Psychoanalytic Case Formulation
McWilliams, Nancy (1999)
Chapter 5- Assessing Defense
An appreciation of what has come to be known as "defensive" processes has characterized psychoanalytic thinking for a long time. Freud's original curiosity about psychopathology began with some observations (Freud, 1894) about what we would now consider the defense of dissociation or disavowal: How can somebody know and not know a thing at the same time? I covered the general topic of defense in Chapters Five and Six of Psychoanalytic Diagnosis, to which the reader is referred for conceptual background. For other summaries and viewpoints, one can also consult A. Freud (1936), Laughlin (1967), and Vaillant (1992). Here, my main concern is to illustrate how assessing a person's defensive tendencies contributes to making psychotherapy as effective as possible. I discuss both habitual defenses, those that have hardened into what Reich (1933) memorably called "character armor," and more reactive defenses that have been situationally provoked.
In a sense, the whole interview process stimulates defense, giving the clinician the opportunity to see how the patient copes with the stress of being invited to expose private and painful information to a stranger. People come to therapists with a potent combination of hope and shame. They want to reveal the psychological issues they are struggling with and, at the same time, they want to minimize them so that the therapist will not be as negative toward them as they themselves tend to be. They are simultaneously striving to be nondefensive and being propelled by their anxieties into being more defensive than usual. Most of the therapist's observations about defense will thus flow from the overall behavior of the person in the interview situation. Some of the specific questions that might highlight defensive functioning, however, include the following: What do you tend to do when you're anxious? How do you comfort yourself when you're upset? Are there any favorite family stories about you that claim to capture your basic personality? What kinds of observations or criticisms or complaints do other people tend to make about you? How do you find yourself reacting to me?
Among analytic concepts, some of which are notoriously hard to study via empirical methods, defense has been one of the most carefully researched. Even though the essential nature of a defensive process is subjective and involuntary, and "defense" remains a hypothetical construct, there are ways of operationalizing processes such as "repression," "denial," "withdrawal," "idealization," and similar mechanisms that make them accessible to controlled experimentation. The concept of defense--sometimes under the nonpsychoanalytically tainted label of "coping style"--has even attained enough empirical validation to have been accepted into the DSM-IV (Axis VI: "Defensive Functioning Scale," under "Criteria Sets and Axes Provided for Further Study"), albeit as a kind of supplementary and optional category of diagnostic information. Vaillant and McCullough (1998) have recently presented research support for the diagnostic importance of defenses to Axis II descriptions, which in their current versions tend to emphasize observable behaviors more than internal motivations and thereby to sacrifice validity for reliability.
As Vaillant (1971) has pointed out, defenses can alter one's perception of any or all of the following: self, other, idea, or feeling. They can operate in the realm of cognition (e.g., rationalization, which seeks relief from painful states by manipulating ideas), emotion (e.g., reaction formation, which handles an upsetting feeling by turning it into its opposite), behavior (e.g., acting out, which provides escape from painful conflicts by external enactments), or some combination of these (e.g., reversal, which operates via cognition and behavior: "I'm not the one who feels X--you are, and so I will treat you in a way that relieves your presumed feeling").
Although there is general agreement among psychoanalytic scholars that some defenses constitute better overall adaptations than others (e.g., Laughlin, 1967; Kernberg, 1984), and although there is a solid empirical basis for assuming that defenses can be put into a hierarchy of relative psychopathology (Weinstock, 1967; Haan, 1977; Vaillant, 1977), there is no normative pattern of defense by reference to which the unhealthy deviate from the healthy. Among therapists, Kernberg's (e.g., 1984) rationale for distinguishing between primitive, or primary,
and secondary, or mature, defenses is probably the most widely accepted. Kernberg argues:
Repression and such related high-level mechanisms as reaction formation, isolation, undoing, intellectualization, and rationalization protect the ego from intrapsychic conflicts by the rejection of a drive derivative or its ideational representation, or both, from the conscious ego. Splitting and other related mechanisms protect the ego from conflicts by means of dissociation or actively keeping apart contradictory experiences of the self and significant others. (p. 15)
The "other related mechanisms" include primitive idealization, projective identification, denial, omnipotence, and primitive devaluation. I have noted (McWilliams, 1994, p. 98) that the defenses we tend to consider more archaic involve the boundary between the self and the outer world, whereas those we consider higher-order processes deal with internal boundaries, such as those between the ego or superego and the id, or between the observing and experiencing parts of the ego.
People's defensive patterns are almost as individual as their voice or their fingerprints. Some people use sadness as a defense against anger, while others get angry to defend against sadness. Some defend against a pervasive underlying shame; others seek not to feel guilt. Some have an extensive repertoire of defenses, while others perseverate with one or two tried-and-true mechanisms, no matter what the circumstances. In order to help a person, we need to appreciate the particular way in which he or she is using thoughts, feelings, and actions to relieve upsetting internal states.
CLINICAL VERSUS RESEARCH CONSIDERATIONS
IN ASSESSMENT OF DEFENSE
For research purposes, nosologies that emphasize observable behaviors are preferable to those that make use of internal and inferred processes. But for clinical purposes, it is more important to know the meaning of a person's behavior than to describe that behavior accurately the way an external observer would. The phenomenon of antisocial personality disorder or psychopathy, in the older language of descriptive psychiatry and psychoanalysis, nicely illustrates the limitations of assessment according to mostly observable behavior, assessment that ignores the significance of a person's inferred defensive proclivities. Since the 1980 edition, the DSM has relied heavily on the research of Lee Robins (e.g., 1966), a sociologist interested in antisocial behavior, because her definitions of psychopathic phenomena are descriptive rather than inferential, and empirically determined rather than theoretically derived. Her behavioral, observable criteria for assessing antisocial personality disorder (a term that itself reflects the sociologist's interest in phenomena that deviate from conventional norms, in contrast with the psychotherapist's concern with motivation and personal meaning) are thus highly adaptable to conventional research. Reflecting its dependence on Robins's work, the DSM-IV has seven criteria for Antisocial Personality Disorder, only one of which, "lack of remorse," is internal.
But to a therapist, the critical indicators of a psychopathic orientation are almost exclusively internal. They include consistently observed and well-documented phenomena such as emotional insincerity (Cleckley, 1941), defects of conscience (Johnson, 1949), contemptuous delight at "getting over on" others (Bursten, 1973), attraction to extreme stimulation (Hare, 1978), lack of empathy (Hare, 1991), egocentricity or grandiosity (Cleckley, 1941; Hare, 1991), obliviousness to affects (Modell, 1975) except perhaps for rage and envy (Meloy, 1988), and perhaps most centrally (and vital to the argument in this chapter), reliance on the primitive defense of omnipotent control (Kernberg, 1984; Meloy, 1988; Akhtar, 1992).
Therapists see many people who do not, at least on the basis of what can be observed in an initial interview, meet the DSM criteria for Antisocial Personality Disorder of engaging in unlawful behaviors (1), acting impulsively (3), displaying overt irritability and aggressiveness (4), showing reckless disregard for the safety of self and others (5), or behaving irresponsibly (6). Some people who take a chronically manipulative, unempathic, power-oriented approach to life are on the surface quite conventional, amiable folks. But experienced clinicians may sense the presence of psychopathy from evidence that a person relies chronically on the defense of omnipotent control. They may infer this from a woman's somewhat intrusive questions, from the charming way a man holds the door open for his female therapist, or from the glee with which a corporate executive describes his or her role in a hostile takeover. Many superficially appealing, apparently law-abiding middleclass people with none of the overt DSM criteria will reveal their antisocial side when given projective tests (Gacano & Meloy, 1994).
The DSM criteria lend themselves to overdiagnosis of psychopathy among people in marginal subgroups, such as adolescent gangs and criminal organizations, and underdiagnosis of it among those who succeed in mainstream roles. They more readily categorize as having Antisocial Personality Disorder those people who are poor or unconnected with powerful others, and who are therefore less likely to be bailed out of the difficulties that their personalities create. It is hardly rare, however, to find psychopathic people in politics, in the business community, the military, the entertainment industry--in any roles in which the opportunity to wield power is great. The DSM, in other words, can lead one to identify unsuccessful psychopathic people rather easily (e.g., those who have been typed as conduct disordered in childhood or arrested for illegal acts in adolescence or adulthood) but provides little help in identifying those whose capacity to con is highly developed and effective.
Understanding the internal subjective world of the psychopathically inclined person is much more useful therapeutically than locating him or her in an "antisocial" role. Clinical ramifications of such understanding include the importance of the therapist's taking an explicitly power-oriented stance with the client, demonstrating incorruptibility, and making interventions that assume a utilitarian rather than a moral compass in decision making (Greenwald, 1958; Meloy, 1988, 1992; Akhtar, 1992; McWilliams, 1994). In many cases, especially in subtler ones in which a person's antisocial proclivities are not picked up by the schools or the legal system, the therapist's assessment of defense will be critical. That assessment can alert the interviewer to antisocial dynamics long before the behavioral consequences of a psychopathic psychology become evident--an outcome of special importance in the case of this diagnosis. Psychopathic people often come to treatment in the service of a manipulation (e.g., with a view to the therapist's testifying on their behalf or qualifying them for disability income, or colluding in the fiction that because they have sought therapy, they are earnestly trying to change some destructive pattern that they fear is about to be exposed).
Although a particularly compelling one, psychopathy is only one exemplar of the importance of assessing the nature of a client's relatively invisible defense system. Just as a person's reliance on omnipotent control in the interview situation alerts a therapist to a possible psychopathic streak in the interviewee, habitual reliance on another defense or constellation of defenses has been associated with (or, in my way of thinking, is definitional of) certain characterological tendencies. Each tendency has a distinguished history of clinical and theoretical investigation. Reliance on splitting, projective identification, and other "primitive" defenses is associated with borderline-level personality organization (Kernberg, 1975); idealization and devaluation suggest narcissism (Kohut, 1971; Kernberg, 1975; Bach, 1985); withdrawal into fantasy indicates schizoid tendencies (Guntrip, 1969); reaction formation and projective defenses constitute a paranoid process (Meissner, 1978; Karon, 1989); regression, conversion, and somatization indicate a psychosomatic vulnerability and associated alexithymia, the inability to put words to feelings (Sifneos, 1973; McDougall, 1989); introjection and turning against the self are implicated in depressive and masochistic psychologies (Menaker, 1953; Berliner, 1958; Laughlin, 1967); denial is the hallmark of mania (Akhtar, 1992); displacement and symbolization suggest phobic attitudes (MacKinnon & Michels, 1971; Nemiah, 1973); isolation of affect, rationalization, moralization, compartmentalization, and intellectualization are definitional of obsessional tendencies (Shapiro, 1965; Salzman, 1980); undoing is an essential defense in compulsivity (Freud, 1926); repression and sexualization imply hysterical issues (Shapiro, 1965; Horowitz, 1991); dissociative reactions characterize posttraumatic states of mind (Putnam, 1989; Kluft, 1991; Davies & Frawley, 1993). This way of thinking is of course subject to all the criticisms about labeling and pathologizing for which many have faulted the DSM and descriptive psychiatric diagnosis in general, but the labels associated with a sophisticated understanding of defense are at least larger, more complex constructs, attached to bodies of literature from which a conscientious clinician can derive extensive knowledge of how to orient treatment.
CHARACTEROLOGICAL VERSUS SITUATIONAL
DEFENSIVE REACTIONS
A specific defensive reaction can be determined mostly by people's individual character structure or by the situation in which they find themselves, as was true with the maturational issues discussed in the previous chapter. As an example of a characterological defensive pattern, consider a man with a paranoid personality. The defining indicator of paranoid functioning is dependence on the defense of projection. A man who is characterologically paranoid will use projection in almost every circumstance. If he is cut off by a car, he will project his rage onto the driver, generating the conviction that the perpetrator had a hostile intent to impede him. If he feels a threatening sexual attraction to someone, he will attribute his erotic wishes to the other party, condemning that person for lustfulness. If he is with a person who provokes his envy, he may focus on an admirable quality in himself and attribute the envy to the other person. In therapy, he will project his personal preoccupations into his understanding of the therapist's communications, wondering whether the therapist's tired look means that she finds him boring, or whether the therapist's passing comment about the weather contained some hidden innuendo about his sexual orientation. He may be uncannily perceptive about emotions in others, including those of a therapist, yet wildly off base and self-referential in his interpretation of the meaning of any given feeling.
It can be difficult to differentiate a characterologically paranoid person from someone in a situation that by its nature tends to stimulate paranoia. Trauma, given its effect in shattering a person's prior expectations and basic security, creates paranoid after-effects in previously nonparanoid people (Herman, 1992). Ambiguous situations also invite projection, as analytic therapists well know; with healthier clients, we deliberately convey only minimal information about ourselves in order to explore what they project on to us. In the absence of adequate external information, people will call upon internal data to understand what is happening to them. The more painful their circumstances, the more they need to try to comprehend them by reference to the only information they have: their inner state. Thus, any condition in which a person feels stirred up emotionally (e.g., when treated arbitrarily or unfairly), and in which he or she has inadequate information about what is going on, will elicit projection. When people feel ashamed, they frequently assume that someone is trying to shame them. When they feel hurt, they often ascribe the wish to hurt to the injurious party. They are only sometimes right, of course, since the effects of people's actions are often quite distinct from the motivations that give rise to them.
All defensive reactions constitute a blend of personal inclinations and situational provocations. It is clinically useful to assess whether any given reaction represents more the former or the latter. When a client reports a particularly dehumanizing work situation and announces that her boss is out to get her, the apparently paranoid quality of her conclusion may reflect mostly her character structure or mostly an adaptation to a reality that tends to induce projection. One clinical basis for determining whether a defense is more characterological or more situational is the therapist's inner subjective response to the patient. If the projective defense is predominantly characterological, the interviewer will be struck with how instantly and unreflectively the patient projects on to him or her. If it is mainly reactive, the therapist will feel taken in as separate, interesting, and potentially helpful despite the client's agitation about a problematic situation. Tactful questions about the person's background and behavior outside the disturbing arena will also help to clarify what is going on. In reactive paranoia, the projective responses will be confined to the situation that induces the reaction; for example, a person with reactive paranoia who feels persecuted at work will not report feeling persecuted by family members or close friends.
To illustrate the same point via a different defense, consider denial, another mechanism that can be automatically set off by overwhelming life events. The first response any of us tends to make when presented with terrible news is, "Oh, no!" Most of us are pretty good intuitively at knowing the difference between someone who is characterologically manic, and who therefore (by definition) uses denial in virtually every circumstance, and someone who is coping with a life challenge, such as a diagnosis of cancer, that has provoked some amount of denial until the person works out more adaptive ways of coping with the disaster. Again, the interviewer's assessment of whether a person is in a transient, situationally induced state of denial or whether he or she habitually denies all upsetting information depends on an attunement to the general tone of an interview. The usual countertransference to a characterologically manic or hypomanic person is a sense of things spinning, moving very fast, being confusing, being unintegrated with feelings. The rather common misdiagnosis of people in serious manic episodes or with hypomanic personalities as less disturbed than they in fact are probably reflects therapists' natural empathy for the uses of denial in many situations--so much so that the characterological basis for a cyclothymic person's problem may be overlooked.
CLINICAL IMPLICATIONS OF ASSESSING DEFENSE
Long-Term versus Short-Term Implications
The traditional rationale for making a careful assessment of a person's stable defensive organization is that in long-term analytic therapy, a pattern of defense can be altered in ways that free people up to have richer experiences and a broader range of options. Clients can learn to identify when they are about to go "on automatic" with a particular defensive strategy and pause to wonder whether that is the most effective response to a situation. They can substitute thoughtful, voluntary actions for unreflective, involuntary, and often self-defeating ones. They can move toward more mature versions of any particular defensive style (e.g., from complete isolation of affect to a somewhat intellectualized acknowledgment of the presence of feelings, or from primitive to mature idealization). They can master a wider and more effective repertoire of coping mechanisms.
In this era of economic pressures to do the minimum therapeutically, most people still appreciate intuitively that what they have come to therapy to work on will take a long time. Some of them are able and willing to make the investments that this kind of growth requires. There are also people--for example, those who depend automatically on radical and total kinds of dissociation--whose defenses are so maladaptive that even third-party payers are occasionally willing to concede that they need long-term treatment to change their defensive pattern. But even in other instances, when one can do only short-term work or crisis intervention, it is of great value to have an understanding of a person's characterological defenses. This knowledge allows us to choose a style of intervention that is most likely to be assimilated by a particular patient.
Let me begin with what most clinicians consider the ideal situation: The client is self-referred, motivated for treatment, able to afford it, and willing to stick with it as long as it takes to do significant work on the sources, not just the current manifestations, of recurrent psychological problems. Under these circumstances, if one determines that the defenses the patient is using to deal with a particular life stress are both maladaptive and situational, one can point them out and encourage the person to consider other ways of addressing the problem. For example, consider an otherwise emotionally involved man who is reacting to a parent's terminal illness with a general pattern of withdrawal. One can tell him that although it is natural for people to try to avoid painful situations, he may regret later that he was not closer to his father during the last months of his life. One can explore his fears that to spend time with his dying father will bring on a deep grief and wonder with him why it would be so terrible to feel the pain that naturally accompanies loss. One can explore whatever fantasies he has about what it would mean to "lose control" over his emotions. One can point out that his withdrawal is not magically extending his father's life or making his final days more bearable. One can brainstorm about other ways he could handle his grief that would be more proactive and ultimately satisfying to him and his family. And so forth.
If, on the other hand, one determines that a patient's current defenses are both maladaptive and characterological, the clinical challenge is significantly greater. In the prior example, in which a relatively expressive, connected man finds himself inexplicably withdrawing, the therapist can access the part of the patient that can see the withdrawal as aberrant and self-defeating. But if a person in the same situation had a lifelong pattern of responding to unpleasant realities by withdrawing, there would be no "observing" part of him to access. His tendency to withdraw would be so natural and automatic to him that he could not initially conceive of handling things another way. Like the air he breathes, his defensive pattern would feel so familiar to him that he could not even conceptualize it as something he could look at and think about.
In cases like these, where a given defense is so ingrained that it is invisible to the person using it, standard analytic practice has been to spend the first months and even years of therapy making ego-alien what has been ego-syntonic. Direct, early interpretation of the defense will be experienced not as helpful but as critical and undermining, because the person's basic modus vivendi is under attack and he or she cannot imagine operating any other way. The therapist must work patiently with such a client, only gradually raising questions about other possible ways to address the stresses he or she encounters. One cannot remove a defense when it is the main structure by which a person attempts to cope. There are numerous books in the psychoanalytic literature that address themselves entirely to this long-term therapeutic process as it applies to a particular kind of character. For example, Mueller and Aniskiewitz (1986) have written about how to work with hysterical patients, who use repression, regression, conversion, and acting out; Salzman (1980) has done it for obsessional clients, who use isolation, compartmentalization, rationalization, intellectualization, and undoing; Davies and Frawley (1993) have done it for people who habitually dissociate.
What about those instances where, for whatever reason, we can do only short-term work or crisis intervention? It is still of value to appreciate that a defense is characterological, even though it is no more confrontable in a situation of limited time than it is in the early phases of an open-ended, long-term contract. Consider a woman with a basically masochistic character structure--a shorthand way of saying that she depends habitually and automatically on the defenses of turning against the self and reversal. She is able to pursue her own needs only by projecting them on to others and taking care of those others; when it comes to care of herself, she is relentlessly self-effacing. In long-term therapy, one could reasonably expect such a person to integrate and better handle the drives and needs that are denied, projected, and addressed in other people. But in the short run, one must simply appreciate that this is the way this woman deals with aspects of herself that she has come to regard as unacceptable, and one must therefore work within that psychology. Thus, if one is trying to influence such a client to consider adopting different behavior toward a partner who is mistreating her, one cannot make a frontal assault on her defenses and announce, "He's being abusive! You shouldn't put up with that. Tell him if he doesn't stop, you'll be out of there!" (If this approach worked, there would be a lot fewer people in psychotherapy, for it seems to be the treatment of choice of most nonprofessionals trying to help their victimized acquaintances.)
Frontal attacks on defenses present the defended person with only two options: (1) Give up the defense and, in the absence of having developed coping mechanisms to substitute for it, become overwhelmed with anxiety, shame, or guilt; or (2) fight off the person who is assaulting one's cherished method for coping with life. People almost always choose the latter. Sometimes they can choose the former via an idealization of the therapist that compensates for the loss of their defense ("I will comply, based on my belief that my therapist is a person of enormous superiority to me. My anxieties about behaving out of character are compensated by my conviction that my therapist knows better than I do what is good for me"). But then one has only changed the locus of the problem: Now the therapist is the dominating one, giving orders with which the client complies at the price of his or her dignity and autonomy. A specific self-defeating behavior has been stopped, and the person's dependence has been shifted to a better object, but the client's disposition to defer has been reinforced rather than weakened.
Because direct assaults on favored defenses are thus doomed, most therapists in short-term situations learn ways to sidestep and finesse clients' defensive patterns, or to use their defenses in the service of their growth rather than their paralysis. With the hypothetical masochistic woman, one stands a far greater chance of persuading her to become more assertive if one can frame one's interventions in a language that is not too far from her defensive needs. For instance, one can say,
"I wonder if it's really good for Bob to be able to push you around like that. Don't you worry that it's corrupting for him to get away with being a bully? That's certainly not a self-image he can be proud of. Is there a way you could respond to his demands that would give him more of a sense of being a reasonable grown-up, negotiating conflicts from a position of equality?"
A woman who is compelled for unconscious reasons to evaluate her actions always from the view of what is good for others may be able to rethink habitual behaviors if she can see that they do not contribute to a healthy pattern for the other person.
To take a dramatically contrasting example of this principle of appreciating someone's defenses and framing one's comments in ways that avoid doing violence to that person's habitual ways of thinking, feeling, and behaving, consider the challenge of therapeutic interventions with characterologically psychopathic clients. A man with an antisocial personality will not be able to assimilate interpretations that fail to take his ubiquitous use of the defense of omnipotent control into account. Any experienced police officer knows that to get a perpetrator to cop to a crime, one cannot simply mount a charge against his need to see himself as a person who is always on top of things. Thus, statements such as "You got out of control," which offer an excuse, but one based on weakness, will not promote a confession. Nor will appeals to a sense of guilt (e.g., "You have to think about the effects on the victims"). Omnipotence does not admit of imperfection or moral fault; it is only about power. So instead of saying to a murderer, "For the sake of the victim's family, you need to admit what you've done," cops learn to say, "Gee, if you claim you weren't aware of what you were doing, people will think you're mentally disturbed. Is that how you want them to see you?" Most antisocial people would rather risk incarceration than be seen as weak and deranged.
The therapeutic analogue to this forensic example is the psychopathic client that the therapist wants to get to stop lying. Empathic reflections of why the person needs to deceive will not elicit honesty, since someone trying to feel omnipotent will not acknowledge need. Statements that implicitly moralize will be similarly fought off, disparaged as the hypocritical rationalizations of a person without enough sense to see how brutal life is. Instead, the therapist can say,
"Look, you're good. You're very convincing, and I can see that even though I encourage you to come clean here, you still can't resist the temptation to lie to me. And I'm sure there will be plenty of times when you'll get over on me. But it's not really in your interest to do that here, since telling me fairy tales only wastes your money and
my time. You're the expert on your psychology: How can I get you to find the guts to tell the truth here?"
By accepting the person's grandiose sense of himself and associating truthfulness with courage, a power position, the therapist maximizes the possibilities that the patient will cooperate.
Systematically Exposing versus "Going Under" Defenses
In circumstances where one has the time and the commitment from a client to work in depth on personality issues, one still needs to assess that person's particular defensive structure in order to know what style of communication is most likely to reach him or her. The classical psychoanalytic approach to doing defense analysis is to go "from surface to depth" (Fenichel, 1941), that is, to visualize the patient's mental organization as layered, with each layer defending against the content of a deeper layer. The therapist systematically and tactfully addresses the conscious or nearly conscious parts of the person's experience. As the client feels increasingly known and safe, each underlying layer of defense or meaning or experience emerges, and the therapist deals with each as it appears in the treatment relationship.
For example, a person with hysterical features often presents in an ingratiating way. Beneath that surface presentation, one typically finds distrust, hostility, and competition. Underneath these more truculent attitudes are serious fears and a profound sense of personal vulnerability. In other words, the ingratiation is a defense against hostile attitudes, which in turn defend against fear and a subjective sense of weakness. In working with a hysterically organized person who manifested these dynamics, one would initially say something like, "I notice that you always agree with me and are very deferential in general. Surely, sometimes you don't feel quite that agreeable." Such a comment typically provokes self-scrutiny by the patient, whose defensive system has been challenged but not so much as to feel overly threatening. He or she might then associate to having a general style of ingratiation, and the therapist could then explore with the patient the question of what attitudes the ingratiation might be covering up.
If instead one tried to "go under" the defensive structure with an interpretation such as, "I think you're really hostile toward me," or "Perhaps underneath that facade of ingratiation you're scared to death of me," most patients would either find that attribution too far from their conscious experience to access any awareness of the ascribed feeling, or would feel traumatically exposed and too threatened to cooperate further with the treatment. This is assuming that the interpretation is correct, which is, of course, assuming too much. In fact, one of the traditional reasons for going carefully from surface to depth is that one can be drastically off base when hypothesizing about the functions of various defenses, and one wants, whenever possible, to work at a level where a patient can take or leave what the therapist says, and do so with the confidence that comes from being in touch with the level of experience under discussion.
Another example of the appropriateness of interpreting from surface to depth would be the patient with obsessive-compulsive features whose clinical presentation is a highly intellectualized and cooperative demeanor that covers over an argumentative, nitpicking attitude that defends against a deep shame. The therapist would generally start addressing not the sense of shame but the person's penchant for intellectualization. An exploration of this would typically lead to the more aggressive components of the patient's personality. As the client felt increasingly understood and accepted despite the unpleasantness of such hostile attitudes, the hostility would eventually soften up and allow the areas of shame to emerge. If one tried to access the shame without going through the defenses against it, layer by layer, one would risk either mortifying the patient or having one's interpretation turned to ice by a penchant for intellectualizing.
Interpreting from surface to depth is almost always the approach of choice, and most therapists do this naturally and intuitively, whether or not they have been trained in psychoanalytic metapsychology. "Start where the patient is" and "Don't mess with a defense until the person has something to replace it with" are the kinds of things that experienced supervisors tell their students every day. But there are some kinds of defensive patterns that require more of a depth-charge strategy from the clinician. Specifically, both hypomanic and paranoid patients need therapists who understand the need to "go under" rather than to stay at the top of their personal hierarchy of defenses.
"Hypomanic" or "cyclothymic" are psychiatric labels for a personality pattern in which denial is the front-line defense. Hypomanic people are frequently "up" in terms of their mood and may have all the ebullience, charm, wit, and energy of the life of the party. Their histories attest, however, to profound difficulties with intimacy and genuineness, and they tend to bolt from relationships that start to feel important to them. They are subject to abrupt swings into depression whenever their defense of denial wears thin, exposing pain about loss, vulnerability, mortality, and other unpalatable facts of life that the rest of us are not quite so primitively defended against facing. They typically come to therapy to get help with depressive plunges and are famous for bolting from therapy as soon as their mood goes up again. Interviewers often react to them as charming and feel some surprise that such an engaging, lighthearted person can report periodic battles with profound despair.
Hypomanic people are virtuosos at denial. Because denial is such a rigid, all-or-nothing defense, it cannot be gently addressed in the surface-to-depth manner that works best with other clients. Anyone who has experience with substance abuse, a condition in which denial is notoriously involved, knows that one sometimes has to go after this defense with both barrels. The therapist who would never take on a person with an ingratiating defense by announcing, "You're trying to ingratiate yourself with me. Stop it!" might, especially under circumstances in which a client is behaving self-destructively, exclaim, "You're in denial. Get real!" Anything less assaultive than this--say, for instance, a tactful question along the lines of "Do you worry that your drinking might be getting out of control? "--typically elicits more denial.
With hypomanic patients, the characterological nature of their denial (as opposed to its operating in a specific area, like an addiction) requires therapists to find creative ways to address it without making the full-scale frontal attack that would only be self-defeating. Clinical experience suggests that going directly to depth--bypassing the surface and ignoring the layer of denial--is often the technique of choice. For example, a cyclothymic woman who is behaving in driven and selfdestructive ways in the context of the therapist's upcoming vacation could be told, "You're probably not conscious of this, but I'm pretty convinced that you're reacting to my upcoming vacation with a lot of anxiety, based on some unconscious fears that I won't come back." Such an intervention may be accepted or rejected, but it will penetrate. If the therapist were instead to ask, in the surface-to-depth manner that makes sense for other kinds of patients, "I wonder if your recent spurt of drinking and picking up men has anything to do with my upcoming vacation," the client would most likely respond with denial and there would be no place to go.
Paranoid patients also require a bypassing of defense to go to what is defended against, but for somewhat different reasons. Paranoid people are terribly afraid at an unconscious level that they are dangerously powerful. Their use of rigid and primitive defenses such as denial, reaction formation, and projection to deal with this internal feeling of a threatening badness creates their sense that the threat will come from outside. For at least two reasons, they need the therapist to go under their defensive structure to the feelings and needs that invoke their defenses: (1) They need to see the therapist as tough and smart, because otherwise, they unconsciously fear that they will damage him or her with their evil power, and (2) they have done so many transformations of a simple feeling by the time they present what is manifestly on their minds that working from surface to depth will never get down to their basic concerns.
To illustrate the second point, consider the paranoid woman who expresses to the therapist a boiling outrage springing from the conviction that her husband is seeing another woman, something for which there seems to be no evidence. The therapist may be able to see that this preoccupation started with a simple feeling of loneliness and the wish to be close to a female friend. It then became transformed by several rigid defenses in succession, as follows:
"Since I am bad, my need for love from a woman must reflect my depravity. The need feels so strong I experience it as erotic. That's unacceptable. Maybe she's the one putting these homosexual thoughts in my mind. She's the bad one, not me. And I'm not the one who desires her--it's my husband."
Thus, via denial, reaction formation, projection, and displacement, a simple need is transformed into a paranoid preoccupation. The therapist who tried to work from surface to depth ("What comes to mind about your idea that your husband is having an affair?") would elicit only more paranoid rumination.
But a therapist might be able to make contact with this woman by saying something like, "I think you've been feeling quite lonely lately, so naturally you're worried about the fidelity of those you depend on." This could lead to some problem-solving discussion about the normality of loneliness and the options the patient has to find friends. Another bypassing kind of intervention would be, "I have the strong sense that unconsciously you have this conviction that there is something terrible and dangerous about you. Maybe at some irrational level you feel your husband sees your badness and would naturally reject you for someone else." Again, a paranoid person would be likely to be interested in this concept, and both she and the therapist could get some relief from the relentlessness of the paranoid concerns that her defenses have created.
Psychoanalytic Case Formulation
McWilliams, Nancy (1999)
Chapter 8- Assessing Relational Patterns
Closely related to the question of a person's identifications is that of his or her repetitive ways of relating to other people. Where the issue of identification addresses mainly who are the patient's models, and what were the qualities about them that he or she wants to assimilate or reject, the issue of relational pattern concerns how the person's connections with his or her main love objects were expressed. A mother can be loving and positively valued, and her daughter may want to be like her in many ways, yet the primary way the girl has learned to relate to her may be compliant or rebellious, withdrawn or involved, demanding or self-abnegating, or any one of a virtually limitless number of possibilities. The interpersonal styles of caregivers and the underlying themes about relationship that they express are taken in by children, along with the more static qualities that people tend to refer to as "traits." In Chapter Seven I discussed internalized objects; in this one, I discuss the more complex topic of internalized object relations.
Specific questions about relationship patterns are often unnecessary in an intake interview. Because recurring interpersonal problems are among the chief reasons people seek psychotherapy, clients will frequently begin the session with a description of a persistent, maladaptive pattern of relationship. "I keep falling in love with abusive men," or "Every time I get excited about someone, I find her flaws and get disillusioned," or "I have this problem with authorities" are common responses to the therapist's opening invitation to patients to describe what brings them to a mental health professional. When a relational pattern is the chief complaint, one's formulation about it can be comparatively straightforward. When the presenting problem is a mood disturbance or obsessional thought or posttraumatic reaction or something else not conspicuously embedded in an interpersonal theme, the therapist must infer the central relational conflicts from transference data and historical information. Sometime it is also helpful to ask questions such as, "How would you describe your most important relationships?" or "What is your marriage like?" or "Are you close to anyone?" or "What do you value in people?" But the most reliable information tends to appear in the client's responses to the therapist.
Let me begin with a couple of examples of recurrent relational patterns that can show themselves in the first meeting of treatment. I recently interviewed a woman who wanted to see me for therapy. She explained that she had a persistent tendency to idealize male authorities and, despite a happy marriage, to become infatuated with certain men. I listened, felt warmly disposed toward her, felt I could probably help her with her problem, and found myself looking forward to working with her. Toward the end of our meeting, when she was recounting her prior experiences in therapy and counseling--all with female practitioners--I asked whether she had ever thought about going to a male therapist, given that her repetitive patterns with men might be immediately stimulated in such a situation. Her face fell, and I could tell that she interpreted my question as meaning that I did not want to work with her.
She very quickly started considering that it might be a good idea to see a man. She began to ask me about male practitioners in the area, but it was clear that her heart was not in this conversation. When I stopped her and explained that I had only been curious, that I had simply wanted to find out her thinking about having chosen only female therapists, she still looked skeptical. She seemed to feel driven to take care of me rather than to stand for her own needs and decisions, and if I wanted to get rid of her, she was not going to give me trouble. As we investigated this, we found a whole recurrent pattern of compliance and caretaking, secondary to fears of rejection, that characterized her behavior with both women and men.
Another person I recently interviewed with the objective of finding a referral for her, because I did not have room in my practice for a new patient, was a deeply dysthymic woman. She speculated that the source of her depression was a family history in which she had been the last child, an unplanned one, and that she had always felt treated like excess baggage. Her parents were overburdened, financially strapped, and preoccupied during her early years, and she never had the feeling that they were interested in listening to her. She commented that she had learned to keep her private feelings very carefully hidden from them. She had had several previous therapies, but she thought they had only made her feel guiltier about how little energy she had. I felt at the end of the interview that my understanding of her was disturbingly incomplete.
With her permission, I called the social worker who had referred her to me for evaluation and asked her perceptions about what kind of practitioner would be a good match for this woman. To my surprise, she told me that to her way of thinking, this client had never had real psychotherapy. She had been to a succession of people who called themselves Christian counselors and mainly used persuasion and Biblical authority to tell patients how they should be feeling and behaving. She had decided she would go to a more conventionally trained therapist, but she was nervous about it, because she was a deeply religious woman who expected a secular practitioner to debunk her faith. In fascinating parallel to the secretive way she had survived her mother's lack of availability to her (probably reinforced by my literal unavailability to take her on as a regular patient), she had not told me any of this.
A therapist needs to become familiar with the internal world of a client. Are its inhabitants generous or stingy, controlling or permissive, impinging or distancing, validating or undermining, exploitive or supportive, autocratic or consensual, merciful or punitive, critical or accepting, warm or cold, active or passive, inhibited or expressive, passionate or indifferent, involved or negligent, predictable or chaotic, stoic or self-indulgent? What were the patient's reactions to the childhood emotional environment? What repetitive conflicts occurred? The subtleties of a person's interpersonal history live on in current relationships, color the therapeutic connection, and constitute an area the clinician must address if he or she is to wield any therapeutic influence.
This observation has been made, with some variation in emphasis and yet with extraordinary commonality of overall conceptualization, by a remarkably diverse group of researchers. Some of them have influenced each other; others have started from isolated positions or less mainstream theoretical assumptions and have found that their data led them to similar relational phenomena. I am thinking of concepts such as Malan's (1976) "nuclear conflict," Gill and Hoffman's (1982) "patient's experience of the relationship with the therapist," Bucci's (1985) "referential set," Stern's (1985) "representations of interactions that have been generalized" ("RIGs"), Henry, Schacht, and Strupp's (1986) "cyclical maladaptive pattern," Tomkins's "nuclear scene" (see Carlson, 1986), Weiss, Sampson, and colleagues' (1986) "higher mental functioning hypothesis," Dahl's (1988) "fundamental repetitive and maladaptive emotional structure" or "frames," Horowitz's (1988) "personal schema," the "model scenes" concept of Lachmann and Lichtenberg (1992), the "core conflictual relationship theme" of Luborsky and Crits-Christoph (1998), and Bretherton's (1998) concept of "representations." Lorna Smith Benjamin's (1993) empirically derived Structural Analysis of Social Behavior represents one of the most thorough-going empirical research projects whose outcome is consistent with this emphasis on the patterning of relationship as crucially diagnostic. In some nonpsychoanalytic writing, one finds a similar emphasis on repetitive patterns, for example, in the work of Klerman and his colleagues (Klerman, Weissman, Rounsaville, & Chevron, 1984) on "interpersonal psychotherapy."
Long before researchers identified repetitive scripts (templates, story lines, cognitive maps, personal tapes, subjective constructions--pick your metaphor) as central to an understanding of individual psychology and psychopathology, therapists were impressed with the recurrent nature of a limited number of themes in their clients' internal worlds and external relationships. Immersion in the effort to help people hour after hour puts a practitioner repeatedly in a role that elicits each patient's unique set of assumptions about authority, dependency, intimacy, gender, power, emotion, and other aspects of relationship. The contemporary psychodynamic clinical literature usually refers to recurring interpersonal configurations as "internalized object relations" (e.g., Kernberg, 1976; Ogden, 1986; Bollas, 1987; Horner, 1991; Scharff & Scharff, 1987, 1992). Sandler and Rosenblatt's (1962) concept of the individual's subjective "representational world" and Atwood and Stolorow's (1984) emphasis on "structures of subjectivity" are related concepts in that they are attempts to capture this dimension of individual psychology. A popularized and highly simplified approach to understanding relational themes appeared in the 1970s in Eric Berne's (1974) "transactional analysis," with its portrayal of certain common "games" or "scripts."
In psychotherapy, the issues that get hashed and rehashed ("worked through") between the patient and therapist, and between the patient and the main people in his or her life, tend to be repetitive dramas that after a while are excruciatingly familiar to both client and clinician. If Oliver Wendell Holmes was right that we all have one speech to give, and we give it repeatedly in various forms all our lives, it is also true that every person in therapy seems to have one main relational territory to explore and expand on, no matter how many different directions there are from which to approach that area. We all have our repetitive patterns, many of which are adaptive and benign. We come to psychotherapists when our central theme is problematic because it embodies a persistent and unremitting conflict. For example, we long for closeness but behave in ways that distance people, or we seek release from inhibition but fear our impulsivity, or we desire autonomy but feel shame and doubt when we act from a position of agency.
RELATIONAL THEMES IN THE TRANSFERENCE
The phenomenon of transference has sometimes been misunderstood as a straightforward displacement of childhood attitudes toward caregivers. It is actually much more complex. Whole atmospheres and intensities and defensive constellations get transferred into the clinical situation. The therapist cannot be limited to the questions that Freud identified as most important--namely, "Who am I to this person?" and "Is that figure mainly positive or mainly negative?" He or she must also feel out the nuances and meanings of what is transferred. There is a two-step process in this aspect of assessment: (1) How can one describe the pattern that keeps being reenacted? and (2) What are the origins, meanings, motives, and reinforcers of that pattern for this person?
Let me illustrate via attention to a fairly common pattern: the tendency to sexualize relationships. This proclivity may become evident as early as during an initial interview; for example, when a heterosexual female patient is in treatment with a male therapist. Parenthetically, let me comment that most therapists concur that a sexualizing tendency is not as immediate and observable when the patient is a heterosexual male in treatment with a female therapist, probably because in Western cultures the combination of higher-authority female with lower-authority male is not perceived as having the same erotic potential. Such a pattern is also likely to take a while to appear in the transference when the patient is gay or lesbian and of the same gender as the therapist, especially if the therapist is assumed to be heterosexual, probably because of the client's inhibition of yearnings that are socially disparaged.
Popular impressions aside, the phenomenon of "falling in love with one's analyst" is neither inevitable nor easily comprehended. Freud was the first person to try to make sense of such reactions, and he oversimplified them greatly. He saw erotic transferences as representing the displacement of positive sexual strivings from infantile objects to current ones. In other words, he would understand a heterosexual woman who became sexually preoccupied with her male therapist as reexperiencing feelings she once consciously had toward her father, feelings that had been repressed at the end of her oedipal period. Analysts have long known that an erotic transference represents much more than this; sexualization or erotization of a therapeutic relationship is never uncomplicated. (Some kinds of love in psychotherapy, in contrast, are quite straightforward and not highly conflicted. As Bergmann, 1987, has noted, the experience of coming to love a therapist is an expectable and therapeutically essential aspect of the treatment process. In fact, analytic psychotherapy derives its effectiveness from just such feelings. The more emotionally important a therapist is to a client, the more power he or she has to counteract the negative effects of the passionately loved and tenaciously internalized early caregivers.)
Contemporary therapists are open to many alternative possibilities in understanding a person's erotization of the therapy relationship. I do not refer to passing erotic feelings here, which occur in all relationships, including professional ones, but a chronic immersion in fantasies of being the therapist's lover. For example, the client's persistent sexual attraction to the therapist can indicate an identification with a powerful and seductive mother. Or it can be based on the opposite attitude, embodying the unconscious conviction that power is a male prerogative and that men must therefore be seduced into sharing it. Or it may be an attempt to master by passive-into-active transformation (Weiss et al., 1986) the anxieties created by childhood molestation. Or it may contain a wish to defeat a hated parent by luring the therapist out of his professional role. Sexualization with a man may be the way a woman learned as an emotionally deprived girl to satisfy her needs for nurturance and warmth. Or it may betray a defensive need to prove that she is not a lesbian. Or it may express a deeply valued victory over erotic inhibition. Or it may represent a general pattern of being unable to feel sexual with anyone other than forbidden figures. Or it may be a woman's desperate attempt to bring life and feeling to a situation that otherwise feels annihilating and dead. A persistently sexualized transference can be a manifestation of any of these dynamics, and many others, and will usually turn out to be a combination of several different unconscious attitudes that have overdetermined an erotic stance (see Gabbard, 1994, 1996).
The empirical literature on the disturbing frequency of sexual misuse of patients by therapists (Pope, 1989) and the analytic literature on boundary violations (Gabbard & Lester, 1995) attest to a problem of considerable magnitude. Its existence suggests that the complex possible meanings of a patient's erotization are not well understood by many practitioners, who apparently prefer to see their clients' attractions to them as expectable reactions to their intrinsic desirability. But even setting aside the problem of disastrous sexual enactments fueled by therapists' narcissism, clinicians must figure out how to free their individual patients of sexual preoccupations so that they can make use of treatment to resolve the problems they came in to address. The erotization of a therapeutic relationship calls for more than ethical clarity and routine tact. Whether one addresses the phenomenon by interpretation, confrontation, limit setting, or quiet tolerance of an important striving that will eventually run its course depends on one's appreciating the main relational meaning to a particular person of an erotized connection.
A client's tendency to approach connection with another person in a certain way will manifest itself in an initial interview and must be factored into an overall formulation. Accuracy in formulating a case depends partly on a practitioner's ability to use his or her subjectivity to understand the probable meaning of a relational form that is being sculpted by a patient. In addition to reflecting on information from the person's history that might explain the centrality of some specific relational tendency, a sensitive therapist uses his or her internal emotional responses diagnostically. To illustrate how one does this, let me continue with the example of a person who tends to sexualize relationships. One's subjective reaction to a seductive patient can be dominated, among other possibilities, by enjoyment, fear, irritation, sexual excitement, or narcissistic inflation. Each reaction would be saying something different about what erotization does for this particular patient.
Naturally, because interviewers' reactions will be a combination of their own relational proclivities and the emotional forces that are making an impact on them, well-trained therapists try to sort out what is "theirs" from what the client brings to the interaction (Roland, 1981). In fact, many contemporary psychoanalysts emphasize the "co-construction" of the transference (e.g., Orange, 1995) by the subjectivities of both participants in the therapy process. One reason for the stress that psychoanalytic training institutes have traditionally placed on the personal analysis of the therapist is that awareness of one's own patterns allows one to distinguish between what a client is inducing and what the therapist is inclined to feel in any interpersonal situation.
Over the years, I have concluded that many analytic supervisors overemphasize the need for beginning therapists to identify their "own stuff" when a client stirs them up. If this is the main direction one takes when a patient activates some affective potential, one can get lost in self-analysis and may conclude that the resolution of a difficult affective state between two people is going to depend mainly on the therapist's working through his or her own conflicts. This is a misguided notion, both because perfect self-knowledge and self-control are unattainable and because patients come to resolve their own conflicts, not those of their therapists. More to the point, such a focus distracts practitioners from attending to the emotional forces that are acting on them, thus depriving both parties of a deeper understanding of what the patient is bringing to the interaction. However significant the therapist's emotional contribution to what goes on between the parties to the therapeutic dyad, for diagnostic purposes, it is important first to get a sense of what the patient seems to bring to any interaction.
Having made that point, I should add the caveat that just feeling something in the presence of a client does not automatically mean that the client is "putting" that feeling there. The appreciation of the diagnostic value of countertransference reactions, a liberative position that at this point is comfortably mainstream, has unfortunately contributed to a glib tendency in some practitioners to ascribe automatically to patients whatever uncomfortable states of mind they notice in themselves (e.g., "I'm feeling angry now, so you must be trying to make me angry" or "I feel confused, so that must be how you really feel"). Knowing that the therapist's subjectivity may say a lot about the client's does not obviate the need for discipline, introspection, and the weighing of more than one explanatory possibility.
Many years ago, I conducted an intake interview with a man who immediately called me "Nance," held the office door for me, and complimented me on my outfit. He seemed to need to relate to me entirely in a flirtation mode. I felt irritated by his manner and noted in myself an inclination to get prissy and judgmental with him, as if to say, "Your behavior is very inappropriate in a professional situation." Not wanting to act out that response to his seductiveness before I understood it, I tried to remain warm while boundaried, and I proceeded to collect information on his personal history. It turned out that he had experienced his mother as extremely dominating and even sadistic in her treatment of him. I began to see that one function of his flirtatiousness was an effort to express dominance over women he saw as potentially powerful. My irritation was expressing my defensive reaction to his effort to put me in a one-down position. Intriguingly, later in the hour, when I commented nonjudgmentally on his tendency to flirt with me, his reaction was to feel exposed and bereft of an important "weapon." He then proceeded to get too sleepy to attend to the rest of the interview. He somewhat reluctantly went on to describe a recurring pattern with women who interested him (and it was only relatively powerful women who did): He would try first to dazzle them. If that failed to work, he would become unbearably weary in their presence. I took this man into treatment, but he and I soon decided that this dynamic was too oppressive for our particular therapeutic partnership--it is not easy do therapy with someone who keeps falling asleep--and I referred him on to a man with whom he did well, because they could talk about his pattern with women without having it immediately sabotage their sessions.
Another man I worked with for many years contributed more subtly and slowly to an erotic feeling between us. As I found myself preoccupied with sexual fantasies during his hour, I felt a disturbing combination of both sexual excitement and fear. I also felt a strong wish to ignore these feelings, to behave with him as if there were nothing erotic in the atmosphere, and certainly nothing that was turning me on. After a while, I felt so disingenuous working with him without commenting on the "vibes" I kept feeling that I brought up my sense that there was some sexual material that he and I seemed to be complicit in avoiding (cf. Davies, 1994). He responded first with denial and then with fear and shame. Although he had not told me in the initial interview that he had ever suffered sexual abuse, he had powerful associations to a repetitive experience with his mother, who gave him enemas in a ritualized, sadistic, and erotized way from the time he was three to the time he was seven. He felt both traumatized and excited by this special, secret activity that she imposed on him regularly. Outside the drama of the enemas, they had a tacit compact never to mention their clandestine rituals. My excitement, fear, and wish to disregard the sexual atmosphere mirrored this complex interpersonal dynamic, which later became obvious as a problem in many of his relationships.
Another client who created a sexual atmosphere in my office induced in me a radically different emotional reaction. He was a profoundly inhibited, schizoid man who had sought treatment at thirty-six, when he began to feel there was something wrong with his remaining single and virginal despite numerous opportunities to develop serious relationships with women, many of whom he was ravishing in his private fantasy life. His psychology was dominated by a counter-identification with a father who had been a guiltless philanderer, and who pressed him from his early teens to join him in seeking the services of prostitutes. In his mind, sex was all bound up with submission to his father's perverse agenda, which included a thinly disguised compulsion to demean women. My client loved his mother and refused to play this game.
In response to my invitation toward the end of the interview to comment on his reaction to me, this patient mentioned that he found me attractive. My subjective response in this case was simply pleasure--not only the narcissistic inflation that is a natural reaction to being complimented but also a more maternal kind of anticipation of his possible capacity to feel and name an erotic inclination that was different from his father's driven sexualizing. Unlike many erotic transferences, his mental erotization of the therapy relationship turned out not to be primarily a resistance to other material (like power issues or memories of an abuse history, as in the two previous examples). Instead, it represented the emergence of a potential for growth toward intimacy that eventually expressed itself in a sexual relationship with a woman he had liked and admired for years. My initial countertransference had been benign at least partly because in this man, there was a benign developmental process going on rather than a more conflicted, resistive one (cf. Trop, 1988).
I have used sexualized interactions to illustrate the phenomena I want to discuss in this section partly because they are among the most difficult for therapists to deal with, and partly because I find that contemporary students of therapy are hesitant to acknowledge and explore their more sexual reactions to clients. (Perhaps our training programs have put so much emphasis on discouraging sexual enactments that therapists fear even to notice any evidence of arousal.) But the same principles apply to the appearance in the transference of any interpersonal dynamic and all its emotional trappings. A therapist who is fully open to the feelings that a client stirs up--even upsetting ones such as sexual arousal, hatred, sadism, shame, boredom, contempt, and envy--will find that a whole drama (a "family romance" in the evocative language of Freud) will unfold in the therapy room and consequently open itself up to new plot twists, characters, and resolutions via the therapy process.
Respective Implications of Transference Themes
in Psychoanalysis and in Psychotherapy
In classical psychoanalytic treatment, the gradual re-creation between the analyst and analysand of the core conflictual relationship has been called the transference neurosis (Freud, 1920). People who have quipped that psychoanalysis creates an illness in order to cure it are not entirely wrong: The analytic situation encourages problematic relational patterns to emerge in exquisite detail and in full emotional intensity. The mutual identification and then working through of a transference neurosis are, in fact, the qualitative features that differentiate psychoanalysis proper from less ambitious treatments. The technical procedures that maximize the chances for a transference neurosis to become manifest (use of the couch, free association, high frequency of sessions, unlimited time) are often cited as definitional of analysis as opposed to analytically oriented therapy, but in fact, they are only the conditions under which a full analysis is likely to become possible. (It is well known that, among healthier people who are motivated for analytic work, some can experience the flowering and pruning of a transference neurosis in twice-per-week treatment, while others in five-times-per-week analysis fail to experience the full replication of the core relational pattern in the analytic partnership. So far, despite lavish attention to the question of "analyzability," no one has yet figured out how one can reliably tell one kind of client from the other at the outset of treatment [Greenson, 1967; Etchegoyen, 1991].) It is this controlled but regressive experience of being reimmersed in early emotional relationships that allows the therapist and patient together to appreciate the power of an individual's interpersonal themes and repetitions, to understand in depth why they have so much power, and to develop new ways of resolving the conflicts they contain.
Classical analysis is widely considered to be the treatment of choice for people with high ego strength, high motivation, and professional or personal interest in going as deeply as possible into their personal subjective world. It is not the best treatment for people in the borderline or psychotic ranges of character structure, or for people with certain kinds of pathology (e.g., dissociative symptoms, paranoid tendencies) even if they are in the neurotic range. And there are many circumstances in which, even if it were the ideal approach, it is not practical. In less intensive therapies, treater and client work with transference reactions rather than a fully elaborated transference neurosis, but the aims are the same: to feel out the recurring conflicts as they appear in the treatment and then to devise together a different set of resolutions for them.
Psychodynamic therapy is harder to do than classical psychoanalysis. In analysis, relational patterns emerge gradually and naturally, relatively uncontaminated by the therapist's pressure to focus on what he or she considers the main interpersonal issues. Practitioners working at a lesser frequency, or in time-limited situations, or with patients for whom analysis would stimulate too much uncontrolled regression, must be more attentive to formulating dynamics before they are painfully obvious. They must be more active in their interventions and more willing to risk being off base or outright wrong about the patterns they begin to discern. Despite some residues of prejudice to the effect that analysis is inherently superior to dynamically oriented therapy (a prejudice that has supported the narcissism of psychoanalysts but seems to have been only obliquely related to clinical outcomes [Wallerstein, 1986]), contemporary clinicians seem to be appreciating that more limited therapies-including expressive and supportive treatments--are harder to conduct, require more creativity, and often meet a patient's needs more adequately than analysis proper.
Relational Patterns Conspicuously Absent
from the Transference
Conscientious therapists not only feel out the nature of relationships that repeat themselves in the therapeutic dyad, but they also sense what kinds of relating are absent in a client's experience. This is a more difficult aspect of diagnosis than articulating what relational paradigms are present, for it requires an empathic leap into areas of void and lack that the patient by definition cannot verbalize. A malnourished person brought up entirely on gruel may know that something is wrong, but he or she has no concept of salad. An important aspect of formulating a case is the assessment of what kinds of relating have never been part of a person's experience, and then figuring out how to introduce such concepts in an emotionally salient way so that the patient may mourn what he or she missed and acquire capacities that he or she could not have previously imagined. The empathic leap into what is missing, not just what is present and problematic, did not characterize most general clinical theory until fairly recently, when deficit formulations such as those of the self psychologists and intersubjectivists (e.g., Kohut, 1977; Stolorow & Lachmann, 1980; Ornstein & Ornstein, 1985; Stolorow, Brandschaft, & Atwood, 1987; Wolf, 1988) were developed. Since their contributions, therapists have had more models for understanding previously unemphasized aspects of their patients' emotional needs and predicaments.
I have long suspected that the etiological speculations of the 1950s and 1960s attributing numerous psychopathologies to maternal failings were products of a clinical situation that mirrored the cultural childrearing climate of too much mother and not enough father. In other words, people whose fathers had been conspicuous by their emotional absence tended to bring internalized mother issues into the treatment room. Patients knew they were upset with their mothers; they often did not know that if they had had more of a father on the scene, mother would not have looked so bad or loomed so large. They might not have had to put so much energy into getting out from under her. It was less painful, and more concrete, to lament a mother's sins of commission than a father's sins of omission. Therapists also found it more compelling to deal with what was being transferred--that is, they were repetitively seen as Mother because they were there and involved--than with what was absent from the transference, namely, a paternal dimension of experience.
It is just as important to assess what relational patterns are not evident in a client's style of connecting with a therapist as it is to feel fully the ones that are. Once, during an early session with a man who had come to me in a depression that he connected to having turned thirty-nine, I noticed that he tended to reiterate things he had already told me. "I get the feeling you weren't always listened to very carefully," I commented. "What do you mean, `listened to'?" he asked, with an edge of sarcasm on the word listened. "I don't know exactly," I answered, "but you tend to repeat things to me as if I don't pay much attention to what you say. I thought maybe some of the people who brought you up had been distracted or preoccupied, and that you had gotten used to reminding them of what you had previously said." His response was, "Do you mean that most parents listen to their children?" This was a novel concept to him. Everyone takes his or her family of origin as modal, and often it is quite late in adulthood that one can identify what was missing and never consciously missed in that family.
Contemporary scholars in trauma and dissociation (e.g., McFarlane & van der Kolk, 1996) are currently stressing something similar. Despite the fact that what captures one's attention with people who have traumatic early histories--of sexual abuse or physical maltreatment or painful medical invasions, for example--one of the most important things to understand about their psychologies is the role of neglect. What was not there in their young lives is just as important as what was. Almost any experience can be rendered nontraumatic if someone spends sufficient time with a child to help him or her understand and emotionally process what happened. At least after the age of two, when children can verbalize, it is often not so much the trauma itself that is pathogenic, but rather the atmosphere of minimization and denial with which a family treats it. When one interviews an abuse victim, the description of the horrors inflicted on him or her may be riveting. But a therapist should also take note of what is absent from the drama that has been reported: No one listened to the abused youngster, offered comfort, helped the child verbalize what happened, modeled a way of coping. These will be the more therapeutic aspects of the subsequent relationship with a clinician.
RELATIONAL THEMES OUTSIDE
THE THERAPY SITUATION
Not everything is discernible in the transference, by its presence or its absence, especially in an intake session. One important reason for taking a detailed look into a prospective client's past--taking family, social, sexual, work, and prior therapy histories--is to discern patterns of relationship that repeat in different forms over the years and across situations. An appreciation of recurrent themes can have value not only in suggesting the emphases that will eventually be therapeutic to an individual client, but also for solidifying enough of a working alliance to keep that person coming back.
Of particular importance in this area is attaining a description of other therapies the client has had, especially in those people who have made several previous, failed attempts to resolve their problems with other professionals. Notwithstanding the possibility that a candidate for therapy has had the bad luck to run into several badly trained or untalented practitioners, the best preliminary hypothesis for an interviewer to make is that what happened to the previous therapists will happen to oneself. Sorting out exactly what the client's complaints are about prior treatment is critical for two reasons. First, if one understands them well enough, one may be able to avoid some of the mistakes made by one's predecessors. For example, identifying how previous treaters may have become involved in some problematic enactment can give one advance notice on how to prepare for handling that situation. Second, and more important, since it is more than likely that one will be "caught," despite one's preparations, in the same mistakes other professionals have made (if not objectively, at least from the client's perspective), a careful examination of the pattern of prior therapeutic failure gives one the opportunity to predict to the client that the same thing may very well happen in this therapy. Could he or she manage not to flee treatment this time but instead verbalize the anger and disappointment?
When I learn from a patient that he or she has seen a bevy of prior therapists, that no one has really understood this suffering person before, that I am the last hope, my vanity is instantly activated. I find myself eager to assure such clients that, unlike the professionals they have seen before me, I can help them. Years of practice have humbled me--not enough to have changed this internal reaction, but enough to avoid acting it out. I now explicitly take the position that I will make mistakes, that they will probably be similar in some way to the mistakes that others have made, and that the client and I can use these failures of mine to understand together something important and find a constructive way to react. This communication rescues both the patient and me from unrealistic demands and conveys the message that when people disappoint, something other than despair may come out of the experience.
Early in my career as a therapist, I became interested in working with people of a psychopathic inclination. I liked expanding my therapeutic repertoire to embrace the difference in style that such patients seemed to require--namely, a more hard-nosed, tough-talking, tell-it-like-it-is confrontational tone so dramatically unlike the softer, more manifestly sympathetic approach that touches most other patients. I felt critical of the naivete of other therapists who had failed to help such clients. I had been taught that it was very important not to let an antisocial client "get over" on the therapist, and I tried to call such clients on every manipulation they attempted, lest I be seen as a "mark" and immediately devalued (see Bursten, 1973). This is fine as far as it goes, but I soon learned that no matter how clever I was, a psychopathic client could find a way to succeed in manipulating me. So I concluded that the most important therapeutic communication is not "Just try--you're not going to be able to con me," but rather "Listen, you can certainly con me if that's what you insist on doing during your appointments--I have no magical way of distinguishing between the truth and a convincing lie--but is that really how you want to spend your time here?" Competition with prior therapists or with imagined other practitioners who lack one's special skills is fine as an internal state, but it can be disastrous if acted out.
Interpersonal patterns that emerge from taking a social, sexual, and work history may also predict problems in treatment and suggest preemptive action. An apposite instance would be the person who reports leaving relationships (friends, jobs, or sexual partners) whenever they begin to seem constricting, or when the person begins to feel exposed, or when he or she notices a feeling of deep attachment or dependency. This kind of pattern is not only fraught with the loneliest kind of suffering--on the part of both the patient and the people left behind--but is also one of the problems for which analytic therapy can be most profoundly healing. That is, if the person can be kept in treatment. When someone reports what sounds like extreme, automatic, and compulsive retreat from relationship whenever he or she gets too connected, it behooves a therapist to make an immediate contract with the client not to act that response out unreflectively. Specifically, the two parties make a pact that if the pattern of fleeing appears in treatment--if the person abruptly decides, whatever the reason (money and time are the most common ones), to terminate precipitously--the client will come back for a designated number of sessions to process what has happened. This precaution has saved more than one treatment of which I have personal knowledge. In instances where the person decided to leave anyway, at least he or she had the experience of talking rather than just acting under emotional duress, and conceivably learned something important in the process. With luck, the next therapist will benefit from the client's expanded self-knowledge.
Sexual patterns contain relational themes in a highly charged, condensed form. Clinical experience suggests that repetitive sexual motifs express either the dominant interpersonal patterns in an individual's life or a sequestered, partially dissociated relationship theme that appears only in sex and needs to be integrated into the person's larger experiential world. If an interviewer can speak with ease about sexuality, a client often reacts with relief that his or her private and possibly shame-filled erotic life is not so mysterious or kinky that it defies articulation. A clinician's candor and comfort about sex encourages frank disclosure and promotes hope in clients that the difficulties in their love lives can be ameliorated. Therapists who have trouble talking explicitly should practice naming sexual activities and body parts aloud to trusted friends. Some of my supervision groups have spent a meeting doing this; members generally experience a combination of excitement, discomfort, embarrassment, and hilarity, but the exercise contributes to a verbal disinhibition that is essential for therapists.
The directive to be forthright applies with special urgency to the interviewing of lesbian, gay, bisexual, and transgendered people, as well as those with presenting sexual problems such as paraphilias and compulsive enactments ("sex addiction," in the trendy language of recent years). Minimally, such patients need to know that a mental health professional will not be shocked by their sexual predilections; ideally, they should feel that their interviewer has a genuine appreciation of and respect for erotic diversity. With gay patients, for example, queries such as, "Are your sexual preferences more oral or more anal?" and "Do you tend to be a `bottom' or a `top'?" can cast light on important relational issues. With bisexual people, investigation of the differing gratifications they experience with women and men, respectively, can be illuminating. The more frank a therapist's tone, the better, although when one treads on delicate personal ground, it is considerate to tell clients that they are free not to answer any questions that feel too intrusive. It is also important to reflect a client's choice of sexual terms; for example, if a man refers to "coming," the interviewer should not then refer to his "ejaculating."
Because all kinds of human motives can be sexualized, the knowledge of a person's particular sexual pattern reveals something about his or her primary preoccupations. Some people sexualize their dependency (valuing the oral and cuddling aspects of sex to the exclusion of other factors); others sexualize their aggression (prizing the dominance and submission aspects); still others use sex mostly in the service of narcissistic needs (valuing the exhibitionistic and voyeuristic features of sexuality, or the illusion of having one's desires magically known and wordlessly satisfied, or the fantasy of defeating and humiliating the other party). Sometimes, especially when there is a childhood history of physical suffering connected with the genitals (from sexual abuse, accidents, or medical procedures), the enduring or inflicting of pain may be a prerequisite to orgasm. In any of these circumstances, a relational theme is embodied starkly in the sexual domain.
IMPLICATIONS OF RELATIONAL PATTERNS
FOR LONG-TERM VERSUS SHORT-TERM THERAPIES
In open-ended therapies, except for instances in which flight from treatment is an obvious risk, one can confidently expect core relational themes to emerge over time. An interviewer who misses some central interpersonal motif in the initial interview has not usually committed a grave oversight, because any theme of import will express itself with unmistakable clarity sooner or later. In time-limited therapies, however, the practitioner's capacity to zero in on the most central conflictual relational pattern is critical to making use of the short time at his or her disposal. For the reader unfamiliar with the empirical literature on short-term dynamic therapy, I recommend the work of my colleagues Stanley Messer and Seth Warren (1995), who note the recurrence of this emphasis on understanding a patient's central relational dynamics in most of the current major approaches to time-limited analytic treatment.
In longer-term therapies and in psychoanalysis proper, one of the motives for change that I have rarely seen discussed in the analytic literature is the fact that patients ultimately get self-conscious, chagrined, and even bored hearing themselves describe the same interactions over and over again. After a while, it becomes easier to try something new than to go back to one's therapist and confess that one has once more acted out the same old pattern. Naming and describing one's central "neurosis" ad nauseam in the presence of a witness to one's irrationality, leading to eventual feelings of ennui and exasperation in both parties, make the risk of new behavior feel better than the misery of repetition. This motivational benefit is probably one of the great unresearched contributants to change in psychotherapy. But it can only happen if the therapist has identified a pattern, named it, and created a safe environment where it can be talked about again and again. Thus, the sooner one can capture a relational dynamic in words, the faster one can help a person to change it into some healthier way of dealing with other people.
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