Wolberg Short Term Psychotherapy

HA N DBOOK OF
SHORT-TERM
PSYCHOTHERAPY
LEWIS R. WOLBERG, M.D.
C o p y rig h t 1980 Louis R Wolberg
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Contents
Preface, vii
1. Model s of Short-term Therapy, 1
2. A Rati onal e for Dynami c Short-term Therapy, 22
3. Cri teri a of Selection, 30
4. A General Outl i ne of Short-term Therapy, 35
5. T he I ni ti al I ntervi ew: A. Common Questi ons, 49
6. T he I ni ti al I ntervi ew: B. Case Hi stori es, 61
7. Choosi ng an I mmedi ate Focus, 90
8. Choosi ng a Dynami c Focus: A. Probi ng into the Past, 101
9. Choosi ng a Dynami c Focus: B. Some Common Dynami c Themes, 113
10. Choosi ng a Dynami c Focus: C. Presenti ng I nterpretati ons, 125
11. Techni ques in Short-term Therapy, 135
12. The Use of Dreams, 170
13. Catal yzi ng the Therapeuti c Process: T he Use of Hypnosi s, 190
14. Cri si s I nterventi on, 208
15. Maki ng a Rel axi ng and Ego-Bui l di ng Tape, 223
16. Homework Assi gnments, 235
17. Termi nati on of Short-term Therapy, 243
References, 250
Preface
I n 1959, I chai red a semi nar at the Post
graduate Center for Mental Heal th in New
Y ork City, duri ng whi ch a number of par
ti ci pants presented materi al detai l i ng thei r
thoughts about and experi ences wi th short
term therapy. Hel en Avnet, Di rector of Re
search, Group Heal th I nsurance Company,
revealed the resul ts of a proj ect that l asted two
and one-hal f years, in whi ch a panel of 1,139
psychi atri sts treated pati ents on a short-term
basis. On termi nati on, 70 percent of the pa
ti ents were rated by the panel as i mproved or
recovered. I t was concluded that a large por
ti on of the communi tys psychi atri c needs
could be met by short-term treatments. J ul es
Masserman detai led the hi stori cal -comparati ve
and experi mental roots of short-term therapy,
traci ng its ori gi ns in the past. Sandor Rado
presented materi al on moti vati onal factors that
could provi de gui del i nes for techni ques in
short-term therapy. Paul Hoch differentiated
the characteri sti cs of short-term versus l ong
term therapy. Franz Al exander deal t wi th psy
choanal yti c contri buti ons to short-term therapy
in faci li tating a correcti ve emoti onal experi
ence. L othar Kal i nowsky lectured on the use of
somati c treatments in short-term therapy.
Al exander Wol f deal t wi th short-term group
psychotherapy. Mol l y Harrower described a
research proj ect rel ated to outcome of l ong
term and short-term therapy. Arl ene Wol berg
discussed the i ncorporati on of case-work proce
dures in a short-term program. I gave two lec
tures, one on general aspects of techni que and
the other on the empl oyment of hypnosi s as an
adj unct in short-term therapy. T he semi nar
was publ i shed l ater by Grune & Stratton
under the title Short-term Psychotherapy.
I t is i nteresti ng in revi ewi ng the current
l i terature that i ndependent studies have val i
dated an astoni shi ngl y l arge percentage of the
ideas and observati ons of thi s semi nar. I t is
rel ati vely recently, however, that there has
been a swi ng toward short-term therapy as a
pri mary and preferred treatment rather than
as an expedi ent. Even nati onal psychoanal yti c
organi zati ons, stronghol ds of l ong-term treat
ment, have begun to preach its vi rtues and
have organi zed conti nui ng-educati on courses
on the subject. A host of articl es and a number
of i nteresti ng books have appeared, outl i ni ng
phi l osophi es, goals, selection procedures and
techni ques that the authors have found val ua
ble in thei r attempts to abbrevi ate treatment.
I n the mai n, si mi l ari ti es of concepts have ex
ceeded differences. Neverthel ess, a great num
ber of questi ons remai n unanswered, and it is
the purpose of the present vol ume to contri bute
to the resol uti on of some of these.
One of the most criti cal questi ons is rel ated
to the val ue of dynami c approaches in short
term therapy. Most i mportantl y, can we empi
ri call y prove the effectiveness of a dynami cal l y
based short-term therapy? Control l ed experi
ments have been few, and even in these the dif
ficulties that shadow outcome studies tend to
obscure results. Yet wi th all our skeptici sm
about quanti fyi ng bri ef clinical operati ons suf
ficiently to satisfy the cri teri a of objectivity,
vali dity, and rel i abi l i ty so essential in scientific
studies, di scri mi nati ng experi ence establi shes
beyond reasonabl e doubt the usefulness of a
dynami c ori entati on in any form of short-term
psychotherapy. Thi s appl i es whether we are
hel pi ng a person recogni ze and then to come to
terms wi th his past, as in insight therapy, or
el i mi nati ng effects of the past through rei n
forcement of adapti ve behavi ors, as in behavi or
therapy, or squeezi ng the past out of muscles
and tissues as in the new body therapi es, or
vii
viii HANDBOOK OF SHORT-TERM PSYCHOTHERAPY
gai ni ng a perspecti ve on i nner emoti onal ef
fects of the past through sensory awareness
techni ques, or correcti ng habi tual past modes
of thi nki ng, as in cognitive therapy. I ndeed, a
dynami c approach, in my opi ni on, is the best
design to follow in all forms of psychotherapy,
however bri ef they may be, and whi l e it may
not have an i mmedi ate dramati c influence on
the personal i ty structure, it can catalyze such
changes eventual l y through its conti nui ng i n
fluence on cognition.
I n this vol ume I have attempted to bri ng
together common el ements in the chief model s
of short-term therapy currentl y in use and to
evolve pri nci pl es that can be empl oyed by i ndi
vidual therapi sts, irrespective of thei r theo
retical biases and styles of operati on. How a
dynami c vi ewpoi nt may practi cal l y be i n
troduced in any form of psychotherapy is one
of my goal s. T he short-term method that I will
describe is not presented wi th il lusion that it is
fl awless, infall ible, or uni versal l y appl i cabl e.
Nor may it prove equal l y helpful to all thera
pi sts or curati ve in every case. I t is, neverthe
less, in my opi ni on, (and in the j udgment of
therapi sts who have uti li zed the method), an
easily l earned and effective techni que servicea
ble for the great maj ori ty of pati ents seen in
clinics and pri vate practice. T he method al so
takes into consi derati on the fact that there will
be pati ents who are not good subjects for
short-term treatment and who will requi re
other forms of help. Under these ci rcum
stances, the method will functi on as a useful
i ni ti al diagnosti c procedure, enabl i ng the thera
pist to select modal i ti es that will serve the pa
ti ent best.
The method al so contai ns a means of pro
vi di ng conti nui ng therapy for the pati ent
through assigned homework and the use of a
casette tape, the maki ng of whi ch will be
described in detai l. I t has al ways confounded
me that so many therapi sts assume that when
the last formal treatment session has ended,
the pati ent can sally forth like the fabl ed
pri nce and pri ncess to live happi l y ever after.
T he facts on the fol low-up are a gri m deni al of
this fantasy. For exampl e, in fol l ow-up re
search of pati ents who had been treated in a
compari son study wi th two forms of bri ef psy
chotherapy (behavi or therapy and psychoana-
l yti cal l y ori ented psychotherapy) and who
were di scharged as i mproved, Patterson, et al
(1977) found that one year after termi nati on,
fully 60 percent had sought out and obtai ned
further treatment. These fi gures are probabl y
low because many di scharged pati ents who do
not seek formal therapy uti li ze other forms of
hel p or self-help to reduce thei r tension and
better thei r adj ustment. Life, after satisfactory
psychotherapeuti c treatment, conti nues to
present a never endi ng series of chall enges that
can tax copi ng capaci ties of even cured pa
ti ents. Thi s is not al together bad, for in meet
ing these chal l enges the i ndi vi dual has an op
portuni ty of strengtheni ng adapti ve patterns,
much like a booster shot can enhance the effect
of a pri or vacci nation. Short-term psychother
apy offers the pati ent a means by whi ch ones
future may be regul ated, provi ded the therapi st
prepares the pati ent for anti ci pated events and
conti ngenci es and teaches a way of deal i ng
wi th these, shoul d they appear.
As a handbook, thi s vol ume provi des an out
li ne of process in short-term therapy. Shoul d
extensive detai ls of techni que be sought, they
may be found elsewhere, i ncl udi ng the thi rd
edition of my book The Technique o f Psy
chotherapy. I t is recommended that the reader
if not al ready acquai nted wi th some techni ques
other than i ndi vi dual psychotherapy experi
ment wi th these to see whether they accord
wi th ones i ndi vi dual styles of worki ng. I n my
opi ni on, a therapi sts usefulness is especiall y
enhanced by knowl edge of group therapy (see
The Technique of Psychotherapy, 3rd ed, pp.
702-729), fami l y therapy (pp. 729-733),
mari tal (couple) therapy (pp. 733-740), be
havi or therapy (pp. 685-701), rel axati on pro
cedures (pp. 761-766), and somati c therapy
(pp. 767-789). Other techni ques may peri
odical ly be useful such as hypnosi s (pp. 791
809), sex therapy (pp. 809-817), and bib-
l i otherapy (pp. 817-833). I t goes wi thout say
i ng that knowl edge of the therapeuti c process
from the ini ti al i ntervi ew to termi nati on (pp.
PREFACE ix
353-684; 743-758) and especiall y i ntervi ew
ing techni ques (pp. 360-382) are indi spensi -
ble.
A final word of cauti on may be indi cated.
One shoul d not assume that it is al ways possi
ble to dupl i cate or surpass wi th short-term ap
proaches what can be done wi th appropriately
selected patients through l onger-term treat
ment. But, for the great maj ori ty of peopl e
seeking hel p for emoti onal probl ems, the ti me
element is not the most i mportant vari abl e in
psychotherapy. Ti me is too frequentl y con
sidered a magi cal device that acts like a de
tergent, washi ng away accumul ated neuroti c
residues. I t is assumed tradi ti onal l y that the
longer a pati ent remai ns in psychotherapy, the
greater the benefi ts he will derive from it.
Common practice, however, convinces that thi s
is true only up to a certain point. Beyond such
a point, resistances pi le up in a di sturbi ng
number of pati ents, gai ns are neutral i zed, and
a setback ensues. Peeri ng into the causes of
these mi sfortunes, we observe in therapy that
goes on for too protracted a peri od an emerg
ing sense of helpl essness that may be concealed
by vari ous reacti on formati ons. T he conse
quence is a sabotage of progress and ul ti matel y
an exacerbati on of symptoms. The therapi st
then becomes for the pati ent a crutch; wi thout
whom i ndependent steps are avoided. Thi s is
parti cul arl y the case in sicker pati ents whose
dependency needs are hal l marks of thei r basic
personal i ty structure, or who have, because of
persistent anxi ety, lost thei r sense of mastery
and di strust thei r own capaci ties to function.
Whatever gai ns may accrue from any evol ving
insights are neutral i zed by the cri ppl i ng influ
ence of the prol onged shel tered rel ati onshi p.
Pl ayi ng a wai ti ng game in the hope that ti me
will eventual l y dislodge a neurosi s too fre
quentl y resul ts in pati ent paral ysi s and thera
pist frustrati on.
Such di sconcerti ng phenomena give i mpetus
to our efforts to shorten the therapeuti c process
wi thout devi tal i zi ng its effect. Thi s is not to
depreci ate economi c and other practi cal rea
sons for abbrevi ati ng short-term therapy. But
apart from cost effecti veness and the need to
mi ni ster to the growi ng mul ti tudes of peopl e
who seek hel p, dynami c short-term treatment
is j usti fi ed onl y if it can prove itself to be a
trul y useful means of deal i ng wi th emoti onal
probl ems in the vast maj ori ty of cases. I n my
opi ni on, this proof has now been establi shed.
Acknowl edgment is made to the Postgradu
ate Center for Mental Heal th, under whose
auspi ces this book was wri tten, and to its Staff
for the sti mul ati on they i nspi red. Thanks are
due to Grune & Stratton, the publ i shers of my
books Short-term Psychotherapy and The D y
namics of Personality (with J ohn K i l dahl ) for
permi ssi on to uti li ze some materi al from these
vol umes in Chapters 7, 8, 9 and 16. Credi t is
also due to my secretary, Ann K ochanske, for
her effective hel p wi th the physi cal preparati on
of the book and the checki ng of references.
L ewi s R. Wol berg, M.D.
New Y ork, New Y ork
November 1, 1979
CHAPTER 1
Models of Short-term Therapy
Brief treatment is no newcomer on the
psychotherapeuti c scene. Chroni cl ed in pri mi
tive archi ves of earl iest recorded history, par
ti cul arl y in Egypt and Greece, are accounts of
what we may consi der speci es of short-term
psychotherapy. I n these anci ent documents
there are transcri bed el aborate ri tual s to heal
the afflicted, to solace troubl ed souls, and to
assuage angui sh and distress. Among such i n
terventi ons are tranqui l i zi ng nostrums, bodil y
mani pul ati ons, trance i ncantati ons, persuasi ve
suggestions, and even rudi ments of rei nforce
ment therapy, emoti onal catharsi s, and i nter
pretati on of fantasies and dreams. El aborati ons
of these therapi es conti nue to thi s day draped
in the sophi sti cati on of modern theories. Up to
the begi nni ng of the twenti eth century methods
of treatment were short term; even the ori gi nal
Freudi an techni ques were i mpl emented over a
peri od of a few months. Gradual l y psychoana
lytic methods stretched out in ti me, and the
number of weekl y sessions i ncreased as efforts
were directed at the task of resolving resistance
to unconsci ous conflict. A few contemporari es
of Freud, notabl y Adl er, Ferenczi , Stekel, and
Rank, tried heroi call y to shorten the pro
tracted ti me of psychoanal ysi s, but thei r meth
ods were repudi ated by the official anal yti c es
tabl i shment. Some Ranki an and Stekel i an stra-
tegems survived, nevertheless, and have been
adapted to fit in wi th present-day styles and
contemporary ideol ogies.
Psychoanalytic Modifications in
Brief Dynamic Therapy
I t was Franz Al exander in 1946 who most
striki ngly chal l enged the vali dity of prol onged
ti me as a necessary component of treatment
methods directed at reconstructi ve goals. Reac
ti on to Al exanders unorthodoxy was at first
harsh, and al though he was accused of aban
doni ng the psychoanal yti c shi p, it is to his
credit that he resisted recanti ng his convictions.
Al ong wi th French he publ i shed a pi oneer
work on bri ef therapy (Al exander & French,
1946) that questi oned many of the assumpti ons
of long-term classical psychoanal ysis.
I n thei r vol ume the authors describe experi
menti ng wi th varyi ng the frequency of i nter
views, the al ternati ve use of the chai r and
couch, del i berate i nterrupti ons of treatment
pri or to termi nati on, strategi c pl ayi ng of
studi ed roles, and combi ned use of psychother
apy wi th drug and other treatments. At the
ti me thei r experi ments were consi dered as dar
ing and i nnovative. Parti cul arl y regarded as
aberrant were the emphasi s on probl em solv
ing and the consi derati on of therapy as a cor
rective emoti onal experi ence that functioned to
break up old reacti on patterns. I n some
cases, they wrote, the devel opment of a full-
fledged transference neurosi s may be desi r
able; in others it shoul d perhaps be avoided
al together. I n some it is i mperati ve that
emoti onal di scharge and insight take place
gradual l y; in others, wi th pati ents whose ego
strength is greater, i ntervi ews wi th great emo
1
2 HANDBOOK OF SHORT-TERM PSYCHOTHERAPY
ti onal tension may be not only harml ess but
highl y desi rable. All this depends upon the
needs of the pati ent in a parti cul ar phase of the
therapeuti c procedure. T he modi fi cati ons
suggested were forms of psychoanal ysi s based
on dynami c pri nci pl es that attempt to secure a
more harmoni ous envi ronmental adj ustment
wi th enhanced devel opment of ones capacities.
Frequent intervi ews over a l ong-term pe
ri od, they insisted, had a regressive conse
quence often grati fyi ng the pati ents de
pendency needs. T he ini ti al soothi ng effect of
the prol onged outl ook gradual l y becomes cor
ruptive, and the therapi st, faced wi th the task
of dri vi ng the pati ent from his comfortabl e i n
fantil e posi ti on, real i zes anew how difficult it
is to force anyone to give up acqui red ri ghts.
It was a fallacy, they contended, to assume
that an anal ysi s ori ented around regressive
materi al was more thorough than one focused
on the i mmedi ate life confl i ct. I ndeed,
regressive materi al was usual l y a si gn of neu
rotic wi thdrawal from a difficult life si tuati on.
I t was the duty of the therapi st to divert this
retreat toward new attempts to solve probl ems
from whi ch the pati ent had fled in the past.
Another di sadvantage of too frequent sessions
was that transference was not al l owed to accu
mul ate, being drai ned off in small quanti ti es at
each session, thus lessening the emoti onal par
ti cipation. They advised mani pul ati on of the
frequency of sessions to intensi fy emoti onal
reactions. A focus on the present hel ped reduce
the evolvement of a transference neuroses and
the substi tuti on of transference grati fi cati ons
for real-l ife experi ences. Putti ng into practice
what had been l earned in therapy encouraged
the bolsteri ng of sel f-confidence and the over
comi ng of neuroti c i mpai rment. T he pati ent
duri ng the course of his experi menti ng wi th
new patterns was to be forewarned of fai lures
and the need to anal yze the reasons for these
shoul d they occur, thus turni ng them to advan
tage.
Wi th the devel opment of communi ty mental
heal th facilities and the servicing of increasi ng
groups of pati ents by staffs depl eted through
shri nki ng budgets, the necessity of l i mi ti ng
ti me devoted to treatment wi thout destroyi ng
its effecti veness has reki ndl ed i nterest in
the observati ons of Al exander and French.
Moreover, restri cti on of payments to a des
i gnated number of sessions by i nsurance com
pani es has forced even those therapi sts who by
trai ni ng and conviction are dedicated to l ong
term therapy to modi fy thei r tactics and to
bri ng treatment to a hal t wi thi n the confi nes of
the all oted rei mbursement term. Economi cs
has thus had a corrosive effect on ideology,
whi ch is probabl y all to the good in a field
where bias and opi ni on have frozen profes
si onals to postul ates that could never have been
otherwi se thawed out and revi sed.
T he work of Al exander and French pro
vided the foundati on for other devel opi ng sys
tems of dynami c short-term therapy and
i nspi red a number of anal ysts who though
loyal to the teachi ngs of Freud refused to con
si der them as divine revel ati ons (Marmor,
1979). Whi l e chal l engi ng classical anal yti c
concepts, they vouchsafed the vali dity of the
dynami c desi gn. Among the best known of con
temporary contri buti ons to dynami c short-term
therapy are the wri ti ngs of Mal an, Sifneos,
and Mann.
I n the study by M al an (1963) at the
Tavi stock Cl i ni c in L ondon, the pati ents
treated were those who were abl e to expl ore
thei r feel ings and who gave the i mpressi on
they could work wi th i nterpreti ve therapy. All
of the therapi sts involved were psychoana-
lytically ori ented and wi l l i ng to empl oy an
acti ve i nterpreti ve techni que. Sessions totaled
from 10 to 40. I t was possible, Mal an wrote,
under these condi ti ons to obtai n qui te far-
reachi ng i mprovements not merel y in symp
toms, but also i n neuroti c behavi or patterns in
pati ents wi th rel ati vely extensive and long
standi ng neuroses. T he best resul ts were
achieved when (1) the pati ent was hi ghl y moti
vated, (2) the therapi st demonstrated hi gh en
thusi asm, (3) transference developed earl y,
especiall y negati ve transference, and was i nter
preted, and (4) gri ef and anger became i mpor
tant issues as termi nati on approached. T he
prognosi s was also best where the pati ent and
MODELS OF SHORT-TERM THERAPY 3
therapi st showed a strong will ingness to get i n
vol vedthe former wi th an intense desi re for
hel p through understandi ng, the l atter wi th
sympathy whi l e i nteracti ng objectivel y and not
wi th countertransference. Even deep-seated
neurotic behavi or patterns could be lasti ngly
changed. T he techni que if properl y used car
ri ed few dangers, even where penetrati ng i n
terpretati ons were made from dreams,
fantasies, and the therapi st-parent li nk of the
transference that connected the present wi th
chil dhood experi ences. Mal an modestl y sug
gested that a cruci al i ngredi ent in change
mi ght not be the techni que empl oyed, but the
nonspeci fi c factor of the anal yst appl yi ng
hi msel f enthusi asti cal l y to his techni que i r
respecti ve of whether it was anal yti c or non-
analytic.
I n a l ater study publ i shed in his book
Frontier of Brief Psychotherapy, Mal an (1976)
confi rmed his previ ous conclusions regardi ng
the uti li ty of dynami c short-term therapy and
described some pri nci pl es of selection of sui ta
ble pati ents for thi s form of treatment. I n
M al ans sampl e the pati ents were carefull y
screened. Chosen were those who appeared to
have the basic strength to stand up to uncover
ing psychotherapy, who were responsi ve to
i nterpretati on, and who could hel p formul ate
a ci rcumscribed focus around whi ch therapy
coul d be done. Severi ty of pathol ogy or
chroni city were not consi dered. Of all factors
in prognosis, moti vati on for insi ght and the
abil ity to focus on si gnifi cant materi al seemed
to be of pri mary i mportance. These were con
sidered to be measures of successful i nterac
ti ons between pati ent and therapi st. Pati ents
who were excluded were alcoholics, homosex
uals, drug addicts, those who had at one ti me
made serious suicidal attempts, who had a pe
ri od of l ong-term hospi tal i zati on, who had
more than one course of ECT , who suffered
from i ncapaci tati ng chroni c obsessi onal or
phobi c symptoms, and who were grossl y
destructi ve or self-destructive in acti ng-out. As
was predi cted, reasons for rej ecti on were that
the pati ent woul d have difficul ty in maki ng
contact, that a great deal of work woul d be
needed to develop proper moti vati on for ther
apy, that ri gid and deep-seated issues requi red
more work than the l i mi ted ti me could al l ow,
that severe dependence and other unfavor
abl e intense transference feel ings woul d be
too obstructi ve, or that depressive or psychotic
di sturbances mi ght be preci pi tated or i nten
sified.
Sifneos (1972), confi rmi ng many of M al ans
fi ndings, adds some other cri teri a of selection
for thi s form of dynami c anxi ety-provoki ng
therapy that lasts from 2 to 12 months. Sui t
abl e pati ents are those who possess five
qual i ti es: (1) existence of above-average i n
telli gence, (2) possession of at least one mean
ingful rel ati onshi p in the past, (3) abil ity to
i nteract wi th the i ni ti al i ntervi ewer whi l e
mani festi ng appropri ate emoti ons and a degree
of flexibili ty, (4) abil ity to identify a specific
chief compl ai nt, (5) wi l l i ngness to understand
oneself, to work on onesel f, to recogni ze ones
symptoms as psychol ogical , to be honest in re
veali ng thi ngs about oneself, to parti ci pate ac
tively in therapy, and to make reasonabl e
sacrifices (Sifneos, 1978).
For pati ents who are selected, sessions are
held once weekl y for 45 mi nutes in face-to-face
intervi ews. T he ini ti al i ntervi ew deals wi th
hi story taki ng, parti cul arl y a j udi ci ous con
frontati on by open-ended and forced-choice
type of questi ons. As areas of conflict and
mal adapti ve reacti ons open up, the therapi st
asks questi ons that will give hi m a cl earer pi c
ture of the psychodynami cs. He may then be
abl e to make a connecti on between the un
derl yi ng conflicts and the superfici al com
pl ai nts. Before long, transference feelings are
apt to emerge. T he therapi st must then con
front the pati ent wi th his transference feel ings
and use them as the mai n psychotherapeuti c
tool . Thi s faci li tates traci ng of ones emo
ti onal probl ems in the past and recogni zi ng
how conflicts give rise to ones symptoms.
Sooner or l ater resistance appears. T he whol e
tone of the i ntervi ews start to change, silences
appear, the whol e i ntervi ew seems f rag
mented. Confrontati on and clarificati on are
empl oyed as tools, but a transference neurosi s
4
HANDBOOK OF SHORT-TERM PSYCHOTHERAPY
is avoided. T he pati ent must be confronted
wi th his anger and his negati ve feelings, and
these may fl air up wi th the therapi sts anxi ety-
provoki ng questions. I nterpretati ons hel p cl a
rify the pati ents reactions. Awareness of his
own countertransference is vital, and the thera
pist must make sure he is not usi ng the pati ent
to gratify his own needs. Repeatedl y demon
strati ng how the pati ent deal s wi th his conflicts
and the adverse effects on hi m, the therapi st
acts as an unemoti onal l y invol ved teacher.
Tangi bl e evidence of progress is shown by the
pati ents abil ity to rel ate what is goi ng on to
past sources and by i mprovement in his i nter
personal rel ati onshi ps. T he therapi st must
work uni nterruptedl y toward termi nati on,
handl i ng his countertransference and real i zi ng
that there are certai n behavi or patterns whi ch
cannot be al tered by psychotherapy. At a pro
pitious ti me termi nati on must be discussed.
The pati ents reactions such as anger, de
pression, and fear must be anti ci pated and
handl ed.
T he fol lowing outl i nes techni cal processes in
Sifneoss techni que:
1. T he pati ent is asked to list in order of urgency
the probl ems that he woul d li ke to overcome.
2. I t is essenti al to devel op a rapi d therapeuti c
al l i ance wi th pati ent, since the pati ents posi ti ve
feel i ngs toward therapi st consti tute a chi ef thera
peuti c tool. Agreement must be reached regardi ng
the probl em to be solved.
3. T he therapi st rapi dl y arri ves at a tentati ve
psychodynami cs and the underl yi ng emoti onal con
flicts.
4. T he focus i n therapy is on these confl icts, the
obj ect bei ng to hel p the pati ent l earn new modes of
sol vi ng difficul ti es.
5. T he therapi st must conf ront pati ent wi th
anxi ety-provoki ng questi ons, hel pi ng hi m to face
and exami ne areas of diffi culty rather than to avoi d
them, and enabl i ng hi m to experi ence hi s confl icts
and to consol i date new sol uti ons for them.
6. I f successful in reachi ng the goal s set forth, the
pati ent shoul d be abl e to uti l i ze hi s l earni ng to
deal wi th the new cri tical si tuati ons in the future.
It must be remembered that the basi s of
Sifneos approach was work wi th a clinic
popul ati on of self-referred, rel ati vely wel l -edu
cated young peopl e who gave freely of thei r
ti me and were eager to hel p. Whi l e these re
qui rements are ideal, the average therapi st will
see a good number of less sui tabl e pati ents ur
gentl y demandi ng symptom rel ief whose prob
lems are li nked to i nner conflicts and who do
not fulfill the sel ection requi rements of Sifneos.
They mi ght still be consi dered for dynami c
therapy, but anxi ety-provoki ng tactics may
have to be avoided.
Sifneos has not neglected consi derati on of
other cl asses of pati ents not quali fi ed for the
anxi ety-provoki ng techni que but amenabl e to
an anxi ety-suppressi ve form of therapy.
Such therapy is desi gned for pati ents wi th
weak ego structures who habi tual l y have poor
i nterpersonal rel ati ons and are disposed to
lifelong emoti onal difficulties. Here the goal
is to di ssi pate anxi ety by such tactics as
reassurance, advice givi ng, emoti onal catharsi s,
envi ronmental mani pul ati on, persuasi on, hos
pi tal i zati on, or medi cati on. Where the pati ent
has adequate moti vati on to receive hel p, recog
nizes that his symptoms are psychol ogical , is
abl e to mai ntai n a j ob, and is wi l l i ng to coop
erate wi th the therapi st, he has the best oppor
tuni ty for relief. Sessions last from a few
mi nutes to an hour and are spaced every week,
twice a week, or oftener. Bri ef crisis supporti ve
therapy lasts up to 2 months and is ai med at
overcomi ng the emoti onal decompensati on.
Pati ents wi th serious difficulties, however, may
requi re support for a prol onged peri od.
An i nteresti ng form of dynami c bri ef ther
apy has been detai l ed by M ann (1973). A few
of the pri nci pl es were ori gi nal l y described by
Rank (1936, 1947). Stressi ng the subjecti ve
and objective meani ngs of ti me (e.g., separa
ti on, loss, death, etc.) both to the pati ent and
therapi st, M ann contends that ambi gui ty
about ti me l i mi tati ons of therapy may act as a
deterrent to acceptance of real i ty and the work
to be done. Pati ents, he avows, are bound to
chil d ti me, an unconsci ous yearni ng for
eterni ty, and must be brought to the accep
tance of real istic li mi ted adul t ti me. He out
li nes a f i x e d 12 session form of treatment based
on psychoanal yti c concepts around whi ch he
has structured a methodology. Experi ence
has demonstrated that 12 treatment sessions is
probabl y the mi ni mal ti me requi red for a
series of dynami c events to develop, fl ourish,
and be avai l abl e for discussi on, exami nati on,
and resol uti on.
The li mi ted intervi ew is concerned wi th
clarifying what the pati ent seeks from therapy.
Two or more sessions may be requi red here.
I n the course of this i nqui ry a formul ati on of
the central conflict producti ve of the present
mani festati ons of distress can be made . . . [the
therapi st] tel li ng the pati ent what is wrong
wi th hi m. Thi s may or may not accord wi th
the pati ents incentive for seeki ng help. A de
l i neati on of other unconsci ous determi nants is
attempted by exami ni ng past sources of the
central conflict. A diagnosi s is made, and there
is an assessment of the pati ents general psy
chologi cal state. There is then an esti mate of
how 12 hour sessions shoul d be di stri buted: 12
full sessions once weekly, 24 hal f-hour sessions
over 24 weeks, or 48 sessi ons of 15 mi nutes
over 48 weeks. The therapi st expresses to the
pati ent his opi ni on of the pati ents chief prob
lem and what he believes shoul d be done. He
consul ts his cal endar and announces the exact
date of termi nati on. He settl es dates and ti mes
of appoi ntments and discusses the fee. He
assures the pati ent that if they find the chosen
central issue erroneous, they will move on to
another issue. T he pati ent is then given the
privil ege to accept or reject the stated condi
ti ons. Assumi ng that the pati ent has sufficient
ego strength to negoti ate a treatment agree
ment and to tol erate a structured schedul e, ar
rangements for therapy are concluded.
T he i ntervi ews are conducted on as hi gh an
emoti onal level as possible, movi ng from adap
tive issues to defenses to geneti c ori gi ns of con
flicts. Thi s, of course, requi res that the thera
pist be empathi c and that he have a high
degree of comprehensi on of dynami cs. The
choice of the central issue will vary wi th the
therapi sts understandi ng and experi ence.
Since free associati on is i mpracti cal in short
term therapy, some other form of communi ca
ti on is needed. M ann recommends Fel i x
Deutschs associati ve anamnesi s (Deutsch,
1949) as one way of worki ng.
Even though a number of conflictual themes
vary, a common one, the recurri ng life crisis
of separati on-i ndi vi duati on is the substanti ve
base upon whi ch the treatment rests. Mastery
of separati on anxi ety serves as a model for
overcomi ng other neuroti c anxieties. Among
basi c uni versal conflict si tuati ons that rel ate to
the separati on-i ndi vi duati on theme are (1) i n
dependence versus dependence, (2) acti vi ty
versus passi vi ty, (3) sel f-suffi ci ency versus
i nadequate self-esteem, and (4) unresol ved or
del ayed gri ef. Mastery of separati on-i ndi vi d
uati on influences the mastery of all of the l at
ter conflicts. Duri ng termi nati on of therapy the
pati ent will undergo a degree of anxi ety reflec
tive of the adequacy of his resol uti on of the
separati on-i ndi vi duati on phase of his earl y de
vel opment. One or another of the four basic
uni versal conflicts will be acti vated duri ng the
termi nati on phase.
Mann advises not to compromi se the 12-
session ti me li mi t by maki ng any promi ses to
conti nue therapy after the all otted peri od has
ended. I n thi s way a fixed ti me structure is
presented to the pati ent in whi ch the drama of
establ i shi ng a dependent rel ati onshi p and of
worki ng through the crisis of separati on and
achi evement of autonomy is repeated in a set
ti ng that permi ts a more satisfactory sol uti on
than the i ndi vi dual real i zed in his past earl y
rel ati onshi ps. I n other words, we are provi ded
wi th two themes in therapy: the first, the
central issue for whi ch the pati ent seeks treat
ment, and the second, the more basic separa
ti on-i ndi vi duati on theme. T he fact that we
focus on an agreed area of investi gati on and
that the pati ent possesses knowl edge of i m
mi nent termi nati on li mi ts the extent of re
gression in the transference. T he rapi d mobi
l i zati on of a posi ti ve transference in the first
few sessions will bri ng symptom rel ief and an
outpouri ng of materi al . Al though the focus is
on the central issue, the adapti ve maneuvers of
the pati ent and the geneti c roots of the central
issue will soon become apparent. T he thera
pist, however, must resist the temptati on to
deviate from the central theme. At all times,
the therapi st is active in supporti ng, en
couragi ng, and educati ng the pati ent. Thi s
does not mean giving advice or gui dance.
About the seventh session the pati ent will
begin to sense di sappoi ntment in therapy since
he is not al l owed to tal k about all of the thi ngs
he wants to bri ng up and must confi ne himsel f
to the central issue. At thi s poi nt negati ve
transference will appear, and ambi val ence re
pl aces positive transference. Resistance rears
its head, and symptoms may return. Despi te
these reactions the therapi st must work toward
termi nati on. Thi s will be difficult for both pa
ti ent and therapi st since the emoti ons of termi
nati on and separati on (such as gri ef and anger)
will be disconcerting. T he pati ent will show
many defenses agai nst termi nati on that will
have to be handl ed.
I nterpretati on of the pati ents reactions is
i mportant as the pati ent expresses his am
bival ent feelings, the therapi st enunci ati ng the
i dea that the pati ents responses are under
standabl e since his expectati ons are not being
fulfilled. Data from the pati ents past will
all ow for a rel ati ng of the pati ents reactions to
earl y experi ences wi th parental fi gures. The
last three sessions at least shoul d be devoted to
deali ng wi th the pati ents feel ings about termi
nati on.
As to sel ection of pati ents for thi s type of
therapy, accordi ng to Mann, most pati ents are
candi dates except those wi th borderl i ne or psy
choti c probl ems. Y oung peopl e in a matura-
ti onal crisis have difficulties exquisitely re
lated to the separati on-i ndi vi duati on process.
Regardi ng therapi sts who can work wi th this
method, Mann says: I t is evident that thi s
ki nd of psychotherapy requi res a hi gh degree
of skill, knowl edge, and experi ence. K nowl
edge of the psychoanal yti c theori es of mental
functi oni ng heavil y buttressed by experi ence in
the l ong-term treatment of pati ents is the first
preparati on for thi s treatment pl an.
Another system of dynami c short-term ther
apy is described by L ewi n (1970), who, fol l ow
i ng the l ead of Bergl er (1949), consi ders
symptoms a consequence of psychic masoch
i sm, whi ch is a uni versal i ngredi ent of
neuroses. T he need to appease guil t through
sufferi ng, he avows, can prevent progress in
therapy. I deal ly, the core of the pati ents
masochi sm, his bad i ntroj ect, shoul d be ex
posed and repl aced, al ong wi th his sadisti c
consci ence. Whi l e this may not al ways be
possible, the least the therapi st can do is to
confront the pati ent wi th hi s masochi sm.
Assi gni ng all of his probl ems and symptoms to
sel f-puni shment for guil t feel ings in rel ati on to
parental fi gures provi des the pati ent wi th a
focus that, accordi ng to L ewi n, helps shorten
the therapeuti c process.
Eclectic Systems
Spurred on by communi ty need, by stric
tures on the number of sessions fi nanced by
thi rd-party payments, and by dissati sfaction
wi th the resul ts of l ong-term treatment, thera
pists of all denomi nati ons have experi mented
wi th bri efer methods and contri buted wri ti ngs
to short-term theory and practice. Some of the
techni ques are a revi val of the methods em
ployed in the preanal yti c and earl y anal yti c
peri od. Some are repl icas of establi shed case
work and counsel ing procedures. Others are
more i nnovative, being influenced by behavi or
therapy, by the contemporary emphasi s on ego
functions, by an i ncreasi ng interest in probl em
solving as a pri mary means of enhanci ng
adaptati on, as well as by a resurgent flexible
eclecticism (Grayson, 1979). Accordingl y, a
number of model s of short-term therapy have
been i ntroduced, and some of these will be
cited as exampl es. Other excellent model s un
doubtedl y exist, but they cannot be i ncl uded
because of lack of space. An exampl e of how
florid the wri ti ngs have become in short-term
therapy is the annotated bi bl i ography of Wel l s
(1976), who in revi ewi ng the l i terature up to
1974 detai l s 243 ci tati ons coveri ng maj or
j ournal s in psychi atry, psychol ogy, and social
work. These arti cl es are categori zed i nto
theoreti cal and revi ew articl es, i ndi vi dual adul t
therapy, indi vi dual therapy of chi l dren and
adolescents, group therapy, famil y therapy,
mari tal therapy, and treatment of hospi tal i zed
pati ents.
I n 1965 Bel i ak and Smal l wrote a book (the
second edition of whi ch appeared in 1978)
that di fferentiated emergency from bri ef psy
chotherapy. T hey contend that emergency
treatment is a temporary approach uti li zed in
crisis, whi l e bri ef psychotherapy is a fore
shortened appl i cati on of tradi ti onal psychother
apy, called into bei ng ei ther by the life si tuati on
of the pati ent or by the setti ng in whi ch treat
ment is offered. They offer a form of bri ef psy
chotherapy that is rooted in orthodox psycho
anal yti c theory and directed at symptoms or
mal adaptati ons, avoi di ng the reconsti tuti on of
personal i ty that may, nevertheless, come about
autonomousl y. Brief psychotherapy may stabi
lize the i ndi vidual suffici entl y so that he may
be enabl ed to conti nue wi th more extensive psy
chotherapy. T he ti me span all otted for treat
ment is one to six sessions. A positi ve trans
ference is fostered, free associati on avoided, and
i nterpretati on tempered, bei ng coupl ed wi th
other types of interventi on like medi cal, envi
ronmental , etc. Bri ef therapy, they observe, is
useful in nearl y every kind of emoti onal di s
turbance, even psychosis. Whi l e extensive re
structuri ng of the character is desi red and possi
ble, or where acti ng-out exists, however, it is
not suitable.
A detai led hi story is essential wi th a com
plete expl orati on of the presenti ng probl em,
the preci pi tati ng factors, the contemporary life
si tuati on, and the devel opmental history, i n
cl udi ng famil y rel ati onshi ps. T he object is to
understand the present illness in dynami c
terms and rel ated to precedi ng geneti c, de
vel opmental , and cul tural events. Out of this,
some i mmedi ate therapeuti c hel p may be
rendered that can take the form of a mi nor
i nterpretati on. Psychotherapy is pl anned
wi thi n the framework of what the pati ent is
wil l i ng to engage i n, in contrast to the posi
ti on taken by some therapi sts like Sifneos to
the effect that the pati ent must fit the treat
ment chosen for hi m by the expert. I n Beli ak
and Smal l s method dreams may be elicited,
proj ecti ve testi ng like the Themati c Appercep
ti on Test used, and hypnosi s empl oyed to
bri ng out repressed materi al . An attempt is
made to establ i sh causal factors in rel ati on to
preci pi tati ng inci dents and specific histori cal
events and structures. J udi ci ous use of i nter
pretati on to i mpart insight, reassurance and
support when necessary, counsel ing, gui dance,
conjoi nt famil y therapy, group therapy, drugs,
el ectroconvul si ve therapy (as in sui ci dal
depressions), and envi ronmental mani pul ati on
will call for a good deal of flexibili ty, di ag
nostic acumen, and clinical j udgment on the
part of the therapi st. Emphasi s in worki ng-
through is upon i mmedi ate l earni ng. The
mai ntenance of the posi ti ve rel ati onshi p, they
state, avoids a sense of rej ecti on in the
termi nati ng process and permi ts the pati ent to
retai n the therapi st as a beni gn, introj ected
fi gure. Treatment is ended by i nformi ng the
pati ent that the therapi st is avai l abl e in the fu
ture when needed.
The l i terature is repl ete wi th descri pti ons of
special techni ques vaunted by the authors as
uni quel y effecti ve for short-term therapy.
Thei r enthusi asm is understandabl e because
therapi sts become skill ed in certai n methods to
whi ch they are by personal i ty, operati onal
style, and theoreti cal bias attuned. Lest we be
come too rhapsodi c over any set of methods,
however, we must remember that whi l e they
may be effective in the hands of some, they
may not be useful for all therapi sts. Matchi ng
pati ent and method is also a chal l engi ng prob
lem (Burke et al, 1979). Except for a few syn
dromes, such as behavi or therapy for phobi as
and pharmacotherapy for psychoses, outcome
studies fail to credi t any special i nterventi ons
wi th global superi ori ty over other approaches.
I ndeed, stati sti cs indi cate equi val ent i mprove
ment rates for a host of avai l abl e techni ques.
Neverthel ess, a study of the vari ous modal ities
in contemporary use is rewardi ng if no more
than to provi de us wi th model s that may sel ec
tively be useful.
Among the most common techni ques, in ad
dition to those previ ously cited under dynami c
therapi es, are interpretive methods that draw
thei r substance from classical (Freudi an) and
noncl assi cal (A dl eri an, Stekel i an, Ranki an,
J ungi an, and Rei chi an) psychoanal ysi s as well
as from behavioral models. T he list that fol
lows includes the more formal modal i ti es cur
rently in use:
1. Autoge nous t raining (Crosa, 1967; L uthe,
1963; Schul tz & L uthe, 1959).
2. Behavioral models (Ayl l on & Azri n, 1968;
Bandura, 1969; Crowe et al, 1972; Ferber et al,
1974; Ferster, 1964; Franks, 1964; Franks &
Wi l son, 1975; Ghadi ri an, 1971; Hand & L a-
Montagne, 1974; Hofmei ster, 1979; L azarus, 1976;
L i ck & Bootzi n, 1970; Patterson, 1973a, 1973b,
1974; Ri chardson & Sui nn, 1974; Stuart, 1969;
Sui nn et al, 1970; Wol pe, 1964).
3. Bioenergetics (L owen, 1958; Pal mer, 1971).
4. B io f e e d b a c k (Bl anchard & Y oung, 1974;
Gl ueck & Stroebel , 1975; Stroebel & Gl ueck,
1973).
5. Cas e wor k t h e r a p y (K erns, 1970; Upham,
1973; Watti e, 1973; A. Wol berg, 1965).
6. Cognitive learning (Bakkar & Bakkar-Rab-
dau, 1973; Greene, 1975).
7. Cognitive t herapy (Beck, 1971, 1976; Ellis,
1957, 1965, 1973; Gl i cken, 1968; Rush, 1978).
8. Confrontation methods (G. Adl er & Bui e,
1974; G. Adl er & Myerson, 1973; Garner, 1970a,
1970b; Godbol e & Fal k, 1972; K aswan & Love,
1969; Sifneos, 1972).
9. C o u n s e l i n g m e t h o d s (Gross & Deri dder,
1966).
10. Dance a n d m oveme nt t herapy (Smal l wood,
1974).
11. Decision t herapy (Greenwal d, 1974).
12. E m o t io n a l catharsis (Ni chol s, 1974).
13. E S T (Kettl e, 1976).
14. Gestalt t herapy (Peri s, 1969; A. C. Smi th,
1976).
15. G oal a t t a i n m e n t s c a l ing (L a Ferri ere &
Cal syn, 1978).
16. Gu id ed affective imagery (Koch, 1969).
17. H y p n o s i s (Crasi l neck & Hal l , 1975;
F rankel , 1973; M orra, 1967; Rabki n, 1977;
Spi egel , 1970; Spi egel & Spi egel , 1978; Stei n,
1972; Wol berg, 1948, 1964, 1965).
18. Int e rp r e t i v e methods (K. A. Adl er, 1972;
Ansbacher, 1972; Barten, 1971; D. Beck, 1968;
Davanl oo, 1978; Davanl oo & Benoi t, 1978;
Gi l l man, 1965; M . Moreno, 1967; Smal l , 1971;
Wahl , 1972).
19. M e d i a t ion (Carri ngton, 1977; Carri ngton &
Ephron, 1975).
20. M i li e u t her apy (Becker & Gol dberg, 1970;
Cl ark, 1972; Gol dberg, 1973; K nobl och, 1973;
Raski n, 1971; Stai nbrook, 1967; V i sher &
O Sul l i van, 1971; Wi l ki ns, 1963).
21. M u l t i m o d a l t herapy (L azarus, 1976).
22. Persuasion (Mal tz, 1960).
23. P r i m a l t her apy (J anov, 1970).
24. P r o g r a m m e d p s y c h o t h e r a p y (H. Y oung
1974).
25. Psychoimagination t her apy (Shorr, 1972).
26. Psychosynthesis (Ti en, 1972).
27. R e a l it y th e r a py (Gl asser, 1965; Gl asser &
Zuni n, 1972).
28. Rel a x a t io n (Benson et al , 1974).
29. Scream t her apy (Casri el , 1972).
30. S e n s i t i v i t y t r a i n i n g (Quaytman, 1969;
Schutz, 1967).
31. Social t her apy (Bi erer, 1948; Fl ei schl &
Wol f, 1967).
32. Somatic t her apy (Dasberg & V an Praag,
1974; Hayworth, 1973; Hol l i ster, 1970; K al -
i nowsky & Hi ppi us, 1969; Ostow, 1962).
33. Str u c tu r a l integration (Rol f, 1958; Sperber et
al, 1969).
34. Sy m bo l d r a m a (L euner, 1969).
35. Transactional analysis (Brechenser, 1972;
Hol l ensbe, 1976; J ohnson & Chatowsky, 1969;
Sharpe, 1976).
36. Videotape pla yb a ck (Al ger, 1972; Berger,
1970, 1971; Gonen, 1971; Mel ni ck & Ti ms, 1974;
Si l k, 1972).
Less formal therapi es have drawn on the fol
lowi ng techni ques:
1. B u d d h is t Sal ipatthana, or mi n d f ul n e ss medi
tation (Deatherage, 1975).
2. Co mmunic ation theory (Kusnetzoff, 1974; R.
C. Marti n, 1968).
MODELS OF SHORT-TERM THERAPY
9
3. Dream analysis (Merri l l & Cary, 1975).
4. E m o t i v e - r e c o n s t r u c t i v e p s y c h o t h e r a p y
( ER P) , whi ch combi nes the use of i magery wi th hy
perventi l ati on (Ful chi ero, 1976; Morri son & Co-
meta, 1977).
5. F i s c h e r - H o f f m a n p r o c e s s (A. C. Smi th,
1976).
6. Flomp m e t h o d (Hagel i n & L azar, 1973).
7. M o n t a t her apy (Reynol ds, 1976).
8. N ai k an (I shi da, 1969).
9. Paradoxical i n t e n t i o n (Frankl , 1965, 1966).
10. Social sk ills t raining (Argyl e et al , 1974).
11. Social sy stems approaches (Cl ark, 1972).
12. St ory telling (De L a Torre, 1972).
13. Team sy stems approaches (Dressi er et al,
1975).
14. T h e r a p e u t i c p a r a d o x t e c h n i q u e (F ul
chi ero, 1976).
Special techni ques have al so been recom
mended for parti cul ar syndromes:
1. Conversion reactions (Di ckes, 1974).
2. Depressive reactions (Campbel l , 1974; Neu et
al , 1978; Regan, 1965; Sokol , 1973).
3. H y s t e r i c a l p e r s o n a l i t y d i s o r d e r s (Sei bovi ch,
1974).
4. Obsessive-compulsive disorders (Suess, 1972).
5. Phobias (Skynner, 1974).
6. P s y c h o s o m a t i c c o n d i t i o n s (M entzel , 1969;
Meyer, 1978; Meyer & Beck, 1978).
7. S e x u a l p r o b l e m s (K apl an, 1974; Levi t, 1971;
Mears, 1978; Spri ngman, 1978).
8. S m o k i n g habits (Marrone et al , 1970; H.
Spi egel , 1970).
9. Unresolved g r i e f (Vol kan, 1971).
10. U n t o wa r d reactions to p h y s i c a l illness (E. H.
Stei n et al , 1969; T uckman, 1970).
11. War neuroses (Pruch & Brody, 1946).
Moreover, selected i nterventi ons have been
advised for specific categories of pati ents:
1. Alcoholics (K ri mmel & Fal key, 1962).
2. D y i n g p a t i e n t s (Cramond, 1970).
3. Geriatric p a t i e n t s (Godbol e et al , 1972; Gol d-
farb & T urner, 1953).
4. Univer sity st u d e n ts (Bragan, 1978; Ki l l een &
J acobs, 1976; L oreto, 1972; W. Mi l l er, 1968).
T he use of short-term approaches in pri
mary care and medi cal setti ngs has been
described by Bl eeker (1978), Budman et al
(1979), Conroe et al (1978), and K i rchner et al
(1978). Al though not focused directl y on short
term therapy, the contri buti ons of Strupp
(1972) and Frank (1973) to rel ated aspects of
treatment are noteworthy.
Short-Term Therapy in Outpatient Clinics
T he urgency in many clinics to al ter tactics
of psychotherapy in line wi th the requi rements
of the pati ents being treated as well as the di s
posi ti on of the communi ty has resul ted in the
shi fti ng from l ong-term treatment toward
eclectic short-term programs. For exampl e, at
the Montreal General Hospi tal in Canada a
change in the treatment phi l osophy away from
the long-term objective of personal i ty recon
structi on was necessary for practi cal reasons:
(1) because the ki nd of pati ent popul ati on the
clinic dealt wi th was unabl e to uti li ze a
prol onged therapeuti c rel ati onshi p and (2) be
cause some of the therapi sts were not fi ttingly
trai ned or were unabl e to spend a sufficiently
long ti me to follow through wi th appropri ate
treatment measures (Davanl oo, 1978; Straker,
1968). The resul t was a hi gh dropout rate or
the rapi d devel opment of chroni c clinic de
pendency. I n addi ti on, wai ti ng lists became
so great that acute emoti onal cri ses could not
receive needed help. A bri ef psychotherapy
program was started in 1961 based on psy
chodynami c formul ati ons. Pati ents who did
not quali fy for the program recei ved support-
tive kinds of help, pharmacotherapy, social
service assistance, ward care, and so on, ac
cordi ng to thei r needs. Wi th this pragmati c
change the dropout rate decreased over five
ti mes, and staff interest and moral e were
greatl y strengthened. Fol l ow-up studi es 2
years after i ntake revealed that 66 percent of
the total case load had benefi ted sufficiently to
need no further therapy. Pati ents selected for
and treated wi th bri ef psychotherapy showed
an 84 percent remission rate.
L argel y through Davanl oos efforts three
I nternati onal Symposi a were organi zed, in
1975, 1976, and 1977, bri ngi ng together pro
fessi onal s i nterested in bri ef approaches.
Davanl oos methods resembl e those of Sifneos
and Mal an. Eval uati on cri teri a for dynami c
therapy are, first, the assay of the abil ity to es
tabl i sh meani ngful rel ati onshi ps based on the
pati ents havi ng had previ ous emoti onal ties
wi th other people. Even in the first i ntervi ew
the pati ents capaci ty to interact wi th the ther
apist will be obvious. Second, there is an esti
mate of the egos capaci ty to experi ence and
tol erate anxi ety that will be mobi li zed in the
intervi ew. Thi rd, moti vati on for true change
must be differentiated from a desi re to satisfy
an infanti le need in therapy. Fourth, psycho
logical mi ndedness and capaci ty for i ntrospec
tion are j udged carefull y. Fifth, the most cru
cial cri terion is the pati ents abil ity to respond
constructi vel y to i nterpretati on duri ng the
eval uati on intervi ew. Sixth, the degree of i n
telli gence is an i mportant factor in the choice
of approach. Seventh, the eval uator must de
termi ne the ri chness and fl exibility of avai l abl e
defenses since these correl ate wi th effective
uti l i zati on of dynami c therapy. Davanl oo is
wedded to cl assical anal yti c formul ati ons, such
as the structural hypothesis, and frames his
l anguage in these terms. There is general
agreement among most therapi sts wi th Davan
l oos belief that selection of a psychothera
peuti c focus is vital in short-term therapy and
that identification and understandi ng of the
psychodynami cs and psychological processes
underl yi ng the pati ents psychol ogical prob
l ems is the key i ssue in the eval uati on
process.
Other clinics that have remodel ed the struc
ture of thei r services al ong short-term lines
al so report an i mproved remi ssi on rate among
pati ents and a hei ghtened staff moral . The
number of sessi ons devoted to treatment is con
sidered arbi trary and has tended to cluster
around l ower li mi ts, whi ch in some studies
have yielded resul ts equal to treatment wi th
numeri cal l y hi gher sessi ons. Errera et al
(1967) compared the resul ts of pati ents at the
Y al e-New Haven Medi cal Center Psychi atri c
Outpati ent Cl i ni c who were in therapy for
from 6 to 10 sessi ons wi th a si mi l ar popul ati on
who recei ved 21 or more treatment sessions
and found that there was no si gnifi cant differ
ence in the i mprovement rates, nei ther as
recorded by the therapi sts nor eval uated by the
raters.
L i ngeri ng doubts as to the extent of hel p pa
ti ents recei ve has been all but di ssi pated by the
experi ence of clinics that have converted thei r
services al ong short-term li nes and conducted
fol l ow-up i nqui ri es. At the Boston Uni versi ty
Medi cal Center Psychi atri c Cli nic, for ex
ampl e, a study was conducted by Haskel l et al
(1969) as to what happened to pati ents after
12 weeks in short-term therapy. Signi fi cant
changes were found in the group as a whol e
(about 71 percent) on five measures of de
pressi on, anxi ety, and overal l i mprovement.
Even though it was felt that the type of pa
ti ent who responds to ti me-l i mi ted therapy dif
fers markedl y from the type who responds to
l ong-term therapy, no clear-cut cri teri a were
apparent.
Cli ni cs associated wi th colleges have also
noted excel lent resul ts wi th a small number of
sessions (Mi l l er, 1968; Speers, 1962; Whi t
ti ngton, 1962). Because college students are at
an age level where probl ems in identity, reso
lution of dependency wi th emergence of au
tonomy, and fi rmi ng of sexual rol e are bei ng
worked through, they are, as a group, bound
to experi ence a good deal of stress. T he pres-
ence of a facility that can offer them crisis- students. For exampl e, a revi ew of 3,000
ori ented psychol ogi cal servi ces can be ex- students who appl i ed for hel p at the City
tremel y helpful in fosteri ng a better adj ust- Coll ege of San Franci sco showed that the
ment. Experi ence indi cates that rel ati vely few average number of contacts was below three
sessions are necessary for the great maj ori ty of (Amada, 1977).
Walk-In Clinics and Crisis Intervention
T he growth of communi ty psychi atry has
encouraged a mul ti tude of short-term pro
grams organi zed for purposes of crisis i nter
venti on and the deal i ng wi th emergenci es (An-
nexton, 1978; Donovan et al, 1979; D. Gol d
stein, 1978; Robbi ns, 1978). Wal k-i n clinics
that bri ng hel p to vi rtual l y thousands of peopl e
have sprouted throughout the country. An ex
ampl e is the I ntake Recepti on Service at the
Psychi atri c Cl i ni c of the Mai moni des Medi cal
Service in Brookl yn, N.Y ., whi ch functi ons as
a wal k-i n clinic offering i mmedi ate hel p to
anyone appl yi ng (Gel b & Al l man, 1967). Four
to eight i ndi vi dual sessions are given. I f more
therapy is needed, maxi mal use is made of
group and famil y therapy. Professi onals from
different discipl ines are used, i ncl udi ng psy
chi atri sts, psychol ogi sts, psychi atri c soci al
workers, and psychi atri c nurses. An experi
enced therapi st may be accompani ed by a ther
apist in trai ni ng, who parti ci pates as an ob
server. Thus the session operates as a trai ni ng
tool. I ndi cati ons for referri ng a pati ent to a
psychi atri st therapi st are any of the following:
(1) somati c symptoms, (2) mental illness in a
pati ent who is dangerous to hi msel f or others,
(3) a need for medi cati ons, (4) hi story of at
tempted or threatened suicide, or (5) a special
request for a psychi atri st. T he approach
uti li zed is dynami cal l y ori ented and is not con
si dered, in the words of Gel b and Al l man
(1967) an emergency shortcut or a poor sub
stitute for an unattai nabl e ideal but is, in itself,
the most effective and human approach to our
pati ents. . . . I mmedi ate, active, emphati c and
accurate confrontati on wi th neuroti c functi on
ing is more effective than years of passive
worki ng-through. Pati ents who requi re more
hel p after therapy ends are invited to return
anyti me the need ari ses, but not on a con
ti nui ng basis. Thi s approach has resul ted in a
60 percent i mprovement rate wi thi n five visits.
Thi s i mprovement rate, that is about two-
thi rds of the pati ents recei ving therapy, is
substanti ated by many other wal k-i n clinics
(Gottschal k et al, 1967; J acobson & Wi l ner,
1965). I n a l arge study of over 8,000 pati ents
treated on an emergency basi s onl y 10 percent
requi red conti nui ng l ong-term therapy
(Col eman & Zwerl i ng, 1959). T he val ue of
short-term group crisis i nterventi on has also
been demonstrated. I n a study of 78 cases
recei ving six group sessions compared wi th 90
control cases in unl i mi ted groups or indi vi dual
therapy, the short-term group cases demon
strated greater i mprovement on a 5-poi nt scale
of functi oni ng (Trakas & Ll oyd, 1971).
Wal k-i n clinics desi gned to provi de i m
medi ate goal -l i mi ted hel p (Bel i ak, 1964;
Col eman & Zwerl i ng, 1959; J acobson et al,
1965; Normand et al, 1967; Peck et al, 1966)
general l y concern themsel ves wi th crisis i nter
venti on and usual l y restri ct the total number of
sessi ons to six or less. Referral for more ex
tended care is provi ded where necessary. Al
though the work-up done in different clinics
will vary, it general l y incl udes some dynami c
formul ati on of the probl em, an assay of exist
i ng ego strengths and weaknesses, and an esti
mate of the degree of pathogeni ci ty of the cur
rent envi ronment. Toward thi s end Normand
et al (1967) have described a j oi nt i ni ti al i nter
view conducted by a psychi atri st-soci al worker
team. Such a team maxi mi zes the selecti on of
an approach to the existi ng probl em and
outl i nes a bl uepri nt for acti on. A worki ng hy
pothesis is formul ated attempti ng to rel ate
i ntrapsychi c and/or envi ronmental aspects to
the di sturbed behavi or or the symptoms, and it
is around thi s hypothesi s that choice of i nter
venti ons is made from a wi de range of sup
portive, educati onal , and i nsi ght-ori ented ap
proaches. Shoul d no i mprovement occur, the
worki ng hypothesi s is reformul ated. Thi s ap
proach has proven itself to be practi cal as an
aid to provi di ng hi gh qual i ty mental heal th
services for the poor in the face of even
overwhel mi ngl y i mpossi bl e envi ronmental
depri vati ons. There is a feel ing that pati ents
from l ower socioeconomic classes do better
wi th short-term cri si s i nterventi on therapy
than wi th any other approach (Haskel l et al,
1969; Meyer et al, 1967; Sadock et al, 1968.)
Wal k-i n clinics thus provi de a vital need in
the practice of communi ty psychi atry by mak
ing treatment i mmedi atel y and easily accessibl e
to all classes of pati ents. Many probl ems can
be managed through thi s means that otherwi se
woul d go unattended. On the basis of an anal
ysis of many intervi ews in the psychi atri c
wal k-i n clinic of the Massachusetts General
Hospi tal in Boston, whi ch handl es about 40
wal k-i n pati ents each day (15,000 visits per
year), L azare et al (1972) have listed 14 cate
gories of pati ents.
1. Pati ents who want a strong person to protect
and control them. ( Pl ease take over. )
2. Those who need someone who wil l hel p them
mai ntai n contact wi th real i ty. ( Hel p me know I
am real . )
3. Those who feel so empty they need suc-
corance. ( Care for me.)
4. Those who need some cli ni c or person around
for securi ty purposes though the contact be occa
si onal . ( Al ways be there. )
5. Those ri dden wi th gui l t who seek to confess.
( T ake away my gui l t. )
6. Those who urgentl y need to tal k thi ngs out.
( L et me get it off my chest )
7. Those who desi re advi ce on pressi ng issues.
( Tel l me what to do. )
8. Those who seek to sort out thei r confl i cting
ideas. ( Hel p me put thi ngs i n perspecti ve. )
9. Those who trul y have a desi re for sel f-under-
standi ng and i nsi ght i nto thei r probl ems. ( 1 want
psychotherapy. )
10. Those who see thei r di scomfort as a medi cal
probl em that needs the mi ni strati ons of a physi ci an.
( I need a physi ci an.)
11. Those who real l y seek some practi cal hel p
l i ke di sabi l i ty assi stance, l egal ai d, or other i nter
cessi ons in thei r life si tuati on. ( I need your legal
powers )
12. Those who credi t thei r diffi cul ty to ongoi ng
current rel ati onshi ps and want the cl i ni c to i nter
cede. ( Do it for me. )
13. Those who want i nformati on as to where to
get hel p to satisfy vari ous needs, actual l y seeki ng
some communi ty resource. ( Tel l me where I can
get what I need. )
14. Nonmoti vated or psychoti c persons who are
brought to the cl i ni c agai nst thei r wi ll . ( I want
nothi ng. )
Where the therapi st is percepti ve enough to
recogni ze the pati ents desi re and where he is
capabl e of grati fyi ng or at least acknowl edgi ng
that he understands the request, he will have
been able to start a worki ng rel ati onshi p.
Shoul d he bypass the pati ents i mmedi ate pl ea
for hel p or probe for confl icts and other dy
nami c forces underl yi ng the request, therapy
may never get started. Obvi ousl y, fulfilli ng the
pati ents desi re al one may not get to the bot
tom of the pati ents troubl es, but it will be an
avenue through whi ch one will be abl e to coor
di nate and uti l i ze the data gathered in the
di agnosti c eval uati ng i ntervi ew. I n cl inics or
pri vate therapy where there is lack of con
gruence between what the pati ent seeks and
what the therapi st decides to provi de, the
dropout rate after the first i ntervi ew i s1as
hi gh as 50 percent (Borghi , 1968; Hei ne &
Trosman, 1960).
T he cl ai m that short-term treatment accords
wi th superfi ci al i ty of goal s has not been
proven, especi all y where therapy is conducted
al ong even modest dynami c li nes. Thus, a type
of crisis i nterventi on that ai ms at more than
symptom rel ief is described by M. R. Harri s et
al (1963), who treated a group of 43 pati ents
wi th up to seven sessions wi th the objective of
(1) resoluti on of the stress factor preci pi tati ng
the request for hel p and (2) clarifying and
resolving, if not the basic confl ict, the second
ary deri vati ve conflicts acti vated by the cur
rent stress si tuati on. Our hypothesi s is that
such expl orati on and worki ng through fa
cil itated the establ i shment of a new adapti ve
bal ance. Duri ng therapy the moti vati on for
further treatment was al so evaluated. Thi rty-
eight (88 percent) of the pati ents were helped
by bri ef therapy. Thi rteen (30 percent) of the
pati ents conti nued in l ong-term treatment.
Three pati ents (7 percent) returned for a
second bri ef series of contacts. Duri ng i nter
vi ewi ng wi th thi s treatment, efforts were made
to establi sh connections between conflicts and
the preci pi tati ng stress since thi s enabl ed the
pati ent to be better able to cope wi th his
distress and achieve a new psychi c equi l i b
ri um. Hi stori cal materi al was uti li zed only
when it was spontaneousl y brought up and re
l ated directl y to the current difficul ty. T he au
thors decl are that where l ong-standi ng vex
ati ons exist, moti vati on for further treatment
may in fact be increased by the experi ence of a
successful bri ef therapeuti c transacti on. Adop
ti on of a psychodynami c stance in crisis i nter
venti on can enhance the qual i ty of resul ts, as
L oui s (1966) and others have poi nted out.
Of all devastati ng stressful experi ences, the
death of a loved one, or a person on whom the
survi vor is dependent, is perhaps the most mi s
managed. Apart from token consol ati ons, a
conspi racy of si l ence smoul ders under the
assumpti on that ti me i tsel f wi l l heal all
wounds. T hat ti me fails mi serabl y in thi s task
is evident by the hi gh rate of morbi di ty and
mortal i ty among survivors fol lowing the fatal
event (K raus & Lil ienfel d, 1959; Rees & L ut-
ki ns, 1967; M. Y oung et al, 1963).
Recogni ti on of these facts has led to some
crisis i nterventi on programs to provi de short
term hel p for the bereaved in the service of
both preventi on and rehabi l i tati on (Gerber,
1969; Sil ver et al, 1957; P. R. Si l verman,
1967). Success of these programs presages
thei r further devel opment and expansi on.
Gerber (1969) has described some methods for
fosteri ng emanci pati on from the bondage of
gri ef and readj ustment to present real ities.
These incl ude (1) hel pi ng the client to put into
words his or her feel ings of sufferi ng, pai n,
guil t, noti ons of abandonment and anger as
well as the nature of the past rel ati onshi p wi th
the deceased, good and bad; (2) organi zi ng a
pl an of activities that draws upon avai l abl e
resources and friends; (3) lendi ng a hand in
resolving practi cal difficulti es invol ving hous
ing, economi c, legal , and famil y rearrange
ments; (4) maki ng essential referral s for medi
cal assistance i ncl udi ng prescri pti on of drugs
for depressi on and i nsomni a and offering future
assistance. Service to a bereaved person is often
best recommended by the famil y physi ci an,
and such recommendati ons may be a requi re
ment. An i ni ti al home visit by a soci al worker
or other professi onal or trai ned paraprofes-
si onal may be necessary before the client will
accept office visits.
Dealing with Unresponsive Patients
Despi te our best efforts to shorten therapy
there will be some pati ents who will need con
ti nui ng treatment. Cli nics only too often be
come clogged wi th such chroni c pati ents whose
treatment becomes i ntermi nabl e. T hi s can
result in long wai ti ng lists and an end to ready
access to therapy for even emergency prob
lems. Thi s is not to depreci ate the value of pro
l onged treatment in some l ong-standi ng emo
ti onal probl ems. However, from a pragmati c
standpoi nt, for the great maj ori ty of chroni c
pati ents other modes of management are not
only helpful, but actual l y are more attuned to
the conti nui ng needs of these pati ents. Such al
ternati ve methods involve, perhaps for the re
mai nder of a pati ents life, occasional short
(10- to 15-mi nute) visits wi th a professi onal
person on a monthl y or bi monthl y basis,
supervisi on of drug intake, i ntroducti on into a
group (therapeuti c, social, or rehabi l i tati ve),
and uti l i zati on of appropri ate communi ty
resources. What the therapi st tries to avoid for
such a pati ent is sti mul ati ng dependency on
hi msel f personally.
An ei ght-year experi ment at an outpati ent
clinic dedicated to the therapy of the chron
ically ill at the Uni versi ty of Chi cago Hos
pitals and Cli nics is reported by Rada et al
(1969). T he clinic is open every Thursday
afternoon for 2 / i hours, pati ents being seen in
order of arri val . Pati ents are accepted only
after a diagnosti c eval uati on and initi al work
up by the referral sources to make sure they
will be sui tabl e for the clinic routi nes. The
staffing is by psychi atri c residents, medi cal
students, a social worker, receptioni st, and two
attendi ng staff supervi sory psychi atri sts, the
l atter four being the only permanent staff.
Upon arri val , the receptioni st greets the pa
ti entand if they come, the fami l yand
bri ngs the pati ent into the wai ti ng room,
where light refreshments (cookies and coffee)
are served. Pati ent i nteracti ons are en
couraged. I ndi vi dual i ntervi ews are for 15 to
25 mi nutes to ascertai n the present physi cal
and emoti onal state, to regul ate the drug i n
take if drugs are taken, to offer recommenda
ti ons for i nterveni ng acti vities, and to make an
appoi ntment for the next ti me. T he pati ents are
then returned to the wai ti ng area for more
coffee and soci ali zati on. Fami l y and couples
therapy are done if necessary. Frequency of
visits range from weekl y sessions to once every 6
months al though pati ents may return vol un
tari l y if they need hel p. Shoul d the pati ent drop
out of therapy, he is permi tted to return in
ti mes of stress wi thout havi ng to go through a
readmi ssi on procedure. After the clinic hours
the staff meets bri efly (30 to 45 mi nutes) to di s
cuss the days probl ems. T he two attendi ng psy
chi atri sts do not see i ndi vi dual pati ents (except
in emergencies); they serve as admi ni strati ve
supervi sors and acti ve parti ci pants in the wai t
i ng area experi ence and the staff group meet
ings. Pati ents see the same therapi st (a resident)
for 3 months to a year and know that they will
be transferred to another professi onal from ti me
to ti me. Di agnosti c categories vary, approxi
matel y hal f bei ng psychotic, the remai nder hav
i ng severe neuroses and personal i ty disorders.
Fees general l y support the clinic and are rel a
tively low.
Short-term Hospitalization and Its Alternatives
Shri nki ng budgets have made it mandatory
to take a hard look at costs versus benefi ts not
only in regard to psychotherapy, but also
protracted psychi atri c hospi tal i zati on. Apart
from pragmati c di sadvantages or i mpracti -
cal i ti es of cost/benefi ts, prol onged i nsti tu
ti onal i zati on fosters regressi on and paral yzi ng
dependenci espl us extended separati on from
communi ty life. These unf ortuante conti n
gencies have sponsored shifts from long-term
confi nement to short-term detenti on organi zed
around the objective of earl y di scharge. Al
ternati ves to hospi tal i zati on have al so been ex
plored. For exampl e, in an experi mental pro
gram Davi s et al (1972) demonstrated that a
team led by visiting nurses goi ng to the homes
of pati ents to oversee proper medi cati on could
prevent hospi tal i zati on and improve rel ati on
shi ps wi thi n the famil y. Another exampl e is
the fi nding by Zwerl i ng and Wi l der (1962)
that a day-care treatment faci lity could often
act as an adequate substi tute for an i npati ent
unit. There are, nevertheless, si tuati ons when
hospi tal i zati on is essential , for exampl e, to
provi de security for di sturbed or sui cidal pa
ti ents or where cri si s-ori ented therapy is
needed and it cannot be done on an outpati ent
basis. A li mi ted hopsi tal stay may be all that is
requi red. Even in chi l dren short-term hospi tal
ization is someti mes consi dered (Shafii et al,
1979).
That it is possible to reduce the ti me of hos
pi tal i zati on of pati ents admi tted to an i nsti tu
ti on through a crisis i nterventi on program
uti li zing a wi de range of treatment modal i ti es
has been demonstrated by Decker and Stub-
blebi ne (1972) in a 2i i year study of 315
young adul ts. At the Connecti cut Mental
Heal th Center a program of bri ef (3-day) i n
tensive hospi tal i zati on and 30-day outpati ent
care has been used to deal wi th pati ents
requi ri ng hospi tal i zati on (Wei sman et al ,
1969). I n the hospi tal , cri si s i nterventi on
methods are empl oyed toward restori ng the
pati ent to the previ ous level of functioni ng. On
discharge there is a 1-month outpati ent peri od
of treatment, whi ch is consi dered a fol l ow-up
measure. An agreement is made in advance as
to this li mi ted ti me arrangement to i nsure that
treatment does not go on indefinitely. One ef
fect of the ti me-l i mi ted contract is to establi sh a
set whi ch promotes rapi d identification of
probl em areas and requi res pati ents to begin
quickl y developi ng new modes of deal i ng wi th
these probl ems. The pati ent is seen each day
by several staff members who are usual l y
nurses or aides in order to di scharge de
pendence on the godli ke fi gure of the doctor.
To expose pati ents to different tactics, a fixed
style of approach is del i beratel y not used.
Team members also interact wi th pati ents in
dail y group therapy and famil y therapy. Self-
rel i ance is stressed by focusing on the pati ents
responsibi li ty, especiall y in maki ng pl ans after
discharge. Whi l e concern and interest are
shown, the staff avoids doi ng thi ngs for the
pati ent whi ch he can be encouraged to do
hi msel f. Psychotropi c drugs are used to
di mi ni sh target symptoms. T here is earl y
famil y invol vement, and the enti re hospi tal day
is structured wi th activities. As for results, at
the end of bri ef hospi tal i zati on of the fi rst 100
pati ents, 18 percent were transferred for longer
i npati ent care after the 3-day intensive experi
ence since they requi red l onger term hospi tal i
zati on. Another 19 percent were rehospi tal i zed
wi thi n 1 year of di scharge. At the 1-year
fol l ow-up routi ne al most two-thi rds of all pa
ti ents had not been rehospi tal i zed or trans
ferred after the 3-day i ntensi ve hospi tal treat
ment. Thi s compares favorabl y wi th rehospi
tal i zati on rates wi th l onger term therapy.
T he function of the usual short-term hospi
tal i zati on (i.e., 3 to 4 weeks) is, fi rst, to bri ng
about a rapi d remi ssi on of symptoms and,
second, to prepare the pati ent for, and to see
that there is made avai l abl e, an adequate
aftercare program. T he fi rst objective is ac
compl ished by drug therapy and ECT if neces
sary, indi vi dual famil y and group treatment,
and mi li eu, occupati onal , and rehabi l i tati ve
therapy, all tai l ored to the pati ents needs. Be
cause of the emphasi s on the control of
symptoms rather than al terati ons in the per
sonal ity structure, cri sis-ori ented behavi oral
approaches al ong eclectic li nes are most com
monl y practiced. I deal ly, bri ef hospi tal i zati on
shoul d provi de psychotherapy to prepare the
pati ent for outpati ent care (A. B. Lewi s,
1973). The second objective, al though most
cruci al to avoid the revol ving door syndrome,
is too often neglected. Unl ess the posthospi
tal envi ronment is regul ated, ensui ng stress
will al most inevi tabl y produce a rel apse in
symptoms. Among the measures necessary to
prevent thi s are the adj ustment of living ar
rangements so that the least strai n is imposed
on the pati ents copi ng capaci ties, the use of
hal fway houses, facilities provi di ng day and
ni ght care, supervised drug management, and
rehabi l i tati ve, social, heal th, and recreati onal
programs. T he selective use of communi ty
outpati ent psychotherapy of a not too intensive
vari ety wi th an empathi c therapi st can be most
helpful.
T o safeguard agai nst the fragmentati on of
an aftercare program, conti nui ty of treatment
wi th one professi onal person can hel p prevent
treatment degenerati ng into management of a
series of emergenci es wi th inevi tabl e rehospi
tal i zati on. Thi s person must have establi shed a
rel ati onshi p wi th the pati ent and know the hi s
tory of the l atters illness and somethi ng about
the dynami cs. What causes most pati ents to
return to the hospi tal is poor aftercare pl an
ni ng wi th little or no provi sion for some kind
of ongoi ng i ndi vi dual or group psychotherapy,
i mproper moni tori ng of drug mai ntenance,
fai l ure to uti li ze emergency measures when
needed (such as ECT), stressful li ving condi
tions, poor housi ng and i nadequate provi sion
of essential soci al and rehabi l i tati ve services.
Where possible, the therapi st who has worked
wi th the pati ent in the hospi tal shoul d be the
one who conti nues seeing the pati ent and di
recting the aftercare program. Someti mes the
hospi tal may provi de some of the aftercare
services, but the admi ni strators shoul d al ways
strive to i ntegrate the pati ent into the commu
ni ty as rapi dl y as possible. Thi s is usual l y the
best course. Where return to a famil y woul d be
di sturbi ngfor instance, where members are
too hostil e, demandi ng, and rej ecti ngpl ace
ment in a hal fway house and l ater in a foster
home may be advisable.
Short-term hospi tal i zati on does not el i mi
nate i ntermedi ate-term intensi ve treatment in a
hospi tal , that is, 130 to 180 days, or for l onger
peri ods where the ai m is a personal i ty change.
However, custodial care in pati ents who re
qui re conti nui ng management can usual l y be
achieved outsi de of a hospi tal facility. Wayne
(1976) has appropri atel y poi nted out that what
determi nes the duration of hospi tal i zati on is
not the diagnosi s but the persistence of a habi
tual di srupti ve life-style, severe famil y, social,
and occupati onal difficul ties, and the presence
of a serious physi cal disabil ity or hypochon
driasis. Where the proper envi ronment is made
avai l abl e and aftercare supervisi on promoted,
even chroni c psychotic persons can make an
adj ustment outside of an i nsti tution.
There is evidence that short-term famil y
therapy can cut down the need for hospi tal i za
ti on in acute cases of decompensati on. T o com
pare the outcome of outpati ent famil y crisis
therapy wi th hospi tal i zati on, Fl omenhaft et al
(1969) treated wi th the former modal i ty 186
pati ents in need of admi ssi on to a mental hos
pital. A control group of 150 pati ents recei ved
hospi tal i zati on. T he outpati ents recei ved an
average of five office visits, one home visit, and
three tel ephone contacts. T he results of outpa
ti ent therapy were at least as good as hospi tal i
zati on, in addi ti on to bei ng more economi cal
and less sti gmati zi ng. I n a study by L angsl ey
et al (1969) 75 acute decompensated psy
chi atri c pati ents were given an average of six
sessi ons of fami l y crisis therapy organi zed
al ong directi ve and supporti ve lines. A control
group of 75 received hospi tal i zati on and i npa
ti ent treatment. I n the famil y therapy group 61
pati ents were abl e to avoid hospi tal i zati on and
onl y 14 pati ents requi red hospi tal i zati on
wi thi n a 6-month peri od. I n the hospi tal i za
ti on group 16 pati ents requi red rehospi tal i za
ti on after di scharge wi thi n a 6-month peri od.
Onl y an average of 8.1 days were requi red for
i mprovement i n the experi mental group as
compared to 24.3 days in the hospi tal i zed
group. Two years l ater a si mi l ar study was
repeated wi th a l arger group of pati ents. I t
confi rmed that most pati ents wi th short-term
fami l y therapy coul d avoi d hospi tal i zati on
(L angsl ey et al, 1971). At the Eastern Penn
syl vani a Psychi atri c I nsti tute these studi es
were repl i cated, i ndi cati ng the efficiency of
short-term fami l y therapy (Rubenstei n, 1972).
Focal therapy in a day hospi tal may also be
empl oyed as an al ternati ve treatment (Frances
et al, 1979).
Short-term Child and Adolescent Therapy
T he questi on is often asked as to whether it peri od of treatment of the chil d pati ent and
is possible to do child therapy on a short-term parents is customary. There are some studies
basis since it is general l y accepted that a long however, that indi cate that good resul ts may be
obtai ned wi th short-term approaches (Cramer,
1974; Kerns, 1970; Marti n, 1967; Negele,
1976; Nicol, 1979; Phi l l i ps & J ohnston, 1954;
Rosenthal & Levine, 1970, 1971; Shaw et al,
1968; Skynner, 1974). Other studies verify the
uti li ty of short-term group trai ni ng for parents
in managi ng probl ems in thei r chi l dren (G. R.
Patterson et al, 1973a; Wal ter & Gi l more,
1973; Wi l tz & Patterson, 1974). Many thera
pi sts believe that where the chil d is under 7
years of age the mai n therapeuti c work is wi th
the parents. From ages 7 to 11 the chil d and
parents are seen separatel y. From 12 on famil y
sessions seem best. Preadol escent chi l dren wi th
acute probl ems have been materi al l y hel ped by
parent groups focused on discussi ons of child
management, power ploys of chi l dren, and al
ternate approaches to probl em solving. T he
chil dren themsel ves are encouraged to experi
ment wi th more mature behavi or through
better ways of copi ng wi th peopl e and si tua
ti ons (Epstei n, 1976).
Uti l i zi ng a so-called heal th model , Wei n
berger (1971) describes a form of bri ef therapy
for chi l dren whi ch sees clients basi call y cop
i ng and adapti ng but experi enci ng probl ems
caused by i gnorance, i nappropri ate expecta
ti ons, social surroundi ngs, or other factors
whi ch do not impl i cate the parents as mal ev
olent and pathol ogi cal l y moti vated. Thi s is
seen as a preferred therapy for the maj ori ty of
chi l dren in contrast to the prevai l i ng model
of short-term treatment, whi ch is ei ther a
compressi on of l ong-term treatment methods
or an elongated diagnosti c procedure that is
appropri ate for only 5 to 10 percent of all
chi dren sent for help.
As part of the therapeuti c process, Wei n
berger states that it is i mportant to try to as
certai n how parents view the chi l ds probl em
and what thei r expectati ons are of the thera
pi st. Thi s leads to the drawi ng up of a verbal
contract of what the parents and therapi st
expect of each other. Usual l y the goal is the
el i mi nati on of undesi red behavior. The ti me
limit set is 6 weeks duri ng whi ch a maxi mum
of 12 sessions are arranged for the child and
other famil y members. T he chil d general l y is
i gnorant of why he is actual l y seeing the thera
pist, has little real noti on of his underl yi ng
probl em, and no moti vati on to do anythi ng
about it. Shoul d the chil d be aware that he is
seeing a doctor, he may regard thi s as
puni shment for hi s cri mes whi l e beli eving that
the doctor expects hi m to change in accord
wi th the wi shes of his parents. If, on the other
hand, the chil d is cogni zant of his probl em, he
may rati onal i ze it as a j usti fi ed consequence of
unfai r demands and acts by his parents and
others. I t may be essential in order to secure
cooperati on wi th the treatment pl an to work
wi th the chil d unti l he verbal i zes a probl em on
whi ch he woul d like to concentrate.
One way of focusing on the probl em in the
event the chil d seems i gnorant of it is to con
front the chil d wi th what others say about hi m
and to handl e his reacti ons to the confronta
ti on. Why does he believe he is seeing the ther
api st? Once the chil d admi ts to a behavi oral
devi ati on, other ways of reacti ng are suggested
to him. Any di storted way the chil d conducts
hi msel f wi th the therapi st may be an i mpor
tant means of bri ngi ng to his attenti on how he
behaves, how other peopl e may be affected by
his behavi or, and how he hi msel f suffers the
consequences of thei r reacti ons. These com
ments are made wi thout anger, disgust, accu
sati on, or threats of recri mi nati on, provi di ng
the chil d wi th a different experi ence in rel ati on
to an authori ty figure. Concurrentl y, the thera
pist may work wi th the parents or see the pa
ti ent together wi th other members of the
famil y in famil y therapy. I n conference wi th
the parents it is i mportant to all eviate thei r
guil t, to try to clarify what is happeni ng in
thei r rel ati on to the chil d, to expl ai n un
reasonabl e expectati ons and devel opmental
norms, and to suggest al ternati ve ways of deal
ing wi th the chi l ds behavi or. T he extent of di
rectiveness of the therapi st will vary wi th the
will ingness and abil ity of the parents to make
proper decisions on thei r own.
T he pl an of acti on and how it is carri ed out
by the chil d and parents is moni tored by the
therapi st in the remai ni ng sessions, the pl an it
self being modified or di scarded and a new one
substi tuted dependi ng on the progress that is
being made. A maj or part of this worki ng
through is to hel p the parents not only recog
nize and accept thei r own and thei r chi l ds
li mi tations, but, to set more real istic goals for
themselves as parents, and thei r chil d as a
child wi th a uni que life style of his own whi ch
must be understood, respected, and not
enmeshed in thei r own needs and probl ems
(Wei nberger, 1971). Based on 5 years experi
ence in the cli nic wi th about 3,000 cases,
Wei nberger esti mates that 50 percent of all
chi l dren can be handl ed in bri ef therapy. More
extensive therapy is requi red by 30 percent,
and hel p other than psychotherapy (special
classes, resi denti al pl acement, etc.) is requi red
by 20 percent.
Short-term Group Approaches
Manpower shortages rei nforced by the fac
tor of cost/benefi t have accel erated the use of
short-term group therapy, both for hospi
tal ized persons and outpati ents. Many group
programs have accordi ngly been i ntroduced,
uti l i zi ng techni ques that draw thei r substance
from psychoanal ysis, behavi or therapy, cogni
tive therapy, gui ded i magery or any other
theoreti cal school to whi ch the therapi sts are
dedicated.
1. Cr i s i s i n t e r v e n t i o n g r o u p s (Berl i n, 1970;
Crary, 1968; Donovan et al, 1979; Morl ey &
Brown, 1969; Stri ckl er & Al l geyer, 1967; T rakas &
L l oyd, 1971).
2. E x p e r i e n t i a l g r o u p s (Back, 1972; Burton,
1969; El more & Saunders, 1972; L ewi s & Mi der,
1973; Peri s, 1969; Rabi n, 1971).
3. Educational grou p s {Druck, 1978).
4. Behavioral g rou p s (Aronson, 1974; Fenster-
hei m, 1971; L azarus, 1968; L i berman, 1970;
Meachem & Wi esen, 1969; Sui nn et al , 1970;
Wol pe, 1964).
5. I n s p i r a t i o n a l g r o u p s (Dean, 1970- 1971;
Greenbl att, 1975; Herschel man & Freundl i ch,
1972).
6. Psychodramatic g ro u p s (Corsi ni , 1966; M or
eno, 1966).
7. Transactional groups (Berne, 1964; T. H ar
ris, 1967; K arpman, 1972).
8. Accelerated short-term g roups (Wol f, 1965).
Between 1947 and 1962 over a hundred
papers were publ i shed on j ust the last cate
gory, (A. Wol f, 1965) and si nce then more
have accumul ated.
Short-term groups are usual l y open-ended
and frequentl y conducted by cotherapi sts
(Gool i shi an, 1962; Sadock et al , 1968;
Shrader et al, 1969; Trakas & Lloyd, 1971.
Outcome studi es on groups report hi ghl y suc
cessful results, in some instances being con
si dered as more effective than i ndi vi dual ther
apy (Trakas & Ll oyd, 1971). T he uses and
abuses of groups are descri bed by I mber et al
(1979).
Short-term groups wi th chi l dren have been
gai ni ng popul ari ty (Graham, 1976; Rosenthal
& Levi ne 1970), some reports cl ai mi ng suc
cesses equal to that in l ong-term therapy
(Rosenthal & Levine, 1971). An exampl e is
the study by Burdon and Neel y (1966) who
treated 55 boys wi th repeated school failures.
A 5-year fol l ow-up showed i ncreased school at
tendance wi th 98 percent passi ng and 73 per
cent earni ng promoti ons. Some useful methods
for worki ng wi th chi l dren in groups have been
outl i ned by Rhodes (1973), Epstei n (1976),
and Levin & Rivelis (1970). Short-term group
treatment may also be helpful for mal adj usted
adolescents (Ei senberg, 1975; Ri vera & Bat-
taggi a, 1967), duri ng bri ef i npati ent care for
adolescents (Chil es & Sanger, 1977; Moser,
1975), for del i nquent adolescents (Danner &
Gamson, 1968), adolescent drug users (Deeths,
1970), and youthful offenders in a detenti on
uni t (Woul d & Reed, 1974). The need to di s
ti ngui sh between adolescents whose probl ems
are the product of entangl ements rel ated to the
devel opmental process and those whose en
counter wi th adolescence stirs up unresol ved
conflicts of earl i er stages of growth will i nfl u
ence techni ques and objectives (Sprince, 1968).
Group work wi th parents of probl em chi l
dren has al so proven rewardi ng (Epstei n,
1970; Mai zl i sh & Hurl ey, 1963; Tracey,
1970), the trai ni ng of parents in behavi oral
methods being especiall y popul ar as an effec
tive i nterventi on method (Bij ou & Redd, 1975;
Ferber et al, 1974; Patterson, 1973a, 1973b,
1974; Wal ter & Gi l more, 1973). One of the
most difficult si tuati ons for the therapi st is the
unmoti vated famil y of chi l dren wi th aggressive
behavi or di sorders. A pi l ot study at the
Uni versi ty of Chi cago School of Medi ci ne by
Safer (1966) describes work wi th 29 such
parents whose chi l dren ranged in age from 4 to
16. Fami l y, conjoi nt and i ndi vi dual sessions
produced i mprovement in most chi l dren, and
this was mai ntai ned in fol l ow-up eval uati ons
after 4 to 16 months. T he areas of change
brought about by therapy in famil ies wi th de
l i nquent adolescents has exposed some i nterest
ing fi ndings. For exampl e, Parsons and Al ex
ander (1973) discovered that one could uti li ze
in studies four i nteracti on measures that were
not a function of extraneous vari ables.
Marital therapy is also often conducted on a
short-term basi s both in groups (L ei bl um &
Rosen, 1979; Wel l s, 1975) and wi th indi vi dual
couples (Bellville et al, 1969; Fi tzgeral d, 1969;
K al i na, 1974; P. A. Marti n & Bird, 1963; P.
A. Marti n & Lief, 1973; Sager et al, 1968;
Sati r, 1965; Si mon, 1978; Watzl awi ck et al,
1967).
An i nteresti ng model is described by Ver-
hulst (1975). He has evolved an intensi ve 3-
week approach resembl i ng cognitive l earni ng
(Bakker & Bakker-Rabdau, 1973) that em
phasi zes confrontati on and probl em solving
wi th the hel p of active, enthusi asti c, faci li ta-
tive therapi sts. Other methods are outl i ned
elsewhere (Wol berg, 1977, pp. 733-740).
A number of reports have indi cated that
short-term mari tal therapy is at least as effec
tive in deal i ng wi th mari tal conflict as l ong
term therapy. Gurman (1975) revi ewed avai l
abl e data and found that a 76 percent i mprove
ment rate was achieved wi th an average of
about 16 sessions. Review studies by Barten
(1969), Reid and Epstei n (1972); and Reid
and Shyne (1969) confi rm these posi ti ve
results. Rati ngs at termi nati on and at an
average of 2Zi years l ater of 49 coupl es who
were involved in conjoi nt mari tal therapy (a
compari son of these wi th reported resul ts of
outcome studies on i ndi vi dual short-term psy
chotherapy as well as wi th another form of
conjoi nt therapy and wi th psychoanal ysi s) i n
dicate that the conjoi nt approach has some
techni cal advantages over and compares fa
vorabl y wi th these other types of treatment
(Fi tzgeral d, 1969).
Short-term fami l y therapy conti nues to grow
in popul ari ty. I ts techni ques are described by
Bartol etti (1969a, 1969b), Bl och (1973),
Deutsch (1966), Eisl er and Herson (1973),
Hal ey and Hoffman (1967), Fangsl ey and
K apl an (1968), Pi ttman et al (1966), Sati r
(1964a), and Watzl awi ck (1963). T he number
of sessions that are opti mal for fami l y therapy
is deal t wi th in experi mental eval uati ons by
Stuart and Tri podi (1973). They randoml y
assigned 73 famil ies wi th predel i nquent and
del i nquent adolescents to 15-, 45-, and 90-day
behavi oral l y ori ented treatments. Outcome
measures showed no difference between the
groups. T hus it was concluded that there is no
reason to choose l onger over shorter famil y
treatments. T he idea that bri ef fami l y therapy
yields superfici al resul ts is chal l enged by Haug
(1971), who describes a case where ego al tera
ti on coincided closely wi th rapi d and persi sti ng
al terati ons in the body i mage. However, where
the adapti ve flexibili ty of parents is blocked by
ri gid defenses or the conflict in the chil d is
markedl y i nternal i zed, tradi ti onal l onger term
psychotherapeuti c methods are probabl y more
sui tabl e (Haug, 1971).
T he combi nati on of group and fami l y ther
apy appears to possess some advantages, as
K i mbro et al (1967) and Durel l (1969) have
pointed out in thei r report of a pil ot study of
ti me-l i mi ted mul ti pl e fami l y therapy wi th
di sturbed adol escents and thei r fami l i es.
Groups of three famil ies met wi th a therapi st
for weekl y meetings. Thi s desi gn is being
uti li zed more and more and L aqueur (1968,
1972) has wri tten extensivel y on the rati onal e
and process of bri ngi ng probl em famil ies from
the same background together as a way of ex
pedi ti ng treatment.
Massing Therapy Sessions
Attempts have also been made to study the
effect of massi ng therapy sessions by l i terall y
i mmersi ng the pati ent in treatment throughout
the day. Thus Swenson and Marti n (1976)
treated pati ents on a ful l-time basis for 3 weeks
wi th combi nati ons of different modal i ti es that
they consi dered compl emented each other.
Assessing the program on 335 pati ents at the
ti me of di scharge reveal ed si gnifi cant i mprove
ment in the presenti ng symptoms, work
capaci ti es, i nterpersonal rel ati onshi ps, and
general level of comfort. A fol l ow-up study
showed that thi s i mprovement was retai ned.
Massed ti me-l i mi t therapy sessions for as
long as 10 hours consecutively have been given
(Berenbaum et al, 1969). A form of thi s ther
apy mul ti pl e i mpact therapy that has
proven successful is described by MacGregor
(1962). Gool i shi an (1962) empl oyed the tech
ni que wi th 60 famil ies and thei r probl em
adolescents. A team consi sti ng of a psychi a
trist, a psychol ogist, and a social worker met
three ti mes wi th the fami l i es for al l -day
sessions. Group and i ndi vi dual therapy focused
on maj or dynami cs and sel f-rehabi l i tati on.
Results were consi dered at least comparabl e to
conventi onal psychotherapy.
Marathon group sessions (Bach, 1966, 1967
a-d; Casri el & Dei tch, 1968; Tei cher et al,
1974; Vernal l i s et al, 1970, 1972) whi l e not as
popul ar as in previ ous years conti nue to have
thei r advocates.
Conclusion
Somehow, short-term therapy has acqui red
the reputati on of bei ng a substandard ap
proach in whi ch qual i ty of results is sacrificed
on the al tar of expediency. Superficiality of
goals, uncertai nty of results, substi tuti on of
symptoms, and a general glossing over of ef
fects are said to be inevitable. These ideas have
proven grossly inaccurate. There is ampl e evi
dence from the reported clinical experi ences
wi th short-term therapy that it has a uti li ty
not only as an economi c expedi ent, but also as
a preferred form of psychi atri c treatment.
Whatever controll ed research studies exist,
these substanti ate its val ue in i ndi vi dual ther
apy wi th adul ts, adolescents and chi l dren, as
well as in group, famil y and mari tal therapy.
A number of model s of short-term therapy
have evolved from whi ch techni ques may sel ec
tively be adapted to the worki ng styles of
psychotherapi sts trai ned in the vari ous the
oretical ori entati ons.
The actual model s in use are usual l y condi
ti oned by the experi ence and theoreti cal
ori entati on of the practi ci ng professi onals and
the pol icies of the agenci es, if any, under
whose supervi si on the work is bei ng done. T he
shortcomi ngs of some of these systems is that
they tend to be monol i thi c, ci rcumventi ng fac
tors rel ated to the specific compl ai nt and to
such elements as the stage of the pati ents
readi ness for change and preferred l earni ng
patterns. Not all persons are capabl e of uti l i z
ing the techni ques that are offered. Thi s is not
extraordi nary si nce pati ents general l y harmo
nize wi th some i nterventi ons and not wi th
others. Some do well wi th a cognitive ap
proach in whi ch they can absorb abstract con
cepts and insights that hel p them to al ter thei r
si ngul ar thi nki ng patterns. Others fai l to
benefit from such tactics. They do better wi th
behavioral techni ques, experi menti ng wi th dif
ferent modes of acti on, solidifying successful
ones though rei nforcements. Still others learn
by model i ng themsel ves after an admi red au
thori ty, general l y the therapi st, bestowi ng on
hi m virtues he may or may not possess. An ef
fective short-term therapi st is one who discerns
the needs and l earni ng procl ivi ti es of each pa
ti ent and is flexibl e enough to al ter his meth
ods as he goes along.
Ri gi d therapi sts doggedl y fol l ow a set
agenda into whi ch they wedge all pati ents wi th
little room for eclectic maneuveri ng. Yet one
hardl y ever sees a pati ent who could not uti li ze
some of the effective i nterventi ons of different
systems at successive stages of thei r treatment.
Thus a therapi st may wi th the same pati ent be
active at some ti mes and passive at others; he
may sel ecti vel y empl oy confrontati on, re
assurance, or suggestive or persuasi ve tech
niques. If fami l i ar wi th the methods, he may
uti li ze role playi ng, psychodrama, rel axati on,
hypnosi s, fami l y therapy, group therapy,
mi l i eu therapy, systemati c densensi ti zati on,
asserti ve trai ni ng, and other behavi oral tech
ni ques when necessary. He may empl oy
psychotropi c drugs when symptoms block ef
fective l earni ng. He may uti li ze the lessons
l earned from psychoanal ysi s that hel p expose
and resolve unconsci ous resistances, parti cu
l arl y transference and acti ng-out. Obvi ousl y
for best resul ts the therapi st must be hi ghl y se
lective about the modal i ti es he uses so that he
does not swamp the pati ent wi th unnecessary
activity. All therapi sts cannot be expert in, or
even aware of, every avai l abl e techni que that
exists. But sufficient flexibili ty shoul d prevai l
to prevent a stal emate when the pati ent fails to
respond to the method that the therapi st is ap
pl yi ng at the moment.
T he fact that the vari ous short-term ther
api es in the hands of competent therapi sts do
bri ng about rel ief or cure indi cates that the
parti cul ar techni ques and stratagems empl oyed
are not the onl y i mportant el ements responsi
ble for i mprovement. T he proposi ti on is invi t
ing that therapeuti c maneuvers merel y act as a
means of communi cati on through whi ch the
therapi st encourages the emergence of positi ve,
and the resol uti on of negati ve, heal i ng ele
ments (Marmor, 1966). I f a therapi st feels
most comfortabl e wi th a more acti ve approach
than wi th a less acti ve one, wi th hypnosi s
rather than formal intervi ewi ng, wi th behavi or
therapy rather than anal yti cal l y ori ented ther
apy, he will probabl y be abl e to hel p more pa
ti ents than were he to force hi msel f to use a
procedure wi th whi ch he is not at ease or
about whi ch he is not enthusi asti c. Thi s is not
to depreci ate the vi rtues of any of the existi ng
model s and techni ques. However, we do tend
to overemphasi ze techni cal vi rtuosi ty whi l e
mi ni mi zi ng the vital heal i ng processes that
emerge in the course of the hel pi ng rel ati on
shi p as a human experi ence.
CHAPTER 2
A Rationale for Dynamic
Short-term Therapy
Short-term therapy general l y has three
goals: (1) modi fyi ng or removi ng the symptom
compl ai nt for whi ch hel p is bei ng sought,
whi ch is the i mmedi ate objective, (2) produc
ing some correcti ve influence on the i ndi
vi dual s general adj ustment, and (3) i ni ti ati ng
essential al terati ons in the personal i ty struc
ture. Wi th properl y conducted treatment
we may anti ci pate substanti al or compl ete
symptom relief as well as some modi fi cati on
for the better of behavi oral coping. However,
we may scarcely have broken ground on the
thi rd goal of personal i ty reconstructi on. We
may hope, nevertheless, that the experi ence of
treatment will have set into moti on a process
following therapy that over a l ong-term peri od
will resul t in true character permutati ons.
T hat such changes do occur has been demon
strated in fol l ow-up studies of pati ents who
have recei ved appropri ate professi onal hel p
over a bri ef span. Though not anti ci pated, sig
nificant and lasti ng changes in the self-image
and the qual i ty of i nterpersonal rel ati onshi ps
have been noted.
When we revi ew the many systems of short
term therapy that address themsel ves to the
goal of personal i ty reconstructi on, we find that
the maj ori ty acknowl edge the operati on of
unconsci ous conflict, al ong wi th the condi ti on
ing of faul ty habi t responses, as a source of the
neuroti c process. I n dynami c forms of therapy
a pri me objective is hel pi ng the pati ent acqui re
greater knowl edge of onesel f i ncl udi ng ones
hi dden motives. A questi on is whether the ki nd
of treatment bei ng empl oyed can lend itself to
the achi evement of thi s objective.
Categories of Short-term Therapy
T hroughout the l i terature one fi nds a
tendency to subdi vi de short-term therapy into
three disti ncti ve categories: (1) crisis i nterven
ti on, (2) supporti ve-educati onal short-term
therapy, and (3) dynami c short-term therapy.
T he goals of crisis interventi on usual l y differ
from those in the other bri ef methods. Here,
after from 1 to 6 sessions, an attempt is made
to restore habi tual balances in the exi sti ng life
si tuati on. Supporti ve-educati onal approaches,
such as behavi or therapy, constitute forms of
interventi on that are undertaken, al ong wi th
educati onal i ndoctri nati on, to rel i eve or
remove symptoms, to al ter famil y habi t pat
terns, and to rectify behavi oral deficits. T o at
tai n these objectives, a vari ety of eclectic tech
ni ques are i mpl emented, dependi ng on the
idosyncrati c needs of the pati ent and the skills
and methodol ogi cal preferences of the thera
pist. T he number of sessions vari es, rangi ng
from 6 to 25. I n dynami c short-term therapy
the thrust is toward achi evi ng or at least start
ing a process of personal i ty reconstructi on.
Sessions here may extend to 40 or more.
Some forms of crisis i nterventi on that are
being practi ced are i ndi sti ngui shabl e from the
22
RATIONALE FOR DYNAMIC SHORT-TERM THERAPY 23
kind of counsel ing commonl y done in social
agencies. The focus is on mobi l i zi ng posi ti ve
forces in the indi vi dual to cope wi th the crisis
si tuation, to resolve remedi abl e envi ronmental
difficulties as rapi dl y as possible, uti l i zi ng if
necessary appropri ate resources in the commu
nity, and to take whatever steps are essential to
forestall future crises of a si mi l ar or rel ated na
ture. No attempt is made at diagnosi s or
psychodynami c formul ati on. Other ki nds of
crisis i nterventi on attempt provi sional ly to de
tect underl yi ng i ntrapsychi c issues and past
formati ve experi ences and to rel ate these to
current probl ems. More extensive goals than
mere emoti onal stabi l i zati on are sought.
The soci al-counseli ng forms of crisis i n
terventi on are general l y empl oyed in wal k-i n
clinics and crisis centers where l arge numbers
of cl ients appl y for hel p and where there is a
need to avoid getting involved too i nti matel y
wi th clients who mi ght get locked into a de
pendent rel ati onshi p. Visi ts are as frequent as
can be arranged and are necessary duri ng the
first 4 to 6 weeks. The fami l y is often invol ved
in some of the intervi ews, and home visits may
have to be made. The i ntervi ew focus is on the
present si tuati onal difficulty and often is con
cerned wi th the most adapti ve ways of coping
wi th i mmedi ate pressi ng probl ems. Vi gorous
educati onal measures are someti mes exploi ted
to acti vate the pati ent. T he empl oyment of
supporti ve measures and the use of other hel p
ing indi vidual s and agencies is encouraged.
T he second, more ambi ti ous, goal -di rected
forms of crisis i nterventi on are often seen oper
ati ng in outpati ent clinics and pri vate practice.
I f the assigned number of sessions have been
exhausted and the pati ent still requi res more
hel p, referral to a clinic or pri vate therapi st or
conti nued treatment wi th the same therapi st is
consi dered.
Bri ef supporti ve-educati onal approaches
have sponsored a vari ety of techni ques, such as
tradi ti onal i ntervi ewi ng, behavi or therapy, re
l axati on, hypnosi s, bi ofeedback, somati c ther
apy, Gestal t therapy, sex therapy, group ther
apy, etc., singly or in combi nati on. T he num
ber of sessions will vary accordi ng to the i ndi
vi dual therapi st, who usual l y anchors his deci
si on on how long it takes to control symptoms
and enhance adaptati on.
T he phi l osophy that enjoi ns therapi sts to
empl oy dynami c short-term treatment is the
conviction that many of the deri vati ves of
present behavi ors are rooted in needs, conflicts,
and defenses that reach into the past, often as
far back as earl y chil dhood. Some of the most
offensive of these components are unconsci ous,
and whi l e they obtrude themsel ves in officious
and often destructi ve ways, they are usual l y ra
ti onal i zed and shi elded wi th a tenaci ty that is
frustrati ng both to the victim and to those
around hi m. T he only way, accordi ng to pre
vail ing theories, that one can bri ng these
mi schi ef makers under control is to propel
them into consci ousness so that the pati ent
real i zes what he is up agai nst. By studyi ng
how the pati ent uti li zes the rel ati onshi p wi th
hi m, the therapi st has an opportuni ty to de
tect how these buri ed aberrati ons operate,
proj ected as they are into the treatment si tua
tion. Dreams, fantasies, verbal associati ons,
nonverbal behavi or, and transference mani
festati ons are consi dered appropri ate medi a for
expl orati on because they embody unconsci ous
needs and conflicts in a symboli c form. By his
trai ni ng, the therapi st believes hi msel f capabl e
of decoding these symbols. Since i mportant
unconsci ous determi nants shape ones everyday
behavi or, the therapi st tries to establi sh a con
necti on between the pati ents present per
sonal ity in operati on, such as temperament,
moods, moral s and manners, wi th earl y past
experi ences and condi ti oni ngs in order to help
the pati ent acqui re some i nsi ght into how prob
lems ori gi nated.
24
Universality of Dynamic Principles
T he subdi visi ons of short-term treatment
that have been descri bednamel y, crisis i nter
venti on, supporti ve-educati onal short-term
therapy, and dynami c short-term therapyare
artificial. I n practi ce thei r boundari es become
diffuse. Because pati ents respond selectively to
different techni ques, effective therapi sts in all
three categories of treatment will vary thei r i n
terventi ons accordi ng to the i mmedi ate prob
lems and needs of thei r pati ents. Moreover, be
cause all operate wi thi n the matri x of a rel a
ti onshi p that develops between pati ents and
therapi sts, underl yi ng personal i ty probl ems
and conflicts will surface duri ng therapy and
yield vitall y si gnifi cant dynami c materi al for
exami nati on. What the therapi st does wi th the
materi al the pati ent bri ngs up duri ng i nter
views can affect the outcome of treatment.
Indeed the techniques and interventions used
by the therapist to influence the p a t i e n t s
symptoms may be less important than the
fantasies and behavioral responses they evoke
in the patient. For exampl e, some mani festa
ti ons reflect proj ecti ons of past fears and
desi res in rel ati on to earl y authori ty figures.
These, if undetected or di sregarded, may effec
tively block therapeuti c progress. Such trans
ference resistances are extremel y common and
are probabl y the chief reason for fai lures in
therapy. Frequentl y they are apparent only in
nonverbal behavi or, dreams, fantasies, and i n
sidious acti ng-out away from the therapi sts of
fice. This is why a dynamic approach, during
which the reactions of patients to the therapist
and to the pervading techniques, constantly
assessed and taken into consideration, can
prove useful in all forms of short-term therapy.
Whi l e the intervi ew focus may be on symp
toms, envi ronmental di storti ons, and other
compl ai nt factors, the real therapeuti c work
will be organi zed around personal i ty reactions
and conflicts mobi li zed by the maneuvers of
the therapi st.
A man wi th emphysema who came to ther
apy requesti ng hypnosi s to el i mi nate his smok
ing habi t was exposed to my usual i nducti on
method. A techni que that I customari l y em
ploy is to ask the pati ent to lift his left i ndex
fi nger when he experi ences certai n thi ngs that
I suggest to hi m, for exampl e, a fantasyi ng of
certai n scenes. At the suggestion that he pi c
ture hi msel f wal ki ng al ong the street and that
he lift his left fi nger (whi ch I touched) as soon
as the i mage came to hi m, the pati ent instead
lifted his ri ght fi nger. He also resisted sugges
ti ons that hi s left arm woul d become so stiff
and heavy that he could not move it. On the
contrary, he spontaneousl y waved his arm in
the air. On termi nati on of the i nducti on, I hu
morousl y poi nted out these facts and specu
lated that his negati ng of my suggestions
was probabl y an expressi on of opposi ti onal
tendencies. Said I , smil ing, Coul d you be
an opposi ti onal character who wont all ow
hi msel f to be pushed around? Hi s i mmedi ate
response was to l augh hearti l y and to say that
peopl e consi dered hi m a stubborn cuss. It
requi red no great effort to connect his opposi
ti onal behavi or wi th a chi l dhood pattern of
asserti ng hi msel f wi th his parents and ol der
si bli ngs by di spl ayi ng negati vi sm and some
ti mes violence to avoid what he consi dered be
ing domi nated and crushed. I commented that
I certai nl y was not his parent, but that he
mi ght react to me and to what I was doi ng for
hi m as if I was somebody who wanted to
domi nate and crush him. He could easily block
hi msel f by such an atti tude from benefi ti ng
from treatment. My statement seemed like a
revel ati on to hi m. He specul ated that thi s was
probabl y why his previ ous psychotherapeuti c
effort wi th another therapi st had failed. He
never could understand why he woul d have
fl ashes of anger toward the therapi st and
woul d someti mes mumbl e to hi msel f after he
left the therapi sts office, I wont let that son-
of-a-bitch brai nwash me. He felt so ashamed
of these reacti ons that he had conceal ed them
from his therapi st, who failed to pick up the
transference resistance. By anti ci pati ng his
transference reacti on, I was able to secure his
cooperati on and to achieve a good resul t in
treatment.
Had I not uti li zed hypnosi s but j ust an or
di nary i ntervi ewi ng techni que or behavi or
therapy, the pati ent woul d undoubtedl y have
revealed his opposi ti onal tendencies were I to
look f o r themif not in his behavi or, then in
dreams and other representati ons. T he pri n
ciple that I am tryi ng to i l l ustrate is that the
therapeuti c tactics empl oyed, whi l e ai med at
rel i evi ng the i mmedi ate cri si s si tuati on or
symptomati c upset, will usual l y set into moti on
customary resistances and defensive operati ons
that may then be closely exami ned and worked
through, if possible, as a means of incul cati ng
essential i nsights. I n other words, even though
the methods may be nonanal yti c, the pati ents
reacti ons to them and to the therapi st become
an i mportant expl oratory focus, if no more
than to deal wi th obstructi ve transference and
other barri ers to change. Personal i ty modi fi ca
ti ons eventually may evolve from thi s as a se
rendi pi tous divi dend, one that may conti nue in
a propi ti ous envi ronment for an indefini te ti me
and ul ti matel y become a permanent change.
I t woul d seem prudent, obviously, in view of
the great demand for services from the rel a
tively small cadre of avai l abl e trai ned thera
pists, that, at the start, at least, short-term
therapy shoul d practi cal l y be geared toward
goals of opti mal functioni ng. Hopeful l y, how
ever, even a bri ef exposure to therapy will un
cover fundamental personal i ty conflicts, whi ch
the therapi st, if he deems the pati ent prepared
to scrutini ze them, may carefull y bri ng to the
pati ents attenti on wi th the object of invi ti ng
reconstructi ve change shoul d the pati ent trul y
desi re to move ahead in his devel opment.
We must not expect to accompl i sh miracl es
wi th dynami c short-term procedures, even
when executed wi th perfecti on. At the end of
the formal bri ef treatment peri od we usual l y
observe some al terati on of the pati ents
symptoms, an all eviation of suffering, and a
certai n degree of behavi oral correcti on. I f we
have dil igently searched for them, we will have
recogni zed fundamental character probl ems
that are likel y to create difficulties in the fu
ture, and duri ng the treatment we may have
been abl e to start the pati ent on a producti ve
path toward al teri ng self-defeati ng personal i ty
patterns. Unfortunatel y, the l atter objective is
avoided by some therapi sts. I n my opi ni on, in
most cases, thi s is because the therapi st writes
it off as unattai nabl e and hence does not appl y
hi msel f to its accompl i shment. T o repeat, we
cannot expect too radi cal a personal i ty reorga
ni zati on wi thi n the li mi ted treatment peri od.
T he most to be hoped for is the i ni ti ati on of
sufficient sel f-understandi ng to chal l enge some
values and defenses and to encourage experi
mentati on wi th new and more constructi ve
ways of rel ati ng to others and to the self. I n
thi s way a chai n reacti on may be set off, con
ti nui ng for months and even years after the
treatment peri od, that will hopeful l y lead ul ti
matel y to extensive personal i ty change. T hat
such far-reachi ng results are achi evabl e in an
i mpressive number of pati ents is the fi ndi ng
among many therapi sts who have appl i ed
themsel ves to a dynami c approach in a di s
cipl ined way. They attai ned success because
they found and worked on a specific i mportant
focus duri ng the treatment.
Dealing with Unconscious Determinants
I n pati ents wi th i ntact personal i ti es a few amel i orati on of symptoms, and no further
well-conducted sessions, however superfici al treatment will be needed. However, there are
they may seem, may suffice to bri ng about an many pati ents whose probl ems are more
26
deeply entrenched who will requi re f o r even
mere symptom relief some resoluti on of per
sonal ity conflicts that are incessantl y generat
ing troubl e for them. Even l earni ng better
modes of probl em sol vi ng requi res some
insight into i nternal forces that govern be
havior.
I t is precisely because the most di sturbi ng
sources of turmoi l so often lie beyond aware
ness that efforts in many pati ents appl i ed ex
clusivel y toward envi ronmental mani pul ati on,
persuasi on, suggestion, reassurance, reeduca
ti on, or recondi ti oni ng so often are onl y
parti al l y successful. Thi s is not to depreci ate
the effectiveness of supporti ve and educati onal
measures, for in sui tabl e pati ents, apart from
bri ngi ng about necessary rel ief from sufferi ng,
a certai n degree of personal i ty change may oc
cur through thei r i mpl ementati on. Unfortu
natel y, lasti ng characterol ogi c al terati ons are
rare. The chances are that if we real l y hope to
succeed in bri ngi ng about expli cit personal i ty
change, assumi ng that thi s is our goal, we will
have to clarify and manage i nner conflicts that
are beyond the peri phery of awareness in an
effort to promote greater sel f-understandi ng.
The questi on in short-term therapy is whether
thi s can be done briefly in a specific case and,
if so, how best it can be done.
Tradi ti onal l y, the method most often em
ployed in deal i ng wi th unconsci ous conflict is
l ong-term psychoanal ysi s. A good deal of
mi sunderstandi ng, however, still exists about
psychoanal ysis, some of whi ch stems from its
mi sappl i cati on to areas in whi ch its com
petence as a therapeuti c procedure may be
chall enged. Such mi sdi recti on has tended to
shred its authenti ci ty. Freuds enduri ng legacy
lies in his penetrati ng insights into human be
havior. These incl ude the concept of the un
conscious, the trenchant nature of behavi or,
the indelible i mpri nt of chil dhood experi ence
on character structure, the consangui nui ty of
abnormal mental symptoms and normal men
tal processes, the significance of anxi ety, the
structure of symboli sm, the nature of dreams,
and the i mportance of transference and
resi stance. T hese i nnovati ons have become
fi rml y i ncorporated into psychi atri c and psy
chological thi nki ng and have inspi red prac
ti call y all current systems of psychotherapy.
They are i ntri nsi c to our contemporary ideas
about dynami cal l y based short-term psycho
therapy.
Psychoanal ysi s in its l ong-term cl assi cal
form has not proven itself to be a practical
form of therapy in the maj ori ty of cases seek
ing hel pnot onl y because it is expensi ve and
drags on for years, but al so, even where fi
nances and a wi ll ingness to parti ci pate in a
prol onged therapeuti c rel ati onshi p are present,
only a small number of pati ents are sui tabl e
candi dates for the techni que. I dentifyi ng who
mi ght sati sfactori l y respond is di ffi cul t.
Roughl y, persons who are not too sick and not
too i mmature, a so-cal led normal -neuroti c
group, quali fy. These consti tute only a small
fracti on of the vast army of peopl e who cluster
around clinics and practi ti oners offices seeki ng
hel p for a wi de vari ety of probl ems.
Attempts to fi nd other means than cl assical
anal ysi s to expose underl yi ng sources of prob
lems conti nue to this very day. Blocki ng such
attempts are obstructi ons to surfaci ng of the
unconsci ous and the strangl ehol d that hi dden
needs and defenses have on ones val ues and
behavi or. Because such unconsci ous i n
gredi ents are frozen into the character struc
ture, efforts to demonstrate thei r unreasonabl e
ness are resisted wi th a desperate tenacity.
Are we then doomed in hel pi ng peopl e reach
reconstructi ve personal i ty transformati ons? It
is fal laci ous to conclude that a seriousl y defec
ti ve chi l dhood i mposes a life sentence on
everyone. Growth is possible at all stages of an
i ndi vi dual s life, correcti ve emoti onal experi
ences bei ng sponsored by constructi ve life
events, parti cul arl y meani ngful i nterpersonal
rel ati onshi ps. Where an i ndi vi dual has lived
through a crisis and has resolved it success
fully, he may also be rewarded wi th new and
better personal i ty responses that can serve hi m
well in handl i ng future stressful si tuati ons.
T he idea that the unconsci ous is forever con
ceal ed unless uprooted by formal psychoana
lytic therapy is no l onger accepted by disciples
of modern cognitive approaches who contend
that an i ndi vidual is not a helpl ess pawn of his
unconscious. Rather the indi vi dual exercises a
certai n degree of command over i nner conflicts,
constantl y strivi ng to make them conscious so
he can gai n mastery over them. To an extent,
he is even capabl e of exerci si ng decisions about
whi ch aspects of his unconsci ous to reveal,
ti trati ng thei r exposure agai nst his tol erance of
anxiety. As he works through his anxi ety, he
becomes increasi ngly aware of segments of
himsel f that have been conceal ed and hence
have evaded detection and control. Counteri ng
thi s, of course, are resi stances that may
obstruct such attempts at self-healing.
The virtue of the cognitive approach is the
phi l osophy it espouses to the effect that tech
ni ques other than formal anal ysi s can be i m
mensely helpful in resolving resistance to the
openi ng up of cruci al areas for expl orati on and
ul ti matel y lead to sel f-understandi ng. Left to
ones own resources, the average i ndi vidual
may not have sufficient moti vati on, the for
ti tude to struggl e wi th the anxi ety inevi tabl e to
the handl i ng of repudi ated aspects of the
psyche, and the wi ll ingness to abandon the
materi al and subversive gai ns accrui ng to neu
rotic i ndul gence. On the other hand, the i ndi
vidual who turns to a carefull y desi gned ap
proach executed by a skilled empathi c therapi st
will l earn to deal wi th resistances to sel f-under-
standi ng and support experi mentati on wi th
more real i ty-ori ented patterns.
How sel f-understandi ng hel ps to bri ng
deeper probl ems to the surface and to en
courage heal thi er adaptati on is not enti rel y
clear. Roy Schafer (1973) expresses it this
way: I t is impressive that, as these changes
take pl ace in the pati ents concepti on of
hi mself, often by di nt of and wi th the accom
pani ment of much sufferi ng, he begins to feel
better and to function better. Hi s symptoms
dimi ni sh in scope and persistence; his mood
improves; his social and sexual rel ati onshi ps
are enhanced. I t seems that it can be a gain
j ust to be abl e to recogni ze ones neuroti c
mi sery. Whatever the involved mechani sms,
the i ndi vi dual s sense of mastery is helped.
Since the goal of sel f-understandi ng requi res
the uncoveri ng of at least some unconsci ous de
termi nants, the manner of thei r exposure and
the ti mi ng are especiall y i mportant in short
term therapy. General l y, the first few sessions
will reveal data from the histori cal materi al
(and parti cul arl y the present behavi oral pat
terns of the pati ent) that offer cl ues regardi ng
the operati ve dynami cs. Usual l y it is unwi se to
present the pati ent wi th such clues, no matter
how si gni fi cant they may seem, unti l he
hi msel f expresses awareness of what is going
on. Even then any i nterpretati ons must be cau
ti ousl y offered in the form of tentati ve
presentati ons (Wol berg, 1977, pp. 589-590).
T he rel ati onshi p of expressed confl ictual ma
teri al to the present compl ai nt factor is vitall y
i mportant if such a rel ati onshi p can be demon
strated.
A mi l d-mannered, soft-spoken pati ent came
to my office wi th the compl ai nt of mi grai ne
headaches. As he wal ked into the room, he
ti pped over a chai r and then profusel y
apol ogi zed whi l e ashes from hi s ci garette
spill ed over the carpet. Duri ng the intervi ew I
got the i mpressi on from his posture, the set of
his j aw, and sl ashi ng movements of his hands
that his fawni ng, obsequi ous manner was a
cover for an i nner boil ing pot of anger. I n my
mi nd I made a connecti on between hi s
smol deri ng rage and his mi grai ne. I also
specul ated that he was not aware of the extent
of his anger and how he repressed it. T o have
confronted hi m wi th my hypothesi s woul d
probabl y have ended our rel ati onshi p before it
began. I nstead, I bided my ti me unti l I had
more evidence to confi rm my i mpressi on whi l e
worki ng on establ i shi ng a cl oser rel ati onshi p.
At the fourth session the pati ent spoke of
needi ng some extensive dental work because he
ground his teeth duri ng his sleep. Thi s rei n
forced my idea that his anger, under control
usual l y, was strong enough to break through
in sleep. Repeti ti ve use of such phrases as
28
The man is all chewed up, I t kills me
to thi nk of how peopl e take advantage of
wel fare, I sl aughtered hi m at tenni s, and
so on, enabl ed me to say, I wonder if you
hold back on your anger when you have a
ri ght to be upset? I then repeated some i n
cidents that he had revealed to me in whi ch he
had felt taken advantage of but had failed to
assert his ri ghts. Thi s led to an expostul ati on
of i ndi gnati on at the state of the worl d and the
nefari ousness of peopl e who needed to J ew
you down. Hi s next associati on was that
Freud was a J ew and Freud was a psy
choanal yst who was currentl y being cri ti cized
in articl es he had read. I s there, I asked him,
anythi ng I as a psychoanal yti c psychothera
pist am doi ng that upsets you or makes you
angry? Why, he repl i ed astoni shed,
shoul d I be? Wel l , I retorted, are you?
The pati ent then l aughed and in an embar
rassed way tal ked about his resentment at the
fee I charged, at the puncti l i ousness of my ap
poi ntment ti mes, and at the fact that I had given
hi m an endi ng date when he was sure he could
not get well in so short a peri od. T he troubl e,
he insisted, wi th most doctors was that they
were too busy to devote themsel ves to any si ngle
pati ent. Thi s was the case also wi th some
parents, i ncl udi ng his own parents, who had
spent little ti me wi th hi m.
Wi thout apol ogi zi ng for my acti ons or acti ng
i ndi gnant, I encouraged hi m to tell me more
about how he fel t, i mpl yi ng that I ap
proved of his frankness and his ri ght to feel
what he felt. As I anti ci pated, he backtracked,
apol ogi zi ng for his boldness and rudeness.
Thi s reacti on, I repl i ed, was in service of his
guil t, a habi tual pattern to keep his anger
under control. But, he retorted, I real l y do
like doctors and J ews. And there is some
J ewi sh blood in my fami l y.
Openi ng up some transference feel i ngs
served to hel p our rel ati onshi p; and to support
his abil ity to cri ti cize his famil y more frankl y
for some of the ways he was handl ed as a
chil d. A noti ceabl e change occurred in the fre
quency of his mi grai ne attacks, and at our
termi nati on date he expressed great satisfacti on
wi th the benefi ts he had received from therapy
both in rel ievi ng his headaches and givi ng hi m a
greater sense of freedom.
Conclusion
All persons, i rrespective of the degree of
emoti onal illness have a potenti al for i mprove
ment and growth, both spontaneousl y through
constructi ve life experi ences and, more expedi
ti ously, when treated wi th appropri ate psycho
therapy. For radi cal and enduri ng amendments
in the personal i ty structure some cognitive
al terati on is essential. Wi thout such change,
i mproved habi t and behavi oral patterns are apt
to be short-l ived. Duri ng therapy far-reachi ng
i mprovements may be approached by expl or
ing and worki ng through basic conflicts, espe
ci al l y those reveal ed in the transference.
Where transference is not apparent in the
therapeuti c si tuati on, it may often be detected
in di storti ons in the i ndi vi dual s rel ati onshi p
wi th other peopl e as well as in the dreams,
fantasies, and acti ng-out tendencies. I rrespec
tive of the techni ques that are bei ng empl oyed,
(e.g., nondi recti ve i ntervi ewi ng, acti ve anxi ety-
provoki ng confrontati on, anal yti c i nterpreta
ti on, behavi or therapy, Gestal t approaches,
etc.), the pati ent will respond to these tech
ni ques wi th a wi de range of habi tual charac-
terol ogi c reacti ons and resi stances. These,
uti li zed as a producti ve focus on whi ch to con
centrate duri ng therapy, may hel p penetrate
defenses and i ni ti ate new ways of thi nki ng,
feeling, and behavi ng. Apart from the fact that
ti me in treatment is usual l y too short to permi t
the devel opment of too i ntensi ve transference
reacti ons that reach a poi nt of a transference
neurosis, it is actual l y not essential for the pa
ti ent to evolve and work through a transference
neurosis to achieve extensive reconstructive
change. I ndeed, the effect of too great an i nten
sification of transference may be to increase
resistance to therapy and to prol ong treatment.
Where a rel ati onshi p is found between the pa
ti ents presenti ng symptoms and compl ai nts,
prevai l i ng character patterns, and thei r ori gins
in earl y life experi ences, the process of recon
structi ve change is expedited. Such change may
conti nue the remai nder of the i ndi vi dual s life,
parti cul arl y where the pati ents envi ronment
supports the change and he conti nues self-
observati on and experi menti ng wi th producti ve
new patterns.
CHAPTER 3
Criteria of Selection
Whi l e the best pati ents are undoubtedl y
those who are adequatel y moti vated for ther
apy, i ntell ectual ly capabl e of graspi ng i m
medi ate i nterpretati ons, proficient in worki ng
on an i mportant focus in therapy, not too de
pendent, have had at least one good rel ati on
shi p in the past, and are i mmedi atel y abl e to
interact well wi th the therapi st, they general l y
constitute only a small percentage of the popu
lati on who appl y to a clinic or pri vate practi
ti oner for treatment. T he chal l enge is whether
pati ents not so bounti ful l y blessed wi th thera
peuti call y posi ti ve qual i ti es can be treated ade
quatel y on a short-term basi s wi th some
chance of i mprovi ng thei r general modes of
probl em solving and perhaps of achi evi ng a
mi nor degree of personal i ty reconstructi on.
Patient Classification
I n practice one may di sti ngui sh at least five
classes of pati ents who seek help. We have
categorized them as Cl ass 1 through 5. In
general , Classes 1 to 3 requi re only short-term
therapy. Classes 4 and 5 will need manage
ment for a l onger peri od after an initi al short
term regi men of therapy.
Class 1Patients
Unti l the onset of the current difficulty Cl ass
1 pati ents have made a good or tol erabl e ad
j ustment. The goal in therapy is to return
them to thei r habi tual level of functioni ng.
Among such pati ents are those whose stabil ity
has been temporari l y shattered by a cata
strophi c life event or crisis (death of a loved
one, divorce, severe acci dent, serious physical
illness, fi nancial disaster, or other calamity).
Some indi vidual s may have been burdened
wi th extensive conflicts as far back as chi l d
hood but up to the present illness have been
abl e to marshal l sufficient defenses to make a
reasonabl e adaptati on. T he i mposi ti on of the
crisis has destroyed thei r capaci ti es for copi ng
and has produced a temporary regressi on and
erupti on of neuroti c mechani sms. The object in
therapy for these pati ents is essential ly suppor
tive in the form of crisis intervention wi th the
goal of reestabl i shi ng the previ ous equi l i bri um.
Reconstructi ve effects whi l e not expected are a
welcome di vi dend. General l y, no more than six
sessions are necessary.
An exampl e of a Cl ass 1 pati ent is a satisfac
toril y adj usted woman of 50 years of age who
drove a fri ends automobi l e wi th an expi red
license and in the process had a severe acci
dent, kil li ng the dri ver of the car wi th whi ch
she col l i ded and severel y i nj uri ng two
passengers in her own car, whi ch was
damaged beyond repai r. She hersel f sustai ned
a concussion and an i nj ured arm and was
moved by ambul ance to a hospi tal , where she
remai ned for a week. Charged wi th dri vi ng
viol ati ons, sued by the owner of the car she
borrowed and by the two i nj ured passengers,
she developed a dazed, depressed reacti on and
30
CRITERIA OF SELECTION 31
then peri ods of severe dizzi ness. Therapy here
consi sted of a good deal of support, reas
surance, and hel p in fi ndi ng a good l awyer,
who counseled her successful ly through her
entangl ed legal compl ications.
Sometimes a crisis opens up closed trau
mati c chapters in ones life. I n such cases it
may be possible to li nk past incidents, feelings,
and conflicts wi th the present upsetti ng ci r
cumstances enabl i ng the pati ent to cl ari fy
anxieties and hopeful ly to influence deeper
strata of personal i ty. I n the case above, for ex
ampl e, the pati ent recalled an inci dent in her
chil dhood when whi l e wheel i ng her young
brother in a carri age, she acci dental l y upset it,
causi ng a gash in her sibli ng that requi red su
turi ng. Shamed, scolded, and spanked, the
fri ghtened chi l d harbored the event that
powered fear and guil t wi thi n herself. T he
i ntensi ty of her feeling surpri sed her, and thei r
discharge duri ng therapy fostered an assump
ti on of a more objective atti tude toward both
the past and the i mmedi ate crisis event. I t may
not be possible in all cases, but an astute and
empathi c therapi st may be able to hel p the pa
ti ent make i mportant connecti ons between the
past and present.
Class 2 Patients
The chief probl em for Cl ass 2 pati ents is not
a critical si tuati on that has obtruded itself into
thei r lives, but rather mal adapti ve patterns of
behavi or and/or di sturbi ng symptoms. T he ob
j ect here is symptom cure or relief, modi fi ca
tion of destructi ve habi ts, and evolvement of
more adapti ve behavi oral confi gurati ons. M ul
ti form techni ques are empl oyed for 8 to 20
sessions fol lowing eclectic supportive-educa
tional model s under the rubri c of many terms,
such as short-term behavi oral therapy, short
term reeducative therapy, and so forth.
A phobi a to ai r travel exempl ifies the com
pl ai nts of a class 2 pati ent. Thi s was a great
handi cap for Mi ss J since job advancement
necessitated visits to remote areas. T he ori gin
of the pati ents anxi ety lay in the last flight
that she had taken 8 years previ ously. A
di sturbance in one of the engi nes reported to
the passengers by the pil ot necessitated a
return to the poi nt of ori gin. Since that ti me
Mi ss J had not dared enter a pl ane. Therapy
consisted of behavi oral systematic desensi ti za
ti on, whi ch in ei ght sessions resul ted in a cure
of the symptom.
I n uti l i zi ng the vari ous eclectic techni ques
the therapi st al erts hi msel f to past patterns
that act as a paradi gm for the present
symptom compl ex, as well as to mani festati ons
of resistance and transference. I n a certai n
number of cases the pati ent may be hel ped to
overcome resi stances through resol uti on of
provocative i nner conflicts and in thi s way
achieve results beyond the profits of symptom
relief.
Class 3 Patients
Those in whom both symptoms and be
havi oral difficulti es are connected wi th deep-
seated i ntrapsychi c probl ems that take the
form of personal i ty di sturbances and i nappro
pri ate coping mechani sms make up the Cl ass 3
classification. Such pati ents have functi oned at
least margi nal l y up to the ti me of thei r break
down, whi ch was perhaps i ni ti ated by an i m
medi ate preci pi tati ng factor. Most of these pa
ti ents seek hel p to al l eviate thei r distress or to
solve a crisis. Some come specifically to achieve
greater personal i ty devel opment. On eval u
ati on ei ther they are deemed unsui tabl e for
long-term treatment, or extensive therapy is
believed to be unnecessary. They often possess
the desi re and capaci ty to work toward acqui r
ing sel f-understandi ng.
T he goal for Cl ass 3 pati ents is personal i ty
reconstructi on al ong wi th symptomati c and be
havi oral i mprovement. Techni ques are usual l y
psychoanal yti cal l y ori ented, invol ving i nter
viewing, confrontati on, dream and transference
i nterpretati ons, and occasi onall y the use of ad
j uncti ve techni ques like hypnosi s. Some thera
pists confi ne the term dynamic short-term ther
apy to this class of pati ents and often empl oy a
careful selection process to el i mi nate pati ents
whom they feel woul d not work too well wi th
thei r techni ques (Buda, 1972; Davanl oo,
1978, Mal an, 1963; Sifneos, 1972; Ursano &
Dressi er, 1974).
An exampl e of a Cl ass 3 pati ent is a young
mother who brought her son in for consul ta
ti on because he was getti ng such low marks in
the final year of hi gh school that the chances
of hi s getti ng i nto col l ege were mi ni mal .
Moreover, he fi rml y announced his unwi l l i ng
ness to go to college, insisting on fi nding a job
after graduati on so that he could buy an au
tomobil e and pursue his two hobbies: basebal l
and girls. Duri ng the i ntervi ew wi th the boy it
was obvious that he had moti vati on nei ther for
further college educati on nor for any ki nd of
therapeuti c help. It was apparent too that his
stubborn refusal to study and to go on to
hi gher l earni ng was a way of fi ghti ng off the
domi nati on of his mother and stepfather. Ac
cordi ngly, the mother was advised to stop nag
gi ng the boy to conti nue his schooling. I nstead
she was urged to permi t hi m to experi ment
wi th fi ndi ng a j ob so that he could l earn the
val ue of a dol l ar and to discover for hi msel f the
ki nds of posi ti ons he could get wi th so little
education.
T he next day the mother tel ephoned and re
ported that she had followed the doctors
i nstructions. However, she asked for an ap
poi ntment for hersel f since she was overl y
tense and suffered from bad backaches that her
orthopedi st clai med were due to nerves.
What she wanted was to l earn self-hypnosis,
whi ch her doctor clai med woul d hel p her
rel ax. Abi di ng by her request, she was taught
sel f-hypnosisnot only for rel axati on pur
poses, but al so to determi ne the sources of her
tension. Through intervi ewi ng ai ded by i n
duced i magery duri ng hypnosi s, she was able
to recogni ze how angry she was at me for not
satisfying her desi re to force her son to go to
college. I mages of attacki ng her father, who
frustrated and domi nated her, soon brought
out her violent rage. She real i zed then that her
obsequi ous behavi or toward her husband was
a cover for her hostil ity. Acti ng on thi s insight,
she was soon abl e to express her anger and to
discuss her reacti ons wi th her husband and the
reasons for her rages. Thi s opened up channel s
of communi cati on wi th a dramati c resol uti on
of her symptoms and an i mprovement in her
feel ings about hersel f and her atti tudes toward
peopl e, confi rmed by a 5-year fol low-up.
Class 4 Patients
Pati ents of the Cl ass 4 category are those
whose probl ems even an effective therapi st
may be unabl e to medi ate in a bri ef span and
who will requi re more prol onged management
after the i ni ti al short-term peri od of formal
therapy has disclosed what i nterventi ons woul d
best be indi cated. The word management
shoul d be stressed because not all l ong-term
modal i ti es need be, and often are not, best
ai med at i ntrapsychi c al terati ons. Among i ndi
vi dual s who appear to requi re hel p over an ex
tended span are those whose probl ems are so
severe and deep-rooted that all therapy can do
for them is to keep them in reasonabl e real i ty
functi oni ng, whi ch they coul d not achi eve
wi thout a prol onged therapeuti c resource.
Cl ass 4 pati ents incl ude the following:
1. I ndi vi dual s wi th chroni c psychoti c reacti ons
and psychoses in remi ssi on who requi re some super
vi sory i ndi vi dual or group wi th whom contact is
regul arl y made over suffi ci entl y spaced i nterval s to
provi de some ki nd of human rel ati onshi p, how
ever tenuous thi s may be, to oversee essenti al
psychotropi c drug i ntake, to regul ate the mi l i eu,
and to sudue the peri l s of psychoti c processes when
these are peri odi cal l y rel eased. Such pati ents do not
usual l y requi re formal prol onged psychotherapy or
regul ar sessions wi th a psychotherapi st; they coul d
do as wel l , or better, wi th a paraprofessi onal
counsel or. Mi l i eu therapy, rehabi l i tati on proce
dures, and soci al or group approaches may be hel p
ful.
2. Persons wi th seri ous character probl ems wi th
CRITERIA OF SELECTION
33
tendenci es toward al cohol i sm and drug addi cti on
who requi re regul ar gui dance, survei l l ance, group
approaches, and rehabi l i tati ve services over an i n
defi ni te peri od.
3. I ndi vi dual s wi th uncontrol l abl e tendenci es
toward acti ng-out who need control s from wi thout
to restrai n them from expressi ng i mpul ses that will
get them i nto difficul ti es. Exampl es are those who
are occasi onal l y domi nated by dangerous perver
si ons, desi res for vi ol ence, l ust for cri mi nal
activities, masochi sti c needs to hurt themsel ves, ac
ci dent proneness, sel f-defeati ng gambl i ng, and other
corrupti ons. Many such persons recogni ze that they
need curbs on thei r uncontrol l abl e wayward desires.
4. Persons so traumati zed and fi xated in thei r de
vel opment that they have never overcome i nfanti l e
and chi l di sh needs and defenses that contravene a
mature adaptati on. For i nstance, there may be a
constant entrapment in rel ati onshi ps wi th surrogate
parental fi gures, whi ch usual l y evol ve for both sub
j ects and hosts i nto a sado-masochi sti c purgatory.
Yet such persons cannot functi on wi thout a de
pendency prop, and the therapi st offers hi msel f as a
more objecti ve and nonpuni ti ve parental agency.
Some of these pati ents may need a dependency sup
port the remai nder of thei r lives.
M any of the pati ents in thi s category fall i nto
devastati ng f rustrati ng dependency rel ati onshi ps
duri ng therapy or al ternati ves to therapy from
whi ch they cannot or wil l not extri cate themselves.
Real i zi ng the dangers of thi s conti ngency, we can,
however, pl an our strategy accordi ngl y, for ex
ampl e, by provi di ng supporti ve props outsi de of the
treatment si tuati on if support is needed. Nor need
we abandon reconstructi ve obj ecti ves, once we make
proper al l owances for possi bl e regressi ve i nterl udes.
I n fol l ow-up contacts, I was pl eased to fi nd, there
had been change after 5, 10, and i n some cases 15
years in pati ents who I bel i eved had li ttle chance to
achi eve personal i ty change.
5. Persons wi th persi stent and uncontrol l abl e
anxi ety reacti ons powered (a) by unconsci ous con
flicts of l ong standi ng wi th exi sti ng defenses so
fragi l e that the pati ent is unabl e to cope wi th or
di nary demands of life or (b) by a noxi ous and i rre
medi abl e envi ronment from whi ch the pati ent can
not escape.
6. Borderl i ne pati ents bal anced precari ousl y on a
razor edge of rati onal i ty.
7. I ntractabl e obsessi ve - compul si ve persons
whose reacti ons serve as defenses agai nst psychosi s.
8. Paranoi dal personal i ti es who requi re an i ncor
rupti bl e authori ty for real i ty testi ng.
9. I ndi vi dual s wi th severe l ong- standi ng psy
chosomati c and hypochondri cal condi ti ons, such as
ul cerati ve coli ti s, or chroni c pai n syndromes that
have resi sted mi ni strati ons from medi cal , psycho
logi cal , and other hel pi ng resources. Often these
symptoms are mani festati ons of defenses agai nst
psychoti c di si ntegrati on.
10. Peopl e presenti ng wi th depressi ve di sorders
who are in danger of attempti ng sui ci de and requi re
careful regul ati on of anti depressi ve medi cati ons or
el ectroconvul si ve therapy fol lowed by psychotherapy
unti l the ri sk of a rel apse is over.
Class 5 Patients
I n Cl ass 5 we place those i ndi vi dual s who
seek and requi re extensive reconstructi ve per
sonal ity changes and have the finances, ti me,
forbearance, and ego strength to tol erate l ong
term psychoanal ysi s or psychoanal yti cal l y
ori ented psychotherapy. I n addi ti on, they have
had the good fortune of fi ndi ng a wel l -trai ned,
experi enced, and mature anal yst who is capa
ble of deal i ng wi th dependent transference and
other resistances as well as wi th ones personal
countertransferences. Pati ents who can benefit
more from l ong-term reconstructi ve therapy
than from dynami cal l y ori ented short-term
therapy are often burdened by i nterferi ng ex
ternal condi ti ons that may be so strong, or by
the press of i nner neuroti c needs so intense,
that they cannot proceed on thei r own toward
treatment objectives after the short-term thera
peuti c peri od has ended. Conti nui ng moni tor
ing by a therapi st is essential to prevent a re
l apse. I n certai n cases the characterol ogi c
detachment is so great that the pati ent is una
ble to establi sh close and trusti ng contact wi th
a therapi st in a bri ef peri od, and a consi dera
ble bul k of ti me duri ng the short-term sessions
may be occupied wi th establ i shi ng a work rel a
ti onshi p.
A special group of pati ents requi ri ng l ong
term therapy are highl y di sturbed chi l dren and
adolescents who have been stunted in the
process of personal i ty devel opment and who
requi re a conti nui ng rel ati onshi p wi th a thera
pist who functions as a guidi ng, educati onal ,
benevolent parental figure.
L ong-term pati ents in Classes 4 and 5 usu
all y consti tute less than one-quarter of the pa
ti ent load carri ed by the average psychothera
pist. T he bul k of ones practi ce will general l y
be composed of pati ents who may adequatel y
be managed by short-term methods.
Conclusion
I f we are pragmati cal l y disposed to treat as
many pati ents as possible for economi c or
other reasons, we may say that all pati ents i r
respecti ve of di agnosi s, and severi ty and
chroni city of probl ems are potenti al candi dates
for short-term therapy. Shoul d any pati ents
fail to respond to abbrevi ated methods, we can
al ways conti nue treatment, havi ng acqui red i n
val uabl e i nformati on duri ng the short-term ef
fort as to what i nterventi ons woul d best be i n
dicated for thei r probl ems. Even where the
yardstick of cost effectiveness is not paramount,
the maj ori ty of i ndi vidual s who seek hel p for
emoti onal probl ems can wi th efficient short
term methods achieve satisfactory resul ts and
may even go on by themsel ves, wi th the l earn
ings they have acqui red, to attai n some degree
of personal i ty growth. A few may requi re an
addi ti onal visit or two from ti me to ti me to re
solve some probl ems that they are unabl e to
handl e by themsel ves. They thus will have
been abl e through a practi cal bri ef therapeuti c
approach to have been spared the expense,
inconveni ence, and in some cases the dangers
of l ong-term therapy.
CHAPTER 4
A General Outline of
Short-term Therapy
There obviously are differences among ther
apists in the way that short-term therapy is
i mpl ementedfor exampl e, the focal areas
chosen for attenti on and expl orati on, the rel a
tive emphasi s on current as compared to past
issues, the attenti on pai d to transference, the
way resistance is handl ed, the depth of prob
ing, the deali ng wi th unconsci ous materi al that
surfaces, the preci se manner of i nterpretati on,
the degree of acti vity, the amount of advice giv
ing, the kinds of i nterventi ons and adj uncti ve
devices empl oyed, and the prescri bed number
of sessions. Moreover, all therapi sts have to
deal wi th thei r own personal i ti es, prej udi ces,
theoreti cal biases, and skills, all of whi ch will
i nfluence the way they work. In spite of such
differences, there are certai n basic pri ncipl es
that have evolved from the experi ences of a
wide assortment of therapi sts worki ng wi th
diverse pati ent popul ati ons that have produced
good results. T he practi ti oner may find he can
adapt at least some of these pri nci pl es to his
own style of operati on even though he con
ti nues to empl oy methods that have proven
themselves to be effective wi th his pati ents and
are not exactly in accord wi th what other pro
fessi onals do. I n the pages that follow 20 tech
ni ques are suggested as a general gui de for
short-term therapy.
Establish as Rapidly as Possible a
Positive Working Relationship
(Therapeutic Alliance)
An atmosphere of warmth, understandi ng,
and acceptance is basic to achi evi ng as posi ti ve
worki ng rel ati onshi p wi th a pati ent. Empathy
parti cul arl y is an i ndi spensi bl e personal i ty
qual i ty that hel ps to solidify a good therapeuti c
all iance.
General l y, at the initi al i ntervi ew, the pa
ti ent is greeted courteousl y by name, the thera
pi st i ntroduci ng hi msel f as in this excerpt:
T h. How do you do, M r. Roberts, I am Dr.
Wol berg. Wont you sit down over there
(p o i n t i n g to a chair), and we'l l tal k thi ngs over
and I ll see what I can do to hel p you (patient
gets seated).
Pt. T hank you, doctor, (pause)
A detached deadpan professi onal atti tude is
parti cul arl y fatal. It may, by eli citing powerful
feelings of rej ecti on, provoke protecti ve defen
sive maneuvers that neutral i ze efforts toward
establ i shi ng a worki ng rel ati onshi p.
I t is difficul t, of course, to del i neate exact
rul es about how a therapeuti c al l i ance may be
establi shed rapi dl y. Each therapi st will uti li ze
hi msel f uni quel y toward thi s end in terms of
his own techni ques and capaci ti es for rapport.
Some therapi sts possess an extraordi nary
abil ity even duri ng the first session, as the pa
ti ent describes his probl em and associated feel
ings, of putti ng the pati ent at ease, of mobi l i z
ing his fai th in the effecti veness of methods that
will be uti li zed, and of subdui ng the pati ents
doubts and concerns. A confi dent enthusi asti c
manner and a conviction of ones abil ity to
hel p somehow communi cates itself nonverbal l y
to the pati ent. Therapi st enthusi asm is an i m
portant i ngredi ent in treatment.
The fol lowing suggestions may prove hel p
ful:
35
Verbalize what the pati ent may be feeling
Putti ng into words for the pati ent what he
must be feeling but is unabl e to conceptual i ze
is one of the most effective means of establ i sh
ing contact. Readi ng between the l i nes of
what the pati ent is tal ki ng about will yield i n
teresti ng clues. Such si mpl e statements as,
Y ou must be very unhappy and upset about
what has happened to you or I can under
stand how unhappy and upset you must be
under the ci rcumstances present the therapi st
as an empathi c person.
Encourage the patient that his situation is
not hopeless
I t is someti mes apparent that, despi te
presenti ng hi msel f for help, the pati ent is con
vi nced that he is hopeless and that little will
actual l y be accomplished from therapy. Where
the therapi st suspects thi s, he may say. Y ou
probabl y feel that your si tuati on is hopel ess be
cause you have al ready tried vari ous thi ngs
that havent been effective. But there are thi ngs
that can be done, that you can do about your
si tuati on and I shall gui de you toward maki ng
an effort. Empathi zi ng wi th the pati ent may
be i mportant: Putti ng myself in your posi
ti on, I can see that you must be very unhappy
and upset about what is happeni ng to you.
Sometimes it is useful to define the pati ents
role in developi ng and sustai ni ng his probl em
in a nonaccusi ng way: Y ou probabl y felt you
had no other al ternati ve than to do what you
di d. What you are doi ng now seems
reasonabl e to you, but there may be other
ways that could create fewer probl ems for
you.
Whi l e no promi se is made of a cure, the
therapi st must convey an atti tude of conviction
and faith in what he is doing.
Pt. I feel hopel ess about getti ng wel l . Do you
thi nk I can get over thi s troubl e of mi ne?
Th. Do you real l y have a desi re to get over thi s
troubl e? I f you real l y do, thi s is ni ne-tenths of
the battl e. Y ou wil l want to appl y yoursel f to
the j ob of getti ng wel l . I will poi nt out some
thi ngs you can do, and if you work at them
yoursel f, I see no reason why you cant get
better.
Where the pati ent becomes sel f-deprecatory
and masochistic, the posi ti ve aspects of his
reacti ons may be stressed. For exampl e, shoul d
he say he is constantl y furious, one mi ght
repl y, Thi s indi cates that you are capabl e of
feeling strongl y about thi ngs. I f he says he
detaches and does not feel anythi ng, the an
swer may be, Thi s is a sign you are tryi ng to
protect yoursel f from hurti ng. Comments
such as these are intended to be protecti ve in
order to preserve the rel ati onshi p wi th the
therapi st. L ater when it becomes apparent that
the rel ati onshi p is sufficientl y sol id, the thera
pi sts comments may be more provocative and
chal l engi ng. T he pati ents defenses bei ng
threatened, anxi ety may be mobi li zed, but the
pati ent will be sustai ned by the therapeuti c
al l i ance and he will begin to uti li ze it rather
than run away from it.
Deal With Initial Resistances
A mong the resi stances commonl y en
countered at the first session are lack of moti
vati on and di sappoi ntment that the therapi st
does not fulfill a stereotype. T he therapi sts
age, race, nati onal i ty, sex, appearance, profes
sional discipl ine, and rel igi on may not corre
spond wi th the pati ents ideas of someone in
whom he wants to confide.
Th. I noti ce that it is di ffi cult for you to tell me
about your probl em.
Pt. ( Obviously in discomfort) I dont know what
to say. I expected that I woul d see an ol der
person. Have you had much experi ence wi th
cases li ke me?
Th. What concerns you is a fear that I dont have
as much experi ence as you bel i eve is necessary
and that an ol der person woul d do a better j ob.
I can understand how you feel, and you ma y
do better wi th an ol der person. However, sup
posi ng you tell me about your probl em and then
if you wi sh I wil l refer you to the best ol der
GENERAL OUTLINE OF SHORT-TERM THERAPY 37
therapi st who can treat the ki nd of condi ti on
you have.
Thi s tactic of accepting the resistance and
invi ti ng the pati ent to tell you more about
himsel f can be appl i ed to other stereotypes
besides age. I n a wel l -conducted i ntervi ew the
therapi st will reveal hi msel f or herself as an
empathi c understandi ng person, and the pa
ti ent will want to conti nue wi th hi m or her in
therapy.
Another common form of resistance occurs
in the person wi th a psychosomati c probl em
who has been referred for psychotherapy and
who is not at all convinced that a psychological
probl em exists. I n such cases the therapi st may
proceed as in thi s excerpt.
Pt. Dr. J ones sent me here. I have a probl em wi th
stomachaches a long ti me and have been seei ng
doctors for it for a long ti me.
Th. As you know, I am a psychi atri st. What makes
you feel your probl em is psychol ogi cal ?
Pt. 1 dont thi nk it is, but Dr. J ones says it mi ght
be, and he sent me here.
Th. Do you thi nk it is?
Pt. No, I cant see how thi s pai n comes from my
head.
Th. Wel l , it mi ght be organi c, but wi th someone
who has suffered as l ong as you have the pai n
will cause a good deal of tensi on and upset.
[To insist on the idea th a t the p r o bl e m is p s y
chological w oul d be a p o o r tactic. First, the
therapist may be wrong, a nd the condition
m a y be or ganic t h o u g h u n d e t e c t a b l e by
pre sent- day tests a nd examinations . Second,
the p a t i e n t may need to retain his notion o f the
s y m p t o m s organicity a n d even to be able to
experience at t enuated pa in f r o m time to time
as a defense against ov e r wh e l mi n g a n x i e t y or,
in certain serious conditions, p sy c h o s i s. )
Pt. I t sure does.
Th. And the tensi on and depressi on prevent the
stomach from heal i ng. Tensi on i nterferes wi th
heal i ng of even true physi cal probl ems. Now
when you reduce tensi on, it hel ps the heal i ng.
I t mi ght hel p you even if your probl em is or
ganic.
Pt. I hope so.
Th. So what we can do is try to fi gure out what
probl ems you have that are causi ng tensi on,
and also lift the tensi on. T hi s shoul d hel p your
pai n.
Pt. I woul d li ke that. I get tense in my j ob wi th
the peopl e I work. Some of them are crumbs.
[.Patient goes on talking, o pening up p oc k e t s o f
anxiety.]
T he object is to accept the physi cal condition
as it is and not label it psychol ogical for the
ti me being. Actual l y, as has been i ndi cated, it
may be an essential adaptati onal symptom, the
pati ent needi ng it to mai ntai n an equi l i bri um.
Deal i ng wi th areas of tensi on usual l y will hel p
relieve the symptom, and as psychotherapy
takes hold, it may make it unnecessary to use
the symptom to preserve psychol ogical homeo
stasis.
Moti vati onal lack may obstruct therapy in
other si tuati ons, as when a pati ent does not
come to treatment on his own accord but is
sent or brought by rel ati ves or concerned
parti es. Addi ti onal exampl es are chi l dren or
adolescents wi th behavi or probl ems, peopl e
who are addi cted (drug, alcohol , food, gam
bli ng), and peopl e receiving pensi ons for physi
cal disabil ities. Case 1 in Chapter 6 il l ustrates
the management of a nonmoti vated adol es
cent. More on handl i ng lack of moti vati on
is detai led el sewhere (Wol berg, 1977, pp.
458-470).
Gather Historical Material and
Other Data
Through sympatheti c l i steni ng the pa
ti ent is all owed to tell his story wi th as little
i nterrupti on as possible, the therapi st i nterpo
l ati ng questi ons and comments that indi cate a
compassi onate understandi ng of the pati ents
si tuati on. T he data gathered in the i ni ti al i n
tervi ew shoul d hopeful l y permi t a tentati ve
diagnosi s and a noti on of the eti ology and pos
sibly the psychodynami cs. Shoul d the pati ent
not bri ng the matter up, he may be asked what
he consi ders his most i mportant probl em to
be? Why has he come to treatment at this
ti me? What has he done about the probl em to
date? Has he hi msel f arri ved at any idea as to
what is causi ng his difficulty? What does
he expect or what woul d he like to get from
therapy?
I t is often advantageous to follow an out
line* in order to do as compl ete a hi story or
behavi oral analysis as possible duri ng the first
session or two. Thi s may necessitate i nterrupt
ing the pati ent after the therapi st is convinced
that he has obtai ned sufficient helpful data
about any one topic.
Among the questi ons to be expl ored are the
following:
1. Have there been previ ous upsets that resembl e
the present one?
2. Were the preci pi tati ng events of previ ous
upsets in any way si mi l ar to the recent ones?
3. What measures aggravated the previ ous upsets
and whi ch al l evi ated the symptoms?
4. A part from the most i mportant probl em
for whi ch hel p is sought, what other symptoms
are bei ng experi enced (such as tensi on, anxi ety,
depressi on, physi cal symptoms, sexual probl ems,
phobi as, obsessions, i nsomni a, excessive dri nki ng?
5. What tranqui l i zers, energi zers, hypnoti cs, and
other medi cati ons are bei ng taken?
Statisti cal data are rapi dl y recorded (age,
educati on, occupati on, mari tal status, how
long marri ed, and chi l dren if any). What was
(and is) the pati ents mother like? T he father?
Any probl ems wi th brothers or sisters? Were
there any probl ems experi enced as a chil d (at
home, at school, wi th heal th, in rel ati onshi ps
wi th other chi l dren)? Any probl ems in sexual
devel opment, career choice, occupati onal ad
j ustment? Can the pati ent remember any
dreams, especiall y ni ghtmari sh and repetitive
dreams? Were there previ ous psychol ogical or
psychi atri c treatments?
To obtai n further data, the pati ent may be
exposed to the Rorschach cards, getti ng a few
responses to these unstructured materi al s wi th
* Further detai l s on hi story taki ng and conveni ent ap-
propri ate forms may be f ound i n Wol berg, 1977, pp. 401
409,1176- 1178.
out scoring. Thi s is opti onal , of course. T he
therapi st does not have to be a clinical psychol
ogist to do this, but he or she shoul d have read
some materi al on the Rorschach. T he pati ent
may al so be given a sheet of paper and a pencil
and be asked to draw a pi cture of a man and a
woman. Some therapi sts prefer showi ng the
pati ent rapi dl y the Themati c Appercepti on
Cards. What di storti ons appear in the pa
ti ents responses and drawi ngs? Can one cor
rel ate these wi th what is happeni ng sympto
mati cal l y? These tests are no substi tutes for
essenti al psychol ogi cal tests where needed,
whi ch can best be done by an experi enced cl i n
ical psychol ogist. But they can fulfill a useful
purpose in picki ng up gross defects in the
thi nki ng process, borderl i ne or schi zophreni c
potenti al i ti es, paranoi dal tendenci es, de
pressive mani festati ons, and so on. No more
than 10 or 15 mi nutes shoul d be uti li zed for
thi s purpose.
An exampl e of how Rorschach cards can
hel p reveal underl yi ng i mpul ses not brought
out by regul ar i ntervi ewi ng methods is il lus
trated in a severely depressed man wi th a con
troll ed, obsessional character whose passivity
and i nabi l i ty to express aggression resul ted in
others taki ng advantage of hi m at work and in
his marri age. When questi oned about feelings
of hostil ity or aggression, he deni ed these wi th
some pri de. T he fol lowing were his responses
to the Rorschach Cards.
1. T wo thi ngs fl ying at each other.
2. Somethi ng sai l i ng i nto somethi ng.
3. T wo fi gures pul l i ng somethi ng apart; two
adul ts pul l i ng two i nfants apart.
4. A ni mal s fur spread out. X -ray (drops card)
5. Fl yi ng i nsect, surgi cal i nstrument, forcepts.
6. Ani mal or i nsect spl i t and fl attened out.
7. X - ray fl uoroscope of embryo; adol escents
l ooki ng at each other wi th thei r hai r whi ppi ng up in
the wi nd.
8. T wo ani mal s cl i mbi ng a tree, one on each
side; femal e organs in all of these cards.
9. Fountai n that goes up and spi l l i ng blood.
10. Underwater scene, fish swi mmi ng, crabs, I n
si de of a womans body.
The conflicts rel ated to aggression and being
torn apart so apparent in the responses became
a pri nci pal therapeuti c focus and brought forth
his repressed anger at his mother.
Select the Symptoms, Behavioral
Difficulties, or Conflicts that You
Feel are Most Amenable for
Improvement
The sel ection wi th the pati ent of an i mpor
tant probl em area or a di sturbi ng symptom on
whi ch to work is for the purpose of avoi di ng
excursions into regi ons that, whi l e perhaps
chall enging, will dil ute a meani ngful effort.
Thus, when you have decided on what to con
centrate, i nqui re of the pati ent if in his opi ni on
these are what he woul d like to el i mi nate or
change. A greement is i mportant that thi s
chosen area is significant to the pati ent and
worthy of concentrated attenti on. I f the pati ent
compl ai ns that the sel ection is too li mi ted, he is
assured that it is best to move one step at a
time. Control l i ng a si mpl e si tuati on or al l evi at
i ng a symptom will hel p strengthen the per
sonal ity, and permi t more extensive progress.
T hus the focal difficulty around whi ch ther
apy is organi zed may be depressi on, anxi ety,
tension, or somati c mani festati ons of tension. It
may be a si tuati onal preci pi tati ng factor or a
crisis that has i mposed itself. It may be a di s
turbi ng pattern or some l earned aberrati on. It
may be a pervasive difficul ty in rel ati ng or in
functioni ng. Or it may be a conflict of which
the pati ent is aware or only parti al l y aware.
Once agreement is reached on the area of
focus, the therapi st may succinctl y sum up
what is to be done.
Th. Now that we have deci ded to focus on the
probl em \designate] that upsets you, what we
wil l do is try to understand what it is all
about, how it started, what it means, why it
conti nues. T hen well establ i sh a pl an to do
somethi ng about it.
Example /. A symptomatic focus
Th. I get the i mpressi on that what bothers you
most is tensi on and anxi ety that makes it hard
for you to get al ong. I s it your feel i ng that we
shoul d work toward el i mi nati ng these?
Pt. Yes. Yes, if I coul d get ri d of feel i ng so upset, I
woul d be more happy. I m so i rri tabl e and
j umpy about everythi ng.
Example 2. A focus on a precipitating event
Th. What you are compl ai ni ng most about is a
sense of hopel essness and depressi on. I f we
focused on these and worked toward el i mi nat
ing them, woul d you agree?
Pt. I shoul d say so, but I woul d also li ke to see
how I coul d i mprove my marri age. I ts been
goi ng downhi l l fast. T he last fight I had wi th
my husband was the li mi t.
Th. Wel l , suppose we take up the probl ems you are
havi ng wi th your husband and see how these
are connected wi th your symptoms.
Pt. I woul d li ke that, doctor.
Example 3. A dynamic focus
Whenever possible the therapi st shoul d at
tempt to link the pati ents symptoms and com
pl ai nts to underl yi ng factors, the connections
wi th whi ch the pati ent may be onl y di ml y
aware. Careful l y phrased i nterpretati ons will
be requi red. It may not be possible to detect
basic conflicts in the first i ntervi ew, only sec
ondary or deri vati ve conflicts being apparent.
Moreover, the pati ent may not have gi ven the
therapi st all the facts due to resistance, guil t,
or anxiety. Or facts may be defensively di s
torted. I t is often helpful (with the permi ssi on
of the pati ent) to i ntervi ew, if possible, the
spouse or another i ndi vi dual wi th whom the
pati ent is rel ated after the first or second i nter
view. The suppl ementary data obtai ned may
compl etel y change the i ni ti al hypotheti cal
assumpti ons gl eaned from the materi al excl u
sively revealed by the pati ent.
Neverthel ess, some i nval uabl e observati ons
may be made from the histori cal data and i n
terview materi al that will lend themsel ves to
i nterpretati on for defi ni ng a focus. Thus a pa
ti ent presenti ng great inferiority probl ems and
repetitive difficul ties in work si tuati ons wi th
supervisors, who as a chil d fought bitterly wi th
an ol der si bli ng, was told the following: I t is
possible that your present anxi ety whi l e re
lated to how you get al ong wi th your boss
touches off troubl es youve carri ed around wi th
you for a l ong ti me. Y ou told me you al ways
felt inferior to your brother. I n many cases this
sense of inferiority conti nues to bother a per
son in rel ati on to all ki nds of new ol der
brothers. I t woul dnt be mysteri ous if this were
happeni ng to you. What do you thi nk? Thi s
comment started off a producti ve series of
remini scences regardi ng his experi ences wi th
his brother, a focus on whi ch resulted in con
si derabl e understandi ng and betterment of his
current rel ati onshi ps.
As has been indi cated, more fundamental
nucl ear conflicts may be revealed in l ater
sessions (for exampl e, in the above pati ent an
al most classical oedipal conflict existed), espe
cially when transference and resistance man
ifest themselves.
Define the Precipitating Events
I t is essential that we identify clearly the
preci pi tati ng factors that led to the pati ents
present upset or why the pati ent came to treat
ment at this ti me.
Th. I t seems as if you were managi ng to get al ong
wi thout troubl e unti l your daughter told you
about the affair she is havi ng wi th thi s marri ed
man. Do you beli eve thi s started you off on the
downsl i de?
Pt. Doctor, I cant tell you the shock thi s was to
me. J ani e was such an ideal chi l d and never
was a bit of a probl em. And then thi s thi ng
happened Shes compl etel y changed, and I
can't understand it.
Sometimes the events are obscured or denied
because the pati ent has an i nvestment in
sustai ni ng si tuati onal i rri tants even whi l e he
seeks to escape from thei r effects. I nvol vement
in an unsati sfactory rel ati onshi p wi th a
di sturbed or rej ecti ng person from whi ch the
pati ent cannot extri cate hi msel f is an exampl e.
I t may be necessary to encourage conti nui ng
conversati on about a suspected preci pi tant,
aski ng poi nted questi ons in the effort to help
the pati ent see the rel ati onshi p between his
symptoms and what he may have consi dered
unrel ated noxi ous events. Shoul d the pati ent
fail to make the connections, the therapi st may
spell these out, aski ng perti nent questi ons that
may hel p the pati ent grasp the associati on.
Evolve a Working Hypothesis
After the fi rst session the therapi st shoul d
have gathered enough data from the present
and past hi story, from any dreams that are
reveal ed, and from the general atti tude and be
havi or of the pati ent to put together some
formul ati on about what is goi ng on. Thi s is
presented to the pati ent in si mpl e l anguage,
empl oyi ng concepts wi th whi ch the pati ent has
some fami l i ari ty. T hi s f ormul ati on shoul d
never be couched in di smal terms to avoid
al armi ng the pati ent. Rather a concise, re
strai ned, opti mi sti c pi cture may be pai nted
maki ng this conti ngent on the pati ents cooper
ati on wi th the therapeuti c pl an. Aspects of the
hypothesi s shoul d i deal l y bracket the i m
medi ate preci pi tati ng agenci es wi th what has
gone on before in the life hi story and, if possi
ble, how the pati ents personal i ty structure has
influenced the way that he has reacted to the
preci pi tati ng events.
A woman experi enci ng a severe anxi ety at
tack revealed the preci pi tati ng inci dent of di s
coveri ng her husbands mari tal infidel ity. As
she di scussed thi s, she disclosed the pai nful
episode of her fathers abandoni ng her mother
for another woman.
Th. I s it possi bl e that you are afrai d your husband
will do to you what your father di d to your
mother?
Pt. (breaking out in tears) Oh, i ts so terri bl e. I
someti mes thi nk I cant stand it.
Th. Stand hi s l eavi ng you or the fact that he had
an affair?
Pt. I f it coul d end ri ght now, I mean if he woul d
stop, it (pause).
Th. Y ou woul d forget what had happened?
Pt. p a u s e ) Y esYes.
Th. How you handl e yoursel f wil l determi ne what
happens. Y ou can see that your present upset
is probabl y l i nked wi th what happened in your
home when you were a chi l d. Woul d you tell
me about your love life wi th your husband?
The focus on therapy was thereafter con
cerned wi th the qual i ty of her rel ati onshi p
wi th her husband. There were evidences that
the pati ent herself promoted what i nwardl y
she believed was an inevi tabl e abandonment.
The therapi st in maki ng a tentati ve thrust at
the dynami cs of a probl em shoul d present it in
si mpl e terms that the pati ent can understand.
The expl anati on shoul d not be so dogmati c,
however, as to precl ude a revi sion of the hy
pothesis at a l ater date, shoul d further elicited
materi al demand this. T he pati ent may be
asked how he feels about what the therapi st
has said. I f he is hazy about the content, his
confusion is expl ored and clarificati on con
tinued.
For exampl e, a pati ent wi th mi grai ne is
presented wi th the hypothesi s that anger is
what is creati ng his symptom. The pati ent
then makes a connection wi th past resentments
and the denial defenses that he erected, whi ch
apparentl y are still operati ve in the present.
Th. Y our headaches are a great probl em obvi ousl y
since they bl ock you in your work. Our ai m is
to hel p reduce or el i mi nate them. From what
you tell me, they started way back probabl y in
your chi l dhood. They are apparentl y connected
wi th certai n emoti ons. For exampl e, upset feel
i ngs and tensi ons are often a basi s for
headaches, but there may be other thi ngs too,
like resentments. What we wi l l do is expl ore
what goes on in your emoti ons to see what
connecti ons we can come up wi th. Of ten
resentments one has in the present are the
resul t of si tuati ons si mi l ar to troubl es a person
had in chi l dhood.
Pt. I had great pai ns and troubl e fi ghti ng for my
ri ghts when I was smal l a bossy mother and
father who di dnt care. I guess I fi nal ly gave
up.
Th. Di d you gi ve up tryi ng to adj ust at home or
work?
Pt. Not exactl y. But fi ghti ng never gets any
wheres. Peopl e j ust dont li sten.
Make a Tentative Diagnosis
Despi te the fact that our current nosological
systems leave much to be desi red, it may be
necessary to fit the pati ent into some diagnosti c
scheme if for no other reason than to satisfy i n
sti tuti onal regul ati ons and i nsurance requi re
ments. There is a temptati on, of course, to
coordi nate di agnosi s wi th accepted label s for
whi ch rei mbursement will be made. Thi s is
unfortunate since it tends to li mi t fl exibili ty
and to i nval i date uti l i zi ng case records for pur
poses of stati sti cal research. Even though cli ni
cal diagnosi s bears little rel ati onshi p to pre
ferred therapeuti c techni ques in some syn
dromes, in other syndromes it may be helpful
toward i nsti tuti ng a rati onal program
(Wol berg, 1977, pp. 6, 62-63, 410-418).
Convey the Need for the Patient's
Active Participation in the
Therapeutic Process
Many pati ents, accustomed to deal i ng wi th
medi cal doctors, expect the therapi st to pre
scribe a formul a or give advice that will oper
ate automati cal l y to pal l i ate the probl em. An
expl anati on of what will be expected of the pa
ti ent is in order.
Th. T here is no magi c about getti ng wel l . T he way
we can best accompl i sh our goal s is to work
together as a partnershi p team. I want you to
tell me all the i mportant thi ngs that are goi ng
on wi th you and I wil l try to hel p you under
stand them. What we want to do is to devel op
new, heal thi er patterns. M y j ob is to see what
is bl ocki ng you from achi evi ng thi s obj ecti ve by
42
poi nti ng out some thi ngs that have and are still
bl ocki ng you. Your j ob is to act to put into
practi ce new patterns we deci de are necessary,
you tel l i ng me about your experi ences and feel
ings. Psychotherapy is li ke l earni ng a new l an
guage. T he l earner is the one who must prac
tice the l anguage. I f the teacher di d all the
tal ki ng, the student woul d never be abl e to
carry on a conversati on. So remember you are
goi ng to have to carry the bal l, wi th my hel p of
course.
Make a Verbal Contract With The
Patient
There shoul d be an agreement regardi ng the
frequency of appoi ntments, the number of
sessions, and the termi nati on date.
Example 7. Where Limitation of the
Number of Sessions is Deemed Necessary in
Advance
Th. We are goi ng to have a total of 12 sessions. I n
that ti me we shoul d have made an i mpact on
your anxi ety and depressi on. Now, l ets con
sult the cal endar. We will termi nate therapy
on October 9, and I ll mark it down here. Can
you al so make a note of it?
Pt. Wi l l 12 sessions be enough?
Th. Yes. T he least it coul d do is to get you on the
road to real l y worki ng out the probl em.
Pt. What happens if I m not better?
Th. Y ou are an i ntel l i gent person and there is no
reason why you shoul dnt be better in that
ti me.
Shoul d the therapi st dal l y and compromi se
his confi dence in the pati ents capaci ty to get
well, the pati ent may in advance cancel the
termi nati on in his own mi nd in favor of an
i ndetermi nate future one.
Example 2. When the Termination Date is
Left Open
Th. It is hard to esti mate how many sessions we
wil l requi re. I li ke to keep them bel ow 20. So
let us begi n on the basi s of twi ce a week.
Pt. A nythi ng you say, doctor. I f more are neces
sary, OK .
Th. I t is real l y best to keep the number of sessions
as l ow as possi bl e to avoi d getti ng dependent
on them. So well pl ay it by ear.
Pt. T hats fine.
The appoi ntment ti mes may then be set and
the fee discussed.
Utilize Whatever Techniques are
Best Suited to Help the Patient
with Immediate Problems
Fol l owi ng the i ni ti al intervi ew, techni ques
that are acceptabl e to the pati ent, and that are
wi thi n the trai ni ng range and competence of
the therapi st, are i mpl emented, beari ng in
mi nd the need for acti vity and flexibility. The
techni ques may i ncl ude supporti ve, educa
ti onal , and psychoanal yti cal l y ori ented i nter
venti ons and a host of adj uncti ve devices, such
as psychotropi c drugs, hypnosi s, biofeedback,
behavi oral and group approaches, and so on,
in whatever combi nati ons are necessary to
sati sfy the pati ents i mmedi ate and future
needs. An expl anati on may be given the pa
ti ent about what will be done.
Th. At the start, I bel i eve it woul d be hel pful to
reduce your tensi on. T hi s shoul d be beneficial
to you in many ways. One of the best ways of
doi ng thi s is by teachi ng you some rel axi ng ex
erci ses. What I woul d li ke to do for you is to
make a rel axi ng casette tape. Do you have a
casette tape recorder?
Pt. No, I havent.
Th. Y ou can buy one qui te i nexpensi vel y. How do
you feel about thi s?
Pt. I t sounds great.
Th. OK . Of course, there are other thi ngs we wil l
do, but thi s shoul d hel p us get off to a good
start.
Many therapi sts practi ci ng dynami c short
term therapy ask thei r pati ents to reveal any
dreams that occur duri ng therapy. Some pa
ti ents insist that they rarel y or never dream or
if they do, that they do not remember thei r
dreams.
Th. I t is i mportant to menti on any dreams that
come to you.
Pt. I cant get hol d of them. T hey sl i p away.
Th. One thi ng you can do is, when you reti re, tell
yoursel f you will remember your dreams.
Pt. What if I cant remember.
Th. K eep a pad of paper and a penci l near the
head of your bed. When you awaken ask your
self if you dreamt. T hen wri te the dream
down. Al so, if you wake up duri ng the ni ght.
Study the Patient's Reaction and
Defense Patterns
T he uti l i zati on of any techni que or stra-
tegem wi l l set i nto moti on reacti ons and
defenses that are gri st for the therapeuti c mill.
T he pati ent will di spl ay a range of patterns
that you can study. Thi s will permi t a dra
mati c demonstrati on of the pati ents defenses
and resistances in actual operati on rather than
as theories. The pati ents dreams and fantasies
will often reveal more than his acti ons or ver
bali zati ons, and he shoul d conti nual l y be en
couraged to tal k about these. T he skill of the
therapi st in worki ng wi th and i nterpreti ng the
pati ents si ngul ar patterns wi l l determi ne
whether these wi l l be i ntegrated or wi l l
generate further resistance. General l y, a com
passionate, tentati ve type of i nterpretati on is
best, spri nkl i ng it if possible wi th a casual
light humorous atti tude. A pati ent who wanted
hypnosi s to control smoki ng appeared restless
duri ng induction:
Th. I noti ced that when I asked you to l ean back in
the chai r and try rel axi ng to my suggesti ons,
you were qui te uneasy and kept on openi ng
your eyes. What were you thi nki ng about?
Pt. (emotionally) M y heart started beati ng. I was
afrai d I coul dnt do it. What youd thi nk of
me. T hat I d fail. I guess I m afrai d of doctors.
My husband is tryi ng to get me to see a gyne
cologist.
Th. But you kept openi ng your eyes.
Pt. (pause) Y ou know, doctor, I m afrai d of l osing
control , of what mi ght come out. I guess I
dont trust anybody.
Th. Afrai d of what woul d happen here, of what I
mi ght do if you shut your eyes? (smiling)
Pt. (laughing) I guess so. Silly. But the thought
came to me about somethi ng sexual .
While the Focus at all Times is on
the Present, be Sensitive to How
Present Patterns Have Roots in the
Past
Exami ni ng how the pati ent was reared and
the rel ati onshi p wi th parents and sibli ngs is
parti cul arl y reveal ing. An attempt is made
to establ i sh patterns that have operated
throughout the pati ents life of whi ch the cur
rent stress si tuati on is an i mmedi ate mani festa
ti on. Thi s data is for the therapi sts own con
sumpti on and shoul d not be too exhaustive,
since the pati ent if encouraged to expl ore the
past may go on endlessly, and there is no ti me
for this. At a propi ti ous moment, when the pa
ti ent appears to have some awareness of con
necti ons of his past wi th his present, a proper
i nterpretati on may be made. At that ti me a re
l ati onshi p may be cited between geneti c de
termi nants, the existi ng personal i ty patterns,
and the symptoms and compl ai nts for whi ch
therapy was ori gi nal l y sought.
Watch for Transference Reactions
T he i mmedi ate reachi ng for hel p encourages
proj ecti on onto the therapi st of positi ve feelings
and atti tudes rel ated to an ideal ized authori ty
figure. These shoul d not be i nterpreted or in
any way di scouraged since they act in the i n
terest of al l evi ati ng tension and supporti ng the
placebo el ement. On the other hand, a negative
transference reacti on shoul d be deal t wi th
rapi dl y and sympatheti cal l y si nce it will i nter
fere wi th the therapeuti c alliance.
Th. [n o t i n g the p a t i e n t ' s h es itant sp e e c h] Y ou seem
to be upset about somethi ng.
Pt. Why, should I be upset?
Th. Y ou mi ght be if I di d somethi ng you di dnt
like.
Pt. (pause) No I m afrai d, j ust afrai d I m not do
i ng what I shoul d. I ve been here six ti mes and
I still have that pani cky feel i ng from ti me to
ti me. Do other pati ents do better?
Th. Y ou seem to be compari ng yoursel f to my other
pati ents.
Pt. I I I guess so. T he young man that came
before me. He seems so sel f-confident and
cheerful . I guess I felt i nferi or, that you woul d
fi nd faul t wi th me.
Th. Do you thi nk I li ke hi m better than I do you?
Pt. Wel l , woul dnt you, if he was doi ng better
than I was?
Th. T hats i nteresti ng. Tel l me more.
Pt. I ve been that way. My parents, I felt, pre
ferred my ol der brother. He al ways came
in on top. T hey were proud of hi s accompl i sh
ments in school.
Th. So i n a way you feel I shoul d be acti ng like
your parents.
Pt. I cant hel p feel ing that way.
Th. Dont you thi nk thi s is a pattern that is real l y
sel f-defeati ng? We ought to expl ore thi s more.
Pt. (emot i ona l l y ) Wel l , I real l y thought today you
were goi ng to send me to another doctor be
cause you were sick of me.
Th. Actual l y, the thought never occurred to me to
do that. But I m gl ad you brought thi s matter
out because we wi l l be abl e to expl ore some of
your i nnermost fears about how peopl e feel
about you.
Examine Possible
Countertransference Feelings
I f you noti ce persi stent irri tabi l i ty, boredom,
anger, extraordi nary interest in or attracti on to
any pati ent, ask yourself whether such feelings
and atti tudes do not call for sel f-exami nati on.
Thei r conti nuance will al most certai nl y lead to
interference wi th a good worki ng rel ati onshi p.
For exampl e, a therapi st is treati ng an unsta
bl e mi ddl e-aged femal e pati ent whom he
regards as a pl umpi sh, sl oppy biddy who sticks
her nose into other peopl es affairs. He tries to
mai ntai n an i mparti al therapeuti c stance, but
peri odical ly he finds hi msel f scol ding her and
feel ing annoyed and enraged. He is al ways
relieved as the session hour comes to an end.
He recogni zes that his reacti ons are coun-
tertherapeuti c, and he asks himsel f if they are
real l y justi fied. The i mage of his own mother
then comes to his mi nd, and he real izes that he
had many of the same feel ings of exasperati on,
di spl easure, and disgust wi th his own parent.
Recogni zi ng that he may be transferri ng in
part some of these atti tudes to his pati ent
whose physi cal appearance and manner re
mi nd hi m of his mother, he is better abl e to
mai ntai n objectivity. Shoul d self analysis, how
ever, fail to hal t his ani mosi ty, he may decide
to send the pati ent to another therapi st.
Constantly Look for Resistances
That Threaten to Block Progress
Obstructi ons to successful therapeuti c ses
si ons are nurtured by mi sconcepti ons about
therapy, lack of moti vati on, needs to mai ntai n
certai n benefits that accrue from ones illness,
and a host of other sources, conscious and
unconsci ous. Where resistances are too stub
born to budge readi l y or where they operate
wi th little awareness that they exist, the few
sessions assigned to short-term therapy may
not suffice to resolve them. One way of deal i ng
wi th resistances once they are recogni zed is to
bri ng them out openl y in a noncondemni ng
manner. Thi s can be done by stati ng that the
pati ent may if he desi res hol d on to them as
defenses, but if thi s is so, he must suffer the
consequences. A frank discussi on of why the
resistances have val ue for the pati ent and thei r
effects on his treatment is in order. Another
techni que is to anti ci pate resistances from the
pati ents past modes of adaptati on, dreams,
and the like, presenti ng the pati ent wi th the
possibil ity of thei r appearance and what could
be done about them shoul d they appear. The
therapi st shoul d watch for mi ni mum ap
pearances of resistance, however mi nor they
may be, that wi l l serve as psychol ogi cal
GENERAL OUTLINE OF SHORT-TERM THERAPY
45
obstructi ons. Merel y bri ngi ng these to the at
tenti on of the pati ent may rapi dl y dissipate
them.
Pt. I di dnt want to come here. L ast ti me I had a
terri bl y severe headache. I felt di zzy in the
head, (pause)
Th. I wonder why. Di d anythi ng happen here that
upset you; di d I do anythi ng to upset you?
Pt. No, i ts funny but i ts somethi ng I cant under
stand. I want to come here, and I dont. I ts
li ke I m afrai d.
Th. Afrai d?
Pt. (Pause; p a t i e n t f l u s h e s . ) I cant understand it.
Peopl e are al ways tryi ng to change me. As far
back as I can remember, at home, at school.
Th. And you resent thei r tryi ng to change you.
Pt. Yes. I feel they cant l eave me al one.
Th. Perhaps you feel I m tryi ng to change you.
Pt. (angrily) A rent you?
Th. Onl y if you want to change. I n what way do
you want to change, if at al l ?
Pt. I want to get ri d of my headaches, and
stomachaches, and all the rest of my aches.
Th. P .t you dont want to change to do this.
Pt. Wel l , doctor, thi s i snt true. I want to change
the way I want to.
Th. Are you sure the way you want to change wil l
hel p you get ri d of your symptoms?
Pt. But thats why I m comi ng here so you wi l l tell
me.
Th. But you resent my maki ng suggesti ons to you
because somehow you put me i n the cl ass of
everybody else who you bel i eve wants to take
your i ndependence away. A nd then you show
resi stance to what I am tryi ng to do.
Pt. (laughs) I snt that silly, I real l y do trust you.
Th. T hen supposi ng when you begi n to feel you
are bei ng domi nated you tell me, so we can
tal k it out. I real l y want to hel p you and not
domi nate you.
Pt. T hank you, doctor, I do feel better.
Give the Patient Homework
I nvolve the pati ent wi th an assi gnment to
work on how his symptoms are rel ated to hap
peni ngs in his envi ronment, to atti tudes, to
fallacies in thi nki ng, to di sturbed i nterpersonal
rel ati onshi ps, or to conflicts wi thi n himself.
Even a bit of insi ght may be a savi ng grace. As
soon as feasible, moreover, ask the pati ent to
revi ew his idea of the evolution of his probl em
and what he can do to control or regul ate the
ci rcumstances that rei nforce the probl em or
al l eviate his symptoms. Practi ce schedules may
be agreed on toward opposi ng the si tuati ons or
tendencies that requi re control. T he pati ent
may be enj oi ned to keep a log regardi ng i n
cidents that exaggerate his difficulti es and
what the pati ent has done to avoid or resolve
such incidents. T he pati ent may al so be given
some cues regardi ng how he may work on
hi msel f to reverse some basic destructi ve per
sonal ity patterns through such measures as
acqui ri ng more understandi ng and i nsi ght, re
wardi ng hi msel f for positi ve acti ons, sel f-hyp
nosi s, and so on. These tactics may be pursued
both duri ng therapy and fol lowing therapy by
oneself.
For exampl e, the fol lowing suggestion was
made to a pati ent who came to therapy for
hel p to abate mi grai ne attacks:
Th. What may hel p you is understandi ng what
tri ggers off your headaches and makes them
worse. Supposi ng you keep a di ary and j ot
down the frequency of your headaches. Every-
ti me you get a headache wri te down the
day and ti me. Even more i mportant, wri te
down the events that i mmedi atel y preceded the
onset of the headache or the feel i ngs or
thoughts you had that brought it on. I f a
headache is stopped by anythi ng that has hap
pened, or by anythi ng you thi nk about or
fi gure out, wri te that down, and bri ng your
di ary when you come here so we can tal k
about what has happened.
Keep Accenting the Termination
Date if One was Given the Patient
I n prepari ng the pati ent for termi nati on of
therapy, the cal endar may be referred to pri or
to the last three sessions and the pati ent
remi nded of the date. I n some pati ents thi s will
acti vate separati on anxi ety and negati ve trans-
46
ference. Such responses will necessitate active
i nterpretati on of the pati ents past dependency
and fears of autonomy. Evidences of past reac
tions to separati on may hel p the pati ent ac
qui re an understandi ng of the underpi nni ngs
of present reactions. T he therapi st shoul d ex
pect a recrudescence of the pati ents symptoms
as a defense agai nst being on his own and as
an appeal for conti nui ng treatment. These
mani festati ons are dealt wi th by further i nter
pretati on. Do not promise to conti nue therapy
even if the pati ent predi cts failure.
Pt. I know were supposed to have onl y one more
session. But I get scared not havi ng you
around.
Th. One of our ai ms is to make you stronger so
you wont need a crutch. Y ou know enough
about yoursel f now to take some steps on your
own. T hi s is part of getti ng well . So I want
you to give yoursel f a chance.
Many pati ents will resent termi nati on of
therapy after the desi gnated number of sessions
have ended. At the mi ddl e poi nt of therapy,
therefore, the therapi st may bri ng up this
possibil ity. The therapi st shoul d search for i n
cidents in the past where separati ons have
created untoward reacti ons in the pati ent. I n
di vi dual s who were separated from thei r
parents at an earl y age, who had school
phobi as produced by i nabi l i ty to break ties
wi th the mother, and who are excessively de
pendent are parti cul arl y vul nerabl e and apt to
respond to termi nati on wi th anxiety, fear,
anger, and depression. The termi nati on proc
ess here may consti tute a pri me focus in ther
apy and a means of enhanci ng indi vi duati on.
Th. We have five more sessions, as you know, and
then we wi l l termi nate.
Pt. I real i ze it, but I al ways have troubl e breaki ng
away. My wife cal l s me a hol der-oner.
Th. Yes, thats exactl y what we want to avoi d, the
dependency. Y ou are likely to resent endi ng
treatment for that reason. What do you thi nk?
Pt. (l au ghing ) I ll try not to.
Th. Wel l , keep thi nki ng about it and if you have
any bad reacti ons l ets tal k about it. I ts i mpor
tant not to make treatment a way of life. By
the end of the five sessions, you shoul d be abl e
to carry on.
Pt. But supposi ng I dont make i t?
Th. T here you go, see, anti ci pati ng fai l ure. T hi s is
a gesture to hol d on.
Pt. Wel l , doctor, I know you are ri ght. I ll keep
worki ng on it.
Terminate Therapy on the Agreed-
upon Date
Whi l e some therapi sts do not consi der it
wise to invite the pati ent who has progressed
satisfactorily to return, others find it a helpful
and reassuri ng aid for most pati ents to do so at
the final session. I general l y tell the pati ent to
wri te to me someti me to let me know thi ngs
are comi ng al ong. I n the event probl ems de
velop that one cannot manage by oneself, the
pati ent shoul d call for an appoi ntment. Rarel y
is thi s i nvi tati on abused and if the pati ent does
return (whi ch is not too common in my experi
ence) the difficulty can be rapi dl y handl ed,
eventuati ng in rei nforcement of ones under
standi ng.
Th. T hi s is, as you know, our l ast session. I want
you now to try thi ngs out on your own. K eep
practi ci ng the thi ngs 1taught you the rel axa
ti on exerci ses \where these have been used],
the fi guri ng out what bri ngs on your symptoms
and takes them away, and so forth. Y ou shoul d
conti nue to get better. But setbacks may occur
from ti me to ti me. Dont let that upset you.
T hats normal and youll get over the setback.
I n fact, it may hel p you fi gure out better what
your symptoms are all about. Now, if in the
future you fi nd you need a li ttle more hel p,
dont hesi tate to call me and I ll try to arrange
an appoi ntment.
Actual l y rel ati vely few pati ents will take
advantage of thi s i nvi tati on, but they will feel
reassured to go out on thei r own knowi ng they
will not be abandoned. Shoul d they return for
an appoi ntment, onl y a few sessi ons will be
needed to bri ng the pati ent to an equi l i bri um
and to hel p l earn about what produced the re
lapse.
Stress the Need for Continuing
Work on Oneself
T he matter of conti nui ng work on oneself
after termi nati on is very much underesti mated.
Pati ents will usual l y return to an envi ronment
that conti nues to sponsor mal adapti ve reac
tions. The pati ent will need some constant
remi nder that old neurotic patterns l atentl y
awai t revival and that he must alert hi msel f to
si gnals of thei r awakeni ng. I n my practi ce I
have found that maki ng a rel axi ng tape (a
techni que detai l ed in Chapter 15) spri nkl ed
wi th positive suggestions of an ego-bui l di ng
nature serves the interest of conti nued growth.
I n the event the pati ent has done well wi th
homework duri ng the acti ve therapy peri od,
the same processes may conti nue. I nsti tuti on of
a proper phi l osophi cal outl ook may al so be in
order pri or to discharge. Such atti tudes may be
encouraged as the need to isolate the past from
the present, the real i zati on that a certai n
amount of tension and anxi ety are normal , the
need to adj ust to handi caps and real istic i rre
medi abl e conditions, the urgency to work at
correcti ng remedi abl e el ements in ones envi
ronment, the recogni ti on of the forces that tri g
ger off ones probl ems and the i mportance of
rectifying these, and the wi sdom of stoppi ng
regretti ng the past and of avoi di ng anti ci pati ng
disaster in the future. I t must be recogni zed
that whi l e the i mmedi ate accompl i shments of
short-term therapy may be modest, the con
ti nued appl i cati on of the methods the pati ent
has l earned duri ng his therapy will hel p bri ng
about more substanti al changes.
Arrange for Further Treatment if
Necessary
The question may be asked regardi ng what
to do wi th the pati ent who at termi nati on
shows little or no i mprovement. Certai n pa
ti ents will requi re l ong-term therapy. I n this
reference there are some pati ents who will
need hel p for a prol onged peri od of ti me; some
requi re only an occasi onal contact the re
mai nder of thei r lives. T he contact does not
have to be i ntensi ve or frequent. Persons wi th
an extreme dependency character di sorder,
borderl i ne cases, and schi zophreni cs often do
well wi th short visits (15 to 20 mi nutes) every
2 weeks or longer. The idea that a supporti ve
person is avai l abl e may be all that the pati ent
demands to keep hi m in homeostasi s. I ntroduc
ing the pati ent into a group may al so be hel p
ful, mul ti pl e transferences di l uti ng the hostile
transference that so often occurs in i ndi vidual
therapy. A social group may even suffice to
provi de the pati ent wi th some means of a
human rel ati onshi p. Some pati ents will need
referral to another therapi st who speci ali zes in
a different techni que, for exampl e, to someone
who does bi ofeedback, or behavi oral therapy,
or another modal ity.
Th. Now, we have compl eted the number of
sessions we agreed on. How do you feel about
matters now?
P t. Better, doctor, but not well. I still have my i n
somnia and feel discouraged and depressed.
Th. T hat should get better as time goes on. 1
should like to have you continue with me in a
group.
P t. Y ou mean with other peopl e I ve heard of it.
I t scares me, but I d like to do it.
Where the pati ent is to be referred to
another therapi st, he may be told:
Th. Y ou have gotten a certain amount of help in
coming here, but the kind of problems you
have will be helped more by a specialist who
deals with such problems. I have someone in
mind for you who I believe will be able to help
you. I f you agree, I shall telephone him to
make sure he has time for you.
Pt. I d like that. Who is the doctor?
Th. D r_________ I f he hasnt time. I ll get someone
else.
48
Conclusion
Twenty operati ons are recommended for an
effective dynami cal l y ori ented short-term ther
apy program. They consist of (1) establ i shi ng a
rapi d positive worki ng rel ati onshi p (thera
peuti c al l i ance), (2) deal i ng wi th i ni ti al
resistances, (3) gatheri ng histori cal data, (4)
selecti ng a focus for therapy, (5) defi ning
preci pi tati ng events, (6) evolving a worki ng
hypothesis, (7) maki ng a tentati ve diagnosis,
(8) conveying the need for the pati ents active
parti ci pati on in the therapeuti c process, (9)
maki ng a verbal contract, (10) uti l i zi ng appro
pri ate techni ques in an acti ve and flexible
manner, (11) studyi ng the reacti ons and
defenses of the pati ent to the techni ques being
empl oyed, (12) rel ati ng present-day patterns to
patterns that have operated throughout the pa
ti ents life, (13) watchi ng for transference reac
ti ons, (14) exami ni ng possible countertrans
ference feel i ngs, (15) al erti ng onesel f to
resistances, (16) assi gni ng homework, (17) ac
centi ng the termi nati on date, (18) termi nati ng
therapy, (19) assi gni ng conti nui ng self-help
activities, and (20) arrangi ng for further treat
ment if necessary.
These operati ons may be uti li zed in toto or
in part by therapi sts who can adapt them to
thei r styles of worki ng. I rrespective of the
oretical persuasi on, there are a number of
areas of general agreement among different
professi onals practi ci ng short-term therapy:
1. Time. T he most frequently designated number
of sessions range from 3 to 6 for crisis intervention,
from 6 to 12 for supportive-educational approaches,
and from 12 to 20 for more extensive psychotherapy
along dynamic lines. T hese may be crowded into a
span of a few weeks, or they may be distributed over
a number of months. Some therapi sts prefer to see
thei r pati ents on a once-a-week basis; others find
twice a week the optimal frequency. I n some cases
40 to 50 sessions are still considered acceptable for
short-term coverage. T ime limits are often set in
advance with the patient.
2. Selection o f cases. Ali types of problems of
acute and chronic durati on are considered suitable.
Even pati ents with serious psychopathology are can
didates. Some therapi sts who confine themselves to
dynamic short-term therapy believe selection of ap
propri ate pati ents is mandatory.
3. Goals. Reconstructive changes are deemed not
only desirable but also obtai nabl e in suitable pa
tients, especially with the use of dynamic ap
proaches, provided there exists proper motivation
and concurrence of reconstructive objectives on the
parts of pati ent and therapi st.
4. Degree o f therapist activity. A relatively high
degree of activity is generally preferred.
5. Focus o f therapy. A restriction of focus to a
zone agreed on by pati ent and therapi st is i mpor
tant, if not essential. I f a nuclear conflict is i dentifia
ble and the pati ent does not defensively avoid it too
much, its consideration as a focus is desirable in dy
namically oriented approaches. Considered signifi
cant are transference phenomena, which in some
systems may occupy a position of central i mpor
tance.
6. Techniques. T he full range of eclectic suppor
tive, educational, and reconstructive techniques are
used including, in dynamic approaches, tradi ti onal
analytic techniques of transference analysis, i nter
pretati on of resistance, dream and fantasy expl ora
tion, and the rel ati ng of transference to genetic de
terminants.
CHAPTER 5
The Initial Interview
A. Common Questions
T he initi al i ntervi ew is perhaps the most
vital of all sessions since in its conduct rests the
fate of the therapeuti c all iance and, even more
i mportantl y, the eventual i ty of whether or not
the pati ent will return for further treatment.
How much ti me shoul d ideal ly be spent on hi s
tory taki ng? Shoul d the i ntervi ew be largely
diagnosti c or therapeuti c? What degree of con
frontati on can safely be empl oyed? These and
many other questi ons chal l enge the i nter
viewer. I n the present chapter some of the
points menti oned in the last chapter will be ex
pounded by presenti ng rel evant questi ons (and
answers) brought up in teachi ng and super
visory sessions wi th therapi sts of different
theoreti cal persuasi ons.
Woul d you consi der the fi rst sessi on
therapeuti c or di agnosti c?
Whi l e the ini ti al i ntervi ew is conducted for
the purpose of assessing the presenti ng prob
lem and pl anni ng treatment strategy, it shoul d
be managed so that it regi sters a constructi ve
i mpact on the pati ent. I t must be stressed that
a si zable number of pati ents, especiall y those
that come to outpati ent clinics, do not return
for a second intervi ew. Fol l ow-up studies show
that the initi al intervi ew can have a defi nite
therapeuti c effect and may even start the pa
ti ent on the road to recovery. T he therapi st,
therefore, shoul d assume that the first i nter
view will be the only opportuni ty to work wi th
the pati ent and thus that enough work must be
done so that the pati ent can leave the session
wi th somethi ng posi ti ve to grappl e onto. The
initi al interview shoul d be conducted in such a
way as to give the pati ent a better idea about
his underl yi ng probl em and an assay of what
he can do to hel p himself. Natural l y, most pa
ti ents will return for more sessions unless the
therapi st has failed to incite thei r confidence or
has commi tted seri ous errors in approach
(detachment, bel i ttl i ng atti tudes, fri ghteni ng
the pati ent wi th depth i nterpretati ons, hos
tili ty, etc.).
How thorough shoul d hi story taki ng be in
the i ni ti al i ntervi ew?
Duri ng the ini ti al intervi ew exhausti ve, ri
tual isti c taki ng of a history is unnecessary. All
that is requi red is the gatheri ng of sufficient i n
formati on to al l ow for treatment pl anni ng and
perhaps for the maki ng of a tentati ve di ag
nosis. I n l ater sessions one may fill in this
skeletal outl i ne of history. More i nformati on
will be revealed as the pati ent gai ns confidence
in the therapi st.
I n apprai si ng the degree of the pati ents
mal adj ustment at the i ni ti al i ntervi ew,
are there any cri teri a that can be appl i ed?
There are a number of adj ustment scales
that are in use, none of whi ch is perfect. I t is
helpful to view the present difficulty agai nst
the backdrop of previ ous mal adaptati ons, par
ti cul arl y those duri ng chil dhood. The data
here is not enti rel y defi nitive since the pati ent
could, in spi te of a di sorgani zed earl y life hi s
tory, still make a reasonabl e adul t adj ustment
under propi ti ous ci rcumstances. T he second
i tem one may consi der is the qual i ty of the
present personal rel ati onshi ps, the adj ustment
to ones mari tal partner and chi l dren, the ex
tent of creativi ty, and the val ues that mol d be
49
havior. Thi rd, one may esti mate the degree of
anxi ety that is mani fest or that expresses itself
in terms of such symptoms as depressi on and
psychosomati c mani festati ons.
A fourth possibil ity is to exami ne the nature
of defenses agai nst anxiety, for instance, thei r
abil ity to contai n the anxi ety and the effect
that they have on the total functioni ng. Fifth,
we ponder the extent of adaptati onal collapse.
Here even though the pati ent seems to be mak
ing a good adj ustment, we must ask at what
expense. Thus, a detached person may show
on the surface a fairly good adj ustment. Con
sequently, it is essential to esti mate how trul y
adequate this is in terms of what is happeni ng
to the indi vi dual as a whole. He may be escap
ing anxi ety and worki ng adequatel y onl y by
the tactic of isolating himsel f from people. Or a
dependent person may be functi oni ng solely by
attachi ng hi msel f to a parental fi gure. The
kind of adaptati on hel ps us to determi ne the
degree of support that will be requi red at the
start of treatment, the amount of parti ci pati on
one may expect from the pati ent and how ac
tive the therapi st shoul d be in the rel ati onshi p.
I s it advi sabl e to spend more ti me on the
i ni ti al i ntervi ew than on other sessions?
If possible, yes. So much has to be done dur
ing the first i ntervi ew that the usual 45 or 50
mi nutes of ti me all otted for a session may be
insufficient. Extendi ng the ti me, however, may
not be practical ly possible. Hence, two sessions
may be necessary in some cases to accomplish
all essential tasks. An experi enced intervi ewer,
however, may requi re no more than one
session.
I s it i mpossi bl e to work wi th an unmoti
vated pati ent, and i f so, can you gi ve
some exampl es of how thi s can be done?
I t is not at all impossi ble provi ded one deals
wi th what is behi nd the lack of moti vati on. To
do this the therapi st may try to retrieve unex
pressed or unconsci ous emoti ons that are act
ing, or will act, as resistances to therapy. Such
emoti ons underl i e the pati ents mani fest be
havior. Very frequentl y these emoti ons cannot
be expressed in words, and the therapi st will
have to make assumpti ons through observati on
of the pati ents behavior. For instance, in the
event that a del i nquent boy is referred for ther
apy, the boy may sul k in his chai r, fidget, be
evasive, answer in a di sarmi ng manner, ex
press di si nterest, or show negati vism. The
therapi st may gai n the i mpressi on from observ
ing the atti tudes of the boy that the boy resents
being at the intervi ew. He, therefore, mi ght
say to the boy, Y ou probabl y resent comi ng
here, or Probabl y you feel that you ought
not to have come here, or I can understand
that you feel ki nd of mad about thi s si tuati on.
Such a remark cuts into the emoti on of the boy
and may enabl e hi m to percei ve that his feel
ings are understood.
Another exampl e is that of a woman re
ferred by a soci al agency on the basis that the
agency believes she is sufferi ng from an emo
ti onal probl em for whi ch she shoul d get help.
Even if she is not yet prepared to recei ve this
hel p, she may still appear for therapy in order
to appease the caseworker or as a means
through whi ch she can gai n further ai d from
the agency. Her moti vati on, consequentl y,
woul d be to give as little i nformati on as possi
ble about hersel f or to be as evasive as she can
wi thout offending. Under these ci rcumstances,
once the therapi st real izes what is going on, he
mi ght say the following:
T h. I can very well see that you would feel resent
ful or uncomfortable about coming here. Y ou
probably do not feel that it is necessary and
might believe that you could very easily do
wi thout therapy. I do not blame you for feeling
this way inasmuch as you did not really come
to the agency in order to seek help for an emo
tional problem.
Thi s expl anati on probabl y woul d rel ax the
woman consi derabl y, si nce she woul d sense in
the therapi st a sympatheti c person. She mi ght
then begin to express her feelings about the
THE INITIAL INTERVIEW: COMMON QUESTIONS 51
agency and at the end be wi l l i ng to tal k about
herself and her probl ems.
A common probl em is provi ded by the pa
ti ent who views psychotherapy in the same
light as consul ti ng an i nterni st. The pati ent
tells the doctor about di sturbi ng symptoms,
and the doctor prescribes a remedy. T he pa
ti ent, consequentl y, will bombard the therapi st
wi th a flood of symptoms and compl ai nts wi th
the hope that everythi ng will then be taken
care of in some mysteri ous way. T he pati ent
real ly has no means of understandi ng what is
supposed to go on in therapy other than
through experi ences wi th previ ous heal th ven
dors. The di sadvantage wi th such an atti tude
is that once the pati ent has el aborated the
probl em, responsi bi l i ty for it is transfered to
the therapi st and a cure will be expected.
Shoul d the therapi st become aware of thi s at
ti tude, he may offer thi s i nterpretati on:
T h. I t is understandabl e that you have suffered so
long that you feel it is impossible for you to do
anything about your problem yourself. I t is
natural for you to want somebody to step in
and do for you what you havent been able to
do for yourself. But you and I have to work
together as a team. I shall help you to under
stand what is happeni ng to you, and you
will find that you can do many constructive
things for yourself. T ogether we should make
progress.
The pati ent wi th a psychosomati c probl em
is often unconvinced that his physi cal symptom
is or can be emoti onal l y determi ned. The best
way of losing such a pati ent is to insist that his
probl em is psychological. Since the pati ent
may, at least temporari l y, need his symptom,
the therapi st is wise at the start of therapy to
all ow the pati ent to retai n the idea of its or-
ganicity. He may i nform the pati ent that any
symptom, even an organi c symptom, creates
tension because of discomfort or pai n. T he ten
sion delays heali ng. What needs to be done is
to reduce tension, and this can sti mul ate the
heal i ng process. Teachi ng the pati ent si mpl e
rel axi ng methods and al l owi ng the pati ent to
verbal i ze freely shoul d soon establi sh a thera
peuti c all iance, and through thi s the pati ent
may be helped to come to gri ps wi th his wor
ri es and conflicts.
A fi nal exampl e is provi ded by the host of
pati ents who are sheparded i nto therapy
agai nst thei r free will, such as court cases,
spouses of compl ai ni ng mates, persons collect
ing disabil ity payments, and i ndi vi dual s de
ri vi ng strong secondary gai ns from thei r
symptoms through avoi di ng hard work, sup
porti ng dependency needs, and getti ng atten
ti on and sympathy. Such pati ents cannot be
forced to change. The pri mary task here, as in
the case of the psychosomati c pati ent, is to first
establi sh a therapeuti c all iance. No hard-and-
fast rul es can be given since each pati ent will
requi re i nnovati ve strategems desi gned for
thei r special si tuati ons. Pati ents recei ving di sa
bil ity checks are parti cul arl y difficult to con
vince that anythi ng psychol ogical keeps them
from returni ng to work. One tactic is never to
impl y that the pati ent is in any way psycho
logically manufacturi ng his symptoms because
thi s will obstruct the establ i shi ng of a worki ng
rel ati onshi p. T he approach at first may, as
in the psychosomati c pati ent, be organi zed
around tension reducti on to hel p the pati ent
assuage sufferi ng. As tensi on is lessened, the
pati ent will begin tal ki ng more about hi msel f
and perhaps about some famil y adj ustment
probl ems. T he therapi st may soon be abl e to
i nqui re about the hopes, ambi ti ons, and goals
of the pati ent. Questi ons may be asked such as
What woul d you like to do? How woul d
you like to feel ? What do you enj oy most?
Very often when the pati ent real i zes that the
therapi st does not expect conformi ty to stand
ards that others set for the pati ent, a thera
peuti c all iance will begin. Reflecting the pa
ti ents anger wi thout condemni ng it helps con
vince the pati ent that he is not bad for feeling
the way he does. How the pati ent can go about
fulfilli ng his own goals is then pl anned. An i n
teresti ng articl e on techni ques of deal i ng wi th
such unmoti vated pati ents has been wri tten by
Swanson and Wool son (1973).
52
I f a pati ent is ref erred who is unprepared
f or treatment, how does a counsel or
prepare the person to accept ref erral to a
therapi st when there is no i ncenti ve to
recei ve hel p?
An exampl e may i l l ustrate the si tuati on. A
college student is referred to a counsel or by her
school advisor because she was becomi ng more
and more of a recluse, avoi di ng social activities
and even stayi ng away from classes. On i nter
view she is mani festly depressed. However, she
has no desire for therapy and no idea that
there is anythi ng wrong wi th the way she is
behaving. She insists i ndi gnantl y that there is
nothi ng wrong wi th her mi nd. Because she
refused to go out does not mean she needs a
psychi atri st. T he questi on is how to get this
girl to accept psychotherapy.
I n handl i ng thi s type of probl em, the first
thi ng the counsel or woul d want to do is es
tabl ish some sort of an incentive for therapy.
Wi thout thi s incentive, it woul d be useless to
refer the pati ent to a therapi st. How to create
an incentive is the case in point. One way is to
ask if she is compl etel y satisfied wi th her
present-day life and adj ustment. I f she says
that everythi ng is goi ng al ong well, the thera
pist may say: I t is very grati fyi ng to feel that
you are compl etel y sati sfi ed, and under
standabl y under those circumstances, you will
want to do very little about yourself. There
may, however, be certai n areas that are not as
pl easant for you as you mi ght want. Are you
satisfied the way everythi ng is going in every
area? Shoul d the adamant repl y be that
thi ngs now are perfect, the therapi st may have
no al ternati ve than to bri ng out the prevai l i ng
adj ustment difficulties, such as stayi ng away
from classes. At the end of the session the still
unconvinced student is invi ted to return at any
ti me she feels she wants to tal k thi ngs over.
On the other hand, the student may admi t
that whi l e thi ngs are not too bad, there is the
probl em that she does not seem to have the
energy to go out wi th boys though she likes
boys. The counsel or retorts: I f you real ly
have a desi re to get more energy, it may be
possible for you to rectify thi s. Perhaps there
i snt any desi re to go out because there are
fears of exposi ng yourself to some sort of con
tact. T he pati ent may then deny thi s vehe
mently.
I f the counsel or has gotten the student to
tal k about herself, the chances are she will ask
for another conference wi th the counsel or. At
the next visit she will perhaps say that she has
thought the matter over and she does feel that
perhaps she mi ght be conceal i ng from herself
reasons why she does not want to go out.
Under these ci rcumstances the counsel or may
i nform her that there are certai n persons who
speci ali ze in handl i ng probl ems of thi s type. I n
the past psychotherapi sts were looked upon as
peopl e who mi ni stered to only severe emo
ti onal difficulties, but in recent years they have
been handl i ng both mi nor and maj or probl ems
of normal people; peopl e who could be much
more happy wi thi n themsel ves and more effi
cient in thei r work or studi es wi th some
psychotherapeuti c help.
Before referri ng a prospecti ve pati ent to a
therapi st it woul d be i mportant for the
counsel or (1) to establi sh the existence of a
defi nite probl em for whi ch hel p is needed, (2)
to deal wi th or to cl arify whatever resistance
there may exi st that makes the person
rel uctant to consul t a therapi st, and (3) to cor
rect any exi sti ng mi sconcepti ons about psycho
therapy. How trul y moti vated for treatment
the pati ent will be when a therapi st is con
sul ted will depend on how good a j ob the
counsel or has done. But, getti ng the pati ent to
a therapi st is the fi rst step.
Si nce the presence of empathy is usual l y
menti oned as the keynote to a therapeuti c
al l i ance, what happens i f you si mpl y can
not empathi ze wi th a parti cul ar pati ent?
Does thi s mean you cannot treat that pa
ti ent?
I t often happens that a therapi st does not
like the ki nd of human bei ng the pati ent is at
the ti me he presents hi msel f for treatment, nor
may the therapi st be abl e to condone the life
THE INITIAL INTERVIEW: COMMON QUESTIONS
53
the pati ent has led, nor approve of hi s at
ti tudes, morals, values, or objectives. Thi s does
not mean one cannot work wi th the pati ent.
Probl ems develop where the therapi st because
of i ntol erance, is hosti l e or j udgmental .
Parti cul arl y destructi ve to establ i shi ng a work
ing rel ati onshi p is repeti ti on by the therapi st of
the same ki nd of arbi trary and di sapprovi ng
manner di spl ayed by other authori ti es wi th
whom the pati ent has come into contact. The
pati ent has al ready set up defenses agai nst
these authori ti es that will block his developi ng
confi dence in a therapi st whom he identifies
wi th past authori ti es. I f the therapi st can ex
ercise control over impulses to verbal i ze di sap
proval , and can avoid di spl ayi ng criti cism
through faci al expressi ons and gestures,
aspects of the pati ents personal i ty will sooner
or l ater come through that may kindl e warm
feelings in the therapi st. Many pati ents at the
start often try to test a therapi st by di spl ayi ng
anger or by presenti ng the most shocki ng or
disagreeabl e aspects of themsel ves. I f the thera
pist does not fall into thi s trap, the worki ng re
lati onshi p may very well develop even in the
first session.
How can you communi cate empathy?
One may show i nterest in what the pati ent
is sayi ng by l i stening carefull y, by aski ng
proper questions, and by di spl ayi ng appro
pri ate facial expressions. Someti mes communi
cati ng what must be on the pati ents mi nd
from clues given, verbal l y and nonverbal l y, can
be helpful. T he therapi st may ask himself,
What goes on in the pati ents mi nd as he sits
there tal ki ng? I f one can penetrate beyond
the facade of the pati ents mani fest verbal i za
ti ons and get to the core of what he may
actual l y be feeling, what fears, and anxieties
exist, one may make a strong i mpressi on on
the pati ent. When the pati ent first comes to
therapy, he is usual l y qui te upset, fearful,
angry, or frustrated and he may anti ci pate
counterhosti li ty or di sapproval . Typi cal ideas
that occupy the pati ents mi nd are these: (1)
Thi s is my last resort. I f thi s doesnt work, I
mi ght as well commi t suici de. (2) I feel de
graded that I have finall y had to resort to psy
chi atri c help. (3) I f anybody finds out about
the real me, it will be too bad for me. (4) I will
probabl y be bl amed, rejected or hated. (5) I feel
fool ish to come here. I t is silly for me to thi nk I
need hel p for my mi nd. (6) Thi s must mean I
am goi ng insane.
The therapi st shoul d also countenance what
may be going on in the therapi sts own mi nd.
These thoughts are very rarel y acknowl edged,
let al one faced. They involve all sorts of
f ormul ati ons such as the fol l owi ng: (1) I
wonder if I m goi ng to like thi s pati ent? (2) I
wonder if he is going to like me? (3) I wonder
if I m abl e to hel p thi s pati ent or whether his
ki nd of probl em is the sort that I can treat? (4)
I wonder if he can pay my fee and how am I
goi ng to handl e the si tuati on in the event that
he is unabl e to afford treatment wi th me?
Assumi ng one can handl e ones own feel
ings, the therapi st may di pl omati cal l y ask the
pati ent questi ons such as I wonder if you are
upset about comi ng here? Do you have
questi ons about what I mi ght be thi nki ng
about you? Y ou may feel thi s is the last
resort! Other questi ons and comments will be
suggested by observi ng the pati ents reacti ons
and readi ng between the li nes of what the pa
ti ent is saying.
I s there any way one can expedi te em
pathy toward a person who comes f rom a
soci oeconomi c group wi th whi ch a thera
pi st has l i ttl e affi ni ty?
I n li stening to a pati ent who belongs to a
stratum of society wi th whi ch one is not too fa
mi l i ar, one may try to understand the ex
pressi ons and idi oms the pati ent empl oys and
to uti li ze the same l anguage forms so that one
can communi cate on the same wave length.
One may also try to find out if the destructi ve
patterns the pati ent indul ges are those common
to or condoned by the pati ents subcul tural
group, for exampl e alcohol ic excesses, dan
gerous drug usage, or del i nquency. I t is neces
sary to make sure at the start that one does not
54
convey di sapproval or disgust at i ndul gences
the pati ent may consi der normal . L ater on,
when a worki ng rel ati onshi p exists wi th the
pati ent, it may be possible to poi nt out destruc
tive patterns that support the probl ems for
whi ch hel p is bei ng sought. T he therapi st may
al so keep aski ng hi mself, especiall y when the
pati ent comes from a di sadvantaged group,
how the therapi st woul d feel and what he
woul d do if he had to endure the intolerances
and abuses the pati ent went through in the pa
ti ents past life. Woul d he be any different?
T he therapi st may then better be able to empa
thi ze wi th the pati ent.
What do you do i f a pati ent turns on you
and attacks you verbal l y duri ng the i ni ti al
i ntervi ew?
Many pati ents are i nwardl y very hostil e
when they come to the ini ti al i ntervi ew. The
reasons for this vary. The pati ent may ri ght
fully resent wai ti ng for an appoi ntment, the
routi ne of a clinic, the fee to be payed, and
other facts of life. Or hostil ity will stem from
i nner sources not at all rel ated to real ity. The
therapi st must accept thi s hostil ity and not act
threatened by it nor respond in any adverse
way. Hosti li ty shoul d be handl ed by bri ngi ng
it out in the open duri ng the intervi ew, clarify
ing the reason for the di sturbi ng real ity si tua
ti on if one exists. Or where hostil ity is not ex
pli cable, a casual statement may be made such
as the fol lowing:
T h. I t is understandabl e that you have suffered a
great deal from your problem. People who suf
fer a great deal often are resentful of the suffer
ing they have experienced and the ineffective
ness of the measures they have adopted to gain
help. Y ou may be angry at the fact that you
are ill, or because of what has happened to
you. Most people do feel resentful of what has
happened to them. T hi s is understandable. I t
is natural not to want to talk about ones feel
ings of resentment, too. T he reason I am tell
ing you this is that it is possible you may even
feel angry at me or at the clinic as a result. I f
you do, do not feel guilty if you talk about it.
I n spi te of al l the efforts you make to be
tol erant, what do you do i f you sti ll fi nd
yoursel f bei ng unsympatheti c, even
actual l y di sl i ki ng the pati ent?
I f your feel ings i nterfere wi th your doi ng
therapy, si mpl y transfer the pati ent to another
therapi st. But, in all probabi l i ty the pati ent
will leave you first.
How woul d you show a pati ent you are
tol erant of behavi or about whi ch the pa
ti ent personal l y is ashamed and cannot or
wi l l not do much about?
Some pati ents will expect you, perhaps even
want you to di sapprove of thei r behavi or. I f
you compl y wi th thi s wish, it may temporari l y
be stabi l i zi ng by furni shi ng the pati ent wi th an
outsi de control. T he i mprovement, however,
will be short-l ived as l ong as the pati ent has a
stake in destructi vel y acti ng out patterns. The
pati ent will then defy you or decei ve you by
perpetuati ng the patterns secretl y at the same
ti me that anger and guil t accumul ate. The
therapeuti c al l i ance will, therefore, suffer. The
best way to manage any revel ati on of conduct
about whi ch the pati ent seems guil ty is to
remark that the pati ent appears to be guil ty
and ashamed of what he or she is doing. T he
fol lowing excerpts i l l ustrate how I handl ed two
such cases:
P t. I want you to know that I am homosexual.
T h. So what?
P t. (pause) Well?
T h. Well what? I s that what you came to see me
about?
Pt. No, but how do you feel about it?
T h. Y ou must feel that I disapprove or should
disapprove.
P t. Dont you?
T h. Why should I if i ts something you want to do.
Y ou told me that you were depressed and
anxious a good deal of the time. I snt that
what you came to see me about?
Pt. Y es, it is.
T h. So l ets work at that. Now, if your choice of a
sexual partner has something to do with these
symptoms well tal k about that.
Pt. [obviously relieved\ Fine, I knew you were
liberal about these things.
A pati ent in her mi ddl e 60s came for hel p to
relieve pai n fol lowing a breast amputati on for
cancer.
Pt. I have to tell you, doctor (la u g h s) that I have a
little habit that I am ashamed to tell you
about.
T h. A re you afraid of what my reaction will be?
Pt. No, I guess 1 dont like it myself. I ts that
whenever I go into a store, I lift-sneak a little
thi ng in my purse or bag.
T h. How do you feel about it?
Pt. I guess I do it for the excitement. I usually
dont need the trinket. I guess youd call it
kleptomania. I read about it.
T h. Y ou must disapprove of it, or doesnt it bother
you?
Pt. M y heart trembles for hours afterward. What
if I m caught? T he disgrace.
T h. I f it does bother you enough, we ought to take
it up in our talks here.
Pt. Do you thi nk I can get over this habi t? It
started shortly after my husband died.
T h. Perhaps you felt deprived. But if you really
want to get over it, thats ni ne-tenths of the
battle.
Are reasons for seeki ng hel p at the ti me of
comi ng for hel p a good thi ng to focus on?
Harri s et al (1964) describe a 3-year proj ect
at the Langl ey Porter Neuropsychi atri c I n
stitute in San Franci sco where a method of up
to seven sessions was desi gned around the focus
of the factors that enj oi ned the pati ent to come
to the clinic. T he questi ons expl ored were why
the pati ent was seeki ng hel p at this time and
what he or she expected out of the contact wi th
the clinic. Thi s approach served not only as a
satisfactory i ntake method, but also produced a
return to adequate functi oni ng in a si gnifi cant
number of pati ents. For the remai ni ng pati ents
the bri ef experi ence hel ped del i neate the prob
lem, clarified the extent of moti vati on, and
acted as preparati on for conti nui ng hel p or i n
tensive treatment. Focusi ng on the hel p-seeki ng
factors is nothi ng new. Soci al -work agencies
have for many years empl oyed it in casework on
a short-term basi s. Si mi l arl y some counsel i ng
approaches have operated around a si mi l ar ex
posure of the i mmedi ate compl ai nt factor. Both
casework and counsel i ng have often substanti
ated i mprovement beyond the mere al terati on of
the envi ronmental di sturbances or symp-
tomi c upsets that ini ti ated the consul tati ons.
How does a therapi st know whether hi s
apprai sal of a chosen focus is the correct
one?
A therapi sts j udgment concerni ng existi ng
core probl ems involves specul ati ons that are
not al ways consi stent wi th what another thera
pist may hypothesi ze. Gi ven the same data,
different therapi sts will vary in what they con
si der is the most si gnifi cant area on whi ch to
focus. I n a smal l experi ment that I conducted
three experi enced therapi sts trai ned in the
same anal yti c school wi tnessed the first two
sessi ons conducted by a fourth col l eague
through a one-way mi rror. Each therapi st had
a somewhat different idea of what meani ngful
topic was best on whi ch to focus. I n my
opi ni on, such differences are not signifi cant be
cause mul ti pl e probl ems can exist and these
are usual l y i nterrel ated. Even where one
stri kes the pati ents core di ffi cul ti es tan-
genti all y, one may still regi ster an i mpact and
spur the pati ent on toward a better adaptati on.
After all , a reasonabl y i ntell igent pati ent is
capabl e of maki ng connecti ons and even of cor
recting the mi spercepti ons of a therapi st where
a good worki ng rel ati onshi p exists and the
therapi st does not respond to bei ng cri ti cized
too drasti cal l y wi th a di spl ay of wounded nar
cissism. From a pragmati c standpoi nt, the
focus is an accurate one if the pati ent responds
positi vely to it.
Can a person get wel l wi thout needi ng to
work on basi c nucl ear confl i cts?
Getti ng well embraces many degrees of
i mprovement. Most peopl e make a fairly good
adaptati on whi l e retai ni ng some aspects of
thei r deepest conflicts. I n short-term therapy
we usual l y deal wi th secondary deri vati ve con
flicts because of the lack of ti me for depth
probi ng and the worki ng-through of resistance.
However, personal i ty changes can result over a
peri od fol lowing therapy if the pati ent con
si stently works on hi msel f and his probl ems.
Apparentl y nucl ear conflicts may someti mes be
influenced through resol uti on of thei r mani
festati ons in secondary conflicts. Hi tchcock and
Mooney (1969), for exampl e, have wri tten
how in mental heal th consul ti on deal i ng wi th
the consul tees work-ego function al one can
have a more than superfici al effect. D. Beck
(1968) has al so wri tten an i nteresti ng articl e
accenting the val ue of worki ng on deri vati ve
conflicts. I n many types of short-term therapy
openi ng up a bag of worms through bl unt
i nterpretati on of a nucl ear conflict may create
more probl ems than it solves. T he therapi st
must j udge how ready the pati ent is for an i n
terpretati onthat is, how conscious the pa
ti ent is of an exi sti ng confl ictbefore expl or
ing it. Where the pati ent has such an aware
ness and wishes to deal wi th his conflict, there
is no reason to avoid it.
Suppose, i n evol vi ng a worki ng hypothe
sis of the probl em, that the therapi st hap
pens to be wrong. Woul d it not be better
to wai t unti l more facts are avai l abl e
before specul ati ng about what is goi ng
on?
Whi l e the therapi st will want to develop a
worki ng hypothesi s of the probl em, he must
consi der it tentati ve at best. Not all of the facts
may be avai l abl e duri ng the first few i nter
views. Even if the therapi st is wrong or
parti al l y wrong in the ini ti al analysis, he will
be able to correct or modify his ideas l ater on.
I f a connection wi th personal i ty factors or i n
ner conflicts is not apparent at the beginni ng,
or if the pati ent is not ready to countenance the
impl i cati ons of such connections, i nterpreta
ti ons may be confined to the i mmedi ate envi
ronmental preci pi tants whi l e wai ti ng for more
data before li nki ng these to underl yi ng i nner
difficul ties or more obscure external events.
How woul d you account for the fact that
even though few or no psychodynami cs
may be apparent duri ng the fi rst i nter
vi ew, the pati ent sti ll may experi ence a
good deal of rel i ef?
There are many reasons for this. Fi rst, the
empathi c understandi ng of the therapi st ena
bles the pati ent to unburden hi msel f or herself
in an atmosphere shorn of bl ame and author-
atati ve pressure. Si mpl y rel ievi ng onesel f of
pai nful thoughts reduces tension. But more i m
portantl y, putti ng into words feelings that float
around in a nebul ous way tends to identify
them and hel ps the pati ent gai n control over
them. Moreover, reveal i ng ideas and experi
ences to an authori ty who does not respond the
way other past authori ti es have acted, or the
way the pati ent i magi ned they woul d act or
shoul d act, softens the i ntroj ected parental
image and relieves guil t. Fai th and trust are
kindl ed. T he pl acebo el ement to the effect that
somethi ng is avai l abl e that can hel p and that
matters are not hopeless, and the i mpact of di
rect or indi rect suggestions made by the thera
pist may i nspi re the pati ent toward taki ng a
correcti ve path of thi nki ng and behavi ng. Of
course, the extent of the pati ents taki ng ad
vantage of these positi ve el ements will depend
on his readi ness for change. Where a readi ness
for change exists in good measure, the i mpact
of the first i ntervi ew can be dramati c even
though basic nucl ear conflicts are not touched.
And the pati ent may be abl e to achieve an
emoti onal equi l i bri um at least equi val ent to
that whi ch prevai l ed pri or to the onset of the
present illness.
Can one prognosti cate from the severi ty
of symptoms or the si ckness of a pati ent
the possi bi l i ty of i mprovement or cure?
No. Someti mes the sickest pati ents, even
hal l uci nati ng psychotics, recover rapi dl y, whi l e
what seems like a mi ld depressi on, anxi ety, or
character probl em will scarcely budge. Many
vari abl es obviously exist other than the current
symptoms, whi ch are rel ated to the pati ents
l atent ego strength, fl exi bi l i ty of defenses,
readi ness for change, secondary gai n, selective
response to techni ques, capaci ty for devel opi ng
a therapeuti c all iance, skill and personal i ty of
the therapi st, and many other factors. These
will all influence the outcome. T he effect of
these vari ables cannot be anti ci pated in ad
vance since they di spl ay themsel ves only after
therapy has started.
I s there one factor you woul d consi der
the most i mportant of al l i n i nsuri ng good
resul ts in therapy?
There are many factors that are operati ve,
but I woul d consi der the qual i ty of the rel a
ti onshi p between the therapi st and pati ent the
most i mportant of all factors.
How much conf rontati on can be uti l i zed
duri ng the i ni ti al i ntervi ew?
There are varyi ng opi ni ons. Where the first
intervi ew is empl oyed as a screening device to
determi ne the sui tabi l i ty of a pati ent for an
anxi ety-provoki ng type of therapy, such as
practiced by Sifneos, confrontati on is part of a
selection procedure. As a general rul e, how
ever, wi th the average pati ent, confrontati on is
best delayed unti l a good therapeuti c al l i ance
has been establi shed to sustai n the pati ents
hostil ity and anxi ety. Otherwi se the pati ent is
apt to drop out of treatment prematurel y,
e'ther because he mi stakes the therapi sts man
ner as an attack or because he is unabl e to
handl e the emoti ons sti rred up in hi msel f as a
resul t of the poi nted chall enges. I n some cases,
however, the therapi st is capabl e of setti ng up
a worki ng rel ati onshi p rapi dl y in the first
sessi on, under whi ch ci rcumstance careful
empathi c confrontati on may be gainfull y em
ployed.
Shoul d not the therapi st choose as a
pref erred focus the rel ati onshi p between
hi msel f and the pati ent?
Effective l earni ng can proceed only in the
medi um of a good i nterpersonal rel ati onshi p.
The l atter serves as the matri x for whatever
theoreti cal and methodol ogi cal structures
fashion the treatment maneuvers of the thera
pist. One usual l y assumes that the pati ent
comes to therapy wi th some basic trust in the
therapi st as a professi onal who can help.
Natural l y, there are al ways l atent some ele
ments of fear and di strust, the degree de
pendent on previ ous experi ences wi th i rra
ti onal authori ty and wi th i ncompetant profes
si onals. I t is usual l y not necessary to focus on
the rel ati onshi p unless there are evidences,
from the behavi or and verbal i zati ons of the pa
ti ent, that the rel ati onshi p is not going well or
that transference exists that is acti ng as a
resistence to treatment. As l ong as the rel ati on
shi p appears to be good, there is no reason to
probe or chal l enge it.
Does not the rel ati onshi p i tsel f sponsor
reconstructi ve change where the therapi st
is accepti ng and tol erant?
An assumpti on is often made that everyone
has wi thi n onesel f the capaci ty to achieve
therapeuti c change, provi ded there is a non-
j udgmental , nonpuni ti ve atmosphere in whi ch
to express feel ings wi thout fear of retal i ati on
or censure. Growth is sai d to be conti ngent on
the constructi ve rel earni ng that comes about as
a by-product of a nontraumati c rel ati onshi p.
T he i ndi vi dual has an opportuni ty here to
revise i nherent concepts of authori ty out of a
new experi ence wi th the therapi st who oper
ates as a different kind of parental symbol. In
practi ce thi s happy resul t does not often follow
because the i ndi vi dual , even in a compl etel y
noncensori ous envi ronment, will usual l y per
petuate personal probl ems by cli nging to un
j usti fi ed and unj usti fi abl e assumpti ons. Even
though the therapi st does not repeat the
parental atti tudes or di spl ay thei r i ntolerance,
the pati ent may react as if the ori gi nal author
ities were still present. Thi s is because the
probl em has been i nternal i zed and forces the
pati ent to operate wi th a sense of values that,
mercil ess as it is, is uncorrected by real ity.
I ndeed, the pati ent may even become i ndi gnant
toward the therapi sts tol erant standards and
behavi or as offering temptati ons for whi ch one
will l ater pay dearl y. Thi s serves as resistance
agai nst al teri ng ones values. We, nevertheless,
try to promote change by detection of negati ve
58
atti tudes and transference feel ings and by thei r
i nterpretati on and worki ng-through.
How i mportant are opti mi sm and en
thusi asm on the part of the therapi st?
Very i mportant. Opti mi sm and enthusi asm
inspi re faith and trust and tend to neutral i ze
despai r and hopelessness. T he therapi sts belief
in himsel f and in his techni ques must, of
course, be real , since si mul ated opti mi sm will
easi ly be detected and will damage the rel a
ti onshi p.
T here is some controversy about the rol e
of posi ti ve expectati on on the part of the
pati ent in promoti ng change. Does expec
tati on i nf l uence short-term therapy?
As is usual in some questi ons, the answer is
yes and no. Expectati on that one will change
acts as a pl acebo enhanci ng the pati ents faith
in the therapi st and in the operati ve tech
niques. The therapeuti c si tuati on itself is a
suggestive arena that promotes expectati ons of
change. On the other hand, expectati on may
be bri dled to certai n assumpti ons about the
therapi sts power and invi ncibi li ty that can be
unreal istic. When the pati ent l earns that the
therapi st has no magi c and that the pati ent
himsel f must work to achieve change, his ex
pectations may dwi ndl e to nothi ng and may
even act as a negati ve placebo.
I s your i mmedi ate i mpressi on of whether
you l i ke a person or not a good gauge of
how the rel ati onshi p wi l l devel op?
That depends on whether the therapi st is
abl e to anal yze his own countertransference
and prej udices. I ni ti al i mpressi ons are often
the products of past experi ences wi th a person
or person whom the pati ent resembles or of i n
tol erance rel ated to the pati ents race, rel igi on,
sex, age, facial expression, manner, speech,
and the like. Mi sconcepti ons can abound, but
a mature therapi st keeps anal yzi ng his own
reacti ons to see whether they are the result of
countertransference or prej udice, and he ac
cordi ngl y tries to correct atti tudes that will i n
terfere wi th establ i shi ng a therapeuti c all iance.
Shoul d the therapi st prepare the pati ent
for termi nati on of treatment at the fi rst
i ntervi ew?
Proper preparati on of the pati ent for termi
nati on is an extremel y i mportant, yet the most
grossly neglected, aspect of treatment. The
therapi st shoul d be al erted for signs, even in
the first intervi ew, of i mpendi ng probl ems wi th
termi nati on since the endi ng of treatment can
be extremel y difficult and di sturbi ng for some
pati ents. Moreover, the therapi st will need to
be aware of his own guil t at di schargi ng some
pati ents, parti cul arl y those who have become
dependent on hi m. The therapi st may consi der
the termi nati on of treatment a form of
abandonment. On the pati ents part, termi na
ti on may ki ndl e previ ous upsetti ng reacti ons
wi th experi ences of separati on or loss even as
far back as chil dhood. T he pati ent may i nter
pret termi nati on as a sign of the therapi sts i r
responsi bi l i ty or lack of concern and thi s will
acti vate a deval ued self-image. I f at the first i n
tervi ew the therapi st discusses wi th the pati ent
that some pati ents respond to termi nati on of
treatment wi th resentment and feelings of loss,
this may ease, though not enti rel y di ssi pate,
the pati ents eventual reacti on of anger and
di sappoi ntment.
Where the hi story reveal s an earl y loss of,
separati on from, or abandonment by a parent,
the therapi st must be tri pl y mi ndful of the
need to prepare the pati ent for termi nati on and
to watch for earl y signs of anger, depressi on,
and grief. T he pati ent, as part of treatment,
shoul d be encouraged to tal k about devel opi ng
separati on reacti ons as well as past separati on
experi ences. Among the emergi ng separati on
reactions will be a return of old compl ai nts
and the devel opment of new symptoms such as
anxi ety, depressi on, and psychosomati c com
plai nts. Some pati ents respond to termi nati on
by denial ; where there are signs of thi s, the
therapi st must actively i nterpret the response.
Vastl y i mportant is the need for the therapi st
not to consi der the pati ents hostil ity as a per
sonal affront.
Are psychol ogi cal tests necessary in short
term therapy?
General l y, no, A rapi d exposure of the pa
ti ent to the Rorschach cards and to a man-
woman drawi ng, though they are stri ctl y
speaki ng not tests in the formal sense, are
someti mes helpful diagnosti call y and toward
spotti ng a dynami c focus. The same can be
said for the Themati c Appercepti on Cards.
What about the Mi nnesota Mul ti phasi c
Test?
A great deal of i nformati on can be gotton
from the M M T , al though a good i ntervi ewer
can get sufficient materi al to work on through
ordi nary history taki ng. Most therapi sts do not
give thei r pati ents routi ne tests like the M M T ,
intell igence tests, and the like, unless there are
speci al reasons for testing.
I s it advi sabl e to make an i ni ti al di agnosi s
on every case?
Yes, for many reasons. T he initi al diagnosis,
however, may have to be changed as more i n
formati on is obtai ned duri ng therapy.
Are past dreams i mportant to expl ore in
the i ni ti al i ntervi ew?
Very much so. Dreams often reveal the op
erative dynami cs not obtai nabl e through usual
intervi ew techni ques. Repeti ti ve dreams and
ni ghtmares are especiall y i mportant. Aski ng
for dreams that the pati ent can remember from
chil dhood may al so be valuabl e.
I t has been stated that pati ents who were
i ntervi ewed and put on a wai ti ng li st di d
al most as wel l on thei r own as those who
were accepted for f ormal treatment. I f
thi s is true, is not therapy superf l uous?
Some skeptics downgrade psychotherapy by-
poi nti ng out that there is no advantage in
formal treatment to si mpl y being placed on a
wai ti ng list after an ini ti al intervi ew. For ex
ampl e, in one study (Sl oane et al., 1975) 94
pati ents were seen i ni ti all y by experi enced
therapi sts and then randoml y assigned to (1) a
wai ti ng list, (2) short-term behavi or therapy,
and (3) short-term psychoanal yti cal l y ori ented
psychotherapy for 13 or 14 sessions. Fol l ow-up
after 4 months by assessors showed that target
symptoms in all three groups i mproved, but
somewhat more so in the treated groups. Work
and social adj ustment showed no differences.
All three groups 1 year and 2 years after the
ini ti al i ntervi ew had improved si gnifi cantl y
regardl ess of whether or not further treat
ment was received duri ng thi s peri od. We
mi ght conclude from this that wi th the no
treatment group doi ng al most as well as the
treated groups after 4 months and fully as well
after 1 and 2 years, formal psychotherapy was
di spensable.
T he fal lacy of thi s assumpti on is that we fail
to credit the ini ti al i ntervi ew wi th the thera
peuti c i mpact that it can score by itself even
where no further professi onal hel p is secured.
Nor is it true that a pati ent on a wai ti ng list
l angui shes wi thout expl oi ti ng other hel pi ng
resources. Often after a good i ni ti al i ntervi ew
the pati ent will have obtai ned sufficient sup
port, reassurance, awareness, and hope to
muster latent copi ng capaci ties or to find sui ta
ble hel pi ng ai ds outside of formal treatment.
We shoul d, therefore, consi der even a single
i ntake i ntervi ew a form of short-term therapy.
T hat even one or two sessi ons have on fol
l ow-up regi stered themsel ves therapeuti cal l y
on pati ents has been reported by a number of
observers, such as Mal an et al (1975). Not
onl y had symptomati c i mprovement occurred,
but in some cases the sol i tary i ntervi ew
appears to have rel eased forces produci ng
noti ceable, and in some cases significant and
lasti ng dynami c, changes. At the Beth I srael
Flospital in Boston a si zable group of pati ents
were gi ven a di agnosti c i ntervi ew in the form
of a two-sessi on eval uati on. No other therapy
was admi ni stered. A fol l ow-up i ntervi ew 1
month l ater reveal ed a subgroup who i m
60
proved wi th no other therapy. T he resul ts
confi rm the concepti on of the diagnosti c i nter
view as a dynami c i nterpersonal process and
adds support to the evidence that bri ef psy
chiatri c contact duri ng ti mes of stress can
produce si gnifi cant changes in affect and be
havi or. Whether pati ents who improve will
sustai n or conti nue thei r i mprovement will
probabl y depend on the nature of thei r trans
formati on, thei r prevai l i ng moti vati on to
change, thei r abi l i ty to rel ease themsel ves
from thei r mal adapti ve copi ng patterns, and
whether or not thei r envi ronment rei nforces or
di scourages the devel opi ng al terati ons.
CHAPTER 6
The Initial Interview
B. Case Histories
Al though every initi al i ntervi ew will be con
ducted somewhat differently dependi ng on the
presenti ng probl em, the capaci ty for verbal i za
ti on, the personal i ty of the pati ent, the initi al
resistances, countertransference arousal , and so
on, certai n basic techni ques are mani fest. Thi s
chapter consi sts of three transcri bed i ni ti al i n
terviews that bri ng out some sal ient features
commonl y encountered in first, a devel opmen
tal personal i ty probl em, second, an obsessive
neurosi s, and, thi rd, a schizoid personal i ty
di sorder, who is not deemed sui tabl e for short
term therapy.
Case 1
The pati ent is a 16-year-old boy whose
parents called for an appoi ntment, sayi ng that
he was fai ling at school, defyi ng his parents,
fi ghti ng wi th some of hi s cl assmates and
general l y being obnoxious. What concerned
them most, however, was his goi ng steady wi th
a girl. They did not approve on the basis that
he was too young for a seri ous rel ati onshi p.
They were desperate for some directi on as to
what to do. T he boy had resisted going to see a
therapi st unti l they cut off his al l owance, and
then he consented to one appoi ntment. The
parents accompani ed hi m and sat in the wai t
ing room. T he session bri ngs out how to deal
wi th a defi ant adolescent so that he may con
ti nue in therapy as well as how to select a dy
nami c focus.
At the appoi nted ti me the pati ent entered
my office, slouched into a chair, and looked
about the room in a noncommi ttal way. The
tactic I have found useful in deal i ng wi th such
reactions is not to engage in criti cisms or accu
sations, and not even to questi on the pati ent
about his difficul ties, but to confront the pa
ti ent. Confronti ng this boy wi th his resistance
and verbal i zi ng his ri ght to be angry may act
as a shock sti mul us starti ng hi m off toward en
li sting the therapi st as an all y to mani pul ate
the parents to abi de wi th his own desi res. In
thi s way a rel ati onshi p gets started that may
have therapeuti c potential ities.
T h. So they finally captured you and brought you
here, huh? (T h e rap i s t smiles an d t he p a t i e n t
looks up, obviously surprised. H e pause s, then
breaks out in an embarrassed laugh.)
P t. Y es sir.
T h. A rent you sore about it?
P t. No, I guess not.
T h. I d be furious, if I were in your position.
P t. No, I m not.
T h. A fter all, why would you come to see me, ex
cept that they inveigled you into this? (s m ilin g
as i f j o k i n g )
Pt. I forgot about this until last night.
T h. How did they spri ng it on you?
P t. We had an appoi ntment at 10:30, they said.
62
T h. Wham, j ust like thatfor what reason did
they give you?
P t. I dont knowthey thi nk I m sick I guess.
T h. Y ou mean they think youre mentally sick?
P t. I dont knowthey thi nk something is wrong
I guess.
T h. What do they thi nkin what area? I havent
spoken to them except briefly. So I dont know
what the real problem is.
Pt. I dont know. I thi nk they thi nk I m mixed
upsomething is wrong.
T h. Do you feel you are mixed up?
Pt. No.
T h. How would they get that conception; whats
the story on that?
P t. 1 dont knowi ts j ust the way I get along
with themour relations.
T h. Y our relationships, (pause) Well, maybe we
can talk about that. Are they giving you a hard
time? \ Here I am tr y in g to ver balize w h a t the
p a t i e n t ma y be feeling.]
P t. I dont know. I guess i ts two ways.
T h. A re you giving them a hard time? A re you
really? What are you doing?
Pt. I dont know, I dont go out of my way, but I
have a little grudge against them. I dont
know, (pause)
T h. Well, what have they donedo they deserve
the grudge?
Pt. I dont know.
T h. T hey mentioned something on the telephone.
Y oure at school now, away from homeand
youve got a gi rlfri endis that the story?
(pause) So? [/ note that the p a t i e n t seems
angry a n d f i d g e t t y . I decide to s h o w him that
in contrast to his p a r e n t s I believe he has the
right to choose his own company.] Why do
you thi nk they stick thei r nose into that thing?
Pt. I dont know.
T h. Dont you resent it? Do you tell them every
thing?
Pt. I tell them to a degree. T hey find out anyhow.
T h. How would they find out if you kept it to
yourself?
Pt. I dont know. Sometimes I see her, then I ll
come home, and then they seem to find out.
T h. How would they know that you see her?
P t. I f someone sees me with J ane, then they tell
them.
T h. Y ou mean they report on you?
P t. Well, someone must because I know I once
went over to her house. Next time when I was
nome, they said. "Y ou saw her, di dnt you?
T h. What do they object to about her?
P t. T hey say her parents are too forward, they
dont like her, and so forth. Because her
parents they invited me over to her house on
her bi rthday for di nner once.
T h. So, whats the big deal about that?
P t. I dont know, and there was a camp reunion
and her mother let her go on the bus with me.
We were going to have a camp reuni on, and
my mother felt she shoul dnt have called up, I
guess. I should have just gone there and met
her. I dont know what it was.
T h. I n other words, what they are trying to do is to
break this thing up?
P t. Y es
T h. A hhh, is that what the whole story is about?
P t. Y es.
T h. A nything else? Any other beefs that you have
with your parents?
P t. Well, j ust sometimes theyre different, I dont
know, they have different views about kids and
that. T hats the biggest gripe, with that girl.
T h. Who do you get along with better, your
mother or your father?
P t. Neither.
T h. Nei ther one of them. T heyre both difficult
ri ght at this time? And they both harp on the
same thi ng? (pause) Do you thi nk that if you
gave up this girl theyd be any different?
Pt. I doubt it.
T h. T heyd pick on something else?
P t. I dont know, you know my sister and I are
very close, (pause)
T h. Y our sister and you are very close.
Pt. And you know, shes up at college right now.
We write. She wrote me a letter that i ts so
di sappoi nti ng to come home because that
anytime that she finds a boyfriend, or anytime
I find someonewell, this is really the first
girl I ve been pretty serious over I dont
know, they find excuses and theyre the worst
excuses. I mean theyre really bad. T hey have
thei r reasons. T hey say you cant do this, you
cant do that. Well, Dotty sai d like when she
came home last time she said it was a di sap
poi ntment to her. Her vacation started when
she went back to school. She said she was more
hurt when she came home like, she said, when
youre away, everything is progressing and
when you come home, i ts j ust as stagnant as
i ts always been, and, I dont know, it looks
pretty bad. T hey wont change.
T h. And you must know, they have thei r own ideas
THE INITIAL INTERVIEW: CASE HISTORIES
63
and they come from a different world than you
come from. I mean, your friends and your as
sociations and your philosophy are different
these days than in thei r day. So you must feel
they are trying to impose old-fashioned ideas
on you.
P t. I dont know, pretty much trying to put their
ideas on me. L ike if they say you cant see her,
I dont know, I ts always the same excuse.
Usually when they say, Y ou cant see her,
youre all set to fight the next line.
T h. I n other words, the minute they say you cant
see her, inwardly you start rebelling.
Pt. I know. Right now my parents notice it, and
thats very upsetting, but anytime they start to
talk to me, I dont know, I get set for a fight or
something.
T h. Because you feel theyre critical of you. What
would be the worst thi ng that could happen if
you could see this girl all you wanted?
P t. Nothing, but they feel that. Well, it started
off I was always seeing one girl. I t was her.
T hi s was after last summer, and then they said
I coul dnt go out with one girl, and yet I had
been out with her only three times. I had been
over her house and stuff like that.
T h. Have you been over since youve been home
only three times? Do you give them an ac
counting of everything that goes on?
P t. I dont tell them anything.
T h. Y ou feel thats your business, ri ght? Have you
thought you should go out with other girls too
j ust to please them?
P t. I can, but I made the mistake then, you know.
I kind of understand it, but then they said I
had to date one gi rl, then another, then
another. I f I wanted I could date this girl, then
another and another, see. A nd I di dnt follow
up, and then they finally said, Y ou cant go
out with her.
T h. At all?
Pt. At all, this is a long time ago, and then I con
tinued to see her a l i ttle bit, and then we, I
dont know, last Thanksgi vi ng, we had a
pretty bad weekend.
T h. Oh, you mean the last time you were home?
T he fur was flying?
Pt. Y es, then they said, finally, Y ou can never see
her again. Well call her if we thi nk i ts neces
sary. Well speak to her parents and tell them
that theyre bringing up thei r child wrong.
M aybe i ts not for me to say, but who are they
to say theyre not bringing up thei r child right?
T h. I s she your steady girlfriend now?
P t. I dont consider it; my parents say so.
T h. I mean are you going steady?
P t. No
T h. Woul d you marry a girl like this?
Pt. I dont see why not.
T h. Eventually?
P t. I mean I m not going to stay with her for the
rest of my life until I get marri ed. I m bound
to go with other girls, I mean, but at the be
gi nni ng they said she had nothi ng in common
with me. I m not saying shes not in common
with me, but I m saying (pause).
T h. Well, she does have something in common
with you; you went to camp together.
P t. Y eah, theres a lot of that stuff and shes not
athletic in the muscular sense, but shes an ac
tive girl, I dont know, Shes smart my parents
say.
T h. I s she a good-looking girl? Sexy? So-so?
P t. Shes not sex starved, but shes all right.
T h. And shes easy to tal k to?
P t. Y eah, we sit around and tal k, and with her
parents. We all get along real good, her
parents and her brother.
T h. Do you like her parents better than yours?
P t. I guess everyone does.
T h. Everybodys own parents are no good, you
mean?
P t. Y eah.
T h. She has a mother and father.
P t. I thi nk her father died.
T h. But her present stepfather is a nice guy?
P t. We get along good like when I go over there.
He and I will start tal ki ng for a while.
T h. C ant you talk that way with your own dad?
P t. I dont know, I clam up when I m around him.
I dont know why.
T h. Do you feel hes looking down on you, or hes
condemning you? Or what?
P t. I dont know what it is, but he bothers me and
I wish he di dnt.
T h. Y oud like to get him off your back? I d like to
help you get him off your back, really, if that is
what you want, but how? [H e r e I am j o i n i n g
the p a t i e n t s feelings. T h i s is in line with the
desire to f o r m an alliance with the p a t i e n t . ]
P t. I hope you can.
T h. I dont know if I can, but I ll try, if you give
me an idea what I can do. What I could tell
him is that the tactics they are using are not
the right tactics. All they do is antagonize you.
After all, this girl i snt going to do anything
64
terri bl e to you. [/ am not sure wh e th e r or not
the p a t i e n t is g i v i n g me the right data about
the pr oble m. He sounds reasonable in resent
ing, at his age, the interference o f his p a re nt s
in w ha t seems to be an average b o y - g i r l rela
tionship. I f wh a t he says is correct, it is the
p a r e n t s w h o n e e d so m e c o u n s e l i n g ab o u t
adolescent needs a nd p r o b l e m s a n d the pr o p e r
way to manage themselves. ]
Pt. I dont know, shes kind of cultured in a way.
T h. Shes cultured.
P t. Y eah, I dont know what they got against her.
She knows how to behave at different times.
Y ou know she knows j ust how to act.
T h. She sounds very nice.
P t. T hank you, thats what she is, but do you
know about Fairview where we live. T hi s new
elite and then the village?
T h. (smiling) Y ou mean thats where all the kids
that have parents who have problems live. T he
parents have problems not the kids? (laughing)
P t. Oh (laughing). Well, my father said the reason
they di dnt like her, she was using me as a bait
to climb socially.
T h. Does your gi rl s family come from a lower eco
nomic status class?
Pt. I dont thi nk so. T hey used to live in Queens,
which i snt good, and they moved to where
they are now. A nice house, but then my father
said some of her best friends are kids that my
father likes. So I told him I thought this would
make him like her or something, and he said
what she is doing is she is climbing, she is us
ing these friends to climb up the ladder. All
she wants is her friends in our area for the
money, etc.
T h. How does he know that, he doesnt even know
her?
P t. I thi nk hes seen her.
T h. How can he analyze what she is doing without
talking to her. [/ am deliberately siding with
the p a t i e n t to f i r m up our r e l ations hip.]
P t. I dont know, but this is what he says. Shes
trying to climb socially, and shes j ust going to
drop me. T hi s is what he says.
T h. T hats what he says, but that doesnt mean i ts
so, is it? [again, siding with the p a t i e n t to p r o
mote an identification]
P t. I know, but how can I argue with him? I dont
know, the way 1 figure it is I wont be home
that long and there will be a couple of argu
ments or so, and then I ll go away.
T h. Go away to college you mean? What are you
going to do this summer?
P t. I dont know yet.
T h. Well listen, between you and me, why cant
you go around with other girls and then do
what you want anyways?
P t. (laughing)
T h. Y ou know you can have a runni ng battle going
on with them all the time the way things are.
T heres no sense to it, because theyll get very
upset and start busting your rel ati onshi ps up.
A pparentl y, you dont want them busted up.
Y ouve got to be smart about these things. I m
not trying to give you any advice on how to
conduct yourself, but I know that these things
can get very, very sticky. Y ou can get yourself
into a j am with them, and you are eco
nomically dependent on them for a while any
ways. So why cant you give them an idea that
youre going out with other girls too? M aybe
bri ng one or two around you know. W hats
the big deal, you could go out with other girls
if you wanted to, cant you? [In g i v i n g the p a
t ient this advice, I am testing m y own capacity
to influence him at this p oi nt . I am not sure he
wi l l take m y advice to defuse the s i t u a t i o n .]
P t. I can.
T h. I mean, you dont even have to tell this gal
anythi ng about it if you dont want to.
P t. Well, you see like last night, I was supposed to
go to a party. Well, I told my parents it was
going to be a party. I t was kinda my fault. I
said it was Chri stmas Eve, and if she was
going to be at this party and if she was going, I
was going with my best friend and some girl he
knew. And I was going to go, and I asked my
mother, and she said I could go providing
and thats only one thi ng we ask you to do and
thats not to see this gi rl j ust like that. And
she said, Y oull have to give your father all
the details, etc., how the party is going to be,
he wants to know more about i t. So I told my
friend to go ahead and see his girl last night.
And what we were going to do? We were
going to pl an a good onethere would be in
vitations.
T h. Y oure letting somebody else do the inviting,
and youre j ust being invited to a party?
Pt. I dont know. T hey usually find out about that
stuff anyhow.
T h. Well, look, whatever they find out, thats it.
Y ou dont have to tell them everything you do
at your age, do you?
THE INITIAL INTERVIEW: CASE HISTORIES 65
P t. No, I dont intend to.
T h. All right, if you want me to I ll try to tell them
that they are making a big fuss over nothing.
[I g e t the impression t he p a t i e n t needs an ally,
a n d 1 am prop o s in g an advocacy role on my
part.]
Pt. See, if you tell them that I dont know.
Sometimes they always have good stories, like
something will go on in the houseyou know
between my mother and I and then when my
father comes home and I listen to her telling
him what goes on. Y ou know, it never went
on.
T h. So that makes you very furious.
P t. I mean they can twist a story so that theyre
the white knights. I mean when theyre here
i ts not usand he goes out I do go out for
arguments I mean, when they make me angry.
T h. Well, it must make you furious and you proba
bly feel youll split a gut unless you come out
with your feelings. Y ou see what they object
to, I thi nk, they dont like to have you lie.
T hey dont like to have you put one over on
them. T hey say youre not supposed to do it,
and they expect that you wont do it. Now,
obviously, it would be silly to expect you to
give up something that is very valuable to you,
but yet they still have a feeling youre still j ust
this big (indicating a small size with fi n g ers ) .
And some parents never get over that feeling
about thei r kids. T hey want to be protective,
and they come through as controlling. They
dont realize that you have your own needs,
and your own life, and everything else. And
they wont get off your back on that account.
What you have to do is reassure themsay to
them what is true. I thi nk the best way you
can reassure them is to convince them that
theres nothing too serious about this busi
nesstheres nothing too serious about your
seeing this girl and that youre not going to
marry her. [more advice g i v i n g to test our rela
tionship]
P t. Do you thi nk they feel I am? ( T h e p a t i e n t acts
surprised.)
T h. T hey may feel youre going to be so serious
that you may even get her pregnant or some
thing. Y oull be in a j am then.
P t. Well, if they do this with every girl, I mean, if
they feel were going to have these great times
and everything, i ts going to happen every
time. T hey have to admit it.
T h. A dmit what?
P t. Y ou, I mean that I m not going to go out and
screw every girl I see.
T h. Wel l , what you do is your own business, thats
the point. What you do is your own business
you can screw the girls you want if thats what
you want. [s u pp o r t i ng the p a t i e n t s right to
autonomy]
P t. What I mean is if theyre going to act like if
those are thei r motives for breaking this up
then theyll do it with the next girl and the
next girl.
T h. T hey might, they might, i ts possible, but the
facts are if you water that si tuati on down,
youll probably get them off your back. What
you do privately is your own business, and if
you screw anybody, I guess you have enough
sense to use a rubber and dont take any
chances. Y ou know what I mean? But thats
your own business and nobody ever need know
about i t you never need tell them or anybody
else, [again, backing the p a t i e n t s right o f au
tonomy]
P t. One day, for some reason or other, my mother
suddenly said, Give me your wal l et, and she
went through it and I had a rubber stuck in
the inside of it.
T h. Did she find it?
P t. Y es, and she took it. She di dnt say much and I
figured it was forgotten. And then my father
we were going to get pizza or somethingand
he starts asking me did you ever use it, when
did you use it, and so on. A nd I said, What
am I supposed to say? T hen I m not sup
posed to say J ane and I did thi s or Sue and
I , and I t was on the thi rd night of M ay or
something.
T h. T hi s is your own pri vate affair, as long as you
are careful and you dont get yourself too
deeply messed up and involved. T hats your
own business and youre right in resenting her
taki ng your pocket book and going through it,
anyways.
P t. T hats true, and oh, the other thing, they
found Playboys in my room, so ohhhhhhhh, no
smut in the house, and they start yelling and at
the same time, I know, I dont see anything
wrong with it.
T h. T here i snt anythi ng wrong with it, but what
they apparentl y feel is that they would like to
have a son the ideal, moral, studious kind of a
guy. I thi nk most parents would like to picture
thei r children as that. I mean from an ideal
standpoint, anythi ng that goes below that ideal
and they start blaming themselves, start feeling
guilty, feel you may be heading for a lot of
trouble. I would thi nk thei r anxieties are not
to hurt youthei r anxieties are motivated by a
concern about you. T hei r motives are probably
honorable ones, you know what I mean? At
least they have a desire to see that you dont
get into problems, that you dont get caught by
any girl, that you dont get any girl pregnant,
that you dont get a venereal disease. T hese are
probably what thei r motives are. T hey may be
living in the last generation and not in this
one. They may not know what goes on these
days. I suppose they felt you were all mixed up
and needed advice and that 1 should evaluate
what your probl em is. I s that why they
brought you here? [I am defending the p are nts
to see i f I can g i ve him a n ot h e r meaning f o r
their behavior than their p u r e l y seeking to
dominate a n d control him.]
Pt. I dont know I was going to ask you.
T h. I dont thi nk youre mixed up in so far as what
you have told me is concerned. [/ ge t the i m
pression that we are developing a relationship.
The p a t i e n t tries to move his chair closer to
me.] So far you havent told me a thi ng that is
abnormal. \ A t this p o i n t I introduce questions
about other sy m p t o m s a n d complaints.]
T h. I want to ask you a few questions about any
symptoms you may have. How about tension?
Do you feel tense?
Pt. Sometimes I mean, yes. Not always.
T h. Under what circumstances?
P t. When I get upset at things.
T h. Any anxiety, a feeling youre falling apart?
P t. Why no.
T h. Depression?
Pt. Not too bad.
T h. Physical complaints or symptoms, like head
aches, stomach trouble, bowel trouble, and so
on?
P t. I dont thi nk so.
T h. How about sexual problems?
P t. Nothing like that.
T h. Phobias or fears or thoughts that crop up that
frighten you?
Pt. No.
T h. How do you sleep? Any insomnia?
P t. Sleep OK .
T h. Do you dream a little or a lot?
P t. A lot, but I dont remember any dreams.
T h. Remember any childhood dreams?
Pt. L ike of falling, scary.
T h. Ni ghtmares?
P t. I dont remember.
T h. How about drugs? T aki ng any pills or things?
P t. No, nothing. Some of the kids take grass. I
dont like it.
T h. Now tell me a little about your mother.
P t. What could I tell. She bosses my father
around. K eeps telling me what to do.
T h. Scared of her?
Pt. No.
T h. How about your father?
Pt. I told you. I cant get to him. He doesnt
understand.
T h. How about your sister, shes a few years older.
How do you get along?
P t. We get along fine. I can talk to her. We used
to fight when I was small. We like each other
now.
T h. How did you get along when you were a kid,
at home, at school?
P t. OK , I guess.
T h. No problems?
P t. No, none I can thi nk of.
T h. Have many friends?
P t. Oh, yes.
T h. Any previous treatment with a psychiatrist or
psychologist?
Pt. No.
[/ decide to show the p a t i e n t the Rorschach
cards to see i f I can p i c k up a n y un der l yi n g d y
namics. From the data he has given me I can
not y e t discern p r o b l e m s other than p are n t s
a nd adolescent in conflict over behavior that is
not too unusual. H i s story m a y conceal other
aspects th a t he deliberately or unconsciously is
holding back. I t is possible th a t som e t hi ng will
c o me t h r o u g h in h i s re s p o n s e s to the
Rorschach cards or in drawings. ]
T h. I m going to show you some cards, and I want
you to tell me what you see. T hi s really is not
a test just an idea of your impressions. (/
s h ow him the f i r s t card)
P t. OK A re those the pictures you look at and I m
supposed to say what it looks like?
T h. T hats ri ghtever seen them?
P t. I ve heard about them.
T h. What does that look like? (first card)
P t. I dont know, an insect. Can I turn this any
way I want?
T h. Any way you want.
Pt. Or a mask.
T h. A nything else?
P t. No.
T h. OK . What does that look like? (second card)
A nything that comes to your mind. So far you
are doing very well.
P t. I dont know, it looks like a footprint or
something. I dont know, a face or something.
T h. Wheres a face?
Pt. T hat.
T h. Show me.
Pt. T here, the lower partthe eyesthe nose
the eyes.
T h. H eres the thi rd one.
P t. I t looks like two people danci ngit looks like
two people dancing back to back the other
way.
T h. A nything else? What kind of people are they?
Pt. Do you mean race-wise?
T h. No, no, are they men, women?
Pt. I dont know they look like both men and
women.
T h. What makes them look like men?
Pt. Th e r e , (points to projection)
T h. Y ou mean this is a penis?
Pt. Right.
T h. And what makes them look like women?
Pt. T hey look like they have breasts right here.
T h. Now, this is the fourth one.
Pt. Ugh, it looks like a dead rabbi t. Also looks like
a bat or some animal that got hit with a steam
roller.
T h. All right, heres the fifth one.
Pt. T hat looks like a bat, that really does.
Pt. No.
T h. All right, heres the next one. (sixth card)
Pt. I t looks like a cat that kind of got hit.
T h. Pussy cat?
Pt. I dont know, some sort of cat, nothing else.
T h. OK , this is the seventh one.
Pt. Are these any special patterns?
T h. No, everybody has different associations.
Pt. Ummmmmnothing.
T h. Well, look at it closely.
Pt. Oh, oh, it looks like two people dancing
agai ntheyre wearing a skirt or dresses or
whatever. Have long hai rdos. T hats all.
T h. OK , heres the next one. (eighth card)
Pt. T wo men hanging onto something. T hi s way it
looks like a face. I guess that looks like a
bomb, (ninth card) I dont know maybe some
muscular guy or something sitting in the back.
Y ou know the back angle.
T h. OK , heres the last one.
P t. I t looks like the anatomy of some body I
dont know, ( hands card back)
T h. All right. Now I m going to ask you to draw
me a pi cture of a person.
P t. A person?
T h. Y es, anythi ng you want. T hi s is no drawing
contest.
P t. Boy or girl?
T h. A nythi ngj ust a pi cture anythi ng you want.
P t. I ll draw about lifting weights. Did I say
anythi ng wrong with those pictures?
T h. No. Y ou did pretty good. I could testify that
youre not nuts if thats what youre afraid of.
I can say theres nothing seriously wrong with
your mind.
P t. W hats the purpose of having me draw this?
T h. I ll tell you when you get throughOK , now
draw me a pi cture of a person.
P t. A woman? (P a tien t draws an ugly woman
with large breasts holding a stick .)
T h. Now a man.
P t. Y ou dont mind if i ts inside? ( He draws a
muscle man l i f t in g weights.)
T h. I t doesnt matter. [/ g e t the impression f r o m
his responses to the Rorschach cards that he is
immer sed in i ncomplete separalion-indwidua-
tion, f e e l s crushed (fourth a n d s ix th cards)
w ith a p ro b l e m in id e n t i t y ( t h ir d card). I con
j e c t u r e that the woman with a stick in his f i r s t
d r a w i n g is his strong, p u n i t i v e m o t h e r and the
man, his c o mpens ating masculine s e l f ] Now,
you see I gave you a test, and the test would
seem to indicate that your basic defenses are
pretty good and that youve got a lot of oomph,
spark, a lot of fire [an a t t e m p t at reassurance].
But you do wi thdraw and you do inhibit when
things get too tough for you [sparse responses
on cards]. Y ou pull back and you j ust dont let
yourself come out of yourself. I t also indicates
that you are working out your feelings of
masculinity, that somehow youre not too con
fident about your feelings of masculinity at the
present time. Why do you smile?
Pt. I forget. [I g et the f e e l i n g f r o m the nonverbal
responses to the interpretations I have made
that the interpretations are correct a ss ump
tions. H i s re mark I f o r g e t indicates to me an
active desire to deny. T h e dyn a mi c f o c u s to be
w o r k e d on, i f I am correct, w o u l d then be
h is s e p a r a t i o n - i n d i v i d u a t i o n a n d i d e n t i t y
p r o b l e m s .]
T h. All ri ght, now where would these problems
come from? From your relations with your
68
mother and your father? Do they have a lot of
trouble together?
P t. Y eaha little bi ta lot.
Th. Y ou see a person is brought up in a family and
you see how the mother and father get along
togetherand you begin to pick up ideas
about how males function with females. Does
she kick him around? dominate him?
P t. Sometimesmost of the times.
Th. T hat makes a woman a strong person in the
conceptual thinking of a boy. He would like to
identify with a strong fatherwho is able to
stand up to his wife, to keep her from being
too control l i ng, and stop her. Where the
woman is too strong in the family, i ts apt to
reflect on the boys feelings that women are the
strong people. Now, this has an impact on the
boys developing sense of masculinity. And this
is the one problemit doesnt make you daffy
or anythi ng like that, but it is something that
you have to work outyou have to begin to
develop a different conceptualization of your
self as a strong masculine person. [This is a
s tr ong interpretation, b ut I believe I am right.
I wonde r h o w the p a t i e n t will handle the inter
p re tation. 1} he denies it or bypasses it, a great
deal o f wor k wi l l be necessary on his defenses.
Where a p e r s o n s i d entity p r ob l e m s are too
s tr ong a nd where t h ey are responsible f o r
m a n y a dj ust m e n t difficulties, long-term ther
a py may be needed. ]
P t. Well, I know when I was in elementary
school I dont know whybut it used to be if
the boys wanted to show off before the girls,
theyd j ump me. I used to be smaller and
everythingand theyd say l ets j ump on the
fag or something like that.
Th. Who would say that?
P t. Oh, some of the kids.
Th. T he kids would say to whom?
P t. T o me. T heyd j ump on meand theyd say
this to the other kidsthats I ki ndaI ve
been doi ng wei ghtsthats probabl y the
reason I drew that. T hen the other day, I went
downtown j ust looking for a fight I dont
know, maybe to prove myselfwho knows.
[ The p a t i e n t s admission that he h ad concern
about others considering him homosexual, his
realization that his drawing refers to himself,
his insight about practicing with weights and
l o oking f o r f i g h t s to compensate f o r his f e a r o f
lack o f mas culinity are good signs. ]
Th. L ook, youll never prove it that way. I ts better
to keep away from fights because all it will do
is create problems for you. [/ am p u s h i n g ad
vice hopi ng that I have established sufficient
credibility f o r hi m to f o l l o w this advice since he
co ul d g e t into serious trouble try in g to prov e
his m as culinity through violence a nd fi ght i ng.]
P t. Y eah, I know, like the last time I was home.
L ike one kid said, Hows school? and I said,
I ts not bad, and he said, I t must be a
pansy school or something like that. And I
said, L ook i ts kinda hard, and he said,
Well, then it must be a good school, and
then he said, I f youre going there, the kids
must be a bunch of J O s. A nd going on like
this. T hi s is one kid I hate. A nd it was j ust
yesterday and I went to town j ust looking for
him. And then before I left for schoolthe last
ti me I j ust went all over town looking for one
kid.
Th. T o beat the hell out of him?
P t. I f I could j ust find him. Because something
happened between me and a gi rl or some
thi ng like that and he was the cause of it. I t
wasnt thi s girl J aneanother girl. I was
really mad then, and I told the girl, T el l him
if I see him again, I ll look for him tomorrow.
T hen some kid called me up, one of his friends,
who must be a senior now, and he said, I f
you lay a hand on him, I ll knock the shit out
of you, and I got a mari ne friend who is going
to do thi s to you. Y ou know the whole
marines, the army, like that. A nd I said,
Well, thi s is j ust between me and him, you
know; if hes so tough let him be there. I
dont know I spent the whole day in town, he
never came around.
Th. Y ou can have beefs with kids, and maybe you
should be able to defend yourself. T heres no
reason why you shoul dnt l earn how to defend
yourself, but to look for fights is another
matter.
P t. I thi nk j uj i tsu is kind of for the birds. I mean if
you get into a fight, you know. I used to think
J udo is pretty good until last year. I saw a kid,
and he said, I take j udo, and the other kid
started laughing like anythi ng, and then he
j ust stood there laughing, and then the kid
starts the fancy advances, and then the next
thi ng you know the j udo expert was on the
ground, and he started bleeding.
Th. Do they have tough kids in that place youre
in?
Pt. Not where I live, but downtown, yes.
Th. Well, listen, I thi nk that you are concerned
about defending yourself because of your own
doubts of your own capacity to defend yourself
and your own feelings of low masculinity. But
thats a problem you wont work out by fight
ing. Y ou work it out by tal ki ng about it, and if
you want to come and see me and tal k about
these things, I ll be glad to see you. Because
you can do a lot better by verbalizing than you
can by fighting, jI m testing m y effectiveness in
the interv ie w here. Ha v e I established a rela
tionship and does he have sufficient confidence
in me to start t herapy with me? H i s response
to m y invitation will tell. ]
Pt. T hats what J i m said, you know J i m Sloan,
my friend. I told him yesterday. He wanted to
go out and I told him I gotta stay home, and I
told him I was going to see a psychiatrist. And
he said, youre really lucky 'cause they can do
a lot of good for you. He said when you walk
in there, trust him, he said, sometimes it may
take a few times, to trust him eough to talk to
him, but once you can, youre lucky. I di dnt
believe him. I di dnt want to come, but I m
glad I came.
Th. Well, if you can clarify some things for your
self, you are lucky. Believe me, insight and
understandi ng can be the greatest savior of
your life. I f you have an idea of whats cooking
with you and where it originated, you can take
a stand against it. But if you havent the
faintest idea of whats going on, all you feel are
emotions and bad feelings, and then youve got
to get rid of these feelings. And before you
know it, youre in a mess. Y ou dont solve
anything. A lot of the feelings youve been hav
ing with your parents are these bad feelings
that are coming up because you cant com
municate with them. Now, maybe i ts impossi
ble to communicate. I dont know what youre
up against with them because I dont know
both of them. But I do believe they must have
your welfare at heart. T hei r motives at least
are good, but the way they express themselves
may be bad.
Pt. Do you really feel that or are you j ust saying
that?
Th. Why should I say that to you if I di dnt mean
it?
Pt. I dont know, to give me a certain feeling or
something.
Th. But I thi nk you can be much smarter than
youve been, because what you have been
doing is j oi ni ng in on a battl e with them. Y ou
are the low man on the totem pole. Y ou
havent got a chance with them unless you use
another kind of tactic.
Pt. How?
Th. Y ou have to be kind of smart in communicat
ing with them. L et them know your feelings,
but dont tell them everything about what you
do, about these girls. Y ou can tell them what is
true. Why not say about your girl, T hi s i snt
seri ous. I f they say, A re you going to see
her? you could say, L ook I have certain
things that I have to keep to myself, and I m
going to keep them to myself. I m not going to
do anythi ng that will embarrass you, or hurt
you. I m not going to marry anybody, I m not
going to get anybody pregnant.
Pt. I told them often. We had a big argument one
night. I said something like, I dont know
what youre so concerned about ri ght now. I m
not going to latch onto one girl until I marry
her. I said. Dont worry. I m not stupid;
I m not going to get into troubl e. T hey get
upset if a girl i snt our religion. I ts a big
thi ng. T hey j ust want to know, I dont know,
but theres a whole bunch of these arguments,
and I say, Dont worry about this, this i snt
going to happen, and they say, A re you
going to see J ane, and so forth and so forth.
Because the other night I came home and my
mother had gone to sleep and it was about
11:00 oclock I came in, and he starts to talk to
me. I had this feeling he wanted to hit on
something, and I said, Get to the point, Dad;
what is i t? And he said, I m not hitti ng on
anything. I j ust like you to go out with other
gi rl s, and so forth.
Th. Whereabouts is the place that youre going to
school ?
Pt. Haverstown.
Th. I wonder if I could find a person for you to
tal k to like youre tal ki ng to me. Would you
want to see someone to talk things over. [-Smce
H a ver stown is f a r f r o m N e w York, I am con
t em p l a t i n g referring the p a t i e n t to another
ther apis t who lives in the neighbor hood o f the
school. ]
Pt. T hat would be pretty good.
70
Th. Y ou havent got communication with your Pt.
parents. Y ou need communication with some
body. Because youre getting too bottled up
within yourself. These kids at school, you cant
talk to kids the way you would talk to a thera
pist. T hey dont know what i ts all about.
Pt. M y sister is pretty smart.
Th. Shes fine. Y ou can talk to her, but shes not
around. Th
Pt. T hats true.
Th. I ll be glad to see you whenever you can come Pt.
into town, but it would be better if you had
somebody nearby. T hat would be great. How Th
would you feel about that?
Pt. T hat would be pretty good.
Th. But there may not be anybody around there in
Haverstown.
Pt. I ts a hicktown; i ts ri ght near nothing. But I
have a friend in one of the teachers. Every so
often hell tell me to drop into his room, his
apartment, and maybe well have a tal k or
something like that.
Th. Y ou need somebody who has more trai ning,
really more expert in this type of thing. Y ou
need somebody who knows about dynamics,
about emotional problems, about relationships
with and between parents, the involvement
with ones own sense of self. T hi s is a highly
specialized and complicated business. An edu
cator usually doesnt have this type of trai n
ing. (pause) I f theres nobody trai ned near
Haverstown, I ll suggest that you come and see
me as often as you can. How often can you
come into the city? Pt.
Pt. Pretty often.
Th. Can you? I ll be glad to see you whenever you
can get away. Y ou know it will also make your
parents feel as if youre not going to get your
self into trouble. Y ou know, you have a lot on
the ball, and you have a lot of very good stuff
in you. I woul dnt say that you are abnormal,
but you can get involved in trouble with all
these feelings to act out, this fear of not being a
man. Y ou have to work it out on another level.
Pt. I dont mean to be untactful, but how much
does one visit cost?
Th. I have a sliding scale. I n other words, depend- Th
ing upon what a person can pay; in other
words, if a person is able to pay a high fee, i ts
going to cost more. I f he cant pay a high fee, I
scale it down.
Suppose I was to be paying for this. [77!!* is a
g o od sign a n d indicates that the p a t i e n t wants
to assume responsibility f o r his own treatment.
In m y m i n d I already have decided t ha t I wi l l
see the p a r e n t s also, who will make up f o r the
sm a ll f e e the boy can afford to p ay. T h e y wi l l
k n o w too that the boy is car rying his own
tre a tm en t costs.}
Y ourself, depends on how much you could af
ford to paywhat could you afford to pay?
I t depends if I could send you my allowance
from school.
I woul dnt want to take away your allowance,
I d work out something. Whatever you could
afford to pay. I ll work that out with you next
ti me. Wel l , l ets leave it thi s way that
whenever you can come into town, let me
know a couple days in advance. T hi s will be
j ust between you and me. T hey wont have
any I m not going to tell them anything
about what we tal k about. I ts the only way I
can work with a person. I f I were to reveal
anythi ng you told me, it would destroy our re
lati onshi p, and it woul dnt be helpful parti cu
larly. T he only thi ng I can tell them about my
talk with you today is that, in my opinion, you
dont have anything seriously wrong with you,
that youre evolving and devel opi ng in a
normal way, and that they have to establish
better communication with you. And they have
to stop going through your pockets. T hat
would be great if I could put that across to
them, woul dnt it?
T hat would be fine, but sometimes, I may be
wrong, but sometimes I feel they thi nk they
can get through to me by giving me something
of a talk. I dont know, they say, Y ouve had
it too easy, weve given you everythi ng. They
say why we dont trust you is because you
were there anyway, meaning about seeing
J ane. T hey dont expect me to say I m not
going to go there, and if she means anythi ng to
me, they dont expect me to say I m not going
to go. And they are trying to corner me into
saying I ll never go and give my word that I
wont go.
Well, I ll do my best. I m trying to figure out
what I can tell them to try to help the si tua
tion. I ll tell them that we talked things over
and that I thi nk that it would be better for you
to tal k to somebody else than to tal k to them,
and that I told you I d be very happy to see
you. I f any problems come up, you would be
able to discuss them with me. How far from
New Y ork City is Haverstown?
Pt. All I know is that i ts about 75 miles.
T h. How would you get here?
Pt. Oh, I could take a trai n in.
T h. Y ou could come in once in two weeks, once in
three weeks, once a month. Y ou know that
isnt bad.
P t. Once a month I could come in.
T h. Do you really want to come and see me and
talk to me, no kidding about it?
Pt. I m serious.
T h. Y ou tell them then that you would very much
like to come and talk things over with me and
that if any problems come up, you will want to
discuss them with me. I ll tell them that I ve
seen you, and I thi nk it would be very helpful
if I could have some talks with you. I ll tell
them that you have no serious intention of get
ting yourself so completely immersed and i n
volved with anybody thats going to interfere
with your freedom. Y ou know, give them some
kind of assurance so that they will stop bug
ging you about this thing. Y ou know what I
mean? T hats if you agree, I should tell them
that.
Pt. I mean I agree with you about what youre
going to tell them, but how am I supposed to
act? Sure we can sit here and talk, but I have
to live with them.
T h. Y ou have to live with them, I know. Why cant
you j ust say, L ook, M om and Dad, I dont
want to fight with you. I dont want to go be
hind your back and do things that are bad. I
can assure you that I m going to go out with
other people, but I also probably want to see
J ane.
Pt. I couldnt say that to them; they would start
an argument. A nytime that name is men
tioned, there is going to be an argument.
Anytime it has been mentioned in the past,
theres an argument. And I know i ts a very
sensitive subject. What could I say?
T h. Why not say simply: L ook, I m going to talk
things over with Dr. Wolberg. Get the idea?
Pt. OK
T h. I better see them for a couple of minutes.
(Patient walks o u t - p a r e n t s come in a n d sit
down.)
Fa. Weve been taki ng it.
T h. Y ouve been real l y taki ng i t? Survi vi ng?
W hats been happeni ng?
Fa. I ts been tough, the son, hes been belligerent,
and hes been walking with a chip on his
shoulder (separates hands widely) this big.
K nock it off, you know. T heres no tal ki ng to
him. I know I cant get through to him. I try
to tal k to him. T heres no rapport, theres
nothing.
T h. (Addr ess ing the mother ) Can you get through
to him?
M o. I cant.
Fa. I j ust cant get through. I dont like whats de
veloping, developing in him.
T h. I dont like whats developing in him either,
between you and me, because he can get
himself into a hell of a lot of trouble the way
he feels.
M o. Well, hes he doesnt want to do anything.
He j ust likes to do nothing. I ts very hard to sit
and watch this for hours, I guess. I feel, I al
most feel I dont give a damn.
T h. I can understand your emotions. I know you
take it on the chin. H es a very handsome boy
with a lot of stuff on the ball, but he is not liv
ing up to his own potential. H es acting out
and so on. I gave him some tests to see whats
what. H es got a lot on the ball, but hes j ust
full of emotion. H es an extremely emotional
kid, ready to explode any time, but his defenses
are pretty good. I mean hes abl e to hold on to
his emotions. T he only basic problem that
comes up is one common at his age, a fear of
his own capacities as a growing boy, a need to
prove his own masculinity. Proving himself
with exercises and weight lifting is OK , but
wanti ng to get into fights this is a serious
problem that I took up with him. He needs
therapy. Now, i ts going to be very difficult to
find anybody around Haverstown. T heres no
body in that area we can call on. I believe I
was able to get to him, to communicate to him,
to rel ate with him. I thi nk he trusts me, and he
opened up with me. He came in very defen
sively as you know. I was able to cut through,
but you can j udge that better when you talk to
him. I thi nk the worst thi ng you can do is keep
putti ng injunctions on hi mrules. He will
break them down; you will not be able to stop
him at this point. Wi th some therapy he
72
should be able to control himself. At the
present time he is focusing everything on a
battle with you, which i snt so unusual at this
age when he is breaking his dependency on
you.
Mo. What kind of rules, excuse me, what kind of
rules? [A p p a r e n t l y , she is qu i t e defensive.]
T h. He wont pay attention to rules.
Mo. T here arent any rules.
T h. Y ou tell him not to see this girl. I would advise
you I dont know if you can do itto lay off
that si tuati on for the ti me being. Dont
countenance it and dont condone it, but dont
quiz him about it. We talked about it, and he
agreed it would be better for him to see other
people. I told him it would be only sensible for
him not to restrict himself to this girl. I t isnt
as serious as you think. He agreed it would be
a good thi ng if he did not restri ct himself to
one person. T he basic thing is he needs some
body to talk to. He needs to communicate with
somebody, to open up with somebody, because
hes a volcano inside, ready to bust wide open.
And if he verbalizes, hes not so likely to act
out. I told him, I can see you anytime you
come, if you call me in advance.
F a. We were tal ki ng about that outside.
T h. And he said to me, What do you charge? I
said, I charge a sliding scale, what a person
could afford to pay. He said, I d like to pay
for this myself out of my all owance. so I said,
All ri ght, well work out something. W ell
work out something between the two of us,
whatever you can afford to pay, because after all
you cant afford a high fee and I do see some
people here at a low fee scale. I t would be bet
ter for him to feel he can handl e it by himself, so
he can send me five bucks or whatever it is.
Mo. T hats his allowance.
T h. T hen I ll talk to him; someday he can pay me.
Mo. He wants to come then?
T h. I thi nk he very much wants to come. He was
telling me that he was tal ki ng to a friend last
night and said they (meaning you) want me to
see a psychiatrist. T hi s other kid said, Y ou
know youre very lucky, youre very lucky you
can see somebody to tal k to.
F a. He told us about it. T he interesti ng thi ng is
the fellow he says said it, his mother and
father, cant get along with him.
(The pati ent came for a session the next
week, agai n accompani ed by his parents. At
that ti me I convinced the parents to conti nue
in therapy wi th me, both singly and together,
duri ng whi ch I counsel ed them on the de
vel opmental requi rements of adolescents and
the need to encourage thei r sons i ndependent
strivings. I t became apparent that the chief
probl em in the fami l y neurosi s was the
mothers need to control and domi nate both
her husband and her chi l dren to a poi nt that
they had to obey wi thout questi on to avoid her
hysterical displays. The father was i ntroduced
to a group who chal l enged his passive yiel ding
to his wife and encouraged his standi ng up to
her and taki ng her sons side. T he mother
recei ved about 40 sessi ons of psychoana-
lytically ori ented therapy al ong wi th about 10
sessions of group therapy. T he boy himsel f
benefited sufficientl y from 5 more sessions to
di sconti nue therapy greatl y improved. On fol
low-up the enti re famil y structure and rel a
ti onshi p between members of the famil y had
changed remarkedl y for the better.)
Case 2
T he following il l ustrates the active, suppor
tive fi rst-session management of an acute ex
acerbati on of anxi ety in a chroni c obsessive-
compul si ve pati ent. I n decidi ng to termi nate
therapy after a few sessions, I toyed wi th the
al ternati ve possibil ity of engagi ng in a l ong
term process, but felt that the ri sks of enhanc
ing the pati ents dependency on me mi ght be
too great. Actuall y, the pati ent hersel f ex
pressed an i nabi l i ty to conti nue in prol onged
therapy. My objective then was to bri ng her
rapi dl y to an anxi ety-free equi l i bri um, offering
her, if possible, some insight into her dy
nami cs, whi ch hopeful ly could in ti me, if she
uti li zed it, have some reconstructive effect.
There was no il lusion that thi s bri ef treatment
i nterl ude woul d forestall future attacks. How
ever, it was felt that if the pati ent could be
ti ded over her i mmedi ate crisis, she mi ght be
helped to a better adj ustment. Si nce tension
was the motor that rel eased her obsessional
symptoms, hel pi ng her to l earn to control ten
si on by rel axati on was the tactic I decided to
utilize.
Pt. I called the Consultation Service and 1spoke to
Dr. G. and told him what I needed and he rec
ommended you. He said that you were the per
son to tell me yes or no. [T h e p a t i e n t speaks
rapidly a nd seems upse t a n d per turbed. I g et
the impression that she needs a good deal o f
reassurance which ma y or ma y not be o f help
to her.}
T h. Y ou mean, whether my kind of therapy would
be of value to you?
Pt. T hats right.
T h. Well, supposing you give me an idea of your
problem, and then I will tell you whether I can
be of any possible help to you.
Pt. Can you treat me? I have obsessions that
crowd into my mind and upset me.
T h. I f you have the desire for help, that is usually
nine-tenths of the battle. [Because she is so
upset, 1 decide to reassure her rather than to
explore w hat she means by obsessions. ]
Pt. Well, thats what I am. I am really obsessive,
very badly.
T h. T ell me about it. How bad is it?
Pt. Well I will tell you the story. I get very upset
over it. ( T h e p a t i e n t p ause s and is manifestly
anxious.)
T h. T ake your time [more reassurance].
Pt. When I was 15, this first came out and it
really bothered me. A word came to my mind,
and I felt forced to repeat it. (pause) I t is the
repeating of the word (pause).
T h. T he repeati ng of the word.
Pt. Y es, you see I come from a very religious
family. I , myself, am not religious or anything
like that. I dont know if you know what I am
talking about. I n the family that I came from
there were constant prayers. Well, as a child,
when I was about 15, I remember my father
having a lot of financial trouble. T here was a
lot of worry and high tension in the house. I
suppose I took this more or less to heart,
whereas my sister and brother di dnt really
believe in all the complaints, the usual kinds of
things that go on. One time I was up in my
bedroom and I was j ust sort of like prayi ng to
God that everything would work out and it
would be all ri ght. I know I was feeling de
fiance and I know how this works, but I said
to myself, Well, if I cant pray to God to
make everything all ri ght, maybe if I say J esus
C hri st over and over again it wi l l . Well, I
started to repeat that in my mind and it
seemed repulsive.
T h. J esus Chri st?
P t. T hats it.
T h. T he repeti tion of J esus Chri st, was it sort of a
defiant gesture?
P t. I suppose it was. I dont qui te understand it.
Well, I coul dnt stop repeati ng thi s thing in
my mind. I t would j ust go on and on and on,
which never happened actually before. I di dnt
know what to do. Finally, I told my mother
about it, and we went to our family doctor. I
was 15 at the time. I am 21 now. He sent me
to a psychiatrist. T hi s guy was a psychiatrist
and neurologist. Now, when I went to him, it
was for a short time. A matter of a few
months. He did absolutely nothi ng for me, as
far as that goes. I told him the same story
which I will tell you now that there is some
thi ng that happened to me when I was 8 years
old. I can remember when this thi ng first came
out. I am positive about it. I am telling the
same rotten story. I hate myself for this be
cause it w as j ust a waste of everything. Well,
finally, after about 5 months I recall that it
started to let downthis repeati ng of the
wordsand I got back to being myself. J ust
being myself. Period. [772^o u t cr opping o f the
obsessional s y m p t o m is a derivative o f many
anxieties, some p e r h a p s unconscious, dating
back to h e r childhood. T h e p a t i e n t recognizes
the connection.]
T h. Duri ng this period that you were seeing the
psychiatrist what happened?
P t. Y es. 1 went to him on and off, and then
eventually he just told me that he really spe
cialized in neurology and there was not a darn
thi ng he could do for me. A nd if I could, I
would have rather avoided this. I was a junior
74
in high school at the time that I was 15.
T oward the end of that year it more or less
went away and I would forget about it. 1
would rather thi nk that it had nothing to do
with me and that I could stand it. I was all
right in my senior year in high school. I was
all right in my freshman year in college.
M aybe it would start coming up, but I could
sort of fight it down. When I was a sophomore
in college, I went away to school.
Th. Y ou were all right as a freshman in college?
Pt. Y es. T hen I wanted to go away to school and
live in a dorm. I t was a new experience. Get
ting away and, of course, the change of envi
ronment suddenly. Everything was going along
well, although it was new and I had never
been away from home. But before I could get
better, this thing got hold of me. Y ou know
what I mean?
Th. Y ou mean the obsessions started agai n? When
was that? How long ago?
Pt. T hi s was when I was 18. I ts not so much the
repeati ng of the word, actually, although that
occurred.
Th. T he same word, J esus Christ?
Pt. Y es, but it changed to all kinds of symptoms
actually. I started j ust with saying, J esus
C hri st, but I know where all this came from.
I will go back, but I j ust wanted to take it from
here. Finally, when I was a sophomore, at the
end of my sophomore year, I got home and
everything was fine. I t di dnt bother me that
much either that year as much as it did the
first time. T hen I became engaged. I was fine
and I thought it woul dnt even bother me any
more. I got married. M y husband and I have a
very nice marri age a successful marriage.
[Up to this p o i n t the p a t i e n t does not pre sen t
too coherent a story. She seems so concerned
and upset with her obsessional s y mp t om that
she bypasses import an t details that I shall ex
plore l a t e r . /
Th. How old were you when you got married?
P t. Nineteen. I m 21 now.
Th. Y ou have been married almost 2 years?
Pt. A year and 3 months. I was married for 10
monthsthis is why I am here nowthis past
A pril I was humming in bed, and, you see
actually when I am out and active and every
thing, and if this starts to bother me, I can j ust
get involved in other things and sort of keep it
depressed, keep it down. When it came to the
surface again, that really bothered me.
Th. I t must have upset you a good deal.
P t. I t did, this past A pril.
Th. T hats 5 months ago.
P t. I have spoken to some people since then be
cause my husband and I want a large family
natural l y. M y husband and I want to plan on
a family, and I dont want to have children be
cause I will be suffering worse then. Because,
if it is an anxiety, or whatever you call it,
when I get it, really get it, I am miserable.
Y ou cant remove it sometimes lying there; you
j ust dont know what it is. I ts like your scared
of something, but you dont know what you
are scared of. I t is very hard to say. I had
spoken to some people about the thing that
happened to me in A pril. I got petrified. I
avoided everything and everybody. T o me if I
am not feeling guilty and it is not bothering
me, I am fine. I realize now that it is some
thi ng that will be recurri ng until I find out
what it is that is needed, or destroy it, or put it
down. I spoke to a few doctors, but nothing
steady.
Th. Any other tries at psychotherapy?
Pt. J ust the one time that I told you about. I had a
girl friend tal ki ng to me once. I never told any
body about it because I am deathly ashamed of
it, and deathly ashamed that anyone should
know. A nyway, that bothers me an awful lot.
She was telling me about when she was away
one time. She stutters. She had gone to a per
son, who I believe is a psychiatrist, who taught
hypnosis to other doctors or something of that
sort, and she was telling me the story of how
she was regressed to earl i er times of her life.
She was regressed to the time where she first
started to stutter. Her mother took a knife to
one of her brothers when she was 2 years old,
when it happened that she stuttered. A fter she
found out about that, then she began to talk.
[T h i s conventional notion o f t he pa t hogenicity
o f buried m e m o r i e s , a nd t heir need to dis
gorge them f o r cure, sends some p a t i e n t s in
qu es t o f therapists who can surgically dissect
into the unconscious.) A fter she found out
about that, then she began to talk. Well, from
what I had read about hypnosis and things like
that, I thought that maybe, maybe this is one
way of going back and finding out why I had
this trouble. What is it covering up? I know
this much at least. When I was 8 years old, I
have three brothers, and an older brother, who
is 6 years older than I there was a lot of sex
play between the two of us. I was brought up
in a very strict home. Sex was something that
was never talked about, and so forth. T he way
I feel about it, I have not a bad adjustment. I
have had a very good adj ustment in marriage.
I cant understand how one has anythi ng to do
with the other. T hi s is the only thi ng I can re
member from my young childhood life. T hi s
thing is bothering me. T here was no actual in
tercourse that took place at all, but there was
like masturbati on. He would touch me, and I
would touch him, and so forth. \ Wh a t the p a
tient wants is hypnos is to u proot i mportant
memories. T h i s , in m y opinion, is not what
will help her. Na t ur ally, she is not told this
since it may discourage her to learn that the
technique that she believes w i l l save her cannot
do so. La ter, when I have a wo r k i n g relation
ship with her, I wi l l be in a better p osition to
apprise her o f w h at I believe can help her.]
T h. Y ou remember the i nci dent today qui te
acutely? Y ou were only 8 years of age then. I t
still bothers you?
Pt. 1remember every single thing that happened.
T h. Do you remember if you felt sexual excitement
at the time?
Pt. Not me.
T h. Not you?
P t. Well, it is a funny thing. I f I were to be truth
ful, I d say that I knew that I liked it. But here
is the story. Y ou see, when we first started
this went on for a very short time, but it
wasnt j ust one time that it took place between
the two of us when it first started, I knew
nothing about sex. I was j ust about 8 years
old. I di dnt even know what it was. Duri ng
the time that this was going on, all the girls
were getting together and starti ng to tal k about
sex. T hen I realized what I was doing and that
what I was doing was wrong. T hat made me
feel different, (pause)
T h. I t made you feel guilty?
Pt. Now, I was only 8, but I remember one time.
Maybe it was extra nice or something like
that. I t was the summertime in my house. I
wanted to tell my mother. I had to get this
thing out of me. I can remember going to my
room and crying about it. A lways deathly
afraid that I was pregnant. Even though, as I
say, I knew I coul dnt be, but I was scared that
I was. I was scared all of my teenage life that
someday I would be pregnant from this thing.
I remember my mother came upstairs to my
room, but she came in with my aunt, and I
was going to tell her, but she was with my
aunt and I coul dnt. I looked at her and said,
"M ommy, I am pregnant. Of course, my
aunt burst out laughing. I would burst out
laughing if it was anybody else. T hey j ust shut
it off. I t was j ust nothing. Some kind of silly
business and that was the end of it. Well, to
this day nobody knows anythi ng about it ex
cept this doctor that I spoke to.
T h. Y our brother was 14 at the time?
Pt. Y es. When this was going on, he would send
me out of the room, and I never knew why. I t
was when he would reach an orgasm and the
sperm would be coming out. One time I asked
him why, and he let me stay, and I saw the
sperm coming out, and he told me, T hats
what makes you pregnant. I became, as a
child of 9 and 10, I became very afraid of
sperm. T hi ngs that my brother would touch I
was afraid to touch for fear I would get
pregnant. Sometimes I was scared in my mar
ried life. I can understand it rati onal ly, but I
do not want to have a pregnancy, and I am
more scared of becoming pregnant j ust from
sperm than I thi nk a normal person would be.
I am qui te sure of that.
T h. Do you use contraceptives?
P t. Y es. I became very afraid to touch anything
that my brother touched. I f I would, then I
would run and wash my hands, wash my
hands, and wash my hands. I t was getting
ridiculous, but I had to do it. I f that is compul
sion, well, then that is compulsion. I dont
know what it is. T hen, of course, I thi nk that
from that maybe you would determine that I
was touchy. T hat doesnt bother me much.
When I was younger, I would pick up the
prayer book and start to read. When I would
come to the end of the sentence, or something
like that, I would have to say, J esus C hri st
over and over to myself. I t got to the point
where I coul dnt read with anybody, although
I di dnt say anything. T hen thi s would come to
my mind. As I grew up, I guess it subsided and
di dnt bother me, with the hand washing and
things like that, although all through my
teenage life I always was afraid I was going to
become pregnant. Even as a child. I t only went
on for a short period, a matter of months. I
dont really remember how long. Well, it was
duri ng this time that I started to repeat J esus
C hri st to myself. And ever since that time,
76
this thing has j ust been growing and growing
and growing. Now it stops, now it flares up,
now it doesnt. T he last time was in A pril. I t
hasnt bothered me for quite a while. A lthough
I could fight it down, I am purposely not fight
ing it down for the simple reason that I want
to get rid of it because natural l y we want to
have a family. I know that I cannot make a
decent mother with this sort of attack coming
upon me. One other thi ng that bothers me I
guess this is because I am oversensitive to the
probl emit is that when we told our family
doctor, I was afraid, I am now scared that
everybody knows. I am so afraid that people
will find me out. T he people around Con
necticut, where I live, are nosy. I believe, I
thi nk it now.
T h. Find out about your obsession?
P t. When it doesnt bother me and I thi nk that
someone knows, I j ust laugh it off. I thi nk, So
what, what can I do about it. I cant help it. I t
is over and done with. I t is a silly thi ng. I n
fact, I can remember actually laughing at
myself in-between times to thi nk that I would
do something like that. A lthough that bothers
me a lot, swallowing sometimes is a symptom.
T h. Swallowing? T ell me about that.
P t. I t is j ust nothing. All of a sudden I j ust cant
swallow. I t doesnt bother me a lot. I t is all of
a sudden. I am not doing it now. I am j ust
talking about this whole thing, parti cul arl y the
word repeating.
T h. T ell me about this. What other word besides
J esus Chri st comes out?
P t. I dont always say J esus C hri st. I change
the word around so that I dont have to say
that parti cul ar word. I would say cocka-
doodle or something like that.
T h. Cockadoodle?
P t. I dont know. J ust anything in order to avoid
saying the word that I am thinki ng of. But
sometimes I will j ust be doing anythi ng and it
will come out j ust like that.
T h. When it comes out, it gives you anxiety?
Pt. Oh, yes.
T h. A great deal of anxiety?
Pt. Not always. But when I am feeling fine, and
all of a sudden it comes out, I j ust pray that it
i snt going to come to the surface, I dont pray.
I di dnt mean it that way. I j ust get scared and
try to avoid it. Because I know how I can get
so involved and engulfed in this thing.
T h. All right. Now, apart from this, do any other
words come up in the same context as J esus
Chri st?
P t. Onl y if I try to cover it up with a swear word,
but it doesnt bother me in the least actually.
T h. T el l me a l i ttl e bi t more about other
symptoms. Do you get tension duri ng the day?
P t. Do you mean when I am upset or j ust a
regul ar day?
T h. Regular day.
P t. I know I have a lot of inferiorities. I can tell
you that much. Here is a curious thing. I dont
know if thi s means that your ego does
strengthen up through time or not. A t one time
I felt like I was the ugliest thi ng in the world. I
would walk down the hal l sthi s my prejudice
coming upand if the colored girls would walk
by me, I would thi nk, Y ou know you are j ust
the ugliest thi ng in the worl d. A nd yet, it
doesnt bother me at all now, and hasnt
bothered me since. I have had the other two at
tacks more or less which have been j ust as bad.
And yet, when I was a senior in high school, I
coul dnt compete in my sorority, which must
have been a shock to my ego. Now it really
doesnt bother me anymore. I have two sisters,
one is a year older than I . I know I was held in
her shadow.
T h. I see. Did you have any other kinds of prob
lems as a child? Did you have any tics or
speech problems of any kind, instances of bed
wetting or walking in your sleep? [/ could
have f o c u s e d more on the competitiveness with
her sister, but I w an t e d to g et as much in
f o rm a t i o n as possible in this in t erv ie w to help
me in designing a tre a tm en t pla n .]
P t. I never walked in my sleep, never wet my bed.
I dont know if thi s has anythi ng to do with it,
but I once asked my mother, although I cer
tainly dont remember back that far myself. Of
course, my sister has a baby now, and I like
the way she is bringing her up. She lets her do
things as she comes of age and thats how she
controls herself. I supposedly never wet my
pants, and by a year or something like it I
never bed wet. I can never remember any one
time in my life where I did bed-wetting. As far
as tics are concerned, which means swallowing
or some such funny thing, I dont know how
old I was, but you know how you can click
your throat or something. I used to do that,
but not a lot. Not that it bothered me. I never
got worried about it. M aybe yesterday or
something it might have happened.
Th. How about depressi ons? Do you get de
pressed?
P t. T he only time 1 get depressed is when I get the
attack. Right now I m not depressed. I f my
husband wanted to go to a party and have a
good time, I d go. When I feel all ri ght in be
tween attacks, I am j ust like any other person.
Sometimes I feel blue one day, but certainly
not depressed. I f somebody calls and wants to
go someplace, okay. But I do get very, very
downhearted when this thi ng gets me. Be
cause, what can I do? Right now I am all right
in that sense. What am I going to do? I cant
break out. W hats the use of going on from
here. I t is j ust ridiculous, (pause)
Th. Do you get any headaches?
Pt. Y es. I know when I get a headache and when I
dont. I know this means i ts a neurotic
symptom, pressing on the sides. I get all this
stuff. I have gotten this pressing feeling ever
since the attacks started, from the time this
started when I was a child.
Th. T hi s depressing feeling?
P t. Pressing not depressing. I had to go to the doc
tor to get a physical checkup because I was
getting so excited and so scared inside that I
would actually work a fever up inside myself. I
cant explain it. I get so scared and so petrified
that I dont know what to do. Well, I know
when I get a fever. When I get a real fever, I
know that I am sick, but when I get this kind
of a hotness or something . . . now I can
relate that to something when I refer back.
When I was 8 years old, I can remember dur
ing the sex play between my brother and I , I
could never understand why the ai r always felt
so warm or so hot. Now I dont know if there
is any direct correlation between these. I dont
even know if it is that which is causing it.
M aybe it is completely subconscious. But for
some reason I always rel ate it to that. But it
may have nothing to do with it.
Th. Do you relate the fever to that incident with
your brother?
P t. No, it was from my brother seeming to get ex
cited or stimulated, of course. Warmth was
j ust part of the sexual sti mulation. I remember
wondering about it especially when I handled
his penis.
Th. When you handled his penis, did you have any
feelings about that?
Pt. M e? Sexually?
Th. Did it excite you or scare you?
P t. I n the beginning, it di dnt scare me. I was very
curious about the whole thi ng and when we
were little telling jokes. At the time I was j ust
curious.
Th. Y our sexual adjustment now, would you say it
is a good one?
P t. Y es.
Th. Wi th a climax?
P t. All the time. Y es. When we first got married,
the only thi ng I coul dnt get over the idea of
having complete freedom in sex. But after a
few months, it was fine.
Th. So that you are uninhibited more or less sex
ually?
P t. M y husband and I have come to an agreement.
We both enjoy what we do, and thats how we
feel about it.
Th. How about when you have a few drinks? D ur
ing the times when you have anxiety does alco
hol help?
P t. I dont drink.
Th. How about tranqui li zers? Have you taken any
medication?
P t. I once went to a doctor who gave me a pill.
T he first psychiatrist whom I went to when I
was 15 gave me some pills, but he told me
ri ght to my face, he said, Y ou know your cure
is not in the bottl e. Which, of course, I know.
T hi s last time, I spoke to thi s one doctor I
j ust went to him onceand he gave me a
prescription which he said would calm me
down and I would forget about it, something
like that. I took the pill, and it di dnt do a
thi ng, and I know myself that a pill is not go
ing to cure me.
Th. Do you know which pill he gave you?
P t. I t was a green and black one.
Th. Sounds like L ibrium.
P t. Y es, it was L ibrium.
Th. I t di dnt help?
P t. I t di dnt do a thing. I ts all up here p o i n t s to
head). [I g e t a better f e e l i n g about her basic
strengths. She has made a g o o d se x u a l adjust
m e n t a n d has some under sta nd in g o f her p r o b
lem.}
Th. How about dreams? Do you dream a great
deal or do you dream very little?
P t. I n fact, I had a dream this morning. I have
been a l i ttle anxious about coming here. I have
dreams. Certai n ones have stood out, because I
knew someday I would be telling somebody my
story and I should remember these dreams.
T hey are about things, and I will place my
older sister doing them, and then I will proba
bly want to do the same thing. T hi s morning I
had a dream about my sister and I. Now when
we were little, we used to fight, at least I d call
it that, because I d retreat. Georgette, my
sister, who is a year older than I am, had an
accident when she was a small child, and so
she was always coddled and everything when
she was about 3 years old. She broke one leg,
she broke an arm, and things like that. I f we hit
her, she was going to fall apart. A nyway, it is
the truth. I remember that we used to fight and
I would never let myself go to really hit her
back. I n other words, I was always the one that
was blamed for things and always got hit and
all this other stuff. T hi s morning I dreamt that
the two of us were fighting and she was hitting
me and really hurting me, and yet I coul dnt
really hit her back. But I was holding back all
my strength, which is something that always
happened when we were children. [ T h e p a t i e n t
continues to refer to h e r relationship with her
sister as a source o f k eeping her down and
crushing her. A c t ua ll y , her sibling rivalry,
never resolved, in later sessions turn e d out to be
a core problem.]
T h. And you have always held back? [ I w ou l d have
li k e d to have gone into her relationship with
her sister at this p o i n t , but I realized this
w oul d have cons umed the re maining minutes
o f the session. ]
Pt. Y es.
T h. What about your mother and father? What
kind of people are they?
Pt. M y mother is a peculiar person. M y family is
the hi gh-strung type.
T h. How did you relate to your mother when you
were a child?
Pt. M other and I were not close. T he reason that
I did what my brother wanted me to do I
know thi sis because I got a lot of love from
my brother. I would say my grandmother, who
did not live with us, when I would see her, I
would feel real true love. Now there is some
thi ng wrong with my rel ati onshi p with my
mother and father. I could never talk to my
mother. M y older sister was always safer. T his
I know. 1have always felt that way. I am close
to my sister now. I t wasnt until I got married
that I could actually go over and look my
mother strai ght in the face, and j ust sit there
and talk and have a regul ar conversation as a
mother and daughter should. As a teenager, I
was very, very hurt when I was about 11 or 12
or 13. Y ou see, my sister was a year older than
me, and she would go in and start tal ki ng to
my mother about her boyfriends and things
like that. Once or twice when I tried to go into
the kitchen, and j ust get together, the two of
us, and speak and try to talk to her, it was al
ways as if Oh, you are j ust a kid; your boy
friends are nothing; j ust little playmates. I
dont want to hear about your silly little
thi ngs. So I kept everything to myself.
T h. How about your dad? What sort of man is he?
How did you relate to him?
P t. I always liked my father. I always liked my
mother, too, but I could never get close to her.
T h. Y ou coul dnt talk to your father either?
P i . No. Well that is something to thi nk about for a
second. I felt that I was i n with my father,
so to speak, and that was all right. M y father
is where all the religion comes to our family.
He is a very religious person, pseudo-religious
person. I t depends on how you look at it. He is
very well educated, in cul ture, background,
and things like that.
[At this p o i n t the p a t i e n t is shown the Rorschach
cards. ]
T h. Now I m going to show you some cards and I
want to ask you to tell me what you see in
these cards. What does this one look like?
P t. A butterfly, a crab, (pause)
T h. All right. How about this second one?
P t. I t looks like two elephants with thei r noses up
and together.
P t. No
T h. T hi s is the thi rd card.
P t. T wo peopl e bendi ng over and touchi ng
something together. Nothing else.
T h. And now the fourth card.
Pt. A bear fug. (pause) T hats all.
T h. T he next card.
Pt. I m thi nki ng of a great big bumblebee we had
in the car the other day with a big furry coat
on it.
T h. A furry bumblebee.
P t. Y es, gigantic with big wings. I t also looks like
a butterfly.
T h. I believe thi s is the sixth card.
P t. T hat looks like a scared cat. (pause)
T h. T hi s is the seventh.
P t. I t j ust reminds me of cherubs inside of a
church or something.
T h. A nything else here?
Pt. A fter looking at it, I can see where there may
be two children or something like that.
T h. T hi s is the eighth card.
P t. T hi s looks like a skeleton I once saw in a
biology l aboratory. (Patient tentatively tilts the
card.)
T h. Y ou can hold it upside down if you wish.
Pt. I see nothing else.
T h. T hi s is the ni nth card.
Pt. T hi s one sort of looks like a volcano.
T h. Hold it any way you wish, (pause) T hi s is the
last card.
P t. T hi s in a way reminds me of the waves on the
water where the water goes through. T hi s
looks like two crabs. T here are other undersea
fishes.
T h. Now we can tal k a bit about your problem. I
get the impression that the sexual experiences
with your brother at the age of 8 initiated a
good deal of guilt in you. Not that you might
not have felt guilty about your feelings before,
especially toward your mother and sister. \In
appraising her dynamics, it w o u l d appear that
the p a t i e n t has an overwhelming, p u n i t i v e su
perego tha t p u n i she s her f o r hostile feelings,
p ro b ab l y towa r d her sister a n d mother. She
had to repress aggression to wa r d her sister be
cause her sister was weak. H e r obsession o f
defiantly repeating Je s u s C h r i s t " serves as an
outlet f o r aggression a n d as a way o f restrain
ing her aggression. A n x i e t y results as even
m i n i m a l hostility comes th r o u g h .] Now sex
play between brothers and sisters is not too
uncommon even though you rarely hear about
it. [This is an a t t e m p t at reassurance.]
P t. I know, I learned about that as I grew up.
T h. A child has to develop some ideas about sex
uality before he or she grows up. Sexuality is
like walking. Y ou have to learn it. Our culture
is prohibitive. Sex is regarded as hideous, terri
ble until one gets married. But like any other
bodily function sex has a beginning early in
life. Obviously, your experiences di dnt do too
much damage to you because you tell me you
function well sexually now. [M o r e reassurance
is given her, p l u s the a t t e m p t to g e t her to
foc u s away f r o m an event she considers ir
reparable, thereby es tablishing the hopeless
ness o f her con di t i o n.]
Pt. But isnt it wrong?
T h. Y ou consider it wrong. Chi l dren in early life
explore the sexual area. Often there is sex play
that goes on among children within the family
or outside of the family. Y ou did nothing that
is parti cul arl y different or bad. But your reac
tion to these incidents was abnormal . Perhaps
the reason why you i nterpreted this as such a
horri bl e and terri bl e thi ng was that, pri or to
the sex-play incident, you were already sen
sitized to being bad. A terri bl e thing, a bad
person, a horri bl e person.p a u s e ) . [I am m a k
i n g a c t i v e e d u c a t i o n a l e f f o r t s t h a t , th o u g h
ai m e d at reassurance are p r o b a b l y n o t goin g to
influence her un der l yi n g g u i l t feelings. Yet I
believe this is w ha t she wa n ts to hear f r o m
me.\
P t. I want to say one thing. When I was a kid, I
was always told that I am bad and rotten and
no good, and when I was told that, I almost
coul dnt take it. I f they would say, Y ou are
pretty or nice or a good gi rl , I was always the
bad, rotten, good for nothing. [The p a t i e n t is
very emo tio na l here. H e r f a c e is f l u s h e d , her
f i s t s are clenched. There are tears in her eyes.]
T h. T hi s is exactly the sort of thi ng that I am tal k
ing about. T hat sexual experience may have
been merely grist for the mill. T hen you went
along with the religious exercises and prayers.
Y ou did this probably with a great burden on
your soul.
Pt. I did, I did. I felt I di dnt deserve to pray, that
I was a hypocrite.
T h. Y ou went along trying to absolve your guilt for
many things. But the experience proved to you
that you did a bad thing. T hat made you, in
your thoughts, a bad person. Now why do you
thi nk you prayed?
P t. I wanted to be forgiven. I wanted God to for
give me.
T h. When you made these pronouncements, these
religious pronouncements, they may have been
a sign of puri ty. But then you may have
thought, How could I pray and act holy
when I know that I am such a horri bl e, awful
and terri bl e person. T he phrase J esus Christ
seems to symbolize something for you.
P t. Y es, but when I d say it, I felt hypocritical;
then I d get defiant and spit.
T h. I t is probable that religion has many meanings
for you. What you may have felt was that only
a terri bl e person like yourself acts defiant in
prayer. But there is a sort of healthy core to
defiance too. Y ou were fighting back. [What I
am tr y in g to do with these tentative interpr eta
tions is to g i ve her some e x p l anation f o r her
sy m p t o m s to s ho w her that t h e y have a mean
ing a nd f u n c t i o n . T h i s ma y g e t her to con
centrate in later sessions on possible sources o f
her conflict rather than on h e r s y mptoms, on
her devalued self-image a n d t he notion that she
is hopelessly ill a n d b a d " because she com
m i t t e d a sexual crime. ]
P t. (e x citedly) Y ou are ri ght. I d say, I ll show
them. Who do they thi nk they are. [I decide
to utilize the p a t i e n t ' s emotion to offer her
m o r e a c t i v e i n t e r p r e t a t i o n s , r e a l i z i n g t h a t
insight at this stage has largely a placebo ef
fect. B ut I am st r i v i n g f o r a rapid relation
s h i p . ]
T h. And why shoul dnt you be aggressive and
angry when you feel put into such a terrible
position? Negated as a human being; a person
who cant act in her own ri ght. Y ou may have
felt you werent supposed to be angry, forced
to be namby-pamby, told that you were no
good. A nd then the defi ance came that
somehow got involved with the word J esus
Chri st. Perhaps you felt that J esus Chri st must
know what an awful person you felt yourself to
be. T herefore you should defy him.
Pt. Oh, yes, yes. [The p a t i e n t is q u i t e moved, w i p
ing tears f r o m her eyes. ]
T h. I t comes out of your depths, out of your deep
emotions, which indicated to you what a horri
ble, terri bl e, evil, ugly person you were. But
you coul dnt countenance this. I t went against
your own ideas of the kind of person you
wanted to be. A fear developed that people
would find out that you were really a terrible
person.
P t. What frightens me more than anythi ng else is
that everybody will know I am bad and horri
ble. (cries) But sometimes I dont feel this way.
T h. What I d like to have you do is to begin notic
ing situations where you feel yourself to be a
terri bl e person. Does this have anything to do
with people or situations, or does this all come
up from the inside at times when you feel
undermined. [/ am assigning the p a t i e n t a task
to keep h er sel f alerted f o r sources o f her
s y mptoms. ]
P t. But why am I this way?
T h. T he mechanism is probably an extremely com
plex one. I t takes many, many forms. I
recently had a girl j ust about your age who
would come up with expostulations of four-let
ter swear words that frightened her. T hi s to
her was horri bl e because the di rty words
were not spoken in her family, indeed were
forbidden. Her outbursts were an indication to
her that she was a horri bl e person. Exactly the
same thi ng you have, but using a different kind
of symbol. T he words used dont mean a thi ng
in themselves. I ts whats behind them. [Some
times the use o f an e x a m p l e o f a case with
p r o b l e m s si m i l a r to the p a t i e n t s p r o b l e m s rein
forc es an interpretation. ]
Pt. Doctor, you know something, I m beginning to
feel better, a lot better. Do you thi nk well use
hypnosis to find out things? [ T h e p a t i e n t is
obviously not go in g to g i ve up easily in her
q u es t to dig up a n d e x t e r m i n a t e det er mi n i n g
repressed m emo r i es. ]
T h. Now, I dont thi nk that you are going to find
any deep remarkable discoveries or secrets in
your past. I really do not, I believe that hyp
nosis may bring you back to your childhood
and help you experience some of the original
fears and anxieties. But a good many of your
mechanisms seem to be on the surface. Once
you absorb what has frightened you, all these
things, and realize how inconsequential these
things really are, you may find yourself living
in the present, not fearful of the past or ter
rified by the future. Once you firm up your
ideas about what is going on in you, the next
step is util i zi ng this insight in the direction of
change. Here hypnosis may be of help to you.
I t may also be able to help you control your
tension and anxiety whenever these pop up
agai n. [/ w i l l often u t i l i z e h y p n o s i s in
obsessional p a t i e n t s to help them control and
turn o f f " t heir to r t u r e d r u m in a t i o n s .[
P t. Dr. Wolberg, I was scared of coming here for
the simple reason that I thought that I would
leave this office as I have left too many or not
hear anythi ng but what I wanted to hear. I
mean it. Y ou j ust cant i magine how I feel i n
side.
T h. How do you feel inside?
P t. Oh, I f I could get rid of this thing, it would be
the greatest thi ng in the world. I so much want
to have a family and be able to be a mother
and a good wife to my husband, and not the
way I was where I coul dnt even cook di nner. I
was j ust too scared to move. I have always had
depressions, and any doctor I went to, espe
cially one I went to when I was 15, I would sit
here, and he would sit over at the desk and I
will tell him a story. He would practi cal l y fall
asleep on me. I know it is funny and every
thing, but it would hurt me so much. I would
walk out of there being the same hopeless per
son. No help, no change nothing. I di dnt
know what is going on inside of me. When it
first came on, I j ust really thought I was going
out of my mind. Y ou dont know what is hap
pening to you.
Th. What I said, does it make sense to you?
P t. Oh, yes. Y ou see, you are the first person who
has ever explained it to me, in words like this.
I always thought I was rotten, miserable,
hated by everybody else, always. I always did
have terri bl e inferiorities when I was a girl
among girls. I was the worst one there. (77m
can offer f e r t i l e f i e l d s f o r exploration later on
involving her desire to be a to mbo y a n d her i n
f e r i o r i t y f e e l i ngs about her f e m i n i n i t y .]
Th. A pparentl y, you felt undermined when you
were little. Y ou never seem to have had a
warm close rel ati onshi p with your mother.
And you had a father you coul dnt communi
cate with too well. And you felt you had no
ri ght to complain. Y ou coul dnt act normal
with your sister either. T he healthy thing
would have been to fight back, to beat the devil
out of her when she beat you, then kiss and
make up later. Y ou were apparentl y frustrated
and hamstrung. Y ou coul dnt express yourself,
and, to boot, when you wanted to pitch into
her, you were considered to be an evil, bad,
horri bl e person who did terri bl e things to a
sister who was so frail and weak. [Active i nter
pre t ati ons are made re peating the things the
p a t i e n t already knows, but with the f oc u s on
her need to repress her f ru s t r a t i o n a n d ag
gression.]
Pt. I was always the one who got hit even if we
got into fights, and afterward my sister would
tell my mother even if it wasnt my fault. I was
the one who got hit and punished and had to
say, I m sorry.
Th. So, there again, the normal impulse would
have been to express aggression to get it out of
your system, to scream at your mother, if nec
essary to fight back with your sister. So far as
sexual curiosity in childhood, there is nothing
so unusual about this. But to you these were
indices of how terri bl e you were. An awful
person. Y ou must have carted this image of
yourself around all your life, and you have had
to run away from this image because in your
opinion it was such a horri bl e thi ng to look at.
P t. Can I get over this?
Th. Y ou are still young, and if you have the desire
to do so, you should be able to get over this.
T he test I gave you seems to indicate that you
really are not too badly off, that you have
fai rl y good potenti al s. [E m p l o y i n g h e r e x
p o s u r e to the Rorschach cards as a reassuring
tool a n d as p r o p to her to w o r k i n g at her p r o b
lem]
P t. How long will I have to come? Y ou see i ts
hard for me to travel here, and besides I cant
afford it.
Th. I t is hard to say how long. Sometimes it takes
time to integrate things you l earn. Y ou have
toted this thi ng around for years and years and
years. How long will it be before you com
pletely discard it, I dont know. But if you
have the ri ght formula to work on, and if you
appl y yourself, you will gradual l y undermine
this misconception of yourself. Perhaps what
we can do is to have a few more sessions
together. I ll teach you self-relaxation so you
can control your tension and help your under
standing better. And then we will see what
happens.
P t. Can I ask another question? I told you that I
have a horri bl e fear of people knowing things
about me. We told our family doctor. T he only
thi ng the family doctor was told, what my
mother probably said was, M y daughter has
J esus C hri st runni ng around her mind, and
so on. He sent me to somebody else. Now,
when I was waiting in this psychi atri sts office
one time, I met my gi rlfriend. She j ust said
hello and that was the end of it. She said,
What are you doing here? and I said, I
was j ust going to talk to hi m. I felt awful that
she knew I was there. When thi s thi ng bothers
me, I become petrified, and I really mean
petrified, when I thi nk people you know know
about it.
Th. T hi s is part of the problem, the constant con
cern with people will know. T hey will know
what a horri bl e person you are. A gain this
is probably your guilt feeling showing in the
form of a fear that people will see the terrible
image you see in yourself. Remember you are
the one who is designing this image. \Again,
active, strong, a u th oritative i nterpr etations to
bolster her against a nxiety. I f e e l I have a
82
wor k i ng relationship with her.] I m afraid our
time is up. Would you like to see me again?
Pt. Oh, yes.
T h. When would you like to see me?
Pt. I have two more years of school before I finish.
I have decided maybe not to go to school this
coming year and maybe work this semester.
T h. Well, then, supposing I see you a few more
times, and then well discuss what to do
thereafter. Perhaps after a few times youll be
able to go on by yourself. T hen you can come
back if necessary for an occasional session.
P t. I know my husband wants to talk to you.
T here are certain things that my husband does
not know. He should know. He wants to know
if I really need it because he doesnt think
there is anything bad about me.
T h. Of course, I ll be glad to see him if this is nec
essary.
P t. And doctor, another thing, you know, the
name I used is not my real name.
T h. (laughing) I guess you felt so ashamed of your
identity that you decided to conceal yourself
under an assumed name. Which is part of the
problem, i snt it?
Pt. Y es (smiling). When shall I come back?
T h. Next week at the same time.
P t. V ery good (arises). Goodbye.
T h. Goodbye, see you next week.
The pati ent returned for three more sessions,
duri ng whi ch we made a rel axi ng tape* for
purposes of rel axi ng wi th her tensions, push
ing obsessive thoughts out of attenti on, and
rei nforci ng her i nsights. Our focus soon con
centrated on her undermi ned conception of
* T he techni que of maki ng a rel axi ng tape wi l l be found
i n Chapter 15.
hersel f and on her rel ati onshi p wi th her ol der
si ster. Her guil t feelings for her resentment
toward her mother and sister, and toward
transferenti al fi gures in her present life,
gradual l y l i fted. M omentary upsurges of
anxi ety were relieved both by her rel axi ng ex
ercises and by her rel ati ng the upsurge of
symptoms to provocative competitive inci dents
in her present envi ronment. A 5-year follow-
up i ndi cated a si gnifi cant change in her self-
i mage. A dream she sent me reflected this dif
ferent concepti on of herself.
L ast night I had two dreams. I n one I dreamt
that I was in a fashion salon looking at a full-length
oyster-white beaver coat being shown to me on a
live model. T he coat was a dupl i cate of one I had
seen yesterday on the T V show. I n the other dream
I was in a very large private home about 10 miles
from where I live. T he home belonged to a lady
psychi atri st, my psychiatrist. She had given me a
parti al physical examination (I listened to my heart)
al though I remember holding the end of the stetho
scope to myself. T he house was full of many people,
all wanti ng to see her, but they were in a party-like
mood, tal ki ng, wal ki ng around, eati ng in the
kitchen, etc. She and I were tal ki ng about my hav
ing a baby, which was fine with her. She asked me
to please bring the baby to her so that she may have
a peek at it after it was born. (I thi nk I felt the baby
would be a girl.)
Shortl y after thi s the pati ent became
pregnant. A temporary upsurge of anxi ety
brought her in for two more sessions. Fol l ow
ing the bi rth of her chil d, a bri ef peri od of
anxi ety was controll ed also wi th a l i mi ted
number of sessions.
Case 3
Some pati ents are not suited for short-term
therapy and requi re a long-term supporti ve
approach unti l sufficient motivation is de
veloped for a more producti ve type of treat
ment. Often such pati ents seek a parental type
of rel ati onshi p wi th the therapi st that
eventually, if the therapi st is not aware of
what is happeni ng nor knows how to deal
wi th the evolving si tutati on, becomes an i nter
mi nabl e sadomasochi sti c encounter traumati c
to both pati ent and therapi st. These pati ents
frequentl y refuse to accept a referral to a clinic
or a therapi st experi enced in deal i ng wi th thei r
type of probl em since therapy is not what they
want. Thi s is il l ustrated in the next i ni ti al i n
terview. The pati ent is a young single woman
who asked for an intervi ew through a l etter in
whi ch she compl ai ned of tensi on and of havi ng
troubl ed dreams. A tal l attracti ve woman
entered my office at the appoi ntment time,
somewhat aggressively seating herself in the
chai r after we i ntroduced ourselves.
Th. Would you like to tell me about your problem?
Pt. Exactly what is it you need to know so that
you know what I m doing? So you ask ques
tions and I ll try to answer.
Th. Y ou would rather have me ask questions.
Pt. I t doesnt matter, except that I thi nk you need
to know what you need to know, and since I
dont know you, I dont know what informa
tion you wish. [H e r initial responses to the in
terview are certainly unusual a n d strange.]
Th. All right. Suppose you give me a general idea
of the problem, and then we will decide the
best thing that can be done for your problem.
P t. T he problem is this. I have found that belief,
j ust belief, raises a tremendous role in the lives
of human beings. What they believe in and
how they believe; and I dont have to tell you
quote miracle cures unquote, and things of this
nature. I d like very much to know how this
operatesand how we can turn this to good
use. I d like to know very importantl y how the
subconscious mind functions because in my ex
perience this is a perfect mechanism. I t always
tells the person exactly what is right for the in
dividual. Now is this common? [Again, her
queries are strange, a n d I g e t the impression
t hat she is quite a sick person. ]
Th. Have you in your experience found that this
works for you?
P t. Works consistently for me.
Th. G ive me an example of that.
Pt. Y es, I can give you a very clear example of
that. I ts really a very funny one, too. I was
going with a young man that I liked very much
and I was trying to make up my mind, do I
like him enough to sleep with him or dont I.
A nd I seemed to need hi s affection and
warmth, and in the middle of the decision I
had a dream and the dream told me that I
would feel like a prosti tute if I slept with him.
Now this is i mportant to me, so the next day I
asked Hans. We got to tal ki ng about it, and
his first experiences. I might add he was from
Chile, a German who lived in Chile. All of the
women he had slept with were prostitutes. My
subconscious mind picked it up. And because I
was very willing to listen to my unconscious, I
found it very accurate.
Th. Well, we may be able to tal k about this specific
qual i ty, whether i ts uni que to yourself or
whether i ts a more general quality.
P t. M ore general.
Th. T hen we can discuss it in terms of whether it
can be put to some constructive use, as you
say.
P t. Well, for me individually, I put it to use all the
time, {pause)
Th. I s that so?
Pt. Oh yes, always.
Th. How? Do you ask yourself questions? How do
you do this?
Pt. A problem is there, for example. Y ou are in
the middle attempti ng to find a solution. I find
the best way is to lie down and relax com
pletely. A nd I use a very funny expression, I
will to will the will of God, which makes me
relax. Which is very, very good for me. And in
this kind of state of suspended animation,
which I suspect is a form of hypnosis, the an
swer to the problem will come to me.
Th. I t will come to you almost like i nspi rati on?
P t. Not like an inspi rati on, but like a feeling.
Th. A kind of feeling. Do you get the impression
that it comes from the outside world?
Pt. No, I do not. Sometimes when I dont like
whats coming out, I stop it you see.
Th. What comes out?
P t. Oh, I dont know, maybe I kind of have a
propensity of making one choice, and another
one is poking i ts nose in. I have the im
pression of a double layer in my mind, of a
thought coming up through. T hi s may be an
associating issue with Freud, however. I ve
had this sensation long before I ever knew
Freud and his theories or anythi ng about him.
I ts a physical feeling.
Th. I see. Now I d like to have you tell me some
thi ng about your problems, the things that
really bother you and upset you. [Now that the
p a t i e n t is beginning to talk more f r e e l y , I
84
believe 1 can be more dema n d i n g o f her to tell
me about her real problems. ]
P t. Y ou mean as an individual?
Th. As a person, yes.
P t. T hat is what I want to do, 1 believe two main
problems. I am unfortunately afflicted with
very bad feet, which throws my spine out of
balancecompletelywhich keeps me a little
tired all of the time. I deeply resent this. I t also
makes me a little nervous and always gives me
a consciousness of being tied to my body,
which in my case is a very bad thi ng because
I m very tall. And so I become conscious about
being tall and have a sense of being different.
T wo, I find it very difficult to believe that I m
an acceptable individual to other people. Now,
there is no basis for this, except that I some
times do very foolish and clumsy things. But
these are derived from the feeling itself and not
from anythi ng inherent in me.
Th. I see.
P t. T hi s is a block that I would like very much to
get over.
Th. What about your self-confidence? Do you feel
confident?
P t. No, I dont.
Th. No confidence at all?
P t. No. I wont say exactly no confidence. I ts a
very funny thing. When I m alone, and when
I m working, and when I m doing something I
like to do, I have a very basic self-confidence. I
thi nk so more than most people. I know I m
ri ght. I ve actually made very few mistakes in
my life in terms of j udgment and in terms of
what I wanted to do. I t always seems to
somehow work out, but that doesnt mean that
other people will accept my personality. And
you see I want to be accepted.
Th. I see. Now to get back to the business about
your belief, that is, your feeling that you are
not acceptable.
P t. I thi nk I can give you the reasons for this.
One, my father is a paranoiac. T hi s problem I
thi nk managed to solve, but you can imagine
his possessive love, and my rejection of this
overdomination and of his heavy-handed way
of handl i ng people and supersensitivity. So you
reject it, and consequently it i snt nice to reject
father, so you dont like yourself. T wo, I di dnt
like my sister arriving at the time she arrived.
T hree, my fi rst experi ences wi th young
playmates were very unfortunate. Now, I dont
Th
Pt.
Th
Pt.
Th
Pt.
Th
Pt.
Th
Pt.
Th
Pt.
Th
Pt.
Th
Pt.
Th
Pt.
Th
Pt.
Th
Pt.
remember this, but my mother tells me, I re
member l ater when I had a reaction si mi l ar to
that. T he first girl I played wi th I thi nk was
about 2 and mother said if she di dnt watch,
I would come runni ng into the house j ust black
and blue because if I wanted something and we
were shari ng something or it was my turn or
something and M ary di dnt like the idea, she
j ust simply beat me up. I still cant be put
against a wall. Now, these are things I m
pretty well adjusted to.
And in your life situation have you adjusted?
Have you gotten along fairly well all through
childhood?
No, no.
Tel l me something about that.
M y whole history as an individual, and in con
tact with other people, has been one of strai n,
tension, of shyness and mal adj ustment. Now
I m reaching the point where this is no longer
true. As a matter of fact, a few years ago I
went through pretty thorough therapy and got
qui te an understandi ng of it.
Oh, is that so?
But it doesnt relieve the shyness, you see.
Who were you treated by?
He was a doctor and they provided this service
for students, and I went through the whole
business with the Rorschachs and the I Q tests
and things like that.
A nd did you get any therapy?
I t was therapy.
How many times a week did you go?
I went twice a week for 6 months.
Did you find out much about yourself?
Nothi ng I di dnt know before.
I see, but it did help you?
I t helped because I liked the doctor, and I had
the sense that he liked me, and that someone
who is intelligent as well as likable would like
me is something I needed very badly.
I see, you went through college, and what do
you do now?
I m a secretary. T hi s is a long sad story, this
business of my occupation. I dont really work
very well for other people.
I s that so? What are your goals?
T hi s is the whole point. I began in theater as
an actress, and I might add I was a very good
actress.
Oh, is that so?
But I am too tall and consequently I di dnt get
the parts I wanted. I coul dnt get them. T here
were no leading men for me. T hey di dnt ex
plain this to me. No one helped; no one took
the time to say, L ook, youre j ust too tall,
dont try. T hey j ust di dnt say anythi ng, and
let me go on and my basic lack of confidence
increased, you see, so that I had nothing left. I
turned to writing, and I m very good at this.
T h. I see.
Pt. But I have a terrific block against writing. I
can tell you this too. I know these thi ngsand
this is the i rri tati ng point. As a child I was
9 I wrote a story about a dog and a little boy
who found the dog, and he loved the dog, and
he coul dnt keep the dog. He had run away
from home. And I remember he went down to
the rai l road tracks or something. I t was a very
complicated and ridiculous childish story. And
my father who thought he could write, and
probably could have at one time, tore it to
shreds. I never got over it quite.
T h. I s that so?
Pt. I ts this rejection you see. Now I understand
his ego couldnt let him say it was all right to a
9-year-old child. He had to prove himself as
being stronger and criticizing. I t doesnt help
the reaction.
T h. Now, I m going to ask you a few questions
rather rapidly. How old are you?
P t. T wenty-nine.
T h. Ever married?
P t. No.
T h. How about tension, do you feel tense?
P t. V ery much.
T h. A good deal of tension?
T h. What about depression?
P t. A week before my period every month. T hi s is
chemical. I feel this coming on.
T h. Y es. What about physical symptoms?
P t. M y back, spondylitis.
T h. Any fatigue or exhaustion?
Pt. M i l d anemia also.
T h. Any headaches?
P t. V ery seldom.
T h. Dizziness?
P t. No
T h. Stomach trouble?
Pt. No.
T h. Would you say you had any sexual problem?
Pt. Some inhibition, unless I know the man ex
tremely well. I m j ust not a casual person.
T h. Yes.
P t. I j ust have to know people a long time. T hen
there is no problem. When I feel accepted, I
have no difficulty.
T h. What about phobias?
P t. None that I can thi nk of.
T h. Any thoughts that come into your mind that
torture you or bother you?
P t. One, and this is the story of the cat-mouses.
T h. T el l me about the cat-mouses.
Pt. T he cat-mouses. Well, I tried to do something,
and it di dnt work very well. I m paying off a
rather large-sized penality for it. T he cat-
mouses are distorted children. T hey are, as
you notice, part mouse and part cat. And so
the first time I had the dream I sensed what it
was and I di dnt like it, so I turned it into a
whimsical thi ng I could like.
T h. I n the dream?
P t. No, no after, and so l ater my subconscious
kept telling me, apparentl y I disliked what
happened. T he story is a very badly handled
aborti on I had, and I mean badly handled, it
was j ust awful.
T h. I s that so?
P t. And so you see the rel ati onshi p, and this is the
story, and this thing occasionally pops up,
under certai n temperature condi ti ons, and
sometimes j ust before my period when there
are cramps and I feel tight. I t is the same
physical feeling as duri ng the operation.
T h. I see. Was the operati on done by a person who
is competent at all?
P t. By an excellent doctor. T he thing that went
wrong was that I had had several shots before
then in order to avoid the operati on itself. So
the fetus had shifted, and the doctor who did
the operati on thought it was a polyp and
di dnt touch it so consequently two days l ater on
a trai n going home, I went into violent labor
pains. A nd that was when it actually oc
curredand that was j ust a messy mess.
T h. Did you see the fetus?
P t. Y es, which is the unfortunate part you see. I f I
had not, I thi nk it would have been better.
T h. I t looked like a cat-mouse?
P t. I t did not. I t looked like a chicken heart.
T h. L ike a chicken heart.
P t. U h-huh, exactly.
T h. How many months pregnant were you?
P t. I d say 6 weeks, a little over.
T h. Well, that isnt too long.
P t. Oh, no.
T h. Well, l ets talk about those cat-mouses a little
more. Give me an idea of what the dreams
were.
Pt. T he dreams all have three things in common
heatthe sensation of bodily heat. T hats why
I have them more often in summer. I ts very
hot, water, a thi ng of being in water or near
water, or surrounded by water, and distorted
animals, peculiar animals, I mean. Some of
them are very charmi ng and very whimsical.
And in one I remember I had absolutely to get
rid of the animals. I had to kill them, and it
woke me up because I coul dnt.
T h. Y ou coul dnt?
P t. I j ust coul dnt. I j ust absolutely coul dnt touch
the animals.
T h. T hese cat-mouses, are there many in the
dream or j ust one?
P t. Oh, they change; theyre not always a cat-
mouse. T hi s is j ust the name I ve given to the
creature that evolved through this. T hey can
be anything, but they are always combinations.
T h. But the cat-mouses symbol itself?
P t. Call it a cat-mouse symbol.
T h. Cat-mouse symbol, can you describe it? How
big is it?
P t. T i ny, theyre always very small, theyre al
ways little.
T h. T he body what does it look like?
P t. L ike a mouse.
T h. A nd the cat?
Pt. T he original one was like a cata cats head
and a mouses body.
T h. And they would shift?
P t. Well, to a dog-fish now.
T h. A dog-fish now?
P t. Well, the cat-mouses are people with whimsy
and who can understand whimsy and who
have a sense of humor, and dog-fishes are j ust
dull people.
T h. I see.
P t. T hi s I ve done, and written some very charm
ing little pieces which I wish I could turn into
some money if I could.
T h. How do you feel? Do you thi nk about these
cat-mouse symbols a good deal?
P t. No, as a matter of fact I dont.
T h. T hey dont bother you?
Pt. No.
T h. Y ou seem to be rather preoccupied about that
in the l etter you sent me.
P t. I did that because ofi ts kind of a trick. I
shoul dnt have done it. A mong other things I
wri te advertising copy. I ts my business to i n
terest people, so I use tricks because people are
attracted by this sort of whimsical thing.
T h. I see, it i snt really a problem then.
Pt. I t i snt really a problem.
T h. All ri ght, fine, now?
P t. I ts a little unpl easant. I t i snt a problem;
theyll go away.
T h. Y ou have anxiety in your dreams with this
symbol?
P t. I dont know if i ts anxiety or not. I ts j ust a
form of tension and a form of anxiety of being
forced to do something I dont want to do. A
very obvious reason. T he aborti on, it was very
painful and very unpleasant.
T h. T hi s symbol only occurred after the aborti on?
Pt. I ve never had it before. Never.
T h. And you feel very well satisfied that this is the
basis of this?
P t. I t clicked over, if you understand this ex
pression. I t felt right.
T h. Now, do you have any insomnia?
P t. No, I can put myself to sleep instantly.
T h. Good, What about ni ghtmares?
Pt. Onl y this. However, I never have this except
when I m taking a nap. I dont have this at
night.
T h. Onl y duri ng the day.
P t. But i ts likely to be warm, and I ll be dressed
and lying down.
T h. OK . Now, tell me a little bit about your
mother and your father. A re they living?
P t. T hey are. I t would be such a story.
T h. What sort of people are they?
P t. M y father is a very intelligent man. As a child
I remember hi m bei ng a very wonderful
manand he adored children. He still does,
but he is a paranoi ac. I dont mean a paranoi a
personal i ty, I mean a psychosis paranoi ac. He
is also an alcoholic.
T h. How did he rel ate to you? Was he close?
P t. As a child, very close. We were very, very
close.
T h. Did you really love him?
P t. Deeply, I still do. T hi s presents a problem.
I ve been unable to solve it because his whole
personality structure is so obnoxious to me that
I have had to split it off. And to love the man,
the individual, the things underneath, and
87
what I know is there and avoid the personality
as if it were the pl ague. T o watch the
degeneration of a mind and a human being is
not a pleasant thi ng for a child.
T h. I should say not, even as a child he was
degenerating then.
Pt. I began to pick it up about 9. T hats when he
started to drink. T hats when a lot of the trou
ble began, and we were never happy since.
T h. How about your mother? What sort of person
is she?
Pt. M y mother is also two people. She is the per
son she was 10 years ago, and the person she is
now; she is was a very stable persona
beautiful woman.
T h. How did you get along with her?
Pt. Wonderful l y, j ust wonderful l y. Oh, we
scrapped a little bit, but with that kind of a
family if we get mad, we say something. I
mean mother threw plates and I stomped out
of the house, but it never meant anythi ng. I
mean there was never any grudges held
overshadowing, long tension periods.
T h. Do you have any brothers and sisters?
Pt. I have a younger brother and younger sister.
T h. How young?
Pt. M y younger sister is 2 years youngershe is
married and has two children. M arri ed a man
j ust like my father who is also an alcoholic. So
she refuses to stay marri ed, and as long as
theyre divorced and live together, life is fine.
She attempted to commit suicide. T hi s proba
bly is due to a brai n injury. She has been sick
all of her life. M y brother is 19, is sensitive
and i ntel l i gent, terri bl y depressed and i n
hibited. 1should say basically j ust a fine boy.
T h. As a child did you have any emotional upsets
that you remember?
Pt. I di dnt remember a day when I di dnt have
any.
T h. What form did those emotional upsets take?
By emotional upsets do you mean tantrums or
outbreaks?
Pt. Outbreaks or nervousness. It was a repression.
I always felt pushed into a corner and forced
off, and my only freedom was when I was by
myself and living in daydreams essentially.
T h. And your previous treatment, any sort of treat
ment pri or to seeing the college doctor?
Pt. None.
T h. T aki ng any medicines or tranqui li zers?
P t. None.
T h. Now, I m going to show you the Rorschach
cards rather rapidly.
P t. Oh, I ve had that (laughing).
T h. I know. J ust to give me an idea.
P t. T he last time it took me 3 hours.
T h. I t will take j ust about 5 minutes with me. (/
h a n d her the f i r s t card.)
P t. M ountains, crab, sea crabs, woman praying,
these are the most pronounced.
T h. All ri ght. T hi s is the second one.
Pt. Bears, two little bears, teddy bears, I always
have to thi nk this is a temple, the white part in
the center. And I associate, the orange part
with menstruati onblood.
T h. All right. T hi s is the thi rd card.
P t. Oh, I remember these, these are my little can
nibal women. T hey are cooking, the little guy
who sits in the two corners here, {fourth card)
T wo tired birds sitting back to back. T hey are
very tired, (fifth card) I associate that with the
beer belly, a vegetable, and I cannot trace it.
T he top is a sol di ers helmet. Women chiefly
women, probably nursi ng or able to nurse and
somehow associated with children in this case.
T h. T hi s is the sixth one.
P t. Navaho rugs, bear rugs, I have a sensation of
wings.
T h. Where do you see the wings there?
P t. T he whole outside, the feathers, and the shape
of it. (seventh card) T hese are the children.
I m remembering, by the way, some reac
tions from before. L ittl e children, facing one
another, in kind of a ballet dancers pose, this
way. (eighth card) T hi s is the most, I can take
it apart more. T hi s one I remember liking. I ts
the colors; i ts a weird combination here, it has
a kind of offbeat like j azz music, the orange
and the pink. I t has a watery feeling to me.
T hese are the polar bears over here, very
strongly shaped. A nimals of sorts around a
wheel, sort of distorted pattern. I noticed
something. I m sort of attracted to the animal
world.
T h. U h-huh. T hi s is the ni nth one.
P t. T hi s is the one I di dnt like. Because i ts
messy, very messy, because it reminds me of
violence and insects, and this is something I
dislike.
T h. Violence, insects.
P t. When people are rough and vicious in a way.
Th. Do you see anythi ng else there? . . . Y ou can
hold it anyway you wish. . . . All ri ght, this is
the last one.
Pt. Chi l dren that are like sea horses, and again
slightly hysterical modern art. I like this one.
Now I get an Eiffel T ower impression from
this immediately, which I automatically switch
over into a preferred symbol. And this is the
feeling I have. T hi s one is good, somehow,
even though it seems discordant and discon
nected. I t has a coherence of warmth and good
feeling that comes sometimes with good things.
[ T h e d i s o r g a n i z a t i o n o f t h o u g h t a n d t he
int en si t y o f f e e l i n g in the last three cards p o i n t
to a sc hizop hre nifo r m- lik e tendency . ]
Th. A good feeling?
P t. Playful is the word I want.
Th. Now, I have a little better idea of the problem
than I did before. So very rapi dl y I m j ust go
ing to give you my ideas, but I may not be
absolutely accurate and I want you then to tell
me your impressions. \In p r e s e n t i n g interpr eta
tions to the p a t i e n t or in g i v i n g her a h y p o t h
esis o f the probl e m, I mus t be careful that she
does not regard w ha t I say as an attack, or as
being critical o f her. She has already told me
that wh a t she seeks f r o m me is approv al and
support. ]
Th. Now, you are an extremely sensitive and crea
tive person. Y ou have a great many talents and
the ability to perceive nuances and to arrive
very rapi dl y to intuitive feelings. T hats be
cause you live very close to your unconscious.
Y ou have a remarkable facility in that direc
tion. T here are people who do and people who
dont. Y ou j ust seem to have this facility. For
that reason many of the phenomena that are
ordi nari l y repressed and are not ordi nari l y
perceived are available to you. So, you can be
come aware of many symbols the average per
son overlooks. Y ou can also be influenced by
your unconscious. Y ou then can pose questions
to your unconscious and get the answers. Now
this is not average. I d say most people cannot
do this.
P t. T hen you see my i nterest in thi s field because
I m aware of this. I ll tell you something else
that might interest you. I f I tal k to someone for
2 hours and let them tal k to me, I can tell you
which parent has caused the trouble in the per
sonj ust instinctively.
Th. I s that so. Y ou would also be very good in ana
l yzing dreams, anal yzi ng the unconscious.
P t. So i ts unbelievable. Aside from myself, as long
as I dont thi nk about it.
Th. So you do have thi s facility, but this very
facility can create problems for you.
P t. Y es, it does.
Th. Y oure extremely sensitive, too sensitive. Y ou
feel slights, you get very tense, you are j ust like
a weather vane. Y ou j ust swing with the wind,
and because of that, you may need some sort of
help. Now, I would thi nk that you could do
very well with therapy maybe not too i nten
sive therapy but seeing someone about once
weekly.
P t. J ust to study it out.
Th. Somebody that would stabilize you and would
enable you to get some stabil i ty because youre
too much like a weather vane.
Pt. I know, it would drive me wild, you see, and
thats part of thi s whole thing. I ve gotten
track of this idea of using hypnosis as a form of
research; now, I m not adverse to working on
myself. I dont mean to use it as an easy way
out. I work awfully hard for everything I ve
ever had, and I dont mind. I even enjoy it, I
have a feeling now of getting something thats
going to mean enough to steady me down.
Th. I m sure that you could utilize hypnosis very
effectively.
P t. I m very good at it, by the way.
Th. A re you?
Pt. I ve done a little bit of it, j ust enough, and if I
use my eyes it works like a charm. I j ust go
ri ght out.
Th. Y ou can certainly uti l i tze your facility in a
very appropri ate way. As far as youre con
cerned, I dont thi nk hypnosis is absolutely
necessary. I t woul dnt make too much differ
ence as far as your getting something beneficial
out of therapy.
P t. T hat wasnt the point. (la u g h i n g )
Th. Y ou understand what I mean?
P t. Y es, I know what you mean.
Th. So were tal ki ng in two different frames of ref
erences: hypnosis is one thing and also you as
a person in terms of your capacity to get
something meaningful out of other kinds of
therapy. As a matter of fact, I dont thi nk hyp
nosis would be the best thi ng for you. Y ou are
too immersed in your unconscious now, and it
89
would be much better for you to stabilize and
build up a little more repression so that you
are not being bombarded all the time by your
unconscious. |M y f e e l i n g is that the p a t i e n t
w oul d ut ilize hypnosis to s t i r up too many
f a n t a s i e s a n d in t hi s w a y w o u l d f r i g h t e n
herself. ]
Pt. Well, you know that was part of the idea.
Th. Now, I thi nk that you probably would do well
in therapy with somebody to whom you could
come on a once-a-week basis to talk things
over. Y oull feel an anchorage there. A nd in
that reference I may be able to refer you to
somebody who may be able to help you.
Pt. Because this costs money and this 1dont have
and you see I m really in a corner on this fi
nancial business.
Th. T hats one of the things I might be able to help
you with by arranging for therapy in terms of
your budget and in terms of your own ability
to pay whatever you can. T here are places in
the city where you can receive some good help.
Pt. I dont need that kind of help. I need a father,
Dr. Wolberg. No, this is true, I need some
body that is very strong, and very stable and
wont laugh at me when I get off on one of my
tangents. \ T h e p a t i e n t is obviously s e eking a
p ro l o n g e d s uppor tive relationship, which is
p r o b a b l y al l she can use at this time. She is
q u i t e close to a s c hizophre nic break, in my
opinion, b u t she st i l l has g o o d defenses, and
might, i f she is motivated, benefit f r o m the
p r o p e r ty p e o f t re atm e nt a n d p e r h a p s some
m i l d neuroleptic. 1 have in m i n d referring her
to a h ospital clinic whe re she could receive
g oo d therapy. ]
Th. Well, give me an idea of what you can afford,
approxi matel y.
Pt. Gee, i ts so awfully tight that even something
as little as $10 a week would be too much.
T hat I could make, I could manage this.
Th. All ri ght, I thi nk I can find somebody for you
at one of the clinics. I shall tel ephone him this
afternoon and let you know.
Pt. All right.
The pati ent was referred to the head of a
cli nic in the nei ghborhood, whom I tel ephoned
and i nformed about her probl em. T he clinic
was will ing to take her, but the pati ent never
accepted the referral . A tel ephone call from me
to her was never returned.
CHAPTER 7
Choosing an Immediate Focus
Many pati ents come to therapy convinced
that thei r probl ems were brought about by
some preci pi tati ng factor in thei r envi ronment.
An alcoholic husband, a di sastrous i nvestment,
a broken love affair, a serious acci dent, these
and many other real or exaggerated cal ami ti es
may be bl amed. What peopl e usual l y want
from treatment is hel p in getti ng rid of pai nful
or disabli ng symptoms that are often ascribed
to such offensive events. The symptoms incl ude
anxi ety, depressi on, phobi as, i nsomni a, sexual
difficulties, obsessions, physi cal probl ems for
whi ch no organi c cause can be found, and a
great many other compl ai nts and afflictions.
Even though we may be correct in our
assumpti on that the basi c troubl es resi de
el sewhere than in envi ronmental or sympto
mati c compl ai nts, to bypass the pati ents i m
medi ate concerns is a serious mi stake. L ater
when there is fi rm evidence of the underl yi ng
causes, for exampl e, faul ty personal i ty oper
ati ons or unconsci ous conflict, a good i nter
viewer shoul d be able to make connections be
tween the preci pi tati ng events or exi sti ng
symptoms and the less apparent dynami c
sources of difficulty. There will then occur a
change in focus. Thi s shift, however desi rabl e
it may seem, is not al ways necessary because
we may find that our objectives are reached,
and that the pati ent achieves stabi l i zati on,
wi thout del vi ng i nto corrosi ve confl i cts or
sti rri ng up ghosts of the past. I t is onl y where
goals go beyond symptom rel ief or behavi oral
i mprovement that we will, in the hope of
ini ti ati ng some deeper personal i ty al terati ons,
del ve into dynami c probl em areas. Even where
the objective is mere symptom relief or be
havi oral i mprovement, resistance to si mpl e
supporti ve and reeducati ve tactics may ne
cessitate a serious look at underl yi ng per
sonal i ty factors that are sti rri ng up obstructi ve
transference and other interferences to change.
I n practi cal l y all pati ents some i mmedi ate
stress si tuati on, usual l y one wi th whi ch the i n
divi dual is unabl e to cope, sparks the decision
to get help. Usual l y the pati ent consi ders
hi msel f to be the victim rather than perpetra
tor of his identified troubl es. Thi s, in some
cases, may be true; in most cases it is false. I t
is necessary, therefore, in all pati ents to ap
prai se the degree of personal parti ci pati on in
thei r difficulties.
Since we are actual l y deal i ng wi th si tuati ons
that generate tensi on and anxi ety, it is
essenti al to vi ew envi ronmental i nci dents
through the lens of thei r special meani ng for
the i ndi vi dual . What may for one person con
stitute an i nsurmountabl e difficulty may for
another be a boon to adj ustment. Duri ng
Worl d War I I , for instance, the L ondon bomb
ings for some citizens were shatteri ng assaul ts
on emoti onal wel l -bei ng; for others they
brought forth l atent prompti ngs of cooper
ati on, brotherl i ness, and self-sacrifice that lent
a new and more constructi ve meani ng to the
i ndi vi dual s existence. I ndeed, warti me wi th its
threat to life marshal l ed an interest in survival
and subdued neuroti c mal adj ustment, whi ch
returned in peaceti me to pl ague the i ndi vi dual .
The understandi ng of stress necessitates ac
knowl edgi ng that there is no objective measure
of it. One cannot say that such and such an en
vi ronment is, for the average adul t, 70 percent
stressful and 30 percent nurturant. No matter
90
CHOOSING AN IMMEDIATE FOCUS 91
how benevolent or stressful the envi ronment,
the i ndi vidual will i mpart to it a speci al mean
ing as it is fi ltered through his conceptual net
work. Thi s shades his worl d wi th a signifi
cance that is l argely subj ective. Conceptual di s
torti ons parti cul arl y twi st feel i ngs toward
other human beings and especiall y toward the
self. A self-image that is hateful or i nadequate
may pl ague the indi vi dual the remai nder of his
life and causes hi m to i nterpret most happen
ings in rel ati on to his feelings that he does not
have much value. Most of what happens to
hi m in life will be viewed as confi rmi ng his
own conviction that he is not much good and
that nothi ng that he does will amount to
anythi ng. Such a pervasive belief, of course,
makes nearl y any occurrence producti ve of
consi derabl e stress.
Wi th this as an i ntroducti on, it may be
asserted that there is such a thi ng as real istic
envi ronmental stress:
1. The env i r onm e n t may expose the i n d i vidual to
grave threats in the form of genuine dangers to life
and to security. Examples are exposure to disasters
such as war, floods, storms, and accidents as well as
severe deprivation of fundamental needs for food,
shelter, love, recognition, and other biological and
social urges engendered by a cruel or barren envi
ronment.
2. The envi r onment may be p a r t i a l l y inimical,
the individual not having the resources to rectify it.
T he environment may be beneficent enough, but the
individual, perhaps through early formative experi
ences, never developed the ability to use those
resources that were potentially available.
3. The env i r onm e n t may contain all elements
essential f o r a good adjustme nt, yet the individual
may, as has been cited, be unable to take advantage
of it because of a personality structure that makes
him experience essential needs as provocative of
danger. Such defects may cause him to proje ct out
into the e nvir onment his i nn e r dissatisfactions, a n d
he m a \ actually create circumstances that bring
upon h i m s e l f the very hazards f r o m which he seeks
escape.
Some persons i nvari abl y regard thei r envi
ronment as one in whi ch thei r asserti veness
bri ngs puni shment. They are commonl y re
ferred to as l osers. A pati ent of mi ne con
stantl y woul d invol ve hi msel f wi th fi nancial i n
vestments that al most i nevi tabl y woul d turn
out to be less than profi tabl e. He woul d then
react wi th depressi on, rage, and shattered self
esteem. Yet no sooner woul d he accumul ate
any surpl us of funds, then he woul d agai n
pl unge into fanciful schemes that ended in
disaster. I t was onl y after we had exposed his
i nner need to fail that he woul d recogni ze how
he brought his troubl es on himself. For a whi l e
it was wi th the greatest effort that he
restrai ned hi msel f from i ndul gi ng in wi l dcat
gambl es. I felt that had he not needed to an
swer to me, he still woul d have taken i mpossi
ble risks.
Character di storti ons engendered by defects
in devel opment, such as extreme dependency,
detachment, aggressi on, masochi sm, perfec
ti oni sm, or compul si ve ambi ti ousness, are what
usual l y prevent the i ndi vi dual from fulfilling
hi msel f and taki ng advantage of envi ronmental
opportuni ti es. They make for the creati on of
abnormal goals and values that may seriousl y
i nterfere wi th adj ustment and that act as
sources of stress irrespective of the envi ronment.
I t is rare then that envi ronmental stress
al one is the sole cul pri t in any emoti onal prob
lem. I ni mi cal , fri ghteni ng, and desperate si tua
ti ons do ari se in the lives of people, but the
reactions of the indi vi dual to happeni ngs are
what determi ne thei r pathol ogi cal potenti al .
Under these ci rcumstances mi nor envi ronmen
tal stress can tax copi ng capaci ties and break
down defenses so that an eventuati ng anxi ety
will promote regressive devices like protecti ve
phobi as. I t is, therefore, essential that any
preci pi tati ng inci dent that bri ngs a pati ent into
therapy be regarded as merel y one el ement in
an assembl y of etiological factors, the most i m
portant vari abl e bei ng the degree of flexibili ty
and i ntegri ty of the personal i ty structure. I t is
thi s vari abl e that determi nes a harmoni ous i n
teracti on of forces that power i ntrapsychi c
mechani sms when security and self-esteem are
threatened by adversi ty from the outsi de and
by common devel opmental crises that impose
themselves from wi thi n. By focusing on what is
regarded as a preci pi tati ng inci dent we may be
abl e not onl y to ini ti ate remedi abl e envi ron
mental correcti ons but al so to open a wi ndow
into hi dden personal i ty resources.
From a practical vi ewpoi nt therefore, any
envi ronmental stress warrants close exami na
ti on for its influence, good or bad, on the pa
ti ent. An understandi ng of the how and why of
its i mpact may prove i nval uabl e. Someti mes
the i ni ti ati ng factor may seem like a trivi al
spark to the therapi st, but an expl orati on of
the pati ents past history, his atti tudes, and his
values may reveal the emoti onal explosive mi x
ture that awai ts detonati on.
Focusing on Symptoms
Because symptoms are frequentl y a by
product of stress, tension, and anxiety, it may
be helpful to exami ne thei r devel opment and
meani ng wi thi n the matri x of adaptati on. As
long as a person is capabl e of copi ng wi th his
current life si tuati on, as l ong as he can gratify
his most i mportant needs and dispose of others
that he is unabl e to satisfy, as long as he can
sustai n a sense of security and self-esteem, and
as long as he is abl e to medi ate troubl es that
vex hi m, he will not experi ence stress beyond
the poi nt of adapti ve balance. When, however,
thi s is not possible, the threat is regi stered as a
state of tension, wi th al tered homeostasi s af
fecting the viscera, the skeletal muscles, and
the psychic apparatus. T he person mobi li zes
hi msel f to cope wi th the stress and if he is suc
cessful, homeostasi s is restored. When attempts
at adaptati on keep faili ng, the conti nui ng pres
ence of tension in turn sabotages the devel op
ment of more effective coping patterns.
Oversti mul ati on resul ti ng from continued
stress is bound to regi ster its effect on the
bodil y i ntegri ty ( exhausti on reacti on ). Bom
bardment of the viscera wi th stimuli will tend
after a whi l e organi cal l y to di sturb the func
ti ons of the vari ous organs and systems. To
such ensui ng di sturbances Selye (1950) has
given the name disease of adaptati on. As i n
si dious as are the physi cal effects of tension,
the devel opment of a castastrophi c sense of
helplessness produces the more di sturbi ng phe
nomenon of anxi ety. And it is often anxi ety
that bri ngs the pati ent to therapy.
Anxiety and Its Defenses
A vast amount of human psychopathol ogy is
covered by the generi c term anxiety. I t is
characteri zed by a viol ent biochemical and
neurophysi ol ogi cal reacti on that di srupts the
physi cal, intel l ectual , emoti onal , and behav
ioral functi ons of the i ndi vi dual . I t is indicati ve
of a coll apse of a persons habi tual security
structure and his successful means of adapta
ti on. So uncomfortabl e are its effects that the i n
divi dual attempts to escape from it through
vari ous maneuvers. These are usual l y self-de
feating because those very maneuvers are often
regressive in naturethat is, they revive out
moded chil dish ways of deal i ng wi th discomfort.
They onl y further i nterefere wi th asserti ve and
producti ve coordi nati ons.
Where anxi ety is uncontrol l ed, an actual
return to infanti l e helpl essness wi th compl ete
loss of mastery may threaten. Real i ty testi ng
may totall y di si ntegrate, endi ng in confusion,
depersonal i zati on, an i nabi l i ty to l ocate the
li mbs in space, i ncoordi nati on, and loss of ca
pacity to differenti ate the me from the not
me. Thi s threat to i ntegri ty may ini ti ate
parent-i nvoki ng tactics rangi ng from qui et
searchi ng for support to screami ng, tantrums,
bewi l dered cri es for help, and fai nti ng. Such
compl ete rel apse to infancy is rare, occurri ng
only in i ndi vi dual s wi th fragile personal i ty
structures.
Anxi ety does not al ways have to be harmful .
As a matter of fact, some anxi ety is an adap
tive necessity; its rel ease acts as a si gnal to
alert the indi vi dual and to prepare hi m for
emergency acti on. Smal l amounts of anxi ety
sponsor somati c and visceral reacti ons that
lead to attack or flight. Anxi ety even facili tates
informati on processing in the forebrai n. The
physi ol ogi cal and bi ochemi cal patterns of
anxi ety are i nnate in the organi sm. I ts psy
chologi cal i ngredi ents are uni que to the experi
ences and condi ti oni ng of the i ndi vi dual .
These, consti tuti ng the security apparatus, are
organi zed to reduce and to remove threats to
the i ntegri ty and safety of the i ndi vidual .
The signal of anxi ety, therefore, acti vates
adapti ve reserves sti mul ati ng somati c and psy
chol ogi cal mechani sms to prepare for an
emergency. The indi vidual l earns to react to
mi ni mal cues of anxi ety wi th a constructi ve de
fensive reaction that dispels the anxi ety and
perhaps el i mi nates its source. But where the
defenses fa i l to operate, anxiety can reach a
pitch where it cannot be dispelled. Somati c
reactions of a diffuse, undi fferenti ated, and
destructi ve nature then flood the body. Psy
chol ogi cal responses become di sorgani zed.
Regressed, chil dish ki nds of behavi or, whi ch
solve little toward handl i ng an adul t anxi ety
si tuati on, may then emerge. Because the i ndi
vidual cannot cope wi th i ntense anxi ety, he
may want someone to take over for him.
What general l y shatters the defenses of the
person so that he responds wi th gl obal
anxi ety? The provocative agent may be any ex
ternal danger or i nternal conflict, recogni zed
or unrecogni zed, that di sorgani zes the i ndi
vi dual s real ity sense, crushes his securi ty and
self-esteem beyond medi ati on, and fills hi m
wi th a catastrophi c sense of helpl essness to a
poi nt where he cannot stabil ize himself. I t is
the meaning to the indi vi dual of an experi ence
or a conflict that is the fundamental cri teri on
as to whether he will respond wi th uncon
troll able anxiety.
Let us proceed wi th exami nati on of the
physiological and psychological mani festati ons
of the i ndi vi dual sufferi ng from extreme
anxiety since these may be chosen as a focus in
therapy.
Fi rst, there is a vast undi fferenti ated, expl o
sive di scharge of tension whi ch di sorgani zes
the physi ologi cal rhythm of every organ and
tissue in the body, i ncl udi ng muscul ar, gl an
dul ar, cardi ovascul ar, gastroi ntesti nal , ge
ni touri nary, and special senses. L ong con
ti nued excitati ons may produce psychosomati c
di sorders and ul ti matel y even irreversi bl e or
ganic changes. Thus, what starts out as a
gastric di sorder may turn into a stomach ulcer;
bowel i rri tabi l i ty may become a colitis; hyper
tension may resul t in cardi ac illness, and so on.
Second, there is a preci pi tati on of cata
strophi c feelings of helpl essness, insecurity,
and deval uated self-esteem. T he victim often
voices fears of fatal physi cal illness, like cancer
or heart disease or brai n tumor, as i nterpreta
ti ons of the pecul i ar somati c sensati ons or
symptoms that are being rel eased by anxiety.
Thi rd, there is a weari ng down of re
pressi ons to the poi nt where they become
paper thi n in certai n areas. Consequentl y, a
breakthrough of repudi ated thoughts, feelings,
and i mpul ses, ordi nari l y control l abl e, now
may occur at random. These outbursts further
undermi ne securi ty and produce a fear of being
out of control, of not knowi ng what to expect.
Fourth, vari ous defenses are mobi l i zed, thei r
vari ety and adapti veness dependi ng upon the
flexibili ty and maturi ty of the indi vidual . I f
these strategi es fail to control or di ssi pate the
sense of terror, then a further set of maneuvers
is ini ti ated.
Sol uti ons for anxi ety will depend on the
source of the anxi ety as well as the si ngul ar
personal i ty confi gurati ons of the indi vidual .
The specific types of defense are chosen by
the i ndi vi dual for reasons that are not, at our
present state of knowl edge, fully known. The
fol lowing factors are probabl e. (1) T he i ndi
vi dual s uni que experi ences and conditioni ngs
focus emphasi s on probl ems and coping mech
ani sms developed duri ng certai n peri ods in his
life. For i nstance, as a chil d the i ndi vi dual s
dependency needs may not have been satisfac
toril y resolved, causi ng hi m to measure his
self-esteem chiefly in terms of how well loved
he was by his parents (and l ater thei r i nter
94
nali zed images in his conscience). He will be
insecure when confronted wi th ci rcumstances
where he must take an i ndependent stand. (2)
Certai n defenses appear in chil dhood that net
the child a special gai n. Such defenses, if suc
cessful, establi sh a pattern of behavi or that
may be pursued l ater on. T hus where violent
and aggressive displays i nti mi date parents into
yielding to the chi l ds demands, he may tend to
have outbursts of anger and to i nti mi date
others as a preferred way of deal i ng wi th op
positi on. (3) Unresol ved chil dish fears, needs,
and strivings, wi th persistence of archai c con
cepts of real ity, will influence the patterns
adopted in the face of stress. Fears of the dark
or of being al one may return whenever stress is
excessive, where these were mani fest in chi l d
hood. (4) Defensi ve reactions are often condi
ti oned by parental neuroti c atti tudes and ill
nesses, whi ch the indi vidual may take over
through the process of i mi tati on. A mothers
terror of l i ghtni ng storms or recourse to
headaches when difficulties come up may be
adopted by her child.
The neuroti c i ndi vidual thus revives earl y
techni ques of adaptati on that ori gi nal l y helped
solve the difficulties in his chil dhood. Since
these techni ques have long outl ived thei r use
fulness, they create many more probl ems than
they solve. Neverthel ess, the i ndi vidual is apt
to i mpl ement them in a reflex manner, al most
as if they were the most natural of devices to
empl oy under the circumstances.
Many defensive responses to anxi ety that
are directed toward the reducti on of anxi ety
may lead to a cri ppl i ng of a persons flexibili ty
and adapti veness. The defensive techni que of
the phobi a il l ustrates the destructi ve influence
that a mechani sm of defense may yield. T he
i nhi bi ti on of function characteri sti c of phobi c
states is cal cul ated to isolate the i ndi vi dual
from certain sources of danger onto whi ch he
has proj ected his i nner anxieties. For instance,
a woman fearful of yiel ding to unrestrai ned
sexual impulses may develop strong anxi eti es
whi l e wal ki ng outdoors. She may shield herself
from such anxi ety attacks through the symp
tom of agoraphobi a, that is, by avoi di ng leav
ing her home, except perhaps in the presence
of her mother. T he phobi a ul ti matel y resul ts in
her i ncapaci tati on, i nterferi ng wi th her liveli
hood and her capaci ty to establi sh normal rel a
ti onshi ps wi th people. She may, as a result,
undergo a shatteri ng of self-esteem, and her
feel ings of i nferi ori ty may sti mul ate a further
attempt to isolate hersel f from others. Her
hostil ity, whi ch is usual l y directed at her
parent on whom she is so helplessly dependent,
may become extreme, and she may have diffi
culty in expressi ng or even acknowl edgi ng her
hateful feel i ngs because they threaten her
standi ng wi th her mother. Thus, whi l e she has
empl oyed a defense to shield her from anxi ety,
she has suffered from gross difficulties in her
functi onal rel ati onshi ps wi th life and people.
T he defense agai nst the ori gi nal anxi ety
pl unged her into difficulti es as great or greater
than the stress that ini ti all y inspi red her reac
tion.
Because defenses so often are sources of diffi
cul ty for whi ch psychotherapeuti c hel p is
sought and because they frequentl y are an i m
medi ate focus in treatment, it may be produc
tive to el aborate on how and why they evolve.
I n general , four levels of defense are em
ployed as outl i ned in Tabl e 7-1: (1) conscious
efforts at mai ntai ni ng control by mani pul a
ti on of the envi ronment, (2) characterol ogi c
defenses ai med at mani pul ati ng i nterpersonal
rel ati ons, (3) repressi ve defenses that mani pu
late the i ntrapsychi c forces, and (4) regressive
defenses that regul ate physi ologi cal mecha
nisms. The i ndi vi dual may stabil ize at any
level, whi l e retai ni ng symptoms and defenses
characteri sti c of previ ous levels. At different
ti mes, as stress is all eviated or exaggerated or
as ego strengtheni ng or weakeni ng occurs,
there may be shifts in the li nes of defense,
ei ther up or down. T he manner in whi ch these
four levels of defense are empl oyed in adapta
ti on is as follows:
F i r s t - l e v e l d e f e n s e s : C o n t r o l m e c h a n i s m s
When tensions and anxi ety are experi enced,
the first maneuver on the part of an i ndi vi dual
is to mani pul ate the envi ronment to fashion it
TABLE 7-1. Mechanisms of Defense
MANI FESTA TI ONS and SY MPTOMS SY NDROMES
Threats to Adaptation
ADAPTATI ON
SY NDROME
tension
anxiety
physiological reactions
Anxiety states
Physical conditions arising
from mental factors
(psychosomatic illness)
1st Line of Defense
CONTROL
MECHANI SMS
Removing self from sources of stress
Escape into bodily satisfactions & extroversion
Wish-fulfilling phantasies
Suppression, rationalization, philosophical credos, self-control, emo
tional outbursts, impulsive behavior, thinking things through
Alcoholic indulgenceexcessive alcohol intake
Sedation, narcoticsdrug overindulgence
Substance use disorders
(alcoholism, drug
dependence)
2nd Line of Defense
CHARA CTEROL OGI C
DEFENSES
STRI V I NGS of an I NTERPERSONA L NATURE
1. Exaggerated dependency {religious fanaticism, etc.)
2. Submissive technics (passivity)
3. Expiatory technics (masochism, asceticism)
4. Dominating technics
5. Technics of aggression (sadism)
6. Technics of withdrawal (detachment)
STRI V I NGS DI RECTED A T SEL F-I MAGE
1. Narcissistic strivings (grandiosity, perfectionism)
2. Power impulses (compulsive ambition)
Educational disorders, habit
disorders, work problems,
marital problems, adjustment
disorders, conduct disorders,
sexual disorders and
perversions, delinquency,
criminality, personality
disorders
3rd Line of Defense
REPRESSI VE
DEFENSES
A EFFORTS DI RECTED at REI NFORCI NG REPRESSI ON
1. General: (a) reaction formations, (b) accentuation of intellectual
controls with compensations and sublimations.
2. Inhibition of function:
a. Disturbed apperception, attention, & thinking
b. Disturbed consciousness (fainting, increased sleep, stupor)
c. Disturbed memory (antegrade and retrograde amnesia)
d. Emotional dulling, indifference, or apathy (emotional inhibi
tions)
e. Sensory defects (hypoesthesia, anaesthesia, amaurosis,
ageusia, etc.)
f. Motor paralysis (paresis, aphonia)
g. Visceral inhibitions (impotence, frigidity, etc.)
3. DI SPL A CEMENT & PHOBI C AVOI DANCE (phobias)
4. UNDOI NG & I SOL ATI ON (compulsive acts &rituals)
Posttraumatic stress disorders
Conversion disorders
Dissociative disorders
Phobic disorders
Compulsive disorders
B. REL EASE of REPRESSED MA TERI A L (direct or symbolic)
1. I mpulsive break through with acting-out (excited episodes)
2. Obsessions, (excessive revery & dreamlike states)
3. Dissociative states (somnambulism, fugues, multi ple per
sonality)
4. Psychosomatic disorders (sensory, somatic, visceral; tics,
spasms, convulsions)
5. Sexual perversions (fetishism, scoptophilia, etc.)
6. I nternalization of hostility (depression)
7. Projection
Obsessive-compulsive disorders
Conversion disorders
Neurotic depression
Paranoidal reactions
4th Line of Defense
REGRESSI VE
DEFENSES
A. Return to helpless dependency
B. Repudiation of and withdrawal from reality
1. Dereistic thinking; disorders of perception (illusions, hallucina
tions), disorders of mental content (ideas o f reference, delu
sions)-, disorders of apperception and comprehension; disorders
of stream of mental activity (increased or diminished speech
productivity, irrelevance, incoherence, scattering, verbigeration,
neologisms)
2. Defects in memory, personal identification, orientation, reten
tion, recall, thinking capacity, attention, insight, judgement
C. Excited acting-out (hostile, sexual, and other impulses)
D. I nternalization of hostility (depression, suicide)
Psychotic episodes
Schizophrenic disorders
Paranoid disorders
Manic-depressive disorders
Involutional psychoses
to his needs, to escape from it, or to change his
mode of thi nki ng about it. Thus he may avoid
certain activities or places or people. He will
try to manage in some different way whatever
he feels to be the source of stress. He may
change his j ob, his wife, his hai rcut, his nose
shape, or his domicil e. Or he may try to
change existi ng atti tudes, attempti ng to thi nk
thi ngs through and to arri ve at some new i n
tel lectual formul ati ons about what his life is all
about. I n thi s regard he may try to suppress
certai n thoughts, to keep his mi nd on more
posi ti ve channel s, to exercise self-control, or to
read self-hel p books that sti mul ate hi m to
thi nk through a new phi l osophy of life. He
may develop different l ei sure-ti me acti vities in
quest of satisfacti ons in a new hobby, a new
social activity, or different friends. He may try
to get outside hi msel f, or, j ust the opposi te,
he may become more absorbed in bodil y satis
factions such as eati ng or dri nki ng. He may
deaden his feel ings wi th sedatives, sti mul ate
them wi th energi zers, or drown them in alco
hol. Daydreami ng of a wish-fulfill ing nature
may hel p in escapi ng the pai nful real ities of his
dail y troubles.
Hi s emoti onal equi l i bri um may al so shift, so
that he permi ts hi msel f emoti onal outbursts,
fits of cryi ng or l aughi ng, and impul si ve out
breaks desi gned to rel ease tension.
All these, and other maneuvers like them,
are the first attempts to be made when a per
son feels the uncomfortabl e tension that i n
dicates a breakdown in homeostati s. Every
person alive at vari ous ti mes empl oys some of
these envi ronment-mani pul ati ng devices.
Pathol ogical expl oi tati on of certai n fi rst-li ne
defenses, howevernamel y, al cohol and
drugscan cause addictive disorders such as
al cohol ism and drug addiction. Other fi rst-li ne
defenses, such as attempts at i ntel l ectual
understandi ng regardi ng the basic nature of
ones conflicts and anxieties, may hel p provi de
some degree of relief. On the other hand, a hit-
or-mi ss appl i cati on of sel f-hel p measures,
wi thout awareness of the nature of ones diffi
culties, may lead to nothi ng, necessitating the
use of the next li ne of defense.
Second-level defenses: Characterologic
defenses
I n si tuati ons of i ncreasi ng threat it is typi cal
for a person to exploi t in exaggerated form his
normal characterol ogi c dri ves. Aggressi on,
wi thdrawal , and abnormal self-image restora
ti on are exampl es.
I di osyncratic adaptati ons to stress are de
veloped earl y i n life, pri mari l y in copi ng wi th
the parental fi gures who are the first source of
a chi l ds security. Certai n character styles were
promoted by the parents, and the chil d l earns
that there is a certai n manner in rel ati ng to
peopl e and events that has the best chance of
keepi ng hi m free of anxi ety. L ater in life,
when anxi ety is experi enced, there is an unwi t
ti ng return to the mode of life that worked
most effectively in the past.
T hus these modes of defense may be termed
mani pul ati ng ones i nterpersonal rel ati on
shi ps. I f dependency is characteri sti c for a
person, then in ti me of stress he may become
abjectly dependent. I f detachment is the way in
whi ch a person handl es untoward experi ences,
then a serious tragedy will cause hi m path
ologicall y to isolate and wi thdraw for long
peri ods. I t is the exaggerati on of the usual
mode that is the key to understandi ng this
second level of defense.
I t is typi cal of the exaggerated maneuvers of
the second defense line that they get the i ndi
vi dual into i nterpersonal difficulties. I f a hi gh
school pri nci pal is accused by his teachers of
bei ng too control l i ng, the pri nci pal may be
come threatened. When threatened, he fears
that he is losing control over his teachers and
reacts perhaps by aski ng that they submi t to
hi m more compl ete lesson pl ans and that they
si gn out of the bui l di ng when leavi ng for
l unch. I t is thi s very control that the teachers
objected to in the first place, and the i nterper
sonal conflict becomes exaggerated.
Exampl es of pathol ogi cal l y exaggerated
character dri ves i ncl ude many ki nds of i nter
personal , vocati onal, and educati onal difficul
ties. T he fol l owi ng are typi cal. Educati onal
and work di sorders may be symptomati c of
such excessive dependency that one is unabl e to
pursue any i ndependent, asserti ve l i ne of
thought or acti on. T he wri ti ng of a term paper
or the maki ng of a busi ness call may represent
the exerci se of personal responsi bi l i ty; an i ndi
vi dual wi th a deval ued sel f-i mage may not be
able to pursue such an acti vity on hi s own.
Mari tal probl ems, so ubi qui tous in our soci ety,
and parental mi shandl i ng of thei r chi l dren
may represent the exaggerati on of any or
several character stri vings.
Del i nquency and cri mi nal i ty are syndromes
representi ng the excess of hostil e aggression.
Sexual di sorders often portray the nature of
the i nterpersonal di sorder. Hypochondri acal
preoccupati ons may depict the fear of inj ury;
psychopaths demonstrate the extravagant cari
cature of many i nterpersonal needs; i mmature,
obsessive, schizoid persons have all , under the
threat of anxi ety, pressed thei r life-styles to ex
treme lengths. Usual l y, second-line defenses do
not work effecti vely. Rather they pl unge
people into such i nterpersonal difficul ties that
conflict and stress are hei ghtened rather than
reduced. T he chroni c empl oyment of de
pendency reactions, for exampl e, is eventual l y
resented by others on whom one leans, serving
to al i enate the person from his sources of sup
port. Rather than have his needs gratifi ed, he
drives others away and is more alone. The
emoti onal l y poor get poorer if there is a bli nd
repeti ti on at the same pattern. Because of the
ul ti mate ineffectiveness of the second li ne of
defense, the i ndi vi dual usual l y goes on to the
next level.
Third-level defenses: Repressive maneuvers
T he thi rd level of defense consi sts of the
mani pul ati on of ones intrapsychic structure. I t
is an attempt to gai n peace by pushi ng troubl es
out of ones mi nd. I n repression a barri er is set
up to the motor di scharge of needs, impulses,
memori es, ideas, or atti tudes, awareness of
whi ch will set off anxiety. T o avoid anxi ety,
selected ideati onal segments are sealed off
al ong wi th any associ ati onal memori es or
li nks, the acti vati on of whi ch may chal l enge
the repressi on. I n this process there may be (1)
a bl ocki ng in the percepti on, processi ng,
storage, and retrieval of experi ences; (2) an i n
hibi ti on or di storti on in the functions of i n
telligence, such as attenti on, l earni ng, di scri mi
nati on, j udgment, reasoni ng, and i magi nati on;
(3) a blocking in the operati ons and ex
pressions of emoti ons; and (4) a bl ocki ng in
behavior.
T he necessity of mai ntai ni ng repressi on can
absorb the energy resources of the indi vidual .
Constantl y threatened are breakdowns in the
repressi ve barri ers, a fi ltering of the seal ed-off
components i nto consciousness, and a mobi
l i zati on of anxi ety. T he i ndi vi dual may con
sequentl y be victimized by a ceaseless stress
reacti on, his physi cal system bei ng in a per
petual uproar. Vul nerabl e organ systems may
become di sorgani zed wi th outbreaks of organi c
illness. At the same ti me a symboli c di scharge
(idis placement o f affect) may occur i n at
tenuated or di storted forms, whi ch will provi de
some grati fi cati on for the repudi ated dri ves. At
phases when repressed needs become parti cu
l arl y urgent, or for some reason or other are
acti vated by physi ologi cal factors (such as a
previ ousl y qui escent sexual dri ve sti rri ng dur
ing adolescence) or experi enti al l y (as when an
i nsul t excites sl umberi ng rage and aggression),
a direct expressi on may occur fol lowed by
retri buti ve reacti ons whi ch will appease guil t
feel ings and serve to restore repressi ons.
T he understandi ng of the repressi ve line of
defense can best be seen in two groupi ngs:
those efforts ai med at rei nforci ng repressi on
and the direct or symboli c rel ease of repressed
materi al .
Fi rst, reaction formations (such as chastity
or hei ghtened moral i ty as a cover for perverse
sexual or anti soci al desi re) may become
pathol ogi cal l y exuberant in the urgent need to
deny the existence of forbi dden impulses.
Second, there is an inhibition of function,
di sturbed appercepti on, attenti on, concentra
ti on, and thi nki ng occurri ng as one selectively
i nattends to certai n upsetti ng aspects of ones
i nner or outer worl d. Di sturbed consci ousness
may take the form of fai nti ng, stupor, or ex
cessive needs for sl eep. Di sturbed memory to
the poi nt of amnesi a may develop. Emoti onal
dul l i ng can be seen in a person who exhi bi ts
i ndifference or apathy as a defense agai nst be
i ng involved in a potenti al l y threateni ng si tua
ti on. Sensory defects, motor paral ysi s, and
even visceral i nhi bi ti ons may be conversion
reactions that serve to bl ock out the direct
awareness of an anxi ety-provoki ng thought or
deed. Thus one may li terall y not be abl e to feel
a fri ghteni ng object, see a threateni ng event, or
experi ence a sexual l y arousi ng sti mul usif
such awareness woul d provoke undue anxiety.
Another effort at rei nforci ng repressi on is
the devel opment of a phobi a. I n phobia for ma
tion there is a di spl acement from a fearsome
i nner dri ve to an external object that sym
boli call y comes to represent this dri ve. T hus a
fear of snakes in a woman may conceal an ex
aggerated but repressed interest in the mal e
sexual organ. A fear of heights may be a cover
of a murderous impul se for whi ch one may
anti ci pate retri butory puni shment.
Further attempts to gai n peace through
repressi on are through undoing and isolation.
By these maneuvers the i ndi vi dual , al most
magicall y, robs a forbidden i mpul se of any vi
tality. When he thi nks an angry thought, he
qui ckl y follows it wi th a thought that un
does the first thought. Or he does not feel
the thought, and so he believes his sexual or
hostil e impulses have no real significance for
him.
The release of repressed material through
direct or symboli c means is the second form by
whi ch repressi ve maneuvers attempt to mai n
tai n a psychic equi l i bri um. As we have j ust
noted, the first form of repressi ve maneuver
rei nforces the repressi on itself. Thi s second
form all ows for an i ntermi ttent direct or sym
bolic di scharge of the repressed materi al .
One such type of rel ease is si mpl y an i mpul
sive breakthrough of some forbidden word or
thought or impul se. Occasi onal l y an exci ted
episode of acti ng out some i mpul se can be
noted in a person who otherwi se rel ies heavil y
on repressi on as his typical form of defense.
T he fi ghti ng drunk may actual l y be a sober
Casper Mi l quetoast whose repressi ons are
temporari l y deadened by alcohol , permi tti ng a
hostil e release.
Obsession, that is the repeti ti ve use of
reveries and daydreams, is a second means that
serves to drai n away the repressed materi al . A
symbol i zati on of forbi dden i nner i mpul ses
through obsessional thi nki ng drai ns off energy
but promotes anxi ety in thei r release. T he i n
divi dual may murder, rape, or torture special
peopl e in his fantasies or may expl ode the
worl d wi th atom bombs to his own di smay and
anxi ous discomfort. He may then neutral i ze
his rel eased impul ses by engagi ng in compul
sive rituals, whi ch on the surface make no
sense but whi ch symboli call y appease his guil t
or divert his mi nd from hi s preoccupati on.
T hus evi l thoughts may i nspi re repeated
hand washi ng as a cl eansi ng ri tual .
A thi rd measure for l i berati ng repressed ma
teri al is through dissociative states, such as
somnambul i sm, fugues, and mul ti pl e per
sonal ity. Acted out are the repressed impulses,
too threateni ng to be i ntegrated into ones con
scious acti vities, but not remembered when the
usual consci ousness is restored.
Psychosomatic disorders may be a fourth ev
idence of the rel ease of tensions that have not
made thei r way into conscious awareness.
Sensory, somati c and visceral changes may
reflect the i nner conflicts of an i ndi vi dual .
Ti cs, spasms and convulsions are often sym
bolic revel ati ons of i nner psychi c processes that
cannot find direct expression.
The fifth means are the sexual perversions,
such as fetishi sm, exhi bi ti oni sm, and the like,
that di scharge erotic tensi on when these be
come uncontrol l abl e.
The use of the self as an object f o r ag
gression is a si xth method by whi ch unaccepted
impul ses gai n some measure of expression.
Angry impul ses ori gi nal l y directed at others
are repressed and then di rected agai nst the
self. T he resul tant condi ti on may be neuroti c
depressi on, a feel ing that one is a mi serabl e
creature. T he conti nui ng sel f-recri mi nati ons
that the depressed person indul ges served to
di scharge his hosti l i tyalbei t in the wrong di
rection. There may also be dangerous abuses
of the self, wi th acci dent proneness, muti l ati on
tendencies, and even sui cide.
Fi nal l y, a defense mechani sm that al l ows for
rel easi ng repressed materi al is projection. Pro
j ecti on is a means of repudi ati ng i nner dri ves
that are painful and anxi ety provoki ng by at
tri buti ng them to outside agencies and i nfl u
ences. Thus i nner feel ings of hate, too dan
gerous to accept and manage, are external i zed
in the conviction of being hated or victimized
by an oppressor. Avarice may be conceal ed by
a belief that one is being exploi ted. Homosex
ual drives may be credi ted to persons of the
same sex toward whom the i ndi vi dual is sex
ual l y attracted. T he proj ecti ve mechani sm
serves the purpose of objectifying a forbidden
and repressed danger that will j usti fy certai n
measures, such as the expressi on of aggression
wi thout guilt. I n this way puni shment and
self-blame are avoided. By proj ecti ng impulses
and desires on to the outsi de worl d one may
i nsidi ously gai n acceptance for his own forbi d
den drives. For exampl e, insisting upon the
fact that the worl d is sexual ly preoccupi ed, and
fi nding pruri ent exampl es for thi s poi nt of
view, a sexual ly fearful i ndi vi dual may try to
lessen the severity of his own conscience that
puni shes hi m for his sexual needs.
Fourth-level defenses: Regressive defenses
When all other measures are faili ng to re
store emoti onal equi l i bri um, psychotic states
are the last i nstrumental i ty wi th whi ch to es
cape the pai nful demands of real ity. There may
be a return to compl etel y helpl ess dependency,
a repudi ati on of and wi thdrawal from real ity,
excited acti ng-out impul ses wi thout reference to
real i ty demands, and depressi on that has
reached del usi onal and sui cidal proporti ons. I n
thi s fourth level of defense the i ndi vi dual shows
evidence of psychotic functi oni ng. There may be
derei sti c thi nki ng, di sorders of percepti on (illu
sions, hallucinations), di sorders of mental con
tent (ideas of reference, delusions), di sorders of
appercepti on and comprehensi on, di sorders in
stream of mental acti vi ty (i ncreased or
di mi ni shed speech producti vi ty, i rrelevance, i n
coherence, scatteri ng, neologi sms), and defects
in memory, personal i dentification, ori entati on,
retenti on, recal l, thi nki ng capaci ty, attenti on,
insight, and j udgment. There is evidence that
special syndromes, such as manic-depressive
psychosis and schizophrenia, have geneti c com
ponents that bri ng out thei r pecul i ar charac
teristics in the face of stressful experi ences.
These four levels of defense must not be
regarded as arbi trary, stati c states. Each level
never occurs in isolation. Each level is al ways
mi xed wi th mani festati ons of other defensive
levels.
Conclusion
Once we have determi ned why at thi s ti me
the pati ent has presented hi msel f for therapy
and expl ored wi th hi m his ideas about his
si tuation i ncl udi ng what he believes is behi nd
his troubles, and what he wants to achieve
from treatment, we may then select an i m
medi ate focus and organi ze our treatment stra
tegies. A too earl y concentrati on on the pa
ti ents psychopathol ogy and past condi ti oni ngs
that have created his conflicts and ci rcum
scribed his growth, however i mportant these
may be, will support regressi on and encourage
long-term l i ngeri ng in treatment. Rather, we
shoul d begin to focus on what is of immediate
concern to the pati ent, such as inci dents in life
that have preci pi tated the symptoms for which
he seeks help. I n focusing on preci pi tati ng fac
tors one must gauge the pati ents vul nerabi l i ty
to stress as well as the viril ity of the stress fac
tor itself. I n focusing on symptoms the thera
pist shoul d view them as an assembl y of reac
ti ons to anxi ety as well as consequences of
mechani sms of defense.
Duri ng the expl orati ons it is i mportant to
concentrate on probl em solving, whi l e exami n
ing, encouragi ng, and hel pi ng the rel ease of
whatever positi ve adapti ve forces are present in
the pati ent, focusing on the resistances that
block thei r operati on. I n the course of doing
thi s we may be confronted by the pati ent wi th
his earl y formati ve experi ences, but these are
handl ed in the context of expl ai ni ng obstruc
ti ons to effective functi oni ng in the present.
Ampl e opportuni ti es will be found l ater on to
switch the focus to areas rel ated to some
central dynami c theme by establ i shi ng some
connection between it and current probl ems
and concerns shoul d this be deemed desi rable.
Powerful resistance to treatment may make a
focus on dynami cs essential . Obvi ousl y, the
therapi st will del i beratel y have to select dy
nami c aspects that he can work wi th ex
pedi entl y, avoi di ng or deal i ng tangenti al l y
wi th even noti ceabl e conflicts that do not seem
offensive and woul d be difficult or i mpossi ble
to handl e i n the bri ef peri od al l otted to
therapy.
CHAPTER 8
Choosing a Dynamic Focus
A. Probing into the Past
L ittl e ti me is avail able in short-term therapy
to expl ore the past. Much better use can be
made of the treatment hour by deal i ng wi th
perti nent elements in the here and now. How
ever, where the therapi st can determi ne i mpor
tant past events and conti ngencies that have
mol ded the personal i ty organi zati on, thi s will
facili tate a better understandi ng of the pa
ti ents illness and hel p select an appropri ate
dynami c focus. Enough data may be avai l abl e
from taki ng a good history to make assump
ti ons of how the past has entered into the
formati on of personal i ty di storti ons that bur
den present-day adaptati ons. More i mmedi ate
clues may be gai ned from the transference that
serves as a vital link to the kinds of earl y rel a
ti onshi ps that existed in actual i ty or fantasy
that have been i nstrumental in l ayi ng down
the foundati ons of the pati ents character struc
ture. Because behavi or reflects to a greater or
l esser degree condi ti oni ngs set up in the past, it
may be difficult to understand it fully wi thout
reference to what has gone on before. From a
practi cal poi nt of view in short-term therapy it
is not possible to devote much effort in expl or
i ng the past beyond provi di ng the pati ent wi th
some guidel ines to pursue on his own after the
formal therapy peri od has ended.
Thi s chapter consti tutes a revi ew of devel op
ment from a psychodynami c perspecti ve. I t is
i ncl uded in thi s vol ume as an i ntroducti on to
the more cli nically i mportant chapters that fol
low.
Transference
Of vital significance to psychotherapi sts of
all persuasi ons was Freuds cruci al percepti on
that to a greater or lesser degree pati ents tend
to proj ect onto authori ty fi gures thoughts,
wishes, and feel ings identical to those formerl y
harbored toward i mportant past personages
(parents, parental substitutes, si bli ngs). Reani
mated duri ng therapy are transference reac
tions, wholly i nappropri ate for the present, but
reactions that recapi tul ate antecedent emo
ti onal si tuations. I t is as if the pati ent seeks to
relive the peri ods of infancy and chi l dhood,
recovering grati fi cati ons and resolving fears
through the i nstrumental i ty of the therapi st,
who is endowed wi th power and attri butes
such as an i nfant harbors toward parental
agencies. There may be exhi bi ted al so toward
the therapi st in transference a host of aberrant
atti tudes, such as rebel li ousness, hostil ity, sub
missiveness, and sexual exci tement. Such feel
ings may also develop outsi de of the thera
peuti c si tuati on wi th any ki nd of an authori ty
or si bli ng figure. Transference is diagnosti call y
i mportant, since it is a l aboratory revi val of
101
102
much of what went cn in the i ndi vi dual s
chil dhood. I t may expl ai n a good deal of cur
rent behavi or that on the surface seems
illogical and mal adapti ve. It may al so contai n
the key to why the pati ent is resisting the ther
api st and fai li ng to respond to the therapeuti c
techni ques that are being used. T he detec
ti on and management of transference may,
therefore, be cruci al and decisive apart from
hel pi ng to select a pivotal dynami c focus.
Synthesizing Factors of Personality
Development
I n order to understand how and why the
past survives in the present and the mi schi ef it
invokes, it is necessary bri efly to summari ze
some of the current fi ndings on personal i ty de
vel opment that come from the biological and
social fields. Attempts are constantl y being
made to bri ng objectivity to the data on de
vel opment by studyi ng materi al from a number
of different sources. These i ncl ude observati ons
by trai ned workers of newborn babies at hos
pitals, insti tuti ons, and day-care centers; ex
peri ences of teachers wi th chi l dren at nursery
schools, ki ndergartens, and grade schools; re
ports of parents describing the behavi or of
thei r offspri ng; studies or recordings of plays,
art producti ons, dreams, fantasies, and spon
taneous verbal i zati ons of presumabl y normal
chil dren; psychological tests of chil dren, espe
cially projecti ve tests; investi gati ons by social
workers, correcti onal workers, and psychol
ogi sts of the soci oeconomi c envi ronment,
famil y rel ati onshi ps, and other areas of poten
tial conflict among mal adj usted, del i nquent,
and cri mi nal youngsters and adults; scruti ny of
case records of chil dren wi th severe emoti onal
probl ems who have been hospi tal i zed in men
tal i nsti tutions; observations of psychothera
pists treati ng chi l dren in thei r pri vate prac
tices or in outpati ent clinics; expl orati on of
memori es, dreams, and transference phenom
ena that reflect chil dhood experi ences of adul t
pati ents receiving psychoanal ysis; field studies
of anthropol ogi sts reporti ng on the customs,
folkways, creative artistic expressions, modes
of chi l d reari ng, and fami l y structure of
vari ous cul tural groups; demographi c surveys
by vari ous social scienti sts of the incidence and
preval ence of emoti onal probl ems in different
parts of the worl d; anal ysi s of reacti ons of i n
divi dual s to psychotropi c drugs; accounts by
ethol ogists of ani mal behavi or in a natural set
ti ng; and research fi ndings of ani mal experi -
mentors who have subjected hi gher mammal s
to artifacts in upbri ngi ng or to moti vati onal
conflicts.
Objecti ve apprai sal of thi s vast data requi res
a more a less preci se appl i cati on of the sci en
tific method. Unfortunatel y, investi gators in
the field of personal i ty research are handi
capped by formi dabl e methodol ogi cal probl ems
in attempti ng to subject thei r observati ons to
clinical research. Moreover, current theori es of
human behavi or are so compl ex, thei r i nherent
terms so operati onal l y indefinabl e, thei r deri
vati ons so diffuse, thei r i mpl i cati ons so global
that we are unabl e to expose them readi l y to
scientific experi ment.
I n spi te of these seemi ngl y i nsuperabl e
obstacles, it has been possible to scruti ni ze
many of the events associated wi th the devel op
ment of personal i ty and to exami ne and ana
lyze thi s data, maki ng appropri ate connec
ti ons, di scerni ng combi nati ons, and otherwi se
synthesi zi ng the materi al in a constructi ve
way. Out of thi s synthesi s a number of
proposi ti ons have emerged that may clarify
pathol ogi cal evolvements on whi ch the thera
pist may wi sh to focus.
1. T he task of human growth is to transform an
amorphous creature, the infant, into a civilized
adul t capable of living adaptively in a complex
CHOOSING A DYNAMIC FOCUS: PROBING THE PAST 103
soci al f ramework. T oward thi s end the chi l d
cul ti vates restrai nts on his bi ol ogi cal i mpul ses, ac
qui res skil ls in i nterpersonal rel ati onshi ps, evolves
val ues that are consonant wi th the soci ety in whi ch
he lives, and perfects techni ques that al l ow hi m to
fulfill hi msel f creati vel y wi thi n the bounds of hi s po
tenti al s.
2. Growth is governed by a number of de
vel opmental l awsfor i nstance, l aws of maturati on
common to the enti re speci es, l aws pecul i ar to the
cul tural and subcul tural group of whi ch the i ndi
vi dual is a part, and, fi nal ly, l aws uni que to hi msel f,
parcel s of hi s personal experi ence that wi l l make his
devel opment unl i ke that of any other i ndi vi dual .
3. Whi l e growth is broadl y si mi l ar in all human
i nfants and chi l dren, there is great di fference in i n
di vi dual styles and the rate of growth.
4. Devel opment may conveni entl y be di vi ded into
a number of stages of growth correspondi ng roughl y
wi th certai n age levels. Whi l e there is some vari a
ti on in ti mi ng and rate, the average i ndi vi dual ap
pears to fol l ow these stages wi th surpri si ng
sequenti al regul ari ty.
5. T he vari ous stages are characteri zed by speci
fic needs that must be propi ti ated, common stresses
that must be resol ved, and speci al skil ls that must be
devel oped. A heal thy personal i ty structure devel ops
on the basi s of the adequacy wi th whi ch these needs
are suppl i ed, stresses mastered, and skil ls l earned at
progressi ve age levels.
6. Diffi cul ti es may ari se at each stage of growth
that engender a parti al or compl ete fai l ure in the
satisfacti on of needs, the sol uti on of current con
flicts, and the l earni ng of skills. Such fai l ures
handi cap the i ndi vi dual in adapti ng to the more
el aborate demands and requi rements that consti tute
the succeedi ng stages of growth.
7. Where essential pe r so na l i t y qualities charac
teristic o f m at ur i t y are not evolved, the individual
wi l l be burdened unth residual childhood needs, at
titudes, a nd ways o f handling stress. These anach
roni sms tend to cl ash wi th the demands of a heal thy
biological and social adj ustment. Pri mi ti ve stri vi ngs
and concepti ons of the worl d, earl y fears and guil t
feeli ngs, and defenses agai nst these usual l y survi ve
in thei r pri sti ne form though they are not al ways
mani fest. They tend to contami nate an adul t type of
i ntegrati on.
8. Personal i ty, evol vi ng as it does from a bl end of
heredi ty and experi ence, is not merel y a reposi tory
of speci al abi l i ti es, atti tudes, and beliefs. I t is a
broad fabri c that covers every facet of mans i nternal
and external adj ustment. T hrough the medi um of
personal i ty operati ons the i ndi vi dual satisfies even
the most el emental of hi s needs.
9. Di sturbed or neuroti c behavi or represents a
col l apse in the i ndi vi dual s capaci ti es for adj ust
ment. T hi s col l apse is sponsored by a personal i ty
structure that cannot sustai n the i ndi vi dual in the
face of hi s i nner confli cts and the external demands.
I nherent i n every neurosi s is an attempt at adapta
ti on that stri ves to restore the person to some ki nd
of homeostati c bal ance. Unf ortunatel y, the ex
pedi ences that are expl oi ted are ul ti matel y destruc
ti ve to adj ustment, cri ppl i ng the i ndi vi dual in hi s
deal i ngs wi th the worl d.
10. T he first few years of life are the most cruci al
i n personal i ty devel opment, establ i shi ng thi nki ng,
feeli ng, and behavi oral patterns that wi ll influence
the i ndi vi dual the remai nder of the life. Where ex
peri ences wi th the parent and wi th the earl y envi
ronment are harmoni ous, the chi l d is encouraged to
evol ve a system of securi ty that regards the worl d as
a bounti ful pl ace and to devel op a sel f-esteem that
promotes asserti veness and sel f-confi dence. T he
chi l d wi l l be convi nced of hi s capaci ti es to love and
to be l oved, and thi s wil l form the foundati on of a
heal thy personal i ty. On the other hand, where the
chi l d has been depri ved of proper sti mul ati on and
care, or where he has been rej ected, overprotected,
i mproperl y di sci pl i ned, or undul y i nti mi dated, the
worl d wi l l consti tute for hi m a pl ace of menace. A
personal i ty organi zati on structured on the bedrock
of such unwhol esome condi ti oni ngs is bound to be
unsubstanti al and shaky. I n c o m p l e t e separation-
i n d i v i d u a t i o n , e x a g g e r a t e d d e p e n d e n c y , i n t e n s e
re sentment, gu i l t , sadomasochistic impulses, i m
p a i r e d independence, a damaged sense o f identity
a n d self-image, detachment, a nd a host o f com
p e n s a t o r y m e c h a n i s m s i n t e r f e r e w i t h a p r o p e r
adaptation.
Psychopathol ogy becomes more under
standabl e when viewed agai nst the backdrop
of personal i ty devel opment. Devel opmental
studies, as has been indi cated above, show that
personal i ty strength or weakness is more or
less determi ned by the experi ences duri ng
chil dhood. T he chil d will tend to identify wi th
the characteri sti cs of those whom he admi res,
and to evolve an ideal ized i mage of hi msel f
(ego ideal ) fashioned after the person or per
sons he venerates. If, in the first few years of
life, the indi vi dual has developed a feel ing of
security, a sense of real ity, a good measure of
104
asserti veness, posi ti ve sel f-esteem, and ca
pacities for self-control, he will probabl y be
abl e to endure consi derabl e envi ronmental
hardshi ps thereafter and still evolve into a
heal thy adult. On the other hand, earl y unfa
vorabl e devel opment handi caps the chil d in
managi ng even the usual vicissitudes that are
common to growi ng up. Thi s does not mean
that all chi l dren wi th a good personal sub
structure will i nevi tabl y emerge as heal thy
adul ts since an overl y harsh envi ronment can
i nhi bi t devel opment at any phase in the
growth process. Nor does it i mpl y that a child
wi th an i nadequate personal i ty structure may
not in the face of favorabl e ci rcumstances over
come severe earl y i mpedi ments in growth and
mature to satisfactory adul thood. Were we to
subscribe to the pessimistic phi l osophy that all
earl y psychi c damage is i rreparabl y per
manent, we woul d bl i nd ourselves to the ef
ficacy of psychotherapy that is predi cated on
the assumpti on that it is possible through the
emoti onal l y correcti ve experi ence provi ded by
treatment to overcome many chi l dhood per
sonal ity distortions.
Personal i ty trai ts in adul t life, however, are
never an exact redupl i cati on of chil dhood stri v
ings. Earl y condi ti oni ngs are tempered by ex
peri ences in l ater life that tend to modify, neu
trali ze, or rei nforce them. Moreover, though
behavi or is influenced by patterns rooted in the
past, responses vary widely in different si tua
ti ons in accordance wi th thei r symboli c si gnifi
cance and the prevai l i ng social role pl ayed by
the person at the time. The sundry vari ati ons
of personal i ty strivi ngs in operati on are i n
finite. I ncorporated are atti tudes, values, and
patterns of behavi or that issue out of a defec
tive security system, di storted concepti ons of
real ity, imperfect social control over bodil y
functi ons, vi ti ated sense of asserti veness,
stunted i ndependence, i mpai red sel f-esteem,
i nadequate frustrati on tol erance, i mproper ma
stery of sexual and hostil e impulses, i ncom
plete i dentification wi th members of ones own
sex, deficient group i dentification, faul ty i n
tegrati on of prevai l i ng social values, and i m
pai red acceptance of ones social role. Pressure
of earl y unsatisfied needs, anti ci pati on of the
same ki nds of turmoi l that existed in chil dhood
or the actual setti ng up of condi ti ons that
prevai l ed in ones earl y life, and survival of
anachroni sti c defenses, symptoms, and thei r
symboli c extensi ons, all are i ncorporated into
the personal i ty structure. Compul si ve in na
ture, they permeate every phase of thought,
feel ing, and acti on; they govern the random
and purposeful acti vities of the i ndi vi dual ,
forcing hi m to conform wi th them in a merci
less way.
Whi l e the personal i ty structure is tremen
dousl y compl ex and is understandabl y different
in every human being by vi rtue of disti ncti ve
consti tuti onal makeup and uni que condi ti on
ings, certai n common i ngredi ents may be ob
served in all persons in our cul ture. Among
these are (1) aspects of nucl ear conflicts that
accrue in the course of personal i ty devel op
ment, (2) i nteracti ng mani festati ons of unre
solved chil dish prompti ngs, and (3) reverbera
ti ons of character dri ves, such as excessive
dependency, aggressi on, compul si ve i nde
pendence, detachment, and mani festati ons of a
devalued self-image. These are ri ch sources of
probl ems that suppl y i mportant areas of dy
nami c focus.
Possible Assumptions Based on the Past
An understandi ng of how the past life (see pati ent has influenced the existi ng psychopa-
Tabl e 8-1 on personal i ty devel opment) of a thol ogy is thus of inesti mabl e val ue in dynami c
(Contd, p. 108)
CHOOSING A DYNAMIC FOCUS: PROBING THE PAST
TABLE 8-1. Personality Development
(See following chart* for corresponding numbers
(1) Her editary a nd c o n s titutional e l e m e n t s are the building blocks o f p e r sonality. A lo n g with
intrauterine influences t h ey d eter min e se nsitivity a n d a c tivity p a t t e r n s a n d thus regulate
the character o f later conditionings. Under the p r o m p t i n g s o f maturation, needs emerge
and skills evolve with sur p ri s i n g regularity. E n v i r o n m e n t a l factors, nevertheless, may
modify these p r e n a t a l forces a n d f a sh i o n the lines along which the p e r so n al i t y s tr ucture is
organized.
(2) Personality evolves out o f the conditionings a n d experiences o f the individual in his rela
tionships with the world. Basic needs mu s t be g ra t i f i e d a n d appropr iate coping
mechanisms evolved, the cons ummation o f which, at a n y age level, i f inadequate will
retard and i f satisfactory wi l l expedite successive stages o f g r o w t h . T h e social milieu,
reflected in the disciplines and values sponsored by the f a m i l y , designs the specific outlets
f o r and modes o f expression o f the emerging needs.
(3) Personality maturation is contingent on execution o f v i t a l tasks that mu s t be successfully
f u l f i l l e d at the different age levels.
(4) What inhibits or distorts g r o w t h are d epr iving experiences that block the p r o p e r satisfac
tion o f needs. An un wholes ome milieu tends to f o s t e r d estructive p a t t e r n s that crush se
curity, under mi n e self-esteem a n d interfere with the devel o pme n t o f essential sk ills and
values that are consonant with t he re q u iremen ts o f adaptation.
(5) A t any age level collapse in adaptation ma y be sponsored whe n basic needs are vitiated,
and security and self-esteem are s hatter ed with no hope o f immediate reparation. I f the
reservoir o f defenses is s u fficiently f l e x i b l e , considerable conflict ma y be endured. On the
other hand, where the p e r s o n a l i t y u n d e r p i n n in g s are unstable, even m i n i m a l conflict may
tax coping capacities. A combination o f sy m p t o m s issue f r o m the f a i l u r e to solve conflicts,
and include, in the main, the various manifestations o f anx i e t y , defenses against an x i e t y , as
well as technics o f counteracting or solving the conflictual situation itself. While the
elaborated sy m p t o m s are u n i q u e f o r every individual, being i nfluenced by the specific
experiences o f the person, a n d by the singular mechanis ms o f defense he has f o u n d success
f u l in p a s t dealing with stress, definite gro u pi n g s o f s y m p t o m s appear with sufficient f r e
quency to constitute f a m i l i a r syndromes. S y m p t o m a t i c evidences o f a f a i l i n g a d j u st m e nt
may pe r si st f r o m one age level to the n ext, accretions o f succeeding difficulties being added
to or sub s t i t u t in g f o r pr o b l e m s ex i s t in g at preceeding age levels.
(6) Residues o f defective rearing c o ntaminate a d j u st m e n t b y influencing disor ganizing rela
tionships w i t h other individuals. Conflict is thus in constant generation. T h e specific de
po s i t s o f defect display themselves in l u x u r ia n t f o r m s , the c u mulative p ro d u c t o f p a t h o
logical accruals f r o m one age level to the next.
(7) Awareness o f f o r m a t i v e experiences a n d elaborated defenses ma y be d i m m e d by repression.
Forgetting or re pudiating them does not p r o t e c t the in d ividu a l against t heir f o r a y s into his
conscious life in direct or derivative f o r m . Ea rl y conflicts may be revived symbolically in
dreams, through the use o f p s y c h o t o m i m e t i c drugs, as a result o f an over power ing emo
tional crisis, d u r i n g an intense relationship with a personage who represents a p a r e n t a l or
sibling fi gure , or by a transference neurosis inspir ed in the course o f p s y chotherapeutic
treatment.
* From L . R. Wol berg, P s y c h o t h e r a p y a n d th e B e h a v i o r a l Sciences (New Y ork, G rune & Stratton,
1966), pp. 62-63. Repri nted with permissi on.
TABLE 8-1, cont'd: Building Blocks of Personality
I. HEREDI TARY EL EMENTS (neurophysi ol ogi cal bi ochemi cal ,)
I I . I NTRAUTERI NE I NFL UENCES (Metabol i c, postural , i nfecti ous)
1
Sensitivity and Acti vity Potenti al s
MATURATI ONAL COMPONENTS AND EXPERI ENTI AL CONDI TI ONI NGS
Y EA R (2) N E E DS
(3) T A SK S T O
A C H I E V E (4) B A SI C T R A U M A S
1
(I nfancy)
I ntense and urgent demands for oral
satisfaction (nutri ti on and sucking
pl easure); sensory stimul ati on (optic,
audi tory, tacti l e, ki nesthetic); love and
approval .
Feelings of security and
trust.
Separati on of self from
nonself.
Coordi nati on; ambul a
ti on. Symbol i zation.
I nterference with nutri ti on (acute or
chronic illness, gastroi ntesti nal upsets,
al l ergies). I nterference wi th sucking
pl easure, sensory stimul ati on, love and
approval (separati on from, death of, or
rejection by mother).
F aul ty weani ng.
2- 3
(Earl y
Chi l d
hood)
I nvestigative and expl oratory needs;
geni tal mani pul ati on.
Beginning strivings for i ndependence and
mastery; aggressive assertiveness.
Feelings of autonomy;
i ncorporati on of disci
plines; tol erance of frus
trati on. Social outl ets for
aggression. Self-
confidence.
H abi t trai ni ng (too l ax or too severe
di sci pl ines, as in rel ati on to toi let trai ni ng).
I nterference wi th independence and
mastery (overprotection).
F aul ty handl i ng of rage and aggression
(too severe restrictions or excessive
permissiveness).
T oo great or too li ttl e emphasi s by parent
on ri ghts of other members of family.
I nterference wi th i nvestigative and
expl oratory activities. I nterference with
geni tal mani pul ati on.
Unconscious encouragement of rebellion
by parent, al ternati ng wi th excessive
puni shment.
3-5
(Chi l d
hood)
Need for extrafami l i al group contacts and
for cooperative play.
K een i nterest in sex, geni tal differences,
and bi rth processes.
Sexual identification.
Oedipal resoluti on.
Probl ems related to entry into nursery
school and ki ndergarten.
I nterference wi th i nterest in sexuality;
masturbatory i ntimi dati on.
Precocious or excessive sexual
stimul ati on. Seductive parent.
M other too domi nant; father too passive
or absent.
5-11
(L ate
Chi l d
hood)
Need for i ntellectual growth and
understandi ng.
Need for further social contacts and for
organized team play.
Need to belong to a group, club, or gang.
Group i dentification. Probl ems related to entry i nto grade
school (i mproper school and teachers: fear
of reli nqui shi ng dependency).
Neighborhood stresses.
Exposure to raci al and religious
prejudices.
11-15
(Earl y
A doles
cence)
I ntense sexual feelings and interests for
which a social outl et is necessary
(recreati onal programs, especially social
danci ng.)
Need to prac tice skills for successful
parti ci pati on in groups.
Soci al i zati on of sex
drives. Resolution of
parental ambivalence.
Confl i ct between need for and defiance of
parents.
Conflict in relation to sexual demands
and social restrictions; masturbatory
conflicts.
T oo lax sexual envi ronment. Poor
supervisi on and di scipline. L ack of
cohesiveness in home.
15-21
(L ate
A doles
cence)
Gradual emanci pati on from parents.
Need to make a vocational choice.
Growi ng sense of responsibi l i ty. Courtshi p;
marri age.
Resolution of
dependency.
A ssumption of
heterosexual role.
Conflict between dependence and
independence.
C onti nui ng sexual conflict.
Severe economic problems.
21-40
(A dult
hood)
Good sexual, mari tal , family, and work
adj ustment.
Communi ty parti cipation.
Producti ve work role
and economic indepen
dence. M arri age; parent
hood. Communi ty re
sponsibilities. Creative
self-fulfillment.
E xtraordi nary family stresses.
Economic hardships. N atural disasters.
I llness, and accidents.
Racial and religious discri mi nati ons.
40-65
(M i ddl e
Age)
A cceptance of a slower life pace,
physically and competitively.
Need for new i nterests, hobbies, and
communi ty activities.
M obi li zati on of ones
total resources toward
achievement of personal
happi ness, family
i ntegrati on, and social
welfare.
M enopausal and cl i macteri c changes.
Conflicts in relation to separati on from
chi l dren, unfulfilled ambi ti ons, sexual
decl ination, and, in women, cessation of
child bearing.
65 on
(Old Age)
A cceptance of physical, sexual, and
memory recession.
Need to engage in social activities, to
culti vate new friends, to develop community
interests and hobbies.
Conti nued work,
interpersonal and social
activities to the l imit of
ones physical capacities.
Conflicts in relation to l oneliness, death
of friends and mate, increased l ei sure time,
reti rement, failing work, physical and
sexual activities. I llness.
Fearful anti ci pati on of death.
TABLE 8-1, cont'd: Building Blocks of Personality
I. HEREDI TARY EL EMENTS (neurophysi ol ogi cal , bi ochemi cal ,)
II. I NTRAUTERI NE I NFL UENCES (metabol i c, postural , i nfecti ous)
4
Sensitivity and Acti vity Potenti al s
MATURATI ONAL COMPONENTS AND EXPERI ENTI AL CONDI TI ONI NGS
(5) SY M P T O M S O F
A D A PT I V E B R E A K D OW N
(6) SU R V I V I N G
P E R SO N A L I T Y D I ST O R T I O N S
(7)
R E PR E SSI ON
l Diffuse anxi ety reactions.
2. Psychosomatic disorders: anorexi a,
vomiting, colic, di arrhea, breathi ng and
ci rcul atory disorders.
3. Rage reacti onsscreami ng, crying.
4. Wi thdrawal reacti onsdul l ness, apathy
stupor.
I nsecuri ty; mi strust; depressiveness.
Preoccupati on with oral activities. Search
for an idealized parental fi gure or for
ni rvana. Propensi ty for addi cti ons. A ltered
body image; austi tic reacti ons;
depersonal i zati on.
4+
1. A nxiety, phobic and compulsive-like
reactions. Psychophysiological reactions:
(a) gastroi ntesti nal di sorders feeding
difficulties like anorexi a;
consti pati on, di arrhea.
(b) speech di sordersstammeri ng.
(c) bowel and bl adder di sorders
soiling, enuresis.
2. Personali ty disorders: (a) rage reacti ons,
(b) wi thdrawal reacti ons, (c) excessive
dependencv, (d) di sturbed identity.
L ack of self-confidence. Stubbornness.
I nabil i ty to control impulses and emotions.
F rustrati on i ntolerance.
Preoccupati on with anal activities.
Paranoi dal ideas; fear of authori ty.
Compulsiveness. Feelings of shame.
4+
1. Psychoneurotic reacti ons: (a) anxietv
states, (b) phobic reacti ons, (c)
psychophysiologic reactions:
gastroi ntesti nal di sorders, speech
di sorders, bl adder di sorders, skin
di sorders, ti ts.
2. Personali ty di sorders (as above).
3. Pri mary behavior disorders.
Persi sting oedipal conflicts; i nabi l i ty to
i dentify wi th persons of own sex.
2+ to
4+
1. Psychoneurotic reactions: (a) anxi ety
states and anxi ety reacti ons, (b) phobic
reacti ons, (c) conversion hysteri a, (d)
compulsion neurosis, (e) psychosomatic
disorders: gastroi ntesti nal , bl adder,
speech, skin, heari ng and visual
disorders, tics, muscle spasms, nail-
biting. compulsive or absent
masturbati on.
2. Personali ty di sorders (as above).
3. Pri mary behavior di sorders learni ng
disabilities.
4. J uvenile schi zophreni a.
I nabil i ty to accept a proper role.
Di sturbed relations wi th others. Problems
in competitiveness and cooperati on.
0 to
2+
as above, plus
Schi zophreni a
Sexual acting-out. Excessively hostile
atti tudes toward authori ty. Probl ems in
i denti ty. I solation.
0 to
2+
as above Excessive dependence.
Devalued self-image.
Confusion regardi ng social rol e. Sexual
i nhi biti ons.
0 to
2+
as above, plus
A lcoholism
Drug addiction
M ani c-depressive psychosis
Reinforcement of existent personal i ty
di sturbances.
0 to
1+
as above, plus
I nvol uti onal melancholia
as above 0 to
1+
as above, plus
A rteriosclerotic and Senile psychoses
as above 0 to
2+
short-term therapy. Whi l e little ti me is avai l
able to expl ore the past, as has been men
ti oned, certai n assumpti ons may be possible
from the symptom picture, a good history,
dreams, and parti cul arl y transference man
ifestations. The i mpact of the past may be
summari zed under seven headings.
Unpropitiated early needs constantly ob
trude themselves on the individual, propelling
him toward direct or symbolic actions to satisfy
these needs. A man depri ved duri ng infancy of
adequate sucki ng pl easure may constantl y be
obsessed wi th a need for mouth sti mul ati on,
over-i ndul gi ng himsel f wi th food and alcohol
to the poi nt of obesity and alcohol ism. A
woman, restri cted as a chi l d in physi cal
activity and asserti ve behavi or on the basis that
she was a girl, may conti nue to envy men and
thei r possessi on of the embl em of mascul i ni ty,
the penis. Accordingl y, she will attempt to pat
tern her life al ong lines commonl y pursued by
mal es, mascul i ni ty bei ng equated in her mi nd
wi th freedom and asserti veness. Wi th dogged
persistence she will deny femini ne i nterests,
and she may even clothe herself in mascul i ne
like atti re, croppi ng her hai r after the style of
men.
Defenses evolved in childhood may carry
over into ad ult life wit h an astonishing
persistence. A boy, overprotected and sexual ly
oversti mul ated by a doti ng mother, may
vigorously detach himsel f from her. When he
grows up, he may conti nue to avoid contact
wi th women; any attempts at sexual pl ay may
result in incestuous guil t to a poi nt where he is
unabl e to function. A chil d ri gorousl y and pre
maturel y toilet trai ned may regard his bowel
activities as di sagreeabl e and filthy. Over
cl eanl i ness, overorderl i ness, overmeti cul ous
ness ensue and burden his adul t adj ustment. A
younger si bli ng may carry over into adul t life
the conviction that he is small and ineffectual
in rel ati on to any person more or less uncon
sci ously identified as his ol der sibli ng. Thi s
will promote wi thdrawal tendencies or provoke
hi m to prove hi msel f by fi ghti ng and pushi ng
hi msel f beyond his habi tual capacities. An
ol der sibli ng may conti nue to harbor hatred
toward any competi tor whom she equates wi th
the preferred and pri vil eged younger chil d in
her famil y who di spl aced her as the favorite.
Mechanisms developed in early childhood
that have insured a gratification of needs will
continue to be indulged to a greater or lesser
degree in adult life. T hus a chil d i nti mi dated
by his parents to avoid masturbatory acti vities
responds wi th great hostil ity and, in a defi ant
manner, covertly conti nues his practice. L ater
the mani festati on of hostil ity seems to be a
condi ti on prerequi si te for any ki nd of sexual
expressi on, sexual sadi sm being the ul ti mate
outcome. Another youngster may have been
enj oi ned by overscrupul ous parents to perform
meticul ousl y on all occasi ons, on the threat of
thei r condemnati on or loss of love. Henceforth
i ndul gence of the trai t of perfecti oni sm may be
come an essenti al factor in hi s experi enci ng
any degree of positi ve sel f-esteem. A pampered
chil d whose temper tantrums compel l ed his
parents and si bli ngs to give in to hi s whi ms,
persists in sel f-oriented, selfish demands on the
worl d to suppl y hi m wi th grati fi cati ons and
satisfacti ons. Sensi ti ve to the sl ightest rej ecti on,
he construes any casual ness toward hi m as a
desi gned personal inj ury. T hi s mobi li zes rage
and rel eases coercive behavi or to force peopl e
to yield to his demands.
The individual wil l repetitively set up and
attempt to live through early destructive situa
tions that he has fai led to master as a child. A
young woman repetitivel y involves hersel f in
competitive rel ati onshi ps wi th older, more at
tracti ve, more gifted women in an attempt to
subdue them. T he feel ings she experi ences and
the si tuati ons she creates paral l el closely the
ri val ry experi ence wi th her ol der si ster whom
she could never vanqui sh. A chil d is severely
rej ected and physi call y mal treated by an al co
hol i c father. When she matures, she is
passi onatel y attracted to detached, sadisti c, and
psychopathi c men, whose affection she desper
atel y tries to wi n. A man in psychoanal ysi s de
velops paranoi dal atti tudes and feel ings toward
the anal yst, i magi ni ng that the anal yst wishes
to humi l i ate and torture hi m. These are trans
ference mani festati ons reflective of the same
CHOOSING A DYNAMIC FOCUS: PROBING THE PAST
109
ki nds of feelings he had toward his father dur
ing the oedi pal peri od.
The individual often unwittingly exhibits
the same kind o f destructive attitudes and be
havior patterns that he bitterly protests were
manifested toward him by his parents. A
woman reared by a petul ant, argumentati ve
mother may engage in the same ki nd of be
havi or wi th her own chi l dren, totall y unaware
of the compul si ve nature of her pattern. A man
victimized duri ng his chil dhood by a hypo
chondri acal father may hi msel f become
obsessionally concerned wi th physi cal illness
following marri age. Through insidi ous i den
tifi cati on a son may become an alcoholic like
his mal e parent, a daughter the victim of mi
grai ne like her mother; the exampl es of such
identification are endless.
The individual may f a i l to develop certain
mature personality features. A child severely
negl ected and rejected duri ng infancy comes
into adul t life wi th pathol ogi cal feelings of i m
pendi ng doom, a conceptual i zati on of hi msel f
as i nhuman and insigni ficant, tendenci es to
depersonal i zati on, and an i nabi l i ty to love or
respect others. A boy whose father is passive
and detached identifies wi th a strong ag
gressive mother, emul ati ng her manner and i n
terests to the poi nt of avoi di ng mascul i ne at
ti tudes and goals. A youngster who was di s
cri mi nated agai nst by his agemates because of
his race may, from the begi nni ng of hi s ex-
trafami l i al contacts, develop a contempt for his
kinfolk and a fear of groups. A girl victimized
by proper and gentl e parents who cannot
stand scenes is shamed into abandoni ng any
demonstrati on of anger. She conti nues to di s
pl ay a bl and, forgiving manner despi te ex
pl oi tati on and i nti mi dati on.
The individual may tend to revive childhood
symptoms in the face of stress. Vomi ti ng, colic,
and di arrhea, whi ch were mani festati ons of
stress duri ng ones earl y i nfancy, may be mobi
lized by l ater episodes of tensi on to the embar
rassment and di smay of the person. Fear of the
dark and of ani mal s, whi ch terrori zed the i ndi
vidual in earl y chi l dhood, may overwhel m hi m
in adul t life when anxi ety taxes his exi stent ca
pacities.
Nuclear Conflicts
Tabl e 8-2 summari zes the chief conflicts,
whi ch we call nucl ear confl icts, i mbedded in
the psyche of each person, products of the
inevi tabl e clash of maturi ng needs and real ity
restri cti ons, the mastery of whi ch constitutes
one of the pri mary tasks of psychosocial de
vel opment. I t must be emphasi zed that these
conflicts are uni versal qual i tati vel y, though
quanti tati vel y differing in all persons as a
resul t of consti tuti onal -condi ti oni ng vari ati ons
and the i ntegri ty of the existi ng defenses.
The earliest nucl ear conflicts are organi zed
in rel ati onshi p to the parents. For instance, the
i nfants associati on of the presence of mother
wi th satisfacti on of his needs (hunger, thi rst,
freedom from discomfort and pai n, demand for
sti mul ati on) resul ts in her becomi ng affiliated
wi th gratifi cati on of these needs, wi th pl easure
and the rel ief of tension. At the same ti me the
absence of mother becomes li nked to di s
comfort, distress, and pai n. Duri ng the last
part of the first year the chil d reacts wi th what
is probabl y a pri mordi al type of anxi ety to
separati on from the mother, and wi th rage at
her turni ng away from hi m toward anybody
else, chil d or adul t. Thi s bl ended gratifi cati on-
depri vati on i mage of mother is probabl y the
precurser of l ater ambi val enci es, poweri ng
sibli ng ri val ry and the ri val ri es duri ng the
oedi pal peri od. I t also gives rise to moti vati ons
to control, appease, and wi n favors from
mother and mother fi gures, to vanqui sh, el i mi
nate, or destroy competi tors for her interest
and attenti on, and to puni sh mother and
mother fi gures for actual or fanci ed depri va
ti ons. T he mother symbol becomes sym-
110
TABLE 8-2. Nuclear Conflicts*
Ages Conflictual Elements L egends
Residual
Manifestations
(repressed or
suppressed)
0-3 mo. Constant freedom from distress and pain
opposed by realistic environmental
restrictions.
I must be everlastingly happy and com
fortable; instead I suffer.
Search for nirvana.
Demand for magic.
4 mo.-l yr. Need for oral, sensory, and affectionate
gratification opposed by realistic depriva
tions.
I want to be fed, loved, stimulated, and
kept free from pain at all times; but
mother denies me this gratification.
Ambivalence toward
mother figures.
Separation anxiety.
1-2 yrs. Self-actualization opposed by essential
restrictive disciplines.
1want to do what I want to do when I
want to do it, but I will be punished and
told I am bad.
I mpulsive aggressiveness.
Guilt feelings.
3-5 Power impulses opposed by sense of help
lessness.
Oedipal desires opposed by retaliatory
fears.
I want to be big and strong, but I know I
am weak and littl e.
I want to possess my mother (father) for
myself, but 1cannot compete with my
father (mother).
I nferiority feelings.
Castration fears.
Compulsive strivings for
masculinity.
6-11 Demand for total group acceptance opposed
by manifestations of aloofness and un
friendliness.
1want everybody to like, admire, and ac
cept me, but there are some people who
are against me and reject me.
Fear of rejection by the
group.
12-15 Sexual impulses opposed by guilt and fear
of punishment.
I feel a need for sexual stimulation, but
this is wrong and not acceptable.
Fear of lack of maleness
in men and female
ness in women.
16-21 Independence strivings opposed by de
pendency.
I need to be a grown, independent person,
but I dont want the responsibility. I
would like to be a child, but this would
make me feel like a nothing.
Continuing dependency.
* From L. R. Wolberg, and J . Kildahl, The Dynamics of Personality (New York, Grune & Stratton, 1970), p. 56. Re
printed by permission.
boli call y li nked to l ater sources of grati fi cati on
or depri vati on. Moreover, if a di srupti on of
homeostati c equi l i bri um occurs at any ti me
later on in life or if for any reason anxi ety
erupts wi th a shatteri ng of the sense of
mastery, the pri mordi al anxi ety i mpri nts
may be revived, acti vati ng separati on fears
and mother-i nvoki ng tendenci es al ong lines
pursued by the i ndi vi dual as an infant.
T he grati fi cati on-depri vati on, separati on-
anxi ety constel l ati ons, laid down duri ng phases
of devel opment earl y in the peri od of concep
tual i zati on, will tend to operate outsi de the
zone of consci ous awareness. Whenever habi
tual copi ng mechani sms fail the i ndi vi dual and
he experi ences anxi ety, he may feel the hel p
lessness and mani fest the behavi or of an i nfant,
and he may seek out, agai nst all logic, a
mother fi gure or her symbol i c substi tute (such
as food in compul si ve eati ng acti vities). I t is l i t
tle wonder that mothers, and thei r l ater repre
sentati ves (protectors, authori ti es), come to
possess symbol i c reward (pl easure) val ues
al ong wi th symbol i c abandonment (pai n,
anxi ety) potenti al s. Thi s conflict, deepl y i m
bedded in the unconsci ous, acts as compost for
CHOOSING A DYNAMIC FOCUS: PROBING THE PAST 111
the fertil ization of a host of deri vati ve at
titudes, impulses, and drives that remai n wi th
the indi vidual throughout his existence. Other
conflicts develop in the chi l ds rel ati onshi ps
wi th the worl d, as noted in Tabl e 8-2, that are
superi mposed on the conflicts associated wi th
the demand for magi c and for the constant
presence of the mother figure.
The actual experi ences of infants duri ng the
first years of life, the degree of need grati fi ca
ti ons they achieve, the rel ati ve freedom from
depri vati on, thei r l earni ng to tol erate some
frustrati on and to accept temporary separati on
from thei r mothers provi de them wi th copi ng
devices to control thei r nucl ear confl i cts,
whi ch, nonethel ess, i rrespective of how satisfy
ing and whol esome thei r upbri ngi ng may have
been, are still operati ve (albeit successfully
repressed), wai ti ng to break out in l ater life
shoul d the psychological homeostasi s collapse.
Nucl ear conflicts, to repeat, are i nherent in
the growi ng-up process i rrespective of the
character of the envi ronment. Thi s is not to
say that a depri vi ng or destructi ve envi ronment
will not exaggerate the effect of conflict or keep
it alive beyond the ti me when it shoul d have
subsided; a whol esome envi ronment will tend
to keep in check operati ons of conflict, hel pi ng
to resolve it satisfactorily. Nuclear conflicts are
in p a r t ordained by biological elements and in
pa r t are aspects of the culture. We should ex
p e c t thei r appearance in minor or major
degree in all persons. Their importance is con
tained in the fact that they give rise to reaction
tendencies that, welded into the personality
structure, may later interfere with a proper
adaptation. Of clinical consequence, too, is
thei r tendency to stir from dormancy into open
expression when anxi ety breaks down the ram
parts of the existent defensive fortifications.
The exposure of repressed nucl ear conflicts
that are creati ng probl ems constitutes a task of
dynami cal l y ori ented therapy, the object being
to determi ne the di storti ons they produce in
the character structure, thei r affiliati on wi th
current conflicts, and the subversive role they
pl ay in symptom formati on. It may be possible
even in short-term therapyespeci al l y in
dreams, transference, acti ng-out behavi or, and
certai n symptomsto observe how an i mpor
tant nucl ear conflict is conti nui ng to di sturb
the present adj ustment of the pati ent.
The operati on of a nucl ear conflict is exem
plified in a person who habi tual l y relies on al
cohol as a means of escapi ng tension and
anxiety. Feel i ngs about depri vati ons in life are
avoided through the tranqui l i zi ng effects of al
cohol. At the same ti me the person reassures
himself, at least as long as he dri nks, that a
nurturi ng agent is avail able to hi m that will
keep hi m free of pai n.
Another exampl e of a nucl ear conflict is evi
denced in a teenager who establi shes pseudoi n
dependence through i nvari abl y doi ng the op
posite of what his parents ask. A request to
wear a green shi rt i mmedi atel y establi shes in
hi m an intensel y felt desire to wear a red shirt.
Hi s own fears that he will succumb to his
desi re to be dependent on his parents dri ve him
to exert his i ndependence, little real i zi ng that
he is still not free because he is now i m
pri soned by his own needs to be opposi ti onal .
And much l ater in life, when a supervi sor says
do it this way, he may still be bound up in
his need to resist, irrespective of the meri ts of
doi ng a task one way or another.
T he current inabi li ty of many persons to
get invol ved may be a mani festati on of several
nucl ear conflicts. T o remai n one step removed
from parti ci pati on in a cause or to be a spec
tator rather than a pl ayer may be skill full y ra
ti onali zed by sayi ng that one does not have the
ti me, or that the cause does not j usti fy the ef
fort, or that the candi date is all too human, or
that the poli ti cal pl atform is just so much
wi ndow dressing. But behi nd these reasons
that sound good, the real reason may be ones
sense of helpl essness and the subsequent de
spai r about fi ndi ng magi cal soluti ons. Or one
may not become involved because of fear of not
being totall y accepted by any group or party
that one j oi ns; so it may be less pai nful not to
expose onesel f to such a possible rejecti on. The
nucl ear conflict is handl ed by avoidance.
Conclusion
Even though ti me does not permi t an exten
sive probi ng of the past, an understandi ng of
how the past has entered i nto and has
produced personal i ty vulnerabi l i ti es may be
i mportant for some pati ents in short-term ther
apy. Dreams and transference phenomena
often yield data regardi ng past condi ti oni ngs
and may expose some nucl ear conflicts that can
serve as a focus in therapy. T he object here is
to determi ne the di storti ons they produce in
the character structure, thei r affili ati on wi th
current conflicts, and the subversive rol e they
pl ay in i ni ti ati ng and sustai ni ng symptoms.
Havi ng grasped the significance of how the
past has entered into promoti ng adj ustment
probl ems in the present, many pati ents become
moti vated to expl ore these connecti ons on thei r
own after formal therapy has termi nated. Such
homework may faci li tate a strengtheni ng of
defenses and ul ti matel y act as a means of posi
tively influenci ng personal i ty growth.
CHAPTER 9
B. Some Common Dynamic Themes
By thei r effect on the personal i ty structure
the devel opmental vi cissitudes set forth in the
last chapter are responsi bl e for a host of
symptoms, copi ng mechani sms, and defenses
that provi de many dynami c themes on whi ch
we may focus. Because it is difficult for some
pati ents to conceptual i ze these themes, it may
be expedi ent to simplify personal i ty operati ons
and distorti ons by pi cturi ng them as products
of the operati on of five powerful motors: ex
cessive dependency, resentment, reduced i nde
pendence, deval ued self-image, and detach
ment.
Dependency
Often at the core of probl ems is the fi rst mo
tor, excessive dependency needs, that had not
been adequatel y resol ved in chi l dhood. A
heal thy balance between dependency and i nde
pendence is essential for emoti onal well-being.
Where it does not exist, probl ems ensue. Most
likely the average persons chi l dhood yearni ngs
for nurture and affection were not opti mal l y
met, leavi ng a resi due of unmet needs that tend
to express themsel ves i ntensel y when the
pressures of life mount. Or dependency was
pathol ogical ly encouraged by a mother who
uti li zed the chil d as a vehicle for her own
unfulfilled demands, hamperi ng the chi l ds
growth and strivi ngs for independence. Unre
solved dependency is a ubiquitous fountain-
head of troubles. It stems from what is perhaps
the most common conflict burdening human
ki n d inadequat e s e par ation - in di vidu at io n .
And peopl e are apt to bl ame thei r troubl es on
the worl d: the revolt of youth, governmental
corrupti on, i nfl ati on, communi sm, capi tal i sm,
or the atom bomb. Most peopl e, however,
somehow muddl e through, worki ng out thei r
troubl es in one way or another. I t is only
where separati on-i ndi vi duati on is too i ncom
plete and dependency needs too i ntense that so
l uti ons will not be found.
Peopl e wi th powerful dependency needs will
often cast about for i ndi vi dual s who demon
strate stronger qual i ti es than they themsel ves
possess. When a swi mmer ti res, he looks about
for somethi ng or someone on whom to l ean or
wi th whi ch to grappl e. A dependent person
can be l i kened to a ti red swi mmer, and he*
wants to fi nd someone or somethi ng who can
do for hi m what he feels he cannot do for
hi mself. What he general l y looks for is a
perfect parent, an ideal that exists onl y in his
own fancy. Actual l y, there are no perfect
parental fi gures who are abl e or wi l l i ng to
mother or father another adul t. So our de
pendent person is conti nual l y being frustrated
because his hopes and expectati ons are not met
by someone else. A man who weds expecti ng
an all -gi ving mother fi gure for a wife is bound
to be di sappoi nted. Further, if he does fi nd a
person who fits in wi th his design and who
* The generic he is employed to designate both males
and females. There are, however, some distinctive roles
played and effects scored for males and females, which will
be differentiated as much as possible.
113
treats hi m like a helpless i ndi vidual , he will
begin to feel that he is being swal l owed up,
that he is losing his i ndi vidual ity, that he is
trapped. Consequentl y, he will want to escape
from the rel ati onshi p. Also, as he senses his
dependency, he will feel that he is being
passive like a chil d. And this is fri ghteni ng be
cause he knows that he is not being manl y; he
may actually have homosexual doubts and
fears si nce mascul i ni ty is associ ated wi th
acti vity and i ndependence.
We will call his first maneuver his de
pendency motor, whi ch begins to operate espe
cially at ti mes when he is under pressure. As
he searches for the el ement mi ssi ng in his psy
chologi cal di et, namel y a parental fi gure, he
will most assuredl y be disil lusi oned. Women
are no less victimized by dependency than are
men. And thei r reacti ons are qui te si mi l ar in
that they are apt to regard both mal es and fe
mal es on whom they get dependent as poten
ti al nurturi ng mother figures. They are also no
less subject to the consequences of the other
motors that we shall describe.
Resentment
A second motor that inevi tabl y accompani es
the first is the resentment motor. Resentment
invari abl y fires off because ei ther one must find
a perfect parent who will take care of hi m or
he feels trapped when someone does take care
of hi m and he senses his own passivity and
helplessness. Resentment breeds guil t because
peopl e j ust are not supposed to be hateful.
Even guil t does not al ways keep the hostil ity
hidden. Sometimes when our man has had too
much to dri nk or when he is very frustrated
about somethi ng, his hate feelings leak or pour
out. T hat in itself can be terri bl y upsetti ng be
cause he may fear he is getting out of control;
or the mere awareness of his i nner angry con
dition can make hi m despi se himself. Sadi sm
and sadistic behavi or may be directed at the
object of his dependency who he believes is
trappi ng hi m or who fails to live up to expec
tations. I t may be drai ned off on scapegoats:
blacks, Chi canos, J ews, Communi sts, capi
talists, and so on. Self-hate compl icates his
exi stence because it sponsors tensi on and
depression. Hatred directed outward and then
turned in resul ts in masochi sm, in the form of
maj or and mi nor sel f-puni shments. These may
range from foul ing up a busi ness deal to
inabi li ty to accept success, to dangerous ac
cident proneness, to physical illness, to foolish,
outrageous, or embarrassi ng behavior.
Low Independence
Now our man has two motors going most of
the ti me when under pressure: the dependency
motor and the resentment motor, wi th ac
companyi ng kickbacks of guil t and masochi sm.
T he pi cture is not compl ete, however, wi thout
a thi rd motor, low independence, whi ch is an
i nvari abl e counterpart of hi gh dependence.
L ow i ndependence is a feeling that one cannot
gai n, by his own reason or strength, the desi ra
ble pri zes of our cul turewhether they be love
and j usti ce or wi ne, women, and song. A spi n
off of low i ndependence is a feel ing of infe
ri ori ty, a lack of proficiency on achieving de
si rabl e goals. Part and parcel of i nferiority
feel ings is the uncertai nty about being manl y
and masculi ne. Self-doubts about ones sexual
i ntegri ty are torturous; the usual sequel is to
try to compensate by bei ng the qui ntessence of
everythi ng mascul i ne: overl y aggressive, overly
competitive, and overl y domi nati ng. Provi ng
himsel f wi th women may lead to satyriasis and
Don J uani sm. Our man may have fantasies
and images in his mi nd of strong men (often
symboli zed by thei r possessi ng l arge penises)
and may be parti cul arl y attracted to them be
cause of thei r strength. But his awareness of
how much he thi nks about men may cause hi m
to wonder if he is homosexual and to fear the
very thi ngs that he admi res. He may actual l y
on occasi on be sexual l y attracted to ideal ized
mal e figures, and he may fantasi ze i ncorporat
i ng thei r penises into himsel f.
I nteresti ngl y, l ow-i ndependence feelings in
women lead to the same sel f-doubt and com
CHOOSING A DYNAMIC FOCUS: SOME COMMON THEMES 115
pensati ons as in men. Such women will try to
repai r the fanci ed damage to themsel ves by ac
qui ri ng and acti ng as if they have the symbols
of masculi nity (e.g., by swaggeri ng and wear
ing mal e apparel ) that in our cul ture are
equated wi th i ndependence. They will compete
wi th and try to vanqui sh and even fi gurati vely
castrate males. I n its exaggerated form, they
wi l l act toward other femal es as if they
themselves are males, domi nati ng and ho-
mosexuall y seduci ng them.
Devalued Self-image
By now in our i l l ustrati on we have a fully
operati ng fourth motor, a devalued self-image.
Wi th the constant reverberati ng of his first
three motors, our man is now feeling spiteful
toward hi msel f. He feels he is mi serabl y
i ncompetent, undesi rabl e, and unworthy.
Everywhere he sees evidence of his insigni fi
cance: he is not tall enough, he has developed
a paunch, women do not seem to pay attenti on
to hi m, his hai r is thi nni ng, his j ob is not
outstandi ng; his car, his house, his wife
nothi ng is perfect. He may even thi nk his penis
is of i nadequate proporti ons. He feels like a
damaged person. These feelings torment hi m,
an'* he vows to prove that he is not as devalued
as he feels. He commi ts himsel f to the task of
being all -powerful , ambi ti ous, perfect so as to
repai r hi s deval ued sel f-i mage. T hen he
imagi nes he can surely respect himself. I f he
can live wi thout a si ngle mi sstep, all will be
well. He tries to boost hi msel f on his own to
the poi nt where others will have to approve of
him. He may only daydream all this, or he
may, if events are fortuitous, accomplish many
of his overcompensatory goals.
I f he cli mbs high, he will most likely resent
those below who now lean on hi m and make
demands on him. To those who exhibi t weak
ness, he will show his anger. Whi l e he may be
able to be giving on his own terms, an unex
pected appeal from someone el se wi l l be
regarded as a vul gar imposi ti on. He actual l y
wants for hi msel f someone on whom to lean
and be dependent. However, givi ng in to such
a desi re speeds up all his motors and makes
hi m feel even worse. He pursues j ust the
reverse course from his ori gi nal dependency
drive; he competes wi th any strong fi gure on
whom he mi ght want to lean. He shows
the pseudoi ndependence remi ni scent of the
adolescent who disagrees on pri nci pl e wi th
whatever his parents say. And he may com
pensate for his deval ued self-image by expl oi t
ing all the cul tural symbols of being a worthy
person, such as being perfecti onistic, compul
sively ambi ti ous, and power dri ven. These
compensatory dri ves may preoccupy hi m
mercil essly, and he may organi ze his life
around them. One fai l ure means more to hi m
than twenty successes, since it is an affi rmati on
of his lowly status.
These difficulties are compounded by the
way they i nteract wi th our mans sexual needs.
When ones dependency needs are bei ng
gratifi ed, there is often a pervasive feeling of
wel l -bei ng that floods ones whol e body. Upon
awakeni ng fol lowing surgery, for exampl e, the
confi dent, smi l i ng face of a nurse can suffuse a
man wi th grateful , loving feelings, at least part
of whi ch may be sexual. T he sexual feel ing is
not that of adul t mal e to adul t female but
rather that of a helpl ess chil d toward a warm
mother. Such a feeling is tantamount to an i n
cestuous surge and may bri ng wi th it great
conflict and guil t. Shoul d thi s dependency be
the nature of a husbands conti nui ng rel ati on
shi p to his wife, he may be unabl e to function
sexual ly wi th her since he is vi rtual l y invol ved
in a mother-son rel ati onshi p. On the other
hand, if the nurturi ng fi gure is a man, ho
mosexual fears and feelings may ari se wi th
equati ons of the hosts peni s wi th a ni ppl e. For
women the dependency si tuati on does j ust the
reverse. A nurturi ng mother fi gure calls up in
her fears and feel ings of homosexual i ty which
may or may not be acted out in passive ho
mosexual i ty wi th yearni ngs for the breast.
Moreover, low feelings of i ndependence may,
as has been i ndi cated, i nspi re ideas of defective
mascul i ni ty in mal es wi th impul ses to identify
wi th muscle men. Fantasi es of homosexual i ty
or direct acti ng-out of homosexual impulses
may follow. I n women feelings of defective i n
dependence may inspi re a rejecti on of the
femi ni ne role and fantasies of possessi ng a
penis, the symbol in our cul ture of power and
independence. Sadi sm and masochi sm may
also be acted out in sexual activities in both
men and women.
T he reverberati ng of all these machi nes calls
for strenuous efforts on the part of our subj ect.
I t all began wi th the dependency motor, whi ch
then acti vated the resentment motor (together
wi th its components of aggression, guil t and
masochism). Thi s threw into gear the thi rd
motor of low independence, whi ch in turn
fueled the fourth motor of sel f-deval uati on wi th
its overcompensati ons and sexual izations.
Detachment
Where can a man turn next to gai n some
sense of composure? He often turns to the fifth
motor, detachment. Detachment is an attempt
at escapi ng from lifes messy probl ems. Our
man by now is fed up wi th the rat race and
wants to get out. He says, No more commi t
tees, no more parti es, no more responsibi li ti es,
no more extras of any ki nd, no more involve
ment wi th peopl e. He wants an i sl and
fortress, or at least a castle wi th a moat around
it, and he woul d pull up the drawbri dge and
say no to everythi ng and everyone. He is sure
that thi s is the sol uti on; he deci des not to be
come ri ch and famous.
But it does not work. Peopl e need people.
Life is not satisfying alone. Our man finds
loneliness to be a worse state than what he was
enduri ng before. He real izes that peopl e con
stitute one of li fes richest gratifi cati ons. So, he
pl unges in agai n. By now his first motor of de
pendency is real l y dri vi ng him. And if he is
desperate enough, he may attach hi msel f all
over agai n to a fi gure who holds out some
promi se of bei ng the perfect parent. Then the
neuroti c cycle is on its way agai n. T he fifth
motor of detachment has agai n revived the
first, second, thi rd, and fourth motors.
These drives, these five motors, are never
enti rel y quiescent. I n the average person there
is i nvari abl y some fuel to keep them going.
There is no one whose dependency needs were
perfectl y met earl y in life. Thi s hunger lives
on, and wi th thi s hunger, the mechani sm of
dependency is conti nual l y operati ve. I n our
cul ture, in thi s generati on, the unmet de
pendency needs sets in moti on the successive
motors just described. As l ong as fuel is avai l
abl e and the speed of the motors can be con
troll ed, the i ndi vi dual may manage to keep go
ing, swi tchi ng on one or the other motors and
turni ng them off if they threaten to carry hi m
away. To some extent all peopl e are victims of
the five motors descri bedto a mi nor degree
at least.
Dependency i nevi tabl y breeds resentment in
our cul ture. I f outl ets for the resentment are
not avai l abl e and if compensati ons for a de
val ued sel f-i mage cannot be pursuedin other
words, if the indi vi dual cannot readi l y switch
from one engi ne to anotherthen the conflict
and stress reach proporti ons where one feels
catastrophi cal l y overwhel med. When the ten
sion mounts excessively and there seems to be
no way of escape, anxi ety stri keswhi ch is the
feeling that one is overwhel med and lost.
Operati ons to defend agai nst the anxi ety will
be insti tuted, but the defense is often ineffective
or more burdensome than the condi ti on it was
desi gnated to combat.
Case History
T he pati ent, Roger, was a man in hi s mi d 30s gentl eman presented hi msel f wi th an expressi on of
whose wife tel ephoned my secretary for an appoi nt- depressi on and bewi l derment. T he probl em, he
ment. At the i ni ti al i ntervi ew a wel l -groomed sai d, started whi l e di scussi ng seemi ngl y casual mat-
ters wi th hi s best fri end and partner duri ng a l unch
hour. He was overwhel med wi th a feel i ng of pani c,
wi th violent heart pal pi tati ons and choki ng sensa
ti ons, whi ch forced hi m to excuse hi msel f on the
basi s of a sudden i ndi sposi ti on. Back at work, he
recovered partl y, but a sensati on of danger en
vel oped hi m a confoundi ng agoni zi ng sensati on,
the source of whi ch el uded all attempts at under
standi ng. Upon returni ng home, he poured hi msel f
two extra j i ggers of whi skey. Hi s fear sl owl y van
ished so that at di nner ti me he had al most com
pl etel y recovered hi s composure. T he next morni ng,
however, he approached hi s work wi th a sense of
forebodi ng, a feel i ng that became stronger and
stronger as the days and weeks passed.
Roger had obviously experi enced an anxi ety
attack the source of whi ch became somewhat
cl earer as he conti nued his story.
T he most upsetti ng thi ng to Roger was the di s
covery that his symptoms became most vi ol ent whi l e
at work. He found hi msel f constantl y obsessed at
the office wi th ways of returni ng home to hi s wife.
Weekends brought temporary surcease; but even
anti ci pati ng returni ng to hi s desk on Monday was
enough to fill hi m wi th forebodi ng. He was unabl e
to avoi d comi ng l ate morni ngs, and, more and more
often he excused hi msel f from appeari ng at work on
the basi s of a current physi cal ill ness. Because he
real i zed ful ly how hi s work was deteri orati ng, he
was not surpri sed when hi s fri end took hi m to task
for hi s deficiency. Forci ng hi msel f to go to work be
came easi er after Roger had consumed several
dri nks, but he found that he requi red more and
more al cohol duri ng the day to subdue hi s tensi on.
At ni ght he needed barbi turate sedati on to i nsure
even mi ni mal sleep.
T he surmi se that I made at this poi nt was
that somethi ng in the work si tuati on was tri g
geri ng off his anxiety. I felt that Roger had at
tempted to gai n surcease from anxi ety by i m
pl ementi ng mechani sms of control (first-line
defenses, see p. 94) such as tryi ng to avoid the
stress si tuati ons of work and deadeni ng his
feelings wi th alcohol and sedatives. These ges
tures seemed not too successful since he was
obli ged to remai n in the work si tuati on no
matter how much he wanted to avoid it.
Conti nui ng hi s story, Roger sai d that wi l d, un
provoked feel i ngs of pani c were not confi ned to hi s
work. Even at home, hi s habi tual haven of comfort
and safety, he experi enced bouts of anxi ety, whi ch
burst forth at i rregul ar i nterval s. Hi s sl eep, too, was
i nterrupted by ni ghtmari sh fears, whi ch forced hi m
to seek refuge in hi s wi fes bed. A pervasi ve sense of
hel pl essness soon compl i cated Rogers life. Fear of
bei ng al one and fear of the dark devel oped. Other
fears then occurred, such as fear of hei ghts, of open
wi ndows, of crowds, and of subways and buses. I n
the presence of hi s wi fe, however, these fears sub
si ded or di sappeared. Roger consequentl y arranged
matters so that hi s wi fe was avai l abl e as often as
possi bl e. For a whi l e she seemed to rel i sh thi s new
cl oseness, for she had resented what she had com
pl ai ned about for a l ong ti me hi s col dness and
detachment from her.
What apparentl y had happened was that
not being abl e to escape from the anxi ety-pro
voki ng si tuati on at work, and bei ng unabl e to
develop adequate fi rst-li ne defenses to control
or neutral i ze hi s anxi ety, Roger was retreati ng
to and sought safety in a dependent rel ati on
shi p wi th his wife (second-li ne defenses, see p.
96) that paral l el ed that of a smal l chil d wi th a
mother. Vari ous fears of the dark and of being
al one were indi cati ve of his chil dli ke hel pl ess
ness. Thi s ki nd of adaptati on obviously had to
fail.
Not l ong after thi s, Roger conti nued, he de
vel oped fantasi es of getti ng i nto acci dents and hav
ing hi s body cut up and muti l ated. When Roger
confi ded to hi s wife that he was greatl y upset by
these occurri ng fantasi es, she enj oi ned hi m to con
sul t a doctor. He rej ected thi s advi ce, contendi ng
that he was merel y overworked, and he promi sed to
take a wi nter vacti on, whi ch he was sure woul d re
store hi s mental cal m. Fearful thoughts conti nued to
pl ague Roger. He became fri ghtened whenever he
heard stori es of vi ol ence, and he avoi ded readi ng
new accounts of sui cides or murders. Soon he was
obsessed wi th thoughts of poi nted obj ects. Kni ves
terri fi ed hi m so that he i nsi sted that hi s wife conceal
them from hi m.
T he return to a chil dish dependent posi ti on
apparentl y mobi l i zed fears that in too close as
soci ati on wi th a mother fi gure he woul d be
subjected to mul ti l ati on and destructi on. Sex
ual feelings toward his wife were equated wi th
forbidden i ncestuous feelings for whi ch the
penal ty was bloody muti l ati on. Fantasi es of ac
cidents and bl oodshed could be reflections of
Rogers castrati on fears. The repeti ti on of the
oedi pal drama thus could follow a shatteri ng of
Rogers repressi ve system. Attempti ng to rei n
force repressi on by repressi ve (thi rd-l i ne
defenses, see p. 76), Roger empl oyed phobi a
formati on strivi ng to remove hi msel f from
symbols of muti l ati on such as knives and other
cutti ng i nstruments.
When asked if he had other symptoms or
fantasi es, Roger, in an embarrassed way, confided
that in the presence of forceful or strong men, he ex
peri enced a pecul i ar fear, whi ch he tried to conceal.
Someti mes he was aware of a desi re to throw hi s
arms around men and to ki ss them in a filial way.
T hi s i mpul se di sturbed Roger greatl y, as di d
fantasi es of nude men wi th huge geni tal organs. Hi s
sexual life conti nued to deteri orate. Whi l e he had
never been an ardent lover, he had pri ded hi msel f
on hi s potency. Hi s sexual powers now seemed to be
di sappeari ng, when he approached his wi fe, he was
i mpotent or had premature ej acul ati ons. T hi s upset
Roger and created fears that he never agai n woul d
functi on wel l sexual l y. T o di sprove thi s, he forced
hi msel f compul si vel y to attempt i ntercourse, onl y to
be rewarded by f urther f ai l ures. A nti ci patory
anxi ety soon made sexual rel ati ons a source of pai n,
and when hi s wife suggested that they abstai n, he
agreed, but he was fri ghtened that she woul d leave
hi m for another man.
The fear Roger mani fested of strong males,
the desire to act in an affecti onate way wi th
them, the terror of homosexual assaul ts by
nude men wi th huge genital organs were, if we
follow our previ ous line of reasoni ng, the
products of his fear of attack by father fi gures
i rate at his appropri ati on of the maternal ob
j ect. A di si ntegrati on of Rogers sexual life was
inevi tabl e because he was rel ati ng to his wife
not as a husband but as a child. Abandonment
of a mal e role wi th his wife was, therefore,
necessary to avoid anxiety. Whi l e serving as a
spuri ous protecti ve device, his sexual i nhi bi ti on
obviously further undermi ned his self-esteem.
I n attempti ng to make a tentati ve diagnosi s
of Rogers condi ti on at thi s point, I was con
fronted wi th the contemporary contradi cti ons
that pl ague our attempts at cl assi fication. All
emoti onal difficulties spread themsel ves over a
wi de pathol ogi cal area, involving every aspect
of the persons functi oni ngintell ectual , emo
ti onal, physi cal, and behavi oral . Based as they
are on presenti ng compl ai nts and symptoms,
systems of nosology often lose sight of the fact
that the enti re human being is embraced
in any emoti onal upheaval . T he parti cul ar
classi fication into whi ch a pati ent fits then may
depend merel y upon the rel ati ve emphasi s the
di agnosti c agent (i.e., the therapi st) or the pa
ti ent puts upon selected symptoms.
Thi s may be i l l ustrated in the case of Roger.
Hi s compl ai nts were those of tension, i r
ri tabi l i ty, explosiveness, anxi ety, depressi on,
psychosomati c symptoms, phobi as, and ob
sessive thoughts. I n addi ti on, he exhi bi ted a
character di sturbance in such mani festati ons as
excessi ve submi ssi veness and dependency.
Were Roger chiefly concerned wi th his physi
cal ai l mentshis headaches, dyspepsi a, list
lessness, fatigue, faili ng heal th, or i mpotence
we woul d be incl ined to regard hi m as a per
son sufferi ng from physi cal di sorders of psy
chological ori gi n, that is, a type of somatoform
di sorder. Shoul d hi s anxi ety attacks have
caused hi m greatest concern and were he to
have focused his attenti on on his anxi ety, we
mi ght classify hi m as anxi ety di sorder. I n the
event his depressi on was of pri me i nterest, a
di agnosi s of psychoneuroti c or reacti ve
depressi on mi ght be entertai ned. I f emphasi s
had been put on his obsessive concern wi th
bloody amputati ons, death, and poi nted objects,
he mi ght be call ed an obsessive di sorder. Hi s
fear of heights, subways, buses, and crowds and
of sol itude and the dark are those often found in
phobi c di sorders. Fi nal l y, had hi s sub
mi ssi veness, passi vi ty, and other character
defects been consi dered his most si gnifi cant
probl em, he mi ght be label ed as a personal i ty
di sorder. T he matter of di agnosi s, then,
woul d be essential ly a matter of what seemed
i mmedi atel y i mportant. Actuall y, we mi ght say
that Roger suffered from a mi xed psychoneu
rotic disorder wi th anxi ety, depressive, psy-
chophysiologic, obsessive, phobic, and di storted
personal i ty el ements. T hi s di agnosti c pot
pourri is not surpri si ng when we consi der that
every i ndi vidual whose homeostasi s has broken
down exploi ts dynami sm characteri sti cs of all
levels of defense in addi ti on to di spl ayi ng
mani festati ons, psychol ogi cal and physi o
logical, of homeostati c i mbal ance and adapta-
ti onal collapse.
When Roger was asked what he beli eved had
preci pi tated hi s anxi ety ori gi nal l y, he was unsure,
but he hazarded that it mi ght have been rel ated to a
change in hi s posi ti on at work. Not l ong after hi s
tenth weddi ng anni versary, at age 33, Roger was
promoted to seni or member of the fi rm. Hi s el ati on
at thi s was short-l i ved as he became consci ous of a
sudden depressed feel i ng, whi ch progressi vel y
deepened. I nerti a, boredom, and wi thdrawal from
hi s ordi nary sources of pl easure fol lowed. Even hi s
work, to whi ch he had felt hi msel f devoted, became
a chore. Al ways eager to cooperate, he experi enced,
duri ng work hours, a vague dread of somethi ng
about to happen whi ch he coul d not defi ne. He
coul d not understand why he woul d react to a pro
moti on that he wanted by getti ng upset.
Shoul d a therapi st not be interested in
pursui ng the pati ents symptoms further to de
termi ne thei r ori gi n in earl y past experi ence or
in unconsci ous conflict, in other words, avoi d
ing a dynami c approach, an abbrevi ated ap
proach ai med at symptom reducti on mi ght
now be selected wi thout further probi ng into
history.
Fi rst, an effort may be made to treat his
symptoms through medi caments, like sedatives
or tranqui l i zers for anxi ety and energi zers for
depression. Roger may be enjoi ned to slow
down in his acti vities and to detach hi msel f as
much as possible. He mi ght be requested to
take a vacation, engage in hobbies and recrea
ti ons in order to divert his mi nd off his diffi cul
ties.
Another way of handl i ng the probl em mi ght
be to assume the source of the difficul ty to be
Rogers work si tuati on and to get hi m to
change his job to one that di d not i mpose too
great responsi bi l i ty on hi m. He woul d be en
couraged to try to detach himsel f more from
his wife and slowly to begin functi oni ng agai n
on the basis of the customary di stances that he
erected between hi msel f and others. Active
gui dance and reassurance may make it possible
for Roger to return to his own bedroom and to
assume the reserve wi th his wife that would
enabl e hi m to function wi thout anxiety.
On another level, the therapi st mi ght utili ze
behavi or modi fi cati on methods to desensiti ze
the pati ent to his anxi eti es as well as to i n
sti tute asserti ve trai ni ng to promote greater
self-sufficiency and independence. Approaches
such as these understandabl y woul d not correct
any basic character probl ems that lay at the
heart of Rogers distress. Yet they mi ght make
it possible for hi m to get al ong perhaps as well
as he had ever done pri or to the outbreak of
his neurosis.
Since my approach was a dynami c form of
short-term therapy ai med at some personal i ty
rectificati on, I proceeded to expl ore as com
pletely as I could his past life through i nter
vi ewi ng and to probe for more unconsci ous
moti vati onal el ements through expl orati on of
dreams and fantasies and through observati on
of the transference.
Roger was the younger of two brothers. He was
reared by a domi neeri ng mother who was resentful
of her rol e as housewi fe, whi ch had hal ted a success
ful career as a fashi on desi gner. Unhappy in her
love life wi th her husband, she transferred her affec
ti on to her younger son, mi ni steri ng to hi s every
whi m and smotheri ng hi m wi th cl oyi ng adul ati on.
Rogers brother, George, bi tterl y contested thi s
si tuati on, but getti ng nowhere, he subj ected hi s si b
l i ng to cruel repri sal . Rogers father, recoi l i ng from
the not too wel l concealed hosti l i ty of hi s wife,
removed hi msel f from the fami l y as much as he
coul d manage and had very li ttle contact wi th hi s
sons.
The dynami cs in Rogers case became ap
parent duri ng therapy. Basic to his probl em
was a di sturbed rel ati onshi p wi th his parents,
parti cul arl y his mother. T he yiel ding of her
120
unmarri ed professi onal status to assume the
role of housewife apparentl y had created in the
mother resentment toward her husband and
rej ecti on of her chi l dren. Thi s i nspi red a
reaction formati on in the form of overpro
tection, parti cul arl y toward her younger chil d,
Roger. Frustrated and unful fil led, she used
Roger as a target for her own needs and ambi
ti ons wi th the fol lowing effects: (a) in Roger,
encouragement of overdependence and pas
sivity, strangl i ng of asserti veness and i nde
pendence, and sti mul ati on of excessive sexual
feelings toward the mother and (b) in George,
hostil ity di spl ayed directl y toward Roger as
aggression, and (c) in her husband, detach
ment.
Overprotected by hi s maternal parent, negl ected
by hi s father, and abused by hi s brother, Roger took
refuge in the rel ati onshi p offered hi m by hi s mother.
Hi s dependency on her nurtured submi ssi veness and
passi vi ty, wi th al ternati ve stri vi ngs of rebel l i ousness
and fi erce resentment whi ch he repressed because
they threatened the securi ty he managed to deri ve
through compl i ant behavi or. Roger both cheri shed
and l oathed the crushi ng attenti veness of hi s
mother. T oward hi s father and brother he felt a
smotheri ng fear, whi ch he masked under a cl oak of
admi rati on and compl i ance.
The wi thdrawal of his father made it dif
ficult for Roger to achieve the identification
wi th a mascul i ne object necessary for a virile
conception of hi mself. Roger turned to his
mother for protecti on. He revol ted, however,
agai nst too great dependency on her, feari ng
that excessive closeness woul d rob hi m of
asserti veness and that his aroused sexual feel
ings woul d bri ng on hi m di sapproval from his
mother as well as puni shment from his father
and brother. Repudi ati ng competitiveness wi th
the other mal e members of the famil y, he at
tempted to wi n thei r approval by a submissive,
i ngrati ati ng atti tude.
Duri ng adol escence Roger emerged as a qui et,
detached l ad, never permi tti ng hi msel f to be drawn
i nto very i nti mate rel ati onshi ps. He was an ex
cel l ent and consci enti ous student, and he was well
l i ked for hi s fai rness and ami abi l i ty. At coll ege he
was reti ri ng, but he had a number of fri ends who
sought hi s compani onshi p because he was so easy to
get al ong wi th. Hi s romanti c attachments were
superfi ci al , and the young women he squi red to
parti es admi tted that he was attracti ve but com
pl ai ned that it was di ffi cult to get to know hi m.
Adopti ng detachment as a defense agai nst a
dependent invol vement, and compl i ance as a
means of avoi di ng physi cal hurt, Roger evolved
a character structure that enabl ed hi m to func
ti on at home and at school , al though at the ex
pense of compl etel y grati fyi ng rel ati onshi ps
wi th people.
Upon l eavi ng coll ege, he entered a busi ness fi rm,
arrangements for thi s havi ng been made by hi s
father. He resi sted for two years the exhortati ons of
hi s mother to marry the daughter of one of her best
fri ends; but fi nal l y he succumbed, and he seemed
satisfied and happy in hi s choice. T he young coupl e
li ved in harmony, and he was consi dered by hi s
group to be an i deal exampl e of an attenti ve hus
band and, after hi s son was born, of a devoted
father. Hi s steadfast appl i cati on to hi s work soon
el evated hi s posi ti on, unti l he became a j uni or
member of the fi rm. Hi s best fri end and confi dant
was one of the seni or members, toward whom
Roger bore the greatest respect and admi rati on.
Hi s work and mari tal life, whi ch were more
or less arranged for hi m by his parents, turned
out to be successful since he was able to em
ploy in them his compl i ance and detachment
mechani sms. Toward his best friend and other
seni or fi rm members Roger rel ated passively as
he had rel ated previ ousl y toward his father
and brother. Toward his wife he expressed
conventi onal devoti on, keepi ng himsel f suffi
ciently di stant to avoid the trap of a tempti ng
dependent rel ati onshi p that woul d threaten the
i ndependent asserti ve rol e he was struggl i ng to
mai ntai n.
T he onl y di stressi ng el ement in Rogers life was
hi s fai l i ng heal th. Constantl y fati gued, he evi denced
a pal l or and li stl essness that i nspi red many so
l i ci tous i nqui ri es. Dyspepti c attacks and severe mi
grai nous headaches i ncapaci tated hi m from ti me to
ti me. I n addi ti on to hi s physi cal symptoms was a
pervasi ve tensi on, whi ch coul d be rel i eved onl y by
recreati onal and social di stracti ons.
I nner confl i ct between dependency, sub
missiveness, compl i ance, detachment, and ag
gressi on, however, constantl y compromi sed
Rogers adj ustment, produci ng a di srupti on of
homeostasi s wi th tension and psychosomati c
symptoms. Hi s faili ng heal th, fatigue, pal l or,
listlessness, dyspepti c attacks, and mi grai nous
headaches were evidences of adapti ve i mbal
ance. What inspi red this i mbal ance was an i n
vasi on of his capaci ty to detach, produced by
the demands made on hi m by his wife and as
sociates. I n addi ti on, his submissive and com
pl i ant behavi or, whi l e protecti ng hi m from
i magi ned hurt, engendered in hi m overpower
ing hostil ity, whi ch probabl y drai ned itself off
through his automati c nervous system produc
ing physical symptoms.
As mi ght be expected, Rogers affabil i ty and
needs to pl ease won for hi m the prai se of hi s superi
ors at work, and he was advanced and fi nal ly of
fered a seni or posi ti on.
Had Roger at thi s poi nt refused to accept
seni or membershi p in the fi rm, he mi ght have
escaped the catastrophe that finall y struck him.
Hi s legi ti mate desi res for advancement, how
ever, enjoi ned hi m to accept. Hi s conflict be
came more and more accentuated unti l finall y
he no longer was abl e to marshal further
defenses. Col l apse in adaptati on wi th hel pl ess
ness and expectati ons of i nj ury announced
themsel ves in an anxi ety attack duri ng
l uncheon wi th his friend.
As long as he had been abl e to satisfy to a
reasonabl e degree his needs for security, asser
tion, satisfacti on in work and pl ay, and crea
tive self-fulfillment, Roger was abl e to make a
tol erabl e adj ustment even wi th his psychoso
mati c symptoms. T he preci pati ng factor that
had brought about the undermi ni ng of Rogers
capaci ties for adaptati on was his promoti on to
seni or membershi p in the fi rm. Whi l e Roger
had ardentl y desi red thi s promoti on, for
reasons of both status and economi cs, actual l y
bei ng put in a posi ti on of pari ty wi th hi s friend
viol ated his defense of passivity, compl i ance,
and subordi nati on and threatened hi m wi th
the very hurt he had anti ci pated as a chil d in
rel ati onshi p to his father and brother. T o ac
cept the promoti on meant that he woul d be
chal l engi ng of and perhaps tri mphant over
father and brother figures. Thi s touched off
fears of i nj ury and destructi on at the hands of
a powerful and puni ti ve force he could nei ther
control nor vanqui sh. Y et Rogers desi re for
advancement, i nspi red by real istic concerns,
made it impossi bl e for hi m to give up that
whi ch he consi dered his due. Since he was
aware nei ther of how fearfull y he regarded au
thori ty nor of how he was operati ng wi th
chil dish atti tudes, he was nonpl ussed by his
reactions.
A dream reveal ed duri ng one psychotherapy
sessi on wi l l i l l ustrate some of our pati ents
maneuvers that became operati ve and apparent in
therapy.
Pt. I had a dream last ni ght that upset me. I am in
bed wi th thi s bi g woman, bi g wonderful
breasts. Shes my wi fe, but she changes i nto a
negress. She strokes and touches me al l over,
and I feel compl etel y loved and accepted. I
awoke from the dream wi th a strong homosex
ual feel i ng that upset me. [Here R o ge r sy mb o
lizes in dream str ucture his dependency i m
p ulse s, his repulsion against his dependency,
his incestuous desire, a nd the re sultant ho
mo s e x ua l residue.]
Th. Y es, what do you make of thi s?
Pt. I dont know. T he woman was comforti ng and
seducti ve. I al ways li ke bi g-breasted women.
Exci ti ng. But my wife i snt as stacked as I d
like her, or as she was in the dream, (pause)
Th. How about the negress?
Pt. I never li ked the i dea of sl eepi ng wi th a col ored
woman. Makes me feel creepy. Col ored peopl e
make me feel creepy. I know I shoul dnt feel
that way. L ast ti me I was here I noti ced you
had a tan li ke you had been i n the sun. I sai d,
Maybe hes got negro bl ood. I know I
shoul dnt care if you di d or not, but the idea
scared me for some reason.
T h. Sounds li ke the woman in your dream was
partl y me. [This i nterpretation was p roffer ed
in the hope o f s tir ring up some tension to
f a cilitate associations.]
Pt. (pause) T he idea scares me. Why shoul d I
want you to make love to me? (pause) By God,
maybe I want you to mother me, be gi vi ng,
ki nd.
T h. How do you feel about me?
Pt. I want you to be perfect li ke a God; to be ac
cepti ng and l ovi ng; to be wi se and strong. I
real i ze I m dependent \motor one], I resent my
need to be dependent on you [mo t o r two].
When you show any weakness, I am furi ous. I
feel gui l ty and upset about my feeli ngs. I feel
like ki l l i ng anybody who control s me. I know I
must face responsi bi l i ty, but I feel too weak
and unmascul i ne \motor three], I feel li ke a
shi t [mo t o r f o u r j and hate myself. I am a
nothi ng and I d li ke to be a somebody, but I
cant.
T h. A pparentl y it scares you to be a somebody.
When you were promoted, you started getti ng
upset.
Pt. Why shoul d I ? I suppose I feel li ke I m step
pi ng out of my depth. L i ke I m not man
enough. T he whol e thi ng puzzl es and fri ghtens
me.
T h. So what do you do?
Pt. I am constantl y runni ng away [m o t or f i v e ] , I
get so angry at peopl e. I dont want to see any
body. I m so upset about myself. I try not to
feel. But I cant seem to make it on my own.
[ T h e r e i n s t i t u t in g o f mo t o r o n e ]
FIG. 9-1. Personality Mechanisms*
THE FIVE MOTORS
MOTOR ONE
HIGH DEPENDENCE
"I want you to be perfect, like a God; to be
accepting and loving; to be wise and
strong."
MOTOR TWO
RESENTMENT
HOSTILITY
"I resent my need to be dependent on
you. When you show any weakness, I am
furious. I feel guilty and upset about my
feelings. I feel like killing anybody who
controls me."
MOTOR FOUR
DEVALUED SELF-IMAGE
"I feel like a shit and hate myself. I am a
nothing and I'd like to a somebody, but I
can't."
MOTOR THREE
LOW INDEPENDENCE
"I know I must face responsibility, but I
feel too weak, and unmasculine." (In fe
males: "If I were a man, I would be strong
and independent.")
MOTOR FIVE
DETACHMENT
"I am constantly running away. I get so
angry at people. I don't want to see any
body. I'm so upset about myself. I try not
to feel."
* From L . R. Wol berg and J . K ildahl, T h e D y n a m i c s o f P e r s o n a l i t y (New Y ork, Grune & Stratton, 1970), p. 215.
Repri nted by permissi on.
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The pati ent in the session was mani festly
gropi ng wi th his passi ve-dependent strivi ngs
(motor one), his rage (motor two), his feel ings
of low i ndependence (motor three), hi s de
valued self-image (motor four), his detachment
(motor five), together wi th concomi tant unre
solved i ncestuous drives and unexpressed ho
mosexual impulses. Many aspects of Rogers
personal i ty probl em were bei ng proj ected onto
his therapi st in transference.
These patterns are del i neated in Fi gure 9-1.
I nterpretati on of the pati ents reacti ons to me
in terms of his habi tual personal i ty responses,
connecti ng them wi th his experi ences in grow
i ng up and rel ati ng them to the inci dents l ead
i ng to the coll apse in his homeostasi s, enabl ed
Roger to approach a different rel ati onshi p
wi th me. Thi s occurred about the twenti eth
sessi on and acted as a nucl eus for different feel
ings toward himself. Not onl y was homeostasi s
restored wi th cessation of his symptoms, but he
al so was abl e to accept his post as a seni or
member of the fi rm wi th subjecti ve and objec
ti ve strengtheni ng of his ego.
Conclusion
Common psychodynami cs are shared by
peopl e i n our cul ture. T hey i ncl ude the
ravages of hi gh dependency, resentment and
hostil ity, low i ndependence, a deval uated self-
image, and detachment. I t is the degree of
intensi ty of these drives that determi ne thei r
pathogeni city. Offshoots from resentment i n
clude aggression, perhaps to the poi nt of
sadi sm, and al so guil t resul ti ng from the hate
ful feelings, even eventuati ng in masochism.
Hi gh dependency is associated wi th passivity
and a femi ni ne i denti fi cati on. Feel i ngs of
hostil ity sponsor guil t, masochi sm, aggression,
and sadi sm. L ow i ndependence prompts the
overcompensatory strivi ngs of compul si ve ag
gressiveness and competitiveness, maki ng for a
neuroti c mascul i ne identification. A devalued
sel f-i mage al so leads to compensatory measures
such as perfecti oni sm, .ambi ti ousness, and
power dri ves. And detachment often provokes
one to abandon ones isolation and pl unge into
compul si ve gregari ousness. Any and all of
these dri ves may become sexual i zed, so that
ones sexual impul ses become li nked to feel ings
of incestuous passivity or competitive domi na
ti on wi th consequent fears of retal i ati on or
wi th masochi sti c or sadisti c impulses. When
these drives fail to mai ntai n homeostasi s and
conflict is unresolved, then anxi ety resul ts and
vari ous levels of defense mechani sms operate to
cope wi th the anxi ety. A great many dynami c
themes eventuate (see Fi gure 9-2) and offer
themsel ves as possible foci for expl orati on.
CHAPTER 10
C. Presenting Interpretations
The most effective focus is one that deals
wi th a basic repetitive conflict, the mani fest
form of whi ch is bei ng expressed through the
i mmedi ate compl ai nt factor. As an exampl e,
consi der a crisis si tuati on invol ving a wife, the
mother of two small chi l dren, who insists on a
divorce because of conti nui ng di senchantment
wi th her marri age. The divorce decision ap
pears to be the termi nal erupti on of years of
di sappoi ntment in her husbands fai l ure to live
up to her ideal of what a man shoul d be like.
After we cut through endless compl ai nts, it be
came apparent that the standard agai nst whi ch
she measures her husband is her father, whom
she worshi ps as the epi tome of success and
mascul i ni ty. T hi s i deal i zati on actual l y has
little basi s in fact, bei ng the remnant of an un
resolved oedipal conflict. Be thi s as it may, it
has thwarted her abil ity to make a proper ad
j ustment to her marri age, and now wi th the
decision of a divorce the i ntegri ty of her fami l y
is being threatened. She comes to therapy at
the urgi ng of her l awyer who real i zes that she
is too upset at present to make reasonabl e deci
sions.
A therapi st who mi ni mi zes the i mportance
of dynami c conflicts may attempt to achieve the
goal of crisis resol uti on by invoki ng logic or
appeal s to common sense. He may suggest
ways of patchi ng thi ngs up, insisting that for
the sake of the chi l dren a father, however
i nadequate, is better than no father. He may,
upon consul ti ng wi th the husband, poi nt out
vari ous compromi ses the husband can make,
and after the wife has verbal l y di sgorged a
good deal of her hostil ity in the therapeuti c
sessi on, she may be wi l l i ng to cancel her di
vorce pl ans and settl e for hal f a loaf rather
than none. T he reconci l i ati on is executed
through a suppressi on of her hostil ity, whi ch
finds an outl et through sexual frigidi ty and
vari ous physi cal symptoms. On the other
hand, shoul d the therapi st recogni ze the core
confl ict that is moti vati ng her idea of divorce,
there is a chance that the pati ent may be
hel ped to an awareness of her mercil ess i n
volvement wi th her father and the destructi ve
unreasonabl eness of her fantasies of what an
ideal marri age is like. She may then all ow
hersel f to exami ne the real vi rtues of her hus
band and the true advantages of her exi sti ng
marri age.
A dynami c focus shoul d, therefore, be pros
pected in the course of expl ori ng the i mmedi ate
compl ai nt factor. Such a focus is often arri ved
at i ntui ti vel y (Bi nder, 1977). T he more
empathi c, skill ed, and experi enced the thera
pist, the more likel y he will be to expl ore the
actual operati ve dynami cs. However, no mat
ter how fi rml y convinced he is in hi s i m
medi ate assumpti ons, he real i zes that these are
bei ng predi cated on i ncompl ete data. He
knows that his pati ent may del i beratel y wi th
hol d i mportant i nformati on, or though the pa
ti ent may recogni ze certai n conflicts she is still
obli vious to thei r si gnificance or compl etel y
unaware of thei r existence. Whatever tentati ve
theori es come to the therapi sts mi nd, he will
conti nue to check and to revise them as further
i nformati on unfolds. I ntervi ews wi th rel ati ves
125
and friends are extremel y val uabl e since they
may open facets of probl ems not evident in the
conversati ons wi th the pati ent. Moreover, once
the pati ent duri ng the first encounter has di
vulged data, l ater i ntervi ews will hel p uncover
rati onal i zati ons, proj ecti ons, and di storti ons
that will force the therapi st to revi se his thesis
and concentrate on a different focus from the
one that ori gi nal l y seemed so obvious.
No matter how astute the therapi st has been
in exposi ng a trul y momentous focus, the pa
ti ents reacti ons will determi ne whether the ex
posure turns out to be fruitful or not. For ex
ampl e, even though an underl yi ng probl em is
causi ng havoc in a persons life and is
responsibl e for the crisis that bri ngs the person
to therapy, thi s does not impl y that the pati ent
will elect to do anythi ng about it. I ts emoti onal
meani ng may be so i mportant to the pati ent,
the subversive pl easures and secondary gains
so great, that sufferi ng and mi sery are easi ly
accepted as condi ti ons for the indul gence of
destructi ve drives even where the pati ent has
full insight into the probl em, recogni zes its
geneti c roots, and real izes the compl i cati ons
that inevi tabl y indemni fy the i ndul gence. I re
call one pati ent whose yearni ng for revenge on
a younger si bli ng produced a repetitive series
of competi ti ve encounters wi th surrogate
fi gures toward whom retal i atory hostil ities and
violence brought forth puni shment by em
ployees, coll eagues, and friends. A series of
abuses cul mi nated in a di sastrous inci dent in
whi ch a physi cal assaul t on a fellow empl oyee
resul ted in the pati ents di scharge from a
promi si ng executive posi ti on. Thi s happeni ng
was so widely publi cized in the i ndustry that
the pati ent was unabl e to secure another j ob.
Duri ng therapy the pati ent was confronted
wi th the meani ng of his behavi or and parti cu
l arly his revenge and masochistic motives; he
readi l y recogni zed and accepted thei r vali dity.
Thi s did not in the least deter his acti ng out on
any occasi on when he could vent his rage on a
si bli ng figure. At the end of our bri ef treatment
peri od, it was recommended that he go into
l ong-term therapy, whi ch he bl untl y refused to
do. He seemed reconciled to pursue a damag
ing course for the momentary j oy that followed
an outburst of aggression.
Experi ence wi th the addi cti ons provi de
ampl e evidence of the futil ity of focusing on the
dynami cs of a dangerous and what appears on
the surface to be a di sagreeabl e way of behav
ing. But, that some pati ents di sregard logic
does not null ify the need to persist in mak
ing careful i nterpretati ons in the hope of
eventual l y erodi ng resi stance to the voice of
reason.
We may expect that a pati ent in need of
hel p will communi cate sufficiently to suppl y
essential materi al from whi ch a focus may be
extrapol ated. Understandabl y, there will be
differences in emphasi s among therapi sts, even
among those who have recei ved si mi l ar
theoreti cal groundi ng. The avai l abl e materi al
is usual l y sufficiently ri ch to enabl e therapi sts
to empathi ze wi th aspects that synchroni ze
wi th thei r needs, i ntui ti ons, ideas, and biases.
Since all peopl e share certai n conflicts that
are basic in our cul ture, some of these can con
sti tute the dynami c focus around whi ch i nter
pretati ons are made. Thus mani festati ons of
the struggl e over separati on-i ndi vi duati on fol
lowi ng the ideas of Mann (1973), persistence
of oedi pal fantasies as exempl ified in the work
of Sifneos (1972), and residues of psychic
masochi sm such as described by L ewi n (1970)
are some of the core conflicts that may be ex
pl ored and i nterpreted. Sensi ti zi ng onesel f to
indi cati ons of such conflicts as they come
through in the pati ents communi cati ons, the
therapi st may repeatedl y confront the pati ent
wi th evidence of how he is bei ng victimized by
the operati ons of speci fic i nner saboteurs.
There is scarcely a person in whom one may
not, if one searches assidiously enough, fi nd i n
dications of i ncompl ete separati on-i ndi vi dua
ti on, fragments of the oedi pal struggle, and
surges of guil t and masochi sm. I t is essential ,
however, to show how these are i nti matel y
connected wi th the anxi eti es, needs, and
defenses of each pati ent and how they ul ti
matel y have brought about the symptoms and
behavi oral difficulti es for whi ch the pati ent
seeks help.
CHOOSING A DYNAMIC FOCUS: PRESENTING INTERPRETATIONS 127
Lest we overemphasi ze the power of insight
in bri ngi ng about change, we must stress that
to a large extent the choice of a focus will
depend on the therapi sts seeing the presenti ng
probl em of the pati ent through the lens of his
theoreti cal convictions. A Freudi an, J ungi an,
A dl eri an, K l ei ni an, Horneyi te, Sul l i vani an,
Exi stenti ali st, or behavi or therapi st will focus
on different aspects and will organi ze a treat
ment pl an in accordance wi th personal i deol
ogies. Whi l e the focus, because of thi s, will
vary, there is consi derabl e evidence that how
the focus is i mpl emented and the qual i ty of the
rel ati onshi p wi th the pati ent are at least as i m
portant factors in the cure, if not more so, than
the prescience of the therapi st and the i nsi ght
ful bone of dynami c wi sdom he gives the pa
ti ent to chew on. T hat i mpl antati ons of insight
someti mes do al ter the bal ance between the
repressed and repressi ve forces cannot be
disputed. How much the benefi ts are due to
this factor and how much are the product of
the placebo effect of insight, however, is dif
ficult to say. Where a therapi st is fi rml y con
vinced of the vali dity of the focus he has chosen
and he convinces his pati ent that neuroti c
demons wi thi n can be controll ed through ac
cepti ng and acti ng upon the i nsi ghts
presented, tension and anxi ety may be suffi
ciently lifted to relieve symptoms and to pro
mote producti ve adaptati on. Even spuri ous
insights if accepted may in thi s way serve a
useful purpose. Wi thout questi on, neverthe
less, the closer one comes in approxi mati ng
some of the sources of the pati ents current
troubles, the greater the li keli hood that si gnifi
cant benefits will follow.
I n this respect for some years I have em
ployed a scheme that I have found val uabl e in
worki ng wi th pati ents. Thi s consi sts of study
ing what resistences ari se duri ng the i mpl e
mentati on of the techni ques that I happen to
be empl oyi ng at the ti me. T he resistances will
yield data on the existi ng dynami c conflicts,
the most obstructi ve of whi ch is then chosen as
a focus.
Experi ence wi th large numbers of pati ents
convinces that three common devel opmental
probl ems i ni ti ate emoti onal difficul ties and
create resistance to psychotherapyfirst, high
levels of dependency (the product of i nadequate
separati on-i ndi vi duati on), second, a hypertro
phi ed sadisti c conscience, and, thi rd, deval uated
self-esteem. Coexi sti ng and rei nforci ng each
other, they create needs to fasten onto and to
di strust authori ty, to torment and puni sh
onesel f masochistical ly, and to wal l ow in a
swamp of hopeless feelings of inferiority and
ineffectuality. They frequentl y sabotage a ther
api sts most skill ed treatment interventi ons,
and, when they mani fest themsel ves, unless
deal t wi th del i beratel y and fi rml y, the treat
ment process will usual l y reach an unhappy
end. Dedi cated as he may be to thei r resol u
ti on, the most the therapi st may be abl e to do
is to poi nt out evidences of operati on of these
saboteurs, to del i neate thei r ori gi n in earl y life
experi ence, to indi cate thei r destructi ve i mpact
on the achi evement of reasonabl e adapti ve
goals, to warn that they may make a shambl es
out of the present treatment effort, and to en
courage the pati ent to recogni ze his personal
responsi bi l i ty in perpetuati ng thei r operati on.
The tenaci ous hold they can have on a pati ent
is i l l ustrated by thi s fragment of an intervi ew.
The pati ent, a wri ter, 42 years of age, who
made a ski mpy living as an edi tor in a publ i sh
ing house came to therapy for depressi on and
for hel p in worki ng on a novel that had defied
compl eti on for years. A nger, gui l t, shame
and a host of other emoti ons bubbl ed over
whenever he compared hi msel f wi th his more
successful coll eagues. He was in a customari l y
frustrated, despondent mood when he com
plai ned:
Pt. I j ust cant get my ass movi ng on anythi ng. I
sit down and my mi nd goes bl ank. Stari ng at a
bl ank pi ece of paper for hours, I fi nal l y give
up.
Th. T hi s must be terri bl y frustrati ng to you.
Pt. (a n gr i l y ) Frustrati ng is a mi l d word, doctor. I
can kill mysel f for bei ng such a shit.
Th. Y ou real l y thi nk you are a shi t?
Pt. (a n g r i l y ) Not onl y do I thi nk I am a shi t, I am
a shi t, and nobody can convi nce me that I m
not.
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Th. Frankl y, Fred, I m not even goi ng to try. But
you must have had some hope for yoursel f,
otherwi se you never woul d have come here.
Pt. I fi gured you coul d get me out of thi s, but I
know i ts no use. Fve al ways been a tai l ender.
Th. (confronting the patient) Y ou know, I get the
i mpressi on that youve got an i nvestment in
hol di ng on to the i mpressi on you are a shit.
What do you thi nk you get out of thi s?
Pt. Nothi ng, absol utel y nothi ng. Why shoul d I
need thi s?
Th. Y ou tell me. [In his upbringing the patient
was exposed to a rejecting father who de
manded perfection from his son. The father
was never satisfied with the even better than
average marks his son obtained at school and
compared him unfavorably with boys in the
neighborhood who were prominent in athletics
and received commendations for their school
work. It seemed to me that the paternal in-
troject was operating in the patient long after
he left home, carrying on the same belittling
activities that had plagued his existence when
he was growing up. ]
Pt. (pause) T here is no reason, (pause)
Th. Y ou know I get the i mpressi on that you are
doi ng the same j ob on yoursel f now that your
father di d on you when you were a boy. I ts
li ke youve got hi m in your head. [In the first
part of the session the patient had talked about
the unreasonableness of his father and his own
inability to please his father.]
Pt. I am sure I do, but knowi ng thi s doesnt hel p.
Th. Coul d it be that if you make yoursel f hel pl ess
somebody wil l come al ong and hel p you out?
[I was convinced the patient was trying to
foster a dependent relationship with me, one in
which I would carry him to success that defied
his own efforts. ]
Pt. Y ou mean, you?
Th. I snt that what you sai d at the begi nni ng, that
you came to me to get you out of thi s thi ng?
Y ou see if I let you get dependent on me it
woul dnt real l y solve your probl em. What I
want to do is hel p you hel p yoursel f. T hi s wil l
strengthen you.
Pt. But if I cant hel p myself, what then?
Th. From what I see there i snt any reason why
you cant get out of thi s thi ngthi s self
sabotage. ( The patient responds with a dubi
ous expression on his face and then quickly tries
to change the subject.)
I n the conduct of bri ef treatment one may
not have to deal wi th the underl yi ng conflicts
such as those above as long as the p ati en t is
moving along and making progress. It is only
when therapy is bogged down that sources of
resistance must be uncovered. These as has
been i ndi cated, are usual l y rooted in the i m
mature needs and defenses of dependent,
masochistic, sel f-deval uati ng prompti ngs. At
some poi nt an expl anati on of where such
prompti ngs ori gi nated and how they are now
operati ng will have to be given the pati ent.
Thi s expl anati on may at fi rst fall on deaf ears,
but as the therapi st consi stently demonstrates
thei r existence from the pati ents reacti ons and
patterns, the pati ent may eventual l y grasp
thei r significance. T he desi re to make oneself
dependent and the destructi veness of thi s i m
pulse, the connecti on of sufferi ng and symp
toms wi th a pervasi ve desi re for puni shment,
the masochistic need to appease a sadi sti c con
science that deri ves from a bad parental in-
troject, the operati on of a deval ued self-image,
wi th the subversive gai ns that accrue from vic
ti mi zi ng oneself, must be repeated at every op
portuni ty, confronti ng the pati ent wi th ques
ti ons as to why he needs to conti nue to sponsor
such activities.
Someti mes a general outl i ne of dynami cs
(such as are detai l ed in Chapter 9) may be of
fered the pati ent wi th the object of ei ther sti r
ri ng up some anxi ety or resi stance or of pro
vidi ng the pati ent wi th an i nterpretati on that
fosters a better understandi ng of hi msel f.
Whi l e the del i neated dri ves and defenses are
probabl y typi cal in our cul ture of both
normal and neuroti c i ndi vi dual s, the specific
modes of operati on and the ki nds of symptoms
and mal adj ustments that exist are uni que for
each indi vi dual . Every person has a thumb,
but patterns of thumbpri nts are all different.
T he therapi st, empl oyi ng a bl uepri nt such as
Fi gure 10-1, may try to fit each pati ents
probl ems into it and then choose for focus
whatever aspects are most i mportant at the
moment. For exampl e, the pati ent may duri ng
a session compl ai n of a severe headache and
thereafter proceed to beat hi msel f masochi s
ticall y, bl ami ng hi msel f for being weak and
ineffectual. T he therapi st shoul d then search to
see how thi s trend affiliates itsel f wi th guil t
feel ings and what i mmedi ate si tuati on inspi red
such feelings. T he therapi st may discover that
what is behi nd the guil t is anger in the pati ent
at his wife for not living up to his expectati ons
in executing her househol d duti es. Further
probi ng may reveal anger at the therapi st for
not doi ng more for the pati ent. Such trans
ference mani festati ons may enabl e the thera
pist to make a connection wi th the pati ents
mother toward whom there has existed since
chil dhood a good deal of anger for her neglect
and rejecti on. Thi s will open up a discussi on of
the pati ents excessive dependency needs and
the i nescapabl e hostil ity, low independence,
and deval ued sel f-esteem that dependency
bri ngs about. An associ ati on may be es
tabl ished between the pati ents hostil ity turned
i nward and the mi grai ne headaches for whi ch
therapy was sought in the first place. The
therapi st shoul d in thi s way take advantage of
every opportuni ty to show the pati ent the i n
terrel ati onshi p between hi s vari ous dri ves,
trai ts,' and symptoms, keepi ng in mi nd that
whi l e a certai n trend may encompass the pa
ti ents chief concern at the moment, it never
occurs in isolation. It is rel ated i nti matel y to
other i ntrapsychi c forces even though the con
necti on may not be i mmedi atel y clear.
An i ndi vidual can make a reasonabl e adj ust
ment for a l ong ti me even wi th a vul nerabl e
character structure. Hi s personal i ty motors,
defective as they may have been, still operate
harmoni ousl y; vari ous bal ances and counter
bal ances mai ntai n the psychological equi l i b
ri um. Then because of the i mposi ti on of an ex
ternal crisis si tuati on or because of stresses as
sociated wi th i nner needs and external de
mands, anxiety, depressi on, phobi as, and other
symptoms appear. The pati ent may consi der
that his adj ustment pri or to the presence of
some preci pi tati ng factor was satisfactory if not
ideal, wi th no awareness of how his tenuous
personal i ty i nteracti ons have been spon
soring vari ous symptoms and ul ti matel y had
produced his breakdown. He is very much like
a man wi th back pai n who credi ts his sci
ati ca to one inci dent of lifting a wei ght that
was too heavy, obli vious of the fact that for
months or years he has, through faul ty posture
and lack of exercise, been accumul ati ng weak
and strai ned muscles.
T hus a pati ent whose sel f-i mage is being
sustai ned by a defense of perfecti onism, for as
far back as he can remember, will have to per
form flawlessly even in ti ny and most i ncon
sequenti al areas of achi evement. T o perform
less than perfect is tantamount wi th fai l ure and
si gnals i nferi ori ty and a shattered identity. The
mercil ess demands he makes on hi msel f may
actual l y be i mpossi bl e of ful fil lment. At a
certai n poi nt when he cannot face up to de
mands in some trul y i mportant si tuati on, his
fai l ure will act like a spark in an explosive mi x
ture. T he eventuati ng symptoms that finall y
bri ng hi m into treatment are depressi on and i n
somni a. I t will requi re little acumen for a thera
pist to spot the perfecti onistic trends around
whi ch the pati ent fashi ons his existence. But to
argue hi m out of his perfecti oni sm and to
counter the barrage of rati onal i zati ons evolved
over a lifetime are difficul t, if not i mpossi ble,
tasks. We may, nevertheless, attempt to work
wi th cognitive therapy and select perfecti oni sm
as a focus, poi nti ng out the di storti ons in logic
that govern the pati ents thi nki ng process. Not
all therapi sts have the skill and stami na to do
thi s, nor do we yet have suffici ent data to testify
to the efficacy of thi s approach in most cases.
What woul d seem i ndi cated is to review
wi th the pati ent the full i mpl i cati ons of his
perfecti onism, its rel ati onshi p to his defective
self-image, the sources of sel f-deval uati on in
i ncompl ete separati on-i ndi vi duati on, the oper
ati ons of masochi sm, and so forth. Obvi ousl y,
the therapi st must have evidence to justi fy
these connections, but even though he presents
an outl i ne to the pati ent of possibil ities and
sti mul ates the pati ent to make connecti ons for
himself, he may be able to penetrate some of
the pati ents defenses. Gi vi ng the pati ent some
idea about personal i ty devel opment may, as I
have indicated, be occasionall y helpful, espe
cially where insuffici ent ti me is avai l abl e in
therapy to pi npoi nt the preci se pathol ogy. Pa
ti ents are usual l y enthusi asti c at first at havi ng
received some clarificati on, and they may even
acknowledge that segments of the presented
outl ine rel ate to themselves. They then seem to
lose the significance of what has been reveal ed
to them. However, in my experi ence l ater on
in fol low-up, many have brought up perti nent
details of the outl i ne and have confided that it
sti mul ated thi nki ng about themsel ves. T hus in
the case of Roger described in the last chapter, I
gave hi m the fol lowing general i nterpretati on:
T h. I beli eve 1 have a fai r idea of what is goi ng on
wi th you, but I d like to start from the begi n
ni ng. I shoul d like to give you a pi cture of
what happens to the average person in the
growi ng-up process. From thi s pi cture you
may be abl e to understand where you fit and
what has happened to you. Y ou see, a chi l d at
bi rth comes i nto the worl d hel pl ess and de
pendent. He needs a great deal of affection,
care, and sti mul ati on. He al so needs to receive
the proper di sci pl i ne to protect hi m. I n thi s
medi um of lovi ng and understandi ng care and
di scipl i ne, where he is gi ven an opportuni ty to
grow, to devel op, to expl ore, and to express
hi msel f, hi s i ndependence gradual l y i ncreases
and hi s dependence gradual l y decreases, so
that at adul thood there is a heal thy bal ance be
tween factors of dependence and i ndependence.
Let us say they are equal l y bal anced in the
average adul t; a certai n amount of dependence
bei ng qui te normal , but not so much that it
cri ppl es the person. Normal l y the dependence
level may temporari l y go up when a person
gets sick or i nsecure, and hi s i ndependence will
temporari l y recede. But thi s shi ft is onl y
wi thi n a narrow range. However, as a resul t of
bad or depri vi ng experi ences in chi l dhood, and
from your hi story, thi s seems to have happened
to you to some extent [the p a t i e n t s f a t h e r a
salesman was away a g o o d deal o f the time and
his older brother brutally i n t i m i d a t e d him],
the dependence level never goes down suffi
ci entl y and the i ndependence level stays low.
Now what happens when a person in adul t life
has excessive dependency and a l ow level of i n
dependence? Mi nd you, you may not show all
of the thi ngs that I shal l poi nt out to you, but
try to fi gure out whi ch of these do appl y to
you.
Now, most peopl e wi th strong feeli ngs of
dependence wil l attempt to fi nd persons who
are stronger than they are, who can do for
them what they feel they cannot do for
themsel ves. I t is al most as if they are searchi ng
for i deal i zed parents, not the same ki nd of
parents they had, but much better ones. What
does thi s do to the i ndi vi dual ? Fi rst, usual l y he
becomes di sappoi nted in the peopl e he picks
out as i deal i zed parental fi gures because they
never come up to hi s expectati ons. He feels
cheated. For i nstance, if a man weds a woman
who he expects wil l be a ki nd, gi vi ng, protec
tive, mother fi gure, he wil l become i nfuri ated
when she fails hi m on any count. Second, he
fi nds that when he does rel ate hi msel f to a per
son onto whom he proj ects parental qual i ti es,
he begi ns to feel hel pl ess wi thi n hi msel f, he
feels trapped, he has a desi re to escape from
the rel ati onshi p. Thi rd, the feel i ng of bei ng de
pendent, makes hi m feel passi ve li ke a chil d.
T hi s is often associ ated in hi s mi nd wi th bei ng
nonmascul i ne; it creates fears of hi s becomi ng
homosexual and rel ati ng hi msel f passi vel y to
other men. T hi s rol e, in our cul ture, is more
acceptabl e to women, but they too fear ex
cessive passi vi ty, and they may, in rel ati on to
mother fi gures, feel as if they are breast-seek
ing and homosexual .
So here he has a dependency motor that is
constantl y operati ng, maki ng hi m forage
around for a parental i mage. I nevi tabl y they
di sappoi nt hi m. ( A t this p o i n t the p a t i e n t i n
te r r u p t e d a n d described h o w d isappointed he
was in his wife, h o w ineffective she was, how
unable she p r o v e d h e r s e l f to be in t a k i n g care
o f him. We discussed this f o r a m i n u t e and
then I con t i nu ed .) I n addi ti on to the de
pendency motor, the person has a second mo
tor runni ng, a resentment motor, whi ch oper
ates constantl y on the basi s that he is ei ther
trapped in dependency, or cannot find an
i deal i zed parental fi gure, or because he feels or
acts passi ve and hel pl ess. T hi s resentment pro
motes tremendous gui l t feel ings. After all , in
our cul ture one is not supposed to hate. But
the hate feel i ngs someti mes do tri ckl e out in
spi te of thi s, and on speci al occasi ons they gush
out, li ke when the person dri nks a li ttle too
much. (The patient laughs here and says this is
exactly what happens to him.) I f the hate feel
i ngs do come out, the person may get
fri ghtened on the basi s that he is l osi ng con
trol. T he very idea of hati ng may be so upset
ti ng to hi m that he pushes thi s i mpul se out of
hi s mi nd, wi th resul ti ng tensi on, depressi on,
physi cal symptoms of vari ous ki nds, and self-
hate. T he hate i mpul se havi ng been bl ocked is
turned back on the self. Thi s is what we call
masochi sm, the weari ng of a hai r shi rt, the
constant sel f-puni shment as a resul t of feed
back of resentment. T he resentment machi ne
goes on a good deal of the ti me runni ng
al ongsi de the dependency motor.
As if thi s werent enough, a thi rd motor gets
goi ng al ong wi th the other two. Hi gh de
pendence means l ow i ndependence. A person
wi th l ow feel i ngs of i ndependence suffers ter
ri bl y because he does not feel sufficient unto
hi msel f; he does not feel competent. He feels
nonmascul i ne, passi ve, hel pl ess, dependent. I t
is hard to live wi th such feel i ngs, so he may try
to compensate by bei ng overl y aggressi ve,
overl y competi ti ve, and overl y mascul i ne. Thi s
may create much troubl e for the person be
cause he may try too hard to make up for his
feeli ngs of loss of mascul i ni ty. He may have
fantasi es of becomi ng a strong, handsome,
overl y acti ve sexual mal e, and, when he sees
such a fi gure, he wants to identi fy wi th hi m.
T hi s may create in hi m desi res for and fears of
homosexual i ty, whi ch may terri fy some men
who do not real l y want to be homosexual .
I nteresti ngl y, in women a l ow-i ndependence
level is compensated for by her competi ng wi th
men, wanti ng to be li ke a man, acti ng li ke a
man, and resenti ng bei ng a woman. Homosex
ual i mpul ses and fears also may someti mes
emerge as a resul t of repudi ati on of femi ni ni ty.
A consequence of low feeli ngs of i nde
pendence is a deval ued sel f-i mage, whi ch starts
the fourth motor goi ng. T he person begi ns to
despi se hi msel f, to feel he is weak, ugl y, and
contempti bl e. He wi ll pi ck out any personal
evi dence for thi s that he can fi nd, like stature,
compl exi on, physi ognomy, and so on. I f he
happens to have a sl i ght handi cap, li ke a phys
ical deformi ty or a smal l peni s, he wil l focus on
thi s as evi dence that he is i rretri evabl y
damaged. Feel i ngs of sel f-deval uati on give ri se
to a host of compensatory dri ves, li ke bei ng
perfecti oni sti c, overl y ambi ti ous, and power
dri ven. As long as he can do thi ngs perfectly
and operate wi thout fl aw, he wi l l respect
hi msel f. Or, if he is bri ght enough and hi s en
vi ronment favorabl e, he may boost hi msel f i nto
a successful posi ti on of power, operate li ke a
strong authori ty and gather around hi msel f a
group of sycophants who wil l worshi p hi m as
the i deal i zed authori ty, whom i n turn the i ndi
vi dual may resent and envy whi l e accepti ng
thei r pl audi ts. He wil l feel expl oi ted by those
who el evate hi m to the posi ti on of a hi gh
pri est. Why, he may ask hi msel f, cant I
find somebody strong whom / can depend on?
What he seeks actual l y is a dependent rel ati on
shi p, but thi s rol e entai l s such confl ict for hi m
that he goes i nto fierce competi ti veness wi th
any authori ty on whom he mi ght want to be
dependent.
So here we have our dependency operati ng
fi rst; second, resentment, aggressi on, gui l t, and
masochi sm; thi rd, dri ves for i ndependence; and
fourth, sel f-deval uati on and maneuvers to over
come thi s through such techni cs as perfec
ti oni sm, overambi ti ousness, and power stri v
i ngs, in fantasy or i n real i ty.
T o compl i cate matters, some of these dri ves
get sexual i zed. I n dependency, for i nstance,
when one rel ates to a person the way a chi l d or
i nfant rel ates to a parent, there may be experi
enced a powerful suffusi on of good feel i ng that
may bubbl e over i nto sexual feeli ng. T here is
probabl y a great deal of sexual i ty in all i nfants
in a very di ffuse form, precursors of adul t sex
ual i ty. A nd when a person reverts emoti onal l y
back to the dependency of i nfancy, he may
reexperi ence di ffuse sexual feel i ngs toward the
parental fi gure. I f a man rel ates dependentl y to
a woman, he may sustai n toward her a ki nd of
i ncestuous feeling. T he sexual i ty wi l l be not as
an adul t, but as an i nfant to a mother, and the
feel i ngs for her may be accompani ed by
tremendous gui l t, fear and perhaps an i nabi l i ty
to functi on sexual l y. I f the parental fi gure hap
pens to be a man i nstead of a woman, the per
son may still rel ate to hi m li ke toward a
mother, and emergi ng sexual feeli ngs will
sti mul ate fears of homosexual i ty. [// the pa
tient is a woman with sexual problems, the
parallel situation of a female child with a
parental substitute may be brought up. A
woman may repeat her emotions of childhood
when she sought to be loved and protected by a
mother. In body closeness she may experience
a desire to fondle and be fondled, which will
stir up sexual feelings and homosexual fears.}
I n sexual i zi ng dri ves for i ndependence and ag
gressi veness, one may i denti fy wi th and seek
out powerful mascul i ne fi gures wi th whom to
fraterni ze and affili ate. T hi s may agai n whi p
up homosexual i mpul ses. Where aggressi ve-
sadi sti c and sel f-puni ti ve masochi sti c i mpul ses
exi st, these may, for compl i cated reasons, also
be fused wi th sexual i mpul ses, masochi sm be
comi ng a condi ti on for sexual rel ease. So here
we have the dependence motor, and the resent-
ment- aggressi on- gui l t-masochi sm motor, and
the i ndependence motor, and the sel f-deval u
ati on motor, wi th the vari ous compensati ons
and sexual i zati ons. We have a very busy per
son on our hands. (At this point the patient
revealed that he had become impotent with his
wife and had experienced homosexual feelings
and fears that were upsetting him because they
were so foreign to his morals. What I said was
making sense to him.)
I n the face of all thi s troubl e, how do some
peopl e gai n peace? By a fi fth motor, that of
detachment. Detachment is a defense one may
try to use as a way of escapi ng li fes messy
probl ems. Here one wi thdraws from rel ati on
shi ps, i sol ates hi msel f, runs away from thi ngs.
By removi ng hi msel f from peopl e, the i ndi
vi dual tri es to heal hi msel f. But thi s does not
usual l y work because after a whi l e a person
gets terri fi ed by hi s i sol ati on and i nabi l i ty to
feel. Peopl e cannot functi on wi thout peopl e.
They may succeed for a short ti me, but then
they real i ze they are dri f ti ng away from
thi ngs; they are depri vi ng themsel ves of li fes
pri me satisfacti ons. Compul si vel y, then, the
detached person may try to reenter the li vi ng at
mosphere by becomi ng gregari ous. He may, in
desperati on, push hi msel f i nto a dependency
si tuati on wi th a parental fi gure as a way out of
hi s di l emma. And thi s wi l l start the whol e neu
roti c cycle all over agai n.
Y ou can see that the person keeps getti ng
caught in a web from whi ch there is no escape.
As l ong as he has enough fuel avai l abl e to feed
hi s vari ous motors and keep them runni ng, he
can go on for a peri od. But if opportuni ti es are
not avai l abl e to hi m to satisfy hi s di fferent
dri ves and if he cannot readi l y swi tch from one
to the other, he may become excessi vely tense
and upset. I f hi s tensi on bui l ds up too much,
or i f he experi ences great troubl e i n hi s
life si tuati on, or i n the event self esteem is
crushed for any reason, he may devel op a
catastrophi c feel i ng of hel pl essness and expecta
ti ons of bei ng hurt. (The patient here excitedly
blurted out that he felt so shamed by his defeat
at work that he wanted to atom bomb the
world. He became angry and weak and
frightened. He wanted to get away from
everything and everyone. Yet he felt so helpless,
he wanted to be taken care of like a child. He
then felt hopeless and depressed. I commented
that his motors had been thrown out of gear by
the incident at work and this had precipitated
excessive tension and anxiety.)
When tensi on gets too great, and there
seems to be no hope, anxi ety may hi t. And the
person wi l l bui l d up defenses to cope wi th his
anxi ety, some of whi ch may succeed and some
may not. For i nstance, excessi ve dri nki ng may
be one way of managi ng anxi ety. Fears, com
pul si ons, physi cal symptoms are other ways.
These defenses often do not work. Some, like
phobi as, may compl i cate the persons life and
make it more di ffi cul t than before. Even
though ways are sought to deal wi th anxi ety
these prove to be sel f-defeati ng.
Now, we are not sure yet how thi s general
outl i ne appl i es to you. I am sure some of it
does, as you yoursel f have commented. Some of
it may not. What I want you to do is to thi nk
about it, observe yoursel f in your acti ons and
rel ati ons to peopl e and see where you fit.
Whi l e knowi ng where you fit wi l l not stop the
motors from runni ng, at l east we wil l have
some i dea as to wi th what we are deal i ng.
T hen well better be abl e to fi gure out a pl an
concerni ng what to do.
Someti mes I draw a sketch on a bl ank paper
showi ng hi gh dependence, l ow depen
dence, deval ued sel f-i mage, resentment-
gui l t-masochi sm, and detachment, and
repeat the story of thei r i nterrel ati onshi p. I
then ask the pati ent to fi gure out and study
aspects that appl y to hi m. I f a general descri p
ti on of dynami cs is gi ven the pati ent, al ong the
lines indi cated above, a little insight may be i n
culcated that can serve as a ful crum for greater
sel f-understandi ng. T he insight may be tempo
rari l y reassuri ng at first; then it seemingl y is
forgotten wi th a resurgence of symptoms. A
review of what has occurred to sti mul ate an at
tack of anxi ety may consol idate the insi ght and
solidify better control. An i mportant tool here
is sel f-observati on, whi ch the therapi st shoul d
try to encourage and whi ch will hel p the
worki ng- through process, wi thout whi ch
insi ght can have little effect.
Conclusion
I n dynami c short-term therapy the most
productive focus is often on some aspect of a
nucl ear conflict. Since the pati ent usual l y de
fends hi msel f agai nst reveal i ng si gni fi cant
unconsci ous content, the therapi st will have to
arri ve at it by observing its mani fest deri va
tives. These may be highl y disguised and sym
boli zed. However, a sensiti ve and astute thera
pist will be abl e to detect vital undercurrent
forces from the pati ents verbal and nonverbal
behavior, from peri odic transference displays,
and from dreams, fantasies and acti ng-out
tendencies. These mani festati ons will be espe
cially promi nent duri ng peri ods of resistance to
techni ques that the therapi st is i mpl ementi ng.
Accordingl y, the therapi st shoul d al ert himsel f
to what lies behi nd the pati ents i nabi li ty or
refusal to respond to treatment i nterventions.
A general outl i ne of dynami cs presented to the
pati ent wi th the object of sti rri ng up some ten
si on in the i ntervi ew and hence expedi ti ng ex
pl orati ons, or of worki ng toward fi tting the pa
ti ents special probl ems and mechani sms into
the outl ine, is someti mes helpful.
CHAPTER 11
Techniques in Short-term Therapy
Psychotherapy as it is practi ced today is no
l onger a homogeneous operati on. E nteri ng
i ts mai nstream are tri butari es f rom vari ous
branches of the bi ol ogi cal and behavi oral
sci ences. T hi s is because behavi or embraces
every consti tuent of the human bei ng f rom
physi ol ogi cal makeup to spi ri tual prompti ngs.
I n T abl e 11- I the vari ous l i nks i n the behav
i oral chai n are del i neated, as wel l as the fi el ds
of i nterest these embrace, and the therapeuti c
modal i ti es rel ated to each l i nk to whi ch certai n
syndromes are of ten assi gned. T ake as an ex
ampl e the syndrome of schi zophreni a.
Schi zophreni a is a di sease that is vari antl y
attri buted to many causes. T here are those
who regard it as a bi ochemi cal af fl i cti on, the
product of def ects i n the f uncti on of the
neurotransmi tter dopami ne, whi ch, operati ng
i n excess, affects the mesol i mbi c, i nf undi bul ar,
and ni gral pathways. U nder these ci rcum
stances pharmacotherapy woul d appear to be
the pref erred approach, neurol epti cs, for ex
ampl e, bei ng empl oyed to bl ock the acti on of
dopami ne. Others regard schi zophreni a as a
neurophysi ol ogi cal di sorder, characteri zed by a
l ack of left cerebral domi nance and def ecti ve
cerebrol i mbi c f uncti oni ng that sponsor abnor
mal i ti es i n l i near cogni ti ve abi l i ty. A dherents
of thi s vi ewpoi nt mi ght consi der certai n f orms
of somati c therapy sui tabl e under some ci rcum
stances, E C T , for i nstance, as wel l as some
f orms of rel axati on therapy. Some ascri be
schi zophreni a to f aul ty l earni ng and condi ti on
i ng, consi deri ng it a devel opmental probl em,
the consequence of severe f ami l y pathol ogy
wi th proj ecti ve use of the chi l d by parents
who communi cate conf l i ctual doubl e- bi nd''
themes. A behavi oral approach, consequentl y,
mi ght be i n order. T hen there are those who
pref er an i ntrapsychi c expl anati on, seei ng it as
a thi nki ng di sorder that provokes pri mary-
process, pri mi ti ve, i rrati onal , wi shf ul i dea
ti on, wi th excessi ve condensati on, di spl ace
ment, and the di storted use of symbol s. T he
resul t is an i nterf erence wi th proper emoti onal
modul ati on. T hi s vi ewpoi nt someti mes spon
sors a psychoanal yti c approach. O n the i nter
personal l evel certai n authori ti es credi t the di s
ease to the mi schi ef of regressi ve, archai c
def enses that encourage detachment, di strust,
and extraordi nary dependency. F ami l y ther
apy, group therapy, and psychoanal yti cal l y
ori ented therapy woul d fit i n here. Soci al
forces are consi dered by some to be the pri me
cul pri ts, i nspi ri ng the pati ent to assume
anomal ous soci al rol es termi nati ng i n al i ena
ti on and devi ati ons i n task perf ormance.
M i l l i eu therapy, casework, counsel i ng, soci al
therapy, and rehabi l i tati ve therapy coul d be
uti l i zed wi th these f actors i n mi nd. F i nal l y,
there are prof essi onal s who pref er a more
esoteri c spi ri tual expl anati on, vi ewi ng
schi zophreni a as a uni que and si ngul ar mode
of percei vi ng and experi enci ng real i ty.
E xi stenti al therapy and a crop of phi l osophi cal
approaches, many deri vi ng thei r substance
f rom E astern systems of thought, have thei r
advocates who seek to i nf l uence thi s el usi ve di
mensi on. Di f f erent approaches to treatment
thus accord wi th mul ti pl e ways of regardi ng
the di sease. A ctual l y, schi zophreni a embraces
al l of the bodi l y systems, and no one eti ol ogi cal
f actor can be consi dered excl usi vel y domi nant.
A nd any of the many modal i ti es si ngl y or i n
combi nati on may i n some cases regi ster a bene
fi ci al effect.
135
TABLE 11-1. The Biological and Behavioral Links of Behavior*
T HE BEHAVI OR
CHAI N FI EL DS
REL ATED
THERA PEUTI C MODA L I TI ES SY NDROMES
Biochemical links Biochemistry Pharmacotherapy Schizophrenia (neuroleptics)
Mania (lithium)
Major depressions
(antidepressants)
Anxiety states (anxiolytics)
Hyperkinetic syndromes of
childhood
Neurophysiological
links
Neurophysiology Biofeedback
Somatic therapy
Relaxation therapy (meditation,
relaxing hypnosis)
Emotive release
Tension states (relaxation,
biofeedback, emotive release)
Suicidal depressions (ECT)
Physical conditions arising from
mental factors (biofeedback)
Developmental-
conditioning links
Developmental theory
L earning theory
Behavior therapy
Cognitive therapy
Persuasion
Suggestive hypnosis
Phobic reactions (behavior
therapy)
Habit disorders (hypnosis)
Behavior disorders (behavior
therapy)
Obsessive-compulsive disorders
(behavior therapy, persuasion,
cognitive therapy)
Adjustment reactions
Developmental delays
Intrapsychic links Psychoanalysis
Cognitive theory
Psychoanalysis
Hypnoanalysis
Existential analysis
Guided imagery
Personality disorders
Neurotic disorders
Interpersonal links Dynamic theory
Role theory
Group dynamics
Social psychology
Psychoanalytically oriented therapy
Group therapy
Marital therapy
Family therapy
Psychodrama
Experiential therapy
Transactional analysis
Cognitive learning
Personality disorders
Neurotic Disorders
Marital problems
Family problems
Borderline personality
Drug abuse and dependence
Social links Sociology
Anthropology
Economics
Political science
Milieu therapy
Social casework
Counseling
Social therapy
Recreational therapy
Situational problems
Psychoses in remission
Spiritual links Theology
Philosophy
Metapsychiatry
Religious therapy
Eastern philosophical systems
Existential therapy
Reactive depression
Anxiety states
Addictions
Behavior is a complex entity composed of a chain of interrelated biochemical, neurophysiological, developmental-
conditioning, intrapsychic, interpersonal, social, and spiritual links Difficulties in one link will by feedback influence all
other links in the chain. Distinctive fields of interest and special theories related to each link inspire a number of thera
peutic modalities that are preferred approaches in certain syndromes even though through feedback interventions
bracketed to other links may also be effective.
TECHNIQUES IN SHORT-TERM THERAPY 137
By the same token, practi cal l y every neu
rotic or behavi oral di sorder may be causal ly
associated wi th mul ti pl e links in the behavi oral
chain. They too may be approached wi th a va
ri ety of techni ques that correspond to different
links. Thi s is the rati onal e of eclecticism,
whi ch in short-term therapy is a preferred
mode of operati on.
The fact that we have so many different ap
proaches to the same emoti onal probl em can in
itself be confusing. Because there is so little
ti me avail able in bri ef therapy, we will want to
select the one method or combi nati on of meth
ods that is most appl i cabl e to the specific diffi
culty. I n thi s respect we can console ourselves
in a mi nor way. No matter what techni que we
empl oy, if we are ski lled in its use, have faith
in its vali dity, and communi cate thi s fai th to
the pati ent, and if the pati ent accepts the tech
ni que and absorbs our fai th, it will influence
hi m in some posi ti ve way. I n resolving a diffi
culty rel ated to one di sturbed li nk in his be
havi oral chai n, thi s will influence by feedback
other links. Thus, if we prescri be neurol epti cs
for a schi zophreni c wi th a di sturbi ng thi nki ng
disorder, the i mpact on his bi ochemi stry will
regi ster itself positi vely in varyi ng degrees on
his neurophysi ol ogy, his general behavi or, his
i ntrapsychi c mechani sms, hi s i nterpersonal
rel ati ons, his social atti tudes, and perhaps even
his phil osophi cal outl ook. Appl yi ng behavi or
therapy to a phobi c will in its correcti on i nfl u
ence other aspects from the biochemical factors
to spi ri tual essences. Worki ng wi th modal i ti es
that are directed at the i ntrapsychi c structure
in a personal i ty di sorder through psychoanal
ysis or cognitive therapy, we may find that all
other li nks in the behavi oral chai n are affected
in a gratifyi ng way. Thi s global response,
however, does not in the least absolve us from
tryi ng to select the best method wi thi n our
range of skills that is most attuned to the pa
ti ents uni que l earni ng apti tudes.
Be this as it may, there are some general
pri ncipl es that are appl i cabl e to most pati ents.
First, we start therapy by al l owi ng the pati ent
to unburden himsel f verbal ly, to tell his story
uni nterruptedl y, i nterpol ati ng comments to i n
dicate our understandi ng and empathy and to
keep hi m focused on i mportant content. Sec
ond, we hel p hi m arri ve at some prel i mi nary
understandi ngs of what hi s difficulty is all
about. Thi rd, we select a method that is tar
geted on that li nk that is creati ng greatest diffi
culty for that pati entbiochemical , behav
ioral, intrapsychi c, i nterpersonal , or social.
Fourth, we try to show hi m how he hi msel f is
not an innocent bystander and that he, in a
maj or or mi nor way, is involved in bri ngi ng
his troubl es on hi mself. Fi fth, we deal wi th
any resistances that he develops that block (a)
an understandi ng of hi s probl em, (b) hi s
producti ve use of the techni ques we empl oy,
and (c) the appl i cati on of his treatment toward
behavi oral correcti on. Si xth, we try to ac
quai nt hi m wi th some of the personal i ty di stor
ti ons that he carri es around wi th hi m that can
create troubl e for hi m in the futurehow they
developed, how they operate now, and how
they may show up after he leaves therapy.
And, seventh we give hi m some homework that
is ai med at strengtheni ng hi msel f so that he
may mi ni mi ze or prevent probl ems from occur
ri ng l ater on. Wi thi n this broad framework
there are, of course, wi de differences on how
therapi sts wi th varyi ng theoreti cal ori entati ons
will operate. By and l arge, however, psy
chotherapi sts wi th adequate trai ni ng shoul d
anti ci pate satisfactory resul ts wi th the great
maj ori ty of thei r pati ents.
Empl oyi ng whatever techni ques or group of
techni ques are indi cated by the needs of the
pati ent and that are wi thi n the scope of ones
trai ni ng and experi ence, the therapi st may be
abl e to achieve the goals agreed on in a rapi d
and effective way. Where the therapi st has be
come aware of the underl yi ng dynami cs, it
may be necessary to menti on at least some
sal i ent aspects and to enj oi n the pati ent to
work on these by hi msel f after therapy has
ended. On the other hand, the therapi st may
not be able to achieve desi red goals unless i n
terferi ng dynami c influences that function as
resistance are deal t wi th duri ng the treatment
peri od because the pati ent is blocked by the
resistance agai nst maki ng progress.
I n long-term therapy a dynami c theme that
expl ai ns the pati ents personal i ty operati ons
and resistances gradual l y reveals itself through
a leisurely study of the pati ents verbal i zati ons,
behavi oral procl iviti es, dreams, fantasies, and
transference proj ecti ons. No such casual i ndul
gence is possible in short-term treatment. Pi ec
ing together data from the pati ents history,
general demeanor, i nterpersonal exploi ts, asso
ciations, and the few fantasies and dreams that
are avail able, and correl ati ng these wi th reac
ti ons to therapy and to the therapi st, as well as
to any bri ef psychological tests that may have
been given (e.g., man-woman drawi ngs and
exposure to Rorschach cards), the therapi st
will be able to make some assumpti ons about
the pati ents dynami cs. These will be a guide
in confrontati ons and i nterpreti ve work.
As has been ampl y i l l ustrated in the past
chapters, a number of dynami c themes, present
in the great maj ori ty of people in our cul ture,
have been repeatedl y observed that can guide
in bri ngi ng some basic probl ems to light dur
i ng therapy, recogni zi ng that many confi gura
ti ons exist that are uni que for each i ndi vidual .
Among fami l i ar themes that have been de
scribed are those rel ated to incompl ete separa
ti on-i ndi vi duati on, resi dual guil t feelings and
needs for sel f-puni shment, and devalued self
esteem. I t is rare that one sees any pati ent in
therapy who does not possess an abundant
share of these leitmotifs, al though the ways
that they mani fest themsel ves in the character
structure and the ki nds of symptoms they
sponsor are disti ncti vely idiosyncratic.
Worki ng wi th the operati ve dynami cs con
stitutes a val uabl e means of hel pi ng a pati ent
to face and, if moti vati on is present, to al ter his
repetitive self-defeati ng behavi or. Poi nted i n
terpretati ons of the dynami cs underl yi ng ego-
syntoni c symptoms, trai ts, and behavi or only
too frequentl y resul t in deni al and anxi ety, for
mal adapti ve as they are, neuroti c conflicts and
needs are wel ded into the pati ents habi tual
copi ng modes and yield flori d grati fi cati ons
compared to whi ch the pl easures of heal thy
patterns pale. What is the best way of deal i ng
wi th such obstructi ons? A pi thy epi gram in the
K oran contends that God is wi th those who
persevere. Thi s certai nl y appl i es to the un
daunted therapi st who in the face of obsti nate
resistance doggedly works agai nst it. I n l ong
term therapy the task of deal i ng wi th re
si stances to a recogni ti on of ones dynami cs
and managi ng stubborn opposi ti onal reacti ons
to the rel i nqui shi ng of destructi ve behavi or
consume a bul k of the ti me devoted to therapy
and can tax the endurance of the most resol ute
therapi st. I n short-term therapy the task
woul d seem tc be doubl y compl i cated since
there is only l i mi ted ti me to prosecute the
search for confl ictual themes and to resolve
resistance to thei r disclosure and rectificati on.
Understandabl y, one cannot dupl i cate in 10
sessions what could be achieved wi th skillfully
conducted therapy in 100. Yet, experi ence
bears out the val ue of bri ngi ng to the pati ents
attenti on a gl i mpse of his operati ve dynami cs
and demonstrati ng to hi m hi s responsi bi l i ty in
bri ngi ng about the disasters that he has hi th
erto credi ted to destiny and mi sfortune.
Confrontation
One techni que that has been advocated by
some short-term therapi sts to cut through
resistance to understandi ng ones dynami cs is
that of confrontati on. T hi s is someti mes
uti li zed to get at underl yi ng trends by pro
voking anxi ety or negati ve feelings. Usual l y
the pati ent will respond to the therapi sts
chall enges of his behavi or wi th anger that may
be promptl y suppressed. What will appear
i nstead are di savowal , protest, self-justi fi ca
ti on, and sel f-abasement, l ayi ng the bl ame for
ones behavi or on mal evol ent ci rcumstances or
the derel iction of others. Negati ve transference
rapi dl y preci pi tates out. Opportuni ti es are
thus rich for i nterpretati on of feelings about
and reactions to the therapi st. Thi s techni que
is dramati c and often effective in pati ents wi th
good ego strength. However, it can drasti cal l y
hurt the therapeuti c rel ati onshi p in a good
number of pati ents if i mpl emented too earl y in
therapy before proper rapport has been es
tabl ished. The pati ent is apt to regard the
therapi sts acti ons and manner as arbi trary,
unj usti fi abl e, recri mi natory, mal i ci ous, and
reflective of the therapi sts i nabi l i ty to under
stand hi m or to empathi ze wi th his suffering
and si tuation. I t takes a great deal of skill to
select those who are suited for confrontati on
and to ti trate the degree of forcefulness of
chall enges to the pati ents existi ng strengths.
Experi enced therapi sts are capabl e of doi ng
thi s even in the first i ntervi ew wi th some pa
tients, but the average therapi st will be com
pensated for his efforts wi th an extraordi nary
number of dropouts from treatment. I n most
pati ents who come for hel p a mi ni mal l y
provocative posture will be indi cated at first;
the therapi st shoul d work toward the establ i sh
ing of a good worki ng rel ati onshi p before bat
teri ng away at the pati ents defenses through
strong confrontations.
Selection of fruitful areas for confrontati on
when it is done is i mportant. Since most pa
ti ents possess an overl y pri mi ti ve and severe
conscience (superego) that provokes guil t, feel
ings of wickedness, and masochistic behavior,
these pathol ogi cal zones provi de a producti ve
area for attack and discussion. Some therapi sts
empl oy a techni que that i nterprets the
symptoms of the pati ent, no matter what they
may be (for exampl e, anxi ety, depressi on,
worry, outbursts of anger, conversion reac
tions, compul si ons, phobi as, i nsomni a, anorex
ia, etc.), as mani festati ons of sel f-puni shment,
the consequences of a guil ty conscience (L ewi n,
1970). Each symptom is del i neated as serving
both sel f-tormenti ng needs and provocative
ai ms toward others. Even an i ndi vi dual s
disturbed character patterns are reduced to the
masochistic need to suffer and dri ve peopl e
away so that he can torment hi msel f wi th
l onel i ness. T he pati ent is hel ped to see what
he wants to do and what hi s consci ence
forces hi m to do and how the di spari ty creates
difficulti es. The contrast between a heal thy con
science that gui des whi l e i nhi bi ti ng destructi ve
acti ons and the pati ents exi sti ng sadisti c con
science that vici ousl y torments and puni shes is
poi nted out. I t becomes essential for the pati ent
to recogni ze that an i ntemperate and mercil ess
consci ence is the common enemy agai nst
whi ch the therapi st is his egos strong al l y. No
i mmedi ate i nterpretati ons are made of specific
conflicts. T he ini ti al confrontati ons are con
fined to the pati ents need for sel f-puni shment
and his masochistic responses to anger.
Thi s focal ization, it seems to me, is used as
an expedi ent to provi de the pati ent wi th a
single insight into whi ch he can converge his
energi es. Si nce masochi sm is a common
defense, the therapi st may not be too far off if
its existence is poi nted outthat is, of course,
if the pati ent presents even slight evidences of
its operati on. Obvi ousl y, masochi sm is not the
onl y basis for symptoms, and the therapi st
shoul d not be si detracked by usi ng the expl a
nati on of masochi sm as a strategy for breaki ng
up the pati ents resistance. T he therapi st will
usual l y discover, if a search is made for them,
addi ti onal reasons for some of the pati ents
symptoms.
Other expl anati ons than masochi sm may be
offered by therapi sts trai ned in specific schools
of psychol ogy or psychi atry. One uni versal
basic cause is presented for all types of emo
ti onal illness, and this single eti ological factor
is tortured to fit in wi th every symptom and
behavi oral mani festati on. Thus, the pati ent
may be dazzl ed by bri l l i ant expl anati ons of the
mal functi ons of pregeni tal spl itti ng, or of the
Oedi pus compl ex, or of the devalued self-
i mage, or of subversive archetypes, or of condi
ti oned anxi ety, or of any of the countl ess
theori es around whi ch current psychologically
ideol ogies are organi zed. Whi l e such single ex
pl anati ons may not be accurate, they certai nl y
are conveni ent and they may be temporari l y ef
fective, especiall y when dogmati cal l y stated.
140
One of the advantages of dogma is that it
makes critical thi nki ng unnecessary. And some
pati ents are onl y too eager to hand over thei r
mi nds to the therapi st who will do thei r thi nk
i ng for themthat is, unti l the treatment ends,
after whi ch the pati ent will begin to recon
stitute his own frame of reference and en
thusi asti cal l y recreate the condi ti ons that got
hi m into troubl e in the first place.
Thi s does not mean that we shoul d throw
the baby out wi th the bath. Some of the
theori es and expl anati ons may be helpful more
than temporari l y when appl i ed to certai n kinds
of symptoms and personal i ty probl ems. Ac
cident proneness, obsessional sel f-torment, sui
ci dal tendencies, and hypochondri acal preoccu
pati ons, for exampl e, may be i ndi cati ons of a
general i zed masochi sm. An expl anati on such
as the fol lowing may be offered: Y ou feel
angry at what your parents did to you as a
child. But you also feel guil ty for your anger
and thoughts. So you puni sh yourself for these
thoughts and feelings. Y our symptoms and
your behavi or seem to me to be the resul ts of
your puni shi ng yourself. Now what are you
going to do about what you are doi ng to your
sel f? M ore di rect suggesti ons may be:
Whenever you torture yourself wi th upsetti ng
thoughts, or you get depressed, or you have
symptoms (enumerate these) ask yoursel f,
Why am I puni shi ng mysel f? Tel l yourself,
I ve puni shed myself enough so j ust stop i t!
Shoul d these expl anati ons and i nj uncti ons fail
to produce results, some therapi sts resort to
stronger chall enges and confrontati ons.
Whi l e aggressive confrontati on under these
ci rcumstances may prove profi tabl e in some
pati ents wi th good ego strength, it may not be
appl i cabl e to sicker pati ents unless the con
frontati ons are toned down to a poi nt where
they are executed in an empathi c reassuri ng
way. Even then it may be necessary to wai t
unti l a good worki ng rel ati onshi p has been es
tabl i shed, and then onl y after it becomes
apparent that masochistic maneuvers are ob
viously being empl oyed by the pati ent in the
i nterests of resi stance Y ou seem to be
puni shi ng yoursel f by refusing to get wel l .
T he phrasi ng of questi ons can be cruci all y
i mportant in hel pi ng a pati ent expl ore and
come to gri ps wi th determi ni ng probl ems. For
exampl e, the pati ent states, I wi sh I had a
father who was like you. T he therapi st may
repl y vari antl y al ong the fol lowing lines: (1)
And I woul d like to have a daughter (son)
like you. (2) I n what way did your own
father di sappoi nt you? (3) Y ou must be very
angry at your father. (4) Reachi ng out for
another father fi gure i snt goi ng to hel p you
much. Y ouve got to l earn to stand on your
own feet. (5) Y our sayi ng that is a
mani festati on of your conti nui ng dependency.
(6) What is there about me that makes you
say that? (7) Y ou dont know me well
enough to be sure of wanti ng me as a father.
(8) What do you thi nk woul d have happened
to you if I had been your father? Each of
these responses will elicit certai n i mportant
reacti ons in the pati ent and will influence the
rel ati onshi p.
Interpretive Activities
As therapy moves on duri ng the fi rst
sessions, the pati ents responses to i nterpreta
ti on will become apparent. I f there is rejecti on
of i nterpretati ons, l ack of tensi on after a
chal l engi ng i nterpretati on is made, or bi zarre
responses, paranoi d tendencies, or acti ng-out
wi thout insight occur following i nterpretati ons,
the pati ent is probabl y not amenabl e to dy
nami c short-term therapy. I n most cases, how
ever, it will be possible to make i nterpretati ons
and to hel p the pati ent acqui re an understand
i ng of probl ems and defenses.
T he i nterpretati on of resi stance is indi cated
from the very start of its appearance, parti cu
l arly where it takes the form of i nterferi ng
wi th the worki ng rel ati onshi p. Shoul d a nega
tive transference appear ei ther in dreams or in
the pati ents behavi or, the therapi st must i m
medi atel y deal wi th it in as expedi ent a way as
possible.
For exampl e, the response of a pati ent after
the second hypnoti c session duri ng whi ch a re
laxi ng cassette tape was made for her was i rri
tati on and anger at li stening to the tape. Upon
urgi ng her to tell me her reacti ons to the tape,
she stated the following.
Pt. When 1 tri ed l i steni ng to the tape, I found my
mi nd wanderi ng. When you say, Y ou are
ti red and drowsy, ti red and drowsy are
antonyms. Ti red means not rel axed. When you
say, Even your leg muscles are rel axed, why
even ? When you say the four Ss (symptom
reli ef, si tuati onal control , sel f-esteem, sel f-sug
gesti ons) I say the four asses. I resented you.
I want to apol ogi ze for my feel ings. I am sur
pri sed at myself for l i ki ng you. When you said
last ti me you mi ght prescri be a drug for my
depressi on, emoti onal l y I felt you wanted to
kill me, to i mmobi l i ze me wi th medi ci ne. I n
the tape you say, Y ou are filled wi th negati ve
thoughts that we must neutral i ze, what
thoughts? At the end you say Y ou wil l rel ax
or fall asl eep. T hey are i ncompati bl e. I sai d
to myself about you, He is so goddam i m
permeabl e, unreachabl e. I felt thi s way also
about my mother and father. Y ou say, Y ou
wi ll i magi ne a beauti ful rel axed scene. I cant
fi gure out if I shoul d j ust see somethi ng or be
in it personal l ysi tti ng, l yi ng, or sl eepi ng.
T he scene I settl ed on was the bank of a ri ver
wi th a boatsunl i ght on the ri ver reflected it
on the water. Y esterday I popul ated the water
wi th a swi m. Also I thought thi s was all non
sense. I tri ed to open my eyes, but my lids
were so heavy they woul dnt open. Y ou say,
Even if you are consci ous, the suggesti ons
will be effective. I am consci ous. T he whol e
thi ng gives me a fear of empti ness. T hi s is
what I felt wi th my parents. I have gui l t in
rel ati on to my parents. Wi th my mother, I re
j ected her much of my life. 1 thi nk I identi fi ed
wi th my father. I took on hi s symptoms.
Her reaction provi ded the basis for our di s
cussion of her transference to me and the possi
bil ity that she woul d reject the tape and its
contents, even refusing to li sten to it.
I felt I had a sufficiently good rel ati onshi p to
offer an i mmedi ate and repeated i nterpretati on
of resistance and negati ve transference. Thi s
did hel p consol i date the worki ng rel ati onshi p.
T he pati ent conti nued l i steni ng to the tape,
and she deri ved a good deal of benefi t from it.
Unl ess the pati ent is hi ghl y moti vated and
the therapi st has been abl e to establi sh an
earl y fi rm worki ng rel ati onshi p, provoki ng
anxi ety too soon by focusing on and i nterpret
ing defenses will tend to dri ve the pati ent out
of therapy. I nterpretati ons shoul d be bal anced
agai nst the state of the pati ents will ingness to
expl ore probl ems and the qual i ty of the pa-
ti ent-therapi st rel ati onshi p. Constant exami
nati on and use of the transference to poi nt out
habi tual patterns of the pati ent and the ori gin
in past rel ati onshi ps may be helpful. Unl i ke
formal anal ysi s, transference neurosi s shoul d
be avoided, and deepest character probl ems re
mai n unexpl ored since to manage them woul d
requi re more ti me than is avai l abl e in the short
span devoted to treatment.
To i nterpret unconsci ous or parti al l y con
scious impul ses prematurel y is worse than use
less. There are therapi sts who di vi ni ng the
conflicts of a pati ent at the fi rst i ntervi ew bom
bard hi m wi th i nterpretati ons that are pre
sumed to put the pati ent expedi ti ousl y on the
road to cure. Actuall y, an astute dynami cal l y
ori ented i ntervi ewer may be abl e to i nduce a
pati ent to di sgorge a good deal of materi al re
lated to earl y dri ves, i ncl udi ng sexual and ag
gressi ve impul ses and fantasies, to show the
pati ent how these are affiliated wi th present
drives and symptoms, and to demonstrate some
transference mani festati ons that refl ect a
carryover of chil dish di storti ons into ones con
temporary rel ati onshi ps. T hese di scl osures,
dramati c as they seem and perhaps are, have
an effect in the great maj ori ty of cases that is
di ametri cal l y opposi te to that whi ch is hoped
for. T he i nterpretati ons fall on deaf ears.
Not long ago I attended a conference on
short-term therapy where, to my astoni shment,
some trai ned anal ysts in tal ki ng about what
they did were naivel y practi ci ng what Freud
himsel f condemned in his 1910 paper on
Wi l d Psychoanal ysi s (Standard Edi ti on,
Vol. 2, pp. 225-226) by confronti ng the pa
ti ent wi th aspects of his unconsci ous duri ng the
first intervi ew. I f knowl edge about the uncon
scious, wrote Freud, were as i mportant for
the pati ent as peopl e i nexperi enced in psycho
anal ysi s i magi ne, li stening to lectures or read
ing books woul d be enough to cure him. Such
measures, however, have as much influence on
the symptoms of nervous illness as a di stri bu
ti on of menu-cards in a ti me of fami ne has
upon hunger. Many years ago in my pri sti ne
enthusi asm wi th deep hypnosi s, I attempted to
uncover in the trance some of the fundamental
core conflicts of pati ents, enj oi ni ng them to re
member the revel ati ons that they themsel ves
wi th great emoti on divul ged, only to discover
that the effect on the pati ents behavi or was
barren and bleak. I learned that a much better
tactic was to safeguard the i nformati on for my
own pri vate enl i ghtenment and not waste ti me
convinci ng pati ents of my bri ll iance as a psy
chologi cal detective. Once I had establi shed a
good worki ng rel ati onshi p wi th my pati ents
(and it requi red more than one session), I
could provi dentl y guide them wi th proper i n
tervi ewi ng techni ques toward comi ng upon the
essential connections of thei r present topical
behavi or wi th fundamental intrapsychi c de
termi nants. They woul d then tell me what I
had previ ously hoped I could smuggle into
thei r mi nds in a flash. Essential ly, I was doi ng
what Freud in 1913 had recommended in his
paper On the Begi nni ng of T reatment
(Standard Edi ti on, Vol. 12, pp. 139-142), that
is, to wai t unti l the pati ent evinced some
preconscious awareness of his conflicts.
There are, of course, ways a skillful and ex
peri enced therapi st can in a roundabout, care
fully phrased, and empathi c way al l ude to the
essential dynami cs by projecti ve techni ques
such as those described by Arl ene Wol berg
(1973) in her book The Borderline Patient. I n
thi s manner one may avoid an escal ati on of the
pati ents anxi ety or a hardeni ng of resistance,
whi ch so often in premature i nterpretati ons
takes the form of ani mosi ty toward the thera
pist and abrupt termi nati on of treatment. For
exampl e, a young woman of 28 came to ther
apy because of anxi ety attacks and a dull para
lyzi ng depressi on. One of her chief concerns
was her 2-year-ol d chil d whom she feared she
was neglecting so much that he woul d not sur
vive. T he di sasters she envisioned ranged from
acci dental lethal poi soni ng to a fatal accident.
A repetitive ni ghtmare rel ated to her child fall
ing out of a wi ndow in spi te of her efforts to
save him. Her symptoms started shortly after
the bi rth of her chil d and caused her to give up
an excellent posi ti on in a fi rm for whi ch she
had worked since graduati ng from college. It
does not requi re a great deal of i magi nati on to
construct a hypothesi s of what was goi ng on
dynami cal l y. A reckless therapi st mi ght reveal
to the pati ent that part of her woul d like to see
her chil d dead so that she can be li berated back
to an i ndependent life and that she un
doubtedl y resents her rol e as a woman, whi ch
resentment started in her earl y tomboy days
and accounts for her present sexual frigidity.
Thi s i ntri gui ng expl anati on, however true it
may be, woul d in all probabi l i ty set off spasms
of renewed anxi ety and i ncrease the pati ents
despai r and hopelessness. On the other hand,
shoul d the therapi st be assured that a thera
peuti c al l i ance has been started, he mi ght
instead empl oy a proj ecti ve techni que i nter
preti ng somewhat as follows:
T h. I can understand how upset you must be.
Women do take a ki nd of a beati ng in our so
ciety. T here are qui te a number of i ntel l i gent
educated women who when they get marri ed
resent gi vi ng up thei r careers. After all , there
is l i ttle sti mul ati ng in washi ng di shes and
pushi ng a mop. Some of these women fantasy
an escape from thi s trap (smi l i ng at thi s poi nt
as if j oki ng) by i magi ni ng that thei r husbands
wi ll in one way or another drop dead, thus
freei ng them agai n. But they real l y dont want
thei r husbands dead. T hey love thei r hus
bands. But thi s is the way the human brai n
works: it operates by pecul i ar symbol s and
fantasi es that do not mean they wil l l i teral l y be
carri ed out.
What the therapi st is doi ng is empl oyi ng an
exampl e roughl y and tangenti al l y rel ated to
the pati ents probl em, but usi ng another per
son as the target. I f she is ready to identify
wi th the exampl e, the pati ent will begin work
ing on it as it appl i es to her and her rel ati on
shi p wi th her own husband and her chil d. I f
not, she will pass it by as i rrel evant. I n the for
mer instance, when the pati ent opens up, the
therapi st may gradual l y be more and more di
rect in his i nterpretati ons, ti trati ng these to the
pati ents level of tol erance of anxi ety whi l e be
ing sure to preserve the worki ng rel ati onshi p.
I n the l atter instance, that is, where the pati ent
avoids the i nterpretati on, the therapi st will
drop the subj ect and wai t for a more strategi c
moment when the pati ent shows greater
awareness before engagi ng in chal l engi ng i n
terpreti ve work again. I n the case of the young
woman j ust cited, my i nterpretati on was com
pletely ignored, but two sessions l ater she
brought up fantasies about the death of her
husband, and we were abl e to discuss her feel
ings and to make good progress from that
poi nt on.
I n presenti ng i nterpretati ons the therapi st
shoul d search for areas where expl anati ons
will be most producti ve and where the most
resistances to getting well reside. Among these
are nucl ear conflicts, deri vati ve conflicts, nega
tive transference; and sundry other resistances.
Nuclear conflicts frequentl y persi st
throughout the life of the person and are
responsibl e for symptoms and behavi oral diffi
culties. Exampl e: A pati ent whose mother died
duri ng his infancy and who was rai sed by a
succession of rel ati ves has si nce chil dhood been
in constant search for a loving, giving, ma
ternal figure. He mi ni mi zes rel ati onshi ps wi th
women who are accepti ng but seeks out
li aisons wi th unstabl e, rej ecti ng females wi th
whom he acts out the theme of enteri ng a
perfect ideal ized uni on, onl y to experi ence re
j ecti on, humi l i ati on, feelings of abandonment,
and separati on anxiety. A current cri sis caused
by discovery of infidel ity on the part of the
young woman wi th whom he has had a rel a
ti onshi p for a year has brought hi m to therapy.
Recogni zi ng the depth of the probl em and the
i mpossi bil ity of al teri ng the dependency need
in a bri ef therapeuti c effort, the therapi st
focuses on al l evi ati ng the separati on anxi ety
wi th ego supports. He bri ngs the pati ent to an
awareness of the ori gi ns and the destructi ve be
havi oral resi dues of his symbiotic needs and
through cognitive approaches hel ps hi m to
fight off the urge for future entangl ements wi th
rej ecti ng women.
Derivative conflicts are cl oser to awareness
than nucl ear conflicts, and the pati ent has
better control over them. Exampl e: A pati ent
who has been unabl e to achieve passi ng grades
at college sees hersel f as a l oser. Her history
reveal s a series of fai lures in achi evement and
in i nterpersonal rel ati onshi ps. I t becomes ap
parent that there is operati ve a fear of success
whi ch is equated wi th bei ng aggressive and
destructi ve toward others. T he therapi st
predi cts that thi s fear of success may sponsor a
fai l ure in therapy. Wi thout probi ng the ori gi ns
of her aversion toward aggression, the thera
pist focuses on the vari ous mani festati ons of
the need to fail and through desensi ti zati on
and other behavi oral techni ques hel ps the pa
ti ent to master anxi eti es rel ated to a comi ng
school exami nati on. Uti l i zi ng the pati ents suc
cessful passi ng as a ful crum, the therapi st
hel ps the pati ent evolve ways of copi ng wi th
future chall enges.
Negative transference will block any produc
tive therapeuti c effort. Thi s focus is perhaps
the most i mportant of al l areas. When
mani festati ons of negati ve transference ap
pear, its resol uti on becomes a pri mary task.
Exampl e: A pati ent after the second session
becomes highl y defensive and argumentati ve
chal l engi ng al most every i nterpretati on the
therapi st makes. I t is apparent that he wishes
to avoid establ i shi ng a worki ng rel ati onshi p
wi th the therapi st. T he therapi st, recogni zi ng
that the pati ent is unresponsi ve and obstruc
tive, confronts the pati ent wi th his behavi or. A
section of the i ntervi ew follows:
T h. I noti ce that you constantl y di sagree wi th what
I say.
Pt. No, shoul d I take for granted everythi ng, like
gospel ?
T h. I ts i nteresti ng that you say gospel . Y our
father, you told me, is a mi ni ster.
Pt. Are you tryi ng to tell me that I m acti ng as if
you are my father?
T h. Are you?
Pt. (long pause ) I dont thi nk so, but (pause)
maybe youre ri ght. I was an athei st ever since
I was 6 years old.
T h. Y ou mean fi ghti ng the gospel ?
Pt. (l aughs) What you are tryi ng to do here is
hardl y rel i gion.
T h. But you may be acti ng wi th me as if I m a
hi gh pri est.
Pt. (laughing) Y oure tryi ng to tel l me I m mi sbe
havi ng.
T h. T hi s is how you must feel. I certai nl y dont
beli eve youre mi sbehavi ng. Y ou have a ri ght
to your own thoughts. What were tryi ng to do
is to find out how you can get al ong better
wi th peopl e. Any maybe if you can work out a
better rel ati onshi p wi th me it wil l hel p you get
al ong better wi th others. T hat doesnt mean
I m al ways ri ght in what I say. But I thi nk I
can be more objecti ve about what you do than
you can. And if I poi nt out thi ngs that seem
like cri ticism, I m not tryi ng to be mean or ar
bi trary. L ets tal k it out. I ts i mportant for you
to deci de if I m ri ght or wrong.
Pt. Doctor, I hope you can be tol erant wi th me. I
know you are ri ght in what you are sayi ng. I ll
try.
T h. T hi s doesnt mean you have to take for granted
everythi ng I say. After all , I m not a hi gh
pri est.
Various other resistances i nterfere wi th
progress in therapy. I t may even be helpful to
anti ci pate resistances if the histori cal data and
ini ti al workup poi nt out areas of i mpendi ng
trouble. Exampl e: An acci dent-prone pati ent
wi th an obsessive-compulsive personal i ty seeks
therapy for anxi ety and depression. From earl y
chil dhood on he has been fearful of harbori ng
a dreadful disease, the present form of whi ch is
cancer. At the fifth session when it becomes
apparent that reassurance has failed to all ay
his fear of succumbi ng to a cancerous process
of the brai n aki n to that of a coll eague in his
professi on, the therapi st confronts hi m wi th his
masochistic need.
T h. I real i ze that, as you have tol d me, doctors
make mi stakes. But I get the i mpressi on that
in your case, wi th so many medi cal and neu
rol ogi cal checks, there is li ttle chance you have
cancer of the brai n. More i mportant than thi s
is why you have to torture yoursel f wi th thi s
i dea or wi th other fears. L i ke all the other
cancers you thought you woul d devel op in the
past and di dnt.
Pt. Doctor, I tel l you, I get so upset. I cant eat or
rest. I get up in the mi ddl e of the ni ght wi th a
cold sweat.
T h. (fir mly) Now l i sten to me. Y ou are gi vi ng
yoursel f a hard ti me. Now why in the devi l do
you have tc wear a hai r shi rt all the ti me. One
torturous i dea after another. Y ouve al ways
had it. I real l y feel youve al ways had it. I
real l y feel youve got a stake in puni shi ng
yoursel f. All the gui l t feeli ngs you have about
your parents. Y ou must feel that you are a ter
ri bl e person for feel i ng the way you do.
Pt. I cant get the thoughts out of my mi nd about
what wi l l happen to me when they die.
T h. L i ke what?
Pt. (pause) I dont know. I m afrai d I cant get
al ong wi thout them. And yet I have these aw
ful thoughts that somethi ng terri bl e wil l hap
pen to them. [Obvious ly the p a t i e n t is caught
in a c o n f l i c t o f d e p e n d e n t l y n e e d i n g his
p a re n t s, f e e l i n g trapped, re senting his help
less dependency, f e a r i n g t h a t his anger wi l l
so m e h ow bring about t heir death and turning
this re sen t ment back on himself. H i s g u i l t f e e l
ing enjoins him to p u n i s h a n d torture himself.
T h i s wi l l pr o b a b l y p r e v e n t h i m f r o m benefit-
ting f r o m therapy. To t ry to take away his
masochistic need f o r s e l f- p u n i s h m e n t w i t h o u t
dealing w i t h the basis f o r his g u i l t w o ul d prov e
e ith er f u t i l e or w o u l d on ly be t emporarily suc
cessful. ]
T h. Now look. Y ou have thi s need to puni sh your
self and al l the torture youre putti ng yoursel f
through, and al l your symptoms and the
messes you get i nto, acci dents and all , are, I
feel, di rectl y rel ated to thi s need for self
puni shment. T he reason I bri ng thi s up is that
as l ong as you have thi s need, you wi l l block
yoursel f from getti ng wel l i n our treatment.
What we are goi ng to do is pl an how you can
break thi s vi ci ous cycle.
A treatment pl an then was evolved to hel p
hi m break his dependency ties by getting hi m
to take vacations away from home and then to
find an apartment for hi msel f away from his
famil y. Havi ng been enj oi ned to vent his
anger, the pati ent became increasi ngly abl e to
tol erate his hostil ity and to accept his parents
for what they were. Wi th support he was able
to resist thei r i nsi nuati ons that he was a di s
loyal son for leavi ng them and for li ving his
own life. A dramati c change occurred in his
symptoms, and a 2-year fol l ow-up showed con
ti nued i mprovement and maturati on.
Separation anxiety will emerge as the end of
therapy approaches. Exampl e: A pati ent who
was maki ng progress up to the seventh session
began to experi ence a return of symptoms. Hi s
dreams revealed fears of abandonment, feelings
of helpl essness, and resentment toward the
therapi st. A frank discussi on of how natural it
was to experi ence fear of bei ng unabl e to func
ti on on his own as therapy threatened to end,
and how i mportant in his growth process it
was to tackl e his fears and master them,
brought out earl y anxi eti es about goi ng to
school , leavi ng home for college, and breaki ng
up wi th former girlfriends. Putti ng his present
reacti on into the perspecti ve of a pattern that
was not so terri bl y abnormal enabl ed hi m to
termi nate at the set date wi th feelings that he
had the strength to carry on by himself.
Special Applications of Technique
Short-term therapy embraces a hetero
geneous group of i nterventi ons catal yzed by
the therapi sts enthusi asm, the pati ents faith,
and shared hope. Whi l e it is true that tech
ni ques serve to rel ease i mportant heal i ng agen
cies, the choice of i nterventi ons and the skill
wi th whi ch they are i mpl emented are cruci al
to success. I t is to be expected that modi fi ca
ti ons in tradi ti onal psychotherapeuti c tech
ni ques will be i ntroduced by certai n therapi sts
who fashion thei r theori es around methods
that seem to work for them personal l y. Thi s is
all to the good, of course, except where the
therapi st attempts to i ncorporate all of psy
chopathol ogy wi thi n his cheri shed theory and
to insist that onl y his methods are valuabl e.
We may forgive these narci ssi sti c maneuvers
shoul d the methods presented have sufficient
value to justi fy experi menti ng wi th them to see
if they fit in wi th our uni que ideol ogies and
worki ng styles. And we may be able to modify
and shape some of them to our personal advan
tage. But, acceptance of the theoreti cal
premises for these innovati ve procedures will
requi re thorough experi mental vali dati on.
Sokol (1973), for exampl e, has devised a
short-term method for handl i ng si mpl e or
endogenous depressi ons based on some pri n
ci ples of psychoanal yti c theory. T he hypothet
ical assumpti ons around whi ch the treatment
process is ori ented contend that several factors
must operate to produce a clinical depressive
reacti on. Fi rst, there must be a current loss of
some kind, such as the death or removal of a
person close to one. Thi s acts as a spark, i gni t
i ng the explosive mi xture of an earl i er loss in
the chi l d-parent rel ati onshi p. Second, a pri mi
tive, puni ti ve conscience (superego) must exist
that will not permi t the rel ease of confl ictual
emoti ons, parti cul arl y hostil ity. Since hostil ity
cannot be handl ed by the si mpl e mechani sm of
repressi on, more pri mi ti ve ego mechani sms are
uti li zed, such as deni al , i ntroj ecti on, and i ncor
porati on. Usual l y other emoti ons cannot also
be tol erated, and both negati ve and posi ti ve
feel ings are blotted out. T hi rd, this leads to
further shame and guil t and begins a regressive
spi ral . I f we concede the vali dity of thi s hy
pothesis in order to cure a depressi on, hostil ity
toward the lost object must be recogni zed,
tol erated, and rel eased. Since the pati ent can
not do thi s for himself, the therapi st must do it
for him. I reasoned, said Sokol, that, if the
attack came from me, the pressure on the pa
ti ents superego woul d be di mi ni shed and the
affecti onate impulses could be expressed in de
fendi ng the lost person from this external at
tacker. Usi ng thi s tactic brought about a re
mission in the cases described by Sokol.
Lest one get too enthusi asti c about Sokol s
method, even though the dynami cs may sound
plausibl e, one must remember that only three
cases were cited in thi s study. Moreover, in
each case both anti depressants and tran
qui l i zers were coordi natel y used. Other i nno
vati ons cl ai mi ng good results wi th depressi on
exist and empl oy different techni ques ori ented
around compl etel y di ssi mi l ar theori es, for
instance, the cognitive therapeuti c methods of
A. T. Beck (1971, 1976).
I n cognitive therapy an attempt is made to
rectify conceptual di storti ons in order to cor
rect the ways that real ity is being experi enced.
I ntervi ewi ng techni ques anal yze defects in a
pati ents views of the worl d (cognitive assump
tions or schema), his methods of stimuli
screening and differentiation, and the erro
neous ideas that medi ate destructi ve response
patterns. Homework assi gnments rei nforce the
pati ents abil ity to deal constructi vely and con
fidentl y wi th adapti ve tasks. The treatment is
short term, consi sti ng of approxi matel y 20
sessions on a twi ce-a-week basis. Cogni ti ve
therapy for depressi on is organi zed around a
number of assumpti ons (Rush & Beck, 1978;
Rush et al, 1977). As a consequence of earl y
events, the pati ent retai ns a schema that
makes hi m vul nerabl e to depression. Among
such events is the death of a parent or other
i mportant person. What results is a pre-
depressive cognitive organi zati on. Operati ve
here is a global negati ve atti tude on the part of
the pati ent. Thus he mi sconstrues si tuati ons to
a poi nt where he has tai lored facts to fit
preconcei ved negati ve concl usi ons (Rush,
1978).
T he pati ent regards hi msel f as unworthy
and assumes thi s is because he lacks essential
attri butes to meri t worthi ness. He assumes his
difficulties will conti nue indefini tel y in the fu
ture, that fai l ure is his destiny. These charac
teristics consti tute the cognitive tri ad in
depressi on. I n treatment the pati ent is enj oi ned
to keep a record of aspects of his negati ve
thi nki ng whenever this occurs and to connect
these episodes wi th any associated envi ron
mental events that tri gger them off. The si mpl e
quanti fyi ng of any symptomsin thi s i nstance
negati ve thi nki ngtends to reduce them. The
therapi st, whenever the pati ent duri ng a
session bri ngs up a negati ve thought, asks the
pati ent to real i ty test it and then, away from
therapy, to do thi s by himself. Through thi s
means the pati ent is hel ped to see how he
makes unjusti fied assumpti ons (arbi trary i n
ferences), how he magni fi es the significance
of selected events ( magni fi cati on,) and how
he uses i nsigni ficant si tuati ons to j usti fy his
poi nt of view ( overgeneral i zati on). Other
cognitive errors are identified, such as how
offensive detai ls are used out of context whi l e
i gnori ng more i mportant constructi ve facts
(selective abstracti on), how ci rcumstances
and thoughts that do not fit in wi th negati ve
schemas are bypassed ( mi ni mi zati on );
how unrel ated events are unj usti fi abl y appro
pri ated to substanti ate his ideas ( personal i za
ti on). The pati ent is encouraged to revi ew his
record of thoughts, to identify themes and
assumpti ons, and to identify past events that
support his faul ty schemas. Poi nt by poi nt the
therapi st offers al ternati ve i nterpretati ons of
these past events. By so doi ng he hopes that
sufficient doubt will develop in the pati ent so
that he will engage in experi mental behavi ors,
recogni zi ng the fallaci ousness of his hypoth
eses, and arri ve at different, less destructi ve ex
pl anati ons for events. A mari tal partner or
famil y may also be involved in cognitive ther
apy to rei nforce correcti on of di storted negati ve
meani ngs.
Step by step the pati ent is encouraged to un
dertake tasks that he hi therto had consi dered
difficult (graded task assi gnment) and to
TECHNIQUES IN SHORT-TERM THERAPY
147
keep a record of hi s acti vi ti es ( acti vi ty
schedul i ng) and the degree of satisfacti on and
sense of mastery achieved ( recordi ng a mood
graph ). Di scussi ons in therapy focus on
the pati ents reacti ons to his tasks and his
tendencies at mi ni mi zati on of pl easure and
success. Homework assi gnments are cruci al.
These range from behavi oral l y ori ented tasks
in severe depressi on to more abstract tasks in
less severe cases ori ented around correcti ng ex
isti ng schemas. Shoul d negati ve transference
occur, it is handl ed in the manner of a biased
cognition.
Empl oyi ng a cognitive model of personal i ty,
Morri son and Cometa (1977) have evolved
what they call emoti ve-reconstructi ve short
term therapy (ERT). T he theory behi nd the
techni que is that unfortunate earl y chi l dhood
stress experi ences lead to a persons i nade
quate constructi on of self and others. Thi s
produces a pl ayi ng of faul ty roles and self-con
ceptual i zati ons in l ater life. T hus some chi l
dren, not being able to endure thei r parents as
nonlovi ng, distort real i ty by construi ng them
as loving and themsel ves as bad. Essenti al l y
locked into the role of bad chil d as a means of
reduci ng the stress and confusion of para
doxical famil y communi cati ons, i ndi vi dual s
subsequent life experi ences are but repl ays of
earl y rol es. What must occur to overcome thi s
di storti on then is a discovery of key conflicts
and a correcti on of thei r i nterpretati on. I nstead
of tryi ng to force this by i nappropri ate search
strategi es, as is the case in tradi ti onal psycho
therapy, a techni que of direct experi enci ng is
used by Morri son and Cometa. Pati ents are
asked to shut thei r eyes and to i mmerse
themselves in past events by focusing on the
contextual surroundi ngs (colors, odors, noises,
texture) of earl y experi ences descri bi ng these
briefly. Peri odical ly, when the therapi st wishes
to arouse the expressi on of a certai n feeling,
the pati ent is asked to hyperventi l ate by
breathi ng deepl y and rapi dl y for 30- to 60-
second ti me peri ods. Gestal t and rol e-pl ayi ng
techni ques may coordi natel y be empl oyed.
Support is gi ven and empathy shown when
necessary to comfort the pati ent. A pprox
i matel y 15 sessi ons often lead, it is reported,
to a reconstrui ng of sel f and si gni fi cant
others, whi ch in turn facili tates the adopti on of
more producti ve life rol es toward rapi d per
sonal ity and behavi or change. T he si mi l ari ty
of many aspects of thi s E RT techni que wi th
F reuds earl y catharti c method wi l l be
recogni zed.
Another exampl e of the use of a theoreti cal
pri nci pl e to fashion a cli nical approach is pro
vided by Suess (1972). He poi nts out that dy
nami c short-term therapy is obstructed in
the obsessive-compulsive i ndi vi dual by rigid
tendencies to avoid feel ings of excessive in-
tel l ectual i zati on, self-control, and attachment
as well as by great fears of surrenderi ng
oneself to hurt and expl oi tati on in any i nter
personal rel ati onshi p. An i mportant objective
in i ntervi ewi ng these pati ents, therefore, is to
hel p them recogni ze thei r feelings by worki ng
on those that are aroused in the current i nter
view si tuati on. These, mani fested in ver
bal i zati ons, voice tone, facial expressi on, body
movement and other nonverbal cues, are
deal t wi th by such phrases as Y ou sound
angry, Y ou look angry, Y ou look di s
gusted, Y ou appear uncomfortabl e i nsi de.
Present meani ngs are more i mportant than
referral to past hi story and geneti c ori gins.
Whenever the pati ent attempts a diversion by
theoreti cal , phi l osophi cal , or i ntell ectual di s
cussion, it is arrested and the focus redi rected
at feelings, such as bei ng angry, guil ty, affec-
ti onal , depressed, and so on. T he defensive na
ture of silences on the part of the pati ent
shoul d also be i nterpreted, for exampl e, the i n
cessant and paral yzi ng need to mai ntai n con
trol. Self-criti cism powered by an excessivel y
puni ti ve superego is tempered by suggesting
the possibil ity of less cri ti cal atti tudes. Focus
ing on the emoti ons behi nd verbal i zati ons
rather than the content is i mportant, especiall y
when the pati ent keeps tal ki ng about his
symptoms. I ntel l ectual i zati ons and doubts
uti li zed as a way of guardi ng agai nst recogni
ti on of feel ings in ones present life may seduce
148
the therapi st into engagi ng in fruitless debates,
thus falli ng into the pati ents trap of avoidi ng
feelings. T he proper response to these ma
neuvers, clai ms Suess, is to expose them as
resistances.
Some innovative attempts at prophyl axi s of
emoti onal illness have been made. Among
these is the work of Stei n et al (1969) on bri ef
therapy wi th seriousl y physi call y ill pati ents.
T he devel opment of an illness, parti cul arl y of
an i ncurabl e and debi l i tati ng nature, i mposes a
severe strai n on any i ndi vi dual . Where the pa
ti ent is unabl e to accept the i mposi ti on of a
temporary or permanent handi cap, where his
securi ty is threatened and hi s sel f-i mage
damaged by the real i zati on of his vul nerabi l i ty,
pathol ogi cal psychological reactions (parti cu
larly anxiety, depressi on, tendencies toward
denial , anger, and a vari ety of neuroti c and oc
casi onall y, in those wi th fragile ego strength,
psychotic mani festati ons) will i mpose them
selves. Because the pati ent may as a conse
quence become a psychi atri c casual ty,
psychotherapeuti c i nterventi ons i nsti tuted as
soon as possible are urgent.
At the Central Psychi atri c Cli nic in Ci nci n
nati an early-access bri ef treatment subdi visi on
(Stei n et al . 1969) accepts pati ents who
preferabl y have severe physi cal probl ems of
recent ori gin. Up to six sessions are gi ven,
each lasti ng from 15 to 50 mi nutes, spaced on
the average of one visit each week. I n the ma
j ori ty of these pati ents symptomati c i mprove
ment and restorati on of satisfactory functi oni ng
has followed thi s bri ef treatment (Gottschal k et
al., 1967). The treatment process is best or
gani zed by (1) handl i ng the tendencies to
denial , (2) managi ng a shatteri ng of the sense
of mastery, and (3) deal i ng wi th the conviction
of i mpai red body integri ty.
Handl i ng of the tendencies to deni al is cru
cial. Bl ank unbel i ef often operates as a pri
mary defense to i nsul ate the pati ent from the
impl i cati ons of his illness (L i ndemann, 1944).
Such deni al , i nterferi ng wi th the true assess
ment of the real ity si tuati on, constitutes a great
danger for the indi vidual . I n coronary illness,
for exampl e, the pati ent may engage in dan
gerous overactivi ty, neglect of his di et, and
forgetti ng to take essential medi cati ons. I t is,
therefore, i mportant to revi ew wi th the pati ent
his ideas of his il lness and his atti tudes toward
it especiall y his hopelessness. By careful clarifi
cati on coupl ed wi th reassurance we may be
abl e to correct existi ng mi sconcepti ons and
cognitive di storti ons. T he rel ati onshi p wi th the
therapi st can greatl y hel p the pati ent to accept
a factual assessment of his si tuati on. The ther
api st here serves in a rol e si mi l ar to the
protecti ng parent who makes pai nful and
threateni ng real i ty less i ntol erabl e to the chil d,
thus enabl i ng the child to accept and face
real i ty, wi th its hazards, rather than havi ng to
deny and shut out (Stein et al., 1969).
Managi ng a shatteri ng of the sense of mas
tery is i mportant, especiall y in those persons
who habi tual l y must mai ntai n control. The
fear that an illness can stri ke wi thout warni ng
and that it may be a harbi nger of other un
known and perhaps more serious physi cal
di sasters destroys the i ndi vi dual s confidence in
his own body. Reassurance that anti ci pated
catastrophes are not inevi tabl e and that pre
venti ve measures are a best means of hel pi ng
to avoid unwel come troubl es may qui et the pa
ti ents fears. Encouragi ng the pati ent to venti
l ate fantasies associated wi th the illness, the
therapi st is then in a better posi ti on to offer
advice concerni ng specific medi cal and neu
rological consul tati on resources.
Deal i ng wi th the conviction of i mpai red
body i ntegri ty involves restori ng fai th in ones
body. Thi s is especi all y necessary in traumati c
i nj uri es and surgical procedures. T o some ex
tent a reacti on of fatigue and a reacti on of
depressi on temporari l y follow even rel ati vely
mi nor acci dents and operati ons. But after
serious operati ons, such as breast and li mb
amputati ons and effects of muti l ati ng acci
dents, a prol onged peri od of upset can be ex
pected. Wi th the advent of open-heart surgery
many untoward resi dual psychol ogi cal se
quel ae have been reported. Severe anxi ety and
psychotic reacti ons are especi all y threatened in
persons whose adapti ve bal ance is precari ous, pati ents physi ci an, and thi s may al i enate the
I t does not requi re intensi ve probi ng to recog- pati ent from essential sources of support and
nize how angry a pati ent is at what has hap- comfort. Openi ng up discussi ons around this
pened to him. Such anger may be displaced or dynami c can be most constructi ve,
proj ected onto famil y members and even on the
Brief Group and Family Therapy
Brief group psychotherapy is an economi cal
way of handl i ng pati ents who have the moti va
tion and capaci ty to i nterrel ate in some way in
a group. As a diagnosti c and i ntake procedure
it has been empl oyed wi th success in certai n
clinics (Peck, 1953; Stone et al, 1954), parti cu
l arly where there are wai ti ng lists and an un
desi rabl e delay in assi gnment to a therapi st.
Here the group serves as more than a hol di ng
operati on, some pati ents benefi tting suffici entl y
from the group contact so that further i n
di vi dual treatment is not needed. At the
Metropol i tan Hospi tal Center in New Y ork,
Sadock and his coll eagues (1968) have oper
ated a short-term group therapy service for
socially and economi call y depri ved pati ents as
part of a wal k-i n clinic. At the initi al i ntervi ew
the 10 sessions li mit is expl ai ned by the social
worker wi th the addendum that shoul d thi s be
insufficient, l onger therapy mi ght be arranged.
One-hour sessions are held weekly, conducted
by a cotherapi st team of psychi atri st and social
worker. No more than eight pati ents are in a
group wi th new pati ents added as vacancies oc
cur. The average number of sessions attended
is five. The pati ent popul ati on is hetero
geneous educati onal l y, raci all y, and diagnos-
tically. Where necessary, communi ty agency
contact is made for envi ronmental al terati ons.
The group discussi ons are poi nted toward pro
blem solving, each new member, after being
i ntroduced, bei ng encouraged to give
bi ographi cal data and to rel ate the probl em
that brought hi m or her to the clinic. Reacti ons
of other members to the pati ents account and
suggestions for coping wi th probl ems are en
couraged, and goal s are formul ated. A p
proxi matel y two-thi rds of the pati ents have
been rated as i mproved at the end of thei r
treatment.
A good deal of l i terature has accumul ated on
the subject of bri ef group therapy, and a num
ber of different model s havi ng been described
in the first chapter of thi s book. Some reports
on the efficacy of short-term groups are espe
cially enthusi asti c. Trakas and L l oyd (1971)
worki ng wi th an open-ended group of pati ents
for no more than six sessions reported twi ce as
much i mprovement as was the case in pati ents
receiving other ki nds of hel p, i ncl udi ng l ong
term group therapy. Waxer (1977) i ntroduced
moti vated pati ents from a general hospi tal psy
chi atri c ward into a group for no more than
one month and was al so very opti mi sti c about
the results. On the other hand, McGee and
Meyer (1971) compared two groups of schi zo
phreni cs uti l i zi ng vari ous rati ng materi al s and
found that l ong-term groups were more effec
tive.
The ki nds of pati ents, thei r preparati on for
therapy, and the skill and personal i ty of the
group therapi st are obviously cruci al el ements
in determi ni ng the resul ts in short-term
groups. T he therapi sts atti tude toward group
therapy and his interest in worki ng wi th a
group are cruci al for success.
A few poi nters may be helpful. One way of
approachi ng a pati ent to enter a group is sug
gested in thi s excerpt:
T h. I beli eve that your type of probl em will be
hel ped best in a group setti ng. We wil l have
about six sessions.
Pt. Wi l l that be enough to cure thi s condi ti on?
Th. Y ou shoul d get enough out of therapy to have
gotten started on the road to getti ng better.
Whether you wil l be all cured is hard to say.
General l y, after so short a ti me in treatment
your symptoms shoul d be i mproved, and you
wil l have an i dea of how you can go about con
ti nui ng to get wel l and stay wel l.
Shoul d the pati ent show resistance to enter
ing a group, thi s is handl ed as in l ong-term
group therapy (see Wol berg, 1977, p. 706).
At the first group session members are i n
troduced by thei r first names and the confident
nature of the meetings emphasi zed. T he obl i
gati on to come to all sessions is stressed, pa
ti ents are told that the number of sessions is so
few that the sooner they open up and focus on
thei r probl ems, the faster they will get better.
Th. Y ou have an opportuni ty to tal k about thi ngs
here that you ordi nari l y keep secret. J ust open
ing up and putti ng your feeli ngs i nto words
wi ll hel p. What you want to do about upset
ti ng matters will be your own deci si on, but you
shoul d be abl e to thi nk more cl earl y about
what to do as a resul t of your group experi ence
and the hel p you get from the di scussi ons.
When you are ready, you wil l want to take ac
ti on and that shoul d set you on the road to get
ti ng well.
Pt. But what shoul d I tal k about?
Th. T he best way to start is to tal k about what
brought you i nto therapy, how it began and
what has happened up to the present.
Shoul d the pati ent delve too much into past
history, he shoul d be di scouraged, as shoul d
any too detai led theori zi ng about his condition.
T he focus shoul d be on the present, and it is
emphasi zed that no matter what has happened
to a person in the past, one can change if one
has the desi re for change. As pati ents begin to
tal k, thei r reacti ons to the group and to the
therapi st will become manifest. Some pati ents
will try to convert the group into a pri vate
session; they are then asked to address thei r re
marks to the group rather than the therapi st.
T he management of the group session as well
as speci al probl ems that occur is described
el sewhere in detai l (Wol berg, 1977, pp. 708-
719).
Most pati ents when they enter a group are
hi ghl y i ntol erant of cri ti cism, whi ch they an
ti cipate will happen shoul d they reveal them
selves. I n a wel l -conducted group the pati ent
becomes capabl e of di sti ngui shi ng between
destructi ve, hostil e attacks and constructi ve
cri ti ci sm moti vated by a desi re to hel p.
Moreover, he begins to real i ze that some
criti cal comments are real l y not personal but
are proj ecti ons that are bei ng falsely directed
at him. Such exposures hel p many pati ents be
come less cri ti cal of themsel ves, less ri gid and
defensive, and more accessible to reasonabl e
values. These l earni ngs may general i ze outside
of the treatment session and influence rel ati on
shi ps wi th others. Less hostil e to themsel ves,
they are more leni ent wi th persons wi th whom
they are rel ated. Cooperati ve and tender i m
pul ses emerge.
A number of stratagems may be empl oyed in
the group to faci li tate activity. One techni que
is to ask each member of the group to tal k
about any fears he or she had as an adolescent.
Group members often are abl e to tal k more
easily about past fears and probl ems, especiall y
those they have overcome, than present unre
solved ones or about si tuati ons wi th an i m
medi ate stress potenti al . Pati ents can find
comfort in l i steni ng to how other persons have
had to cope wi th difficul ties si mi l ar to thei r
own. Once past fears are aerated, present con
cerns are taken up about some common prob
lem. Shoul d pati ents be on a hospi tal ward,
they may be questi oned as to how each feels
about a routi ne that some have found di staste
ful. Once the ice is broken and communi cati on
is fl owi ng, more personal i mmedi ate probl ems
may be approached.
An i nteresti ng techni que that may be used
wi th pati ents who are not too sick, in a group
that is inactive and bogged down, is aski ng for
a vol unteer to leave the room so that the rest of
the group can tal k about hi m, ai ri ng thei r i m
pressions of the ki nd of a person he is. After a
short peri od the pati ent is invited back into the
room and asked to rel ate how he felt when he
was out of the room, what thoughts came to
him, and what he believes the group felt and
said about hi m. T hen another vol unteer pa
ti ent leaves the room, and the process is
repeated. L ater when the group is more i n
tegrated, the pati ents may compare how they
ori ginal ly felt about each other wi th changes in
thei r perceptions. Thi s techni que can stir up a
great deal of feeling and anxi ety and shoul d be
restri cted to pati ents wi th good ego structures.
I ndi vi dual sessions may coordi natel y be held to
handl e anxieties.
Role playi ng and psychodrama may also be
uti li zed in some groups to hel p a pati ent act
out what he feels about different peopl e i mpor
tant to hi m as well as to rehearse new patterns
and different ways of rel ati ng. Vi deotape re
cordi ng and feedback may also be empl oyed as
a way of giving the pati ent insight into para
doxical and ambi guous behavi or and com
muni cati ons.
Since groups are usual ly open-ended and
pati ents enter therapy at vari ous levels of psy
chol ogi cal sophi sti cati on and readi ness for
change, the therapi st will have to di spl ay a
consi derabl e degree of flexibili ty in the meth
ods uti li zed at different times. Parti cul arl y dif
ficult is work wi th actively psychotic pati ents.
T he conduct of such a group will call for meth
ods of a speci al kind, such as those didactical ly
ori ented toward an educati onal goal (Druck,
1978; K l apman, 1950, 1952; Preston, 1954;
Standi sh & Semrad, 1963). Here topi cs are
chosen that deal only tangenti al l y wi th the pa
ti ents affects and conflicts. Thus if pati ents
wish to discuss hal l uci nati ons and delusions, a
general discourse is gi ven on hal l uci nati ons
and delusions and not any i ndi vi dual s del u
sions as a personal probl em.
I n a bri ef group therapy wi th the soci ally
and economi call y depri ved there are advan
tages in havi ng the group composed of peers
who can identify wi th each others experi ences
and tri bul ati ons. The therapi st is often re
garded as a representati ve of bureaucrati c au
thori ty, and the presence of persons wi th si mi
l ar socioeconomic backgrounds is desi rabl e to
lend support to the pati ent and to i nterpret
what is bei ng felt.
Because hospi tal i zati on is consi dered as
sponsori ng regressi ve patterns and destroyi ng
sel f-confi dence and soci al rel ati onshi ps, al
ternati ves to psychi atri c hospi tal i zati on have
suggested famil y group approaches on the
basi s that the famil y is actively involved in
sponsori ng and mai ntai ni ng pathol ogy in the
presenti ng pati ent. At the Col orado Psycho
pathi c Hospi tal a Fami l y Treatment Uni t set
out to test the hypothesi s that fami l y-ori ented
cri sis therapy has advantages over other meth
ods (Pi ttman et al, 1966). T he uni t is manned
by a team of psychi atri st, psychi atri c social
worker, and psychi atri c publ i c heal th nurse
and operates 24 hours a day. All cases con
si dered candi dates for i mmedi ate hospi tal i za
ti on and who live not too far from the hospi tal
are scruti ni zed for treatment by the Fami l y
Treatment Uni t. Usual l y the crisis is brought
on by a change in rol e demanded of one or
more famil y members produced by some shift
in the famil y si tuati on.
At the uni t, work is done wi th the famil y to
bri ng the members to a real i zati on that the
desi gnated pati ent is not the onl y cause of the
crisis and that a sol uti on will not appear wi th
his removal to a hospi tal . Rather, the enti re
famil y is involved and, therefore, responsi bl e
for bri ngi ng about sol uti ons. The behavi or of
the desi gnated pati ent is i nterpreted as an at
tempt at communi cati on. An i nterpretati on is
al so made of the famil y rol e changes that led to
the crisis, wi th fi rm but empathi c confronta
ti on of all members of the famil y as to thei r
part in the pati ents upset. Thei r responsi bi l i ty
is outl i ned, the around-the-cl ock avai l abi l i ty of
the therapi st expl ai ned, and a home visit
schedul ed wi thi n 24 hours. Tasks are assigned
to each famil y member. T he pati ent and famil y
are informed that any insistance on hospi tal i
zati on is a way of escapi ng responsi bi l i ty and
that the crisis will be resolved only if famil y
roles and rul es are al tered. I n thi s way each
famil y member is given somethi ng to do, such
as cleaning the kitchen, wri ti ng a letter, taki ng
medi cati ons, and so on. Thi s is a way of test
ing the fami l ys cooperation. A member of the
team may actual l y parti ci pate in hel pi ng wi th
one of the tasks. T he pati ents and occasionall y
famil y members may be given psychotropi c
medi cati ons in adequate dosage if necessary.
The next step is the home visit to observe
the famil y i nteracti ons and if necessary to rene
goti ate role assi gnments. At first the fami l y as
a uni t is seen dail y, at whi ch ti me the behavi or
of the members is moni tored. The therapi st
may appl y direct or indi rect pressure to en
courage one or another person (pati ent or
famil y member living wi thi n or outsi de the
home) to change. T he focus is on the fi rm and
uncompromi si ng need to accept responsibi li ty.
The pati ent may be i nstructed to communi cate
more clearly and not through his symptoms.
T hi s often dramati cal l y produces i mprove
ment.
Wi th thi s techni que hospi tal i zati on was
compl etel y avoided in 42 of 50 cases, onl y an
average of six home or office visits per famil y
bei ng needed. Ten of the 50 famil ies call ed
over a month fol lowing di scharge about a sub
sequent crisis, whi ch was usual l y handl ed over
the tel ephone; several requi red one or two of
fice visits.
Short-term famil y therapy has had i ncreas
ing acceptance in clinics devoted to crisis i nter
venti on, the theoreti cal base being that be
havi or di sturbance is a product of a conti nui ng
fami l y system di sorgani zati on rather than
rooted in i ndi vidual pathol ogy. Combi ni ng
pri nci pl es from group therapy and famil y-
centered educati onal approaches, the practi
ti oner functions as both therapi st and educator
(Guernsey et al, 1971; Wel l s, 1974).
I n famil y therapy the therapi st must utili ze
a much more chal l engi ng and confronti ng tech
ni que than in ordi nary group therapy si nce the
interl ocking neuroti c famil y mechani sms are
extremel y ri gid and sel f-perpetuati ng. Y et, the
degree of chal l enge must be ti trated agai nst the
qual i ty of the rel ati onshi p that exists between
the therapi st and the famil y being treated. The
therapi st must al so be ready to expose himsel f
to chall enge. Growth is not restri cted to the
parti ci pants of the group; it also involves the
therapi st.
M ul ti pl e fami l y therapy especi al l y has
i ncreased in popul ari ty in recent years (L a-
queur, 1968; 1972), and an excellent articl e on
its l i terature, rati onal e, and some of its tech
ni ques has been wri tten by L uber and Wel l s
(1977). I n mul ti pl e fami l y therapy the
fami l i es and thei r members can become
mutual l y supporti ve of each other in confront
ing stressful areas; i ntense famil y feelings are
more di l uted in the group context, and hence
more approachabl e, and famil ies can l earn by
observati on and i denti fi cati on wi th other
f ami l i es (L uber & Wel l s, 1977). M any
famil ies may be hel ped wi th a ti me-l i mi ted ap
proach in this way, and for those who requi re
a l onger peri od of treatment the ki nds of prob
lems needi ng further hel p will have been i den
tified.
Donner and Gamson (1968) have described
thei r experi ence in deal i ng on a short-term
basi s (16 sessions) wi th groups of famil ies ex
peri enci ng probl ems wi th adolescents. T he ob
jectives were (1) to provi de a setti ng conducive
to expl orati on of famil y probl ems that con
tri buted to difficul ties of the adolescent mem
bers, (2) to hel p famil ies acqui re new and bet
ter sol uti ons to quandari es confronti ng them,
and (3) to empl oy insights gai ned as a means
of recommendi ng further therapy if needed.
Eveni ng sessi ons of 1Zi hours once weekly
were conducted, usual l y by a cotherapi st team.
Out of thei r experi ence a number of techni ques
are recommended. At the i ni ti al session the
group is i nstructed that a probl em in one
famil y member involves not only the member
but the enti re famil y. One shoul d not regard
any member as the bad one or sick one
because when troubl e starts, there is somethi ng
goi ng on in the enti re famil y. A fami l y ex
pl orati on of the probl em enabl es them to deal
wi th the cause. All of us together will try to
understand what is goi ng on in the different
fami l i es that contri bute toward the young
peopl es difficul ties, and each can make con
tri buti ons to the others. T he group is told
that since famil y members in one famil y live so
closely, they may not be abl e to see the prob
lem as clearly as when they see the same prob
lem going on in another famil y. By observi ng
how other famil ies solve thei r probl ems each
famil y may obtai n val uabl e insights. Feeli ngs
should be venti lated freely wi th no restri cti ons,
and there must be no puni shment at home for
what is said. Other ground rul es are that all
present members must attend each session
(father, mother, adolescent, and, if possible,
other siblings). Fami l i es duri ng thi s treatment
process are not to sociali ze outside the group
since thi s will affect how they i nteract in the
group.
As famil y members ai r thei r anger, despai r,
hurt, and i ndi gnati on, new ways of deal i ng
wi th probl ems general l y emerge. T he famil ies
lose thei r feeling of havi ng somethi ng wrong
about them, whi ch isolates them from others.
T he changes in one famil y group reinforce
changes in the others; the famil ies become ac
tive hel pers of one another.
Common Questions about Techniques
in Short-Term Therapy
T here is a great deal of current i nterest in
bi ochemi cal causes of emoti onal prob
l ems, and parti cul arl y chemi cal neuro-
transmi tters, that may be i nf l uenced by
pharmacotherapy. Do you bel i eve that
thi s mi ni mi zes the rol e of psychotherapy?
Certai nl y it woul d be qui cker and
cheaper to gi ve a person a drug rather
than to spend sessi on after sessi on i n i n
tervi ewi ng.
What you are aski ng is whether drugs
eventually will repl ace psychotherapy. A cur
rent articl e in a nati onal magazi ne i mpli es that
we will in the not too di stant future be abl e to
control all behavi or by i nj ecti ng or extracti ng
chemi cals into and from the body. I n my
opini on, thi s fri ghteni ng possibil ity is qui te re
mote. I n expl i cati ng neurotransmi tters, or any
other chemi cals, as the ul ti mate i ngredi ents in
behavior, biochemical enthusi asts commi t the
same kind of error that the classical Freudi ans
made in deifying the Oedi pus compl ex as the
fountai nhead of all mortal bl i ghts. Both
neurotransmi tters and the Oedi pus compl ex
may come into play, but they are merel y some
of the agencies that are operati ve in the com
pl ex seri es of transacti ons that consti tute
human behavior. Bi ochemical , neurophysi o
logical, devel opmental -condi ti oni ng, i ntrapsy
chic, i nterpersonal , social, and spi ri tual factors
are all vital li nks in the behavi oral chai n, i n
fl uencing each other by feedback. No one link
is most i mportant. Every thought, idea, wish,
and fantasy has its biochemical correlates.
Conversel y, biochemical changes, i ncl udi ng the
i nfl uences of psychotropi c drugs, resonate
throughout the enti re chai n affecting other
links. But whi l e drugs may molify, it has been
demonstrated that they will not solve the mani
fold social, i nterpersonal , and other di storti ons
that are ubi qui tous. Actuall y, more peopl e are
bei ng funnel ed back into hospi tal s in spi te of
medi cati ons than ever before. So let us give
bi ochemi stry and pharmacotherapy thei r
proper due wi thout encouragi ng the publ i c to
seek cures for spi ri tual , soci al, i nterpersonal
and emoti onal ills in thei r local drug stores. I n
short, it is foolish to anti ci pate that drugs will
ever repl ace good psychotherapy.
Can you gi ve exampl es of what you mean
by ecl ecti c therapy?
I t is a rari ty today to find a therapi st who
confines hi msel f to one specific techni que.
There are several ways of al l evi ati ng psycho
logical distress. Among the most recent entri es
i nto the therapeuti c arena are the modern so
mati c therapi es that ai m at rectificati on of ex
isti ng neurophysi ol ogi cal and biochemical dis
torti ons. An effective therapi st may, from ti me
to time, have to prescri be or refer his pati ent
for prescri pti on of neurol epti cs for schi zo
phreni c and other psychotic reactions, anti -
depressants (Tofrani l , Elavi l, Si nequan, Nar
dil, Parnate, etc.) for deep depressions, anti -
mani c medi cati ons (L i thi um for mani c at
tacks), mi nor tranqui l i zers (Val i um, L i bri um,
Serax, etc.) for severe anxieties, sedatives and
hypnoti cs for the temporary rel ief of i nsomni a,
and electric convulsive therapy for suicidal
depressions. So doi ng will resul t in correcti ng
rapi dl y a host of symptoms that i nterfere wi th
psychotherapy.
A second mode avai l abl e to the therapi st is
di verti ng the pati ent and produci ng a cal mi ng
effect through biofeedback or rel axi ng ex
ercises, like medi tati on, hypnosi s, and auto
genic trai ni ng. A thi rd way is fl ooding the
mi nd wi th phi l osophi cal , persuasi ve, or sug
gestive formul ati ons, as in cognitive therapy. A
fourth group of techni ques attempts to divert
the pati ent through external i zati on of interests,
music therapy, dance and movement therapy,
poetry therapy, soci al therapy, and occupa
ti onal therapy. A fifth mode is al terati on of the
envi ronment to reduce stresses being i mposed
on the pati ent and to surround hi m wi th con
structi ve stimuli . Among the tactics empl oyed
here are gui dance, mi li eu therapy, mari tal
therapy, famil y therapy, therapeuti c counsel
ing and casework, and supporti ve group ther
apy. A si xth mode ai ms at rectifying faulty
habi ts and devel opi ng new and more produc
tive patterns through behavi or therapy, role
playi ng, and cognitive l earni ng. A seventh
mode expl ores unconsci ous confl i ct and
rel eases latent creative potenti al s through dy
nami c psychotherapy, exi stenti al anal ysi s,
transacti onal therapy, experi enti al therapy,
hypnoanal ysi s, narcoanal ysi s, expl oratory art
and pl ay therapy, visual imagery, and anal yti c
group therapy. As has been stressed, however,
techni ques in each of the modes do not confi ne
thei r influence to one area. They will influence
other parameters in cognitive, emotional , and
behavi oral areas.
I snt the pri nci pl e of ecl ecti ci sm an i n
vi tati on to conf usi on that ul ti matel y
def eats i ts purpose?
I f you are referri ng to ecl ecticism as a mi x
ing of vari ous theori es into one grand stew,
yes. I t is foolish to attempt to appl y theori es
rel ated to one area of functi oni ng, say the
bi ochemical li nk, to another area, for exampl e,
the i ntrapsychi c and i nterpersonal li nks or vice
versa. All you will achieve is confusion. Even if
one attempts to mi x different theori es that
rel ate to a si ngle link in the behavi oral chai n,
the resul t can be a mess of scrambl ed ideas that
expl ai n nothi ng. On the other hand, if
eclecticism refers to a techni cal bl endi ng of
methods, each of whi ch is sui ted for a different
di mensi on of functi oni ng, you can through
such bl endi ng enhance the efficiency of your
operati ons. For exampl e, in a severe depres
si on you may want to correct the pathol ogy
i n the bi ochemi cal l i nk by prescri bi ng
i mi prami ne. Y ou may al so si mul taneousl y
decide to deal wi th the i ntrapsychi c probl em
by uti l i zi ng psychoanal yti c psychotherapy or
cognitive therapy. Moreover, if a famil y prob
lem exists, you will be wise to do some famil y
therapy. These blended techni ques enhance
each other. After all, if a surgeon had onl y one
techni que at his disposal, like appendectomy, it
woul d be silly to try to treat every stomachache
or bowel cramp by taki ng out the appendi x.
I f a pati ent does not respond to the tech
ni ques you are usi ng even though there
appears to be a good therapeuti c rel ati on
shi p, what do you do?
T he first thi ng is to search for transference
that may not be apparent on the surface. The
pati ents resistance to the therapi st and to re
l i nqui shi ng his illness may be masked by a
compl ai nt and seemingl y cooperati ve atti tude.
Often transference becomes apparent onl y by
observi ng nonverbal behavi or or by searchi ng
for acti ng-out tendencies away from therapy. It
may be detected someti mes in the pati ents
dreams. Once transference is confi rmed, con
frontati on, frank discussion, and i nterpretati on
155
are in order. Another reason why the pati ent
may not be respondi ng well to treatment is
that the proper techni ques are not being em
ployed that accord wi th the pati ents l earni ng
capacities. For exampl e, some pati ents cannot
seem to uti li ze the abstract concepts of i nter
pretive techni ques. They do better wi th role
pl ayi ng or asserti ve trai ni ng. Other pati ents
respond better to rel axati on methods. One may
fruitlessl y work wi th an alcoholic and his
famil y, yet will find that he i mproves i m
medi atel y wi th an i nspi rati onal supporti ve
group patterned after Alcoholi cs Anonymous.
T o do good short-term therapy, the therapi st
must be flexible and exploi t a range of eclectic
techni ques. I f certai n techni ques best sui ted for
a pati ent are not wi thi n ones range of skills,
one shoul d refer the pati ent to a speciali st.
Whether the pati ent is to be transferred
enti rel y or seen jointl y will depend on the spe
cific probl em and on how advi sabl e it is to
mai ntai n a therapeuti c rel ati onshi p wi th
another professi onal as a cotherapi st.
How i mportant are the therapi sts at
ti tudes i n short- term therapy?
Atti tudes are i mportant, for instance, en
thusi asm and conviction about what one is do
ing. Begi nni ng therapi sts, in thei r eagerness to
hel p, often communi cate enthusi asm that
catalyzes therapy. Apparentl y experi ence for
some reason dampens enthusi asm, therapi sts
becomi ng more scienti fic, cauti ous, and con
servative about thei r heal i ng powers. Such at
ti tudes have a dampeni ng influence. Somehow
the therapi st must get across to the pati ent
conviction in the vali dity of his approach. Thi s
enhances both the placebo effect of therapy and
consolidates the pati ents fai th in the therapi st,
thus strengtheni ng the therapeuti c all iance. A
show of confi dence on the part of the therapi st
wi l l hel p carry the pati ent through the
resistance phases of treatment. Where the ther
apist anti ci pates a long peri od of treatment,
cues may be rel eased that pl ay into the pa
ti ents dependency and fears of separati on,
thus prol ongi ng therapy.
When is countertransf erence most l i kel y
to appear?
Countertransf erence is l i kel y to appear
among therapi sts at any phase of treatment,
selective characteri sti cs in pati ents sponsori ng
aversi ve reacti ons that can i nterfere wi th
progress. Seri ous psychi atri c i mpai rment in
pati ents is an especiall y promi nent sti mul us
that sparks off untoward responses in many
professi onals. Thi s was borne out in a study of
the reacti ons of nonpsychi atri c physi ci ans to
medi cal pati ents (Goodwi n et al., 1979). The
most disli ked pati ents were those who pos
sessed strong psychopathol ogi cal characteri s
tics. T he author of the articl e concluded that
the emoti on of disli ke in physi ci ans was a sen
sitive clue to psychi atri c i mpai rment in pa
tients. Recogni ti on of the i nappropri ati veness
of ones negati ve feelings gives one an opportu
ni ty to exami ne those feel ings and to control
them, thus hel pi ng to avoid adverse effect on
therapy.
Can countertransf erence ever be used i n
a therapeuti c way?
Yes. Therapi sts recogni zi ng that thei r own
neuroti c feel ings are bei ng acti vated may look
not only into themsel ves, but al so into what
neuroti c needs and drives in thei r pati ents are
acti vati ng thei r personal reactions. They may
then bri ng up these provocati ons as foci for ex
pl orati on. They may ask, is the pati ent aware
of aberrant impul ses and behavi ors? What
does the pati ent want to accompl i sh by them?
Confronti ng the pati ent wi th his behavi or may
have a therapeuti c i mpact on him.
A re negati ve feel i ngs i n the therapi st al
ways evi dence of countertransf erence?
Of course not. T he pati ent may be acti ng in
an offensive and destructi ve way, l egi ti mately
sti rri ng up i rri tati on and anger in the thera
pist. There is no reason why, when a worki ng
rel ati onshi p exists, the therapi st shoul d not
confront the pati ent wi th his behavi or in a
noncondemni ng but fi rm manner.
Can you descri be what is meant by the
need f or acti vi ty i n short- term ther-
apy?
The need for acti vity on the part of the ther
apist is expli cable on the basis of the li mi ted
ti me avail able for treatment. Passive wai ti ng
for the pati ent to work through his probl em
wi thi n a few sessi ons will bri ng meager results.
I t may be necessary to guide, support, exhort,
and confront the pati ent as forcefully as is re
qui red at the moment, al ways mindful of the
need to preserve a warm therapeuti c cli mate.
Activity in therapy may requi re anci l l ary serv
ices of physi cians, l awyers, social workers,
teachers, and other professi onals as well as
whatever communi ty resources are needed at
the moment. Especially in crisis i nterventi on,
assistance wi th economi c, housi ng, and other
si tuati onal probl ems may be necessary. By his
acti vity the therapi st communi cates the expec
tati ons that an earl y resol uti on of the present
ing crisis is achievable. Often it is exactly that
expectation which serves as the pri mary thera
peutic agent (Amada, 1977) Activity will re
qui re an abandonment of anonymi ty and the
reveal i ng of oneself as a genui ne person rather
than as a professi onal automaton. Thi s does
not mean a rel i nqui shi ng of the propri eti es of
an ethi cal therapi st-pati ent rel ati onshi p, but
rather a loosening of the strai ghtj acket of rigid
formal i ty and detachment that are so destruc
tive to good rapport. Activity may take the
form of putti ng into words the nebul ous feel
ings of the pati ent, and it may even be
expressed in di rect advi ce gi vi ng through
presenti ng the pati ent wi th several opti ons and
hel pi ng hi m to make the proper choice.
How acti ve shoul d the therapi st be? What
i f by nature the therapi st is a passi ve per
son?
Activity is the keynote of short-term ther
apy. Thi s does not mean the therapi st shoul d
do all the tal ki ng. Even a therapi st who is
qui te qui et and reserved can adopt a style of
greater acti vi ty, avoi di ng si tti ng back and
al l owi ng the pati ent to rambl e on wi th verbal
inconsequenti al i ti es. By uti li zing the pri nci pl e
of selective focusing (Wol berg, 1977, pp. 366-
370), searchi ng for evidences of transference
and countertransference, i mmedi atel y deal i ng
wi th resistances when they arrive, changi ng
from one techni que to another when the for
mer proves ineffective, and posi ng chal l engi ng
questi ons and confrontati ons, a good degree of
acti vity will come into play.
I n f ocusi ng on a l i mi ted area, do we not
stand the danger of negl ecti ng i mportant
parameters of a persons l i fe?
I n short-term therapy it is pragmati cal l y
necessary to ci rcumscri be the number of vari a
bles wi th whi ch one deals duri ng the i nter
view. By concentrati ng on a li mi ted area for
focus and confi ni ng ones work to that area,
some therapi sts feel they achieve the greatest
i mpact. T he pati ent reveal s hi s probl em
through mul ti pl e channel s: the way he walks,
the way he sits, his bodil y movements in tal k
ing, his facial expressions, revel ati ons of his
past life, hi s current entangl ements, hi s
dreams, the manner of his rel ati onshi p to the
therapi st, and so on and so on. The therapi st
may decide to work wi th one constel l ati on, let
us say the i ndi vi dual s present rel ati onshi ps,
perhaps focusing on his i mmedi ate famil y. The
hope is that by al teri ng the character of the
famil y i nteracti ons a chai n reaction will have
been started to influence other rel ati onshi ps
and ul ti matel y the deepest patterns of ones
thi nki ng and feel ing life. Memori es of past dif
ficulties may someti mes break through wi th a
reapprai sal of ones past existence. I ndeed, a
compl ete revol uti on may take place in the per
sonal ity structure. Or we may focus on a speci
fic symptomexpl ori ng its history, the events
or conflicts that i ni ti ate it, the ci rcumstances
that amel i orate i tand even start a regi men to
control it. We may then find that wi th sympto
mati c i mprovement other di mensi ons of the
personal i ty are positi vel y influenced.
Once a focus i s chosen, shoul d you i gnore
or di rect the pati ent away f rom materi al
brought up that has nothi ng to do wi th
the focus?
Because there is so little ti me avail able, it is
unproducti ve to deal wi th all of the random
events and ideas the pati ent bri ngs up duri ng a
session. Often these are advanced in the i nter
ests of resistance. Yet there will occur inci dents
of great concern to the pati ent that on the sur
face have little to do wi th the area of focus. To
ignore these will indi cate to the pati ent di si n
terest and lack of empathy, apart from it being
bad therapy. For exampl e, if a core probl em is
destructi ve competi ti veness i ssui ng out of
ri valry wi th a parent or si bli ng and the pati ent
has that morni ng found a l ump on her breast,
it woul d be foolish to bypass the pati ents
desi re to tal k about the i nci dent. Even lesser
areas of troubl e preoccupyi ng the pati ent
shoul d in commandi ng attenti on chal l enge the
therapi st to find a connection wi th a deeper
focal probl em. Thi s can be done in most cases
even though the route chosen may be devious.
T hus a pati ent wi th a core probl em of
passivity and lack of asserti veness, a product of
incomplete separati on-i ndi vi duati on, is i ntent
on tal ki ng about an art exhi bi t he had attended
at a local museum. Underneath the great ad
mi rati on for the arti st is, it seems, a feeling of
envy and despai r at ones own lack of produc
tiveness. The pati ent may then be brought
back to the core probl em wi th the statement,
How woul d you compare your own tal ents
wi th those of the arti st? I f a therapi st cannot
find any connections, a questi on like What
does that have to do wi th your own basic prob
lem we have been expl ori ng? will usual l y
hel p the pati ent resume deal i ng wi th more sig
nificant materi al .
How much advi ce gi vi ng shoul d be used
i n short- term therapy?
Advice giving in psychotherapy shoul d be
handed out spari ngl y and sel ecti vel yand
only when pati ents cannot seem to make an
i mportant decision by themsel ves or if thei r
j udgments are so faul ty that they will get into
difficulties shoul d they pursue them. Even in
the l atter case it is best to present al ternati ves
to the pati ents for thei r own choice and to con
ti nue questi oni ng them as to why they find it
difficult to pursue a constructi ve course of ac
tion wi thout help.
I s tel ephoni ng the therapi st permi ssi bl e
i n short- term therapy?
I n short-term therapy, and especiall y in
crisis i nterventi on, the avai l abi l i ty of the thera
pist can be most reassuri ng. Whi l e the thera
pist does not encourage the pati ent to tel e
phone as a routi ne, tel li ng the pati ent to call if
an emergency ari ses can al l ay anxi ety and
present the therapi st as a cari ng person, thus
bol steri ng the therapeuti c all iance.
What is the conventi onal number of
sessi ons that shoul d be spent i n short
term therapy?
A good deal of vari ati on exists in the times
all oted to short-term therapy. These range
from 1 session to 40, the frequenci es varyi ng
from once to three ti mes weekly, the session
lengths from 15 mi nutes to 2 hours. On the
average, however, there are approxi matel y 6
sessions over a 6-week peri od in crisis i nter
venti on, from 7 to 15 sessions over a 4-month
span in supporti ve-educati onal short-term
therapy, and as many as 40 sessions in dy
nami c short-term psychotherapy. Most ses
sions are for a 45-mi nute hour. Some thera
pists establi sh a set number of sessions at the
first intervi ew and firmly adhere to a termi na
tion date. Other therapi sts are more flexible
and determi ne the length of treatment accord
ing to the response of the pati ent to therapy.
How eff ecti ve is the f i rm advanced setti ng
of the number of sessi ons, and i f ef f ecti ve,
shoul dnt thi s be a routi ne wi th al l pa
ti ents?
T he fi rm setti ng of li mi ts of ti me on ther
apy, ori gi nal l y described by Rank (1947) and
Taft (1948), has been benefi cially empl oyed by
many therapi sts (Haskel l et al , 1969; S.
L i pki n, 1966; Meyer et al, 1967; Muench
1965; Shli en, 1964; Shli en et al, 1962). An in
teresti ng fi ndi ng is that a termi nati on date ac
cepted as an i mmedi ate real i ty will influence
the process of therapy and sti mul ate greater
pati ent activity than where an unl i mi ted num
ber of sessions seduces the pati ent into com
pl acent torpor. T he research done tends to
support the advantages of restri cti ng sessions
158
in short-term therapy to a desi gnated figure.
Agai n, the therapi st will have to exercise suffi
cient fl exibili ty so as not to subvert his clinical
j udgment to a rigid rul e. I n certai n cases he
will want to keep his opti ons open, merely
menti oni ng to the pati ent that he will li mi t the
number of sessions and that he will decide on
the exact number soon after therapy has
started. The therapi st may quote the fi gure as
soon as he has a better idea of the extent of the
probl em and the capaci ty of the pati ent to
achieve proj ected goals.
How f l exi bl e shoul d one be about
appoi ntment ti mes, whi ch usual l y are
spaced at weekl y i nterval s.
A certai n flexibili ty of appoi ntment ti mes
will be requi red, parti cul arl y in crisis i nterven
tion when doubl e and tri pl e sessions, several
sessions on the same day, and the spaci ng of
sessions are determi ned by the pati ents rather
than the therapi sts needs. Also duri ng the first
week of therapy wi th pati ents who are ex
tremel y anxi ous three sessions will be needed
for adequate support, reassurance, and the
consol idation of a rel ati onshi p. Weekl y ses
si ons thereafter usual l y suffice. Then there
may be a taperi ng off to one session in 2 weeks
and the next in a month, followed by termi na
ti on. Shoul d there be no i mprovement wi th
weekly sessions, an addi ti onal weekly session
in a group may be helpful, the group therapy
also being conducted on a short-term basis.
What do you do about taki ng a vacati on
i n the mi ddl e of a pati ents therapy?
Prepari ng pati ents for vacations or other
absences of the therapi st is often overl ooked.
Sufficient noti ce shoul d be given to all ow at
least two sessions before the therapi st departs
in order to observe and manage the pati ents
reactions. Natural l y, if a verbal contract was
made wi th the pati ent that included the ti me of
termi nati on and no notice had been given the
pati ent that there woul d be an i nterrupti on of
treatment, spri ngi ng a vacation on the pati ent
can have a bad effect on the rel ati onshi p. I n
the absence of a defi nite contract involving the
exact date of sessi ons or the date of termi nati on
no difficul ty shoul d be encountered where the
pati ent has been forewarned at least two
sessions in advance, except in the instance of
prol onged vacati ons (a conti ngency that can
occur parti cul arl y in ol der therapi sts by vi rtue
of thei r havi ng achieved sufficient levels of age,
fatigue, or economi c security).
What do you do i f a pati ent keeps tal ki ng
about how hopel ess he feel s about getti ng
wel l and l i ttl e el se?
Pati ents often express hopelessness about
getting well soon after they start therapy. T o
such l amentati ons the therapi st may repl y,
These are resistances fi ghti ng back as soon as
you begin maki ng efforts to get well. They will
pass if you di sregard them and go ahead wi th
the pl an of acti on we di scussed. No matter
how pessimi stic the pati ent may seem about
himself, the therapi st shoul d retai n an opti
mistic stance: No matter how bad and i mpos
sible thi ngs seem, if you keep worki ng on your
probl ems, you can get better. Natural l y, an
anal ysi s of why the pati ent feels hopeless wi th
proper i nterpretati on of his masochi sm woul d
be indi cated. I f the therapi st knows how to do
cognitive therapy, he mi ght try to use this
next. I n the event the pati ent is severely
depressed, and parti cul arl y where there is
earl y morni ng awakeni ng, loss of appeti te, or
retardati on, an anti depressant shoul d be
prescri bed al ong wi th any of the other
measures recommended above. Shoul d negati ve
di scouragi ng thoughts persist, the pati ent may
be taught methods of behavi oral aversive con
trol (Wol berg, 1977, pp. 694-695).
How soon shoul d you deal wi th angry,
negati ve atti tudes that a pati ent mani f ests
toward you, expressed by cri ti ci zi ng your
cl othes, your offi ce f urni ture, etc.
T he mai ntenance of a positi ve warm work
ing rel ati onshi p is, of course, the best thera
peuti c cl i mate. Whenever negati ve feel i ngs
threaten, unl i ke l ong-term therapy where they
may be al l owed to foster regressi on and then
anal yzed, they must i mmedi atel y be expl ored
and dissipated as rapi dl y as possible to restore
the pati ents confidence. By the same token, in
personal dress and groomi ng the therapi st
should not appear so offbeat as to offend the
sensibilities of his pati ent. On some level the
therapi st becomes a model for the pati ent. The
arrangement and furni shi ngs of ones office
shoul d also reflect orderliness and good taste.
Are there any ri sks i n seei ng another
member of a pati ents fami l y, such as a
husband or wife?
Yes. A hostil e member may uti li ze the i nter
view as a way of attacki ng the pati ent by mi s
quoti ng for the pati ents discomfort somethi ng
the therapi st has said that is detri mental to
the pati ent. An exampl e is the following letter
received from a pati ent who did well in short
term therapy. I had an i ntervi ew wi th the wife
duri ng whi ch she vented her anger at her hus
band. She refused to consi der mari tal therapy
or i ndi vidual treatment for herself even though
I felt I had made some contact wi th her when I
saw her.
Dear Dr. Wol berg:
For some ti me, I have been taunted by Mrs. G
wi th deri si ons based on specific remarks she fi rml y
states you made to her concerni ng me. These state
ments are that I am "hopel ess, that 1 wil l never
get better, that I am too ol d to get hel p, and
worse than all , that I have nei ther the desi re nor
the i ncl i nati on to get better. These remarks have
been repeatedl y hi ssed at me, and al though I have
tri ed to di scount and erase them as statements from
you, they have been repeated and I am deepl y hurt
and humi l i ated that they may possi bl y have had you
as thei r source.
As you wil l recal l , 1 came to you in a desperate
emoti onal state pl eadi ng for hel p. 1 had a severe
anxi ety and depressi on and the di stressi ng symp
toms of muscle spasm. I attri buted these to the
confli ct at home, parti cul arl y the i nteracti ons be
tween my son and hi s mother. How coul d I not
have the desi re nor the i ncl i nati on to get better? I
devel oped a very effective rapport wi th you and
after a few months my symptoms left me. Some two
months l ater, the si tuati on at home sporadi cal l y
erupted, and it soon devel oped that Mrs. G was the
common denomi nator (not my son) as the provoki ng
and di sturbi ng i nfluence at home, that her cruel ty
and constant agi tati on created the dai l y envi ronment
of hosti l i ty and chaos at home and these had thei r
di re effects upon me and my son. Thi s proved to be
true because every symptom of anxi ety, fear, and
depressi on left me when Mrs. G left last J une for
Fl ori da.
She returned home a few weeks ago and the tur
moi l , cruel ti es, and hosti l i ti es returned wi th her. I
had reached a state of i nternal stabi l i ty and equa
ni mi ty whi l e she was away, but now her dai l y
ti rades have resumed, openi ng up ol d wounds, and
parti cul arl y referri ng to you as maki ng the specific
remarks I have al ready stated. I real i ze she is doi ng
thi s wi th sadi sti c i ntent, and al though I have every
reason to di scount and di sbeli eve such statements
from you, I do feel deepl y hurt and 1do not want to
go on thi nki ng that you mi ght, for some reason,
have gi ven her these terri bl e i mpressi ons Except for
what is understandabl y a personal hurt wi th the
weapon she is usi ng agai nst me, 1 am otherwi se
feel i ng fine. I felt I shoul d wri te you of thi s and give
you an opportuni ty to let me know the truth of what
you di d or di d not rel ate to Mrs. G Y our repl y wil l
remai n stri ctl y between us, but I do owe it to myself
to seek the truth.
Cordi al l y,
M r. G
Credi ti ng certai n remarks to the therapi st is
bound to affect the rel ati onshi p wi th the pa
ti ent. The best way to handl e the mi sunder
standi ng is to arrange a j oi nt session wi th the
pati ent and other famil y member avoi di ng ac
cusati ons about who said what about whom.
T he therapi st may then in a noncondemnatory
way hel p clarify what has been happeni ng.
Thi s can be a sticky si tuati on and will call for
a great deal of tact. T hat inci dents such as the
one cited in the l etter above can occasionall y
occur shoul d not di scourage the therapi st from
seeki ng i ntervi ews wi th other famil y members.
Can supporti ve therapy be anythi ng more
than pal l i ati ve, and i snt dependency en
couraged i n thi s ki nd of treatment?
The supporti ve process may become more
than pall iative where, as a result of the rel a
ti onshi p wi th the hel pi ng agency, the person
gai ns strength and freedom from tension, and
substi tutes for mal adapti ve atti tudes and pat
terns those that enabl e hi m to deal produc
tively wi th envi ronmental pressures and i nter
nal conflicts. Thi s change, brought about most
effectively through the i nstrumental i ty of a re
l ati onshi p ei ther wi th a trai ned professi onal in
i ndi vidual therapy or wi th group members and
the l eader in group therapy, may come about
also as a result of spontaneous rel earni ng in
any hel pi ng si tuati on. Some dependency is, of
course, inevi tabl e in thi s ki nd of a therapeuti c
interacti on, the adequate handl i ng of whi ch
constitutes the di fference between the success
or fai lure of the therapeuti c rel ati onshi p in
scoring a true psychotherapeuti c effect. De
pendency of thi s ki nd, however, can be
managed therapeuti cal l y and consti tutes a
probl em only in pati ents who feel wi thi n
themselves a pathol ogi cal sense of helplessness.
T he sicker and more i mmature the pati ent, the
stronger his dependency is apt to be. I t is
essential that the hel pi ng agency be abl e to ac
cept the pati ents dependency wi thout resent
ment, gradi ng the degree of support that is ex
tended and the responsibi li ti es imposed on the
pati ent in accordance wi th the strength of the
pati ents defenses. (See al so the second and
thi rd questi ons that follow.)
Where the ai m is the si mpl e al l evi ati on of
symptoms and no personal i ty al terati ons
are deemed necessary, what tacti c shoul d
be used?
The therapeuti c tactics essential for the
modest ai m of symptom rel ief are uncompl i
cated, consisti ng essential ly of devel opi ng a
worki ng rel ati onshi p, encouragi ng emoti onal
catharsi s, giving proper support, gui dance, and
suggestions, empl oyi ng techni ques such as be
havi or therapy and rel axati on procedures
where these are indi cated, and, if necessary,
temporari l y admi ni steri ng psychotropi c medi
cati ons.
I snt symptom control a very superfi ci al
therapy, and doesnt it often resul t i n a
return of symptoms?
There are still a substanti al number of ther
api sts who believe methods ai med at symptom
control, whi l e rapi dl y pal l i ati ng sufferi ng and
perhaps even rei nstati ng the previ ous psycho
logical equi l i bri um, operate like a two-edged
sword. J usti fi abl e as symptom control may
seem, these skeptics insist that it fails to resolve
the underlying probl ems and difficulties that
nurture the current crisis. I rreconci l abl e un
consci ous needs and conflicts conti nue to press
for ful fil lment, and, therefore, they insist, we
may anti ci pate a recrudescence or substi tuti on
of symptoms. These assumpti ons are based on
an erroneous cl osed-symptom theory of per
sonal ity dynami cs. Symptoms once removed
may actual l y resul t in producti ve feedback that
may remove barri ers to constructi ve shifts
wi thi n the personal i ty system itsel f. Even
though these facts have been known for years
(Al exander, 1944; Al exander & French, 1946;
Avnet, 1962; Marmor, 1971; Wol berg, 1965)
Marmor, 1971) and have been corroborated in
the therapeuti c resul ts brought about by active
psychotherapeuti c methods, the ti me-honored
credo brandi ng symptom removal as worthl ess
persi sts and feeds l ack of enthusi asm for
symptom-ori ented techni ques. (See also the
second questi on above and the questi on that
follows.)
Does therapy focused on hel pi ng or re
movi ng symptoms prevent a person from
achi evi ng deeper changes?
The evidence is overwhel mi ng that symp
tom-ori ented therapy does not necessaril y ci r
cumscri be the goal. T he acti ve therapi st still
has a responsi bi l i ty to work through much of
the pati ents resi dual personal i ty difficulti es as
is possible wi thi n the confines of the avai l abl e
ti me, the exi sti ng moti vati ons of the pati ent,
and the basic ego strengths that may be rel ied
on to sustai n new and better defenses. I t is true
that most pati ents who appl y for hel p only
when a crisis cri ppl es thei r adaptati on are mo
ti vated merel y to return to the dubi ousl y
happy days of thei r neuroti c homeostasi s. M o
ti vati on, however, can be changed if the thera
pist clearly demonstrates to the pati ent what
real ly went on behi nd the scenes of the crisis
that were responsi bl e for his upset. (See also
161
the precedi ng questi on and the thi rd questi on
above.)
What do you thi nk of Gestal t therapy,
and is it useful i n short- term therapy?
Gestal t therapy is one of the many methods
that if executed properl y by a therapi st who
has faith in its efficacy can be extremel y useful.
Some of the techni ques, like the empty chai r
techni que, are especiall y val uabl e as a means
of sti mul ati ng emoti onal catharsi s, arri vi ng at
an understandi ng of suppressed and repressed
feelings, and provi di ng a pl atform for the prac
tice of behavi ors that the pati ent regards as
awkward or forbidden. As wi th any other tech
ni que, resistances are apt to erupt that will re
qui re careful anal ysi s and resoluti on.
What is ego-ori ented psychotherapy ?
Sarvis et al (1958) have wri tten about the ef
fectiveness of ti me-l i mi ted ego-oriented psy
chotherapy wi thout setti ng up predetermi ned
cri teri a for moti vati on or readi ness. No arbi
trary topi c is set, but focus is a process ari si ng
out of the i nterchange between the pati ent and
therapi st. The authors conceive of therapy as
bei ng open-ended, appl i cabl e at any poi nt in
the adapti ve-mal adapti ve i ntegrati ons of ex
i stence. They regard it as a l i mi ted dy
nami cal l y directed form of psychotherapy that
is disti nguished from psychoanal ysi s and psy-
choanal ytical ly ori ented psychotherapy in both
process and goal s. A cruci al focus is what has
brought the pati ent to therapy at the ti me he
appl i es for hel p (why now?). Frequency of
sessions is flexible, dependi ng on the needs of
the pati ent; the total ti me devoted to therapy is
li mi ted though not predetermi ned in advance.
The therapi st tries acti vel y to empathi ze
wi th, conceptual i ze, and i nterpret the pati ents
materi al parti cul arl y preconsci ous trends, the
current therapeuti c i nteracti on, and the evi
dence of transference, in terms of ongoi ng i n
tegrati ve adaptati ons rather than toward
regressi veness.
What are the obj ecti ves of cogni ti ve ap
proaches to therapy?
Recent cogni ti ve approaches attempt to
improve probl em-sol vi ng operati ons as well as
to enhance soci al adj ustment. Where rudi
ments of adapti ve skills are present and where
anxi ety is not too paral yzi ng, the i ndi vi dual in
a rel ati vely bri ef peri od wi th proper therapy
al ong cognitive li nes may be abl e to reorgani ze
his thi nki ng strategi es and to find al ternati ve
sol uti ons for probl ems in li ving that are much
more attuned to a constructi ve adj ustment. I n
terventi on programs al ong cognitive li nes have
been described that are appl i cabl e in a vari ety
of clinical and educati onal setti ngs (Spi vack et
al., 1976). I n my opi ni on, the techni ques re
lated to cognitive approaches can be i mpl e
mented wi thi n a dynami c framework.
Is cogni ti ve therapy of any val ue as a
method i n short- term therapy?
Prel i mi nary studies are encouragi ng, but
whether it is superi or to other methods in
certai n condi ti ons is difficult to say and will be
j udged by further research. T he many factors
that influence all psychotherapi es for better or
worse undoubtedl y appl y also to cognitive
therapy. I t has parti cul arl y been recommended
in depressi on, but it is doubtful that it is a sub
sti tute for anti depressant pharmacotherapy,
especiall y in endogenous depressi on. I t may, as
a psychotherapeuti c adj unct, functi on here
as a prophyl acti c retardi ng further attacks.
Cogni ti ve therapy is most helpful in pati ents
wi th biased and faul ty thi nki ng probl ems,
obsessional and phobi c pati ents respondi ng
positi vely to a wel l -conducted and skill full y op
erated program. An i mportant thi ng is how
cognitive therapy is done and the fai th of the
therapi st in its efficacy. To a therapi st who
believes in its val ue and who dedicates hi msel f
to the arduous task of al teri ng establi shed
cognitive frames of reference, it may be a
preferred approach. Other therapi sts may be
more dedicated to and get better results wi th
techni ques wi th whi ch they have a special per
sonal affinity.
Are there any drawbacks to usi ng be
havi or therapy i n dynami c short- term
therapy?
Not at all. I t can be qui te useful. Where the
therapi st is ori ented toward behavi or therapy,
he will approach some of the pati ents difficul
ties as mani festati ons of faul ty l earni ng. He
will usual ly start therapy wi th a behavioral
analysis. T he symptom to be al tered is ana
lyzed to determi ne what benefi ts the pati ent
deri ves from it. Expl orati ons will deal wi th
identification of factors that touch off and rei n
forcements that sustai n the mal adapti ve be
havi or and of elements that reduce such be
havior. Action rather than insight is accented.
A method that hel ps to encourage moti vati on is
the keepi ng of a dai l y di ary that scores the fre
quencies of symptomati c occurrences. Si mpl e
score keepi ng has been found to reduce the
number of symptomati c upsets. The pati ents
posi tive efforts to control, al ter, and reverse his
mal adapti ve behavi or are rewarded by atten
ti on, prai se, and enthusi asm. The pati ents
reactions to the techni ques shoul d be observed,
the therapi st being alerted to transference and
resistance. There is no reason why dynami c
pri ncipl es cannot be appl i ed to what is hap
peni ng duri ng behavi or therapy or any ki nd of
therapy. (See al so the fol lowing questi on.)
Can behavi or therapy be used for condi
ti ons other than phobi as?
Yes, for vari ous condi ti ons like obsessions,
hypochondri as, depression, and habi t di sorders
where the symptoms are ci rcumscri bed and the
events that produce the symptoms are i denti
fiable. Behavi or therapi sts utili ze behavi oral
techni ques al ong wi th other methods li ke
pharmacotherapy and vari ous ki nds of psycho
therapy. More and more therapi sts are seei ng
the advantage of uti l i zi ng behavi or therapy
wi thi n a dynami c framework. I ncreasi ng num
bers of anal yti cal l y trai ned therapi sts are fi nd
ing desensi ti zati on, asserti ve trai ni ng, and
other forms of behavi or therapy useful in thei r
work. (See also the precedi ng questi on.)
What is the val ue of hypnosi s i n short
term therapy?
Hypnosi s is chiefly empl oyed as a catal yst in
psychotherapy. I t potenti al l y facili tates the
therapeuti c process in a number of ways. First,
hypnosi s may exert a posi ti ve influence on the
rel ati onshi p wi th the therapi st by mobi l i zi ng
the essential hope, fai th, and trust that are
parcel s of every hel pi ng process and by cutti ng
through resistances that del ay the essential es
tabl i shi ng of rapport. Thi s is especiall y i mpor
tant in detached and fearful i ndi vi dual s who
put up defenses agai nst any ki nd of closeness
and hence i mpede the evolvement of a worki ng
rel ati onshi p. Second, hypnosi s, owi ng to its
enhancement of suggestibi li ty, will promote
the absorpti on by the pati ent of posi ti ve
pronouncements, verbal and nonverbal , that
may alleviate, at least temporari l y, symptoms
that i nterfere wi th expl oratory techni ques.
T hi rd, hypnosi s often expedi tes emoti onal
catharsi s by openi ng up founts of bottl ed-up
emoti on, thereby promoti ng temporary rel ief
and si gnal i ng some sources of resi dual conflict.
Fourth, i mpedi ments to verbal i zati on are often
readi l y lifted by even li ght hypnosi s. Fifth,
where moti vati on is lacki ng toward i nqui ry
into sources of probl ems, hypnosi s, through
its tensi on-abati ng and suggestive symptom-
relieving properti es, may hel p convince the pa
ti ent that he can deri ve benefi ts from treatment
if he cooperates. Si xth, by its effect on
resistances hypnosi s may hel p expedite such
insight techni ques as imagery, dream recall,
and the release of forgotten memori es. Seventh,
hypnosi s may light up transference, rapi dl y
bri ngi ng fundamental probl ems wi th authori ty
to the surface. Ei ghth, by deal i ng directl y wi th
deterrences to change hypnosi s may expedi te
the worki ng-through process, parti cul arl y the
conversion of insi ght into acti on. Toward this
end, teachi ng the pati ent sel f-hypnosis may be
of value. Fi nal l y, hypnosi s may someti mes be
helpful in the termi nati on of therapy, enabl i ng
the pati ent who has been taught sel f-rel axati on
and sel f-hypnosis to carry on the therapeuti c
process by himself.
I s hypnosi s ever used wi th a psychomi -
meti c drug to speed up therapy?
L udwi g and Levi ne (1967) cl ai m substanti al
therapeuti c changes of a reconstructi ve nature
through the use of a combi nati on of hypnosi s
and L SD admi ni strati on in a techni que they
term hypnodel i c therapy. Few other thera
pists use this combi nati on.
What are the pri nci pl e obj ecti ves of dy
nami c psychotherapy, and how are these
obj ecti ves reached?
I n dynami cal l y ori ented therapy the objec
tive is to bri ng the i ndi vi dual to an awareness
of prevai l i ng emoti onal conflicts, the defenses
empl oyed in avoidi ng such awareness, the way
such conflicts ori gi nal l y had developed in the
past, the influence they have exerted on de
vel opment, the insidi ous ways they poll ute
ones present existence, and thei r rel evance in
sponsori ng existi ng symptoms and compl ai nt
factors. Such clarificati on is in the interest of
hel pi ng to face anxieties and to develop new
ways of rel ati ng to onesel f and to people. I n
terpretati ons, the chief methodologi cal tool, are
targeted on defenses at the start, on any exist
ing anxiety, and finall y on the drives and i m
pulses that are being warded off. Essenti al is
the mai ntenance of sufficient tension in the i n
terview to create an incentive for handl i ng and
worki ng through of the i ni ti ati ng conflicts. A
most fertile arena for expl orati on is the trans
ference, whi ch presents the pati ent wi th a liv
ing exampl e of some of the core conflicts in ac
ti on. Most vitall y transference i nterpretati on
enables the li nki ng of what is going on in the
present wi th i mportant determi nants in the
past. Transference may not be di spl ayed excl u
sively toward the therapi st. It may be proj ected
toward others outside of the treatment si tua
tion.
I n dynami c therapy shoul dnt the chi ef
ai m be the devel opi ng of i nsi ght in the
pati ent si nce wi thout knowi ng the causes
a cure is i mpossi bl e?
Many therapi sts still believe that under
standi ng the causes of a probl em is tantamount
to a cure. The search for sources then goes on
relentl essl y. Shoul d i mprovement fail to occur,
the pati ent is enjoi ned to dig deeper. Obvi
ousl y, one task of therapy is to determi ne un
derl yi ng causes; but we are still at a stage
where our knowl edge of which causes are
paramount is not yet too clear. However, prac
ticall y speaki ng, assi gni ng to symptoms some
reasonabl e eti ology that the pati ent can accept
serves to enhance self-confidence and to l ower
anxi ety and tension levels. T he pati ent may
then be wil l i ng to experi ment wi th more adap
tive patterns. I f no more than a placebo, then,
insight can serve in the interests of expedi ti ng
therapeuti c goal s.
Obvi ousl y, the more percepti ve and well
trai ned the therapi st, the more likely will the
pati ent be hel ped to arri ve at underl yi ng eti o
logical factors. But, however, accurate these
di scoveries may be, a tremendous number of
el ements other than insight enter into the
therapeuti c Gestal t. Agai n, thi s is not to de
preci ate insight, but rather to assign to insight
a si gnifi cant but not excl usive i mportance.
How i mportant- i s dream . anal ysi s as an
adj unct to whatever techni ques are bei ng
used?
Dream anal ysi s consti tutes a vital means of
hel pi ng pati ents recogni ze some of thei r fun
damental probl ems and thei r own parti ci pa
ti on in fosteri ng neuroti c mal adj ustment.
Worki ng wi th college students, Merri l l and
Cary (1975) found that focusing on dreams
l owered resi stance to sel f-experience in stu
dents struggl i ng wi th the i ndependence-depen-
dence conflict. I t al so reduced acti ng-out by
encouragi ng the acceptance of di sowned feel
ings. A dream is best uti li zed in rel ati on to
current experi ence, though its roots in past
condi ti oni ngs are not neglected especiall y when
transference el ements are obvi ous in the
dream. (Chapter 12 deals extensivel y wi th the
use of dreams in short-term therapy).
Are psychoanal yti c techni ques, such as
dream anal ysi s, i magery evocati on, i nter
pretati on of resi stance and transf erence,
and other modes of expl ori ng the un
consci ous absol utel y essenti al toward
promoti ng depth changes in the per
sonal i ty? I t is someti mes poi nted out
that a number of pati ents do achi eve
consi derabl e personal i ty growth when
164
treated by a therapi st who uti l i zes sup
porti ve and educati onal methods excl u
si vel y, purposel y avoi di ng probi ng for
confl i cts and deal i ng onl y wi th mani fest
symptoms and probl ems.
There are a few pati ents whose repressi ons
are not too severe, whose defenses are not too
ri gid, and who possess a strong readi ness for
change. I f the therapi st is nonj udgmental and
empathi c, the therapeuti c rel ati onshi p itself
can serve as a correcti ve emoti onal experi ence.
T he conception of puni ti ve authori ty is altered,
and softeni ng of the superego resul ts in
strengtheni ng of the self-image. Thi s, how
ever, is more likely in l ong-term than in short
term therapy. Most people do requi re some
chall enge in order to change, and a certai n
amount of anxi ety needs to be tol erated to give
up old habi ts and patterns exchangi ng them
for unfami l i ar ways of behaving. We see this
duri ng and after crises when peopl e real ize
that thei r usual adaptati ons are ineffective and
can only get them into more trouble. Duri ng
short-term therapy confrontati ons and i nter
pretati ons impose on the indi vi dual chall enges
wi th whi ch he must come to grips. A purpose
ful focusing on unconsci ous materi al can be
most helpful in promoti ng sel f-understandi ng,
whi ch may then act as an incentive for change.
Does one have to be a psychoanal yst to
deal wi th resi stance?
Of course not. But the therapi st who has no
understandi ng of psychoanal yti c theory and
method is at a di sadvantage in deal i ng wi th
resistance. I n my supervi sory work I have
gotten the i mpressi on that it is resistance that
pri nci pal l y accounts for fai lures in the active
approaches like hypnosi s and behavi or ther
apy. Referral s to me of a si zable number of pa
ti ents who were unabl e to achieve satisfactory
results wi th nonanal yti c therapi es, reveal ed in
practical ly every case that transference had i n
terfered wi th posi ti ve responses to the thera
pi sts methods. Such reacti ons occurred wi th
me also, but I was soon able to detect them
from the pati ents associati ons and dreams.
They then constituted the focus in our therapy.
For exampl e, in several cases referred to me
for hypnosi s by experi enced hypnotherapi sts
who were unabl e to induct a hypnoti c state, I
was abl e easily to detect the transference
resistance that interfered wi th hypnoti c i nduc
ti on. Wi thout exception, once thi s i mpedi ment
was brought to the surface and expl ored wi th
the pati ent, he was abl e easi ly to achieve a
satisfactory trance.
Some authori ti es i nsi st that transf erence
is not a probl em i n short- term therapy
si nce the ti me el ement is too bri ef for its
appearance. Other authori ti es base thei r
enti re strategy around the detecti on and
expl orati on of transf erence. What is the
di screpancy?
I n dynami c short-term therapy transference
is a key di mensi on and shoul d al ways be
looked for. I t is often purposeful l y bypassed or
overl ooked when the therapi st decides to act
like a giving, helpful, active, benevolent au
thori ty, symptom rel ief being expedi ted by this
ki nd of rel ati onshi p. I n nondynami c short-term
therapy a benevol ent type of transference thus
may be desi rabl e for results. We are not so
much concerned wi th thi s form of transference.
We are more vitall y concerned wi th another
type of transference that acts as resistance to
treatment mani festi ng itself in di strust, hos
tili ty, excessive demands for love and attenti on,
sexual i mpul ses, and so forth. Progress will be
i nterrupted unless this show of transference is
resolved. Whether it can be resolved depends
on the skill of the therapi st and the pati ents
moti vati on and abil ity to work it through.
Sicker pati ents may requi re an extended peri od
of treatment to overcome such destructi ve
transference. Where a therapi st is trai ned to
detect transference (e.g., by observi ng non
verbal behavi or, slips of speech, acti ng-out,
dreams, etc.) and deals wi th it by appropri ate
i nterpretati on, it may serve as a means toward
hel pi ng the pati ent to understand some of the
deepest conflicts. I n summary, whi l e the thera
pist may not wi sh to i nterfere wi th a posi ti ve
transference, indeed he may empl oy it as a
prod toward symptom rel ief and posi ti ve cor
rective behavioral acti onsa negati ve trans
ference will defi nitely requi re attenti on and
resoluti on. I n some cases negati ve transference
will appear toward the end of therapy as
termi nati on poses a threat. Thi s is especiall y
the case where separati on-i ndi vi duati on has
been impai red.
Woul d you uti l i ze other techni ques when
the chi ef method empl oyed is group ther
apy or fami l y therapy?
Group therapy or famil y therapy does not
restri ct the use of any other techni ques that
mi ght hel p any of the members. These incl ude
pharmacotherapy, i ndi vi dual therapy, mi li eu
therapy, and so on.
I snt el ectroconvul si ve therapy passe?
By no means. I t still is a most, if not the
most, effective treatment measure in deep sui
cidal depressions. I n exci ted mani c and schi zo
phreni c pati ents it al so is occasi onall y used
when l i thi um and neurol epti cs fail to qui et the
pati ent down.
I s drug therapy sti ll warranted i n de
pressi on, and i f so, what is its rati onal e?
Defini tel y it is warranted. There are differ
ent ki nds of depressi on, of course, for exampl e,
depression as a pri mary condi ti on and as
secondary to anxi ety or hostil ity. There are
certainl y biological correl ates in depression.
The latest hypothesi s is that in depressi on
there is a deficiency of neurotransmi tters, that
is, of catechol ami nes at the adrenergi c receptor
sites in the brai n, parti cul arl y a deficiency of
norepi nephri ne, and also a deficiency of in-
dol eami nes (serotoni n). Anti depressant drugs,
namel y the tricyclic anti depressants (Tofrani l ,
Elavil, Si nequan), increase the concentrati on
of neurotransmi tters at the receptor site by
blocking thei r reuptake from the synapse.
When tricyclic anti depressants are used, they
must be given in adequate dosage (i ndivi duall y
regul ated) and the effects may not be apparent
for 3 to 4 weeks. After the depressi on lifts,
the dosage is lowered to as small a mai nte
nance dose as symptom control requi res. An
other way of i ncreasi ng the concentrati on of
neurotransmi tters in the brai n and l i fti ng
depressi on is by preventi ng thei r metabol i sm
through i nhi bi ti ng the enzyme monoami ne oxi
dase (MAO). Usual l y the response to the
M A O i nhi bi tors (Nardi l , Parnate) is also de
layed. Psychosti mul ants like dextroampheta
mi nes (Dexamyl ), for exampl e, are someti mes
cauti ousl y used in mi ld depressions. Where
depressi on is secondary to anxi ety, tranqui
li zers (L i bri um, Val i um) occasi onall y hel p, but
because of the danger of habi tuati on, tricyclic
anti depressants or low doses of neurol epti cs
(Mel l ari l ) are preferred. I n pri mary depressi on
compl i cated by anxi ety tricyclics (Elavi l, Si ne
quan) are the drugs of choice. A pati ent taki ng
anti depressants shoul d be seen peri odi cal l y by
a physi ci an, preferabl y a psychi atri st ac
quai nted wi th drug therapy, where the thera
pist is a nonmedi cal person, since side effects
are common.
Is l i thi um hel pf ul i n schi zophreni a?
Neurol epti cs are the preferred drug. A few
studies do reveal that in some cases l i thi um
may be useful, but the subgroups that respond
have not as yet been identified.
How do neurol epti cs operate?
Neurol epti cs block the dopami ne receptors
in the brai n i nterferi ng wi th dopami ne trans
mission. Some of the symptoms of schi zo
phreni a are believed to be the product of dop
ami ne excesses.
Whi ch neurol epti cs are pref erred i n
schi zophreni a?
There are several classes of neurol epti cs:
first, the phenothi azi nes (Thorazi ne, Mel l ari l ,
and Prol i xi n); second, the di benzoxazepi nes
(L oxapi ne); thi rd, the butyrophenones (Hal
dol ); fourth, the thi oxanthenes (Navane);
and fi fth, the di hydroi ndol ones (Moban).
Other cl asses will probabl y be i ntroduced as
well as addi ti ons to each class. There is little
difference among the vari ous drugs, but occa
si onall y a pati ent may develop an intol erance
to specific drugs and not to others. Some pa
tients do well on drug therapy; some do not re
spond at all; and still others respond so badly
that they have to be taken off medi cati ons.
Shoul d neurol epti cs be used wi th psycho
therapy in schi zophreni a?
It has been shown in schi zophreni a that
adequate dosages of neurol epti cs coupled wi th
famil y therapy are followed by the small est
number of rel apses. Great flexibility is neces
sary on the part of the therapi st, experi ment
ing wi th other modal ities also since special
techni ques will sui t some pati ents and not
others. Perhaps the most i mportant therapeuti c
agency is a good rel ati onshi p wi th the thera
pist. Psychotherapeuti c techni ques are val ue
less wi thout this.
Shoul d neurol epti cs al ways be empl oyed
i n schi zophreni a?
By no means. Actuall y, they are being
overemployed and in some cases used wi thout
proper supervisi on and fol low-up. Y oung pa
ti ents in thei r first attack, especiall y those
going through an identity crisis, often do well
wi thout drugs. Where symptoms are too di s
rupti ve, however, neurol epti cs shoul d be used.
I f neurol epti cs are usef ul i n schi zo
phreni a, why shoul dnt they be gi ven i n
defi ni tel y?
There are some di sagreeabl e side effects and
sequel ae wi th neurol epti cs, especiall y when
given over a l ong peri od and in l arge dosage.
Tardi ve dyski nesia is a neurol ogical condition
that affects as many as 40 percent of pati ents
on prol onged drug therapy. Once tardi ve dys
kinesia has become entrenched, it may pl ague
the pati ent permanentl y even after the drug is
wi thdrawn. Neurol epti cs shoul d, therefore, be
l owered in dosage after the desi red effect has
been achieved, and peri odical ly they shoul d be
wi thdrawn (drug-free holi days) to see how the
pati ent reacts.
After an acute epi sode of schi zophreni a
and the pati ent is rel ati vel y symptom-
free, shoul d neurol epti cs be conti nued?
Yes, for a whi l e, if the pati ent has been on
neurol epti cs. The rel apse rate is greater where
drugs are not conti nued. Roughl y after the first
attack the pati ent shoul d conti nue on medi ca
ti on for 1 to I /2 years. After a second attack
they shoul d be prescri bed for 2 to 5 years.
After a thi rd attack they may have to be used
indefinitely wi th occasional drug-free holi days.
Supervi si on is essential to see that the medi ca
ti ons are taken and to adj ust the dosage to
lessen side effects and sequel ae.
When woul d you prescri be sl eepi ng pi l l s,
and whi ch woul d you recommend?
Whi l e benzodi azepi nes (Val i um, Dal mane)
are safer than barbi turates, they shoul d very
rarel y if ever be given to new pati ents for i n
somni a for more than 2 to 4 weeks. Beyond
that ti me consi stent use causes them to lose
thei r effectiveness. Occasi onal use of hypnoti cs,
however, can prove helpful, as when a tempo
rary stress si tuati on i nterferes wi th sl eep.
Dal mane (fl urazepam) in the 15-mi l l i gram
dosage is general l y as effective as the 30-mil li -
gram dosage, many persons al so fi nd 5
mi l l i grams of Val i um (di azepam) effective.
I n matchi ng pati ent and method how
val uabl e is a devel opmental di agnosi s,
that is, knowl edge of where in the pa
ti ents devel opment the pri mary arrest
occurred?
Matchi ng pati ents and methods is still an
unsolved probl em. A number of attempts have
been made to establi sh cri teri a for a pati ent-
method al i gnment, for exampl e, the sympto
mati c diagnosi s (like behavi or therapy for
phobi as, an i nspi rati onal group such as AA for
alcohol ism, etc); the characterol ogi c diagnosi s
(like the personal i ty typol ogies proposed by
Horowi tz, see p. 217); responses to hypnoti c
i nducti on (Spi egel & Spiegel, 1978); and the
devel opmental diagnosis (Burke et al., 1979).
The l atter authors believe that therapeuti c
methods may be selected to resolve conflicts
whi ch develop in different stages of devel op
ment (Eri kson, 1963). T hus M anns techni que
(1973) of focusing on separati on-i ndi vi duati on,
in an empathi c feel ing atmosphere, woul d
seem most useful wi th passi ve-dependent pa
ti ents unsuccessful in resolving the adol escents
conflict of identity vs. role confusi on. Here
the struggle over termi nati on of therapy bri ngs
the earl y separati on-i ndi vi duati on conflict to
the fore and gives the pati ent an opportuni ty to
resolve it in a favorable setti ng. The hypothesi s
is that if pati ents successfully master separa
tion from the therapi st, they will move on to
greater i ndi vi duati on and overcome thei r de
pendency needs. Pati ents who in thei r devel op
ment have moved beyond the crisis of identity
toward the Fi rst Adul t L i fe Structure
(Levinson, 1977) and, in thei r efforts to es
tabl ish inti mate rel ati ons, have been blocked
by resurgence of oedipal conflicts are well
suited to the intell ectual , interpreti ve, con
frontati on style of Sifneos and Mal an. Prob
lems of the latency peri od that emerge dur
ing the midlife transi ti on brought about by
chall enges of productivi ty, creativity, and the
maturi ty to deal wi th new generati ons at home
and at work woul d be sui ted most for a cor
rective acti on approach such as that of Al ex
ander and French, the maxi mum therapeuti c
effect comi ng from transference mani pul a
ti ons and a manageri al stance by the thera
pi st. Under these ci rcumstances. Burke et al
(1979) contend, a careful devel opmental di ag
nosi s wi l l hel p i denti fy pati ents who can
benefit from psychotherapy; it can al so hel p in
the selection of an appropri ate therapeuti c
method.
However, none of these sel ection schemes,
involving symptom mani festati ons, character
structure, or devel opmental conflicts, has been
proven enti rel y rel iabl e. Thi s is because of the
interference of numerous mi scel laneous pa
ti ent, therapi st, envi ronmental , transferenti al ,
countertransferenti al , and resistance vari ables.
The very choice of a diagnosi s and the identifi
cati on of the prevai l i ng devel opmental conflict
around whi ch the therapeuti c pl an is or
gani zed is subj ect to the therapi sts bias as is
the method to whi ch the therapi st is attuned.
Thi s bias will prej udi ce the pati ents response.
A therapi st who appl i es hi msel f to a favorable
techni que wi th enthusi asm and conviction will
expedite the pati ents progress, whereas the
same techni que used casual l y and unen
thusi asti cal l y may have a mi ni mal effect on the
pati ent. T he style of some therapi sts and thei r
investment in thei r theori es will support or
mi l i tate agai nst the effective use of any of the
methods such as those proposed by Sifneos,
M al an, Davanl oo, A l exander and French,
L ewi n, Beck, and others. I n summary, at the
present stage of our knowl edge we cannot be
sure that a selected method exists for every pa
ti ent we treat. Our opti ons must remai n open,
and we must be wi l l i ng to change our methods
when a selected techni que proves to be sterile.
Conclusion
A wide vari ety of techni ques is avai l abl e to a
therapi st, thei r selection being determi ned by
the existi ng symptoms and compl ai nts of the
pati ent, the fami l i ari ty of the therapi st wi th
appli cable methods, and the pati ents wi l l i ng
ness and abil ity to work wi th the chosen i nter
venti ons.
Whether we attempt to influence the pa
ti ents bi ochemistry through pharmacotherapy,
or his neurophysi ol ogy through other somati c
therapi es or rel axati on procedures, or his habi t
patterns through behavi or therapy, or his
intrapsychi c structure through psychoanal ysis,
or his i nterpersonal reacti ons through group or
famil y therapy, or his social behavi or through
mi l i eu therapy, or his phi l osophi cal outl ook
through exi stenti al therapy, the pati ent will
react gl obal l y to our mi ni strati ons, every
aspect of his being, from physi ologi cal makeup
to hi gher psychi c processes, being influenced
through a feedback effect.
The proper use of techni ques calls for a high
degree of expertise. Requi red are qual i ti es in
the therapi st that permi t establ i shi ng rapi dl y a
worki ng rel ati onshi p wi th the pati ent, a deal
ing wi th moti vati onal deficienci es and other
resistances as they develop, and a managi ng of
those personal reactions that are prej udi ci al to
mai ntai ni ng an objective and empathi c thera
peuti c climate. The atmosphere for the most
effective operati on of techni ques may peri
odi cal l y cal l for support and reassurance
tempered by sufficient mai ntenance of tension
duri ng the i ntervi ewi ng process to promote i n
centives for expl orati on and for experi menta
tion wi th new patterns of behavior. Confronta
tion may peri odical ly be requi red to break
through resistances to change, but confronta
tion if used must be carefull y ti trated agai nst
the pati ents tol erance of anxiety. I nterpreti ve
activites on some level are requi red, especiall y
when resistance to the therapi st, to the thera
pi sts techni ques, and to change paral yzes the
therapeuti c effort. T he most effective detect
i ng of and deal i ng wi th such resi stances
necessitates understandi ng of how to i mpl e
ment dynami c i nterventi ons such as the use of
dreams and the analysis of transference.
Short-term therapy, even where the methods
are supporti ve or reeducative, as has before
been repeatedl y emphasi zed, is much more ef
fective where it is skillfully executed in a
psychodynami c framework. No more than a
few intervi ews conducted al ong dynami c lines
may be needed to unbal ance the shaky homeo
stasis that has rul ed the pati ents existence
and to make possible begi nni ng constructi ve
changes in the way that the pati ent rel ates to
himsel f and others. Where the indi vi dual has
been brought to some recogni ti on of the i ni ti at
ing factors preci pi tati ng the difficulti es for
whi ch he sought help, where he becomes cog
ni zant through intervi ewi ng of the presence of
some pervasi ve personal i ty probl ems that
sabotage hi s happi ness, where he rel ates
aspects of such probl ems to his current illness,
and where he gai ns a gl i mmer of awareness
into earl y sources of difficul ty in his rel ati on
shi p wi th his parents and other significant per
sons, he will have the best opportuni ty to
proceed beyond the profits of symptom relief.
By pointed questi oni ng the pati ent is en
couraged to put the pieces together for himself,
parti cul arl y to fi gure out the ci rcumstances
that have i mpai red his adj ustment pri or to
comi ng to treatment. There is an expl orati on
as to why the pati ent is now unabl e to work
out his present difficulty by hi mself, comi ng
hopeful ly to a real i zati on of the resistances that
prevent a resol uti on of probl ems. The pati ent,
encouraged in sel f-observati on, is taught how
to rel ate symptoms to preci pi tati ng happeni ngs
in the present envi ronment as well as to i nner
conflicts wi thi n hi mself. What we are tryi ng to
do is to mobi li ze some insight into the underl y
ing difficul ties. We must modestl y admi t that
some of the insights we offer the pati ent are
not al ways compl ete or even correct. Even
though they are parti al l y vali d, however, they
often serve to al l eviate tensi ons by provi di ng
an expl anati on that may hel p the process of
stabi l i zati on.
T he nonspecific wi ndfal l s of insight do not
i nval i date the specific profits that can deri ve
from a true understandi ng of the forces that
are undermi ni ng security, vi ti ati ng sel f-esteem,
and provoki ng acti ons ini mi cal to the interests
of the indi vidual . I n openi ng up areas for ex
pl orati on, the short-term therapi st must con
fine hi msel f as closely as possible to observable
facts, avoi di ng specul ati ons as to theory so as
to reduce the suggestive component. T he more
experi enced the therapi st, the more capabl e he
wi l l be of col l ati ng wi th mi ni mal del ay
perti nent datafrom the pati ents verbal
content and associ ati ons, gestures, faci al
expressi ons, hesi tati ons, si l ences, emoti onal
outbursts, dreams, and i nterpersonal reac
ti onstoward assumpti ons that, i nterpreted to
the pati ent, enabl e hi m to reflect on, accept,
deny, or resist them. Deal i ng wi th the pati ents
hesi tanci es to the acceptance of i nterpretati ons
and to the uti l i zati on of his expanded aware
ness toward acti ons that may lead to change,
the therapi st conti nues to exami ne his ori gi nal
assumpti ons and to revi se them in terms of any
new data that present themselves.
Even though a therapi st may uti li ze a va
ri ety of techni ques, thei r empl oyment wi thi n a
dynami c framework seems to catal yze the
therapeuti c process. T he pati ents uni que
response to the methods empl oyed (i ntervi ew
ing, confrontati on, behavi or modi fi cati on,
hypnosi s, etc.) will al most inevi tabl y expose
habi tual characterol ogi c styles and perhaps
resistances that can become an i mportant focus
duri ng treatment. Where the pati ent mani fests
a desire to exami ne his reactions, the results
may be parti cul arl y gratifyi ng. And where a
transference si tuati on can be detected and ex
plored, and its geneti c roots understood, an en
duri ng i mpri nt may be etched. T he therapi st
shoul d, therefore, be al erted to any behavi or or
atti tudes that in any way reflect transference.
Often such behavi or is not mani fest and is de
tected only in dreams and acti ng-out. Even
though ti me in therapy is short, the therapi st,
if suffi ci entl y percepti ve, wi l l detect some
transferenti al behavi or in the way the pati ent
rel ates to the therapeuti c si tuati on, especi all y if
the therapi st is active and provocative. And yet
in a consi derabl e number of cases the pati ent
may control or mask his transferenti al re
sponses so that they are not at all apparent.
Here, all is not lost; since wi th the other data
avail able, one may still be abl e to establ i sh a
consoci ati on between the pati ents symptoms
and compl ai nts, character structure and the
geneti c roots of the prevai l i ng neuroti c needs
and defenses. A hopeful prospect is that thera
peuti c change will not cease at the termi nati on
of the short-term contact but will conti nue the
remai nder of the i ndi vi dual s life.
CHAPTER 12
The Use of Dreams
The growth of ego psychol ogy and the de
vel opment of new concepts regardi ng energy
and identity have encouraged mi ni mi zati on of
the i mportance of dreams. Moreover, as we
have gai ned greater understandi ng of ego dy
nami sms, we have tended to veer away from
the tradi ti onal search for latent dream content.
T hi s di versi on is unfortunate because the
average dream embodi es a mass of i nformati on
that, sorted out and selected in rel ati on to the
probl ems being deal t wi th at the ti me and the
parti cul ar goal s wi th whi ch we are i m
medi atel y concerned, can be of inesti mabl e
value in short-term therapy.
Properl y uti li zed, dreams i l l umi nate the ex
isti ng dynami cs of emoti onal illness. They re
veal conflicts, copi ng mechani sms, defenses,
and character trai ts. Most i mportantl y, they
reflect what is going on in and the pati ents
responses to the therapeuti c process. Thus,
where therapy is not proceedi ng well, dreams
may reveal more than any other form of com
muni cati on what resistances are obstructi ng
progress. Even if the therapi st does not l abo
riously work out the meani ng wi th the pati ent,
as in supporti ve and reeducati ve therapy,
dreams may still provi de guidel ines for ci rcum
venti ng roadbl ocks to the most effective use of
techni ques.
What are dreams? We may conceive of them
as images or fantasies that are an i ntri nsic part
of normal sleep. We know from human experi
ments that dream depri vati on (i nterferi ng wi th
dreami ng by awakeni ng the subject when he
shows physi ol ogi cal RE M Sor el ectroen-
cephal ographi c evi dences of begi nni ng to
dream) can produce personal i ty aberrati ons.
We have l earned a great deal about dreams
from contemporary dream research. The REM
peri ods duri ng sleep that are accompani ed by
dreami ng have been found to be associated
wi th acti vity in the limbic system, the pri mi ti ve
porti on of the brai n associated wi th the emo
ti onal life of the i ndi vi dual . Thi s lends em
phasi s to the theory that the dream is a
regressi ve phenomenon. However, we are
merel y tal ki ng here of the neurophysi ol ogi cal
acti vity that sponsors the formati on of dream
images, not of thei r specific content or si gnifi
cance, whi ch may involve other di mensi ons
than regressive emoti onal ones.
Rel axati on of ego controls l i berates needs
and impul ses that, l acki ng opportuni ti es for
motor release, find access in sensory discharge.
The content of the dream draws from past i m
pulses, memori es, and experi ences as far back
as earl y chi l dhood. T he conversion of re
pudi ated dri ves and desi res into dream images
sets into moti on opposi ti onal defenses and pro
hi bi ti ons that may appear in the dream in a di
rect or masked way. I mmedi ate experi ences
and current conflicts parti ci pate in the struc
ture of the dream. It is likely that a happeni ng
in dail y life that the i ndi vi dual i nterprets as
significant serves to stir up i mportant needs,
frustrati ons, memori es, and dri ves from the
past. The l atter, constantl y dormant, invest
certai n i mmedi ate experi ences wi th speci al
meani ng, al erti ng the indi vidual to signals that
in other persons woul d go unnoti ced.
Some years ago, I ini ti ated a group of ex
peri ments in the hypnoti c producti on of
dreams. Dreams under hypnosi s range from
fleeting fantasy-l ike producti ons in light trance
170
THE USE OF DREAMS 171
states to, in deeper stages of hypnosi s, hi ghl y
di storted symbol i zati ons aki n to regul ar
dreami ng duri ng sleep. I found that hypnoti c
dreams could easi ly be triggered by i mmedi ate
stimuli and that from the content of the dream
one could not al ways identify the specific
provocative sti mul i that produced the dreams.
Thus bri ngi ng an open bottle of perfume under
the nose of a person in a trance, wi th no verbal
suggestions to influence associati ons, woul d in
some indi vidual s i nspi re a dream that revi ved
memori es of previ ous experi ences. At different
times the same sti mul us acted to provoke dif
ferent kinds of dream content. For exampl e, in
one subject the perfume ini ti all y touched off a
dream of bei ng scolded by a maternal -l i ke
fi gure, the subj ect crouchi ng in guil t. No other
dreams or fantasies were recalled. On rehyp
nosis the subject was asked to redream the same
dream and to reveal it in the trance. She
brought up a pl easurabl e sexual dream, whi ch
was followed by a second puni ti ve dream i den
tical to the one previ ously described duri ng the
waki ng state. A pparentl y the subj ect had
repressed the ini ti al part in the first trance,
denyi ng the content and reprocessi ng it by
el aborati ng the puni shment scene. T he puni ti ve
dream mi ght be consi dered equi val ent to the
mani fest content, those mani festati ons accepta
ble to the pati ent. The repressed porti on could
be regarded as the l atent content that the pa
ti ent could not accept. On another occasion the
perfume sti mul us created a dream of wanderi ng
through a botani cal garden.
The mood of a dream also fashions the
dream content. An upset pati ent duri ng hyp
nosi s uti li zed the sound of a bell that I rang to
el aborate a dream of fire and fire engines wi th
reacti ons of anxiety. At another session, duri ng
a quiescent peri od of thi s pati ents therapy, the
same sound produced a dream of worshi ppi ng
in a church. A di sturbed female pati ent at the
begi nni ng of therapy i nterpreted my touchi ng
her hand duri ng hypnosi s adversely by dream
ing of a man choki ng her. L ater in therapy the
same sti mul us produced a dream in whi ch her
father was embraci ng her tenderly.
T he dream content is addi ti onal l y subject to
changes of atti tude on the part of the dreamer.
For exampl e, a pati ent on bei ng asked to bri ng
in dreams responded wi th the fol lowing wri t
ten comments to thi s suggestion:
T he doctor requests that I dream. He is i nter
ested in hel pi ng me, so I better dream. I n dreami ng
I am pl easi ng hi s authori ty, so why shoul d I dream
j ust because he asks me to. He is tryi ng to force me
to do what he wants. But I want to do what / want
to do. I may not want to dream. But if I dont bri ng
in a dream, the doctor wil l be di spl eased. Shoul d I
defy hi m or shoul d I pl ease hi m? What wi l l happen
if I dont dream? What does he want me to tell
hi m? I f I dream and confi rm what he has said about
me, he wi l l l i ke me. I f I dream opposi ng hi s ideas
about me, he wi l l not li ke me or he wil l puni sh me.
I f I dont dream or I dream somethi ng that opposes
hi s ideas, thi s wil l make me feel strong and supe
ri or. I do want to find out about mysel f so I can get
wel l , since my therapi st tel ls me thi s is how I can
hel p hi m hel p me. T hi s is why I shoul d dream. But
I am gui l ty about some thi ngs and afrai d of some
thi ngs, and I am afrai d of what I wi l l find out about
mysel f if I dream. So maybe I better not dream.
Maybe I ll find out somethi ng about myself I dont
like. I t is normal to dream, and I want to be
normal . But if I do dream, I have a better chance of
getti ng wel l , but getti ng well wil l throw more
responsi bi l i ty on my shoul ders. I ll have to be more
i ndependent, take responsi bi l i ty. Maybe I better not
get wel l so fast. Therefore, I shoul dnt dream. Or
maybe if I do dream, I can menti on onl y those
thi ngs that pl ease hi m and that dont scare me and
dont make me get wel l too fast.
Not all pati ents are so obsessivel y sti mul ated
by a casual suggestion. But in all pati ents the
act of dreami ng does involve varyi ng moti va
ti ons that are i ncorporated in the dream work
and fused into a compl ex ki nd of symboli sm,
di storti ng, repressi ng, di spl aci ng and otherwi se
di sgui si ng the content. What may come
through is a compromi se of part forgetti ng and
part rememberi ng, of pri mary and secondary
process thi nki ng, of present and past, of i m
pulse and defense.
The Structure of Dreams
T he tradi ti onal components of a dream are
its (1) mani fest content, (2) l atent content, and
(3) dream work. The mani fest content is or
gani zed in the form of a cryptic l anguage that
requi res transl ati on before its true meani ng
can be comprehended. T he l atent content
embodi es conscious, preconscious, and uncon
scious elements reflective of both past and
present i mpressions. The bricks and mortar of
the dream are what Freud described as the
dream work, whi ch defies the laws of ra
ti onali ty and logic. T he chaoti c upsurge of ex
citati on characteri sti c of regressive pri mary
process mental operati ons makes for a tumul
tuous and bi zarre fusion of emoti ons, symboli c
forms, and ti me sequences. Operati ve are
mechani sms of condensati on and di spl acement.
I n condensati on, characteri sti cs of mul ti pl e ob
j ects are combi ned into a composite symboli c
enti ty. A single i mage may embrace so many
compl ex formul ati ons that a good deal of
searchi ng may be requi red to reveal the great
vari ety of imbedded meani ngs. I n di spl acement
energy i nherent in one idea is transferred over
to another. Thi s may take the form of proj ect
ing feelings and acti ons from significant objects
or areas to seemingl y i nnocuous ones, and
from whol e to parti al areas. What resul ts is
consi derabl e di storti on, whi ch is parti cul arl y
promi nent in the phenomenon of representa
ti on by opposi tes wherei n there is a reversal of
the true meani ng of the dream. Thus acti on of
a kindl y and concerned nature in a dream may
conceal murderous intent. The indi vi dual often
empl oys di sgui sed symbol s of hi msel f in
dreams, cl ues to his i dentity becomi ng ap
parent only in his associati ons to the dreams.
Symbol ism contri butes to the rich and often bi
zarre nature of dream structure. An under
standi ng of the dreamer, his probl ems, and the
way that he conceptual i zes is usual l y manda
tory for a transl ati on of the symbols. T he use
of pictori al metaphors and the empl oyment of
secondary revision are modes empl oyed by the
ego to make unconsci ous and repudi ated el e
ments acceptabl e to the dreamer.
Symbol i sm is an unconsci ous process or
gani zed around associ ati on and si mi l ari ty
whereby one object comes to represent another
object through some qual i ty or aspect that the
two have in common. I n symbol i sm abstract
and compl ex ideas are expressed in sensorial
and concrete terms. Someti mes the dream
symbols are recrui ted from the cul tural and
social worl d that envelops the dreamer. At
other ti mes the ki nds of representati ons draw
from pri mi ti ve l anguage forms in whi ch oral ,
excretory, and phal l i c components are prom
inent. These symbols, actual or disguised,
portray i ncorporati on, power, puni shment,
and anni hi l ati on meani ngs. A fear of snakes or
daggers may accordi ngl y be a symbol for a
wi sh for an i ntact peni s or penal penetrati on.
T error of bei ng bitten by ani mal s may disguise
in i nfanti le i mpul se to devour the mother or
her breast. Del usi ons, hal l uci nati ons,
obsessi ons, compul si ons, phobi as, hysteri cal
conversi ons, morbi d affects, hypochondri as,
and personal i zati on of organs or organ systems
are often expl i cabl e by consi deri ng thei r sym
bolic connotati ons. Si mi l arl y in dreams.
Because the dream is a condensati on of a
host of life experi ences, past and present, be
cause it contai ns unconsci ous components,
defenses, character dri ves in operati on, and ap
provi ng and condemnatory atti tudes of author
ity (superego), a selection of areas perti nent to
the i mmedi ate goals of the therapi st woul d
seem to be in order. Thi s does not mean that
we are al ways abl e to track down the essential
meani ng of every dream, for many of them are
so spotti ly remembered or so highl y di storted
that, wi th all of our anal yti c experti se, we may
be unabl e to understand them.
General l y, we deal wi th the mani fest con
tent, whi ch reflects the probl em-sol vi ng ac
tivities of the ego or self system. A study of the
mani fest content will general l y reveal a good
deal about the defensive i ntegri ty of the ego,
and specifically about the copi ng mechani sms
the dreamer habi tual l y empl oys or l atentl y
wishes to empl oy for purposes of probl em solv
ing in general and speci fically for the probl em
preval ent at the time. Not only does the dream
give insights into the defensive structure and
unconsci ous needs of the dreamer, it also
throws l i ght on the contemporary soci al
real i ti es that preci pi tated the probl em for
whi ch hel p is being sought. The i ndi vidual
may have rati onal i zed soci al di storti ons by
subtle psychological mechani sms of sel f-decep
ti on or phi l osophi cal camouflage. The scotoma
that cl oud percepti on of what is goi ng on in
the envi ronment may lift somewhat duri ng
dreami ng. Thi s awareness may, however, be
masked by converti ng social symbols into per
sonal symbols. The l atent content of the dream
may in addi ti on to unconsci ous conflicts refer
to social conflicts that the i ndi vi dual may have
been unabl e to process and resolve readi l y in
his waki ng life. Proper i nterpretati on can force
on the indi vi dual cl earer understandi ng of the
social and envi ronmental real ities wi th whi ch
he must deal.
Techniques of Dream Interpretation
How dreams are used in therapy will vary
among different therapi sts. It general l y suffices
to ask the pati ent to remember and bri ng in
any dreams. Where the pati ent forgets his
dreams, he may be enjoi ned to keep a pad of
paper and a pencil near the head of the bed
and to record the dream when awakeni ng.
Dreams are usual l y freshest in mi nd before the
days activities crowd out memori es. I f there
are no dreams, resistance may be operati ng
since it is normal to dream several ti mes dur
ing sleep. Some therapi sts attempt to sti mul ate
thei r dreamless pati ents through hypnosi s dur
ing whi ch it is suggested that the pati ent be
abl e to recal l i mportant dreams. Fantasi es and
dreams may al so be sti mul ated duri ng the
trance state itsel f and discussed if desi red dur
ing or after the hypnoti c session.
Because the dream embodi es so much ma
terial , therapi sts general l y select aspects for
discussion that accord wi th what they are try
ing to emphasi ze at a specific session: incul ca
ti on of insight, confi rmati on of a hypothesis,
probi ng of past traumati c events and mem
ori es, defensi ve operati ons, transference
mani festati ons, resistances to the therapi st and
to the techni ques, fears of uti li zing insi ght in
the directi on of change, and so forth. Some
ti mes a therapi st will merely li sten to a dream
for his own i nformati on; at other ti mes i nter
pretati ons are gi ven the pati ent. I n advance of
this the pati ent is asked for associati ons to a
dream and for formul ati on of i mpressi ons
about it. Many pati ents rapi dl y become ski lled
at understandi ng the meani ng of thei r dreams.
To facili tate associati ons, some therapi sts sum
mari ze the dream events and ask the pati ent
specific questi ons in rel ati on to peopl e and i n
cidents in the dream. Dreami ng about different
peopl e is occasi onall y a way of representi ng
different aspects of oneself. T he therapi st, if
the meani ng of the dream is not clear, may ask
about the setti ng of the dream. Does the pa
ti ent recogni ze it? Is it in the past or present?
Does it have any significance for the pati ent?
Do the characters in the dream have any
meani ng for or rel ati onshi p to the dreamer?
Do any of the characters represent the pa
ti ents parents, or the therapi st, or oneself?
Are any underl yi ng wi shes or needs apparent?
What personal i ty trai ts are revealed in the
characters? What mechani sms of defense are
di spl ayedflight, aggression, masochi sm, hy
pochondri acal preoccupati on? What conflicts
are apparent? What is the movement in and
the outcome of the dream inci dents?
Therapi sts i nterpret dreams in line wi th
thei r theoreti cal persuasi ons, some treati ng a
dream like a Rorschach, proj ecti ng into it thei r
own speci al fantasies. Whi l e this may be effec
tive for highl y skill ed, experi enced, and i ntui
tive professi onals, it is better for most thera
pists to work out the meani ng together wi th
the pati ent. It is a poor tactic to i nterpret dog
mati cal l y the l atent content of the i ni ti al
dreams reveal ed by a pati ent. Fi rst, the ther
apist does not know enough about the pa
ti ent and the operati ve defenses. Second, to
penetrate into the unconsci ous prematurel y
will merel y promote greater repressi on of and
distortion in l ater dreams as a way of avoidi ng
anxi ety. One may, however, producti vel y
search for current real i ty reactions (for ex
ampl e, resistances to the therapi st or to the
techni ques; fears, or mi si nterpretati ons the pa
ti ent may harbor about therapy) or for bi zarre
hopes and expectati ons that could resul t in a
defeat of the therapeuti c attempt. Or character
drives may advantageousl y be expl ored as they
exhi bi t themsel ves in the dream, provi ded that
the pati ent is al ready aware of these.
Resistance is apt to occur as the treatment
process proceeds. It may appear in rel ati on to
the setti ng up of the worki ng rel ati onshi p at
the start of treatment, to the expl orati on of the
dynami cs of the i nherent neuroti c process, to
the putti ng into acti on of insight, and, fi nall y,
to the termi nati on of therapy. Mani festati ons
of resistance may first appear in dream struc
ture. The dream provi des a great opportuni ty
to deal wi th it before it becomes an i rreparabl e
obstacle to treatment. Of confoundi ng concern,
however, is the empl oyment of dreami ng itself
as a form of resistance as the pati ent becomes
aware of the i mportance of dreams. He may
thus use dreami ng as an outl et to frustrate or
i mpede the therapi st. T he pati ent here may
dream incessantl y and try to flood the thera
peuti c hour wi th an aval anche of dreams, or he
may unconsci ously el aborate the symbol i sm of
the dream as a way to confuse the therapi st
and to divert from central issues. Some pa
tients bri ng in pages of wri tten dreams, which
may overwhel m the therapi st, and this may be
one way of avoi di ng deal i ng wi th real ity prob
lems. These resistances shoul d be i nterpreted.
Of vital i mportance are the revel ati ons in
dreams of transference in whi ch impulses, ex
peri ences, and defenses in rel ati onshi p to i m
portant past personages are revi ved through
the agency of the therapi st. A weal th of i n
formati on can be exposed in such dreams, and
opportuni ti es are afforded the pati ent and ther
api st for understandi ng of how earl y atti tudes
and patterns di sturb the pati ents present ex
i stence. T hi s provi des a means to work
through transference di storti ons. I n the process
of i nterpreti ng transference, one must al ways
search for real i ty provocati ons that are i ni ti
ated by the therapi st personal l y. The way
transference in dreams is handl ed will depend
on when it appears and its functi on as
resistance. A demand for i nfanti le gratifi cati on
in terms of compl ete gi vi ngness, lovingness,
and understandi ngness, an expectati on of hurt
and condemnati on for the revel ati on or ex
pressi on of impul ses of whi ch the pati ent is
ashamed, can serve as blocks to therapeuti c
progress. Such demands and expectati ons will
requi re careful i nterpretati on. On the other
hand, a delvi ng into geneti c foci, into i mpor
tant earl y formati ve experi ences, if empl oyed
at all, may requi re tact and great pati ence.
Premature or too forceful i nterpretati ons may
do more harm than good.
One of the ways that the dream can hel p the
therapeuti c process is by reveal i ng si gnals of
anxi ety before it becomes too intense and i nter
feres wi th therapy. Where the dream bri ngs
out anxi ety in rel ati on to i mportant incidents,
past or present, it may be possible to hel p the
pati ent endure it enough to avoid the upsurge
of too great resistance.
Often the dream will reveal the nascent
dri ves that marshal l anxiety. These may be
i mbedded in a pregeni tal fusion of sexual i ty
and aggression. Thei r emergence in symptoms
and in acti ng-out tendencies may be responsi
ble for the pati ents current difficulties as well
as for a pervasive i nhi bi ti on of function and
other ego defenses. The studi ed i nterpretati on
of dream el ements will do much toward dari -
THE USE OF DREAMS
175
fying the puni shi ng and masochistic repri sal s
of the superego. By ferreti ng out projecti ve,
denial , isolating, and repressi ve defenses, as
they come out in the dream work, one may oc
casionall y li berate earl y memori es that concern
themselves wi th the fantasies or actual experi
ences associated wi th the pati ents sadisti c and
masochistic maneuvers. Obvi ousl y, the i nter
pretati ons preferred must take into account the
pati ents readi ness for change and the intensi ty
of anxi ety. Above all, the manner of i nter
pretati on serves as an i mportant factor in hel p
ing or retardi ng the pati ent in accepti ng and
i ntegrati ng the si gnificance of the dreams.
Case Illustrations
Case 1
Sometimes a pati ent will present a long
compl ex dream that crystall izes an awareness
in symboli c terms of feelings that are being
shielded from oneself. Often, as is brought out
in the session that follows, the repressi ng agent
is guilt. Because the feelings are not being
acknowledged, they may be converted into
symptomsphysi cal symptoms as in conver
sion reactions, sel f-casti gation and remorse as
in reactive depressions, and fears as in phobi c
reactions. Duri ng therapy wi th empathi c, en
couragi ng, nonj udgmental therapi sts, pati ents
may come to gri ps wi th thei r guil t and begin
accepting thei r ri ght to express feelings. Such
was the case in my pati ent, a marri ed woman
of 40, sent to me by a general practi ti oner who
could find no organi c reason for the leg pai ns
and difficulties in wal ki ng for whi ch the pa
ti ent had consul ted him. After referri ng the pa
ti ent to a neurol ogi st and an orthopedi c sur
geon, who si mi l arl y could fi nd no organi c basis
for her compl ai nts, the practi ti oner advised the
pati ent to receive psychological help. She ac
cepted his advice readi ly and duri ng the initi al
intervi ew we decided on a short-term program.
A worki ng al l iance was readi ly achieved,
and the pati ent spoke freely about her earl y re
l ati onshi p difficulties, but she could seem to
find little wrong wi th her present si tuati on ex
cept for a feeling of detachment from her hus
band, a man eight years younger than herself
about whom she spoke little at first. She was,
she admi tted, not trul y happy wi th her rel a
ti onshi p, but it was tol erabl e and she did not
believe she was too affected by it. It was better,
she said, than her first marri age to an author
itati ve man who kept her down and mi ni mi zed
her abil ities, cri ti cizi ng her incessantl y. She
chose her present husband because he was
gentl e, noncompeti ti ve, and easy to get al ong
wi th. But, for some reason she was not happy.
Her leg symptoms started after the marri age,
but the pati ent could see no connecti on be
tween the two. Wi th the pati ents permi s
sion, I i ntervi ewed her husband. He gave me
some pri mi ti ve, di sorgani zed, contami nated
responses to the Rorschach cards. Cl i ni cal l y, he
impressed me as being at least borderl i ne but
probabl y schi zophreni c.
My pati ent, an extremel y capabl e and i n
tel li gent woman, rapi dl y caught on to what a
dynami c approach was all about. There were,
however, no dreams, even though I constantl y
remi nded her of the need to report dreams to
me. I kept focusing on her rel ati onshi p wi th
her husband and encouraged her to begin to
come to gri ps wi th her di sappoi ntment in him.
I insisted that she work on her leg symptoms,
sayi ng that they had somethi ng to do wi th the
way she felt. Two sessions pri or to the present
one, she was finall y abl e to arti cul ate her
anger at her husband and even some hatred
toward him. She noti ced that her awareness of
her anger tended to rel ieve her leg symptom.
T he breakthrough of these emotions, I felt,
inspi red dreams that convinced her of the
depths of her hostil ity toward her husband, the
rel ati onshi p of thi s hosti l i ty to her leg
symptoms, and the need to do somethi ng about
her marri age. The session that follows is the
seventh.
Pt. I ve deci ded that I ve gotten myself in a bad
si tuati on, (pause)
T h. I ts a si tuati on youve been in or one youve
gotten yoursel f i nto recentl y?
Pt. What r ve gotten mysel f i nto, and I try to act
ni ce, but so hel p me God I cannot say: Wel l ,
look sweeti e [to A lf r e d her h u s b a n d ] I love
you, and well work thi s thi ng out. I cant do
it. I m ni ce to hi m, but i ts a very i mpersonal
ni ce, and, of course, I m terri bl y aware of it.
I dont know how where he is, and agai n I
may proj ect and I m more aware than he is. I
try to do thi ngs that he wants done and so
forth, the best I can, but i ts hell. Brother, do I
gi ve mysel f the busi ness! Y ou tal k about
symptoms, then do I get them!
T h. T hen you get them after that. How do you
make the connecti on then? What happens to
you?
Pt. Oh, then thats when I feel gui l ty. I feel so ter
ri bl y gui l ty. I still do today, (pause)
T h. Y ou feel evi dence of gui l t connectedcon
nected to what?
Pt. T he way I react to Al freds i ll ness and per
sonal ity.
T h. And how does the gui l t refl ect i tsel f in
symptoms?
Pt. Feet and legs al ways. Wel l , not al ways, but
mostl y I get there.
T h. How do they seem now? Feet and legs.
Pt. Very bad.
T h. T hey do?
Pt. Today theyre bad.
T h. Y ou connect it up wi th your gui l t feelings
toward Al fred then
Pt. Wel l , thats what I connect up wi th, but I can
be wrong about that too, because in si mi l ar
ci rcumstances I usual l y get the same thi ng. But
yet I know what I m doi ng, so I dont feel as
depressed. I dont have the depressi on that
someti mes comes wi th it.
T h. T he knowl edge of what you are doi ng does
that hel p lift the symptoms too?
Pt. Not so far. At least not i mmedi atel y. I thi nk it
does after a whi l e.
T h. How l ong?
Pt. Wel l , maybe 24 hours.
T h. And after 24 hours what do you noti ce?
Pt. Wel l , then I dont have the symptoms.
T h. And then you dont thi nk about them.
Pt. T hats ri ght, but not i mmedi atel y. I mme
di atel y knowi ng does not i mmedi atel y rel i eve
the symptoms, but i mmedi atel y getti ng the
reacti onwhatever thi s thi ng is, thi s gui l t th
ing or whi ch is combi ned wi th superego and
bl ah, bl ah, bl ah, but l ets cal l it gui l tthat
will do. I i mmedi atel y get symptoms. I get
symptoms fast, but i mmedi atel y knowi ng why
I m getti ng them is not i mmedi atel y rel i evi ng.
They dont cut off that fast.
T h. Yes.
Pt. Wel l , theyre cut off in a hurry in thi s way.
Probabl y tomorrow morni ng when I wake up,
I wont have thembut that woul d be a peri od
of 24 hours after I know what I m doi ng. But
you see, thi s terri fi c thi ng of hate thi s week. I
can scarcel y be in the same room wi th hi m. I ts
col ossal , and I had it yesterday and i ts all I
can do to be decent. I t is a superhuman effort.
T h. Have you noti ced that the hate has been pi l i ng
up on the surface more and more?
Pt. Sure, sure.
T h. T here was a ti me when you di dnt have any
hate for hi m at all.
Pt. Oh, but you know that, yes. Y ou see now, it
gets cl oser and cl oser to the surface, and i ts
just al most physi cal l y i mpossi bl e to control it.
T h. What do you feel li ke doi ng when you get thi s
thi ng, thi s feel ing?
Pt. Wel l , i ts a pecul i ar thi ng, I woul d li ke to
make hi m i nani mate. I said the other day, to
put hi m in hi s pl ace, I woul d li ke to make hi m
nonfuncti onal so that he coul dnt bother me at
all. T he onl y reason I woul dnt want to kill
hi m is because I know that that woul d be on
my consci ence. But I d li ke to hit hi m physi
cal l y at ti mes. I l ook and lie in bed and I
l oathe hi m, oh, l oathe hi m. Wel l , anyway,
well qui t thi s and go on to somethi ng else.
Sort of the same subj ect. I ts very i nteresti ng.
L ast ni ght when I went to bed earl y and I con
sci ousl y thought to myself, al l ri ght now, thi s
leg department, because thi s thi ng kept mount
ing yesterday, you see.
T h. Y ou noti ced that the symptoms began pi l i ng
up?
Pt. Worser and worser, and I m goi ng to dream
what the hell is real l y wrong wi th my legs.
Unconsci ousl y I must know what the hell is
goi ng on; now I m goi ng to dream. My dream
is the most fabul ous thi ng you heard in your
life. Wai t unti l you hear. Y ou better record
thi suh, I wrote it in the dark. I thi nk I can
recal l it, and then I ll go and check it and see if
I m ri ght.
T h. All ri ght.
Pt. I dreamed that I was in a bedroom and two
women were in the room wi th me. Now they
seemed to be in some capaci ty li ke a mai d and
a fri end, or somethi ng li ke thatrather i mper
sonal capaci ty but they were there. And it
was all very fri endl y, and I forget what we
were doi ng, whether we were getti ng cl othes
ready to wear or somethi ng. But it was all a
very pl easant atmosphere. And all of a sudden
I saw thi s very strange li ttle creatureani mal s
agai nabout thi s big (spreads f i n g e r s apart
about 5 inches), and it was a creature li ke I
had never seen before, and it was sort of tryi ng
to get up my desk. T here was a desk on the
opposi te wal l and it was tryi ng to get up on
my desk. I t coul d move somewhat li ke a squi r
rel or like a monkey, and I sai d, L ook at that
thi ngwhat is i t? And one of the women
sai d, Gol l y, I dont know what it i s.
Wel l , I sai d, thats the strangest creature I
had ever seen. T he other one sai d, I t looks
like a bat, but it cant fly, it looks li ke a bat.
And I sai d, I dont want to see that thi ng, it
is so odd. T hen I sort of l ay over. I was si t
ti ng up on top of the bed li ke I do so often
and then I sort of l ay over there and I knew
the creature was comi ng around. I t came over
the bed toward me and, Oh God, it was sort of
a marked fear and a certai n shudder. And one
of the women sai d to me, Wel l , you al ways
said you werent afrai d of rodents. Of course,
I m not, for a long ti me I m not afrai d of
rodents. And thi s li ttle creature came over and
got on me. I t was onl y about so bi git had
brown and whi te spots, not pol ka dots but
mottl ed.
T h. Yes.
Pt. And it had arms and legs like a spi der monkey.
Y ou know what a spi der monkey is; its arms
and legs are too long for it and very agi l e, and
its nose and its head, wel l they looked li ke a
frog. There was no di fferenti ati on between the
head and the body, and i ts face l ooked
somewhat frogl i ke in that its face was flat and
its snoot was square. It di dnt have the face of
a monkey at all. but I deci ded it bel onged to
the monkey fami l y because of its movements.
And let me seesomethi ng came in there be
tweenoh, yes, some of the words I got were
terri fi c. So I turned to one of the women and
sai d, I wonder what thi s thi ng isand si tti ng
up there on my shoul der. I wasnt fri ghtened
of it, but I di dnt li ke it. I had no feel i ng of
petti ng it.
T h. Yes.
Pt. Y ou know my usual reacti on about all ani
mal s. I mean if i ts a cat, or a dog, or a horse,
or a whi te mouse, or a gui nea pi g, or a rab
bi tmakes no di fference to me I woul d pet
it. But thi s creature di dnt parti cul arl y fri ghten
me. I di dnt have a feel i ng that it was a spi der
in the sense of my horri bl e feel i ng about
insects, but I di dnt want to touch it. I t was
j ust there.
T h. Uh-huh.
Pt. So thi s one woman sai d, I wonder what it
i s. And she sai d, I t looks li ke an emu.
T h. An emu?
Pt. What she thought an emu issoft Ameri can
goat I thi nk it is, I di dnt look thi s up. I sai d,
No, i ts an anus.
T h. I ts an anus.
Pt. And then I sai d it was in the monkey fami ly.
So then it came over and it got on my ri ght
breast, and it j umped up and down li ke
monkeys j ump up and down and chattered,
j ust chattered. Wel l , then the dream faded.
And on the fol l owi ng day I m on the same bed
and tal ki ng on the tel ephone to my mother. I
tol d her about thi s strange creature, and I
thought about it and wondered what happened
to it. I t was there, I wonder what happened.
I ve got to find out what happened. I t must be
here in the house somewhere. So the mai d
sai d, I ts behi nd the door. So I got up and
went over and behi nd the bedroom doorthi s
all happened in the bedroomthi s all hap
pened in the bedroom behi nd the bedroom
door is thi s anus, I cal l ed it, folded up li ke a
frog mi ght fold up. Onl y the frog, I ve never
seen one that di d, but they woul d be abl e to
folded up li ke this. L eani ng up agai nst the
wal l and next to it is a li ttle anus. Duri ng the
ni ght it had had a baby. So I got off the
tel ephone and took the two they had awak
ened up and unfol ded. T he bi g anus i m
medi atel y got over on my ri ght breast and
started j umpi ng up and chi tteri ng and chatter
ing, and the li ttle one exactl y the same was
over here on thi s shoul der j umpi ng up and
down and chi tteri ng and chatteri ng. And I was
qui te i ntri gued that thi s anus one day ol d coul d
chi tter. I t had l earned so fast. And I thought,
my God, these thi ngs must reproduce, but wi th
terri fi c rapi di ty. T hi s woul d be awful , the
whol e house woul d be full. I ve got to do
somethi ng. And bei ng as I dont di sl i ke it and I
hate ki l l i ng creatures, what am I goi ng to do?
What was I goi ng to do? And then my feeli ngs,
my emoti onal feel ings were the thi ng in thi s
dream, because usual l y I dont real i ze them so
much, but I di d in thi s. I n l ooki ng for the
anus, the combi nati on of not wanti ng to see it
but wanti ng to know where it was, and then
my terri fi c feel i ng agai nst ki l l i ng any crea
tureany ani mal or doi ng away wi th an
ani mal . And I got thi s thi ng, and, of course,
the baby of any ani mal is al ways cute. I dont
care what it is, I got the thi ng, and I thought
by gol l y the onl y thi ng to do is I have to di s
pose of one of them. Now I have to find out
whi ch one is the one that bears, whi ch one is
femal e, or whether theyre both femal e or
whether theyre both mal e. Of course, that got
mi xed up there, but anyways one of them must
have given bi rth to the other one. Maybe the
big one was pregnant when it came i nto the
room yesterday, whi ch now shoul d be logical,
but I know that all ani mal s do not mi nd incest.
So, therefore, if thi s little one that shes had is
a son, then at a given l ength of ti me whatever
thei r peri od woul d be, why I d have a lot more
anuses around the house.
T h. T he son woul d have rel ati ons wi th the
mother? [ What the p a t i e n t is i m p l y i n g is that
her own relationship with her husba n d , s y m
bolized by the mo nk e y creature, is incestuous.]
Pt. T he son woul d have rel ati ons wi th the mother.
I s thi s a l il y? (laughing) And so I thought I ll
see if I m ri ght now. So I started exami ni ng
them, and they had no sexual organs at all.
They were j ust in the l i ght as sil ver dol l ars
they were the same on both ends except one
end opened, whi ch was obvi ousl y a mouth.
They had no tail s. T hey had these legs, so I
gave that deal up and thought the god damned
thi ngs dont have any sex. What am I goi ng to
do now, because I di dnt want to kill both of
them. I had thi s thi ng, and I di dnt know what
to do wi th it. T hen somethi ng I mi ssed in there
was when I first asked what that thi ng was,
and thi s is goi ng way back, was that one of the
women sai d, I dont know what it is, but I al
ways stay away from thi ngs that I dont know
what they are. T hen the two anuses (laugh
ing) kept j umpi ng up and down and chi tteri ng
and chatteri ng at me and chi tteri ng and chat
teri ng and that was the end of the dream.
T h. And that was the end of the dream. Y ou were
upset wi th both of them?
Pt. I was rather upset, but I woul dnt face thi s
even in my dream; I was revol ted wi th both of
them or I was revol ted wi th the i dea of ki l l i ng
both because there was no way to determi ne
whether or not they coul d concei ve or produce
maybe thousands of these l i ttl e creatures.
(pause)
T h. Wel l , thats rather an i nteresti ng dream.
Pt. And the fact that I let them j ump up and down
on me, I let them chatter at me. And it was i n
teresti ng that they were very pecul i ar creatures
that have never been seen the li ke of on thi s
earth. But I di d not want to touch them or pet
them or fondl e them, whi ch I do all creatures.
So if that i snt somethi ng, so that is the answer
to what is wrong wi th my feet. Now you take
it from there (laughing).
T h. Y ouve thrown it my way.
Pt. (laughing)
T h. (laughing) Now where do the feet come i nto
the pi cture? What do you make out of the
dream i nci dental l y?
Pt. Now, of course, that is Al fred. How in Gods
worl d I coul d ever. . . . I n my consci ous mi nd I
coul d never get the attri butes together that I
real l y feel about hi m and put them in words
neverso practi cal l y compl etel y in the dream.
T h. As you di d in representi ng hi m as an anus. All
ri ght, what are your associ ati ons wi th that
creature? What does that creature have that
Al fred has?
Pt. L ong arms and l egs monkeyl i ke from the
monkey fami l y. I ve al ways thought that Al
fred was a rather queer-l ooki ng person. And
I ve often thought he looked rather frogl i ke be
cause of thi s great wi de j aw and pop eyes. So I
had thi s square nose on thi s creature. When I
fi rst see hi m, I dont know what it is. H es a
hybri d of some type. T he creature cant tal k,
chatters al l the ti me and cant tal k whi ch is
one of the thi ngs that aggravates me about Al
fred.
THE USE OF DREAMS
179
T h. He chatters?
Pt. He chatters all the ti me, but he cant tal k and
j umps up and down on me.
T h. I s that what Al fred does?
Pt. Yes, I thi nk so; it is the way I feel about what
he does I m tel l i ng you about.
T h. Y ou al so brought up from ti me to ti me that
hes qui te hai ry.
Pt. Hai ry? I coul d j ust si mpl y fix hi m up for good.
T h. What about?
Pt. T hen hes compl etel y sexless.
T h. Sexl ess?
Pt. He wasnt mal e or femal e. I coul dnt find out
what he was; I looked hi m over and I coul dnt
find out what he was.
T h. T hat represents how you feel about Al fred?
T hats a pretty good descri pti on of how you
feel about hi m?
Pt. Y eah, I dont thi nk theres any doubt of it.
When I woke up I thought, my God, thats a
pi cture of Al fred and I coul dnt beli eve it.
Brown and whi te mottl ed. I f youve ever
noti ced, peopl e have col ors to me. Now youre
grey, and Al fred is brown, whi ch mi ght al so
cover the anus department, you see (laughing).
T h. Brown?
Pt. Hes what I call a brown person. Y oure a
grey person. Some peopl e are pi nk peopl e, and
so forth. T hat may be a l i ttle farfetched, but
I ve al ways regarded peopl e that way.
T h. Also you feel as if you are stuck wi th Al fred,
the way you were stuck wi th these ani mal s.
Pt. Y eah, I coul dnt kill them. I was afrai d there
mi ght get more of them, whi ch woul d be terri
ble. He was draggi ng down on my breasts,
whi ch woul d mean put me in the mother role.
I n a way Alfred chatters exactl y li ke monkeys.
T he monkeys chatter and cl i mb over thi ngs
and j ump up and down, and these creatures
had no tai l s, (laughing)
T h. Wel l , now how can you uti l i ze thi s dream con
structi vel y for yoursel f? What does thi s expl ai n
to you that you coul d use in a constructi ve
way?
Pt. Wel l , it expl ai ned thi s much to me: that as
long as I feel thi s way about Al fred, whi ch is
the most graphi c thi ng I ve had whi ch
doesnt necessari l y say hes li ke that but I feel
that way about hi m I better do somethi ng
about it.
T h. Wel l , how does that ti e i n wi th your legs?
Pt. Wel l , the way I find i tand maybe I m
fantasti c on thi s and I wi sh youd tell me
(laughing). I ti e it in wi th my leg symptoms
because they arri ved i mmedi atel y upon marry
ing Al fred. So it makes some sense when I said
to mysel f very powerful l y l ast ni ght before I
went to sl eepbecause it was earl y and I
hadnt had but a coupl e of dri nks duri ng the
eveni ng, one as a matter of factbefore I went
to bed. I sai d I m goi ng to dream about thi s leg
thi ng. What does give me these symptoms be
cause I noti ced the whol e thi ng mount yester
day, parti cul arl y when I was ki nd of di sgusted
wi th the whol e idea that he di dnt go to work
on Tuesday. Wel l , yesterday morni ng when he
wakened up and saw that I was more di sgusted
than ever, I j ust thought I ll see if the old
unconsci ous wil l unbutton by dreami ng.
T h. A pparentl y it came through.
Pt. I t di d (laughing), and thats how I connect the
leg symptoms wi th Al fred because if I had had
the leg symptoms before I marri ed Al fred, I
woul dnt say that. T hat woul dnt make too
good sense, but I got them i mmedi atel y after
marryi ng hi m. When I say i mmedi atel y, I say
wi thi n 4 weeks, and I never had troubl e wi th
my legs before. I danced, I wal ked, I d done
everythi ng. And I ve never been wi thout trou
ble since the marri age.
T h. I t sounds very suspi ci ous.
Pt. I t sounds more than suspi ci ous doesnt it? And
thi s dream was so vivid.
T h. I t sounds very, very suspi ci ous as if youve
been l i ving wi th it real l y.
Pt. T hi s is my bedroom, in back of the door, and I
had the feel i ng that I must know where it is a
menace. I t has a menaci ng qual i ty, and yet I
wasnt afrai d of it from the standpoi nt of get
ti ng stunned.
T h. What do you thi nk has ti ed you down to hi m,
whi l e real l y feel i ng thi s way about hi m as you
obvi ousl y have felt? What has ti ed you down
to hi m? Y ou dont feel any di fferentl y toward
hi m now than you di d before for a l ong ti me,
do you? At l east youre more consci ous of
certai n feeli ngs.
Pt. I m more consci ous of them, and I suppose I
dont feel any di fferent, but I coul dnt admi t it
to myself.
T h. But how come you are ti ed down wi th hi m for
so l ong 3 years? T hat is a l ong ti me . . . to
live wi th a monkey named anus.
Pt. I real l y thi nk thats a qui te bri l l i ant dream
mysel f (laughing). I had to l augh the mi nute I
real i zed what I had dreamed, and then I felt
terri bl y gui l ty.
T h. Di d you?
Pt. Yes, of course, the reason I ve lived wi th hi m
all these years is j ust thatgui l tthats the
whol e thi ng. I felt terri bl y gui l ty, and thats
why my legs are bad.
T h. I f you live wi th a person on the basi s of gui l t,
what do you feel about yoursel f for doi ng a
thi ng li ke that?
Pt. Wel l , you see, that I havent di sentangl ed
mysel f yet.
T h. But if on the basi s of gui l t, you live wi th some
body, what do you feel mi ght happen in your
self eval uati on, in your atti tudes toward your
self? [ /f e e l I can use confrontation to challenge
her defenses since she appears to have f a i r l y
good insight into what is happening. Also we
have a good wo r ki ng relationship and she
w o u l d n t f e e l 1 was p u t t i n g h e r down.]
Pt. Depreci ati on.
T h. Sel f-depreci ati on. How can you respect your
self under those ci rcumstances? Woul dnt it be
expecti ng the i mpossi bl e of yoursel f? And then
what woul d you do if you di dnt respect your
self? T here woul d be ways of coveri ng yoursel f
under the ci rcumstances woul dnt there?
Pt. Y eah.
T h. Not bei ng abl e to express hosti l i ty, what have
you been doi ng wi th it?
Pt. K nocki ng the hel l out of mysel f (laughing).
[H e r l aughter is actually a self-conscious de
f e n s iv e maneuver. I t conceals a gre at deal o f
misery a nd self-concern.]
T h. Y ou mean youre an expert on puni shi ng your
self, arent you?
Pt. I m an expert on hosti l i ty and what to do wi th
it. Wel l , thats the story as pl ai n as the nose on
your face, and I can see it. I m still reacti ng to
it, but I can still see it.
T h. Al l ri ght, the potenti al i ti es for doi ng somethi ng
about it posi ti vel y are l i mi ted to a number of
thi ngs. One, ei ther youre proj ecti ng i nto hi m
atti tudes and feeli ngs that you have toward
men in general , or toward certai n men; or,
two, hes a speci al ki nd of person whom you
marri ed on a fl uke and therefore youre re
spondi ng to hi m as a special ki nd of person.
Three, theres a possi bi l i ty you may feel that
he may devel op, he may change, and thi s may
j usti fy to yoursel f your l i vi ng wi th hi m; or
four, you coul d l eave hi m, peri od. Are there
any other possi bi l i ti es you can thi nk of?
Pt. No. Wel l , one, I may proj ect some, I dont
proj ect compl etel y because we know that he
was a speci al ki nd of creature. Two, I marri ed
hi m on a fl uke in an attempt to run away from
my own superego thi nki ng if I got away from
control or anythi ng representi ng a parent, I
woul dnt feel the way I di d, and suffer the way
I di d. So I chose a weak man, one who
woul dnt control me.
T h. I n other words, if you di dnt marry your
parent thi s ti me, li ke you di d your previ ous
husband, youd be in control of the si tuati on.
Y oud be abl e to mani pul ate and handl e the
si tuati on.
Pt. T hree, I was normal enough apparentl y to
make some attempt at adj usti ng Al fred to some
sense of normal i ty otherwi se I woul dnt have
worked so hard on hi m. I di dnt know that at
the ti me, but I must have had a very strong
dri ve, or, beli eve me, I woul dnt have put in
the effort and ti me that I di d in tryi ng to make
some sort of a man out of hi m.
T h. Wel l , what sort of a job have you done wi th
that?
Pt. I have come to the concl usi on that anybody, i n
cl udi ng you, coul d compl etel y waste your ti me
in tryi ng to adj ust a homosexual to normal i ty.
I do not thi nk it is possible.
T h. Y ou thi nk all the effort you have made toward
adj usti ng hi m to a heterosexual life has gone to
waste?
Pt. I thi nk I probabl y feel more strongl y than that
in the case of Al fred, because he was abl e to
make a better adj ustment probabl y than 9 out
of 10, and it l eaves hi m bei ng nothi ng. God,
the homosexual s that I know, and I know
pl enty of them, they are homosexual s and they
love the fact that I m a gi rl, and I love it. And
they are better adj usted peopl e than Al fred or
the other boys that I have seen and have gotten
marri ed. Some of them had one chi l d. J esus,
they get themsel ves i nto a thi ng where they
never get themsel ves out of it.
T h. I n what way?
Pt. T hey are nothi ng. T hey never become hetero
sexual they dont. And if they do, they must
be hangi ng in the Hal l of Fame, because there
arent many of them. Al fred is not heterosex
ual , but nei ther are the homosexual s, and my
guy cant accommodate hi msel f to anythi ng.
We never have sex.
T h. He s neuter?
Pt. He becomes neuter.
T h. J ust like that monkey.
Pt. Y eah, honestl y, that's what I thi nk today. Ask
me another day, and I mi ght have another
i dea. I dont thi nk so I ve watched, so I guess
thats one pl ace my gui l t feel i ng arri ves.
T h. T hat youve taken hi m away from homosexual
life?
Pt. I ve taken hi m away from somethi ng that he
obvi ousl y enj oyed. And the way he earns hi s
living, it i snt looked down on too much. [Al
f r e d is a wi ndow designer. \ Most of them
arethey have a terri fi c ti me. They have a
l ousy ol d agethats true. When they get to be
ol d, they have thesewhy i t's pretty bad, but
even that they adj ust to. A bunch of them get
ol d together. So what, they j ust dont grow up
in one area, so they dont grow up in it. Or
theyre arti sts or si ngers, or they accommodate
themsel ves to the femi ni ne part of thei r nature.
Why, they have a pretty good life. Onl y when
they get so that they real i ze that they arent
l i vi ng a full life that they suffer so damned
much, and I thi nk thats where I feel gui l ty
about Al fred, I real l y do.
T h. Y ou ki nd of feel that you weaned hi m away
from that group and that he cant go back to it.
Pt. Hell go back, but that wil l be as much an ad
j ustment as it was to adj ust to a heterosexual
si tuati on. And wi th it he will have hel l i sh gui l t
because he will know theres somethi ng better,
because he will have gl i mpsed it. I thi nk ho
mosexual sthei r mothers shoul d be strangl ed
poi nt number onethey shoul d be let al one
I m speaki ng now not of ki ds in thei r young
teens, but I m tal ki ng about guys who get to be
25 and 28 and thei r pattern is pretty wel l set.
I t's a pecul i ar thi ng. I have them around the
house all the ti me and I m fai rl y observant; I
can't hel p but be I ts a pecul i ar thi ng. I ts true
even wi th Al fred, and I know another one who
had a si mi l ar experi encethats George who
is marri ed and has a chi l d. He went back to
homosexual i ty. George cal l ed me thi s morni ng,
and I had a l ong tal k wi th hi m. Ni ce guy,
mal adj usted as hell to every part of life. Y ou
get them in a room wi th other homosexual s,
and the rovi ng eye is real l y somethi ng. They
cant hel p it; i ts part of themanymore than
I can put Ti ger, my mal e dog, wi th a li ttle fe
mal e dog and expect hi m to sit and l ook at her.
I m si tti ng and tel l i ng you about psychi atry. I
l ove this. Anyway, i ts my observati onsee,
you asked me what I ve done to Al fred. See,
thats what I thi nk I ve done, and thats why I
feel so goddamned gui l ty about l eavi ng hi m.
Y ou wanted to know why I di dnt l eave hi m
earl i er.
T h. I ts qui te possi bl e that your gui l t has been such
that you felt it woul d practi cal l y kill hi m to
l eave hi m, and you know that he is a rather
unstabl e person H es unstabl e, and there is no
tel l i ng what may happen in hi m whether you
live wi th hi m or not.
Pt. My l i vi ng wi th hi m, I ve come to real i ze that
now, my l i vi ng wi th hi m wi l l not prevent it,
but I di dnt real i ze that before.
T h. I n other words, youre j ust not goi ng to save
hi m. I f the process wi thi n hi m is a destructi ve
one, it may defy anybodys abi l i ty to hel p hi m.
On the other hand, you may want to handl e
whatever you deci de to do i n a careful way
wi th hi m.
Pt. T hats what wi l l have to be because I dont
thi nk I know thi s, but it is somethi ng I feel i n
tui ti ve about, if you beli eve in i ntui ti on. There
have been a few ti mes in my life wi th Al fred
when I have seen hi m wal k away from hi msel f.
T hat is the onl y way I can put it. Now he was
starti ng to wal k away from hi msel f before he
came up to see you yesterdayas if he wasnt
here.
T h. T hats sort of a psychoti c-l i ke retreat.
Pt. He gets what I call over the border. ( pause)
T h. Over the border?
Pt. Some damned thi ng that he wil l wal k away
from hi msel f is the onl y way I can put it. H es
not thereand that scares the hel l out of me.
Of course, I connect it wi th somethi ng I ve
done to hi m. Now, that may be very neuroti c,
but I apparentl y connect it wi th what I ve
done.
T h. Wel l , you happen to be the person hes li vi ng
wi th now, and consequentl y hi s experi ences
wi th you can act as a tri gger. But if it werent
you, it mi ght be somethi ng else.
Pt. I real i ze that now, but I still bl ame myself on
that score.
T h. Wel l , do you bl ame yoursel f so much that i ts
goi ng to paral yze yoursel f from doi ng what
you thi nk is the best for you?
Pt. No, no, i ts not goi ng to stop me.
T h. What woul d be the best thi ng to do?
Pt. T he best thi ng for me to do is to l eave hi m.
I m sure of that. I dont know how the hell I m
goi ng to do it ri ght thi s mi nute. As you know
what ki nd of spot I ve gotten myself i nto fi
nanci al l y.
T h. Fi nanci al ci rcumstances are certai nl y such that
you woul dnt want to do anythi ng unti l you
were more self-sufficient and secure?
Pt. T hats ri ght. Wel l , I cant, I dont know how
to do it. So I ve got myself in that ki nd of spot,
and I thi nk I feel gui l ty about thatgetti ng
mysel f in that ki nd of spot. But after marryi ng
hi m I wanted to go down the road to destruc
ti on, and I pl ayed every card i n such a manner
that I di d. Now, I dont feel that way about it
anymore, and I can see what I ve been doi ng to
myself. But it l asted suffi ci entl y unti l I was in
physi cal pai n. How I feel gui l ty that Alfred
has to spend every cent he makes on me, whi ch
I know rati onal l y I shoul dnt because God
knows he had the advantage of all the money I
had for many years before our marri age. So he
puts in a few months of forki ng up the dough
and I dont see why I shoul d feel too badl y
about it. But bei ng the ki nd of creature I am, I
act that way. I dont see anythi ng to do except
to wai t unti l I can feel not even sure, but j ust
even partl y sure that what I m worki ng on
now wil l have some meri t.
T h. I n terms of fi nances you mean?
Pt. T hats ri ght, I mean fi nances. I f I find that it
has even some meri ta l i mi ted meri tl iving
al one, I can live on very l i ttl ewhy I woul d
take the pl unge then.
T h. Y ou woul d?
Pt. Oh yes, I woul d. I real l y woul d because I
dont thi nk, I dont feel there is any foundati on
to bui l d on for the two of us at all. I thi nk it
woul d be a crutch department from here on
out for both of us. And if hes ever goi ng to
make anythi ng of hi s life one way or the
otherwhi chever way he deci des to go i ts
hi gh goddamn ti me he starts.
T h. Vi rtual l y, you know the character of hi s rel a
ti onshi p wi th you.
Pt. T he son and I 'm the mother.
T h. Hes the son, and the atti tude and feeli ng he
has toward you is as if you are his mother. Do
you beli eve that?
Pt. T hats why he vaci l l ates so terri fi cal l y from
thi s terri fi c love to j ust l oathi ng me.
T h. And youre ki nd of fed up wi th that deal you
dont want to be hi s mother.
Pt. I ts no decent rel ati onshi p if I m goi ng to be
hi s mother I mi ght as wel l real l y act like hi s
mother (laughing). Ri ght? I ts j ust no good. So
I can see the pattern cut out for what I have to
do, and I d rather stop beati ng mysel f on the
head.
T h. Beati ng yoursel f on the feet.
Pt. Duri ng the ti me peri od that I have to go
through to do it, that is somethi ng we can
work out a little bit.
T h. And your own feeli ngs about l eavi ng hi m too.
Pt. T hats beati ng myself on the feet, the gui l t
thi ng. And I dont qui te know how to act wi th
Al fred in that if I let my aggressi ve feel ings
come out, it woul d probabl y come out way
overboard anyway. I ve hel d them in a l ong
ti me. I m afrai d I mi ght do somethi ng awful to
hi m so I keep sort of pretendi ng around the
house about thi s and that, and hell say, Oh,
I love you so much. And I dont know what
the hel l to say to that I mean I dont know
because what I say doesnt have any ri ng of
truth, and that itself keeps me in an uproar. I
get vari ous reacti ons from it Someti mes I shut
up from anxi ety. I feel very sorry, and then I
look at hi m and thi nk how i n the hel l I
coul dnt see it before. Now I see, I mean real l y
see. Now li ttle thi ngs li ke thi s are ri di cul ous,
but they show how hard I react. We have thi s
bed whi ch is fixed j ust li ke your couch i ts
got a back li ke this. I ts a l ounge. T he
bedroom is not fi xed up li ke a bedroom; i ts
fi xed up as another room. We sl eep there and
watch T V or read wi th our feet outstretched
agai nst thi s thi ng on my si de, and he has his
side. Al fred wil l never sit up strai ght in thi s
thi ng; he wil l al ways l ean over as close to me
as he can get. M y reacti on is to take hi m and
shove hi m away. When he gets in bed, he
never lies strai ght he curves toward me and it
j ust aggravates me.
T h. It does?
Pt. Sure, it aggravates the hel l out of me.
T h. Y ou dont want any monkeys j umpi ng up and
down on you.
Pt. (l aug hi ng) I dont want any spi der monkeys
j umpi ng up and down on me, anuses (laugh
ing) in other words.
Case 2
One of the most difficult pati ents I have ever
treated was a young college student who went
into a negati ve transference even before she
saw me at the first visit. A severe phobi c reac
ti on motivated her to seek hel p, but upon mak
ing the appoi ntment she began to fantasy my
forcing her to perform agai nst her will. Sens
ing her resistance duri ng the first sessi on, I
said, I get the impressi on you find it hard to
tal k because you are afraid of my reacti ons.
To this remark she expl oded, I feel people
have no respect for me, if I show weakness
especially. I m getting angry at you. I thi nk
you get some satisfacti on about humi l i ati ng
me. Li ke my parents, my father especially. He
gets some kind of thril l out of cri ti cizi ng me. I
thi nk they say, Y ou are shy, weak. Y ou are
embarrassed. Get up there and perform and
well watch! But I feel so humi l i ated. My
whol e life is spent savi ng face. I never let them
know. They al ways try to shame me. My
repl y was to the effect that she did not thi nk I
could accept her as she was wi th all her faul ts
and probl ems. How could you, she retorted.
The probl em real ly was, I countered, that she
could not accept herself and therefore proj ected
this feeling onto me. Wi th thi s the pati ent
stormed out of the room. She returned, never
thel ess, for her next session, and she conti nued
to upbrai d and attack me. At the twelfth
session she presented thi s dream whi ch i ndi
cated the begi nni ng of resol uti on of her nega
tive transference.
Pt. I was comi ng back from a l ong tri p duri ng the
summer. 1 had been hi tchhi ki ng. 1 tal ked to
peopl e and felt di scouraged. I nstead of engag
i ng in normal activities, I wi thdrew and said I
was dead, contrary to appearances. However, I
saw a tall man wi th a moustache, and I began
to assaul t hi m verbal l y. I sai d he was di cta
tori al like a Nazi in deal i ng wi th me. He had
been oppressi ng me even though he was a
stranger. After a few mi nutes of thi s, I got a
sudden new i dea l argel y because thi s man re
sponded sympatheti cal l y. I felt I wasnt real l y
dead, but suffered amnesi a. I was extremel y
happy. I real i zed my di sappearance for 2 to 3
months was that I was in amnesi a, not dead. I
started to tell peopl e I had a wei rd experi ence
in whi ch I thought I was dead. 1 thought it
was an amazi ng thi ngbi zarre and wei rd. I
felt I was an expert on conformi ty, but I had
j ust acted as a conformi st in an unusual way. I
had been submi ssi ve even though I knew all
about what made for conformi ty. But I was
happy about thi s, to real i ze that I felt di s
couraged because I felt nobody cared about me.
I n her associati ons she said that bei ng away
was like nobody cared for her. As a chil d she
felt thi s, and she was surpri sed when she had
been away for 2 or 3 hours to discover that her
mother and father had been worri ed. All of her
life she had felt like a strange abnormal per
son, and thi s was like bei ng dead. T he tall
man wi th the moustache was like her father
when she was 6 or 7. I remember accusing
my father of indifference or disli ke, of wanti ng
to hurt me. He gradual l y convinced me I was
wrong. I got a sudden feel ing you are like my
father.
Case 3
Frequentl y the transference el ements are not
as clearly obvious as they were in the foregoing
dream, the i dentification of the therai st being
more hi ghl y symboli zed. T he therapi st who is
on the watch for transference resistance will be
al erted to transl ate dream symbol s that
forecast stormy weather ahead. Pati ents who
have some psychol ogical knowl edge, or who
have read psychol ogical books, or who have
had some therapy are often abl e to decode the
disguised symbol s themsel ves, operati ng as a
cotherapi st. Thi s is i l l ustrated by a pati ent
wi th a probl em of dependency who dreamt in
oral terms and who wrote out the following:
Wednesday night
I am in a bakery wi th an unusual l y l uscious-look-
ing array of baked goods. I seem to remember that
somethi ng I bought looked so good that I ate a pi ece
whi l e I was in the shop. Al so, I vaguel y remember
arrangi ng wi th the woman behi nd the counter to de
li ver some baked goods to my home l ater on. I re
member gi vi ng her qui te expl i ci t di recti ons about
getti ng to my pl ace. (My associ ati ons when I awoke
went somethi ng li ke thi s, T he woman was a
mother substi tute. I was seeki ng from her the
comfort I never got from my own mother. . . .
Then, Dr. Wol berg is a mother substi tute too. Hi s
voice was comforti ng, sympatheti c; he was givi ng
me somethi ng I d wanted from my mother )
Thurs day or Friday night
I am in a cafeteri a. Apparentl y I am earl y, for I
am the onl y customer there. I wal k down the long
food tabl e, but I cant seem to remember anythi ng
on it except a l arge roast turkey, whi ch was al most
at the very end of the tabl e. When I come to the
turkey, I deci de that thi s is what I d like, but I
wonder if the cafeteri a peopl e wil l want to spoil its
appearance by carvi ng some off for me before the
other customers get there. Someoneand agai n I
have a vague feel i ng that it was a woman worker
assures me that it will be qui te all ri ght. (I dont re
member any associ ati ons to thi s dream. As I type it
now, it occurs to me that I want to be fi rst wi th
my mother? perhaps wi th Dr. Wol berg?but am
afrai d that i ts not ri ght that I shoul d be.)
Case 4
Perhaps the most i mportant use of dreams
in short-term therapy is, as has been indi cated,
the signals that they emi t poi nti ng to the be
gi nni ng devel opment of a negati ve transference
reacti on that, if unheeded, may expand to
bl ock or destroy progress in therapy. Where a
therapi st does not encourage the pati ent to re
port all dreams, the pati ent may forget or
repress them, and the only si gn the therapi st
may noti ce that thi ngs are not going well is
that the pati ents symptoms return or get
worse, that di sturbi ng acti ng-out behavi or ap
pears, or, worse, that the pati ent si mpl y drops
out of therapy. Where dreams are regul arl y re
ported, the therapi st will have avail able a sen
siti ve barometer that indi cates the oncomi ng of
an emoti onal storm. A pati ent in the mi ddl e
stages of therapy began comi ng late for ap
poi ntments. Onl y upon urgi ng did she report
the fol lowing dream:
Pt. I was asl eep on a desk or tabl e in your office. I
way l yi ng on my si de wi th my knees bent. Y ou
wal ked over to me. Y ou were a shadowy fi gure
that I coul d barel y see through closed lids. I
knew I shoul d wake up, but I was curi ous to
see what you woul d do and I l acked the wi l l to
awaken. Y ou touched me. I had been covered,
but you removed the cover and I remember
thi nki ng I hope I have a pretty sl i p on. At
first your touch was pl easant, sexual -l i ke, and
I felt rather gui l ty for not l etti ng you know I
was real l y awake. Gradual l y you began to turn
i nto a si ni ster fi gure. Y ou l ooked i nto my eyes
wi th a l i ght and sai d, T hats a lovely bl ue
eye. I barel y mumbl ed, I ts green, feeli ng
that if you di dnt know the col or of my eyes it
meant you di dnt know me. I real i zed wi th a
shock I di dnt know the col or of your eyes,
ei ther. Brown, I thought, but I wasnt sure.
T hen you sai d to me, What are the thi ngs
I ve tol d you? I started to mumbl e, Many
thi ngs. Y ou sai d, No, I have told you noth
i ng. I took thi s to mean that you are
absol utel y not responsi bl e for anythi ng I mi ght
do. These thi ngs made you seem si ni ster to me.
Y ou sl owl y began to change i nto another man
who seemed to be a derel i ct, and I knew I mus t
get up. I struggl ed to awaken myself, and I fi
nal l y succeeded. I ran to the door and ran out
of the room, but there were a lot of peopl e. I n
a mi rror there I saw an utter rui n I looked
80 years ol d and terri bl y ugl y and I beli eve
scarred. All the peopl e were ol d and ugl y. I t
was a vi l l age of di scarded useless, and hel pl ess
peopl e. A feeli ng of horror overcame me, and,
as I stared at that face, I tri ed to comfort
mysel f that it was onl y a ni ghtmare and I
woul d soon wake up, and I found it very di f
ficul t unti l I wasnt sure anymore if it was a
ni ghtmare or real .
I f i nal l y woke up from the dream so
fri ghtened that I wanted to wake my husband,
but I deci ded to try to cal m down. I fell asl eep
agai n and had a second dream. I dreamed I
had stayed up all ni ght wri ti ng a paper you
asked me to do. I started to bri ng it i nto the
room you tol d me to. I t was l ocked. I deci ded to
have some coffee and come back. I di d. T hi s
ti me your wi fe was in the room. She tol d me
who she was. I sai d I knew. T hen she tol d me
she was your daughters mother as though thi s
made her a fi gure of great i mportance and
di gni ty. T hi s made me feel gui l ty and gave me
the feel ing that I coul d not see you anymore.
She di dnt want me to and i n respect to her
sacredness as a mother I coul dnt.
Had I not become al erted to the begi nni ng
transference, whi ch certai nl y refl ected an
oedipal probl em, I am convinced that my
si ni ster qual i ti es woul d have become so
overwhel mi ng in her unconsci ous mi nd that
she woul d have di sconti nued therapy. As mat
ters stood, we were able to engage in fruitful
discussions fol lowing my i nterpretati on of her
dream.
Case 5
The following dream i l l ustrates the erupti on
of negati ve transference in a young man wi th a
probl em of uri nary frequency. Thi s occurred at
the tenth session and was rel ated to his havi ng
met a young lady wi th whom he made a date.
He had a penchant for meeti ng control l i ng
women who domi nated hi m and who finall y
frightened hi m off. T he uri nary symptom was
associated in his mi nd wi th lack of mascul i ni ty.
Our rel ati onshi p had been going al ong well
and the pati ent had been i mprovi ng, but at the
last session he spoke of the sl owness of his
progress. The dream that he rel ated to me in
the tenth session was in six parts:
Pt. (1) I met a fri end in a l aundramat. I tol d hi m
I was engaged and he wanted to see pi ctures of
my gi rl. I kept thumbi ng through a lot of
boyi sh pi ctures and the last one was a good
one, more femi ni ne. M y associ ati ons to thi s is
that the new girl is a physi cal ed teacher and I
wondered how femi ni ne she is. I do meet di f
ferent peopl e in the l aundramat I use.
(2) T he second dream was that a math pro
fessor was tryi ng to start my gi rl s car and he
coul dnt start it, but I coul d. [I had a f e e l i n g
here that he was being competitive with me
a nd was p u t t i n g me down f o r not m a k i ng him
we ll faster . ]
(3) T hen I was l ooki ng for shoes in a
wi ndow. I saw somethi ng I li ked. I went in,
and he di dnt have my size. T he shoes were
ni ce mascul i ne-l ooki ng ones. [ Was he really
saying here that he c o u l d n t f i t into a m a n s
shoes or th a t the storekeepe r who mi g h t be me
c o u l d n t help h i m ? Probably both.]
(4) I was wi th a barber and he punched a
hol e in my head and he wanted to cover it wi th
a toupe. I bel ieve I sai d, Nothi ng doi ng. I
was angry at hi m. [A p p a r e n t l y a n o t h e r refer
ence to m y ineffectuality a n d to his building
r e sentment t o war d me.]
(5) T hen I was wi th one of the ki ds I grew
up wi th. T here was a toi l et in the room. I was
wai ti ng for an opportuni ty to go. I deci ded to
sit down it woul dnt make me so sel f-con
sci ous standi ng there and uri nati ng onl y a few
drops. But he got up and wal ked out.
(6) T hen you were at di nner at my house.
Y ou had to go to the bathroom. Y ou opened up
the wrong door. T hen you went i nto the
bathroom and were away a l ong ti me. I
wondered if you had the same probl em I had.
I n di scussi ng his dream he stated that sitting
down on a toi let was an escape from his em
barrassment. Di d it mean, I asked, al so that it
was a femi ni ne gesture and a way of sayi ng
that he was not qui te a man? And di d he
believe that I could not hel p hi m achieve his
goals? T he dream, I insisted, poi nted out his
feel ings that I was ineffective. At thi s j uncture
I prai sed hi m for his abil ity to criti cize me,
and I asked hi m to associate to his feelings
about me. Thi s opened the door to his critical
atti tude toward his passive father for not doi ng
more for him. For the next two sessions we
worked on his negati ve transference; i nterest
ingl y, hi s uri nary symptom i mproved re-
markedl y. He was del i ghted al so that he could
act more aggressive toward his new girlfriend
than he had toward any other woman in the
past.
Case 6
I l lustrative of the use of dreams to select a
therapeuti c focus as well as a measure of
progress is the case of a young single woman of
30 who had been admi tted to a mental i nsti tu
tion after she had tried to commi t suicide. At
the end of 18 months of hospi tal i zati on she
was taken out by her parents, and I was asked
to see her in consul tati on wi th the object of
decidi ng who the best therapi st for her mi ght
be. Apart from a slight emoti onal dul l i ng, I
could find no acti ve evidence of schi zophreni a,
whi ch was the di agnosi s given her at the hos
pital. T he dream she reveal ed at the ini ti al i n
terview was the following:
Pt. I was on a date wi th a man and he proposed to
me. I was fri ghtened about goi ng to bed wi th
thi s man. T hen I saw myself suckl i ng at my
mothers breast. I felt nauseated and ran away.
I felt empty and hel pl ess. T hen I saw some
body hol di ng up two fi ngersone represented
mal e and the other femal e. Somebody came
al ong and took the mal e fi nger, and I was left
wi th the femal e finger. I was upset at bei ng
forced to give up bei ng a boy. I had to be a
gi rl. Thi s made me anxi ous.
The dream, whi ch I recorded but did not i n
terpret, gave me a clue as to her separati on-i n-
di vi duati on, dependency-i ndependency prob
lem, and I decided that this woul d be the dy
nami c focus in our therapy after we had
worked out the ti me in my schedule. I saw her
once weekly and I focused, whenever propi
ti ous, on her need for a mother fi gure, her fear
of functioni ng like a woman, and her probl em
of identity. After 6 months of therapy at the
twenty-fourth session she brought in the fol
lowi ng two dreams:
Pt. T he fi rst dream was that I was havi ng an af
fai r wi th a teacher I had i n hi gh school. (I had
a crush on thi s teacher when I was in school.)
My mother found out and was furi ous. She
wanted to kill me. She said I d rui n my life.
She pul l ed out a knife, and she told my brother
and fri ends to get kni ves. I was goi ng to get a
kni fe and kill her. I sai d i nstead, Y ou real l y
hate yoursel f and want to ki ll yoursel f. She
tri ed to ki ll hersel f by throwi ng hersel f under a
car. I grabbed her and sai d, Pl ease let me
hel p you. She cri ed and cri ed and sai d she
di dnt want to live. She sai d she felt gui l ty for
tryi ng to take my life. [The t h ought I had
a b out this dream was that she f e l t t hat g r o w i ng
up and a ss uming a h eter osexual role was f o r
bidden by her mother, or r athe r the introjected
m o t h e r w i t h i n herself. Could her suicidal a t
t e m p t be a desire to k i l l this introject?]
T he second dream was I was ri di ng on a
bi cycl e wi th my mother and brother. We
stopped at a house wi th peopl e I coul dnt
stand. Mother stayed there wi th a cousi n
J anet. My mother and my brother got on one
bicycle. I was on another bicycle. T hey kept
gi vi ng me di recti ons, and I resented that. Then
I was ri di ng al one in the country and went
over a cliff and di ed. [The p a t i e n t ad dedj I
seem to be in terror of my new i ndependence.
I ts li ke in the dream. Yet I feel a feel ing of
l i berati on. I know my rel ati ons wi th peopl e
since we began to tal k about dependence are
much better. I can get angry at my father and
brother and at mysel f for bui l di ng them up as
those who can take care of me.
For the next 10 sessions we worked on her
guil t feel ings and kil li ng fantasies in rel ati on to
her emergi ng i ndependence. I n the course of
thi s the fol lowing dream occurred:
Pt. I am al one in a car, dri vi ng all al one. I am
enj oyi ng it. I knew where to go. M y mother
smi l es at me and I am happy. [Her associ
ations f o l l o w ] Si nce comi ng to see you I feel
my acti vi ty is rel eased. L ast week I had a date
and I enj oyed myself. I know you feel I m
keepi ng mysel f in a box because of gui l t and I
know you are ri ght. As you say, i ts better for
me to make mi stakes and wal k by mysel f than
to have someone carry me.
T he pati ent hersel f spontaneousl y termi
nated therapy after the forty-first session. She
sent me an announcement of her marri age 11
months after this. I tel ephoned her to come to
my office for a fol l ow-up session. T he change
in the pati ent was stri ki ngher posture, her
poise, the confi dent manner in her speaki ng.
Apart from a few mi nor rifts wi th her parents,
there were no upsetti ng episodes to speak of.
She avowed bei ng happy and adj usted to mar
ri age, which she described as a gi ve-and-take
proposi ti on. A tel ephone fol l ow-up 5 years
after her termi nati on reveal ed that she had
given bi rth to a chil d and had made an ex
cellent adj ustment.
Case 7
The worki ng-through of a probl em in i den
ti ty through transference may be seen in
another case of a 32-year-ol d marri ed woman
wi th an obsessive personal i ty structure who
peri odi cal l y woul d get strong attacks of
depression and anxi ety. Duri ng these episodes
she became ri ddl ed wi th great doubts about
mi nor choices and woul d badger her husband,
J ohn, and her friends to make decisions for
her, whi ch she then woul d reject. An attracti ve
femi ni ne-appeari ng woman, she expressed at
the initi al i ntervi ew concern about who she
was and where she was headed. Duri ng the i n
terview I asked her to tell me about any past
dreams, and she stated she could not remember
her dreams. At the thi rd session she brought in
the following dream whi ch she had wri tten
down:
We were at a resortJ ohn and I and another
coupl e. I was attracted to someone there who
seemed to change from a man to a woman, to a gi rl
in her 20s. T here were endl ess detai l s about a car
ni val ni ght wi th ani mal s and all sorts of games. T he
ni ght before we were l eavi ng, thi s girl and I were
goi ng down the stai rs and tri pped. She stooped
down to hel p me. I grabbed her, pul l ed her down,
and ki ssed her (I was defi ni tely a mal e at thi s
poi nt). I put my tongue in her mouth. I was still on
the bottom and she was l eani ng over me, but I was
a man. She asked me why I hadnt let on sooner
that I cared for her. I told her it woul dnt work out
because of J ohn and it was j ust as wel l. I got up to
leave. I ran down the stai rs and said goodbye.
T hen I changed it to au revoi r.
She reported that she felt terri bl e after this
dream and that old fears of homosexual i ty
came up. Her associati ons were to the effect
that her sexual rel ati ons wi th her husband
(toward whom she bore a great deal of
hostil ity) had ceased. When he is unhappy
whi ch is most of the ti me I have to make the
first advances. But I refuse to because I dont
feel like it. I m not i nterested.
My i nterpretati on of the dream was to the
effect that she was strivi ng to achieve strength
and i ndependence through mascul i ni tythe
symbol of strength in our cul ture. We di s
cussed her anger at di scovering as a chil d the
fact that she lacked a peni s and her envy of
mal es for thei r sense of freedom and i nde
pendence. Al though she fantasied functi oni ng
li ke a mal e, she stated that there were no epi
sodes of homosexual i ty. She fell in love wi th a
young man whom she marri ed and bore a
chil d whom she cheri shed, but she conti nued to
be dissati sfied wi th herself as a woman, beli ev
i ng that somehow she was damaged and infe
ri or.
She developed a good rel ati onshi p wi th me,
and we conti nued to discuss her unhappy
mari tal uni on and her conflict in rel ati on
to the dependency-i ndependency i mbal ance.
Evidence of transference followed the first hyp
noti c session, whi ch was i ntroduced at the
si xth visit. T he fol lowing dream is an exampl e
of how a response to a therapeuti c techni que
(hypnosi s here) may reveal a pati ents struggl e
wi th resistance and how it hel ps the therapi st
to organi ze strategi es to deal wi th emergi ng
resistance.
Pt. I was in D r_________s office | her g ener al p r a c
titioner] then somehow I left and it was more
li ke a school bui l di ng. I was in my ol d publ i c
school. I was hesi tati ng about goi ng back to
school [Could she be i d e n t i f y i n g me with her
gener al p r a c t it i o n e r a n d g o i n g back to school
the tre atm ent with me?] T hen the doctor saw
me on the l andi ng and tol d me to come in.
T hi s somehow solved the probl em as it made
me feel wanted and di d not give me the feeli ng
I have when I have to make the overtures. He
tri ed to hypnoti ze me. [This establishes me as
the doctor in the dream.] I started to go under
deepl y, but I suddenl y caught myself. He tried
agai n. He touched my breasts. When I pul l ed
back, he got angry. I had the di sti nct feeli ng in
the dream that he touched me not out of any
desi re, but onl y to make me real i ze that I had
breasts j ust li ke any other woman and that I
was li ke any other woman no better, no
worse. T hi s atti tude of compl ete lack of put
ti ng me on a pedestal gave me all at once a
feel ing of freedom and a feel i ng of i ntense sor
row. I t was as though I was struggl i ng for my
ri ght to be di fferent, but at the same ti me I
real i zed that my struggl e was in a wrong di rec
ti on. He tri ed to hypnoti ze me agai n. Thi s
ti me there were tri cks i nvol ved, maki ng me see
col ored bal l s comi ng out of a bag and so forth.
My rati onal mi nd kept struggl i ng agai nst such
a possi bi l i ty, and even though I saw them, I
felt they real l y werent there. Agai n, I had thi s
feel i ng of our wil ls bei ng pi tted agai nst each
other. I wanted so much to love, but I coul dnt
seem to give up the struggl e.
My i nterpretati ons dealt wi th her resistance
to giving up the ki nd of i dentity that made her
feel safe, whi ch she, of course, could do if thi s is
what she wanted. I woul d like to hel p her, but
she had a ri ght not to change if she so wi shed.
At thi s poi nt the pati ent started cryi ng, and she
confessed being unhappy wi th the way she was,
but she was afrai d to change. At the ni nth
session she spoke of a dream that she had that
appeared to indi cate that she trusted me more
and was uti l i zi ng her rel ati onshi p wi th me as a
growth vehicle:
Pt. I had a dream of someone runni ng after me
and maki ng love to me in the sunl i ght. |H e r
associations were to the effect that later the
next m or ning she was reading J u n g ' s T he Un
di scovered Self. | Thi s gave me a wonderful
feel ing of compl eteness and a sense of sti mul a
ti on and peace at the same ti me. A feel ing of
wel l -bei ng so strong that I real l y di d not feel
that angry feel ing I usual l y have when J ohn
goes out. I real l y di d not mi ss hi m; even my
fear of bei ng al one was somewhat sti l l ed, not
compl etel y, but a great deal . I felt a wave of
strong sexual desi re and wi shed you were there
wi th me. I wanted to tal k to you about the
book. I thought it woul d be so pl easant to have
a cup of coffee wi th you, and I thought, al
though I supressed thi s thought, 1 wanted you
to make love to me. But it was a qui et feeli ng
wi th a feel i ng of softness, fl i rtati ousness, and
even a l i ttle sadness. Not li ke the i mage I
someti mes have of my maki ng love to you be
cause I want to see you aroused; I want to feel
some form of passi on from you j ust because
your constant cal mness seems a ki nd of rej ec
ti on. T hi s feel i ng has a great deal of hosti l i ty
in it, but the feel i ng I had at home was di ffer
ent.
Why do I feel the sexual i mpul se when I am
al one or when I feel my rel atedness to the total
worl d as when 1 looked in Brentanos wi ndow
and saw reproducti ons of some of the art ob
j ects I l ove? T he strength of the sexual i ty
fri ghtens me. I f I had been wi th a man in my
apartment, I do not thi nk I coul d have resisted
goi ng to bed wi th hi m. I n fact, the urge to
adul tery is very strong. I seem to want my sex
ual partner to ai d me in keepi ng thi s rel ated
ness to the worl d (to life, eterni ty, etc.). I know
that I cant now have a compl ete and satisfying
orgasm any other way. J ohns compl ete preoc
cupati on wi th hi msel f stands in my way so that
love maki ng becomes an eroti c epi sode onl y.
M y soul is not rel eased or nouri shed.
I n our discussi on we tal ked about her up
bri ngi ng, her i ntensel y close rel ati onshi p wi th
her mother, and the detachment of her father,
who was a somewhat shadowy figure in her
life.
Several sessi ons l ater she reveal ed thi s
dream:
Pt. I came to your office whi ch was somehow di f
ferent. I t had a bedroom. We wal ked i nto the
bedroom. Somehow we were on the bed and
we were ki ssi ng. Y ou were on top of me, and I
was happy to be in that posi ti on. I felt your
tongue in my mouth, and 1 put my hands
under your shi rt and felt your back. For a spli t
second, I had the fear that I woul d not find
your back mascul i ne feeli ng like, hut it was.
Y ou refused to go any further, expl ai ni ng that
if we di d, you woul d not be abl e to hel p me.
Y ou seemed sorry that it had gone that far,
and I began to be fri ghtened that it mi ght i n
THE USE OF DREAMS
189
fl uence our rel ati onshi p. However, I al so felt
qui te happy, and then you came in I saw that
it real l y woul d he all ri ght. T here was no real
change in the rel ati onshi p except that I felt
more femi ni ne and perhaps a li ttle gui l ty as
though I had seduced you. But I was real l y
qui te pl eased.
Among her associati ons was her statement,
My rel ati onshi p wi th J ohn that day was
easi er, and I felt as though I wanted hi m. She
avowed the need for a strong mal e fi gure in
her life to hel p make her feel feminine.
Therapy was termi nated agai nst her wishes
but at my insistence that it was necessary for
her to conti nue worki ng at her probl em by
herself. T he pati ent accepted this. Duri ng the
next few years she came in two ti mes because
of a bri ef obsessional episode when she could
not make up her mi nd in rel ati on to her con
ti nui ng career as a book edi tor and the school
ing of her chil d. No more than several sessions
were needed on each occasion to get her to
recogni ze that she was tryi ng to make herself
dependent agai n on an authori ty fi gure who
woul d treat her like a chil d. Her mari tal and
sexual adj ustment i mproved constantl y, and
the i mage of hersel f as a female became
increasi ngly consol idated.
Conclusion
Dreams, like conscious thi nki ng, are dy
nami cal l y motivated by urgent conscious and
unconsci ous needs. Because real i ty testi ng,
logic, and correct concepti ons of ti me and
space are more or less suspended in sleep and
because repressi on is l owered, the dreamer
may express basic wishes, conflicts, and fears
that one woul d not ordi nari l y permi t onesel f to
experi ence in waki ng life.
Dreams may thus serve not only as a revel a
tory screen for unconsci ous wishes and past
memori es, but al so perhaps more i mportantl y
as a way of reflecting present adapti ve and
probl em-sol vi ng acti vities, habi tual character
patterns, and the special ways an indi vi dual is
i nterpreti ng and copi ng wi th current si tuati ons
in the present. Duri ng therapy dreams are
parti cul arl y i mportant in (l ) identifying con
flicts and defenses toward provi di ng a dynami c
focus, (2) recogni zi ng what i mmedi ate envi ron
mental events are so si gnifi cant as to promote a
dream and what meani ng these events have for
the pati ent, (3) understandi ng what is goi ng on
from the pati ents standpoi nt in the rel ati on
shi p between the therapi st and the pati ent, (4)
detecti ng earl y resistances and transference di s
torti ons that potenti al l y can block progress in
treatment, (5) determi ni ng what progress the
pati ent is maki ng in therapy, and (6) provi di ng
a wi ndow into the pati ents views of future
probl ems and exi sti ng and l atent capaci ti es for
adaptati on.
I n worki ng wi th dreams the therapi st has a
tool appl i cabl e in all forms of short-term ther
apy that can lead to a better understandi ng of
a pati ents probl ems, to recogni ti on of the
qual i ty of the worki ng rel ati onshi p, and to
an overcomi ng of devel opi ng obstacles that
threaten the effectiveness of the therapeuti c
process.
CHAPTER 13
Catalyzing the Therapeutic Process
The Use of Hypnosis
I n therapy much ti me is consumed in copi ng
wi th resistances to the yiel ding of ego-syntonic
patterns. I t is tradi ti onal l y assumed that this
extended peri od is inevi tabl e as part of the
process of worki ng-through. There is, how
ever, some evidence that certai n expediences
may be empl oyed to catalyze progress. One
mode has a paradi gm in crisis si tuati ons dur
ing whi ch moti vati on has been created for
change that otherwi se woul d not have de
veloped. Usi ng this idea, some therapi sts at
tempt duri ng therapy to create mi nor crisis
si tuati ons for the pati ent by tactics such as ag
gressive confrontati on and other ways of sti r
ri ng up anxi ety. The object is to convince the
pati ent that pursui t of ones usual mode of be
havi ng is offensive to others and unpl easant for
oneself. In this way the therapi sts try to break
through resistances to producti ve change.
I n pati ents who are capabl e of countenanc
ing chall enge and confrontati on such methods
may prove successful. Unfortunatel y, where a
weak ego structure exists, where the pati ent is
hostil e to or excessively defensive wi th author
ity, or where negati ve transference preci pi tates
too readi ly, the rel ati onshi p will not sustain
the pati ent duri ng the tumul tuous readj ust
ment peri od. The pati ent will ei ther leave
therapy or show no response to the procedures
being used. Wi th such pati ents it is better to
empl oy an approach ori ented around a de
li berate mai ntenance of a positi ve rel ati onshi p.
A search for other strategems that can
hasten the therapeuti c process has yielded a
number of i nterventi ons that have, in the
opi ni on of those skilled in thei r use, proven to
be of special merit. Such vaunted catalysts are
subject, however, to vari abl es of therapi st per
sonal ity and pati ent response that can negate
and even reverse thei r influence. Among the
most commonl y empl oyed techni ques uti li zed
to accel erate treatment are hypnosi s, narco
anal ysi s, emoti ve rel ease strategi es, gui ded
i magery, behavi or therapy, Gestal t therapy,
experi enti al therapy, dream anal ysi s, famil y
therapy, and i ntroducti on of the pati ent into
an active group.*
Certai n ways of expedi ti ng insi ght have also
been helpful, for exampl e, ci ti ng specific epi
sodes from the treatment of other pati ents (of
course, anonymi ty is mai ntai ned) that in some
respects rel ate to the pati ents probl em. Thi s
may serve as a proj ecti ve techni que to cushi on
the pati ents anxi ety and hel p mai ntai n
defenses that mi ght otherwi se be shattered by
direct i nterpretati ons of the pati ents personal
reacti ons (A. Wol berg, 1973, pp. 185-234).
A nother method is the use of metaphors
through rel ati ng stories or anecdotes that i l lus
trate poi nts the therapi st wants to get across to
the pati ent (De L a Torre, 1972).
Therapi sts develop personal preferences in
the choice of catal yzi ng techni ques. These
general l y rel ate to thei r successes wi th the ma
j ori ty of pati ents. I n my own experi ence I have
found hypnosi s of great val ue, and I recom
mend it wi th no illusion that it can be helpful
to all therapi sts. It shoul d be experi mented
wi th to see if it blends wi th ones style of work
ing therapeuti cal l y.
* See Wol berg 1977, pp. 245-250, 685-740, and 761-
823 for a full descri pti on of these methods.
190
CATALYZING THE THERAPEUTIC PROCESS: HYPNOSIS 191
When to Use Hypnosis
Hypnosi s is parti cul arl y suited for the pa
ti ent who is paral yzed by resistance. Resi s
tance is embodi ed in overt or covert behavi or
patterns. Usual l y, the pati ent is unaware of
such maneuvers. Resi stance is parti cul arl y
obstructi ve when it blocks the special tech
ni ques that are empl oyed in psychotherapy.
Hypnosi s may hel p resolve such resistance and
enabl e the person to respond better to treat
ment.
Hypnosi s may be advantageousl y empl oyed
in the course of psychotherapy under the fol
l owi ng conditions:
When the Patient Lacks
Motivation for Treatment
Hypnoti c techni ques may be helpful in con
vincing an unmoti vated pati ent that he can
deri ve somethi ng meani ngful from treatment.
A pati ent may feel resentment toward those
who insist that he get psychological hel p; he
may be afraid of reveal ing secret or di sgusti ng
aspects of his life; he may feel di strust for the
therapi st or refuse to recogni ze an emoti onal
basis for his compl ai nts. These and other
obstructi ons that contri bute to the lack of i n
centive for therapy can usual l y be handl ed by a
skilled therapi st in the ini ti al intervi ews wi th
out recourse to hypnosi s. Occasi onal l y, though,
even skillful approaches do not resolve the pa
ti ents resistance to accepti ng help. At this
point, if the pati ent permi ts induction, hyp
nosis may provi de a positi ve experi ence that
significantly al ters recal ci trant attitudes.
For exampl e, a pati ent who had great
resistance to psychotherapy was referred to me
by an interni st. He suffered from uri nary fre
quency, whi ch had defied all medi cal i nterven
ti on and had become so seri ous that it
threatened his livelihood. He resented being
sent to a psychi atri st and announced to me that
there was no sense in starti ng what mi ght
prove to be a long and costly process when he
was not fully convinced that he needed it. I ac
cepted the pati ents negati ve feelings, but I
specul ated that his tension mi ght be respon
sible for at least some of his symptoms. I of-
ferred to show hi m how to rel ax so that he
mi ght derive somethi ng beneficial out of the
present session. He agreed, and I then i nduced
a li ght trance, in the course of whi ch I suggested
a general state of rel axati on. After the trance
was termi nated, the pati ent spontaneousl y an
nounced that he had never felt more rel axed in
his life and asked if he could have several more
sessions of hypnosi s. I n the course of hypnore-
l axati on I casual l y suggested to hi m that there
mi ght be emoti onal reasons why his bl adder
had become tense and upset, and I i nqui red
whether he woul d be i nterested in fi nding out
whether thi s was so. When he agreed, I gave
hi m a posthypnoti c suggestion to remember
any dreams he mi ght have wi thi n the next few
days.
He responded wi th a series of dreams in
whi ch he saw himsel f as a frightened person
escapi ng from si tuati ons of danger and being
blocked in his efforts to achieve freedom. Hi s
associati ons were about the democrati c ri ghts
of oppressed peopl e throughout the worl d and
the futil ity of expressi ng these ri ghts in the face
of cruel and uncompromi si ng di ctatorshi ps that
seemed to be the order of the day. When asked
how thi s affected hi m personal l y, living as he
did in a democrati c regi me, he sarcasti call y re
pli ed that one could be a pri soner even in a
democracy. Since his father had died, he had
been obli ged to take over the responsi bi l i ty of
looki ng after his mother. Not only did she
insist that he stay in her home, but she al so de
manded an account of all of his movements.
He real i zed that she was a sick, frightened
woman and that consequentl y it was his duty
to devote hi msel f to her comfort for her few re
mai ni ng years. These revel ati ons were the
turni ng poi nt at whi ch we were able to convert
our sessions into expl orati ons of his needs and
confl i cts. As he recogni zed hi s repressed
hostil ity and his tremendous need for personal
freedom, he real i zed that he hi msel f was
largely responsibl e for the condition that was
vi rtual l y ensl avi ng him. I t was then possible
for hi m to hel p his mother find new friends
and to move into a reti rement village. When
he resolved some sources of his deep resent
ments, his bl adder symptoms di sappeared com
pletel y. More significant was a growth in
asserti veness and self-esteem that i mproved the
qual i ty of his social rel ati onshi ps.
When the Patient Refuses to
Begin Therapy Unless Assured of
Immediate Relief of Symptoms
Symptoms may be so upsetti ng to the pa
ti ent that therapy will be refused unless there
is first a reducti on or removal of symptoms.
When symptoms are so severe that they create
physi cal emergencies, as in cases of persi stent
vomi ti ng, hi ccupi ng, or paral ysi s, the therapi st
may be abl e to restore function through sug
gestions in hypnosi s. After this the therapi st
may proceed wi th other psychotherapeuti c
techni ques. I n less severe cases, insistence on
symptomati c rel ief may be a tactic for demon
strati ng the therapi st as a sympatheti c person
concerned wi th the sufferi ng of the pati ent.
Hypnosi s wi th suggestions ai med at rel axa
ti on, tension control , and symptom reducti on
can create an atmosphere conducive to a thera
peuti c worki ng rel ati onshi p. Hypnosi s can also
expedite the l earni ng of new habi t patterns
through desensi ti zati on and recondi ti oni ng (be
havi or therapy).
A pati ent who came to me wi th an obses
sional neurosis compl ai ned of belchi ng and hic
cupi ng after meal s. Thi s caused her great em
barrassment and frequentl y forced her to skip
meals. She was so preoccupi ed wi th whether
or not her symptoms woul d overwhel m her
that she could scarcely enjoy food when invited
out to dine. Her symptoms forced her to seek
medi cal help, in the course of whi ch she was
referred to me. At the ini ti al intervi ew she
testi l y protested bei ng sent for psychi atri c
treatments, parti cul arl y in view of a past
unsuccessful psychotherapeuti c experi ence.
What she wanted, she insisted, was sufficient
rel ief from physi cal distress to enabl e her to
function at work and in her rel ati onshi p wi th
her famil y. I n li ght of her di sappoi ntment wi th
intervi ew psychotherapy, I suggested hypnosi s
as a possible way of hel pi ng her to achieve
some lessening of her troubl e. She agreed to
give it a trial . T he next five sessions were
spent in teachi ng her how to rel ax and how to
control her symptoms. Her response was dra
matic, and her atti tude toward me changed
from suspicion and hostil ity to friendly cooper
ati veness. She readi l y entered into a thera
peuti c rel ati onshi p, and once therapy had
started, there was no need for further hyp
nosis.
When the Patient has Such Deep
Problems in Relationships with
People that Therapy Cannot Get
Started
A good worki ng rel ati onshi p between pa
ti ent and therapi st is mandatory for any kind
of psychotherapy. Thi s is parti cul arl y essential
in therapy that tries to bri ng about modi fi ca
ti on of a personal i ty that is prone to anxiety.
Thi s type of personal i ty often feels great stress
when the therapi st probes for conflicts and
chall enges habi tual defenses. Wi th some sick
pati ents the proper worki ng rel ati onshi p may
never develop or may take many months to ap
pear because of such factors as fear of closeness
or intense hostil ity toward authori ty. Rel axa
ti on duri ng hypnosi s may resolve fears, reduce
hostil ity, and cut down the ti me peri od re
qui red for the devel opment of rapport. T he pa
ti ent often feels an extraordi nary warmth and
closeness toward the therapi st even after only
one or two hypnoti c sessions. A therapeuti c re
l ati onshi p may crystall ize under these ci rcum
stances, and it will then be possible to proceed
wi th psychotherapy wi thout hypnosi s.
One of the most severely di sturbed pati ents I
ever treated was a paranoi dal man who
upbrai ded me duri ng our fi rst session for my
delay in arrangi ng a consul tati on wi th him.
He was upset, he said, because he was i n
volved in liti gious proceedi ngs agai nst his busi
ness partners, who had presumabl y decei ved
hi m about thei r busi ness prospects when they
first induced hi m to buy a share of the com
pany. Another legal case was pendi ng agai nst
a nei ghbor who had in a lot adj oi ni ng his
house buil t a garage that the pati ent con
sidered an eyesore. But what he most desired
from the consul tati on wi th me was to de
termi ne the feasibil ity of hypnoti zi ng his wife
in order to obtai n from her the truth of her ex
act whereabouts duri ng an eveni ng when he
was out of town on business. He had carefull y
exami ned her tube of contracepti ve j el l y before
his departure and agai n upon his return. At
first he could see no difference, but he compul
sively returned to it, rumi nati ng about whether
he had not made a mi stake in his ori gi nal con
clusion about his wi fes innocence. For weeks
he had been subj ecti ng her to cross-exami na
tions, carefull y tabul ati ng contradi ctory re
marks unti l he had convinced hi msel f that she
was conceal ing the truth about a rendezvous
wi th her lover. T he poor woman, protesti ng
her innocence from the start, had become so
confused by his confrontati on that she des
peratel y tried to make up stories to cover ti ny
di screpanci es in her mi nute-by-mi nute account
of activities on the fatal evening. Wi th a sharp
eye for her inconsistencies, the pati ent had
seized on her fl ounderi ngs to trap her into an
admi ssi on of lying, whi ch then convinced hi m
all the more of her infidel ity. A fi rm beli ever in
the powers of hypnosi s, he chall enged her to
submi t to a hypnoti c rel ivi ng of the eveni ng in
questi on in his presence.
Upon fi nishi ng thi s account, the pati ent i n
qui red about my methods of trance inducti on
since he had been readi ng about the subject. I
vol unteered to demonstrate the hand-l evi tati on
techni que to hi m, and he cauti ousl y agreed to
be a subject. Before too long he entered into a
trance, duri ng whi ch I suggested that he woul d
soon begin to feel more rel axed, secure, and
self-confident. I f he visuali zed a happy scene or
had a dream about the most wonderful thi ng
that could happen to a person, he would
probabl y feel free from tension as well as ex
peri ence a general state of pl easure that woul d
make hi m happi er than he had ever been in his
life. After an i nterval of 10 mi nutes he was
brought out of the trance. Upon openi ng his
eyes, he reveal ed, wi th humor, havi ng had a
dream of lying on a hammock whi l e lovely
slave girls circled around hi m wi th baskets of
fruit. I suggested that he return in 2 days and
bri ng his wife if she wi shed to accompany him.
Duri ng the second session, whi ch was held
j oi ntl y wi th hi s wife, his wife tearful l y pro
clai med her innocence, whereupon the pati ent
petul antl y asked her to leave my office if she
was going to act like a baby. When she
promi sed to control herself, he requested that
she wai t for hi m in the recepti on room. He
then told me he had felt so well since his first
visit that he had decided that several more
sessions of hypnosi s woul d be val uabl e for his
i nsomni a. Hi s wi fes probl em could wai t, he
cl ai med, unti l he had heal ed his own nerves.
After this i ni ti ati on into therapy, he underwent
a number of sessi ons of psychotherapy wi th
and wi thout hypnosi s, duri ng whi ch we
worked on several probl ems that concerned
hi m. He ended therapy when he had achieved
a marked reducti on of his symptoms, an easi ng
of his tensions wi th his partners, and the rees
tabl i shment of a satisfactory rel ati onshi p wi th
his wife.
Another pati ent spent the first 3 months of
treatment wi th me in fruitl ess associ ati onal ex
pl orati ons. He protested that nothi ng was
happeni ng in regard to his symptoms or
anythi ng else. He did not have ei ther a
warm or hostil e atti tude toward psychother
apy. He appeared to resent any conti nued
questi oni ng concerni ng his feelings about me.
There was a consi stent deni al reacti on to my
i nterpretati ons. After I i nduced hi m to try hyp
nosi s, he was abl e to achieve a medi um trance.
From the very first hypnoti c session his en
thusi asm and energy increased. Hi s activity
and producti vi ty al so improved remarkabl y,
and we were abl e to achieve a good therapeuti c
result. Wi thout hypnosi s, I am convinced that
his detachment could not have been pene
trated.
When the Patient is Unable to
Verbalize Freely
When communi cati on is blocked, there can
be no therapy. Someti mes the usual unbl ocki ng
techni ques may fail to restore verbal communi
cati on. In such an event hypnosi s can often be
effective, al though the way in which it is used
will depend on the causes of the difficulty. The
mere induction of a trance may uncork expl o
sive emoti ons agai nst whi ch the pati ent had
defended by refusing to tal k in the waki ng
state. Catharti c rel ease in the trance may re
store normal verbal expression. I f the pati ents
silence is due to some resistance, it may be pos
sible to explore and resolve it by encouragi ng
the pati ent to tal k duri ng hypnosi s. I n speech
paral ysi s (aphoni a) resul ti ng from hysteri a
these techni ques may not suffice, and direct
suggestion may be needed to lessen or el i mi
nate the symptom. Speech disorders may be
treated and someti mes helped by lessening ten
sion duri ng the trance, and there may then be
a carryover into the waki ng state. When the
speech difficulty is caused by needs that forbid
the expression of pai nful sounds or ideas, an
explosive outburst duri ng hypnosi s may not
only rel ease the capaci ty to tal k freely, but will
also open up areas of conflict that can be bene
ficially explored.
A young woman, a severe stammerer, came
for therapy because of i ncapaci tati ng phobias.
Once she had establi shed rapport wi th me, she
expressed hersel f sati sfactori l y, but as we
began to exami ne her fantasies and dreams,
she experi enced so pronounced a rel apse in her
speech di sturbance that she was al most
inarti cul ate. She compl ai ned that whi l e she
could tal k better than ever before wi th her
friends, she could scarcely communi cate wi th
me. Since progress had come to a halt, I sug
gested hypnosi s as a way of hel pi ng her to
rel ax. She reacted to thi s suggestion wi th
anxi ety but, nevertheless, agreed to try. Dur
ing the process of deepeni ng the trance she
suddenl y broke down and cri ed fitfully. En
couraged to discuss what she felt, she clenched
her fists and shri eked, No, no! After expl od
ing into a coughi ng spel l, duri ng whi ch she
could hardl y catch her breath, she gasped over
and over that she was choking. At my sugges
ti on that she bri ng it up, she broke into a
torrent of foul l anguage, pronounci ng the word
shi t repeatedl y and spi tti ng wi th angry ex
citement. A few mi nutes of this frenzied be
havi or were followed by compl ai nts of exhaus
ti on. T hereupon she resorted to normal
speech, whi ch conti nued for the remai nder of
the session, even after she had been aroused.
Thi s performance was repeated in subsequent
sessions, al though the pati ent responded wi th
di mi ni shed fury. T he therapeuti c process
gai ned great momentum, and the young
woman was abl e to curb her stammer. The ex
peri ence opened the door to a discussi on of her
great concern over bowel activities. Thi s was
rel ated to extremel y ri gid toilet trai ni ng as a
chil d by an obsessive, overdi sci pl i nary mother
who made her feel guil ty and fri ghtened about
toi let activities. Feces, from earl y chi l dhood on,
were equated wi th poison and destructi on. Our
therapeuti c sessions were l argely concerned
wi th clarifying her mi sconceptions. As she de
veloped a more whol esome atti tude toward her
bowel functions, her general feel ings about
hersel f improved, and her speech difficul ty
practi cal l y di sappeared.
When During Therapy the Patient
is Unable to Engage in
Unrestricted Exploration
A pati ent may mai ntai n ri gid control when
he dreads psychol ogical areas of conflict that
may be exposed. He thus cannot permi t his
ideas to emerge freely and unrestrai nedl y in
the process of expl ori ng unguarded aspects of
his psyche. When the pati ent is blocked be
cause of resistance, hypnosi s may be a possible
sol uti on. Not onl y may it bri ng the pati ent into
contact wi th repressed emoti ons and thoughts,
but it also may hel p hi m to anal yze his blocks.
Thi s was true of a pati ent who had retreated
to a highl y structured and rigidly directed form
of verbal expression. Attempts to anal yze his
loss of spontanei ty produced little response.
After fl ounderi ng, wi th no i mprovement and
mere repetition of insigni ficant items, I i n
duced hypnosi s and encouraged the pati ent to
tal k about what real ly was botheri ng him. He
revealed that he had felt guil ty in the past few
weeks for havi ng masturbated in my office
bathroom after one of our sessions. He had not
wanted to tell me about this inci dent because
he knew it was not an adul t act. He then asso
ciated this acti on wi th havi ng been caught as a
child masturbati ng in his aunts bathroom.
Not onl y had he been repri manded and
warned by his aunt, but also his parents had
promptl y been told, T he physi ci an who re
ferred the pati ent to me al so frowned on his
masturbatory practices, classi fying masturba
tion as i di ots deli ght, whi ch is never i n
dulged in by a mature person. Reassured by
my handl i ng of these revel ati ons, the pati ent
was able to conti nue wi th his associati ons in
the waki ng state.
I n instances where there is a dearth of
dream materi al the pati ent may be trai ned to
dream in the trance or through posthypnoti c
suggesti ons duri ng normal sl eep. General
topics of specific topics may be suggested as the
dream content. Once this process is started, it
may be possible for the pati ent to conti nue
dreami ng wi thout hypnosi s. Hypnosi s can also
be used to restore forgotten el ements of
dreams, to cl arify di storti ons el aborated to di s
guise thei r meani ng (secondary el aborati ons),
and to help the pati ent expl ore by means of
dreams atti tudes toward peopl e and di sturbi ng
el ements in everyday life. Duri ng hypnosi s
spontaneous dreams may occur refl ecti ng
unconsci ous atti tudes, memori es, emoti ons,
and conflicts. Sometimes they reveal to the pa
ti ent the meani ng of the i mmedi ate hypnoti c
experi ence as well as di storti ons in rel ati onshi p
wi th the therapi st, caused by confusing the
therapi st wi th earl y authori ty figures.
The i mprovement shown by one of my pa
ti ents il l ustrates how val uabl e hypnoti c dream
i nducti on can be. T he pati ent came to me for
psychotherapy when he could find no rel ief for
severe rectal itching. He had tried every kind
of medi ci nal oral and injecti on treatment. Al
though we soon establi shed a good worki ng re
l ati onshi p, he was unabl e to remember his
dreams. I n the trance I suggested that he
woul d have a dream that woul d expl ai n his
rectal itching. He responded wi th an anxi ety
dream of a man wi th a huge peni s approachi ng
hi m from the rear. He was told to forget the
dream or recall any part of it that he wi shed to
remember after he had awakened. Upon open
ing his eyes, he compl ai ned -of tension, but he
did not remember his dream. He admi tted
some relief in his rectal itching. T hat same
ni ght he had a dream of ri di ng a rol ler coaster
wi th a mal e friend. Hi s dream suggested con
cerns about homosexual i ty. I n l ater dreams he
was able to countenance homosexual impulses
and to discuss them duri ng the session. Hyp
nosi s was responsi bl e for openi ng up a
repressed and repudi ated area of guil t and con
flict.
When the Patient Seems Blocked
in Transferring to the Therapist
Distorted Attitudes toward
Parental and Other Early Figures of
Authority
Chi l dhood experi ences, parti cul arl y rel a
ti onshi ps wi th parents and sibli ngs, by thei r
formati ve influence on atti tudes, values, feel
ings, and behavi or leave an indel ibl e i mpri nt
and affect the way the adul t responds not only
to other peopl e but al so to oneself. Because
some of the most i mportant formati ve experi
ences are forgotten, or remai n hazy, or are
dissociated from the fears and anxi eti es wi th
whi ch they were ori gi nal l y li nked, they subver-
sively influence faul ty ways of thi nki ng and act
ing. Some of the transference di storti ons may be
uncovered by hypnosi s, and thei r i nterpretati on
may bri ng the pati ent to a real i zati on that he
also responds in destructi ve and unnecessary
ways in many other si tuati ons. T he lesson
learned can serve as the basi s of new, more
whol esome atti tudes to present-day authori ty,
atti tudes that fortunatel y will in all likeli hood
make life more comfortabl e and productive.
A pati ent who came for therapy entered
easi ly into the hypnoti c state but became more
and more recal ci trant to suggestions. He had
al ways been submissive to his father (and l ater
to other mal e authori ti es). Al ong wi th thi s he
felt great i nner rage, turmoi l , and depression,
al though he was outwardl y calm. It seemed to
me that his enteri ng hypnosi s was a means of
pl easi ng me. Thi s was the customary role
wi th mal e authori ty, patterned after the way
he reacted to his father. For years, I hated
my father, he said. He coul dnt stand being
contradicted. I remember needi ng to lose at
cards del i beratel y so that father woul d not get
upset over my wi nni ng. I am never abl e to be
successful: it makes me too anxi ous. When I
i nterpreted to hi m the way that he was react
ing to me, he at first denied it. But then he ap
peared to see the li ght, wi th the result that he
chall enged me first by resisting hypnosi s and
finall y by mani festi ng a total i nabi l i ty to enter
the hypnoti c state, I accepted his refusal to
compl y, even encouraged it. At thi s phase the
pati ent experi enced dreams of tri umph. I ts
heal thi er to dream of feel ing love rather than
hate. For the first ti me, I real ize I loved my
father. I cri ed in my sleep. I felt my father
real ly loved me, but we had this wall between
us. I awoke feel ing I real ly loved hi m. Thi s
change in feel ing was accompani ed by an
abatement of symptoms and a capaci ty to
rel ate more cooperativel y. Soon the pati ent
was abl e to enter hypnosi s easily and wi thout
resentment, as a means of pl easi ng hi msel f
not me.
Another pati ent, experi enci ng frigidity, was
referred to me by her psychoanal yst for some
hypnoti c work. After the thi rd i nducti on she
told me that she felt the need to keep her legs
crossed duri ng the enti re trance state. So
ti ghtl y did she squeeze her thi ghs together that
they ached when she emerged from the trance.
Before the next i nducti on I i nstructed her to
keep her legs separated. As I proceeded wi th
suggestions, she became fl ushed, opened her
eyes, and excl ai med that she knew what was
upsetti ng her. I remi nded her of her grand
father, she sai d, who, when she was a small
chil d, had tossed her into bed and held her
close to his body on several occasions. She had
felt his erect peni s agai nst her body, and thi s
had both excited and frightened her. I t became
apparent that the hypnoti c experi ence repre
sented for her an episode duri ng whi ch she
hoped for and feared sexual seduction. Her leg
crossing was a defense agai nst these fantasies.
Conti nued trance i nducti ons wi th the pati ent
di mi ni shed her fears, and she then reveal ed be
ing abl e to have better sexual rel ati ons wi th
her husband.
Another pati ent, who suffered from peri odic
attacks of nausea, vomi ti ng, and gastroi ntesti
nal crises, was referred for hypnosi s after two
years of tradi ti onal psychoanal ysi s had failed
to relieve her symptoms. Because she tended to
shield herself from awareness of her probl ems
wi th strong repressi ons, I felt that trans
ference, whi ch had not developed si gnifi cantl y
duri ng her previ ous therapy, mi ght be i mpor
tant in hel pi ng her to gai n insi ght into her
probl ems. After she had been trai ned to enter a
medi um trance, I suggested that she woul d
dream of her feel ings about me. She failed to
dream; instead she had a hal l uci nati on consi st
ing of a pecul i ar taste in her mouth, whi ch she
described as bi ttersweet. Thi s taste persisted
for several hours after her session. T hat even
ing she had a ni ghtmari sh dream in whi ch a
woman, whose handbag bore the i ni ti als B.S.,
took a small boy into the bathroom to hel p hi m
to uri nate and wash up. She was unabl e to i n
terpret the dream. A trance was induced in
whi ch she recal l ed forgotten el ements of the
dream, namel y that the sexes of the two par
ti ci pants had changed as they had entered the
bathroom; the adul t had been a man, the child
a girl. T he next few sessi ons were spent di s
cussing a reacti on to me that the pati ent had
developed and that made her want to stop
treatment. She was posi ti ve that I resented her,
and she recounted several mi nor inci dents i ndi
cati ng to her that I did not have her best i nter
ests at heart. She was positi ve that I preferred
a young man whose sessions preceded hers be
cause I once had kept hi m late, thus overl ap
pi ng her time.
I n the trance that followed, she broke into
hysterical cryi ng, identifying me as her father,
whose ni ckname was Bing. (The i ni ti als B.S.
in the dream stood for Bing. Hi s last name
began wi th an S. B.S. apparentl y was li nked
to the bi ttersweet taste she had in her
hal l uci nati on.) He had been both father and
mother to her (changed from mal e to female in
the dream), had preferred her brother to her
(her reaction to the mal e pati ent whose hour
preceded hers), and had al ways remi nded her
that he regretted that she had not been born a
boy (her being brought into the bathroom as a
boy in the dream possibly indi cated that she
had fi nall y succeeded in achieving a mascul i ne
status). Thereafter, she experi enced strong sex
ual feelings toward me and shameful l y asked if
I did not have a preference for her among all
my other pati ents. From then on it was possi
ble to anal yze the ori gins of these feelings in
her rel ati ons wi th her father and to see that
some of her symptoms were associated wi th
fantasies of wanti ng to be a boy through ac
qui ri ng a penis. Hypnosi s succeeded rapi dl y in
al l owi ng us to understand what was behi nd
her difficulty.
When the Patient has Forgotten
Certain Traumatic Memories
Whose Recall May Help the
Therapeutic Process
I n some emoti onal states memori es may be
submerged. Because they constantl y threaten
to come to the surface, anxi ety and defensive
symptoms, whi ch bolster repressi on, affect be
havi or adversely. T he trance can be i nstrumen
tal in recal li ng the repressed experi ence, and
the exami nati on of the associated emoti ons
hel ps to el i mi nate debi l i tati ng symptoms.
One pati ent suffered from peri odic attacks of
shortness of breath, an affliction that resem
bled asthma. He was given a suggestion in
hypnosi s that he woul d return (regress) to his
first attack. I n a scene in whi ch he saw hi msel f
as a chil d of 3 standi ng in a snowdri ft on a
back porch, he described how he sl i pped and
fell into a hi gh snowdri ft, gaspi ng for breath as
the snow filled his nose and throat. Wi th
pani c, choki ng as he tal ked, he tol d of being
rescued by his mother and father. Thi s story
was verified by his parents as a true experi
ence. They were amazed that the pati ent re
membered the exact detai ls of the acci dent, and
they confi rmed that asthmati c attacks had
begun soon after thi s inci dent. It was then es
tabl i shed in therapy that i nterpersonal si tua
ti ons in whi ch the pati ent felt trapped caused
hi m to respond wi th the symptom of choki ng
for breath. Thi s pattern had ori gi nal l y been es
tabl i shed when he actual l y had been physi call y
trapped. Wi th thi s recogni ti on, the symptom
was markedl y all eviated.
When the Patient Seems to "Dry
Up" in Conversations, Being
Unable to Produce Any More
Significant Material
Peri ods of resistance may develop duri ng the
course of therapy characteri zed by an al most
compl ete cessation of activity. The pati ent will
spend many sessions in fruitl ess attempts at
conversati on; he seems to be up agai nst a bar
ri er that he cannot break through. Atti tudes of
di sappoi ntment and hopelessness contri bute to
his i nerti a unti l he resigns hi msel f to maki ng
no further efforts. He may even decide to
abandon therapy. When such ci rcumstances
threaten, hypnosi s may be tried to mobi li ze
productivi ty. A vari ety of techni ques may be
used, i ncl udi ng verbal i zi ng one's thoughts
wi thout restrai nt (free associ ati on) in the
trance, dream and fantasy sti mul ati on, mi rror
gazi ng, automati c wri ti ng, pl ay therapy, dra
mati c acti ng, regressi on and rel ivi ng (revivifi
cati on), and the producti on of experi mental
conflicts (Wol berg, 1964). The specific method
empl oyed is usual l y determi ned by the thera
pi sts experi ence and preference as well as by
the pati ents apti tudes in worki ng wi th one or
another techni que.
A pati ent who had been worki ng satisfac
toril y wi th me began to develop silences that
greatl y puzzled her since she had up to this
ti me been qui te garrul ous in her rambl i ngs.
When I try to thi nk, my mi nd goes bl ank,
she said. Nothi ng comes to me. After several
frustrati ng sessions, hypnosi s was i nduced, and
she was encouraged to tal k about her mental
meanderi ngs. She began to moan and cry.
Grief, grief. I ts all deathas if i ts all over.
I ts my father; he died of cancer, and I took
care of him. He keeps comi ng back. It chokes
me up. I ts as if i ts all happeni ng agai n. The
pati ent then revealed, expressi ng great feelings
of guil t, that whi l e she had nursed her father
duri ng his illness, she had experi enced tender
and then vol uptuous feelings for him. Duri ng
his illness she was able to have hi m all to
herself for the first time. Her mother was only
too will ing to let her take care of him. Sexual
excitement was strong duri ng this peri od, and
she harbored guil t feelings duri ng and after her
fathers death, scarcely dari ng to thi nk about
it. I 'm frightened. I know I felt guil ty about
my desi re to be close to my father. After he
died, I felt cold and detached. Maybe that is
why I can't feel anythi ng for men now. I
real ize I do this wi th all men, that is, I want to
baby them, take care of them. I had been tak
ing care of one man I know who got sick wi th
the flu. I sponge-bathed hi m and got so sex
uall y excited I could hardl y stand it. The
thought occurs to me that I woul d like to take
care of you too. I 'm so ashamed to tal k about
thi s. From this the pati ent stated she under
stood the reason for her guil t feelings and why
they were causi ng resistance to therapy. She
hersel f was abl e to i nterpret the transference to
me of her feelings for her father. From then on
she progressed satisfactorily in treatment.
When the Patient is Unable to
Deal with Forces that Block the
Transformation of Insight into
Action
T he mere devel opment of insight is not
enough to i nsure the correcti on of neuroti c at
ti tudes and patterns; it must be empl oyed
toward constructi ve acti on. Unfortunatel y,
there are often anxi eti es and resistances that
obstruct thi s process and bri ng therapy to an
incompl ete end. Hypnosi s is someti mes useful
in converti ng insightful percepti on into acti on,
and it can achieve thi s goal in a number of
ways. First, one may attempt by vari ous tech
ni ques to expl ore resistance to change, the pa
ti ent associ ati ng to fantasies or the dramati c
acti ng-out of certai n heal thy courses of acti on.
Second, posthypnoti c suggestions can be made
to the effect that the pati ent will want more
and more to engage in acti ons that are neces
sary and that are being resisted. Thi rd, role
pl ayi ng can be used, the pati ent dramati zi ng
vari ous si tuati ons in the present or future and
verbal i zi ng insights or fears to the therapi st.
Fourth, in somnambul i sti c subjects experi men
tal conflicts may be set up to test the pati ents
readi ness to execute necessary and desi rabl e
acts and to investi gate reacti ons to thei r com
pletion.
One of my pati ents, a man wi th a passive
personal i ty, had gai ned insight into some of
the roots of his probl em duri ng therapy; he
also real i zed the destructi ve consequences of
his fai l ure to be self-assertive. He wanted to
change but was paral yzed at knowi ng how to
begin. The best he could do was to fantasi ze
wal ki ng into his empl oyers office and boldly
aski ng for a promoti on. In his fantasy he was
rewarded wi th a hi gher posi ti on and a hand
some rai se in sal ary. But. he could not muster
the courage to face his empl oyer in real life.
and he expressed fears of bei ng turned down.
I n hypnoti c role pl ayi ng he took the part both
of himsel f and his empl oyer and vehementl y
discussed the pros and cons of his posi ti on.
However, he still could not get hi msel f to act.
Since he was abl e to develop posthypnoti c am
nesia, I decided to try to set up an experi men
tal conflict. I suggested that he imagi ne himsel f
aski ng for a promoti on. Then I told hi m to
forget the suggestion but, upon emergi ng from
the trance, to feel as if he had actual l y made
the request. T he first two attempts were fol
lowed by tension, headaches, and di scourage
ment. Thi s indi cated that the pati ent was not
yet prepared to take the necessary step for
ward. We, nonethel ess, conti nued discussion
and role pl ayi ng, and a thi rd experi mental
si tuation resul ted in a feel ing of elation and ac
compl i shment. The next day the pati ent spon
taneousl y approached his empl oyer and was
rewarded wi th success. Thereafter the pati ent
began to act wi th more assurance, and his
progress in therapy helped hi m to become
more positive in his general behavior.
When the Patient has Problems in
Terminating Therapy
Difficulties in endi ng therapy are someti mes
experi enced by pati ents who, havi ng been freed
of neuroti c symptoms, are afrai d of losing what
they have gai ned and suffering a rel apse.
Pati ents wi th dependent personal i ti es may
resist endi ng treatment wi th astoundi ng stub
bornness. Contrary to what mi ght be expected,
the adroi t appl i cati on of hypnosi s can help
some of these pati ents toward self-reli ance by
relieving thei r tension at poi nts where they try
to act independentl y. The pati ent may also be
taught self-hypnosis for purposes of rel axati on
and shown how to investi gate spontaneousl y
through dreams, fantasies, and associati ons
the probl ems that ari se dail y from demands to
adj ust to speci fic si tuati ons. I n thi s way
responsi bi l i ty is transferred to the pati ent
toward becomi ng more capabl e of sel f-determi
nati on. I nterval s between visits wi th the thera
pist are gradual l y prol onged. I n the begi nni ng
the pati ent may resort to dai l y sessions of self
hypnosi s because of anxi ety. But as more con
fidence is developed in the abil ity to survive
alone, sel f-hypnosis exerci ses become i rregul ar,
and finall y they are resorted to onl y when ten
sions cry for relief. I n many pati ents, however,
regul ar rel axati on exercises are an i mportant
part of adj ustment and may be prol onged i n
definitely wi th beneficial effect. I n thi s respect
a rel axi ng and ego-bui l di ng cassette tape may
be of help.
The si tuati ons just described are no more
than bri ef outl i nes of how hypnosi s may be ef
fective in psychotherapy and only suggest the
vari ous ways in whi ch the trance can be used as
an adj uncti ve catal yzi ng procedure. Si nce all
psychotherapy is a blend of the therapi sts i ndi
vidual personal i ty and techni ques, no two ther
api sts will operate identical ly. Each therapi st
has a parti cul ar phi l osophy about how peopl e
become neuroti cal l y ill and how they get well
agai n. I f a therapi st believes that unconsci ous
memori es and conflicts are the basis for all neu
rotic ai l ments, diggi ng will be indul ged to un
cover the emoti onal conflictual poison that has
accumul ated. Once it is rel eased, the psyche
will presumabl y heal. Freud and Breuer ori gi
nall y used hypnosi s in thi s way and scored
occasi onal success wi th some pati ents. They
recorded thei r fi ndi ngs in Studien uber
Hystene, the revol uti onary book that was a
precursor of psychoanal yti c theori es and meth
ods. Al though hypnosi s used in thi s way may be
i nstrumental in rel easi ng repressed memori es,
we now know that the maj ori ty of pati ents are
not helped by thi s process alone. I nteresti ng
and dramati c as are the results, addi ti onal tech
ni ques are necessary if we are to achieve lasti ng
benefit.
There are other therapi sts whose theories
about how peopl e become emoti onal l y ill i n
volve the concepts of faulty l earni ng and condi
ti oning. They use hypnosi s to rei nforce thei r
strategems of teachi ng thei r pati ents new pat
terns of habi t formati on, thi nki ng, and acti on.
200
A l though these behavi oral methods are
responsibl e for consi derabl e progress in the
treatment of some ai l ments, they are not suc
cessful in deal i ng wi th all probl ems. But
nei ther is any other techni que.
One of the most i mportant points to be
made about hypnosi s is that it can be helpful
as a catalyst i rrespective of the method of psy
chotherapy. Some therapi sts are not able to use
hypnosi s wi th any measure of success, ei ther
for personal i ty reasons or because of un-
resolvable prej udices. Thi s does not inval idate
hypnosi s as a procedure. Hypnosi s, like any
other area of speci ali zati on, requi res parti cul ar
abil ities and skills. Not every therapi st is able
to amal gamate hypnosi s wi th ones personal i ty
and techni cal trai ni ng.
I t shoul d be stressed agai n that hypnosi s and
any other catal yzi ng techni que must be used
i ntell igently wi thi n the context of a compre
hensi ve treatment pl an and wi th due regard for
l i mi tati ons. A ppl i ed i ndi scri mi natel y such
techni ques not onl y fail to serve a therapeuti c
purpose, but thei r ineffectiveness tends to di s
credi t them as worthwhi l e procedures and to
impede thei r acceptance. Used at strategi c
poi nts in psychotherapy, catal yzi ng methods
may facili tate progress. I n thi s way they can
add an i mportant di mensi on to the technical
skills of the psychotherapi st.
Case Illustration
T he fol l owi ng is the fourth therapeuti c
session wi th a mal e pati ent who came to treat
ment because of work probl ems and terri fyi ng
ni ghtmares of whi ch the pati ent had no
memory. These condi ti ons had existed for
several years, and after a peri od of psychother
apy wi th a psychoanal yst in the Mi dwest, he
had derived some benefit from the sessions.
However, he was unabl e to remember any
dreams or to associate freely. The session that
follows is the first one duri ng whi ch hypnosi s
was empl oyed. I t i l lustrates the use of vari ous
techni ques in hypnoanal ysi s for the purpose of
exposi ng a dynami c focus.
Pt. I am in good shape today, real l y, for no parti c
ul ar reason that I can thi nk of, and yesterday I
di dnt feel so good. I had a fi ght wi th my wife
where I came off very badl y.
T h. Shal l we go i nto that3
Pt. I was thi nki ng the last ti me that thi s has
degenerated i nto one session after another, my
compl ai ni ng about my wife. Y ou know, I mean
the materi al is all the same. When 1 thi nk
about it, 1 am real l y convi nced the troubl e is
wi th me, not wi th her. Not that she doesnt
have her troubl es, don't mi stake me; but I am
real l y convi nced if she had marri ed a man, in
every sense of the word, who real l y behaved as
one, that many of her diffi cul ti es and hosti l i ti es
woul d be erased.
T h. I f she marri ed a man? [Obviously the p a t i e n t
has doubts about his masculinity.]
Pt. I f she had marri ed a man you know what I
mean a forceful guy who real l y ran the roost
and her, who, wel l {pause).
T h. Y ou mean, she woul d then strai ghten out?
Pt. Yes
T h. So that the emphasi s woul d be on whether you
woul d like to be thi s ki nd of guy. Woul d you?
Pt. Yes. Yes. Yes.
T h. Do you thi nk you woul d li ke to be a forceful
guy?
Pt. Certai nl y. Wel l , I dont say that a man has to
be I dont mean he has to be bruti sh or stub
born or i nsensi ti ve or uni ntel l i gent or dul l . I
dont thi nk any of those thi ngs are necessary
j ust to be a wel l -adj usted man. Dont you
agree?
T h. Mm. All ri ght, if you sense that there is a
certai n lack in you, that shoul d be where we
di rect our therapeuti c effort.
Pt. Ri ght, I shoul d say so; I agree a hundred per
cent. T hat is exactl y my poi nt, that, you know,
I felt not much was accompl i shed l ast ti me,
that I had spent all thi s ti me tal ki ng about my
wi fe, what I sai d and what she sai d. What she
said is not as i mportant as what I di d about it,
or why the si tuati on ever got to the poi nt
where she woul d say such a thi ng. She is not
the pati ent, {pause)
T h. All ri ght, then what woul d you li ke to tal k
about?
Pt. Wel l , I had a ni ghtmare Tuesday ni ght, that
was the ni ght. I had no memory of it, except
when I woke up I thought I was choki ng; not
exactl y choki ng, but my throat was full of
phl egm, or somethi ng. I had never had that
one before, al though, as you know, I have
never been abl e to remember a ni ghtmare. [It
is quite possible, I feel at this point, that the
nightmare contains a core problem that he is
repressing. ]
T h. I t may be possi bl e to catch it, to have it repeat
itsel f and remember it in hypnosi s.
Pt. T hat woul d be fasci nati ng.
T h. We mi ght be abl e to revive it so that you wil l
be abl e to see the ki nd of ni ghtmare that you
repress, and maybe get some cl ues as to what
these ni ghtmares are all about. Now what was
thi s fi ght al l about? J ust tell me very rapi dl y.
Pt. V ery rapi dl y, l ast ni ght, as you know, our
house is i n a bi g turmoi l , wi thout a ki tchen
real l y; we have a temporary ki tchen, and so
forth. I took a nap before di nner, before we
went out to di nner l ast ni ght. We go out to
di nner al most every ni ght because we have no
ki tchen. I sai d, I actual l y am afrai d that I am
getti ng anemi c agai n, because I was, and she
sai d, Are you taki ng your medi ci ne? thi s is
pi l l s and stuffand I sai d to her, No, I am
not, because I dont have enough for l unch.
T he poi nt of it is, when I take thi s medi ci ne,
these pil ls, I have a ravenous appeti te; I have
to have for l unch a compl ete meal wi th po
tatoes and vegetabl es, the whol e damned thi ng.
Thi s was a cri ticism of her and she bl ew sky-
hi gh, and I felt lousy anyway, and I di d not
come up to scratch at all . T hat is what it was
all about. We went to di nner. Wel l , no, we
had a fi ght a hal f hour l ater. We came home.
She wanted to make love. I felt so l ousy, I was
real l y so ti red, sick, ti red.
T h. What day was thi s?
Pt. Oh, that was yesterday.
T h. T hat was yesterday?
Pt. T hat was yesterday, that was l ast ni ght.
T h. Thursday?
Pt. Yes.
T h. What events happened on the day precedi ng
your ni ghtmare?
Pt. Wel l , I came here.
T h. Y ou were here?
Pt. Y es
T h. Anythi ng el se?
Pt. No. I havent even done much work. I tri ed it.
I have a very difficult ti me worki ng. I tri ed
readi ng, a romanti c story, actual l y i n romanti c
terms. I t is about a woman who never thought
she had any charm but pl enty of character, and
a guy wi th tremendous charm who thought he
had no character. Thi s, as I say, i n fi ctional,
dramati c, romanti c terms are my wi fe and I.
Now, my wi fe, she had done a tremendous lot
for me, in many, many ways, tremendous ther
apy, and I actual l y have done a lot for her. She
l ooks di fferent. She wal ks i nto a room di ffer
entl y. She is an assured, attracti ve, charmi ng
woman. She is very wel l l i ked and admi red,
and she wasnt thi s when I met her.
T h. Y ou have real l y hel ped her a great deal in thi s
area.
Pt. Yes, and she hel ped me tremendousl y.
T h. Does she real i ze how much you have hel ped
her?
Pt. Yes, sure she does.
T h. She real i zes then thi s marri age has to go on?
Pt. Oh, yes; oh, yes. Actual l y thi s marri age wil l
go on, no matter what I say. T hi s marri age
basi cal l y, basi cal l y is a good marri age. We
need each other; we need each other very
much. We gi ve a lot to each other. I t has been
goi ng to pi eces a lot l atel y, but basi cal l y the
foundati on is good, I thi nk; I am not sure.
(laughs) I thi nk I am sure, (pause)
T h. All ri ght. Do you want to rel ax now?
Pt. Yes. Do you mi nd if I take my coat off? I ts
hot; i ts ti ght; and I thi nk I ll do better wi th it
off. (takes off coat.)
T he hypnoti c i nducti on process I will use is
hand levi tation. There are many methods of
trance i nducti on and a therapi st may empl oy
any of these, usual l y perfecti ng one techni que.
T he rel axati on method descri bed in the
chapter deal i ng wi th the maki ng of a rel axi ng
and ego-bui l di ng cassette tape I find is the
most sui tabl e techni que for most pati ents.
T h. Supposi ng you j ust l ean back; stretch yoursel f
out, and, for a moment, close your eyes and
begi n rel axi ng. Rel ax your forehead; purposel y
concentrate on your forehead, and your eyes,
and your face, and your neck, and your
shoul ders. L et your arms rel ax. Rel ax your
body. T hen bri ng your hands, the pal ms of
your hands, down on your thi ghs. Open your
eyes; watch your hands. J ust observe your
hands. Concentrate on everythi ng your hands
do; sort of focus all your attenti on on your
hands and keep all other sensati ons i n the pe
ri phery. Y ou may noti ce that your hands feel
heavy as they press down on your thi ghs.
Perhaps you noti ce the roughness of the tex
ture of your trousers on your fi ngerti ps and
pal ms. Y ou may noti ce the warmth of your
hands, or a little ti ngl i ng in your hands. Noti ce
whatever sensati ons there may be. Concentrate
your attenti on on your hands; watch your
hands. T he next thi ng you wil l noti ce as you
observe thi s over here, thi s ri ght hand, is that
very sl owl y your fi ngers will begi n to spread,
the spaces between the fi ngers will be wi der
and wi der.
T he spaces between fi ngers grow wi der, and
wi der, and wi der, j ust li ke that. And then you
begi n to noti ce that there wil l be a l i fti ng of the
fi ngers, slowl y. One of the fi ngers wil l start
l i fti ng from your thi gh, and then the rest of the
fi ngers wi l l fol low, and then the hands will
sl owl y begi n to lift and move strai ght up in the
ai r, movi ng, movi ng, and as they move, you
will watch them, fasci nated, as they move,
sl owl y, automati cal l y, wi thout any effort on
your part. T hen your hand moves up, up. I t
moves toward your face; eventual l y it will
touch your face, but onl y when it touches your
face wil l you be asl eep. [77i<? word sleep is
used only because it signifies the deepest kind
of relaxation. Obviously the patient will not be
asleep]. Y ou wil l get drowsi er and drowsi er,
but you wil l not fall asl eep, and you must not
fall asl eep unti l your hand touches your face.
And as your hand moves toward your face, you
get drowsi er, and drowsi er, and drowsi er, and
j ust as soon as your hand touches your face,
you wil l feel yoursel f dozi ng off and goi ng to
sleep, deepl y asl eep. Y ou are getti ng very ti red
now, very, very drowsy; your eyes are getti ng
heavi er and heavi er; your breathi ng is getti ng
deeper and automati c; you feel yoursel f getti ng
very, very ti red, very drowsy; your hand is
movi ng up, up, up toward your face. As soon
as it touches your face, you wil l be asl eep,
deepl y asl eep. Y ou wi l l be very, very ti red.
Everythi ng is fl oati ng off in the di stance. Y ou
are getti ng very drowsy, very drowsy, drowsi er,
drowsi er, drowsi er. Y our hand is movi ng up,
up, up, up, toward your face; it approaches
your face. Y our eyes wi l l soon close, and you
wi l l go deepl y to sleep; but do not fall asl eep
unti l your hand touches your face. Y our breath
i ng is getti ng deep; you are getti ng very ti red;
everythi ng is sl i ppi ng away i nto the di stance.
Y our eyes are shutti ng. Y ou are goi ng i nto a
deep, deep, deep sleep; you are very drowsy
now. Y ou are very ti red, very sl eepy. Y our hand
is comi ng toward your face; now it touches your
face. Now you are goi ng to sl eep, and you are
goi ng to stay asl eep unti l I give the command to
wake up. Y our sl eep is getti ng deeper, and
deeper, and deeper. [The pati ents hand
touches his face; his eyes close; and he is breath
ing deeply and regularly. ]
1 am goi ng to take your hand over here and
bri ng it down to your thi gh, j ust like this. Y ou
keep getti ng drowsi er, and drowsi er, and
drowsi er. L i sten careful l y to me. I am goi ng to
stroke your left arm, and your forearm and
your hand, and as I stroke them, I am goi ng to
count from one to five. Y ou wil l noti ce that as
I count, you get the feel i ng as if your arm has
become j ust as stiff and heavy as a board. As I
stroke it, the arm gets heavi er, and heavi er,
and heavi er. Y our arm is getti ng heavy and
stiff, heavy and stiff, heavy and stiff, j ust like a
board. T he arm is getti ng heavi er, heavi er,
stiff, stiff, stiff, stiff. One, it gets stiff and heavy
li ke a board. T wo, j ust as stiff as a board.
Three, stiffer and stiffer; the arm is getti ng
stiff. Four, stiff and heavy. Fi ve, stiff, heavy;
when I try to bend it, it wi l l resi st moti on. T he
harder you try to move it, the heavi er and stif
fer it becomes. It wil l be i mpossi bl e to rai se it
no matter how hard you try. However, when I
snap my fi ngers, when I snap my fi ngers, your
arm wil l rel ax, (pause, then sound of fingers
snapping) Now you can rai se your arm, if you
wi sh. (The patient lifts his arm slightly.)
Now, rel ax yoursel f all over and fall asl eep,
even deeper. Y our eyes are gl ued together,
very, very, very ti ghtl y gl ued together, as if
li ttle steel bands bi nd them together. T hey are
very ti ghtl y bound together. T he harder you try
to open your eyes, the heavi er your lids are. Fi
nal l y together, and you feel yoursel f dozi ng off,
goi ng i nto an even deeper sl eep. Y ou are getti ng
drowsi er, drowsi er, very ti red, very, very
sl eepy, (long pause )
L i sten careful l y to me. I am goi ng to stroke
your hand, and your forearm, and your arm,
and as I do that, it wil l become j ust as li ght as
a feather. As a matter of fact, it may start
swi ngi ng up in the ai r spontaneousl y; it wil l be
come so l i ght that it wil l al most automati cal l y
swi ng strai ght up in the ai r, j ust as l i ght as a
feather, strai ght up. I t fl oats around in the ai r
now, fl oats around i n the ai r, j ust as l i ght as a
feather. I t fl oats around in the ai r, j ust as l i ght
as a feather, unti l I snap my fi ngers. ( T h e p a
t ient easily lifts his arm a n d waves it.) T hen it
wil l sl owl y come down, sl owl y down. Now it
sl owl y comes down, ri ght down to your thi gh,
and you sli p off i nto a deeper sl eep, a deeper
sl eep. (T he arm comes d o w n . ) When I tal k to
you next, you wil l be still more deepl y asl eep.
(long pause )
Now, I want you to i magi ne yoursel f wal k
i ng outdoors. As soon as you see yoursel f wal k
i ng outdoors, rai se your left hand about 6
i nches. (H a n d rises.) Now bri ng it down.
A gai n vi sual i ze yoursel f wal ki ng outdoors,
rai se your left hand about 6 inches. (H a n d
rises.) Now bri ng it down. Agai n vi sual i ze
yoursel f wal ki ng outdoors on the street, and
see yoursel f enteri ng an al l ey between two
bui l di ngs. Y ou turn i nto the al l eyway and you
wal k sl owl y, and, as you do, on the ri ght-hand
side of the al l eyway you noti ce a pai l of water,
steami ng hot water. As soon as you see that,
rai se your hand about 6 i nches. ( H a n d rises.)
Good. Now bri ng it down. L i sten careful l y to
me. T ry now to test how hot that water is. See
yoursel f wal ki ng over to the pai l of water. Y ou
take your ri ght hand and pl unge it i nto the
water, and as you do, you get a sensati on of
scal di ng, of heat. As soon as you feel that, i ndi
cate it to me by your hand ri si ng about 6
inches. ( H a n d rises.) T he hand feels ti ngl y and
sensi ti ve and tender. I am goi ng to show you
how tender. I am goi ng to show you how
tender it is by poki ng it wi th a pi n.
As soon as I poke your hand wi th a pi n, it
may feel very, very pai nful and tender. I wil l
show you. Very, very pai nful , j ust li ke that.
(Patient wi thdr aws h an d . ) I n contrast, thi s
other hand is normal . ( T o u c h e d with a p i n ,
the h a n d does not w i t h d r a w . ) Now your hand
returns to normal sensati on. Now the left hand
is goi ng to start getti ng numb. I t is goi ng to
have a feeli ng, a pecul i ar feel ing, al most as if I
had i nj ected novocai n all the way around the
wri st. T hi s gi ves you a sensati on of numbness
that i ncreases to a poi nt where you get the feel
ing you are weari ng a stiff, heavy, l eather
glove. T here is a sense of feel i ng, but no real
sense of pai n, a sense of feel i ng, but no real
sense of pai n, a sense of feel i ng, but no real
sense of pai n. As soon as you feel your hand
growi ng numb and you have a sensati on as if
you are weari ng a stiff, heavy, l eather gl ove,
i ndi cate it to me by rai si ng your hand about 6
i nches. ( H a n d rises.) Good. Now bri ng it
down.
I am goi ng to poke thi s hand wi th a pi n,
and you wil l noti ce, in contrast to your ri ght
hand, whi ch is rather tender, that thi s left
hand wil l be numb; there will be no real pai n.
Y ou wi l l have a sensati on of feel ing, but no
real pai n. I wil l show you, no pai n even when
I poke it very deepl y, no pai n. Y ou noti ce the
di fference when I touch thi s hand over here
and the hand here. Y ou noti ce that, dont you?
Pt. Yes.
Th. Al l ri ght, now go to sl eep, more deepl y al seep.
When I tal k to you agai n, you wi l l be even
more deepl y asl eep, more deepl y asl eep, (long
pau se )
Now l i sten careful l y to me. Even though you
are asl eep, it wil l be possi bl e for you to tal k to
me j ust li ke a person tal ks i n hi s sleep. Y ou
wi l l be abl e to tal k l oudl y and di sti nctl y, but
you wi l l not wake up. I want you to i magi ne
yoursel f wal ki ng outdoors agai n, but thi s ti me
you wal k out i nto a courtyard and you see a
church, a beauti ful church, steepl e, spi re, and
a bell. As soon as you see the church, i ndi cate
it by your hand ri si ng. ( H a n d rises.) Good.
Now bri ng it down. Next you see the bell; the
bell begi ns to move; the bel l moves, and it
starts cl angi ng. Y ou hear the cl ang cl earl y. As
soon as you hear the bell cl angi ng, i ndi cate it
to me by your hand ri si ng about 6 inches.
( H a n d rises.) Now bri ng your hand down.
Y ou turn around from the courtyard, and
you go back to your home. Y ou wal k i nto the
l i vi ng room. Y ou go over to the radi o. Y ou
turn your radi o on, and you hear a symphony
orchestra Beauti ful musi c comes from the
204
radio. As soon as you hear it, indicate this to
me by your hand rising about 6 inches. (Hand
rises.) Good. Now bring it down. Can you
recognize the music?
Pt. Uh-huh.
T h. What was the music?
Pt. It is something by Bach.
T h. Good. Next, you decide to go to the theater.
You walk along the street. Then you notice a
theater; you have a hunch that you want to see
something in this particular theater, but you
dont know exactly what it is you want to see.
You dont even look at the billboard to see
what may be playing. You walk right into the
theater, down to the fourth row orchestra and
sit down. You look up and notice that the cur
tain is down. There are very few people in the
theater. You are rather curious as to what is
behind that curtain.
Pt. Uh-huh.
T h. As soon as you observe yourself sitting in the
theater, indicate it to me by your hand rising
about 6 inches. (Hand rises.) Good. Now bring
it down.
In your curiosity you notice that there is a
man with a gray suit, a tall young man, up
there on the platform. [To enhance identifica
tion, this person is of the same sex and attire
as the patient.] He seems to be peering behind
the curtain as if his patience has almost come
to an end and he would like to see what is go
ing on backstage. But as he turns around, you
notice that he has a horrified expression on his
face as if he has seen something horrible, about
the most horrible thing that could happen to a
person. As you observe that, you begin to
absorb some of that feeling. [This is a tech
nique of imagery evocation often useful in
many ways.) And you wonder what is behind
that scene. I am going to count from one to
five, and then snap my fingers. At the count of
five, as I snap my fingers, the curtain will sud
denly rise and you will see a scene that is what
this man saw, the most horrible thing that can
happen to a person, (counting to five, then
sound of fingers snapping) Tell me about it as
soon as you see it.
Pt. No, no (crying)-, no, no, no (crying)-, no, no,
no, no, no; I dont know; I dont know
(screams with anguish).
T h. Tell me.
Pt. I dont know; I dont know.
T h. What has frightened you?
Pt. Oh (crying), oh, no, no, no.
T h. The curtain is down.
Pt. Yes.
T h. Something frightened you.
Pt. Yes. (crying)
T h. The curtain goes down.
Pt. (crying) Oh, oh, oh.
T h. You saw something that frightened you.
Pt. I dont know; I dont know what I saw.
T h. All right, now listen carefully to me. I am go
ing to help you. Something frightened you;
something continues to frighten you all the
time, and we have got to liberate you from
that. You want to be liberated from that fright,
dont you?
Pt. Yes, yes, yes.
T h. You would like to get over that fright. That
fright makes you insecure. That fright may
hold the key to your trouble.
Pt. Yes, yes, yes, yes, to the nightmare.
T h. And when we uncover that fright and see what
it is and get it out of your system, get rid of it,
well solve your nightmares.
Pt. Yes, that will be good.
T h. Now listen carefully to me. You dont know
when this is going to happen. I am going to
help you. You want to be helped?
Pt. Yes, yes.
T h. All right, now listen to me. As you sit there,
the scene is going to change completely.
Instead of being a horrible scene, it will change
to a happy scene. You are going to notice the
same man peering behind the curtain again,
but this time when he turns around, he has a
happy expression on his face. The whole at
mosphere has changed. He feels very happy,
very contented. As you see this wonderful ex
pression on his face, you too feel a part of it.
You realize he has seen the most wonderful
thing that can happen to a person. You feel as if
it is about to happen to you. You watch that
curtain very closely. At the count of five, I will
snap my fingers and you will see the most won
derful thing that can happen to a person.
(counting to five, then sound of fingers snap
ping) As soon as you do, I want you to tell me
about it without waking up.
Pt. It is a play. No, no. (crying)
T h. It is a play?
Pt. No. It is a play (crying in an agitated way).
T h. It is a play?
Pt. I am not happyoh, oh. [Apparently the
nightmarish image is still with the patient,
neutralizing the happy scene.]
Th. You are not happy. The other thing bothers
you, doesnt it?
Pt. I dont know what is behind that curtain. I
dont know. I dont want to know. (crying in
anguish)
Th. You dont know?
Pt. No
Th. Listen carefully to me. You dont know what is
behind it, but you would like to know and get
rid of it?
Pt. Yes.
Th. I am going to try to help you now so you will
get rid of it once and for all. (Patient continues
crying.) Listen.
Pt. Yes, yes.
Th. I am going to count from one to five. At the
count of five, suddenly a number is going to
flash into your mind.
Th. The number will be the number of letters in
the word that holds the clue to what is behind
the curtain that frightens you. It may hold the
clue to what is behind the nightmare that
frightens you. As I count from one to five, a
number will suddenly flash into your mind as
if it has been etched out. That number will be
the number of letters in the word, the key
word, which contains a clue to this whole
thing.
Pt. Uh-huh.
Th. And the letters all taken together, unscram
bled, will give us the clue to the word that is so
significant, that has within it the core of your
problem. Do you understand me?
Pt. Yes, yes.
Th. Give me the first number that flashes in your
mind when I count to five. One, two, three,
four, five.
Pt. Eleven.
Th. Eleven. All right, now rapidly from one to five,
when I reach the count of five, a letter will
flash into your mind. Give me the letters,
regardless of the order. One, two, three, four,
five.
Pt. H.
Th. One, two, three, four, five.
Pt. P.
Pt. R.
Pt. M
Pt. I.
Pt. L.
Pt. E.
Pt. H
Pt. O.
Pt. A, m, nI dont know.
Th. I will do it again. One, two, three, four, five.
Pt. A. O.
Th. All right, now listen carefully to me. I am go
ing to count from one to five, and this time
when I reach the count of five, all these letters
will just scramble together and make a word
that will give you a clue. You understand me?
Pt. Yes.
Pt. Oh, oh, homophrile, homophrile.
Th. Homophrile? [77iir word, it was determined
later, was friend and lover of men, a
designation of homosexual. The patients
concern of his wife not being married to a man
is somehow related to the fear that he is a ho
mosexual. ]
Th. Now, you have a clue. You are going to have a
dream. The dream will not be too scary a
dream, but it will be a first step in coming to
an understanding of what this fear is. Do you
understand me? The dream will be the first
step.
Pt. Yes.
Th. It will have within it the essence of the word
that you just spelled out for me. As soon as you
have this dream, which may or may not be like
the nightmares you have, you will open your
eyes and wake up. As soon as you awaken,
everything will be blotted out of your mind. It
will be as if you are waking from a sound
sleep. Then what I will do is tap three times
on the side of the desk, like this. (three taps)
Wi th the third tap you will suddenly re
member the dream that caused you to wake
up. Do you understand me?
Pt. Yes.
Th. You will have a dream. The dream will con
tain a clue, and then, as soon as you have had
the dream, you will wake up. But you will blot
the dream from you mi nd, or it wil l be very
vague in your mi nd. Y ou wont remember, but
on the thi rd tap the whol e thi ng wi l l pop i nto
your mi nd. Do you understand me?
Pt. Yes.
T h. Go to sl eep and have a dream, and then wake
up. [The object in having the p a t i e n t repress
the dreams is to p ro t e c t him f r o m any associ
ated anxiety. T h e t apping signal may release
the dream i f the a n x i e t y is not too great.]
T h. ( Af t e r several m i n u t e s the p a t i e n t awak ens.)
How do you feel?
Pt. A li ttle ti red.
T h. A li ttle ti red. What are you thi nki ng about?
Pt. Wel l , wel l , I know I cri ed. But . . .
T h. Anythi ng el se? (pause a n d three taps)
Pt. Oh, yes, I was on that stage.
T h. Yes.
Pt. And onl y I came i ntoit wasthere was a
woman seated at a desk and she had her hai r
ti ed on top of her head, and the whol e thi ng
was so red, damask, a red house on the stage, a
sort of a whorehouse. T hi s woman I guess was
sort of a madame; and there is a pai nti ng by
Toul ouse-L autrec, that is who her face was.
She had a very sharp nose. Maybe it was one
of the entertai ners. Anyway, she was seated at
her desk, and thi s is on the stage, red l i ghts,
and I wal ked in and she gets up and greets me;
and she is an ol der woman, sort of, and she
begi ns to caress me. Onl y it gets too much,
cl utchi ng at my cl othes. And then about five
gi rls come out, and they begi n caressi ng me,
but then after thei r caresses started, they start
to bi te me, to attack me, to tear off my clothes.
I am surpri sed, a li ttle fri ghtened, turn al most
i nto harpi es actual l y, in the cl assi cal sense of
the word. I back away from them and back
away from them, and I fall over the footli ghts
i nto the orchestra pi t. T hat was the dream I
j ust had.
T h. I see.
Pt. T he whol e thi ng is red. Oh, boy, what di d I go
through today?
T h. Y ou seemed to go through pl enty.
Pt. I remember cryi ng, and I coul dnt stop. I
remember what I went through, actual l y. I re
member you told me to l ook behi nd that cur
tai n, and, you know, I coul dnt see behi nd it. I
dont know why I cri ed though. I was scared.
T h. Somethi ng scared you. Y ou have gotten a clue
as to what the essence of your ni ghtmares
mi ght be. I t is j ust the first cl ue, the first
breaki ng down of your repressi on. As we keep
at thi s, you shoul d gradual l y be abl e to lift
your repressi ons and become l i berated from
thi s monster that has you by the throat.
Pt. I cant expl ai n it to you. I dont know what
made me cry because I di dnt see anythi ng. I
know you sai d it was pl easant as I approached
that curtai n agai n. What made me cry, I have
no idea.
T h. M m, hmm.
Pt. I certai nl y had a strange experi ence.
T h. Do you feel you were in a trance?
Pt. I must have been. I t is a funny thi ng, I coul d
hear you, I knew what was happeni ng. I can
remember. I am sure I recal l the thi ng, and yet
there is no questi on that I was hardl y myself,
l ike in the cryi ng.
T h. I am sorry that it had to be as pai nful as it
was.
Pt. Strangel y enough, I cant expl ai n it to you. I
cant remember. I t was al most a rel ease.
T h. Yes.
Pt. And that is true.
T h. Uh-huh.
Pt. T he cryi ng, and it wasnt p a u s e ) .
T h. I t shoul d make you feel better, and it shoul d
possi bl y enabl e you to remember your dreams
or ni ghtmares. How do you thi nk you woul d
feel if a thi ng li ke your dream happened in
real i ty? Supposi ng you were to wal k i nto a
house and were greeted by these cl awi ng
harpi es who came at you and started teari ng at
your ski n? How do you thi nk you woul d feel
i n a si tuati on li ke that?
Pt. I was fri ghtened, fri ghtened; I wanted to get
out of the whorehouse.
T h. T here is a sexual ti nge to thi s?
Pt. Oh, yes, very defi ni tely; yes, very definitely.
T h. Do you remember anythi ng about l etters?
Pt. I remember all the l etters, but it di dnt come
out wi th anythi ng, di d it?
T h. Y ou came out wi th a group of l etters that start
wi th h-o-m-o.
Pt. I di dnt use al l the l etters, di d I ?
T h. Not all.
Pt. I am not very good at anagrams, but I wil l try
to fi gure out what thi s means.
At the next session the pati ent reported
another dream that he actual l y remembered,
the hypnoti c experi ence apparentl y havi ng re
solved the resi stance to dreami ng. A woman
weari ng a red gown descended a flight of
stairs. He noti ced wi th terror her exposed
pubi c area, whi ch consisted of an open gapi ng
mouth. As he watched, the woman changed
into a threateni ng ti ger wi th a fierce open
mouth. At this poi nt the pati ent began to di s
cuss his feelings about his mother, whom he
remembered as weari ng a red gown. He was
overprotected by his mother, his father havi ng
been an extremel y passive person who died
when the pati ent was young. He remembered
wi th guil t havi ng some vague sexual feel ings
toward her. When he marri ed, there were
some probl ems wi th i mpotence and sexual
indifference, but his wife wooed hi m out of his
apathy. But thi s seduction apparentl y opened
up a pocket of oedi pal anxieties. Occasi onal
homosexual fantasies were not acted out. I t is
interesti ng that he began to remember his
ni ghtmares whi ch were patterned after the
hypnoti c dream and deal t wi th his fears of
women. Soon he identified his wife in his
dreams. After a quarrel he woul d al most al
ways have a ni ghtmare that eveni ng. At
around the fifteenth session he started com
pl ai ni ng that his symptoms were not being
relieved as rapi dl y as he wi shed, and he associ
ated thi s wi th the fact that his father did not
hel p hi m much. T he transference el ements
were exposed in his dreami ng about me as be
ing ineffectual like his father. I i nterpreted his
transference feelings, and the i nterpretati ons
had a dramati c effect on hi m, enabl i ng hi m to
see how he was transl ati ng what had happened
before in the here and now. From thi s poi nt on
we were abl e to establi sh excel lent rapport. He
was abl e to rel ate spendi dl y to his wife and his
chi l dren, his work block di sappeared, and his
ni ghtmares vanished.
Hypnoti c i nducti on techni ques are il lus
trated in Chapter 15, whi ch deal s wi th the
maki ng of a cassette tape, as well as in the case
i l l ustrati on in thi s chapter. Other techni ques
may be found el sewhere (Wol berg, 1948).
Conclusion
I n most cases intervi ew psychotherapy will
proceed satisfactorily wi thout needi ng to resort
to catal yzi ng techni ques. However, when
certai n blocks to treatment develop or when it
is difficult to define a dynami c focus, measures
to resolve resistance or to accel erate progress
may be of value. Here a wi de range of methods
is avail able, i ncl udi ng confrontati ons, hyp
nosis, narcoanal ysi s, behavi or therapy, Gestal t
therapy, guided imagery, emotive rel ease strat
egies, experi enti al therapy, dream anal ysi s,
famil y therapy, and anal yti c group therapy.
Preference for techni ques is general l y de
termi ned by the therapi sts trai ni ng and ex
peri ence wi th certai n modal ities. Resistance, of
course, can also develop wi th these catal yzi ng
interventions, and the mani festati ons of re
sistance may serve as a dynami c focus, the
understandi ng and worki ng through of whi ch
may be of consequence for both symptom relief
and personal i ty change.
Certai n advantages accrue to the use of hyp
nosis as an accel erati ng techni que where (1)
incentives for i ntervi ew therapy are l acki ng,
(2) symptom rel i ef is an exclusive moti vati on,
(3) rapport is delayed in devel opi ng, (4) ver
bal i zati on is bl ocked or i mpoveri shed, (5)
dreams and fantasies are forgotten, (6) trans
ference arousal is deemed essential , (6) re
pressed memori es requi re recal l, (7) greater
acti vity is essential in the i ntervi ew, (8) little
materi al is forthcomi ng, (9) insight is not being
converted into acti on, and (10) when there are
probl ems in termi nati on. Hypnosi s al so
enhances the pl acebo effect i n therapy,
intensifies the force of suggestion, and opens
the fl oodgates of emoti onal catharsi s. Some
therapi sts may not be abl e to uti li ze hypnosi s
as an adj unct in therapy because they fear its
effects or are skeptical of its value. I n such
cases they may be more amenabl e to other ac
cel erati ng techni ques (Wol berg, 1977, pp.
761-833).
CHAPTER 14
Crisis Intervention
I n recent years a great deal of pl anni ng has
been conducted in the Uni ted States in an at
tempt to l ower the rate of admi ssi ons to mental
i nsti tutions, di mi ni sh the incidence of suici des,
qui et the outbreak of violence in the streets,
and in general reduce psychi atri c morbi di ty.
One of the mai n devel opments toward these
goals has been the evolvement of methodologi es
in the area of crisis i nterventi on. T he recogni
tion that crises are so common in the lives of
all people has encouraged the growth of wal k-
in cl i ni cs, psychi atri c emergency uni ts in
general hospi tal s, suicide preventi on hot-l i ne
tel ephone services, and a vari ety of other
facilities whose ai m is restori ng, in as few
sessions as possible, the psychological bal ance
of persons in states of emoti onal exci tement or
collapse.
What has become pai nful l y apparent is that
practical ly every indi vi dual alive is a potenti al
candi date for a breakdown in the adapti ve
equi l i bri um if the stressful pressures are suffi
ciently severe. A crisis may preci pi tate around
any i nci dent that overwhel ms ones copi ng ca
pacities. The crisis sti mul us itself bears little
rel ati onshi p to the i ntensi ty of the vi cti ms
reaction. Some persons can tol erate wi th equa
ni mi ty tremendous hardshi ps and adversity.
Others will show a catastrophi c response to
what seems like a mi nor mi shap. A specifically
i mportant event, like abandonment by a love
object, can touch off an explosive reacti on in
one who woul d respond much less drasti cal l y
to bombi ngs, hurri canes, cataclysmic floods,
shi pwreck, di sastrous reverses of economi c
fortune, and maj or accidents. The two i mpor
tant vari abl es are, first, the meaning to the i n
divi dual of the cal ami ty and, second, the f l e x
ibility o f on es defenses, that is, the prevai l i ng
ego strength.
T he i mmedi ate response to a si tuati on that
is i nterpreted as cataclysmic, such as the sud
den death of a loved one, a viol ent acci dent, or
an i rretri evabl e shatteri ng of security, is a
dazed shock reacti on. As if to safeguard
oneself, a pecul i ar deni al mechani sm i nter
venes accompani ed by numbness and detach
ment. Thi s defensive maneuver, however, does
not prevent the i ntrusi on of upsetti ng fantasies
or fri ghteni ng ni ghtmares from breaki ng
through peri odi cal l y. When thi s happens,
deni al and detachment may agai n i ntervene to
reestabl i sh a tenuous equi l i bri um, onl y to be
followed by a repeti ti on of fearsome rumi na
tions. I t is as if the i ndi vi dual is both denyi ng
and then tryi ng somehow to acqui re under
standi ng and to resolve anxi ety and guil t.
V ari ous reacti ons to and defenses agai nst
anxi ety may preci pi tate sel f-accusati ons, ag
gression, phobi as, and excessive i ndul gence in
alcohol or tranqui l i zers. Moreover, dormant
past conflicts may be aroused, marshal l i ng
neuroti c symptomati c and di storted charac-
terologic displays. At the core of thi s confound
ing cycle of deni al and twisted repeti ti ve re
memberi ng is, first, the mi nds attempt to
protect itself by repressi ng what had happened
and, second, to heal itself by reprocessi ng and
worki ng through the traumati c experi ence in
order to reconci le it wi th the present real i ty
si tuati on. I n an i ndi vidual wi th good ego
strength thi s struggl e usual l y termi nates in a
successful resol uti on of the crisis event. Thus,
fol lowing a crisis si tuati on, most peopl e are ca
pabl e after a peri od of 4 to 6 weeks of pi cki ng
up the pieces, putti ng themsel ves together, and
208
CRISIS INTERVENTION 209
resumi ng thei r lives al ong li nes si mi l ar to
before. Peopl e who come to a clinic or to a
pri vate practi ti oner are those who have failed
to achieve resol uti on of stressful life events.
I n some of these less fortunate i ndi vi dual s
the outcome is dubi ous, eventuati ng in pro
longed and even permanent cri ppl i ng of func
ti oning. T o shorten the struggl e and to bol ster
success in those who otherwi se woul d be
destined to a fai li ng adaptati on, psychotherapy
offers the i ndi vi dual an excel lent opportuni ty
to deal constructi vely wi th the crisis.
I n the psychotherapeuti c treatment of cri sis
si tuati ons (crisis therapy) the goal is rapi d
emoti onal reliefand not basic personal i ty
modi fi cati on. Thi s does not mean that we
neglect opportuni ti es to effectuate personal i ty
change. Si nce such al terati ons will requi re
ti me to provi de for resol uti on of i nner conflicts
and the reshuffl i ng of the i ntrapsychi c struc
ture, the most we can hope for is to bri ng the
pati ent to some awareness of how underl yi ng
probl ems are rel ated to the i mmedi ate crisis. I t
is grati fyi ng how some pati ents will grasp the
si gnifi cance of thi s associati on and in the post
therapy peri od work toward a betterment of
fundamental characterol ogi c di storti ons. Ob
viously, where more than the usual six-sessi on
l i mi t of cri si s-ori ented therapy can be offered,
the greater wi l l be the possibil ity of demon
strati ng the operati ve dynami cs. Y et where the
pati ent possesses a moti vati on for changeand
the exi sti ng crisis often sti mul ates such a moti
vati oneven six sessions may regi ster a sig
ni fi cant i mpact on the psychol ogical status
quo.
Variables Determining the Mode of
Crisis Therapy
Catastrophic Symptoms Requiring
Immediate Attention
Selection of techni ques in crisis therapy are
geared to four vari abl es (Wol berg, 1972). T he
first vari abl e we must consi der rel ates to
catastrophi c symptoms that requi re i mmedi ate
handl i ng. T he most common emergenci es are
severe depressi ons wi th strong sui cidal ten
dencies, acute psychotic upsets wi th aggressive
or bi zarre behavi or, intense anxi ety and pani c
states, excited hysterical reacti ons, and drug
and al cohol i c i ntoxi cati ons. Occasi onal l y,
symptoms are sufficiently severe to consti tute a
portentous threat to the i ndi vi dual or others,
under whi ch ci rcumstances it is essential to
consi der i mmedi ate hospi tal i zati on. Con
ferences wi th responsi bl e rel ati ves or friends
will then be essential in order to make provi sion
for the most adequate resource. Fortunatel y,
thi s conti ngency is rare because of the
avai l abi l i ty of modern somati c therapy. Consul
tati ons wi th a psychi atri st skill ed in the admi n
i strati on of somati c treatments will , of course,
be i n order. El ectroconvul si ve therapy may be
necessary to i nterrupt sui cidal depressi on or ex
citement. Acute psychotic attacks usual l y yield
to a regi men of the neurol epti cs in the medi um
of a supporti ve and sympatheti c rel ati onshi p. It
may requi re al most superhuman forebearance
to li sten attenti vel y to the pati ents concerns,
wi th mi ni mal expressi ons of censure or i n
credul i ty for del usi onal or hal l uci natory con
tent. Pani c reacti ons in the pati ent requi re not
onl y forti tude on the part of the therapi st, but
also the abi l i ty to communi cate compassi on
bl ended wi th hope. I n an emergency room in a
hospi tal it may be difficult to provi de the qui et
objective atmosphere that is needed, but an at
tentive sympatheti c doctor or nurse can do
much to reassure the pati ent. L ater, frequent
vi si ts, even dai l y, do much to reassure a
fri ghtened pati ent who feels hi msel f or hersel f to
be out of control.
Less catastrophi c symptoms are handl ed in
accordance wi th the prevai l i ng emoti onal state.
T hus duri ng the first stages of deni al and
detachment, techni ques of confrontati on and
active i nterpretati on of resistances may hel p to
get the pati ent tal ki ng. Where there is extreme
repressi on, hypnoti c probi ng and narcoanal ysi s
may be useful. On the other hand, where the
pati ent is flooded by anxi ety, tension, guil t,
and rumi nati ons concerni ng the stressful
events, attempts are made to reestabl i sh con
trols through rel axati on methods (like medi ta
ti on, autogeni c trai ni ng, rel axi ng hypnother
apy, and biofeedback), or by pharmacol ogi cal
tranqui l i zati on (Val i um, L i bri um), or by rest,
diversions (like social acti vities, hobbies, and
occupati onal therapy), or by behavi oral desen
si ti zati on and reassurance.
The Nature of the Precipitating
Agency
Once troubl esome symptoms are brought
under reasonabl e restrai nt, attenti on can be
focused on the second i mportant vari abl e in the
crisis reaction, the nature of the preci pi tati ng
agency. Thi s is usual l y in the form of some en
vi ronmental episode that threatens the i ndi
vi dual s security or damages the self-esteem. A
devel opmental crisis, broken love affair, rej ec
ti on by or death of a love object, violent
mari tal discord, persi sti ng del i nquent behavi or
and drug consumpti on by i mportant famil y
members, transportati on or i ndustri al and
other accidents, devel opment of an i ncapaci tat
ing or l i fe-threateni ng illness, cal ami tous fi
nanci al reverses, and many other provocative
events may be the tri ggers that set off a crisis.
I t is rare that the external preci pi tants that the
pati ent holds responsi bl e for the present trou
bles are enti rel y or even most i mportantl y the
cause.
I ndeed, the therapi st will usual l y find that
the pati ent parti ci pates acti vely in i ni ti ati ng
and sustai ni ng many of the envi ronmental mi s
fortunes that presumabl y are to bl ame. Yet
respectful li stening and questi oni ng will give
the therapi st data regardi ng the character
structure of the pati ent, the need for upsetti ng
invol vements, proj ecti ve tendencies, and the le
gi ti mate hardshi ps to whi ch the pati ent is
inescapabl y exposed. An assay of the exi sti ng
and potenti al i nner strengths in rel ati on to the
unavoi dabl e stresses that must be endured and
i dentification of remedi abl e probl em areas will
enabl e the therapi st better to focus the thera
peuti c efforts. Cruci al is some ki nd of cognitive
reprocessi ng that is most effectively accom
pli shed by i nterpretati on. T he object is to hel p
the pati ent fi nd a different meani ng for the
upsetti ng events and to evolve more adequate
ways of coping.
The Impact of the Family on the
Patient
T he thi rd vari abl e, the i mpact on the pa
ti ent of the fami l y system, is especi all y i mpor
tant in chi l dren and adol escents as well as in
those living in a closely kni t fami l y system.
T he i mpact of the fami l y may not be i m
medi atel y apparent, but a crisis frequentl y i n
dicates a col l apsi ng fami l y system, the end
resul t of whi ch is a breakdown in the identified
pati ents capaci ti es for adaptati on. Cri si s
theory assumes that the fami l y is the basic uni t
and that an emoti onal illness in any famil y
member connotes a di srupti on in the famil y
homeostasi s. Such a di srupti on is not al to
gether bad because through it opportuni ti es
are opened up for change wi th potenti al
benefit to each member. Tradi ti onal psycho
therapy attempts to treat the i ndi vi dual pati ent
and often relieves the fami l y of responsi bi l i ty
for what is goi ng on wi th the pati ent. Cri si s
theory, on the other hand, insists that change
must involve more than the pati ent. T he most
frequentl y used modal i ty, consequentl y, is
fami l y therapy, the object of whi ch is the
harnessi ng and expansi on of the constructi ve
el ements in the fami l y si tuati on. T he therapi st
does not attempt to hal t the cri si s by
reassurance but rather to uti li ze the crisis as
an i nstrument of change. Duri ng a cri sis a
famil y in distress may be wi l l i ng to let a thera
pist enter into the pi cture, recogni zi ng that it
cannot by i tsel f cope wi th the exi sti ng
emergency. The boundari es are at the start
fluid enough so that new consol i dati ons be
come possible. The famil y system pri or to the
crisis and after the crisis usual l y seal s off all
poi nts of entry. Duri ng the crisis, before new
and perhaps even more destructi ve decisions
have been made, a poi nt is reached where we
may i ntroduce some new perspecti ves. Thi s
poi nt may exist for onl y a short peri od of ti me;
therefore it is vital that there be no del ay in
renderi ng service.
Thus a crisis will permi t i nterventi on that
woul d not be acceptabl e before nor subsequent
to the crisis explosion. One deterent frequentl y
is the fami l ys i nsistentence on hospi tal i zati on,
no l onger being abl e to cope wi th the identified
pati ents upsetti ng behavior. Al ternati ves to
hospi tal i zati on will present themsel ves to an
astute therapi st who establi shes contact wi th
the famil y. Some of the operati ve dynami cs
may become starti ngl y apparent by l i steni ng to
the i nterchanges of the pati ent and the famil y.
The most i mportant responsi bi l i ty of the
therapi st is to get the famil y to understand
whac is going on wi th the pati ent in the exi st
ing setti ng and to determi ne why the crisis has
occurred now. Understandabl y there is a hi s
tory to the crisis and a vari ety of sol uti ons have
been tried. T he therapi st may ask hi msel f why
these measures were attempted and why they
failed, or at least why they have not succeeded
sufficiently. T he famil y shoul d be involved in
sol uti ons to be uti li zed and shoul d have an
idea as to the reasons for this. Assi gnment of
tasks for each member is an excellent method
of getting peopl e to work together and such
assi gnments may be qui te arbi trary ones. T he
i mportant thi ng is to get every member i n
volved in some way. Thi s will bri ng out
certai n resistances whi ch may have to be ne
goti ated. Trades may be made wi th the object
of securing better cooperati on. Since crisis i n
terventi on is a short-term process, it shoul d be
made clear that visits are li mi ted. T hi s is to
avoi d dependenci es and resentments about
termi nati on.
The Patient's Behavior and Its
Roots
T he fourth vari abl e is often the cruci al fac
tor in i nti ati ng the cri sis si tuati on. Unresol ved
and demandi ng chi l dhood needs, defenses and
conflicts that obtrude themsel ves on adul t ad
j ustment, and compul si vely dragoon the pa
ti ent into activities that are bound to end in
di saster, woul d seem to invite expl orati ons that
a therapi st, trai ned in dynami c psychothera
peuti c methodol ogy, may wi th some probi ng
be abl e to identify. T he abi l i ty to rel ate the pa
ti ents outmoded and neuroti c modes of behav
ing, and the ci rcumstances of thei r devel op
ment in earl y condi ti oni ngs, as well as the
recogni ti on of how personal i ty difficulti es have
brought about the crisis, woul d be hi ghl y de
si rable, probabl y consti tuti ng the difference be
tween merel y pal l i ati ng the present probl em
and provi di ng some permanent sol uti on for it.
Si nce the goal s of cri si s i nterventi on are
li mi ted, however, to reestabl i shi ng the precrisi s
equi l i bri um, and the ti me al l otted to therapy is
ci rcumscri bed to the mere achi evement of thi s
goal, we may not be abl e to do much more
than to merel y poi nt out the areas for further
work and expl orati on. Because crisis therapy
is goal li mi ted, there is a tendency to veer
away from insi ght therapi es organi zed around
psychodynami c model s toward more acti ve be-
havi oral -l earni ng techni ques, whi ch are di
rected at rei nforci ng appropri ate and di s
couragi ng mal adapti ve behavi or. The effort
has been directed toward the treatment of cou
ples, of enti re famil ies, and of groups of nonre
lated peopl e as pri mary therapeuti c i nstru
ments. T he basi c therapeuti c thrust is, as has
been menti oned, on such practi cal areas as the
i mmedi ate di sturbi ng envi ronmental si tuati on
and the pati ents di srupti ve symptoms, em
ployi ng a combi nati on of acti ve procedures like
drug therapy and mi li eu therapy. T he few
sessions devoted to treatment in cri sis i nterven
ti on certai nl y prevent any extensive concern
wi th the operati ons of unconsci ous conflict. Yet
a great deal of data may be obtai ned by tal ki ng
to the pati ent and by studyi ng the i nteracti ons
of the famil y, both in fami l y therapy and
through the observati ons of a psychi atri c
nurse, caseworker, or psychi atri c team who
visit the home. Such data will be hel pful in
crisis therapy pl anni ng or in a conti nui ng
therapeuti c program.
I n organi zi ng a conti nui ng program we
must recogni ze, wi thout mi ni mi zi ng the val ue
of depth approaches, that not all persons,
assumi ng that they can afford l ong-term ther
apy, are sufficientl y well moti vated, i ntrospec
tive, and possessed of qual i ti es of sufficient ego
strength to permi t the use of other than ex
pedi ent, workabl e, and goal -l i mi ted methods
ai med at crisis resol uti on and symptom relief.
Technical Suggestions
T he average pati ent appl yi ng for hel p
general l y compl ai ns about a di sturbi ng symp
tom such as tension, anxi ety, depressi on, i n
somni a, pani cky feelings, physi cal probl ems,
and so on. Associated life events are consi dered
secondary ci rcumstances even though it may
become obvious that they are the pri mary eti o
logical preci pi tati ng agencies. Someti mes the
pati ent recogni zes the i mportance of a trau
mati c si tuati on, such as separati on, divorce,
death of a famil y member, an acci dent, or fi
nanci al di saster, and will focus discussi ons
around pai nful associati ons to these. I n ap
proachi ng such a pati ent, empathi c l i steni ng is
the keynote. T he most that can be done duri ng
the first two sessions is to identify the key trou
ble areas, and perhaps reassure the pati ent
that there are ways of copi ng wi th the diffi
culty since others have also gone through si mi
l ar upsetti ng events and wi th proper therapy
have overcome them and even have gotten
stronger in the process. T he fol lowing is an ex
cerpt from an earl y i ntervi ew wi th a woman
suffering from a reactive depression.
Pt. I t al l seems hopel ess. I j ust cant seem to pul l
mysel f together after J ack left me. I keep fal l
i ng apart and cant i nterest mysel f in anythi ng.
Th. Y our reacti on is certai nl y understandabl e.
Why shoul dnt you feel i ndi gnant, hurt and
angry, and depressed. But you woul d li ke to
get over J ack, woul dnt you, and go on to be
happy agai n?
Pt. (pause) Do you thi nk thats possi bl e?
Th. I f I di dnt, I woul dnt be si tti ng here wi th you.
Other women have gone through si mi l ar deser
ti ons and have come out on top. A nd you can
too.
Pt. I d l i ke to start.
Th. We have started.
I n al l owi ng a pati ent to focus on his present
i ng probl em the therapi st must al ways attempt
to answer the questi ons Why now? Why did
the difficulty break out at thi s ti me? Di d the
pati ent in any way parti ci pate in bri ngi ng
about the crisis? Though the l atter may seem
obvious, the pati ent may not see thi s clearly,
but through i ntervi ewi ng and clarificati on he
may be hel ped to identify the sources of the
crisis and ones personal parti ci pati on in it.
I t is i mportant to be al ert to how the crisis
can be converted i nto an opportuni ty for
change. Apprai sal of the pati ents ego strength,
fl exibili ty, and moti vati on are helpful, though
thi s assay at first may not be enti rel y accurate.
T he pati ent when first appl yi ng for hel p is at
low ebb and may not present an opti mi sti c pi c
ture of l atent potential ities. These may fi lter
through l ater on as hope penetrates the
depressive fog in whi ch the pati ent is en
veloped.
As probl ems become clarified and identified
CRISIS INTERVENTION
213
through i ntervi ewi ng, the pati ent and the
famil y in fami l y therapy will better be abl e to
deal wi th such probl ems constructi vely. The
therapi st may someti mes do nothi ng more than
faci li tate venti l ati on of thoughts and feel ings
among the famil y members. Verbal i zati on and
communi cati on have great powers of heali ng.
The therapi st need not sit in j udgment over
what is being sai d nor al ways offer golden
words of advice. By keepi ng communi cati on
open, by aski ng the ri ght questi ons, one may
hel p the famil y to producti ve decisions that
will lead to probl em solving and resol uti on. I t
may be difficult at the start to get the fami l y
members to open up after years of wi thdrawal
and secret mani pul ati ons. A si mpl e i nvi tati on
like I believe you will all feel better if you
each tell me what is on your mi nd may get
the conversati onal process goi ng. I f none
starts, the therapi st may ask a perti nent ques
tion as an opener or make a si mpl e statement
such as I ll bet each of you feels worri ed
about what has happened. Why dont you each
tal k about thi s.
Some pati ents are extremel y concerned wi th
thei r physi cal symptoms that accompany or are
mani festati ons of anxi ety, and they may be
convinced, in spi te of negati ve physi cal fi nd
ings, that they have a termi nal disease. Where
there is a preoccupati on wi th these symptoms,
an expl anati on such as the fol lowing may help:
Th. When a person is upset emoti onal l y every part
of the body is affected. T he heart goes faster;
the muscles get tenser; headaches may occur;
or the stomach may get upset. Practi cal l y every
organ in the body may be affected. Fortu
natel y, when the emoti onal upset passes, the
organs wi l l tend to recover.
Shoul d the pati ent wonder why other peopl e
react less intensel y to troubl es than he does
and bl ame hi msel f for faili ng, he may be told
that he can do somethi ng about it:
Th. Chi l dren are born di fferent some are active,
some less acti ve. Y ou have a sensi ti ve nervous
system, whi ch is both good and bad; good be
cause you are a responsi ve person to even
nuances, but al so bad for you si nce you react
very acti vel y to stress and suffer a good deal .
Y ou can do somethi ng about thi s to reduce
your overreacti on to stress.
T he fol lowing is a summati on of practi cal
poi nts to pursue in the practi ce of cri sis i nter
venti on.
1. See the patient within 24 hours of the
calling for help even if it means cancel i ng an
appoi ntment. A cri sis in the life of an i ndi
vi dual is apt to moti vate one to seek hel p from
some outside agency that otherwi se woul d be
avoi ded. Shoul d such ai d be i mmedi atel y
unavai l abl e, one may i n desperati on expl oi t
spuri ous measures and defenses that abate the
crisis but compromi se an opti mal adj ustment.
More i nsidi ously, the incentive for therapy will
vani sh wi th resol uti on of the emergency. The
therapi st shoul d, therefore, make every effort
to see a person in crisis preferabl y on the very
day that hel p is requested.
2. At the i ni ti al i ntervi ew alert yourself to
patients at high risk for suicide. These are (a)
persons who have a previ ous hi story of at
tempti ng sui cide, (b) endogenous depressi on
(hi story of cycli c attacks, earl y morni ng
awakeni ng, loss of appeti te, retardati on, loss of
energy or sex dri ve), (c) young drug abusers,
(d) alcoholic femal e pati ents, (e) mi ddl e-aged
men recentl y wi dowed, divorced, or separated,
(f) elderly i solated persons.
3. Handle immediately any depression in
the above patients. Avoid hospi tal i zati on if
possible except in deep depressi ons where at
tempts at sui cide have been made recentl y or
the past or are seriousl y threatened now. Elec-
troconvulsi ve therapy is best for dangerous
depressions. I nsti tute anti depressant medi ca
ti ons (Tofrani l , Elavi l, Si nequan) in adequate
dosage where there is no i mmedi ate ri sk.
4. Evaluate the stress situation. Does it
seem sufficiently adequate to account for the
present cri si s? What is the famil y si tuati on,
and how is it rel ated to the pati ents upset?
What were past modes of deal i ng wi th crises,
and how successful were they?
5. Evaluate the existing support systems
available to the patient that you can uti li ze in
the therapeuti c pl an. How solid and rel iabl e
are certai n members of the famil y? What com
muni ty resources are avai l abl e? What are the
strengths of the famil y wi th whom the pati ent
will live?
6. Esti mat e the p a t i e n t s ego resources.
What ego resources does the pati ent have to
depend on, esti mated by successes and achieve
ments in the past? Positi ve copi ng capaci ties
are of greater i mportance than the prevai l i ng
pathol ogy.
7. Help the pati ent to an awareness of the
factors involved in the reaction to the crisis.
T he pati ents i nterpersonal rel ati ons shoul d be
revi ewed in the hope of understandi ng and
reeval uati ng atti tudes and patterns that get the
pati ent into difficulty.
8. Provide thoughtful, empathic listening
and s u p p o r tiv e reassurance. T hese are
essential to enhance the worki ng rel ati onshi p
and to restore hope. T he therapi st must com
muni cate awareness of the pati ents difficulties.
The pati ent shoul d be hel ped to real i ze what
probl ems are stress rel ated and that wi th
gui dance one can l earn to cope wi th or remove
the stress.
9. Utilize tranquilizers only where anxiety
is so great that the patient cannot make deci
sions. When the pati ent is so concerned wi th
fi ghti ng off anxi ety that there is no cooperati on
wi th the treatment pl an, prescri be an
anxiol yti c (Val i um, L i bri um). Thi s is a tempo
rary expedi ent only. I n the event a schi zo
phreni c pati ent must conti nue to live wi th
hostil e or di sturbed parents who fail to re
spond to or refuse exposure to famil y therapy,
prescri be a neurol epti c and establi sh a way to
see that medi cati ons are taken regul arl y.
10. Deal with the immediate present and
avoid probing o f the past. Our chief concern is
the here and now. What is the pati ents
present life si tuati on? I s troubl e i mpendi ng?
The focus is on any i mmedi ate di srupti ve
si tuati on responsibl e for the crisis as well as on
the correcti ve measures to be exploi ted. Hi s
torical materi al is consi dered only if it is di
rectly li nked to the current probl em.
11. Avoid exploring f o r dynamic factors.
Ti me in therapy is too short for this. Therapy
must be real i ty ori ented, geared toward prob
l em solving. T he goal is restorati on of the
precri si s stabil ity. But if dynami c factors like
transference produce resi stance to therapy or
to the therapi st, deal rapi dl y wi th the re
sistances in order to di ssi pate them. Where dy
nami c materi al is thrown at the therapi st,
uti li ze it in treatment pl anni ng.
12. Aim f o r increasing self-reliance and
finding alternative constructive solutions fo r
problems. I t is essential that the pati ent anti
ci pate future sources of stress, l earni ng how to
cope wi th these by strengtheni ng adapti ve
skills and el i mi nati ng habi ts and patterns that
can lead to troubl e.
13. Always involve the fam il y or significant
others in the treatment plan. A cri sis repre
sents both an i ndi vi dual and a famil y system
coll apse, and fami l y therapy is helpful to al ter
the famil y system. A famil y member or signifi
cant friend shoul d be assi gned to supervise
drug i ntake where prescri bed and to share
responsi bi l i ty in depressed pati ents.
14. Group therapy can also be helpful both
as a therapy in itsel f and as an adj unct to i ndi
vi dual sessions. Contact wi th peers who are
worki ng through thei r difficul ties is reassuri ng
and educati onal . Some therapi sts consi der
short-term group therapy superi or to i ndi
vi dual therapy for crises.
15. Terminate therapy within six sessions if
possible and in extreme circumstances no later
than 3 months after treatment has started to
avoid dependency. T he pati ent is assured of
further hel p in the future if requi red.
16. Where the pati ent needs and is moti
vated f o r fur ther help f o r purposes o f greater
p e r s o n a l i t y dev e l o p m e n t aft er the p r e c r i s i s
equilibrium has been restored, institute or
refer f o r dynamically oriented short-term ther
apy. I n most cases, however, further therapy is
not sought and may not be needed. Mastery of
a stressful life experi ence through crisis i nter
venti on itself may be followed by new l earn
ings and at least some personal i ty growth.
Common Questions About Crisis Intervention
What woul d you consi der a cri si s by defi
ni ti on?
What constitutes a crisis varies in definition.
Some restrict the definition to only violent
emergencies. Others regard a crisis as reactions
to any situation that upsets the adaptive bal
ance. M any consider that any individual ap
plying for help is actually in some state of
crisis.
How far back was cri si s i nterventi on or
gani zed as a structured techni que? Are
there useful readi ngs?
Eric L indemann (1944) was among the first
to recognize the value of crisis intervention in
his work with the victims of the Coconut
Grove (Boston) fire disaster. T he organization
of emergency services in hospitals and commu
nity mental health centers to help persons un
dergoing critical adaptive breakdowns has con
tributed a body of literature out of which may
be mined valuable ideas about short-term in
tervention (Butcher & M audal , 1976; Caplan,
1961, 1964; Coleman & Zwerl i ng, 1959;
Darbonne & Allen, 1967; Harri s et al, 1963;
J acobson, 1965; J acobson et al, 1965; K alis et
al, 1961; M orl ey, 1965; Rusk, 1971; J .
Swartz, 1971).
Can one appl y the pri nci pl es of cri si s i n
terventi on to condi ti ons other than emer
genci es?
Emergencies constitute only a small propor
tion of the conditions for which people seek
help. Crises for the most part are of a lesser
intensity, but, nonetheless, are in need of im
mediate services to insure the highest degree of
therapeutic effectiveness.
Are one-sessi on contacts for cri si s i nter
venti on of any val ue?
Very much so, but most patients will re
quire more sessions for an adequate work-up,
institution of treatment, and follow-up. T he
average number of sessions is six; sometimes a
few more sessions are given.
Are communi ty mental heal th concepts of
any use i n cri si s i nterventi on?
Drawi ng on community mental health con
cepts is considered by some to be of inestimable
help in crisis intervention (Silverman, 1977),
particul arly when the goal is a servicing of
si zabl e popul ati ons. Here a publ i c heal th
orientation employing systems theory and an
ecological point of view may reduce the inci
dence of future crisis among target popula
tions. I dentification of potential users of men
tal health services, exploration of the kinds of
problems that exist, and an assay of available
support systems and service providers are im
portant in planni ng educational programs as
well as in fostering political activity to meet
existing needs.
I s there any way of sol vi ng the wai ti ng-
l i st probl em, whi ch i n many cl i ni cs pre
vents seei ng cri si s pati ents i mmedi atel y?
How to reduce waiti ng lists is a problem in
most clinics. Converting long-term therapeutic
services to short-term services and the use of
group therapy are often helpful. Some innova
tive programs have been devised to deal with
this situation, for example, the screening eval
uation technique described by Corney and
Grey (1970) that allows in all cases an im
mediate access to professional help, eliminating
the waiting list and serving as the first step in
a crisis-oriented program.
What has the experi ence been wi th wal k-
i n cl i ni cs as to the ki nds of pati ents who
seek cri si s i nterventi on?
T here is general agreement on the need for
a flexible policy of admitting pati ents for crisis
therapy without exclusion irrespective of diag
nosis, age, and socioeconomic status. Citing
thei r experience in operating the Benjamin
Rush Center, J acobson et al (1965) list some
interesting statistics. A bout one-third of the
patients were diagnosed psychoneurotic, one-
thi rd personality disorders, one-fifth psychotic,
and somewhat less transient situational dis
orders. A pproximately 15 percent had mainly
acute problems, and 63 percent had chronic
problems with acute difficulties superimposed.
I n the first year and one-half of operation,
56.6 percent of patients saw thei r therapist for
less than four sessions, almost one-half having
one session. Only 1.8 percent had more than
six visits. T he improvement rate was estimated
at two-thirds of those treated. M ore data on
this question may be found in Chapter 1,
Models of Short-term T herapy.
Dont soci al caseworkers do a good deal
of cri si s i nterventi on i n soci al agenci es?
Crisis therapy is often appropriately man
aged by trai ned social workers, and its
theoreti cal concepts as conceptual i zed by
L indemann (1944) Caplan (1961), and others
are compatible with general social work theory
(Rapaport, 1962). I n many cases social case
work by itself is more adequately designed for
certai n probl ems than psychi atry. T yhurst
(1957) has remarked that turning to the psy
chiatrist may represent an impoverishment of
resources in the relevant social environment as
much as an indication of the type of severity of
disorder.
I s behavi or therapy ever used i n fami l y
therapy for cri si s?
A wide variety of techniques have been used
many of them behaviorally oriented, for ex
ample, feedback, modeling and role playing,
rehearsal, and reciprocal reinforcement (Eisler
& Herson, 1973). V ideotape replays are also
used showing interactive sequences.
What team members are best i n cri si s i n
terventi on?
I n a clinic setup a team approach is ideal. A
good team for the handling of emergencies is a
psychiatric nurse, a psychiatrist, and a psy
chiatric social worker who have had traini ng
in emergency psychiatry and crisis interven
tion. A multidisciplinary team can also include
psychologists and members of other disciplines,
such as rehabi li tation workers, provided they
are trained to work with people in crises.
Has anythi ng been done wi th cri si s i nter
venti on groups, and are there any l eads as
to techni que?
Some work has been done with crisis i nter
vention in a group setting (Berlin, 1970;
C rary, 1968; Stri ckl er & A llgeyer, 1967;
T rakas & L loyd, 1971). At the Benjamin
Rush Center-V eni ce Branch (a division of the
L os Angeles Psychiatric Service) crisis group
therapy is instituted with walk-in patients.
T he groups are open-ended and heterogeneous
(M orley & Brown, 1969). T he format allows
one individual pregroup interview followed by
five group sessions. Excluded from group ther
apy are serious suicidal or homocidal risks
and overt psychoses. At the first group session
the pati ent is asked to tell the group what
brought him to the clinic. T he therapist en
courages the pati ent to discuss the preci pitat
ing factor, the events of the crisis and what
measures have been taken to solve it. T he
group explores al ternate coping measures.
Group support and the expression of opinions
are often helpful. Unlike traditional group
therapy there is no analysis made of the group
process. M ost of the time is spent focusing on
each individuals presenting problem. A go-
ing-around procedure is employed to give
each person a chance to talk. Transference i n
terpretation is minimized due to the lack of
time. I n reviewing results with 1,300 patients
it is claimed that a number of advantages are
available to a crisis group as compared to indi
vidual therapy. Group support and reassur
ance have been valuable. Social relationships
have developed between the members and good
alternate coping measures seem to be more pa
latable to a pati ent when offered by a member
who comes from the same subcultural milieu
with knowledge of problems and defenses ex
ploited within the culture that are better
known to the group members than to the ther
api st. Expressi on of si gni fi cant feel ings is
greater in the group than in i ndi vi dual
therapy. T he forces of modeling and desensiti
zation are also more potent. One disadvantage
is the greater difficulty of keeping discussions
in focus.
I s it possi bl e to sel ect techni ques i n cri si s
i nterventi on that are speci al l y sui ted for
certai n pati ents?
Some attempts have been made to correlate
responses to stressful events with the character
structures of the victims (Shapiro, 1965) and
then to choose techniques best suited for char
acter styles. Horowitz (1976, 1977) has out
lined the various ways that hysterical, ob
sessional, and narcissistic personalities respond
to stress as a consequence of thei r unique con
flicts, needs, and defenses. F or exampl e,
preferred techniques in the hysteric are or
ganized around dealing with impediments to
processing; in the obsessive, with methods that
support maintenance of control and substitu
tion of realistic for magical thinking; in the
narci ssi sti c personal i ty, wi th intervi ewi ng
tactics that cautiously deflate the grandiosity of
the pati ent and at the same time build up self
esteem.
I n many cases, however, it is difficult, par
ticularly in severe crises, to delineate sharply
habitual personality styles that would make
preferred techniques possible since the pati ent
may be responding with emergency reactions
that contaminate or conceal his basic patterns.
All that the therapist may be able to do is to
try to help the pati ent develop a clearer idea of
the stress incident and its meaning to him,
with the hope of helping him understand his
defensive maneuvers. T he pati ent is en
couraged to put into words his feelings and at
titudes about the traumatic incident and its
implications for him. Support, reassurance,
confrontation, interpretati on, and other tech
niques are utilized in relation to existing needs
and as a way of counteri ng obstructi ve
defenses. T he aim is to put the pati ent into a
position where he can embark on a construc
tive course of action in line with the existing
reality situation, hoping that he will accept the
therapi sts offerings irrespective of his per
sonality style.
Doesnt a short peri od of hospi tal i zati on
provi de a breathi ng space for the pati ent
i n a crisi s?
Hospitali zati on should be resorted to only as
a last resort recognizing that it will solve little
in the long run. I ndeed, it will probably be
used by the family as an escape from facing
thei r involvement in the crisis and from al ter
ing the family climate that sponsored the crisis
in the first place.
Si nce cri si s i nterventi on is a ki nd of hol d
i ng operati on to defuse a cri ti cal si tua
ti on, shoul dnt al l cases recei ve more
thorough treatment after the cri si s is re
sol ved?
I t is a misconception to conceive of crisis i n
tervention as a holding operation. L imited as it
seems, it is a substanti al form of treatment in
its own ri ght, and it may for many pati ents be
the treatment of choice. T he experience is that
only a small number of pati ents receiving ade
quate crisis intervention need seek more inten
sive therapy, satisfactory results having been
obtained with crisis therapy alone. I ndeed,
there is evidence that in some instances deep
and lasting personality changes have been
brought about by working through a crisis.
Often the pati ent has gained enough so that
there is no future incidence of crises.
Does cri si s therapy requi re speci al trai n
ing?
T he key factor in this model of mental
health service is the availability of trained and
skilled personnel. Unfortunatel y, crisis i nter
vention has been regarded as a second-best
form of treatment that can be done by rel a
tively untrai ned paraprofessi onal s. A ppro
pri ate professional trai ni ng in this model is
rarely given and is an essential need in psy
chiatric and psychological trai ni ng programs.
T he usual trai ni ng does not equip a profes
sional to do crisis intervention. A dditional
skills related to the crisis model are required.
As a matter of fact, the crisis model is best
learned by professionals at an advanced stage
of traini ng and supervision. Excessive anxiety
and an erosion of confidence is often precipi
tated in students at lower levels of traini ng
when handling the problems of highly dis
turbed people in crisis. Supervision by experi
enced crisis therapists is also most important.
Some li terature on traini ng methods and direc
tions may be found in the writings of Baldwin
(1977), K app and Weiss (1975), and Wallace
and Morley (1970).
I snt the mai n goal of cri si s i nterventi on
namel y the bri ngi ng of a person back to a
previ ous dubi ous precri si s stabi l i ty too
superfi ci al ?
When one considers that a patient may
reach habitual stability in from one to six
sessions, we may consider such a goal quite an
achievement. T hi s is usually all a patient seeks
from therapy. But in a considerable number of
pati ents the worki ng-through of the crisis
starts a process that can lead to extensive
change in patterns of behavior and perhaps
even in alterations of the personality structure.
And the fact that a pati ent stops therapy in six
sessions or less does not mean that he cannot
later seek further treatment aimed at more ex
tensive goals, should he so desire.
I snt the ti me devoted to therapy too
l i mi ted in cri si s i nterventi on?
Experience shows that most people can be
helped to resolve a crisis within the traditional
time limitation of six sessions. A good therapist
can accomplish more with a patient in six
sessions than a bad therapi st can in six
hundred.
I f a pati ent comes to an emergency room
i n a hospi tal i n an agi tated state sayi ng he
is afrai d of gi vi ng i n to an i mpul se to ki l l
someone, what is the best way of handl i ng
this?
First, assure the patient that he will receive
help to protect him from these fears. I n an
acute state it is obviously difficult to probe the
sources of his fears of violence. Bringing him to
some immediate stability is the aim. For this
purpose neuroleptics should be administered in
proper dosage to calm the patient down. The
therapist will be wise to summon security per
sonnel to aid him if violence breaks through.
T hi s measure not only can allay the therapi sts
fears, but also the pati ent often realizes that he
will be protected from acting out his impulses,
and this helps calm him down. T he greatest
help is rendered by the pati ents ability to
communicate to an understandi ng person;
therefore, pri or to giving the pati ent intensive
tranquil ization, he should be allowed to verba
lize freely. Hospitalization must be considered
to protect the pati ent should violent tendencies
reappear. Too frequently the pati ents threats
are taken l i ghtl y. T he pati ent shoul d be
assured that it is essential that he be tempo
rarily hospitalized for his own protection and
that he will not need to stay in a hospital
longer than is necessary. Even where the pa
tient does not agree to hospitalization, he may
still be willing to accept it if he feels that the
therapist is sincere and concerned about his
welfare. T ransportati on to another hospital
should be done by ambulance with enough se
curity attendants to manage violent displays
should they occur. A proper diagnosis is neces
sary. Is the violence a manifestation of a
neurological condition like a brain tumor or
epilepsy, a breakthrough of psychosis, a conse
quence of a recent head injury, an indication of
excessive alcohol or drug intake? Continuing
therapy will be contingent on the proper diag
nosis.
Even i n cri si s therapy of a very bri ef na
ture some therapi sts cl ai m that it is possi
bl e to i nf l uence deeper parameters of
personal i ty. Are there techni ques that can
bri ng thi s desi red resul t about?
No better way exists than to study the reac
tions of the pati ent to the techniques that are
being utilized in the effort to resolve the crisis.
T he pati ents reacti ons to the therapeuti c
situation, irrespective of the specific techniques
employed, will reflect basic needs, defenses,
and reaction patterns that embody i nterper
sonal involvements dating back to formative
experiences in the past. Responses to the cur
rent treatment experience, if one understands
psychoanalytic theory and methodology and
has the motivation to use this knowledge, are
like a biopsy of the smoldering psychopathol
ogy. Patterns excited by therapy and the thera
pist will reveal both the sources and effects of
faulty early programming. These effects are
often expressed in the form of resistance. Be
cause the pati ent has learned to operate with a
social facade and because the more fundamen
tal operations of repression shield him from
anxiety, he may not mani fest resi stances
openly. I t is here that the trained and experi
enced therapist operates with advantage. From
the pati ents gestures, hesitations, manner of
talking, slips of speech, dreams, and associ
ations, one may gather sufficient information
to help identify and deal directly and ac
tively with resistances to techniques. These
resistances embody fundamental defensive op
erations, and their resolution may influence
many intrapsychic elements, ini ti ati ng a chain
reaction that ultimately results in reconstruc
tive change. T hi s change, started in relatively
brief therapy focused on the existing crisis,
may go on the remainder of the indi viduals
life. I f the pati ent has been able to establish a
continuity between the crisis situation, his ac
tive participation in bringing it about, the
forces in his character organization that sus
tain his maladjustment, and thei r origin in his
early conditionings, the opportunities for con
tinued personality maturation are good.
Shoul d ti me l i mi ts be set i n advance in
cri si s i nterventi on even i f you dont know
the di recti on treatment wi l l take?
Definitely. Crisis intervention is one si tua
tion where advance setting of the number of
sessions is required. I nexperienced therapists
are usually hesitant about doing this. Where a
termination date is not agreed on, the patient
will usually settle back and wait for a miracle
to happen no matter how long it takes.
What about the advance setti ng of goal s
i n cri si s i nterventi on?
I t is important to project achievable goals
and to get the patient to agree to these. Where
goals are too ambitious and will requi re exten
sive time to reach, or where they are unreacha
ble irrespective of time, the therapist may
undershoot his mark and at termination be left
with a disgruntled and angry patient.
I f on termi nati on the pati ent sti l l has un
resol ved probl ems, what do you do?
T he goal of crisis intervention, from a
purely pragmatic viewpoint, is to bring a pa
tient to precrisis equilibrium. Once this is
achieved, the chief aim of this model of therapy
has been reached. I nexperienced therapists
especially have difficulty discharging patients
because the patients have some unresolved
probl ems at termi nati on. Whi l e goals are
modest in crisis therapy, and while we may
termi nate therapy abruptly, it is often gratify
ing to see on follow-up how much progress has
actually occurred after treatment as a result of
the learnings acquired duri ng the active treat
ment period. T he therapist, therefore, should
learn to handle his own separation symptoms
and fears and let the pati ent go at the proper
time. Natural ly, if the pati ent is still seriously
and dangerously sick, further treatment will be
necessary.
Doesnt the tradi ti onal l i mi ted goal of
cri si s i nterventi on i n i tsel f ci rcumscri be
the therapeuti c effort and prevent more
extensi ve personal i ty growth?
T hi s is an important point. T he goal of
precrisis homeostasis is, for better or worse,
pragmatic; cost effectiveness is the cursed term.
Being pragmatic, however, does not mean that
one cannot proceed beyond the pati ents es
tablished precrisis neurotic homeostasis. I f one
accepts the dictum that a crisis is an opportu
nity for growth, a means of transgressing
modes of coping that have failed, and an in
vitation to release spontaneous growth proc
esses, it is possible within the prescribed f e w
sessions available to bring an individual in
crisis as well as the family to new poten
tialities. I believe this is where a dynamic
orientation is so helpful. I t is not necessary to
delve too deeply in the unconscious during
crisis; the unconscious with its wealth of en
crusted needs and conflicts is already near the
surface with the defenses shattered as they are.
And latent creative drives may also be trying to
surface. T he therapist can, if alert, harness
these forces and bring the pati ent to an aware
ness of how and why he is being victimized by
some of his distortions and interpersonal short
comings. I f interpretations are presented skill
fully in the context of the here and now, and
identified underlying nuclear problems are re
lated to the crisis situation, the therapist may
promote changes far beyond pragmatic bar
riers.
Have tel ephone hot- l i nes f or cri ses
proven successful ? Have any books been
wri tten on thi s subj ect?
On the whole, yes. But the adequacy of the
service is entirely dependent on the quality of
volunteer help available. Where volunteers are
untrained and unskilled, the effect can be anti -
therapeuti c. A book on the subject has
been edited by D. L ester and G. W. Brockopp
(Cri sis Int erventi on and Counseling by
Telephone, Springfield, 111., Thomas, 1976).
What is the best tacti c i n the case of a sui
ci de ri sk?
A person who really is intent on taking
his life will manage to do so steal thi l y.
Endogenous depressions are especi all y di s
posed to do thi s; therefore, where in a
depression there is a past history of a genuine
suicidal attempt, or the pati ent has expressed a
threat of sui cide, electroconvul sive therapy
should be instituted without delay. T emporary
hospitalization may be essential in these cases
unless the pati ent is consistently watched 24
hours a day. Suicide is especially possible as
the patient begins to feel better and has more
energy at his disposal.
Does a sui ci de threat cal l for i mmedi ate
use of cri si s i nterventi on?
Suicide is often an angry communication
and reflects an inability to resolve a personal
crisis. Ruben (1979) reports a study of 151 sui
cidal patients at the emergency department of
a large general hospital over a 2-year period,
56 percent of whom acted impulsively and had
no previous history of an emotional problem.
He suggests that two-thirds of suicidal patients
are excellent candidates for crisis intervention.
I n the event of an actual sui ci dal attempt
how shoul d one proceed?
An assessment of the suicidal attempt is nec
essary. Was it motivated by a truly genuine
desire to kill oneself or was it an appeal for
understanding or help? Was there a revenge
motif? I f so, against whomthe people the pa
tient is living with, parents, or whom else?
Had there been threats of suicide pri or to the
attempt? What immedi ate events, if any,
prompted the attempt? I f the pati ent suffered a
loss, is the loss permanent (such as the death of
a mate)? I s there a chronic debilitating physi
cal illness present, a desire to escape intracta
ble pain, or evidence of a termi nal illness like
cancer? Was the method employed a well-
designed and truly lethal method? Or was it
poorly organized, and if so, was the attempt
made with a hope to be rescued? How deeply
depressed is the pati ent now? Is the depression
recent, one of long-standing, or one that peri
odically appears? Has the pati ent received psy
chiatric help in the past, and if so, what kind
of help and for what? What kind of support is
now available to the patient (relatives, friends,
organizations, etc.)? I s it possible for the ther
apist to establish a good contact with the pa
tient and to communicate with him? How are
relatives and friends reacting to the pati ents
attempt (angry, frightened, desire to be help
ful, etc.)? Once answers to these questions are
obtained, the therapist will be in a better posi
tion to deal constructively with what is behind
the attempt. Should hospitalization be decided
on, as when there is a possibility that the at
tempt may be repeated, the therapist should
see to it that a responsible member of the
family is brought into the picture immediately
and follows through on recommendations pro
tecting the pati ent from any lethal objects
(drugs, knives, razors, etc.) and npt permitting
the patient to be alone until the pati ent is
actually hospitalized. I n the event hospi tal iza
tion is not deemed necessary, the principles of
crisis intervention with the pati ent and the
family should immediately be instituted.
Are there any data on what happens to pa
ti ents i n a cri si s who cannot be seen i m
medi atel y and are put on a wai ti ng list?
According to one study, fully one-third to
one-half of the patients on a waiting list when
contacted later on will no longer be interested
in treatment (L azare et al, 1972). T he reasons
for this generally are that the pati ent having
come for help in a crisis finds other resources
to quiet him down or he works out the prob
lems by himself even though some of the solu
tions prove to be poor compromises. T hus a
man suffering from intense anxiety finds that
drinking temporarily abates his suffering with
the consequence that he becomes an alcoholic.
A depressed woman who seeks companionship
gets herself involved with and so dependent on
a rejecting exploitative psychopath that she
cannot break the relationship. A man having
experi enced several episodes of impotency
detaches himself from women to avoid the
challenge of sexuality. A youth out of college
fearful of failing in an executive post with a
good future decides to give up his j ob in favor
of work as a laborer. T o forestall such com
promises it is important to interview the appl i
cant if possible within 24 hours of the request
for help. One way of circumventing a waiting
list is to organize an intake group pending an
opening in a therapi sts schedule. Such an in
terim provision may surprisingly be all that
some patients need.
Conclusion
Disruptive as a state of crisis may be, it can
offer the victim an opportunity to develop new
and healthier coping mechanisms. I n ini ti ati ng
a state of disequilibrium that fails to clear up
with habitual problem-solving methods, the
crisis may energize old unresolved conflicts,
reacti vati ng regressi ve needs and defenses.
Working out solutions for the crisis often will
encourage more appropriate ways of coping.
T hus, the crisis with its mobilization of
energy operates as a second chance in correct
ing earlier faulty problem-solving (Rapaport,
1962).
Studies of crisis states indicate that they usu
ally last no longer than 6 weeks, duri ng which
time some solution, adaptive or maladaptive, is
found to bring about equilibrium. T he initial
dazed shock reaction to a crisis is usually fol
lowed by great tension and mobilization of
whatever resources individuals have at their
command. Should efforts at resolution fail,
they will exploit whatever contrivances or strat
agems they can fabricate to resolve their trou
bles. T he more flexible the person, the more
versatile the maneuvering. A batement of ten
sion and cessation of the crisis state may
eventually result in the restoration of the
previous adapti onal level and hopefully in the
learning of more productive patterns of be
havior. Fail ure to resolve the crisis, however,
or continuance of unresolved conflicts may ulti
mately lead to more serious neurotic or psy
chotic sol uti ons. T herapeuti c i nterventi on
through crisis intervention is requi red when
pati ents cannot overcome difficulties by them
selves and before there is entrenchment in
pathological solutions.
Crisis therapy incorporates a number of ac
tive techniques implemented in the medium of
a directive therapist relationship with the pa
tient. I t is essentially short term, oriented
around two goals: (1) the immediate objective
of modifying or removing the critical situation
or symptom complaint for which help is being
sought, and (2) the hoped-for objective of
initiating some corrective influence on the indi
viduals and familys customary behavior. T he
unbalancing of the family equation will opti
mistically institute changes in the behavioral
patterns that have led up to the crisis. T he
theoretical framework governing the approach
is problem solving. T he methodologic strat
egies are eclectic in nature and recruit sundry
tactics including interviewing, confrontation,
envi ronmental mani pul ati on, drug therapy,
hypnosis, group therapy, family therapy, and
behavior therapy, depending on the needs and
problems of the patient and the parti cul ar ap
titude for working with a selected method.
T he techni que or techni ques employed,
while aimed at relieving the immediate crisis
situation or symptomatic upset, will often set
into motion certain resistances and defensive
operations that if detected must be managed to
prevent sabotage of the treatment process. I n
other words, even though the tactics may be
nonanalytic, the pati ents response to the tech
niques and to the therapist become a focus for
exploration for the purpose of detecting and
resolving resistances to change. Extensive per
sonality modifications are not expected, but
some modifications may eventuate as a ser
endipitous dividend, which often expands after
therapy has ended. Follow-up interviews over
a period of years have shown that this ap
proach can score sustained symptomatic relief,
freedom from further crises, and in some cases
actual constructive personality alterations.
CHAPTER 15
Making a Relaxing and
Ego-Building Tape
One of the simplest ways of promoting re
laxation and enhancing morale is through the
employment of a cassette recording. Among the
advantages of this adjunct is that the patient
can use it away from the therapi sts office. Too
often treatment begins and ends with each
weekly or biweekly therapeutic session. T he
only carryover is the memory of the patient,
which tends to be blunted by resistance and by
the intrusi on of everyday di stracti ons and
responsibilities. By playing the tape at least
twice daily, the patient reenforces and consoli
dates the lessons learned in the therapeutic
session.
Other tangible dividends accrue too: (1) T he
tape is materi al evidence that somethi ng
definite and palpable is being done for the
patient. Some persons consider the talking
cure temporary and flimsy. They seek some
thing more substantial. T his, in part at least,
is why demonstrable techniques, such as those
used in behavior therapy, make a greater im
pact on certain patients than simply verbaliz
ing. I t may be that the placebo effect is also
enhanced through the instrumentality of a
tape. (2) A relationship with the therapist be
comes more intensified. L istening to someone
who soothes, quiets, relaxes, and reassures so
lidifies rapport. T he ideal ized image of
empathic authority is augmented. Even when
the voice on the tape is not that of the thera
pist, it becomes identified with the therapist. A
relationship that may not develop in the brief
time devoted to treatment will have a better
chance of evolving because of the more inten
sive contact with an extension of the therapist.
(3) Tensions and anxieties become alleviated
through relaxing and reassuring suggestions.
T hi s subdues defensive maneuvers that have
diverted the pati ent from putting into practice
more adaptive patterns. (4) A more construc
tive self-image is encouraged through positive
persuasive suggestions neutrali zing negative
suggestions with which the pati ent has been
habi tual l y preoccupi ed. (5) T ermi nati on is
more easily achieved since a token of the thera
pist, embodied in the cassette, remains with
the patient, and this ameliorates separation
anxiety. (6) After therapy the patient has a
helping resource to turn to in the tape should
anxiety emerge, symptoms return, or critical
situations arise that threaten to overwhelm
coping capacities.
Understandably, several questions arise re
garding limitations, disadvantages, and dan
gers of supplying the patient with an ersatz
therapist in the form of a tape.
Does not a tape enhance the pati ents de
pendency and provi de hi m wi th a crutch
he can use i nstead of standi ng on hi s own
feet?
I n follow-ups, which have extended in some
cases over 15 years, I have not encountered a
single patient who has become dependent on a
tape or in whom dependency has increased as
a consequence of having a tape available to
him or her. T he problem is not that patients
will overuse the tape; rather, it is that they
will stop using it when they start feeling bet-
223
ter, putting it aside before they have achieved
its full benefit. Some tape suggestions are akin
to forms of assertive training, and they lead to
greater, not lesser, self-sufficiency.
Doesnt a tape, whi ch contai ns supporti ve
and reeducati ve suggesti ons, take away
f rom a dynami c approach that deal s wi th
deeper and more f undamental issues?
On the contrary, it adds to a dynamic
approach. T ransference may be enhanced
through the pati ents reactions to the tape (as
will be illustrated later in the chapter), and
characteristic resistances may surfacethat is,
if one watches for these responses and if the
patient is encouraged to report dreams. Several
reasons account for this. Contact with the ther
apist through the tape is on a daily basis, thus
preventi ng the pati ent from avoidi ng or
repressing emerging destructive feelings, which
can happen when therapeutic contact is mi ni
mal. Moreover, inducing relaxation results in
an altered state of consciousness that invigo
rates regressive phenomena. How one handles
transference, resistance, emergence of archaic
emotions, and the el i ci tati on of memories
should these erupt will determine whether or
not a therapeuti c effect will be registered. Of
course, the therapist may choose to ignore
these manifestations. But where resistances are
powerful enough to block the therapeuti c ef
fort, learning about them expeditiously (which
can occur by studying the pati ents responses
to the tape) may enable the therapist to deal
with them and thus salvage treatment that
otherwise would end in failure.
I n the event the tape breaks or is l ost,
wont the pati ents symptoms return?
An adjunctive cassette tape is no substitute
for psychotherapy. I t supplements and ex
pedites psychotherapy. T here is no reason why
symptoms should return if psychotherapy has
dealt satisfactorily with the pati ents problems.
Preliminary Preparations
T he equipment for making a tape is simple.
A good cassette recorder and a microphone
that has a start and stop switch are essential. I t
is best not to rely on the pati ents recorder,
with which idiosyncrasies the therapist may
not be acquainted. A metronome is optional. I
use an electonic metronome that is tuned to a
base tone at a speed of about one beat per
second. A metronome may be purchased in any
music store. A small bottle of rubbing alcohol,
some Q-tips and a needle should be available
in the event the therapist wishes to test for
glove anaesthesia. I n making a tape the sug
gestions should be given fluently, with convic
tion and without stumbling for words. To
prevent omissions and embarrassing speech
blunders, a prepared script is essential, one
that is sufficiently general so that it applies to
practically all patients, yet into which the ther
apist can interpolate special suggestions that
are applicable to specific patients. T he script
in this chapter has been tested over a number
of years, and it has many advantages. T he
therapist may copy it on cards and experiment
with it. I t is best to rehearse the making of a
tape wi th pauses and emphasi s at certai n
points so that when it is played back it sounds
like natural talk. Performers on radio or televi
sion have mastered the skill of reading a script
so that it sounds spontaneous. T he therapist
should practice by dictating several tapes, try
ing to articul ate naturall y, then listening to
what has been dictated, and continuing to
recite until the art of tal king casually from
script has been mastered. Some therapists
prefer to give thei r patients a prerecorded tape
made by another person.* I t may also be help
* A prerecorded rel axi ng and ego-bui l di ng tape was
made from the scri pt in thi s chapter and may be obtai ned
from El ba I ndustri es, 491 Seventh A ve., New Y ork, N.Y .
10018.
MAKING A RELAXING AND EGO-BUILDING TAPE
225
ful for a therapist to secure a tape that can
serve as a model to follow.
When to introduce the desirability of mak
ing a tape is a concern. 1 usually decide to do
this if I have the time at the end of the first
session after collecting data about the patient
and presenting a hypothesis of the problem.
However, it may be done at the second or a
later session. T he pati ent may be approached
as in the following excerpt:
Th. I believe you would benefit if I make a rel ax
ing cassette tape for you. Understandably, with
what you have gone through, you have a lot of
tension, and the tape should help.
Pt. I see.
Th. Have you ever noticed how much better you
feel when you are free from tension and re
laxed?
Pt. Y es, but thats the trouble. I cant relax.
Th. For that reason I m going to teach you a
method that will help you relax. Y ou know
when you are tense, every organ in your body
is keyed up. T hi s makes it hard for you to
heal. By learni ng how to rel ax your muscles
and breathe easily you should begin to notice
an improvement. T hi s will give you the best
chance to overcome tension.
Pt. T hats good. I s that like meditation?
Th. M edi tati on is one form of rel axati on. Hypnosis
is another. T here are other forms too. I will
show you one that should be suitable for you.
Do you have a tape recordera cassette
recorder? [ I f the p a t i e n t has no recorder, it is
best that he purc hase one, p r e f e r a b l y one that
has an automatic s h u t o f f with the end i ng o f the
tape.]
Pt. Y es, I play music on it.
Th. Fine, I ll make a rel axi ng tape for you that
should be of help. T he next time you come
here bring a blank 1-hour tape, that is, 30
minutes on each side. Get a good qual i ty tape
so that it will last. I t is not necessary to bring
your recorder since I ll use mine.
Pt. All right.
I t is usually best to employ the word re
laxation rather than hypnosis since the l at
ter may have connotations for the pati ent that
will complicate matters. People are acquainted
with the symptoms of relaxation, but they may
anti ci pate some mysteri ous, extramundane
phenomenon in hypnosis, which when not ex
perienced will inspire disappointment and a
sense of failure. I n the course of responding to
the rel axi ng exerci ses many pati ents will
actually enter a state of hypnosis. For practical
purposes it is not necessary to differentiate re
laxation from hypnosis in making a tape since
the suggestions that are given are effective in
both states. I ndeed, it may be wise to minimize
the need for hypnosis by stating that all we
wish to do is to practice relaxation. I f the pa
tient asks whether what will be done is a form
of hypnosis, he may be advised: Some people
relax so deeply that they may go into hypnosis,
and some actually doze off. But this is not im
portant. How deep you go makes little differ
ence. T he suggestions I will give you can be
equally effective whether you are lightly re
laxed or close to sleep.
I t is often expedient at the end of the initial
interview to have a preparatory session of re
laxation as a prel iminary to making a tape,
which is done at the next session. T he reason
this is helpful is that it enables the therapist to
observe how the pati ent responds to sugges
tions. I t also prepares the pati ent for what will
happen at the tape-making session.
T he patient is made comfortable in a chair
that should be sufficiently high so that it pro
vides support for the head. An ottoman, if
available, provides support for the feet. T he
pati ent may be told the following:
Th. Pri or to making a rel axi ng tape for you, which
we will do next time, I would like to see how
you relax. What I would like to have you do is
j ust lean back, close your eyelids and keep
them closed unti l I give you the command to
open them. Remember you will not be asleep
and you will not be hypnotized, j ust pleasantly
relaxed.
T he following script is then slowly read in a
kind of drawling, chanting tone as if lulling a
person to sleep.
Now j ust settle back and shut your eyes. L isten
comfortably to the sound of your breathi ng. Breathe
in ri ght down into the pi t of your stomach. D-e-e-p-
1-y, but gently, d-e-e-p-l-y. J ust deeply enough so
that you feel the ai r soaking in. I n . . . and out.
D-e-e-p-l-y, d-e-e-p-l-y. I n . . . and out. And as you
feel the ai r soaking in, you begin to feel yourself get
ti ng pleasantly tired and r-e-l-a-x-e-d, very r-e-l-a-x-
e-d. Even d-r-o-w-s-y, d-r-o-w-s-y and rel axed.
Drowsy and relaxed.
Now I want you to concentrate on the muscle
groups that I point out to you. L oosen them, relax
them, all while visualizing them. Y ou will notice
that you may be tense in certain areas and the idea
is to relax yourself completely. Concentrate on your
forehead. L oosen the muscles in your forehead.
Now your eyes. L oosen the muscles around your
eyes. Y our eyelids relax. Now your face, your face
relaxes. And your mouth . . . relax the muscles
around your mouth. Y our chin; let it sag and feel
heavy. And as you relax your muscles, your breath
i ng conti nues r-e-g-u-l -a-r-l -y and d-e-e-p-l -y,
deeply within yourself.
Now your neck, your neck relaxes. Every muscle,
every fiber in your neck relaxes. Y our shoulders
rel ax . . . your arms . . . your elbows . . . your fore
arms . . . your wrists . . . your hands . . . and your
fingers relax. Y our arms feel loose and relaxed;
heavy and loose and relaxed. Y our whole body
begins to feel loose and relaxed. Y our neck muscles
relax; the front of your neck; the back muscles. I f
you wish, wiggle your head to get all the kinks out.
K eep breathi ng deeply and relax. Now your chest.
T he front part of your chest relaxes . . . and the
back part of your chest relaxes. Y our abdomen . . .
the pit of your stomach, that relaxes. T he small of
your back, loosen the muscles. Y our hi ps . . . your
thighs . . . your knees relax . . . even the muscles in
your legs. Y our ankles . . . your feet . . . and your
toes. Y our whole body feels loose and relaxed. And
now as you feel the muscles relaxing, you will notice
that you begin to feel relaxed and pleasantly tired
al l over. Y our body begi ns to feel
v-e-r-y, v-e-r-y relaxed . . . and you are going to feel
d-r-o-w-s-i-e-r, and d-r-o-w-s-i-e-r, and d-r-o-w-
s-i-e-r, from the top of your head ri ght down to
your toes. Every breath you take is going to soak in
deeper and deeper and deeper, and you feel your
body getting drowsier and drowsier, (pause)
A nd now I want you to imagine, to visualize the
most relaxed and quiet and pl easant scene imagi na
ble. V isualize, a relaxed and pl easant quiet scene.
A ny scene that is comfortabl e. Drowsi er, and
drowsier, and drowsier. Y ou are v-e-r-y weary, and
every breath will send you into deeper and deeper
and deeper. [ I f a metr onome is to be used the p a
t i e n t ma y be told, I am going to turn on a
metronome and every beat of the metronome will
send you in deeper and deeper. ] As you visualize
thi s quiet scene, I shall count from one to twenty,
and when I reach the count of twenty, you will feel
yourself in deep, sufficiently deep to absorb the sug
gestions I m going to give you. One, deeper and
deeper. T wo, deeper, and deeper, and deeper.
T hree . . . drowsi er and drowsi er. F our, deeper
and deeper. Five . . . drowsier, and drowsier, and
drowsier. Six . . . seven, very ti red, very relaxed.
Eight, deeper and deeper. Ni ne . . . ten, drowsier
and drowsier. Eleven, twelve, thi rteen, deeper and
deeper, d-r-o-w-s-i -e-r and d-r-o-w-s-i-e-r. Four
teen, drowsier, and drowsi er, and drowsier. Fifteen
. . . sixteen . . . seventeen, deeper and deeper. Eigh
teen . . . nineteen . . . and finally twenty, (pause)
I want you (the p a t i e n t s f i r s t n a me m a y be men
tioned) for the next few minutes, to continue vis
ual i zi ng a qui et and wonderfully relaxed scene, and,
as you do, you will get more, and more, and more,
and more relaxed. Y our body will begin to get more
pl easantl y tired and more relaxed, and you will get
drowsier and drowsier; your arms may feel heavy,
your hands tingly. When I tal k to you next, youll
be more deeply relaxed. Deep, d-r-o-w-s-y and re
laxed; d-r-o-w-s-y, and deep, and relaxed; deep,
d-r-o-w-s-y, and relaxed; relaxed, and deep, and
drowsy, (pause f o r about 3 0 seconds)
Now I d like to have you concentrate on your left
arm. I am going to stroke the arm and as I stroke it,
the muscles get firm and rigid and the arms get stiff.
Every muscle, every fiber in the arm stiffens, and
the arm will feel as if it is glued ri ght down to the
side of the chai r. (T h e therapist at this p o i n t may
walk over to the p a t i e n t a nd w h i l e suggestions are
given s tr oke the left arm. Th e intonation should
n o w change f r o m a lul l i n g chant to a f i r m e r more
co m m a n d i n g tone.) Every muscle, every fiber feels
stiff and firm and rigid. T he arm feels as if a 100-
pound weight presses on the arm (the therapist ma y
p r e s s the arm d o wn ) as if a suction pad holds the
arm down, as if steel bands bind the arm down to
the chai r. T he arm seems glued to the chai r, and
when I try to lift it, it feels heavy and rigid, glued
against the chai r. (T h e therapist then li gh t l y tries to
lift the a r m . ) Heavy and stiff and rigid. [ T h i s is the
f i r s t test as to w h e th e r the p a t i e n t is re sponding to
suggestions. T h e gre at maj o ri t y o f p a t i e n t s wi l l e x
h i b i t a stiffness o f the arm. Th o se who s h o w no
stiffness a n d r ig id ity are resisting f o r some reason.
In the la t t e r event the ther apis t m a y re mark, I t is
MAKING A RELAXING AND EGO-BUILDING TAPE 227
a little hard to do this the first time. Next time you
will probably find it easi er. Th e n the therapist
may go on uninterr uptedly.] A nd now I m going to
stroke the arm, and whatever stiffness is there will
leave. I n fact, the arm will feel light as a feather.
( T h e arm is str oked a nd then ra p i d l y lifted.)
Feel your eyelids glued together now. Y our
eyelids feel ti ght, tight and when you try to lift
them, they feel as if they are glued together. T i ght,
tight, tight. [This is the n e x t test, a n d mos t p a t i e n t s
w i l l comply with the suggestions. In the event the
p a t i e n t is in resistance a nd lifts the eyelids, s i m p l y
pre ss them down to close them a n d say, I t is a l i t
tle difficult now. Next time it will be easi er, and
continue with the suggestions.]
Now what I d like to have you do is to picture
things in your mind as I describe them, and, as you
do, indicate it by lifting this finger an inch or so in
the air. ( T h e index f i n g e r o f t he l eft h a n d is
touched.) For example, imagine yourself walking
outside on the street, and when you see yourself
walking on the street, indicate this by lifting up
your finger. \T h e s e suggestions are a imed at t rain
ing the p a t i e n t in imagery. M o s t p a t i e n t s easily vis
ualize themselves w a l k i n g on t he street. Occa
sionally, a p a t i e n t w i l l block doing this f o r one
reason or another. Where this occurs a n d after a
m i n u t e or so has pa ss e d w i t h o u t t he f i n g e r lifting,
the therapist may say: I t is a difficult to do this. So
now picture yourself sitting in the chai r and you are
in looking at me. I n your imagination see me as I
tal k to you, and when you do, lift the fi nger. This
usually brings a posi t i v e response since the image o f
the therapist is f re sh in the p a t i e n t s mind. Once the
p a t i e n t has lif t e d the f i n g e r , the suggestion about
p i c t u r i n g o nes elf wa l k i n g on the street is made and
shoul d be successfully executed. In the very u nusual
event the p a t i e n t resists all these suggestions, or
later suggestions du ri ng the session, the therapist
may say: I t is a little difficult now. Y ou will find it
easier next ti me. T he hope is th a t the p a t i e n t will
eventually work through the resistance.)
V isualize yourself walking into an alleyway be
tween two buildings. See yourself stepping into this
al l eyway. And you wal k ri ght i nto an open
courtyard. See yourself walking into this courtyard,
and right in front of you you see a tall churchthe
steeple, spire, and bell. T hen lift the finger. ( T h e
therapist continues suggestions.) Now watch the bell.
Now watch the bell. I t will begin to move from one
side to the next, from one side to the next, and as it
does, you get the sensation of a clanging, c-l-a-n-g-
i-n-g in your ears. As soon as that happens, as soon
as you see the bell move, lift your finger. [It is po ss i
ble that t he p a t i e n t ma y be an excellent h y p no t i c sub
j e c t a n d actually hallucinate ringing o f the bell at this
p o i n t . T h i s is, however, n ot q u e s t io n e d so t ha t in the
event no aud i t o ry hallucinations exis t the p a t i e n t
does n ot i nfer he has f ailed. Ac t u a ll y , it makes no dif
fe r e n c e wh e th e r or n o t the p a t i e n t hallucinates in
sofar as t he l ater m a k i n g o f the tape is concerned.)
(pause, u n t i l the f i n g e r lifts)
T urn away from the church building now and see
yourself walking back through the courtyard into
the alley. Over the ri ght-hand side of the alley, on
the ground, you see a pail with steaming water. L ift
your finger when you see this, (pause, u n t i l f i n g e r
lifts)
Now see yourself taking your right hand and
waving it through the steam. As you do this, your
hand will get tingly and tender and sensitive as if it
has been soaked in steam. When you see yourself
doing this, lift your finger. I n a moment your hand
will become sensitive and tender as if you have
waved it in steam, (pause, u n t i l f i n g e r lifts)
I n contrast to your sensitive ri ght hand, your left
hand is going to get numb and insensitive. I t will
feel as if I have created a wrist block with novocaine
( T h e therapist ma y touch the p a t i e n t ' s left wrist
w i t h his f i n g e r in a n u m b e r o f spots, circling it as i f
novocaine is being injected.) As a matter of fact, you
are now going to i magine yourself weari ng a thick
heavy l eather glove on your left hand, and as soon
as you see yourself in your i magination weari ng a
thick heavy l eather glove on your left hand, indicate
it by lifting your finger, (pause, u n t i l f i n g e r lifts)
Now I am going to show you the difference be
tween the sensitive ri ght hand and the left hand en
veloped in a glove. |In mos t cases a p a r t i a l glove
anaesthesia w i l l be obtained, a n d this more than
any other p h e n o m e n o n d u r i n g the p r e s e n t relaxing
session w i l l impre ss the p a t i e n t t h a t so m e t h i n g i m
p o r t a n t may be accomplished with suggestion. A ft e r
the session is over, m a n y p a t i e n t s express surprise
or incr edulity th a t anaesthesia has occurred. Some
d o ubt th a t the ther apis t actually t ouched the hand
with the needle, a n d the therapist w i l l have to
assure them this was ro.] I am going to touch your
left hand with a sterilized needle, and it will feel as
if I am touching it through a thick, heavy leather
glove. Y ou will feel touch, but no pain; touch but no
pai n. T ouch, but no real pai n. (A needle, a small
bottle o f alcohol a n d a swab o f cotton or Q-tip being
available, the needle is w i p e d with alcohol, a n d the
alcohol-soaked swab is applied to the back o f the
h a n d in the triangle between the t h um b a n d f o r e
fi nge r. T he therapist sh o ul d then touch the skin
w i t h the needle lightly to avoid d r aw i ng blood). On
the contrary, the other hand, the ri ght hand, will be
very sensitive and tender and painful even to the
slightest touch. ( T h e same process with the needle is
re peated with the back o f the right h a n d to de mo n
strate the difference in sensation between the two
hands.)
What we have done is to produce an anesthesia,
which is sometimes used in minor surgical oper
ations. But what it indicates is the power of the
mind in controlling physical functions. And if the
mind can do this with a fundamental function like
pai n, it can also control your symptoms (these may
be mentioned).
I am now going to count slowly from one to five.
When I reach the count of five lift your eyes and
you will be out of it. One . . . two . . . three . . .
four . . . five.
Most patients will slowly lift thei r eyelids
and spontaneously comment on how relaxed
they feel. They may inquire if the therapist
really touched the left hand with a needle. I f
the patient does not present his comments
spontaneously, the therapist may inquire about
his personal reactions. I n the event the patient
resisted certain suggestions (which as has been
mentioned before is not unusual), the therapist
may ask whether the patient was upset or had
any other feelings or thoughts during the re
laxing exercises.
I n one patient, for example, when asked
what thoughts came to him when he could not
visualize a church when asked to do so, he re
plied: I had a peculiar fantasy, visionlike.
T here was a manhole in the street, and I was
walking toward it. And there was a machine
with teeth in it ready to grind me up. At this
point, the patient smiled and he said; I knew
a man who went for analysis and referred to
his analysts office as a hell hole. T he fantasy
and his association provided a dynamic focus
for our interviews, which dealt with trans
ference feelings that I , like his father, was a
dangerous authority who, if he relaxed his
guard, might injure him.
I n most cases resistances will not be en
countered and the therapist may then proceed
with these instructions: T he next time you
come here bring a 1-hour blank cassette tape of
good quality, 30 minutes on each side. I t is not
necessary to bring your recorder since I will
use my own machi ne.
At the next session, if the pati ent does not
spontaneously report dreams, the therapist
should inquire about them. Following the re
laxing session, many patients are apt to have
dreams that relate to thei r relaxation experi
ence and that expose transference as well as
resistance maneuvers. These reactions may be
very important because not only do they open
a window into the underlying dynamics, but
they are warning signals of problems that will
have to be handled that may sabotage the
benefits of the recorded tape.
T hus a male patient brought in this dream
after the first session: I was ill in bed.
Friends were visiting me. I ts grandpas house,
and my mother is there. She talks about help
ing me, but she gets me pink ribbons for my
bed and tells me to sleep. I say, T hi s is for
gi rl s. She tries to persuade me i ts all right.
But I dont want to believe her. T hen I had
another dream. T here was a rope around my
penis; it changed to ribbons and it was choking
my penis. T he transference elements came
out rapidly after the relaxation session. Had I
not been alerted to the pati ents fear of castra
tion (which apparently stemmed from his un
resolved oedipal fantasies and which he was
projecting onto me) I would not have been able
to deal with his core problem. I delayed the
making of the tape until we had worked suffi
ciently on this material so that he would not
i nterpret my tape-making activities as a cas
trati ng threat.
I n the great majority of patients the dreams
and fantasies that follow the first relaxing
session are pleasant ones and do not indicate
any need for delay in dictating the cassette.
MAKING A RELAXING AND EGO-BUILDING TAPE
229
Making the Tape
T he patient is made comfortable in a chair
(some patients prefer lying on a couch since
they are more relaxed in it), and the blank
cassette is put into the therapi sts recorder. It
is wise to test the voice level, counting from
one to ten in the microphone, at the volume
that one will use during the dictation, and then
listening to the playback. After the proper ad
justments have been made, the therapist says
to the patient, I f you hear some rustling it is
because I may refer to my cards and to the case
record to make sure I include all the material
that is important. Now I want you to shut
your eyelids and keep them shut until I give
you the command to open your eyes.
T he script, which has been copied on cards,
is essentially similar to that in my book, The
Technique of Psychotherapy (1977, pp. 795-
796). T he first part is identical with that of the
beginning of the preliminary session, but to
avoid confusion the complete script will be i n
cluded here. Dictation should be slow, with
proper pauses and emphases much as in the
first session. T he pati ents first name may be
interpolated in certain spots to make the tape
more personal. T he patient having shut the
eyes, the recorder is turned on and the script
dictated.
Now j ust settle back and shut your eyes. L isten
comfortably to the sound of your breathi ng. Breathe
in right down into the pit of your stomach. D-e-e-p-
1-y, but gently, d-e-e-p-l-y. J ust deeply enough so
that you feel the ai r soaking in. I n . . . and out.
D-e-e-p-l-y, d-e-e-p-l-y. I n . . . and out. And as you
feel the ai r soaking in, you begin to feel yourself get
ting pleasantly tired and r-e-l-a-x-e-d, very r-e-
1-a-x-e-d. Even d-r-o-w-s-y, d-r-o-w-s-y and relaxed.
Drowsy and relaxed.
Now I want you to concentrate on the muscle
groups that I point out to you. L oosen them, relax
them, all while visualizing them. Y ou will notice
that you may be tense in certai n areas and the idea
is to relax yourself completely. Concentrate on your
forehead. L oosen the muscles in your forehead.
Now your eyes. L oosen the muscles around your
eyes. Y our eyelids rel ax. Now your face, your face
relaxes. And your mouth . . . rel ax the muscles
around your mouth. Y our chin; let it sag and feel
heavy. And as you rel ax your muscles, your breath
i ng conti nues r-e-g-u-l -a-r-l -y and d-e-e-p-l -y,
deeply within yourself.
Now your neck, your neck relaxes. Every muscle,
every fi ber in your neck rel axes. Y our shoul
ders rel ax . . . your arms . . . your elbows . . . your
forearms . . . your wri sts . . . your hands . . . and
your fingers relax. Y our arms feel loose and re
laxed; heavy and loose and relaxed. Y our whole
body begins to feel loose and relaxed. Y our neck
muscles relax; the front of your neck; the back
muscles. I f you wish, wiggle your head to get all the
kinks out. K eep breathi ng deeply and relax. Now
your chest. T he front part of your chest relaxes . . .
and the back part of your chest relaxes. Y our
abdomen . . . the pi t of your stomach, that relaxes.
T he small of your back, loosen the muscles. Y our
hi ps . . . your thighs . . . your knees relax . . . even
the muscles in your legs. Y our ankles . . . your feet
. . . and your toes. Y our whole body feels loose and
relaxed. And now as you feel the muscles relaxing,
you will notice that you begin to feel relaxed and
pl easantly tired all over. Y our body begins to feel
v-e-r-y, v-e-r-y relaxed . . . and you are going to feel
d-r-o-w-s-i-e-r, and d-r-o-w-s-i-e-r, and d-r-o-w-
s-i-e-r, from the top of your head right down to your
toes. Every breath you take is going to soak in
deeper and deeper and deeper, and you feel your
body getting drowsier and drowsier, (pause)
And now I want you to imagine, to visualize the
most relaxed and quiet and pl easant scene i magi na
ble. V isualize, a relaxed and pl easant quiet scene.
A ny scene that is comfortabl e. Drowsi er, and
drowsier, and drowsier. Y ou are v-e-r-y weary, and
every breath will send you into deeper and deeper
and deeper. [I f a metr onome is to be used the p a
t ien t ma y be told, I am going to turn on a
metronome and every beat of the metronome will
send you in deeper and deeper. ] As you visualize
this quiet scene, I shall count from one to twenty,
and when I reach the count of twenty, you will feel
yourself in deep, sufficiently deep to absorb the sug
gestions I m going to give you. One, deeper and
deeper. T wo, deeper, and deeper, and deeper.
T hree . . . drowsier and drowsier. Four, deeper and
deeper. Five . . . drowsi er, and drowsi er, and
drowsier. Six . . . seven, very ti red, very relaxed.
Eight, deeper and deeper. Nine . . . ten, drowsier
and drowsier. Eleven, twelve, thi rteen, deeper and
deeper, d-r-o-w-s-i -e-r and d-r-o-w-s-i -e-r.
Fourteen, drowsier, and drowsier, and drowsier.
Fi fteen . . . si xteen . . . seventeen, deeper and
deeper. Ei ghteen . . . ni neteen . . . and fi nal ly
twenty, {pause)
I want you {the p a t i e n t s f i r s t name ma y be m e n
tioned) for the next few minutes, to continue vis
ualizing a quiet and wonderfully relaxed scene, and,
as you do, you will get more, and more, and more,
and more relaxed. Y our body will begin to get more
pleasantly tired and more relaxed, and you will get
drowsier and drowsier, your arms may feel heavy,
your hands tingly. When I talk to you next, youll
be more deeply relaxed. Deep, d-r-o-w-s-y and re
laxed; d-r-o-w-s-y and deep and relaxed; deep,
d-r-o-w-s-y, and relaxed; relaxed, and deep, and
drowsy, (pause f o r about 30 seconds)
Relax and feel drowsy. As you begin to feel more
drowsy, you have a sort of floating sensation and
you relax more. T hi ngs seem to fade a little and lose
thei r immediacyany anxiety and depression fade.
A sort of fuzzy and tingling sensation and a feeling
of welcoming sleep, yet different from the reaction
to ordi nary sleep.
T he mind is like a sponge. I t soaks up sugges
tions. I n your case it has been filled with negative
suggestions that have piled up in you over the years.
[These may be enumerated. For example, i f the p a
t ient has a f e e l i n g that he cannot g et better, or is
unable to succeed at any t h i ng or i f he has a devalued
self-image, these may be m e n t i o n e d as negative
thoughts. ]
I shall now give you a number of suggestions and
you may utilize those that apply to you at this mo
ment and put aside those that do not, which may
apply at some other moment.
Every day . . . you will become physi cal ly
S T R O N G E R and F I T T E R . Y ou wi l l become
M O R E A L E R T . . . M O R E W I D E A W A K E . . .
M O R E E N E R G E T I C . Y ou will become M U C H
L E S S E A S I L Y T I R E D . . . M U C H L E S S E A S -
I L Y FA T I G U E D . . . M U C H L E S S E A S I L Y D E
P R E S S E D . . . M U C H L E S S E A S I L Y D I S C O U R
A G E D . Because of resol uti on of your troubl es
[.specific s y m p t o m s that have burde ned t he p a t i e n t
m ay be me n t i o n e d here i f d esired]. Every day . . .
you will become . . . S O D E E P L Y I N T E R E S T E D
I N W H A T E V E R Y O U A R E D O I N G . . . S O
D E E P L Y I N T E R E S T E D I N W H A T E V E R I S
G O I N G O N . . . T H A T Y O U R M I N D W I L L B E
C O M E M U C H L E S S P R E O C C U P I E D W I T H
Y O U R S E L F A N D Y O U R P R O B L E M S . . . A N D
Y O U R O W N F E E L I N G S .
Every day . . . Y O U R N E R V E S W I L L B E
C O M E S T R O N G E R A N D S T E A D I E R . . .
Y O U R M I N D W I L L B E C O M E C A L M E R A N D
C L E A R E R . . . M O R E C O M P O S E D . . . M O R E
P L A C I D . . . M O R E T R A N Q U I L . Y ou will be
come M U C H L E S S E A S I L Y W O R R I E D . . .
M U C H L E S S E A S I L Y A G I T A T E D . . . M U C H
L E S S F E A R F U L A N D A P P R E H E N S I V E . . .
M U C H L E S S E A S I L Y U P S E T . Y ou will be able
to T H I N K M O R E C L E A R L Y . . . Y ou will be able
to C O N C E N T R A T E M O R E E A S I L Y . Y O U R
M E M O R Y W I L L I M P R O V E . . . and you will be
able to S E E T H I N G S I N T H E I R T R U E P E R
S P E C T I V E . . . W I T H O U T M A G N I F Y I N G
T H E M . . . W I T H O U T A L L O W I N G T H E M T O
G E T O U T O F P R O P O R T I O N .
Every day . . . you will become E M O T I O N
A L L Y M U C H C A L M E R . . . M U C H M O R E
S E T T L E D . . . M U C H L E S S E A S I L Y D I S
T U R B E D . Every day . . . you wi l l feel a
G R E A T E R F E E L I N G O F P E R S O N A L W E L L
B E I N G . . . A G R E A T E R F E E L I N G O F P E R
S O N A L S A F E T Y . . . A N D S E C U R I T Y A N D
C O N T R O L than you have felt for a long, long
time.
Every day . . . Y O U will become . . . and Y O U
will remai n . . . M O R E A N D M O R E C O M
P L E T E L Y R E L A X E D . . . A N D L E S S T E N S E
E A C H D A Y . . . B O T H M E N T A L L Y A N D
P H Y S I C A L L Y . . . A nd, you become . . . and,
d-S1you remai n . . . M O R E R E L A X E D . . . A N D
L E S S T E N S E E A C H D A Y . . . S O , you will de
velop M U C H M O R E C O N F I D E N C E I N Y O U R
S E L F . M U C H more confidence in your ability to
D O . . . N O T O N L Y what you H A V E to do each
day, . . . but M U C H more confidence in your abi l
ity to do whatever you O U G H T to be able to
do . . . W I T H O U T F E A R O F C O N S E Q U E N C E S
. . . W I T H O U T U N N E C E S S A R Y A N X I E T Y . . .
W I T H O U T U N E A S I N E S S . Because of this . . .
every day . . . you will feel M O R E A N D M O R E
I N D E P E N D E N T . . . M O R E A B L E T O S T A N D
U P O N Y O U R O W N F E E T W I T H O U T P R O P S
[ I f the p a t i e n t is u t i l i z i n g p ro p s , l i k e tranquilizers
or pills, these may be mentioned, L ike tranqui l
i zers and sl eepi ng pi l l s. ] A N D W I T H O U T
W O R R Y I N G . T O H O L D Y O U R O W N . . . no
matter how difficult or trying things may be.
A nd, because all these things W I L L begin to
happen . . . E X A C T L Y as I tell you they will hap
pen, you will begin to feel M U C H H A P P I E R
. . . M U C H M O R E C O N T E N T E D . . . M U C H
M O R E C H E E R F U L . . . M U C H M O R E O P T I
M I S T I C . . . M U C H L E S S E A S I L Y D I S C O U R -
A G E D . . . M U C H L E S S E A S I L Y D E P R E S S E D .
Now relax and rest for a mi nute or so, going
deeper, d-e-e-p-e-r, d-e-e-p-e-r, and in a minute or
so I shall talk to you, and you will be more deeply
relaxed, (pause about 10 seconds)
T here are four things we are going to accomplish
as a result of these suggestions. I call them the four
Ss: symptom relief, self-confidence, si tuati onal con
trol, and self-understanding. Fi rst, your various
symptoms (e numer ate ) are going to be less and less
upsetting to you. Y ou will pay less and less atten
tion to them because they will bother you less and
less. Y ou will find that you have a desire to over
come them more and more. And as we work at your
problems, you will feel that your self-confidence
grows and expands. Y ou will feel more assertive and
stronger. Y ou will be able to handl e yourself better
in any situations that come along, parti cul arl y those
that tend to upset you (enumerate). Fi nal l y, and
most importantl y, your understandi ng of yourself
will improve, (pause)
I want you to continue to listen to this recording
as often as possible and as practical. I t makes no
difference how deep you go. Even if you feel you are
conscious, or if your mind wanders off while listen
ing, or if you fall asleep, the suggestions will
penetrate, (pause)
Relax and rest and, if you wish, give yourself any
addi ti onal suggestions to yourself to feel better, or
suggestions to handl e an immediate problem, using
the word you as if you are tal ki ng to yourself.
T hen rel ax, go to sleep or arouse yourself. T ake as
long as you like. When you are ready you will
arouse y o u r s e l f no matter when that is by counting
slowly to yourself from one to five. Y ou will be com
pletely out of it thenawake and al ert. Remember
the more you practice the more intense will be your
response, the more easily will your resistances give
way.
K eep on practicing: and now go ahead . . . relax
. . . and when you are ready . . . wake y o u r s e l f up.
After the pati ent lifts the eyelids, he may be
asked how he feels. Generally, the reply will
be Relaxed. T he therapist then plays back
the last sentence and then rewinds to the be
ginning and plays back the first few words to
make sure the tape contains the start and end
of the script. T he patient is given the tape with
the injunction; I f you can borrow another
recorder, it is best to copy the tape. Use the
copy so that if the tape breaks or is lost you
have a master to copy from.
Reactions to the Tape
T he pati ents experiences in playing the
tape should be reviewed at the next session. A
number of questions may concern the pati ent,
such as the following:
Q. I fall asleep before the tape ends. Does this mat
ter?
A. No. T he suggestions will still get through. All it
means is that you are a good subject.
Q. Should I count out loud before I come out of it?
A. I t is best to count to yourself.
Q. Supposing someone is at the door buzzing or the
telephone rings while the tape is playing, what
do I do?
A. I f you wish to i nterrupt the session, j ust count
to yourself from one to five and tell yourself to
lift your eyelids.
Q. At the end of the tape before I come out of it,
what suggestions should I give myself?
A. Whatever your immediate problems are, tell
yourself you will work them out. I f you are an
tici pati ng difficulties in facing a si tuati on, try to
outline in advance the best way of handl i ng it
and tell yourself you will do it.
Q. I f my mind wanders and I am not concentrating
on what the tape says, what then?
A. L et it wander. Some of the suggestions will still
get through even if you fall asleep. T here are
peri pheral areas of attenti on that sti l l are
absorbing the suggestions that are being made.
Q. What are the best times to use the tape?
A. I f convenient the first thi ng in the morning and
the last thing at night before going to sleep.
Some people put themselves to sleep with the
tape. T he tape should be played daily.
Q. When I use the tape at night my wife listens to
it. I thi nk she gets as much out of it as I do.
A. Y our problems are different than hers. But you
probably do share some common problems. Y ou
can get an ear plug [one usually comes w i t h a
recorder] to let you listen privately wi thout dis
turbing your wife.
Q. How often shall I use the tape?
A. At least twice a day, every day.
T he pati ents reactions to the tape are im
portant because they may reveal some basic
problems, transference manifestations, resist
ances, and the movement in therapy. Occa
sionally a pati ent will become quite argu
mentative after listening to the tape a few
times. For example, one pati ent at the third
session (the tape had been made at the second
session) handed me the following typewritten
comments:
T he tapequestions and reactions.
Lean back M ust I sit? I have no chair where I
can rest my head. I f I do get drowsy I get to be like
a J apanese wobblehead doll, and the sudden j erk of
the head distracts. Can I lie down? (Then I tend to
fall asleep.)
In a nd o u t " I dont breathe that fast, and the
in and out never coincide.
Ti re d a nd relaxed. V ery tired, very rel axed. A
total contradiction, and I must add pl easantl y,
and i ts distracting. T o me ti red means extreme
tension and collapse, tension to the point of violent
pain.
Cannot relax, not most of the time (or much of
the time. Not really relax). A nd cannot follow the
points enumerated so fast. A rms never feel loose.
Neck is most difficult. A ndhow can anyone relax
on order?
Cant wriggle my head if I lie down.
Enumerati on of parts of body is felt like physical
touchan i ntrusi on, an invasion of my private
selfwith erotic undertonesand resented.
Cannot visualize a pleasant, qui et, wonderfully
relaxed scene. Every time respond with bitterness
I ve never experienced one.
When you mention my name it always surprises
and touches mea recognition of me (unworthy of
notice).
Floating sensation . . . t h ings f a d e a little and
lose t heir immediacy. A n x i e t y a n d depression f a d e
. . . a sort o f f u z z y a n d t i ngling sensation and a f e e l
ing o f we lc o mi n g s l e e p . I t does not happen. Also
sl eep. Why sleep?
Ne ga tive suggestions th a t p i l e d up in you over
the y e a r s . I f the thoughts and feelings are sugges
tions, they must have come from somewhere or
someone. From where? From whom?
We m u s t replace them with p o s i t i v e sugges
t i o n s . M y reacti ona bi tter and angry the power
of positive thi nki ng, every day in every way I get
better and better.
Description of how I ve felt brings me to the
poi nt of tears. Every day now, etc., etc.
promises that are not being fulfilled (too good to be
true, unattai nabl eto me). None of it is happening.
How long must it take to take effect?
Y o u ll be much less easily t i r e d . T i red
again. Contradi cti on is disturbi ng. I was urged to
feel ti red before. A re there di fferent ki nds of
ti red ? Every day, you will become so deeply in
terested . . . Felt as a derogation. I ve always been
deeply i nterestedin what I was doing, in people,
in so many things, except when the depression got
so bad that I di dnt w a n t to do anythi ng or see
anyone. And thi s persists, even though to a lesser
degree. Enough to keep me stuck and paralyzed.
T he what the hell for? still operates. I dont, or
almost dont work. I cannot answer letters. I am not
functioning f r o m w i t h i n (only, to some extent, in
response to outside stimuli and people), ei ther emo
ti onally or creatively. Whatever potenti al is there, is
still locked up ti ght. And when I say I am nothing,
I am not self-depreciating, I am merely describing
the awful sense of emptiness within.
I dont want to be much less conscious o f m y s e l f
a n d m y feelings. I want to be conscious, but I want
the feelings to change. I want to f e e l (and not only
pain and rage). I want to be able to feel love. T o feel
joy. T o have a feeling of personal well-being. See
things in thei r true perspective. What the devil is
true perspective? T here is no such thing.
Afore relaxed, less tense each d a y . I t isnt hap
pening.
" N o t only w h a t you have to do each day, but
w hat you ought to be able to d o . (M eani ng? But,
of course, I am to supply the meaning.)
Without fear of consequences. (M eaning?)
M ore and more able to stand on your own feet
wi thout props. I s the tape a prop? A re the W s
props?
T hey will happen, exactly as I tell you they will
happen. When?
Cannot stand / call them the f o u r S s . I can
scream whenever I hear a formula. Can it be omi t
ted, please? (I f another tape is made).
" A s we work on y o u r p r o b l e m s (? Do we?)
" I n situations that upset y o u . Situations dont
upset me. (Of course not. I avoid what I fear).
" I t makes no difference h o w deep you go. Even i f
you f e e l you are conscious (Am I supposed to be
unconscious? I am conscious every ti menot every
time or all the time. At times I ve fallen asleep).
" M a k e y o u r own suggestions. A mong them:
Stop rejecting yourself. Stop rejecting life. Be glad
you are alive. Feel good. Feel alive. Dont feel
worthless. Y ou are worthwhile. Y ou are intelligent.
Y ou are talented. Y ou have accomplished much.
Relax, feel rested. Feel bright. Feel alert. Feel. Re
memberthis or that.
" G o to sleep. Or arouse y o u r s e l f . Confusing
each time. I s this deliberate?
Fortunately, it is rare that one encounters so
negative a reaction. I n this case I listened
silently to her objections and merely told the
pati ent to conti nue l i steni ng to the tape,
promising that if she needed a new tape in the
future I would make one. I then discussed her
dreams and her feelings about me. Her
response was a good one, and she did not
request another tape, benefiting from the one I
had dictated to which originally she had so
many negative reactions. She seemed to be
fighting off closeness to me as indicated in this
dream:
P t. A herd of wild hogs across the field, moving
rapi dl y, full of wild angry energy, but rather
small. I wonder I thought they were bigger.
T hey are dangerous.
Back to where I came from. M other says I
shoul dnt have gone. T hat area is very dan
gerous. I am frightened in retrospect. I look
across the water at the di stant, green land. I t
seems peaceful from here. But no, it is very dan
gerous.
T otal loneliness. I can see strangers to whom
I mean nothing. Aside from thatnothing. I
can run and run. When I stop, there is nothing.
I love no one, and no one loves me.
I walk with my hand in Dr. Wol bergs arm.
Somewhat behind us walks his wife. Will she
feel j eal ous? I am mildly anxious. (T here was
more, but I cant recall it.)
I was listening to the tape and I kept thinking
maybe you di dnt hate me. But I pushed it out
of my mind. Because I coul dnt tolerate that be
cause it would make me vulnerable. I said, I m
going to ask him if he is sure he approves me. I
had another dream:
I was on a stage giving a performance, and I
felt I could do it. I wanted everybody to like me,
and I wanted to put on a pose of confi
dence. I kept saying, Dr. Wolberg says I m
not bad. T hen I was in an embryonic saclike a
ballonlike I was giving bi rth to a baby. A man
was blowing on it as if he was helping me.
T he positive aspects of the dream predicted
the responsive relationship the pati ent de
veloped with me.
A nother pati ent with a strong fear of au
thority had the following reaction and dream
after the playback of the tape.
P t. I felt comfortable and protected and I thought
maybe I can stand up to my supervisor. T hat
night I dreamed, that there was a woman at a
campsite. She was a cross between a fury and a
witch. T here was also a man and a child. I
was coming for help. As I approached the
campsite, this woman came forward. I was
supposed to have inner conviction, the strength
of will to overcome this specter. She comes
toward meawful looking, pale. I awoke in a
cold sweat. T hen I fell asleep again and the
dream resumed. T he di rector came in and
said: T hi s thi ng is not real all imagi nary
no real i ty. I went in again to the campsite.
T hi s time it is not so bad, but I sweat and have
anxiety and I woke up. A gain I went to sleep
and the dream continued. T he director said,
O.K . L ook at it as it is. Recognize the reality
for what it is and face i t. I did it and that was
it. I looked at the vision and the dream ended.
I awoke relaxed and happy. Played the tape
again. I have had recurrent dreams all my life
of a child or baby. M ust be some aspect of
myself, I m sure. T he child is usually dying or
sick or in danger. A burden. And I as an adul t
am saving it. T he woman in this dream, the
fury-witch, the awfullooked like a combina
tion of my mother, the woman analyst I had
once seen, and myself. T he man I m not
suremy stepfather? T he director looks like
you and the man I live with. T hi s week I was
able to face and tal k to my supervisor wi thout
shaking.
I t may not always be possible to get dreams
or associated feelings from patients in reponse
to the tape, but the therapist will be able to
deduce the responses from behavioral and
other clues. I n the event the pati ent does not
bring up the matter, the therapist should i n
quire as to how the pati ent feels listening to
the tape. I t is rare that objections to some
aspects of the tape are so strong that a new
tape deleting these sections will be needed.
Conclusion
A cassette tape containing relaxing and ego-
building suggestions offers the patient a con
tinuing means of supportive and educational
help away from the therapi sts office. Re
sponses to the tape provide transference and
resistance material for a dynamic focus that
may be explored and interpreted. Upon termi
nation of therapy the tape may serve as an im
portant aid toward furtheri ng the objectives of
treatment.
CHAPTER 16
Homework Assignments
One of the most neglected aspects of short
term therapy is assigning homework through
which patients can facilitate means of control
ling or eliminating self-defeating patterns. I t is
often assumed that the lessons absorbed in the
therapi sts office will automatically carry over
into everyday life. This cherished hope does
not always come to pass. T he average patient
generally dissociates the learnings in the thera
pists office from behavior at home, at school,
at work, and in the community. After psycho
logically stripping oneself during a session,
outside the patient puts back on the familiar
neurotic suit of clothes. I t can be helpful,
therefore, in consolidating therapeutic gains to
insist that therapy does not stop with the exit
from the treatment room. T he patient must
put into practice what is learned during the
sessions in order for any change to register i t
self permanently. And when treatment has
ended, the patient will certainly need to rei n
force new modes of coping by continuing
homework; otherwi se, in returni ng to the
customary environment, relapse may be i n
evitable.
I nstructions may thus be given the patient
along the following lines:
1. L o o k squar ely at y o u r immed ia te life s i t ua
tion. What elements are to your liking? A re these
elements good for you and constructive, and do they
need reinforcement? Or should they be minimized
or eliminated because they get you into problems?
What elements are destructive? What can you do to
make them less destructive? Should they be elimi
nated completely? How can you go about doing
this? Once you have decided on a plan of action,
proceed with it a step at a time, doing something
about it each day.
2. Wh a t p a t t e r n s o f behavior w o u l d you like to
change, p a t t e r n s th at should be changed? How far
back do they go? Do you see any connection be
tween these patterns and things that happened to
you as a child? Realize that you may not have been
responsible for what happened to you as a child, but
you are responsible for perpetuati ng these patterns
now, for letting these patterns rui n your happiness
at the present time. You can do so m e t h i ng about
them. When you observe yourself acting these pat
terns out, ST OP. Ask yourself are you going to let
them control you? Say to yourself, I am able now
to stop this nonsense, a n d do it. For example,
every time you beat yourself and depreciate yourself,
or act out a bad pattern and say you are helpless to
control it, are you doing these things to prove that
you are defenseless and that therefore somebody
should come along and take care of you? A re you
puni shi ng yourself because you feel guilty about
something? I t is easy to say you are a crippled child
and that some kind person must take care of you.
But remember you pay an awful price for this de
pendency by getting depressed, feeling physically ill,
and destroying your feelings of selfworth. Every time
you control a bad pattern, reward yourself by doing
something nice for yourself, something you enjoy and
that is good for you.
3. W h a t p a t t e r n s o f behavior w o u l d you l ike to
develop th a t are constructive? Woul d you like to be
more assertive for instance? I f so, pl an to do
something that calls for assertiveness each day.
These assignments may be given verbally to
the pati ent in the therapi sts own words. I f a
relaxing and ego-building cassette tape (see
preceding chapter) has been made, remind the
pati ent that results are contingent on utilizing
the tape preferably at least twice daily.
I n addition to the above, some patients may
benefit from a pri nted or typewritten set of di
235
236
rections, such as suggested below. These may
be adapted to specific problems. T he list may
be given to and discussed with the pati ent
shortly before termination.
1. Whenever you g e t upse t or y o u r s y m pt o m s
r e turn or g e t worse, ask y o u r s e l f w h y this is so. T ry
to establish a rel ati onshi p between the symptoms
and happeni ngs in your environment. Did some
thi ng occur that made you feel guilty or angered you
or that you di dnt like? A re you puni shi ng yourself
because you feel guilty? I s something going on in
your rel ati onshi p with a person who is close to you
or with the people who are around you that is hard
for you to take? Or is something botheri ng you that
you find difficult to admit even to yourself? I t is
often helpful to keep a wri tten record of the number
of times daily that your symptoms return and ap
proximately when they started and when they
stopped. I f you j ot down the things that happened
i mmediately before the symptoms started, and the
circumstances, if any, that relieved them, you may
be able to learn to control your symptoms or elimi
nate them.
2. What are the circumstances t h a t boost a n d the
t hings that diminish the f e e l i ng s about yourself?
When do you feel good about yourself and when do
you feel bad? A re these feelings connected with your
successes or your failures? What makes you feel i n
ferior, and what makes you feel superi or? Do you
feel better when you are alone and away from
people, or do you feel better when you are with
people? What kind of people?
3. Observe t he f o r m o f y o u r re lationship with
people. What tensions do you get with people?
What kind of people do you like and dislike? A re
these tensions with all people or certai n kinds of
people? What do people do to upset you? I n what
ways do you get upset? What do you do to upset
them or to get yourself upset when you are with
them? What do you do and what do they do that
tends to make you angry? What problems do you
have with your parents, mate, children, boss, associ
ates at work, authori ti es, people in general? Do you
tend to treat anyone in a way si mi l ar to the patterns
that you established with your father, mother, sib
lings? How is your reaction to people above you,
below you, equal to you? What are your expecta
tions when you meet a very attractive person of the
opposite sex? Do you try to make yourself too de
pendent on certain people?
4. Observing daydreams or n i g h t dreams. A use
ful outline for observing the meaning of ones day or
ni ght dreams includes these three questions: What
is your feeling about yourself in the dream? What
problem are you wrestling with in the dream? By
what means do you reach, or fail to reach, a solu
tion to the problem that presents itself in the
dream?
Recurri ng dreams are parti cul arl y significant be
cause they represent a continuing core problem in
ones life. A gain, whenever possible, you should at
tempt, if you can, to rel ate the content of your
dreams to what is happeni ng in your life at that
time. One man found that he had recurri ng dreams
of bloodshed but that those dreams only occurred
after he had made an attempt to assert himself by
asking for a rai se in pay or by going out with a girl
that he liked. He was much surpri sed to discover
that his fri ghteni ng dreams were actually evidence
that he still had some old childish fears about stand
ing up for himself.
5. Observing resistances to p u t t i n g under stand
ing into action. Expect inevitable resistance when
you try to stop neurotic patterns. A nd there can be
tension and fear when one faces a challenge that for
merly has been evaded. When delaying and avoid
ance continue to occur, it is well to question the
reasons for the delay and ask why one is afraid
and then to take heart and deliberately challenge the
fear to see if it can be overcome.
T he disciplined practice of these principles
of sel f-observati on can lead to progressi ve
growth. Patterns have to be recognized and
revised if one is to achieve more satisfying
goals in life. But as everyone knows, the habits
of years give ground grudgingly and slowly.
I deally, however, the process of personality
understandi ng and growth is marked by
several discrete features: T here is the aware
ness that ones problems do not occur for
tuitously but are intimately connected with the
events (especially the human interactions) of
ones life. For a given individual there is a
certain quali ty of human event that generates
anxiety, conflict, and stress. These phenomena,
once detected, may lead next to a searching for
the origin and history of these patterns. I t is
not impossible to see how these patterns oper
ated as far back as a person can remember
HOMEWORK ASSIGNMENTS
237
perhaps even the very earliest memory con
tains something of the same thing. Seeing the
conditions under which fears originated, and
under which they are not retriggered, one may
next determine whether one can be more the
master of ones life rather than a victim of it.
Could we be different from the way we have
always known ourselves to be? And ever so
slowly, we may challenge one habitual childish
fear at a time, pushing ourselves to break out
of the prison of our neurotic self-defeating pat
terns. Success breeds success, and victory leads
to victory. Defeats are reanalyzed in accord
with thei r place in the psychic structure.
Seeing ourselves defeated by the same old
enemies, we are buoyed up in knowing that
formulations about our personalities are cor
rect, and we are then encouraged to fight on.
I ncreasingly, we can express a claim to a new
life; we find ourselves able to be more ex
pressive. Self-recriminations diminish. Our ca
pacities expand, and we gratify more of our
needs. Feeli ng less frustrated in life, and
therefore less angry, we can enter into rel a
tionships with people with more openness and
a greater ability to share.
These are idealistic goals, but they represent
a guide along the way toward greater self
observation and ri cher living. Fidelity to the
practice of self-observation, together with the
actual translation of understanding into action,
can be a lifelong quest marked by high adven
ture and notable results.
T he knowledge of oneself and how one
reacts continues to constitute the surest path to
health and to mature behavior.
Evolving a More Constructive Life Philosophy
One of the ways psychotherapy influences
people is by helping them to develop new
values and philosophies of living. However,
the history of the majority of patients, pri or to
thei r seeking therapy, attests to futile gropings
for some kind of philosphical answer to their
dil emmas. T he search may proceed from
Christi an to Oriental philosophies, from pru
rience to moralism, from self-centeredness to
community mindedness. What at first seems
firmly established soon becomes dubious as
new ideas and concepts are proffered by differ
ent authorities. I t is far better to evolve philos
ophies that are anchored in some realistic con
ception of ones personal universe than to
accept fleeting cosmic sentiments and supposi
tions no matter how sound thei r source may
seem. Even a brief period of psychotherapy
may till the soil for the growth of a healthier
sense of values. We may be able duri ng this
span to inculcate in the person a philosophy
predicted on science rather than on cultism.
T he question that natural l y follows in a
short-term program is: Can we as therapists
expedite matters by acting in an educational
capacity, pointing out faulty values and indi
cating healthy ones that the pati ent may ad
vantageousl y adopt? I f so, what are the
viewpoints to be stressed?
Actually, no matter how nondirective a ther
apist may imagine himself to be, the patient
will soon pick up from explicit or implicit cues
the tenor of the therapi sts philosophies and
values. T he kinds of questions the therapist
asks, the focus of his interpretive activities, his
confrontations and acquiescences, his silences
and expressions of interest, all designate points
of view contagious to the pati ent, which he
tends to incorporate, consciously and uncon
sciously, ultimately espousing the very con
ceptual commodities that are prized by the
therapist. Why not then openly present new
precepts that can serve the pati ent better?
Superficial as they sound, the few precepts that
can be tendered may be instrumental in ac
celerating a better adjustment. Among possible
propositions are the following:
Isolating the Past from the Present
All persons are victimized by thei r past,
which may operate as mischief mongers in the
present. A good adjustment presupposes modu
lating ones activities to present-day considera
ti ons rather than resi gni ng to prompti ngs
inspired by childish needs and mi si nterpreta
tions. I n therapy the pati ent may become
aware of what early patterns are repeating
themselves in his adult life. T hi s may provide
him with an incentive for change. On the other
hand, it may give the pati ent an excuse to ra
ti onal i ze his defections on the basis that
unalterable damage has been done to him by
his parents, who are responsible for all of his
trouble. T he therapist may remind the patient
that he, like anyone else, has a tendency to
project outmoded feelings, fears, and attitudes
into the present. His early hurtful experiences
undoubtedly contribute to his insecurity and to
his devalued self-esteem. They continue to
contami nate his adj ustment now, and he,
therefore, must try to overcome them. Thus,
the therapist would make a statement similar
to the following:
Th. Rumi nati ng on your unfortunate childhood
and bi tter past experiences are indulgences you
cannot afford. T hese can poison your present
life if you let them do this. I t is a credit to you
as a person to rise above your early mis
fortunes. A ttempt to restrai n yourself when
you fall back into thinki ng about past events
you no longer can control or when you find
yourself behaving childishly. Remember, you
may not have been responsible for what hap
pened to you when you were a child, but you
are responsible for perpetuati ng these patterns
in the present. Say to yourself, I m going to
release myself from the bonds of the past.
And work at it.
Handling Tension and Anxiety
T he pati ent may be reminded that tension
and anxiety may appear but that he can do
something positive about them.
Th. Everytime you experience tension, or any other
symptoms for that matter, ask yourself why? I s
it the immediate si tuati on you are in? I s it
something which happened before that is sti r
ri ng you up? I s it something you believe will
happen in the future? Once you have identified
the source of your tension or trouble, you will
be in a better position to handl e it. T he least
that will occur is that you will not feel so hel p
less since you know a little about its origins.
Y ou will then be in a better position to do
thi ngs to correct your trouble.
T he idea that one need not be a helpless
victim of symptoms tends to restore feelings of
mastery. A pati ent who has given this sugges
tion went to a new class. While listening to the
lecturer, she began to experience tension and
anxiety. Asking herself why, she realized she
was reacting to the presence of a classmate
who came from her own neighborhood and
knew her family. She then recognized that she
felt guilty about her interest in one of the men
in the class. T hi s happened to be the real
reason why she registered for the course. She
realized that she feared the neighbors reveal
ing her interest in the man to her parents if she
sat near him or was friendly to him. She then
thought about her mother who was a re
pressive, punitive person who had warned her
about sexual activities. With this understand
ing, she suddenl y became angry at her
classmate. When she asked herself why she
was so furious, it dawned on her that she was
actually embittered at her own mother. Her
tension and hostility disappeared when she re
solved to follow her impulses on the basis that
she was now old enough to do what she
wished.
HOMEWORK ASSIGNMENTS 239
Tolerating a Certain Amount of
Tension and Anxiety
Some tension and anxiety are inherent parts
of living. T here is no escape from them. T he
patient must be brought around to accept the
fact that he will have to tolerate and handle a
certain amount of anxiety.
Th. Even when you are finished with therapy, a
certain amount of tension and anxiety are to be
expected. All persons have to live with some
anxiety and tension, and these may precipitate
various symptoms from time to time. I f you do
get some anxiety now and then, ride it and try
to figure out what is sti rring it up. But, re
member, you are no worse off than anyone else
simply because you have some anxiety. I f you
are unabl e to resolve your tensions entirely
through self-observation, try to involve yourself
in any outside activities that will get your mind
off your tensions.
Hostility
I f the patient can be made to understand
that he will occasionally get resentful and that
if he explores the reason for this, he may be
able to avoid projecting his anger or converting
it into symptoms.
Th. I f you feel tense and upset, ask yourself if you
are angry at anything. See if you can figure out
what is causing your resentment. Permit your
self to feel angry if the occasion j ustifies it; but
express your anger in proporti on to what the
situation will tolerate. Y ou do not have to do
anythi ng that will result in trouble for you;
nevertheless, see if you can release some of
your anger. I f you can do nothi ng more, talk
out loud about it when you are alone, or
engage in muscular exercises to provide an
outlet for aggression, like punchi ng a pillow.
I n spite of these activities you may still feel
angry to a certain degree. So long as you keep
it in hand while recognizing that it exists, it
need not hurt you. All people have to live with
a certain amount of anger.
Frustration and Deprivation
No person can ever obtain a full gratifica
tion of all of his needs, and the pati ent must
come to this realization.
Th. I t is i mportant to remember that you still can
derive a great deal of j oy out of eighty per cent
rather than one hundred percent. Expect to be
frustrated to some extent and l earn to live
with it.
Correcting Remediable Elements
in One's Environment
T he pati ent may be reminded of his re
sponsibility to remedy any alterabl e factors in
his life situation.
Th. Once you have identified any area of trouble,
try to figure out what can be done about it.
L ay out a plan of action. Y ou may not be able
to implement this entirely, but do as much of it
as you can immediately, and then routinely
keep worki ng at it. No matter how hopeless
things seem, if you appl y yourself, you can do
much to rectify matters. Do not get dis
couraged. J ust keep working away.
Adjusting to Irremediable
Elements in One's Life Situation
No matter how much we may wish to cor
rect certain conditions, practical considerations
may prevent our doing much about them. For
example, one may have to learn to live with a
handicapped child or a sick husband or wife.
Ones financial situation may be irreparabl y
marginal. T here are certain things all people
have to cope with, certain situations from
which they cannot escape. I f the patient lives
in the hope of extricating himself from an un
fortunate plight by magic, he will be in con
stant frustration.
T h. T here are certain things every person has to
learn to accept. T ry your best to al ter them as
much as you can. And then if some troubles
continue, j ust tell yourself you must live with
some of them, and resolve not to let them tear
you down. I t takes a good deal of courage and
character to live with your troubles, but you
may have a responsibility to carry them. I f you
start feeling sorry for yourself, you are bound
to be upset. So j ust plug away at it and build
up insulation to help you carry on. Say to
yourself: I am not going to respond to trouble
like a weather vane. I will remedy the trouble
if I can. If I cannot, I will adjust to it. I will
concentrate on the good things in my life and
minimize the bad.
Using Will Power to Stop Engaging
in Destructive Activities
One of the unfortunate consequences of a
dynamic approach is that it gives the pati ent
the idea that he is under the influence of un
conscious monsters he cannot control. He will,
therefore, justify the acting-out on the basis of
his automati c repeti ti on-compul si ons.
Actually, once he has a glimmer of what is
happening to him, there is no reason why he
cannot enlist the cooperation of his will power
to help inhibit himself.
T h. I f you know a situation will be bad for you, try
to divert yourself from acting it out even if you
have to use your will power. T here is no
reason why you cant work out substi tute solu
tions that are less destructive to you even
though they may not immediately be so grati
fying. Remember, a certain amount of depriva
tion and frustrati on is normal, and it is a com
pliment to you as a person to be able to give up
gratifications that are ultimately hurtful to
you. Remember, too, that some of the chief
benefits you get out of your symptoms are
masochistic, a kind of need to puni sh yourself.
Y ou can learn to overcome this too. When you
observe yourself acting neurotically, stop in
your tracks and figure out what you are doing.
A woman, living a conventional life as a
housewife, was involving herself sexually with
two of her friends husbands. She found herself
unable to resist thei r advances, even though
the sexual experiences were not particul arly
fulfilling. She felt ashamed and was guil t-rid
den by her actions. T here was obviously some
deeper motive that prompted the patient to act
out sexually, but the threat to her marriage
and relationship with her husband requi red an
immediate halting of her activity. I remarked
to her: Until you figure out some of your un
derlying feelings, it is best for you to stop your
affairs right now. How would you feel about
stopping right now? L ets give ourselves a
couple of months to figure out this thing.
F rankl y, I dont see how we can make
progress unless you do. T he pati ent re
luctantly acquiesced; but soon she was relieved
that somebody was supporting her inner reso
lution to resist. T he interval enabled us to ex
plore her disappointment with her husband,
her resentment toward him, and to find out
lets for her desi res for freedom and self-
expression in more appropri ate channels than
sexual acting-out. I f the pati ent has been given
a chart detailing the interaction of dependency,
low feelings of independence, hostility, de
valued self-esteem and detachment, thei r
manifestations as well as reaction formations
to neutralize them, he may be enjoined to
study the chart and see how his own drives and
needs, with thei r consequences, fit into the
overall design.
Stopping Unreasonable Demands
on Oneself
I f the pati ent is pushing himself beyond the
limits of his capacities or setting too high
standards for himself, it will be essential for
him to assess his actions. Are they to satisfy his
ambitions or those of his parents? Are they to
do things perfectionistically? I f so, does he feel
he can achieve greater independence or stature
as a person when he succeeds?
T h. All people have thei r assets and liabilities. Y ou
may never be able to accomplish what some
HOMEWORK ASSIGNMENTS 241
persons can do; and there are some things you
can do that others will find impossible. Of
course, if you try hard enough, you can proba
bly do the impossible, but youll be worn down
so it wont mean much to you. Y ou can still
live up to your creative potentials wi thout go
ing to extremes. Y ou can really wear yourself
out if you push yourself too hard. So j ust try to
relax and to enjoy what you have, making the
most out of yourself wi thout teari ng yourself to
pieces. J ust do the best you can, avoiding using
perfectionism as a standard for yourself.
Challenging a Devalued Self-
image
Often an individual retires on the invest
ment of his conviction of sel f-deval uati on.
What need is there for him to make any effort
if he is so constitutionally inferior that all of
his best intentions and well-directed activities
will lead to naught? I t is expedient to show the
patient that he is utilizing his self-devaluation
as a destructive implement to bolster his help
lessness and perhaps to sponsor dependency.
I n thi s way he makes capi tal out of a
handicap. Pointing out realistic assets the pa
tient possesses may not succeed in destroying
the vitiated image of himself; but it does help
him to reevaluate his potentialities and to
avoid the despair of considering himself com
pletely hopeless. One may point out to the pa
tient instances of his successes. I n this respect,
encouraging the patient to adopt the idea that
he can succeed in an activity in which he is i n
terested, and to expand a present asset, may
prove to be a saving grace. A woman with a
deep sense of inferiority and lack of self-con
fidence was exhorted to add to her knowledge
of horticulture with which she was fascinated.
At gatherings she was emboldened to talk
about her specialty when an appropriate occa
sion presented itself. She found herself the
center of attention among a group of subur
banites who were eager to acquire expert in
formation. T hi s provided her with a means of
social contact and with a way of doing things
for others that built up a more estimable feel
ing about herself.
L ogic obviously cannot convince a person
with devalued self-esteem that he has merit.
Unless a proper assessment is made of his ex
isting virtues, however, the person will be
retarded in correcting his distorted self-image.
Th. Y ou do have a tendency to devalue yourself as
a result of everything that has happened to
you. From what I can observe, there is no real
reason why you should. I f you do, you may be
using self-devaluation as a way of punishing
yourself because of guilt, or of making people
feel sorry for you, or of rendering yourself
helpless and dependent. Y ou know, all people
are different; every person has a uniqueness,
like every thumbpri nt is uni que. T he fact that
you do not possess some qual i ti es other people
have does not make you inferior.
Deriving the Utmost Enjoyment
from Life
Focusing on troubles and displeasures in
ones existence can deprive a person of joys
that are his right as a human being. T he need
to develop a sense of humor and to get the
grimness out of ones daily life may be stressed.
Th. T ry to minimize the bad or hurtful elements
and concentrate on the good and constructive
things about yourself and your si tuation. I t is
i mportant for every person to reap out of each
24 hours the maximum of pl easures possible.
T ry not to live in recrimi nati ons of the past
and in forebodings about the future. J ust con
centrate on achieving happi ness in the here
and now.
Accepting One's Social Role
Every adult has a responsibility in assuming
a variety of social roles: as male or female, as
husband or wife, as a parent, as a person who
must relate to authority and on occasions act
as authority, as a community member with ob
ligations to society. Though he may feel imma
ture, dependent, hostile, and hypocritical, the
individual still must try to fill these roles as
completely as he can. I f the patient is destruc
tively involved with another person with whom
he must carry on a relationship, like an em
ployer, for example, he must attempt to under
stand the forces that serve to disturb the rel a
tionship. At the same time, however, he must
try to keep the relationship going in a way that
convention dictates so that he will not do
anything destructive to his security.
Th. One way of trying to get along with people is
to attempt to put yourself in thei r position and
to see things from their point of view. I f your
husband [wife, child, employer, etc.] is doing
something that is upsettti ng, ask yourself:
What is he [she] feeling at this time; what is
going on in his ]her] mind? How would I feel
if I were in his [her] posi ti on? At any rate, if
you can recognize what is going on, correcting
matters that can be resolved, adj usti ng to those
that cannot be changed; if you are able to
rel ate to the good rather than to the bad in
people, you should be able to get along with
them wi thout too much difficulty.
T he form by which the above guidelines are
verbally or graphically communicated to the
pati ent will vary, and each therapist may
decide whether they are useful in whole or in
part for specific patients. Reading assignments
may also be given and suggestions for con
tinued self-education made after therapy has
ended. A full list of reading materials will be
found elsewhere (Wolberg, 1977, pp. 816-
833).
Conclusion
I t is important to supply patients with
homework assignments to reinforce the value
of their sessions. These tasks are usually re
lated to what is immediately going on in ther
apy, whether they involve exploring the nature
of ones problems, charting the frequency of
symptoms and recording the circumstances
under which they appear, recognizing the con
structive and destructive elements in the im
medi ate envi ronment, observing behavioral
patterns and reinforcing those that are adap
tive, picking out situations that enhance or
lower self-esteem, studying ones relationships
with people, examining dreams and fantasies,
or seeing what resistances block the putting of
understanding into productive action. Practice
sessions devoted to assertive and other con
structive forms of behavior are especially help
ful. Some of the assigned exercises strive to i n
culcate new values and phi l osophi es that
contribute to a more productive adjustment. A
relaxing and ego-building cassette tape as well
as assigned readings are additional useful ac
cessories.
CHAPTER 17
Termination of Short-term Therapy
Proper termination of treatment is one of
the most neglected aspects of the therapeutic
process. I deally, it should start in the initial in
terview during which the limited time span is
emphasized. Even though the pati ent i m
mediately accepts this provisional arrange
ment, later, as the therapeutic relationship
crystallizes, its ending can pose a threat.
T ermi nati on of therapy is no problem in
most patients who are adequately prepared for
it, or who are characterologically not too de
pendent, or who are seen for only a few
sessions and discharged before a strong rel a
tionship with the therapist develops, or who
are so detached that they ward off a close
therapeutic contact. I t may, however, become a
difficult problem in other cases. Patients who
in early childhood have suffered rejection or
abandonment by or loss of a parent, or who
have had difficulties in working through the
separati on-i ndi vi duati on dimensi ons of thei r
development are especially vulnerable and may
react with fear, anger, despair, and grief. A
return of their original symptoms will tend to
confound the pati ent and inspire in the thera
pist frustration, disappointment, guilt feelings,
and anger at the patient for having failed to re
spond to therapeutic ministrations.
Resistance to termination affects not only the
patient; it is present also in the therapist
who for conscious or unconscious reasons may
not be willing to let his pati ent separate.
T herapi sts countertransferentially form attach
ments to some of thei r patients, and they
may resent sending them away. Sometimes
monetary factors influence delays in termi na
tion, particularly during periods when new
referrals are sparse. Sometimes the projected
goals of therapy have been set too high, and
both pati ent and therapist are disappointed
with what seem meager results. They will then
eagerly cancel the termi nati on contract and
hopefully embark on a search for a cure with a
fresh series of sessions that will usual l y
eventuate in long-term and in some cases i nter
minable treatment.
T he word cure is an ambiguous ex
pression when related to emotional problems.
Most optimistically it designates an eli mi na
tion of pathology and the induction of a total
and robust state of well-being. To anticipate
such a goal in short-term therapy excites un
realistic hope and optimism. M any of the im
pri nts of unfortunate life experience, parti cu
larly those compounded in early childhood, are
more or less indelible and cannot be eliminated
completely by any method known today. Nor
can all characterol ogi c deficits be total l y
regenerated, residual distortions often obtrud
ing themselves impertinently at unguarded mo
ments even in the most successfully treated in
dividual. On the other hand, it is possible to
neutralize the effects of inimical past experi
ence, to enhance security, to bolster self
esteem, and to improve adaptation and prob
lem solving through well-conducted short-term
psychotherapy. T he objectives that we may
practically achieve are these:
1. M odification or removal of symptoms and relief
of suffering.
2. Revival of that level of functioning that the pa
ti ent possessed pri or to the outbreak of the illness.
3. Promotion of an understandi ng that there are
patterns indulged that sponsor symptoms, sabotage
243
functioning, and interfere with a more complete en- 5. Provision of useful ways of dealing with such
j oyment of life. patterns and thei r effects in order to rectify and
4. A ttai nment of some idea of how to recognize repl ace them wi th more constructi ve copi ng
the existence of self-defeating patterns and how to measures,
explore thei r consequences.
Termination Procedures
Following the suggestions detailed in Chap
ter 4 A General Outl i ne of Short-term
T herapy, the pati ent is appri sed of the
limited number of sessions that will constitute
treatment, ei ther by desi gnati ng the exact
number in advance and setting a termination
date or, after indicating that the number of
sessions will be circumscribed, by postponing
announcing the ending date until after therapy
has started. Once the target date is settled, the
patient is periodically reminded of it and
responses to this briefing handled (see pp. 45-
46). With rare exceptions therapy should be
ended on the agreed-upon date (p. 46). T he
need to work on oneself is stressed (p. 47), and
arrangements for further treatment made if
necessary (p. 47).
T he question is often asked as to whether
symptomatic improvement by itself without
some understanding of the underlying sources
of the current upset is sufficient justification for
the termination of therapy. I deally the answer
would be no. Symptomatic relief may occur as
a consequence of the placebo effect and may
expend itsel f rapi dl y unless changes are
brought about in the environment as well as in
the self. Nevertheless, we should not minimize
the importance of symptom removal since
without it no therapy can justify itself. Relief
of symptoms can restore important defenses
that are a part of the individuals habitual
adaptive machinery. In this way we may best
achieve the objective of restituti ng the optimal
past adjustment. Most patients are satisfied
with this accomplishment, but occasionally
some individuals expect more extensive results
within a few sessions.
I t is manifestly impossible to uproot per
sonality difficulties that date back to childhood
in a short period, and quite likely even inten
sive prolonged treatment will fail to budge
some patterns. T he pati ent will therefore have
to be prepared for termi nati on with the
achievement of only less than a complete cure.
A pati ent who came for treatment with a prob
lem of obesity, depression, and strong feelings
of inferiority was helped in 10 sessions to cor
rect his food habits and to lose weight. His
depression lessened to a great extent, but there
was no change in the sleazy image he had of
himself. I reminded him that our agreed-upon
goal in therapy was to help him develop better
food habits and moderate his depression. An ex
cerpt follows:
Pt. I feel a lot better, the weight and all, but I still
feel like I dont amount to much.
Th. W eve gone over some of the reasons why you
always have felt this way.
Pt. But cant I be cured of this?
Th. Y our problem goes so far back that a complete
cure would take a long time. Even then a few
residues of your childhood may pop up from
time to time. T hi s i snt i mportant because you
can still keep growing and developing on your
own with what you have al ready l earned in
therapy. Right now you can overcome your
symptoms, like overeating and depression, and
function a lot better in spite of how you feel
about yourself. T he reality is that you are not
an i nferior person even though you feel you
are. Over a long period appl yi ng the under
standing you now have will wear out thi s delu
sion about yourself. But expect no miracles. I t
will take time. T he i mportant thi ng is to keep
working at yourself. Suppose you try things on
TERMINATION OF SHORT-TERM THERAPY 245
your own, and in about 3 months we will
make another appoi ntment to see how you are
doing.
Pt. T hats great. M aybe I can work at this by
myself, and if I need further help, I ll call you.
Th. Fine. Dont hesitate to call me if any further
problems develop.
I n avoiding the pati ents request for longer-
term therapy, we indicate that it is essential for
the patient to try to resolve his problems by
himself. This is done with no illusion that a
cure will come about in any characterologic dis
tortions, but rather to avoid becoming de
pendent on therapy. Proceeding on ones own,
progress may be made with interim sessions of
short-term therapy if necessary. I n this case two
such brief periods of five and six sessions each
were used the first year and three sessions the
second year. Single follow-up sessions the third
and fifth years revealed extensive and gratifying
personality changes.
T hi s does not imply that long-term therapy
may not be the treatment of choice in some
cases. But the selection of patients must be
carefully made.
A nother common question that confronts the
therapist is if at the end of the alloted treat
ment time a pati ent feels better but has not
reached the goals set by the therapist origi
nally, should termination then be delayed? I t is
difficult to generalize an answer to this ques
tion other than to say that certain patients will
benefit from further therapy and others will
not. Much as we would like to continue work
ing with a patient, the danger of interminable
therapy must be kept in mind. Some patients
will not, for sundry reasons, be able to achieve
the objectives that the therapist has anticipated
or that they themselves covet, no matter how
long we keep them in treatment. I ndeed,
continued therapy may dissipate the gains
achieved in the prel iminary short-term treat
ment period, the patient becoming steeped in a
negative transference and in cri ppl i ng de
pendency from which he cannot l i berate
himself. T he way this problem is best handled
is to terminate therapy, enjoining the patient
to continue working on his own (with the
assigned homework) listening regularly to the
cassette tape if one is given him, and reporting
back for a session in 2 weeks, then once a
month, and after a while once every 3 months.
I t is not unusual for a pati ent to have achieved
considerable progress by himself after formal
therapy has ended once the momentum has
been started duri ng the short-term span.
Should no progress have occurred several
months after termi nati on, and should the pa
tient be dissatisfied with his status, another in
tensive short-term treatment can be instituted,
duri ng which an assay is made of the kind of
therapy best to use, the capacity of the patient
to change, and realistic goals that may be
achieved. Sometimes the second brief treatment
trial does the j ob without further formal ther
apy being needed. On the other hand, we may
not be able to avoid resorting to long-term
therapy, and here the kind of therapy and the
depth of therapy will suggest itself from the
data already obtained.
We must, nevertheless, brace ourself to the
possibility of failure no matter what we do.
I nevitably there will be persons who do not
well with any kind of therapy. M any of these
individuals go on to prolonged treatment with
the object of achieving reconstructive change
through the alchemy of time. T he idea that
long-term therapy will i nevi tabl y succeed
where short-term approaches have failed is de
ceptive. T here are some patients who seem
doomed to a perpetual immature adjustment,
clinging to a parental figure in a dependent
way the remainder of thei r lives. Some theories
of why this is so have been presented. One
speculation for a certain type of pati ent is that
in treatment the pati ent is unable to bring
about the internalization of the therapist as an
object-anchor around which the patient can or
ganize himself or to mai ntai n an equilibrium
in the face of the anxiety released by interpre
tive work (A ppelbaum, 1972). T here are
other surmises too, but some sicker patients
will respond much more to adjunctive environ
mental mani pulation, rehabilitative treatment,
social therapy, and pharmacotherapy than to
246
formal psychotherapy, although periodic psy
chotherapeutic sessions with a skillful and
empathic therapist along with adjunctive ap
proaches should produce optimal results.
M ost patients, fortunately, may be helped
and significantly helpedby dynamic short
term therapy. Even deep personality difficul
ties may be influenced. Because entrenched
character patterns are dislodged reluctantly,
however mal adapti ve they may be, it is
assumed that character al terati ons while
initiated duri ng the formal treatment period
will need to continue to develop in the post-
therapeuti c span over an extended interval,
even over years, before permanent altered im
pri nts are etched into the personality structure.
Managing Untoward Reactions to Termination
I n patients who have been in therapy for
more than a handful of sessions and who have
established a good therapeutic alliance, stormy
clouds may gather as the termination date
draws near. T he fact that the ending of ther
apy brings out unresolved issues related to the
separation-individuation theme is not entirely
a liability. I ndeed, as Rank (1936, 1947)
insisted years ago it may become the most im
portant aspect of the helping process by forcing
the patient to face paralyzing dependencies and
to assume the responsibilities of individuation.
M any other authorities affirm Ranks belief
that the working-through of residues of child
ish helplessness is essential toward sponsoring
greater personality maturation. I t is, however,
naive to assume that adulthood will break out
in a flash solely as a consequence of being
evicted from therapy. I t will requi re perhaps
years before the fruits of maturity can mellow.
T he therapist should not deceive himself into
believing that individuation is easy to achieve
and that with termination the patient, sword
in hand, can happily saunter out to conquer
the world. Nevertheless, the seeds of self-
reliance have a greater chance of germination
in the soil provided by the proper management
of the terminal phases of the pati ent-therapi st
relationship.
How intense the reactions to termination be
come will depend on the pati ents residual de
pendency needs, how thoroughly these needs
have been supported during treatment, the
way that the pati ent was prepared for termi na
tion, and bringing into the open the pati ents
feelings about termination. Often these feelings
are not explicit, the patient being afraid to ex
press anger or grief openly and the therapist
avoiding areas that might be upsetting or em
barrassi ng to him. I t is i mportant, con
sequently, to face the fact that termination can
be difficult for the therapist also and because of
this may requi re some soul searching on his
part. Will the therapist be relieved in getting
rid of a burdensome patient and consequently
facilitate the easing of the pati ent out of his of
fice? Will he feel guilty at discharging a pa
tient who still suffers from residuals of the
problem for which help was originally sought?
Will he resent the financial loss created by a
hole in his caseload? Will he himself suffer
separation anxiety caused by his own unre
solved separation-individuation problems? I t
will take a good deal of courage to face up to
these issues.
Where dreams and exploration of acting-out
tendencies are employed, the pati ents feelings
about termination will be most readily avail
able. A patient was asked at the tenth session
how she felt about termi nati ng treatment the
following month. She admitted feeling better
and said that she was happy that I considered
her well enough to be on her own. T he next
session she admitted feeling a bit shaky
about handling matters by herself and that this
reaction lasted for several hours after she left
TERMINATION OF SHORT-TERM THERAPY 247
my office. She denied any feelings of resent
ment or depression. At the following session
she brought in this dream: I am attending a
funeral. A girl with arms cut off in a coffin.
She looks like me. I am frightened and run
home. For the next few sessions we focused
on her feelings of helplessness and fears of
what might happen to her after she stopped, as
well as her anger at me. Early dependencies
fostered by an overprotective mother were ex
plored. No revision of the termination time
was made. At the fourteenth session she admi t
ted feeling a great deal better, and she
presented this dream: I am sliding down a
chute and falling down, then standing up, then
falling down, then standing up, then falling
down. M other and father run up to pick me
up. I push them away and I stand alone. I
walk unsteadily but under my own power. In
her associations she stated that at work she
had taken a definite stand. She was proud of
herself because she refused to go to her em
ployer for advice. I know more about these
things than he does. T ermi nati on occurred
after the next session. A 2-year follow-up
showed continuing and extensive improvement
in her adjustment.
T he importance of allowing patients to ex
press their feelings of disappointment, anger,
and sadness cannot be overemphasized. T he
therapist will especially be alerted for prob
lems where, as has been mentioned before, the
patient as a child experienced a death of or
separation from a parent or where in later life
a catastrophic reaction followed the loss of or
separation from a parent or mate. Patients
with a high level of characterologic dependency
may regard termination as a personal injury,
an unwarranted desertion, or a sign of their
lack of importance or self-worth. I t is essential
not to act defensive or guilty about terminating
treatment. Explanations should focus on the
need to protect the patient from getting locked
into a dependency situation in treatment that
will prove crippling and infantalizing. Most
patients will handle the termination experience
when given a chance to express themselves
freely. Occasionally, though, the pati ent may
become so angry or distrustful as to break ap
pointments. I f this occurs, the therapist should
contact the pati ent by telephone and discuss
what is happening. T he fact that sufficient in
terest exists to induce the telephone call in all
probability will motivate the pati ent to return
for the remaining sessions.
I have found that the use of a cassette tape
helps the termination process immeasureably
pp. 223-234). T he patient does not experi
ence the shock of being left alone on his own
devices. He has a tool that he can utilize by
himself to expand the gains that he has derived
from treatment. T herapi sts who imagine that
the i ndi vi duati on process is expedited by
abruptly tossing patients out of treatment after
the last session on the theory that the absence
of the therapist and the presence of insight are
remedial will encounter a rude shock when
adqequate follow-ups are done. A surprisingly
large number of patients, who presumably had
achieved maturi ty at discharge, sooner or later
lock themselves into new paral yzi ng de
pendencies with some surrogate parental figure
or exploit successive offbeat treatment mo
dal i ti es once they reexperi ence tension or
anxiety. T he use of the tape makes these feck
less resources unnecessary. Speculation that
the pati ent may get dependent on the tape and
that this will thwart the individuation process
is completely groundless. On the contrary, the
tape enjoins the pati ent to continue the work
ing-through process toward greater self-suffi
ciency.
No short-term treatment program is com
plete without some provision for this or some
other type of self-help as well as maintenance
of proper vigilance to prevent slipping back to
the previous state. T he pati ent should be en
joined to pursue homework assignments
given him duri ng the active treatment period
(see Chapter 16) and invited to return to see
the therapist briefly should serious problems
develop in the future that he cannot manage by
himself (p. 46).
An aspect in therapy that is also neglected is
providing pati ents with some means of correct
ing distorted cognitions. Supplying them with
a way of looking at life and at their own ex
periences, in short with a proper life phi
losophy, may add to their enhancement of
well-being. We might consider this a kind of
cognitive therapy. T he spontaneous evolution
of more wholesome ways of looking at things
often occurs subtly as a result of the cogent ap
plication of principles that the pati ent has
learned in therapy. L ife is approached from an
altered perspective. What was at one time
frightening or guilt inspiring is no longer dis
turbi ng; what bri ngs insecuri ty and un
dermines self-esteem ceases to register such ef
fects. T his revolution takes time. V alue change
may not be discernible until years have passed
beyond the formal treatment period.
I t is often helpful to warn the patient that,
while one may feel better, there will be re
quired a consistent application of what has
been learned in therapy to insure a more
permanent resolution of deeper problems. T he
need for self-observation and for the active
challenging of neurotic patterns is stressed.
T he patient is also enjoined not to get upset if
a setback is experienced.
Th. Setbacks are normal in the course of develop
ment. A fter all, some of these patterns are as
old as you are. T hey will try to repeat
themselves even when you have an understand
ing of thei r nature. But what will happen is
that the setbacks will get shorter and shorter
as you appl y your understandi ng to what
produced the setback. G radual l y you will
restructure yourself. I n a way it is good if a set
back occurs, for then you will have an opportu
nity to come to grips again with your basic
problems to see how they work. T hi s can build
up your stami na. I t is like taki ng a vaccine.
Repeated doses produce a temporary physical
upset, but complete immuni zati on eventually
results. I n other words, if your symptoms come
back, dont panic. I t doesnt mean anything
more than that something has stirred up power
ful tensions. Ask yourself what has created your
tensions. I s there anythi ng in your immediate
si tuati on that triggered thi ngs? Relate this to
what you know about yourself, about your per
sonality in general. Eventually, you will be able
to stop your reaction. But be pati ent and keep
worki ng at it.
A nother neglected aspect of therapy are fol
low-up sessions. Pri or to his discharge the pa
tient may be told that it is customary to have a
follow-up session 1 year after treatment, then
yearly thereafter for a few years. M ost patients
do not object to this; indeed, they are flattered
by the therapi sts interest. An appointment for
a session is best made by a personal telephone
call. Where the pati ent, for any reason, finds it
impossible to keep the appointment, a friendly
letter may be sent asking him to write the ther
apist detailing his feelings and progress if any.
Conclusion
T he termination phases of short-term treat
ment are often minimized, many therapists
imagining that the end of therapy will come
about automatically. L eft to thei r own re
sources, a considerable number of patients, if
they can afford it, or if treatment is paid for by
a third party, will want to continue in treat
ment indefinitely. T he goals of short-term
therapy are often set too high by both patients
and therapists. Realistically, it is a forlorn
hope that patients can undo in a few sessions a
li fetime bundl e of personal i ty i mmaturi ti es
they could not eliminate with long-term treat
ment over an indefinite period. I t will be
essential, therefore, for the therapist to accept
modest attainabl e goals within the brief span
of treatment, while alerting the pati ent to
problems to be worked on by oneself after ther
apy has ended. T herapy with a few exceptions
should be terminated at the designated set time
limit.
T ermi nati on, however, can be a problem for
TERMINATION OF SHORT-TERM THERAPY
249
both patient and therapist. As the termination
date approaches, the patient may experience a
regression with symptom revival. T he thera
pist will then be tempted to proceed beyond
the termination date hoping that a few more
sessions will save the day. I nstead of yielding
to this temptation, the therapist more propi
ti ousl y should exami ne what termi nati on
means to the pati ent and to himself. Usually it
will have sti rred up the old dependency-
autonomy conflict in the pati ent. And the fact
that the patient has not achieved the entire
hoped-for cure may, in turn, open old un
healed wounds in the therapi st, incl udi ng
grandiosity and narcissistic need to prove i n
vincibility as a therapist. I t may also kindle the
separation anxiety sparked by the pati ents
threatened departure. Both transference and
countertransference will requi re exploration at
thi s poi nt to help the separati on process
toward allowing patients to stand on their own
feet, putting into practice the lessons learned in
therapy. T he therapist must accept the fact
that no patient can be completely cured at the
termination of short-term therapy. T he most
that can be hoped for is that enough has been
gained in treatment to have achieved symptom
relief, abandonment of an old destructive pat
tern or two or at least some understanding of
these patterns, and ideas of how one can keep
working on onesel f to assure conti nui ng
improvement.
Therapeutic change does not cease at the
termination of therapy. I t may continue long
after treatment has ended, perhaps the re
mainder of the individuals life. I ndeed, follow-
up studies of patients who stopped therapy in a
stalemate or because of no apparent improve
ment have revealed gratifying alterations that
seem to have required the ripening effects of
time.
T oo frequentl y therapy is presumed to
termi nate with the last interview. T he fact that
over 60 percent of patients who have com
pleted short-term therapy seek out further
treatments (Patterson et al, 1977) indicates
that an ongoing therapeutic experience of some
kind, formal or informal, is deemed necessary
by the great majority. I f the therapist does not
provide a direction, the pati ent will search for
one personally, perhaps blundering into adven
tures that are unrewardi ng to say the least.
One way to foster continued improvement is
to prepare the pati ent to work toward altering
a destructive environment so that it ceases to
impose strains on adjustment. T he lines along
which such modulations may be made will be
determined duri ng the active treatment phase.
Homework should be encouraged. These
may embody (1) tension reduction and ego-
building through self-relaxation exercises or
listening to a cassette tape, (2) inculcation of a
proper philosophical outlook by imparting new
meanings to ones existence, (3) observation of
ones behavior to detect patterns that provoke
problems, and (4) the studied practice of more
constructive modes of coping with essential
responsibilities.
L est we chide ourselves at not having
achieved with dynamic short-term therapy a
completely analyzed pati ent on termination,
we may heed the wise words of Freud who
wrote: Our aim will not be to rub off every
peculiarity of human character for the sake of
a schematic normality, nor yet to demand that
the person who has been thoroughly analyzed
shall feel no passions and develop no internal
conflicts. T he business of the analysis is to
secure the best possible psychological condi
tions for the functions of the ego; with that it
has discharged its task. We are, of course,
hopeful that with continued work on them
selves our pati ents will proceed beyond this ob
jective.
References
A dler A: T he I ndivi dual Psychology of A lfred A dler. New
Y ork, Basic Books, 1956.
A dler G, Buie DH : T he misuses of confrontati on with
borderl i ne pati ents, in M asserman J H (ed): C urrent
Psychiatric T herapi es, Vol 14. New Y ork, G rune &
Stratton, 1974.
A dler G, M yerson PG: Confrontati on in Psychotherapy.
New Y ork, A ronson, 1973.
A dl er K A : T echni ques that shorten psychotherapy:
I l l ustrated wi th five cases. J I nd Psychol 28(21): 155
168.1972.
A kiskal HS, M cK i nney W T , J r: Psychiatry and pseu
dopsychi atry. A rch Gen Psychiatry 28:367, 1973.
A lexander F: T he bri ef psychotherapy council and its out
look. Proc Brief Psychother Counci l 2:14, 1944.
A lexander F, French T M : Psychoanal ytic T herapy. New
Y ork, Ronal d Press, 1946.
A l exander J F , Parsons BV : Short-term behavi oral i nter
vention wi th del i nquent families: I mpact on family
process and recidivism, I A bnorm Psychol 81:219
225.1973.
A lger I : T elevi si on image confrontati on in group therapy,
in Sager C J , K apl an HS (eds): Progress in Group
and Fami l y T herapy. New Y ork, B runner/M azel ,
1972.
A mada G: Cri si s-ori ented psychotherapy: Some theo
retical and practi cal considerations. J Contemp Psy
chother 9:104-111, 1977.
A nnexton M : T reatment for del ayed stress response.
J A M A 240:1948, 1978.
A nsbacher H L : A dl eri an psychology: T he tradi ti on of
bri ef psychotherapy. J I nd Psychol 28:137- 151,
1972.
A ppel baum SA: How long is long-term psychotherapy?
Bull M enni nger Cl i ni c 36:652, 1972.
A rgyle M , et al : Social skill s trai ni ng and psychotherapy:
A comparati ve study. Psychol M ed 4:435-443, 1974.
A ronson M L : A group program for overcoming the fear of
flying, in Wol berg L R , A ronson M L (eds): Group
T herapy 1974: A n Overview. New Y ork, Stratton I n
terconti nental , 1974.
A vnet H H : Psychiatric I nsurance: Fi nanci ng Short-term
A mbul atory T reatment. New Y ork, G roup Heal th
I nsurance, 1962.
A yllon T , A zri n N H : T he T oken Economy: A M oti va
ti onal System for T herapy and Rehabi l i tati on. New
Y ork, A ppl eton-Century-Crofts, 1968.
Bach G R : T he marathon group: I ntensi ve practi ce in i nti
mate i nteracti on. Psychol Rep 18:995-1002, 1966.
Bach G R : M arathon group dynamics: I. Some functions
of the professional group faci l i tator. Psychol Rep
20:995-999, 1967 (a).
Bach G R : M arathon group dynamics: I I . Di mensi ons of
hel pfulness: T herapeuti c aggression. Psychol Rep
20:1147-1158, 1967 (b).
Bach GR : M arathon group dynamics: I I I . Disjunctive
contacts. Psychol Rep 20:1163-1172, 1967 (c).
Bach G R : Group and l eader phobi as in marathon groups.
V oices 3:41- 46, 1967 (d).
Back K W: Beyond Words: T he Story of Sensiti vity T rai n
ing and the E ncounter M ovement. New Y ork, Russell
Sage F oundati on, 1972.
B akker CB, B akker-R abdau M K : N o T respassi ng, E x
pl orati ons in H uman T erri tori al i ty. C orte M edera,
Cal if, C handl er & Sharp, 1973.
B al dwi n BA : Cri si s i nterventi on in professional practice.
A m J Orthopsychi atry 47:659-670, 1977.
B andura A: Pri nci pl es of Behavior M odi fi cati on. New
Y ork, H ol t, R i nehart & Wi nston, 1969.
B arten H H : T he coming of age of the bri ef psycho-
therapi es, in Bel iak L , B arten H H (eds): Progress in
Communi ty M ental H eal th. New Y ork, G rune &
Stratton, 1969.
B arten H H : B ri ef T herapi es. N ew Y ork, B ehavi or
Publ i cati ons, 1971.
B arten H H : Comments on A dl eri an psychology: T he
tradi ti on of bri ef psychotherapy. J I nd Psychol
28:152-153, 1972.
B artol etti M D : Conj oi nt family therapy wi th cl inic team
in a shoppi ng pl aza. G roup Psychother 22:203-211,
1969 (a).
B artol etti M D : Conj oi nt family therapy wi th cl inic team
in a shoppi ng pl aza. I nt J Soc Psychi atry 15:250-
257, 1969 (b).
Beck A T : Rel i abi l i ty of psychi atri c diagnosi s. I . A cri ti que
of systematic studies. A m J Psychi atry 119:210, 1962.
250
REFERENCES 251
Beck A T : Cogni ti on, affect, and psychopathology. A rch
Gen Psychiatry 24 .495-500, 1971.
Beck A T : Cognitive T herapy and Emoti onal Disorders.
New Y ork, I nternati onal Universities Press, 1976.
Beck A T , W ard C H , M endel son M , et al : Rel i abi l i ty of
psychiatric diagnosi s. 2. A study of consistency of
cl inical j udgments and rati ngs. A m J Psychiatry
119:351, 1962.
Beck D: T reatment techni ques in short-term psychoana
l yti c therapy. Z Psychosom M ed Psychoanal
14(2):125136, 1968.
Beck DF : Research findi ngs on the outcome of mari tal
counsel ing. Soc Casework 56:153-181, 1975.
Beck SJ : R orschachs T est, V ols 1-3. New Y ork, G rune &
Stratton, 1944-1952.
Becker A, Gol dberg H L : Home treatment services, in
Grunebaum H (ed): T he Practi ce of Communi ty
M ental H eal th. Boston, L i ttl e. Brown, 1970.
Beliak L : Handbook of Communi ty Psychiatry and Com
muni ty M ental H eal th. New Y ork, Grune & Strat
ton, 1964.
Beliak L : Combi ned psycho and pharmacotherapy with
special reference to short-term therapy and emergency
therapy Psychi atr Cl i n (Basel) 10(1 3): 102-112,
1977.
Beliak L , Smal l L (eds): T he choice of i nterventi on, in
Emergency Psychotherapy and Brief Psychotherapy.
New Y ork, G rune & Stratton, 1965; 2nd ed, 1978.
Beliak L , Smal l L : Emergency Psychotherapy and Brief
Psychotherapy. New Y ork, Grune & Stratton, 1965;
2nd ed, 1978.
Bellville T P , et al : Conj oi nt marri age therapy wi th a hus-
band-and-wi fe team. A m J Orthopsychi atry 39:73-
83, 1969.
Bender L : A V isual M otor Gestal t T est and I ts Cl i ni cal
Use New Y ork, A meri can Orthopsychi atri c A ssoci a
ti on, 1938.
Benj ami n J : A method for di sti ngui shi ng and eval uati ng
f ormal thi nki ng di sorders in schi zophreni a, in
K asani n J S (ed): L anguage and T hought in Schi z
ophreni a. Berkeley, University of Cal i forni a Press,
1944.
Benson H, Beary J F , Carol M P: T he rel axati on response.
Psychiatry 37:37-46, 1974.
Bention A L : Psychological tests for brai n damage, in
F reedman A M , K apl an H I , Sadock BJ (eds):
Comprehensi ve T extbook of Psychi atry, Vol 2, 2nd
ed. Bal timore, Wi l l i ams & Wi l ki ns, 1975, pp. 757-
768.
Berenbaum H L , et al : M assed ti me-l i mi ted therapy. Psy-
chother T heory Res Prac 6:54-56, 1969.
Berger M M : V ideotape T echni ques in Psychi atri c T rai n
i ng and T reatment. New Y ork, B runner/M azel ,
1970.
Berger M M : Sel f-confrontati on through video. A m J Psy
choanal 31:48-58, 1971.
Bergl er E: T he Basic Neuroses, Oral Regression, and Psy
chic M asochism. New Y ork, G rune & Stratton, 1949.
Berl in I N: Cri si s i nterventi on and short-term therapy: An
approach in a child psychi atri c clinic. J A m A cad
Chi l d Psychi atry 9:595-606, 1970.
Berne E: Games People Play. New Y ork, Grove Press,
1964.
Bi erer J : T herapeuti c Social Cl ubs. L ondon, L ewi s, 1948.
Bijou SW, Redd W H : Behavior therapy for chi l dren, in
A rieti S (ed): A meri can H andbook of Psychi atry, Vol
5, 2nd ed. New Y ork, Basic Books, 1975.
Bi nder J L : M odes of focusing in psychoanal yti c short-term
therapy. Psychother T heory Res Prac 14:232-241,
1977.
B l anchard E B , Y oung L D : C l i ni cal appl i cati ons of
biofeedback trai ni ng: A review of evidence. A rch Gen
Psychi atry 3:573-589, 1974
Bleeker J A : Brief psychotherapy wi th living cancer pa
ti ent. Psychother Psychoanal 29:282-287, 1978.
Bloch DA : T echni ques of F ami l y P sychotherapy: A
Pri mer. New Y ork, G rune & Stratton, 1973.
Borghi J : Premature termi nati on of psychotherapy and
pati ent- therapi st expectati ons. A m J Psychother
22:460-473, 1968.
B ragan K : T i me-l i mi ted psychotherapy wi th universi ty
students. A ust N Z J Psychiatry 12(3): 151 155, 1978.
Brechenser D M : Brief psychotherapy using transacti onal
analysis. Soc Casework 53:173-176, 1972.
Brown J S, K osterl i tz N: Selection and treatment of psy
chi atri c outpati ents. A rch Gen Psychi atry 11:425-
438, 1964.
Buck J N : T he-H ouse-T ree-Person T est. Colony, V a,
L ynchburgh State Colony, 1947.
B uda B: U ti l i zati on of resi stance and paradox communi ca
ti on in short-term psychotherapy. Psychother Psy
chosom 20:200 211, 1972.
B udman SH, et al: A dult mental heal th services in a
heal th mai ntenance organi zati on. A m J Psychiatry
136:392-395, 1979.
B urdon A P, Neel y J G : C hroni c school fai l ure in boys: A
short-term group therapy and educati onal approach.
A mJ Psychi atry 122:1211-1220, 1966.
Burke J D , Whi te H H , Havens L L : M atchi ng pati ent and
method. A rch Gen Psychi atry 35:177-186, 1979.
Burton A: Encounter: T he T heory and Practi ce of E n
counter Groups. San Franci sco, J ossey-Bass, 1969.
Butcher J H , M audal GR: Cri si s i nterventi on, in Wei ner
I B (ed): Cli nical M ethods in Psychology. New Y ork,
Wi l ey, 1976.
Campbel l DD: A short-term psychotherapy for depres
si on: A second control l ed study. D i ssertati on
A bstracts I nt 35(2-B ):1039, 1974.
Campbel l RJ : F aci l i tati on of short-term cl inic therapy, in
M asserman J H (ed): C urrent Psychi atri c T herapi es,
V ol 7. New Y ork, G rune 8c Stratton, 1967.
C apl an G: A n A pproach to Communi ty M ental Heal th.
New Y ork, G rune & Stratton, 1961.
C apl an G: Pri nci pl es of Preventive Psychi atry. New Y ork,
Basic Books, 1964.
252
C arr A C: I nstruments commonly used by cl inical psychol
ogists, in Freedman A M , K apl an H I , Sadock BJ
(eds): Comprehensi ve T extbook of Psychi atry, V ol 2,
2nd ed. Bal ti more, Wi l l i ams & Wi l ki ns, 1975, pp.
768-771.
C arr A C: Psychological testi ng of intell igence and per
sonali ty, in F reedman A M , K apl an H I , Sadock BJ
(eds): Comprehensi ve T extbook of Psychi atry, V ol 2,
2nd ed. Bal timore, M d. Wi l l i ams & Wi l ki ns, 1975,
p p . 736-757.
C arri ngton P: Freedom in M edi tati on. New Y ork, Dou
bleday, 1977.
Carri ngton P, Ephron HS: Cl i ni cal use of medi tati on, in
M asserman J H (ed): C urrent Psychiatric T herapi es,
V ol 15. New Y ork, Grune & Stratton, 1975.
Casri el D: A Scream A way from Happi ness. New Y ork,
Grosset & Dunl ap, 1972.
Casri el D, Deitch D: T he marathon: T i me extended
group therapy, in M asserman J H (ed): C urrent Psy
chi atri c T herapi es, V ol 8. New Y ork, G rune & Strat
ton, 1968.
Castelnuovo-T edesco P: Decreasi ng the length of psycho
therapy: T heoreti cal and practi cal aspects of the
probl em, in A rieti S (ed): T he Worl d Bienniel of Psy
chi atry and Psychoanal ysi s, V ol 1. New Y ork, Basic
Books, 1971, pp 55-71.
Castelnuovo-T edesco P: Brief psychotherapy, in A rieti S,
Freedman DX , Dyrud J E (eds): A meri can Handbook
of Psychi atry, V ol 5, 2nd ed. New Y ork, Basic Books,
1975, pp. 254-268.
Chil es J A , Sanger E: T he use of groups in bri ef i npati ent
treatment of adol escents. H osp C ommuni ty Psy
chi atry 28:443-445, 1977.
C l ark CC: A social systems approach to short-term psy
chi atri c care. Perspect Psychi atr C are 10(4): 178182,
1972.
Col eman M D, Zwerl i ng I : T he psychiatric emergency
cl inic: A flexible way of meeti ng community mental
heal th needs. A mJ Psychi atry 115:980-984, 1959.
Conroe R M , et al : A systematic approach to bri ef psy
chological i nteracti on in the pri mary core setting. J
F am Pract 7:1137-1142, 1978.
Corney R T , Grey W H : T oward removing the barri cade
to psychiatric clinic avai l abi l i ty. A m J Psychiatry
126:144-148, 1970.
Corsi ni RJ : Role Pl ayi ng in Psychotherapy: A M anual .
Chicago, A ldine, 1966.
C ramer B: Brief therapy i nterventi ons wi th parents and
chi ldren. Psychi atrar enfant 17(11 ):53118, 1974.
Cramond WA : Psychotherapy of the dying pati ent. Br
M ed J 3:389-393, 1970.
C rary WG: Goals and techni ques of transi tory group ther
apy. Hosp Communi ty Psychiatry 19:389-391, 1968.
Crasi l neck HB, Hal l J A : Cli nical Hypnosi s: Princi ples
and A ppl i cati ons. New Y ork, Grune & Stratton,
1975.
Crosa G: T he Schultz method of autogenous trai ni ng:
Gl obal therapeuti c techni que. Riv Psi chi atri a 2(6):
534-539, 1967.
Crowe M J , et al : T i me-l i mi ted desensi ti zati on, implosion
and shapi ng for phobi a pati ents. Behav Res T heory
Prac 10:319-328, 1972.
Dahl strom G, Welsh GS, Dahl strom L E : A n M .M .P .I
H andbook. V ol I , C l i ni cal I nterpretati on M i n
neapol i s, U ni versi ty of M i nnesota Press, 1972.
D anner J , Gamson R: Experi ence wi th mul ti -fami l y ti me-
li mi ted, outpati ent group at a communi ty psychiatric
clinic. Psychi atry 3:126-137, 1968.
Darbonne A R, A llen R: Cri si s: A review of theory, prac
ti ce and research. Psychother T heory Res Prac
4(2):49-56, 1967.
Dasberg H, V an Praag H M : T he therapeuti c effect of
short-term oral di azepam treatment on acute clinical
anxi ety in a cri si s center. A cta Psychi atr Scand
50(3):326-340, 1974.
Davanl oo H (ed): Short-term Dynami c Psychotherapy.
New Y ork, Spectrum, 1978.
Davanl oo H , Benoi t C: T ransf erence in short-term dy
nami c psychotherapy. Psychother Psychosom 29:305-
306, 1978.
Davis A E, Di ni tz S, Pasamani ck B: T he preventi on of
hospi tal i zati on in schi zophreni a five years after an ex
peri mental program. A mJ Orthopsychi atry 42:375-
388, 1972.
Dean SR: Self-help group psychotherapy: M ental pati ents
redi scover will power. I nt I Soc Psychi atry 17:72-78,
1970-1971.
Deatherage G: T he cl inical use of mi ndful ness medi ta
ti on techni ques i n short- term psychotherapy. J
T ranspersonal Psychol 7:133-143, 1975.
Decker B, Stubbl ebi ne J M : Cri si s i nterventi on and pre
vention of psychi atri c di sabi l i ty: A foll ow-up study.
A mJ Psychi atry 129:725-729, 1972.
Deeths A: Psychodrama cri si s interventi on wi th del i n
quent male drug users. G roup Psychother 23:41-44,
1970.
De L a T orre J C : T he therapi st tells a story: A techni que
in bri ef psychotherapy. Bull M enni nger Cl i n 36:609-
616, 1972.
Deutsch D: G roup subgroup and indi vidual therapy com
bined to treat the family. Roche Report 3:3, 1966.
Deutsch F: A pplied psychoanal ysis. New Y ork, G rune &
Stratton, 1949.
Dickes RA : Bri ef therapy of conversi on reactions: A n in-
hospi tal techni que. A m J Psychi atry 131:584-586,
1974.
Doll E: M easurement of Social Competence: V i nel and
Soci al M aturi ty Scal e. M i nneapol i s, E ducati onal
T est B ureau, 1947.
Donner J , Gamson A: Experi ence wi th mul ti fami l y, ti me-
li mi ted, outpati ent group at a communi ty psychi atri c
cl inic. Psychi atry 31:126-137, 1968.
REFERENCES 253
Donovan WB, et al : T he cri si s group A n outcome study.
A mJ Psychiatry 136:906-910, 1979.
Dressi er D, et al : T he development of a mental heal th
entry service. J Communi ty Psychol 3:88- 92, 1975.
Druck A B: T he role of didacti c group psychotherapy in
short- term psychi atri c setti ngs. G roup 2:98- 109,
1978.
Durel l V G: A dolescents in mul ti pl e family group therapy
in a school setting. I nt J G roup Psychother 19:44-52,
1969.
Ei senberg M : Brief psychotherapy: A viable possi bili ty
wi th adol escents. Psychother T heory Res Prac
12:187-191, 1975.
Ei sl er R M , Herson M : Behavioral techni ques in family-
ori ented cri si s i nterventi on. A rch Gen Psychiatry
28:111-116, 1973.
El lis A: Outcome of empl oyi ng three techni ques of psycho
therapy. J Cl i n Psychol 13:344-350, 1957.
El lis A: A n answer to some objecti ons to rati onal -emoti ve
psychotherapy. Psychother 2:108-111, 1965.
El lis A: M y phi l osophy of psychotherapy. J Contemp Psy
chol 6:13-18, 1973.
El more J L , Saunders R: Group encounter techni ques in
the short-term psychi atri c hospi tal . A m J Psychother
26:490-500, 1972.
Epstei n N: Brief group therapy in a chi ld gui dance clinic.
Soc Work 15:33-38, 1970.
Epstei n N: T echni ques of bri ef therapy wi th chi l dren and
parents. Soc Casework 57:317-323, 1976.
Eri kson E H : Chi l dhood and Society. New Y ork, N orton,
1963.
E rrera P, Braxton M C , Smi th C, G ruber R: L ength of
psychotherapy. A rch Gen Psychi atry 17:454-458,
1967.
Fei ghner J P , Robins E, Guze SB et al : Di agnosti c cri teri a
for use in psychi atri c research. A rch Gen Psychi atry
26:57, 1972.
Fensterhei m H: H el p W i thout Psychoanal ysi s. New Y ork,
Stei n & Day, 1971.
Ferber H , K eeley SM , Shemberg K M : T rai ni ng parents
in behavior modi fication. Behav T her 5:415-419,
1974.
Ferster CB: Positive rei nforcement and behavi oral deficits
of auti sti c chi l dren, in F ranks C M (ed): Condi ti oni ng
T echni ques in Cli nical Practi ce and Research. New
Y ork, Spri nger, 1964, pp 255-274.
F i tzgeral d RV : Conj oi nt mari tal psychotherapy: A n out
come and foll ow-up study. Fam Process 8:260-271,
1969.
Fleischl M F , Wol f A: T echni ques of social rehabi l i tati on,
in M asserman J H (ed): C urrent Psychiatric T her
api es, Vol 7. New Y ork, Grune & Stratton, 1967.
Fl omenhaft K , et al: A voiding psychi atri c hospi tal i zati on.
Soc Work 14:38-46, 1969.
Frances A , et al : Focal therapy in the day hospi tal . Hosp
Communi ty Psychi atry 30:195-199, 1979.
F rank J D : Persuasi on and H eal i ng: A Comparati ve Study
of Psychotherapy, 2nd Ed. Bal ti more, J ohns Hopki ns
Press, 1973.
F rankel BL , et al: I neffectiveness of el ectrosleep in chroni c
pri mary insomni a. A rch Gen Psychi atry 29:563-568,
1973.
F rankl V E: F ragments from the l ogotherapeuti c treatment
of four cases, in Burton A (ed): M odern Psychothera
peuti c Practice. Pal o A lto, Cal if, Science & Behavior
Books, 1965.
F rankl V E : L ogotherapy and exi stenti al anal ysi s A
revi ew. A mJ Psychother 20:252-260, 1966.
F ranks C M : Condi ti oni ng T echni ques in Cl i ni cal Practice
and Research. New Y ork, Spri nger, 1964.
F ranks, C M , Wi lson G T : A nnual Review of Behavioral
T herapy, T heory and Practice, Vol 3. New Y ork,
B runner/M azel , 1975.
F reud S: On Begi nning the T reatment (1913). T he
Standard E di ti on of the C ompl ete Psychol ogi cal
Works, V ol 12. L ondon, H ogarth Press, 1958, pp
139-142.
Ful chi ero C F : E val uati on of a therapeuti c paradox tech
ni que in bri ef psychotherapy. Di ssertati on A bstracts
I nt 36(8-13) 4153, 1976.
F ul kerson SC, B arry J R : M ethodol ogy and research on
the prognosti c use of psychologi cal tests. Psychol Bull
58:197-204, 1961.
G arner H H : Bri ef psychotherapy and the confrontati on
approach. Psychosomati cs 11:319-325, 1970 (a).
G arner H H : Psychotherapy: C onfrontati on Problem-Sol v
ing T echni ques. St. L oui s, Green, 1970 (b).
Gel b L A , A l l man M : I nstant psychi atry offered at an
outpati ent psychi atri c clinic. Roche Report, V ol 4,
A ug 1, 1967.
Gerber I: Bereavement and the acceptance of professional
services. C ommuni ty M ent H eal th I 5:487-495,
1969.
Gerber I: Bereavement and the acceptance of professional
advice, in B arten H H (ed): Brief T herapi es. New
Y ork, Behavioral Publ i cati ons, 1971, pp 236-245.
Ghadi ri an A: T wo cases of phobi a treated according to a
dynami c behavi or approach. L aval M ed 42(3):242-
244, 1971.
Gi l l man RD: Bri ef psychotherapy: A psychoanal yti c view.
A mJ Psychi atry 122:601-611, 1965.
Gl asser W: Reality T herapy: A New A pproach to Psy
chi atry. New Y ork, H arper & Row, 1965.
Gl asser W, Zuni n L M : Reality therapy, in M asserman
J H (ed): C urrent Psychi atri c T herapi es, Vol 12. New
Y ork, G rune & Stratton, 1972.
Glicken M D: A rati onal approach to short-term counsel
ing. J Psychi atr N urs M ent H eal th Serv 6:336-338,
1968.
254
Glueck BC, Stroebel CF: Biofeedback and medi tati on in
the treatment of psychi atri c illnesses, in M asserman
J H (ed): C urrent Psychiatric T herapi es, V ol 15. New
Y ork, Grune & Stratton, 1975.
Godbol e A , F al k M : C onf rontati on P robl em-sol vi ng
therapy in the treatment of confusional and del irious
states. Gerontol ogi st 12:151-154, 1972.
Gol dberg H L : Home treatment. Psychi atr A nn 3:59-61,
1973.
Gol dberg PA: A review of sentence completion methods in
personal i ty assessment. J Proj T ech Pers Assess
29:12, 1965.
Gol dfarb A l , T urner H: Psychotherapy of aged peopl e: I I .
U ti l i zati on and effectiveness of brief therapy. A m J
Psychiatry 109:916-921, 1953.
Goldstei n D: Cri si s i nterventi on: A brief therapy model.
N urs Cl i n N Am 13:657-663, 1978.
Goldstei n K , Gel b A: U eber F arbennamenamnesi e. Psy
chol Forsch 6:127, 1924.
Goldstei n K , Scheerer M : A bstract and concrete behavior.
Psychol M onograph 53:239, 1941.
Gonen J Y : T he use of psychodrama combined with
videotape pl ayback on an i npati ent floor. Psychiatry
34:198-213, 1971.
Goodenough F: M easurement of I ntelli gence by D raw
ings. Y onkers, NY , Worl d Book, 1926.
Goodwi n J M , Goodwi n J S , K el l ner R: Psychi atri c
symptoms in di sl i ked medi cal pati ents. J A M A
241:1117-1120. 1979.
G ool i shi an HA : A bri ef psychotherapy program for
di sturbed adol escents. A m J Orthopsychi atry 32:142-
148,1962.
Gottschal k L A , M ayerson P, Gottl i eb A A : Predictions
and eval uati on of outcome in an emergency bri ef psy
chotherapy clinic. J Nerv M ent Dis 144:77-96, 1967.
Graham P: M anagement in child psychiatry: Recent
trends. Br J Psychiatry 129:97-108, 1976.
Grayson H (ed): Short-term A pproaches to Psychother
apy. New Y ork, H uman Sciences Press, 1979.
Greenbl att M : M ental heal th consul tati on, in F reedman
A M , K apl an H I , Sadock BJ (eds): Comprehensi ve
T extbook of Psychiatry, 2nd ed. Bal timore, Wi l l i ams
& Wi l ki ns, 1975.
Greene BL : T reatment of mental di sharmony when the
spouse has a pri mary affecti ve di sorder (mani c-
depressive illness). I. General revi ew 100 coupl es. J
M arr Fam Counsel 1:82-101, 1975.
Greenwal d H: Decision therapy. Personal Growth, No.
20,1974.
Gross W F , Deri dder L : Signifi cant movement in compara
ti vel y short- term counsel i ng. J C ounsel Psychol
13:98-99. 1966.
Guernsey BG, Stoll ack G, Guernsey L : T he practi ci ng
psychologist as educator An al ternate to the medical
practi ti oner model. Prof Psychol 2:276-282, 1971.
G urman A S: Some therapeuti c i mplicati ons of mari tal
therapy research, in G urman A S, Rice DG (eds):
Couples in Confli ct. New Y ork, A ronson, 1975.
Hagel i n A , L azar P: T he Fl omp method. I nt M ent
H eal th Res Newsl etter 15:1-18, 1973.
Hal ey J , Hoffman L : T echni ques of Fami l y T herapy.
New Y ork, Basic Books, 1967.
H ammer E F (ed): T he Cli nical A ppl i cati on of Projective
Drawi ngs. Spri ngfi el d, 111, T homas, 1958.
H and I , L aM ontagne Y : Paradoxi cal i ntenti on and be
havi oral techni ques in short-term psychotherapy. Can
Psychi atr Assoc 19:501-507, 1974.
Hansel l N: Casual ty management method: A n aspect of
mental heal th technology in transi ti on. A rch Gen
Psychi atry 19:281-289, 1968.
H arri s M R , K ali s BL , F reeman E H : Preci pi tati ng stress,
an approach to bri ef therapy. A mer J Psychother
17:465-471, 1963.
H arri s M R , K ali s M B , Freeman E H : A n approach to
short-term ps>chotherapy. M i nd 2:198-207, 1964.
H arri s T : I m OK Y oure OK . New Y ork, H arper &
Row, 1967.
Haskell D, Pugatch D, M cN ai r DM : T i me-l i mi ted psy
chotherapy. A rch Gen Psychiatry 21:546-550, 1969.
H athaway SR, M cK i nl ey J C : M i nnesota M ul ti phasi c
Personal i ty I nventory. New Y ork, Psychological C or
porati on, 1951.
H aug M : Focal therapy of the family: A n appl i cati on of
psychoanal ysi s to child guidance. Psyche Stuttgart
25(8) :595602, 1971.
H ayworth R M : Posi tive outcome in psychi atri c crisis:
E val uati on of T hi ori dazi ne concentrate in an i nten
sive, short-term psychi atri c program. Psychosomati cs
14:42- 45,1973.
Hei ne R, T rosman H: I ni ti al expectati ons of the doctor-
pati ent i nteracti on as a factor in conti nuance in psy
chotherapy. Psychi atry 23:275-278, 1960.
Herschel man P, F reundl i ch D: L arge group therapy with
mul ti pl e therapi sts, in M asserman, J H (ed): C urrent
Psychi atri c T herapi es, V ol 12. New Y ork, Grune &
Stratton, 1972.
Hi tchcock J , M ooney WE : M ental heal th consul tati on. A
psychoanal yti c f ormul ati on. A rch Gen Psychi atry
21:353- 358,1969.
Hofmei ster J F , et al : A behavi oral program for the treat
ment of chroni c pati ents. A m J Psychiatry 136:396-
400, 1979.
Hol l ensbe SM : Script enactment as a techni que for brief
psychotherapy. D i ssertati on A bstracts I nt 36(8-
B):4160, 1976.
Hol l i ster L E : Cl i ni cal use of psychotherapeuti c drugs.
Postgrad M ed 47:100-105, 1970.
Holt RR (ed): Di agnosti c Psychological T esti ng. New
Y ork, I nternati onal Universities Press, 1968.
Horowi tz M J : Stress Response Syndrome. New Y ork,
A ronson, 1976.
REFERENCES 255
Horowi tz M J : Stress Response Syndromes and Brief Psy
chotherapy. Strecker M onograph Seri es No. 14.
Phi l adel phi a I nsti tute of the Pennsyl vani a Hospi tal ,
1977.
I mber SD, et al : Uses and abuses of the bri ef i nterventi on
group. I ntJ G roup Psychother 29:39-49, 1979.
I shi da R: N ai kan-anal ysi s. Psychologia: I nt J Psychol in
the Ori ent 12(2):81-92, 1969.
J acobson G: T he briefest psychi atri c encounter. A rch Gen
Psychiatry 18:718-724, 1968.
J acobson G F : Cri si s theory and treatment strategy: Some
sociocultural and psychodynamic consi derati ons. J
Nerv M ent Dis 141:209-218, 1965.
J acobson GF , et al : T he scope and practi ce of an earl y-ac-
cess brief treatment psychi atri c center. A m J Psy
chi atry 121:1176-1182, 1965.
J anov A: T he Pri mal Scream: Pri mal T herapy. T he C ure
for Neurosis. New Y ork, Putnam, 1970.
J ohnson RL , Chatowsky A P: Game theory and short-term
group counsel ing. Personnel Gui dance J 47:758-761,
1969.
K al i na E: Psychoanal ytic psychotherapy of the coupl e: A
bri ef psychotherapy approach, in W ol berg L R ,
A ronson M L (eds): G roup T herapy 1974: A n
Overvi ew. New Y ork, Stratton I nterconti nental ,
1974.
K ali nowsky L B, H i ppi us H: Pharmacol ogi cal , Convulsive
and Other Somatic T reatments in Psychi atry. New
K ali s L , H arri s M R , Crestwood A K , et al : Preci pi tati ng
stress as a focus in psychotherapy. A rch Gen Psy
chi atry 5:219, 1961.
K anfer F H , Saslow G: Behavioral diagnosi s, in F ranks
C M (ed): A pprai sal and Status. New Y ork, M c
G raw-H i l l , 1969.
K apl an HS: T he New Sex T herapy. New Y ork, B runner/
M azel , 1974.
K app RA , Weiss SD: A n i nterdi sci pl i nary cri si s-ori ented
graduate trai ni ng program with a student heal th serv
ice mental heal th clinic. J A m Coll H eal th Assoc
23:340-344, 1975.
K arpman SB: Devel opments in transacti onal anal ysi s, in
M asserman J H (ed): C urrent Psychiatric T herapi es,
V ol 12. New Y ork, G rune & Stratton, 1972.
K aswan J , L ove L R: Confrontati on as a method of psy
chological i nterventi on. J Nerv M ent Dis 148:224-
237,1969.
K erns E: Pl anned short-term treatment. Soc Casework
51:340-346, 1970.
K ettle J : T he E ST Experience. New Y ork, K ensington,
1976.
K illeen M R , J acobs CL : Brief group therapy for women
students. Soc Casework 21:521 -522, 1976.
K i mbro E L , et al: A mul ti pl e-fami l y group approach to
some probl ems of adolescence. I nt J G roup Psy
chother 17:18-24, 1967.
K i rchner F, et al: I dentification and management of the
anxi ous pati ent wi th a model family practi ce uni t. J
F am Pract 6:533-540, 1978.
K l apman J W : T he case for didacti c group psychotherapy.
Di s Nerv Syst 11:3541, 1950.
K l apman J W : Objective apprai sal of textbook mediated
group psychotherapy with psychotics. I nt J Group
Psychother 2:116-126, 1952.
K nobloch F: Czech-type therapeuti c uni t successfully used
i n C anada. Psychi atr News 8:32-33, 1973.
K och W: Short-term therapy of obsessive compulsive
neuroses wi th guided affective imagery. Z Psychother
M ed Psychol 19(5): 187-191, 1969.
K ramer M : Cross-nati onal study of diagnosi s of the men
tal di sorders: Ori gi n of the problem. A m J Psychiatry
125:1 (Suppl ), 1969.
K raus A S, L i lienfeld A M : Some epi demi ological aspects of
the high mortal i ty rate in the young widowed group.
J C hron Dis 10:207-217, 1959.
K rimmel H E , Falkey BD: Short-term treatment of alco
holics. Soc Work 7:102-107, 1962.
K usnetzoff SC: C ommuni cati on theory and bri ef psycho
therapy: I ts appl i cati on in therapy of chi l dren and
adolescents. A mJ Psychoanal 34:141-149, 1974.
L a F erri ere L , Cal syn R: Goal attai nment scal ing: A n ef
fective treatment techni que in short-term therapy. A m
J Comm Psychol 6(3):271-282, 1978.
L angsl ey DG, K apl an D M : T he T reatment of Fami l i es in
Cri si s. New Y ork, Grune & Stratton, 1968.
L angsl ey DG, et al : Fami l y cri si s therapy Results and
i mplicati ons. Fam Process 7:145-148, 1968.
L angsl ey DG, et al : F ol l ow-up eval uati on of family crisis
therapy. A mJ Orthopsychi atry 39:753-759, 1969.
L angsl ey DG, M achotka P, Fl omenhaft K: A voiding men
tal hospi tal admissi on: A foll ow-up study. A mJ Psy
chi atry 127:1391-1394. 1971.
L aqueur H P: General systems theory and mul ti pl e-fami l y
therapy, in M asserman J H (ed): C urrent Psychiatric
T herapi es, V ol 8. New Y ork, G rune & Stratton,
1968.
L aqueur H P: M echani sms of change in mul ti pl e-fami l y
therapy, in Sager C J , K apl an HS (eds): Progress in
G roup and Fami l y T herapy. New Y ork, B runner/
M azel , 1972, pp 400-415.
L azare A , Cohen F, J acobson A M , et al: T he wal k-i n pa
ti ent as a customer : A key dimension in evaluati on
and treatment. A m J Orthopsychi atry 42:872-883,
1972.
L azarus A A: Behavior therapy in groups, in Gazda G
(ed): Basic A pproaches to Group Psychotherapy and
Group Counsel i ng. Spri ngfi el d, 111., T homas 1968.
L azarus A A: M ul ti model Behavior T herapy. New Y ork,
Spri nger, 1976.
L eiblum SR, Rosen RC: T he weekend workshop for dy
namic dysfuncti onal couples: A ssets and li mi tati ons. J
Sex M ari tal T her 5:57-69, 1979.
L ester D, Brockopp GW : Cri si s I nterventi on and C oun
seli ng by T el ephone. Springfield, 111., T homas, 1976.
L euner H: Gui ded affective i magery (GA I ): A method of
intensive psychotherapy. A m J Psychother 23:4-22,
1969.
L evin RE, Rivelis de Paz, L : Contri buti ons to the theory
of the techni que for group psychotherapy: Short-term
groups for chi l dren in latency age. A cta Psi qui atr
Psicol A m L at 16(3):265-268, 1970.
L evinson DJ : T he mi d-life transi ti on. A peri od of adul t
psychosoci al devel opment. Psychi atry 40:99- 112,
1977.
L ewi n K K : Brief Encounters. St. L oui s, Green, 1970.
L ewi s A B: Brief psychotherapy in the hospi tal setting:
T echni ques and goal s. P sychi atr Q 47:341- 352,
1973.
L ewi s J , M i der PA : Effects of l eadershi p style content and
work styles of short-term therapy groups. J Counsel
Psychol 20:137-141, 1973.
L i berman RA : Behavioral approach to group dynamics. I.
Rei nforcing and prompti ng of cohesiveness in group
therapy. Behav T her 1:141-175, 1970.
L i ck J R , Bootzin RR: Expectancy, demand characteri s
tics, and contact desensi ti zati on in behavior change.
Behav T her 1:176-183, 1970.
L i ndemann E: Symptomatol ogy and management of acute
grief. A mJ Psychi atry 101:141-148, 1944.
L i pki n S; Round robi n ti me-l imi ted therapy. A m Acad
Psychother N ewsl etter 2:37-42, 1966.
L oreto G: M ental heal th for universi ty students. N euro-
biologia 35(4):253-276, 1972.
L oui s P: Crisis i nterventi on. M ent Hygiene 50:141-145,
1966.
L owen A: Physical Dynami cs of C haracter Structure. New
L uber RF, Wells RA : Structured, short-term mul ti pl e
family therapy: A n educati onal approach. I nt J
G roup Psychother 27:43-58, 1977.
L udwi g A M , L evine J : Hypnodel i c therapy, in M asser-
man J H (ed): C urrent Psychiatric T herapi es, Vol 7.
New Y ork, Grune & Stratton, 1967.
L uri a A: H i gher Corti cal F uncti ons in M an. New Y ork,
Basic Books, 1966.
L uthe W: A utogeni c trai ni ng: M ethod, research and ap
pli cation in medicine. A m J Psychother 17:174-175,
1963.
M cGee T E , M eyer W: T i me-l i mi ted and ti me-unl i mi ted
group psychotherapy: A comparison wi th schizo
phreni c pati ents. C omp G roup Studi es 2:71- 84,
1971.
M acG regor R: M ul ti pl e i mpact psychotherapy wi th
famili es. F am Process 1:15-29, 1962.
M achover K : Personal i ty Projection in the Drawi ngs of
the H uman F i gure. Springfield, 111., T homas, 1949.
M ai zl i sh L , H url ey J R : A tti tude changes of husbands and
wives in ti me-l i mi ted group psychotherapy. Psychi atr
Q Suppl 37:230-249, 1963.
M al an D H : A Study of Brief Psychotherapy. L ondon,
T avi stock, 1963. (A lso Spri ngfi el d, 111., T homas,
1964.)
M al an D H : T he F ronti er of Brief Psychotherapy. New
Y ork, Pl enum, 1976 (a).
M al an D H : T oward the V al i dati on of Dynami c Psy
chotherapy. New Y ork, Pl enum, 1976 (b).
M al an D H , Bacal HA , Heath ES, et al : A study of
psychodynamic changes in untreated neuroti c pa
ti ents. I . I mprovements that are questi onabl e on dy
nami c cri teri a. B rJ Psychi atry 114:525, 1968.
M al an D H . H eath ES, Bacal HA , et al : Psychodynami c
changes in untreated neuroti c pati ents. A rch Gen
Psychi atry 32:110-126, 1975.
M al tz M ; Psycho-cyberneti cs. E ngl ewood Cl i ffs, N J ,
Prenti ce-H al l , 1960 (paperback: New Y ork, Pocket
Books, 1973).
M ann J : T i me-l i mi ted Psychotherapy. Cambri dge, H ar
vard U ni versi ty Press, 1973.
M armor J : T heori es of l earni ng and the psychotherapeuti c
process. B rJ Psychi atry 112:363-366, 1966.
M armor J : Dynami c psychotherapy and behavi or therapy.
A rch Gen Psychi atry 24:22, 1971.
M armor J : Short-term dynami c psychotherapy. A mJ Psy
chi atry 136:149-155,1979.
M arrone RL , et al : A short durati on group treatment of
smoking behavi or by sti mul us saturati on. J Behav
Res T heory 8:347-352, 1970.
M arti n B: Fami l y i nteracti on associated wi th child di s
turbance: A ssessment and modi fication. Psychother
Res Prac 4:30- 35, 1967.
M arti n PA , Bird H W : A n approach to the psychotherapy
of marri age partners: T he stereoscopi c technique.
Psychi atry 16:123-127, 1963.
M arti n PA , L i ef H I : Resistance to innovati on in psy
chi atri c trai ni ng as exempli fied by mari tal therapy, in
U sdi n G (ed): Psychi atry: E ducati on and I mage.
New Y ork, B runner/M azel , 1973.
M arti n RC: T he acute si tuati onal cri si s and communi ca
ti on theory. Di ssertati on A bstracts 29(4-A ):1296,
1968.
M atarazzo J D : Wechsl ers M easurement and A pprai sal of
A dult I ntelli gence. Bal timore, Wi l l i ams & Wi l ki ns,
1972.
M eacham M L . Wi esen A E: C hangi ng Cl assroom Be
havi or: A M anual for Preci si on T eachi ng, 2nd ed.
New Y ork, I ntext Educati onal Publ i shers, 1974.
M ears E: Sexual probl em clinics: A n assessment of the
work of 26 doctors trai ned by the i nsti tuti on of
REFERENCES 257
psychosexual medicine. Public H eal th 92:218-223,
1978.
M el ni ck J , T i ms A R, J r.: A ppl i cati on of videotape equi p
ment to group therapy. I nt I G roup Psychother
24:199-206, 1974.
M entzel G: Goal -di rected short-term therapy wi th func
ti onal di sturbances. Z Psychosomat M ed Psychoanal
15(l ):37- 44, 1969.
M erri l l S, C ary GL : Dream analysis in brief psychother
apy. A mJ Psychother 29:185-193, 1975.
M eyer E, et al: Contractual l y ti me-l imi ted psychotherapy
in an outpati ent psychotherapy clinic. A m J Psy
chi atry 124(Supp!):57-68, 1967.
M eyer R: T he psychosomatic pati ent in anal yti c brief psy
chotherapy. A f ol l ow-up study. Psyche (Stuttg)
32(10):881 928. 1978.
M eyer R, Beck D: T he outcome of bri ef psychotherapy in
28 psychosomatic pati ents (authors trans). Praxi s
67(39): 1434-1439, 1978.
M i l l er WB: A psychiatric emergency service and some
mental concepts. A mJ Psychiatry 24:924-933, 1968.
M i l l man RB: A n edi tori al repl y. T he Bull eti n (A rea I I ,
A meri can Psychiatric A ssoci ati on) 21 (4): 1, 1979.
M one L C: Short-term group psychotherapy wi th postcar
diac pati ents. I nt J G roup Psychother 20:99-108,
1970.
M oreno J L (ed): T he I nternati onal Handbook of G roup
Psychotherapy. New Y ork, Philosophical L i brary,
1966.
M oreno M : Perspectives of anal yti c psychology for short
term psychotherapy. Riv Psi chi atri a 2(6):488-491,
1967.
M orl ey WE : T reatment of the pati ent in crisis. West J
M edicine 6:77-87, 1965.
M orl ey W E , Brown V E: T he cri si s i nterventi on group: A
natural mati ng or a marri age of convenience. Psy
chother T heory Res Prac 6:30-36, 1969.
M orra M : A mbul atory short-term psychotherapy: T he
oretical pri nci pl es and some experi ments. Riv Psi chi
atri a 2(6):491-498, 1967.
M orri son J K , Cometa M S: Emoti ve-reconstructi on psy
chotherapy: A short-term cognitive approach. A m J
Psychother 31:294- 301, 1977.
M oser A J : Structural group i nteracti on: A psychothera
peutic techni que for modifying focus of control. J
Contemp Psychother 7:23-28, 1975.
M uench GA : An investigation of the efficiency of time-
li mited psychotherapy. J Counsel Psychol 12:294-
299, 1965.
M urray HA : Expl orati ons in Personal i ty. New Y ork, Ox
ford U niversity Press, 1938.
Negele R A - A study of the effectiveness of brief time-
l i mi ted psychotherapy wi th chi l dren and thei r
parents. Di ssertati on A bstracts I nt 36(8-B ):4172,
1976.
Neu C, et al : M easuri ng the interventi ons used in the
short-term i nterpersonal psychotherapy of depression.
A mJ Orthopsychi atry 48:629-636, 1978.
Nichol s M P: C atharsi s in brief psychotherapy: A n out
come study. Di ssertati on A bstracts I nt 35(1-B ):520,
1974.
Nichol s M P , et al : T he study of bri ef psychotherapy in a
college heal th setting. I A m Coll ege H eal th Assoc
22:128-133, 1973.
Nicol A R: Psychotherapy and the school. J Chi l d Psychol
Psychi atry 20:81-86, 1979.
N ormand WC, F ensterhei m H , Schrenzel S: A systematic
approach to bri ef therapy for pati ents from a low
socioeconomic community. Communi ty M ent Heal th
J 64:349-354, 1967.
Ostow M : T he Use of Drugs in Psychoanal ysi s and Psy
chotherapy. New Y ork, Basic Books, 1962.
Pal mer RD: Desensi ti zati on of the fear of expressi ng ones
own i nhi bi ted aggression: Bioenergeti c asserti ve tech
niques for behavi or therapi sts. Paper presented at
the A ssoci ati on for the A dvancement of Behavior
T herapy, Washi ngton DC, September 1971.
Parsons BV , A l exander J F : Short-term family interven
ti on: A therapy outcome study. J Consul t Cl i n Psy
chol 41:195-201, 1973.
Patterson GR : R etrai ni ng of aggressive boys and thei r
parents. J C an Psychi atr Assoc 19:142-158, 1974.
Patterson G R , et al: A social engi neeri ng technology for
retrai ni ng the famili es of aggressive boys, in A dams
H E , Uni kel I P (eds): I ssues and T rends in Behavior
T herapy. Spri ngfi el d, 111., T homas, 1973 (a).
Patterson G R , Reid J B : I nterventi on for famili es of ag
gressive boys: Repl i cati on study. Behav Res T heory
11:383-394, 1973 (b).
Patterson V , L evene H , Breger L : A one year foll ow-up of
two forms of bri ef psychotherapy. A m J Psychother
31:76- 82,1977.
Paul G L : Experi mental -behavi oral approaches to schiz
ophreni a, in C ancro R, Fox N , Shapi ro L (eds):
Strategi c I nterventi on in Schi zophreni a. New Y ork,
Behavioral Publ i cati ons, 1974.
Peck H: A n appl i cati on of group therapy to the intake
process. A mJ Orthopsychi atry 23:338-349, 1953.
Peck H , K apl an S, Romar M : Preventi on, treatment and
social action: A strategy of i nterventi on in a di sadvan
taged urban area. A m J Orthopsychi atry 36:57-59,
1966.
Peri s FS: Gestal t T herapy V erbati m. M oab, U tah, Real
People Press, 1969.
Phi l l i ps E L , J ohnston M S: T heoreti cal and cl i ni cal
aspects of short-term parent chi ld psychotherapy.
Psychi atry 17:267-275, 1954.
Pi ttman FS: M anagi ng acute psychi atri c emergencies:
Defini ng the family cri si s, in Bloch DA (ed): T ech
niques of Fami l y Psychotherapy: A Pri mer. New
Y ork, Gri me & Stratton, 1973.
Pi ttman FS, DeY oung C, Fl omenhaft K , et al: Crisis
family therapy, in M asserman J H (ed): C urrent Psy
chi atri c T herapi es, V ol 6. New Y ork, Grune &
Stratton, 1966.
Pi ttman FS, et al: Work and school phobias: A family
treatment approach. A m J Psychiatry 124:1535-
1541,1968.
Preston BH: Class method in treatment of psychoti c pa
ti ents. I nt J G roup Psychother 4:321-330, 1954.
Pruch D, Brody B: Brief rel ati onshi p therapy in the
mi l i tary setting. A m J Orthopsychi atry 16:707-721,
1946.
Quaytman W: I mpressi ons of the Esal en (Schutz) phe
nomenon. J Cont Psychother 2:57-64, 1969.
R abi n A l: Projective T echni ques in Personal i ty A ssess
ment. New Y ork, Spri nger, 1968.
Rabi n H M : A ny answers to the compell ing arguments
agai nst encounters and marathons? Psychother Bull
4:16-19, 1971.
Rabki n R: Strategi c Psychotherapy: Brief and Sympto
matic T reatment. New Y ork, Basic Books, 1977.
R ada R T , Dani el s RS, D raper E: A n outpati ent setting
for treati ng chroni call y ill psychiatric pati ents. A m J
Psychiatry 126:789-795, 1969.
R ank O: Wi l l T herapy. New Y ork K nopf, 1936.
R ank O: Wi l l T herapy and T ruth and Reality. New
Y ork, K nopf, 1947.
R apaport D, Gill M M , Schafer R, et al : Diagnosti c Psy
chological T esti ng. New Y ork, I nternati onal U ni
versities Press, 1968.
R apaport L : T he state of crisis. Some theoreti cal con
siderations. Soc Sci Rev 36:211-217, 1962.
Raski n DE: Problems in the therapeuti c community. A m J
Psychiatry 128:492, 1971.
Reder P: A case of bri ef psychotherapy. Br J M ed Psychol
51 (2): 147154, 1978.
Rees WD, L utki ns SG: M ortal i ty of bereavement. Br
M ed J 4:13-16, 1967.
Regan PF: Brief psychotherapy of depression. A m I Psy
chi atry 122:27-32, 1965.
Reid WJ , Epstei n L : T ask Centered Casework. New Y ork,
Col umbi a University Press, 1972.
Reid W J , Shyne A: Brief and Extended Casework. New
Y ork, Col umbi a U niversity Press, 1969.
Reynol ds DK : M ori ta Psychotherapy. Berkeley, U ni
versity of Cal i forni a Press, 1976.
Rhodes SL : Short-term groups of latency-age chi l dren in a
school setting. I nt J G roup Psychother 23:204-216,
1973.
Richardson F C, Sui nn R M : Effects of two short-term
desensi ti zati on methods in the treatment of test
anxi ety. J Counsel Psychol 21:445-458, 1974.
Rivera GG, Battaggi a PG: Consi derati ons in different
types of short-term psychotherapeuti c treatment. Riv
Psi chi atri a 2(6):498-503, 1967.
Robbi ns OS: Cri si s theory and its rel ati on to psychother
apy. Psychother Psychosom 29:288-292, 1978
Robkin R: Strategi c Psychotherapy. New Y ork, Basic
Books, 1977.
Rol f I : Structural I ntegrati on. San Franci sco, Gui l d for
Structural I ntegrati on, 1958.
Rorschach H: Psychodiagnosti c. Bern, Bircher, 1921.
Rosenthal A J , L evine SV: Bri ef psychotherapy wi th chi l
dren: A prel i mi nary report. A m J Psychi atry
127:646-651, 1970.
Rosenthal A J , L evine SV: Bri ef psychotherapy with chi l
dren: Process of therapy. A m J Psychiatry 128:M i
l d?, 1971.
Rosenthal D, F rank J D : T he fate of psychi atri c clinic
outpati ents assigned to psychotherapy. I Nerv M ent
Di s 127:330-343, 1958.
Rosenwald A K : T he psychologi cal exami nati on, in A rieti
S (ed): A meri can Handbook of Psychi atry. New
Y ork, Basic Books, 1974, pp 1181-1199.
Ruben H L : M anagi ng suici dal behavior J A M A 241:282-
284, 1979.
Rubenstei n D: Rehospi tal i zati on versus family crisis. A m
J Psychi atry 129:715-720, 1972.
Rush A J : Cognitive T herapy. Weekly Psychi atry U pdate
Series. L esson 52, 1978.
Rush A J , Beck A T : Cogni ti ve therapy of depression and
suici de. A m J Psychother 32:201-219, 1978.
Rush A J , Beck A T , K ovacs M , et al : C omparati ve efficacy
of cogni tive therapy in pharmaco therapy in the treat
ment of depressed outpati ents. Cogni ti ve T her Res
1:17-37, 1977.
Rusk T N - Opportuni ty and techni que in cri si s psychiatry.
C ompr Psychi atry 12:249-263, 1971.
Sadock B, Newman L , N ormand WC: Short-term group
psychotherapy in a psychi atri c wal k-i n clinic. A m J
Orthopsychi atry 38:724-732, 1968.
Safer DJ : F ami l y therapy for chi l dren wi th behavior
disorders. F am Process 5:243-255, 1966.
Sager C J , et al : T he marri ed in treatment. A rch Gen Psy
chi atry 19:205-217, 1968.
Sarvis M A , Dewees S, J ohnson RF: A concept of ego-
ori ented psychotherapy. Psychi atry 22:277- 287,
1958.
Sati r V M : Conj oi nt Fami l y T herapy. Pal o A lto, Cal if,
Science & Behavior Books, 1964 (a).
Sati r V M : Symptomatol ogy: A Fami l y Producti on. Palo
A lto, Cal if, F ami l y Project I nsti tute, 1964 (b).
Sati r V M : Conj oi nt mari tal therapy, in Green BL (ed):
T he Psychotherapi es of M ari tal Di sharmony. New
Y ork, Free Press, 1965.
Schafer R: T he termi nati on of brief psychoanal yti c psy
chotherapy. I nt J Psychoanal P sychother 2:139,
1973.
Schrei ber K A: Does trai ni ng prepare for practi ce: A case
REFERENCES 259
in point. T he Bull eti n (A rea I I , A meri can Psychiatric
A ssociation) 21(4): 1, 1979.
Schul tz J A , L uthe W: A utogeni c T rai ni ng A Psy-
chophysi ol ogi c A pproach in Psychotherapy. New
Schutz W: I nterpersonal U nderworl d. (Ori gi nal ti tle:
F iro: A T hree-di mensi onal T heory of I nterpersonal
B ehavior.) Palo A lto, Cal if, Science & Behavior
Books, 1967.
Sei bovi ch M A : Short- term i nsi ght psychotherapy for
hysteri cal personal i ti es. Psychother Psychosom 24:
67- 78,1974.
Selye H: Stress, T he Physiology and Pathol ogy of E x
posure to Stress. M ontreal , A cta, 1950.
Shafii M , et al : T he development of an acute short-term
i npati ent child psychi atri c setting: A pedi atri c-psy
chi atri c model. A m J Psychiatry 136:427-429, 1979.
Shapi ro D: Neuroti c Styles. New Y ork, Basic Books,
1965.
Sharpe K M : A study of the i nfl uence of transacti onal anal
ysis on ego structure. Di ssertati on A bstracts I nt
37(1 A ): 137138, 1976.
Shaw R, et al : A short-term treatment program in a child
gui dance clinic. Soc Work 13:81-90, 1968.
Shlien J M : Cross-theoreti cal cri teri a in ti me-l i mi ted ther
apy. Paper presented at the Si xth I nternati onal
Congress of Psychotherapy, L ondon, 1964.
Shlien J M , et al: Effects of ti me li mits: A compari son of
two psychotherapies. J Counsel Psychol 9:31-34,
1962.
Shorr J E : Psycho-i magi nati on T herapy. New Y ork,
Stratton I nterconti nental , 1972.
Shrader WK , et al: A didacti c approach to sti mul us in
short-term group therapy. A m J Orthopsychi atry
39:493-497, 1969.
Sifneos PE: Seven years experi ence wi th short-term dy
namic psychotherapy, in Proceedi ngs of the Sixth
I nternati onal Congress of Psychotherapy, Part I V .
Basil , K arger, 1965, pp 127-135.
Sifneos PE: Psychoanal ytically oriented short-term dy
namic or anxi ety-provoki ng psychotherapy for mild
obsessional neurosis. Psychi atr Q 40:271-282, 1966
(a).
Sifneos PE: T wo different kinds of psychotherapy of short
durati on. Paper presented at the 122nd A nnual
M eeti ng of the A PA . A tl anti c Ci ty, N J , M ay 1966.
(A lso in A m J Psychiatry 123:1069-1074, 1967) (b).
Sifneos PE: T he moti vati onal process: A selection and
prognostic cri teri on for psychotherapy of short dura
ti on. Psychi atr Q 42:271-279, 1968 (a).
Sifneos PE: L earni ng to solve emoti onal problems: A con
trol led study of short-term anxi ety provoking psycho
therapy, in Porter R (ed): T he Role of L earni ng in
Psychotherapy: A C i ba F oundati on Symposi um.
L ondon, C hurchi l l , 1968, p 87 (b).
Sifneos PE: Short-term Psychotherapy and Emotional
Crisis. Cambri dge, H arvard Uni versi ty Press, 1972.
Sifneos PE: A n overview of a psychi atri c cl inic popul ati on.
A mJ Psychi atry 130:1033, 1973.
Sifneos PE: M oti vati on for change: A prognosti c guide for
successful psychotherapy. Psychother Psychosom
29:293-298, 1978.
Silk S: T he use of videotape in bri ef j oi nt mari tal therapy.
A mJ Psychother 26:417-424, 1972.
Silver GA , Cherkasky M , A xelrod J : A n experi ence in
group practi ce, M ontefi ore Hospi tal M edi cal Group,
1948-1956. N Engl J M ed 256:785-791, 1957.
Si l verman PR: Services to the widowed: F i rst steps in a
program of preventi ve i nterventi on C ommuni ty
M ent H eal th J 3:37-44, 1967.
Si l verman W H : Pl anni ng for cri si s i nterventi on wi th com
muni ty mental heal th concepts. Psychother T heory
Res Prac 14:293-297, 1977.
Simon L : M ari tal counsel ing: A dynami c-hol i sti c ap
proach. A mJ Psychoanal 38:243-254, 1978.
Skynner A CR: School phobi a: A reapprai sal . Br J M ed
Psychol 47:1- 16, 1974.
Sletten I , A l tman H, U l ett G: Routi ne diagnosi s by com
puter. A m J Psychi atry 127:1147, 1971
Sloane RB, Stapl es F R , Cri stol A H , et al: Short-term
anal yti cal l y ori ented psychotherapy versus behavior
therapy. A mJ Psychi atry 132:373-377, 1975.
Sloane RB, Stapl es F R, W hi ppl e K , et al : Pati ents at
ti tudes toward behavi or therapy and psychotherapy.
A mJ Psychi atry 134:134-137, 1977.
Smal l L : T he B ri ef er Psychotherapi es. New Y ork,
B runner/M azel , 1971.
Smal lwood J C : Dance-movement therapy, in M asserman
J H (ed): C urrent Psychi atri c T herapi es, Vol 14. New
Smi th A C: I denti ty in transformati on: A study of i ndi
vidual change in the Fischer-Hoffman process of psy
chotherapy. Di ssertati on A bstracts I nt 37(2-B ):990,
1976.
Smi th W: A model for psychi atri c diagnosi s. A rch Gen
Psychi atry 14:521, 1966.
Sokol RJ : A short-term techni que of psychotherapy for
psychoti c depressive reactions. I nt J Psychoanal Psy
chother 2:101-111, 1973.
Speers RW: Brief psychotherapy wi th college women:
T echni que and cri teri as for selection. A m J Orthopsy
chi atry 32:434-444, 1962.
Sperber E, F ei tas R, Davis D: Bull eti ns of Structural I n
tegrati on, V ols I , I I , 1969.
Spiegel H: A single treatment method to stop smoking us
ing anci l l ary self-hypnosis. I nt J Cl i n Exp Hypn
18:235-250, 1970.
Spiegel H, Spiegel D: T rance and T reatment: Cli nical
Uses of Hypnosi s. New Y ork, Basic Books, 1978.
Spi tzer R L , Endi cott J : Can the computer assist clinicians
in di agnosi s? A mJ Psychi atry 131:523, 1974.
Spi tzer R L , Wi lson PT : Nosology and the official psy
chi atri c nomencl ature, in F reedman A M , K apl an H I ,
Sadock BJ (eds): Comprehensi ve T extbook of Psy
chi atry, V ol 2, 2nd ed. Bal ti more, Wi l l i ams & Wi l
kins, 1975, pp 826-845.
Spivack G, Pl att J J , Shure M B : T he Problem-Sol ving A p
proach to A dj ustment; A Gui de to Research and I n
terventi on. San Franci sco, Cal if, J ossey-Bass, 1976.
Spri nce M P: Work wi th adol escents: Brief psychotherapy
with a li mited ai m. J Chi l d Psychother 2(2):31 37,
1968.
Spri ngman RR: Single session psychotherapy in secondary
male impotence. M ent H eal th Soc 5:86-93, 1978.
Stai nbrook E: T he hospital as a therapeuti c community,
in Freedman A M , K apl an H I , Sadock BJ (eds):
Comprehensi ve T extbook of Psychiatry. Bal timore,
Wi l l i ams & Wi l ki ns, 1967, pp 1296-1300.
Standi sh C T , Semrad EV : G roup psychotherapy with
psychotics, in Rosenbaum M , Berger M (eds): G roup
Psychotherapy and G roup Functi on. New Y ork,
Basic Books, 1963.
Stei n C: Hypnoti c projecti on in brief psychotherapy. A m J
Cl i n Hypn 14:143-155, 1972.
Stei n E H , M urdaugh J , M acL eod J A : Brief psychother
apy of psychi atri c reacti ons to physical illness. A m J
Psychiatry 125:1040-1049, 1969.
Stekel W: Condi ti ons of Nervous A nxiety. New Y ork,
L i veri ght, 1950.
Stone A, Parloff M , F rank J , et al : T he use of di agnostic
groups in a group therapy program. I nt J G roup Psy
chother 4:274-284, 1954.
Straker M : Brief psychotherapy in an outpati ent clinic:
Evol ution and eval uati on. A m J Psychi atry 124:
1219-1225, 1968.
Stri ckl er M , A llgeyer J : T he crisis group: A new appl i ca
ti on of cri si s theory. Soc Work 12:28-32, 1967.
Stroebel C F , Gl ueck BC: B i ofeedback treatment in
medicine and psychi atry: A n ul ti mate pl acebo? Semin
Psychiatry 5:379-393, 1973.
Strupp H H : On the technology of psychotherapy. A rch
Gen Psychiatry 26:270-278, 1972.
Stuart RB: Operant-i nterpersonal treatment for mari tal
discord. J Consul t Cl i n Psychol 33:675-682, 1969.
Stuart RB, T ri podi T : Experi mental eval uati on of three
ti me-constrai ned behavi oral treatment for predel i n
quents and del i nquents, in Rubi n RD, Brady J P
(eds): A dvances in Behavior T herapy, V ol 4. New
Y ork, A cademic Press, 1973.
Suess J F : Short-term psychotherapy wi th the compulsive
personal i ty and the obsessive-compulsive neurotic.
A m J Psychiatry 129:270-275, 1972.
Sui nn R M , et al : A ccel erated massed desensi ti zati on:
U nmoti vati on in short-term treatment. J Behav T her
1.303-311, 1970.
Swanson M G , Wool son A M : Psychotherapy wi th the
unmoti vated pati ent. Psychother, T heory Res Prac
10:175-183, 1973.
Swartz J : T i me-l i mi ted bri ef psychotherapy. Semi n Psy
chi atry 1:380-388, 1969.
Swartz J : T i me-l i mi ted bri ef psychotherapy, in B arten
H H (ed): Brief T herapi es. New Y ork, Behavioral
Publ i cati ons, 1971.
Swenson W M , M arti n H R : A descri pti on and eval uati on
of an outpati ent intensive psychotherapy center. A m J
Psychi atry 133:1043-1046, 1976.
Szasz T S: T he M yth of M ental I ll ness. New Y ork,
H arper & Row, 1961.
T af t J (ed): Fami l y Casework and Counsel i ng: A F unc
ti onal A pproach. Phi l adel phi a, Uni versi ty of Penn
sylvani a Press, 1948.
T ei cher A , de F rei tas L , Osherson A: G roup psychother
apy and the intensive group experi ence: A prel i mi
nary rati onal e for encounter as a therapeuti c agent in
the mental heal th field. I nt J G roup Psychother
24:159-173, 1974.
T erman L M , M erri l l M A : M easuri ng I ntel l i gence.
Boston, H oughton, M i ffl i n, 1937.
T i en HC: F rom couch to coffee shop: A new personal i ty
via psychosynthesis. Roche Report 2(18,19), 1972.
T ol or A T eachers eval uati on of chi l dren in short-term
treatment wi th subprof essi onal s. J C l i n Psychol
24:377-378, 1968.
T omki ns SS: T he T hemati c A ppercepti on T est: T he
T heory and T echni que of I nterpretati on. New Y ork,
G rune & Stratton, 1947.
T racey J : Parent gui dance groups: I s thi s therapy? J Psy-
chi atr N urs M ent H eal th Services 8(3): 1112, 1970.
T rakas D, L l oyd G: Emergency management in a short
term open group. C ompr Psychi atry 12:170-175,
1971.
T uckman A J : Brief psychotherapy and hemodial ysi s. A rch
Gen Psychi atry 23:65- 69, 1970.
T yhurst J S: T he roles of transi ti on states including
di sasters in mental illness. Symposium on Preventive
and Social Psychi atry. Washi ngton, DC , W al ter
Reed A rmy I nsti tute of Research, 1957.
U pham F: Ego A nalysis in the Hel pi ng Professi ons. New
Y ork, F ami l y Service A ssoci ati on of A meri ca, 1973.
U rsano R M , Dressi er D M : Brief vs. l ong-term psycho
therapy: A treatment decision. J Nerv M ent Dis
159:164-171, 1974.
V erhul st J : M ari tal change: A n i ntensive, short-term ap
proach. I nt M ent H eal th Res Newsl etter 17(2):710,
1975.
V ernal l i s F F , et al : Saturati on group psychotherapy in a
weekend cl i ni c: A n outcome study. Psychother
T heory Res Prac 7:144-152, 1970.
V ernal l i s F F , et al : T he treatment process in saturati on
group therapy. Psychother T heory Res Prac 9:135-
138, 1972.
V i sher J S, O Sulli van M : N urse and pati ent responses to
a study of mi lieu therapy. A m J Psychi atry 127:451,
1971.
REFERENCES 261
V olkan V : A study of a pati ents re-gri ef work through
dreams, psychological tests and psychoanal ysis. Psy-
chi atr Q 45:244-273, 1971.
V olkan V , Showal ter CR: K nown object loss, di sturbance
in real ity testing, and re-gri ef work as a method of
brief psychotherapy. Psychi atr Q 42:358-374, 1968.
Wahl CW: T he techni que of brief psychotherapy wi th hos
pi tal i zed psychosomatic pati ents. I nt J Psychoanal
Psychother 1:69-82, 1972.
W al ker RG, K elley F E: Short-term psychotherapy with
hospitalized schi zophreni c pati ents. A cta Psychi atr
Scand 35:34-56, 1960.
W al ker RG, K elley F E: Short-term psychotherapy with
schi zophreni c pati ents evaluated over a three-year fol
low-up peri od. J Nerv M ent Dis 137:349-352, 1963.
Wallace M A , M orl ey WE : T eachi ng cri si s i nterventi on.
A m J N urs 70:1484-1487, 1970.
W al ter H, Gi l more SK : Placebo versus social learni ng ef
fects in parent trai ni ng procedures designed to al ter
the behavior of aggressive boys. Behav T her 4:367-
370, 1973.
W atti e B: E val uati ng short-term casework in a family
agency. Soc Casework 54:609-616, 1973.
Watzl awi ck P: A review of the doubl e-bi nd theory. Fam
Process 2:132-153, 1963.
Watzl awi ck P, Beaven J H , J ackson DD: Pragmati cs of
H uman Communi cati on: A Study of I nteracti onal
Patterns, Pathol ogies, and Paradoxes. New Y ork,
N orton, 1967.
Waxer PH : Short-term group psychotherapy: Some pri n
ci ples and techniques. I nt J G roup Psychother 27:33-
42, 1977.
Wayne G J : Cli nical aspects of short-term hospi tal i zati on.
J N atl Assoc Pri vate Psychi atr Hospi tal s 9:21, 1976.
Wechsl er D: I ntelli gence Scale for C hi l dren: M anual .
New Y ork, Psychological C orporati on, 1949.
Wechsl er D: T he M easurement and A pprai sal of A dult
I ntelli gence, 4th ed. Bal timore, Wi l l i ams & Wi l ki ns,
1958.
Wei nberger G: Brief therapy with chi l dren and thei r
parents, in B arten H H (ed): Brief T herapi es. New
Y ork, Behavioral Publ i cati ons, 1971.
W ei senberg T , M cB ri de K E: A phasi a. N ew Y ork,
Hafner, 1964.
Wei sman G, Feurstei n A, T homas C: T hree-day hospi tal
i zati on A model for intensive i nterventi on. A rch
Gen Psychiatry 21:620-629, 1969.
Wells RA : Structured Short-term T herapeuti c I nterven
ti on. L eoni a, N J , Behavioral Sciences T ape L i brary,
1974.
Wells RA : Group faci li tati ve trai ni ng wi th conflicted
mari tal coupl es, in G urman A , Rice D (eds): Coupl es
i n Confli ct. New Y ork, A ronson, 1975.
Wel l s RA : Short-term T reatment: A n A nnotated Bib
l i ography 1945-1974. (Catal og of Selected Docu
ments in Psychology) 6(1), 13 M S 1189, 1976.
W hi tti ngton H G: T ransf erence in bri ef psychotherapy:
Experi ence in a college psychi atri c clinic. Psychi atr Q
36:503-518, 1962.
Wi l der J F : Roche Report: F ronti ers of Psychi atry, 9(1),
1979.
Wi l kens G D, et al : A therapeuti c community development
in a state psychi atri c hospi tal . M ed J A ust 2:220-
224, 1963.
Wi l tz NA , Patterson GR : A n eval uati on of parent trai n
ing procedures designed to al ter i nappropri ate ag
gressive behavi or in boys. Behav T her 5:215-222,
1974.
Wol berg A: T he B orderl i ne Pati ent. New Y ork, Stratton
I nterconti nental , 1973.
Wol berg A , Padi l l a-L awson E: T he goal s of community
mental heal th consul tati on, in M asserman J H (ed):
Science and Psychoanal ysi s, V ol 8. New Y ork, Grune
& Stratton, 1965, pp 243-261.
Wol berg L R: M edi cal Hypnosi s, V ols 1, 2. New Y ork,
Grune & Stratton, 1948.
Wol berg L R : Hypnoanal ysi s, 2nd ed. New Y ork, Grune
& Stratton, 1964.
W ol berg L R : Short- term P sychotherapy. N ew Y ork,
G rune & Stratton, 1965.
Wol berg L R : Psychi atri c technics in cri si s therapy. NY
State J M ed 72:1266-1269, 1972.
Wol berg L R: T he T echni que of Psychotherapy, 3rd ed.
New Y ork, G rune & Stratton, 1977.
Wol f A: Short-term group psychotherapy, in Wol berg L R
(ed): Short-term Psychotherapy. New Y ork, Grune &
Stratton, 1965, pp 219-255.
Wol pe J : Behavi or therapy in complex neuroti c states. Br
J Psychi atry 110:28-34, 1964.
Wol pe J : T he effects of psychotherapy. I nt J Psychiatry
1:175-178, 1965.
Woul d RL , Reid R: A study of group psychotherapy
resul ts wi th youthful offenders in detenti on. Group
Psychother 17:56-60, 1964.
Y oung H : A Rati onal Counsel i ng Pri mer. New Y ork, I n
sti tute for A dvanced Study in Rati onal Psychother
apy, 1974.
Y oung M , Benj ami n B, Wal l i s C: T he mortal i ty of
widowers. L ancet 2:454-456, 1963.
Zwerl i ng I , Wi l der J F : Day hospi tal treatment of psy
chotic pati ents, in M asserman J H (ed): C urrent Psy
chi atri c T herapi es, V ol 2. New Y ork, G rune &
Stratton, 1962.

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