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THE INITIAL PSYCHIATRIC INTERVIEW AND THE PRINCIPLES

OF PSYCHOTHERAPY; SOME RECENT CONTRIBUTIONSl

VICTOR H. ROSEN, M.D.2

The initial psychiatric interview as a problem in technique, a phase of

therapy and an area of research opportunity has certainly been inadequately
exploited by psychoanalysts. Freud (3) made very few comments on the
subject of "history taking" as such. His most extended remarks appeared in
his 1913 paper, "Further Recommendations in the Technique of Psycho-
analysis." These suggestions appear to have influenced a great deal of past
and current procedure in regard to this initial interview in psychoanalytic
practice. In the beginning of "A Case of Obsessional Neurosis" (2) one
notes a short, condensed initial interview which includes more than the
chief complaint of the patient. It is reasonable to assume that this was con-
ducted vis-a-vis since the next part of the report is entitled "The Beginning
of Treatment." It is also apparent here that Freud felt it permissible to ask
for certain direct information beyond what was freely volunteered. If one
looked for injunctions rather than suggestions in his paper on technique, it
might lead to the suspicion that there had been an interdiction of such
previews. In this latter context he says in regard to diagnosis and the selec-
tion of suitable cases, "I have formed the practice of first undertaking it [the
treatment] only provisionally for one or two weeks. If one breaks off within
this period the patient is spared the distress of an unsuccessful attempt at

1 Lewis R. Walberg, THE TECHNIQUE OF PSYCHOTHERAPY. New York:

Grune & Stratton, 1954, xiv + 869 pages, $14.75.
Merton M. Gill, Richard Newman, Fredrick C. Redlich (with the collaboration
of Margaret Sommers), THE INITIAL INTERVIEW IN PSYCHIATRIC PRAC-
TICE. New York: International Universities Press, 1954, 423 pages, $6.00 (with set
of three twelve-inch long-playing phonographic records, combined cost, $10.60).
Felix Deutsch and William F. Murphy, THE CLINICAL INTERVIEW. New
York: International Universities Press, 1955. Vol. I: "Diagnosis-A Method of
Teaching Associative Exploration," 613 pages, $10.00; Vol. II: "Therapy-A Method
of Teaching Sector Psychotherapy," 336 pages, $7.50.
James L. McCary and Daniel E. Sheer, eds., SIX APPROACHES TO PSYCHO·
THERAPY. New York: Dryden Press, 1955, vi + 402 pages, $3.75.
2 Clinical illustrations are from the records of the Treatment Center of the New
York Psychoanalytic Institute.

154
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THE INITIAL PSYCHIATRIC INTERVIEW 155

cure; it was only 'taking a sounding' in order to learn more about the case
and to decide whether it was a suitable one for psycho-analysis. No other
kind of preliminary examination is possible; the most lengthy discussions
and questionings in ordinary consultation are no substitute. This experi-
ment, however, is in itself the beginning of an analysis, and must conform
to its rules; there may perhaps be this difference in that on the whole one
lets the patient talk, and explains nothing more than is absolutely necessary
to keep him talking" (3). Not only suitability in a general characterological
sense must be so ascertained but also apparently differential diagnosis, par-
ticularly in regard to "incipient paraphrenia." In another place Freud (3)
says, "Lengthy preliminary discussions before the beginning of treatment ...
have certain disadvantageous consequences for which one must be prepared."
A further comment on this topic is the following, "What subject-matter the
treatment begins with is on the whole immaterial, whether with the patient's
life-story, with a history of the illness or with recollections of childhood."
Strong predilections and prejudices among analysts in regard to the initial
contact with the patient have undoubtedly been influenced by these technical
remarks without due consideration to their original context or certain
modifications that are necessarily imposed by other conditions.
Others who have contributed in extenso to the problems of technique,
for example, Nunberg (8), Fenichel (1), and Lorand (7), have made no
reference to this subject in their well-known monographs. Glover (4) devotes
a few pages to the problem. He is in apparent agreement with Freud that
it is undesirable for the patient to "repeat the emotionally strenuous experi-
ence of a prolonged anamnesis (that is, after an examination by a con-
sultant)." Glover holds that it is advisable "as a prelude to the first session
in all transferred cases" to hold a brief and informal consultation. He says,
"To carry this out successfully he [the analyst] should have some experience
of analytic methods of consultation, a part of his training which incidentally
is too often neglected." In subsequent remarks Glover indicates a continuity
with tradition in the feeling that in an "analytic consultation" (presumably
as distinguished from a psychiatric consultation) there should be a minimum
of interrogatives, although there is no absolute interdiction implied, es-
pecially in regard to "leading questions to uncover the existence of symptoms
or peculiarities or conflicts insofar as it is necessary or possible to do so."
Stone (11) appears to be the first psychoanalytic author to assert the useful-
ness of modifications of the "free association interview" in the light of the
"widening scope" of analysis today and some special situations in which it
is utilized that were perhaps unforeseen by Freud in 1913.3 In regard to the
subtleties of evaluation of various kinds of borderline phenomena, Stone (II)
expresses a preference for "longer (and often multiple) psychiatric examina-
tions than we have usually employed." He says, "We need detailed histories,
detailed observation of the patient's thought processes and language ex-
3 As for example the selection of cases for supervised psychoanalysis in a Treat-
ment Center of a Psychoanalytic (training) Institu teo
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156 BOOK SECTION

pression, and an opportunity to observe his postural, gait, voice and mimetic
reactions. Certainly in these modalities the patient may reveal to the sensi-
tive observer psychotic fragments from a descriptive point of view. Further-
more, in being allowed to talk spontaneously at times, in his choice of ma-
terial, in his response or manner of response, or non-response to questions,
the patient may tell us much that might be expected to appear in a diag-
nostic 'free association' interview; often more because certain questions can-
not be evaded, at least from an inferential point of view. In his longitudinal
history and in the current patterning of the patient's activities one can learn
much of the personality structure which underlies the symptoms. Most sig-
nificant of all is the character and pattern of his relationship with people.
Finally, as a strong personal preference, I believe that the patient's reaction
to the examiner in the interview can be of great diagnostic importance.
Irritability, detachment, shallowness, euphoria, pompousness may sometimes
mean more than pages of symptom description."
The present writings on the subject are therefore timely and begin to fill
a vacuum that has been apparent to many for some time. The four books
toward which the present discussion is directed are an assortment of more
or less general dissertations on the theory and practice of psychotherapy. All
of them explicitly or implicitly deal with the problem of obtaining significant
information from psychiatric patients. Gill, Newman, and Redlich, for
example, focus solely on this problem. Deutsch and Murphy devote Volume I
of their two-volume work to this subject. Wolberg devotes 108 pages of dis-
cussion to the "initial interview." The various contributors to McCary's
symposium are also concerned with eliciting clinical data, although in some
of their papers the problem is underscored by relative neglect.
From the author's point of view the most congenial statement of the
problem is found in Gill, Newman, and Redlich, The Initial Interview in
Psychiatric Practice. These writers, by the way, also cite psychoanalytic
contributions to the subject by Stekel, Reik, Karl Menninger, and Knight.
These references are amply reviewed in their book. Gill and his co-workers
discuss four major determinants of the interchange in the initial interview,
and use a rather original pedagogical tool of auxiliary recordings on standard
33Ys rpm. discs to illustrate with sample interviews. They discuss the problem
in relation to: (1) the personality structures of the two participants, (2) the
way in which they view their own and each other's roles, (3) the purposes that
each is pursuing (both conscious and unconscious), and (4) the technique
which the interviewer employs. They make the point, with which this author
is in complete sympathy, "that there is a wide range of relevant content in
initial interviews just as there are many differing practical psychiatric situa-
tions. An interview to determine admissibility to a hospital, for example,
may differ from one to determine admissibility to an outpatient clinic, which,
in turn, will differ from an interview held by a psychiatrist in private prac-
tice." This part of the content is therefore determined from the point of view
of the interviewer. The patient's purpose will play an important part as well.
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THE INITIAL PSYCHIATRIC INTERVIEW 157

"It may vary from a genuine desire to get help, to a conscious plan to avoid
imprisonment for a sex crime, to an unconscious need to defeat the ther-
apist." Further, these authors point out (and this is one of the new contexts
in which psychoanalytic interviewing will find itself more and more fre-
quently involved in the years to come) that "unconscious forces within the
interviewer are not the only factors which can modify his theoretical intent.
His reality situation may force him to direct the interview into certain chan-
nels. In a particular clinic setting, for example, the alleged purpose of the
intake interview may be to determine the suitability of the patient for psy-
chotherapy by a resident under supervision." In general these authors feel
that the initial interview has three main aims, the first being to establish
"rapport:' the second being an "appraisal" of the patient's psychological
status, and the third being "reinforcement" of the patient's wish for therapy
or presumably whatever other plans are indicated. In this work, as in the
others to be discussed below, one finds a strong reaction against the tradi-
tional "syllabus" type of diagnostic interview. Gill and his co-workers feel
that we are not necessarily forced to choose between a "nondirective" ap-
proach and a formal cataloging of information, but that rather an attempt
should be made to teach an "appraisal" method which allows for the spon-
taneous unfolding of the patient's account of himself as suggested by Knight
(6). Since such a technique places maximal emphasis on the spontaneity of
the patient, guided and prompted by the skill, experience and theoretical
grounding of the interviewer, it is bound to be a method in which there is a
greater variability in the diagnostic and prognostic usefulness of the inter-
view in different hands, than would be likely to occur in either a completely
nondirective interview or in the traditional method. This is underscored by
the publication (with considerable apology on the part of the authors) of an
interview by a third-year medical student utilizing the "spontaneous unfold-
ing" technique. The interviewer's inexperience in such an examination and
his lack of theoretical grounding in psychodynamics lead to many striking
(and to be expected) technical errors. One must disagree to some extent with
the authors who assert that "the patient is impelled to tell his story and that
his story flows out despite the student's inexperience and even despite some
obstacles which the student puts in his path," implying that even with the
novice this technique would be the method of choice. However, it is necessary
to remind ourselves that the classical "syllabus" type of interview was designed
to cover just such pedagogical situations. A more conservative reaction to this
kind of experience might include the possibility that even flexibility can be
inflexible and that there is room for a great variety of interviewing tech-
niques to fit the special stages of development of the interviewer as well
as his particular predilections and the problems of the particular patient.
In this sense, for the inexperienced medical student there might still be a
greater learning potential in the traditional diagnostic interview than in the
spontaneous interchange, without in any sense mitigating the thesis that in
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158 BOOK SECTION

the hands of the experienced examiner such an attempt would have a strait-
jacketing effect.
Deutsch and Murphy in their book propose a novel and somewhat radical
method of eliciting clinical data which they refer to as the "associative
anamnesis." This is described as "an interviewing method based on the con-
cept of free association as used in analysis." Less emphasis is placed, however,
on "content association than on individual words." The method, according
to the authors, "consists of recording not only what the patient says but also
how and in what order he gives the information." It is of consequence not
only that the patient tells his complaints but also in what phase of the
interview and in which connection he introduces his ideas, complaints and
recollections of his somatic and emotional disturbances. They feel "that if
one asks the patient to give not only all his ideas but also all accompanying
somatic sensations it is possible to observe the somatic and the psychic com-
ponents more nearly simultaneously." The proposal is an interesting and
stimulating one and the authors provide the records of extensive interviews
in selected cases to buttress their thesis that such breast-pocket analysis, so
to speak, is possible and rewarding. In a sense this is a condensation into
a single session of Freud's original recommendations for a "trial sounding."
After describing the associative anamnesis, it is somewhat surprising to read
the following statement five pages below the one quoted above: "It should
be borne in mind that in using psychological methods for eliciting informa-
tion the interviewer must not be at the mercy of the patient's intention and
inclination to give information. On the contrary, knowledge of the person-
ality traits in the different diseases tells him how and where to guide the
patient's thoughts." Thus, some knowledge of the psychological forces govern-
ing human behavior is the presupposition for an interview which should
reveal the emotional content involved in the symptom formation. This is a
method presumably to be placed in the hands of internes and residents in a
learning situation, unless the authors' meaning is misunderstood. One is
bound to feel the same objection here in even greater force than was made in
connection with Gill's, Newman's, and Redlich's "pedagogical proposals." A
real understanding of "personality traits" and "the psychological forces gov-
erning human behavior" is a synthetic process that begins with clinical
observations and interviewing. Granted that there is an interacting maturing
influence between theory and practice, one is bound to have certain reserva-
tions about a teaching method in which the first steps in practice presuppose
an advanced stage of theoretical sophistication. One is impressed with the
information elicited in these detailed interviews. The dynamic formulations,
however, which follow each brief series of questions and answers seem to this
writer to be of the type that would require considerable validation by further
investigation before they could be considered as usable psychotherapeutic
tools. One can see the possibility in this method of occasional intuitive
"bull's-eye" formulations in the hands of particularly experienced and intui-
tive therapists. However, when it is employed as an over-all method in inex-
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THE INITIAL PSYCHIATRIC INTERVIEW 159

perienced hands, one suspects that it may contribute to considerable sub-

jective distortion and erroneous inference.
Wolberg attempts to give a detailed, comprehensive guide for the initial
contact with a prospective case for psychotherapy. It is difficult to tell toward
what levels of theoretical and practical experience his account is directed. In
some areas it would seem to presuppose very little training on the part of
the therapist, whereas in others there appears to be the expectation of con-
siderable sophistication. In his account, Wolberg gives detailed advice on
dealing with initial resistances, recommendations on how to elicit data con-
cerning the chief complaint, its history and development. He discusses dreams,
family data, previous emotional upsets and detailed diagnostic considera-
tions, with recommendations for a somewhat modified nomenclature. There
is a discussion of the formulating of tentative dynamic considerations, recom-
mendations on the estimation of prognosis and many brief "blueprints" for
handling such questions as the frequency of visits, questions concerning the
duration of therapy, arrangements of the fee, referral procedures, etc. Al-
though there are many interesting ideas and formulae which might prove
useful on certain occasions to the beginner, the discussion seems to suffer
from a certain overcomprehensiveness and an attempt to provide over-all
guides which are likely, in the hands of beginners, to produce a certain
stereotypy of performance. Although technical hints and procedural sugges-
tions are indispensible in the teaching of psychotherapy or psychoanalysis, it
is likely that when these are too specific they are extrapolated loosely by the
beginner to what may erroneously seem to be an analogous situation in an-
other case with consequent confusion rather than clarification.
Brief comments are in order on at least three of the articles in McCary's
symposium. The one on "Client-Centered Psychotherapy," by Nicholas Hobbs,
appears to be a general summary of the much-discussed Rogerian "nondirec-
tive therapy." Here one finds procedural recommendations which are very
far removed from accustomed psychiatric as well as psychoanalytic concepts.
The author says "with reference to the function of diagnosis in psycho-
therapy, Rogers has taken a position radically different from that prescribed
by tradition, has precipitated controversy and has provided critics with a
favorite issue with which to do battle." In this discussion the terms "diag-
nosis" and "formulation" appear to be used interchangeably. It is quite
apparent that for Hobbs and Rogers the term "diagnosis" is semantically so
different from that in general use among psychiatrists that it would make an
interchange of ideas very difficult. For example, "Rogers maintains that little
good can accrue to the client from the fact that the therapist has arrived at
a formulation of his problem because it is the client who must arrive at the
formulation and experience its meaningfulness in his own terms. The issue
rests largely upon who is to do the diagnosing." Rogers thinks that "the
client must do it." In another place the author states, "the therapist cannot
speed the process by a prior discernment of the problem. To do so may make
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160 BOOK SECTION

the therapist feel good but it cannot make the client feel better." The reader
who has an investment in the principles of logical consistency will find
further confusion in this account when a few pages later he reads, "Further
clinical experience and research should give us better understanding of the
relationship between personality structure and ability to respond to client-
centered treatment. The concept of individual differences, confirmed time
and again in psychological observations, may certainly be counted on to
operate with reference to the appropriateness of client-centered therapy for
various people. From accumulative experience one thing is clear: Like other
therapies, client-centered therapy helps some people a great deal, others
somewhat, and still others not at all. The problem is to identify the factors
that are related to differential responsiveness to various kinds of therapy.
There is some evidence that intrapunitive males respond well to client-
centered experience and that aggressively dependent people are difficult to
work with from this orientation."
A directly opposing point of view is expressed by Thorne in a chapter on
"Directive and Eclectic Personality Counseling." This reveals a pronounced
Meyerian background. Thorne makes a strong plea for the therapeutic im-
plications of the case history. He feels "that the relationship between ade-
quate case history-taking and rational psychotherapy is of both theoretical
and practical significance." Thorne gives an outline for a personality inven-
tory and a history outline which appears to be a useful modification of the
traditional "mental examination." It is one that could be quite helpful at
the medical student and interne level.
For the present writer the most interesting discussion is the chapter by
Norman Reider entitled, "Psychotherapy Based on Psychoanalytic Prin-
ciples." This author discusses several cases of "spontaneous cures" in patients
who had a "brief interview" contact with the author. The discussion is a
retrospective attempt to understand the possible dynamics of the result.
Reider's succinct and well-organized case abstracts reveal certain stimulating
ways in which the interview information can be retrospectively used for
reconstructive hypotheses concerning this interesting phenomenon.
In the work of the Treatment Center at the New York Psychoanalytic
Institute diagnostic interviewing has taken on a particularly prominent role
in regard to the selection of suitable cases for supervised psychoanalysis by
candidates in training. Thus the function of the interview has been not
only the selection of cases on the basis of their conformity with certain
standard nosological schemes, but the estimation of certain other subtle
elements such as motivations for treatment, integrity of ego structure, unusual
character defenses, susceptibility to regressive tendencies, etc. It is hoped
by this selective process to provide the student with a case that will provide
not only an insight into clinical phenomena, but also an optimum prob-
ability of a sustained therapeutic experience without interruptions and
unusual technical difficulties, in so far as these can be foreseen. For this
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THE INITIAL PSYCHIATRIC INTERVIEW 161

purpose, largely under the influence of Dr. Leo Stone.s multiple interviewing
by experienced analysts has seemed to provide the greatest probability for the
kind of comprehensive diagnostic estimate that is necessary in this context.
Each examiner uses his own "flexible" interviewing technique and the in-
formation is pooled and discussed in a final conference. In addition to a pos-
sible superiority in eliciting crucial sensitive information, this method is also
less time-consuming than the so-called "trial analysis." It is possible that it is
also preferable in terms of minimizing the traumatic effect upon a patient
of the discontinuance of a therapeutic process in which important transfer-
ence affects may already have been mobilized.
In the records of the Treatment Center there are many examples at the
present time of the kind of information that is elicited in this manner. The
following two cases are presented as illustrations of this experience.v
The first case is that of a single, young professional woman, who gave
as her principal complaint in the application form "persistent intense anxiety
symptoms, including excessive perspiration, palpitations, tremors and general
feelings of apprehension usually associated with work situations." The psy-
chiatrist who had seen her in consultation and had referred her to the Treat-
ment Center felt that she would be a suitable case for analysis, but not an
easy one. To the second interviewer she suggested "the studious but healthy
high school girl, appearing somewhat more youthful than suggested by her
chronological age." To him she divided her difficulties into two parts. The
first was the discomfort itself and the second "the sheer problem of getting
her work in." The discomfort was related mainly to persistent sweating and
palpitations. In response to a brief question about her relationship with men
she stated that she has always gotten along well with them, that she would
not come for any treatment in regard to troubles with men or in relationship
to any social problem. On the basis of a somewhat brief interview this ex-
aminer felt that the patient was probably a good candidate for analysis in
our setting, suggesting a more detailed third interview. With the third inter-
viewer, she continued to discuss her anxiety and the details of her work
problem. At the end of this interview the examiner wrote: "This appears
to be an intelligent and probably quite capable young woman with a char-
acter disorder, marked at the present time in so far as our information goes by
a fairly circumscribed work inhibition mostly connected with the completion
of written records and accompanied by anxiety symptoms in relation to her
inhibition and to authority figures. The dynamics of the problem appear
quite obscure at the present time. One is somewhat suspicious of the intel-

4 Medical Director, Treatment Center, New York Psychoanalytic Institute.

5 It is anticipated that the Committee doing this work will also review those cases
accepted for analysis after multiple interviewing to determine the extent to which
important information that should have led to a negative decision failed to be
elicited.
The following interviewers participated in these two examinations: Drs. Leo
Stone, Ernst Kris, Henry Lowenfeld, Dora Hartmann, Yela Lowenfeld, Victor Rosen.
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162 BOOK SECTION

lectualization concerning her 'defiance of mother figures,' the paucity of

heterosexual material and the almost surprised response to questions con-
cerning marriage and the possibility of conflict between interest in marriage
versus interest in work. This seems to point to a denial-like mechanism in
regard to these problems. She may very well turn out to be an interesting
'second case' for student analysis, but another interview would seem to be
indicated." In a fourth interview, the patient almost immediately launched
into an account of a sexual relationship that she had had while at college
with a girl of her own age. She herself managed somehow to consider this
not a very serious problem (in spite of the fact that the patient worked in a
field closely related to psychiatry and had considerable academic training
at least in psychology). Her present problem had started when in relation to
her professional work she had interviewed an overtly homosexual girl. This
examiner noted in his impressions "the doubts of her previous interviewers
proved to be quite justified by the revelation she gave suddenly today. Her
anxiety symptoms seem to be related to her homosexual problems. Whereas
she appears to be quite healthy outside this sphere, the dynamics of her
homosexual trends are hardly understandable. The fear of her mother may
be considered important." A fifth interviewer closed his report with the
following final comment: "The genesis of this patient's homosexuality re-
mains unclear even from a speculative reconstructive point of view. My own
broad intuitive hunch would be that it is connected with her masturbation
conflict and that perhaps the homosexual temptation supplanted the mas-
turbatory temptation as the 'lesser evil.' " In this case it was still felt that the
possibilities of a candidate analysis were not excluded, although the original
"hysterical" diagnostic impression was certainly considerably modified.
The second case was that of a young musician whose chief complaint was
that of marked uneasiness in social situations especially with the opposite
sex. He had a feeling of standing on the side lines and "just watching what
other people were doing." In the first interview he discussed his family back-
ground and early history at some length. His father had been a missionary
for a Fundamentalist denomination in H--, Africa, where the patient lived
until about the age of ten. He revealed that at the age of six he had had
sexual intercourse with a somewhat younger girl cousin. At the age of about
ten or eleven he recalled having attempted genital penetration of a younger
sister. In this same interview this patient revealed that his mother had left his
father when he was in his early adolescence, and that his father had since
remarried. He stressed the fact that he thought that his father needed "some
kind of psychiatric help" without being able to be explicit about his precise
problem. The first interviewer had the impression "that the major symptom
appears to be a rather severe social inhibition particularly with members of
the opposite sex." From the data at hand he suspected this of being largely
hysterical and part of a hysterical character disturbance. The history of what
appears to have been active overt incestuous experiences with actual coitus
at the age of six, possibly followed by massive repression was considered as a
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THE INITIAL PSYCHIATRIC INTERVIEW 163

possibility. The second interviewer obtained the history that impulsive sexual
behavior continued until the age of fourteen at which time the patient had
attempted anal penetration of his two-year-old brother. She also obtained the
history that during most of his childhood in H-- his care was given over
largely to domestics who came from the local native population. This inter-
viewer also felt that this was a hysterical character disturbance, but was
"somewhat disturbed" by the long period of childhood sexual activity. She
felt, however, that this might be explained by the unusual environment of
the patient as a child when he may have been subjected to actual seduction
by the primitive people who were left to care for him. The patient was then
seen by a third examiner who wrote: "When I inquired about some contra-
dictory features in the image of his father as it arose out of his statements he
supplemented previously given information as follows: the maternal grand-
parents who had been missionaries in H--, Africa, for many years had
lived with them on the same station. They had always been opposed to his
father. When his parents came to R--, the father was dismissed by the
mission. In this connection he mentioned that his father had been observed
masturbating at an open window and was arrested. The patient recalls all
of the details." The third interviewer adds the following impression: "From
the material gained in the interview and contained in the patient's letter
one gains the impression of the existence of a painfully controlled impulse
disorder. The hysterical features and the social inhibitions seem super-
imposed. There is definitely the possibility of a malignant basis. I would
hold as an opinion that the impulsiveness is a reflection of an early seduc-
tion by the father, be it in direct sexual contact, be it as witness to some
of the father's perversions."
To what extent such "surprise" information is part of a continuing process
already set in motion by the first interview and to what extent the informa-
tion is a response to the unique features of the personality (and perhaps sex)
of the individual interviewer or other special and unpredictable stimuli, is
entirely speculative. To the extent that it is the latter factors that predom-
inate, it reminds one of the untransmissible residue of "art" in all interview-
ing techniques.
More striking perhaps than their contributions to the problems of eliciting
data for the diagnosis is the renewed impetus that such expositional works
give to the manifold questions of indications, techniques, principles and
theoretical assumptions in psychotherapy, especially in so far as they are
indigenous to it and distinct from psychoanalysis.
At a panel on "Psychoanalysis and Psychotherapy" (9) at the Annual
Meeting of the American Psychoanalytic Association in 1951 it was generally
agreed that it was particularly difficult to find, in what we generally under-
stand as "psychotherapy," any "rules or particular generalizations of its own."
This observation deserves some scrutiny in view of the fact that many analysts,
for example, advise psychotherapy for certain patients, not only in lieu of
psychoanalysis, on purely opportunistic or practical grounds, but because they
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164 BOOK SECTION

see in it special affirmative values of its own for certain clinical problems.
The most recent systematic discussions of this problem from the point of
view of the psychoanalyst have been those of Stone (10) and Knight ( 5, 6).
The former author attempts to sort out the specific indications for psycho-
therapy in contradistinction to psychoanalysis under certain broad, but well-
defined categories, an attempt that is largely missing in the current volumes.
Wolberg, for example, in a volume of 869 pages, discusses almost every phase
of the problem. He makes distinctions between psychoanalysis and psycho-
therapy and discusses psychotherapeutic techniques in different clinical con-
ditions, but he does not attempt a sufficiently critical differentiation of the
conditions in which psychotherapy because of its own special "parameters"
has a superior therapeutic value.
The same assessment of fundamental assumptions in regard to the general
principles of psychotherapy as distinct from psychoanalysis is made particu-
larly relevant by these presentations. Where, for example, does the descrip-
tion of a personal style, special predilection or bias leave off, and the intro-
duction of a new methodology begin? Wolberg attempts to categorize and
describe different types of psychotherapy and also subdivides one particular
category, "insight psychotherapy with reconstructive goals" into "Freudian"
and "non-Freudian" psychoanalysis and "psychoanalytically oriented psycho-
therapy." He utilizes the character of such variables as the duration of ther-
apy, the frequency of visits, completeness of initial history taking, degree of
reliance upon psychological examinations, the type of communication by the
patient, the general activity or inactivity of the therapist, the admissibility
of direct advice, the transference characteristics, the physical position of the
patient, the use of dream material and the role in the therapy of adjunctive
treatment. All of this would certainly give a superficial observer an advance
picture of how things would look in these various approaches, but it does
not go to the heart of the matter. It is certainly not a statement of a funda-
mental rule of psychoanalysis, for example, to say that "advice is never
given." Similarly, in regard to the transference, Wolberg asserts that "Freudian
analysis" encourages the transference "to the point of the transference neu-
rosis," while the "non-Freudian analyst" tends to avoid the transference
neurosis. Without attempting a detailed discussion of the validity of such as-
sertions, one may be permitted to express a doubt as to the possibility of
achieving any sharpness of definition by such means. It has been abundantly
evident that fundamental distinctions between psychoanalysis and psycho-
therapy are difficult enough to delineate with any clarity. What can be reaped
but confusion by pointing to fundamental differences of principle in
methodologies that we designate by essentially the same name?
Deutsch and Murphy, in their second volume, develop a psychotherapeutic
discipline which appears to be a logical consequence of the "associative
anamnesis." It is given the descriptive title of "clinical sector psychotherapy."
"Sector psychotherapy" is defined as "a goal-limited therapy based directly
upon psychoanalytic principles . . . it is a planned therapy and conducted
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THE INITIAL PSYCHIATRIC INTERVIEW 165

so as to work on the unconscious factors that influence the reality situation

rather than the reality situation itself ... ." An "induced positive transfer-
ence" is utilized and the "associative anamnesis is used in lieu of free asso-
ciation. . . ." The aim of "sector psychotherapy" is the adjustment of the
patient within and to a given life situation to which he has not adjusted
previously. For this purpose only a strategically chosen sector of the total
conflict is selected for major emphasis (in this connection also see Stone, 10).
The authors illustrate their technique with a great deal of detailed clinical
material and the actual dialogue of sample sessions. The reader must be
referred to the source itself for an adequate discussion of the authors' tech-
nical devices and theoretical assumptions.
The McCary symposium covers a wide range of existing "psychotherapies."
It illustrates the variety of concepts that lie behind apparent similarities in
terminology as well as the multiplicity of terminologies that describe the
same concept. Among these are articles on "Hypnotherapy" by Wolberg,
"Group Psychotherapies" discussed by Slavson, and Moreno's "Psychodrama."
Reference was made above to chapters on "Nondirective" and "Directive and
Eclectic Personality Counseling." A complete discussion of these presenta-
tions is beyond the scope of the present essay.
In the paper by Stone cited above (10) in which the principles that are
indigenous to psychotherapy are discussed, the following statement is made:
"My own practice of brief interpretative psychotherapy includes the possible
applicability in certain cases of almost any technique I have heard described."
The following, however (here reproduced in outline form), are the general
principles that appear most relevant in our present stage of knowledge:

1. An initial comprehensive picture of the entire case is more necessary

than in psychoanalysis. A decision in regard to the patient's crucial
dynamic problems is emphasized with therapeutic activity largely con-
ditioned by this selection.
2. The interviews center largely around the patient's actual personal rela-
tionships and events of his daily life.
3. "Observations are made on the general dynamic role of the illness with-
in this system" (this, Stone suggests, does not resemble the "associative
anamnesis" of Deutsch, except possibly in the relative localization of
effort).
4. The patient sits facing the therapist and is encouraged to express him-
self "spontaneously and without reservation"; however, the interviews
are definitely guided or influenced largely by questions.
5. Interest is centered on large and decisive dynamic issues rather than
the details of fantasy, and in close relationship to immediate realities.
6. Interpretations are made in the patient's own idiom or a reasonable
compromise between it and the therapist's natural modes of expression.
7. Efforts are made to "integrate in single simple communications, ma-
terial involving levels of varying psychic depth and different psychic
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166 BOOK SECTION

structures, resolving contradictions and antagonisms, exploiting to a

maximum the areas of the overlapping in clarifying the patient's
problems."

In many of the specific technical procedures advised in the foregoing

works one is struck by either the omission of the "initial comprehensive
picture of the entire case" or the application of a procedure that would seem
to preclude "spontaneous" communication "without reservation." Many
questions are raised by such procedures as "hypnotherapy" or the "sector
psychotherapy" of Deutsch. To what extent, for example, can the infinite
complexity and mobility of the interaction of drives, defenses and the chang-
ing flux of external reality be directed into ad hoc channels? Is it more or
less likely that the limiting of the free range of communication will require
special capacities and experience in the therapist? In addition to the in-
cidence of symptomatic improvement, future studies of these methods should
also report upon the incidence of superimposed iatrogenic psychopathology
or other complications. Such questions can be permitted without in any way
detracting from our debt of gratitude to those thoughtful and sincere indi-
viduals who are attempting to explore this largely uncharted terrain. If a
defensive vested interest in a particular method can be avoided, then there
is much to be learned from error as well as success.
From among this welter of contributions upon the subject one conclusion
appears to be justified at the present time. We are not yet capable of devising
a complete nosology that will adequately cover the wide range of clinical
phenomena. When to this is added a most limited appreciation of even the
invariable patterns of genetic, economic and structural characteristics in those
entities covered by our incomplete nosology, then it should be apparent that
a "goal-limited psychotherapy" with "rules" of its own must lie in the realm
of future possibility rather than present actuality. Psychoanalysis, because its
goals are relatively unlimited and its judgments relatively suspended while
awaiting the painstaking and time-consuming collection and collation of data,
can be said to have (at least general) "rules," albeit incomplete and at times
rudimentary ones. Psychotherapy, on the other hand, with its multitude of
methodologies, each with its own advocates, can only be said to have "tenets"
of varying degrees of acceptance. Perhaps in the crucible of practical testing
these will someday evolve into "rules" which have more than highly con-
ditional and personal validity.

BIBLIOGRAPHY

1. Fenichel, O. Problems of Psychoanalytic Technique. New York: Psychoanalytic

Quarterly, Inc., 1941.
2. Freud, S. Notes upon a case of obsessional neurosis (1909). Collected Papers,
3:296-383. London: Hogarth Press, 1946.
3. Freud, S. Further recommendations in the technique of psycho-analysis: on the
beginning of treatment; the question of the first communications; the dy-
Copyrighted Material. For use only by 20021. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).

THE INITIAL PSYCHIATRIC INTERVIEW 167

namics of the cure (1913). Collected Papers, 2:342-369. London: Hogarth Press,
1946.
4. Glover, E. The Technique of Psychoanalysis. New York: International Uni-
versities Press, 1955.
5. Knight, R. P. A critique of the present status of the psychotherapies. In:
Psychoanalytic Psychiatry and Psychology, 1:52-64. New York: International
Universities Press, 1954.
6. Knight, R. P. Evaluation of psychotherapeutic techniques. In: Psychoanalytic
Psychiatry and Psychology, 1:65-76. New York: International Universities Press,
1954.
7. Lorand, S. Technique of Psychoanalytic Therapy. New York: International
Universities Press, 1946.
8. Nunberg, H. Principles of Psychoanalysis. New York: International Universities
Press, 1955.
9. Panel: Psychoanalysis and psychotherapy. Bull. Am. Psychoanal, Assoc., 7:252-
265,1951.
10. Stone, L. Brief psychotherapy. Psychoanal. Quart., 20:215-236, 1951.
II. Stone, L. The widening scope of psychoanalysis. This Journal, 2:567-594, 1954.
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