How I Have Changed Over Time as a Psychotherapist

Stanley B. Messer
Rutgers University
Reflecting on my career as a psychotherapist has led me to consider 3 major areas that have affected
the way I practice, namely, assimilative integration, the visions of reality, and brief psychodynamic
therapy. Although starting out as a traditional psychoanalytic therapist, I became more integrative as I
was exposed to other approaches and to patients with a variety of needs. As a result I developed a mode
of integration, which I call assimilative. After applying the literary genres of tragedy, comedy, romance,
and irony to psychoanalytic, behavioral, and humanistic psychotherapies, I found that they also could
be used to describe any patient’s multiple facets and psychological challenges. I demonstrate here
how such visions helped in the treatment of a case of bipolar disorder. Upon recognizing the need for
briefer forms of treatment, I developed an interest in conducting, conceptualizing, and researching brief
psychodynamic therapy. I conclude the article by answering questions posed by the editors regarding
how I have changed over time in conducting psychotherapy.  C 2015 Wiley Periodicals, Inc. J. Clin.

Psychol.: In Session 71:1104–1114, 2015.

Keywords: aging; change in psychotherapy practice; career development; integrating visions of reality;
assimilative integration; brief psychodynamic therapy; bipolar disorder case

To gauge how I have changed over time in how I think about and practice psychotherapy
requires describing and reflecting upon where I started. My training in clinical psychology was
very broad insofar as it took place in a department of social relations (or Soc. Rel., as the
department was colloquially called) that was an interdisciplinary endeavor at Harvard, begun in
the mid-1940s, to combine, in one department, the social side of psychology with sociology and
cultural anthropology. The “social side” meant developmental, clinical, and social, rather than
experimental and physiological, psychology, which were housed in the psychology department
proper. Emphasis was on the individual’s functioning within the social system.
As graduate students, we were taught by personality theorists such as Gordon Allport, Robert
White, Erik Erikson, Jerome Kagan, and David McClelland, all of whom wrote and taught
about the importance of recognizing that people had more or less enduring characteristics that
were shaped developmentally and were affected by the surrounding culture and society. I was
then and am now still strongly influenced by that basic outlook in the way I think about and
practice psychotherapy, namely, that behavior is a function of the interaction of person and
environment. To state it in terms most relevant to psychopathology, the diathesis–stress model
explains behavior as a function of a person’s predisposition or vulnerability together with stress
from their life experiences. If the predisposition and stress exceed a certain threshold, the person
will develop a disorder (Ingram & Luxton, 2005).
Although we learned to conduct psychotherapy at Soc. Rel., it was not a particularly promi-
nent feature of the curriculum. Much of our clinical training took place outside of our highly
academic department in Boston hospitals and clinics, such as the Massachusetts Mental Health
Center (previously called the Boston Psychopathic Hospital), and much of it was psychoanalyt-
ically based. There was some exposure in courses, however, to the growing literature on behavior
therapy and family therapy.
It was when I finished my doctorate and started teaching psychological assessment to the
PhD graduate students in the clinical psychology program at Rutgers and the psychology of
personality to undergraduates that I became interested in deepening my exposure to psychoan-
alytic theory and therapy. I did so by taking a 2-year postdoctoral fellowship in psychoanalytic

Please address correspondence to: Stanley B. Messer, Rutgers University, 152 Frelinghuysen Rd., Piscataway,
NJ 08854. E-mail: smesser@rci.rutgers.edu

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 71(11), 1104–1114 (2015) 

C 2015 Wiley Periodicals, Inc.

Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22220

 How I Have Changed 1105

psychotherapy at Hillside Hospital in Queens, New York, where I spent a good deal of time
conducting psychoanalytic therapy, seeing patients (mostly twice a week), and taking seminars
with, and being supervised by, psychoanalysts from the New York and Downstate Psychoana-
lytic Institutes (e.g., Robert Langs, Martin Blum, Harold Blum, and several others). Watching
the psychoanalyst Herbert Waldhorn conduct psychoanalytic therapy from behind a one-way
mirror for a year contributed greatly to our training.
The fellowship program was an outstanding experience in learning how to listen to patients,
and particularly how to tune in to unconscious meanings of surface verbal behavior. Being in
psychoanalytic therapy at the time was also formative. Robert Langs, who supervised me for
a year and emphasized the importance of the frame or ground rules set by the therapist, quite
strongly influenced me. Secured-frame therapy, as he later called it, included relative anonymity,
complete privacy and confidentiality, a clear and firm fee structure, a strict adherence to session
length, and the conduct of therapy in an atmosphere of full integrity and honesty on both the
therapist’s and patient’s part. He firmly believed that the consequences of breaking the frame,
whether through modifications or violations of it, were picked up in unconscious, derivative, or
indirect communications from the patient, to which the therapist had to tune in and respond to
maintain the therapeutic alliance and help therapy progress (Langs, 1978).
Basically, Langs viewed the unconscious mind as an entity that functions outside of direct
awareness, adapts to external reality, and aims at resolution of conflicts. This differed from the
mainstream psychoanalytic understanding of the unconscious, which was purely intrapsychic.
He claimed that because there are unconscious perceptions of reality, one should expect the
unconscious mind of a patient to experience and communicate about errors on the part of the
therapist, and this constituted an aspect of what he called the bipersonal field (Langs, 1976).
That is, Langs emphasized the management of the ground rules and frame, with many therapists,
he claimed, being unaware of their importance and consequences. The therapist was largely to
remain neutral and silent to tune in to unconscious communications from the patient and avoid
what he considered trivial therapy, where there is a back and forth dialogue between therapist
and patient. Self-disclosure was shunned and a too-friendly attitude to the patient was seen as
seductive.
The stress on therapist neutrality and anonymity was not unusual at the time among psycho-
analysts, but Langs’ insistence on it in a rather inflexible way led to certain difficulties, at least
for me. Although I had my share of successes, there were patients who were not able to tolerate
the relative deprivation or even what they may have perceived as detachment on my part, and
they simply quit. In other words, although I found the approach brilliant and compelling, I also
began to find it confining and not sufficiently responsive to patient needs. It also required a
level of discipline and deferred gratification that was not compatible with my own personality
or with that of at least some of the patients I treated. Interestingly, Langs acknowledged that
patients too often abruptly ended the secure-frame strict-boundaries therapy he conducted,
which he attributed to the emergence of existential death anxiety. I would say that it took too
little cognizance of the importance of interpersonal connectedness and warmth stressed by other
approaches.
Following that fellowship, I was conducting only open-ended, long-term, and fairly traditional
psychoanalytically oriented psychotherapy in a very part-time practice, which was adjunctive
to a regular faculty position at Rutgers University. (I always felt that the clinical psychology
faculty at Harvard was limited by not being engaged in an ongoing way in at least some form
of practice). I began to be exposed to and to explore other forms of therapy that, ultimately,
were to influence the way in which I practiced. To begin with, I was associated with a clinical
psychology program that had become increasingly behaviorally oriented since I had first joined
it. Peter Nathan, Arnold Lazarus, Cyril Franks, and Terry Wilson, pioneers and proponents of
the burgeoning field of behavior therapy, all arrived at Rutgers during the time that I was on a
2-year partial leave of absence, to be in the fellowship program.
When I returned, I had become the “token psychoanalyst” (although I was not a psycho-
analyst) with a need to defend the theory and practice I espoused. It led me to an exploration
of the similarities and differences between psychoanalytic and behavioral approaches, which
Meir Winokur (then a student in the new PsyD program) and I spelled out in an article in the
1106 Journal of Clinical Psychology: In Session, November 2015

American Psychologist that received wide attention (Messer & Winokur, 1980). We elaborated
on that article in a book chapter (Messer & Winokur, 1984), which was part of an edited volume
on the possibilities and challenges of integrating psychoanalytic and behavior therapy (Arkowitz
& Messer, 1984). Winokur and I also expanded the comparison to include client-centered or
humanistic approaches to therapy (Messer & Winokur, 1986).

My Move From Pure Psychoanalytic Psychotherapy to Assimilative

Psychotherapy Integration
As I learned more about other therapies such as cognitive and person-centered therapy, my
purview and practice broadened to include some elements from them. I also began to develop
a form of integrative psychotherapy I called “assimilative psychotherapy integration.” Below is
an example of when I started incorporating cognitive techniques (Messer, 1992) with a patient I
was seeing at the time in a psychodynamic therapy.

I am treating a young professional man who experiences severe anxiety bordering

on panic in his new work setting, the first since his recent graduation from a profes-
sional school. He feels that he will not succeed at his work, thinks of himself as less
able and less prepared than his colleagues, and worries that he will be fired. We had
been exploring the roots of the problem both in his relationship to a demanding
and critical father who had very high expectations of him, and in a life threatening
illness contracted when he was 11 years old, leaving him with the feeling that doom
and catastrophe always lay around the corner. The illness also markedly increased
his dependency on his parents. In line with the goals of psychoanalytic therapy, my
work was aimed at freeing him from the no longer present dangers to which he was
psychically held hostage, and which he generalized to the work situation. Never-
theless, he was having trouble getting through the day at work without becoming
overtly anxious and inhibited in pursuing his work. Therefore, I decided to adopt
some procedures from cognitive therapy. We discussed his “selective negative focus”
on the worst aspects of the work setting, his “magnification” of it, and “catastro-
phizing” about it (Beck, Emery, & Greenberg, 1985; Persons, 1989). I asked what
he could say to himself at such times to counter his dysfunctional thinking, and
together we came up with strategies that turned out to be helpful for him. These
included reminding himself that he had succeeded in similar situations in the past;
that he was only a beginning professional and need not expect so much of himself;
and that he could focus on just getting started on the task without “predicting the
future” (Persons, 1989), namely a failed conclusion. (p. 153)

In cognitive-behavioral terms, I was using elements of cognitive restructuring therapy, which

teaches clients to change distorted and erroneous thoughts that are maintaining their problem
behaviors. The idea was to recognize the maladaptive cognitions and substitute more adaptive
ones (e.g., Spiegler & Guevremont, 2009). In essence, I tried to be helpful to my patient without
becoming too directive, which would make me into an authority figure like his father. I also knew
that this client tended to become overly dependent on the guidance and advice of older men at
work. My concern was that he would play the role of the helpless child (his transference mode)
and I would be put into the role of the strong, all-knowing parent (the countertransference
mode). The way in which I avoided this was to try to have him come up with the solutions as
much as possible, and for me to follow up with him on the meaning of my more active, less
neutral exploratory stance. He acknowledged his wish for more of this kind of direct guidance,
which I examined with him in terms of his feeling dependent and inadequate. This is an example
of how gratifying patient wishes has its downside in that it can lead the patient to a more passive
stance and away from coming to grips with the maladaptive elements of his personality.
To elaborate on assimilative integration, it is a mode of conducting psychotherapy in which
a technique, concept, or perspective from a different form of therapy is incorporated into
 How I Have Changed 1107

one’s home or preferred therapeutic approach (Messer, 2015). It recognizes that although most
therapists are trained in and practice from within one theoretical model, as they gain experience
they are very likely to include some features of another approach that has been demonstrated
to help therapy progress more effectively and/or efficiently. In this way, therapists build on and,
hence, modify the theoretical modality to which they have primary allegiance by integrating new
methods. This leads to an accommodation of sorts in the home theory.
One might, for example, incorporate systematic desensitization or social skills training—that
is, cognitive-behavioral techniques–into a psychodynamic or person-centered therapy, or include
in cognitive-behavioral therapy special attention to the therapeutic relationship as described
in person-centered therapy. Homework is often used within a cognitive-behavioral therapy
framework, but it can be incorporated into a psychodynamic therapy as well. For example, I have
given anxious patients a relaxation tape made by my recently deceased colleague, Arnold Lazarus,
which they have found useful. We may then discuss in a subsequent session what kind of thoughts
they had while relaxing or what barriers there were to their using the tape. In an example of what
Stricker and Gold (1996) call assimilative psychodynamic integration, Stricker (2013) asked a
patient to do homework different from what a cognitive behavior therapist might assign, namely,
to write a poem about her therapeutic experience, which he then worked with much as he would
with a dream. Likewise, Castonguay and colleagues (Castonguay, Newman, Borkovec, Grosse
Holtforth, & Maramba, 2005) have described a cognitive-behavioral assimilative integration,
which includes aspects of other therapies such as facilitating emotional deepening from process–
experiential therapy.
Assimilative integration became a primary mode of practice for me and has remained so to
this day. This is one of my answers to the question posed by the editors of this issue, namely,
how has my work as a therapist changed as a result of growing older. I would answer that it
was not age per se, in the developmental sense of that term, that led to the changes I have
just noted, but what transpired over time: (a) my exposure to the realities of practice with a
variety of patients, not all of whom were amenable to a standard or secure-frame psychoanalytic
approach; (b) recognition of my own inclinations, strengths, and weaknesses as a therapist;
and (c) the different professional environment in which I found myself, namely, the Rutgers
behaviorally oriented clinical psychology program versus Hillside Hospital’s psychoanalytic
atmosphere, especially in its psychotherapy fellowship program.
According to a survey by Norcross, Karpiak, and Lister (2005), assimilative integration is
now one of the four major kinds of integration to which integrative and eclectic practitioners
most often subscribe (the others being theoretical integration, common factors, and technical
eclecticism). That is, roughly 27% of this sample described themselves as preferring assimilative
integration. In another study, Hickman, Arnkoff, and Shottenbauer (2009) surveyed experts in
psychotherapy integration who were asked to assess the extent to which they were influenced by
the major modalities of practice, namely, psychodynamic, cognitive-behavioral, humanistic, and
family system. For 75% of these experts, only one of the four theories was a salient influence,
which provides good evidence that most clinicians have a home base in one theory–a major tenet
of assimilative integration.

Tacking Between Opposing Perspectives on Reality

As I stated above, my exposure to behavioral outlooks by colleagues at Rutgers, and watch-
ing Arnold Lazarus conduct therapy, led Winokur and me to formulate the differences and
similarities of the two, basically explaining and justifying why we were psychoanalytic and not
behavioral therapists. The ways in which we framed the differences were their contrasting per-
spectives on and visions of reality. Below I will spell out the meaning of these terms, especially
the visions and how they differentiated the therapies and eventually led to my taking a broader
view of how to think about my patients and their therapy.
The perspectives on reality refer to three dimensions: realism versus idealism, objectivism
versus subjectivism, and extraspection versus introspection. The realist thinks of the world as
having an existence of its own, almost independent of the perceiver. By contrast, the idealist
1108 Journal of Clinical Psychology: In Session, November 2015

claims the external world doesn’t exist independent of the ideas of the perceiver. Viewing events
objectively means having a common understanding of events or experience that can be checked
and generalized. Subjectivity implies that experience is unique and cannot be generalized beyond
the individual. When viewing others extraspectively, one constructs a hypothesis about them
from one’s own vantage point regardless of the subject’s viewpoint, whereas viewing them
introspectively means taking the other person’s point of view seriously.
Using these terms (Messer & Winokur, 1980), we described the behavior therapist as inclined
to be realistic, objective, and extraspective, whereas the psychodynamic therapist holds a more
idealistic, subjective, and introspective outlook. The behavior therapist demonstrates this incli-
nation by using therapist- or researcher-rated measures of outcome, when referring to negative
self-statements as irrational, and in formulating issues from the therapist’s perspective. In focus-
ing on private or unconscious events, and exploring symbolic meanings and patients’ feelings of
being false or inauthentic, the psychodynamic therapist is operating within a more subjective,
idealistic, and introspective framework.
In a relative sense, my own inclinations in conducting therapy continue to be in the direction
of idealism, subjectivity, and introspection. Nevertheless, I am mindful of the necessity, at times,
to take a more external and objective view and give more credence to the reality situation in
which the patient finds himself. At such times, a direct problem-solving approach may supersede
delving further into the intrapsychic responses to the situation. I believe that there is an advantage
to being able to tack back and forth between the depths of a patient’s subjective reality and the
surface but compelling qualities of the environment with which he is trying to cope.

How the Concept of Visions of Reality Have Shaped My Practice

In a series of articles and chapters, Winokur and I (Messer & Winokur, 1980, 1984, 1986) applied
what are known as “visions of reality” to three major schools of therapy, namely, psychoanalytic,
behavioral, and humanistic. The visions include the romantic, ironic, tragic, and comic, which
were originally used to describe different genres of literature (Frye, 1957) and psychoanalysis
(Schafer, 1976). At first, we were fairly skeptical about the prospects for integration, seeing the
visions of each therapy as leading in quite different directions. However, I discerned a trend
in the psychotherapy literature: Therapists were increasingly including elements, perspectives,
or visions of other therapies (Messer, 1986). In the latter article, I presented a case that I
had supervised, in which I presented possible behavioral and psychoanalytic interventions at
therapeutic choice points, discussed the rationale for each, and demonstrated the way in which
they were intersecting. I also drew out the implications of this increased overlap for their visions
of reality.
I then began to realize that it is both possible and desirable to keep in mind each of the visions
in treating the same patient, to appreciate fully his or her complexity. They can be usefully
brought to bear in therapy to either highlight the many dimensions of an individual’s experience
or consider how each vision may best apply to different clients or specific circumstances. I will
now briefly spell out the nature of the four visions and then apply them to a current case. This will
also demonstrate how my outlook has changed over time, from one in which I saw the therapies
as largely differentiated by the visions to now seeing these visions as being able to broaden
the perspective of any integratively inclined therapist. The following summary is adapted from
Messer (2006).

The Visions of Reality

The tragic vision. Within the tragic vision, the limitations of life are accepted: not all is
possible, not all is redeemable, not all potentialities are realizable. The clock cannot be turned
back, death cannot be avoided, and human nature cannot be radically perfected. As in the
ironic posture described below, these sensibilities favor reflection and contemplation on the part
of both client and therapist, whereas the romantic and comic views predispose them towards
action. Unlike irony, however, tragedy involves commitment. In a tragic drama, the hero suffers
 How I Have Changed 1109

by virtue of the conflict between impulse and duty and, after considerable inner struggle, arrives
at a state of greater self-knowledge. Many aspects of traditional psychoanalysis fall within the
tragic vision. The outcome of psychoanalytic treatment is not unalloyed joy and happiness or
“all obstacles overcome” as in the comic vision, but the client’s fuller recognition of what one’s
struggles are about and a more complete understanding of the conditions and limitations of life.

The comic vision. Whereas tragedy emphasizes the dark side of human nature and exis-
tence and a tendency for things to go downhill, in comedy the direction of events is typically
from problematic to better or best. There is always light at the end of the tunnel. Although there
are obstacles and struggles in a comedy, these ultimately are overcome and there is reconciliation
between hero and antagonist, between the person and his or her social world. Joy, harmony,
and unity prevail. The conflicts portrayed in a comedy are ones between people and the difficult
situations in which they find themselves, and not the kind of inner struggles or implacable op-
positions encountered in dramatic tragedy. Cognitive-behavioral therapy is a good example of
this outlook: Conflict is ascribed to external situations or internal forces that can be mastered
through application of correct therapeutic technique or technology (e.g., Fishman & Franks,
1997).

The romantic vision. From the romantic viewpoint, life is an adventure or quest in which
each person is a hero. This vision idealizes individuality and what is “natural,” encompassing the
creative spark, which is said to reside in everyone. It advocates free, uninhibited, and authentic
self-expression. The romantic vision is often manifested in people seeing life through rose-colored
glasses, such as lovers idealizing each other. Not surprisingly, this perspective is fundamental to
humanistic psychotherapy (Messer & Winokur, 1986). Using existential therapy as an example,
"one of the primary objectives is to have clients face the givens of existence and confront
the attendant anxiety so that they can learn to live more authentically and responsibly in the
moment” (Watson, Greenberg, & Lietaer, 1998, p. 18).

The ironic vision. The ironic attitude is antithetical to the romantic view. In fact, the tragic
and ironic visions are linked insofar as they both include a distrust of romantic illusions and
happy (comic) endings. It is an attitude of detachment, of keeping things in perspective, of recog-
nizing the fundamental ambiguity of every issue that life presents to us. Each aspect of a person’s
behavior may represent something else, be it a dream (latent vs. manifest content), a symptom
(a displaced or distorted wish), or an interpersonal interaction (hostility disguised by excessive
smiling or kindness). In common with the tragic vision, the ironic viewpoint underscores that
there are inherent difficulties in human existence and that life cannot be fully mastered, nor can
its mysteries be truly understood. Irony suggests that human behavior can be quite at odds with
conscious intention.
The following case will be used to illustrate how the perspectives and visions of reality might
be integratively applied in an actual clinical situation, reflecting a way in which I now think
about my patients.

The Visions Applied to a Case of Bipolar Disorder With Social Anxiety

and Obsessive-Compulsive Symptoms
When D came to see me he was single, 19 years old, and a college student who had recently spent
2 weeks in a psychiatric hospital after a manic episode. Among other irrational and dangerous
behaviors, he had been driving on a highway at breakneck speed and was apprehended by the
police, and ended up being hospitalized. He had to drop out of a college, which was situated in
a different state, and move home. He subsequently registered in a university closer to home and
where I practice. I have been seeing him for over 20 years, at first once or twice a week, and now,
for the last several years, once every 2 weeks. The therapy has been a mixture of psychodynamic
exploration with supportive and cognitive-behavioral features.
1110 Journal of Clinical Psychology: In Session, November 2015

The tragic vision in D’s therapy. How did I view D’s situation and conduct the therapy
from the angle of the tragic vision? This vision highlights the irreversible features of D’s life. He
is stuck with a mental illness that, while amenable to improvement, usually afflicts the bearer
throughout life, at times with dire consequences. He often comments on how it was bad luck
that he ended up with his disorder, and complains about the fact that it makes life much harder
for him. For example, in the past he has gotten into trouble by acting in a high-handed way,
a not infrequent narcissistic quality accompanying this diagnosis. In his case, the disorder also
comes with a high degree of social anxiety, irritability, and obsessive–compulsive traits such as
a strong compulsion for neatness, structure, and order, and a frequent need to check that he has
not left the stove on or the water running before leaving his house.
From the point of view of process and technique, the tragic view calls for exploration and re-
flection, which are elements of psychoanalytic and humanistic therapies in particular. Therapists
recognize the universal nature of the anxieties and mood swings of the kind that D faces and
respond empathically based on tragic themes in their own lives. In terms of the perspectives on
reality, understanding and treating them requires, in part, an introspective and subjective stance
with a strong internal focus, which has been an important emphasis in my therapy with D.
In terms of outcomes, the tragic vision stresses the limitations brought on by his mental
illness. One can expect occasional exacerbations or even reversals, which D has experienced, and
ongoing struggle with his issues, albeit to a lesser degree. One can’t expect a straight line forward
or a complete cure, nor has there been one. As I have grown older as a therapist, and perhaps
wiser, I have come to accept such limitations in my ability to bring about thoroughgoing change
and transformation in the face of certain kinds of psychiatric disorders. However, keeping in
mind the other visions of reality can give one a more sanguine outlook than that offered by the
tragic vision alone.

The comic vision in D’s therapy. Regarding the content of D’s problems, from a comic
perspective these might be seen as ameliorable through direct action. D’s tendency at work is to
isolate himself from his fellow employees, a manifestation of his social anxiety. At home, due
to his obsessive–compulsive personality and ongoing anxieties, he tends to be overly critical of
his wife for not keeping the house sufficiently tidy despite her having a full-time job and young
children to raise. How can the comic vision help here?
With respect to technique, one can approach D’s problems with a sense of optimism and
can-do. For one thing, his mood can be and has been stabilized by the use of medication. Earlier
on in treatment his main medication was lithium. When that began to affect his kidneys (because
lithium is a salt), his psychiatrist switched him to a combination of Depakote and Lamictal to
stabilize his mood. For his social anxiety, he is also taking a small dose of Buspar and that has
helped as well.
Regarding his tendency to isolate himself at work and be critical of his fellow employees,
we have discussed that it is important for him to be friendlier and view his fellow employees
more sympathetically, if for no other reason than to keep his job. This has been handled through
direct advice and reframing rather than deeper exploration. And, indeed, it has helped him relate
at least somewhat better to others. Regarding his fussiness about the tidiness of his home, he
has come to realize the pressures that his wife is under and how she can’t be expected to keep
the house in immaculate condition. Although this doesn’t remove his obsessive–compulsive
symptoms entirely, it does help him to control them, as do other cognitive-behavioral techniques
I employed. As an aside, one can see the intersection here with assimilative integration.
With respect to outcomes, within the comic vision there is an ability to perform social roles
more adequately. D is now doing so with both fellow employees and his wife. Happy endings
are viewed as the norm within the comic vision insofar as problems are not merely explored and
insight attained but also directly ameliorated through action. This has helped D maintain both
his job and his marriage in a relatively harmonious and satisfactory state. In these ways, the
comic vision is an antidote to the tragic elements in his life.

The romantic vision in D’s therapy. I find it important not to neglect the interests and
strengths that patients have in spheres such as art, music, sports, religion, spirituality, reading,
 How I Have Changed 1111

travel, and the more creative aspects of their work and recreational pursuits. The romantic
vision keeps these arenas of the patient’s life on the therapist’s radar, as they can be considerable
sources of satisfaction in life and wellsprings of strength to combat the deleterious effects of
mental illness. In terms of therapeutic technique, I help patients delve into their fantasies and
daydreams and to try to pursue their dreams and goals that so that they may see themselves as
multifaceted and multidimensional human beings who are not defined solely by their illness or
current life difficulties. In D’s case, and in terms of the process of therapy, I encouraged his own
inclinations to enter professional school to develop his vocational interests, which currently give
him considerable satisfaction and which have led to praise, promotions, and a sense of pride
and authenticity in his professional strivings. Self-fulfillment is an outcome consonant with the
romantic vision.

The ironic vision in D’s therapy. The ironic vision provides a corrective to the romantic
vision in particular. The process or technique of therapy within the ironic perspective calls for
therapists to be skeptical of all that they hear from clients. D’s grandiosity that he sometimes
displayed and what I referred to in therapy as his high-handedness, belied an underlying sense
of inadequacy. In contrast to his typical view of himself as smart, knowledgeable, and quite
special was his anxiety about speaking, eating, or dancing in public. At times he would feel that
his speech was indistinct or his eyesight impaired, leading him to see physicians unnecessarily,
which I interpreted as indicators of his sense of inadequacy. I explored these contrasts in a
psychodynamic fashion and tried to reassure him that I noticed nothing untoward about his
speech or manner. A goal of irony is to see oneself as honestly as possible, free from illusion.
For example, D came to recognize that he may not be quite as superior as he first imagined, but
neither was he inadequate as he had feared. The ironic vision also predisposes the therapist to
keep the four visions in balance.
I have found that each of these angles of regard can influence the conduct of a case, allowing
the therapy to assume an integrative character of the therapist’s choosing according to the
mix of visions brought to bear or his or her degree of rootedness in a particular theoretical and
therapeutic framework. Of course, I am also guided by the nature of the complaints, the patient’s
personality and goals, and how receptive he or she is to working within one or another vision.

My Interest in Brief Psychodynamic Therapy

In addition to the influences on my practice of assimilative integration and the perspectives and
visions of reality, I became interested in the prospects for making psychodynamic psychotherapy
briefer and hence more accessible to a larger and more diverse population. The vast majority of
those in psychotherapy remain for fewer than 20 sessions, clinic waiting lists are typically long,
and open-ended insurance coverage was shrinking, so it became clear to me that short-term
therapy was worth exploring. I attended a 5-day workshop in Montreal in the 1970s where I was
exposed to the work of Malan, Davanloo, and Sifneos, all pioneers in the development of a type
of brief psychodynamic therapy (BPT) called short-term dynamic psychotherapy (STDP). Each
had written about this new approach and showed videotapes of his clinical work, which was a
rather new and exciting way of teaching and training at the time.
I subsequently learned about other approaches within the BPT umbrella, including Mann’s
time-limited psychotherapy, Strupp and Binder’s time-limited dynamic psychotherapy, and eclec-
tic models based on common factors (e.g., Garfield), technical eclecticism (e.g., Bellak), or the-
oretical integration (e.g., Gustafson). Eventually, I coauthored a book (Messer & Warren, 1995)
on BPT, which organized the brief dynamic therapies according to their theoretical base, which
included drive-structural, relational, integrative and psychoanalytic, and the eclectic varieties.
The book included chapters on assessing and treating the more severely disturbed (“difficult”)
patient in brief therapy, as well as treating children, adolescents, and the elderly viewed from
a lifespan developmental approach. It covered the research on BPT and critiqued each model
according to its strengths and weaknesses.
1112 Journal of Clinical Psychology: In Session, November 2015

There are common features of BPT, which are worth describing here, as they have affected
my mode of practice. To be sure, I continue to practice long-term psychotherapy alongside
BPT because I don’t regard the two modalities as mutually exclusive. Each has its appropriate
applications and general advantages and disadvantages.
The major features of BPT are as follows: (a) a range of 1–40 sessions, with most models
lying between 8 and 25; (b) a time limit, which is established at the start of therapy and which
sets in motion certain psychological expectancies such as Parkinson’s law–that a task will fill
the time allotted to it; (c) use of psychoanalytic theory, e.g., drive-structural, ego psychology,
object relations, or self-psychology; (d) application of psychoanalytic techniques such as clari-
fication, interpretation, and, in some models, confrontation of defenses, impulses, motives, and
interpersonal patterns; (e) therapist activity, which is greater than in long-term psychodynamic
therapy; (f) a focus, expressed in psychodynamic terms, e.g., a core conflictual relationship
theme (Luborsky), a chronically endured pain (Mann), or a maladaptive interpersonal pattern
(Levenson); (g) goals that are set early on, e.g., a conflict will be at least partially resolved; an
interpersonal pattern will be modified; patients will be more in touch with their feelings and/or
have a greater sense of freedom to make choices; (h) exclusion criteria, usually the more seriously
disturbed diagnostic groups; and (i) special attention to termination, which brings to the fore
issues of loss, separation, and individuation and the fact that limitations of therapy as in life
must be faced and reconciled.
Overall, I would say that exposure to BPT has led me to conduct brief therapy, compared to
long-term therapy, in a more pragmatic, active, focused, and goal-oriented way, albeit within the
parameters of a psychodynamic therapy. In terms of the visions of reality, there is a relative shift
involved in conducting BPT from the romantic (open-ended, adventurous) and tragic (delving
into the darker side of human nature) to the more comic (pragmatic, hope-inducing, action
oriented) vision, although the differences are not absolute. For cases on BPT, see Messer and
Warren (1995), and for a case that shows how the visions of reality apply to brief therapy
compared to long-term psychoanalytic therapy, see Messer (2000).

Further Reflections on How I Have Changed as a Psychotherapist

In this final section, I will try to answer some of the questions posed by the editors, ones that I
may not have addressed directly above, and in this way summarize how I have changed as I have
grown older. To begin with, I am more informal and friendly with patients than I once was. I
agree with Strupp (1973) that psychotherapy is first and foremost a human endeavor in which
the patient is looking for a good relationship. I believe I do better at providing that now than I
once did. Although I still keep fairly strict boundaries between that which is personal and that
which is professional, I am more supportive and more likely to be self-disclosing. For example,
with a patient I am currently seeing who has a child with a chronic and fairly serious disease, I
shared how my wife and I managed such a situation with one of our own children. I found that
this sharing gave me much greater credibility in the eyes of the patient without any untoward
effects. However, there is an important line to be drawn between sharing your life experience and
wisdom with a patient and raising their concerns about you, even inadvertently making them
into your therapist.
I feel more on top of my game than when I was a novice and, therefore, less anxious. I would
not say that my goals have changed except when I am doing brief psychodynamic therapy as
described above. I am more prone to give advice and tell an occasional joke if the situation calls
for it. Regarding advice giving, I will support, for example, the importance of physical exercise
for good mental health especially for those patients who are depressed. Regarding joke telling,
I do this only in the context of getting a point across and not merely to schmooze.
I use telephone sessions more than I once did because some patients have moved from the area
but want to keep up the therapy even if on a less frequent basis. I have not yet experimented with
Skype or another visual medium. I am more prone to see patients on a less-than-once-weekly
basis if they have been in therapy for a time and can profit from a more supportive and less
intense, uncovering psychodynamic therapy. I find that as I have aged, more of my referrals are
 How I Have Changed 1113

older patients with whom I enjoy working. I accept Medicare, which takes the cost of therapy
with such patients out of the equation. This means that I am being paid less than my usual fee
but I am quite agreeable to this arrangement because I don’t have the same financial obligations
at my current life stage.
I am not aware that patients have concerns about losing me through retirement or death and
I believe it is because I have not been infirm. I have always been tuned in to the health and
physical issues of patients and, if they haven’t already done so, I may recommend that they see
an appropriate medical specialist. I don’t believe that my clinical work has affected my family
any more than in the past insofar as I don’t talk with them about patients. I remain optimistic
about the value of therapy based on both my own experience and the large number of studies
supporting it. At the same time, I have become more realistic in terms of the limitations of what
we can offer certain patients seeking our help.
Regarding advice to the younger generation of therapists, I suggest that training in psychody-
namic approaches gives one the capacity to really hear what patients are conveying, that is, to be
able to tune in to unconscious messages. Being in therapy oneself is personally helpful and makes
you more aware of your own issues and countertransference. I find that novice therapists are
prone to talk more than to listen and suggest action prematurely, whereas it is most important
to be able to maintain sufficient silence to allow the underlying conflicts to emerge. I suggest
learning more than one approach to therapy so one can judiciously assimilate techniques from
one into the other as one gains experience.
All the perspectives and visions of reality as applied to a person’s life count and one should
keep them all in mind. Self-care is important as well—that is, to keep one’s life in balance. I
continue to believe that what patients are looking for in therapy is a good relationship and new
insights and new ways to help them cope with and overcome their difficulties. We may not have
something to offer everyone, but what we have to offer, such as a caring and listening attitude, a
responsive style and professional expertise, is worth a great deal.

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