of psychoanalysis and
2009). The overall success rate was 64% of patients psychoanalytic psychotherapy tend to be quite
at termination and 55% at longer follow-up for similar. On the other hand, we cannot conclude
moderate and mixed psychopathology. Those that psychoanalytic psychotherapy outperforms
figures are quite similar to the numbers reported less intensive and less expensive psychotherapies.
in the surveys of psychoanalysts, as reviewed earlier. (The considerable research conducted on short-
When patients were compared from the beginning term psychodynamic therapy will be considered
to the end of treatment, large effect sizes (1.03) were in Chapter 3.)
found for symptom reduction and medium effect
sizes (0.54) for personality change.
Although favorable, such pre- to posttreat- Criticisms of Psychoanalysis
ment effects tend to be inflated because they do From a Cognitive-Behavioral Perspective
not separate out the contribution of nonspecific Behavioral criticisms of psychoanalysis have been
factors (such as the value of attention and the frequent and intense. One set of criticisms revolves
passage of time) and because the psychoanalytic around the view that as a theory, psychoanalysis is

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44 Chapter 2

much too subjective and unscientific. The psycho- to theory construction to gather controlled data,
analytic notions of unconscious processes, ego, and but surely not all of his followers can hide behind
defenses are mentalistic, and incapable of direct that excuse. Unless psychoanalytic researchers
observation in a way that can be objectively mea- demonstrate scientifically that their treatment out-
sured and scientifically validated. All too frequently, performs other bona fide psychotherapies, we will
Freudians have reified rather than verified their continue to ignore this once-dominant system as if
concepts, such as the ego and the id. Freud’s it were a therapeutic dinosaur, too slow to survive.
ideas about superego formation, female sexuality,
dream interpretation, and other fanciful notions From an Existential Perspective
simply do not stand up under scientific scrutiny In contrast to the behavioral view, psychoanalysis is
(Fisher & Greenberg, 1996). much too objective for existentialists—not empiri-
The notion that “insight” itself is frequently cally, but theoretically and practically. Just look at
therapeutic is another mentalistic fiction. As B. the psychoanalytic conceptualization of humans.
F. Skinner (1971, p. 183) wrote, Psychoanalysis conceives of human beings as
objects, mere bundles of instinctual and defensive
Theories of psychotherapy which emphasize
energy. We are portrayed as neurotic collections of
awareness assign a role to autonomous man
complexes, stages, defenses, and conflicts. This psy-
which is properly, and much more effectively,
choanalytic conception has filtered into the very
reserved for contingencies of Psychoanalytic Ther-
core of our self-concepts, becoming one of the
apies 51 reinforcement. Awareness may help if
dominant forces in our dehumanization.
the problem is in part a lack of awareness, and
Psychoanalysis is also much too deterministic
“insight” into one’s condition may help if one
for our tastes. Where are freedom, choice, and
then takes remedial action, but awareness or
responsibility, the subjective experiences that
insight alone is not always enough, and it may
allow humans the option of being different from
be too much. One need not be aware of one’s
all the objects of the universe? How can a system
behavior or the conditions controlling it in order
that has placed so much emphasis on conscious-
to behave effectively—or ineffectively. On the con-
ness as the process of freeing people from psycho-
trary, as the toad’s inquiry of the centipede
pathology not take freedom and choice seriously?
demonstrates, constant self-observation may be a
We can freely choose to transcend psychoanalytic
handicap.
determinism and reductionism.
But there is a more devastating reaction. Beha-
viorists do not argue with psychoanalytic theory; From a Cultural Perspective
they ignore it. Why bother learning how psycho- Freud was indeed the grandfather of psychotherapy.
analysis is supposed to work when there are no He created psychoanalysis as a treatment for and by
empirical data to demonstrate that it does work? educated, middle-class Western Europeans. As is
The absence of any controlled experiments unfortunately true of many patriarchs, he
designed to evaluate the effectiveness of psycho- legitimized intrapsychic (inside the mind) and
analysis after 110 years of practice is a scientific androcentric (male-centered) biases adopted
disgrace! Even a few experiments every decade by generations of subsequent psychotherapists.
would be slower than the average analysis. Freud Virulent attacks have been leveled over the
himself can be excused as a genius too committed years against psychoanalysis from a cultural

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Chapter 2 Psychoanalytic Therapies 45

perspective, which emphasizes the centrality of penis and cathects with her father to share his
context, gender, and race/ethnicity. phallus. Freud (1933/1965b, p. 124) wrote that
For starters, the broader social context is prac- “girls hold their mother responsible for their lack
tically ignored in psychoanalytic treatment. The of a penis and do not forgive her for their being
exclusive focus on the intrapsychic makeup of thus put at a disadvantage.” How sexist is that?
the individual neglects the family, the culture, Note that the convoluted and unsubstantiated rea-
and the society. Disorders and fixations are attrib- soning does not apply to boys. Why is there no
uted to internal conflicts rather than family dys- vagina envy? Freud focused too much on sexual
function or social problems. An exemplar: Early fantasy and not enough on sexist ideology.
on, Freud courageously attributed many of his Psychoanalytic theory is so clearly patriarchal
female patients’ disorders to the childhood sexual and Eurocentric that much more could be criti-
abuse they had encountered, but later he retracted cized about it—the upper-class male values, the
this position and characterized these allegations as paucity of female psychoanalysts in Freud’s inner
fantasies. As a result, generations of therapists circle, its historical orientation, its expensive and
treated childhood sexual abuse as an intrapsychic inefficient process, its focus on personality
fantasy rather than an actual assault. restructuring at the expense of behavior change,
When psychoanalysts do venture from their to name a few. All in all, we cast a mote in Freud’s
internal psychopathological orientations to consider eye (Lerner, 1986).
relationships, it is largely to engage in mother-
bashing. One study (Caplan, 1989) analyzed a From an Integrative Perspective
decade of psychological research to determine the It is the essence of integration to seek what is of
nature and extent of mother-blaming. Of four value in any therapy system, especially one as rich
categories—things that mothers do, things that and complex as psychoanalysis. Some integrative
mothers fail to do, things that fathers do, and things therapists use a psychoanalytic approach, espe-
that fathers fail to do—only one regularly turned out cially in their formulation of their clients’ pro-
to be viewed as problematic: things that mothers do. blems. Psychoanalysis presents one of the few
Mothers have been blamed for causing more than theories with enough personality and psychopa-
70 different disorders in their children, including thology content to be the core of a diagnostic
bedwetting, schizophrenia, and learning disabilities. manual or the content of a Rorschach evaluation.
The father’s role is assumed to be peripheral. Psy- Most integrationists will also use the concepts of
choanalysts define “good enough mothering”; what resistance, defenses, and transference in their
about “good enough fathering?” (Okun, 1992). The thinking about the content of therapy.
impact of the father, the family, and the culture on As a system of psychotherapy, however, clas-
the child are minimized, at least when development sical psychoanalysis has become way too anti-
goes awry. Mothers must be to blame. quated and dogmatic for integrative tastes. As in
Freud’s infamous declaration that “biology is most systems, the disciples of a genius like Freud
destiny” represents an attempt to restrict women’s are usually less creative and, therefore, less flexi-
power and status. A classic illustration of the sex- ble. With Freud, theory and therapy continued to
ist nature of classic psychoanalysis is penis envy. evolve, but to many of the present practitioners of
A girl, we are told, concludes that something is psychoanalysis, it seems more important to be
wrong with her because she does not have a orthodox than to be innovative and effective.

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46 Chapter 2

A Psychoanalytic Analysis of Mrs. C


During the early years of her marriage, Mrs. C anger as a child and would probably have to
apparently made an adequate though immature defend against it as a parent.
adjustment. As an obsessive or anal personality, A case of pinworms is also characterized by
she expressed such traits as excessive orderli- anal itching, with the pinworms locating in the
ness in the alphabetical ordering of her children’s anus. In fact, to confirm that the problem was pin-
names, meticulousness in her concern with clean- worms, Mrs. C’s physician directed her to exam-
liness, stinginess in holding onto unused clothes ine her daughter’s anus with a flashlight while her
while buying no new ones, and constrictedness in daughter was sleeping. So while on one level the
never letting go of her sexual feelings and becom- pinworms were painful, on another level the pos-
ing excited. As time wore on and stress escalated, sibility of contracting pinworms could tempt Mrs.
Mrs. C graduated into a full-blown obsessive- C to exercise that secret pleasure of scratching an
compulsive disorder (OCD). itchy anus. With defenses weakened by illness
These problems probably resulted from Mrs. and fatigue, and with threatening impulses of
C’s interactions in the anal stage with overcontrol- aggression and anal sexuality stimulated by her
ling and overdemanding parents. We know Mrs. daughter’s pinworms, the conditions were set
C’s mother was a compulsive person who was for the emergence of neurotic symptoms that
overly concerned with cleanliness and disease. both defend against and give indirect expression
Her father overcontrolled Mrs. C’s expression of to Mrs. C’s unacceptable impulses.
aggression and her interest in men. We can imag- Look at how her neurotic symptoms provided
ine that such parents would be quite harsh in their further defense against her threatening impulses.
demands on issues such as toilet training and The compulsive showers and hand washing
could produce many conflicts in their daughter intensify her long-standing preoccupation with
over holding on and letting go of her bowels cleanliness. If danger lies in being dirty, then
and other impulses. From psychoanalytic theory, wash! These compulsive symptoms are in part
we can hypothesize that Mrs. C’s anal character- an intensification of her reaction formation of
istics developed, in part at least, as defenses keeping clean to control desires to play with dirt
against anal pleasures such as being dirty and and other symbols of feces. If desires to damage
messy and against impulses to express anger. her daughter were also breaking through, then
Why did the experiences surrounding her her washing could serve both as a means of
daughter’s case of pinworms precipitate a break- removing Mrs. C from interactions with her
down in Mrs. C’s previously adaptive traits and daughter in the morning and as a means of undo-
defenses and lead to the emergence of a full- ing any guilt over aggression by washing her
blown neurosis? Illness and fatigue from the hands clean of such bloody thoughts. The under-
Asian flu and from caring for so many sick chil- wear piled in each corner literally served to isolate
dren would place stress on Mrs. C’s defenses. Mrs. C and her family from more direct contact
But the precipitating event was also of such a with anal-related objects.
nature as to elicit the very impulses that Mrs. C How did Mrs. C’s neurotic symptoms allow
had come to defend against since early child- some gratification of her desires? The shower rit-
hood. First of all, how would anyone feel when a ual is most obvious, because each time she lost
daughter brings home pinworms when the family her place in her ritual, she had to go back to giv-
is already down with the Asian flu and the mother ing herself anal stimulation. In the process of iso-
is burdened with pregnancy and a toddler in dia- lating dirty materials like underwear and items
pers? Relatively unrepressed parents would be dropped on the floor, Mrs. C could also make a
upset, even though they might not express their mess of her house. It does not take much of an
anger directly because the child did not intend to interpretation to appreciate how Mrs. C was
get pinworms. But Mrs. C was not free to express expressing her aggression toward her husband
(continued)

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Chapter 2 Psychoanalytic Therapies 47

by making him get up at 5:00 A.M. and toward her would confront and clarify her pattern of talking
children by not cooking or adequately caring for about pinworms whenever she became anxious
them. and then interpret this pattern in a way that would
Why was Mrs. C unable to express her feelings allow Mrs. C to become aware that she uses her
and desires directly and thereby prevent the need obsession to defend against experiencing associa-
for a neurotic resolution of her conflicts? First, tions even more threatening than pinworms.
such direct expression would be entirely contrary The psychoanalyst would, in addition, deal
to her core personality concerned with controlling with Mrs. C’s well-established defense of isolating
such impulses. Second, the regression induced her affect. The analyst would slowly confront her
by her defenses’ weakening would cause Mrs. C pattern of saying only what she thinks about
to react more on a primary-process level than on events and not what she feels about them. The
a rational, secondary-process level. At the uncon- analyst would also be very sensitive to occasions
scious primary level, Mrs. C would be terrified when Mrs. C is being excessively warm and affec-
that loosening controls would result in her losing tionate, because such expressions would likely be
all control and being overwhelmed by her reactions to her true feelings of hatred and loath-
impulses. Being overwhelmed by instinctual stim- ing for the nongiving, controlling therapist.
ulation produces its own panic, but Mrs. C would The psychoanalyst would slowly assist Mrs. C
also panic about facing the wrath of her over- in understanding what her ritual cleaning is sym-
controlling parents for being a bad girl who soiled bolically washing away. For which “dirty acts” is
her pants or expressed anger. At an atemporal, Mrs. C atoning? Sexual impulses, homosexual
unconscious level, Mrs. C would not experience feelings, murderous urges toward her controlling
herself as the adult parent who is safe to express father, and rage toward a burdensome family are
anger, but as the controlled little girl who had bet- all probable unconscious culprits. All were for-
ter not express any resentment. bidden by her parents and society and all inter-
In considering psychoanalysis for Mrs. C, an nalized into her punitive superego, but all are
analyst would have to be quite confident that natural urges and curiosities of homo sapiens.
Mrs. C’s problem was indeed obsessive- As Mrs. C gradually became aware of the defen-
compulsive neurosis and not pseudoneurotic sive nature of her symptoms, she would gradually
schizophrenia, in which the neurotic symptoms experience intensely the feelings that would be
mask a psychotic process. Given how much she emerging toward the analyst. As she regressed,
has already regressed and how much her life is she might become aware of fears that her analyst
dominated by defensive symptoms, there could was trying to control her sex life, just as her father
be a real risk in encouraging her to regress further seemed to want to control it when he followed her
in psychoanalysis. If the analyst felt that further on a date during her teens. Even more threatening
evaluation confirmed previous reports that Mrs. would be her desires to have her fatherlike analyst
C. did not show evidence of a psychotic process, control her sexuality and thereby satisfy his and
then psychoanalysis might proceed. her desires together. As she regressed further,
When directed to lie on the couch and say what- she might become aware of desires to have her
ever comes to mind, Mrs. C would become quite fatherlike analyst satisfy her by having anal inter-
anxious about having to give up some of her con- course or to have her motherlike analyst pleasure
trols to the analyst. Obviously, she has to trust her by wiping her anus.
enough to believe that her analyst knows what to Mrs. C’s transference reactions would include
do and will not let her get out of control entirely. considerable hostility displaced from both of her
Resistance to letting her thoughts go would begin parents onto her analyst, so she would be fre-
immediately. It might take the form of returning quently enraged that the analyst was demanding
immediately to her obsession with pinworms and controlling while being ungiving, as were
whenever she became anxious. The analyst both her mother and her father. But she could
(continued)

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48 Chapter 2

not become conscious of hostile and sexual insight into the meaning and causes of her
impulses without also becoming conscious of neurosis. She would eventually become
fears that her parent/analyst was going to destroy conscious of ways in which she could channel
her or reject her by sending her to a state psychi- her dangerous impulses into more mature
atric hospital. She would then become acutely outlets that provide both controls and grati-
aware of how frequently she would try to control fication for her desires, such as expressing her
both her anxiety and her impulses by expressing anger in words. Over many years, Mrs. C might
the opposite of what she felt, by apologizing, or in consciously restructure her personality enough
other ways undoing her reactions, or by isolating to give her ego some flexibility in expressing
her impulses into more neutral thoughts. hostile and sexual impulses without having
As Mrs. C worked through the neurotic trans- to panic when situations threatened to
ference with her analyst, she would slowly gain stimulate them.

We are much more at home with the flexi- on shaky grounds. Central to contemporary psy-
bility of psychoanalytic psychotherapy and choanalytic theory are a series of propositions that
relational psychoanalysis. However, we are not have received considerable research support and
comfortable with the fact that psychoanalytic clinical consensus. Among these are—the uncon-
psychotherapy, like psychoanalysis, has not been scious is alive and powerful; the origins of many
demonstrated to be more effective than any other behavioral disorders are rooted in childhood;
form of therapy. One certainly cannot justify recom- humans are in internal conflict and tend to pro-
mending classical psychoanalysis to clients when it duce compromise solutions; and mental represen-
is the lengthiest and most expensive alternative. tations of ourselves, others, and relationships
Psychoanalysis may provide a rich source of therapy profoundly impact our daily functioning (Westen,
content, but it has yet to establish any real advantage 1998). These are Freud’s legacies.
in patient success. At the same time, bewildering changes in
practice confront the new generation of psycho-
analysts. These include a diminishing number of
Future Directions patients for psychoanalysis proper; an increasing
Many psychotherapists in the past century have number of nonpsychoanalytically based psy-
sounded the death knell for psychoanalysis. They chotherapies; a societal retreat from insurance
are convinced that psychoanalysis will disappear as coverage for long-term psychotherapeutic care; a
a body of knowledge and as a form of treatment. growing preoccupation with cost-effectiveness and
Allusions to psychoanalysis as a “dinosaur,” “a cost containment; a rise in the use of psychotropic
relic,” and a “gas-guzzler in an era of compacts” medication; and the increased use of managed
reflect this dismissive sentiment. However, we and care and accountability, with their inevitable
many others agree with Silverman’s (1976) assess- infringements on the confidentiality of the thera-
ment of psychoanalytic theory—borrowed from peutic relationship (Rouff, 2000).
Mark Twain’s famous quip when confronted with For all these reasons, the future of psychoanal-
news reports of his own demise—that “the reports ysis probably lies in time-limited psychoanalytic
of my death are greatly exaggerated.” therapy and briefer forms of relational psychoanal-
Although commentators periodically declare ysis. The “gold standard” of psychoanalysis proper
that Freud is dead, his repeated burials lie has given way to the “gold leaf” or copper of

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Chapter 2 Psychoanalytic Therapies 49

psychoanalytic therapy. Although there will always theories Freud sketched a century ago (Solms,
be classical psychoanalysis available to psychoana- 2004). The term (and journal title) neuropsych-
lysts in training and the wealthy in need, less than oanalysis unites the previously divided fields of
1% of all patients receiving psychotherapy or neuroscience and psychoanalysis.
counseling today receive psychoanalysis proper. If there were ever a Book of Genesis on psy-
The future we foresee for psychoanalysis can chotherapy, it would probably start out something
be summed up by the terms interpersonal and like this: “In the beginning, there was nothing
integration. Although there is honest disagreement until psychoanalysis” (Scaturo, 2005). Freud had
as to the permanence of the resurgence of psycho- the formidable task of creating something from
analysis, almost all observers concur that this is nothing and of structuring the structureless. He
attributable to its interpersonal and relational was the pioneer of psychotherapy. It is easy years
emphasis. New attention is being paid to the later to contradict the pioneer, but it is not the
two-person or dyadic character of the therapeutic function of the pioneer to say the last word but
relationship. Both patient and therapist continu- to say the first word (Guntrip, 1973). Psychoanal-
ally and reciprocally contribute to the therapeutic ysis can no longer be simply identified with the
situation, which always contains real and transfer- original, classic psychobiology; Freud himself
ence elements. The notion of “pure” transference began the first major move beyond that starting
and the singular power of interpretation have point, when in the 1920s he turned his attention
proved illusions. The two-person, relational to the analysis of the ego. Freud was the coura-
model is on the ascendancy. geous pioneer who opened up an entirely new
In practice, few psychotherapists are “purists.” field of systematic inquiry into the inner workings
Integration dominates the contemporary scene of human experience.
(see Chapters 16 and 17), and the modern psycho-
analytic therapist demonstrates greater openness
to tailoring treatment to the needs of the patient
Key Terms
and adapting to changing circumstances. Many anal personality incorporation
psychotherapists continue to embrace a psychoan- anal stage insight
alytic orientation while carefully integrating or analysand instincts
assimilating methods from other systems of psy- castration anxiety intellectualization
chotherapy, especially humanistic and cognitive compromise formation interpretation
therapies. In fact, reviews of Freud’s own treatment corrective emotional intersubjective
cases (e.g., Lynn & Vaillant, 1988; Yalom, 1980) experience latency stage
indicate that the master used many “non- countertransference latent content
psychoanalytic” methods, such as suggesting defense mechanisms manifest content
behavioral homework assignments and intervening denial meta-analysis
with a patient’s family on her behalf. Freud was an displacement neuropsychoanalysis
early integrationist. dynamic view neurosis
Contributing to the renewed vitality of psy- fixation oedipal conflict
choanalysis is the tremendous interest in integrat- free association oral personality
ing advances in neuroscience. Neuroscientists are genetic view oral stage
discovering that their biological descriptions of the genital personality phallic stage
brain may fit together best with the psychological genital stage primal anxiety

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50 Chapter 2

primary-process resistance Greenson, R. R. (1967). The technique and practice


thinking secondary process of psychoanalysis (Vol. 1). New York: Interna-
projection structural tional Universities Press.
psychic determinism structural change McWilliams, N. (2004). Psychoanalytic psychother-
psychoanalysis sublimation apy: A practitioner’s guide. New York: Guilford.
psychoanalytic therapy transference Mitchell, S. (1988). Relational concepts in psycho-
psychosexual stages transference neurosis analysis: An integration. Cambridge: Harvard
reaction formation unconscious University Press.
relational undoing JOURNALS: American Journal of Psychoanalysis;
psychoanalysis working alliance Bulletin of the Menninger Clinic; Contemporary
repression working through Psychoanalysis; International Journal of Psycho-
analysis; International Review of Psycho-Analysis;
Recommended Readings Journal of Clinical Psychoanalysis; Journal of the
American Psychoanalytic Association; Modern
Fisher, S., & Greenberg, R. P. (1996). Freud
Psychoanalysis; Neuro-Psychoanalysis; Psycho-
scientifically reappraised: Testing the theories
analysis and Contemporary Thought; Psychoanal-
and therapy. New York: Wiley.
ysis and Psychotherapy; Psychoanalytic Dialogues;
Freud, A. (1936). The ego and the mechanisms
Psychoanalytic Inquiry; Psychoanalytic Psychology;
of defense. New York: International Universities
Psychoanalytic Quarterly; Psychoanalytic Review;
Press.
Psychoanalytic Social Work.
Freud, S. (1900/1953). The interpretation of
dreams. First German edition, 1900; in Recommended Websites
Standard edition (Vols. 4 & 5), Hogarth
Press, 1953. American Psychoanalytic Association:
Freud, S. (1933/1965b). New introductory lectures www.apsa.org
on psychoanalysis. First German edition, 1933; www.teachpsychoanalysis.com
in Standard edition (Vol. 22), Hogarth Press, APA Division of Psychoanalysis:
1965. www.apadivisions.org/division-39/
Gabbard, G. O., Litowitz, B. E., & Williams, P. International Association for Relational
(2012). Textbook of psychoanalysis (2nd ed.). Psychoanalysis:
Washington, DC: American Psychiatric www.iarpp.net/
Publishing. Psychodynamic Diagnostic Manual:
Galatzer, R. M., Bachrach, H., Skolnikoff, A., & www.pdm1.org
Waldron, S. (2000). Does psychoanalysis work? Sigmund Freud and the Freud Archives:
New Haven: Yale University Press. www.freudarchives.org

Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
CHAPTER 3
Psychodynamic
Therapies

Courtesy of Alfred Adler Institute of Chicago


Alfred Adler

Max was preoccupied with getting into Harvard


Medical School. He was convinced that acceptance
at such a superior school was his only chance of
demonstrating to others that he was not a clod.
His own deep-seated feelings of inferiority were
attributed to the fact that his younger brother had
been favored at home and was superior at school.
Max himself had always been a good student but
never outstanding. He believed that his college
performance was handicapped by his concern that
other students were spreading rumors about his
being homosexual. Max was afraid that he might
Courtesy of Heinz Kohut

one day reach out and grab the penis of one of his
fellow students in his all-male college.
In spite of what others might think, Max was Heinz Kohut
certain that he was not gay. He said he had never
desired sex with a man and had experienced two thought, so that he could succeed in his quest for
fairly satisfying relationships with women. Max admission to Harvard.
believed that his obsession to reach out and grab One of Max’s previous therapists, himself a
his fellow students was a hostile desire to strike Harvard MD, had assured Max that he was
back at those who were bothering him. His goal Harvard material. In spite of a glowing letter from
in psychotherapy was to extinguish his obsession the therapist, Max had failed to get into Harvard or
with penises and with what fellow students any other medical school, for that matter. When I

51

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52 Chapter 3

(JOP) suggested to Max that his goals might be Freud’s direct descendants attempt to complete
unreasonable and unnecessarily high, he didn’t and expand all that he had left undone. These neo-
want to hear it. He was zealously doing analysts or neo-Freudians (neo meaning after or new)
postgraduate work to improve his scores on the are now more commonly known as psychodynamic
medical school admissions test, and there was no therapists. Although they are a diverse lot, psychody-
holding him back. As our relationship developed, I namic therapists share similar directions away from
expressed my admiration for his ambition but felt he classical psychoanalysis. These central revisions can
was overly preoccupied with himself. He agreed, but be summarized as follows.
countered that if he received his MD from Harvard,
then he could really do something for others. Taking PSYCHOANALYSIS PSYCHODYNAMIC
a lead from Alfred Adler, I challenged Max to prove Id Ego
that he cared about others. I challenged him to find a Intrapsychic Interpersonal
way to make at least one person a little happier each Defenses Mastery, adaptation
day for the next week. Biological Social
That particular week, the staff at a state
hospital happened to be on strike. Max met my The classic psychoanalytic emphasis on the
challenge by volunteering each day to help care id (so-called drive theory) is transformed in psy-
for some of the most troubled patients. Then he chodynamicism into an emphasis on the ego and
went even further. He became quite upset over its functioning, hence the term ego psychology.
the way the patients were treated in the hospital Whereas Freud was primarily concerned with
and began organizing the other volunteers and intrapsychic (inside the person) conflicts, his des-
some patients to form a citizens’ group for cendants are more concerned with interpersonal
patients’ rights. When he learned that such an (between people) conflicts. In fact, a major
organization already existed, he combined forces branch of psychodynamic therapy is known as
and was elected to the citizens’ advisory board. object relations—objects meaning people (or
As his concern for others increased, Max’s their mental representations). Freud’s original
preoccupation with penises and his peers’ opinions emphasis on biological forces and defense
faded. He began an intense relationship with a mechanisms shifts to social forces and coping
woman volunteer who was also a strong advocate or mastery experiences.
for patients’ rights. His goal to get into Harvard, The dividing line between psychoanalytic
however, became even stronger, as he decided to therapies and psychodynamic therapies is hazy.
eventually become a psychiatrist in order to make Deciphering where one ends and the other begins
a meaningful impact on the state hospital system. is a genuine challenge but the differences are real
enough. Adding to the confusion is the inconsis-
tent use of terminology; some authors refer to all
A Sketch of Freud’s post-Freudian therapy as psychoanalytic, whereas
Descendants others prefer the term psychodynamic.
Quoting Freud in psychotherapy is like quoting In Chapter 2, we considered Freud’s original
Newton in physics. Both men are assured of that drive theory of psychoanalysis and the newer rela-
permanent place in the history of thought that tional psychoanalysis. In this chapter, we examine
belongs to the genuine pioneer. Those who come five variants of psychodynamic therapy: Adlerian
after faithfully follow up and extend the original therapy, ego psychology, object relations, support-
theory. We all warm our hands in Freud’s fires. ive therapy, and brief psychodynamic therapy.

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Chapter 3 Psychodynamic Therapies 53

Of course, other prominent theorists have A Sketch of Alfred Adler


contributed to the evolution of psychodynamic
Alfred Adler (1870–1937) was the first person to for-
therapy. As mentioned in Chapter 2, Anna Freud
mulate how feelings of inferiority could simulate a
(1895–1982), Sigmund’s daughter, made substantive
striving for superiority, as evidenced by Max. Adler
contributions in her own right. Wilhelm Reich
himself had striven to be an outstanding physician, in
(1897–1957) was originally a member of Freud’s
part to compensate for the frailty he had experienced
inner circle but broke ranks when he rejected Freud’s
as a youngster with rickets. As the second son in a
death instinct. Reich developed character analysis as
family of six, he was further spurred to stand out by
an alternative to classical psychoanalysis.
his rivalry with his older brother and his somewhat
Likewise, Carl G. Jung (1875–1961), once hand-
unhappy relationship with his mother. His strongest
picked by Freud as his successor and hailed as the
support, both emotionally and financially, came from
“crown prince” of psychoanalysis, launched his own
his grain-merchant father, who encouraged him to
analytical psychology. Jung pursued a path different
complete his MD at Vienna University.
from Freud’s when he found himself unable to accept
In 1895, Adler began as an ophthalmologist and
the exclusively sexual nature of Freud’s notion of
then switched to general practice, which he main-
libido. Jung relied extensively on the interpretation
tained long after he became known as a psychiatrist.
of dreams and symbols to access the patient’s arche-
As a psychiatrist in Vienna, he could not help but
types (inherited predispositions or models on which
consider Freud’s theories, which were creating such
similar things are patterned). Jung was convinced of
a stir and generating so much criticism. Adler was
the existence of a collective unconscious, along with
quick to appreciate the importance of Freud’s ideas,
a personal unconscious. The collective unconscious
and he had the courage to defend the controversial
contains primordial archetypes inherited from our
system. Freud responded by inviting Adler to join
past that record common experiences repeated over
his select Wednesday evening discussion circle.
countless generations. Common archetypes include
Frequently cited as a student of Freud, Adler
the hero, the shadow (or “dark side”), the Mother,
was actually a strong-minded colleague in har-
and the trickster. These controversial propositions
mony with Freud on some issues and in conflict
along with his word association test and the
on others. Adler’s book Study of Organ Inferiority
introvert-extravert distinction remain Jung’s original
(1917) was highly praised by Freud. On the
contributions to the field.
other hand, when Adler introduced the concept
Jung and Reich enjoyed tremendous popularity
aggression instinct in 1908, Freud disapproved.
in the 1950s and 1960s; in fact, previous editions of
It was not until long after Adler had rejected
this text devoted entire chapters to their theories.
his own aggression-instinct theory that Freud
However, their influence has gradually waned,
incorporated it into psychoanalysis in 1923.
reflected in the repeated finding that less than 1% of
By 1911, the differences between Adler and
psychotherapists designate themselves as Jungians
Freud were becoming irreconcilable. Adler criticized
or Reichians (see Table 1.1). As a result, we have
Freud for an overemphasis on sexuality, although
condensed our presentation on them.
Freud condemned Adler’s emphasis on conscious
We begin this chapter, instead, with Alfred
processes. At a series of tense meetings, Adler dis-
Adler. He is, arguably, the first and most promi-
cussed his criticisms of Freud and faced heckling
nent psychodynamic theorist whose impact con-
from the most ardent of Freud’s followers. Follow-
tinues to this day. Thereafter, we consider ego
ing the third meeting, Adler resigned as president of
psychology, object relations, supportive therapy,
the Vienna Psychoanalytic Society and soon
and brief psychodynamic therapy.

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54 Chapter 3

resigned as editor of the society’s journal. Later that for those suffering from social ills, Adler showed a
year, Freud indicated that no one could support light side and loved good food, music, and the com-
Adlerian concepts and remain in good standing as pany of others. He entertained his guests and his
a psychoanalyst. Freud thus pressured other mem- audiences with his excellent humor. In spite of his
bers to leave the society, at the same time setting an own fame, he abhorred pomposity. He was commit-
unfortunate precedent of stifling serious dissent. ted both professionally and personally to expressing
Adler quickly established himself as the leader of his commonality with his fellow humans.
an emerging system of psychotherapy. He called his
system individual psychology to underscore the
importance of studying the total individual in ther- Theory of Personality
apy. His productivity was interrupted by service as a Striving for superiority is the core motive of the
physician in the Austrian army during World War I. human personality. To be superior is to rise above
Following the war, he expressed his interest in chil- what we currently are. To be superior does not
dren by establishing the first of 30 child guidance necessarily mean to attain social distinction, domi-
clinics in the Viennese school system. Adler nance, or leadership. Striving for superiority means
expressed his social interest by speaking out strongly striving to live a more perfect and complete life. It
for school reforms, improvements in child-rearing is the superordinate dynamic principle of life; striv-
practices, and the rejection of archaic prejudices ing for completion and improvement encompasses
that persistently led to interpersonal conflict. and gives power to other human drives.
Adler’s interest in common people was Striving for superiority can be expressed in
expressed by his commitment to avoid technical jar- many ways. Ideals of the perfect life vary from
gon and to present his work in a language readily “peace and happiness throughout the land” to “hon-
understood by nonprofessionals. Unlike many intel- esty is the best policy” to “Deutschland über Alles”
lectuals, he was eager to speak and write for the (Germany above all). Perfection is an ideal created in
public, and his influence among the public probably the minds of humans, who then live as if they can
spread further than his influence on mental health make their ideals real. Individuals create their own
professionals of that era. As an indefatigable writer fictional goals for living and act as if their personal
and speaker, he traveled extensively to bring his goals are the final purpose for life. This fictional
message to the public. His influence seemed to finalism reflects the fact that psychological events
peak just prior to the advent of Hitler, when 39 sepa- are determined not so much by historical circum-
rate Adlerian societies were established. stances as by present expectations of how one’s
Adler saw the United States as a place of great future life can be completed. If a person believes
potential for his ideas. In 1925, at a relatively late that a perfect life is found in heaven as the reward
age, he was struggling to learn English so he could for being virtuous, then that person’s life will be
speak to American professionals and to the public in greatly influenced by striving for that goal, whether
their own language. He became a professor of psy- heaven exists or not. Such fictional goals represent
chiatry at the Long Island School of Medicine and the subjective cause of psychological events. Humans
settled in New York in 1935. Two years later, at the evolve as self-determined participants who influence
age of 67, he ignored the urging of his friends to their futures by striving for internally created ideals.
slow down and died from a heart attack while on Each of us creates an ideal self that represents the
a speaking tour in Scotland. perfect person we might strive to become.
Adler’s influence on people was as much per- What are the sources of this striving for superior
sonal as intellectual. Besides his serious compassion ideals? Superiority strivings are the natural reaction

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Chapter 3 Psychodynamic Therapies 55

to inescapable feelings of inferiority, an inevitable superior intellectual. An intellectual style of life then
and virtually innate experience of all humans. Sub- becomes the integrating principle of the person’s life.
jective feelings of inferiority may be based on objec- An intellectual arranges a daily routine, develops a
tive facts such as organ inferiorities—physical set of reading and thinking habits, and relates to
weaknesses of the body that predispose us toward family and friends in accordance with the goal of
ailments such as heart, kidney, stomach, bladder, intellectual superiority. An intellectual style of life is
and lung problems. Organ inferiority can be a a more solitary and sedentary existence than is the
stimulus to compensate by striving to be superior. active life of a politician, for example. A lifestyle is
The classic case is that of Demosthenes, who com- not the same as the behavioral patterns of a per-
pensated for his early stuttering by becoming one of son’s existence. All of a person’s behavior springs
the world’s great orators. from that individual’s unique style of life. A lifestyle
Feelings of inferiority—or, more broadly, an is a cognitive construction, an ideal representation
inferiority complex—can arise from subjectively of what a person is in the process of becoming.
felt psychological or social weaknesses as well as People construct their lifestyles partly on the
from actual bodily impairments. Young children, basis of early childhood experiences. The child’s
for example, can be aware of being less intelligent position in the family constellation—the birth
and less adept than older siblings, and so they strive order or ordinal position—is especially influen-
toward a higher level of development. To feel infe- tial on his or her lifestyle. A middle child, for exam-
rior is not abnormal. To feel inferior is to be aware ple, is more likely to choose an ambitious style of life,
that we are finite beings who are never wise enough, striving to surpass the older sibling. Second children,
fast enough, or powerful enough to handle all of in particular, are born to rebel (Sulloway, 1996). The
life’s contingencies. Feelings of inferiority have oldest child faces the inevitable experience of being
stimulated every improvement in humanity’s ability dethroned by a new center of attention. Having to
to deal more effectively with the world. give up the position of undisputed attention and
Feeling inferior and consequently striving for affection produces feelings of resentment and hatred
superiority applies to gender as well. Adler’s notion that are part of sibling rivalry. The oldest child enjoys
of masculine protest refers chiefly to a woman looking to the past when there was no rival and is
protesting against her feminine role. Unlike Freud’s likely to develop a more conservative style of life. The
proposal that a woman wishes to be a man and youngest child possesses older siblings who serve as
desires his anatomical structure, Adler recognized pacemakers to goad development. Youngest children
that a woman wishes to have a man’s freedom and never have the experience of losing attention to a
desires his privileged position in society. Status, not successor and are more likely to expect to live the
genitalia, is the real goal. A man, too, can suffer life of a prince or princess.
from masculine protest when he believes his mas- Although objective facts such as organ inferio-
culinity is in some fashion inferior and conse- rities and birth order will influence the lifestyle a
quently compensates by adopting hypermasculine person constructs, they do not ultimately determine
behaviors. Preoccupation with big trucks, large how a person lives. The prime mover of the lifestyle
guns, huge muscles, and other symbols of male is the creative self. As such, the creative self is not
power may reflect such compensation. easily defined. It is a subjective power that gives
A person’s particular feeling of inferiority influ- humans the unique ability to transform objective
ences the style of life that person chooses for facts into personally meaningful events. The creative
becoming superior. Feeling intellectually inadequate self keeps a person from becoming just a product of
as a child, for example, may lead one to become a biological and social circumstances by acting on

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56 Chapter 3

these circumstances to give them personal meaning. discourage social interest. Children from such fami-
The creative self is an active process that interprets lies are more likely to strive for a more complete life
the genetic and environmental facts of a person’s life at the expense of others. Children discouraged from
and integrates them into a unified personality that is social interest tend to choose one of four selfish goals
dynamic, subjective, and unique. From all the forces for attaining superiority: attention seeking, power
impinging on a person, the creative self produces a seeking, revenge taking, and declaring deficiency or
personal goal for living that moves that person defeat (Dreikurs, 1947, 1948). Although these selfish
toward a more perfect future. goals may be the immediate strivings of misbehaving
Every style of life must come to grips with the children, they can also become the final traits that
fact that humans are social beings born into inter- lead to pathological lifestyles.
personal relationships. A healthy style of life reflects A pampered lifestyle results from parents dot-
a social interest in all human beings. A healthy ing on their children, doing tasks for them that are
personality is aware that a complete life is possible well within the children’s abilities to do themselves
only within the context of a more perfect society. (Adler, 1936). The message the children receive is
A healthy personality identifies with the inferiorities that they are not capable of doing things for them-
common to us all. The ignorance we all share, such selves. If children conclude that they are inadequate,
as how to have peace in the world or how to be free they develop an inferiority complex, which is more
from dreaded diseases, spurs the healthy personality than just inferiority feelings; they acquire a total
to help humanity transcend these weaknesses. As self-concept of inadequacy. Inferiority complexes
Adler (1964, p. 31) wrote, “Social interest is the lead pampered personalities to avoid tackling the
true and inevitable compensation for all the natural basic life tasks of learning to work, relating to
weaknesses of individual human beings.” intimates, and contributing to a constructive society.
Social interest is an inherent potential that can Lacking adequate social interest, they attempt to
capture the commitment of any person, but it will compensate through constant attention seeking.
not develop on its own. Social interest must be The worldview of people with pampered lifestyles
nourished within a healthy family atmosphere, suggests that the world should continue to take
which fosters cooperation, respect, trust, support, care of them and attend to them even when they
and understanding. The enduring values and are noncontributing adults. A passive, pampered
action patterns of family members, especially the lifestyle results in laziness, in which the clear mes-
parents, make up a family atmosphere that can, if sage is a dependent desire to be taken care of. Lazy
healthy, encourage children to reject purely selfish adolescents and adults receive considerable negative
interests in favor of larger social interests. Healthy attention from family and friends trying to steer
personalities are those encouraged by the prospect them into a more constructive style of life. If
of living a more complete life by contributing to being lazy or a nuisance fails to bring sufficient nur-
the construction of a more perfect world. turance, the pampered person is likely to withdraw
into angry pouting.
One of the most common neurotic styles to
Theory of Psychopathology emerge from parental domination is the compulsive
Pathological personalities have become discouraged lifestyle (Adler, 1931). The constant nagging, scold-
from attaining superiority in a socially constructive ing, deriding, and fault finding of dominating parents
style. Pathological personalities tend to emerge from can lead to an inferiority complex in which the com-
family atmospheres of competition, mistrust, neglect, pulsive person feels powerless to solve life’s problems.
domination, abuse, or pampering, all of which Afraid of ultimate failure in life’s tasks, compulsives

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Chapter 3 Psychodynamic Therapies 57

move into the future in a hesitating manner. When value. The more passive isolates despair and
feeling powerless to handle their futures, they will declare that, because of such overwhelming
hesitate, using indecision and doubt to try to hold personal deficiencies, there is no way they can be
back time. They may also resort to rituals to keep of interest or service to others.
dreaded time from moving ahead. Besides giving a The destructive goals of pathological personal-
sense of timelessness by repeating the same act over ities are typically understandable, given the family
and over, rituals serve as a safeguard against further atmospheres that encourage such goals. Though
loss of self-esteem. The compulsive can always say, “If understandable, these goals are mistakes. Patholog-
it weren’t for my compulsiveness, look how much I ical personalities construct maladaptive goals by
could have done with my life.” making such basic mistakes as generalizing about
Compulsions as a compensatory means can ren- the nature of all human relationships on the basis
der an almost godlike sense of power. The compul- of the very small sample they have experienced.
sive ritual is experienced as an epic struggle between Their particular parents or siblings may have
the good and evil forces of the universe that only the acted cruelly, indifferently, or abusively. However,
compulsive has the power to control. Compulsives if it weren’t for distorted perceptions, such troubled
act as if they have the power to save other humans persons could find evidence of kindness and caring
from harm, disease, or death, if only they carry out from more constructive relationships. Pathological
their rituals. So they check and recheck to see if the personalities also make the basic mistake of form-
gas is off; they put knives on the table at just the ing conclusions about themselves based on dis-
proper angle; or they touch every classroom desk torted feedback from just a few people. Neglected
to make sure that no one has been hurt. To fail to children, for example, may erroneously conclude
repeat their compulsions is to risk evil consequences that they are unlovable because one or both of
for the world. If compulsives feel they cannot their parents were unable to care for them.
succeed on the stage of life, they can at least create
their own secondary theater of operations, their own Therapeutic Processes
dramatic rituals. The compulsive can ultimately With their lifestyles created at a young age, most
declare a superior triumph: “See, I have succeeded psychotherapy patients are too preoccupied follow-
in controlling my own urges.” ing the details of their cognitive maps to be fully
Abused children are more likely to seek revenge aware of the pattern of their lifestyles and the goals
on society than to help it. As adolescents and adults, toward which they are directed. Many patients do
these individuals often develop a vicious style of life not even want to think about the fact that their
that actively seeks superiority by aggressing against a troubled lives are the result of their self-created styles
society that seems so cold and cruel. More passive of life. They prefer to experience themselves as the
revenge can be taken by those who adopt a passive- unfortunate victims of external circumstances. As a
aggressive style of life and hurt others through con- result, therapy must involve an analysis of the cog-
stant inconsiderateness. nitive lifestyles of patients in order to help them
Neglected children are apt to declare defeat as become more fully conscious of how they are direct-
adults. They cannot expect to succeed in a society ing their own lives toward destructive goals.
that does not care. The message in their with-
drawal is that they are above needing others. To Consciousness Raising
shore up their shaky sense of superiority, such The Client’s Work. Because the lifestyle is expressed in
isolates may denigrate others and convince them- all that an individual does, clients cannot help but
selves that they really have not lost anything of reveal their styles of life. Their behaving, speaking,

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58 Chapter 3

sitting, writing, responding, asking questions, and their behaviors, including their pathological beha-
paying bills all have the personalized stamp of a viors, serve the goal of making real the fictional
unique style of life. If the cognitive lifestyles are to finalisms that were created early in life.
be brought into bold relief and clear consciousness, To become aware of the overarching pattern and
then clients must be willing to reveal special phenom- purpose of a patient’s life, the therapist must conduct
ena in therapy, including their dreams, earliest mem- a fairly complete evaluation of the lifestyle. A lifestyle
ories, and family constellations. Besides revealing analysis includes a summary of the client’s family
important information, clients are encouraged to constellation. The order of birth, the gender of
participate actively in the analysis of their lifestyles. siblings, the absence of a parent, and the feelings of
Becoming more aware of one’s lifestyle and which child was favored are all crucial factors in a
disorder can be accelerated by reading books writ- family constellation that can be interpreted as influ-
ten by others, a process known as bibliotherapy. encing the lifestyle. An interpretation of the client’s
Adler and his followers were among the first psy- earliest recollections (anamnesis) will give a picture
chotherapists to pen self-help books for the lay of whether the client felt encouraged or discouraged
public, and their clients are frequently asked to to compensate for inferiority feelings in a socially
read these and related works. The Adlerian goals constructive style.
for bibliotherapy are embodied in six “E’s” A lifestyle analysis will also include an inter-
(Riordan, Mullis, & Nuchow, 1996): pretation of the basic mistakes the client made in
constructing a view about the nature of the world.
Educate by filling in psychological knowledge and
The most common cognitive mistakes include
gaps
(1) overgeneralizations, such as “nobody cares”;
Encourage by reading inspirational materials (2) distortions of life’s demands, such as “you
Empower by reviewing goal formation and can’t win at life”; (3) minimization of one’s worth,
attainment such as “I’m really inadequate” or “I’m only a
Enlighten by increasing self- and other-awareness housewife”; (4) unrealistic goals to be secure, such
Engage with the social world through modeling as “I must please everyone”; and (5) faulty values,
and social mentoring such as “get ahead, no matter what it takes” (Mosak &
Dreikurs, 1973).
Enhance by reinforcing specific lifestyle changes
Unlike many therapists, Adlerians do not stop
addressed in psychotherapy
at analyzing their patients’ problems. They are
The Therapist’s Work. In raising consciousness, equally committed to giving clients feedback
Adlerian therapists rely on interpreting the impor- about their personal assets. Thus, a summary of
tant information that clients present. Adlerian a client’s strengths is included as part of a lifestyle
interpretations are not concerned with making analysis, which is presented to the client in a
causal connections between past events and present teacher-to-student fashion. The lifestyle summary
problems. The past is connected to the present only is offered as if the therapist were presenting at a
to demonstrate the continuity of a patient’s style of case conference, but here the client has a chance to
life. Interpretations are concerned mainly with con- cooperate in the analysis. Clients can indicate
necting the past and the present to the future. whether they agree or disagree with the therapist’s
Interpretations help clients become aware of the summary. Therapists can make necessary changes
purposive nature of their lives, of how their past in their view of the client’s lifestyle, or they can
and present experiences are directed toward fulfill- interpret the client’s response as resistance to a
ing future goals. Patients become aware of how all more complete view of the lifestyle if clients are

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Chapter 3 Psychodynamic Therapies 59

indeed resisting seeing themselves more related images encourage clients to laugh at their
completely. styles rather than to condemn themselves. Once cli-
The presentation of a lifestyle summary involves ents can laugh about playing Bozo the Clown or Cae-
both feedback and education. Individual clients are sar the Conqueror, they can devalue the desire for
given personal feedback about their unique family attention or control.
constellation, their personal feelings of inferiority, Adlerians also assign tasks to patients
and their particular assets and basic mistakes. At designed to help them experiment with expressing
the same time, clients are educated in a theory of a social interest. A therapist might assign a patient
lifestyle that emphasizes the creative self, social inter- the task of doing something each day that gives
est, and the striving for superiority. In interpreting pleasure to another person. In the process of com-
life goals and demonstrating the basic mistakes in pleting such tasks, clients experience for them-
living for selfish values instead of social interests, selves the valuable consequences that come from
Adlerians teach clients a new philosophy of life. In doing something for others.
fact, Adlerians believe that psychotherapy is incom- As patient values change, therapists may still
plete if it does not include an adequate philosophy of have to offer methods that help patients avoid
life (Mosak & Dreikurs, 1973). slipping back into old habits of responding to self-
ish goals. Catching oneself is a technique that
Contingency Control encourages clients to think about catching them-
The Client’s Work. As a cognitive approach to change, selves “with their hands in the cookie jar.” They
Adlerian therapy tries to weaken the effects of present should try to actually catch themselves in the pro-
contingencies by having clients reevaluate their future cess of acting out a destructive behavior—for
goals. By reevaluating their goals pertaining to power, instance, overeating or overdrinking. With prac-
revenge, and attention, clients decrease reinforcing tice, including the internal practice of anticipating
consequences such as being the center of attention “putting a hand in a cookie jar,” clients can learn
or controlling others. In the process of reevaluating to anticipate a situation and to turn their attention
selfish goals, patients may experiment with behaviors to more constructive consequences rather than
directed toward a social interest to experience the automatically responding to destructive goals.
consequences that result from striving for social inter-
est. After experiencing the good feelings that come Choosing
from helping another person, clients can realistically The Client’s Work. Just as patients originally chose
compare and reevaluate the consequences that they particular lifestyles as children, so too are they
had been receiving from a self-centered life. capable of choosing to radically change their life-
The Therapist’s Work. A technique to help a client styles at a later age. Once they are more fully con-
reevaluate the consequences of selfish goals is to create scious of their fictional finalisms, and once they
images that capture the essence of the client’s goals. have evaluated selfish goals in comparison with
Clients who are constantly striving to be the center of social goals, clients are freer to choose to stay
attention, for instance, may be asked to imagine with their old styles or to create a new life. Some
themselves as Bozo the Clown, who becomes the cen- goals, such as holding power over others or craving
ter of attention by having people throw things at him, excessive attention, are highly valued by many peo-
such as insults or sarcastic remarks. When clients find ple, and there is no assurance clients will choose to
themselves playing the buffoon, they can imagine that give up such goals in the name of social interest.
they are like Bozo the Clown sitting in a dunk tank Clients may elect to stay with the security of an
just egging people on to knock him down. These and unsatisfying style of life because it is a known

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60 Chapter 3

quantity or because many people value it in society. that they can indeed create whatever feelings they
To consider choosing a radically new lifestyle can wish by deciding what they will think about. After
threaten security, and clients may opt to reaffirm practicing cognitive control of emotions, clients are
their long-standing lifestyles. impressed with their enhanced ability to determine
The Therapist’s Work. Rather than have cli- emotions. With an increased ability to choose
ents face a sudden and dramatic decision to whether to be angry or not, or depressed or not,
throw themselves into the darkness of an clients are in the process of liberating their lifestyles
unknown style of life, therapists use techniques from emotions that once seemed overwhelming.
that encourage clients to experiment slowly with
new alternatives for living. One such technique is Therapeutic Content
the acting “as if .” For example, a 35-year-old Intrapersonal Conflicts
widow had decided that now, after having
Psychological problems are primarily intrapersonal in
known the security of 6 years of relying only on
origin, reflecting the destructive lifestyle adopted at an
herself, she valued the idea of developing an inti-
early age. With its focus on the lifestyle of the individ-
mate relationship with a man. She had met a man
ual, Adlerian therapy was traditionally carried out in
to whom she was attracted at her Parents Without
an individual format. Nevertheless, Dreikurs (1959), a
Partners group, but he had not asked her out.
prominent student of Adler, is credited with being the
Because she had not been making any progress
first to use group therapy in private practice. Because
in pursuing her goal for more intimacy, I (JOP)
destructive lifestyles are acted out interpersonally, a
suggested that she ask him if he would like to go
group setting yields firsthand information on how
for coffee after the meeting. She said she found
patients create problems in relating to others.
that alternative exciting but insisted that she was
not the kind of person who could do such a thing. Anxiety and Defenses
Using an Adlerian technique, I suggested that she However self-defeating a lifestyle may be, it at least
only act “as if” she were an assertive woman, provides a sense of security. When a therapist
rather than worrying about becoming such a per- questions or threatens lifestyle convictions, anxiety
son. With considerable courage, she acted as if she is aroused and the client is ready to resist treat-
were assertive and got closer to the man. At the ment. Anxiety can be used to frighten the therapist
same time, she discovered that if she acted as if from pushing ahead, as when the patient threatens
she were stronger, she could soon transform such to panic if the therapist continues to probe. Anxi-
fiction into reality. ety serves a primary purpose, then, of keeping the
For clients who insist that they would change if client from taking action and moving ahead into
only they could control overpowering emotions, a the future. Anxiety can also serve as a secondary
push-button technique demonstrates that they can theater of operations, allowing clients to turn their
indeed choose to control their emotions. Using fan- attention from solving life’s tasks to solving the
tasy, clients are instructed to close their eyes and considerable anxiety they are creating by their con-
imagine very happy incidents in their pasts. They stant self-preoccupation. Psychotherapists need not
are to become aware of the feelings that accompany worry about treating anxiety directly. However,
the scenes. Then clients are instructed to imagine a they must be aware of the temptation to avoid
humiliating, frustrating, or hurtful incident and directly analyzing a destructive lifestyle out of fear
note the accompanying feelings. Following this, the client will create a tremendous amount of anx-
the pleasant scenes are imagined again. By pushing iety as an excuse for holding onto a secure but
the button on particular thoughts, clients are taught unsuccessful style of life.

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Chapter 3 Psychodynamic Therapies 61

The most frequent and powerful defense mech- clients accept responsibility for shaping their own
anism is compensation. Compensation serves not lives, they must also accept the responsibility for
as a defense against anxiety per se but rather as a the impact that their lifestyles exert on society.
defense against the aversive feelings of inferiority. Will they, for instance, live a more complete life by
Compensation itself does not produce problems. It creating a more perfect personality while at the same
is the goal toward which a person strives to be time producing a more polluted planet? The person
superior that determines whether compensation who can hope to attain wholeness is one who can
leads to problems. A person suffering from intense respond to the hopes of humanity.
feelings of organ inferiority might compensate and
strive for superiority by becoming the community’s Interpersonal Conflicts
most plagued hypochondriac. Or the same person Intimacy and Sexuality
could compensate by becoming the community’s Commitment to selfish interests prevents intimacy.
most revered physician. Intimacy requires concern for a valued other above
The goal in psychotherapy is not to remove feel- one’s own immediate interests. Intimacy also
ings of inferiority or to replace compensation with requires cooperation with others in pursuing com-
more effective coping mechanisms. Therapy is monly shared goals. The inherent selfishness of psy-
intended to help clients redirect their compensatory chopathology preempts such intimate cooperation.
strivings from selfish, self-absorbing goals toward Yet so many people are surprised that they cannot
social, self-enhancing values. have life both ways—they cannot dedicate them-
selves to a life of selfish competitiveness, for exam-
Self-Esteem ple, without that competitiveness eventually tearing
Enough has been said about feelings of inferiority to apart their relationships or their families. People
indicate that problems with self-esteem are central in would like to pretend that a lifestyle can be fragmen-
Adlerian therapy. The secret to solving problems of ted into convenient parts, with competition, domi-
esteem is not to reassure maladjusted people that nation, and ruthlessness at work and cooperation,
they are indeed well. Nor is self-esteem particularly equality, and caring at home. This pretense may
enhanced through encouraging client self-absorption operate for awhile, but eventually the goals of selfish
with the intricate details of their early years. The success will exact their toll on intimate relationships.
paradox of self-esteem is that it vanishes as a prob-
lem when people forget themselves and begin living Communication
for others. A solid sense of self-esteem can be The innate preparedness of humans for language
secured only by creating a style of life of value to acquisition indicates that we are born to be social.
the world. Live a life that affirms the value of fellow Language alone, however, does not guarantee effec-
humans, and the unintended consequence will be tive communication. Problems with communication
the creation of a self worthy of the highest esteem. are fundamentally problems with cooperation.
Effective communication is, by its very nature, a
Responsibility cooperative endeavor. If one person is holding
Those who would be free from psychopathology back information out of self-interest, or if another
must have the strength to carry the double burden is sending misleading messages to gain a competitive
of personal responsibility and social responsibility. advantage, then communication is bound to be con-
Clients are asked to assume the ultimate responsibil- flicted. Couples suffering with competition conflicts,
ity of choosing in the present those goals that will such as who makes the final decisions in their
allow their most perfect future to unfold. Once relationships, frequently complain of problems in

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62 Chapter 3

communicating with each other, even though each is on symptoms to control others, including
able to communicate effectively with a friend of the psychotherapists, in order to get others to care for
same sex. The task in therapy is not to correct com- them.
munication patterns, but rather to help the couples Control over others brings a sense of security,
reorient their values toward common goals so that a position of superiority, and an exaggerated con-
their communications can be for shared rather than viction of self-value. With these gains from con-
selfish interests. trol, many clients rely on subtle and not-so-subtle
maneuvers to control treatment. Effective thera-
Hostility
pists will be aware of patients’ efforts to control,
Adler originally considered the aggressive instinct to and they can respond with countercontrol techni-
be the most important human drive. He later elabo- ques. Patients who try to control therapy, for
rated his position to include hostility as one expres- example, by insisting on how bad off they are
sion of the basic will to power. Now we understand and how unable they are to progress, may cry
hostility as perhaps the worst of many mistaken paths out in exaggerated self-worth, “I bet you’ve never
of striving for superiority. For those discouraged from had such a tough case as me before.” The therapist
attaining perfection through social contributions, vio- may refuse to be impressed by responding, “No,
lence seems to provide a sense of superiority. To beat not since last hour.” The therapist is not attempt-
someone, to hold another person at gunpoint, to ing to win some control game, but rather to com-
threaten someone’s life can transform the most municate that he or she is unwilling to cooperate
inferior-feeling individual into a godlike giant who with the client’s maneuvers.
can destroy another existence. To resort to hostility
is to deny the value of another human being. Hostility
Individuo-Social Conflicts
is the worst expression of the belief that self-interest
is of higher value than social interest. The tragic rise Adjustment versus Transcendence
in violence in contemporary society may well be tes- The tension between adjustment and transcendence
timony to the prevalence of the belief that only the should not pit the individual against society. Striving
self, and never the society, is really sacred. for transcendence is synonymous with striving for
superiority; both entail finding fulfillment by trans-
Control cending a present level of personal adjustment to
All people have a need to control, to master certain attain a higher and more complete level of life.
situations and exercise restraint over others. Path- Healthy people will resist the discredited idea that
ological personalities, however, are frequently pre- fulfillment requires placing oneself against the sys-
occupied with dominating others. The most blatant tem. Healthy people do not place self-esteem over
controller was once dominated by parents and has social esteem in an attempt to rise above the society
subsequently committed to seek power over others to which they are integrally related. Social transcen-
in order to never again feel the intense inferiority dence is for snobs who can feel superior only at the
that comes from being under another person’s expense of the commoners who surround them.
domination. The pampered personality represents Healthy people commit to helping the entire society
a more subtle despot, using neurotic symptoms transcend its present level of functioning to become
such as anxiety, depression, and hypochondriasis a more perfect social system.
to get others to satisfy every whim. Pampered
people are trained to use the services of others Impulse Control
for solutions to problems rather than to become The civilizing role of parents and clinicians is not to
self-reliant. As adults, pampered people rely inhibit bad impulses but to strengthen social interest.

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Chapter 3 Psychodynamic Therapies 63

Children are not primarily biological beasts who patterns that provide ready-made excuses for fail-
must have controls imposed on destructive drives. ing to add to the world. The healthy person is at
Children are social beings who are prepared to coop- home in the world. The ideal person embraces
erate if encouraged by parents and teachers. Accord- Gemeinschaftsgefühl, the social interest that
ingly, impulses must be directed toward prosocial allows us to contribute to the common welfare.
goals as part of the total lifestyle. Impulses such as Social interest is not just an idealistic or inspira-
sex and aggression can be brought to completion for tional value; it is also a pragmatic goal that pro-
higher social interests, as in providing a pleasure duces mental health in life. The interests of the self
bond between partners or aiding in the defense of and the interests of others do not conflict among
a country against terrorists. Impulses become a those who care enough to find completion
problem for society only when the overall direction through cooperation. The ubiquitous social values
of a lifestyle is antisocial rather than prosocial in of security and success are rejected in favor of the
nature. Impulses threaten to break out of control even higher social value of the common good.
not because of an excess of civilization but because Healthy people are egalitarians who identify
some individuals lack dedication to civilization. with the imperfections that we all share and with
the aspirations of those who truly care.
Beyond Conflict to Fulfillment
Meaning in Life Therapeutic Relationship
We create meaning in our lives by the lives we The therapeutic relationship is an integral part of
create. We are not born with intrinsic meaning the Adlerian process of helping clients overcome
in our existence, but we are born with a creative their long-standing discouragement so that they
self who can fashion intrinsic meaning from our can reorient themselves toward a healthy social
existence. From the raw materials of our genetic interest. Psychotherapists draw clients toward social
endowment and our childhood experiences, we interest by showing the personal interest they have
shape the goals and the means to the goals that for the well-being of their clients. In many ways, the
will give significance to our existence. If our vision therapeutic relationship is a prototype of social
is good enough and our goal is noble enough, then interest. The classical values of love, faith, and
the lifestyles we construct may be valued works of hope for the human condition are essential to
art dedicated to the best in humanity. If, out of both social interest and an effective therapeutic
discouragement and distortion, we dedicate our relationship. The therapist’s positive regard for the
lives to banal goals, then our lifestyle will reflect patient reflects the love and caring of an individual
more basic mistakes than basic meaning. A basic dedicated to the well-being of human beings. The
mistake of many people is that existence can have therapist’s willingness to relate as a genuine equal
meaning if it becomes a shrine to the self. The communicates a faith in the client’s ability to
creative self seeks completion not by turning co-discover solutions to serious problems.
inward and drawing away from the world, but by The therapist is not the doctor who acts on the
reaching out to become connected to the greatest client, no matter how helpless pampered clients act
needs and the highest aspirations of humanity. to persuade the doctor-therapist to take over their
Ideal Person lives. The therapist is a teacher who exudes faith in
Inspired by goals that transcend immediate wants the unused potential of the student-client to create
or worries, the superior person is drawn to life a fulfilling style of life. The teacher-therapist is
with excitement and anticipation. Energies are willing to recommend readings (bibliotherapy),
not wasted on evasive defenses or on neurotic assign homework experiments, and offer personal

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64 Chapter 3

encouragement. The genuineness of the therapist As part of the educational orientation toward
reveals a willingness to make mistakes, to be per- solving or preventing emotional problems, Adlerian
fectly human, which expresses the conviction that workshops have become a popular format for
imperfect humans have the power to enhance life. teaching parents how to raise children to cooperate,
The faith and love, which the patient experiences to care, and to strive as individuals. Similar work-
through the therapeutic relationship, give him or shops are available for couples, who can attend the
her hope that counteracts the discouragement that educational sessions and either sit back and learn
prevents meeting life head on. Support, faith, and from others or come to center stage and discuss
hope from an empathic therapist make clients conflicts in their relationships, with the audience
concretely aware of the intrinsic value that social giving considerable support and positive sugges-
interest from one human can have for another. tions. Adlerians have also established social clubs
With renewed hope and a vital awareness of the to foster social interest both within and outside of
value of social interest, clients are provided fresh psychiatric hospitals. Within the social clubs, the
opportunities to break out of a self-centered exis- strengths of individuals are stressed, as they are
tence and begin caring for others. encouraged to enjoy the social aspects of the clubs
rather than focusing on their weaknesses.
Adlerian therapy is also flexible with regard to
Practicalities of Adlerian fees and activities. As a reflection of their own
Therapy social interests, clinicians are encouraged to provide
Adlerians are comparatively flexible and innovative a significant contribution to the community with-
in the formal aspects of psychotherapy. Formats out charge. This pro bono service may be done
vary from traditional individual sessions, to conjoint through free evening couples workshops, free
family sessions, to a multiple-therapist approach workshops for parents, or some private therapy
(two or more therapists working together with one hours for patients unable to pay.
patient), to group approaches with multiple thera- Although Adlerians have traditionally worked
pists as well as clients. The multiple-therapist with a full range of clients, they are especially active
approach was originated by Dreikurs (1950) as a in working with delinquents, criminals, families, and
means of preventing serious transference or counter- organizations. The resurgence of Adlerian activity in
transference problems from interfering with thera- these areas reflects a concern with social relationships
peutic progress. The presence of two therapists also in danger of disintegrating because of excessive
allows clients to become aware of how two indivi- self-interest. Following Adler’s original example,
duals can differ and still cooperate. Adlerians are heavily involved in school settings,
The course of psychotherapy is expected to be especially with guidance counselors eager to help stu-
relatively short-term, at least in comparison to dents clarify their values to find constructive goals for
classical psychoanalysis. The Adlerians were their energies. Adlerian principles and methods have
among the first to advocate time-limited treatment been increasingly applied to workplace problems and
and to develop active methods to accelerate the organizational changes (Barker & Barker, 1996;
therapeutic process. In fact, many methods Ferguson, 1996).
embraced by brief therapists—clinician flexibility, The Adlerian movement is now largely cen-
group and family sessions, homework assignments, tered in the United States, with several training
psychoeducational materials, lifestyle analysis, opti- institutes that offer certificates in psychotherapy,
mistic perspective, and collaborative relationship— counseling, and child guidance. Becoming an
were pioneered by the Adlerians (Sperry, 1992). Adlerian therapist is more a matter of the

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Chapter 3 Psychodynamic Therapies 65

individual’s social values than of formal The ego’s striving to adapt to and master an
credentials—at least as compared to the counter- objective reality motivates the development of per-
vailing priorities in other psychotherapy systems sonality. Ego analysts certainly do not deny that
of psychotherapy. As a consequence, Adlerian conflicts over impulses striving for immediate grat-
institutes have been receptive to educators, clergy, ification influence our development. Rather, they
and even paraprofessionals, as well as to members assume that the separate striving of the ego for
of the traditional mental health professions. adaptation and mastery is an equally important
influence.
Ego Psychology Although development of impulse control is
Adlerian therapy emerged as one of the earliest and regarded as one of the early ego tasks, it is by no
most influential psychodynamic therapies, but means the only task. Individuals are also striving to
assuredly not the only one. To appreciate the evolv- be effective and competent in relating to reality
ing orientation of the neo-Freudians, we now turn to (White, 1959, 1960). The emergence of effective-
a discussion of four other forms of psychodynamic ness and competence requires the development of
therapy: ego psychology, object relations, supportive ego processes other than defense mechanisms.
therapies, and brief psychodynamic therapy. Individuals are motivated to master visual-motor
Classical psychoanalysis was based primarily on coordination, discrimination of colors, and lan-
an id psychology, in which the instincts and con- guage skills, for example, all independent of long-
flicts over such instincts are seen as the prime ings for sexual or aggressive gratification. With its
movers of personality and psychopathology. own energies, then, the ego becomes a major force
Although id psychology (or the drive theory) in the development of an adaptive and competent
remains the theory of choice of some analysts, personality. Failure to adequately develop ego
others have followed the lead of Hartmann, processes, such as judgment and moral reasoning,
Kris, and Loewenstein (1947), Erikson (1950), can lead to psychopathology just as readily as can
and Rapaport (1958), who established an influen- early sexual or aggressive fixations. The person
tial ego psychology. Freud himself began a move with inadequate ego development is, by definition,
beyond the id, when in the 1920s he turned his poorly prepared to adapt to reality.
attention to the analysis of the ego. Once the ego is assumed to have its own ener-
Whereas id psychology assumes the ego derives gies and developmental thrust, it becomes clear
all of its energies from the id, ego psychology that more is involved in maturation than only
assumes there are inborn ego processes—such as the resolution of conflicts over sex and aggression.
memory, perception, and motor coordination— The psychosexual stages of Freud are no longer
that possess energy separate from the id (Rapaport, adequate to account for all of personality and psy-
1958). Whereas id psychology assumes that the ego chopathology. Development of the conflict-free
serves only a defensive function in balancing the spheres of the ego during the first three stages of
ongoing conflicts between instincts and the rules life is just as important as defending against the
of society, ego psychology assumes that there are inevitable conflicts over oral, anal, and phallic
conflict-free spheres of the ego (Hartmann et al., impulses. Furthermore, the strivings of the ego
1947). That is, for Heinz Hartmann and other ego for adaptability, competency, and mastery con-
psychologists, there is an autonomous ego, an ego tinue well beyond the first 6 years of life. As a
that functions independently of the id drives. These result, later stages of life are as critical in the devel-
involve the individual’s adaptation to reality and opment of personality and psychopathology as are
mastery of the environment (Hendricks, 1943). the early ones.

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66 Chapter 3

Erik Erikson (1950) broadened Freud’s psy- creating a lifestyle that brings a sense of genera-
chosexual stages to psychosocial stages that tively, creating something of worth with one’s life
begin in infancy and extend through life to old lest a sense of stagnation take over. And aging
age. The life cycle is described in terms of eight adults must look back over their lives to see
discrete crisis periods. The oral stage, for example, whether they can maintain ego integrity in the
is critical to the child’s development of trust versus face of death, whether they can look back and
mistrust. The latency stage, as another example, is affirm their entire life cycle as worth living. If not,
seen by Erikson as critical in the development of a they are drained by despair.
sense of industry, which involves learning to mas- Achieving identity, intimacy, and ego integrity
ter many of the skills used in work. Freud, on the are critical therapy goals of ego analysts. Much of
other hand, saw the latency stage as a quiet time- therapy is focused on such contemporary struggles
out during which no new personality traits devel- of patients. Treatment delves into history only as
oped. From Erikson’s point of view, some far as necessary to analyze the unresolved child-
individuals fail to develop a sense of industry not hood conflicts that might be interfering with the
because of unconscious conflicts but because their person’s present adaptation to life. Clearly,
culture discriminates against people of particular the content of ego analysis will differ from the
races or religions and fails to educate them ade- content of classical analysis. The process of ego
quately in the tools of that culture’s trade. Failure analysis may, however, be quite similar to the clas-
to develop a sense of industry leads to a sense of sical process, with long-term intensive therapy
inadequacy and inferiority. A sense of inferiority and use of free association, transference, and
can lead to symptoms such as depression, anxiety, interpretation. On the other hand, most ego
or avoidance of achievement. Thus, individuals analysts tend to follow the more flexible format
can develop problems later in life even if they of psychodynamic psychotherapy.
have developed a healthy personality during the
first three stages of life. Of course, serious conflicts
from early stages make it more difficult for later Object Relations
stages to progress smoothly. A person with serious Psychodynamic therapy has evolved by new theor-
dependency conflicts from the oral stage, for ists emphasizing different aspects of personal devel-
example, will probably have more problems devel- opment as the core organizing principles for
oping a sense of industry than would a person free personality and psychopathology. Freud empha-
from such conflicts. sized conflicts over gratification and control of id
The essential point for psychotherapy here is processes as the central organizing principle of peo-
that ego analysts concern themselves equally with ple’s lives. Ego analysts emphasized the ego as the
early developmental stages and later developmental central organizing principle; the resolution of ego
stages. By no means are all problems reduced to challenges such as basic trust, autonomy, and
repetitions of unconscious conflicts from child- initiative, determines an individual’s way of life.
hood. The adolescent stage, in particular, brings Object relations theorists, including Fairbairn
the massive challenge of developing ego identity (1952), Kernberg (1975, 1976, 1984), and Kohut
versus ego diffusion (Erikson, 1950). Young adults (1971, 1977), emphasize relationships between the
must use their maturing ego processes if they are to self and other people as the major organizing
move toward intimacy rather than lapse into isola- principle in people’s lives. David Winnicott, a child
tion. Mid-adulthood involves the ego energies in psychoanalyst and prominent theorist of object

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Chapter 3 Psychodynamic Therapies 67

relations, once risked the remark, “There is no such by a failure of attachment to objects and a failure of
thing as a baby…. A baby cannot exist alone, but is mental organization due to a lack of self-image
essentially part of a relationship” (Winnicott, (Horner, 1979).
1931/1992; also Monte & Sollod, 2003). Through the process of attachment, described
Object relations are the mental representations by Mahler (1968) and Bowlby (1969, 1973), the
of self and others (the objects). Object is the term child enters the stage of normal symbiosis. In this
Freud (1923) used for other people, because in id stage, there is confusion in the child’s mind as to
psychology others serve primarily as objects for what is self and what is object, because neither is
instinctual gratification of pleasure rather than as perceived as independent of the other. This stage
authentic individuals with needs and wants of their normally lasts 2 to 7 months.
own. Object relations are intrapsychic structures, The child then enters the differentiation period,
not interpersonal events (Horner, 1979). Object during which the child practices separating and indi-
relations are strongly impacted by early interper- viduating from significant others (Mahler, 1968).
sonal relationships, which profoundly impact later Crawling away from parents and then crawling
interpersonal relationships. back, walking away from parents and then running
The key difference between Freud’s id model back, and even playing peekaboo, in which the
and the object relations model is aptly captured by parent disappears for a moment and then reappears,
the dictum, “libido is object seeking, not pleasure are patterns of physical play that allow children to
seeking.” Freud saw the id as relentlessly pursuing mentally differentiate themselves as separate from
pleasure alone, even at the expense of other peo- the parents to whom they are attached. A failure
ple. But object relations therapists see us seeking to differentiate can result in symbiotic psychosis,
other people to secure attachment and nurturance. reflecting a fixation at the symbiotic stage. In
Object relations theorists differ somewhat on the Mahler’s (1968, p. 35) words, “The salient feature
importance of id forces in the relationship between in childhood psychosis is that individuation, i.e., a
child and parent. Otto Kernberg (1976) views object sense of individual identity, is not achieved.”
relations as partly energized by basic instincts, espe- Under normal conditions, the stages of differen-
cially aggression, whereas Heinz Kohut (1971) deem- tiation shift at about 2 years of age into an integra-
phasizes id impulses in early relationships. Kohut tion stage. Through integrating processes, the self
(1971) assumes that children have inherent needs to and object representations, which have become inde-
be mirrored and to idealize. These needs obviously pendently perceived, are now fit into relationships
require others who can serve as objects that reflect the with each other. Parent and self are perceived as
developing self and as objects that the self can idealize both separate and related. When all goes well, chil-
as models for future development. dren at this stage can learn to relate without having
The self develops through stages that differ from overwhelming fears of losing their autonomy, their
the classic oral, anal, phallic, and genital stages pro- individuality, or their sense of self.
posed by id and ego psychologies. According to the During the integration stage, the child also
influential theorist Margaret Mahler (1968), the first begins to integrate the good and the bad self-
stage of self-development is normal autism, which images into a single, ambivalently experienced
comes in the first few months of life. In this primary, self. Similarly, the child needs to integrate the
undifferentiated state, there is neither self nor object. good and the bad object images into a single,
Fixation at this stage results in the severe pathology ambivalently experienced object. Experiences that
of primary infantile autism, which is characterized originate from within the person that were not

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68 Chapter 3

integrated into the early self-representation, such as ideal identity is an autonomous self, characterized
the image of oneself as capable of anger, continue by self-esteem and self-confidence. Secure in this
to be split off from the sense of self. If these experi- identity, the person is not excessively dependent
ences are evoked later in life, they can produce a on others and is also not merely a replica of the
state of disintegration, with the person’s sense of parents. Developmentally, the ideal situation is for
self falling apart. children to have both their need to be mirrored
The task of development is not only differenti- (appreciated and respected) and their need to ide-
ation but also the emergence of identity. In the alize met through interaction with the parents.
earliest stage, children vacillate between different Who the parents are is more important than
ways of thinking and acting, expressing first one how the parents intend to interact. If the parents
part of themselves and then another. This instabil- have accepted their own needs to shine and succeed,
ity is due to splitting, a defensive attempt to deal then their children’s exhibitionism will be accepted
with being overwhelmed by more powerful parents and mirrored. If the parents have adequate self-
(Kernberg, 1976). If the child splits off bad self- esteem, then they can be comfortable with their
images, such as the angry self, then there is less children’s needs to idealize them. If, during the
to fear from punitive parents. Similarly, if children stages of self-development, the parents are not able
can split off bad object images, such as the angry to meet the child’s needs to be mirrored and to
mother, then the object becomes less threatening. idealize, the child will develop a troubled identity.
The next step in identity development Kohut (1971) focuses on different types of
involves introjection, which is the literal incorpo- narcissistic personalities that result from insufficient
ration of objects into the mind. This tends to mirroring or idealizing. Mirror-hungry personalities,
occur during symbiosis: Mother can be experi- for example, are famished for admiration and appre-
enced as less threatening if mother and child are ciation. They incessantly need to be the center of
one. A more mature identity, however, requires the attention. These people tend to shift from relation-
process of identification, in which objects have ship to relationship, performance to performance, in
influence but need not be “swallowed whole.” an insatiable attempt to gain attention. Ideal-hungry
With a more mature sense of identity, individuals personalities are forever in search of others whom
can value both autonomy and community; they are they can admire for their prestige or power. They
open to influence from others without the fear of feel worthwhile only as long as they can look up to
being overwhelmed by others. someone.
Throughout all of these stages of identity From Kohut’s self-psychology perspective, nar-
development, the role of attachment is paramount. cissistic personalities cannot be treated by classical
Winnicott (1965) stressed the centrality of “good psychoanalysis, in which the analyst alternates
enough” mothering in a holding environment. between being a blank screen and raising conscious-
Such an environment makes the child feel taken ness through verbal interpretations. Psychoanalysis
care of, protected, understood, and loved. Transi- is successful when patients are able to project
tional objects, known to parents as the security emotions toward others onto the therapist by
blanket, help to cultivate the child’s international- means of transference experiences. Persons with
ization of the continuing presence of parental love. self disorders, however, cannot project emotions
Years of a holding environment facilitates the and images consistently, because they are too per-
child’s capacity to be alone and, eventually, leads sonally preoccupied. These clients must be mirrored
to independence. In Kohut’s self psychology, the and must be permitted to idealize the therapist.

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Chapter 3 Psychodynamic Therapies 69

To be idealized, therapists must let themselves rage, assertiveness, sexuality, and exhibitionism of
be known rather than remain shadows for the cli- his autonomous self. To oversimplify, the case formu-
ents’ projections. By combining Rogers’s emphasis lation moved from a purely intrapsychic matter dom-
on empathy and positive regard (mirroring) inated by the patient’s id drives and deficiencies to a
and the existential emphasis on being authentic fuller interpersonal configuration considering the
(idealizing), the object relations therapist can fill patient’s competencies as well. And Kohut’s stance
the void that clients experienced in childhood. By evolved from a relatively detached, cerebral analyst
meeting some of the clients’ unmet narcissistic to a more empathic, involved, mirroring therapist.
needs, they enable clients to develop either a mir- Object relations therapists believe that tradi-
roring transference or an idealizing transference. tional psychoanalysis can effectively treat neurotic
After such transferences are developed, the self- patients who can develop normal transference
psychology therapist can use the traditional relationships. But patients with severe self
consciousness-raising technique of interpretations disorders, such as those suffering from borderline
to help patients become aware of how they try to personality disorders or narcissistic personality
organize their lives around narcissistic relation- disorders, cannot be effectively treated merely
ships. Clients can then begin to participate in the with interpretations of transference and resistance.
development of a more autonomous self. Borderline patients can develop psychotic trans-
In his famous 1979 article, “The Two Analyses ferences and can thus experience the therapist as
of Mr. Z,” Heinz Kohut (1913–1981) vividly pre- the split-off “bad parent.” Profound fears of being
sented the clinical differences between classical overwhelmed, uninhibited, rejected, or abandoned
psychoanalysis and his self psychology. Kohut can cause such patients to leave therapy or can
treated Mr. Z initially with classical psychoanaly- prevent the development of a working alliance.
sis, but some 5 years later, Mr. Z was treated for a Otto Kernberg (1975; Clarkin et al., 1998;
second time with self-psychology therapy when Kernberg et al., 1989) and James Masterson
Kohut was deeply immersed in the writing of (1976, 1981), who specialize in the treatment of
The Analysis of the Self (1971). As seen in the borderline disorders, combine limit setting and
classical dynamic-structural terms of the first emotional support in this exhausting work. Setting
analysis, Mr. Z was suffering from overt grand- limits on telephone calls, on acting out aggression
iosity and arrogance due to an imaginary oedipal toward the therapist, and on how often the thera-
victory. The psychoanalytic goal—only partially pist can be seen are critical with borderline
accomplished—was to access and resolve the patients. Setting limits on acting out will provoke
patient’s repressed castration anxiety and depres- anxiety that helps to clarify the underlying mean-
sion due to an actual oedipal defeat. As seen in ing of the acting out. Only by setting clear limits
self-psychology terms of the second treatment, with such clients will the therapist maintain the
Mr. Z was suffering from overt arrogance and iso- opportunity for interpretations to be effective. In
lation on the basis of persisting merger with the ide- a therapeutic relationship that offers both sus-
alized mother. The therapy tasks here occurred in two tained empathy and boundary setting, patients
stages: The first was to help Mr. Z confront fears of can gradually become conscious of the parts of
losing his merger with the mother and thus losing themselves that have been split off. Without
himself as he knew it. The second stage was to assist clear limits, the split-off parts of self and objects
Mr. Z in confronting traumatic overstimulation and can threaten to produce disintegration within the
disintegration fear as he became conscious of the individual or within the therapeutic relationship.

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70 Chapter 3

Supportive Therapy mistrusting, and withholding personality pattern.


We were uncovering and processing multiple trau-
The broad expanse of psychoanalytic (Chapter 2)
matic experiences early in his life and his ensuing
and psychodynamic therapies (this chapter) can be
insecure attachment style. Then, about the eighth
arranged along a continuum of expressive-
session, his home burned to the ground. We imme-
supportive treatment. At the one end is psycho-
diately transitioned into a supportive mode to
analysis proper with its emphasis on the patient’s
strengthen his defenses, enlist his coping skills, and
expression, free association, and regression along
assist his recovery from the crisis.
with the therapist’s interpretation of transference,
In practice, psychodynamic therapy constitu-
defenses, and unconscious conflicts. At the other
tes an admixture of both expressive/exploratory
end of the continuum is supportive therapy
and supportive interventions. Long ago, Freud
informed by psychodynamic concepts. Supportive
(1919, p. 167) recognized the inevitability that
therapy aims to strengthen the patient’s coping,
the “pure gold of analysis” would be mixed “freely
provide encouragement, and prevent regression.
with the copper of suggestion.” Not all patients are
Rather than dissecting defenses, supportive therapy
capable of, or benefit from, the expressive, insight-
bolsters defenses. Direct support and suggestion are
oriented treatment. The trick is to determine
favored over insight and interpretation.
which patients respond best to the expressive
Supportive therapy is widely practiced, particu-
side and which best to the supportive side.
larly in counseling, in psychiatry, and in concert
with medication management (Rockland, 2003;
Sudak & Goldberg, 2012). It is generally indicated Brief Psychodynamic Therapy
when the patient does not possess the requisite Continuing the evolution of Freud’s original theory,
psychological-mindedness or financial resources for recent decades have witnessed a proliferation of
an intensive, insight-oriented therapy, which is still brief psychodynamic therapies. Leading theorists
preferred by most psychodynamic therapists on the and practitioners in this vein include Lester
conviction that insight exercises a more lasting Luborsky (1984; Luborsky & Crits-Cristoph,
impact than suggestion and support alone. Given 1990), James Mann (1973; Mann & Goldman,
constraints in the patient or the setting, the therapist 1982), and Hans Strupp (1992; Levenson, 1995;
actively reinforces the patient’s adaptive behaviors in Strupp & Binder, 1984). These psychodynamic
order to reduce the intrapsychic conflicts that may treatments are united by several characteristics:
produce or aggravate psychiatric symptoms. As in
psychoanalytic psychotherapy and object relations • Setting a time limitation on treatment, typi-
therapies, the therapist engages in an encouraging cally 12 to 40 sessions
and engaging relationship with the patient as a • Targeting a focal interpersonal problem
method of furthering healthy relationships. In this within the first few sessions
respect, supportive therapy moves toward an inte- • Adopting a more active or less neutral thera-
grative therapy (Chapter 16) that incorporates meth- peutic stance
ods from the person-centered, cognitive-behavioral, • Establishing a rapid and strong working
interpersonal, and solution-focused therapies. alliance
Supportive therapy may be used as the entire • Employing interpretation and transference
treatment or as a portion of the treatment. For interpretation relatively quickly
example, I (JCN) was seeing a patient in expressive- • Emphasizing the process and inevitability of
exploratory psychotherapy for his cranky, terminating treatment

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Chapter 3 Psychodynamic Therapies 71

As direct descendants of psychoanalysis, all which no medical reason could be identified and for
short-term psychodynamic therapists incorporate which she presented to psychotherapy. These cramps
the cardinal psychoanalytic principles, including the are experienced only in the presence of her mother in
presence of resistance, the value of interpretation, and the past, in the presence of her boyfriend in the pres-
the centrality of a strong working alliance. But all ent, and now in the presence of the therapist in the
have also responded to the empirical research that consulting room. One interpretation is that the
strongly questions the value of lengthy over briefer cramps are the patient’s habitual way of dealing
psychodynamic psychotherapy and to the socioeco- with her difficulty in expressing aggression; instead
nomic constraints on the number of psychotherapy of expressing her anger directly, she swallows it and
sessions permitted by insurance carriers. turns it against herself (Messer & Warren, 1995).
Briefer therapy requires thorough case formu- Even as short-term psychodynamic therapists
lation and planning. Calling on all that is known are more active and eclectic in practice than psy-
about a particular client and all that is known about choanalysts, they continue to employ distinctive
the dynamics of psychopathology, the psycho- psychoanalytic methods. Comparative psychother-
dynamic therapist plans a more precise treatment apy research (Blagys & Hilsenroth, 2000) reveals
that fits the needs of a particular client. Modest that seven themes and techniques characterize
and achievable goals are set, such as an improved brief psychodynamic therapy:
interpersonal pattern, greater attunement to feel-
• A focus on patients’ expression of emotions
ings, or a resolution of a specific conflict (Messer
• An exploration of patients’ attempts to avoid
& Warren, 1995). Where standard psychoanalysis
topics or engage in resistance
might let the treatment take its own course, the
• The identification of repetitive patterns in
short-term dynamic therapist decides whether it
patients’ lives and relationships
should be oriented primarily toward supporting
• An emphasis on past experiences
the ego, uncovering the id impulses, or changing
• A focus on a client’s interpersonal experiences
the external conditions of the client’s life. Not all
• An exploration of patients’ wishes, dreams,
details of treatment can be planned, of course, so
and fantasies
the therapist will rely on conscious use of various
• An emphasis on the therapeutic relationship
techniques in a flexible manner, shifting tactics to
fit the particular needs of the moment. The latter theme refers to the therapist
The brief dynamic therapist is obviously more actively establishing a facilitative therapeutic, or
active and directive in procedure and more interac- working, alliance with the client. This alliance is
tive in the relationship than are orthodox psycho- characterized by conscious collaboration and
analysts. In classic psychoanalysis, the therapist explicit consensus, in contrast to the unconscious
allows the transference to emerge slowly over time, distortion of the relationship between therapist
with gradual and frugal interpretations. In short- and client. The alliance is typically measured as
term dynamic treatment, the therapist actively agreement on the therapeutic goals, consensus
engages the patient early in the process, focuses on on treatment tasks, and a relationship bond (Bor-
a core interpersonal theme, and offers frequent din, 1976). It is two people who like and respect
transference interpretations regarding links among each other working together toward mutual goals.
the patient’s behavior toward the therapist, current The positive relation between the therapeutic
life figures, and significant past figures. alliance and treatment outcome is one of the
For example, a transference interpretation might most robust findings in psychotherapy research.
concern a patient’s frequent stomach cramps for Among both adult (Horvath et al., 2011) and

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72 Chapter 3

child (Shirk & Karver, 2011) clients, the quality In theory, they rely on the comprehensive and
of the alliance contributes to and predicts therapy guiding knowledge afforded by psychoanalysis
success. Indeed, the success rate increases from and its contemporary variants. In method, they
37% to 63% in low versus high alliance cases. flexibly apply a host of techniques, most rooted
By emphasizing the therapeutic alliance, psycho- in the psychoanalytic tradition, and pragmatically
dynamic therapists become more empathic, more emphasize the therapeutic alliance, a pantheoreti-
humanistic in the tradition of Carl Rogers (Chapter cal concept.
5). Confrontation and interpretation give way to
clarification and support, as illustrated in these con- Effectiveness of
trasting statements (McCullough, 1997, p.13). A psy- Psychodynamic Therapies
choanalyst might offer this interpretation: Adlerian Therapy
You are avoiding my eyes right now as I ask Adler (1929) did not conduct or favor controlled
about your feelings. And now you’re drumming studies on the effectiveness of his individual psychol-
your fingers on the table. This silence erects a ogy, preferring instead to relate cases. “Experiments,”
barrier between us. What will happen if you he wrote, “look only like a shadow of reality.”
continue to evade these issues in treatment? Although many of Adler’s seminal concepts—
ordinal position, earliest childhood memories, social
A brief psychodynamic therapist might interest, to name a few—have been extensively inves-
address the same phenomena by offering more tigated (Watkins, 1982, 1983, 1992), little empirical
empathy and mutuality: research has been conducted on the actual effective-
ness of Adlerian therapy. Early major reviews (e.g.,
As I ask about your feelings, you often look away
Smith et al., 1980) located only four controlled studies
and become silent. Are you aware that this is
of Adlerian therapy. The average treatment results in
happening? Is this topic painful for you to look
the admittedly small set of available studies were just
at? Is there some way that I can help you make it
slightly better than the results of placebo treatments.
more bearable to face?
Similarly, literature reviews fail to locate any substan-
Some brief psychodynamic treatments go by the tial body of controlled outcome research on Adlerian
name of supportive-expressive therapy. As system- therapy on either adults (e.g., Grawe et al., 1998) or
atized by Lester Luborsky and colleagues at the children (e.g., Weisz et al., 2004).
University of Pennsylvania, supportive-expressive A handful of controlled studies, all with dif-
psychotherapy assists patients in identifying the ferent foci, is inadequate to draw any firm conclu-
recurrent themes in their lives that have negatively sions about the efficacy of Adlerian therapy.
impacted their relationships with other people. The Perhaps the most we can say at this time is that
therapist uses collaborative psychodynamic methods it is superior to no treatment and, when compared
to establish a supportive relationship and then uses with alternative treatments, it has been found to
interpretative techniques to encourage patients to be as effective as client-centered therapy and psy-
express and come to understand their core conflic- choanalytic therapy in several studies.
tual relationship patterns. Thus, it has two main
components: providing support in an understanding Object Relations Therapies
relationship (supportive) and stimulating insight via We and others are unable to locate any controlled
clarifications and interpretations (expressive). outcome studies on Kohut’s self-psychology psy-
In short, brief dynamic therapists seek the best chotherapy, but can report on several con-
of both the theoretical and methodological worlds. trolled outcome evaluations of Kernberg’s object

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Chapter 3 Psychodynamic Therapies 73

relations treatment, called transference-focused Supportive Therapy


psychotherapy (Yeomans et al., 2002). The first The effectiveness of supportive therapy in controlled
study was a nonrandomized trial comparing studies has been most frequently evaluated in the
transference-focused psychotherapy (TFP) and treat- treatment of adult depression, with and without
ment as usual (TAU) for patients diagnosed with medication. A meta-analysis of 31 studies on sup-
borderline personality disorder. TFP was superior portive therapy found it was effective in the treat-
to TAU on virtually all indices of effectiveness ment of depression (ES ¼ 0.58) compared to control
(Clarkin et al., 2001). conditions. Supportive therapy was mildly less effec-
Subsequent studies were more rigorous, ran- tive than other psychological treatments, but this
domized controlled trials comparing the effective- difference was no longer present after controlling
ness of TFP to alternative therapies. In one such for researcher allegiance (Cuijpers et al., 2012).
study, TFP, dialectical behavior therapy (Chapter In an analysis of three randomized clinical trials
11), and supportive therapy were compared for 12 (de Maat et al., 2008), short psychodynamic support-
months among patients diagnosed with borderline ive psychotherapy was as effective as medication for
personalities. At posttreatment, patients receiving depression. Combined treatment (supportive therapy
any of the three therapies were improved, but plus medication) was more effective than either alone
patients receiving TFP fared slightly better on most according to independent observers, patients, and
measures (Clarkin et al., 2007). Another controlled therapists. In short, supportive therapy has proven
study was conducted in multiple community mental itself effective for depression.
health centers in the Netherlands. It compared TFP
to schema-focused therapy in 88 patients suffer- Psychodynamic Therapies (General)
ing from borderline personality disorder. Both The effectiveness of psychodynamic therapies has
treatments proved effective in reducing border- been extensively studied in controlled research.
line symptoms and in improving quality of life. This body of research has been summarized in
Among all patients beginning treatment, schema- recent years through meta-analysis, a statistical
focused seemed slightly more effective; among technique that quantitatively combines the results
those actually completing treatment, about the of many different studies.
same percentage of schema-focused patients and The results of meta-analyses are typically pre-
TFP patients recovered or evidenced clinical sented as an effect size (ES). As shown in
improvement (Giesen-Bloo et al., 2006). Table 3.1, an ES is a quantitative index of the
The composite results from these studies and magnitude and direction of therapy effects. Higher
from general reviews of treatment for borderline effect sizes indicate greater effectiveness. Each ES
pathologies (Oldham, 2002) indicate that specific, can be thought of as reflecting a corresponding
structured psychotherapies are superior to unstruc- percentile value; that is, the percentile standing
tured TAUs. TFP has demonstrated its effectiveness of the average treated patient after psychotherapy
in treating this severe disorder in several studies, relative to untreated patients.
but whether it is slightly more effective or slightly Effect sizes can be calculated by a variety of
less effective than other treatments has not been methods, but the typical ES is reported as d—a dif-
conclusively determined. In the meantime, the bal- ference between two groups or two different points
anced conclusion remains that psychodynamic and in time. Throughout this book, we shall report effect
cognitive-behavioral therapies are of comparable sizes in terms of the d value or its equivalent in order
effectiveness in the treatment of these personality to simplify explanations and to permit direct com-
disordered patients (Leichsenring & Leibing, 2003). parisons. In psychotherapy, the consensual rules of

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74 Chapter 3

Table 3.1 The Interpretation of Effect Size (ES) Statistics


PERCENTILE SUCCESS RATE
E F F EC T S I ZE OF TREA TED OF TREATED TYPE OF C O H E N ’S
( E S O F D) PATIENTS PATIENTS EF FE CT STANDA RD
1.00 84 72% Beneficial
0.90 82 70% Beneficial
0.80 79 69% Beneficial Large
0.70 76 66% Beneficial
0.60 73 64% Beneficial
0.50 69 62% Beneficial Medium
0.40 66 60% Beneficial
0.30 62 57% Beneficial
0.20 58 55% Beneficial Small
0.10 54 52% No effect
0.00 50 50% No effect
–0.10 46 <50% No effect
–0.20 42 <50% Detrimental
–0.30 38 <50% Detrimental
SOURCES: Adapted from Weisz et al. (1995) and Wampold (2001).

ES interpretation are that 0 indicates no effect, 0.20 an effort to improve their design and include more
represents a small effect, 0.50 represents a medium recent studies. Meta-analyses on general psycho-
effect, and 0.80 and above a large effect (Cohen, dynamic treatments for youth and adults (Grawe
1988). et al., 1998; Shapiro & Shapiro, 1982; Weisz et al.,
A benchmark meta-analysis was undertaken by 1995) converge in their conclusions. Psychody-
Smith, Glass, and Miller (1980; Smith & Glass, namic therapy is effective, certainly more than no
1977) to examine the benefits of psychotherapy treatment or a wait-list condition. At the same
using a total of 475 studies. Approximately 29 stud- time, several meta-analyses showed a modest but
ies were found at that time on psychodynamic consistent superiority of behavioral and cognitive
treatments and 28 on psychodynamic-eclectic treat- methods over psychodynamic therapies. This was
ments, producing average effect sizes of 0.69 and a small difference; more treatment outcome could
0.89, respectively. Patients treated with psychody- be accounted for by the type of patient problem
namic therapy (ES ¼ 0.69) were, on average, more being treated than by the type of treatment.
improved than 76% of the untreated patients. As Much debate ensued over the meaning of these
also seen in Table 3.1, an ES of 0.69 or 0.70 trans- small differences uncovered by meta-analyses. Dif-
lates in a success rate of approximately 66% among ferences in effect sizes between psychotherapies can
treated patients. When compared with effect sizes be due to a variety of factors, including the type of
for other forms of therapy, the psychodynamic problems treated, the reactivity of the measures
therapies were judged to be comparably effective used, and the type of patients studied. Because the
to slightly less effective, depending on one’s inter- majority of comparative studies have been con-
pretation of the data. ducted by cognitive and behavior therapists, these
Many meta-analyses have been conducted therapists may consciously or unconsciously design
since the classic Smith, Glass, and Miller study in studies that involve variables, measures, and

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Chapter 3 Psychodynamic Therapies 75

clinicians that favor their preferred therapy. Rela- Brief Psychodynamic Therapy
tively minor statistical advantages in such con- Multiple meta-analyses have been conducted on the
trolled studies do not necessarily mean that effectiveness of brief psychodynamic psychotherapy
cognitive and behavior therapies invariably possess with adults. In this section, we summarize those
clinical superiority in real-world settings. analyses, but first we begin by reviewing the results
Research confirms that the researcher’s own of a seminal study.
therapy allegiance impacts the results of treatment In a rigorous study conducted at Temple
comparison studies. In many separate reviews of University, Sloane and colleagues (1975) compared
the literature, the most effective therapy tends to the effectiveness of short-term psychodynamic
be that favored by the researchers conducting the psychotherapy with that of short-term behavior
study—the allegiance effect as it has come to be therapy. Thirty patients were randomly assigned to
known. A review of treatment comparisons in each of the therapy conditions, and 34 assigned to a
adult therapy found that about two thirds of the waiting-list control group. Two thirds of the patients
variance in outcome differences between different were diagnosed as neurotics and one third as exhibit-
psychotherapies was due to the researcher’s own ing personality disorders. The therapists were
therapy allegiances (Luborsky et al., 1999). Another matched for experience. Treatment lasted for 4
review of studies on child and adolescent therapy months, with an average of 14 sessions. The most
found that, when allegiance was controlled, there striking findings of the study were that, at the end
was no evidence of any outcome differences of 4 months of therapy, both treatment groups were
among various treatments (Miller et al., 2008). significantly more improved than the no-treatment
Cognitive-behavioral researchers tended to find group, and neither form of psychological treatment
better results for cognitive-behavioral therapies, was more effective than the other. On symptom rat-
whereas psychodynamic researchers discovered ings, 80% of the patients in each therapy group were
more impressive results for psychodynamic thera- considered either improved or recovered, compared
pies. Such findings throw a wild card into interpret- to 48% in the control group. On ratings of overall
ing treatment differences and remind us to temper adjustment, 93% of the patients in behavior therapy
any claims of the superiority of one therapy over were considered improved, compared with 77% of
another, unless the studies have been fairly con- the psychoanalytic psychotherapy group and 47%
ducted by theoretically neutral researchers. of the waiting list.
When dispassionate researchers conduct the Consistent with the results of that single study,
studies or control for the allegiance effect, most the efficacy of brief psychodynamic therapy with
major therapies work about equally well for most adults has been repeatedly confirmed by meta-
disorders (Lambert, 2002; Wampold, 2001). Meta- analytic research. Meta-analyses (e.g., Abbass et al.,
analyses of comparative studies involving thousands 2009; Anderson & Lambert, 1995; Crits-Christoph,
of patients suggests that long-term psychodynamic 1992; Driessen et al., 2010; Svartberg & Stiles, 1991)
therapy is as effective or perhaps a shade more effec- have all found large effects for brief psychodynamic
tive than shorter forms of psychotherapy for complex therapy relative to wait-list controls. The average
mental disorders (Bhar et al., 2010; Leichsenring & effect sizes are in the 0.85 to 1.0 range and compare
Rabung, 2008, 2011). After long-term psychody- favorably with the results of other therapies (Shedler,
namic therapy, complicated patients on average 2010). Translated into percentages, the average brief
were better off than 96% of the patients in the control dynamic therapy patient is better off than 79% to
groups. Such findings should also remind us, as Freud 86% of wait-list patients. A couple of the meta-
himself assuredly would, that our personal biases and analyses found that short-term psychodynamic psy-
emotional allegiances effect our conclusions! chotherapy was slightly inferior to alternative

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76 Chapter 3

psychotherapies at posttreatment, but the allegiance (Shedler, 2010). In contrast, the benefits of other
effect was probably at work here as well. therapies tend to decay over time. This proposition
To address the controversial possibility of slightly of enhanced gains activates the allegiance effect as
inferior outcomes of brief psychodynamic psy- well: psychodynamic clinicians now claiming it as
chotherapies, a meta-analysis was performed on fact, and non-psychodynamic clinicians claiming it
17 more recent, methodologically rigorous studies as a methodological artifact.
(Leichsenring et al., 2004). Short-term psycho- All in all, the controlled outcome research con-
dynamic psychotherapy yielded significant and large sistently finds that the measurable outcomes of psy-
pretreatment to posttreatment effect sizes for target chodynamic therapy and its brief versions are
problems (ES ¼ 1.39), general symptoms (0.90), and superior to no treatment and TAU. Many non-
social functioning (0.80). These effect sizes exceeded psychodynamic clinicians still refer to the early
those of waiting-list controls and TAUs. No dif- meta-analyses suffering from the allegiance effect
ferences were found in outcomes between brief and argue for the superiority of their treatments,
psychodynamic therapy and other forms of whereas psychodynamic clinicians cite the later
psychotherapy. That is, they evidenced equal effec- research and argue for comparable effectiveness of
tiveness. The results of sensitive meta-analyses their treatments. The question of “How good is brief
accounting for researchers’ allegiance demon- psychodynamic therapy?” can now be answered
strate that psychodynamic treatments produce with meta-analyses: It is definitely superior to no
comparable effects for specific disorders. treatment and probably just as effective as alternative
Short-term psychodynamic therapy may be psychotherapies. But, as in all matters of the mind,
especially well suited to personality disorders and the answer seems to depend on who is conducting
somatic disorders. A meta-analysis examined the the study and on who is interpreting the results.
efficacy of both psychodynamic therapy (14 stud-
ies) and cognitive-behavioral therapy (11 studies)
for personality disorders (Leichsenring & Leibing,
Criticisms of Psychodynamic
2003). Both treatments demonstrated effectiveness, Therapies
with a slight edge to the lengthier psychodynamic From a Psychoanalytic Perspective
therapy (also see Leichsenring & Rabung, 2008; Freud anticipated that Adler’s break with psycho-
Town et al., 2011). Another meta-analysis of the analysis would lead to the development of a super-
efficacy of short-term psychodynamic therapy ficial and sterile theory (Colby, 1951). In rejecting
examined 14 controlled studies involving 1,870 psychoanalysis, Adler rejected half of the human
patients. The analysis yielded effect sizes of 0.69 personality. The result is a one-dimensional theory
for improvement in psychiatric symptoms and that emphasizes the ego or self at the expense of the
0.59 for improvement in somatic symptoms, both id, consciousness at the expense of the unconscious,
equal to the effects of alternative psychotherapies social strivings at the expense of biological drives,
found in other studies (Abbass et al., 2009). and compensation at the expense of other defenses.
A recent empirical thrust examines an old con- Here we have a yin without a yang, half of the
viction that psychodynamic therapies may consoli- person presented as if it were the whole.
date gains after treatment ends. That would lead to As a result of the holes in Adler’s holism, there
greater benefits and higher effect sizes at long-term emerges a naive psychotherapy that suggests people
follow-up than immediately at the conclusion of can be helped with all types of cute gimmicks. Just ask
therapy. Five or six meta-analyses now support a frightened, submissive woman to act “as if” she is
the notion that the benefits of psychodynamic ther- assertive, and she will be liberated. Just push a button,
apy not only endure but also increase with time and an embittered recluse can change his fantasies

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Chapter 3 Psychodynamic Therapies 77

and feelings as fast as he can change the television not social ills. Intrapsychic forces of superiority
channel. The power of positive thinking has been ped- and inferiority still rule the mental roost. The life-
dled as a lasting cure for centuries, when it is nothing style analysis considers the impact of the family con-
but a temporary pep talk. People are not really locked stellation, but the patient is still responsible for the
into unconscious conflicts; they are only discouraged. illness and the cure. Psychodynamic therapy tries to
Just have hope, faith, and charity, and that is the way change the sick patient, not the sick society.
to live successfully. Adler does indeed promise a rose Women fare a bit better under Adler than
garden to those willing to share his rose-colored under Freud, but not much. Adlerian theory
glasses that filter out the dark side of life. accepts psychotherapy as an extension of the
socialization process. Be more socialized and civi-
From a Cognitive-Behavioral Perspective lized, and you will be free from psychopathology.
Adlerians cannot decide whether they are social- That may be true for many men and children in
learning theorists who attribute maladaptive need of socialization or resocialization, but what
behavior to family constellations and other envi- of the many women who are troubled because
ronmental conditions or mystics who attribute they are oversocialized? The ever-polite and pas-
distorted lifestyles to an undeveloped creative self sive client suffering from stress headaches will not
that sounds much like a soul. Why Adlerians feel be freed by striving to be more perfect. She needs
the need to resort to the mythical concepts of to express her anger and resentment over always
choice and a creative self when observable beha- stifling herself for the sake of social harmony. The
viors of parental pampering, abusing, and ignor- self-sacrificing spouse who experiences no sense of
ing would serve as explanations is unclear. self because she has always lived for others doesn’t
It is clear, however, that theoretical propositions need to be encouraged to make someone else
concerning the effects of birth order can be defined happy once a day. She needs to know how to
and tested, whereas concepts such as striving for care for herself and to assert herself.
superiority and the creative self are vague and
unamenable to scientific investigation. Perhaps From an Integrative Perspective
Adlerians hold to such concepts in order to place There is much of value in psychodynamic therapies
the responsibility for change on the clients, because to those committed to integrating the psychothera-
the therapy system has been unable to generate tech- pies. Alfred Adler broadened the exclusive reliance
niques powerful enough to produce adequate change on insight and private knowledge to include action-
in the behavior of clients. Whatever the reasons, the oriented and psychoeducational processes in ther-
Adlerian school remains a strange combination of a apy. The therapeutic relationship was construed
theory that borders on scientific respectability and a and offered as more egalitarian and more real
religion that dedicates the soul to social interest. than it was in psychoanalysis. Individuality and
relatedness were accorded equal consideration in
From a Cultural Perspective psychotherapy, reversing a trend toward self-
Give Adler and his psychodynamic colleagues credit contained individualism (Guisinger & Blatt, 1994).
for moving away from the overly sexual nature of Adler and his followers were more flexible in their
Freud’s drive theory and toward an appreciation of formats, innovative in their practices, and eclectic
the broader family and cultural forces at work. But in their techniques than were Freud and his disci-
they do not go far enough. No matter how you ples. Not surprisingly, many contemporary eclec-
repackage it, psychodynamic theory represents the tics, including Arnold Lazarus (see Chapter 16),
same sexist, intrapsychic perspective in more social have been heavily influenced by Adler’s work and
terms. Problems are still attributed to individuals, are enthusiastic about his psychotherapy.

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78 Chapter 3

On pragmatic grounds, systemization and On more theoretical grounds, it is ironic that


evidence are sorely needed (Dryden & Lazarus, Adler called his approach individual psychology,
1991). Although there are many interesting con- when he ultimately valued social interests over the
structs and a prescribed lifestyle analysis, little interests of the individual. Adler attempted to
systematic direction exists regarding which resolve the inherent conflicts between society
interventions should be used with which and the individual by suggesting the individual’s
patients with which disorders. Just do the same best interests are really served by subjugating self-
thing for all patients—not a notion likely to be interest to the interests of society. Adlerian theory
endorsed by any genuine eclectic! The empirical may indeed help balance therapeutic approaches
evidence on the effectiveness of Adlerian ther- that worship only the self at the expense of others.
apy, moreover, is far too scant for an eclectic to Nevertheless, it would be a mistake to conclude
even consider wholly adopting its theory or its that a complete life can be found only in living
interventions. for social interests and never for self-interest.

An Adlerian Analysis of Mrs. C


Mrs. C is a person almost entirely preoccupied Quickly Mrs. C became the perfect compulsive,
with herself. Other people are mere shadows, the most complete washer others had ever
minor characters who move in and out of her known. What a special person she is, how
dramatic rituals. Her life has become a parody unusual! She has already stumped several clini-
of a great epic. She is in a mortal struggle with cians and a prominent psychiatric hospital. Her
the dreaded evil of pinworms, and only she can compulsive lifestyle serves, then, as a compensa-
be powerful enough and perfect enough to pre- tion for her inferiority complex of being unable to
vent the pinworms from becoming the victors. solve life’s tasks, as a built-in excuse for not doing
She has obviously switched her striving for more with her life, as a means of freezing time by
superiority from solving the primary tasks of repeating the same rituals that seem to keep life
life to a secondary theater of operations in from moving ahead, and as a dramatic struggle
which she can be the heroine, the star in her that proves how superior she is at holding back
own style of life. the evil forces of the world.
Mrs. C’s dramatic dilemma is common to Progress in therapy would be a real threat to
those with a compulsive personality. Having Mrs. C. She has judged herself as too inferior to
been raised under the constant castigation and progress in life. She has made a basic mistake of
derision of dominating parents, Mrs. C was dis- evaluating herself on the basis of early recollections
couraged from believing that she was capable of of how her parents perceived her—as an inferior
facing life’s tasks successfully. She had indeed being, requiring constant control and domination.
failed at the task of coming to grips with her What distortions she may have added to these
own sexuality. She was in the process of failing recollections may never be known. Did her parents
at the work of caring for five children with a never support her strengths or her strivings for
sixth on the way. The intense inferiority complex independence? Did she encourage their domination
that she had accepted early in life was in danger because she found security in being protected from
of proving to be all too true. What she decided as sex, disease, or boys? Were there not adults in her
a child was becoming a self-fulfilling prophecy: life, teachers or neighbors, who encouraged her,
She was too inferior to find completion through even if her folks were really such tyrants? Again,
life’s tasks. Her solution was to switch the arena answers to such questions may never be known.
to a neurotic struggle that was more of her own What must become known to Mrs. C is that she
making and more under her control. continues in her neurotic patterns because she
(continued)

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Chapter 3 Psychodynamic Therapies 79

concluded early in life that she was ultimately Mrs. C would also be encouraged to participate in
unable to succeed in life. She must come to under- a full analysis of her life script, including basic mis-
stand that she is not special or disturbed because takes such as judging herself inadequate because
she has intense feelings of inferiority, but that she she felt dominated by her parents. Her earliest recol-
shares these feelings with all humans. Her distur- lections would be interpreted, as would her percep-
bance is the result of striving to be special and try- tions of her position in her family constellation. The
ing to compensate for her inferiorities by investing group could be especially supportive in helping
all her energies in a completely self-centered life. Mrs. C to become more fully conscious of her
If Mrs. C continues to withdraw from living with inferiority complex. Finding that others share intense
and for others, she is indeed at high risk of becom- feelings of inferiority can give Mrs. C the opportunity
ing psychotically disabled. Her thinking and com- to rediscover a genuine interest in others.
munication are of little social interest. They are Experiencing the caring of her therapist and of
almost entirely directed toward pinworms, toward special group members can reorient Mrs. C from
her fears, and toward convincing others how spe- sheer self-interest to an emerging social interest.
cial are her life circumstances. The social ties that Tasks would be assigned to facilitate interest in
connect thinking with social reality can break down others, such as assigning Mrs. C to call certain
if others continue to be of no interest to Mrs. C. group members who are in a crisis to see how they
Given Mrs. C’s intense self-preoccupation, it will are doing each evening. Mrs. C would be encour-
be difficult to engage her with another human in the aged to step further out of her special drama back
form of a psychotherapist. Because she has had con- into the relational world by being assigned simple
siderable individual therapy, and because she tasks to add pleasure to her children’s lives, such
seems only to have convinced herself of how special as baking them a pie. Any reasons for avoiding
she is, it would be better to start Mrs. C in an Adle- these tasks would be interpreted as excuses. In the
rian group. Although she would probably resist process of experimenting with such tasks, Mrs. C
group therapy, on the grounds that she is too trou- can become aware of the healing effect that caring
bled and too in need of individual attention, a group for others can have on self-preoccupation.
would give the direct message that, in fact, she is not Assigning tasks can help Mrs. C reevaluate the
so special. She would have the opportunity to dis- consequences of living for others versus living to
cover that others also have serious problems and ward off pinworms. Acting as if she is free, for the
serious feelings of inferiority, and yet many of moment at least, to create something of value for
them are moving ahead in life. Bibliotherapy would others, even a simple pie, can demonstrate that she
also advance this message. Finding herself unable indeed has some choice in how she is going to con-
to really care about others, Mrs. C might insist that tinue living. Ultimately, she will have to confront the
if she were not so preoccupied with her own prob- choice of whether to come off the stage of her limited
lems, then she could care about the others. The theater of operations to reengage the world. After so
therapist and group members could correct such many years of living for her own drama, Mrs. C may
mistaken thinking by indicating that the reverse choose to hold onto the security and esteem of being
idea is really true: If she can begin to learn to care the world’s greatest container of pinworms, rather
about others in the group, she can begin to forget than risk creating a life that might be more useful to
about herself for awhile. others, even if it is a bit more mundane.

Future Directions involving basic mistakes and “as if” anticipated the
cognitive therapies; and his community outreach
Adler was clearly ahead of the learning curve in
and psychoeducational programs foreshadowed
psychotherapy. His social recasting of Freudian the-
community mental health. Many of Adler’s ideas
ory initiated psychodynamic therapy; his task assign-
have quietly permeated modern psychological think-
ments foreshadowed the development of behavioral
ing, often without notice. It would not be easy to
and other directive therapies; his techniques

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80 Chapter 3

find another author from which so much has been psychoanalysis. A case in point: When we asked
borrowed from all sides without acknowledgment hundreds of psychologists conducting psychother-
than Alfred Adler (Ellenberger, 1970, p. 645). apy to declare their theoretical orientations, only
In some cases, success of a psychotherapy sys- 2% identified themselves as psychoanalytic. But
tem begets more success and popularity. In other 18% identified themselves as psychodynamic
cases, success begets gradual disappearance as a (Bechtoldt et al., 2001). A decisive shift from psycho-
distinct system and incorporation by other sys- analysis to psychodynamicism has occurred.
tems and the public. The fate of Adlerian therapy We offer four forecasts for the future of psy-
definitely seems to be following the second track. chodynamic psychotherapy. First, and most
The future impact of Adlerian therapy, then, assuredly, increasing attention will be paid to rela-
will probably be more indirect than direct. Adler’s tional disturbances originating in infancy and
influence will be represented in the cognitive and early childhood (Strupp, 1992). Fueled by the
behavioral therapies it inspired. His system will be object relations theorists and John Bowlby’s
embodied, unknowingly in most instances, in the (1969, 1973) seminal writings, attachment styles
eclectic and integrative therapies it helped to are serving as useful clinical guidelines. An inse-
spawn. The concepts of inferiority complex, supe- cure attachment style complicates a patient’s later
riority strivings, social interest, ideal self, and ordi- relationships, including the therapeutic relation-
nal position, among others, have been widely ship, whereas a secure attachment style predicts
incorporated, often without acknowledgment of better relationships and therapy outcomes (Levy et
Adler, into many psychotherapy systems and, al., 2011). The therapist can not only become an
indeed, into the public lexicon. Thus incorporated attachment figure for the client, but also respond
and assimilated, Adlerian therapy may gradually differently depending on that attachment style.
disappear as a distinct orientation as a result of Indeed, attachment is quickly becoming a
its own success. pantheoretical construct among child, couples,
The principal direction for Adlerians is to go trauma, and psychodynamic therapists.
“on beyond Adler” (Manaster, 1987a, 1987b). Second, the treatment focus will increasingly
What’s needed are evolutionary Adlerians who shift from the traditional neurotic disorders to
will view Adler as an ancestor but who will do more complex disorders, such as borderline and
so critically, noting where they think he was narcissistic personality disorders, multiple
essentially correct and where he may have missed trauma, and somatoform disorders. The psycho-
the mark (Hartshorne, 1991). This evolution will dynamic treatment of these conditions is now
certainly entail combining Adlerian techniques considered to be one of the treatments of choice.
with those of other systems in a coherent brief When other, typically shorter treatments fail, the
therapy. “On beyond Adler” may well become discerning clinician will certainly consider the
the rallying cry of those who desire to avert the ambitious and comprehensive psychodynamic
premature disappearance of Alfred Adler’s semi- alternative.
nal theory as a distinct system of psychotherapy. Third, having now proved in the research that
The future of Freudian practice indisputably lies psychodynamic therapy represents an evidence-
in psychodynamic therapy. In practice, most con- based treatment for multiple disorders, psycho-
temporary followers of Freud lean more heavily on dynamic therapists will drill down to determine
ego psychology, object relations, supportive therapy, which form works best for which patient. When is
and brief psychodynamic therapy than on classical long-term versus short-term psychodynamic therapy

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Chapter 3 Psychodynamic Therapies 81

indicated? For which clients is supportive versus object striving for superiority
expressive therapy called for? The next generation object relations style of life
of researchers will ask not only, “Does it work?” organ inferiority supportive therapy
but “Does it work best for this particular patient in psychodynamic supportive-expressive
this situation?” therapists therapy
Fourth, future training will focus heavily on the psychosocial stages symbiotic psychosis
preparation of brief psychodynamic therapists. push-button technique therapeutic, or
Time-limited psychodynamic therapy reflects the self-interest working, alliance
ongoing march toward evidence-based and cost- self psychology transference-focused
effective treatments for specific disorders applicable social interest psychotherapy
to the largest number of patients. Guided by treat- splitting treatment manuals
ment manuals, analogous to a flight plan or a road
map, training will ensure competence in appropriate Recommended Readings
therapist stances and techniques.
Adler, A. (1927). The practice and theory of
All of these future directions will provide
individual psychology. New York: Harcourt,
needed specificity in training, research, and prac-
Brace.
tice for the descendants of Sigmund Freud. And,
Carlson, J., Watts, R. E., & Maniacci, M. (2005).
all these directions will converge in enabling our
Adlerian therapy: Theory and practice.
clients to live fuller, deeper, more joyful lives with
Washington, DC: American Psychological
secure attachments and social interests.
Association.
Kohut, H. (1977). The restoration of the self.
Key Terms New York: International Universities Press.
acting “as if” creative self Luborsky, L. (1984). Principles of psychoanalytic
aggression instinct drive theory psychotherapy. New York: Basic.
allegiance effect effect size (ES) Rockland, L. H. (2003). Supportive therapy: A psy-
analytical psychology ego analysis chodynamic approach. New York: Basic Books.
anamnesis ego psychology Strupp, H. H., & Binder, J. L. (1984). Psychotherapy in
archetypes fictional finalism a new key: A guide to time-limited dynamic
attachment Gemeinschaftsgefühl psychotherapy. New York: Basic Books.
attachment styles (social interest) Summers, R. F., & Barber, J. P. (Eds.). (2009).
autonomous ego holding environment Psychodynamic therapy: A guide to evidence-
autonomous self ideal self based practice. New York: Guilford.
basic mistakes individual psychology Yeomans, F. E., Clarkin, J. F., & Kernberg, O. F.
bibliotherapy inferiority complex (2002). A primer of transference-focused psycho-
birth order/ordinal introjection therapy for the borderline patient. Northvale, NJ:
position lifestyle analysis Jason Aronson.
catching oneself masculine protest JOURNALS: Dynamic Psychotherapy; International
character analysis meta-analysis Journal of Intensive Short-Term Dynamic
collective unconscious mirroring Psychotherapy; Individual Psychology: Journal
compensation narcissistic personality of Adlerian Theory, Research and Practice;
compulsive lifestyle normal autism International Journal of Psychoanalytic Self
conflict-free spheres normal symbiosis Psychology; Issues in Ego Psychology; Journal of

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82 Chapter 3

Analytical Psychology; Journal of Analytic Social International Association for Psychoanalytic Self
Work; Psychoanalysis and Psychotherapy; Psychology (Kohut):
Psychoanalytic Dialogues; Psychoanalytic www.psychologyoftheself.com/
Inquiry; Psychoanalytic Psychology. Journal of Individual Psychology:
www.utexas.edu/utpress/journals/jip.html
North American Society of Adlerian Psychology:
Recommended Websites www.alfredadler.org
APA Division of Psychoanalysis: Society of Analytical Psychology (Jung):
www.apadivisions.org/division-39 jungian-analysis.org/

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CHAPTER 4
Existential Therapies

Courtesy of Rollo May


Rollo May

Lilly entered psychotherapy haunted by the dread that


she was dying from terminal failure. Her marriage
had failed. Worse, she felt she had never really
gotten to know her husband. Lilly didn’t bother to
get a divorce, so she wouldn’t have to explain why
she wasn’t married in middle age. She also felt she
failed by her inability to have a child, even though
she cared deeply about her nieces and many of her
students. But she felt, too, that she had failed in her

Courtesy of James Bugental


career as a teacher. Lily had to move from one part-
time job to another, with colleges relying increasingly
on temporary rather than tenured faculty.
Lilly had failed to live up to all the expectations James Bugental
of her family which once was famous. Worse, she
failed to live up to her own expectations. At a time of deep despair for Lilly, I (JOP)
Lilly’s finances were also failing to sustain her, asked her to share with me the experiences she
especially in the face of her failing health. It turned most loved in her life. Lilly came alive when she
out Lilly was dying from terminal cancer. But it relived her adventures with different cultures,
wasn’t the cancer that haunted her. It was the speaking foreign languages with people who
constant questioning about what had she became her friends. Lilly came alive when she
accomplished with her life. It was an existential recalled her favorite novels that took her back
crisis. What had she achieved with all the time into earlier eras. She sometimes wished that she
and talent she was given? had lived in simpler times. She loved to paint

83

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84 Chapter 4

watercolors of landscapes on the island where she the existential nature of psychopathology and the
lived in a small shingled shack by the sea. therapeutic uses of the existential crisis that Lilly
Lilly could laugh, and she could cry. She had was experiencing. Binswanger believed that crises
deep feelings and deep thoughts. As she shared in psychotherapy usually represented critical
these she gradually started to appreciate that her choice points for patients. His commitment to a
life was filled with rich experiences. How person’s freedom to choose in therapy went as far
liberating it was for Lilly to choose that she would as his acceptance of the suicide of one of his
evaluate her life on what she had experienced patients, Ellen West, who found death to be her
rather than what she had achieved. most legitimate alternative (Binswanger, 1958).
Lilly gave me a special painting of a flower. She Existentialists, like Binswanger, do not run
also left me memories of a special life. from the dark side of life. Following the example
of Kierkegaard (1954a, 1954b), the Danish philoso-
pher, existentialists are willing to face aspects of life
A Sketch of Early Existential that are awful but meaningful at the same time.
Therapists Binswanger had originally struggled to find
Most systems of psychotherapy emerge in a meaning in madness by translating the experience
particular time and context in human events. Psy- of patients into psychoanalytic theory. After read-
choanalysis, as we have seen, emerged near the end ing Heidegger’s (1962) profound philosophical
of the repressive Victorian era with a correspond- treatise, Sein und Zeit (Being and Time), however,
ing emphasis on sex. Cognitive therapy, with its Binswanger (1958) became more existential and
focus on mind and sensory data, accompanied the phenomenological in his therapy. The phenome-
dawn of computers and the Information Age nological approach enabled Binswanger to face
(Miller & Hubble, 2004). directly the immediate experience of patients and
The developmental context of existential phi- to understand the meaning of such phenomena in
losophy was the lost generation following the the patient’s language rather than in terms of the
madness of World War I and the search for mean- therapist’s abstract theory.
ing following the destruction of World War II. Binswanger began applying his emerging exis-
The human species was capable of exceptional tential ideas in the Sanatarium Bellevue in Kreu-
violence and cruelty; an estimated 61 million peo- glinger, Switzerland, where he succeeded his father
ple were lost during World War II alone. People as chief medical director in 1911. After interning
were understandably preoccupied with death, under the famous psychiatrist Eugen Bleuler, from
dread, and despair on a daily basis. The prospect whom he learned much about the symptoms of
of death and nonexistence was imminent for mil- schizophrenia, he became intrigued with under-
lions. What did it all mean? Was life meaningless? standing the existence of the people experiencing
How does one grapple with death anxiety? How psychopathological states. He worked on this for
could people become free from oppression? How the rest of his life. Although he retired in 1956, he
did people avoid responsibility for their heinous continued his work until his death in 1966 at the
behaviors? Existentialism, first as a philosophy age of 85.
and then as a psychotherapy, addressed these Medard Boss (1903–1991), a second early and
fundamental questions of life, and of death. influential existential psychotherapist, had a career
Ludwig Binswanger (1881–1966) was one of remarkably similar to Binswanger’s. Born in Swit-
the first mental health professionals to emphasize zerland in 1903, he also worked under Bleuler in

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Existential Therapies 85

Zurich. Like Binswanger, he knew Freud and was a “discordant” marriage (May, 1989, p. 436).
heavily influenced by his thinking. Heidegger was May’s early life was lonely and conflicted; his child-
his most important influence and, like Binswan- hood experiences sensitized him to the pain of
ger, Boss was concerned with translating Heideg- loneliness and the inescapable anxiety associated
ger’s philosophical position into an effective with tumultuous family life (Monte, 1991).
psychotherapy. Boss’s particular concern was to Following travel and a “breakdown” in Greece,
integrate the ideas of Heidegger with the methods May traveled to Vienna to study briefly with Alfred
of Freud, as indicated in the title of his major Adler, which strengthened his interest in psycho-
work, Daseinanalysis and Psychoanalysis (1963). dynamic psychotherapy. But returning to the
Boss worked for many years in the medical states, he found that the psychology of the time
school as professor of psychoanalysis at the was not investigating the profound questions of
University of Zurich, which continues to be the death, love, will, and hate that occupied his exis-
European center of Daseinanalysis (being-there or tence. Instead, May enrolled at Union Theological
existential analysis) even after his death in 1991 Seminary, where he began his lengthy friendship
(Craig, 1988). with theologian Paul Tillich. Thereafter, while
Although most existential therapists draw on trying to complete his doctorate in psychology at
the clinical formulations of Binswanger and Boss, Columbia University, May came down with tuber-
neither dominates existentialism the way Freud culosis, then a killer disease. He was confined for
dominated psychoanalysis or Rogers eclipsed the balance of 2 years at a tuberculosis sanatorium,
person-centered therapy. One reason is that nei- where he needed to confront the possibility of his
ther existentialist developed a comprehensive sys- own death. May embraced an active stance toward
tem or theory of psychotherapy. Boss, in fact, his disease and found meaning that sustained him
seems even antitheoretical. In a letter to Hall and over the course of a productive and prolific career.
Lindzey (1970), he wrote: May’s own existential struggles have informed his
books, among them The Meaning of Anxiety
I can only hope that existential psychology will
(1950/1977), Existence (May et al., 1958), Love and
never develop into a theory in its modern mean-
Will (1969), and The Discovery of Being (1983).
ing of the natural sciences. All that existential
Like Binswanger and Boss before him, Rollo
psychology can contribute to psychology is to
May never developed a formal system of existen-
teach the scientists to remain with the experi-
tial therapy. In fact, May and colleagues (1958)
enced and experienceable facts and phenomena,
defined existential therapy as an attitude that
to let these phenomena tell the scientists their
transcends orientation. Others have defined it as
meaning and their references, and so do the
a dynamic therapy that addresses life’s ultimate
encountered objects justice.
concerns (Yalom, 1980) or practically any antide-
The most influential existential therapist in the terministic psychotherapy (for example, Edwards,
United States has been Rollo May (1909–1994). 1982). Not surprisingly, then, the existential
In contrast to the European context and medical movement is a diffuse school of theorists and
training of Binswanger and Boss, May was born practitioners more aligned in their philosophical
and raised in the United States and was trained in emphases than in concrete techniques or practical
theology and clinical psychology. His immediate fam- consequences. Put another way, existential therapy
ily consisted of five brothers and a sister, who later is more a philosophy about psychotherapy than a
suffered from psychosis, and parents who endured system of psychotherapy.

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86 Chapter 4

Several American psychotherapists have tried that a behaviorist would swear are figments of the
to pull together the many strands of existentialism Freudian imagination. The behaviorist might argue
into a coherent clinical approach. They combine that eventually we will all respond to the same
the philosophical base of existentialism, as enun- world once it is defined by the scientific method,
ciated by Søren Kierkegaard, Martin Heidegger, but the existentialist argues that the scientific
Jean-Paul Sartre, and Martin Buber, among method itself is a human construction, inadequate
others; the clinical themes of the early existential for understanding the very reason that created it.
therapists, principally Binswanger, Boss, and May; Rather than reconciling differences in worldviews,
and their own therapy experiences into a recog- the existentialist accepts that, to understand a par-
nizable system of psychotherapy. Central among ticular human, is to understand the world as that
these American systematizers are James Bugental person construes it.
(1965, 1987, 1990), Irving Yalom (1980), and Kirk We exist in relation to three levels of our world.
Schneider (2007), from whose collective work we In German these are called Umwelt, Mitwelt, and
will also draw in this chapter. Eigenwelt (Binswanger, 1963; Boss, 1963; May,
1958). Umwelt connotes ourselves in relation to the
biological and physical aspects of our world, and we
Theory of Personality will translate it as being-in-nature. Mitwelt refers to
Existentialists are uncomfortable with the term the world of persons, the social world; we will call it
personality if it implies a fixed set of traits within being-with-others. Eigenwelt literally means own-
the individual (Boss, 1983). For them existence is world and refers to the way we reflect on, evaluate,
an emerging, a becoming, a process of being that and experience ourselves; it will be translated as
is not fixed or characterized by particular traits. being-for-oneself.
Being is a verb form, a participle, implying an Personalities differ in their ways of existing at
active and dynamic process. Nor does existence each of these three levels of being. Imagine being
occur just within the individual, but rather on a beautiful, secluded beach by the ocean. One
between individuals and their world. person might be afraid to set foot in the ocean
Existence is best understood as being-in-the- because it is the home of sharks waiting to attack,
world. The use of hyphens is the best we can do in whereas another person dives in, eagerly seeking
English to convey the idea that a person and the refreshment in the cool waters. One person desires
environment are an active unity. Existentialists a lover in such a sensuous setting, whereas
reject dualism that assumes a split between mind another feels all alone. One person walks along
and body, experience and environment. Being and looking at the nearby land as a golden opportunity
world are inseparable, because they are both for a seaside housing development, but another
essentially created by the individual. feels sad about the encroachment of houses
Phenomenologically, the world is our own con- already under construction nearby. Still others
struction that to a greater or lesser extent reflects feel at one with the ocean from which all life has
the construction of others, depending on how con- come, whereas someone, somewhere wants to join
ventional we are. For example, a traditional Chris- the ocean to end life.
tian’s world includes a Superior Being with which When we-are-with-others, we know that they
one can communicate, whereas the atheist’s exis- are conscious beings who can reflect on us, evalu-
tence contains no such spiritual being. In therapy, ate us, and judge us. This may cause us to fear
a psychoanalyst experiences dynamics in patients others and want to run from them. We may

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Existential Therapies 87

choose to clam up or to talk only about super- The best alternative is to be authentic. For the
fluous topics such as the weather lest we reveal existentialists, authenticity is its own reward. An
something about ourselves that others would authentic existence brings with it an openness to
dislike. Frequently, we anticipate what others are nature, to others, and to ourselves, because we
thinking or feeling about us, and we guide our have decided to meet the world straight on with-
observable behavior in order to have a favorable out hiding it from us or us from it. Openness
impact on them. This is the way, unfortunately, means that authentic individuals are more aware,
we typically are with others, a level of existence because they have chosen not to hide anything
known as being-for-others. This mode of existence from themselves. An authentic existence also
parallels the characterization of the modern brings the freedom to be spontaneous with others,
personality as other-directed (Reisman, 1961). because we do not fear that we might reveal some-
Fortunately, there are precious times with thing about ourselves that contradicts what we
special others in which we can let ourselves be, have pretended to be. A healthy existence brings
silly or sad, anxious or mad, without having to with it an awareness that any relationship we do
worry about what the other person is thinking have is authentic and that if anyone cares about
about us. When we are being-for-ourselves, we us, it is really us they care about and not some
are the ones who are reflecting on, evaluating, or facade constructed on their behalf. Authentic rela-
judging our own existence. tionships allow us to truly trust others because we
Because self-reflection can be painful at times, know they will be honest about their experience
we may choose not to be introspective. Or we may and not tell us what they think we want to hear.
choose to think about ourselves only after having a An authentic existence is healthy because the
few drinks or a few pills to deaden the pain. Or we three levels of our being are integrated, or in-joint,
may become incessantly introspective and have rather than in conflict. We experience ourselves as
difficulty being with others. For existentialists, together: The way we are in nature is the way we
however, the risk of pain or self-preoccupation is present ourselves to others and also the way we
the price we pay to achieve the considered, conscious know who we are. We do not get caught up in
life so important in creating a healthy existence. idealizing images about ourselves that prevent us
In trying to create a healthy existence, we are from being intimate with others lest they tell us
faced with the dilemma of choosing the best way what we do not want to hear. Nor do we get so
to be in-nature, with-others, and for-ourselves. preoccupied with ourselves that we cannot get
With the emergence of consciousness, we realize involved in the world around us. A healthy exis-
how ambiguous the world is and how open it is to tence, then, involves a simultaneous and harmoni-
different interpretations. In this book alone, we ous relationship to each level of being without
are considering 16 different interpretations that emphasizing one level at the expense of others,
could serve as guides for interpreting the natural, such as sacrificing our self-evaluation for the
social, and personal aspects of our world. What is approval of others.
the existential alternative for living? The best alter- With authenticity promising so much, why
native is not necessarily to choose to maximize don’t we all choose to be authentic? Why are so
reinforcements and minimize punishments, as many of us terrified that if other people really
some behaviorists would suggest, or to adapt our knew us they wouldn’t want to be with us? Why
instinctual desires to the demands of our environ- does the other-directed personality seem to be the
ment, as some Freudians would suggest. stereotype of our time? What is the dread that

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88 Chapter 4

comes with being more fully aware of ourselves ignorance of their ramifications, knowing that we
and our world? will hurt people regularly without intending to.
Theologian Paul Tillich (1952) outlined cer- In critical choices, we alone are responsible.
tain conditions inherent in existence that tempt Inherent in our responsibility is the anxiety of
us to run from too much awareness. These condi- knowing that we will make serious mistakes, but
tions fill us with a dread called existential anxiety. not knowing whether this choice is one of those
The first source of anxiety comes with our acute mistakes. For example, when I (JOP) was origi-
awareness that at some unknown time we must nally deciding whether to spend a year of my life
die: Being implies nonbeing. Death may be denied writing the first edition of this book, I was quite
by our culture, including psychology, yet the fact anxious that such a decision might be a miserable
that our total existence will end in nothingness mistake and might lead me to avoid other attrac-
can make us shudder. When we are honest, we tive pursuits. (Some of you may now believe that I
are also aware that our most significant others had good reason to be anxious!)
can die at any time, ending not only their exis- The threat of meaninglessness is another contin-
tence but also the part of our being that was inti- gency of human existence that produces anxiety. We
mately connected with them. all want to do something meaningful with our lives.
Many summers ago my wife and I were The particular meaning may vary from love for one
swimming with our young son and daughter in person, to sex for another, to faith for still another.
a salt pond near the ocean. A woman came over But when we honestly question the significance of
to borrow a paper cup, and when she turned our existence, the issue becomes whether life itself
around she immediately realized that her means anything. We can rarely go to the theater or
4-year-old son was missing. She was convinced a modern museum or read a current novel without
that he was in the water, so we began diving and being confronted with this profound issue. For many
diving and diving. The more we dove, the more of us, what we once believed in—our former religions,
anxious we became, hoping we would find him, our former politics, or our former therapies—no lon-
then gradually hoping that we wouldn’t. Two ger seem as significant as they once did. This suggests
hours later, when the fire department pulled that our current source of meaning may also disap-
his lifeless body out of the deepest waters pear. All therapists see formerly vital marriages that
where no one expected him to be, all we could have become entirely devitalized, with nothing left
do was shudder and hold each other close. but deadly boredom. We see people trapped in previ-
Once we become conscious beings, we become ously gratifying jobs that are now nothing more than
aware that inherent in existence is a necessity- a means of structuring time, ruts that lead nowhere.
to-act. We must make decisions that will pro- Our clients become anxious, and so do we.
foundly affect the rest of our lives, such as where Part of our anxiety comes from knowing we are
we go to school, what career we choose, if and the ones who created the meaning in our lives, and
whom we choose to marry, and whether we have we are the ones who let it die. Therefore, we must be
children. We must act, and yet in modern times, we the ones to continue to create a life worth living.
are less and less certain about the basis for deciding. The prospect that existence has no significance
We cannot know beforehand with any degree of whatsoever can be terrifying. The conclusion that
certainty how our decisions will turn out, and so one’s existence is totally absurd can be immobiliz-
we are continually under the threat of uncertainty ing. This immobilization is exemplified by the main
and guilt. We must make decisions in relative character in John Barth’s (1967) The End of the

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Existential Therapies 89

Road. If there is no meaning in life, then there is no Our being is conscious, chosen, and free,
basis on which to make a decision, so he could not whereas nonbeing is without light, closed, and
act. His psychotherapist hatched the ingenious necessary. In daily living, we experience being as
solution that because nothing mattered, he could our “subjectness,” in which we are the active sub-
do just as well by applying arbitrary principles ject or agent in directing our own lives; nonbeing
when faced with the necessity to act. His principles is experienced as our “objectness,” in which we are
for living included alphabeticity and sinistrality: objects determined by forces other than our will.
When confronted with a choice in life, he would Authentic being survives to the extent that it takes
choose the option that began with the first letter of nonbeing into itself. It perishes to the extent that it
the alphabet or the option on the left. attempts to affirm itself by avoiding nonbeing. Our
Our isolation, our fundamental aloneness in self as a conscious, choosing, and open subject can be
the universe, is another condition of life that brings only through confronting and surviving the anxiety of
anxiety (Bugental, 1965). Regardless of how inti- existence. To avoid existential anxiety is to avoid non-
mate I am with others, I can never be them, nor being in its various forms. To avoid choice and its
can they be me. We share experiences, but we are anxiety, for example, is to fail to be a choosing subject.
always under the threat of never totally under- An authentic personality is aware that existence is a
standing each other. Furthermore, we know that constant flow from nonbeing into being and back into
choosing to follow our unique direction and create nonbeing again. This can be seen most clearly in the
our own meaning in life may lead to others’ not overall course of our existence, as we come from the
wanting to be with us. The possibility of such rejec- darkness of having never been, live in the light of
tion brings forth the anxiety of being literally alone. consciousness, and then return to the darkness of
These multiple sources of existential anxiety death. Our daily cycle is similar, as our present exis-
attest to the defining characteristic of the human tence emerges from the yesterday that no longer exists
condition: finiteness. Death reflects the finiteness into the being of the present and thrusts into the
of our time; accidents represent the limits of our unconscious nonbeing of tomorrow. That is why
power; anxiety over decisions reflects the inade- authentic being is said to occur only in the present.
quacy of our knowledge; the threat of meaning-
lessness, the finiteness of our values; isolation,
the finiteness of our empathy; and rejection, the Theory of Psychopathology
finiteness of control over another human being. Lying is the foundation of psychopathology. Lying
These contingencies of life have also been is the only way we can flee from nonbeing, to not
called the realm of nonbeing. These existential allow existential anxiety into our experience.
givens are matters of necessity—we must die, we When confronted with nonbeing, such as the
must act—and hence are a negation of being, which drowning of the 4-year-old boy, we have two
is by definition open-ended and in the realm of choices: to be anxious or to lie. We may choose
possibility. Nonbeing is the ground against which to lie by telling ourselves that if we keep a constant
the figure of being is created. Death is the ground eye on our family, we can prevent accidents. We
that accents the figure of life in bold relief. Chance hold close our children and our spouse, and when
is the ground that determines the limits of our they are in sight we feel relaxed. The lie has
choice. Meaninglessness is the ground against worked. We have avoided an encounter with the
which meaning can be seen. And isolation is the existential anxiety of accidents, but nonbeing is
ground from which intimacy emerges. always there, threatening to emerge into our

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90 Chapter 4

consciousness. Lying always leads to a closing off Psychopathology is also characterized by an


of part of our world; in this case, we must close off overemphasis on one level of being at the expense
any thoughts about the man who slipped right in of other levels of being. In this case, there is an
front of his family and broke his neck. Conscious- overemphasis on being-with-others—namely, our
ness of such events not only brings existential anx- family—at the expense of being-in-nature or
iety but also threatens to expose our lie. being-for-oneself. We must be-with-others lest
Lying also leads to neurotic anxiety. If we we become filled with neurotic anxiety.
become anxious, for example, just because our Lying can occur at any level of existence.
children are momentarily out of sight, we are Hypochondriacs, for example, lie about the nature
experiencing neurotic anxiety. Neurotic anxiety of illness and healing. They fabricate a theory that
is an inauthentic response to being, whereas exis- diseases can be avoided if only they see the doctor
tential anxiety is an honest response to nonbeing. often enough and fast enough. Their bodies are
Our children’s leaving our sight is essential to constant sources of anxiety that send them scur-
many expressions of their own being; they do rying to a doctor with every ache and twitch. “If
not exist to shore up our lies. We decide that only I run soon enough, I can outsmart nature at
they need to be in sight in order for us to be her games of chance,” they lie. After convincing
more comfortable; they decide to be away from themselves they must run, trying not to run fills
us in order to exist more fully and freely. their being with neurotic anxiety. They have given
We choose our lies, and are stuck with their up their will to their aches and their medicine
consequences. The consequence now is that unless man. “You take over, doctor,” they seem to say.
we are aware of our family at all times, we are “This business of living is too scary for me.”
anxious. Like a mother we saw in therapy, we Lying-in-nature drastically reduces their freedom
may neurotically order our children to play in the to be-with-others or to be-for-themselves, because
living room at all times. We may choose to walk all they can talk about or think about is their most
them to and from school, to go see them at recess recent attack of this or that.
and lunch time, or be anxious. We may telephone People of a paranoid persuasion decide nature
our spouse repeatedly, pretending to have some- is filled with evil forces out to destroy them. The
thing to say but wanting only to be reassured that food, the water, or the air is poisoned, so we must
our spouse is well. If we try not to call, the anxiety constantly beware. Others of a more depressive
may become extremely intense. Thus, we tell our- temperament conclude that the world is falling
selves we have no choice—we must call. apart, that the world is going to the dogs. The
When neurotic anxiety leads to acting on that good old days are gone forever, and it is only
anxiety, we develop psychopathology, such as a downhill from here.
compulsion to check on our family. By saying Perhaps the most common level of lying is for
that we must check on our family, we have others. Early in life, we learn that we can misrepre-
become an object that no longer has the choice sent ourselves to others with some success. As chil-
to let our family be. Symptoms of psychopathol- dren, we are smart enough to see that the option to
ogy are objectifications of ourselves. In pathol- lie can be a tremendous source of power. How to
ogy, we experience ourselves as objects without influence others by faking sad or mad or innocent,
choice or will. This can be terrifying, like the depending on their weak spot, is a lesson not missed
nightmares in which we are chased by someone by many. But, of course, every lie is accompanied by
and want to run, but no matter how hard we will fear of discovery and the shame of being caught.
it, we cannot run. We are trapped as a conse- Over the years, the impending shame builds and
quence of our own lies. leaves us feeling that if people really knew who we

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Existential Therapies 91

are they would leave us alone. So we spend much existentialists argue that in order to close off the
of our time lying-for-others, seldom free to “bad” parts of ourselves like anger, we have to first
be-with-others. know that the anger is “bad.” Sartre (1956) argues
Some brag of their ability to lie-to-others. that all we need to assume is one conscious person
Selling themselves, they call it—the royal road to who uses self-deception and chooses what aspects
success. People want them to smile, they smile; of the self to turn away from. Once we act on such
people want their egos built up, they build. The bad faith in ourselves, we are faced with the
other people may be the customer, the boss, or impending guilt of knowing who we really are.
the professor—it doesn’t matter. The liars are As a result, our lying snowballs into symptoms,
happy to sell themselves—a small price for suc- such as having to get depressed in order to never
cess, they think. The lie up their sleeves, of course, get angry.
is that someday they will be free to be themselves. Lying-for-oneself can occur in a wide range of
They promise themselves that once they get their pathologies. Many people are convinced they can
graduate degree, then they will live their own attain perfection—be beyond criticism and, there-
lives—or maybe they better wait until they get fore, free from rejection—if they only work
their first job, or that final promotion, or that new harder. So they become workaholics. Others pro-
position. tect their saintly self-concepts by turning their
But “can this be pathological?” we ask. It is so backs on their sexuality, modeling the Virgin
common, so natural. The ability to delay gratifica- Mary. Still others are convinced they are the
tion, even the gratification of being ourselves, is a perfect spouse and yet are afraid to come in for
necessary part of succeeding in society. The ability couples therapy. They send their partner. Once
to play roles is essential for making it in the academic the psychotherapist straightens out their spouse,
or mental health marketplaces. Those elitist Euro- their marriage can be perfect again.
pean existentialists would reserve health for only What we believe about our future critically
the authentic few. But what they ask is that we not affects how we act today. If we are overly objec-
become so alienated that we equate statistically nor- tive, we may lose any basis on which to choose,
mal self-estrangement with health. If we are going to and experience ourselves as being tossed and
compromise ourselves away for others, then let us at turned by the wind. Through lying, we may lose
least remain healthy enough to hurt about it, rather contact with the source of our personal direction,
than hide behind the data that show we all do it to our intentionality. Intentionality is the creation
some extent. of meaning, the basis of our identity. Sartre
Lying-for-ourselves is more complicated. First, (1967) wrote that “man is nothing else but what
we must consciously choose to lie; then at some he makes of himself. Such is the first principle of
point, usually beginning when we are children, we existentialism.”
come to believe our own lies. For years, I (JOP) Our intentionality entails taking a stand in life.
believed that I never got angry. I became depressed Our stance determines what we attend to—as when
all right, but never angry. When I finally got tired of one person attends to the beauty of a beach, whereas
getting depressed, I became aware in my personal another person attends to its business potential. The
therapy that I could indeed get angry. To protect orientation we choose in life is the source of what our
my idealized image of myself as a character who lives mean, and the source of the meaning we attri-
never lost his cool, I had to close off most of my bute to a beach. Lying, however, may convince us that
feelings and be cold and depressed, but never angry. our life is determined by a pathology that attacks us
The psychoanalysts would say that I was like an infectious disease—an accident over which we
unconsciously repressing my anger. But the have no control.

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92 Chapter 4

Therapeutic Processes existentialists see it as a result of the patients’ objec-


tification of themselves, which keeps them from
Because lying is the source of psychopathology,
being flexible and open to more authentic ways of
honesty is the solution for dissolving symptoms.
being-in-the-world-of-therapy. Patients will impose
With authenticity as the goal of existential psycho-
their psychological categories onto therapy, so that
therapy, increasing consciousness becomes one of
if, for example, their experience of space with-
the change processes through which people become
others is a distant space, they will keep their dis-
aware of aspects of the world and of themselves that
tance from the therapist. If a patient is consumed
have been closed off by lying. Because lying also
with the past, then the patient will talk in therapy
leads to an objectification of oneself in which the
primarily about the past.
ability to choose is no longer experienced, therapy
Patients are encouraged to engage in a process
must involve processes through which individuals
similar to free association but perhaps more appro-
can again experience themselves as subjects or
priately called free experiencing. Patients are encour-
agents capable of directing their own lives through
aged to express freely and honestly whatever they are
active choosing.
experiencing in the present, although traditionally
Techniques are slighted in existential therapy
such “free” expression has been limited to expression
because technology is an objectifying process in
through language, not action. In trying to freely expe-
which the therapist as subject decides the best
rience, patients can become increasingly conscious
means by which to change the patient as object.
that they are repeating the same patterns of being,
Although many patients want their therapists to fix
such as being-in-the-past or being-for-the-future.
them as a mechanic repairs a car, a technical focus
They can become aware that there are parts of
only adds to patients experiencing themselves as
themselves and their world that they are not open
mechanical objects. Existentialism encourages clients
to experiencing or expressing—for instance, their
to enter into an authentic relationship with a therapist
angry self or the reality of the therapist.
and thereby become increasingly aware of themselves
Patients will ordinarily try to maneuver the ther-
as subjects, free to differ with the therapist even to the
apist into agreeing with their reasons for closing off
point of choosing when treatment will end. Although
such experiences, but because the reasons are lies,
technique is deemphasized, we shall see that in prac-
they will run into disagreement with the authenticity
tice the classical existentialists, such as Binswanger,
of the psychotherapist. For example, in saying “Don’t
Boss, and May, draw heavily upon psychoanalytic
you agree that it is immature to get angry?” the
techniques, especially in the early stages of therapy.
patient is pressuring the therapist for validation, but
Consciousness Raising may instead meet with an honest response such as
The Client’s Work “No, I get angry at times, and I don’t feel like a baby.”
If the explicit direction in psychoanalysis is to say Eventually the patient is encouraged to change from
whatever comes to mind, the implicit direction in an egocentric experiencing of the process and person
existentialism is to be whatever you want to be. of the psychotherapy to a more authentic dialogue.
Patients are allowed to present themselves as they By the time the client is able to enter into an ongoing
typically would relate to the world, with little inter- dialogue, however, therapy is ready for termination.
vention from the therapist early in therapy. The work of the patient in existential therapy
Existentialists share the psychoanalytic assumption requires enormous courage and honesty. Rollo May
that patients will repeat their previous patterns of was convinced that we should ask more from our
relating and will begin to form transference patients: “Their life is at stake” (Schneider et al.,
relationships. Whereas psychoanalysts assume that 2009). Broadening consciousness and enlarging
the transference is due to instinctual fixations, experience is a hunk of life-changing work.

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Existential Therapies 93

The Therapist’s Work of being. Although Boss and Bugental use psychoan-
Unfortunately, classical existentialists have not alytic explanations of the patient’s reactions when
clearly identified their methods to increase the con- they fit, they also rely heavily on existential explana-
sciousness of clients. As with personality, many tions, such as pointing out how the patient repeat-
existentialists view existentialism as the philosophy edly runs from experiences related to death,
they embrace in therapy and not as a system they decisions, or other aspects of nonbeing.
use. As a result, many existentialists would oppose Other traditional existentialists seem to prefer a
a systematic approach as contrary to an authentic type of confrontation, in which the information
encounter between the participants. they provide the patient is generated by the thera-
The writings of Binswanger (1963), Boss (1963), pist’s genuine reaction to the patient. Existential
and May (1958), do give some idea of the variety of confrontation differs from psychoanalytic confron-
strategies traditional existentialists use in therapy. tation in that existentialists reveal their own experi-
They agree that the therapist’s work begins with ence of the patient and do not just reflect the
understanding the phenomenal world of the patient. patient’s experience. The existentialist is by no
The phenomenological method focuses on the means concerned with remaining a blank screen,
immediacy of experience, the perception of experi- because it is the therapist’s honest feedback that can
ence, the meaning of that experience, and observa- eventually break through the patient’s closed world.
tion with a minimum of a priori biases (Spiegelberg, An example of such confrontation occurred
1972). The therapist attempts to experience the when my (JOP’s) wife, Jan, and I were conducting
patient’s unique construal of the world without conjoint therapy with a couple in which the hus-
imposing any theoretical or personal preconceptions band was complaining that his wife was refusing
onto the patient’s experience. In understanding the to have sex with him. At one intense point when
patient’s phenomenological world, most existential- the man insisted on dominating and degrading his
ists seem to use clarification, a type of feedback wife, Jan told him, “You make me want to vomit.”
through which they illuminate the patient’s experi- He was beside himself; he did not respond. He just
ence, using the patient’s own language rather than fumed and the next morning came to see me indi-
theoretical jargon. Such illuminating feedback helps vidually, declaring that no woman had ever
patients to become more conscious of their being, responded to him like that before. He couldn’t
including some aspects that have been closed off. imagine why, especially when the woman was a
Once the therapist has gained a phenomenal therapist. As I encouraged him to consider that
understanding of the patient, the therapist chooses stirred up similar feelings in his wife but she was
what techniques to follow. As Rollo May states, afraid to express them because of his anger, he
therapeutic technique follows understanding, in began to think that maybe, just maybe, he had
contrast to the more common, reverse order in something to do with his wife’s feeling sick when
which a clinician tries to understand a patient via he approached her sexually. His idealized image of
the therapist’s preferred theory. What is imperative himself had been shaken by Jan’s intense confron-
is to avoid a gimmicky, quick-fix patch for the per- tation, and he tried to shore up his lies by pressur-
son; instead, in the tradition of Freud and his dis- ing me into agreeing that a responsible therapist
ciples, the therapist’s work is to bring forth a new doesn’t talk like that. When I encouraged him to
authentic person (Schneider et al., 2009). face Jan’s honest feedback, his lying-for-himself
Existentialists vary most at this step. Some, such began to come out into the open. He began to
as Boss (1963) and Bugental (1965), rely mainly on see himself as the not-so-perfect man who perhaps
interpretation to analyze or make conscious the had real trouble in being-with-women and not
patient’s transference reactions or repeated patterns just with his “selfish” wife.

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94 Chapter 4

A literary example of existential confrontation is working with a particular clinician. Patients are
the haunting of Ebenezer Scrooge by the Ghost of also confronted with having to decide what they
Christmas Yet to Come in Charles Dickens’s classic will talk about in session and how they will be in
tale. The job of the Ghost, like the existential thera- therapy. The therapist will encourage clients to con-
pist, is to assist Scrooge in confronting the unpleas- sider new alternatives for being, but the clients are
ant truths about his life. By literally confronting his expected to carry the burden of creating new alter-
own death, Scrooge, like a patient, becomes instru- natives in order for them to experience themselves
mental in transforming his life (Yalom, 1980). as subjects capable of finding new directions for liv-
Although psychotherapy may begin with inter- ing. Once conscious of new alternatives, it is the
pretations, for it to become existential, the therapist client who must experience and exist with the
must eventually confront the patient with the anxiety of being responsible for which alternative
therapist’s own authentic being. If the therapist to follow. The burden of choosing, then, is on the
cannot be authentic, the patient may remain in a client.
transference relationship, and this may be the rea- This burden is perhaps most evident when
son psychoanalysis seems interminable. How can a patients are faced with kairos, critical choice
patient be authentic with the therapist if the analyst points and momentous opportunities for deciding
remains an objectified blank screen? whether to risk changing a fundamental aspect of
By being authentic in the session, the therapist existence (Ellenberger, 1958), such as to be sepa-
fosters a genuine encounter, which is a new relation- rate or partnered, to remain in the security of
ship that opens up new horizons rather than a trans- symptoms or to enter the anxiety of authenticity.
ference relationship that repeats the past The clients are the ones who must look deep into
(Ellenberger, 1958). Patients may continually try to themselves to see whether they can muster up the
freeze the therapist into the categories of their path- courage to leap into the unknown future, knowing
ological world—keeping the therapist distant or cast- there is no guarantee that they will not fall flat on
ing her as a controlling authority figure, for instance. their faces. As an existential friend (Atayas, 1977)
By being authentic, the therapist refuses to be frozen. puts it, once clients become conscious that at least
By remaining authentic in the face of the patient’s one person can be authentic, then they no longer
demands, the therapist confronts the patient, both have the choice of being a slave who is blind to
verbally and experientially, with the patient’s better alternatives. The patient must now choose
attempts at freezing the therapist and thereby keep- between being a coward and becoming a free
ing the patient frozen as a role or a symptom. Grad- person.
ually the patient becomes aware that the therapist is
taking risks to be honest and sees that the therapist The Therapist’s Work
can remain authentic in the face of such existential The existential therapist takes every opportunity to
anxieties as being rejected by the patient or making clarify the choices that patients continually confront
mistakes. The patient becomes aware of a new alter- in their treatment, whether the choice pertains to
native for being and is then confronted with the what they should talk about each hour, how they
choice of changing his or her existence. should structure their therapy relationship, or
whether they will return for future sessions. With
Choosing such clarification, the patient becomes acutely con-
The Client’s Work scious of being an active chooser, in spite of frequent
Clients are confronted with the burden of choosing protestations about being a patient, a helpless victim
from the very beginning of therapy, when they must of psychopathology. The therapist also encourages
decide whether they will commit themselves to patients to use their uniquely human processes of

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Existential Therapies 95

consciousness—their imagination, intellect, and Doctor: I don’t blame you. [Refusing role of
judgment—to create rational alternatives to an subject-curer and supporting desire on part of
apparently irrational way of being. patient-as-subject.]
The therapist will remain with patients through- Patient: If you think I should stay, okay, I will.
out their small choices and their kairos, empathizing [Refusing role of subject-who-decides.]
with their anxiety and their turmoil. But the thera-
Doctor: You want me to tell you to stay? [Confron-
pist knows that the road to being an authentic
tation with patient’s evasion of the decision and
chooser rather than an objective symptom is basi-
calling attention to how the patient is construing
cally a lonely one on which the patient alone must
the therapy.]
take responsibility for the choices. To jump in and
rescue the patient, no matter how much the patient Patient: You know what’s best; you’re the doctor.
pulls on the therapist’s rescue fantasies, would be to [Patient’s confirmation of her construing
reinforce the lie that patients by definition are inad- therapy.]
equate to direct their own lives. Doctor: Do I act like a doctor?
Keen (1970, p. 200) provides the following
Keen does not mention it, but if in fact the ther-
example of an existential therapist confronting a
apist acts like an omnipotent doctor or an authority
patient with both the responsibility she has for
figure who will cure the patient, then the therapist is
choosing to change and the boring way that she is
lost. The patient’s construal of therapy as a doctor-
being.
object relationship would be accurate, rather than a
Patient: I don’t know why I keep coming here. All I lie that allows her to run from her necessity-to-act as
do is tell you the same thing over and over. I’m a responsible subject. With the therapist’s authentic-
not getting anywhere. [Patient complaining that ity, however, this is neither a game nor a battle. It is
therapist isn’t curing her; maintenance of self-as- an honest confrontation between one person who
therapist’s-object.] experiences the potential of the other to choose
Doctor: I’m getting tired of hearing the same thing and the other’s desire to shore up the lie.
over and over, too. [Therapist refusing to take
responsibility for the progress of therapy and Therapeutic Content
refusing to fulfill patient’s expectations that he Existentialism is a relatively comprehensive theory of
cure her; refusal of patient-as-therapist’s- existence concerned with the individual at all levels
object.] of personal functioning. Being-for-oneself is focused
Patient: Maybe I’ll stop coming. [Patient threat- on intrapersonal functioning; being-with-others is
ening therapist; fighting to maintain role as the existential concept for interpersonal functioning;
therapist’s object.] being-in-the-world includes, but is more than, the
Doctor: It’s certainly your choice. [Therapist individual’s relationship to society; and the search
refusing to be intimidated; forcing patient- for authenticity reflects the goal of existentialists to
as-subject.] go beyond conflict to fulfillment.
Patient: What do you think I should do? [Attempt Intrapersonal Conflicts
to seduce the therapist into role of subject who Anxiety and Defenses
objectifies patient.] Anxiety is an ontological characteristic of every
Doctor: What do you want to do? [Forcing again.] person, rooted in our very existence as a threat of
Patient: I want to get better. [Plea for therapist to nonbeing. The acceptance of freedom and the
cure her.] awareness of finitude will unavoidably result in

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96 Chapter 4

anxiety, or as Kierkegaard called it, the dizziness of hidden from others. Choosing to let others, such
freedom. Anxiety is not something we have, but as a psychotherapist, become aware of our pre-
something we are (May, 1977). tenses removes the power inherent in lying.
The existential approach retains Freud’s basic
dynamic structure but has a radically different Self-Esteem
content. The old Freudian formula of “instinctual In spite of what many behavioral scientists might
drive produces anxiety which produces defense say, self-esteem is not a function of how much
mechanisms” is replaced in existential therapy by other people value us. That is social esteem. If
“awareness of ultimate concerns produces anxiety we make the same mistake as many behavioral
which produces defense mechanisms” (Yalom, scientists and base our self-esteem on social
1980). Accordingly, much of the focus is on the esteem, then we are reduced to being-for-others,
conflicts between the existential anxieties inherent which usually includes lying-for-others in order
in being and the lies that individuals use as to win or maintain their approval. The fact that
defenses against such anxieties. As with psycho- researchers report high correlations between how
analysis, anxiety is a central concept in existential we value ourselves and how others value us just
therapy, but anxiety is viewed as a natural conse- supports the existential conviction that we have
quence of becoming conscious of nonbeing. indeed become a sick and other-directed society
Rather than approach anxiety gradually in (Reisman, 1961).
therapy, existentialists frequently confront it head An inner-directed person accepts that self-
on, especially during the periods of kairos. The only esteem occurs at the level of being-for-oneself
solution to existential anxiety is that suggested by and as a function of self-evaluation. An authentic
Tillich (1952) in The Courage to Be: We must find person accepts that approval by oneself must
courage within ourselves to accept existential anxi- come above approval by others. To strive to be
ety as part of the price we pay for being uniquely free from what others think of us is romantic non-
human. In return, we can gain the excitement of sense. We can be free, however, by caring more
becoming a unique and authentic human. about what we think of ourselves than about what
Because existential anxiety is a consequence of others think of us. When we are honest with our-
consciousness, the only defense against it is con- selves, we know that we can feel genuinely good
scious lying—turning our attention away from about ourselves only when we are genuine.
threats of nonbeing by pretending to be something An existential therapist is not concerned with
we are not, such as immortal, omnipotent, omni- boosting a patient’s shaky self-esteem. For example,
scient, or anything other than finite humans. We if a patient becomes depressed over living an empty
can give different names to different forms of life, the therapist might say something along the
lying if we prefer. Projection would be the lie lines of “It’s natural that you are depressed. I
that the responsibility for particular experiences would be worried about you if you could feel good
belongs outside of us. Denial would be the lie of about the way you’ve been living.” The existentialist
insisting that either we or the world are not what knows that all a therapist can do is boost a patient’s
we honestly know them to be. social esteem through such measures as positive
Over time, these and other defenses can regard and positive reinforcements. In doing so,
become unconscious and habitual parts of our however, the therapist risks reinforcing the patient
objectified selves. But defenses can remain frozen to remain a pigeon of other people—in this case, the
only if we continue to run from the anguish of therapist’s pigeon. Self-esteem is the hard-earned
being more open and authentic. Lying-for-others natural response that patients can make only to
can succeed, for example, only when our lies are themselves after struggling to be authentic.

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Existential Therapies 97

Responsibility or even two robots could fill the roles, and it would
Much has already been said about the centrality of make no essential difference to the relationship.
responsibility in existential therapy. We have seen Sexuality is less of a concern for existentialists
how, in choosing to be authentic, individuals are con- than is intimacy. The assumption seems to be that if
fronted with the existential anxiety of being responsi- individuals are free to be intimate, they will be free to
ble for who they become. We should also point out be sexual if that is what they choose. Sexual conflicts
that to choose against authenticity—to lie, to con- are considered to the extent that the person’s sexu-
form, to avoid—makes us responsible for missing ality has been disowned or idealized in the process of
an opportunity to be ourselves, and we are faced self-objectification. In contrast to what psychoana-
with existential guilt (May, 1958). Existential guilt lysts believe, sexuality is certainly not the essence of
is a consequence of having sinned against ourselves. humanity. It is bad faith to say either that we must be
If our lives become essentially inauthentic—whether sexual or that we cannot be sexual. We can be
obviously pathological, as with the neurotic or psy- sexually free, which means the freedom to say yes
chotic, or normally pathological, as with the conven- to our own sexuality when we believe it is best to say
tional conformist—we may at some time find yes, and the freedom to say no to our sexuality when
ourselves faced with neurotic guilt. It is a more total it is best for us to say no. It is only in response to our
self-condemnation for having abdicated our respon- repressive culture that we have adopted a perverted
sibility to become a genuine human being and not notion that sexual freedom means saying only yes.
just a ghost of a person. Such self-condemnation Existential sex therapy would help free people to say
can be so intense that some individuals may want to no in sexual relationships, whether to the demands
destroy their lives without their having really existed. of a spouse or to an internal calendar that says you
Guilt if we choose against ourselves and anxi- are falling behind the national average of having
ety if we choose for ourselves—no wonder Sartre sex. Existential sex therapy would be better
said that we are “condemned to be free.” The exis- described as sensual therapy, with clients encour-
tentialist insists a patient be strong enough to aged to experience their whole body as sensual
become more responsible and hence freer and beings who enjoy touching and being touched
more authentic. from head to toe and not just genital to genital.

Interpersonal Conflicts Communication


Intimacy and Sexuality Existentialists suggest that conflicts in communica-
Intimacy with others is an integral part of being tion are almost inherent in our isolation. Because we
human. The existential ideal for intimacy is poeti- can never enter directly the experience of another, we
cally expressed in Buber’s (1958) book, I and Thou. can never know fully what the other is attempting to
Intimate relationships involve the caring and shar- communicate. Our own perspective is bound to do
ing of what is most central in the lives of two authen- some violence to what the other is communicating;
tic people. Although this is the ideal, the reality is therefore, we again experience some existential guilt
that many people feel safe to relate only to objectified over our inability to fully be-with-others. Such guilt
others and enter only into I–it relationships. Per- need not lead to withdrawal from others, but can
haps even more frequently, the interactions of two motivate us to be more sensitive so that we do the
objectified people result in it–it relationships, which least damage possible to another’s experience. Guilt
are at best two human objects relating as roles with can also help us to be authentically humble as we
each other. Such relationships are safe and predict- recognize that, no matter how hard we try, we can
able, but are devoid of giving or receiving anything never be smart enough or sensitive enough to know
unique to the two people involved. Any two people precisely what the other is experiencing. We cannot sit

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98 Chapter 4

back smugly as we listen and say, “I know, I know, the For existentialists, however, violence is not
same thing happened to me”—because it never did. always a pathological act. As Camus and Sartre
Problems in communication are inevitable learned from their meaningful days in the French
also because of the meager way in which language resistance, one of their most authentic acts was to
reflects experience. Experience is so much richer assist in the destruction of the Nazis. Camus (1956)
than the abstraction that words usually relay. It is later suggested, in his beautiful book The Rebel, that
no wonder that existentialists sound like poets or the first question of existence is suicide: To be or not
novelists when they attempt to communicate the to be is what we decide each day we go on living. The
most significant experiences of themselves or their second is the equally violent question of homicide—
clients. The meagerness of words and the isolation to let another be or not. The power to kill, whether it
of persons are no excuses, however, for a psycho- be oneself or another, tells us just how free we can be.
therapy to omit experience from the realm of If freedom is our first principle, then nihilism is justi-
understanding. Communication through the fied, and we are free to destroy others in the faith that
medium of words can still present a rich enough something better may emerge. But if we are to control
picture of an individual’s experience if the receiver our freedom to kill, then our first principle is the
drops theoretical decoders and listens with the affirmation of life, not freedom. Camus concludes
openness of a trained phenomenologist. that we can be free to kill if revolution is the only
means available to remove the oppression that pre-
Hostility
vents others from being free.
To experience hostility is to experience the threat of
nonbeing, because hostility is one of the quickest Control
and surest means to end life. This hostility can elicit For Sartre, the attempt to control another person is
existential anxiety and drive us to lie and tell our- psychologically the most violent thing we can do to
selves or others we never get angry. The repression the other. Because freedom is the essence of exis-
that follows can lead to our unwillingness to enter tence, to control other human beings is essentially
into intense relationships because such relationships to destroy them. Sartre (1955) is well aware, how-
are always potentially frustrating and thus may lead ever, that most people have a strong desire to control
to hostility. To close off our aggression can also lead others; this is one of the reasons for his saying, “Hell
to depression and emptiness as we close off one of is other people.” To control another person is to
our body’s sources of vital assertions. objectify that person, to deny that individual the
Just as we lie if we say we cannot get angry, so freedom to leave us or hurt us or to remind us
too we lie if we say we cannot control our hostility. that we are not as special as we pretend to be.
Some choose to be hostile to deny their finitude so The existential therapist teaches patients the
they can play God and decide who will live and who futility of attempting to control others by remaining
will die. Once they tell themselves lies, they choose unwilling to be controlled. No matter whether the
the power of violence, the power to end an existence. patient threatens to quit therapy, not pay a bill, or go
The people they choose to destroy will be those who crazy, the existentialist is enjoined to respond only
threaten them of their nonbeing, such as by rejecting out of honesty, never fulfilling a patient’s desire to
them. The killer says, in effect, “You cannot reject find false security through controlling others.
me if you no longer exist.” Favorite targets for
violence—Jesus Christ, John F. Kennedy, Martin Individuo-Social Conflicts
Luther King, Jr., and Malcolm X, for instance— Adjustment versus Transcendence
threaten to remind some individuals of how empty The only way a life based on adjustment might be
and inauthentic their own lives are in comparison. healthy is if the society a person is adjusting to is

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Existential Therapies 99

basically honest. Few observers of our age would may choose to control even such a basic impulse as
argue that honesty is a hallmark of our society. hunger for 40 days to express a stand for freedom.
A majority of business managers admit to having To say that we must eat too much, drink too
surreptitiously broken the law in order to succeed; much, have sex too much, or get angry too much
a large percentage of college students confess to shows bad faith in our potential as self-directed
having cheated in the classroom; practically all individuals. People with impulse-control problems
politicians routinely misrepresent themselves to lie daily: “I’ll just have one beer, or one potato
their constituencies to get elected, to the point chip”; or “Now that I’ve started, I may as well eat
where we expect no less of them. How can one the whole thing”; or “You made me get angry.”
be sane in an insane society that does not discrim- They tell themselves assorted lies rather than hon-
inate between truth and delusion? estly acknowledge that they prefer to eat or drink
The only way to rise above the morass of lies rather than feel bored, anxious, or depressed.
and inauthenticity is to become conscious of how Impulses are not the dominant forces in humans,
the forces of socialization and industrialization although many people let them become dominant.
prefer to make us automatons, easily controlled. Consciousness and choice direct a mature person,
Once we become conscious of the pressures to so that being freer does not mean becoming a beast
sacrifice ourselves for success or security, we or a Dionysian irrationalist who is authentic only
must take responsibility for becoming our own when expressing every spontaneous desire.
person rather than someone else’s pigeon. Con-
sciousness and choice are the uniquely human Beyond Conflict to Fulfillment
characteristics through which we can become Meaning in Life
uniquely human. We can still be-with-others and One does not discover meaning in life; one creates
be-in-the-world without having to be owned by meaning out of life. The question is not what is the
others or bought out by the world. answer to life; the answer is that life is an ongoing
We must not delude ourselves into thinking we process to be experienced, not a problem to be
can transcend all that we have been thrown into. solved. The meaning of our existence emerges out
The givens of our life—our time in history, our of what we choose to stand for. Individuals can
native language, our genetic makeup—put real lim- choose to take quite different but nevertheless
its on our freedom. As Camus (1956) suggested, authentic stances in their existences, and thus we
transcendence begins with choosing that which is find a multitude of conflicting meanings through-
necessary. To fight against our bodies, for example, out history. Jesus stands for love, Marx stands for
trying to fly to the sun, can only destroy our limited justice, Sartre stands for freedom, Galileo stands for
freedom for rising above our society. Freedom is truth, Picasso stands for creativity, Martin Luther
not just another word for nothing more to lose; it stands for faith, Hitler stands for power, and Mar-
is a core commitment that nothing our society can tin Luther King, Jr., stands for equality.
give us is worth the loss of creating ourselves. To know the meaning of our existence, we
must ask ourselves: What do I stand for? Do I
Impulse Control take a stand? Is what I am to become worth the
Unlike psychoanalysts, existentialists do not fear price I pay, worth all the other possibilities I give
that choosing one’s own rules will precipitate dys- up in choosing to be this particular person? These
control over impulses because of a weakening of are questions of meaning that can haunt us but
social controls. Some people may indeed choose a also motivate us to break out of the safe or suc-
hedonistic lifestyle if that is most authentic for cessful route if what we see emerging is not signif-
them. Other authentic individuals, such as Gandhi, icant enough to spend our existence on. If we do

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100 Chapter 4

not break out during these critical periods of life, Therapeutic Relationship
then we may at some later date break down
The central task of the existential psychotherapist
because of the overwhelming depression, terror,
is to understand the client as a being-in-the-world.
or nausea that accompanies the awareness that
All technical and theoretical considerations are
we can no longer stand what we stand for. Many
subordinate to this understanding. The therapeu-
such breakdowns are the result of breakthroughs
tic relationship is a direct relationship of two peo-
of the sense of meaninglessness; but rather than
ple, I–Thou, a sharing and experiencing together
being just symptoms of an inadequate existence,
that leads to an elucidation of the patient’s mode
they can be seen as fresh opportunities to begin a
of being with an enlightened understanding of the
more meaningful life.
implications for existence. The chief characteristic
Ideal Individual of the therapy relationship is a “being-together” of
The ideal for living, and therefore for psychother- the therapist and client in the spirit of “letting be”
apy, is authenticity by making life choices that (Hora, 1959, 1960). The concept of letting be
create meaning out of our existence. In Heideg- means the authentic affirmation of the existence
ger’s terms, later borrowed by Sartre, an authentic of another person.
life is one based on an accurate appraisal of the The therapy relationship is both part of the pro-
human condition and a fulfillment of one’s poten- cess of change and the prime source of content for
tialities. A person is authentic to the degree to existential psychotherapy. In engaging a patient in an
which that person’s being-in-the-world is unqual- authentic encounter, the psychotherapist helps the
ifiedly in accord with the givenness of his or her patient become aware of the ways in which he or
own nature and of the world (Bugental, 1976). she avoids an encounter, such as insisting on remain-
Authenticity requires awareness of one’s self, ing a patient rather than a person. The therapeutic
relationships, and the world; recognition and accep- relationship provides one of the best opportunities for
tance of choices; and acceptance of full responsibility patients to enter into a deep and authentic encounter,
for those choices. To make choices requires the because the existential therapist is committed to
courage to be responsible for acting in the face of responding authentically. If a patient has the courage
limited information on how our life may turn out. to choose to be-authentic-with-the-therapist, then the
An authentic person must also find the courage to patient has radically changed from lying-for-others
exist in the face of the fact that the very meaning we or lying-for-self to being-with-another.
intend in our life can be negated at any time by the As a source of content, the therapy relation-
forms of nonbeing, such as death or isolation. The ship brings into the here and now the patient’s
only value a person must follow to become authentic pathological style. For psychoanalytically inspired
is to be honest, even in the face of nothingness. existentialists such as Boss (1963) and Binswanger
Once a patient finds the courage to be basi- (1963), pathology results in a transference rela-
cally honest, then we can no longer predict what tionship that is the first content to be analyzed
that person will be. We can only predict what a or made conscious in order for a patient to enter
conventional person will be, a reflection of the an encounter. For other existentialists, the fact
norms and expectations of the society, or what a that the patient’s lying-for-others or lying-for-self
pathological person will be, a reflection of the fro- is occurring right in the consulting room allows
zen past. To attempt to further define authentic patients to be confronted with their pathological
individuals is to freeze them within the limits of ways of being. Patients cannot hide their patho-
our ideal. Authentic people refuse to be frozen, logical existence, because it is occurring in their
even by the ideals of their psychotherapists. immediate relationship to the existential analyst.

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Existential Therapies 101

Patients will eventually be forced to become con- for example, reports spending 4 days at the bedside
scious of their running from the existential anxiety of an obsessive-compulsive patient as the patient
of responsibility by the therapist’s remaining lived through a psychotic experience brought on
unwilling to take over for the patient. by his repulsion at his own existence.
In Rogerian terms, existentialists would agree To our knowledge, traditional existentialists have
that the therapist initially must be more congruent no formalized criteria for judging the preparedness of
or authentic than the patient. Congruency on the someone to be an existential therapist. Existential
therapist’s part is necessary for the therapist to be work depends heavily on getting into the subjectivity
genuine in session. If the patient is as congruent of clients and thus calls extensively on the subjectivity
and genuine as the therapist, the two could have a of therapists. Enriching a therapist-to-be’s own sub-
rewarding encounter, but then there would really jectivity would entail intensive personal psychother-
be no need for therapy. Existentialists also agree apy, considerable life experiences in the larger world,
with Rogers’s requirement of accurate empathy: extensive reading of both fiction and nonfiction por-
The therapist strives to experience the world as traying the human condition, and internships that
the patient experiences it. Dasein—the therapist’s nurture the sensitivities, skills, and innovation of the
literally “being there” with the patient—means an trainee (Bugental, 1987). Existentialists have been
unconditional meeting of experience and rela- quite flexible about the formal educational back-
tional presence (Bolling, 1995). grounds of their colleagues; medicine, psychology,
Existentialists do not agree, however, that a education, and theology are just some of the disci-
therapist must maintain unconditional positive plines represented among existential analysts.
regard toward the patient. To be authentic, the Existentialists appear to be less amenable than
therapist can respond with positive regard only other clinicians to the use of medication as an adjunct
toward honesty and authenticity but never toward to psychotherapy. They prefer to have patients expe-
lying and pathology. That the therapist at first rience authentic, though acutely painful, emotions
allows the patient to lie and objectify without such as anxiety and guilt rather than pop a pill,
overt judgment is accepted in order for the thera- thereby deadening the hurt. Medication also risks
pist to experience the patient’s phenomenal world. deadening themselves by treating themselves as
But an authentic therapist can hold no positive objects that could be free from existential anxiety.
regard for a patient’s lying. Who is to say whether existential therapy should
be lengthy or brief? Why, the patient, of course. In a
freely choosing relationship, the content, goals, and
Practicalities of Existential length of the psychotherapy will be largely deter-
Therapy mined by the client. In the spirit of “being together”
Existential analysts seem to be too unconcerned with and “letting be,” the client is responsible for his or
mundane practicalities to write about them. Therapy her choices. The existential therapist will weigh in
schedules, fees, and formats are rarely broached in with an honest and authentic opinion, but trying
the existential literature. The impression one gathers to control a freedom-enhancing psychotherapy
is that much of existential analysis is similar to psy- would be antithetical to its purpose.
chodynamic psychotherapy, except during times of To the limited extent that one can generalize,
kairos. That is, a regular appointment seems to last existential analysis appears to be comparatively
50 minutes and is scheduled weekly. When a patient lengthy along the lines of psychoanalytic psycho-
is in one of the critical crises, however, the existen- therapy. At the same time, the major alternatives
tialist seems to become much more flexible and may to existential analysis lend themselves more read-
spend extended hours with the patient. Boss (1963), ily to briefer therapy. The centrality of choice, the

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102 Chapter 4

I–Thou relationship, the here-and-now orienta- can be viewed as an intermediate step between
tion, and the imperative to act in the face of psychoanalysis proper and contemporary human-
inevitable existential anxiety—all catalyze the ther- istic existentialism (Norcross, 1987). Existential-
apeutic process (Ellerman, 1999). We now turn to humanistic therapy operates at the interface of
these briefer alternatives to existential analysis. existentialism and humanistic theory and is
closely allied with the “third force” in psychology
Major Alternatives: Existential- (psychoanalysis being the first force and behavior-
ism the second; Maslow, 1962). A related, but not
Humanistic, Logotherapy, identical, distinction (Yalom, 1980) is that
Reality Therapy between the “old country cousins” (existential
The focus of this chapter so far has been on tradi- analysts) and their “flashy American cousins”
tional existential psychotherapy, also known as (existential-humanistic therapists). Whereas the
existential analysis, Daseinanalysis, and existential- Europeans are more likely to discuss limits, accep-
analytic therapy. The early existential analysts, as tance, anxiety, life meaning, apartness, and isola-
we have seen, were originally trained in psycho- tion, the American existential humanists focus on
analysis and then created and converted to an potential, awareness, peak experiences, self-
existential orientation to clinical work. Subsequent realization, I–Thou, and encounter.
generations of existential therapists, however, less A phenomenological study of the clinical prac-
frequently hail from a psychoanalytic background. tices of 22 self-identified existential-humanistic
Instead, they are likely to come from the humanis- therapists and 11 self-identified existential-analytic
tic traditions or to have been trained explicitly as therapists also supports the distinction (Norcross,
existentialists. 1987). Not surprisingly, the existential analysts
Moreover, owing to existential therapy’s paucity reported using significantly more classic psychoana-
of technical procedures and practice guidelines, lytic techniques—analysis of the transference and
therapists committed to an existential stance have interpretations, for instance—than did their
been free to choose from a variety of therapeutic existential-humanistic colleagues. By contrast, the
systems compatible with the major tenets of existen- existential-humanistic therapists reported substan-
tialism. Although the traditional practice was to fol- tially more physical contact (touching, embracing)
low a psychoanalytic bent, there are those who with their patients and more Rogerian-type warmth
prefer client-centered, Gestalt, Adlerian, or even and positive regard than did their existential-analytic
cognitive-behavioral methods within an existential counterparts. Limiting existentialists to two types
philosophy (for example, Denes-Radomisli, 1976; may be a crude categorization, but these seem to
Dublin, 1981; Edwards, 1990; Maddi, 1978). These accurately capture variation in existential practice.
therapies are examined elsewhere in this volume. James F. T. Bugental (1915–2008), a promi-
Here we will briefly consider existential-humanistic nent American example, identifies himself as an
therapy, logotherapy, and reality therapy as three existential-humanistic psychotherapist. The kind
alternatives to classical existential analysis. of existential psychotherapy he practices no longer
carries the adjective “analytic,” although it still
Existential-Humanistic Therapy owes much to the insights of psychoanalysis.
Clinical experience and published literature sug- Instead, he prefers to speak of it as “humanistic”
gest at least two types of existential therapy: exis- to emphasize a value system less concerned with
tential analysis and existential-humanistic finding components (analysis) than with fostering
therapy. Existential analysis, or Daseinanalysis, the realization of human possibilities. For him, a

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Existential Therapies 103

goal of therapy is the increase in the In his classic Man’s Search for Meaning, Frankl
true livingness of those who engage in the process (1963) writes movingly of the terrifying deaths of
(Bugental, 1991; Bugental & Bracke, 1992). his wife, parents, and brother, the brutality of his
Following in the footsteps of his revered own imprisonment in four of the camps, and his
teachers, Jim Bugental and Rollo May, Kirk encroaching apathy. In the midst of this seemingly
Schneider has systematized existential-integrative overwhelming trauma, he found meaning by help-
therapy. It represents an expansion of existential ing his fellow prisoners restore their own health.
therapy as well as an integration with other thera- For Frankl and others, the search for meaning is
peutic methods and modalities when in the needs the cornerstone of psychological well-being and
of the patient and when in congruence with the the antidote to suicide.
tenets of humanism (Schneider, 2007; Schneider “Why don’t you kill yourself?” can be a threat-
& May, 1995). It also signals a plea to the psycho- ening but effective question for beginning psycho-
therapy community to wake up and recognize exis- therapy with some clients. After the initial startle,
tential dimensions of practice; without the the person begins to realize that the reasons given
existential awareness, clinical practice often devolve for not committing suicide contain the seeds of a
into adjustment rituals, gimmicky strategies, that meaning that can blossom into a profound pur-
quell but rarely transform. pose for living. By facing each form of nonbeing,
clients can become aware of a meaning for living.
Logotherapy The accidents of one’s genetic composition and
Of the forms of nonbeing, logotherapy is most family heritage place limits on who one can
concerned with meaninglessness (logo ¼ meaning). become, but also help form the contours of one’s
After suffering through years in Nazi concentration unique identity. Death is seen as a negation of
camps in which his mother, father, brother, and being that also brings a responsibility for acting,
wife perished, Viktor Frankl (1905–1997) became because if life were endless, decisions could be
convinced that a will-to-meaning is the basic sus- postponed indefinitely.
tenance of existence (Frankl, 1967, 1969). Stripped Even in the face of fate, a person is responsible
to a bare existence, he experienced the truth of for the attitude assumed and choices made toward
Nietzsche’s dictum: “He who has a why to live for that fate. The victims of concentration camps, for
can bear with almost any how.” But facing the hor- example, could choose to die for the sake of a
ror of World War II and the madness of a nuclear fellow prisoner, collaborate with the enemy for
future, more and more people find their lives the sake of survival, or give meaning to the future
becoming existential vacuums. Patients in greater by struggling to hold on for a better day (Frankl,
numbers doubt the meaning of work, of love, of 1963, 1978). “Between stimulus and response
death, of life. Psychotherapies may be adequate there is a space. In that space is our power to
for resolving discrete psychological disorders and choose our response. In our response lies our
mental conflicts, such as those between drives and growth and freedom” (Frankl, 1963).
defenses, but a relevant modern therapy must also The meaning of life is not an abstraction. Peo-
be a philosophical therapy—a therapy of meaning ple who are preoccupied with asking, “What is the
for those confronted with the existential frustration meaning of life?” should realize that it is life that
of being unable to find a “why to live for.” asks us what meaning we give to our existence. We
Frankl himself survived Nazi concentration can respond to life only by being responsible. We
camps and the death of his family by creating accept our responsibility when we accept the cate-
meaning in his helping others face the ordeal. gorical imperative of logotherapy: “So live as if you

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104 Chapter 4

were living already for the second time and as if union only to discover that when he intended that
you had acted the first time as wrongly as you are which he feared, he ended up having much more
about to act now” (Frankl, 1963). Facing each control over his anxiety than he had anticipated.
moment with such acute awareness and with such Anxious patients frequently use wrong activity
responsibility enables us to find the meaning of life in efforts to fight off obsessive ideas or compulsive
unique to us at this singular moment in our life. acts. Instead of excessively attending and intending
Logotherapy is quite similar in content to exis- to control obsessive-compulsive behaviors, clients
tential therapy, although Frankl gives meaning an are instructed in de-reflection. In de-reflection,
even more central position. Whereas existential anal- clients are instructed to ignore that which they
ysis is similar in form to psychoanalysis, logotherapy are obsessed with by directing their awareness
is closer in form to the briefer psychodynamic ther- toward more positive aspects of life. By attending
apies. Although philosophical issues will often be to a life full of potential meaning and value, clients
discussed in a warm, accepting manner, logothera- substitute the right activity of actualizing personal
pists will also confront, instruct, reason, and work in potentials for the wrong activity of trying to fight
a variety of ways to convince a client to take a more off psychopathology.
conscious and responsible look at the existential vac-
uum that life has become. Therapy transcripts Reality Therapy
(Frankl, 1963, 1967) indicate that therapy techniques Whereas logotherapy emphasizes a lack of meaning
include interpretations and confrontations but also as the central concern, reality therapy emphasizes
rely on persuasion and reasoning to a considerable a lack of responsibility. Patients routinely prefer
extent. Logotherapy appears to be a form of con- avoidance and blaming others, but reality therapists
sciousness raising that relies on a combination of ask patients to choose their lives and insist that
personal feedback and persuasive education in a phi- they assume responsibility for those choices.
losophy of existence. Some readers may be surprised to find reality
In treating psychological problems, Frankl therapy presented in a chapter on existential therapy.
developed two special techniques. Clients with anx- However, the developer of reality therapy, Southern
iety disorders are plagued by anticipatory anxiety. California psychiatrist William Glasser (1925–) did in
They anticipate dreadful consequences from feared fact derive many of his principles of therapy from
encounters and struggle to avoid such encounters. Helmuth Kaisar, one of the first existential therapists
In avoiding, however, they only increase their anx- in America. Furthermore, many of the central
ious anticipation of what will happen if they are concerns of reality therapy parallel an existential
forced into a feared encounter. To reverse this neu- approach toward personality and psychopathology.
rotic pattern, Frankl encourages clients to adopt an Glasser’s (1975, 1984, 2001) approach to therapy is
attitude of self-detachment and humor toward admittedly a unique blend of existential philosophy
themselves and to intend to do the very thing and behavioral techniques. For these reasons, several
they are dreading. With this paradoxical intention, reviewers of this book suggested that reality therapy
clients find that the way they anticipated acting is might be better placed in the behavior therapy chap-
rarely the way they in fact will act. ter or in the eclectic chapter. On balance, though, we
A student who was afraid that he would vomit if believe it is best suited for this chapter.
he went into the student union was instructed by me To attain our goals, we must have adequate
to go into the union and vomit intentionally. We control over our environment. According to
joked about how he could explain his vomiting. Glasser (1984), the human brain functions like
With sufficient self-detachment he entered the a thermostat that seeks to regulate its own

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Existential Therapies 105

behavior to change the world around it. All preoccupied with how special their symptoms
behavior is aimed at fulfilling the four psycho- are. Psychopathic patients believe they can ignore
logical needs of belonging, power, enjoyment reality and succeed by breaking the rules, laws,
and freedom, and the physical need for survival. and other realistic limits set by society. Once peo-
Successful satisfaction of these needs results in a ple begin to ignore or deny reality, they are more
sense of control. likely to repeat their failures. A person who has
The need for belonging motivates us to learn to failed to gain adequate love, for example, might
cooperate and function as a unit, such as in cou- deny the need for love and withdraw from others,
ples, families, teams, clubs, or religious organiza- and by this withdrawal fail to find the love that
tions. Power does not imply exploitation of others could produce a sense of worth.
but rather achievement, competence, and accom- Another source of human misery is that peo-
plishment. These consequences provide a sense of ple try to control other people. Glasser (1999)
control—we can make things happen. The need for believes we misdirect our energy and depress our-
fun or enjoyment balances our need for achieve- selves when we try to force others to conform to
ment. Life is meant to be enjoyed, not just endured. our standards. The reality is that we cannot rule
The need for freedom, independence, or autonomy others. The only behavior we can control is our
implies that, to function in a truly human manner, own. And when we realize that we can control
we must have the opportunity to make choices and only our own behavior, we can immediately rede-
to act on our own. A successful identity develops fine and enhance our personal freedom.
from experiences of having the power and the plea- Reality therapy begins with helping clients
sure of choosing to meet our own needs. become aware of what they are doing in the present
A failure identity is likely to develop when a to make themselves disturbed. The question for a
child receives inadequate love or is made to feel depressed patient, for example, is not, “What’s mak-
worthless. Regardless of how cruel or unusual our ing you depressed?” but rather, “What are you doing
early childhood, however, that is no excuse to to make yourself depressed?” If patients focus on
avoid assuming responsibility for our present past difficulties, the question is not why the person
behavior. In fact, the only way we can transcend got into such difficulties, but rather why they didn’t
an early failure identity is to take responsibility for get into even more difficulty. Such a focus helps
what we do now. Obviously the past cannot be clients to become aware that even in the process of
changed. The past is closed and fixed, a part of making difficulties for themselves, they still main-
nonbeing. The present and future are open to us, tained strengths and responsibility that kept them
however, and can come more under our control if from totally destroying their own lives or the lives
we will take responsibility for our present actions. of others. Clients are taught to focus on the
Troubled people are those who maintain a strengths they have, not on the failures they had.
failure identity because they are unwilling to With increasing awareness of their strengths, clients
accept responsibility and face reality honestly. begin to realize that they can succeed without deny-
Mental disorder is the name we give to the variety ing or ignoring reality.
of strategies that people use to ignore or deny Reality therapy is primarily present centered
reality and responsibility. People with grandiose and choice focused. The past is important only as
delusions, who believe they are the Virgin Mary it relates to present actions. Obviously the present
or Napoleon, are attempting to deny failure is where clients can choose to change. Blaming
by creating a false identity. Other patients mis- present problems on past abuses is one of the com-
takenly attempt to develop worth by becoming mon client cop-outs that unfortunately has been

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106 Chapter 4

reinforced all too often by traditional therapists. choice theory groups. If clients are taking on
Reality therapists do not, however, point a cold, more than they can realistically accomplish
blaming finger at patients. Clients have already within their present limits, then the therapist’s
had enough coldness and condemnation. Therapy task is to offer feedback and to help the clients
needs to be personal, with a warm, real, and caring design more realistic plans for the week. What
therapist providing some of the love and confirma- clients need are experiences of success, not more
tion missing in the client’s early life. experiences of failure. Reality therapists encour-
The personal nature of reality therapy does not age a behavioral form of successive approxima-
imply an all-accepting therapist. Value judgments tion in which a success identity is gradually
must be made, but it is the judgment of clients that established through weekly action plans that
is critical. Having the therapist make the value bring increasing consequences of success. Suc-
judgments only serves to take responsibility away cess comes not through the therapist’s manage-
from clients. If clients are to succeed they must ment of contingencies, but rather through the
come to judge their behavior as acceptable when client’s self-management of behavior.
it is responsible, which means good for the client Weekly plans are put in writing, frequently in
and for those with whom the client is meaningfully the form of a contract. Putting a plan in writing is a
related. If clients are hurting themselves or others, clearer commitment to change. Written contracts
then their hurtful actions are irresponsible and also avoid the excuses of forgetting or distorting
should be changed. Effective change comes only what was said. The therapist asks for details of
after there is a responsible awareness of how the plan to see how realistic it is and how much
one’s actions are destructive to self or others. chance it has for succeeding. Obviously plans, even
Choice is really the main process of change; in written plans, are not absolutes. If a plan does not
fact, Glasser (1999, 2001) now calls his choice the- succeed, then it can be changed in response to feed-
ory the new reality therapy. Therapeutic change is back from reality. No excuses are accepted, how-
the result of responsible choice based on the ever, if a plan does not work. The client takes
awareness of the hurt that one has been creating. responsibility, including the responsibility for
One of the therapist’s tasks is to call clients on choosing to change the plan. Most of us realize
their cop-outs. Therapists should not engage in that things usually go wrong because people do
the irresponsible activity of excusing clients’ mis- not do what they said they were going to do. Blam-
behavior by blaming personal problems on the ing or deprecating does not help. The critical ques-
past actions of parents or on the present condi- tion is, “Are you going to fulfill your commitment
tions of society. Successful people know they can or not? If so, when?” Or the therapist might say,
work within the reality of society without being “The plan didn’t work. Let’s change it.”
swallowed up by its immorality. The starting
point for changing any immoral aspect of society
is to accept responsibility for one’s own actions.
Effectiveness of Existential
Once a patient chooses to change irresponsi- Therapy
ble behavior, the reality therapist is available to Our review of the existential literature and the psy-
help the person create specific plans for chang- chotherapy outcome research revealed no controlled
ing specific behaviors. The therapist serves as a research to evaluate the effectiveness of existential
guide for those failing to progress in reality. therapy, traditional or otherwise. The standard
Plans must have a chance of succeeding from meta-analytic studies, similarly, do not report on
week to week, either in individual therapy or any outcome studies on existential therapy with

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Existential Therapies 107

children, adults, or older adults (Roth et al., 2005; mean effect size for paradoxical interventions com-
Scogin et al., 2005; Weisz et al., 1995). Apparently, pared to no-treatment controls was 0.99; thus, on
existential therapists do not tally conventional “suc- average, a treated patient would be more improved
cess” rates, whether based on subjective or objective than 84% of the no-treatment group (Hill, 1987).
outcome criteria. To be sure, researchers have empir- Several meta-analyses also found that paradoxical
ically investigated the existential givens of death, iso- interventions showed greater effectiveness than
lation, identity, and meaning (Koole et al., 2006). But other methods with more severe and resistant cases
the dearth of outcomes studies on existential psycho- (Beutler, Harwood, et al., 2011; Shoham-Salomon &
therapy have kept it on the fringes of mainstream, Rosenthal, 1987). These results, we should reiterate,
evidence-based practice (Keshen, 2006). do not directly attest to the demonstrated efficacy of
This resistance to standard empirical research is logotherapy, but to a broad class of techniques that
consistent with the existential distaste for ordinary includes Frankl’s paradoxical intention.
“scientific” research. Objective research adds to the
dehumanization of people by reducing their experi-
ence to test scores or aggregate data. The abstraction Criticisms of Existential
of people into numbers further objectifies patients, Therapy
whereas existential therapy is committed to helping From a Cognitive-Behavioral Perspective
people experience their unique subjectiveness while With no controlled outcome studies, we fully under-
giving up their escapes into self-objectification. Exis- stand why some existentialists consider their
tential therapists, in particular, lead the charge against approach a philosophy about psychotherapy and
the “accountability” movement and the medical not a system of psychotherapy. The title of the 2003
model (Elkins, 2009a, 2009b) underlying managed Society for Existential Analysis conference was the
care that relies on objectification of emotions and philosophy-friendly but research-oppositional “The
that places a monetary value on human lives. On (Im)Possibility of Research in Psychotherapy”!
phenomenological principles, existentialists are But what kind of authentic philosophy would
opposed to contributing to the myth that the usual be unwilling to fall or stand on the basis of its
experimental methods of science can do justice to the effectiveness in helping patients overcome their
study of humanity. pathologies? Let the existentialists use phenome-
Logotherapy has experienced the same paucity nological methods if they prefer, but let them also
of controlled outcome research (Batthyany & demonstrate that such methods result in greater
Guttmann, 2006). Many studies have been con- authenticity than do alternative approaches,
ducted on freedom, choice, and hope, of course, but including the placebo effect of expecting patients
we and others are unable to identify any controlled to be more open and honest.
studies testing the effectiveness of logotherapy. As a theory, existentialism takes a giant step
Frankl was an early proponent of paradoxical backward with such romantic-sounding ideas as
interventions, but was by no means the only or love and will (May, 1969), which held back a science
most systematic. Family systems therapists have of humanity for so long. Not only is such philoso-
been far more specific and prolific in examining phizing damaging to the human sciences, it is also, as
the efficacy of paradoxical interventions. Meta- Skinner (1971) so cogently argued, damaging to
analyses of paradoxical interventions in general, human societies. The continued emphasis on the
not Frankl’s paradoxical intention in particular, myths of freedom and dignity can do nothing more
have shown they are as effective as, but no more than lead to the continued disintegration of our
effective than, typical treatment methods. The society. If existentialists are truly concerned with

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108 Chapter 4

alienating phenomena such as the fragmentation of on despair, and the like, for which their only rem-
our communities, then let them use their eloquence edy seems to be to keep a stiff upper lip. This [is]
in support of well-designed communities in which high I.Q. whimpering on a cosmic scale.
the contingencies are sane and the consequences of
rule breaking severe. To sacrifice society in the name From a Cultural Perspective
of the elitist authentic individual is a luxury we can no Dead white European men develop another elitist
longer afford. individual psychotherapy that ignores the realistic
context of people’s lives. Sound familiar? Existen-
From a Psychoanalytic Perspective tialism has been roundly attacked by feminist,
How can existential analysis borrow so much of family-systemic, multicultural, and other therapists
psychoanalytic technique and yet reject so much of advocating a cultural position. The dearth of influ-
psychoanalytic theory? How can existentialists be ential women in existential theory and the predict-
authentic and still act as psychoanalysts in therapy? able neglect of their phenomenological worlds
Doesn’t that violate their own principles, and doesn’t convey a distinct impression of existentialism as a
it also show that effective therapy necessitates a rela- bastion of male intelligentsia. In viewing each client
tionship in which transference can be developed? as a unique essence, existential therapists fail to see
As a theory, existentialism does serious injustice or treat the family system as a whole. The passive
to patients in the midst of unconscious conflicts by stance of the therapist and the abstract nature of
insisting that they are responsible for and even choose the concepts would make family therapy difficult in
the very pathologies from which they struggle to any case.
extricate themselves. Can the existential therapist The lack of direction and concrete solutions
really believe that patients with severe compulsions make existential therapy particularly unsuitable for
to wash or psychotic delusions of persecution have ethnic/racial minority clients seeking relief. Kairos
any choice over what they are driven to do? brought on by poverty, racism, homelessness, and
The logical but ludicrous consequence of the the- crime will surely not be solved by analysis of existen-
ory can be seen in Binswanger’s (1958) analysis of tial concerns, but such analysis might provoke a few
the phenomenological meaning of his patient’s sui- more suicides in the face of the existentialist’s benign
cide rather than his attempting to prevent her from neglect. The money and time would be much better
lethally directing her hostility inward. Mowrer spent in solving real problems in clients’ Umwelt and
blamed Freud for giving us a generation of psycho- Mitwelt than in interminable philosophizing about
paths, but existentialism is the more likely culprit. As their Eigenwelt. Even if disadvantaged patients
a philosophy of our modern times, existentialism’s change internally, as existentialists maintain, they
emphasis on the freedom to choose and on individual see little hope for—or have little choice or impact
rules for living is more responsible for the breakdown on—their external realities. Only in existentialism
of social order than is psychoanalysis. and the movies do people possess unlimited freedom,
construct their own meanings, and execute boundless
From a Humanistic Perspective choices. Save it for the wealthy, worried well.
Lest anyone erroneously conclude that all huma-
From an Integrative Perspective
nists are sympathetic to traditional existential
analysis, here is a quote from Abraham Maslow Existentialism is rich in its appreciation of the human
(1960, p. 57) regarding the concept of nonbeing: condition, yet meager in its therapy methods and
outcome research. For example, the existential analyst
I do not think we need take too seriously the Euro- focuses on the existential anxiety of responsibility at
pean existentialist’s harping on dread, on anguish, the expense of the other equally important forms of

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Existential Therapies 109

nonbeing. The existential analysts provide little person’s truth is another person’s lie? Existentialists
insight into their therapeutic methods other than would do well to recognize the truth in Bronowski’s
repeating much of psychoanalysis combined with a (1959) seminal book, Science and Human Values,
few slogans about therapist authenticity. The inade- that honesty is the fundamental value of science
quate development of therapeutic procedures has and that the scientific method is the most honest
proven May’s (1958) fear that existentialism might method we have. There is nothing inherent in the
degenerate into an anything-goes anarchy. scientific method that says we cannot compare the
The existential rejection of scientific evaluation phenomenological description of patients following
of psychotherapy has also encouraged an irrational- different forms of therapy. Existentialists need to
ism in which many clinicians feel no responsibility to participate in the shared honesty of such compari-
evaluate the effectiveness of their work. What criteria sons, which can lead to the truth on which therapies
are we going to use to judge the honesty of different are most effective with which patients and with
therapists? Are we left with a solipsism in which one which problems.

An Existential Analysis of Mrs. C


An existential analysis of Mrs. C is restricted by the response for Mrs. C would have been to experience
case description, which contains just the facts and the intense anxiety that no matter how hard she
little of the subjective phenomena of her existence. cleaned and cared for her children, they were still
From the facts, it looks as if Mrs. C’s pre-pinworm infected and were now faced with the possibility
existence was already heavily objectified. In sexual of additional infestation. Mrs. C had never been
relations she was unable to be-in-nature, because authentic at facing such threats of nonbeing, but
she was nonorgasmic and thus unable to freely under the additional stress of her own illness, she
and fully enjoy the natural joys of sexuality. Because chose to lie to escape the anxiety related to the
her mother had lied about sex being disgusting, Mrs. prospect of further diseases. The lie was ready-
C at some point probably began to lie to herself that made in the form of the physician’s orders for her
she was not sexual in order to close off anything to boil clothes and wash intensely. At this point she
about herself that would be experienced as disgust- was not particularly responsible for the orders, but
ing. The original existential anxiety associated with she was responsible for telling herself, “If I just
sexuality was probably expressed in isolation in the wash enough, I can keep the nonbeing of diseases
form of rejection for being disgusting. away from my children and myself.” So she
In everyday affairs, Mrs. C had also objectified washed. With her washing based on this lying-
herself by being so orderly, as exemplified by her about-nature, she was now faced with neurotic anx-
cataloging her children alphabetically and sched- iety over not washing. Her conclusion was that she
uling them exactly 2 years apart. This orderliness must wash, and her bad faith resulted in the objec-
suggests that she reduced her anxiety over the tification of herself into a human washing machine.
responsibility of having and naming children by With full self-objectification in place, Mrs. C
placing the responsibility outside of herself onto experienced herself as unable to keep from wash-
an alphabet and a calendar. In spite of consider- ing. Causality in her life was no longer intentional,
able objectification, Mrs. C is probably no more but a compulsive drive like a motor that automati-
pathological than most conventional people who cally switched on in the presence of dirt. With so
try to control their anxieties through arbitrary much of her time and energy dedicated to washing,
rather than authentic principles. Mrs. C was bound to be faced with existential guilt
A crisis occurred when the Asian flu infected her over the many opportunities she was missing to be-
family at a time when Mrs. C was tired from caring for-herself and to be-intimate-with-her-family. Her
for five children and a sixth on the way. When the washing also served as an attempt to cleanse her-
pinworms infested her daughter, an authentic self of existential guilt. However, the longer she
(continued)

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110 Chapter 4

continued her washing compulsion, the less she objects, it could be extremely difficult to engage
was guilty over what she was doing and the more Mrs. C in an authentic encounter. But this would
she was faced with the possibility of experiencing be one of the few ways we would have to keep
neurotic guilt for what she was becoming—a wash- her from becoming totally washed up as a human
ing machine in human clothes. being. To help Mrs. C experience her own subjectiv-
After years of compulsive washing, to be con- ity, an existentialist would look for every possibility
fronted with the choice of not washing would raise of confronting her with choices in psychotherapy.
tremendous existential anxiety over how meaning- For example, when Mrs. C stops at doors and
less her past decade had been. To face the waits for others to open them so that she can
choice of not washing would also be to face avoid contact with germs, the existentialist would
self-condemnation for having wasted precious confront Mrs. C with the choice of seeking help by
years of her life and for having hurt her family. Bet- opening a new door to therapy or returning to her
ter to hold onto the lie that she must wash! At least secure but deadening patterns from the past.
that way she is not responsible: She has not failed Given the choice of what to talk about in ther-
in life; her physician has failed her. When her psy- apy, Mrs. C would probably ramble endlessly
chotherapist said he was washing his hands of her about her preoccupation with pinworms and the
case, she made a suicide gesture to force him to details of her washing. At some point, her obses-
remain responsible for her by arranging for some- sive preoccupations would be interpreted as her
one else to cure her. We can further see Mrs. C’s means of remaining a patient so that she would
desire to run from responsibility by the way she not have to face her therapist as a person. The
pressured her husband into assuming responsibil- therapist might also choose to confront Mrs. C
ity not only for the family but even for her very with the therapist’s own feelings, for example: “I
compulsion. “You tell me, George, what to wash am tired of hearing the endless details about pin-
next because I am so mechanical I cannot remem- worms and washing. I want to see if you still exist
ber or decide what to wash” is the essence of her within that laundromat you call a life. I know it will
communication to her husband. be scary and hurt like hell to open yourself up, but
The reason Mrs. C began her washing ritual with look, my hands are not clean either.”
her anus is that the anus was the locus of pinworms If Mrs. C could respond by sharing herself with
and was seen in her phenomenological world as a the existential therapist, a kairos would occur dur-
source of disease, as it is with many compulsive ing which Mrs. C would feel overwhelmed with
people. Even if Mrs. C could not control all the guilt and anxiety. Both she and her therapist
sources of illness in the universe, she could keep would recognize that one cannot face a decade
her own anus clean and could pretend that no of waste without being overwhelmed with the
germs would penetrate her immaculate body. existential anxiety and guilt that are the authentic
Mrs. C lived in a vigilant future where she kept responses to such absurd waste. The therapist
an ever-watchful eye open for any signs of dis- would do Mrs. C an injustice in trying to minimize
ease. Her space was surrounded by germs and her anxiety and guilt as only feelings of anxiety
worms, her symbols of nonbeing. She could be and guilt; she would be anxious and guilty. The
secure in such a dreaded world only if she only route to health would be to live through her
remained clean, not only of dirt but also of any confrontation of having not been authentic. The
responsibility and, therefore, any guilt for having therapist can no more cleanse Mrs. C of her guilt
let her family down. In effect, she was attempting and anxiety than she could cleanse herself. By
to literally wash her hands clean of the whole remaining with her through such crises, however,
mess—a Pontius Pilate maneuver to absolve her- the therapist can communicate that new options
self of responsibility and to avoid authenticity. exist for the future and that Mrs. C can choose not
As with many obsessive-compulsive patients to waste her options, including the chance to be-
who devote their lives to making themselves into authentic-with-the-therapist.

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Existential Therapies 111

Future Directions autonomy. These will be social forces more than


therapeutic endeavors, but powerful correctives
Existentialism has a rich and established basis in
nonetheless.
psychology, sociology, education, and the humani-
Looking specifically at existential-humanistic
ties; as Medard Boss put it, existentialism has a
psychotherapy, it promises to be valuable in, first,
potential voice in “everything with which human
serving as a philosophical base for the majority of
beings have something to do” (quoted in Craig,
contemporary clinicians who integrate multiple
1988). In the arts, the thriving Theatre of the
methods (Chapter 16), and second, assisting a grow-
Absurd attempts to convey the situation of human-
ing number of clients complaining of feelings of emp-
kind in a universe without meaning. In psychother-
tiness and lack of personal meaning (Bugental &
apy, the historical influence of existentialism is
Bracke, 1992). Integration of existential tenets with
equally established, but its future is equivocal.
other psychotherapy systems, positive psychology,
In many respects, existentialism’s contemporary
and the well-being/happiness movement will cer-
influence on psychotherapy is far greater than the
tainly intensify. Economic, technological, and social
small percentage of psychotherapists endorsing it as
forces over the past decades have drastically assailed
their primary theoretical orientation (see Chapter 1).
the capacity of being oneself, complicating the quest
The existential orientation frequently underlies clini-
for freedom and authenticity. Existentialism offers
cal practice without explicit recognition (Norcross,
fulfillment in an age of emptiness; it embraces
1987; Rubinstein, 1994). Core existential concepts—
authenticity in an era of medicalization; it addresses,
meaning, freedom, responsibility, individuality,
in the words of Frankl’s (1978) book title, The
authenticity, choice—have been incorporated into
Unheard Cry for Meaning. Existential therapy,
many contemporary systems of psychotherapy. Exis-
existential-integrative therapy, and logotherapy will
tentialism is a “strange yet oddly familiar” orientation
help clients find meaning in their suffering, be it
to psychotherapy and life (Yalom, 1980).
chronic pain, social ostracism, or posttraumatic stress
What does this implicit but selective incor-
disorder (Schulenberg et al., 2008). The meaning in
poration portend for the future of existential
trauma and terror can then be used for self-
therapy? As long as there are philosophically
transcendent giving to the world, as in the case of
inclined psychotherapists and angst-plagued
Viktor Frankl himself (Lantz, 1992).
patients, existential therapy will surely survive as
The rise of managed health care will threaten
a distinct orientation, but its overriding contribu-
the affordability of insight-seeking therapy, but the
tion to the 21st century will probably be as an
short-term treatment offered by managed care may
indirect social force. It will serve as a vital coun-
stimulate, paradoxically, a desire for more life-
terbalance to the flourishing victimology in the
changing therapy in the existential-humanistic
world: When people convincingly deceive them-
tradition. Patients’ appetites for deeper self-
selves into believing they are the unwitting, choi-
exploration may be whetted by brief treatment,
celess victims of fate, existentialists will confront
kindling a desire for more comprehensive explora-
them with the undeniable existence of active
tion into their inner life. Although existentialists are
choice and personal responsibility. Existential
probably overly optimistic about the paradoxical
therapy will promote the possibility and power of
demand for long-term psychotherapy in an era of
self-initiated change: When people delude them-
short-term treatment, the full impact of enhanced
selves about the necessity of professional treat-
freedom from the information age and increased
ment, existentialists will challenge them with the
isolation from the technological revolution just
efficacy of personal change and individual

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112 Chapter 4

may fuel a resurgence in the existential perspective Glasser, W. (1975). Reality therapy. New York:
on psychotherapy and, indeed, life. Harper & Row.
Glasser, W. (2001). Counseling with choice theory:
Key Terms The new reality therapy. New York:
HarperCollins.
aloneness/isolation finiteness
May, R. (1977). The meaning of anxiety (rev. ed.).
authenticity I–Thou (I–it, it–it)
New York: Norton.
bad faith relationship(s)
May, R., Angel, E., & Ellenberger, H. (Eds.).
being-in-the-world intentionality
(1958). Existence: A new dimension in
choice theory kairos
psychology and psychiatry. New York: Basic.
Dasein logotherapy
Schneider, K. J. (2007). Existential-integrative
de-reflection lying
psychotherapy: Guideposts to the core of
Eigenwelt (being-for- meaninglessness
practice. New York: Routledge.
oneself) Mitwelt (being-with-
Yalom, I. D. (1980). Existential psychotherapy.
existential analysis others)
New York: Basic.
existential anxiety objectification
JOURNALS: Existential Analysis; International
existential paradoxical intention
Forum for Logotherapy; International Journal
confrontation phenomenological
of Existential Psychology & Psychotherapy;
existential givens method
International Journal of Reality Therapy;
existential guilt reality therapy
Journal of Humanistic Psychology; Journal
existential-humanistic self-esteem
of Phenomenological Psychology; Review of
therapy Umwelt (being-in-
Existential Psychology and Psychiatry.
existential-integrative nature)
therapy will-to-meaning
Recommended Websites
Recommended Readings Existential Therapy:
Binswanger, L. (1963). Being-in-the-world: Selected www.existential-therapy.com
papers of Ludwig Binswanger. New York: Basic. International Society for Existential Psychology &
Boss, M. (1963). Daseinanalysis and psycho- Psychotherapy:
analysis. New York: Basic. www.existentialpsychology.org/
Bugental, J. F. T. (1965). The search for authen- Society for Existential Analysis:
ticity. New York: Holt, Rinehart & Winston. www.existentialanalysis.org.uk
Bugental, J. F. T. (1987). The art of the psycho- Viktor Frankl Institute (logotherapy):
therapist. New York: Norton. logotherapy.univie.ac.at/
Frankl, V. (1963). Man’s search for meaning. William Glasser Institute (reality therapy):
New York: Washington Square. www.wglasser.com

Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
CHAPTER 5
Person-Centered
Therapies

Courtesy of Dr. Natalie Rogers


Carl Rogers

Marty was wealthy financially but impoverished


emotionally. He rotated through glamorous
houses in Miami, Phoenix, and the Hamptons,
but his life was superficial. Golf, tennis, polo,
parties, and dining out helped pass the time. But
his wife, his children, and his friends were moving
away from Marty. His superficial conversations, his
sarcastic jokes, his negative attitude, and his limited
feelings were causing others to seek more enriching

Courtesy of Dr. William Miller


relationships elsewhere.
At first, Marty was enraged at others. He blamed
his increasing isolation on other people’s self-
centeredness or on the fact that he was no longer as
important since selling his major company. Then, William Miller
Marty tried to deny that being alone even bothered
him. He preferred his independence; he had always fantasies and his dreams. He dreamed about
been a lone wolf. Who needed others anyhow? dolphins, and he believed they represented the type
It wasn’t until his wife separated from him and of person he wanted to become. The dolphins could
left him alone in the Hamptons that Marty’s denial jump for joy at the surface of the sea, but they
began to break down. He asked his wife to join him could also dive to the depths of experience. They
in psychotherapy, and he began to experience and could communicate acutely with sounds and
express emotions. Instead of talking about his golf signals; they were sensitive and caring about each
game or the polo match, Marty began to share his other’s needs.

113

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114 Chapter 5

Through a caring and empathic therapeutic training in psychotherapy. He received his PhD in
relationship, Marty discovered that he was not clinical psychology in 1931 from Columbia in a
emotionally retarded, as he had originally feared. He highly Freudian program.
discovered that he had learned to close off his feelings Beginning as an intern in 1927–1928, Rogers
because of his mother’s teaching that men don’t show spent 12 years as a psychologist at a child guid-
emotions. He had replaced genuine feelings with silly ance clinic in Rochester, New York. One of the
jokes. As an awkward teenager, he had defended later misconceptions about Rogers’s approach
himself with cutting comments and cognitive was that it was largely useful to middle-class or
scanning for any signs of rejection. He had upper-class adults with neurotic problems. Yet,
supplanted genuine relationships with social events. the seeds of Rogers’s ideas germinated in his
In psychotherapy, Marty gradually reduced his work with lower-class children and their mothers
defensiveness. He learned that men could exchange (Barrett-Lennard, 1998).
emotions without threat of becoming effeminate. He During this time, he let his own clinical expe-
found that he could get close to his wife without being rience guide his theorizing and therapy. In the
hurt by her. As all of this was occurring and as Marty midst of a very busy but fertile schedule, he
was becoming more of the person he wanted to be, I found time to put together his first book, The
(JOP) asked him what about therapy was the most Clinical Treatment of the Problem Child, published
helpful to him. He replied immediately: “You really in 1939. Rogers found both inspiration and con-
listen, and you really care.” Carl Rogers taught firmation of his views in the work of Otto Rank
generations of psychotherapists the profound value (1936), who emphasized the importance of the
of active listening and human caring. Later he added humanity of therapists rather than their technical
the importance of genuine sharing. skills in remedying human problems.
In 1940, Rogers moved to Ohio State Univer-
sity to train students in psychotherapy. As is so
A Sketch of Carl Rogers often true of students, they taught Rogers several
Carl Ransom Rogers (1902–1987) demonstrated a important lessons. One of these lessons was that
profound openness to change, beginning with his his ideas represented a new view of the nature of
movement away from the fundamentalist Protes- effective therapy and not a distillation of generally
tantism of his Wisconsin farm family to the liberal accepted principles, as Rogers had originally
religion of Union Seminary in New York. His strict thought. Students also convinced him that if his
ascetic and religious family of origin allowed no new therapy was going to be accepted by scientifi-
drinking, dancing, card playing, or theatergoing. In cally minded practitioners, he would have to dem-
his early upbringing, Rogers personally experienced onstrate its efficacy through controlled research.
the devastating effects on one’s self-esteem of With his own strong commitment to the scientific
parents imposing conditions of worth on children. method, Rogers began an extended series of out-
Foreshadowing his later research interests, he come studies with his students both at Ohio State
showed scientific interests early and became a seri- and later at the University of Chicago, where he
ous student of agriculture at the age of 14, thus gain- moved in 1945.
ing an early appreciation of experimental design and The clarity of Rogers’s clinical and theoretical
empiricism (Sollod, 1978). After 2 years of prepara- writings in such books as Counseling and Psycho-
tion for the ministry, Rogers made a move common therapy (1942) and Client-Centered Therapy
to a number of actual or potential clergy, toward (1951) and the controls in his scientific research

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Person-Centered Therapies 115

brought widespread recognition. For a humanistic see that his model of a therapist as reflective and
psychologist, Rogers was tremendously successful nondirective had been very comfortable for a per-
in the traditional academic world, and in 1957 he son like him. For most of his life he had been
returned to his home state at the University of rather shy and therefore nondisclosing. In the
Wisconsin. Here he was willing to make the acid sunny climate of California, with its emphasis on
test of any therapy, to see if his system could be openness in groups, he had come to recognize that
effective in producing profound change in schizo- too much of his former style was a convenient role
phrenic clients. During the 5-year study, Rogers that had protected him from having to reveal
and the other therapists found themselves becom- much of himself. Right until his death, Rogers
ing more actively genuine, disclosing more of their was realizing more fully in psychotherapy, as in
inner experiencing, which seemed to lead to his life, the genuineness he had always valued
greater improvement in such clients. but never fully actualized.
In 1964, Rogers moved to the Western Behav-
ioral Sciences Institute in La Jolla, California, and
began working with groups of normal individuals Theory of Personality
struggling to improve their interpersonal abilities. All humanity has but one basic motivational force,
In 1968, Rogers and some of his research colleagues a tendency toward actualization. Rogers (1959,
established their own Center for Studies of the p. 196) defines the actualizing tendency as “the
Person in La Jolla. As a world figure in humanistic inherent tendency of the organism to develop all
therapy, Rogers became as deeply involved in its capacities in ways which serve to maintain or
inspiring humanistic changes in education, busi- enhance the organism.” This includes not only the
ness, marriage, and world relations (Rogers, 1970, tendency to meet physiological needs for air, food,
1977, 1983, 1987b) as he was in helping individuals and water and the tendency to reduce tensions, but
to more fully realize their basic humanity. His long- also the propensity to expand ourselves through
time commitment to peacemaking led to many growth, to enhance ourselves through relating and
workshops between warring factions and culmi- reproducing. It also refers to expanding our effec-
nated in the Rust Workshop on Central America tiveness, and hence ourselves by moving from con-
in 1985 (Solomon, 1990). Enlarging the focus of trol by external forces to control from within.
his work from psychotherapy and clients to We are also born with organismic valuing
human interactions and all people was accompanied that allows us to value positively those experiences
by a name change from the “client-centered” to the perceived as maintaining or enhancing our lives
“person-centered” approach. and to value negatively those experiences that
When Carl Rogers spoke, it was apparent that would negate our growth. We are born, then,
the audience was in the presence of a great man. with actualizing forces that motivate us and with
The aura around him was warm and gentle, valuing processes that regulate us. What’s more,
though his words were strong. He was willing to we can trust that these basic organismic processes
field any question and respond to even the most will serve us well.
critical comments. When asked how he as a ther- In relating to the world, we respond not to
apist could be both genuine and nondisclosing, he some “real” or “pure” reality, but rather to reality
surprised us with his candor. He said that over the as we experience it. Our world is our experienced
years of working first with psychiatric clients and or phenomenal world. If others wish to under-
then with growth-oriented groups, he had come to stand our particular actions, they must try to

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116 Chapter 5

place themselves as much as possible into our and our total perception of how much we are
internal frame of reference and become conscious loved by our parent is weakened. Consequently,
of the world as it exists within our subjective the expression of positive regard by significant
awareness. Our reality is certainly shaped in part others is so powerful that it can become more com-
by the environment, but we also participate pelling than the organismic valuing process. The
actively in the creation of our subjective world, individual becomes more attracted to the positive
our internal frame of reference. regard of others than to positive experiences that
As part of our actualizing tendency, we also actualize the organism. When the need for such
begin to actively differentiate—to see the differ- other-love becomes dominant, individuals begin
ence between experiences that are part of our to guide their behavior not by the degree to
own body and functioning and those that belong which an experience maintains or enhances the
to others. The special experiences that we come to organism, but by the likelihood of receiving love.
own are self-experiences. We are able to become Soon individuals learn to regard themselves in
conscious of self-experiences by representing these much the same way as they experience regard
experiences symbolically in language or other from other people, liking or disliking themselves
symbols. This representation in awareness of as a total configuration for a particular behavior.
being alive and functioning becomes further elab- This learned self-regard leads to individuals’ view-
orated through interaction with significant others ing themselves and their behavior in the same way
into a concept of self. Our self-concept includes that significant others have viewed them. As a
our perceptions of what is characteristic of “I” or result, some behaviors are regarded positively
“me,” our perceptions of our relationships to that are not actually satisfying, such as feeling
others and to the world, and the values attached good about ourselves for getting an A after spend-
to these perceptions (Rogers, 1959, p. 200). ing many dull hours memorizing tedious material.
As our self-consciousness emerges, we develop Other behaviors are regarded negatively that are
a need for positive regard for that self. This need is not actually experienced as unsatisfying, such as
universal in human beings, but we also learn to feeling bad about masturbating.
need love. This need for positive regard—the need When individuals begin to act in accordance
to be prized, to be accepted, to be loved—is so with the introjected or internalized values of others,
addictive that it becomes the most potent need of they have acquired conditions of worth. They can-
the developing person. “She loves me, she loves me not regard themselves positively as worthy unless
not” is the endless puzzle of the emerging individ- they live according to these conditions. For some,
ual who looks to the mother’s face, gestures, and this means they can feel good about themselves, feel
other ambiguous signs to see if she holds the child lovable and worthy, only when achieving, no mat-
in positive regard. Although a mother’s love is ter what the cost to their organism; others feel good
emphasized, positive regard from all others, espe- about themselves only when they are nice and
cially significant others, becomes compelling. agreeable and never say no to anyone. Once such
Whenever another person, such as a parent, conditions of worth have been acquired, the person
responds to a particular behavior with positive has been transformed from an individual guided by
regard, our total image of how positively we are his or her own values to an individual controlled by
prized by the other is strengthened. On the other the values of other people. We learn at an early age
hand, let a parent respond to a behavior with a to exchange our basic tendency for actualization for
frown or another expression of negative regard, the conditional love of others.

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Person-Centered Therapies 117

Theoretically, such a trade need not be made. As angry. My wife has since told me that in situations
Rogers (1959, p. 227) states so clearly, “If an individ- where I would be expected to get angry, I would
ual should experience only unconditional positive first begin to pucker my lips. If the frustration con-
regard, then no conditions of worth would develop, tinued, I would then begin to whistle. I never
self-regard would be unconditional, the needs for allowed myself to become aware of these somatic
positive regard and self-regard would never be at clues of anger even though I was going around
variance with organismic evaluation, and the indi- like a whistling teapot ready to explode.
vidual would continue to be psychologically adjusted For Rogers, the core of psychological malad-
and would be fully functioning.” Unfortunately, such justment is the incongruity between the person’s
a hypothetical situation does not appear to occur in total experience and what is accurately symbolized
reality, except perhaps in psychotherapy. as part of the self-concept. The incongruence
between self and experience is the basic estrange-
ment in human beings. The self is threatened. The
Theory of Psychopathology person can no longer live as a unified whole,
The more conditional the love of parents, the more which is the birthright of every human. Instead,
pathology is likely to develop. Because of the need for we allow ourselves to become only part of who we
self-regard, children begin to perceive their experi- really are. Our inherent tendencies toward full
ences selectively, in terms of their parents’ condi- actualization do not die, however, and we become
tions of worth, which have been internalized. like a house divided against itself. Sometimes our
Behaviors consistent with conditions of worth are behavior is directed by the self we like to believe
allowed accurate representation in awareness. Chil- we are, and at other times behavior can be driven
dren whose parents insisted on achievement, for by those aspects that we have tried to disown.
instance, should be able to perceive and accurately Psychopathology reflects a divided personality,
recall experiences in which they were indeed doing with the tensions, defenses, and inadequate func-
well. Experiences that conflict with conditions of tioning that accompany a lack of wholeness.
worth, however, are distorted in order to fit the con- Psychological maladjustment is a result of this
ditions of worth, or may even be excluded from basic estrangement of human beings. For the sake of
awareness. People who must achieve in order to maintaining the positive regard of others, we no lon-
feel good about themselves may, for example, distort ger remain true to who we really are, to our own
their vacations into achievement times, as they count natural organismic valuing of experience. At a very
the number of historical sites, museums, or states early age, we begin to distort or to deny some of the
they visit. Some workaholics may deny entirely values we experience and to perceive them only in
that they have any desire to play or just lounge terms of their value to others. This falsification of
around. “Fun is for fools” is their motto. ourselves is not the result of conscious choices to lie,
As some experiences are distorted or denied, as the existentialists would hold; rather, it is a natural,
there is incongruence between what is being expe- though tragic, development in infancy (Rogers, 1959).
rienced and what is symbolized as part of a person’s As individuals live in a state of estrangement,
self-concept. An example of such incongruence was experiences incongruent with the self are subceived
suggested earlier when I (JOP) indicated that I as threatening. Subception is the ability of the
could not allow myself to experience anger and organism to discriminate stimuli at a level below
still feel good about myself. I perceived myself as what is required for conscious recognition. By sub-
one of those rare individuals who never gets ceiving particular experiences as threatening, the

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118 Chapter 5

organism can use perceptual distortions, such as without even asking about my views on open mar-
rationalizations, projections, and denial, to keep riage. In rigidly defending their views of the world and
from becoming aware of experiences, such as of themselves, people end up becoming rigid and
anger, which would violate conditions of worth. If inadequate in their styles of information processing.
individuals were to become aware of unworthy The more defensive and pathological the person, the
experiences, their concepts of themselves would be more rigid and inadequate are that person’s
threatened, their needs for self-regard would be perceptions.
frustrated, and they would be in a state of anxiety. Some individuals suffer such a significant
Defensive reactions, including symptoms, are degree of incongruence between self and experience
developed to prevent threatening experiences from that particular events can prevent their rigid
being accurately represented in awareness. People defenses from functioning successfully and can
who feel unlovable for getting angry, for instance, lead to personality disorganization. If the event
may deny their anger and end up with headaches. threatens to demonstrate the degree of incongru-
The headaches may not feel good, but at least most ence between self and experience, and if the event
other people can love someone who is sick. Those occurs suddenly or obviously, then such individuals
who have self-regard only for success may develop are flooded with anxiety because their very self-
compulsions to work. They may drive themselves concepts are threatened. With their defenses not
into the late hours of the night with the aid of sti- working successfully, previously disowned experi-
mulants, feeling good about each success while their ences are now symbolized accurately in awareness.
body experiences tremendous stress. For these individuals, the organized self-images are
Some people are so threatened by sexual shattered by unacceptable experiences.
desires that they distort their perceptions to the Panic and disorganization were experienced by
point where they believe that they are pure and a sophomore who came to see me (JOP) following a
innocent and godlike, while others are trying to bad trip with LSD. Before the experience, he had
make them think dirty, rotten thoughts. A patient been convinced that he was a true follower of
I tested at a state psychiatric hospital looked at the Jesus. He had seen himself as loving and kind and
first Rorschach card I gave him, threw it down, working for the well-being of others through a radi-
and shouted, “Why the hell don’t you go show cal Christian movement. During his experience with
these pictures to the goddamned communists? acid, he saw himself as an egomaniac, misusing his
They’re the ones that are perverting our kids leadership role in his Christian group to win a fol-
with all of their sex education.” lowing of female admirers and to see his picture in
All human beings are threatened by some experi- the news. He said he kept running in a circle, trying
ences incongruent with their self-concepts. To a lesser to catch his picture of himself from the newspapers,
or greater degree, then, we all use some defenses or but he had this eerie feeling that the picture was a
symptoms to preserve our self-regard and to prevent stranger. He could not rationalize these self-
undue anxiety. Defenses help preserve positive self- perceptions as being due to LSD. He was so panicky
regard, at a price. Defenses result in an inaccurate and disorganized that he thought he might jump off
perception of reality due to distortion and selective a bridge to destroy his life in order to save his self.
omission of information. Early in my (JOP’s) career, a Fortunately, with the aid of crisis intervention from
45-year-old man walked into my office and said, “Oh, the counseling center and the support of friends, he
you’re younger. You must be in favor of open decided to enter psychotherapy to begin the arduous
marriages. I won’t be able to work with you.” He process of reintegrating a sense of self that was more
requested a referral to another psychotherapist complete and less idealized.

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Person-Centered Therapies 119

Whether a person enters psychotherapy because does not mean that therapists are always
of a breakdown, because of inadequate functioning genuine in all aspects of life, but it is necessary
due to perceptual distortions, because defensive when entering a therapeutic relationship.
symptoms are hurting too much, or because of a Rogers (1957, 1959) originally believed that
desire for greater actualization, the goal is the same: within this condition there was no necessity
to increase the congruence between self and experi- for therapists to disclose their genuine experi-
ence through a process of integration. Because Rogers ences to clients overtly; it seemed necessary
conceptualizes the reintegration of self and experi- only that therapists not deceive clients or them-
ence as emerging from the therapeutic relationship, selves. Following client-centered therapy with
we will break with our standard chapter format and schizophrenic clients (Rogers et al., 1967) and
present Rogers’s view of the therapeutic relationship work in human relations groups (Rogers, 1970),
before examining his theory of therapeutic processes. Rogers (1970) came to the conclusion that
therapist genuineness includes self-expression.
Therapeutic Relationship The degree of self-disclosure by Rogers
Rogers (1957, 1959) has stated very explicitly that himself was rather minimal when compared
the necessary and sufficient conditions for ther- with the extensive, spontaneous disclosure char-
apy are contained within the therapeutic relation- acteristic of many leaders of encounter groups.
ship. Six conditions are necessary for a relationship The following excerpt from a session with a
to result in constructive personality change. Taken schizophrenic client is an example that Rogers
together, these conditions are sufficient to account used to demonstrate his increased willingness to
for any therapeutic change. That is, these and only express his own feelings of the moment.
these conditions were hypothesized to produce Client: I think I’m beyond help.
therapeutic personality changes in all clients, in all Rogers: Huh? Feeling as though you’re beyond
therapies, and in all situations. help. I know. You feel completely hopeless
1. Relationship. Obviously, two persons must be about yourself. I can understand that. I don’t
in a relationship in which each makes some feel hopeless, but I realize you do. (Meador &
perceived difference to the other. Rogers, 1973, p. 142)
2. Vulnerability. The client in the relationship We shall see that other client-centered thera-
lives in a state of incongruence and is there- pists go considerably further in disclosing
fore vulnerable to anxiety because of the their own immediate feelings.
potential for subceiving experiences threaten- 4. Unconditional positive regard. The therapist
ing to the self, or is anxious because such sub- must experience unconditional positive regard
ception is already occurring. The vulnerability for the client. The client’s incongruence is due
to anxiety is what motivates a client to seek to internalized conditions of worth. For the cli-
and to stay in the therapeutic relationship. ent to accept experiences that have been dis-
3. Genuineness. The therapist is congruent and torted or denied to awareness, there must be a
genuine in the therapeutic relationship. decrease in the client’s conditions of worth and
Genuineness means that therapists are an increase in the client’s unconditional self-
freely and deeply themselves, with the actual regard. If the clinician can demonstrate uncon-
experiences of the therapists being accurately ditional positive regard for the client, then the
represented in their awareness of themselves. client can begin to become accurately aware of
It is the opposite of presenting a façade. This previously distorted or denied experiences

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120 Chapter 5

because they threatened a loss of positive regard interactions between client and therapist to pro-
from significant others. When clients perceive duce such change. Throughout the 1950s, it
positive regard, existing conditions of worth seemed adequate to postulate that the three facili-
are weakened or dissolved and are replaced tative conditions of therapist genuineness, positive
by a stronger positive self-regard. When the regard, and accurate empathy were all that was
therapist consistently prizes and cares about necessary to release a client’s inherent tendency
clients, no matter what the clients are expres- toward actualization. During the 1960s, Rogers
sing or how they are feeling, the clients and colleagues (1967) began to theorize that the
become free to accept all that they are with curative process involved the direct and intense
love and caring. expression of feelings, leading to corrective emo-
5. Accurate empathy. The therapist experiences tional experiences. Later, client-centered theorists
the client’s inner world and endeavors to (e.g., Wexler, 1974; Zimring, 1974) began to view
communicate his or her understanding to client-centered therapy as a process of expanding
the client. Through empathy we sense the consciousness or awareness through the therapist
client’s private world as if it were our own, with- bringing about more effective information proces-
out our own anger, fear, or confusion getting sing in clients. Currently, then, the processes of
bound up in the experience. With this clear change in client-centered therapy are most accu-
sense of the client’s world, we can communicate rately conceptualized as a combination of con-
our understanding, including our awareness of sciousness raising and corrective emotional
the meanings in the client’s experience of which experiencing that occurs within the context of a
the client is scarcely aware. genuine, affirming, and empathic relationship.
Without deep and accurate empathy, cli-
ents could not trust the therapist’s uncondi- Consciousness Raising
tional positive regard. Clients would feel The Client’s Work
threatened that once the therapist came to Given positive regard, clients are free to discuss
know them more completely, there would be whatever they wish in sessions. Clients, rather
aspects of the client that would not be than therapists, direct the flow of therapy. This is
accepted with positive regard. With accurate the primary reason Rogers (1942) originally used
empathy and unconditional positive regard, the label nondirective to describe his therapy.
clients come close to being fully known and Because clients come to treatment in distress, they
fully accepted (Rogers, 1959). can be expected to express personal experiences
6. Perception of genuineness. The client perceives, that are troubling them. The responsibility of cli-
at least to a minimal degree, the acceptance ents, then, is to inform the therapist about their
and understanding of the therapist. In order personal experiences and to be available for feed-
for the client to trust the caring and empathy back from the therapist.
of the therapist, the therapist must be seen as The Therapist’s Work
genuine and not as just playing a role. Traditionally, the therapist’s work in increasing the
client’s consciousness was seen as almost entirely
Therapeutic Processes composed of reflection. As a mirror or a reflector
Although Rogers wrote extensively about the con- of the client’s feelings, the therapist would commu-
ditions of the client–therapist relationship that nicate to the client messages that said, in essence,
facilitate positive change, he had less to say “You feel….” The specifics might be, “You feel dis-
about the actual processes that occur in the appointed in your father for leaning on alcohol,” or

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Person-Centered Therapies 121

“You feel envious because your roommate has a just a feedback function. Part of the person-
special boyfriend and you wish you did.” Through centered therapist’s work is to help clients reallo-
a commitment to understand the client with accu- cate their attention so that they can make greater
rate empathy, the therapist is not dogmatically, use of the richness in their feelings (Anderson,
authoritatively, or interpretively telling the client 1974). By more flexibly and fully attending to the
how or what to feel. The client-centered therapist client’s feelings, the therapist helps clients break
is instead able to sensitively and exquisitely cap- through their perceptual distortions in order to
ture the essence of the client’s expressions. The attend to the personal meaning of experiences
therapist can reflect so empathically and accurately that previously have not been processed into aware-
because there is no distortion caused by interpre- ness. The client-centered therapist can thereby
tation or self-expression. The therapist is free to serve as a surrogate information processor.
listen actively and reflect accurately the clients’ In compensating for the client’s more rigid
feelings. and deficient style of information processing, the
With such a caring and congruent mirror, clients therapist first serves an attentional function. The
become more fully conscious of experiences that pre- client’s experiences, especially threatening experi-
viously were partly distorted or denied. These experi- ences, can be held in awareness for further proces-
ences, of course, include their feelings, or more sing. If the therapist did not reflect some of the
importantly, their real feelings. Perhaps of even client’s threatening experiences, the client’s selec-
greater significance, clients become more fully aware tive attentional processes would cause such infor-
of the You the therapist is reflecting—the You with mation to be lost in short-term memory, crowded
increasing richness; the You who produced experi- out by other information receiving attention.
ences once judged to be unworthy of self-regard, but A case in point: In talking about her room-
which are now prized and shared by a significant mate’s boyfriend, a shy sophomore was expressing
other. Gradually the You of the therapist’s empathic a variety of feelings, including her close relation-
feedback is a richer and more congruent human. ship to her roommate, her admiration of the
More recently, person-centered therapists boyfriend, and vague feelings of envy. Because
have recognized the mistake of equating the spe- envy was not a feeling she could accept, this client
cific technique of reflection with the complex atti- would have focused her attention on her admira-
tude of empathy. This error has resulted in tion or her sense of closeness and would have lost
limitations on the modes of empathic response the opportunity to become aware of feelings of
(Bohart, 1993b; Bozarth, 1984). Rogers (1987a, envy that might be the source of her recent argu-
p. 39) wrote later in his life, “I even wince at the ments with her roommate.
phrase reflection of feeling.” He regretted that this Because there is always more information
simple intellectual skill was being (mis)taught as an impinging on a client than he or she can attend
accurate description of a complex interpersonal to, information from threatening experiences is
reaction. The evolving definition of empathy and most likely to be lost unless it is empathically
the expanding role of the person-centered therapist reflected by the therapist and thereby kept available
emphasize the therapist’s experiencing the world for further processing. By selecting out such threat-
of the client by developing more active and idio- ening information to process into awareness, the
syncratic means of empathy predicated on the person-centered therapist is, in fact, quite directive,
particular client (Bohart & Greenberg, 1997). but in a subtle and noncoercive style, and only by
The contemporary view is that the therapist’s responding to information already in process in the
work in raising consciousness involves more than client. In other words, person-centered therapists

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122 Chapter 5

are relatively controlling of the process of therapy, damaging to the client’s self-regard. As clients
but not its content. become aware of how therapists can capture the
As a surrogate information processor for the cli- client’s own feelings in more vital and enriched
ent, the therapist also helps the client adopt a more language, they have the opportunity to use sym-
optimal mode of organizing information. As clients bols that allow them to be conscious of how vital
approach feelings that threaten self-regard, they typi- their lives can really be.
cally become anxious, confused, or defensive, and Zimring (1974) uses the philosophy of Wittgen-
may be unable to find adequate words for organizing stein (1953, 1958) to explain that as clients become
and integrating such feelings into conscious experi- aware of more vital, enhancing, and actualizing
ence. Some clients may anxiously search for language modes of expressing themselves, their experiences
to organize their previously unacceptable feelings of become more vital, more enhancing, and more
anger or envy, whereas others will quickly give up and actualizing. In Wittgenstein’s view, expression and
go on to something else. Therapists can move the experience are a unity. Experiences do not exist
work ahead by empathically organizing the informa- somewhere in the organism, waiting to be expressed
tion from a client’s experience in a concise and accu- into awareness. Experiences are created by expres-
rate manner. Organized information is then more sion. Thus, the richer, the more potent, and the fuller
fully available to awareness. the symbols that clients learn to use in expressing
An example of such helpful organization themselves, the richer, the more potent, and the
occurred with a 55-year-old woman who was fuller humans they become.
expressing a variety of upsetting feelings toward
her husband. She was angry because he wouldn’t Catharsis
spend money to fix up the house for their daugh- In the process of raising consciousness, person-
ter’s wedding. She was depressed over how many centered therapists have emphasized the primacy of
years she had worked to make their restaurant a the client’s feelings. The therapist’s continual focus on
success, but now that they had money she still “You feel…” helps clients to become more aware of
wasn’t happy. She was trying to understand her feelings but also to release, express, and own their
husband’s view that it would be better to remodel most powerful feelings. For Rogers (1959), feelings
the house after they saved up the money rather have both emotional and personal meaning compo-
than cash in one of their bonds. She said she felt nents. In the previous section, we examined the
torn and confused. When I (JCN) responded, “You expression, organization, and integration of the per-
feel impatient with his promises that someday the sonal meaning, informational, or cognitive compo-
two of you are really going to live,” she broke into nent of feelings. Now we will examine the cathartic
tears and said, “Yes, that’s it, that’s it, that’s what release of the emotional component of feelings, which
he’s always been holding out in front of me.” is equally important in the curative process. Although
Therapists help clients effectively process Rogers considered the expression of emotional and
information by using symbols or words that are cognitive components of feelings as inseparable, we
active, vivid, and poignant. All too frequently, the have taken the liberty of discussing them separately
language and symbols of clients are conventional, while recognizing their experiential unity.
repetitive, dull, and safe, reflecting the defensive
ways clients process their experiences into aware- The Client’s Work
ness. Evocative symbols threaten to bring experi- In the process of expressing themselves, clients
ences into awareness that have previously been usually begin by avoiding emotionally laden

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Person-Centered Therapies 123

experiences. When feelings are talked about early The Therapist’s Work
in therapy, they are described as past experiences Originally, the therapist’s work seemed to be sim-
that are external to self (Rogers & Rablen, 1958). ply to allow clients to get in touch with their basic
Clients will talk about emotional problems, but feelings by demonstrating an attitude of uncondi-
describe such problems as coming from outside tional prizing of all the clients’ feelings. Now, it is
themselves. “My partner is driving me up a recognized that therapists help clients get in touch
wall”; “My folks are really on my back”; and with and express threatening emotional experi-
“My studies are giving me a bad time” are some ences by continually redirecting the client’s atten-
examples of early communications. tion to the feeling aspect of whatever is being
Gradually, in response to the therapist’s discussed. As the therapist explicitly reflects back
empathy and positive regard, clients describe to the client the essence of what the client is feel-
their feelings, but they are still primarily past emo- ing implicitly, the client eventually attends to and
tions and thus lacking in intensity. As clients feels the emotion and the meaning of experiences.
experience themselves as accepted, they can No relationship is completely unconditional,
begin to describe present feelings more freely, of course. Person-centered therapists genuinely
but they are not yet fully living and expressing express their conviction in, say, the value of life
their emotional experiences. Part of the work of and safety. The early use of the term nondirective
clients involves staying with emerging emotions perpetuated the misperception that Rogers never
even though anxiety is aroused and their defensive disagreed with a client and passively consented to
responses are mobilized. anything. Rogers would actively intervene if a cli-
Eventually, clients begin to fully express their ent tried to kill himself or herself or tried to phys-
feelings of the moment. These feelings are owned ically injure the therapist during a session
and accepted as coming from within the person. (Patterson, 1985). But Rogers would always try
At the same time, emotional experiences that to understand the client’s destructive impulses
were previously denied are bubbling up. Rather and communicate this understanding in a way
than continue to deny all such feelings, clients that would facilitate the client’s self-exploration.
gain more confidence that emotions can be val- Many client-centered therapists follow
ued and valuable. They discover that experienc- Rogers’s lead of directly expressing some of their
ing feelings with immediacy and intensity is a own feelings. Especially in group work, therapists
possible guide for living. They begin to trust might express such emotions as, “I feel angry
their feelings and base more of their valuing on about the way you’re attacking Tom,” or “I feel
what they like or dislike, what makes them happy deeply moved and saddened by what you’ve
or sad, what produces joy or anger. With the expressed,” or “I really do care about you.” The
release and owning of emotional experiences, cli- theoretical justification for person-centered thera-
ents get in touch once again with their inherent pists disclosing their own emotional experiences
organismic basis for valuing their genuine feel- of the moment is that it allows for greater genu-
ings. The release and acceptance of such feelings ineness or congruence. Furthermore, if psy-
are frequently vivid, intense, and dramatic as cli- chotherapists use nondirectiveness as an excuse
ents discover an internal basis for directing their to suppress their own annoyance because the
own lives rather than having to be dominated, weak client could not take it, an attitude of funda-
distorted, and threatened by the internalized mental disrespect for the client’s powers will be
values of others. communicated (Barton, 1974).

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124 Chapter 5

The empirical justification for therapist self- anxiety in order to discover more fully what
expression is the discovery that therapists who organismic experiences are threatening to enter
speak genuinely out of their strong feelings tend awareness.
to encourage and liberate clients to express their In practice, person-centered therapists respect
own emotional experiences (Rogers et al., 1967). the potentially disorganizing effects of anxiety, and
In important respects, the self-expressing therapist thus do not flood a client with threatening emo-
may create emotional experiences in clients tions. Instead, they allow a more gradual corrective
through such transactions, rather than releasing emotional experiencing to occur. The person-
some feelings that are implicitly present within centered style of catharsis may be slower and less
the client. The traditional view in client-centered dramatic than the exposure therapies (see Chapter
therapy, however, is that threatening emotions are 8), but it is also seen as less risky because anxiety
implicitly present in clients and are not being can cause incongruent people to deteriorate.
released because of the client’s defensiveness. The defense against anxiety-arousing experi-
Through the therapist’s emotional self-disclosure ences is either to deny them, banishing them from
and, most importantly, empathic communication, awareness entirely, or to use a whole range of dis-
clients are gradually freed from denying or distort- torting perceptions, such as projection or rationali-
ing their emotions and can begin to speak and live zation, that the experiences slant in favor of
out their strongest feelings. maintaining the person’s self-concept. In Piaget’s
terms, distorting defenses involve the assimilation
of new experiences into the schema of the self
Therapeutic Content with no accommodation of the self-concept to
Intrapersonal Conflicts those new experiences. The self is left unthreatened,
Person-centered therapy is more of a process than but only at the expense of personal growth.
a content theory, but it has had important things to
Self-Esteem
say about many of the common content issues in
Rogers placed the need for self-esteem at the center
treatment. As we have seen, person-centered theory
of intrapersonal problems, only he called it self-
has been especially concerned with the intraper-
regard. Low self-esteem is directly proportional to
sonal conflict between the client’s self-concept
the gap between who we think we were and who
and the total client’s experience, which includes
we really are. The problem is not that we have too
feelings that are threatening to the person’s self-
great concepts of ourselves that we cannot live up
concept. Even in the movement toward group ther-
to; the problem is that our concepts of ourselves are
apy and institutional consultation, person-centered
too meager to let us be all that we were born to be.
therapists remain centrally committed to establish-
Striving for self-esteem falls into an age-old
ing an atmosphere of positive regard to help indi-
trap. It keeps us locked into trying to actualize
viduals overcome incongruence in order to be more
self-concepts created out of our parents’ confining
fully functioning.
conditions of worth. The more restrictive our striv-
Anxiety and Defenses ing, the more we can feel good about ourselves only
Anxiety is not the cause of people’s problems but when we do not allow ourselves to feel much at all.
the troubling consequence of a divided life. Rogers’s solution lies not in increasing self-esteem
Although anxiety is frequently what drives people based on what we are supposed to be but rather in
into treatment, our task is not to desensitize anxi- expanding our conditions of worth so that we can
ety but rather to listen sensitively to the client’s prize all that we can be.

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Person-Centered Therapies 125

Responsibility major strides toward actualization without receiv-


Being the scientist that he was and having been ing professional assistance. Unfortunately, truly
educated in a time in which the behavioral sciences intimate relationships are rare, in part because it
assumed determinism, Rogers did not include free- is so difficult for us to grant to others what we
dom and responsibility as core constructs in his withhold from ourselves: our love of our human-
original theory. In later years, however, he placed ness, including our blemishes, our defects, our
freedom and responsibility at the cornerstone of his imperfections. To love and to feel intimate, most
work with committed couples, educational systems, people must distort their perceptions of their part-
and international relations. ners to fit their conditions of what is worthy of
In the context of the clinical setting, the troubled love, just as they distort their perceptions of them-
person is the victim needing parental regard that was selves. Eventually, when they discover who they are
all too conditional. The therapist is responsible for really relating to, they are likely to believe that the
providing four of the six conditions necessary faults and the gaps in their relationship are due to
for effective therapy; clients provide themselves their partner’s incompleteness rather than to the
and a willingness to relate to the therapist. Even narrow conditions of their own love.
within this seemingly deterministic system, we can Our society has traditionally placed narrow
see that freedom is experienced in releasing a safe but conditions on our sexual worth. These restrictive
restrictive self-concept to actualize the inherent conditions have led too many people to disown
tendencies to be all that we can be. Becoming the fullness of their sexuality so that they can hold
responsible means learning again to respond to themselves in high regard. In reacting to the pleth-
our natural organismic valuing rather than to the ora of prohibitions against being sexual, we may
internalized values of others. The responsible person have gone to the opposite extreme of believing
is the actualizing person who moves from that to feel worthy we have to be sexually successful,
heteronomy, or control by others and the environ- to be routinely orgasmic or even multiply orgasmic,
ment, to autonomy, or inner control. to always be aroused and maintain lubrication or
erections, to never ejaculate too quickly but to
Interpersonal Conflicts always ejaculate. Much performance anxiety reflects
Intimacy and Sexuality the restrictive conditions of worth that say we must
Intimacy is therapeutic, and therapy is intimate. In be sexually successful rather than sexually natural.
defining the necessary and sufficient conditions for a A more natural sexuality, one that is neither
therapeutic relationship, Rogers presents an ideal for goal consumed nor performance oriented, is most
an intimate relationship: positive regard, accurate likely to occur within an intimate relationship. In
empathy, and interpersonal genuineness. The major such a relationship, we are most likely to jettison
difference between an ongoing intimate relationship either overly restrictive or overly demanding con-
and the therapeutic relationship is that in the former, ditions of worth regarding either our own or our
both partners are, or at least become, relatively equal partner’s style of sexual relating. When things go
in their levels of congruence in order for the relation- wrong sexually, as they will at times for nearly
ship to progress. In the latter, treatment is ready for everyone, there is little threat of rejection in an
termination when such a level of intimacy is reached, intimate relationship. The atmosphere is present
often to the sadness of both therapist and client. for the couple to work through their own sexual
Given the similarity between psychotherapy difficulties. Rogers (1972) himself revealed an inti-
and intimacy, some incongruent people can make mate experience of how his wife’s unconditional

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126 Chapter 5

regard allowed him to work through a period of Control


erectile dysfunction. If therapists focus only on Control becomes a problem in interpersonal rela-
sexual dysfunctions without cultivating more inti- tionships when individuals attempt to impose
mate relationships, they are liable to leave couples their conditions of worth on others. In subtle or
in relationships that will continue to need therapy not-so-subtle ways, such individuals communicate
when things go wrong. that they will continue to care only if others live up
Communication to their images of lovable human beings. Be nice, be
a winner, be assertive, be deferential, be witty, be
At one time communication problems were
quiet, be sexy, and behave are just a few of the
believed to be inevitable, given the inadequacy of
conditions that people place on their partners or
words to express feelings. With our enhanced
their children. We let ourselves be controlled by
awareness of accurate empathy, however, we now
others because we value maintaining their regard
know that we can indeed understand the fullness of
above what is organismically pleasing. We, in
what another is communicating if we truly care to
turn, act in restricted ways to control the positive
listen. The problem of communication is no longer
regard of others. As long as our conditions of worth
a language problem; it is a problem in caring. The
coincide, we tend to go on controlling each other
testimony of clients from many forms of effective
without feeling conflict. Accusations of control
therapy indicates how fully people feel they can
become acute when conditions of worth conflict,
communicate and be understood when someone
as when some people can feel worthy only when
really cares to listen. Just as we can train therapists
they keep others waiting. To give up being con-
(Truax & Carkhuff, 1967) and paraprofessionals
trolled and to give up controlling, people must
(Carkhuff, 1969) to increase their ability to listen
work hard in therapy at giving up their restrictive
actively, so too have we learned how to train par-
conditions of worth.
ents (Gordon, 1970) and teachers (Gordon, 1974)
to listen actively and communicate effectively.
Individuo-Social Conflicts
Hostility Adjustment versus Transcendence
From his humanistic orientation, Rogers sees the Going beyond one’s internalized conditions of
natural actualizing tendency as bringing people worth to become a whole person suggests trans-
toward each other rather than driving them cending one’s acculturation process. But once a
against each other. Hostility is not an inherent person is in the process of becoming more con-
drive that must be controlled. It is, in part, a gruent, there is no inherent conflict between being
reaction to being overcontrolled by the restrictive an actualizer and being part of a society. Rogers’s
conditions of parental regard. Hostility is our (1959) view of the natural actualizing tendencies
organismic way of rebelling against having to dis- involves remaining in society in order to relate, to
own parts of our lives in order to be prized by create, and to grow through the mastery of cul-
others. It can also manifest itself when people can- tural tools. Rogers is certainly in favor of human-
not express angry feelings without feeling guilty or izing social institutions, such as couples, families,
unworthy. There are individuals who use hostility schools, universities, and businesses. Perhaps
against others with little caring, but such hostile because so much of Rogers’s professional life was
individuals were most likely raised in dehuma- spent in universities and growth-oriented centers,
nizing atmospheres in which they themselves probably two of the most humane institutions of
received little caring. society, he seemed confident that autonomous

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Person-Centered Therapies 127

clients can go out into society, be fully function- individual would, of course, demonstrate organis-
ing, and still be at-home in the world. mic trusting. Being open to each new experience,
the person would let all of the significant informa-
Impulse Control
tion in a situation flow in and through them and
Natural organismic valuing provides inherent regu-
would trust in their eventual course of action. The
lation over impulses. A person raised in a humanis-
person would not have to ruminate about decisions
tic atmosphere will eat, drink, and relate sexually in
but would find the best decision naturally emerging
a manner that is organismically enhancing and not
as a result of not distorting or denying relevant
organismically destructive. Attempts at bringing par-
information. The openness to experiencing indi-
ticular impulses under control through fancy techni-
cates a person who is living primarily in the pres-
ques or faddish diets may produce short-term gain
ent, who is neither processing information that
but little long-term maintenance, because they fail to
belongs to the past nor omitting information that
enhance natural abilities for self-regulation. Once
belongs to the present.
people feel good about who they are and are not
The fully functioning person does not process
under constant stress to be what others want,
experience through structured categories—through
they will not resort to overeating, drinking, or smok-
a rigid concept of self, for example. Instead, in what
ing to feel good for the moment or to reduce stress.
Rogers (1961) calls existential living, people let the
Acceptance of self begets control of impulses.
self and the personality emerge from experience:
Beyond Conflict to Fulfillment They discover a sense of structure in experience
Meaning in Life that results in a flowing, changing organization of
Meaning emerges from the process of actualizing self and personality. Self is thus experienced as a
our tendencies to become all that we are intended process—a rich, exciting, challenging, and reward-
to be. Those convinced that there must be some- ing process—rather than a constricted structure
thing more to life than natural living have probably that can process only what is consistent with inter-
not experienced all that there is to their lives. The nalized conditions of worth.
haunting suspicion that there must be something Organismic trusting, openness to experiencing,
“more” to life represents a subception that there is and existential living characterize the fully func-
indeed a good deal more to life than what they are tioning person. He or she has the power to choose
experiencing. What’s missing is to be found within and direct life from within, regardless of the sad
them and not outside them. There is no need to fact that actions may indeed be predictable on the
give life meaning for those in the process of living basis of past experiences. The greatest sense of free-
a congruent, complete life. The locus of evaluation, dom comes in being creative, in producing new
the source of meaning, is found within the individ- and effective thoughts, actions, and entities, because
ual. The person should be the center of his or her the person is in touch with the spring of life.
meaning, rather than having a meaning imposed by
other individuals or society as a whole. The criterion Practicalities of
for values is the actualizing tendency: Does this Person-Centered Therapy
action or experience enhance the organism?
The central focus of person-centered therapy on
Ideal Individual self-authority tends to mitigate against the use of
Rogers’s (1961) ideal for the good life is found in psychometric tests and routine assessment in psy-
a fully functioning person. This ideal type of chotherapy. Only three conditions suggest the use

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128 Chapter 5

of tests in person-centered counseling: The client Fees seem to follow the going rate for other
may request testing; clinic policy may demand that forms of therapy in a given locale. The genuine
tests be administered; and tests may be administered therapeutic relationship typically translates into a
as an “objective” way for the client and clinician face-to-face encounter, with no intervening desk.
to consider a decision for action, as in making The terms brief and person-centered therapy
vocational and career choices (Bozarth, 1991). were rarely used in the same sentence during
Because the person of the psychotherapist is Rogers’s lifetime. Rogers’s own therapy cases
more important than formal training in person- almost always ran into tens of sessions and
centered work, therapists from diverse back- frequently went into hundreds. Although years of
grounds are welcomed. Counseling psychology, psychotherapy are unnecessary, due to the client’s
counseling, social work, and pastoral counseling self-actualizing tendencies, the most common prac-
have been especially well represented in the tice was to see clients individually, once a week for
Rogerian approach. 6 to 12 months. Thus, little clinical or research
Client-centered counselors have been among the attention was paid to brief or short-term person-
most active in developing training approaches for centered therapy (Koss & Shiang, 1994).
paraprofessionals, such as students conducting peer Person-centered therapy (like most psy-
counseling or laypersons facilitating self-help groups chotherapies) has increasingly expanded into
(Carkhuff, 1969). Through methods originally devel- couple, group, and family therapy formats. Follow-
oped by Truax and Carkhuff (1967), students are ing Rogers’s lead in moving from strictly individual
trained through modeling, role-playing, videotaping, work to more systems interventions, contemporary
and feedback to learn the skills involved in becoming person-centered clinicians are active in group ther-
increasingly empathic, genuine, and positive in their apy, couple and family therapy (see August 1989
regard. The bulk of paraprofessional counseling is special issue of Person-Centered Review for an over-
performed according to Rogerian principles. view), and indeed entire communities and nations
Personal therapy is seen as desirable, though (see Levant & Shlien, 1984, for illustrations). Rogers
not essential. In addition, aspiring person- has also exerted a profound influence on group
centered therapists are strongly encouraged to treatment through his emphasis on the genuine
participate in growth-oriented experiences. Any encounter between people. Enlarging the scope of
experience that enhances the sensitivity of the cli- practice from the consulting room to planetary
nician and that fosters full functioning is regarded concerns, such as nuclear war and international
as valuable training. relations, reaffirms the name change from client-
Unfortunately, academic efforts to enhance centered therapy to person-centered approach.
trainees’ empathy have become confused with
mindless parroting or a sterile technique. In one A Major Alternative and
of his last articles before his death, Rogers (1987a,
p. 39) deplored the teaching of empathy as a cog-
Extension: Motivational
nitive skill: “Genuine sensitive empathy, with all its Interviewing
intensity and personal involvement, cannot be so William R. Miller (1947–) describes his motiva-
taught.” Training in empathy—or rather experienc- tional interviewing (MI) as Carl Rogers in new
ing and witnessing empathy—will come about only clothes. MI is a person-centered, directive approach
in authentic, I–Thou relationships, including expe- that enhances intrinsic motivation to change by
riential groups and personal therapy. helping clients explore and resolve ambivalence

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Person-Centered Therapies 129

(Rollnick & Miller, 1995). As such, it combines empathy and reflective listening advocated by Rogers
elements of both person-centered style (warmth, must play a central part in any effective brief therapy.
empathy, egalitarian relationship) and person- Although he did not set out to create a new
centered technique (key questions, reflective listen- system of psychotherapy, Bill Miller faithfully fol-
ing). MI expands on person-centered therapy by lowed the data and developed MI. He has now
incorporating therapist goals about desirable published more than 30 books and the Institute
changes and by providing specific methods for Scientific Information lists him among the
to move the patient toward behavior change World’s Most Cited Scientists. He is emeritus dis-
(Moyers & Rollnick, 2002). tinguished professor of psychology and psychiatry
Some of our colleagues wonder whether MI at the University of New Mexico. Fundamentally
ought to be classified as an extension of person- interested in the psychology of change, he has
centered therapy or as an alternative to it. Those focused his research on the development, testing,
in the humanistic camp and Miller himself favor and dissemination of treatments for addictions.
the former characterization, but many cognitive- From his research and an analysis of effective
behavioral colleagues insist that the operationali- brief therapies, Miller and Rollnick (1991, 2002)
zation of MI methods, its directive elements, and identified four principles of motivational
its voluminous research base distinguish it from interviewing.
the original Rogerian treatment. To accommodate
both positions and to roll with the resistance, we • Express empathy by using reflective listening to
will discuss MI as both an alternative to and an convey understanding of the client’s message
extension of person-centered therapy. and to express genuine caring for the person. At
Miller (1978) began his career by applying heart, MI fundamentally respects the client and
behavioral self-control techniques to the treatment understands his or her need for self-preservation.
of problem drinkers. As a good scientist, he was • Develop discrepancy between the client’s deeply
struck (and annoyed) by his findings that the con- held values and current behavior. Change is
trol group showed excellent improvement, compa- motivated by the perceived discrepancy. The
rable in magnitude to that of clients receiving 10 client, rather than the clinician, should present
therapy sessions. The control group had received the arguments for change. Clients literally talk
initial assessments, encouragement, advice, and a themselves into changing.
self-help book (Miller & Munoz, 1982). • Roll with resistance by meeting it with reflection
Miller so disbelieved the results that he replicated rather than confrontation. Resistance is simply
them twice after increasing the intensity of therapy to understood as clients voicing the status quo side
18 sessions (Miller et al., 1980). In one of the studies, of their ambivalence. The therapist should avoid
the in-therapy behavior of the counselors was arguing for change; client resistance is a signal
observed and rated on the empathy scale developed that the therapist should respond differently.
by Truax and Carkhuff (1967). Although the treat- • Support self-efficacy by actively conveying the
ment group and control group showed comparable message that the client is capable of change.
outcomes, the empathy ratings of the therapists could The therapist builds client confidence that
account for outcomes at 6 months (r ¼ .82), 12 change is possible and provides brief inter-
months (r ¼ .71), and 2 years (r ¼ .51). Therapist ventions that permit change and reinforce
empathy, not the specific treatment method, strongly optimism. The client is the primary resource
predicted client success. Miller concluded that the in finding answers and solutions.

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130 Chapter 5

In MI, therapists carefully avoid the classic con- Client: Yes! I know that when you were asking me
frontation in which the therapist asserts the need how much I drink usually, it sounded like a lot.
for change (“You must quit drinking!”) while the But I drink about the same as most of my
client denies it. Therapists who respond to client friends do.
resistance with confrontation or arguments are Interviewer: So, this is confusing for you. On the one
said to be exhibiting counterresistance. Direct con- hand, you can see that it’s a lot, and this (test
frontation is likely to escalate resistance rather than result) says it’s more than 95% of adults drink.
reduce it. MI methods leverage the inherent energy Yet, it seems about normal among your friends.
that resistance brings to the therapeutic interaction, How could both things be true? [Expressing empa-
seeking to redirect it in a manner that avoids a rup- thy for both sides and introducing discrepancy.]
ture in the therapeutic relationship and allows the Client: I guess I can drink with the top 5%.
emergence of client change talk. Just as a canoeist
Interviewer: Your friends are pretty heavy
would probably not paddle upstream against a
drinkers.
strong current, so too the motivational interviewer
will not argue with clients. He or she will try to roll Client: I don’t know about “heavy.” I guess we
with resistance by using the energy in the current/ drink more than our share. Later in the same
the client to steer the interaction (Moyers & session:
Rollnick, 2002). Interviewer: So, what does this mean about your
Instead of seeking to persuade directly, the own drinking? What happens now? [Asking
therapist systematically elicits from the client open-ended key questions.]
and reinforces reasons for concern and for change. Client: Well, I want to do something. I don’t want
That is, the therapist actively facilitates the client’s to just let this go on.
self-directed change. The therapist maintains a
Interviewer: And what are the possibilities on that
warm and empathic atmosphere that permits
“do something” list? What’s the next step?
patients to explore ambivalent feelings about
[Avoiding the expert trap.]
changing. Resistance is not confronted head-on
but is skillfully deflected to encourage open explo- Client: I guess I have to do something about my
ration. Underlying this process is a goal of devel- drinking—either cut down or give it up.
oping with the client a motivational discrepancy Interviewer: One or the other.
between present behaviors (real self) and desired Client: Well, I can’t just let it go! If I keep drinking,
goals (more ideal self). Evidence indicates that won’t all of this get worse?
such discrepancy provides motivation that triggers Interviewer: Probably.
behavior change (Miller & Rollnick, 1991).
Client: Then something’s got to change. I either
Here is an exchange between a motivational
cut down or quit.
interviewer and a client minimizing his alcohol
abuse (from Miller & Rollnick, 2002, pp. 148–149). Interviewer: But if it were clear to you that you had
to quit altogether, then you could. [Supporting
Client: It sounds like (I’m drinking) a lot. I never self-efficacy.]
really added it up before, but I don’t think of Client: Sure. If I knew I had to.
myself as a heavy drinker. Interviewer: How can you find out? [Leaving solu-
Interviewer: You’re surprised. [Reflecting, instead tions and decision to the client.]
of confronting.] Client: I guess I try something and see if it works.

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Person-Centered Therapies 131

Four specific skills are used in MI to foster therapist could use MI to explore the client’s
client safety, acceptance, and change. These skills ambivalence toward treatment and to build his
are summarized by the acronym OARS: intrinsic motivation to participate in the treat-
ments. Second, MI is used as a stand-alone brief
• Open questions evoke change talk in the client
intervention. For example, patients can be
and avoid closed questions by the therapist
screened for alcohol abuse and then MI briefly
that would lead to the status quo (e.g., Why
applied in the context of primary health care.
haven’t you…?).
Third, MI is used with other treatments. It can
• Affirmation emphasizes the client’s strength,
be integrated into many systems of psychotherapy
efforts, and steps in the right direction; Rogers
to reduce client ambivalence and to minimize the
would call it positive regard or support.
resistance (Miller & Moyers, 2005).
• Reflective listening encapsulates the Rogerian
Once a psychotherapy system has been cre-
skill of accurate empathy that allows the client
ated and shown effective in controlled research,
to explore and experience the dilemma at hand.
the treatment developer focuses on its dissemina-
• Summaries draw together the client’s change
tion and implementation (D and I). Dissemina-
statements and then deliver them back to the
tion refers to spreading the evidence-based
client for ever larger impacts.
treatment to professionals and the public; it’s out
The most recent version of MI (Miller & Roll- there. The related process of implementation
nick, 2012; Miller & Rose, 2009) increasingly refers to practitioners using the treatment and
emphasizes the spirit of MI. Rather than a series thereby altering their clinical behavior; it’s actually
of techniques for tricking ambivalent clients in implemented. The usual means of D and I—
changing, MI should be considered a collaborative writing books, publishing articles, giving talks—
and unfolding relationship respectful of client have largely proven ineffective in changing thera-
autonomy. As Carl Rogers (1980) said, it’s more a pist behavior (Norcross et al., 2008).
way of being than a method. When you listen gen- Instead, treatment developers like Bill Miller
erously to people, they can hear the truth in them- have begun leveraging implementation science to
selves, often for the first time. That spirit allows the widely install MI skills in health care professionals
therapist to harness client ambivalence, develop a and programs. A network of MI trainers has been
plan, and strengthen commitment to change. created, and most of the training resources have
MI was originally advanced for addictive dis- been placed online for public access (www.motiva-
orders but has since been applied to a host of tionalinterview.org). Further, a series of controlled
health-related behaviors (Arkowitz et al., 2008). studies has been performed to determine the most
MI has been effectively used with both typical men- effective method for learning it. Miller and col-
tal health disorders—such as anxiety, depression, leagues (2004) evaluated five training methods:
post-traumatic stress disorder, eating disorders— clinical workshop only; workshop plus practice
and broader social concerns—such as clean drink- feedback; workshop plus individual coaching
ing water and the criminal justice system. sessions; workshop, feedback, and coaching; or a
MI has at least three applications. First, it is wait-list control group of self-guided training.
used early in or as a prelude to treatment, in order Licensed substance abuse professionals were ran-
to enhance client motivation for change. A client domly assigned to one of the five training methods,
may be reluctant to engage in diabetes treatment, and their MI practice analyzed over 12 months.
monitor his diet, or take his glucose readings; a Professionals attending the workshop fared better

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132 Chapter 5

than those training themselves. Feedback and psychotherapy (Strupp, 1971). Two separate lines
coaching produced superior MI performance over of research on the effectiveness of person-centered
and above the workshop alone. MI can be success- therapy have been pursued. The first concerns the
fully disseminated through systematic training, veracity of Rogers’s necessary and sufficient condi-
ideally including coaching and feedback, with tions hypothesis; the second line of research relates
real-world substance abuse practitioners. But long- to the overall efficacy of person-centered therapy.
term implementation, as expected, takes longer to We will consider each in turn.
accomplish.
The Facilitative Conditions
Rogers’s (1957) provocative identification of pur-
Effectiveness of portedly “necessary and sufficient conditions of
Person-Centered Therapies therapeutic personality change” precipitated scores
Carl Rogers consistently stood for an unusual of published studies, at least a dozen reviews, and
combination of a phenomenological understand- even a “review of reviews” (Patterson, 1984). The
ing of clients and an empirical evaluation of psy- empirical research on empathy, genuineness, and
chotherapy. He is widely regarded as one of the positive regard, which Rogers anticipated eagerly,
parents of psychotherapy research, particularly for has demonstrated that these facilitative interpersonal
initiating the rich tradition of process research. conditions are valuable contributors to outcome but
(Process research concerns the interactions are neither necessary nor sufficient. Dispassionate
between client and therapist, whereas outcome reviews conclude that “patients’ positive perceptions
research tracks the success or effectiveness of of therapist facilitative attitudes have a modest ten-
therapy.) Rogers and his followers have demon- dency to enhance treatment gains” (Beutler et al.,
strated that a humanistic approach to conducting 1986, p. 279), and that “the evidence for the
therapy and a scientific approach to evaluating therapeutic conditions hypothesis [as necessary
therapy need not be incompatible. and sufficient] is not persuasive. The associations
In one of his last articles, which addressed the found are modest and suggest that a more complex
future development of the person-centered association exists between outcome and therapist
approach, Rogers (1986, pp. 258–259) continued skills than originally hypothesized” (Parloff et al.,
to emphasize the need for empirical research: 1978, p. 251).
Most person-centered therapists now concede
There is only one way in which a person-
the point and have reformulated the original
centered approach can avoid becoming narrow,
hypothesis. One set of person-centered researchers
dogmatic, and restrictive. That is through
conclude that the evidence, “although equivocal,
studies—simultaneously hardheaded and tender
does seem to suggest that empathy, warmth, and
minded—which open new vistas, bring new
genuineness are related in some way to client
insights, challenge our hypotheses, enrich our
change but that their potency and generalizability
theory, expand our knowledge, and involve us
are not as great as once thought” (Mitchell et al.,
more deeply in an understanding of the phe-
1977, p. 481). Raskin (1992), an influential client-
nomena of human change.
centered practitioner, summarizes his position on
The impetus given research by client-centered the original Rogerian qualities by saying they were
therapy is at least equal in importance to Rogers’s not necessary, perhaps sufficient, definitely facili-
theoretical contributions or the effectiveness of his tative. Few researchers seriously suggest that these

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Person-Centered Therapies 133

conditions are necessary and sufficient, even higher than the average effect of 0.56 for placebo
within person-centered psychotherapy (Bohart, treatment. Person-centered therapy was found to
1993b; Kirschenbaum & Jourdan, 2005). be comparable in effectiveness to psychodynamic
However, the facilitative conditions are facili- and other insight-oriented therapies, but slightly
tative. The accumulating research demonstrates below—some would say negligibly below—that of
that therapist qualities of positive regard, empa- behavioral treatments (Shapiro & Shapiro, 1982).
thy, and genuineness are indeed effective for The one type of outcome measure on which
most people and most circumstances. As discov- client-centered therapy demonstrated higher
ered by Rogers and rediscovered by Miller decades change than a number of other orientations was in
later, client perception of their therapist’s empathy self-esteem, an area particularly prized by the
is the single strongest therapist determinant of person-centered approach (Rice, 1988).
successful psychotherapy (Bohart et al., 2002; A reassessment of the 17 published studies on
Elliott et al., 2011). Although rarely sufficient for client-centered therapy contained in the Smith,
personality change, empathy is facilitative—in Glass, and Miller (1980) meta-analysis indicated
person-centered and all other systems of psycho- that the apparent effectiveness of client-centered
therapy (Burns & Nolan-Hoeksema, 1992; Nor- therapy was largely based on the treatment of pro-
cross, 2011). The facilitative conditions represent blems that occur in academic settings (Champney &
the core of the nonspecific or common factors Schulz, 1983). Caution was recommended in gener-
across diverse forms of psychotherapy (as alizing the effectiveness of Rogerian therapy beyond
described in Chapter 1). Empathy is assuredly an academic problems and educational counselors to
evidence-based practice. psychological problems and private practices.
More recent reviews of person-centered ther-
Person-Centered Therapy apy show that it is definitely superior to no treat-
The general pattern of early outcome research was ment and a placebo treatment. Whether it is as
that person-centered therapy outperformed no- effective as or slightly less effective than other
treatment and wait-list control groups in samples systems of psychotherapies brings us back to the
of college students and mildly disturbed clients. In allegiance effect, the tendency of the investigators
the early 1960s, Rogers and his colleagues (1967) to favor their own preferred treatment in conduct-
courageously applied person-centered therapy to a ing studies. The early meta-analyses found client-
group of institutionalized schizophrenics—one of centered therapy to produce statistically significant
the few psychotherapies then to be tested with this benefits compared to wait-list or no treatment in
seriously disturbed population. Those results dem- over 90% of the studies (Grawe et al., 1998) and
onstrated little effectiveness. produce an average effect size of 0.95 compared to
Turning to the overall effectiveness of person- no treatment, a large impact to be sure (Greenberg
centered therapy with nonpsychotic clients, we et al., 1994). At the same time, in direct compar-
shall review the conclusions of several meta- isons, client-centered therapy fared slightly poorly
analyses on the subject. Aggregating about 60 stud- (Greenberg et al., 1994; Reicherts, 1998).
ies, the Smith and Glass (1977; Smith et al., 1980) But then researchers began accounting for the
meta-analysis found that person-centered therapy allegiance effects in meta-analyses and discovered
showed an average effect size of 0.63. This was that most of these small, between-therapy differ-
interpreted as a respectable and moderate effect, ences began to fade away, leaving equivalent out-
clearly superior to no treatment, but just barely comes. Case in point is the treatment of depression.

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134 Chapter 5

When controlled for investigator allegiance, nondi- therapy at all but probably not as efficacious than
rective therapies worked about as well as cognitive, cognitive-behavioral treatments. Finally, the inves-
behavior, psychodynamic, and interpersonal thera- tigator allegiance effect remains a potent wild card
pies (Cuijpers et al., 2008). Direct comparisons when interpreting such differences.
revealed that the nondirective treatments were
just slightly less effective (d ¼ −0.13), a tiny differ- Motivational Interviewing
ence. There are no large differences in efficacy There are now more than 200 randomized clinical
between the major psychotherapies for mild to trials investigating the success of MI. Its body of
moderate depression. research, in fact, now surpasses the outcome liter-
Another case in point is the large controlled ature on person-centered therapy. We shall review
study, involving over 5,000 patients suffering from the results of a seminal study involving MI and
anxiety and depression, treated at one of the then summarize its burgeoning body of outcome
National Health Service primary-care centers in research.
the United Kingdom over a 3-year period (Stiles et In Project MATCH, one of the largest psycho-
al., 2008). All treatment groups began with similar therapy outcome studies in history, four sessions of
levels of distress, and all averaged marked improve- an early form of MI was compared to 12 sessions of
ment (pre- to posttreatment effect size of 1.39). Cognitive-Behavioral Coping Skill Training and to
Patients treated with person-centered, cognitive- 12 sessions of Twelve-Step Facilitation Therapy
behavioral, and psychodynamic therapies all (Project MATCH Research Group, 1993, 1997).
achieved equivalent outcomes. When theoretically Two parallel but independent randomized clinical
neutral investigators conduct the study, more times trials were conducted, one with 952 alcohol-
than not theoretically different approaches tend to dependent clients receiving outpatient psychother-
show similar treatment outcomes. apy and one with 774 clients receiving aftercare
One area in which person- or client-centered therapy following alcohol inpatient treatment. The
therapy appears not to achieve comparable effec- first two sessions included MI and personal feed-
tiveness is with children and adolescents. One back based on intensive assessments of problems
meta-analysis (Weisz et al., 1987) located approxi- related to alcohol abuse. The last two sessions
mately 20 controlled studies that included client- were basically booster sessions (Miller et al., 1992).
centered therapy. The average effect size was 0.56, The briefer MI was just as effective at each
which was smaller than those obtained for various follow-up as the lengthier and more established
behavioral treatments (ranging from 0.75 to 1.19). 12-step and cognitive-behavioral treatments. Of spe-
A subsequent meta-analysis of child and adolescent cial note was that, at long-term follow-up, MI was
outcome research (Weiss & Weisz, 1995a, 1995b) more effective than Cognitive-Behavioral Coping
identified six new studies testing the effectiveness of Skills Training with patients who initially were less
client-centered therapy. The effect size was again motivated to change as measured by being in earlier
clearly better than no treatment but lower than stages of readiness for change. Just as Carl Rogers
that found for a variety of behavioral, cognitive, predicted, clients can go a long way in a short time
and parent-training interventions. when provided with facilitative conditions, an
The emerging conclusions are that person- or accepting therapist, and considerable autonomy.
client-centered therapy is effective for adults, just At least four meta-analyses have been con-
as or a tad less effective than alternative therapies. ducted on the effectiveness of MI (Lundahl &
For children and adolescents, better than no Burke, 2009; Lundahl et al., 2010). The 2010

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Person-Centered Therapies 135

meta-analysis examined 119 studies on the effective- Hettema, Steele, and Miler (2005) made a
ness of MI relative to either a control group or a challenging observation in their meta-analysis of
comparison treatment across multiple problems. 72 clinical trials spanning a range of target pro-
Compared to wait-list or no treatment, the four blems. They found that effect sizes comparing MI
meta-analyses found that MI produced average to control groups decrease rapidly and signifi-
effect sizes between 0.27 and 0.40. One could expect cantly over time. Across all studies, the effect
that 14% to 20% of MI patients to do better than size (d) was 0.77 at 0 to 1 month posttreatment,
the untreated after only two or three sessions of MI. but dropped to 0.39 at 1 to 3 months. At follow-
Compared to alternative active treatments, the four ups longer than 12 months, a very small d of 0.11
meta-analyses found that MI performed as effec- was found. An interesting exception to this trend
tively or a bit more effectively, with average effect was in studies where MI was added to another
sizes between 0.04 and 0.32 favoring MI. One could therapy, like cognitive-behavioral therapy. Here
expect that 2% to 15% of MI patients to do better the effects of the combined treatments remained
than patients receiving other therapies. Note, how- consistent over time, with effect sizes hovering
ever, that MI was typically shorter (by two sessions) around 0.60. These results suggest that to produce
and less expensive than the alternative treatments. durable effects over time, MI may need to be com-
All told, MI has demonstrated large effects with bined with another evidence-based treatment.
small interventions (Burke et al., 2002).
Strongest support by far for MI efficacy is in
the area for which it was originally designed: sub-
Criticisms of Person-Centered
stance abuse among adults and adolescents (Jensen Therapies
et al., 2011; Smedslund et al., 2011). MI, averaging From a Cognitive-Behavioral Perspective
just 100 minutes in length, showed clinical impact: Rogerians should be praised for their willingness
51% improvement rates and a 56% reduction in to place person-centered therapy under scientific
client drinking (Hettema et al., 2005). The meta- scrutiny. They must realize, however, that they
analytic results also support its effectiveness for were responsible for the many methodological
smoking, but the results are not as dramatic as errors in their original experiments. Fatal flaws
for drinking problems (Lai et al., 2010). in their studies include (1) omitting an untreated
MI appears to be particularly effective with two control group; (2) failing to control for placebo
populations: ethnic minority clients and resistant effects; and (3) neglecting the actual behavior
clients (Hettema et al., 2005; Lundahl et al., 2010). and functioning of clients in favor of ratings of
The meta-analyses report larger effects with sam- their subjective experiences. More recent con-
ples composed primarily or exclusively of people trolled studies have corrected several of these
from ethnic minority groups. The client-centered, faults, but the science is weaker than that
supportive, and nonconfrontational style of MI demanded of evidence-based health care.
may represent a more culturally respectful form Even when sufficient controls and rigorous
of psychotherapy. MI also seems to be differentially methods are employed, the general meta-analytic
effective with clients who are more resistant, angry, conclusion is that exposure, behavior, and cogni-
or less ready for change. This finding is consistent tive therapies are as effective and probably more
with the original intent of MI—enhancing clients’ effective than person-centered therapy. The
intrinsic motivation to change by helping them greater use of empathy and warmth by behavior
explore and resolve their ambivalence. therapists would probably prove useful, but the

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136 Chapter 5

therapist’s interpersonal behavior is rarely suffi- From a Psychoanalytic Perspective


cient to conquer behavioral disorders. Don’t stop The Rogerian approach exemplifies how our per-
with “touchy, feely” therapist qualities when spe- ceptions can be distorted by the people we are
cific, teachable behavioral methods have been most likely to see for psychological treatment.
found to be more effective and efficient. That’s Person-centered therapy is an inspirational theory
why we insist on putting some distance between of humanity of enormous appeal to college stu-
the original person-centered therapy and the dents because it was based primarily on work
modern MI. with students. It is a theory and therapy for ambi-
From a theoretical perspective, person- tious individuals whose typically American drive
centered therapy is also open to serious question. to achieve is mistaken for some inherent tendency
Beneath all the rhetoric, Rogers is advocating a to actualize. Where was such a driving tendency to
treatment based on a fuzzy form of extinction— actualize in the chronic schizophrenics that
the client’s distress will gradually fade if the ther- Rogers and his colleagues (1967) failed to make
apist ignores conditions of worth. Troubled into fully functioning individuals?
responses are assumed to have been conditioned What person-centered therapy actually pro-
by the contingent love and regard of parents. The vides is a transference relationship that has all
therapist is supposed to reverse the process by the elements of an idealized maternal love. Clients
establishing a social-learning environment in are promised a rose garden in which all that they
which there are no contingencies, no conditions are, their worst as well as their best, will be met
for positive regard. The client is allowed to talk with unconditional love. The fact is that research
on and on about troubled behavior without (Truax, 1966) has demonstrated that even Carl
being reinforced or punished. Eventually, the Rogers made his responses to clients highly con-
absence of contingencies leads to an extinction ditional on the clients’ expressing feelings. When
of talking about troubles. Of course, we cannot clients expressed particular feelings, Rogers was
determine from verbal extinction alone whether much more likely to show interest or express
the client’s troubled behavior itself has changed empathy. To pretend to be unconditional in our
or whether the client has just quit talking about love is to do our clients a disservice; the real world
it. But why rely on extinction when it is necessar- is, in actuality, conditional with love. Such pre-
ily lengthy and can lead to complications, such as tense can encourage clients to believe that, com-
spontaneous recovery of the extinguished pared to the rest of the world, only a therapist
responses? Further, when only extinction is used, could really love them.
there is no way of telling which new behaviors will
be learned in place of the maladaptive responses From a Cultural Perspective
being extinguished. The person-centered disregard of the larger envi-
Rogers advocates trusting in a mysterious ronment beyond the therapy relationship often
organismic actualizing tendency. This tendency leads to naiveté and ineffectiveness. The social
is reminiscent of the ancient belief in teleology, milieu in humanistic theories is treated simplisti-
which assumed that an acorn would grow straight cally as an obstacle to self-realization, rather than
and tall if we only kept our foot off it. Of course, as an arena in which the self will be either lost or
we now know that the manner in which even an realized. Downplaying external “reality” or the “real
acorn develops is in part a function of how it is world,” concepts Rogers often placed in quotation
nourished by its ongoing environment. marks, can only confirm the public image of

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Person-Centered Therapies 137

psychotherapy as unrealistic, self-indulgent, expen- sounds like a Hollywood melodrama in which one
sive talk about one’s inner feelings and potentials. unconditional love relationship comes along and
“Reality” consists of much more than emotions emancipates a fully functioning person who lives
expressed in 50-minute sessions; family relation- happily ever after. What power he attributes to one
ships, social institutions, economic considerations, caring relationship that meets only 1 hour per week!
and political power, to name just a few, routinely We are asked to believe that one special relationship
exert more influence on selfhood than person- alone is powerful enough to overcome the crippling
centered therapists care to admit. effects of the conditional relationships that character-
Rogers’s preoccupation with selfhood, individ- ize our past and present lives.
uation, and self-actualization is culture specific. His Rogers’s overemphasis on relationship quali-
position both reflects and reinforces the high value ties encourages the fantasy that an effective psy-
that Western culture places on individualism chotherapist merely feels and relates without
(Usher, 1989). Not all cultures share this emphasis knowing much. His system suggests that anyone
on “self.” In at least one culture, the term for “self” who is congruent, whether a peer counselor or a
does not even exist (Pervin, 1993). Rogers’s charac- paraprofessional, can do effective psychotherapy
terization of the ideal individual does not apply with all patients and problems, without pos-
across cultures. Some ethnic groups favor an exter- sessing knowledge about personality or psycho-
nal (not internal) locus of evaluation and function pathology. Knowledge in Rogers’s system is of
quite well. Person-centered therapists may be com- little consequence; it certainly is not a necessary
paratively nondirective in the content addressed in condition for effective therapy. Yet one wonders
therapy, but the underlying values are anything but if it is sheer coincidence that master psychothera-
nondirective. The value on separateness and auton- pists, such as Freud, Adler, May, and Rogers
omy over interdependence and connectedness himself, have all been individuals with intense
reflects a Western (and masculine) perspective. intellectual commitments as well as an enormous
Unlike Rogers, feminists insist it is not enough capacity for caring.
for a woman to alter her self-perception. “To imply Finally, Rogers embodied unitary formulations
that such an internal change would eliminate all and singular treatments for all clinical encounters
cultural, economic, legal, and interpersonal obsta- (Norcross & Beutler, 1997). All clients suffer from
cles to a woman’s physical and psychological actu- the same essential problem of conditions of worth,
alization is absurd” (Lerman, 1992, p. 15). Vigorous and all require the identical treatment. For his
group advocacy, not gradual individual change, will avowed interest in an individualistic psychology,
better solve most of the contemporary problems Rogers rarely managed to individualize his therapy
plaguing women and minorities. to fit the particular client! Some patients thrive on a
comparatively passive and unstructured form of
From an Integrative Perspective psychotherapy, such as person-centered therapy,
We praise Rogers for his outstanding contributions but other people do not. Instead, they require direc-
to psychotherapy research and to articulating what tive therapy and await active advice. History taking,
constitutes a therapeutic relationship. The problem confronting, teaching, interpreting, directing, and
is, however, that he has gone too far and concluded advising are all essential clinical activities in treat-
that what may be necessary conditions for therapy to ing some clients with some problems. In these
proceed are also sufficient conditions for therapy to situations, person-centered therapy is contraindi-
succeed. His promise of facilitative therapist qualities cated at best, poor practice at worst.

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138 Chapter 5

A Person-Centered Analysis of Mrs. C


Mrs. C was raised in an extremely rigid atmo- love me only if I stop washing; I can love myself
sphere in which her parents’ conditions of worth only if I am clean and pure. I am in a trap where I
centered on her being clean, germ-free, asexual, gain their regard at the loss of my own, or hold
and meek. From her compulsive pattern of exis- onto what little self-worth I have by continuing to
tence, we can imagine that her own internalized clean and risk losing the few people who have
conditions of worth are just as rigid as those of any regard left for me. Suicide seems like the
her parents. The only experiences she lets herself only alternative in this no-win situation.”
possess are those in which she is obsessed with Is Mrs. C’s view just the distorted perception of
proving how clean and disease-free she is. a troubled person? Do we not cast aside the dirty
In her early years of marriage, Mrs. C had felt and the diseased? In our society, in which every
loved and regarded highly enough to be more major religious group values cleanliness more
flexible and better adjusted. Just what went than mature love (Rokeach, 1970), should we be
wrong is open to speculation. Her family was surprised that some people, like Mrs. C, base their
struck with a severe flu, and then the possibility existence on distorted social values and sacrifice
of a pinworm epidemic might have threatened their own organismic experiencing? Mrs. C is a
her self-regard by confronting her with not having tragic prototype of a culture so enamored with
been clean enough and careful enough with her social values such as cleanliness as to be
family. At a more central level, she may have estranged from organismic values like love.
been threatened by a subception that she could Mrs. C’s family and therapist have indeed made
not really love her children when they were sick their caring as rigidly conditional as she has. They
or dirty. Mrs. C may well have been experiencing say, “Don’t wash and we will care about you”; she
the rigid limits of her love in relationship to her says, “Only when I wash can I care about myself.”
sick children and may have been threatened by An effective psychotherapist must establish a rela-
doubts about the kind of mother she was if she tionship in which Mrs. C is held in high regard
could not really love her children when they when she washes as well as when she doesn’t,
needed her the most. But she had internalized when she talks about washing as well as when
her parents’ lessons: love is contingent on clean- she doesn’t. When we appreciate that we are talk-
liness, love is too scarce to waste on the dirty or ing with a woman who is obsessed with maintain-
the diseased. ing the little self-regard she has left, we will not
Although we do not know the exact experi- demand that she give up her one remaining source
ences that were threatening to emerge into of esteem—her washing.
awareness, we do form the impression of a per- First, Mrs. C needs to experience the positive
son who panicked, who was confronted with regard of those who care, whether she washes
intense and undeniable experiences of being or not, whether she is obsessed or not. Then,
unlovable. Mrs. C’s life became disorganized as and only then, can she begin to understand that
she struggled to hold onto what little self-regard being positively regarded is not contingent on
she could maintain by organizing her life around either washing or not washing. Only then can
washing and avoiding germs. If we empathize she begin to gradually become a little freer to
with the communications contained in her symp- consider that maybe she, too, can love herself
toms, we may hear how desperately she cries out, whether she washes or does not wash.
“I am worthy. I am lovable. Look how clean I am. I Caring is the fundamental issue, not cleaning.
am not diseased. Don’t send me away. I will make Mrs. C has been providing unconditional clean-
myself more lovable, more worthy of your regard. ing, cleaning whether it is warranted or not,
I will work harder, be cleaner.” when what she really wants is unconditional car-
If she could express her genuine feelings, she ing, caring whether she at this moment warrants
might go on: “My therapist and my family can it or not.

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Person-Centered Therapies 139

Future Directions psychotherapy. There need be no inherent conflict


between relationship and technique as long as the
As with Adler and the existentialists, Rogers’s
experience of the client remains the continuous
major contributions have been gratefully incor-
touchstone for what is introduced by the
porated by most practitioners whose preferred
therapist.
orientations are not Rogerian. Person-centered
Many clinicians make a crucial distinction
values and methods have become part of the
between the primary relationship conditions
therapeutic mainstream and assimilated into cog-
and the specialized therapist interventions that
nitive, self-psychology, feminist, experiential, and
are indicated by certain client markers (Rice,
constructivist therapies. Rogers’s lasting influ-
1988). These markers represent an expressed or
ences include the centrality of accurate empathy,
inferred readiness for specific change tasks.
the importance of the person of the therapist, the
Direct feedback, for instance, is particularly use-
primacy of the relationship over technique, and
ful when a therapist picks up discrepant messages
the healing power of the therapeutic relationship.
from the client. Offered in an accepting relational
No wonder that, in national surveys of mental
context, even feedback or confrontation can be
health professionals, Carl Rogers is routinely
an extension of accurate empathy (Norcross &
identified as one of the most influential psy-
Beutler, 1997; Sachse, 1990). Homework tasks
chotherapists in history.
outside the session can be mutually designed
Person-centered therapists can point with
when a client expresses a desire to implement
pride to the infusion of its principles into most
specific actions outside of the therapeutic rela-
systems of psychotherapy, but at the same time,
tionship. By selecting those interventions missing
this widespread assimilation has contributed to its
in client-centered therapy, therapists could have
slow decline in popularity (Lietaer, 1990). As a
the best of both worlds—the relationship and the
distinct, 70-year-old system, person-centered ther-
technique.
apy is definitely on the wane in the United States
Motivational interviewing has brought energy
(although it is more popular on the European
to person-centered therapy and kept it alive in
continent).
new clothes. If you calculate the number of journal
In the past, person-centered therapy’s historical
articles or professional books in psychotherapy,
strictures against authority, teaching, and telling
you will see the rapid interest in MI starting in the
have made clinicians hesitant to experiment with
mid-1990s. MI has taken by storm not only the
means to accelerate the therapeutic process. As
addictions field, but also health care generally by
Arthur Combs (1988, p. 270), a respected person-
helping clinicians prepare ambivalent people for
centered psychologist, humorously observed, “Any-
change. Decidedly brief and demonstrably effec-
one who has watched a group of person-centered
tive for a multitude of disorders, MI has redirected
counselors decide where to go on a picnic must
our attention back to the curative powers of client
surely have asked themselves whether there are
autonomy and therapist empathy.
not speedier ways of reaching good decisions.” In
Empathy as a core of psychotherapy may be
the present, many practitioners of person-centered
making a comeback (Bohart & Greenberg, 1997).
therapy argue for augmenting its process focus with
As clients tire of technical interventions delivered
specific, evidence-based methods from other orien-
in a few sessions by a hurried practitioner “man-
tations (Bohart, 1993b; Tausch, 1990). Facilitative
aged” by an insurance carrier, they may hunger
therapist qualities can be profitably integrated
for a real human relationship, a genuine meeting
with specific techniques from other systems of

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140 Chapter 5

of two individuals. As therapists reacquaint them- incongruence process research


selves with the relational world of their clients, motivational Project MATCH
they may discover an empathic perspective sur- discrepancy reflection (of feelings)
prisingly similar to that of Rogers, as has been motivational roll with resistance
experienced in relational psychoanalysis, self- interviewing (MI) self-authority
psychology, multicultural counseling, cognitive necessary and self-concept
therapy, and yes, even in behavior therapy (Gold- sufficient conditions self-regard
fried & Davison, 1994). Researchers too may nondirective therapy subception
return to the compelling awareness that psycho- organismic valuing unconditional positive
therapy is most fruitfully conceived and studied as person-centered regard
a human relationship, rather than as a technical approach
enterprise.
Person-centered therapies will appeal to new
generations of helpers. Patient-centered training Recommended Readings
for medical professionals, especially physicians Arkowitz, H., Westra, H. A., Miller, W. R., &
and nurses, should thrive in a consumer-oriented Rollnick, S. (Eds.). (2008). Motivational inter-
and holistic health care system. Executive coaches, viewing in the treatment of psychological problems.
wellness practitioners, and paraprofessionals will New York: Guilford.
rely on the core Rogerian skills of accurate empa- Cooper, M., O’Hara, M., Schmid, P. F., & Wyatt,
thy, positive regard, and congruence in their daily G. (Eds.). (2007). Handbook of person-centered
work. Perhaps most importantly, person-centered psychotherapy and counselling. Hampshire,
therapies will need to maintain an openness to England: Palgrave Macmillan.
new theoretical ideas and to active, eclectic meth- Farber, B. A., Brink, D. C., & Raskin, P. M. (Eds.).
ods in the era of short-term treatments. This (1998). The psychotherapy of Carl Rogers: Cases
openness is exactly what Rogers’s own life demon- and commentary. New York: Guilford.
strated and what his later writings (1986, p. 259) Miller, W. R., & Rollnick, S. (2012). Motivational
implored: “Open new vistas, bring new insights, interviewing (3rd ed.). New York: Guilford.
challenge our hypotheses, enrich our theory, Rogers, C. R. (1951). Client-centered therapy.
expand our knowledge, and involve us more Boston: Houghton Mifflin.
deeply in an understanding of the phenomena of Rogers, C. R. (1961). On becoming a person.
human change.” Boston: Houghton Mifflin.
Rogers, C. R. (1980). A way of being. Boston:
Key Terms Houghton Mifflin.
actualization dissemination and Schneider, K., Bugental, J. F. T., & Pierson, J. F.
actualizing tendency implementation (Eds.). (2002). The handbook of humanistic
allegiance effect empathy psychology. Thousand Oaks, CA: Sage.
autonomy existential living JOURNALS: Journal of Humanistic Education and
client markers fully functioning Development; Journal of Humanistic Psychology;
client-centered therapy person Journal of Phenomenological Psychology; Person-
conditions of worth genuineness Centered Journal; Person-Centered & Experiential
counterresistance heteronomy Psychotherapies.

Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
Person-Centered Therapies 141

Recommended Websites Motivational Interviewing:


www.motivationalinterview.org/
Association for Humanistic Psychology:
World Association for Person-Centered
www.ahpweb.org/
Psychotherapy:
Association for the Development of the Person-
www.pce-world.org/
Centered Approach:
www.adpca.org/
Center for Studies of the Person:
www.centerfortheperson.org/

Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
CHAPTER 6
Experiential Therapies

National Library of Medicine


Fritz Perls

As long as sex was going well for Howard, all was


well with the world. From ages 17 to 27, he had been
very active sexually, with most of his time and
energy spent in erotic adventures or in fantasizing
about such adventures. Sexual relating was by far the
most significant and satisfying activity in his life. No
wonder he was so puzzled at the onset of his erectile
dysfunction. Except for his first experience with a
prostitute at age 17, he had never had any Courtesy of Dr. Leslie Greenberg

difficulty performing in bed. In fact, Howard loved


to perform and prided himself on what a great lover
he was. But now, no matter how hard he tried, he
just could not succeed. Needless to say, he was quite
Leslie Greenberg
depressed and anxious.
Fortunately, Howard had a special partner other’s bodies (but not genitalia or breasts). The
named Ginny, for whom he cared deeply. She results were discouraging because of the amount
wanted to be with him sexually in spite of his of depression and anxiety Howard experienced in
impotence, and was willing to join him in sex the nondemanding, pleasuring exercises. Because
therapy. We began psychotherapy with the his erections remained inhibited when he was with
standard, Masters and Johnson (1970) method of Ginny, we decided to try systematic desensitization
sensate focusing, a series of couples exercises used and then come back to sensate focusing. Although
to alleviate anxiety related to intercourse in which Howard progressed to the point of imagining
partners take turns exploring and massaging each intercourse without anxiety, he did not show

142

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Experiential Therapies 143

much generalization to the actual sensate-focusing his professional career doing psychoanalysis with
situation. a few select clients.
Finally, I (JOP) decided to use some Gestalt As an aware individual, he anticipated the
work to help Howard discover the significance of horrors of Hitler, and in 1934, when Ernst Jones
the intense, relentless pressure on his sexual drive. announced a psychoanalytic position in Johan-
I asked Howard to imagine as vividly as he could nesburg, South Africa, Perls accepted. Besides
that he was his penis and that his penis had establishing a practice, he also began the South Afri-
something to say. As he got into the fantasy, can Institute for Psychoanalysis. Over the next dozen
I encouraged him to let the mouth of his penis years, he developed what he initially considered a
say whatever it spontaneously desired, and here is revision and elaboration of psychoanalysis. In 1947
what came out: “You’re asking too much of me, he published his first book, Ego, Hunger and Aggres-
Howard. You’ve been asking me to carry the sion: A Revision of Freud’s Theory and Method. At
whole meaning of your life on my back, and that time Perls was still committed to an instinct
that’s just too big a load for any one penis to theory but argued for the acceptance of hunger as
carry. I’m bound to bend under such weight.” an instinct as critical to the survival of the individual
Such direct experiential work on a client’s as the sexual instinct is to the survival of the species.
emotions is the sine qua non of the broad class In the face of the many revisions that Perls was sug-
of treatments known as the experiential gesting for psychoanalysis, it became obvious that he
therapies. Gestalt therapy emerged first and most was really beginning a new psychotherapy system.
prominently, so we devote the first part of this When he republished his first book in 1969 he
chapter to it. We then review a few other subtitled it The Beginning of Gestalt Therapy.
therapies in the experiential tradition, principally With the rise of apartheid in South Africa,
the influential emotion-focused therapy of Leslie Perls again chose to leave a country heading
Greenberg and colleagues. toward unacceptable oppression. He emigrated to
the United States in 1946, and with his therapist
wife, Laura, began the New York Institute for
A Sketch of Fritz Perls Gestalt Therapy. There, Perls was probably influ-
Frederich (Fritz) Perls (1893–1970) was the enced by Jacob Moreno, the psychiatrist who
developer of Gestalt therapy and the master of founded psychodrama and who insisted on com-
using Gestalt work to assist people to become bining action with the mentalistic talk of psycho-
deeply aware of themselves and their bodies. therapy. In 1951, Perls coauthored Gestalt
Perls did not start out with such an action- Therapy: Excitement and Growth in the Human
oriented approach, however. Like so many pro- Personality, an exciting and engaging presentation
creators of psychotherapy systems, his early of Gestalt exercises.
career was heavily influenced by his studies of As a person, Perls was similar to his writings:
psychoanalysis with Freud. After receiving his vital and perplexing. It was probably his many
MD in Berlin, where he was born, he studied at workshops with clinicians more than his writings
the Berlin and the Vienna Institutes of Psycho- that had such an impact on the psychotherapy
analysis. He was analyzed by Wilhelm Reich, who profession. People saw him as keenly perceptive,
had a profound influence on his development. provocative, manipulative, evocative, hostile, and
Perls (1969b) said that if it had not been for the inspiring. Indeed, it is difficult to separate Perls’s
advent of Hitler, he probably would have spent personality from his method. Many professionals

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144 Chapter 6

came away from an encounter with Perls feeling based on our biological needs, which are limited to
more alive and complete. Those who went out to hunger, sex, survival, shelter, and breathing. The
spread the Gestalt gospel talked affectionately and social roles we adopt are the means-whereby we
almost worshipfully of Fritz. He certainly did not fulfill our end-goals. Our role of psychotherapist,
discourage such a cult. Believing that modesty is for instance, is a means-whereby we earn a living,
for modest people, Perls (1969b) wrote in his auto- which is a means-whereby we fulfill such end-
biography, “I believe that I am the best therapist for goals as hunger and shelter. As healthy beings,
any type of neurosis in the States, maybe in the our daily living centers around the particular
world. How is this for megalomania. At the same end-goals that are emerging into awareness in
time I have to admit that I cannot work successfully order to be fulfilled. If we listen to our body, the
with everybody.” most urgent end-goal emerges, and we respond to
Such unabashed egotism was fashionable in it as an emergency—that is, without any obsessive
the 1960s, and many people flocked to Esalen in doubt that the most important action we can take
Big Sur, California, where Perls held court. If it at this moment is to fulfill the particular end-goal
was uniqueness, honesty, and spontaneity they emerging into awareness. We then interact with
sought in Fritz, they were not disappointed; if it the environment to select the substances we need
was a grandfatherly positive regard they desired, to satisfy that end-goal.
they were frustrated. As a result of his personal End-goals are experienced as pressing needs
impact and his professional writings, the Gestalt as long as they are not completed; they are quies-
movement became a significant force in the last cent once they are given closure through an
decade of Perls’s life. He wanted to close out his adequate exchange with the environment. If we
life by building a Gestalt Training Center and are thirsty, for example, we experience a need to
Community in British Columbia, so he moved bring completeness to our thirst by responding to
there just before his death in 1970. our need with an adequate supply of water from
With Fritz’s death, Gestalt therapists lost their our environment. It is this continual process of
touchstone of just what Gestalt therapy can and bringing completeness to our needs, the process
should be. As one would expect from such a of forming wholes or Gestalts, that Perls posits
dynamic and spontaneous force as Fritz, there as the one constant law of the world that main-
were many changes in his approach over the tains the integrity of organisms.
years. Consistency was not one of his strengths. The serious concerns in living, then, lie in the
Most Gestaltists, however, point to the 1969 pub- completion of these organismic needs, as is well
lication of Gestalt Therapy Verbatim as the best known by the millions of starving poor in the
representation of Perls’s nature to Gestalt theory world. In a spoiled society such as the United States,
and therapy, and so that book serves as the main we spend little of our time or energy in completing
source for our presentation. our natural needs. Instead we preoccupy ourselves
with social games that are nothing more than social
means to natural ends. Once we experience these
Theory of Personality social means as end-goals, we identify with them
In spite of the centuries-old wish to disown our as essential parts of our ego, so that we act as if
bodies, we humans must accept that we are we must put almost all our energy into playing
basically biological organisms. Our daily goals, or roles such as student, teacher, or therapist. Much
end-goals as Perls (1969a) prefers to call them, are of our thinking is involved with practicing how we

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Experiential Therapies 145

can better act out our roles to more effectively able to respond for themselves, and the matura-
manipulate our social environment and convince tion process includes shedding responsibility for
ourselves and others of the inherent value of our anyone else. We give up our childish feelings of
roles. As we repeatedly practice our roles, they omnipotence and omniscience and accept that
become habits—rigid behavioral patterns that rep- others know themselves better than we can ever
resent the essence of our character. Once we know them and can direct their own lives better
develop our social character and have a fixed per- than we can direct them. We allow others to be
sonality, we have transformed our basic natural self-supporting, and we give up our need to inter-
existence into a pseudosocial existence. fere in the lives of others. Others do not exist to
In a healthy natural existence, our daily life cycle live up to our expectations, nor do we exist to live
would be an open, flowing process of organismic up to theirs.
needs emerging into awareness. This process The healthy personality does not become pre-
would be accompanied by a means-whereby we occupied with social roles. They are nothing more
bring closure to the most pressing need of the than a set of social expectations that we and others
moment, followed by the emergence of another set for ourselves. The mature person does not
end-goal into awareness. As long as we remain cen- adjust to society, certainly not to an insane society
tered on what is occurring within us right now, we such as ours. Healthy individuals do not repeat the
can trust our organic wisdom to select the best same old, tired habits that are so safe and so
means-whereby we complete the most pressing deadly. In taking responsibility for being all that
need of the moment. they can be, such people accept Perls’s attitude of
In a healthy existence, our entire life cycle living and reviewing every second afresh. They
involves a natural process of maturation in discover that there are always new and fresh
which we develop from children dependent on means-whereby they can complete their end-
environmental support into adults who rely on goals. This freshness is what the creative cook dis-
self-support. Our development begins as unborn covers, what the joyful sex partner experiences,
children entirely dependent on our mothers for and what the vital therapist thrives on.
support—for food, oxygen, shelter, everything. With these attractive possibilities emerging
As soon as we are born, we have to do our own from the natural process of maturation, how is it
breathing at least. Gradually we learn to crawl, to that most people remain stuck in the immature,
stand on our own two feet, to walk, to use our own childish patterns of dependency? Several child-
muscles, our senses, our wit. Eventually we have to hood experiences can interfere with the develop-
accept that wherever we go, whatever we do, what- ment of a healthy personality. In some families,
ever we experience is our own responsibility and parents withdraw needed environmental support
only ours. As healthy adults, we are aware that we before children have developed the capacity for
possess the ability to respond, and to have inner support. The child can no longer rely on
thoughts, reactions, and emotions that are the safe, secure environmental support, nor can
uniquely ours. This mature responsibility is fun- the child rely on self-support. The child is at an
damentally the ability to be what one is. For Perls impasse. Perls’s (1970) example of an impasse is a
(1969a), “responsibility means simply to be willing “blue baby” who has had the placenta severed and
to say ‘I am I’ and ‘I am what I am.’ ” cannot rely on oxygen from the mother but is not
As healthy adults, we are simultaneously yet prepared to breathe on its own—a very scary
aware that other maturing organisms are equally situation. Another example of an impasse occurs

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146 Chapter 6

when parents demand that a child stand without Many parents are also afraid to frustrate their
support before the child’s muscles and balance are children; yet it is only through frustration that we
adequately developed. All the child can experience are motivated to rely on our own resources to
is the fear of falling. Experiencing impasses can overcome what is frustrating us. By giving too
result in becoming stuck in the maturation much and not frustrating enough, parents estab-
process. lish an environment that is so secure and satisfy-
A more frequent source of interference comes ing that the children become stuck in desiring to
from parents who are convinced that they know maintain constant environmental support. Perls’s
what is best for their children in all situations. In emphasis on being stuck by being spoiled is remi-
such families, children may fear “the stick,” which niscent of Freud’s emphasis on overindulgence as
is punishment for trusting their independent one source of infantile fixations.
direction when it differs from what the parents Perls does not blame the parents, however,
believe is best. The child develops catastrophic for the spoiled child’s remaining stuck. These
expectations for independent behavior, such as children are still responsible for using all of
“If I take the risk on my own, I won’t be loved their resources to manipulate the parents and
anymore or my parents won’t approve of me.” others in the environment to take care of them.
Perls (1969a) suggests that catastrophic expecta- These children develop a whole repertoire of
tions are frequently projections onto the parents manipulations, such as crying, if that is what it
of the child’s own fears of the consequences of takes to get support, or being the nice little child,
independence, rather than memories of how par- if that is the role that gets others to respond. To
ents actually responded. allow immature personalities to blame their par-
As we become more aware, we realize that ents for their problems is to allow them to avoid
marching to a different drummer can indeed be responsibility for their lives, which is a critical
risky. If we act differently from our parents or part of the maturation process.
peers, we may risk losing their love or approval.
But they are not responsible if we choose to avoid
the risks of being our own person. There are even Theory of Psychopathology
more serious risks in our society if we refuse to The pathological person has become stuck in the
play roles or to adjust to social expectations. We natural process of growth or maturation. Accord-
can lose jobs, friends, money, and even face cruci- ingly, Perls preferred the term growth disorders
fixion for being outside the boundaries of society. rather than neuroses to refer to the common pro-
But we still cannot blame society if we refuse to blems in living, although he frequently relied on
take the risks of being healthy. the more traditional term neurosis when talking
Fear of repercussions for independent behav- about psychopathology.
ior is a major cause of maturational delays, but it For Perls (1970), there are five different layers or
is not the most common. More people get stuck levels of psychopathology: (1) the phony, (2) the
because they have been spoiled by parents who phobic, (3) the impasse, (4) the implosive, and
overindulged them as children. Perls believes (5) the explosive. The phony layer is the level of exis-
that too many parents want to give their children tence in which we play games and enact roles. At this
everything they never had. As a result, the chil- level, we behave as if we are big shots, as if we are
dren prefer to remain spoiled and let their parents ignorant, as if we are demure ladies, as if we are he-
do everything for them. men. Our as-if attitudes require that we live up to a

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Experiential Therapies 147

concept, live up to a fantasy that we or others have In the process, we create our phony
created, whether it comes out as a curse or an ideal. characters—phony because they represent only
We may think it is an ideal to act as if we were Jesus, half of who we are. If the character we construct
for example, but Perls would see it as a curse, because is mean and demanding, for instance, then we can
it is still an attempt to get away from who we really be sure that below the surface is the opposite
are. The result is that neurotic people have given up polarity of wanting to be kind and yielding. Our
living in a way in which they can actualize them- phony characters attempt to shield us from the
selves; they live to actualize a concept. Perls (1970) fact that authentic existence involves, for each
compares such pathology to an elephant that would individual, facing personal polarities (Polster &
rather be a rosebush and a rosebush that tries to be Polster, 1973). We may rigidly adhere to being
a kangaroo. pious and saintly to keep from experiencing our
What we create in place of our authentic selves opposite desires to be devilish and sexual. The
is a fantasy life that Perls (1969a) calls maya, from healthy person attempts to find wholeness by
the Hindu for illusion. Maya is part of the phony accepting and expressing the opposite poles of
level of existence that we construct between our real life. Pathological individuals attempt to hide unac-
selves and the real world, but we live as if our maya ceptable opposites by pretending that their lives
is reality. Our maya serves a defensive purpose, are composed entirely of their phony characters.
because it protects us from the threatening aspects Perls called the most famous Gestalt polarities
of ourselves or our world, such as the possibility Top Dog and Under Dog. We experience Top
of rejection. Much of our mental life is involved Dog as our conscience, the righteous part of us
with making us better prepared to live in maya. that insists on always being right. Top Dog
Thinking, for example, is rehearsal for acting, for attempts to be master by commanding, demand-
role-playing. This is one reason that Perls says he ing, insisting, and scolding. Under Dog is the slav-
disesteems thinking. We become so preoccupied ish part of us that appears to go along with the
with our concepts, our ideals, and our rehearsals bullying demands of Top Dog’s ideals but in fact
that soon we no longer have any sense of our real controls through passive resistance. Under Dog is
nature. In maya, things are not as they seem. the part of us that acts stupid, lazy, or inept as a
In the struggle to be something we are not, we means of trying to keep from successfully com-
disown those aspects of ourselves that may lead to pleting the orders of Top Dog.
disapproval or rejection. If our eyes cause us to sin, Polarities are much more general and inclusive
we cast out our eyes. If our genitals make us than Top Dog and Under Dog. Our psychological
human, we disown our genitals. We become alien- lives are dominated by polarities, be it connection/
ated from properties of ourselves that we and sig- separation or strength/vulnerability. In health, we
nificant others frown on, and we create the holes, creatively balance and continually recalibrate these
the void, where something should exist. Where polarities. But in neurosis, we keep one aspect out
the voids are, we build up phony artifacts. If we of awareness, and as a result, polarities lose their
disown our genitals, for example, then we can act fluidity and become hardened into dichotomies. As
as if we are by nature pious and saintly. We try to long as people avoid accepting that they are also the
create the characteristics that are demanded by opposite of what they pretend to be—that they are
our society for approval and that are eventually strong as well as weak, cruel as well as kind, and
demanded by the part of ourselves that Freud master as well as slave—they are unable to com-
called the superego. plete the Gestalt of life.

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148 Chapter 6

To try to face all that we are, to try to be character that seems safe and secure but oh, so
whole, leads us to confront the phobic layer of dead. To go through the implosive level, the person
our pathology. At this layer, we are phobic about must be willing to shed the very character that has
the pain that ensues from facing how dissatisfied served as a sense of identity. The person is threat-
we are with parts of ourselves. We avoid and run ened with experiencing his or her own death in
from emotional pain, even though such pain is a order to be reborn. That is obviously not easy.
natural signal that something is wrong and needs To let go of one’s roles, one’s habits, and one’s
to change. The phobic layer includes all of our very character is to release tremendous energy that
childish catastrophic expectations—that if we con- has been invested in holding back from being a
front who we really are, our parents will not love responsible and fully alive human being. The per-
us, or if we act the way we want to act, society will son is now confronted with the explosive layer of
ostracize us, and so forth. These phobic responses neurosis, which entails an emancipation of life’s
frequently help us avoid what is really hurting; energies. The size of the explosion depends on
thus, most people come to therapy not to be the amount of energy bound up in the implosive
cured but to have their neuroses improved. layer. To become fully alive, the person must
Below the phobic layer is the most critical explode into orgasm, into anger, into grief, and
level of psychopathology: the impasse. The into joy. With such explosions, the neurotic has
impasse is the very point at which we are stuck moved well beyond the impasse and the implosive
in our own maturation. It is what the Russians call and has taken a giant stride into the joy and sor-
the sick point. The impasse is the point at which row of maturity.
we are convinced that we have no chance of sur-
vival because we cannot find the means within
ourselves to progress when environmental support Therapeutic Processes
is withdrawn. People will not move beyond this Explosively breaking out of a neurotic life is an
point because of terrors that they might die or exciting, cathartic experience. The powerful release
fall apart because they cannot stand on their of the emotions of anger, orgasm, joy, and grief
own feet. But neurotics also refuse to move promises to bring a profound sense of wholeness
beyond this point because it is still easier for and humanness. That’s why so many people sought
them to manipulate and control their environ- out Fritz Perls as he traveled throughout the coun-
ment for support. So they continue to play help- try. But Perls quickly let people know that cathartic
less, stupid, crazy, or enraged to get others to take explosions could be attained only after increasing
care of them, including their therapists. their consciousness of the phony games and roles
To experience the implosive layer is to experi- they play and of the parts of themselves they dis-
ence deadness, the deadness of parts of ourselves own. Patients need to become aware of how they
that we have disowned. Neurotics would experience are stuck in childish fantasies, of how they try to be
the deadness of their ears, or their heart, or their something they are not.
genitals, or their very soul, depending on what fun-
damental processes of living they have run from. Consciousness Raising
Perls (1970) compares the implosive layer to a Consciousness raising in Gestalt therapy aims to lib-
state of catatonia, in which the person is frozen erate people from maya, from the phony, fantasy
like a corpse. The catatonia is due to the investment layer of existence. Because maya is an illusory mental
of energy in the development of a rigid, habitual world, a world of concepts, fantasies, and intellectual

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Experiential Therapies 149

rehearsals, Perls says the way for us to become free and dramatically repeat a nonverbal behavior,
from maya is to “lose our mind and come to our such as a kicking leg or an anxious smile.
senses.” This loss of mind is actually a radical change As clients participate in the Gestalt exercises,
in consciousness from future-oriented thinking and they become more deeply aware of their phobic
theorizing to a present-oriented sensory awareness. layer, of what they run from in the here and now
At this phenomenological level of consciousness, we and the catastrophic expectations that they use as
sense the reality of ourselves and the world rather excuses to run. For example, they may feel
than only theorizing how things are supposed to be. extremely angry at the therapist for not being sup-
We can have an experience of satori, or waking up. portive but refuse to express their anger for fear the
Suddenly the world is there again, right in front of therapist may want nothing more to do with them.
our eyes. We wake up from an intellectual trance as The clients may then be asked to own the projec-
we wake up from a dream. And with our senses, we tion of rejection and to role-play who is actually
are again in touch with all that we are. threatening to reject them, such as their parents or
their conscience. At each step in the exercises, cli-
The Client’s Work
ents do not merely talk about what is entering their
The client’s work sounds quite simple—to stay in
awareness. Clients are asked to express their con-
the here and now. Awareness of the moment
scious experiences in action—for example, by taking
allows clients to work on the healthy Gestalt prin-
the chair that represents their parents or their Top
ciple: The most important unfinished situation
Dog and expressing exactly what that person would
will always emerge into consciousness and can
say. Through such active expression, they become
be resolved. But clients soon discover that staying
more profoundly aware of what is interfering with
in the here and now is not so simple. As soon as
their ability to exist in the here and now.
clients enter the hot seat, indicating that they are
ready to be the focus of the Gestalt therapist, they The Therapist’s Work
can be expected to reenact the phony layer of their The therapist’s work in consciousness raising is,
neurosis. Some clients will play the helpless role, first and foremost, to frustrate the patient. More
unable to proceed without more encouragement precisely, therapists frustrate the client’s desires to
or direction from the therapist; others will play be protected and to be shielded from unpleasant
stupid, unable to understand just what the thera- emotions and the client’s efforts to deny responsi-
pist means; others will strive to be the “perfect bilities for choices. Frustration itself is a by-
patient” with their Top Dog insisting that they product of the Gestalt interaction that provokes
should do just what is expected of them. something the patient is attempting to avoid.
Patients will then be asked to participate in Attempts to manipulate the therapist into taking
Gestalt exercises designed to help them become responsibility for the client’s well-being must be
more aware of their phony roles or games. These blocked, producing frustration. If the therapist is
exercises are not ends in themselves; they are committed to “helping” the client, the therapist
employed as a method to prevent avoidance of is lost from the start. Such a helping attitude is
conflicting emotions. In the Top Dog/Under Dog paternalistic, and the client will probably make
exercise, for example, the client sits in one chair as the therapist feel inadequate as compensation for
Top Dog shouting out the “shoulds” at Under needing the therapist.
Dog, then switches to Under Dog’s chair to give Early in treatment, the Gestalt therapist
all of the excuses for not being perfect. Or the instructs clients on just how responsible they are
patient may be asked to become more aware of for what they do in therapy. Perls (1969a, p. 79)

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150 Chapter 6

used the following instructions in beginning a If clients continue to drift back into resentment
workshop: of the past by blaming their parents, for example, the
Gestalt therapist may employ an empty-chair tech-
So if you want to go crazy, commit suicide,
nique. Here clients are asked to imagine that the
improve, get “turned-on,” or get an experience
parent is present in the empty chair, and they are
that will change your life, that’s up to you. I
now free to express to the parent what they always
do my thing and you do your thing. Anybody
held back from saying. Such expression in the pres-
who does not want to take the responsibility
ent of unfinished resentments allow clients to bring
for this, please do not attend this seminar. You
closure to their blaming game with their parents.
come here out of your own free will, I don’t
Although exercises cannot be predetermined,
know how grown up you are, but the essence
the Gestalt therapist does have a wealth of exer-
of a grown-up person is to be able to take
cises that can be called on to enhance awareness.
responsibility for himself—his thoughts, feelings,
In Gestalt Therapy (Perls et al., 1951), various
and so on. Any objections? … OK.
exercises are systematically presented so that read-
And he begins. ers can experience their own blocks of awareness.
Gestalt therapists are aware that such instruc- Theoretically, the types of exercises are limited
tions alone will not keep clients from trying to only by the clinician’s creativity. In practice, how-
turn their lives over to mental health profes- ever, most Gestalt therapists seem to fall back on
sionals. Ultimately, the only way therapists can the classical exercises devised by Perls (1947,
keep from being manipulated is to be mature indi- 1969a; Perls et al., 1951). Levitsky and Perls
viduals who take responsibility for their own lives (1970) have articulated the most frequent Gestalt
and avoid responsibility for others. Mature indivi- exercises or games. The exercises most involved in
duals, be it clinicians or clients, have adequate consciousness raising include
inner support so that they are not dependent on
others’ liking or needing them, nor are they afraid • Games of dialogue, in which patients carry on
of colleagues’ condemning them. Perls (1969a) a dialogue between polarities of their person-
was not afraid to write, for example, that if a client ality, such as a repressed masculine polarity
rattled on in a meaningless monologue, he would confronting a dominant feminine polarity
take a snooze if he felt sleepy, even though such a • I take responsibility, in which clients are asked
response would be frowned on by traditional to end every statement about themselves with
therapists and clients alike. Such an honest “and I take responsibility for it”
response, however, would surely frustrate a client • Playing the projection, in which clients play
who was trying to make Perls responsible for mak- the role of the person involved in any of their
ing the session an exciting adventure. projections, such as playing their parents
Part of the Gestalt therapist’s responsibility is to when they blame their parents
be in the here and now just as clients are invited to be • Reversals, in which patients are to act out the
in the present. Being present-centered means that very opposite of the way they usually are in order
Gestalt therapists cannot use any predetermined pat- to experience some hidden polarity of themselves
tern of exercises. An exercise is selected because at • Rehearsals, in which patients reveal to the
that moment the Gestalt therapist believes it will group the thinking or rehearsal they most
facilitate clients’ awareness of what is keeping them commonly do in preparation for playing social
from remaining in the here and now. roles, including the role of patient

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Experiential Therapies 151

• May I feed you a sentence?, in which the Catharsis


therapist asks permission to repeat and try on As clients become increasingly aware of their
for size a statement about the patient that the phony games, as they become more aware of
therapist feels is particularly significant for their bodily resistances and phobic avoidance of
the patient the here and now, they are less likely to run
from themselves. The fear of being themselves,
Gestalt therapists do not interpret what clients
however, can bring them to an impasse. They
say while participating in Gestalt work. Interpre-
will want to communicate to the therapist that
tation is seen as a representation of the traditional
they are unable to continue on their own, that the
therapist’s maya—the therapist’s fantasy that the
therapist must take over for them or they will go
real meaning of a client and the client’s world can
crazy, panic, or terminate treatment. They try to
be found in a favorite theory rather than in the
convince the therapist that their catastrophic expec-
client’s present experience. It is just another form
tations are real and not just residual childhood
of one-upmanship. It is a way for therapists to
fantasies. By pressing ahead, Gestalt therapists
convince clients that they should listen to the
communicate through their actions that they
magnificent mind of the therapist rather than to
believe clients do indeed have the inner strength
their own senses. In practice, however, the use of
to continue on past the impasse into their areas
May I feed you a sentence? comes awfully close to
of deadness. Through sensitively selected exercises,
straight interpretations, although Gestaltists prefer
clients begin to reown those parts of their person-
to see this exercise as feedback in which the client
ality that were sacrificed in the name of roles and
is free to actively spit out the therapist’s message if
games. Clients can begin to release all of the emo-
it doesn’t fit.
tions that others will not love or approve of them if
Gestalt therapists raise clients’ consciousness
they are truly human.
by allowing the clients’ own eyes and ears to
serve as a source of feedback. Clients are already The Client’s Work
aware of the sentences they have spoken, so Cathartic releases require that clients take respon-
Gestalt therapists do not reflect their clients’ sibility for continuing in therapy when they most
words as would Rogerian therapists. Gestalt thera- want to run. The therapist will not try to talk them
pists are more attuned to clients’ nonverbal into staying in the hot seat if they feel it is getting
expressions—the quality of their voices, their pos- too hot; they can and often do leave before the
ture, and their movements. Gestalt therapists feed fireworks begin. If clients do stay in the hot seat,
back what they see or hear, especially what they they must be responsible for throwing themselves
see as bodily blocks to awareness. They ask clients into the suggested exercises and not playing
not only to attend to their nonverbal expressions, passively.
such as their arms folded across their chest, but If clients are prepared to take back and own
also to “become” their arms in order to express what has been dead within, then they must be
how they are tensing up the muscles to keep willing to participate in Gestalt dream work.
from opening up the feelings in their hearts. Dreams are used in Gestalt therapy because they
With the assistance of these action-oriented exer- represent a spontaneous part of personality.
cises, clients develop a deeper awareness that Dreams are the time and place in which people
emerges from the depths of their bodies rather can express all parts of themselves that have
than off the top of their heads. been disowned in the rat race to succeed at daily

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152 Chapter 6

roles. For dreams to be cathartic, clients cannot The empty-chair dialogue pioneered by Perls
just talk about their dreams; they must act them and systematized by his followers demonstrates
out. Clients are encouraged to “become” each the therapeutic value of dramatic relief followed
detail of a dream, no matter how insignificant it by a corrective emotional experiencing.
may seem, in order to give expression to the rich- The empty chair is used when emotional
ness of their personality. Only when we become as memories of other people trigger the reexperien-
rich and as spontaneous as our dreams can we be cing of unresolved emotional reactions: for exam-
healthy and whole again. ple, unfinished business with a dead parent or
At a time when I (JOP) was preoccupied with unavailable ex-spouse. The client is to express feel-
my academic promotion and tenure, I found ings fully to the imagined significant other, such
myself unable to experience any joy, not even as an alcoholic parent, in an empty chair. This act
the joy of sex. I sought the assistance of a friend helps remobilize the client’s suppressed needs and
who is a Gestalt therapist, and she asked me to give full expression to them, thereby empowering
conjure up a daydream rather than a dream. The the client to separate emotionally from the other.
daydream that emerged spontaneously was of ski- The critical components of the resolution of the
ing. She asked me to be the mountain, and I began unfinished business appear to be the arousal of
to experience how warm I was when I was at my intense emotions, the declaration of a need, and
base. As I got closer to my top, what looked so a shift in the view of the other person (Greenberg
beautiful was also very cold and frozen. She asked et al., 1994).
me to be the snow, and I expressed how hard and
icy I could be near the top. People tripped over me The Therapist’s Work
there and were unable to cut through me because Because catharsis in Gestalt therapy can be very dra-
of how hard I was. But near the bottom people ran matic, we can conceive of the therapist’s work as
over me easily and wore me out. When we fin- beginning with setting the stage for the event. The
ished, I did not feel like crying or shouting; I felt group waits with anticipation for someone to step
like skiing. So I went, leaving my articles and forward to fill the emotionally charged hot seat.
books behind. In the sparkle of the snow and the The therapist’s attention is then focused like a spot-
sun, I realized again what Goethe had suggested light on the client. The therapist suggests that the best
through Faust: Our joy in living emerges through scene for now is some particular exercise—let’s say,
deeds and not through words. In my rush to suc- dream work. The script is created mostly by the cli-
ceed, I was committing one of the cardinal sins ent, who decides which dream to act out. Once the
against myself—the sin of not being active. client enters the scene, the therapist is like a director
Because catharsis in Gestalt therapy occurs pri- who is prepared to help the client live, rather than just
marily as a result of clients’ expressing their inner play a part in, the dramatic exercise.
experiences, such as their dreams, we can talk about Like a good director, the Gestalt therapist
the process as a form of corrective emotional will observe carefully and listen for a process
experiencing. Gestalt therapy also entails dramatic diagnosis—the emergence of markers of particular
relief, inasmuch as it is often conducted in groups types of affective problems with which the client is
or workshops; the corrective emotional experiences currently struggling, such as splits between two
of the person on the hot seat serve as cathartic parts of the self (Greenberg, 1995). When a marker
releases for the people who are actively observing emerges, the therapist will suggest a specific in-
what is occurring there. session experiment or task to facilitate conflict

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Experiential Therapies 153

resolution. Although Perls was able to do much of Jane: (she screams it, a real blast) Leave me alone! I
this automatically, contemporary Gestalt therapists don’t have to do what you say! (still crying)
have tried to delineate specific markers for specific I don’t have to be that good! I don’t have to
in-session experiments. The emergence of splits is a be in this chair! I don’t have to. You make me.
marker for a two-chair dialogue, and a client You make me come here! (screams) Aarhh! You
expression of genuine vulnerability is a marker for make me pick my face (crying), that’s what you
empathic affirmation. do. (screams and cries) Aarhh! I’d like to
Gestalt therapists must also be aware of times kill you.
when clients are trying to avoid the pain and fear of Fritz: Say this again.
taking off their masks. Therapists try to block these
Jane: I’d like to kill you.
avoidances by providing feedback and directing the
client’s attention to avoidance maneuvers, such as Fritz: Again.
expressing important parts of a dream in a soft Jane: I’d like to kill you.
voice. If feedback alone does not produce change, Gestalt therapists also direct clients to change
then the Gestalt therapist will challenge clients to their lines toward a more emotional and responsible
put more of themselves into the exercises, like a direction, following the rule of using “I” language
famous director challenging actors to give their (Levitsky & Perls, 1970). Fritz Perls (1969a, p. 115)
best performance. Challenging clients to be more demonstrates this direction with Max.
intense is especially effective in our competitive
society, where people are so geared to meet any Max: I feel the tenseness in my stomach and in my
challenge. “OK, try it again with a fuller voice!” hands.
the Gestaltist might yell out. Such challenges also Fritz: The tenseness. Here we’ve got a noun. Now
communicate the therapist’s belief that clients do the tenseness is a noun. Now change the noun,
indeed have the inner resources to throw them- the thing, into a verb.
selves more fully into the work, even when they
Max: I am tense. My hands are tense.
are facing frightening or embarrassing scenes.
The Gestalt therapist can use other theater Fritz: Your hands are tense. They have nothing to
techniques to intensify the situation. Clients may do with you.
be challenged to use the repetition or exaggera- Max: I am tense.
tion game (Levitsky & Perls, 1970) until the true Fritz: You are tense. How are you tense? What are
affect is expressed. Exaggeration or repetition is you doing?
exemplified in the following excerpt from Perls Max: I am tensing myself.
(1969a, p. 293):
Fritz: That’s it.
Fritz: Now talk to your Top Dog! Stop nagging. An outstanding therapist like Perls is also able
Jane: (loud, pained) Leave me alone. to use comic relief to reduce tension and humor to
Fritz: Yah, again. release joy. An example of comic relief occurred
Jane: Leave me alone. with a client who was plagued by an incredible
inferiority complex. He felt uglier than everyone
Fritz: Again.
and more inadequate than anyone. After several
Jane: (screaming it and crying) Leave me alone! sessions of tense psychotherapy he said, “I hope
Fritz: Again. you don’t misunderstand this, but I’m beginning

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154 Chapter 6

to feel inferior to everyone but you.” I (JCN) spon- the future, we experience anxiety. If we are antic-
taneously responded, “That makes me feel real ipating future performances, such as exams,
good.” He laughed and I laughed and after awhile speeches, or therapy sessions, then our anxiety is
he said, “You don’t know how good it feels to say nothing more than stage fright. How will I per-
that to someone.” form on the exam? How will my speech go over?
The creative process in Gestalt therapy means What will I do with that difficult client? We can
the clinician will be an artist, not a scientist or a also experience anxious anticipation over won-
technician (Zinker, 1991). Fritz was admired for derful things that will happen: I just can’t wait
his artistic spontaneity, including his humor, for that vacation to come! Many people fill this
which emerged in his workshops. Perhaps it is in gap between the now and the future with all types
humor that it is most obvious that a Gestalt ther- of planned activities, repetitive jobs, and insur-
apist cannot predetermine the steps of effective ance policies to make the future predictable.
therapy. For humor to be effective, the therapist These people try to replace anxiety with the secu-
must be free to be spontaneous, to capture the rity of sameness, but in the process they lose the
moment in creative humor. richness of future possibilities. In a rapidly chang-
ing society, people clinging